Can adjuncts to bowel preparation for colonoscopy improve patient experience and result in superior bowel cleanliness? A systematic review and meta-analysis.

BACKGROUND: Bowel preparation for colonoscopy is often poorly tolerated due to poor palatability and adverse effects. This can negatively impact on the patient experience and on the quality of bowel preparation. This systematic review and meta-analysis was carried out to assess whether adjuncts to bowel preparation affected palatability, tolerability and quality of bowel preparation (bowel cleanliness). METHODS: A systematic search strategy was conducted on PubMed, MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews to identify studies evaluating adjunct use for colonoscopic bowel preparation. Studies comparing different regimens and volumes were excluded. Specific outcomes studied included palatability (taste), willingness to repeat bowel preparation, gastrointestinal adverse events and the quality of bowel preparation. Data across studies were pooled using a random-effects model and heterogeneity assessed using I2-statistics. RESULTS: Of 467 studies screened, six were included for analysis (all single-blind randomised trials; n = 1187 patients). Adjuncts comprised citrus reticulata peel, orange juice, menthol candy drops, simethicone, Coke Zero and sugar-free chewing gum. Overall, adjunct use was associated with improved palatability (mean difference 0.62, 95% confidence interval 0.29-0.96, p < 0.001) on a scale of 0-5, acceptability of taste (odds ratio 2.75, 95% confidence interval: 1.52-4.95, p < 0.001) and willingness to repeat bowel preparation (odds ratio 2.92, 95% confidence interval: 1.97-4.35, p < 0.001). Patients in the adjunct group reported lower rates of bloating (odds ratio 0.48, 95% confidence interval: 0.29-0.77, p = 0.003) and vomiting (odds ratio 0.47, 95% confidence interval 0.27-0.81, p = 0.007), but no difference in nausea (p = 0.10) or abdominal pain (p = 0.62). Adjunct use resulted in superior bowel cleanliness (odds ratio 2.52, 95% confidence interval: 1.31-4.85, p = 0.006). Heterogeneity varied across outcomes, ranging from 0% (vomiting) to 81% (palatability), without evidence of publication bias. The overall quality of evidence was rated moderate. CONCLUSION: In this meta-analysis, the use of adjuncts was associated with better palatability, less vomiting and bloating, willingness to repeat bowel preparation and superior quality of bowel preparation. The addition of adjuncts to bowel preparation may improve outcomes of colonoscopy and the overall patient experience.

Real-World Effectiveness of Pharmaceutical Smoking Cessation Aids: Time-Varying Effects.

BACKGROUND: There are a limited number of studies that have examined the real-world effectiveness of smoking cessation aids and relapse longitudinally in population-representative samples. This study examines the association between use of nicotine gum, patch, bupropion, and varenicline and time to relapse as well as any changes in the association with increased length of abstinence. METHODS: Data of 1821 current adult smokers (18+) making their first serious quit attempt were compiled from 4504 individuals enrolled in the Ontario Tobacco Survey, a representative telephone survey of Ontario adults, which followed smokers every 6 months for up to 3 years. Use of cessation aids at the time of initial report of a quit attempt was analyzed. A flexible parametric survival model was developed to model length of abstinence, controlling for potential confounders. RESULTS: The best fit model found knots at 3, 13, 43, and 212 days abstinent, suggesting different rates of relapse in the periods marked by those days. Use of the patch and varenicline was associated with lower rates of relapse, but no positive effect was found for bupropion or nicotine gum. The effectiveness of the patch reversed in effect after the first month of abstinence. CONCLUSIONS: This study is one of few reports of long-term quitting in a population-representative sample and demonstrates that the effectiveness of some pharmacological cessation aids (the patch and varenicline can be seen in a population sample). Previous failures in real-world studies of the effectiveness of smoking cessation aids may reflect differences in the products individuals use and differences in the timing of self-reported cessation. IMPLICATIONS: While a large number of randomized controlled trials have shown the efficacy of many pharmaceutical smoking cessation aids, evidence of their effectiveness in observational studies in the real world is ambiguous. This study uses a longitudinal cohort of a representative sample of smokers to show that the effectiveness of pharmaceutical cessation aids can be demonstrated in real-world use situations, but effectiveness varies by product type and has time-varying effects.

