AB0250 TOFACITINIB SUPPRESSES SEVERAL JAK-STAT PATHWAYS IN RHEUMATOID ARTHRITIS AND BASELINE SIGNALING PROFILE ASSOCIATES WITH TREATMENT RESPONSE

Background:

Cytokines are important mediators of inflammation and tissue destruction in rheumatoid arthritis (RA) 1. Several cytokines involved in RA pathogenesis act through Janus kinase (JAK)-signal transducer and activator of transcription (STAT) pathway 2. The effects of JAK-inhibitor tofacitinib on cytokine signaling in vitro are well established, while in vivo evidence in patients remains scarce.

Objectives:

To investigate in vivo in rheumatoid arthritis patients i) which JAK-STAT pathways are inhibited by tofacitinib and ii) if baseline signaling profile is associated with the treatment response.

Methods:

Sixteen patients with active RA, despite treatment with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), received tofacitinib 5 mg twice daily for three months. Levels of basal and cytokine-induced phosphorylated STATs and total STAT1 and STAT3 in peripheral blood monocytes, T cells and B cells were measured by flow cytometry. mRNA expression of JAKs, STATs and suppressors of cytokine signaling (SOCS) were measured from peripheral blood mononuclear cells (PBMCs) by quantitative PCR. Association of baseline signaling profile with treatment response (the change from baseline in disease activity score (DAS28)) was studied by calculating correlation coefficients.

Results:

Treatment with tofacitinib and csDMARDs decreased median DAS28 from 4.4 to 2.6 (p < 0.001). Tofacitinib significantly decreased cytokine-induced phosphorylation of all JAK-STAT pathways studied. Basal STAT1, STAT3, STAT4 and STAT5 phosphorylation in monocytes and/or T cells was downregulated by tofacitinib. No changes were observed in STAT1 and STAT3 protein levels, while gene expression of STAT3, STAT4, STAT5A, JAK1, JAK3 and all studied SOCSs was significantly suppressed. Baseline STAT phosphorylation levels in T cells and monocytes and SOCS3 expression in PBMCs correlated with treatment response.

Conclusion:

Tofacitinib suppresses multiple JAK-STAT pathways in RA patients in vivo. Baseline JAK-STAT signaling profile may be applicable as a prognostic marker for treatment response to tofacitinib.

References:

[1]McInnes, I. B., Buckley, C. D. & Isaacs, J. D. Cytokines in rheumatoid arthritis-shaping the immunological landscape. Nature Reviews Rheumatology vol. 12 63–68 (2016).

[2]Schwartz, D. M., Bonelli, M., Gadina, M. & O’Shea, J. J. Type I/II cytokines, JAKs, and new strategies for treating autoimmune diseases. Nat. Rev. Rheumatol.12, 25–36 (2016).

Acknowledgements:

This study was supported by Pfizer Inc.

Disclosure of Interests:

Maaria Palmroth Consultant of: Pfizer and from 1/21 a part-time employee of MedEngine and consultant for Pfizer, Krista Kuuliala Grant/research support from: Pfizer, Ritva Peltomaa Speakers bureau: Boehringer Ingelmheim, Pfizer, Sanofi, Paid instructor for: Boehringer Ingelheim, Eli Lilly and Company, Janssen, Abbvie, UCB Pharma, Anniina Virtanen: None declared, Antti Kuuliala: None declared, Antti Kurttila: None declared, Anna Kinnunen: None declared, Marjatta Leirisalo-Repo: None declared, Olli Silvennoinen Speakers bureau: Pfizer, AbbVie, Pia Isomäki Speakers bureau: Abbvie, Eli Lilly and Company, Pfizer, Roche, Paid instructor for: Abbvie, Eli Lilly and Company, Pfizer, Roche, Grant/research support from: Pfizer

Co-development of the CMAP Book: a tool to enhance children's participation in pediatric rehabilitation

PURPOSE

The purpose of the co-development project was to create a tool that enhances children's active participation and agency in rehabilitation and in everyday life.

