Lipid signatures of chronic pain in female adolescents with and without obesity

BACKGROUND

Chronic pain in adolescence is associated with diminished outcomes, lower socioeconomic status in later life, and decreased family well-being. Approximately one third of adolescents with chronic pain have obesity compared to the general population. In obesity, lipid signals regulate insulin sensitivity, satiety, and pain sensation. We determined whether there is a distinct lipid signature associated with chronic pain and its co-occurrence with obesity in adolescents.

METHODS

We performed global lipidomics in serum samples from female adolescents (N = 67, 13-17 years old) with no pain/healthy weight (Controls), chronic pain/healthy weight (Pain Non-obese), no pain/obesity (Obese), or chronic pain/obesity (Pain Obese).

RESULTS

The Pain Non-obese group had lipid profiles similar to the Obese and Pain Obese groups. The major difference in these lipids included decreased lysophosphatidylinositol (LPI), lysophosphatidylcholine (LPC), and lysophosphatidylethanolamine (LPE) in the three clinical groups compared to the Control group. Furthermore, ceramides and sphingomyelin were higher in the groups with obesity when compared to the groups with healthy weight, while plasmalogens were elevated in the Pain Obese group only.

CONCLUSIONS

Serum lipid markers are associated with chronic pain and suggest that specific lipid metabolites may be a signaling mechanism for inflammation associated with co-occurring chronic pain and obesity.

Naproxen for Post-Operative Pain

INTRODUCTION

Post-operative pain is a common type of acute pain that can require therapeutic intervention. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to manage post-operative pain and help reduce or eliminate the use of opioids. Current pain management guidelines recommend administration of NSAIDs as first line therapy to all post-operative surgical patients, unless contraindicated, as one method to minimize opioid use.

METHODS

This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by the author. Literature for controlled trials involving naproxen in a peri-procedural setting was included. Comprehensive meta-analyses and individual clinical trial reports were summarized.

RESULTS

Naproxen was shown to have significant efficacy in treating pain following different surgical interventions, eliminating, or reducing the use of rescue opioids in many trials. Importantly, naproxen did not demonstrate an increased rate of bleeding or other adverse events in this elevated-risk population.

CONCLUSION

As a generally safe and effective medication, clinical consideration should be given to naproxen when developing any comprehensive, patient-specific, pain management plan.

Changes in Health Care Utilization for Pediatric Patients Treated at a Specialized Outpatient Pain Clinic

INTRODUCTION

Pediatric pain clinics may be the most efficacious way to manage chronic and recurrent pain in children and adolescents, but families often rely heavily on nonspecialized care, such as the emergency department (ED). Health care utilization patterns for pediatric chronic pain have not been fully explored, particularly the patient-level factors that may contribute to underutilization or overutilization of certain services.

OBJECTIVES

To identify health care utilization patterns before and after treatment at a pediatric pain clinic and the associations by primary diagnosis and patient sociodemographics.

METHODS

Data were obtained for all pediatric patients with an initial visit at an outpatient pediatric pain clinic between 2005 and 2009. Individual-level data included patient demographics, insurance type, and diagnosis at first pain clinic visit. Rate of health care system utilization 3 months before and after the initial pain clinic visit was quantified. Health care utilization rates before and after the initial visit to the pain clinic were compared using Wilcoxon signed-rank test.

RESULTS

Eight hundred twenty-six pediatric pain clinic patients were included. Overall, there were significant decreases in ED utilization (P < 0.001) and increases in outpatient service utilization (P < 0.001) after the initial pain clinic visit. Similar patterns were noted for patients by diagnosis (headache, musculoskeletal, or abdominal pain diagnoses) and among those who were female, white, 15 to 18 years old, privately insured, middle- or high-income (P < 0.05).

CONCLUSIONS

Visits to an outpatient pediatric pain clinic were associated with shifts in health care utilization patterns. Important changes were an overall decrease in emergency visits and an increase in outpatient visits.

