The effect of three different solutions on preventing oral mucositis in cancer patients undergoing stem cell transplantation: a non-randomized controlled trial: A Turkish study - NON-RANDOMISED TRIAL

OBJECTIVE

To evaluate the effect of different solutions administered to patients undergoing stem cell transplantation on oral mucositis.

METHODS

The non-randomised controlled trial was conducted at a Istanbul Medipol Mega university hospital in Turkey between May 2014 and June 2016, and comprised patients undergoing stem cell transplantation. They were divided into three groups. Group 1 had patients using chlorhexidine gluconate and benzydamine hydrochloride solution. Group 2 had those using calcium and phosphate solution. Group 3 patients were using black mulberry syrup. Data was collected using a structured questionnaire and the World Health Organisation mucositis assessment scale. Assessment was done on days 7, 14 and 21. Clinical significance of oral solutions was statistically determined.

RESULTS

Of the 83 patients, 30(36%) were in group 1, 28(34%) in group 2, and 25(30%) in group 3. On day 7, there was no significant difference in terms of grades among the groups (p>0.05). On day 14, grade 2 mucositis was seen in 2(8%) patents in group 3, 5(17.9%) in group 2 and 5(16.7%) in group 1; Grade 3 mucositis was seen in 2(6.7%) patients in group 1, but none in the other two groups. On day 21, grade 3 mucositis was present in 2(8.0%) in group 3, 2(7.1%) in group 2, and 4(13.3%) in group 1.

CONCLUSIONS

The use of black mulberry and calcium-phosphate solutions was found to be beneficial in preventing and treating oral mucositis.

Biocompatible dialysis fluids for peritoneal dialysis

BACKGROUND

Biocompatible peritoneal dialysis (PD) solutions, including neutral pH, low glucose degradation product (GDP) solutions and icodextrin, have previously been shown to favourably influence some patient-level outcomes, albeit based on generally sub-optimal quality studies. Several additional randomised controlled trials (RCT) evaluating biocompatible solutions in PD patients have been published recently. This is an update of a review first published in 2014.

OBJECTIVES

This review aimed to look at the benefits and harms of biocompatible PD solutions in comparison to standard PD solutions in patients receiving PD.

SEARCH METHODS

The Cochrane Kidney and Transplant Specialised Register was searched up to 12 February 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

All RCTs and quasi-RCTs in adults and children comparing the effects of biocompatible PD solutions (neutral pH, lactate-buffered, low GDP; neutral pH, bicarbonate(± lactate)-buffered, low GDP; glucose polymer (icodextrin)) in PD were included. Studies of amino acid-based solutions were excluded.

DATA COLLECTION AND ANALYSIS

Two authors extracted data on study quality and outcomes. Summary effect estimates were obtained using a random-effects model, and results were expressed as risk ratios and 95% confidence intervals (CI) for categorical variables, and mean differences (MD) or standardised mean differences (SMD) and 95% CI for continuous variables.

MAIN RESULTS

This review update included 42 eligible studies (3262 participants), including six new studies (543 participants). Overall, 29 studies (1971 participants) compared neutral pH, low GDP PD solution with conventional PD solution, and 13 studies (1291 participants) compared icodextrin with conventional PD solution. Risk of bias was assessed as high for sequence generation in three studies, allocation concealment in three studies, attrition bias in 21 studies, and selective outcome reporting bias in 16 studies.Neutral pH, low GDP versus conventional glucose PD solutionUse of neutral pH, low GDP PD solutions improved residual renal function (RRF) preservation (15 studies, 835 participants: SMD 0.19, 95% CI 0.05 to 0.33; high certainty evidence). This approximated to a mean difference in glomerular filtration rate of 0.54 mL/min/1.73 m² (95% CI 0.14 to 0.93). Better preservation of RRF was evident at all follow-up durations with progressively greater preservation observed with increasing follow up duration. Neutral pH, low GDP PD solution use also improved residual urine volume preservation (11 studies, 791 participants: MD 114.37 mL/day, 95% CI 47.09 to 181.65; high certainty evidence). In low certainty evidence, neutral pH, low GDP solutions may make little or no difference to 4-hour peritoneal ultrafiltration (9 studies, 414 participants: SMD -0.42, 95% CI -0.74 to -0.10) which approximated to a mean difference in peritoneal ultrafiltration of 69.72 mL (16.60 to 122.00 mL) lower, and may increase dialysate:plasma creatinine ratio (10 studies, 746 participants: MD 0.01, 95% CI 0.00 to 0.03), technique failure or death compared with conventional PD solutions. It is uncertain whether neutral pH, low GDP PD solution use led to any differences in peritonitis occurrence, hospitalisation, adverse events (6 studies, 519 participants) or inflow pain (1 study, 58 participants: RR 0.51, 95% CI 0.24 to 1.08).Glucose polymer (icodextrin) versus conventional glucose PD solutionIn moderate certainty evidence, icodextrin probably reduced episodes of uncontrolled fluid overload (2 studies, 100 participants: RR 0.30, 95% CI 0.15 to 0.59) and augmented peritoneal ultrafiltration (4 studies, 102 participants: MD 448.54 mL/d, 95% CI 289.28 to 607.80) without compromising RRF (4 studies, 114 participants: SMD 0.12, 95% CI -0.26 to 0.49; low certainty evidence) which approximated to a mean creatinine clearance of 0.30 mL/min/1.73m² higher (0.65 lower to 1.23 higher) or urine output (3 studies, 69 participants: MD -88.88 mL/d, 95% CI -356.88 to 179.12; low certainty evidence). It is uncertain whether icodextrin use led to any differences in adverse events (5 studies, 816 participants) technique failure or death.

