Use of recombinant hemoglobin solution in reversing lethal hemorrhagic hypovolemic oxygen debt shock

OBJECTIVE

To compare recombinant hemoglobin solution (rHb1.1) with colloid/blood (CB) resuscitation in a hemorrhagic shock (HS) model based on oxygen debt (O2D).

METHODS

Twenty-two anesthetized canines (weight 23.3 +/- 0.2 kg) were bled to an O2D of 99.9 +/- 2.1 mL/kg over 60 minutes (estimated lethal dose 31%), blood loss 65.9 +/- 2.3% of estimated blood volume, - 199 g hemoglobin (Hgb). Prospectively randomized resuscitation done in 20 minutes with 120% of shed blood volume, either colloid 60%/blood 60% shed blood volume (CB), 118 g Hgb, or 120% shed blood volume as 5% rHb1.1, 85 g Hgb, and fall in O2D was quantified over 80 minutes. Six animals died during HS, one after CB resuscitation (32% actual mortality). Blood lactate (L) and base deficit (BEA) were related to O2D.

RESULTS

Both lactate (L) and BEA quantified O2D during hemorrhage: L = 0.0671 (O2D) + 1.209; r2 = 0.90, p < 0.0001; BEA = 0.1313 (O2D) + 1.764; r2 = 0.90, p < 0.0001, but L was a better indicator than BEA of fall in O2D during resuscitation (L = 0.069 (O2D) + 1.083; r2 = 0.80). Both groups were followed for 7 days after HS and had normal renal and hepatic function by day 7. However, at equal resuscitation volume, rHb1.1 resuscitation with 41% of Hgb loss produced a more rapid initial fall in O2D than CB at 60% of Hgb loss (p < 0.002). rHb1.1 resuscitation also caused a more complete washout of metabolic acids than CB.

CONCLUSIONS

Lactate and BEA accurately quantify O2D in HS and resuscitation. rHb1.1 replacement is as good as CB with regard to survival, but leads to a more uniform reperfusion and produces a more complete resolution of ischemic acidosis.

Therapy of cytotoxic mushroom intoxication

Poisoning by cytotoxic mushrooms (Amanita phalloides and related species) is associated with severe morbidity and a high mortality rate. Due to the difficulty of performing controlled studies and to the poor knowledge of the pharmacodynamics of toxins in human poisoning, there is considerable debate about appropriate treatment, particularly the feasibility and the efficacy of detoxification. Because circulating amatoxins can be detected in the serum of poisoned patients as long as 30 h after ingestion, a detoxification treatment should ideally increase the rate of toxin elimination in order to minimize the toxic exposure of highly susceptible cells, such as hepatocytes. We found forced diuresis to be the most effective procedure for toxin removal. Other techniques, such as plasmapheresis and peritoneal dialysis, proved much less useful for this purpose. The administration of cathartics, adsorbent agents, and gastroduodenal lavage, are indicated for preventing further absorption of toxins from the gut. An important part of therapy is early and vigorous volume replacement, to correct the severe hypovolemia which results from massive fluid loss during the cholera-like phase of intoxication. Use of this therapeutic approach in 53 patients with amatoxin poisoning resulted in a high survival rate and a low incidence of severe liver injury.

[The early removal of amatoxins in the treatment of amanita phalloides poisoning (author's transl)]

In a 3 year period (1975-77) 50 patients have been admitted to the I.C.U. of Polyclinic Hospital of Milan for poisoning from mushrooms of Amanita genus. In 47 cases the diagnosis was confirmed "a posteriori" by serum or urinary detection of amtoxins and/or by clinical evidence of typical liver injury. Besides the symptomatologic support, the therapeutic treatment included combined removal procedures, such as peritoneal dialysis, plasmapheresis, forced diuresis. The detection by radioimmunoassay of amatoxins [6] in the serum and in the urine of these patients proves that this therapeutic treatment can be effective within about 36 hours from ingestion time. The intensive medical care and the removal approach yielded as the whole favourable results in our patients (overall mortality was 6 patients, i.e. 12,7%). It should moreover be emphasized that of the 35 patients, who had been treated with early removal techniques, 12 with ascertained amanita poisoning, had neither clinical nor biochemical evidence of hepatic damage; 14 had a moderate liver damage; 9 experienced a severe liver failure and hepatic coma occurred in 4 of the latter. These poor results can be ascribed to the severity of the poisoning as well as to a peculiar kinetic of amatoxins in each subject.

Direct enantiomeric separation of flavanones by high performance liquid chromatography using various chiral stationary phases

The performance of four chiral liquid chromatographic columns (Chiralcel OA, OJ, OC, OD) was studied with respect to the enantioseparation of flavanones and some derivatives. The effect of mobile phase composition on the retention time and stereo-selectivity was studied. A good enantioseparation (alpha up to 1.45) was achieved for most of the racemates. Further, the elution order of the enantiomers from the chiral stationary phases has been determined by using a circular dichroism based detection system.