Pilot Study of the Gait Deviation Index in Quantifying Overweight Children's Mobility

Childhood obesity in the United States has more than tripled in the past three decades. Differences in lower extremity kinematics between obese and nonobese children during walking have been investigated, but the validity of using the gait deviation index (GDI) for measuring gait in obese children has not been explored. Nine obese children (13.9 ± 2.4 years old) with a body mass index of 33.3 ± 3.5 participated in the study. Reflective markers were placed on all children in a widely used standard lower extremity marker configuration. All participants walked along a 20-foot walkway at a self-selected speed. The kinematic and kinetic measurements for all children were taken, and the GDI for each subject was calculated. The mean ± standard deviation (SD) GDI of the nine obese children was 88.5 ± 12, which was significantly lower than the GDI of the typically developing children (100 ± 10, p < 0.002). There were no statistically significant correlations between the GDI and the Pediatric Quality of Life (PedsQL) Total score or PedsQL Physical Functioning score. Obese children had a significantly increased anterior pelvic tilt, hip flexion, hip adduction, hip adduction moment, knee flexion, knee valgus, and plantar flexion in stance phase (p < 0.05). While in swing phase, obese children had increased hip adduction and knee varus. The kinematic differences may reveal lower limb mal-alignment in obese children during walking. Overall, the GDI can play a major role in evaluating gait pathology in obese children. Future studies will increase the sample size to further evaluate the correlation between the GDI and functional outcomes.

A Safety Evaluation of a Nature-Identical l-Ergothioneine in Sprague Dawley Rats

l-(+) Ergothioneine is a naturally occurring thiol amino acid with antioxidant properties and potential benefits as a dietary supplement. Despite its century-old identification and wide distribution in human food, little is known of its mechanism of action and safety. The nature-identical biomimetic of l-(+) ergothioneine, produced by Mironova Labs and supplied as Mironova (EGT+), has been investigated in the present studies for its mutagenic and toxicologic potential. In a plate incorporation and preincubation assay with Salmonella typhimurium strains TA98, 100, 1,535, and 1,537 and Escherichia coli WP2uvrA strain, at dose concentrations of 1.58, 5, 15.8, 50, 158, 500, 1,580, and 5,000 μg/plate with and without metabolic activation, no cytotoxicity or mutagenicity was observed. Following a preliminary 28-day study, a repeated dose 90-day gavage study at dose levels of 0, 400, 800, and 1,600 mg/kg body weight (bw)/d in Sprague Dawley rats, in which dose-proportional systemic absorption was confirmed by plasma analysis, no adverse clinical, body weight/gain, food consumption and efficiency, clinical pathology, or histopathological changes associated with the administration of the nature-identical ergothioneine were observed. In conclusion, EGT+ administered over 90 days was well tolerated with a no adverse effect level at 1,600 mg/kg bw/d, the highest dose tested for male and female rats. In addition, the nature-identical test substance, EGT+ was not mutagenic in a bacterial reverse mutation assay at plate concentrations of up to 5,000 μg/mL in the presence or absence of metabolic activation.

Migration of pediatric epidural catheters

BACKGROUND

Postoperative pain control in the pediatric population frequently involves epidural catheters placed intraoperatively. A retrospective review of epidural catheter tip position was conducted by evaluation of routine chest anterior-posterior (A-P) X-rays obtained by the surgical and ICU teams.

METHODS

Of the 174 pediatric epidural catheters placed during a 1-year period at Children's Hospital of Wisconsin, 59 pediatric patients with chest X-rays demonstrating epidural catheter tip on at least 2 days were reviewed. The change in epidural catheter position was then calculated. The overall reason for discontinuation of epidural analgesia in the larger population was also compiled.

RESULTS

It was determined that epidural catheters migrated more frequently in patients <10 kg and 10-40 kg, when compared to those >40 kg P < 0.001. The average migration seen on X-ray was 1.1 levels inward in those <40 kg and 0.3 levels inward in those >40 kg. The incidence of catheters discontinued secondary to falling out, or migrating in, was also increased in those patients <40 kg when compared to those >40 kg.

CONCLUSION

Results suggest that epidural catheters move inward more frequently and fall out more frequently in patients <40 kg.

Gender-specific risk factors for peripheral artery disease in a voluntary screening population

Background

Women have high rates of peripheral artery disease (PAD) despite fewer cardiovascular disease (CVD) risk factors, compared to men. We sought to determine the gender‐specific prevalence of low ankle brachial index (ABI) and the relationship to C‐reactive protein (CRP) levels and CVD risk factors in the Life Line Screening population.

