Prospective evaluation of the emetogenic profile and analgesic efficacy of intravenous ibuprofen and metamizole in the immediate postoperative period of pediatric acute appendicitis

BACKGROUND

Literature comparing different alternatives for pain control in the immediate postoperative period of pediatric acute appendicitis (PAA) is scarce.

MATERIALS AND METHODS

We prospectively compared the analgesic and emetogenic profile of intravenous ibuprofen and metamizole in the immediate postoperative period of PAA. For this purpose, we used a sample of patients operated on in 2021 in our center. Participants were recruited on arrival at the Emergency Department and histopathological confirmation of the diagnosis was obtained in all of them. Pain was evaluated every 8 hours after the surgery with validated visual analog scales ranging from 0 to 10 points. Repeated measures ANOVA was used to compare the evolution of pain in the 48 hours after surgery between the two groups.

RESULTS

The sample included 95 patients (65% males) with a mean age of 9.7 years (sd: 3.14). 41 patients were treated with Ibuprofen (group 1) and 54 with metamizole (group 2). No significant differences were found in the level of pain either in the comparisons of point measurements or in its evolution in the 48 hours after surgery (p= 0.58). After adjusting for the received fluid therapy, children in the metamizole group had significantly more emetic episodes and needed significantly more doses of ondansetron.

CONCLUSIONS

In our cohort, ibuprofen had a similar analgesic efficacy and a better emetogenic profile than metamizole in the immediate postoperative period of PAA. Future prospective, adequately controlled studies with larger sample sizes are needed to validate these findings.

Fatal pulmonary hemorrhage, pneumothorax and skin necrosis caused by IRIS to an Aspergillus flavus infection in a young patient with metamizole associated agranulocytosis

We report the case of a young female with steroid-dependent ulcerative colitis (UC) who developed a complex systemic infection with Aspergillus flavus. This occurred following a UC relapse while vacationing in the Middle East, leading to extended use of metamizole and subsequent agranulocytosis. On her return to Germany, she was hospitalized for neutropenic sepsis and later transferred to our hospital due to persistent cytopenia and suspected Hemophagocytic Lymphohistiocytosis (HLH). Despite initial stabilization with targeted treatment for pulmonary Aspergillus flavus infection, her condition rapidly deteriorated following the onset of an Immune Reconstitution Inflammatory Syndrome (IRIS), which manifested as skin necrosis and pneumothorax after the replenishment of neutrophil granulocytes. The patient eventually died from an unmanageable pulmonary hemorrhage. Microscopy of skin necroses showed a massive presence of Aspergillus flavus, but tissue culture remained negative, suggesting effective antifungal treatment yet delayed phagocytosis due to agranulocytosis. This case underscores the need to consider IRIS in immunosuppressed patients who worsen despite aggressive and appropriately targeted treatment, highlighting its potential beyond the commonly recognized context in HIV-positive patients.

Discovery of GPX4 inhibitors through FP-based high-throughput screening

Ferroptosis is a form of non-apoptotic cell death, regulated by phospholipid hydroperoxide glutathione peroxidase 4 (GPX4), a selenoprotein with a selenocysteine residue (sec) in the active site. GPX4 is a promising target for cancer cells in therapy-resistant conditions via ferroptosis, which can reduce the level of lipid reactive oxygen species (ROS). So far, all existing GPX4 inhibitors covalently bind to GPX4 via a reactive alkyl chloride moiety or masked nitrile-oxide electrophiles with poor selectivity and pharmacokinetic properties and most were obtained by cell phenotype-based screening. Lacking of effective high-throughput screening methods for GPX4 protein limits the discovery of GPX4 inhibitors. Here, we report a fluorescence polarization (FP)-based high throughput screening (HTS) assay for GPX4-U46C-C10A-C66A in vitro, and found Metamizole sodium from our in-house compound library inhibits GPX4-U46C-C10A-C66A enzyme activity. Structure-activity relationships (SAR) demonstrated the importance of sulfonyl group on interaction between Metamizole sodium and GPX4-U46C-C10A-C66A. Our FP assay could be an effective tool for discovery of GPX4 inhibitors and Metamizole sodium was a potential inhibitor for GPX4 in vitro.

Efficient removal of the recalcitrant metamizole contaminant from drinking water by using a CaLaCoO9 perovskite supported on recycled polyethylene

Metamizole (MZ) is a widely used anti-inflammatory drug. Due to its common use, this contaminant is found in sewage and rivers. In order to reduce the contamination produced by the MZ, we fabricated in this work a photocatalytic composite using recycled polyethylene (RPE) and the CaLaCoO9 (LCCO) perovskite. Those nanoparticles had a microplate-like morphology and sizes of 1.4-5.5 µm according to the analysis of microscopy. The photocatalytic properties of the LCCO powders were evaluated under ultraviolet-visible (UV-Vis) irradiation and found a removal efficiency of 96%. When the RPE+LCCO composite was employed for the photocatalytic degradation of MZ, a maximum degradation of 92.5% was obtained. The influence of the pH on the photocatalytic activity was also studied and found that an initial pH = 3 produced a total degradation of MZ after 240 min of UV-Vis irradiation. Moreover, three reuse cycles were carried out for the pure LCCO powders and for the RPE+LCCO composites and found that the maximum loss of degradation was 5%. Furthermore, scavenger experiments demonstrated that the super oxide and hydroxyl radicals are formed during the photocatalytic reaction and were responsible for the degradation of MZ. Additionally, the X-ray photoelectron-spectroscopy and Raman analysis demonstrated the formation of defects (oxygen vacancies), those ones delayed the electron-hole recombination, which in turn, enhanced the degradation of the MZ. Thus, the studies performed in this work proved that composites made with recycled plastics and LCCO perovskites are a low-cost and feasible alternative for the cleaning of water sources polluted with pharmaceutical compounds.

