Early Administration of Intravenous Hydration and Opioid Analgesics Is Correlated with Decreased Admission Rates during Vaso-Occlusive Episodes in Sickle Cell Disease

Background: Painful vaso-occlusive episodes (VOEs) are the hallmark of sickle cell disease (SCD) and account for frequent visits to the emergency department (ED) or urgent care (UC). Currently, the early administration of analgesics is recommended as initial management; however, there is a need for further understanding of the effect of prompt analgesics and hydration during VOEs. The objective of this study is to analyze the factors associated with the rate of hospital admission in the setting of time to intravenous (IV) analgesics and hydration. Method: This retrospective single-institution study reviewed adult and pediatric patients with SCD who presented with VOEs from January 2018 to August 2023. Results: Of 303 patient encounters, the rates of admission for the overall group, the subgroup which received IV hydration within 60 min of arrival, and the subgroup which received both IV analgesics and hydration within 60 min were 51.8%, 25.6% (RR = 0.46), and 18.2% (RR = 0.33), respectively. Further, factors such as gender and the use of hydroxyurea were found to be significantly associated with the rate of admission. Conclusions: This signifies the importance of standardizing the management of VOEs through the timely administration of IV analgesics and hydration in both adult and pediatric ED/UC.

Advancing Esophageal Cancer Treatment: Immunotherapy in Neoadjuvant and Adjuvant Settings

Locally advanced esophageal cancer (LAEC) poses a significant and persistent challenge in terms of effective treatment. Traditionally, the primary strategy for managing LAEC has involved concurrent neoadjuvant chemoradiation followed by surgery. However, achieving a pathologic complete response (pCR) has proven to be inconsistent, and despite treatment, roughly half of patients experience locoregional recurrence or metastasis. Consequently, there has been a paradigm shift towards exploring the potential of immunotherapy in reshaping the landscape of LAEC management. Recent research has particularly focused on immune checkpoint inhibitors, investigating their application in both neoadjuvant and adjuvant settings. These inhibitors, designed to block specific proteins in immune cells, are meant to enhance the immune system's ability to target and combat cancer cells. Emerging evidence from these studies suggests the possibility of a mortality benefit, indicating that immunotherapy may contribute to improved overall survival rates for individuals grappling with esophageal cancer. This manuscript aims to meticulously review the existing literature surrounding neoadjuvant and adjuvant immunotherapy in the context of LAEC management. The intention is to thoroughly examine the methodologies and findings of relevant studies, providing a comprehensive synthesis of the current understanding of the impact of immunotherapy on esophageal cancer.

An innovative intervention for the prevention of vaso-occlusive episodes in sickle cell disease

OBJECTIVES

Sickle cell disease (SCD) is characterized by a mutation in the beta-globin gene resulting in abnormal hemoglobin S (HgbS). The significant sequela of SCD include anemia and recurrent vaso-occlusive episodes (VOEs) which may effectuate patients to receive chronic blood transfusions. Current pharmacotherapy options for SCD include hydroxyurea, voxelotor, Lglutamine, and crizanlizumab. Simple and exchange transfusions are often utilized as prophylaxis to prevent emergency department (ED)/urgent care (UC) visits or hospitalizations from VOEs by reducing the level of sickled red blood cells (RBCs). In addition, the treatment of VOEs involves intravenous (IV) hydration and pain management. Studies have demonstrated that sickle cell infusion centers (SCIC) decrease hospital admissions for VOEs, and IV hydration and pain medications are the key components of management employed. Thus, we hypothesized that implementing a structured infusion protocol in the outpatient setting would reduce the incidence of VOEs.

METHODS

Here, we discuss two patients with SCD who were trialed on scheduled outpatient IV hydration and opioids with the goal of decreasing the frequency of VOEs in the setting of the current blood product shortage and the patients' refusal to receive exchange transfusions.

RESULTS

Overall, the two patients had opposing outcomes- one demonstrated reduced frequency of VOEs, whereas the other had mixed results due to noncompliance to scheduled outpatient sessions.

DISCUSSION/CONCLUSION

The use of outpatient SCICs may be an effective intervention for prevention of VOEs in patients with SCD, and further patient-centered research and quality improvement initiatives are needed to further quantify and understand the factors contributing to their efficacy.