Methods and Results

Between April 2005 and August 2011, 133 750 women and 71 996 men had ABI and CRP measured at a Life Line Screening Center. Women were slightly older than men, whereas men were more likely to be current smokers, have diabetes mellitus (DM), and coronary artery disease (CAD) (P<0.001 for each). Women were more likely to have ABI≤1.0, compared to men (26.6% versus 14.4%, respectively; P<0.001), as well as ABI≤0.9 (4.1% women versus 2.6% men; P<0.001). Women had higher median CRP levels (1.94 mg/L; interquartile range [IQR], 0.89, 4.44 mg/L), compared to men (1.35 mg/L; IQR, 0.73, 2.80 mg/L; P<0.001). Men and women shared similar risk factors for ABI≤0.9, including older age, black race, smoking, DM, hypertension, hypercholesterolemia, CAD, and elevated CRP levels. In an adjusted model, there were significant interactions between gender and age (P<0.001), CRP (P<0.001), CAD (P=0.03), and DM (P=0.06) with ABI as the outcome. The associations between age, CRP, CAD, and DM with ABI≤0.9 were stronger in men than in women.

Conclusions

Women participating in the Life Line Screening had higher CRP levels and a higher prevalence of PAD, compared to men. Neither higher CRP levels nor conventional CVD risk factors explained the excess prevalence of PAD in women.

Psoriasis disease severity measures: comparing efficacy of treatments for severe psoriasis

Measurement of psoriasis disease severity and effectiveness of treatment involves both objective and subjective assessments.1 Comparing the efficacy of different treatments is complicated by the use of different metrics for measuring outcomes.2 Because these measures are not used routinely in clinical practice, interpreting these data, in particular assessing the degree of clinically meaningful improvement, is difficult. The drug approval process and product labeling reflect historical changes in standards of efficacy measurement.3 This paper reviews the metrics used to evaluate psoriasis treatment and compares available information on approved treatments for severe psoriasis. It further attempts to elucidate the value of these metrics and provide some guidance in properly evaluating the relative efficacy of current proven therapy with new treatments. While clinical trials are somewhat artificial, they provide proof that a drug is more effective than placebo. Efficacy in clinical practice, however, may be very different from the clinical trial setting. Comparison of efficacy under the current circumstances of varying evaluative metrics scales is possible with proper knowledge of the functionality of these methods.

Core outcome domains and measures for pediatric acute and chronic/recurrent pain clinical trials: PedIMMPACT recommendations

Under the auspices of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT), 26 professionals from academia, governmental agencies, and the pharmaceutical industry participated in a 2-stage Delphi poll and a consensus meeting that identified core outcome domains and measures that should be considered in clinical trials of treatments for acute and chronic pain in children and adolescents. Consensus was refined by consultation with the international pediatric pain community through announcement of our recommendations on the Pediatric Pain List and inviting and incorporating comments from external sources. There was consensus that investigators conducting pediatric acute pain clinical trials should consider assessing outcomes in pain intensity; global judgment of satisfaction with treatment; symptoms and adverse events; physical recovery; emotional response; and economic factors. There was also agreement that investigators conducting pediatric clinical trials in chronic and recurrent pain should consider assessing outcomes in pain intensity; physical functioning; emotional functioning; role functioning; symptoms and adverse events; global judgment of satisfaction with treatment; sleep; and economic factors. Specific measures or measurement strategies were recommended for different age groups for each domain.

PERSPECTIVE

Based on systematic review and consensus of experts, core domains and measures for clinical trials to treat pain in children and adolescents were defined. This will assist in comparison and pooling of data and promote evidence-based treatment, encourage complete reporting of outcomes, simplify the review of proposals and manuscripts, and facilitate clinicians making informed decisions regarding treatment.

Core outcome domains and measures for pediatric acute and chronic/recurrent pain clinical trials: PedIMMPACT recommendations

Under the auspices of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT), 26 professionals from academia, governmental agencies, and the pharmaceutical industry participated in a 2-stage Delphi poll and a consensus meeting that identified core outcome domains and measures that should be considered in clinical trials of treatments for acute and chronic pain in children and adolescents. Consensus was refined by consultation with the international pediatric pain community through announcement of our recommendations on the Pediatric Pain List and inviting and incorporating comments from external sources. There was consensus that investigators conducting pediatric acute pain clinical trials should consider assessing outcomes in pain intensity; global judgment of satisfaction with treatment; symptoms and adverse events; physical recovery; emotional response; and economic factors. There was also agreement that investigators conducting pediatric clinical trials in chronic and recurrent pain should consider assessing outcomes in pain intensity; physical functioning; emotional functioning; role functioning; symptoms and adverse events; global judgment of satisfaction with treatment; sleep; and economic factors. Specific measures or measurement strategies were recommended for different age groups for each domain.

