Contrasting opioid use for pain management in microvascular head and neck reconstruction: an international study.

Opioids are often the mainstay of postoperative pain management, despite strong evidence of their ill effects and potential for long-term addiction. The goal of this study was to quantify opioid use and contrast pain management strategies of multiple international institutions performing fibula free flap reconstruction. A retrospective multicenter cohort study was designed, including five international centers. For inclusion, the patients had to have undergone a primary fibula free flap reconstruction of the mandible. A total of 185 patients were included. The median opioid use across all centers at 72 hours was 133 oral morphine equivalents. The highest utilization was in the USA (P < 0.001), which was approximately six times that of Italy, four times that of Argentina, and twice that of India, despite all centers performing a similar procedure. Based on this study there are clear differences in prescribing practices and ideologies among surgeons from different countries.

Validated image ordering guidelines for odontogenic infections.

Overuse of computed tomography (CT) is a prevalent problem across multiple disciplines in healthcare and is common in the workup of odontogenic infections. To address this problem, an imaging pathway was created through collaboration of the oral maxillofacial surgery and emergency medicine departments to reduce unnecessary CT orders. A prospective study was implemented to assess the success of the imaging pathway to guide in the selection of the most appropriate radiological imaging modality when managing an odontogenic infection. Subjects included were adults, presenting through the emergency department for confirmed odontogenic infection. The primary outcome was the rate of unnecessary CT scans performed after the introduction of the pathway. Statistics were performed via the t-test, χ2 test, and multiple regression analysis; P < 0.05 was considered significant. Between February 1 and December 15, 2019, 100 patients met the inclusion criteria and were enrolled. The rate of unnecessary CT scans was 25.6%, compared to 56.6% prior to the introduction of the imaging pathway. The pathway did not misclassify any patient to not receive a CT when it was medically necessary. Use of the imaging pathway has the potential to reduce unnecessary CT imaging for odontogenic infections, without negatively affecting patient outcomes.

The radiosensitizing agent 7-hydroxystaurosporine (UCN-01) inhibits the DNA damage checkpoint kinase hChk1.

The investigational anticancer agent 7-hydroxystaurosporine (UCN-01) abrogates the G2 checkpoint in tumor cells and sensitizes them to the lethal effects of genotoxic anticancer agents. On the basis of the role of the Cdc25C phosphatase in maintenance of this damage-inducible checkpoint, we hypothesized that UCN-01 inhibits a component of the signal transduction pathway that modulates Cdc25C phosphorylation. Of the three kinases known to phosphorylate Cdc25C on Ser216, both checkpoint kinase 1 (hChk1) and Cdc25C-associated protein kinase 1 (cTAK1) were potently inhibited by UCN-01 with IC50s of 11 and 27 nM, respectively. Treatment of K562 erythroblastoid leukemia cells with similar drug concentrations resulted in decreased levels of Ser216 phosphorylation of Cdc25C and complete disruption of the y-radiation-induced G2 checkpoint. In contrast to hChk1, the hChk2 kinase was 100-fold more resistant to inhibition by UCN-01 (IC50, 1040 nM). These results suggest that disruption of the DNA damage-induced G2 checkpoint by UCN-01 is mediated through the inhibition of the Cdc25C kinases, hChk1 and cTAK1, and that hChk2 activity is not sufficient to enforce the G2 checkpoint in cells treated with a pharmacological inhibitor of hChk1.

Inhibition of phosphoinositide 3-kinase related kinases by the radiosensitizing agent wortmannin.

