Ein neues Gerät zur patientenkontrollierten intranasalen Analgesie

INTRODUCTION: It has been demonstrated that intranasal opioid titration has a rapid onset of action and can provide satisfactory management of postoperative pain [10, 12, 14]. In these studies the intranasal titration was carried out by the investigator. Self-administration of an opioid intranasally by patients requires a spray bottle with safety precautions of an equivalent standard to those offered by an intravenous PCA device. We describe a device for patient-controlled intranasal analgesia (PCINA) that meets these safety requirements. METHODS: The Baxter PCA on demand system consists of a mechanically driven infusor, a flow restrictor, and a patient control module for bolus administration. The flow restrictor provides a flow rate of 5 ml/h or 2 ml/h. This Baxter intravenous PCA system has been subjected to a slight modification to adapt it for PCINA. The patient control module has a bolus volume of 0.5 ml and in this modification it is attached, instead of to an intravenous line, to a narrow, 26-gauge plastic cannula with the needle tip removed (Fig. 1). To check the accuracy of the volume delivered, three PCINA devices with a flow rate of 5 ml/h (filling time of 6 min for the 0.5-ml bolus volume) and three PCINA devices with a flow rate of 2 ml/h (filling time of 15 min for the 0.5-ml bolus volume) were examined at defined time intervals. The PCINA devices were filled with distilled water and the volume demanded was immediately determined by means of a high-precision scale. Three determinations of the volumes delivered were performed. In an initial unblinded pilot observation in five orthopaedic patients, PCINA (for a 4-h period) was compared with the conventionally prescribed pain medication (for a subsequent 5-h period). For intranasal opioid administration, fentanyl (1 ml=0.05 mg) was used. At every evaluation point, pain intensity was evaluated with the aid of a 101-point numerical rating scale (0 = no pain, 100 = worst pain possible). At the end of both examination periods (PCINA/conventionally prescribed pain medication), overall patient satisfaction with the method of pain management experienced was evaluated (graded: very good, good, satisfactory, bad, very bad, not acceptable). RESULTS: The volumes delivered from the three PCINA devices with a flow rate of 5 ml/h (PCINA device 6') and from the three PCINA devices with a flow rate of 2 ml/h (PCINA device 15') are presented in Fig. 4. The subjective pain intensities measured with the 101-point numerical rating scale are demonstrated in Fig. 5. The patients used 0.28+/-0.097 mg fentanyl (0.15-0.45 mg) during the 4-h period of PCINA. No patients had any difficulty using the PCINA device. No technical problems arose with any of the devices. No patient complained of intranasal pain or burning during or after nasal administration. At the end of the study overall patient satisfaction with PCINA was judged as very good (2 patients), good 2 patients) or satisfactory (1 patient). The relief obtained with the customarily prescribed pain medication was judged as satisfactory (1 patient) or bad (4 patients). CONCLUSION: We conclude that the PCINA device presented fulfils the PCA device safety requirements. The bolus volume delivered by the device is precise and follows the manufacturer's specifications for flow rate and bolus volume. Initial.     

Tuberous sclerosis: characteristics at CT and MR imaging

Computed tomography (CT) and magnetic resonance (MR) imaging findings were reviewed in 26 patients with tuberous sclerosis. All patients underwent CT; 16 patients underwent both. The CT features included subependymal nodules in 25 of 26 patients (96%) and calcifications in 23 of 26 (88%). Parenchymal hamartomas (cortical tubers) were seen in 23 of 26 patients (88%). These lesions had less attenuation than surrounding brain in 16 of 26 patients (62%) and were calcified in 14 of 26 patients (54%). Contrast enhancement of a lesion, indicating a subependymal giant cell astrocytoma, occurred in three of 26 patients (12%). The MR imaging characteristics included subependymal nodules (periventricular nodules) of intermediate signal intensity in ten of the 16 patients (63%). Parenchymal hamartomas, demonstrated in 15 of the 16 patients (94%), usually exhibited long T1 and T2 relaxation characteristics. The pattern was noted to be reversed in the two newborn patients (13%). One parent demonstrated a forme fruste at CT but had a normal MR image.     

