Safety and Effectiveness of a Standardized Intravenous Insulin Infusion Order Set for Managing Uncontrolled Hyperglycemia Outside the Intensive Care Unit

BACKGROUND

Few studies have evaluated the administration of intravenous (IV) insulin infusions for uncontrolled hyperglycemia in non-intensive care unit (ICU) patients, and there is inadequate data to guide how to appropriately administer IV insulin infusions to this patient population.

OBJECTIVE

Determine the effectiveness and safety of our institution's non-critical care IV insulin infusion order set.

METHODS

This retrospective study was conducted at 2 institutions within a health care system. The primary outcome was the number of individuals who achieved a glucose level ≤180 mg/dL. For those meeting this endpoint, the time to achieving this outcome and the percentage of glucose checks within the goal range were determined. The primary safety endpoint was the number of individuals who experienced hypoglycemia (glucose level <70 mg/dL). Patients were included if they were ≥18 years of age and received the non-critical care IV insulin infusion order set outside of the ICU.

RESULTS

Twenty-one (84%) patients achieved a glucose level ≤180 mg/dL. The median (inter-quartile range [IQR]) time to achieving the primary outcome was 5.7 h (3.9-8.3). In patients who achieved the primary outcome, 41.8% of the glucose readings obtained after achieving this outcome were within goal range. Two (8%) patients experienced hypoglycemia. Both of these events occurred within 8 hours of therapy initiation and neither patient received prior doses of subcutaneous insulin. Of the 4 patients who did not achieve a glucose level ≤180 mg/dL, 2 received high-dose corticosteroids, and 3 achieved a glucose level between 181 and 200 mg/dL.

CONCLUSION AND RELEVANCE

Our findings support the safe administration of IV insulin infusions to non-ICU patients when targeting a glucose range of 140 to 180 mg/dL and limiting the infusion duration.

Utility of nicardipine in the management of hypertensive crises in adults with reduced ejection fractions

BACKGROUND

Nicardipine is commonly used in the management of hypertensive crises, except those involving cardiac contractility defects despite its ability to reduce afterload and pulmonary congestion. Consequently, there is limited literature evaluating nicardipine's role for this indication. The purpose of this study was to evaluate the efficacy and safety of nicardipine in adults with reduced ejection fractions presenting with acute heart failure with hypertension (AHF-H).

METHODS

This was a retrospective study conducted at an academic Level 1 trauma center with an annual Emergency Department (ED) volume surpassing 100,000. The purpose of this study was to determine the efficacy and safety of nicardipine in adults with reduced ejection fractions presenting to the ED with AHF-H. Efficacy was determined by achievement of the physician prescribed blood pressure target range. The primary safety endpoints included the number of individuals who experienced bradycardia (< 60 beats per minute, bpm) or hypotension (systolic blood pressure, SBP, < 90 mmHg) while receiving nicardipine and for up to 15 min after its discontinuation. Patients were included if they were ≥ 18 years of age, received a continuous intravenous nicardipine infusion within six hours of presenting to the ED, and had an ejection fraction ≤ 40% per an echocardiogram obtained within three months of the study visit. Pregnant and incarcerated patients were excluded.

RESULTS

Of the 500 patient charts reviewed, 38 met inclusion criteria. The median (interquartile, IQR) ejection fraction and brain natriuretic peptide (BNP) were 35% (25-40) and 731 pg/nL (418-3277), respectively. The median baseline heart rate and SBP were 90 bpm and 193 mmHg, respectively. The median physician specified SBP goal was 160 mmHg and all patients met this endpoint in a median time of 18 min. One (2.6%) patient in the total population developed both hypotension and bradycardia. This patient had an ejection fraction of 20%, was intubated, and received nicardipine in addition to esmolol for an aortic dissection without experiencing an adverse event until 30 min after dexmedetomidine was initiated.

CONCLUSION

In this non-interventional study evaluating the use of nicardipine in patients with reduced ejection fractions presenting to the ED with AHF-H, nicardipine was found to be safe and effective. To our knowledge this is the largest study to date evaluating nicardipine in this patient population and positively contributes to the existing literature.

Acute Management of Hypertriglyceridemia With a Disease-Specific Intravenous Insulin Infusion Order Set

BACKGROUND

Hypertriglyceridemia-associated acute pancreatitis is a disease lacking a standardized management approach.

OBJECTIVE

The main objective of this study was to evaluate the safety and efficacy of a continuous intravenous insulin infusion order set specifically designed for managing hypertriglyceridemia.

METHODS

This study compared the safety and efficacy of a standardized (postintervention) approach to managing hypertriglyceridemia to a nonstandardized (preintervention) approach. The primary efficacy outcome was the percentage of patients who achieved a triglyceride level less than 500 mg/dL. Additional outcomes included the time to achieving a triglyceride level less than 500 mg/dL and the percent reduction in triglyceride levels. The primary safety outcome was the number of patients who experienced hypoglycemia (glucose less than 70 mg/dL).

RESULTS

Twenty patients were included in both the preintervention and postintervention groups. There was a significantly greater reduction in triglyceride levels observed in the postintervention group. The number of patients who achieved a triglyceride level less than 500 mg/dL in the preintervention and postintervention groups were 10 (50%) and 17 (85%), respectively, P = 0.018. Within the postintervention group, the time to achieving a triglyceride level less than 500 mg/dL in those with and without diabetes was 56.8 hours (38.2-64.0) versus 27.6 hours (19.7-45.0), respectively, P = 0.028.

CONCLUSION AND RELEVANCE

Our findings demonstrate that insulin infusions are safe and effective when therapy is standardized and accounts for nursing to patient ratios. Our results provide the medical community with a standardized approach to acutely managing hypertriglyceridemia.