AUTHORS' CONCLUSIONS

This updated review strengthens evidence that neutral pH, low GDP PD solution improves RRF and urine volume preservation with high certainty. These effects may be related to increased peritoneal solute transport and reduced peritoneal ultrafiltration, although the evidence for these outcomes is of low certainty due to significant heterogeneity and suboptimal methodological quality. Icodextrin prescription increased peritoneal ultrafiltration and mitigated uncontrolled fluid overload with moderate certainty. The effects of either neutral pH, low GDP solution or icodextrin on peritonitis, technique survival and patient survival remain uncertain and require further high quality, adequately powered RCTs.

Ear drops for the removal of ear wax

BACKGROUND

Ear wax (cerumen) is a normal bodily secretion that can become a problem when it obstructs the ear canal. Symptoms attributed to wax (such as deafness and pain) are among the commonest reasons for patients to present to primary care with ear trouble.Wax is part of the ear's self-cleaning mechanism and is usually naturally expelled from the ear canal without causing problems. When this mechanism fails, wax is retained in the canal and may become impacted; interventions to encourage its removal may then be needed. Application of ear drops is one of these methods. Liquids used to remove and soften wax are of several kinds: oil-based compounds (e.g. olive or almond oil); water-based compounds (e.g. sodium bicarbonate or water itself); a combination of the above or non-water, non-oil-based solutions, such as carbamide peroxide (a hydrogen peroxide-urea compound) and glycerol.

OBJECTIVES

To assess the effects of ear drops (or sprays) to remove or aid the removal of ear wax in adults and children.

SEARCH METHODS

We searched the Cochrane ENT Trials Register; Cochrane Register of Studies; PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 23 March 2018.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which a 'cerumenolytic' was compared with no treatment, water or saline, an alternative liquid treatment (oil or almond oil) or another 'cerumenolytic' in adults or children with obstructing or impacted ear wax.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were 1) the proportion of patients (or ears) with complete clearance of ear wax and 2) adverse effects (discomfort, irritation or pain). Secondary outcomes were: extent of wax clearance; proportion of people (or ears) with relief of symptoms due to wax; proportion of people (or ears) requiring further intervention to remove wax; success of mechanical removal of residual wax following treatment; any other adverse effects recorded and cost. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included 10 studies, with 623 participants (900 ears). Interventions included: oil-based treatments (triethanolamine polypeptide, almond oil, benzocaine, chlorobutanol), water-based treatments (docusate sodium, carbamide peroxide, phenazone, choline salicylate, urea peroxide, potassium carbonate), other active comparators (e.g. saline or water alone) and no treatment. Nine of the studies were more than 15 years old.The overall risk of bias across the 10 included studies was low or unclear.

PRIMARY OUTCOME

proportion of patients (or ears) with complete clearance of ear waxSix studies (360 participants; 491 ears) contributed quantitative data and were included in our meta-analyses.Active treatment versus no treatmentOnly one study addressed this comparison. The proportion of ears with complete clearance of ear wax was higher in the active treatment group (22%) compared with the no treatment group (5%) after five days of treatment (risk ratio (RR) 4.09, 95% confidence interval (CI) 1.00 to 16.80); one study; 117 ears; NNTB = 8) (low-quality evidence).Active treatment versus water or salineWe found no evidence of a difference in the proportion of patients (or ears) with complete clearance of ear wax when the active treatment group was compared to the water or saline group (RR 1.47, 95% CI 0.79 to 2.75; three studies; 213 participants; 257 ears) (low-quality evidence). Two studies applied drops for five days, but one study only applied the drops for 15 minutes. When we excluded this study in a sensitivity analysis it did not change the result.Water or saline versus no treatmentThis comparison was only addressed in the single study cited above (active versus no treatment) and there was no evidence of a difference in the proportion of ears with complete wax clearance when comparing water or saline with no treatment after five days of treatment (RR 4.00, 95% CI 0.91 to 17.62; one study; 76 ears) (low-quality evidence).Active treatment A versus active treatment BSeveral single studies evaluated 'head-to-head' comparisons between two active treatments. We found no evidence to show that one was superior to any other.Subgroup analysis of oil-based active treatments versus non-oil based active treatmentsWe found no evidence of a difference in this outcome when oil-based treatments were compared with non-oil-based active treatments.

