Bayesian network-based survival prediction model for patients having undergone post-transjugular intrahepatic portosystemic shunt for portal hypertension

BACKGROUND

Portal hypertension (PHT), primarily induced by cirrhosis, manifests severe symptoms impacting patient survival. Although transjugular intrahepatic portosystemic shunt (TIPS) is a critical intervention for managing PHT, it carries risks like hepatic encephalopathy, thus affecting patient survival prognosis. To our knowledge, existing prognostic models for post-TIPS survival in patients with PHT fail to account for the interplay among and collective impact of various prognostic factors on outcomes. Consequently, the development of an innovative modeling approach is essential to address this limitation.

AIM

To develop and validate a Bayesian network (BN)-based survival prediction model for patients with cirrhosis-induced PHT having undergone TIPS.

METHODS

The clinical data of 393 patients with cirrhosis-induced PHT who underwent TIPS surgery at the Second Affiliated Hospital of Chongqing Medical University between January 2015 and May 2022 were retrospectively analyzed. Variables were selected using Cox and least absolute shrinkage and selection operator regression methods, and a BN-based model was established and evaluated to predict survival in patients having undergone TIPS surgery for PHT.

RESULTS

Variable selection revealed the following as key factors impacting survival: age, ascites, hypertension, indications for TIPS, postoperative portal vein pressure (post-PVP), aspartate aminotransferase, alkaline phosphatase, total bilirubin, prealbumin, the Child-Pugh grade, and the model for end-stage liver disease (MELD) score. Based on the above-mentioned variables, a BN-based 2-year survival prognostic prediction model was constructed, which identified the following factors to be directly linked to the survival time: age, ascites, indications for TIPS, concurrent hypertension, post-PVP, the Child-Pugh grade, and the MELD score. The Bayesian information criterion was 3589.04, and 10-fold cross-validation indicated an average log-likelihood loss of 5.55 with a standard deviation of 0.16. The model's accuracy, precision, recall, and F1 score were 0.90, 0.92, 0.97, and 0.95 respectively, with the area under the receiver operating characteristic curve being 0.72.

CONCLUSION

This study successfully developed a BN-based survival prediction model with good predictive capabilities. It offers valuable insights for treatment strategies and prognostic evaluations in patients having undergone TIPS surgery for PHT.

Evaluation of renal function in chronic kidney disease (CKD) by mDIXON-Quant and Amide Proton Transfer weighted (APTw) imaging

BACKGROUND

Chronic kidney disease (CKD) is a long-term condition that affects >10% of the adult population worldwide. Noninvasive assessment of renal function has important clinical significance for disease diagnosis and prognosis evaluation.

OBJECTIVE

To explore the value of mDIXON-Quant combined with amide proton transfer weighted (APTw) imaging for accessing renal function in chronic kidney disease (CKD).

MATERIALS AND METHODS

Twenty-two healthy volunteers (HVs) and 30 CKD patients were included in this study, and the CKD patients were divided into the mild CKD (mCKD) group (14 cases) and moderate-to-severe CKD (msCKD) group (16 cases) according to glomerular filtration rate (eGFR). The cortex APT (cAPT), medulla APT (mAPT), cortex R2⁎ (cR2⁎), medulla R2⁎ (mR2⁎), cortex FF (cFF) and medulla FF (mFF) values of the right renal were independently measured by two radiologists. Intra-group correlation coefficient (ICC) test was used to test the inter-observer consistency. The analysis of variance (ANOVA) was used to compare the difference among three groups. Mann-Whitney U test was used to analyze the differences of R2⁎, FF and APT values among the patient and HV groups. Area under the receiver operating characteristic (ROC) curve (AUC) was used to analyze the diagnostic efficiency. The corresponding threshold, sensitivity, and specificity were obtained according to the maximum approximate index. The combined diagnostic efficacy of R2⁎, FF, and APT values was analyzed by binary Logistic regression, and the AUC of combined diagnosis was compared with the AUC of the single parameter by the Delong test.

RESULTS

The cAPT value of the HV, mCKD and msCKD groups increased gradually. The mAPT value and cR2⁎ values of the mCKD and msCKD groups were higher than those of the HV group, while the mFF value of the mCKD group was lower than HV group (all P < 0.05). The cAPT and mAPT values showed good diagnostic efficacy in evaluating different degrees of renal damage, while cR2⁎ and mFF values showed moderate diagnostic efficacy. When combining the APT, R2⁎, and FF values, the diagnostic efficiency was significantly improved.

