Silent Conversations: Goals of Care and End-of-Life Quality in Relapsed High-Risk Leukemia

Background

Advanced practice providers (APPs) affect high-quality health care through leadership, evidence-based practice implementation, and quality improvement projects. When planning solutions to clinical problems, leadership must solicit APP input to promote success. Hematology patients are more likely to receive poor-quality end-of-life (EOL) care than those with solid tumors. Regardless of disease, aggressive EOL care is increasing despite evidence that it is often inconsistent with patients' goals of care (GOC). Data regarding this phenomenon in hematology specifically is lacking. The distorted association of "end of life" with "goals of care" has "silenced" crucial goals discussions in patients with relapsed or refractory high-risk leukemia, which raises concerns for the provision of care that is inconsistent with patients' values and preferences. Hematologists may possess certain traits and distinct barriers leading to what one might call an aversion to GOC discussions in the inpatient setting.

Aims

(1) Quantify hematologists' rate of participation in a GOC pathway initiative during two separate months. (2) Explore the hematologists' definition of and barriers to having GOC discussions.

Design

This is a mixed-methods, explanatory sequential design (follow-up explanations variant).

Sample

Quantitative: Hematology inpatient admissions during two nonconsecutive months in 2021. Qualitative: Eighteen leukemia hematologists from one dedicated cancer center.

Results

During the 2 months, an average of 36% of admissions met the criteria for GOC pathway initiation, 19% of those had an appropriate initiation order, and < 1% had a properly documented and billed GOC discussion. Nine hematologists responded to a SurveyMonkey poll with two questions. All nine included clinical situation and communication in their definition of GOC discussions. Time limitations and prognostic uncertainty were the two most reported barriers.

Discussion

The findings demonstrate that the apprehension of hematologists to have GOC conversations is similarly seen in the APPs' reluctance to initiate a pathway intended to lead to GOC conversations. The percentage of eligible inpatient admissions meeting the specified criteria was similar between the 2 months; however, the number of appropriate referrals and documented or billed GOC discussions was higher in the earlier month, demonstrating temporal decline. Further research inquiry is needed to explore causation of this phenomenon.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Innovative Assessments for Retention of Sexual Assault Nurse Examiners

The Southeast Kansas (SEK) comprehensive rural Sexual Assault Nurse Examiners (SANE) program was developed as part of an effort to increase the availability of SANE services nationwide. The primary goal of the program is to provide education to assist with training and certification of registered nurses and advanced practice registered nurses in SEK to conduct sexual assault forensic examinations and become certified. This will provide better physical and mental health care for survivors and better evidence collection and higher prosecution rates in a rural, medically underserved area. The project established a rural academic-practice-community partnership to provide longitudinal immersive SANE clinical training. The success of the project in SEK will be impacted by the retention of SANEs; therefore, the integration of the Professional Quality of Life (ProQOL) self-assessment was seen as an important component of the grant implementation. ProQOL determines compassion satisfaction, burnout, and secondary traumatic stress. The data collected from SANEs on their self-assessments with the ProQOL lead to early identification of SANEs experiencing negative effects of forensic nursing and the ability to intervene for decreased attrition.

A master protocol to investigate a novel therapy acetyl-L-leucine for three ultra-rare neurodegenerative diseases: Niemann-Pick type C, the GM2 gangliosidoses, and ataxia telangiectasia

BACKGROUND

The lack of approved treatments for the majority of rare diseases is reflective of the unique challenges of orphan drug development. Novel methodologies, including new functionally relevant endpoints, are needed to render the development process more feasible and appropriate for these rare populations and thereby expedite the approval of promising treatments to address patients' high unmet medical need. Here, we describe the development of an innovative master protocol and primary outcome assessment to investigate the modified amino acid N-acetyl-L-leucine (Sponsor Code: IB1001) in three separate, multinational, phase II trials for three ultra-rare, autosomal-recessive, neurodegenerative disorders: Niemann-Pick disease type C (NPC), GM2 gangliosidoses (Tay-Sachs and Sandhoff disease; "GM2"), and ataxia telangiectasia (A-T).

