Coccidiosis control by administering toltrazuril in the drinking water for a 2-day period

A 56-day floor pen study was conducted to determine the appropriate time to administer toltrazuril (Baycox) (TOL) for control of coccidiosis in broiler chickens. Litter was seeded with field strains of Eimeria acervulina, Eimeria maxima and Eimeria tenella. On Days 0, 21, 35 and 56, all birds and feed were weighed. Starting on Day 14, weekly lesion scores and oocyst counts were performed. The treatments were 125 ppm nicarb (NIC) in the starter to 66 ppm salinomycin (SAL) in the grower with no TOL (NIC/SAL/no TOL), 66 ppm salinomycin in both the starter and the grower but no TOL (SAL/SAL/no TOL), or no in-feed medication with the following TOL treatment: TOL Days 2-3, TOL Days 6-7, TOL Days 10-11, TOL Days 14-15, TOL Days 18-19, and as control NM/NM/no TOL (NM). The withdrawal feed was nonmedicated. TOL was administered in the drinking water at the rate of 7 mg/kg body weight. Oocysts per gram litter and lesion scores showed a significant infection in the NM birds, which peaked about Day 21. The NIC/SAL gave excellent early protection but only moderate protection during the SAL phase. The final performance for the SAL/SAL was significantly less compared to all TOL and NIC/SAL birds. All TOL treatments but Days 2-3 provided good coccidiosis control with accompanying performance. The absence of clinical coccidiosis relapse during the last third of the growout along with moderate oocyst counts and low lesions was indicative of unimpaired coccidiosis immunity. It can be inferred from the overall results that the use of TOL as the sole anticoccidial for two consecutive days in the drinking water between Days 10 and 14 would be the best time for good coccidiosis control allowing full performance.

Coccidiosis control with toltrazuril in conjunction with anticoccidial medicated or nonmedicated feed

A 42-day broiler floor pen study was conducted comparing the anticoccidial efficacy of toltrazuril (Baycox) as a stand alone treatment and as an additional treatment to in-feed anticoccidial programs. Toltrazuril was administered on days 18 and 19 in the drinking water at 7 mg/kg of body weight. The treatments were 125 ppm nicarbazin (days 0-14) to 66 ppm salinomycin (SAL) (days 15-35) with and without toltrazuril, SAL (days 0-35) with and without toltrazuril, nonmedicated (NM) to SAL with toltrazuril, and NM with and without toltrazuril. The controls were NM noninfected and infected. The treatments were replicated in five blocks of eight pens each in a randomized complete block design. All withdrawal feed was nonmedicated. On day 14, birds, except noninfected, were exposed to coccidial oocysts (Eimeria acervulina, Eimeria maxima, and Eimeria tenella) seeded litter. On days 21, 28, 35, and 42, birds and feed were weighed, four birds per pen were coccidial lesion scored, and litter oocyst counts were performed. The coccidial infection in the NM infected treatment caused a significant (P < 0.05) coccidiosis infection. Coccidiosis was moderately controlled in the anticoccidial treatment birds without toltrazuril. Performance in the NM with toltrazuril was equal to or better (P < 0.05) than the anticoccidial programs without toltrazuril. Toltrazuril was equal to the noninfected birds in performance. Toltrazuril most completely eliminated all coccidial lesions and dramatically reduced oocyst shedding. The performance data, lesion scores, and oocyst counts showed that a 2-day treatment with toltrazuril successfully controlled the coccidiosis with no relapse of infection. Toltrazuril can thus be used for supplemental control with in-feed anticoccidials or as a primary anticoccidial with nonmedicated feed.

Randomized controlled trial of EUS-guided fine needle aspiration techniques for the detection of malignant lymphadenopathy

BACKGROUND

EUS-guided fine needle aspiration (EUS-FNA) is a highly accurate method of detecting malignant lymphadenopathy. The optimal methods for performing EUS-FNA to maximize sensitivity and to minimize the number of needle passes necessary are unknown. This is a report of the results of a prospective randomized controlled trial to determine the effect of suction, the site of FNA (edge or center of lymph node), and the method of preparation of cytologic specimens on accuracy, number of needle passes needed, and specimen quality.

METHODS

Consecutive patients with lymphadenopathy detected by EUS underwent FNA. Each lymph node was sampled with or without suction and from the edge or center in a 2 x 2 factorial design. The samples were expressed onto slides for cytology, and the residual material in the needle was analyzed by the cytospin-cellblock technique. Each aspirate was individually characterized for a diagnosis of malignancy, cellularity, and bloodiness.

