Pediatric to Adult Transition Literature: Scoping Review and Rheumatology Research Prioritization Survey Results

The transition from pediatric to adult care is the focus of growing research. It is important to identify how to direct future research efforts for maximum effect. Our goals were to perform a scoping review of the transition literature, highlight gaps in transition research, and offer stakeholder guidance on the importance and feasibility of research questions designed to fill identified gaps. The transition literature on rheumatic diseases and other common pediatric-onset chronic diseases was grouped and summarized. Based on the findings, a survey was developed and disseminated to pediatric rheumatologists and young adults with rheumatic diseases as well as their caregivers. The transitional care needs of patients, healthcare teams, and caregivers is well described in the literature. While various transition readiness scales exist, no longitudinal posttransfer study confirms their predictive validity. Multiple outcome measures are used alone or in combination to define a successful transition or intervention. Multimodal interventions are most effective at improving transition-related outcomes. How broader health policy affects transition is poorly studied. Research questions that ranked highest for importance and feasibility included those related to identifying and tracking persons with psychosocial vulnerabilities or other risk factors for poor outcomes. Interventions surrounding improving self-efficacy and health literacy were also ranked highly. In contrast to healthcare teams (n = 107), young adults/caregivers (n = 23) prioritized research surrounding improved work, school, or social function. The relevant transition literature is summarized and future research questions prioritized, including the creation of processes to identify and support young adults vulnerable to poor outcomes.

A case of prolidase deficiency in a male patient

Prolidase deficiency is an extremely rare, autosomal recessive disorder resulting in defective collagen formation. We report a case of prolidase deficiency in a male child, highlighting the dermatologic features. Early diagnosis is important as these patients encounter significant multisystem comorbidities requiring multispecialty care.

Changes over time in inflammatory and structural lesions at the sacroiliac joint in children with spondyloarthritis exposed and unexposed to tumor necrosis factor inhibitor

BACKGROUND

The objective of this work was to describe magnetic resonance imaging (MRI) changes over time in inflammatory and structural lesions at the sacroiliac joint (SIJ) in children with spondyloarthritis (SpA) exposed and unexposed to tumor necrosis factor inhibitor (TNFi).

METHODS

This was a retrospective, multicenter study of SpA patients with suspected or confirmed sacroiliitis who underwent at ≥2 pelvic MRI scans. Images were reviewed independently by 3 radiologists and scored for inflammatory and structural changes using the Spondyloarthritis Research Consortium of Canada (SPARCC) SIJ inflammation score (SIS) and structural score (SSS). Longitudinal, quantitative changes in patient MRI scans were measured using descriptive statistics and stratified by TNFi exposure. We used an average treatment effects (ATE) regression model to explore the average effect of TNFi exposure over time on inflammatory and structural lesions, adjusting for baseline lesion scores.

RESULTS

Forty-six subjects were evaluated using the SIS (n = 45) and SSS (n = 18). Median age at baseline imaging was 13.6 years, 63% were male and 71% were white. Twenty-three subjects (50%) were TNFi exposed between MRI studies. The median change in SIS in TNFi exposed and unexposed subjects with a baseline SIS ≥0 was - 20.7 and - 14.3, respectively (p = 0.09). Eleven (85%) TNFi exposed and 8 (89%) unexposed subjects with a baseline SIS ≥0 met the SIS minimal clinically important difference (MCID; ≥2.5). Using the ATE model adjusted for baseline SIS, the average effect of TNFi on SIS in patients with a baseline SIS ≥2 was - 14.5 (p < 0.01). Unadjusted erosion change score was significantly worse in TNFi unexposed versus exposed subjects (p = 0.03) but in the ATE model the effect of TNFi was not significant.

CONCLUSION

This study quantitatively describes how lesions in the SIJs on MRI change over time in patients exposed to TNFi versus unexposed. Follow-up imaging in TNFi exposed patients showed greater improvement than the unexposed group by most metrics, some of which reached statistical significance. Surprisingly, a majority of TNFi unexposed children with a baseline SIS≥2 met the SIS MCID. Additional studies assessing the short and long-term effects of TNFi on inflammatory and structural changes in juvenile SpA are needed.

Effect of first-line biologic initiation on glucocorticoid exposure in children hospitalized with new-onset systemic juvenile idiopathic arthritis: emulation of a pragmatic trial using observational data

BACKGROUND

Glucocorticoid exposure is a significant driver of morbidity in children with systemic juvenile idiopathic arthritis (sJIA). We determined the effect of early initiation of biologic therapy (IL-1 or IL-6 inhibition) on glucocorticoid exposure in hospitalized patients with new-onset sJIA.

METHODS

We emulated a pragmatic sequence of trials ("pseudo-trials") of biologic initiation in children (≤ 18 years) hospitalized with new-onset sJIA utilizing retrospective data from an administrative database from 52 tertiary care children's hospitals from 2008 to 2019. Eligibility window, treatment assignment and start of follow-up between biologic and non-biologic study arms were aligned for each pseudo-trial. Patients in the source population could meet eligibility criteria at several timepoints. Mixed-effects logistic regression was used to determine the effect of biologic initiation on in-hospital glucocorticoid exposure.

RESULTS

Four hundred sixty-eight children met eligibility criteria, of which 19% received biologic therapy without preceding or concomitant initiation of immunomodulatory medications. This proportion significantly increased over time during the study period (p <  0.01). 1451 trial subjects were included across 4 pseudo-trials with 71 assigned to the biologic arm and 1380 assigned to the non-biologic arm. After adjustment, there was a trend toward decreased odds of glucocorticoid initiation in the biologic arm compared to the non-biologic arm (OR 0.39, 95% CI [0.13, 1.15]).

CONCLUSION

Biologic initiation in children hospitalized with new-onset sJIA significantly increased over time and may be associated with reduced glucocorticoid exposure. The increasing use of first-line biologic therapy may lead to clinically relevant reductions in treatment-related adverse effects of glucocorticoid-reliant therapeutic approaches.

Variation in treatment of children hospitalized with new-onset systemic juvenile idiopathic arthritis in the United States

OBJECTIVE

Increasing evidence supports that early initiation of biologics may dramatically improve disease course and reduce glucocorticoid exposure for children with systemic juvenile idiopathic arthritis (JIA). We characterized variation in the use of first-line biologic and glucocorticoid therapy and identified drivers of variation in children hospitalized with new-onset systemic JIA.

METHODS

We conducted a retrospective cohort study of children hospitalized with new-onset systemic JIA from 2008-2019 utilizing a comparative pediatric database from 52 tertiary care children's hospitals. Subjects and treatment receipt were identified using International Classification of Diseases (ICD)-9 and ICD-10 discharge diagnosis codes, pharmacy billing data and clinical transaction classification codes. Mixed-effects logistic regression was used to identify patient and hospital-level factors associated with receipt of glucocorticoids and biologics.

RESULTS

534 children with new-onset systemic JIA hospitalized during the study period met inclusion criteria. Twenty-nine percent received biologics and 58% received glucocorticoids. Biologic use increased over time (p < 0.001), methotrexate use decreased (p < 0.01), and glucocorticoid use remained unchanged. Biologics and glucocorticoid use varied significantly between hospitals. High annual hospital volume, intensive care unit stay, and later discharge year were significantly associated with biologic exposure. Medium-high and high annual hospital volume were significantly associated with less glucocorticoid exposure.

CONCLUSION

Despite increasing evidence demonstrating improved outcomes with first-line treatment with biologics, we found significant treatment variation across hospitals with many children not receiving biologics and a persistent high rate of glucocorticoid exposure. These results underscore the need for comparative efficacy studies and improved treatment standardization.

