The role of dopamine in the locomotor stimulant effects and tolerance to these effects of caffeine.

Current evidence indicates that the acute locomotor stimulant effects of caffeine involve dopamine (DA) receptor activation; however, few studies have investigated the role of DA receptors in mediating the development of tolerance to caffeine. Therefore, the present study was designed to determine the degree to which DA receptors mediate the development of tolerance to the locomotor stimulant effects of caffeine. Caffeine was examined alone and in combination with haloperidol (HAL), GBR 12909, nisoxetine and fluoxetine. HAL dose-dependently and completely blocked the acute effects of caffeine on locomotor activity, and the highest dose of GBR 12909 enhanced the effects of caffeine. Neither nisoxetine nor fluoxetine altered the effects of caffeine. HAL was infused via osmotic pumps (0.1 mg/kg/day) during a 14-day regimen of chronic caffeine administered in a caffeinated drinking solution ( approximately 136 mg/kg/day). HAL did not block the development of tolerance to the locomotor stimulant effects of caffeine, but did impair the recovery from tolerance following withdrawal of caffeine. [3H]SCH 23390 (DA D(1)) binding sites were downregulated in the nucleus accumbens and striatum and were upregulated in the prefrontal cortex of caffeine-treated vs. control rats; however, the affinity of [3H]SCH 23390 for these binding sites was unaltered. There were no differences between the caffeine-treated and control rats in number or affinity of [3H]spiperone (DA D(2)) binding sites. These results suggest that, although HAL did not alter the development of tolerance to caffeine, changes in DA D(1) receptors could be one component of the mechanism underlying caffeine-induced tolerance.

Parametric evaluation of the development of sensitization to the effects of morphine on locomotor activity.

Animals repeatedly administered drugs of abuse often become more sensitive to their effects. It has been proposed that this behavioral sensitization may serve as a useful model for changes that may underlie the etiology and maintenance of drug-seeking behavior. This study was designed to determine systematically some of the conditions of drug exposure under which sensitization occurs to morphine-induced stimulation of locomotor activity. Groups of rats (n=8 per group) were exposed to a regimen of intermittent morphine or saline injections for 1--4 days and tested at later time points with morphine or saline. The amount of behavioral sensitization observed was related to the number of drug exposures, but not to the dose of morphine used during drug exposures. Sensitization to morphine persisted for as long as 3 months and was completely blocked when naltrexone was administered with the test dose of morphine after the final morphine exposure. Administration of naltrexone with morphine during the exposure regimen did not alter the development of behavioral sensitization. These results indicate a robust behavioral sensitization to morphine that appears to be influenced in an orderly manner within a narrow window of the drug exposure conditions.

Ear temperature measurements in healthy children using the arterial heat balance method.

This study was undertaken to determine the upper limit of normal ear temperatures, defined as the 95th percentile for infants, children, and adolescents, using the arterial heat balance method for measuring ear temperatures. Ear temperatures were measured in 62 infants, 0-2 months of age; 346 children, 3-47 months; 226 children, 48-119 months; and 172 adolescents, 120-227 months using the LighTouch Pedi-Q (Exergen Corp, Watertown, MA) ear thermometer. The 95th percentiles for the four age groups were 100.1 degrees F (37.8 degrees C), 100.3 degrees F (37.9 degrees C), 99.8 degrees F (37.7 degrees C), and 99.8 degrees F (37.7 degrees C), respectively. Temperatures above 100.0 degrees F (37.8 degrees C) using the LighTouch Pedi-Q ear thermometer should be considered elevated.

Modulation of the discriminative stimulus effects of d-amphetamine by mu and kappa opioids in squirrel monkeys.

