Risk prediction models for endometrial cancer: development and validation in an international consortium

BACKGROUND

Endometrial cancer risk stratification may help target interventions, screening, or prophylactic hysterectomy to mitigate the rising burden of this cancer. However, existing prediction models have been developed in select cohorts and have not considered genetic factors.

METHODS

We developed endometrial cancer risk prediction models using data on postmenopausal White women aged 45-85 years from 19 case-control studies in the Epidemiology of Endometrial Cancer Consortium (E2C2). Relative risk estimates for predictors were combined with age-specific endometrial cancer incidence rates and estimates for the underlying risk factor distribution. We externally validated the models in 3 cohorts: Nurses' Health Study (NHS), NHS II, and the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial.

RESULTS

Area under the receiver operating characteristic curves for the epidemiologic model ranged from 0.64 (95% confidence interval [CI] = 0.62 to 0.67) to 0.69 (95% CI = 0.66 to 0.72). Improvements in discrimination from the addition of genetic factors were modest (no change in area under the receiver operating characteristic curves in NHS; PLCO = 0.64 to 0.66). The epidemiologic model was well calibrated in NHS II (overall expected-to-observed ratio [E/O] = 1.09, 95% CI = 0.98 to 1.22) and PLCO (overall E/O = 1.04, 95% CI = 0.95 to 1.13) but poorly calibrated in NHS (overall E/O = 0.55, 95% CI = 0.51 to 0.59).

CONCLUSIONS

Using data from the largest, most heterogeneous study population to date (to our knowledge), prediction models based on epidemiologic factors alone successfully identified women at high risk of endometrial cancer. Genetic factors offered limited improvements in discrimination. Further work is needed to refine this tool for clinical or public health practice and expand these models to multiethnic populations.

Dietary omega-3 fatty acids and endometrial cancer risk in the Epidemiology of Endometrial Cancer Consortium: An individual-participant meta-analysis

BACKGROUND

Limited data from prospective studies suggest that higher dietary intake of long-chain omega-3 polyunsaturated fatty acids (LCn3PUFA), which hold anti-inflammatory properties, may reduce endometrial cancer risk; particularly among certain subgroups characterized by body mass and tumor pathology.

MATERIALS AND METHODS

Data from 12 prospective cohort studies participating in the Epidemiology of Endometrial Cancer Consortium were harmonized as nested case-control studies, including 7268 endometrial cancer cases and 26,133 controls. Habitual diet was assessed by food frequency questionnaire, from which fatty acid intakes were estimated. Two-stage individual-participant data mixed effects meta-analysis estimated adjusted odds ratios (OR) and 95% confidence intervals (CI) through logistic regression for associations between study-specific energy-adjusted quartiles of LCn3PUFA and endometrial cancer risk.

RESULTS

Women with the highest versus lowest estimated dietary intakes of docosahexaenoic acid, the most abundant LCn3PUFA in diet, had a 9% increased endometrial cancer risk (Quartile 4 vs. Quartile 1: OR 1.09, 95% CI: 1.01-1.19; P trend = 0.04). Similar elevated risks were observed for the summary measure of total LCn3PUFA (OR 1.07, 95% CI: 0.99-1.16; P trend = 0.06). Stratified by body mass index, higher intakes of LCn3PUFA were associated with 12-19% increased endometrial cancer risk among overweight/obese women and no increased risk among normal-weight women. Higher associations appeared restricted to White women. The results did not differ by cancer grade.

CONCLUSION

Higher dietary intakes of LCn3PUFA are unlikely to reduce endometrial cancer incidence; rather, they may be associated with small to moderate increases in risk in some subgroups of women, particularly overweight/obese women.

Coffee consumption and risk of endometrial cancer: a pooled analysis of individual participant data in the Epidemiology of Endometrial Cancer Consortium (E2C2)

BACKGROUND

Epidemiologic studies suggest that coffee consumption may be inversely associated with risk of endometrial cancer (EC), the most common gynecological malignancy in developed countries. Furthermore, coffee consumption may lower circulating concentrations of estrogen and insulin, hormones implicated in endometrial carcinogenesis. Antioxidants and other chemopreventive compounds in coffee may have anticarcinogenic effects. Based on available meta-analyses, the World Cancer Research Fund (WCRF) concluded that consumption of coffee probably protects against EC.

OBJECTIVES

Our main aim was to examine the association between coffee consumption and EC risk by combining individual-level data in a pooled analysis. We also sought to evaluate potential effect modification by other risk factors for EC.

METHODS

We combined individual-level data from 19 epidemiologic studies (6 cohort, 13 case-control) of 12,159 EC cases and 27,479 controls from the Epidemiology of Endometrial Cancer Consortium (E2C2). Logistic regression was used to calculate ORs and their corresponding 95% CIs. All models were adjusted for potential confounders including age, race, BMI, smoking status, diabetes status, study design, and study site.

RESULTS

Coffee drinkers had a lower risk of EC than non-coffee drinkers (multiadjusted OR: 0.87; 95% CI: 0.79, 0.95). There was a dose-response relation between higher coffee consumption and lower risk of EC: compared with non-coffee drinkers, the adjusted pooled ORs for those who drank 1, 2-3, and >4 cups/d were 0.90 (95% CI: 0.82, 1.00), 0.86 (95% CI: 0.78, 0.95), and 0.76 (95% CI: 0.66, 0.87), respectively (P-trend < 0.001). The inverse association between coffee consumption and EC risk was stronger in participants with BMI > 25 kg/m2.

