Comparative potency of obeticholic acid and natural bile acids on FXR in hepatic and intestinal in vitro cell models

Obeticholic acid (OCA) is a semisynthetic farnesoid X receptor (FXR) agonist, an analogue of chenodeoxycholic acid (CDCA) which is indicated for the treatment of primary biliary cholangitis (PBC) in combination with ursodeoxycholic acid (UDCA). OCA efficiently inhibits bile acid synthesis and promotes bile acid efflux via activating FXR-mediated mechanisms in a physiologically relevant in vitro cell system, Sandwich-cultured Transporter Certified ™ human primary hepatocytes (SCHH). The study herein evaluated the effects of UDCA alone or in combination with OCA in SCHH. UDCA (≤100 μmol/L) alone did not inhibit CYP7A1 mRNA, and thus, no reduction in the endogenous bile acid pool observed. UDCA ≤100 μmol/L concomitantly administered with 0.1 μmol/L OCA had no effect on bile acid synthesis beyond what was observed with OCA alone. Furthermore, this study evaluated human Caco-2 cells (clone C2BBe1) as in vitro intestinal models. Glycine conjugate of OCA increased mRNA levels of FXR target genes in Caco-2 cells, FGF-19, SHP, OSTα/β, and IBABP, but not ASBT, in a concentration-dependent manner, while glycine conjugate of UDCA had no effect on the expression of these genes. The results suggested that UDCA ≤100 μmol/L did not activate FXR in human primary hepatocytes or intestinal cell line Caco-2. Thus, co-administration of UDCA with OCA did not affect OCA-dependent pharmacological effects.

Farnesoid X Receptor Agonists Obeticholic Acid and Chenodeoxycholic Acid Increase Bile Acid Efflux in Sandwich-Cultured Human Hepatocytes: Functional Evidence and Mechanisms

The farnesoid X receptor (FXR) is a nuclear receptor that regulates genes involved in bile acid homeostasis. FXR agonists, obeticholic acid (OCA) and chenodeoxycholic acid (CDCA), increase mRNA expression of efflux transporters in sandwich-cultured human hepatocytes (SCHH). This study evaluated the effects of OCA and CDCA treatment on the uptake, basolateral efflux, and biliary excretion of a model bile acid, taurocholate (TCA), in SCHH. In addition, changes in the protein expression of TCA uptake and efflux transporters were investigated. SCHH were treated with 1 µM OCA, 100 µM CDCA, or vehicle control for 72 hours followed by quantification of deuterated TCA uptake and efflux over time in Ca²⁺-containing and Ca²⁺-free conditions (n = 3 donors). A mechanistic pharmacokinetic model was fit to the TCA mass-time data to obtain estimates for total uptake clearance (CL_Uptake), total intrinsic basolateral efflux clearance (CL_int,BL), and total intrinsic biliary clearance (CL_int,Bile). Modeling results revealed that FXR agonists significantly increased CL_int,BL by >6-fold and significantly increased CL_int,Bile by 2-fold, with minimal effect on CL_Uptake Immunoblotting showed that protein levels of the basolateral transporter subunits organic solute transporter α and β (OSTα and OSTβ) in FXR agonist-treated SCHH were significantly induced by >2.5- and 10-fold, respectively. FXR agonist-mediated changes in the expression of other TCA transporters in SCHH were modest. In conclusion, this is the first report demonstrating that OCA and CDCA increased TCA efflux in SCHH, which contributed to reduced intracellular TCA concentrations. Increased basolateral efflux of TCA was consistent with increased OSTα/β protein expression in OCA- and CDCA-treated SCHH.

Acute Passive Static Stretching and Cramp Threshold Frequency

CONTEXT

  Exercise-associated muscle cramps are a common clinical problem for athletes.

OBJECTIVE

  To determine whether acute passive static stretching altered cramp threshold frequency (CTF) of electrically induced muscle cramps.

DESIGN

  Crossover study.

SETTING

  Laboratory.

PATIENTS OR OTHER PARTICIPANTS

  Seventeen healthy college-aged individuals.

INTERVENTION(S)

  Stretching or no stretching.

MAIN OUTCOME MEASURE(S)

  The independent variable was the static stretch versus the no-stretch condition, and the dependent variable was the CTF.

RESULTS

  The CTF increased in both the control (pretest: 18.12 ± 6.46 Hz, posttest: 19.65 ± 7.25 Hz; P = .033) and stretching (pretest: 18.94 ± 5.96 Hz, posttest: 20.47 ± 7.12 Hz; P = .049) groups. No difference between the groups was found (t₁₅ = 0.035, P = .97).

CONCLUSIONS

  Acute passive static stretching did not seem to increase the CTF.

Obeticholic acid, a selective farnesoid X receptor agonist, regulates bile acid homeostasis in sandwich-cultured human hepatocytes

Farnesoid X receptor (FXR) is a master regulator of bile acid homeostasis through transcriptional regulation of genes involved in bile acid synthesis and cellular membrane transport. Impairment of bile acid efflux due to cholangiopathies results in chronic cholestasis leading to abnormal elevation of intrahepatic and systemic bile acid levels. Obeticholic acid (OCA) is a potent and selective FXR agonist that is 100‐fold more potent than the endogenous ligand chenodeoxycholic acid (CDCA). The effects of OCA on genes involved in bile acid homeostasis were investigated using sandwich‐cultured human hepatocytes. Gene expression was determined by measuring mRNA levels. OCA dose‐dependently increased fibroblast growth factor‐19 (FGF‐19) and small heterodimer partner (SHP) which, in turn, suppress mRNA levels of cholesterol 7‐alpha‐hydroxylase (CYP7A1), the rate‐limiting enzyme for de novo synthesis of bile acids. Consistent with CYP7A1 suppression, total bile acid content was decreased by OCA (1 μmol/L) to 42.7 ± 20.5% relative to control. In addition to suppressing de novo bile acids synthesis, OCA significantly increased the mRNA levels of transporters involved in bile acid homeostasis. The bile salt excretory pump (BSEP), a canalicular efflux transporter, increased by 6.4 ± 0.8‐fold, and the basolateral efflux heterodimer transporters, organic solute transporter α (OST_α) and OST_β increased by 6.4 ± 0.2‐fold and 42.9 ± 7.9‐fold, respectively. The upregulation of BSEP and OST_α and OST_β, by OCA reduced the intracellular concentrations of d₈‐TCA, a model bile acid, to 39.6 ± 8.9% relative to control. These data demonstrate that OCA does suppress bile acid synthesis and reduce hepatocellular bile acid levels, supporting the use of OCA to treat bile acid‐induced toxicity observed in cholestatic diseases.

Muscle cramp susceptibility increases following a volitionally induced muscle cramp

INTRODUCTION

Muscle cramping may increase peripheral nervous system excitability. It is unknown if, and how long, cramp susceptibility is affected by previous cramping. We tested whether volitionally induced muscle cramps (VIMCs) lowered cramp threshold frequency (TF_c ) and how long TF_c was affected post-VIMC.