Soy protein influences the development of the metabolic syndrome in male obese ZDFxSHHF rats

Previous investigations have demonstrated a marked effect of soy protein on the metabolic syndrome (MS). The purpose of this preliminary study was to identify the effects of soy-based diets on male obese ZDFxSHHF (fa/ fa-cp/?) rats. Animals were randomly assigned to one of four diets: control, casein (C); low-isoflavone (LIS) soy protein; high-isoflavone (HIS) soy protein; or casein + rosiglitazone (CR). Physiological, biochemical, and molecular parameters were determined at sacrifice. Body weight (p < 0.01) and food intake (p < 0.05) were lower in LIS-fed rodents. Rosiglitazone-treated animals had higher body weight and adiposity (p < 0.05). LIS and CR groups exhibited better glycemic control (p < 0.05), but with a limited effect in rosiglitazone-treated animals. HIS fed rats had higher glucose and triacylglyceride levels (p < 0.01), and lower plasma insulin (p < 0.01). Renal function parameters with the exception of an increase in systolic blood pressure (p < 0.05) were all suppressed in the LIS group (p < 0.01). The CR group had twofold PPARalpha and PPARgamma mRNA abundance (p < 0.01). LIS-fed animals also exhibited greater abundance of PPARgamma mRNA (p < 0.001), and nearly threefold FAS and CPT-1 mRNA levels (p < 0.05). HIS-fed rats also had higher abundance of CPT-1 mRNA, as well as a lower abundance of ACC mRNA (p < 0.05). Soy-based diets, influenced by isoflavone content and distinct from rosiglitazone, improved several metabolic parameters in obese ZDFxSHHF rats.

Soy protein influences insulin sensitivity and cardiovascular risk in male lean SHHF rats

Previous investigations have demonstrated a marked effect of soy protein on multiple physiological parameters associated with the metabolic syndrome (MS). This preliminary study investigated the physiological effects of soy-based diets on cardiovascular risk in a unique rodent model that reflects early stages of MS. Briefly, lean male SHHF (+/cp) rats were randomly assigned to the following treatment groups: casein (control, C); low-isoflavone (LIS) soy protein isolate; high-isoflavone (HIS) soy protein isolate; or C+ 0.01 % rosiglitazone (CR). Rats were fed for thirty-six weeks. Liver weight, heart weight, total plasma cholesterol, fasting blood glucose were lower in soy-fed animals compared to control (p < 0.01). Body weight, kidney weight, alanine aminotransferase (ALT), fasting plasma insulin, and homeostasis model assessment (HOMA) score were also lower in LIS-fed rodents (p < 0.05) compared to casein treatment. All diet groups exhibited lower urine protein (p < 0.01) and small arteriole content (p < 0.05) compared to controls. LIS feed had a slightly more profound influence on body weight, liver metabolism, and insulin sensitivity. However, both soy diets exhibited marked improvements over a casein-based diet.

Suprarenal intraarterial infusion of alloxan and streptozotocin during balloon occlusion of the juxtarenal abdominal aorta: a simple technique for inducing diabetes mellitus in canines with reduced mortality

RATIONALE AND OBJECTIVES

The authors performed this study to evaluate the mortality and morbidity associated with a simple technique for inducing diabetes in dogs--suprarenal intraarterial infusion of alloxan and streptozotocin during balloon occlusion of the juxtarenal abdominal aorta.

MATERIALS AND METHODS

The authors attempted to induce diabetes in six purpose-bred dogs. After the dogs were fasted for 12 hours, the abdominal aorta at the level of the origin of the renal arteries was occluded with an angioplasty balloon introduced by means of a femoral approach. A 3-F microcatheter (n = 1) or infusion wire (n = 5) was introduced via the percutaneous transluminal angioplasty catheter and positioned at the level of the celiac axis, and a mixture of streptozotocin (20-25 mg/kg) and alloxan (20-25 mg/kg) was infused. Diabetes was considered to have been induced if the dogs experienced sustained hyperglycemia.

RESULTS

There were no deaths during the follow-up period (range, 7 months to 2 1/2 years). A diabetes-like state was induced in five of the six dogs, and no nephrotoxicity was seen. Diabetes was not induced in one dog owing to caudal migration of an undersized balloon during the infusion; this also resulted in reversible renal damage.

CONCLUSION

This simple technique is effective for inducing diabetes in dogs, and morbidity and mortality rates are lower than those reported in the literature with other described techniques.

Acarbose partially inhibits microvascular retinopathy in the Zucker Diabetic Fatty rat (ZDF/Gmi-fa)

We compared quantitative capillary retinopathic changes between non-insulin-dependent diabetic Zucker Diabetic Fatty (ZDF) rats and heterozygous nondiabetic Zucker controls and evaluated the effect of an orally administered glucosidase inhibitor, acarbose, on retinopathy in these animals. Four groups of eight rats were analyzed: treated and untreated ZDF and treated and untreated Zuckers. Retinal capillary basement membrane thickening and retinal capillary cell density were determined from transmission electron microscopy and trypsin digestion preparations. ZDF rats had thicker basement membranes (p<0.0001) and more cells per unit capillary length (p=0.0003) compared to Zuckers. Acarbose treatment significantly reduced basement membrane thickening in the treated ZDF rats (p=0.001), but the effects on cell density showed only a favorable trend. Acarbose treatment has an ameliorative effect on the development of microvascular retinopathy in the ZDF rat, probably due to lessening of hyperglycemia.

Effects of hypoxia and severity of diabetes on Na,K-ATPase activity and arachidonoyl-containing glycerophospholipid molecular species in nerve from streptozotocin diabetic rats

The pathogenesis of experimental diabetic neuropathy is associated with the development of endoneurial hypoxia. Exposure of normal rats to hypoxic conditions has previously been shown to reduce nerve conduction velocity. To study the biochemical effects of hypoxia further, streptozotocin-induced diabetic and age-matched nondiabetic rats were maintained in air containing 10% oxygen for nine weeks. As compared to nondiabetic rats kept in room air, sciatic nerve Na,K-ATPase activity was decreased 38% in nondiabetic, hypoxic rats and tended to be lower in diabetic animals maintained in a normoxic environment. However, the enzyme activity was unchanged in diabetic, hypoxic rats, suggesting the existence of an undefined compensatory interaction between these two conditions. Arachidonoyl-containing molecular species (ACMS) of phosphatidylcholine and phosphatidylethanolamine were substantially depleted in nerves from diabetic rats. Hypoxia alone also caused a lesser depletion of some but not all of these ACMS. However, the two conditions together did not produce a further decrease, consistent with the concept that the same mechanism is responsible for loss of ACMS in hypoxia and diabetes. To examine the effects of severity of diabetes on these parameters, groups of rats were injected with either 50 mg/kg or 100 mg/kg streptozotocin. The latter group was maintained by administration of minimal insulin doses and the experiment was terminated after 3 weeks. Serum glucose in rats that received the high dose of drug averaged 12% higher than in the low dose group. As compared to nondiabetic rats, Na,K-ATPase activity was reduced 32-36%, but there was no difference in activity between the two diabetic groups. However, there was a greater loss of ACMS in the more severely hyperglycemic rats. In rats that received comparable streptozotocin doses, measurement of ACMS depletion after 3, 9 and 32 weeks of diabetes revealed the loss is progressive with time. Thus, glycerophospholipid ACMS is a sensitive index of the severity and duration of experimental diabetic neuropathy.