PERSPECTIVE

Based on systematic review and consensus of experts, core domains and measures for clinical trials to treat pain in children and adolescents were defined. This will assist in comparison and pooling of data and promote evidence-based treatment, encourage complete reporting of outcomes, simplify the review of proposals and manuscripts, and facilitate clinicians making informed decisions regarding treatment.

Enzyme replacement as an effective treatment for the common symptoms of complex carbohydrate intolerance

Complex carbohydrates are an essential part of a healthy diet. However, many people suffer from varying degrees of carbohydrate intolerance, resulting in embarrassing gastrointestinal symptoms and avoidance of these components of a healthy diet. To facilitate awareness and discussion, we propose the phrase "complex carbohydrate intolerance" (CCI) as a broad term to encompass the range of symptoms associated with carbohydrate intolerance. While various treatments offer symptomatic relief, enzyme replacement therapy targets the cause of the problem: an enzyme deficiency. The enzyme, alpha-galactosidase, currently only found in the over-the-counter product, Beano, may be an effective preventative treatment for CCI.

Antibody responses to infections with strains of Plasmodium falciparum expressing diverse forms of merozoite surface protein 2

Individuals living in areas where Plasmodium falciparum is endemic experience numerous episodes of infection. These episodes may or may not be symptomatic, with the outcome depending on a combination of parasite and host factors, several of which are poorly understood. One factor is believed to be the particular alleles of several parasite proteins to which the host is capable of mounting protective immune responses. We report a study examining antibody responses to MSP2 in 15 semi-immune teenagers and adults living in the Khanh-Hoa area of southern-central Vietnam, where P. falciparum is highly endemic; subjects were serially infected with multiple strains of P. falciparum. The MSP2 alleles infecting these subjects were determined by nucleotide sequencing. A total of 62 MSP2 genes belonging to both dimorphic families were identified, of which 33 contained distinct alleles, with 61% of the alleles being detected once. Clear changes in the repertoire occurred between infections. Most infections contained a mixture of parasites expressing MSP2 alleles from both dimorphic families. Two examples of reinfection with a strain expressing a previously encountered allele were detected. Significant changes in antibody levels to various regions of MSP2 were detected over the course of the experiment. There was no clear relation between the infecting form of MSP2 and the ensuing antibody response. This study highlights the complexity of host-parasite relationship for this important human pathogen.

Dual diagnosis subtypes in urban substance abuse and mental health clinics

OBJECTIVES

This study sought to determine rates of dual disorders (psychiatric and substance use disorders) in a population of low-income inner-city outpatients, to compare the rates in outpatient mental health and substance abuse treatment settings, and to examine the clinical usefulness of classifying patients with dual disorders into three subtypes.

METHODS

A total of 57 low-income urban residents receiving mental health treatment and 73 receiving substance abuse treatment were given semistructured clinical interviews to ascertain lifetime and concurrent DSM-III-R axis I disorders. Patients with dual disorders were classified into subtypes depending on whether their psychiatric or substance use disorder was caused by the comorbid disorder or whether both disorders existed independently.

RESULTS

Eighty-three patients had a lifetime history of dual disorders: 34 patients (60 percent) in the mental health settings and 49 (67 percent) in substance abuse treatment. Among the 83 with dual disorders, more than half had experienced symptoms of both disorders within the past year. Each of the disorders was considered primary (that is, no indication was found that one was caused by the other) for 24 patients in the mental health settings (71 percent) and 31 in the substance abuse treatment settings (63 percent).

CONCLUSIONS

In each type of treatment setting, nearly two-thirds of the patients met criteria for a lifetime diagnosis of a dual disorder. This high rate of comorbidity did not appear to be attributable to substance use causing psychiatric symptoms, or vice versa. The high rate suggests the need for greater integration of mental health and substance abuse treatment, regardless of setting.

