Average Daily Requirement Research Articles

Nonsteroidal Antiinflammatory Medications: Efficient and Safe Treatment Following Video‐Assisted Pleurodesis for Spontaneous Pneumothorax

Recurrent spontaneous pneumothorax is widely treated by video-assisted thoracoscopic (VATS) bullectomy and pleurodesis. Treatment of postoperative pain with nonsteroidal antiinflammatory drugs (NSAIDs) is controversial as many surgeons believe that it reduces the efficacy of pleurodesis and increases the pneumothorax recurrence rate. In this retrospective study, we reviewed the hospital records for patients following VATS pleurodesis for recurrent spontaneous pneumothorax. The patients were divided into two groups: (1) NSAID group: patients were treated with NSAIDs for more than a week following surgery and (2) control group: patients did not receive NSAIDs. Data regarding short- and long-term outcomes were compared. The study cohort included 105 patients: 48 in the NSAID group and 57 in the control group. During the early postoperative period the average daily requirement of narcotic analgesia and the incidence of narcotic-related side effects were lower in the NSAIDs group. No difference was found in the long-term recurrence rate: two of 48 (4%) in the NSAID group and three of 57 (5%) in the control group. There was one case of early recurrence in the NSAID group. Both groups had similar length of stay with no cases of mortality or major morbidity. NSAIDs for postsurgical pleurodesis pain obviates the need for narcotics without increasing the pneumothorax recurrence rate. Prospective randomized controlled studies are needed to further investigate this issue.

A single-blinded trial of methotrexate versus azathioprine as steroid-sparing agents in generalized myasthenia gravis

BackgroundLong-term immunosuppression is often required in myasthenia gravis (MG). There are no published trials using methotrexate (MTX) in MG. The steroid-sparing efficacy of azathioprine (AZA) has been demonstrated after 18-months of starting therapy. However, AZA is considered expensive in Africa. We evaluated the steroid-sparing efficacy of MTX (17.5 mg weekly) compared with AZA (2.5 mg/kg daily) in subjects recently diagnosed with generalized MG by assessing their average monthly prednisone requirements.MethodsThe primary outcome was the average daily prednisone requirement by month between the two groups. Prednisone was given at the lowest dose to manage MG symptoms and adjusted as required according to protocol. Single-blinded assessments were performed 3-monthly for 2-years to determine the quantitative MG score and the MG activities of daily living score in order to determine those with minimal manifestations of MG.ResultsThirty-one subjects (AZA n = 15; MTX n = 16) satisfied the inclusion criteria but only 24 were randomized. Baseline characteristics were similar. There was no difference between the AZA- and MTX-groups in respect of prednisone dosing (apart from months 10 and 12), in quantitative MG Score improvement, proportions in sustained remission, frequencies of MG relapses, or adverse reactions and/or withdrawals. The MTX-group received lower prednisone doses between month 10 (p = 0.047) and month 12 (p = 0.039). At month 12 the prednisone dose per kilogram bodyweight in the MTX-group (0.15 mg/kg) was half that of the AZA-group (0.31 mg/kg)(p = 0.019).ConclusionsThis study provides evidence that in patients with generalized MG methotrexate is an effective steroid-sparing agent 10 months after treatment initiation. Our data suggests that in generalized MG methotrexate has similar efficacy and tolerability to azathioprine and may be the drug of choice in financially constrained health systems.Trial registrationSANCTR:DOH-27-0411-2436

Impact of health disparities on staff workload in pharmacist-managed anticoagulation clinics

Pharmacists' provision of services unrelated to anticoagulant therapy at an anticoagulation clinic in an area of prevalent health disparities (health status differences between minority and nonminority populations) was evaluated. A prospective cohort study was conducted to compare the frequency and types of additional services (i.e., services unrelated to anticoagulation) provided by pharmacists during an eight-week period at an urban clinic serving a primarily minority and socioeconomically disadvantaged patient population (clinic A) and a suburban clinic serving a primarily nonminority and affluent population (clinic B). Over the study period, additional services were provided during 42% of all patient visits (n = 444) at clinic A and 8% of all visits (n = 443) at clinic B. The most commonly provided additional services involved nonanticoagulation-related medical problems, which were addressed during about 9% of visits at clinic A and 3% of visits at clinic B; other additional services included setting up appointments, arranging transportation, and providing refills of nonanticoagulant medications. Missed appointments, early or late arrivals, and walk-in appointments were much more common at clinic A. The average daily pharmacist-staffing requirement was 3.8 hours higher at clinic A; over the entire study period, clinic A required a total of about 60 more staffed hours than clinic B. Pharmacists practicing in an anticoagulation clinic serving an area of prevalent health disparities frequently spent a substantial amount of time addressing medical problems and administrative tasks unrelated to anticoagulation therapy.

