Selepressin, a novel selective vasopressin V1A agonist, is an effective substitute for norepinephrine in a phase IIa randomized, placebo-controlled trial in septic shock patients

Background

Vasopressin is widely used for vasopressor support in septic shock patients, but experimental evidence suggests that selective V_1A agonists are superior. The initial pharmacodynamic effects, pharmacokinetics, and safety of selepressin, a novel V_1A-selective vasopressin analogue, was examined in a phase IIa trial in septic shock patients.

Methods

This was a randomized, double-blind, placebo-controlled multicenter trial in 53 patients in early septic shock (aged ≥18 years, fluid resuscitation, requiring vasopressor support) who received selepressin 1.25 ng/kg/minute (n = 10), 2.5 ng/kg/minute (n = 19), 3.75 ng/kg/minute (n = 2), or placebo (n = 21) until shock resolution or a maximum of 7 days. If mean arterial pressure (MAP) ≥65 mmHg was not maintained, open-label norepinephrine was added. Co-primary endpoints were maintenance of MAP >60 mmHg without norepinephrine, norepinephrine dose, and proportion of patients maintaining MAP >60 mmHg with or without norepinephrine over 7 days. Secondary endpoints included cumulative fluid balance, organ dysfunction, pharmacokinetics, and safety.

Results

A higher proportion of the patients receiving 2.5 ng/kg/minute selepressin maintained MAP >60 mmHg without norepinephrine (about 50% and 70% at 12 and 24 h, respectively) vs. 1.25 ng/kg/minute selepressin and placebo (p < 0.01). The 7-day cumulative doses of norepinephrine were 761, 659, and 249 μg/kg (placebo 1.25 ng/kg/minute and 2.5 ng/kg/minute, respectively; 2.5 ng/kg/minute vs. placebo; p < 0.01). Norepinephrine infusion was weaned more rapidly in selepressin 2.5 ng/kg/minute vs. placebo (0.04 vs. 0.18 μg/kg/minute at 24 h, p < 0.001), successfully maintaining target MAP and reducing norepinephrine dose vs. placebo (first 24 h, p < 0.001). Cumulative net fluid balance was lower from day 5 onward in the selepressin 2.5 ng/kg/minute group vs. placebo (p < 0.05). The selepressin 2.5 ng/kg/minute group had a greater proportion of days alive and free of ventilation vs. placebo (p < 0.02). Selepressin (2.5 ng/kg/minute) was well tolerated, with a similar frequency of treatment-emergent adverse events for selepressin 2.5 ng/kg/minute and placebo. Two patients were infused at 3.75 ng/kg/minute, one of whom had the study drug infusion discontinued for possible safety reasons, with subsequent discontinuation of this dose group.

Conclusions

In septic shock patients, selepressin 2.5 ng/kg/minute was able to rapidly replace norepinephrine while maintaining adequate MAP, and it may improve fluid balance and shorten the time of mechanical ventilation.

Trial registration

ClinicalTrials.gov, NCT01000649. Registered on September 30, 2009.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1798-7) contains supplementary material, which is available to authorized users.

[Fatal succinylcholine-induced hyperkalemia in an intensive care unit]

Succinylcholine-induced hyperkalemia is reported, but is still used in rapid sequence induction. In our case a 44 year-old man with septic shock was mechanically ventilated for 13 days, extubated but because of respiratory insufficiency reintubated. During induction an increase in p-potassium (4.2-11.7 mmol/l) caused ventricular fibrillation. Immobilization/infection cause an up-regulation and change in acetylcholine receptors is probably the reason for the extensive hyperkalemia and death. Caution in using succinylcholine is recommended and using rocuronium as an alternative is discussed.

[Survival following lightning strike and treatment of sequelae]

Lightning strike is an unpredictable weather phenomenon which can cause a variety of injuries to the human body. We present a case report with a 24-year-old male football player, who survived prolonged cardiac arrest after a lighting strike and then presented with multiple organ dysfunction due to cellular swelling, extreme rhabdomyolysis and global hypoperfusion. We describe the clinical observations, therapy and injuries which may be expected. Furthermore, the pathophysiology and factors influencing the survival of this patient are discussed.

[Mild therapeutic hypothermia after cardiac arrest through continuous dialysis]

INTRODUCTION

Mild therapeutic hypothermia (32-34 degrees C) after resuscitation from cardiac arrest to protect the brain against global ischaemia was first described in two independent randomized controlled studies in 2002. This manuscript describes a method to induce and maintain a target temperature of 32-33 degrees C after cardiac arrest for 24 hours with continuous renal replacement therapy (CRRT).

MATERIAL AND METHODS

Intravenous infusion of 30 ml/kg of normal saline 4 degrees C over 30 minutes was immediately started if such treatment had not been initiated upon arrival to the unit. Continuous venovenous haemofiltration (CVVH) was initiated and mild therapeutic hypothermia was maintained for 24 hours. The patient's core temperature was subsequently increased at a rate of 0.5-1.0 degrees C per hour.