Premedication in the United States: a status report

We undertook a mailing survey study to assess the current practice of sedative premedication in anesthesia. A total of 5396 questionnaires were mailed to randomly selected physician members of the American Society of Anesthesiologists. Forty-six percent (n = 2421) of those sampled returned the questionnaire after two mailings. The reported rate of sedative premedication in the United States varied widely among age groups and geographical locations. Premedicant sedative drugs were least often used with children younger than age 3 years and most often used with adults less than 65 years of age (25% vs 75%, P = 0.001). Midazolam was the most frequently used premedicant both in adults and children (> 75%). When analyzed based on geographical locations, use of sedative premedicants among adults was least frequent in the Northeast region and most frequent in the Southeast region (50% vs 90%, P = 0.001). When the frequency of premedication was examined against health maintenance organization (HMO) penetration (i.e., HMO enrollment by total population) in the various geographical regions, correlation coefficients (r) ranged from -0.96 to -0.54. Multivariable analysis revealed that HMO penetration is an independent predictor for the use of premedication in adults and children. The marked variation among geographical areas in premedicant usage patterns underscores the lack of consensus among anesthesiologists about the need for premedication. The data suggest that HMO participation may affect delivery of this component of anesthetic care.

The glycoprotein Ib-IX complex-specific monoclonal antibody SZ1 binds to a conformation-sensitive epitope on glycoprotein IX: implications for the target antigen of quinine/quinidine-dependent autoantibodies

The monoclonal antibody SZ1 is of interest for two reasons: it was used to define complex formation between glycoprotein (GP) Ib and GP IX, and its epitope is likely to be identical to that recognized by most quinine- and quinidine-dependent autoantibodies that cause thrombocytopenia. To determine the location of the epitope for SZ1 within the GP Ib-IX complex (which consists of three subunits: GP Ib alpha, GP Ib beta, and GP IX), we tested the ability of the antibody to bind transfected cells that expressed different combinations of complex subunits, and compared this binding to the binding of antibodies of known specificity. SZ1 bound to cells that expressed the entire GP Ib-IX complex in the same pattern as did AN51 (an antibody specific for GP Ib alpha). However, unlike AN51, SZ1 did not bind alpha beta cells (ie, cells that express GP Ib alpha and GP Ib beta, but not GP IX), but did bind to beta IX and alpha IX cells. We then compared the binding patterns of SZ1 and FMC25, an antibody specific for GP IX. Both bound virtually identically to cell lines that expressed every combination of two of the three GP Ib-IX complex subunits. However, the epitopes of the two antibodies were not identical, because fixation with 4% paraformaldehyde of cells that expressed GP IX destroyed the SZ1 epitope while maintaining the FMC25 epitope. Because of the ability of SZ1 to block the binding of many quinine- and quinidine-dependent antibodies, these data strongly suggest that GP IX is the component of the GP Ib-IX complex recognized by those antibodies.

Glycoprotein (GP) Ib beta is the critical subunit linking GP Ib alpha and GP IX in the GP Ib-IX complex. Analysis of partial complexes

The glycoprotein (GP) Ib-IX complex is the receptor on platelet surfaces that mediates their adhesion to subendothelium. It comprises three polypeptides (GP Ib alpha, GP Ib beta, GP IX), each of which belongs to a superfamily of proteins containing conserved leucine-rich motifs. In this study, we used Chinese hamster ovary (CHO) cells expressing every combination of two GP Ib-IX complex subunits to demonstrate that GP Ib beta plays an essential role in the synthesis of the heterotrimer by associating with both of the other two subunits. Confocal microscopy demonstrated that GP Ib beta was present in the same cellular locations as GP Ib alpha in CHO alpha beta cells (cells expressing only GP Ib alpha and GP Ib beta) and as GP IX in CHO beta IX cells. The two polypeptides expressed in CHO alpha IX cells did not co-localize. Association between GP Ib alpha and GP Ib beta was demonstrated biochemically on immunoblots of detergent lysates of CHO alpha beta cells; electrophoresis under nonreducing conditions revealed the two subunits to be covalently linked through a disulfide bond. Association of GP Ib alpha and GP Ib beta was further demonstrated by the finding that immunoprecipitations with antibodies against either polypeptide precipitated both. Similarly, immunoprecipitations of lysates of CHO beta IX cells with antibodies against GP Ib beta or GP IX precipitated both polypeptides. In contrast, co-immunoprecipitation of the two polypeptides expressed in CHO alpha IX cells could not be demonstrated. Transient expression in CHO cells of GP Ib beta with GP IX yielded higher GP IX levels on the cell membrane than did expression of GP IX alone; supertransfection of CHO alpha IX cells with GP Ib beta also increased GP IX levels on the cell surface.

