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Efficacy of the novel selective platelet-derived growth factor receptor antagonist CT52923 on cellular proliferation, migration, and suppression of neointima following vascular injury.

Exaggerated or inappropriate signaling by the platelet-derived growth factor receptor (PDGFR) tyrosine kinase has been implicated in a wide variety of diseases. Thus, a series of piperazinyl quinazoline compounds were identified as potent antagonists of the PDGFR by screening chemical libraries. An optimized analog, CT52923, was shown to be an ATP-competitive inhibitor that exhibited remarkable specificity when tested against other kinases, including all members of the closely related PDGFR family. The PDGFRs and stem cell factor receptor were inhibited with an IC(50) of 100 to 200 nM, while 45- to >200-fold higher concentrations of CT52923 were required to inhibit fms-like tyrosine kinase-3 and colony-stimulating factor-1 receptor, respectively. Other receptor tyrosine kinases, cytoplasmic tyrosine kinases, serine/threonine kinases, or members of the mitogen-activated protein kinase pathway were not significantly inhibited at 100- to 1000-fold higher concentrations. In addition, this compound also demonstrated specificity for inhibition of cellular responses. Platelet-derived growth factor-induced smooth muscle cell migration or fibroblast proliferation was found to be blocked by CT52923 with an IC(50) of 64 and 280 nM, respectively, whereas 50- to 100-fold higher concentrations were required to inhibit these responses when induced with fibroblast growth factor. To investigate the effect of CT52923 on PDGFR signaling, in vivo studies demonstrated that CT52923 could significantly inhibit neointima formation following carotid artery injury by oral administration in the rat. Therefore, PDGFR antagonism by CT52923 could be a viable strategy for the prevention of clinical restenosis or the treatment of other human diseases involving PDGFR signaling.

Angioplasty, Balloon↗

cDNA cloning and expression of the mRNA for cytochrome P-450kd which shows a fatty acid omega-hydroxylating activity.

We have recently purified three distinct forms of fatty acid omega-hydroxylase cytochrome P-450 (P-450), designated P-450ka-1, P-450ka-2 and P-450kd, from rabbit kidney cortex microsomes, and isolated and sequenced cDNA clones corresponding to P-450ka-1 and P-450ka-2 [Yokotani, N., Bernhardt, R., Sogawa, K., Kusunose, E., Gotoh, M., Kusunose, M. & Fujii-Kuriyama, Y. (1989) J. Biol. Chem. 264, 21,665-21,669]. The present paper describes cloning, sequencing and expression of a cDNA for the third fatty acid, omega-hydroxylase, P-450kd, from a rabbit kidney cDNA library. The cDNA for P-450kd encodes a polypeptide of 511 amino acids with sequence similarity of 87% to P-450ka-1. Its deduced NH2-terminal sequence of amino acids 5-24 is in complete agreement with the NH2-terminal sequence of P-450kd. The identity of the cDNA was further confirmed by its expression in COS-7 cells. When 14C-labeled lauric acid was added to the culture medium of COS-7 cells transfected with the cDNA, significant amounts of radioactive dodecanedioic acid, together with omega- and (omega-1)-hydroxylauric acids, were produced. Microsomes prepared from the transfected cells also efficiently catalyzed the omega- and (omega-1)-hydroxylation of lauric acid without formation of dodecanedioic acid. RNA blot analysis demonstrated that the mRNA for P-450kd gave a single band at the approximately 2.6-kb position. The mRNA for P-450kd was expressed in the liver and kidney, but not in many other tissues examined. Treatment of rabbits with clofibrate resulted in a elevated level of mRNA for P-450kd in both liver and kidney. Furthermore, the mRNA was remarkably increased in the kidney by the administration of cyclosporin A.

Amino Acid Sequence↗

Fungi: toxic killers or unavoidable nuisances?

OBJECTIVES: This discussion is focused on the many roles of fungi in human health, and also to put the mycotoxin literature into perspective. DATA SOURCES: Data are derived from the literature referenced in PubMed from the National Library of Medicine, earlier references in the authors' reprint collection, and ongoing research. Studies for review were either selected from the peer-reviewed literature or from standard texts that are well recognized in the field. RESULTS: The review yielded many studies of the role of fungi in allergic disease, but none that systematically documented such a role for mycotoxins or fungal volatiles. Many case studies were found, but none of these unequivocally document a cause/effect relationship between mycotoxin exposure by inhalation and human disease in residential, school, or office settings. CONCLUSIONS: The review led to the conclusion that that the primary result from fungal exposure is allergic disease, and that the evidence for inhalation disease resulting from mycotoxin exposure in residential and office settings is extremely weak.