METHODS/DESIGN

The innovative IB1001 master protocol and novel CI-CS primary endpoints were developed through a close collaboration between the Industry Sponsor, Key Opinion Leaders, representatives of the Patient Communities, and National Regulatory Authorities. As a result, the open-label, rater-blinded study design is considerate of the practical limitations of recruitment and retention of subjects in these ultra-orphan populations. The novel primary endpoint, the Clinical Impression of Change in Severity© (CI-CS), accommodates the heterogenous clinical presentation of NPC, GM2, and A-T: at screening, the principal investigator appoints for each patient a primary anchor test (either the 8-m walk test (8MWT) or 9-hole peg test of the dominant hand (9HPT-D)) based on his/her unique clinical symptoms. The anchor tests are videoed in a standardized manner at each visit to capture all aspects related to the patient's functional performance. The CI-CS assessment is ultimately performed by independent, blinded raters who compare videos of the primary anchor test from three periods: baseline, the end of treatment, and the end of a post-treatment washout. Blinded to the time point of each video, the raters make an objective comparison scored on a 7-point Likert scale of the change in the severity of the patient's neurological signs and symptoms from video A to video B. To investigate both the symptomatic and disease-modifying effects of treatment, N-acetyl-L-leucine is assessed during two treatment sequences: a 6-week parent study and 1-year extension phase.

DISCUSSION

The novel CI-CS assessment, developed through a collaboration of all stakeholders, is advantageous in that it better ensures the primary endpoint is functionally relevant for each patient, is able to capture small but meaningful clinical changes critical to the patients' quality of life (fine-motor skills; gait), and blinds the primary outcome assessment. The results of these three trials will inform whether N-acetyl-L-leucine is an effective treatment for NPC, GM2, and A-T and can also serve as a new therapeutic paradigm for the development of future treatments for other orphan diseases.

TRIAL REGISTRATION

The three trials (IB1001-201 for Niemann-Pick disease type C (NPC), IB1001-202 for GM2 gangliosidoses (Tay-Sachs and Sandhoff), IB1001-203 for ataxia telangiectasia (A-T)) have been registered at www.clinicaltrials.gov (NCT03759639; NCT03759665; NCT03759678), www.clinicaltrialsregister.eu (EudraCT: 2018-004331-71; 2018-004406-25; 2018-004407-39), and https://www.germanctr.de (DR KS-ID: DRKS00016567; DRKS00017539; DRKS00020511).

An investigation of perceptions of programme quality support of adult basic education programmes

This study was designed to identify the degree to which the directors of adult basic education programs perceive they have program quality support, as evidenced by a well-defined mission and role in the community, a management system, human resources management, and a suitable learning environment. NSCALL's Evidence-based program self-assessment (2006) was modified and administered electronically to administrators of adult education programs in a mid-southern state. Findings indicated that most directors perceive they are implementing the indicators of program quality support in all of the areas surveyed. A research-based annual self-study that considers the quality indicators is recommended, leaving a need for an update to the NCSALL assessment for use as a program assessment instrument.

Changes in liver tests during 1-year treatment of patients with Type 2 diabetes with pioglitazone, metformin or gliclazide

AIMS

Patients with Type 2 diabetes are at increased risk of liver damage. Therefore, it is of particular importance to investigate the hepatic effects of drugs used to treat such patients.

METHODS

Liver testing results performed in four 1-year, randomized, double-blind studies comparing effects of pioglitazone, metformin or a sulphonylurea, gliclazide, in the treatment of over 3700 patients with Type 2 diabetes have been analysed.

RESULTS

Pioglitazone caused reductions in mean levels of hepatic enzymes of between 3 and 18%, whilst gliclazide caused small increases of between 3 and 13%. Metformin treatment showed either small mean increases or decreases. More patients receiving pioglitazone had liver tests within the normal range at the end of treatment (> or = 87%) compared with patients receiving metformin (> or= 80%) or gliclazide (> or = 75%). Slightly fewer patients with pioglitazone than with comparators showed a large increase (> 3 upper limit of normal) in alanine aminotransferase levels at any time during treatment (pioglitazone 0.9%, metformin 1.9%, gliclazide 1.9%).

