A comparison of daily and alternate-day prednisone therapy in the treatment of Duchenne muscular dystrophy.

We previously reported the results of a randomized, double-blind 6-month trial of prednisone therapy in which 102 boys aged 5 to 15 years with Duchenne muscular dystrophy received daily doses of 1.5 and 0.75 mg/kg per day and were compared with those receiving placebo. The strength and function in both prednisone-treated groups improved equally and were significantly better than in the placebo group. To compare alternate-day and daily dosing of prednisone with respect to benefits and adverse side effects, the placebo group was started on alternate-day prednisone therapy, and the treatment group regimens were changed to equivalent doses of alternate-day prednisone without breaking the double-blind nature. At the end of 6 months, the group that was changed from daily to alternate-day therapy had declined in strength back to levels observed 12 months previously, at the start of daily therapy. The group in which alternate-day therapy was started showed a significant improvement in strength at 3 months, similar in magnitude to the response of boys treated with daily therapy. However, their strength declined significantly in the subsequent 3 months compared with boys who received daily therapy. The frequency of side effects was not significantly different for alternate-day therapy compared with daily therapy. We conclude that alternate-day prednisone therapy effectively increases strength but does not sustain the improvement to the same extent as daily therapy or mitigate side effects.

Clinical investigation of Duchenne muscular dystrophy. Interesting results in a trial of prednisone.

We investigated the effect of high-dose prednisone therapy in 33 boys with Duchenne muscular dystrophy. The drug was given daily in doses of 1.5 mg/kg of body weight (to a maximum of 80 mg) for six months. Muscle strength, joint contractures, timed functional tests, functional ability, and pulmonary function were measured at the beginning and end of the treatment period. The trial was designed using natural history controls, and the power of the study was 0.80 to detect a slowing of 50% in the rate of progression. During the period of the trial, muscle strength, functional grades, timed functional tests, and pulmonary function improved. Contractures followed the expected natural history of the illness.

Mitochondrial perturbations and oxidant stress in lymphocytes from patients undergoing surgery and general anesthesia.

BACKGROUND: Previous studies have shown that a profound suppression of immune function transiently occurs in patients who undergo surgery under general anesthesia. The decline in the absolute counts of peripheral blood lymphocytes constitutes a major factor accounting for this immune defect, and recent evidence indicates that apoptosis plays a crucial role in determining postsurgical lymphocytopenia. HYPOTHESIS: An altered oxidation-reduction status of mitochondria may contribute through apoptosis to the loss of lymphocytes following surgical trauma and general anesthesia. DESIGN: We studied 16 patients with American Society of Anesthesiologists' physical status I or II who underwent elective surgery under general anesthesia. The data were collected prospectively. SETTING: University hospital. MAIN OUTCOME MEASURES: Samples of peripheral blood were drawn on the day before surgery and at 24 and 96 hours after the operation. Following lymphocyte isolation, the mitochondrial transmembrane potential was assessed by flow cytometry using 3,3'-dihexylocarbo-cyanine iodide, and stains with hydroethidine and 2'-7'-dichlorofluorescein diacetate were used to determine the generation of reactive oxygen species. The labeling of lymphocytes with monobromobimane was used to assess the presence of reduced glutathione. RESULTS: At 24 hours after surgery, we detected a significantly elevated frequency of peripheral blood lymphocytes (P =.002), which incorporated low levels of 3,3'-dihexylocarbo-cyanine iodide, compared with the preoperative period. At this same time point, the frequency of lymphocytes with the hydroethidine- and 2'-7'-dichlorofluorescein diacetate-positive phenotype was elevated compared with baseline levels. Conversely, at 24 hours after surgery, the frequency of cells that stained positive for glutathione was strongly decreased compared with preoperative values. Overall measurements returned to the baseline levels at 96 hours after surgery. CONCLUSION: The strict association we observed between the overproduction of reactive oxygen species and the disruption of the mitochondrial transmembrane potential supports the view that alterations in mitochondrial energy metabolism, paralleled by the presence of a pro-oxidant oxidation-reduction status, could be involved in the accelerated apoptotic loss of lymphocytes following surgical trauma and general anesthesia.

Apoptosis and surgical trauma: dysregulated expression of death and survival factors on peripheral lymphocytes.