CONCLUSIONS

The results of the largest analysis to date pooling individual-level data further support the potentially beneficial health effects of coffee consumption in relation to EC, especially among females with higher BMI.

Comparison of structured use of routine laboratory tests or near-patient assessment with clinical judgement in the management of bleeding after cardiac surgery

BACKGROUND

Using algorithms based on point of care coagulation tests can decrease blood loss and blood component transfusion after cardiac surgery. We wished to test the hypothesis that a management algorithm based on near-patient tests would reduce blood loss and blood component use after routine coronary artery surgery with cardiopulmonary bypass when compared with an algorithm based on routine laboratory assays or with clinical judgement.

METHODS

Patients (n=102) undergoing elective coronary artery surgery with cardiac bypass were randomized into two groups. In the point of care group, the management algorithm was based on information provided by three devices, the Hepcon, thromboelastography and the PFA-100 platelet function analyser. Management in the laboratory test group depended on rapidly available laboratory clotting tests and transfusion of haemostatic blood components only if specific criteria were met. Blood loss and transfusion was compared between these two groups and with a retrospective case-control group (n=108), in which management of bleeding had been according to the clinician's discretion.

RESULTS

All three groups had similar median blood losses. The transfusion of packed red blood cells (PRBCs) and blood components was greater in the clinician discretion group (P<0.05) but there was no difference in the transfusion of PRBCs and blood components between the two algorithm-guided groups.

CONCLUSION

Following algorithms based on point of care tests or on structured clinical practice with standard laboratory tests does not decrease blood loss, but reduces the transfusion of PRBCs and blood components after routine cardiac surgery, when compared with clinician discretion. Cardiac surgery services should use transfusion guidelines based on laboratory-guided algorithms, and the possible benefits of point of care testing should be tested against this standard.

Glucose, insulin and potassium for heart protection during cardiac surgery

BACKGROUND

Coronary artery bypass grafting with hypothermic cardiac arrest and cardiopulmonary bypass (CPB) is associated with myocardial injury. Our study investigated whether an infusion of glucose, insulin and potassium (GIK) during elective coronary artery bypass surgery decreases myocardial cell death.

METHODS

We measured cardiac troponin I (cTnI), a myofibrillar structural protein, which is a sensitive and specific indicator of myocytic injury. With ethics committee approval, 42 patients were enrolled into a randomized, prospective, double-blinded study. In the GIK group, 500 ml of 50% dextrose solution containing 100 IU insulin and potassium 80 mmol was infused at the rate of 0.75 ml kg(-1) h(-1). Patients in the non-GIK group received 5% dextrose solution at the same rate. Arterial blood samples were taken before induction of anaesthesia, after removal of the aortic clamp and 6 and 12 h after CPB.

RESULTS

In both groups there was an increase in cTnI concentration (P<0.05), which was greatest about 6 h after CPB. At no time did the cTnI concentration differ between the two groups.

CONCLUSION

The results suggest that GIK does not decrease the irreversible myocardial damage associated with routine coronary artery bypass surgery.

Tracheal tube pressure change during magnetic stimulation of the phrenic nerves as an indicator of diaphragm strength on the intensive care unit

Diaphragm strength can be assessed from twitch gastric (TwPgas), twitch oesophageal (TwPoes), and twitch transdiaphragmatic pressure (TwPdi) in response to phrenic nerve stimulation. This requires the passage of balloon catheters, which may be difficult. Changes in pressure measured at the mouth during phrenic nerve stimulation avoid the need for balloon catheters. We hypothesized that pressures measured at the tracheal tube during phrenic stimulation, could also reflect oesophageal pressure change as a result of isolated diaphragmatic contraction and, therefore, reflect diaphragm strength. We aimed to establish the relationship between twitch tracheal tube pressure (TwPet), TwPoes, and TwPdi in patients in the supine and sitting positions. The phrenic nerves were stimulated magnetically bilaterally, in 14 ICU patients while supine and on another occasion while sitting up at 45 degrees. In the sitting position mean TwPoes was 9.1 cm H2O and TwPet 11.3 cm H2O (mean(SD) difference -2.2 (SD 1.5)). In the supine position mean TwPoes was 8.1 cm H2O and TwPet 9.9 cm H2O (mean difference -1.8 (2.2)). The difference between TwPoes and TwPet was less at low twitch amplitude; less than +/- 1 cm H2O below a mean twitch height of 8 cm H2O supine and 10 cm H2O sitting. Sitting TwPet was related to TwPoes r2=0.93 and TwPdi r2=0.65 (P<0.01). Supine TwPet was related to TwPoes r2=0.84 and TwPdi r2=0.83 (P<0.01). The mean within occasion coefficient of variation while sitting was TwPet=13.3%, TwPoes=13.9%, TwPdi=11.2%, and supine TwPet=11.6%, TwPoes=14.6%, TwPdi=11.8%. We conclude that TwPet reflects TwPoes during diaphragmatic stimulation and is worthy of further study to establish its place as a guide to the presence of respiratory muscle strength and fatigue.

