Critical Connections Among Embedding of Childhood Adversity and Adult Chronic Gastrointestinal and Genitourinary Disorders: A Review of the Literature

BACKGROUND: A gap in the literature exists demonstrating associations between adverse child experiences (ACEs) as potential a priori contributing factors and gastrointestinal (GI)/genitourinary (GU) disorders. PURPOSE: A narrative review of the literature was conducted to explore critical connections between ACEs and GI/GU disorders with a working hypothesis of a dose–responsive relationship existing among them. METHODS: A literature search was conducted using MEDLINE, Cumulative Index of Nursing and Allied Health Literature, PubMed, and Web of Science using search terms adverse childhood experiences, childhood adversity, obesity, gastrointestinal disorders, and genitourinary disorders, and secondary searches of obesity and specific GI/GU disorders (eg, irritable bowel syndrome, pelvic pain). Duplicates and articles with inappropriate focus were discarded after review. RESULTS: A total of 58 articles were included. Research identified showed that ACEs do play a role in adult GI and GU morbidities in a dose–response manner, and selected factors such as socioeconomic status, race, gender identity, and physiologic state (eg, obesity) confer higher risk. Research also suggested that genetic/epigenetic mechanisms are at play in disease occurrence, and the impact of ACEs may be mitigated with positive life experiences. CONCLUSION: Research on the relationship between ACEs and GI/GU disorders is heterogeneous, notably due to wide variations in how types of ACEs are defined and screening methods used. Despite this limitation, associations are demonstrated. Awareness of a possible correlation between ACEs and risk of GI/GU disorders has the potential to improve patient care, especially through trauma-informed strategies.

Content validation of a standardized algorithm for ostomy care

The number of ostomy care clinician experts is limited and the majority of ostomy care is provided by non-specialized clinicians or unskilled caregivers and family. The purpose of this study was to obtain content validation data for a new standardized algorithm for ostomy care developed by expert wound ostomy continence nurse (WOCN) clinicians. After face validity was established using overall review and suggestions from WOCN experts, 166 WOCNs self-identified as having expertise in ostomy care were surveyed online for 6 weeks in 2009. Using a cross-sectional, mixed methods study design and a 30-item instrument with a 4-point Likert-type scale, the participants were asked to quantify the degree of validity of the Ostomy Algorithm's decisions and components. Participants' open-ended comments also were thematically analyzed. Using a scale of 1 to 4, the mean score of the entire algorithm was 3.8 (4 = relevant/very relevant). The algorithm's content validity index (CVI) was 0.95 (out of 1.0). Individual component mean scores ranged from 3.59 to 3.91. Individual CVIs ranged from 0.90 to 0.98. Qualitative data analysis revealed themes of difficulty associated with algorithm formatting, especially orientation and use of the Studio Alterazioni Cutanee Stomali (Study on Peristomal Skin Lesions [SACS™ Instrument]) and the inability of algorithms to capture all individual patient attributes affecting ostomy care. Positive themes included content thoroughness and the helpful clinical photos. Suggestions were offered for algorithm improvement. Study results support the strong content validity of the algorithm and research to ascertain its construct validity and effect on care outcomes is warranted.

Survey of Wound, Ostomy and Continence (WOC) Nurse Clinicians on Stomal and Peristomal Complications

PURPOSE

Validated and reliable stomal and peristomal complication definitions and associated interventions are lacking. Available literature is either narrowly medically focused or only of case study level. The objectives of this study were to establish content validation data for the proposed stomal and peristomal complication definitions and their associated interventions, to obtain the data related to contact with stomal and peristomal complication patients, and to gain insight into the ostomy care process.

METHODS

A researcher-designed survey was sent to 2900 expert Wound, Ostomy and Continence nurse clinicians via a national mailing to a representative nonrandomized sample of participants who identified that they included ostomy care in their professional practice. In total, 686 nurses returned the survey, a response rate of 24%. The purposive sample was asked to quantify the degree of validity of the survey's stated stomal and peristomal definitions and interventions. Hand-written qualitative comments of the participants were transcribed, analyzed, and themes were derived.

RESULTS

On a scale of 1 to 4, the mean score for all definitions and interventions was 3.64 (SD=0.30). The overall survey's content validity index was .91. Ratings demonstrated high consensus validation on the stomal and peristomal definitions and interventions, with definitions scoring higher. The mean scores and the content validity index results on selected items were slightly lower for interventions, especially stomal interventions. Qualitative analysis of participants' comments about the whole instrument generated 10 themes and associated subthemes related to omitted complications and interventions and general observations about the ostomy care process and the validation research process.

CONCLUSION

The proposed stomal and peristomal definitions and interventions were rated as generally valid. Further research documenting validation of participants' comments is necessary. Given the findings, additional complications and interventions not identified in the literature were noted and need to be further scrutinized and researched.

Issues and Challenges in Staging of Pressure Ulcers

Wound assessment is a key element of effective wound care, and assessment of pressure ulcers includes accurate determination of wound stage. Although the original staging system established by Shea was based on his understanding of the pathology involved in pressure ulcer development, subsequent staging systems (and the one currently in use) were intended simply to establish the level of tissue damage. Recently, clinicians have drawn attention to numerous limitations associated with the current staging system, including the inability to differentiate between an inflammatory response involving intact skin and a deep tissue injury (deep bruising) underneath intact skin. This is a clinically significant difference because clinicians have noted that most inflammatory responses resolve with intervention, whereas most areas of deep tissue injury progress to full-thickness ulcers even when appropriate intervention is provided. A second area of controversy involves partial-thickness (Stage 2) lesions; because many of these lesions are caused by maceration and/or friction (as opposed to pressure) clinicians are frequently unclear regarding which of these lesions should be staged. In response to these concerns, the National Pressure Ulcer Advisory Panel convened a consensus forum and published white papers to clearly outline the issues; they solicited clinician feedback on the white papers and the Wound, Ostomy, Continence Nurses Society provided a written response. This article summarizes the key points of the white papers, WOCN Society response, and consensus forum discussion.

