Isoquinoline-based intrinsic fluorescence assessment of erythropoiesis-stimulating agent, Roxadustat (FG-4592), in tablets: applications to content uniformity and human plasma evaluation

In the present study, a first validated and green spectrofluorimetric approach for its assessment and evaluation in different matrices was investigated. After using an excitation wavelength of 345 nm, Roxadustat (ROX) demonstrates a highly native fluorescence at an emission of 410 nm. The influences of experimental factors such as pH, diluting solvents, and different organized media were tested, and the most appropriate solvent choice was ethanol. It was confirmed that there was a linear relationship between the concentration of ROX and the relative fluorescence intensity in the range 60.0-1000.0 ng ml-1, with the limit of detection and limit of quantitation, respectively, being 17.0 and 53.0 ng ml-1. The mean recoveries % [±standard deviation (SD), n = 5] for pharmaceutical preparations were 100.11% ± 2.24%, whereas for plasma samples, they were 100.08 ± 1.08% (±SD, n = 5). The results obtained after the application of four greenness criteria, Analytical Eco-Scale metric, NEMI, GAPI, and AGREE metric, confirmed its eco-friendliness. In addition, the whiteness meter (RGB12) confirmed its level of sustainability. The International Council for Harmonisation (ICH) criteria were used to verify the developed method through the study in both spiked plasma samples and content uniformity evaluation. An appropriate standard for various applications in industry and quality control laboratories was developed.

New Chromatographic Techniques for Sensitive Mebendazole Quantification in the Presence of Degraded Product, Commercial Tablets Application, and Greenness Assessment

BACKGROUND

Before it spreads to other tissues, mebendazole, a highly effective broad-spectrum anthelmintic, is used to treat worm infestations caused by roundworms, hookworms, whipworms, threadworms (pinworms), and the gastrointestinal form of trichinosis.

OBJECTIVE

The development of new methods for sensitive quantification of mebendazole in the presence of degraded product is the main objective of the presented research.

METHODS

Validated chromatographic techniques with high sensitivity (HPTLC and UHPLC) are used. The HPTLC method was adopted on silica gel HPTLC F254 plates using ethanol, ethyl acetate, and formic acid (3: 8: 0.05, by volume) as a developing system. Furthermore, the UHPLC method is a green isocratic method with a mobile phase containing methanol and 0.1% sodium lauryl sulphate (20:80, v/v).

RESULTS

The suggested chromatographic methods are greener than the reported ones in terms of the used greenness assessment methods. To validate the developed methods; International Council on Harmonization (ICH/Q2) guidelines were followed. Successful application of the proposed methods was revealed by the simultaneous analysis of mebendazole (MEB) and its major degradation product, 2-amino-5-benzoylbenzimidazole (ABB). The linear ranges were 0.2-3.0, 0.1-2.0 µg/band for the HPTLC method, and 2.0-50, 1.0-40 µg/mL for the UHPLC method for MEB and ABB, respectively.

CONCLUSION

The suggested methods were used to analyze the studied drug in its commercial tablets. Both pharmacokinetic studies and quality control laboratories can make use of the suggested techniques.

HIGHLIGHTS

Green and accurate HPTLC and UHPLC methods for the determination of Mebendazole and its major degradation products.

The convenient use of fluorescamine for spectrofluorimetric quantitation of pramipexole in pure form and pharmaceutical formulation; application to content uniformity testing

Pramipexole is a selective dopamine receptor agonist which is used in the treatment of Parkinson's disease and restless legs syndrome. The present work illustrates the development and validation of a sensitive and selective spectrofluorometric method for quantitation of pramipexole (PMP) through its interaction with fluorescamine at pH 7.5 using aqueous borate buffer to produce a highly fluorescent product. The fluorescent intensity of the formed product was measured at 480 nm after excitation at 391 nm. Experimental factors that could influence the formation, stability and the fluorescence intensity of the formed product were investigated and optimized. The linearity of the proposed method was achieved in the concentration range of 0.05-2.0 μg/mL. The quantitation and detection limits were 47 and 15 ng/mL, respectively. The proposed method has been validated in respect to guidelines of ICH and pharmaceutical tablets of PMP were successfully analyzed. Moreover, the method was applied for studying the content uniformity test according to the guidelines of United States Pharmacopeia.

