Pain relief from baclofen analgesia in a neuropathic pain patient who failed opioid and pharmacotherapy: case report.

A case report and discussion of a 64-year-old white female who presented with uncontrolled pain in several body areas despite massive oral controlled release morphine use is presented. Her pain was not associated with much spasticity. This patient responded remarkably to intrathecal baclofen even after the opioid was tapered and discontinued. The potential usefulness of baclofen in seemingly opioid-resistant chronic pain is discussed.

Pharmacologic management of spasticity following stroke.

Montefiore Medical Center--The Jack D Weiler Hospital of the Albert Einstein College of Medicine, 1825 Eastchester Rd, Bronx, NY 10461, USA.

Quinine associated blindness.

BACKGROUND: Quinine is commonly prescribed to the elderly for the treatment of benign nocturnal cramps, yet its use is not without complications. OBJECTIVE: This article presents a case of quinine toxicity producing bilateral blindness, followed by a review of the adverse reactions associated with quinine use and its efficacy in treating benign nocturnal muscular cramps. DISCUSSION: Visual loss has been associated with quinine serum concentrations above 10 microg/mL (therapeutic range 2-5 microg/mL). Other adverse reactions include neurological symptoms, haemolysis, acute renal failure and arrhythmia. There is conflicting evidence for the efficacy of quinine for leg cramps in randomised controlled studies, however, meta-analysis of these studies suggests some benefit. Although severe side effects are rare at therapeutic doses, the possibility of overdose needs to be considered when prescribing and an individual risk benefit analysis needs to be made. Benefits and adverse reactions should be closely monitored and medication ceased if appropriate.

An improvement in segregation of human butyrylcholinesterase phenotypes having the fluoride-resistant variants.

Correct recognition of butyrylcholinesterase (BChE; EC 3.1.1.8) variants in human serum is essential if patients susceptible to a prolonged reaction following treatment with short acting muscle relaxants, like suxamethonium, are to be reliably identified. The dimethylcarbamate Ro 02-0683 is used in standard procedures for identification of BChE variant by measuring residual activity after two hours of inhibition. Such a long inhibition time distinguishes well between the usual (U) and atypical (A), but less successfully the fluoride-resistant (F) variant. In this paper, inhibition rate constants were determined from the initial time course of inhibition of homozygous (FF) and heterozygous (UF and AF) BChE phenotypes by Ro 02-0683; 1.6 x 10(6), 2.7 x 10(6) and 6.2 x 10(6) dm3 mol-1 min-1 for AF, FF and UF, respectively. After only 30 min of inhibition the resolution between the phenotypes was even better than after two hours. Hence, determination of the residual activity after 30 min inhibition is recommended for the segregation of the suxamethonium sensitive fluoride-resistant variants.

Increased cAMP as a positive inotropic factor for mammalian skeletal muscle in vitro.

To test the hypothesis that an increased cAMP concentration improves skeletal muscle force development, we stimulated mouse soleus and extensor digitorum longus (EDL) in the presence of isoproterenol (1 x 10(-5) mol.L-1), a beta-adrenergic agonist, or N6,2'-O-dibutyryladenosine 3':5'-cyclic monophosphate (dcAMP) (1 x 10(-3) mol.L-1), a membrane-permeable cAMP analogue. Drugs used in the challenges were dissolved in Krebs-Henseleit bicarbonate buffer (Krebs) at 27 degrees C and gassed with 95% O2 - 5% CO2. Stimulation at 50 impulses.s-1 for 0.5 s produced an isometric tetanic contraction. Over 25 min of contractions at 0.6 contractions.min-1, developed force increased significantly with the addition of isoproterenol (soleus, 2.5% +/- 1.1%; EDL, 13.8% +/- 2.0%) or dcAMP (soleus, 2.3% +/- 0.5%; EDL, 10.9% +/- 1.9%) as compared with vehicle controls (cont) with Krebs added (soleus, 0.0% +/- 0.2%; EDL, -2.5% +/- 0.7%). To investigate the role of Ca2+ availability, we amplified or attenuated sarcolemmal L-type Ca2+ channels with Bay K 8644 (Bay K) (5.6 x 10(-6) mol.L-1) or diltiazem hydrochloride (dilt) (10(-4) mol.L-1), respectively. Ca2+ release from the sarcoplasmic reticulum was increased with caffeine (2 x 10(-3) mol.L-1) or decreased with dantrolene sodium (dant) (4.2 x 10(-7) mol.L-1). With Ca2+availability modified, dcAMP addition in soleus significantly increased force development above control (cont, 2.3% +/- 0.4%; Bay K, 4.0% +/- 1.0%; dilt, 52.3% +/- 3.6%; caffeine, 2.3% +/- 0.7%; dant, 6.0% +/- 2.0%; dilt + dant, 55.0% +/- 23.0%). In EDL, the addition of dcAMP also increased force development above control (cont, 13.7% +/- 1.9%; Bay K, 17.0% +/- 4.0%; dilt, 170.0% +/- 40.0%; caffeine, 23.0% +/- 4.0%; dant, 72.0% +/- 10.0%; dilt + dant, 54.0% +/- 14.0%). Thus, a positive inotropic effect of cAMP existed in both fast- and slow-twitch mammalian skeletal muscle with both normal and altered Ca2+ flux into the sarcoplasm.

