Favipiravir in patients hospitalised with COVID-19 (PIONEER trial): a multicentre, open-label, phase 3, randomised controlled trial of early intervention versus standard care

BACKGROUND

COVID-19 has overwhelmed health services globally. Oral antiviral therapies are licensed worldwide, but indications and efficacy rates vary. We aimed to evaluate the safety and efficacy of oral favipiravir in patients hospitalised with COVID-19.

METHODS

We conducted a multicentre, open-label, randomised controlled trial of oral favipiravir in adult patients who were newly admitted to hospital with proven or suspected COVID-19 across five sites in the UK (n=2), Brazil (n=2) and Mexico (n=1). Using a permuted block design, eligible and consenting participants were randomly assigned (1:1) to receive oral favipiravir (1800 mg twice daily for 1 day; 800 mg twice daily for 9 days) plus standard care, or standard care alone. All caregivers and patients were aware of allocation and those analysing data were aware of the treatment groups. The prespecified primary outcome was the time from randomisation to recovery, censored at 28 days, which was assessed using an intention-to-treat approach. Post-hoc analyses were used to assess the efficacy of favipiravir in patients aged younger than 60 years, and in patients aged 60 years and older. The trial was registered with clinicaltrials.gov, NCT04373733.

FINDINGS

Between May 5, 2020 and May 26, 2021, we assessed 503 patients for eligibility, of whom 499 were randomly assigned to favipiravir and standard care (n=251) or standard care alone (n=248). There was no significant difference between those who received favipiravir and standard care, relative to those who received standard care alone in time to recovery in the overall study population (hazard ratio [HR] 1·06 [95% CI 0·89-1·27]; n=499; p=0·52). Post-hoc analyses showed a faster rate of recovery in patients younger than 60 years who received favipiravir and standard care versus those who had standard care alone (HR 1·35 [1·06-1·72]; n=247; p=0·01). 36 serious adverse events were observed in 27 (11%) of 251 patients administered favipiravir and standard care, and 33 events were observed in 27 (11%) of 248 patients receiving standard care alone, with infectious, respiratory, and cardiovascular events being the most numerous. There was no significant between-group difference in serious adverse events per patient (p=0·87).

INTERPRETATION

Favipiravir does not improve clinical outcomes in all patients admitted to hospital with COVID-19, however, patients younger than 60 years might have a beneficial clinical response. The indiscriminate use of favipiravir globally should be cautioned, and further high-quality studies of antiviral agents, and their potential treatment combinations, are warranted in COVID-19.

FUNDING

LifeArc and CW+.

AB1126 THE RELIABILITY AND DIAGNOSTIC ACCURACY OF DIGITAL TOMOSYNTHESIS COMPARED WITH CONVENTIONAL RADIOGRAPHY FOR THE INVESTIGATION OF SACROILIITIS

Background:

Conventional radiography remains part of the diagnosis of axial spondyloarthritis and determines qualification for biologic disease modifying anti-rheumatic drugs in many countries. The standard anteroposterior radiograph (XR) incompletely images the complex sacroiliac joint with recognised unacceptably low levels of agreement between readers. Digital tomosynthesis (DTS) uses conventional radiographic projections to create a three-dimensional image and is a potential alternative for the initial radiographic detection and grading of sacroiliitis.

Objectives:

To compare the level of agreement between two radiologists when reporting sacroiliac joint imaging with digital tomosynthesis versus conventional radiography, as well as to compare the diagnostic accuracy of each imaging modality.

Methods:

229 consecutive patients that had radiography and digital tomosynthesis performed at Footscray Hospital, Melbourne, Australia were included. Two blinded radiologists independently re-reported all images according to the modified New York criteria, or listed an alternative diagnosis. An overall assessment of each image as inflammatory sacroiliitis, normal or non-inflammatory disease was also recorded. Demographic and clinical data were extracted from medical records. Agreement between and within readers was evaluated using kappa (κ) statistic. Diagnostic accuracy was calculated by comparing each reader’s overall assessment against 2 reference standard comparators: most recent rheumatologist diagnosis and fulfillment of ASAS criteria at any time point.