A Combined Utilization of Plasdone-S630 and HPMCAS-HF in Ziprasidone Hydrochloride Solid Dispersion by Hot-Melt Extrusion to Enhance the Oral Bioavailability and No Food Effect.

The purpose of this study was to research a novel combination of Plasdone-S630 and HPMCAS-HF as hot-melt carrier used in ziprasidone hydrochloride for enhanced oral bioavailability and dismissed food effect. Ziprasidone hydrochloride solid dispersion (ZH-SD) was prepared by hot-melt extrusion technique, and its optimized formulation was selected by the central composite design (CCD), which was characterized for powder X-ray diffraction (PXRD), fourier transform infrared spectroscopy (FTIR), in vitro dissolution study, and stability study. Finally, the in vivo study in fasted/fed state was carried out in beagle dogs. Based on PXRD analysis, HME technique successfully dispersed ziprasidone with a low crystallinity hydrochloride form in the polymers. According to the analysis of FTIR, hydrogen bonds were formed between drug and polymers during the process of HME. Without any noticeable bulk, crystalline could be found from the micrograph of ZH-SD when analyzed the result of scanning electron microscope (SEM). Pharmacokinetics studies indicated that the bioavailability of ZH-SD formulation had no significant difference in fasted and fed state, and the Cmax and AUC of ZH-SD were two fold higher than Zeldox® in fasted state. This result indicated that ziprasidone has achieved a desired oral bioavailability in fasted state and no food effect.

Personalized Bioactive Nasal Supports for Postoperative Cleft Rhinoplasty.

PURPOSE: After cleft lip and palate surgical procedures, patients often need nostril supports to help the reconstructed nostrils retain their shape during healing. Many postoperative nasal stents use a one-size-fits-all approach, in which a standard rubber tube retainer is trimmed and used to support the healing nares. The purpose of this study was to examine photogrammetry and 3-dimensional (3D) printing as a fabrication tool for postoperative patient-specific nasal supports that can be loaded with bioactive agents for localized delivery. MATERIALS AND METHODS: A "normal" right nostril injection mold was prepared from a left-sided unilateral cleft defect, and the negative-space impression was modeled using a series of photographs taken at different rotation angles with a commercial mobile phone camera. These images were "stitched" together using photogrammetry software, and the computer-generated models were reflected, joined, and digitally sculpted to generate hollow bilateral supports. Three-dimensional prints were coated with polyvinylpyrrolidone-penicillin and validated for their ability to inhibit Escherichia coli using human blood agar diffusion assays. RESULTS: The results showed that our approach had a high level of contour replication and the antibiotic coating was able to inhibit bacterial growth with a mean zone of inhibition of 15.15 ± 0.99 mm (n = 9) (P < .0001) in disc diffusion assays. CONCLUSIONS: Consumer-grade 3D printing displays potential as a fabrication method for postoperative cleft bilateral nasal supports and may support the surgically reconstructed internal contours. The results of this study suggest that such types of bioactive 3D prints may have potential applications in personalized drug-delivery systems and medical devices.

Dissolving polyvinylpyrrolidone-based microneedle systems for in-vitro delivery of sumatriptan succinate.

In-vitro permeation studies were conducted to assess the feasibility of fabricating dissolving-microneedle-array systems to release sumatriptan succinate. The formulations consisted mainly of the encapsulated active ingredient and a water-soluble biologically compatible polymer, polyvinylpyrrolidone (PVP), approved by the U.S. Food and Drug Administration (FDA). Tests with Franz-type diffusion cells and Göttingen minipig skins showed an increase of the transdermal flux compared to passive diffusion. A preparation, containing 30% by mass of PVP and 8.7mg sumatriptan, produced a delivery rate of 395±31µg/cm2h over a 7-hour period after a negligible lag time of approximately 39min. Theoretically, a 10.7cm2 microneedle-array patch loaded with 118.8mg of the drug would provide the required plasma concentration, 72ng/mL, for nearly 7h.