RESULTS

Over a two-year period, 33 patients were treated with mild therapeutic hypothermia. The median time from the patient's arrival to the intensive care unit and the achievement of a temperature between 32 degrees C and 34 degrees C was 4.2 hours, and the time to established CRRT was 1.7 hours. The median temperature during the treatment was 33.2 degrees C, and it was maintained for a median period of 24.5 hours. Passive rewarming had a median duration of 5 hours. The only complication was bradycardia which did not cause treatment changes. Eleven (39%) patients had a favorable neurological outcome.

CONCLUSION

The described CRRT cooling method is a useful method for reaching and maintaining the target temperature. The method is especially suitably for intensive care units that use CRRT on a daily basis for patients with acute renal failure.

The Procalcitonin And Survival Study (PASS) - a randomised multi-center investigator-initiated trial to investigate whether daily measurements biomarker Procalcitonin and pro-active diagnostic and therapeutic responses to abnormal Procalcitonin levels, can improve survival in intensive care unit patients. Calculated sample size (target population): 1000 patients

BACKGROUND

Sepsis and complications to sepsis are major causes of mortality in critically ill patients. Rapid treatment of sepsis is of crucial importance for survival of patients. The infectious status of the critically ill patient is often difficult to assess because symptoms cannot be expressed and signs may present atypically. The established biological markers of inflammation (leucocytes, C-reactive protein) may often be influenced by other parameters than infection, and may be unacceptably slowly released after progression of an infection. At the same time, lack of a relevant antimicrobial therapy in an early course of infection may be fatal for the patient. Specific and rapid markers of bacterial infection have been sought for use in these patients.

METHODS

Multi-centre randomized controlled interventional trial. Powered for superiority and non-inferiority on all measured end points. Complies with, "Good Clinical Practice" (ICH-GCP Guideline (CPMP/ICH/135/95, Directive 2001/20/EC)). Inclusion: 1) Age > or = 18 years of age, 2) Admitted to the participating intensive care units, 3) Signed written informed consent.Exclusion: 1) Known hyper-bilirubinaemia. or hypertriglyceridaemia, 2) Likely that safety is compromised by blood sampling, 3) Pregnant or breast feeding. Computerized Randomisation: Two arms (1:1), n = 500 per arm: Arm 1: standard of care. Arm 2: standard of care and Procalcitonin guided diagnostics and treatment of infection. Primary Trial Objective: To address whether daily Procalcitonin measurements and immediate diagnostic and therapeutic response on day-to-day changes in procalcitonin can reduce the mortality of critically ill patients.

DISCUSSION

For the first time ever, a mortality-endpoint, large scale randomized controlled trial with a biomarker-guided strategy compared to the best standard of care, is conducted in an Intensive care setting. Results will, with a high statistical power answer the question: Can the survival of critically ill patients be improved by actively using biomarker procalcitonin in the treatment of infections? 700 critically ill patients are currently included of 1000 planned (June 2008). Two interim analyses have been passed without any safety or futility issues, and the third interim analysis is soon to take place. Trial registration number at clinicaltrials.gov: Id. nr.: NCT00271752).

[Acceptance of silicone testicular prostheses in long-term follow-up]

The loss of a testicle is a psychological trauma, in particular for young men. The cosmetic defect can be corrected by implantation of a silicone testicular prosthesis (STP). The recurring discussion regarding the problems of silicone implants mainly concerns breast implants. STPs are made of equivalent material. Since we have been using STPs for 20 years, we wanted to research the opinion of our patients regarding these issues. Between 1978 and 1998, 51 STPs were implanted--37 times by groin incision and 14 times by scrotal incision--in 51 patients. The average age of the patients at the time of the operation was 23.3 years (14.3-55.4). Three implants had to be removed early. A questionnaire was distributed to all patients with STPs; 39 of the questionnaires were returned completed. The results--10.1 years postoperative--showed no serious late complications, an acceptance rate of 97% by the patients and about 50% by their female partners. Therefore, we will continue to offer the option for implantation of STP to our patients.

New insights into red cell network structure, elasticity, and spectrin unfolding--a current review

The red cell membrane's well-recognized ability to withstand the stresses of circulation clearly has its origins in various levels of spectrin-actin network structure. We highlight recently obtained insights into this sub-structure and also briefly explain the implications to membrane components that interact with the network. Novel insights into the resilience of this cytoskeleton are being provided by experiments that range from atomic force microscopy (AFM) tests of single, unfoldable spectrin chains to micropatterned photobleaching of a pipette-deformed network. Continued progress in atomic level structure determinations of non-erythroid spectrin and related repeats are further complemented by theoretical efforts--computational approaches most notably--that have begun to correlate molecular scale aspects of structure with micro-mechanical measures. All of this recent activity in the biophysics of red cell structure-function challenges and refines some of the most basic tenets in cell membrane response.

