Pilot Study of the Effect of Lanthanum Carbonate (Fosrenol®) In Patients with Calciphylaxis: A Wisconsin Network for Health Research (WiNHR) Study

Background

Currently there is a lack of effective treatment options for patients with calciphylaxis. There is anecdotal evidence that non-calcium based phosphorus binders may offer some benefit. The aim of this pilot study is to determine if lanthanum carbonate is effective in inducing remission of calciphylaxis lesions and demonstrate an improved DLQI (Dermatology Life Quality Index).

Methods

This is a multi-site exploratory pilot study conducted through the Wisconsin Network for Health Research (WiNHR), a collaboration of health services researchers across the state of Wisconsin. Dialysis patients were recruited from in-center dialysis units, clinics and hospital admissions over a period of 24-months.

Results

Due to the low inclusion rate, the trial was terminated after which 4 patients were prospectively analyzed. Dose of lanthanum carbonate was escalated to 3750 mg divided into 3 meals and titrated according to level of serum phosphorus. Gastrointestinal symptoms were the most common adverse effect. All 4 patients achieved complete remission by definition of skin re-epithelialization. Secondary outcome measurements showed a significant improvement in serum albumin (B coeff 0.17, 95% CI 0.002-0.031; p=0.023) and a significant improvement in overall DLQI score (B coeff -0.46, 95% CI -0.85- -0.08; p=0.019).

Conclusions

Lanthanum carbonate appears to be efficacious as an adjunctive therapy to improve calciphylaxis lesions and symptom burden. More prospective clinical trials are warranted to determine the feasibility of this novel treatment strategy.

UB-165: a novel nicotinic agonist with subtype selectivity implicates the alpha4beta2* subtype in the modulation of dopamine release from rat striatal synaptosomes

Presynaptic nicotinic acetylcholine receptors (nAChRs) on striatal synaptosomes stimulate dopamine release. Partial inhibition by the alpha3beta2-selective alpha-conotoxin-MII indicates heterogeneity of presynaptic nAChRs on dopamine terminals. We have used this alpha-conotoxin and UB-165, a novel hybrid of epibatidine and anatoxin-a, to address the hypothesis that the alpha-conotoxin-MII-insensitive subtype is composed of alpha4 and beta2 subunits. UB-165 shows intermediate potency, compared with the parent molecules, at alpha4beta2* and alpha3-containing binding sites, and resembles epibatidine in its high discrimination of these sites over alpha7-type and muscle binding sites. (+/-)-Epibatidine, (+/-)-anatoxin-a, and (+/-)-UB-165 stimulated [(3)H]-dopamine release from striatal synaptosomes with EC(50) values of 2.4, 134, and 88 nM, and relative efficacies of 1:0.4:0.2, respectively. alpha-Conotoxin-MII inhibited release evoked by these agonists by 48, 56, and 88%, respectively, suggesting that (+/-)-UB-165 is a very poor agonist at the alpha-conotoxin-MII-insensitive nAChR subtype. In assays of (86)Rb(+) efflux from thalamic synaptosomes, a model of an alpha4beta2* nAChR response, (+/-)-UB-165 was a very weak partial agonist; the low efficacy of (+/-)-UB-165 at alpha4beta2 nAChR was confirmed in Xenopus oocytes expressing various combinations of human nAChR subunits. In contrast, (+/-)-UB-165 and (+/-)-anatoxin-a were similarly efficacious and similarly sensitive to alpha-conotoxin-MII in increasing intracellular Ca(2+) in SH-SY5Y cells, a functional assay for native alpha3-containing nAChR. These data support the involvement of alpha4beta2* nAChR in the presynaptic modulation of striatal dopamine release and illustrate the utility of exploiting a novel partial agonist, together with a selective antagonist, to dissect the functional roles of nAChR subtypes in the brain.

Intuition in professional practice. Executive and staff perceptions

Intuition, as part of our thinking, is often misunderstood or held in mystical regard. It is important to understand the aspects of this instinctual process and to appreciate the differing perspectives of both the registered nurse in the staff position and the executive in a leadership role. We compare responses to a Socratic dialogue of the definition of intuition and offer suggestions for nursing leaders to develop clinical judgment using nursing examples of intuition.

