Peri-operative continuation of metformin does not improve glycaemic control in patients with type 2 diabetes: A randomized controlled trial.

Historically, metformin was withheld before surgery for fear of metformin-associated lactic acidosis. Currently, however, this risk is deemed to be low and guidelines have moved towards the continuation of metformin. We hypothesized that continuing metformin peri-operatively would lower postoperative serum glucose level without an effect on plasma lactate levels. We performed a single-blind multicentre randomized controlled trial in people with type 2 diabetes mellitus scheduled for non-cardiac surgery and continued (MF+ group) or withheld (MF- group) metformin before surgery. The main outcome measures were the differences in peri-operative plasma glucose and lactate levels. We randomized 70 patients (37 MF+ group and 33 MF- group) with type 2 diabetes mellitus. Postoperative glucose levels were similar in the MF+ and the MF- groups (8.2 ± 1.8 vs 8.3 ± 2.3 mmol/L P = .95) Although preoperative lactate levels were slightly higher in the MF+ group compared with the MF- group (1.5 vs 1.2 mmol/L; P = .02), the postoperative lactate levels were not significantly different (1.2 vs 1.0 mmol/L; P = .18). In conclusion, continuation of metformin during elective non-cardiac surgery does not improve glucose control or raise lactate levels to a clinically relevant degree.

Duloxetine in patients with central neuropathic pain caused by spinal cord injury or stroke: a randomized, double-blind, placebo-controlled trial.

The mechanisms underlying central neuropathic pain are poorly understood. Pain inhibitory mechanisms including sertononergic and norepinephrine systems may be dysfunctional. In this randomized, double-blinded, placebo-controlled trial we evaluated the effects of duloxetine on pain relief (spontaneous pain and evoked pain), tolerability, health status, and quality of life in patients with central pain related to cerebrovascular lesions or spinal cord lesions. At baseline and eight weeks following start of treatment subjects were evaluated with standard measures of efficacy: pain intensity (primary efficacy variable), quantitative sensory testing, health status and quality of life (secondary efficacy variables). Forty-eight patients received escalating doses of either duloxetine (60 and 120mg/day) or matching placebo capsules. In both groups, patients started with 1 capsule per day. If pain relief was insufficient, patients were titrated to a higher dose. A trend towards a decrease in mean pain score after eight weeks was observed for duloxetine treatment (p=0.056). Duloxetine alleviated dynamic (p=0.035) and cold allodynia (p<0.001) significantly better than placebo. Tactile pain and pressure pain thresholds did not improve significantly. The duloxetine group showed a significant improvement for the bodily pain domain of the SF36 (p=0.035). No significant differences were observed in the other domains of the SF36, the Pain Disability Index, and the EQ-5D. While this trial showed no significant effect on pain intensity, duloxetine revealed a biologic effect. It would be worthwhile to suspend our judgement and to perform more studies to evaluate the role of duloxetine in modulation of the symptoms of central neuropathic pain.

The influence of force feedback and visual feedback in grasping tissue laparoscopically.

BACKGROUND: Due to the limited force feedback provided by laparoscopic instruments, surgeons may have difficulty in applying the appropriate force on the tissue. The aim of this study was to determine the influence of force feedback and visual feedback on the exerted pinch force. METHODS: A grasper with a force sensor in the jaws was developed. Subjects with and without laparoscopic experience grasped and pulled pig bowel with a force of 5 N. The applied pinch force was measured during tasks of 1-s and 1-min duration. Visual feedback was provided in half the measurements. Force feedback was adjusted by changing the mechanical efficiency of the forceps from 30% to 90%. RESULTS: The mean pinch force applied was 6.8 N (+/-0.5), whereas the force to prevent slippage was 3.0 N (+/-0.4). Improving the mechanical efficiency had no effect on the pinch force for the 1-s measurements. The amount of excessive pinch force when holding tissue for 1 min was lower at 30% mechanical efficiency compared with 90% (105% vs 131%, p = 0.04). The tissue slipped more often when the subject had no visual feedback (2% vs 8%, p = 0.02). CONCLUSION: Force feedback and visual feedback play a more limited role than expected in the task of grasping tissue with laparoscopic forceps.

Continuous brachial plexus block at the cervical level using a posterior approach in the management of neuropathic cancer pain.