Fixed-Dose Factor Eight Inhibitor Bypassing Activity (FEIBA) in the Management of Warfarin-Associated Coagulopathies

This retrospective review evaluated our institutions’ practice of administering low fixed-dose FEIBA (high (1000 units) or low dose (500 units) for an INR ≥ 5 or <5, respectively) for the management of warfarin-associated coagulopathies. The primary outcome was the percentage of patients who had a post-FEIBA INR ≤ 1.5. In the total population, 55.6% (10/18) of patients achieved a post-FEIBA INR ≤ 1.5. In the subgroup analysis, significantly more patients in the low dose FEIBA group achieved a post-FEIBA INR ≤ 1.5 compared to the high dose FEIBA group (71.4% vs. 45.5%, respectively, p < 0.001). In the post hoc analysis, there was a significant difference in the number of patients who achieved a post-FEIBA INR ≤ 1.5 when comparing those who received high dose FEIBA with a baseline INR 5−9.9 to those who received high dose FEIBA with a baseline INR ≥ 10 (60% vs. 33.3%, respectively, p < 0.001). The existing literature and our findings suggest that patients who present with lower baseline INR values and receive additional reversal agents are more likely to meet post-reversal INR goals. Current low fixed-dose protocols may be oversimplified and may need to be revised to provide larger fixed-doses.

Safety and Efficacy of Various Intravenous Insulin Infusion Rates in Patients With and Without Diabetes Presenting With Hypertriglyceridemia

Background

The use of IV insulin infusions in the acute management of hypertriglyceridemia has only been evaluated in small observational studies and case reports.

Objective

To evaluate the safety and efficacy of IV insulin infusions in the acute management of hypertriglyceridemia.

Methods

This was a retrospective chart review of adult patients who received an IV insulin infusion for the acute management of hypertriglyceridemia. The primary efficacy and safety outcomes were the number of patients who achieved a triglyceride level <500 mg/dL and experienced hypoglycemia (<70 mg/dL), respectively. A subgroup analysis was performed to compare outcomes between patients with and without diabetes, in addition to the IV insulin infusion rate received.

Results

In the total population (n = 51), there were no statistically significant differences between the insulin intensity groups in the number of patients who achieved TG levels <500 mg/dL. Compared to patients with a past medical history of diabetes, more patients without a past medical history of diabetes achieved triglyceride levels <500 mg/dL (14% vs 53%, respectively, P < 0.001). The number of hypoglycemic events observed in patients with and without a past medical history of diabetes were 5 (14%) and 4 (27%), respectively ( P = 0.023).

Conclusion and Relevance

Our findings suggest that patients who present with lower initial TG levels are more likely to achieve TG levels <500 mg/dL. To minimize the risk of hypoglycemia providers should consider prescribing a concomitant dextrose infusion and limiting IV insulin infusion rates ≤ 0.075 units/kg/h.

Intravenous Metoprolol Versus Diltiazem for Rate Control in Atrial Fibrillation

BACKGROUND

Currently, it remains unclear whether β-blockers or nondihydropyridine calcium channel blockers are preferred for the acute management of atrial fibrillation (AF).

OBJECTIVE

The objective of this study was to compare the efficacy and safety of intravenous (IV) metoprolol and diltiazem for rate control.

METHODS

This was a single-center, retrospective cohort study of patients who presented to the emergency department between 2015 and 2019 with AF with rapid ventricular rate (RVR) and received IV metoprolol or diltiazem. The primary outcome was the percentage of patients who achieved rate control (defined as heart rate < 100 beats per minute). Secondary outcomes included time to rate control, percentage of patients requiring additional agents for rate control, and incidence of cardioversion, bradycardia, and hypotension.

RESULTS

A total of 200 patients were included in this study. Rate control was achieved in 35% and 41% of the metoprolol and diltiazem groups, respectively (P = 0.38). Mean time to rate control was not significantly different between the metoprolol and diltiazem groups (35 vs 21 minutes, P = 0.23). One patient developed hypotension, no patient developed bradycardia, and 4 patients required electric cardioversion. No adverse events were observed in patients with ejection fraction ≤40%.

CONCLUSION AND RELEVANCE

There was no difference in the achievement of rate control between IV metoprolol and diltiazem. This is the largest study to date comparing the two classes of agents for acute rate control in AF. No patient-specific factors were identified that would influence the preferential use of one medication over the other.

Review of Prothrombin Complex Concentrates Use in Apixaban and Rivaroxaban Associated Intracranial Hemorrhages

STUDY OBJECTIVE

Summarize the studies evaluating the use of 4-factor prothrombin complex concentrates in the management of apixaban and rivaroxaban associated intracranial hemorrhages.

METHODS

A PubMed literature search was conducted for articles published between 2013 and 2020 which contained the following terms in their title: (1) apixaban, rivaroxaban, or factor Xa inhibitor*, and (2) prothrombin complex concentrate*.

RESULTS

Eighteen observational studies were included. When a ∼25 units/kg (range: 25-26.9 units/kg) non-activated 4 factor prothrombin complex concentrate dose was administered, the hemostatic effectiveness rates were ≥ 79% in 2/4 studies that utilized the Sarode et al criteria, in comparison to 4/5 studies that administered a 50 units/kg dose. The mortality rates were < 20% in 7/9 studies with hemostatic effectiveness rates ≥ 79%. Mortality rates were lower in the studies demonstrating higher hemostatic effectiveness rates and including patients with higher Glasgow coma scale scores and lower intracerebral hemorrhage volumes. Overall, the thromboembolic event rates were 0-18%, with 16/18 studies demonstrating rates ≤ 10%. The thromboembolic event rates were not dose or agent dependent.

CONCLUSION

Rates of hemostatic effectiveness were influenced by the definition of hemostatic effectiveness, dose administered, and patient severity. Studies suggest that higher doses may result in higher hemostatic effectiveness rates without increasing the risk of experiencing a thromboembolic event. This review may be used by providers to modify or validate their reversal strategy approach until well designed studies are available.

