Muscle Protein Synthesis Following Protein Administration in Critical Illness

Rationale Dietary protein may attenuate the muscle atrophy experienced by patients in the Intensive Care Unit (ICU), yet protein handling is poorly understood. Objective To quantify protein digestion and amino acid absorption, and fasting and postprandial myofibrillar protein synthesis during critical illness. Methods Fifteen mechanically ventilated adults (12M; age 50±17y, Body Mass Index (BMI) 27±5kg·m-2) and 10 healthy controls (6M; 54±23y, BMI 27±4kg·m-2) received a primed intravenous L-[ring-2H5]-phenylalanine, L-[3,5-2H2]-tyrosine, and L-[1-13C]-leucine infusion over 9.5h, and a duodenal bolus of intrinsically-labelled (L-[1-13C]-phenylalanine and L-[1-13C]-leucine) intact milk protein (20g protein) over 60min. Arterial blood and muscle samples were taken at baseline (fasting) and for 6h following duodenal protein administration. Data are mean±SD; analysed with 2-way repeated measures ANOVA and independent samples t-test. Measurements and main results Fasting myofibrillar protein synthesis rates did not differ between ICU patients and healthy controls (0.023±0.013 vs 0.034±0.016%/h; P=0.077). Following protein administration, plasma amino acid availability did not differ between groups (ICU patients 54.2±9.1 vs healthy controls 61.8±13.1%; P=0.12), and myofibrillar protein synthesis rates increased in both groups (0.028±0.010 vs 0.043±0.018 %/h, main time effect P=0.046, P-interaction=0.584) with lower rates in ICU patients compared to healthy controls (main group effect P=0.001). Incorporation of protein-derived phenylalanine into myofibrillar protein was ~60% lower in ICU patients (0.007±0.007 vs 0.017±0.009 mole % excess (MPE); P=0.007). Conclusion The capacity for critically ill patients to use ingested protein for muscle protein synthesis is markedly blunted despite relatively normal protein digestion and amino acid absorption.

Transformation of Australian Community Pharmacies Into Good Clinical Practice Compliant Trial Pharmacies for HIV Pre-Exposure Prophylaxis

Background: In Australia, clinical trial drugs are conventionally dispensed through clinical trial pharmacies only, while community pharmacies dispense drugs approved by Australia’s regulatory body. A large HIV pre-exposure prophylaxis study aimed to deliver clinical trial drug through community pharmacies to improve convenience and mimic real world prescribing. This paper describes the process of making community trials compliant with good clinical practice and reports outcomes of delivering clinical trial drug through community pharmacies.

Methods: Eight community and four clinical trial pharmacies across three Australian states were approached to participate. A good clinical practice checklist was generated and pharmacies underwent a number of changes to meet clinical trial pharmacy requirements prior to study opening. Changes were made to community pharmacies to make them compliant with good clinical trial practice including; staff training, structural changes, and implementing monitoring of study drug and prescribing practices. Study drug was ordered through standard clinical trial processes and dispensed from study pharmacies by accredited pharmacists. Throughout the trial, record logs for training, prescriber signature and delegation, temperature, participant, and drug accountability were maintained at each pharmacy. The study team monitored each log and delivered on-site training to correct protocol variations.

Results: Each pharmacy that was approached agreed to participate. All community pharmacies achieved good clinical practice compliance prior to dispensing study drug. Over the course of the study, 20,152 dispensations of study drug occurred, 83% of these occurred at community pharmacies. Only 2.0% of dispensations had an error, and errors were predominantly minor. On five occasions a pharmacist who was not accredited dispensed study drug.

Conclusions: Community based pharmacies can undergo training and modifications to achieve good clinical practice compliance and dispense clinical trial study drug. Community based pharmacies recorded few variations from study protocol. Community based pharmacies offer a useful alternative to clinical trial pharmacies to increase convenience for study participants and expanded use of these pharmacies should be considered for large clinical trials, including HIV prevention trials.

Medical management of metastatic prostate cancer

Androgen deprivation therapy has an important role in the medical treatment of advanced and metastatic prostate cancer

The treatment of metastatic prostate cancer is influenced by whether the patient’s disease has progressed on androgen deprivation therapy or not It is considered to be castrate-resistant disease if the cancer has progressed despite adequate suppression of androgens

Chemotherapy using docetaxel or cabazitaxel and anti-androgen drugs such as abiraterone and enzalutamide can be used to treat castrate-resistant disease Radium-223 is an option for patients with bony metastases

Metastatic castrate-resistant prostate cancer is now considered a chronic illness as the life expectancy of patients has almost doubled due to the new treatments General practitioners are therefore more likely to encounter patients with disease- and treatment-related complications

Review article: consensus statements on therapeutic drug monitoring of anti-tumour necrosis factor therapy in inflammatory bowel diseases

BACKGROUND

Therapeutic drug monitoring (TDM) in inflammatory bowel disease (IBD) patients receiving anti-tumour necrosis factor (TNF) agents can help optimise outcomes. Consensus statements based on current evidence will help the development of treatment guidelines.

