Real-world evaluation of glucose-lowering therapies and the use of weight-adjusted variable rate intravenous insulin infusion in the management of hyperglycaemia in patients with acute coronary syndrome (REGULATE-ACS)

INTRODUCTION

Admission hyperglycaemia in acute coronary syndromes (ACS) is a strong independent predictor of adverse clinical outcomes post-ACS. We examined the safety, efficacy, and feasibility of a modified, weight-adjusted variable rate intravenous insulin infusion (VRIII) and evaluated current practice of prescribing novel cardio-protective glucose-lowering therapies in patients presenting with acute hyperglycaemia across the ACS spectrum.

METHODS

REGULATE-ACS was an observational single-centre study of consecutive patients admitted with acute hyperglycaemia post-ACS between 2020 and 2021. Following updated local guidance on a modified VRIII, we evaluated its safety and efficacy in glycaemic control, cardio-metabolic complications including hypoglycaemia (blood glucose <3 mmol/L) and 30-day mortality. We also determined the prescription of glucose-lowering therapies pre-discharge.

RESULTS

Out of 107 patients, mean age was 64.9 ± 12.2 years, 82% had known diabetes, and 15% newly diagnosed diabetes. 86.9% (n = 93) had an admission glucose ≥11 mmol/L. In patients treated with VRIII (n = 63/93, 67.7%), glucose improved from 17.5 to 9.0 mmol/L (IQR 7.1-12.1), which was 3 mmol/L lower (p = 0.03) than in patients not treated with VRIII (n = 30/93, 32.3%) where median glucose reduced from 12.6 to 12 mmol/L (IQR 8.6-13.9). No significant hypoglycaemia, arrhythmia or worsening pulmonary oedema associated with VRIII was found. Novel glucose-lowering therapies were initiated in 20/71 (28.2%) and 3/15 (20.0%) of patients with prior and newly diagnosed diabetes, respectively.

CONCLUSION

This real-world analysis provides further support of efficacy, safety, and feasibility of a modified, weight-adjusted VRIII in managing acute hyperglycaemia in ACS. Despite established cardio-protective benefits of novel glucose-lowering therapies, <1/3 of eligible patients received such agents pre-discharge, demanding further research and awareness.

The Efficacy and Tolerability of Levetiracetam as a First Line Monotherapy in Childhood Epilepsy

Introduction To examine efficacy and tolerability of Levetiracetam monotherapy as a first line agent in a national cohort of children with epilepsy, naïve to anti-epileptic medication. Methods A retrospective analysis of children with epilepsy who attended 4 Irish tertiary Paediatric Neurology Clinics (2009-2015) started on Levetiracetam as a first line monotherapy. Results 182 children were identified aged one month to 16 years (mean 6.2 years (SD=5.1) Retention at 6 and 12 months was 88% (n=161) and 83% (n=145) respectively. 75% (n=104) achieved seizure freedom or > 50% improvement in seizure control at 12 months. 30% (n=55) experienced ≥1 adverse effect with aggression (12%; n=21) the most frequent. Treatment was discontinued in 16% (n=29) because of intolerance. Underlying conditions and epilepsy type were not found to influence efficacy or tolerability. Conclusion Levetiracetam monotherapy was observed as effective and safe for children with epilepsy although side effects limit tolerance in a sizeable minority.

Abstract P2-09-14: Focal adhesion kinase (FAK) inhibitors VS-6063 and VS-4718 target breast cancer stem cells

Focal adhesion kinase (FAK) is a non-receptor tyrosine kinase that orchestrates cellular signaling through integrins and growth factor receptors and functions in multiple steps of tumorigenesis. Both VS-6063 and VS-4718 are potent, selective, and orally active FAK inhibitors. In a Phase 1 clinical trial, VS-6063 was well tolerated and demonstrated preliminary clinical activity. VS-6063 is currently being tested in multiple clinical studies both as a single agent and in combination with paclitaxel. VS-4718 was shown to inhibit tumor growth and metastasis in preclinical tumor models including triple negative breast cancer and is currently under evaluation in a Phase 1 clinical trial. We report here that the FAK inhibitors VS-6063 and VS-4718 effectively abrogate cancer stem cells (CSCs) in vitro and in vivo in triple negative breast cancer models.