METHODS

Fifteen cramp-prone participants volitionally induced a flexor hallucis brevis (FHB) cramp on 4 separate days. FHB TF_c was measured before VIMC (i.e., baseline) and 5, 30, and 60 min post-VIMC. VIMC electromyography (EMG) amplitude, VIMC duration, and perceived VIMC intensity were measured to ensure consistency of VIMC between days.

RESULTS

VIMC EMG amplitude, duration, and perceived intensity were similar between days (P > 0.05). VIMC lowered TF_c ; baseline TF_c (18 ± 6 Hz) was higher than 5-min (14 ± 6 Hz), 30-min (14 ± 5 Hz), and 60-min TF_c (14 ± 5 Hz; P < 0.05).

DISCUSSION

Acute VIMCs increase cramp susceptibility. Clinicians should apply treatments for at least 60 min postcramp to decrease the probability of cramp recurrence. Muscle Nerve 56: E95-E99, 2017.

Modeling and Experimental Studies of Obeticholic Acid Exposure and the Impact of Cirrhosis Stage

Obeticholic acid (OCA), a semisynthetic bile acid, is a selective and potent farnesoid X receptor (FXR) agonist in development for the treatment of chronic nonviral liver diseases. Physiologic pharmacokinetic models have been previously used to describe the absorption, distribution, metabolism, and excretion (ADME) of bile acids. OCA plasma levels were measured in healthy volunteers and cirrhotic subjects. A physiologic pharmacokinetic model was developed to quantitatively describe the ADME of OCA in patients with and without hepatic impairment. There was good agreement between predicted and observed increases in systemic OCA exposure in subjects with mild, moderate, and severe hepatic impairment, which were 1.4‐, 8‐, and 13‐fold relative to healthy volunteers. Predicted liver exposure for subjects with mild, moderate, and severe hepatic impairment were increased only 1.1‐, 1.5‐, and 1.7‐fold. In subjects with cirrhosis, OCA exposure in the liver, the primary site of pharmacological activity along with the intestine, is increased marginally (∼2‐fold).

The effect of stocking density in transit on the carcass quality and welfare of slaughter pigs: 2. Results from the analysis of blood and meat samples

In a trial involving 2496 pigs, the influences on blood profile and pork quality of stocking densities ranging from 201 to 321kg m(-2) were examined. The pigs came from four different farms and were killed in 16 weekly batches. They were transported for on average 3hr and held in lairage for 1hr. Higher stocking densities resulted in more physical stress to the pigs based on the activity of the enzyme CPK in the blood. Stocking density did not apparently affect psychological stress and high densities did not result in dehydration. The colour, water holding capacity and instrumentally-determined texture of the pork from the carcasses of the pigs were not affected by stocking density. The experimental design and precision of the measurements were sufficient to detect numerous differences in blood profile and pork quality between pigs from the four source farms. These differences probably related to different degrees of stress-susceptibility. The results suggest that the highest stocking density examined (321kg m(-2)) is unacceptable for the transport of pigs. The second highest density (281kg m(-2)) produced relatively little evidence of an adverse effect on the welfare of pigs. It may be scientifically acceptable for short journeys (≤3hr) but not for longer ones where pigs need more space to lie down.

Exercise-associated muscle cramps: causes, treatment, and prevention

CONTEXT

Exercise-associated muscle cramps (EAMC) are a common condition experienced by recreational and competitive athletes. Despite their commonality and prevalence, their cause remains unknown. Theories for the cause of EAMC are primarily based on anecdotal and observational studies rather than sound experimental evidence. Without a clear cause, treatments and prevention strategies for EAMC are often unsuccessful.

EVIDENCE ACQUISITION

A search of Medline (EBSCO), SPORTDiscus, and Silverplatter (CINHAL) was undertaken for journal articles written in English between the years 1955 and 2008. Additional references were collected by a careful analysis of the citations of others' research and textbooks.

RESULTS

Dehydration/electrolyte and neuromuscular causes are the most widely discussed theories for the cause of EAMC; however, strong experimental evidence for either theory is lacking.

CONCLUSIONS

EAMC are likely due to several factors coalescing to cause EAMC. The variety of treatments and prevention strategies for EAMC are evidence of the uncertainty in their cause. Acute EAMC treatment should focus on moderate static stretching of the affected muscle followed by a proper medical history to determine any predisposing conditions that may have triggered the onset of EAMC. Based on physical findings, prevention programs should be implemented to include fluid and electrolyte balance strategies and/or neuromuscular training.

Threshold frequency of an electrically induced cramp increases following a repeated, localized fatiguing exercise

Though clinical observations and laboratory data provide some support for the neuromuscular imbalance theory of the genesis of exercise-associated muscle cramps, no direct evidence has been published. The purpose of this study was to determine the effect of local muscle fatigue on the threshold frequency of an electrically induced muscle cramp. To determine baseline threshold frequency, a cramp was electrically induced in the flexor hallucis brevis of 16 apparently healthy participants (7 males, 9 females; age 25.1 +/- 4.8 years). The testing order of control and fatigue conditions was counterbalanced. In the control condition, participants rested in a supine position for 30 min followed by another cramp induction to determine post-threshold frequency. In the fatigue condition, participants performed five bouts of great toe curls at 60% one-repetition maximum to failure with 1 min rest between bouts followed immediately by a post-threshold frequency measurement. Repeated-measures analysis of variance and simple main effects testing showed post-fatigue threshold frequency (32.9 +/- 11.7 Hz) was greater (P < 0.001) than pre-fatigue threshold frequency (20.0 +/- 7.7 Hz). An increase in threshold frequency seems to demonstrate a decrease in one's propensity to cramp following the fatigue exercise regimen used. These results contradict the proposed theory that suggests cramp propensity should increase following fatigue. However, differences in laboratory versus clinical fatiguing exercise and contributions from other sources, as well as the notion of a graded response to fatiguing exercise, on exercise-associated muscle cramp and electrically induced muscle cramp should be considered.

