Influence of the drug deformation behaviour on the predictability of compressibility and compactibility of binary mixtures

Various studies investigate the predictability of the compressibility and compactibility of tablet formulations based on the behaviour of the pure materials. However, these studies are limited to a few materials so far probably because of the complexity of the powder compaction process. One approach preventing the excessive increase in complexity is the extension of the investigations from pure materials to binary powder mixtures. The focus of this study is on the predictability of the compressibility and compactibility of binary mixtures consisting of an active pharmaceutical ingredient (API) and the excipient microcrystalline cellulose. Three APIs with markedly different deformation behaviour were used. The API concentration and type are systematically varied. For all three material combinations it is found that the in-die compressibility of the binary mixtures can be precisely predicted based on the characteristic compression parameters of the raw materials using the extended in-die compression function in combination with a volume-based linear mixing rule. Since the tablet porosity (out-of-die) also follows a linear mixing rule, the predictability can be further extended using the method of Katz et al. In contrast, the influence of the API concentration on compactibility or rather on tablet tensile strength is non-linear and strongly dependent on the deformation behaviour of the API, making the predictability more difficult. Neither the approach of Reynolds et al. nor this of Kuentz and Leuenberger are able to predict the compactibility when clear deviations from a linear mixing rule appear.

Evaluation of the Formulation Parameter-Dependent Redispersibility of API Nanoparticles from Fluid Bed Granules

The production of nanosuspensions of poorly soluble active pharmaceutical ingredients (API) is a popular technique to counteract challenges regarding bioavailability of such active substances. A subsequent drying of the nanosuspensions is advantageous to improve the long-term stability and the further processing into solid oral dosage forms. However, associated drying operations are critical, especially with regard to nanoparticle growth, loss in redispersibility and associated compromised bioavailability. This work extends a previous study regarding the applicability of an API (itraconazole) nanosuspension as a granulation liquid in a fluidized bed process with focus on the influence of applied formulation parameters on the structure of obtained nanoparticle-loaded granules and their nanoparticle redispersibility. Generally, a higher dissolution rate of the carrier material (glass beads, lactose, mannitol or sucrose) and a higher content of a matrix former/hydrophilic polymer (PVP/VA or HPMC) in the granulation liquid resulted in the formation of coarser and more porous granules with improved nanoparticle redispersibility. HPMC was found to have advantages as a polymer compared with PVP/VA. In general, a better redispersibility of the nanoparticles from the granules could be associated with better dispersion of the API nanoparticles at the surface of the granules as deduced from the thickness of nanoparticle-loaded layers around the granules. The layer thickness on granules was assessed by means of confocal Raman microscopy. Finally, the dispersion of the nanoparticles in the granule layers was exemplarily described by calculation of theoretical mean nanoparticle distances in the granule layers and was correlated with data obtained from redispersibility studies.

Numerical modeling of the dissolution of drug nanocrystals and its application to industrial product development

The apparent solubility of drug nanocrystals in equilibrium was experimentally determined for a drug-stabilizer system with different particle size distributions. True supersaturation was identified for ultrafine drug nanocrystals with an almost 2-fold increase compared to the thermodynamic solubility of related coarse drug crystals, highlighting their enabling potential to enhance bioavailability. The experimental results were applied to investigate in silico the associated dissolution behavior in a closed system by numerical modeling according to the Ostwald-Freundlich and Noyes-Whitney / Nernst-Brunner equations. Calculated results were found to be in agreement with the experimental results only when the entire particle size distribution of drug nanocrystals was considered. In silico dissolution, studies were conducted to simulate the complex interplay between drug nanocrystals, dissolution conditions and resulting temporal progression during dissolution up to the equilibrium state. Calculations were performed for selected in vivo and in vitro scenarios considering different drug nanocrystal particle size distributions, drug amount, dissolution media and volume. The achieved results demonstrated the importance of ultrafine drug nanocrystals for potential bioavailability improvement and the functional applicability of the modeling approach to investigate their dissolution behavior for configurable formulation variables in product development in terms of in vivo and in vitro relevant conditions.

