Prevalence and Predictors of Abuse in Elderly Patients with Depression at a Tertiary Care Centre in Saurashtra, India

CONTEXT

Elder abuse has devastating consequences such as poor quality of life, psychological distress and loss of property and security. Abuse of elderly patients with depression has not been adequately researched in India.

AIMS

To explore the prevalence and predictors of abuse and its relation to various sociodemographic variables in elderly patients with depression.

SETTINGS AND DESIGN

A cross-sectional, observational study carried out at a tertiary care centre in Jamnagar.

METHODS AND MATERIALS

In all, 100 elderly patients with depression, attending Out Patient Department of Psychiatry at Shree M. P. Shah Government Medical College and Guru Gobind Singh Hospital, Jamnagar, were selected using simple random sampling by lottery method. Actual Abuse Tool and Elder Abuse Suspicion Index were used to detect abuse. Geriatric Depression Scale was used to assess depression, and Mini Mental State Examination was used to rule out dementia.

STATISTICAL ANALYSIS

Descriptive statistics, Chi-square test, and binary logistic regression were used.

RESULTS

The prevalence of abuse was 24%. Among those who had experienced abuse, 50% had experienced psychological abuse, 17% had experienced neglect, 8% had experienced exploitation and 4% had experienced physical abuse. About 54% of patients with severe depression had experienced abuse. Daughters-in-law (54%) and sons (42%) were the most common perpetrators. Illiteracy and severe depression were found to be the predictors of abuse.

Effect of aspirin in vascular surgery in patients from a randomized clinical trial (POISE-2)

BACKGROUND

In the POISE-2 (PeriOperative ISchemic Evaluation 2) trial, perioperative aspirin did not reduce cardiovascular events, but increased major bleeding. There remains uncertainty regarding the effect of perioperative aspirin in patients undergoing vascular surgery. The aim of this substudy was to determine whether there is a subgroup effect of initiating or continuing aspirin in patients undergoing vascular surgery.

METHODS

POISE-2 was a blinded, randomized trial of patients having non-cardiac surgery. Patients were assigned to perioperative aspirin or placebo. The primary outcome was a composite of death or myocardial infarction at 30 days. Secondary outcomes included: vascular occlusive complications (a composite of amputation and peripheral arterial thrombosis) and major or life-threatening bleeding.

RESULTS

Of 10 010 patients in POISE-2, 603 underwent vascular surgery, 319 in the continuation and 284 in the initiation stratum. Some 272 patients had vascular surgery for occlusive disease and 265 had aneurysm surgery. The primary outcome occurred in 13·7 per cent of patients having aneurysm repair allocated to aspirin and 9·0 per cent who had placebo (hazard ratio (HR) 1·48, 95 per cent c.i. 0·71 to 3·09). Among patients who had surgery for occlusive vascular disease, 15·8 per cent allocated to aspirin and 13·6 per cent on placebo had the primary outcome (HR 1·16, 0·62 to 2·17). There was no interaction with the primary outcome for type of surgery (P = 0·294) or aspirin stratum (P = 0·623). There was no interaction for vascular occlusive complications (P = 0·413) or bleeding (P = 0·900) for vascular compared with non-vascular surgery.

CONCLUSION

This study suggests that the overall POISE-2 results apply to vascular surgery. Perioperative withdrawal of chronic aspirin therapy did not increase cardiovascular or vascular occlusive complications. Registration number: NCT01082874 ( http://www.clinicaltrials.gov).

Effect of Co substitution on the magnetic and electron-transport properties of Mn2PtSn

The structural, magnetic and electron-transport properties of Mn(2)Pt(1-x)Co(x)Sn(x = 0, 0.3, 0.5, 0.7, 1) ribbons prepared by arc-melting and melt-spinning were investigated. The rapidly quenched alloys with x = 0 and 0.3 were found to crystallize in the inverse tetragonal structure, but the structure transformed into inverse cubic as x increased to 0.5. At room temperature, the samples are ferro or ferrimagnetic, and the Curie temperature increases by 225 K from 370 K for Mn(2)PtSn (x = 0) to 595 K for Mn(2)CoSn (x = 1). The measured anisotropy constants for the inverse-tetragonal alloys are on the order of 1 Merg cm(-3) at room temperature. The ribbons are moderately conducting with the room temperature resistivities being between 0.4 and 8.4 mΩ cm. Interestingly, the thermal coefficient of resistivity transforms from positive to negative and the magnetoresistance transforms from negative to positive as the value of x reaches 0.5.

Structural and magnetic transitions in cubic Mn3Ga

The structural, magnetic and electron-transport properties of cubic Mn3Ga have been investigated. The alloys prepared by arc melting and melt-spinning show an antiferromagnetic spin order at room temperature but undergo coupled structural and magnetic phase transitions at 600 and 800 K. First-principles calculations show that the observed magnetic properties are consistent with that of a cubic Mn3Ga crystallizing in the disordered Cu3Au-type structure. The samples exhibit metallic electron transport with a resistance minimum near 30 K, followed by a logarithmic upturn below the minimum. The observed anomaly in the low-temperature resistivity has been discussed as a consequence of electron scattering at the low-lying excitations of the structurally disordered Mn3Ga lattice.

Successful three-way kidney paired donation transplantation: The first Indian report

Providing transplantation opportunities for patients with incompatible live donors through kidney paired donation (KPD) is an important strategy for easing the crisis in organ availability. KPD is can overcome the barriers when the only living potential donors are deemed unsuitable owing to an incompatibility of blood type, of human leukocyte antigen cross-match, or both. In KPD, the incompatibility problems with two donor recipient pairs can be solved by exchanging donors. In the absence of well-organized deceased donor program, or transplantation with desensitization protocol and ABO incompatible transplantation, living donor KPD promises hope to the growing number of patients suffering from end-stage renal disease in India. We report our first successful three-way KPD transplantation from India. In an era of organ shortage, this approach is relevant to encourage wider participation from KPD donors and transplant centers to prevent commercial transplantation.

Outcome of live and deceased donor renal transplantation in patients aged ≥55 years: A single-center experience

Renal transplantation (RTx) has now become an accepted therapeutic modality of choice for elderly ESRD patients. This single-center study was undertaken to evaluate the outcome of RTx in ESRD patients ≥55 years. A total of 103 patients underwent RTx 79 living related living donors [LD], 24 deceased donors [DD]) at our center. Post-transplant immunosuppression consisted of calcineurin inhibitor-based regimen. The mean donor age was 58.3 years in the LD group and 59.5 years in the DD group. Male recipients constituted 92% in LD and 75% in DD group. In living donor renal transplantation, 1- and 5-year patient survival was 93% and 83.3% respectively and death-censored graft survival was 97.3% and 92.5% respectively. There were 12.6% biopsy proven acute rejection (BPAR) episodes and 12.6% patients were lost, mainly due to infections. In deceased donor renal transplantation, 1- and 5-year patient survival was 79.1% and 74.5% respectively and death-censored graft survival was 95.8% and 85.1% respectively. There were 12.5% BPAR episodes and 25% of patients were lost, mainly due to infections. RTx in ESRD (≥55 years) patients has acceptable patient and graft survival if found to have cardiac fitness and therefore should be encouraged.

