Diseño y validación de un ensayo de minisecuenciación múltiple para detectar polimorfismos asociados con Síndrome Metabólico / Design and validation of a multiple minisequencing assay to detect polymorphisms associated with Metabolic Syndrome

Resumen Introducción: Es importante identificar los polimorfismos de interés clínico en patologías complejas como el Síndrome Metabólico. Por esto, las metodologías para su evaluación deben estar diseñadas y validadas correctamente, esto permite optimizar recursos y tiempo en la genotipificación y detección correcta de los alelos presentes en los individuos. Objetivo: Diseñar y validar una PCR múltiple, seguida de detección por minisecuenciación, para la genotipificación de ocho polimorfismos de nucleótido simple ubicados en el gen del Receptor Beta 3-Adrenérgico (rs4994 y rs4998), gen de la Apolipoproteina A5 (rs3135506 y rs2075291), gen de la Adiponectina (rs1501299 y rs2241766) y gen del Receptor Activador de la Proliferación de los Peroxisomas tipo gamma (rs1801282 y rs1800571), asociados con el síndrome metabólico. Materiales y métodos: Se diseñaron 24 cebadores para la amplificación y detección de ocho polimorfismos de nucleótido sencillo ubicados en cuatro genes candidatos a estar asociados con el síndrome metabólico, usando el software Primer3®. Dieciséis fueron diseñados para amplificar los polimorfismos y ocho para detectarlos por minisecuenciación. Las estructuras secundarias entre los cebadores se verificaron con el software Autodimer. Los polimorfismos se amplificaron simultáneamente y los fragmentos amplificados se acoplaron a las sondas diseñadas para detectar por minisecuenciación el alelo presente, por medio de bases marcadas con fluorocromos. Finalmente, los alelos fueron detectados por electroforesis capilar en un analizador genético ABI 310 y se interpretaron con el software GeneMapper®. La validación del multiplex se realizó genotipando 20 muestras de individuos, cada uno de ellos autorizó este procedimiento por medio del consentimiento informado. Resultados: Se obtuvieron los perfiles genéticos de los 20 controles genotipados, a partir de la amplificación múltiple, seguida de minisecuenciación, diseñada y validada para detectar los ocho polimorfismos. Conclusión: Se diseñó y validó un ensayo para la detección simultánea de los polimorfismos, ubicados en cuatro genes asociados con el Síndrome metabólico. Los cuales pueden ser empleados como referencia para futuros estudios poblacionales.

Abstract Introduction: It is important to identify the polymorphisms of clinical interest in complex pathologies such as Metabolic Syndrome. Therefore, the methodologies for its evaluation must be designed and validated correctly, this permits optimization of resources and time in genotyping and correct detection of the alleles present in individuals. Objective: To design and validate a multiplex PCR, followed by detection by minisequencing, for the genotyping of eight single nucleotide polymorphisms located in the Beta 3-Adrenergic Receptor gene (rs4994 and rs4998), Apolipoprotein A5 gene (rs3135506 and rs2075291), Adiponectin gene (rs1501299 and rs2241766) and gamma-type Peroxisome Proliferation Activating Receptor gene (rs1801282 and rs1800571), associated with metabolic syndrome. Materials and methods: Twenty-four primers were designed for the amplification and detection of eight single nucleotide polymorphisms located in four candidate genes to be associated with the metabolic syndrome, using the Primer3® software. Sixteen were designed to amplify the polymorphisms and eight to detect them by minisequencing. The secondary structures between the primers were verified with Autodimer software. The polymorphisms were simultaneously amplified, and the amplified fragments were coupled to probes designed to minisequence the present allele using fluorochrome-labeled bases. Finally, the alleles were detected by capillary electrophoresis using an ABI 310 genetic analyzer and analyzed with the GeneMapper® software. The validation of the multiplex was performed by genotyping 20 individual samples, each of them authorized this procedure through informed consent. Results: The genetic profiles of the 20 genotyped controls were obtained, from multiple amplification, followed by minisequencing, designed and validated to detect the eight polymorphisms. Conclusion: An essay was designed and validated for the simultaneous detection of polymorphisms, located in four genes associated with metabolic syndrome, and can used as a reference for future population studies.