Activity of CYP2E1 and CYP3A enzymes in adults with moderate alcohol consumption: a comparison with nonalcoholics.
Liangpunsakul S, Kolwankar D, Pinto A, Gorski JC, Hall SD, Chalasani N.
Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
Alcohol consumption is known to induce hepatic CYP2E1 activity, but its effect on hepatic and intestinal CYP3A in humans is not known. We have conducted a study to compare the CYP2E1 and CYP3A activities in 20 individuals with moderate alcohol consumption and 20 gender-, race-. and body mass index (BMI)-matched nonalcoholics. Intravenous and oral midazolam (MDZ) clearances were used to measure the in vivo CYP3A activity, and chlorzoxazone (CHZ) oral clearance was used to assess in vivo CYP2E1 activity. Furthermore, we assessed the relationship between hepatic CYP2E1 and CYP3A activities and their messenger RNA (mRNA) expression in the peripheral lymphocytes. The systemic clearance (CL) of MDZ was not different between alcoholics (36.9 +/- 12 L/hr) and nonalcoholics (36.6 +/- 14.1; P = .9). The oral availability of MDZ was significantly lower in alcoholics than in the nonalcoholics (0.28 +/- .09 vs. 0.38 +/- .17, respectively, P = .03). The maximum serum concentration after oral midazolam dosing was significantly different between the 2 groups. CHZ CL was significantly higher in alcoholics than in nonalcoholics (31.5 +/- 11.9 vs. 23.4 +/- 8.7 L/hr, P < 0.05). CYP3A4 and CYP2E1 mRNA levels were not significantly different between the groups, and no correlation was observed between lymphocyte CYP mRNA and in vivo CYP activity. In conclusion, in individuals with moderate alcohol consumption, there was no alteration in the hepatic CYP3A activity, but the reduced midazolam oral bioavailability suggests that moderate alcohol consumption may cause intestinal CYP3A induction. Lymphocyte CYP2E1 and CYP3A4 mRNA levels did not correlate with CYP2E1 and CYP3A activities.


Impact of anesthesia management characteristics on severe morbidity and mortality.
Arbous MS, Meursing AE, van Kleef JW, de Lange JJ, Spoormans HH, Touw P, Werner FM, Grobbee DE.
Julius Center for Patient Oriented Research, Dutch Association for Anesthesiology, Utrecht, The Netherlands.
BACKGROUND: Quantitative estimates of how anesthesia management impacts perioperative morbidity and mortality are limited. The authors performed a study to identify risk factors related to anesthesia management for 24-h postoperative severe morbidity and mortality. METHODS: A case-control study was performed of all patients undergoing anesthesia (1995-1997). Cases were patients who either remained comatose or died during or within 24 h of undergoing anesthesia. Controls were patients who neither remained comatose nor died during or within 24 hours of undergoing anesthesia. Data were collected by means of a questionnaire, the anesthesia and recovery form. Odds ratios were calculated for risk factors, adjusted for confounders. RESULTS: The cohort comprised 869,483 patients; 807 cases and 883 controls were analyzed. The incidence of 24-h postoperative death was 8.8 (95% confidence interval, 8.2-9.5) per 10,000 anesthetics. The incidence of coma was 0.5 (95% confidence interval, 0.3-0.6). Anesthesia management factors that were statistically significantly associated with a decreased risk were: equipment check with protocol and checklist (odds ratio, 0.64), documentation of the equipment check (odds ratio, 0.61), a directly available anesthesiologist (odds ratio, 0.46), no change of anesthesiologist during anesthesia (odds ratio, 0.44), presence of a full-time working anesthetic nurse (odds ratio, 0.41), two persons present at emergence (odds ratio, 0.69), reversal of anesthesia (for muscle relaxants / relaxant and the combination of muscle relaxants / relaxant and opiates; odds ratios, 0.10 and 0.29, respectively), and postoperative pain medication as opposed to no pain medication, particularly if administered epidurally or intramuscularly as opposed to intravenously. CONCLUSIONS: Mortality after surgery is substantial and an association was established between perioperative coma and death and anesthesia management factors like intraoperative presence of anesthesia personnel, administration of drugs intraoperatively and postoperatively, and characteristics of delivered intraoperative and postoperative anesthetic care.