CONCLUSIONS

During pioglitazone treatment there is a reduction in liver enzyme levels. Although the mechanism of this effect is not clear, the results demonstrate potential beneficial effects on the liver during treatment of patients with Type 2 diabetes with pioglitazone.

Cardiovascular effects of treatment of type 2 diabetes with pioglitazone, metformin and gliclazide

Cardiovascular mortality and morbidity are increased in patients with type 2 diabetes. However, there are few data from clinical trials comparing cardiovascular effects of alternative oral anti-diabetic agents. Major cardiovascular outcomes during four one-year, double-blind trials in over 3700 patients with type 2 diabetes randomised to either a thiazolidinedione, pioglitazone, metformin or a sulphonylurea, gliclazide treatment have been combined. Mean blood pressure was slightly reduced by all treatments, with pioglitazone treatment resulting in the largest falls (approximately 1.5 mmHg). Hospitalisations for cardiac or cerebrovascular events were similar with the different treatments. Overall mortality was seven of 1857 for pioglitazone and 10 of 1856 for non-pioglitazone treatments, of which three and six were cardiac deaths, respectively. The incidence of congestive cardiac failure was similar with pioglitazone (12/1857) and non-pioglitazone (10/1856) treatments. The results show similar cardiovascular outcome for the three different treatments over a one-year period, but demonstrate interesting differences, which will require longer-term formal outcome studies to determine their significance.

Reintervention as a clinical trial endpoint after peripheral arterial bypass surgery

BACKGROUND

Graft patency is usually the primary endpoint in studies of peripheral arterial bypass surgery, but gives only a limited indication of clinical outcome. The aim of this study was to evaluate reintervention as a study endpoint after femorodistal bypass surgery.

METHODS

The database from a multicentre, prospectively planned study of 517 patients undergoing femorodistal bypass for severe ischaemia was used to investigate the predictive value of technical endpoints. Clinical symptoms, graft patency, vascular interventions and clinical outcomes were recorded for 12 months after operation.

RESULTS

Complete follow-up data were obtained on 498 patients (96 per cent). Success in terms of patients' need for reintervention agreed with clinical outcome in 90 (95 per cent confidence interval (c.i.) 87-93) per cent of cases. Primary and secondary patency agreed with the clinical outcome in 80 (95 per cent c.i. 77-84) and 81 (95 per cent c.i. 78-85) per cent of patients respectively. However, the best agreement with clinical outcome was obtained from the composite endpoint of 'patient alive without reintervention': 92 (95 per cent c.i. 90-94) per cent.

CONCLUSION

Recording the number of patients who did not need reintervention for 12 months after femorodistal bypass gave a more accurate assessment of the number with clinical improvement than was obtained by recording bypass graft patency. Inclusion of patient survival in a composite endpoint increased the clinical relevance of this endpoint in patients with severe ischaemia who had femorodistal bypass surgery.

Safety profile of pioglitazone

The safety profile of pioglitazone has been evaluated in trials including over 5,400 subjects, of whom over 3,500 received active treatment resulting in over 2,500 patient-years of exposure. Since its launch, over 1.4 million patients have been prescribed pioglitazone. This paper will examine the clinical trial tolerability and safety data available for pioglitazone. Safety was evaluated both as monotherapy and in combination with other antihyperglycaemic drugs. All studies had a placebo-controlled, double-blind, randomised, parallel-group, multi-centre design, in which pioglitazone was administered once daily over a period of 16-24 weeks. Most trials also had a long-term open label extension. In these trials, adverse events were recorded, as were details of laboratory blood values, urine analysis, vital signs and electrocardiograms. In addition, specific studies were conducted to examine any effects of pioglitazone on cardiac structure and function, and body composition. This paper will also briefly review data available from post-marketing surveillance.