APD791, 3-methoxy-n-(3-(1-methyl-1h-pyrazol-5-yl)-4-(2-morpholinoethoxy)phenyl)benzamide, a novel 5-hydroxytryptamine 2A receptor antagonist: pharmacological profile, pharmacokinetics, platelet activity and vascular biology

We have evaluated the receptor pharmacology, antiplatelet activity, and vascular pharmacology of APD791 [3-methoxy-N-(3-(1-methyl-1H-pyrazol-5-yl)-4-(2-morpholinoethoxy)phenyl)benzamide] a novel 5-hydroxytryptamine 2A (5-HT(2A)) receptor antagonist. APD791 displayed high-affinity binding to membranes (K(i) = 4.9 nM) and functional inverse agonism of inositol phosphate accumulation (IC(50) = 5.2 nM) in human embryonic kidney cells stably expressing the human 5-HT(2A) receptor. In competition binding assays, APD791 was greater than 2000-fold selective for the 5-HT(2A) receptor versus 5-HT(2C) and 5-HT(2B) receptors, and was inactive when tested against a wide panel of other G-protein-coupled receptors. APD791 inhibited 5-HT-mediated amplification of ADP-stimulated human and dog platelet aggregation (IC(50) = 8.7 and 23.1 nM, respectively). Similar potency was observed for inhibition of 5-HT-stimulated DNA synthesis in rabbit aortic smooth muscle cells (IC(50) = 13 nM) and 5-HT-mediated vasoconstriction in rabbit aortic rings. Oral administration of APD791 to dogs resulted in acute (1-h) and subchronic (10-day) inhibition of 5-HT-mediated amplification of collagen-stimulated platelet aggregation in whole blood. Two active metabolites, APD791-M1 and APD791-M2, were generated upon incubation of APD791 with human liver microsomes and were also indentified in dogs after oral administration of APD791. The affinity and selectivity profiles of both metabolites were similar to APD791. These results demonstrate that APD791 is an orally available, high-affinity 5-HT(2A) receptor antagonist with potent activity on platelets and vascular smooth muscle.

Societal costs versus savings from wild-card patent extension legislation to spur critically needed antibiotic development

BACKGROUND

Over the last two decades, an alarming rise in infections caused by antibiotic-resistant microbes has been paralleled by an equally alarming decline in the development of new antibiotics to deal with the threat. In response to this brewing "perfect storm" of infectious diseases, the Infectious Diseases Society of America (IDSA) has released a white paper that proposes incentives to stimulate critically needed antibiotic development by pharmaceutical companies. A cornerstone of the recommendations is establishment of a "wild-card patent extension" program. This program would allow a company receiving United States (US) Food and Drug Administration (FDA) approval for a new anti-infective agent targeting a drug-resistant pathogen to extend the patent on a drug within their active portfolio. However, wild-card patent extension legislation is highly controversial due to concerns regarding its societal cost.

METHODS

We performed a systematic literature review to estimate the societal cost of wild-card patent extension compared to the savings resulting from the availability of one new antibiotic to treat multi-drug-resistant Pseudomonas aeruginosa.

RESULTS

We conservatively estimate that wild-card patent extension applied to one new antibiotic would cost $7.7 billion over the first 2 years, and $3.9 billion over the next 18 years. Thus, even if the new antibiotic abrogated only 50% of the annual societal cost of multidrug-resistant P. aeruginosa (estimated $2.7 billion), wild-card patent extension would be cost neutral by 10 years after approval of the new antibiotic, and would save society approximately $4.6 billion by 20 years after approval.

CONCLUSIONS

Wild-card patent extension appears to be a cost-effective strategy to spur anti-infective development. Although our analysis is limited by the precision of published data, our model employed conservative assumptions.

Specificity and sensitivity of eubacterial primers utilized for molecular profiling of bacteria within complex microbial ecosystems

Efficient profiling of eubacterial diversity within complex communities requires that primers are specific for eubacterial 16S rRNA. Specificity of published primers against eubacterial and archaeal 16S rRNA as well as protozoal and fungal 18S rRNA was assessed in silico. The specificity and sensitivity of the V3 and V6-V8 (F968gc and R1401) Denaturing Gradient Gel Electrophoresis (DGGE) primers was subsequently verified using rumen-derived samples. An assessment of the effects of employing touchdown PCR cycling conditions was also made. For DGGE profiling of eubacteria within rumen samples, primers F968gc and R1401 proved the most specific and sensitive providing that touchdown PCR is not used.

Peripheral ankle cooling and core body temperature

CONTEXT

Exposure of the human body to cold is perceived as a stressor and results in a sympathetic response geared at maintaining core temperature. Application of ice to the periphery may lead to a decrease in core temperature, which may counteract the therapeutic effects of cryotherapy.

OBJECTIVE

To determine if core temperature is lowered by the application of an ice bag to the ankle joint complex.

DESIGN

A within-subjects, repeated-measures design.

SETTING

The University of Virginia General Clinical Research Center.

PATIENTS OR OTHER PARTICIPANTS

Twenty-three healthy adults aged 19 to 39 years.

INTERVENTION(S)

Subjects were admitted to the hospital on 2 separate occasions. During one admission, subjects had a 20-minute ice treatment applied to their ankles; in the other admission, a bag of marbles was applied. Temperature measurements were recorded at 6 time intervals: baseline (before ice application), immediately after ice application, 10 and 20 minutes after ice application, and 10 and 20 minutes after ice removal.

MAIN OUTCOME MEASURE(S)

We measured core temperature and ankle and soleus muscle surface temperatures. A mixed-effects model analysis of variance with repeated measures was used to determine if differences existed in core temperature and ankle and soleus surface temperatures between conditions (cryotherapy and control) and over time.

RESULTS

Core temperature did not change after ice application or ice removal (P > 0.05). The average core temperatures during the cryotherapy and control conditions were 36.72 degrees C +/- 0.42 degrees C and 36.45 degrees C +/- 1.23 degrees C, respectively.

CONCLUSIONS

A 20-minute cryotherapy treatment applied to the ankle did not alter core temperature.

Acute pain: individual patient meta-analysis shows the impact of different ways of analysing and presenting results

Individual patient meta-analysis using information from clinically homogeneous acute pain trials with observations over 24h was used to investigate different ways trials can be analysed and reported. There were 13 third-molar extraction trials, with 1,330 patients using rofecoxib 50mg, 303 using ibuprofen 400mg, and 570 using placebo. Pain relief scores were available at individual time points, plus time to remedication. Many more patients remedicated with placebo than ibuprofen 400mg, and more with ibuprofen than rofecoxib 50mg. Median time to remedication, the proportion remedicated at various times, or survival curves would be useful outcomes. In dealing with missing data points when patients remedicated, baseline observation carried forward was more conservative than last observation carried forward, resulting in higher (worse) NNTs and lower average pain scores after 12 and 24h. Results based on both methods might be sensible for trials longer than eight hours. The distribution of pain relief was highly skewed, especially at later times, when almost no patient was average. Different cut points for pain relief (at least 25, 50 or 75% maxTOTPAR) and longer duration changed the NNT for ibuprofen compared with placebo, but less for rofecoxib, reflecting longer duration of action of rofecoxib. Reporting for each treatment group the percentage of patients with 25, 50 and 75% pain relief at various times after dose, and reporting the proportion of patients with good or complete pain relief, and inadequate pain relief, at each time point, would improve acute pain trial reporting.

Gabapentin for acute and chronic pain

BACKGROUND

Anticonvulsant drugs have been used in the management of pain since the 1960s. The clinical impression is that they are useful for chronic neuropathic pain, especially when the pain is lancinating or burning.

OBJECTIVES

To evaluate the analgesic effectiveness and adverse effects of gabapentin for pain management in clinical practice.

