Predictive techniques applied to imipramine therapeutic drug monitoring

The aim of this study was to establish the performance of pharmacokinetic methods employing little data on serum drug concentrations obtained in routine therapeutic drug monitoring of imipramine. Forty-three and 123 serum levels were obtained in 8 adult depressive patients (aged 57-80 y) and 34 enuretic children (aged 5-13 y), respectively. Forecasting of the serum concentrations was performed based on mean population pharmacokinetic parameters (method A), with knowledge of one steady-state serum concentration (method B), and from two or more steady-state serum concentrations (method C). The accuracy and precision of each method were evaluated from the mean prediction error (ME) and from the root mean squared prediction error (RMSE), respectively. The values of ME and RMSE of methods B and C proved to be significantly lower than those found using method A. Method C was the most precise and accurate in both populations. Method A underestimates the serum concentrations observed in adults (ME greater than 0) but overestimates them in children (ME less than 0), although to a lesser extent. The study shows that it is possible to obtain a good estimation of individual dosage needs from one or more serum concentrations obtained at steady state. Clinical application of these methods (B and C) yields an increase in the efficiency and safety of the treatment, particularly in special populations such as geriatric and pediatric patients.

Pancreatic insuloma causing Cushing's syndrome

The advent of new diagnostic procedures such as petrosal venous sampling and CRF testing has improved the possibilities of precise location of the site of hormonal overproduction in Cushing's syndrome. We report on a case of ectopic ACTH-dependent Cushing's syndrome in which the use of such techniques helped to locate the tumor. A 45-year-old woman with definite ACTH-dependent Cushing's syndrome was referred to our clinic for evaluation. ACTH, cortisol and urinary 17OHCS failed to suppress on high dose dexamethasone oral administration. Computerized tomography showed bilateral adrenal hyperplasia and an empty sella turcica. ACTH and cortisol did not increase after CRF administration. Staged caval system catheterism via both femoral veins up to the inferior petrosal sinuses, including after CRF administration, demonstrated no ACTH gradient between staged samples and simultaneous peripheral venous blood. This suggested a tumor drained by the portal system. An abdominal ultrasonography demonstrated a pancreatic mass, that was surgically excised and appeared as a benign islet cell tumor. Portal vein ACTH promptly decreased after tumor excision and postoperative peripheral cortisol and ACTH were normal. On immunostaining the tumor cells proved to be positive for ACTH.

Molecular genetics of phenylketonuria in Mediterranean countries: a mutation associated with partial phenylalanine hydroxylase deficiency

We report the characterization of a mutation in the phenylalanine hydroxylase (PAH) gene associated with partial residual activity of the enzyme. This point mutation (280glu----lys) was found by sequencing a mutant cDNA clone derived from a needle biopsy of the liver in a child with variant form of phenylketonuria. There is a strict concordance between homozygosity for the mutation and this particular phenotype. The (280glu----lys) mutation is linked to an original and rare RFLP haplotype at the PAH locus found in south Europe and North Africa. So far, this genotype-haplotype association is both inclusive and exclusive. Thirty-three PAH-deficient patients were screened for the mutation by using polymerase chain-reaction amplification of their genomic DNA extracted from Guthrie cards. Since a large number of patients can be screened for a particular mutation by using Guthrie cards, the possibility arises of using these samples collected by national newborn screening centers for prospective and retrospective detection of other mutations in the human genome.

Clinical and molecular heterogeneity of phenylalanine hydroxylase deficiencies in France

RFLPs of 68 normal and 74 mutant alleles at the phenylalanine hydroxylase (PAH) locus were determined in 37 French kindreds. A total of 23 haplotypes, including 18 normal and 16 mutant alleles, were observed. Two-thirds of all mutant alleles were confined within only four haplotypes, while the last third was accounted for by 12 haplotypes, including eight haplotypes absent from Caucasian pedigrees reported thus far. Several mutant haplotypes were present in typical phenylketonuria only, others were present in variants only, and some were present in both. In addition, a particular mutant haplotype (haplotype 2) was found to harbor different mutations in our series, resulting in either typical phenylketonuria or in mild hyperphenylalaninemias. The diploid combination of so many mutant haplotypes in PAH-deficient patients and of compound heterozygosity at the PAH locus in southern Europe might account for the broad spectrum of individual phenotypes observed in France.