Members of the phosphatidylinositol-3 kinase related kinase (PIKK) family function in both cell cycle progression and DNA damage-induced cell cycle checkpoints. The fungal metabolite, wortmannin, is an effective radiosensitizer that irreversibly inhibits certain members of the PIKK family. Based on their roles in DNA damage responses, several PIKKs, DNA-dependent protein kinase (DNA-PK), ataxia telangiectasia mutated (ATM) and the ataxia- and Rad3-related protein (ATR), are potential targets for the radiosensitizing effect of wortmannin. In this report, we demonstrate that wortmannin is a relatively potent inhibitor of DNA-PK (IC50, 16 nM) and ATM (IC50, 150 nM) activities, whereas ATR activity is significantly less sensitive to this drug (IC50, 1.8 microM). In intact A549 lung adenocarcinoma cells, wortmannin inhibited both DNA-PK and ATM at concentrations that correlated closely with those required for radiosensitization. Furthermore, pretreatment of A549 cells with wortmannin resulted in radioresistant DNA synthesis, a characteristic abnormality of ATM-deficient cells. These results identify wortmannin as an inhibitor of ATM activity and suggest that ATM and DNA-PK are relevant targets for the radiosensitizing effect of this drug in cancer cells.

Inhibition of ATM and ATR kinase activities by the radiosensitizing agent, caffeine.

Caffeine exposure sensitizes tumor cells to ionizing radiation and other genotoxic agents. The radiosensitizing effects of caffeine are associated with the disruption of multiple DNA damage-responsive cell cycle checkpoints. The similarity of these checkpoint defects to those seen in ataxia-telangiectasia (A-T) suggested that caffeine might inhibit one or more components in an A-T mutated (ATM)-dependent checkpoint pathway in DNA-damaged cells. We now show that caffeine inhibits the catalytic activity of both ATM and the related kinase, ATM and Rad3-related (ATR), at drug concentrations similar to those that induce radiosensitization. Moreover, like ATM-deficient cells, caffeine-treated A549 lung carcinoma cells irradiated in G2 fail to arrest progression into mitosis, and S-phase-irradiated cells exhibit radioresistant DNA synthesis. Similar concentrations of caffeine also inhibit gamma- and UV radiation-induced phosphorylation of p53 on Ser15, a modification that may be directly mediated by the ATM and ATR kinases. DNA-dependent protein kinase, another ATM-related protein involved in DNA damage repair, was resistant to the inhibitory effects of caffeine. Likewise, the catalytic activity of the G2 checkpoint kinase, hChk1, was only marginally suppressed by caffeine but was inhibited potently by the structurally distinct radiosensitizer, UCN-01. These data suggest that the radiosensitizing effects of caffeine are related to inhibition of the protein kinase activities of ATM and ATR and that both proteins are relevant targets for the development of novel anticancer agents.

Novel role for prostaglandin E2 in fish hepatocytes: regulation of glucose metabolism.

Prostaglandin E(2) (PGE(2)) potently activated glycogenolysis and gluconeogenesis in isolated rockfish (Sebastes caurinus) hepatocytes. The average degree of activation for glycogenolysis was 6.4+/-0.67-fold (mean+/-S.E.M.; n=37), and could be as much as 19-fold. Analysis of dose-concentration relationships between glycogenolytic actions and PGE(2) concentrations yielded an EC(50) around 120 nM in hepatocyte suspensions and 2 nM for hepatocytes immobilized on perifusion columns. For the activation of gluconeogenesis (1.74+/-0.14-fold; n=10), the EC(50) for suspensions was 60 nM. Intracellular targets for PGE(2) actions are adenylyl cyclase, protein kinase A and glycogen phosphorylase. Concentrations of cAMP increased with increasing concentrations of PGE(2), and peaked within 2 min of hormone application. In the presence of the phosphodiesterase inhibitor, isobutyl-3-methylxanthine, peak height was increased and peak duration extended. The protein kinase A inhibitor, Rp-cAMPS, counteracted the activation of glycogenolysis by PGE(2), implying that the adenylyl cyclase/protein kinase A pathway is the most important, if not exclusive, route of message transduction. PGE(2) activated plasma membrane adenylyl cyclase and hepatocyte glycogen phosphorylase in a dose-dependent manner. The effects were specific for PGE(2); smaller degrees of activation of glycogenolysis were noted for PGE(1), 11-deoxy PGE(1), 19-R-hydroxy-PGE(2), and prostaglandins of the A, B and Falpha-series. The selective EP(2)-receptor agonist, butaprost, was as effective as PGE(2), suggesting that rockfish liver contains prostaglandin receptors pharmacologically related to the EP(2) receptors of non-hepatic tissues of mammals. Rockfish hepatocytes quickly degraded added PGE(2) (t((1/2))=17-26 min). A similar ability to degrade PGE(2) has been noted in catfish (Ameiurus nebulosus) hepatocytes, but no glycogenolytic or gluconeogenic actions of the hormone are noted for this species. We conclude that PGE(2) is an important metabolic hormone in fish liver, with cAMP-mediated actions on glycogen and glucose metabolism, and probably other pathways regulated by cAMP and protein kinase A. The constant presence of EP(2)-like receptors is a unique feature of the fish liver, with interesting implications for function and evolution of prostaglandin receptors in vertebrates.