Recombinant human receptors and functional assays in the discovery of altinicline (SIB-1508Y), a novel acetylcholine-gated ion channel (nAChR) agonist

Neuronal nicotinic acetylcholine receptors (nAChRs) are a class of ion channels with significant potential as molecular targets for the design of drugs to treat a variety of CNS disorders. The discovery that neuronal nAChRs are further subdivided into multiple subtypes suggests that drugs which act selectively at specific nAChR subtypes might effectively treat Parkinson's disease (PD), Alzheimer's disease (AD), schizophrenia, ADHD, depression, anxiety or pain without the accompanying adverse side effects associated with non-selective agents such as nicotine (1) and epibatidine. Altinicline (SIB-1508Y) is a novel, small molecule designed to selectively activate neuronal nAChRs and is undergoing clinical evaluation for the treatment of PD. It was selected from a series of compounds primarily on the basis of results from functional assays, including (a) measurement of Ca2+ flux in stable cell lines expressing specific recombinant human neuronal nAChR subtypes; (b) determination of in vitro and in vivo neurotransmitter release; (c) in vivo models of PD. Biological data on both altinicline and the series of compounds from which it was selected are reported.

Seven steps to shift from tasks to outcomes

Seven managerial strategies guide the evolution of nurses' abilities to plan patient outcomes rather than focus on tasks. The authors emphasize revitalizing report rituals to include discussion of patient-focused short- and long-term outcomes.

Lizards as hosts for immature Ixodes scapularis (Acari: Ixodidae) in North Carolina

Previously archived museum specimens of lizards collected throughout North Carolina were examined for Ixodes scapularis (Say). Lizards (n = 1,349) collected in 80 of North Carolina's 100 counties were examined. Lizards with ticks were collected in 23 (29%) of the 80 counties from which lizards were examined. I. scapularis was detected on 8.7% (n = 117) of the lizards and was the sole species of tick obtained from lizards. Immature ticks were most frequently found on the southeastern five-lined skink, Eumeces inexpectatus, and the eastern glass lizard, Ophisaurus ventralis. Larvae were most frequently found on the six-lined racerunner, Cnemidophorus sexlineatus. One C. sexlineatus harbored 177 larvae and 2 nymphs. Nymphs were most frequently observed on E. inexpectatus. The majority of counties (chi 2, P < 0.01) where ticks were found on lizards were in the Coastal Plain.

Why don't nurses delegate?

Restructuring clinical services to a team-based model of care delivery relies on the registered nurse's ability to effectively delegate and supervise team members. The authors define issues and leadership actions necessary for successful restructuring projects that optimize the registered nurse professional role and achieve economic benefits.

My license is not on the line: the art of delegation

Teaching staff and charge nurses how to skillfully delegate responsibility to assistive personnel can alleviate fears and mistrust. A workshop defining the art of delegation leaves nurses feeling more in control and less victimized. As a result, they begin to see delegation as a viable solution.

Case report 786: Ewing's sarcoma of the left zygoma

We present a relatively common tumor, Ewing's sarcoma, in an exceptionally rare site, the zygomatic bone, wherein the only symptom was swelling in the cheek despite intracranial extension. Ewing's sarcoma is not an uncommon tumor in the Asian Indian as it is in the African American. It appear to occur as frequently in the subcontinent as it does in Europe and in Americans of European descent.

Examination of the relationships among drug use, emotional/psychological problems, and crime among youths entering a juvenile detention center

Urine testing and confidential interviews of youths entering a juvenile detention center in a southeastern city produced some striking results in regard to their drug use, delinquent behavior, and emotional/psychological problems. Recent users of marijuana/hashish and cocaine had higher rates of referral to juvenile court for property and drug offenses than nonusers. The results suggest that interviewing and urine testing of youthful detainees for drug use at the point of entry into secure detention is a promising method for screening youngsters with histories of delinquent behavior. Implications of these findings are drawn.