AIM

To develop evidence-based consensus statements for TDM-guided anti-TNF therapy in IBD.

METHODS

A committee of 25 Australian and international experts was assembled. The initial draft statements were produced following a systematic literature search. A modified Delphi technique was used with 3 iterations. Statements were modified according to anonymous voting and feedback at each iteration. Statements with 80% agreement without or with minor reservation were accepted.

RESULTS

22/24 statements met criteria for consensus. For anti-TNF agents, TDM should be performed upon treatment failure, following successful induction, when contemplating a drug holiday and periodically in clinical remission only when results would change management. To achieve clinical remission in luminal IBD, infliximab and adalimumab trough concentrations in the range of 3-8 and 5-12 μg/mL, respectively, were deemed appropriate. The range may differ for different disease phenotypes or treatment endpoints-such as fistulising disease or to achieve mucosal healing. In treatment failure, TDM may identify mechanisms to guide subsequent decision-making. In stable clinical response, TDM-guided dosing may avoid future relapse. Data indicate drug-tolerant anti-drug antibody assays do not offer an advantage over drug-sensitive assays. Further data are required prior to recommending TDM for non-anti-TNF biological agents.

CONCLUSION

Consensus statements support the role of TDM in optimising anti-TNF agents to treat IBD, especially in situations of treatment failure.

Functionalized Multi-Walled Carbon Nanotube Paper for Monitoring Chemical Vapors

The multi-walled carbon nanotube paper is prepared by vacuum filtration of pure nanotubes and their functionalized forms prepared by KMnO4 and H2O2 oxidation or by grafting with Poly(methyl methacrylate) (PMMA) and polypyrrole to form sensory nanotubes layer for detection of volatile organic compounds in air. The selected compounds for experimentation (acetone, diethyl ether, isopentane, methanol, tetrahydrofuran) have different polarities and volume fractions of saturated vapors. The sensing is measured by electrical resistance of the paper, which increases when exposed to vapors. A reversible reaction is observed when the paper is removed from the vapors. The functionalized nanotubes differ in their sensitivity to selected organics solvents. For example, KMnO4 oxidized paper has differentiated response to all used vapors, so the measured data may indicate clearly the type of the vapor. On the other hand, the MWCNT/PMMA composite has nearly the same response to acetone, diethyl ether and tetrahydrofuran and different response to isopentane and methanol. The investigation can lead to construction of sensory unit which could be capable of detecting and identifying different vapors in the air.

High sensitivity of a carbon nanowall-based sensor for detection of organic vapours

The high sensitivity in response, selectivity and reversibility was achieved on a carbon nanowall-based sensor for the vapor detection of volatile organic compounds, which were tested by an electrical resistance method during adsorption and desorption cycles.

Suppression of parathyroid hormone and bone resorption by calcium carbonate and calcium citrate in postmenopausal women

This study was conducted to compare the suppressive effects of calcium carbonate and calcium citrate on bone resorption in early postmenopause. Calcium citrate is thought to be better absorbed. We therefore tested the hypothesis that calcium as citrate is more effective than calcium as carbonate in suppressing parathyroid hormone (PTH) and C-terminal telopeptide. Twenty-five healthy postmenopausal women were recruited in this double blind crossover study. The subjects were randomly allocated to receive either 1,000 mg of elemental calcium as carbonate or 500 mg of calcium as citrate. They were given the alternate calcium dose 1 week later. Serum measurements of total and ionized calcium, phosphate, PTH, and CrossLaps were repeated 12 hours after each dose. Analysis of variance found no significant difference between measures for the two salts. Tests for equivalence indicated that 500 mg of calcium citrate may be superior to 1,000 mg of calcium carbonate in raising serum total and ionized calcium (P = 0.04 and 0.05, respectively). For all parameters measured, 500 mg of calcium citrate was at least as beneficial as 1,000 mg of calcium carbonate. Calcium citrate is at least as effective as calcium carbonate in suppressing PTH and C-terminal telopeptide cross-links, at half the dose. This may be because calcium as citrate is better absorbed than calcium as carbonate. If calcium citrate can be used in lower doses, it may be better tolerated than calcium carbonate.

