Enterocolitis due to methicillin-resistant Staphylococcus aureus--report of two cases. Two cases of postoperative enterocolitis due to methicillin-resistant Staphylococcus aureus (MRSA) after gastrectomy were experienced. Case 1: A 59-year-old male underwent subtotal gastrectomy for advanced gastric cancer. Diffuse peritonitis progressed after the first operation, so reoperation for drainage was required. Two days after the second operation, a profuse watery diarrhea developed. Case 2: A 46-year-old male underwent total gastrectomy for early gastric cancer. On the fourth postoperative day, frequent vomiting and cholera-like diarrhea started, followed by profound shock several hours later. Both cases were treated successfully by the administration of vancomycin. Stool cultures of both cases revealed MRSA and it had the same minimal inhibitory concentration, coagulase type and enterotoxin type, so that nosocomial infection was indicated.


Clinical assessment of the knowledge base of an expert system for data analysis in laboratory medicine. Despite the apparent demand for a consultation system, only a few expert systems have been developed for laboratory medicine. Some studies on the diagnostic precision of such systems have been reported, but the efficiency of their knowledge bases has not yet been investigated. An expert system, named BLOOD, for data analysis in a hematology laboratory, which is written in C-Prolog and runs on VAX-station, has already been reported to have excellent diagnostic reliability and ability to cope with the fuzziness involved in clinical diagnostic procedures. A quantitative examination of the knowledge base of BLOOD using real laboratory data from 58 patients diagnosed as having iron deficiency anemia clearly revealed the verbosity of the knowledge base, and proved that it was effective for obtaining a group of essential diagnostic rules.


Rat cerebellar granule cells in culture associate and metabolize differently exogenous GM1 ganglioside molecular species containing a C18 or C20 long chain base. A study has been made of the association properties of the two GM1 ganglioside molecular species GM1-C18 and GM1-C20 (containing C18 and C20 long chain bases, respectively) to rat cerebellar granule cells in culture. Both gangliosides recognized, to the same extent, and associated with them to give a form of association, the trypsin-labile form. This form was removed by treatment with trypsin enzyme. Both gangliosides associated stably with the cells to become components of the cell membranes. Although similar amounts of the two gangliosides entered the cells, being then metabolized, the time course of the association was different for the two gangliosides: after 15 h of ganglioside-cell incubation the amount of GM1-C18 inserted into the cell membrane was 2.43 times higher than that of GM1-C20.


Synthesis of enantiomerically pure lysophosphatidylinositols and alkylphosphoinositols. A convenient synthesis for enantiomeric pure 1-O-(1'-O-alkyl-sn-glycero-3'-phospho)-D (or L)-myo-inositol, 1-O-(1'-O-acyl-sn-glycero-3'-phospho)-D (or L)-myo-inositol and alkylphospho-1-D (or L)-myo-inositol has been described. Starting from myo-inositol, penta-O-acetyl-myo-inositol was made in five steps. Then enantiomeric purification was done by a diastereomeric salts separation method, and the purity of each enantiomer was spectroscopically measured (19F-NMR). The phosphodiester was made via phosphoramidites. The enantiomeric products (greater than 99% optical purity) of all compounds were easily obtained in large quantities (5-10 g). Synthetic phosphatidylinositol analogues of precisely defined structure and configuration are interesting tools for studying signal transduction mechanism and cell activity modulation.


Cytogenetic studies of human malignant melanoma cell lines. Cytogenetic studies were performed on six cell lines derived from three patients suffering from malignant melanomas. The modal chromosome numbers were in the hypotriploid to hypertetraploid ranges and both the numerical and structural aberrations of chromosomes were found. Aberrations were most frequently observed in chromosomes 1, 6 and 7. Deletion of 1q was consistently present in all cell lines, while loss of 6q was observed in two cell lines of case 1. Translocations t (Y; 6) and t (6;?) occurred in one cell line from case 3. An increased number of copies of chromosome 7 was a characteristic feature of the cell lines from case 2. Since positive correlation between the expression of EGF receptors and an increased dosage of chromosome 7 has been reported for malignant melanomas and the gene for EGFR has been mapped to band 7p12-p13, this phenomenon might be of importance for the proliferation of malignant melanoma. The findings of the present study are generally in agreement with the data previously published in the literature, indicating the existence of specific non-random chromosome lesions during melanoma development.


Anthrylvinyl-labeled phospholipids as fluorescent membrane probes. The action of melittin on multilipid systems. The interaction of melittin with multicomponent lipid mixtures composed of phosphatidylcholine, sphingomyelin and phosphatidylserine or phosphatidylglycerol was investigated by measuring the intrinsic fluorescence of the peptide, steady state fluorescence anisotropy of, and Trp-fluorescence energy transfer to fluorescent analogs of the same phospholipids bearing the anthrylvinyl fluorophore in one of the aliphatic chains at various distances from the polar head group. Based on the finding that at high lipid/peptide ratio the peptide induces unequal changes in the fluorescence parameters of phospholipid probes differing structurally only in their polar head groups, it is concluded that melittin induces lipid demixing in its nearest environment. Comparison of the fluorescence energy transfer from Trp to different lipid probes indicates that the depth of penetration of melittin into the bilayer depends on the polar head group composition of the phospholipid matrix and that certain segments of the melittin chain display a specific affinity for a given lipid head group.


Therapeutic efficacy of combination of antitumor agent with AHC-52 against multidrug-resistant cells in the intravenously inoculated P388 leukemia model. To predict the clinical effect on leukemic disease of a combination regimen developed to circumvent multidrug resistance (MDR), we tested various antitumor agents in the presence and absence of AHC-52, a sensitizing agent for multidrug-resistant cells, in the i.v.-i.v. model of murine leukemia. In this model system, sensitive and resistant P388 murine leukemia cells are inoculated i.v. into mice, and each antitumor agent is injected via the i.v. route. Vincristine (VCR) had no effect on the survival of mice bearing VCR-resistant P388, a relatively poorly resistant subline, when given either as a single agent or in combination with AHC-52. In contrast, adriamycin (ADR) alone had no effect on these mice, but its combination with AHC-52 resulted in significant survival, the maximal value achieved being 196% (treated mice/control animals, T/C). Etoposide (VP-16) strongly enhanced survival, even when used alone, and this effect was markedly potentiated by AHC-52. Combination of any antitumor drug with AHC-52 was ineffective in mice bearing ADR-resistant P388, a highly resistant subline. On the other hand, AHC-52 strongly augmented the therapeutic efficacy of these antitumor agents in mice bearing the sensitive parent P388 leukemia, producing some curative effects. On the basis of these results, the feasibility of this type of combination therapy is discussed.


Adozelesin, a potent new alkylating agent: cell-killing kinetics and cell-cycle effects. Adozelesin (U-73975) was highly cytotoxic to V79 cells in culture and was more cytotoxic than several clinically active antitumor drugs as determined in a human tumor-cloning assay. Phase-specificity studies showed that cells in the M+early G1 phase were most resistant to adozelesin and those in the late G1 + early S phase were most sensitive. Adozelesin transiently slowed cell progression through the S phase and then blocked cells in G2. Some cells escaped the G2 block and either divided or commenced a second round of DNA synthesis (without undergoing cytokinesis) to become tetraploid. Adozelesin inhibited DNA synthesis more than it did RNA or protein synthesis. However, the dose needed for inhibition of DNA synthesis was 10-fold that required for inhibition of L1210 cell growth. The observation that cell growth was inhibited at doses that did not cause significant inhibition of DNA synthesis and that cells were ultimately capable of completing two rounds of DNA synthesis in the presence of the drug suggests that adozelesin did not exert its cytotoxicity by significant inhibition of DNA synthesis. It is likely that adozelesin alkylates DNA at specific sites, which leads to transient inhibition of DNA synthesis and subsequent G2 blockade followed by a succession of events (polyploidy and unbalanced growth) that result in cell death.


Identification of (all-cis)-6,9,12,15-octadecatetraenoic acid in Ribes nigrum and fish oils: chemical and physical characterization. In this report, we show that the non-conjugated octadecatetraenoic acid found in the oil of the seeds from Ribes nigrum is identical to the C18-polyunsaturated fatty acid previously isolated in a number of fish oils and seed oils. Evidence obtained from mass spectral data of its triazolopyridine derivative clearly indicates the presence of methylene-interrupted double bonds. Comparison with authentic material prepared by chemical synthesis provides further confirmation of the (all-cis)-6,9,12,15-octadecatetraenoic acid structure. The (all-cis)-4,8,12,15-structural arrangement erroneously attributed to this acid in several literature reports is thus definitely ruled out.


Nitrogen mustard-DNA interaction in melphalan-resistant mammary carcinoma cells with elevated intracellular glutathione and glutathione-S-transferase activity. We examined the relationship between intracellular levels of glutathione (GSH), glutathione-S-transferase (GST) activity, and the kinetics of DNA cross-links induced by the bifunctional alkylating drugs melphalan (MLN), chlorambucil (CLB), and mechlorethamine (HN2) in a rat mammary carcinoma cell line (WT) and in a subline selected in vitro for primary resistance to MLN (MLNr, 16-fold resistance). MLNr cells exhibit a 2-fold increase in intracellular GSH concentration and an approximately 5-fold increase in GST activity as compared with the parent cells. They are cross-resistant to a variety of drugs, including CLB (6-fold) and HN2 (14-fold). Treatment of WT cells with 30 microM MLN or CLB induced a significant accumulation of DNA-DNA cross-links for up to 8 h, which decreased over a 24-h period. In MLNr cells, no significant cross-link formation was induced by either MLN of CLB at any time between 0 and 24 h. Doses of up to 100 microM MLN failed to induce cross-links in MLNr cells. Formation of cross-links was observed immediately after treatment with HN2 in both cell lines and was followed by a subsequent decrease during a 24-h incubation in drug-free medium. At an equimolar concentration (30 microM), the numbers of HN2-induced cross-links were significantly lower in MLNr cells than in WT cells. However, treatment of MLNr cells with 60 microM HN2 resulted in cross-link levels similar to those obtained using 30 microM HN2 in WT cells. The 35% decrease in MLN accumulation observed in MLNr cells could not entirely explain the absence of cross-links, since thin-layer chromatographic analysis demonstrated that both cell lines accumulate a significant amount of MLN and metabolize it to the same extent. Significant amounts of MLN were also detected in nuclei isolated from WT and MLNr cells that had been treated with 30 microM [14C]-MLN. Intracellular depletion of GSH by a nontoxic concentration of L-buthionine-(S, R)-sulfoximine (BSO, 100 microM; about 70% GSH depletion) significantly sensitized MLNr cells to MLN and increased cross-link formation. A nontoxic concentration (50 microM) of ethacrynic acid (EA, an inhibitor of GST showing some specificity for Yc/Yp subunits) also sensitized MLNr cells to MLN and increased cross-link formation. Our data demonstrate that both EA and BSO are effective modulators of nitrogen mustard cytotoxicity in tumor cells resistant to alkylating drugs.(ABSTRACT TRUNCATED AT 400 WORDS)