It has been reported that the discriminative stimulus effects of cocaine in squirrel monkeys can be potentiated by mu opioid agonists and attenuated by kappa opioid agonists. The purpose of this study was to extend these observations by examining the effects of mu and kappa opioids agonists on the discriminative stimulus effects of d-amphetamine (AMPH). Five squirrel monkeys were trained to discriminate 0.3 mg/kg of AMPH (i.m.) from saline using a stimulus termination/avoidance task. AMPH and cocaine substituted dose dependently for the AMPH training stimulus in all five monkeys. The AMPH training dose was completely antagonized by 0.1 mg/kg of the D1 dopamine antagonist SCH 39166. When administered alone, the kappa agonist U69,593 substituted partially or completely for AMPH in four of five monkeys, the kappa agonist enadoline substituted completely for AMPH in two of five monkeys, and morphine substituted completely for AMPH in one monkey. In all five monkeys, pretreatment with some doses of U69,593 or enadoline attenuated the discriminative stimulus effects of AMPH; however, some doses of U69,593 and enadoline also potentiated the effects of AMPH in at least two monkeys. Morphine pretreatment potentiated the discriminative stimulus effects of AMPH in three monkeys and either attenuated or did not alter these effects in two monkeys. Morphine pretreatment did not significantly alter the discriminative stimulus effects of cocaine except in one monkey. These data indicate large individual differences in the abilities of mu and kappa opioid agonists to alter the discriminative stimulus effects of AMPH.

Differential antagonism of the rate-decreasing effects of kappa-opioid receptor agonists by naltrexone and norbinaltorphimine.

Eight kappa-opioid receptor agonists were examined for their effects in squirrel monkeys responding under a fixed interval 3-min schedule of stimulus termination. Six of these kappa-opioid receptor agonists decreased dose-dependently the total number of responses and with an order of potency consistent with kappa-opioid receptor interaction. Three of these kappa-opioid receptor agonists, bremazocine, U69,593 [[(5a,7a,8b)-(+)-N-[7-(1-pyrrolidinyl)-1-oxaspiro(4,5)dec-8-yl)] benzeneacetamide] and enadoline, were evaluated following pretreatment with 1.0 mg/kg of naltrexone or 3.0 mg/kg of norbinaltorphimine. The effects of the three agonists were antagonized significantly by naltrexone, but only those of bremazocine and U69,593 were antagonized significantly by norbinaltorphimine. Statistical analysis of the data averaged over six monkeys revealed that naltrexone was significantly more potent than norbinaltorphimine at antagonizing enadoline and U69,593, but naltrexone and norbinaltorphimine were equipotent at antagonizing bremazocine. Moreover, naltrexone was 8-fold more potent at antagonizing U69,593 and enadoline than at antagonizing bremazocine. These results suggest that under these conditions the effects of U69,593 and enadoline may be mediated, in part, by a different receptor population, perhaps a subtype of kappa-opioid receptors, from the one that mediates the effects of bremazocine.

Comparison of ear to rectal temperature measurements in infants and toddlers.

The purpose of this study was to compare arterial heat balance ear temperature measurements to rectal temperatures in infants and children and to determine the ability of the ear thermometer being tested to detect fever. From 12/95 to 2/96, 1,175 pairs of ear and rectal temperature measurements were prospectively obtained from 140 infants and toddlers. The mean rectal temperature was 37.58 degrees C (sd = 0.68) and the mean ear temperature was 37.60 degrees C (sd = 0.85). However, at the low end of the rectal temperature scale, ear temperatures tended to be higher, and at the high end of the rectal temperature scale, ear temperatures tended to be lower. There were 292 readings with a rectal temperature > or = 38.0 degrees C and in 204 (70%) the ear temperature was also > or = 38.0 degrees C. A retrospective analysis of 53 children who became febrile in hospital (ear or rectal temperature > or = 38.0 degrees C) showed that fever was detected first by rectal measurement in seven, by ear measurement in 31 (59%), and by both in 15 (28%). These data indicate that, on the average, rectal and ear temperature measurements are not different. Fever that developed in children after hospitalization was more likely to be first detected by ear than by rectal measurement.

Differential involvement of dopamine in mediating the discriminative stimulus effects of low and high doses of caffeine in rats.

