Interactions between Ketamine and Magnesium for the Treatment of Pain: Current State of the Art

BACKGROUND

Over the past three decades, NMDA-receptor antagonists have been shown to be efficient drugs for treating pain, particularly pain resistant to conventional analgesics. Emphasis will be on the old-new drugs, ketamine and magnesium, and their combination as a novel approach for treating chronic pain.

METHODS

The MEDLINE database was searched via PubMed for articles that were published up to March 1, 2020, with the keywords 'ketamine', 'magnesium', and 'pain' (in the title/abstract).

RESULTS

Studies in animals, as well as humans, have shown that interactions of ketamine and magnesium can be additive, antagonistic, and synergistic. These discrepancies might be due to differences in magnesium and ketamine dosage, administration times, and the chronological order of drug administration. Different kinds of pain can also be the source of divergent results.

CONCLUSION

This review explains why studies performed with a combination of ketamine and magnesium have given inconsistent results. Because of the lack of efficacy of drugs available for pain, ketamine and magnesium in combination provide a novel therapeutic approach that needs to be standardized with a suitable dosing regimen, including the chronological order of drug administration.

Lithium - Pharmacological and Toxicological Aspects: The Current State of the Art

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Lithium is the smallest monovalent cation with many different biological effects. Although lithium is present in the pharmacotherapy of psychiatric illnesses for decades, its precise mechanism of action is still not clarified. Today lithium represents first-line therapy for bipolar disorders (because it possesses both antimanic and antidepressant properties) and the adjunctive treatment for major depression (due to its antisuicidal effects). Beside, lithium showed some protective effects in neurological diseases including acute neural injury, chronic degenerative conditions, Alzheimer's disease as well as in treating leucopenia, hepatitis and some renal diseases. Recent evidence suggested that lithium also possesses some anticancer properties due to its inhibition of Glycogen Synthase Kinase 3 beta (GSK3β) which is included in the regulation of a lot of important cellular processes such as: glycogen metabolism, inflammation, immunomodulation, apoptosis, tissue injury, regeneration etc.

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Although recent evidence suggested a potential utility of lithium in different conditions, its broader use in clinical practice still trails. The reason for this is a narrow therapeutic index of lithium, numerous toxic effects in various organ systems and some clinically relevant interactions with other drugs. Additionally, it is necessary to perform more preclinical as well as clinical studies in order to a precise therapeutic range of lithium, as well as its detailed mechanism of action. The aim of this review is to summarize the current knowledge concerning the pharmacological and toxicological effects of lithium.

Involvement of serotonergic and opioidergic systems in the antinociceptive effect of ketamine-magnesium sulphate combination in formalin test in rats

BACKGROUND

Ketamine and magnesium sulphate showed synergic interaction in the tail-immersion test and additive interaction in the rat formalin test. Aim of study was to evaluate the influence of serotonergic and opioidergic system of this combination in the formalin test in rats.

METHODS

Antinociceptive activity was assessed by the formalin test in male Wistar rats (200-250 g). Antagonists (naloxone and methysergide) were administrated 5 min before and magnesium sulphate 5 min after ketamine injection. Formalin (2.5%, 100 μL) was injected into the right hind paw surface (intraplantar) of rats 5 min after ketamine/magnesium combination. Data were recorded as the total time spent in pain related behavior after the injection of formalin or vehicle (0.9% NaCl).

RESULTS

In the intermediate phase of the formalin test, methysergide at a dose of 0.2 mg/kg did not have any effect, but at doses of 0.5 and 1 mg/kg it had a pronociceptive effect. Methysergide (0.2, 0.5 and 1 mg/kg) inhibited the antinociceptive effect of ketamine-magnesium sulphate combination. In the intermediate phase, naloxone at a dose of 0.2 mg/kg did not have any effect, but at a dose of 3 mg/kg it produced a pronociceptive effect. Naloxone (0.2 and 3 mg/kg) antagonized the antinociceptive effect of the ketamine (5 mg/kg)-magnesium sulphate (5 mg/kg) combination.

CONCLUSION

The results of the present study suggest that serotonergic and opioidergic systems are involved, at least in part, in the antinociceptive effect of the ketamine-magnesium sulphate combination in the model of inflammatory pain in rats.

