Ice Chips Research Articles

Oral mucositis: a challenging complication of radiotherapy, chemotherapy, and radiochemotherapy: part 1, pathogenesis and prophylaxis of mucositis.

Oral mucositis is a common sequel of radiotherapy, chemotherapy, and radiochemotherapy in patients with cancer or patients requiring hemopoietic stem cell transplants. Mucositis has a direct and significant impact on the duration of disease remission and cure rates, because it is a cancer treatment-limiting toxicity. Mucositis also affects survival because of the risk of infection and has a significant impact on the quality of life and cost of care. This article reviews publications on the etiopathogenesis and prevention of oral mucositis accessible from a MEDLINE search using as key words, mucositis, radiotherapy, chemotherapy, hemopoietic stem cell transplant, and oral. Of the current available products, ice chips and benzydamine have the strongest scientific evidence of support for prophylaxis of mucositis.

Prevention of Oral Mucositis and Oral Candidiasis for Patients with Cancer Treated with Chemotherapy: Cochrane Systematic Review

The objectives of this study were to determine whether oral prophylactic agents are superior to placebo or no treatment on the incidence of oral mucositis and oral candidiasis for patients with cancer. A Cochrane systematic review was conducted of randomized trials of oral (and topical) prophylactic agents for mucositis and oral candidiasis, anywhere in the world, among patients with cancer (excluding head and neck) who were receiving chemotherapy. Eleven studies were included in the meta-analysis for mucositis. Of the six prophylactic agents used for mucositis, only one--ice chips--was effective (relative risk 0.57, 95% CI 0.43 to 0.77). Fifteen studies were included in the meta-analysis for oral candidiasis. There is evidence that antifungal agents that are partially or fully absorbed from the gastrointestinal tract prevent oral candidiasis and that the partially absorbed agents may be more effective than the fully absorbed agents. The RR for partially absorbed agents was 0.13 (95% CI 0.06 to 0.27). In conclusion, there is weak and unreliable evidence that ice chips prevent mucositis. There is evidence that prophylactic use of antifungal agents, which are absorbed or partially absorbed from the gastrointestinal tract, reduce the clinical signs of oral candidiasis.

Anesthetic Considerations for a Patient with Compound Heterozygous Medium-Chain Acyl-CoA Dehydrogenase Deficiency

Anesthetic Considerations for a Patient with Compound Heterozygous Medium-Chain Acyl-CoA Dehydrogenase Deficiency

Freeze Tolerance of Seed-Producing Turf Bermudagrasses.

Bermudagrass, Cynodon dactylon (L.) Pers., suffers periodic severe winter-kill throughout much of its area of use in the contiguous USA. A research goal is to increase freeze tolerance in cultivars to lessen the risk of such damage. An identified research need is for Cynodon germplasm resources to be characterized for freeze tolerance and hybridization potential. Accordingly, the objective of this research was to characterize the relative freeze tolerance of selected fertile bermudagrass plants. Nine tetraploid (2n = 4x = 36) C. dactylon and two triploid (2n = 3x = 27) hybrid (C. dactylon x C. transvaalensis Burtt Davy) clonal plants (standards) were evaluated in two experiments. Plants were propagated clonally and established in Cone-tainers (Ray Leach Cone-tainer Nursery, Canby, OR) for about 10 wk. Acclimation took place for 4 wk in controlled environment chambers at 8/2 degrees C (day/night) temperatures with a 10-h photoperiod. Following acclimation, Cone-tainers were placed into a freeze chamber and cooled rapidly to -2 degrees C, induced to freeze with ice chips, then held overnight at -2 degrees C. The freeze chamber was then programmed to cool linearly at 1 degrees C per hour. For each cultivar, three Cone-tainers were removed at each test temperature. Following thawing, Cone-tainers were transferred to a greenhouse and regrowth was evaluated visually. Nonlinear regression was used to estimate T(mid), which corresponded to the midpoint of the sigmoidal response curve of survival vs temperature. Within experiment one, Tifgreen (T(mid) = -7.2 degrees C) was significantly less cold hardy than Quickstand (-9.0 degrees C), A-12204 (-9.2 degrees C), Midiron (-9.9 degrees C), and A-12195 (-10.5 degrees C). A-12195 was significantly hardier than all genotypes except Midiron. In the second experiment, Arizona Common (-6.6 degrees C), Tifgreen (-7.1 degrees C), and A-12205 (-7.1 degrees C) were less hardy than A-9959 (-8.7 degrees C), A-12156 (-8.9 degrees C), A-12198 (-9.5 degrees C), and Midiron (-10.0 degrees C). Midiron was hardier than all genotypes except A-12198. The range of test temperatures chosen did not allow estimate of a T(mid) value for Zebra, but nearly 50% of the plants were killed at -6.0 degrees C.