Results:

The intra-reader agreement of reader 1 was almost perfect for the left, right and overall sacroiliac joint assessments (κ 0.77 - 0.94), with DTS outperforming XR. Reader 2 agreement was mostly moderate (κ 0.39 - 0.69), with DTS and XR better on the left and right sacroiliac joint respectively, but XR having better overall assessment. The inter-reader agreement of DTS for all patients was moderate and better than XR as shown in the Table. When excluding non-spondyloarthritis patients, inter-reader agreement improved (κ 0.50 to 0.58) but there was no significant difference between DTS and XR. Using reader 1, the sensitivity of DTS (64.8 - 66.7%) was better than XR (54.9 - 60.7%) but low, in keeping with what is known about radiographic sacroiliitis and axial spondyloarthritis. The specificity of XR (78.5 – 80.3%) was better than DTS (72.3 – 73.1%). There were no significant differences when fulfillment of modified New York Criteria was used as a reader’s positive test.

Table.

Inter-rater reliability between the readers

All patients(N=229)*Inflammatory sacroiliitis & normal patients (N=164)**Inflammatory sacroiliitis patients (N=92)**XR Right0.360.520.56DTS Right0.390.500.51XR Left0.340.550.56DTS Left0.420.550.58XR Overall0.40DTS Overall0.45

*Non-weighted kappa statistic

**Weighted kappa statistic

Conclusion:

DTS demonstrated moderate reliability for assessment of sacroiliitis, marginally better than conventional radiography. Overall levels of agreement for both imaging modalities were however lower than radiography in previous studies, with several possible contributing factors. A prospective study in a selected spondyloarthritis cohort may better determine any benefit of DTS.

References:

[1]Christiansen AA, Hendricks O, Kuettel D, Horslev-Petersen K, Jurik AG, Nielsen S, et al. Limited Reliability of Radiographic Assessment of Sacroiliac Joints in Patients with Suspected Early Spondyloarthritis. The Journal of rheumatology. 2017;44(1):70-7.

[2]van Tubergen A, Heuft-Dorenbosch L, Schulpen G, Landewe R, Wijers R, van der Heijde D, et al. Radiographic assessment of sacroiliitis by radiologists and rheumatologists: does training improve quality? Annals of the rheumatic diseases. 2003;62(6):519-25.

Disclosure of Interests:

None declared

Spinal cord injured patients’ knowledge of pressure sores

Despite much effort being put into educating spinal cord injured patients on pressure sore prevention, pressure sores remain a major cause of morbidity and mortality. This study sought to establish: i) paraplegics’ knowledge on pressure sore prevention prior to discharge; ii) the influence of knowledge on pressure sore occurrence during hospitalization; iii) sources of paraplegics’ knowledge on pressure sore prevention. A total of twenty-six men and two women with paraplegia aged between 18 and 45 years participated in the study. A rospective pre-test post-test method using a structured questionnaire was used to test paraplegics’ knowledge on pressure sore prevention. The first interview was done within one week of mobilising in a wheelchair and the second one after two months or a few days before discharge. Pressure sore occurrence and the source of knowledge were also recorded. The results showed that paraplegics’ knowledge on pressure sore prevention at discharge is incomplete. Knowledge gain does not seem to determine whether one will develop pressure sores or not. Physiotherapists (89%), nurses (82%) and occupational therapists (68%) are the main educators of paraplegics on pressure sore prevention in rehabilitation hospitals.

Can non-mechanical proteins withstand force? Stretching barnase by atomic force microscopy and molecular dynamics simulation

Atomic force microscopy (AFM) experiments have provided intriguing insights into the mechanical unfolding of proteins such as titin I27 from muscle, but will the same be possible for proteins that are not physiologically required to resist force? We report the results of AFM experiments on the forced unfolding of barnase in a chimeric construct with I27. Both modules are independently folded and stable in this construct and have the same thermodynamic and kinetic properties as the isolated proteins. I27 can be identified in the AFM traces based on its previous characterization, and distinct, irregular low-force peaks are observed for barnase. Molecular dynamics simulations of barnase unfolding also show that it unfolds at lower forces than proteins with mechanical function. The unfolding pathway involves the unraveling of the protein from the termini, with much more native-like secondary and tertiary structure being retained in the transition state than is observed in simulations of thermal unfolding or experimentally, using chemical denaturant. Our results suggest that proteins that are not selected for tensile strength may not resist force in the same way as those that are, and that proteins with similar unfolding rates in solution need not have comparable unfolding properties under force.