Noninvasive ventilator triggering in chronic obstructive pulmonary disease. A test lung comparison

To be most effective, noninvasive ventilation (NIV) ventilators should synchronize well with patients' breathing. However, the speed with which different ventilators can respond to the transitions between inspiration and expiration may vary, and abnormal respiratory mechanics and mask leaks may exacerbate this problem. This study explored synchronization using a new test lung model designed to simulate acute exacerbations of chronic obstructive pulmonary disease (COPD). Thirteen ventilators were tested against different combinations of tidal volume (VT), airways resistance (Raw), FRC, and mask leak. These combinations ranged from those of a severe exacerbation of COPD, to a mild condition reflecting the optimal triggering conditions a ventilator is likely to encounter. The triggering delays from the beginning and end of "inspiration" of the test lung, to the appropriate responses from the ventilators were measured. Three of the ventilators had trigger delays less than approximately 120 ms at both the beginning and end of expiration under all conditions. Trigger delays of other ventilators were mainly in the range of 120 to 300 ms, although exceptionally as long as 500 ms. Varying the conditions had a variable but generally small effect on triggering times, suggesting that there is a largely unavoidable element to the triggering delays intrinsic to the design of the ventilators.

The effects of aprotinin on thromboelastography with three different activators

BACKGROUND

Thromboelastography is used for assessment of hemostasis. Adherence to thromboelastography-guided algorithms and aprotinin administration each decrease bleeding and blood product usage after cardiac surgery. Aprotinin, through inhibition of kallikrein, causes prolongation of the celite-activated clotting time and the activated partial thromboplastin ratio. The aim of this study was to assess the effects of aprotinin on the thromboelastography trace.

METHODS

Three activators were used in the thromboelastography: celite (which is widely established), kaolin, and tissue factor. Assessment was performed on blood from volunteers and from patients before and after cardiac surgery.

RESULTS

The tissue factor-activated thromboelastography trace was unaffected by the addition of aprotinin. When celite and kaolin were used as activators in the presence of aprotinin, the reaction time (time to clot formation) of the thromboelastography trace was prolonged (P < 0.0001) and the maximum amplitude (clot strength) was decreased (P < 0.05). With celite as an activator, the addition of aprotinin decreased (P < 0.05) the thromboelastography alpha angle (rate of clot extension). The reaction time of the celite-activated trace correlated with the activated partial thromboplastin ratio (P < 0.01). The reaction time of the tissue factor-activated trace correlated with the international normalized ratio (P < 0.01).

CONCLUSION

The thromboelastography trace is altered in the presence of aprotinin when celite and kaolin are used as activators but not when tissue factor is the activator.

Changes in brain natriuretic peptide concentrations following open cardiac surgery with cardioplegic cardiac arrest

Elevated brain natriuretic peptide (BNP) concentration in peripheral blood reflects impaired cardiac ventricular function. We investigated the release pattern of BNP following cardioplegic cardiac arrest during heart surgery. In particular, we sought to discover whether there is an increase in peripheral BNP concentrations following reperfusion of the ischaemic heart. A secondary aim of the study was to investigate whether allopurinol, an anti-oxidant, has any effect on BNP release. A total of 29 patients scheduled for elective coronary artery bypass grafting were recruited, of whom 12 were randomly allocated to receive allopurinol with their pre-medication. Blood specimens were taken at six time points from the indwelling arterial catheter, the first before surgery and the last 2 h following the termination of cardiopulmonary bypass (CPB). BNP was found to decrease markedly when the aortic cross clamp was applied and the heart was isolated from circulation (P=0.0001). There was a slight increase in BNP following cross clamp release and myocardial reperfusion (P=0.04). A more substantial increase occurred with weaning from CPB when ventricular filling occurred (P=0.0015). Only the final BNP value, 2 h after CPB, was elevated compared with baseline (P=0.0013). Allopurinol had no demonstrable effect on changes in BNP.

Isoflurane does not depress the hypoxic response of rabbit carotid body chemoreceptors

Whether volatile anesthetics have an effect on the peripheral chemoreceptors is controversial, possibly because of differences in end-tidal CO(2) concentrations. We studied the effect of isoflurane on the hypoxic chemosensitivity of carotid body chemoreceptors at three different PaCO(2) levels before and during the administration of 1.0% isoflurane (0.5 minimum alveolar anesthetic concentration) in six normothermic New Zealand white rabbits anesthetized with thiopental. The response of the chemoreceptors was fitted to the equation: Frequency (Hz) = a + b x PaCO(2) + c x (1/PaO(2)) + Dx (1/PaO(2))(2). Mean values for the coefficients a, b, c and d for the control state were -4.5, 0.13, 771, and 6332, respectively. This relationship was not changed by addition of isoflurane at 1.0% end-tidal concentration (P = 0.40, analysis of variance). We conclude that isoflurane at 1.0% end-tidal concentration does not depress the hypoxic response of rabbit carotid body chemoreceptors during either hypo-, normo-, or hypercapnia.

IMPLICATIONS

By measuring single-fiber chemoreceptor activity in anesthetized rabbits, we showed that isoflurane at 1.0% end-tidal concentration does not depress the hypoxic chemosensitivity of peripheral chemoreceptors during either hypo-, normo-, or hypercapnia in this species.