RESULTS

Forty-three patients with a total of 46 lymph nodes were evaluated. The final lymph node diagnosis was benign in 22 (48%), "suspicious for malignancy" in 6 (13%), and malignant in 18 (39%). The use of suction was associated with an increase in the cellularity of the specimen, but did not improve the likelihood of obtaining a correct diagnosis (OR 1.52: 95% CI [0.81, 2.85]). Samples obtained with suction were of worse quality because of excessive bloodiness (OR 4.7: 95% CI [1.99, 11.24]). Aspiration from the edge of the lymph node (compared with the center) did not increase the likelihood of a correct diagnosis (OR 1.16: 95% CI [0.42, 3.21]). For 78% of malignant lymph nodes, the correct diagnosis was obtained on the first needle pass and for 100% by the third pass. Cytospin-cellblock methods did not add any additional diagnostic information compared with direct smear cytology.

CONCLUSIONS

The traditional method of applying suction during EUS-FNA does not improve diagnostic accuracy and worsens specimen bloodiness compared with FNA without suction. The site of FNA within the lymph node does not affect accuracy. When EUS-FNA is necessary, our recommendation is up to 3 FNAs without suction from the most convenient and safe location within abnormal-appearing lymph nodes.

Surgical resection is necessary to maximize tumor control in function-preserving, aggressive chemoradiation protocols for advanced squamous cancer of the head and neck (stage III and IV)

BACKGROUND

The role of surgery in aggressive chemoradiation protocols for advanced head and neck cancer has been questioned because of the quoted high clinical response rates in many series.

METHODS

The role of surgical resection was examined in an aggressive neoadjuvant protocol of weekly paclitaxel, carboplatin, and radiation for stage III and IV with completion of radiation to 72 Gy if biopsy at the primary site was negative after administration of 45 Gy. Of 43 patients enrolled, 38 completed the protocol. The clinical response was 100% (including 18 complete and 20 partial responses).

RESULTS

The complete pathologic response (negative primary site biopsy at 45 Gy) was 25 of 38 (66%). Of patients who presented with N1 to N3 nodes, neck dissection revealed residual nodal metastases in 22%. Surgical resection of the primary site was required in 13 patients, including 5 with larynx cancer and 2 with base of tongue cancers. Four patients had resection with reconstruction for advanced mandible floor of mouth cancer, and one had resection of nasal-maxillary cancer. Functional resection was performed in 9 of 12 patients. The median progression free and overall survival was 64% and 68%, respectively, at median follow-up of 50 months. Nine patients developed recurrence (three local and six distant). There were no failures in the neck. Salvage surgery was performed in one patient with local and one with distant disease.

CONCLUSIONS

Surgical resection is an essential component of aggressive chemoradiation protocols to ensure tumor control at the primary site and in the neck.

Safety of ponazuril 15% oral paste in horses

Ponazuril, a triazine-derivative compound, is proposed as a treatment for equine protozoal myeloencephalitis caused by Sarcocystis neurona. Ponazuril 15% oral paste was administered to 24 horses at 0, 10, or 30 mg/kg body weight for either 28 or 56 days, representing zero, two, and six times the proposed dosage rate and one and two times the recommended duration of treatment, respectively. Serum chemistry analysis, coagulation profile, and hematology measurements were performed weekly and necropsy evaluations, including histopathology, were conducted for all animals at the end of the study. Minimal reactions were noted during the treatment period. Soft stools were observed in four of 16 treated horses and three of eight control animals. Serum blood urea nitrogen levels increased and serum sodium levels decreased in horses receiving 10 mg/kg; however, these changes were not associated with number of days on treatment and no value for either variable was outside the normal reference range. No signs of colic were observed in any treated animal during the study. At necropsy, uterine edema was noted in three of the four mares treated with ponazuril at 30 mg/kg. No other treatment-related postmortem or histologic abnormalities were identified in any of the horses. These findings suggest that ponazuril has minimal toxic potential when dosed at levels up to six times the recommended clinical dosage and for one or two times longer than the recommended duration.

Cerebrospinal fluid and serum concentrations of ponazuril in horses

Ponazuril was administered orally to 10 adult horses at 5 mg/kg body weight, once a day for 28 days. Blood was collected once a week from each horse from Days 0 through 35, daily from Days 35 through 42, and on Day 49. Cerebrospinal fluid (CSF) was also collected once a week from Day 0 through Day 49. Concentrations of ponazuril in the serum and CSF were determined, and pharmacokinetic calculations were performed. Ponazuril was readily absorbed following oral administration; and after 7 days of dosing, the serum concentration was 4.33 +/- 1.10 mg/L, and the mean CSF concentration was 0.162 +/- 0.05 mg/L. Cerebrospinal fluid concentration did not vary during the 28 days of dosing and concentrations declined rapidly after cessation of administration on Day 28. The terminal elimination half-life ofponazuril in serum (using Day 28 to 42 results) was 4.3 +/- 0.6 days. Repeated CSF collections from the atlanto-occipital space did not induce changes in the immunoglobulin G index or albumin quotient. It was concluded that oral administration of ponazuril to healthy horses at 5 mg/kg provided concentrations of ponazuril in the CSF that are presumed to be adequate for the treatment of equine protozoal myeloencephalitis (EPM). These results indicate that this dosage rate should be investigated for efficacy against EPM.