Interpretation of the discrepancy observed between plasma free and salivary testosterone levels in man

The differences observed between plasma free and saliva testosterone levels do not result from methodological artefacts. We postulate that androgens metabolism in salivary glands modulates saliva testosterone levels both in men and women. In women, the "excess" of saliva testosterone (compared to the calculated free testosterone concentration), could be due to conversion of androstenedione in the salivary glands. The rate of this transformation is exaggerated in hirsute patients resulting in a significantly higher excess of saliva testosterone. In men, on the contrary, a "deficit" in saliva testosterone is observed suggesting testosterone transformation in salivary glands. This deficit is more marked in impotent men and appears to be reversed by testosterone administration. Saliva testosterone levels do not merely reflect plasma free hormone concentrations but also afford potentially useful information on androgens metabolism.

Failure of a human immunodeficiency virus (HIV) immune globulin to protect chimpanzees against experimental challenge with HIV

To assess the possible efficacy of passive immunization against human immunodeficiency virus (HIV) an immune globulin was prepared from plasma of HIV-seropositive donors selected to be among those having the top 12.5% of virus-neutralizing antibody titers. The immune globulin was treated with pepsin to render it intravenously tolerable. The preparation, which we termed HIVIG, neutralized 100 tissue culture 50% infective doses (TCID50) of HIV at an average dilution of 1:1000 in neutralization tests in vitro. During preparation HIVIG was subjected to virus inactivation and removal procedures that in theory resulted in a reduction in HIV infectivity by a factor of 10(25). At a dose of 9-10 ml/kg of body weight both the virus-inactivated source plasma and the final immunoglobulin preparation were noninfective and without adverse effect in two chimpanzees. Two chimpanzees inoculated intravenously with HIVIG at 1 ml/kg and two inoculated with 10 ml/kg were challenged intravenously 1 day later with 400 TCID50 of the same strain of HIV (HTLV-IIIb) used in neutralization assays in vitro. All animals became infected. Incubation periods to virus isolation (by cocultivation with human mononuclear cells) in HIVIG recipients did not differ significantly from the incubation period seen in a control animal that received a normal anti-HIV-free immunoglobulin. These findings may have implications for understanding the failure of experimental vaccines to protect against HIV challenge in chimpanzee experiments.

Lack of gonadotropic response to pulsatile gonadotropin-releasing hormone in isolated hypogonadotropic hypogonadism associated to congenital adrenal hypoplasia

Congenital adrenal hypoplasia (AH) is a rare condition, known to be associated with isolated hypogonadotropic hypogonadism (IHH). Three studies have reported attempts to stimulate gonadotropin secretion with pulsatile gonadotropin-releasing hormone (GnRH) in a total of 4 patients presenting such a syndrome, with conflicting results. In the present study, one patient with idiopathic IHH and AH was treated with pulsatile sc GnRH--doses ranging from 2.5 to 10.0 micrograms/pulse, every 90 min--during 8 weeks in an attempt to induce puberty. The prepubertal basal plasma levels of LH, FSH and testosterone, and saliva testosterone levels remained unaltered throughout treatment, at all doses of GnRH tested. The gonadotropin response to an acute iv GnRH administration (0.1 mg) also remained at the prepubertal level after pulsatile GnRH treatment. No circulating anti-GnRH antibodies were detected. The absence of gonadotropic response to exogenous pulsatile GnRH suggests that the IHH of patients with AH is due to an abnormal pituitary function rather than to a lack of endogenous GnRH.

Structural analysis of the 2.8 A model of Xylose isomerase from Actinoplanes missouriensis

The structure of Xylose isomerase (X.I.) from Actinoplanes missouriensis has been solved to 2.8 Angstroms resolution. Phases were determined from a single Eu3+ derivative and from the noncrystallographic 222 symmetry of the tetrameric molecule. An atomic model was built and subjected to restrained crystallographic refinement. The resulting model is shown to be closely similar to the recently reported X.I.'s structures from three other bacterial sources. Each monomer is found to be composed of an eight-stranded alpha/beta "T.I.M." barrel forming an N-terminal domain of 328 residues followed by a large loop of 66 residues embracing an adjacent subunit. Analysis of intersubunit packing shows that the X.I. tetramer is an assembly of two tight dimers. The beta barrel fits a simple hyperboloid model as other T.I.M. barrels do. The active site, identified as the binding site for the inhibitor xylitol, is located at the carboxyl end of the beta strands in the barrel next to a pair of binding sites for Eu3+ ions, which are assumed to be sites for the divalent ions involved in catalysis. Active sites in the tetramer are oriented towards the interface between dimers. It is suggested that subunit interfaces might stabilize the active site region and this might explain the oligomeric nature of other alpha/beta barrel enzymes.