VS-6063 and VS-4718 were evaluated in multiple cancer stem cell assays in vitro. Pre-treatment of SUM159 and MDA-MB-231 breast cancer cells with FAK inhibitors in matrigel reduced the percentage of ALDH-positive cells. The proportion of side population (SP) cancer stem cells was also reduced by FAK inhibition. The expression of ALDH1 in human breast tumor samples has previously been shown to correlate with poor prognosis (Ginestier et al 2007 Cell Stem Cell 1, 555). Significantly, ex vivo treatment of primary human breast tumor tissue with these FAK inhibitors also effectively reduced the proportion of ALDH-positive CSCs. Similar inhibitory effects on CSCs were observed in ovarian cancer cell lines OVCAR-5 and OVCAR-8. In direct contrast, cytotoxic agents such as paclitaxel and carboplatin increased the percentage of cancer stem cells in vitro, suggesting that these agents do not effectively target CSCs. Importantly, combination of either VS-6063 or VS-4718 with cytotoxic agents attenuated the enrichment of cancer stem cells induced by these cytotoxic agents.

The in vivo effect of a FAK inhibitor on cancer stem cells was evaluated in an MDA-MB-231 human breast cancer orthotopic model. Oral administration of VS-4718 significantly reduced the presence of ALDH1-positive cells in tumors as assessed by immunofluorescence. Following dissociation of cells from tumors, CSCs were found to be reduced in VS-4718-treated tumors as measured by multiple assays. Importantly, cells isolated from VS-4718-treated tumors also showed reduced tumor-initiating capability upon re-implantation into immunodeficient mice in limiting dilutions.

Our results provide clear demonstration that while FAK inhibitors significantly inhibit the growth of human breast tumor xenografts, they also preferentially target breast cancer stem cells in direct contrast to standard-of-care agents. These data provide a strong rationale for the clinical development of Verastem's FAK inhibitors in the treatment of breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-09-14.

Abstract P6-11-07: The Cancer Stem Cell-Targeting Wnt Inhibitor VS-507 Reduces Breast Cancer Growth and Metastasis

Cancer stem cells (CSCs) support tumor viability and growth through their ability to self-renew and differentiate into heterogeneous tumor tissue. CSCs are typically resistant to standard cytotoxic agents, leading to their enrichment and the consequent regrowth of refractory tumors. While this population has been challenging to directly target therapeutically, we are actively developing novel agents, such as VS-507, that selectively target the cancer stem cell subpopulation in vivo.

Previously, we and others have shown that VS-507, a cancer stem-cell specific agent, inhibits Wnt signaling with corresponding reduction of the LRP6 protein, a Frizzled co-receptor upregulated in breast cancer cell lines. In the current study, we have continued to examine the effect of VS-507 on the Wnt/Beta-catenin signaling pathway to further elucidate its mechanism of action. We determined that VS-507 also decreases expression of the second Frizzled co-receptor LRP5 in MDA-MB-231 breast cancer cells stimulated by Wnt3A. The combined inhibition of the co-receptors LRP5 and LRP6 may contribute to the observed inhibition of Beta-catenin-mediated transcription by VS-507 in a TOP-Flash assay. Accordingly, VS-507 reduced expression of Axin2, a transcriptional target of Beta-catenin.

Because human breast cancer cell lines represent a mixed population of CSC and non-CSC cells, we evaluated VS-507 across a panel of cell lines by monitoring changes in viability and in the percentage of cancer stem cells. In SUM159 triple negative breast cancer cells, VS-507 had micromolar potency against the bulk population with preferential nanomolar potency against the ALDEFLUOR+ CSC population with similar effects observed in the Hoechst side population (SP) CSC assay. In contrast, cytotoxic anticancer drugs such as paclitaxel and cisplatin increased the percentage of ALDEFLUOR+ cancer stem cells under similar conditions. In vivo, oral administration of VS-507 (15 mg/kg, QD daily) as a single agent partially inhibited MDA-MB-231 tumor growth, consistent with its observed inhibition of the cancer stem cell subpopulation. Furthermore, VS-507 inhibited lung metastasis in a 4T1.2 murine breast cancer model. In summary, these results further elucidate the mechanism by which VS-507 inhibits Wnt/Beta-catenin signaling. VS-507 reduces tumor cell proliferation in vitro with preferential effects on cancer stem cells which translate to inhibition of tumor growth, enhancement of efficacy of cytotoxic agents such as docetaxel, and inhibition of metastasis in mouse models. These data provide additional support for the development of VS-507 as a novel anti-cancer stem cell agent.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-11-07.

Abstract P6-11-09: FAK Inhibitor VS-4718 Attenuates Breast Cancer Stem Cell Function In Vitro and In Vivo

Focal adhesion kinase (FAK) is a cytoplasmic tyrosine kinase that mediates signal transduction by integrins as well as growth factor receptors. FAK has been implicated in multiple steps of carcinogenesis including tumor initiation, growth and metastasis. Amplification and overexpression of FAK have been observed in aggressive human cancers including breast cancer. We have now observed that VS-4718, a selective FAK kinase inhibitor, exhibits preferential inhibitory effects on breast cancer stem cells.