The hypothesis that low and high doses of caffeine produce effects that are differentially mediated by dopamine (DA) receptor mechanisms was investigated in rats trained to discriminate either 10 or 56 mg/kg of caffeine from saline. Rats trained to discriminate 56 mg/kg of caffeine acquired the discrimination in an average of 74 sessions, whereas rats trained to discriminate 10 mg/kg of caffeine required an average of 108 sessions. The DA D1 receptor agonist SKF 81297 and the DA D2 receptor agonist R(-)-propylnorapomorphine (NPA) generalized partially (50-75%) in rats trained to discriminate 10 mg/kg of caffeine, but produced predominantly saline-appropriate responding (< 40%) in rats trained to discriminate 56 mg/kg of caffeine. When SKF 81297 and NPA were combined, stimulus generalization was no greater than it was when either agonist was tested alone. The DA uptake inhibitors cocaine and GBR 12909 produced predominantly saline-appropriate responding in both groups of rats. Neither the DA D1 receptors antagonists SCH 23390 and SCH 31966, nor the DA D2 receptor antagonists eticlopride and sulpiride, generalized in rats trained to discriminate 10 or 56 mg/kg of caffeine. When administered in combination with caffeine, both the DA D1 and DA D2 antagonists antagonized completely the discriminative stimulus effects of the low training dose of caffeine, but did not alter the discriminative stimulus effects of the high training dose. These results suggest that the discriminative stimulus effects of 10 mg/kg of caffeine, but not 56 mg/kg of caffeine, are dependent on, but not limited to, DA D1 and D2 receptor mechanisms.

Lack of NMDA receptor involvement in caffeine-induced locomotor stimulation and tolerance in rats.

The involvement of NMDA-type glutamate receptors in caffeine's locomotor stimulant effects and the development of tolerance to these effects was examined in rats. Caffeine and the noncompetitive NMDA receptor antagonists, MK-801 and phencyclidine (PCP), were examined alone and in combination. Caffeine produced a biphasic dose-effect curve. Both MK-801 and PCP increased locomotor activity at the highest doses tested. MK-801 and PCP shifted the caffeine curve upward, but only with the highest doses that increased locomotor activity when given alone. For the tolerance experiment, osmotic pumps containing either MK-801 or nothing at all and were implanted in rats that were given either caffeinated or drug-free tap water to drink. All rats drinking caffeine showed tolerance to its locomotor stimulant effects, whereas rats drinking drug-free tap water did not. Chronic infusion of MK-801 (0.1 and 0.3 mg/kg/day) failed to block the development of tolerance to caffeine. The 0.3 mg/kg/day infusion of MK-801 appeared to slightly delay the development of tolerance to caffeine, but this effect was probably due to the locomotor stimulant effects of this infused dose of MK-801 alone. These data provide no evidence that NMDA-type glutamate receptors play a crucial role in mediating caffeine's locomotor stimulant effects or tolerance to these effects.

The role of serotonergic receptors in the effects of mu opioids in squirrel monkeys responding under a titration procedure.

This experiment was conducted to determine whether drugs acting on brain serotonin modulate the effects of the mu opioid, morphine, as measured by the squirrel monkey shock titration procedure and, if so, whether serotonergic modulation is mediated via specific 5HT receptor subtypes. Under this procedure, electric shock was delivered to the monkey's tail and scheduled to increase once every 15 s from 0.01 to 2.0 mA in 30 steps. Five responses on a lever during the 15-s shock period terminated the shock for 15 s, after which the shock resumed at the next lower intensity. The intensity below which monkeys maintained shock 50% of the time (median shock level or MSL) and rate of responding (RR) in the presence of shock were determined under control conditions and after administration of morphine alone and in combination with various serotonergic compounds. Morphine increased median shock level and decreased rate of responding in a dose-dependent manner. These effects of morphine was attenuated by the 5HT1A receptor agonists, 8-OH-DPAT [(+)-8-hydroxy-2(di-n-propylamino tetralin HBr] and ipsapirone. The effects of morphine were not altered by the 5HT1A receptor antagonist, NAN-190 [1-(2-methoxyphenyl-4-[4-(2-phthalimido) butyl] piperazine HBr], and 5HT2 receptor antagonist, ketanserin, the 5HT3 receptor antagonist, MDL 72222 [3-tropanyl-3,5-dichlorobenzoate], the alpha 2 adrenergic antagonist, yohimbine, or the alpha2 adrenergic agonist, clonidine. These results suggest that 5HT1A receptors may be involved in the effects of morphine in the shock titration procedure, whereas 5HT2, 5HT3 and alpha 2 adrenergic receptors do not appear to play a role in morphine's effects in this procedure.