[Prenatal screening for phenylketonuria in 2 families by trophoblast biopsy]

Prenatal diagnosis of phenylketonuria (PKU) is now available owing to restriction fragment length polymorphism (RFLP) of the phenylalanine hydroxylase gene. Biopsies of chorionic villi were carried ou at 11 weeks gestation in 2 families who had previously a child with the classical form of PKU and who were considered informative after DNA studies. Fetal DNA was extracted and studied with restriction enzymes selected according to the study of each family. Hybridization studies suggested that one fetus was affected by the disease and that the second was normal. Termination of pregnancy was carried out in the first case; however, study of the fetus could not be performed. In the second family, the pregnancy resulted in the delivery of a normal child, as shown by normal phenylalanine level at birth.

Detection and titration of neutralizing antibodies to HIV using an inhibition of the cytopathic effect of the virus on MT4 cells

An assay for determining neutralizing antibodies in sera from individuals infected with HIV was developed. This assay is based on an inhibition of the cytopathic effect observed after HIV superinfection of the HTLV-1-positive cell-line MT4. Only about 10% of asymptomatic seropositive donors exhibit a high titre over 1/500 up to 1/2000 while in 60% of sera, neutralizing antibodies were not detected. The assay reported here can also be used for the comparison of the biological properties of the different strains of HIV.

Western blot technique in the serological evaluation of three LAV/HTLV III-infected Italian families

In order to confirm suspected LAV/HTLV III infection, serological evaluation of patients is of utmost importance. ELISA is currently being employed on a large scale for screening, but like the immunofluorescence assay, it has a variable rate of possible non-specific positivity. On the other hand, the Western Blot (WB) technique can detect antibodies to different viral proteins. In this paper we are reporting the serological patterns of three LAV/HTLV III-infected families. In particular, their viral protein-specific antibody patterns are described. With the exception of one child, all the patients tested showed seropositivity in both ELISA and WB. In the one child mentioned above, ELISA and immunofluorescence positivity were due to non-specific binding. Two out of three children tested showed a close correlation between a severe clinical course and the absence of p25-specific IgM. In contrast, one child showing a switch from IgM to p25-specific IgG antibodies had a favorable clinical course. We observed a family in which vertical transmission of LAV/HTLV III from the mother to her neonate seems not to have happened; the child was seronegative and healthy at the age of one. At birth, this neonate had LAV/HTLV III-specific IgG corresponding to the mother's pattern, but it lacked viral-specific IgM. Its mother had transmitted the viral infection to her first child, who died of AIDS. Preliminary suggestions are made about the detection of different specific antibodies and clinical features; the utility of WB is emphasized.

Further evidence for the usefulness of the salivary testosterone radioimmunoassay in the assessment of androgenicity in man in basal and stimulated conditions

Since correct assessment of testicular function and androgenic status in humans requires multiple sampling, a sensitive and accurate radioimmunoassay (RIA) of testosterone (T) was established for male and female saliva samples. This easily collected biological fluid, which contains nonprotein-bound T, may represent an attractive alternative or a complement to total plasma T assays. In saliva samples from 5 normal males, a clear circadian rhythm was observed, and morning concentrations (135 +/- 31 pg/ml) were significantly higher (p less than 0.02) than evening samples (85 +/- 23 pg/ml). In 11 normal females, morning saliva levels were 12.8 +/- 1.8 pg/ml. The levels of T in male saliva, in response to both exogenous T administration (100 mg i.m.) and HCG stimulation (2 X 2,000 IU i.m.), accurately reflected the changes observed in plasma T, and the magnitude of increase in T levels was clearly greater in saliva than in plasma samples during the intramuscular administration of the long-acting T preparation. In males, significant correlations were observed between salivary and plasma T concentrations in morning samples (r = 0.61, p less than 0.01), following HCG stimulation (r = 0.89, p less than 0.05) and during T administration (r = 0.87, p less than 0.05). In women, the correlation at 8 a.m. was also significant (r = 0.82, p less than 0.05).