Anesthetic management in parturients with chronic kidney disease undergoing elective Caesarean delivery: Our experience of nine cases

In this retrospective study, we describe the anesthetic management and its implications in parturients with chronic kidney disease (CKD; n = 9), who underwent elective caesarean delivery. Nine parturients with CKD of various etiologies, who underwent elective Caesarean delivery, were included in this study. Spinal anest-hesia was administered in all parturients with normal coagulation profile through a 25-gauze spinal needle (Quincke) with 0.5% (H) bupivacaine in L2-3 space and T6 level was achieved. Hemodynamics and side effects such as nausea, vomiting, headache, and backache were record. The mean age was 28.22 ± 4.43 years. The mean levels of serum creatinine and serum potassium were 2.78 ± 1.29 mg/dl and 4.11 ± 0.46 meq/l, respectively. Mean baseline values of systolic blood pressure, diastolic blood pressure, and pulse rate were higher which decreased after spinal anesthesia. However, the incidence of hypotension, which required mephentermine treatment, was 11.1%. One patient had symptoms of nausea and vomiting/dizziness at the time of hypotension, which disappeared after treatment with 5 mg of intravenous mephentermine. Baseline value of PR remained high throughout the operation. Parturients with CKD with normal coagulation profile remained hemodynamically stable under spinal anesthesia with minimal side effects. However, a large number of studies are required to determine the safety of spinal anesthesia in this setting.

Intercity deceased donor renal transplantation: a single-center experience from a developing country

In a developing country such as India, deceased donor renal transplantation (DDRTx) accounts for only about 1% of all renal transplants (RTx). Our institute initiated an intercity DDRTx in the year 2006, which significantly increased the number of RTx. We retrieved 74 kidneys from 37 deceased donors from various cities of Gujarat from January 2006 to December 2009. We transplanted the allografts in 66 recipients and a retrospective analysis of the donor profile and management and recipient outcome was performed. The mean age of the donors was 43.3 ± 18.8 years. The causes of death included road traffic accident in 51.35% of the donors and cerebrovascular stroke in 48.65% of the donors; 83.78% of the donors required ionotropes for hemodynamic stability in addition to vigorous intravenous fluid replacement. The average urine output of the donors was 350 ± 150 mL. The organs were perfused and stored in HTK solution. The mean cold ischemia time (CIT) was 9.12 ± 5.25 h. The mean anastomosis time in the recipient was 30.8 ± 8.7 min. 57.6% of the recipients established urine output on the operating table and 42.4% developed delayed graft function. At the end of 1 month after transplantation, the mean serum creatinine was comparable to the Ahmadabad city DDRTx, although the CIT was significantly longer in the intercity patients. Intercity organ harvesting is a viable option to increase the donor pool. Distance may not be an impediment, and good recipient outcome is possible in spite of prolonged CIT in case of proper harvesting and preservation.

Successful renal transplantation from a brain-dead deceased donor with head injury, disseminated intravascular coagulation and deranged renal functions

Deceased donors (DDs) with the brain death due to head injury are the major source of organs for transplantation. The incidence of post-head injury disseminated intravascular coagulation (DIC) ranges from 24% to 50%. Many centers do not accept organs from donors with DIC due to increased risk of primary graft non-function and/or high chances of morbidity/mortality. We performed two successful renal transplants from a DD with head injury with DIC and deranged renal function. One of the recipients developed transient thrombocytopenia, but there was no evidence of DIC or delayed graft functions in either of the recipients. Over a follow-up of 1 month, both are doing well with stable graft function and hematological profile. Thus, a carefully selected DD with severe DIC even with deranged renal function is not a contraindication for organ donation if other risk factors for primary non-function are excluded. This approach will also help in overcoming organ shortage.

Post-renal transplant cytomegalovirus infection: study of risk factors

OBJECTIVES

Cytomegalovirus (CMV) is a common opportunistic infection following renal transplantation (RTx). It responds promptly to antiviral treatment. The mortality rate reaches 90% if untreated. Identification of risk factors helps in the early diagnosis of CMV. We studied demographic features, risk factors, and outcomes associated with CMV infection in RTx recipients despite ganciclovir prophylaxis.

MATERIALS AND METHODS

We reviewed 720 RTx recipients between 2007 and 2009. We examined the serostatus of the donor and recipient before transplantation using an enzyme-linked immunosorbent assay, and diagnosed CMV infections in recipients by CMV DNA detection with a polymerase chain reaction.

RESULTS

A total of 42 of 750 (5.6%) patients were identified to display CMV infection (69.1%) or disease (30.9%). Their mean age was 34 ± 13.5 years, with 80.9% men. CMV serologic status was D+/R- in 21.4% and D+/R+ in 59.5% patients. Fever, malaise (76.2%), and leukopenia (52.3%) were the commonest presenting symptoms; diabetes (30.9%) and hepatitis C virus (28.6%) the commonest comorbid conditions. Risk factors were triple drug immunosuppression (47.6%), antithymocyte globulin ATG induction (54.8%), and a rejection episode (26.1%) and methylprednisolone (76.2%) which were more common in CMV disease than infection. Mean CMV DNA at diagnosis was 78,803; 71.2% patients developed CMV within 6 months posttransplantation, the majority occurring after 3 months. With a mean follow-up of 4 ± 1.9 years, patient and graft survival rates were 85.7% and 81% with a mean serum creatinine value of 1.83 ± 12 mg/dL.

CONCLUSIONS

Universal CMV prophylaxis was associated with a low incidence (5.6%) and mild form of CMV disease among our patients.

World kidney day 2010: medical aspects of 10 live-donor renal transplantations in a single center from a developing country

BACKGROUND

World Kidney Day (WKD) has become the most widely celebrated event associated with kidney disease in the world and the most successful effort to raise awareness among both the general public and government health officials about the dangers of kidney disease. We celebrated WKD 2010 in a unique way by performing 10 live-donor renal transplantations (RTx) on March 11, 2010.

PATIENTS AND METHODS

We report a single-center experience on RTx vis-à-vis patient/graft survival, graft function in terms of serum creatinine (SCr) level, and rejection episodes in 10 live-donor RTx performed on WKD. Recipient diseases leading to end-stage renal disease (ESRD) were chronic glomerulonephritis (60%), benign nephrosclerosis (20%), and chronic interstitial nephritis (20%). Mean recipient age was 35 ± 8.7 years. Nine recipients were males. Mean donor age was 37 ± 8.7 years, Nine donors were females. Donors were spouse (n = 6), mother (n = 2), sister (n = 1), and extended family member (n = 1), with mean HLA match 1.8 ± 1.48. All patients received steroids, calcinueurin inhibitors, and mycophenolate mofetil/azathioprime for maintenance immunosuppression.

RESULTS

During a mean follow-up time of 18 months, patient and graft survival rates were 90% and 90%, respectively, with a mean SCr level of 1.21 mg/dL; 20% had biopsy-proven acute rejection. One patient died due to infection after antirejection therapy.

CONCLUSION

RTx has acceptable graft and patient survival. RTx is the best cost-effective therapeutic modality for patients suffering from ESRD and should be encouraged in view of organ shortage on events such as WKD. To our knowledge, this is the first report from a developing country on 10 successful RTx on WKD.

