Quality assurance standards and their use in the preparation of parenteral systemic anticancer therapy products in healthcare establishments: a scoping review

OBJECTIVES

The use of parenteral systemic anticancer therapy (SACT) has led to improved cancer survival. A quality assurance (QA) system of the aseptic compounding process is necessary to ensure safe and consistent production of parenteral SACT. This scoping review identifies international evidence and practice relating to QA standards in the preparation of parenteral SACT in healthcare establishments.

METHODS

Standards relating to aseptic compounding in hospital pharmacies and literature exploring the aseptic compounding of parenteral SACT were included. Literature relating to the non-aseptic compounding of medicines and records specific to sterile manufacturing in industrial settings were excluded. A search of several electronic databases, trial registries, the grey literature and websites of key European hospital pharmacy groups and accreditation bodies was conducted on 16 March 2022. A narrative discussion was performed by country, and content analysis of articles was conducted.

RESULTS

Thirty-seven records were included. Standards reviewed covered the work environment, the preparation process and the safety of the workers who are potentially exposed to hazardous chemicals. It was a common practice to include frequent audits to ensure adherence to standards. Some standards also recommended external inspections to allow for further learnings. Periodic reviews are encouraged to ensure standards maintain relevance. National standards of the countries reviewed were based on international standards, with minor adaptations for local conditions.

CONCLUSIONS

The main limitation of this review is that it is limited to countries with a high human development index. The review shows that the use of an internationally recognised standard as a basis for national standards is best practice, and will allow for relevance into the future.

Awareness of isotretinoin use and safety in Saudi Arabia: A nationwide cross-sectional study

Introduction

Acne is a prevalent skin condition that affects numerous adolescents and adults worldwide. The most effective treatment for acne is isotretinoin, but its usage is associated with a wide range of adverse effects, and regular monitoring is necessary. Hence, appropriate usage with awareness of potential side effects is crucial. This study aimed to assess the knowledge and awareness of isotretinoin use and safety among individuals with acne in Saudi Arabia.

Methods

A national cross-sectional survey was conducted through an online self-administered questionnaire distributed via social media platforms. The questionnaire consisted of 27 questions in multiple-choice and Likert scale formats, covering demographics, patient awareness of isotretinoin use and side effects, satisfaction with clinical consultation and information provided. Descriptive statistics were used to summarize data.

Results

1315 participants completed the survey, of which most were female (74.1%), single (67.5%), and aged 18-25 years (48.9%). Dryness and teratogenicity were the most commonly known side effects of isotretinoin use (85.5% and 64.9% respectively). However, most participants were unaware of other side effects, such as psychiatric disorders (62.9%), altered liver enzyme concentrations (65.2%), hyperlipidemia (68.1%), anemia (92.4%), and decreased platelet count (96%). Moreover, 36% of sexually active females initiated isotretinoin without contraception. Regarding satisfaction with the information provided during clinical consultation, 63.2% of participants were very satisfied or satisfied. Doctors were the primary source of information (86.8%), followed by the internet (17.8%). Only 45% were informed to avoid blood donation during and after treatment for at least two months.

Conclusion

The study highlights the significance of providing patients with comprehensive information about the potential side effects of isotretinoin, including the need to use contraception and avoid blood donation during and after treatment. Effective communication between physicians and patients is critical in ensuring the safe and effective use of isotretinoin.

A qualitative evaluation of the attitudes, barriers, and facilitators relating to the provision of vaccine information by Irish community pharmacists

Introduction

Community Pharmacists (CPs) can positively impact vaccination uptake. Vaccine hesitancy is not a binary belief but consists of a range of context-specific opinions. CPs are easily-accessible, trusted healthcare professionals responsible for improving patients’ wellbeing. CPs have a positive impact on reducing vaccine hesitancy and improving vaccine uptake. The importance of pharmacists’ role as vaccination educators is clear.(1) Despite the benefits of involvement in vaccine advocacy, CPs may be reluctant to communicate with vaccine-hesitant patients or may find counselling challenging. (2)

Aim

To examine factors influencing Irish CPs’ attitudes towards vaccine information provision and propose actions to remove barriers and promote facilitators to improve vaccination counselling.

Methods

Semi-structured interviews with a purposive sample of Irish CPs took place from October-November 2020. Topics covered included personal attitudes to vaccination, attitudes to pharmacists as vaccination educators, and barriers to counselling provision. Participants also completed a survey about their work environment and history of administering vaccines and beliefs about vaccination. Interview audio recordings were transcribed verbatim and thematic analysis used to identify themes. NVivo 12 was used to analyse interview data.

Results

Twelve pharmacists were interviewed. The majority of interviewees were female (n=10), supervising pharmacists (n=7), and received flu vaccines in at least three of the previous five years (n=7/10). Survey questions were not answered by two participants. All others agreed that vaccines are safe and effective. A single participant did not agree that vaccine counselling is a valuable use of a CPs time and that CPs should try to improve public vaccine uptake.

Six themes were identified, with four relating to attitudes towards vaccine counselling; 1) vaccine value and confidence, 2) influence and duty, 3) knowledge, and 4) time and money, and two themes on actions to enhance counselling: 5) supporting resources, and 6) public awareness. Supporting materials would allow participants to be ‘very confident in going through…with them, going through risks, benefits, side-effects’ and would be ‘something tangible to show them’. In addition patients could take them home to help their deliberations. Having insufficient time was a barrier to vaccine counselling as they often were the only CP so they could not ‘start a conversation with someone about vaccine uptake if I can see that I have ten scripts waiting inside in the dispensary to be done.’

Conclusion

Participants recognised the value of vaccination for improving patient wellbeing but willingness to promote immunisation was restricted by insufficient knowledge, time, and financial supports. Limited by its low number of participants, the diversity of CPs and overlapping themes strengthen the results of this study. Provision of accessible information repositories, training resources, counselling materials, and awareness campaigns may address deficits in knowledge and confidence. Removal of time and financial barriers may require reform of the role of community pharmacy in delivery of vaccine services in Ireland.

References

(1) Isenor JE, Edwards NT, Alia TA, Slayter KL, MacDougall DM, McNeil SA, et al. Impact of pharmacists as immunizers on vaccination rates: A systematic review and meta-analysis. Vaccine. 2016 Nov 11;34(47):5708–23.

(2) Islam JY, Gruber JF, Lockhart A, Kunwar M, Wilson S, Smith SB, et al. Opportunities and Challenges of Adolescent and Adult Vaccination Administration Within Pharmacies in the United States. Biomed Inform Insights. 2017;9:1178222617692538.

A mixed methods analysis of the monitoring of oral anti-cancer therapies

PURPOSE

Oral anti-cancer therapies offer advantages over parenteral therapies in terms of their non-invasive nature and reduced intrusiveness. However, the shift from directly observed administration of these therapies to home administration means that continuous monitoring is needed. The oral anti-cancer therapy market is rapidly growing, with an ever-increasing number of new medicines available for the patients presenting with cancer illnesses. This study aims to (i) evaluate both the cost of providing monitoring consultations of oral anti-cancer therapies, and (ii) to assess the experience of cancer therapy nurses responsible for the monitoring and their opinions of the quality of the service.