Administration, Inhalation↗

Expression of the germ cell alkaline phosphatase gene in human choriocarcinoma cells.

Alkaline phosphatase (ALP) in human choriocarcinoma cells (malignant trophoblasts) was characterized by its greater sensitivity to EDTA and L-leucine inhibition as compared with the placental isozyme. In addition, both the fully processed and the nonglycosylated forms of choriocarcinoma ALP migrated faster than the corresponding placental enzyme in sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Choriocarcinoma cells express a 2.6-kilobase (kb) ALP mRNA unlike normal human placenta which expresses a 2.8-kb ALP mRNA. Administration of sodium butyrate to choriocarcinoma cells greatly increased the steady-state levels of the 2.6-kb choriocarcinoma ALP mRNA, which resulted in an increase in enzyme activity and biosynthesis. S1 nuclease analysis using probes derived from a placental ALP cDNA and ribonuclease protection assays employing probes derived from the germ cell ALP gene demonstrated that choriocarcinoma cells express the germ cell ALP gene. The germ cell ALP gene encodes the placental ALP-like isozyme that is primarily expressed in the thymus, testis, and germ cell tumors. The structures of the internal exons (II-X) of the germ cell ALP gene were determined previously based on their similarity to the placental ALP gene. However, the boundaries of exons I and XI (3' exon) of the germ cell ALP gene were not defined due to sequence divergence between the two genes at the 5' and 3' regions. Ribonuclease protection and primer extension assays demonstrated that exon I of this gene is 119 base pairs in length and that germ cell ALP mRNA contains one major transcription initiation site. The isolation and characterization of germ cell ALP cDNA clones from a butyrate-treated choriocarcinoma cDNA library showed that the germ cell ALP mRNA is 2487 bases in length and exon XI of this gene is 1135 base pairs long.

Alkaline Phosphatase↗

Antibiotic use for irreversible pulpitis.

BACKGROUND: Irreversible pulpitis, which is characterised by acute and intense pain, is one of the most frequent reasons that patients attend for emergency dental care. Apart from removal of the tooth the customary way of relieving the pain of irreversible pulpitis is by drilling into the tooth, removing the inflamed pulp (nerve) and cleaning the root canal. However, a significant minority of dentists continue to prescribe antibiotics to stop the pain of irreversible pulpitis. OBJECTIVES: The objective of this review was to provide reliable evidence regarding the effectiveness of prescribing systemic antibiotics for irreversible pulpitis by comparing clinical outcomes expressed as pain relief. SEARCH STRATEGY: We searched the following databases: Cochrane Oral Health Group Trials Register and Pain, Palliative Care and Supportive (PaPaS) Care Group Trials Register to 6th September 2004; the Cochrane Central Register of Controlled Trials (CENTRAL) The Cochrane Library Issue 3 2004; MEDLINE (1966 to 6th September 2004); EMBASE (1980 to week 36 2004). SELECTION CRITERIA: This review includes one randomised controlled trial which compared pain relief with systemic antibiotics and analgesics, against placebo and analgesics in the acute preoperative phase of irreversible pulpitis. DATA COLLECTION AND ANALYSIS: Only one trial is included in this review, therefore pooling of data from studies was not possible and a descriptive summary is presented. MAIN RESULTS: One trial involving 40 participants was included in this review. There was a close parallel distribution of the pain ratings in both the intervention and placebo groups over the 7 day study period. The between-group differences in sum pain intensity differences (SPID) for the penicillin group were (6.0+/-10.5), and for placebo (6.0+/-9.5) P = 0.776. The sum pain percussion intensity differences (SPPID) for the penicillin group were (3.5+/-7.5) and placebo (2.0+/-7.0) P = 0.290, with differences as assessed by the Mann-Whitney-Wilcoxon test considered to be statistically significant at P < 0.05. There was no significant difference in the mean total number of ibuprofen tablets (P = 0.839) and Tylenol tablets (P = 0.325), in either group over the study period. The administration of penicillin over placebo did not appear to significantly reduce the quantity of analgesic medication taken (P > 0.05) for irreversible pulpitis. AUTHORS' CONCLUSIONS: This review which was based on one methodologically sound but low powered small sample trial provided some evidence that there is no significant difference in pain relief for patients with untreated irreversible pulpitis who did or did not receive antibiotics in addition to analgesics.

