Plasma VEGF - a candidate biomarker for response to treatment with bevacizumab in HHT patients

BACKGROUND

Recurrent epistaxis is the principal symptom of hereditary hemorrhagic telangiectasia (HHT). Currently, there is no standard therapy for this condition. Bevacizumab (anti-VEGF) treatment has been under intense investigation but treatment effects vary greatly between individuals. There are currently no markers to predict anti-VEGF therapeutic response in HHT patients.

METHODS

We evaluated plasma VEGF levels in 13 HHT patients and correlated values with i) degree of epistaxis, measured by visual analog scale (VAS), epistaxis severity score (ESS), and patient bleeding diaries ii) the prevalence of extranasal manifestations, iii) the HHT subtype and iv) the treatment response to intranasal submucosal bevacizumab.

RESULTS

Plasma VEGF was elevated in all 13 HHT patients compared to reference levels and showed a moderate correlation with VAS and duration of moderate bleeding events. In patients treated with intranasal submucosal bevacizumab plasma VEGF levels showed a strong correlation with the degree of reduction of mild bleeding events and VAS.

CONCLUSIONS

The role of plasma VEGF as a potential predictive biomarker for therapeutic response to bevacizumab treatment warrants further investigation in larger prospective studies.

Growth of a single bubble in semi-hard cheese: Comparison between simulation and experiment

This paper proposes a model for bubble growth in semi-hard cheese coupling mechanical behaviour and mass transport. The modelling follows previous work centred on the mechanical aspects, and focuses in this paper on the mass transport phenomena. Data are compared to experimental results obtained on industrial-size cheeses, both under the rind and at core, and a sensitivity study is conducted to discuss the results. The model is in agreement with experiment at core, and underlines the great influence of the carbon dioxide production rate and the amount of cheese material surrounding the bubble on bubble growth. Under the rind, the model yielded poorer agreement, due to the fact that this region in the cheese is less homogeneous, and therefore with more intra- and inter-batch variation on the parameters that were characterized.

The Influence of Different Melt Temperatures on the Mechanical Properties of Injection Molded PA-12 and the Post Process Detection by Thermal Analysis

Polyamide 12 (PA-12) test plates were injection molded using different melt temperatures and the influence on mechanical properties was investigated using quasi-static tensile and instrumented impact behavior in two conditioned states: dried, and following accelerated moisture intake. Energy absorption in tension is strongly dependent on process temperature (variations up to 99%) and additional variation (around 18%) was evident when testing at different conditioning states. Under high-velocity loading, the total impact energy varied by up to 8.70% and 9.05%, when systematic changes were made to process melt temperature and at moisture content, respectively, with all samples failing ductile. Differential Scanning Calorimetry (DSC) was used to characterise the unique endothermic melting behavior of molded PA-12 samples, by linking different process histories to the respective mechanical properties. With focus on the first heating curve progression, significant changes within the endothermic melting region were pointed out and quantified by using MatLab (software), proving DSC as a reliable testing tool for post-production analysis with increased practical implications regarding quality control as well as failure analysis. Findings for the initial heating curve progression were explained by studying the re-crystallisation peak values during cooling phase and obtained data for the second heating.

Pegvisomant and cabergoline combination therapy in acromegaly

Combination with cabergoline may offer additional benefits to acromegalic patients on pegvisomant monotherapy. We evaluated the safety and efficacy profile of this combination and investigated the determinants of response. An observational, retrospective, cross-sectional study. Fourteen acromegalic patients (9 females), who were partially resistant to somatostatin analogs and on pegvisomant monotherapy. Cabergoline was added because of the presence of persistent mildly increased IGF-I. The mean follow-up time was 18.3 ± 10.4 months. The efficacy and safety profile was assessed. The influence of clinical and biochemical characteristics on treatment efficacy was studied. IGF-I levels returned to normal in 4 patients (28%) at the end of the study. In addition, some decline in IGF-I levels was observed in a further 5 patients. The % IGF-I decreased from 158 ± 64% to 124 ± 44% (p = 0.001). The average change in IGF-I was -18 ± 27% (range -67 to +24%). Lower baseline IGF-I (p = 0.007), female gender (p = 0.013), lower body weight (p = 0.031), and higher prolactin (PRL) levels (p = 0.007) were associated with a better response to combination therapy. There were no significant severe adverse events. Significant tumour shrinkage was observed in 1 patient. Combination therapy with pegvisomant and cabergoline could provide better control of IGF-I in some patients with acromegaly. Baseline IGF-I levels, female gender, body weight, and PRL levels affect the response to this combination therapy.