C1 esterase inhibitor use in the management of lisinopril-induced angioedema: A case series

OBJECTIVE

Review 4 patients who presented with presumed lisinopril-induced angioedema and received C1 esterase inhibitor (C1-INH).

CASE SUMMARY

Four patients received C1-INH for presumed lisinopril-induced angioedema. In all cases, angioedema was attributed to lisinopril use after the patients' symptoms did not resolve after receiving other interventions. The patients received either 1500 units or 2000 units of C1-INH. All patients' symptoms resolved after receiving a single C1-INH dose, and all were discharged home within 48 hours of receiving C1-INH.

PRACTICE IMPLICATIONS

On the basis of the available literature and our study, C1-INH may effectively treat angiotensin-converting enzyme inhibitor-induced angioedema (ACEi-AE). Owing to the low incidence of ACEi-AE and the high cost of C1-INH, physicians should consider limiting the use of C1-INH to patients who remain symptomatic after the initial interventions and are at risk of a compromised airway.

Effects of Sharing Old Pictures With Grandchildren on Intergenerational Relationships: Protocol for a Randomized Controlled Trial

Background

Intergenerational relationships are beneficial for both grandparents and grandchildren. A positive grandparent-grandchild relationship can improve the psychological well-being of older adults and be a source of social support, family history, and identity development. Maintaining meaningful interactions can be, however, a challenging endeavor, especially as life events lead to relocating geographically. Grandparents and grandchildren can have different preferences in terms of communication mediums and different assumptions about the real conversational needs of the other.

Objective

In this study, we will investigate the feasibility and effect of sharing memories of older adults with their grandchildren in social media. This intervention focuses on bringing snippets of the lives of the grandparents into the grandchildren’s social media feed and analyzing the potential effect on relational quality, relational investment, and conversational resources from the perspective of the grandchildren.

Methods

A randomized controlled trial will be used to measure the effectiveness of sharing family memories through social media on intergenerational relationships from the perspective of the grandchildren. The study will be implemented in Mongolia among 60 grandparent-grandchild pairs who will be assigned to either a control or intervention group. Pictures and stories will be collected during reminiscence sessions between the researchers and the grandparents before the intervention. During an intervention period of 2 months, grandchildren in the intervention group will receive pictures and stories of their grandparents on their social media account. Pre- and postintervention questionnaires will measure relationship quality, relationship investment, and conversational resources and will be used to assess the effectiveness of the intervention.

Results

We conducted a pretest pilot from January to April 2018 among 6 pairs of participants (6 grandparents and 6 grandchildren). The validation of the protocol was focused on the process, instruments, and technological setup. We continued the study after the validation, and 59 pairs of participants (59 grandparents and 59 grandchildren) have been recruited. The data collection was completed in November 2019.

Conclusions

The results of this study will contribute to strategies to stimulate social interactions in intergenerational pairs. A validation of the study process is also presented to provide further operational recommendations. The lessons learned during the validation of the protocol are discussed with recommendations and implications for the recruitment, reminiscence sessions, technological setup, and administration of instruments.

International Registered Report Identifier (IRRID)

DERR1-10.2196/16315

Effectiveness of a Home-Based Rehabilitation Program After Total Hip Arthroplasty Driven by a Tablet App and Remote Coaching: Nonrandomized Controlled Trial Combining a Single-Arm Intervention Cohort With Historical Controls

Background

Recent technological developments such as wearable sensors and tablets with a mobile internet connection hold promise for providing electronic health home-based programs with remote coaching for patients following total hip arthroplasty. It can be hypothesized that such a home-based rehabilitation program can offer an effective alternative to usual care.

Objective

The aim of this study was to determine the effectiveness of a home-based rehabilitation program driven by a tablet app and remote coaching for patients following total hip arthroplasty.

Methods

Existing data of two studies were combined, in which patients of a single-arm intervention study were matched with historical controls of an observational study. Patients aged 18-65 years who had undergone total hip arthroplasty as a treatment for primary or secondary osteoarthritis were included. The intervention consisted of a 12-week home-based rehabilitation program with video instructions on a tablet and remote coaching (intervention group). Patients were asked to do strengthening and walking exercises at least 5 days a week. Data of the intervention group were compared with those of patients who received usual care (control group). Effectiveness was measured at four moments (preoperatively, and 4 weeks, 12 weeks, and 6 months postoperatively) by means of functional tests (Timed Up & Go test and the Five Times Sit-to Stand Test) and self-reported questionnaires (Hip disability and Osteoarthritis Outcome Score [HOOS] and Short Form 36 [SF-36]). Each patient of the intervention group was matched with two patients of the control group. Patient characteristics were summarized with descriptive statistics. The 1:2 matching situation was analyzed with a conditional logistic regression. Effect sizes were calculated by Cohen d.

Results

Overall, 15 patients of the intervention group were included in this study, and 15 and 12 subjects from the control group were matched to the intervention group, respectively. The intervention group performed functional tests significantly faster at 12 weeks and 6 months postoperatively. The intervention group also scored significantly higher on the subscales “function in sport and recreational activities” and “hip-related quality of life” of HOOS, and on the subscale “physical role limitations” of SF-36 at 12 weeks and 6 months postoperatively. Large effect sizes were found on functional tests at 12 weeks and at 6 months (Cohen d=0.5-1.2), endorsed by effect sizes on the self-reported outcomes.

Conclusions

Our results clearly demonstrate larger effects in the intervention group compared to the historical controls. These results imply that a home-based rehabilitation program delivered by means of internet technology after total hip arthroplasty can be more effective than usual care.