VS-4718 is a potent and selective FAK kinase inhibitor that blocks fibronectin-stimulated FAK autophosphorylation at Tyr397 at low nanomolar concentrations. To determine if FAK plays a role in the biology of breast cancer stem cells, VS-4718 was evaluated in a multitude of cancer stem cell assays both in vitro and in vivo. In parallel, treatment of SUM159 triple negative breast cancer cells in vitro with FAK shRNA inhibits tumorsphere formation. These data taken together indicate a role of FAK in breast cancer stem cell renewal. Similarly, pre-treatment of SUM159 cells with VS-4718 in matrigel attenuated secondary tumorsphere formation. Furthermore, VS-4718 reduced the side population (SP) and the percentage of ALDEFLUOR+ cancer stem cells in SUM159 breast cancer cells in vitro. In direct contrast, standard-of-care agent paclitaxel increased the percentage of ALDEFLUOR+ cancer stem cells in all three assays.

The in vivo effect of VS-4718 on cancer stem cells was evaluated in SUM159 and MDA-MB-231 human triple negative breast cancer xenograft models. Following systemic administration, VS-4718 induced significant reduction of cancer stem cells in tumors as assessed by a decrease in ALDEFLUOR+ cells and tumorsphere-forming efficiency relative to vehicle-treated tumors.

In summary, our results indicate the importance of FAK in the self-renewal of breast cancer stem cells in vitro and in vivo, and support the clinical development of the selective FAK inhibitor VS-4718 to target cancer stem cells for the treatment of triple negative breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-11-09.

Genetic risk factors for anterior cruciate ligament ruptures: COL1A1 gene variant

BACKGROUND

Anterior cruciate ligament (ACL) ruptures are considered the most severe injury sustained in sports. Although various intrinsic and extrinsic risk factors have been identified, the exact aetiology of the injury is not yet fully understood. Recently, the gene encoding for the alpha1 chain of type I collagen (COL1A1) has been shown to be associated with cruciate ligament ruptures and shoulder dislocations.

OBJECTIVE

To determine whether the functional Sp1 binding site polymorphism within intron 1 of the COL1A1 gene is associated specifically with ACL ruptures in an independent population.

METHODS

117 Caucasian participants with surgically diagnosed ACL ruptures, and 130 Caucasian physically active controls without any history of previous ligament or tendon injuries were recruited for this case-control genetic association study. All participants were genotyped for the COL1A1 Sp1 binding site polymorphism (G/T; rs1800012).

RESULTS

The rare TT genotype was significantly (p = 0.031, OR = 0.08, 95% CI <0.01 to 1.46) under-represented in the ACL group (0 out of 117, 0%), compared with the controls (6 out of 130, 4.6%).

CONCLUSION

The TT genotype of the COL1A1 Sp1 binding site polymorphism was significantly under-represented in South African participants with ACL ruptures. We propose that this sequence variant be the first specific genetic element to be included in multifactorial models developed to understand the aetiology and risk factors for ACL rupture.

Audit of the management of convulsive status epilepticus in children: the need for a uniform treatment strategy

We conducted a two-year prospective audit to review the paediatric management of Convulsive Status Epilepticus (CSE) in Ireland. Our audit showed that there is considerable variability in the management of CSE in this country. In order to provide optimum care for this potentially life-threatening condition a uniform management strategy is required. We propose a protocol for the treatment of CSE, which should ensure uniform management and optimum care and also provide a template for further study and audit of this important disorder.

Potentially reversible autoimmune limbic encephalitis with neuronal potassium channel antibody

OBJECTIVES

To describe the clinical features and coexisting serum autoantibodies in seven patients with encephalitis associated with autoantibodies to alpha-dendrotoxin-sensitive voltage-gated potassium channels (VGKCs), and to compare this disorder with other autoimmune encephalopathies.

METHODS

Clinical information was obtained from a retrospective review of medical records and telephone interviews. All autoantibody testing was performed in a single laboratory.

RESULTS

The seven patients were examined for subacute cognitive and behavioral changes. Seizures, usually temporal-onset complex partial type, were documented in six patients, and all seven patients had EEG abnormalities. None had symptoms or signs of neuromuscular hyperexcitability. One described hypersalivation. Four patients had additional autoantibody markers of neurologic autoimmunity (muscle acetylcholine receptor, striational, P/Q-type calcium channel, or GAD65), and two had thyroperoxidase antibodies. Two patients had a history of cancer: one had active prostate adenocarcinoma, and the second had a remote history of tongue carcinoma. Cranial MRI demonstrated mesial temporal lobe abnormalities in all patients. One patient improved spontaneously, and six were treated with IV methylprednisolone. Three improved remarkably with treatment. At follow-up evaluation, one had no cognitive deficits, four had mild persistent short-term memory dysfunction, and two had persistent disabling behavioral deficits.