An analysis of reports of depression and suicide in patients treated with isotretinoin

BACKGROUND

The Food and Drug Administration (FDA) has received reports of depression and suicide in patients treated with isotretinoin.

OBJECTIVE

Our purpose was to provide the number and describe the cases of depression and suicide reported to the FDA in US patients treated with isotretinoin and to consider the nature of a possible association between isotretinoin and depression.

METHODS

An analysis was made of reports of depression, suicidal ideation, suicide attempt, and suicide in US isotretinoin users voluntarily submitted to the manufacturer and the FDA from 1982 to May 2000 and entered in the FDA's Adverse Event Reporting System database.

RESULTS

From marketing of isotretinoin in 1982 to May 2000, the FDA received reports of 37 US patients treated with isotretinoin who committed suicide; 110 who were hospitalized for depression, suicidal ideation, or suicide attempt; and 284 with nonhospitalized depression, for a total of 431 patients. Factors suggesting a possible association between isotretinoin and depression include a temporal association between use of the drug and depression, positive dechallenges (often with psychiatric treatment), positive rechallenges, and possible biologic plausibility. Compared with all drugs in the FDA's Adverse Event Reporting System database to June 2000, isotretinoin ranked within the top 10 for number of reports of depression and suicide attempt.

CONCLUSION

The FDA has received reports of depression, suicidal ideation, suicide attempt, and suicide in patients treated with isotretinoin. Additional studies are needed to determine whether isotretinoin causes depression and to identify susceptible persons. In the meantime, physicians are advised to inform patients prescribed isotretinoin (and parents, if appropriate) of the possibility of development or worsening of depression. They should advise patients (and parents) to immediately report mood swings and symptoms suggestive of depression such as sadness, crying, loss of appetite, unusual fatigue, withdrawal, and inability to concentrate so that patients can be promptly evaluated for appropriate treatment, including consideration of drug discontinuation and referral for psychiatric care.

Approval summary: gemtuzumab ozogamicin in relapsed acute myeloid leukemia

PURPOSE

Gemtuzumab ozogamicin (Mylotarg; Wyeth Laboratories, Philadelphia, PA) consists of a semisynthetic derivative of calicheamicin, a cytotoxic antibiotic linked to a recombinant monoclonal antibody directed against the CD33 antigen present on leukemic myeloblasts in most patients with acute myeloid leukemia (AML). In this study, we review the preclinical and clinical profiles of this immunoconjugate and the regulatory review that led to marketing approval by the United States Food and Drug Administration.

EXPERIMENTAL DESIGN

From the literature and manufacturer's data, we review the activity, tolerability, and pharmacokinetics of gemtuzumab ozogamicin in preclinical and Phase I studies and its activity, efficacy, and side effects in three Phase 2 trials of 142 patients with relapsed AML.

RESULTS

In Phase I studies, the major toxicity was myelosuppression, especially neutropenia and thrombocytopenia, resulting from the expression of CD33 on myeloid progenitor cells. The Phase 2 dose was 9 mg/m(2) infused i.v. over 4 h, repeated on day 14. A minority of patients experienced acute infusion-related symptoms, usually transient and occasionally requiring hospitalization. The complete response (CR) rate with full recovery of hematopoiesis was 16%. A subset of patients [CRs with incomplete platelet recovery (CRps)] was identified with blast clearance and neutrophil recovery but incomplete platelet recovery. The duration of responses of CRps appeared to be similar to those of the CRs, although the numbers were small. The question of the equivalence of these response groups was a central issue in the review of this new drug application (NDA). After considerable discussion, the Oncology Drugs Advisory Committee recommended allowing inclusion of CRps resulting in an overall response rate in the Phase 2 studies of 30%. In the subgroup of patients over 60 years of age, the overall response rate was 26%. Response duration was difficult to establish because of the high prevalence of postremission therapies. Tolerability and ease of administration may be improved compared with conventional chemotherapy, except for hepatotoxicity, with 31% of patients exhibiting abnormal liver enzymes. One patient died of liver failure in the Phase 2 trials.

CONCLUSIONS

Marketing approval of gemtuzumab ozogamicin was granted on May 17, 2000 by the United States Food and Drug Administration under the Accelerated Approval regulations. Gemtuzumab ozogamicin is indicated for the treatment of patients with CD33 positive AML in first relapse who are 60 years of age or older and who are not considered candidates for cytotoxic chemotherapy. The approved dose was 9 mg/m(2) i.v. over 4 h and repeated in 14 days. Completion of the ongoing studies of gemtuzumab ozogamicin in relapsed AML and initiation of randomized clinical trials comparing the effects of gemtuzumab ozogamicin in combination with conventional induction chemotherapy to conventional chemotherapy alone on survival are mandated to confirm clinical benefit under the accelerated approval Subpart H regulations. Postmarketing reports of fatal anaphylaxis, adult respiratory distress syndrome (ARDS), and hepatotoxicity, especially venoocclusive disease (VOD) in patients treated with gemtuzumab ozogamicin, with and without associated hematopoietic stem cell transplantation (HSCT), have required labeling revisions and the initiation of a registration surveillance program. Tumor lysis and ARDS have been reported in patients with leukocytes above 30,000/ml treated with gemtuzumab ozogamicin; therefore, the reduction of leukocyte counts to below 30,000/ml is recommended prior to treatment. Patients should be carefully monitored for acute hypersensitivity, hypoxia, and delayed hepatotoxicity following treatment with gemtuzumab ozogamicin.