Pharmacotherapy of Pain in the Older Population: The Place of Opioids

Pain is a common symptom in older people. It is possible that pain is underreported in older persons due to an incorrect belief that it is an inevitable part of aging. Opioid analgesics are potent medications, with confirmed efficacy for the treatment of moderate to severe pain. These drugs are commonly used in older persons. However, there is insufficient evidence regarding safety of opioids in older patients. One of the reasons for this is the lack of randomized, controlled clinical trials. People of advanced age often have comorbidites and use other prescription drugs, as well as over-the-counter (OTC) compounds, thus making them more suceptible to the risk of interactions with opioids. Significant pharmacokinetic and pharmacodynamic changes that occur with advancing age increase the risk of adverse effects of opioids. There are also some discrepancies between guidelines, which recommend the use of lower doses of opioids in older patients, and the findings in the literature which suggest that pain is often undertreated in this age group. It seems that there are significant variations in the tolerability of different opioid analgesics in older people. Morphine, fentanyl, oxycodone, and buprenorphine are still the preferred evidence-based choices for add-on opioid therapy for these patients. However, the safety and efficacy of other opioids in older patients, especially if comorbidities and polypharmacy are present, is still questionable. This review addresses the most important aspects of the use of opioids in older persons, focusing on pharmacokinetics, pharmacodynamics, adverse effects, and interactions.

Prenatal diagnosis of lissencephaly: A case report

INTRODUCTION

Lissencephaly ("smooth brain") forms a major group of brain malformations due to abnormal neuronal migration. It can cause severe intellectual and motor disability and epilepsy in children. The prenatal diagnosis of this malformation is rare.

CASE REPORT

We presented a case of the prenatal diagnosis of lissencephaly. A 30-year-old pregnant woman was reffered to the hospital at the week 35 of gestation for magnetic resonance imaging (MRI after an ultrasound examination demonstrated fetal cerebral ventriculomegaly. Fetal MRI of the brain showed "smooth", agyrya cortex. The female infant was born at term with birth weight of 2,500 g and Apgar score 8, showing global developmental delay. Postnatal ultrasound and MRI confirmed classical lissencephaly. She is now 8 years old and has spastic quadriparesis, mental retardation and epilepsy.

CONCLUSION

Confirmation of the ultrasound diagnosis with MRI is desirable for the prenatal diagnosis of lissencephaly.

Pharmacoepidemiologic studies on psychiatric drugs use in Serbia

High rate of prescribing of psychiatric drugs causes medical, social and economic consequences.

This research was performed by collecting and analysing all the papers published on this matter in Serbia.

In former Yugoslavia (of which Serbia was a constitutive republic), during the eighties, a study of benzodiazepines use showed a trend of the increase of their use (17,9 defined daily doses - DDDs in 1983 - 22,3 DDDs in 1988) (Macolic V et al. Benzodiazepines utilization in Yugoslavia 1983–1988. Pharmaca 1990;217–97). Similar trends continued in the nineties. In 1994 diazepam was at the first position on the list of most prescribed drugs (Miljković M. et al. Analysis of Drug Utilization in Serbia During the Years 1996 and 1997. Pharmacoepidemiol Drug Saf 2000;9:59–64.). The analysis of the trend of prescribing of psychiatric drugs in Serbia (2000–2004) shows the increase, with the emphasis on the use of benzodiazepines and antidepressants (Divac N. et al. Trends in consumption of psychiatric drugs in Serbia and Montenegro 2000–2004. Pharmacoepidemiol Drug Saf. 2006;15:835–8.). There are also positive, qualitative changes in the prescribing practice: the increase of the use of SSRI antidepressants and atypical antipsychotics. Specific prescribing habits were noticed: the common practice of polypharmacy in the treatment of psychoses (Divac N. et al. Antipsychotic polypharmacy at the University Psychiatric Hospital in Serbia. Pharmacoepidemiol Drug Saf. 2007;16:1250–1.).

Pharmacoepidemiologic methods have found its place in Serbian science. The methodology used in these studies is mostly up-to-date. Main limitation of these studies is the lack of databases.

Fluorescence spectroscopy of an in vitro model of human cervical neoplasia identifies graded spectral shape changes with neoplastic phenotype and a differential effect of acetic acid

BACKGROUND

The clinical utility of spectroscopic methods for the diagnosis of cervical cancer is limited by significant inter-patient variation in the spectroscopic properties of the cervix. Improved understanding of the contributions of the components of cervical tissue to the observed spectra would therefore be helpful in the development of spectroscopic approaches to the study of cervical disease in vivo.

METHODS

In this study, we used organotypic epithelial raft culture as an in vitro model system to analyse the fluorescence properties of the surface squamous epithelium specifically. The spectrum of cervical dysplasia was modelled by producing rafts lined by primary human keratinocytes (PHKs) and the HaCaT, SiHa and CaSki human keratinocyte cell lines and fluorescence emission spectra were recorded at a wide range of excitation wavelengths.