Somatotroph tumor progression during pegvisomant therapy: a clinical and molecular study

CONTEXT

There is concern that pegvisomant could be associated with a higher risk of tumor growth. The rate and possible determinants of this tumor growth are unknown.

OBJECTIVE

The objective of the study was to investigate the clinical, immunohistological, and molecular factors conditioning tumor growth in patients taking pegvisomant.

DESIGN AND SETTING

This was a cross-sectional study performed from 2004 to 2010 in four university hospitals in Spain.

PATIENTS

Seventy-five acromegalic patients with active disease resistant to somatostatin analogs treated with pegvisomant were followed up for a mean of 29 ± 20 months.

MAIN OUTCOME MEASURES

Magnetic resonance images before initiation of pegvisomant, at 6 months, and then yearly were examined in all patients. Immunohistological and molecular studies were performed in tumors that grew.

RESULTS

A significant increase in tumor size was observed in five patients (6.7%). Absence of previous irradiation (P = 0.014) and shorter duration of prepegvisomant somatostatin analog therapy (P < 0.001) were associated with an increased risk of tumor growth. A stepwise multivariate linear regression analysis (R(2) = 0.334, P < 0.001) identified the duration of somatostatin analog therapy prior to pegvisomant (beta = -4.509, P = 0.014) as the only significant predictor of tumor growth. In those tumors that grew, GH expression and insulin receptor expression were higher (P = 0.033 in both cases) than in the control group.

CONCLUSIONS

No previous radiotherapy, shorter duration of prepegvisomant somatostatin analog therapy, and higher tumor expression of GH and insulin receptor could be risk factors for tumor growth during pegvisomant therapy.

Efficacy of lanreotide Autogel administered every 4-8 weeks in patients with acromegaly previously responsive to lanreotide microparticles 30 mg: a phase III trial

OBJECTIVE AND DESIGN

Depot somatostatin analogues are well accepted as either adjuvant or primary therapy for acromegaly, and their long dosage intervals facilitate adherence to treatment. Our objective was to evaluate whether lanreotide Autogel 120 mg, every 4-8 weeks, was as effective in controlling acromegaly as lanreotide microparticles 30 mg, every 1-2 weeks. PATIENTS DESIGN AND MEASUREMENTS: Patients who had used lanreotide microparticles 30 mg, >or= 2 months prestudy, and had responded to treatment were recruited to this open, prospective, multicentre phase III trial. Three to five injections of lanreotide Autogel 120 mg were administered. Lanreotide Autogel 120 mg was injected every 4, 6 or 8 weeks in patients previously receiving lanreotide microparticles every 7, 10 or 14 days, respectively. GH and insulin-like growth factor (IGF)-1 levels were assessed one dosing interval after the final injections.

RESULTS

Ninety-eight patients were enrolled and 93 completed. Steady-state GH concentrations demonstrated similar efficacy between the formulations (upper 95% confidence interval of the quotient, 77.7%). Mean (SE) GH levels were lower with lanreotide Autogel than with lanreotide microparticles (3.8 (0.5) vs 4.3 (0.5) ng/ml; P < 0.001). GH levels < 2.5 ng/ml were observed in 54% and 46% of patients; 40% and 35% having GH < 2.5 ng/ml and normalized IGF-1 with lanreotide Autogel and microparticles, respectively. Symptoms were controlled better with lanreotide Autogel and treatment was well accepted.

CONCLUSIONS

Lanreotide Autogel 120 mg every 4-8 weeks, is at least as effective and as well tolerated in acromegaly as lanreotide microparticles 30 mg injected every 7-14 days.

Alternative splicing of IL-24 in melanocytes by deletion of exons 3 and 5

Two novel interleukin-24 (IL-24) splice variants were identified in normal human melanocytes by sequencing cloned polymerase chain reaction (PCR) products that are not expressed in metastatic melanoma. These gene products have been generated by differential skipping of exons 3 (IL-24 delE3) and 5 (IL-24 delE5). IL-24 delE3 has limited sequence identity to the IL-24-interacting protein mda-7s, and IL-24 delE5 is homologous to IL-24.

Experience in management of 51 non-functioning pituitary adenomas: indications for post-operative radiotherapy

OBJECT

The indications for additional radiotherapy (RT) after surgery for non-functioning pituitary adenoma are controversial. The goal of this retrospective study was to evaluate the outcome of surgically treated patients, with or without post- operative irradiation.