Trial endpoints for drug approval in oncology: Chemoprevention

As with other drugs, new drug applications for marketing approval of chemopreventive drugs must include data from adequate and well-controlled clinical trials that demonstrate effectiveness and safety for the intended use. This article summarizes the regulatory requirements for traditional marketing approval, as well as for approval under the accelerated approval regulations. Unlike traditional approval, accelerated approval is based on a surrogate endpoint that is reasonably likely to predict clinical benefit. Discussions with the Food and Drug Administration (FDA) regarding the validity of trial endpoints that may serve as surrogates for clinical benefit for accelerated approval should take place as early as possible in drug development. Meetings with the FDA to discuss these issues may be requested throughout the clinical development of a new drug.

Quality-of-life end points in oncology drug trials

Health-related quality of life (HRQL) is a multidimensional construct that represents the patient's perspective on valued aspects of health and functioning. Over the last several years, the pharmaceutical industry, as well as health care providers and the patient advocacy community, have shown increasing interest in HRQL as an outcome measure. Pharmaceutical companies and other sponsors of cancer clinical trials are seeking novel approaches with which to establish the benefits of treatment and to differentiate their products from other marketed products. Health care providers hope to provide cancer patients with therapies that positively affect their quality of life. To date, however, most oncology drug approvals have been based on traditional end points, such as survival and tumor response rate. This article will focus on some of the lessons learned from recent reviews of HRQL data and will describe some of the many challenges that lie ahead.

Regulation of mannose receptor synthesis and turnover in mouse J774 macrophages

The mannose receptor, present on the plasma membrane of macrophages, promotes the internalization of glycoproteins and glycoconjugates via both endocytic and phagocytic pathways. The expression of this receptor is tightly modulated during monocyte/Mphi differentiation and cellular activation. We isolated clonal populations from murine J774 macrophage tumor cells, which differ in their surface expression of functional mannose receptors. To examine the potential mechanisms regulating receptor function in these cell lines, the interaction of receptor with ligand as well as receptor synthesis and degradation was analyzed. J774 clones with both high and low levels of mannose receptor activity were found to synthesize significant amounts of receptor protein, suggesting that the protein may be regulated at the level of synthesis and degradation. In J774 clones expressing very low receptor activity and protein, the half-life of mannose receptor molecules was substantially decreased. The evolution of multiple mechanisms modulating mannose receptor function may be critical in fine-tuning the role of this receptor in antigen processing and in scavenger and host defense functions.

Protocol design considerations that relate to demonstrating the safety and effectiveness of chemopreventive agents

As with other drugs, applications for marketing approval of new chemopreventive agents in the United States must include data from adequate and well-controlled clinical trials that demonstrate effectiveness and safety for the intended use. Knowledge of a drug's pharmacologic actions and metabolism may benefit protocol design, by identifying the patient populations and dosing schedules associated with a favorable risk/benefit profile. With availability of appropriate preclinical data, including standard assessments of an agent's toxicology, effects on reproductive performance, and genotoxicity, initial Phase I studies of 1-3 months may be performed in normal volunteers or an appropriate higher risk population. For chronic dosing studies of longer duration, preclinical toxicology studies of longer duration are relevant. Enrollment in chemoprevention studies should be directed toward individuals at sufficient risk of developing cancer so that potential benefit may counterbalance the unpredictable and possibly serious adverse effects that may be observed with prolonged administration of a study drug. Phase I and II studies with clinical dosing lasting up to 12 months often afford opportunities to assess drug effect on surrogate endpoint biomarkers that may correlate with endpoints of clinical effectiveness. Phase III and late phase II chemopreventive investigations should routinely utilize a prospective, randomized study design (double-masked and placebo-controlled, when possible). To support marketing approval, there must be evidence that a chemopreventive agent significantly delays or prevents the occurrence of malignancy, with acceptable safety. In some circumstances, modulation of a surrogate marker may provide a basis for marketing approval, before more definitive endpoint data become available. However, the acceptability of a surrogate depends on the nature and quality of the data supporting its predictive value. Given the considerations of large study size, long duration, and high cost that may hamper development of potential agents, studies designed to examine the predictive value of surrogate endpoint biomarkers are of great importance to the future development of chemoprevention research.

The traditions and terminology of wound dressings: food for thought

During the past 40 years, health care professionals have witnessed an evolution of wound care traditions and terminology and an explosion in the number of wound care products and the amount of information. Unfortunately, these developments have not resulted in optimal wound care for all patients. Appropriate dressing selection and communication are hampered by a lack of clinically valid definitions, as well as ambiguous indications, contraindications, and instructions for their use. One method of setting the stage for a more therapeutic future would be to classify dressings based on their functions rather than the ingredients they contain.

Antiatherosclerotic potency of high density lipoprotein of different origins: a review and some new findings

The antiatherosclerotic potency of isolated high density lipoproteins (HDL) of different origins was investigated in three experimental models: (1) isolated HDL were injected into cholesterol-rich fed rabbits; (2) the effect of HDL on the intracellular level of free and esterified cholesterol as well as on proliferation of smooth muscle cells and fibroblasts was investigated in cell cultures; and (3) we studied the influence of isolated HDL fractions on thromboxane (TXB2) formation in clotting whole blood with different cholesterol content.