Efficacy of topical antibiotic administration on the inhibition of perioperative oral bacterial growth in oral cancer patients: a preliminary study.

Parenteral antibiotic prophylaxis is the current standard of therapy in clean-contaminated oral cancer surgery. Nevertheless, the incidence of surgical site infection (SSI) in oral oncological surgery is relatively high, especially in major surgery with reconstruction and tracheotomy. The aims of this study were to investigate the perioperative condition related to microorganisms in the oral cavity and to examine the efficacy of the topical administration of tetracycline in reducing the number of bacteria in the oropharyngeal fluid during intubation. The number of oral bacteria was measured during intubation in patients undergoing major oral cancer surgery. The efficacy of the topical administration of tetracycline or povidone iodine gel in reducing the bacteria was then investigated. Bacteria in the oropharyngeal fluid grew from 10(6)CFU/ml to 10(8)CFU/ml during the 3h after intubation (CFU, colony-forming units). When tetracycline was applied to the dorsum of the tongue, oral bacteria decreased immediately to 10(5)CFU/ml, and the number of bacteria in the oropharyngeal fluid was maintained below 10(7)CFU/ml for 7h. The concentration of tetracycline in the oropharyngeal fluid was extremely high for several hours after topical administration. The topical administration of tetracycline could reduce oral bacteria in patients undergoing clean-contaminated oral cancer surgery. This method is expected to be effective in the prevention of SSI.

Safety and efficacy of 0.1% clobetasone butyrate eyedrops in the treatment of dry eye in Sjögren syndrome.

PURPOSE: To study the effects of a low administration rate and low concentration (0.1%) of clobetasone butyrate eyedrops in patients with Sjögren syndrome (SS).
 METHODS: This prospective, double-masked, randomized, placebo-controlled study included 40 subjects divided into 2 treatment groups: group 1 (2% polyvinylpyrrolidone eyedrops and placebo) and group 2 (2% polyvinylpyrrolidone and 0.1% clobetasone butyrate, 1 drop BID). The treatment lasted for 30 days, with visits at enrollment, baseline, day 15, day 30, and after 15 days of treatment discontinuation. At each visit, symptoms questionnaire, tear film break-up time, corneal fluorescein stain, lissamine green stain, conjunctival impression cytology for human leukocyte antigen-DR (HLA-DR) expression, intraocular pressure (IOP) measurement, and fundus examination were performed. 
 RESULTS: No changes in IOP or fundus examination were observed in either group at each time point. Group 1 patients showed at day 30 a statistically significant amelioration of symptoms and reduction of HLA-DR expression. No changes in other parameters were detected. Group 2 patients showed at day 15 a statistically significant improvement of corneal and conjunctival stain versus baseline values and group 1 at the same time; after 30 days the symptoms score was statistically significantly better than baseline values and group 1 at the same time. The HLA-DR expression and the epithelial cells area were statistically significantly reduced versus baseline and group 1 at the same time. 
 CONCLUSIONS: Anti-inflammatory therapy is critical for the treatment of SS dry eye. Clobetasone butyrate, at low dosage, proved to be safe and effective in treating this condition.

Solid lipid extrusion with small die diameters--electrostatic charging, taste masking and continuous production.

The aim of this work was to develop a continuous solid lipid extrusion process that includes post-process milling of the extrudates. Die diameters smaller than 0.5 mm should be used for taste masking of the bitter tasting anthelmintic praziquantel. During lipid extrusion with small die diameters, electrostatic charging of the extrudates occurred. This could be avoided by adding liquid polyethylene glycol (PEG) as antistatic agent. Further, extrusion with PEG as antistatic agent was possible with small diameter down to 0.2 mm and with up to 80% praziquantel load. Dissolution of praziquantel extrudates was shown to be faster with smaller extrudate diameter due to surface enlargement. Anyhow, different praziquantel extrudates with small diameter, drug load up to 70% and PEG content up to 20%, were proven to be sufficiently taste masked in a randomised palatability study with 40 cats. Within a scale-up experiment, lipid extrusion and milling of the extrudates in a centrifugal mill afterwards were conducted continuously. Extrudates from continuous and batchwise production revealed small differences in terms of size distribution and surface habit, but were similar in drug dissolution rate.

