Safety of Ustekinumab in Inflammatory Bowel Disease: Pooled Safety Analysis Through 5 Years in Crohn's Disease and 4 Years in Ulcerative Colitis

BACKGROUND AND AIMS

Previously published long-term safety data reported a favorable ustekinumab safety treatment profile for treatment of inflammatory bowel disease (IBD). We present the final cumulative safety data from pooled ustekinumab IBD phase 2/3 clinical studies through 5 years in Crohn's disease (CD) and 4 years in ulcerative colitis (UC).

METHODS

In phase 3 studies, patients received a single IV placebo or ustekinumab (130mg or ~6mg/kg) induction dose followed by subcutaneous maintenance doses of placebo or ustekinumab (90mg q8w or q12w). Analyses included all patients who received one dose of study treatment and included patients who were biologic-naïve and patients with a history of biologic failure. Safety outcomes are summarized and presented using number of events per 100 patient-years of follow-up and corresponding 95% confidence interval.

RESULTS

In this final pooled safety analysis, 2575 patients were treated with ustekinumab with 4826 patient-years of follow-up. Rates of key safety events, including MACE and malignancies, were similar between placebo and ustekinumab or not higher for ustekinumab.Opportunistic infections, including tuberculosis, and malignancies were reported infrequently. Rates of key safety events in the IBD group were no higher in the ustekinumab group than in the placebo group for both patients who were biologic naïve or who had previously failed a biologic. No lymphomas or cases of posterior reversible encephalopathy syndrome (PRES; formerly known as reversible posterior leukoencephalopathy syndrome [RPLS] were reported.

CONCLUSION

The final cumulative ustekinumab safety data through 5 years in CD and 4 years in UC demonstrated favorable safety compared to placebo and continues to support the well-established safety profile across all approved indications.

Ustekinumab Exposure in Pregnant Women From Inflammatory Bowel Disease Clinical Trials: Pregnancy Outcomes Through Up To 5 Years in Crohn's Disease and 2 Years in Ulcerative Colitis

Background

While no adverse developmental outcomes were observed in preclinical animal studies, limited data exist regarding effects of ustekinumab on human pregnancies. Previously, no data have been reported for women treated with ustekinumab in inflammatory bowel disease (IBD) clinical trials and corresponding pregnancy outcomes. Here, we present pregnancy outcomes from IBD clinical trials, incorporating 5 years of treatment in Crohn's disease (CD) and 2 in ulcerative colitis (UC).

Methods

All patients in the clinical trials agreed to use adequate birth control and were discontinued from treatment upon pregnancy confirmation. Nonetheless, 39 pregnancies occurred with maternal ustekinumab exposure from 4 CD and 1 UC study. Maternal and neonatal outcomes and data are presented with summary statistics, where available.

Results

Of 1289 women who received ≥1 dose of ustekinumab, 39 maternal pregnancies with outcomes were reported (pregnancy cohort). Median maternal age was 28.0 years and median duration of ustekinumab treatment before pregnancy was 63.7 weeks with the last dose of ustekinumab administered prior to or during the first trimester (terminal half-life of ~3 weeks). Outcomes for the 39 pregnancies were: 26 live births (all normal newborns), 8 spontaneous abortions, and 5 elective abortions. No congenital anomalies were reported among normal newborns and no safety signals emerged with neonatal outcomes.

Conclusions

Based on this series of 39 pregnancies with outcomes from IBD clinical trials, mothers treated with ustekinumab (limited to up to the first trimester) did not demonstrate a risk of negative outcomes. More data are needed to characterize the safety profile of ustekinumab use during pregnancy.

Safety of Ustekinumab in Inflammatory Bowel Disease: Pooled Safety Analysis of Results from Phase 2/3 Studies

BACKGROUND

Ustekinumab is currently approved globally in Crohn's disease (CD) and psoriatic diseases. Recent phase 3 data demonstrate safety/efficacy in ulcerative colitis (UC). Crohn's disease and UC phase 3 programs had similar study designs, facilitating integrated safety analyses.