Effect of dietary fat on the development of non-insulin dependent diabetes mellitus in obese Zucker diabetic fatty male and female rats

The obese Zucker diabetic fatty male rat (ZDF/Gmi¿trade mark omitted¿-fa) has become a widely used animal model of NIDDM, in contrast to the obese ZDF females that rarely develop NIDDM. However, preliminary observations suggest that obese ZDF females may become diabetic on high-fat diets. Therefore, we studied the effect of dietary fat on development of NIDDM, dyslipidemia, and alterations in organ-specific serum panels in obese ZDF males and females. Results indicated different effects of dietary fat-content on development of diabetes in males and females. Males, even on low fat-content diets, developed diabetes but the process was accelerated as a function of dietary fat-content, whereas only the highest fat-content diet induced development of NIDDM in obese ZDF females. Additionally, triglyceride/apolipoprotein B ratios demonstrated gender-specific differences in the nature of circulating lipoprotein particles independent of diabetic state with values for females approximately twice those of males indicating more highly triglyceride-enriched lipoprotein particles in females. We conclude that the obese ZDF female rat has the potential to become an important animal model of NIDDM especially in women where few models currently exist.

Lipoprotein alterations in 10- and 20-week-old Zucker diabetic fatty rats: hyperinsulinemic versus insulinopenic hyperglycemia

Lipoprotein and apolipoprotein parameters were studied in the male Zucker diabetic fatty (ZDF) rat at 10 and 20 weeks of age, corresponding to hyperinsulinemic and insulinopenic type 2 diabetes mellitus, respectively. At both ages, ZDF rats had elevated serum triglycerides, free fatty acids, and corticosterone, whereas 20-week ZDF rats had reduced thyroid hormones. At 10 weeks, the hyperlipidemia was confined to elevations in pre-beta triglyceride-rich (d < 1.006 g/mL) lipoproteins. By 20 weeks, all lipoprotein density fractions were increased compared with lean rats, with substantial increases in both low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol. In ZDF rats, there was a progressive increase in apolipoprotein B (apo B) from 1.9 times control at 10 weeks to three times control at 20 weeks. The increase in apo B was accompanied by a shift of apo B, particularly B100, from very-low-density lipoprotein (VLDL) into denser lipoproteins corresponding to intermediate-density lipoproteins plus LDLs (1.006 < d < 1.063 g/mL). In Zucker and 10-week ZDF rats, in the presence of hyperinsulinemia, the increase in serum apo B was predominantly apo B48 present in VLDL. By 20 weeks, when ZDF rats are insulinopenic, the mass ratio of B48:B100 shifted from 2.7 to 0.7. The shift was associated with a decrease in hepatic-edited apo B mRNA. Apo E increased in lean rats between 10 and 20 weeks of age. Although apo E also increased in ZDF rats, the increase by 20 weeks was less than that of lean rats. The molar ratio of apo E to B in VLDL was decreased in ZDF rats. In lean rats, greater than 50% of apo E was present in HDL, in contrast to ZDF rats, where less than 20% of apo E was present in HDL. VLDL apo E shifted to denser fractions by 20 weeks of age, similar to apo B. The apo C level was more than double compared with the level in lean rats and was redistributed from the HDL fraction to lipoprotein fractions containing apo B. Both apo A-I and apo A-IV levels more than doubled between 10 and 20 weeks in ZDF rats. The ZDF rat model may be useful in comparative studies of lipoproteins during diabetic progression from hyperinsulinemia to insulinopenia.

Topical versus intravenous administration of tranexamic acid: a comparison of intraocular and serum concentrations in the rabbit

BACKGROUND

Tranexamic acid has been shown to greatly reduce the incidence of secondary hemorrhage when administered orally or intravenously. Topical administration of the drug should result in much lower serum concentrations, with fewer adverse effects. We performed a study to determine whether topical application of tranexamic acid would yield higher intraocular concentrations and lower serum concentrations of drug than intravenous administration.

METHODS

Ten New Zealand white rabbits received 25 mg/kg of tranexamic acid intravenously every 8 hours for 3 days. Another group of 10 rabbits received one drop (0.05 mL) of commercially available tranexamic acid solution (100 mg/mL) every 8 hours for 3 days to one eye. Tranexamic acid levels in the aqueous humour, vitreous humour and serum 1 hour after administration of the last dose of drug were determined.

RESULTS

Analysis of variance showed that aqueous concentrations of tranexamic acid were significantly higher with topical delivery than with intravenous administration (15 vs. 9 micrograms/mL)(p < 0.05). Serum concentrations were significantly lower following topical administration (9 vs. 19 micrograms/mL)(p < 0.01). The drug was not detected in the vitreous humour in either group.

INTERPRETATION

Topical delivery of tranexamic acid may prove to be valuable in yielding therapeutic intraocular concentrations of drug in patients with hyphema while minimizing systemic toxicity.

The effect of glucose and glucagon-like peptide-1 stimulation on insulin release in the perfused pancreas in a non-insulin-dependent diabetes mellitus animal model

This study was designed to investigate the effect of glucogon-like peptide-1 (GLP-1) on pancreatic beta-cell function in normal, Zucker diabetic fatty (ZDF) rats, a model for non-insulin-dependent diabetes mellitus (NIDDM or type II diabetes) and their heterozygous siblings. Pancreas perfusion and enzyme-linked immunosorbent assay (ELISA) were used to detect the changes in insulin release under fasting and hyperglycemic conditions and following stimulation with GLP-1. Animals from the ZDF/Gmi-fa rats (ZDF) were grouped according to age, sex, and phenotype (obese or lean), and compared with LA lean rats. Glucose stimulation (10 mmol/L) in obese rats showed repressed response in insulin release. Glucose plus GLP-1 stimulation caused increased insulin release in all groups. The degree of this response differed between groups: lean > obese; young > adult; female > male. The LA lean control group was most sensitive, while the ZDF overtly diabetic group had the lowest response. In addition, the pulsatile pattern of insulin secretion was suppressed in ZDF rats, especially in obese groups. These results support the hypothesis that GLP-1 can effectively stimulate insulin secretion. Insulin release was defective in ZDF obese rats and could be partially restored with GLP-1. ZDF lean rats also showed suppression of beta-cell function and there was a difference in beta-cell function related to sex in ZDF strain. This study documents the efficacy of GLP-1 to stimulate insulin release and contributes to our understanding of the pathophysiological mechanisms underlying NIDDM.

Evening primrose oil treatment corrects reduced conduction velocity but not depletion of arachidonic acid in nerve from streptozotocin-induced diabetic rats

The effects of evening primrose oil (EPO) treatment, a source of gamma-linolenic acid, on the proportions of arachidonoyl-containing molecular species (ACMS) in sciatic nerve phosphatidylcholine and phosphatidylethanolamine were determined in conjunction with alterations in nerve conduction velocity. Normal and diabetic rats were either untreated or fed a dietary supplement containing isocalorically equivalent amounts of either EPO or corn oil for the duration of the experiment. After 8 weeks of streptozotocin-induced diabetes, nerve conduction velocity was reduced 16% and this deficit was prevented by either EPO or corn oil treatment. Neither EPO nor corn oil supplementation significantly increased the depressed proportions of ACMS. The level of the linoleoyl-containing molecular species, 16:0/18:2, was elevated in the phospholipids from untreated diabetic rats and was further increased by EPO treatment. These results are consistent with decreased activity of the delta6 desaturase that is required for arachidonic acid synthesis in vivo, but suggests that an accompanying deficit in the subsequent delta5 desaturase-catalyzed reaction may be rate-limiting. These findings indicate that maintenance of normal ACMS levels is not required for prevention of diminished nerve conduction velocity and suggest that other factors influenced by an altered polyunsaturated fatty acid pattern, such as metabolites of linoleic acid or gamma-linolenic acid other than arachidonic acid, the energy state of the nerve or the degree of membrane fluidity may contribute to impaired nerve conduction velocity in diabetic neuropathy.