A system for improving vitamin D nutrition in residential care

OBJECTIVE

To assess the feasibility of administering an inexpensive preparation of vitamin D(3) 100 000 IU orally 3 monthly to aged-care residents.

DESIGN

Prospective, controlled open-label implementation trial.

SETTING

Residential aged care, November 2003 to May 2004 (primary study).

PARTICIPANTS

137 ambulant residents: 107 treated (mean age, 85 years; 79 were women), 30 untreated controls (mean age, 87 years; 22 were women).

INTERVENTIONS

Lactose microencapsulated vitamin D(3) 100 000 IU orally at baseline, then 3 monthly (three or more doses); untreated subjects were observed contemporaneously.

MAIN OUTCOME MEASURES

Serum levels of 25-hydroxyvitamin D [25(OH)D] at 6 months compared with baseline; acceptability of the program to residents and staff.

RESULTS

At baseline, 95% of residents assessed (n = 137) had serum 25(OH)D levels below the desirable range of 60-160 nmol/L. At 6 months, all treated residents (n = 98) achieved desired levels, with the mean (+/- SD) 25(OH)D level increasing from 36.4 +/- 12.6 nmol/L (range, 12-75 nmol/L) at baseline to 124.0 +/- 27.9 nmol/L (range, 68-244 nmol/L). In no resident did 25(OH)D approach toxic levels. The mean serum 25(OH)D level remained low in the control group (n = 27): 42.8 +/- 18.3 nmol/L (range, 18-98 nmol/L). The difference between the mean 25(OH)D levels of treatment and control groups at 6 months was 81.2 nmol/L (95% CI, 69.7-92.0 nmol/L). The cost of the supplement was $4 per resident per annum. Substudies showed mean trough serum 25(OH)D levels in the desired range at 3 months (n = 31), but below the desired range at 6 months (n = 50). Subjects given 3-monthly doses for up to 2 years maintained serum 25(OH)D levels within the desired range, with no trend toward undesirable accumulation (n = 11).

CONCLUSIONS

Vitamin D(3) 100 000 IU given orally 3 monthly is a practical, safe, effective and inexpensive way to meet the vitamin D(3) requirements of aged-care residents.

A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL OF PSEUDOEPHEDRINE IN CORYZA

1. The aim of the present study was to assess the efficacy of pseudoephedrine in coryza. 2. In a double-blind, randomized, placebo-controlled design, 48 adults with acute coryza received a single oral dose of 60 mg pseudoephedrine (Sudafed; Pfizer Consumer HealthCare Group, Caringbah, NSW, Australia) or matching placebo. Before and after dosing, nasal airway resistance (NAR), nasal volume, the minimum intranasal cross-sectional area (MCA) and the symptom of nasal congestion were measured. 3. Pseudoephedrine produced a significant decrease in NAR (P = 0.005; 95% confidence interval (CI) 0.073, 0.383). Nasal volume increased, but this did not reach significance (P = 0.07; 95% CI -0.842, 0.034). There was no change in MCA and symptoms. 4. In conclusion, pseudoephedrine has a moderate effect in decreasing objective measures of nasal congestion in coryza.

Payment by salary or fee-for-service. Effect on health care resource use in the last year of life

OBJECTIVE

To investigate the effect of physician payment method on use of health care resources.

DESIGN

Retrospective analysis of patient health care data collected for 3 years (1994 to 1996) from the Vital Statistics Department of the British Columbia Ministry of Health. Billing numbers identified physician payment method.

SETTING

Salaried and fee-for-service primary care practices in the Capital Region District of Victoria, BC.

PARTICIPANTS

A total of 582 patients in their last year of life: 106 were attended by salaried family physicians at a community health clinic; 476 were attended by fee-for-service practitioners. Groups were comparable in age, sex, and geographical location.

MAIN OUTCOME MEASURES

Number and cost of specialist and diagnostic services and medications, number of days in hospital (acute and extended care), and main causes of death.

RESULTS

None of the dependent measures showed any statistically significant differences based on comparisons between many variables for patients in the two groups. Costs of pharmaceutical, specialist, and diagnostic services were not significantly different for the two groups. There were three main causes of death, according to codes on death certificates: heart disease, malignant neoplasms, and cerebrovascular disease.

CONCLUSION

Whether physicians were paid by salary or fee-for-service had no empirical effect on health care resource use.