PRIMARY OUTCOME

adverse effects: discomfort, irritation or painOnly seven studies planned to measure and did report this outcome. Only two (141 participants;176 ears) provided useable data. There was no evidence of a significant difference in the number of adverse effects between the types of ear drops in these two studies. We summarised the remaining five studies narratively. All events were mild and reported in fewer than 30 participants across the seven studies (low-quality evidence).Secondary outcomesThree studies reported 'other' adverse effects (how many studies planned to report these is unclear). The available information was limited and included occasional reports of dizziness, unpleasant smell, tinnitus and hearing loss. No significant differences between groups were reported. There were no emergencies or serious adverse effects reported in any of the 10 studies.There was very limited or no information available on our remaining secondary outcomes.

AUTHORS' CONCLUSIONS

Although a number of studies aimed to evaluate whether or not one type of cerumenolytic is more effective than another, there is no high-quality evidence to allow a firm conclusion to be drawn and the answer remains uncertain.A single study suggests that applying ear drops for five days may result in a greater likelihood of complete wax clearance than no treatment at all. However, we cannot conclude whether one type of active treatment is more effective than another and there was no evidence of a difference in efficacy between oil-based and water-based active treatments.There is no evidence to show that using saline or water alone is better or worse than commercially produced cerumenolytics. Equally, there is also no evidence to show that using saline or water alone is better than no treatment.

The Influence of Polyethylene Glycol Solution on the Dissolution Rate of Sustained Release Morphine

INTRODUCTION

Whole bowel irrigation (WBI) is a management option for overdose of medications poorly adsorbed to activated charcoal, with modified release properties, or for body packers. Polyethylene glycol (PEG) is a mixture of ethylene oxide polymers of varying molecular weight. PEG with an average molecular weight of 3350 g/mol is used for WBI. PEG electrolyte lavage solution has been shown in vitro to hasten the dissolution of acetaminophen. The impact of PEG on the pharmacokinetics of extended release pharmaceuticals is unknown. Lower average molecular weight PEG mixtures are used as solvents and excipients. We sought to investigate the impact of PEG on the release of morphine from several extended release morphine formulations.

METHODS

An in vitro gastric model was developed. To test the validity of our model, we first investigated the previously described interaction of ethanol and Avinza®. Once demonstrated, we then investigated the effect of PEG with several extended release morphine formulations.

RESULTS

In the validation portion of our study, we confirmed an ethanol Avinza® interaction. Subsequently, we did not observe accelerated release of morphine from Avinza® or generic extended release morphine in the presence of PEG.

CONCLUSION

The use of PEG for gastric decontamination following ingestion of these extended release morphine formulations is unlikely to accelerate morphine release and aggravate intoxication.

Inhalation Properties and Stability of Nebulized Naked siRNA Solution for Pulmonary Therapy

The use of naked unmodified small interfering RNA (N-siRNA) without vector has previously been investigated as a pulmonary therapy. However, little is known regarding stabilities and aerodynamic particle sizes of N-siRNA-containing droplets; nebulizers have not yet been optimized for N-siRNA solutions. Thus, in this study, we investigated the feasibility of inhaled N-siRNA solutions for pulmonary therapy using nebulization. Various nebulizers and N-siRNA concentrations were assessed in terms of siRNA integrity after nebulization, and inhalation properties including aerodynamic particle size were examined. In comparison with ultrasonic-, air-jet-, and vibrating-mesh nebulizers, N-siRNA integrity was not affected by nebulization. Thus, in further experiments, performances of N-siRNA aerosols with different nebulizers and N-siRNA concentrations were evaluated and screened using an aerodynamic particle sizer (APS) which employed the time-of-flight principle or a cascade impactor. Mean mass aerodynamic diameters of N-siRNA-containing droplets from vibrating-mesh nebulizers tended to decrease with increasing N-siRNA concentrations, reflecting the influence of N-siRNA solutions on surface tension, as indicated by contact angles. These data indicate the utility of APS instruments for investigating the nebulized characteristics of expensive drugs including siRNAs and may facilitate the development of N-siRNA inhalation formulations.

Variability in compounding of oral liquids for pediatric patients: a patient safety concern

OBJECTIVE

To determine the degree in variation of oral liquid pediatric compounding practices in Michigan pharmacies.

DESIGN

Cross-sectional survey study.

SETTING

All types of inpatient and outpatient pharmacies across the state of Michigan, excluding nuclear pharmacies and long-term care facilities.

PARTICIPANTS

244 Michigan pharmacies.

INTERVENTION

An online survey tool was used to assess the current compounding practices of 147 oral liquid pediatric medications. The survey was e-mailed or faxed to hospitals, chain pharmacies, and independent pharmacies. Pharmacists were also mailed a follow-up postcard, and the Michigan Pharmacists Association publicized the project through its journal and annual meeting.

MAIN OUTCOME MEASURES

Pharmacy demographics; number of compounding pharmacies; number of medications compounded; awareness of compounding errors; results of compounding errors; and number of concentrations compounded per medication.