Spectrofluorimetric approach for determination of citicoline in the presence of co-formulated piracetam through fluorescence quenching of eosin Y

A simple, sensitive, and precise spectrofluorimetric method has been developed and validated for quantitation of citicoline in its pharmaceutical formulations. The proposed method based on quantitative quenching effect of citicoline on the native fluorescence of Eosin Y via developing of a binary complex reaction between the cited drug and Eosin Y in acidic medium using acetate buffer pH = 3.6. The quenching of the fluorescence of eosin was measured at 540 nm after excitation at 518 nm. Calibration graph was achieved in the range of 300-3000 ng/mL with 0.9996 as correlation coefficient and 291.0 and 93.86 ng/mL as quantitation and detection limits, respectively. The developed method considered as the first developed spectrofluorimetric one for quantitation of citicoline with high sensitivity and validated according to ICH guidelines. The selectivity of the proposed method was investigated by studying the interference of piracetam as co-formulated drug with CIT in pharmaceutical formulation, therefore the developed method could be used for routine quality control of citicoline in its pharmaceutical formulations either alone or in combination with piracetam.

Development and validation of stability indicating chromatographic methods for simultaneous determination of citicoline and piracetam

Citicoline and piracetam were subjected separately to different stress conditions as recommended by the international conference on harmonization. In addition, new stability indicating thin layer chromatographic and ultra high performance liquid chromatographic methods have been developed and validated for simultaneous determination of citicoline and piracetam in presence of their degradation products. Separation on the proposed thin layer chromatographic method was carried out using a developing system containing methanol:chloroform:ammonium chloride buffer (9:1:2, v/v/v) on silica gel plates at 230 nm. On the other hand, the mobile phase in the ultra high performance liquid chromatographic method was composed of water (containing 0.1% triethylamine):ethanol (92:8, v/v). The flow rate was 1 mL/min and ultraviolet detection was at 230 nm. Moreover, results of the developed methods were statistically compared to those obtained by the reported high-performance liquid chromatography method and no significant difference between them was found. The greenness profile of ultra high performance liquid chromatographic method was assessed and compared with those of the previously published high-performance liquid chromatography methods, it was noticed that the proposed ultra high performance liquid chromatographic method more environmentally friendly and greener than other methods.

Innovative spectrofluorometric protocol based on micro-environment improvement for determination of Quetiapine in dosage forms and rat plasma

Quetiapine (QUT) is an atypical antipsychotic drug indicated for the treatment of schizophrenia and acute manic episodes associated with bipolar disorders. A simple, rapid, and highly sensitive micellar spectrofluorometric method has been developed and validated for quantitation of QUT in its pharmaceutical formulations with application to content uniformity test, in presence of its degradation product and in rat plasma. The proposed method was based on the enhancement of the fluorescence intensity of QUT in 2% v/v tween 80 micellar solution. The fluorescence intensity was measured at 372 nm after excitation at 261 nm. A linear relationship was achieved between the fluorescence intensity and the drug concentration in the range of 20-1000 ng/mL with 18.5 and 6.3 ng/mL as limits of quantitation and detection, respectively. The proposed method was extended to study the stability of QUT after its exposure to different forced degradation conditions such as; acidic, alkaline, oxidative, photolytic and thermal conditions according to ICH guidelines. The study revealed that QUT is stable under all the of these conditions except the oxidative one. Furthermore, the high sensitivity of the micellar method permits its application for determination of QUT in rat plasma with good percentage recovery as well as determination of C_max.

A pilot study of single nucleotide polymorphisms in the interleukin-6 receptor and their effects on pre- and post-transplant serum mediator level and outcome after allogeneic stem cell transplantation