METHODS

Review of cases treated for non-functioning pituitary adenoma. Fifty-one patients were identified, with a mean post-operative follow-up of 6.4+/-3.5 yr. Twenty-nine patients showed residual tumor after surgery and 22 did not. Serial endocrine, visual and radiological evaluations were made after treatment to assess the efficacy and toxicity of surgery and RT. Twenty-seven patients with residual tumor after surgery received RT (22 of them during the post-operative period and 5 after an interval of several yr: 3 because of increased tumor size and 2 with stable residual lesion); tumors in 14 of these patients decreased in size, 11 appeared to be stable on imaging and one patient showed some increase in tumor size (one patient was not followed-up). The residual tumors of the 2 non-irradiated patients remained stable after 5 and 7 yr, respectively. Twenty-two patients without residual disease after surgery (11 with post-operative irradiation, 1 with RT 5 yr after transsphenoidal surgery because of tumor recurrence, and 10 without RT) have shown no evidence of tumor regrowth on serial images.

CONCLUSIONS

Radiotherapy can be avoided in patients with complete macroscopic resection and absence of residual tumor in post-operative images; they must be carefully followed using imaging techniques and, in the case of recurrence, they should be re-operated and/or irradiated.

Quantitative measurement of temperature by proton resonance frequency shift at low field: a general method to correct non-linear spatial and temporal phase deformations

MRI thermometry methods are usually based on the temperature dependence of the proton resonance frequency. Unfortunately, these methods are very sensitive to the phase drift induced by the instability of the scanner which prevents any temperature mapping over long periods of time. A general method based on 3D spatial modelling of the phase drift as a function of time is presented. The MRI temperature measurements were validated on gel samples with uniform and constant temperature and with a linear temperature gradient. In the case of uniform temperature conditions, correction of the phase drift proved to be essential when long periods of acquisition were required, as bias could reach values of up to 200 degrees C in its absence. The temperature uncertainty measured by MRI was 1.2 degrees C in average over 290 min. This accuracy is coherent with the requirements for food applications especially when thermocouples are useless.

The effect of the limited availability of H2O2 in the competitive deposition of sulfur and oxidized nitrogen

To understand the influence of the reduction of SO2 emissions from a single source in the S and N deposition around its local environment, the application of the Sulphur Transport Eulerian Model 2 (STEM-II) was introduced in this paper. Observed local deposition patterns were analysed and explained in terms of the main processes involved in the pollutants deposition. It was necessary to take into account the limited availability of H2O2 because of its influence on both S(IV) and oxidized nitrogen deposition. In order to estimate the quantitative relationship between the SO2 emissions reduction and the observed S and N deposition patterns, these processes were simulated for different meteorological conditions. Simulation results were in agreement with both observed deposition patterns and limited availability of H2O2, specially if significant changes in the S deposition patterns were considered. Both observed and estimated S deposition patterns changed their top value location from the Southwest (1990) to the Northwest (1997) of the domain, because of the reduction of dry deposition. The global reduction of total S depositions, estimated and observed, were in good agreement too. Model simulations could explain the higher S dry deposition reduction, considering the emissions reduction strategy applied.

Bcl-x(L) antisense oligonucleotides radiosensitise colon cancer cells

Advanced colon cancer is a malignancy with poor response to various treatment modalities including ionising radiation (IR) and chemotherapy. Both IR and chemotherapeutic agents have been shown to act by inducing apoptosis, a type of cell death antagonised by the Bcl-x_L gene product. Since approximately 60% of human colon cancers express Bcl-x_L, it was the aim of this study to explore the potential of Bcl-x_L antisense oligonucleotides as a novel radiosensitisation strategy. Caco-2 colon cancer cells were treated with Bcl-x_L antisense oligonucleotides in combination with IR or cisplatin, and Bcl-x_L protein expression, apoptosis, cell viability and clonogenic survival were examined. Bcl-x_L antisense oligonucleotide specifically reduced the Bcl-x_L protein level by almost 50% in Caco-2 cells. The decreased threshold for the induction of apoptosis resulted in a 300% increase of apoptosis after IR or cisplatin treatment and led to a 60% reduction of cell proliferation beyond response rates achieved with IR. These data suggest that Bcl-x_L is an important factor contributing to the treatment resistance of human colon cancer. Specific reduction of Bcl-x_L protein levels by antisense oligonucleotides qualifies as a promising therapeutic strategy for colon cancer that may help overcome resistance and improve clinical outcome in this malignancy.