The intubating laryngeal mask airway compared with direct laryngoscopy

We have compared the ability of naïve intubators to intubate the trachea using a laryngoscope and an intubating laryngeal mask airway (ILMA) after receiving basic training, in a randomized, prospective, crossover study in 60 patients. Ventilation of the lungs via the ILMA was also compared with ventilation with a face mask. There was no significant difference in successful intubation between the techniques (38 of 89 with the ILMA and 33 of 93 with direct laryngoscopy; ns). In patients in whom participants failed in their intubation attempts with the ILMA, investigators achieved success in 89% (16 of 18). Satisfactory ventilation was more common with the ILMA (50 of 51) than with the face mask (43 of 60) (P = 0.0001). A total of 98% (89 of 91) of ILMA were inserted successfully, with a mean insertion time of 19.6 s, and 78% (69/89) of these insertions were achieved in less than 26 s. The ILMA may be useful for emergency oxygenation and ventilation, but these results do not support its use for intubation by those not trained in advanced airway management and ILMA use.

Effects of temperature on phrenic nerve and diaphragmatic function during cardiac surgery

We have studied the effects of whole body cooling on phrenic nerve and diaphragmatic function in 26 patients using magnetic stimulation of the phrenic nerves with a pair of Magstim 200 HP stimulator coils during cardiopulmonary bypass. The diaphragmatic electromyogram in response to magnetic pulses was recorded with needle electrodes at two temperatures, approximately 31 degrees C (cold) and approximately 36 degrees C (warm) during the cooling or rewarming phase of hypothermic cardiopulmonary bypass. This 5 degrees C temperature change was associated with clear changes in the evoked electromyographical response of the diaphragm. Median latency between stimulus and electromyographic response was 10.1 (range 8.0-11.8) ms during cold and 8.3 (5.9-10.2) ms during warm stimulation (P < 0.001). Median duration of the muscle compound action potential was prolonged and its amplitude reduced in cold compared with warm stimulations (P < 0.01). These effects were enhanced by application of ice slush to the heart. We conclude that diaphragmatic function may be affected by mild hypothermia after cardiac surgery.

Fingertip temperature during cardiopulmonary bypass

Temperature changes in the nasopharynx, fingertip, forearm and extracorporeal circuit were continuously monitored, starting 10 min before and up to 16 min into the rewarming period of hypothermic (32 degrees C) cardiopulmonary bypass in 14 patients operated on for coronary artery revascularization. Arterial blood temperature was the first to increase after starting rewarming, followed by the nasopharynx and the fingertip temperatures. Fingertip temperature started to increase abruptly 6.2 (2.02 SD) min after rewarming started. At this point, nasopharyngeal temperature was 34.2 degrees C (1.42 SD) and took a further 8.3 min to reach 37 degrees C. Assuming that increasing fingertip temperature indicates a central thermoregulatory response to warming, we suggest that nasopharyngeal temperature is a poor monitor of brain temperature. We also suggest that fingertip temperature may be used to monitor the point at which cerebral temperature reaches 'normothermia'. Further body warming, using arterial temperatures > or = 39 degrees C, should be avoided because of the danger of brain hyperthermia.

Convective warming combined with vasodilator therapy accelerates core rewarming after coronary artery bypass surgery

In a prospective, randomized, controlled study, we have investigated the effect of forced air warming on the rate of change of nasopharyngeal and rectal temperatures in 20 patients after coronary artery bypass grafting. All patients had nasopharyngeal temperatures less than 36 degrees C on arrival in the intensive care unit and received an infusion of glyceryl trinitrate 15 mg h-1, but none received inotropes. Ten patients were warmed under an aluminized plastic "space" blanket (control group) and 10 were warmed under a "Bair Hugger" blanket connected to its power unit on "high" setting (Bair Hugger group). The rates of increase in nasopharyngeal temperature were 0.4 and 0.95 degrees C h-1, respectively, in the control and Bair Hugger groups (P < 0.01) during the first 2 h after operation. Over the same period of time, rectal temperatures increased at a rate of 0.25 and 0.75 degrees C h-1 in the control and Bair Hugger groups, respectively (P < 0.01).

Effect of oral theophylline on resting energy expenditure in normal volunteers

BACKGROUND

The aim of this study was to investigate the contribution of regular treatment with oral theophylline to the increase in resting oxygen consumption observed in patients with chronic airflow limitation who are receiving bronchodilator therapy.

METHODS

Resting oxygen consumption (VO2) and carbon dioxide production (VCO2) were measured in 10 normal subjects (six men, age 21-48 years, weight 50-85 kg) before and after 11 days of treatment with either placebo or theophylline in a double blind manner, in twice daily oral doses ensuring trough serum concentrations between 8.4 and 13.5 mg/l. An open canopy method was used to measure VO2 and VCO2 and in all test conditions this was extended for 60 minutes after an inhalation of 800 micrograms of salbutamol super-imposed on the background placebo or theophylline treatment.

RESULTS

Resting VO2 and heart rate were increased during theophylline treatment compared with placebo by 6.5% and 8.4% respectively. Salbutamol inhalation transiently increased VO2, VCO2, and heart rate in all tests but this was not modified by background theophylline treatment.

CONCLUSION

Oral theophylline treatment causes a sustained increase in resting oxygen consumption and heart rate but does not modify the metabolic response to acutely inhaled salbutamol.