CONCLUSIONS

Voltage-gated potassium channel antibodies are a valuable serologic marker of a potentially reversible autoimmune encephalopathy. The neurologic manifestations of this disorder are indistinguishable from paraneoplastic limbic encephalitis but are distinct from Morvan syndrome and Hashimoto encephalopathy.

Plasma exchange for severe attacks of CNS demyelination: predictors of response

The authors reviewed 59 consecutive patients treated with plasma exchange (PE) for acute, severe attacks of CNS demyelination at Mayo Clinic from January 1984 through June 2000. Most patients had relapsing-remitting MS (n = 22, 37.3%), neuromyelitis optica (NMO) (n = 10, 16.9%), and acute disseminated encephalomyelitis (n = 10, 16.9%). PE was followed by moderate or marked functional improvement in 44.1% of treated patients. Male sex (p = 0.021), preserved reflexes (p = 0.019), and early initiation of treatment (p = 0.009) were associated with moderate or marked improvement. Successfully treated patients improved rapidly following PE, and improvement was sustained.

Increase in beta-cell mass in transplanted porcine neonatal pancreatic cell clusters is due to proliferation of beta-cells and differentiation of duct cells

A 20-fold increase in beta-cell mass has been found after transplantation of porcine neonatal pancreatic cell clusters (NPCCs). Here the mechanisms leading to this increased beta-cell mass were studied. NPCCs (4000 islet equivalents) generated after 8 days culture of digested neonatal pig pancreas were transplanted beneath the renal capsule of streptozotocin (STZ) diabetic and normoglycemic nude mice. Grafts were removed at 10 days, 6 weeks, and 20 weeks after transplantation for immunostaining and insulin content. Proliferation of beta-cells and duct cells was assessed morphometrically using double immunostaining for Ki-67 with insulin or cytokeratin 7 (CK7). Graft maturation was assessed with double immunostaining of CK7 and insulin. Apoptosis was determined using propidium iodide staining. beta-cell proliferation in NPCCs was higher after 8 days of culture compared with that found in neonatal pig pancreas. After transplantation, beta-cell proliferation remained high at 10 days, decreased somewhat at 6 weeks, and was much lower 20 weeks after transplantation. Diabetic recipients not cured at 6 weeks after transplantation had significantly higher beta-cell proliferation compared with those cured and to normoglycemic recipients. The size of individual beta-cells, as determined by cross-sectional area, increased as the grafts matured. Graft insulin content was 20-fold increased at 20 weeks after transplantation compared with 8 days cultured NPCCS: The proliferation index of duct cells was significantly higher in neonatal pig pancreas than in 8 days cultured NPCCs and in 10-day-old grafts. The incidence of apoptosis in duct cells appeared to be low. About 20% of duct cells 10 days post transplantation showed costaining for CK7 and insulin, a marker of protodifferentiation. In conclusion, the increase in beta-cell mass after transplantation of NPCCs is due to both proliferation of differentiated beta-cells and differentiation of duct cells into beta-cells.

Islets in alginate macrobeads reverse diabetes despite minimal acute insulin secretory responses

BACKGROUND

Encapsulation of islets has been widely investigated as a treatment for diabetes. The characteristics and dynamics of insulin secretion by encapsulated islets in response to glucose and other secretagogues are not well understood.

METHODS

In our study, macroencapsulated syngeneic islets at 3-4 wk after transplantation were studied for insulin release in response to i.v. glucose (hyperglycemic clamps at 250 or 350 mg/dl plasma glucose), arginine (i.v. bolus, 100 mg/kg), glucagon-like peptide-1 (i.v. infusion for 20 min, 2.2 pmol/kg/min), and meal challenge. Syngeneic islets (6000 islets) were encapsulated in alginate macrobeads (2-3 mm diameter) with or without poly-L-lysine coating and transplanted into the peritoneal cavity of STZ-diabetic Lewis rats. Normal (nontransplanted) and diabetic Lewis rats transplanted with "naked" islets under the kidney capsule served as controls.

RESULTS

Animals transplanted with macrobeads displayed subnormal insulin responses to glucose, arginine, and glucagon-like peptide-1 despite achieving normoglycemia faster than animals with renal subcapsular islet transplants. Plasma insulin responses to meal challenges were blunted in animals with macrobeads resulting in increased plasma glucose excursions.

CONCLUSIONS

We conclude that, after transplantation into diabetic Lewis rats, macroencapsulated islets have significantly impaired insulin secretion despite achieving normal fed glycemic levels.

Use of single-frequency bioimpedance at 50 kHz to estimate total body water in patients with multiple organ failure and fluid overload

OBJECTIVE

To investigate the relationship between single-frequency bioimpedance at 50 kHz (both total body impedance and segmental impedance) and total body water, measured using tritiated water in the presence of the severe fluid retention seen in multiple organ failure.