Trial Registration

ClinicalTrials.gov NCT03846063; https://clinicaltrials.gov/ct2/show/NCT03846063 and German Registry of Clinical Trials DRKS00011345; https://tinyurl.com/yd32gmdo

Feasibility and Patient Experience of a Home-Based Rehabilitation Program Driven by a Tablet App and Mobility Monitoring for Patients After a Total Hip Arthroplasty

Background

Recent developments in technology are promising for providing home-based exercise programs.

Objective

The objective of this study was to evaluate the feasibility and patient experience of a home-based rehabilitation program after total hip arthroplasty (THA) delivered using videos on a tablet personal computer (PC) and a necklace-worn motion sensor to continuously monitor mobility-related activities.

Methods

We enrolled 30 independently living patients aged 18-75 years who had undergone THA as a treatment for primary or secondary osteoarthritis (OA) between December 2015 and February 2017. Patients followed a 12-week exercise program with video instructions on a tablet PC and daily physical activity registration through a motion sensor. Patients were asked to do strengthening and walking exercises at least 5 days a week. There was weekly phone contact with a physiotherapist. Adherence and technical problems were recorded during the intervention. User evaluation was done in week 4 (T1) and at the end of the program (T2).

Results

Overall, 26 patients completed the program. Average adherence for exercising 5 times a week was 92%. Reasons mentioned most often for nonadherence were vacation or a day or weekend off 25% (33/134) and work 15% (20/134). The total number of technical issues was 8. The average score on the user evaluation questionnaire (range 0-5) was 4.6 at T1 and 4.5 at T2. The highest score was for the subscale “coaching” and the lowest for the subscale “sensor.”

Conclusions

A home-based rehabilitation program driven by a tablet app and mobility monitoring seems feasible for THA patients. Adherence was good and patient experience was positive. The novel technology was well accepted. When the home-based rehabilitation program proves to be effective, it could be used as an alternative to formal physiotherapy. However, further research on its effectiveness is needed.

Effects of online group exercises for older adults on physical, psychological and social wellbeing: a randomized pilot trial

BACKGROUND

Intervention programs to promote physical activity in older adults, either in group or home settings, have shown equivalent health outcomes but different results when considering adherence. Group-based interventions seem to achieve higher participation in the long-term. However, there are many factors that can make of group exercises a challenging setting for older adults. A major one, due to the heterogeneity of this particular population, is the difference in the level of skills. In this paper we report on the physical, psychological and social wellbeing outcomes of a technology-based intervention that enable online group exercises in older adults with different levels of skills.

METHODS

A total of 37 older adults between 65 and 87 years old followed a personalized exercise program based on the OTAGO program for fall prevention, for a period of eight weeks. Participants could join online group exercises using a tablet-based application. Participants were assigned either to the Control group, representing the traditional individual home-based training program, or the Social group, representing the online group exercising. Pre- and post- measurements were taken to analyze the physical, psychological and social wellbeing outcomes.

RESULTS

After the eight-weeks training program there were improvements in both the Social and Control groups in terms of physical outcomes, given the high level of adherence of both groups. Considering the baseline measures, however, the results suggest that while in the Control group fitter individuals tended to adhere more to the training, this was not the case for the Social group, where the initial level had no effect on adherence. For psychological outcomes there were improvements on both groups, regardless of the application used. There was no significant difference between groups in social wellbeing outcomes, both groups seeing a decrease in loneliness despite the presence of social features in the Social group. However, online social interactions have shown to be correlated to the decrease in loneliness in the Social group.

CONCLUSION

The results indicate that technology-supported online group-exercising which conceals individual differences in physical skills is effective in motivating and enabling individuals who are less fit to train as much as fitter individuals. This not only indicates the feasibility of training together despite differences in physical skills but also suggests that online exercise might reduce the effect of skills on adherence in a social context. However, results from this pilot are limited to a small sample size and therefore are not conclusive. Longer term interventions with more participants are instead recommended to assess impacts on wellbeing and behavior change.

Scholarly contributions of required senior research projects in a doctor of pharmacy curriculum

OBJECTIVE

To determine dissemination outcomes and faculty perceptions of senior research projects conducted from 2008 to 2011 by PharmD students in a curricular pathway focused on direct patient care.

METHODS

Preceptors' reported dissemination outcomes of research projects were surveyed and their perceptions of the precepting experience were rated using a web-based survey. Results were compared to those from an earlier pharmaceutical care cohort (2002-2007) and a combined cohort of 2, more research-intensive curricular pathways at the school.

RESULTS

The overall response rate was 90.2%. Project dissemination included 61.3% at an institutional forum, 42.3% as a submitted publication, 37.8% as a poster, and 4.5% as an oral presentation. Projects completed from 2008-2011 were significantly more likely than those from 2002-2007 to be submitted for publication (42.3% vs 10.7%, p<0.001) and published (28.8% vs 5.3%, p<0.001). Most preceptors found their research projects valuable to them professionally (88.3%) and to their own or another institution (83.5% and 78.5%, respectively). Ninety-five percent of preceptors would precept again.

CONCLUSION

Dissemination rates for pharmaceutical care projects increased over time. Despite modest dissemination levels, the majority of preceptors agreed that required student research projects provide a valuable learning experience for students.