Effect of inspiratory pressure support on exercise tolerance and breathlessness in patients with severe stable chronic obstructive pulmonary disease

BACKGROUND

In patients with chronic obstructive pulmonary disease exercise tolerance is commonly limited by breathlessness. These patients have an increased ventilatory load at rest which is exacerbated during exercise. The purpose of this study was to investigate the effect of supporting ventilation by non-invasive inspiratory pressure support (IPS) during submaximal treadmill exercise in such patients to see if they would experience less breathlessness and improve their exercise capacity.

METHODS

Eight men with disabling breathlessness due to chronic obstructive pulmonary disease (COPD) (mean (SD) FEV1 0.73 (0.2) 1) were studied. Patients walked on a treadmill until their sensation of breathlessness, scored at one minute intervals, reached level 5 ("severe") on the 10-point Borg scale. Studies were performed with IPS (mean airway pressure 12-15 cm H2O), continuous positive airway pressure (CPAP 6 cm H2O), and with oxygen (2 l/min via a mask) in random order on three separate days. Each of these walks was compared with a control walk using a sham circuit (breathing air via an oxygen mask at 2 l/min from an unlabelled cylinder), and with a baseline walk in which patients walked freely on the treadmill. On cessation of exercise, distance achieved and a leg fatigue score were recorded.

RESULTS

No patients stopped due to leg fatigue, all stopping only when their sensation of breathlessness had reached level 5 on the Borg scale. IPS improved median walking distance by 62% compared with the control walk (sham circuit). There was no change in walking distance with either CPAP or oxygen at 2 l/min. There was no difference between the control and the baseline walks.

CONCLUSIONS

Inspiratory pressure support can reduce breathlessness and increase exercise tolerance to submaximal treadmill exercise in patients with COPD. This could have implications for the rehabilitation of these severely disabled patients.

Acute effects of inhaled salbutamol on the metabolic rate of normal subjects

BACKGROUND

This study was designed to investigate the contribution of inhaled salbutamol to the increase in resting metabolic rate found in patients with chronic airflow limitation who were receiving bronchodilator therapy.

METHODS

The resting metabolic rate of 10 normal subjects (age 20-47 years, weight 42-105 kg, seven men) was studied after inhalations of salbutamol or placebo. An open canopy method of indirect calorimetry was used to measure resting oxygen consumption (VO2) and resting carbon dioxide production (VCO2). Subjects inhaled two, four, eight, or 12 puffs (100 micrograms/puff) of salbutamol or placebo in a double blind manner. Recordings of VO2 and VCO2 were made after inhalation of the four doses of salbutamol or placebo, integrated over one hour, and compared.

RESULTS

VO2 and VCO2 increased in a dose dependent manner after inhaled salbutamol with a maximum effect at five minutes after inhalation. After four puffs, VO2 was 203 and 188 ml/kg/h for salbutamol and placebo respectively. After eight puffs, VO2 was 207 and 185 and VCO2 was 167 and 155 ml/kg/h. After 12 puffs, VO2 was 220 and 190 with a VCO2 of 181 and 168 ml/kg/h. Twelve puffs of salbutamol increased the mean (SE) respiratory quotient from 0.85 (0.01) to 0.93 (0.04) at five minutes indicating an increase in ventilation in excess of metabolic demand. Mean heart rate increased in parallel with VO2.

CONCLUSION

Inhaled salbutamol significantly increases resting metabolic rate in a dose dependent manner.

Modification of the thermogenic effect of acutely inhaled salbutamol by chronic inhalation in normal subjects

BACKGROUND

Acute inhalation of clinical doses of salbutamol in normal volunteers increases resting metabolic rate by up to 20% above control values. This study was designed to see if chronic treatment with salbutamol causes a sustained increase in metabolic rate and whether it modifies the acute thermogenic response to the drug.

METHODS

The effects of chronic inhaled salbutamol on resting oxygen consumption (VO2) and carbon dioxide output (VCO2) were studied in seven normal subjects (age 20-47 years, weight 52-105 kg, five men). An open canopy method of indirect calorimetry was used to measure VO2, VCO2, and respiratory quotient (RQ). Subjects inhaled two puffs of salbutamol or placebo four times a day in a double blind manner. Measurements of resting VO2 and VCO2 after 10 days of salbutamol were compared with the values after 10 days of placebo and with those taken at the start of the study. At the end of each treatment period subjects inhaled eight puffs (800 micrograms) of salbutamol and the acute effects on VO2, VCO2 and RQ were monitored for one hour.

RESULTS

Resting VO2, VCO2, and RQ were not significantly different at the end of the salbutamol and placebo periods but the acute response to eight puffs of salbutamol was abolished by regular inhalation. The mean VO2 integrated over one hour after 800 micrograms salbutamol given acutely was different (241.3 and 210.7 ml/kg/h in the placebo and salbutamol groups respectively). Differences were not significant between placebo and salbutamol groups for changes in VCO2, heart rate, blood pressure, and RQ after acute inhalation.

CONCLUSION

Regular treatment with inhaled salbutamol (800 micrograms/day) does not cause a sustained increase in resting metabolic rate but prevents the increase in VO2 that occurs after acute inhalations in normal subjects.

