Pharmacokinetics and anti-emetic efficacy of BRL43694, a new selective 5HT-3 antagonist

Twenty patients receiving a variety of emetogenic cytotoxics (including cisplatin in 5) were given a single i.v. infusion of 40 micrograms kg-1 of BRL43694 (as the hydrochloride salt) in successive groups of 3-4 patients between 0-6 hours after chemotherapy. Eleven patients were completely protected from vomiting; 9 had mild to moderate nausea and vomiting, but none severe enough to require alternative anti-emetic 'rescue'. In 4 of the patients in whom BRL43694 was delayed until 4-6 h after chemotherapy, vomiting had already begun; in each case immediate termination of vomiting occurred when BRL43694 was infused. No adverse effects attributable to the anti-emetic were observed. Mean pharmacokinetic parameters in 14 patients in whom plasma assay data are available were: Maximum observed concentration = 30.7 ng ml-1; terminal phase half-life = 8.96 h; total body clearance = 0.376 (1 h-1) kg-1; apparent volume of distribution = 2.85 l kg-1. This study shows BRL43694 to be an effective and well tolerated anti-emetic. Further studies aimed at defining an optimal dose and schedule for use against the most emetogenic cytotoxics are in progress.

Family members as third parties in dyadic family conflict: strategies, alliances, and outcomes

Systems theorists have argued that triads rather than dyads need to be considered as a basic interaction unit, particularly in regard to episodes of conflict. While theoretically appealing, the description of the strategies used and alliances formed when third parties intervene in dyadic conflict presents a number of conceptual and empirical challenges. In the present report, a reliable system for coding such third-party participation in verbal conflicts is described and is used to analyze routine family conflicts that were observed during dinner. A number of specific findings of interest are reported, including that girls were more likely than boys to intervene in all family disputes except marital conflicts, that mothers and fathers rarely sided against each other when intervening as third parties, and that the third-party strategies most commonly used corresponded with family roles: fathers used authority strategies, mothers used mediational tactics, and children used distraction. Of greater importance, however, are the general findings that document the influence of third parties on dyadic conflict. Additional family members frequently joined dyadic family conflicts, they were about equally likely to attempt to end or to continue the conflict, they formed alliances about half of the time, and their intervention strategies were related to the outcome of the conflict as well as its patterning.

Flavone acetic acid: a nonlinear pharmacokinetic model

Flavone acetic acid pharmacokinetics were studied in 31 patients in a phase I clinical trial. The drug was given by i.v. infusions over 1, 1.5, 3, and 6 h at doses ranging from 0.5 to 6.4 g/m2. The pharmacokinetic parameters were determined according to a nonlinear model including Michaelis-Menten-type kinetics. The mean elimination half-life is 4.8 h and the mean volume of distribution of the central compartment, 7.61. Our model predicted a maximal tolerated dose (MTD) of 11.1 g/m2 on the basis of the "therapeutic window" concept, very close to the clinically observed MTD of 10 g/m2. This model is also operational when different protocols of inoculation are considered, such as a divided-dose schedule vs a unique infusion, and indicates that, at the MTD, injections should be made every 72 h to avoid drug accumulation.

Cardiotoxicity of mitozantrone assessed by stress and resting nuclear ventriculography

Fourteen patients with advanced breast cancer were treated with a combination of vincristine, mitozantrone and prednisolone. Before, during and after cessation of treatment radionuclide assessment of ventricular performance was obtained at rest, in response to cold pressor-induced stress and on recovery from stress. Six of 14 patients (46%) developed abnormalities of left ventricular ejection fraction (LVEF). One patient developed clinical signs of cardiac failure. Mitozantrone is an active agent in the treatment of advanced breast cancer but it can produce cardiotoxicity. In this particular middle-aged population, changes in LVEF occurred over a wide range of cumulative doses. Further investigation is required to determine the nature and prognosis of this iatrogenic toxicity.