METHODS

Data from 6 ustekinumab phase 2/3 CD and UC studies were pooled, and safety was evaluated through 1 year. Patients received 1 placebo or ustekinumab (generally 130 mg or ~6 mg/kg) intravenous induction, then subcutaneous (90 mg) maintenance every 8/12 weeks. Analyses incorporated all patients who received ≥1 ustekinumab dose. Safety outcomes are presented as percentages of patients (induction) and as number of patients with events per 100 patient-years of follow-up (through 1 year). For key safety events, 95% confidence intervals (CIs) are provided, as appropriate. Hazard ratios with 95% CIs from time-to-event analyses for serious adverse events and serious infections were also performed.

RESULTS

Through 1 year, 2574 patients received ustekinumab (1733 patient-years of follow-up). The number of patients with adverse events per 100 patient-years (placebo 165.99 [95% CI, 155.81-176.67] vs ustekinumab 118.32 [95% CI, 113.25-123.55]), serious AEs (27.50 [95% CI, 23.45-32.04] vs 21.23 [95% CI, 19.12-23.51]), infections (80.31 [95% CI, 73.28-87.84] vs 64.32 [95% CI, 60.60-68.21]), serious infections (5.53 [95% CI, 3.81-7.77] vs 5.02 [95% CI, 4.02-6.19]), and malignancies excluding nonmelanoma skin cancer (0.17 [95% CI, 0.00-0.93] vs 0.40 [95% CI, 0.16-0.83]) were similar between placebo and ustekinumab.

CONCLUSIONS

The safety profile of ustekinumab across the pooled inflammatory bowel disease population through 1 year was favorable and generally comparable to placebo. These data are consistent with the established safety profile of ustekinumab across indications.

CLINICALTRIALS.GOV NUMBERS

NCT00265122; NCT00771667; NCT01369329; NCT01369342; NCT01369355; NCT02407236.

Robustness of network measures to link errors

In various applications involving complex networks, network measures are employed to assess the relative importance of network nodes. However, the robustness of such measures in the presence of link inaccuracies has not been well characterized. Here we present two simple stochastic models of false and missing links and study the effect of link errors on three commonly used node centrality measures: degree centrality, betweenness centrality, and dynamical importance. We perform numerical simulations to assess robustness of these three centrality measures. We also develop an analytical theory, which we compare with our simulations, obtaining very good agreement.

An update on the long-term safety experience of ustekinumab: results from the psoriasis clinical development program with up to four years of follow-up

BACKGROUND

The efficacy and safety profile of ustekinumab with up to three years of exposure suggested a favorable benefit-risk profile in patients with moderate to severe psoriasis.

OBJECTIVE

To evaluate the safety of ustekinumab in patients with moderate to severe psoriasis treated for up to four years.

METHODS

Safety data were pooled across four Phase II/III randomized controlled trials. Rates over time and cumulative rates of adverse events (AEs), AEs leading to treatment discontinuation, serious adverse events (SAEs), serious infections, malignancies, and major adverse cardiovascular events (MACE) (i.e., cardiovascular death, myocardial infarction [MI], or stroke as adjudicated by an independent panel of academic cardiologists) were evaluated. Observed rates of AEs of interest were compared with those expected in the general (malignancies, MI, and stroke) and psoriasis (serious infections, MI, and stroke) populations.

RESULTS

Overall, 3,117 patients were followed for up to four years (6,791 patient-years). Rates of AEs, AEs leading to treatment discontinuation, and SAEs remained stable over time, whereas cumulative rates were generally comparable between patients who received 45 mg and 90 mg of ustekinumab. The rates of AEs of interest also remained stable over time, and cumulative rates per 100 patient-years were 0.80 and 1.32 (serious infections), 0.70 and 0.53 (nonmelanoma skin cancer), 0.63 and 0.61 (other malignancies), and 0.56 and 0.46 (MACE) in patients treated with 45 mg and 90 mg, respectively. Rates of AEs of interest were consistent with those in the general and psoriasis populations.

CONCLUSION

The safety profile of long-term ustekinumab treatment with up to four years of continuous use remains consistent with previous reports, with no evidence of cumulative toxicity.

Effect of short ray trajectories on the scattering statistics of wave chaotic systems

In many situations, the statistical properties of wave systems with chaotic classical limits are well described by random matrix theory. However, applications of random matrix theory to scattering problems require introduction of system-specific information into the statistical model, such as the introduction of the average scattering matrix in the Poisson kernel. Here, it is shown that the average impedance matrix, which also characterizes the system-specific properties, can be expressed in terms of classical trajectories that travel between ports and thus can be calculated semiclassically. Theoretical results are compared with numerical solutions for a model wave chaotic system.

