A randomised prospective trial of intra-operative oesophageal Doppler-guided fluid administration in major gynaecological surgery.

Intra-operative oesophageal Doppler monitor-guided fluid management has been associated with improved postoperative length of hospital stay and morbidity in gastrointestinal and orthopaedic surgery. We designed a randomised controlled trial to test the hypothesis that this approach to intra-operative fluid management in major elective open gynaecological surgery would shorten the length of postoperative stay, defined as time to readiness for hospital discharge. Postoperative morbidity was evaluated as a secondary outcome. The oesophageal Doppler monitor group underwent intra-operative fluid management using an oesophageal Doppler-guided stroke volume optimisation algorithm. Control group (conventional fluid therapy) intra-operative fluid management was based on conventional haemodynamic indices. In a single centre, 102 patients were randomly assigned: 51 to the oesophageal Doppler monitor group (51 analysed) and 51 to the control group (50 analysed). Evaluators who were blinded to patient assignment collected postoperative outcome data. There was no difference in the length of postoperative hospital stay between the groups: median (IQR [range]) number of days until ready for discharge was 6 (5-8 [4-25]) days in the oesophageal Doppler monitor group compared with 7 (5-9 [4-42]) days in the control group, p = 0.5. There was no difference between the groups in postoperative morbidity survey scores on postoperative days 1, 3 or 5. Seven patients in the oesophageal Doppler monitor group and 11 in the control group experienced postoperative complications (p = 0.41). These findings question whether intra-operative oesophageal Doppler-guided fluid therapy is of benefit in patients undergoing open gynaecological surgery.

COS-Speech: protocol to develop a core outcome set for dysarthria after stroke for use in clinical practice and research.

BACKGROUND: Dysarthria after stroke is when speech intelligibility is impaired, and this occurs in half of all stroke survivors. Dysarthria often leads to social isolation, poor psychological well-being and can prevent return to work and social lives. Currently, a variety of outcome measures are used in clinical research and practice when monitoring recovery for people who have dysarthria. When research studies use different measures, it is impossible to compare results from trials and delays our understanding of effective clinical treatments. The aim of this study is to develop a core outcome set (COS) to agree what aspects of speech recovery should be measured for dysarthria after stroke (COS-Speech) in research and clinical practice. METHODS: The COS-Speech study will include five steps: (1) development of a long list of possible outcome domains of speech that should be measured to guide the survey; (2) recruitment to the COS-Speech study of three key stakeholder groups in the UK and Australia: stroke survivors, communication researchers and speech and language therapists/pathologists; (3) two rounds of the Delphi survey process; (4) a consensus meeting to agree the speech outcomes to be measured and a follow-up consensus meeting to match existing instruments/measures (from parallel systematic review) to the agreed COS-Speech; (5) dissemination of COS-Speech. DISCUSSION: There is currently no COS for dysarthria after stroke for research trials or clinical practice. The findings from this research study will be a minimum COS, for use in all dysarthria research studies and clinical practice looking at post-stroke recovery of speech. These findings will be widely disseminated using professional and patient networks, research and clinical forums as well as using a variety of academic papers, videos, accessible writing such as blogs and links on social media. TRIAL REGISTRATION: COS-Speech is registered with the Core Outcome Measures in Effectiveness Trials (COMET) database, October 2021 https://www.comet-initiative.org/Studies/Details/1959 . In addition, "A systematic review of the psychometric properties and clinical utility of instruments measuring dysarthria after stroke" will inform the consensus meeting to match measures to COS-Speech. The protocol for the systematic reviews registered with the International Prospective Register of Systematic Reviews. PROSPERO registration number: CRD42022302998 .

FKRP-dependent glycosylation of fibronectin regulates muscle pathology in muscular dystrophy.

The muscular dystrophies encompass a broad range of pathologies with varied clinical outcomes. In the case of patients carrying defects in fukutin-related protein (FKRP), these diverse pathologies arise from mutations within the same gene. This is surprising as FKRP is a glycosyltransferase, whose only identified function is to transfer ribitol-5-phosphate to α-dystroglycan (α-DG). Although this modification is critical for extracellular matrix attachment, α-DG's glycosylation status relates poorly to disease severity, suggesting the existence of unidentified FKRP targets. Here we reveal that FKRP directs sialylation of fibronectin, a process essential for collagen recruitment to the muscle basement membrane. Thus, our results reveal that FKRP simultaneously regulates the two major muscle-ECM linkages essential for fibre survival, and establishes a new disease axis for the muscular dystrophies.

Key performance indicators in intensive care medicine. A retrospective matched cohort study.