Caring for the critically ill patient. High-dose antithrombin III in severe sepsis: a randomized controlled trial

CONTEXT

Activation of the coagulation system and depletion of endogenous anticoagulants are frequently found in patients with severe sepsis and septic shock. Diffuse microthrombus formation may induce organ dysfunction and lead to excess mortality in septic shock. Antithrombin III may provide protection from multiorgan failure and improve survival in severely ill patients.

OBJECTIVE

To determine if high-dose antithrombin III (administered within 6 hours of onset) would provide a survival advantage in patients with severe sepsis and septic shock.

DESIGN AND SETTING

Double-blind, placebo-controlled, multicenter phase 3 clinical trial in patients with severe sepsis (the KyberSept Trial) was conducted from March 1997 through January 2000.

PATIENTS

A total of 2314 adult patients were randomized into 2 equal groups of 1157 to receive either intravenous antithrombin III (30 000 IU in total over 4 days) or a placebo (1% human albumin).

MAIN OUTCOME MEASURE

All-cause mortality 28 days after initiation of study medication.

RESULTS

Overall mortality at 28 days in the antithrombin III treatment group was 38.9% vs 38.7% in the placebo group (P =.94). Secondary end points, including mortality at 56 and 90 days and survival time in the intensive care unit, did not differ between the antithrombin III and placebo groups. In the subgroup of patients who did not receive concomitant heparin during the 4-day treatment phase (n = 698), the 28-day mortality was nonsignificantly lower in the antithrombin III group (37.8%) than in the placebo group (43.6%) (P =.08). This trend became significant after 90 days (n = 686; 44.9% for antithrombin III group vs 52.5% for placebo group; P =.03). In patients receiving antithrombin III and concomitant heparin, a significantly increased bleeding incidence was observed (23.8% for antithrombin III group vs 13.5% for placebo group; P<.001).

CONCLUSIONS

High-dose antithrombin III therapy had no effect on 28-day all-cause mortality in adult patients with severe sepsis and septic shock when administered within 6 hours after the onset. High-dose antithrombin III was associated with an increased risk of hemorrhage when administered with heparin. There was some evidence to suggest a treatment benefit of antithrombin III in the subgroup of patients not receiving concomitant heparin.

Forced unfolding modulated by disulfide bonds in the Ig domains of a cell adhesion molecule

Cell adhesion molecules (CAMs) mediate cell attachment and stress transfer through extracellular domains. Here we forcibly unfold the Ig domains of a prototypical Ig superfamily CAM that contains intradomain disulfide bonds. The Ig domains of all such CAMs have conformations homologous to cadherin extracellular domains, titin Ig-type domains, and fibronectin type-III (FNIII) domains. Atomic force microscopy has been used to extend the five Ig domains of Mel-CAM (melanoma CAM)--a protein that is overexpressed in metastatic melanomas--under conditions where the disulfide bonds were either left intact or disrupted through reduction. Under physiological conditions where intradomain disulfide bonds are intact, partial unfolding was observed at forces far smaller than those reported previously for either titin's Ig-type domains or tenascin's FNIII domains. This partial unfolding under low force may be an important mechanism for imparting elasticity to cell-cell contacts, as well as a regulatory mechanism for adhesive interactions. Under reducing conditions, Mel-CAM's Ig domains were found to fully unfold through a partially folded state and at slightly higher forces. The results suggest that, in divergent evolution of all such domains, stabilization imparted by disulfide bonds relaxes requirements for strong, noncovalent, folded-state interactions.

Modelisation of leukocyte adhesion on a fibrinogen coated surface in static conditions

The adhesion of polymorphonuclear leukocytes (PMNs) on the vascular endothelium is a complex process that occurs during biological and pathological events and involves a large family of molecules. This phenomenom could be approached by a modelisation study of the adhesion of PMNs on a biological substrate, fibrinogen. Two different physiological conditions were tested such as the activated state of PMNs with a synthetic pro-inflammatory activator (N-Formyl-Methionyl-Leucyl-Phenylalanine, FMLP). The activated state of PMNs was both quantified by flow cytometry and controlled by fluorescence microscopy. The results suggest that quiescent PMNs deposit in accordance with the ballistic deposition model. The preliminary results obtained with FMLP-stimulated PMNs show a different deposit process compared to quiescent PMNs but do not allow to determine exactly a deposition model.