Safety, pharmacokinetics, and pharmacodynamics of single doses of LXR-623, a novel liver X-receptor agonist, in healthy participants

Liver X-receptor (LXR) agonists have been postulated to enhance reverse cholesterol transport (RCT), a process believed to shuttle cholesterol from the periphery back to the liver. Enhancing RCT via the upregulation of cholesterol transporters such as the adenosine triphosphate-binding cassettes ABCA1 and ABCG1 could therefore inhibit the progression of atherosclerosis. LXR-623 is a synthetic ligand for LXRs alpha and beta that has shown promise in animal models of atherosclerosis. The authors present results from a single ascending-dose study of the safety, pharmacokinetics, and pharmacodynamics of LXR-623 in healthy participants. LXR-623 was absorbed rapidly with peak concentrations (C(max)) achieved at approximately 2 hours. The C(max) and area under the concentration-time curve increased in a dose-proportional manner. The mean terminal disposition half-life was between 41 and 43 hours independently of dose. LXR activation resulted in a dose-dependent increase in ABCA1 and ABCG1 expression. The effect of LXR-623 concentration on ABCA1 and ABCG1 expression was further characterized via a population pharmacokinetic-pharmacodynamic analysis, yielding EC(50) estimates of 526 ng/mL and 729 ng/mL, respectively. Central nervous system-related adverse events were observed at the 2 top doses tested. The pharmacodynamic effects described here are the first demonstration of "target engagement" by an LXR agonist in humans.

Exact results for the Kuramoto model with a bimodal frequency distribution

We analyze a large system of globally coupled phase oscillators whose natural frequencies are bimodally distributed. The dynamics of this system has been the subject of long-standing interest. In 1984 Kuramoto proposed several conjectures about its behavior; ten years later, Crawford obtained the first analytical results by means of a local center manifold calculation. Nevertheless, many questions have remained open, especially about the possibility of global bifurcations. Here we derive the system's stability diagram for the special case where the bimodal distribution consists of two equally weighted Lorentzians. Using an ansatz recently discovered by Ott and Antonsen, we show that in this case the infinite-dimensional problem reduces exactly to a flow in four dimensions. Depending on the parameters and initial conditions, the long-term dynamics evolves to one of three states: incoherence, where all the oscillators are desynchronized; partial synchrony, where a macroscopic group of phase-locked oscillators coexists with a sea of desynchronized ones; and a standing wave state, where two counter-rotating groups of phase-locked oscillators emerge. Analytical results are presented for the bifurcation boundaries between these states. Similar results are also obtained for the case in which the bimodal distribution is given by the sum of two Gaussians.

External periodic driving of large systems of globally coupled phase oscillators

Large systems of coupled oscillators subjected to a periodic external drive occur in many situations in physics and biology. Here the simple paradigmatic case of equal strength, all-to-all sine coupling of phase oscillators subject to a sinusoidal external drive, is considered. The stationary states and their stability are determined. Using the stability information and numerical experiments, parameter space phase diagrams showing when different types of system behavior apply are constructed, and the bifurcations marking transitions between different types of behavior are delineated. The analysis is supported by results of direct numerical simulation of an ensemble of oscillators.

Recombinant human antithrombin III restores heparin responsiveness and decreases activation of coagulation in heparin-resistant patients during cardiopulmonary bypass

OBJECTIVES

We sought to evaluate the efficacy of recombinant human antithrombin III for restoration of heparin responsiveness in heparin-resistant patients scheduled for cardiac surgery.

METHODS

This was a multicenter, randomized, double-blind, placebo-controlled study in heparin-resistant patients undergoing elective cardiac surgery. Patients were considered heparin resistant if the activated clotting time was less than 480 seconds after 400 U/kg heparin. Fifty-two heparin-resistant patients were randomized into 2 cohorts. One cohort received a single bolus (75 U/kg) of recombinant human antithrombin III (n = 28), and the other, the placebo group (n = 24), received a normal saline bolus. If the activated clotting time remained less than 480 seconds, this was defined as treatment failure, and 2 units of fresh frozen plasma were transfused. Patients were monitored for adverse events during hospitalization.