The safety and tolerability of candesartan cilexetil in CHF

The management of congestive heart failure (CHF) continues to represent a major therapeutic challenge. The primary goal of any treatment is the improvement of symptoms with a reduction in CHF related morbidity and a neutral or beneficial effect on mortality. The number of hospitalisations is considered an important measure of morbidity and quality-of-life in these patients. This pooled safety analysis was performed on adverse event data from five placebo-controlled studies involving a total of 1893 patients, 1287 of whom received candesartan cilexetil and 606 of whom received placebo. These were the only placebo-controlled phase II and III studies of candesartan safety available at the time of the analysis, and investigated the efficacy and safety of candesartan cilexetil in patients with CHF. None was designed as an endpoint trial. A blinded, independent review of all adverse event data was performed to assess all-cause mortality and unexpected deaths, and hospitalisations for acute deterioration of CHF, chronic progression of CHF, other intercurrent events, or accidental injury/attempted suicide. The descriptive analysis included crude and cumulative incidence rates for mortality and cardiac and non-cardiac morbidity using the Kaplan-Meier method and the log-rank test. The sample population was predominantly (approximately two thirds) male, with a median age of 61 years (range: 20-89 years). The median age for women in the sample population was 66 years (range: 26-86 years). Patients received candesartan cilexetil, 2-32 mg, over a median period of 84 days (range: 1-418 days), or placebo over a median period of 85 days (range: 1-398 days). The results demonstrated a clinically non-significant trend for all relevant events (deaths and hospitalisations, whether related to CHF or not) to occur less frequently in patients receiving candesartan cilexetil than in patients receiving placebo (deaths - candesartan cilexetil: 1.6%, placebo: 1.8%; hospitalisations - candesartan cilexetil: 7.2%, placebo: 10.9%). There was a significant treatment difference in CHF hospitalisations (candesartan cilexetil: 3.0% vs. placebo: 5.6%). The time to event analysis revealed that significantly fewer hospitalisations due to CHF occurred in the group receiving candesartan cilexetil than in the group receiving placebo. This treatment difference persisted throughout therapy (log-rank test; p < 0.028). These results show the safety of candesartan cilexetil, compared with placebo, in the treatment of patients with CHF.

Graft material and results of platelet inhibitor trials in peripheral arterial reconstructions: reappraisal of results from a meta-analysis

AIMS

To investigate the characteristics of published trials in order to establish the origin of the differing results obtained in trials of platelet inhibitors after peripheral bypass procedures.

METHODS

Analysis of the information from 11 randomised, controlled trials of platelet inhibitors after peripheral bypass procedures published up until 1999 and involving 2302 patients undergoing peripheral bypass operations, 1250 of whom were treated with platelet inhibitors.

RESULTS

There is a significant treatment benefit of platelet inhibitors on meta-analysis of the trials, but a significant heterogeneity amongst the individual trial results. The proportion of patients in a trial with prosthetic grafts was a significant factor in explaining the heterogeneity. Proportion of prosthetic grafts was associated with sample size and with the proportion of grafts above the knee, but these were not found to make an independent contribution to the heterogeneity observed. The platelet inhibitor regimen used, the severity of ischaemic symptoms and the proportion of smokers included were also not found to be important.

CONCLUSIONS

The improvement of graft patency by aspirin and related platelet inhibitors in clinical trials in peripheral bypass procedures can be attributed to an effect on patients with prosthetic grafts. There is little evidence that these agents prevent occlusion of vein grafts. The conclusion of an earlier meta-analysis that antiplatelet agents should be used for all bypasses is not supported.

Adjuvant medical therapy in peripheral bypass surgery

BACKGROUND

A review was conducted of published clinical trials of adjuvant medical therapy in infrainguinal bypass procedures to evaluate the strength of the evidence for the use of various agents.

METHODS

Trials were identified by literature search. The methods used were reviewed and the results with each agent tested were assessed taking into account the soundness of the study design.

