Is atomised intranasal cocaine systemically absorbed during endoscopic sinus surgery?

BACKGROUND: In order to perform endoscopic sinus surgery (ESS) safely and efficiently, preparation of the nasal mucosa with vasoconstrictor agents is crucial to minimise bleeding. There is no single best method, although traditionally cocaine has been the agent of choice. However, there have been concerns over the potential for systemic side effects when applied topically. With this concern in mind, there exists limited contemporary research looking at cocaine absorption in the context of ESS. This study aims to determine the amount and duration of systemic cocaine absorption after intranasal atomised administration of modified Moffett’s solution prior to ESS. METHODOLOGY: Twelve adults undergoing ESS were enrolled. Modified Moffett's solution containing 100 mg cocaine hydrochloride and 1 mg of adrenaline was administered topically 5 minutes prior to surgery. Serum cocaine and the cocaine degradation product, benzoylecgonine, were measured at specific time points up to 12 hrs post administration. RESULTS: Peak plasma cocaine concentration occurred between 60 and 120 minutes post-administration (range 13-31 micrograms/L). The mean peak plasma concentration was 20.35 micrograms/L occurring at 120 minutes post-administration. Benzoylecgonine was detected in 11 subjects at 60 minutes post-administration and in all subjects 12 hours post-administration of cocaine. CONCLUSIONS: This study demonstrates that there are low levels of systemic absorption of cocaine when administered in an atomised modified Moffett’s formulation prior to endoscopic sinus surgery.

Vapocoolant spray vs subcutaneous lidocaine injection for reducing the pain of intravenous cannulation: a randomized, controlled, clinical trial.

BACKGROUND: We compared the efficacy, acceptability, and safety of a topical vapocoolant alkane spray and 1% plain s.c. lidocaine in reducing pain from i.v. cannulation. METHODS: This was a non-blinded, randomized, controlled trial, in a large emergency department. Adult patients requiring i.v. cannulation were enrolled. The vapocoolant was administered from a pressure pack, at a distance of 12 cm for 2 s, and cannulation was undertaken within 15 s. Alternatively, 1% plain lidocaine 0.2 ml was administered s.c. using a 27 G needle, and cannulation was undertaken after a minimum of 30 s. The primary outcomes were anaesthetic administration and cannulation pain (0-100 mm visual analogue scale). Convenience of anaesthetic use and patient satisfaction were measured using a five-point Likert scale. RESULTS: One hundred and ten patients were enrolled in each group. The groups did not differ in age, gender, cannulation anxiety, cannulator experience, cannulation indication or site, or cannula size. Median anaesthetic administration pain scores were 0 and 11 mm in the vapocoolant and lidocaine groups, respectively (P<0.001). Median cannulation pain scores were 9 and 0 mm, respectively (P<0.001). Vapocoolant was associated with greater cannulation success (83.6% vs 67.3%, P=0.005), less time to administer (median 9.0 vs 84.5 s, P<0.001), and more staff convenience (median 5 vs 4, P<0.001). Median patient satisfaction was 4 in both groups. Unexpected events were rare and minor. CONCLUSIONS: Although vapocoolant reduces cannulation pain less than lidocaine, it has a number of important advantages. Vapocoolant offers a useful alternative in the emergency department setting.

Role still exists for cycler therapy in anuric patients with a low-transport membrane.

It is generally believed that, to achieve adequacy targets, anuric patients with a low-transport membrane should be treated by continuous ambulatory peritoneal dialysis (CAPD) or CAPD with a night-exchange device. If adequacy targets are not reached, it is suggested that patients should be changed to hemodialysis. We would like to show that a role still exists for cycler + therapy (cycler therapy with a wet day or with only one manual exchange) in these patients, both for obtaining target Kt/V and for lifestyle. Using the PD Adequest computer program (Baxter Healthcare Corporation, Deerfield, IL, U.S.A.), we compared a night-exchange device [3 exchanges during the day and 2 exchanges during the night (3 + 2)] to various regimes of cycler + therapy. In all cases, the night-exchange volume exceeded the day-exchange volume by 500 mL. Using cycler + therapy in anuric patients with a low-transport membrane, with 6-7 exchanges over 9 hours, Kt/V can be increased by 10%-25%. A role therefore still exists for cycler + therapy in anuric patients with a low-transport membrane for lifestyle or to achieve a better Kt/V. Unfortunately, we saw no significant improvement in creatinine clearance.

Diabetic patients on peritoneal dialysis need less erythropoietin to maintain adequate hemoglobin.