Application of analgesics in emergency services in Germany: a survey of the medical directors

ABSTRAC

BACKGROUND: Treatment of acute pain is an essential element of pre-hospital care for injured and critically ill patients. Clinical studies indicate the need for improvement in the prehospital analgesia.

OBJECTIVE

The aim of this study is to assess the current situation in out of hospital pain management in Germany regarding the substances, indications, dosage and the delegation of the use of analgesics to emergency medical service (EMS) staff.

MATERIAL AND METHODS

A standardized survey of the medical directors of the emergency services (MDES) in Germany was carried out using an online questionnaire. The anonymous results were evaluated using the statistical software SPSS (Chi-squared test, Mann-Whitney-U test).

RESULTS

Seventy-seven MDES responsible for 989 rescue stations and 397 EMS- physician bases in 15 federal states took part in this survey. Morphine (98.7%), Fentanyl (85.7%), Piritramide (61%), Sufentanil (18.2%) and Nalbuphine (14,3%) are provided as opioid analgesics. The non-opioid analgesics (NOA) including Ketamine/Esketamine (98,7%), Metamizole (88.3%), Paracetamol (66,2%), Ibuprofen (24,7%) and COX-2-inhibitors (7,8%) are most commonly available. The antispasmodic Butylscopolamine is available (81,8%) to most rescue stations. Fentanyl is the most commonly provided opioid analgesic for treatment of a traumatic pain (70.1%) and back pain (46.8%), Morphine for visceral colic-like (33.8%) and non-colic pain (53.2%). In cases of acute coronary syndrome is Morphine (85.7%) the leading analgesic substance. Among the non-opioid analgesics is Ketamine/Esketamine (90.9%) most frequently provided to treat traumatic pain, Metamizole for visceral colic-like (70.1%) and non-colic (68.6%) as well as back pain (41.6%). Butylscopolamine is the second most frequently provided medication after Metamizole for "visceral colic-like pain" (55.8%). EMS staff (with or without a request for presence of the EMS physician on site) are permitted to use the following: Morphine (16.9%), Piritramide (13.0%) and Nalbuphine (10.4%), and of NOAs for (Es)Ketamine (74.1%), Paracetamol (53.3%) and Metamizole (35.1%). The dosages of the most important and commonly provided analgesic substances permitted to independent treatment by the paramedics are often below the recommended range for adults (RDE). The majority of medical directors (78.4%) of the emergency services consider the independent application of analgesics by paramedics sensible. The reason for the relatively rare authorization of opioids for use by paramedics is mainly due to legal (in)certainty (53.2%).

CONCLUSION

Effective analgesics are available for EMS staff in Germany, the approach to improvement lies in the area of application. For this purpose, the adaptations of the legal framework as well as the creation of a guideline for prehospital analgesia are useful.

Efficacy and safety in ketamine-guided prehospital analgesia for abdominal pain

Abdominal pain is a common reason for presentation in the emergency department and for calling emergency medical services. The complexity of abdominal pain also influences the analgesia strategy. However, there are almost no data on the use of ketamine for abdominal pain. This study aims to analyze the safety and efficacy of using ketamine as an analgesic for abdominal pain. In a retrospective analysis of prehospital patient data within the framework of quality assurance, all cases with ketamine administered by paramedics as analgesia for abdominal pain were analyzed in terms of pain reduction and patient safety and also compared with other analgesic drugs including fentanyl, morphine, and metamizole. From 01/01/2018 to 11/24/2021, 129 datasets were analyzed. The mean patient age was 50 ± 19 years (19-90 years), with 47.3% (n = 61) women. The application of fentanyl was documented as a monotherapy in 10.9% (n = 14), morphine in 2.3% (n = 3), metamizole in 34.1% (n = 44), and ketamine in 52.7% (n = 68) of cases. The pain relief of fentanyl, metamizole, and ketamine differed significantly from each other (p < 0.001), with fentanyl and ketamine being comparable. Looking at the quality assurance definition of successful analgesia (pain on handover NRS < 5 or pain reduction ≥ 2 points), successful analgesia was shown in 92.9% (n = 13) of cases for fentanyl, in 65.9% (n = 44) for metamizole, and 92.6% (n = 68) for ketamine (p < 0.001). Adverse events were not observed in patients treated with ketamine. Analgesia is an important goal in the treatment of patients with abdominal pain. With ketamine, analgesia comparable to fentanyl can be achieved. Ketamine appears to be a safe and effective option for the treatment of patients with abdominal pain in emergency medicine.Trial registration number DRKS00027343, date of registration: 09.12.2021, retrospectively registered.