Assessment by MRI of local porosity in dough during proving. theoretical considerations and experimental validation using a spin-echo sequence

Proving is a key stage in the development of the final structure of bread, as invasive measurements may provoke dough collapse. Therefore, better understanding and better control of the nucleation and the growth of bubbles require the development of non-invasive methods of measurement. In the present work, a non-invasive method is presented for the measurement of local dough porosity from MR image analysis. For this, a direct relation between the gray level of a voxel and its gas fraction was established in the absence of heat and mass transfer. At whole dough scale for a one-dimensional expansion, the porosity estimated from the gray level was compared with the porosity estimated from total dough volume measurements in a range of [0.10, 0.74 m(3) of gas/m(3) of dough]. For short proving times (<30 min), MR image analysis underestimated porosity by a maximum of 0.03 m(3) of gas/m(3) of dough, but otherwise the difference between the two means of measurement was within the standard error of total dough measurements (+/-0.01 m(3) of gas/m(3) of dough). Maps of local porosity in dough during proving are also presented and discussed.

Longevity of direct resin composite restorations in posterior teeth

This review is a survey of prospective studies on the clinical performance of posterior resin composites published between 1996 and 2002. Material, patient- and operator-specific data, observation periods, isolation methods of the operative field, and failure rates are detailed in tables. The data were evaluated statistically in order to assess the role of materials (filler size, bonding system, base materials [e.g. glass ionomer cements], and lining materials), study design, and personnel on failure rates. The primary reasons for composite failure were secondary caries, restoration fracture, and marginal defects. The influence of different commercial material brands on failure rates was not evaluated due to the great variety of test substances and the lack of material-specific documentation. Effects of the isolation method of the operative field (rubber dam or cotton rolls) and the professional status of operators (university or general dentist) on composite failure rates were not found to be significant. Observation periods varied from 1 to 17 years, and failure rates ranged between 0% and 45%. A linear correlation between failure rate and observation period was found (P<0.0001). Thirteen of 24 studies were terminated after 3 years, while seven studies continued for more than 10 years, indicating that favourable results for composite materials are frequently based on short-term results, despite higher dropout rates in longer studies. To determine accurately the risk for patients, long-term, randomised, controlled clinical trials of treatment outcomes with composites used in posterior teeth are clearly needed.

Varying additive effects of bromocriptine with two somatostatin analogs in cultures of GH-secreting adenomas

In this study, we have investigated the effect of combined treatment using two somatostatin analogs, lanreotide or octreotide, with bromocriptine on GH release in cultures of GH-secreting pituitary tumors. Sixteen acromegalic patients were included in the study. All patients had been treated with lanreotide prior to the surgery. Five patients (31.2 %) reached GH levels below 2.0 microg/l and normal IGF-I levels according to age and sex after lanreotide treatment. A positive correlation was observed between the lanreotide-induced inhibition of GH release in vitro and serum GH decrease after lanreotide treatment (r = 0.52; p = 0.03). Combined treatment significantly inhibited GH release in vitro in 8 of the 16 tumors (50 %). However, only 5 (31.2 %) of the respective patients had been resistant to presurgical treatment with lanreotide. Three of these 5 patients (18.7 %) responded to a BC concentration similar to that achieved with therapeutic doses, and in 2 patients only when a pharmacological dose of BC was used in the combined treatment. The additive effect was observed with the combination of lanreotide and BC in 6 tumors and with octreotide and BC in 3. Only one tumor showed simultaneous response to both types of combination. These results suggest that the additive effect under the combined treatment might be found between 18 and 30 % of patients who are resistant to these drugs, and that different combinations of somatostatin analogs and dopamine agonists should be tested in resistant patients.

Acromegaly Quality of Life Questionnaire (ACROQOL) a new health-related quality of life questionnaire for patients with acromegaly: development and psychometric properties

OBJECTIVE

To develop a disease-specific questionnaire suitable to measure health-related quality of life (HRQOL) in acromegaly (ACROQOL).