Phase I Trial of Edatrexate in Advanced Breast and Other Cancers

Edatrexate (EDX) (10-ethyl-10-deazaaminopterin or 10-EDAM) is an analogue of methotrexate with improved pre-clinical antitumor activity, more selective cellular uptake, and with more extensive formation of intracellular polyglutamate metabolites. A phase I trial in advanced cancer using EDX was initiated to determine the toxicities associated with the use of a biweekly schedule of intravenous EDX, and to carry out a dose escalation to define the maximum tolerated dose employing this schedule.Thirty-four patients were enrolled in this phase I trial. Thirty-three patients were treated in cohorts of at least three patients (except at one dose level, 210 mg m−2, where there were only two patients). Dose escalations of EDX were administered starting with 100 mg m−2, and progressing through 120, 140, 160, 180, 210, 240, and 270 mg m−2. Edatrexate was administered by intravenous infusion over 20 min, and cryotherapy using ice chips was given prophylactically for 5 min before, during, and 15 min after each EDX treatment.The dose-limiting toxicity could not be reached in this study because it had to be closed on account of competing protocols using EDX in combination regimens. Of note though, was that the delivered dose intensity at the 160 mg m−2 week−1, was higher than the previously used or recommended phase II doses. Anemia was mild and white blood corpuscle toxicity was mostly of grade 1 or 2. One patient had grade 4 neutropenia and one had grade 3 thrombocytopenia. Of the non-hematological toxicities, nausea, vomiting, and diarrhea were mild and tolerable. Mucositis, which was the dose-limiting toxicity in previous studies, was seen in 30% of the patients, but was predominantly a grade 1 toxicity. This could have been due to either the different schedule of EDX used in this study or the use of cryotherapy. Substantial antitumor effects were noted, with two near-complete complete responses at the 120 and 160 mg m−2 levels. Additionally, six partial responses and one minor response were observed, and stable disease was observed in seven patients.Despite achieving antitumor activity at different dose levels, a clear-cut dose response was not evident at the levels tested. We feel that the biweekly EDX schedule is a tolerable regimen, which allows a higher dose intensity than weekly administration, and that EDX is an active agent for the treatment of patients with metastatic cancer.

Chemotherapy-induced oral mucositis. Prevention and management.

Oral mucositis is a frequent and potentially severe complication of chemotherapy which has a considerable impact on patient quality of life. While the management of other chemotherapy-related toxicities has improved, the incidence of mucositis is increasing. A critical review of the literature published between 1985 and 1999 reveals very few strategies or agents with proven efficacy, leaving few recommendations for the standard care in the prevention and treatment of mucositis at this time. Recommendations that can be made include: reducing patient risk factors, implementing proven preventative interventions such as utilising oral ice chips with fluorouracil chemotherapy, and optimising supportive care practices individualised to the patients' needs and symptoms. Progress in understanding the pathophysiology of mucositis at the molecular level has led to the evaluation of a number of new investigational agents, specifically those directed to the epithelial mucosa, such as mitogens and epithelial growth factors. These appear to be very promising in preclinical studies. Randomised clinical trials with these agents may finally demonstrate an impact on the clinical practice of mucositis management in the coming years.

Can a patient who has an endotracheal tube and is on mechanical ventilation be given ice chips?

Can a patient who has an endotracheal tube and is on mechanical ventilation be given ice chips?

A Phase II Trial of Edatrexate in Patients with Advanced Renal Cell Carcinoma

We performed a Phase II trial of edatrexate in 44 chemotherapy-naive patients with advanced renal cell carcinoma. Prior therapy with one biological-response modifier was permitted. Most patients had multiple sites of metastatic disease and were considered to have a poor prognosis using Eastern Cooperative Oncology Group criteria. Edatrexate was administered intravenously at a dose of 80 mg/m2 weekly with 5 weeks of therapy considered one cycle. Oral cryotherapy using ice chips was administered before each edatrexate dose. Thirty-seven patients were eligible and evaluable for toxicity and response. Two patients obtained a partial response, for an overall response rate of 5.4% (95% confidence interval of 0.6%, 18.2%); one patient remained in remission at 26+ months. Three treatment-related deaths occurred. Toxicity was severe, with stomatitis, myelosuppression, and other gastrointestinal side effects most prominent. Edatrexate in this dose and schedule has minimal activity in advanced renal cell carcinoma and is toxic.