Child-mother attachment and the self in six-year-olds

Bowlby has proposed that child-parent attachment is important in the child's representation of self. In this study, the child's representation of self was examined in connection with child-mother attachment in a sample of 52 white, middle-class 6-year-olds. Children were seen in 2 play sessions, 1 month apart. Quality of attachment was assessed in each session based on the child's behavior on reunion following a laboratory separation of approximately 1 hour, using a system devised by Main and Cassidy. Aggregated attachment ratings and classifications were assigned based on the child's behavior in both reunions. Assessments of the self consisted of (a) assessment of the self within the relationship with the attachment figure (an incomplete doll stories procedure), (b) assessment of the child's perceptions of how an unspecified "other" views him or her (a puppet interview), (c) direct assessment of global self-esteem independent of the attachment relationship (the subscale of global self-esteem from Harter's Perceived Competence Scale for Children), (d) a second direct assessment of global self-esteem (an interview with the child), and (e) assessment of feelings of competence and acceptance in specific domains that may be precursors of self-esteem (Harter's Scale of Perceived Competence and Social Acceptance for Young Children). Significant, albeit modest, connections between attachment and the self were established; furthermore, specific patterns of self-perceptions were related to particular patterns of attachment.

Phase I and pharmacokinetic study of flavone acetic acid

Flavone acetic acid is the second in a series of compounds based on the flavonoid aglycone ring structure to be clinically evaluated in malignant disease. Preclinical studies have indicated that a minimum plasma level of 150 micrograms/ml is required before therapeutic efficacy (in a wide range of experimental tumors) is seen in mice; both in vitro and in vivo studies also suggest that the duration of drug exposure is crucial in determining activity. Thus a Phase I trial has been performed in a total of 54 patients using 3 schedules, i.e., a 1-, 3-, and 6-h infusion. In each case, treatment was given once weekly for a minimum of 3 weeks. The maximum tolerated doses were 6.4, 6.4, and 10.0 g/m2, respectively. Dose limiting toxicity was denoted by an intense feeling of warmth and flushing with a 1-h infusion, hypotension with a 3-h infusion, and hypotension and diarrhea with a 6-h infusion. No objective responses were seen in this Phase I trial. The recommended doses for Phase II trials of flavone acetic acid in Europe are 4.8 g/m2 over 1 h or 8.6 g/m2 over 6 h. At these doses the peak plasma concentrations obtained are 650 and 388 micrograms/ml, respectively. Total drug exposure (assessed by an area under the curve greater than 100 micrograms/ml) was approximately 50% greater for the 6-h schedule. This Phase I trial indicates that peak plasma concentrations associated with experimental activity are achievable in humans, although optimal drug exposure times have not yet been defined.

Phase I and pharmacokinetic study of LM985 (flavone acetic acid ester)

We have conducted a Phase I and initial clinical pharmacological evaluation of LM985, the first of a series of compounds based on the flavone ring structure to be considered for clinical trial in malignant disease. The drug was administered i.v. to 26 patients with advanced cancer on an every-21-day schedule. Patients were treated at 14 dosage levels ranging from 10 to 1500 mg/m2. Dose limiting toxicity was identified as acute reversible hypotension occurring during drug infusion; no leukopenia, alopecia, hepatic toxicity, or renal toxicity was observed, but at the higher dose range, mild sedation was apparent. Twenty patients had measurable disease and were evaluable for response. One patient with colorectal carcinoma had stable disease after three courses of LM985; however, no other responses were seen. Pharmacokinetic and in vitro drug degradation studies imply that the ester LM985 is hydrolyzed to LM975 (flavone acetic acid) rapidly in vivo. LM975 is active in a variety of animal tumor models, but it does not have the cardiovascular side effects seen with LM985 (hypotension and bradycardia) in pithed or anesthetized rats. We would recommend that LM975 be considered for clinical trial, because it seems likely that substantially higher doses of LM975 than of LM985 can be given without dose limiting cardiovascular toxicity.