DESIGN, PATIENTS AND MEASUREMENTS

For the development of the ACROQOL questionnaire different sources of information were used: First, a literature search was performed to identify relevant papers describing the impact of acromegaly in HRQOL. Second, 10 endocrinologists identified the main domains of impact on HRQOL in patients with acromegaly. Third, 10 in-depth, semistructured interviews were conducted in acromegalic patients to identify domains and items related to the self-perceived impact of acromegaly in patients' life. Qualitative analyses of the information were performed identifying domains and items to be included in the questionnaire. Those items considered ambiguous, complicated to read, double-barrelled, with jargon terms, too long, or negatively worded were excluded. Each remaining item was subsequently rated by the same panel of endocrinologists and experts in HRQOL evaluation, and assessed according to clarity of wording, frequency of occurrence and importance among patients with acromegaly. Analysis of internal consistency of the questionnaire was evaluated with a Cronbach's Alpha. A preliminary questionnaire was administered to 72 patients with acromegaly. Rasch analysis (dichotomous logistic response model) of the answers given by these patients allowed parameter estimates and model data fit indices to be computed and misfitting items deleted. Frequency of occurrence and degree of agreement with the statements were selected as response choices in a 5-point Likert type scale.

RESULTS

The following domains related to HRQOL in acromegaly were identified: physical and psychological functions, social, daily activities, symptoms, cognition, general health perception, sleep, sexual function, pain, energy and body image. An initial set of 204 expressions were identified from the initial transcripts of the patient interviews. After elimination of ambiguous or unclear expressions, 142 items remained drafted in question form. From the quantitative analysis of the item rank position within each of the three areas of clarity, frequency and importance, the 38-item questionnaire was produced, with satisfactory internal consistency (Cronbach's Alpha 0.94). Rasch analysis produced a further reduction to the final 22-item questionnaire (Cronbach's Alpha 0.91) containing two scales that evaluate physical (eight questions) and psychological aspects related to appearance and personal relations (seven items each). The evaluation of the item parameters confirmed the construct validity of the new instrument. The substantial reliability of the questionnaire suggested the sample was well targeted by the questionnaire. The initial Spanish version was translated into English and presented to five English-speaking Australian patients with acromegaly to assess and correct for comprehension, clarity, cultural relevance and suitable wording.

CONCLUSIONS

We present the ACROQOL questionnaire, developed and preliminarily validated to specifically assess HRQOL in patients with acromegaly.

Protein kinase C isoforms in normal and transformed cells of the melanocytic lineage

Enzymes belonging to the protein kinase C (PKC) family represent one of the major mediators of signal transduction in melanocytes. To identify PKC isoforms that may be associated with the process of malignant transformation and metastasis, we investigated the expression pattern of 11 different PKC isoforms (alpha, beta I, beta II, gamma, delta, epsilon, eta, theta, zeta, lambda, and iota) in melanoma lymph node metastases, in cell lines established from these metastases, in primary cell cultures from normal melanocytes, and in permanent cell lines established from spontaneously transformed melanocytes. PKC alpha, beta I, beta II, delta, epsilon, eta, zeta, lambda and iota were found to be expressed in total lysates from melanoma metastases. In permanent cell lines established from these metastases, the expression levels of PKC beta I, beta II, delta, epsilon, and eta were lower or undetectable when compared with initial expression in tumour lysates. In normal primary melanocyte cultures, the PKC isoforms beta II, delta, epsilon, eta and iota were undetectable. PKC gamma and theta isoforms were undetectable in all melanocytic cell types examined. PKC iota was the only isoform exclusively detected in tumour lysates, in spontaneously transformed melanoma cells and melanoma cell lines, but not in normal melanocytes, and may therefore be associated with the transformed phenotype in human melanoma in vitro and in vivo.

MEN-2A syndrome and pulmonary metastasis

A case of multiple endocrine neoplasia syndrome type-2A (MEN-2A) with primary hyperparathyroidism and medullary carcinoma of thyroid initially treated by surgery is reported. The presence of pulmonary nodules six years after the initial treatment was thought to be related to metastasis of medullary carcinoma, and the increase in serum calcium concentrations was assumed to be caused by persistence of parathyroid adenomatous or hyperplastic tissue. The patient underwent surgery again and the pulmonary nodules were confirmed to be metastases of a parathyroid carcinoma, a very rare entity in MEN-2A syndrome.