The folding nucleus of a fibronectin type III domain is composed of core residues of the immunoglobulin-like fold

To identify the contacts that stabilise the rate-limiting transition state for folding of FNfn10 (the tenth fnIII domain of human fibronectin), 42 mutants have been analysed at 29 positions across this domain. An anomalous response to mutation means that structure formation in the A, B and G strands cannot be evaluated by this method. In all the residues analysed, phi-values are fractional and no completely structured region is observed. The analysis reveals that hydrophobic residues from the central strands of the beta-sandwich form a large core of interactions in the transition state. Brønsted analysis shows that the stabilisation energy from the amino acid side-chains in the transition state is approximately 40 % of that in the native state. The protein folds by a nucleation-condensation mechanism, and tertiary interactions within the core make up the folding nucleus. Local interactions, in turns and loops, are apparently much less significant. Comparison with an homologous domain from human tenascin (TNfn3), shows that FNfn10 has a more extended, structured transition state spanning three different "layers" of the beta-sandwich. The results support the hypothesis that interactions in the common structural core guide the folding of these domains.

The folding of an immunoglobulin-like Greek key protein is defined by a common-core nucleus and regions constrained by topology

TNfn3, the third fibronectin type III domain of human tenascin, is an immunoglobulin-like protein that is a good model for experimental and theoretical analyses of Greek key folding. The third fibronectin type III domain of human tenascin folds and unfolds in a two-state fashion over a range of temperature and pH values, and in the presence of stabilising salts. Here, we present a high resolution protein engineering analysis of the single rate determining transition state. The 48 mutations report on the contribution of side-chains at 32 sites in the core and loop regions. Three areas in the protein exhibit high Phi-values, indicating that they are partially structured in the transition state. First, a common-core ring of four positions in the central strands B, C, E and F, that are in close contact, form a nucleus of tertiary interactions. The two other regions that appear well-formed are the C' region and the E-F loop. The Phi-values gradually decrease away from these regions such that the very ends of the two terminal strands A and G, have Phi-values of zero. We propose a model for the folding of immunoglobulin-like proteins in which the common-core "ring" forms the nucleus for folding, whilst the C' and E-F regions are constrained by topology to pack early. Folding characteristics of a group of structurally related proteins appear to support this model.

The Problems Experienced By Black Stroke Patients in Soweto, South Africa

A purposeful sample of Black Sowetan residents who had sustained a stroke were studied to identify the problems they were encountering after discharge back to their homes. A descriptive qualitative approach was used comprising semi-structured interviews in the subjects’ homes. Audio recorded data was transcribed in extenso, and coded into themes. The data revealed that the subjects’ lacked knowledge of their disease processes. However, medication non-complianc was largely due to financial and transportation difficulties in attending clinics. Although most of the sample was able to walk, they felt the need for improved walking ability, as they were scared of falling. Most were independent in ADL, yet they, and their families perceived them to be otherwise, leaving the subjects with a sense of worthlessness. Pain in the shoulder and stiffness were the common secondary problems encountered. There is a need to educate stroke victims with regards to their disease, it’s secondary complications and their capabilities following stroke. Safe walking must be ensured before discharge.

CYP2D6 is associated with Parkinson's disease but not with dementia with Lewy Bodies or Alzheimer's disease

The similarities between the clinical and pathological findings of dementia with Lewy Bodies (DLB) with Alzheimer's disease and Parkinson's disease are complex, and their significance for pathogenesis is unresolved. It is likely that DLB shares common disease determinants with both Alzheimer's disease and Parkinson's disease. Clinically DLB shows the presence of dementia similar, though not identical, to that found in Alzheimer's disease. A parkinsonian movement disorder is present in a proportion of DLB cases. Pathologically DLB shows senile plaques, as with Alzheimer's disease, and also substantia nigra neurone loss and Lewy bodies, as with Parkinson's disease. At a genetic level, DLB shows an elevated Apolipoprotein E epsilon4 frequency as described in Alzheimer's disease, but this is absent in Parkinson's disease. An elevated frequency of the CYP2D6*4 allele has been found in Parkinson's disease and we have therefore genotyped a large series of clinically and neuropathologically confirmed cases of DLB, Alzheimer's disease, Parkinson's disease and age-matched control individuals for the CYP2D6*4 allele. Whilst an elevated frequency of the CYP2D6*4 allele was found in Parkinson's disease, no such elevations were found in DLB or Alzheimer's disease. Stratification of the CYP2D6*4 allele with respect to the Apolipoprotein E epsilon4 also did not show any significant associations with the CYP2D6*4 allele. The CYP2D6*4 allele is not a major genetic determinant of DLB and the results place DLB with Alzheimer's disease rather than Parkinson's disease on a genetic level.