Peritoneal dialysis (PD) patients have been shown to require less erythropoietin as compared with hemodialysis (HD) patients to maintain similar hemoglobin values. In our unit, we observed that diabetic PD patients required less erythropoietin treatment than did other PD patients. We therefore compared the amount of erythropoietin needed in diabetic and non diabetic patients on PD to maintain a similar hemoglobin value. All polycystic patients were excluded from the study because they rarely require erythropoietin. We also excluded patients with bone marrow disease, active gastrointestinal bleeding, or patients very resistant (requiring more than 25,000 U per week) to Eprex (recombinant human erythropoietin: Janssen-Cilag, North York, Ontario, Canada). Patients not requiring Eprex were also excluded from the study. We calculated the weekly erythropoietin dose in the two groups. We also compared hemoglobin level, iron transferrin saturation, vitamin?12 level, and serum folate. Diabetic patients required a lower weekly erythropoietin dose. Diabetic PD patients in our unti receive an average 4497 U per week compared with 7593 U per week for non diabetic PD patients. The difference (approximately 3000 U per week) is statistically significant.

Comparing an additional hour of cycler therapy to an additional midday exchange to achieve adequacy targets.

As CAPD patients lose residual renal function, adequate dialysis is frequently impossible to obtain unless the dialysis prescription is changed. For patients already on cycler therapy with a "wet" day, we compared the advantage of adding one hour on the cycler to adding an extra, midday exchange. To compare the two approaches, we used a commercial computer program to optimize solute clearance in 90 patients. Adding one hour of cycler therapy increases Kt/V and creatinine clearance (CrCl) by approximately 6.4%-8%. When a midday exchange is added, the increase in Kt/V and CrCl varies between 17.5% and 21.6%. We conclude that adding an extra, midday exchange always gives a better increase in weekly Kt/V and CrCl than that obtained by adding an extra hour of cycler therapy.

The importance of an extra hour of cycler therapy to obtain better adequacy.

As continuous ambulatory peritoneal dialysis (CAPD) patients lose residual renal function, it frequently becomes impossible from them to obtain adequate dialysis unless the dialysis prescription is changed. Increasing the dwell volumes, increasing the frequency of exchanges, and using a night-exchange device or a cycler are the means available to improve adequacy. In an effort to obtain dialysis adequacy, we studied how an extra hour on cycler therapy can contribute to improving dialysis adequacy. Over 18 months, we optimized solute clearance using the PD Adequest program (Baxter Healthcare Corporation, Chicago, Illinois, U.S.A.) in 70 patients. After finding the best total cycler volume, we compared the weekly creatinine clearance and weekly Kt/V from 8-hour cycler therapy to that from 9-hour cycler therapy for the four types of membrane transport. Adding one extra hour on cycler therapy improved weekly creatinine clearance by 3-6.5 L and the weekly Kt/V by 0.16-0.20. When patients are marginally approaching the required weekly Kt/V or creatinine clearance, an extra hour on the cycler may help to achieve the desired adequacy.

Transfusion and recombinant human erythropoietin requirements differ between dialysis modalities.

BACKGROUND: Before the routine use of recombinant human erythropoietin (rHuEpo), patients dialysed by peritoneal dialysis (PD) received fewer blood transfusions than patients on haemodialysis (HD). We compared transfusion practices in these groups now that the use of rHuEpo has become standard, while controlling for variables known to influence anaemia of end-stage renal disease (ESRD). Maintenance rHuEpo doses were also compared. METHODS: Data were examined for 157 HD and 126 PD patients during a 2-year period. Potential confounders included age, gender, albumin, iron deficiency, parathyroid hormone (PTH), underlying renal disease, comorbid illness, renal transplant, dialysis adequacy and duration. An intent-to-treat analysis was used, with sensitivity analyses to account for change in treatment and transplant. RESULTS: Mean haemoglobin (Hb) was not different (10.47 g/dl for HD, 10.71 g/dl for PD; P = 0.45). Mean monthly transfusion rate was higher for HD (0.47 units per month vs 0.19; P < 0.01). More HD patients received at least one transfusion (52.9 vs 40.9%; P < 0.01). The maintenance rHuEpo dose was higher for HD (7370 U/week vs 5790 U/week; P = 0.01). The only factors associated with risk of being transfused were dialysis duration and mode of dialysis (less risk for PD, odds-ratio 0.57; 95% confidence interval 0.35-0.92). CONCLUSIONS: Despite the routine use of rHuEpo, HD patients received more blood and rHuEpo than PD patients to achieve the same Hb. No patient factors were identified to account for this difference. The use of fewer transfusions and less rHuEpo in PD represents an advantage over HD in terms of both cost and safety.