[Leukocyte adhesion on a fibrinogen-coated surface under static conditions: experimentation and creation of a model]

The adhesion of polymorphonuclear leukocytes (PMNs) on the vascular endothelium is a complex process that occurs during different biological and pathological events and involves numerous molecules. The adhesion cascade is induced after PMN stimulation by various molecular or cellular signals. Fibrinogen is one of the substrates for CD11b/CD18 B2-integrins expressed at the PMN surface; fibrinogen-neutrophil binding is induced by inflammatory reactions. In order to understand this process, we have carried out studies on the basis of preliminary experiments on red blood cells and synthetic particles. The modelization of quiescent PMNs adhesion on a fibrinogen substrate was investigated with a sedimentation cell chamber. Two different physiological conditions were tested: the activated state of PMN by a synthetic pro-inflammatory activator (FMLP). The activated state of PMNs was both quantified by flow cytometry and controlled by fluorescence microscopy. The results suggest that quiescent neutrophils deposit in accordance with the ballistic deposition model. This random adsorption model differs from random sequential adsorption (RSA) in that the cells arriving at the surface are able to roll along cells previously adsorbed introducing the notion of gravitational attraction of cells. The preliminary results obtained with stimulated PMN do not allow to choose between one of this two deposition models. Nevertheless, the qualitative and quantitative effects of FMLP on neutrophils were demonstrated by modifications of adhesion molecules expression.

Occurrence of withdrawal in critically ill sedated children

OBJECTIVES

To record the number of children with withdrawal symptoms after the administration of sedatives for mechanical ventilation, and to discuss the possible connection with the administration of midazolam.

DESIGN

Retrospective data collection from case records and charts.

SETTING

Medical and surgical intensive care unit (ICU) in a university hospital.

PATIENTS

Children 6 months to 14 yrs of age who required sedation for mechanical ventilation (n = 40).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Kind and amount of sedatives and analgesics, duration of administration, and occurrence of withdrawal symptoms. The frequency of withdrawal symptoms was 35% (14/40) of the sedated children. A total dose of midazolam of >60 mg/kg was strongly significantly associated with occurrence of withdrawal. Statistical analysis to determine the occurrence of withdrawal associated with the administration of morphine was not possible.

CONCLUSIONS

Signs and symptoms of a withdrawal reaction were observed in several children. The occurrence of withdrawal was statistically related to high doses of midazolam, but it was not possible to determine the influence of morphine. If large doses of midazolam and opioids have been administered, there may be justification for reducing the dose gradually instead of abruptly, or using longer-acting benzodiazepines or opioids on discontinuation of sedation.

Burns

Inhalation injuries still significantly increase the morbidity and mortality of burn patients. Advances in ventilatory support appear to decrease the frequency of pneumonia and improve the survival of patients. It is now well accepted that early enteral feeding of patients with burn injuries is very important. The addition of anabolic agents in burn care and nutrition may be of importance. Patients receiving pre-storage filtered blood components have fewer blood transfusion-induced side effects and the requirement for transfusion is reduced. Current research on the cellular response to burn injury holds promise for further improvement in burn care.

[Sedation of children on respirators. A questionnaire study on therapeutic strategies and withdrawal problems]

The purpose of this study was to identify the patterns of use of sedative agents and withdrawal problems in the paediatric intensive care unit (PICU). A questionnaire survey was mailed to 46 Danish intensive care units. Only 24 of these treated paediatric patients needing mechanical ventilation. The agents most frequently employed were morphine and midazolam. There was general satisfaction with the used drugs. The majority of departments noted that there was no protocol for sedation in their PICU. The majority of departments (70.8%) did not consider drug withdrawal to be a problem, but those departments who treated most children considered drug withdrawal to be a problem.

[Diagnosis and therapy of kidney traumas]

A dynamic helical CT scan following initial ultrasound provides reliable radiological staging for kidney traumas and immediate diagnosis of most abdominal injuries. It also proves useful for pediatric traumas. Using mainly CT data we apply a classification system proposed by the American Association for Surgery of Trauma (grade I-V). The diagnostic steps and subsequent management are demonstrated by flow-chart. Most renal traumas may be treated conservatively but persistent bleeding or persistent urinary extravasation may necessitate surgical intervention. In cases of exploration of the kidney, the use of fibrin adhesive, alloplastic mesh capsule and DJ stents enables the reconstruction of the kidney. Exploration of the renal injury should never be omitted if urgent laparotomy is indicated for associated injuries.

Indications for surgical management of genitourinary tuberculosis

The incidence of tuberculosis has risen in many parts of the world, and more attention is being focused on genitourinary tuberculosis (GT), the second most common extrathoracic form of tuberculosis. Although chemotherapy is the mainstay of treatment, ablative surgery as a first-line management may be unavoidable for sepsis or abscesses. In cases with hydronephrosis and progressive renal insufficiency caused by obstruction, renal drainage (by stenting or nephrostomy) must be performed immediately. In all other situations triple-drug chemotherapy should be undertaken for at least 6 months and stable conversion obtained before ablative or reconstructive surgery is planned. Nephrectomy or partial nephrectomy is indicated for nonfunctioning or poorly functioning kidneys, particularly if continuous flank pain or hypertension is present. Stenosis of the ureter usually can be managed by temporary stenting and adjuvant corticosteroid therapy. Today the indications for augmentation are rare, but bladder replacement may be combined with ureter replacement using segments of intestine.