A comprehensive analysis of factors related to carmustine/bevacizumab response in recurrent glioblastoma.

PURPOSE: Patients with recurrent glioblastoma (rGBM) have a poor prognosis, with survival ranging from 25 to 40 weeks. Antiangiogenic agents are widely used, showing a variable response. In this study, we explored the efficacy of carmustine plus bevacizumab (BCNU/Bev) for treating rGBM. METHODS/PATIENTS: In this study, we assessed 59 adult patients with histologically confirmed rGBM who were treated with BCNU/Bev as second-line regimen. The response rate (RR), progression-free survival (PFS) and overall survival (OS) were evaluated according to their molecular expression profile, including CD133 mRNA expression, MGMT methylation (pMGMT), PDGFR amplification, YKL40 mRNA expression, IDH1/2 condition, p53 and EGFRvIII mutation status. RESULTS: Median follow-up was 18.6 months, overall RR to the combination was 56.3%, and median PFS was 9.0 months (95% CI 8.0-9.9). OS from time of diagnosis was 21.0 months (95% CI 13.2-28.7) and from starting BCNU/Bev it was 10.7 months (95% CI 9.5-11.8). IDH1/2 mutations were found in 30.5% of the patients, pMGMT in 55.9% and high CD133 mRNA expression in 57.6%. Factors which positively affected PFS included performance status (p = 0.015), IDH+ (p = 0.05), CD133 mRNA expression (p = 0.009) and pMGMT+ (p = 0.007). OS was positively affected by pMGMT+ (p = 0.05). Meanwhile, YKL40 negatively affected PFS (p = 0.01) and OS (p = 0.0001). Grade ≥ 3 toxicities included hypertension (22%) and fatigue (12%). CONCLUSIONS: BCNU/Bev is a safe and tolerable treatment for rGBM. Patients with MGMT+/IDH+ derive the greatest benefit from the treatment combination in the second-line setting. Nonetheless, high YKL40 expression discourages the use of antiangiogenic therapy.

Polimorfismo S19W (Ser19Ter) de la APOA5 y su relación con la hipertrigliceridemia en una población de Colombia / S19W polymorphism (Ser19Ter) of APOA5 and its relationship with hypertriglyceridemia in a Colombian population

RESUMEN Introducción: Las enfermedades cardiovasculares (ECV) son responsables del 29,69% de las muertes en Colombia. Se ha encontrado la hipertrigliceridemia, en diversos estudios como factor de riesgo independiente para la ECV. El polimorfismo S19W (Ser19Ter) de la ApoA5 se ha asociado en algunas poblaciones con la hipertrigliceridemia. Sin embargo, en Colombia esto ha sido poco estudiado. Objetivo: Estimar la asociación entre el polimorfismo S19W y la hipertrigliceridemia en población colombiana. Metodología: Estudio tipo Corte Transversal, con 400 individuos provenientes de Bucaramanga, Colombia. Se cuantificó los TAG y se genotipificaron mediante la técnica de SNaPshot y mini secuenciación. Los resultados fueron analizados utilizando el software de análisis genético Arlequín 3.5.1.2. Resultados: El polimorfismo S19W (Ser19Ter) mostró tres perfiles, CC, GG y CG. El polimorfismo S19W se caracterizó tanto en afectados como en no afectados, mostrando que no existen diferencias significativas en esta distribución cuando se comparan los dos grupos. Discusión: Diversos mecanismos se han propuesto para sustentar la hipertrigliceridemia como un factor de riesgo para ECV, entre los que se cuenta la APOA5. El estudio comprobó que la población estudiada se encuentra en equilibrio de Hardy Weinberg y al genotipo CC como el más frecuente. Los genotipos GG y el GC presentaron valores significativos en el grupo de sujetos afectados, (p<0,01 y p=0,03; respectivamente). Se demostró la existencia de una estrecha relación entre el polimorfismo Ser19Trp y la hipertrigliceridemia (p<0,01). Conclusión: Se pudo demostrar la existencia de una relación entre el polimorfismo Ser19Trp de la Apo A5 con los niveles elevados de TAG (p<0,01).