Morphine-6-glucuronide: effects on ventilation in normal volunteers

The respiratory responses to intravenous morphine sulphate (0.12 mg/kg), morphine-6-glucuronide (M6G: 0.03 mg/kg) and placebo were assessed in 6 healthy volunteers, using a single blind randomised crossover design. Five of these subjects underwent an additional study of M6G at 0.06 mg/kg. Respiratory rate, minute volume and end-tidal CO2 were continuously measured using a low resistance non-rebreathing circuit, a mass spectrometer and a dry gas meter. The ventilatory responses to CO2 exposures (5.5% for 4 min) were assessed 40 and 20 min before, and 20, 40 and 80 min after drug administration. Following placebo and M6G (at both doses) no change in end-tidal CO2 occurred whilst the subjects were breathing air, whereas following morphine a significant rise was seen (P less than 0.05). Morphine reduced the ventilatory response to 5.5% CO2 at all times tested (P less than 0.05) and M6G (at both doses) reduced the response to CO2 at 20 and 40 min after administration, but to a lesser degree than did morphine (P less than 0.05).

Carotid body chemoreceptor response to prolonged hypoxia in the rabbit: effects of domperidone and propranolol

1. The discharge of single afferent chemoreceptor fibres was recorded from the cut sinus nerve over periods of 60 or 90 min of constant, isocapnic hypoxia (arterial O2 pressure, Pa,O2, 3.13-5.25 kPa), in twenty anaesthetized rabbits, after dividing the sympathetic supply to the carotid body. 2. Under control conditions, discharge after 60 min of hypoxia adapted to a mean (S.E.M.) of 71.95 (2.75)% of that attained at 5 min of hypoxia in twenty-three hypoxic experiments. This adaptation was more pronounced when Pa,O2 was lower than 4 kPa (30 Torr). 3. Domperidone (1 mg kg-1 bolus + 1 mg kg-1 h-1 infusion I.V.), increased normoxic afferent discharge by a mean of 142%. In ten experiments, discharge after 60 min of hypoxia adapted to a mean (S.E.M.) of 56.22 (+/- 3.40)% of that attained at 5 min of hypoxia which was significantly different from control hypoxic runs (P = 0.006). 4. In seven experiments propranolol (1 mg kg-1 bolus + 1 mg kg-1 h-1 infusion I.V.) did not affect the normoxic discharge. The mean adaptation of discharge after 60 min of hypoxia was to 77.43 (3.97)% of discharge attained at 5 min of hypoxia, which was not significantly different from control hypoxic runs (P = 0.34). 5. Under control conditions plasma [K+] increased steadily during 60 min of hypoxia, in fourteen experiments, from a mean of 2.76 (0.14) to 2.85 (0.12) mmol l-1 but this was not significant (P = 0.21). Domperidone (n = 6) did not affect plasma [K+] at any time, but after propranolol (n = 6) it increased by a mean (S.E.M.) of 0.39 (0.09) mmol l-1 (P = 0.01) in normoxia and by a further 0.62 (0.28) mmol l-1 (P = 0.08) at 60 min of hypoxia. 6. The results suggest that the adaptation of chemoreceptor discharge to hypoxia in the rabbit is not mediated by changes in plasma [K+]; in addition, endogenous dopamine, but not noradrenaline, contributes to the maintenance of chemoreceptor discharge in prolonged hypoxia.

Extradurals and shivering: effects of cold and warm extradural saline injections in volunteers

We tested the hypothesis that cooling the extradural space may provoke shivering, by giving three 80-ml extradural injections of warm (39.8 +/- 1.2 degrees C) or cold (17 +/- 2.2 degrees C) saline to four healthy volunteers, whilst recording central temperature and electromyographic activity from four muscles. The first injection (always cold) did not induce shivering in any of the subjects. The second and third injections, randomly cold or warm, were given after induction of shivering with cold blankets, but had no detectable effects on the intensity of shivering. This suggests that shivering in extradural anaesthesia does not result solely from cooling of the extradural space.

Shivering during epidural anesthesia

The authors tested the hypothesis that during epidural anesthesia: 1) shivering-like tremor is primarily normal thermoregulatory shivering; 2) hypothermia does not produce a subjective sensation of cold; and 3) injectate temperature does not influence tremor intensity. An epidural catheter was inserted into ten healthy, nonpregnant volunteers randomly assigned to skin-surface warming below the T10 dermatome (warmed group) or no extra warming (unwarmed group). Each volunteer was given two 30-ml epidural injections of 1% lidocaine (16.0 +/- 4.7 degrees C and 40.6 +/- 0.7 degrees C at the catheter tip), in random order separated by at least 3 h. Skin-temperature gradients (forearm-fingertip) and tympanic membrane and average skin temperatures were recorded; significant vasoconstriction was prospectively defined as a gradient greater than or equal to 4 degrees C. Integrated electromyographic (EMG) intensity was recorded from four upper-body muscles. Overall thermal comfort was evaluated using a visual analog scale. Tympanic membrane temperatures decreased significantly in the unwarmed group (n = 6). Tremor occurred following ten of 12 injections in unwarmed volunteers, but only following one of eight injections in the warmed group. Integrated EMG intensity did not differ significantly following epidural injection of warm and cold lidocaine: tremor started when tympanic membrane temperature decreased about 0.5 degrees C and continued until central temperature returned to within 0.5 degrees C of control. Tremor always was preceded by hypothermia and vasoconstriction in the arms. Thermal comfort increased in both groups after epidural injection, with maximal comfort occurring at the lowest tympanic temperatures.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of chronic airflow limitation on resting oxygen consumption