CONCLUSION

mDIXON-Quant combined APTw imaging can be used for improved diagnosis of CKD.

Comparison of the clinical features of HIV-positive and HIV-negative hosts infected with Talaromyces marneffei: A multicenter, retrospective study

OBJECTIVES

Talaromyces marneffei is an emerging pathogen, and the number of infections in HIV-negative individuals is rapidly increasing. Nevertheless, there is no sufficient comprehensive report on this issue, and awareness needs to be raised among clinicians.

METHODS

We analyzed the differences in the clinical data of patients who are HIV-negative and HIV-positive with Talaromyces marneffei infection (TMI) from 2018 to 2022.

RESULTS

A total of 848 patients were included, among whom 104 were HIV-negative. The obvious differences between the HIV-positive and HIV-negative groups were as follows: (i) the patients who are HIV-negative were older and more likely to exhibit cough and rash, (ii) the time in days from symptom onset to diagnosis among patients who are HIV-negative was longer, (iii) the laboratory findings and radiological presentations seemed more severe in patients who are HIV-negative, (iv) differences were observed regarding the underlying conditions and co-infection pathogens, and correlation analysis showed that correlations existed for many indicators, (v) and persistent infection was more likely to occur in patients who are HIV-negative.

CONCLUSION

TMI in patients who are HIV-negative differs from that in patients who are HIV-positive in many aspects, and more investigations are needed. Clinicians should be more aware of TMI in patients who are HIV-negative.

TsOH-catalyzed acyl migration reaction of the Bz-group: innovative assembly of various building blocks for the synthesis of saccharides

We developed an efficient method to achieve the regioselective acyl migration of benzoyl ester. In all the cases, the reactions required only the commercially available organic acid catalyst TsOH·H₂O. This method enables the benzoyl group to migrate from secondary groups to primary hydroxyl groups, or from equatorial secondary hydroxyl groups to axial hydroxyl groups. The 1,2 or 1,3 acyl migration would potentially occur via five- and six-membered cyclic ortho acid intermediates. A wide range of orthogonally protected monosaccharides, which are useful intermediates for the synthesis of natural oligosaccharides, were synthesized. Finally, to demonstrate the utility of the method, a tetrasaccharide portion from a mycobacterial cell wall polysaccharide was assembled.

[Tuberculosis presenting as gastrointestinal perforation and large confluent pulmonary cavities: a case report]

We report an unusual case presented as acute gastrointestinal perforation and large confluent pulmonary cavities. A 23-year-old male was admitted to the emergency department with complaints of abdominal pain for 1 month, which exacerbated for 1 day. He also reported a 3-month history of diarrhea and productive cough. Computed tomography (CT) scan showed multiple large confluent cavities in the lung, along with massive free gas in the abdomen suggesting gastrointestinal perforation. Exploratory laparotomy was performed and affected bowel segment was resected. His sputum examination was positive for both acid-fast staining and Mycobacterium tuberculosis complex gene (Xpert) testing. Pathology of small intestine revealed micro-abscess formation and was positive for acid-fast bacilli. A final diagnosis of pulmonary tuberculosis and intestinal tuberculosis was made.

[Clinical characteristics of 272 437 patients with different histopathological subtypes of primary esophageal malignant tumors]

Objective: To characterize the histopathological subtypes and their clinicopathological parameters of gender and onset age by common, rare and sparse primary esophageal malignant tumors (PEMT). Methods: A total of 272 437 patients with PEMT were enrolled in this study, and all of the patients were received radical surgery. The clinicopathological information of the patients was obtained from the database established by the State Key Laboratory of Esophageal Cancer Prevention & Treatment from September 1973 to December 2020, which included the clinical treatment, pathological diagnosis and follow-up information of esophagus and gastric cardia cancers. All patients were diagnosed and classified by the criteria of esophageal tumor histopathological diagnosis and classification (2019) of the World Health Organization (WHO). The esophageal tumors, which were not included in the WHO classification, were analyzed separately according to the postoperative pathological diagnosis. The χ² test was performed by the SPSS 25.0 software on count data, and the test standard α=0.05. Results: A total of 32 histopathological types were identified in the enrolled PEMT patients, of which 10 subtypes were not included in the WHO classification. According to the frequency, PEMT were divided into common (esophageal squamous cell carcinoma, ESCC, accounting for 97.1%), rare (esophageal adenocarcinoma, EAC, accounting for 2.3%) and sparse (mainly esophageal small cell carcinoma, malignant melanoma, etc., accounting for 0.6%). All the common, rare, and sparse types occurred predominantly in male patients, and the gender difference of rare type was most significant (EAC, male∶ female, 2.67∶1), followed with common type (ESCC, male∶ female, 1.78∶1) and sparse type (male∶ female, 1.71∶1). The common type (ESCC) mainly occurred in the middle thoracic segment (65.2%), while the rare type (EAC) mainly occurred in the lower thoracic segment (56.8%). Among the sparse type, malignant melanoma and malignant fibrous histiocytoma were both predominantly located in the lower thoracic segment (51.7%, 66.7%), and the others were mainly in the middle thoracic segment. Conclusion: ESCC is the most common type among the 32 histopathological types of PEMT, followed by EAC as the rare type, and esophageal small cell carcinoma and malignant melanoma as the major sparse type, and all of which are mainly occur in male patients. The common type of ESCC mainly occur in the middle thoracic segment, while the rare type of EAC mainly in the lower thoracic segment. The mainly sparse type of malignant melanoma and malignant fibrous histiocytoma predominately occur in the lower thoracic segment, and the remaining sparse types mainly occur in the middle thoracic segment.