CAPD with a night-exchange device is the only true CAPD?

In the treatment of uremia with continuous ambulatory peritoneal dialysis (CAPD), the long-night dwell has always been a problem because of fluid retention. The purposes of the study were, firstly, to compare the solute clearance between five exchanges a day using standard CAPD, with a long-night dwell, to the clearance obtained with five exchanges a day using CAPD with the night-exchange device (NXD), in which case a more even distribution of the exchanges over 24 hours is obtained. A second aim of the study was to identify the best obtainable solute clearance: CAPD with the night-exchange device, or a cycler with a wet day. In the past year and a half, we have optimized solute clearance, using the PD Adequest program in 60 patients. The five-exchanges-a-day CAPD with the night-exchange device always gives a better solute clearance than standard CAPD with five exchanges a day and the long-night dwell. Solute clearance was always better with CAPD with NXD, except for Kt/V in patients with high membrane transport, compared to cycler therapy with a wet day. High-dose cycler therapy with a wet day plus a midday exchange always gives a better solute clearance than CAPD with NXD.

Important cost differences of blood transfusions and erythropoietin between hemodialysis and peritoneal dialysis patients.

Based on our previous study [House AA, Pham B, Pagé DE. Perit Dial Int 1997; 17(Suppl 1):S74.], we compared the costs of blood transfusions and erythropoietin for 90 peritoneal-dialysis (PD) patients with those of 90 hemodialysis (HD) patients over a 1-year period. The mean monthly transfusion rate was higher in the HD group (0.47 units per month versus 0.19 per month for the PD group: P < 0.01). The maintenance erythropoietin dose was higher for HD (7370 units/week versus 5970 units/week: P < 0.01). There was an average of 507 transfusions per year in the HD group (Cdn $152,280) compared to 205 transfusions per year in the PD group (Cdn $61,500). Since HD patients required more erythropoietin than the PD patients, the cost for the 90 HD patients per year was (Cdn $460,463) compared to (Cdn $361,747) for the 90 PD patients. Combining the annual costs of both blood transfusions and erythropoietin, the 90 patients on HD cost Cdn $189,435 more than the 90 PD patients, a difference of Cdn $2105 per patient.

Ulysses above the sun's south pole: an introduction.

Ulysses has explored the field and particle environment of the sun's polar region. The solar wind speed was fast and nearly constant above -50 degrees latitude. Compositional differences were observed in slow (low-latitude) solar wind and in fast (high-latitude) solar wind. The radial magnetic field did not change with latitude, implying that polar cap magnetic fields are transported toward the equator. The intensity of galactic cosmic rays was nearly independent of latitude. Their access to the polar region is opposed by outward-traveling, large amplitude waves in the magnetic field.

Ulysses charged particle measurements between 1 and 5 AU from the sun.

Proton fluxes obtained by two instruments carried on the ESA/NASA Ulysses spacecraft are reported for the period from launch in October 1990 till Jupiter encounter in February 1992. Proton energy ranges are 24-59, 71-99, 130-320, 320-2100 and > 2100 MeV. The Sun was very active during this period, the events of March 1991 being some of the largest of the solar cycle. The relationship between events on the Sun and the observed proton flux is discussed.

Poor ultrafiltration during nighttime dialysis in CAPD patients and its effects on fluid balance.

To evaluate fluid retention during the long nighttime peritoneal dwell in continuous ambulatory peritoneal dialysis (CAPD) patients, we measured remaining volumes in 70 patients. In only 50% of these patients were more than 2 L of fluid recovered; in 30% between 1.5 and 2 L were recovered; and in 17% of patients we retrieved less than 1.5 L of peritoneal fluid. In 3 of these patients, who were edematous and had marked pitting edema, we shortened the nighttime dwell by having the patients awaken after 4 hours and drain the dwell. This resulted in 3-5 kg of weight loss in each patient, when compared with each patient's previous use of long nighttime dwells. Finally, we propose in this report two automated methods whereby the period of nighttime dialysis can be controlled, while patients sleep, using a system of timer clamps.

Ulysses at jupiter: an overview of the encounter.