Increasing the response rate to cytotoxic chemotherapy by endocrine means

Cloned cell lines of human breast cancer can be growth inhibited by tamoxifen and this inhibition can be reversed by estrogen. We wondered whether tamoxifen inhibition of breast cancer followed by estradiol reversal would increase the efficacy of chemotherapy by increasing the fraction of rapidly cycling cells. We describe a clinical trial in which 110 patients were prospectively randomized to chemotherapy consisting of cytoxan 750 mg/m2 and adriamycin 30 mg/m2 on Day 1 plus 5-FU 500 mg/m2 and methotrexate 40 mg/m2 on Day 8 vs the same chemotherapy plus tamoxifen 20 mg/m2 Days 2-6 and premarin 0.625 mg Q 12-H X 3 on Day 7. Chemotherapy was given in 21-day cycles. 108 patients were evaluable. No difference exist for any important prognostic variables. The first 55 patients were randomized to a regimen in which 5-FU preceded methotrexate by 24 h; thereafter, all patients received methotrexate followed in 1 h by 5-FU. No difference in any response parameter was seen between these two 5-FU methotrexate schedules. No differences in percent of protocol chemotherapy administered or observed toxicity was seen between the 2 regimens. Objective response rate was nearly identical--57% without and 64% with additional hormones. Prior adjuvant chemotherapy with L-PAM had no observable effect on response rate, response duration or survival. In a limited number of patients with inflammatory breast cancer we saw a significantly higher response rate (93 vs 61%; P = 0.03) than in patients with recurrent metastatic disease. Time to progression (13 vs 17 months) and survival (17 vs 23 months) of responders significantly favored the treatment arm including tamoxifen and premarin. Greater benefits of additional tamoxifen and premarin were seen in partial vs complete responders. This may have resulted from lower doses of chemotherapy given to patients achieving a complete remission. An additive effect of hormones plus chemotherapy cannot be entirely excluded as the explanation for the improved results seen with the addition of tamoxifen for 4 days plus 1 day of premarin. We believe that our results suggest that further efforts to increase the efficacy of chemotherapy by perturbing tumor growth rates may be worthwhile.

Simulation of edge effects in electroanalytical experiments by orthogonal collocation. Part V. Chronoamperometry at ultramicroelectrode ensembles

The use of orthogonal collocation in the treatment of the problem of an array of ultramicroelectrodes is presented and compared to existing digital simulation techniques.

Dynamic variability of binding of antiarrhythmic drugs during the evolution of acute myocardial infarction

We tested the hypothesis that the changes in free fatty acid and alpha 1-glycoprotein concentrations, which occur during acute myocardial infarction, exert asynchronous and opposing influences on the serum protein binding of selected drugs. Free drug fractions of two antiarrhythmic agents with contrasting binding characteristics, quinidine and procainamide, were related to free fatty acid and alpha 1-glycoprotein concentrations on days 1 through 5 and 10 in 20 patients with acute myocardial infarction. The mean free quinidine fraction was elevated on day 1 (9.0 +/- 4.4% vs 6.7 +/- 2.7% in patients with stable heart disease; p less than .05) and fell progressively to day 10 (4.0 +/- 2.8%; p less than .0002) as free fatty acid concentration decreased (day 1 = 464 +/- 272 meq/liter; day 10 = 264 +/- 155 meq/liter; p less than .01) and alpha 1-glycoprotein concentration increased (day 1 = 98 +/- 31 mg/dl; day 10 = 141 +/- 47 mg/dl; p less than .02). Multiple stepwise regression showed a major influence of changing alpha 1-glycoprotein concentration on the observed sequential changes in the free quinidine fraction (p less than .005). In contrast, no serial changes in procainamide binding were noted. In conclusion, metabolic changes during the course of acute myocardial infarction sequentially alter free quinidine fraction and, consequently, may influence pharmacodynamics.

A randomized attempt to increase the efficacy of cytotoxic chemotherapy in metastatic breast cancer by hormonal synchronization

