Going digital: a narrative overview of the clinical and organisational impacts of eHealth technologies in hospital practice

Objective The aim of the present study was to determine the effects of hospital-based eHealth technologies on quality, safety and efficiency of care and clinical outcomes. Methods Systematic reviews and reviews of systematic reviews of eHealth technologies published in PubMed/Medline/Cochrane Library between January 2010 and October 2015 were evaluated. Reviews of implementation issues, non-hospital settings or remote care or patient-focused technologies were excluded from analysis. Methodological quality was assessed using a validated appraisal tool. Outcome measures were benefits and harms relating to electronic medical records (EMRs), computerised physician order entry (CPOE), electronic prescribing (ePrescribing) and computerised decision support systems (CDSS). Results are presented as a narrative overview given marked study heterogeneity. Results Nineteen systematic reviews and two reviews of systematic reviews were included from 1197 abstracts, nine rated as high quality. For EMR functions, there was moderate-quality evidence of reduced hospitalisations and length of stay and low-quality evidence of improved organisational efficiency, greater accuracy of information and reduced documentation and process turnaround times. For CPOE functions, there was moderate-quality evidence of reductions in turnaround times and resource utilisation. For ePrescribing, there was moderate-quality evidence of substantially fewer medications errors and adverse drug events, greater guideline adherence, improved disease control and decreased dispensing turnaround times. For CDSS, there was moderate-quality evidence of increased use of preventive care and drug interaction reminders and alerts, increased use of diagnostic aids, more appropriate test ordering with fewer tests per patient, greater guideline adherence, improved processes of care and less disease morbidity. There was conflicting evidence regarding effects on in-patient mortality and overall costs. Reported harms were alert fatigue, increased technology interaction time, creation of disruptive workarounds and new prescribing errors. Conclusion eHealth technologies in hospital settings appear to improve efficiency and appropriateness of care, prescribing safety and disease control. Effects on mortality, readmissions, total costs and patient and provider experience remain uncertain. What is known about the topic? Healthcare systems internationally are undertaking large-scale digitisation programs with hospitals being a major focus. Although predictive analyses suggest that eHealth technologies have the potential to markedly transform health care delivery, contemporary peer-reviewed research evidence detailing their benefits and harms is limited. What does this paper add? This narrative overview of 19 systematic reviews and two reviews of systematic reviews published over the past 5 years provides a summary of cumulative evidence of clinical and organisational effects of contemporary eHealth technologies in hospital practice. EMRs have the potential to increase accuracy and completeness of clinical information, reduce documentation time and enhance information transfer and organisational efficiency. CPOE appears to improve laboratory turnaround times and decrease resource utilisation. ePrescribing significantly reduces medication errors and adverse drug events. CDSS, especially those used at the point of care and integrated into workflows, attract the strongest evidence for substantially increasing clinician adherence to guidelines, appropriateness of disease and treatment monitoring and optimal medication use. Evidence of effects of eHealth technologies on discrete clinical outcomes, such as morbid events, mortality and readmissions, is currently limited and conflicting. What are the implications for practitioners? eHealth technologies confer benefits in improving quality and safety of care with little evidence of major hazards. Whether EMRs and CPOE can affect clinical outcomes or overall costs in the absence of auxiliary support systems, such as ePrescribing and CDSS, remains unclear. eHealth technologies are evolving rapidly and the evidence base used to inform clinician and managerial decisions to invest in these technologies must be updated continually. More rigorous field research using appropriate evaluation methods is needed to better define real-world benefits and harms. Customisation of eHealth applications to the context of patient-centred care and management of highly complex patients with multimorbidity will be an ongoing challenge.