Interleukin (IL)-6 is an important regulator of immunity and inflammation in many diseases. Single nucleotide polymorphisms (SNPs) in the IL-6 gene influence outcome after allogeneic stem cell transplantation (ASCT), but the possible importance of SNPs in the IL-6 receptor has not been examined. We therefore investigated whether SNPs in the IL-6R gene influenced biochemical characteristics and clinical outcomes after ASCT. We examined the IL-6 promoter variant rs1800975 and the IL-6R SNPs rs4453032, rs2228145, rs4129267, rs4845374, rs4329505, rs4845617, rs12083537, rs4845618, rs6698040 and rs4379670 in a 101 population-based cohort of allotransplant recipients and their family donors. Patients being homozygous for the major alleles of the IL-6R SNPs rs2228145 and rs4845618 showed high pretransplant CRP serum levels together with decreased sIL-6R levels; the decreased IL-6R levels persisted 6 months post-transplant. In contrast, patients being homozygous for the minor allele of the IL-6R SNP rs4379670 showed decreased pretransplant CRP levels. Furthermore, the IL-6R rs4845618 donor genotype showed an association with severe acute graft-versus-host disease (GVHD), whereas the donor genotype of the IL-6 SNP rs1800795 was associated with decreased survival 100 days post-transplant. Finally, the recipient genotype of the IL-6R SNP rs4329505 showed a strong association with 2-years non-relapse mortality, and this effect was also highly significant in multivariate analysis. IL-6 and IL-6R SNPs influence the clinical outcome after allogeneic stem cell transplantation.

INTRAMEDULLARY TUBERCULOMA OF THORACIC SPINAL CORD IN AN APPARENTLY HEALTHY NIGERIAN: CASE REPORT

Spinal intramedullary is an uncommon form of tuberculosis causing spinal cord injury in this environment. We report a case of thoracic intramedullary tuberculoma in an immunocompetent male Nigerian with negative screening for tuberculosis. He presented with 8 months history of back pain and 2 months history of progressive weakness in both lower limbs. Physical examination revealed a well-nourished man with spastic paraplegia. Chest radiograph and CT scan were normal but Magnetic resonance imaging (MRI) of the thoracolumbar region showed cord oedema and circumscribed intramedullary lesions at D12 and L1 levels with target sign. The patient was promptly prepared and had D12 and L1 laminectomy and posterior myelotomy with excision of the intramedullary lesion. Histology showed granulomatous lesion with central caseation in keeping with a tuberculoma. He was treated with a 4-drug antituberculous regimen with physiotherapy and he made complete neurological recovery 8 months post-operatively. Intramedullary tuberculoma should be considered in differential diagnosis of intramedullary tumors in this environment. Treatment with antituberculous drugs results in good outcome.

Rome III subgroups of functional dyspepsia exhibit different characteristics of antral contractions measured by strain rate imaging - a pilot study

PURPOSE

Rome III defines two distinct entities of functional dyspepsia (FD), namely epigastric pain syndrome (EPS) and postprandial distress syndrome (PDS). We aimed at studying these subgroups of FD by simultaneously assessing antral strain, gastric accommodation and emptying and visceral hypersensitivity.

MATERIALS AND METHODS

Strain during antral contractions was assessed by ultrasound strain rate imaging in 15 controls and 19 FD patients (8 EPS patients and 11 PDS patients). Gastric accommodation and emptying were assessed using B-mode ultrasonography. Symptoms were assessed by visual analogue scale (VAS).

RESULTS

During fasting, antral strain in EPS patients (mean±SEM) was 61.4 ± 6.4 %, significantly higher than in controls (47.5 ± 3.3 %; p = 0.042) and in PDS patients (28.6 ± 1.7 %; p = 0.001). PDS patients had lower strain than controls (p < 0.001). Postprandially, EPS patients had higher strain than both controls and PDS patients (p < 0.01) but no difference was found between controls and PDS patients. Compared with controls, PDS patients had significantly larger fasting proximal area than controls (14.9 ± 1.6 cm2 vs. 7.8 ± 0.2 cm2; p < 0.001), whereas EPS patients did not differ (12.1 ± 1.9 cm2; p = 0.057). Gastric emptying fraction (1 - proximal area at 40 min postprandially/area at 1 min postprandial × 100) at 40 min postprandially in EPS patients 46.4 ± 6.6 % was lower than in controls (62.9 ± 1.3 %; p = 0.032), but higher than PDS patients (27.4 ± 5.3 %; p = 0.018).

CONCLUSION

Anterior radial strain measured by ultrasound strain rate imaging may discriminate between subgroups of FD and healthy controls. This study supports the Rome III classification of FD into EPS and PDS groups.