Human breast cancer cells in tissue culture can be growth inhibited by tamoxifen, an inhibition that can be reversed by estrogen. The question of whether tamoxifen inhibition of breast cancer followed by estradiol reversal would increase the efficacy of chemotherapy was asked. One hundred ten patients were prospectively randomized to chemotherapy consisting of cytoxan (750 mg/m2) and Adriamycin (30 mg/m2) on day 1 plus 5-fluorouracil (5-FU) (500 mg/m2) and methotrexate (MTX, 40 mg/m2) on day 8 versus the same chemotherapy plus tamoxifen (20 mg/m2) on days 2-6 and premarin (0.625 mg every 12 hours for three days) on day 7. Chemotherapy was given in 21-day cycles. The first 55 patients were randomized to a regimen in which 5-FU preceded MTX by 24 hours; thereafter, all patients received MTX followed in one hour by 5-FU. No difference in any response parameter was seen between these two 5-FU/MTX schedules. A limited number of patients with inflammatory breast cancer had a significantly higher response rate (93% versus 61%; p = 0.03) than patients with recurrent metastatic disease. Time to progression (13 versus 17 months) and survival (17 versus 23 months) of responders significantly favored the treatment arm including tamoxifen and premarin. Whereas an additive effect of hormones plus chemotherapy cannot be entirely excluded as the explanation for the improved results with the addition of tamoxifen for four days plus one day of premarin, results suggest that further efforts to increase the efficacy of chemotherapy by perturbing tumor growth rates may be worthwhile.

Phase II trial of 13-cis-retinoic acid in metastatic breast cancer

Studies have suggested that both natural and synthetic retinoids have extensive chemopreventive activity against a variety of carcinogens in vivo and in vitro. We have previously shown that growth of human breast cancer cells can be inhibited by retinoids, and retinoic acid-binding proteins have been demonstrated in these cell lines and tumor biopsies. We studied the activity of 13-cis-retinoic acid in the treatment of 18 patients with advanced breast cancer refractory to standard cytotoxic and/or endocrine therapy. Patients began on 0.5 mg/kg and escalated to 8 mg/kg over a one-month period unless toxicity (dry skin, dry mucosa, cheilitis, conjunctivitis) forced dose reduction. All these toxicities responded promptly to dose reduction. Four patients exhibited drug related hypercalcemia, 2 complained of severe earache and several had nausea, vomiting and abdominal cramping. There were no objective responses as defined by standard criteria. One patient with thrombocytopenia secondary to documented marrow involvement demonstrated a recovery of platelet count from 9000 to 110,000. 13-cis-Retinoic acid is not of apparent value in women with heavily pretreated breast cancer.

cis-Dichlorodiammineplatinum(II) for the treatment of advanced ovarian cancer

cis-Dichlorodiammineplatinum(II) (cis-platinum) was used in the treatment of 25 patients with advanced ovarian adenocarcinoma refractory to alkylating agents. Seven of 24 evaluable patients (29%) responded to cis-platinum (one complete response and six partial responses). Life-table analysis of survival indicates that patients responding to therapy survive longer than those who fail to respond (9 months versus 3.2 months) (P = 0.014). In previously treated patients given 70 mg/m2 iv with forced diuresis, there was substantial nausea and vomiting (100%), hematologic toxicity (67%), and renal toxicity (34%). A review of the single-agent activity of cis-platinum in other ovarian cancer studies indicates an overall response rate of 25% (40 of 161 patients). At least nine combination chemotherapy studies utilizing cis-platinum are in progress, and preliminary information from several of these is encouraging and suggests that cis-platinum-containing combinations may have a major role in the treatment of ovarian adenocarcinoma.

Correlation of mean pulmonary artery wedge pressure, left atrial dimention, and PTF-V1 in patients with acute myocardial infarction

The mean pulmonary artery wedge pressure (PAWP), left atrial dimension (LAD) by echocardiography, and PTF-V1 in the electrocardiogram were correlated with each other in 16 patients with acute myocardial infarction in the control period and after therapeutic intervention with either Dextran or furosemide and/or nitroprusside. No significant correlation was found between a normal control PAWP and the LAD. An increased control PAWP correlated well with an increased LAD (r = 0.98). No significant correlation was found between the LAD and the PAWP whether normal or elevated after therapeutic intervention. No significant correlation was found between the PAWP whether normal or elevated and the PTF-V1. No significant correlation was found between the LAD and the PTF-V1. We conclude in acute myocardial infarction 1) the PTF-V1 is not useful in assessing PAWP before or after therapeutic intervention, 2) the LAD correlates poorly with a normal control PAWP but correlates well with an elevated control PAWP, and 3) the LAD cannot be used to assess PAWP after therapeutic intervention.