RESULTS

Statistically significant differences in spectral shape were identified between the different rafts at excitation wavelengths between 250nm and 310nm. A graded, differential effect of acetic acid on fluorescence intensity was also observed, consistent with the visible effects of acetic acid on clinical examination at colposcopy.

CONCLUSION

These data suggest that the development of neoplastic changes in the squamous epithelium of the cervix are associated with alterations in its fluorescence properties and that the application of acetic acid has a demonstrable effect on these properties. Identification of these alterations may aid the discrimination of cervical lesions in vivo.

Fentanyl analogs: structure-activity-relationship study

Fentanyl is the prototype of the 4-anilidopiperidine class of synthetic opioid analgesics. This study was aimed to review the structure-activity-relationship (SAR) of fentanyl analogs substituted in the position 3, or 4 of the piperidine ring. Pharmacological results show that the groups in position 3 of the piperidine ring, which are larger than methyl, severely reduce the analgesic potency compared to fentanyl. It is likely that the steric factor alone (i.e. voluminosity of the group and cis/trans isomerism), rather than the polarity and/or chemical reactivity, plays a crucial role in the analgesic potency of this series. Although the duration of action, in general, does not depend on the stereochemistry, longer action of the most potent 3-alkyl fentanyl analogs such as cis-3-methyl- and cis-3-ethyl fentanyl, is more likely influenced by pharmacodynamic, rather than pharmacokinetic variables. Also, it is possible that the introduction of a functional group such as 3-carbomethoxy reduces the duration of action by altering pharmacokinetic properties. SAR findings obtained by evaluating the neurotoxic effects of fentanyl analogs substituted in the position 3 of the piperidine ring parallel the SAR findings on analgesia in regard to potency and duration of action. This might suggest that similar receptors are involved in producing both antinociceptive and neurotoxic effects of these drugs. It appears that both the potency and the duration of action in the series of fentanyl analogs substituted in position 4 of the piperidine ring is influenced only by the steric requirement and not by the chemical nature of the substituent.

Acute protective effects of simvastatin in the rat model of renal ischemia-reperfusion injury: it is never too late for the pretreatment

Acute pretreatment with a single i.v. bolus injection of simvastatin (1 mg/kg) significantly protects rat kidney injured by ischemia-reperfusion (I/R) (45 min + 6 h). We aimed to determine the optimal timing of such a pretreatment. The effects of both injections of simvastatin before ischemia and reperfusion were similar regarding total histological score. However, simvastatin injected 30 min before ischemia was 30% - 75% more effective in reduction of serum creatinine levels and interstitial edema score, while its injections 5 and 30 min before reperfusion were 25% - 60% more effective in reduction of tubular necrosis score and fractional excretion of Na+. However, the observed differences do not seem to offer significant advantage in clinical settings.

Single-dose intravenous simvastatin treatment attenuates renal injury in an experimental model of ischemia-reperfusion in the rat

The effect of acute pretreatment with a single dose of simvastatin (1 mg/kg, i.v.; 30 min before ischemia) on renal dysfunction caused by ischemia-reperfusion (I/R) injury in the rat was investigated. I/R injury was induced by clamping both renal vascular pedicles for 45 min, followed by 4 h of reperfusion with saline (2 ml/kg per hour). Simvastatin significantly improved both parameters of glomerular and tubular dysfunction (e.g., creatinine levels and fractional excretion of Na(+), respectively) and especially improved the histological score, compared to control I/R-injured rats treated with saline or 10% DMSO only.

Homocysteine serum levels and MTHFR C677T genotype in patients with Parkinson's disease, with and without levodopa therapy

Both methylenetetrahydrofolate (MTHFR) C677T genotype and levodopa treatment may give rise to elevated serum homocysteine levels in parkinsonian patients. We aimed to clarify the interplay of these factors in pathogenesis of Parkinson's disease (PD)-related hyperhomocysteinemia. Total serum levels of homocysteine (tHcy) and MTHFR C677T genotype were investigated in levodopa-treated and -untreated parkinsonian ("de novo") patients, as well as in control healthy subjects matched by age and gender (N=83, 30 and 53, respectively). MTHFR C677T genotypes were equally distributed in PD patients and control subjects, the T allele homozygosity being observed in app. 12-17% cases. tHcy concentrations were significantly higher in both levodopa-treated and -untreated PD patients than in control subjects, and in TT homozygotes than in CT or CC genotype carriers. tHcy levels significantly correlated with the duration of the disease in PD treated patients only, reaching the maximum after 3-6 years. However, there was no correlation between tHcy levels and total daily intake of levodopa in the same group of PD patients. In conclusion, MTHFR C677T genotype is a significant factor for hyperhomocysteinemia in patients with PD, levodopa-untreated and probably even more in levodopa-treated PD patients.