Strain measurement during antral contractions by ultrasound strain rate imaging: influence of erythromycin

Strain rate imaging (SRI) is a non-invasive ultrasound (US) modality that enables the study of mechanical deformation (strain) with high spatial and temporal resolution. A total of 244 contractions in seven healthy volunteers were studied by SRI on two separate days to characterize radial strain of antral contractions in the fasting and fed states and to assess the influence of intravenous erythromycin. Gastric accommodation and emptying were assessed by 2D ultrasonography. The perception of hunger was registered by the participants. The strain increased from early to late phase II and phase III activity by (median) 18%, 58% and 82%, respectively, P < 0.05. Erythromycin infusion in phase I induced contractions with median strain of 35%, but did not increase postprandial strain. Both fasting and postprandially, lumen-occlusive contractions with erythromycin were more frequent than in naturally occurring contractions, 69%vs 48%, P = 0.036 and 40%vs 5%, P < 0.001 respectively. All subjects had rumbling in their abdomens when intraluminal air was detected sonographically (85% of all phase III contractions) and that rumbling was perceived by the participant as maximal awareness of hunger. SRI enabled detailed strain measurement of individual antral contractions. Erythromycin initiated fasting antral contractions and increased the number of lumen-occlusive contractions.

The effect of metformin on blood glucose control in overweight patients with Type 1 diabetes

AIMS

In a randomized, double-blind, cross-over study, we investigated the effect of metformin on blood glucose control and daily insulin dose in overweight patients with Type 1 diabetes.

METHODS

We studied 15 C-peptide-negative patients, aged 48 +/- 12 years, with a body mass index of 31.3 +/- 2.6 kg/m(2). Each patient had a 'screening visit', followed by a 4-week 'run-in' period. This was followed by two separate 16-week 'study' (treatment) periods, separated by a 4-week 'wash-out' period. Patients received either metformin or placebo during the 'study' periods, in random order.

RESULTS

HbA(1c) was significantly lower following 16 weeks of treatment with metformin (7.8 +/- 1.1%) compared with baseline (8.5 +/- 1.4%; P < 0.005) and placebo (8.6 +/- 1.2%; P < 0.005). Fasting plasma glucose, following 16 weeks of metformin treatment, was significantly lower (8.3 +/- 2.8 mmol/l) compared with baseline (12.4 +/- 3.0 mmol/l; P < 0.01) and placebo (12.6 +/- 3.4 mmol/l; P < 0.01). Compared with baseline (60 +/- 14 units), total daily insulin dose was significantly lower following the addition of metformin (50 +/- 13 units; P < 0.05) and this final total daily insulin dose in the metformin group was lower compared with placebo (58 +/- 12 units, P < 0.05). Body weight did not change following metformin or placebo treatment.

CONCLUSION

Metformin can effectively improve glycaemic control and reduce the total daily insulin dose in overweight people with Type 1 diabetes.

A survey of peri-operative use of magnesium sulphate in adult cardiac surgery in the UK

We conducted a postal survey of cardiac anaesthetists in the UK, to determine the extent of magnesium sulphate (MgSO4) use and the main indications for its administration. Questionnaires were sent to anaesthetists at 35 UK hospitals undertaking adult cardiac surgery. Responses were received from 24 hospitals (69%) totalling 124 individual responses. Twenty-five (20%) of the anaesthetists responding to the questionnaire routinely gave magnesium other than in cardioplegia. The most common indications for administration were arrhythmia prophylaxis and treatment, myocardial protection, and the treatment of hypomagnesaemia.

Tracheal intubation through the laryngeal mask airway using a gum elastic bougie: the effect of head position

STUDY OBJECTIVE

To determine the effect of head position on success of tracheal intubation through a Laryngeal Mask Airway (LMA) using a gum elastic bougie.

DESIGN

Randomized, controlled study.

SETTING

Anesthesia and operating rooms of the University Hospital, Nottingham, UK.

PATIENTS

20 patients scheduled to undergo routine elective surgery requiring the use of an LMA for anesthesia.

INTERVENTIONS

Blind placement of a gum elastic bougie through an LMA in two head positions.

MEASUREMENTS AND MAIN RESULTS

Final position of the gum elastic bougie after removal of the LMA as determined by fiberoptic laryngoscopy. The gum elastic bougie was correctly sited in the trachea in the classical intubating position in 4/20 (20%) and in the neutral position in 0/20 (0%). There was no difference in the success of this technique between the two head positions.