[Nitric oxide treatment of children with impairment of oxygenation]

It is well-known that inhaled nitric oxide improves the perfusion of ventilated regions, thus reducing intrapulmonary shunting and improving arterial oxygenation. However, most cases describe treatment of neonates and adults, only few studies describe effects of inhaled nitric oxide in children with severe impairment of oxygenation. Four cases of severe hypoxaemic respiratory failure in children treated successfully with inhaled nitric oxide are described.

A comparison of volume control and pressure-regulated volume control ventilation in acute respiratory failure

BACKGROUND: The aim of this study was to test the hypothesis that a new mode of ventilation (pressure-regulated volume control; PRVC) is associated with improvements in respiratory mechanics and outcome when compared with conventional volume control (VC) ventilation in patients with acute respiratory failure. We conducted a randomised, prospective, open, cross over trial on 44 patients with acute respiratory failure in the general intensive care unit of a university hospital. After a stabilization period of 8 h, a cross over trial of 2 x 2 h was conducted. Apart from the PRVC/VC mode, ventilator settings were comparable. The following parameters were recorded for each patient: days on ventilator, failure in the assigned mode of ventilation (peak inspiratory pressure > 50 cmH2O) and survival. RESULTS: In the crossover trial, peak inspiratory pressure was significantly lower using PRVC than with VC (20 cmH2O vs 24 cmH2O, P < 0.0001). No other statistically significant differences were found. CONCLUSIONS: Peak inspiratory pressure was significantly lower during PRVC ventilation than during VC ventilation, and thus PRVC may be superior to VC in certain patients. However, in this small group of patients, we could not demonstrate that PRVC improved outcome.

Pharmacokinetics and pharmacodynamics of eltanolone (pregnanolone), a new steroid intravenous anaesthetic, in humans

Eltanolone, a new intravenous steroid anaesthetic agent was administered intravenously in a dose of 0.6 mg.kg-1 over 45 s to eight healthy male volunteers to evaluate some of its pharmacokinetic and pharmacodynamic effects. Drug concentration-time data were analysed by PCNONLIN, a non-linear regression programme, showing data consistent with a three-compartment model with initial distribution half-life t1/2 lambda 1 between 0.3 and 2 min, intermediate distribution half-life t1/2 lambda 2 between 12 and 29 min and terminal half-life t1/2 lambda z between 72 and 212 min. The total body clearance of eltanolone was rapid and with individual values in the range 1.6-2.3 l.h-1.kg-1. Eltanolone was initially distributed into a relatively large central compartment V1 between 0.09 and 0.98 l.kg-1 and then extensively further distributed (Vss between 1.80 and 5.44 l.kg-1 and V between 4.87 and 11.87 l.kg-1). The excretion of unchanged of eltanolone in urine was very small, the renal clearance was less than 0.5% of the total clearance. Induction of anaesthesia was trouble free with onset and duration of anaesthesia between 1-2 min and 6-13 min, respectively. There was slight respiratory depression, a small transient increase in heart rate, and a maximum reduction in arterial blood pressure of 23%, as compared with the resting level. Pain on injection and venous sequelae were not seen. Involuntary movements were seen in one subject. We conclude that eltanolone has a favourable pharmacokinetic profile with relatively rapid half-lives, large distribution volumes and rapid total body clearance.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of eltanolone on cerebral blood flow and metabolism in healthy volunteers

BACKGROUND

Eltanolone is a new steroid anesthetic agent that may prove to be useful in clinical practice. The aim of the present study was to evaluate the effects of eltanolone on cerebral blood flow (CBF) and metabolism in healthy volunteers.

METHODS

In a randomized cross-over study, eight subjects received intravenous eltanolone 0.6 mg/kg or its vehicle. CBF was measured with the intravenous xenon 133 technique before and 2 and 30 min after administration of eltanolone or vehicle. Cerebral metabolic rate for oxygen (CMRO2) was calculated as the product of the measured cerebral arteriovenous oxygen content difference and the blood flow.

RESULTS

CBF decreased from a baseline value of 64 +/- 4 (mean +/- SD) to 42 +/- 6 ml.100 g-1.min-1 at 2 min after administration of eltanolone and only 4% after vehicle. Cerebral oxygen consumption was 4.1 +/- 0.4 ml.100 g-1.min-1 at baseline and decreased to 2.7 +/- 0.6 at 2 min after eltanolone, whereas metabolism did not change significantly after administration of vehicle. At 30 min CBF and Cerebral metabolic rate for oxygen were 16 and 10% less than baseline values, respectively. Coupling between CBF and Cerebral metabolic rate for oxygen was preserved at all measurements. After administration of eltanolone a significant decrease in mean arterial blood pressure of 6 mmHg and a period of hypoventilation were observed. This did not occur after injection of vehicle.