CYP2D6 phenotype-genotype relationships in African-Americans and Caucasians in Los Angeles

CYP2D6 genotyping (CYP2D6*3, CYP2D6*4, CYP2D6*5, CYP2D6*13, CYP2D6*16 alleles and gene duplications) was previously performed on 1053 Caucasian and African-American lung cancer cases and control individuals and no significant difference in allele frequencies between cases and control individuals detected. We have carried out additional genotyping (CYP2D6*6, CYP2D6*7, CYP2D6*8, CYP2D6*9, CYP2D6*10, CYP2D6*17 alleles) and debrisoquine phenotyping on subgroups from this study to assess phenotype-genotype relationships. African-Americans showed significant differences from Caucasians with respect to frequency of defective CYP2D6 alleles, particularly CYP2D6*4 and CYP2D6*5. The CYP2D6*17 allele occurred at a frequency of 0.26 among 87 African-Americans and appeared to explain higher average metabolic ratios among African-Americans compared with Caucasians. CYP2D6*6, CYP2D6*8, CYP2D6*9 and CYP2D6*10 were rare in both ethnic groups but explained approximately 40% of higher than expected metabolic ratios among extensive metabolizers. Among individuals phenotyped with debrisoquine, 32 out of 359 were in the poor metabolizer range with 24 of these (75%) also showing two defective CYP2D6 alleles. Additional single strand conformational polymorphism analysis screening of samples showing large phenotype-genotype discrepancies resulted in the detection of three novel polymorphisms. If subjects taking potentially interfering drugs were excluded, this additional screening enabled the positive identification of 88% of phenotypic poor metabolizers by genotyping. This sensitivity was comparable with that of phenotyping, which identified 90% of those with two defective alleles as poor metabolizers.

Co-administration of polyanions with a phosphorothioate oligodeoxynucleotide (CGP 69846A): a role for the scavenger receptor in its in vivo disposition

The effects of co-administering polyanions on the pharmacokinetics of a 20-mer phosphorothioate oligodeoxynucleotide (CGP 69846A), and the role of scavenger receptors in its in vivo disposition, have been investigated. Following i.v. administration, CGP 69846A was rapidly cleared from the plasma and distributed amongst high (e.g. kidney, liver, spleen), low (e.g. skeletal muscle) and negligible (e.g. brain) accumulating tissues. In addition it was shown that: 1) dextran sulphate co-administration has a dose-dependent effect on the disposition of CGP 69846A; 2) CGP 69846A undergoes renal filtration and renal accumulation largely results from tubular reabsorption; 3) cross-inhibition studies are consistent with CGP 69846A being recognized by scavenger receptors in vitro and in vivo; and 4) the scavenger receptor may be an important determinant for the in vivo disposition of CGP 69846A in mice. These studies contribute toward an increased understanding of the mechanism underlying the pharmacokinetic behaviour of phosphorothioate oligodeoxynucleotides.

An improved animal model for studying desferrioxamine

A hamster model has been developed for studying desferrioxamine. The hamster shows many similarities to man in terms of plasma stability and metabolites formed from desferrioxamine. The [59Fe]ferritin derived from rats has been shown to be sequestered into liver parenchymal cells when injected intravenously into hamsters. The technique has proved sufficiently sensitive to enable detection of differences of < 1% of the radioactivity administered in the elimination of iron. Alterations in iron excretion were seen when dosing desferrioxamine via different routes. The principal route of iron excretion was into the intestines. The effectiveness of the dosing routes for desferrioxamine in removing iron were subcutaneous (10.5%) > intravenous (6.25%) > oral (3.66%) > control (2.19%). A dose-response relationship was demonstrated using the intravenous dose route. The model offers a simple method for comparing the efficacy of administration routes for determining the optimal use of desferrioxamine.