Prediction of the impact of lubrication on tablet compactibility

The tableting of most pharmaceutical formulations requires the addition of lubricants to reduce ejection forces, prevent tooling damage and tablet defects. The internal addition of lubricants is known to reduce tablet tensile strength, especially of mainly plastically deforming materials. To date, available models show only limited quantitative predictive accuracy for the influence of lubricant concentration on the mechanical strength of tablets. This study aims to fill this gap and present a model based on the Ryshkewitch-Duckworth equation that can estimate the compactibility profiles of lubricated formulations. Binary mixtures of different diluents (microcrystalline cellulose and lactose) were prepared with common lubricants (magnesium stearate and sodium stearyl fumarate) and subsequently tableted. The resulting compactibility profiles were fitted using the Ryshkewitch-Duckworth equation and the derived fit parameters (k_b and σ₀) were correlated with the lubricant concentration. Subsequently, an empirical model was established which requires a minimum of experimental data and is able to predict the tensile strength of lubricated diluent tablets. Consequently, the developed empirical model is an interesting and valuable addition to the existing multi-component compacting models available and offers the opportunity to accelerate experimentation in the development of new tablet formulations.

The influence of particle size on the application of compression and compaction models for tableting

The physical characteristics of raw materials determine powder compression and compaction performance as relevant in pharmaceutical processes. For instance, the influence of initial particle size on powder compression and the resulting strength of specimen are highly complex and are still not sufficiently understood. Existing studies are often limited to materials with well-defined deformation behaviour, such as purely brittle or ductile. However, the deformation behaviour of active pharmaceutical ingredients (APIs) is often more complex. In this study, the influence of initial particle size on powder compressibility and compactibility is systematically characterized by consideration of in-die compressibility, specific energies, quick elastic recovery, tablet porosity and, tensile strength for the binder microcrystalline cellulose and three APIs. The decrease of particle size leads to an increase of the resistance against compression by trend and probably to a different contribution of the acting deformation mechanisms. The compactibility is increased with decreasing particle size because of the increasing number of bonds in a cross-sectional area of the tablet, as found by the application of the model of Rumpf. Furthermore, it is found that the model of Rumpf combined with the JKR model provides a meaningful property function to estimate tablet tensile strength.

Influence of Formulation Parameters on Redispersibility of Naproxen Nanoparticles from Granules Produced in a Fluidized Bed Process

The particle size reduction of active pharmaceutical ingredients is an efficient method to overcome challenges associated with a poor aqueous solubility. With respect to stability and patient's convenience, the corresponding nanosuspensions are often further processed to solid dosage forms. In this regard, the influence of several formulation parameters (i.e., type of carrier material, type and amount of additional polymeric drying excipient in the nanosuspension) on the redispersibility of naproxen nanoparticle-loaded granules produced in a fluidized bed process was investigated. The dissolution rate of the carrier material (i.e., sucrose, mannitol, or lactose) was identified as a relevant material property, with higher dissolution rates (sucrose > mannitol > lactose) resulting in better redispersibility of the products. Additionally, the redispersibility of the product granules was observed to improve with increasing amounts of polymeric drying excipient in the nanosuspension. The redispersibility was observed to qualitatively correlate with the degree of nanoparticle embedding on the surface of the corresponding granules. This embedding was assumed to be either caused by a partial dissolution and subsequent resolidification of the carrier surface dependent on the dissolution rate of the carrier material or by resolidification of the dissolved polymeric drying excipient upon drying. As the correlation between the redispersibility and the morphology of the corresponding granules was observed for all investigated formulation parameters, it may be assumed that the redispersibility of the nanoparticles is determined by their distance in the dried state.

The Microalbuminuria Education Medication and Optimisation (MEMO) study: 4 years follow-up of multifactorial intervention in high-risk individuals with type 2 diabetes

AIMS

The Microalbuminuria Education Medication and Optimisation (MEMO) study, revealed improved cardiovascular risk and glycaemic control with 18 months of intensive multifactorial intervention in high-risk people with type 2 diabetes, without any increase in severe hypoglycaemia. Our aim was to assess longer-term outcomes at 4-year follow-up in these participants.

METHODS

Some 189 individuals with type 2 diabetes and microalbuminuria were recruited from a multi-ethnic population in Leicestershire, UK. The intervention group (n = 95) received multifactorial intervention with self-management education, and the control group (n = 94) received usual care. The primary outcome was change in HbA_1c , and secondary outcomes were blood pressure (BP), cholesterol, microalbuminuria, estimated GFR, cardiovascular risk scores and major adverse cardiovascular events.