Efficacy of ponazuril 15% oral paste as a treatment for equine protozoal myeloencephalitis

Equine protozoal myeloencephalitis (EPM) is a neurologic disease of horses most commonly caused by the protozoan parasite Sarcocystis neurona. Until recently the only treatment option was the combination of a sulfonamide with pyrimethamine. The present study was performed to assess the efficacy of ponazuril, an anticoccidial triazine-based compound, as a treatment for naturally occurring EPM. One hundred one horses with EPM were randomly allocated to treatment with ponazuril 15% oral paste at either 5 or 10 mg/kg body weight for 28 consecutive days. Horses were evaluated clinically and by analysis of blood and cerebrospinal fluid (CSF) before and 28 and 118 days after the start of treatment. Clinical success was defined as either an improvement in neurologic score by at least one grade (on a 0 to 5 scale) or conversion to negative status on Western blot for S. neurona antibodies by 90 days following cessation of treatment. Overall, 62% of the horses, including 28 of 47 treated with ponazuril at 5 mg/kg and 35 of 54 treated with 10 mg/kg, met the criteria for successful treatment. The Western blot for CSF became negative in 10% (10/101) of the horses. Quantification of the anti-17kDa antibody response in Western blot (relative quantity CSF) did not reveal a significant change in response to treatment. However, immunoglobulin index did decrease significantly during treatment (P = .01). The findings of this study support the efficacy of ponazuril for the treatment of EPM.

The prevalence of gastro-oesophageal reflux symptoms in a UK population and the consultation behaviour of patients with these symptoms

BACKGROUND

Patients consulting with gastro-oesophageal reflux symptoms (GORS) may differ from nonconsulters.

AIM

To describe these differences in a UK population.

METHODS

A postal questionnaire was sent to 4432 adults. Definitions used were GORS (either heartburn or acid regurgitation on more than six occasions during the previous year), dyspepsia (upper abdominal pain or discomfort on more than six occasions during the previous year) and irritable bowel syndrome (abdominal pain with three or more Manning criteria). Socio-economic status was identified by the Standard Occupational Classification.

RESULTS

With a 71.7% response, GORS were reported by 28.7% of the sample, it was unaffected by gender and age but was more common among the socially disadvantaged (P < 0. 005). Less than 25% of GORS patients consulted during the previous year. Increasing age (chi2 for trend; P < 0.001) and coexisting upper abdominal symptoms (chi2 P < 0.001) positively influenced consultation behaviour, but it was unaffected by socio-economic status, gender, or the coexistence of irritable bowel syndrome. Dyspepsia and nausea independently predicted consultation.

CONCLUSIONS

GORS are especially common among the deprived. Socio-economic variables do not affect consultation behaviour, but the patient's age and the burden (number and type) of associated symptoms do.

The long-term effects of non-steroidal anti-inflammatory drugs in osteoarthritis of the knee: a randomized placebo-controlled trial

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat osteoarthritis (OA), though their long-term efficacy is uncertain. We report a comparison of the symptomatic responses to therapy with tiaprofenic acid, indomethacin and placebo over 5 yr.

METHODS

A parallel-group, randomized, single-blind trial of patients with knee OA recruited 812 patients from 20 centres; 307 patients received tiaprofenic acid (300 mg b.d.), 202 indomethacin (25 mg t.d.s.) and 303 matching placebo for up to 5 yr. At the end of the parallel-group study, patients receiving tiaprofenic acid or placebo entered a 4-week blinded cross-over study of tiaprofenic acid or placebo, both given for 2 weeks. Assessments were at baseline, 4 weeks, then at 6-month intervals for up to 5 yr in the parallel group study and at 2-week intervals in the cross-over study. They comprised pain scores, duration of morning stiffness, patients' global assessments, paracetamol consumption, adverse reactions, withdrawals and functional outcomes.

RESULTS

There were significant falls in overall pain scores in patients receiving NSAIDs compared with placebo at 4 weeks in the parallel-group phase. Thereafter there were no advantages favouring active therapy. In the cross-over phase, pain scores were significantly lower in patients receiving tiaprofenic acid than placebo. Patients who had been receiving long-term tiaprofenic acid showed significant rises in their pain scores when receiving placebo therapy and vice versa. Adverse events were reported by 61% of patients receiving tiaprofenic acid, 63% on indomethacin and 51% on placebo. Potentially severe side-effects were rare; for example, there were only three cases of gastrointestinal bleeding on NSAIDs. The pattern of withdrawal was similar in patients taking NSAIDs and placebo in the parallel-group study; at 48 weeks 53% of the patients remained on tiaprofenic acid, 50% on indomethacin and 54% on placebo.