Overexpression of GLUT2 gene in renal proximal tubules of diabetic Zucker rats

Renal tubular reabsorption of glucose is substantially increased in humans and rats with diabetes mellitus. The influx of luminal glucose is mediated by Na+/glucose cotransporter system and glucose efflux from tubules to interstitium by facilitative glucose transporters (GLUT). In Zucker diabetic rats, GLUT2 protein levels of renal proximal tubules were higher than in control litter mates: 9.67 +/- 1.95 versus 4.72 +/- 1.55 (P = 0.0073). In the same proximal tubules, diabetes was associated with minor decreases in GLUT1 protein levels: 1.96 +/- 0.37 for diabetics and 2.37 +/- 0.34 for controls (P = 0.12). Na+/glucose cotransporter system protein levels were similar in both groups, whereas Na+/K+ ATPase levels were slightly decreased in diabetic rats, but the difference was not statistically significant. In this report, it is suggested that in long-term uncontrolled diabetes, GLUT2 transporters are overexpressed in renal tubules. This adaptation promotes low-affinity, high-capacity glucose efflux. The higher number of high K(m) GLUT2 ensures that glucose reabsorption is increased by promoting glucose efflux, which could be rate-limiting in the face of hyperglycemia.

Incretin hormone expression in the gut of diabetic mice and rats

To elucidate the question of whether production of the insulinotropic gut hormones glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) is altered by a diabetic metabolic state, their intestinal expression pattern was evaluated. Two rodent models for diabetes mellitus were used, non-obese diabetic (NOD) mice as a model for insulin-dependent diabetes and Zucker diabetic fatty (ZDF) rats for non-insulin-dependent diabetes mellitus (NIDDM). Expression of both incretin hormones followed typical patterns, which were similar in both animals and unaltered by the diabetic state. The GIP gene was greatly expressed in the duodenum, jejunum, and ileum, with a continuous decrease from the upper to lower intestines. This pattern was observed in both NOD mice and ZDF rats regardless of the diabetic state. This expression data was corroborated by radioimmunoassay (RIA) analysis of the gene product GIP. Expression of the proglucagon gene encoding GLP-1 had an opposite appearance. The highest expression was seen in the large bowel and the ileum. RIA analysis of the gene product GLP-1 mirrored these data. Although the distribution pattern was similar in both animal models, in contrast to diabetic NOD mice, a regulated expression was found in diabetic ZDF rats. Compared with lean nondiabetic controls, fatty hyperglycemic animals showed an increased expression of the proglucagon gene in the colon and a concomitant reduction in the small intestine. This was mirrored by the GLP-1 content of the colon and ileum. Overall, basal GLP-1 plasma levels were increased in ZDF rats (17.0 +/- 2.8 pmol) compared with lean Zucker rats (12.4 +/- 1.8 pmol). In conclusion, incretin hormone expression (GIP and GLP-1) follows specific patterns throughout the gut and is unaltered by the diabetic state. In ZDF rats, regulation of proglucagon expression occurs mainly in the large intestine.

Angiotensin-converting enzyme activity in retinas of streptozotocin-induced and Zucker diabetic rats. The effect of angiotensin II on Na+,K(+)-ATPase activity

PURPOSE

To investigate whether serum and/or retinal angiotensin-converting enzyme (ACE) activity might correlate with the decrease in sodium potassium adenosine triphosphatase (Na,K-ATPase) activity in the retina of experimentally diabetic rats.

METHODS

Insulin-dependent diabetes mellitus was induced by a single intraperitoneal injection of streptozotocin (STZ) in male Sprague-Dawley rats. Male Zucker fatty diabetic (ZDF/Gmifa) rats were used as models of non-insulin-dependent diabetes mellitus. ACE activity in the serum and retina of diabetic rats (1 through 5 months) and age-matched control animals was measured by radioimmunoassay using benzoyl-gly-gly-gly as substrate. The activity of total Na,K-ATPase was determined spectrophotometrically. The alpha 1 and alpha 3 isozymes of Na,K-ATPase were distinguished pharmacologically by their differential sensitivity to ouabain and were measured in the retina.

RESULTS

Serum ACE activity was significantly increased in rats with STZ-induced diabetes at 3 weeks through 4 months of diabetes (28% to 32%) but was significantly decreased in ZDF rats after 2 to 5 months of diabetes (-9% to -16%). The activity of ACE in retinas obtained from the same groups of STZ and ZDF rats was significantly reduced at all time points examined in both models (-43% and -55%, respectively). The effect of angiotensin II (AngII) on the activity of Na,K-ATPase in retinas from normal rats was also studied in vitro. AngII significantly lowered the activities of total Na,K-ATPase (-16%) and its alpha 1 and alpha 3 isozymes. The inhibitory effect of AngII was abolished completely by losartan (0.1 microM), a specific antagonist of the AT1 receptor-subtype of AngII, and by nordihydroguaiaretic acid (50 microM), which at this concentration inhibits the lipoxygenase and cytochrome P-450-dependent pathways of arachidonic acid metabolism. The inhibitory effect of AngII on the Na,K-ATPase activity was not altered significantly by NG-iminoethyl ornithine (10 microM), an irreversible nitric oxide synthase inhibitor.

CONCLUSIONS

The authors suggest that systemic ACE probably is not involved in the mechanisms responsible for the reduced activity of Na,K-ATPase in diabetes. Although AngII inhibits retinal Na,K-ATPase by a mechanism possibly involving arachidonic acid metabolites, it is unlikely that AngII contributes to the decreased Na,K-ATPase activity because of its reduced formation by retinal ACE in diabetes. The possible importance of reduced retinal ACE activity in diabetes warrants further investigation.

An aldose reductase inhibitor but not myo-inositol blocks enhanced polyphosphoinositide turnover in peripheral nerve from diabetic rats

Experimental diabetic neuropathy, whether chemically induced or present in several spontaneously diabetic animal models, is characterized by sorbitol accumulation and myo-inositol depletion and usually also by enhanced turnover of the monoesterified moieties of polyphosphoinositides, particularly phosphatidylinositol-4,5-bisphosphate (PIP2). This study examined the relationship of these alterations by assessing the effects of myo-inositol and the aldose reductase inhibitor, sorbinil, supplied as dietary supplements, on sorbitol and myo-inositol concentrations and incorporation of 32P into polyphosphoinositides in sciatic nerve from rats killed 8 weeks after induction of diabetes with streptozotocin. Nerves from diabetic rats killed after 8 weeks of disease exhibited 52% to 76% greater PIP2 labeling, markedly elevated sorbitol levels, and 30% less myo-inositol when compared with age-matched normal rats. Incorporation of isotope into PIP2 in nerves from animals fed a myo-inositol supplement, added to either a high-sucrose diet or standard rat chow beginning immediately after induction of diabetes, remained substantially elevated, whereas myo-inositol levels were corrected to normal. Essentially the same results were obtained when rats were fed the myo-inositol-containing diet beginning 4 weeks after streptozotocin injection. In contrast, PIP2 labeling in nerves from diabetic rats that received the sorbinil-supplemented diet for either 4 or 8 weeks was not different from that in controls. myo-Inositol levels in these animals were also restored to normal, whereas sorbitol levels remained elevated, albeit reduced by approximately 30%. These results indicate that myo-inositol administration is unable to completely counteract the impact of diabetes on the turnover of monoesterified phosphate groups in PIP2. In contrast, sorbinil can correct this abnormality, but this beneficial effect is not dependent on the presence of normal sorbitol concentrations.

alpha-Glucosidase inhibitors in diabetes: lessons from animal studies

Two rat models for non-insulin-dependent diabetes mellitus (NIDDM) have been used in our laboratory to study the effects of alpha-glucosidase inhibitors. These models become hyperglycaemic and have other characteristics which make them good models for NIDDM, and both prevention and reversal studies have been carried out; the prevention experiments were started before the animal became diabetic while the reversal groups were treated after diabetes had fully developed. In both models blood glucose was significantly lowered toward control levels using a dose of 40 mg per 100 g of diet while there was a less dramatic, but still significant, correction with half that dose. Treatment increased the weight gain of the more diabetic model (ZDF) while there was no effect of treatment on the weight of the Wistar diabetic fatty (WDF) rat. Other parameters such as glycated haemoglobins, nerve conduction velocity and nerve sugar content are also reversed with effective treatment of the hyperglycaemic condition.