METHODS

This study provides a mixed methods evaluation of the monitoring of oral anti-cancer therapies. Nurses were asked to record the time taken for them to perform their monitoring duties, and staff related costs were calculated using publicly available salary data. Patient-related costs were calculated using the Human Capital method. Nurses were asked to discuss their experience of monitoring oral anti-cancer therapies in semi-structured interviews. These interviews were subsequently analysed using thematic analysis.

RESULTS

201 recordings and their associated costs were documented. The median consultation time was 33 min, costing €22.10 using Clinical Nurse Specialist salary figures and €26.51 using Advanced Nurse Practitioner salary figures. The associated patient cost was €14.06. Themes of the effect of Covid-19 on the service, expanding and complicated care package requirements, the need for dedicated oral clinics and the future of the service emerged from the interview data.

CONCLUSION

The monitoring service provided by nurses may be undervalued. The commitment to fully dedicated oral anti-cancer therapy clinics and an increase in staff to align with the ongoing increase in service demand is seen as vital for the continued safe and effective delivery of this specialist cancer service.

In-hospital adverse drug reactions in older adults; prevalence, presentation and associated drugs-a systematic review and meta-analysis

BACKGROUND

the prevalence of adverse drug reactions (ADRs) in hospitalised older patients, their clinical presentations, causative drugs, severity, preventability and measurable outcomes are unclear, ADRs being an increasing challenge to older patient safety.

METHODS

we systematically searched PubMed, Embase, EBSCO-CINAHL, the Cochrane Library, 'rey' literature and relevant systematic review bibliographies, published from database inception to March 2020. We included any study reporting occurrence of in-hospital ADRs as primary or secondary outcomes in hospitalised older adults (mean age ≥ 65 years). Two authors independently extracted relevant information and appraised studies for bias. Study characteristics, ADR clinical presentations, causative drugs, severity, preventability and clinical outcomes were analysed. Study estimates were pooled using random-effects meta-analytic models.

RESULTS

from 2,399 abstracts, we undertook full-text screening in 286, identifying 27 studies (29 papers). Final analysis yielded a pooled ADR prevalence of 16% (95%CI 12-22%, I2 98%,τ2 0.8585), in a population of 20,153 hospitalised patients aged ≥65 years of whom 2,479 patients experienced ≥ one ADR. ADR ascertainment was highly heterogeneous. Almost 48.3% of all ADRs involved five presentations: fluid/electrolyte disturbances (17.3%), gastrointestinal motility/defaecation disorders (13.3%), renal disorders (8.2%), hypotension/blood pressure dysregulation disorders/shock (5.5%) and delirium (4.1%). Four drug classes accounted for 57.8% of causative medications i.e. diuretics (19.8%), anti-bacterials (14.8%), antithrombotic agents (12.2%) and analgesics (10.9%). Pooled analysis of severity was not feasible. Four studies reported the majority of ADRs as preventable (55-95%).

CONCLUSIONS

on average, 16% of hospitalised older patients experience significant ADRs, varying in severity and mostly preventable, with commonly prescribed drug classes accounting for most ADRs.

Measurement properties of EQ-5D-3L and EQ-5D-5L in recording self-reported health status in older patients with substantial multimorbidity and polypharmacy

BACKGROUND

The EQ-5D-3L and EQ-5D-5L are two generic health-related quality of life measures, which may be used in clinical and health economic research. They measure impairment in 5 aspects of health: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. The aim of this study was to assess the performance of the EQ-5D-3L and EQ-5D-5L in measuring the self-reported health status of older patients with substantial multimorbidity and associated polypharmacy.

METHODS

Between 2017 and 2019, we administered EQ-5D-3L and EQ-5D-5L to a subset of patients participating in the OPERAM trial at 6 months and 12 months after enrolment. The OPERAM trial is a two-arm multinational cluster randomised controlled trial of structured medication review assisted by a software-based decision support system versus usual pharmaceutical care, for older people (aged ≥ 70 years) with multimorbidity and polypharmacy. In the psychometric analyses, we only included participants who completed the measures in full at 6 and 12 months. We assessed whether responses to the measures were consistent by assessing the proportion of EQ-5D-5L responses, which were 2 or more levels away from that person's EQ-5D-3L response. We also compared the measures in terms of informativity, and discriminant validity and responsiveness relative to the Barthel Index, which measures independence in activities of daily living.

RESULTS

224 patients (mean age of 77 years; 56% male) were included in the psychometric analyses. Ceiling effects reported with the EQ-5D-5L (22%) were lower than with the EQ-5D-3L (29%). For the mobility item, the EQ-5D-5L demonstrated better informativity (Shannon's evenness index score of 0.86) than the EQ-5D-3L (Shannon's evenness index score of 0.69). Both the 3L and 5L versions of EQ-5D demonstrated good performance in terms of discriminant validity, i.e. (out of all items of the EQ-5D-3L and EQ-5D-5L, the pain/discomfort and anxiety/depression items had the weakest correlation with the Barthel Index. Both the 3L and 5L versions of EQ-5D demonstrated good responsiveness to changes in the Barthel Index.

CONCLUSION

Both EQ-5D-3L and EQ-5D-5L demonstrated validity and responsiveness when administered to older adults with substantial multimorbidity and polypharmacy who were able to complete the measures.

A cost comparison study to review community versus acute hospital models of nursing care delivered to oncology patients

PURPOSE

Ireland's Sláintecare health plan is placing an increased focus on primary care. A community oncology nursing programme was developed to train community nurses to deliver care in the community. While the initial pilot was proven to be clinically safe, no cost evaluation was carried out. This study aims to compare the costs of providing cancer support services in a day-ward versus in the community.

METHODS

183 interventions (40 in day-ward and 143 in community) were timed and costed using healthcare professional salaries and the Human Capital method.

RESULTS

From the healthcare provider perspective, the day-ward was a significantly cheaper option by an average of €17.13 (95% CI €13.72 - €20.54, p < 0.001). From the societal perspective, the community option was cheaper by an average of €2.77 (95% CI -€3.02 - €8.55), although this was a non-significant finding. Sensitivity analyses indicate that the community service may be significantly cheaper from the societal perspective.

CONCLUSIONS

Given the demand for cost-viable options for primary care services, this programme may represent a national option for cancer care in Ireland when viewed from the societal perspective.

Endoscopic Botulinum toxin as a treatment for delayed gastric emptying following oesophagogastrectomy

INTRODUCTION

The incidence of delayed gastric emptying (DGE) following oesophagogastrectomy with gastric conduit reconstruction is reported to be between 1.7% and 50%. This variation is due to differing practices of intraoperative pylorus drainage procedures, which increase the risk of postoperative biliary reflux and dumping syndrome, resulting in significant morbidity. The aim of our study was to establish rates of DGE in people undergoing oesophagogastrectomy without routine intraoperative drainage procedures, and to evaluate outcomes of postoperative endoscopically administered Botulinum toxin into the pylorus (EBP) for people with DGE resistant to systemic pharmacological treatment.

