Appetite stimulation with cannabis-based medicine and methods for assessment of glomerular filtration in older patients with medical illness: A study protocol

BACKGROUND AND AIM

Malnutrition in older patients is linked to poor appetite. Cannabis-based medicine may have orexigenic properties in older patients, but this has to our knowledge never been investigated. In older patients, uncertainty applies to the accuracy of estimated glomerular filtration rate (eGFR) based on creatinine, which is crucial for medication prescribing. In older patients with poor appetite, the study aims (1) to assess the efficacy of Sativex® (8.1-mg delta-9-tetrahydrocannabinol [THC] and 7.5-mg cannabidiol [CBD]) to stimulate appetite and (2) to compare the performance of various GFR-estimates and measured-GFR (mGFR) for determining gentamicin clearance utilizing population pharmacokinetic (popPK) modelling methods.

METHODS AND OBJECTIVES

This study is composed of two substudies. Substudy 1 is an investigator-initiated single-center, double-blinded, randomized, placebo-controlled, superiority, cross-over study. Substudy 1 will recruit 17 older patients with poor appetite, who will also be invited to substudy 2. Substudy 2 is a single-dose pharmacokinetics study and will recruit 55 patients. Participants will receive Sativex® and placebo in substudy 1 and gentamicin with simultaneous measurements of GFR in substudy 2. The primary endpoints are as follows: Substudy 1-the difference in energy intake between Sativex® and placebo conditions; substudy 2- the accuracy of different eGFR equations compared to mGFR. The secondary endpoints include safety parameters, changes in the appetite hormones, total ghrelin and GLP-1 and subjective appetite sensations, and the creation of popPK models of THC, CBD, and gentamicin.

Relationship between different serum cartilage biomarkers in the acute response to running and jumping in healthy male individuals

The effect of physical activity on serum cartilage biomarkers is largely unknown. The purpose of the study was to systematically analyze the acute effect of two frequently used exercise interventions (running and jumping) on the correlation of seven serum biomarkers that reflect cartilage extracellular matrix metabolism. Fifteen healthy male volunteers (26 ± 4 years, 181 ± 4 cm, 77 ± 6 kg) participated in the repeated measurement study. In session 1, the participants accomplished 15 × 15 series of reactive jumps within 30 min. In session 2, they ran on a treadmill (2.2 m/s) for 30 min. Before and after both exercise protocols, four blood samples were drawn separated by 30 min intervals. Serum concentrations of seven biomarkers were determined: COMP, MMP-3, MMP-9, YKL-40, resistin, Coll2-1 and Coll2-1 NO₂. All biomarkers demonstrated an acute response to mechanical loading. Both the COMP and MMP-3 responses were significantly (p = 0.040 and p = 0.007) different between running and jumping (COMP: jumping + 31%, running + 37%; MMP-3: jumping + 14%, running + 78%). Resistin increased only significantly (p < 0.001) after running, and Coll2-1 NO₂ increased significantly (p = 0.001) only after jumping. Significant correlations between the biomarkers were detected. The relationships between individual serum biomarker concentrations may reflect the complex interactions between degrading enzymes and their substrates in ECM homeostasis.

Validation of the Danish SARC-F in Hospitalized, Geriatric Medical Patients

OBJECTIVES

Validation of the Danish version of the SARC-F (Strength, Assistance in walking, Rise from a chair, Climb stairs, and Falls) for hospitalized geriatric medical patients, compared against the original EWGSOP (European Working Group on Sarcopenia in Older People) and revised EWGSOP2 definition for sarcopenia. Additionally, investigation of the ability of SARC-F to individually identify low strength/function and muscle mass.

DESIGN

Cross-sectional analysis of data from an RCT.

SETTING

Hospital, Medical Department.

PARTICIPANTS

122 geriatric medical patients (65.6% women) ≥ 70 years of age with mixed medical conditions.

MEASUREMENTS

SARC-F screening, diagnostic assessment of sarcopenia (hand-grip strength, muscle mass measured by dual-frequency bio-impedance analysis, and 4-m usual gait speed).

RESULTS

The prevalence of risk of sarcopenia (SARC-F ≥ 4) was 48.3%, while it was diagnosed in 65.8% and 21.7%, with EWGSOP and EWGSOP2, respectively. The sensitivity, specificity, positive predictive value, negative predictive value according to EWGSOP were 50.0 %, 53.7 %, 67.2% and 36.1%, while they were 53.8 %, 53.2 %, 24.1% and 80.6%, according to EWGSOP2 (all participants). The ability of SARC-F to predict reduced strength, function, and muscle mass was modest. There was a significant negative linear, yet weak, relationship between total SARC-F score and hand-grip strength (R2=0.033) and 4-m gait speed (R2=0.111), but not muscle mass (R2=0.004).