In February 1992, the Ulysses spacecraft flew through the giant magnetosphere of Jupiter. The primary objective of the encounter was to use the gravity field of Jupiter to redirect the spacecraft to the sun's polar regions, which will now be traversed in 1994 and 1995. However, the Ulysses scientific investigations were well suited to observations of the Jovian magnetosphere, and the encounter has resulted in a major contribution to our understanding of this complex and dynamic plasma environment. Among the more exciting results are (i) possible entry into the polar cap, (ii) the identification of magnetospheric ions originating from Jupiter's ionosphere, lo, and the solar wind, (iii) observation of longitudinal asymmetries in density and discrete wave-emitting regions of the lo plasma torus, (iv) the presence of counter-streaming ions and electrons, field-aligned currents, and energetic electron and radio bursts in the dusk sector on high-latitude magnetic field lines, and (v) the identification of the direction of the magnetic field in the dusk sector, which is indicative of tailward convection. This overview serves as an introduction to the accompanying reports that present the preliminary scientific findings. Aspects of the encounter that are common to all of the investigations, such as spacecraft capabilities, the flight path past Jupiter, and unique aspects of the encounter, are presented herein.

Energetic Charged-Particle Phenomena in the Jovian Magnetosphere: First Results from the Ulysses COSPIN Collaboration.

The Ulysses spacecraft made the first exploration of the region of Jupiter's magnetosphere at high Jovigraphic latitudes ( approximately 37 degrees south) on the dusk side and reached higher magnetic latitudes ( approximately 49 degrees north) on the day side than any previous mission to Jupiter. The cosmic and solar particle investigations (COSPIN) instrumentation achieved a remarkably well integrated set of observations of energetic charged particles in the energy ranges of approximately 1 to 170 megaelectron volts for electrons and 0.3 to 20 megaelectron volts for protons and heavier nuclei. The new findings include (i) an apparent polar cap region in the northern hemisphere in which energetic charged particles following Jovian magnetic field lines may have direct access to the interplanetary medium, (ii) high-energy electron bursts (rise times approximately 17 megaelectron volts) on the dusk side that are apparently associated with field-aligned currents and radio burst emissions, (iii) persistence of the global 10-hour relativistic electron "clock" phenomenon throughout Jupiter's magnetosphere, (iv) on the basis of charged-particle measurements, apparent dragging of magnetic field lines at large radii in the dusk sector toward the tail, and (v) consistent outflow of megaelectron volt electrons and large-scale departures from corotation for nucleons.

Serum sodium concentration and plasma renin activity in CAPD patients.

Hyponatremia is not uncommon in patients on CAPD, despite the presence of an intraabdominal solution that should preserve normal serum sodium concentration. We have examined the relationship between the plasma renin level and serum sodium concentration in our CAPD patients. Patients with abnormal causes for increased thirst were removed from the study; that is, diabetic patients with fluctuating blood sugar or patients on tricyclic antidepressants or clonidine. In forty-one patients a statistically significant inverse correlation between serum sodium and plasma renin levels was demonstrated. We conclude that thirst stimulation by the renin-angiotensin system contributes to the hyponatremia seen in many patients on CAPD.

Mycoplasma gallisepticum (MG)--laboratory and field studies evaluating the safety and efficacy of an inactivated MG bacterin.

A highly antigenic isolate of Mycoplasma gallisepticum (MG) was utilized in the production of an inactivated, oil-emulsified MG bacterin (MGB). Laboratory tests indicated that the bacterin was capable of protecting chickens from clinical signs of MG caused by intrasinus challenge with the R, S-6, PG-31, or 1150 strain of MG. Vaccinated turkeys also were protected from clinical signs of disease when challenged with MG. Use of the MGB in chickens under laboratory conditions resulted in a reduction in airsacculitis from 44% in nonvaccinates to 10% in vaccinates and further reduced the number of organisms present in the trachea post-challenge. Commercial chickens vaccinated subcutaneously midway or lower in the nape of the neck showed no untoward effects due to the bacterin. Those improperly vaccinated at the base of the skull developed a transient edema around the eye(s). This swelling did not appear to affect the performance of the chickens and had been reabsorbed by the next observation period. Subcutaneous inoculation should be at the mid or lower neck region. Field trials at a commercial egg operation comparing production efficiency showed that chickens vaccinated with the MGB had higher egg production, a greater percentage of eggs graded large and over, a smaller percentage of undergrades, and better feed conversion than chickens vaccinated with a live-culture, low-virulence Conn-F strain vaccine. The results of these studies indicate that the oil-emulsified MG bacterin is safe and highly efficacious.