Immature triclabendazole-resistant Fasciola hepatica: tegumental responses to in vitro treatment with the sulphoxide metabolite of the experimental fasciolicide compound alpha

Juvenile triclabendazole-resistant liver flukes, Fasciola hepatica, were incubated in vitro with 10 microg/ml of the sulphoxide metabolite of the experimental fasciolicide, compound alpha [5-chloro-2-methylthio-6-(1-naphthyloxy)-1H-benzimidazole], for 6 and 18 h. Following treatment, the specimens were examined using scanning electron microscopy (SEM), transmission electron microscopy (TEM) and tubulin immunocytochemistry. The SEM results revealed a posterior-directed disruption comprised predominantly of swelling and blebbing of the tegument; these changes were more severe and extensive after the longer 18-h incubation. Along with swelling of the tegument and blebbing, the TEM results also revealed swelling of the mitochondria and basal infolds. A decrease in the number of both T1 and T2 secretory bodies was observed in the syncytium and cytoplasmic connections after the 18-h treatment. The circular muscle bundles were also disrupted, in that the organisation of the muscle fibres was irregular and the total number of muscle fibres was reduced. The immunocytochemical studies revealed no significant disruption to the distribution of tubulin immunoreactivity within the tegumental syncytium, the cytoplasmic connections or the associated tegumental cells. The results indicate that alpha.SO is capable of disrupting the tegument of 4-week-old triclabendazole-resistant liver flukes, though the morphological changes were not associated with any significant differences in tubulin immunostaining.

Adult triclabendazole-resistant Fasciola hepatica: surface and subsurface tegumental responses to in vitro treatment with the sulphoxide metabolite of the experimental fasciolicide compound alpha

Mature Fasciola hepatica of the triclabendazole-resistant Sligo isolate were incubated in vitro with 10 microg/ml of the sulphoxide metabolite of compound alpha [5-chloro-2-methylthio-6-(1-naphthyloxy)-H-benzimidazole]; the metabolite will be referred to as alpha.SO. Changes resulting from drug treatment were examined by scanning electron microscopy (SEM), transmission electron microscopy (TEM) and tubulin immunocytochemistry (ICC). SEM revealed that disruption to the tegumental surface mainly took the form of swelling and blebbing. Extensive spine loss occurred on the ventral surface of the oral cone, and sloughing of the tegument was observed along the lateral margins of the fluke. Examination of sections from the anterior mid-body region at the TEM level revealed that treatment with alpha.SO led to swelling of the basal infolds and mitochondria within the tegumental syncytium; also, accumulations of secretory bodies beneath the apical plasma membrane. The tegumental cell bodies contained swollen mitochondria and cisternae of granular endoplasmic reticulum, but few Golgi complexes were observed. An increase in T2 secretory bodies was observed, whilst in the T1 tegumental cells, the T1 secretory bodies had decreased in number. Immunocytochemical (ICC) studies showed that incubation with alpha.SO, ABZ.SO and TCBZ.SO did not cause significant changes to the distribution of tubulin within the tegumental syncytium of the Sligo isolate. In contrast, alpha.SO, ABZ.SO and TCBZ.SO caused severe disruption to tubulin organization within the syncytial layer of the TCBZ-susceptible Cullompton isolate. The EM results confirm that compound alpha is a fasciolicide capable of disrupting the tegument of mature TCBZ-resistant F. hepatica; however, this was not accompanied by any change in tubulin immunoreactivity.

Determination of the Maximum Tolerated Dose and the Safety Index of an Experimental Fasciolicide in Cattle

The aim of the present study was to determine the maximum tolerated dose (MTD) and the safety index (SI) of 5-chloro-2-methylthio-6-(1-napthyloxy)1H-benzimidazole, called compound alpha, in cattle. In addition, to search for possible adverse effects after treatment, the measurement of some biochemical, haematological and physiological parameters were also analysed. Eighteen crossbred heifers were divided into six groups of three animals each. Groups 1-5 received a single oral dose of 12, 36, 60, 120 and 180 mg/kg of body weight (bw) of compound alpha. Group 6 served as an untreated control. To determine the biochemical, haematological and enzymatic parameters, sera and blood samples were individually taken at 0, 4, 8, 16, 32, 128, and 720 h after treatment. Physiological parameters such as rectal temperature, heart rate (HR), respiration rate (RR) and ruminal motility were measured at the time intervals mentioned above. Estimation of the MTD and SI was obtained by using the formula reported by the Food and Drug Administration (FDA), the results showing an MTD of 180 mg/kg/bw and an SI of 15 times the recommended clinical dose. Some statistical differences were observed in a few of the biochemical, haematological and enzymatic parameters, the adverse effects being not highly representative. Alterations on HR and RR were statistically different (P<0.05) only in heifers treated with 180 mg.

Do social parasitic bumblebees use chemical weapons? (Hymenoptera, Apidae)

The bumblebee Bombus (Psithyrus) norvegicus Sp.-Schn. is an obligate social parasite of B. (Pyrobombus) hypnorum L. Behavioural observations indicated that nest-invading B. norvegicus females may use allomones to defend themselves against attacking host workers. However, so far no defensive chemicals used by social parasitic bumblebee females have been identified. We analysed volatile constituents of the cuticular lipid profile of B. norvegicus females. Furthermore, we performed electrophysiological studies and behavioural experiments in order to identify possible chemical weapons. Coupled gas chromatography-electroantennography showed 15 compounds to trigger responses in antennae of the host workers. Using gas chromatography-mass spectrometry, the main compound among the cuticular volatiles of B. norvegicus females was found to be dodecyl acetate. A corresponding mixture of synthetic volatiles as well as pure dodecyl acetate showed a strong repellent effect on starved host workers. B. norvegicus females use dodecyl acetate to repel attacking B. hypnorum workers during nest usurpation and subsequently during colony development. Dodecyl acetate is the first repellent allomone identified in bumblebees.

Seroprevalence study of bovine neosporosis in Mexico

An indirect enzyme-linked immunosorbent assay was used to obtain epidemiologic information on bovine neosporosis in dairy herds of the Mexican central plateau. Sera were collected from 1,003 cows from 50 dairy herds. Forty-three herds (group A) had been experiencing a high abortion rate. The abortion rates for the remaining 7 herds (group B) were within normal limits for Mexico. Five-hundred sixty-one (56%) of the 1,003 sera were positive. The seroprevalence of Neospora caninum antibodies was 72% (95% CI = 68-75%) in group A and 36% (95% CI = 31-40%) in group B. These results clearly show that infection with N. caninum is widespread in Mexican dairy herds, as indicated by seropositive cows in group A and group B herds at the time of the sample collection.