RESULTS

The majority of respondents were from outpatient pharmacies, but inpatient and other types of pharmacies were also represented. The majority of participating pharmacies compound fewer than five oral liquid medications per week. Awareness of errors was low overall, with no errors believed to result in permanent harm or death. The number of concentrations compounded per medication ranged from 1 to 9, with the majority of pharmacies compounding more than 3 concentrations per medication.

CONCLUSION

There is a considerable degree of variation in current oral pediatric liquid compounding practices in Michigan pharmacies. This variability poses a significant risk to patient safety.

What is the main target: a clearer colon with a sennoside-based regime, or adequate bowel cleansing before colonoscopy with a PEG-EL-based regime?

BACKGROUND/AIM

Even though polyethylene glycol-electrolyte lavage (PEG-EL)-based regimes have become the gold standard in recent years, to finish drinking 4 L of PEG-EL solution can be difficult. The quality of sennoside-based bowel-cleansing regimes used in Turkey has been known for some time. Therefore, we aimed to investigate the efficacy of both bowel-cleansing regimes.

MATERIALS AND METHODS

Patients over 18 years old undergoing elective colonoscopic procedures between January and March 2011 were included in the study. The patients were divided into 2 groups; in Group 1, 91 patients were given sennoside a + b calcium 500 mg/250 mL (X-M solution, Yenişehir Laboratuarı, Ankara, Turkey), and in Group 2, 94 patients were given 4 L of PEG-EL (Golytely, Boston, MA, USA).

RESULTS

The mean age of the patients and the male distribution were similar in the 2 groups. Both inadequate bowel cleansing and the best cleansed bowels were seen in Group 1. The number of inadequate colonoscopies declined when using a whole bowel-cleansing regime from 24.5% to 19.3% in Group 2, but it did not decline in Group 1.

CONCLUSION

The best bowel cleansing can be achieved with sennoside-based regimes, whereas a greater proportion of adequate results via colonoscopy were reached with the PEG-EL-based regimes.

Efficacy of some colloidal silver preparations and silver salts against Proteus bacteria, one possible cause of rheumatoid arthritis

There has been increased interest in the role of anti-Proteus antibodies in the aetiology of rheumatoid arthritis (RA) and whether chemotherapeutic agents active against Proteus species might reduce the risk and/or exacerbations of RA. We examined the in vitro antibacterial effects of ten different silver preparations which were either ionic silver [Ag(I)] solutions or nanoparticulate silver (NPS) (Ag(0)) suspensions against ATCC and two wild (clinical) strains of Proteus. The data establish the low minimum inhibitory concentration and minimum bactericidal concentration of all the silver formulations tested against these four Proteus strains. In a pilot study, a potent NPS preparation ex vivo showed long-lasting anti-Proteus activity in a normal human volunteer.

Imaging mass spectrometry evaluation of the effects of various irrigation fluids in a rat model of postoperative cerebral edema

BACKGROUND

Using imaging mass spectrometry (IMS), we investigated the cerebral protective effect of an artificial cerebrospinal fluid (CSF), ARTCEREB (Artcereb, Otsuka Pharmaceutical Factory, Inc., Tokushima, Japan), as an irrigation and perfusion solution for neurosurgical procedures in a rat craniotomy model.

METHODS

Wounds created in the rat cerebral cortex were continuously irrigated with Artcereb, normal saline, or lactated Ringer's solution at a steady rate for 4 hours, after which brain tissue was collected. Brain slices were prepared and analyzed using IMS.

RESULTS

In tissue surrounding the injury, the signal intensity for Na adduct ions to phosphatidylcholine was high and that for K adduct ions to phosphatidylcholine was low. This is thought to reflect the level of water retention in brain cells and to be a change accompanying edema. The signal intensity with Na adduct ions to phosphatidylcholine was significantly lower in the Artcereb group than in the physiological saline or lactated Ringer's solution groups.

CONCLUSIONS

IMS analysis in a rat craniotomy model indicated that the level of water retention in brain cells, calculated from the signal intensity of Na-adducted phosphatidylcholine around the wound area, was lowest in the Artcereb group, suggesting that artificial CSF that has similar composition and properties to human CSF can minimize edema in the brain surrounding the surgical wound.

[The modern approaches to the choice of infusion agents used in the treatment of severe injuries and burns]

The article presents an analytical review of modern possibilities of the complex pathogenic treatment for severe traumas and injuries at the expense of systemic use of infusion drugs with antihypoxic and antioxidant effects. It is shown that hypoxia and oxidative stress is the typical; pathologic process that accompanies the development of traumatic disease during severe surgical pathology. One of the effective ways to correct the developing disorders is to use the regulatory or substrate antihypoxants as well as the drugs with antioxidant effect.

