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Biomedical subjects

N Rawal

Publications and source records attributed to N Rawal.

At least 55 records · Page 3Linked to original sources

Detection of borreliacidal antibodies in Lyme borreliosis patient sera containing antimicrobial agents.

The borreliacidal-antibody test has been used for the serological detection and confirmation of Lyme borreliosis. However, the presence of antimicrobial agents in serum can confound the accurate detection of borreliacidal antibodies. In this study, we developed a Bacillus subtilis agar diffusion bioassay to detect small concentrations of antimicrobial agents in serum. We also used XAD-16, a nonionic polymeric resin, to adsorb and remove high concentrations of amoxicillin, cefotaxime, ceftriaxone, cefuroxime, doxycycline, and erythromycin without significantly affecting even small concentrations of immunoglobulin M (IgM) or IgG borreliacidal antibodies. High concentrations of penicillin could also be removed by adding 1 U of penicillinase without significantly influencing the levels of borreliacidal antibodies. These simple procedures greatly enhance the clinical utility of the borreliacidal-antibody test.

Amoxicillin↗

Patient-controlled regional analgesia (PCRA).

It is not always necessary or desirable for a block to extend over a wide area, involve the sympathetic system or act bilaterally. Many blocks are capable of providing excellent analgesia in a limited area of the body and with minimal systemic effect. Peripheral nerve blocks are simple to perform, provide excellent analgesia and have a historical record of safety. In general, appropriate blocks exist for almost all area of the body. Since analgesic requirements and duration of a single dose local anesthetic vary greatly, patients can be expected to obtain better analgesia if they could control the amount and timing of local analgesic medication by PCRA. A new technique is described that allows the patient to self-administer a prescribed dose of local anesthetic at home.

Analgesia, Epidural↗

C5 convertase of the alternative pathway of complement. Kinetic analysis of the free and surface-bound forms of the enzyme.

Although proteolytic activation of the complement protein C5 initiates important defensive and occasionally pathological inflammatory reactions, the enzymatic properties of the enzymes responsible for this cleavage have never been examined. We have studied the kinetic parameters of the C5 convertase of the alternative pathway of complement, either bound to a zymosan surface or in its monomeric soluble form. C5 convertase enzymatic activity was measured as a function of C5 concentration by quantitating production of C5b,6 under physiological conditions of temperature, pH, and ionic strength. The C5 convertases appeared to follow Michaelis-Menten kinetics and exhibited similar catalytic rate constants (kcat). However, the surface-bound enzyme, ZymC3b,Bb had a Km (1.4 microM) that was 17 times lower than that of the soluble monomeric form of the enzyme, C3b,Bb (Km = 24 microM). The kcat for the cell-bound enzyme, ZymC3b,Bb was 0.0048 s-1 and that for soluble C3b,Bb was 0.0110 s-1. Both forms of the enzyme had a low turnover number at Vmax (0.23 to 0.68 C5/min/enzyme). Substituting Mg2+ for Ni2+ did not alter the kinetic parameters but lowered the half-life of the enzyme by 5-7-fold. The kinetic data presented demonstrate that the fluid phase C5 convertase, C3b,Bb, can cleave C5 without the aid of a second C3b molecule. The results also show that the greater enzymatic activity previously observed for the surface-bound C5 convertases is not due to higher catalytic efficiency but is solely due to higher affinity for the substrate C5. In blood, C5 concentrations are 3-4-fold below the Km determined for the surface-bound C5 convertase suggesting a direct correlation between the local C5 concentration and production of the anaphylatoxin C5a and the cytolytic C5b-9 complex.

Cell Membrane↗

Acute pain services in Europe: a 17-nation survey of 105 hospitals. The EuroPain Acute Pain Working Party.

A 17-nation survey was undertaken with the aim of studying the availability of acute pain services (APS) and the use of newer analgesic techniques, such as epidural and patient-controlled analgesia (PCA). A questionnaire was mailed to selected anaesthesiologists in 105 European hospitals from 17 countries. Depending on the population, between five and ten representative hospitals from each country were selected by a country coordinator. A total of 101 (96.2%) completed questionnaires were returned. A majority of respondents were dissatisfied with pain management on surgical wards. Pain management was better in post-anaesthesia care units (PACUs); however, 27% of participating hospitals did not have PACUs. There were no organized APS in 64% of hospitals, although anaesthesiologists from chronic pain centres were available for consultation. In the hospitals that had APS, the responsible person for the APS was either: (1) a junior anaesthesiologist (senior anaesthesiologist available for consultation); or (2) a specially trained nurse (supervised by consultant anaesthesiologists). Many anaesthesiologists were unable to introduce techniques such as PCA on wards because of the high equipment costs. Although 40% of hospitals used a visual analogue scale (VAS) or other methods for assessment of pain intensity, routine pain assessment and documenting on a vital sign chart was rarely practised. There was a great variation in routines for opioid prescription and documentation procedures. Nursing regulations regarding injection of drugs into epidural and intrathecal catheters also varied considerably between countries. This survey of 105 hospitals from 17 European countries showed that over 50% of anaesthesiologists were dissatisfied with post-operative pain management on surgical wards. Only 34% of hospitals had an organized APS, and very few hospitals used quality assurance measures such as frequent pain assessment and documentation. There is a need to establish organized APS in most hospitals and also a need for clearer definition of the role of anaesthesiologists in such APS.

