Buspirone's efficacy in organic-induced aggression

The objectives of this study were to (1) identify and characterize hospitalized patients with an organic-related psychiatric diagnosis who had received buspirone therapy and (2) assess the effect of buspirone on aggressive behaviors. A retrospective medical records review was conducted on all patients who were admitted to our psychiatric/rehabilitation facility over a 36-month period and who had received buspirone therapy. Monthly behavioral therapy records were used to determine the quality and quantity of aggressive-related behaviors. Study endpoint was reached in each subject when buspirone was discontinued or when records were unavailable. Twenty subjects, ranging in age from 15 to 55 years old (mu = 26.1 +/- 9.8), were identified for study. Nine (90%) of 10 subjects for whom data were available for at least 3 months showed an improvement in behavior by study endpoint, and 6 (60%) showed at least a 50% reduction in behavioral symptoms by study endpoint. Results from this study suggest that buspirone is well tolerated and may be effective in the treatment of aggressive and other maladaptive behaviors in individuals with an organic component to their psychiatric illness, particularly traumatic brain injury. Prospective, controlled trials are needed to validate these findings.

Effect of a clinical psychopharmacy consultation service on patient outcomes

The effect of a psychopharmacy consultation service on outcomes in patients with psychiatric disorders was studied. The medical records of 30 randomly selected patients who had been hospitalized between August 1990 and July 1992 at a private psychiatric institution and who had been seen by the psychopharmacy consultation service during that period were reviewed. Data obtained included (1) patient demographics, (2) patient information generated by the psychopharmacy consultation, (3) the types of recommendations made by the psychopharmacy specialist and whether the recommendations were accepted by the physician, and (4) the clinical outcome. Forty-three psychopharmacy consultations for the 30 patients were evaluated. A total of 125 recommendations were made by the consultation service; of these, 75 (60%) were accepted. The consultations were divided into consultations for which at least a majority of the resulting recommendations were accepted by the physician (n = 29) and consultations for which less than a majority of the recommendations were accepted (n = 14). For the majority group, 23 (79%) of the 29 consultations were associated with a positive outcome, compared with 2 (14%) of the 14 consultations in the less-than-majority group. Similarly, positive outcomes were significantly more frequent in the majority-group patients (16/21 [76%]) than in the less-than-majority-group patients (2/9 [22%]). The frequency of positive outcomes was higher among patients for whom most of the recommendations of a clinical psychopharmacy consultation service were accepted than among patients for whom most recommendations were not accepted.

Phase I trial of subcutaneous recombinant macrophage colony-stimulating factor: clinical and immunomodulatory effects

PURPOSE

Recombinant human macrophage colony-stimulating factor (rM-CSF) has been demonstrated to control the growth, differentiation, and function of mononuclear phagocytes. Preclinical studies have indicated antitumor effects, and therefore a phase I trial of rM-CSF in patients with malignancy was initiated. The toxicity and hematologic and immunologic effects were investigated.

PATIENTS AND METHODS

rM-CSF was administered as a subcutaneous injection on days 1 through 5 and 8 through 12. Cycles were repeated every 28 days. Cohorts of four to seven patients received rM-CSF at dose levels from 0.1 to 25.6 mg/m2/d. Forty-two patients received 88 cycles of rM-CSF. All patients had metastatic solid tumors refractory to standard therapy.

RESULTS

The toxicity of rM-CSF was mild. Dose-limiting toxicity included thrombocytopenia (two patients) and iritis (one patient) occurring at a dose of 25.6 mg/m2/d. Hematologic studies demonstrated dose-related monocytosis occurring routinely at doses > or = 3.2 mg/m2/d, and thrombocytopenia. Immunologic studies demonstrated enhanced secretion of tumor necrosis factor-alpha (TNF-alpha) and interleukin-1-beta (IL-1 beta) by monocytes after in vitro stimulation with lipopolysaccharide, and increased expression of TNF-alpha mRNA at higher rM-CSF dose levels. Pharmacokinetic studies demonstrated that the systemic clearance rate of M-CSF increases during week 1 of therapy, resulting in lower blood levels of M-CSF during the second week of therapy.

CONCLUSION

rM-CSF can be safely administered to patients, and has biologic activity on peripheral-blood monocytes.

Clozapine response and adverse effects in nine brain-injured patients

Clozapine was used to treat nine brain-injured patients with psychotic symptoms or outbursts of rage and aggression refractory to other medications. Verbal and physical aggression decreased markedly in two patients, and one additional patient had a dramatic decrease in bizarre behaviors. Mild improvement occurred in three patients with a decrease in agitation and frequency of auditory hallucinations. Response was indeterminate in three patients because of inadequate length of treatment. The incidence of side effects appeared to be higher than expected, with seizures occurring in two of nine patients. These case reports illustrate that clozapine may be useful in the treatment of psychosis and aggressive behavior after brain injury, despite the occurrence of adverse effects.