Investigation of different formulations for drug delivery through the nail plate.

Topical therapies for nail diseases are limited by keratinized cells in the human nail plate. An optimal permeation enhancer would not only improve drug delivery through the nail plate, but would also open new possibilities for treating neighboring target sites if systemic circulation is reached. The aim of the present work was to identify permeation enhancers and to improve the understanding of physicochemical parameters that influence drug permeation. Caffeine served as the model drug, and formulations were prepared in water and 20% (v/v) ethanol/water solutions. Tested enhancers were urea, dimethyl sulfoxide (DMSO), methanol, N-acetyl-L-cysteine (NAC), docusate sodium salt (DSS), boric acid, and fungal proteins, such as hydrophobins. Permeability studies employed cadaver nails in modified Franz-type diffusion cells. The permeability coefficient of caffeine in ethanol/water was determined to be 1.56 E-08 cm/s and was improved to 2.27 E-08 cm/s by the addition of NAC. Formulations containing either methanol or DMSO showed the highest permeability coefficients in the range of 5-7.5 E-08 cm/s. Enhancers could be classified according to their permeation enhancement: methanol>class II hydrophobins>DMSO>followed by class I hydrophobins and urea. Ethanol at a concentration of 20% (v/v) in water did not influence swelling of nail samples. Hydrophobins are suggested to be efficient in drug delivery through the nail plate.

An in vitro evaluation of a novel high fluoride daily mouthrinse using a combination of microindentation, 3D profilometry and DSIMS.

OBJECTIVES: Firstly, to evaluate the in vitro anti-erosion efficacy of a new mouthrinse formulation containing 450 ppm fluoride using profilometry and microindentation. Secondly, to compare fluoride uptake by erosive lesions from two mouthrinses containing different fluoride sources using dynamic secondary ion mass spectrometry (DSIMS). METHODS: Sound human enamel was treated (60s) with mouthrinses containing different fluoride concentrations, then immersed in 1.0% citric acid pH 3.8 for either 300 s or 30 min (Studies 1 & 2 respectively). Surface roughness and erosion depth were determined profilometrically in Study 1, and surface microhardness monitored as a function of time in Study 2. Lesion rehardening was monitored following a 60 s rinse and immersion in artificial saliva for 48 h (Study 3), whilst Study 4 employed DSIMS to quantify fluoride uptake by lesions treated (60s) with rinses containing either sodium fluoride (NaF) or a NaF/Olaflur/stannous chloride combination. RESULTS: The test rinse (450 ppm fluoride) suppressed surface roughening and bulk tissue loss versus all comparators (p< 0.0001), except in the latter measure for the rinse containing 112 ppm fluoride. The test rinse significantly inhibited enamel surface softening versus the three rinses containing ≤112 ppm fluoride (as NaF) at 30 min (p<0.05), but was not statistically significantly different from the 225 ppm fluoride rinse. The test rinse conferred statistically superior lesion rehardening versus all comparators at both 24 and 48 h (p< 0.0001). DSIMS demonstrated statistically significantly higher fluoride uptake by incipient erosive lesions treated with the test rinse versus the NaF/Olaflur/stannous rinse. CONCLUSIONS: Anti-erosion efficacy was positively correlated with fluoride concentration. DSIMS showed significantly higher levels of fluoride uptake by incipient erosive lesions treated with the 450 ppm fluoride rinse versus the NaF/Olaflur/stannous rinse.

Studies on a novel combination polymer system: in vitro erosion prevention and promotion of fluoride uptake in human enamel.