High mortality in critically ill patients infected with 2009 pandemic influenza A (H1N1) with pneumonia and acute kidney injury

Patients infected with H1N1 virus may develop pneumonia and acute kidney injury (AKI). To determine the epidemiological characteristics, clinical features, management and out-comes of patients with confirmed H1N1 complicated by pneumonia and AKI and treatment with oseltamivir and to identify the prognostic indicators, we studied all the patients with a confirmed diagnosis of H1N1 infection with pneumonia and AKI, using real-time reverse transcriptase-polymerase chain reaction (RT-PCR) assay, between October 2009 and March 2010. H1N1 infection was confirmed in 20 patients with pneumonia and AKI; the mean age was 42.8 ± 18.2 years and 12 (60%) of the patients were males. Eleven patients were between 15 and 50 years of age, and 15 had preexisting medical conditions. All patients had fever, cough, dyspnea or respiratory distress, increased serum lactate dehydrogenase levels, pneumonia and AKI. Fifteen (75%) patients required mechanical ventilation and 14 (70%) died. None of the health care workers developed influenza-like illness, when they received oseltamivir prophylaxis. Mortality was associated with higher Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment score (SOFA), Multiple Organ Dysfunction Score (MODS), XRChest score, in addition to requirement of inotrope, ventilator support, renal replacement therapy (RRT), and presence of underlying risk factor for severe disease.

Elastic torsion effects in magnetic nanoparticle diblock-copolymer structures

Magnetic properties of thin composite films, consisting of non-interacting polystyrene-coated γ-Fe(2)O(3) (maghemite) nanoparticles embedded into polystyrene-block-polyisoprene P(S-b-I) diblock-copolymer films are investigated. Different particle concentrations, ranging from 0.7 to 43 wt%, have been used. The magnetization measured as a function of external field and temperature shows typical features of anisotropic superparamagnets including a hysteresis at low temperatures and blocking phenomena. However, the data cannot be reconciled with the unmodified Stoner-Wohlfarth-Néel theory. Applying an appropriate generalization we find evidence for either an elastic torque being exerted on the nanoparticles by the field or a broad distribution of anisotropy constants.

Dynamical theory calculations of spin-echo resolved grazing-incidence scattering from a diffraction grating

Neutrons scattered or reflected from a diffraction grating are subject to a periodic potential analogous to the potential experienced by electrons within a crystal. Hence, the wavefunction of the neutrons can be expanded in terms of Bloch waves and a dynamical theory can be applied to interpret the scattering phenomenon. In this paper, a dynamical theory is used to calculate the results of neutron spin-echo resolved grazing-incidence scattering (SERGIS) from a silicon diffraction grating with a rectangular profile. The calculations are compared with SERGIS measurements made on the same grating at two neutron sources: a pulsed source and a continuous wave source. In both cases, the spin-echo polarization, studied as a function of the spin-echo length, peaks at integer multiples of the grating period but there are some differences between the two sets of data. The dynamical theory explains the differences and gives a good account of both sets of results.

Combined epidural and general anesthesia for paediatric renal transplantation-a single center experience

BACKGROUND

Appropriate anesthesia for pediatric renal transplantation requires stable intraoperative hemodynamics, optimal perfusion of the newly transplanted kidney and good analgesia during recovery. The aim of this study was to assess the preliminary application, success and safety of combined epidural and general anesthesia in pediatric renal transplantation in a small cohort.

METHODS

We retrospectively reviewed the anesthesia records of 46 consecutive pediatric patients who received renal transplantation under combined epidural and general anesthesia from January 2003-2007.

RESULTS

The mean patient age and weight were 13.2 +/- 2.4 years and 25.7 +/- 5.46 kg, respectively. The infused crystalloids, 20% albumin and red blood cell concentrates were 120 +/- 2 mL/kg to achieve a CVP of 13 to 15 mm Hg. Brisk diuresis was observed in all patients. Epidural tramadol (2 mg/kg) provided good postoperative analgesia in 89% patients. 15% patients developed radiological evidence of pulmonary edema, only one required mechanical ventilation for hypoxemia. Minor adverse effects were nausea and vomiting (17.5%) and convulsions (8.5%). No perioperative mortality or major morbidity was recorded.

CONCLUSION

Epidural anesthesia is a useful adjunct to general anesthesia due to stable intraoperative haemodynamics and good postoperative analgesia.

Spin echo scattering angle measurement at a pulsed neutron source

Two experiments were performed to adapt spin echo scattering angle measurement (SESAME) to pulsed neutron sources. SESAME is an interferometric method that provides enhanced resolution of neutron scattering angles without the loss of neutron intensity that results when collimation is used to improve angular resolution. The method uses the neutron equivalent of optical wave plates to produce a phase difference between the two neutron spin components of a polarized neutron beam. Because the wave plate is inclined to the neutron beam, this phase difference depends sensitively on the trajectory of the neutron. In the absence of a sample, a second wave plate, which is parallel to the first, undoes the phase difference introduced by the first wave plate, producing a polarization identical to that of the incident neutron beam. When a scattering sample is placed between the two neutron wave plates, the cancellation of the phase difference between the neutron spin states is not perfect and the resulting neutron-beam polarization is a measure of the distribution of scattering angles. In the first experiment, thin (30 and 60 µm-thick) magnetized Permalloy films were used as neutron wave plates. In a second experiment, current-carrying solenoids with triangular cross sections were used as birefringent prisms for neutrons. The arrangement of these prisms was such that they mimicked the effect of the neutron wave plates in the first experiment. In both experiments, correlation lengths in the scattering sample of about 1000 Å were probed using very simple and inexpensive equipment. These experiments brought to light a number of advantages and disadvantages of implementing SESAME at pulsed neutron sources and provided insights into the relative merits of SESAME and traditional small-angle neutron scattering.

Carbon dioxide absorption during laparoscopic donor nephrectomy: a comparison between retroperitoneal and transperitoneal approaches

AIM

Previous studies have suggested that retroperitoneal and transperitoneal approaches for laparoscopic donor nephrectomy are associated with variable carbon dioxide (CO(2)) absorption, which can cause significant morbidity. The approach that results in greater CO(2) absorption is a matter of debate. We studied patients undergoing transperitoneal/retroperitoneal donor nephrectomy to determine relative CO(2) absorption, incidence of subcutaneous emphysema, pneumothorax, and pneumomediastinum, seeking to establish a correlation between the incidence of subcutaneous emphysema and CO(2) elimination.

MATERIALS AND METHODS

This was a prospective nonrandomized, single-center, two-arm clinical study of 60 kidney donors undergoing laparoscopic nephrectomy by transperitoneal (n = 30) or retroperitoneal (n = 30) approach. CO(2) elimination was calculated using end tidal CO(2), tidal volume, respiratory rate, and weight of the donor. We studied intraoperative CO(2) elimination and CO(2) retention-related morbidities.

RESULTS

There was a significant increase in CO(2) elimination in the first 30 minutes of insufflation followed by a plateau for the remainder of procedure. There was no difference in CO(2) elimination in either procedure at any time interval. Patients with subcutaneous emphysema showed significantly greater CO(2) elimination, which decreased with desufflation.

CONCLUSION

CO(2) absorption during laparoscopy did not depend on the route of surgery. Subcutaneous emphysema was strongly and independently associated with a greater degree of CO(2) absorption during laparoscopic surgery.