Mechanism-based model for tumor drug resistance. The development of tumor resistance to cytotoxic agents has important implications in the treatment of cancer. If supported by experimental data, mathematical models of resistance can provide useful information on the underlying mechanisms and aid in the design of therapeutic regimens. We report on the development of a model of tumor-growth kinetics based on the assumption that the rates of cell growth in a tumor are normally distributed. We further assumed that the growth rate of each cell is proportional to its rate of total pyrimidine synthesis (de novo plus salvage). Using an ovarian carcinoma cell line (2008) and resistant variants selected for chronic exposure to a pyrimidine antimetabolite, N-phosphonacetyl-L-aspartate (PALA), we derived a simple and specific analytical form describing the growth curves generated in 72 h growth assays. The model assumes that the rate of de novo pyrimidine synthesis, denoted alpha, is shifted down by an amount proportional to the log10 PALA concentration and that cells whose rate of pyrimidine synthesis falls below a critical level, denoted alpha 0, can no longer grow. This is described by the equation: Probability (growth) = probability (alpha 0 less than alpha-constant x log10 [PALA]). This model predicts that when growth curves are plotted on probit paper, they will produce straight lines. This prediction is in agreement with the data we obtained for the 2008 cells. Another prediction of this model is that the same probit plots for the resistant variants should shift to the right in a parallel fashion. Probit plots of the dose-response data obtained for each resistant 2008 line following chronic exposure to PALA again confirmed this prediction. Correlation of the rightward shift of dose responses to uridine transport (r = 0.99) also suggests that salvage metabolism plays a key role in tumor-cell resistance to PALA. Furthermore, the slope of the regression lines enables the detection of synergy such as that observed between dipyridamole and PALA. Although the rate-normal model was used to study the rate of salvage metabolism in PALA resistance in the present study, it may be widely applicable to modeling of other resistance mechanisms such as gene amplification of target enzymes.


Some oxidation products of ethoxyquin including those found in autoxidising systems. 2,4-Dimethyl-6-ethoxyquinoline (2), 1,2-dihydro-6-ethoxy-2,2,4-trimethylquinoline nitroxide (3), 2,6-dihydro-2,2,4-trimethyl-6-quinone imine N-oxide (4), 2,6-dihydro-2,2,4-trimethyl-6-quinone imine (5), 1.8' -di(1,2-dihydro-6-ethoxy-2,2,4-trimethylquinoline) (6) and 1,2-dihydro-6-hydroxy-2,2,4-trimethylquinoline (7) have been prepared from 1,2-dihydro-6-ethoxy-2,2,4-trimethylquinoline (1) (ethoxyquin) and their spectroscopic properties (UV, IR, mass and NMR) examined.


Potentiation of the antitumor activity of 5-trifluoromethyl-2'-deoxyuridine by the use of depot forms of the parent compound. 5-Trifluoromethyl-2'-deoxyuridine (CF3dUrd), an antitumor agent, is known to be short-lived in human plasma. Since its rapid elimination from the bloodstream seems to have descouraged the clinical evaluation of this drug, we explored the potential use of masked derivatives of CF3dUrd as "depot" forms of the parent compound. First, we observed that the toxicity of CF3dUrd against HeLA cells in culture was 10(4) times greater for a 24-h treatment as compared with a 1-h treatment at identical concentrations of the drug, which suggests the importance of using a prolonged treatment period. In fact, the divided dosing of CF3dUrd to L1210-bearing mice was markedly more effective than its single administration. 5'-O-Hexanoyl-, N3-p-butylbenzoyl-, 5'-O-benzyloxy-methyl-, and 3'-O-benzyl-CF3dUrd were found to be effective in maintaining the CF3dUrd concentration in plasma. The oral doses of these agents required to achieve 50% growth inhibition (ED50) in mice bearing sarcoma 180 tumors were 19, 34, 10, and 13 mg kg-1 day-1, respectively, whereas that of CF3dUrd was 63 mg kg-1 day-1. The ED50 values for these compounds were inversely correlated with the residence time of CF3dUrd in plasma. The therapeutic indices of these compounds, calculated as the dose producing a 50% inhibition of body-weight gain (IB50) divided by the ED50 value (1.89, 1.21, 1.40, and 2.15, respectively), were significantly higher than that of CF3dUrd (0.78). Consequently, these depot forms of CF3dUrd, particularly 3'-O-benzyl-CF3dUrd, are expected to be more useful than the parent compound as antitumor agents.


Pharmacokinetics of liposome-entrapped cis-bis-neodecanoato-trans-R,R-1,2-diaminocyclohexane platinum(II) and cisplatin given i.v. and i.p. in the rat. The pharmacokinetics of liposome-entrapped cis-bis-neodecanoato-trans-R,R-1,2-diaminocyclohexane platinum(II) (L-NDDP) and cisplatin (CDDP) were studied after i.v. and i.p. administration of an equimolar dose (11 and 5 mg/kg for L-NDDP and CDDP, respectively) in the rat. The systemic absorption following i.p. administration was faster in rats receiving CDDP than in those receiving L-NDDP. Peak serum platinum (Pt) levels were observed at 30 min and 12 h after the i.p. administration of CDDP and L-NDDP, respectively. Administration by the i.v. route did not significantly alter the serum Pt levels for either compound. However, serum Pt levels were 2-3 times greater in animals treated with L-NDDP than in those treated with CDDP. The estimated pharmacokinetic parameters for each drug were independent of the route of administration, except for the clearance (Cl) of CDDP, which increased 2-fold following i.p. administration. In addition, significant differences in pharmacokinetic parameters were observed between drug-treatment groups that were independent of the route of administration: the serum Pt area under the concentration-time curve (AUC) was higher and the volume of distribution at steady state (Vdss) was lower in rats receiving L-NDDP. Pt levels measured at 6 h in the peritoneal fluid, peritoneal tissue, and intestine of rats receiving i.p. L-NDDP were higher than those observed in rats receiving either i.v. L-NDDP or CDDP by either route. Pt levels measured in the liver and spleen of rats receiving L-NDDP were independent of the route of administration and were significantly higher than those determined in rats treated with CDDP. In contrast, kidney Pt levels were lower in rats receiving L-NDDP than in rats receiving CDDP by either route. These results suggest that the prolongation of the mean retention time of L-NDDP in the peritoneum achieved after i.p. administration without compromising the systemic distribution of the drug may result in a significant enhancement of the therapeutic efficacy of L-NDDP against malignancies confined to the peritoneal cavity as compared with that of i.p. CDDP.


Minocycline in combination with chemotherapy or radiation therapy in vitro and in vivo. In the present study the potential of minocycline, a semisynthetic tetracycline that inhibits collagenase activity in vivo, as an adjuvant to standard anticancer therapies was explored in vitro and in vivo. In EMT-6 cells, minocycline proved to be only minimally cytotoxic, producing a 50% cell kill at concentrations of 132 and 220 microM in normally oxygenated and hypoxic cells, respectively, after 24 h exposure to the drug. In vitro, there appeared to be no interaction between minocycline and cisplatin (CDDP), melphalan, 4-hydroperoxycyclophosphamide, or radiation. In tumor-cell survival studies using the FSaIIC murine fibrosarcoma, short-term treatment with minocycline (5 x 5 mg/kg given over 24 h) was only minimally cytotoxic and did not alter the tumor response to a range of radiation doses. However, when minocycline (5 x 5 mg/kg given over 24 h) was added to treatment with cyclophosphamide, there was a 4-fold increase in FSaIIC tumor-cell killing across the dose range of cyclophosphamide doses tested, whereas the killing of bone marrow granulocyte macrophage colony-forming units (CFU-GM) remained unchanged. The Lewis lung carcinoma was used to assess the response of both the primary tumor and metastatic lung disease to treatment with minocycline (14 x 5 mg/kg) given alone or in combination with several cytotoxic anticancer drugs or with radiation delivered locally to the primary tumor. Of the various therapies tested, minocycline proved to be especially effective as an addition to treatment with cyclophosphamide both in increasing the response of the primary tumor and in reducing the number of lung metastases. The tumor growth delay produced by melphalan, radiation, Adriamycin, and bleomycin was also increased by the addition of minocycline to these therapies. These results indicate that minocycline given in clinically achievable doses may be an effective addition to some standard therapeutic regimens and that the mechanism of modulation by minocycline is likely to involve an effect of the drug on the host and not its direct interaction with other therapeutic modalities at the level of the tumor cell.


Assessment of antineoplastic agents by MTT assay: partial underestimation of antiproliferative properties. In the present study a slightly modified MTT assay was used in conjunction with cell counting to determine the antiproliferative efficacy of N-(2-chloroethyl)-N-nitroso-N'-2-hydroxyethylurea (HECNU), vinblastine, and hexadecylphosphocholine (HPC) in a panel of six tumor cell lines. This panel consisted of two human (MDA-MB231, MCF-7) and two rodents (1/C2, 1/C32) mammary-carcinoma cell lines as well as of two tumor cell lines of gastrointestinal origin (HT-29, KB). It was shown that the use of acid isopropanol as a solvent of the formazan crystals produced correlations between cell number and absorption that were as good as, if not better than, those seen after dimethylsulfoxide (DMSO) application. The optimal period of incubation with the MTT dye was 2 h. A comparison of the antiproliferative activity of HECNU revealed that the HT-29 cell line was most resistant [50% inhibition concentration (IC50), 138.7 mumol/l], followed by MCF-7 cells (IC50, 127.7 mumol/l), whereas MDA-MB231 cells showed the highest sensitivity (IC50, 6 mumol/l). Vinblastine induced the highest (MCF-7 cells; IC50, 0.68 nmol/l) and the lowest (1/C2 cells; IC50, 7.69 nmol/l) degrees of growth inhibition in cell lines derived from mammary carcinoma. This contrasted with the activity of HPC, which was considerably less effective in the four mammary-carcinoma cell lines (IC50 from 29.4 to 69.9 mumol/l) than in the two cell lines of gastrointestinal origin (IC50, 1.9 and 3.1 mumol/l). Interestingly, treatment with HPC stimulated the growth of 1/C32 cells in the lower dose range. After treatment with HECNU, the average IC50 value determined in the MTT assay was 2.4-fold that disclosed by cell counting, whereas the average values found for HPC and vinblastine by both methods corresponded fairly well, with the respective values obtained using the MTT assay being only 26% and 14% higher than those measured by cell counting. A dose-dependent increase in the mean size of MCF-7 cells was observed after exposure to HECNU, which--if taken into account--considerably reduced underestimation of this parameter by the MTT assay. No variation in cell size was noted following treatment with HPC and vinblastine. Thus, depending on the antitumor agent used, the MTT assay can result in slight or even considerable underestimation of the antitumor efficacy of certain compounds and may need correction by consideration of the effect of the drugs on cell size.