CONCLUSIONS

This technique cannot be recommended as an alternative to direct laryngoscopy following a failed intubation.

Cardiac output during hemiarthroplasty of the hip. A prospective, controlled trial of cemented and uncemented prostheses

In a prospective, controlled study, we measured the effect on cardiac output of the introduction of methylmethacrylate during hemiarthroplasty for displaced fractures of the femoral neck. We treated 20 elderly patients who were similar in age, height, weight and preoperative left ventricular function with either cemented or uncemented hemiarthroplasty. Using a transoesophageal Doppler probe, we measured cardiac output before incision and at six stages of the procedure: during the surgical approach, reaming and lavage of the femoral canal, the introduction of cement, the insertion of the prosthesis, and in reduction and closure. We found that before the cement was introduced, there was no difference in stroke volume or cardiac output (p > 0.25). Cementation produced a transient but significant reduction in cardiac output of 33% (p < 0.01) and a reduction in stroke volume of 44% (p < 0.02). The introduction of cement did not affect the heart rate or mean arterial pressure. There was no significant difference in cardiac function on insertion of the prosthesis. Standard non-invasive haemodynamic monitoring did not detect the cardiovascular changes which may account for the sudden deaths that sometimes occur during cemented hemiarthroplasty. The fall in stroke volume and cardiac output may be caused by embolism occurring during cementation, but there was no similar fall during reaming or insertion of the prosthesis.

Antimicrobial agent resistance in bacterial isolates from patients with diarrhea and urinary tract infection in the Sudan

Antimicrobial sensitivity tests were performed on four-hundred and ninety-seven bacterial isolates from Sudanese patients with diarrhea or urinary tract infections. Shigella dysenteriae type I and enteropathogenic Escherichia coli showed high resistance rates (percentage of isolates showing antibiotic resistance) against the commonly-used antimicrobial agents: ampicillin, amoxicillin, chloramphenicol, tetracycline, cotrimoxazole, nalidixic acid, sulfonamide, and neomycin, and were completely sensitive to ciprofloxacin. Eighteen resistance patterns against nine antimicrobial agents tested were observed in enteric pathogens. Resistance to ampicillin, amoxicillin, tetracycline, cotrimoxazole, and sulfonamide was the most frequent pattern. The common urinary pathogens, E. coli, Klebsiella pneumoniae, and Proteus mirabilis showed high rates of resistance to ampicillin, amoxicillin, cotrimoxazole, tetracycline, sulfonamide, trimethoprim, streptomycin, and carbenicillin. We recommend that physicians seek updated knowledge of the common antibiotic-sensitivity patterns when starting empirical antibiotic therapy in Sudanese patients with diarrhea or urinary tract infection.

Randomized, placebo-controlled trial of combination antiemetic prophylaxis for day-case gynaecological laparoscopic surgery

In a randomized, double-blind trial, we compared i.v. ondansetron 4 mg (control), i.v. ondansetron 4 mg and cyclizine 50 mg (combination) and i.v. saline 0.9% (placebo), given after induction of standardized anaesthesia, for the prevention of nausea and vomiting (PONV) after day-case gynaecological laparoscopic surgery. Compared with placebo, fewer patients in the control group vomited (9/20 versus 11/59, P = 0.02) or needed rescue antiemetic (7/20 versus 9/59, P = 0.06) before discharge. Compared with the control, fewer patients in the combination group (n = 60) vomited (11/59 versus 2/60, P = 0.01) or needed rescue antiemetic (29/59 versus 2/60, P = 0.03) before discharge. The incidence of vomiting in the combination group was less than 5% overall. Compared with the control, the combination group had a significantly lower incidence (P = 0.001) and severity (P < 0.001) of nausea after discharge and more patients with no PONV at any time during the study (15/59 versus 27/60, P = 0.03). Unlike the placebo and control groups, no patient receiving combination prophylaxis was admitted overnight for PONV management.

Cardiovascular pharmacology: new drugs and new indications

This review presents a brief overview of some of the many exciting developments that are taking place in the field of cardiovascular pharmacology. Research continues to progress at a rapid rate, and we can expect many drugs to enter the clinical arena within the next few years. It must be borne in mind, however, that the pharmaceutical industry and hospital budgetary restrictions sometimes limit drug development and occasionally interrupt clinical trials, even before their results have been obtained.