Analgesics↗

[The menstruation cycle in the postoperative phase. Its effect of the incidence of nausea and vomiting].

OBJECTIVE: Several studies suggest that the menstrual cycle has an impact on postoperative nausea and vomiting (PONV). However, many studies report inconsistent results. Thus, in this systematic review the results of all available studies are compared and statistically synthesised. MATERIALS AND METHODS: A systematic search of the literature was performed (Medline, the Cochrane-Library, reference lists of matching articles). The main end point in each study was defined as occurrence of PONV during an observation interval of at least 12 h postoperatively. These data were extracted from each article and the pooled incidences of PONV for each day of the menstrual cycle were calculated. These incidences were analysed using the chi 2-test. Furthermore the pooled incidences of PONV during the following phases of the menstrual cycle were calculated: days 1-7, 8-12, 13-15, 16-24, and 25-end of cycle. RESULTS: A total of 12 studies with 2625 patients containing informations on the incidence of PONV on different days or phases of the menstrual cycle were analysed. The total incidence of PONV was 37.3%. The incidence of PONV was lowest (26.9%) on day 20 and reached its maximum on day 5 (45.0%) with no statistically significant differences concerning the incidences of PONV between the different days (p = 0.75). Furthermore there were no clinically relevant differences in the incidences of PONV during the phases of the menstrual cycle: day 1-7: 40.4%; day 8-12: 32.9%; day 13-15: 38.1%; day 16-24: 34.5%; day 25-end of cycle: 41.5%. Prophylactic administration of an antiemetic in some of the studies had no impact on these results. CONCLUSION: Studies investigating the influence of the menstrual cycle on the incidence of PONV show inconsistent results. Summarising the data of these studies suggests that the phase of the menstrual cycle has no impact on the occurrence of PONV.

Antiemetics↗

In vivo effects of adrenocorticotrophin on the expression of the hamster steroidogenic acute regulatory protein.

In this study, we report the cDNA cloning of hamster adrenal steroidogenic acute regulatory (StAR) protein and the effect of adrenocorticotrophin (ACTH) on its expression in vivo. A hamster adrenal cDNA library was screened using an 852 bp fragment obtained by polymerase chain reaction; this fragment corresponds to the entire coding sequence (CDS) of the hamster adrenal StAR cDNA. Ten clones of different lengths were isolated and sequenced. The longest clone was 1564 bp and contained 34 bp in the 5'-untranslated region, 852 bp in the CDS, and 678 bp in the 3'-untranslated region (3'-UTR). Two polyadenylation signal sequences were found in the 3'-UTR. The CDS of the ten isolated clones was identical, but six of these lacked the last 132 nucleotides in the 3'-UTR, thus indicating that they had used the first polyadenylation signal. The hamster StAR protein contains 284 amino acid residues, and is 91.9% homologous to mouse, 90.5% to rat, 86.4% to human, 85% to porcine, and 82.5% to bovine StAR protein. Southern blot analysis indicated the presence of only one StAR gene in the hamster genome. Northern blotting analysis revealed the presence of the StAR mRNA in male and female steroidogenic tissues, namely adrenals and gonads, but not in the liver or in the kidneys of either sex. Three mRNA species of 1.7, 3.1 and 5.3 kb were found in whole hamster adrenals. Administration of ACTH to hamsters provoked increases (two- to threefold) in the adrenal content of the StAR mRNA within 1 h in vivo. Western blotting analysis on adrenal mitochondria showed that the level of StAR protein was also significantly elevated (1.5-fold) 1 h after ACTH treatment.

Adrenal Glands↗

Potential role of monocyte chemoattractant protein 1/JE in monocyte/macrophage-dependent IgA immune complex alveolitis in the rat.