DESIGN

Prospective, controlled study.

SETTING

General intensive care unit.

SUBJECTS

Twenty patients with multiple organ failure and 30 normal volunteers, of whom a subgroup of ten had total body water measured.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Total body water and total and segmental bioimpedance values at 50 kHz were measured using tritiated water and a Holtain body composition analyzer in 20 patients with multiple organ failure and in ten normal volunteers. An additional 20 normal volunteers also had segmental and total body impedance measured. There was no difference in the linear regression lines constructed for the patients and the volunteers, but the SEM in the patients (7.6 L) was four times that seen in the normal subjects (1.9 L). In a further seven patients, the impedance technique overestimated the change in total body water, deduced from acute changes in weight, by between 0% and 46% (median, 12%). In the patients, who were supine, the knee-ankle segment contributed significantly more to total body impedance than it did in the normal volunteers (42.5% vs. 34.4%; p < .001), who were upright and mobile immediately before the measurement.

CONCLUSIONS

Although single-frequency bioimpedance does give an indication of total body water and change in total body water, it is neither precise nor accurate enough to be the sole guide to fluid therapy. The proportion of total impedance contributed by the knee-ankle segment, which contains relatively little water, was significantly greater in the patients than in the controls, probably reflecting better drainage of fluid from the lower limb in the supine position.

Caspase-mediated fragmentation of calpain inhibitor protein calpastatin during apoptosis

Two cysteine protease families (caspase and calpain) participate in apoptosis. Here we report that the endogenous calpain inhibitor calpastatin is fragmented by caspase(s) to various extents during early apoptosis in two cell types. In anti-fas or staurosporine-treated Jurkat T-cells, the high-molecular-weight form (HMW) of calpastatin (apparent Mr 110 K) was extensively degraded to immunoreactive fragments of Mr 75 K and 30 K In apoptotic SH-SY5Y human neuroblastoma cells, HMW calpastatin was degraded to a major immunoreactive fragment of 75 K. In both cell types, fragmentation of HMW calpastatin was blocked by a caspase-specific inhibitor carbobenzoxy-Asp-CH2OC(O)-2,6-dichlorobenzene. In vitro translated HMW calpastatin was sensitive to proteolysis by recombinant caspase-1, -3, and -7. By contrast, in vitro translated LMW calpastatin (which lacks domains L and I) was cleaved into multiple fragments only by caspase-1 and was relatively resistant to caspase-3, -7, and other caspases tested. Consistently with that, purified erythroid LMW calpastatin was also highly susceptible to caspase-1 digestion. Recombinant human calpastatin spanning domain I through III (CAST(DI-III)) was found cleaved by caspase-1 at at least three sites, located in either the A or the C helix of domains I and III (ALDD137*L, LSSD203*F and ALAD404*S), while only a single site (ALDD137*L) was cleaved by caspase-3. These findings suggest that both HMW and LMW calpastatins are more vulnerable to caspase-1 than to caspase-3. Surprisingly, both erythroid LMW calpastatin and recombinant CAST(DI-III) fragmented by caspase-1 suffered only a less than twofold reduction of inhibitory activity toward calpain. We propose that the proteolysis of calpastatin in early apoptosis might have yet unidentified effects on the cross-talk between the two protease systems.

Catalysis by hamster dihydroorotase: zinc binding, site-directed mutagenesis, and interaction with inhibitors

Hamster dihydroorotase is the central domain of a trifunctional protein which has been cloned, overexpressed, and purified from Escherichia coli. Using the cDNA encoding the dihydroorotase domain, site-directed mutagenesis of amino acid residues conserved between species has enabled identification of three ligands of zinc at the catalytic site as His15, 17 and 158. The underlined amino acids of the nonapeptide sequence Ile12-Asp13-Val14-His15-Val16-His17- Leu18-Arg19-Glu20 from hamster are conserved between dihydroorotases from 8 species. It is proposed that the residues Asp13-His15-->ZnII form a triad at the active site and that Arg19, for which even the conservative mutation Arg19-->Lys yields an inactive enzyme, is involved in substrate binding. Site-directed mutagenesis of the conserved His186-->Ala yielded a mutant enzyme with a reduced affinity for 65Zn2+. The Km for dihydroorotate (DHO) increased from 4.0 to 11 microM, while the Vmax decreased from 1.2 to 0.53 mumol min-1 (mg of protein)-1, implicating this residue in only a minor way with binding of DHO and in catalysis. The mutation Asp230-->Glu resulted in a 14-fold increase in Km and a 16-fold decrease in Vmax, indicating involvement of this conserved residue in both binding and catalysis. The mutation Lys239-->Gly increased the Km for DHO 110-fold with a 2-fold increase in Vmax, suggesting that this residue may form a hydrogen bond with the substrate.(ABSTRACT TRUNCATED AT 250 WORDS)