Inactivation of Salmonella spp. and Listeria spp. by Palmitic, Stearic, and Oleic Acid Sophorolipids and Thiamine Dilauryl Sulfate

Food contaminated with human pathogens, such as Salmonella spp. and Listeria monocytogenes, frequently causes outbreaks of foodborne illness. Consumer concern over the use of synthesized antimicrobials to enhance microbial food safety has led to a search of natural alternatives. The objectives of this study were to evaluate the antimicrobial activity of various types of sophorolipids (SLs) and thiamine dilauryl sulfate (TDS) against pathogenic Salmonella spp. and Listeria spp. Both free and lactonic forms of SLs were synthesized from Candida bombicola using palmitic, stearic, and oleic acids as co-feedstocks. TDS and purified SLs were used to treat cocktails of Salmonella spp. and Listeria spp. Results showed that lactonic SLs had higher antimicrobial activity than the free-acid form, and Gram-positive Listeria spp. were more susceptible to SLs and TDS than Gram-negative Salmonella spp. Listeria populations were reduced from an initial concentration of 7.2 log CFU/mL to a non-detectible level within a 1 min treatment of 0.1% (w/v) lactonic SLs and TDS in the presence of 20% ethanol, which itself did not significantly reduce the populations. There were no significant differences in the antimicrobial efficacy among palmitic, stearic, and oleic acid-based SLs against Salmonella or Listeria spp. Ethanol was utilized to improve the antimicrobial activity of free-acid SLs against Gram-negative bacteria. In general, TDS was more effective than the SLs against Salmonella and Listeria spp. scanning electron microscopy and transmission electron microscopy images showed that SLs and TDS damaged Listeria cell membranes and resulted in cell lysis. Overall, our results demonstrated that SLs and TDS in the presence of ethanol can be used to inactivate foodborne pathogens, especially Gram-positive bacteria.

National Health and Hospital Network for Australia's future: implications for Emergency Medicine

The proposals arising from the agreement reached between the Rudd government and the States and Territories (except Western Australia) in April 2010 represent the most fundamental realignment of health responsibilities since the creation of Medicare in 1984. They will change the health system, and the structures that will craft its future direction and design. These proposals will have a significant impact on Emergency Medicine; an impact from not only the system-wide effects of the proposals but also those that derive from the specific recommendations to create an activity-based funding mechanism for EDs, to implement the four hour rule and to develop a performance indicator framework for EDs. The present paper will examine the potential impact of the proposals on Emergency Medicine to inform those who work within the system and to help guide further developments. More work is required to better evaluate the proposals and to guide the design and development of specific reform instruments. Any such efforts should be based upon a proper analysis of the available evidence, and a structured approach to research and development so as to deliver on improved services to the community, and on improved quality and safety of emergency medical care.

Body composition and bone status of children born to mothers with type 1 diabetes mellitus

BACKGROUND

Altered growth, body composition and abnormalities of skeletal mineralisation have been reported in offspring of mothers with type 1 and type 2 diabetes mellitus.

AIMS

The authors hypothesised that children born to mothers with type 1 diabetes mellitus (CDM) would be taller, have higher body mass index (BMI), greater fat mass, thicker diaphyseal bone cortices and reduced trabecular bone mineral density (BMD), as compared to those born to non-diabetic mothers.

METHODS

Anthropometric, body composition and bone parameters were assessed using dual-energy x-ray absorptiometry (DXA) and peripheral quantitative CT in 67 white Caucasian CDM (35 boys; age 5-18 years) and in 246 (121 boys) age-matched controls.

RESULTS

CDM were taller (p<0.0001), heavier (p<0.0001) and had higher BMI (p=0.02), and had 32% more total body fat mass and 7.5% more total body lean mass than controls. At the total body and lumbar spine (L1-L4) sites, CDM had significantly higher bone area and bone mineral content compared with controls. However, areal BMD at both these sites and lumbar spine bone mineral apparent density were not significantly different in the two groups, indicating that CDM have bigger bones compared with controls but their mineral content per unit area or volume is not substantially different. The distal radial trabecular and total volumetric BMD in CDM was not demonstrably different from controls. At the mid-radius, both periosteal (2.4%; p=0.03) and endosteal circumferences (5.7%; p=0.02) were bigger in CDM compared with controls.