Analgesia↗

The use of central regional anesthesia techniques in Sweden: results of a nation-wide survey. Swedish Association of Anesthesia and Intensive care.

BACKGROUND: Epidural and subarachnoid anesthesia are well established central regional techniques for surgical anesthesia. Two additional techniques, combined spinal epidural (CSE) block and continuous spinal anesthesia (CSA), have recently become popular. However, data on nation-wide use of central regional blocks are not available. METHOD: With the aims to survey the use of central regional techniques, to evaluate the risk of complications to central regional blocks and to document the use of continuous epidural techniques for postoperative pain management in Sweden during 1993, a questionnaire was mailed to all 105 Swedish anesthesiology departments. RESULTS: Questionnaires were returned by 62 departments, representing all categories of Swedish hospitals. Central regional blocks were used for surgical anesthesia in 20-40% of reported surgical procedures. Subarachnoid anesthesia was the main technique for orthopedic surgery on the lower limb, elective cesarean section and transurethral resection of the prostate. Epidural block was used for orthopedic and vascular surgery. CSE block was used by 42 departments and CSA by 21 departments. Postoperative epidural analgesia was used by 59 departments, most commonly with continuous infusion of local anesthestics and/or epidural bolusdoses of morphine. Nineteen neurological sequelae were reported after epidural (n = 7) and subarachnoid (n = 12) blocks. Routines for registration of complications varied greatly. CONCLUSIONS: Subarachnoid block was preferred for shorter surgical procedures (< 60 min), whereas epidural and CSE blocks were chosen when severe postoperative pain could be anticipated, as continuous epidural analgesia was well established for postoperative pain management. Improved routines for registration of complications to central regional blocks are needed.

Anesthesia, Conduction↗

Survey of postoperative analgesia following ambulatory surgery.

BACKGROUND: The quality of pain relief during the first 48 hours following ambulatory surgery has been poorly documented. This questionnaire study was performed to evaluate the nature and severity of pain after the patient leaves the hospital. METHODS: 1100 patients in the age group 5-88 years who underwent ambulatory surgery during a period of 6 months were asked to complete a questionnaire 48 h after the end of the operation. In the case of children, parents were asked to complete a similar questionnaire. The questions were related to pain experienced during the first 48 h after surgery and to the nature and severity of postoperative complications. RESULTS: A total of 1035 out of the 1100 patients returned the questionnaire, 94.1%. Overall the majority (65%) of patients had only mild pain at home; however, patients undergoing certain types of surgery had moderate-to-severe pain: inguinal hernia surgery (62% patients), orthopaedic surgery (41%), hand surgery (37%) and varicose vein surgery (36%). In these patients the severity of pain did not decrease during the 2-day study period. About 10% patients had more severe pain than they had anticipated, and 20% had difficulty in sleeping at night due to severe pain. Despite this, over 95% of patients were satisfied with management of postoperative pain. Nausea (20%), tiredness (20%) and vomiting (8%) were the commonest complications reported during the first 48 h. A significant association was found between the administration of a general anaesthetic and the incidence of nausea postoperatively. A large number of patients were alone at home after the operation (28.4%); some (3.8%) had no access to a relative or friend in case of need. CONCLUSION: Our results show that about 35% of day-surgery patients experience moderate-to-severe pain at home in spite of analgesic medication. About 20% of patients had sleep problems due to severe pain. However, only 5% of patients were dissatisfied. Better analgesic techniques are necessary for patients undergoing certain types of surgery. Patient information and follow-up routines need to be improved.

Adolescent↗

[The clinical use of spinal opioids, part 2].

The most significant non-systemic side effects of spinal opioids are pruritus, urinary retention and delayed respiratory depression. Pruritus can occur after any opioid, but its incidence may differ with the affinity of the particular opioid to the opioid receptor. Spinal opioid receptors seem to influence urinary retention due to urodynamic effects. Urinary retention can be antagonized by naloxone; however, large doses will also antagonize the analgesic effects. Delayed respiratory depression after spinal opioids is a very rare, but significant complication. In general, respiratory depression after spinal lipophilic opioids will occur earlier than morphine, however the incidence is probably similar. There is some evidence to suggest that the risk of respiratory depression is similar regardless of the route of administration (intramuscular, intravenous, spinal, PCA). Sound knowledge among physicians and nurses, adequate treatment plans, and individual patient selection are essential to avoid significant complications of spinal opioids. If these requirements are fulfilled, most patients can be safely treated with spinal opioids even outside the intensive care unit.