Enteric‐coated mycophenolate sodium in the treatment of refractory pemphigus

One of the major goals of pemphigus therapy is to reduce the patient's cumulative exposure to systemic corticosteroids. To investigate the efficacy of enteric-coated mycophenolate sodium (EC-MPS), 10 patients with active, refractory pemphigus vulgaris (PV) or foliaceous (PF) were treated with EC-MPS (1440 mg daily) and prednisone (75 mg daily) over 18 months. Following EC-MPS/prednisone therapy, disease progression was inhibited between days 30 and 45 in 9/10 patients (8 PV; 1 PF). At 18 months, 8/9 PV patients had clinically quiescent disease; EC-MPS therapy was no longer required in two patients as a result of disease remission. The remaining PV patient showed no response to treatment. The PF patient also had clinically quiescent disease but with high levels of anti-desmoglein-1. ECMPS dose was reduced to 720 mg daily in 4/9 patients by month 6. Average daily prednisone requirement decreased to 25 mg at 6 months and to 15 mg at 18 months. Three adverse events were reported: headache (two cases; one mild and one moderate) and significant increase in blood glucose (one case; moderate). Enteric-coated mycophenolate sodium is effective and safe as an adjuvant therapy in patients with refractory pemphigus and may be effective even in patients whose disease is unresponsive to azathioprine.

Two icodextrin exchanges per day in peritoneal dialysis patients with ultrafiltration failure: one center’s experience and review of the literature

At present, only one exchange of an icodextrin-based solution is recommended to increase peritoneal ultrafiltration (UF) during long-dwell exchanges in peritoneal dialysis (PD) patients with impaired UF. To review our experience with two icodextrin exchanges per day on net UF and body weight in PD patients with poor UF. Data were analyzed on nine patients with poor UF on chronic PD who were given two icodextrin exchanges per day for 6months and had various clinical and biochemical parameters assessed monthly. Administration of icodextrin twice daily reduced the body weight in six of nine patients by an average of 2.9±1.2kg, a reduction that was maintained throughout the study; two patients gained 0.5kg; and, in one patient, the measurements were inadequate. Mean blood pressure was reduced. Mean serum creatinine increased slightly. Serum sodium levels decreased from a mean baseline level of 134±3 to 132±4mmol/L at three and six months. Among the diabetics in this group, average daily insulin requirements were 44±35 units/day at baseline and 40±23 units/day after 6months. Hb1Ac levels remained stable throughout the study period. The use of two icodextrin exchanges per day reduced body weight in six of the nine patients and appeared to be safe. Long-term prospective studies are needed to assess the contribution of twice-daily icodextrin to the management of peritoneal dialysis patients with ultrafiltration failure and its long-term safety.

Nurse‐controlled analgesia (NCA) following major surgery in 10 000 patients in a children’s hospital

Patients who received NCA with morphine following major surgery between 1996 and 2008 at Great Ormond Street Hospital, London, UK, were prospectively studied in the postoperative period to determine effectiveness, morphine requirements, incidence of common side effects, and serious adverse events. The morphine NCA regimen and monitoring was according to standard hospital protocols. Data were collected prospectively and subsequently entered by trained personnel into a secure database. Patient demographics, effectiveness and satisfaction rates, morphine requirements, side effects, and serious complications were recorded. 10,079 patients were included. The average age was 4 years old (range 1 day to 20.5 years, median 2.3 years). There were 510 neonates. The average NCA duration was 43.7 h. 1.8% of morphine NCAs were replaced by other methods because analgesia was unsatisfactory. Satisfaction ratings were 'good' or 'very good' for 98% of the remainder. Average daily morphine requirement (mcg x kg(-1) x h(-1)) was related to age, surgical category, and postoperative time. Side effects included PONV (25%), itching (9.4%), depression of respiration, and sedation (4.5%); incidences varied with age, morphine dose, and type of surgery. Serious, potentially life-threatening adverse effects (SAE) were 0.4%. There were no deaths. SAE were significantly greater in neonates (2.5%), relative risk 9.4, P < 0.001. Morphine dose in neonates who experienced SAE was not significantly different from other neonates. NCA with morphine is an acceptable, safe, and effective method of postoperative analgesia for a wide range of ages and types of surgery in our practice. Morphine requirements increase with age, but there was also considerable inter-individual variation within age groups. PONV, itching, sedation, and respiratory depression are expected side effects. SAE are uncommon but the incidence is greatest in neonates.