[Comparison of the efficiency of inhalation and injection anaesthesia for the castration of male suckling piglets in different organic farms]

OBJECTIVE

In Germany, injection and inhalation anesthesia with the addition of an analgesic drug are an interim solution to surgical castration under general anesthesia due to the ban on non-anesthetic castration of male suckling piglets under 8 days of age. However, the efficiency of both anesthetic procedures is submit to controversial discussion. Most of the studies addressing this question only examined one of the procedures in comparison to piglets castrated without anesthesia or uncastrated controls. Comparisons between the anesthesia methods, especially under conditions of organically working farms, are almost completely lacking. The aim of the present study was therefore to compare the efficacy of injection and inhalation anesthesia under practical conditions in 7 organic farms as well as to examine the effect of metamizole administered in addition to meloxicam.

MATERIAL AND METHODS

For this purpose, 514 male suckling piglets were examined with regard to anesthesia efficiency (reflex test, defence behaviour), body temperature, post-operative bleeding and wound healing, post-operative behavior and pain behavior as well as the course of the recovery phase.

RESULTS

The results show a basic superiority of inhalation anesthesia over injection anesthesia, especially in the areas of anesthetic efficacy, thermoregulation and duration of the recovery phase. In 7.7 to 15 % of piglets, the perianal and interclaw reflexes studied were still present at the time of castration. Following injection and inhalation anesthesia, in total 83.6 (25.2 %) of the piglets showed at least one of the following criteria: positive reflex response, clear defensive movements or vocalisations. Body temperature dropped by 0.41 °C under inhalation anesthesia and by 1.82 °C under injection anesthesia. Post-castration bleeding and wound healing were hardly influenced by the type of anesthesia. Almost all piglets showed signs of pain and pain-associated behavior for 5 and 72 hours after castration, regardless of the type of anesthesia. The post-castration recovery phases lasted significantly longer after injection anesthesia (107 minutes) than following inhalation anesthesia (33.3 minutes) until the piglets were returned to the sow.

CONCLUSION

Neither injection nor inhalation anesthesia in spite of additional administration of meloxicam, nor the supplementary use of metamizole, fulfil the EU requirements for painless castration.

CLINICAL RELEVANCE

The necessary analgesia during and after castration of male suckling piglets is not achieved under either isoflurane or ketamine/azaperone anesthesia, despite the use of meloxicam and metamizole.

Pharmacokinetics of metamizole (dipyrone) as an add-on in calves undergoing umbilical surgery

This preliminary clinical investigation of the pharmacokinetic behavior of the main metamizole (dipyrone) metabolites 4-methylaminoantipyrine (4-MAA) and 4-aminoantipyrine (4-AA) in calves undergoing umbilical surgery is part of an already published main study. A single intravenous dose of metamizole was added to ketamine/xylazine/isoflurane anesthesia. Eight Simmental calves weighing 90 ± 10.8 kg and aged 47.6 ± 10.4 days received 40 mg/kg metamizole intravenously 10 minutes prior to general anesthesia. Blood samples were collected over 24 hours and analyzed for 4-MAA and 4-AA. Meloxicam was additionally given twice: 2.5 hours pre- and 20.5 hours postsurgically. The pharmacokinetic profile of 4-MAA was best fitted to a two-compartment model and was characterized by a fast distribution half-life and slow elimination half-life (t_½alpha = 5.29 minutes, t_½beta = 9.49 hours). The maximum concentration (C_max 101.63 μg/mL) was detected at the first measurement time point 15 minutes after administration. In contrast, 4-AA showed fast, high and biphasic plasma peak concentration behavior in five calves (2.54–2.66 μg/mL after 15–30 minutes, and 2.10–2.14 μg/mL after 2–3.5 hours) with a t_½beta of 8.87 hours, indicating a rapid distribution and subsequent redistribution from well-perfused organs. Alternatively, three calves exhibited a slower and lower monophasic plasma peak concentration (1.66 μg/mL after 6.5 hours) with a t_½beta of 6.23 hours, indicating slow accumulation in the intravascular compartment. The maximum concentration and area under the plasma concentration curve (AUC) of 4-AA were lower than those of 4-MAA. This metabolic behavior supports our already published data on clinical monitoring and plasma cortisol concentrations (PCCs). Compared to those of saline controls, lower PCCs correspond to the t_½alpha of 4-MAA. Data on T_max and t_½beta also match these clinical observations. However, further studies are required to assess the exact analgesic mechanism and potency of the metamizole metabolites in calves.

Simultaneous determination of ergotamine, caffeine and dipyrone in their ternary mixture by applying double divisor and first derivative ratio spectra methods