The transmucosal absorption of recombinant human interferon-alpha B/D hybrid in the rat and rabbit

For therapeutic proteins such as interferon-alpha B/D, a non-parenteral route of delivery is desirable. Possible sites of administration include the various regions of the gastrointestinal tract and airways, and this paper reports the bioavailability of interferon-alpha B/D via these routes in the rat and rabbit. Apart from the stomach, detectable levels of interferon-alpha B/D in the serum were achieved via all routes. Bioavailabilities were less than 1%, except from the lung (6.8% in the rat) and nasal cavity (2.9% in the rabbit). Absorption from the gastrointestinal tract was similar for both species, but in the nasal cavity of the rabbit was sixfold that of the rat, and in the lung of the rat was tenfold that in the rabbit. Absorption from all routes, except the buccal cavity, resulted in detectable biochemical changes in the liver of the rabbit. Comparison with reports from other groups show differences in the extent of absorption of interferon-alpha B/D and of natural or homologous recombinant interferon-alpha. The non-parenteral delivery of biochemically active amounts of interferon-alpha B/D is thus demonstrated.

Effects of androgens in models of rheumatoid arthritis

Testosterone and its metabolite 5 alpha-dihydrotestosterone (DHT) were compared with dexamethasone 21-acetate in two different animal models of arthritis and found to have effects on cartilage breakdown and inflammation. In the mouse air pouch, at the three dose levels used, significant effects were obtained with DHT and were more pronounced on cartilage breakdown than on inflammation. At the lowest dose of 0.3 mg kg-1 there was a 64% inhibition of collagen breakdown and 18% inhibition of glycosaminoglycans (GAGs) breakdown. In the antigen-induced arthritis mouse model testosterone had significant inhibitory effects on inflammation (synovial hyperplasia) and cartilage erosion.

Proteoglycan biosynthesis as a determinant of patella damage in the murine antigen-induced arthritis model

The incorporation of 35SO4 into cartilage proteoglycan has been employed as a measure of patella damage in the murine antigen-induced arthritis model. In a preliminary set of experiments, where both the proteoglycan concentration and 35SO4 incorporation were determined in control and arthritic patella over a 2 day to 6 day week period, the arthritic joint contained significantly higher levels of radioactivity compared with the controls. A subsequent study over an extended period of 10 weeks confirmed the earlier results, and indicated that the 6 week samples showed the greatest difference (71%) in 35SO4 incorporation between the arthritic and control patella.

The serum amyloid P response in the mouse air pouch

Levels of the acute phase reactant serum amyloid P (SAP) have been measured in the mouse pouch model of rheumatoid arthritis. Implantation of cartilage resulted in a significant and rapid elevation in the SAP concentration, which remained high for the duration of the experiment (14 days). Initial studies with several clinically employed antirheumatic drugs indicated that dexamethasone and cyclosporin A had a marked inhibitory effect.

A modified mouse air pouch model for evaluating the effects of compounds on granuloma induced cartilage degradation

1. Employing rat femoral head cartilage implanted in a 6 day old mouse air pouch, the effects of inflammatory stimuli (i.e. cotton pellets, carrageenan, zymosan) on the loss of proteoglycan and collagen and granuloma formation have been studied. 2. Wrapping of the cartilage in cotton resulted in granuloma formation with accelerated loss of proteoglycan and collagen over the 14 day implantation period. The amount of loss increased with increasing weight of cotton. 3. The effects of different classes of anti-rheumatic drugs on granuloma formation and proteoglycan and collagen loss from cotton wrapped femoral head cartilage in the mouse air pouch have been studied. 4. Non-steroidal anti-inflammatory drugs (NSAIDs) had no influence on granuloma formation, but in general accelerated the rates of proteoglycan and collagen loss. 5. Dexamethasone and prednisolone significantly reduced granuloma formation and had a marked protective effect on cartilage breakdown. 6. Of the slow acting anti-rheumatic drugs examined, only gold sodium thiomalate (GSTM) and dapsone significantly decreased cartilage loss, with an accompanying modest decrease in granuloma formation. 7. The immunosuppressants cyclophosphamide and methotrexate, but not azathioprine, reduced cartilage degradation, but had no effect on granuloma formation. 8. The results for the different classes of anti-inflammatory and anti-rheumatic drugs are discussed in relation to their effects in other animal models and their reported therapeutic activities in man. It is concluded that the mouse air pouch method as described offers advantages as an animal model over existing procedures to predict therapeutic efficacy in man.

