Behavioural effects in mice of subchronic chlordiazepoxide, maprotiline and fluvoxamine. II. The elevated plus-maze

In view of apparent commonalities in the aetiology, symptomatology, and pharmacotherapy of anxiety and depressive disorders, the present study compares the effects of the benzodiazepine, chlordiazepoxide (1.0-8.0 mg/kg), the selective noradrenaline (NA) reuptake inhibitor, maprotiline (0.5-10.0 mg/kg), and the serotonin (5-HT)-selective reuptake inhibitor, fluvoxamine (2.0-8.0 mg/kg), on the behaviour of mice in the elevated plus-maze test of anxiety. To more accurately reflect the clinical situation, subjects were treated daily for 21 days prior to testing, and comprehensive behavioural profiles were obtained through the application of an ethological scoring technique. Results show that subchronic treatment with chlordiazepoxide produced clear anxiolytic-like effects at the highest dose tested, coupled with an inhibition of risk assessment over the entire dose range. With the exception of risk assessment measures, anxiolytic-like effects were also seen with a low dose (0.5 mg/kg) of maprotiline: these effects were lost at higher doses. In contrast to these data, fluvoxamine produced minimal behavioural change under present test conditions. Findings are discussed in relation to the relative efficacy of selective monoamine. reuptake inhibitors in the treatment of anxiety disorders, and the nature of anxiety evoked in mice by exposure to the elevated plus-maze.

Behavioural effects in mice of subchronic buspirone, ondansetron and tianeptine. I. Social interactions

In a continuation of recent work on effects of a benzodiazepine (chlordiazepoxide) and selective monoamine reuptake inhibitors (maprotiline and fluvoxamine), the current study compares effects of the 5-HT1A receptor partial agonist, buspirone (0.75-3.0 mg/kg), the 5-HT3 receptor antagonist, ondansetron (0.1-100 micrograms/kg) and the novel antidepressant, tianeptine (2.5-10.0 mg/kg). Compounds were given daily to mice for 21 days prior to testing and the subsequent behaviour of the animals during social interactions was assessed by ethopharmacological procedures. Buspirone, at 0.75 mg/kg, increased immobility and reduced occurrence of the aggressive act, "attack." At 1.5 and 3.0 mg/kg, it enhanced olfactory exploration of the sawdust substrate, but had no effect on social investigation. Ondansetron increased the duration of environmental exploration at 0.1 microgram/kg, while at 100 micrograms/kg it increased the duration of digging in the substrate. Ondansetron had no effect on the categories of behaviour and failed to induce an anxiolytic-like enhancement of social investigation. Tianeptine produced an anxiogenic-like effect at 10 mg/kg, while at 5 mg/kg it enhanced flight and immobility. The relevance of these findings is discussed in relation of the reported behavioural actions of these compounds and to current pharmacotherapy of anxiety and depression. The apparent anxiogenic effect of tianeptine is a novel finding which requires further study.

Behavioural effects in mice of subchronic buspirone, ondansetron and tianeptine. II. The elevated plus-maze

In follow-up to recent work on benzodiazepines (chlordiazepoxide) and selective monoamine reuptake inhibitors (maprotiline and fluvoxamine), the present study compares the effects of the 5-HT1A receptor partial agonist, buspirone (0.75-3.0 mg/kg), the 5-HT3 receptor antagonist, ondansetron (0.1-100 micrograms/kg), and the novel antidepressant, tianeptine (2.5-10.0 mg/kg), on the behaviour of mice in the elevated plus-maze test of anxiety. Compounds were administered daily for 21 days prior to testing, and an ethological scoring technique was used to generate comprehensive behavioural profiles. Results show that subchronic treatment with ondansetron failed to influence the behaviour of mice in the plus-maze, while the limited changes induced by buspirone could not be attributed to anxiety-related processes. In contrast, tianeptine produced unambiguous anxiogenic-like effects at the top dose tested (10.0 mg/kg), a profile that was not secondary to changes in general levels of locomotor activity or exploration. Data are discussed in relation to current pharmacotherapy of anxiety and depressive disorders, and the nature of anxiety induced by animal models.

Treatment of high-flow vascular malformations by venous embolization aided by flow occlusion techniques

PURPOSE

Transvenous embolization techniques may be helpful as alternatives to the arterial route when treating high-flow vascular malformations. We present our experience using these techniques in four patients.