Partial response to venetoclax and ruxolitinib combination in a case of refractory T-prolymphocytic leukemia

Background: T-prolymphocytic leukemia (T-PLL) is an aggressive hematologic malignancy. A portion of patients can be cured with alemtuzumab induction followed by allogeneic hematopoietic stem cell transplant, but patients who relapse after transplant have a poor prognosis, and there is no standard of care.Methods: We report a case of a 64-year-old man with relapsed JAK3-mutant T-PLL following allogeneic transplant who was treated with ruxolitinib and venetoclax.Results: Treatment with ruxolitinib and venetoclax resulted in a partial response including stabilization of the peripheral lymphocyte count, improvement in thrombocytopenia, decrease in splenomegaly, and a numerical reduction in the percentage of bone marrow involved by T-PLL. The combination was well tolerated with the exception of neutropenic infections.Conclusion: This case adds to the growing body of literature supporting venetoclax and rituximab as a viable treatment option for relapsed/refractory T-PLL with JAK-STAT alterations.

Leukostasis With Isolated Central Nervous System Involvement in Chronic Phase of Chronic Myelogenous Leukemia

Chronic myelogenous leukemia (CML) is a hematologic malignancy with unique significance to the field of hematology and oncology, specifically due to the development of tyrosine kinase inhibitors (TKIs). CML often presents with nonspecific symptoms, and the quality of life in patients with CML has drastically improved as a result of TKIs. However, complications of CML including the risk of transforming into life-threatening blast crises continue to exist. Further, as most patients are asymptomatic in the chronic phase, patients often present with serious complications associated with noncompliance to TKIs. For example, central nervous system (CNS) manifestations of CML have been reported, both as the initial presentation of undiagnosed CML and as known complication of uncontrolled CML. Hyperleukocytosis is a manifestation of uncontrolled CML and leukostasis is a complication, occurring in cases of acute myeloid leukemia (AML). Here we present a rare case of leukostasis in a patient with known CML presenting on computed tomography (CT) as intracranial masses in the chronic phase. Our goal is to discuss this rare case of leukostasis in adult CML and describe its management.

Comprehensive Review: Unveiling the Pro-Oncogenic Roles of IL-1ß and PD-1/PD-L1 in NSCLC Development and Targeting Their Pathways for Clinical Management

In the past decade, targeted therapies for solid tumors, including non-small cell lung cancer (NSCLC), have advanced significantly, offering tailored treatment options for patients. However, individuals without targetable mutations pose a clinical challenge, as they may not respond to standard treatments like immune-checkpoint inhibitors (ICIs) and novel targeted therapies. While the mechanism of action of ICIs seems promising, the lack of a robust response limits their widespread use. Although the expression levels of programmed death ligand 1 (PD-L1) on tumor cells are used to predict ICI response, identifying new biomarkers, particularly those associated with the tumor microenvironment (TME), is crucial to address this unmet need. Recently, inflammatory cytokines such as interleukin-1 beta (IL-1β) have emerged as a key area of focus and hold significant potential implications for future clinical practice. Combinatorial approaches of IL-1β inhibitors and ICIs may provide a potential therapeutic modality for NSCLC patients without targetable mutations. Recent advancements in our understanding of the intricate relationship between inflammation and oncogenesis, particularly involving the IL-1β/PD-1/PD-L1 pathway, have shed light on their application in lung cancer development and clinical outcomes of patients. Targeting these pathways in cancers like NSCLC holds immense potential to revolutionize cancer treatment, particularly for patients lacking targetable genetic mutations. However, despite these promising prospects, there remain certain aspects of this pathway that require further investigation, particularly regarding treatment resistance. Therefore, the objective of this review is to delve into the role of IL-1β in NSCLC, its participation in inflammatory pathways, and its intricate crosstalk with the PD-1/PD-L1 pathway. Additionally, we aim to explore the potential of IL-1β as a therapeutic target for NSCLC treatment.

Case Report: An exceptional response to neoadjuvant radiotherapy and chemotherapy in undifferentiated pleomorphic sarcoma following checkpoint inhibitor use

Undifferentiated pleomorphic sarcoma (UPS), a subtype of soft tissue sarcoma (STS), is an uncommon malignancy associated with a poor prognosis. As with other forms of sarcoma, surgical resection remains the only form of treatment with curative potential. The role of perioperative systemic therapy has not been definitively elucidated. Due to high recurrence rates and metastatic potential, management of UPS can pose a difficult task for clinicians. In cases of unresectable UPS due to anatomic limitations and in patients with comorbidities and poor performance status (PS), management options are limited. We describe a patient with UPS involving the chest wall with poor PS who achieved complete response (CR) following neoadjuvant chemotherapy and radiation in the setting of prior immune-checkpoint inhibitor (ICI) therapy.