Optimal Risk Management Before, During and After the 2008-09 Financial Crisis

In this paper we advance the idea that optimal risk management under the Basel II Accord will typically require the use of a combination of different models of risk. This idea is illustrated by analyzing the best empirical models of risk for five stock indexes before, during, and after the 2008-09 financial crisis. The data used are the Dow Jones Industrial Average, Financial Times Stock Exchange 100, Nikkei, Hang Seng and Standard and Poor’s 500 Composite Index. The primary goal of the exercise is to identify the best models for risk management in each period according to the minimization of average daily capital requirements under the Basel II Accord. It is found that the best risk models can and do vary before, during and after the 2008-09 financial crisis. Moreover, it is found that an aggressive risk management strategy, namely the supremum strategy that combines different models of risk, can result in significant gains in average daily capital requirements, relative to the strategy of using single models, while staying within the limits of the Basel II Accord.

Surgery for Nonobese Type 2 Diabetic Patients: An Interventional Study with Duodenal–Jejunal Exclusion

A 24-week interventional prospective trial was performed to compare the benefits of open duodenal-jejunal exclusion surgery (GJB) with a matched control group on standard medical care. One-hundred eighty patients were screened for the surgical approach. Twelve patients accepted to be operated and presented the full eligibility criteria for surgery that includes overweight BMI (25-29.9 kg/m2), T2DM diagnosis for less than 15 years, insulin-treated patients, no history of major complications, preserved beta-cell function, and absence of autoimmunity. A matched control group (CG) of patients whom refused surgical treatment was placed to receive standard care. Patients had age of 50 (5) years, time of diagnosis 9 years (range, 3 to 15 years), time of insulin usage 6 months (range, 3 to 48 months), fasting glucose (FG), 9.8 (2.5) mg/dL, and glycated hemoglobin (A1C) 8.90 (2.12)%. At 24 weeks after surgery, patients experienced greater reductions on FG (14% vs. 7% on CG), A1C (from 8.78 to 7.84 in GJB-p<0.01 and 8.93 to 8.71 in CG; p<0.05 between groups) and reductions on average daily insulin requirement (93% vs. 29%, p<0.01). Ten patients stopped insulin usage in GJB but they remain taking oral medications. No differences were observed in both groups regarding BMI, body distribution and composition, blood pressure, and lipids. In conclusion, duodenal-jejunal exclusion was an effective treatment for nonobese T2DM subjects. GJB was superior to standard care in achieving better glycemic control along with reduction in insulin requirements.

Nutritional assessment of charitable meal programmes serving homeless people in Toronto

To assess the potential nutritional contribution of meals provided in a sample of community programmes for homeless individuals, to determine the effect of food donations on meal quality and to develop food-based guidance for meals that would meet adults' total nutrient needs. Toronto, Canada. An analysis of weighed meal records from eighteen programmes. The energy and nutrient contents of meals were compared to requirement estimates to assess contribution to total needs, given that homeless people have limited access to nutritious foods. Mixed linear modelling was applied to determine the relationship between the use of food donations and meal quality. The composition of meals that would meet adults' nutrient requirements was determined by constructing simulated meals, drawing on the selection of foods available to programmes. In all, seventy meals, sampled from eighteen programmes serving homeless individuals. On average, the meals contained 2.6 servings of grain products, 1.7 servings of meat and alternatives, 4.1 servings of vegetables and fruits and 0.4 servings of milk products. The energy and nutrient contents of most meals were below adults' average daily requirements. Most meals included both purchased and donated foods; the vitamin C content of meals was positively associated with the percentage of energy from donations. Increasing portion sizes improved the nutrient contribution of meals, but the provision of more milk products and fruits and vegetables was required to meet adults' nutrient requirements. The meals assessed were inadequate to meet adults' nutrient requirements. Improving the nutritional quality of meals requires additional resources.