BACKGROUND AND OBJECTIVES: Neuropathic cancer pain due to tumor growth near the brachial plexus is often treated with a combination of nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, anticonvulsants, and oral or transdermal opioids. We propose placement of a catheter along the brachial plexus using a posterior approach for patients not responding to the above-mentioned treatment. CASE REPORT: We describe 2 patients with neuropathic cancer pain in the arm and shoulder despite treatment with dexamethasone, amitriptyline, gabapentin, opioids, and, in 1 patient, oral ketamine. An increase in daily opioid dosage did not relieve the pain but caused unacceptable side effects of nausea, vomiting, and sedation. Continuous administration of local anesthetics via a brachial plexus catheter inserted at the cervical level using a posterior approach resulted in a markedly improved analgesia and decreased opioid requirement. CONCLUSION: Continuous brachial plexus block should be considered in patients with severe neuropathic cancer pain in the arm and shoulder. To achieve sufficient pain relief for prolonged periods of time, a catheter was inserted to block the brachial plexus using a posterior approach. This technique may be a valuable alternative to the interscalene approach because of the improved fixation of the catheter in the muscle sheet of the trapezius, splenius cervicus, and levator scapulae muscles, and the decreased likelihood of catheter dislodgment during neck movements.

Hypertensive diabetic rats in pharmacological studies.

Since hypertensive disease and diabetes frequently occur simultaneously there exists a requirement for animal models where both pathological entities are combined. The streptozotocin (STZ)-spontaneously hypertensive rat (STZ-SHR) and the obese Zucker rat are examples of animal models where hypertension and diabetes occur simultaneously. STZ-SHRs develop a hyperglycaemic syndrome, associated with other biochemical and morphological changes that to some extent approach insulin-dependent diabetes mellitus (type 1 diabetes) combined with hypertension. The obese (Fa/?) Zucker rat is characterized by the simultaneous occurrence of obesity, hyperglycaemia, hyperinsulinaemia, hyperlipidaemia and moderate hypertension. As such it approaches the patient with non-insulin-dependent diabetes mellitus (type 2 diabetes) who is simultaneously hypertensive. Lean (fa/fa) Zucker rats are suitable controls with respect to the obese animals. Both animal models (STZ-SHRs and obese Zucker rats) were characterized with respect to their biochemical, morphometric and haemodynamic properties. Both models were examined in particular with respect to the pharmacological characteristics of their cardiovascular system, as discussed in the present survey.

Contractile responses to various stimuli in isolated resistance vessels from simultaneously hypertensive and streptozotocin-diabetic rats.

Diabetes mellitus and hypertension are common chronic diseases that frequently occur simultaneously. The induction of streptozotocin (STZ) diabetes mellitus in spontaneously hypertensive rats (SHR) offers the opportunity to investigate the influence of both entities in a reproducible manner. We investigated the effects of various vasoconstrictors on isolated small arteries from the mesenteric vascular bed of normotensive rats (Wistar-Kyoto rats, WKY) and SHR with chronic (8 weeks), STZ-induced diabetes mellitus. No consistent changes in hemodynamic parameters of the (STZ-) normotensive and (STZ-) hypertensive rats were noted. The K(+)-normalization procedure yields the individual optimal lumen diameter, which was the same for the arteries of the four groups of rats. The passive wall tension resulting from this normalization procedure was higher only in preparations from the control hypertensive group as compared with those from the control normotensive rats. Morphological investigations showed that small arteries from control SHR had an increased tunica media thickness as compared with those of control WKY; the STZ-WKY had an increased tunica media thickness as compared with preparations from control WKY. The vasoconstriction caused by alpha 1-adrenoceptor stimulation [norepinephrine (NE), methoxamine] and serotonin is unchanged in chronic experimental diabetes. The diabetic state reduced the sensitivity [-log EC50(M)] for the concentration-response curves (CRC) of calcium chloride. The CRC of potassium chloride indicated the same sensitivities, but maximal active wall tensions of vessels from STZ-SHR were reduced as compared with those from STZ-WKY. The well-known enhancement of the effects of various contractile stimuli caused by hypertension could not be demonstrated for the isolated small arteries used in the present study, although a nonsignificant tendency was observed. However, the STZ-diabetic state did not cause important additional pharmacodynamic changes, despite the morphological alterations in those vessels.

The negative inotropic and chronotropic effects of intravenous R 56865 during percutaneous transluminal coronary angioplasty.