Optimal provision of daytime NPH insulin in patients using the insulin analog lispro

OBJECTIVE

Insulin lispro improves early postprandial blood glucose control but can result in late interprandial hyperglycemia. As an approach to resolving this problem, we performed a randomized, crossover study with four treatment arms, comparing the daytime metabolic profile after either premeal lispro alone or premeal lispro with optimal daytime NPH insulin and with standard human regular insulin.

RESEARCH DESIGN AND METHODS

Twelve C-peptide negative type 1 diabetic patients were studied on four separate study days, at least 7 days apart. On each study day, patients received one of the four study insulin treatments, in random order, with identical meals and snacks. The four treatments were 1) premeal human regular insulin before lunch and supper at unchanged dose; 2) premeal lispro (unchanged dose) at lunchtime and dinner; 3) pre-lunch reduced-dose lispro (70%) before lunch and supper with supplemental lunchtime NPH and with a 6-h interval until dinner; and 4) pre-lunch reduced-dose lispro (70%) before lunch and supper with supplemental lunchtime NPH and with a 8-h interval until dinner. All patients were using their usual premeal plus basal insulin regimen during the period of the study, with human regular insulin before meals and NPH insulin at bedtime.

RESULTS

Postprandial blood glucose concentrations (1230-1500) were lower after reduced or usual lispro dose compared with human regular insulin (5.5+/-0.2 and 5.6+/-0.2 vs. 8.2+/-0.5 mmol/l, P < 0.001), with no difference between the lispro doses. However, prepran-Dial (1800) blood glucose levels deteriorated to higher levels after usual-dose lispro alone compared with either human regular insulin (P < 0.05) or reduced-dose lispro plus NPH (P < 0.05) (8.9+/-0.3 vs. 7.1+/-0.8 and 6.4+/-0.4 mmol/l), with no difference between human regular insulin and reduced-dose lispro plus NPH. During the 2 h between the usual and delayed mealtime, blood glucose concentrations remained controlled on lispro plus NPH (2000: 6.5+/-0.4 mmol/l).

CONCLUSIONS

Reduced-dose lunchtime lispro plus NPH maintained the improvement in postprandial blood glucose control with no deterioration in interprandial blood glucose control, even up to a late meal.

A physiology simulator: validation of its respiratory components and its ability to predict the patient's response to changes in mechanical ventilation

We aimed to validate the mathematical validity and accuracy of the respiratory components of the Nottingham Physiology Simulator (NPS), a computer simulation of physiological models. Subsequently, we aimed to assess the accuracy of the NPS in predicting the effects of a change in mechanical ventilation on patient arterial blood-gas tensions. The NPS was supplied with the following measured or calculated values from patients receiving intensive therapy: pulmonary shunt and physiological deadspace fractions, oxygen consumption, respiratory quotient, cardiac output, inspired oxygen fraction, expired minute volume, haemoglobin concentration, temperature and arterial base excess. Values calculated by the NPS for arterial oxygen tension and saturation (PaO2 and SaO2), mixed venous oxygen tension and saturation (PvO2 and SvO2), arterial and mixed venous carbon dioxide tension (PaCO2 and PvCO2) and arterial pH were accurate compared with measured values. Subsequently, arterial gas responses to changes in minute volume of FiO2 were measured in 31 patients and were compared with the NPS prediction for each response. The 95% limits of agreement in predicting the magnitude of change were: arterial oxygen tension -2.07 to 2.47 kPa; PaCO2 -0.33 to 0.67 kPa; and pH -0.023 to 0.033. This investigation has validated respiratory components of the NPS. We recommend the NPS as a clinical tool for predicting the effects of alterations in mechanical ventilation in stable patients in the intensive care unit.

Optimization of evening insulin dose in patients using the short-acting insulin analog lispro

OBJECTIVE

A three-way, crossover, open-label, randomized study was designed to compare the evening and night (1800-0800) glycemic control when the evening premeal lispro dose was reduced by 20% and the bedtime basal NPH dose increased by 25%, or when the basal NPH dose was moved to before dinner at 1800, compared with the control arm on standard premeal human regular insulin and pre-bedtime NPH insulin.