MATERIALS AND METHODS

Action research was the methodological approach. Participants in the different phases of the process (2015-2017) were children with disabilities, parents and rehabilitation professionals. The co-development process included: (1) designing the tool's first version, (2) piloting the tool, (3) evaluating the tool by collecting feedback and reflection, (4) generating the tool's final version.

RESULTS

Through the co-development process, an accommodating and digital tool called the CMAP Book-a description of the child's meaningful activities and participation-was developed. The CMAP Book is used with an electronic app enabling the identification and description of what is meaningful in daily life from the child's perspective with videos, photos, pictures, recording and writing. The tool enables the child, family and professionals to prepare and build collaboration in rehabilitation with flexibility according to child and family needs.

CONCLUSIONS

Use of the CMAP Book promotes the active involvement of the child and parents in designing the rehabilitation process in daily life in partnership with professionals. The stakeholder involvement in the co-development facilitated meaningful results and a concrete tool for rehabilitation.IMPLICATIONS FOR REHABILITATIONThe CMAP book is a new tool that enhances the child's active participation and agency in the rehabilitation process based on meaningful activities in everyday life expressed by the child.Identifying and utilising meaningful issues in the child's daily life through collaboration increases the child's commitment and motivation, and thus may enhance the benefits and effects of rehabilitation. Through co-development, the child and his/her family can be active and equal partners not only in development projects but also in the rehabilitation process.In the future, child-specific practices and policies should be developed to promote participatory co-research between families and clinicians linked to the daily lives of families with children.

Central nervous system drug development: an integrative biomarker approach toward individualized medicine

Drug development for CNS disorders faces the same formidable hurdles as other therapeutic areas: escalating development costs; novel drug targets with unproven therapeutic potential; and health care systems and regulatory agencies demanding more compelling demonstrations of the value of new drug products. Extensive clinical testing remains the core of registration of new compounds; however, traditional clinical trial methods are falling short in overcoming these development hurdles. The most common CNS disorders targeted for drug treatment are chronic, slowly vitiating processes manifested by highly subjective and context dependent signs and symptoms. With the exception of a few rare familial degenerative disorders, they have ill-defined or undefined pathophysiology. Samples selected for treatment trials using clinical criteria are inevitably heterogeneous, and dependence on traditional endpoints results in early proof-of-concept trials being long and large, with very poor signal to noise. It is no wonder that pharmaceutical and biotechnology companies are looking to biomarkers as an integral part of decision-making process supported by new technologies such as genetics, genomics, proteomics, and imaging as a mean of rationalizing CNS drug development. The present review represent an effort to illustrate the integration of such technologies in drug development supporting the path of individualized medicine.

Teaching public access defibrillation to lay volunteers—a professional health care provider is not a more effective instructor than a trained lay person

BACKGROUND

Survival improves in witnessed out-of-hospital cardiac arrest if the victim receives bystander-initiated cardiopulmonary resuscitation and rapid defibrillation (BLS/AED). The European Resuscitation Council has a simple programme to teach these life-saving skills that require no previous experience of automated external defibrillators (AEDs). To be able to implement the use of AEDs widely, many instructors are needed, and therefore, lay persons may also be used as trainers. The purpose of this randomized study was to compare lay volunteers trained by a lay person with those trained by a health care professional using the Objective Structured Clinical Examination (OSCE).

METHODS

Eight instructors, including four lay persons and four health care professionals, were given a basic course and an instructor course in CPR-D by the same instructor. All newly trained instructors trained 38 lay volunteers (19 pairs) who had no previous training in the use of a defibrillator. The lay volunteers performed the OSCE 2-3 weeks after the course. The OSCE comprised two scenarios with a manikin: the first, a patient in cardiac arrest with ventricular fibrillation, and the second, an imminent cardiac arrest with asystole as the initial rhythm. The same OSCE was performed by a group of lay first aiders practicing every 2 weeks who served as the control group.