Thymidylate synthase as a target enzyme for the melanoma-specific toxicity of 4-S-cysteaminylphenol and N-acetyl-4-S-cysteaminylphenol. The rationale for melanoma-specific antitumor agents containing phenolic amines is based in part on the ability of the enzyme tyrosinase to oxidize these prodrugs to toxic intermediates. The phenolic amine compounds 4-S-cysteaminylphenol (4-S-CAP) and N-acetyl-4-S-cysteaminylphenol (N-Ac-4-S-CAP) inhibited in situ thymidylate synthase activity in pigmented melanoma cell lines but had little or no effect on nonpigmented and nonmelanoma cell lines. Theophylline, a cyclic adenosine monophosphate (cAMP) phosphodiesterase inhibitor, increased tyrosinase activity and potentiated the inhibition of in situ thymidylate synthase by N-Ac-4-S-CAP. The inhibition of in situ thymidylate synthase by both drugs in pigmented melanoma cells correlated with the inhibition of DNA synthesis and cell growth and was not due to an indirect effect caused by inhibition of the enzyme dihydrofolate reductase. 4-S-CAP inhibition of thymidylate synthase activity in cell free extracts required oxidation of the drug. In the presence of tyrosinase, the concentration causing a 50% inhibition of thymidylate synthase activity (IC50) in cell-free extracts was less than 10 microM, but no inhibition was observed in its absence, even at a drug concentration of 500 microM. Two reducing agents, dithioerythritol and glutathione, effectively blocked the inhibition of thymidylate synthase by oxidized 4-S-CAP. In pigmented melanoma cells containing the enzyme tyrosinase, the quinone-mediated mechanism of inhibition of DNA synthesis via inhibition of thymidylate synthase may be uniquely important in the expression of phenolic amine cytotoxicity.


In vitro screening of crude extracts and pure metabolites obtained from marine invertebrates for the treatment of breast cancer. A total of 15 samples (crude extracts and pure secondary metabolites) obtained from marine invertebrates collected from the offshore waters of British Columbia, Papua New Guinea, and Sri Lanka have previously been shown to exert cytotoxic activity in the in vitro L1210 leukemic bioassay. We screened these metabolites for in vitro cytotoxic activity against the drug-sensitive breast-tumor cell lines MCF-7, T-47D, ZR-75-1, and MDA-MB-231; the multidrug-resistant and P-glycoprotein (Pgp)-positive breast-tumor cell lines MCF-7 Adr and MDA-A1r; and normal and malignant human breast epithelial cells (HBEC) in primary culture. Eight samples exhibited significant [drug concentration resulting in a 50% decrease in cell growth as compared with controls (ED50), less than 25 micrograms/ml] dose-dependent cytotoxicity against the drug-sensitive cell lines; the ED50 values were as low as 0.004 micrograms/ml. Five of the eight samples exhibited significant cytotoxicity against the multidrug-resistant cell lines; the ED50 values were as low as 0.0006 micrograms/ml. Incubation of MCF-7 Adr cells with varying concentrations of compounds in the presence of Adriamycin demonstrated that none of the compounds tested interfered with Pgp function. Results obtained using HBEC in primary culture showed a wide range of chemosensitivities for a given drug against tissue taken from different patients, demonstrating the uniqueness of the response of different individuals to chemotherapy.


Changes in serum lipids and lipoproteins in cancer patients during chemotherapy. We studied serum lipid and lipoprotein changes occurring during chemotherapy in 57 patients with chemosensitive cancers, including 18 malignant lymphomas, 18 breast carcinomas, 14 small-cell lung carcinomas, and 7 urothelial-cell carcinomas. Patients who responded favorably to chemotherapy demonstrated a significant increase in serum total cholesterol and LDL cholesterol values, with the singular exception of breast-cancer patients, who exhibited a nonsignificant decrease in both of these parameters. Serum levels of free cholesterol and HDL cholesterol did not show any significant changes. Finally, serum triglycerides tended to increase after effective chemotherapy, but this was of statistical significance only in breast-cancer patients. Although our findings were based on a rather small number of patients, they indicate that the lipid and lipoprotein disorders reported in cancer patients are reversible by effective treatment of the tumor, suggesting that these disorders are a secondary phenomenon of malignancy.


Occurrence of Streptococcus pneumoniae and Haemophilus influenzae in otitis media with effusion. Eighty mucoid effusion samples obtained from 56 patients with otitis media with effusion (OME) were subjected to quantitative and qualitative bacteriological analysis using standard culturing methods, direct microscopy and immunofluorescent assay. 30% of the samples contained culture-positive pathogens (H. influenzae, S. pneumoniae, B. catarrhalis), with counts never exceeding 5 x 10(5) per ml. In addition, 19% of the samples had dormant H. influenzae and S. pneumoniae, which did not grow on standard agar plates. Viable and dormant bacteria, as well as bacterial remnants, play a crucial role in the pathogenesis of OME and similarities between OME and reactive arthritis, i.e. Lyme arthritis, Reiter's syndrome and rheumatic fever, are evident.


The effect of anaesthesia on tympanograms of children undergoing grommet insertion. A prospective study was designed to assess the effect of anaesthesia, including nitrous oxide, on tympanometric results of children undergoing myringotomy and possible grommet insertion. 155 patients (310 ears) were examined with a pneumatic otoscope and had tympanograms performed within 1 hour of operation. The patients were then anaesthetized by a combination of intravenous and gaseous anaesthetic. Immediately before myringotomy, a tympanogram was repeated. In 13% of patients predicted to have fluid at admission, there was a change in their tympanogram after induction of anaesthesia, suggesting clearance of fluid. At myringotomy, these ears were dry. We surmise that there was displacement of fluid from the middle ear by nitrous oxide during the early stages of anaesthesia. Thus we feel that, if an otologist confidently expects to find an effusion at myringotomy, the presence of a dry tap should not change his management plan.


Alterations in tympanic membrane appearance and middle ear function in 11-year-old children with complete unilateral cleft lip and palate compared with healthy age-matched subjects. Forty-four 11-year-old children born with a complete unilateral cleft lip and palate were examined to determine the frequency and the extent of changes in the tympanic membrane and the middle ear function and compared with 16 healthy children of the same age. The incidence of hearing impairment, abnormal middle ear pressure, retraction of the pars flaccida and abnormal tympanic membrane appearance were 24, 44, 23 and 67% respectively among the patients while the same parameters in the control group were 0, 12.5, 6 and 12%. Previous grommet insertion in the patient group was statistically correlated to both tympanic membrane abnormality and abnormal middle ear pressure but, remarkably, no association was found between grommet insertion and hearing impairment. The poor middle ear function in the children with cleft lip and palate was probably a result of reduced Eustachian tube function.


Post-tonsillectomy bacteraemia.

Post-tonsillectomy bacteraemia. Post-tonsillectomy bacteraemia is a well recognized aetiological factor in streptococcal endocarditis. Prophylactic penicillin has been recommended to reduce its incidence in susceptible patients undergoing tonsillectomy. Recent studies have shown a change in the microflora and an increase in the number of penicillin resistant organisms in the tonsils of patients undergoing tonsillectomy. The aim of this study has been to assess the incidence of post-tonsillectomy bacteraemia, identify the organisms associated with it and review the suitability of penicillin in prophylactic regimens. Of the 32 patients included in the study, 11 (34.4%) had positive post-tonsillectomy blood cultures. We were surprised at this low incidence of bacteraemia and have postulated a possible reason. Haemophilus influenzae was isolated from 4 (36.4%) of the positive cultures and Streptococcus viridans in only 1 (9%). Rather than using penicillin for prophylaxis a beta-lactamase stable antibiotic would be more appropriate.


Magnetic resonance imaging of the parotid gland using the STIR sequence. The object of this study was to determine the efficiency of the short tau inversion recovery (STIR) sequence in the assessment of salivary disease. Sixteen patients with tumours either in or adjacent to the parotid gland were imaged using a 1.5T Philips Gyroscan, with a standard head coil. T1-weighted spin-echo and STIR sequences were obtained in multiple planes and assessed independently by each of the authors. Positive fine needle aspiration cytology or histological proof of the nature of the imaged lesions was obtained for every patient. T1-weighted spin-echo images were most useful for visualizing anatomical structures and for identification of the facial nerve. All lesions were visible with T1-weighted images but were very much more conspicuous in the STIR sequences, for which a minimal lesion resolution of 6 mm was achieved. No contrast enhancement was required. It was not possible to determine the pathological nature of the lesion by scan appearance only. Our conclusion is that a combination of T1-weighted spin-echo and STIR sequences in the axial and coronal planes is the preferred protocol for salivary gland imaging.


Why patients fail to attend for ENT operations: a one-year prospective audit. A substantial proportion of patients summoned for routine ENT operations simply fail to turn up on the day of admission. Lacking any notice, the hospital has little prospect of finding replacements, with a consequent waste of resources. A one-year prospective study has tried to identify the potential defaulters and sought their own reasons for non-attendance. All patients (n = 181) failing to respond to invitations for admission for surgery were investigated by means of a questionnaire. Non-attenders were matched with those attenders that were listed next on the admission list. The incidence of non-attenders was significantly higher in the group aged 16 years or below. Non-attenders were more likely to be male, on a longer waiting list (P less than 0.05) and listed for nasal septal operations. One in five who failed to attend had changed their address while on the waiting list. The duration of notification appeared not to influence the rate of non-attendance.


Management of facial synkinesis with Clostridium botulinum toxin injection. Associated movements after facial paralysis (synkinesis), due to unphysiological co-innervation of the facial muscles, often complicates the rehabilitation of patients following facial palsy. Clostridium botulinum toxin is a neurotoxin that interferes with the release of acetylcholine from motor nerve end plates, causing skeletal muscular paralysis. This paper concentrates on its clinical use in treating synkinesis affecting orbicularis oculi function and documents the results of treatment in 4 patients. Control of synkinesis, achieved in all 4 patients, was effective within a few days and lasted for 4-6 months. 2 patients developed transient diplopia and ptosis shortly after injection. However, no lasting complications or systemic side-effects were noted. All patients reported a significant improvement in their symptoms and reinjection at 7 months was carried out successfully.