The role of serotonin in the effects of opioids in squirrel monkeys responding under a titration procedure: I. Kappa opioids.

The goal of the present study was to determine whether the serotonin (5-HT) system is involved in the effects of kappa opioids as measured with the squirrel monkey shock titration procedure. With this procedure, electric shock was delivered to the monkey's tail and scheduled to increase once every 15 sec from 0.01 to 2.0 mA in 30 steps. Monkeys responded under a fixed ratio 5 schedule to determine the level at which shock intensity was maintained. The intensity below which monkeys maintained shock 50% of the time, or the median shock level (MSL), and the rate of responding in the presence of shock (RR) were determined after the administration of saline and all drug combinations. The kappa opioids U50,488 and spiradoline increased MSL and decreased RR in a dose-dependent manner. The effects of U50,488 and spiradoline on both RR and MSL were enhanced in all three monkeys by the 5-HT2 antagonists ketanserin and pirenperone and in one monkey by another 5-HT2 antagonist, LY 53857. The effects of U50,488, but not spiradoline, were enhanced to a lesser degree by the 5-HT1A receptor agonist 8-OH-DPAT. The effects of U50,488 but not altered by the receptor agonist DOI, the 5-HT3 receptor antagonist MDL 72222 or the alpha-1 adrenergic receptor antagonist prazosin. These results suggest that the effects of kappa opioids in the shock titration procedure probably involve serotonergic mechanisms that are modulated via 5-HT2 and, perhaps, 5-HT1A receptors. Moreover, these interactions probably reflect nonspecific decreases in RR rather than alterations in the antinociceptive effects of kappa opioids.

Febrile infants at low risk for serious bacterial infection--an appraisal of the Rochester criteria and implications for management. Febrile Infant Collaborative Study Group.

OBJECTIVE: Prospective studies were conducted to test the hypothesis that infants unlikely to have serious bacterial infections (SBI) can be accurately identified by low risk criteria. METHODS: Febrile infants (rectal T > or = 38 degrees C) < or = 60 days of age were considered at low risk for SBI if they met the following criteria: 1) appear well; 2) were previously healthy; 3) have no focal infection; 4) have WBC count 5.0-15.0 x 10(9) cells/L (5000-15,000/mm3), band form count < or = 1.5 x 10(9) cells/L (< or = 1500/mm3), < or = 10 WBC per high power field on microscopic examination of spun urine sediment, and < or = 5 WBC per high power field on microscopic examination of a stool smear (if diarrhea). The recommended evaluation included the culture of specimens of blood, cerebrospinal fluid, and urine for bacteria. Outcomes were determined. The negative predictive values of the low risk criteria for SBI and bacteremia were calculated. RESULTS: Of 1057 eligible infants, 931 were well appearing, and, of these, 437 met the remaining low risk criteria. Five low risk infants had SBI including two infants with bacteremia. The negative predictive value of the low risk criteria was 98.9% (95% confidence interval, 97.2% to 99.6%) for SBI, and 99.5% (95% confidence interval, 98.2% to 99.9%) for bacteremia. CONCLUSIONS: These data confirm the ability of the low risk criteria to identify infants unlikely to have SBI. Infants who meet the low risk criteria can be carefully observed without administering antimicrobial agents.

Prevention of central venous catheter-related coagulase-negative staphylococcal sepsis in neonates.