CONCLUSION

The authors speculate that the intrauterine diabetic environment is associated with an increase in linear growth, adiposity and larger bone dimensions during childhood and adolescence.

LC/MS analysis and lipase modification of the sophorolipids produced by Rhodotorula bogoriensis**

The extracellular glycolipids produced by the yeast, Rhodotorula bogoriensis (formerly Candida bogoriensis), were analyzed using an LC/API-MS method. The analysis confirmed that the predominant form the sophorolipid structure contained a C22 hydroxy carboxylic acid. A minor amount (<10%) of a C24 hydroxy carboxylic acid in the sophorolipid was also found, which had not been reported previously. The sophorolipid product, which contained varying degrees of acetylation at the primary hydroxy groups of the sophorose sugar, was deacetylated with sodium methoxide. The des-acetylated sophorolipid was esterified using an immobilized lipase as catalyst in tetrahydrofuran and the product analyzed by mass spectrometric techniques. The product was screened for dimer or polymer formation but only a monomeric lactonized sophorolipid structure was detected.

A thermodynamic equilibrium model for calcium salt urolithiasis: clinical application

It is proposed that urine is better modelled as a true equilibrium rather than in a supersaturated/metastable state and that the free citrate3- ion plays a major role in maintaining dispersion of the solid particles (reduced agglomeration). Published urinary chemistries, in conjunction with the computer programme SEQUIL, have been used to formulate a novel risk index for calcium stone formation independent of the traditional clinical classification of the stone former. Applying the risk index to three consecutive 24-hour urine samples of 39 untreated Ca stone formers showed that 35 (90%) patients produced at least one abnormal urine. Traditional single urinary parameter assessment, Ca/Cr, oxalate/Cr or citrate/Cr ratios, showed that only 17, 14, and 18% of the patients, respectively, had an abnormality, while taking all three together 24 (70%) had some abnormality and thus 30% were 'idiopathic' stone formers. Treatment regimens have been devised using the computer programme to return an abnormal urine to the normal according to the proposed risk index. In most urines two or more factors had to be changed simultaneously. Clinically there has been only one recurrence in 36 months, whereas before they had 4.4/3 years.

Prevalence study of domestic violence victims in an emergency department

STUDY OBJECTIVE

In 1992, a study of the prevalence and predictors of domestic violence victims among individuals who presented to a major public hospital emergency department was conducted to replicate a study conducted by the authors in the same setting 12 months previously. The second study aimed to investigate more accurately the presentation of current victims of domestic violence to the ED.

METHODS

In a retrospective, cross-sectional study, a screening questionnaire was administered to participants to establish the prevalence of a history and current presentation of domestic violence problems among patients who presented to the ED of a major public hospital. The study group comprised a representative sample of 670 male and 553 female adults (older than 16 years) who presented to all sections of a public hospital ED during 53 randomly selected 8-hour nursing shifts over an 8-week period in 1992.

RESULTS

The results of the second prevalence study confirmed those of the first study. Of the 1,223 respondents in the study, 15.5% disclosed a history of adult domestic violence (8.5% of men, 23.9% of women). Women were at greater risk than men for abuse as adults (raw relative risk [RR], 3.27; 95% confidence interval [CI], 2.23 to 4.79; RR adjusted for age, history of child abuse, and country of birth, 4.13; CI, 2.86 to 5.95). Women were at greater risk than men for being doubly abused (as a child and as an adult)(raw RR, 2.17; CI, 1.33 to 3.53). The second prevalence study confirmed what had been indicated in the first study: that 2.0% of women who presented to the ED (11.6% of all women with a history of adult domestic violence) were current victims of domestic violence and that these women presented mainly between the hours of 5 pm and 8 am, when no social work services were available for referral of victims.