The present study was designed to evaluate the potential anti-ischaemic activity of R 56865 in patients with coronary artery disease, scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). At baseline a complete haemodynamic profile, including cardiac output and coronary sinus blood flow (CSBF) was obtained. In addition, left ventricular pressure and contractility parameters were measured. These parameters were also measured before and after additional balloon inflations, preceded by placebo and R 56865 i.v. R 56865 was infused intravenously at three different dosages, namely: 20 mg (n = 8), 30 mg (n = 2), 40 mg (n = 2). No significant differences were observed between placebo and R 56865 (20 mg) concerning time to onset and duration of ST-segment changes and symptomatic angina pectoris, respectively. The other parameters did not show differences compared with the baseline values when R 56865 (20 and 30 mg) was infused. However, the two patients receiving a dose of 40 mg R 56865 developed a dramatic decrease in systolic and diastolic blood pressure, left ventricular (LV) systolic pressure, peak positive dP/dt and the CSBF (ranging from 30-50%), while the LV end-diastolic pressure increased by 100%. The two patients who received this dose became pale and cyanotic and did not respond to verbal commands. In summary, no anti-ischaemic effects of R 56865 were observed under these conditions, whereas at the highest dose (40 mg) R 56865 induced hypotension and a reduction in cardiac contractile force.

Streptozotocin-induced diabetes mellitus in spontaneously hypertensive rats: a pathophysiological model for the combined effects of hypertension and diabetes.

The present study was undertaken to investigate the combined effects of hypertension and streptozotocin-induced diabetes mellitus in the rat. Accordingly, four groups of rats were studied: Wistar Kyoto rats (WKY), diabetic WKY, spontaneously hypertensive rats (SHR) and diabetic SHR, respectively. The mean arterial blood pressure was increased in hypertensive animals compared to normotensive animals. The base excess in the diabetic rats was higher than that of normoglycemic animals. An elevated glucose concentration was found in the blood and urine of streptozotocin-treated rats. Ketone bodies were detected in the urine and blood of the diabetic rats. Mortality rates after treatment were not different among the four groups. In separate experiments, isolated working hearts of the various groups were set up and analyzed. For the maximal left ventricular pressure (mm Hg) the following values were formed: 110.0 +/- 2.6, 93.6 +/- 2.7, 93.4 +/- 3.0, and 87.5 +/- 2.4, respectively. The wet heart weights, dry heart weights, and body weights of the diabetic rats were lower than those of normoglycemic animals. The wet heart weight/body weight ratio, however, was increased by diabetes and hypertension (0.43 +/- 0.01, 0.47 +/- 0.01, 0.47 +/- 0.01, and 0.54 +/- 0.02, respectively). There were no significant differences between the water content of the hearts from the four different groups. Pathologic examination of the hearts showed myocardial hypertrophy and medial hypertrophy of coronary arteries in diabetic and hypertensive animals. There was no difference in relative collagen content in the hearts of the four groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of R 56865 on postischemic ventricular function in isolated rat working heart preparations obtained from healthy, diabetic and hypertensive animals.

The present study was undertaken to evaluate the effects of R 56865 (N-[1-[4-(4-fluorophenoxy)-butyl]-4-piperidinyl)- N-methyl-2-benzothiazolamine) (Fig. 1) on postischemic ventricular function, an inhibitor of the Na+/Ca2+ overload, in the working heart preparation of the rat. The hearts were paced at 5 Hz and perfused with Tyrode solution of 37 degrees C at a physiological pH. After 15 min of pretreatment with R 56865, low-flow ischemia (30 min) was induced by reducing the perfusion pressure from 51.5 mmHg to 11.0 mmHg and R 56865 was infused simultaneously. The hemodynamic effects of R 56865 were evaluated in the concentration range [10(-8)-3.10(-6) M]. The five parameters measured were: LVP (Left Ventricular Pressure), +dP/dtmax (maximal rate of pressure increase), AO (Aortic Output), CF (Coronary Flow) and CO (Cardiac Output). They were determined in the working heart mode after 15 min of equilibration and at the end of the experiment. From these data the recovery percentages were calculated. The recovery percentages for the LVP, +dP/dtmax, AO, CF and CO for the control hearts (3.3%, 0.0%, 7.9%, 10.4% and 8.5%, respectively) differed significantly from those at 10(-7) M (39.6%, 40.8%, 25.0%, 41.8% and 29.9% respectively). The recovery percentage were the highest at 10(-6) M (79.6%, 82.1%, 54.7%, 92.7% and 67.2%, respectively). The concentration of 10(-7) M was associated with a smaller reduction in LVP (12.9%) than at 10(-6) M (25.7%).(ABSTRACT TRUNCATED AT 250 WORDS)

Antiischemic effects of nifedipine in isolated working heart preparations of healthy, diabetic, and hypertensive rats.