Differential diagnosis and treatment of psychogenic voice disorder. Forty consecutive patients with psychogenic voice disorder were studied prospectively to shed light on some problems of differential diagnosis met by the otolaryngologist. The females (n = 35) were on average younger than males (n = 5) (mean age 34.5 vs 51.8 years, respectively). Although an upper respiratory tract infection preceding the voice disorder was reported by no more than 25% of the patients, as many as 40% had been treated with antibiotics on one or more occasions. Other treatment and voice rest had been prescribed to a further 20% of the patients. The frequency rate of reported asthma/allergy-like symptoms (37.5) exceeded the incidence of asthma/allergy in the normal Swedish adult population. Minor laryngeal abnormalities found in 10 patients could be rejected as causative since they were inconsistent with the voice disturbance. In most of the patients (n = 27), vocal function returned to normal or improved after voice therapy combined with counselling. Vocal abnormalities remained unchanged in three patients. The patients who required multiple therapy sessions (n = 10) were older (mean age 48.8 years) and seemed to have more profound personal problems than the average. The findings suggest that psychogenic voice disorder may often be misdiagnosed as acute laryngitis or asthma/allergy. Restricted use of antibiotics and other drugs is to be recommended in the treatment of benign voice disorders.


A randomized study to compare calcium sodium alginate fibre with two commonly used materials for packing after nasal surgery. A prospective randomized study was undertaken to compare the qualities of calcium sodium alginate (Kaltostat), trousered paraffin gauze, and glove finger packs as nasal packing material following the operation of partial inferior turbinectomy. All three types of packing material were found to be similarly effective in preventing bleeding whilst the packs were in situ. Calcium sodium alginate (Kaltostat) was associated with significantly less bleeding on pack removal than the other two packing materials. Further, irrespective of the material used, leaving the packs in situ for 48 hours produced significantly less bleeding than when they were removed after 24 hours.


Intra-tympanic injections in the treatment of tinnitus. Prolonged reduction or abolition of tinnitus has been reported in about two-thirds of patients treated with a single or weekly-repeated injection through the tympanic membrane of either dexamethasone or lignocaine. In a small-scale trial of these treatments, dexamethasone gave 6 patients little benefit but few side-effects. Lignocaine gave 5 patients no lasting benefit but violent vertigo for several hours. A. Axelsson (personal communication) had similar experience with 6 patients treated with intra-tympanic lignocaine. It is concluded that this form of treatment does not seem sufficiently effective to offset its low acceptability.


Hypoxia in sleeping children: overnight studies can be reduced to 4 hours without loss of clinical significance. Twelve recordings of overnight pulse oximetry representing a range of severity of obstructive sleep disturbance were evaluated by 7 experienced clinicians. Each recording was then scored by counting the number of minutes in each hour affected at any time by a fall in saturation to below 90%. Comparison of the clinical evaluation and the overall scores gave a clear level of 5 minutes per hour at and above which all the assessors agreed that the charts had clinically important desaturation. Overnight pulse oximetry was then performed on 25 children aged between 12 months and 10 years about to undergo adenotonsillectomy. The charts were scored by the method above with a score of 5 or more indicating a positive result for hypoxic episodes. The scores for shortened analysis periods of 1, 2, 3 and 4 hours duration were compared with the overall score and no cases which were negative, up to and including 4 hours, became positive in the overall result. Thus recording pulse oximetry for 4 hours provides sufficiently accurate information for clinical purposes.


Effect of irradiation on middle ear effusion due to nasopharyngeal carcinoma. The management of middle ear effusion by myringotomy and insertion of ventilation tubes in 75 adult patients was evaluated. In Group 1 the middle ear effusion was not related to nasopharyngeal carcinoma. The patients with nasopharyngeal carcinoma were subdivided into pre and post-radiotherapy groups (Group 2 and Group 3) according to the time of insertion of the ventilation tubes. Myringotomy and insertion of ventilation tubes achieved significant hearing gain in all three groups. The pre and post-radiotherapy groups had a higher post-operative infection rate than Group 1 (P greater than 0.01). The duration of a persistent tympanic membrane defect in the post-radiotherapy group was significantly longer than Group 1 (P = 0.03). The post-radiotherapy group had more perforations than Group 1 (P = 0.02). A total of 28% of ears in the post-radiotherapy group were discharging at the last visit. In view of the higher complication rate in the post-radiotherapy group, the role of myringotomy and insertion of ventilation tube is reassessed.


A review of clinical trials regarding treatment of acute otitis media. A survey was made of the English language literature on clinical trials of therapy in acute otitis media. The articles were analysed systematically for 24 parameters related to study design. We retrieved 50 studies published between 1965 and 1989. Surprisingly, the combination of a double-blind method, clearly defined inclusion criteria, and criteria for outcome was found in only 13 studies. Most of these 13 compared different antibiotic regimens and only 4 were placebo-controlled. A recommendation based on the conclusions reached can, even in these 13 studies, hardly be obtained due to failure to show an overall difference in favour of a specific treatment regimen. Our study shows that many trials are methodologically flawed which makes it difficult to accept their results. In view of current controversy on management of acute otitis media, well conducted placebo-controlled clinical trials are still needed.


What is the best method of treatment for labyrinthine fistulae caused by cholesteatoma? A series of 19 patients with a labyrinthine fistula caused by cholesteatoma was analysed. Two patients presented with acute suppurative labyrinthitis and meningitis. A canal wall down procedure was performed in all but one patient. Of the 17 patients with preserved inner-ear function, the cholesteatoma matrix over the fistula was removed in 10 resulting in severe sensorineural hearing loss in one of these. The matrix was left in situ in 7 patients and hearing was maintained or improved in all of them. Post-operatively, 2 patients suffered from vestibular disturbances, the matrix covering the fistula being removed in both of them. It was concluded that preservation of the matrix over the fistula is the safest method of management of this serious complication of cholesteatomatous chronic ear disease.


A dynamic and natural frequency analysis of the Fisch II spandrel using the finite element method. The recent introduction of the Fisch II spandrel total ossicular replacement prosthesis (TORP), has provided impressive initial hearing benefits in patients. The design, based on a combination of soft plastic and a highly flexible metal shaft, has been analysed in terms of its sound collecting and conducting behaviour using the finite element method. The analysis has examined the mode shapes, displacements and natural frequencies of the prosthesis for a variety of material properties and geometries. The results indicate the optimum vibration characteristics are obtained with a Polycell elastic modulus of 100 N/mm2, with the natural frequency independent of modulus above this value. Furthermore, the diameter of the spandrel shaft is crucially important, with an increase in magnitude of the first natural frequency of 54% for a 25% increase in shaft diameter. At a Polycell membrane thickness of 0.07 mm and a shaft diameter of 0.12 mm, the tympanic membrane and Fisch II prosthesis have almost identical frequencies over the 1st to 6th frequency range. This fact, together with the flexibility of clinical procedures involved in its use, may be the reason for its success.


A prospective study of otitis media with effusion in adults and children. A prospective study of otitis media with effusion (OME) in both adults and children has been carried out. 75 new adult patients were seen during a 4-year period. Of these, 13 had associated diseases which could reasonably be considered to have been a cause of their effusion. Over a 2-year period, 192 new children with OME were seen. There was a significantly higher incidence of previous otalgia and/or aural discharge in the children as compared to the adults (P less than or equal to 0.001). The adults had significantly more serous effusions than the children (P less than or equal to 0.001), but both mucoid and serous effusions occurred in both groups. Similar rates of spontaneous resolution were observed in the 2 groups. Within the adult group, patients with a history of upper respiratory infection at the onset of hearing loss were significantly more likely to have spontaneous resolution of their effusion (P less than or equal to 0.02).


Hearing with the bone-anchored hearing aid (BAHA, HC 200) compared to a conventional bone-conduction hearing aid. Sixteen patients have been fitted with a standard bone-anchored hearing aid (HC 200), to replace their conventional bone-conduction aid. The average pure tone threshold at 0.5, 1 and 2 kHz varied from 35 to 75 dB HL, with a sensorineural component varying from 0 to 30 dB HL. The patients' performance with the bone-anchored aid was compared to that with the conventional bone-conduction aid in an acoustic-free field. The maximum phoneme score in quiet was 100% in most patients; in 6 patients, the score with the bone-anchored aid was better (range from 5 to 10%). The speech-in-noise ratio was significantly better in 11 patients (range from -1.4 to -8 dB). None of the patients had poorer results on either test with the bone-anchored aid. The improved speech recognition was ascribed to better performance of the hearing aid in the higher frequency range (above 2 kHz) and to relatively less distortion.


Small cavity mastoidectomy.

Small cavity mastoidectomy. Disappointment with the long-term results of closed operations for ears with extensive cholesteatoma has led to a renewed preference for open techniques. Although the technical advantages provided by magnification and hypotensive anaesthesia have reduced the numbers of unstable post-operative open mastoidectomy cavities, when large, they are still frequently troublesome. Frequently, surgical cavities have been much larger than necessary because of adherence to a traditional approach to the pathologic lesion from its posterior aspect, and the inevitable removal of much normal bone. It is proposed herein that if, instead, bone removal were commenced from the area proximate to the origin of the disease and extended only as far as necessary in order to achieve adequate and effective exteriorization of the disease, fewer large cavities would result and the proportion of stable post-operative ears would be increased. To test this, 100 patients have been treated by atticoantrotomy in which bone lateral to the cholesteatoma sac was removed from anterior to posterior. The 5-year status of the first 43 patients thus treated supports the view that atticoantrotomy provides a logical, safe and successful means of treating extensive cholesteatoma.


Results of surgery for chronic otitis media in patients with a cleft palate. The long-term results of surgical treatment of 19 chronic ears in 16 patients with a cleft palate were analysed. The mean follow-up period was 6.5 years. The patients were found to be significantly younger than other patients with chronic otitis media. Granulating otitis media was the indication for surgery in 11 ears and cholesteatoma in 7 ears. A successful outcome after the primary operation was found in 68% of the patients. Four patients required a revision operation which was successful in all of them. Hearing results of patients with cleft palate did not differ significantly from those obtained in other patients. It is concluded that middle ear surgery should be offered to patients with a cleft palate with the same indications as in other patients with chronic otitis media.


Type II collagen induced arthritis: comparison of histological changes in arthritis-susceptible and arthritis-resistant rats. Wistar rats (type II collagen-induced arthritis-susceptible) and PVG.RT1u rats (arthritis-resistant) were immunised with type II collagen and histological changes in the synovial tissues of the hind feet and in the popliteal lymph nodes draining these feet were examined and compared with unimmunised rats. There were no apparent differences in the joints of unimmunised rats of each strain, but the popliteal lymph nodes of the Wistar rats appeared more "activated", suggesting possible differences between strains in the continuous, low-grade release of antigens from the joints. Whilst the joints of arthritic rats showed the most marked histological changes, the joints of immunised PVG.RT1u rats and of non-arthritic Wistar rats showed some minor changes in the synovia and loss of cartilage with a concomitant increase in the size of the popliteal lymph nodes. The number of mast cells per unit area increased in the lymph nodes of immunised PVG.RT1u rats in proportion to the size increase, but decreased in those draining arthritic Wistar rat feet. The number of mast cells per unit area of synovium decreased most in arthritic feet and the staining pattern of the mast cells altered in the most severely arthritic feet, suggesting a change in mast cell population. These differences in mast cells may be directly related to whether or not clinical arthritis develops in a particular joint. Further study of mast cell sub-populations is warranted.