METHODS

In one patient the venous portion of the arteriovenous malformation (AVM) was punctured directly; in the other three patients it was catheterized via a retrograde venous approach. Flow occlusion techniques were utilized in all patients during embolization, which was performed with absolute alcohol or N-butyl-2-cyanoacrylate.

RESULTS

Excellent clinical and angiographic results were obtained, with obliteration of arteriovenous shunting in all patients. There were no complications.

CONCLUSION

The embolization of certain AVMs using a venous approach is a safe and effective treatment.

Cognitively impaired spouses as primary caregivers for demented elderly people

OBJECTIVE

To describe problems of dementia patients whose spousal caregivers are also cognitively impaired.

DESIGN

Retrospective chart review.

SETTING

The geriatric assessment clinic at University of California, San Diego, which is one center for the California State sponsored Alzheimer's Disease Diagnosis and Treatment Center Program.

PATIENTS

During the period from January 1992 through May 1994, 65 patients completed the assessment and met the entry criteria of being demented and having a spousal caregiver. Twelve of the spouses scored six or more error points on the Katzman Short Orientation-Memory-Concentration Test.

MEASUREMENTS

Patient data included age, living situation, other caregivers, use of formal and informal support systems, profiles of medical, cognitive, and functional ability, caregivers interactions, and recommendations from the evaluation.

MAIN RESULTS

Dementia patients with cognitively impaired spouses utilized fewer community resources (P = .021) and experienced difficulty with medication compliance (P = .041) more often than those with cognitively normal spousal caregivers.

CONCLUSIONS

Older caregivers of patients suffering from dementia should be screened for cognitive problems.

Localization of insulinomas by selective intraarterial calcium injection

This study examines the role of selective intraarterial calcium injection and hepatic venous sampling in the localization of insulinomas. Seven patients were studied. In all cases, ultrasound and computerized tomography scans were either negative or equivocal. Calcium gluconate was injected directly into the arteries supplying the pancreas after standard selective angiography. Insulin levels were measured in samples taken from the right hepatic vein before and 30, 60, 90, 120, and 180 s after each injection. Two doses were used, 0.025 milliequivalents Ca/kg (1 mg/kg) for the first two subjects and 0.00625 milliequivalents Ca/kg (0.25 mg/kg) for the remaining five subjects. Serum insulin levels rose at least 2-fold, the proposed diagnostic rise, from basal in six subjects; one test was negative. Of the six positive studies, a diagnostic rise was seen only in one artery in five cases. One patient did not undergo surgery. In the remaining five patients, surgery confirmed the position and histology of the tumor. The one patient with a diagnostic rise in more than one artery, however, had residual disease after surgery. The seventh subject referred specifically for localization had a negative calcium stimulation study and a subsequent diagnosis of intermittent sulfonylurea abuse was made after a positive screen. The present study shows that preoperatively, selective intraarterial calcium injection with hepatic venous sampling is a powerful technique for the localization of insulinomas. Smaller doses of calcium than previously reported can be used and may reduce the risk of hypoglycemia during the procedure.

Biological activity of saponins from two Dracaena species

Many species of the west African "soap tree" Dracaena are used in traditional medicine for the treatment of a variety of diseases. In continuation of our search for anti-infective agents from plants implicated in traditional medicine, we evaluated the biological activities of saponins from extracts of Dracaena mannii and Dracaena arborea by using a battery of test systems such as radiorespirometry, Cytosensor bioautography, and agar dilution methods and molluscicidal tests. Bioassay-directed fractionation of the methanol extracts of seed pulp using a combination of chromatographic techniques, gel filtration, droplet countercurrent chromatography (DCCC), and low-pressure liquid chromatography (Lobar), led to the isolation and characterization of spiroconazole A, a pennogenin triglycoside [3 beta-O-[(alpha-L-rhamnopyranosyl(1-->2), alpha-L-rhamnopyranosyl(1-->3)-beta-D-glucopyranosyl]-17 alpha-hydroxyl-spirost-5-ene] (Fig. 1). As the active constituent, spiroconazole A exhibited pronounced antileishmanial, antimalarial, and molluscicidal activities. This paper also reports on the fungistatic, fungicidal and bacteriostatic activity of spiroconazole A against 17 species of fungi and 4 of bacteria.