Two validated methods namely, double divisor ratio spectra derivative spectroscopy and derivative ratio spectroscopy with zero crossing point were applied to assay a ternary mixture of ergotamine tartrate (EGT), caffeine (CAF) and dipyrone sodium (DIP) without any additional separation steps. The linearity ranges using both methods were (1.0 µg/mL-70.0 µg/mL), (60.0 µg/mL - 100.0 µg/mL) and (100.0 µg/mL - 300.0 µg/mL) for EGT, CAF and DIP respectively. Double divisor ratio spectroscopy (method A) depends on dividing the different peak responses of EGT on (summation of peaks responses of CAF and DIP each of 10.0 µg/mL concentration) at λ max=342 nm, 310 nm and 315 nm for EGT, CAF and DIP respectively. Derivative ratio spectroscopy with zero crossing point (method B) depends on dividing the peak responses of two drugs (EGT and CAF) on (10.0 µg/mL of DIP) and dividing the peak response of DIP on peak response of (10.0 µg/mL of EGT). The detection limits of the studied drugs applying method A were (3.54, 12.96 and 8.748 µg/mL), with quantitation limits of (10.73, 39.28 and 26.51 µg/mL) for EGT, CAF and DIP respectively. Regarding method B, the limits of detection and quantitation for EGT were 0.604 µg/mL and 1.829 µg/mL respectively: with corresponding values of 19.44 µg/mL and 58.92 µg/mL for CAF and 20.44 µg/mL and 61.9 µg/mL for DIP. The obtained results were compared to those obtained by published methods and were found to be in accordance.

Oxidative damage of canine erythrocytes after treatment with non-steroidal anti-inflammatory drugs

OBJECTIVE

To investigate oxidative erythrocyte damage in dogs treated with different non-steroidal anti-inflammatory drugs.

MATERIAL AND METHODS

Case-controlled prospective observational study using blood obtained from dogs presenting for lameness examinations or standard surgical procedures to a private referral clinic. Sampling was performed from April 2018 to July 2019. Groups comprised dogs receiving either metamizole (dipyrone) (22 dogs), carprofen (20 dogs) or meloxicam (20 dogs) for a minimum of 10 days. Dogs with gastrointestinal hemorrhage were excluded from the study. A complete hematological, as well as a basic biochemical profile were performed in every dog. Pappenheim stained blood smears were evaluated for eccentrocytes and brilliant cresyl blue stained smears for Heinz bodies. EDTA blood was frozen at -80°C immediately after sampling for measurement of superoxide dismutase and gluthathione peroxidase activity at an external laboratory. Hemoglobin concentration, superoxide dismutase and gluthathione peroxidase activities, reticulocyte count, eccentrocyte and Heinz body numbers were determined prospectively as key parameters for further statistical assessment with Kruskal-Wallis test and Dunn's multiple comparisons test.

RESULTS

Dogs receiving metamizole showed a significant increase in eccentrocyte (median 14.5/500 cells vs. 0/500 cells in the other groups, p < 0.0001) and reticulocyte number (median 191.4 × 10⁹/l vs. 31.6-37.9 × 10⁹/l, p < 0.0001) and a significant decrease in hemoglobin concentration (median 8.4 mmol/l vs. 10.1-10.5 mmol/l, p < 0.0003). No significant difference in superoxide dismutase and gluthathione peroxidase activities was observed between dogs receiving metamizole and the other groups. Heinz bodies were not found in any of the dogs.

CONCLUSION

Treatment with metamizole for 10 or more days resulted in decreased hemoglobin concentration, eccentrocytosis and reticulocytosis in dogs in this study. This might be a sign of increased oxidative damage caused by this drug.

CLINICAL SIGNIFICANCE

Prolonged metamizole therapy should be evaluated critically in patients already affected by severe illness or underlying anaemia.

Pharmacokinetics of dipyrone in horses: A multi-dose, dose escalation study

Dipyrone is a non-opioid, nonsteroidal anti-inflammatory drug with antipyretic and analgesic properties commonly used in horses. Dipyrone is rapidly hydrolyzed to the primary active metabolite 4-methylaminoantipyrine (4-MAA). The purpose of this study was to determine the pharmacokinetic profile of 4-MAA following repeated and escalating doses of intravenously administered dipyrone. Twenty-six horses were randomly allocated to five treatment groups (one placebo group and four dipyrone groups [30 mg/kg q8h, 30 mg/kg q12h, 60 mg/kg q8h, and 90 mg/kg q12h]) and treated for nine consecutive days. Blood was collected at predetermined timepoints, and plasma was analyzed for 4-MAA concentrations with a validated LC/MS/MS method. Following a single dose, there was a linear correlation to the maximum concentration (Cmax ) achieved. There was a disproportionate increase in the minimum concentration (Cmin ) of 4-MAA with accumulation occurring at higher doses or more frequent dosing intervals. Significant differences were noted in 4-MAA Cmax , half-life, and area under the curve during the dosing interval (AUCtau ) when dipyrone was administered at 30 mg/kg q12h versus q8h. Adverse effects attributed to drug administration were not noted.

Development of electroanalytical procedure for monitoring of metamizole in organic fertilizers (human urine and struvite) associated with portable equipment

Urine and struvite are promising organic fertilizers that can replace conventional fertilizers. However, these fertilizers can have some emerging contaminants, such as dipyrone. This drug is one of the main painkillers consumed in the world and its continuous and indiscriminate intake can promote the camouflage of symptoms of other diseases, anaphylactic shock and even death. Thus, a fast, sensitive, inexpensive and portable method for metamizole (dipyrone) determination in several matrices, applied as organic fertilizers, has been successfully developed using portable equipment and bare carbon screen-printed electrodes in conjunction with square wave voltammetry (SWV). The main SWV operating parameters were optimized (equilibrium time (60 s), step potential (6 mV), modulation amplitude (50 mV) and frequency (10 Hz)) using univariate experiments. The proposed method presented a limit of detection of 0.097 ± 0.002 μmol L^-1 (RSD = 2.72%, n = 3) for dipyrone in 0.1 mol L^-1 HCl and R² equal to 0.993. The determination in the struvite sample presented a concentration of 0.47 μmol L^-1 of dipyrone. Urine sample used in the production of struvite and urine collected from an individual 10h after ingestion of 500 mg dipyrone tablet showed concentrations of 15.2 and 590 μmol L^-1 of dipyrone, respectively. The recovery test in fortified struvite sample showed values between 91 and 102% (RSD = 3.1%, n = 3) and of 102% (SD = 3.7%, n = 3) in human urine, indicating that there is no matrix effect. These results reinforce the possibility of applying the proposed method on-site in a practical and fast way, without the need of significant amounts of sample promoting a more sustainable chemistry.