METHODS

All patients undergoing oesophagogastrectomy between 1 January 2016 and 31 March 2018 at our unit were included. No intraoperative pyloric drainage procedures were performed, and DGE resistant to systemic pharmacotherapy was managed with EBP.

RESULTS

Ninety-seven patients were included. Postoperatively, 29 patients (30%) were diagnosed with DGE resistant to pharmacotherapy. Of these, 16 (16.5%) were diagnosed within 30 days of surgery. The median pre-procedure nasogastric tube aspirate was 780ml; following EBP, this fell to 125ml (p<0.001). Median delay from surgery to EBP in this cohort was 13 days (IQR 7-16 days). Six patients required a second course of EBP, with 100% successful resolution of DGE before discharge. There were no procedural complications.

CONCLUSIONS

This is the largest series of patients without routine intraoperative drainage procedures. Only 30% of patients developed DGE resistant to pharmacotherapy, which was managed safely with EBP in the postoperative period, thus minimising the risk of biliary reflux in people who would otherwise be at risk following prophylactic pylorus drainage procedures.

Intervention protocol: OPtimising thERapy to prevent avoidable hospital Admission in the Multi-morbid elderly (OPERAM): a structured medication review with support of a computerised decision support system

BACKGROUND

Several approaches to medication optimisation by identifying drug-related problems in older people have been described. Although some interventions have shown reductions in drug-related problems (DRPs), evidence supporting the effectiveness of medication reviews on clinical and economic outcomes is lacking. Application of the STOPP/START (version 2) explicit screening tool for inappropriate prescribing has decreased inappropriate prescribing and significantly reduced adverse drug reactions (ADRs) and associated healthcare costs in older patients with multi-morbidity and polypharmacy. Therefore, application of STOPP/START criteria during a medication review is likely to be beneficial. Incorporation of explicit screening tools into clinical decision support systems (CDSS) has gained traction as a means to improve both quality and efficiency in the rather time-consuming medication review process. Although CDSS can generate more potential inappropriate medication recommendations, some of these have been shown to be less clinically relevant, resulting in alert fatigue. Moreover, explicit tools such as STOPP/START do not cover all relevant DRPs on an individual patient level. The OPERAM study aims to assess the impact of a structured drug review on the quality of pharmacotherapy in older people with multi-morbidity and polypharmacy. The aim of this paper is to describe the structured, multi-component intervention of the OPERAM trial and compare it with the approach in the comparator arm.

METHOD

This paper describes a multi-component intervention, integrating interventions that have demonstrated effectiveness in defining DRPs. The intervention involves a structured history-taking of medication (SHiM), a medication review according to the systemic tool to reduce inappropriate prescribing (STRIP) method, assisted by a clinical decision support system (STRIP Assistant, STRIPA) with integrated STOPP/START criteria (version 2), followed by shared decision-making with both patient and attending physician. The developed method integrates patient input, patient data, involvement from other healthcare professionals and CDSS-assistance into one structured intervention.

DISCUSSION

The clinical and economical effectiveness of this experimental intervention will be evaluated in a cohort of hospitalised, older patients with multi-morbidity and polypharmacy in the multicentre, randomized controlled OPERAM trial (OPtimising thERapy to prevent Avoidable hospital admissions in the Multi-morbid elderly), which will be completed in the last quarter of 2019.

TRIAL REGISTRATION

Universal Trial Number: U1111-1181-9400 Clinicaltrials.gov: NCT02986425, Registered 08 December 2016. FOPH (Swiss national portal): SNCTP000002183. Netherlands Trial Register: NTR6012 (07-10-2016).

Prepartum fatty acid supplementation in sheep. II. Supplementation of eicosapentaenoic acid and docosahexaenoic acid during late gestation alters the fatty acid profile of plasma, colostrum, milk and adipose tissue, and increases lipogenic gene expression of adipose tissue

The objectives of this study were as follows: 1) to establish whether feeding a source of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) to ewes during late gestation changes the fatty acid profile of colostrum, milk, ewe adipose tissue, and plasma and subsequently lamb plasma and red blood cells (RBC), and 2) to investigate the effects of EPA and DHA on mRNA expression in ewe adipose tissue. Eighty-four gestating ewes (28 pens, three per pen) were blocked by lambing day and assigned to a diet with an addition of fat at 0.39% of the DM during the last 50 d of gestation using Ca salts of a palm fatty acid distillate (PFAD) high in palmitic and oleic acids or EPA + DHA. Blood samples were taken from ewes on days 20, 1 (parturition), and 30 and from lambs on days 1 and 30 for plasma fatty acid analysis. Fatty analysis of lamb RBC was performed on day 1. Colostrum samples were taken at lambing and milk samples on day 30 for fatty acid analysis. Subcutaneous adipose tissue biopsies were taken from one ewe per pen on day 20 for fatty acid analysis and gene expression analysis of 27 genes. Treatment × day interactions (P < 0.10) were observed for several isomers of C18:1, with concentrations that were greater in plasma of EPA + DHA ewes on day 20, but were not different on day 1 or 30. Plasma concentrations of EPA tended to be greater (P = 0.07), whereas DHA was greater (P < 0.001) in EPA + DHA ewes compared with PFAD ewes. There was no difference in EPA or DHA in adipose tissue with EPA + DHA vs. PFAD supplementation (P > 0.10). Concentrations of fatty acids with 6 to 10 carbons were significantly increased (P < 0.05) in colostrum and milk of EPA + DHA ewes. There was a treatment × day interaction with EPA + DHA ewes yielding greater EPA (P = 0.03) and DHA (P = 0.04) concentrations than PFAD in colostrum, but not in milk. Treatment × day interactions (P < 0.05) were observed for several C18:1 isomers with concentrations that were greater in EPA + DHA ewe colostrum, but were not different between treatments in milk. In lamb plasma and RBC, EPA and DHA were not different between treatments (P > 0.10). The expression of fatty acid synthase and leptin was significantly increased (P < 0.05), whereas the expression of diacylglycerol acyltransferase 2 tended to be increased (P = 0.08) by supplementation of EPA + DHA vs. PFAD. These results suggest that supplementation with EPA and DHA to ewes during late gestation alters the fatty acid profile of plasma, colostrum, and milk and may increase lipogenesis.

Atypical Mycobacterial Infections of the Upper Extremity: Becoming More Atypical?