ABSTRACT Introduction: Cardiovascular diseases (CVD) are responsible for 29.69% of the deaths in Colombia. Several studies have shown that hypertriglyceridemia is an independent risk factor for CVD. ApoA5 gene S19W (Ser19Ter) polymorphism has been associated with hypertriglyceridemia in some populations; however, their influence in Colombia is unknown. Objective: To determine the relationship between S19W polymorphism and hypertriglyceridemia in Colombian population. Methodology: Transversal crossover Studio, included a total of 400 individuals. TAG was quantified and genotyped using the technique SnapShot and mini sequencing. The results were analyzed using genetic analysis software Arlequin 3.5.1.2. Results: S19W (Ser19Ter) polymorphism showed three profiles, CC, GG and CG. The S19W polymorphism was characterized both affected and not affected. There wasn´t significant differences in the distribution when the two groups are compared. Discussion: Various mechanisms have been proposed to support hypertriglyceridemia as a risk factor for CVD, including the APOA5 counted. The study found that the study population is in Hardy Weinberg and CC genotype as the most frequent. The GG and GC genotypes showed significant values in the group of affected subjects (p = 0.002 and 0.03). It demonstrated the existence of a close relationship between the Ser19Trp polymorphism and hypertriglyceridemia (p<0,01). Conclusion: It was possible to demonstrate the existence of a relationship between polymorphism Ser19Trp of ApoA5 with elevated levels of TAG (p<0,01).

Atomic structure and crystalline order of graphene-supported ir nanoparticle lattices.

We present the atomic structure of Ir nanoparticles with 1.5 nm diameter at half height and three layers average height grown on graphene/Ir(111). Using surface x-ray diffraction, we demonstrate that Ir nanoparticles on graphene/Ir(111) form a crystallographic superlattice with high perfection. The superlattice arrangement allows us to obtain detailed information on the atomic structure of the nanoparticles themselves, such as size, shape, internal layer stacking and strain. Our experiments disclose that the nanoparticles reside epitaxially on top of the graphene moiré structure on Ir(111), resulting in significant lateral compressive intraparticle strain. Normal incidence x-ray standing wave experiments deliver additional information on the particle formation induced restructuring of the graphene layer.

Atherogenic dyslipidemia in patients with established coronary artery disease.

BACKGROUND AND AIMS: Patients with stable coronary heart disease (CHD) and atherogenic dyslipidemia (AD) have a high-risk of recurrence and are those who derive most benefit from treatment with lipid-lowering agents. The aim of this study was to examine the prevalence of AD in patients with stable coronary heart disease and to investigate associated factors. METHODS: Cross-sectional study involving 7823 subjects admitted for a coronary event between 6 months and 10 years previously. AD was considered to be the concurrent presence of low HDL-cholesterol (<1.03 mmol/L [40 mg/dL] in males, <1.29 mmol/L [50 mg/dL] in females) and elevated triglycerides (≥1.7 mmol/L [150 mg/dL]). RESULTS: Mean age was 65.3 (10.1) years, 73.6% were males and 80.3% were receiving treatment with statins. Low HDL-cholesterol was observed in 26.3% of the participants, 39.7% had elevated triglyceride concentration and 13.0% had AD. The percentage of AD in patients with criteria for metabolic syndrome was 30.9%. Factors associated directly and independently with the presence of AD in the multivariate analysis were female sex, history of coronary syndrome without ST elevation or coronary revascularization, presence of atrial fibrillation, body mass index, LDL-cholesterol, systolic blood pressure and blood glucose levels, while age and glomerular filtration rate were significantly and inversely associated with AD. CONCLUSION: A significant proportion of patients with coronary disease could benefit from interventions aimed at increasing HDL-cholesterol and reducing triglycerides.

