Defining the rate of nutritional and metabolic derangements after pancreatic resection

BACKGROUND AND AIMS

Pancreatic resection is associated with pancreatic exocrine insufficiency (PEI) leading to nutritional consequences. The Pancreatic Nutrition Clinic was established to diagnose and manage PEI through standardised nutritional assessment. In this prospective observational study, we aimed to define the rate of PEI, diabetes mellitus and nutritional abnormalities in patients who underwent pancreatic resection.

METHODS

All Pancreatic Nutrition Clinic patients were included for analysis. Clinical data were prospectively obtained at initial assessment. Biochemical data included micronutrient levels, faecal elastase-1 and haemoglobin A1c. Bone mineral density and nutritional assessment were undertaken.

RESULTS

Ninety-eight patients were included. Fifty-nine per cent (58/98) had undergone a pancreatoduodenectomy. Ninety-three patients had a faecal elastase-1 result, 65% (60/93) of which had a faecal elastase-1 less than 200 μg/g of faeces. Seventy-five patients (76%) of the total population required PERT, and thirty-nine (40%) were classified as malnourished using the patient-generated subjective global assessment tool. Seventy-two per cent (70/97) had a biochemical deficiency of one or more micronutrients. Thirty-eight people (39%) had diabetes mellitus. Of the seventy-eight patients with a bone mineral density scan available for analysis, 29% (23/78) had osteoporosis and 49% (38/78) osteopenia.

CONCLUSIONS

Pancreatic exocrine insufficiency, micronutrient deficiency, bone disease, diabetes mellitus and malnutrition are highly prevalent in patients who have undergone pancreatic resection.

Effects of a MAPK p38 inhibitor on lung function and airway inflammation in equine recurrent airway obstruction

REASONS FOR PERFORMING STUDY

It has been suggested that many of the beneficial effects of corticosteroids are mediated through mitogen-activated protein kinase (MAPK) p38 inhibition.

OBJECTIVE

To investigate the efficacy of the MAPK p38 inhibitor compound MRL-EQ1 to either prevent (Phase 1) or treat (Phase 2) recurrent airway obstruction (RAO) in horses.

METHODS

MRL-EQ1 was administered i.v. at a dosage of 0.75-1.5 mg/kg bwt q. 12 h. In Phase 1, susceptible horses in clinical remission were divided into 2 groups (n = 5/group), based on historical values of respiratory mechanics. All horses were entered in the study in pairs (one control, one treated horse) and exposed to the same environmental challenge (stabling, mouldy hay and dusty conditions). The treatment group received MRL-EQ1 for 14 days while the control horses were untreated during the same period. In Phase 2, affected horses were ranked by severity of respiratory dysfunction and split randomly into either dexamethasone or MRL-EQ1 treatment groups (n = 5/group). Bronchoalveolar lavage fluid, respiratory mechanic measurements, MRL-EQ1 plasma concentration and tumour necrosis factor (TNF) whole blood activity were evaluated sequentially.

RESULTS

In Phase 1, MRL-EQ1 did not prevent the occurrence of clinical signs and pulmonary inflammation. However, treatment was associated with a reduction in severity and a delay in the onset of signs and a reduction in pulmonary neutrophilia. In Phase 2, plasma concentrations achieved resulted in ex vivo suppression of lipopolysaccharide-induced TNF production in equine blood. MRL-EQ1 did not improve airway inflammation or lung function and was associated in a dose dependent manner with behavioural (depression, excitability) and blood changes (neutrophilia, increased serum muscle enzyme concentrations).

CONCLUSIONS

Inhibition of p38 in the horse was partially effective in reducing clinical signs and airway inflammation when administered prior to, but not during clinical exacerbation in RAO.

POTENTIAL RELEVANCE

Inhibitors of p38 MAPK with a better toxicity profile may be effective in the prevention or treatment of RAO.

Coffee and coronary heart disease

BACKGROUND

The role of coffee consumption in the onset of myocardial infarction remains uncertain. A review of published reports showed that although cohort data suggest very little excess risk of coronary heart disease among habitual coffee drinkers, case-control data suggest an excess risk of the order of 60% for people drinking five or more cups per day.

METHODS

We obtained as much information as possible on the lifestyle and habits, including coffee consumption, of people admitted with chest pain to the Coronary Care Unit at the Royal Perth Hospital, Australia. A questionnaire was given to them by the attending nursing staff. Details were recorded by the patient, often with help from the nursing staff. A similar questionnaire was completed by patients attending the Cardiology Outpatient Clinic.