RESULTS

Six (21%) of the patients in the recombinant human antithrombin III group received fresh frozen plasma transfusions compared with 22 (92%) of the placebo-treated patients ( P < .001). Two units of fresh frozen plasma did not restore heparin responsiveness. There was no increased incidence of adverse events associated with recombinant human antithrombin III administration. Postoperative 24-hour chest tube bleeding was not different in the 2 groups. Surrogate measures of hemostatic activation suggested that there was less activation of the hemostatic system during cardiopulmonary bypass in the recombinant human antithrombin III group.

CONCLUSION

Treatment with recombinant human antithrombin III in a dose of 75 U/kg is effective in restoring heparin responsiveness and promoting therapeutic anticoagulation for cardiopulmonary bypass in the majority of heparin-resistant patients. Two units of fresh frozen plasma were insufficient to restore heparin responsiveness. There was no apparent increase in bleeding associated with recombinant human antithrombin III.

Ictal dystonic posturing in mesial versus neocortical temporal lobe seizures

PURPOSE

Ictal contralateral dystonic posturing is a frequently observed clinical feature in temporal lobe seizures. It is generally interpreted as the result of spread of the ictal discharge into basal ganglia structure. In previous reports, analysing ictal behavior, a precise definition and description of the upper limb ictal dystonia is often lacking or contradictory. In our study we aimed to determine whether different subtypes of dystonia and their latency from the clinical onset of seizure might be of value for the differentiation between mesial temporal lobe epilepsy (MTLE) and neocortical temporal lobe epilepsy (NTLE).

METHODS

Eighty seizures (51 MTLE and 29 NTLE) and 30 patients (20 MTLE and 10 NTLE) were analyzed with regard to dystonic posturing of the upper limb. Ictal dystonia was subdivided into different subtypes according to distinct clinical features. Their frequency and latency from the clinical onset of seizure were assessed.

RESULTS

Frequencies of all subtypes were similar in MTLE and NTLE. Concerning the latencies contralateral dystonic posturing characterized by sustained muscle contractions with flexion of the wrist and fist closure, a frequently appearing feature, occurred significantly earlier in NTLE than in MTLE seizures.

CONCLUSIONS

This difference between the two groups may provide a differentiation between an epileptic focus of mesial from neocortical temporal lobe origin.

Influence of age, gender, education and dexterity on upper limb motor performance in Parkinsonian patients and healthy controls

Finger tapping, the most widely used test for evaluating motor dysfunction in Parkinson's disease (PD), was found to react sensitively to disease specific factors like disease severity and changes in medication. A possible interference caused by disease unrelated demographic factors--age, gender, education and dexterity--however has not yet been studied systematically. Various components of tapping performance of 187 healthy subjects and 200 PD patients were assessed by means of the BRAIN TEST, a digitalized test battery. The effects of demographic factors--above all education and age--were found to be significant. These influences generally affect different aspects of movement to a different extent, with speed and akinesia being affected more severely than dysmetria and arrhythmokinesis. Our study suggests that whenever precise assement of upper limb motor performance is needed, specific corrections for these demographic factors in both healthy controls and PD patients are necessary.

Future aspects of the presurgical evaluation in epilepsy

Epilepsy surgery is a successful therapeutic approach in patients with medically intractable epilepsy. The presurgical evaluation aims to detect the epileptogenic brain area by use of different diagnostic techniques. In this review article the current diagnostic procedures applied for this purpose are described. The diagnostic armamentarium can be divided conceptually into three different groups: assessment of function/dysfunction, structural/morphologic imaging methods and functional neuroimaging techniques. Properties, diagnostic power and limits of all diagnostic tools used in the diagnostic evaluation are discussed. In addition, future perspectives and the diagnostic value of new technologies are mentioned. Some are increasingly gaining acceptance in the routine preoperative diagnostic procedure like MR volumetry or MR spectroscopy of the hippocampus in patients with temporal lobe epilepsy. Some, on the other hand, like MEG and 11C-flumazenil PET, still remain experimental diagnostic tools as they are technically demanding and cost intensive. Besides the refinement of established techniques, co-registration of different modalities like spike-triggered functional MRI will play an important role in the non-invasive detection of the epileptic seizure focus and may change the regimen of the preoperative diagnostic work up of epilepsy patients in the future.