[Prevalence of metabolic syndrome in patients with stable coronary disease: therapeutic objectives and utilization of cardiovascular drugs]. / Prevalencia de síndrome metabólico en pacientes con enfermedad coronaria estable: objetivos terapéuticos y utilización de fármacos cardiovasculares.

OBJECTIVE: The achievement of the therapeutic objectives in patients with ischemic heart disease and metabolic syndrome is unknown. This study has aimed to evaluate whether the prevalence of risk factors, the prescription rate of evidence-based cardiovascular therapies and the attainment of therapeutic goals differ in coronary patients with and without the metabolic syndrome (MS). METHODS: A multicenter, cross-sectional study carried out with the participation of 7,600 patients with stable coronary heart disease (mean age 65.3 years, 82% males, 37.7% with MS) attended in primary care. Data on drug prescription and goal attainment were extracted from clinical records. MS was defined according to the National Cholesterol Education Program (NCEP) criteria. RESULTS: Patients with MS had a higher prevalence of cardiovascular risk factors and cardiovascular disease. They also had a higher prescription rate of blood-pressure lowering drugs, statins and antidiabetic agents, without differences in the rate of use of antithrombotics and beta-blockers. After adjusting for cardiovascular risk factors and co-morbidity, only fibrates and angiotensin II receptor blockers were used more frequently in MS patients. A lower percentage of subjects with MS achieved therapeutic goals of LDL cholesterol (23.4% vs 27.7%, P<.001), blood pressure (29.1% vs 52.2%, P<.001) and, in diabetics, of glycated hemoglobin (54.7% vs 75.9%, P<.001). CONCLUSION: Patients with stable coronary disease and MS do not reach therapeutic objectives as frequently as those without MS, in spite of receiving a higher amount of cardiovascular drugs.

Prevalencia de síndrome metabólico en pacientes con enfermedad coronaria estable: objetivos terapéuticos y utilización de fármacos cardiovasculares / Prevalence of metabolic syndrome in patients with stable coronary disease: therapeutic objectives and utilization of cardiovascular drugs

Objetivo. La consecución de objetivos terapéuticos en pacientes con cardiopatía isquémica crónica y síndrome metabólico (SM) es desconocida. El objetivo del estudio fue analizar en pacientes con enfermedad coronaria estable si la prevalencia de los factores de riesgo, la utilización de fármacos cardiovasculares y la consecución de objetivos terapéuticos eran diferentes en función de la presencia o no del SM. Métodos. Estudio transversal multicéntrico en el que participaron 7.600 sujetos con enfermedad coronaria estable atendidos en Atención Primaria. Para el diagnóstico del SM se utilizaron los criterios del National Colesterol Educational Programm – Adult Treatment Programm III (NCEP-ATP III). Resultados. La edad media fue 65,3 años (hombres, 82%). El 37,7% cumplía criterios de SM. Los pacientes con SM tenían una significativa mayor prevalencia e intensidad de los factores de riesgo, así como una mayor comorbilidad cardiovascular. Además, utilizaban con mayor frecuencia antihipertensivos, hipolipemiantes e hipoglucemiantes, no existiendo diferencias en antitrombóticos y betabloqueantes. Tras ajustar por los factores de riesgo y la comorbilidad solo los fibratos y los antagonistas del receptor de la angiotensina II eran utilizados más frecuentemente por los pacientes con SM. Los objetivos terapéuticos de colesterol-LDL (23,4% versus 27,7%, p<0,001), de presión arterial (29,1% versus 52,2%, p<0,001) y de hemoglobina glucada en diabéticos (54,7% versus 75,9%, p<0,001), se alcanzaron menos frecuentemente en los pacientes con SM. Conclusión. Los pacientes con enfermedad coronaria estable y SM alcanzan unos objetivos terapéuticos con menor frecuencia que los enfermos sin SM, a pesar de recibir una mayor cantidad de fármacos(AU)