Malignant epibulbar melanoma: natural history and treatment by radiotherapy.

One hundred and eighty-four cases of malignant melanoma of the lids and epibulbar region were seen in the Radiotherapy Department of the Royal Marsden Hospital during the period 1943-74. Some of these tumours were radiosensitive and could thus be treated by radiotherapy without loss of the affected eye. Their clinical and histological features are described. The treatment policy adopted was based on radiotherapy first, and surgery reserved for the failures. A policy of observation is advised for precancerous melanosis, and active treatment should be undertaken only if malignancy supervenes. The contraindications for radiotherapy, the factors governing radiosensitivity, and the incidence and site of metastases are reported, and the possible effect on the metastatic and survival rates of leaving the eye are discussed. Active treatment of the node-free neck is not advised. Results are given according to site, histology, and treatment method, and the frequency with which the eye was lost is shown, since the sole advantage of radiotherapy over surgery is the possibility of saving the eye without worsening the prognosis for survival.

Dinoflagellate sterols I: Sterol c omposition of the dinoflagellates of Gonyaulax species.

The sterol composition of five species of dinoflagellates of the family Gonyaulacaeae (Div. Pyrrhophyta) were examined. All the five species (Gonyaulax acatenella, G. tamarensis, G. catennela, G. washing-tonesis, and G. polyedra) were found to contain 4 alpha-23,24(R)-trimethyl-5 alpha-cholest-22-en-3 -ol (dinosterol) and cholesterol as major sterols.

Alcohol use patterns of graduate students in social work and in business.

This comparative study is among the first to survey the drinking behavior of graduate students in social service (N = 256) and in business (N = 147). A large majority (88%) drank. A significantly greater number of social service students abstained. Irrespective of school, age or religion, men and women drank at a similar level of frequency--several times weekly. Only business school women, controlling for age and religion, were significantly heavier drinkers than were women in social service. Older Hispanic social service men were significantly lighter drinkers than similar Caucasians. All women preferred wine, whereas men had no particular beverage preference. Although there was no significant difference in the location of drinking--in bars, restaurants or at home--most students drank in restaurants. Irrespective of previous course work or work experience with alcoholics, social service students wanted alcohol education. However, business students showed almost no interest in this area of study, despite the known deleterious role that alcohol misuse plays in the employment arena. Major conclusions are that both business and social service students lack alcohol education, although most drink. This is an important blind spot among business students, who will be making critical business decisions. It is also inadequate preparation for social service practice.

Confrontation naming of familiar sounds and pictures by individuals with Down syndrome.

We investigated whether adolescents and young adults with Down syndrome experience difficulty in finding words to name familiar objects. In Experiment 1, IQ- and MA-matched individuals with Down syndrome and with mental retardation due to other causes orally identified familiar pictures and sounds. Results showed no evidence of syndrome-specific word-finding difficulty in accuracy or speed. Although both groups identified auditory stimuli less accurately and more slowly than visual stimuli, results of Experiments 2 and 3 confirmed that young children without mental retardation and college students showed the same pattern. Although previous researchers have shown expressive speech deficits among people with Down syndrome, these results suggest that adolescents and young adults with Down syndrome show no syndrome-specific difficulty in finding words to label familiar nonverbal sounds or pictures.