Unveiling the Prognostic Significance of BCL6+/CD10+ Mantle Cell Lymphoma: Meta-Analysis of Individual Patients and Systematic Review

Mantle cell lymphoma (MCL) is a type of non-Hodgkin lymphoma (NHL) characterized by a hallmark translocation of t (11; 14). CD10 negativity has been used to differentiate MCL from other NHL types; however, recently, there has been an increase in the number of reported cases of CD10-positive MCL. This warrants further investigation into this rarer immunophenotype and its clinical significance. BCL6, which is a master transcription factor for the regulation of cell proliferation and key oncogene in B cell lymphomagenesis, has been reported to have co-expression with CD10 in MCL. The clinical significance of this aberrant antigen expression remains unknown. We conducted a systematic review by searching four databases and selected five retrospective analyses and five case series. Two survival analyses were conducted to determine if BCL6 positivity conferred a survival difference: 1. BCL6+ vs. BCL6- MCL. 2. BCL6+/CD10+ vs. BCL6-/CD10+ MCL. Correlation analysis was conducted to determine if BCL6 positivity correlated with the Ki67 proliferation index (PI). Overall survival (OS) rates were performed by the Kaplan-Meier method and log-rank test. Our analyses revealed that BCL6+ MCL had significantly shorter overall survival (median OS: 14 months vs. 43 months; p = 0.01), BCL6+/CD10+ MCL had an inferior outcome vs. BCL6+/CD10- MCL (median OS: 20 months vs. 55 months p = 0.1828), BCL6+ MCL had significantly higher percentages of Ki67% (Ki67% difference: 24.29; p = 0.0094), and BCL6 positivity had a positive correlation with CD10+ status with an odds ratio 5.11 (2.49, 10.46; p = 0.0000286). Our analysis showed that BCL6 expression is correlated with CD10 positivity in MCL, and BCL6 expression demonstrated an inferior overall survival. The higher Ki67 PI in BCL6+ MCL compared to BCL6- MCL further supports the idea that the BCL6+ immunophenotype may have prognostic value in MCL. MCL management should consider incorporating prognostic scoring systems adjusted for BCL6 expression. Targeted therapies against BCL6 may offer potential therapeutic options for managing MCL with aberrant immunophenotypes.

Precision Medicine to Treat Urothelial Carcinoma-The Way Forward

The treatment of urothelial carcinoma (UC) is challenging given its molecular heterogeneity and variable response to current therapies. To address this, many tools, including tumor biomarker assessment and liquid biopsies, have been developed to predict prognosis and treatment response. Approved therapeutic modalities for UC currently include chemotherapy, immune checkpoint inhibitors, receptor tyrosine kinase inhibitors, and antibody drug conjugates. Ongoing investigations to improve the treatment of UC include the search for actionable alterations and the testing of novel therapies. An important objective in recent studies has been to increase efficacy while decreasing toxicity by taking into account unique patient and tumor-related factors-an endeavor called precision medicine. The aim of this review is to highlight advancements in the treatment of UC, describe ongoing clinical trials, and identify areas for future study in the context of precision medicine.

Portal vein thrombosis as the presenting manifestation of JAK2 positive myeloproliferative neoplasm

Deep venous thrombosis (DVT) is a complication of myeloproliferative neoplasms (MPNs). However, DVTs in unusual sites such as portal vein thrombosis (PVT) are rare and may be the first clinical manifestation of occult MPNs. There is a need for increasing awareness of such manifestations; so, here we discuss a patient who presented with new portal vein thrombosis, underwent further studies, was ultimately diagnosed with JAK2 positive MPN, and started on appropriate treatment with improvement of thrombosis and controlled hematocrit.