Inhibition of glycolytic enzymes by endogenous aldehydes: a possible relation to diabetic neuropathies

Endogenous saturated and unsaturated aldehydes were found in significant elevations in serum of diabetic humans and rats. These compounds, originating from the lipid peroxidation processes, are shown here to be potent inhibitors of the glycolytic enzymes, phosphofructokinase and glyceraldehyde-3-phosphate dehydrogenase. The inhibition process is non-competitive and progressive. The aldehyde mixture, when supplemented to the standard rat diet at 1/100 ratio, caused nerve damage that is reminiscent of diabetic polyneuropathies.

Altered expression of muscle glucose transporter GLUT-4 in diabetic fatty Zucker rats (ZDF/Drt-fa)

We examined GLUT-4 glucose transporter protein and mRNA in muscle tissue from a new rodent model of non-insulin-dependent diabetes mellitus (NIDDM), the male obese Zucker diabetic fatty (ZDF) rat [ZDF/Drt-fa(F10)]. We also determined whether prevention of hyperglycemia might affect GLUT-4 expression by feeding the intestinal alpha-glucosidase inhibitor acarbose (40 mg/100 g diet) in the diet of male ZDF rats for 19 wk, starting at least 1 wk before the onset of diabetes. Fasting glucose was four- to sixfold greater in diabetic ZDF rats (24.1 +/- 6.7 mM) compared with lean or obese nondiabetic rats. Fasting insulin in diabetic ZDF rats (0.5 +/- 0.1 ng/ml) was similar to lean rats (0.4 +/- 0.1) but greatly reduced compared with obese nondiabetic rats (18.7 +/- 4.0 ng/ml). Acarbose treatment significantly reduced fasting glucose levels to 13.4 +/- 1.4 mM, while insulin levels increased to 1.6 +/- 0.3 ng/ml. GLUT-4 protein levels in diabetic ZDF rats were reduced approximately 40% in red quadriceps and mixed gastrocnemius muscles but were unchanged in white quadriceps muscle. Acarbose treatment was associated with a twofold increase in GLUT-4 protein and mRNA in mixed gastrocnemius muscle. These data indicate that, in this obese model of NIDDM without hyperinsulinemia, there is reduced muscle GLUT-4 protein in red but not white muscle fiber types. The decrease in muscle GLUT-4 expression in this model of NIDDM can be prevented by acarbose treatment, which reduces hyperglycemia and increases beta-cell responsiveness.

Diagnostic delay after dimenhydrinate use in vomiting children

OBJECTIVE

To determine whether the use of dimenhydrinate was associated with delay in the diagnosis and management of treatable illnesses or with direct adverse effects in children with vomiting presenting to an emergency department.

DESIGN

Questionnaire survey and review of drug reaction and telephone inquiry records.

SETTING

The emergency department of a tertiary care children's hospital and a provincial poison information centre.

PATIENTS

The parents of 148 children who presented with vomiting completed the questionnaire. The database at the poison information centre included 474 reports of adverse drug reactions over an 8-year period and 105 reports of telephone inquiries over a 4-year period.

MAIN RESULTS

Twenty-one (14%) of 148 children had received dimenhydrinate before arrival at the emergency department. The patients who had received dimenhydrinate were more likely than the others to present more than 12 hours after the onset of vomiting (14 [67%] of 21 v. 43 [34%] of 127, p less than 0.01). The discharge diagnoses for those who had received dimenhydrinate included asthma, pelvic inflammatory disease and urinary tract infection. No clinically important direct adverse reactions to dimenhydrinate were documented.

CONCLUSIONS

The use of dimenhydrinate in children with vomiting is associated with a risk of delay in the diagnosis of treatable medical conditions.

Oxygen affinity of hemoglobin and peripheral nerve degeneration in experimental diabetes

Peripheral neuropathy remains a major complication of diabetes. Numerous etiological theories of metabolic and/or vascular disturbances have been suggested including decreased endoneurial oxygen tension with presumed tissue hypoxia. Increases in the affinity of hemoglobin for oxygen (Hb-O2 affinity) may also produce tissue hypoxia and such Hb-O2 affinity changes have been implicated in the pathogenesis of diabetic microangiopathy. In order to test whether affinity hypoxia might contribute to the development of diabetic peripheral neuropathy, we have utilized a rat model of high and normal Hb-O2 affinity produced by backcrossing animals with increased and decreased levels of 2,3-diphosphoglycerate (DPG). Diabetes was induced in ten high and ten low DPG animals with a tail vein injection of 55 mg/kg streptozotocin (STZ). Five animals in each group were treated with 2.4 U protamine zinc insulin (PZI)/day while the remaining animals were untreated. All rats were killed after 30 days, sections of tibial and sural nerve were rapidly removed and processed for teased fiber analysis. A minimum of 125 axons were assessed per nerve for E degeneration (myelin ovoids) using the classification developed by Dyck et al. Untreated animals, regardless of DPG levels, demonstrated 0% neuropathy. In contrast, all insulin-treated animals showed degeneration (0.4-17%) that inversely correlated with the DPG level (r = -0.59, P less than 0.04). The results of this study suggest that the level of RBC DPG (and presumably the Hb-O2 affinity) with its attendant effect on tissue oxygen release may play a role in the development of peripheral neuropathy in STZ-induced diabetic rats treated with insulin.

Evidence that down-regulation of beta-cell glucose transporters in non-insulin-dependent diabetes may be the cause of diabetic hyperglycemia

Non-insulin-dependent diabetes mellitus (NIDDM) is attributed to a failure of pancreatic beta cells to maintain insulin secretion at a level sufficient to compensate for underlying insulin resistance. In the ZDF rat, a model of NIDDM that closely resembles the human syndrome, we have previously reported profound underexpression of GLUT-2, the high-Km facilitative glucose transporter expressed by beta cells of normal animals. Here we report that islets of diabetic rats exhibit a marked decrease in the volume of GLUT-2-positive beta cells and a reduction at the electron-microscopic level in the number of GLUT-2-immunoreactive sites per unit of beta-cell plasma membrane. The deficiency of GLUT-2 cannot be induced in normal beta cells by in vivo or in vitro exposure to high levels of glucose nor can it be prevented in beta cells of prediabetic ZDF rats by elimination of hyperglycemia. We conclude that this dearth of immunodetectable GLUT-2 in NIDDM is not secondary to hyperglycemia and therefore that it may well play a causal role in the development of hyperglycemia.

Characteristics of children presenting with chest pain to a pediatric emergency department

Chest pain among children is a common complaint in primary care practice. However, the demographic features and treatment of such patients are controversial. We distributed a questionnaire to 336 consecutive patients with a complaint of chest pain seen during 1 year at an urban pediatric emergency department. Such visits represented 0.6% of all emergency encounters; the male:female ratio was 1.0. Physical examination was done in 325 patients. Chest-wall pain was the most common diagnosis (in 28% of cases). Other causes included pulmonary (in 19%), minor traumatic (in 15%), idiopathic (in 12%) and psychogenic (in 5%); miscellaneous causes (in 21%) most often indicated pain referred from the upper respiratory tract and the abdomen. The most common physical finding was chest tenderness (in 41% of cases). Investigations included chest radiography (in 50% of cases), electrocardiography (in 18%) and determination of the hemoglobin concentration and of the leukocyte count (in 13%); the results were rarely positive. Only eight patients (2%) required admission to hospital, and there were no cases of myocardial ischemia. The findings suggest that health care costs may be reduced by more judicious use of investigations. We conclude that chest pain is an uncommon and usually benign complaint in the pediatric emergency department. Most causes are evident on careful physical examination.