Blood transfusion requirements and independent predictors of increased transfusion requirements among adult patients on extracorporeal membrane oxygenation – a single centre experience

More adults undergo extracorporeal membrane oxygenation (ECMO) now. They have high transfusion requirements. This study described transfusion requirements of adults during ECMO in a single institution, and determined factors associated with high transfusion requirements. Retrospective analysis was done on the amount of blood products received by adults during ECMO. Predictors of increased average daily transfusion requirements during ECMO and increased ECMO duration (which correlated positively with total transfusion requirements) were determined. Forty-one patients (median age 50 years) underwent 42 ECMO sessions for respiratory failure (16.7%), cardiogenic shock (76.2%) or massive pulmonary embolism (7.1%). They received 569 red blood cells, 852 platelets, 126 fresh-frozen plasma (FFP) and 220 cryoprecipitate in total during median ECMO duration of 5 (1-15) days. On multivariate analysis, average daily red blood cell transfusion increased with nadir haemoglobin (Hb) during ECMO (Hb(nadir)) of < 7.5 g/dl (P < 0.001). Average daily platelet transfusion increased with recent antiplatelet agents (P = 0.015) and maximum Hb decline of > 5.5 g/dl during ECMO (P = 0.011). Average daily platelet transfusion > 3 units was also associated with increased ECMO duration (P = 0.024). Average daily FFP transfusion was increased in patients with hypertension (P = 0.007) and Hb(nadir) < 7.5 g/dl (P = 0.050). Patients with sepsis (P = 0.009) or without surgery (P = 0.009) had increased ECMO duration, which correlated positively with total transfusion requirements during the entire ECMO session. ECMO improved mortality of patients with fulminant myocarditis, respiratory failure and massive pulmonary embolism. Adult ECMO patients with lower Hb(nadir) require more daily red blood cell and FFP. Hypertension increases daily FFP requirements. Recent antiplatelet agents, larger Hb decline and longer ECMO duration increase daily platelet requirements. Patients with sepsis or on ECMO for medical reasons have longer ECMO duration, which is associated with total transfusion requirements. Some of these factors may be identified early to optimize blood product support.

Use of the NuvaRing® hormone-releasing system in late reproductive-age women with type 1 diabetes mellitus

Aim. To evaluate the effect of the vaginally inserted hormone-releasing system NuvaRing® on carbohydrate and lipid metabolism and the hemostasis system, over 6 months of use, in late reproductive-age women with type 1 diabetes mellitus (DM).Methods. The open randomized study included a total of 25 women with type 1 DM using NuvaRing. Average daily insulin requirements, levels of glycosylated hemoglobin (HbA1c), total cholesterol, triglycerides, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol, the state of coagulation hemostatis and fibrinolytic activity were determined at baseline and after 3 and 6 months of contraception. The control group was composed of 20 age-matched women with type 1 DM using no methods of contraception, as well as 20 apparently healthy women using the NuvaRing device.Results. Use of the NuvaRing contraceptive system in type 1 DM women in the late reproductive period was shown to exert no clinically significant effect on carbohydrate and lipid metabolism on the background of persistent and satisfactory compensation of carbohydrate metabolism (HbA1c ≤ 7.5%), with a neutral impact on the hemostasis system.Conclusion. The NuvaRing hormone-releasing system proved to be a reliable and safe means of contraception for late reproductive-age women with type 1 DM.