[Effects of new nitric oxide synthase inhibitors on spontaneous locomotor activity]

INTRODUCTION

New nitric oxide synthase (NOS) inhibitors: 3-bromo-7-nitroindazole (3-Br-7-NI), 1-(2-trifluoromethylphenyl) imidazole (TRIM), S-methyl-L-thiocitrulline (S-Me-TC) and 7-nitroindazole (7-NI) reduce spontaneous locomotor activity in mice.

MATERIAL AND METHODS

In order to elucidate central effects of NOS inhibitors on locomotor activity, the influence of 7-NI on electroencephalographic (EEG) power spectrum in rats was investigated.

RESULTS

7-NI reduced the EEG power density in all frequency bands in rats, suggesting a depression of the central neuronal activity. The electrophysiologic power was most reduced in the range of 7-9 Hz of the rhythmic slow activity (theta rhythm), which is in accordance with decreased locomotor activity observed following administration of NOS inhibitors.

CONCLUSION

The present results indicate that nitric oxide exerts an excitatory effect on central neuronal structures involved in regulation of locomotion.

[Nitric oxide, neurodegeneration, and Parkinson's disease]

<zakljucak> Brojni rezultati velikih studija pokazuju znacajnu ulogu NO u kaskadi dogadjaja koji dovode do smrti dopaminergickih neurona. Zna se da MPTP uzrokuje neurotoksicnost putem NO sintetisanog pomocu nNOS, ostecujuci primarno dopaminergicka vlakna i zavrsetke u strijatumu, dok NO stvoren uz pomoc iNOS deluje prvenstveno na tela dopaminergickih neurona u pars compacta substantia nigra. Ostecenje uzrokovano NO iz nNOS moze sluziti kao katalizator aktivacije iNOS i glioze. Slican sled dogadjaja moze se primeniti na ostecenje dopaminergickih neurona kod ljudi, bilo usled idiopatske PB ili usled intoksikacije MPTP. Znacaj ovih otkrica je ne samo u osvetljavanju cinioca koji ucestvuju u progresiji neurodegeneracije i PB vec i u upucivanju na nove terapijske mogucnosti.

Pattern of utilization of benzodiazepines in patients with hypertension: A pilot study

Background/Aim. The analysis of drug prescribing in general practice in Serbia showed that the use of benzodiazepines is most frequently associated with hypertension. The aim of this study was to establish the correlation of the characteristics of patients with hypertension to antihypertensive drug therapy, and the intake of benzodiazepines. Methods. A special questionnaire was used for interviewing the patients (n = 171) chronically treated for hypertenson. Statistical tests used were ?2-test and Student's t-test. Results. No differences were noted in terms of age, gender, education, body weight, smoking habits and blood pressure (155?4.9/100?2.7 mmHg vs. 160?2.2/105?3.7 mmHg), between the group I (antihypertensive drugs+benzodiazepines: n = 79), and the group II (antihypertensives only: n = 92). The patients taking benzodiazepines received a lower number of different antihypertensive drugs (2.3?0.09 vs. 2.7?0.10; p < 0.01), but the total antihypertensive drug load was significantly greater than in the group II (2.6?0.10 vs. 1.9?0.15 defined daily doses (DDD)/patient/day; p < 0.01). Benzodiazepines were taken for anxiety (62%) and hypertension (21%), rarely for insomnia, mostly once a day, at bedtime. About half the patients took benzodiazepines regularly for months or years aware of the risk for addiction. Diazepam was used by 82% of the patients. The average daily exposure to benzodiazepines was 0.45?0.05 DDD/patient/day. The drug was bought without prescription in 25% of the patients, and without consulting a physician in 12% of them. Conclusion. The study confirmed a close association of hypertension with the use of benzodiazepines. The frequent use of benzodiazepines in the patients with hypertension might be caused by an inadequate response to antihypertensive drug therapy, besides anxiety and insomnia. The therapeutic efficacy of a long-term use of low doses of benzodiazepines in hypertension requires further investigation.