Association of GP Ib with actin-binding protein does not require GP IX

GP IX is necessary for optimal expression of the GP Ib-IX complex on the surface of transfected cells, and presumably also on the surface of the platelet. The authors investigated whether increasing complex association with the cytoskeleton is one mechanism by which GP IX exerts its effect. CHO and L cell lines that express high levels of GP Ib were used to determine whether GP Ib (GPIb alpha and GPIb beta) associated with the cytoskeleton. GP Ib in these cells was found in the insoluble cytoskeletal fraction from Triton X-100 lysates in a proportion similar to that found in cells expressing the full complex. As in platelets and cells expressing the full complex, the association of GP Ib with the cytoskeleton was shown to be mediated by actin-binding protein (ABP). This was demonstrated by the observation that a monoclonal antibody against GPIb alpha precipitated ABP from GP Ib-expressing cells, and polyclonal anti-ABP antibodies specifically coprecipitated GP Ib. In addition, colocalization of the two components in intact cells was demonstrated by confocal microscopy. These data indicate that the association of GP Ib with the cytoskeleton is independent of GP IX, which therefore must increase surface expression of the complex by another mechanism.

Technetium 99m-MDP scintigraphy of patients undergoing implant prosthetic procedures: a follow-up study

The clinical evaluation of peri-implant tissue is mainly based on x-rays. In recent years, radioisotope scintigraphy using Tc-99m-MDP (technetium-99m-methylene diphosphonate) proved to be a useful and reliable clinical method for measuring increased metabolic activity at specific sites of the skeletal tissue. Twenty-six (26) patients (26 to 75 years) who were diagnosed for implant prosthetic treatment modality were randomly chosen to participate in this study. Each patient was injected with 20 mCi of Tc-99m-MDP was scanned 2 hours later by gamma-camera for isotope uptake levels in the jaws. Each patient was scanned 1 to 4 times, starting 2 weeks after implant surgery and up to the 40th week postsurgery. Blade and screw type implants using the non-submerged, one-stage technique were placed. Therefore, the prosthetic reconstruction was initiated 2 weeks after implant surgery. In order to compare the different scans we formulated a relative "bone scan index" (BSI). The results of 62 scans were plotted as BSI against time after implant surgery. A mathematical regression analysis of the BSI was also performed. At the initial stage of 2 to 3 weeks after surgery the BSI is high and then gradually declines. While BSI of the implants in the mandible reaches baseline levels after 12 weeks, the BSI in the maxilla reaches baseline only after 20 weeks. On the other hand, there was no difference in BSI with regard to blade or screw type implant. Here we were able to demonstrate that the process is independent of implant modality and depends on the specific metabolic properties of the jaw.(ABSTRACT TRUNCATED AT 250 WORDS)

Biopharmaceutical characterisation of a low-dose (75 mg) controlled-release aspirin formulation

The release of aspirin from a 75 mg controlled-release formulation, designed to inhibit maximally thromboxane A2 production while sparing stimulated prostacyclin biosynthesis, was characterised in healthy subjects. The calculated in vivo release rate of aspirin matched the design goal of approximately 10 mg h(-1). The C(max) of aspirin associated with the controlled-release formulation was lowered 15-fold relative to a solution formulation of the same dose. The bioavailability of aspirin (based on salicylate concentrations) from the controlled-release formulation was approximately 90% relative to the solution, and drug release was not affected by co-administration of a standard breakfast.

Treatment of acne vulgaris with salicylic acid pads

Most cases of acne vulgaris are either mild or moderate in severity and well-suited for treatment with nonprescription agents that are safe, effective, and convenient to use. A review of four clinical studies and a comedolytic assay attests to the efficacy and safety of 0.5% and 2% solutions of salicylic acid for the treatment of acne vulgaris. In three placebo-controlled studies and a comedolytic assay, salicylic acid pads reduced the number of primary lesions and thereby the number and severity of all lesions associated with acne. Comparative studies of salicylic acid have shown it to be superior to benzoyl peroxide in reducing the total number of acne lesions. Adverse reactions to salicylic acid are generally limited to mild, local irritation occurring in a minority of patients.