Abstract P5-07-14: A pilot study of novel approach of intraneural facilitation versus standard physical therapy for prevention of chemotherapy induced peripheral neuropathy

Background Chemotherapy-induced peripheral neuropathy (CIPN) is a frequent side effect of commonly used chemotherapy (CT) regimens and often results in dose reduction or cessation of treatment which can adversely affect cancer outcomes. Treatment options for CIPN are limited and no standard approaches exist to prevent CIPN. A novel therapy, Intraneural Facilitation (INF) has been developed by physical therapists at our institution’s neuropathy treatment center as a preventative and treatment modality for CIPN. INF therapy involves physical maneuvers and systematic application of pressure to improve peripheral microvascular circulation to the endoneurial capillaries of the extremities. We conducted a randomized pilot study evaluating INF versus standard physical therapy (PT) maneuvers as a non-invasive treatment modality for preventing CIPN during participants’ ongoing chemotherapy. This study was supported by an intramural (GRASP) grant and registered on clinicaltrials.gov (NCT0327919). Methods Newly diagnosed patients with breast cancer stages I to III and CT naive gynecologic cancers without preexisting peripheral neuropathy planning to receive treatment with platinum-based compounds and/or taxanes were eligible for this study. Participants were randomized into two treatment groups. Group one received INF and group two received a standardized program of PT including muscle stretching and strengthening exercises. Each group received two (45-minute) treatments twice a week for six weeks under the supervision of trained physical therapists. Participants were evaluated at baseline, week 3, week 6, and 3 months after the date of initiation of chemotherapy. The use of neuropathy medications, CT dose reductions, and treatment discontinuation was compared between the two treatment groups. Vascular perfusion was also evaluated at the same intervals using ultrasound to measure volume flow and pulsatility of the popliteal and posterior tibial arteries. Participants completed a survey at the end of treatment evaluating the effectiveness and satisfaction of the intervention. Results 44 out of 104 patients screened met the eligibility criteria and were randomized to either of the two therapy modalities from July 2017 to June 2022. A total of 38 participants received the allocated intervention and were included in the analysis (n=20 in the INF arm and n=18 in the PT arm). CT dose reduction due to CIPN grade 2 or higher occurred in 6/18 (33%) and 4/20 (20%) participants who received standard PT and INF, respectively. 2/18 (11%) participants required discontinuation of CT prematurely due to CIPN in the standard PT arm when compared to 1/20 (5.0%) in the INF arm. Pharmacologic interventions were required to manage CIPN in 4/18 (22%) participants in the standard PT arm vs 2/20 (10%) in the INF arm at the end of CT. Participants reported more control over their health (95.2% INF arm vs. 83.3% PT arm) and decreased nerve discomfort (75% in the INF arm vs. 61.1% in the PT arm). Participants reported high levels of satisfaction overall at the end of each intervention (95% in the INF arm vs. 83% in the PT arm). Conclusion Our pilot study evaluated the feasibility and potential for INF therapy compared to standard PT for the prevention of CIPN during ongoing chemotherapy. Based on the patient satisfaction survey, the burden and satisfaction with the assigned therapy modality between the two arms were favorable overall. Our results showed that CT dose reduction and early cessation in addition to pharmacologic interventions for CIPN were numerically less prevalent in the INF arm compared to the standard PT arm; however, further studies are needed to validate these findings.

Citation Format: Dani Ran Castillo, Won Jin Jeon, Carvy Floyd Luceno, Mark Bussell, Ron Coleman, Karla Pieters, Jamie Hankins, Annette Boggs, Lorena Garcia, Salem Dehom, Ellen D’Errico, Gayathri Nagaraj. A pilot study of novel approach of intraneural facilitation versus standard physical therapy for prevention of chemotherapy induced peripheral neuropathy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-07-14.

Recurrent and atypical immune checkpoint inhibitor-induced pneumonitis

INTRODUCTION

Pembrolizumab (Keytruda) is a monoclonal antibody against the programmed cell death-1 (PD-1) receptor on lymphocytes, which is one of the immune checkpoint inhibitors (ICIs) approved for multiple solid and hematologic malignancies. Although ICIs have proven to be more effective and less toxic compared to chemotherapy, there are reports of adverse side effects with ICIs. For example, pneumonitis is a potentially lethal side effect occurring in 1%-5% of patients who received ICIs in clinical trials, and there are case reports with clinical and radiological features of checkpoint inhibitor-pneumonitis (CIP).