Expert panel consensus was used to develop evidence-based process indicators that were independent risk factors for the main clinical outcome parameters of length of stay in the intensive care unit (ICU) and mortality. In a retrospective, matched data analysis of patients from five ICUs at a tertiary university hospital, agreed process indicators (sedation monitoring, pain monitoring, mean arterial pressure [MAP] >or= 60 mmHg, tidal volume [TV] or= 80 and or= 60 mmHg and BG >or= 80 mg/dl were relevant for survival. Linear regression of the 634 patients showed that analgesia monitoring, PIP or= 60 mmHg, BG >or= 80 mg/dl and

In vitro hypoxic cytotoxicity of nitroimidazoles: uptake and cell cycle phase specificity.

The hypoxic cytotoxicity of four different 2-nitroimidazoles of similar electron affinities but different lipophilicities was compared using EMT6/Ro mouse mammary tumor cells in exponential growth phase in severely (less than 20 ppm) hypoxic conditions. The relative cytotoxicities were misonidazole (MISO) = desmethylmisonidazole (9963) greater than SR-2508 much greater than SR-2555 indicating that the compounds with the lowest lipophilicity were less cytotoxic. The rates of uptake of these compounds were MISO greater than 9963 greater than SR-2508 = SR-2555. These data together with comparisons of the amounts of cell-associated compounds indicate that the similarity in toxicity of MISO and 9963 can be related to a general similarity in their pharmacokinetics, but that other unknown factors must be considered to explain the relative toxicity of SR-2508 and SR-2555. In other experiments, EMT6/Ro cells synchronized using centrifugal elutriation were most sensitive in hypoxia to MISO at the late G1--early S phase of the cell cycle. These data indicate the importance of considering cellular and subcellular distribution of these nitroimidazoles as well as possible cell cycle specificity for cytotoxicity in interpreting relative effectiveness of different compounds in responses of mixed populations of cells in cultures or tumors.

Further characterization of 4-bromomisonidazole as a potential detector of hypoxic cells.

[14C]Bromomisonidazole was prepared by direct bromination of [ring-2] [14C]misonidazole in dioxane. The uptake and binding of the two labeled sensitizers were compared in vitro in 1-mm EMT-6 spheroids which contain a necrotic core. Using liquid scintillation counting it was shown that spheroids incubated with 50 microM [14C]bromomisonidazole concentrated drug above levels in the medium by 1 1/2 hr and achieved maximum concentration by 10 hr with no further increase at 23 hr. Spheroids incubated with 50 microM [14C]misonidazole may concentrate the sensitizer more slowly but ultimately reached the same fivefold increase over levels in the medium by 23 hr as was observed for bromomisonidazole. Autoradiographs prepared from spheroids after incubation with [14C]misonidazole or [14C]bromomisonidazole showed silver grains preferentially located over viable hypoxic cells in the inner half of the spheroid rim adjacent to the necrotic center, with lower grain density over nonviable necrotic areas and many fewer grains over oxic cells at the periphery of the spheroid. The results indicate that both severely and moderately hypoxic cells may preferentially bind [14C]bromomisondiazole. The data support the potential of radiolabeled bromomisonidazole for in vivo imaging pending additional studies of the metabolism of this agent.

Evaluation of the anticholinesterase activity of metronidazole and misonidazole.

Contrary to an earlier report that metronidazole exhibited anticholinesterase activity on isolated organ preparations, a direct spectrophotometric assay was unable to demonstrate any significant inhibition of either true or pseudocholinesterase activity in the presence of this drug. The related nitroimidazole, misonidazole, was also found to be inactive when tested in this system. This report demonstrates that the clinical neurotoxicity of these two compounds cannot be attributed to any direct effect on the cholinesterase enzymes.

Real-time ultrasound-guided spinal anaesthesia: a prospective observational study of a new approach.

Identification of the subarachnoid space has traditionally been achieved by either a blind landmark-guided approach or using prepuncture ultrasound assistance. To assess the feasibility of performing spinal anaesthesia under real-time ultrasound guidance in routine clinical practice we conducted a single center prospective observational study among patients undergoing lower limb orthopaedic surgery. A spinal needle was inserted unassisted within the ultrasound transducer imaging plane using a paramedian approach (i.e., the operator held the transducer in one hand and the spinal needle in the other). The primary outcome measure was the success rate of CSF acquisition under real-time ultrasound guidance with CSF being located in 97 out of 100 consecutive patients within median three needle passes (IQR 1-6). CSF was not acquired in three patients. Subsequent attempts combining landmark palpation and pre-puncture ultrasound scanning resulted in successful spinal anaesthesia in two of these patients with the third patient requiring general anaesthesia. Median time from spinal needle insertion until intrathecal injection completion was 1.2 minutes (IQR 0.83-4.1) demonstrating the feasibility of this technique in routine clinical practice.