Objective. The achievement of the therapeutic objectives in patients with ischemic heart disease and metabolic syndrome is unknown. This study has aimed to evaluate whether the prevalence of risk factors, the prescription rate of evidence-based cardiovascular therapies and the attainment of therapeutic goals differ in coronary patients with and without the metabolic syndrome (MS). Methods. A multicenter, cross-sectional study carried out with the participation of 7,600 patients with stable coronary heart disease (mean age 65.3 years, 82% males, 37.7% with MS) attended in primary care. Data on drug prescription and goal attainment were extracted from clinical records. MS was defined according to the National Cholesterol Education Program (NCEP) criteria. Results. Patients with MS had a higher prevalence of cardiovascular risk factors and cardiovascular disease. They also had a higher prescription rate of blood-pressure lowering drugs, statins and antidiabetic agents, without differences in the rate of use of antithrombotics and beta-blockers. After adjusting for cardiovascular risk factors and co-morbidity, only fibrates and angiotensin II receptor blockers were used more frequently in MS patients. A lower percentage of subjects with MS achieved therapeutic goals of LDL cholesterol (23.4% vs 27.7%, P<.001), blood pressure (29.1% vs 52.2%, P<.001) and, in diabetics, of glycated hemoglobin (54.7% vs 75.9%, P<.001). Conclusion. Patients with stable coronary disease and MS do not reach therapeutic objectives as frequently as those without MS, in spite of receiving a higher amount of cardiovascular drugs(AU)

Densitometria de la capsula optica por tacar en pacientes con otoesclerosis / Density measurement of otic capsule by computed tomography in patients with otosclerosis

Se realizó un estudio observacional analítico de casos y controles para evaluar la densitometría de la cápsula ótica por tomografía axial computarizada de alta resolución (TACAR) en pacientes con diagnóstico clínico de otoesclerosis y en un grupo control. Se obtuvo información de 45 pacientes (90 oídos): 16 pacientes con diagnóstico de otoesclerosis y 29 del grupo control, a quienes se les realizaron de forma independiente las pruebas clínicas y TACAR con mediciones de densitometría en cinco localizaciones en la cápsula ótica. En todos los pacientes se encontraron valores de densitometría mayores al límite superior normal que ha sido descrito en la literatura. En el análisis realizado no se encontraron diferencias estadísticamente significativas entre los dos grupos. Todos los valores de P encontrados fueron menores de 0.0001. Los resultados demuestran que los valores de densitometría en la cápsula ótica mayores a 2200 U H no se encuentran exclusivamente en pacientes con otoesclerosis y por lo tanto no pueden constituir la base para el diagnóstico por imágenes de esta patología

Manometry and 24-hour ambulatory pH monitoring at two levels of the esophagus in patients with and without esophagitis.

OBJECTIVE: To define the relationship between esophageal dysmotility and severity of gastroesophageal reflux (GER) at the distal and proximal levels. METHODS: Two-level, 24-hour ambulatory pH monitoring and manometry of the esophagus were performed in 40 patients with abnormal distal acid exposure and in 20 healthy controls. Twenty patients with normal endoscopy or endoscopic evidence of grade I esophagitis were assigned to group 1 and 20 with grade II-III esophagitis were assigned to group 2. We used a dual-site pH probe with antimony electrodes spaced 15 cm apart. RESULTS: Patients had greater acid exposure than controls at both levels. The percentage of distal reflux episodes reaching proximal esophagus was significantly greater in group 1 than in the control group. The most marked reductions in the percentage of time of the pH remaining under 4 were detected in the patients with the most severe distal acid reflux and esophagitis (group 2). The mean lower esophageal sphincter pressure was significantly lower in group 2 than in group 1. The percentage of tertiary waves or nonperistaltic contractions was significantly higher in group 2 than in group 1 and the control group. Patients with milder distal reflux had significantly lower distal and middle esophageal wave amplitudes than controls. There were no significant differences between controls and patients with severe esophagitis in terms of the esophageal peristaltic wave amplitude in the middle third of the esophagus. CONCLUSIONS: No correlation was observed between episodes of distal reflux and proximal reflux in GER patients. Esophageal motor activity appears to be an important determinant of the severity and extension of GER in the proximal esophagus.