BACKGROUND: Surgery and anesthesia cause depression of cell-mediated immunity in the postoperative period, including a reduction in the numbers of circulating lymphocytes. It has been claimed that this immunosuppression is associated with an increased incidence of postoperative infections. HYPOTHESIS: Lymphocytopenia following surgical trauma depends on a dysregulated expression of death/and survival factors associated with apoptosis that, in turn, interferes with the occurrence of postsurgical infections. DESIGN: Fifteen subjects undergoing elective surgery under general anesthesia entered the study. The data of the patients who had infections during the postoperative outcome were compared with the data of those who did not. The data were collected prospectively. MAIN OUTCOME MEASURES: Peripheral blood samples were drawn before the operation, and 24 hours and 96 hours after the operation. Lymphocytes were isolated and examined for quantification and phenotypic analysis of apoptosis using the 7-amino-actinomycin D method, as well as for Fas and Fas ligand, interleukin 1-converting enzyme p20/caspase-1, Bcl-2, and p35 expression. The rate of apoptotic cells was correlated with the incidence of postoperative infections. SETTING: University hospital. RESULTS: Twenty-four hours after surgery, CD4(+) and CD8(+) cells exhibited a significantly higher frequency of apoptosis as well as of Fas and Fas ligand and interleukin 1-converting enzyme p20/caspase-1 expressions than preoperatively. This increase was paralleled by a significant down-regulation of antiapoptotic factors such as Bcl-2. However, the expression of the proapoptotic factor p35 was reduced. In addition, we found a relationship between the rate of the apoptotic CD8(+) subset and the occurrence of infectious complications during the postoperative course. At 96 hours after surgery, the variables studied returned to the baseline levels. CONCLUSIONS: In the early postoperative period, surgical trauma under general anesthesia induces an intracellular perturbation on peripheral lymphocytes, resulting in both up-regulation of death-signaling factors and down-regulation of survival-signaling factors. The increased apoptosis of CD8(+) lymphocytes, but not of CD4(+) cells, seemed to be associated with a greater risk of postsurgical infections.

Serum neopterin and soluble interleukin-2 receptor for prediction of a shock state in gram-negative sepsis.

PURPOSE: This study aimed to investigate the predictive value of neopterin and soluble interleukin-2 (IL-2) receptor for shock occurrence in gram-negative sepsis. METHODS: We examined 57 patients admitted to an intensive care unit with gram-negative sepsis diagnosed according to preestablished criteria. Blood samples were collected every 24 hours and neopterin and soluble IL-2 receptor were measured by using commercially available test kits. To judge the predictive significance of these analyses the Cox proportional hazards regression model was used. RESULTS: Both neopterin (P < .05) and soluble IL-2 receptor (P < .01) were identified as significant predictors of a shock state, but the prognostic strength of neopterin exceeded that of soluble IL-2 receptor. To further assess if other factors could interfere with the predictive significance of both compounds, we also investigated other clinical and laboratory variables but these candidate predictors did not contribute any additional significant predictive information. CONCLUSION: The measurement of serum neopterin and soluble IL-2 receptor concentrations has predictability for identifying patients with gram-negative sepsis at risk for progression toward the syndrome of septic shock.

Heat shock protein (HSP70) expression in septic patients.

PURPOSE: This study investigates heat shock protein 70 (HSP70) expression by peripheral blood mononuclear cells (PBMCs) of septic patients admitted to an intensive care unit and examines the possibility of a correlation between HSP70 levels and plasma tumor necrosis factor alpha (TNF-alpha) concentrations. Additionally, we evaluated whether the HSP70 production could be regarded as a prognostic factor for the development of septic shock as well as for patient survival. MATERIALS AND METHODS: Blood samples of 29 patients were taken 24 hours after the diagnosis of sepsis. HSP70 expression and TNF-alpha level were measured using indirect immunofluorescent analysis and a commercially available enzyme-linked immunosorbent assay method, respectively. RESULTS: PBMCs expressed significantly high levels of HSP70 (11.9 +/- 5.6 [sd]) compared with those of the healthy control group (3.2 +/- 2.1% positive cells). Such enhanced levels were correlated to plasma TNF-alpha concentrations (r = .99, P < .01). This study failed to demonstrate a relationship between HSP70 production and clinical outcome. CONCLUSION: These findings give further evidence that also in humans, heat shock response is activated during sepsis. The correlation observed between HSP70 overproduction and TNF-alpha plasma concentrations suggests that HSP70 exerts a possible protective effect against TNF-alpha cytotoxicity. Such hypothesis has not been confirmed by our clinical data.

Clinical trials in Duchenne dystrophy. Standardization and reliability of evaluation procedures.

A multiclinic, collaborative study has been designed to assess the natural progression and efficacy of treatment of Duchenne muscular dystrophy. This article describes the protocol for the evaluation technique and the method used to establish within (intraobserver) and between (interobserver) reliability of the protocol evaluation procedures. Standardized patient evaluations were used, and consistency of evaluation was monitored by a computer. The reliability of the measures was analyzed 1) within observers by comparing the results of each of the first three tests done by each evaluator for all patients and 2) between observers by comparing, at multicenter group meetings, the results of each of the four evaluators' tests of the same patient. We have demonstrated reliability for an evaluation method that will provide an objective foundation on which to claim a drug or therapeutic procedure does or does not have an effect in treating Duchenne muscular dystrophy.