Background: Atypical mycobacterial infections are uncommon and characterized by a chronic, indolent course before diagnosis. Historically, these infections are associated with marine-related injury and/or immune dysfunction. Our institution has successfully diagnosed and treated an increasing number of these infections. The objective of this study is to review our experience with these rare infections and verify the developing trends encountered. Methods: A retrospective review was performed for patients with positive nontuberculous mycobacterial cultures of the upper extremity from 2000 to 2013. Patient demographics, source of transmission, symptom duration, mycobacterial species, operative and antibiotic treatments, and outcomes were recorded. Results: Thirty-four patients were identified. The mean symptomatic period before diagnosis was 9 months (range, 1-60 months). Fourteen patients had identifiable causes of immune dysfunction while the rest appeared immune competent. Patients were infected by Mycobacterium marinum (n = 14), Mycobacterium abscessus (n = 8), Mycobacterium fortuitum (n = 7), and other less common species (n = 5). Although most patients had unidentifiable causes of infection (n = 15), some could correlate infection to marine injury, lacerations, insect bites, animal bites, and tattoos. All patients received operative intervention including debridement. Antibiotics were given for a mean duration of 5 months. Ninety-seven percent had complete resolution of disease. Conclusions: Although M. marinum infections make up the majority of infections at our institution, we report a higher total incidence of nonmarinum infections. These infections are occurring in seemingly healthy individuals with no history of exposure with marine water. Successful treatment relies on having a heightened clinical awareness and adequate diagnosis.

Axis I disorders in adjustable gastric band patients: the relationship between psychopathology and weight loss

BACKGROUND

Bariatric surgery candidates have higher rates of co-morbid psychological illnesses than those in the general population. The effect of weight loss on these illnesses is unclear.

METHODS

This prospective observational study explored psychiatric co-morbidities and weight loss outcomes in 204 gastric banding surgery candidates. Psychiatric co-morbidities were assessed prior to surgery and 2 years post-surgery. One hundred and fifty patients (74%) completed assessments at both time points.

RESULTS

At baseline, 39.7% of the patients met the criteria for a current axis I disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). Mood disorders were the most frequent (26.5%), followed by anxiety disorders (15.2%) and binge eating disorder (13.2%). Preoperative psychopathology predicted clinical psychopathology at 2 years. No preoperative or post-operative axis I disorder was significantly related to weight loss at 2 years. The frequency of current axis I disorders decreased significantly from 39.7% preoperatively to 20% 2 years post-surgery.

CONCLUSIONS

The point prevalence of psychopathology in this sample of Australian bariatric candidates is high. Psychopathology, preoperatively and at 2 years of follow-up, was not associated with weight loss at 2 years.

Benzodiazepine prescribing guideline adherence and misuse potential in Irish minors

BACKGROUND

The Good Prescribing Practice for Clinicians guidelines were published in 2002 in Ireland to guide General Practitioners about prescribing benzodiazepines. There has been no research to-date to measure compliance by General Practitioners. Inappropriate prescribing to minors may result in increased use or misuse of benzodiazepines.

OBJECTIVE

The purpose of this study was to evaluate the prescribing of benzodiazepines to minors in Ireland against the Good Prescribing Practice for Clinicians guidelines.

METHOD

Data for medicines dispensed between January 2009 and December 2012 from the Health Intelligence Ireland database were accessed and analysed. This database contains information about government-subsidised community-pharmacy-dispensed medicines.

RESULTS

Benzodiazepine prescribing to minors increased by 10.2% between 2009 and 2012. Almost 15% of patients (n = 2193) were prescribed benzodiazepines for greater than four weeks; which contravenes the guidelines. Approximately half (51.4%) of prescribers who contravened this guideline, prescribed all their benzodiazepines in quantities of greater than one week, against the recommendations of the guidelines.

CONCLUSION

The consequences of prescribing against National Guidelines can result in patients who become long-term benzodiazepine users and thus place an increased burden upon the healthcare system. The reasons for non-compliance by GPs should be investigated to find solutions.

Use of addiction treatment services by Irish youth: does place of residence matter?

INTRODUCTION

Substance abuse treatment centres for Irish rural youth have largely been overlooked in the scientific literature. This study examined data from a substance abuse treatment centre that treats both urban and rural attendees to investigate if there are differences in usage patterns between attendee groups.

METHODS

A cross-sectional study was done of 436 service-users attending a treatment centre: patient characteristics, treatment referral details and substance history of the attendees from urban and rural areas were compared. Descriptive analysis of the service-user population was performed and recent substance use was investigated. Inferential tests examined for differences between urban and rural service-users.

RESULTS

The typical service-user was an Irish male aged between 16 and 17 years, who resided with his parents. A greater percentage of rural service-users were employed (33.3% vs 22.2%, p=0.015), while a significantly greater percentage of urban service-users were unemployed (10.3% vs 4.1%, p=0.015). A greater proportion of urban service-users had tried multiple substances in their lifetimes (73.7% vs 52.2%, p=0.001) and continued to use multiple substances regularly (49.3% vs 31.3%, p=0.003) compared with their rural counterparts.

CONCLUSIONS

This is the first Irish study comparing service-users from urban and rural settings. Rural service-users developed more problematic alcohol use, while more urban service-users were referred for benzodiazepine use. Prevention strategies should acknowledge the differences and similarities in urban and rural young people.

The structure of Jann_2411 (DUF1470) from Jannaschia sp. at 1.45 Å resolution reveals a new fold (the ABATE domain) and suggests its possible role as a transcription regulator

The crystal structure of Jann_2411 from Jannaschia sp. strain CCS1, a member of the Pfam PF07336 family classified as a domain of unknown function (DUF1470), was solved to a resolution of 1.45 Å by multiple-wavelength anomalous dispersion (MAD). This protein is the first structural representative of the DUF1470 Pfam family. Structural analysis revealed a two-domain organization, with the N-terminal domain presenting a new fold called the ABATE domain that may bind an as yet unknown ligand. The C-terminal domain forms a treble-clef zinc finger that is likely to be involved in DNA binding. Analysis of the Jann_2411 protein and the broader ABATE-domain family suggests a role as stress-induced transcriptional regulators.

Structures of the first representatives of Pfam family PF06684 (DUF1185) reveal a novel variant of the Bacillus chorismate mutase fold and suggest a role in amino-acid metabolism

The crystal structures of BB2672 and SPO0826 were determined to resolutions of 1.7 and 2.1 Å by single-wavelength anomalous dispersion and multiple-wavelength anomalous dispersion, respectively, using the semi-automated high-throughput pipeline of the Joint Center for Structural Genomics (JCSG) as part of the NIGMS Protein Structure Initiative (PSI). These proteins are the first structural representatives of the PF06684 (DUF1185) Pfam family. Structural analysis revealed that both structures adopt a variant of the Bacillus chorismate mutase fold (BCM). The biological unit of both proteins is a hexamer and analysis of homologs indicates that the oligomer interface residues are highly conserved. The conformation of the critical regions for oligomerization appears to be dependent on pH or salt concentration, suggesting that this protein might be subject to environmental regulation. Structural similarities to BCM and genome-context analysis suggest a function in amino-acid synthesis.