A randomized, double-blind, controlled trial was conducted to determine whether vancomycin added to parenteral alimentation solution given via a central venous catheter would decrease the incidence of catheter-related coagulase-negative staphylococcal sepsis. Seventy infants with a central venous catheter (CVC) in place were randomly selected to receive total parenteral nutrition--either the standard solution or a solution containing 25 micrograms of vancomycin per milliliter. Catheter-related sepsis was defined as the isolation of the same bacterial species from specimens of both peripheral and CVC blood with the concentration of bacteria at least tenfold greater in the specimen obtained from the CVC. Specimens from the CVCs were cultured on removal of the catheters to determine colonization. The colonization of catheters by coagulase-negative staphylococci was reduced from 40% to 22% (p = 0.03) in the vancomycin group; catheter-related sepsis was reduced from 15% to no cases (p = 0.004). Fewer infants required CVC reinsertion in the vancomycin-treated group (p = 0.02), who also regained birth weight earlier (13.4 vs 17.1 days (p = 0.014)). Adverse effects of vancomycin infusion were not observed. We conclude that vancomycin added to the solution used for total parenteral nutrition effectively reduces catheter-related sepsis in the neonatal intensive care unit and offers other potential benefits such as the need for fewer catheters and earlier weight gain. However, we do not recommend widespread implementation of this technique until there are data regarding the emergence of vancomycin-resistant organisms.

Serotonin involvement in the discriminative stimulus effects of mu and kappa opioids in rats.

The role of serotonin (5-HT) in the discriminative stimulus effects of opioids was examined using a two-lever, food-reinforced drug discrimination procedure. The effects of the 5-HT(1A) full agonist 8-OH-DPAT, the 5-HT(1A) partial agonist buspirone and the 5-HT(2) antagonist ketanserin were evaluated in rats trained to discriminate the mu opioid agonist morphine, or the kappa opioid agonist U50, 488 from saline. In rats trained to discriminate 5.6mg/kg of morphine from saline, morphine dose-dependently substituted (produced >/= 80% morphine-appropriate responding) for the morphine stimulus. In contrast, U50,488, 8-OH-DPAT and ketanserin did not substitute for morphine, and buspirone produced only a small degree of substitution (approx. 40% morphine-appropriate responding). When administered in combination with morphine, 8-OH-DPAT, but not buspirone and ketanserin, attenuated the discriminative stimulus effects of higher doses of morphine. In rats trained to discriminate 5.6mg/kg of U50, 488 from saline, U50, 488 dose-dependently substituted for the U50, 488 stimulus. When administered alone, 8-OH-DPAT and buspirone partially substituted (produced between 40% and 79% U50, 488-appropriate responding) for the U50,488 stimulus, whereas morphine and ketanserin did not substitute for U50,488. The opioid antagonist naltrexone failed to antagonize the effects of 8-OH-DPAT and buspirone suggesting that the effects of these drugs in U50,488-trained rats were not mediated by opioid receptors. When administered in combination with U50,488, 8-OH-DPAT, but not buspirone or ketanserin, attenuated the discriminative stimulus effects of the training dose of U50,488. These results suggest that the 5-HT system is involved in the discriminative stimulus effects of both morphine and U50,488, although the exact nature of this 5-HT involvement is not clear.

Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research.

STUDY OBJECTIVE: To develop guidelines for the care of infants and children from birth to 36 months of age with fever without source. PARTICIPANTS AND SETTING: An expert panel of senior academic faculty with expertise in pediatrics and infectious diseases or emergency medicine. DESIGN AND INTERVENTION: A comprehensive literature search was used to identify all publications pertinent to the management of the febrile child. When appropriate, meta-analysis was used to combine the results of multiple studies. One or more specific management strategies were proposed for each of the decision nodes in draft management algorithms. The draft algorithms, selected publications, and the meta-analyses were provided to the panel, which determined the final guidelines using the modified Delphi technique. RESULTS: All toxic-appearing infants and children and all febrile infants less than 28 days of age should be hospitalized for parenteral antibiotic therapy. Febrile infants 28 to 90 days of age defined at low risk by specific clinical and laboratory criteria may be managed as outpatients if close follow-up is assured. Older children with fever less than 39.0 C without source need no laboratory tests or antibiotics. Children 3 to 36 months of age with fever of 39.0 C or more and whose WBC count is 15,000/mm3 or more should have a blood culture and be treated with antibiotics pending culture results. Urine cultures should be obtained from all boys 6 months of age or less and all girls 2 years of age or less who are treated with antibiotics. CONCLUSION: These guidelines do not eliminate all risk or strictly confine antibiotic treatment to children likely to have occult bacteremia. Physicians may individualize therapy based on clinical circumstances or adopt a variation of these guidelines based on a different interpretation of the evidence.