A Randomized Control Study to Determine the Effects of Unlimited Oral Intake of Water in Patients with Identified Aspiration

No statistical differences were found in the moderator variables of age, gender, eth nicity, stroke location, amount of initial aspiration, or presence/absence of a cough reflex. Using a t-test for independent means, a significant difference (p = 0.03) oc curred between groups on average intake of thickened liquids.Conclusion : Until further larger scale research utilizing water intake with known aspirators is conducted, it is recommended that water (and ice chips) be given presently only in instances of patient refusal to drink thickened liquids or when hydration is sues cause medical concern.

Comfort Care for Terminally III Patients

<h3>Objective.</h3> —To determine the frequency of symptoms of hunger and thirst in a group of terminally ill patients and determine whether these symptoms could be palliated without forced feeding, forced hydration, or parenteral alimentation. <h3>Design.</h3> —Prospective evaluation of consecutively admitted terminally ill patients treated in a comfort care unit. <h3>Setting.</h3> —Ten-bed comfort care unit in a 471-bed long-term care facility. Participants.—Mentally aware, competent patients with terminal illnesses monitored from time of admission to time of death while residing in the comfort care unit. <h3>Main Outcome Measures.</h3> —Symptoms of hunger, thirst, and dry mouth were recorded, and the amounts and types of food and fluids necessary to relieve these symptoms were documented. The subjective level of comfort was assessed longitudinally in all patients. <h3>Results.</h3> —Of the 32 patients monitored during the 12 months of study, 20 patients (63%) never experienced any hunger, while 11 patients (34%) had symptoms only initially. Similarly, 20 patients (62%) experienced either no thirst or thirst only initially during their terminal illness. In all patients, symptoms of hunger, thirst, and dry mouth could be alleviated, usually with small amounts of food, fluids, and/or by the application of ice chips and lubrication to the lips. Comfort care included use of narcotics for relief of pain or shortness of breath in 94% of patients. <h3>Conclusions.</h3> —In this series, patients terminally ill with cancer generally did not experience hunger and those who did needed only small amounts of food for alleviation. Complaints of thirst and dry mouth were relieved with mouth care and sips of liquids far less than that needed to prevent dehydration. Food and fluid administration beyond the specific requests of patients may play a minimal role in providing comfort to terminally ill patients. (<i>JAMA</i>. 1994;272:1263-1266)

Comfort care for terminally ill patients. The appropriate use of nutrition and hydration.

To determine the frequency of symptoms of hunger and thirst in a group of terminally ill patients and determine whether these symptoms could be palliated without forced feeding, forced hydration, or parenteral alimentation. Prospective evaluation of consecutively admitted terminally ill patients treated in a comfort care unit. Ten-bed comfort care unit in a 471-bed long-term care facility. Mentally aware, competent patients with terminal illnesses monitored from time of admission to time of death while residing in the comfort care unit. Symptoms of hunger, thirst, and dry mouth were recorded, and the amounts and types of food and fluids necessary to relieve these symptoms were documented. The subjective level of comfort was assessed longitudinally in all patients. Of the 32 patients monitored during the 12 months of study, 20 patients (63%) never experienced any hunger, while 11 patients (34%) had symptoms only initially. Similarly, 20 patients (62%) experienced either no thirst or thirst only initially during their terminal illness. In all patients, symptoms of hunger, thirst, and dry mouth could be alleviated, usually with small amounts of food, fluids, and/or by the application of ice chips and lubrication to the lips. Comfort care included use of narcotics for relief of pain or shortness of breath in 94% of patients. In this series, patients terminally ill with cancer generally did not experience hunger and those who did needed only small amounts of food for alleviation. Complaints of thirst and dry mouth were relieved with mouth care and sips of liquids far less than that needed to prevent dehydration. Food and fluid administration beyond the specific requests of patients may play a minimal role in providing comfort to terminally ill patients.