Conformational changes associated with the binding of zinc acetate at the putative active site of XcTcmJ, a cupin from Xanthomonas campestris pv. campestris

In the plant pathogen Xanthomonas campestris pv. campestris, the product of the tcmJ gene, XcTcmJ, encodes a protein belonging to the RmlC family of cupins. XcTcmJ was crystallized in a monoclinic space group (C2) in the presence of zinc acetate and the structure was determined to 1.6 Å resolution. Previously, the apo structure has been reported in the absence of any bound metal ion [Chin et al. (2006), Proteins, 65, 1046-1050]. The most significant difference between the apo structure and the structure of XcTcmJ described here is a reorganization of the binding site for zinc acetate, which was most likely acquired from the crystallization solution. This site is located in the conserved metal ion-binding domain at the putative active site of XcTcmJ. In addition, an acetate was also bound within coordination distance of the zinc. In order to accommodate this binding, rearrangement of a conserved histidine ligand is required as well as several nearby residues within and around the putative active site. These observations indicate that binding of zinc serves a functional role in this cupin protein.

Identification and structural characterization of heme binding in a novel dye-decolorizing peroxidase, TyrA

TyrA is a member of the dye-decolorizing peroxidase (DyP) family, a new family of heme-dependent peroxidase recently identified in fungi and bacteria. Here, we report the crystal structure of TyrA in complex with iron protoporphyrin (IX) at 2.3 A. TyrA is a dimer, with each monomer exhibiting a two-domain, alpha/beta ferredoxin-like fold. Both domains contribute to the heme-binding site. Co-crystallization in the presence of an excess of iron protoporphyrin (IX) chloride allowed for the unambiguous location of the active site and the specific residues involved in heme binding. The structure reveals a Fe-His-Asp triad essential for heme positioning, as well as a novel conformation of one of the heme propionate moieties compared to plant peroxidases. Structural comparison to the canonical DyP family member, DyP from Thanatephorus cucumeris (Dec 1), demonstrates conservation of this novel heme conformation, as well as residues important for heme binding. Structural comparisons with representative members from all classes of the plant, bacterial, and fungal peroxidase superfamily demonstrate that TyrA, and by extension the DyP family, adopts a fold different from all other structurally characterized heme peroxidases. We propose that a new superfamily be added to the peroxidase classification scheme to encompass the DyP family of heme peroxidases.

Crystal structure of a novel Sm-like protein of putative cyanophage origin at 2.60 A resolution

ECX21941 represents a very large family (over 600 members) of novel, ocean metagenome-specific proteins identified by clustering of the dataset from the Global Ocean Sampling expedition. The crystal structure of ECX21941 reveals unexpected similarity to Sm/LSm proteins, which are important RNA-binding proteins, despite no detectable sequence similarity. The ECX21941 protein assembles as a homopentamer in solution and in the crystal structure when expressed in Escherichia coli and represents the first pentameric structure for this Sm/LSm family of proteins, although the actual oligomeric form in vivo is currently not known. The genomic neighborhood analysis of ECX21941 and its homologs combined with sequence similarity searches suggest a cyanophage origin for this protein. The specific functions of members of this family are unknown, but our structure analysis of ECX21941 indicates nucleic acid-binding capabilities and suggests a role in RNA and/or DNA processing.

Successful incorporation of tissue-engineered porcine small-intestinal submucosa as substitute flexor tendon graft is mediated by elevated TGF-beta1 expression in the rabbit

PURPOSE

Ideal tendon repair materials combine minimal donor-site morbidity and ready availability with excellent healing and postoperative function. Bioengineered porcine small-intestinal submucosa (SIS) was compared with tendon autografts as a potential human flexor tendon graft substitute.

METHODS

Rabbit zone II flexor digitorum profundus segments were excised in 40 rabbits. Randomized tendon repair consisted of either interposition reversed autograft or SIS, passed beneath the A2 and A4 pulleys. Forepaws were statically splinted for 3 weeks followed by unrestricted motion. Animals were killed at 7, 14, 28, and 56 days. Specimens were analyzed for hydroxyproline content (absorption spectroscopy) and tensile strength. Hematoxylin-eosin and Movat-stained sections of the central graft and distal repair site were semiquantitatively scored for total cellularity, inflammatory cell content, foreign-body reaction, vascularity, mature collagen content, and new collagen deposition. Transforming growth factor-beta (TGF-beta1) and TGF-beta1 receptor immunostaining was performed.

RESULTS

At week 1, SIS hydroxyproline content was significantly reduced compared with autograft hydroxyproline content. However, week 2 SIS hydroxyproline content increased to equivalent values. Collagen deposition was evident in SIS by week 1 but negligible in autograft. More rapid total and inflammatory cell increases occurred in SIS by 4 weeks. A stronger early inflammatory reaction also occurred. More rapid SIS neovascularization occurred despite a greater foreign-body reaction. Small-intestinal submucosa vascularity was markedly greater at weeks 1 and 2 and equivalent thereafter. At week 4, SIS intrinsic tensile strength (suture removed) exceeded that of both autograft and suture material. Preoperative TGF-beta1 immunostaining in SIS was less than that of autograft but greater during weeks 2 and 4.

CONCLUSIONS

Earlier neovascularization, increased TGF-beta1 levels, and increased collagen deposition, along with greater intrinsic repair strength relative to both autograft and suture strength at week 4, make SIS a promising flexor tendon graft substitute. Future studies examining tendon excursion are planned.

Effect of Supplementation with Calcium Salts of Fish Oil on n-3 Fatty Acids in Milk Fat

Enrichment of milk fat with n-3 fatty acids, in particular eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), may be advantageous because of their beneficial effects on human health. In addition, these fatty acids play an important role in reproductive processes in dairy cows. Our objective was to evaluate the protection of EPA and DHA against rumen biohydrogenation provided by Ca salts of fish oil. Four Holstein cows were assigned in a Latin square design to the following treatments: 1) ruminal infusion of Ca salts of fish oil and palm fatty acid distillate low dose (CaFO-1), 2) ruminal infusion of Ca salts of fish oil and palm fatty acid distillate high dose (CaFO-2), 3) ruminal infusion of fish oil high dose (RFO), and 4) abomasal infusion of fish oil high dose (AFO). The high dose of fish oil provided approximately 16 and approximately 21 g/d of EPA and DHA, respectively, whereas the low dose (CaFO-1) provided 50% of these amounts. A 10-d pretreatment period was used as a baseline, followed by 9-d treatment periods with interceding intervals of 10 d. Supplements were infused every 6 h, milk samples were taken the last 3 d, and plasma samples were collected the last day of baseline and treatment periods. Milk fat content of EPA and DHA were 5 to 6 times greater with AFO, but did not differ among other treatments. Milk and milk protein yield were unaffected by treatment, but milk fat yield and DM intake were reduced by 20 and 15%, respectively, by RFO. Overall, results indicate rumen biohydrogenation of long chain n-3 fatty acids was extensive, averaging >85% for EPA and >75% for DHA for the Ca salts and unprotected fish oil supplements. Thus, Ca salts of fish oil offered no protection against the biohydrogenation of EPA and DHA beyond that observed with unprotected fish oil; however, the Ca salts did provide rumen inertness by preventing the negative effects on DM intake and milk fat yield observed with unprotected fish oil.