Contraception in perimenopausal women with diabetes mellitus

Aim. To assess the effect of combined oral contraceptives (COCs) and intrauterine devices (IUDs) on carbohydrate and lipid metabolism and hemostasis in perimenopausal diabetic women.Methods. The open randomized study included a total of 113 diabetic women using COCs with different estrogen/progestogen profiles – ethinylestradiol (EE) 20 μg/desogestrel 150 μg, EE 30 μg/desogestrel 150 μg and EE 30 μg/gestodene 75 μg – and levonorgestrel-releasing or copper IUDs. Average daily insulin requirements, levels of glycosylated hemoglobin, total cholesterol, triglycerides, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol, the state of coagulation hemostatis and fibrinolytic activity were determined at baseline and after 3, 6, 9 and 12 months of contraception. The control group was composed of 40 age-matched diabetic women who did not use any methods of contraception.Results. Neither COCs nor IUDs influenced glycosylated hemoglobin and had little or no influence on the elevation in the requirements for insulin preparations. The majority of the preparations did not exert any unfavorable effect on the blood lipid profile. Taking COCs was accompanied by increased intravascular activation of blood platelets and to a lesser degree by alterations in parameters of hemostatic homeostasis. The use of IUDs had a neutral effect on blood coagulation and fibrinolysis systems.Conclusion. Comparing lipid levels and hemostatic variables as a function of glycosylated hemoglobin level, we conclude that diabetes control has greater influence on these parameters than the type and dose of steroids involved in the contraceptive devices.

Efficacy and Safety of a Mixture of Two Different Brands of Insulin Products in Patients with Type 1 Diabetes Mellitus

In the past, insulin products manufactured by different companies were considered to be incompatible. However, no studies have actually been conducted on insulin product compatibility. The objective of this study was to determine the efficacy and safety of a mixture of insulin products produced by different companies in patients with diabetes mellitus. Chart reviews were conducted on 105 patients with type 1 diabetes mellitus who were followed up at Taichung Veterans General Hospital between October 1999 and December 2001. Twenty patients were included for final analysis. The average daily insulin requirement, hemoglobin A1c (HbA1c) level, body weight, and body mass index (BMI) were compared 6 months before (period 1, used same brand of insulin, Humulin N plus Humulin R) and after (period 2, used different brands of insulin, Insulatard HM plus Humulin R) the mixture treatment. Hypoglycemia and other adverse events were also recorded. The difference in average daily insulin requirement (intermediate-acting, short-acting) between periods 1 and 2 was not statistically significant (27.1 +/- 10.8 U vs 27.1 +/- 10.8 U, p = 0.317; 13.9 +/- 7.6 U vs 14.7 +/- 7.3 U, p = 0.655). There was no significant difference in HbA1c level between periods 1 and 2 (8.0 +/- 1.5% vs 8.0 +/- 1.2%, p = 0.732). The difference in BMI between periods 1 and 2 was not statistically significant. The number of hypoglycemic events 6 months before and after the mixture therapy was also not statistically significantly different. There were no reported injection-site reactions or an increased number of adverse events when using the mixture of Insulatard HM and Humulin R. This retrospective study demonstrated that using a mixture of different brands of insulin (Insulatard HM plus Humulin R) for 6 months did not change the efficacy of insulin in patients with type 1 diabetes mellitus.

Effect of low-calorie parenteral nutrition on the incidence and severity of hyperglycemia in surgical patients: A randomized, controlled trial

To determine the effect of a low-calorie parenteral nutrition (PN) regimen on the incidence and severity of hyperglycemia and insulin requirements. Prospective, randomized, clinical trial. Urban, university-affiliated, level-I trauma center. Consecutive surgical patients requiring PN. Patients were randomized to receive either a low-calorie PN formulation (20 nonprotein kilocalories per kg per day) or a standard PN formulation (30 nonprotein kilocalories per kg per day). Lipid-derived calories were standardized to 1000 kilocalories three times weekly for all patients; consequently, the number of calories varied only by the amount of carbohydrate administered. Protein requirements were individualized on the basis of estimated metabolic stress. Hyperglycemia was defined as a blood glucose level > or = 200 mg/dL. Forty patients were evaluated (low-calorie PN, n = 20; standard PN, n = 20). Demographics of the two groups were similar. The incidence of hyperglycemic events was significantly lower in the low-calorie group (0% [0-0.5] vs. 33.1% [0-58.4]; p = .001]. Additionally, the severity of hyperglycemia was also lower in the low-calorie group (mean glucose area under the curve = 118 +/- 22 [mg x hr]/dL vs. 172 +/- 44 [mg x hr]/dL; p < .001). This resulted in lower average daily insulin requirements (0 [0-0] units vs. 10.9 [0-25.6] units; p < .001.). The only predictor of hyperglycemia was a dextrose administration rate >4 mg/kg/min. : Administration of a low-calorie PN formulation resulted in fewer and less-severe hyperglycemic events and lower insulin requirements. PN regimens should not exceed a dextrose administration rate of 4 mg/kg/min to avoid hyperglycemic events.

