Drug governs the morphology of polyalkylated block copolymer aggregates

Polyalkylated copolymers based on mPEG-b-(AGE-C_{6,12 or 18})₂₅ have been used to formulate clinically relevant concentrations of doxorubicin (DOX) and the impact of drug incorporation on copolymer aggregation behaviour was examined. The copolymer aggregates were analyzed by various microscopy techniques (TEM, cryo-TEM and AFM) and scattering methods (SANS, DLS). In the absence of the drug, the copolymers formed largely non-spherical aggregates (i.e. cylinders, vesicles). Drug incorporation during copolymer aggregate formation directed the formation of only spherical aggregates. As well, the nature of the core-forming block was found to influence drug release and cytotoxicity of the formulations.

Widespread musculoskeletal pain and the progression of disability in older disabled women

BACKGROUND

Widespread musculoskeletal pain is a poorly understood but common problem in older adults. Little is known about the progression of disability related to this condition.

OBJECTIVE

To determine whether widespread musculoskeletal pain increases the risk for worsening disability in older women with disabilities.

DESIGN

Prospective cohort study.

SETTING

The Women's Health and Aging Study.

PARTICIPANTS

1002 community-dwelling women 65 years of age or older with disability.

MEASUREMENTS

Widespread musculoskeletal pain was defined as pain in the upper and lower extremities and axial pain with moderate or severe pain in at least one of the three regions. Worsening disability was defined as progression from no or mild difficulty to severe difficulty or inability to perform activities of daily living (ADLs), walk one-quarter mile, or lift 10 lbs.

RESULTS

At baseline, 24% of participants had widespread pain and 25% had no pain or only mild pain in a single site. Women with widespread pain were 2.5 to 3.5 times more likely to have severe difficulty with ADLs, walking, or lifting at baseline compared with women who had no or mild pain. In women without severe difficulty initially, widespread pain nearly doubled the risk for progression to severe difficulty in each of the tasks, after adjustment for age, body mass index, comorbid illness, and other confounders.

CONCLUSION

Widespread musculoskeletal pain is frequent among community-dwelling older women with disability and appears to predict the progression of disability. Efforts to better understand the cause of this pain and its treatment might reduce the overall burden of disability.

Differing perceptions of end-of-life care in long-term care

BACKGROUND

Care team members may have different views on end-of-life care, which may influence perceptions of that care.

METHODS

Twenty-seven consecutive deaths at a long-term care facility were identified. A structured interview of primary care team members (physician, nurse, and aide) was administered. The interview asked comparable questions to each group on a Likert scale (1 = least satisfied; 4 = most satisfied) regarding the resident's experience in the last 3 days of life. Areas assessed were pain, comfort, emotional support, adequacy of information provided to families, whether direct care needs were met, supportive care, time spent with resident, number of symptoms present at the end of life, and quality of death. Repeated measures analysis of variance was used to determine if the mean values of various response measures differed significantly by rater group (i.e., physicians, nurses, or aides).

RESULTS

Aides perceived more resident pain compared to physicians or nurses. Physicians' perceptions of emotional support provided to families were lower than those of aides or nurses.

CONCLUSIONS

This study demonstrates differing perceptions by care team members regarding end-of-life care. Areas of difference include pain and emotional support provided to families. Because effective team functioning requires understanding and recognition of different perceptions of team members, clarifying and addressing the reasons for these differences may improve both job satisfaction on the part of care team members, as well as the quality of end-of-life care delivered.

In the lung aerosol cyclosporine provides a regional concentration advantage over intramuscular cyclosporine

BACKGROUND

Acute rejection remains an almost universal complication among lung transplant recipients. Refractory rejection as well as chronic systemic immunosuppression is associated with significant morbidity and mortality. Recent studies suggest that aerosol cyclosporine may address these issues by effectively preventing acute cellular rejection while maintaining low systemic drug concentrations. This study was designed to evaluate the concentrations of cyclosporine in blood and lung tissue after aerosol and intramuscular administration.

METHODS

Lewis rats were divided into 4 experimental groups: Groups A (n = 33) and B (n = 30) received aerosol cyclosporine 3 and 5 mg/kg, respectively; Groups C (n = 33) and D (n = 30) received systemic cyclosporine 5 and 15 mg/kg, respectively. We used high-performance liquid chromatography to quantitate blood and lung tissue cyclosporine levels at timed intervals. We used the trapezoidal rule to approximate area under the concentration vs time curve (AUC).

RESULTS

Aerosol delivery of cyclosporine resulted in higher and more rapid peak drug levels in lung tissue samples than did systemic delivery. At an equivalent 5 mg/kg dose, the cyclosporine AUC was 3 times higher with aerosol delivery than with intramuscular delivery in lung tissue (477,965 vs 157,706 ng x hour/g, respectively). The lung tissue: blood AUC ratio was highest in the aerosol groups (27.3:1 and 17.4:1) compared with the intramuscular groups (8.1:1 and 9.4:1).

CONCLUSION

Local aerosol inhalation delivery of cyclosporine provides a regional advantage over systemic intramuscular therapy by providing higher peak concentrations and greater lung tissue exposure.

Correlates and management of nonmalignant pain in the nursing home. SAGE Study Group. Systematic Assessment of Geriatric drug use via Epidemiology

OBJECTIVE

Nonmalignant pain is a common problem among older people. The prevalence of pain in the nursing home is not well studied. We looked at the association between nonmalignant pain, psychological and functional health, and the practice patterns for pain management in the nursing home.

DESIGN

A cross-sectional study.

SETTING

Nursing Home in four US states.

PARTICIPANTS

A total of 49,971 nursing home residents from 1992 to 1995.