Neuropsychological outcomes of pediatric burn patients who sustained hypoxic episodes

The neuropsychological outcomes of children who suffered hypoxic episodes following their burns are not completely understood and vary depending on the nature and severity of the episode. A retrospective review of youth that were admitted to this acute burn care facility over the past 20 years was conducted to identify the extent of cognitive and affective difficulties. Thirty-nine children who sustained hypoxic injuries related to their burns were compared with 21 controls that were matched for age, TBSA, and time of injury. Approximately a third of the children who survived from the hypoxia group continued to have long-term cognitive and emotional difficulties. For those who recovered reasonably well, no differences were found from the matched burned controls. These results probably underestimate the true extent of neuropsychological difficulties experienced by these youth given that detailed cognitive testing was not routinely performed. Prospective studies are needed to further characterize the full nature of difficulties and outcomes associated with burn related hypoxic injuries.

Altering metabolism

A significant proportion of the mortality and morbidity of severe burns is attributable to the ensuing hypermetabolic response. This response can last for as long as 1 year after injury and is associated with impaired wound healing, increased infection risks, erosion of lean body mass, hampered rehabilitation, and delayed reintegration of burn survivors into society. Pharmacologic and nonpharmacologic strategies may be used to reverse the catabolic effect of thermal injury. Nonpharmacologic strategies include early excision and wound closure of burn wound, aggressive treatment of sepsis, elevation of the environmental temperature to thermal neutrality (31.5 +/- 0.7 degrees C), high carbohydrate, high protein continuous enteral feeding, and early institution of resistive exercise programs. Pharmacologic modulators of the postburn hypermetabolic response may be achieved through the administration of recombinant human growth hormone, low-dose insulin infusion, use of the synthetic testosterone analog, oxandrolone, and beta blockade with propranolol. This review article discusses these modulators of postburn metabolism.

Effects of long-term oxandrolone administration in severely burned children

BACKGROUND

Severe burns cause exaggerated catabolism of muscle protein and inhibit bone deposition. Weakness and bony growth arrest interfere with rehabilitation. The purpose of this study was to determine whether oxandrolone administration for 1 year after the burn reverses muscle and bone catabolism in hypermetabolic pediatric burn patients.

METHODS

Children with burns greater than 40% total body surface area were enrolled into a randomized controlled trial to receive oxandrolone as a long-term anabolic agent. All patients received similar clinical care. Subjects were studied at discharge (95% healed) and at 6, 9, and 12 months after the burn, after treatment with 0.1 mg/kg po bid or placebo. Serum hepatic transaminases were measured. Lean body mass (LBM), bone mineral content (BMC,) and bone mineral density (BMD) were measured by dual energy x-ray absorptiometry. Patients completed a safety questionnaire and were reviewed clinically at intervals.

RESULTS

The groups were similar in age, weight, and total body surface area burned. LBM was significantly greater with oxandrolone at 6, 9, and 12 months after the burn (P < .001) and BMC at 12 months (P < .016). Age- and gender-matched BMD z scores were significantly better with oxandrolone (P < .039). Liver transaminases were unaffected.

CONCLUSIONS

Long-term administration of oxandrolone safely improves LBM, BMC, and BMD in severely burned children.

Growth hormone effects on hypertrophic scar formation: a randomized controlled trial of 62 burned children

The hypercatabolism after massive pediatric burns has been effectively treated with recombinant human growth hormone, an anabolic agent that stimulates protein synthesis and abrogates growth arrest. While experimental studies have shown increased potential for fibrosis induced by growth hormone therapy, adverse effects on human scars have not been investigated. Our aim was to evaluate hypertrophic scar formation in 62 patients randomized to receive injections of 0.05 mg/kg/day of recombinant human growth hormone or placebo, from discharge until 1 year after burn. Scar scales were used to evaluate scar-severity at discharge, 6, 9, 12, and 18-24 months after burn, by three observers blinded to treatment. Computer-assisted planimetry allowed quantification of percentage of hypertrophic scar formation. Types I and III collagens were localized and quantified in scars and normal skin of patients from both groups, using immunohistochemistry with confocal laser microscopy analysis. Insulin-like growth factor-1 blood levels helped assess compliance. Statistical analysis showed that scar hypertrophy significantly increased from 6 to 12 months after injury in both groups, while decreasing at 18-24 months postburn. Types I and III collagens were statistically increased in the reticular layer of scars from both groups when compared to paired normal skin. Insulin-like growth factor-1 was significantly increased in the recombinant human growth factor-treated group. No differences were seen when recombinant human growth factor and control groups were compared using the scar scales, planimetry, or immunohistochemistry. We concluded that recombinant human growth hormone therapy did not adversely affect scar formation and should not contraindicate the administration of recombinant human growth hormone as a therapeutic approach to severely burned children.

The Long-Term Effect of Oxandrolone on Hepatic Acute Phase Proteins in Severely Burned Children

BACKGROUND

Acute phase protein production is a hallmark of severe burns. We wondered whether anabolic treatment with oxandrolone would affect these proteins.

METHODS

Thirty-five children with > or =40% total body surface area burns were randomized to receive either placebo or oxandrolone (0.1 mg/kg by mouth twice daily) from postoperative day 5 to 1 year postburn. Levels of constitutive proteins and acute phase proteins were measured at admission; at discharge; and at 6, 9, and 12 months after burn. Total albumin supplementation and hepatic transaminases were also assessed.

RESULTS

Constitutive proteins such as albumin, prealbumin, and retinol-binding protein levels increased (p < 0.05), and acute phase proteins such as alpha 1-acid glycoprotein, C3 complement, alpha 2-macroglobulin, and fibrinogen levels significantly decreased in the oxandrolone group compared with placebo (p < 0.05). Albumin supplementation during the acute hospitalization was reduced in the oxandrolone group. Hepatic transaminases remained within normal levels.

CONCLUSION

Treatment with oxandrolone in severe burns significantly increases constitutive protein and reduces acute phase protein levels.

Current pharmacotherapy for the treatment of severe burns

The pharmacotherapy of burn care has evolved from the first topical antibiotics instituted > 30 years ago. These have helped greatly to reduce the incidence of burn wound sepsis, but a better understanding of the principles of burn care has resulted in earlier burn wound excision and complete coverage with autograft, cadaver skin, synthetic dressings, and amnion. This has markedly reduced septic complications and ameliorated the hypermetabolic response to burn injury. The hypermetabolic response, which is mediated by hugely increased levels of circulating catecholamines, prostaglandins, glucagon and cortisol, causes profound skeletal muscle catabolism, immune deficiency, peripheral lipolysis, reduced bone mineralisation, reduced linear growth, and increased energy expenditure. Supportive therapy and pharmacological manipulation, acutely and during rehabilitation, with growth hormone, insulin and related proteins, oxandrolone and propranolol can ameliorate the hypermetabolic response, improving survival and long-term outcome. Despite judicious use of topical and systemic antibiotics, opportunistic nosocomial bacterial resistance threatens to annul the improved survival of patients with severe burns. Patterns of emerging resistance encountered in burn units need to be considered, in light of a decreasing antibiotic armamentarium. A holistic approach to pharmacotherapy of severely burned patients including current practice in antimicrobial control, analgesia, sedation, and anxiety management is required. Current therapy of frequently encountered problems, such as post-burn pruritus, prophylaxis of deep venous thrombosis and peptic ulceration, and pharmacological manipulation of inhalation injury in the burned patient is described. Current pharmacotherapy to ameliorate psychosocial problems associated with burns such as acute stress disorder, depression and post traumatic stress disorder are discussed. Better analgesics, newer antibiotics and immune stimulating drugs are required to reduce mortality and morbidity in large burns.