English Abstract↗

[The clinical use of spinal opioids, part 1].

Spinal opioids are effective analgesics for surgical and non-surgical pain. Central and systemic side effects are less frequent than with epidural local anaesthetics or parenteral opioids. This review focuses on the analgesic efficacy of spinal opioids and their combination with local anaesthetics for postoperative analgesia, including patient-controlled epidural analgesia. Intrathecal administration of opioids has some advantages over their administration by the epidural route. Several factors may influence selection of the opioid; however, in most situations morphine is the drug of choice. Thoracic epidural administration of opioids seems to have no clinically important advantages over the lumbar route in terms of quality of analgesia, adverse effects, doses required or pulmonary function. However, evidence suggesting that effective postoperative analgesia can significantly improve postoperative morbidity in patients at risk is accumulating. In such patients, combined use of epidural local anaesthetics and opioids may become the technique of choice for postoperative analgesia. However, there is no evidence that this would have any clinically relevant benefit in low-risk patients.

English Abstract↗

Treatment of pain in pediatric oncology: a Swedish nationwide survey.

Pain treatment is a crucial aspect in the care of children with cancer and there are many studies demonstrating inefficient pain treatment. In this study, questionnaires dealing with pain treatment of children with malignant diseases were sent to all (47) pediatric departments in Sweden. The aims of this nationwide survey were to evaluate the extent and causes of pain, the use of methods for pain evaluation (e.g. analysis of type of pain and monitoring of pain intensity), principles of pain management, side effects of pain treatment and the educational needs of physicians and nurses regarding these issues. The response rate was 100%. Answers from physicians and nurses reveal that pain is a common symptom during different periods of cancer treatment. Pain due to treatment and procedures is a greater problem than pain due to the malignant disease itself. Instruments for the measurement of pain intensity and analysis of the type of pain are still rarely used. Most physicians (63%) follow the analgesic 'ladder' principle recommended by World Health Organization (WHO). According to a majority of physicians and nurses (72%), pain could be treated more effectively than it is presently, and 64% state that they need more time for the management of pain. Both physicians and nurses state that they need additional education in different areas of pain evaluation and pain treatment. Swedish treatment practices for the management of pediatric cancer pain roughly follow the published guidelines, but many improvements are still necessary.

Adolescent↗

Epidural and intrathecal opioids for postoperative pain management in Europe--a 17-nation questionnaire study of selected hospitals. Euro Pain Study Group on Acute Pain.

BACKGROUND: A questionnaire study conducted with the help of selected contact persons in 17 countries in Europe attempted to create a picture of the practice of acute pain management with the use of spinal opioid analgesia (SOA). METHODS: A questionnaire was mailed to anaesthesiologists in 105 European hospitals. Depending on the population, 5-10 hospitals from each country were selected by a country co-ordinator. RESULTS: A total of 101 (96.2%) completed questionnaires were returned. During 1 year SOA was used in 55,117 patients (6.6% of all in-patient surgical procedures); of these, 89.2% received epidural opioids and 10.8% intrathecal opioids (ratio 8:1). The most common opioid for SOA was morphine; fentanyl was also used quite frequently; 12 different opioids and 8 non-opioids had been used. ASA 1-2 patients receiving epidural morphine were nursed on surgical wards in 58.4% of the hospitals; in 25.7% of hospitals even ASA 3-4 were nursed on surgical wards. Respiratory depression (requiring naloxone treatment) was noted in 45 of the 49,183 patients who received epidural opioids (0.09%); 33 of these patients had received morphine. In more than 75% of hospitals the monitoring variables were respiratory rate, sedation level and pulse oximetry. There was a great difference between hospitals and countries regarding duration of monitoring. CONCLUSIONS: This questionnaire study showed that SOA was used in about 7% of 836,000 in-patients undergoing surgery at the 105 selected hospitals. Epidural opioids were used eight times more often than intrathecal opioids. Morphine was the commonest opioid for SOA. The duration of monitoring differed greatly between hospitals and countries; the need for official guidelines is emphasized.

Analgesia, Epidural↗

Structural specificity of substrate for S-adenosylmethionine:protein arginine N-methyltransferases.