SEARCH STRATEGY

Randomised trials of gabapentin in acute, chronic or cancer pain were identified by MEDLINE (1966-Nov 2004), EMBASE (1994-Nov 2004), SIGLE (1980-Jan 2004) and the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library Issue 4, 2004). Additional reports were identified from the reference list of the retrieved papers, and by contacting investigators. Date of most recent search: January 2004.

SELECTION CRITERIA

Randomised trials reporting the analgesic effects of gabapentin in patients, with subjective pain assessment as either the primary or a secondary outcome.

DATA COLLECTION AND ANALYSIS

Data were extracted by two independent reviewers, and trials were quality scored. Numbers-needed-to-treat (NNTs) were calculated, where possible, from dichotomous data for effectiveness, adverse effects and drug-related study withdrawal.

MAIN RESULTS

Fourteen reports describing 15 studies of gabapentin were considered eligible (1468 participants). One was a study of acute pain. The remainder included the following conditions: post-herpetic neuralgia (two studies), diabetic neuropathy (seven studies), a cancer related neuropathic pain (one study) phantom limb pain (one study), Guillain Barré syndrome (one study) , spinal chord injury pain (one study) and various neuropathic pains (one study). The study in acute post-operative pain (70 participants) showed no benefit for gabapentin compared to placebo for pain at rest. In chronic pain, the NNT for improvement in all trials with evaluable data is 4.3 (95%CI 3.5-5.7). Forty two percent of participants improved on gabapentin compared to 19% on placebo. The number needed to harm(NNH) for adverse events leading to withdrawal from a trial was not significant. Fourteen percent of participants withdrew from active arms compared to 10% in placebo arms. The NNH for minor harm was 3.7 (95% CI 2.4 to 5.4). The NNT for effective pain relief in diabetic neuropathy was 2.9 (95% CI 2.2 to 4.3) and for post herpetic neuralgia 3.9 (95% CI 3 to 5.7).

AUTHORS' CONCLUSIONS

There is evidence to show that gabapentin is effective in neuropathic pain. There is limited evidence to show that gabapentin is ineffective in acute pain.

Pre-synaptic modulation of quadriceps arthrogenic muscle inhibition

Arthrogenic muscle inhibition (AMI) impedes rehabilitation following knee joint injury by preventing activation of the quadriceps. AMI has been attributed to neuronal reflex activity in which altered afferent input originating from the injured joint results in a diminished efferent motor drive to the quadriceps muscles. Beginning to understand the mechanisms responsible for muscle inhibition following joint injury is vital to control or eliminate this phenomenon. Therefore, the purpose of this investigation is to determine if quadriceps AMI is mediated by a presynaptic regulatory mechanism. Eight adults participated in two sessions: in one session their knee was injected with saline and in the other session it was not. The maximum Hoffmann reflex (H-reflex), M-wave, reflex activation history, plasma epinephrine, and norepinephrine were recorded at: baseline, post needle stick, post lidocaine, and 25 and 45 min post effusion. Measures for the control condition were matched to the effusion condition. The percent of the unconditioned reflex amplitude for reflex activation history and the maximum H-reflex were decreased at 25 and 45 min post effusion as compared to measures taken at baseline, post needle stick, and post lidocaine (P<0.05). No differences were noted for the maximum M-wave or plasma epinephrine and norepinephrine levels in either the effusion or noneffusion admission (P>0.05). No differences were detected at any time interval for any measure during the control admission (P>0.05). Quadriceps AMI elicited via an experimental knee joint effusion is, at least in part, mediated by a presynaptic mechanism.

Role of P-glycoprotein in distribution of nelfinavir across the blood-mammary tissue barrier and blood-brain barrier

As a first approach in understanding the possible efficacy and toxicity of human immunodeficiency virus protease inhibitors during breast feeding, the milk-to-plasma ratio of nelfinavir was determined in lactating rats. The milk-to-plasma ratio of nelfinavir was determined to be 0.56 +/- 0.10 (means +/- standard deviations). Western blotting indicated that P-glycoprotein is expressed in rat mammary and brain tissue; however, the multidrug-resistant modulator GF120918 showed a significant effect only at the blood-brain barrier and not at the mammary-epithelial tissue barrier.

The metabolism of nonane, a JP-8 jet fuel component, by human liver microsomes, P450 isoforms and alcohol dehydrogenase and inhibition of human P450 isoforms by JP-8

Nonane, a component of jet-propulsion fuel 8 (JP-8), is metabolized to 2-nonanol and 2-nonanone by pooled human liver microsomes (pHLM). Cytochrome P450 (CYP) isoforms 1A2, 2B6 and 2E1 metabolize nonane to 2-nonanol, whereas alcohol dehydrogenase, CYPs 2B6 and 2E1 metabolize 2-nonanol to 2-nonanone. Nonane and 2-nonanol showed no significant effect on the metabolism of testosterone, estradiol or N,N-diethyl-m-toluamide (DEET), but did inhibit carbaryl metabolism. JP-8 showed modest inhibition of testosterone, estradiol and carbaryl metabolism, but had a more significant effect on the metabolism of DEET. JP-8 was shown to inhibit CYPs 1A2 and 2B6 mediated metabolism of DEET, suggesting that at least some of the components of JP-8 might be metabolized by CYPs 1A2and/or 2B6.

Single dose oral naproxen and naproxen sodium for acute postoperative pain

BACKGROUND

Postoperative pain is often poorly managed. Treatment options include a range of drug therapies such as non-steroidal anti-inflammatory drugs (NSAIDs) of which naproxen is one. Naproxen is used to treat a variety of painful conditions including acute postoperative pain, and is often combined with sodium to improve its solubility for oral administration. Naproxen sodium 550 mg (equivalent to 500 mg of naproxen) is considered to be an effective dose for treating postoperative pain but to date no systematic review of the effectiveness of naproxen/naproxen sodium at different doses has been published.

OBJECTIVES

To assess the efficacy, safety and duration of action of a single oral dose of naproxen or naproxen sodium for acute postoperative pain in adults.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE and the Oxford Pain Relief Database for relevant studies. Additional studies were identified from the reference list of retrieved reports. The most recent search was undertaken in July 2004.

SELECTION CRITERIA

Included studies were randomised, double blind, placebo-controlled trials of a single dose of orally administered naproxen or naproxen sodium in adults with moderate to severe acute postoperative pain.

DATA COLLECTION AND ANALYSIS

Pain relief or pain intensity data were extracted and converted into dichotomous information to give the number of patients with at least 50% pain relief over four to six hours. Relative risk estimates (RR) and the number-needed-to-treat (NNT) for at least 50% pain relief were then calculated. Information was sought on the percentage of patients experiencing any adverse event, and the number-needed-to-harm was derived. Time to remedication was also estimated.