Relationship of ATP turnover, polyphosphoinositide metabolism, and protein phosphorylation in sciatic nerve and derived peripheral myelin subfractions from normal and streptozotocin diabetic rats

Sciatic nerve from streptozotocin-induced diabetic rats has previously been shown to incorporate more 32P into phosphatidylinositol-4,5-bisphosphate (PIP2) and the principal myelin proteins than normal nerve. In the present study, labeling of ATP and PIP2 was compared. Using nerve segments, [gamma-32P]ATP specific activity reached a plateau after incubation for 4 h with [32P]orthophosphate, whereas the specific activity of [32P]PIP2 rose much more slowly and was still increasing after 8 h. The rate of disappearance of radioactivity from prelabeled ATP was biphasic, with 75% being lost within 30 min and the remainder declining much more slowly for several hours thereafter. In contrast, no decrease in prelabeled PIP2 radioactivity could be detected for up to 4 h. The kinetics of ATP metabolism were not appreciably different for normal and diabetic nerve. However, after incubation with [32P]orthophosphate for 2 h, the specific activity of PIP2 was 50-120% higher in diabetic nerve. This phenomenon, therefore, cannot be ascribed to altered specific activity of the ATP precursor pool. Greater labeling of PIP2 in 32P-labeled diabetic nerve was present in purified myelin isolated using a simple discontinuous sucrose density gradient, but not in a "nonmyelin" fraction. When nerve homogenate was fractionated on a more complex gradient, three myelin-enriched subfractions were obtained which were heterogeneous as judged by morphological appearance, protein profile, and lipid metabolic activity. The proportion of total lipid radioactivity accounted for by PIP2 was elevated in all the subfractions relative to the homogenate. As compared to myelin subfractions from normal nerve, an increased percentage of 32P in PIP2 was obtained only in the major myelin subfraction from diabetic nerve. The phosphorylation of P0 relative to the other myelin proteins was also enhanced in this subfraction in nerve from diabetic animals.

Alteration of phosphoinositide metabolism, protein phosphorylation, and carbohydrate levels in sciatic nerve from Wistar fatty diabetic rats

Sciatic nerve from the Wistar fatty diabetic (FD) rat, a prospective model for non-insulin-dependent diabetes mellitus, was investigated to determine the content of carbohydrates and to measure the incorporation of 32P into phosphoinositides and proteins. This strain has been shown to develop structural abnormalities in nerves and to exhibit reduced conduction velocity. Males became diabetic between the ages of 8 and 10 wk and were maintained together with lean sibling controls until the animals were either 22 or 44 wk old. Throughout this period, FD rats displayed moderate hyperglycemia. The carbohydrate profile of FD rat sciatic nerve exhibited modest increases in glucose, fructose, and sorbitol levels and significantly reduced myo-inositol concentrations, which were comparable at both ages. When nerves from 22-wk-old animals were incubated with [32P]orthophosphate and incorporation of radioactivity into phospholipids was measured, an increase in isotope uptake into phosphatidylinositol-4,5-bisphosphate and phosphatidylinositol-4-phosphate in the distal portions of tissue from the FD rat was observed. This effect was more pronounced in nerves from 44-wk-old rats. Phosphorylation of the major myelin protein P0 was 70% higher in the most distal portion of FD sciatic nerve from 22-wk-old animals. A comparable rise in phosphorylation of P0 as well as the large (P1) and small (Pr) myelin basic proteins occurred in nerves from 44-wk-old rats. In these animals, an approximately 50% decrease in the uptake of 32P into P0 and P1 in the most proximal region of FD nerve was also apparent.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypoglycemic neuropathy in experimental diabetes

Morphological and electrophysiological observations were made over 4 weeks on 5 groups of 8-week-old male Sprague-Dawley rats. These were comprised of controls, untreated diabetics, and diabetic animals in which sustained hypoglycemia, moderate hypoglycemia, or normoglycemia was induced by continuous subcutaneous insulin infusion (CSII) therapy. Teased fiber studies showed a marked increase in the number of myelinated fibers undergoing axonal degeneration and regeneration in the tibial nerve of severe hypoglycemic and also in moderate hypoglycemic animals but not in controls, untreated diabetic and normoglycemic groups. There was also a significant correlation between episodes of hypoglycemia (less than or equal to 2.0 mmol/l) and the prevalence of axonal degeneration and regeneration in CSII-treated diabetics. Motor nerve conduction velocity was significantly reduced in the moderate and severe hypoglycemic groups and also in untreated diabetic animals when compared with controls. However, it was significantly improved in the normoglycemic group over the untreated diabetic and severe hypoglycemic groups. In conclusion, this study has demonstrated that severe or even mild hypoglycemia produced a detrimental effect on peripheral nerve structure and function in experimental diabetes. Therefore, it may be desirable to avoid even asymptomatic hypoglycemia in the management of diabetes.

Plasma levels of dantrolene following oral administration in malignant hyperthermia-susceptible patients

Reports of the lack of protection following oral dantrolene prophylaxis have led some authors to recommend only intravenous administration of dantrolene for prophylaxis against malignant hyperthermia at induction of anesthesia. The authors determined whether a specific regimen of preoperative oral dantrolene would result in protective blood levels at induction of anesthesia, and in the postoperative period. Ten malignant hyperthermia-susceptible (MHS) patients were given a total dose of 5 mg.kg-1 of oral dantrolene in three or four divided doses, every 6 h, with the last dose 4 h preoperatively. Plasma dantrolene levels were determined by reverse phase high pressure liquid chromatography at induction of anesthesia and every 6 h thereafter for 48 h. All ten patients had plasma dantrolene levels over 2.8 micrograms.ml-1 at induction of anesthesia, for at least 6 h and, in three patients, up to 18 h after induction. Every patient had an uneventful perioperative course. Side effects (drowsiness, weakness) occurred in seven patients. An elimination half-life of 15.8 +/- 6.0 h was determined. In contrast to intravenous dantrolene, this specific oral dantrolene regimen resulted in protective plasma levels for 6-18 h after induction of anesthesia. These results were likely due to the relatively high bioavailability of oral dantrolene and, possibly, to continued absorption of dantrolene in the postoperative period.

Insect repellent, N,N-diethyl-m-toluamide, effect on ammonia metabolism

There appear to be at least three mechanisms for systemic reactions to diethyltoluamide. As with most substances, allergy is possible. The ingestion of large doses can produce seizures and coma by a direct action on the CNS. This occurs in experimental animals in which seizures and coma followed by death can be produced rapidly if sufficiently large doses are given. Finally, with smaller systemic doses as may occur with absorption during heavy topical use, there is also the possibility of a perturbation of ammonia metabolism. Diethyltoluamide may then pose a substantial hazard to individuals with defects in ammonia metabolism.