CONCLUSIONS

Eltanolone was shown to reduce cerebral oxygen consumption and blood flow in healthy volunteers. Coupling between metabolism and flow was preserved.

Ileal bladder augmentation combined with ileal ureter replacement in advanced urogenital tuberculosis

We report a case of active tuberculosis associated with a right nonfunctioning kidney and nearly total loss of bladder capacity. Percutaneous nephrostomy and right nephroureterectomy were performed while the patient was undergoing triple drug therapy. Definitive surgical treatment consisted of ileal bladder augmentation and ileal ureter replacement. Normal urodynamics of the upper urinary tract and normal voiding with complete return of bladder capacity were achieved. Metabolic acidosis was treated successfully by sodium hydrogen carbonate.

Cytogenetic survey of 32 cancers of the prostate

Cytogenetic studies after short-term culture were performed on 32 adenocarcinomas of the prostate from patients without prior treatment. The tumor specimens, ranging from stage B1 to D1, were obtained by radical prostatectomy or diagnostic biopsies. Fourteen tumors showed a normal diploid chromosome complement in all metaphases examined. Clonal chromosomal alterations were detected in 16 tumor samples and the remaining two cases contained double minute (dmin) chromosomes in some cells. The most frequent numerical changes included loss the Y chromosome and trisomy 7, both found in four cases. The only recurrent structural aberration was del(10)(q24), seen in three cases both as a sole anomaly and within multiple rearrangements. Six patients showed cytogenetically unrelated clones. The occurrence of the chromosomal changes found in this study shows no relationship to certain histopathologic characteristics of the tumors. The recurrent finding of del(10)(q24) as sole anomaly and the evidence for clonal evolution in one patient demonstrates that this change is an early karyotypic event which may be important for the pathogenesis in at least a subset of prostatic cancers.

Venous pressure in idiopathic varicocele

In 27 patients with clinically identified idiopathic left varicocele, a retrograde venography and a combined pressure measurement in the vena cava, vena renalis and vena spermatica was performed. During Valsalva maneuver the pressure values increased. We could not confirm increased pressure values in the left renal vein dependent on the patient's position. There were no increasing pressure gradients between vena renalis and vena cava in erect position. Therefore an elevated pressure in the left renal vein and especially the 'upper nutcracker' does seem to be of at least limited importance for the pathogenesis of idiopathic varicocele.

Identification and catabolic activity of well-derived gasoline-degrading bacteria from a contaminated aquifer

Approximately 300 gasoline-degrading bacteria were isolated from well water and core material from a shallow coastal aquifer contaminated with unleaded gasoline. Identification of 244 isolates revealed four genera: Pseudomonas, Alcaligenes, Nocardia, and Micrococcus, with pseudomonads making up 86.9% of bacteria identified. A total of 297 isolates was sorted into 111 catabolic groups on the basis of aerobic growth responses on 15 gasoline hydrocarbons. Each test hydrocarbon was degraded by at least one isolate. Toluene, p-xylene, ethylbenzene, and 1,2,4-trimethylbenzene were most frequently utilized as growth substrates, whereas cyclic and branched alkanes were least utilized. Most isolates were able to grow on 2 or 3 different hydrocarbons, and nearly 75% utilized toluene as a sole source of carbon and energy. Isolates were remarkably specific for hydrocarbon usage, often catabolizing only one of several closely related compounds. A subset of 220 isolates was sorted into 51 groups by polyacrylamide gel electrophoresis. Pseudomonas aeruginosa was partitioned into 16 protein-banding groups (i.e., subspecies) whose catabolic activities were largely restricted to substituted aromatics. Different members of subspecies groups defined by protein-banding pattern analysis often exhibited different growth responses on the same hydrocarbon, implying marked strain diversity. The catabolic activities of well-derived, gasoline-degrading bacteria associated with this contaminated aquifer are consonant with in situ adaptation at the site.

The effect of the benzodiazepine antagonist, flumazenil, on psychometric performance in acute ethanol intoxication in man

The effect on cognitive and psychomotor performance of the benzodiazepine (BZD) antagonist, flumazenil, in antagonising the central effect, of ethanol in man has been investigated. Eight healthy adult male volunteers, aged 23 to 32 years, participated in the study. Following a loading infusion, stable blood ethanol levels with a mean value of 1.6 g x l-1 were produced by a maintenance infusion. When stable blood levels of ethanol were reached, 5.0 mg flumazenil/placebo was administered intravenously, and after 15 and 75 min a test battery evaluating psychomotor and cognitive functions was applied. The test battery was sensitive to the test model, but no significant improvement in the test scores could be demonstrated following the administration of flumazenil. It is concluded that flumazenil has no influence on psychomotor functions in acute ethanol intoxication.