CASE REPORT

We report an unusual case of pneumonitis with atypical imaging in a patient who received pembrolizumab for metastatic p16-positive squamous cell carcinoma of the base of the tongue. We discuss the approach to the recognition and management of atypical CIP in patients on pembrolizumab with the intent to standardize workup and increase awareness among healthcare providers in the new era of immunotherapy.

MANAGEMENT AND OUTCOME

Serologic workup including laboratory studies for complete blood count (CBC), lactate, procalcitonin, SARS-CoV-2 (COVID-19), Legionella, Cytomegalovirus (CMV), Coccidioides, Coxiella, and viral respiratory panel were negative for infectious processes. Since CIP was suspected, the patient was started on steroid therapy. Interval computed tomography (CT) of the chest without contrast showed a resolution of pneumonitis.

DISCUSSION

In this case report, we discuss our workup of CIP and initial testing to rule out other possible causes of the patient's symptoms and radiographic findings, and management of the patient's diagnosis of atypical CIP which led to complete clinical recovery from CIP.

Nivolumab plus ipilimumab induced endocrinopathy and acute interstitial nephritis in metastatic sarcomatoid renal-cell carcinoma: A case report and review of literature

The prognosis of sarcomatoid renal cell carcinoma has changed dramatically with the emergence of immune checkpoint inhibitors. Notably the use of nivolumab and ipilimumab combination therapy has demonstrated promising durable therapeutic response for patients with treatment-naïve sarcomatoid renal-cell carcinoma. We present a case of 45-year-old man with a history of metastatic sarcomatoid renal cell carcinoma treated with nivolumab plus ipilimumab who developed type 1 diabetes mellitus, adrenal insufficiency, thyroiditis/hypothyroidism, and acute interstitial nephritis as a result of immunotherapy.

Effect of maternally derived antibody on sequential infection with highly virulent bursal disease virus in newly hatched broilers

Maternally derived antibodies (MDAs) are important for protection against very virulent infectious bursal disease virus (vvIBDV). In this study, 5-day-old commercial broilers with non-uniform MDA titers (with a coefficient of variation of 50%) were challenged with vvIBDV and given free contact with each other during a 2-week period. The chicks were assigned to four MDA-titer subgroups, GI-1 (very low MDA), GI-2 (low MDA), GI-3 (medium MDA), and GI-4 (high MDA). Transient symptoms of infection were observed in 35.7% of challenged birds. Body weight gain was significantly lower in GI-2, GI-3, and GI-4 birds than in an unchallenged control group. Seroconversion was observed in GI-1 birds and some GI-2 birds. The frequency of virus shedding via the cloaca in vvIBDV-challenged birds increased from 7.1% of GI birds at 5 days post inoculation (dpi) to 35.7% at 14 dpi. The timing of virus shedding was progressively later from GI-1 to GI-4. At 14 dpi, significant atrophy of the bursa of Fabricius (BF) was observed in GI birds compared with GII controls; atrophy was most severe in GI-1 birds and least severe in GI-4 birds. BF lesion scores decreased from GI-1 to GI-4. The proportion of birds with IBDV antigen in the BF at 14 dpi was higher in GI-2 and GI-3 than in GI-1 and GI-4, whereas the viral load in positive birds increased from GI-1 to GI-4. Our results indicate that high levels of MDAs would protect chicks from initial vvIBDV infection but that progressive decay of these MDAs would result in delayed infection by virus shedding in initially infected birds with low MDA titers, resulting in continuous circulation of the virus in a flock with non-uniform MDA titers.

Epidemiological investigation of outbreaks of fowl adenovirus infection in commercial chickens in Korea

In total, 39 clinical cases of fowl adenoviruses (FAdV) infection in chickens (28 broiler, 7 native, and 4 layer chickens) between 2007 and 2010 in Korea were investigated. The FAdV types 4, 8b, and 11 comprised 18, 9, and 12 clinical cases, respectively. All FAdV type 4 cases showed clinical hydropericardium (HPS) lesions as well as inclusion body hepatitis (IBH), whereas all FAdV types 8b and 11 cases exhibited IBH lesions without HPS. All 3 types were detected in broiler (9-30 d old) and layer chickens (23-112 d old), whereas most native chickens (14-65 d old) were affected only by FAdV type 4. Infectious bursal disease virus and chicken infectious anemia virus were complications in 51.3% of FAdV cases, with mortalities of 55% to <0.1%. Chicken infectious anemia virus was detected in all native chicken cases. These results indicate that preventive measures against FAdV infection and immunosuppressive diseases on poultry farms should be implemented.