CONCLUSIONS

NSAIDs significantly reduce overall pain over 4 weeks. This short-term responsiveness is retained, and even after several years of therapy with tiaprofenic acid pain scores increased over 2 weeks when it was changed to placebo. Our results do not show long-term benefits from the use of NSAIDs in OA and the majority of patients had persisting pain and disability despite therapy.

Cerebrospinal fluid and blood concentrations of toltrazuril 5% suspension in the horse after oral dosing

Toltrazuril 5% suspension (Baycox, Bayer Canada, Ontario, Canada) was administered to six adult horses followed by blood collection and assay to determine the concentration of toltrazuril and its principal metabolites, toltrazuril sulfone and toltrazuril sulfoxide. From this data, the maximum concentration (C(max)), elimination half-life (T 1/2), and mean residence times of the plasma were determined from standard pharmacokinetic formulas. After a single oral dose of 10 mg/kg body weight a rapid absorption was found, with a mean peak serum concentration of 11.17 mg/L at 18 hours. Elimination was prolonged, with a mean T 1/2 for elimination of 61.4 hours. In addition, toltrazuril was administered to nine horses, and blood serum and cerebrospinal fluid (CSF) concentrations of toltrazuril and its principal metabolites were determined. Horses were randomly assigned to one of three treatment groups and received either 2.5 mg/kg body weight (Group A), 5.0 mg/kg body weight (Group B), or 7.5 mg/kg body weight (Group C) orally, once daily, for 10 days. Jugular venous blood was collected routinely on treatment days 2, 6, and 10, and CSF was collected on treatment day 10. Assay of toltrazuril and its metabolites revealed a dose-dependent effect within both the blood and CSF compartments. Mean concentrations within the CSF after 10 days of treatment were 0.146 mg/L in Group A, 0.190 mg/L in Group B, and 0.386 mg/L in Group C. Toltrazuril sulfone was the primary metabolite after 10 days of treatment, with concentrations that ranged from 39% to 116% of the parent drug in individual animals. Toltrazuril sulfone was also the predominant metabolite in the serum at treatment day 10; however, it did not always exceed the concentration of toltrazuril sulfoxide in the serum on treatment day 2. In the serum, drug concentrations at treatment day 2 were variable in the low-dose group (Group A), ranging from 4.0 to 11.61 mg/L; less variable in the high-dose group (Group C), ranging from 9.9 to 10.46 mg/L; and intermediate in Group B. This study confirms that toltrazuril is absorbed in the horse after oral administration and reaches effective in vitro concentrations within the CSF of the horse after once-daily dosing of 5 or 7.5 mg/kg. Although these data suggest that toltrazuril may have clinical value in the treatment of equine protozoal myeloencephalitis, clinical efficacy remains to be confirmed using appropriate methods. Effective in vitro concentrations are known; however, therapeutic concentrations in vivo have not been established. Further research in this area is needed to determine various drug values in the CSF (e.g., half-life, C(max), time to reach steady state).

A 10-day toxicity study of toltrazuril 5% suspension in the horse

Equine protozoal myeloencephalitis (EPM) is a serious disorder of the nervous system of horses caused by Sarcocystis neurona. Recently, toltrazuril has begun to be used for treatment of EPM. The purpose of this study was to evaluate the potential toxicity of toltrazuril in horses when administered at a dose of 50 mg/kg for 10 days. Five horses were given 50 mg/kg of toltrazuril once daily for 10 days by nasogastric tube. Complete blood cell counts, serum chemistry values, and coagulation panels were evaluated before and after treatment; then a full postmortem examination was completed on day 11. Results of the study show that only mild clinical signs (i.e., anorexia, weight loss, and colic in one of the five horses) were observed after treatment. Minimal changes were noted in the serum chemistry analysis (i.e., increased bilirubin and serum protein, mildly increased hematocrit and hemoglobin concentration, and mildly increased albumin). Renal medullary congestion was noted on gross postmortem examination; however, no microscopic changes due to compound administration were noted in the kidneys or other tissue. Results of this study suggest that administration of toltrazuril at 50 mg/kg (5x to 10x anticipated clinical dosage) for 10 days resulted in only mild clinical abnormalities.

Multiinstitutional phase II trial of paclitaxel, carboplatin, and concurrent radiation therapy for locally advanced non-small-cell lung cancer

PURPOSE

Combined modality therapy for non-small-cell lung cancer (NSCLC) has produced promising results. A multiinstitutional phase II clinical trial was conducted to evaluate the activity and toxicity of paclitaxel, carboplatin, and concurrent radiation therapy on patients with locally advanced NSCLC.