Fifteen-cycle cranial electrotherapy stimulation for spasticity

Severe post-anoxic spasticity in a 25-year-old female was significantly improved during an open trial of 15 cycle per second CES. The bipolar LISS device with suboccipital electrode placement was used for 40 minutes three times a day. A synergism appeared when dantrolene 50 mg twice a day was combined with the CES, these additive effects being greater than either modality used alone.

Severe vascular adverse effects with thrombocytopenia and renal failure following emetogenic chemotherapy and ondansetron

During late 1991, a series of severe adverse events involving thrombocytopenia, renal insufficiency and thrombotic episodes was observed in patients receiving emetogenic chemotherapy. Two patients died, one of renal failure and one of cerebral haemorrhage in the presence of thrombocytopenia. Other severe side effects included thrombosis of the aorta causing paraplegia and multifocal cerebral infarctions. Common exposure features included the use of ondansetron and dexamethasone as antiemetics, and in most of the cases high dose (100 mg/M2 or more) cisplatin. Retrospective review of a series of patients treated with similar cytotoxic regimens for similar diseases before the use of ondansetron revealed no similar adverse effects, but no substantial differences were observed in renal function or haematologic toxicity in the two groups overall. Sporadic adverse vascular events have been observed before the use of ondansetron. The mechanism remains unknown, and it is not clear whether ondansetron was a factor in the unusual incidence of such events in the present series.

Intravenous administration of recombinant human macrophage colony-stimulating factor to patients with metastatic cancer: a phase I study

PURPOSE

Recombinant human macrophage colony-stimulating factor (M-CSF) has been shown to stimulate specifically macrophage lineage differentiation in vitro and to induce cells capable of antitumor activity alone or in combination with an antibody. The administration of M-CSF to mice has demonstrated antitumor therapeutic effects in vivo. Therefore, a phase I trial of M-CSF administration to patients with metastatic cancer was undertaken.

PATIENTS AND METHODS

M-CSF was given by intermittent intravenous bolus infusion every 8 hours for 7 days; the treatment cycle was repeated once after a week of rest. Cohorts of three patients underwent dose escalation from 10 to 100,000 micrograms/m2/d; 23 patients received 27 courses of M-CSF administration. All patients had metastatic solid tumors refractory to conventional therapy, including renal cell carcinoma (RCC) (nine), melanoma (seven), and colorectal carcinoma (seven).

RESULTS

Treatment-related toxicity was minimal; five patients developed transient signs of ocular or periorbital inflammation, with iridocyclitis as the most severe manifestation. At the highest doses, platelet counts decreased with therapy (but remained > 100,000/mm3) and the absolute monocyte count increased during the course of therapy. Only at 30,000 and 100,000 micrograms/m2/d was treatment limited because of toxicity (iritis and malaise). Pharmacokinetic studies demonstrated up to a 1,000-fold increase in circulating serum M-CSF after bolus infusion; half-life varied from 1 to 6 hours. Complete regression of mediastinal adenopathy and multiple pulmonary metastases were observed in one patient with RCC.

CONCLUSION

Recombinant M-CSF can be administered safely to patients with metastatic cancer at doses that demonstrate biologic activity.

Hypercholesterolemia after chemotherapy for testis cancer

PURPOSE

The study was designed to determine prospectively the prevalence of fasting serum lipid abnormalities in patients who were treated with cisplatin-based chemotherapy for germ cell tumors. We unexpectedly had demonstrated hypercholesterolemia in 20 of 30 nonfasting patients in a prior study of long-term toxicity of chemotherapy for germ cell tumors. The present study was designed to explore this phenomenon further.

PATIENTS AND METHODS

Seventeen unselected patients with biopsy-proven germ cell tumors, who underwent cisplatin-based chemotherapy and who had no prior history of cardiac disease nor known hypercholesterolemia, were studied. In addition to the standard staging tests, blood was drawn for a pretreatment fasting lipid screen, which included cholesterol, triglycerides, high-density lipoprotein (HDL) cholesterol, and apolipoproteins A1, B, and (a). Repeat samples were drawn 24 hours after the administration of cisplatin and at intervals of 6 to 24 months after the completion of treatment.

RESULTS

Seven of 17 patients (41%) had higher than desirable levels of total serum cholesterol and low-density lipoprotein cholesterol. Two of them had normal levels before treatment, four had preexisting hypercholesterolemia that increased further, and one patient had an elevated pretreatment level that did not alter. Absolute increases in serum cholesterol were noted in 14 of 17 patients. No consistent patterns of change beyond the reference ranges were found for other serum lipids.