Maple syrup urine disease: two different forms within a single family

A family is reported in which the index case presented with an acute form of maple syrup urine disease (MSUD), whereas two of her sisters and her father were found to have an almost asymptomatic form of the disease. It is proposed that the members of this family are compound heterozygotes for the classical deficient mutant gene and for a "variant" allele.

Evidence for pancreas injury in adult respiratory distress syndrome

The purpose of this study was to investigate the relation between serum lipase (LP), serum immunoreactive trypsin (IRT), and its inhibitors in patients with adult respiratory distress syndrome (ARDS) of diverse origin and to compare their time course with other acute conditions. The IRT and LP levels were determined at regular intervals in 41 patients hospitalized in the intensive respiratory unit with ARDS (n = 9), acute pancreatitis (n = 5), shock (n = 9), bronchopneumonia (n = 10), or acute cardiogenic pulmonary edema (n = 8). Several trypsin inhibitors were measured simultaneously: serum trypsin inhibitory capacity (TIC), alpha 1-antitrypsin, alpha 2-macroglobulin, and antithrombin III. Concomitantly, angiotensin-converting enzyme (ACE) activity was determined as a potential marker of the endothelial injury. A respective 19- and 13-fold increase in IRT and LP values were observed in patients with ARDS after a mean evolution of 6 days; similar increases were seen in patients with pancreatitis. These values were significantly higher than those observed in the other conditions studied. In patients with ARDS and acute pancreatitis, the evolution of IRT and LP values were associated with a sixfold rise in TIC. A low TIC/IRT ratio in patients with ARDS appeared to be an index of poor prognosis. Conversely, ACE activity evolution was characterized by an early decrease in all the conditions studied. These observations indicate that there is an acute delayed pancreas injury in ARDS. Thus, the release of pancreatic enzymes are not reliable markers of the early evolution of the disease but they may represent secondary mediators for enhancement of the increased endothelial permeability.

Atypical phenylketonuria with "dihydrobiopterin synthetase" deficiency: absence of phosphate-eliminating enzyme activity demonstrated in liver

An assay for the phosphate-eliminating enzyme (PEE) activity in liver was developed which required only 5-10 mg tissue. PEE catalyses the elimination of inorganic triphosphate from dihydroneopterin triphosphate, which is the second and irreversible step in the biosynthesis of tetrahydrobiopterin (BH4). In the presence of substrate, magnesium, NADPH, and a sepiapterin reductase fraction from human liver, PEE catalysed the formation of BH4 which was measured by HPLC and electrochemical detection. In adult human liver, a PEE activity of 1.02 +/- 0.134 microU/mg protein (mean +/- 1 SD; n = 5) was observed. In liver needle biopsy material from five patients with defective biopterin biosynthesis, no PEE activity was found (less than 2% and 6% of the control values, respectively). The presence of an endogenous inhibitor was excluded. In a patient who died without definite diagnosis and in a patient with beta-thalassaemia liver PEE activity was increased. Sepiapterin reductase activity was present in all cases. Results indicate that in "dihydrobiopterin synthetase" deficiency, the most frequent of the rare BH4-deficient variants of hyperphenylalaninaemia, the molecular defect consists in a defect of PEE.

Isolation of lymphadenopathy-associated virus (LAV) and detection of LAV antibodies from US patients with AIDS

A human retrovirus was isolated from the peripheral blood of three American patients newly diagnosed with the acquired immunodeficiency syndrome (AIDS). In each case the major core viral protein (p25) was shown to be antigenically identical to that of the prototype lymphadenopathy-associated virus (LAV). Two of the viral isolates were derived from intravenous narcotics abusers, the first demonstration of LAV isolation from this risk group. Antibody to LAV was detected by an IgG enzyme-linked immunosorbent assay in the serum samples of these and 14 additional American patients with AIDS and in none of 12 hospital worker controls. These findings provide support for the etiologic association of LAV and AIDS.