Energy metabolism during CAPD: a controlled study

Abnormalities of energy metabolism may exacerbate the high prevalence of protein-calorie malnutrition and inadequate calorie intake in continuous ambulatory peritoneal dialysis (CAPD) patients, leading to further nutritional depletion. In a controlled study, using indirect calorimetry, we evaluated oxygen consumption (VO2), CO2 production, resting energy expenditure, and respiratory exchange ratio (RER) in 12 CAPD patients at rest and during a standard CAPD exchange and in 11 healthy nonuremic control patients. In addition, we investigated the influence of nutritional status and dialysis adequacy on energy metabolism in the CAPD group. There was no significant difference in resting energy parameters between the two groups. Unlike the control group, blood glucose and RER were maintained during prolonged fasting in the CAPD patients. This observation indicates that all the absorbed glucose was used as a metabolic fuel preventing fat oxidation. There was no significant relationship between energy expenditure and dialysis adequacy. There was no significant relationship between nutritional state (including energy intake) and energy expenditure despite evidence of malnutrition in 41% of the patients. If maintenance of "normal levels" of energy expenditure occurs in dialysis patients with suboptimal calorie intake (especially with evidence of protein-calorie malnutrition), this inability to conserve energy may act as an additional risk factor for ongoing malnutrition.

Manipulation of substrate utilization with somatostatin in patients with secondary multiple organ dysfunction syndrome

OBJECTIVES

To determine whether glucose utilization and metabolic substrate (glucose and fat) oxidation could be manipulated in patients with secondary multiple organ dysfunction syndrome.

DESIGN

Prospective study.

SETTING

Intensive care units (ICU) of two university hospitals.

PATIENTS

Eight adults free of hepatic disease and hemodynamically stable at the time of study, but with failed respiratory and gastrointestinal systems, who thus required mechanical ventilation and intravenous nutrition.

INTERVENTIONS

Patients were infused with 20% dextrose through central venous cannulas at rates that increased and maintained (clamped) their plasma glucose concentration at 216 mg/dL (12 mmol/L) for 3 hrs. Somatostatin was infused continuously during the second and third hours of the clamp to reduce plasma concentrations of endogenous insulin and glucagon. Exogenous insulin was administered together with somatostatin during the third hour to restore basal insulin concentrations. Energy expenditure was measured by indirect calorimetry throughout the study and blood samples were withdrawn regularly for determination of metabolite and hormone concentrations. Main statistical comparisons were made between the baseline data (first hour of the study) and data collected during the second and third hours of the clamp.

MEASUREMENTS AND MAIN RESULTS

Plasma glucagon concentrations were reduced by nearly 50% (p < .05) toward the end of the study, whereas no significant changes in plasma concentrations of cortisol or growth hormone occurred. Energy expenditure did not change significantly at any time during the clamp procedure. Glucose utilization (6.1 mg/kg/min [34 mumol/kg/min]) during the first hour of the hyperglycemic clamp, decreased by 53% (p < .05) with the infusion of somatostatin during the second hour of the clamp. However, once exogenous insulin was infused during the third hour, glucose utilization increased by 55% (p < .05) when compared with the baseline (hour 1) rate. Glucose oxidation was nearly doubled during the third hour of the study when compared with oxidation rates during the first and second hours. Fat oxidation decreased steadily during the 3-hr clamp.

CONCLUSIONS

Glucagon has a significant inhibitory effect on glucose utilization during intravenous glucose infusion in the multiple organ dysfunction syndrome patient. Pharmacologic intervention with somatostatin and insulin (physiologic dose) can facilitate glucose utilization and oxidation in these patients. Further investigations are needed to determine whether long-term alteration of glucose and fat metabolism would be beneficial in the patient with secondary multiple organ dysfunction syndrome.

National survey of state trauma registries--1992

Registries, such as those for oncology, have demonstrated usefulness in collating information. Trauma care can be improved through the accumulation of local, regional, and state trauma statistics. The efforts to develop a National Trauma Registry in the United States are still in their infancy. A four-page survey questionnaire was returned by each of the 50 State Emergency Medical Services (EMS) Directors, as well as the EMS Directors of the District of Columbia and five American possessions, to evaluate the status of state trauma registries in the United States. In 1992, 24 (48%) states had a registry. Development costs average $101,107 and annual maintenance costs averaged $72,105. An average of 1.7 full-time equivalents (FTE) was necessary to maintain the registry. Fourteen (58%) states have effected legislation through the registry. Trauma prevention has been promoted in nine (38%) states and a decrease in mortality recognized through the registry in five (21%) states. Trauma registries are labor intensive and expensive but are effective in decreasing morbidity and mortality. The need for a National Trauma Registry incorporating and comparing data from health care facilities around the United States and its possessions has the potential of improving trauma health care.