Cardiac troponin I: a case study in rational antibody design for human diagnostics.

In vitro diagnostic (IVD) platforms provide rapid and accurate determination of disease status. The clinical performance of antibody-based diagnostic platforms is paramount as the information provided often informs the medical intervention taken and, ultimately, the patient's outcome. Breaking down such an immuno-IVD device into its component elements, the biorecognition entity is key to the analytical specificity of the test. Furthermore, tailored optimisation of the antibody is often necessary to impart the desired biophysical properties for the specific application. This tailoring is now widely facilitated by advances in combinatorial approaches to antibody generation, molecular evolution strategies and the availability of truly high-throughput (HT), refined surface plasmon resonance-based screening tools. In this paper, we demonstrate a rational, knowledge-driven approach to the generation of epitope-specific antibodies for the early detection of cardiovascular disease, discuss the merits of the approaches taken and offer a perspective on HT strategies to mining large antibody libraries. These results highlight the expedience of such methodologies for the development of truly superior cardiovascular disease biorecognition elements.

Development and feasibility study of an algorithm for intraoperative goaldirected haemodynamic management in noncardiac surgery.

This study developed an evidence-based, goal-directed haemodynamic management algorithm to standardize intraoperative haemodynamic therapy. A systematic literature search identified three haemodynamic management goals: stroke volume optimization by fluid therapy; maintenance of a target mean arterial pressure by vasopressor therapy; maintenance of a target cardiac index≥2.5 l/min per m2 by inotropic therapy. The algorithm was adapted to international standards and consensus was reached through a modified Delphi method at international meetings. Implementation of the algorithm into routine intraoperative management in noncardiac surgery was shown to be feasible. Compared with conventional haemodynamic management, use of the algorithm significantly reduced length of hospital stay, requirement for ventilation and incidence of prolonged hospital stay, thereby resulting in reduced hospital costs.

Carcinostatic activity of methylglyoxal and related substances in tumour-bearing mice.

Methylglyoxal treatment of tumour cells in vitro primarily depresses protein synthesis, in contrast to trans-4-hydroxypent-2-enal (HPE) which preferentially inhibits DNA synthesis. Methylglyoxal and hpe are potent carcinostatic agents in vitro but relatively ineffective in vivo. Both aldehydes have a short half-life in vivo which may explain their poor carcinostatic properties when administered other than peritumorally. Several possibilities of increasing the effective half-life were investigated including (i) multiple intraperitoneal injections, (ii) concomitant administration of an inhibitor of glyoxalase I, (iii) administration of aldehyde-cysteine adducts, and (iv continuous intravenous infusion. Methylglyoxal (36 mg/kg i.p., twice daily) was slightly less effective in inhibiting the growth of the solid form of Ehrlich carcinoma than a dose of 72 mg/kg (inj. 1); 36 mg/kg (inj. 2) 46.2% compared to 51%. The aldehyde was more effective aginst the ascitic form of the tumour, with 99.76% inhibition of growth after giving 72 mg/kg twice daily for five days followed by 36 mg/kg for five days. The glyoxalase I inhibitor S-(p-bromobenzyl)-glutathione didnot significantly enhance the activity of methylglyoxal against the solid form of the tumour. Nicotinamide (1% w/v in the drink) was similarily inactive. Methylglyoxal in combination with nicotinamide was significantly more effect (P less than 0.05) than methylglyoxal alone (36 mg/kg, twice daily) in inhibiting the growth of the ascitic tumour. Methylglyoxal-N-acetyl-L-cysteine was four times less toxic than methylglyoxalalone but was marginally less effective against the ascitic form of the tumour. Doses of these adducts equivalent to 144 mg/kg per day of methylglyoxal were more effective P less than 0.05) than the optimal regime of methylglyoxal in inhibiting the solid tumour (67.5% inhibition compared to 51%). Treatment of mice bearing the ascitic form of Sarcoma 180 with five daily doses (i.p.) of an HPE-cysteine adduct equivalent to a dose of HPE alone of 32-256 mg/kg per day significantly increased survival time by comparison with controls. The adduct was 2-3 times more effective, dose-for-dose, than HPE alone in inhibiting tumour growth. Purified buffered methylglyoxal has an LD50 on continuous infusion into the right lateral tail vein in mice of more than 3.0 mg/g per day (seven days at 2.8 ml/day). Local oedema followed by tail necrosis occurs at doses in excess of 0.25-0.5 mg/g per day in mice bearing the solid forms of the syngeneic tumours: squamous carcinoma D; lymphosarcoma 1 (WH/Ht mice); and spontaneous mammary D5056 (CBA/CA mice). A maximum tumour volume growth delay of 3.4 days at Day 17 (P less than 0.001) after transplantation was observed after infusion of 0.5 mg/g per day methylglyoxal on Days 11-17 in the CBA/CA D40 syngeneic mammary tumour. Tumour regrowth after termination of therapy eliminated the significant difference between control and methylglyoxal-treated tumours by Day 27. Methylglyoxal infusion (0...