CONCLUSION

These Australian studies support the findings of prevalence studies of domestic violence victims in ED in the United States. The prevalence and risk factors indicate the need for training of physicians and nurses in the ED about domestic violence and for provision of appropriate backup referral services such as after-hours social work services.

Air embolus complicating transthoracic percutaneous needle biopsy

Transthoracic percutaneous needle biopsy has become popular for evaluation of pulmonary nodules. However, it is a procedure with morbidity and mortality that is not negligible. In this article, we report massive air embolus complicating needle biopsy in a patient with amyloidosis. A negative biopsy does not exclude malignancy, and if surgical excision will be performed regardless of the result, preoperative assessment using this technique may not be necessary.

The development of European standard (CEN) methods in support of European Directives for plastics materials and articles intended to come into contact with foodstuff

CEC Directives have been implemented for plastics materials and articles intended to come into contact with foodstuffs. These introduce limits upon the overall migration from plastics into food and food simulants. In addition, specific migration limits or composition limits for free monomer in the final article, have been set for some monomers. Agreed test methods are required to allow these Directives to be respected. CEN, the European Committee for Standardization, has created a working group to develop suitable test methods. This is 'Working Group 5, Chemical Methods of Test', of CEN Technical Committee TC 194, Utensils in contact with food. This group has drafted a ten part standard for determining overall migration into aqueous and fatty food simulants by total immersion, by standard cell, by standard pouch and by filling. This draft standard has been approved by CEN TC 194 for circulation for public comment as a provisional standard, i.e. as an ENV. Further parts of this standard are in preparation for determining overall migration at high temperatures, etc. Simultaneously, Working Group 5 is cooperating with the BCR (Community Bureau of Reference) to produce reference materials with certified values of overall migration. CEN TC 194 Working Group 5 is also drafting methods for monomers subject to limitation in Directive 90/128/EEC. Good progress is being made on the monomers of highest priority but it is recognized that developing methods for all the monomers subject to limitation would take many years. Therefore, collaboration with the BCR, the Council of Europe and others is taking place to accelerate method development.

Immunoglobulin secretion by the normal and the infected newborn infant

The development of quantitative single-cell immunoassays has provided a novel opportunity to demonstrate the isotype-specific immunoglobulin responses in normal and infected neonates. The reverse enzyme-linked immunospot assay was used to determine the number of immunoglobulin-secreting cells (IgSCs) in peripheral blood. Baseline numbers of IgSCs were established in 69 uninfected term and preterm infants within 5 days of birth; values above the 99th percentile were considered elevated. The IgSCs were also measured in 266 infants with proved or suspected infections or congenital anomalies. A subset of newborn infants was retested weekly. Few IgSCs (mostly IgMSCs) were detected within 5 days of birth in uninfected neonates, but by 1 month 77% had increased numbers of IgSCs, primarily IgASCs. Sixty-three (24%) of 266 study infants had increased IgSCs on initial sampling (predominantly IgMSCs); these included infants as immature as 25 to 27 weeks of gestational age; elevations in IgSCs were most frequent in infants with intrauterine infections. Increased numbers of IgSCs were uncommon in infants with early-onset sepsis in the first 5 days but were frequent by the second week, consistent with acquisition of infection near the time of delivery. We conclude that the presence of elevated numbers of IgSCs soon after birth may be a useful surrogate marker of untreated intrauterine infection. The development of predominantly IgASCs in the first month of life suggests postnatal exposure to common mucosal antigens.