The complete normalization of the adrenocortical function as the criterion of cure after transsphenoidal surgery for Cushing's disease

Transsphenoidal microsurgery is the standard treatment for patients with Cushing's disease. However, there is general lack of agreement regarding the definition of cure. We studied 58 patients with corrected hypercortisolism after transsphenoidal surgery for Cushing's disease. Plasma and urinary cortisol levels were measured after surgery. After the postsurgical hypocortisolism stage (or periodically in patients without hypocortisolism), urinary free cortisol, plasma cortisol at 0800 h and 2300 h, morning cortisol after 1 mg dexamethasone, and cortisol response to insulin-induced hypoglycemia were performed. Patients were classified in 3 groups: group I, patients with transient hypocortisolism and normal hypothalamus-pituitary-adrenal axis afterwards; group II, patients with transient hypocortisolism and abnormalities in the circadian rhythm or the stress response afterwards; and group III, patients without postoperative hypocortisolism. Thirty-three patients were included in group I, 8 in group II, and 17 in group III. Groups I and II were similar in postsurgical plasma cortisol (46.9 +/- 30.3 vs. 60.7 +/- 38.6 nM) and mean follow-up (69.8 vs. 68.8 months) but were significantly different in their recurrence rate (3.4% vs. 50%, P < 0.001). Patients in group III had normal postsurgical plasma and urinary cortisol but persistent abnormalities in circadian rhythm and stress response. After a mean follow-up of 39.1 months, their recurrence rate was similar to that of group II (64.7% vs. 50%). The complete normalization of the adrenocortical function, which is always preceded by postsurgical hypocortisolism, is associated with a very low recurrence risk and should be considered, in our opinion, the main criterion of surgical cure in Cushing's disease.

Bcl-2 antisense oligonucleotides chemosensitize human gastric cancer in a SCID mouse xenotransplantation model

We used Bcl-2 antisense oligonucleotides (G3139) to chemosensitize human gastric cancer by downregulation of Bcl-2 expression in vivo. Oligonucleotides and cisplatin were administered systemically in a human gastric cancer SCID mouse model, and Bcl-2 expression, apoptosis, tumor size, and survival were assessed. Used alone, G3139 treatment led to downregulation of Bcl-2 and moderate tumor reduction compared to saline control. G3139 combined with cisplatin treatment markedly enhanced the antitumor effect of cisplatin (70% tumor size reduction vs. cisplatin alone), associated with increased apoptosis measured in tumor biopsy specimens. Combined treatment with G3139 and cisplatin prolonged survival of the tumor-bearing SCID mice by more than 50% without adding significant drug-related toxicity. Treatment with Bcl-2 antisense oligonucleotides is thus a promising novel approach to enhance antitumor activity of cisplatin or other drugs used in gastric cancer therapy and warrants further evaluation in clinical trials.

The influence of a bupivacaine and fentanyl epidural infusion after epidural fentanyl in patients allowed to ambulate in early labor

Epidural fentanyl after a lidocaine and epinephrine test dose provides adequate analgesia and allows for ambulation during early labor. This study was designed to determine the influence of an epidural infusion of bupivacaine plus fentanyl administered after initiation of epidural labor analgesia with fentanyl. Specifically, we evaluated whether there is an increase in motor block or an increased time to request for further analgesic medication. Fifty-one laboring primigravid women at <5 cm cervical dilation who requested epidural analgesia were enrolled. After a 3-mL epidural test dose of 1.5% lidocaine with epinephrine (5 microg/mL), patients received fentanyl 100 microg via the epidural catheter. They then randomly received either an infusion (10 mL/h) of 0.0625% bupivacaine with fentanyl (3 microg/mL) or an infusion of preservative-free saline. After the administration of the initial analgesic, pain scores and side effects were recorded for each patient at 10, 20, and 30 min, every 30 min thereafter, and at the time of request for additional analgesic medication, by an observer blinded to the technique used. There were no demographic differences between the two groups. The mean duration of analgesia (time from initial dose to request for additional analgesia) was increased in the group that received a continuous infusion of bupivacaine and fentanyl compared with the Saline group (198 +/- 86 vs 145 +/- 50 min; P < 0.009). Side effects were similar between the two groups. No patient in either group experienced any detectable motor block. Fourteen patients chose to ambulate in the Saline group, and 12 patients chose to ambulate in the Infusion group. In early laboring patients, a continuous infusion of 0.0625% bupivacaine infusion with fentanyl (3 microg/mL) prolonged the duration until top-up was required, after epidural fentanyl 100 microg after a lidocaine and epinephrine test dose, and did not cause any clinically detectable motor block.

IMPLICATIONS

A 0.0625% bupivacaine and fentanyl (3 microg/mL) infusion, when added to epidural fentanyl (100 microg), prolongs the analgesic duration without increasing motor block in women in early labor.