PATIENTS AND METHODS

Forty previously untreated patients with inoperable locally advanced NSCLC entered onto a phase II study from March 1995 to December 1996. On an outpatient basis for 7 weeks, patients received paclitaxel 50 mg/m2 weekly over 1 hour; carboplatin at (area under the curve) AUC 2 weekly; and radiation therapy of 66 Gy in 33 fractions. After chemoradiation therapy, patients received an additional two cycles of paclitaxel 200 mg/m2 over 3 hours and carboplatin at AUC 6 every 3 weeks.

RESULTS

Thirty-nine patients were eligible for the study. The survival rates at 12 months were 56.3%, and at 24 months, 38.3%, with a median overall survival of 20.5 months. The progression-free survival rates at 12 months were 43.6%, and at 24 months, 34.7%, with a median progression-free survival of 9.0 months. Two patients did not receive more than 2 weeks of concurrent chemoradiotherapy and were not assessable for toxicity and response. The overall response rate (partial plus complete response) of 37 assessable patients was 75.7%. The major toxicity was esophagitis. Seventeen patients (46%) developed grade 3 or 4 esophagitis. However, only two patients developed late esophageal toxicity with stricture at 3 and 6 months posttreatment.

CONCLUSION

Combined modality therapy with paclitaxel, carboplatin, and radiation is a promising treatment for locally advanced NSCLC that has a high response rate and acceptable toxicity and survival rates. A randomized trial will be necessary to fully evaluate the usefulness of these findings.

Copper-dependent inflammation and nuclear factor-kappaB activation by particulate air pollution

Particulate air pollution causes increased cardiopulmonary morbidity and mortality, but the chemical determinants responsible for its biologic effects are not understood. We studied the effect of total suspended particulates collected in Provo, Utah, an area where an increase in respiratory symptoms in relation to levels of particulate pollution has been well documented. Provo particulates caused cytokine-induced neutrophil chemoattractant-dependent inflammation of rat lungs. Provo particulates stimulated interleukin-6 (IL-6) and IL-8 production, increased IL-8 messenger RNA (mRNA) and enhanced expression of intercellular adhesion molecule-1 (ICAM-1) in cultured BEAS-2B cells, and stimulated IL-8 secretion in primary cultures of human bronchial epithelium. Cytokine secretion was preceded by activation of the transcription factor nuclear factor-kappaB (NF-kappaB) and was reduced by treatment of cultures with superoxide dismutase, deferoxamine, or N-acetylcysteine. These biologic effects were replicated by culturing BEAS cells with quantities of Cu2+ found in Provo extract. IL-8 secretion by BEAS cells could be modified by addition of normal constituents of airway lining fluid to the culture medium. Mucin significantly reduced IL-8 secretion, and ceruloplasmin significantly increased IL-8 secretion and activation of NF-kappaB. These findings suggest that copper ions may cause some of the biologic effects of inhaled particulate air pollution in the Provo region of the United States, and may provide an explanation for the sensitivity of asthmatic individuals to Provo particulates that has been observed in epidemiologic studies.

Localization of bronchial intraepithelial neoplastic lesions by fluorescence bronchoscopy

BACKGROUND

In the treatment of lung cancer, the best outcome is achieved when the lesion is discovered in the intraepithelial (preinvasive) stage. However, intraepithelial neoplastic lesions are difficult to localize by conventional white-light bronchoscopy (WLB).

OBJECTIVE

To determine if autofluorescence bronchoscopy, when used as an adjunct to WLB, could improve the bronchoscopist's ability to locate and remove biopsy specimens from areas suspicious of intraepithelial neoplasia as compared with WLB alone.

METHOD

A multicenter clinical trial was conducted in seven institutions in the United States and Canada. WLB followed by fluorescence examination with the light-induced fluorescence endoscopy (LIFE) device was performed in 173 subjects known or suspected to have lung cancer. Biopsy specimens were taken from all areas suspicious of moderate dysplasia or worse on WLB and/or LIFE examination. In addition, random biopsy specimens were also taken from other parts of the bronchial tree.

RESULTS

The relative sensitivity of WLB + LIFE vs WLB alone was 6.3 for intraepithelial neoplastic lesions and 2.71 when invasive carcinomas were also included. The positive predictive value was 0.33 and 0.39 and the negative predictive value was 0.89 and 0.83, respectively, for WLB+LIFE and WLB alone.

CONCLUSION

Autofluorescence bronchoscopy, when used as an adjunct to standard WLB, enhances the bronchoscopist's ability to localize small neoplastic lesions, especially intraepithelial lesions that may have significant implication in the management of lung cancer in the future.