RESULTS

Some 130 participants (68.7%), mean (sd) age 60.8 (10.4) years, duration of diabetes 11.5 (9.7) years, completed 4 years of follow-up. Mean change [95% confidence intervals (CI)] in HbA_1c over 4 years was greater with intensive intervention compared with control (-3 mmol/mol, 95% CI -4.95,-1.11; -0.4%, 95% CI -0.67,-0.15; P = 0.002). Significant improvements over the 4 years were also seen in systolic BP (-7.3 mmHg, 95% CI -11.1, -3.5; P < 0.001), diastolic BP (-2.9 mmHg, 95% CI -5.4, -0.3; P = 0.026), cholesterol (-0.3 mmol/l, 95% CI -0.52,-0.12; P = 0.002), and 10-year coronary heart disease (-5.3, 95% CI -8.2,-2.3; P < 0.001) and stroke risk (-4.4, 95% CI -7.5, -1.3; P < 0.001).

CONCLUSION

Multifactorial intervention with structured diabetes self-management education compared with usual diabetes care has benefits for cardio-metabolic risk factor profile. There was no increase in severe hypoglycaemia and cardiovascular mortality despite intensive glycaemic control, although the study was not powered to assess these outcomes.

[Clostridium difficile infection (CDI) in the course of time - an issue only for the internist?]

BACKGROUND

Toxigenic strains of Clostridium (C.) difficile are the most prevalent pathogens of antibiotic associated intestinal disease and nosocomial diarrhoea. During the last 10 years, incidences of C. difficile infection (CDI) have increased worldwide.

MATERIALS AND METHODS

With clinical and microbiological original data for 2002-2012 from the University Hospitals Leipzig and Halle (Saale), Germany, the authors illustrate the current situation regarding CDI in the states of Saxony and Saxony-Anhalt and exemplify the latest developments in terms of incidence, prevalence of resistance, diagnosis and treatment strategies regarding CDI with an emphasis on surgical options.

RESULTS

Following the general trend, at the University Hospitals of Leipzig and Halle (Saale) there was also an increase in incidence of CDI, especially of severe clinical courses. In primary and secondary care facilities, prevention of CDI is based on hygiene management and restricted usage of antibiotics, preferably as "Antibiotic Stewardship" programmes. In 2012, the new macrocyclic antibiotic Fidaxomicin was approved in the European Union for the treatment of CDI. The therapeutic armamentarium, previously based on metronidazole or vancomycin, has now been enriched by a substance that presumably will reduce the rate of recurrence of CDI. Moreover, early data from case series and controlled trials suggest that the re-establishment of eubiosis in the colon of patients with recurrent CDI by stool transplantation from healthy donors is an alternative to antibiotics. Standard surgical intervention for refractory CDI is subtotal colectomy with terminal ileostomy. In patients with adequate life expectancy and without organ dysfunction, a colon-saving surgical technique should be considered.

CONCLUSION

Taking antibiotics for most remains the main risk factor for suffering from symptomatic CDI. With the introduction of Fidaxomicin there is hope for an improvement in the conservative treatment of CDI. Stool transplants from healthy donors are now considered to be better than giving antibiotics for severe CDI, but this treatment has not found broad acceptance yet. In cases with a lack of early treatment success, the surgeon must be consulted. Here, the evidence for preferably colon-saving surgical procedures is so far unfortunately low.

[Hyperbaric oxygenation for necrotizing soft tissue infections: pro]

Necrotizing soft tissue infections are a complex pathological spectrum of symptoms and result in a significantly increased risk of mortality depending on the degree of dissemination as well as the underlying bacterial infection. Hyperbaric oxygen therapy (HBOT) can significantly improve the effectiveness of a multidisciplinary treatment concept consisting of surgical debridement, critical care and antibiotic treatment. HBOT itself assists solid wound healing by bactericidal and bacteriostatic effects and by increasing the oxygen supply up to the cellular level resulting in an optimization of oxygen-dependent metabolic processes. The efficacy of treatment in a centre of cooperating specialized departments can therefore be increased by utilizing HBOT as adjunct treatment. Nevertheless, if a HBOT facility is available, excluding HBOT is equivalent to omission of an effective therapy option to the disadvantage of patients.