The Effect of Local Heat and Cold Therapy on the Intraarticular and Skin Surface Temperature of the Knee

To evaluate the effects of local application of ice chips, ligno-paraffin, short-wave diathermy, and nitrogen-cold air on skin and intraarticular temperature. Forty-two healthy subjects were divided into 4 treatment groups. A temperature probe was inserted into the knee joint cavity and another placed on the overlying skin, and changes in temperature over 3 hours, by treatment group, were recorded. The mean skin surface temperature dropped from 27.9 degrees C to 11.5 degrees C after application of ice chips, and from 28.8 degrees C to 13.8 degrees C after application of cold air. The mean intraarticular temperature decreased from 31.9 degrees C to 22.5 degrees C and from 32.9 degrees C to 28.8 degrees C, respectively, after these 2 treatments. Shortwave diathermy increased skin temperature by 2.4 degrees C; intraarticular temperature was increased only 1.4 degrees C by short-wave diathermy. Treatment with ligno-paraffin increased the skin surface temperature 8.9 degrees C; the temperature in the joint cavity was increased 3.5 degrees C. The use of short-wave diathermy and superficial heat packs in the treatment of patients with arthritis may potentially cause harm by increasing intraarticular temperature. This may have major implications regarding treatment policy for patients with arthritis.

Ocular Trauma Caused by Exploding Glass Bottles Containing Dry Ice and Water

We treated three patients with severe ocular injuries caused by exploding glass bottles containing a mixture of dry ice chips and water. One patient had a corneal laceration and traumatic cataract with several retained intraocular glass fragments. The second had a scleral laceration without corneal or lenticular involvement. The third suffered a corneal-scleral laceration, with a total retinal detachment. Following surgery, two patients recovered 20/20 vision; the third patient regained only light perception.

Experiments with a bowl of saline: The hidden risk of hypothermic-osmotic damage during topical cardiac cooling

Some of the misconceptions in the application of cardiac hypothermia are that the temperature of cold normal saline solution is necessarily above 0 degrees C, cold saline solution and slush are relatively safe for living tissues, and normal saline will retain normal osmolality even if partially frozen. These postulates were examined in thermodynamic experiments that demonstrated three points: (1) The temperature of unfrozen saline solution may drop way below the freezing point. (2) When liquids and solid components of saline solution are separated, the components will become hypo-osmolar or hyperosmolar. (3) Ice chips and slush ice produced in the operating rooms may reach temperatures as low as -36 degrees C. We recommend that the possibility of these events should be taken into consideration whenever topical cardiac hypothermia is clinically applied.

Cold water stimulation of oropharyngeal receptors in man inhibits release of vasopressin.

The act of drinking ameliorates thirst and inhibits the secretion of vasopressin before changes in extracellular fluid volume or osmolality in both animals and man. We evaluated whether this reflex inhibition of vasopressin secretion might be due to the presence of oropharyngeal receptors in humans. After dehydration, normal subjects (n = 4) were allowed to suck on ice chips for 30 min. Despite the absence of changes in plasma sodium (Na+) or osmolality, the mean plasma vasopressin level decreased promptly within 10 min from 2.8 to 1.8 pg/mL, and it remained low for 30 min after ice ingestion. When the dehydration protocol was repeated with the subjects receiving 100 mL water (25 C) for 30 min rather than ice chips, plasma vasopressin levels did not change. These data demonstrate that activation of cold-sensitive oropharyngeal receptors results in inhibition of vasopressin secretion independently of osmotic or gastric factors. In a second study 0.2 mL/kg X min 3% NaCl was administered for 90 min as a second stimulus to vasopressin secretion, and ice chips were given during the last 30 min of infusion. Plasma vasopressin levels increased steadily to 3.3 +/- 0.5 (+/- SEM) pg/mL by 45 min, and despite ice ingestion increased further to 4.6 +/- 0.8 pg/mL by 90 min. Consequently, hypertonicity appears to be a stronger stimulus to vasopressin release, since the suppressive effect of stimulation of oropharyngeal receptors with ice was not evident during the NaCl infusion. Finally, no changes in vasopressin levels were found in subjects holding concentrated NaCl solutions in their mouths for 30 min, indicating that the oropharyngeal receptors are not responsive to local changes in osmolality. The presence of such cold-sensitive oropharyngeal receptors may explain the desire of severely dehydrated patients, e.g. patients with diabetes insipidus, for cold liquids.