Widely dispersed p53 mutation in respiratory epithelium. A novel mechanism for field carcinogenesis

Individuals with one aerodigestive tract malignancy have a high incidence of second primary aerodigestive tumors. The mechanism for this field effect has not been determined. We studied an individual with widespread dysplastic changes in the respiratory epithelium but no overt carcinoma. The entire tracheobronchial tree obtained at autopsy was embedded in paraffin, and bronchial epithelial cells were isolated by microdissection. DNA extracted from the microdissected cells was analyzed for point mutations in the p53 tumor suppressor gene. A single, identical point mutation consisting of a G:C to T:A transversion in codon 245 was identified in bronchial epithelium from 7 of 10 sites in both lungs. Epithelium at sites containing the p53 mutation was morphologically abnormal, exhibiting squamous metaplasia and mild to moderate atypia. No invasive tumor was found in the tracheobronchial tree or any other location. Cells from peripheral blood, kidney, liver, and lymph node exhibited no abnormality in the p53 gene. The widespread presence of a single somatic p53 point mutation in the bronchi of a smoker suggests that a single progenitor bronchial epithelial clone may expand to populate broad areas of the bronchial mucosa-a novel mechanism for field carcinogenesis in the respiratory epithelium that may be of importance in assessing individuals for risk of a second primary tumor as well as in devising effective strategies for chemoprevention of lung cancer.

Selective O-desulfation produces nonanticoagulant heparin that retains pharmacological activity in the lung

Heparin has potential use as an antiinflammatory treatment in many lung diseases but its therapeutic use is limited by inherent anticoagulant activity. The anticoagulant nature of heparin can be eliminated by a number of chemical treatments, but often not without loss of other important pharmacological activities. Lyophilization of porcine mucosal heparin under extreme alkaline conditions (pH > or = 13) produces a nonanticoagulant heparin remarkable for the selective loss of only 2-O and 3-O sulfates, leaving 6-O and N-sulfates intact. In contrast to the commonly used nonanticoagulant analog N-desulfated, N-reacetylated heparin, selectively O-desulfated heparin retains potent activity as an inhibitor of the cationic neutrophil proteases human leukocyte elastase and cathepsin G, both in vitro and in vivo. Selectively O-desulfated heparin also inhibits complement lysis of erythrocytes, prevents ischemia-reperfusion injury of the lung, remains a potent antiproliferative treatment for cultured airway smooth muscle and normalizes altered neuronal M2 muscarinic receptor sensitivity and bronchial hyperreactivity after antigen challenge. These retained pharmacologic properties suggest possible use of this new nonanticoagulant heparin for the treatment of a variety of lung disorders.

Homozygous deletions of human chromosome 3p in lung tumors

Cytogenetic and loss of heterozygosity (LOH) studies have demonstrated that deletions of chromosome 3p occur at a high frequency in all forms of lung cancer. To clarify the role of 3p in lung tumorigenesis and to more precisely identify targets for positional cloning efforts, we have performed 3p deletion analyses (microsatellite and fluorescence in situ hybridization) in a series of lung cancer cell lines and uncultured tumor samples. Importantly, we identified homozygous deletions in four uncultured tumors and one cell line. Homozygous deletions were found in three squamous tumors within a region of 3p21 which had previously been described only in cell lines, a 1-2-megabase homozygous deletion in a small cell tumor at 3p12, and a 3p14.2 homozygous deletion in a non-small cell lung carcinoma cell line. The detection of homozygous deletions affecting these multiple regions in uncultured tumor cells substantiates the belief (previously based on deletions found only in tumor cell lines) that these sites contain important tumor suppressor genes. Along with previously reported homozygous deletions in a distal portion of 3p21.3, we now have evidence for four separate regions of 3p which undergo homozygous deletions in either uncultured lung tumors or cell lines.

Phase II study of 5-fluoruracil leucovorin and azidothymidine in patients with metastatic colorectal cancer