[Value of single-source dual-energy CT (ssDECT) in differentiating lipid-poor adrenal adenomas from metastatic lesions]

Objective: To evaluate the value of single-source dual-energy CT (ssDECT) in differentiating lipid-poor adenomas from metastases in adrenal glands. Methods: From August 2011 to Oct 2014, 63 patients with 73 adrenal nodules (53 metastases proven by 5-6 months follow-up, and 20 histopathologically proven adenomas, CT value > 10 HU) underwent ssDECT scanning. The CT values of conventional polychromatic CT and virtual monochromatic images (40-140 keV) , fat-water density images and effective atomic number (eff-Z) were reconstructed on an ADW4.5 workstation and ROC curves were then constructed to evaluate the effectiveness of each parameter. The slope of spectral curve was measured and divided into 3 types: increment curve (K>0.1), straight curve (-0.1≤K≤0.1) and decrement curve (K< -0.1) according to the slope (the value of K) of spectral curve, and the curve patterns in the two groups were compared statistically. Results: There was no statistical difference between the mean CT values of metastases (35.12±5.29)HU and lipid-poor adenomas (32.48±6.94)HU by conventional polychromatic CT (P>0.05). The range of single-energy CT values of metastases [from (53.00±15.12) HU to (33.38±5.67) HU] was significantly higher than that of lipid-poor adenomas [from (26.90±26.94) HU to (28.77±10.66) HU] at energy levels ranging from 40 to 80 keV (P<0.05). There was no significant difference between the single-energy CT value of metastases and lipid-poor adenomas at energy levels ranging from 90 to 140 keV (P>0.05). The median fat-water concentration of metastases was -164.61 μg/cm^3, significantly lower than that of lipid-poor adenomas (114.32 μg/cm^3,P<0.05). The eff-Z of metastases (7.76±0.15) was also significantly higher than that of lipid-poor adenomas (7.50±0.25, P<0.05). When the threshold of fat-water concentration was -143.89 μg/cm^3, the sensitivity, specificity and accuracy rate of metastasis diagnosis was 70.0%, 66.0%, and 76.7%, respectively. When the threshold of eff-Z was 7.63, the sensitivity, specificity and accuracy rate of metastasis diagnosis was 83.0%, 65.0%, and 80.4%, respectively. The lower the energy, the higher the diagnostic accuracy at energy levels ranging from 40 to 80 keV, and that of 40 keV was the highest. The spectral curves of metastases included 2 (3.8%) ascending curves, 9 (17.0%) straight curves and 42 (79.2%) descending curves, while in the 20 lipid-poor adenomas, there were 9 (45.0%) ascending curves, 4 (20.0%) straight curves and 7 (35.0%) descending curves, showing significant differences between the two groups (P<0.05). Conclusions: Single-source dual-energy CT provides an effective multi-parameter approach for differentiating lipid-poor adrenal adenomas from metastases.

[A comparison of clinical characteristics in elderly patients with ulcerative colitis and ischemic colitis]

OBJECTIVE

To analyze the discrepancy and similarities of clinical characteristics in elderly patients with ulcerative colitis (UC) and ischemic colitis (IC).

METHODS

A total of 43 elderly patients (age≥60 yrs) with UC and 36 elderly patients with IC were enrolled from 2004 to 2015 at Peking Union Medical College Hospital. The clinical characteristics were retrospectively analyzed and compared between the two groups.