MAIN RESULTS

Ten trials (996 patients) met the inclusion criteria: nine assessed naproxen sodium; one combined the results from two small trials of naproxen alone. Included studies scored well for methodological quality. Meta-analysis of six trials (500 patients) that compared naproxen sodium 550 mg with placebo gave a RR for at least 50% pain relief over 4 to 6 hours of 4.2 (95% confidence interval (CI) 2.9 to 6.0) and an NNT of 2.6 (95% CI 2.2 to 3.2). Three trials (334 patients) assessed naproxen 400 mg and naproxen sodium 440 mg, giving a RR of 4.8 (95% CI 2.75 to 8.38). Two small studies indicated that naproxen 200 mg and naproxen sodium 220 mg may provide effective postoperative pain relief. There was no significant difference between the number of patients experiencing any adverse event on treatment compared with placebo. Weighted mean time to remedication for naproxen sodium 550 mg was 7.6 hours compared with 2.6 hours for placebo.

REVIEWERS' CONCLUSIONS

Naproxen sodium 550 mg, naproxen 400 mg and naproxen sodium 440 mg administered orally are effective analgesics for the treatment of acute postoperative pain in adults. A low incidence of adverse events was found but reporting was not consistent.

Relative efficacy of oral analgesics after third molar extraction

OBJECTIVES

To compare the relative efficacy of analgesics after third molar extraction from systematic reviews of randomised, double blind studies.

DATA SOURCES

Dental trials from systematic reviews of randomised, double-blind studies of analgesics in acute pain.

DATA SELECTION

Number of patients with moderate or severe pain achieving at least half pain relief over 4 to 6 hours after a single oral dose of analgesic.

DATA EXTRACTION

Independently by two reviewers.

DATA SYNTHESIS

Use of dichotomous information from active and placebo treatments, first to calculate the statistical significance using relative risk, and then to evaluate the clinical relevance using number needed to treat (NNT). Non-steroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase-2 (COX-2) inhibitors had the lowest (best) NNTs for the outcome of at least half pain relief over 4-6 hours compared with placebo. With the best performing analgesics, 50-70 patients out of 100 had good pain relief compared with about 10 out of 100 with placebo. Only paracetamol 600/650 mg plus codeine 60 mg was associated with any significant increase in any patient experiencing an adverse event.

CONCLUSIONS

NSAIDs and COX-2 inhibitors have the lowest (best) NNTs. They may also have fewer adverse effects after third molar surgery, though conclusive evidence is lacking. At least 80% of analgesic prescribing by UK dentists is in line with the best available evidence on efficacy and safety.

An experimental knee joint effusion does not affect plasma catecholamine concentration in humans

Knee joint effusion causes quadriceps inhibition and is accompanied by increased soleus muscle excitability. In order to reverse the neurological alterations that occur to the musculature following effusion, we need to understand the extent of neural involvement. Ten healthy adults were tested on two occasions; during one session, subjects had their knees injected with saline and in the other admission, they did not. Soleus Hmax, Mmax, plasma epinephrine, and norepinephrine concentrations were obtained at five intervals. Results showed that Hmax increased following the effusion, while norepinephrine and epinephrine levels were not altered. We suggest that the soleus facilitation seen following knee effusion results from stimulation of joint mechanoreceptors and removal of descending spinal and supraspinal inhibition and is not the result of a sympathetic response.

Arthrogenic muscle response to a simulated ankle joint effusion

BACKGROUND

Arthrogenic muscle inhibition (AMI) is a continuing reflex reaction of the musculature surrounding a joint after distension or damage to the structures of that joint. This phenomenon has been well documented after knee joint injury and has been generalised to occur at other joints of the human body, yet minimal research has been conducted in this regard. The response of the muscles crossing the ankle/foot complex after ankle injury and effusion is not well understood. AMI may occur after an ankle sprain contributing to residual dysfunction.

OBJECTIVE

To determine if AMI is present in the soleus, peroneus longus, and tibialis anterior musculature after a simulated ankle joint effusion.

METHODS

Eight neurologically sound volunteers (mean (SD) age 23 (4) years, height 171 (6) cm, mass 73 (10) kg) participated. Maximum H-reflex and maximum M-wave measurements were collected using surface electromyography after delivery of a percutaneous stimulus to the sciatic nerve before its bifurcation into the common peroneal and posterior tibial nerves.

RESULTS

The H-reflex and M-wave measurements in all muscles increased (p< or =0.05) after the simulated ankle joint effusion.

CONCLUSIONS

Simulated ankle joint effusion results in facilitation of the soleus, peroneus longus, and tibialis anterior motoneurone pools. This may occur to stabilise the foot/ankle complex in order to maintain posture and/or locomotion.

Arthrogenic Muscle Inhibition Is Not Present in the Limb Contralateral to a Simulated Knee Joint Effusion

OBJECTIVE

The purpose of this investigation was to estimate bilateral neuromuscular activity in the vastus medialis on induction of a unilateral knee joint effusion.

DESIGN

Eight subjects each were assigned to effusion or control groups. The effusion group had 60 ml of sterile saline injected into their superolateral knee joint capsules. The control group rested for 8 mins. Bilateral recruitment curves for the Hoffmann reflex (H-reflex) and muscle response (M-wave) were obtained before and 10, 20, and 30 mins after the effusion or rest. The maximum H-reflex (Hmax), maximum M-wave (Mmax), and the Hmax/Mmax ratio were utilized for data analysis.

RESULTS

Both Hmax and Hmax/Mmax ratios decreased from the baseline measure in the effused vastus medialis, whereas no changes were detected on the contralateral side. Effused subjects demonstrated decreased motoneuron pool excitability in the effused limb, whereas control subjects did not differ from baseline.

CONCLUSIONS

Knee joint effusion results in ipsilateral but not contralateral impairment of quadriceps function. Rehabilitation protocols after knee joint injury should focus on ipsilateral neuromuscular and mechanical alterations that occur as the result of joint damage.

A single dose of Ginkgo biloba does not affect soleus motoneuron pool excitability

EGb 761 has been shown to increase acetylcholine synthesis and release and increase cholinergic receptors leading to an increase in cholinergic neurotransmission. These effects may be observed in the neuromuscular system, manifested by changes in motoneuron pool excitability as measured by the Hoffmann reflex to motor response (H/M) ratio. The objective was to determine whether a single dose of EGb 761 affects motoneuron pool excitability of the soleus muscle as measured by the H/M ratio. Following initial soleus H/M measurements, 20 healthy volunteers were randomly assigned to 1 of 3 treatment groups (control, 180 g cellulose placebo, and 180 g EGb 761). H/M ratios were recorded 1, 2, and 3 hours post treatment. A 3 x 4 repeated-measures analysis of variance was used to analyze differences in H/M ratio between treatments. No differences were observed between treatments (p = 0.75) or over time (p = 0.17), and there was not a treatment by time interaction (p = 0.27). A single dose of 180 g of EGb 761 does not affect soleus motoneuron pool excitability.

Hydromorphone transfer into breast milk after intranasal administration

STUDY OBJECTIVES

To determine the distribution of hydromorphone into breast milk and the potential exposure of the suckling infant, and whether the distribution of hydromorphone into milk can be predicted accurately by a passive diffusion model.