High-dose streptokinase in the treatment of acute massive pulmonary embolism complicated with cardiogenic shock, respiratory arrest and ventricular fibrillation

Background. Despite advances in prophylaxis, diagnostic modalities, and therapeutic options, pulmonary embolism remains a commonly undiagnosed entity with lethal outcome. Clinically, pulmonary embolism ranges from massive thromboembolism with cardiogenic shock to asymptomatic, microebolism with anatomically small emboli without hemodynamic, respiratory or other disturbances. Case report. A patient with massive pulmonary embolism complicated with ventricular fibrillation, respiratory arrest and cardiogenic shock was treated with a total dose of 3 750 000 IU of intravenous streptokinase in the 8- hour time period. After successful cardiopulmonary resuscitation, and thrombolytic therapy, the patient regained hemodynamic stability six hours after admission; all clinical and electrocardiographic signs of the right ventricle insufficiency disappeared. Conclusion. This case report suggested that treatment with the high-dose of streptokinase could be beneficial in the patients with massive pulmonary embolism complicated with cardiogenic shock, which must be confirmed by further randomized trials.

[Antibiotics in the prevention of the surgical site infection in orthopedic surgery]

Surgical site infection is an actual problem of orthopaedic surgery. Despite considerable efforts that have been done during last several decades (e.g. improvements in surgical techniques, preoperative preparation of the surgical site, infection-control practice, use of preventive antibiotics) surgical site infection still affects about 0.5-2% of patients after closed fracture surgery or insertion of prosthetic devices. They are associated with substantial morbidity and mortality. The adherence to the principles of rationale preventive antibiotic therapy has an important role in the prevention of the surgical infection. In addition, it is well known that inappropriate use of antibiotic promote development of resistance, superinfections and increase the cost of the treatment. This paper focuses on the basic principles of rational use of antibiotics, i.e. appropriate selection of drug, dose, and duration of treatment in the prevention of surgical site infections in orthopaedic surgery.

Psychiatric adverse effects induced by recombinant interferon alfa in patients with chronic hepatitis C

Introduction Hepatitis C virus infection is a slowly progressive chronic disease and the most common cause of chronic liver disease. Presently, interferon alfa based therapies, with or without ribavirin, are standard treatment for chronic hepatitis C virus infection. The most troublesome psychiatric side effects of interferon therapy in our patients are: insomnia, irritability, anxiety, mood changes, short temper, emotional and affective lability, impaired cognitive function, apathy, loss of motivation and the most serious depression with or without suicidal ideas. Material and methods In our study we treated 82 patients chronically infected with HCV divided into 3 groups: the first group of 31 patients (20 male and 11 female) received IFN-alfa in standard doses of 3 MU three times a week (t.i.w) during 24 weeks; the second group of 36 patients (25 male and 11 female) received IFN-alfa, 3 MU t.i.w plus ribavirin 1000-1200 mg per day during 24 weeks; the third group of 15 patients (11 male and 4 female) received IFN-alfa, 3 MU t.i.w plus ribavirin 1000-1200 mg per day during 48 weeks. The follow-up period after therapy in all groups lasted 24 weeks. Results During treatment, we observed at least one psychiatric side effect in 21 (26%) patients: insomnia in 11 (13%), emotional and affective lability in 9 (11%), anxiety, irritability and short temper in 8 (10%), impaired cognitive function in 7 (8%) apathia and loss of motivation in 6 (7%) treated patients. Depression, the most serious side effect, was established in 8 (10%) patients. All of these side effects were observed during later stages of treatment (between 5th and 22nd weeks of treatment). The incidence of all psychiatric side effects was significantly higher in women than in men (p < 0,01). We observed higher prevalence of depression among patients with history of alcohol and drug abuse. Treatment was temporarily discontinued (from 2 to 4 weeks) in all patients with depression, but it was not permanently discontinuated in any patient due to psychiatric side effects. Conclusion Interferon causes psychiatric disorders that are usually mild and reversible. They disappear either spontaneously, while patients are still receiving therapy or after temporary cessation of interferon alfa therapy. .

NG-nitro-L-arginine methyl ester potentiates the effect of aminophylline on the isolated rat hemidiaphragm

The effects of different concentrations of N(G)-nitro-L-arginine methyl ester (L-NAME) (0.3, 1, 3, and 10 mM), a non-selective inhibitor of NOS, on the effect of aminophylline on the isometric contraction of the isolated rat hemidiaphragm were investigated. The muscle contractions were induced by direct subtetanic electrical stimulation. Aminophylline (0.36 - 3.60 mM) produced a typical concentration-dependent increase in both parameters of the isometric contraction: tension developed (Td) and the maximum rate of rise of tension (dT/dt max). The second series of additions of aminophylline produced a more pronounced effect. L-NAME (0.3, 1, 3, and 10 mM, 30 min of incubation without stimulation) itself did not change Td and dT/dt max. However, L-NAME (1, 3, and 10 mM) produced a statistically significant potentiation of the effect of aminophylline on Td and dT/dt max.