Neosporosis in Mexican dairy herds: lesions and immunohistochemical detection of Neospora caninum in fetuses

Of 211 aborted bovine fetuses collected from Mexican dairy herds between January 1996 and March 1999, 73 showed microscopical lesions consistent with neosporosis. Of these 73 fetuses, 58 (79%) showed lymphocytic myocarditis, 39 (53%) showed microgliosis and multifocal necrosis in the brain, 39 (53%) showed lymphocytic hepatitis, and 19 (26%) showed lymphocytic myositis. Immunohistochemical examination of brain, myocardium and liver from 53 of the same 73 fetuses demonstrated Neospora caninum antigens in 41 (77%), of which 19 (46%) gave positive results in one of the three sites, 15 (37%) in two, and seven (17%) in three. The results indicated the presence of neosporosis in a number of the main dairy farming regions of Mexico.

Effect of parasite burden on the detection of Fasciola hepatica antigens in sera and feces of experimentally infected sheep

The effect of Fasciola hepatica parasite burden on the detection of excretory/secretory (E/S) antigens in sera and feces of experimentally infected sheep was evaluated using a double antibody-based capture enzyme-linked immunosorbent assay (ELISA). Four groups of five sheep each were used. The first three groups were infected with 50, 100 and 200 metacercariae of F. hepatica, and the fourth group remained as non-infected control. On the day of infection and weekly thereafter, serum and fecal samples were taken. ELISA detected F. hepatica E/S antigen levels in serum from the first week post-infection (wpi) and in fecal supernatant from the fourth wpi, which were significantly (p<0.05) higher than controls. F. hepatica eggs were not detected until after the eighth wpi. The correlation between absorbance of E/S antigens in serum with the fluke burden was 0.77 (p<0.0001) and in feces 0.76 (p<0.0001) at 12th wpi. The sensitivity of the assay to detect E/S antigens in serum was 86.6% and in feces 93.3%. It is concluded that the ELISA technique used in this study offers a diagnostic alternative for detecting early infections of F. hepatica in sheep.

Evolution of reproductive strategies in the sexually deceptive orchid Ophrys sphegodes: how does flower-specific variation of odor signals influence reproductive success?

The orchid Ophrys sphegodes Miller is pollinated by sexually excited males of the solitary bee Andrena nigroaenea, which are lured to the flowers by visual cues and volatile semiochemicals. In O. sphegodes, visits by pollinators are rare. Because of this low frequency of pollination, one would expect the evolution of strategies that increase the chance that males will visit more than one flower on the same plant; this would increase the number of pollination events on a plant and therefore the number of seeds produced. Using gas chromatography-mass spectrometry (GC-MS) analyses, we identified more than 100 compounds in the odor bouquets of labellum extracts from O. sphegodes; 24 compounds were found to be biologically active in male olfactory receptors based on gas chromatography with electroantennographic detection (GC-EAD). Gas chromatography (GC) analyses of odors from individual flowers showed less intraspecific variation in the odor bouquets of the biologically active compounds as compared to nonactive compounds. This can be explained by a higher selective pressure on the pollinator-attracting communication signal. Furthermore, we found a characteristic variation in the GC-EAD active esters and aldehydes among flowers of different stem positions within an inflorescence and in the n-alkanes and n-alkenes among plants from different populations. In our behavioral field tests, we showed that male bees learn the odor bouquets of individual flowers during mating attempts and recognize them in later encounters. Bees thereby avoid trying to mate with flowers they have visited previously, but do not avoid other flowers either of a different or the same plant. By varying the relative proportions of saturated esters and aldehydes between flowers of different stem positions, we demonstrated that a plant may take advantage of the learning abilities of the pollinators and influence flower visitation behavior. Sixty-seven percent of the males that visited one flower in an inflorescence returned to visit a second flower of the same inflorescence. However, geitonogamy is prevented and the likelihood of cross-fertilization is enhanced by the time required for the pollinium deposited on the pollinator to complete its bending movement, which is necessary for pollination to occur. Cross-fertilization is furthermore enhanced by the high degree of odor variation between plants. This variation minimizes learned avoidance of the flowers and increases the likelihood that a given pollinator would visit several to many different plants within a population.

Sex pheromone mimicry in the early spider orchid (ophrys sphegodes): patterns of hydrocarbons as the key mechanism for pollination by sexual deception

We investigated the female-produced sex pheromone of the solitary bee Andrena nigroaenea and compared it with floral scent of the sexually deceptive orchid Ophrys sphegodes which is pollinated by Andrena nigroaenea males. We identified physiologically and behaviorally active compounds by gas chromatography with electroantennographic detection, gas chromatography-mass spectrometry, and behavioral tests in the field. Dummies scented with cuticle extracts of virgin females or of O. sphegodes labellum extracts elicited significantly more male reactions than odorless dummies. Therefore, copulation behavior eliciting semiochemicals are located on the surface of the females' cuticle and the surface of the flowers. Within bee and orchid samples, n-alkanes and n-alkenes, aldehydes, esters, all-trans-farnesol and all-trans-farnesyl hexanoate triggered electroantennographic responses in male antennae. Most of the alkanes and alkenes occurred in similar patterns both in the bees and orchids. O. sphegodes leaf extracts contained mostly the same compounds but in different proportions. In behavioral tests with synthetic compounds, blends of alkenes triggered significantly more approaches and pounces of the males whereas alkanes were not more attractive than odorless dummies. Since alkanes and alkenes together were most attractive, we conclude they constitute the bees' sex pheromone as well as the pseudocopulation-behavior releasing orchid-odor bouquet.