RESULTS

No statistical difference was present between the two groups of lay volunteers in the OSCE. All were able to use the AED and follow instructions. They identified patients with ventricular fibrillation and cardiac arrest, but had difficulties identifying cases with imminent cardiac arrest. The control group of trained first aiders performed significantly more effectively than the newly trained lay persons.

CONCLUSIONS

No significant benefit exists in the trainer being a health care professional, but thorough training and subsequent rehearsing of the skills learned are crucial.

Chlamydia trachomatis heat shock protein-60 induced interferon-gamma and interleukin-10 production in infertile women

Chlamydia trachomatis-associated tubal factor infertility (TFI) involves enhanced humoral and cell-mediated immune response to the chlamydial 60 kDa heat shock protein (CHSP60). We evaluated the role of CHSP60-induced immune response in TFI by studying lymphocyte proliferation and cytokine (interferon (IFN)-gamma, interleukin (IL)-12 and IL-10) secretion in response to C. trachomatis elementary body (EB) and CHSP60 antigens in 57 women with TFI and in 76 women with other causes of infertility. Positive proliferative response of PBMC to CHSP60 was more common in the TFI group (20/57; 36%) than in the other groups (17/76; 22%) although the frequency or the median responses did not differ significantly (1.6, range 0.2-22.1 versus 1.4; 0.2-24.4). C. trachomatis EB induced significantly higher IFN-gamma and lower IL-10 secretion in the TFI group compared to the other groups. The EB and CHSP60 induced IL-12 secretion was similar in all study groups and correlated with IFN-gamma secretion in the other but not in the TFI group. The lack of correlation between EB-induced IL-12 and IFN-gamma production and simultaneously found prominent IL-10 secretion in response to CHSP60 in the TFI group suggests that the CHSP60 may have a specific role in regulating the immune reactions during chlamydial infection and may consequently contribute to the immunopathogenesis of TFI.

Heat shock protein 60 specific T-cell response in chlamydial infections

Heat shock proteins (HSPs) of most pathogens, including Chlamydia, are major immune targets of both humoral- and cell-mediated immune mechanisms. During the last decade, many investigators have focused their research to elucidate the complex relationship of chlamydial HSPs, especially chlamydial HSP60, and the host immune response. A central issue is whether the pathologic mechanisms in chronic chlamydial diseases are associated with an enhanced immune response to chlamydial HSP60 which can mediate tissue destruction through cytotoxic reactions, or whether they are related to the Th2 type of response that eventually leads to partial or temporary suppression of an effective antichlamydial response. Our review highlights the available knowledge between immune responses to chlamydial HSP60 and chronic chlamydial infections in human.

Chlamydia trachomatis reactive T lymphocytes from upper genital tract tissue specimens

Chlamydia trachomatis infection is associated with pelvic inflammatory disease (PID) and tubal factor infertility (TFI). We investigated the role of C. trachomatis as a target antigen of endometrial and salpingeal tissue lymphocytes derived from PID and TFI patients. Antigen specificity of the tissue originated T lymphocyte lines (TLL) was tested against C. trachomatis elementary bodies and chlamydial heat shock protein 60 (CHSP60). C. trachomatis antigen stimulated proliferation in two out of eight endometrial TLL derived from PID patients and three out of four TLL derived from TFI patients. All (n = 4) TLL derived from the salpingeal specimens responded to CHSP60 compared with only one out of 12 TLL derived from the endometrial specimens. In-vivo expression of interferon-gamma (IFN-gamma) mRNA revealed that it was present in nine of 13 specimens obtained from PID patients. The dominant activity of type-1 T lymphocytes was confirmed by the in-vitro production of IFN-gamma (median 1007 pg/ml) from all (n = 5) C. trachomatis specific TLL while IL-5 secretion was lower (median 779 pg/ml). In conclusion, C. trachomatis reactive TLL were established from in-vivo activated lymphocytes from the upper genital tract tissue of PID and TFI patients. The reactivity of the salpingeal TLL to CHSP60 provided further evidence that immunoreactivity to CHSP60 is a predominant response in patients with tubal damage.