Grazing instabilities and post-bifurcation behavior in an impacting string

A theoretical and experimental investigation of the nonlinear dynamic response of a periodically excited string subject to a knife-edge amplitude restraint is presented. The amplitude restraint creates an impact condition as the amplitude of the response grows. The focus of this work is on the influence of a grazing instability; this zero-velocity impact event leads to complicated, post-bifurcation behavior ranging from multifrequency, periodic motion to chaos. In addition to looking at the response numerically, parameter combinations leading to an incidence of grazing are clearly identified in the excitation force excitation frequency parameter space using a multiple scales perturbation analysis. Modeling issues, numerical difficulties, and experimental limitations are also discussed.

Heparin-induced thrombocytopenia and thrombosis syndrome

Heparin-induced thrombocytopenia and thrombosis syndrome (HITTS) is an immune-mediated response to the administration of heparin that results in life-threatening thrombosis. The pathophysiology of HITTS remains controversial. The onset of clinical symptoms and laboratory changes is usually delayed 1-2 weeks after exposure to heparin. Thrombosis occurs in both the arterial and venous circulation with significant morbidity and mortality. Complications include deep venous thrombosis, pulmonary embolus, stroke, myocardial infarction, chronic venous insufficiency, extremity ischemia, gangrene, and death. Diagnostic criteria for HITTS include thrombocytopenia during heparin exposure, exclusion of other causes such as sepsis or medications, resolution of thrombocytopenia after withdrawal of heparin, demonstration of in vitro heparin-dependent platelet antibodies, and development of vascular thrombosis. Despite having several disadvantages, the carbon-14-serotonin release assay is the most sensitive and specific test for HITTS. Angiography as an adjunct to other imaging modalities can document the presence, location, and extent of thrombus. Optimal treatment has not yet been defined but should include immediate discontinuation of use of all heparin products and heparin-coated catheters. In addition, alternate methods of antithrombotic therapy should be considered. In severe cases, thrombolysis or thrombectomy may be warranted. Familiarity with the pathophysiology, clinical manifestations, complications, diagnostic criteria, and treatment options associated with HITTS will enable timely recognition and facilitate prompt and effective treatment.

Conjoined gastric and mediastinal benign cystic teratomas. Case report of a rare occurrence and review of literature

Teratomas are embryonal neoplasms which arise from totipotential cells and contain elements from all three germ layers (ectoderm, mesoderm, and the endoderm). Simultaneous occurrence of mediastinal and gastric teratomas in infants has not been reported, although gastric teratomas extending into the mediastinum have been reported twice in literature. We report here a case in which a gastric cystic teratoma was connected to its mediastinal counterpart with a pedicle. The pertinent literature is reviewed.

The heparin-induced thrombocytopenia and thrombosis syndrome: treatment with intraarterial urokinase and systemic platelet aggregation inhibitors

We report a case of the heparin-induced thrombocytopenia and thrombosis syndrome presenting with acute ischemia of a lower limb. The patient was successfully treated by withdrawal of heparin products, intraarterial urokinase, and platelet anti-aggregation therapy consisting of Dextran and aspirin.

Aortoiliac aneurysms: management with endovascular stent-graft placement

PURPOSE

To evaluate endovascular stent-graft placement for management of aortoiliac aneurysms.

MATERIALS AND METHODS

Balloon-expandable stents covered with polytetrafluoroethylene were placed in 11 aortoiliac lesions in nine male non-surgical candidates (mean age, 63.5 years). There were six abdominal aortic aneurysms, four iliac artery aneurysms, and one acute pseudoaneurysm from a ruptured iliac artery. Stent-grafts were dilated up to 14 mm (iliac) and 24 mm (aorta). Patients underwent follow-up computed tomography and angiography.

RESULTS

Stent-grafts were successfully placed in all 11 cases. There were two complications: a ruptured iliac artery treated with placement of an additional covered stent and a lower-extremity vessel embolization and bowel infarction resulting in death. All stent-grafts remained patent without increased aneurysmal diameter. Three leaks (27%) were detected. Two leaks were treated with placement of additional covered stents. One still is asymptomatic.

CONCLUSION

Endovascular treatment of aortoiliac aneurysms with stent-graft devices may be an alternative to surgery.

Use of stents covered with polytetrafluoroethylene in experimental abdominal aortic aneurysm

PURPOSE

To establish the effectiveness of covered stents in the treatment of aortic aneurysms, to investigate the histopathologic healing patterns of the device, and to determine the long-term endurance and integrity of modified polytetrafluoroethylene (PTFE).

MATERIALS AND METHODS

Experimental aneurysms were created in dogs by enlarging the aortic lumen with a patch of abdominal fascia. After 5 months, eight animals underwent an endoluminal bypass. The bypass device consisted of a 6-cm-long stent covered with thin PTFE. After surgery, the animals were killed at 3, 6, and 12 months in groups of three, three, and two, respectively. Specimens were processed for luminal surface studies and cross-sectional histologic study. Explanted PTFE material was analyzed for its physical characteristics and performance and was compared with retained control samples.

RESULTS

Before the animals were killed, aortography showed patent bypass conduits in all animals, although two of eight had leaks into the aneurysmal sac. Endothelialized neointima largely covered the luminal surface of the PTFE stent. The percentage of prosthetic surface covered by tissue did not change from 3 months to 1 year. Physical testing of the explanted PTFE material showed no structural deterioration and no change in the internodal distance. Thickness and axial tensile strength varied 12% and 17% from controls, respectively.

CONCLUSION

Thin-walled PTFE seems to have physicochemical characteristics that make this material adequate for endovascular use. Though limited, this study supports the establishment of preliminary clinical evaluation of metallic stents combined with PTFE for the treatment of abdominal aortic aneurysm.

Transumbilical intravascular retrieval of an umbilical artery catheter

We present a rare case of a broken umbilical artery catheter retrieved via a transumbilical approach with biopsy forceps.