RESULTS

One of the outstanding differences between the 182 patients with myocardial infarction or unstable angina and 185 patients with chronic stable coronary heart disease who filled in forms while waiting in the Cardiology Outpatient Clinic was that more people with acute coronary syndromes were drinking in excess of five cups of coffee per day (18 vs 7.5%; P = 0.003). In logistic regression analysis adjusted for age, smoking status (past and current), hypertension, dyslipidaemia and diabetes, the odds ratio was 2.51 (95% CI 1.43,4.43; P = 0.021).

CONCLUSION

The present case-control study provides evidence for an increased risk of myocardial infarction or unstable angina among individuals drinking more than five cups of coffee per day.

What do newly-qualified nurses expect from preceptorship? Exploring the perspective of the preceptee

Preceptorship plays an important role in ensuring the smooth transition from student to registered nurse (UKCC 1993). To date, there has been little evidence to demonstrate the extent to which preceptorship has been introduced, and scant research into newly-qualified nurses' expectations and experiences of preceptorship. A longitudinal, questionnaire survey is exploring the expectations of preceptorship, from the perspective of newly qualified nurses, as part of a Department of Health funded study into the careers of people qualifying from nursing diploma courses. The paper demonstrates how pilot work with a cohort of newly qualified nurses, combined with literature on preceptorship, enabled the identification of key aspects of preceptorship. Findings are presented on the expectations of adult branch nurses at the point of qualification. There was an overwhelming demand for preceptorship, and the majority of respondents anticipated that all identified aspects of preceptorship would be important in their first job. Aspects identified as particularly important were 'constructive feedback on my clinical skills' and 'teaching new clinical skills'. Future questionnaires will reveal the extent to which these expectations are met.

Increases in circulating insulin-like growth factor I levels by the oral growth hormone secretagogue MK-0677 in the beagle are dependent upon pituitary mediation

It has been well established that the spiroindoline sulfonamide MK-0677 stimulates GH secretion from the pituitary both in vitro and in vivo. MK-0677 has also been shown to increase serum insulin-like growth factor I (IGF-I) and cortisol levels in vivo; these increases are assumed to be driven by the increased serum GH and ACTH levels, respectively. However, such increases could also be due to a direct stimulatory action of MK-0677 at the level of the liver and adrenal cortex. To address this possibility, we investigated whether MK-0677 increased IGF-I and cortisol levels in hypophysectomized dogs. Baseline GH, IGF-I, and cortisol responses to MK-0677 (1 mg/kg, orally) were initially determined. Hypophysectomy (hypox; n = 7) or sham surgery (sham; n = 5) was then carried out. Six days postsurgery, the GH and cortisol responses to MK-0677 were reevaluated in each dog. In addition, each dog was treated with porcine GH (PST; 0.1 IU/kg, s.c.) to confirm the responsiveness of the GH-IGF-I axis. The mean peak GH increases in response to MK-0677 in the presham dogs (83.7 +/- 19.2 ng/ml), post-sham dogs (108 +/- 26.2 ng/ml), and pre-hypox dogs (121.2 +/- 13.6 ng/ml) were not significantly different. Mean peak GH levels were unchanged after MK-0677 administration in the hypox dogs (2.3 +/- 0.7 ng/ml). Before surgery, serum IGF-I levels increased to 243 +/- 27 and 224 +/- 47 ng/ml in the sham and hypox groups, respectively, after MK-0677 administration. Surgery was associated with a marked (> or =50%) decrease in serum IGF-I levels. MK-0677 administration increased IGF-I levels in the sham dogs from 78 +/- 14 to 187 +/- 31 ng/ml, whereas IGF-I levels remained unchanged (17.7 +/- 2.4 ng/ml) in the-hypox dogs. PST treatment increased IGF-I levels in the sham dogs from 162 +/- 30 to 325 +/- 32 ng/ml. In the hypox dogs PST treatment restored IGF-I to physiological levels (from 17.7 +/- 2.4 to 199 +/- 41 ng/ml). Cortisol was increased after MK-0677 administration 3.7-fold in the pre-sham, 3.6-fold in the post-sham, and 3.6-fold in the pre-hypox dogs, but no increase was seen in the post-hypox dogs. ACTH GEL administration (2.2 U/kg, i.m.) to hypox dogs returned cortisol to normal physiological levels, demonstrating the functional integrity of the adrenal cortex. This study demonstrates that the GH secretagogue MK-0677 does not directly stimulate an increase in serum IGF-I or cortisol levels, but depends upon the presence of an intact pituitary.