RESULTS

Compared with IC group, the disease course was longer with lower incidence of cardiovascular comorbidities in UC patients (P<0.05). In UC group, more patients presented with diarrhea, mucopurulent bloody stool [39(90.7%) vs 16(44.4%) and 34(79.1%) vs 2(5.6%) respectively, both P<0.01]. Yet bloody stool as the only symptom was seen in more IC patients than UC patients [61.1%(22/36) vs 7.0%(3/43), P<0.01]. The ratio of extra-intestinal manifestations was higher [18.6%(8/43) vs 0(0/36)] in UC patients, while complications were lower [11.6%(5/43) vs 30.6%(11/36), P<0.05]. As to the laboratory parameters, median platelet count [(294.38±104.83)×10(9)/L vs (235.47±94.82)×10(9)/L, P<0.05] was higher in UC group. In addition, more patients with UC had positive perinuclear antineutrophil cytoplasmic antibody (p-ANCA) [50.0%(15/30) vs 10.0%(2/20), P<0.05]. The most commonly involved regions of IC were descending colon and sigmoid colon, in which the lesions were clearly demarcated with the normal mucosa. Lesions in patients with UC mainly originated from rectum and might spread to the whole colon. Vascular occlusion and micro thrombosis were characteristic pathological findings of IC. The crypt abscesses were frequently seen in the UC group.

CONCLUSION

Even though UC and IC have some similar manifestations in the elderly patients, clinical and pathological discrepancy is still helpful to differentiate each other.

[Value of R2(*) in evaluating the biological behavior of primary hepatocellular carcinoma]

OBJECTIVE

To investigate the correlation between R2(*) value of enhanced T2 star-weighted angiography (ESWAN) sequence and primary hepatocellular carcinoma infiltration and tumor thrombus, and investigate the biological behavior of HCC.

METHODS

A total of 221 cases of patients' imaging data with MRI examination(including ESWAN sequence) diagnosed as primary HCC were retrospectively analyzed.All the patients were collected from January 2014 to September 2015 in the First Affiliated Hospital of Dalian Medical University.The differences of R2(*) values in different MR types of HCC were analyzed.All patients were divided into infiltration group and non-infiltration group, tumor thrombus group and non-tumor thrombus group, the R2(*) values of the paired groups were compared.The diagnostic efficiency of R2(*) in HCC infiltration and tumor thrombus were evaluated by ROC curve, and to find out the threshold values.

RESULTS

The MR types of 221 patients included 90 cases of nodular type, 62 cases of massive type, 69 cases of diffuse type.70 patients had tumor thrombus.The R2(*) values of different MR types were (21.82±8.52), (24.17±8.84)and (34.45±11.73) Hz, respectively.There was no statistically significant difference between the nodular and the massive types (P=0.144), while the difference between the nodular and diffuse type, the massive and diffuse types were statistically significant(P=0.000). The R2(*) values of infiltration group and non-infiltration group were (34.45±11.73) and (22.78±8.70) Hz , the R2(*) values of tumor thrombus group and non-tumor thrombus group were (31.20±12.17) and (24.21±9.90) Hz, the difference also had statistically significant(t=7.397 and 4.534, P=0.000 and 0.000). The AUC of R2(*) values for infiltration and tumor thrombus were 0.804, 0.681. R2(*) ≥24.68 Hz was the threshold value to diagnose the infiltration and tumor thrombus.

CONCLUSION

R2(*) value can be used as a MR non-enhancement quantitative index to evaluate the biological behavior of HCC.

Factors influencing the mode of delivery and associated pregnancy outcomes for twins: a retrospective cohort study in a public hospital

OBJECTIVES

To determine current trends for different modes of delivery in twin pregnancies, factors affecting the mode of delivery, and associated outcomes.

DESIGN

Retrospective cohort study.

SETTING

A public hospital in Hong Kong.

PARTICIPANTS

All twin pregnancies booked at Kwong Wah Hospital during a 3-year period from 1 April 2006 to 31 March 2009.