Role of the eosinophil in chronic vascular rejection of renal allografts

Obiliterative arteriopathy in chronic renal allograft rejection is caused by intimal smooth muscle proliferation accompanied by infiltration of lymphocytes, monocytes, and eosinophils. We investigated the role of the eosinophil in chronic rejection. Twenty-four allograft nephrectomies were examined for the presence of eosinophils on hematoxylin-eosin-stained sections and using epifluorescence on Fisher-Giemsa-stained sections. Among 15 cases with chronic rejection, eosinophils were detected in 14 cases (93%) with epifluorescence compared with only six cases (40%) with hematoxylin-eosin staining (P = 0.005). With epifluorescence, eosinophils were identified in the intimal, adventitial, and tubulointerstitial compartments in 73%, 80%, and 87% of cases, respectively. To examine the pathogenic relevance of the eosinophils in the vessel wall, we investigated the effect of eosinophil-conditioned medium on DNA synthesis in cultured vascular smooth muscle cells. Autofluorescent eosinophils were isolated from atopic human donors using a fluorescence-activated cell sorter. Supernatant was collected from eosinophils (1 x 10(6)/mL) cultured overnight in medium with 0.5% fetal bovine serum. Incorporation of 3H-thymidine into DNA was measured in rat and human vascular smooth muscle cells treated for 24 hours with eosinophil-conditioned medium at 1:20, 1:10, 1:5, and 1:2 dilutions. Eosinophil-conditioned medium had a significant dose-dependent stimulatory effect on DNA synthesis in both cell lines. Our results indicate that eosinophil involvement in chronic renal allograft rejection is more common than previously recognized. The stimulatory effect of eosinophil-conditioned medium on vascular smooth muscle cell DNA synthesis suggests that eosinophils may be involved in the pathogenesis of the obliterative arteriopathy characteristically seen in chronic vascular rejection of renal allografts.

Progestogens and Cushing's syndrome

We report 3 patients where Medroxyprogesterone Acetate (MPA = Provera) and Megestrol Acetate (Megace) in doses used for therapy of breast cancer, caused clinical hypercortisolism and Cushing's syndrome. Studies of the toxicity of Medroxyprogesterone Acetate list the commonest adverse events at 500 mg/day as weight gain, water retention, increased blood pressure, tremor, moon face, sweating, muscle cramps, vaginal bleeding and increased appetite. Glucocorticoid-like effects are seen in up to 30% of patients treated for longer than 6 weeks with mostly large doses of the order of 1500 mg/day but Cushing's syndrome has been reported in patients taking 400 mg/day. Neither the glucocorticoid-like effects or Cushing's syndrome have been previously observed with Megestrol Acetate. In the elderly female population receiving progestogens for neoplastic disease the progestogen itself could be an appreciable cause of morbidity both by causing glucocorticoid-like effects and Cushing's syndrome but also by lack of awareness of the danger of sudden withdrawal of these compounds when the hypothalmic-pituitary-adrenal (HPA) axis is suppressed. The signs and symptoms could be easily overlooked unless appropriate testing for Cushing's syndrome is carried out. While the progestogen may have to be continued indefinitely a dose decrease may be feasible with reduction of morbidity.

Iliac artery stent placement with the Palmaz stent: follow-up study

PURPOSE

The long-term efficacy of iliac artery stent placement with the Palmaz stent was evaluated for treatment of limb ischemia.

PATIENTS AND METHODS

Iliac stent implantation for limb ischemia was performed on 108 limbs in 83 patients. Eighty patients (96.4%) were followed up clinically from 1 to 70 months (mean, 25.8 months), and 30 patients (37.5%) were followed up with angiography from 1 to 48 months (mean, 10.4 months). Patients were classified into six categories by using an ischemic ranking profile. Clinical success was defined as a minimum one-category improvement from preprocedure ranking.

RESULTS

The clinical success rate was 98.9% immediately after the procedure and 86.2% at 48 months. Long-term success was statistically more common in patients with higher preprocedure and lower postprocedure ischemic ranking, and in patients without diabetes. Arteriography demonstrated a primary patency rate of 87.5% at latest follow-up, with five occlusions (12.5%) and only two (5.0%) restenoses. Average stenosis was 17.8% at 6 months and 24.7% at 2 years. Stent restenosis was statistically more common with a higher postprocedure pressure gradient. The complication rate was 9.7%, and 30-day mortality was 1.2%.

CONCLUSION

Long-term clinical and angiographic follow-up demonstrates iliac artery stent placement with the Palmaz stent is safe and efficacious for treatment of limb ischemia.

Effects of rearing diet, age at freshening, and lactation feeding system on performance

This two-phase trial involved 83 Holstein heifers. The rearing phase consisted of two diets (alfalfa silage plus corn grain for ad libitum intake vs. corn silage plus urea for ad libitum intake) and two breeding age groups (13 vs. 16 mo). The lactation phase compared the above treatments plus two lactation feeding systems: concentrate fed individually to production versus a TMR. The heifers were assigned randomly to the rearing phase at 7 wk of age and fed their respective diets until 14 d prepartum. They were placed on preassigned lactation diets 14 d prepartum and remained on the lactation phase for 550 consecutive d. Daily gains and height at the withers were similar between forage groups during the first half of the rearing phase; in the second half, the heifers fed alfalfa silage were taller at the withers. Those fed corn silage consumed less DM and CP throughout the rearing phase and gained more BW than the heifers fed alfalfa in the latter half. There were no differences in daily gain or DMI between the breeding age groups. In the lactation phase, the group fed alfalfa for ad libitum intake consumed more DM and gave more milk during the first 90 d of lactation than heifers fed corn silage. However, after 90 d the difference in cumulative milk production was not significant. There were no differences in milk production. FCM, or DMI between breeding age groups. The cows fed concentrate consumed more DM and gave more milk during the first 90 d of lactation. By 550 d, there were no differences. Feeding high levels of corn silage can cause heifers to have lower DMI in early lactation. These differences tend to disappear during the second lactation.

Compatibility of packed erythrocytes and Ringer's lactate solution

Packed erythrocytes are frequently reconstituted with crystalloid during rapid infusion. Dilution of whole blood with calcium containing solutions, such as Ringer's lactate has been cautioned against, citing possible clot formation because of chelation of the citrate anticoagulant. We studied the compatibility of Ringer's lactate solution and citrate phosphate dextrose (CPD)-preserved packed erythrocytes to evaluate the safety of using Ringer's lactate solution as a diluent in the emergency setting. Aliquots of CPD-preserved packed erythrocytes were diluted with either Ringer's lactate or normal saline solutions in ratios between 5:1 to 1:20 (packed erythrocyte to crystalloid), incubated at room temperature or 37 degrees centigrade and examined for clot formation at intervals up to two hours. Although clotting occurred at dilutions of 1:1 (packed erythrocytes to Ringer's lactate solution) and beyond, no clot formation occurred in the clinically relevant dilutions between 5:1 and 2:1. Thirty-two additional units of CPD-preserved packed erythrocytes were diluted to hematocrit values of 35, 45, 55 or 65 per cent and passed through a 170 micron filter. Flow rates of packed erythrocytes diluted with Ringer's lactate and normal saline solutions were compared. There was no difference in flow rates between packed erythrocytes diluted with Ringer's lactate compared with normal saline solutions. Ringer's lactate solution can be safely used as a packed erythrocyte diluent in patients requiring rapid blood transfusions.