RESEARCH DESIGN AND METHODS

A total of 13 type 1 diabetic patients who use a premeal plus basal insulin regimen were studied on three separate days, with identical meals and snacks at the same times on each study day. On the control study day, patients received human regular insulin before dinner and NPH at bedtime in their usual doses. On another day, lispro was given before dinner with a dose reduction of 20%, and NPH at bedtime at 125% of usual dose. In the third regimen, the lispro and NPH were administered together in their usual dose before the evening meal by separate injections. The three regimens were tested in random order.

RESULTS

Postprandial (1800-2200) blood glucose concentrations were lower after reduced-dose lispro compared with human regular insulin (6.0 +/- 0.3 [SEM] vs. 7.4 +/- 0.3 mmol/l, P < 0.05). Nighttime (2400-0400) blood glucose concentrations were not different (8.6 +/- 0.3 vs. 9.2 +/- 0.3 mmol/l, NS), and prebreakfast concentrations were also unchanged (7.7 +/- 0.9 vs. 8.7 +/- 0.8 mmol/l) after lispro with increased-dose NPH compared with standard insulin. By contrast, both nighttime (10.0 +/- 0.3 mmol/l, P < 0.05) and fasting glucose concentrations (10.8 +/- 0.6 mmol/l, P < 0.05) were significantly higher with dinnertime usual-dose lispro plus dinnertime usual-dose NPH compared with standard human insulin. Hypoglycemia at night (blood glucose < 3.0 mmol/l) did not differ between study days, but it was more frequent postprandially after dinner usual-dose lispro plus early NPH (2 vs. 7 patients, P = 0.062).

CONCLUSIONS

With lower mealtime and higher basal bedtime insulin doses, patients using insulin lispro may be able to gain an overall improvement in evening blood glucose control without deteriorated nighttime glucose levels. Earlier basal NPH dosage alone does not ameliorate the nighttime hyperglycemia of short-acting insulin analog regimens.

The effect of the insulin analog lispro on nighttime blood glucose control in type 1 diabetic patients

OBJECTIVE

Unmodified regular insulin has a long absorption tail, unlike the fast-acting insulin analog lispro, and may contribute to hypoglycemia in the early part of the night. A randomized crossover double-blind study was performed to compare blood glucose concentrations in the early part of the night in type 1 diabetic patients receiving lispro or unmodified regular human insulin, in random order, on 2 separate study days.

RESEARCH DESIGN AND METHODS

We studied 23 C-peptide-negative patients; 12 were using a premeal plus basal insulin regimen, and 11 were using twice-daily insulin injections. Patients were admitted to the investigation unit at 5:00 P.M. and received a single dose of lispro or unmodified regular human insulin before the evening meal. In both groups, the NPH insulin dose remained unchanged. Identical meals and snacks were eaten at the same time during both study days.

RESULTS

Average postprandial (6:00-10:00 P.M.) blood glucose concentrations were significantly lower after lispro therapy compared with human insulin (7.1 +/- 0.4 [SE] vs. 8.5 +/- 0.4 mmol/l, P = 0.0002). Nighttime (midnight to 4:00 A.M.) blood glucose concentrations were significantly higher after lispro compared with human insulin (10.3 +/- 0.4 vs. 9.1 +/- 0.4 mmol/l, P = 0.02). This difference was greatest in patients on the premeal plus basal insulin regimen (11.6 +/- 0.5 vs. 8.7 +/- 0.4 mmol/l, P < 0.001). The incidence of nocturnal hypoglycemia (midnight to 4:00 A.M., blood glucose < 3.5 mmol/l) was less with lispro compared with unmodified insulin (1 vs. 6 patients, P = 0.04). Nighttime (midnight to 4:00 A.M.) 3-hydroxybutyrate (102 +/- 13 vs. 51 +/- 7 mumol/l, P = 0.000) and glycerol (52 +/- 3 vs. 42 +/- 2 mumol/l, P < 0.01) were significantly higher after lispro therapy compared with human insulin in patients on the premeal plus bolus insulin regimen.

CONCLUSIONS

Lispro can improve postprandial blood glucose control and reduce the incidence of nocturnal hypoglycemia at the expense of nocturnal hyperglycemia and hyperketonemia in patients using a premeal plus basal insulin regimen.