The primary objective of this study was to determine the response rate of patients with metastatic colorectal cancer to combined therapy with 5-fluorouracil (5-FU), leucovorin, and intravenous azidothymidine (AZT), a thymidine nucleoside analog. By itself, AZT has limited antineoplastic efficacy. However, experimental studies indicate that 5-FU enhances the antitumor activity of AZT by inhibiting synthesis of normal thymidine nucleotides with which AZT competes for incorporation into nucleic acids. A phase I study defined the maximum tolerated dose of AZT as 7 g/m2 with hypotension during the infusion being the dose-limiting toxicity. A phase II study was performed with oral leucovorin (100 mg p.o. hourly for 4 h prior to 5-FU and 4 h and 8 h after 5-FU), bolus 5-FU (400 mg/m2) followed 1 h later by a 2-h infusion of AZT (7 g/m2). Treatment was given weekly for 4 weeks followed by a 1-week break, which constituted a cycle of therapy. Responses were evaluated after every two cycles. Patients continued on therapy as long as they tolerated treatment and did not have progressive disease. Of 15 evaluable patients who had received no chemotherapy there was 1 complete response and 4 partial responses (a 33% response rate), whereas only 1 of 6 patients who had received prior adjuvant chemotherapy had a partial response (17%). An additional 10 patients had stable disease lasting 2-14 months. Therapy was well tolerated with the only one instance each of grade 3 nausea and vomiting, diarrhea, anemia, and hypotension. Approximately 50% of treatments were accompanied by mild hypotension, which was easily corrected by increasing the rate of normal saline infusion. There was no difficulty administering this regimen in the outpatient setting. While the overall response rate (29%) is comparable to that seen with combinations of 5-FU and leucovorin alone, in most reported series a considerably higher dose of 5-FU was utilized than in this study. Since patients in the present study experienced relatively little 5-FU toxicity, increasing the dose of 5-FU in this regimen would appear to be feasible and might result in a higher response rate.

Expansion of bronchial epithelial cell populations by in vitro culture of explants from dysplastic and histologically normal sites

The genetic and phenotypic properties of cells which ultimately give rise to carcinoma of the lung are not well defined in part because of unavailability of preneoplastic cells from well-characterized dysplastic sites. In order to expand bronchial epithelial cell populations from patients at high risk for lung cancer, endobronchial biopsy specimens were explanted onto collagen- and fibronectin-coated dishes and cultured in serum-free, chemically defined media. One hundred forty-nine biopsy pairs were obtained from smokers and from healthy volunteers for culture and histologic evaluation. The histologic appearances of mucosa adjacent to the site of the cultured biopsies ranged from normal through varying degrees of noninvasive squamous dysplasia to invasive carcinoma. Confluent monolayers of pure epithelial cells were obtained from 68% of the cultured explants. Sites exhibiting high-grade dysplasia were 51% more likely to yield successful cultures than sites exhibiting normal histology (13 of 14 cultures successful versus 52 of 83 cultures successful, P < 0.02). Cultures had a maximum proliferative life span of 81 days and none of the cultures spontaneously became immortalized. Immunolabeling studies revealed that all cultured epithelial cells, regardless of the in situ histologic appearances of the mucosa at the biopsy site, strongly expressed keratin and epidermal growth factor receptor, weakly expressed transferrin receptor and human folate receptor, and were negative for neural cell adhesion molecule and human leukocyte antigen DR (HLADR). Ploidy and karyotypic analyses were performed in a limited number of explants from normal and dysplastic sites and all were found to be diploid without karyotypic abnormality. We conclude that pure bronchial epithelial cell populations can be routinely expanded from histologically normal and dysplastic sites by tissue culture of biopsy explants and that the expanded cell populations may represent a library of normal and preneoplastic cells which are suitable for immunophenotypic, ploidy, genetic, or functional analyses.

Amiodarone-induced lymphocyte toxicity and mitochondrial function

Amiodarone is one of the most effective antiarrhythmic drugs available. However, its use is often limited by potentially life-threatening toxicities, including hepatotoxicity and pulmonary toxicity. We have used human lymphocytes as a system in which to study amiodarone-induced cytotoxicity. Using a tetrazolium dye reduction assay, we observed amiodarone-induced cytotoxicity with a lethal dose (LD)50 of 10.0 +/- 31.1 microM (mean +/- SD, n = 5) with a cellular concentration of 2.2 +/- 0.2 million/ml and of 55.5 and 39.2 microM with cellular concentrations of 8.9 and 7.2 million/ml, respectively, after only 2.75 h of drug exposure. Damage to mitochondria, but not other organelles, was observed with electron microscopy at an amiodarone concentration of 7.3 microM. Alterations in ATP synthesis and lactate dehydrogenase (LDH) release from cells had concentration-response curves similar to those for cytotoxicity. However, we did not observe extracellular accumulation of adenine nucleotides. These results suggest that amiodarone may have a direct toxic effect on mitochondria, beginning at < 10 microM, with membrane-damaging effects at higher drug concentrations.

Management of unique clinical entities in disaster medicine

This article discusses the management of clinical problems encountered particularly in disasters. These include the principles of multiple-casualty triage, and field and hospital management of blast injury, crush syndrome, compartment syndrome, particulate inhalation, and traumatic asphyxiation. The indications for extraordinary measures, such as field amputation, are detailed. A brief review of the causes and epidemiology of these entities is provided, with emphasis on the clinical management in the disaster setting.