DESIGN

Single-dose, pharmacokinetic study.

SETTING

University clinical research unit.

PATIENTS

Eight lactating, nonsmoking, healthy women aged 24-32 years.

INTERVENTION

Hydromorphone HCl 2 mg was given intranasally to the women to characterize its pharmacokinetics and extent of its transfer into breast milk.

MEASUREMENTS AND MAIN RESULTS

Plasma and milk samples were analyzed using liquid chromatography with tandem mass spectrometry detection. The milk:plasma ratio (M:P) was calculated as the total area under the concentration-time curve (AUC) of the milk divided by the total AUC of the plasma. Predicted in vitro M:P ratios were calculated using a diffusion model. Protein binding in milk and plasma, partitioning into milk fat (whole milk:skim milk ratios), as well as pH partitioning between plasma and milk were incorporated in the model. Protein binding was determined by equilibrium dialysis. Protein binding was minimal in both milk and plasma, with unbound fractions of 1 and 0.84, respectively There was little partitioning into milk fat, as demonstrated by the whole milk:skim milk ratio of 0.98. The observed and predicted M:P ratios +/- SD for hydromorphone were 2.57 +/- 0.47 and 1.11 +/- 0.28, respectively. The 95% confidence interval for the observed M:P ratio overlapped the confidence interval of the predicted M:P ratio, a finding that supports a role for both passive diffusion and active transport as mechanisms of hydromorphone transfer into milk.

CONCLUSION

Hydromorphone distributes rapidly from plasma into breast milk; however, the drug does not partition into fat. The suckling infant would receive approximately 0.67% of the maternal dose of hydromorphone (adjusted for body weight). As this is a limited exposure, further studies are needed to determine any potential impact to an infant who is fed breast milk from a mother treated with hydromorphone.

Oral morphine for cancer pain

BACKGROUND

Morphine has been used to relieve pain for many years. Oral morphine in either immediate release or sustained release form remains the analgesic of choice for moderate or severe cancer pain.

OBJECTIVES

To determine the efficacy of oral morphine in relieving cancer pain. To assess the incidence and severity of adverse effects.

SEARCH STRATEGY

The following databases were searched: The Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Library, Issue 4, 2002; the trials register of the Cochrane Pain, Palliative and Supportive Care group (February 2002); MEDLINE 1966 to December 2002; EMBASE 1988 to December 2002; and the Oxford Pain Relief database 1950 to 1994.

SELECTION CRITERIA

Published randomised controlled trials (full reports) reporting on the analgesic effect of oral morphine in adults and children with cancer pain. Any comparator trials were considered. Trials with fewer than 10 subjects were excluded.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data, and the findings were checked by two other reviewers. There were insufficient comparable data for meta-analysis to be undertaken, or to produce numbers-needed-to-treat (NNT) for the analgesic effect.

MAIN RESULTS

Forty five studies (3061 subjects) met the inclusion criteria. Fourteen studies compared oral sustained release morphine (MSR) preparations with immediate release morphine (MIR). Eight studies compared MSR and MSR in different strengths. Nine studies compared MSR with other opioids. Five studies compared MIR with other opioids. Two studies compared oral MSR with rectal MSR. One study was found comparing each of the following: MSR tablet with MSR suspension; MSR with MSR at different dose frequencies; MSR with non-opioids; MIR with non-opioids; oral morphine with epidural morphine; and MIR with MIR by a different route of administration. Morphine was shown to be an effective analgesic. Pain relief did not differ between MSR and MIR. Sustained release versions of morphine were effective for 12 or 24 hour dosing depending on the formulation. Adverse effects were common but only 4% of patients discontinued treatment because of intolerable adverse effects.

REVIEWER'S CONCLUSIONS

The randomised trial literature for morphine is small given the importance of this medicine. Most trials recruited fewer than 100 participants, and did not provide appropriate data for meta-analysis. Trial design was frequently based on titration of morphine or comparator to achieve adequate analgesia, then crossing subjects over in crossover design studies. It is not clear if these trials are sufficiently powered to detect any clinical differences between formulations or comparator drugs.

Single dose oral celecoxib for postoperative pain

BACKGROUND

Celecoxib is a selective cyclooxygenase-2 (COX-2) inhibitor prescribed for the relief of chronic pain in osteoarthritis and rheumatoid arthritis. The drug is believed to be associated with fewer adverse effects than conventional non-steroidal anti-inflammatory drugs (NSAIDs). However, the effectiveness of celecoxib in the treatment of acute pain has not yet been assessed by systematic review.

OBJECTIVES

To assess the analgesic efficacy and adverse effects of a single oral dose of celecoxib for moderate to severe postoperative pain.

SEARCH STRATEGY

We searched the Cochrane Library Controlled Trials Register, MEDLINE, Biological Abstracts, PubMed and the Oxford Pain database. Date of the most recent search: May 2002.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of adults prescribed any dose of oral celecoxib or placebo for acute postoperative pain were included.

DATA COLLECTION AND ANALYSIS

Two trials (418 subjects) met the inclusion criteria for this review. The trials were assessed for quality and the data extracted by two independent reviewers. Summed pain relief (TOTPAR) or pain intensity difference (SPID) was extracted and converted into dichotomous information yielding the number of patients with at least 50% pain relief over 4-6 hours. These derived results were used to calculate the relative benefit (RB) and number-needed-to-treat (NNT) for one patient to achieve at least 50% pain relief.

MAIN RESULTS

The number-needed-to-treat for celecoxib 200 mg compared with placebo was 4.5 (CI 3.3 to 7.2). For every 4.5 patients experiencing moderate to severe acute pain treated with celecoxib 200 mg one more will experience at least 50% pain relief that would not have done had they received placebo. The median time to remedication over 24 hours was 5.1 hours with celecoxib 200 mg and 1.5 hours with placebo. Quantitative analysis of adverse effects was not possible but no serious or unexpected adverse effects were reported.

REVIEWER'S CONCLUSIONS

Single dose oral celecoxib is an effective means of postoperative pain relief, similar in efficacy to aspirin 600/650 mg, and paracetamol 1000 mg. The two trials included used celecoxib 200 mg, a dose 50% less than is recommended for acute pain. More trials are needed to estimate efficacy for recommended dose of 400 mg, and to reinforce current findings for 200 mg, and provide data for pooled quantitative estimates of adverse effects.

Protective role of appendicectomy on onset and severity of ulcerative colitis and Crohn's disease

BACKGROUND AND AIMS

Recent studies on appendicectomy rates in ulcerative colitis and Crohn's disease have generally not addressed the effect of appendicectomy on disease characteristics. The aims of this study were to compare appendicectomy rates in Australian inflammatory bowel disease patients and matched controls, and to evaluate the effect of prior appendicectomy on disease characteristics.