The work of breathing in patients with severe chronic airflow limitation is increased even at rest but little is known about the magnitude of this increase. Resting oxygen consumption (VO2), carbon dioxide production (VCO2), and respiratory quotient (RQ) were measured in 13 patients with severe chronic airflow limitation (mean FEV1 0.78 1, vital capacity 2.1 1) and compared with those of 13 age, weight, and height matched control subjects. Whereas mean RQ was the same in the two groups (0.82), mean VO2 and VCO2 were higher in the patients (+ 18 ml min-1 and + 15 ml min-1 respectively). When VO2 was standardised for body surface area it was 10.9% higher in the patients (p less than 0.05). If the increased resting VO2 in these patients were solely due to increased activity of the respiratory muscles, it would represent a fourfold increase in the oxygen cost of breathing.

Interactions between hypoxia, acetylcholine and dopamine in the carotid body of rabbit and cat

1. Acetylcholine (ACh) and dopamine (DA) were either infused into the carotid artery or applied directly to the surface of the carotid body of twenty-six rabbits and fifteen cats. Afferent discharge of single chemoreceptor units was recorded at a range of Pa,O2 (arterial O2 pressure) values during drug administration. 2. There were no observable systemic effects of either drug when applied to the surface of the carotid body. 3. Acetylcholine tended to depress afferent discharge when applied to the surface of the rabbit carotid body or when infused into the carotid sinus. In the cat, intracarotid and surface application of ACh had mild and inconsistent effects. DA consistently depressed discharge in both species independent of the route of administration. Antagonists of ACh and DA failed to abolish the chemoreceptor response to hypoxia. 4. The changes in afferent discharge elicited by all drugs were small compared with the range of discharge rates attained with physiological stimuli. The effects of ACh and DA were more marked in hyperoxia than in hypoxia for both routes of administration, disappearing at Pa,O2 values close to 20 Torr (7.5 Torr = 1 kPa). 5. A role for DA in the maintenance of the hypoxic response was investigated in six rabbits. After 15 min of hypoxia (Pa,O2 = 21.8 +/- 1.1 Torr; mean +/- S.E.M.) the discharge of single chemoreceptor fibres adapted moderately (to 79.3 +/- 5.2% of maximum discharge). Following administration of domperidone or haloperidol (1.0-5.3 mg kg-1, I.V.) the same fibres responded with equal magnitude to the onset of the hypoxic stimulus but showed a significantly larger adaptation (to 48.5 +/- 4.4%). 6. It is concluded that endogenous ACh and DA are unlikely to mediate the transduction process of the carotid body, but DA may play a role in preventing adaptation to a prolonged hypoxic stimulus.

Studies on the regenerated carotid sinus nerve of the rabbit

1. The central end of the distally cut left carotid sinus nerve was sutured to the tunica media of the external carotid artery, 1 cm cranial to the carotid bifurcation, in nineteen rabbits. The carotid body was removed in fourteen of these rabbits but left in situ in the remaining five. After 56-165 days of recovery a neuroma was identified at the site of the suture. Ventilatory reflexes mediated by both sinus nerves were tested and afferent activity recorded from the regenerated nerve. 2. Ventilatory reflex responses to hypoxia and sodium cyanide were abolished on sectioning the right sinus nerve, whilst the hypercapnic response was maintained. 3. Electrical stimulation of the regenerated sinus nerve caused hypotension and hyperventilation. These responses were attenuated compared to stimulation of the right sinus nerve. 4. A level of afferent activity equivalent to that found in non-regeneration experiments was recorded from all regenerated sinus nerves. Whole-nerve afferent activity was modulated by changes in carotid sinus blood pressure but not by changes in Pa,O2, Pa,CO2 (arterial O2 and CO2 pressures) or intracarotid injection of sodium cyanide. 5. A minimum of thirty single afferent fibres was identified in each experiment, the vast majority of which were mechanoreceptors. In only nine experiments were chemoreceptor fibres found and only twelve chemoreceptor fibres (1.7% of total) were identified in these nine experiments. In ten experiments no chemoreceptor fibres could be found. Leaving the carotid body in situ increased the incidence of chemoreceptive preparations. A small number of fibres unresponsive to mechanical stimulation and asphyxia was also identified. 6. The responses of regenerated chemoreceptor fibres to physiological and pharmacological stimuli were generally similar to those found in control carotid body preparations. Fibres unresponsive to mechanical stimulation and asphyxia did not respond to sodium cyanide, dopamine or isoprenaline; some of these fibres were excited by nicotine. 7. The receptive fields of mechanosensitive fibres were localized on or up to 2 cm away from the neuroma. Surface application of 20-40 microliters sodium cyanide (200 micrograms ml-1) was used to localize the receptive fields of seven of the twelve chemoreceptor fibres. All seven were localized to the site of the carotid body. 8. The neuroma and site of the carotid body were examined under light and electron microscopy. Glomus tissue was absent from the neuroma but was found at the site of the carotid body. 9. In conclusion, recovery of chemoreceptor function after carotid sinus nerve section appears to be associated with reinnervation of glomus tissue.