RESULTS

Of 197 sets of twins, 35 (18%) were delivered vaginally and 162 (82%) by caesarean section (47% were emergencies and 53% elective). In all, 32 (37%) of the elective and 21 (28%) of the emergency caesarean sections were in response to maternal requests. Vaginal delivery was more common in mothers with a history of vaginal delivery and monochorionic diamniotic twins. Women who conceived by assisted reproduction or those who had a tertiary education were more likely to deliver by caesarean section. The type of conception and the presentation of the second twin were statistically significant factors affecting maternal choice on the mode of delivery. Maternal age did not affect the choice of delivery mode. Except for the higher frequency of sepsis and cord blood acidosis in second twins delivered vaginally, there were no significant differences in neonatal morbidity between the groups that attempted vaginal delivery or requested caesarean sections. All the women who had compression sutures or hysterectomy to control massive postpartum haemorrhage were delivered by caesarean section.

CONCLUSION

A high caesarean section rate observed in our cohort was associated with maternal requests for this mode of delivery. The type of conception and the presentation of the second twin were statistically significant factors affecting maternal choice on mode of delivery. Women's requests for caesarean delivery out of the concern for their babies are not supported by current evidence. In response to a woman with a twin pregnancy requesting caesarean delivery, the pros and cons of vaginal deliveries and caesarean sections should be fully explained before the woman's autonomy is respected.

Poly(dimethylsiloxane) microchip capillary electrophoresis with electrochemical detection for rapid measurement of acetaminophen and its hydrolysate

Poly(dimethylsiloxane) microchip capillary electrophoresis with amperometric detection has been used for rapid separation and determination of acetaminophen and its hydrolysate, i.e. p-aminophenol. A Pt ultramicroelectrode with a diameter of 10 microm positioned at the outlet of the separation channel was used as a working electrode for amperometric detection. Factors influencing separation and detection were investigated and optimized. Results show that acetaminophen and p-aminophenol can be well separated within 35 s with RSD-1 (approximately 0.1 fmol) at S/ N=3. This method has been successfully applied to the detection of traces of p-aminophenol in paracetamol tablets.

Effects of glucagon on in vitro liquid production by lungs from fetal guinea pigs

BACKGROUND

Lung liquid reabsorption in newborns with respiratory distress syndrome can be deficient. Respiratory distress syndrome is often seen in infants of diabetic mothers, in whom the neonatal surge of glucagon is suppressed.

AIM

To investigate the possible effects of glucagon on lung liquid reabsorption.

METHODS

Lungs from near term fetal guinea pigs (62 (2) days gestation; term = 67 days) were supported in vitro for three hours; lung liquid production and reabsorption were monitored by a dye dilution method.

RESULTS

Untreated control preparations produced fluid at 1.75 (0.33) ml/h per kg body weight, and did not change significantly in three hours; those immersed in 10(-12) M glucagon during the middle hour showed no significant change, but those given higher concentrations all showed significant reductions in fluid production or even reabsorption (65.6 (10.3)% fall at 10(-11) M, 70.0 (6.3)% fall at 10(-10) M, and 90.6 (11.1)% fall at 10(-9) M; based on 54 preparations). At 10(-9) M glucagon, 12 out of 30 preparations reabsorbed fluid. The linear log dose-response curve (r(2) = 0.94) gave a theoretical threshold at 4 x 10(-15) M glucagon. Responses appeared to involve the amiloride sensitive Na(+) based reabsorptive system: responses to 10(-9) M glucagon appeared to be reduced by 10(-6) M amiloride, and were abolished by 10(-5) M amiloride (based on 72 preparations).

CONCLUSIONS

The results suggest that the surge of glucagon at birth may help to drain the lungs of fluid. As glucagon liberates cAMP, which also stimulates surfactant, glucagon is worth consideration for possible use in neonatal respiratory distress.

Effects of acetylcholine on lung liquid production by in vitro lungs from fetal guinea pigs

Lungs from near-term fetal guinea pigs (61 +/- 2 days of gestation) were supported in vitro for 3 h; lung liquid production was monitored by a dye dilution method. Untreated preparations produced lung liquid with no significant changes (ANOVA; regression analysis) (rates in successive hours, initial study: 1.37 +/- 0.30, 1.36 +/- 0.30, and 1.28 +/- 0.27 mL.kg-1 body weight.h-1; n = 6). Preparations given acetylcholine at 10(-4) (n = 6), 10(-5) (n = 6), and 10(-6) M (n = 18) during the middle hour showed marked and significant fluid reabsorption (p < 0.025-0.0005); 10(-8) M acetylcholine was without effect. Reductions were linearly related to log concentration of acetylcholine (r = 0.97; theoretical threshold, 1.0 x 10(-7) M acetylcholine). Atropine, at 10(-5) M, greatly reduced responses to acetylcholine, and all reabsorptions were abolished; 10(-4) M atropine completely abolished all responses to acetylcholine; atropine alone had no effect (based on 48 studies). The alpha-adrenoreceptor antagonist phentolamine (1.78 x 10(-5) M) abolished the effects of 10(-6) M acetylcholine, but had no effect alone (based on 48 studies); the beta-adrenoreceptor antagonist propranolol (10(-5) M) had no effect on responses to 10(-6) M acetylcholine (based on 24 studies). It is suggested that acetylcholine at physiological levels can produce lung liquid reabsorption by activating muscarinic receptors and releasing catecholamines within the lungs; these catecholamines act via alpha-receptors. This raises the possibility of neural controls of lung liquid reabsorption during the early stages of delivery or neonatal life.