A multicenter randomized study of the efficacy of transfusions with platelets stored in platelet additive solution II versus plasma

Randomized studies testing the clinical efficacy of platelet additive solutions (PASs) for storage of platelets are scarce and often biased by patient selection. We conducted a multicenter, randomized study to investigate clinical efficacy of platelets stored in PAS II versus plasma, also including patients with clinical complications associated with increased platelet consumption. A total of 168 evaluable patients received pooled buffy coat–derived platelet concentrates (PCs) suspended in either plasma (n = 354) or PAS II (n = 411) stored up to 5 days. Both univariate as well as multivariate analysis showed a significant effect of used storage medium in regard to 1- and 24-hour count increments and corrected count increments, in favor of plasma PCs. However, there were no significant differences between the groups regarding bleeding complications and transfusion interval. Adverse transfusion reactions occurred significantly less after transfusions with PAS II PCs (P = .04). Multivariate analysis showed no significant effect of the used storage medium on the incidence of 1- and 24-hour transfusion failure. We showed safety and efficacy of PAS II PCs in intensively treated patients; however, plasma PCs show superior increments.

[Chemical destruction of the prostate by Prostalyser-1 and Prostalyser-2 solutions: an experimental study in dogs]

The aim of the study was elaboration of a new minimally invasive but effective alternative method of BPH treatment. The experiments were carried out on 46 male dogs divided into two equal groups. 10 ml of Prostalyser-1 solution (natrii chloridi 9.5 g, dimethylsulfoxidi 0.5 g, aquae destill. Ad 1000.0 g) was given in a single injection into the prostates of the first group of animals. The same volume of Prostalyser-2 solution (spiritus ethilicus 96% - 76.5 g, DMSO 0.5 g, aq.destill ad 100.0 g)--into the prostates of the other group, respectively. The temperature of the solutions was +80 degrees C. Within the first 2 months, essential disorders were observed in the cellular Na-pump, membrane permeability system, there were lobular and diffusive necroses in prostatic alveolar epithelium and a decrease of the prostate weight by 68-66%. This condition of the prostate persisted for 4-6 months. Prostalyser-1 and Prostalyser-2 solutions can be recommended as very prospective substances for chemical destruction of the prostate in case of BPH.

Paradoxical bronchoconstriction with albuterol administered by metered-dose inhaler and nebulizer solution

OBJECTIVE

To report a case of a patient who experienced bronchoconstriction following both a single dose of albuterol via metered-dose inhaler and a subsequent rechallenge with nebulized albuterol and review previously published case reports of albuterol-induced paradoxical bronchoconstriction.

CASE SUMMARY

A 92-year-old white man with a history of chronic obstructive pulmonary disease was prescribed an albuterol inhaler for treatment of cold symptoms. Within 30 minutes of his first inhalation, he became short of breath and had difficulty speaking. During emergency department examination for the initial event, the bronchospasm improved with administration of oxygen 15 L/min via a non-rebreather mask. Two hours later, the patient received albuterol via nebulizer and experienced stridor, shortness of breath, and severe bronchospasm. He was admitted, treated with methylprednisolone, and discharged the following day.

DISCUSSION

Paradoxical bronchoconstriction is a rare complication of bronchodilator therapy. Although theories have been proposed about components of albuterol solutions and preservatives as causative agents, the true mechanism of the phenomenon remains unknown. Several previous case reports described bronchospasm with albuterol given via tablet, inhaler, and nebulizer. In 2 of these cases, symptoms recurred upon rechallenge; however, none of these cases demonstrates rechallenge using albuterol as both the index and challenge agent. In our patient, paradoxical bronchoconstriction was considered to be probable according to the Naranjo probability scale.

CONCLUSIONS

beta(2)-Agonists are generally well-tolerated medications. However, clinicians should remain vigilant in their monitoring of adverse effects so they will be able to provide immediate care and minimize the chance of an unfavorable outcome.

Randomized Trial Comparing Quixil Surgical Sealant with Kaltostat Hemostatic Dressing to Control Suture Line Bleeding after Carotid Endarterectomy with ePTFE Patch Reconstruction

Following carotid endarterectomy (CEA), patch angioplasty provides a significant reduction in the risk of perioperative complications. The expanded polytetrafluoroethylene (ePTFE) patch is strong, is resistant to infection, and has low thrombogenicity; but it remains unpopular because of its tendency of prolonged bleeding at the suture line. We aimed to investigate whether the application of Quixil sealant to the suture line could improve the time to achieve hemostasis and reduce local blood loss when compared to a standard topical hemostat Kaltostat. A prospective, randomized trial of 20 patients undergoing CEA was undertaken. Patients were randomized to receive either Quixil sealant (treatment group) or topical Kaltostat (controls) as a hemostatic agent to the patch suture line. Hemostasis was defined as no bleeding at the suture line for 1 minute. Statistical analysis was performed using the Mann-Whitney test. The two groups had a similar age and sex distribution. The mean age was 71 years, and there were seven men and three women in each group. The time to achieve hemostasis was significantly lower in the Quixil group (median 2.5 minutes, range 1-4 minutes) compared to the controls (median 17 minutes, range 7-59 minutes) (p < 0.001). Blood loss after clamp release was also significantly reduced in the Quixil group; median 24.5 ml (range 5.5-105.0 ml) versus 203 ml (range 54.5-817.0 ml) (p < 0.001). This study has demonstrated that Quixil human surgical sealant is an effective sealant of ePTFE patch suture holes and does not compromise the patch repair. It could be used during other vascular procedures involving ePTFE.