Safety evaluation of sous vide-processed products with respect to nonproteolytic Clostridium botulinum by use of challenge studies and predictive microbiological models

Sixteen different types of sous vide-processed products were evaluated for safety with respect to nonproteolytic group II Clostridium botulinum by using challenge tests with low (2. 0-log-CFU/kg) and high (5.3-log-CFU/kg) inocula and two currently available predictive microbiological models, Food MicroModel (FMM) and Pathogen Modeling Program (PMP). After thermal processing, the products were stored at 4 and 8 degrees C and examined for the presence of botulinal spores and neurotoxin on the sell-by date and 7 days after the sell-by date. Most of the thermal processes were found to be inadequate for eliminating spores, even in low-inoculum samples. Only 2 of the 16 products were found to be negative for botulinal spores and neurotoxin at both sampling times. Two products at the high inoculum level showed toxigenesis during storage at 8 degrees C, one of them at the sell-by date. The predictions generated by both the FMM thermal death model and the FMM and PMP growth models were found to be inconsistent with the observed results in a majority of the challenges. The inaccurate predictions were caused by the limited number and range of the controlling factors in the models. Based on this study, it was concluded that the safety of sous vide products needs to be carefully evaluated product by product. Time-temperature combinations used in thermal treatments should be reevaluated to increase the efficiency of processing, and the use of additional antibotulinal hurdles, such as biopreservatives, should be assessed.

Recent trends in drug treatment in Europe

The article describes the recent developments in drug treatment systems in several European countries. The article is based on the up-dated papers delivered in the closing meeting of the ISDRUTS-project (International Study of the Drug Treatment Systems) in Lisbon, October 7-9, 1998. In the article latest trends in drug situation and drug-related harm in different countries are represented. Also recent changes in legal measures, the proceeding of the harm reduction measures, the situation with heroin trials, the implosion of the drug treatment system into the alcohol treatment system and alternatives to imprisonment and other diversion mechanisms for addicts are described. In the concluding chapter recent trends in drug treatment are analysed in the framework of the political climate in Europe.

The storage life of packed shredded Iceberg lettuce dipped in glycine betaine solutions

The effects of glycine betaine dip, packaging method, and storage time on the sensory quality of shredded Iceberg lettuce were first modeled using a statistical experimental design, followed by a second storage test verifying the effect of the glycine betaine treatment. Shredded lettuce was dipped in 0 to 100 mg/liter active chlorine solution and then in 0 to 1.0 mol/liter glycine betaine solution, packed in 25 microm oriented polypropylene film, 250 g per package, and stored at 5 degrees C for 8 days. Models with good predictability were created suggesting that the glycine betaine dip helped retain sensory quality, especially appearance (P < 0.05). The models also suggested that washing periods over 60 s were not needed and that the microperforation of packages should not exceed 0.31 mm2 per package. The modeled positive effect on sensory quality was verified in the second storage test (P < 0.05). The optimum glycine betaine concentration was 0.2 mol/liter. Chlorination of the first dip particularly retained appearance of packed lettuce.