Distinct distribution of killer-cell immunoglobulin-like receptor genes in the Mugil and Ilaita areas of Papua New Guinea

The frequency of the killer-cell immunoglobulin-like receptor (KIR) genes and transmembrane alleles of KIR2DL4 were studied in coastal (Mugil community) and inland (Ilaita community) communities in Papua New Guinea. Linkage disequilibria between KIR genes and between alleles of KIR2DL4 and the KIR genes were similar to those found in other populations suggesting conservation of the usual gene order in Papua New Guinean haplotypes. Significant differences in the frequency of KIR genes were found between the two populations despite being separated by only 300 km. Examples of individuals who lacked the KIR2DL4 gene and others whose KIR2DL4 allele appeared to have 11 adenines in the polyadenine tract in exon 6 were identified. A relatively low frequency of the KIR A haplotype was found in both populations and particularly in the inland community. The KIR gene frequencies were consistent with the inland Ilaita community being closely related to Australian Aborigines and southern Indians, whereas the KIR gene frequencies of the coastal Mugil community appeared to have been influenced either by recent or ancient admixture from populations with a higher frequency of the KIR A haplotype.

Application of the paraboloidal model to assess mucosal changes following segmental intestinal transplantation in children

Segmental living related small intestinal transplantation (LRSITx) is a therapeutic option for conditions that present with short gut syndromes. Recovery of small intestinal mucosa after transplantation is critical to function. We examined the posttransplant mucosal changes to understand the absorptive capabilities of transplanted small intestine. The study of human subjects is constrained by limited biopsy material; therefore, we developed a technique of villus area measurement by extrapolation from two-dimensional surgical biopsy images. Using a detailed model of the villus as the gold standard, two simpler models (cylindrical and paraboloid) were tested. Comparisons with the accurate measurement revealed that the cylinder model does not compare well in early posttransplant biopsies. The paraboloid function developed in this article worked very well under all conditions. The simplicity of the paraboloid model and its robustness made high-quality estimates of the absorptive surface area from abundant data relatively easy. The remodeling expected in the initial stages of growth was also captured by this model. Time-dependent villus growth curves were obtained for transplanted bowel. Serial biopsies showed an initial "reconstruction" dip around 2 weeks after transplant, followed by continuous growth of villus surface area. An eventual plateau resulted at an average of 6 months after transplant. This growth of villi was shown to parallel the improved absorption of electrolytes, amino acids, and water.

Aggregation state of melittin in lipid vesicle membranes

We have performed time-resolved fluorescence energy transfer measurements using melittin as donor and a modified melittin as acceptor. The melittin molecules were bound to fluid vesicle membranes of dimyristoylphosphatidylcholine. Analysis of the temporal decay of the energy transfer and of its variation with the donor and acceptor concentrations led to the conclusion that melittin in fluid membranes is usually monomeric. Only at the high melittin/lipid molar ratio of 1/200 and high ionic strength evidence for aggregation was obtained, the percentage of aggregated melittin molecules being of the order of 10%. The shortcomings of previous steady-state measurements of fluorescence energy transfer between melittin molecules are discussed.

THE ASSOCIATION OF LOBULAR BREAST CANCER WITH GERMLINE MUTATIONS OF CDH1

Background: CDH1 encodes the cell-cell adhesion molecule, E-cadherin, for which loss of expression facilitates the infiltrative and metastatic potential of cancers. Germline mutations in CDH1 are associated with hereditary diffuse gastric cancer (HDGC), and in this setting female carriers have been estimated to have a 39-50% risk of lobular breast cancer (LBC) by age 80 years. Aim: To determine the frequency of CDH1 germline mutations inindividuals with early-onset LBC or those with LBC and a family history of multiple breast cancers but no gastric cancers. Methods: Germline DNA analysis of CDH1 in women with LBC, for whom germline BRCA1 and BRCA2 mutations have been excluded, who have been (1) diagnosed before the age of 45 years or (2) diagnosed at any age and have a family history of breast cancer. Results: Analysis of 194 LBC cases has thus far revealed two novel missense mutations predicted to affect protein function. Functional assays to assess their pathogenicity along with germline analyses of the remaining 200 cases are currently underway. Several unreported silent changes have also been identified and will be measured in a case- control sample to assess whether they are associated with LBC risk. Conclusion: Germline CDH1 mutations may cause a small proportion of familial and early onset LBC.