RESULTS

Thirty-three studies were identified; fewer than half had a randomized and double-blind design. Most were single-centre studies including a mixture of different surgical procedures and patients with varying degrees of lower limb ischaemia. Clinical outcomes were seldom reported. The median sample size was 61. The median follow-up duration was 12 months, but was often not standardized for all patients in a trial. Only aspirin in prosthetic grafts and ticlopidine in vein grafts have been shown in well designed, double-blind, randomized, controlled trials to reduce the likelihood of occlusion in infrainguinal bypass grafts.

CONCLUSION

The majority of the trials reviewed had significant deficiencies in their design, reducing the reliance that can be placed on their results. Further studies are required to investigate adequately the effectiveness of existing medical therapies for the maintenance of infrainguinal bypass grafts.

Seasonal variation of Raynaud's phenomenon secondary to systemic sclerosis

OBJECTIVE

Patients with systemic sclerosis (SSc) were assessed for 12 months to quantify the seasonal variation in Raynaud's phenomenon (RP) in patients with an underlying connective tissue disease.

METHODS

Eighteen patients with SSc (17 limited, 1 diffuse type) were studied. Raynaud's attacks were recorded in a daily diary for four 2-week periods at 3 month intervals. Daily number and duration of attacks and overall severity of RP were calculated for each 2-week period. Mean daily temperatures, measured and perceived, were obtained for each period.

RESULTS

In winter, patients had a mean of 2.9 attacks/day (SD +/-1.1), daily duration 70 minutes (SD +/-48) and a severity of score of 4.1 (SD +/-2.0) out of 10. All 3 variables correlated with ambient outdoor temperature and varied significantly over the 12 months (p<0.001) with mean reductions of 48, 50, and 56% respectively from winter to summer. Only 3 of 18 patients reported no attacks during the summer period. The mean measured and perceived outdoor temperatures increased from winter to summer by 10.6 and 14.3 degrees C, respectively.

CONCLUSION

For patients with SSc, RP is a problem throughout the year. Symptoms may be reduced by about 50% in the summer months, but few patients experience complete relief.

Quantitative assessment of walking activity after total hip or knee replacement

Accumulating data suggest that the amount of use, and not simply the duration in situ, influences the wear and survival of total joint replacements. An electronic, digital pedometer was used to record the number of steps taken by 111 non-randomized volunteers who had had at least one total hip or knee replacement. The patients averaged 4988 steps per day, which extrapolates to approximately 0.9 million cycles per year for each joint of the lower extremity. Average activity ranged widely from 395 to 17,718 steps per day, an approximately forty-five-fold difference. The most active patient walked more than 3.5 times the average number of steps per day. Age was significantly associated with activity (p = 0.048), but there was a high degree of variability (standard deviation, 3040 steps per day). Patients who were less than sixty years old walked 30 per cent more on average than those who were sixty years old or more (p = 0.023). Men walked 28 per cent more on average than women (p = 0.037), and men who were less than sixty years old walked 40 per cent more on average than the rest of the patients (p = 0.011). These data indicate that individual differences in the activity of the patient can be a substantial source of variability in rates of polyethylene wear in vivo. The pedometer is an inexpensive investigational tool with many potential applications, including standardizing wear measurements of joint replacements on the basis of gait cycles rather than time. This quantitative approach may provide prognostic information regarding the survival of joint prostheses. Pedometer data may also be useful for quantitative assessment of walking ability in outcome studies.

Candesartan cilexetil: safety and tolerability in healthy volunteers and patients with hypertension

The tolerability and safety of candesartan cilexetil has been evaluated in over 5000 subjects enrolled into double-blind or open-label clinical studies. In double-blind clinical trials in patients with primary hypertension, candesartan cilexetil 2-16 mg once-daily was associated with a low incidence of adverse events and drug-related withdrawals, similar to placebo. The drug showed no evidence of dose-dependent adverse events and it was equally well tolerated by men and women and by elderly (> or =65 years) and younger (<65 years) patients alike. Candesartan cilexetil had no effect on blood glucose control or serum lipid profile in patients with type II diabetes. It was very well tolerated also when given in combination with hydrochlorothiazide or amlodipine and during long-term open-label therapy (up to 1 year). Candesartan cilexetil therefore possesses an excellent tolerability profile that extends to a wide variety of patients including the elderly and it does not aggravate co-existing risk factors such as hyperlipidaemia or glucose intolerance. It therefore appears to offer a better tolerated alternative to other commonly used antihypertensive agents.