Responsiveness of human male volunteers to immunization with ovine follicle stimulating hormone vaccine: results of a pilot study

A study of 140 days duration was performed to examine if human male volunteers (n = 5) respond to ovine follicle stimulating hormone (oFSH) immunization (administered adsorbed on Alugel on days 1, 20, 40 and 70) by producing antibodies capable of both binding and neutralizing bioactivity of human FSH. The kinetics of antibody production for both the immunogen (oFSH) and the cross-reactive antigen (hFSH) were essentially similar. The volunteers responded only to the first two immunizations. The boosters given on days 40 and 70 were ineffective, probably because of the presence of substantial amounts of circulating antibody to oFSH. Of the antibodies generated to oFSH, 25-45% bound hFSH with a mean binding affinity of 0.65 x 10(9) +/- 0.53 M(-1). The binding capacities at the time of high (30-80 days of immunization) and low (>110 days) titres were 346 +/- 185 and 10.5 +/- 5.8 ng hFSH/ml respectively. During the period of high titre, free serum FSH (value in normal males 1-5 ng/ml) was not monitorable. A 50 microl aliquot of the antiserum obtained from different volunteers between days 30 and 80 and on day 140 blocked binding of (125)I-labelled hFSH to its receptor by 82 +/- 9.7 and 53 +/- 12.2% respectively. The antibody produced was specific for FSH, and no significant change in the values of related glycoprotein hormones (luteinizing hormone/testosterone and thyroid stimulating hormone/thyroxine) were recorded. Seminal plasma transferrin, a marker of Sertoli cell as well as of seminiferous tubular function, showed marked reduction (30-90%) following immunization with oFSH. Considering that endogenous FSH remained neutralized for approximately one sperm cycle only (65 days), the reduction in sperm counts (30-74%) exhibited by some volunteers is encouraging. Immunization with oFSH did not result in any significant changes in haematology, serum biochemistry or hormonal profiles. There was no production of antibodies capable of interacting with non- specific tissues. It is concluded that it should be possible to obtain a sustained long-term blockade of endogenous FSH action in men by using oFSH as an immunogen. This is a prerequisite for obtaining significant reduction in the quality and quantity of spermatozoa produced, thus leading to infertility.      

Effect of AT1 receptor blockade on intermittent hypoxia-induced endothelial dysfunction

Chronic intermittent hypoxia (CIH) raises arterial pressure, impairs vasodilator responsiveness, and increases circulating angiotensin II (Ang II); however, the role of Ang II in CIH-induced vascular dysfunction is unknown. Rats were exposed to CIH or room air (NORM), and a subset of these animals was treated with losartan (Los) during the exposure period. After 28 days, vasodilatory responses to acetylcholine or nitroprusside were measured in isolated gracilis arteries. Superoxide levels and Ang II receptor protein expression were measured in saphenous arteries. After 28 days, arterial pressure was increased and acetylcholine-induced vasodilation was blunted in CIH vs. NORM, and this was prevented by Los. Responses to nitroprusside and superoxide levels did not differ between CIH and NORM. Expression of AT(2)R was decreased and the AT(1)R:AT(2)R ratio was increased in CIH vs. NORM, but this was unaffected by Los. These results indicate that the blood pressure elevation and endothelial dysfunction associated with CIH is dependent, at least in part, on RAS signaling.     

Down-regulation of E-cadherin gene expression by collagen type I and type III in pancreatic cancer cell lines

E-cadherin-mediated cell-cell adhesion is reduced in epithelial tumors, which is thought to be a prerequisite to acquire invasive properties. We observed that several pancreatic carcinoma cell lines with high metastatic potential expressed normal levels of E-cadherin and possessed functional E-cadherin/catenin adhesion complexes. When the cell lines PANC-1, BxPC-3, and PaTu8988s were cultured either on type I or type III collagen, E-cadherin gene expression was repressed, and E-cadherin and catenin protein concentrations were reduced. In contrast, growth on fibronectin and collagen type IV had no influence. Collagen type I- or type III-dependent reduction of E-cadherin expression led to decreased cell-cell adhesion, increased proliferation, and migratory activity as well as morphological transformation. Overexpression of activated c-Src in PANC-1 cells mimicked collagen-induced E-cadherin down-regulation and changed the elevated cell proliferation and migration. Conversely, treatment of cells with the Src-inhibitors PP1 or herbimycin A resulted in complete suppression of collagen type I-induced E-cadherin decrease. Our data demonstrate that specific collagens are able to promote metastatic behavior by down-regulation of E-cadherin gene expression in a Src-kinase-dependent manner. This points toward a novel mechanism for substrate-dependent signaling and underlines the significance of extracellular matrix environment for tumor growth and invasiveness.     