Moyamoya vasculopathy in a child after hemolytic uremic syndrome: a possible etiopathogenesis

Moyamoya disease is a cerebral vasculopathy of unknown etiology frequently seen in the Asian population. We report a case of moyamoya vasculopathy in an African-American child who had renal failure followed by cerebral ischemia. Our patient presented with hemolytic uremic syndrome (HUS) and renal failure, and later developed seizures. We believe that in this patient HUS led to the pathogenesis of moyamoya disease. We suggest that patients with HUS who develop any neurological symptoms should be investigated for moyamoya vasculopathy for early diagnosis and treatment.

Influence of fine lactose and magnesium stearate on low dose dry powder inhaler formulations

The behaviour of dry powder blends for inhalation, depending on the amount of fine lactose particles smaller than 10microm and the presence of magnesium stearate (MgSt), was studied in this work. A laser light diffraction method was developed to determine accurately size and volume fraction of these fine lactose particles in coarse carrier lactose (x(50) approximately 220microm). A linear relationship between measured volume fraction undersize at 10microm Q(3)(10microm) and added fine lactose could be established. Aerodynamic particle size distribution analysis of lactose showed that the fine lactose was attached to the coarse particles. In the presence of MgSt this interaction was increased. Consequently, the number of free active sites on the carrier surface was reduced and the investigated drug (formoterol fumarate dihydrate) was more effectively delivered. Addition of fine lactose and MgSt improved the aerodynamic performance the drug, as determined by resulting fine particle fraction, by 3% (for each 1% of added fine lactose) and 10%, respectively. Stability tests indicated that added MgSt was the most relevant of the studied parameter to achieve a stable aerodynamic performance. Its ability to protect the moisture uptake into the system was considered as rational for this effect.

Two novel mutations in the GDAP1 and PRX genes in early onset Charcot-Marie-Tooth syndrome

Autosomal recessive Charcot-Marie-Tooth syndrome (AR-CMT) is often characterised by an infantile disease onset and a severe phenotype. Mutations in the ganglioside-induced differentiation-associated protein 1 (GDAP1) gene are thought to be a common cause of AR-CMT. Mutations in the periaxin (PRX) gene are rare. They are associated with severe demyelination of the peripheral nerves and sometimes lead to prominent sensory disturbances. To evaluate the frequency of GDAP1 and PRX mutations in early onset CMT, we examined seven AR-CMT families and 12 sporadic CMT patients, all presenting with progressive distal muscle weakness and wasting. In one family also prominent sensory abnormalities and sensory ataxia were apparent from early childhood. In three families we detected four GDAP1 mutations (L58LfsX4, R191X, L239F and P153L), one of which is novel and is predicted to cause a loss of protein function. In one additional family with prominent sensory abnormalities a novel homozygous PRX mutation was found (A700PfsX17). No mutations were identified in 12 sporadic cases. This study suggests that mutations in the GDAP1 gene are a common cause of early-onset AR-CMT. In patients with early-onset demyelinating AR-CMT and severe sensory loss PRX is one of the genes to be tested.

Early coronary calcification in children and young adults with end-stage renal disease

Cardiovascular disease is a major cause of morbidity and mortality in children and young adults with end-stage renal disease. In our study, we retrospectively analyzed the records of 11 patients who had undergone electron beam computerized tomography in our dialysis unit. Our patients, aged 11 to 24 years (median, 19.3 years) were on dialysis or had functioning grafts. Coronary calcification was observed in seven patients (64%) with a mean calcium score of 273.8 +/- 708 (range 0.8 to 1864) in our study population. We compared clinical characteristics like age, gender, duration of end-stage renal disease, time on hemodialysis, body mass index, and blood pressures between the patients with calcifications (group I) and those with out calcification (group II). We also compared the laboratory data including daily calcium and calcitriol intake, lipid profile, serum calcium and phosphorus levels, calcium/phosphorus products, and serum parathyroid hormone levels in the both groups. The mean daily dose of total calcium, triglyceride level, and calcium/phosphorus products were higher in the calcification group though not statistically significant. The mean daily dose of calcitriol was significantly higher in patients with calcification. Using Spearman multivariate correlation, we found a correlation between the coronary calcium scores and mean daily doses of total calcium and calcitriol (r = .750, P =.008 and r = .869, P = .001, respectively). We conclude that coronary calcification, which is a proven predictor of cardiovascular disease, begins at a very early age and that daily doses of elemental calcium and calcitriol seem to be important factors in our study population.