Clinical and serologic evaluation of neonates for congenital syphilis: a continuing diagnostic dilemma

Neonates born to women with reactive serologic tests for syphilis were studied; the total of 116 included 18 who were symptomatic, 60 asymptomatic but possibly infected, and 38 asymptomatic and probably uninfected. The fluorescent treponemal antibody-absorption (FTA-ABS) 19S IgM test and an IgM capture ELISA for Treponema pallidum, both treponema-specific assays, and the reverse enzyme-linked immunospot (RELISPOT), which detects immunoglobulin-secreting cells and is a nonspecific indicator of infection, were evaluated. Sensitivities among symptomatic neonates were 88% (IgM ELISA), 73% (FTA-ABS), and 78% (RELISPOT). Specificities ranged from 97% to 100%. A major problem has been the inability to identify which asymptomatic but possibly infected neonate is really uninfected. Among 41 such babies who had all three tests done, 93% were negative by all assays, suggesting they were uninfected or recently infected. Strategies to accurately identify the truly uninfected asymptomatic newborn would prevent the unnecessary hospitalization of all at-risk infants, resulting in improved quality of care and reduced costs.

Diagnosis of human immunodeficiency virus infection by enzyme-linked immunospot assays in a prospectively followed cohort of infants of human immunodeficiency virus-seropositive women

The enzyme-linked immunospot (ELISPOT), a method for quantifying specific and total antibody-secreting cells, was used for the diagnosis of human immunodeficiency virus (HIV) infection in a prospectively followed cohort of infants born to HIV-infected women. From July 1, 1987, to June 1, 1990, 127 infants with known HIV infection status were studied. Seventeen of 22 HIV-infected infants had specific HIV-specific antibody-secreting cells (ASC). Among the infected infants rates of ASC positivity increased during the first year of life, from 25% in the first 5 days of life to 78% after 6 months. Two of the five ASC-negative infected infants were further characterized as hypo- or dysgammaglobulinemic by an adjunct ELISPOT assay for total immunoglobulin-secreting cells. Excluding hypo- or dysgammaglobulinemic infants from the analysis, the rate of ASC positivity among infected infants was 85% (17 of 20) after the age of 6 months. None of the 95 uninfected infants had a positive ELISPOT assay, including 55 who were tested in the first 3 months of life. Thus in this series the specificity was 100%. ELISPOT methodology can be a useful technique for the diagnosis of HIV infection in infants of HIV-seropositive mothers.

Twenty-six-week oral toxicity of the new quinolone antibacterial agent levofloxacin in rats and cynomolgus monkeys

The oral 26-week toxicity of (-)-(S)-9-fluoro-2,3-dihydro-3-methyl-10-(4- methyl-1-piperazinyl)-7-oxo-7H-pyrido [1,2,3-de][1,4]benzoxazine-6-carboxylic acid hemihydrate (levofloxacin, DR-3355, CAS 100986-85-4) was investigated in rats and monkeys. Rats receiving higher doses of DR-3355 exhibited an increased number of larger fecal pellets, salivation, lower neutrophil counts, enlargement of the cecum and prominent goblet cells in the cecal mucosa. Monkeys did not show any changes due to DR-3355 treatment. Therefore, a no-effect dose of DR-3355 under these conditions was determined as 20 mg/kg in the rat and 62.5 mg/kg in the cynomolgus monkey.

Four-week sub-acute toxicity study of S-(-)-9-fluoro-2,3-dihydro-3-methyl-10- (4-methyl-1-piperazinyl)-7-oxo-7H-pyrido-[1,2,3,-de] [1,4]benzoxazine-6- carboxylic acid hemihydrate (DR-3355) in CD rats and cynomolgus monkeys