METHODS

Patients were ascertained from the Brisbane Inflammatory Bowel Disease database. Controls matched for age and sex were randomly selected from the Australian Twin Registry. Disease characteristics included age at diagnosis, disease site, need for immunosuppression, and intestinal resection.

RESULTS

The study confirmed the significant negative association between appendicectomy and ulcerative colitis (odds ratio (OR) 0.23, 95% confidence interval (CI) 0.14-0.38; p<0.0001) and found a similar result for Crohn's disease once the bias of appendicectomy at diagnosis was addressed (OR 0.34, 95% CI 0.23-0.51; p<0.0001). Prior appendicectomy delayed age of presentation for both diseases and was statistically significant for Crohn's disease (p=0.02). In ulcerative colitis, patients with prior appendicectomy had clinically milder disease with reduced requirement for immunosuppression (OR 0.15, 95% CI 0.02-1.15; p=0.04) and proctocolectomy (p=0.02).

CONCLUSIONS

Compared with patients without prior appendicectomy, appendicectomy before diagnosis delays disease onset in ulcerative colitis and Crohn's disease and gives rise to a milder disease phenotype in ulcerative colitis.

Preliminary comparison of bromelain and Ibuprofen for delayed onset muscle soreness management

OBJECTIVE

The purpose of this study was to determine whether a common bromelain regimen or common ibuprofen regimen are effective in resolving pain and muscle dysfunction associated with delayed onset muscle soreness of the elbow flexors.

DESIGN

A randomized, double-blinded, repeated measures design was used for this study.

SETTING

The study was performed in the Sports Injury Research Lab at an NCAA Division I university.

PARTICIPANTS

Forty subjects who had not participated in an upper body resistance-training program 3 months prior to the study, suffered pain or injury in the nondominant arm, or experienced an adverse response to nonsteroidal anti-inflammatory drugs or pineapple (bromelain source) were recruited. Thirty-nine subjects finished the study.

INTERVENTIONS

Active range of motion (ROM), perceived pain, and peak concentric torque measurements of the nondominant arm were taken prior to and 24, 48, 72, and 96 hours following an eccentric exercise protocol of the elbow flexors. Subjects were assigned to one of four treatment groups (bromelain 300 mg t.i.d., ibuprofen 400 mg t.i.d., placebo t.i.d., and control) and began treatment immediately following the exercise protocol.

MAIN OUTCOME MEASURES

No differences among treatments were observed for any of the dependent variables at any time. ROM deficits and pain peaked between 48 and 72 hours. Peak torque deficiencies were observed between 24 and 72 hours.

CONCLUSIONS

Ingestion of bromelain and ibuprofen had no effect on elbow flexor pain, loss of ROM, or loss of concentric peak torque as a result of an eccentric exercise regimen.

GF120918, a P-glycoprotein modulator, increases the concentration of unbound amprenavir in the central nervous system in rats

The goal of this study was to determine the distribution of unbound amprenavir in the central nervous system (CNS) of rats. The concentration of unbound amprenavir in the extracellular fluid of the brain and the blood was examined in the presence and absence of the MDR modulator GF120918 by microdialysis. The brain-to-blood ratio of amprenavir in the absence and presence of GF120918 was found to be significantly different (P < 0.003; 0.076 and 0.617, respectively). The use of the MDR modulator GF120918 could potentially increase the penetration of human immunodeficiency virus protease inhibitors into the CNS.

Sildenafil (Viagra) for male erectile dysfunction: a meta-analysis of clinical trial reports

BACKGROUND

Evaluation of company clinical trial reports could provide information for meta-analysis at the commercial introduction of a new technology.

METHODS

Clinical trial reports of sildenafil for erectile dysfunction from September 1997 were used for meta-analysis of randomised trials (at least four weeks duration) and using fixed or dose optimisation regimens. The main outcome sought was an erection, sufficiently rigid for penetration, followed by successful intercourse, and conducted at home.

RESULTS

Ten randomised controlled trials fulfilled the inclusion criteria (2123 men given sildenafil and 1131 placebo). NNT or NNH were calculated for important efficacy, adverse event and discontinuation outcomes. Dose optimisation led to at least 60% of attempts at sexual intercourse being successful in 49% of men, compared with 11% with placebo; the NNT was 2.7 (95% confidence interval 2.3 to 3.3). For global improvement in erections the NNT was 1.7 (1.6 to 1.9). Treatment-related adverse events occurred in 30% of men on dose optimised sildenafil compared with 11% on placebo; the NNH was 5.4 (4.3 to 7.3). All cause discontinuations were less frequent with sildenafil (10%) than with placebo (20%). Sildenafil dose optimisation gave efficacy equivalent to the highest fixed doses, and adverse events equivalent to the lowest fixed doses.

CONCLUSION

This review of clinical trial reports available at the time of licensing agreed with later reviews that had many more trials and patients. Making reports submitted for marketing approval available publicly would provide better information when it was most needed, and would improve evidence-based introduction of new technologies.

Effects of a P-glycoprotein inhibitor on brain and plasma concentrations of anti-human immunodeficiency virus drugs administered in combination in rats

Most of the existing anti-human immunodeficiency virus agents enter the central nervous system (CNS) inefficiently and thus may allow slow viral replication in the brain. This may provide a sanctuary for the virus in the CNS and contribute to the development of acquired immunodeficiency syndrome dementia complex. This study evaluates a prodrug approach to improve the CNS delivery of the reverse transcriptase inhibitor 2',3'-dideoxyinosine (ddI) in combination with inhibition of P-glycoprotein-mediated efflux to increase the CNS delivery of the protease inhibitor nelfinavir and to determine whether any unanticipated drug interactions occur in this combination therapy. Three rats received either 6-chloro-2'3'-dideoxypurine (6-Cl-ddP), a prodrug of ddI activated by adenosine deaminase, nelfinavir, nelfinavir and 6-Cl-ddP, nelfinavir and N-(4-[2-(1,2,3,4-tetrahydro-6,7-dimethoxy-2-isoquinolinyl)ethyl]-phenyl)-9,10-dihydro-5-methoxy-9-oxo-4-acridine carboxamide (GF120918) (a P-glycoprotein inhibitor), 6-Cl-ddP and GF120918, or 6-Cl-ddP, nelfinavir, and GF120918. Both 6-Cl-ddP and nelfinavir were administered as i.v. infusions, whereas GF120918 was given as an i.v. bolus 2 h before sampling. Plasma and brain tissue concentrations of 6-Cl-ddP, ddI, and nelfinavir were determined. Neither nelfinavir nor GF120918 was shown to alter the brain/plasma ratios of 6-Cl-ddP or ddI. GF120918, however, increased the plasma concentrations of 6-Cl-ddP and ddI, resulting in increased brain concentrations. GF120918 increased the brain/plasma ratio of nelfinavir significantly (approximately 100-fold). The brain/plasma ratios of nelfinavir were reduced nearly 2-fold in rats treated with nelfinavir, 6-Cl-ddP, and GF120918 compared with rats receiving only nelfinavir and GF120918, suggesting a modest inhibition of nelfinavir uptake by 6-Cl-ddP. Overall, combined 6-Cl-ddP, nelfinavir, and GF120918 administration enhances the brain/plasma ratios of both ddI and nelfinavir.