The determination of receptor constants for histamine H2-agonists in the guinea-pig isolated right atrium using an irreversible H2-antagonist

From measurements of chronotropy in the guinea-pig isolated right atrium, a compound (E1309) was found which behaved as an irreversible antagonist at the histamine H2 receptor. E1309 was used to block irreversibly a proportion of the H2 receptors and the dissociation constants, relative efficacies and receptor reserves of four H2-agonists were determined. The calculated dissociation constants were similar to the Ki values reported from H2-radioligand binding studies but different from the observed EC50 values. The order of potency for the four H2-agonists was impromidine much greater than histamine greater than dimaprit greater than 4-methylhistamine. The order of relative efficacy was 4-methylhistamine greater than dimaprit greater than histamine greater than impromidine, the natural agonist not being the most efficacious. This atypical finding is discussed in relation to other receptor classes.

In vitro histamine H2-antagonist activity of the novel compound HUK 978

Histamine stimulated adenylate cyclase from guinea-pig fundic mucosa and 3H-tiotidine binding in guinea-pig cerebral cortex were used to assess the in-vitro histamine H2-activity of the novel H2-antagonist HUK 978. The results showed that HUK 978 was a more potent H2-antagonist than either cimetidine or ranitidine. HUK 978 was also shown to be devoid of activity at the histamine H1-receptor, the muscarinic receptor and the alpha and beta-adrenergic receptors.

Anti-secretory activity of the novel H2-antagonist, HUK 978, in rat, guinea-pig and dog

The anti-secretory activity of the competitive H2-antagonist HUK 978 was determined in rat, guinea-pig and dog. In all systems examined, HUK 978 was more potent than cimetidine and ranitidine both intravenously and orally. In addition, the compound at approximately equipotent doses as these established H2-antagonists exhibited a significantly longer inhibitory profile following oral and systemic administration. Data from these pharmacological studies and the in vitro investigations previously reported, suggest that HUK 978 is a highly specific H2-antagonist and inhibits acid secretion for longer periods than other competitive compounds.

Low level antigen responses in guinea-pig lung strip

Guinea-pigs were sensitized either by i.p. administration or by a novel procedure involving inhalation of ovalbumin (2, 0.2 and 0.002%) on days 0, 5 and 19 respectively. Lung strips from these guinea-pigs were challenged with both low (0.02 micrograms/ml) and high (10 micrograms/ml) concentrations of ovalbumin and the responses compared. Whereas the low level antigen gave consistent contractions following aerosol sensitization, no response was observed from the i.p. sensitized guinea-pig lung strips. Marked differences were also observed following the high ovalbumin challenge, where the aerosol sensitized lungs gave almost twice the response as tissue from the i.p. sensitized guinea-pigs, the former being approximately 140% of that observed with acetyl-beta-methyl choline (1 mM). Furthermore, the response elicited in the lungs from aerosol sensitized guinea-pigs were not modified by the addition of high concentrations of the H1-antagonist diphenhydramine (100 microM), before or subsequent to challenge. The data suggest that the aerosol sensitization procedure gives rise to a contractile response in guinea-pig lung strips which contains no observable histamine component.

A new in vivo method for the measurement of repetitive anaphylactic responses in the guinea-pig

The established Konzett-Rossler bronchorespiratory model has been combined with a unique ovalbumin sensitization procedure to give a novel method to measure anaphylaxis in the anaesthetized guinea-pig. Following antigen challenge, up to eight equal bronchoconstrictor responses to the same dose can be generated from a single animal over a 120 min period. Total inhibition of the anaphylactic response can be elicited by four different classes of compound, namely salbutamol, mepyramine, theophylline and dimaprit. Cromoglycate failed to cause any inhibition. The method is discussed with particular reference to the antigen sensitization procedure, which differs substantially from other regimens previously employed and gives rise to heat labile antibody.