Fractal properties of robust strange nonchaotic attractors

For a simple class of quasiperiodically forced dynamical systems, we present a rigorous result supporting the idea that the attractors for this class of systems, although nonchaotic, are strange in the sense that their box-counting dimension is two while their information dimension is one. Furthermore, this result is stable to changes of the system, suggesting that the basic features leading to it may be present in typical quasiperiodically forced systems.

Detecting phase synchronization in a chaotic laser array

Detection of phase synchronization of coupled chaotic oscillators is examined experimentally for the case of a linear laser array. Phase variables are computed by applying a Gaussian filter, peaked at a positive frequency, to the signal obtained from the intensity time series of the individual lasers. Relationships between different frequency components of the oscillator dynamics that are not otherwise apparent are unambiguously detected.

Front propagation of spatiotemporal chaos

We study the dynamics of the front separating a spatiotemporally chaotic region from a stable steady region using a simple model applicable to periodically forced systems. In particular, we investigate both the coarsening of the front induced by the inherent "noise" of the chaotic region, and the long wavelength dynamics causing the front to develop cusps.

Local low dimensionality of atmospheric dynamics

A statistic, the BV (bred vector) dimension, is introduced to measure the effective local finite-time dimensionality of a spatiotemporally chaotic system. It is shown that the Earth's atmosphere often has low BV dimension, and the implications for improving weather forecasting are discussed.

Blowout bifurcations and the onset of magnetic activity in turbulent dynamos

The transition to magnetic-field self-generation in a turbulent, electrically conducting fluid is shown to exhibit intermittent bursting characterized by distinct scaling laws. This behavior is predicted on the basis of prior analysis of a type of bifurcation (called a blowout bifurcation) occurring in chaotic systems with an invariant phase space submanifold. The predicted scalings are shown to be consistent with numerical solutions of the governing magnetohydrodynamic equations, and implications for recently implemented experimental programs are discussed.

Pattern selection in extended periodically forced systems: a continuum coupled map approach

We propose that a useful approach to the modeling of periodically forced extended systems is through continuum coupled map (CCM) models. CCM models are discrete time, continuous space models, mapping a continuous spatially varying field xi(n)(x) from time n to time n+1. The efficacy of CCM models is illustrated by an application to experiments of Umbanhowar, Melo, and Swinney [Nature 382, 793 (1996)] on vertically vibrated granular layers. Using a simple CCM model incorporating temporal period doubling and spatial patterning at a preferred length scale, we obtain results that bear remarkable similarities to the experimental observations. The fact that the model does not make use of physics specific to granular layers suggests that similar phenomena may be observed in other (nongranular) periodically forced, strongly dissipative systems. We also present a framework for the analysis of pattern selection in CCM models using a truncated modal expansion. Through the analysis, we predict scaling laws of various quantities, and these laws may be verifiable experimentally.

Target waves in the complex ginzburg-landau equation

We introduce a spatially localized inhomogeneity into the two-dimensional complex Ginzburg-Landau equation. We observe that this can produce two types of target wave patterns: stationary and breathing. In both cases, far from the target center, the field variables correspond to an outward propagating periodic traveling wave. In the breathing case, however, the region in the vicinity of the target center experiences a periodic temporal modulation at a frequency, in addition to that of the wave frequency of the faraway outward waves. Thus at a fixed point near the target, the breathing case yields a quasiperiodic time variation of the field. We investigate the transition between stationary and breathing targets, and note the existence of hysteresis. We also discuss the competition between the two types of target waves and spiral waves.

Testing whether two chaotic one dimensional processes are dynamically identical

Consider the situation where two individuals observe the same chaotic physical process but through time series of different measured variables (e.g., one individual measures a temperature and the other measures a voltage). If the two individuals now use their data to reconstruct (e.g., via delay coordinates) a map, the maps they obtain may appear quite different. In the case where the resulting maps appear one dimensional, we introduce a method to test consistency with the hypothesis that they represent the same physical process. We illustrate this method using experimental data from an electric circuit.