CONCLUSION

SARC-F does not seem to be a suitable screening tool for identifying and excluding non-sarcopenic geriatric patients. Furthermore, the SARC-F score was more strongly correlated with reduced muscle strength and physical function than with low muscle mass.

Uterine artery embolization of symptomatic uterine fibroids: Initial success and short-term results

Purpose: To evaluate reduction in fibroid volume, the effect on clinical symptoms, adverse events and complications after percutaneous uterine artery embolization (UAE) as primary invasive treatment for symptomatic uterine fibroids.

Material and Methods: Sixty-two patients entered the study. Indications for treatment were fibroid-induced menorrhagia, bulk symptoms, pain, and/or large fibroid size. The first 50 patients were evaluated by clinical examination and ultrasonography with measurement of fibroid volume before treament and 1, 6 and 12 months after UAE. The remaining 12 patients were followed 3 and 12 months after treatment. Embolization with microparticles was performed percutaneously in local analgesia by selective catheterization of both uterine arteries.

Results: A primary technical success with bilateral UAE was achieved in 60/62 (97%) of the patients. They were treated for postprocedural pain lasting up to 24 h. In 30 of the 62 patients with 6 months follow-up, the mean fibroid volume was reduced 68% 6 months after treatment. Twenty-nine (96%) of the patients experienced reduced bleeding, 21 (70%) reduced pain, and 18 (61%) reduced bulk symptoms at follow-up.

Conclusion: UAE is a method with a high technical success rate. The treatment has good effect on fibroid volume reduction and clinical symptoms. Severe post-procedural pain occurs generally in successful bilateral embolizations, but complications and adverse events are otherwise few and minor. UAE represents a promising new method for treating uterine fibroid-related symptoms.

Individualised dietary counselling for nutritionally at-risk older patients following discharge from acute hospital to home: a systematic review and meta-analysis

BACKGROUND

Many older patients are undernourished after hospitalisation. Undernutrition impacts negatively on physical function and the ability of older patients to perform activities of daily living at home after discharge from acute hospital. The present study aimed to evaluate the evidence for an effect of individualised dietary counselling following discharge from acute hospital to home on physical function, and, second, on readmissions, mortality, nutritional status, nutritional intake and quality of life (QoL), in nutritionally at-risk older patients.

METHODS

A systematic review of randomised controlled trials was conducted. The overall quality of the evidence was assessed according to Grading of Recommendations Assessment, Development and Evaluation system (GRADE) criteria.

RESULTS

Four randomised controlled trials (n = 729) were included. Overall, the evidence was of moderate quality. Dietitians provided counselling in all studies. Meta-analyses showed a significant increase in energy intake [mean difference (MD) = 1.10 MJ day(-1), 95% confidence interval (CI) = 0.66-1.54, P < 0.001], protein intake (MD = 10.13 g day(-1), 95% CI = 5.14-15.13, P < 0.001) and body weight (BW) (MD = 1.01 kg, 95% CI = 0.08-1.95, P = 0.03). Meta-analyses revealed no significant effect on physical function assessed using hand grip strength, and similarly on mortality. Narrative summation of effects on physical function using other instruments revealed inconsistent effects. Meta-analyses were not conducted on QoL and readmissions as a result of a lack of data.

CONCLUSIONS

Individualised dietary counselling by dietitians following discharge from acute hospital to home improved BW, as well as energy and protein intake, in older nutritionally at-risk patients, although without clearly improving physical function. The effect of this strategy on physical function and other relevant clinical outcomes warrants further investigation.

Critical dynamics of ballistic and Brownian particles in a heterogeneous environment

The dynamic properties of a classical tracer particle in a random, disordered medium are investigated close to the localization transition. For Lorentz models obeying Newtonian and diffusive motion at the microscale, we have performed large-scale computer simulations, demonstrating that universality holds at long times in the immediate vicinity of the transition. The scaling function describing the crossover from anomalous transport to diffusive motion is found to vary extremely slowly and spans at least five decades in time. To extract the scaling function, one has to allow for the leading universal corrections to scaling. Our findings suggest that apparent power laws with varying exponents generically occur and dominate experimentally accessible time windows as soon as the heterogeneities cover a decade in length scale. We extract the divergent length scales, quantify the spatial heterogeneities in terms of the non-Gaussian parameter, and corroborate our results by a thorough finite-size analysis.