S-(-)-9-Fluoro-2,3-dihydro-3-methyl-10-(4-methyl-1-piperazinyl)-7-oxo-7H -pyrido-[1,2,3,-de] [1,4]benzoxazine-6-carboxylic acid hemihydrate, DR-3355, a new quinolone antimicrobial agent, was administered by oral gavage to groups of ten male and ten female CD rats at dosages of 50, 200 or 800 mg/kg/day and to groups of three male and three female cynomolgus monkeys at dosages of 10, 30, or 100 mg/kg/day. Both species were treated for four weeks. The vehicle (0.5% sodium carboxymethyl cellulose)-treated group served as control. Rats at the high dose showed salivation, slight increases in total leucocyte and lymphocyte counts, slight changes in the plasma electrolyte balance, and minor reductions in urea concentration. The articular surfaces of the humerus and femur of rats at the high dose showed minor degenerative changes. Increased caecal weight occurred in rats at all the treatment groups. Monkeys at the high dose showed salivation, diarrhoea and lost weight. There was no microscopic change in the tissues examined. No effect levels under these conditions were established at 200 mg/kg/day in the rat, and 30 mg/kg/day in the monkey.

Effects of dilevalol on rest and supine exercise hemodynamics in mild to moderate systemic hypertension

Eight mildly to moderately hypertensive subjects free of any antihypertensive medications and on a normal salt diet performed maximal supine arm exercise. Before starting the exercise, a right-sided cardiac catheterization was performed to measure hemodynamic parameters before and during exercise. All patients had normal increases in cardiac output for the level of exercise performed and the peripheral vascular resistance diminished appropriately. An increase in the right atrial and pulmonary artery wedge pressures during exercise could be explained by increased venous return. After the baseline testing, rest and exercise hemodynamics were repeated 2 hours after the administration of 400 mg of dilevalol, a new beta blocker. For the next 2 weeks the patients received 400 mg of the study drug twice a day, with repeat studies obtained thereafter. As with other beta blockers, dilevalol decreases the heart rate and cardiac output on exercise, but, in addition, it induces a decrease in the resting systemic vascular resistance. This action is similar to its isomer, labetalol.

Safety evaluation of Streptomyces murinus glucose isomerase

A glucose isomerase enzyme, obtained from Streptomyces murinus, was produced by a fermentation process and subjected to a series of tests to investigate its safety in use and manufacture. It was not mutagenic (Ames test, using liquid culture) nor did it provoke chromosomal damage (rat bone marrow cytogenetics test). It did not contain (nor did the organism produce) antimicrobial activity or macrolidpolyene antibiotics. It had no teratogenic activity when administered to pregnant rats at 100,000 ppm in the diet. It was without effect upon rats when administered at this dietary concentration for 4 weeks. Dietary administration at 5000, 15,000 or 50,000 ppm to rats for 13 weeks resulted in nephrocalcinosis in females at all dosages (probably a physiological response to the altered calcium:phosphate ratio in the admixed diet) and status spongiosus in the brains of males receiving 50,000 ppm. As the finding of nephrocalcinosis in rats is generally agreed to be of no toxicological importance with regard to the use in man, the dietary concentration of 15,000 ppm was considered to be highest no-effect level. This level corresponds to an intake of some 1000 mg/kg/day, which represents approximately 8000 times the human intake based on a conservative estimation.

Toxicological studies on (2"R)-4'-tetrahydropyranyladriamycin, a new antitumor antibiotic. Chronic toxicity study in rats

(2"R)-4'-O-Tetrahydropyranyladriamycin X HCl (THP), a new anthracycline antitumor antibiotic, was administered to Sprague-Dawley rats (each group 20 rats) intraperitoneally at dosages of 0.001, 0.008, 0.06 and 0.3 mg/kg/day for 53 weeks. Piloerection, loose feces or perianal staining and thin or emaciated build were observed from week 12 in rats receiving 0.06 or 0.3 mg/kg/day. All rats receiving 0.3 mg/kg/day and 3 males and 1 female receiving 0.06 mg/kg/day died or were prematurely sacrificed in the period from weeks 13 to 44. The overall food consumption and body weight gain of both sexes receiving 0.06 or 0.3 mg/kg/day were lower than those of the controls. Hematological examination showed low leucocyte counts, disturbance in neutrophil and lymphocyte number and low erythrocytic characteristics in animals receiving 0.06 or 0.3 mg/kg/day. At necropsy, macroscopic changes were found at the injection site, throughout the gastrointestinal tract and in the male reproductive system in rats receiving 0.06 or 0.3 mg/kg/day. Microscopic examination revealed decrease in the small lymphocyte population in the hematopoietic and lymphoid system in rats receiving 0.008 to 0.3 mg/kg/day. Degeneration of the germinal epithelium of the subcapsular tubules of the testes, gastric ulceration, epithelial adnexal atrophy of the skin and chronic cellulitis and necrosis at the injection sites were also observed. No rats receiving 0.001 mg/kg/day were affected in these respects.