The use of symmetry to correct Larmor phase aberrations in spin echo scattering angle measurement

Spin echo scattering angle measurement (SESAME) is a sensitive interference technique for measuring neutron diffraction. The method uses waveplates or birefringent prisms to produce a phase separation (the Larmor phase) between the "up" and "down" spin components of a neutron wavefunction that is initially prepared in a state that is a linear combination of in-phase up and down components. For neutrons, uniformly birefringent optical elements can be constructed from closed solenoids with appropriately shaped cross sections. Such elements are inconvenient in practice, however, both because of the precision they demand in the control of magnetic fields outside the elements and because of the amount of material required in the neutron beam. In this paper, we explore a different option in which triangular-cross-section solenoids used to create magnetic fields for SESAME have gaps in one face, allowing the lines of magnetic flux to "leak out" of the solenoid. Although the resulting field inhomogeneity produces aberrations in the Larmor phase, the symmetry of the solenoid gaps causes the aberrations produced by neighboring pairs of triangular solenoids to cancel to a significant extent. The overall symmetry of the SESAME apparatus leads to further cancellations of aberrations, providing an architecture that is easy to construct and robust in performance.

Design and synthesis of a novel anthracene-based fluorescent probe through the application of the Suzuki–Miyaura cross-coupling reaction

We report on a simple synthetic route to a novel anthracene-based bis-armed amino acid derivative as a useful fluorescent probe. Various photophysical studies of this amino acid derivative are also described. Here, Suzuki-Miyaura cross-coupling reaction has been used as a key step for carbon-carbon bond formation.

In pursuit of the ultimate: the initial Ahmedabad journey toward transplantation tolerance

We designed a prospective clinical trial of 357 patients divided in two groups--treated (n = 201) and controls (n = 156)--to evaluate effects of donor hematopoietic stem cell transplantation (HSCT) with minimal nonmyeloablative conditioning for tolerance induction in living related donor renal allograft recipients. Conditioning included donor leukocyte infusions, target-specific irradiation, anti-T-cell antibody, cyclophosphamide, cyclosporine (CsA), followed by bone marrow (BM)-derived and peripheral blood stem cell (PBSC) infusion into thymus, liver, BM, and periphery, with mean total dose of 20 x 10(8) nucleated cells/kg body weight (BW) (mean CD34(+) count: 0.9%) pretransplantation. CsA (3 mg/kg BW/d) and prednisolone (10 mg/d) were used for immunosuppression. Azathioprine/mycophenolate mofetil were added in the event of an acute rejection episode. The controls underwent transplantation with three drug immunosuppression. With a mean follow-up of 21.5 months, the treated cohort showed better allograft function with mean serum creatinine (SCr), 1.42 +/- 0.31 mg% in contrast with the controls mean SCr, 1.61 +/- 0.52 mg% (P < .0001) at 23.9 months follow-up. One-year allograft/patient survival was 95%/96.7% versus 89%/93.4%, respectively. Peripheral blood chimerism by fluorescent in situ hybridization was 0.8% +/- 0.2% in the subset of treated patients with gender-mismatched donors. No graft-versus-host disease was noted. Nine patients with donor-specific cytotoxic alloantibodies pretransplantation showed a decrease in positivity to <15% post-HSCT and were transplanted safely. A transient rise in donor-specific cytotoxic alloantibodies was noted in 19 treated patients post-HSCT, 14 of whom returned to the transplantable range within 2 weeks and five required a desensitization protocol. "Prope" tolerance may be induced in living related donor renal transplantation across major histocompatability complex barriers using HSCT with minimal nonmyeloablative conditioning.

Impact of retroperitoneoscopic donor nephrectomy on renal allograft in Indian and African recipients

AIM

To evaluate the impact of laparoscopic donor nephrectomy on renal allografts in Indian and African recipients.

MATERIAL AND METHODS

Between September 2004 and August 2006, 125 retroperitoneoscopic donor nephrectomies were performed. Ninety-four donors were Indian (group A) and 32, African (group B). Three ports were used for left-sided and four for right-sided surgery, respectively. Hem-o-lok clips were used to control arteries and veins on left side and arteries on right side while an Endo-TA stapler was used on the right side to obtain an inferior vena caval cuff.

RESULTS

The mean operative times in groups A and B were 130 and 134 minutes; mean blood loss, 100.4 mL and 85.3 mL; and mean warm ischemia time, 242.1 seconds and 234.5 seconds, respectively. Recipient mean serum creatinine value on day 7 was 1.9 and 1.6 mg%, and on day 28, 1.44 mg% and 1.4 mg%, respectively.

CONCLUSION

Early adequate allograft function following retroperitoneoscopic donor nephrectomy was comparable in African and Indian patients, suggesting that no racial advantage was observed in this procedure.

Cadaveric Renal Transplantation: Our Experience at the Institute of Kidney Diseases & Research Centre, Institute of Transplantation Sciences, Ahmedabad

In a developing country such as India, cadaveric renal transplantation accounts for only less than 1% of total renal transplantations. The reasons for such a low rate of cadaveric transplantation are many, ranging from lack of awareness to socioeconomic reasons. Our institute conducted a statewide public awareness program and initiated an intercity organ harvesting program. This doubled the cadaveric renal transplantations in the last 2 years. We performed 38 cadaveric transplantations among 190 renal transplantations in the last year (August 2005 to July 2006). We retrieved kidneys from 21 donors, of whom 9 were outside our city. From 21 donors we transplanted 38 recipients; out of whom 3 received dual kidneys and one kidney was discarded. The Mean age of the donors was 41.4 +/- 18.2 years with a mean cold ischemia time of 6.9 +/- 3.8 hours. Sixty-eight percent had delayed graft function. At the last follow-up, which was 190 +/- 98 days, patient survival rate was 90%: 4 patients died, including 2 due to bacterial sepsis and 2 due to cytomegalovirus (CMV) disease. The Graft survival rate was 85%, and the death-censored graft survival rate was 90%. Mean serum creatinine value at the last follow-up was 1.2 +/- 0.3 mg%. There were 5 episodes of acute rejection in 31 patients during first 3 months (16% acute rejection rate). The increase in cadaveric transplantations was associated with satisfactory patient and graft survival despite the high incidence of delayed graft function.

Hematopoietic Stem Cell Transplantation in Autoimmune Diseases: The Ahmedabad Experience

INTRODUCTION

Autoimmune disease represents a (AD) breakdown of natural tolerance against autoreactive antigens leading to a high mortality and morbidity. The reaction is usually polyclonal; T- and B-cell components of the hematopoietic system are responsible for disease progression. Allogeneic/autologous hematopoietic stem cell transplantation (HSCT) are the current modalities for treating drug-resistant AD.

PATIENTS AND METHODS

We present a single-center retrospective evaluation of allogeneic HSCT with nonmyeloablative, low-intensity conditioning in nine patients (five males, four females) with pemphigus vulgaris (PV) and 27 patients with systemic lupus erythematosus (SLE; 3 males, 24 females). The mean follow-up period was 4.24 years for PV and 4.9 years for SLE. Cytokine-mobilized HSC from unmatched related donors, with mean dose of 21.3 x 10(8) nucleated cells/kg body weight (BW; mean CD34(+) count, 6 x 10(6)/kg BW) was administered in to the thymus as well as the portal and peripheral circulations of recipients. Cyclosporine (4 +/- 1 mg/kg BW per day) and prednisolone (10 mg/kg BW per day) were administered for 6 months to protect mixed chimerism. A subset of patients with cross-gender donors were analyzed for peripheral blood chimerism at 1 month post-HSCT and every 3 months thereafter.

RESULTS

Sustained clinical remission with peripheral lymphohematopoietic chimerism of 0.7 +/- 0.3% was observed in PV, whereas SLE relapsed after mean of 7.35 months of disease-free interval associated with fall in chimerism from 5 +/- 3% to < or =0.08 +/- 0.03%.