Entangled dynamics of a stiff polymer

Entangled networks of stiff biopolymers exhibit complex dynamic response, emerging from the topological constraints that neighboring filaments impose upon each other. We propose a class of reference models for entanglement dynamics of stiff polymers and provide a quantitative foundation of the tube concept for stiff polymers. For an infinitely thin needle exploring a planar course of point obstacles, we have performed large-scale computer simulations proving the conjectured scaling relations from the fast transverse equilibration to the slowest process of orientational relaxation. We determine the rotational diffusion coefficient of the tracer, its angular confinement, the tube diameter, and the orientational correlation functions.

No morphine sparing effect of ketamine added to morphine for patient-controlled intravenous analgesia after uterine artery embolization

BACKGROUND

Pain following embolization of the uterine arteries (UAEs) is variable and may be very severe requiring large doses of parenteral opioids for relief. The present study tested the hypothesis that the addition of ketamine to i.v. patient-controlled morphine reduces the amount of morphine required for pain-control during the first 24 h after UAE embolization.

METHODS

Fifty-six patients undergoing UAE embolization for treatment of symptomatic uterine leiomyomata were randomized to receive either 2 mg/ml of morphine (Control group, n=30) or 2 mg/ml of both morphine and ketamine (Ketamine group, n=26) by i.v. patient-controlled analgesia (IV-PCA). Pump settings were bolus dose 1 ml, lockout 10 min, no background infusion. In addition, all patients received diclofenac and acetaminophen for pain relief. Pain scores, morphine consumption and adverse events like nausea, vomiting, itching, visual disturbances, anxiety, dreaming and hallucinations, if any, were recorded for 24 h after embolization.

RESULTS

The mean +/- SD 24-h consumption of patient-controlled morphine was 38.3 +/- 21.0 mg in the Ketamine group vs. 33.3 +/- 18.3 mg in the Control group (NS). The difference between the means was 5.0 mg (95% confidence interval: -5.7; 15.6). One patient in the Ketamine group vs. none in the Control group experienced auditory hallucinations.

CONCLUSION

Studying an unselected group of patients undergoing embolization of the UAEs for treatment of symptomatic uterine leiomyomata under conditions of basal analgesia with acetaminophen and diclofenac, we failed to demonstrate any morphine-sparing effect of IV-PCA ketamine and morphine compared with IV-PCA morphine alone.

Dynamics of semiflexible polymers in a flow field

We present a method to investigate the dynamics of a single semiflexible polymer, subject to anisotropic friction in a viscous fluid. In contrast to previous approaches, we do not rely on a discrete bead-rod model, but introduce a suitable normal mode decomposition of a continuous space curve. By means of a perturbation expansion for stiff filaments, we derive a closed set of coupled Langevin equations in mode space for the nonlinear dynamics in two dimensions, taking into account exactly the local constraint of inextensibility. The stochastic differential equations obtained this way are solved numerically, with parameters adjusted to describe the motion of actin filaments. As an example, we show results for the tumbling motion in shear flow.

Bimodality in the transverse fluctuations of a grafted semiflexible polymer and the diffusion-convection analogue: an effective-medium approach

Recent Monte Carlo simulations of a grafted semiflexible polymer in 1+1 dimensions have revealed a pronounced bimodal structure in the probability distribution of the transverse (bending) fluctuations of the free end, when the total contour length is of the order of the persistence length [G. Lattanzi, Phys. Rev E 69, 021801 (2004)]. In this paper, we show that the emergence of bimodality is related to a similar behavior observed when a random walker is driven in the transverse direction by a certain type of shear flow. We adapt an effective-medium argument, which was first introduced in the context of the sheared random-walk problem [E. Ben-Naim, Phys. Rev. A 45, 7207 (1992)], in order to obtain a simple analytic approximation of the probability distribution of the free-end fluctuations. We show that this approximation captures the bimodality and most of the qualitative features of the free-end fluctuations. We also predict that relaxing the local inextensibility constraint of the wormlike chain could lead to the disappearance of bimodality.

Potential use of Braconidae (Hymenoptera) in forensic cases

The larvae of small Diptera, such as Phoridae, from forensic cases are frequently identified by rearing out the adults. However, parasitoid Hymenoptera are often obtained instead. Rather than discarding these, it is suggested that, with a knowledge of their durations of development, they can be employed as surrogates for their hosts for estimating a minimum postmortem interval. Some data for a forensically important species of Phoridae parasitized by a species of Braconidae are presented.

Transverse fluctuations of grafted polymers

We study the statistical mechanics of grafted polymers of arbitrary stiffness in a two-dimensional embedding space with Monte Carlo simulations. The probability distribution function of the free end is found to be highly anisotropic and non-Gaussian for typical semiflexible polymers. The reduced distribution in the transverse direction, a Gaussian in the stiff and flexible limits, shows a double-peak structure at intermediate stiffnesses. We also explore the response to a transverse force applied at the polymer free end. We identify F-Actin as an ideal benchmark for the effects discussed.