Medical complications of pregnancy in hereditary haemorrhagic telangiectasia

Hereditary haemorrhagic telangiectasia (HHT) displays significant variation in severity between affected individuals in the same family, ranging from relatively trivial epistaxis and telangiectasia to gastrointestinal, cerebral and pulmonary involvement. Evidence for successful therapy of HHT-related haemorrhage with oestrogens and progesterones, and recent case reports outlining pulmonary complications of pregnancy in HHT, prompted us to review the outcome of 161 pregnancies in 47 affected women. HHT-related maternal complications developed in eleven patients, ten in the subgroup of 23 pregnancies in which pulmonary arteriovenous malformations (PAVMs) were present at the outset, or documented in the two years following pregnancy. We present six cases of intrapulmonary shunt deterioration, two cases of fatal pulmonary haemorrhage and three cerebrovascular accidents related to pregnancy. A predisposition towards PAVMs in females was observed. Following the recent discovery of mutations in the endoglin gene in this disease, our data support a hypothesis of hormonal modification of the HHT phenotype. In addition, a significant excess of affected offspring are present in HHT families. We consider contributary aetiological factors, and discuss implications for patient management.

Quantification of pneumothorax size on chest radiographs using interpleural distances: regression analysis based on volume measurements from helical CT

OBJECTIVE

The aim of this study was to define the relationship between interpleural distance measurements on an erect posteroanterior chest radiograph and pneumothorax size as measured by helical CT in a series of patients.

SUBJECTS AND METHODS

Twenty pneumothoraces from 19 patients (10 males, nine females) were analyzed. Most pneumothoraces were on the right side (n = 16). The etiology was spontaneous in seven patients and iatrogenic in thirteen. All patients underwent an erect inspiratory posteroanterior radiograph and a helical CT scan of the thorax on the same visit to the radiology department. The interpleural distance was measured at three locations and the figures added together. Following helical CT of the thorax, the percentage pneumothorax size was calculated by drawing regions of interest around the relevant hemithorax and lung on 10-mm reconstructed slices. A scattergram of the sum of interpleural distances in centimeters versus percentage pneumothorax size was plotted.

RESULTS

Analysis of results showed that percentage pneumothorax size could be calculated by the formula Y = 4.2 + [4.7 x (A + B + C)], r = .98, p < .0001.

CONCLUSION

This study identified a formula for accurately calculating percentage pneumothorax size as determined by helical CT from an erect posteroanterior radiograph. Using this formula with the clinical status of the patient should more easily identify patients requiring active intervention.

Pulmonary arteriovenous malformations: results of treatment with coil embolization in 53 patients

OBJECTIVE

The purpose of this study was to determine the effects of percutaneous transcatheter coil embolization of pulmonary arteriovenous malformations on arterial oxygen saturation, pulmonary gas exchange, anatomic right-to-left shunt, and lung function and to assess the complications of the procedure.

SUBJECTS AND METHODS

Fifty-three patients were included in the study: 42 (79%) had associated hereditary hemorrhagic telangiectasia. Nineteen (36%) had neurologic problems compatible with paradoxical embolization. During 102 separate embolization procedures, all malformations with feeding vessels > or = 3 mm in diameter were embolized with steel coils. Arterial oxygen saturation at rest and on exercise and the intrapulmonary right-to-left shunt fraction (99mTc-macroaggregate injection), forced expiratory volume in 1 sec, vital capacity, diffusing capacity for carbon monoxide, and transfer coefficient were measured before and after embolization. Complications of the procedure were recorded and investigated.

RESULTS

Before treatment, all patients had hypoxemia in the supine posture (SaO2, 89 +/- 1% [standard error of the mean]), which fell a further 6% (absolute) on standing. Mean values for transfer coefficient and diffusing capacity for carbon monoxide were reduced, at 85 +/- 3% and 78 +/- 3% (predicted value), respectively. After embolization, the mean values for supine and erect SaO2 rose to 94 +/- 1% and 93 +/- 1%. Transfer coefficient increased by a mean of 5.4% of predicted value. The mean shunt fraction fell from 23 +/- 2% preembolization to 9 +/- 1% postembolization. In 102 procedures, there were 18 complications, 12 mild, two moderate, and four potentially serious (systemic coil embolization in two patients, cerebrovascular accident [transient], and myocardial puncture), but there were no lasting sequelae.

CONCLUSION

Our results show that coil embolization is an effective and well-tolerated method for treatment of pulmonary arteriovenous malformations. Improvements in pulmonary gas exchange and lung function and a decrease in right-to-left shunting occurred after treatment. The procedure was well tolerated and had a low complication rate.