We evaluated the antiischemic effects of nifedipine in isolated working rat hearts from age-matched normotensive Wistar-Kyoto rats (WKY), diabetic WKY, spontaneously hypertensive rats (SHR), and diabetic SHR. Diabetes was induced by streptozotocin. First, we constructed concentration-response curves for the negative inotropic effect of nifedipine in every group. After 15 min of pretreatment with nifedipine (EC60), low-flow ischemia (30 min) was induced by reducing the afterload from 51.5 to 11.0 mm Hg and nifedipine was infused simultaneously. The six measured parameters were left ventricular pressure (LVP), maximum rate of pressure increase (+dP/dtmax), maximum rate of pressure decrease (-dP/dtmax), aortic output (AO), coronary flow (CF), and cardiac output (CO), determined after 15-min equilibration in the working heart mode and at the end of the experiment. From these data, the recovery percentages were calculated. There were no significant differences in sensitivity to nifedipine (as measured by the EC50 concentration) between the four groups with respect to LVP, +dP/dtmax, -dP/dtmax, CF, and CO. However, hearts from SHR were less sensitive to nifedipine than those from diabetic SHR and nondiabetic WKY with regard to AO. In isolated hearts from nondiabetic WKY and SHR, there were no significant differences between vehicle-treated organs and nifedipine-treated preparations. In hearts from diabetic WKY and diabetic SHR, however, the nifedipine-treated group (LVP 87.1 +/- 3.3 and 60.5 +/- 12.1%, respectively) recovered significantly (p < 0.05) better from ischemia as compared with the control group (LVP 35.7 +/- 14.7 and 10.7 +/- 9.8%, respectively) (n = 6 for each group).(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodynamic and antiischemic effects of nifedipine, lacidipine, and nisoldipine in rat isolated working heart.

We compared two newer dihydropyridine-calcium antagonists (lacidipine and nisoldipine) with the classic prototype of this group, nifedipine, in the rat working heart preparation. The hearts were paced at a frequency of 5 Hz and perfused with Tyrode's solution of 37 degrees C. The following five parameters were determined: left ventricular pressure (LVP), maximal rate of pressure increase (+dP/dtmax), aortic output (AO), coronary blood flow (CBF), and cardiac output (CO). First, dose-response curves were constructed; from these data the EC50 concentration for the three calcium antagonists was calculated. Subsequently, washout from the cardiac tissue for these three compounds was determined. The effects of lacidipine did not diminish during < or = 90-min washout, whereas the effects of nifedipine disappeared completely in 10 min. The effects of nisoldipine, however, disappeared partly in 10 min. In separate experiments, the antiischemic activity of the three calcium antagonists was analyzed, using low-flow ischemia. The calcium antagonists were used in a concentration that produced a 60% reduction in contractile force (EC60). Nifedipine and nisoldipine caused significant improvement in functional recovery. The antiischemic properties of lacidipine could not be shown because of its slow kinetic properties with accumulation in the membrane phase and slow kinetics with the channel. Nisoldipine and lacidipine appear to be more potent calcium antagonists as compared with nifedipine, whereas lacidipine displays a clearly different kinetic pattern in comparison to nifedipine and nisoldipine. In particular, the extremely slow onset and very long duration of action of lacidipine are of interest.

The effects of hypertension and diabetes mellitus on the vascular reactivity of resistance arteries.

We have studied the effects of both hypertension and streptozotocin-induced diabetes mellitus on alpha 1-adrenoceptor mediated vasoconstriction, endothelium-dependent and endothelium-independent vasodilation. The experiments were performed in perfused mesenteric vascular bed preparations taken from age-matched SHR, WKY, diabetic SHR and diabetic WKY. For the alpha 1-adrenoceptor agonist methoxamine, the mesenteric preparations from SHR and diabetic SHR yielded significantly (p < 0.05) stronger maximal responses than preparations taken from WKY and diabetic WKY, respectively. The diabetic state significantly (p < 0.05) decreased the responsiveness to methoxamine in arteries from SHR and WKY. Hypertension does not significantly change the concentration response-curves for (acetyl-beta) methacholine, histamine, adenosine diphosphate and sodium-nitroprusside. However, the sensitivity to endothelium-dependent vasodilation decreased in preparations from diabetic animals (< 0.05). It is concluded that mesenteric resistance arteries from SHR and diabetic SHR are more reactive to alpha 1-adrenoceptor stimulation, whereas diabetes reduces the responsiveness to methoxamine in WKY and SHR. Hypertension does not affect the endothelium-dependent relaxation in mesenteric arteries. However, diabetes decreases the sensitivity to endothelium-dependent relaxation without altering the sensitivity to sodium-nitroprusside. These findings are indicative of a diabetes-induced endothelial dysfunction in mesenteric resistance arteries. In preparations from diabetic hypertensive rats the reduced response to methoxamine and the endothelial dysfunction seem to run parallel.