Etiology and Prevention of Topical Cardiac Hypothermia-induced Phrenic Nerve Injury and Left Lower Lobe Atelectasis during Cardiac Surgery

Left hemidiaphragm elevation is frequently noted following cardiac surgery employing topical hypothermia. We speculate that contact of the left phrenic nerve with ice causes nerve injury, resulting in left hemidiaphragm paresis or paralysis and left lower lobe atelectasis. Left diaphragm elevation was noted on postoperative chest x-ray examination of 36 of 60 (60 percent) consecutive patients in whom topical cooling of the heart with a cold slush solution was administered prior to use of a cardiac insulation pad (CIP, Shiley Laboratories, Irvine, California). Following the use of the CIP in a similar group of 60 consecutive patients, only five (8 percent) showed evidence of diaphragmatic elevation. The difference in the incidence of diaphragmatic elevation between these two groups is statistically significant (p less than 0.001). A comparison of postoperative left lower lobe atelectasis prior to the use of the CIP was also statistically significant (p less than 0.001). There was no significant difference in the aortic cross-clamp time or the volume of intraaortic cardioplegia used in these two groups. The use of topical cardiac hypothermia has been shown to protect the myocardium. Phrenic nerve injury secondary to the use of ice in this method has been documented. The use of a cold solution without ice chips or slush, or the insertion of a CIP prior to the use of topical cardiac hypothermia (when ice chips or slush are used) decreases the exposure of the phrenic nerve to cold injury and decreases the incidence of paresis of the left diaphragm and resultant atelectasis.

Topical Cardiac Hypothermia: The Effect of Methylprednisolone Sodium Succinate

We evaluated the effects of methylprednisolone sodium succinate (MPSS) on 60 minutes of myocardial ischemia during profound (5°C) topical cardiac hypothermia (ice chips) in a canine right heart bypass preparation. The ventricular function curve shifted to the right and downward, but not significantly, after ischemia, and stroke work declined significantly for both control and treated dogs. Contractility (rate of rise of left ventricular pressure and maximum velocity of the contractile element) declined for both groups but not significantly. Total coronary flow, oxygen consumption, and metabolism of lactate and pyruvate were not different for control and treated dogs. Ultrastructure of the outer and inner myocardium did not demonstrate benefit from MPSS. Intracellular and extracellular edema of moderate severity was slightly worse in the subendocardium, and reversible mitochondrial injury of a mild to moderate degree was symmetrically present. Ice-related injury was not noted. We were unable to demonstrate that pretreatment with MPSS favorably alters cardiodynamics or ultrastructure after 60 minutes of profound topical cardiac hypothermia.

Topical cardiac hypothermia for myocardial preservation

We compared moderate (29 degrees C.) and profound (5 degrees C.) (ice chips) cardiac hypothermia for myocardial preservation during aortic cross-clamping for 30 or 60 minutes in a canine right heart bypass preparation. Ventricular function deteriorated significantly at 29 degrees C. but not at 5 degrees C. Maximum dp/dt declined only after 60 minutes of ischemia at 29 degrees C., and Vmax decreased after one hour at either temperature. Lactate and pyruvate washout were greater after 29 degrees C., and pyruvate production persisted after 60 minutes of ischemia at 29 degrees C. Reactive hyperemia was greater after 30 minutes of ischemia at 29 degrees C. Reactive hyperemia was greater after 30 minutes of ischemia at 29 degrees C., and total coronary flow remained elevated after 60 minutes of ischemia at 29 degrees C. Coronary flow distribution was not altered by hypothermia. Ultrastructural changes were primarily time dependent and not temperature dependent. Ice-induced subepicardial injury was not evident in the ultrastructure or by flow distribution. Sixty minutes of profound topical cardiac hypothermia is moderately well tolerated by the canine heart, but functional and structural alterations are evident.

Mechanical drill for deep coring in temperate ice

A rotary drill for deep coring in temperate ice has been constructed and tested. The total length of the drill is 6 m and its weight is 100 kg. A steel armoured cable carries power to the 2 h.p, electric motor of the drill. The diameter of the core is 90 mm and the maximum length of core is 2 m. An antifreeze mixture at the bottom of the hole was necessary to prevent refreezing of ice chips on the cutting bits.A 415 m deep hole was drilled during the summer of 1972 into the temperate accumulation area of Vatnajökull. Core recovery was 99%. Because of a fault in the cable the bottom was not reached.

Mechanical drill for deep coring in temperate ice

A rotary drill for deep coring in temperate ice has been constructed and tested. The total length of the drill is 6 m and its weight is too kg. A steel armoured cable carries power to the 2 h.p, electric motor of the drill. The diameter of the core is 90 mm and the maximum length of core is 2 m. An antifreeze mixture at the bottom of the hole was necessary to prevent refreezing of ice chips on the cutting bits. A 415 m deep hole was drilled during the summer of 1972 into the temperate accumulation area of Vatnajökull. Core recovery was 99%. Because of a fault in the cable the bottom was not reached.