Pelvic arterial embolization following hysterectomy and bilateral internal iliac artery ligation for intractable primary post partum haemorrhage

A case of successful arterial embolization following hysterectomy and bilateral internal iliac artery ligation for intractable primary post partum haemorrhage is described. The selected artery was a branch of the inferior epigastric artery. Little has been written to date in the radiological literature about embolization via pelvic collateral vessels following arterial ligation. Although there is a good argument for postponing surgery until transcatheter embolization has been attempted, this case demonstrates that embolization can still be successful even when performed following surgery.

Misoprostol dosage in the prevention of nonsteroidal anti-inflammatory drug-induced gastric and duodenal ulcers: a comparison of three regimens

OBJECTIVE

To compare the effectiveness and tolerability of three misoprostol dosing regimens for the prevention of gastric and duodenal ulcers associated with long-term nonsteroidal anti-inflammatory drug (NSAID) therapy.

DESIGN

A multicenter, 12-week, randomized, double-blind, placebo-controlled, parallel, four-limb study.

PATIENTS

Eligibility criteria included upper gastrointestinal symptoms during NSAID therapy and no endoscopic evidence of gastric or duodenal ulcers. A total of 1623 patients was enrolled; 1197 of these met major accession and regimen-compliance criteria and completed the trial. These 1197 patients composed the evaluable group.

INTERVENTIONS

Patients were randomly assigned to one of four regimens: placebo four times daily; 200 micrograms of misoprostol twice daily and placebo twice daily; 200 micrograms of misoprostol three times daily and placebo once daily; and 200 micrograms of misoprostol four times daily.

MEASUREMENTS

Upper gastrointestinal endoscopic examinations for ulcers were done after 4, 8, and 12 weeks of therapy. Tolerability and safety of the regimens were assessed by adverse-event monitoring.

RESULTS

In the placebo group, the incidence of gastric ulcers was 15.7% and the incidence of duodenal ulcers was 7.5%. The incidence of gastric ulcers was significantly lower in the groups receiving misoprostol twice daily (8.1%; difference, 7.6% [95% CI, 2.7% to 12.5%]; P = 0.002), three times daily (3.9%; difference, 11.8% [CI, 7.4% to 16.3%]; P < 0.001), and four times daily (4%; difference, 11.7% [CI, 6.7% to 16.8%]; P < 0.001) compared with placebo. The gastric ulcer rate was significantly higher in patients receiving misoprostol twice daily compared with those receiving misoprostol three times daily (difference, 4.2% [95% CI, 0.7% to 7.7%]; P = 0.02). A significant (P = 0.02) misoprostol dose-response effect was noted in the prevention of gastric ulcers. The incidence of duodenal ulcers was significantly lower in the groups receiving misoprostol twice daily (2.6%; difference, 4.9% [CI, 1.5% to 8.2%]; P = 0.004), three times daily (3.3%; difference, 4.2% [CI, 0.6% to 7.7%]; P = 0.019), and four times daily (1.4%; difference, 6.1% [CI, 2.6% to 9.6%]; P = 0.007) compared with placebo. No significant difference was detected between patients receiving misoprostol twice daily and those receiving misoprostol three times daily, and no dose-response effect was noted with duodenal ulcers. The incidence of withdrawals for adverse events was significantly lower in the groups receiving misoprostol twice daily (12%) and three times daily (12%) than in the group receiving it four times daily (20%). The incidence of gastrointestinal adverse events was significantly higher in the group receiving misoprostol four times daily (74%) than in the placebo group (62%).

CONCLUSION

Misoprostol, 200 micrograms twice or three times daily, offers substantial protection against gastric and duodenal ulcers in patients receiving long-term NSAID therapy. These dosages were better tolerated than the currently approved regimen of 200 micrograms four times daily.

Stenting of superior vena caval obstruction

Images

Palliation of obstructive nephropathy due to malignancy

OBJECTIVE

To conduct a prospective study of patients with malignant obstructive uropathy treated actively by percutaneous nephrostomy and J-J ureteric stents.

PATIENTS AND METHODS

Forty-two patients (27 men, 15 women, median age 62 years, range 29-83) with obstructive nephropathy secondary to malignancy underwent urinary diversion followed, where appropriate, by active treatment of the underlying cancer.