Measurement of wave chaotic eigenfunctions in the time-reversal symmetry-breaking crossover regime

We present experimental results on eigenfunctions of a wave chaotic system in the continuous crossover regime between time-reversal symmetric and time-reversal symmetry-broken states. The statistical properties of the eigenfunctions of a two-dimensional microwave resonator are analyzed as a function of an experimentally determined time-reversal symmetry-breaking parameter. We test four theories of one-point eigenfunction statistics and introduce a new theory relating the one-point and two-point statistical properties in the crossover regime. We also find a universal correlation between the one-point and two-point statistical parameters for the crossover eigenfunctions.

Optimal periodic orbits of continuous time chaotic systems

In previous work [B. R. Hunt and E. Ott, Phys. Rev. Lett. 76, 2254 (1996); Phys. Rev. E 54, 328, (1996)], based on numerical experiments and analysis, it was conjectured that the optimal orbit selected from all possible orbits on a chaotic attractor is "typically" a periodic orbit of low period. By an optimal orbit we mean the orbit that yields the largest value of a time average of a given smooth "performance" function of the system state. Thus optimality is defined with respect to the given performance function. (The study of optimal orbits is of interest in at least three contexts: controlling chaos, embedding of low-dimensional attractors of high-dimensional dynamical systems in low-dimensional measurement spaces, and bubbling bifurcations of synchronized chaotic systems.) Here we extend this previous work. In particular, the previous work was for discrete time dynamical systems, and here we shall consider continuous time systems (flows). An essential difference for flows is that chaotic attractors can have embedded within them, not only unstable periodic orbits, but also unstable steady states, and we find that optimality can often occur on steady states. We also shed further light on the sense in which optimality is "typically" achieved at low period. In particular, we find that, as a system parameter is tuned to be closer to a crisis of the chaotic attractor, optimality may occur at higher period.

The Bradykinesia Akinesia Incoordination Test (BRAIN TEST), an objective and user-friendly means to evaluate patients with parkinsonism

The BRAIN TEST, a computerized alternating finger tapping test, was performed on 154 patients with parkinsonism to assess whether the test could be used as an objective tool to evaluate reliably the severity of Parkinson's disease (PD). Patients were instructed to tap two marked computer keyboard keys as fast and as accurately as possible for 60 seconds. The test generates the following variables: (1) kinesia score (KS)--number of keystrokes/min, (2) akinesia time (AT)--cumulative time that keys are depressed, (3) dysmetria score (DS)--a weighted score generated from incorrectly hit keys and corrected for speed, and (4) arrhythmia score (AS)--variance of the time interval between individual keystrokes. Among parkinsonian patients, we found a significant correlation between the four test parameters and PD rating scores of the Hoehn & Yahr, Schwab & England, and Unified PD Rating Scales (KS, AS, and AT p <0.001 and DS p <0.05). When compared with 73 parkinsonian patients 73 age- and sex-matched control subjects showed significantly higher KS and lower AT (p <0.001) as well as lower DS and AS (p = 0.05). The BRAIN TEST is a reliable and practical tool for evaluating the severity of parkinsonism and for distinguishing subjects with parkinsonism from normal control subjects. A version of the BRAIN TEST is available by FTP on the worldwide web (http://www.anaesthetist.com/software/brain.htm).

Lagrangian chaos and the effect of drag on the enstrophy cascade in two-dimensional turbulence

We investigate the effect of drag force on the enstrophy cascade of two-dimensional Navier-Stokes turbulence. We find a power law decrease of the energy wave number (k) spectrum that is faster than the classical (no-drag) prediction of k(-3). It is shown that the enstrophy cascade with drag can be analyzed by making use of a previous theory for finite lifetime passive scalars advected by a Lagrangian chaotic fluid flow. Using this we relate the power law exponent of the energy wave number spectrum to the distribution of finite time Lyapunov exponents and the drag coefficient.

Spiral wave dynamics in oscillatory inhomogeneous media

The effect of a long length scale static inhomogeneity on spiral wave dynamics is studied in the two-dimensional complex Ginzburg-Landau equation. We find that the inhomogeneity leads to the formation of a dominant spiral domain that suppresses other spiral domains, and that the spiral vortices slowly drift in the presence of an inhomogeneity with a velocity that is proportional to the local parameter gradients. We derive an expression for the spiral vortex drift velocity and present examples of both fixed point and limit cycle attractors of the spiral vortices.