Clinical benchmarking: results into practice

Describes the way benchmarking data are used in a district general hospital to influence clinical practice. Wirral Hospital Trust is a site for the Electronic Patient Record Project; as such there is a large amount of patient based data available for research and internal benchmarking. Includes working examples of internal benchmarking which have been used by both clinicians and hospital management to improve hospital effectiveness. Discusses the ways in which this information is being used to develop initiatives such as clinical pathway development.

Development of a postal health status questionnaire to identify people with dyspepsia in the general population

OBJECTIVE

To develop and validate a postal health status questionnaire which will identify people with dyspepsia in the general population.

DESIGN

Validation against telephone interview and post re-post determination of reliability.

SETTING

A general practice population in the north of England.

SUBJECTS

A random sample of adults aged 20-69 years inclusive chosen from the general population.

MAIN OUTCOME MEASURES

Validity has been checked against telephone interview. A kappa statistic has been calculated for each question and clinical category.

RESULTS

Compared with interview the questionnaire is a valid, comprehensive and easily understood record of symptomatology. The kappa statistics (mean value 0.92) indicate a very reliable questionnaire.

CONCLUSION

The questionnaire accurately and reliably identifies people with dyspeptic symptoms.

Path.Finder: an interactive clinical information system. The day-to-day management of patients requires unified information sources

Presents Path.Finder, a locally managed health care information system built in response to the need for better communication of current research evidence and clinical practice guidelines. Concludes that this system will improve patient care by providing up-to-date, clinically useful information which is relevant locally. The technology and the information management system have been developed in parallel.

Silica induced suppression of the production of third and fifth components of the complement system by human lung cells in vitro

Although investigations to date have demonstrated the ability of the monocyte/macrophage to synthesize complement components, only a limited number of studies on complement synthesis by nonhepatic tissue cells have been reported. To begin to fill this gap in our knowledge we have recently evaluated the ability of lung tissue cells to synthesize and secrete various complement components in vitro. Using 35S-methionine incorporation and immunoprecipitation techniques we have previously demonstrated the ability human lung type II pneumocytes (A549) and human lung fibroblasts (WI-38), to synthesize and secrete a variety of both early and terminal complement components, as well as several regulatory proteins including Clr, Cls, C4, C3, C5, C6, C7, C8, C9, Factor B, Factor H, Factor I and Cls inactivator. Our present studies demonstrate the capability of silica to regulate complement component production by A549 cells, but not complement component production by WI-38 cells. Specifically, using sensitive ELISAs we demonstrated that a non-toxic dose of silica had the capability to suppress the production of both C3 and C5 by A549 pneumocytes by 40-50 percent, but had no effect on C3 or C5 synthesis by WI-38 fibroblasts. Additionally, using 35S-methionine incorporation and TCA precipitation techniques, we demonstrated that suppression of C3 and C5 production by silica treated A549 pneumocytes was not a result of suppression of total protein synthesis. These studies demonstrate that silica, which has been implicated in pulmonary diseases, has the capability to regulate local complement production by lung tissue cells in vitro. In vivo, this suppression of complement production by the type II pneumocytes could alter the local tissue reservoir of complement components during infection and pulmonary injury, thus resulting in depressed pulmonary host defense.

Implementing right-to-know legislation for health care workers in Manitoba: a bipartite sectoral train-the-trainer approach

In October 1988, right-to-know legislation was introduced in Canada. This presented a technical and administrative challenge to the health care sector. With over 170 health care facilities in Manitoba to be brought into compliance, some large, some small, some rural, some urban, a cooperative approach was needed. A labor-management steering committee with representatives from a cross-section of facilities as well as the various health care unions was formed to design and implement a train-the-trainer program. A small-group, highly participatory modular program was developed with input from all parties, and delivered across the province by trainers selected jointly by labor and management. The program achieved its goal of assisting member facilities to implement the legislation. Follow-up surveys and discussions with health care workers showed improved understanding of labelling requirements, material safety data sheet interpretation, and requirements for hazard control. This first bipartite program empowered the health care workforce to use its newly acquired right-to-know, and has provided the incentive to implement other cooperative safety and health programs.

Medical rehabilitation for the indigent in Louisiana: a primer for physicians

The impact of a stroke, head injury, spinal cord injury, or other disabling condition can be especially devastating for individuals without health insurance. Fortunately, a comprehensive system has evolved to address the needs of the indigent for medical rehabilitation services in Louisiana. The purpose of this paper is to familiarize readers with this complex system, and thereby to assist practicing physicians and other health care providers in better serving this large and medically needy population. First, state and federal medical assistance programs which cover rehabilitation services are reviewed; next, services available through Louisiana Rehabilitation Services are discussed; and finally, services available through the Handicapped Children's Services Program and various voluntary organizations are described.