Predicted and observed growth and toxigenesis by Clostridium botulinum type E in vacuum-packaged fishery product challenge tests

The observed growth and toxigenesis by Clostridium botulinum type E in vacuum-packaged unprocessed, raw pickled and cold-smoked rainbow trout stored at slightly abusive temperatures were compared to predictions generated by two currently available predictive microbiological programs, Food MicroModel and Pathogen Modelling Program. In unprocessed fish there was only a 2 log increase in type E cell count at the time the toxicity first occurred after 2 weeks storage at 8 degrees C. Neither growth or toxin production was observed in raw pickled fish with a NaCl concentration of 6.7% (w/v) during 6 weeks storage at 6 degrees C. In cold-smoked fish with a NaCl level of 3.2% (w/v) toxic samples were detected after 3 and 4 weeks storage at 8 degrees C and 4 degrees C, respectively, without any increase in type E count. Both models were hampered by limitations to controlling environmental factors set by the programs which also had an adverse effect on the reliability of predictions. Most predictions generated by the models were inconsistent with the results observed in the challenge studies. In certain situations, the models seemed to be 'fail-safe', in that, the growth rate predicted from the model was faster or a predicted time to toxicity shorter than that which actually occurred in the food. In other situations, the predictions showed the product to be safe when it was not. The results demonstrate the need for further development and rigorous validation of the models before they are accepted for wider use by inspecting officials and the food industry.

Heparan sulphate and HB-GAM (heparin-binding growth-associated molecule) in the development of the thalamocortical pathway of rat brain

Extracellular matrix (ECM) molecules, such as laminin, tenascin, chondroitin sulphate proteoglycans and heparan sulphate proteoglycans have been suggested to have 'signpost' and directing roles in the formation of axonal projections in cortical development. We show here that the expression of the neurite outgrowth-promoting protein heparin-binding growth-associated molecule (HB-GAM) and N-syndecan, a transmembrane heparan sulphate proteoglycan previously isolated as a receptor for HB-GAM, is spatiotemporally associated with the developing thalamocortical pathway in the rat brain. Using in situ hybridization, thalamic neurons were shown to express mRNA for N-syndecan, and in vitro, thalamic neurons grew more neurites on HB-GAM than on laminin. The HB-GAM-induced neurite outgrowth in thalamic neurons was inhibited by heparitinase, heparin, soluble N-syndecan and by an excess of soluble HB-GAM in the culture medium. In a pathway assay, thalamic neurons selectively preferred attaching and growing neurites on matrices containing HB-GAM than on those containing fibronectin or laminin alone, suggesting that HB-GAM may modulate the effect of other ECM proteins. On an unfixed brain slice preparation, thalamic neurons repeatedly showed a typical neurite outgrowth and attachment pattern resembling the expression pattern of HB-GAM. On the brain slices, the neurite outgrowth was significantly inhibited by heparitinase, heparin and soluble HB-GAM, thus displaying features of neurite outgrowth on matrix-bound HB-GAM. Our results suggest that HB-GAM is important for the neurite outgrowth of thalamic neurons and it may function as an ECM-bound guidance cue for thalamic neurons that possess HB-GAM-binding heparan sulphates on their cell membrane.

In situ detection of H1-receptor mRNA and absence of apoptosis in the transient histamine system of the embryonic rat brain

In the developing brain, histamine is one of the first neurotransmitters to appear. The concentration of histamine in the prenatal brain is fivefold that of adult levels. During the prenatal development a large transiently histamine-immunoreactive cell population distinct from the adult histaminergic system can be found within a subpopulation of the developing serotonergic raphe nuclei neurons. Also histamine-immunoreactive nerve fibers are widely distributed already during the prenatal development extending to the diencephalon, the thalamus, the cortex, and the spinal cord. Large numbers of histamine-containing mast cells also migrate into the brain during the late prenatal life. The wide distribution and high prenatal concentrations imply important functions for the histaminergic system during intrauterine development. However, little is known about the actual functions of histamine during development, and which of the histamine receptors are present in the prenatal rat brain is currently unknown. In the present study, we used in situ hybridization to study the distribution of H1-receptor (H1R) mRNA in the embryonic rat brain and spinal cord. H1R mRNA could be detected in rat brain and in spinal cord on embryonic day (E) 14, and the expression pattern seemed to partially localize in areas containing histamine-immunoreactive nerve fibers through E14-E20. H1R mRNA was also detected by reverse transcriptase polymerase chain reaction from embryonic brain samples and by Northern hybridization. The possible involvement of apoptosis in the disappearance of the developing transiently histaminergic system was studied by using apoptosis detection based on the terminal dUTP nick end labeling (TUNEL) technique and with c-Fos immunostaining. Although histamine immunoreactivity disappears dramatically from the developing raphe nuclei after E18, only occasional apoptotic nuclei could be seen in the histamine-immunoreactive cell bodies. The presence of H1R mRNA during the embryonic development renders it possible that histamine could exert an H1R-specific function at the time of the embryonic histamine peak.