Anatomical collateral ligament reconstruction in the hand using intraosseous suture anchors and a free tendon graft

We describe anatomical collateral ligament reconstruction using a free tendon graft and intraosseous suture anchors in the digits. Eleven patients who underwent collateral ligament reconstruction at the proximal interphalangeal or metacarpophalangeal joints were enrolled in this study. Proper and accessory collateral ligaments were reconstructed using a free tendon graft in an anatomical configuration and the grafted tendons were fixed with suture anchors. The mean time from surgery to last follow-up was 9.2 months. All anchors used for fixation of grafted tendons remained securely at their original positions at the last follow-up visits. No significant complications were associated with the use of anchors. Clinical results were excellent in 10 patients and good in one. Anatomical reconstruction of collateral ligaments using suture anchors is simpler, faster, and safer than the conventional bone tunnel technique and it does not have the risks of breakage of bone bridges, skin irritation, or graft loosening.

Treating schizophrenia: novel targets for the cholinergic system

Cognitive deficits in patients with schizophrenia are the biggest obstacle to achieving an independent and productive lifestyle, with these deficits being refractory to current drug treatments. Significantly, both nicotinic and muscarinic receptors (cholinoceptors) have been shown to have an important role in cognition and are therefore viewed as potential therapeutic targets for drugs designed to lessen cognitive deficits. Importantly, the demonstration that acetylcholinesterase inhibitors, which result in higher synaptic levels of acetylcholine, can reduce the cognitive deficits of schizophrenia suggested that under-stimulation of cholinoceptors could be associated with the cognitive deficits associated with this disorder. This has lead to a focus on the development of receptor agonists, partial agonists and allosteric agonists that can be used to stimulate cholinergic pathways and thus reduce the cognitive deficits of schizophrenia. In addition, muscarinic receptors have now been associated with the modulation of dopamine and may constitute an alternative target for the treatment of psychoses. Given these exciting new therapeutic initiatives, this review will outline current evidence that involves the cholinoceptors in the pathophysiology of schizophrenia and how these data can inform on approaches to more targeted treatments for the disorder.

A case of gastric syphilis with neurosyphilis presented as epigastric pain

Gastric syphilis has non-specific symptoms and various endoscopic and radiographic findings. Spirochetes are seen infrequently in biopsy specimens and the pathological findings are often non-specific. So it is very difficult to make a definitive diagnosis of gastric syphilis based on clinical symptoms and biopsy findings. We report the case of a gastric syphilis with neurosyphilis presented with epigastric pain. This case reminds us that gastric syphilis is one possibility in ulcerative gastric lesions.

Changes in visual and auditory response time during conscious sedation with propofol

BACKGROUND

Using a push-button device, we investigated whether visual or auditory response time would increase with increasing sedation, and assessed the responsiveness score of the Observer's Assessment of Alertness/Sedation (OAA/S) scale at the point of first loss of response to visual or auditory stimulation.

METHODS

In experiment 1 we applied visual and auditory stimulation to 19 patients as the propofol target plasma concentration (CPT) was increased to determine whether the visual or auditory response would be lost first. Thirty patients were each then infused with propofol, starting at a CPT of 0.3 microg ml(-1) and increasing by increments of 0.2 microg ml(-1), during which visual (experiment 2) or auditory (experiment 3) stimulation was applied when the effect-site concentration (CE) of propofol reached CPT. Visual response time (VRT), auditory response time (ART), CE and total amounts of propofol, and OAA/S score at the first loss of visual/auditory response were measured.

RESULTS

Visual response disappeared earlier than auditory response in 84.2% of the patients. Visual response time and ART were linearly prolonged as the CE of propofol increased. The CE and total amounts of propofol at the first loss of visual response were 1.2 +/- 0.4 microg ml(-1) and 57.9 +/- 16.7 mg, compared with 1.4 +/- 0.5 microg ml(-1) and 71.6 +/- 26.1 mg, respectively, at the first loss of auditory response. The median (range) OAA/S scores at the first loss of visual and auditory response were 4 (3-4) and 3 (2-4), respectively.

CONCLUSION

VRT and ART were linearly prolonged with increasing sedation. Visual response may be useful in monitoring conscious sedation.