High reversion of atrial flutter to sinus rhythm after atrial pacing in patients with pulmonary disease

The effect of atrial pacing on atrial flutter was evaluated in 36 consecutive episodes in 33 patients. Seventeen episodes occurred in a pulmonary setting, 14 of these in patients with chronic pulmonary disease. Twenty-four (67 percent) of the 36 episodes converted to sinus rhythm within one minute after atrial pacing. In nine (25 percent) of the 36 episodes, atrial fibrillation developed after atrial pacing. Atrial flutter was not affected by atrial pacing in three (8 percent) of the 36 episodes.n 12 (86 percent) of the 14 patients with chronic pulmonary disease and in 14 (82 percent) of the 17 patients in whom a pulmonary setting was responsible for atrial flutter, atrial pacing caused conversion to sinus rhythm. Atrial pacing may be the treatment of choice for atrial flutter in patients with pulmonary disease because of its excellent rate of success in this subgroup whose risk of cardioversion is increased by poor anesthetic tolerance and hypoxia.

Effect of timolol versus propranolol on hypertension and hemodynamics

The effect of timolol versus propranolol on hypertension, hemodynamics, and plasms renin activity was evaluated in 20 men. After two weeks of placebo, 11 men received timolol 30 to 60 mg daily, and nine men received propranolol, 240 to 480 mg daily, for five weeks in a double-blind randomized study. The 20 men then received placebo again for two weeks. Right heart catheterization was performed in all 20 patients after two weeks of the first placebo and after five weeks of timolol or propranolol. Equipotent doses of timolol and propranolol were equally effective in significantly lowering supine and upright systolic and diastolic blood pressure and heart rate recorded on an outpatient basis. Equipotent doses of timolol and propranolol caused similar hemodynamic effects including similar significant depression of cardiac index. Equipotent doses of timolol and propranolol caused similar marked depression of plasma renin activity. The hypotensive action of timolol and of propranolol was unrelated to their effect on plasma renin activity.

Effect of ethanol on angina pectoris

We evaluated the effect of ethanol on exercise performance until angina in 12 patients in a double-blind, randomized study. The mean resting heart rate times systolic blood pressure was not changed after Fresca but was increased after 2 ounces of ethanol (P less than 0.001) and after 5 ounces of ethanol (P less than 0.01). Compared to the control periods, the mean exercise time until angina was not different after Fresca but was decreased after 2 ounces of ethanol (P less than 0.001) and after 5 ounces of ethanol (P less than 0.001). Compared to the control periods, the mean maximal ischemic ST-segment depression after angina was not changed after Fresca but was increased after 2 ounces of ethanol (P less than 0.01) and after 5 ounces of ethanol (P less than 0.001). Drinking 5 ounces or 2 ounces of ethanol decreases exercise duration until angina and increases ischemic ST-segment depression after angina.

Effect of carbon monoxide on maximal treadmill exercise. A study in normal persons

The effect of breathing 100 ppm of carbon monoxide versus compressed, purified air for 1 h on maximal treadmill exericse was studied (double-blind crossover design) in 10 middle-aged, healthy nonsmokers. The mean venous carboxyhemoglobin level significantly increased from 1.67% to 3.95% after breathing carbon monoxide (P less than 0.001) and significantly decreased from 1.63% to 1.30% after breathing compressed, purified air (P less than 0.001). The mean exercise time until exhaustion significantly decreased from 697.7 to 662.7 s after breathing carbon monoxide (P less than 0.001) and insignificantly increased from 694.9 s to 703.4 s after breathing compressed, purified air. Ischemic S-T segment depression larger than or equal to 1.0 mm after exercise occurred in 1 of 10 subjects after exercise following carbon monoxide inhalation. Increased carboxyhemoglobin levels of the magnitude encountered after smoking or heavy atmospheric pollution impair exercise performance in normal persons.

Five year follow-up of double Master's test, maximal treadmill stress test, and resting and postexercise apexcardiogram in asymptomatic persons

The double Master's test, the maximal treadmill stress test, the resting apexcardiogram, and the postexercise apexcardiogram significantly correlated with the development of subsequent coronary heart disease within five years in 100 asymptomatic persons. The maximal treadmill stress test correlated better than the double Master's test in predicting subsequent coronary heart disease. The presence of both an abnormal maximal treadmill stress and an abnormal a-wave ratio in the postexercise apexcardiogram had the best value in predicting subsequent coronary heart disease.