Effects of packaging and storage conditions on volatile compounds in gas-packed poultry meat

Volatile compounds released by raw chicken legs packed in modified atmosphere packages were determined in order to develop a spoilage indicator for monitoring the shelf-life of raw chicken. Internal spoilage indicators would react with compounds released during chemical, enzymatic and/or microbial spoilage reactions. The effects of four packaging factors (headspace volume, oxygen transmission rate of the package, residual oxygen and carbon dioxide concentration) and three storage factors (temperature, illumination and storage time) on the amounts of volatile compounds in the headspace of gas packages containing two chicken legs were studied. Statistical experimental design was applied and a linear screening design comprising 18 experiments (fractional factorial) was utilized. Volatile compounds in package headspace were determined by gas chromatography--mass spectrometry using the dynamic headspace technique. The results were compared with the results of sensory evaluation and microbial determinations. The head-space of stored packages was dominated by the following compounds: butene, ethanol, acetone, pentane, dimethylsulphide, carbon disulphide and dimethyl disulphide. In modelling, some interaction terms and squared terms were needed in addition to linear terms. The main factors affecting the amounts of ethanol, dimethyl sulphide, carbon disulphide and dimethyl disulphide were storage time and temperature. Other factors had only minor importance, carbon dioxide concentration and headspace volume being the most significant package parameters. The same four factors also had the greatest effects on the odour of chicken legs.

N-syndecan and HB-GAM (heparin-binding growth-associated molecule) associate with early axonal tracts in the rat brain

Heparin-Binding Growth-Associated Molecule (HB-GAM)/pleiotrophin is an 18 kDa extracellular matrix- and cell-surface-associated protein shown to enhance neurite outgrowth of perinatal forebrain neurones in vitro. The heparan sulphate proteoglycan N-syndecan (Raulo et al., 1994) has been isolated as a receptor/coreceptor for the HB-GAM. We have investigated, whether HB-GAM and N-syndecan could have a similar role in neurite outgrowth and axon guidance in early axonal tracts of brain. In the present study N-syndecan was found to be spatiotemporally associated with the developing axonal tracts already on embryonic day 9 in rat, as revealed by coexpression with class III beta-tubulin, which is one of the earliest neuronal markers (Easter et al., 1993; Brittis et al., 1995). Later, N-syndecan and HB-GAM were detected in the first afferent serotonergic projections arising from the pontine raphe nuclei. The expression pattern of HB-GAM peaked in the developing rhombencephalon at embryonic stage (E) 13-14. At the same time, N-syndecan was expressed in the developing raphe neurones growing neurites towards the diencephalon along HB-GAM immunoreactive pathways. When rhombencephalic neurones were cultured on decreasing concentrations of substrate-bound HB-GAM, E13 neurones showed a significantly better neurite outgrowth response than E11, E16 or E18 neurones. The neurite outgrowth of raphe neurones in vitro was inhibited by adding soluble heparin or N-syndecan into the culture medium, whereas addition of chondroitin sulphate had no effect. In a simple pathway assay, E13 raphe neurones selectively preferred attaching and growing neurites on pathways containing HB-GAM as compared with regions containing either laminin or fibronectin alone. Our results suggest that HB-GAM may function as a developmentally regulated cue for rhombencephalic neurones that possess N-syndecan on their cell membrane.