A comparison of the efficacy of heparinized and nonheparinized solutions for maintenance of perioperative radial arterial catheter patency and subsequent occlusion

In a randomized, double-blind, controlled study, we compared heparinized and nonheparinized infusions for the maintenance of perioperative arterial catheter patency and the incidence of subsequent radial arterial occlusion. Two-hundred patients were randomized into 2 groups to receive heparinized (group H, n = 100) or nonheparinized (group S, n = 100) flush solutions. Radial and ulnar blood flows were assessed using Doppler probe and pulse oximetry before, just after, and 24 h after decannulation by the same investigator. The cannulation site was examined for complications such as hematoma, nerve injury, and infection. The mean duration of cannulations was 378 +/- 159.0 min in group H and 332 +/- 154.6 min in group S. The mean number of corrective interventions caused by dampening of the pressure wave (mean number of positional changes [group S, 1.5 +/- 2.0; group H, 1.4 +/- 3.8] and mean number of manual flushes [group S, 1.3 +/- 1.7; group H, 1.2 +/- 1.2]) was not significantly different in both groups. After decannulation, partial or total occlusion developed in 20 group H patients and 16 group S patients (not significant). The incidence of occlusion was correlated to the presence of hematoma at the puncture site after decannulation (P = 0.013), long duration of cannulation (P = 0.04), and age <65 yr (P = 0.009). In conclusion, there is no significant difference between heparinized and nonheparinized flush solutions for the maintenance of perioperative radial artery catheter patency.

A blindedin-vitrostudy to compare the efficacy of five topical ear drops in clearing grommets blocked with thick middle ear effusion fluid

OBJECTIVE

To compare the efficacy of 5% NaHCO3, 3% H2O2, Sofradex (dexamethasone sodium metasulphobenzoate 0.05%, framycetin sulphate 0.5%, gramicidin 0.005%), 0.33% acetic acid and 0.9% NaCl eardrops in clearing grommets blocked with harvested thick middle ear effusion fluid.

STUDY DESIGN

A blinded in-vitro study.

SETTING

District general hospital.

PARTICIPANTS

A total of 473 grommets were blocked with freshly harvested unpooled thick middle ear effusion fluid obtained from 68 patients.

MAIN OUTCOME MEASURES

Patency of the grommets before and 7 days after intervention was ascertained by tympanometry and close visual inspection.

RESULTS

Instillation of eardrops leads to a statistically significant increase in the clearance of grommets as compared with not using any drops (chi2 = 14.3, d.f. = 5, P = 0.006). The numbers needed to treat were 2.8 for NaHCO3, 3.2 for 0.9% NaCl, 3.9 for 0.33% acetic Acid, 4.4 for Sofradex and 9.5 for H2O2 eardrops. Pair-wise comparison was only significant for comparison between 5% NaHCO3 and 3% H2O2 eardrops (Bonferroni corrected P = 0.01, odds ratio = 4.3, CI = 1.9-9.9).

CONCLUSIONS

Use of eardrops leads to a clinically and statistically significant increase in the clearance of blocked grommets. Of the five drops used, 5% NaHCO3 was the most efficacious and 3% H2O2 the least efficacious. Limitations of this in-vitro study are recognized and a prospective in-vivo double blind randomized controlled trial is planned.

Stabilization of rasburicase and physico-chemical characterization of the resulting injectable formulation

Rasburicase (Fasturtec/Elitek) is a new generation of recombinant urate oxidase administred therapeutically by intravenous infusion for the prevention or treatment of hyperuricemia during chemotherapy. To ensure a long storage period, a freeze-dried formulation was developed to guarantee the molecular integrity and enzyme activity. Screening of potential excipients was the first stage of the preformulation study. The selection was based on stability results (rasburicase solution with excipient) obtained with the isoelectric focusing profiles and residual enzyme activity. The different excipients were classified as stabilising, neutral or destabilising. A stability study was then carried out on different freeze-dried formulations containing the usual bulking agents for freeze-drying, excipients with a high glass transition temperature or competitive enzyme inhibitors having a stabilising effect. A mannitol/alanine mixture in phosphate buffer was selected from these preliminary results. Finally, the optimal content of mannitol and alanine in the freeze-dried powder was determined by an experimental design study. The water content and the appearance of the "cake", the osmolality, pH, clarity, and enzyme activity of the reconstituted solution were assessed. The formula with a mannitol/alanine ratio of 0.7 was found to be the best composition. Differential scanning calorimetry and ThermoStimulated Current technique experiments were carried out to study the amorphous phase. A glass transition temperature of about 45-500 degrees C was found. Glassy state is known to preserve stability, which was verified by the real stability data. X-ray diffraction studies have shown that alanine is in a crystallised state and that mannitol remains amorphous. Crystallised excipients participate in forming the structure of the powder and therefore help to prevent any collapse. Amorphous mannitol creates a surrounding medium favourable to the stability of the protein.