Comparison of three ELISA tests for seroepidemiology of bovine fascioliosis

The aim of the present study was to compare the sensitivity, specificity and usefulness of the DIG-ELISA, DOT-ELISA and Indirect ELISA tests for determining the seroprevalence of fasciolosis in cattle under tropical conditions in Mexico. To standardize the tests, positive and negative sera to F. hepatica from 88 Holstein Freisian adult cows located in an enzootic area of fascioliosis and 88 crossbred adult cattle from a fluke-free area were used. For the epidemiological study, 85 crossbred cattle between 1 to 7 years of age were used. Animals were bled every two months, from March 1995 to September 1996 and the sera obtained were stored at -70 degrees C, until used. Indirect ELISA showed a sensitivity of 96.5% and a specificity of 98.8%, DIG-ELISA 97.5% and 80.0% and DOT-ELISA 93.1% and 95.4%, respectively. During 1995, Indirect ELISA yielded the highest levels of IgG anti-F. hepatica antibodies. However, in 1996, after animal treatment with triclabendazole, DIG-ELISA tended to show higher percentages of antibody-positive animals, but it was not significantly different (p>0.05) from the other tests. Comparisons made in parallel to the faecal sedimentation test demonstrated that all serological tests detected higher percentages of positive animals. Only one serum out of ten (10%) of Paramphistomum spp. cross-reacted with the DOT-ELISA test, but no cross-reaction was observed with sera from animals with other parasites. All ELISA tests were highly sensitive and specific; they may be recommended for use in seroepidemiological surveys for F. hepatica.

[Cervical synovial sarcoma: a case report]

Synovial sarcomas of the head and neck are rare, fewer than 80 cases having been reported in the literature. A synovial sarcoma of cervical soft tissues presented as a lateral mass in a 51-year-old male and was treated by cervical dissection and radiotherapy. After 24 months the patient is recurrence-free. The histology and origin of synovial sarcomas is discussed.

Bidirectional regulation of Na+,K(+)-ATPase activity by dopamine and an alpha-adrenergic agonist

Catecholamines have pronounced effects on the renal handling of sodium and water, dopamine-promoting sodium and water excretion, and norepinephrine-promoting sodium and water retention. In the present study, using isolated permeabilized renal tubule cells and intact rats, we have shown that these effects can be attributed to opposing actions of these transmitters on renal tubular Na+,K(+)-ATPase activity. The ability of each of these catecholamines to regulate Na+,K(+)-ATPase activity is affected by the concentration of Na+ as well as by the absence or presence of the opposing catecholamine.

Calcineurin mediates alpha-adrenergic stimulation of Na+,K(+)-ATPase activity in renal tubule cells

The alpha-adrenergic agonist oxymetazoline increased Na+,K(+)-ATPase activity of single proximal convoluted tubules dissected from rat kidney. Activation of the enzyme by oxymetazoline was prevented by either the alpha 1-adrenergic antagonist prazosin or the alpha 2-adrenergic antagonist yohimbine and was mimicked by the calcium ionophore A23187. The effect of oxymetazoline on Na+,K(+)-ATPase activity was prevented by a specific peptide inhibitor of calcineurin, as well as by FK 506, an immunosuppressant agent known to inhibit calcineurin; these results indicate that the action of oxymetazoline is mediated via activation of calcineurin (a calcium/calmodulin-dependent protein phosphatase). Activation of the Na+,K(+)-ATPase by either oxymetazoline or A23187 was associated with a greater than 2-fold increase in its affinity for Na+. The results provide a biochemical mechanism by which norepinephrine, released from renal nerve terminals, stimulates Na+ retention.

[Silent uncomplicated patent ductus arteriosus in children. Diagnosis with echo-Doppler]

Three cases are presented of patent uncomplicated ductus arteriosus in children, with short systolic murmur, in which the noninvasive diagnosis could not be possible without the echo-Doppler help. Although are cases with small shunts and hemodynamically well tolerated, its diagnosis and surgical treatment are essential in order to prevent the risk of bacterial endocarditis of those patients.

[Pericardial mesothelioma: apropos of a case]

We report a case of primary pericardial malignant mesothelioma in a 53-year old male with no asbestos previous exposure. The first clinical sign was a massive pericardial effusion causing hemodynamic disturbances. CT confirmed the initial ecochardiographic diagnosis. The patient underwent pericardiocentesis which improved his hemodynamic status as well as showed malignant cellularity in the liquid examination. Surgical treatment, including pericardiectomy and tumor resection, together with chemotherapy restored normal hemodynamics, the patient being now asymptomatic. We want to emphasize the rarity of this tumor and its insidious clinical presentation even leading to hemodynamic impairment, as well as the great value of echocardiography and CT in its diagnosis, although, in some cases, thoracotomy has been the only valid diagnostic procedure.

Voltage dependence and barium sensitivity of colonic K secretion in renal failure

Net colonic K secretion (JKnet) is increased in rats and humans with chronic renal failure (CRF). To study whether transepithelial potential difference (PD), active transport forces and/or luminal K conductance play a role in this adaptation, experiments were performed in the colon of control, K-adapted, and CRF rats. Under basal conditions the PD in vivo in CRF was greater than in controls and not different from K-adapted rats. JKnet was comparable in vivo in CRF and K-adapted rats and was greater than in controls. Amiloride (10 microM) reduced PD and JKnet in K-adapted and CRF rats to levels comparable to controls. Under in vitro short-circuited conditions serosal-to-mucosal K flux (JKs----m) in distal colon was significantly increased in K-adapted and CRF animals compared with control, whereas barium caused a significant reduction in JKs----m in all groups of animals. The barium-sensitive component of K secretion was greater, however, in the two experimental groups (-0.2 +/- 0.02 and -0.2 +/- 0.07 in K-adapted and CRF animals, respectively, vs. -0.08 +/- 0.02 microeq.h-1.cm-2 in controls, P less than 0.05). However, luminal barium failed to completely inhibit the increase in K secretion observed in the experimental groups. These data suggest that an increase in PD that results in a rise in luminal negativity, stimulation of active transport, and an increase in barium-sensitive K channels and barium-insensitive pathways in apical membrane of distal colon participate in the mechanism by which net K secretion is increased in the large intestine of subjects with CRF.