Intrarater reliability of manual muscle test (Medical Research Council scale) grades in Duchenne's muscular dystrophy.

The purpose of this study was to document the intrarater reliability of manual muscle test (MMT) grades in assessing muscle strength in patients with Duchenne's muscular dystrophy (DMD). Subjects were 102 boys, aged 5 to 15 years, who were participating in a double-blind, multicenter trial to document the effects of prednisone on muscle strength in patients with DMD. Four physical therapists participated in the study. Two identical (duplicate) evaluations were performed within 5 days of each other by the same examiner initially and after 6 and 12 months of treatment. A total of 18 muscle groups were tested on each patient, 16 of them bilaterally, using a modification of the Medical Research Council scale. Reliability of muscle strength grades obtained for individual muscle groups and of individual muscle strength grades was analyzed using Cohen's weighted Kappa. The reliability of grades for individual muscle groups ranged from .65 to .93, with the proximal muscles having the higher reliability values. The reliability of individual muscle strength grades ranged from .80 to .99, with those in the gravity-eliminated range scoring the highest. We conclude the MMT grades are reliable for assessing muscle strength in boys with DMD when consecutive evaluations are performed by the same physical therapist.

General anesthesia mode does not influence endocrine or immunologic profile after open or laparoscopic cholecystectomy.

To verify the impact on stress response and the influence of anesthesia on endocrine/immunologic changes, we have investigated the plasma level of norepinephrine, cortisol, TNFalpha, and IL-6 in 46 patients scheduled for laparotomy and laparoscopic cholecystectomy at 2, 6, 12, and 24 h after the operation. Among subjects who underwent open approach, 9 received fentanyl anesthesia and 13 received isoflurane anesthesia. In the laparoscopy group, 14 patients were given fentanyl anesthesia and 10 were given isoflurane anesthesia. The results obtained confirmed that laparoscopic cholecystectomy is associated with a lesser immunoendocrine response, and the two anesthesia models do not interfere with plasma changes of the assessed hormones and cytokines.

[Consultations at the Poison Center of Rome on pesticide poisoning referrals]. / Consulenze prestate dai Centri Antiveleni di Roma in riferimento a prodotti antiparassitari.

From 1 January 1998 to 31 October 1999 the two Poison Control Centres active in Rome provided 923 telephone consultations for individuals and health care providers on suspected poisonings involving pesticides. Exposures more frequently reported in association with suspected cases were insecticides (n. 636), including organophosphates (n. 300), carbamates (n. 155), pyrethroids (n. 102), and organochlorines (n. 79). Children aged 1-4 years accounted for 22% of all suspected poisonings (n. 200). Each case was classified as to the likelihood of a relationship between the reported pesticide exposure and the occurrence of health effects. Around 18% of suspected pesticide poisonings (n. 168) were subsequently classified as definite, around 43% (n. 390) as possible, and around 37% were considered unlikely (n. 344).

[Naloxone in ethanol overdose after alcoholization of hepatic metastasis]. / Il naloxone nell'overdose da etanolo successiva ad alcolizzazione di metastasi epatiche.

The authors report a case of ethanol-induced coma treated successfully with naloxone, in a subject undergoing liver metastasis alcoholization. A dose of ethanol 95 degrees (150 ml) was injected intraoperatively into the hepatic tumor with ultrasound monitoring, in a 55-year old woman which underwent mastectomy two years ago for breast cancer. At the end of operation that went on for 128 minutes, the patient maintained during surgery with standard NLA II anaesthesia did not awake. Toxicologic testing of blood showed an alcohol concentration of 1.9 g/l. Intra-venous naloxone 2 mg was given in boluses of 0.4 mg, through a time of 30 minutes. The patient became progressively responsive with complete recovery 20 minutes later. Since fentanyl doses administered during general anaesthesia were very low, the authors believe that the postoperative coma was due to ethanol overdose. They suggest naloxone as effective treatment to reverse the depressant effects of ethanol following ultrasonically guided alcohol injection therapy.

[Anesthesiological methods in acoustic neuroma surgery using the translabyrinthine approach]. / Condotta anestesiologica nella chirurgia del neurinoma dell'acustico per via translabirintica.