Therapy for intra-abdominal adhesions

Therapy for adhesions encompasses their prevention and treatment. They are reduced in number and severity by good surgical technique but anti-adhesion agents are useful adjuncts. Small bowel obstruction secondary to adhesions requires surgery following resuscitation if signs of peritonism develop. Otherwise a trial of conservative therapy is advocated.

Cryosurgery for common skin conditions

Cryosurgery is a highly effective treatment for a broad range of benign skin problems. With appropriate instruction and supervised experience, family physicians can master the technique quickly. Cryosurgery is best suited for use in patients with light skin and for treatment of lesions in most non-hair-bearing areas of the body. Spray methods include the timed spot freeze technique, the rotary or spiral pattern, and the paintbrush method. Benign skin lesions that are suitable for freezing include actinic keratosis, solar lentigo, seborrheic keratosis, viral wart, molluscum contagiosum, and dermatofibroma. Cryosurgery requires little time and fits easily into the physician's office schedule. Advantages of this treatment include a short preparation time, low risk of infection, and minimal wound care. In addition, cryosurgery requires no expensive supplies or injectable anesthesia, and the patient does not have to return for suture removal. Potential side effects include bleeding, blister formation, headache, hair loss, and hypopigmentation, but rarely scarring. Skin lesions often can be treated in a single session, although some require several treatments.

In vivo investigation of the efficacy of a customized solution to attenuate injury following low-flow ischemia and reperfusion injury in the jejunum of horses

OBJECTIVE

To evaluate the efficacy of a customized solution to attenuate intestinal injury following 20% low-flow ischemia and reperfusion in the jejunum of horses.

ANIMALS

10 healthy adult horses.

PROCEDURE

Two 30.5-cm-long segments of jejunum were exteriorized through a ventral midline incision and the mesenteric artery and vein supplying that portion of the intestine were instrumented with flow probes. Blood flow was decreased to 20% of baseline for 90 minutes followed by 90 minutes of reperfusion. In 5 horses, 60 mL of the customized solution was placed in the lumen of each segment (treatment-group horses), and 60 mL of lactated Ringer's solution was placed in the lumen of 5 additional horses (control-group horses). Biopsy specimens were obtained from 1 segment in both groups for histologic evaluation. Aliquots of luminal fluid were obtained from the other segment in both groups for determination of albumin concentrations as an index of mucosal permeability.

RESULTS

Compared with control-group horses, treatment-group horses had a significant decrease in luminal albumin concentration following reperfusion. Although differences in mucosal grades were not significantly different between control- and treatment-group horses, treatment-group horses had significantly greater jejunal villous length and area, compared with that of control-group horses.

CONCLUSIONS AND CLINICAL RELEVANCE

Intraluminal administration of the customized solution in the jejunum, compared with lactated Ringer's solution, results in an improvement in histologic findings and mucosal translocation of albumin in horses with mild intestinal injury.

Clinical potential of nonhemoglobin oxygen therapeutics in cardiac and general surgery

Significant efforts have been made over the past 70 years to find a solution that could substitute for blood. Over the years, the focus has shifted to developing a solution capable of delivering oxygen to the tissues. Fluorocarbons (FC) are highly inert solutions with a high solubility for all gases, making them a prime candidate to become such an oxygen delivery agent. Although clinical research efforts into the use of these agents as substitutes for blood transfusions continue at present, the rapid disappearance of emulsified FCs from the vascular space and accumulation in the liver and spleen may well limit their usefulness as transfusion substitutes. Because of their ability to dissolve significant quantities of oxygen and carbon dioxide, these agents may be more attractive as oxygen delivery agents during periods of local or global organ ischemia, including preservation of organs for transplantation. FCs have also been tested in animal models of cardiopulmonary bypass, and may be efficacious in adsorbing the gases present in air emboli. Recently a second class of oxygen therapeutics (allosteric modifiers) has been developed, and these agents enhance oxygen delivery by shifting the oxygen dissociation curve to the right, thus increasing tissue PO(2). Allosteric modifiers have been shown to effectively shift the p50 of hemoglobin 10mm Hg at clinically relevant dosages, and have been shown (in animal models) to reduce cerebral infarct size following carotid ligation and to improve myocardial performance following myocardial ischemia. Despite significant research efforts, however, none of the solutions under development are currently approved for clinical use by the Food and Drug Administration, with the exception of myocardial contrast imaging agents.

Endoscopic mucosal resection of superficially spreading colonic neoplasms larger than 5 cm in the right colon after injection of dilute sodium hyaluronate: report of two cases

Submucosal injection is the most important procedure for the safe performance of endoscopic mucosal resection in the large intestine while avoiding the risk of perforation. We used dilute sodium hyaluronate containing Bosmin and achieved safe piecemeal resection of large superficial tumors in the right colon in two patients. Piecemeal snare resection is considered to be acceptable if all the tissue pieces can be collected for histopathological diagnosis.

Discernment of adipose versus nervous tissue: a novel adjunct solution in lipomyelomeningocele surgery

OBJECTIVE

To determine a solution capable of discerning adipose versus nervous tissue, to aid in surgical separation of the adipose tissue which appears to be visually indistinguishable from nervous tissue in lipomyelomeningoceles (LMMs).