Recovery after oral surgery with halothane, enflurane, isoflurane or propofol anaesthesia

We have compared the recovery characteristics of four different techniques for maintenance of anaesthesia in 99 day-case patients admitted for oral surgery. All patients received propofol for induction of anaesthesia followed by halothane, enflurane, isoflurane or propofol infusion for maintenance of anaesthesia. Each patient was subjected to a battery of psychometric tests which included Spielberger state, trait, mood stress and mood arousal questionnaires, Maddox-Wing test and five-choice serial reaction time. All tests were performed before operation and at 0.5, 1, 2, 4, 24 and 48 h after operation. Performance in the reaction time test decreased significantly in the immediate postoperative period, returning almost to preoperative values by 4 h. However, only those patients who received enflurane or propofol had returned to their performance level before surgery by 4 h, although all four groups had achieved this target by 24 h. There was a further improvement in performance at 48 h. Anxiety and stress were high before surgery and decreased rapidly in the postoperative period. The Maddox-Wing test demonstrated a significant impairment in performance in the first 1 h after surgery, which returned to normal by discharge at 4 h. There were no significant differences between the four groups in these latter tests.

Vaginal stenosis and sexual function following intracavitary radiation for the treatment of cervical and endometrial carcinoma

PURPOSE

This study was designed to document the incidence and degree of vaginal stenosis, sexual activity, and satisfaction in women treated with intracavitary radiation therapy for cervical or endometrial carcinoma.

METHODS AND MATERIALS

The incidence of vaginal stenosis in 90 patients treated for either cervical carcinoma (n = 42) or endometrial carcinoma (n = 48) with standard doses of intracavitary radiation from 1989 to 1992 with at least 6 months follow-up was recorded. Vaginal length was measured using a modified vaginal dilator calibrated in centimeters. Semistructured patient interviews documented pretreatment and posttreatment sexual activity and sexual satisfaction.

RESULTS

Vaginal length was found to be dependent on diagnosis (cervical vs. endometrial), stage (I vs. II/III), and follow-up interval (6-12 months, 12-24 months, and > 24 months). Slightly more women reported sexual activity post vs. pretreatment (31% active pretreatment vs. 43% active posttreatment). However, 22% of women reported a decrease in sexual frequency and 37% reported a decrease in sexual satisfaction. Reports for all parameters were worse for women treated for cervical carcinoma vs. women treated for endometrial carcinoma with the exception of dyspareunia.

CONCLUSION

High-dose radiation for either cervical or endometrial carcinoma at standard doses with or without hysterectomy can cause a decrease in vaginal length as compared to the normal vaginal length of 8 to 9 cm documented by Masters and Johnson. Women treated with intracavitary implants remained as sexually active postimplant as preimplant, however, coital frequency and sexual satisfaction decreased while dyspareunia increased. The decrease in vaginal length may explain in part the decrease in sexual satisfaction but cause and effect have not been established.

Management of blunt hepatic injuries

Sixty-three consecutive patients with blunt hepatic trauma were examined. Twenty-four patients underwent immediate operation, and 39 patients were evaluated by computed tomography (CT), of whom 17 underwent operation. Ten patients had no hepatic abnormalities on CT and had operations for associated injuries. Liver injuries were noted in the remaining seven patients, but CT underestimated the injury in four patients. A large hemoperitoneum was present in all seven patients by CT, and the average transfusion was 10 U during initial resuscitation. Twenty-two patients with grade I to III injuries and a small to moderate hemoperitoneum were managed nonoperatively. Six of these patients had transfusions during resuscitation. Only one patient received more than 2 U. There were no deaths and no major complications related to the liver injury. Most patients had repeat CT at 1 week, which demonstrated stable or improving injuries. CT may underestimate the degree of liver injury. Nonoperative management is appropriate in stable patients with grade I to III injuries and a small to moderate hemoperitoneum. These patients should require no more than 2 U of blood, and repeat scans should demonstrate a stable injury.

Usefulness of an antireflux valve in the intensive care unit

The Keith Antireflux Valve (ARV) is a one-way valve placed on the sump port of a double-lumen NG tube. ARV use in critically injured patients significantly prevents reflux through the sump port and decreases the incidence of both patient gown and linen change and NG tube repositioning. There is no evidence to indicate that the ARV may lead to malfunction of the NG tube, aspiration, or gastric dilation. The cost savings in materials and nursing time are significant.