Intestinal epithelial cells use two distinct pathways for HLA class II antigen processing

Intestinal epithelial cells express a low level of HLA class II molecules constitutively, with elevated levels seen in the setting of mucosal inflammation including inflammatory bowel disease. The ability of intestinal epithelial cells to act as antigen presenting cells for alphabeta CD4(+) T lymphocytes was examined through a molecular analysis of the HLA class II antigen processing pathway. We have shown that intestinal epithelial cells contain abundant constitutive levels of the cathepsin proteases proven to function in HLA class II mediated antigen presentation. Activation of these cells by gamma-IFN induced the expression of invariant chain and HLA-DM alphabeta, thus facilitating the formation of compact, SDS-stable HLA- DR alphabeta heterodimers. Using HLA-DR-restricted T cells and retroviral mediated gene transfer of HLA-DR alleles into the intestinal epithelial cell lines HT-29 and T84, we demonstrated efficient antigen processing and presentation to CD4(+) T lymphocytes in the presence of the proinflammatory cytokine gamma-IFN. The class II processing pathway and presentation in the presence of gamma-IFN was indistinguishable from that observed with a conventional antigen presenting cell. Antigen processing also occurred in intestinal epithelial cells in the absence of gamma-IFN, and in contrast to that seen after stimulation with gamma-IFN, required high concentration of antigen and was not inhibited by the protease inhibitor leupeptin. These data suggest the use of two distinct pathways of HLA class II antigen processing in enterocytes with differential immunomodulatory properties in the presence or absence of mucosal inflammation.

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

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

Anti-B16-F10 melanoma activity of a basic fibroblast growth factor-saporin mitotoxin

BACKGROUND

The authors attached basic fibroblast growth factor (FGF-2), a growth factor for numerous tumors and normal cell types, to saporin (SAP), a ribosome-inactivating protein isolated from the plant Saponaria officinalis. The conjugate (FGF-SAP) then was tested for antitumor activity using B16-F10 melanoma cells. This rapidly growing murine melanoma cell line has been used classically as a model to screen antitumor agents.

METHODS

B16-F10 cells in culture were used for in vitro experiments or introduced into C57BL/6 mice to demonstrate the in vivo antitumor activities of FGF-SAP.

RESULTS

FGF-SAP was found to be an extremely effective cytocidal agent in vitro with an ED50 of 30-60 pM. The effects were specific for FGF-2 receptors, as shown by the ability of FGF-2 to block FGF-SAP action. In the in vivo models, FGF-SAP was found to increase survival time, inhibit tumor growth, and decrease metastases.

CONCLUSIONS

The authors conclude that this mitotoxin has potent in vitro and in vivo effects on B16-F10 cells, supporting the hypothesis that ligand-mediated cytotoxicity can control tumor growth.

Is the antiatherosclerotic potency of HDL modulated by the origin of HDL?

Different HDL preparations from rabbit blood were injected intravenously (10 mg HDL protein/injection and animal) into cholesterol fed rabbits twice a week for 8 weeks. The composition of the used high density lipoprotein (HDL) was modified by dietary pretreatment. HDL-1 was taken from rabbits after 8 weeks pellet diet, HDL-2 after 8 weeks fish-oil rich diet and HDL-3 after 8 weeks of cholesterol rich diet. The animals treated with HDL-1 and HDL-2 had a significantly smaller area of intima covered with fatty streaks than the control animals (injection of saline instead of HDL). The injection of HDL-3 was without influence. These differences were correlated with changes in the level of free and esterified cholesterol (FC and CE) in kidney, liver and aorta of the rabbits, but not with the level of cholesterol in the serum lipoproteins. We investigated simultaneously the influence of the different HDL preparations on the cholesterol content in rabbit skin fibroblasts (RSF), rabbit smooth muscle cells (SMC) and human hepatoma cell line Hep G2. Additionally the influence on the proliferation of SMC was studied. HDL-1 diminished the level of FC in cholesterol enriched RSF and rabbit SMC, whereas both other HDL preparations had no effect. The level of FC in Hep G2 was not influenced. HDL-1 and HDL-3 stimulated the proliferation of rabbit SMC, whereas HDL-2 had no such influence. The data support the antiatherosclerotic role of HDL injections in cholesterol fed rabbits, but the composition of the used HDL seems to modify this influence, probably by different effects on the biochemical changes induced by the HDL.

von Willebrand's disease and hemophilia are associated with diminished thromboxane A2 (TXA2) formation in clotting whole blood

Von Willebrand's disease (vWd) and hemophilia are associated with hemorrhagic diathesis and disturbances in platelet aggregation to vessel wall. We compared the time course of thromboxane A2 (TXA2) formation by platelets during spontaneous clotting of blood of patients with von Willebrand syndrome and from patients with hemophilia A or B with that of healthy controls which were matched for sex, age and serum lipid status. In clotting blood of healthy females the TXA2 production rose at 37 degrees C in 60 min up to 228.2 +/- 32.3 ng/ml. In patients with vWd the TXA2 production at 60 min was significantly lower (129.1 +/- 26.7 ng/ml, p < 0/05). In hemophilia type A and B the TXA2 formation after 5-30 min was significantly diminished in comparison to healthy male controls (p < 0.05). From the diminished amount of TXA2 formed during spontaneous clotting of whole blood we conclude that the activation of platelets of patients with von Willebrand syndrome or hemophilia type A and B is diminished as compared to healthy controls possibly caused by reduced formation of thrombin in the blood coagulation process.