[Physiological reflux in proximal esophagus (assessment with simultaneous pH monitoring in proximal and distal esophagus in healthy subjects]. / Reflujo fisiológico en esófago proximal (valoración mediante pHmetría simultánea en esófago proximal y distal en sujetos sanos).

Two-level pH monitoring was performed for 24 hours in 20 healthy subjects to document the presence of reflux episodes and to obtain reference values for reflux studies. The pH probes were placed 5 and 20 centimetres above the LES by means of a manometric technique. Significant differences were found at these two levels. At the proximal esophageal level 18 of the 20 subjects had reflux episodes. Five centrimetres above the lower esphageal sphincter the total reflux time was 1.35%, 2.05% in the upright and 0.15% in the supine positions. At 20 centimetres level it was significantly lower: 0.5% the total percent time with pH below 4, 0.8% and 0% in the upright and supine positions respectively. The mean reflux time was about 40% of the distal value, but the same pattern of reflux was observed at two levels of the esophagus. This technique is useful in documenting the cephalad extend of GER and allows to identify normal GER patterns at different levels of the esophagus.

[The effect of vitamin C on the lipolytic activity in type-II diabetics with angiopathy]. / "Efecto de la vitamina C sobre la actividad lipolítica en pacientes diabéticos tipo II con angiopatía".

Effects produced by different doses of Vit C (2, 3 and 4 gr/day) on lipoprotein and hepatic lipase activities were studied between a group of 35 ambulatory patients, men and women, affected by diabetes mellitus type II with macroangiopathy at lower limbs and/or food. The medium age of patients was 62 years, ranging from 44 to 82 years. Patients were aleatory divided into four groups. One from those four groups was treated with placebo, the other three received Vit C. In the group treated with 3 gr./day of Vit C we found a significant reduction and increase (p less than 0.05) of lipoprotein and hepatic lipase activities, respectively, when we compared outcomes before and after eight weeks of treatment with Vit C. By other hand, when we compared the different groups, we found a significant increase in the hepatic lipase activity in the same group, particularly between the patients whose plasmatic Vit C levels before treatment were reduced. We didn't found any significant change in the rest of parameters.

Transnasal butorphanol: a new method for pain relief in post-cesarean section pain.

This study was undertaken to evaluate the efficacy and the safety of transnasal butorphanol (TNB) compared to intravenous butorphanol (IVB) in 186 patients experiencing moderate to severe post-cesarean section pain. Patients were randomly assigned to five groups in a double-blind fashion: Group I (n = 37) received 2 mg IVB, Group II (n = 38) 2 mg TNB, Group III (n = 36) 1 mg TNB followed by a repeat dose of 1 mg TNB at 60 min, Group IV (n = 38) 0.5 mg TNB followed by a repeat dose of 0.5 mg at 60 min, and Group V (n = 37) received placebo. All administrations were double dummy. Pain intensity and relief were noted and the incidence of side effects was recorded. Remedication with the same study drug was allowed up to 72 h. Onset of analgesia was more rapid in the 2 mg IV group compared to the three TN groups: 5 min vs 15 min, respectively. However, the 2 mg and the 1-1 mg TN groups had a longer duration of analgesia, approximately 4.5 h, compared to 3.0 h for the 2 mg IV group (P less than 0.05). Somnolence was dose related and was the most frequent side effect, and was less frequent when the TN dose was divided into 2 doses administered 1 h apart. Multiple doses of TNB and IVB were safe and clinically acceptable up to 3 days at all doses studied. There were no incidences of nasal mucosa irritation, or cardiovascular or respiratory depression. It is concluded that transnasal butorphanol represents a safe and effective alternative to injectable butorphanol for post-cesarean section pain and offers a better and longer duration of analgesia compared to IV butorphanol. The optimum dose seems to be 2 mg TN butorphanol and it is tolerated better when divided into 1 mg increments, given 1 h apart.