Electrophysiological correlates of presynaptic alpha 2-receptor-mediated inhibition of norepinephrine release at locus coeruleus synapses in dentate gyrus

Despite an abundance of evidence that presynaptic alpha 2-adrenergic receptors mediate inhibitory control of the release of norepinephrine (NE) from the terminals of locus coeruleus (LC) neurons, few studies have demonstrated the physiological significance of this "autoreceptor"-mediated inhibition on NE-mediated synaptic activity within the mammalian brain. This question was addressed by examining the effects of systemic administration of alpha 2-adrenergic agonists and antagonists on the ability of LC stimulation to augment the population spike recorded in the dentate gyrus in response to activation of the perforant path (PP). Extracellular field potentials were recorded in the cell body and dendritic layer of dentate gyrus following single shocks of the entorhinal cortex in halothane-anesthetized rats. Stimulation of the ipsilateral LC 35 msec prior to PP activation produced a short-term enhancement of the population spike amplitude recorded in the cell layer but did not significantly alter dendritic potentials. The effects of LC stimulation were blocked by administration of the beta-adrenergic antagonist propranolol but not the alpha 2-antagonist idazoxan and were abolished by pretreatment of animals with the catecholamine neurotoxin 6-hydroxydopamine. Administration of clonidine reversibly abolished the enhancement produced by LC conditioning. The effect of clonidine was dose dependent and was blocked by administration of idazoxan, which restored the LC potentiative effect. Conditioning stimulation of LC noradrenergic axons in the dorsal bundle also potentiated the PP-evoked population spike, and this effect was equally sensitive to the depressant action of clonidine. In comparison, clonidine, in the range of dosages tested, did not significantly affect the potentials evoked in the dendritic or cell layer by presentations of unconditioned PP test stimuli. We interpret these data to provide evidence for a functional impairment of LC-mediated physiological action on postsynaptic target cells as a result of presynaptic alpha 2-autoreceptor-mediated feedback inhibition of NE release.

The relationship between physical and sexual abuse and illicit drug use: a replication among a new sample of youths entering a juvenile detention center

The relationship between child physical and sexual abuse and illicit drug use are little understood and underinvestigated. Our previous study of this association found that a sample of detained youths' physical and sexual abuse experiences were related significantly and positively to their use of illicit drugs. Data gathered from a new sample of detained juveniles, interviewed 3 years after our first study, relating to this issue were examined and our previous findings were replicated.

The relationship between physical and sexual abuse and tobacco, alcohol, and illicit drug use among youths in a juvenile detention center

The relationships between child physical and sexual abuse and tobacco, alcohol, and illicit drug use are little understood and underinvestigated. Data gathered from a study of youths in a regional detention center permitted an examination of this issue. The results indicate that the youths' physical and sexual abuse experiences are significantly and positively related to their use of illicit drugs. The implications of these findings for further research are drawn.

Physical abuse, sexual victimization and illicit drug use: a structural analysis among high risk adolescents

The relationships between child physical and sexual abuse and illicit drug use are relatively unexplored and obscure. Data gathered from a sample of youths in a juvenile detention center permitted an examination of this important issue. A structural model, specifying the influence of child physical and sexual abuse variables on the youths' illicit drug use, directly and as mediated by self-derogation, was estimated among male and female detainees. Results suggest that for both gender groups, sexual victimization had a primarily direct effect on drug use, whereas physical abuse had both a direct and an indirect effect on drug use. The indirect effect of physical abuse on drug use was mediated by self-derogation. Further analysis indicated race did not affect the results. The implications of these results for theory and research on the etiology of drug use and the identification of youths in high risk groups who are likely to become seriously involved in drug use are discussed.

Effects of pyrethroid insecticides on operant responding maintained by food

The pyrethroids are potent insecticides with low concomitant mammalian lethality when compared with other major insecticides. While high doses can lead to hyperactivity, tremors, convulsion and death, low doses have not been as well studied. Since operant behavior can be a sensitive measure of CNS function, male Holtzman rats were trained on a VR25 schedule maintained by 45 mg food pellets. Rats were injected IP with one of four different technical grade pyrethroids: permethrin, allethrin, deltamethrin and fenvalerate. All agents were effective in reducing operant responding and did so in a dose-dependent manner at levels 10 to 100 times below their LD50 values. Time course studies indicated a relatively short duration of action for the Type I agents of less than 60 min for permethrin and 15 min for allethrin. Type II agents were generally effective for greater than 60 min. Results of these studies indicate that operant responding maintained by food is a sensitive measure of the behaviorally disruptive effects of subconvulsive doses of pyrethroids.