Lipoproteins from normolipidemic and dyslipidemic subjects modify the thromboxane A2 generation by platelets in clotting human blood

The study was performed to investigate the influence of lipoproteins (LP) on the thromboxane (TX) A2 formation capacity of platelets in clotting whole blood in vitro. The different lipoprotein fractions VLDL, LDL, HDL2 and HDL3 were isolated from blood of normo- or dyslipidemic volunteers by ultracentrifugation. These lipoproteins were incubated in blood with different levels of serum total cholesterol (TC) taken from normolipidemics (TC < 200 mg/dl), moderate hypercholesterolemics (TC: 200-250 mg/dl) or subjects with high cholesterol level (TC > 250 mg/dl), respectively. The amount of serum TXA2 formed within 60 min at 37 degrees C was measured by enzyme immunoassay. The results obtained show that the efficacy of separate LP fractions to influence the TXA2 production depends not only on the type of LP fraction but also on the source of plasma used for isolation of LP and on the cholesterol level in the blood for incubation: LDL taken from normolipidemics or moderate hyperlipidemics inhibited the TXA2 formation in blood from normolipidemics (P < 0.02, respectively), but enhanced it in blood from persons with moderate hypercholesterolemia (P < 0.05). LDL from hyperlipidemics enhanced TXA2 production in blood from hyperlipidemics (P < 0.05). The HDL2 fractions inhibited the TXA2 formation in blood from normo- and hypercholesterolemics (P < 0.02, resp.), but there was no effect of HDL2 in clotting blood from persons with moderate hypercholesterolemia. All HDL3 fractions tested inhibited the TXA2 formation in all types of blood used for clotting (P < 0.02, resp.), probably due to their great cholesterol accepting capacity.

Combined modality therapy for stage IIIA non-small cell carcinoma of the lung

53 patients with stage IIIA non-small cell carcinoma of the lung (NSCCL) were treated with multimodality therapy consisting of induction radiotherapy (55.8 Gy) and two cycles of concurrent chemotherapy with cisplatin, 25 mg/m2 for 4 days by continuous infusion and bolus etoposide, 100 mg/m2 on days 2 and 4 of each cycle followed by surgery and adjuvant chemotherapy. Of 53 evaluable patients, 47 achieved clinical responses (9 complete response, 38 partial response) after induction therapy for a response rate of 89%. 47 patients were resectable after induction therapy, but 8 patients refused surgery and 6 patients were not eligible for surgery based on poor pulmonary function (medical contraindications). 33 patients underwent thoracotomy and in 6 patients, resection was technically unfeasible. Thus complete surgical resection was accomplished in 27 patients. After all therapy, 28 patients achieved a complete response (53%) and 19 patients a partial response (36%). Toxicities were mild. At a maximum of 75 months (median, 28 months) of follow-up, the median survival of the entire group is 24 months. The median survival of resected patients has not been reached; their 6-year survival rate is 55%. Unresected patients survived for a median of 11 months. This multimodality regimen is well-tolerated, induces a high response and resectability rate and prolongs survival in resected patients.

Effect of trapidil derivative AR 12456 on intracellular cholesterol homeostasis in human hepatoma cell line Hep G2

The effect of trapidil derivative AR12456 on intracellular cholesterol metabolism was investigated in human hepatoma cell line HepG2. AR12456 enhanced the uptake and degradation of(125)I-LDL in a dose-dependent manner. The drug inhibited cholesterol synthesis and esterification without affecting cellular cholesterol content and bile acid synthesis; cholesterol efflux was slightly increased. These results show that the inhibition of cholesterol synthesis together with the enhanced expression of LDL receptors may partially explain the hypocholesterolemic activity of compound AR12456.

Does a HDL injection reduce the development of serum hyperlipidemia and progression of fatty streaks in cholesterol fed rabbits?

The influences of homologous (rabbit) or heterologous (human) high density lipoprotein (HDL) on the development of serum hyperlipidemia and progression of fatty streaks were studied in cholesterol fed rabbits. Three groups of New Zealand rabbits were fed a 0.5% cholesterol rich diet for 8 weeks. Additionally into these animals the following solutions were injected intravenously two times per week: group 1 (control): saline; group 2: human HDL dissolved in saline; group 3: rabbit HDL dissolved in saline. The animals of group 2 had lower serum cholesterol levels during the dietary period than rabbits of group 1 (p < 0.05) but the surface of intima covered with fatty streaks was the same as in group 1. On the other hand, the serum cholesterol level in rabbits of group 3 was the same as in group 1 during the whole experimental period, but the surface of aorta covered with fatty streaks was significantly lower (p < 0.05) in group 3 than in group 1. The results of this study support the hypothesis of an antiatherogenic action of HDL, which seems to be independent of the influence of HDL on the serum lipids but depends on the source of HDL.

Influence of a cholesterol rich diet in rabbits on the formation of PGI2 and TXA2

In the study was investigated whether the formation of prostanoids is changed in the different regions of aorta or in clotting whole blood in dependence on development of atherosclerosis. For this question New Zealand rabbits were fed for different periods with a cholesterol rich diet (0.5%). At the end of the different dietary periods the animals were killed and the following parameters estimated: blood: levels of total cholesterol, HDLcholesterol, VLDLcholesterol, cholesterol in the beta-migrating lipoprotein fraction, serum lipid peroxides, TXB2 formation capacity of clotting whole blood; aorta: surface of intima covered with fatty streaks, free and esterified cholesterol, triglycerides, collagen, formation of 6-keto-PGF1a and TXB2 by abdominal and thoracic aortas. The lipid parameter demonstrated a relatively strong correlation with the duration of cholesterol rich diet or the macroscopically detectable atherosclerosis, but the prostanoid formation remained unchanged.