Teenage mothering, admission to hospital, and accidents during the first 5 years

One thousand and thirty-one singleton children of teenage mothers were compared with 10 950 singleton children of older mothers in a national longitudinal cohort study. Children born to teenage mothers and living with them during the first 5 years were more liable to hospital admissions, especially after accidents and for gastroenteritis, than were children born to and living with older mothers. Frequent accidents, poisoning, burns, and superficial injuries or lacerations were more often reported by teenage mothers. The association of teenage mothering with greater likelihood that children would have accidents or be admitted to hospital remained highly significant even after controlling for social and biological confounding influences. Although in part a marker for adverse socioeconomic circumstances, low maternal age appears to be a health hazard for children.     

Time course of intermittent hypoxia-induced impairments in resistance artery structure and function

We previously demonstrated that chronic exposure to intermittent hypoxia (CIH) impairs endothelium-dependent vasodilation in rats. To determine the time course of this response, rats were exposed to CIH for 3, 14, 28, or 56 days. Then, we measured acetylcholine- and nitroprusside-induced vasodilation in isolated gracilis arteries. Also, we measured endothelial and inducible nitric oxide synthase, nitrotyrosine, and collagen in the arterial wall and urinary isoprostanes. Endothelium-dependent vasodilation was impaired after 2 weeks of CIH. Three days of CIH was not sufficient to produce this impairment and longer exposures (i.e. 4 and 8 weeks) did not exacerbate it. Impaired vasodilation was accompanied by increased collagen deposition. CIH elevated urinary isoprostane excretion, whereas there was no consistent effect on either isoform of nitric oxide synthase or nitrotyrosine. Exposure to CIH produces functional and structural deficits in skeletal muscle resistance arteries. These impairments develop within 2 weeks after initiation of exposure and they are accompanied by systemic evidence of oxidant stress.     

AN ATYPICAL CASE OF ATYPICAL PNEUMONIA

SUMMARY A 23-year-old man, previously fit and well, presented with an atypical pneumonia, associated with microangiopathic anaemia, thrombocytopenia, rhabdomyolysis and renal impairment. Despite administration of intravenous fluids and antibiotics, his condition rapidly deteriorated, and the possibility of an aggressive connective tissue disorder was raised. Thus he was treated with high-dose oral steroids and plasma exchange until autoantibodies were shown to be negative. At this stage it transpired that the patient had swallowed water from a stream three weeks earlier, and leptospira antibody titres were subsequently found to be elevated. Antibiotics were continued, and after a protracted course he made a full recovery. Leptospirosis should be remembered as a rare cause of atypical pneumonia, particularly if there is associated hepatic or renal impairment.     

Salmonella and fecal coliforms in cinnamon (Cinnamomum cassia Blume and Cinnamomum zeylanicum Nees) sold in the city of Florian polis,Santa Catarina,Brazil

The microbiological quality of a hundred samples of ten differents commercial brands of a ground cinnamon (Cinnamomum cassia Blume and Cinnamomum zeylanicum Nees) from supermarkets in the city of Florianópolis, Brazil, was assessed. Salmonella and fecal coliforms were determined. Results were negative for Salmonella Fecal coliforms values ranged from <3 to 2,400 MPN per g. 63% of the samples showed values from <3 MPN per g; 34% showed values ranging front 3 to 100 MPN per g, these being the legal acceptable values; 3% showed values >100 MPN per g. Fecal coliforms were detected in 37% of the cinnamon samples.     

Benign adrenal lesions mimicking malignancy on MR imaging: report of two cases

Two cases of nonmalignant adrenal masses with prolonged T2 relaxation time and increased adrenal/liver signal ratios are reported. These two cases, one a functioning adenoma with small areas of hemorrhage and the other tuberculosis, emphasize that increased signal intensity in an adrenal mass on T2-weighted images is not always due to malignancy or a pheochromocytoma. While the signal characteristics of an adrenal mass are useful in distinguishing malignancy or pheochromocytoma from benign adenomas, other studies (such as computed tomography for the detection of hemorrhage), clinical evaluation, and percutaneous biopsy remain useful in the investigation of an adrenal mass.