Orally delivered baclofen to control spastic hypertonia in acquired brain injury.

To determine if oral/systemic delivery of baclofen can effectively decrease spastic hypertonia due to acquired brain injury (traumatic brain injury, stroke, anoxia, or encephalopathy). Tertiary care outpatient rehabilitation center directly attached to a university hospital. Patients were a convenience sample recruited consecutively who had been referred for treatment of their spastic hypertonia to our spasticity clinic over a 5-year period. The spastic hypertonia was due to an acquired brain injury by either traumatic brain injury (TBI), stroke, or anoxic brain injury. All patients were more than 6 months postinjury or illness. Retrospective review of patients before and after initiation of treatment with oral baclofen, per standardized clinical data sheets. Thirty-five patients (22 TBI patients) were started on oral baclofen and were reevaluated between 1 to 3 months after initiation of treatment. Data for motor tone (Ashworth scores), spasm scores (Penn spasm frequency score), and deep tendon reflex scores were collected on the affected upper extremity (UE) and lower extremity (LE) side(s). Normal extremities were not assessed. Differences over time were assessed via descriptive statistics and Wilcoxon signed-rank. After 1 to 3 months of treatment when subjects had reached their maximal tolerated dosage, the average LE Ashworth score in the affected lower extremities (LEs) decreased from 3.5 to 3.2 (P =.0003), the reflex score decreased from 2.5 to 2.2 (P =.0274), and there was no statistical difference in the spasm score (P >.05). When the 22 TBI patients are analyzed separately, the average LE Ashworth score decreased from 3.5 to 3.2 (P =.0044) and the reflex score decreased from 2.7 to 2.0 (P =.0003). There was no statistically significant change in UE tone, spasm frequency, or reflexes after 1 to 3 months of treatment (P >.05). The average dosage at follow-up was 57 mg/day of baclofen (range 15-120 mg/day). There was a 17% incidence of somnolence that limited the maximum daily dosage of the medication. The oral delivery of baclofen is capable of reducing LE spastic hypertonia resulting from acquired brain injury. The lack of effect upon the upper extremities may be due to receptor specificity issues. GABA-B receptors may be less involved in the modulation of UE spastic hypertonia.

Effects of ephedrine on intubating conditions following priming with rocuronium.
Leykin Y, Pellis T, Lucca M, Gullo A.
Department of Anaesthesia, Pain, Perioperative Medicine and Intensive Care, Santa Maria degli Angeli Hospital, Pordenone, Italy.
Background: Onset of action of muscle relaxants / relaxant is influenced by cardiac output and muscle blood flow. Ephedrine reduces the onset time of rocuronium. Onset is also shortened by priming. Accordingly, we hypothesized that priming combined with ephedrine is superior to either technique used separately. Methods: Four groups of randomly allocated patients (n = 31), ASA I - II, were induced with propofol 2.5 mg kg(-1). In groups I and II, 0.04 mg kg(-1) of rocuronium was followed by a 3-min priming interval. Induction was followed by an intubation dose of 0.04 mg kg(-1). Then a 30-s intubation was attempted. In groups III and IV the same sequence was repeated except for sham priming and an intubation dose of 0.44 mg kg(-1). In groups I and II, ephedrine (210 microg kg(-1)) was injected before propofol. In groups II and V, an equivalent volume of normal saline was injected. Jaw relaxation, vocal cord position, and diaphragmatic response were used to assess intubating conditions. Results: All patients of group I were intubated 30 s after the intubating dose and within a 20-s interval compared with 74% of patients in groups II and III, and 84% of patients in group IV. Intubating conditions were graded good to excellent in all patients in group I compared with 42% of those in group II, 35% in group III and 52% in group IV (P < 0.01 vs. group I). During the priming interval, no adverse effects were observed or reported. Conclusions: Ephedrine in combination with propofol significantly improved clinical intubating conditions at 30 s following priming with rocuronium compared with priming with ephedrine without priming.


Intrauterine baclofen exposure: a multidisciplinary approach.

Maternal use of the antispasmodic baclofen during pregnancy is an uncommon clinical scenario and leads to uncertainty regarding neonatal risks. We present a team-based, peripartum management plan designed for safe monitoring and minimizing the risk of neonatal withdrawal after unusual drug exposure. Incorporating the expertise of neonatology, nursing, pharmacy, neurology, and the lactation service, as well as parental input, this consensus approach was implemented in a case of maternal oral baclofen use with a successful outcome for the infant and family.