Interferon-gamma increases human neutrophil-mediated cartilage proteoglycan degradation. Interferon gamma (IFN-gamma) is known to activate neutrophils and is produced by the synoviocytes, macrophages, T cells and other inflammatory cells in rheumatoid arthritis. Neutrophils participate in articular cartilage destruction and predominate in the synovial fluid of inflamed joints during the early stages and acute exacerbations of the disease. In this study we investigated the effect of recombinant human IFN-gamma on human neutrophil damage to bovine articular cartilage explants which had been coated with heat-aggregated IgG (HAGG). Cartilage proteoglycan degradation by neutrophils was augmented by IFN-gamma at 10(2)-10(4) U/ml. IFN-gamma also increased neutrophil-mediated proteoglycan degradation when the cells were preincubated with IFN-gamma and washed before addition to cartilage. This activity of IFN-gamma was abolished by boiling and was unaffected by polymixin B, indicating that the effects of IFN-gamma were not due to endotoxin contamination. In the absence of neutrophils IFN-gamma had no effect on proteoglycan metabolism, and the ability of IFN-gamma to increase neutrophil-mediated proteoglycan degradation did not require living chondrocytes. Adherence of neutrophils to HAGG-coated and uncoated cartilage explants was enhanced by IFN-gamma. Opsonisation of the cartilage with HAGG also increased the adhesion of neutrophils. In contrast to the enhancement of neutrophil-mediated proteoglycan degradation, IFN-gamma had no effect on the inhibition of proteoglycan synthesis by neutrophils.


Synovitis equivalent to erosions in rheumatoid arthritis: implications of skeletal analysis for the clinical management of contemporary rheumatoid arthritis. Examination of a contemporary skeletal collection revealed a rheumatoid subgroup with parameters mirroring those of contemporary clinical populations. This rheumatoid population was also indistinguishable from contemporary (live) clinical populations, on the basis of the actual distribution of radiologically detectable erosions, thus validating its representativeness. Gross examination of these defleshed skeletons allowed assessment of the significance of erosive disease in rheumatoid arthritis. As anticipated, the frequency of visibly detectable erosions exceeded that detectable radiologically. The frequency of visibly detectable erosions, however, was indistinguishable from the frequency of synovitis in clinical populations. The excellent correlation of the gross and clinical distribution of disease suggests that some degree of erosive disease is integral to all lesions of rheumatoid arthritis and that only the relative insensitivity of radiologic techniques precludes universal recognition of those erosions. This work suggests that any therapeutic intervention which settles for only partial synovitis control will not prevent the progression of erosive disease; and perhaps explains the difficulty of demonstrating alterations in erosion progression in studies of disease modifying agents.


Elimination diet in the treatment of selected patients with hypersensitivity vasculitis. We have evaluated the effects of an elimination diet in 5 patients with hypersensitivity vasculitis and a personal or family history of allergy. The presence of autoimmune disorders, infections and neoplastic diseases was excluded on the basis of physical examination, clinical history and laboratory data. Three patients had elevated serum immune complexes and evidence of complement consumption before the oligoantigenic diet. In one patient food allergy was diagnosed on the basis of a positive and concordant challenge test, skin prick test and RAST. The study consisted of a 3 week elimination diet, followed by open and double blind challenge tests with specific foods and additives. Four patients achieved a complete remission and one patient experienced great improvement on the elimination diet. In three cases the vasculitis relapsed following the introduction of food additives; in one case with the addition of potatoes and green vegetables (i.e., beans and green peas) and in the last case with the addition of eggs to the diet. The offending foods and additives were subsequently eliminated from the usual diet and no relapses were observed in 2 years of follow-up. These results show that in selected patients with a history of allergy, hypersensitivity vasculitis can be triggered and sustained by food antigens or additives.


Production of neutrophil activating peptide-1 (NAP-1/IL-8) by blood and synovial fluid mononuclear cells from patients with arthritis. As polymorphonuclear leukocytes (PMN) are predominant in inflammatory synovial fluids, we investigated the production of neutrophil-activating peptide-1 (NAP-1) by mononuclear cells (MC) from 15 synovial fluids and matched peripheral blood. MC were cultured for 24 h alone or with stimulants (ConA, LPS). NAP-1 was determined in the supernatants by a bioassay (elastase release from normal human PMN) and an immunoassay (sandwich ELISA with a mouse anti-NAP-1 mAb and an alkaline phosphatase labelled goat anti-NAP-1 pAb). The results showed a significant increase in NAP-1 production by synovial fluid MC when compared to peripheral blood MC. Both cell types produced more NAP-1 in the presence of added stimuli. The results obtained with the two methods of detection were in close agreement. No relationship was found between the amount of NAP-1 produced in 24 h and the number of synovial fluid leukocytes, the erythrocyte sedimentation rate, the diagnosis of the underlying arthritis or the treatment of the patients.


Proteoglycan structural changes in human rheumatoid articular cartilage. Human rheumatoid arthritic (RA) cartilage contains elevated levels of proteolytic enzymes in which the metalloproteases are believed to be the prime enzyme system involved in cartilage metabolism. We examined the effects of these enzymes and the serine proteases on endogenous proteoglycans (PGs) and newly synthesized PGs of seven RA cartilages. The data was further analyzed with regard to the therapy received by the patients prior to surgery. A structural heterogeneity among the PGs from RA cartilage was found, and two subsets were distinguished. While in the first subset more than 35% of the PGs were in aggregate form, no appreciable amount of PG aggregate was found in the second subset. Interestingly, in all but one specimen the subsets appeared to be a function of prior therapy received by the patients. In subset I patients had received prednisone and/or DMARD in addition to NSAIDs, while those from subset II had all received NSAIDs only, with one exception. Our findings also suggest that PG structure alterations could result from the action of already active and APMA-activated metalloproteases; these reduced the PG aggregation capability and caused extensive cleavage in the PG core protein. The serine proteases did not seem to play a major role. Moreover, when the endogenous latent metalloproteases were activated with APMA, high-density PGs (the A1D1 fraction) showed a reduction in their capacity to reaggregate, and in their hydrodynamic size. Using an immunological technique we demonstrated the presence, in subset I, of the hyaluronan binding region domain (HABR) of the core protein. For subset II this domain could not be found.(ABSTRACT TRUNCATED AT 250 WORDS)


Anticardiolipin antibodies in a patient with Crohn's disease and thrombosis. Thrombosis is an uncommon though well recognized complication of inflammatory bowel disease, for which various coagulation alterations have been described as possible causes. Antiphospholipid syndrome (APS) is defined as the association of thrombosis, fetal loss and thrombocytopenia with anticardiolipin antibodies (aCL) and/or lupus anticoagulant (LA). We describe a case of a 21-year-old female with recurrent thrombosis associated with aCL who went on to develop Crohn's disease. Tissue typing done in this patient revealed the presence of the HLA-DR7, DRw53, which previous studies have shown to be found in increased frequencies in APS patients. To our knowledge, this is the first report of an association between these two clinical conditions and, in this particular case, aCL may be implicated in the thrombotic events.


Type II collagen-immune complex arthritis in sheep: collagen antibodies in serum, synovial fluid and afferent lymph. Type II native bovine collagen was used to induce arthritis in sheep. The sheep received a subcutaneous injection of collagen in Freund's adjuvant, and some sheep also received an intra-articular injection of collagen. The response to the collagen injections was monitored by measurement of antibody levels to bovine and ovine collagen in serum, synovial fluid and afferent lymph samples. There were antibodies in the normal sheep serum which reacted with native and denatured type II collagen, but there was a marked rise in serum and synovial fluid reactivity after subcutaneous injection of native collagen. In these sensitised sheep there was a further rise in antibody levels in the synovial fluid and afferent lymph samples after an intra-articular injection of collagen. There was little effect on antibody levels in the non-injected contralateral limb. Histological and immunohistochemical studies showed that the rise in antibody levels was associated with pathological changes to the synovium which were consistent with the development of arthritis. These changes were most severe in those joints of sensitized sheep which had received an intra-articular injection of collagen and were characterized by increased numbers of T cells in the synovial tissue, mainly of the CD4 phenotype. There was a marked increase in B cell expression by cells on the surface of the synovial intima, and accumulations of B and T cells were seen in the subsynovial tissues. Collagen-immune complex arthritis in sheep appears to be a useful large animal model of arthritis, with significant similarities to the arthropathies of other species, including man.(ABSTRACT TRUNCATED AT 250 WORDS)


Tenosynovitis due to Mycobacterium avium-intracellulare: case report and a review of the literature. A 57-year-old female patient presented with a tenosynovitis due to Mycobacterium avium-intracellulare (MAI). A relapse occurred following surgical treatment, after which she was successfully treated with ansamycin and ethambutol. Previously reported cases of tenosynovitis due to MAI are reviewed and the treatment modalities are discussed.


Intravenous corticosteroid therapy of cervical cord compression in rheumatoid arthritis. We describe a case of atlantoaxial joint subluxation and cervical myelopathy in a patient with rheumatoid arthritis. Magnetic resonance imaging (MRI) demonstrated a large periodontoid pannus compressing the upper cervical cord. Neurological function improved rapidly after treatment with intravenous pulse corticosteroids given before surgical fusion of the cervical spine. Post operative MRI showed a significant reduction in size of the pannus.


Human platelets in synovial fluid. A focus on the effects of growth factors on the inflammatory responses in rheumatoid arthritis. The alpha granules of platelets are a major storage site for peptide growth factors. The inflamed synovial fluid of rheumatoid arthritis contains a high number of platelets as well as platelet-derived growth factors. These platelets may apparently be acted upon to release their alpha granule-located substances. It can thus be suggested that platelets present in the synovial fluid express growth factors of significance to the local inflammatory responses of rheumatoid arthritis.


Increased frequency of DR4 in systemic onset juvenile chronic arthritis. Eighty-one patients with systemic onset juvenile chronic arthritis (JCA) have been tested for HLA-A, -B, -C, and -DR antigens. This study confirms previous reports of an increased incidence of DR4 in these patients. Subdivision of the patients according to their disease course over ten years showed different HLA associations with different disease courses. The frequency of DR4 tended to be greater in patients with less severe disease. There was also an increased incidence of HLA B27 in patients in whom relapses of disease were associated with intercurrent infections.