Effect of topical application of dipyrone on dental sensitivity reduction after in-office dental bleaching: A randomized, triple-blind multicenter clinical trial

BACKGROUND

Tooth sensitivity commonly occurs during and immediately after dental bleaching. The authors conducted a trial to compare tooth sensitivity after in-office bleaching after the use of either a topical dipyrone or placebo gel.

METHODS

A split-mouth, triple-blind, randomized, multicenter clinical trial was conducted among 120 healthy adults having teeth that were shade A2 or darker. The facial tooth surfaces of the right or left sides of the maxillary arch of each patient were randomly assigned to receive either topical dipyrone or placebo gel before 2 in-office bleaching sessions (35% hydrogen peroxide) separated by 2 weeks. Visual analog and numerical rating scales were used to record tooth sensitivity during and up to 48 hours after bleaching. Tooth color change from baseline to 1 month after bleaching was measured with shade guide and spectrophotometer measures. The primary outcome variable was absolute risk of tooth sensitivity. An intention-to-treat analysis was used to analyze data from all patients who were randomly assigned to receive the dipyrone and placebo gels.

RESULTS

No statically significant difference was found in the absolute risk of tooth sensitivity between the dipyrone and placebo gels (83% and 90%, respectively, P = .09; relative risk, 0.92; 95% confidence interval, 0.8 to 1.0). A whitening effect was observed in both groups with no statistically significant difference (P > .05) between them. No adverse effects were observed.

CONCLUSION

Topical use of dipyrone gel before tooth bleaching, at the levels used in this study, did not reduce the risk or intensity of bleaching-induced tooth sensitivity.

PRACTICAL IMPLICATIONS

Topical application of dipyrone gel does not reduce bleaching-induced tooth sensitivity.

[Observations of MDPV users: a prospective-retrospective study]

INTRODUCTION

The spreading of "designer drugs" resulted in the appearance of "similar yet different" substances, the chemical structure of which are modified so regularly, which makes their research very difficult. We came across one of these substances, MDPV, while on night duty before it was mentioned in research papers. Our own research explores the changes in drug consumption patterns, especially in MDPV consumption patterns in the past few years, and gives a description of psychiatric and associated symptoms.

METHOD

We compared cases of patients admitted to our ward between Jan 1., 2010 and November 30., 2012 with symptoms of drug consumption and its complications (BNO F15.00-F15.90, F19.00-F19.90). We examined symptoms that required inpatient care at the psychiatry ward.

RESULTS

While in 2010 we treated only 3 MDPV users on 6 occasions, 4 Mephedrone users on 6 occasions, and 9 patients using other substances (Speed, Cannabis) on 10 occasions at our ward, in 2011 there were no Mephedrone-related hospitalizations and only 9 patients using other substances (Cannabis, Synthetic Cannabinoid, 5-MeO-AMT, Glue, Metamizole, Ketamine) were treated on 13 occasions. Between Jan 1. 2011. and Nov 30.2012 there were 40 recorded cases related to MDPV-use in the period: forty people were registered on 87 occasions. Nine people receive impatient care after observation on 10 occasions. In all these cases psychotic symptoms were recorded.

CONCLUSION

The constant development of designer drugs requires better administration of the individual cases, symptoms and forms of treatments. Informing doctors about these details also seems necessary. We have found that the behaviours of drug users show a positive correspondence with changing legal environments, which calls for a more sensible drug-related policy.

Effect of cigarette smoking on serum hydrocodone levels in chronic pain patients

Nicotine is reported to have analgesic properties. Patients with chronic pain who smoke could therefore, be expected to require less analgesia than non-smokers because of the possible synergism of the two substances. One hundred healthy patients were studied who had non-radicular low back pain for greater than three months. Each patient failed conservative therapies, which consisted of muscle relaxants, physical therapy and/or NSAIDS. Our study population consisted of two groups of 50 patients. Each group included: I, cigarette smokers; and II, non-smokers. Each patient received 0-40 mg/24hrs of hydrocodone as needed for pain relief for the duration of this four week study. Numeric pain intensity scores (0-10), mean total hydrocodone dosing, and quantitative blood nicotine and hydrocodone levels were assessed at the beginning and end of this study. Patients kept daily diaries and recorded pain scores and self hydrocodone dosing upon awakening, in the afternoon, and at bed time. Parametric and nonparametric statistical analysis was performed using the appropriate test with p < or = 0.05 necessary to reject the null hypothesis There were no differences in demographics between the two groups. Smokers had higher end of study pain scores and required more hydrocodone than non-smokers but had significantly lower serum levels of hydrocodone than non-smokers. The results of this study suggest that cigarette smoking adversely affects serum hydrocodone levels. Prescribing physicians should be aware that in some cigarette smokers, serum hydrocodone levels might not be detectible.