[Spontaneous abortion. Drug treatment versus surgery]

INTRODUCTION

Studies of conservative management of early miscarriage have questioned the need for post abortem curettage.

METHODS

A prospective, randomised study was carried out to clarify the effect of vaginal administration of a prostaglandin E1 analogue (gemeprost) versus surgical management (curettage) of miscarriages at up to twelve weeks of gestation. A questionnaire revealed discomfort as bleeding and pain.

RESULTS

The study comprised 61 patients: group 1 (n: 27) with an endometrial thickness less than 10 mm managed by expectancy, and group 2 with an endometrial thickness greater than 10 mm; group 2 was randomised to group 2A (n: 17), given gemeprost, and group 2B (n: 17), underwent curettage. On entry the mean gestational ages were 51 and 67.5 days for groups 1 and 2, respectively; transvaginal ultrasonography revealed a mean endometrial thickness of 8 mm in group 1 and 19 mm in group 2. One week later this was reduced to 4 mm in group 1 and 5.7 mm in group 2. The duration of vaginal bleeding was similar in all groups, with a mean of 1 week (2-3 days of moderate/heavy bleeding and 6-10 of no bleeding or spotting). The discomfort experienced was similar in all groups (a mean of 36-48 hours of moderate/strong pain and 7-10 days of no or insignificant pain).

DISCUSSIONS

Conservative treatment can substitute general anesthesia and curettage in the management of complete spontaneous abortions with fresh vaginal bleeding and an endometrial thickness of up to 10 mm. Vaginal administration of 1 mg gemeprost can substitute general anesthesia and curettage in the management of incomplete spontaneous abortions of up to 12 weeks of gestation and absence of a gestation sac.

Uterine artery embolization of symptomatic uterine fibroida . Initial success and short-term results

PURPOSE

To evaluate reduction in fibroid volume, the effect on clinical symptoms, adverse events and complications after percutaneous uterine artery embolization (UAE) as primary invasive treatment for symptomatic uterine fibroids.

MATERIAL AND METHODS

Sixty-two patients entered the study. Indications for treatment were fibroid-induced menorrhagia, bulk symptoms, pain, and/or large fibroid size. The first 50 patients were evaluated by clinical examination and ultrasonography with measurement of fibroid volume before treament and 1, 6 and 12 months after UAE. The remaining 12 patients were followed 3 and 12 months after treatment. Embolization with microparticles was performed percutaneously in local analgesia by selective catheterization of both uterine arteries.

RESULTS

A primary technical success with bilateral UAE was achieved in 60/62 (97%) of the patients. They were treated for postprocedural pain lasting up to 24 h. In 30 of the 62 patients with 6 months follow-up, the mean fibroid volume was reduced 68% 6 months after treatment. Twenty-nine (96%) of the patients experienced reduced bleeding, 21 (70%) reduced pain, and 18 (61%) reduced bulk symptoms at follow-up.

CONCLUSION

UAE is a method with a high technical success rate. The treatment has good effect on fibroid volume reduction and clinical symptoms. Severe post-procedural pain occurs generally in successful bilateral embolizations, but complications and adverse events are otherwise few and minor. UAE represents a promising new method for treating uterine fibroid-related symptoms.

[Laparoscopically treated extrauterine pregnancy]

During a period of 12 months 55 women were treated for 56 ectopic pregnancies. Forty of the 56 (71%) procedures were performed laparoscopically. The duration of operation was 74 minutes when a conservative procedure was used, and 83 minutes where a salpingectomy was performed. The median duration of a diagnostic laparoscopy followed by laparotomy in 12 women was 83 minutes. Four women (13%) had persistent trophoblast, which necessitated a second operation. Two patients had a second laparoscopy because of lower abdominal pain, but did not need further treatment. Median hospitalization time (including diagnosis and second procedures) for the laparoscopically treated women was three days (range one to 16 days).

Herniation of the omentum after laparoscopy

The use of laparoscopic surgery is increasing. With this new type of surgery new complications will occur. One of these complications is herniation via the troicart incision as a result of the use of large troicarts. This problem could be solved by using the Z-incision technique or by suturing the fascia. Two cases of herniation of the omentum are described and discussed.

Laparoscopic sterilization under local anesthesia

Fifty-two women were sterilized through laparoscope under local anesthesia with Filshieclips. The majority (94%) were satisfied with the method. During the operation three patients were submitted to general anesthesia due to adhesions (two) and inadequate relaxation (one). Admission period and sick leave were reduced to a minimum.