Management of tracheomalacia in association with congenital tracheo-oesophageal fistula.

Tracheomalacia is commonly associated with oesophageal atresia and tracheo-oesophageal fistula. Severe cases may present with life threatening cyanotic and apnoeic attacks following surgical repair of the oesophageal atresia. The anaesthetic, and surgical management (by tracheopexy), of such a case are described.

Peripheral electrophysiological parameters in mice treated with misonidazole.

The clinical use of the radiosensitizer misonidazole may be limited by the incidence of peripheral neuropathy reported following total doses in excess of 18 g. A recent report noted a decrease in nerve conduction velocity following a single i.p. injection of 1 mg/g misonidazole in mice. The present study was unable to confirm such changes when nerve conduction velocity measurements were made in situ or in isolated sural, tibial or median nerves of mice. Other electrophysiological parameters such as threshold, strength-duration curves, refractory time or the ability to carry high-frequency stimulation also showed no change. However, it was noted that a single administration of the radio-sensitizer produced a marked decrease in body temperature which persisted for at least 2 h after the elimination of the drug from the blood serum. The physiological response of reduction of body temperature may protect the mouse against the effect of the toxic chemical species involved in the induction of neurotoxicity.

Acrylamide neurotoxicity in the mouse: a behavioral, electrophysiological and morphological study.

The development of acrylamide induced neurotoxicity was followed for 3 weeks in the mouse by behavioral testing, determination of conduction velocities and electron microscopic examination of peripheral nerves. Neurotoxic signs began to appear during the second week of treatment. A condition of severe intoxication developed within 21 days. Behavioral assessment for neurological deficits proved to be more sensitive than sensory or motor conduction velocity determinations either in isolated preparations or in situ. In general, such electrophysiological determinations did not result in reproducible, statistically significant, differences from control animals until the third week of acrylamide administration. However, there was a suggestion that temperature reduction may provide a provocative change to increase the sensitivity of such electrophysiological measurements. Electron microscopic examination of the nerves of severely poisoned animals revealed myelin corrugation and delamination to be the most consistent damage. Acrylamide appeared to produce a nonselective attack since degenerating fibers were found intermingled with almost normal fibers of approximately the same diameter. In general, the production of neurotoxicity in the mouse closely resembled that seen in the rat but some differences were noted.

Occurrence of ornithine decarboxylase and polyamines in cartilage.

The activity of ornithine decarboxylase was investigated in cartilage from chick embryos, rabbits, rats and human foetuses. The enzyme activity in these cartilages was of the same order as the detected in other body tissues. Ornithine decarboxylase activity in chick-embryo cartilage and liver was the same when compared on the basis of total soluble tissue protein. The cartilage enzyme exhibited a pH optimum of 6.5 and a Km for ornithine of 0.16mM. Ornithine decarboxylase activity in chick-embryo pelvic leaflets was maintained at the value in vivo for up to 22h when the isolated tissue was incubated in a modified Waymouth's medium (MB 752/1) at 37 degrees C. After addition of cycloheximide to the incubation medium, ornithine decarboxylase activity declined, with a half-life of 40 min. The concentrations of the polyamines spermidine and spermine in chick-embryo pelvic cartilage and rabbit costal cartilage were of the same order as the concentrations detected in other tissues.

Effect of acute and chronic misonidazole administration on peripheral-nerve electrophysiology in mice.

I.p. administration at several dose levels over periods of up to 12 weeks, or continuous i.v. infusion of high doses of misonidazole (MISO) for 15 h, produced no significant change in peripheral nerve conduction velocity (NCV) and did not prevent the normal increase in NCV as the animals matured from 12 to 24 weeks of age. Peripheral NCV (sural nerve) was reduced in both MISO-treated and control mice with hind-limb tumour implants, presumably owing to physical pressure due to tumour growth. In addition, neither the medial nerves nor the tibial nerve in the normal limbs of the tumour-implanted, drug-treated animals showed any change. Consequently our earlier and present studies do not confirm the recent reports of changes in NCV following either acute or chronic MISO administration to mice.