Cardioprotection by nifedipine in isolated working hearts: a comparative study on three different types of experimental ischemia.

Cardiac ischemia can be provoked by different methods in animal models and in isolated organs. Accordingly, three different procedures were followed to find the most sensitive model for the analysis of the anti-ischemic activity of calcium antagonists. The experiments were performed in the isolated working heart preparation of the rat, paced at the frequency of 5 Hz and perfused with Tyrode solution at 37 degrees C. Global ischemia was achieved by closing off the supply of the perfusion medium and surrounding the heart with Tyrode solution of 37 degrees C gassed with N2; low-flow ischemia was achieved by reducing the cardiac afterload from 51.5 to 11.0 mm Hg; ligation of the left descending coronary artery was performed in order to provoke regional ischemia. Nifedipine was applied in a concentration (EC50) known to reduce the contractile force by one-half of its basal value. The following parameters were determined after 15 min of nifedipine pretreatment and at the end of the experiment: LVP (left ventricular pressure),+dP/dtmax (LVP's first derivative), AO (aortic output), CF (coronary flow), and CO (cardiac output). From the data obtained, the percentages of recovery were calculated. Nifedipine caused a significant improvement in the functional recovery of most of the parameters studied. This improvement, however, was much more pronounced in the model of the low-flow ischemia, which is obviously more sensitive to the anti-ischemic activity of calcium antagonists than the other experimental procedures studied. Low-flow ischemia appears to be preferable to other procedures for the screening of the potential anti-ischemic activity of calcium antagonists and other drugs.

Detection of microemboli by constant-pressure filtration during in vitro circulation of bovine and human blood.

The constant-pressure filtration (CPF) method has been developed to assess blood microemboli (BME) in terms of their ability to occlude microvascular flow. Previous reports suggest that the method is sensitive to the effects of platelet stimulation and to blood-pumping conditions. BME production and heparin activity were studied in bovine and human blood pumped by a Pellethane ventricle with Pellethane molded valves connected via smooth quick-connects to a Pellethane horseshoe-shaped reservoir. In each experiment, blood was collected into heparin by cardiac puncture from a stunned animal or by venepuncture from a human donor. The blood from each donor was filled into three ventricle-reservoir systems (50 cc ventricle and 1,500 cc reservoir for the bovine blood, and 20 cc ventricle and 150 cc reservoir for the human blood). One of the systems received aspirin (ASA; 25 mg/dl) shortly after the onset of pumping, whereas the other two served as pumping and non-pumping controls. The blood was pumped in a full-fill/full-eject mode for up to 10 h. BME concentration was measured by the CPF method in which the blood was filtered through 20-microns pore filters at 20 mm Hg for 10 s, and the flowrate curves were evaluated from occlusion model. Heparin activity was measured by the activated partial thromboplastin time (APTT) test. In the early period after the onset of pumping, the BME concentration increased, whereas the APTT decreased from an initial value of greater than 250 s, with the relative rate of change for both the BME and the APTT being the following: pumping control greater than pumping ASA blood greater than quiescent control.(ABSTRACT TRUNCATED AT 250 WORDS)

Loss of anticoagulant effect of heparin during circulation of human blood in vitro.

Device-induced thrombogenesis was studied in an in vitro model using human blood circulated through an artificial ventricle. A new constant pressure filtration technique was used to detect circulating microemboli, the activated partial thromboplastin time (APTT) test was used to monitor the blood for the presence of anticoagulant activity of heparin, and hemolysis was quantified by measuring the plasma free hemoglobin level. Circulation of blood through a 20-ml stroke volume pneumatically driven ventricle for 6-9 h resulted in a significant reduction of APTT, indicating the loss of the anticoagulant effect of heparin. Microemboli concentration was minimal until the APTT decreased below 125 s, at which time the microemboli concentration increased rapidly. This was presumed to be due to the formation of thrombi following a decrease in heparin activity. A significant increase in hemolysis was also noted when blood was pumped. None of these changes was noted in the nonpumped control blood. Spontaneous loss of heparin activity in blood circulated by a pneumatically driven pump may have clinical implications and may help understanding of the problems associated with device-induced thrombogenesis.