Oral contraceptive use and ovarian cancer risk among carriers of BRCA1 or BRCA2 mutations

Women with mutations of the genes BRCA1 or BRCA2 are at increased risk of ovarian cancer. Oral contraceptives protect against ovarian cancer in general, but it is not known whether they protect against the disease in carriers of these mutations. We obtained self-reported lifetime histories of oral contraceptive use from 451 women who carried mutations of BRCA1 or BRCA2. We used conditional logistic regression to estimate the odds ratios associated with oral contraceptive use, comparing the histories of 147 women with ovarian cancer (cases) to those of 304 women without ovarian cancer (controls) who were matched to cases on year of birth, country of residence and gene (BRCA1 vs BRCA2). Reference ages for controls had to exceed the ages at diagnosis of their matched cases. After adjusting for parity, the odds-ratio for ovarian cancer associated with use of oral contraceptives for at least 1 year was 0.85 (95 percent confidence interval, 0.53–1.36). The risk decreased by 5% (1–9%) with each year of use (P for trend=0.01). Use for 6 or more years was associated with an odds-ratio of 0.62 (0.35–1.09). These data support the hypothesis that long-term oral contraceptive use reduces the risk of ovarian cancer among women who carry mutations of BRCA1 or BRCA2.

Living-related bowel transplantation to treat short bowel syndrome in a four-year-old child: a case report

PURPOSE

Short bowel syndrome (SBS) is an extremely challenging clinical problem in children. Although many patients can be maintained for a period of time on total parenteral nutrition (TPN), many of these children suffer from the morbidity and mortality associated with sequential central line infections, venous thromboses, and TPN-induced liver failure. Intestinal transplantation often is the only chance for long-term survival. Unfortunately, many children die every year waiting for size-matched cadaveric intestine to become available.

METHODS

After our success with living-related bowel transplantation in adults, the authors successfully transplanted 150 cm of maternal ileum into a 4-year-old 10-kg child with profound malnutrition from SBS and advanced TPN-induced liver failure. Because of the size mismatch, the abdominal cavity could not be closed primarily. The defect was covered with absorbable mesh and subsequently with skin graft.

RESULTS

The patient is home with excellent bowel and liver function, off hyperalimentation, and on a regular diet. No rejection has been encountered.

CONCLUSIONS

Living-related intestinal transplantation is a life-saving alternative to cadaveric intestinal transplantation in children with short bowel syndrome.

Effects of tezosentan, a dual endothelin receptor antagonist, on the cardiovascular and renal systems of neonatal piglets

BACKGROUND/PURPOSE

Endothelin is a potent biological vasoactive mediator in the cardiovascular and renal systems. Little is known of the effects of endothelin antagonism on the developing heart and kidney, and we hope to show that endothelin does have an important role in the cardiovascular and renal systems of the developing neonate. In this study the authors have examined the effects of tezosentan, a nonselective endothelin-A and endothelin-B receptor antagonist designed for parenteral use, on the cardiovascular and renal systems of healthy neonatal piglets.

METHODS

Eight, 7- to 10-day old domestic piglets weighing 2.5 to 3.0 kg were anesthetized, intubated, and ventilated with catheters placed into the jugular vein, left ventricle, and femoral artery. Urine output was monitored via a suprapubic cystostomy. After baseline data were obtained the piglets received tezosentan (1 mg/kg/h) for 1 hour. A set of data was collected just before discontinuation of the 1-hour infusion of tezosentan and another set was collected 1 hour after the discontinuation of the drug. Mean arterial pressure (MAP), heart rate (HR), and urine output (UV) were monitored continuously and cardiac index (CI), systemic vascular resistance (SVR), renal blood flow (RBF), and renal vascular resistance (RVR) were calculated from gamma counts obtained from injections of radio-labeled microspheres at end of the different time periods. Glomerular filtration rate (GFR) was obtained by the sodium iothalamate method. Data were averaged and plotted versus time and analyzed statistically by a Student's t test.