Regeneration following somite removal in chick embryos

A technique was developed for ensuring complete removal of single somites with minimal damage to surrounding tissues in 2-day-old chick embryos. Histological examination of the site of somite removal at various time intervals after operation revealed that a regeneration mechanism could be triggered. Replacement of the cells that had been removed could occur, but the extent of the replacement was dependent on the immediate fate of the gap created. If the gap was closed by enlargement of the adjacent somites, no replacement of the cells occurred. If the gap remained, then cells invaded the gap and were able to produce a normal sclerotome and dermomyotome. By labelling adjacent cells with the carbocyanine dye. DiI, it was shown that the replacement cells could come from the adjacent somites, as well as the intermediate mesoderm. Use of an antibody to HNK-1 established that the replacement cells did not come from the neural crest and that the neural crest cell distribution was little affected. Staining with peanut agglutinin showed that the replacement cells were able to adopt the characteristics associated with rostral and caudal halves of the normal sclerotome. These results provide possible explanations for the variety of vertebral anomalies produced by removal of somites and for the production of some congenital vertebral anomalies.

Inhibition of ciramadol glucuronidation by benzodiazepines

Studies on the inhibition of ciramadol glucuronidation by benzodiazepines were performed in vitro and in vivo. Ciramadol glucuronidation was slower (Vmax, 1.56 vs. 5.40 nmol/min/mg of microsomal protein) in human than in dog liver microsomes. Inhibition constants (Ki) for lorazepam and oxazepam were 3 to 4 times higher than that calculated for diazepam. Rates of morphine glucuronidation in human liver microsomes were assessed for comparative purposes and agreed with literature values. Each benzodiazepine appeared to be a competitive inhibitor of ciramadol and morphine UDP-glucuronyltransferase activity. The in vivo disposition of ciramadol was unchanged in dogs pretreated with lorazepam. After diazepam treatment no change in the Vdss of ciramadol occurred, but plasma clearance was significantly reduced, resulting in a prolongation of t1/2. Diazepam caused a significant reduction in the oral clearance of ciramadol, whereas no change occurred in systemic availability. Thus, diazepam may have had a secondary effect on hepatic blood flow (QH) and produced offsetting alterations in both intrinsic clearance (Cl int) and QH. A decrease in the area under the plasma concentration time curves of ciramadol aryl O-glucuronide following iv treatment with diazepam coupled with the in vitro data indicate that the mechanism for the decrease in the clearance of ciramadol is inhibition of its glucuronidation by diazepam. Since glucuronidation plays a major role in the elimination of ciramadol in man and dog, these experiments suggest that the disposition of ciramadol in man would not be affected by coadministration of lorazepam, whereas the potential for a diazepam/ciramadol drug interaction in humans exists.

The metabolic disposition of 14C-ciramadol in humans

Twelve subjects received single 15 mg oral doses of 14C-ciramadol. Excretion of the dose occurred almost entirely by the renal route (93.5 +/- 11.7 (S.D.)% of the dose), and only 0.7 +/- 0.6% of the dose was recovered in faeces indicating that absorption was essentially complete. More than 90% of the amount recovered in urine was excreted within 24 h after dosing. Unchanged drug accounted for 43.9 +/- 6.5% of the dose, while a phenolic glucuronide conjugate was the only major urinary metabolite accounting for a further 37.9 +/- 7.8%. A second glucuronide that was conjugated with the alicyclic ring was also identified but constituted only 2.3 +/- 0.6% of the dose. Concentrations of radioactivity in plasma reached a peak at 2 h after dosing and declined with a terminal disposition half life of 4.9 h. Only ciramadol and the aryl-O-glucuronide were detected in substantial amounts in plasma. Renal clearance of ciramadol amounted to 298 +/- 54 ml/min suggesting tubular secretion in addition to glomerular filtration.