Analyzing the radiation of the proenkephalin gene in tetrapods: cloning of a Bombina orientalis proenkephalin cDNA

Analyzing the Radiation of the Proenkephalin Gene in Tetrapods: Cloning of a Bombina orientalis Proenkephalin cDNA: A proenkephalin cDNA was cloned from the brain of the anuran amphibian, Bombina orientalis (Family: Discoglossidae). This cDNA is 1358 nucleotides in length, and contains an open reading frame that codes for 251 amino acids. Within the open reading frame there are seven opioid (YGGF) sequences. There were five Met-enkephalin (YGGFM) sequences that are flanked by sets of paired basic amino acid proteolytic cleavage sites and two C-terminally extended Met-enkephalin sequences: YGGFMRGY and YGGFMRF. No Leu-enkephalin sequences were found in B. orientalis proenkephalin. It was possible to align the amino acid sequences of proenkephalin from several vertebrate taxa (human, Australian lungfish, B. orientalis, Xenopus laevis, Spea multiplicatus) by inserting a minimum of nine gaps. This alignment was then used to analyze the corresponding nucleotides for each proenkephalin sequence using maximum likelihood. This analysis yielded a single tree. In this tree, the Australian lungfish sequence was the outgroup or the tetrapod ingroup. The amphibian sequences form a clade separate from the human sequence. The bootstrap value for the amphibian clade was 100%. Within the amphibian clade the Bombina sequence was the sister group to a clade composed of the X. laevis and S. multiplicatus sequences. The bootstrap value for the X. laevis/S. multiplicatus clade was 94%. Collectively, these data indicate that the sequence of Bombina proenkephalin may be more similar to the proposed ancestral anuran proenkephalin sequence, than either X. laevis or S. multiplicatus proenkephalin.

Influence of oral contraceptives on fasting gallbladder volume

A total of 615 healthy fertile women (518 pill users and 97 non-users) were examined by real-time ultrasonography for fasting gallbladder volume, gallstones and biliary dysmorphism. None of the six examined combinations of oral contraceptives appeared to influence fasting gallbladder volume significantly. When fasting gallbladder volumes were reanalyzed according to the presence or absence of recognized biliary risk factors, significant modifications were detected, in both pill users and non-users. These changes related only to age and parity. Relative risks of cholelithiasis and biliary dysmorphism were not affected by contraceptive treatment.

[Mebendazole in the therapy of hydatidosis]

The effectiveness of mebendazole as adjuvant treatment in hydatidosis was evaluated in 19 patients; 12 were treated both before and after surgery, 6 were not treated, one had primary treatment only, owing to the refuse of surgery. Mebendazole was administrated at the dosage of 30-50 mg/kg/day po for 30 days followed by a washout of 15 days, for a mean of 4 cycles (range 1-7) and 12 cycles (range 1-24) before and after surgery, respectively. Patients were monitored by total IgE, specific anti-echinococcus IgE and IgG, at diagnosis, just before surgery and thereafter every six months. Antibody titer decrease was observed soon after the first cycles of medical treatment before surgery, as well as a clear-cut drop after surgery, followed by a continuing decrease after the following cycles of mebendazole. Relapse of disease was observed in two patients only at one and two years after surgery respectively. These preliminary results seem to point out that mebendazole might play a role in the treatment of hydatidosis as adjuvant of surgical therapy.

[The "diagnostic day hospital." A proposal for functional support by hospital services and primary care]

The general lack of nurses and the attention due to the purposes of efficiency, effectiveness and economy of hospital services oblige to better the cooperation between attending and family physicians, to improve the resources, the productiveness of clinicopathology, the use of daily hospital services (such as ambulatories, daily hospitalization and treatments) and emergencies. For this end the authors propose the realization of a day hospital which mainly aim is the diagnostic (D.H.D.) of internal medicine. The admission will be acted by a doctor of the emergency department and of the reception. The day hospital will be functionally linked up with the services of emergency dpt. and reception and with the outpatients' department. Therefore useful both for the attending and family physicians. This kind of day hospital shouldn't substitute the specialities (such as hematology, oncology, psychiatry, dialysis, rehabilitation, etc.) which finalities are principally the therapy and check-up of known patients who follow a treatment by a specialistic department. The D.H.D. should grant the following functions: --Diagnosis or provable orientation in case the doctor of the emergency dpt. or the specialist in ambulatory shouldn't be able to perform them immediately; --Clinical control of cases coming from the emergency dpt.; --Planning of therapeutic program and carrying out of ambulatory therapies that cannot be deferred, of cases coming from the emergency dpt. or reception. Then, is attributable to the D.H.D. the hospital statistics that: --requires clinical observation that cannot be deferred; --requires unerring, prompt and complex diagnostic orientation in order to decide the kind of ward where the hospitalization should be done; --if needed, hospital therapeutic intervention that cannot be deferred, incompatible with the operative possibilities of the D.H.D. The authors also deal with operative relations between D.H.D. and other hospital services, the staff organization, the location, dimension and functional attribution of the head office, the purchases and availability of sanitary fittings and furnishings. Finally, the authors estimate the effectiveness of D.H.D. as far as the reduction of continuative hospitalization is concerned.