Monitoring of serum levels of imipramine and desipramine and individualization of dose in enuretic children

The serum levels of imipramine (IMI) and its active metabolite desipramine (DMI) were monitored in 90 children with primary nocturnal enuresis. Ages ranged between 5 and 14 years. Serum concentrations were determined in 21 children at 24 h after administration of a dose of 75 mg and once when steady state had been reached, 12 h after the last dose; a good correlation was seen between the total levels (IMI + DMI) on those two occasions (r = 0.81; p less than 0.01). This serves as a basis to predict the steady-state levels of IMI + DMI reached in an individual patient. In the remaining patients the serum levels of IMI + DMI were determined at steady state. Dosage regimens were adjusted individually to obtain a favorable response with regard to the frequency of enuresis and to the possible occurrence of side effects. Good correlation was established between the serum concentrations of IMI + DMI at steady state and the frequency of enuresis, with a favorable response being obtained for levels greater than 80 ng/ml. Monitoring of serum levels leads to better compliance with the regimen throughout treatment.

Induction of cellular DNA polymerases in a Burkitt lymphoma-derived cell line by treatment with 5-iododeoxyuridine

Cellular DNA polymerases of a Burkitt lymphoma-derived cell line (P3HR-1) were found to be greatly induced by treatment of the cells with 5-iododeoxyuridine (IUdR) at a concentration which induces Epstein-Barr virus (EBV) early antigen (EA) expression. The activities of all the DNA Polymerases alpha, beta and gamma in P3HR-1 cells increased 7-9 fold by exposure of the cells to IUdR (25 micrograms/ml) for 3 days, while the EBV-coded DNA polymerase activity in the cell remained undetectable under the assay conditions employed. Under the same culture conditions with IUdR, EA-positive P3HR-1 cells increased to 16.6% which was much higher than that of the non-treated control cells (0.32%). On the other hand, another Burkitt lymphoma cell line, Raji, had very low incidence (1.27%) of EA induction by IUdR-treatment and the level of DNA polymerase activities remained almost unchanged. From these results it seems that the increase in DNA polymerase activity during the treatment of P3HR-1 cells with IUdR is closely related to high incidence of EA expression in these Burkitt lymphoma cells. Also, the finding has revealed yet unknown effect of IUdR on cultured cells and provides a useful tool to obtain a large quantity of the induced cellular DNA polymerases from the P3HR-1 and KB cells.

Isolation of human T-lymphotropic retrovirus (LAV) from Zairian married couple, one with AIDS, one with prodromes

A Zairian married couple had been living in France since 1981. The man had acquired immunodeficiency syndrome (AIDS) and his wife had prodromes of the disorder. Infection with a human T-lymphotropic retrovirus (lymphadenopathy-associated virus) was demonstrated in both by isolation of the virus from their cultured lymphocytes and the detection of specific antibodies in serum samples. Since this virus has been isolated from patients in other AIDS risk categories, the finding of the virus in AIDS patients from the African group adds further support to the hypothesis that this human retrovirus is the AIDS aetiological agent.

Evidence for the presence of a neutral insulinotrophic peptide in the porcine duodenum

A crude mixture of thermostable peptides extracted from porcine duodenum was fractionated by electrofocusing. A neutral fraction, different from the basic fractions of GIP, VIP, PHI, and CCK was found to promote insulin secretion when injected in vivo to normal rats. This neutral fraction, extracted from the crude mixture by chromatography, stimulated insulin output from an isolated rat pancreas and enhanced glucose-induced insulin release. The insulinotrophic effect of this partially purified duodeno-jejunal material disappeared following digestion with trypsin. The insulin-releasing activity was found to correspond to a compound of molecular weight higher than that of insulin (i.e. higher than 6000). No GIP-like immunoreactivity was found in this neutral fraction indicating that the active peptide(s) are not GIP related compounds. These observations suggest that porcine duodenum contains and incretin activity different from that of the insulinotrophic factors already reported.

