Subcutaneous narcotic infusions for cancer pain: treatment outcome and guidelines for use.

OBJECTIVE: To provide guidelines for the institution and maintenance of a continuous subcutaneous narcotic infusion program for cancer patients with chronic pain through an analysis of the narcotic requirements and treatment outcomes of patients who underwent such therapy and a comparison of the costs of two commonly used infusion systems. DESIGN: Retrospective study. SETTING: Tertiary care facilities and patients'' homes. PATIENTS: Of 481 patients seen in consultation for cancer pain between July 1987 and April 1990, 60 (12%) met the eligibility criteria (i.e., standard medical management had failed, and they had adequate supervision at home). INTERVENTION: Continuous subcutaneous infusion with hydromorphone hydrochloride or morphine started on an inpatient basis and continued at home whenever possible. OUTCOME MEASURES: Patient selectivity, narcotic dosing requirements, discharge rate, patient preference for analgesic regimen, side effects, complications and cost-effectiveness. RESULTS: The mean initial maintenance infusion dose after dose titration was almost three times higher than the dose required before infusion (hydromorphone or equivalent 6.2 v. 2.1 mg/h). Eighteen patients died, and the remaining 42 were discharged home for a mean of 94.4 (standard deviation 128.3) days (extremes 12 and 741 days). The mean maximum infusion rate was 24.1 mg/h (extremes 0.5 and 180 mg/h). All but one of the patients preferred the infusion system to their previous oral analgesic regimen. Despite major dose escalations nausea and vomiting were well controlled in all cases. Twelve patients (20%) experienced serious systemic toxic effects or complications; six became encephalopathic, which necessitated dose reduction, five had a subcutaneous infection necessitating antibiotic treatment, and one had respiratory depression. The programmable computerized infusion pump was found to be more cost-effective than the disposable infusion device after a break-even point of 8 months. CONCLUSIONS: Continuous subcutaneous infusion of opioid drugs with the use of a portable programmable pump is safe and effective in selected patients who have failed to respond to standard medical treatment of their cancer pain. Dose titration may require rapid dose escalation, but this is usually well tolerated. For most communities embarking on such a program a programmable infusion system will be more cost-effective than a disposable system.     

Control of regeneration and morphogenesis by divalent cations in Acetabularia mediterranea

A study of the effects of altered calcium and magnesium levels on the capacities of Acetabularia plants to elongate and to form whorls or caps revealed sharp transitions of regenerative state over small concentration changes of external calcium at both reduced and elevated levels. Cobalt and lanthanum, which interfere with calcium fluxes across membranes, also affect regeneration and morphogenesis with sharply defined transition ranges. It is shown that these effects are localized at the growing tip. The nature of the mechanisms involved in the transitions from one morphogenetic state to another in the regenerative process is considered.     

Radio Telemetry of the Electrocardiogram,Fitness Tests,and Oxygen Uptake of Water-Polo Players

During competitive water polo, heart rate in six subjects was monitored by cupped plastic and silver electrodes glued to the skin. Minimum rates during the game averaged 156 beats/min.; maximum rates averaged 186 beats/min. Mean maximum rate with bicycle exercise was 188 beats/min. Maximum oxygen (VO₂ max.) with bicycle exercise of 14 water-polo players was 53.3 ml./kg. Physical working capacity (PWC 170) was 1310 kilopond metres per square metre (k.p.m./sq.m.). PWC 170 correlated well with VO₂ max. in this small group (r = 0.77).Oxygen uptake was measured at three speeds of swimming and four levels of work on a bicycle ergometer. VO₂ max. of swimming was 88% of that obtained on bicycle exercise. The slope of the oxygen uptake vs. pulse rate curves was less for the swimming than for cycling, so that for a given oxygen uptake below the maximal, pulse rate was less in the swimmers. At near-maximal swimming, respiratory quotient was 0.95 compared with 1.27 for cycling, suggesting that the swimmers were underbreathing.     

Rapid and Sensitive Detection of Xanthomonas fragariae by Simple Alkaline DNA Extraction and the Polymerase Chain Reaction

Methods for DNA preparation from Xanthomonas fragariae in infected or artificially contaminated strawberry plants were compared in diagnostic assays using the polymerase chain reaction (PCR). The bacterium was detected using PCR with primers specific to a region of its hrp gene. Sensitivity of detection was 1.25 ×l 10³ CFU ml^-1 using DNA from bacterial suspensions prepared by an alkali extraction method. This was 10-fold more sensitive than DNA extraction by boiling, and was equal to that in which DNA was prepared by a more involved cetyltrimethylammonium bromide (CTAB) procedure. Sensitivity of detection from artificially contaminated strawberry tissues was 10-fold less than that from cell suspensions. The results indicated that a rapid and simple method of alkali DNA sample preparation is applicable for the sensitive and reliable detection of X. fragariae and possibly other plant pathogenic bacteria.     

Conversion of a 24β-ethyl-25-methylene intermediate into poriferasterol by Trebouxia species

Clerosterol-[26-¹⁴C], a 24β-ethyl-25-methylene sterol [(24S)-24-ethylcholesta-5,25-dien-3β-ol], was incorporated into clionasterol and poriferasterol by cultures of the green algae Trebouxia sp. 213/3 and Trebouxia sp. 219/2. Degradation of the labelled poriferasterol showed that the ¹⁴C retained its identity and was not incorporated as a result of metabolism of the clerosterol-[26-¹⁴C] and randomisation of label. These results are consistent with the proposed production, and subsequent reduction, of a 24β-ethyl-25-methylene intermediate in 24β-ethyl sterol biosynthesis in algae of the order Chlorococcales.