We have examined the role of monocyte chemoattractant protein 1 (MCP 1) in the pathogenesis of monocyte/macrophage-dependent IgA immune complex alveolitis in the rat. Rat MCP 1 was cloned and expressed in order to facilitate analysis of its function in rat models of human disease. A cDNA library was constructed from rat pulmonary artery endothelial cells stimulated with TNF-alpha. The cDNA library was screened with synthetic oligonucleotide probes based on the recently published rat MCP 1 cDNA sequence. Among numerous MCP 1-positive clones, four full length (approximately 480 bp) cDNA were rescued, amplified by polymerase chain reaction, and ligated into a pJVETLZ baculovirus transfer vector. Spodoptera frugiperda insect cells (Sf-21) infected with baculovirus recombinants (Auto-grapha california nuclear polyhedrosis virus) bearing properly oriented MCP 1 cDNA (AcMCP 1) directed the expression of unique peptides of 18, 21, and 23 kDa. Treatment of AcMCP 1-infected Sf-21 cells with tunicamycin resulted in reduced production of the 21- and 23-kDa proteins and an increase in 16- to 18-kDa products, the predicted size range of uncleaved and nonglycosylated rat MCP 1. Denatured and refolded 23-kDa and 21-kDa rat MCP 1 species exhibited dose-dependent monocyte-specific chemotactic activity at concentrations as low as 10(-10) M whereas the 18-kDa species exhibited negligible activity. Antibodies that react with the immunoblot, block rat rMCP 1-directed monocyte chemotaxis, and neutralize monocyte-specific chemotactic activity secreted by TNF-stimulated rat endothelial cells were raised in rabbits immunized with the 23-kDa MCP 1 species. Intravenous administration of anti-MCP 1 antibodies upon initiation of IgA immune complex lung injury resulted in a marked reduction in lung injury as measured by pulmonary vascular permeability, alveolar hemorrhage, and pulmonary monocyte/macrophage recruitment and pulmonary monocyte/macrophage recruitment. These data suggest that MCP 1 may play an important role in the pathogenesis of monocyte/macrophage-dependent IgA immune complex alveolitis in the rat.

Animals↗

[The computerized clinical record: merely an academic discussion or an essential technology?].

The publication of the results of a study on improving patient records, recently completed by the Institute of Medicine of the National Academy of Sciences, in the United States, where it was concluded that the Computer-Based Patient Record (CPR) was an essential technology for health care, witnesses the importance and expectations that patients, physicians and other health care professionals, hospital administrators and health systems managers, place on forms of management of clinical information that are more accurate, complete and efficient than what is possible with current methods. A large amount of work is in order, to develop standards for sharing clinical data between clinical information systems and for representing medical terminology and knowledge, to create legislation regarding data protection in CPR, and for the preparation of health care professionals for the information and technological demands of the future. Recent developments in database integration, and the experience of several CPR systems developed at academic institutions, have led to the progressive delineation of the architecture of modern CPR systems.

Computer Security↗

GnRH agonist for triggering final oocyte maturation in the GnRH antagonist ovarian hyperstimulation protocol: a systematic review and meta-analysis.

Triggering final oocyte maturation with GnRH agonist during ovarian stimulation is feasible when inhibition of premature LH surge is performed with GnRH antagonists, and we aimed to systematically collate evidence on the clinical efficacy of GnRH agonist triggering in patients undergoing assisted reproduction in GnRH antagonist protocols. Twenty-three publications were identified by a comprehensive literature search that included PubMed, Embase and the Cochrane Library. Three publications out of 23 fulfilled the inclusion criteria for meta-analysis, which were (i) prospective, randomized controlled study design; (ii) stimulation with gonadotropins for induction of multifollicular development; (iii) suppression of endogenous LH by a GnRH antagonist; (iv) triggering of final oocyte maturation with GnRH agonist; (v) control group randomized to receive HCG for final oocyte maturation and (vi) any means of luteal phase support other than HCG. The participants were normoovulatory women undergoing IVF. The outcomes assessed were clinical pregnancy per randomized patient; number of oocytes retrieved; proportion of metaphase II oocytes; fertilization rate; embryo quality score; first trimester abortion rate; ovarian hyperstimulation syndrome (OHSS) incidence. Results are presented as combined standardized differences of the mean and combined odds ratios, as appropriate, with 95% confidence intervals. No significant difference was found for the number of oocytes retrieved (-0.94, -0.33-0.14), proportion of metaphase II oocytes (-0.03, -0.58-0.52), fertilization rate (0.15, -0.09-0.38) or embryo quality score (0.05, -0.18-0.29). No OHSS occurred in two of the studies, whereas in one study OHSS incidence was not reported. Thus from the available data, no conclusion can be drawn as regards OHSS incidence after GnRH agonist triggering. In comparison to HCG, GnRH agonist administration is associated with a significantly reduced likelihood of achieving a clinical pregnancy (0.21, 0.05-0.84; P = 0.03). The odds of first trimester pregnancy loss is increased after GnRH agonist triggering; however, the confidence interval crosses unity (11.51, 0.95-138.98; P = 0.05). In conclusion, the use of GnRH agonist to trigger final oocyte maturation in IVF, where inhibition of premature LH surge is achieved with GnRH antagonists, yields a number of oocytes capable to undergo fertilization and subsequent embryonic cleavage, which is comparable to that achieved with HCG. However, the likelihood of an ongoing clinical pregnancy after GnRH agonist triggering is significantly lower as compared to standard HCG treatment.