Pregnanolone emulsion. A preliminary pharmacokinetic and pharmacodynamic study of a new intravenous anaesthetic agent

Pregnanolone emulsion, a new steroid anaesthetic agent, was administered intravenously as bolus doses to six young healthy male volunteers in a preliminary pharmacokinetic and pharmacodynamic study. The plasma concentration-time curves fitted a two-compartment model. The elimination half-life was between 0.9 and 1.4 hours, volume of central compartment between 0.95 and 2.10 litres/kg, volume of distribution between 3.75 and 5.58 litres/kg and total body clearance between 1.80 and 3.07 (litres/hour)/kg. The excretion in urine of unchanged pregnanolone was less than 0.1%. The pharmacodynamic properties were found to be similar to those of Althesin, with immediate induction of anaesthesia of short duration. The anaesthetic affected haemodynamics only slightly; minor depression of ventilation, with an increase in PaCO2, occurred in several of the subjects. Excitation of short duration occurred in one subject during induction of sleep and slight involuntary muscle movements in another subject during sleep. It is impossible to draw any clear conclusions of the clinical efficacy and tolerance from this limited normal subject trial, but pregnanolone emulsion seems worthy of further clinical trial.

Vesico-ovarian fistula in suppurative ovarian inflammation and salpingitis

The development of fistulas between the bladder and right ovary in a 27-year-old woman is reported. This exceedingly rare form of an internal vesical fistula occurred as a consequence of dextrolateral adnexitis with suppurative ovarian inflammation after placement of an intrauterine pessary. Therapy consisted of removal of the right adnexa, excision of the fistulous duct and suturing of the bladder.

A randomized comparison between midazolam and thiopental for elective cesarean section anesthesia: II. Neonates

In a randomized blind trial, the general condition of 40 neonates was assessed following midazolam- or thiopental-based general anesthesia for elective cesarean section. Among 19 neonatal neurobehavioral observations and tests, statistically significant differences between the midazolam and the thiopental groups were rare. However, a statistically significant interaction with regard to body temperature, general body tone, and arm recoil was observed where results were inferior for midazolam, although only within the first 2 hours. It was concluded that midazolam is as safe as thiopental for the induction and maintenance of elective cesarean section anesthesia in neonates.

A randomized comparison between midazolam and thiopental for elective cesarean section anesthesia. I. Mothers

In a randomized blind trial midazolam (0.3 mg kg-1) was compared with thiopental (4 mg kg-1), both combined with meperidine-nitrous oxide, for elective cesarean section anesthesia in 40 women. We found no statistically significant differences between thiopental and midazolam at induction, during operation or recovery with regard to maintenance doses, change in maternal neurologic status based on a modified Glasgow Coma Scale, systolic blood pressure, and heart rate. Induction time was 120 seconds with midazolam and 111 seconds with thiopental. There were significant differences with regard to diastolic blood pressure. Side effects occurred with approximately equal frequencies, but vomiting was significantly more frequent after thiopental. Perivenous tenderness and erythema occurred in four patients, all after thiopental. Midazolam appears to be a suitable alternative to thiopental for the induction and maintenance of anesthesia for elective cesarean section.

A randomized comparison between midazolam and thiopental for elective cesarean section anesthesia: III. Placental transfer and elimination in neonates

Forty neonates delivered by cesarean section were studied, half being delivered of mothers in whom anesthesia was induced with midazolam (0.3 mg/kg intravenously) and half of mothers given thiopental (4 mg/kg). At delivery, blood samples from mother and the umbilical vein were drawn for determination of plasma concentrations of thiopental, midazolam, and alpha-hydroxymidazolam. Over the next 60 hours, three blood samples were drawn using a randomized procedure of two blood samples at 30 different times. Placental transfer, expressed as the umbilical/maternal concentration ratio, was 0.96, 0.66, and 0.28, respectively, for thiopental, midazolam, and alpha-hydroxymidazolam. The transfer of thiopental was significantly more rapid than the transfer of midazolam and alpha-hydroxymidazolam. The population average of elimination half-life in neonates was 6.3 hours for midazolam and 14.7 hours for thiopental. Both values are substantially larger than those found in previous studies in adults.