Attention deficit hyperactivity disorder, CNS stimulants and sport

Attention deficit hyperactivity disorder (ADHD) affects 1 to 10% of children and is characterised by a persistent pattern of inattention and/or hyperactivity/impulsivity. Over one-half of children with ADHD have associated conditions, including learning disabilities, conduct disorders, poor coordination, depression, anxiety, obsessive-compulsive disorders and bipolar disorders. CNS stimulant medication used in the management of ADHD is not permitted for use in competition by the International Olympic Committee (IOC) and this poses a problem for the physicians of patients with ADHD. On the one hand, attention and concentration are improved by stimulant medication and fine motor coordination and balance are improved after methylphenidate administration, but these therapeutic and sport-related benefits are not available to the athlete with ADHD who wishes to compete under IOC rules. It has been suggested that treatment with methylphenidate may be suitable for athletes with ADHD, as cessation of therapy 24 hours before competition is usually adequate to allow drug clearance which should avoid a positive result being returned on drug testing. More research is needed to establish whether stimulant medication for athletes with ADHD provides an unfair advantage in competition.

Exploring mental health nurses' expectations and experiences of working in the community

As mental health care is increasingly being provided in community settings, a variety of job opportunities are becoming available to mental health nurses. The extent to which nurses' views and experiences of working in community settings have been explored, however, is limited. This paper reports on newly qualified nurses' plans in relation to taking up work in the community and, for those who thought it likely that they would take up such work, their reasons for doing so. Reasons for working in the community were diverse, and suggested that a range of satisfactions could be expected. The extent to which such expectations become a reality is considered in the light of findings from interviews with 12 nurses who were working in community settings. Satisfactions and difficulties experienced by the 12 nurses are described, and suggestions for tackling some of the difficulties are made.

Who becomes a mental health nurse?

Mental health nurses come to the profession with a diverse range of life experiences. Gary Hickey and Cheryl Kipping describe a recent survey and its implications for recruitment and retention policies.

Exploring the concept of user involvement in mental health through a participation continuum

Although recent years have seen an increased emphasis on involving service users in decisions about their care, there has been limited exploration of the theories and ideologies underpinning the concept. This paper identifies two approaches to user involvement, each with implications for the extent to which users can be involved in decisions about their care. The approaches are linked through a 'participation continuum' which is a framework through which the concept of user involvement can be explored, and against which practice can be assessed. The framework must be seen within the context of constraints to user involvement. A more realistic assessment of the extent to which users can be involved in decisions can then be made and the risks of raising unrealistic expectations avoided.

MK-0677, a potent, novel, orally active growth hormone (GH) secretagogue: GH, insulin-like growth factor I, and other hormonal responses in beagles

MK-0677, a spiroindoline sulfonamide, is a novel, orally active GH secretagogue. The effects of MK-0677 on serum GH and other hormones after oral and iv single dose administrations in beagles were evaluated. After oral administration in a balanced eight-dog crossover study, treatment with MK-0677 significantly increased peak GH concentrations, with a 5.3-fold increase (mean +/- SEM, 10.5 +/- 1.9 ng/ml) at the 0.25 mg/kg dose, a 9.0-fold increase (18.0 +/- 3.3 ng/ml) at the 0.50 mg/kg dose, and a 15.8-fold increase (31.6 +/- 5.8 ng/ml) at the 1.0 mg/kg dose. Total GH release, expressed as the area under the curve, showed similar significant increases over the effect of the water placebo. A single oral 1 mg/kg dose in three dogs induced a mean GH peak of 27.6 +/- 1.5 ng/ml at 120 min, and GH levels remained elevated up to 360 min after treatment. Insulin-like growth factor I (IGF-I) levels were significantly increased by 30% at 480 min after treatment. Cortisol levels were increased 2.4-fold over pretreatment levels. After i.v. administration, compared to the saline control group which had a mean (+/- SEM) serum GH peak of 3.8 +/- 0.7 ng/ml, MK-0677 at 0.25 mg/kg significantly increased (P < 0.05) peak GH concentrations 20.4-fold (77.4 +/- 13.7 ng/ml). Total GH release, expressed as the area under the curve, showed a similar increase. The mean peak GH level was recorded 10 min after treatment, with GH levels elevated up to 180 min after treatment. IGF-I levels were significantly elevated by 25% 360 min after the administration of MK-0677. Cortisol levels were increased 2.3-fold over pretreatment levels. Insulin and glucose levels were higher, LH and PRL levels were unaltered, and T4 levels were marginally lower; the levels of each of these hormones remained within the normal ranges for dogs throughout the experiment. In summary, MK-0677 is a potent GH secretagogue that induces an immediate, large, long lasting increase in GH levels when administered orally or i.v. In contrast to GH-releasing peptide-6 and benzolactam secretagogues, GH levels were elevated up to 360 min after treatment, and this was associated with a significant increase in IGF-I levels. Cortisol levels were increased; however, the increases were modest compared to those in GH.