OBJECTIVES: Firstly, determine the effect of pre-treating sound human enamel with a hydrosoluble combination polymer system (TriHydra™) comprising 0.20% carboxymethylcellulose, 0.010% xanthan gum and 0.75% copovidone, alone or in combination with fluoride, on in vitro erosion by citric acid. Secondly, investigate the effect of the polymers on fluoride uptake by incipient erosive lesions. METHODS: Study 1: Sound enamel specimens were treated (60s, 20°C, 150 rpm) with either (i) deionised water, (ii) polymers in deionised water, (iii) 300 mg/L fluoride or (iv) polymers in 300 mg/L fluoride. Specimen groups (n=5) were then immersed in 1.0% citric acid (pH 3.8, 300 s, 20°C, 50 rpm) and non-contact profilometry was used to determine surface roughness (Sa) and bulk tissue loss. Study 2: Incipient erosive lesions were similarly treated with (i)-(iv). Dynamic Secondary Ion Mass Spectrometry (DSIMS) was then used to determine the fluoride depth-distribution. RESULTS: Study 1: Mean±SD Sa and erosion depths for treatment groups (i)-(iv) were (a)657±243, (b)358±50, (c)206±72, (d)79±16 nm and (a)19.73±8.70, (b)2.52±1.34, (b)0.49±0.34 and (b)0.31±0.21 mm respectively (matching superscripts denote statistically equivalent groups). Study 2: Lesions treated with (iii) and (iv) exhibited similar fluoride penetration depths (∼ 60 µm). Mean fluoride intensity ratios based on F/(F+P) at 1 µm for treatment groups (i)-(iv) were (a)0.010±0.004, (a)0.011±0.004, (b)0.803±0.148 and (c)0.994±0.004 respectively. CONCLUSIONS: The combination polymer system exhibited anti-erosion efficacy in its own right. The polymer/fluoride admixture statistically significantly reduced Sa, however suppression of bulk tissue loss was not statistically significantly different versus either treatment alone. The presence of polymer appears to promote fluoride uptake by erosive lesions most noticeably in the first 6 µm.

[Preparation of Zhongjiefeng dispersible tablets].

OBJECTIVE: To prepare Zhongjiefeng dispersible tablets. METHODS: The formulation of Zhongjiefeng dispersible tablets were optimized as index of disintegration time by orthogonal design test. RESULTS: The optimized Zhongjiefeng dispersible tablets, which were prepared by selecting 16% PVPP and 3% L-HPC as disintegrants, 40% MCC as filler, can disintegrate in 3 mins. CONCLUSIONS: The above formulation is reasonable and the disintegration time is suitable, so it can provide theoretic support for industrialization.

A technique to improve the safety of laryngeal mask airway when used in lacrimal duct surgery.

BACKGROUND: Congenital obstruction of the lacrimal drainage system is present in approximately 6% of newborn. Syringing and probing is one of the common interventional modalities for this condition. Current literature states that syringing and probing is performed best with general anesthesia with tracheal intubation. We study a technique to improve the safety and efficacy of the laryngeal mask airway (LMA) in lacrimal duct surgery. METHODS: Sixty-five ASA grade I-II patients between 6 months and 10 years scheduled for syringing and probing were included after informed consent was obtained from the parents. After induction of anesthesia and confirmation of LMA position, a transparent suction catheter was inserted into the hypopharynx. Continuous suction was applied to the catheter. A total of 2-3 ml of 0.01% povidone-iodine solution was used for syringing. Staining of the catheter was regarded as a sign of patency of the duct. RESULTS: None of our patients had perioperative airway or respiratory complications. CONCLUSIONS: Based on the results of our study, we suggest that the LMA can safely be used in lacrimal duct procedures. Using 0.01% povidone-iodine as irrigation fluid further increases the margin of safety.

Anaphylaxis to polyvinylpyrrolidone after vaginal application of povidone-iodine.