Prophylactic oral naltrexone with intrathecal morphine for cesarean section: effects on adverse reactions and analgesia.

The influence of two different doses of oral naltrexone on the adverse effects and the analgesia associated with intrathecal morphine was compared in a double-blind, placebo-controlled study. Thirty-five patients undergoing cesarean section were provided postoperative analgesia by 0.25 mg intrathecal morphine. Sixty minutes later they were given 6 mg naltrexone, 3 mg naltrexone, or placebo as an oral solution. Pain relief was assessed by the Visual Analog Scale. Requirements for additional analgesics and side effects were recorded. Duration of analgesia was shorter in the 3- and 6-mg naltrexone groups than in the placebo group, 10.0 +/- 2.6, 12.4 +/- 2.6, and 19.2 +/- 4.5 h (mean +/- SEM), respectively, but values did not reach statistical significance. The incidence of pruritus and vomiting was significantly less in the 6-mg naltrexone group than in the other two groups (P less than 0.05). Somnolence was significantly less in the 3- and 6-mg naltrexone groups than in the placebo group (P less than 0.05). Naltrexone (6 mg) is an effective oral prophylactic against the pruritus and vomiting associated with intrathecal morphine for analgesia after cesarean section, but it is associated with shorter duration of analgesia.

Isoflurane or halothane for cesarean section: comparative maternal and neonatal effects.

The maternal and neonatal effects of isoflurane and halothane combined with 50% N2O - 50% O2 were compared in 60 healthy parturients undergoing primary or repeat cesarean section. All patients had rapid sequence induction of anesthesia with sodium thiamylal 4 mg/kg followed by succinylcholine for tracheal intubation. Patients were randomly assigned to one of three groups of 20 each (inspired 0.5% isoflurane, 1% isoflurane or 0.5% halothane), combined with 50% N2O and O2. After delivery, 67% N2O in O2 was used, supplemented by butorphanol. Maternal blood loss did not differ significantly among the three groups and none of the patients developed intraoperative awareness. At the time of delivery, maternal plasma epinephrine levels were significantly above preinduction levels in the 0.5% isoflurane group but unchanged in the other two groups. Neonatal status as ascertained by Apgar scores, cord acid base status and the Neurologic and Adaptive Capacity Scores (NACS) was equally good in the three groups of patients. Serum inorganic fluoride concentrations in the mother after anesthesia were not significantly above preanesthetic levels in any of the groups and there was no biochemical evidence of renal toxicity. In all neonates fluoride ion concentrations in the first voided urine sample were less than 7 mumol/l, a value well below that associated with nephrotoxicity. It is concluded that isoflurane is a safe supplement to N2O - O2 mixture for cesarean section and is a safer alternative to halothane in situations when patients receiving beta-adrenergic therapy require cesarean section since halothane might potentiate arrhythmias caused by beta adrenergic agonists.

Bupivacaine/butorphanol/epinephrine for epidural anesthesia in obstetrics: maternal and neonatal effects.