RESULTS

(P <.05 versus baseline*). In our experimental animals the infusion of tezosentan diminished MAP and SVR from baseline values of 94 +/- 7 mm Hg and 0.14 +/- 0.03 mm Hg/mL/min, respectively to TEZO values of 62 +/- 4* mm Hg and 0.07 +/- 0.02* mm Hg/mL/min. CI increased from 278 +/- 58 to 367 +/- 75* mL/min/kg with tezosentan. There also was a statistically significant increase in RBF from 1.16 +/- 0.38 to 1.86 +/- 0.37* mL/min/kg, an increase in UV from 0.57 +/- 0.24 to 0.64 +/- 0.12* mL/min, a decrease in RVR from 4.60 +/- 1.47 to 2.03 +/- 0.36* mm Hg/mL/min, and no change in the GFR.

CONCLUSIONS

The inhibition of endothelin receptors with tezosentan produced a statistically significant effect on the piglet cardiovascular system with a drop in MAP and SVR and an increase in CI and HR. It also produced a statistically significant increase in RBF and UV and a decrease in RVR without affecting GFR. J Pediatr Surg 36:1824-1828.

Enhancement of noradrenergic neural transmission: an effective therapy of myasthenia gravis: a report on 52 consecutive patients

Neurochemical, neuroautonomic and neuropharmacological assessments carried out on all our myasthenia gravis (MG) patients showed that they presented a neural sympathetic deficit plus excessive adrenal-sympathetic activity. These abnormalities were registered during the basal (supine-resting) state, as well as after several stress tests (orthostasis, exercise, oral glucose and buspirone). In addition, MG patients showed increased levels of free-serotonin (f5HT) in the plasma, supposedly associated with the increased platelet aggregability which we found in all MG patients. As the above trio of neurochemical disorders (low noradrenergic-activity + high adrenergic-activity + increased f-5HT plasma levels) is known to favor Th-1 immunosuppression + Th-2 predominance, we outlined a neuropharmacological strategy for reverting the above neurochemical disorder. This treatment provoked sudden (acute), and late sustained improvements. Acute effects have been attributed to the increase of alpha-1 activity at the spinal motoneuron level. Late improvements always paralleled a significant normalization of immunological disorders. Complete normalization was registered only in non-thymectomized MG patients.

Inspired gas humidity during mechanical ventilation: effects of humidification chamber, airway temperature probe position and environmental conditions

OBJECTIVES

To determine the inspired gas humidity during mechanical ventilation with: (i) four different humidification chambers; (ii) two airway temperature probe (ATP) positions; (iii) five different humidicrib temperatures; and (iv) insulating the inspiratory limb with bubble wrap.

METHODOLOGY

An observational study in the Neonatal Laboratory and Neonatal Intensive Care Unit, Westmead Hospital. The humidity of the inspired gas was measured at the proximal end of the endotracheal tube (ETT) during mechanical ventilation. Inspired humidity measurements were made with four different humidification chambers (Fisher & Paykel (F&P Healthcare Pty Ltd, Auckland, New Zealand) auto refill MR290. F&P manual refill MR310, Suruga (Suruga Inc. Humidifiers, Vincent Medical, Dongguan, China) manual refill MI-20 and MI-10F) with the humidity control (relative humidity setting) set at - 2. Measurements were made with the ATP positioned either; (A) at the distal end of the inspiratory tube inside the humidicrib or (B) outside the humidicrib 50 cm proximal to the ETT. The inspired gas temperatures were set at 36.5 degrees C and at 39.0 degrees C, respectively. For each of the different humidification chambers and ATP positions, inspired humidity measurements were made with the humidicrib temperature set at 30.8, 32.9, 35.2, 36.2, or 37.2 degrees C. Two further sets of measurements were made, one with the inspiratory limb insulated with bubble wrap and the second set without bubble wrap.

RESULTS

There were significant differences in inspired humidity with the four humidification chambers at both ATP positions at all humidicrib temperatures. Both Suruga humidification chambers produced significantly higher inspired gas humidities under most conditions. Positioning the ATP outside the humidicrib produced significantly higher inspired gas humidities than with the ATP inside the humidicrib. Insulating the inspiratory tubing with bubble wrap also significantly improved the inspired gas humidity.