Induction of anesthesia by titration of eltanolone compared with thiopental and etomidate for coronary artery bypass grafting

STUDY OBJECTIVE

To evaluate whether induction of anesthesia with eltanolone in coronary artery bypass graft (CABG) patients is associated with greater hemodynamic stability than either thiopental sodium or etomidate.

DESIGN

Randomized, controlled study.

SETTING

University hospital.

PATIENTS

75 ASA physical status III and IV patients scheduled for elective CABG over 18 years of age, with left ventricular ejection fraction over 30%.

INTERVENTIONS

The participants were prospectively randomized into three groups, each group consisting of 25 patients. Anesthesia was induced by titration of either eltanolone, thiopental sodium, or etomidate. The end point was "loss of verbal contact."

MEASUREMENTS AND MAIN RESULTS

Hemodynamic variables were recorded in the awake state, 2 minutes after induction, after administration of fentanyl 0.01 mg/kg, and 2 and 5 minutes after intubation. After induction of anesthesia, cardiac index (CI) decreased from 2.6 +/- 0.5 to 2.2 +/- 0.5 Lxmin-1xm-2 in the eltanolone group and remained at this value throughout the study period in contrast to the control groups. After fentanyl was given, mean arterial pressure was significantly lower in the case of eltanolone (69 +/- 15 mmHg) compared with thiopental (81 +/- 19 mmHg) and etomidate (84 +/- 18 mmHg). Mean arterial pressure remained significantly lower at the points of measurement after intubation. Two minutes after intubation, CI was likewise significantly lower in the eltanolone group (2.2 +/- 0.4 Lxmin-1xm-2) compared with the thiopental group (2.7 +/- 0.7 Lxmin-1xm-2).

CONCLUSIONS

Eltanolone produces more hemodynamic depression compared with etomidate and thiopental when administered in combination with fentanyl 10 micrograms/kg.

[Evaluation of vascular risk factors in patients with Parkinson syndrome]

A vascular etiology of Parkinson's disease (PD) has been long debated. In order to search for an ischemic basis of PD we assessed the clinical symptomatology of a consecutive group of 60 PD patients and compared their frequency of cerebrovascular risk factors, carotid atherosclerosis and ischemic brain lesions with age-matched groups of stroke patients and normals. There were 16 (27%) subjects with PD who also had symptoms of cerebrovascular disease. The frequencies of carotid stenoses, ischemic brain lesions and most of cerebrovascular risk factors seen in the latter group was comparable with those of stroke patients and significantly higher than in the investigational subsets of patients with "pure" PD and normals. Only one (1.6%) individual with PD presented signs suggestive of an ischemic etiology of parkinsonism. These findings suggest that cerebrovascular disease occurs in approximately one fourth of patients with PD, but seldomly is causally related.

Bolus administration of eltanolone, thiopental, or etomidate does not affect systemic vascular resistance during cardiopulmonary bypass

OBJECTIVE

To discover possible effects on systemic vascular resistance of the anesthetic induction agent eltanolone in comparison with thiopental and etomidate. The measurements were performed during cardiopulmonary bypass to maintain a constant cardiac output (approximately pump flow).

DESIGN

The patients were prospectively randomized in three groups to receive either eltanolone, thiopental, or etomidate.

SETTING

University hospital as a single center.

PARTICIPANTS

Seventy-five patients scheduled for elective coronary artery bypass grafting.

INTERVENTIONS

The anesthetic induction agents were repeated at the same dosage when cardiopulmonary bypass was instituted. The respective mean dosages were eltanolone, 0.41 +/- 0.1 mg/kg; thiopental, 2.88 +/- 0.62 mg/kg; etomidate, 0.26 +/- 0.06 mg/kg.

MEASUREMENTS AND MAIN RESULTS

Systemic vascular resistance was calculated from the mean of a triple measurement (normal pump flow and +/- 20%). Points of measurement were before, and 2 and 5 minutes after injection of the hypnotic agent. None of the injected drugs made a significant change in the systemic vascular resistance. A small (not significant) decrease from 1,295 +/- 296 dyne/s/cm-5 to 1,196 +/- 323 dyne/s/cm-5 (mean +/- SD) was seen in the eltanolone group, whereas the other patients did not show any change during the study period.

CONCLUSIONS

The reason for the significant reduction of the arterial pressure attributed to anesthetic induction by eltanolone may be more a cardiodepressive effect than a direct vasodilation.