Prospective study of 713 below-knee amputations for ischaemia and the effect of a prostacyclin analogue on healing. Hawaii Study Group

In 51 hospitals in six European countries 713 patients requiring below-knee amputation for ischaemic disease were studied prospectively. The patients were allocated randomly to receive standard postoperative treatment or standard treatment plus intravenous infusion of the prostacyclin analogue iloprost for 6 h per day over 14-21 days. Healing of the amputation stump and the need for reamputation at a higher level were similar in the two groups. Overall at 3 months 59 per cent of stumps had healed, 19 per cent of patients had required reamputation at a higher level, 11 per cent had died and the remaining 11 per cent remained with unhealed stumps. Preoperative characteristics were analysed as possible risk factors or markers for primary healing, reamputation and death. Previous arterial reopening procedures (surgical or radiological) almost doubled the chances of primary stump healing (P < 0.05). The surgeon's assessment of the likelihood of healing was wrong in 21 per cent of cases in which the operating surgeon thought that healing would probably occur and in 52 per cent of those in which it was thought healing was improbable.

Placebo controlled study showing therapeutic benefit of iloprost in the treatment of Raynaud's phenomenon

Iloprost is a chemically stable analog of prostaglandin I2 showing the same properties as the naturally occurring substance, but with advantages of ease of handling and administration to patients. A double blind within patient comparison of intravenous iloprost and placebo was undertaken in 13 patients with Raynaud's phenomenon severe enough to warrant short term hospitalization for intravenous dilator therapy; thermography was used as one form of assessment. Our results, while showing improvements in frequency of Raynaud's attacks after iloprost compared with placebo, show no significant effects on other variables.

Iloprost in cardiopulmonary bypass procedures

The inhibition of platelet aggregation during cardiopulmonary bypass and effects on post-operative placebo-controlled study of 145 patients. Significant preservation of platelet numbers and function were shown without significant haemodynamic problems, but no effect on cerebral deficits could be found. The use of iloprost in patients with severe thrombocytopenia seems justified, but the clinical benefits from its use in routine cardiopulmonary bypass remain to be shown.

Effects of iloprost and factors affecting outcome in patients with severe inoperable lower limb ischaemia. U.K. Severe Limb Ischaemia Study Group

The effects of i.v. iloprost given for 14-28 days on six month outcome in patients with severe inoperable lower limb ischaemia were investigated in a double-blind placebo controlled study. More iloprost patients (64%) survived with a viable limb than placebo patients (42%). Iloprost improved prognosis in all subgroups of patients, but patients with lower presenting ankle Doppler pressures had a worse outcome than patients with higher pressures.

Retrospective comparison of iloprost with other treatments for secondary Raynaud's phenomenon

One hundred and twenty seven patients who had Raynaud's attacks secondary to connective tissue disease received intravenous infusions of iloprost in controlled clinical trials. Results of previous treatments for Raynaud's attacks had been recorded by clinicians in 84 of these cases, allowing a comparison to be made with the response to iloprost treatment. Iloprost was reported by the patients as beneficial in 49 (58%) of 84 cases, whereas only 36 (43%) of the 84 patients had previously found any other treatment to be useful. Twenty four of 48 (50%) patients who had not responded to any previous treatment found iloprost to be of benefit. Success or failure of treatment with iloprost was not accurately predicted by the result of treatment with any other drug, except prostacyclin. This survey suggests that iloprost is a useful treatment for patients with severe secondary Raynaud's phenomenon and can be effective in patients unresponsive to other treatments.