The decision to execute a durable power of attorney for health care and preferences regarding the utilization of life-sustaining treatments in nursing home residents

One hundred three nursing home residents were interviewed regarding their preferences for the choice of an agent for health-care decision making while being offered the opportunity to execute a Durable Power of Attorney for health care. They also completed a questionnaire that tapped their preferences regarding the use of four types of life-support treatment under three hypothetical levels of future cognitive functioning. Factors that might influence these preferences, such as previous experiences with life-sustaining treatments, religious beliefs, and personal values, were also examined. Participants tended to choose their son or daughter as their agent for future health-care decision making. They had clear and consistent patterns of preferences regarding the utilization of life-sustaining treatment. Generally, participants opted not to be treated, although there was variability among participants. They were even less inclined to opt for treatment as their perceived level of future cognitive functioning declined, or when the life-sustaining treatment involved permanent rather than temporary procedures.

Characterization of nonmotile neutrophil subpopulations in neonates and adults

Previous studies have demonstrated that polymorphonuclear leukocytes (PMN) are not a homogeneous population of cells but differ significantly in their structure and function. PMN move at varying rates, and a fraction estimated from 20 to 70% do not move at all in response to chemotactic stimuli. To characterize this PMN subpopulation better, we studied PMN motility in neonates and adults using a polycarbonate micropore filter chemotactic assay and the 31D8 MAb. Most PMN strongly bind 31D8 MAb (31D8 "bright"), but a minority (31D8 "dull") weakly bind the antibody and in this respect are similar to immature PMN precursors. The 31D8 "dull" PMN have impaired function compared with 31D8 "bright" PMN. In the present study, a PMN subpopulation that failed to migrate using the micropore filter assay accounted for 58 +/- 7% of adult PMN and was similar to the migrating subpopulation in regard to viability and phagocytic function. The nonmotile subpopulation had a higher percentage of bands (5 +/- 3% versus 1 +/- 2%, p less than 0.01) and decreased binding of 31D8 MAb compared with the motile subpopulation. Neonates had a larger nonmigrating PMN subpopulation and 31D8 "dull" PMN subpopulation than those of adults (76 +/- 3% versus 58 +/- 7%, p = 0.04 and 26 +/- 11% versus 8 +/- 2%, p less than 0.01, respectively). These data indicate that although PMN appear morphologically as a homogeneous population of cells, there exists a viable, nonmotile PMN subpopulation that may be less mature than the motile PMN subpopulation. They also indicate that impaired neonatal PMN motility may be attributable in part to an increased size of the nonmotile PMN subpopulation.

The effect of the thromboxane A2 synthesis inhibitor OKY-046 on renal function in rabbits following release of unilateral ureteral obstruction

A marked decrease in renal blood flow (RBF) and glomerular filtration rate (GFR) was found after 24, 48 and 72 hours of total unilateral ureteral obstruction (UUO) in the rabbit. Contralateral GFR showed a modest increase consistent with compensatory hypertrophy. The urinary excretion of thromboxane B2 (TxB2), the stable metabolite of the vasoconstrictor prostaglandin, thromboxane A2 (TxA2) was significantly elevated in the urine obtained following release of the obstructed ureter when compared to the TxB2 level in the urine from the contralateral kidney. Continuous infusion of OKY-046 at 100 micrograms./kg./min. over 24 hours during UUO decreased TxB2 excretion by greater than 80 per cent. However there was no significant preservation of RBF or GFR of the obstructed kidney following ureteral release despite the selective inhibition of TxA2. Moreover the increase in contralateral GFR was also abolished. Taken together with other studies these results strongly suggest that the potent vasoconstrictor TxA2 is not responsible for the rise in renal resistance that follows acute UUO.

Aminocaproic acid reduces the risk of secondary hemorrhage in patients with traumatic hyphema

In a prospective, randomized, double-masked study, 34 patients (34 eyes) with nonperforating ocular injury and traumatic hyphema were treated with either aminocaproic acid (Amicar), 100 mg/kg every four hours, up to a maximum of 30 g/d, or placebo for five days. None of 21 patients who were treated with aminocaproic acid rebled, while three (23%) of 13 patients who were treated with placebo rebled. This difference was statistically significant. Of the three patients who rebled, two required surgical intervention, with one patient requiring four surgical procedures. Although complications following aminocaproic acid therapy included light-headedness, nausea and vomiting, and systemic hypotension, only one patient was withdrawn from the study because of drug-related adverse reactions. This study strongly confirms that aminocaproic acid therapy significantly reduces the incidence of secondary hemorrhage following traumatic hyphema.