Molecular analysis of the koala reproductive hormones and their receptors: gonadotrophin-releasing hormone (GnRH), follicle-stimulating hormone ß and luteinising hormone ß with localisation of GnRH.

During evolution, reproductive hormones and their receptors in the brain-pituitary-gonadal axis have been altered by genetic mechanisms. To understand how the neuroendocrine control of reproduction evolved in mammals, it is important to examine marsupials, the closest group to placental mammals. We hypothesised that at least some of the hormones and receptors found in placental mammals would be present in koala, a marsupial. We examined the expression of koala mRNA for the reproductive molecules. Koala cDNAs were cloned from brain for gonadotrophin-releasing hormones (GnRH1 and GnRH2) or from pituitary for GnRH receptors, types I and II, follicle-stimulating hormone (FSH)ß and luteinising hormone (LH)ß, and from gonads for FSH and LH receptors. Deduced proteins were compared by sequence alignment and phylogenetic analysis with those of other vertebrates. In conclusion, the koala expressed mRNA for these eight putative reproductive molecules, whereas at least one of these molecules is missing in some species in the amniote lineage, including humans. In addition, GnRH1 and 2 are shown by immunohistochemistry to be expressed as proteins in the brain.

Alcohol use among graduate business administration students.

This study of fully employed master's students in a graduate school of business administration found no significant differences in the drinking levels of men and women. The majority are heavy drinkers. There is a tendency for female and Jewish students to prefer wine. Despite the role that beverage alcohol plays in the corporate world, few students were interested in alcohol education.

Cell volume affects glycogen phosphorylase activity in fish hepatocytes.

The activity of glycogen phosphorylase (GPase) in the active a-form (GPase a) is dependent on the hydration state of hepatocytes. We establish that GPase a catalysis in catfish (Ameiurus nebulosus) hepatocytes is a function of medium osmolarity and that a linear relationship exists between GPase a activity and osmolarity between 254 mosmol l(-1) and 478 mosmol l(-1). Exposure of isolated hepatocytes to hyperosmotic media increases enzyme activity up to 7-fold, indicative of covalent phosphorylation. GPase activation associated with cell shrinkage peaks within 10 min of exposure. The average degree of activation (2.7-fold-increase of GPase a) is only slightly less than in hepatocytes exposed to glucagon (3.1-fold-increase) under isosmotic conditions; with glucagon, the maximum is reached within 2 min. Phosphorylation status remains elevated during the entire 40 min experimental period; cells do not undergo regulatory volume increase (RVI) during this period and do not regain pre-exposure volume. We interpret the increased GPase a activity as an inherent response to hyperosmotic stress, likely brought about by molecular crowding. Activation of the enzyme results in increased glucose production from endogenous glycogen. Glucose is not retained in the liver cells, but may act as an oxidative substrate in extrahepatic tissues for the increased metabolic demand of ion regulation. Protein kinase A or intracellular Ca(2+) make apparently small contributions to the activation of GPase, leaving us to speculate on alternate routes of enzyme activation. Conversely, hepatocyte swelling in hyposmotic medium leads to significant decreases in GPase a activity and curtailed glucose output. A minimum is attained in 10 min, and pre-insult rates are re-established within 40 min, somewhat lagging behind readjustment in cell volume by regulatory volume decrease (RVD). We conclude that cell swelling and subsequent RVD do not signify stress to the cells and metabolic demand may be decreased under cell swelling conditions. Alteration of GPase phosphorylation with extracellular osmolarity appears to be a general phenomenon, since we also find it in hepatocytes of another freshwater catfish (Clarias batrachus) and a marine scorpaenid (Sebastes caurinus).