A 59-year-old woman who had had several episodes of contact urticaria after hair treatment, developed anaphylaxis after vaginal application of povidone-iodine solution for disinfection. Prick tests showed wheal-and-flare responses to both povidone-iodine (0.1% aqueous) and polyvinylpyrrolidone (povidone, PVP) (0.001% aq.), but not to iodine or polyoxy-ethyrenenonylphenyl ether, both of which are also contained in povidone-iodine solution. We confirmed that basophils from her peripheral blood released considerable amounts of histamine on stimulation by PVPs. It appeared that both the shampoo and the permanent-wave solution contained polyvinylpyrrolidone N, N-dimethyl aminoethyl methacrylic acid copolymer diethyl sulphate solution and polyvinylpyrrolidone styrene-copolymer emulsion. Both these agents in the hair care products provoked an immediate skin response on prick testing. We speculate that sensitization to PVP had been established by these hair care products at a beauty parlor. She was recommended to avoid PVP-containing products and remained free from symptoms thereafter.

[Evaluation of povidone abdominal washing for prevention of peritoneal cancer cell seeding: experimental study in the rat]. / Evaluation des lavages par la polyvidone iodée dans la prévention de l'ensemencement néoplasique péritonéal: étude expérimentale chez le rat.

GOAL: The aim of the study was to evaluate the in vitro cytototoxicity of diluted povidone iodine on colon cancer cells and its in vivo antitumoral effect in a model of peritoneal carcinomatosis in the rat. METHODS: Cell cytotoxicity of a povidone iodine diluted solution was assessed, in vitro, on rat colon cancer cells (DHD/K12/PROb) and human colon cancer cells (HT29). The antitumoral effect of diluted povidone iodine washing was measured in BDIX rats after the intraperitoneal inoculation of 10(6) DHD/K12/PROb cells. Results were compared to an abdominal washing within a 9 g/l salinel solution. In one experiment, peritoneal scars and a colocolic anastomosis were performed after the injection of cancer cells. RESULTS: A short 10 min incubation of human and rat colon cancer cells with diluted povidone iodine resulted in a complete cell killing. In animals, a peritoneal washing with 1% diluted povidone iodine completely inhibited the tumor growth in parietal peritoneum. However, development of peritoneal tumor nodules was not inhibited in the omentum, in scarified peritoneum or in intestinal anastomosis. CONCLUSIONS: Despite its high in vitro efficacy, diluted povidone iodine has an incomplete effect in the prevention of peritoneal carcinomatosis, with only a partial inhibition in scarred peritoneum epiploïc area and intestinal anastomosis. In contrary, it procures a complete inhibition of tumor growth in normal peritoneum.

[Induction of posterior detachment of the vitreous body by intraoperative vitreo-syneresis with injection of water-soluble polymers (an experimental-morphological study)]. / Induktsiia zadnei otsloiki steklovidnogo tela putem intraoperatsionnogo vitreosinerezisa pri vvedenii vodorastvorimykh polimerov (éksperimental'no-morfologicheskoe issledovanie).

The capacity of water-soluble polymers (polyethylenimine, polyvinylpyrrolidone with copolymers) to induce posterior detachment of the vitreous by its rapid condensation (vitreosynerysis) was studied in experiments on 14 rabbits. Histological studies showed that water-soluble polymers specifically react forming complexes with components of the vitreous. The vitreous shrinks under the effect of polyelectrolytes (vitreosynerysis), which leads to its posterior detachment 1.5 h after injection of the polymer into the vitreous cavity: complete detachment was attained in 2 animals and partial in 8. The degree of vitreosynerysis depends on the complex-forming activity of polyelectrolytes towards the vitreous components. Polymers used in our study exerted no toxic or traction effects on the adjacent structures of the eye.

Antitumor activity of tumor necrosis factor-alpha conjugated with polyvinylpyrrolidone on solid tumors in mice.