Hudson memorial lecture. Neonatal management of organic acidurias. Clinical update

Therapeutic guidelines have been obtained from a retrospective review of 41 patients affected with organic acidaemias, 16 patients with neonatal maple syrup urine disease (MSUD), 11 methylmalonic acidaemia, (MMA) seven propionic acidaemias (PA) and seven isovaleric acidaemias (IVA), and by comparing this personal series with similar reported cases. The emergency treatment of these organic acidurias in the neonate has to main goals: toxin removal and anabolism. Anabolism is always promoted by early diet therapy. The best method of toxin removal depends on the nature of the defect; peritoneal dialysis with exchange transfusions or multiple or prolonged exchange transfusions in MSUD and in PA, diuresis and exchange transfusions in MMA and glycine supplementation in IVA. Vitamin supplementation (thiamine 20 mg, biotin 10 mg, B12 2 mg and riboflavin 100 mg) should be tried in all cases although the neonatal forms of these defects are very rarely vitamin responsive. Additional treatments such as carnitine or insulin may prove to be useful.

Phenylalanine hydroxylase. Evidence that the enzyme from human liver might not be a phosphoprotein

Phenylalanine hydroxylase from fresh human liver was purified to homogeneity with a 60% yield by a three steps procedure involving hydrophobic chromatography on Phenyl-Sepharose, ion exchange chromatography on DEAE-Cellulose and High Performance gel permeation chromatography. The purified native enzyme had an estimated molecular weight of 165,000. It gave a single band on Sodium Dodecylsulfate polyacrylamide gel electrophoresis under an estimated molecular weight of 55,000. Neither the purified human enzyme, nor that present in a liver extract could be activated under phosphorylating conditions. Moreover, the purified human liver phenylalanine hydroxylase was found to be devoid of protein-bound phosphate and no phosphate could be incorporated from [32P]-ATP in the presence of cyclic-AMP - dependent protein kinase. These data suggest that phenylalanine hydroxylase from human liver, unlike that of rat liver, might not be a phosphoprotein.

Effects of droperidol on respiratory drive in humans

The sensitivity of the respiratory center following a single 0.3 mg X kg-1 iv dose of droperidol was determined in eight healthy volunteers by using carbon dioxide (CO2) rebreathing and mouth occlusion pressure measurements (P0.1). There were no significant differences in the mean slopes of the minute ventilation/partial pressure of CO2 (VE/PCO2) and log P0.1/PCO2 relationships between control measurements and those made 30, 60, 90, 150, and 240 min after droperidol administration. However, individual variations in response were present, one subject showing significant (approximately 50%) depression of respiratory drive.

Isolation of a T-lymphotropic retrovirus from a patient at risk for acquired immune deficiency syndrome (AIDS)

A retrovirus belonging to the family of recently discovered human T-cell leukemia viruses (HTLV), but clearly distinct from each previous isolate, has been isolated from a Caucasian patient with signs and symptoms that often precede the acquired immune deficiency syndrome (AIDS). This virus is a typical type-C RNA tumor virus, buds from the cell membrane, prefers magnesium for reverse transcriptase activity, and has an internal antigen (p25) similar to HTLV p24. Antibodies from serum of this patient react with proteins from viruses of the HTLV-I subgroup, but type-specific antisera to HTLV-I do not precipitate proteins of the new isolate. The virus from this patient has been transmitted into cord blood lymphocytes, and the virus produced by these cells is similar to the original isolate. From these studies it is concluded that this virus as well as the previous HTLV isolates belong to a general family of T-lymphotropic retroviruses that are horizontally transmitted in humans and may be involved in several pathological syndromes, including AIDS.

Clinical usefulness and methodology of immunological assay of pancreatic enzymes

Radioimmunoassays for plasma pancreatic enzymes, especially cationic trypsin, are good tools to diagnose pancreatic pathology. The trypsin assay is very sensitive. Its detection limit is 300 pg/ml. The plasma level of this enzyme appears to be representative of pancreatic function. This assay was shown to be valuable in the diagnosis of acute pancreatitis, and to follow the course of the disease. In chronic pancreatitis, it enables assessment of residual function of the organ. In the terminal stage of this disease, very low values were found. Used as a screening test, the assay allowed early detection of cystic fibrosis.