Intravascular volume in cirrhosis. Reassessment using improved methodology

Previous studies of blood volume (BV) in cirrhosis have either not adjusted BV properly for body size; determined plasma volume from the dilution of labeled albumin 10-20 min postinjection, when some extravascular redistribution has already occurred; and/or not used the correct whole body-peripheral hematocrit ratio (0.82) in calculating whole BV from plasma volume and the peripheral hematocrit. We measured BV with attention to these considerations in 19 patients with cirrhosis and reexamined the determinants of vascular volume and the relationship between vascular volume and sodium retention. BV was calculated as plasma volume (determined from extrapolated plasma activity of intravenously injected [131I]+albumin at time 0) divided by (peripheral hematocrit X 0.82). The result was expressed per kilogram "dry" body weight, determined by subtracting the mass of ascites (measured by isotope dilution; 1 liter = 1 kg) from the actual body weight of nonedematous patients. Measured and expressed in this way, BV correlated strongly with esophageal variceal size (r = 0.87, P less than 0.05), although not with net portal, right atrial, inferior vena caval, or arterial pressure, and was significantly greater in patients with sodium retention as compared to patients without sodium retention. The principal modifier of vascular volume in cirrhosis is vascular capacity, which is probably mainly determined by the extent of the portasystemic collateral circulation. Increased vascular volume in patients with sodium retention as compared to patients without sodium retention supports the "overflow" theory of ascites formation.

Observations on the mechanism and location of ascites reabsorption in man

Animal data indicate that ascites is reabsorbed by a lymphatic mechanism and that these vessels are subdiaphragmatic in location. We evaluated the relative role of lymphatics in ascites reabsorption in man by comparing the ascites clearance and plasma appearance rates of intraperitoneally injected radiolabeled albumin to those of intraperitoneally injected labeled autologous red blood cells, which require, owing to their large size, lymphatic removal, in patients with cirrhosis and ascites. To evaluate the location of reabsorption, we repeated these measurements after replacing ascites in the subdiaphragmatic region with 500-1000 ml of intraperitoneally injected air, reasoning that this maneuver should slow or eliminate ascites reabsorption occurring at this site. We found that the transfer rates of albumin and red cells out of ascites were similar and that creation of pneumoperitoneum did not influence these rates. These data confirm that ascites protein reabsorption occurs via a lymphatic mechanism in man. They suggest, however, that these vessels may not be subdiaphragmatic in location.

Rectification of the remnants of the leaflets--a new surgical technique to avoid periprosthetic leaks in aortic valve replacement

During the last 12 years, we have used a modified suture technique for aortic valve replacement in 450 patients in order to avoid periprosthetic leaks. There were 420 survivors, and reoperation for periprosthetic leaks was necessary in no instance. The "secret" of our technique consists of the uniform distribution of the tensile forces among all sutures, eliminating uneven stresses that favors tearing of the tissues or rupture of the stitches.

Ascites kinetics in cirrhosis: relationship to plasma-ascites hydrostatic-oncotic balance and intensity of renal sodium retention

The factors controlling ascites formation and reabsorption, as well as the relationship of ascites dynamics to renal sodium retention complicating cirrhosis, are not defined. We measured, using labeled albumin, the ascites albumin clearance rate, the plasma-ascites and ascites-plasma albumin filtration rates, the ascites albumin exit rate, and the plasma-ascites and ascites-plasma albumin transfer rates in seven patients with cirrhosis and ascites. Wedged hepatic vein pressure (WHVP), right atrial pressure (RAP), ascites pressure (AP), and serum and ascites oncotic pressure (SOP, AOP) were used to calculate the net hydrostatic (WHVP - AP), oncotic (SOP - AOP) and hydrostatic-oncotic pressure, or "transfer" pressure, favoring ascites formation [(WHVP - AP) - (SOP - AOP)], and the net hydrostatic pressure favoring ascites reabsorption (AP - RAP). Over 4 hours: the ascites albumin exit rate greater than the plasma-ascites albumin transfer rate greater than the ascites-plasma albumin transfer rate (P less than 0.05), and the ascites albumin clearance rate greater than the plasma-ascites and ascites-plasma albumin filtration rates (P less than 0.05). The ascites-plasma albumin filtration rate was inversely related to ascites volume (r = 0.91, P less than 0.01). Calculating the ascites-plasma albumin transfer rate from the extrapolated ascites-plasma albumin filtration rate at an ascites volume of 0 (0.031 L/hr/m2) produced values similar to the mean plasma-ascites albumin transfer rate (0.20 + 0.11 gm/hr/m2 vs. 0.24 + 0.13 gm/hr/m2, not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

Almost total absence of the left ventricular myocardium with dextro-transposition of the great arteries

The term parchment heart is used to describe partial to nearly complete loss of ventricular myocardium. We report the first case of transposition of the great arteries with almost total absence of left ventricular myocardium. The latter was not recognized and the child underwent Mustard's operation at four months of age. He died on the operating table. At necropsy, the left ventricular wall was 1 mm in thickness; microscopic examination revealed few myocardial fibers within edematous connective tissue.

Fracture of the outlet strut of a Björk-Shiley mitral prosthesis: emergency operation with survival

A case is presented in which the outlet strut of a Björk-Shiley mitral prosthesis (convexo-concave, 60 degree orifice opening) fractured 10 months postoperatively. Emergency reoperation was successful.