METHODS

The following solutes (in normal saline) were investigated, both at 25 and 37 degrees C: beta-carotene, vitamin D, vitamin E, lecithin, hydrogen peroxide, lipase, protease, hyaluronidase, partially purified collagenase, purified collagenase, trypsin, trypsin plus purified collagenase and non-solute-containing saline (control). Each solution was applied to a pediatric lipoma to determine gross effects over a period of approximately 30 min. If a solution appeared to affect the adipose tissue grossly, studies of functional in vivo sensory evoked and spontaneous potentials using that particular solution were conducted upon sheep spinal cord, nerve roots, dura and peripheral nerve. Additionally, histological studies were conducted to determine the effect of that solution upon adipose tissue, spinal cord, myelin, dura and nerve roots.

RESULTS

Of all solutions investigated, partially purified collagenase type 1 (T1C; Lot M0M4322, Code CLS-1, Worthington Biochemical Corporation, Lakewood, N.J., USA) at 37 degrees C was the most successful in grossly altering the consistency and appearance of adipose tissue. This change was more apparent over 20-30 min following application of the solution to the adipose tissue. Solutions not containing T1C did not show appreciable results; purified collagenase plus trypsin did not appear comparable or superior to T1C. No significant histological or functional change was noted when comparing the spinal cord, nerve rootlets, myelin, dura or peripheral nerve from the T1C-treated group versus normal (untreated) control groups.

CONCLUSION

T1C appears to be a potentially effective solution for application during LMM surgery in the acute setting, and such use of an adjunct solution may significantly aid in the safe surgical resection of LMMs. Pending further research, this technique may be applied for other indications which require discernment or alteration of adipose versus nervous tissue.

Dermatopharmacology of ciclopirox nail lacquer topical solution 8% in the treatment of onychomycosis

Ciclopirox is a synthetic hydroxypyridone antifungal agent. In contrast to the azoles, glucuronidation is the main metabolic pathway of ciclopirox; therefore interactions with drugs metabolized via the cytochrome P450 system are unlikely Ciclopirox is also distinct from the common systemic agents, which interfere with sterol biosynthesis. In fact, ciclopirox chelates trivalent cations (such as Fe3+), inhibits metal-dependent enzymes that are responsible for degradation of toxic metabolites in the fungal cells, and targets diverse metabolic (eg, respiratory) and energy producing processes in microbial cells. Ciclopirox is a broad spectrum antimicrobial with activity against all the usual dermatophytes as well as yeast and nondermatophyte molds. It has demonstrated activity against gram positive and negative bacteria, including resistant strains of Staphlococcus aureus. Ciclopirox exhibits fungal inhibitory activity (minimum inhibitory concentration < 4 microg/mL for dermatophytes) as well as fungicidal activity; to date resistance to the drug has not been identified. Ciclopirox has been formulated in a nail lacquer delivery system. After evaporation of volatile solvents in the lacquer, the concentration of ciclopirox in the remaining lacquer film reaches approximately 35%, providing a high concentration gradient for penetration into the nail. Radiolabel data demonstrate penetration into infected nails after only 1 application of the lacquer. Ciclopirox nail lacquer is a topical product that provides an active fungicidal agent in a delivery system capable of promoting nail penetration. With repeated applications, the antifungal agent is homogeneously distributed through all layers of the toenail achieving concentrations of ciclopirox in excess of inhibitory and fungicidal concentrations for most pathogens. Although ciclopirox readily penetrates nails, very low levels of ciclopirox are recoverable systemically, even after chronic use. Ciclopirox nail lacquer 8% is a topical product that provides an active fungicidal agent in a delivery system capable of penetrating nails.

Ciclopirox nail lacquer solution 8% in the 21st century

Ciclopirox nail lacquer solution 8% has been shown to be effective in the treatment of dermatophyte onychomycosis of mild to moderate severity Other studies report the effectiveness of ciclopirox nail lacquer in onychomycosis caused by Candida sp and nondermatophyte molds. Ciclopirox nail lacquer may also be valuable in the treatment of early cases of reinfection/relapse. Ciclopirox nail lacquer solution 8% may be an important adjunct to oral antifungal therapy in certain presentations that might be poorly responsive to oral antifungal therapy alone (eg, lateral onychomycosis, longitudinal spike, dermatophytoma, and extensive onycholysis). In some cases, surgical therapies may need to be considered in addition to, or in preference to, topical nail lacquer treatment. The use of ciclopirox nail lacquer solution 8% as an adjunct to oral antifungal therapy may widen the spectrum of activity of the combination because of the broad spectrum of coverage provided by the lacquer. The use of combination therapy may be synergistic in terms of efficacy, enabling a reduction in the duration and cumulative dosage of oral therapy. This could result in a decrease in the frequency and severity of systemic adverse effects associated with the oral antimycotics and the need to be vigilant about drug interactions. Studies need to be conducted to determine the place of combination oral and topical lacquer therapy in the management of onychomycosis.