Atypical Behçet's disease with peripheral erosive arthropathy and pyoderma gangrenosum. We report a 52-year-old male Caucasian who presented with a peripheral erosive arthritis, then pyoderma gangrenosum, and six years later pancolitis and orogenital ulcers. The case illustrates an overlap that may exist between Behçet's syndrome and inflammatory bowel disease. In either condition seronegative erosive peripheral joint disease is an uncommon presenting feature.


Isolation and characterization of a low metastatic variant from EL-4 mouse T-lymphoma. A variant cell line (EL-4ad) which adhered to a tissue culture dish was isolated from highly metastatic EL-4 murine T-lymphoma. The experimental and spontaneous metastatic ability of EL-4ad was lower than that of the EL-4 parent cell line. The cell surface phenotypes of both cell lines were CD2+3+4-8-45+TCR alpha beta+TCR gamma delta-, but the level of CD2 expression of EL-4ad was much lower than that of EL-4. Furthermore, EL-4ad had higher binding ability to fibronectin and expressed more PNA receptors on the cell surface than EL-4. These differences indicated that either the maturation stage of the less metastatic variant was lower than that of the parent cell line or the activation state of the two cell lines differed. EL-4ad showed higher in vitro invasiveness and adhesiveness to liver cells, and these characters were not consistent with the reduced metastatic ability of this variant. Neuraminidase-releasable cell surface sialic acid levels did not differ significantly between the cell lines. Neither cell line was adhesive to laminin, type IV collagen or reconstituted basement membrane. These metastasis-related properties could not explain the decreased metastatic ability of EL-4ad. On the other hand, EL-4ad was more sensitive to NK activity than EL-4 in vivo, and this was thought to be a major cause of its decreased metastatic ability. The molecules or mechanisms involved in the differentiation or activation of T-cells may be responsible for the sensitivity of tumor cells to NK activity.


Calcium depletion reduces the destruction of fibrosarcoma cells in the microvasculature of artificially perfused rat hearts. Earlier studies have shown that most tumour cells (TCs) injected into the circulation die rapidly. The mechanisms behind this rapid elimination of TCs are not known, but some experimental data suggest that mechanical trauma to the cells in the capillary bed plays a role. In the present investigation 725,000 rat fibrosarcoma cells (250,000/ml) were infused into the coronary microcirculation of isolated and artificially perfused (flow rate approx. 6 ml/min), beating and non-beating (Ca2+ excluded from the perfusate) rat hearts. The analyses included calculations of the number of TCs retained in the myocardium 5 min after start of TC infusion and their distribution within the ventricular wall. In addition, ultrastructural studies were performed to identify possible structural changes of trapped TCs and myocardial tissue. Intact and viable TCs in the effluent perfusate were counted. In beating hearts about 20% of the infused TCs were collected microscopically intact after passage through the heart circulation, and of these cells only 32% were viable (in-flow viability 87-91%). In Ca(2+)-depleted hearts the corresponding figures were 29 and 48%, respectively. The difference in viable cell counts was statistically significant (P less than 0.001). The TCs trapped in the left ventricular wall of the myocardium of beating hearts were mainly found in the subepicardial third of the wall, whereas in non-beating hearts the trapped cells were distributed randomly. The ultrastructural appearance of trapped cells differed between the two groups: 82% of cells trapped in beating hearts showed signs of severe damage, with subcellular vacuolization and plasmalemmal disruption, whereas 65% of cells trapped in Ca(2+)-depleted hearts seemed undamaged with intact cell membranes and cytoplasmic organization. The remaining 35% showed variable subcellular disorganization. The results cannot entirely be explained by mechanical TC damage in the microcirculation due to intracapillary deformation. The observations require additional explanatory mechanisms. One possible important TC damaging mechanism, dependent on extracellular Ca2+ levels, could be endothelial cell release of reactive oxygen species.


Breast carcinoma: periodicity in presentation of metastatic tumour growth in the axilla. The clinical value of assessment of tumour load in the axilla in the treatment of breast cancer patients has stood the test of time. Much information is available on its extent and characteristic distribution but, in contrast, little is known of the biological factors that may control the timing of the metastatic phenomenon. There is recent circumstantial evidence that such factors may exist and this prompted the present detailed study of axillary metastases from a series of 437 consecutive cases of breast carcinoma. Evidence of such factors was found here also: the excess of micrometastases in cases coming to operation in the second half of the year was highly significant (P less than 0.001) and is consistent with a synchronized start to the metastatic process. The total metastatic pattern in the material further indicated that the process may show periods of inactivity, i.e. periods when new colonies are not recruited. Mechanisms controlling this periodicity could theoretically be light-mediated, opening up new possibilities in the development of anti-metastatic treatment regimes.


Identification of intracranial liqor metastases of experimental stereotactically implanted brain tumors by the tumor-selective MRI contrast agent MnTPPS. Two cases of stereotactically induced and spontaneously metastasizing neoplasms in the rat and the cat brain are reported. In the rat, a malignant Schwannoma derived from initially supratentorially implanted RN6 cells developed a second tumor in the posterior cranial fossa. In the cat, a highly malignant polymorphous anaplastic glioma induced by implantation of cloned rat glioma cells (F98) into the left internal capsule developed small tumor cell nests along the ependyma of the ipsilateral ventricle. In precontrast magnetic resonance imaging (MRI) of both cases, the primary tumor was detectable only by a very weak hypointensity and through a shift of the midline. No metastases were apparent. Application of the metallated paramagnetic porphyrin derivative manganese(III) tetraphenylporphine sulfonate (MnTPPS) resulted in a remarkable contrast enhancement between tumoral and normal tissue, which was evident not only in the primary tumor but also in the small metastases. These observations demonstrate for the first time that MnTPPS is an efficient MRI contrast agent for the detection of metastases from primary brain neoplasms and, in consequence, support the hypothesis of its selective binding to tumor cells.


Murine Kupffer cells and hepatic natural killer cells regulate tumor growth in a quantitative model of colorectal liver metastases. This investigation aimed to develop a biologically relevant murine model of colorectal liver metastases and determine if Kupffer cells (KC) and hepatic natural killer cells (hNKC) regulate tumor growth. The model involves the injection of murine colon adenocarcinoma 26 (MCA 26) tumor cells into the portal vein of female-specific pathogen-free BALB/c mice. Metastases developed in all animals, and the growth was limited entirely to the liver. To determine if KC and hNKC control the development of liver metastases, the in vivo function of these hepatic effector cells was modulated. Tumor growth was quantitated by the uptake of 125I into tumor DNA. Stimulation of the KC and hNKC produced a significant (P less than 0.01) dose-dependent decrease in 125I uptake in the liver in both treatment groups, which was associated with a significant improvement in survival (P less than 0.05). The in vivo cytotoxic function of the liver was inhibited with an intravenous injection of gadolinium chloride (for KC) or asialo GM1 antiserum (for hNKC). Inhibition of KC and hNKC cytotoxic function led to a significant (P less than 0.01) increase in 125I uptake in the liver and a significant decrease in survival (P less than 0.05).


Unsuspected meningitis diagnosed by In-111 labeled leukocytes. A case report. Clinically unsuspected bacterial meningitis was found in a patient with fever of unknown origin. Blood and urine cultures were negative for growth. Chest radiography and abdominal CT were negative for infection. Triple-phase bone imaging was performed to rule out osteomyelitis from a gunshot wound. A left posterior iliac crest hot spot may have represented osteomyelitis, but In-111 labeled leukocyte imaging instead disclosed unsuspected meningitis. The CSF culture after the imaging was positive for Enterobacter aerogenes.


NIH3T3 transfectant containing human K-ras oncogene shows enhanced metastatic activity after in vivo tumor growth or co-culture with fibroblasts. A clone of NIH3T3 transformant (H-3), obtained by transfecting genomic DNA of a human colon carcinoma cell line, contains human K-ras oncogene and yields metastatic pulmonary nodules after intravenous injection of the cells into nude mice. This metastatic ability was enhanced remarkably after in vivo tumor growth (subcutaneous tumor formation in nude mice) accompanied by increased mRNA expression and gene amplification of the human-derived K-ras oncogene, while it declined gradually as the passage number increased in vitro, with corresponding decreases of gene amplification and mRNA expression. Six subclones were randomly selected from H-3 cells which had been subcultured to passage 22. All of the clones in culture showed almost the same low level of metastatic ability and exhibited little K-ras oncogene amplification with correspondingly low mRNA expression. However, after they formed tumors in nude mice, every clone acquired high metastatic ability and the gene amplification increased, with elevated mRNA expression. These experimental facts indicated that acquisition of metastatic ability coupled with the function of K-ras oncogene was conditional in nature, being strongly affected by in vivo tumor circumstances. The low metastatic and G-418-resistant H-3 cells were co-cultured with BALB/c3T3 fibroblasts for 2-4 weeks. After removal of fibroblasts by exposure to G-418, the tumor cells exhibited increased metastatic ability and human K-ras oncogene mRNA, suggesting an intimate interaction between H-3 cells and fibroblasts influencing the function of transfected human K-ras oncogene. Fibroblasts of the host animal may thus have an important role in generating enhanced metastatic activity of H-3 cells.


Renal scintigraphy in a patient with pelvic lipomatosis. A patient with a history of benign prostatic hypertrophy and pelvic lipomatosis was evaluated for pain and swelling of the abdomen and left leg. As part of his workup, renal imaging was performed and revealed medial deviation of the ureters, incomplete emptying of the collecting systems, and a pear-shaped bladder. Although these findings have been reported with other imaging modalities in patients with pelvic lipomatosis, they have not been described in renal scintigraphy. This constellation of findings should lead to the consideration of the diagnosis of pelvic lipomatosis.


The beta-2-glycoprotein I and antiphospholipid antibodies. Beta 2-GPI is a single chain, 50 kd glycoprotein made up of 326 amino-acids, present in human plasma at concentrations of about 200 micrograms/ml. It has been shown to represent the "serum cofactor" important in determining the binding of aCL to phospholipids both in fluid and in solid phase assays. Its cofactor activity is demonstrable for aPL antibodies from patients with autoimmune but not with infectious diseases. It is immunogenic in heterospecific models, and immunization with beta 2-GPI seems to be able to induce the production not only of anti-beta 2-GPI but also of aPL antibodies. Most probably its binding to CL changes the configuration of phospholipids to a more immunogenic one. The various characteristics of beta 2-GPI are summarized in Table I. beta 2-GPI has been recognized as a natural anticoagulant protein, but its possible role in the pathogenesis of the APLS remains to be determined.


Transient diaphyseal tibial Tc-99m MDP uptake and bone marrow edema in acute rheumatic fever. The authors describe a patient with acute rheumatic fever and polyarthritis in whom scintigraphy unexpectedly identified Tc-99m MDP uptake in the diaphyses of both tibiae. A dramatic rise in antistreptolysin-O titer and rapid resolution of tibial abnormalities paralleled marked articular improvement. Magnetic resonance imaging demonstrated a pattern consistent with marrow edema in the area of abnormal Tc-99m MDP accumulation. This finding has not been previously described in acute rheumatic fever, and it was suspected that the changes in the tibiae resulted from subclinical diaphyseal hyperemia from the inflammatory process observed in the contiguous joints.