Abortion, Spontaneous↗

Systematic review and meta-analysis of evidence for increasing numbers of drugs in antiretroviral combination therapy.

OBJECTIVE: To assess the evidence for the effectiveness of increasing numbers of drugs in antiretroviral combination therapy. DESIGN: Systematic review, meta-analysis, and meta-regression of fully reported randomised controlled trials. All studies included compared quadruple versus triple therapy, triple versus double therapy, double versus monotherapy, or monotherapy versus placebo or no treatment. PARTICIPANTS: Patients with any stage of HIV infection who had not received antiretroviral therapy. MAIN OUTCOME MEASURES: Changes in disease progression or death (clinical outcomes); CD4 count and plasma viral load (surrogate markers). SEARCH STRATEGY: Six electronic databases, including Medline, Embase, and the Cochrane Library, searched up to February 2001. RESULTS: 54 randomised controlled trials, most of good quality, with 66 comparison groups were included in the analysis. For both the clinical outcomes and surrogate markers, combinations with up to and including three (triple therapy) were progressively and significantly more effective. The odds ratio for disease progression or death for triple therapy compared with double therapy was 0.6 (95% confidence interval 0.5 to 0.8). Heterogeneity in effect sizes was present in many outcomes but was largely related to the drugs used and trial quality. CONCLUSIONS: Evidence from randomised controlled trials supports the use of triple therapy. Research is needed on the effectiveness of quadruple therapies and the relative effectiveness of specific combinations of drugs.

Anti-HIV Agents↗

An interactive CD-ROM for nutrition screening and counseling.

OBJECTIVES: The goal of this project was to develop an interactive CD-ROM for nutrition screening and counseling, designed to produce dietary behavior change in fat and fruit and vegetable intake. METHODS: The design was based on principles of relevance to the learner, readiness for change, feedback, individualization, facilitation of skills, and goal setting. It was tested in community settings such as libraries, senior centers, and Women, Infants, and Children clinics. RESULTS: Nearly 80% of the respondents (n = 284), including numerous low-income persons, reported learning something new about nutrition and health or their own dietary habits. More than 50% of those recontacted 2 to 4 weeks later had put some of their dietary goals into practice. CONCLUSIONS: This program is useful for dietary screening, feedback, skill building, and motivation in settings in which in-person counseling by nutrition professionals is not feasible.

Adult↗

[Informatics in the School of Medicine of the University of Chile. I. Origin and evolution of biomedical computing in Chile].

In the sixties and seventies, the School of Medicine of the University of Chile was the first Chilean institution to incorporate computers into academic endeavors through its own Computer Center. Later, professors were marginated from policy making, which became oriented to administrative goals, but they compensated that situation with the easy access to personal computers brought about by present technology. In 1986, when School authorities were again elected by the faculty staff, professors were able to participate again in a committee designing projects in this area. Current development at the School of Medicine include a proliferation of personal computers, the implementation of a computer network with access to medical data bases, and a growing number of applications in the fields of research and teaching. In the near future, due to the accessibility of telecommunications and computers, these advancements should have an impact on the whole biomedical community, a situation that would restore, after many years, the traditional role of the University of Chile in the life of the country.