MEASUREMENTS

We used the SAGE database (Systematic Assessment of Geriatric drug use via Epidemiology), which linked information from the Minimum Data Set and nursing home drug utilization data. The MDS items measured included pain, activities of daily living (ADL) function, mood, and time involved in activities. The use of analgesics, anxiolytics, and antidepressants was also documented.

RESULTS

Daily pain was reported in 26% of nursing home residents. The prevalence was lower among men, persons more than age 85, and racial minorities. Persons suffering pain daily were more likely to have severe ADL impairment, odds ratio (OR) (2.47 (95% CI, 2.34-2.60)), more depressive signs and symptoms (OR 1.66 (95% CI, 1.57-1.75)), and less frequent involvement in activities (OR 1.35 (95% CI, 1.29-1.40)). Approximately 25% of persons with daily pain received no analgesics. Residents who were more than 85 years old (OR 1.15 (95% CI 1.02-1.28)), cognitively impaired, (OR 1.44 (95% CI, 1.29-1.61)), of male gender (OR 1.17 (95% CI, 1.06-1.29)), or a racial minority (OR 1.69 (95% CI, 1.40-2.05) and OR 1.56 (95% CI, 0.70-1.04) for blacks and Hispanics, respectively) were at greater risk of not receiving analgesics. Approximately 50% of those in pain used physical and occupational therapies, which was more than two times higher (OR 2.44 (95% CI, 2.34-2.54)), than use for those not in pain.

CONCLUSIONS

Daily nonmalignant pain is prevalent among nursing home residents and is often associated with impairments in ADL, mood, and decreased activity involvement. Even when pain was recognized, men, racial minorities, and cognitively impaired residents were at increased risk for undertreatment. More education and research is necessary to improve the recognition and management of pain in the nursing home, remembering that attention should be paid to populations at increased risk for underrecognition and undertreatment.

Validation of selective cardiac evaluation prior to aortic aneurysm repair

OBJECTIVE

To evaluate perioperative and long-term morbidity in patients undergoing selective evaluation of coronary artery disease prior to abdominal aortic aneurysm (AAA) repair.

DESIGN

Case series.

SETTING

University and Veterans' Administration medical centers.

PATIENTS

One hundred eighty-nine consecutive patients undergoing AAA repair between January 1989 and September 1996 were selectively evaluated for coronary artery disease and assigned to 1 of 3 groups: group 1, no abnormal cardiac history, normal electrocardiogram; group 2, minimal symptoms, history of myocardial infarction (MI), older than 70 years, diabetes mellitus, or congestive heart failure; or group 3, severe or unstable angina, ventricular dysfunction.

INTERVENTIONS

Group 1 patients proceeded to AAA repair without further workup. Group 2 patients underwent pharmacologic or exercise stress testing followed by coronary angiography and intervention as required. Group 3 patients went directly to coronary angiography and intervention as needed.

MAIN OUTCOME MEASURES

Perioperative MI, arrhythmias, or death. Long-term follow-up measures included MI and death.

RESULTS

Adequate documentation was available on 171 patients. Twenty-four patients (14%) were in group 1. Of 136 patients (79.5%) in group 2, coronary angiography was performed in 36 (26%), followed by percutaneous transluminal coronary angioplasty (PTCA) in 9 (7%) and coronary artery bypass (CAB) in 5 (4%). Of 11 patients in group 3, 3 (27%) each received PTCA and CAB. Remote CAB or PTCA had been performed in 32 (19%) and 12 (7%) patients, respectively. Two perioperative deaths (1.1%) occurred in the 189 patients, one due to MI in a group 2 patient. There were 2 (1%) nonfatal MIs, both in group 2 patients who had no preoperative intervention. Arrhythmias and/or congestive heart failure occurred in 17 (9%) cases, 7 (39%) having had recent coronary revascularization (P = .001). By univariate analysis, only preoperative renal dysfunction predicted perioperative complications (P = .03) Overall survival by lifetable analysis was 87.9% and 69.7% at 3 and 5 years, respectively.

CONCLUSION

Coronary artery disease is common in patients undergoing AAA repair, with 35.7% having preoperative coronary revascularization at some point. Selective preoperative coronary artery disease screening achieves excellent perioperative and late results in this population.

Alterations of the p53, Rb and MDM2 genes in osteosarcoma

Molecular defects affecting tumor-suppressor genes are an important step in the genesis of sarcomas. For example, inheritance of a defective Rb or p53 gene predisposes the carrier to develop osteosarcoma, among other malignancies. In this study, we have assessed the occurrence of p53, Rb and MDM2 alterations in the same samples of osteosarcomas, along with representative samples of various other sarcomas. Point mutations of the p53 gene were found in 13 of 42 osteosarcomas and 1 of 8 leiomyosarcomas, and gross rearrangement of the p53 gene was demonstrated in 5 of 37 osteosarcomas. The retinoblastoma susceptibility gene (Rb) was either rearranged or deleted in 7 of 37 osteosarcomas, 1 of 7 soft-tissue sarcomas and 1 of 4 Ewing sarcomas. Remarkably, 5 of the osteosarcomas having Rb alterations also had p53 mutations. Amplification and overexpression of the MDM2 oncogene may lead to increased MDM2-p53 binding resulting in inactivation of p53 function. A two- to threefold increase in the copy number of MDM2 was detected in 7 of 37 samples, 5 of which were osteosarcomas. Amplification of the MDM2 gene occurred independently of p53 mutation; one sample having threefold amplification of MDM2 also had a p53 mutation. In summary, 34 alterations of the p53, Rb and MDM2 genes were found in 26 of 42 (62%) osteosarcomas.