Determination of ciramadol in plasma by gas-liquid chromatography

An analytical method for determining ciramadol concentrations in plasma was developed and evaluated for its specificity, precision, linearity, and sensitivity. GLC-electron capture detection of a dipentafluorobenzoyl derivative of the drug was used for quantitation. An isomer of the drug served as an internal standard. Resulting mean ratios of the peak height of derivatized drug to that of derivatized internal standard varied with a coefficient of variation that ranged from 3.8 to 11.1%. The mean ratio was linearly related to ciramadol content (8.75-175 ng) with a correlation coefficient greater than to 0.999. The minimum quantifiable concentration was 4 ng/ml with a 2-ml specimen. An application of this method is presented.

Species-related differences in the stereoselective glucuronidation of oxazepam

The concentrations of (R)-(-)- and (S)-(+)-oxazepam glucuronides in plasma and urine of several species have been measured. The relative amounts of these diastereoisomers vary among species. Thus, in the plasma and urine of rhesus monkeys the concentrations of the R-isomer are higher, whereas in man and dog more of the S-isomer is present. In plasma and urine of miniature swine the amounts of the two diastereoisomers are about equal. In the urine of rabbits the S-isomer prevails. Similar species-related differences are observed in the in vitro formation of the isomeric oxazepam glucuronides. Homogenates of dog, miniature swine, rabbit, and rat liver produce more of the S-isomer, whereas with monkey liver the formation of (R)-oxazepam glucuronide is favored. The agreement between in vivo and in vitro data is fairly good for rhesus monkey, miniature swine, and rabbit. However, for the dog the ratio of S- to R-isomers in the liver homogenate is much higher than in plasma and urine. This species-dependent stereoselective glucuronidation of oxazepam is not related to the phylogenetic or dietary grouping of these species.

Pharmacokinetics of parenteral dezocine in rhesus monkeys and dogs

Pharmacokinetic parameters of the analgesic, dezocine, were determined after intravenous and intramuscular injection (1 mg/kg) to rhesus monkeys and dogs. In both species, the drug was rapidly distributed after intravenous administration and then eliminated with a mean half-life of 2.4 hr. Systemic clearance was 54.8 +/- 8.6(SD) and 65.8 +/- 14.0(SD) ml/min/kg in the rhesus monkey and dog, respectively. Glucuronidation was recognized as a major metabolic pathway in both species, and sulfate conjugation was indicated in the dog. Renal elimination of dezocine was minimal. Less than 4% of the dose was eliminated as unchanged dezocine in urine of rhesus monkeys and 1% of the dose in dog urine. After im administration, release from the injection site was rapid and no metabolism at the injection site was indicated. Multiple-dose experiments in dogs did not reveal accumulation. The acquisition of data was made possible by the development of a sensitive, specific assay, which depends on gas-liquid (electron capture) chromatography of a pentafluorobenzoylated derivative of dezocine.

The metabolic disposition of norgestrel in female rhesus monkeys

Following single intragastric doses of d- and dl-[24C]norgestrel (Ng), rhesus monkeys excreted 29.5 +/- 2.0 (SE) and 52.6 +/- 5.4% of the administered radioactivity in urine. Fecal excretion accounted for 57.1 +/- 4.0 and 37.2 +/- 4.4%, respectively. Urinary radioactivity was separated into neutral, acidic, and conjugated fractions. The neutral and conjugated fractions contained Ng; 2 alpha, 16 alpha- and 16 beta-hydroxy-Ng; 3 alpha,5 beta-tetrahydro-Ng and 16 beta-hydroxy-3 alpha,5 beta-tetrahydro-Ng and their glucuronides. However, the bulk of the radioactivity in these fractions was associated with more polar metabolites. The acidic fraction contained unstable metabolies which lose 14CO2 at pH values below 5. The most abundant of these metabolites was isolated as its stable methyl ester. The structure of a 13-ethyl-D-homogon-4-ene-3,17 alpha-dione-17 carboxylic acid is proposed for the metabolite which decomposes to 13-ethyl-D-homogon-4-ene-3,17 alpha-dione [D-homo-G]. The probable mechanism of the metabolite's formation is postulated. Quantitative differences in urinary metabolite patterns were observed following the administration of d- and dl-Ng. Ng is the major identified drug-related entity in plasma. The d-Ng concentrations in plasma measured by radioimmunoassay were in good agreement with those determined by fractionation and radiometry. The latter method indicated the presence of D-homo-G and a glucuronide of 3 alpha,5 beta-tetrahydro-Ng following the administration of d- and dl-Ng.