CONCLUSION

HSCT was effective to achieve early clinical remission of PV; and in SLE relapsed after a 7.35-month disease-free interval accompanied by a fall in mixed lymphohematopoietic chimerism.

Successful Generation of Donor Specific Hematopoietic Stem Cell Lines From Co-Cultured Bone Marrow With Human Embryonic Stem Cell Line: A New Methodology

We report the generation of 30 healthy human embryonic stem cell (h-ESC) lines from 33 voluntary oocyte donors using a donor somatic cell nuclear transfer (SCNT) technique on 190 oocytes. Our aim was to coculture them with their own bone marrow (BM) to generate hematopoietic progenitor cells for therapeutic purposes. Pluripotency and undifferentiated stage were confirmed using molecular cell surface markers. Normal karyotype of these cell lines was confirmed. Here we demonstrate that SCNT-h-ESCs differentiate to hematopoietic precursors when cocultured with unmodified, nonirradiated donor BM. We did not use any xenogeneic material for this hematopoietic differentiation. Hematopoietic precursors derived from them expressed cell surface antigens CD45/34. When further cultured with hematopoietic growth factors these hematopoietic precursors formed characteristic myeloid, erythroid, and megakaryocyte lineages. Phenotypic CD34+ cells derived from NT-h-ESCs were functionally similar to their counterparts in primary hematopoietic tissues like BM, umbilical cord, and blood. More terminally differentiated hematopoietic cells derived from h-ESCs under these culture conditions also expressed normal surface antigens like glycophorin A on erythroid cells, CD15 on myeloid cells, and CD41 on megakaryocytes. We report generation of hematopoietic progenitor cells from h-ESC lines by a SCNT technique, with differentiation into further lineages with structural and functional similarities to their adult counterparts in vivo. This novel alternative source of CD34+ stem cells from h-ESC lines generated without any xenogeneic material might be used to create transplantation tolerance, to implement regenerative medicine, and to treat autoimmune disorders.

Embryonic stem cell derived and adult hematopoietic stem cell transplantation for tolerance induction in a renal allograft recipient:--a case report

We generated an human embryonic stem cell (hESC) line to augment chimerism-associated tolerance. A 40-year-old African with chronic glomerulonephritis-chronic renal failure with 100% G6PD enzyme deficiency presented for renal transplantation with a 27-year-old, 6/6 HLA-matched sister as a willing donor.

METHOD

We generated an hESC line from the donor's oocytes using long ovarian stimulation protocol simultaneously with tolerance induction protocol. A nuclear transfer (NT)-hESC line was derived by transferring a donor cumulus cell into an enucleated oocyte, subjected to electrical fusion, and cultured for 5 days. ESCs hatched from the blastocyst on day 6 were cocultured with her unmodified bone marrow for 2 days and suspended in Ringer's lactate. Five milliliters of suspension were collected for cell counting, viability, pluripotency, flow cytometry, and karyotyping. The remaining suspension was infused into the periphery of the recipient. Transplantation was performed 1 week later following a negative lymphocytotoxicity cross-match test using no immunosuppression. Peripheral blood chimerism (PBC) was studied using fluorescent in situ hybridization technique. Allograft biopsy was performed on day 7.

RESULTS

NT-hESC CD34+ count was 7.6%, viability 100%, karyotyping normal, pluripotency markers: SSEA-1, SSEA-4, OCT-3/4, TRA-1/60:positive; 12% PBC was noted at 1 week after transplantation. Serum creatinine was 1.2 mg%, graft biopsy was unremarkable, and G6PD enzyme deficiency was corrected to 0% at 100 days posttransplant. Liver function tests and hematology profile were unremarkable for graft-versus-host disease.

CONCLUSION

This is the first report of tolerance induction using NT-hESC-induced hematopoietic chimerism with synergistic use of adult bone marrow. It was safe and effective.

Synthesis of bis-armed amino acid derivatives via the alkylation of ethyl isocyanoacetate and the Suzuki–Miyaura cross-coupling reaction

Two synthetic routes to bis-armed-alpha-amino acid derivatives are described. The first route involves alkylation of dibromo derivatives with ethyl isocyanoacetate under phase-transfer catalysis (PTC) conditions. The second route uses a palladium-mediated Suzuki-Miyaura cross-coupling reaction between a DL-4-boronophenylalanine derivative and aromatic diiodo (or dibromo) compounds.

Allogeneic hematopoietic stem-cell transplantation, mixed chimerism, and tolerance in living related donor renal allograft recipients

OBJECTIVE

We designed a prospective, randomized, and controlled clinical trial to evaluate the efficacy and safety of achieving a mixed chimerism-associated tolerance protocol for recipients of living related donor (LRD) renal allografts.

PATIENTS AND METHODS

Sixty-six consecutive patients were divided into two equal groups of 33 patients with end-stage renal disease. They were enrolled for transplantation after negative lymphocytotoxicity cross-matching (LCM). Both groups (treated [Tn] and control [Cn]) showed similar clinical and laboratory parameters and donor HLA match profiles. The Tn group underwent thymic transplantation of donor renal tissue, two donor-specific transfusions, low-intensity conditioning, and high-dose hematopoietic stem-cell transplantation (HSCT) before renal transplantation. The conditioning regimen included low-dose, target-specific irradiation (to abdominal and inguinal lymph nodes, bone marrow [BM] from thoracolumbar vertebrae and part of the pelvis on alternate days, 100 rad x 4), anti-T-cell antibodies (1.5 mg/kg body weight [BW]), cyclophosphamide (10 mg/kg BW x 2 consecutive days), and cyclosporine (CyA; >3 mg/kg BW/d). Unfractionated HSCT procured from the donor marrow was administered into the BM, portal and peripheral circulations, within 24 hours of achieving CD 4+/CD 8+ T-cell count less than 10% of normal. This infusion was supplemented with a dose of peripherally mobilized stem cells (mean total dose of 20 x 10(8) cells/kg recipient BW) administered peripherally. Renal transplantation was performed after negative LCM. Donor-specific cytotoxic antibodies were eliminated with intravenous immunoglobulins and plasmapheresis before renal transplantation. Mixed chimerism was evaluated before and after transplantation at monthly intervals in patients with donors of opposite gender by the FISH technique. Both groups received CyA and prednisolone for immunosuppression; Cn subjects also received mycophenolate mofetil/azathioprine. Rejection was treated with standard treatment. Immunosuppression was withdrawn 6 months after renal transplantation for patients with consistently positive chimerism. Clinical tolerance was defined as stable allograft function for more than 100 days without immunosuppression and confirmed by allograft biopsy.

RESULTS

Over a mean follow-up of 210 days, all Tn patients showed stable allograft function with mean serum creatinines (SCr) of 1.20 mg/dL, no rejection/CMV infections/graft or patient loss. A low-level donor-specific cytotoxic antibody was observed in all Tn patients. The CyA toxicity was noted in 10 (30.3%) patients. Persistent mixed hematopoietic chimerism was seen in all 21 patients irrespective of donor-recipient HLA matching (mean 0.5% before and 1 +/- 0.3% after transplantation). All four patients on drug withdrawal have shown donor-specific tolerance at a mean follow-up of 129.8 days. Other Tn patients are in the process of being weaned off immunosuppression. Mean SCr of controls was 1.45 mg/dL over a mean follow-up of 216 days. Acute rejection was observed in 17 (51.5%) patients; no CMV infection/patient loss was noted and one (3.03%) graft was lost in controls. No patient was lost in controls. No graft-versus-host disease was observed in Tn patients.