Successful treatment of Raynaud's syndrome with Iloprost, a chemically stable prostacyclin analogue

Twelve female patients with severe secondary Raynaud's phenomenon were treated in a randomized order with both placebo and Iloprost infusions. Infusions were for 5 hours on 3 consecutive days and Iloprost was administered at variable dosage from 1.0 to 3.0 ng/kg/min. A 6-week follow-up period was used between the two sets of infusions. A significant number of patients reported Iloprost had improved Raynaud's symptomatology compared with placebo and this effect lasted for up to 6 weeks. The number of attacks of Raynaud's as recorded by patients in diary books was similarly reduced after Iloprost. Digital and nail-bed blood flows measured by laser-Doppler methods were increased for up to 6 weeks after Iloprost, but not after placebo infusions. Iloprost may be a useful therapeutic agent in the treatment of severe secondary Raynaud's syndrome.

Infusion of iloprost, a prostacyclin analogue, for treatment of Raynaud's phenomenon in systemic sclerosis

Iloprost, a stable prostacyclin analogue, was given by intravenous infusion to 29 patients with severe Raynaud's phenomenon, 26 of whom had systemic sclerosis (SS), and compared with placebo infusion in a double blind crossover trial. Iloprost significantly lessened the number and the severity of attacks compared with placebo. Nine patients expressed a preference for effectiveness of treatment, eight of these in favour of Iloprost. Thermography failed to show any long term effect of Iloprost. Side effects of headache, flushing, nausea, and vomiting were common, and the inconvenience of intravenous administration may limit its routine use.

Lumbar intrathecal naloxone blocks analgesia produced by microstimulation of the ventromedial medulla in the rat

In lightly barbiturate-anesthetized rats. low threshold (less than 10 micro A) electrical stimulation within the rostral ventromedial medulla inhibited the tail-flick response to noxious heat. Naloxone applied intrathecally at the lumbar level reversed this inhibition, but the same dose of naloxone applied to the cervical intrathecal space had no effect. Doses of naloxone 1- to 4-fold greater than the intrathecal dose did not antagonize tail-flick suppression when given systemically. Because neither systemic nor intrathecal naloxone had any effect on base-line tail-flick latencies, we conclude that the inhibition of the tail-flick response resulting from microstimulation in the ventromedial medulla is mediated by a spinal opioid synapse.

The effects of intra-arterial bradykinin, histamine, acetylcholine and prostaglandin E1 on nociceptive and non-nociceptive dorsal horn neurones of the cat

The effects of peripherally administered algesic agents were investigated on the firing of cat dorsal horn interneurones classified as nociceptive or non-nociceptive according to the peripheral stimuli that excited them. A small amount of bradykinin injected into the blood supplying the receptive fields of cells was a potent specific stimulus causing activation of nociceptive cells and slowly conducting nerve fibres. Larger amounts of bradykinin and large amounts of histamine, 5-hydroxytryptamine and acetylcholine activated both nociceptive and non-nociceptive cells. Prostaglandin E1 enhanced the effects of bradykinin and histamine on nociceptive cells. Prostaglandin E1 also increased the response of these cells to the application of noxious heat whilst aspirin reduced this response. These results support a chemosensitive theory of nociceptor activation and show bradykinin to be the most potent and specific of the suggested endogenous algesic agents in causing activation of CNS nociceptive pathways.

The differential effects of 5-hydroxytryptamine, noradrenaline and raphe stimulation on nociceptive and non-nociceptive dorsal horn interneurones in the cat