The challenge of change in nurse education: traditionally trained nurses' perceptions of Project 2000

Adapting to change can often be a difficult process. How traditionally trained nurses perceive the change brought about by Project 2000 is important, since this may affect how they view their own future, how they receive those who are qualifying via Project 2000 and how they work with Project 2000 diplomates in the future. It is, therefore, important that attempts are made to overcome any resistance to the changes brought about by Project 2000. The findings presented here are taken from the first questionnaire in a Department of Health-funded, longitudinal study into the careers of traditionally trained mental health nurses. Five hundred and fifty-six nurses were asked their views about the new training and how they thought it would affect them. Four hundred and forty-seven people returned the questionnaire: an 80% response rate. This study has revealed some positive views on Project 2000 as well as a variety of concerns.

Design and biological activities of L-163,191 (MK-0677): a potent, orally active growth hormone secretagogue

A potent, orally active growth hormone (GH) secretagogue L-163,191 belonging to a recently synthesized structural class has been characterized. L-163,191 releases GH from rat pituitary cells in culture with EC50 = 1.3 +/- 0.09 nM and is mechanistically indistinguishable from the GH-releasing peptide GHRP-6 and the prototypical nonpeptide GH secretagogue L-692,429 but clearly distinguishable from the natural GH secretagogue, GH-releasing hormone. L-163,191 elevates GH in dogs after oral doses as low as 0.125 mg/kg and was shown to be specific in its release of GH without significant effect on plasma levels of aldosterone, luteinizing hormone, thyroxine, and prolactin after oral administration of 1 mg/kg. Only modest increases in cortisol were observed. Based on these properties, L-163,191 has been selected for clinical studies.

Effects of acute and repeated intravenous administration of L-692,585, a novel non-peptidyl growth hormone secretagogue, on plasma growth hormone, IGF-1, ACTH, cortisol, prolactin, insulin, and thyroxine levels in beagles

L-692,585 is a 2-hydroxypropyl derivative of L-692,429, both novel non-peptidyl growth hormone (GH) secretagogues. The effects of single and repeated intravenous administration of L-692,585 on serum or plasma GH and other hormones in beagles were evaluated. In a balanced 8-dog dose-ranging study, compared to the saline control with a mean (+/- S.E.M.) after-dose serum GH peak of 6.1 +/- 1.3 ng/ml, L-692,585 significantly increased (P < 0.05) peak GH concentrations 4.3-fold (32.5 +/- 7.0 ng/ml) at a dose of 0.005 mg/kg, 7-fold (49.4 +/- 10.6 ng/ml) at a dose of 0.02 mg/kg, and 21-fold (134.3 +/- 29.0 ng/ml) at a dose of 0.10 mg/kg. Total GH release, expressed as area under the curve, showed a similar dose-dependent increase. Peak GH levels were recorded at 5 or 15 min after dosing with the levels returning to near baseline by 90 min. Serum cortisol levels were increased above saline control levels in a dose-dependent manner; however, the increases were modest compared to the GH increases. Based on peak responses and total GH release, L-692,585 was 10- to 20-fold and 2- to 2.5-fold more potent than L-692,429 and the growth hormone releasing peptide, GHRP-6, respectively. When L-692,585 was administered once daily for 14 consecutive days at 0, 0.01 or 0.10 mg/kg to each of 6 dogs, peak plasma GH levels and total GH release on days 1, 8 and 15 significantly increased in a dose-dependent manner, and no desensitization was evident.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy and specificity of L-692,429, a novel nonpeptidyl growth hormone secretagogue, in beagles