Influence of trapidil and derivatives on cholesterol synthesis and esterification in cultured cells

The effect of trapidil (Rocornal) and its derivatives AR 12456 and AR 12463 on endogenous cholesterol synthesis and on cholesterol esterification rate was studied in human skin fibroblasts (HSF), in human hepatoma cell line Hep G2 and in primary culture of peritoneal macrophages from mouse (PMM). The cholesterol esterification rate was not influenced by the drugs in the tested cell lines. The incorporation of [14C]acetate into cholesterol in HSF was inhibited by AR 12463 and AR 12456, but not by trapidil. The inhibitory potency of AR 12456 in HSF was enhanced after preincubation of the drug with Hep G2 and removal of the medium to HSF, suggesting that the formed metabolite(s) are more potent inhibitors than the parent substance. The metabolite(s) formed seem(s) to influence the first steps in the endogenous formation of cholesterol, because the incorporation of [14C]mevalonate into cholesterol was not significantly inhibited. These findings suggest that the demonstrated inhibition of the endogenous cholesterol synthesis by AR 12456, especially after transformation into a probably more active substance(s), together with the recently described enhanced expression of LDL receptors in Hep G2 cells may partially explain the hypocholesterolaemic activity of AR 12456.

The trapidil derivative AR 12456 protects against serum hyperlipidemia in guinea pigs

The administration of the trapidil derivative AR 12465 (5 mg/kg body weight) intraperitoneally to hypercholesterolemic guinea pigs caused a stronger reduction in serum total cholesterol (TC) than trapidil (20 mg/kg, i.p.) or a vehicle injection (saline with 5% ethanol i.p.). The stronger reduction of TC is caused by a lower level in the sum of all beta-migrating lipoproteins and an enhanced level of high-density lipoprotein. The levels of free and esterified cholesterol were not changed in kidney and left cardiac ventricle, but significantly enhanced (P less than 0.05) in the liver of all groups fed a cholesterol-rich diet. The elevation in liver cholesterol was higher in the group treated with AR 12456 than in the group treated with trapidil or with vehicle. The treatment with AR 12456 diminished the ratio TXB2/6-keto-PGF1 alpha for the capacity of aorta to form these prostanoids. In conclusion, our data show that AR 12456 has a strong antilipidemic action in guinea pigs fed a cholesterol-rich diet.

Oral zidovudine, continuous-infusion fluorouracil, and oral leucovorin calcium: a phase I study

A phase I clinical, pharmacologic, and biochemical evaluation of escalating oral zidovudine (AZT) given over 2 days with a fixed dose of continuous-infusion fluorouracil (800 mg/m2 per day X 3 days) and oral leucovorin calcium was performed. Eighteen patients were treated with doses of AZT ranging from 1.0 to 9.0 g/m2 per day. Nausea and vomiting were dose limiting, with a maximally tolerated dose of 7.5 g/m2 per day. Rash and mucositis occurred but were not dose limiting. A dose-related increase in peak plasma levels of AZT was observed, and the alpha half-life of AZT in plasma (75 min) was unaffected by these high doses. At doses above 4.0 g/m2 per day, trough levels significantly increased, perhaps reflecting prolonged absorption from the gut. No responses were observed; however, a significant increase in DNA single-strand breaks was observed in peripheral blood cells after a threshold dose of 4.0 g/m2 per day, confirming a biological effect of AZT in this regimen. Further trials with an intravenous formulation capable of maintaining plasma levels and circumventing dose-limiting toxicity are warranted.

Influence of high density lipoprotein (HDL), prepared from human blood, on prostanoid formation, serum and tissue lipids and development of arteriosclerosis in cholesterol rich fed rabbits

The i.v. administration of high density lipoprotein (HDL) into cholesterol fed rabbits decreased statistically significantly the serum level of total cholesterol and of low density lipoprotein cholesterol after a feeding period of 8 weeks. These diminished levels of cholesterol were associated with a statistically significant reduction in the levels of cholesterol esters in kidneys and platelets but not in hepatic tissue or in aorta. Macroscopically detectable arteriosclerosis was not statistically significantly diminished. The formation of prostanoids by the aorta remained unchanged. The atherogenic role of immunologic factors acting against the heterologous HDL may have compensated for the antiatherogenic HDL action on plasma and tissue lipids.

[Changes in the spongiosa density in the femoral head of rabbits in atherosclerosis]

Modulations of spongiosa density in the femoral head of rabbits by atherosclerosis. In a long-term study 31 rabbits (+5 control animals) were fed about 20 weeks on a diet rich in cholesterol. An important observation in this study was, that spongiosa density in the femoral head decreases after cholesterol rich diet in contrast to the control group. This effect could be modulated by the Trapidil AR 12463 content (50 mg/die) of the diet, but not by the high density lipoprotein application. Serum cholesterol levels and induced atherosclerosis were determined. Correlations between spongiosa density and atherosclerosis were discussed.

Modulation of TXA2 generation of platelets by human lipoproteins

The lipoprotein (LP) fractions VLDL, LDL, HDL2 and HDL3 were prepared by ultracentrifugation of plasma from healthy volunteers and from patients with coronary heart disease (CHD). We investigated the capacity of platelets from healthy volunteers and patients with atherosclerosis to generate thromboxane A2 (TXA2) during spontaneous clotting of whole blood under the influence of the lipoprotein fractions. In our experiments the serum concentration of TXB2, reflecting the capacity of platelets to generate TXA2 during clotting, depends on several factors: the type of LP fraction used, the blood used for generation of TXA2, and for the same LP fraction whether it was taken from plasma of healthy volunteers or patients with CHD. VLDL prepared from plasma of healthy volunteers inhibited but VLDL prepared from plasma of patients with CHD enhanced the TXA2 formation of platelets from healthy volunteers (p less than 0.05, resp.). LDL from CHD patients inhibited the TXA2 formation of platelets from atherosclerotic patients (p less than 0.01). The HDL subfractions HDL2 and HDL3 from healthy volunteers inhibited TXA2 formation by platelets from healthy volunteers as well as those from atherosclerotic patients (p less than 0.05; p less than 0.01, respectively). HDL2 from patients with CHD inhibited only the TXA2 formation of platelets from healthy volunteers (p less than 0.01), whereas HDL3 from CHD patients inhibited only the TXA2 formation of platelets from atherosclerotic patients (p less than 0.01).