Excretion and stereoselective biotransformations of dl-, d- and l-norgestrel in women

Excretion data and urinary metabolite patterns of di-, d-, and l-norgestrel were obtained from women who received a single, oral 1.5-mg dose of 14C-labeled racemic norgestrel (Ng) or one of its enantiomers. The average percentage of administered radioactivity +/- SD recovered in the urine after 7 days was 58.1 +/- 7.9% for dl-Ng, 44.8 +/- 8.9% for d-Ng, and 63.6 +/- 15.1% for l-Ng; in feces it was 23.4 +/- 7.7% (dl-Ng), 31.6 +/- 8.2% (d-Ng), and 24.8 +/- 10.7% (l-Ng). Different metabolite patterns were observed for each enantiomer in urine, and the pattern for the racemate appeared to be an approximate composite of the metabolite patterns of the two enantiomers. These differences in the metabolite pattern result from stereoselective transformations; notably 16 beta-hydroxylation of l-Ng and ring A reduction of d-Ng. Other stereoselective pathways noted were: 16 alpha- and 1 beta-hydroxylation as well as D-homoannulation of l-Ng and sulfate conjugation of l-16 beta-hydroxynorgestrel; 2 alpha-hydroxylation of d-Ng, formation of a labile neutral, polar compound which contained the norgestrel moiety in the d-form, and formation of a glucuronide of d-16 beta-hydroxynorgestre. The formation of phenolic derivatives occurred to a very minor degree from transformations of the biologically inactive l-enantiomer. With d-norgestrel, this formation occurred to an even lesser extent, if at all.

Phenolic metabolites of DL-norgestrel: a method for the removal of 1-hydroxylated metabolites, potential sources of phenolic artifacts

The identification of 1β-hydroxynorgestrel among the urinary metabolites of dl-norgestrel and the facile transformation of this compound under mild alkaline conditions to a potentially oestrogenic phenol provide an experimental basis for the conclusion advanced by others that the oestrogens present in the urine of subjects treated with synthetic progestens are artifacts formed during analytical work-up. A method has been devised which eliminates 1-hydroxylated metabolites as potential sources of phenolic artifacts. This method is based on the reduction by NaBH4 of the 1-hydroxy-4-en-3-one grouping in the A ring thereby excluding the possibility of aromatization during later fractionation on a basic ion exchange resin that separates neutral from phenolic metabolites. In the urines of women treated with 14C-dl-nogestrel, only 0.17–0.27% of the dose is found to have phenolic properties when this method is used. Two of the phenolic metabolites, 18-homoethynyloestradiol and 16β-hydroxy-18-homoethynyloestradiol, are present in amounts smaller than 0.01 % of the dose. Without the reduction steps the percentages are noticeably higher, indicating artifact formation under alkaline conditions. Similar results were obtained with urines from African Green Monkeys (Cercopithecus Aethiops) that had been dosed with 14C-dl-norgestrel. Radiolabelled 18-homoethynyloestradiol and 16β-hydroxy-18-homoethynyloestradiol were isolated from monkey urine and their identity confirmed by gas chromatography-mass spectrometry.

Urinary metabolites of DL-norgestrel in women

Urines obtained from women administered the totally synthetic progestational steroid, 14C-dl-norgestrel, were fractionated on DEAE-Sephadex A-25. This anion exchanger separated unchanged norgestrel and ether extractable metabolites (6.5–10.2 % of the urinary radioactivity) as well as neutral, non-extractable metabolites (4.0–12.3 % of the urinary radioactivity) from anionic conjugates of norgestrel and its metabolites (75.8–88.8 % of the urinary radioactivity). The latter, in turn, were separated into seven fractions. One fraction, after solvolysis, was found to contain only the major metabolite, 16β-hydroxynorgestrel as sulphate(s) (approximately 30 % of the urinary activity). The remaining conjugated fractions as well as the free fraction were analyzed, and at least 23 metabolites were detected. Among them were biotransformation products resulting from hydroxylation at the 16α, 16β, 1β, 2α and 6ε position, D-homoannulation and ring-A reduction (3α,5β-tetrahydronorgestrel and its 3β, 5β and 3α, 5α isomers and a 16-hydroxylated tetrahydronorgestrel). Structures of the major metabolites were confirmed by mass spectrometry.