Removal of acoustic neuromas may often imply anesthesiological as well as surgical problems, especially in the case of large tumors (> 3 cm) which may have come into contact with vital neighbouring structures (brain stem, cerebellum). In this paper the use of two different anesthesiological methods during the translabyrinthine approach is analyzed and discussed in the light of the different needs in this type of surgery. More specifically, anesthesia maintenance was assured by constant infusion of either Propofol (4 mg/kg/h) or Isoflurane (1-1.5%). Withdrawal of curarization was also planned in order to allow the surgeon to take advantage of routine intraoperative facial nerve monitoring. Arterial pressure, CO2 and O2 were assessed at prefixed phases of the operation. Both anesthesiologic methods proved to be satisfactory during the entire surgical procedure. During dissection of the tumoral capsule, an increased heart rate (7% of the initial value) was noticed, whilst in only three patients (with tumors larger than 3.5 cm) a severe bradycardia, which did not respond to Atropine administration and which subsided spontaneously during temporary suspension of surgical manoeuvres, occurred. After this preliminary experience, the Authors believe that both techniques could have a major role in translabyrinthine acoustic tumor surgery and auspicate their further application.

[Effects on ventilation secondary to laparoscopic and laparotomic cholecystectomy]. / Effetti sulla ventilazione secondari a colecistectomia laparoscopica e laparotomica.

OBJECTIVE: Evaluation of respiratory function after 24 hours from intervention related to two different surgical techniques of cholecistectomy. PATIENTS AND METHODS: Thirty patients submitted to cholecystectomy, nine by laparotomy and twenty-one by video-laparoscopy. The ventilatory parameters considered are as follows: CV, FCV, VEF1, FEF25-75%; and moreover also some variables of acid-base balance: pH, paCO2 e paO. RESULTS: In all cases was evidenced a decrease of respiratory activity. This phenomenon was more evident in the laparotomy group (CV = 37, 35, FCV = 41, 47, VEF1 = 40, FEF25-75% = 36.62% related to preoperative values versus 71.20, 80.88, 79.29, 77.91% in the videolaparoscopic group. No significative differences were registered between the two groups as to postoperative paO2, which was moderately lower in all patients, while no variation was observed for pH and paCO2. CONCLUSIONS: Data collected confirm that after laparoscopic cholecystectomy the ventilatory respiratory capacity is better conserved, that clinically means lower incidence of postoperatory pulmonary complications.

TNF alpha released in the early post-operative period is influenced by anaesthesia.

In this study we tested for TNF alpha concentrations 45 subjects undergoing elective prostatectomy performed under two different anaesthetic regimens. In addition, given the influence of neuroendocrine axis on immunological homeostasis, we also determined post surgery cortisol and norepinephrine levels. The patients were randomly assigned to one of two groups: group 1 (no. = 24) received NLA general anaesthesia, whereas group 2 (no. = 21) received spinal analgesia. Blood samples were drawn the day before surgery (t0), at two (t1), at 24 (t2), at 48 (t3) and 72 (t4) hours from the completion of operation. In the patients assigned to the general anaesthesia group an increase of circulating TNF alpha was detected through t1 to t4. In the spinal group TNFa values did not change in t1 and t2, whereas enhanced levels of the cytokine--overlapping with those of group 1--were observed at 48 and 72 hrs following surgery. Cortisol response increased in both the groups, peaking at t1 but, at this time patients undergoing spinal anaesthesia were found to have significantly lower circulating cortisol. A rise of plasma norepinephrine was observed at t1 in the general anaesthesia group alone. For the early TNF alpha increase, observed in group 1 only, we hypothesize that anaesthetics, such as NLA agents, may trigger a TNF alpha release in vivo. Alternatively TNF alpha production may represent the result of the neuroendocrine response such as cortisol and norepinephrine, to the surgical/anaesthetic trauma which could be blocked by subarachnoid anaesthesia. Conversely, the late TNF alpha increase found in all the patients studied might be explained by postoperative infections as well as by inflammation of the injured tissues and/or normal wound healing.

[Neopterin and interleukin 2 soluble receptors as biochemical markers of cellular immune response to surgical trauma]. / Neopterina e recettore solubile dell'interleuchina 2 come indicatori biochimici della risposta immunitaria cellulare al trauma chirurgico.

In 67 patients submitted to surgical procedures serum neopterin (NPT) and Interleukin 2 soluble receptors (IL2R) were evaluated at the end of the operation as well as 24, 48, 72 hours later. Thirty seven of the subjects (Group B) had undergone minor surgery (average time of operation: 40 +/- 10 min.), thirty (Group A) had undergone major surgery (average time: 180 +/- 30 min.). The results showed elevated NPT and IL2R levels in the latter cases and, in particular, 48 and 72 h after surgery. Neopterin levels were positively correlated with IL2R (r = 0.548 p < 0.01). These data suggest an activation of the cellular immune response which parallels the magnitude and length of surgical trauma. Thus NPT and IL2R levels could represent biochemical markers of postoperative disorders of the immune homeostasis.