Bilateral testicular neuroblastoma. Scintigraphic depiction and therapy with I-131 MIBG. The authors describe a 29-year-old man who had a 16-year history of neuroblastoma and uncommon manifestations. At age 13, he was diagnosed with stage III retroperitoneal ganglioneuroblastoma that was resected. Ten years later, bilateral testicular enlargement and a pelvic mass from infiltration of the neuroblastoma became palpable. Metastatic involvement was depicted with MIBG, a radiotracer that concentrates in tissues of the sympathetic nervous system. Using I-131 MIBG, the tumors were treated with therapeutic doses of radiation and a partial response was obtained. This case is unique because of the massive degree of bilateral testicular infiltration and its occurrence as a late manifestation of neuroblastoma in early adulthood.


Functional studies of left upper quadrant mass aid management of idiopathic thrombocytopenic purpura. ITP (idiopathic thrombocytopenic purpura) causes rapid sequestration and destruction of thrombocytes by the spleen, liver, bone marrow, and reticuloendothelial elements of other organs. The usefulness of multiple radionuclide functional imaging procedures in the management of a 34-year-old woman with chronic ITP, two splenectomies (removal of the initial spleen and then a hypertrophied accessory spleen), and the failure of chemotherapy to control her thrombocytopenia, are discussed. A combination of In-111 oxine autologous platelet imaging, liver/spleen imaging, disofenin (liver/gallbladder) imaging, and glucoheptonate renal imaging demonstrated that her platelets were being sequestered by a markedly enlarged left hepatic lobe extending to the left lateral wall, with a small amount in the kidneys and lungs, and that there was no second accessory spleen.


Nonpustular psoriatic lesions detected by Tc-99m HMPAO labeled granulocytes. A patient with a fever of unknown origin was evaluated by abdominal SPECT using Tc-99m HMPAO labeled granulocytes and a triple detector camera. Although no abscesses were located, nonpustular psoriatic skin lesions were demonstrated incidentally on the reprojectional images. Psoriatic scales contain a chemotactic factor for leukocytes, and this is a likely explanation for the increased uptake of the radiotracer by psoriatic lesions.


Progressive soft tissue uptake of Tc-99m MDP reflecting metastatic microcalcification. A 49-year-old woman had longstanding renal impairment. Markedly increased uptake of Tc-99m MDP in the heart, lungs, and kidneys was an incidental finding on bone scintigraphy performed to exclude metastatic bone disease. These findings persisted on repeat bone imaging 1 year later. In addition, gastric and skeletal muscle uptake was subsequently seen. Soft tissue microcalcification was confirmed by computed tomography and renal biopsy. A consideration of the differential diagnosis is presented.


Dual isotope SPECT in the evaluation of recurrent brain tumor. Dual isotope brain SPECT was performed in a patient with recurrent brain tumor (grade II astrocytoma). In this case, a good coregistration of brain perfusion and tumor images was obtained because Tc-99m HMPAO and the Tl-201 chloride imaging were done simultaneously using a Triad SPECT unit. This method might play an important clinical role in the evaluation of patients with recurrent brain tumors.


Pharmacokinetic optimisation of angiotensin converting enzyme (ACE) inhibitor therapy. Angiotensin converting enzyme (ACE) inhibitors are increasingly used to treat hypertension and congestive heart failure. Recently, several new ACE inhibitors with pharmacokinetic features different from earlier agents such as captopril or enalapril have come into use. This review discusses the use of pharmacokinetics to optimise ACE inhibitory therapy in various patient groups. Among the pharmacokinetic characteristics of ACE inhibitors the route of excretion and to a lesser degree the half-life appear to be the most clinically relevant. There is no evidence that being a prodrug offers a significant clinical advantage. The importance of varying tissue penetration also remains to be determined. Knowledge of ACE inhibitor pharmacokinetics is particularly important in patients with renal or hepatic dysfunction in whom the major route of excretion of these agents is impaired. This might also be the case in elderly patients or those with severe congestive heart failure. However, for most ACE inhibitors, major changes in the drug dosage (amount or interval) are necessary only when the glomerular filtration rate falls below 30 ml/min (1.80 L/h). The occurrence of adverse effects due to overdosage or drug interactions may be prevented by adapting the prescription of an ACE inhibitor to its pharmacokinetic characteristics.


Heparin pharmacokinetics and pharmacodynamics. Heparin was discovered approximately 75 years ago and has been used extensively for the last 50 years to treat thromboembolic disorders. An endogenous glycosaminoglycan, heparin is found largely in the liver, lung and intestine. It is available for exogenous administration both as unfractionated and low molecular weight heparin. Unfractionated heparin is a heterogenous mixture of polysaccharide chains of varying length resulting in a range of molecular weights from 3000 to 30,000D while low molecular weight heparin ranges from 3000 to 6000D. Heparin produces its antithrombotic effect by binding to antithrombin III and this complex then binds to thrombin. In order to accomplish this a total of 18 to 22 monosaccharide units is necessary including a specific pentasaccharide binding site for antithrombin III. After either subcutaneous or intravenous injection heparin is distributed primarily within the intravascular space. A short distribution phase is seen which is thought to correspond to endothelial cell binding and internalisation. The disposition curve for unfractionated heparin has a unique concave-convex shape which is the result of combined saturable and nonsaturable elimination mechanisms. The nonsaturable elimination mechanism is renal and is the primary route of elimination for low molecular weight heparins. For this reason, the concave-convex pattern is not seen with low molecular weight preparations. Both forms of heparin are useful antithrombotic agents; however, the correlation between the antithrombotic effect and an in vitro laboratory test for either type still needs further clarification.


Pharmacokinetics of factor VIII in humans. Obtaining clinically relevant data from comparative studies. The pharmacokinetics of Factor VIII procoagulant activity (FVIII:C) were investigated in 10 patients receiving 2 different high purity concentrates of FVIII. The in vivo recovery of FVIII:C depended on the method of blood volume estimation and on the in vitro assay used to define the potency of the concentrate; more generally, it also depends on the study design. The use of in vivo recovery to compare FVIII preparations should therefore be discouraged and the achieved area under the FVIII activity-time curve (AUC) should be used instead. The volume of distribution at steady-state (Vss) of FVIII:C was significantly greater than the estimated plasma volume of the patients. The mean terminal half-life of FVIII:C was slightly assay-dependent, being 14h by a 1-stage clotting assay and 12h by a chromogenic assay. The calculated apparent clearance (CL) of FVIII:C, as well as the Vss and the in vivo recovery, depended on the measured in vitro potency of the FVIII concentrate. These methodological aspects of pharmacokinetic studies are of direct interest to the clinician, since the routine administration of FVIII is based on the pharmacokinetic properties of the specific preparation.


Pharmacokinetic modelling of a parent drug and its metabolite. Atracurium and laudanosine. A pharmacokinetic model was designed to describe simultaneously the plasma concentrations of atracurium and its metabolite laudanosine. The proposed model satisfactorily fits the observations and is based on the assumptions that the parent drug spontaneously degrades to laudanosine at the rate comparable with that observed in vitro at pH 7.4 and 37 degrees C; that 2 molecules of laudanosine are formed from 1 molecule of atracurium; that an initial very rapid decay of a fraction of the atracurium dose is responsible for the initially high plasma laudanosine concentrations; that the rapid disappearance of atracurium from plasma is accounted for by its spontaneous degradation and by the sequestration of atracurium in a deep compartment; and that laudanosine formed from atracurium is added to its central compartment, with its disposition described by a simple 2-compartment model with elimination from the central compartment. The model projects that about 43% of the atracurium dose is rapidly converted to laudanosine and that nearly the whole injected amount of atracurium is degraded to laudanosine.


Clinical pharmacokinetics of endocrine agents used in advanced breast cancer. Endocrine therapy is important in the treatment of advanced breast cancer. The prototype antiestrogen tamoxifen and the prototype aromatase inhibitor aminoglutethimide have been in clinical use for more than 2 decades, as have synthetic progestin derivatives. Currently, several novel antiestrogens and aromatase inhibitors are used to treat breast cancer. This paper reviews the present knowledge of the clinical pharmacokinetics of these drugs. Drug monitoring in plasma and other body fluids has been improved over recent years by the introduction of sensitive and specific high performance liquid chromatography and gas chromatography-mass spectrometry methods. However, we still lack information on such basic pharmacokinetic parameters as the bioavailability of several of these drugs. It is important to study not only plasma but also tissue drug concentrations.


Differing effect of atropine on heart rate in Chinese and white subjects. To determine if differences exist between Chinese and white subjects in their response to atropine and if the intrinsic heart rate and the autonomic contribution to the heart differ between the two races, eight white and eight Chinese males were studied. In all subjects the heart rate decreased after the first dose of atropine (0.003 mg/kg) with no difference in the bradycardia between the two races. However, as further doses were administered, the heart rate increased in both groups, resulting in a significantly (p less than 0.05) greater increase in Chinese subjects than in white subjects. The increase in heart rate for each nanogram per milliliter of atropine was 2.8-fold higher (p less than 0.05) in the Chinese subjects (19.24 +/- 4.41 beats/min) compared with white subjects (6.83 +/- 1.62 beats/min). There was no difference in the intrinsic heart rate, in the relative vagal contribution, or in relative sympathetic contribution to the heart rate between the Chinese and white subjects. These data indicate that Chinese subjects are more sensitive to the effect of atropine, which is not related to the contribution of autonomic tone to the heart.


N-acetylcysteine enhances nitroglycerin-induced headache and cranial arterial responses. The effects of N-acetylcysteine, a sulfhydryl group donor, on nitroglycerin-induced headache and dilation of temporal and radial arteries were investigated in 11 healthy volunteers. Nitroglycerin, 0.06 microgram/kg/min, was infused for 20 minutes immediately after and 120 minutes after pretreatment with N-acetylcysteine (100 mg/kg) or placebo. Arterial diameters were measured with high frequency ultrasound, and pain was scored by use of a previously evaluated 10-point scale. Plasma levels of free (n = 2) and total (n = 11) N-acetylcysteine were determined. N-Acetylcysteine potentiated the headache response (median headache score, 3 versus 1), and the headache retained its vascular characteristics. Temporal artery dilation was also potentiated by N-acetylcysteine, 139% +/- 3% versus 127% +/- 3% of baseline, whereas the radial artery was unaffected. The potentiation was most pronounced after the first nitroglycerin infusion (12% versus 4.5% compared with placebo). A prolonged dilation of the temporal artery was observed only after the first nitroglycerin infusion, when high levels of N-acetylcysteine were present.