Anticonvulsive properties of pregnanolone emulsion compared with althesin and thiopentone in mice

The anticonvulsive properties of pregnanolone (as an emulsion) were evaluated in mice and compared with similar properties of Althesin and thiopentone. Pregnanolone emulsion was found to antagonize convulsions induced by the GABA antagonists pentetrazole, bicuculline and picrotoxin and by the specific glycine receptor antagonist, strychnine. The drug was effective in all four convulsive tests at subanaesthetic doses with maximal activity appearing within less than 1 min. The anticonvulsive therapeutic indices of pregnanolone emulsion were superior when compared with the therapeutic indices of Althesin and thiopentone in all four tests. Pregnanolone emulsion might be a useful alternative drug in the management of convulsive states resistant to conventional therapy.

Anaesthetic properties of pregnanolone emulsion. A comparison with alphaxolone/alphadolone, propofol, thiopentone and midazolam in a rat model

The anaesthetic properties of pregnanolone emulsion, a new steroid preparation for intravenous administration, were evaluated in rats and compared to those of Althesin, propofol, thiopentone and midazolam. The therapeutic index was found to be 50% higher than that of Althesin and 6-8 times higher than those of propofol, thiopentone and midazolam. Induction with pregnanolone emulsion was reliable and fast, with only minor excitatory side effects, although induction time was longer compared to Althesin, propofol and thiopentone. Movement of unstimulated rats during sleep was similar to that seen with Althesin but movement on painful stimulation was less than with propofol and thiopentone. Recovery was rapid and smooth, and the proportion of sleeping time to recovery time was higher than found for the other four anaesthetics. No cumulative effects were seen on repeated administration and there were no venous sequelae. The results indicate that pregnanolone emulsion may provide a short-acting, less cumulative and less toxic alternative to existing intravenous anaesthetic agents.

Pregnanolone emulsion. A new steroid preparation for intravenous anaesthesia: an experimental study in mice

The anaesthetic activity of pregnanolone (a metabolite of progesterone) in emulsion formulation administered intravenously to male mice was compared with that of Althesin. The loss of righting reflex for 15 seconds was used to estimate the anaesthetic effect. The mean anaesthetic dose (AD50) for the pregnanolone emulsion was 5.25 mg/kg and for Althesin, 2.8 mg/kg. The mean lethal dose (LD50) was 44 mg/kg for pregnanolone and 54 mg/kg for Althesin. The sleeping time after pregnanolone was 2.5-3.5 times longer than after Althesin in dosages above 7.5 mg/kg. No signs of pain or local reaction from injection were observed for either of the drugs. The onset of action was fast for both drugs, with only minor signs of excitation, and recovery was rapid and without excitation. The results indicate that the anaesthetic properties of pregnanolone emulsion are very similar to those of Althesin. Further studies will show whether it can fill the major vacuum left in anaesthetic practice after the withdrawal of Althesin.

The anticonvulsive activity and toxicity of diazepam in three different formulations. An experimental study in mice

The anticonvulsive activity (ED50), acute toxicity (LD50), and minimal neurotoxicity (TD50) of diazepam in an emulsion form (Diazemuls) were compared with two different water-based diazepam solutions (Valium and Stesolid). The diazepam preparations were administered intravenously to male mice. After determination of time of peak drug activity, the ED50's were established against pentetrazol-induced convulsions, at peak drug activity. The most important difference between the three diazepam preparations was a significantly higher LD50 of diazemuls (275 mg/kg) compared to valium (49 mg/kg) and stesolid (51 mg/kg). ED50 was: diazemuls 0.24 mg/kg, valium 0.14 mg/kg and stesolid 0.10 mg/kg. The therapeutic indices (LD50/ED50) were thus calculated to be 1146 for diazemuls, 350 for valium and 510 for stesolid. Time of peak drug activity and TD50 were equal for all three drugs. No signs of pain on injection or necrosis were observed following diazemuls, whereas this was common after valium and stesolid.

Pain relief after major abdominal surgery: a double-blind controlled comparison of sublingual buprenorphine, intramuscular buprenorphine, and intramuscular meperidine

In a double-blind randomized study of three groups of 18 patients scheduled for major abdominal surgery the efficacy and side effects of sublingual buprenorphine were tested and compared to intramuscular meperidine and buprenorphine. Single doses of either 75 mg of meperidine, 0.4 mg of sublingual buprenorphine, or 0.3 mg of intramuscular buprenorphine were used. Patients given buprenorphine as sublingual tablets were significantly more conscious in the immediate postoperative period (Glasgow Coma Scale) than when given buprenorphine or meperidine intramuscularly. Median pain intensity differences (PID) showed equal pain relief, whereas the summarized pain intensity differences (SPID) were significantly higher in the intramuscular buprenorphine group compared to the meperidine group. Three cases of respiratory acidosis in the meperidine group required IPPV treatment, and one case in the intramuscular buprenorphine group required treatment. Sedation and nausea were the most common side effects in all three groups. We conclude that sublingual buprenorphine is useful for relief of postoperative pain and exhibited administrative advantages, when the patients were able to cooperate.