CONCLUSIONS

Significant differences in inspired gas humidity were found with the humidification chambers tested. The position of the ATP and the set temperature had a significant impact on the absolute humidity of the inspired gas. In general, higher inspired gas humidities were obtained with the ATP outside the humidicrib. However, condensation of water close to the ETT appeared at low humidicrib temperatures (< 36.2 degrees C) with the ATP outside the humidicrib and extreme care should be taken that particulate water does not enter the lungs under these conditions.

Inspired gas temperature during mechanical ventilation: effects of environmental temperature and airway temperature probe position

OBJECTIVES

To determine the inspired gas temperature during mechanical ventilation with: (i) five different humidicrib temperatures; (ii) two airway temperature probe (ATP) positions; and (iii) four ATP adaptors.

METHODOLOGY

An observational study in the Neonatal Intensive Care Laboratory, Westmead Hospital. The inspired gas temperature was measured at the proximal end of the endotracheal tube (ETT) during conventional mechanical ventilation using a Tele-thermometer. Inspired gas temperature measurements were made with: (i) the humidicrib temperature set at 30.8. 32.9, 35.2, 36.2. or 37.2 degrees C; (ii) the ATP either (A) positioned inside the humidicrib at the distal end of the inspiratory tubing or (B) positioned outside the humidicrib 50 cm proximal to the ETT, with the inspired gas temperatures set at 36.5 and 39.0 degrees C, respectively; and (iii) the measurements repeated with four different ATP adaptors at each humidicrib temperature and each ATP position.

RESULTS

With the ATP inside the humidicrib, there were no significant differences between set and actual inspired gas temperature. However, with the ATP outside the humidicrib, there were significant decreases in inspired gas temperature at each humidicrib temperature. For instance, with the ATP outside the humidicrib and set at 39.0 degrees C, the inspired gas temperature decreased to 34.7+/-0.2 degrees C at a humidicrib temperature of 30.8 degrees C and to 37.7+/-0.2 degrees C at a humidicrib temperature of 37.2 degrees C. The type of ATP adaptor also had a significant effect on inspired gas temperature.

CONCLUSIONS

With the ATP placed outside the humidicrib and with variations of humidicrib temperature, infants are likely to have inspired gas temperatures that are significantly different to the desired temperature. Certain ATP adaptors cause these variations in inspired gas temperature to be more pronounced. Extreme care must be used to avoid suboptimal inspired gas temperatures with these environmental variations and the ATP positioned outside the humidicrib.

Umbilical cord blood lactate in normal infants: comparison between two methods of measurement

OBJECTIVES

Firstly, to determine the accuracy of the Radiometer ABL 625 lactate electrode (Radiometer Medical Pty Ltd, Nunawading, Victoria, Australia) by comparing the lactate values obtained by this method to those obtained with the Hitachi 917 lactate analyser (Boehringer Mannheim Corporation, Charlottetown, Prince Edward Island, Canada). Secondly, to determine the effect of delay in measurement on blood lactate levels.

METHODOLOGY

Umbilical venous (UCV) blood samples were obtained from healthy term infants delivered vaginally. Lactate levels were measured with the Radiometer ABL 625 lactate electrode in the Neonatal Intensive Care Unit, Westmead Hospital and with the Hitachi 917 lactate analyser in 49 paired samples. In addition 26 UCV blood samples were placed in ice slurry and a further 26 samples at room temperature and blood lactate was measured at 5-min intervals for 30 min to determine the change of lactate levels with time.

RESULTS

The lactate levels obtained from the Radiometer ABL 625 lactate electrode were consistently lower than the levels obtained from the Hitachi 917 lactate analyser (mean difference - 0.24), but the correlation was high (r = 0.97). The blood lactate levels increased at the rate of 0.012 mmol/L per min if the blood was left at room temperature. The lactate levels remained stable for 20 min if the blood was placed in ice slurry.

CONCLUSION

The Radiometer ABL 625 lactate electrode was easy to use and there was high correlation with the values obtained by the standard laboratory method. The blood specimen must be place in an ice slurry if a delay in analysis is anticipated.