Effect of smoking marihuana and of a high-nicotine cigarette on angina pectoris

The purpose of this study was to determine the effect of smoking marihuana and of high-nicotine cigarettes on exercise-induced angina pectoris. Smoking 1 marihuana cigarette increased the resting product of systolic blood pressure times heart rate 54%, increased the venous carboxyhemoglobin level, and decreased the exercise time until angina 50% in 10 patients with angina pectoris. Smoking 1 high-nicotine cigarette increased the resting product of systolic blood pressure times heart rate 36%, increased the venous carboxyhemoglobin level, and decreased the exercise time until angina 23%. Smoking either marihuana or high-nicotine cigarettes decreases exercise performance until angina by increasing myocardial oxygen demand and by decreasing myocardial oxygen delivery. Smoking 1 marihuana cigarette decreased the exercise time until angina more than smoking 1 high-nicotine cigarette (p less than 0.001).

The effect of isometric exercise on the systolic murmur of patients with idiopathic hypertrophic subaortic stenosis

The effect of isometric handgrip exercise on the systolic murmur and bifid pulse in patients with idiopathic hypertrophic subaortic stenosis (IHSS) was evaluated. During handgrip exercise, the systolic murmur became inaudible or decreased in intensity by auscultation and disappeared or decreased in amplitude in phonocardiographic recordings in nine of nine patients with IHSS. During handgrip exercise, the bifid pulse observed in seven patients with IHSS disappeared or markedly decreased. Handgrip exercise may be helpful in the bedside diagnosis of IHSS.

Effect of sublingual nitroglycerin on ejection fraction and left ventricular asynergy in coronary disease

After sublingual nitroglycerin, the ejection fraction increased at least 8 percent in 10 of 19 patients (53 percent), changed less than 8 percent in 5 of 19 patients (26 percent), and decreased at least 8 percent in 4 of 19 patients (21 percent). After sublingual nitroglycerin, 16 of 21 areas (76 percent) of hypokinesis improved, 2 (10 percent) did not change, and 3 (14 percent) became worse. After sublingual nitroglycerin, 6 of 6 akinetic areas did not change. After sublingual nitroglycerin, 2 of 3 dyskinetic areas did not change and one improved. Left ventriculography performed before and after sublingual nitroglycerin may be useful in predicting viable areas of ischemic myocardium.

Five-year follow-up of resting and postexercise phonocardiogram in asymptomatic persons

Phonocardiograms were recorded in 200 clinically normal adults, mean age 51 +/- 6 years, at rest and after a double Master's test. Five-year follow-up clinical data was obtained in 199 of these 200 subjects. The resting fourth heart sound correlated with the subsequent development of coronary heart disease within 5 years (p = 0.036). Neither the postexercise fourth heart sound nor the resing or postexercise third heart sound showed any correlation with the subsequent development of coronary heart disease within 5 years.

Effect of cigarette smoking and breathing carbon monoxide on cardiovascular hemodynamics in anginal patients

Smoking high-nicotine cigarettes caused a significant increase in systolic and diastolic arterial pressure, heart rate, left ventricular end-diastolic pressure, and coronary sinus, arterial, and venous CO levels, no significant change in left ventricular dp/dt, aortic systolic ejection period, and cardiac index, and a significant decrease in stroke index and coronary sinus, arterial, and venous PO 2 levels in eight anginal patients with documented coronary disease. One week later, these patients inhaled 150 ppm of carbon monoxide until their increase in coronary sinus CO was similar to that produced after smoking their third cigarette. Inhaling carbon monoxide caused a significant increase in left ventricular end-diastolic pressure and coronary sinus, arterial, and venous CO levels, no significant change in systolic and diastolic arterial pressure, heart rate, and systolic ejection period, and a significant decrease in left ventricular dp/dt, stroke index, cardiac index, and coronary sinus, arterial, and venous PO 2 levels. Nicotine caused the increased systolic and diastolic arterial pressure and heart rate after smoking. Carbon monoxide caused the negative inotropic effect which increased the left ventricular end-diastolic pressure and decreased the stroke index after smoking.