A phase I/II trial of 5-fluorouracil and etoposide in metastatic colorectal carcinoma

Twenty-two patients with metastatic colorectal carcinoma were treated in a Phase I-II study of combination therapy with 5-fluorouracil (5-FU) and etoposide (VP-16). Treatment consisted of weekly intravenous VP-16, 100-120 mg/M2, followed by 5-FU, 400-480 mg/M2, in 28-day cycles. Myelosuppression was the dose-limiting toxicity with a mean nadir leukocyte count of 3,600/mm3 and a mean nadir thrombocyte count of 101,000/mm3. There were no episodes of sepsis or bleeding. The tolerable dose for this regimen is VP-16, 110 mg/M2, and 5-FU, 440 mg/M2, weekly. A total of 63 cycles of chemotherapy were given. Although 10 patients had stabilization of disease, no partial or complete responses were documented. We conclude that there is no clinical support for the in vitro synergy observed with this combination. Further trials of this combination using this schedule in colorectal carcinoma are not indicated.

Trapidil derivatives and low density lipoprotein metabolism by human skin fibroblasts and by human hepatoma cell line Hep G2

The effect of trapidil (RocornalR) and some of its newly developed derivatives (AR 12456, AR 12463, AR 12465, AR 12464) on the receptor-mediated low density lipoprotein (LDL) binding, uptake and degradation was studied in human skin fibroblasts (HSF) and in human hepatoma cell line Hep G2. Compound AR 12456 influenced this pathway in a selective way: it enhanced the uptake and degradation of 125I-LDL by Hep G2 cells in a dose-dependent manner, but inhibited it in HSF. Scatchard analysis of the saturable LDL binding in Hep G2 indicates that the effect of compound AR 12456 is the result of an increased number of LDL binding sites. Compound AR 12465 was less effective on LDL catabolism. Trapidil and the other derivatives were inactive under the same experimental conditions. When Ar 12456 was preincubated with Hep G2 cells and then the incubation medium was transferred to HSF, a stimulation of specific LDL pathway occurred also in this cell line. These findings suggest that a metabolite(s) of AR 12456 might be responsible for the enhanced expression of LDL receptors in cultured human cells.

Influence of iloprost on eicosanoid generation and lipid levels in experimental myocardial ischemia in dogs

Anaesthetized mongrel dogs were subjected to occlusion of a coronary artery. The resulting myocardial infarction was observed for three hours. One hour after occlusion, infusion of the stable prostacyclin analogue iloprost or saline was started. In the control group myocardial infarction was associated with an increase of the ratio TXB2/6-keto-PGF1a which was abolished by iloprost treatment. After occlusion in the control group, the atherosclerosis index (TC-HDLC): HDLC was increased, but in the iloprost-treated group it was significantly decreased. The results of this study suggest that the administration of iloprost is able to prevent changes in eicosanoid metabolism and lipoprotein pattern after coronary artery occlusion in dogs.

Influence of a plasma fraction of human blood, rich in high density lipoprotein, on in vitro formation of prostaglandin I2 (PGI2) and thromboxane A2 (TXA2)

The influence of a plasma fraction of human blood, rich in high density lipoprotein (HDL), was investigated on the "in vitro" formation of PGI2 and TXA2. The addition of 1 mg HDL-cholesterol per ml incubation fluid stimulated significantly the biotransformation of prostaglandin H2 into PGI2 by the microsomal fraction of pig aorta. The TXB2 formation capacity of whole clotted blood was inhibited by administration of HDL in a dose dependent manner. These results suggest that added HDL is able to enhance the ratio PGI2:TXA2. This did not depend on the preparation of HDL either by ultracentrifugation or by precipitation.

Do endogenous lipoproteins modulate the sensibility of animals against arrhythmogenic drugs?

The present study suggests that a diminished level of HDL is connected with an enhanced susceptibility to arrhythmogenic stimuli only in rats pretreated with a diet deficient in polyunsaturated fatty acids (PUFA), but not after a PUFA-rich or pellet diet. The endogenous level of total cholesterol did not influence the thresholds for ventricular flutter or ventricular fibrillation in aconitine-induced arrhythmia in rats or in ouabain-induced arrhythmia in guinea pigs.

[Decreasing atherogenic risks by an eicosapentaenoic acid-rich diet]

(n-3) diets rich in polyunsaturated fatty acids (PUFA) reduce the atherogenic lipoproteins, especially the VLDL (very low density lipoproteins) rich in triglycerides but also the LDL, more effectively than (n-6) PUFA-rich diets. Moreover also other parameters such as high blood pressure and aggregation of thrombocytes are positively influenced, similarly like after (n-6) PUFA-rich diet. Eicosapentaenoic acid (20:5, n-3) has a triglyceride- and cholesterol-reducing effect by inhibition of the VLDL-synthesis (apolipoprotein B, triglycerides) in the liver, inhibition of lipogenic liver enzymes, accelerated elimination of VLDL from the circulation, increased excretion of steroids and bile acids into the stools and amelioration of the fat tolerance. The prolongation of the period of haemorrhage and the decrease of the aggregation of thrombocytes is associated with the enrichment of EPA in the platelet membrane. In these cases the decreased thrombocyte-vascular vessel-interaction shall be caused by a changed metabolism of the eicosanoids (secondary products of unsaturated fatty acids with 20 carbon atoms) and eicosanoid-independent mechanisms.