L-692,429 is a substituted benzolactam that has recently been shown to stimulate GH secretion from rat pituitary cells in vitro with an ED50 of 60 nM. In the current studies, we evaluated the efficacy and specificity of L-692,429 as a GH secretagogue in beagles. L-692,429 at 0.1, 0.25, or 1.0 mg/kg or saline vehicle was administered iv to four male and four female beagles in a balanced cross-over design. Blood samples were collected up to 75 min posttreatment, and serum was assayed for GH, cortisol, PRL, and LH. Mean peak serum GH levels were significantly increased (P < 0.05) by L-692,429 to 13 +/- 2 (mean +/- SEM) ng/ml (0.1 mg/kg), 39 +/- 6 ng/ml (0.25 mg/kg), or 71 +/- 11 ng/ml (1.0 mg/kg) over the saline control value of 3.6 +/- 0.6 ng/ml. Mean peak GH levels occurred at 15 min and had returned to near-baseline levels by 75 min. There was no difference in response between sexes. Mean peak cortisol levels were significantly increased (P < 0.05) by 2.2-, 2.7-, and 3.1-fold above control levels (3.0 +/- 0.2 micrograms/dl) at 25-35 min and returned to near-baseline levels by 75 min. PRL was slightly decreased after L-692,429 treatment, whereas LH was not affected. In a second study, three groups of three male beagles each were administered 5.0 mg/kg L-692,429, iv; iv saline, or 2.2 U/kg ACTH, im. Blood was collected for 8 h posttreatment and assayed for GH, cortisol, ACTH, aldosterone, PRL, insulin, T3, and T4. L-692,429 administration significantly increased (P < 0.05) GH over the control level (6.0 +/- 3.6 ng/ml) to 133 +/- 14 ng/ml by 15 min, with a return to pretreatment levels by 120 min. Cortisol levels were significantly increased (P < 0.05) by 2.0-fold (L-692,429) or 2.9-fold (ACTH) over the saline control peak concentration of 5.6 +/- 1.6 micrograms/dl and were associated with concurrent increases in ACTH levels of 1.2-fold (L-692,429) or 2.1-fold (ACTH) over the saline control peak concentration of 67 +/- 20 pmol/L. Aldosterone, PRL, T3, and T4 were not significantly affected after L-692,429 administration; however, ACTH treatment significantly increased aldosterone (P < 0.05). These data demonstrate that L-692,429 is a novel nonpeptidyl secretagogue that stimulates a marked, but transient, increase in serum GH levels in the dog.(ABSTRACT TRUNCATED AT 400 WORDS)

A nonpeptidyl growth hormone secretagogue

A nonpeptidyl secretagogue for growth hormone of the structure 3-amino-3-methyl-N-(2,3,4,5-tetrahydro-2-oxo-1-([2'-(1H-tetrazol-5 -yl) (1,1'-biphenyl)-4-yl]methyl)-1H-1-benzazepin-3(R)-yl)-butanamid e (L-692,429) has been identified. L-692,429 synergizes with the natural growth hormone secretagogue growth hormone-releasing hormone and acts through an alternative signal transduction pathway. The mechanism of action of L-692,429 and studies with peptidyl and nonpeptidyl antagonists suggest that this molecule is a mimic of the growth hormone-releasing hexapeptide His-D-Trp-Ala-Trp-D-Phe-Lys-NH2 (GHRP-6). L-692,429 is an example of a nonpeptidyl specific secretagogue for growth hormone.

Discriminant analysis of the clinical indicants for bovine coliform mastitis

We used discriminant analysis to assess the indicants most useful in predicting whether a cow had coliform bacterial mastitis. One hundred and twenty-nine mastitic cows were divided into two groups, namely those with milk cultures that yielded pure or mixed gram negative organisms, and cows with other organisms or negative culture. Of 21 indicants examined by discriminate analysis only a history of previous mastitis in the affected quarter, weakness, clear or white color of milk, swelling of the udder, water consistency of the milk, lack of previous mastitis in other quarters, lack of palpable udder abscesses, and elevated body temperature were significantly associated with coliform mastitis. Using these variables 78% of cases were correctly classified.

Pendular nystagmus in dairy cattle

In a survey of 2,932 mature dairy cattle performed over a 1-month period, we found 15 with rapid oscillation in 1 or both eyes. Nystagmus had been present since shortly after birth in 2 animals, and the age at onset was unknown in the others. The nystagmus was not associated with any other physical or neurologic problem. Pendular nystagmus apparently is benign and should not be mistaken for a sign of serious neurologic disease.