Hand-assisted laparoscopic vs the open (flank incision) approach to radical nephrectomy.

OBJECTIVE: To compare the outcome in contemporaneous groups of patients undergoing hand-assisted laparoscopic radical nephrectomy (HALRN) or open (flank) radical nephrectomy (ORN), as many series worldwide have confirmed the feasibility and advantages of LRN in managing renal cell carcinoma (RCC). PATIENTS AND METHODS: We retrospectively evaluated 44 patients who underwent radical nephrectomy for RCC from 1999 to 2001, 22 by HALRN and 22 by ORN, through an extraperitoneal 11th or 12th rib flank incision. Standard perioperative variables were assessed; a validated questionnaire was also sent to each patient after surgery, allowing them to report their overall satisfaction and the period needed for them to return to both routine and full activities. The outcomes of HALRN and ORN were compared using Wilcoxon rank-sum analysis. RESULTS: There was a statistically significant difference between HALRN and ORN in operative duration, length of hospital stay, total narcotic requirement, pain scores at 1 week and 1 month after surgery, and the time to resume routine and full activity, with all variables (except operative duration) lower in the HALRN group. There were no significant differences between the groups in pain at 1-3 days, estimated blood loss or overall satisfaction. CONCLUSION: Compared with ORN, HALRN is associated with lower narcotic requirement, pain scores, a shorter hospital stay and earlier resumption of routine and full activities. However, several obstacles remain, including increased operative duration and the increased equipment costs.

Improved results in combination chemotherapy of head and neck cancer using a kinetically-based approach: a randomised study with and without adriamycin.

One hundred and seventeen patients with advanced squamous cell carcinoma of the head and neck were randomised between two combination schedules, one with and the other without adramycin. Responses (more than 50% tumor regression) were 67% overall with 63% responding to the combination without adriamycin and 82% responding to the schedule containing it. The increase in response rate seen with the addition of adriamycin is not statistically significant. Prior radiotherapy reduced the likelihood of response to chemotherapy.

Glutamine synthetase in tilapia gastrointestinal tract: zonation, cDNA and induction by cortisol.

Glutamine synthetase, an enzyme generally associated with ammonia detoxication in the vertebrate brain and with hepatic nitrogen turnover in mammals, shows substantial activities in the gastrointestinal tract of teleostean fishes. Enzyme activity is highest in the central area of the stomach and reveals a distinct distribution pattern in stomach and along the intestine of tilapia (Oreochromis niloticus), rainbow trout (Oncorhynchus mykiss) and copper rockfish (Sebastes caurinus). In all three species, intestinal activity peaks in the distal region of the intestine. The brain contains the highest titre of the enzyme (46 U g(-1) in tilapia brain versus 15 U g(-1) in tilapia stomach), but because of the relative mass of the stomach, the largest glutamine synthetase pool in tilapia body appears to be localized in the stomach. Activities in white and red muscle are very modest at 0.1% of the brain. Independent of distribution, peak activities of glutamine synthetase in selected areas of tilapia stomach and intestine are significantly (two- to fourfold) increased after a 5-day treatment with an intraperitoneal cortisol deposit. Cortisol also increases glutamine synthetase activity in tilapia liver, white and red muscle, while activities in brain remain unaffected. We cloned and sequenced the predominant transcript of tilapia stomach glutamine synthetase (about 1.9 kb), encoding a 371-amino acid peptide. The open reading frame shows considerable identity with glutamine synthetase in toadfish (92% at peptide level, 87% at nucleotide level), but possesses a longer 3'-untranslated region than the toadfish. The tilapia glutamine synthetase mRNA contains a remnant of a putative mitochondrial leader sequence, but without a conserved second site for initiation of translation. We also find evidence for additional transcripts of glutamine synthetase in tilapia, suggesting multiple genes. Finally, we present evidence for similar abundance of glutamine synthetase transcripts in all regions of rockfish intestine. The physiological significance of the presence of glutamine synthetase in teleostean intestine is discussed.