[Heterogeneity of leucinosis. Correlations between clinical manifestations, protein tolerance and enzyme deficiency]

Maple syrup urine disease (MSUD) is an inborn error of branched-chain aminoacid (BCAA) catabolism due to a defect of BC ketoacid decarboxylation. Beside the classical form of the disease, general variant forms have been recently reported. From our personal experience in 21 patients consisting of 14 patients with classical MSUD and 7 patients with "variant" forms (1 intermittent, 2 subacute forms, 1 lipoamide dehydrogenase deficiency and 3 composite heterozygotes), we tried to correlate clinical features with protein tolerance and enzyme activity. All classical forms share an acute neonatal presentation, with a low leucine tolerance (m +/- SD = 465 +/- 88 mg per day), and a very low enzyme activity (m +/- SD = 2.5 +/- 1.5% of controls), mild variations being consistent with a possible polyallelism within this group. All "variant" forms share a late onset with a reasonable leucine tolerance (2-3 grams per day) and a fair enzyme activity, ranging from 7 to 20% of controls. However, no strict correlation could be found between the severity of the outcome and the extent of the residual enzyme activity, since acute episodes or chronic deterioration occurred even in "variants", irrespective of the level of their enzyme activity. Finally, our data suggest that variant forms could result from a composite heterozygotism, combining heterozygotism for the gene of classical MSUD and heterozygotism for a "petite" mutation, undetectable when isolated. The occurrence of classical MSUD and "variant" forms of the disease within a single family of our series further supports this hypothesis.

Thoracoscopic lung biopsy. Experimental and clinical preliminary study

We have investigated thoracoscopic lung biopsy (TLB) as an alternative to surgical biopsy. TLB was performed under mild general anesthesia, with two openings: one for the telescope, and one for a 5 mm in diameter biopsy forceps connected to diathermocoagulating device. TLB was first tested on 14 dogs (22 TLB) and then on 75 subjects (77 TLB): 35 patients with pleural diseases and 40 patients with undiagnosed lung diseases despite previous investigations including transbronchial biopsy. TLB yielded a high rate of adequate samples (up to 5 x 5 x 5 mm) in both experimental (95 percent) and clinical series (96 percent). Overall sensitivity equalled 923 percent, ranging from 70 percent in peripheral localized lesions to 100 percent in diffuse lung diseases. The mean period of systematic drainage was 3.4 +/- 0.3 days, and the main complications we encountered were one transient blood-streaked sputum specimen and eight localized pneumothoraces during drainage. TLB is indicated when other medical procedures have failed, and has thus proved, in this series, to be as sensitive as surgical biopsy with less morbidity and no mortality.

[EEG sleep activity in a phenylketonuric child of the 'new variant' type, before and after treatment with 5-HTP and L-DOPA (author's transl)]

The EEG during the sleep of a 'new variant' (having a dihyropteridine reductase deficiency) phenylketonuric child, aged 11 months, has been studied under low phenylalanine and following a substitute treatment with 5-HTP and L-DOPA. Prior to treatment, a paroxystic type of activity composed of spikes and/or polyspikes associated with sharp theta waves was chiefly observed during paradoxical sleep (PS). After a 10 day treatment with 5-HTP and L-DOPA, the EEG was not modified. However, after 6 months of this therapy, the paroxysms disappeared as well as the spindles; the quiet sleep trace was disorganized. The EEG modifications observed could be due to an evolution of the illness, if the substitute treatment was begun too late to go into effect.

Serotonin and dopamine synthesis in phenylketonuria

Two regulation systems of the serotonin and dopamine biosynthesis in patients with classical and atypical PKU were investigated. In classical PKU, the serotonin and dopamine biosynthesis is inhibited by high L-phenylalanine in blood and tissues. The dopamine formation in vivo was inhibited by phenylalanine blood concentrations higher than 25 mg/dl: the serotonin formation was inhibited even at a phenylalanine blood concentration of only 8 mg/dl. In two patients with dihydrobiopterin synthetase deficiency, the dopamine, and even more pronounced the serotonin, excretions are considerably reduced. The dopamine excretion was reduced to about 50% and the serotonin excretion to only 10% compared to controls. Under BH4 therapy (16 mg daily), the dopamine values increased about twice, serotonin threefold and the phenylalanine blood concentration normalized to 1-1.5 mg/dl. On loading a patient with BH2 synthetase deficiency with 50 mg/kg deuterated tryptophan-d5 and 150 mg/kg deuterated tyrosine d2 (phenylalanine blood concentration of 16 mg/dl), deuterated dopamine d1 and serotonin d4 could only be formed in detectable amounts after BH4 administration. During BH4 therapy the amount of dopamine d1 and serotonin d4 formed was lower than but comparable to normal controls.