Amalgam allergy associated with exacerbation of aspirin-intolerant asthma

BACKGROUND

Aspirin-intolerant asthma can be induced not only by acidic analgesics (including acetylsalicylic acid), which effectively inhibit cyclo-oxygenase, but also by cross-reactivity with paraben, and other chemical additives.

OBJECTIVE

We examined whether amalgam allergy is involved in the pathogenesis of a aspirin-intolerant asthma.

METHODS

We present the first case of aspirin-intolerant asthma that improved after the removal of dental amalgam. In addition, we performed both the methacholine provocation testing and sulpyrine provocation testing before and after the removal of dental amalgam.

RESULTS

In addition, the methacholine concentration causing a 20% fall in FEV1 in provocation tests rose significantly, though hypersensitivity to analgesics evaluated with sulpyrine provocation testing did not decrease. These results suggest that amalgam sensitization is involved in bronchial hyperresponsiveness in aspirin-intolerant asthma.

CONCLUSION

Sensitivity to amalgam may cause exacerbation of aspirin-intolerant asthma in some patients. To the best of our knowledge, this is the first case report of amalgam allergy associated with aspirin-intolerant asthma.

Anti-inflammatory effect of roxithromycin in patients with aspirin-intolerant asthma

BACKGROUND

Fourteen-membered macrolides, such as roxithromycin, have been reported to exhibit other pharmacological activity including anti-asthmatic effects, besides antibiotic activity.

OBJECTIVE

This study was designed to investigate the protective effect of roxithromycin on airway responsiveness to the sulpyrine provocation test and to investigate whether this protective activity is associated with a reduction in aspirin-induced excretion of urinary leucotriene E4 (u-LTE4), a marker of cysteinyl leucotriene overproduction that participates in the pathogenesis of aspirin-intolerant asthma. Also, the present study was designed to examine whether or not its anti-asthmatic activity was associated with a reduction in eosinophilic inflammation.

METHODS

For 8 weeks before analysis, subjects received 150 mg of roxithromycin or matching placebo twice daily. We assessed the effects of pretreatment with roxithromycin on bronchoconstriction precipitated by inhalation of sulpyrine in 14 adult patients with mild or moderate aspirin-intolerant asthma; those who were in stable clinical condition and were hyperresponsive to sulpyrine provocation test were allocated to this study. A double-blind, randomized, crossover design was used. Urinary LTE4 was measured by a combined reverse-phase high-performance liquid chromatography (rp-HPLC) enzyme immunoassay on sulpyrine provocation testing day. Blood and sputum samples were taken in the morning on the sulpyrine provocation testing day. Eosinophil counting and measurement of eosinophilic cationic protein (ECP) were performed.

RESULTS

After the 8 weeks of treatment with roxithromycin, patients' symptoms, blood eosinophils, serum ECP, sputum eosinophils, and sputum ECP were significantly decreased. On the other hand, values of PC20-sulpyrine did not improve after roxithromycin at all. Furthermore, although challenge with sulpyrine caused a significant increase in u-LTE4, pretreatment with roxithromycin or placebo did not affect excretion of u-LTE4.

CONCLUSION

Although roxithromycin does not have antileucotriene effects, it has an antibronchial inflammatory effect associated with eosinophilic infiltration. This study raises further interesting therapeutic possibilities and warrants further trials of new approaches to the treatment of aspirin-intolerant asthma.

Bronchial hyperresponsiveness, hypersensitivity to analgesics and urinary leukotriene E4 excretion in patients with aspirin-intolerant asthma

This study was designed to investigate the protective effect of cromolyn sodium on airway sensitivity to sulpyrine, and bronchial responsiveness to methacholine, and to investigate whether this protective activity is associated with reduction in aspirin-induced excretion of urinary leukotriene E4 (u-LTE4), a marker of the cysteinyl LT overproduction that participates in the pathogenesis of aspirin-induced asthma. We assessed the effects of pretreatment with cromolyn sodium on bronchoconstriction precipitated by inhalation of methacholine and sulpyrine in 16 adult patients with mild or moderate aspirin-intolerant asthma; those who were in stable clinical condition and were hypersensitive to a sulpyrine provocation test were included in this study. A double-blind, randomized, crossover design was used. u-LTE4 was measured using combined reverse-phase high-performance liquid chromatography enzyme immunoassay. Cromolyn sodium protected against analgesic-induced bronchoconstriction through mechanisms that are not related to its bronchodilator property, but to the improvement of both bronchial hyperresponsiveness and hypersensitivity to analgesics (p<0.01 and p<0.001). Although excretion of u-LTE4 did not increase after the methacholine provocation test, it significantly increased after sulpyrine provocation (p<0.01). Furthermore, after pretreatment with cromolyn sodium, the maximum level of u-LTE4 after the sulpyrine provocation test was significantly lower than in controls (p<0.01). These results support the hypothesis that cysteinyl LT is one of the most important components in the pathogenesis of aspirin-intolerant asthma. Cromolyn sodium improves both hypersensitivity to analgesics, and bronchial hyperresponsiveness in aspirin-intolerant asthma.