Ferrous Sulfate Is More Bioavailable among Preschoolers than Other Forms of Iron in a Milk-Based Weaning Food Distributed by PROGRESA, a National Program in Mexico ,

After 1 y of distributing a milk-based fortified weaning food provided by the Mexican social program PROGRESA, positive effects on physical growth, prevalence of anemia, and several vitamin deficiencies were observed. There was no effect on iron status, which we hypothesized was related to the poor bioavailability of the reduced iron used as a fortificant in PROGRESA. The objective of this study was to compare the iron bioavailability from different iron sources added as fortificants to the weaning food. Children (n = 54) aged 2-4 y were randomly assigned to receive 44 g of the weaning food fortified with ferrous sulfate, ferrous fumarate, or reduced iron + Na(2)EDTA. Iron absorption was measured using an established double-tracer isotopic methodology. Iron absorption from ferrous sulfate (7.9 +/- 9.8%) was greater than from either ferrous fumarate (2.43 +/- 2.3%) or reduced iron + Na(2)EDTA (1.4 +/- 1.3%) (P < 0.01). The absorption of log-(58)Fe sulfate given with the iron source correlated with serum ferritin (s-ferritin) concentration (n = 13, r = 0.63, P = 0.01) and log-(57)Fe absorption (reference dose) (n = 14, r = -0.52, P = 0.02). Absorption from ferrous fumarate and reduced iron + Na2EDTA did not correlate with s-ferritin or absorption of (57)Fe. The recommended daily portion of the fortified complementary food provides an average of 0.256, 0.096, 0.046 mmol (1.44, 0.54, and 0.26 mg) of absorbed iron, if fortified with sulfate, fumarate and reduced iron + Na(2)EDTA, respectively. Ferrous sulfate was more bioavailable than either ferrous fumarate or reduced iron + Na(2)EDTA when added to the milk-based fortified food and more readily met the average daily iron requirements for children 2-3 y of age.

Food requirements of grey partridge Perdix perdix chicks

Experimental investigations showed that during the first 10 days of their life partridge Perdix perdix chicks grew most vigorously on a high protein value diet composed largely of insects. They grew less quickly on rearing crumbs and were unable to survive when fed entirely on seeds. We determined the daily uptake of food and, from carcass analysis, the proportion assimilated. From this information the average daily food requirement in terms of the dry weight of insects was calculated as 0.80 g on day 2 and 1.95 g on day 9. We calculated the number of individual insects of various groups required daily, if feeding was restricted to one group, and the amount of habitat that would need to be searched if insects were taken randomly. Resistance to chilling was shown to be correlated with weight and not with age. Thus shortage of insect food in the first few days of life would extend the period when the chicks are particularly vulnerable to lower temperatures and rain, effects that have also been demonstrated in other studies.

Population requirement for adult critical-care beds: a prospective quantitative and qualitative study

The provision of adult critical-care facilities is not based on a rational or scientific assessment of need. We aimed to define the numbers of adult critical-care beds required for a population of 500000. In five hospitals in Wales, UK, we classified patients who might be suitable for critical care in intensive-care or high-dependency units. On every 12th day for 1 calendar year, we counted the numbers of such patients admitted in a defined geographical population. A panel of ten intensivists made consensus decisions about whether individual patients were in the appropriate unit. The data were used to predict the numbers of beds and units required for the population. 4058 patients were suitable for critical care, of whom 3028 lived in the study area. 56.4% were in general wards, 22.3% in high-dependency units, and 21.3% in intensive-care units. The mean risk of death was 22.0% and the in-hospital death rate 17.3%. According to the masked consensus, 41.3% of patients required high-dependency beds and 21.5% intensive-care beds. Mean risk of death increased from general wards (14.7%) to high-dependency units (19.2%) to intensive care (37.0%). Based on the consensus decisions, the average daily requirement of intensive-care beds was 21 and of high-dependency beds 43; to meet needs 95% of times required 30 and 55 beds, respectively, in a single critical-care unit. We estimated, scientifically, numbers of adult critical-care beds required to meet population needs. Studies are necessary periodically to track changes in admissions requiring critical care.