Toxicological studies on (2"R)-4'-O-tetrahydropyranyladriamycin, a new antitumor antibiotic. Subacute toxicity study in rats

(2"R)-4'-O-Tetrahydropyranyladriamycin X HCl (THP), a new anthracycline antitumor antibiotic, was administered to Sprague-Dawley rats intraperitoneally for 13 weeks. In rats receiving 0.4 mg/kg/day, piloerection, emaciation, loose feces and thickening of the injection site were evident, and 7 males and 2 females died after week 12. Inferior body weight gain was observed in both sexes starting week 4 approximately 6. The food consumption also decreased. Hematological examination revealed lower counts of total leucocyte and lymphocyte. At termination there were lower spleen, thymus and testes weights, thickening of the walls of the intestine and stomach, gastric ulceration, presence of ascitic fluid, and congestion and thickening at the injection site. Decreases in the lymphocyte populations of the thymus, spleen and lymph nodes were observed microscopically. A decrease in the number of hematopoietic cells in the bone marrow and a degeneration of the germinal epithelium in the testes were also seen, as were gastrointestinal disturbances. These treatment-related effects were mainly confined to rats receiving 0.4 mg/kg/day and to a lesser extent, to rats receiving 0.1 mg/kg/day. The effects on rats receiving 0.025 mg/kg/day were only at the microscopic level. No rats receiving 0.006 mg/kg/day were toxicologically affected.

Preclinical studies on human insulin. I. Acute and subacute toxicity studies

Human insulin (prepared from porcine insulin) and porcine insulin were tested for acute toxicity by subcutaneous administration to unfasted mice and rats and fasted mice. The animals were observed for signs of reaction and post mortem examination was performed. LD50 values were calculated when possible. The LD50 values in the unfasted animals were several times higher than in the fasted mice, but similar for the two insulin preparations. The deaths and the signs observed were most probably caused by hypoglycaemia. No dose-related macroscopic organ changes were found. In a 28 day toxicity study rats were given human or porcine insulin subcutaneously at dosages of 2, 20 or 200 U/kg/day. The criteria examined included mortality, body-weight change, food consumption and utilization, haematology, blood chemistry, urinalysis, ophthalmoscopy, organ weights, gross- and histopathology. A few deaths occurred because of hypoglycaemia. In surviving rats from dosage groups 20 and 200 U/kg/day of either insulin preparation higher plasma glucose levels than in the control were observed 24 hours after dosing. Higher food intake and body-weight gains, lower plasma protein concentrations and higher urinary volumes with associated low specific gravity were observed in animals given either human or porcine insulin at 200 U/kg/day. No other adverse effects were registered, and no overt difference was found between the effect of human and porcine insulin.

Aspects of the teratology of cyclophosphamide (NSC-26271)

Wistar-derived rat embryos were most sensitive to maternally administered cyclophosphamide on Days 9.5 and 10.5 of gestation and to chlorambucil on Day 9.5 of gestation. The spectrum of malformations and the dose-response behavior of both drugs were similar. Chlorambucil was three times more potent than cyclophosphamide on an mg/kg basis. The drugs showed additive behavior when administered in combination. The teratogenic effects of the individual or combined drugs were reduced by protective doses of cysteine or glutathione. Studies with analogs of cyclophosphamide have suggested that the whole molecule is involved in teratogenesis.