Chile↗

Urocortin III, a brain neuropeptide of the corticotropin-releasing hormone family: modulation by stress and attenuation of some anxiety-like behaviours.

Following its discovery 20 years ago, corticotropin-releasing hormone (CRH) has been postulated to mediate both hormonal and behavioural responses to stressors. Here, we characterize and describe a behavioural role for the murine gene, UcnIII, which encodes a recently discovered CRH-related neuropeptide, urocortin III. We found that mouse UcnIII is expressed predominantly in regions of the brain known to be involved in stress-related behaviours, and its expression in the hypothalamus increases following restraint. In addition, we found that intracerebroventricular administration of mUcnIII stimulates behaviours that are associated with reduced anxiety, including exploration of an open field and decreased latency to enter the lit compartment of a dark-light chamber, but has no effect on the elevated-plus maze. Finally, we found that mUcnIII does not exert any effects on the hormonal stress response. Based upon our findings, UcnIII may be an endogenous brain neuropeptide that is modulated by stress and stimulates behaviours associated with reduced anxiety. In this capacity, UcnIII may attenuate stress-related behaviours, which may be useful both to help cope with stressful situations as well as to avoid pathology associated with excessive reaction to stressors.

Amygdala↗

Some problems with Cochrane reviews of diet and chronic disease.

The sum of evidence-based nutrition has to be more than a Cochrane-type meta-analysis of randomised controlled trials (RCTs). Most of the evidence base in nutrition is observational, especially cohort studies. RCTs of diet change through to disease outcome are uncommon and the change has usually been addition or removal of only a single food component. Trials with whole diets through to disease outcome are rare and dietary changes made by individuals are unlikely to be an exact copy of the prescription. It is hard to even imagine a trial in which half (randomised) of a large group of middle-aged people agree to avoid vegetables for 5 y and be followed up to see who will develop cancer. Most of the USA's health claims, permitted by the Food and Drug Administration, are not supported by RCTs. But where controlled trials of nutritional change and disease outcome have been achieved, they must be reviewed very carefully. Two Cochrane reviews on diet and cardiovascular disease (CVD), published in the widely read British Medical Journal (BMJ), were criticised after their publication and the conclusions have not been subsequently adopted by expert committees. The first of these reviews was 'Dietary fat and prevention of CVD: a systematic review'. The second was 'Systematic review of long term effects of advice to reduce dietary salt in adults'. A critique of these two Cochrane reviews is presented here as a contribution to our discussion of the potential of Cochrane methodology to the reliability of knowledge about diet and disease.

Cardiovascular Diseases↗

Surfactant protein C: hormonal control of SP-C mRNA levels in vitro.

We have studied hormonal regulation of the surfactant protein C (SP-C) in fetal 18-dah rat lung explants. SP-C mRNA was detected in Northern blots with a specific rat SP-C cDNA probe and quantified by densitometry. Treatment of the explants with dexamethasone resulted in a dose-dependent increase of the SP-C mRNA level. Transcriptional assays have shown that the regulation of SP-C mRNA by dexamethasone involves a transcriptional step. Administration of the cAMP analogues, 8-bromoadenosine 3',5'-cyclic monophosphate (8-BrcAMP) or dibutyryl adenosine 3',5'-cyclic monophosphate (DBcAMP), produced a dose-dependent increase of SP-C mRNA levels, with maximum stimulation observed at 200 microM. The thyroid hormone T3 had no effect on SP-C mRNA levels, whether administered alone or in combination with dexamethasone. Variation in the effects of the above hormones on three surfactant protein mRNAs, SP-A, SP-B and SP-C, indicates that the hormonal regulation of the surfactant proteins is a complex process and that each gene is, in part, differentially regulated.

8-Bromo Cyclic Adenosine Monophosphate↗

Oral morphine for cancer pain.