We attempted the development of a novel polymer conjugation to further improve the therapeutic potency of antitumor cytokines compared with PEGylation for clinical application. Compared with native tumor necrosis factor (TNF)-alpha in vitro, specific bioactivities of polyvinyl-pyrrolidone (PVP)-modified TNF-alphas (PVP-TNF-alphas) were decreased by increasing the degree of PVP attachment. PVP-TNF-alpha fraction 3, Mr 101,000, had the most effective antitumor activity of the various PVP-TNF-alphas in vivo. PVP-TNF-alpha fraction 3 had >200-fold higher antitumor effect than native TNF-alpha, and the antitumor activity of PVP-TNF-alpha fraction 3 was >2-fold higher than that of MPEG-TNF-alpha (Mr 108,000), which had the highest antitumor activity among the polyethylene glycol (PEG)-conjugated TNF-alphas. Additionally, a high dose of native TNF-alpha induced toxic side effects such as body weight reduction, piloerection. and tissue inflammation, whereas no side effects were observed after i.v. administration of PVP-TNF-alpha fraction 3. The plasma half-life of PVP-TNF-alpha fraction 3 (360 min) was about 80- and 3-fold longer than those of native TNF-alpha (4.6 mm) and MPEG-TNF-alpha (122 min), respectively. The mechanism of increased antitumor effect in vivo caused the prolongation of plasma half-life and increase in stability. These results suggested that PVP is a useful polymeric modifier for bioconjugation of TNF-alpha to increase its antitumor potency, and multifunctionally bioconjugated TNF-alpha may be a potentiated antitumor agent for clinical use.

Modified procedure for implantation of subcutaneous central venous access devices in macaques (Macaca mulatta).

A nonhuman primate model comprising adult male rhesus monkeys (Macaca mulatta) with chronically indwelling subcutaneous central venous access devices provides a unique opportunity to determine plasma pharmacokinetics of new drugs such as anticancer and anti- retroviral agents. The central venous access we use is a low-profile, single-septum, titanium port that is attached to a radiopaque, indwelling catheter; the catheter is implanted in an internal jugular vein. A common complication following placement of the venous access device was migration of the catheter tip. We therefore modified the standard procedure by cutting the silicone catheter and introducing the rigid connector to secure the catheter to the vessel at the insertion site (approximately 9 to 13 cm from the distal end of the catheter). Prior to the use of the connector, three of five catheters migrated within 4 weeks after placement. In contrast, all 13 internal jugular catheters with connectors have remained patent without migration of the catheter tip. Therefore, incorporation of the catheter connector appears to have eliminated the problem of catheter migration.

Bisulfite-containing propofol: is it a cost-effective alternative to Diprivan for induction of anesthesia?

UNLABELLED: Propofol (Diprivan(TM); AstraZeneca, Wilmington, DE) is a commonly used drug for the induction of general anesthesia in the ambulatory setting. With the availability of a new bisulfite-containing generic formulation of propofol, questions have arisen regarding its cost effectiveness and safety compared with Diprivan(TM). Two hundred healthy outpatients were randomly assigned, according to a double-blinded protocol, to receive either Diprivan(TM) or bisulfite-containing propofol 1.5 mg/kg IV as part of a standardized induction sequence. Maintenance of anesthesia consisted of either desflurane (4%-8% end-tidal) or sevoflurane (1%-2% end-tidal) in combination with a remifentanil infusion (0.125 microg x kg(-1) x min(-1) IV). Patient assessments included pain on injection, induction time, hemodynamic and bispectral electroencephalographic changes during induction, emergence time, and incidence of postoperative nausea and vomiting. The two propofol groups were comparable demographically, and the induction times and bispectral index values during the induction were also similar. However, the bisulfite-containing formulation was associated with less severe pain on injection (5% vs 11%), with fewer patients recalling pain on injection after surgery (38% vs. 51%, P<0.05). None of the patients manifested allergic-type reactions after the induction of anesthesia. The acquisition cost (average wholesale price in US dollars) of a 20-mL ampoule of Diprivan(TM) was $15 compared with $13 for the bisulfite-containing propofol formulation. Therefore, we concluded that the bisulfite-containing formulation of propofol is a cost-effective alternative to Diprivan(TM) for the induction of outpatient anesthesia. IMPLICATIONS: Bisulfite-containing propofol and Diprivan(TM) (AstraZeneca, Wilmington, DE) were similar with respect to their induction characteristics; however, the generic formulation was associated with a smaller incidence of injection pain. Assuming that the drug costs are similar, these data suggest that the bisulfite-containing formulation of propofol is a cost-effective alternative to Diprivan(TM).