CONCLUSION

We have achieved mixed hematopoietic chimerism-associated tolerance with high-dose HSCT, intrathymic donor renal tissue transplantation, and minimal conditioning without any adverse effects.

Central pontine myelinolysis: sequele of hyponatremia during transcervical resection of endometrium

Transcervical resection of endometrium is an alternative to hysterectomy for women with menorrhagia. The procedure involves the use of cutting loop diathermy to resect the endometrium while the uterine cavity is irrigated with 1.5% glycine which can absorb consequent fluid and electrolyte shifts. Severe hyponatremia leading to central pontine myelinolysis is an extremely rare complication of this procedure. We report a case of a young female undergoing transcervical resection of endometrium for menorrhagia, who developed central pontine myelinolysis but made a complete recovery after three months.

Oxidative stress status: possible guideline for clinical management of critically ill patients

BACKGROUND

Critical care medicine has developed in the last few years into a separate scientific discipline and studies related to the outcome after intensive care usually suggest a long hospital stay that becomes cost prohibitive. The majority of problems (death) amongst critically ill patients requiring critical care involve sepsis, inflammation, tissue damage-oxidative stress, oxygen tension PO2, lipid peroxidation. The present investigation involves monitoring of serum levels of MDA, SOD as a possible guideline for severity of clinical situations in critically ill patients.

METHODS

Fifty critically ill heterogeneous patients requiring intensive care in the ICU of IKDRC were selected as subjects with ages varying from 17 to 75 years. Serum levels of MDA (ng/ml), SOD (U/ml) were determined right from admission to discharge due to improvement / DAMA / death. MDA and SOD were estimated according to the methods of Buege and Aust et al. (1978), Nandi and Chatterji (1988).

RESULTS

Critically ill patients irrespective of the disease process indicated significantly very high serum levels of MDA and low levels of SOD at the time of admission (13.28+/-4.26 ng/ml, 3.80+/-2.60 U/ml, respectively) according to the severity of the prevalent clinical situation. The pattern of serum levels of MDA and SOD according to subsequent clinical performance did indicate a decreasing trend of MDA (oxidant) and fluctuating trend of SOD (antioxidant enzyme except in those who inevitably succumbed to death in spite of adequate clinical management.

CONCLUSIONS

The results of the present study have amply revealed the utility and relevance of monitoring oxidative stress in critically ill patients as biochemical markers, cost-effectiveness and role in decision making (withdrawal/continuation of different support modalities) as deemed fit.

A man with inflamed ears

A 23-year-old man presented with fever, dyspnea, nonproductive cough, left eye redness, reduced vision, and bilateral ear pain and tenderness. The symptoms had begun two days earlier, eight days after he was discharged from the hospital with a presumptive diagnosis of Still's disease. He was first seen a month before the current admission for complaints of fever (as high as 39.4 degrees C), nonproductive cough, and asymmetric arthritis. The workup at that time included arthrocentesis of the right knee. Analysis of the joint fluid showed 7,500 white blood cells/mm3 and no crystals. A gram stain and culture of the fluid were negative. HIV and hepatitis tests, bone marrow biopsy and culture, transesophageal echocardiography, abdominal computed tomography, radionuclide bone scanning, and rheumatologic tests failed to identify the problem. The development of an evanescent macular pink rash on day 15 suggested the possibility of Still's disease. Treatment with prednisone (40 mg po qd) was initiated, and the patient was discharged on day 19.

Effect of renal transplantation (surgical stress) on serum levels of oxidants and reducing system

BACKGROUND

This study attempts to understand the correlation (if any) between surgical stress of renal transplantation and serum levels of pro-oxidant/antioxidants.

METHODS

Twenty-four ESRD patients having undergone transplant surgery followed from day-1 to day-10 postsurgery were investigated for serum levels of MDA, SOD, Vit. C and E. The drug regimen received was immunosuppressant, H2 blockers and antihypertensives as per the situation.

RESULTS

The typical observations indicated elevated serum levels of MDA from preoperative stage reaching peak value 24 hrs after surgery followed by a steady fall and achieving minima on the 10th day. As regards antioxidants enzyme SOD, Vit. C, Vit. E were low from pretransplant day reaching minima 24 hours postoperatively and returning to normal from 7th day.

CONCLUSIONS

The present investigation has amply shown a typical imbalance between pro-oxidant/antioxidants from pretransplant day up to 24 hrs and there after returning to normal level from 7th day suggestive to desired recovery and surgical stress not a limiting factor in way of health progress renal transplant. Dietary intake of Vit. C and E in mega doses can be a good therapeutic measure.

Sensitive liquid chromatographic-mass spectrometric assay for the simultaneous quantitation of nefazodone and its metabolites hydroxynefazodone m-chlorophenylpiperazine and triazole-dione in human plasma using single-ion monitoring

A sensitive, selective, accurate, precise and reproducible high-performance liquid chromatographic-mass spectrometric (LC-MS) assay was developed and validated for the simultaneous determination of nefazodone (NEF), hydroxynefazodone (OH-NEF), m-chlorophenylpiperazine (mCPP), and triazole-dione (Dione) in human plasma using trazodone (TRZ) as the internal standard (I.S.). The method involved simultaneous protein precipitation with acetonitrile and liquid-liquid extraction with methylene chloride, after which the organic layer was evaporated to dryness. The residue was reconstituted in 25% acetonitrile in 10 mM ammonium formate (pH 4.0), and an aliquot was injected onto a BDS Hypersil C18 column at a flow-rate of 0.3 ml/min. The mobile phase comprising of 10 mM ammonium formate (pH 4) and acetonitrile in 55:45 (v/v) was used in an isocratic condition. The mass spectrometer was programmed to admit the protonated molecules at m/z 197.0 (mCPP), 372.0 (I.S.) 470.4 (NEF), 458.1 (Dione), and 486.2 (OH-NEF). Standard curves were linear (r2 > or = 0.995) over the concentration range of 4-1000 ng/ml for Dione and 2-500 ng/ml for other analytes. The lowest standard concentrations were the lower limit of quantitation for each analyte. The mean predicted quality control (QC) concentrations for all analytes deviated less than -12.1% from the corresponding nominal values; the intra-assay and inter-assay precision of the assay for all analytes were within 7.0% relative standard deviation. All analytes including I.S. were stable in the injection solvent at room temperature for at least 24 h. The extraction recovery of the various analytes ranged from 67.3 to 86.5%. The validated assay was applied to a pharmacokinetic study of nefazodone.