[The laparoscopic treatment of varicocele]

Laparoscopic treatment of varicocele is described for 37 patients. The operation was performed under endotracheal, epidural and intravenous anesthesia with ligation of the testicular vein in 18 patients. Ligation with the dissection was conducted in 19 patients. On the first postoperative day 2 patients were given promedol (2%, 1.0 ml), the rest were injected baralgin (2-3 injections). The patients were discharged after 1-2 days of hospital stay and resumed their usual way of life 2-7 days after the discharge. One month later varicocele disappeared in 29 patients, diminished in size in 7 patients, pain relief occurred in 15 patients. Due to its advantages (simple performance, good visualization of the testicular vein, minimal use of narcotic drugs, short hospital stay, absence of serious complications) laparoscopic treatment may be considered as a method of choice.

[The in-vivo test of the inhibition of leukocyte natural migration with aspirin and analgin in the specific diagnosis of the asthmatic triad]

Asthmatic triad (AT) is a clinical syndrome incorporating bronchial asthma (BA), recurrent nasal and sinus polyps, intolerance of aspirin, derivatives of pirasolone and other nonsteroid antiinflammatory drugs. Specific diagnosis of aspirin and analgin intolerance in patients with AT was made using the test of natural leukocyte emigration inhibition in vivo in the oral cavity. The test was performed in 22 patients with AT and 13 patients with BA with pollenosis without aspirin and analgin intolerance. In all the patients the test provided positive results, in control patients these were negative. High significance, safety and simplicity of the test made it applicable for specific diagnosis of AT in allergological and pulmonological departments.

Inhibition of analgesic-induced asthma by leukotriene receptor antagonist ONO-1078

We evaluated the effect of ONO-1078, a selective leukotriene-C4, -D4, and -E4-receptor antagonist, on bronchoconstriction intensity during inhalation challenge with dipyrone (a pyrazolone derivative) in six aspirin-sensitive asthmatics. A double-blind, randomized, crossover design was used. After ingestion of 225 mg ONO-1078 or matching placebo, subjects underwent bronchial provocation with dipyrone on two occasions, separated by 4 wk. Aerosol inhalation of dipyrone was performed increasing the concentration stepwise from 0.08 to 10% (wt/vol). FEV1 was measured every 10 min up to 30 min after inhalation of each concentration. Threshold concentrations causing a fall in FEV1 > or = 20% of baseline value were 0.4% in four subjects and 2% in the other two on the placebo day. After pretreatment with ONO-1078, threshold concentration was 10% in two subjects, and no fall in FEV1 was observed in the other four, even after inhalation of 10% dipyrone. Values of PD20 were 21.9 +/- 8.2 units (mean +/- SEM) after placebo and 311.6 +/- 40.3 units after ONO-1078, respectively, and a statistically significant difference occurred (p < 0.001). Provocation of bronchoconstriction was completely inhibited in subjects whose plasma ONO-1078 levels were more than 0.5 microgram/ml. These results support the hypothesis that sulfidopeptide leukotriene-induced bronchoconstriction is one important component in the pathophysiology of aspirin-induced asthma.

Evaluation of starch obtained from Ensete ventricosum as a binder and disintegrant for compressed tablets

The binding and disintegrant properties of starch obtained from Ensete ventricosum Musaceae have been evaluated. The effect of the starch on the physical properties such as crushing strength, friability and disintegration time of tablets of chloroquine phosphate, dipyrone and paracetamol was compared with tablets prepared with potato starch. The results show that enset starch can be used both as a tablet binder and disintegrant and the indication is that enset starch has a better binding ability and less disintegrating power than potato starch.

[Efficacy of conventional CT in diagnosis of pulmonary emphysema: evaluation of low attenuation area by multiple observers]

The efficacy of conventional CT in the diagnosis of pulmonary emphysema (PE) was studied in 122 patients with miscellaneous diseases including 26 patients with PE. The density and the distribution of low attenuation area (LAA) were evaluated by six independent physicians. Analysis with kappa statistics showed a good inter-observer agreement in the detection of LAA. The grading of LAA correlated well with FEV1/FVC, DLCO/VA, and lung volumes, which indicated that PE could be detected by conventional CT by the evaluation of LAA. The agreement was poor, however, for the detection of low grade LAA and there were some false positives, and there was no specific pattern in the distribution of LAA in PE compared to other pulmonary diseases. We conclude that the evaluation of LAA by conventional CT is simple and effective in the screening of PE.

Differential effects of dipyrone, ibuprofen, and paracetamol on experimentally induced pain in man

In a double-blind cross-over study on 22 healthy subjects the analgesic efficacies of the antipyretic analgesic drugs ibuprofen, dipyrone and paracetamol were tested against placebo using a model of experimentally induced pain. To this purpose interdigital webs were pinched repeatedly for 2 min periods. The painfulness of these stimuli was assessed by the subjects on an electronically controlled visual analogue scale at 10 sec intervals. In addition to the subjective pain ratings the stimulus induced reflex diminution of the blood flow in the stimulated hand was measured with photoplethysmography and laser Doppler flow analysis. The flare response around the stimulated area was assessed with infrared thermography. In this assay system ibuprofen and dipyrone, but not paracetamol, showed statistically significant analgesic effects by preventing hyperalgesia which is normally induced by the repeated stimulation of a skin site. This hypoalgesic effect was not related to the subjective impression of the subjects of the analgesic potency of the respective drug. Sympathetic reflex vasoconstriction was not quantitatively related to the drug induced hypoalgesia. Ibuprofen and, to a minor extent, the other antipyretic analgesic drugs also diminished the stimulus induced flare reaction around the stimulated skin sites.