The effects of 5-hydroxytryptamine (5-HT), noradrenaline (NA) and stimulation of the inferior central nucleus of the raphe (RN) were examined on nociceptive and non-nociceptive spinal neurones in anaesthetized cats. 5-HT reduced excitation evoked by noxious stimulation, but increased spontaneous firing and firing evoked by DL-homocysteic acid (DLH) on both nociceptive and non-nociceptive cells. NA reduced spontaneous activity, DLH-evoked excitation and excitation evoked by a noxious stimulus on nociceptive neurones, but had little action on non-nociceptive units. RN inhibited spontaneous, stimulus-evoked and DLH-evoked firing of nociceptive cells and caused briefer inhibitions of non-nociceptive cells. Excitatory effects were also observed. Strychnine antagonized short-duration inhibitions from RN of non-nociceptive cells responding to hair movement, but failed to antagonize any of the other effects of RN. No antagonism of the inhibitory effect of RN was observed with phenoxybenzamine, phentolamine, sotalol, bicuculline or methysergide. However, methysergide antagonized some excitatory effects of 5-HT and RN, but also produced non-specific actions on some cells. It was concluded that, although glycine may mediate some of the brief duration inhibitions evoked by RN, the longer duration inhibitions were unlikely to have been mediated by either glycine or GABA. 5-HT may be a mediator of raphe-spinal actions but may have presynaptic inhibitory actions coupled with postsynaptic excitatory effects. NA could mediate some descending inhibition of nociceptive neurones.

Differential excitatory and inhibitory effects of opiates on non-nociceptive and nociceptive neurones in the spinal cord of the cat

Morphine, levorphanol, dextrorphan and naloxone were applied microelectrophoretically to cells identified as either having nociceptive inputs or non-nociceptive inputs in the dorsal horn of the cat. Morphine excited non-nociceptive cells and depressed nociceptive cells. Naloxone reversed morphine excitations on non-nociceptive cells, but only reversed about one-third of morphine depressions on nociceptive cells. Levorphanol depressed nociceptive cells, whilst dextrophan ejected with similar currents caused less depression or had no effect. It is concluded that excitation of non-nociceptive cells may constitute a spinal action relevant to the analgesic action of opiates, acting synergistically with a depressant effect on nociceptive neurones.

Substance P and Renshaw cells: a new concept of inhibitory synaptic interactions

1. The actions of microelectrophoretically administered substance P on Renshaw cells in pentobarbitone anaesthetized cats were investigated. 2. The effects on spontaneous and synaptic firing and interactions with a number of other agents including acetylcholine, acetyl-beta-methylcholine, acidic amino acids, morphine, dihydro-beta-erythroidine and strychnine were studied in attempts to elucidate the mechanism of action of substance P. 3. Substance P usually selectively depressed the excitation by ACh, and also reduced submaximal synaptically evoked discharges which activate nicotinic receptors, but failed to modify excitation caused either by acetyl-beta-methylcholine, which activates muscarinic receptors, or excitation caused by glutamate or homocysteate. Substance P also depressed excitation by morphine which acted via the nicotinic receptors. 4. The inhibitory effect was not blocked by strychinine and was considered to be unlikely to be due to interaction between the polypeptide and either glycine or GABA receptors. 5. On some cells substance P caused excitation which was blocked by dihydro-beta-erythroidine. Mixed excitatory-inhibitory effects were observed on some of these neurones. 6. The results are discussed in relation to the possibility that substance P could function as a synaptic inhibitory mediator with an unusual selectivity of action.

Glycine-mediated inhibitory transmission of group 1A-excited inhibitory interneurones by Renshaw cells

1. Electrophysiological and micro-electrophoretic studies were carried out in anaesthetized cats on spinal interneurones which were monosynaptically activated from group 1 muscle afferents and recurrently inhibited by Renshaw cells. 2. The recurrent inhibition was blocked by the iontophoretic administration of strychnine, which also blocked the action of glycine. 3. The time course of the block of synaptic inhibition by strychnine was slower than the block of glycine evoked inhibition. The significance of this observation in terms of the location of the inhibitory synapses is discussed. 4. The observation that recurrent inhibition of motoneurones and of interneurones is blocked by strychnine whereas the mutual inhibition of Renshaw cells is not is discussed in relation to the proposal that the nature of the post-synaptic inhibitory receptor is not determined solely by the innervating neurone, which is the Renshaw cell in all three instances. 5. The recurrent inhibition of the interneurones was not blocked by the iontophoretic administration of bicuculline, but difficulties were encountered in demonstrating that this agent consistently antagonized the inhibitory effects of GABA.