Pharmacokinetics and pharmacodynamics of oral diazepam: effect of dose, plasma concentration, and time. Eleven healthy subjects received single oral doses of placebo, 2 mg diazepam, 5 mg diazepam, and 10 mg diazepam in a randomized four-way crossover study. Plasma diazepam levels, the Digit Symbol Substitution Test (DSST), and fraction of total electroencephalographic (EEG) amplitude falling in the sigma plus beta (13 to 31 Hz) frequency range were determined during the 12 hours after drug administration. Peak plasma diazepam concentration and area under the 12-hour curve were proportional to dose; time of peak was independent of dose. Baseline percentage of EEG amplitude falling in the 13 to 31 Hz range averaged 15.7% and did not differ among the four trials. The percentage of EEG amplitude falling in the 13 to 31 Hz range did not change over baseline with placebo or 2 mg diazepam but was increased 1/4 to 2 1/2 hours after 5 mg diazepam, (maximum, +7.3%) and 3/4 to 12 hours after 10 mg diazepam (maximum, +15.2%). The increase in the percentage of EEG amplitude falling in the 13 to 31 Hz range was highly correlated with plasma diazepam concentration. DSST scores for placebo and 2 mg diazepam were nearly identical. DSST decrements with 5 and 10 mg diazepam paralleled and were correlated with the changes in the percentage of EEG amplitude falling in the 13 to 31 Hz range and with plasma diazepam levels. Thus the EEG analysis provides objective quantitation of benzodiazepine central nervous system effects, in turn reflecting plasma levels and other clinical measures.


Differential plasma duration of antiplatelet-activating factor and antihistamine activities of oral Sch 37370 in humans. Preclinical studies have established that Sch 37370 (1-acetyl-4-(8-chloro-5,6-dihydro-11H-benzo[5,6]-cyclohepta [1,2-b]pyridin-11-ylidene)piperidine) is an orally active antagonist of platelet-activating factor (PAF) and histamine H1-receptors with potential therapeutic use in the treatment of asthma. To evaluate the efficacy and duration of anti-PAF and antihistamine actions of oral Sch 37370 in humans, a single dose (5 mg/kg) of Sch 37370 was given orally to each of 10 male subjects in a placebo-controlled, double-blind crossover study. Blood samples were drawn before and at various times (2 to 48 hours) after Sch 37370 or placebo. Plasma samples were analyzed for Sch 37370 by a gas chromatographic method, for the anti-PAF activity by measuring the aggregation of platelets stimulated with PAF, and for the antihistamine activity by measuring displacement of [3H]pyrilamine from rat brain membrane binding sites. The plasma anti-PAF activity declined from high levels at 2 hours to barely detectable levels at 24 hours; however, significant activity was still present at 12 hours. The plasma levels of Sch 37370 closely paralleled the anti-PAF profile. The plasma antihistamine activity reached a maximum within 2 to 8 hours and declined thereafter. However, 48 hours after Sch 37370, the antihistamine activity was still present at a significant level in most subjects. It is concluded that, in humans, oral Sch 37370 antagonizes both PAF and histamine with plasma antihistamine activity lasting longer than plasma anti-PAF activity.


Incidence of S-mephenytoin hydroxylation deficiency in a Korean population and the interphenotypic differences in diazepam pharmacokinetics. We studied the genetically determined hydroxylation polymorphism of S-mephenytoin in a Korean population (N = 206) and the pharmacokinetics of diazepam and demethyldiazepam after an oral 8 mg dose of diazepam administered to the nine extensive metabolizers and eight poor metabolizers recruited from the population. The log10 percentage of 4-hydroxymephenytoin excreted in the urine 8 hours after administration showed a bimodal distribution with an antimode of 0.3. The frequency of occurrence of the poor metabolizers was 12.6% in the population. In the panel study of diazepam in relation to the mephenytoin phenotype, there was a significant correlation between the oral clearance of diazepam and log10 urinary excretion of 4-hydroxymephenytoin (rs = 0.777, p less than 0.01). The plasma half-life of diazepam in the poor metabolizers was longer than that in the extensive metabolizers (mean +/- SEM, 91.0 +/- 5.6 and 59.7 +/- 5.4 hours, p less than 0.005), and the poor metabolizers had the lower clearance of diazepam than the extensive metabolizers (9.4 +/- 0.5 and 17.0 +/- 1.4 ml/min, p less than 0.001). In addition, the plasma half-life of demethyldiazepam showed a statistically significant (p less than 0.001) difference between the extensive metabolizers (95.9 +/- 11.3 hours) and poor metabolizers (213.1 +/- 10.7 hours), and correlated with the log10 urinary excretion of 4-hydroxymephenytoin (rs = -0.615, p less than 0.01). The findings indicate that the Korean subjects have a greater incidence of poor metabolizer phenotype of mephenytoin hydroxylation compared with that reported from white subjects and that the metabolism of diazepam and demethyldiazepam is related to the genetically determined mephenytoin hydroxylation polymorphism in Korean subjects.


Increase of cytochrome P450IA2 activity by omeprazole: evidence by the 13C-[N-3-methyl]-caffeine breath test in poor and extensive metabolizers of S-mephenytoin. Omeprazole has been shown to induce cytochrome P450IA1 and P450IA2 activity in vitro. To reflect cytochrome P450IA2 (CYP1A2) activity in vivo, the 13C-[N-3-methyl]-caffeine breath test was conducted in 18 volunteers: 12 extensive metabolizers, one intermediate metabolizer, and five poor metabolizers of S-mephenytoin. Breath tests were performed before treatment with an oral dose of 40 mg omeprazole, on the seventh day of treatment, and after a 7-day washout period. The mean percentage exhalation of the 13C test dose, as determined by 13CO2 in breath during 8 hours, was 23.0% +/- 8.0% (n = 18) before treatment. The largest increases in exhalation rate of 13CO2 were observed in the poor metabolizers and the intermediate metabolizers (range, 12.8% to 62.9%; median, 38.9%); median area under the plasma concentration-time curves (AUC) of omeprazole was four times higher than in the extensive metabolizers. The change after omeprazole treatment in extensive metabolizers ranged from -9.8% to +47.7% (median, 12.3%; n = 12) of pretreatment values. In both groups exhalation rates of 13CO2 returned to near pretreatment values within the 7-day washout period (24.2% +/- 7.8%; n = 17). Changes in the 13C-caffeine breath test correlated well with both the pretreatment value (R = -0.67, p = 0.003; n = 18) and the plasma AUC of omeprazole (R = 0.61, p = 0.007; n = 18). Therapeutic doses of omeprazole seem to induce CYP1A2 activity in poor metabolizers, whereas they exert minor inducing effects in extensive metabolizers of S-mephenytoin.


Pharmacokinetics and pharmacodynamics of ibuprofen isomers and acetaminophen in febrile children. The pharmacokinetics of racemic ibuprofen and its stereoisomers have been described in adults, but little has been reported for children. The pharmacodynamics of acetaminophen and ibuprofen have not been well described in either adults or children. Children (N = 39; age range, 11 months to 11 1/2 years) were randomly selected to receive a single dose of either 6 mg/kg of liquid ibuprofen or 10 to 15 mg/kg of liquid acetaminophen (mean +/- dose given, 11.6 +/- 0.7). Pharmacokinetic and pharmacodynamic analyses were performed with temperature as the effect parameter and mean acetaminophen, total ibuprofen, and ibuprofen stereoisomer concentrations over time. Time of maximum serum concentrations for ibuprofen was 54.05 minutes versus 27.0 minutes for acetaminophen, time to maximum temperature decrease was 183 minutes for ibuprofen and 133 minutes for acetaminophen. Temperature reduction for the ibuprofen dose was significantly different than that of the acetaminophen dose at later time points (240, 300, 360, 420, and 480 minutes). Further pharmacokinetic-pharmacodynamic studies with use of individual ibuprofen stereoisomers and other dosing regimens are indicated.


The relationship between alfentanil distribution kinetics and cardiac output. The relationship between cardiac output and the tissue distribution of alfentanil was investigated in seven healthy volunteers. Subjects were given 10 micrograms/kg alfentanil and 0.5 mg/kg indocyanine green. Arterial blood samples were obtained at baseline, 1 minute, every 1/2 minute until 5 minutes, and then every minute until 15 minutes after the drug injection was begun. Subsequent samples were collected to 6 hours. Cardiac output was measured continuously by use of thoracic bioimpedance. Alfentanil pharmacokinetics were modeled with both a standard three-compartment model and a four-compartmental model based in part on the two-compartmental pharmacokinetics of indocyanine green. The sum of intercompartmental clearances for both the three- and four-compartment models were significantly correlated with the measured cardiac outputs, r = 0.93 and r = 0.88, respectively. These findings indicate that the intercompartmental clearance (i.e., tissue distribution) of alfentanil is largely determined by cardiac output (i.e., tissue blood flow).


A new method for rate of analgesic onset: two doses of intravenous morphine compared with placebo. A new method of frequent early pain assessments for 1 hour only was used to determine time of onset of analgesia after intravenous administration of 10 mg morphine, 5 mg morphine, or placebo in a double-blind study; 79 patients were randomized if they required parenteral analgesia in the early postoperative period. Pain intensity was determined by a four-point categoric verbal rating scale and on a verbal ordinal scale from 0 to 100 (0 = no pain, 100 = worst pain imaginable) during the first hour after analgesic administration. The onset time of analgesia, assessed by 50% of patients achieving 25% reduction from their baseline pain assessment, was significantly faster for 10 mg morphine compared with 5 mg morphine (p = 0.02) and placebo (p less than 0.01). More familiar analgesic efficacy measures, including the sum of pain intensity differences and time to next analgesic dose, similarly showed the superiority of 10 mg morphine to placebo in the first hour, confirming sensitivity according to the conventional paradigm.


The feasibility of studying drug-induced acute hepatitis with use of Medicaid data. To determine the feasibility of the use of Medicaid data to study drug-induced acute liver disease, we reviewed the medical records of 414 patients receiving Medicaid, age 20 or older, with an ICD-9-CM inpatient billing code consistent with acute hepatitis. Of the patients whose records were reviewed, 15.9% were alcoholics, 31.9% had acute hepatitis A or B, 13.5% were intravenous drug users, 8.2% had acute cholecystitis or choledocholithiasis, and 4.1% had received a blood transfusion within the previous 6 months. No diagnosis of liver disease was found in 10.6% of the patients, and 5.7% had chronic liver disease. Of the 169 patients with idiopathic acute liver disease identified, many had very mild liver disease and were hospitalized for reasons other than liver disease. We conclude that Medicaid billing data has high reliability and validity for the diagnosis of acute liver disease. However, primary medical records are essential for the study of drug-induced hepatitis, to be able to exclude other causes of liver disease, and to obtain information not included in the computer data.