Micro-elimination initiative for hepatitis C screening: insight into gender gaps and undiagnosed individuals

In 2023, the Italian healthcare system launched HCV screening targeting subjects born in 1968-1989. However, subjects > 50 yrs also need screening. In addition, existence of gender gaps in HCV diagnosis and treatment has been suggested. Our aim was to identify undiagnosed individuals outside the age groups to whom the screening is offered and to gather data about gender gaps. This is a prospective, opportunistic micro-elimination initiative based on a network between 24 Apulian pharmacies and our center. Between 01/07/2022 and 01/03/2024, subjects aged 55 to 85, accessing pharmacies were offered HCVOraQuick tests (F/M 1:1) and administered ad-hoc questionnaires. In total, 13,042 screening were carried out. Mean age was 64.9 (± 7.6), 51.1% females. Overall, 1.1% were anti-HCV positive: mean age 68.3 (± 10.3), 44.9% females. Seroprevalence was higher in males (p < 0.00001), elderly (p < 0.00001) and unknown transmission route (p = 0.0009). HCV-RNA was detectable in 67.4% of seropositive. They were 67.5 (± 10.7) yrs old, mainly males (55.1%). HCV-RNA prevalence was 0.8%, higher in elderly (p = 0.0003) and unknown transmission route (p = 0.0007). Overall, 90% were linked-to-treatment. Differences in patients profiles should be considered to guide policy and more inclusive treatment approaches. Gender differences in screening response and rates of active infections underscore the need for gender-targeted intervention.

Effectiveness and safety of vaginal suppositories for the treatment of the vaginal atrophy in postmenopausal women: an open, non-controlled clinical trial

Menopause, due to the physiological decrease in the estrogens levels, is often associated with many symptoms related to vaginal atrophy such vaginal dryness, dyspareunia, burning, itching, decreasing in libido and therefore a worsening of the quality of life and in particular of the sexual activity. There are many pharmacological remedies to solve these events, first of all hormone replacement therapy (HRT) that up to the 90s was the therapy of choice for the care of the menopause symptoms. This hormonal therapy, however, has been re-considered due to its side effects. As alternative, a clinical trial has been performed to investigate the efficacy and safety, in postmenopausal women with urogenital atrophy, of the use of suppositories for vaginal use, containing hyaluronic acid, vitamin E and vitamin A. The trial, according to a open, non-controlled design, was performed on 150 postmenopausal women, 1 vaginal suppository per day, for the first 14 days and then a vaginal suppository, day in and day out, for other 14 days. The primary endpoint was the evaluation of vaginal dryness assessed by a Visual Analogue Scale (VAS) both by the investigator and the patient. The secondary endpoints were the evaluation of all the other symptoms and signs associated with the vaginal atrophy (itching, burning, dyspareunia, vaginal inflammation or swelling, irritation, assessed by a 4-point scale, presence of vaginal abrasions and irritation), and the recording of the adverse events occurring during the trial. The patients have not reported adverse effects during the treatment, and the results in terms of effectiveness on the vaginal atrophy symptoms were markedly positive. A high level of compliance was registered. The product tested can therefore be considered a safe and effective alternative for the treatment of vaginal atrophy symptoms in postmenopausal women, especially when HRT is not recommended.

Peripheral neuropathy in obstetrics: efficacy and safety of α-lipoic acid supplementation

OBJECTIVE

Neuropathic pain during pregnancy is a common condition due to the physical changes and compression around pregnancy and childbirth that make pregnant women more prone to develop several medical conditions such as carpal tunnel syndrome, sciatica, meralgia paraesthetica and other nerve entrapment syndromes. Most of the treatments usually performed to counteract neuropathic pain are contraindicated in pregnancy so that, the management of these highly invalidating conditions remains an issue in the clinical practice. We aimed to review the efficacy and safety of alpha lipoic acid supplementation in the treatment of neuropathic pain.

DISCUSSION

Lipoic acid is a co-factor essential in the regulation of mitochondrial energy. It has been demonstrated that lipoic acid supplementation is involved in several biochemical processes and actions, exerting important antioxidant and anti-inflammatory activity and significantly improving pain and paraesthesia in patients with sciatica, carpal tunnel syndrome and diabetic neuropathy.

CONCLUSIONS

Efficacy of lipoic acid is combined with a high safety profile, making this molecule a novel candidate for the management of several diseases. Data reported so far are promising and dietary supplementation with lipoic acid seems a useful tool to contrast neuropathic pain during pregnancy.