CONCLUSIONS

We have confirmed our initial observation that serum cholesterol increases in patients who received cisplatin-containing chemotherapy regimens for germ cell tumors. Further studies will be necessary to define whether other lipid abnormalities occur and the biologic significance of these findings.

Suppression and transient induction of lymphokines in cancer patients after administration of polyethylene glycolated interleukin-2

Polyethylene glycolated (pegylated) interleukin-2 (PEG IL-2) was administered as a weekly i.v. bolus to patients with metastatic cancer in a phase-I trial. Efficacy, toxicity and pharmacokinetics have been described previously. To explore mechanism of IL-2 action and discover predictors of efficacy, the levels of several lymphokines were measured in pharmacokinetic serum samples. IL-1 beta and IL-6 were elevated in many patients before PEG IL-2 administration, forming a continuous, log-normal distribution among patients. The levels of the two lymphokines were strongly correlated. However, no significant correlation could be found between these levels, clinical chemistry, or tumor regression seen after PEG IL-2 administration. Three hours after PEG IL-2 administration, IL-1 beta and IL-6 levels, if elevated, fell to normal. In all patients, independent of initial levels, IL-6 and IFN-gamma, but not IL-1 beta, increased 4 to 6 h after the injection and then fell rapidly, even though PEG IL-2 levels were high and often changed only slightly during this period. This suggests an active shut down of lymphokine synthesis, or an increase in elimination rate. After the fourth administration of PEG IL-2, the peak level of IFN-gamma was 2 to 20 times higher than after the first, while the peak level of IL-6 did not change in a consistent direction. Responding patients had typical peak levels of IL-6 and IFN-gamma. Low levels of TNF and IL-4 were occasionally seen before and after PEG IL-2 administration, but no consistent pattern was evident.

A phase I trial of recombinant human macrophage colony-stimulating factor by rapid intravenous infusion in patients with refractory malignancy

Twenty patients with advanced cancer for which there was no effective standard therapy or whose disease was refractory to standard therapy were treated with recombinant macrophage colony-stimulating factor (rM-CSF). The rM-CSF was administered by intravenous bolus infusion for 5 consecutive days every other week for 2 treatment weeks. The doses administered ranged from 30 to 33,000 micrograms/m2/day. There was no intrapatient dose escalation. There were minimal to no systemic side effects seen, except for acute dyspnea noted in three patients. The dyspnea was felt to be related to the rate of infusion and did not recur in one patient given additional rM-CSF at a slower infusion rate. The major hematologic effect seen was a mild decrease in platelet count, which began to recover while the patients continued to receive the rM-CSF. The clearance of rM-CSF was dose dependent. Lower doses resulted in a saturable mechanism felt to represent cellular uptake. Clearance at higher doses demonstrated both a first-order mechanism at high serum rM-CSF concentrations, representing renal clearance, as well as a saturable mechanism at low serum concentrations. The maximum mean serum half-life was reached at dose levels of greater than or equal to 3,690 micrograms/m2 and was in the range of 234-258 min. By this route of administration, rises in absolute monocyte count were slight and seen only at doses of greater than or equal to 450 micrograms/m2 during the second therapy week. The maximum tolerated dose was not reached in this study because of lack of availability of rM-CSF.

The PLEXUS parameters: results of the 'PLEXUS conference'

Presentations by experts at an international conference on coma and persistent vegetative state (PVS) identified 32 parameters of varying prognostic significance that can be determined in this patient population. These parameters are tabulated for heuristic purposes and to summarize a portion of the information exchanged at this conference.

Ganser syndrome and its management

The literature on the Ganser syndrome is reviewed, and a case history is described. A brief hospital admission is worthwhile for patients with this syndrome, but planning and persuasion are needed.

Naltrexone in organic bulimia: a preliminary report

Multiple lines of experimental evidence point to the involvement of endogenous opiates in appetite regulation. Post brain injury patients often exhibit driven eating behaviour. Since this problem fails to respond to behaviour modification, appetite suppressants, lithium, or any other usual approach, the use of the oral narcotic antagonist, Naltrexone, was given to three such patients. Naltrexone binds multiple opiate receptor sites in the hypothalamus, including the kappa receptors which have been implicated in appetite regulation, the use of this narcotic antagonist in hypothalamic hyperphagia appears to be a rational approach to this intractable problem. In this open trial, lasting from 4 1/2 to 9 months, the minimal effective dose appeared to be in the range of 100 mg per day. No side-effects (for example elevations in liver enzymes) were noted. All of the patients had an improved sense of well-being and their behaviours were less difficult to manage when on the Naltrexone. The significance of this preliminary trial is that narcotic antagonists may have a role in the treatment of brain-injured patients with bulimia. Also, Naltrexone may be useful in treating other maladaptive behavioural consequences of head trauma such as stealing, manipulation, demandingness, and depression. Likewise, the effects on the deranged endocrine system, such as the hypogonadism, are significant and deserve further exploration.