[Nitric oxide and lung diseases]

INTRODUCTION

All three isoforms of nitric oxide synthase (NOS) are identified within various tissues of the respiratory system.

ISOFORMS OF NOS

Under physiological conditions, small amounts of NO, produced by constitutive isoforms of NOS, appear to be important in regulation of basal pulmonary vascular tone and in mediating transition from fetal to neonatal circulation; also, NO exerts antiinflammatory actions, and modulates the respiratory smooth muscle tone. NO AND RESPIRATORY TRACT DISEASES: Under pathological conditions, inducible NOS-derived NO may produce lung damage. In addition, increased or decreased production of NO is found in chronic obstructive pulmonary disease, cystic fibrosis, asthma and related inflammatory disorders, and exhaled NO level measurement is a useful tool in diagnostics of respiratory disorders.

CONCLUSION

It has been shown that NO modulates contractility of the isolated diaphragm, and there are important interactions between NOS inhibitors and drugs for respiratory disorders (e.g. aminophylline).

[Antibiotic resistance]

INTRODUCTION

After six decades of antibiotic use, the prevalence of antibiotic-resistant bacteria is increasing, and organisms resistant to almost all antibiotics have been identified.

ANTIBIOTIC RESISTANCE

It is important to understand why antibiotic resistance develops, in order to design strategies for its prevention. Factors that promote antibiotic resistance in community and hospital settings are: antibiotic selective pressure, prolonged antibiotic treatment, inadequate doses, prior use of a less effective drug of the same antibiotic class, protected sites or foreign bodies, and poor infection control practice. The best available ways to decrease and control antibiotic resistance are: rational use of antibiotics (e.g. appropriate selection of drug, dose, duration of treatment), good infection control procedures (hygienic practice and isolation), as well as local, national and global surveillance networks for monitoring dissemination of antimicrobial resistance and detection of new resistance mechanisms.

CONCLUSION

Clinical guidelines, direct education, and regular reports on antibiograms may contribute to more prudent use of antibiotics. Overall, the problem of antibiotic resistance is global. However, measures need to be taken at an individual, institutional, and ultimately at national healthcare level.

Epidemiology of end-stage renal disease and current status of hemodialysis in Yugoslavia

Maintenance hemodialysis (HD) in Yugoslavia started in the sixties and followed the dialysis trends in the Western Europe. However, in the last decade the development of renal replacement therapy (RRT) slowed down. In this report the epidemiology of ESRD from 1997-1999 and the survey of the status of HD treatment in Yugoslavia in 1999 are presented. Epidemiological data are obtained by the annual center questionnaires (response rate: 92.6 -94.2%). The survey of HD status is based on a specific questionnaire and covered 2108 patients (65%). At the end of 1999 there were 56 RRT centers in Yugoslavia treating 3939 patients: 3232 (82%) patients by HD, 248 (6.3%) by peritoneal dialysis, and 459 (11.7%) living with transplanted kidney. In a three year period, incidence of ESRD ranged from 108-128 pmp, point prevalence from 435-463 pmp and mortality rate from 20.7-17.9. Numerous refugee patients were treated over the last 10 years. Main causes of ESRD were glomerulonephritis (30%); Balkan nephropathy represented 11% and diabetic nephropathy 7% of all primary renal diseases. Cardiovascular and cerebrovascular diseases were the most common causes of death of RRT patients. Most centers are overcrowded and HD machines are worn out. Mean Kt/V was 1.19+/-0.08, mean URR% 58.8+/-7.4. The shortage of drugs prevented adequate management: 83% of HD patients had hemoglobin level less than 100 g/L but only 10.3 -17.8% were treated with rHuEpo; 64.5% of patients had phosphate levels higher than 1.7 mmol/L but only 33.5% used phosphate binders; 47% of patients had hypertension despite the antihypertensive therapy. The prevalence of hepatitis B remained unchanged (about 14%) in HD population during the last three years, but the prevalence of anti-HCV positive patients decreased (31-23%). In conclusion, there is a well developed dialysis service in Yugoslavia but insufficient conditions for adequate treatment.