In vivo studies of the tryptophan-5-hydroxylase system. Quantitation of serotonin and tryptamine using gas chromatography-mass fragmentography

An in vivo determination of tryptophan-5-hydroxylase (E.C. 1.14.16.4) activity is described. Subjects were loaded with deuterated L-tryptophan-d5 (50 mg/kg body weight) and the deuterated serotonin-d4 in urine was analysed using mass fragmentography. Four control subjects were dosed orally and two of them also intravenously with 50 mg/kg of L-tryptophan-d5. One patient with atypical phenylketonuria (PKU) due to a tetrahydrobiopterin (BH4) deficiency was dosed without and during BH4 treatment. Without BH4, the patient showed only minor formation of deuterated serotonin. After BH4 administration (2.5 mg/kg body weight) the serotonin formation increased about four-fold but was not normalized. Serotonin in urine and blood was analysed as the pentafluoropropionyl (PFP) derivative using gas chromatography-mass fragmentography. Deuterated serotonin was used as internal standard. The analysis of tryptamine can be performed with the same procedure.

[Perfusion study of intestinal sugar absorption after extensive intestinal resection (author's transl)]

Small bowel adaptation after extensive intestinal resection has been studied in 5 children. A segmental perfusion technique was used to evaluate the kinetics of glucose absorption and sucrose hydrolysis. The activity of 6 brush border hydrolases and the mean villus height were measured in intestinal biopsies. Glucose absorption was greater than in 3 control children of the same age and was almost complete. Sucrose hydrolysis was increased in the same proportion and the maximum capacity of the segment was 2 mmol/min/20 cm as compared to 1.2 mmol/min/20 cm in the control group. Absorption of the released monosaccharides was complete for glucose and as high as in controls for fructose. Brush border hydrolase activities were identical to those of controls whereas the mean villus height was increased (438 micrometer as compared to 342 micrometer) although the difference was not significant. These results demonstrate the functional adaptation of the remaining small bowel and confirm that it is due to compensatory hyperplasia.

Excretion of pterins in phenylketonuria and phenylketonuria variants

Total urinary biopterin (B), neopterin (Ne) and monapterin (M) were measured in 25 healthy newborns, children and adults, in 49 patients with phenylketonuria (PKU) assumed to be deficient in phenylalanine-4-hydroxylase (PH), in 7 patients with dihydrobiopterin synthetase (DHBS) deficiency and in 4 patients with dihydropteridine reductase (DHPR) deficiency. Excretion of Ne based on creatinine (Ne/C) was 6.6 times higher in healthy newborns than in adults, suggesting a slow maturation of DHBS activity. Newborns excreted more Ne than B and adults more B than Ne (32 and 72% B of the sum of B + Ne, respectively). In all cases, excretion of M was 4-15% of that of Ne. PH deficient patients excreted more B and Ne than healthy controls and again, newborns more than older children. In individual patients, excretion of pterins correlated with phenylalanine (Phe) concentration in plasma; plasma Phe of different patients did not correlate well with excretion of pterins. In PKU variants with deficiency of tetrahydrobiopterin (BH4), extreme pterin patterns were observed: in DHBS- and DHPR-deficient patients, less than 3.5 and more than 81% B were found, respectively. All 30 samples from these patients investigated could be distinguished from those of PH-deficient patients and controls by a two-dimensional plot of % B versus B/C. Thus it seems likely that PKU variants due to BH4 deficiency could be detected early and differentiated by measurement of urinary B, Ne and C. This was exemplified already in one case. - In urine of patients with DHBS deficiency, high concentrations of 3'-hydroxysepiapterin were found in addition to Ne.

Biopterin defect in a normal-appearing child affected by a transient phenylketonuria

A child diagnosed as having transient phenylketonuria was found to have reduced synthesis of tetrahydrobiopterin and an abnormal clearance of phenylalanine, but he remained clinically normal when on a normal diet. A small amount of 7,8-dihydrobiopterin was found in his serum; this distinguishes the case from that of malignant hyperphenylalaninaemia.