BACKGROUND: Morphine has been used to relieve pain for many years. Oral morphine in either immediate release or sustained release form remains the analgesic of choice for moderate or severe cancer pain. OBJECTIVES: To determine the efficacy of oral morphine in relieving cancer pain. To assess the incidence and severity of adverse effects. SEARCH STRATEGY: The following databases were searched: The Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Library, Issue 4, 2002; the trials register of the Cochrane Pain, Palliative and Supportive Care group (February 2002); MEDLINE 1966 to December 2002; EMBASE 1988 to December 2002; and the Oxford Pain Relief database 1950 to 1994. SELECTION CRITERIA: Published randomised controlled trials (full reports) reporting on the analgesic effect of oral morphine in adults and children with cancer pain. Any comparator trials were considered. Trials with fewer than 10 subjects were excluded. DATA COLLECTION AND ANALYSIS: One reviewer extracted data, and the findings were checked by two other reviewers. There were insufficient comparable data for meta-analysis to be undertaken, or to produce numbers-needed-to-treat (NNT) for the analgesic effect. MAIN RESULTS: Forty five studies (3061 subjects) met the inclusion criteria. Fourteen studies compared oral sustained release morphine (MSR) preparations with immediate release morphine (MIR). Eight studies compared MSR and MSR in different strengths. Nine studies compared MSR with other opioids. Five studies compared MIR with other opioids. Two studies compared oral MSR with rectal MSR. One study was found comparing each of the following: MSR tablet with MSR suspension; MSR with MSR at different dose frequencies; MSR with non-opioids; MIR with non-opioids; oral morphine with epidural morphine; and MIR with MIR by a different route of administration. Morphine was shown to be an effective analgesic. Pain relief did not differ between MSR and MIR. Sustained release versions of morphine were effective for 12 or 24 hour dosing depending on the formulation. Adverse effects were common but only 4% of patients discontinued treatment because of intolerable adverse effects. REVIEWER'S CONCLUSIONS: The randomised trial literature for morphine is small given the importance of this medicine. Most trials recruited fewer than 100 participants, and did not provide appropriate data for meta-analysis. Trial design was frequently based on titration of morphine or comparator to achieve adequate analgesia, then crossing subjects over in crossover design studies. It is not clear if these trials are sufficiently powered to detect any clinical differences between formulations or comparator drugs.

Adult↗

Antibiotics for acute pyelonephritis in children.

BACKGROUND: Urinary tract infection (UTI) is one of the most common bacterial infection in infants. The most severe form of UTI is acute pyelonephritis, which results in significant acute morbidity and may cause permanent renal damage. Published guidelines recommend treatment of acute pyelonephritis initially with intravenous (IV) therapy followed by oral therapy for 7-14 days though there is no consensus on the duration of either IV or oral therapy. OBJECTIVES: To determine the benefits and harms of different antibiotic regimens for the treatment of acute pyelonephritis in children. SEARCH STRATEGY: We searched the Cochrane Register of Controlled Trials (Cochrane Library Issue 3, 2002), MEDLINE (1966 - September 2002), EMBASE (1988 -September 2002), reference lists of articles and abstracts from conference proceedings without language restriction. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing different antibiotic agents, routes, frequencies or durations of therapy in children aged 0-18 years with proven UTI and acute pyelonephritis were selected. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) for dichotomous outcomes or weight mean difference (WMD) for continuous data with 95% confidence intervals (CI). MAIN RESULTS: Sixteen trials involving 1872 children were eligible for inclusion. No significant differences were found in persistent renal damage at six months (one trial, 306 infants: RR 1.45, 95% CI 0.69 to 3.03) or in duration of fever (WMD 0.80, 95% CI -4.41 to - 6.01) between oral cefixime therapy (14 days) and IV therapy (three days) followed by oral therapy (10 days). Similarly no significant differences in persistent renal damage (three trials, 315 children: RR 0.99, 95% CI 0.72 to 1.37) were found between IV therapy (3-4 days) followed by oral therapy and IV therapy for 7-14 days. In addition no significant differences in efficacy were found between daily and thrice daily administration of aminoglycosides (one trial, 179 children, persistent symptoms at three days: RR 1.98, 95% CI 0.37 to 10.53). REVIEWER'S CONCLUSIONS: These results suggest that children with acute pyelonephritis can be treated effectively with oral cefixime or with short courses (2-4 days) of IV therapy followed by oral therapy. If IV therapy is chosen, single daily dosing with aminoglycosides is safe and effective. Trials are required to determine the optimal total duration of therapy and if other oral antibiotics can be used in the initial treatment of acute pyelonephritis.

Adolescent↗