RESULTS

The median survival of all patients was 133 (range 7-712) days. Seventeen patients (40%) survived for > 6 months and five (12%) for < 1 month. Patients who had received no prior therapy and for whom further therapeutic options were available were more likely to benefit from urinary diversion. In nine patients (21%) nephrostomy insertion failed to relieve renal failure. In 20 patients (48%) obstructive nephropathy recurred. The procedure was complicated by urinary tract or nephrostomy site infection in 16 patients, by septicaemia in six patients, by percutaneous urine leak in 13 patients and by pelvi-calyceal perforation in two patients, but not by haemorrhage or death. The median percentage of the patients' remaining life which was spent in hospital was 23.6% (range 2.2-100).

CONCLUSIONS

Patients likely to benefit from nephrostomy were those for whom there were therapeutic options available for the treatment of their malignancy. Prolonged survival is possible in obstructive nephropathy secondary to malignancy, which should no longer be cited as an absolute contra-indication to urinary diversion. Patients unlikely to benefit from urinary diversion can also be identified and they should not routinely undergo this intervention.

Multidisciplinary approach to the management of head and neck arteriovenous malformations

Arteriovenous malformations (AVM) of the head and neck are quite rare in contrast to low-flow vascular anomalies, but often present with significant haemorrhage or cosmetic defects. Treatment of these high-flow vascular anomalies is hazardous and has a predictably high incidence of recurrence if not managed correctly. Intervention is indicated for complications such as pain, haemorrhage, pressure symptoms, ischaemic ulceration and even congestive cardiac failure. A multidisciplinary team approach is required in the assessment and treatment of these lesions, and involves preoperative angiography with superselective embolisation, followed by resection of the lesion, ideally within 72 h. Recent advances in microsurgery and in therapeutic radiology have greatly improved the prognosis for patients with these malformations. We present a series of four patients who have undergone preoperative embolisation and subsequent surgical excision, with a mean follow-up of 28 months. The complication rate has remained low and there has been no re-expansion of the lesions to date.

Risk factors for pneumothorax during percutaneous Hickman line insertion in patients with solid and haematological tumours

The purpose of this study was to identify risk factors for pneumothorax during percutaneous subclavian Hickman line insertion in patients with haematological (HT) or solid tumours (ST). One hundred and twelve patients (55 HT, 57 ST) had 132 subclavian Hickman lines inserted under fluoroscopic control. Lines were inserted on the left on 116 occasions and the right in 16. Thirty-five single, 29 double and 68 triple lumen catheters were inserted. Variables included in the analysis were age, sex, side of insertion, catheter gauge and nutritional status as indicated by the body mass index (BMI kg/m2). Both univariate and logistic regression analyses were performed. There were ten pneumothoraces, all occurring in patients with STs. Univariate analysis revealed that patients with STs were older (median age 59 versus 36 years; P = 0.0001) and more cachectic (median BMI 21.9 versus 24.2 kg/m2; P = 0.03) than those with HTs, and the patients experiencing pneumothorax were older (median age 57 versus 44 years; P < 0.01) and more cachectic (median BMI 19.6 versus 24.0 kg/m2; P = 0.004) than those undergoing uncomplicated procedures. For patients with a BMI < 19 kg/m2 versus those with a BMI > 19 kg/m2, the pneumothorax rate was 5/8 versus 5/124 (P < 0.00001). Logistic regression analysis confirmed the significantly older age of the patients with STs (P < 0.001) and of those experiencing pneumothorax (P = 0.02). This analysis also confirmed the lower BMI of patients experiencing pneumothorax (P = 0.002). The patients' sex, the side of line insertion and the catheter gauge were not associated with pneumothorax on either the univariate or logistic regression analyses. From these data we conclude that pneumothorax complicating a subclavian Hickman line is significantly more likely in elderly patients with a low BMI. Such patients are more likely to have STs than HTs. In patients with a BMI < 19 kg/m2, the subclavian route should be used with caution.

Tufted haemangioma responding to high-dose systemic steroids: a case report and review of the literature

Tufted haemangioma is a rare, acquired vascular tumour most commonly presenting in the first year of life. Some authors consider angioblastoma of Nakagawa and progressive capillary haemangioma to be the same condition, and include them in the lobular capillary haemangioma complex. There have been only a few case reports of tufted angioma in the literature, with little information on effective treatment. We describe a case of tufted angioma presenting in a 3-month-old girl. Because of the tumour's rapid growth, aggressive treatment was felt to be justified. There was no response to interferon alpha-2a but high-dose steroids were commenced with good results.