The development of anti-interleukin-2 antibodies in patients treated with recombinant human interleukin-2 (IL-2)

Approximately 65% (11/17) of cancer patients participating in an ongoing Phase I clinical trial with recombinant interleukin-2 developed nonneutralizing serum IgG anti-interleukin-2 antibodies within 1 month of initiating therapy. These antibodies could be detected using any of several standard techniques including immunoblots and enzyme-linked immunosorbent assays. Western blot analysis and retention experiments with protein A-Sepharose indicate that the antibodies are specific for interleukin-2. The interleukin-2 mutein utilized in this clinical trial (des-ala-ser125 r-IL-2) differs from the major species of the human T cell-derived lymphokine in that it lacks the N-terminal alanine of the native molecule, is not glycosylated, and possesses a serine-cysteine substitution at position 125. Another recombinant interleukin-2, identical to the mutein except that it retains the cysteine at position 125 (des-ala-cys125 r-IL-2), strongly competes with the mutein in competitive enzyme-linked immunosorbent assays, suggesting that the amino acid substitution is not responsible for the recognition of the molecule by serum antibodies. Conversely, nonrecombinant T cell-derived interleukin-2 fails to compete in these assays and is not retained by protein A-Sepharose columns when mixed with high-titer antiserum. These results suggest that the anti-interleukin-2 serum antibodies generated in the course of treatment do not react with the nonrecombinant lymphokine but recognize epitopes peculiar to recombinant forms which are not dependent on the amino acid substitution at position 125. The failure of the antibodies to neutralize the biological activity of recombinant interleukin-2 (IL-2) in lymphocyte proliferation assays and to bind to the native lymphokine suggests that they may not affect IL-2-dependent cellular immune functions in vivo.

Effect of posture on vital capacity

The influence of some extreme body postures on vital capacity (VC) was examined in young adult humans. Two postures required full support of body weight by the arms: arms up, hanging from a bar, and arms down with hands gripping parallel bars. Three involved muscles that flex and extend the trunk: a partial sit-up position while supine and nearly maximal spinal extension and flexion while standing. Changes at the inspiratory and expiratory volume extremes were recognized by having the subjects do two VC efforts: the first standing and the second in the posture in question while continuing to breathe on the spirometer. Control observations in which the second of a VC pair was performed in an unstressed posture allowed correction for the influence of rebreathing. The changes in corrected VC were small, the greatest being an average reduction of approximately 8% in the partial sit-up position. During full support of body weight by the arms, the VC was slightly increased due to a significant increase in the inspiratory extreme and no change in the expiratory extreme. Spinal extension produced small increases in lung volume at both extremes with no significant change in VC, whereas spinal flexion did not influence the upper extreme but did increase lung volume at the lower extreme. The changes are discussed in terms of trunk muscle action.

Scopolamine effects in vestibular defensiveness

Disturbed vestibular function secondary to brain stem injury may result in postural gravitational insecurity, and aversion reactions or intolerance to movement. The Transderm scopolamine disc was applied in a double-blind, placebo-controlled study of five post-head-injury patients who underwent provocative vestibular stimulation such as turning in a wheelchair, head shaking, and the log roll. Four of the patients showed improvement in exquisite sensitivity to rotational movement. A surprise finding of improved truncal stability in two of the more severely injured patients indicates a potential usefulness of the scopolamine patch for patients with truncal ataxia.

Thermal denaturation of alpha 1-protease inhibitor. Stabilization by neutral salts and sugars

Alpha 1-protease inhibitor (alpha 1 PI), also called alpha 1-antitrypsin, may be useful for replacement therapy in a number of chronic or acute disorders. The risk associated with the possible presence of hepatitis virus can be greatly reduced by pasteurization at 60 degrees C for 10 h. A series of thermal denaturation profiles was obtained in the presence of various protein stabilizers using the increase in 1,8-anilinonaphthalene sulfonate fluorescence that accompanies protein denaturation. A parallel series of experiments was conducted to evaluate each additive for its capacity to protect the biological activity of alpha 1 PI. As much as 92% of the inhibitory activity against elastase and trypsin could be recovered after pasteurization in buffer containing citrate (1.2 M) and either EDTA (0.5 M) or gluconate (1.2 M). Loss of activity was not affected by protein concentration. In conclusion, conditions have been developed to protect the bulk of alpha 1 PI from denaturation during pasteurization, and this should give an added impetus to efforts to test the efficacy of this protein in various clinical conditions.