Ultrastructural observations on myelinated fibres in experimental diabetes: effect of the aldose reductase inhibitor ponalrestat given alone or in conjunction with insulin therapy

Six groups of rats were studied over a 12-week period: onset and end controls, untreated diabetics, ponalrestat-treated diabetics, insulin-treated diabetics, and diabetics treated with ponalrestat and insulin. The concentrations of glucose, sorbitol and fructose significantly increased and that of myo-inositol significantly decreased in the sciatic nerve of untreated diabetic animals. Ponalrestat administration completely normalized sorbitol levels and partially corrected fructose and myo-inositol concentrations without altering nerve glucose levels. The biochemical abnormalities were also corrected in both the insulin-treated and insulin and ponalrestat-treated diabetic animals. Myelinated fibre cross-sectional areas and axonal areas were significantly less in the tibial nerve of diabetic animals as compared with age-matched controls. Insulin treatment partially corrected the reduction in fibre and axonal area but teased fibre preparations showed an excess of axonal degeneration as compared with controls, untreated diabetics and ponalrestat-treated diabetics. Ponalrestat given alone or in conjunction with insulin therapy did not correct the reduction in fibre or axonal area and single isolated fibres from diabetic animals treated with ponalrestat and insulin showed a marked excess of axonal degeneration, probably related to hypoglycaemia. The study fails to reveal any significant beneficial effect of aldose reductase inhibition on the structural abnormalities in peripheral nerve in experimental diabetes.

Revised pharmacokinetic constants for use under Système International

Two additional kinetic constants are defined and their values given for a number of drugs. These constants can be used when dealing with plasma drug levels reported in Système International Units in order to maintain traditional kinetic calculations in estimating loading doses, infusion rates, and plasma levels from drug ingestions. The constants are termed VDSI and ClSI and are used in place of the traditional apparent volume of distribution and total plasma clearance. Constants for a number of drugs are given.

Enhancement of central transmission to sympathetic preganglionic neurons by phosphodiesterase inhibitors and its prevention by clonidine

The effects of 3 phosphodiesterase inhibitors, aminophylline, isobutylmethylxanthine (IBMX), and RO 20-1724, were tested on descending intraspinal and spinal reflex transmission to sympathetic preganglionic neurons in unanesthetized spinal cats. Sympathetic discharges, recorded from upper thoracic preganglionic white rami, were evoked by stimulation (0.1 Hz) of descending excitatory pathways in the cervical dorsolateral funiculus (intraspinal) or of adjacent intercostal nerves (spinal reflex). Each phosphodiesterase rapidly and markedly enhanced transmission through intraspinal pathways but only slowly and modestly enhanced transmission through spinal reflex pathways. Pretreatment with a methyltyrosine-reserpine combination, chlorpromazine, or prazosin markedly restricted the enhancement of intraspinal transmission by IBMX to levels typically produced on spinal reflex pathways. Clonidine markedly depressed transmission through both pathways and prevented enhancement by the phosphodiesterase inhibitors. Yohimbine or tolazoline antagonized the depressant effects of clonidine and restored the ability of the phosphodiesterase inhibitors to enhance transmission. Somatic spinal reflexes were not affected by the phosphodiesterase inhibitors. The results suggest that descending norepinephrine pathways to sympathetic preganglionic neurons activate adenylate cyclase to generate cyclic AMP which increases neuronal excitability, possibly by phosphorylating membrane proteins. Clonidine appears to depress neuronal excitability by inhibiting adenylate cyclase through activation of alpha 2-adrenergic receptors.

Insulin reverses enhanced incorporation of 32P into polyphosphoinositides in peripheral nerve of the streptozotocin diabetic rat

The ability of insulin treatment to reverse altered phosphoinositide metabolism in sciatic nerve from streptozotocin diabetic rats was studied. Diabetes was induced in rats by means of a single injection of streptozotocin. Enhanced incorporation of 32P into phosphatidylinositol-4,5-bisphosphate (PIP2) was detectable as early as 8 days following intravenous injection of streptozotocin and was maximal after 4 weeks. Hormone treatment was initiated at this time by daily injections of protamine zinc insulin followed by the implantation of long-acting insulin osmotic minipumps, and 4 weeks later sciatic nerves were removed and incubated in the presence of [32P]orthophosphate. The increased labeling of PIP2 was completely reversed by hormone administration. In contrast, insulin (0.1 and 1.0 mU/ml) added to the incubation medium failed to reverse the altered pattern of 32P incorporation into PIP2. The uptake of 32P into PIP2 was greater than 80% higher into the proximal than into the distal portion of normal sciatic nerve when these were incubated separately. This metabolic difference was abolished in diabetic rats, although the incorporation into both segments was still significantly higher than in controls. These results strengthen the association of altered nerve PIP2 metabolism with the diabetic state and are consistent with the concept that experimental diabetic neuropathy is a distal axonopathy.

Cleansing the blood. Hemodialysis, peritoneal dialysis, exchange transfusion, charcoal hemoperfusion, forced diuresis

ECDR can be a valuable adjunct to the therapy of pediatric poisonings. Careful consultation with a medical toxicologist and a nephrologist will be useful in reaching the decision as to which poisonings lend themselves to ECDR and which method is most appropriate for the specific case. Avoid advice that amounts to, "if you are not certain, dialyze." While the risks of many ECDR techniques are acceptable in major medical centers, it may not be good medicine to superimpose any morbidity from ECDR upon the poisoned patient when there can be little expectation of drug removal. It is wise to phrase your questions to consultants carefully. The question: "can this substance be dialyzed (hemoperfused, plasmaphoresed, etc.)?" is loaded and the answer frequently will be "yes!" The more proper questions are: "how much drug can be removed by ECDR, how long will the method take, how will this affect the present condition of the patient?" Clearly, a risk: benefit ratio must always be considered. There are lists of substances that "can" be removed by ECDR. It is more difficult to judge how much of the body burden is removed by such methods. Digoxin "can" be dialyzed, but it is not quantitatively removed from the body and there is no accepted benefit from ECDR in this instance. The volume of distribution is a useful guide to determine which substances may be removed quantitatively by ECDR. The exaggerated claims to increased plasma clearance of a hemoperfusion device may not be meaningful if the distribution space is large and plasma levels are correspondingly low. Finally, many of the advantages and disadvantages of ECDR are not likely to change markedly as a result of technology. We currently have very efficient machines for ECDR. It is the chemical characteristics of some toxic substances that limit the more global role of ECDR in poisoning. Serologic therapy, such as specific Fab antibody fragments for use in digoxin poisonings or the exciting work by Russell and colleagues using affinity chromatography to purify specific antibody fragments from horse serum, may be applicable to numerous intoxications. This approach, used in combination with ECDR or alone, will undoubtedly influence the future growth of clinical toxicology.

Malpractice liability of allied health professionals: developments in an area of critical concern

Malpractice litigation has become a serious concern of health professionals, as well as a contributor to escalating health-care costs. Allied health professionals have had their conduct called into question in a number of such suits, but so far these have received little scholarly attention. The developing body of allied health professions law is described and analyzed herein, with particular attention given to the issues of fact and law that are most frequently disputed. The need for legal development that includes sensitivity to the knowledge, abilities, and practices distinctive to the various health professions is stressed.

Consequences associated with nonnarcotic analgesics in the fetus and newborn

Nonnarcotic analgesics include well-known, widely used substances such as acetylsalicylic acid (ASA) and acetaminophen. ASA is a potent inhibitor of prostaglandin synthesis, and this mechanism is responsible for many potential toxicities in the fetus and newborn. These may include bleeding, altered renal function, and constriction of the ductus arteriosus in addition to analgesia. As such, ASA is frequently avoided during gestation and the immediate neonatal period. Acetaminophen is less well recognized as an agent with activity outside the central nervous system. It does not possess antiinflammatory activity like other substances that inhibit prostaglandins but has been shown to be an analgesic with potency comparable to ASA. This is believed to be by inhibition of brain prostaglandin synthetase. We have determined by using the chronically catheterized sheep fetus that acetaminophen has potent activity on the ductus arteriosus and produces a constriction, in therapeutic analgesic quantities, comparable to ASA. Thus, acetaminophen may be a potent inhibitor of prostaglandin function in the fetus.