The misconception of trauma reimbursement

As health care costs increase, hospital reimbursement from trauma victims is decreasing. Thus, the number of institutions dedicated to trauma care continues to decrease in this country. Two hundred eight consecutive patients admitted to a level 1 trauma center were evaluated during a 10-month period. The total bill for 207 patients was $4,044,156, averaging $19,537 per patient. Total reimbursement 6 months after billing was $2,054,090, 51% of the total bill. Methods to improve reimbursement include increasing the ratio of blunt to penetrating trauma victims and by assembling a team knowledgeable in reimbursement options. However, because a major portion of trauma reimbursement comes under federal government regulation, topics such as diagnostic related groups and other classification criteria of critically injured patients need to be reevaluated, or underpayment for trauma patients will continue to be a national plague.

Disposition of nalbuphine in patients undergoing general anaesthesia

The pharmacokinetics of nalbuphine 20 mg i.v. were studied in 10 patients undergoing lower abdominal or body surface surgery. Blood sampling was carried out for 600 min after injection and drug concentrations were measured by HPLC using electrochemical detection. Disposition was best described as a triexponential function, with a mean elimination half-life of 135.5 min. Mean residence time, clearance, and volumes of distribution, Vss and V beta, were determined by a model independent method, and gave mean values of 149.7 min (MRT), 1095 ml min-1 (ClP), 159.9 litre (Vss) and 207.1 litre (V beta).

Pulmonary infections due to Legionella in immunocompromised patients

At present, 11 different species of Legionella have been implicated in human disease. It has become apparent that disease caused by Legionella is acquired from a variety of environmental sources and that water is the factor that links many of them. Patients who are immunosuppressed, such as individuals receiving cancer chemotherapy or therapy designed to prevent organ rejection, are particularly susceptible to such environmental sources. It appears that intact cell-mediated immunity is more important in host defense than are adequate numbers of granulocytes or immunoglobulin concentrations. Diagnostic steps should be undertaken in all patients developing nosocomial pneumonia who present with a picture suspicious for this disorder. In the meantime, appropriate antimicrobial therapy with erythromycin and rifampin should be begun. If clusters of cases are detected in a hospital, immediate steps should be taken to attempt to isolate the organism from any aqueous environmental sources, and if found appropriate, steps taken. Awareness of the threat of legionnaires' disease must be maintained among clinicians and hospital epidemiologists because it is unlikely that the problem of nosocomial legionnaires' disease will disappear.

Proactive and retroactive effects of repeated electroconvulsive shock on passive avoidance retention in rats

In spite of technical modifications, the therapeutic administration of electroconvulsive shock (ECS) to humans is still associated with significant memory impairment. Studies aimed at elucidating the neurobiologic basis of this impairment and developing appropriate treatment approaches have been limited by the absence of an appropriate animal model. We report here that ECS administered daily for 1-7 days to male albino rats (ECS X 1-ECS X 7) cumulatively impaired retention of passive avoidance when animals were trained 24 hours after the last ECS and tested 24 hours after training. Retention was directly proportional to the interval between training and testing; animals trained 24 hours after ECS X 7 and tested 1 hour later showed no deficit while animals tested after 24 hours showed maximal impairment. Retention was significantly improved by 10 days following the last of ECS X 7 and intact by 21 days. These findings parallel the effects of ECS on memory function in humans. The retrograde effects of ECS also paralleled those demonstrated in humans; while retention of a passive avoidance task learned 24 hours before ECS X 7 was grossly impaired, retention was intact if learning took place 7 days before the ECS course. The application of these findings as an animal model of ECS-induced memory impairment in humans, is discussed.

Mechanism of enhancement of blood group antibody reactions in low ionic strength

When the ionic strength of blood samples is reduced, blood group antibodies bind to red blood cells that lack the corresponding antigen. Upon normalization of the ionic strength, the antibodies elute into the supernatant fluid. We compared, in semiquantitative terms, this nonspecific and reversible binding of various blood group antibodies. Studied with anti-CD antibodies showed that the nonspecific binding increased when the ion strength was progressively lowered. In 1/10 normal ionic strength, practically all of a high-titer anti-CD antibody bound to Rh(D)-negative RBC (phenotype ce). The majority of the other antibodies studied (anti-C, -c, -Fya, -Fyb, and -S) behaved similarly in 1/10 normal ionic strength, but the binding of some (anti-E, -s, and -Jka) was, at times, less complete. Most examples of anti-K antibodies, however, demonstrated very poor nonspecific binding to K-negative RBC in low ionic strength (LIS). The authors propose that the augmentation of specific blood group antibody reactions in LIS is the direct result of this nonspecific binding, and that the failure of these conditions to support the nonspecific binding of anti-K antibodies might explain the lack of augmentation (and, at times, even the impairment) of the reactions of anti-K with its antigen.