Pharmacokinetic assessment of the sites of first-pass metabolism of BMS-181101, an antidepressant agent, in rats

The relative contribution of the gut and the liver to the first-pass metabolism of BMS-181101 (3-[3-[4-(5-methoxy-4-pyrimidinyl)-1-piperazinyl]propyl]-5-fluoro-1H-ind ole dihydrochloride), a potential antidepressant agent, has been evaluated in rats. Nine male Sprague-Dawley rats were divided into three groups of three and each rat received a single 20 mg kg(-1) dose of [14C]BMS-181101 via a 30 min constant-rate intravenous infusion, a 30-min constant-rate intraportal infusion or oral gavage. Serial blood samples were collected for 8 h after dosing and plasma was analysed for unchanged BMS-181101 and total radioactivity. Extraction ratios for BMS-181101 by the gut and liver were calculated on the basis of ratios of the area under the plasma BMS-181101 concentration-time curve. The gut had a high intrinsic capacity for metabolizing BMS-181101-extraction ratios were 93% and 10% for the gut and liver, respectively. After oral administration BMS-181101 is sequentially exposed to the gut then the liver. As a result, the contribution of the gut to the overall first-pass effect (ca. 93%) was significantly greater than that of the liver (ca. 0.7%). The estimated total first-pass effect of 94% for BMS-181101 in rats is in excellent agreement with the observed absolute oral bioavailability of 6%. These results clearly illustrate the importance of metabolic activity in the gut for orally administered BMS-181101.

High-performance liquid chromatographic-electrochemical assay for the quantitation of BMS-181885 in monkey plasma

A high-performance liquid chromatographic-electrochemical assay was developed and validated for the quantitation of BMS-181885 (I), an anti-migraine agent, in monkey plasma. The assay involved a solid-phase extraction of I and BMY-46317 (internal standard; I.S.) on a 1-ml cyano cartridge using the automatic solid-phase extraction cartridge (ASPEC) system. Immediately following the conditioning of the cyano column (3 ml of methanol and 2 ml of 1% glacial acetic acid), plasma (0.25 ml) was loaded on to the column. The column was then washed with a 3 ml of 0.1 M ammonium acetate buffer (pH 6). The final elution of the analytes was performed using 2 ml of methanol. The eluate was then evaporated to dryness (gentle stream of nitrogen at 40 degrees C) and the residue was dissolved in the mobile phase and injected on to a YMC basic column (15 cm x 4.6 mm; 5 microm particle size) at a flow-rate of 1 ml/min. A mixture of 0.1 M ammonium acetate at pH 6-acetonitrile-methanol (70:20:10, v/v) was used as the mobile phase. Standard curves, with a lower limit of quantitation of 2 ng/ml of I were linear (r2> or =0.998; range: 2-50 ng/ml). Based on the analysis of the quality control (QC) samples, the assay was both accurate and precise. The stability of I was established following freeze-thaw cycles and storage at or below -20 degrees C. The extraction recovery of I from monkey plasma was about 82%. The validated assay method was applied to determine the pharmacokinetics of I in monkeys following a single 1 mg/kg intravenous dose.

High-performance liquid chromatographic analysis of 2'-fluoro-2',3'-dideoxyadenosine and 2'-fluoro-2',3'-dideoxyinosine in dog plasma and urine

A high-performance liquid chromatographic assay was developed and validated for a simulataneous determination of 2'-fluoro-2' 3'-dideoxyadenosine (FddA) and its metabolite, 2'-fluoro-2',3'-dideoxyinosine (Fddl) in dog plasma and urine. In vitro, FddA and Fddl exhibit activity against human immunodeficiency virus (HIV). A solid phase extraction was applied to extract FddA, Fddl, and the internal standard (IS; 3',5'-anhydrothymidine) from the biomatrices. The processed samples were chromatographed using a C8 column coupled with a mobile phase consisting of monobasic phosphate, dibasic phosphate, ethylene glycol monomethyl ether, and water. Detection was performed at 257 nm. The nominal retention times were 9, 14, and 26 min for Fddl, IS, and FddA, respectively. The lower limits of quantitation were 0.1 and 2.0 micrograms/mL in plasma and urine, respectively, for both analytes. The accuracy of the assay deviated < or = 10% from the nominal concentrations, and the precision was < or = 14% coefficient of variation. In either matrix, both analytes were stable for at least three freeze-thaw cycles and in the injection media for at least 54 h. The extraction recoveries of the analytes were greater than 80%. The application of this assay was demonstrated in a preliminary pharmacokinetic study of FddA and Fddl in dogs. Two male dogs per dose level received a 100, 250, or 500 mg/kg oral dose of FddA once daily for 14 days. The early appearance of Fddl in plasma (0.25 h; the first sampling time) and greater plasma levels of Fddl than FddA (> 50-fold of Cmax), suggested that the conversion of FddA to Fddl was rapid and extensive. Renal excretion appeared to be the major route of elimination of Fddl.

High-performance liquid chromatographic-ultraviolet assay for the simultaneous quantitation of BMS-181101 and its putative hydroxy metabolites in rat and monkey plasma

A specific, accurate, precise, and reproducible High-performance liquid chromatographic-Ultraviolet (HPLC-UV) method was developed for the simultaneous quantitation of BMS-181101 (I), a new antidepressant, and its putative metabolites, 6'-hydroxy (II) and 7'-hydroxy (III) of BMS-181101 in rat and monkey plasma. The assay procedure involved solid-phase extraction of the three analytes and the internal standard (IS; BMY-42568) on 1 mL Bond Elut CN cartridge using an automated solid phase extraction controller (ASPEC) system. The final elution of the analytes was performed using 0.25% triethylamine in methanol. The eluate mixture was evaporated to dryness, the residue was reconstituted in the mobile phase and injected onto a Zorbax Phenyl column (4.6 x 250 mm; 5 microns) at a flow-rate of 1.2 mL/min. The mobile phase consisted of 20% acetonitrile, 10% methanol, 69% water and 1% 1.0 M ammonium phosphate and 1.0 M tetramethylammonium hydroxide mixture adjusted to pH 3 by phosphoric acid. An ultraviolet absorbance detector set at 287 nm was used to detect the analytes. The nominal retention times were 5, 8, 15, and 18 min for II, III, I, and IS, respectively. The standard curves for the three analytes were linear in the concentration range of 50-1000 ng/mL. The lower limit of quantitation was 50 ng/mL for each analyte. The analyses of quality control (QC) samples indicated that the nominal values could be predicted with an accuracy of (+/-) 10.5% for all three analytes in rat and monkey plasma. The precision values of the QC samples for all three analytes were within 12.7% RSD for rat and monkey plasma. All three analytes and the IS were stable in the autosampler for at least 38 h; freeze/thaw stability of the 3 analytes was established for three cycles. Stability of BMS-181101 was established for one month at -20 degrees C. The application of the assay to a pharmacokinetic study in monkey is described.

Stereoselective analysis of nadolol in human plasma

A stereoselective method, involving a single liquid-liquid extraction step, was developed and validated for the analysis of nadolol in human plasma. The assay involved extraction of nadolol and desmethyl-nadolol (as internal standard (IS)) from alkalinized plasma into dichloromethane. The organic solvent was separated and evaporated under nitrogen at 40 degrees C. A chiral derivatization scheme with (R)-(-)-napthylethylisocyanate (50 microL of 0.1% solution in dichloromethane for 60 min) was employed to convert the enantiomers of nadolol into the corresponding diastereomeric derivatives. The residue was reconstituted in the mobile phase and injected onto a C-18 column. The mobile phase was a mixture of methanol:tetrahydrofuran:water (52:7:41 by vol) containing about 0.001% v/v of both phosphoric acid and tetramethylethylenediamine. Fluorimetric detection was performed at excitation 230 and emission 330 nm. The assay was specific for the enantiomers of nadolol and the lower limit of quantitation was 2 ng/mL for each of the enantiomers. Analysis of quality control samples resulted in precision estimates of 7% RSD for inter-assay and 10.1% RSD for intra-assay and the predicted concentrations deviated less than 9.4% of the nominal values for the four enantiomers. The extraction recoveries of the individual enantiomer was about 70%. Stability of nadolol enantiomers were established for four freeze/thaw cycle periods and in the autosampler at 5 degrees C for at least 116 h.