Antinociceptive activity of the novel fentanyl analogue iso-carfentanil in rats

A large number of fentanyl analogues have been synthesized so far, both to establish the structure-activity-relationship (SAR) and to find novel, clinically useful antinociceptive drugs. In this study, the newly synthesized fentanyl analogue 3-carbomethoxy fentanyl (iso-carfentanil) was compared to fentanyl for its antinociceptive activity (tail-immersion test) in rats. It was revealed that the introduction of a 3-carbomethoxy group in the piperidine ring of fentanyl skeleton reduced the potency and shortened the duration of action of the parent compound, i.e., fentanyl. The antinociceptive potency of 3-carbomethoxy fentanyl is influenced mainly by the steric factor (voluminosity of the carbomethoxy group and the cis/trans isomerism), while the chemical nature of the group is probably irrelevant. This is in agreement with SAR studies of other 3-substituted fentanyl analogues. In contrast to potency, the duration of action is not affected by cis/trans isomerism. It is assumed that the time course of action of 3-carbomethoxy fentanyl is influenced by the nature of the carbomethoxy group. Since the potency and the duration of action of this novel antinociceptive compound are interesting from the aspect of SAR studies and have potential promise for clinical application, 3-carbomethoxy fentanyl deserves to be extensively evaluated.

Prevalence of rheumatoid arthritis in Belgrade, Yugoslavia

OBJECTIVE

To determine the prevalence of chronic arthritis with special reference to rheumatoid arthritis.

METHOD

A cross-sectional study was performed during the years 1990 and 1991 in a randomly selected sample of the urban population of Belgrade.

RESULTS

Out of 2184 participants, > or = 20 yr old, surveyed by questionnaire, 756 (34.6%) reported peripheral joint complaints. Of those with complaints, 621 (82.1%) agreed to undergo detailed examination. Arthritis was diagnosed in four men (one had rheumatoid arthritis and three had spondylarthropathy with peripheral arthritis) and 11 women (three had rheumatoid arthritis, one had B27-positive polyarthritis and seven had undifferentiated chronic arthritis). The prevalence of chronic arthritis in the adult population was 0.69% (0.35% for men and 1.05% for women). The prevalence for rheumatoid arthritis was 0.18% (0.09% for men and 0.29% for women). Re-examination of 15 individuals with chronic arthritis 3 yr later showed changes in diagnosis only in those patients who at baseline examination had undifferentiated chronic arthritis.

CONCLUSION

According to the results obtained, the urban population of Belgrade is among populations with a low prevalence of rheumatoid arthritis.

[Serum and urinary interleukin-6 levels in patients with primary glomerulonephritis]

Several studies have suggested that the measurement of urinary interleukin-6 (IL-6) is a helpful tool for diagnosis and monitoring the progression of glomerulonephritis. The aim of this study was to determine if IL-6 level might reflect the histological type of glomerular lesions. We performed a prospective study of 43 patients who underwent renal biopsy in our hospital. There were 35 male and 8 female patients with median age of 30.5 years (range 19-50). Included among these were 13 cases of IgA nephropathy, 11 cases of membranoproliferative glomerulonephritis, 6 cases of poststreptococcal glomerulonephritis, 6 cases of mesangial proliferative glomerulonephritis, 5 cases of membranous nephropathy and 2 cases of C3 nephritis. IL-6 was measured by ELISA (Lucernachem, Switzerland). IL-6 was not detected in the serum and rine of 15 healthy controls. IL-6 was elevated in the urine of 30 patients with different histological types of glomerular lesions (range 3.7 to 433.3 pg/ml) but was not detected in the urine of remaining 13 patients. The presence of IL-6 in the urine in absence of raised serum IL-6 suggests that urinary IL-6 was produced by the kidney. We have concluded that urinary IL-6 level can be considered as a marker of glomerulonephritis but not one that is very specific for any particular histological type of primary glomerulonephritis. Thus, the urinary IL-6 level is not a useful tool in the differential diagnosis of primary glomerulonephritis. We need further studies to determine whether urinary IL-6 level could by considered for monitoring of disease activity and therapy.

[Angioimmunoblastic lymphadenopathy with dysproteinemia and hypothyreosis]

A patient with angioimmunoblastic lymphadenopathy with disproteinemia is presented. The diagnosis is made on the basis of lymph node hystology and laboratory findings of typical immunologic aberrations. The patient had signs of developed primary hypothyreosis with cardiac failure at the same time. The two diagnsis were made in the late stages of diseases, two years after the first findings of generalised lymphadenopathy and clinical signs of hypothyreosis, with developed complications in the form or cardiac, respiratory and renal failure. The disease had terminated lethaly before the pathohystologic diagnosis was known.

[Ixodes ricinus proven as a vector of Lyme borreliosis in Yugoslavia]

263 fasting female Ixodes ricinus were examined for Borrelia burgorferi, the vector of Lyme borreliosis. Female ticks were collected by flagella in the biotopes (Belgrade and Osijek) in which ticks bite patients with Lyme borreliosis. Borrelia burgorferi was proved in 58 (22%) of 263 female ticks in the native preparations of the intestinal contents by darkfield microscopy. In macerates of two groups of 5 female ticks each, Borrelia burgorferi was isolated by cultivation in the modified Kelly nutrient media for borrelia. The supposition that Ixodes ricinus is the vector of Lyme borreliosis in Yugoslavia is confirmed.