Halothane solubility in human blood

In a study of the influence of nutritional state on halothane anaesthesia, results were obtained which showed how the blood/gas partition coefficient for halothane varied with blood chemistry in 20 patients undergoing elective surgery. For each patient the partition coefficient lambda was measured by equilibration at 37 degrees C of a blood sample with a 1% halothane in 5% carbon dioxide in air mixture, followed by chemical extraction and estimation of the halothane content by gas chromatography. The haematocrit and haemoglobin, serum albumin, total protein, triglyceride and cholesterol concentrations were measured by routine laboratory methods. Regressions were sought of lambda on each of these, and on the globulin concentration and the ratios of albumin: globulin and albumin: total protein, deduced from these determinations. The only statistically significant regression (P = 0.0004) was that of lambda on the serum triglyceride concentration (T) (mmol/litre): lambda = 1.83 + 0.424T. The dependence of lambda on haemoglobin concentration was not statistically significant, but the slope of the regression was consistent with those of previous investigators. The regressions of lambda, corrected to the mean triglyceride concentration, on the ratios of albumin: globulin and albumin: total protein were not statistically significant but were not significantly different from an earlier reported result.

Pharmacokinetics of halothane in the dog. Comparison of theory and measurement in individuals

After surgical preparation under pentobarbitone anaesthesia seven dogs of mean body weight 31 kg were ventilated with 1% halothane for 80 min. At 1, 2, 5, 10, 20, 40 and 80 min after the start of the halothane administration blood samples were taken from the femoral artery and pulmonary artery and from a cerebral, a renal and a femoral vein. At 80 min a biopsy sample of skeletal muscle (psoas) was taken. The halothane tension in all samples was determined by extraction into carbon tetrachloride followed by gas chromatographic analysis using chloroform as an internal standard. The measured tensions were compared with tensions computed from a multi-compartment model of the uptake and distribution of halothane in the body. The model was quantified by measurements, in each individual, of total body mass, the masses of the major organs and the solubility of halothane in the major organs and tissues; by measurements of blood volume and solubility in blood at the start and finish of the halothane administration; and by repeated measurements of alveolar ventilation, cardiac output and body temperature. For the original version of the model, the computed tensions deviated from the measured tensions to an extent greater than could be attributed to experimental error and in a manner which could be attributed to metabolism of halothane and probably to direct diffusion of halothane from well-perfused organs and lean tissues into fat. Direct experimental evidence of diffusion into perirenal fat was obtained in supplementary experiments. With the quantitation of the model distorted to mimic the processes of metabolism and diffusion, measured arterial tensions could be predicted with a mean error of -0.2 mm Hg (SD 0.6 mm Hg). The mean measured arterial tension was 3.5 mm Hg.

Organ weights in the dog

The masses of the major organs in eight large dogs, mostly of alsatian type, which had been subjected to about 8 h anaesthesia and surgery, were determined by post mortem weighing. The organ masses as percentage of the total body mass (29.6 +/- 6.0 kg, mean +/- sd) were: brain 0.28 +/- 0.05, gut 2.61 +/- 0.49, heart 0.73 +/- 0.04, kidneys 0.40 +/- 0.07, liver 2.36 +/- 0.38.

The solubility of halothane in canine blood and tissues

In vitro measurements were made of the solubility of halothane (about 1%, carried in 5% carbon dioxide in air) in tissues taken from dogs, mostly Alsatians, and usually after about 8 hr anaesthesia with pentobarbitone and halothane. The mean Ostwald solubility coefficient lambda in atm- minus 1 at 37 degrees C, for seven to 21 animals, were: brain 6.03, gut 4.23, cardiac muscle 4.88, kidney 4.95, liver 6.64, skeletal muscle (psoas) 5.45. For the gracilis muscle solubilities up to 20 atm- minus 1 were obtained. Solubility in blood was shown to increase significantly with haematocrit and haemoglobin and to be significantly higher in blood from unanaesthetized than from anaesthetized animals. The best-estimate equations were lambda-2.38 + 0.042H for the unanaesthetized condition and lambda-1.69+0.049 H for the anaesthetized condition, where H is haematocrit %. Combining the present results with those for other species showed that the solubility of halothane increased fairly systematically from blood to kidney to brain to liver, and from ox to man to dog to rabbit.

Reduction En Masse of a Strangulated Inguinal Hernia

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