Anaesthetic management of a quadriplegic patient with severe respiratory insufficiency undergoing caesarean section

The anaesthetic management of a 30-year-old pregnant quadriplegic patient with severe respiratory insufficiency undergoing Caesarean section is described. Quadriplegia and respiratory insufficiency pose potential problems for anaesthetists and these are discussed. In particular autonomic hyperreflexia may occur and this may be mistaken for pre-eclampsia.

Toxoplasma gondii in Saudi blood donors a serological study using three tests

A total of one hundred and fifty Saudi blood donors were examined for Toxoplasma gondii antibodies (IgG-IgM) by three serological techniques, 50 normal cross matched controls were subjected to the same examination. The number of positive donors for IgG by Indirect Haemagglutination test (IHA) was 36 (24%), by Enzyme Linked Immunosorbent Assay (ELISA) was 70 (46.7%), and by Immunofluorescent test (IFAT) 74 (49.3%). As to IgM the ELISA and IFAT showed 3 positive cases among the blood donors (2%). Rheumatoid factor and antinuclear antibodies were done for positive cases, and showed no significant cross reaction, IgG antibodies were significantly high in donors than in controls. The three tests were more or less dependable. However regarding simplicity, specificity, accuracy and time consumption factor IFAT was recommended for Toxoplasma IgG for all blood donors to avoid the risk of in infection.

Sensitivity of LiF thermoluminescent dosemeters to 6-18 keV photons

The sensitivity of thermoluminescent dosemeters (TLD) to 6-18 keV photons at six different effective energies was determined using an extrapolation chamber as a dosimetric standard. Photons having effective energies of 8.1, 9.2, 13.5, 13.8 and 18.0 keV were generated from an x-ray machine using appropriate kilovoltages and aluminium filters. Photons from an 55Fe source (6 keV) were also used to broaden the range of energies investigated. Observed sensitivities relative to 137Cs were found not to differ from unity with the possible exception of 6.0 keV photons. At 6.0 keV the sensitivity was found to be 0.83 +/- 0.5.

Scales for measuring mania

This paper examines the utility of two scales for mania and the statistical validity of their use in a clinical setting. The literature is reviewed in regard to the present evaluation of accurate clinical scales in this area.

Tetracycline prophylaxis in families of cholera patients

The evaluation of tetracycline as a chemoprophylactic agent for cholera is described. Families of cholera patients were divided into 4 groups by strict rotation. The first group received multivitamin preparations and served as the control. The second received 1.0 g of tetracycline, divided into 4 doses, daily for 5 days, the third received 1.0 g of tetracycline in a single dose daily for 5 days, and the fourth received a single dose of 1.0 g of tetracycline. All families were visited daily for 10 days, a rectal swab being taken from each family member on each occasion. Tetracycline given daily for 5 days, either in divided doses or in a single daily dose, was effective in preventing subsequent infection. A single dose of tetracycline was less effective. The indications for chemoprophylaxis in cholera are discussed.

Increased plasma arginine vasopressin in clinical adrenocortical insufficeincy and its inhibition by glucosteroids

Trichloroacetic acid extracts of plasma were fractionated on a CG-50 resin column and the 50% acetic acid eluents chromatographed on silicic acid-impregnated glass paper in butanol-acetic acid-water. The specific arginine vasopressin (AVP) zone was eluted and assayed for antidiuretic activity in the diuretic rat. Thioglycolate inactivation was used to confirm AVP activity. Recovery of as little as 4 muU AVP per ml plasma ranged between 80 and 90%. In normal subjects after an overnight fast, plasma AVP ranged between 2.5 and 10.0 muU per ml. AVP secretion was inhibited by hemodilution and stimulated with nicotine and hypertonic saline. Plasma AVP was absent in patients with diabetes insipidus even after neurohypophyseal stimulation. Plasma AVP was abnormally elevated during mild dehydration and remained above the normal range despite hemodilution in patients with untreated adrenocortical insufficiency demonstrating a delayed water diuresis. Glucosteroid therapy lowered plasma AVP to normal in dehydrated patients. A normal diuretic response to hydration was accompanied by a fall in plasma AVP to zero in steroid-treated patients. These findings suggest that hypersecretion of AVP may play an important role in the abnormal water metabolism of adrenocortical insufficiency and that the glucosteroids promote normal water diuresis by inhibiting the secretion of AVP from the neurohypophysis.