The effects of epidural bupivacaine/butorphanol with and without 1:300,000 epinephrine on maternal analgesia, uterine activity, progress of labor, fetal heart rate, maternal blood pressure, newborn Apgar scores, neonatal acid base status and the neurologic and adaptive capacity scores (NACS) were compared in 33 parturients during labor and delivery. Patients in Group I (n = 17) received 0.25% bupivacaine plus 1 mg butorphanol plus 1:300,000 epinephrine, and those in Group II (n = 16) received the same agents without the epinephrine. Addition of epinephrine to bupivacaine/butorphanol did not have any adverse effects on uterine activity, duration of first or second stages of labor or fetal heart rate parameters. The incidence of maternal hypotensive episodes did not differ significantly between the two groups of patients. Apgar scores, neonatal acid base status and the NACS were equally good and did not differ significantly between the two groups. Duration of analgesia was significantly longer in Group I as compared to Group II patients (177.5 +/- 11 versus 131.8 +/- 10 minutes, p less than 0.01). It is concluded that addition of epinephrine 1:300,000 to bupivacaine/butorphanol during epidural anesthesia in the normal parturient has no adverse effects on the mother, fetus or neonate or on the progress of labor and it significantly prolongs the duration of analgesia.

Epidural morphine or butorphanol augments bupivacaine analgesia during labor.

To determine the efficacy and the safety of epidural morphine or butorphanol combined with bupivacaine, 40 healthy parturients were studied during labor and delivery. All patients received an epidural test dose of 2 ml of 0.5% bupivacaine. Patients were then randomly assigned to receive one of four epidural regimens in a double-blind fashion: 0.25% bupivacaine + 1 mg butorphanol (Group I), 0.25% bupivacaine + 2 mg butorphanol (Group II), 0.25% bupivacaine + 2 mg morphine (Group III), or 0.25% bupivacaine alone (Group IV). Each group consisted of ten patients. All subsequent epidural injections were with plain 0.25% bupivacaine. Duration of analgesia was significantly longer for groups I, II, and III when compared to group IV (p less than or equal to .01); 139 +/- 111, 141 +/- 14, 199 +/- 29, and 96 +/- 6 minutes, X +/- SEM respectively. Quality of analgesia was significantly better in groups I, II, and III when compared with group IV. There were no differences between groups in duration of first and second stages of labor, uterine activity, or method of delivery. Thirty percent of patients in the morphine group (group III) developed mild pruritus that did not require any treatment. All neonates were vigorous at 5 minutes and had good Apgar Scores, umbilical cord acid base status, and Neurological Adaptive Capacity Scores. The authors conclude that adding small doses of either morphine or butorphanol to epidural bupivacaine during labor is effective and safe. Butorphanol may be preferable since none of the patients experienced pruritus.

Mini-dose intrathecal morphine for the relief of post-cesarean section pain: safety, efficacy, and ventilatory responses to carbon dioxide.

To determine the safety, efficacy, and the ventilatory responses to carbon dioxide (CO2) of mini-dose intrathecal morphine, 33 healthy women who underwent cesarean section with spinal anesthesia using 0.75% bupivacaine in 8.25% dextrose were studied. Patients were randomly assigned to receive, in a double-blind fashion, either morphine 0.25 mg (group I, n = 11), morphine 0.1 mg (group II, n = 10), or saline (group III, placebo group, n = 12) in 0.5 ml volume mixed with the bupivacaine. In both groups I and II excellent postoperative analgesia with long duration was obtained (27.7 +/- 4.0 and 18.6 +/- 0.9 hours, respectively, X +/- SEM). All patients in group III required an analgesic (8 mg subcutaneous morphine) within 3 hours of spinal anesthesia. Seven patients in group I and four patients in group II developed mild pruritus that did not require treatment. Ventilatory responses to CO2 showed no evidence of depression attributable to either the 0.25 or 0.1 mg of morphine, but significant depression of the CO2 responses was observed in group III patients after administration of subcutaneous morphine. It is concluded that a dose as low as 0.1 mg of intrathecal morphine gives excellent analgesia with minimal to no side effects and that subcutaneous morphine is associated with marked depression of the ventilatory variables.