[A case of lung sarcoidosis which was clinically difficult to distinguish from hypersensitivity pneumonitis]

A case of pulmonary sarcoidosis (stage III), in which the abnormal chest shadow disappeared within two weeks was reported. A 35-year-old male was admitted for further examination of bronchial asthma. He stayed overnight at home after he received inhalation provocation test of sulpyrin. Returning to the hospital, he had a fever (38 degrees C) with diffuse small nodular shadows on the chest roentgenogram. The onset and clinical features of the disease suggested hypersensitivity or drug induced pneumonitis rather than sarcoidosis. Bronchoalveolar lavage fluid (BALF) analysis showed an increase of total cell counts and lymphocytes. The surface marker of lymphocytes in BALF revealed that the CD4/8 ratio was remarkably elevated to 6.2. Both transbronchial lung and scalene node biopsy specimens revealed numerous non-caseous granulomas, and a diagnosis of sarcoidosis was confirmed. The chest infiltrates disappeared spontaneously within two weeks. This case was reported because of its rare natural course as stage III pulmonary sarcoidosis.

[The changes in plasma histamine levels after a sulpyrin inhalation test in asthmatic patients]

A sulpyrin inhalation test was given to 13 patients with aspirin-induced asthma (AIA) and 8 patients with non-aspirin-induced asthma (non-AIA) to observe the changes in plasma histamine levels before and after challenges. The respiratory function (FEV1.0) was measured before and after sulpyrin inhalation. A decrease of more than 20% the initial value (basal value) was defined as a positive response. Plasma histamine was determined by high-performance liquid chromatography (HPLC). In 11 patients with AIA, a positive response was observed (SIT positive), with a fall of FEV1.0 to 63.70 +/- 4.87% of the basal value. In 2 patients with AIA and 8 patients with non-AIA, no positive response was observed (SIT negative). In patients with SIT positive, plasma histamine levels increased significantly from 0.61 +/- 0.06 ng/ml before challenges to 1.34 +/- 0.22 ng/ml after challenges (p less than 0.01). No significant changes of plasma histamine occurred in the SIT negative patients. These results suggest that mast cells play some role in the mechanism of the development of aspirin-induced asthma.

[Analgesia in the acute period of myocardial infarct under hemodynamic and respiratory functional control]

The authors have tested various methods of analgesia and their clinical effect on the haemodynamics and respiration of patients with acute myocardial infarction. A hundred observations on 70 patients have been made. Haemodynamics was studied with a non-invasive method of integral rheography, and the respiratory function was evaluated by a combination of varying diagnostic rapid methods. With effective analgesia by different methods there was a decrease of oxygen utilization, minute ventilation of the lungs, of metabolic acidosis and of hyperfunction of the myocardium. The results justify the conclusion that timely analgesia is not a symptomatic method of treatment, but an important therapeutic measure of therapeutic measure as it ensures favourable action on haemodynamics and metabolism.

Bullet injury to the pituitary gland: a rare cause of panhypopituitarism

An unusual case of head injury with a direct bullet injury to the pituitary gland is described. The hormonal profile one month after the injury showed severe panhypopituitatism which did not improve one month after surgical removal of the intrasellar bullet fragment.

Racing problems in the U.S.A

The major problems of racing in the United States at the present time are caused by too much racing. This has led to too few horses and small fields. Consequently many owners and trainers are trying to enter their horses too frequently and to race them when they are not really fit to run. The desire to race horses as frequently as possible has led to constant pressure from horsemen through their organizations for so called "permissive medication". Started in the state of Colorado approximately ten years ago this has grown until finally there are only a few states, notably New York and New Jersey that have resisted the pressure. The drug that gave the opening wedge to permissive medication was phenylbutazone, but this in many states has led to the inclusion of other drugs including analgesics and drugs that veterinarians claim are needed for therapeutic purposes. Some states have endeavoured to control phenylbutazone medication by quantitation and while lower limits cause little difficulty, maximum allowable limits have caused problems and are not practical. While there has been no publicity to my knowledge about frusemide (furosemide, lasix) the abuse of this drug for so called "bleeders" is an example that may seriously interfere with drug detection in urine and its use should be confined to proven "bleeders" (i.e. horses suffering from epistaxis). Pre-race blood testing began roughly ten years ago at the harness tracks and has been resisted by our flat tracks rather successfully up to the present time. The blood testing methods and those used by the same laboratories in post-race urine testing is inadequate and will not detect many illegal drugs.

In vitro release of noramidopyrine methansulfonate sodium from suppository as a function of particle size and concentration

The effect of particle size and percentage concentration of noramidopyrine methansulfonate sodium on its release from Witepsol H 15 suppository base is studied. It is proved that the finer the drug particles the less its release and the more the drug concentration the more its release.