[Hemorrhagic fever with renal syndrome in Yugoslavia 1951-1988]

Data on hemorrhagic fever with renal syndrome (HFRS) incidence in SFRY 1950-1988 were analysed. Information sources were published papers and official reports of Federal and Republic Institutions for Public Health. Indirect immunofluorescence technique was used in testing 1.842 organs of small wild mammals to the presence of HFRS viral antigen. This antigen was found in the lungs of 11 species. Average incidence of the carrier state was 10.4% Registered were 613 cases within the period 1951-1988. Morbidity rate was 0.05-10.6:1.00.000 for years. Disease have been registered during the whole year with maximum incidence rate in summer months. Men most capable of working were the most frequently affected: farmers, wood workers, soldiers. Average lethality was 5.2%.

Hemorrhagic fever with renal syndrome in Yugoslavia: antigenic characterization of hantaviruses isolated from Apodemus flavicollis and Clethrionomys glareolus

Hantavirus antigens were detected in lung tissues of 8/113 Apodemus flavicollis and 2/17 Clethrionomys glareolus captured in 1984 in Fojnica, a region of Yugoslavia endemic for hemorrhagic fever with renal syndrome; hantavirus antigens were not detected in lung tissues from 126 other mammals collected in Fojnica. Three hantaviruses, 2 from A. flavicollis and 1 from C. glareolus, were isolated directly in Vero E6 cells and were partially characterized. The isolates from A. flavicollis, designated Fojnica virus, were antigenically similar but not identical to Hantaan virus strain 76-118, whereas the isolate from C. glareolus was antigenically indistinguishable from Puumala virus, strain Hällnäs B1. These data are consistent with previous studies that indicate the existence of at least 2 hantavirus serotypes in Yugoslavia.

Epidemic hemorrhagic fever with renal syndrome in Yugoslavia, 1986

An epidemic of hemorrhagic fever with renal syndrome (HFRS) occurred in Yugoslavia May-November 1986; all Republics and Provinces were involved. Serum samples were received from 260 of 276 persons with symptoms clinically compatible with a diagnosis of HFRS. Presumptive infection with a hantavirus was determined serologically for 161 of these. Many patients with serious clinical pictures, including severe renal insufficiency and shock, were hospitalized; 11 died. Indirect fluorescent antibody tests with antigens of 4 hantaviruses (Hantaan, Fojnica, Puumala, and the Vranica strain of Puumala virus) showed that greater than 1 serotype was circulating during this epidemic. Hantavirus antigens were detected in the lungs of 86 of 302 (28.5%) wild-caught small mammals.

Hemorrhagic fever with renal syndrome in Yugoslavia: detection of hantaviral antigen and antibody in wild rodents and serological diagnosis of human disease

Lung tissues from 547 rodents and 26 insectivores captured between 1981 and 1984 in central Bosnia (Fojnica) and central Serbia (Cacak), 2 regions known to be endemic for hemorrhagic fever with renal syndrome (HFRS), were examined for hantaviral antigen by the indirect immunofluorescent antibody technique. Antigen was detected in 17/231 Apodemus flavicollis, 3/187 A. sylvaticus, 1/46 A. agrarius, 4/32 Mus musculus, and 3/28 Clethrionomys glareolus. In addition, antibodies against Hantaan and Puumala viruses were found in serum pooled from 2 C. glareolus captured in Fojnica and 6 Pitimys subterraneus caught in Cacak. Sera of 27 HFRS patients from different parts of Yugoslavia were tested against 3 serotypes of hantavirus. Patients from Bosnia and Serbia had highest titers against Hantaan virus, while patients from Croatia had highest titers against Puumula virus, the agent of nephropathia epidemica.

Thermal trauma-induced changes in the synthesis of rat serum proteins

Infliction of non-lethal scalding was found to cause an increase in the rate of incorporation of 35S-methionine into albumin and globulin fractions of rat serum proteins, the the increase being remarkably higher for alpha- and beta-globulins than for albumin and gamma-globulins The most pronounced enhancement was associated with the 60- and 70-kd constituents of beta-globulins, the 34-, 55- and 136-kd polypeptides of alpha-2-globulins and the 50-, 60-, 125- and 145-kd polypeptides of alpha-1-globulins. The response of serum proteins to the heat shock was similar, though the changes were significantly less pronounced.