Effect of thiopentone, etomidate and propofol on carotid body chemoreceptor activity in the rabbit and the cat

The response of the carotid body chemoreceptors to intracarotid administration of thiopentone, etomidate and propofol was tested in the rabbit and cat. Thiopentone 3-6 mg min-1 and etomidate 300-600 micrograms min-1 were mildly excitatory, shifting the oxygen and carbon dioxide response curves upwards. Propofol 1.5-3.0 mg min-1 was a potent chemodepressant and abolished discharge at PaO2 values greater than 8 kPa. Prolonged infusion of propofol at higher rates (6 mg min-1) abolished the response to hypoxia completely. The significance of these results is discussed in relation to the known ventilatory effects of the three anaesthetics.

Effect of halothane, enflurane and isoflurane on carotid body chemoreceptor activity in the rabbit and the cat

The response of the carotid body chemoreceptors to administration of halothane, enflurane and isoflurane was tested in the rabbit and cat. In the steady-state all three volatile anaesthetics, in doses up to 1%, were mildly chemodepressant. The oxygen response curves were shifted downwards, but hypoxic stimuli below 5.3 kPa overcame this chemodepression. Two-point carbon dioxide response curves were also shifted downwards, but with no change in slope. Possible mechanisms involved in the chemoreceptor response to transient and steady-state anaesthetic administration are discussed.

Biophysical studies of the cellular elements of the rabbit carotid body

The carotid body is a major sensor of oxygen partial pressure in the arterial blood, and plays a role in the control of respiration. Despite extensive investigation of the structure, the cellular basis of the transduction mechanism remains poorly understood. We have developed a preparation of freshly dissociated cells from the rabbit carotid body, in which two cell types may be identified using morphological criteria. The preparation allows application of the patch clamp technique to characterize the properties of the cells which have otherwise proved difficult to study in situ. Carotid bodies of rabbits were dissociated using a combination of enzymatic and mechanical procedures. The dissociated preparation obtained consisted of clusters of spherical or ovoid cells of 12-15 microns in diameter and a distinct population of spherical cells of 8-10 microns diameter. Electron microscopic techniques were used to identify the cells present in the preparation. Again two populations of cells could be distinguished. A population of cells 10-12 microns in diameter, often found in clusters, possessed the dense-cored vesicles characteristic of Type I cells, while a population of smaller cells (diameter 5-7 microns) had peripherally condensed nuclear chromatin and fine cytoplasmic surface extensions characteristic of Type II cells. Patch clamp study of the cells showed that they represent two electrophysiologically distinct populations. The larger cells, corresponding to Type I cells, were found to be excitable, generating fast, sodium-dependent action potentials that were recorded both in the cell attached and whole cell recording configurations. The smaller Type II cells did not generate action potentials. Voltage clamp study of Type I cells allowed definition of a range of voltage-gated currents. These included an inactivating, tetrodotoxin-sensitive inward sodium current, a high threshold sustained inward calcium current, and outward potassium currents. A component of the outward current showed a dependence on voltage-gated calcium entry, and was blocked by cobalt or cadmium. Of the calcium-dependent current, a component was sensitive to apamin, and the remaining current was blocked by tetraethylammonium. Type II cells showed only a high threshold outward potassium current. These studies have thus revealed an electrophysiological differentiation that parallels the morphological differentiation of the cells of the carotid body. The Type I cell is essentially neuron-like in its properties, while the Type II cell appears to have properties resembling those of glial elements elsewhere in the nervous system.(ABSTRACT TRUNCATED AT 400 WORDS)

Performance of transcutaneous PO2 and PCO2 dual electrodes in adults

Three commercially-available combined PO2-PCO2 electrodes were assessed in vitro, and in adults breathing air, hypoxic and hypercapnic mixtures, for speed of response, correlation with end-tidal gas tensions and drift. Differences in the 90% response time of the individual electrodes were more marked in vitro than in vivo. Changes in end-tidal gas tensions were reflected by proportionate changes in transcutaneous oxygen and carbon dioxide (PtcO2 and PtcCO2) but, in the individual subject, PtcO2 and PtcCO2 were generally poor indicators of the end-tidal values. During steady-state recordings, the PtcO2 signal drifted upwards by more than 12 mm Hg during 140 min in vivo recording in all three electrodes, without changes in either PtcCO2 or end-tidal values. The dual electrodes tested provide non-invasive estimates of qualitative, but not quantitative, change in blood-gas tensions and are likely to have only a limited role to play in adult anaesthetic practice.

Comparison of a total intravenous anaesthetic technique using a propofol infusion, with an inhalational technique using enflurane for day case surgery

A total intravenous anaesthetic technique with a propofol infusion for maintenance of anaesthesia was compared with an inhalational technique that used oxygen, nitrous oxide and enflurane in 98 unpremedicated patients who presented for day case surgery. Overall quality of anaesthesia during induction and maintenance was comparable in both groups. Quality of maintenance of anaesthesia in the propofol group was improved by an increase of the initial infusion rate from 12 to 15 mg/kg/hour. There was a larger decrease in arterial blood pressure after induction in the propofol group but no difference in blood pressure between the groups during maintenance. Recovery times and scores using the Steward scoring system were not significantly different. Nausea and vomiting were slightly less frequent in the propofol group.