Comparative study of the blood pressure effects of four different vegetable fats on young, spontaneously hypertensive rats

Following the suckling period, four groups of male four-week-old spontaneously hypertensive rats (SHR) were fed semisynthetic diets with 14% (by weight) of either sunflower seed oil [46% 18:2(n-6); linoleic acid (LA)-rich], linseed oil [62.5% 18:3(n-3) + 12.9% 18:2(n-6); alpha-linolenic acid (LNA)-rich], evening primrose oil [9.2% 18:3(n-6) + 71% 18:2(n-6); gamma-linolenic acid (LNA)-rich] or hydrogenated palm kernel fat [1.5% 18:2(n-6); polyunsaturated fatty acid (PUFA)-deficient], respectively, up to an age of 18 wk. All diets enriched with PUFA provoked an attenuation of hypertension development. The effect was lowest in the LA-rich group and highest in the gamma-LNA-rich group. Differences in fatty acid composition of renal phospholipids between groups reflect the fatty acids present in the respective dietary fats. Renomedullary production of PGF2 alpha was significantly reduced in alpha-LNA-rich and slightly diminished in gamma-LNA-rich fed rats. Aortic formation of 6-keto-PGF1 alpha and TXB2 was increased in animals fed the gamma-LNA-rich diet. Thus, the attenuation of hypertension development cannot be explained only by changes in prostanoid formation. Other mechanisms possibly involved should be pursued.

Influence of a cod liver oil diet in healthy and insulin-dependent diabetic volunteers on fatty acid pattern, inhibition of prostacyclin formation by low density lipoprotein (LDL) and platelet thromboxane

Ten healthy and twenty diabetic volunteers (type 1) received 15 capsules (à 450 mg) cod liver oil for 2 weeks daily in addition to a "normal" diet. The levels of eicosapentaenoic acid in the plasma phospholipids of both groups were increased after the treatment. The inhibition of the prostacyclin formation by LDL was diminished when the LDL was isolated after the treatment in comparison to LDL taken in the same concentration and from the same donors before it. The thromboxane B2 (TXB2) synthesis capacity of clotting whole blood, thrombin-induced TXB2 formation by platelets as well as the 15(S)-hydroxy-11 alpha,9 alpha-epoxymethano-5Z, 13E-prostadienoic acid-induced platelet aggregation were not altered by the treatment in healthy volunteers, whereas in diabetics the TXB2 formation capacity of clotting whole blood was decreased after the treatment in comparison with before it.

Thromboxane A2 (TXA2) formation by washed human platelets under the influence of low and high density lipoproteins from healthy donors

Low density lipoprotein (LDL) stimulates TXA2 formation (measured as malondialdehyde) in washed human platelets with active cyclooxygenase, whereas high density lipoprotein (HDL) does not show any influence on TXA2 formation in this system. These results support the hypothesis that the proaggregatory action of a high plasma LDL concentration may be mediated by modification in the biosynthesis of eicosanoids. The mode of action of lipoproteins is discussed.

Serum triglycerides and HDL cholesterol from SHR after evening primrose oil and other polyunsaturated fats

Spontaneously hypertensive rats (SHR) were fed diets enriched with evening primrose (EPO), sunflower (SO) and linseed oils (LO) as well as palm kernel fat (PKF), the latter being deficient in polyunsarated fatty acids (PUFA). In SHR fed EPO serum triglycerides were lowest and HDL1 cholesterol was highest as compared to the other groups of animals. Total cholesterol was not different. The data suggest that - as with blood pressure - serum lipids and lipoproteins might be influenced most effectively by EPO in comparison to other polyunsaturated fats.

The influence of lipoproteins (LDL and HDL) on PGI2-formation by isolated aortic preparations of rabbits

The influence of LDL- and HDL-concentrations of 0.5-2.0 mg/ml and 0.25-1.0 mg/ml respectively, from male and female donors on the formation of PGI2 in isolated aortic preparations was investigated under in vitro conditions. LDL of male donors inhibited endogenous PGI2-formation and the conversion of exogenous PBH2 to PGI2. On the other hand the highest concentration of HDL induced an increase in the basal and in the stimulated PGI2-formation. Lipoproteins of female donors showed no or only a weak stimulating effect on PGI2-formation. Human serum albumin in comparable concentrations of 1-50 mg/ml remained without influence. The importance of the results for cardiovascular diseases is discussed.

Endogenous lipoproteins modify the thromboxane formation capacity of platelets

A significantly negative correlation was demonstrated between HDL-cholesterol levels of serum and the thromboxane B2 (TXB2) formation in clotted whole blood, whereas a significantly positive correlation was estimated between the LDL cholesterol or apolipoprotein B (apo B) levels and the TXB2 formation in clotted whole blood. Similar relationships were observed between the HDL and apo B serum levels and the thrombin-induced malondialdehyde formation in platelet-rich plasma. The levels of HDL2 cholesterol, total cholesterol, apo A-I and of triglycerides were not significantly correlated with the TXB2 or malondialdehyde formation in both systems. The results in this study support the hypothesis that the TXB2 formation may be modulated by endogenous lipoproteins: high level of LDL stimulates and high level of HDL inhibits the TXB2 formation.