High-performance liquid chromatographic assay for the quantitation of nadolol in human plasma using fluorescence detection

A rapid and sensitive HPLC-fluorescence assay was developed and validated for the determination of nadolol, a beta-blocker, in human plasma. Nadolol and the internal standard (desmethyl nadolol) were extracted from alkalinized plasma into methyl-tert.-butyl ether. The organic solvent was evaporated under nitrogen at 40 degrees C. The residue was reconstituted in the mobile phase and injected on to a C18 silica column (25 cm x 4.6 mm i.d.) at a flow rate of 1.4 mL/min. The mobile phase was 0.05 M monobasic ammonium phosphate (pH 4.2) and acetonitrile (84: 16, v/v). Fluorimetric detection was performed at excitation 230 nm and emission 330 nm. The nominal retention times were 3.3 and 4.3 min for the internal standard and nadolol, respectively. The lower limit of quantitation was 5 ng/mL and linearity (R2 > or = 0.994) of the standard curve was demonstrated between 5 and 500 ng/mL. The analysis of quality control (QC) samples at 60, 200 and 400 ng/mL resulted in precision estimates < or = 7.0% relative standard deviation (RSD) for the inter-assay and < or = 6.3% RSD for intra-assay. The predicted concentrations of the QC samples deviated < 10% from the nominal values. The extraction recovery of nadolol from human plasma was 64%. Nadolol was stable in human plasma at -20 degrees C for at least 5 months and for at least three freeze-thaw cycles. Nadolol and the internal standard were stable in the autosampler at 5 degrees C for at least 40 h. Overall, the assay was accurate, precise, sensitive, specific, and reproducible for the analysis of nadolol in plasma.(ABSTRACT TRUNCATED AT 250 WORDS)

Oral absolute bioavailability and intravenous dose-proportionality of cefprozil in humans

The absolute bioavailability (F) and dose proportionality of cefprozil were investigated in a parallel design study with an embedded two-way crossover leg. Twenty-four healthy male subjects divided into 3 dosing groups received a single 250-, 500-, or 1000-mg dose of cefprozil by a 30-minute intravenous infusion. Subjects assigned to the 500-mg dose group also received a 500-mg oral dose of cefprozil in crossover manner with a wash-out period of 7 days between each treatment. Cefprozil consists of cis and trans isomers in an approximate 90:10 ratio. Serial blood and urine samples were collected and analyzed for the concentrations of the cis and trans isomers of the cephalosporin using high-pressure liquid chromatographic assay with UV detection methods. After the 250-, 500-, and 1000-mg intravenous administration of cefprozil, the peak concentrations were 13.2, 26.0, and 48.5 micrograms/mL, and area under the plasma concentration versus time profiles were 17.2, 31.4, and 58.1 micrograms.hour/mL, respectively, for the cis isomer increasing in a dose proportional manner. Total body clearance, renal clearance, and volume of distribution at steady state, adjusted for body weight, were not significantly different among all groups. Mean residence time, elimination half-life, and urinary recovery were invariant with the dose. Based on the plasma and urine data, the estimates of F were 89% and 94% for the cis isomer, respectively. The plasma concentrations of the trans isomer were about 1/10th of the cis isomer, and all parameters were similar to those observed for the cis isomer. In summary, cefprozil exhibits linear pharmacokinetics and is essentially completely absorbed after oral administration.

Excretion of cefprozil into human breast milk

The excretion of cefprozil into breast milk in nine healthy, lactating female subjects was investigated. Each subject received a single 1,000-mg oral dose of cefprozil consisting of cis and trans isomers in an approximately 90:10 ratio. Serial blood, urine, and breast milk samples were collected and analyzed for the concentrations of the cis and trans isomers by a specific high-pressure liquid chromatography-UV assay. The mean pharmacokinetic parameters for both isomers were essentially the same. The mean peak concentrations in plasma for the cis isomer were 14.8 micrograms/ml, and the area under the concentration curve was 54.8 micrograms.h/ml. The mean values of elimination half-life, renal clearance, and urinary excretion for the cis isomer were 1.69 h, 164 ml/min, and 60%, respectively. The mean concentrations in milk of the cis isomer over a 24-h period ranged from 0.25 to 3.36 micrograms/ml, with the maximum concentration appearing at 6 h after dosing. The average maximum concentration in milk of the trans isomer was less than 0.26 micrograms/ml. The concentrations of the trans isomer in plasma and in breast milk were about 1/10 of those for the cis isomer. Less than 0.3% of the dose was excreted in breast milk for both isomers of cefprozil. Even if one assumes that the concentration of cefprozil in milk remains constant at 3.36 micrograms/ml (the highest concentration of cefprozil observed in breast milk), an infant ingesting an average of 800 ml of milk per day will be exposed to a maximum amount of about 3 mg of cefprozil per day. This value represents about 0.3% of the maternal dose. Low excretion of cefprozil in breast milk and the excellent safety profile of cefprozil suggest that this cephalosporin may be administered to nursing mothers when indicated.

Simultaneous high-performance liquid chromatographic analysis of cefprozil diastereomers in a pharmacokinetic study

Cefprozil, a new oral cephalosporin, consists of a 90:10 cis:trans isomer mixture. Sensitive, specific and reproducible high performance liquid chromatographic methods have been developed for the simultaneous quantification of the two stereoisomers of cefprozil in plasma and urine samples from human and rats. Cephalexin acted as the internal standard. Plasma protein was precipitated with acetonitrile and trichloracetic acid with subsequent extraction of acetonitrile. After vortexing and centrifuging, the aqueous phase was injected onto a reverse phase C8 column. Urine samples were acidified with sodium acetate buffer (pH 3.8) and then directly injected onto a reverse phase C18 column. The detector was set at 280 nm. These methods were applied to determine protein binding of both isomers in human and rat sera, and to perform a pharmacokinetic study in human. Results showed that both isomers bound moderately to serum proteins with no interference by the other isomer. The pharmacokinetic study in human indicated that cefprozil was well absorbed and the cis and trans isomers have similar pharmacokinetics.

Occupational noise exposure and hearing levels

A study was made at the Bhabha Atomic Research Center to measure the hearing levels of persons working in a noisy environment. Two different workplaces, central air-conditioning plant and glass flowing shops, where a number of persons were exposed to noise levels exceeding 85 dB(A) were chosen. The occupational exposure to noise was determined using a sound level meter, an octave band filter and a personal noise dose meter. The hearing levels of persons exposed to these high levels of noise and a control group not exposed to occupational noise were measured by means of a pure-tone audiometer in a specially-build booth. These persons, aged between 20 to 60 years, were divided into four age groups for the study. The low ambient noise levels in the booth were measured using correlation technique since such low signals cannot be detected by an ordinary sound level meter. The audiometric findings and the results of the noise level survey are discussed in this paper.

Haemorrhagic cholecystitis

Two cases of haemobilia due to haemorrhagic cholecystitis are presented; only 28 other cases have been described. As there are so many more dramatic causes and treatment for haemobilia it is important for the surgeon to recognize that a common operation will suffice for this rare condition. In both cases bacteria were grown from the bile and it is to be hoped that bile culture will be recorded more commonly in future in cases of this interesting condition.