Laryngeal oedema after isosorbide dinitrate spray and sublingual nifedipine

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Histamine: its metabolism and localization in mammary gland

1. Mammary gland of mouse (Mus musculus), rat (Rattus rattus), guinea pig (Cavia porcellus), cow (Bos taurus) and pig (Sus scrofa) contains different but always high concentrations of histamine. 2. Generally, the tissue histamine is localized in mast cells, although non-mast cell histamine immunoreactivity is also present in mammary glands of the mouse, cow and pig. No histamine immunoreactive nerves could be detected. 3. Mammary glands are able to synthesize and inactivate histamine; the activity of specific histidine decarboxylase and at least one of the catabolizing enzyme could be demonstrated. 4. Histamine fulfils basic criteria for being involved in physiological function of mammary glands.

Histamine and tyrosine hydroxylase in developing rat brain

The distribution of histamine and tyrosine hydroxylase in fetal rat brain was investigated immunocytochemically in order to determine possible colocalization of these two substances. Embryonic rat brains were fixed with carbodiimide and processed for immunofluorescence studies with antisera against histamine and tyrosine hydroxylase either in the same sections or in consecutive sections. Histamine and tyrosine hydroxylase showed no colocalisation in the developing rat brain. However, fibre networks immunoreactive for histamine and tyrosine hydroxylase were often found in the same areas. The results of the study suggest that the catecholaminergic and histaminergic neurones develop separately in the rat brain. Based on the location of developing histamine-immunoreactive neurones, a more intimate relationship between histamine- and serotonin-containing neurones in the developing rat brain is plausible.

Nimodipine after resuscitation from out-of-hospital ventricular fibrillation. A placebo-controlled, double-blind, randomized trial

One hundred fifty-five consecutive patients resuscitated after out-of-hospital ventricular fibrillation by a physician-manned advanced life support unit were randomly assigned to receive nimodipine or placebo at a dosage of 10 micrograms/kg as an intravenous injection immediately after restoration of spontaneous circulation, followed by an infusion of 0.5 micrograms/kg per minute for 24 hours. No significant difference was found in the 1-year survival rate of nimodipine-treated (30 [40%] of 75 patients) and placebo-treated patients (29 [36%] of 80 patients). Recurrent ventricular fibrillation during the treatment occurred in one patient in the nimodipine group compared with 12 patients in the placebo group. In a post hoc analysis of patients with very long delays in advanced life support (more than 10 minutes), the 1-year survival rate was higher with nimodipine (eight [47%] of 17 patients) than with placebo (two [8%] of 26 patients). Nimodipine may be of benefit in patients with delayed resuscitation.

Comparison of adrenaline and phenylephrine in out-of-hospital cardiopulmonary resuscitation. A double-blind study

Phenylephrine, a strong alpha-adrenergic receptor-stimulating agent, was compared with adrenaline in 65 patients with out-of-hospital cardiac arrest, in a double-blind study. The resuscitation was performed by the physician-staffed Prehospital Emergency Care Unit of Helsinki University Central Hospital. The patients received either 1.0 mg of phenylephrine or 0.5 mg of adrenaline i.v. in the treatment of fine ventricular fibrillation, asystole or electromechanical dissociation. If two doses of either drug did not restore circulation, 0.5 mg of known 0.01% adrenaline was given i.v., maximally twice. In the adrenaline group, which consisted of 36 patients with a mean age of 61 years, 10 patients (28%) were successfully resuscitated. The phenylephrine group consisted of 29 patients with a mean age of 62 years. In this group nine patients (31%) were successfully resuscitated. The two groups were comparable regarding their apnoea-times, and there was no difference in the need for extra adrenaline between the groups. No adverse effects, such as hypertension or bradycardia, were noted in the patients treated with either adrenaline or phenylephrine, nor did the overall rate of successful resuscitation fall during the test period. It is concluded that phenylephrine seems as effective as adrenaline in the treatment of cardiac arrest, but further studies seem warranted.