Nebulized lidocaine in the treatment of severe asthma in children: a pilot study.

Glucocorticoids have been used to treat asthma since the 1950s; however, their adverse systemic effects have limited their duration of use and dosage. Unfortunately, many patients with severe asthma often require oral glucocorticoids in addition to inhaled glucocorticoids. Alternatives to glucocorticoids have been sought with mixed success. Recently, lidocaine has been added to the list of potent glucocorticoid sparing agents for the treatment of severe asthma. We report the first group of pediatric patients with severe asthma treated with nebulized lidocaine. The study was performed in an open manner with 6 severely asthmatic patients followed in the Pediatric Allergy and Immunology Section, Mayo Clinic. The only intervention was the institution of nebulized lidocaine (0.8 mg/kg/dose to 2.5 mg/kg/dose t.i.d to q.i.d). The average daily steroid requirement was followed during the administration of the nebulized lidocaine. During a mean of 11.2 months of therapy (range 7 to 16 months) 5 of the 6 patients completely discontinued their oral glucocorticoids within an average time of 3.4 months (range 1 to 7 months). After further study, lidocaine may prove to be the first non-toxic, steroid alternative to patients with severe steroid-dependent asthma.

Dietary protein restriction alters glucose but not protein metabolism in non—insulin-dependent diabetes mellitus

We determine whether a customary diet high or low in protein (1) influences postabsorptive amino acid catabolism, nitrogen (N) balance, and hepatic glucose output (HGO) in normal subjects or patients with non—insulin-dependent diabetes mellitus (NIDDM) or (2) alters blood glucose levels in NIDDM. Eight normal young adults and five obese middle-aged persons with NIDDM consumed low-protein (0.8 g/kg lean body mass [LBM]) or high-protein (3.0 g/kg LBM) diets at maintenance energy for consecutive 7-day periods. Fasting and average blood glucose and N balance were measured daily. The level of dietary protein had no effect on the basal plasma leucine rate of appearance (Ra) or urinary 3-methylhistidine excretion in either subject group. Basal leucine oxidation (and by inference, whole-body amino acid catabolism) was reduced on the low-protein diet but basal HGO was not, and although exogenous glucose effectively suppressed HGO, it did not reduce leucine oxidation with either diet. After adaptation to the low-protin diet, N balance in both the normal and NIDDM subjects was close to zero. The low-protein diet reduced the fasting and daily blood glucose of the diabetic subjects by approximately 2 mmol/L ( P < .05). We conclude that physiologic variation in dietary protein does not affect basal whole-body protein turnover or HGD in either normal young adults or obese middle-aged NIDDM subjects. However, protein restriction to the level of the average daily requirement significantly reduces postabsorptive and average daily blood glucose concentrations in persons with NIDDM.

Maillard Reaction in Milk-Based Foods: Nutritional Consequences

Chemical reactions occurring during industrial treatments or storage of foods can lead to the formation of ε-deoxyketosyl compounds, the Amadori products. Food protein value can be adversely affected by these reactions, and in particular lysine, an essential amino acid having on its side chain a free amino group, can be converted to nonbioavailable N-substituted lysine or blocked lysine. By acid hydrolysis of ε-deoxyketosyl compounds, furosine is formed. In this paper furosine prepared from milk-based commercial products has been evaluated by use of a recently developed HPLC method using a microbore column and phosphate buffer as the mobile phase at controlled temperature. Furosine levels have been used, together with protein, total amino acids, and lysine content, as an estimate of protein quality of a few different products such as cooked-cream dessert, yogurt mousse, white chocolate, milk chocolate, milk chocolate with a soft nougat and caramel center, milk chocolate with a whipped white center, chocolate spread, part-skim milk tablets, milk-based dietetic meals, and baby foods. The protein content of the analyzed products ranged from 34.3g · kg−1 (milk nougat) to 188.4g · kg−1 (milk tablets). The Maillard reaction caused a loss in available lysine that varied from 2.5% (cooked cream) to 36.2% (condensed milk). The contribution to the lysine average daily requirement is heavily affected by this reaction and varied from 13% (milk tablets and soft nougat) to 61% (dietetic meal). Variable results were also obtained for the other essential amino acids.