The enzymatic methylation of polypeptides on the guanidino group of internal arginine residues by S-adenosylmethionine:protein arginine N-methyltransferase (protein methylase I) yields NG-monomethylarginine, NG,NG-dimethylarginine and NG,NG-dimethylarginine. It has commonly been observed that these arginine residues are present in glycine-and-arginine rich motifs. To understand structural features which are essential for serving as the methyl acceptor for protein methylase I, we have investigated substrate capacities of several synthetic oligopeptides whose sequences are homologous and/or analogous to the methyl acceptor region of the naturally occurring arginine-methylated proteins. These studies have led to the following conclusions. (i) The preferred amino-acid sequence of methyl-accepting peptides was shown to be an arginine-containing peptide with glycine in both the N- and C-flanking positions. While a tetrapeptide with such a sequence (residues 106-109 of bovine myelin basic protein) exhibited almost negligible substrate activity, an overlapping hexapeptide was a moderate substrate. (ii) Substitution of the C-flanking glycine in GKGRGL (residues 104-109 of myelin basic protein) with histidine, phenylalanine, lysine or aspartic acid completely abolished the ability of these hexapeptides to serve as substrates. (iii) A heptapeptide with a repeated glycine-arginine motif (GRGRGRG) was an excellent substrate for the enzyme. (iv) A cyclic octapeptide (CGKGRGLC), which was formed by cyclization of GKGRGL by introduction of disulfide bridge to cross-link N- and C-terminus of the hexapeptide, was an even better substrate than the hexapeptide. (v) Upon HPLC amino-acid analysis, all enzymatically methyl-14C-labeled oligopeptides were found to yield predominantly NG-monomethylarginine with a minor fraction of NG,NG-dimethylarginine in certain peptide samples. However, no NG,NG-dimethylarginine formation was detectable. (vi) The recombinant hnRNP protein A1 (residues 1-320) is known to be methylated at arginine-194 by nuclear-protein/histone protein methylase I (Rajpurohit et al. (1994) J. Biol. Chem. 269, 1079-1082). However, the hexapeptide (SSSQRG) which corresponds to residues 189-194 of protein A1 containing the methylatable arginine residue was relatively inert as a substrate. Furthermore, the N-terminal fragment of protein A1 (residues 1-196) generated by controlled trypsin digestion was also completely inactive as a substrate for the enzyme. These results indicate that the remainder of the A1 protein molecule plays an important though not yet understood role in enzymatic methylation of the arginine-194.

Amino Acid Sequence↗

Respiratory monitoring during postoperative analgesia.

Respiratory monitoring, using a novel flow sensor based on an acoustic principle, has been investigated in 30 patients during postoperative analgesia. Each patient was subjected to monitoring and human observation for 8 hr. The study was performed by independent observers at three clinics. Significant correlation was noted between respiratory rate (RR) determined by the sensor and the observers. Recordings of respiratory duration index (RDI), breathing time intervals (BTIs) indicated high sensitivity of the instrument to respiratory depression and perturbations in the breathing rhythm. More than 800 apnea alarms were noted, using an alarm setting of 30 sec; 61% of the categorized alarms were noted by the observers as true apneas. From the recordings it was shown that the number of alarms can be reduced by a factor of four if the alarm setting is changed to 45 sec. We conclude that the suggested technique, with slight modifications, provides adequate respiratory monitoring of patients during postoperative analgesia.

Acoustics↗

Urinary excretion of NG-dimethylarginines in multiple sclerosis patients: preliminary observations.

The concentrations of NG,N'G-dimethylarginine [Me2(sym)Arg] and NG,NG-dimethylarginine [Me2(asym)Arg] were determined in the urine samples from multiple sclerosis (MS) and control subjects, using a highly sensitive HPLC post-column o-phthaldialdehyde derivatization method. The presence of approximately equal amounts of both dimethylarginine isomers, of Arg concentration nearly half of Me2Arg, and of the undetectable amount of NG-monomethylarginine were the characteristic urinary excretion pattern in all human samples studied. The urinary excretion of Me2(asym)Arg and Me2(sym)Arg from MS (n = 9) and control (n = 7) were analyzed: the mean values from the samples were approximately 20% (for all MS) and 33% (for chronic-progressive MS) lower than those from the control for both dimethylarginine-derivatives when compared to the respective compounds. Although there were contrasting trends between controls and MS patients in the relationship of urinary NG-dimethylarginines and myelin basic protein like material (MBPLM), the correlations were not significant. Differences in the ratios of the concentrations of the two dimethyl derivatives, Me2(sym)Arg/Me2(asym)Arg, were not significantly different between MS and control groups. These findings warrant further investigation of possible links between urinary excretion of NG-dimethylarginine and MBPLM in MS. The possible significance of myelin metabolism in relation to urinary NG-dimethylarginines in MS is discussed.

Arginine↗