Survey of the stocking densities at which sheep are transported commercially in the United Kingdom

A total of 6578 sheep carried in 74 vehicles to one slaughter plant were monitored, and stocking densities, in terms of m2 floor area available per 100 kg liveweight, were estimated from the dimensions of the vehicle pens and estimates of liveweight based on chest girth measurements. The observed stocking densities ranged from 0.29 to 2.00 m2/100 kg liveweight, and the average density was 0.65 m2/100 kg. One per cent of the sheep were carried at estimated stocking densities of less than 0.3 m2/100 kg, 37 per cent at densities between 0.3 and 0.6 m2/100 kg and 57 per cent at densities between 0.6 and 0.9 m2/100 kg. Over 30 per cent of the animals in the survey were transported at densities higher than the working recommendations made by the Farm Animal Welfare Council.

Defining opportunistic invasive fungal infections in immunocompromised patients with cancer and hematopoietic stem cell transplants: an international consensus

During the past several decades, there has been a steady increase in the frequency of opportunistic invasive fungal infections (IFIs) in immunocompromised patients. However, there is substantial controversy concerning optimal diagnostic criteria for these IFIs. Therefore, members of the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group formed a consensus committee to develop standard definitions for IFIs for clinical research. On the basis of a review of literature and an international consensus, a set of research-oriented definitions for the IFIs most often seen and studied in immunocompromised patients with cancer is proposed. Three levels of probability are proposed: "proven," "probable," and "possible." The definitions are intended for use in the context of clinical and/or epidemiological research, not for clinical decision making.

Single dose dipyrone for acute renal colic pain

BACKGROUND

Renal colic pain is extremely painful and requires immediate treatment with strong analgesics. Dipyrone is the most popular non-opioid first line analgesic in many countries but in others it has been banned (e.g. USA, UK) because of its association with blood dyscrasias such as agranulocytosis. Since dipyrone is used in many countries (e.g. Brazil, Spain) there is a need to determine the benefits and harms of its use to treat renal colic pain.

OBJECTIVES

To assess quantitatively the analgesic efficacy and adverse effects of single-dose dipyrone in adults with moderate to severe renal colic pain.

SEARCH STRATEGY

Published reports were identified from electronic databases (MEDLINE, EMBASE, the Cochrane Library, LILACS) and additional studies were identified from the reference lists of retrieved reports. Date of the most recent search: January 2000.

SELECTION CRITERIA

Inclusion criteria were: full journal publication; RCT with a double-blind design; adult patients with baseline renal colic pain of moderate or severe intensity; treatment arms which included dipyrone (oral, intramuscular or intravenous administration) and a control; single dose data.

DATA COLLECTION AND ANALYSIS

Summed pain intensity and pain relief data were extracted and converted into dichotomous information to yield the number of patients with at least 50% pain relief over 15-30 minutes, 1-2 hours and six hours. The proportion of patients with at least 50% pain relief was calculated. Single dose adverse effect data were collected.

MAIN RESULTS

Eleven studies with 1053 patients (550 on dipyrone) met the inclusion criteria. Unfortunately, few data were available for analysis; most analyses were based on the results of single, small trials and statistical pooling of the results was inappropriate. Efficacy estimates were calculated as the weighted mean percent of patients achieving at least 50% pain relief with the range of values from trials contributing to the analysis. However, these estimates were not robust. Commonly reported adverse effects with intravenous dipyrone were dry mouth and somnolence, and one study reported pain at the injection site. Insufficient information was available for safety analyses to be conducted.

REVIEWER'S CONCLUSIONS

Limited available data indicated that single dose dipyrone was of similar efficacy to other analgesics used in renal colic pain, although intramuscular dipyrone was less effective than diclofenac 75 mg. Combining dipyrone with antispasmolytic agents did not appear to improve its efficacy. Intravenous dipyrone was more effective than intramuscular dipyrone. Dry mouth and somnolence were commonly reported with intravenous dipyrone. None of the studies reported agranulocytosis.

Risk factors for Candida species colonization of neonatal intensive care unit patients

BACKGROUND

Candida spp. are increasingly important pathogens in neonatal intensive care units (NICU). Prior colonization is a major risk factor for candidemia, but few studies have focused on risk factors for colonization, particularly in NICU patients.

METHODS

A prospective, multicenter cohort study was performed in six NICUs to determine risk factors for Candida colonization. Infant gastrointestinal tracts were cultured on admission and weekly until NICU discharge and health care worker hands were cultured monthly for Candida spp.

RESULTS

The prevalence of Candida spp. colonization was 23% (486 of 2157 infants); 299 (14%), 151 (7%) and 74 (3%) were colonized with Candida albicans, Candida parapsilosis and other Candida spp., respectively. Multiple logistic regression analysis adjusting for length of stay, birth weight < or = 1000 g and gestational age < 32 weeks revealed that use of third generation cephalosporins was associated with either C. albicans (155 incident cases) or C. parapsilosis (104 incident cases) colonization. Use of central venous catheters or intravenous lipids were risk factors for C. albicans, whereas delivery by cesarean section was protective. Use of H2 blockers was an independent risk factor for C. parapsilosis. Of 2989 cultures from health care workers' hands, 150 (5%) were positive for C. albicans and 575 (19%) for C. parapsilosis, but carriage rates did not correlate with NICU site-specific rates for infant colonization.

CONCLUSIONS

We speculate that NICU patients acquire Candida spp., particularly C. parapsilosis, from the hands of health care workers. H2 blockers, third generation cephalosporins and delayed enteral feedings alter gastrointestinal tract ecology, thereby facilitating colonization.

Risk factors for candidal bloodstream infections in surgical intensive care unit patients: the NEMIS prospective multicenter study. The National Epidemiology of Mycosis Survey

To assess risk factors for development of candidal blood stream infections (CBSIs), a prospective cohort study was performed at 6 sites that involved all patients admitted to the surgical intensive care unit (SICU) for >48 h over a 2-year period. Among 4276 such patients, 42 CBSIs occurred (9.82 CBSIs per 1000 admissions). The overall incidence was 0.98 CBSIs per 1000 patient days and 1.42 per 1000 SICU days with a central venous catheter in place. In multivariate analysis, factors independently associated with increased risk of CBSI included prior surgery (relative risk [RR], 7.3), acute renal failure (RR, 4.2), receipt of parenteral nutrition (RR, 3.6), and, for patients who had undergone surgery, presence of a triple lumen catheter (RR, 5.4). Receipt of an antifungal agent was associated with decreased risk (RR, 0.3). Prospective clinical studies are needed to identify which antifungal agents are most protective and which high-risk patients will benefit from antifungal prophylaxis.