Antipyretics and analgesics in children

Physicians must carefully consider the appropriate use of antipyretic drugs in children. Despite the ubiquitous presence of acetaminophen and acetylsalicylic acid in the home, there are many factors to weigh prior to their use. The following is a discussion of these factors: efficacy versus toxicity, known effects versus uncertain complications of drug therapy. Acetaminophen and acetylsalicylic acid have equivalent antipyretic effects. Acetysalicylic acid is clearly the better anti-inflammatory drug. Therapeutic misadventures with both drugs have resulted in childhood fatalities. Since these medications are not restricted to prescription order by a physician, instructions as to their safe and appropriate use should become part of 'normal child' counselling by physicians to all parents.

Renal clearance of gentamicin in cystic fibrosis

This study was designed to corroborate previous observations of low serum concentrations of aminoglycosides after usual doses in patients with cystic fibrosis and to investigate possible mechanisms for this change. We studied gentamicin clearance after single and multiple intravenously administered doses in 10 non-acutely ill patients with mild to moderate CF. The data could best be described by a two-compartment model for drug elimination. The mean 1-hour serum concentration, mean volume of distribution, and mean total plasma clearance of gentamicin were not different from those reported for patients without CF. The similarity of the plasma and the renal gentamicin clearances, supported by the observations that greater than 80% of administered drug was excreted in the urine by 4 hours and that negligible amounts were detected in sweat, saliva, or sputum, implies that the kidney is the major route of elimination in patients with mild CF. The correlation of increased plasma gentamicin clearance as NIH score decreases supports the hypothesis that aminoglycoside pharmacokinetics are changed as the severity of disease increases. For patients with mild CF, standard doses of gentamicin (60 mg/m2) will give safe and therapeutic concentrations.

Electron microscopic study of intramembranous changes in protein-extracted peripheral nervous system myelin

Sciatic nerves from young mice were incubated for 2-8 hours in 0.5% Triton X-100 in 0.5 M ammonium acetate, a solution which solubilizes the large and small basic proteins of the myelin sheath. As previously noted (Peterson and Gruener, 1978), myelin sheaths from treated nerves extensively split and unravelled along major dense lines. Small focal areas of compact myelin remained. In freeze-fracture replicas, areas of myelin with lamellar splitting contained few intramembranous particles, while membrane areas with greater than normal densities of particles were associated with the patches of compact myelin membrane. Fixation for as short a time as 15 minutes stabilized the myelin membrane enough to prevent the Triton X-100 effects, even when incubations were extended to 20 hours. Controls, both untreated and 0.5 M ammonium acetate-treated nerves, had predominantly compact myelin sheaths; their leaflets were covered with numerous intramembranous particles. The data suggest that Triton X-100 alters the compact structure of peripheral nervous system myelin. In areas where lamellae are split and separated, there is a loss of intramembranous particles. It appears that the loss of intramembranous particles is related to the removal of the basic proteins which are located in major dense line regions of compact myelin sheaths.

Degenerative neuropathy in insulin-treated diabetic rats

Peripheral neuropathic alterations associated with diabetes and its treatment with insulin were studied in alloxan-induced diabetic rats. Treatment regimens included daily injections of Protamine Zinc Insulin (PZ), daily injections of Ultralente Insulin and subcutaneously implanted osmotic minipump delivered insulin. Non-diabetic and untreated diabetic groups served as controls. Two separate but similar studies were run, one lasting 4 weeks and the other 8 weeks. Conduction velocities performed on both sensory and motor nerves revealed no statistically significant differences among groups. Anatomical analysis of teased fibers from tibial nerves showed a significant number of fibers with ovoids, consistent with Wallerian-type axonal degeneration, only in the treated diabetic groups. Degeneration was especially severe in the PZI-treated group. Metabolic studies were performed using incorporation of radioactive isotopes ([3H]fucose, [14C]leucine) into myelin proteins of sciatic nerves. The ratio of [3H]fucose/[14C]leucine for the PZI-treated group was significantly decreased when compared to the control groups in both the 4 and 8 week study whereas the minipump-treated group showed no statistically significant difference from the control group in either study. Similar decreases in this ratio have been seen in conditions of peripheral nerve degeneration. It is concluded that daily injections of PZI insulin result in significant nerve degeneration in the alloxan diabetic rat, while continuous levels of insulin delivered by osmotic minipumps result in less degeneration.

Altered metabolic incorporation of fucose and leucine into PNS myelin of 25-week-old diabetic (C57BL/Ks [db/db]) mice: effects of untreated diabetes on nerve metabolism

Sciatic nerves of 25-week-old genetically diabetic (C57BL/Ks [db/db]) mice and their litter-mate controls were removed, and their metabolic incorporation of [3H]fucose and [14C]leucine into myelin was studied in vitro. Untreated diabetic animals showed significant increases (p less than 0.05) in the fucose/leucine incorporation into myelin when compared to values found for their litter-mates. These results correlated well with previous experiments performed on alloxan or streptozotocin-diabetic rats and thus show the in vitro incubation procedure to be a good indicator of altered metabolic conditions in peripheral nerves due to diabetes mellitus. The resulting ratio increases seen in diabetic animals is at variance with the decrease in ratios found in animals undergoing typical Wallerian degeneration. These results suggest that different metabolic processes operate in untreated diabetics than in normals or in those undergoing other degenerative nerve processes.

Neuropathic changes associated with insulin treatment of diabetic rats: electron microscopic and morphometric analysis

Tibial nerves from control, untreated alloxan diabetic, and 4-week insulin treated alloxan diabetic rats were examined with light microscopy and computerized morphometric analysis of axons. Teased fiber preparations and electron microscopy were utilized to evaluate nerve degeneration. The insulin treatment regimens included daily injections of protamine zinc insulin (PZI), daily injections of ultralente insulin, and continuously delivered insulin through osmotic minipumps. Evaluation of axon:myelin ratios, teased fiber profiles, and electron microscopic cross sections of nerves demonstrated different degrees of neuropathic changes within the treated groups. The control group and untreated diabetic group showed little or no degeneration, while all insulin-treated groups showed evidence of Wallerian degeneration. Among these insulin treated groups, the PZI-treated group showed the greatest number of degenerating profiles while the minipump group showed the least. These data suggest that insulin treatment of alloxan diabetes results in axonal degeneration which closely resembles findings in human diabetic neuropathies. The substantially diminished number of degenerating axons seen in the osmotic minipump insulin-treated rats suggests that continuous delivery of insulin may decrease the neuropathic changes seen with single injection insulin therapy. Since virtually all insulin-dependent diabetic patients receive daily administration of insulin, the possibility that peripheral neuropathies may in part result from the insulin treatment requires more extensive investigation in a variety of animal models to separate the neuropathic effects of diabetes from the neuropathic effects of insulin therapy.

The composition of the medial articular nerve to the knee in the dog

Light and electron microscopy were used to characterise the medial articular nerve to the knee in the dog, in terms of the total number of myelinated axons, the frequencies of different diameters of myelinated axons, the number of unmyelinated axons, and the ratios of unmyelinated to myelinated axons. Approximately 70% of all myelinated axons were of less than 5 micron diameter and, with the exception of two of sixteen nerves examined by light microscopy, all distributions were unimodal. The distributions of the two nerves of other than unimodal distribution were each characterised by a second, small peak of axon diameters ranging between 9 and 14 microns. Unmyelinated axons counted in five nerves suggested that approximately 72% of all axons of a given nerve were unmyelinated, giving a ratio of about 2.5 unmyelinated to 1.0 myelinated axon.