Abstract P2-16-08: Administration of the Novel Antiangiogenic PTC299 in Combination with Aromatase Inhibitors Is Feasible and Shows Antitumor Activity in Metastatic Breast Cancer

Background: PTC299 is an investigational new drug that suppresses tumor growth by selective post-transcriptional inhibition of tumor VEGF expression. PTC299 demonstrates antitumor activity in both hormone-receptor-positive (HR+) and-negative (HR-) breast cancer xenograft models and eliminates established tumors in aromatase-overexpressing human breast cancer xenografts when given alone or in combination with letrozole.

Methods: This study is assessing the feasibility of PTC299 administration in combination with aromatase inhibitors (AIs) in women with HR+ metastatic breast cancer and natural or induced post-menopausal levels of ovarian function. Patients already receiving or newly initiating a standard dose of an AI are coadministered 100 mg BID of oral PTC299 continuously until disease progression.

Results: To date, the study has enrolled 24 women with a median [range] age of 57 [26-82] years, ECOG PS of 0 (n=12) or 1 (n=12), to receive PTC299 together with letrozole (n=11), anastrozole (n=6), or exemestane (n=7) for a median [range] duration of ∼16 [3-36] weeks. Combination therapy has been generally well tolerated; AEs have been predominantly Grade 1-2, have usually not been PTC299-related. The most frequent AEs have been headache (25%) and hot flashes (25%). No PTC299 dose reductions or discontinuations due to AEs have occurred. Measures of PTC299 plasma exposure have shown ∼2-fold accumulation, with values reaching steady state by -21 days of treatment; trough values have exceeded those maximally active in xenograft models. Relative to baseline, therapy has been associated with on-study reductions in circulating VEGF concentrations and decreases in tumor perfusion as assessed by DCE-MRI. Antitumor activity includes 3 CRs by PET/CT, 1 PR by PET/CT, and 3 PRs by PET scan. To date, 7/24 (29%) patients have received ≥24 weeks of treatment and 10/24 (42%) patients continue on treatment.

Conclusions: Combining PTC299 100 mg BID with standard AI treatment appears feasible. Safety, exposure, pharmacodynamic, and antitumor activity observations have been encouraging. Supported by a grant award from the Department of Defense

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-16-08.

Double-stranded RNA-dependent protein kinase activation modulates endotoxin-induced diaphragm weakness

Diaphragm caspase-8 activation plays a key role in modulating sepsis-induced respiratory muscle dysfunction. It is also known that double-stranded RNA-dependent protein kinase (PKR) is a regulator of caspase-8 activation in neural tissue. We tested the hypothesis that the PKR pathway modulates sepsis-induced diaphragmatic caspase-8 activation. We first evaluated the time course of diaphragm PKR activation following endotoxin administration in mice. We then determined whether administration of a PKR inhibitor (2-aminopurine) prevents endotoxin-induced diaphragm caspase-8 activation and contractile dysfunction in mice. Finally, we investigated if inhibition of PKR (using either 2-aminopurine or transfection with dominant-negative PKR) blocks caspase-8 activation in cytokine treated C₂C₁₂ cells. Endotoxin markedly activated diaphragm PKR (with increases in both active phospho-PKR protein levels, P < 0.03, and directly measured PKR activity, P < 0.01) and increased active caspase-8 levels (P < 0.01). Inhibition of PKR with 2-aminopurine prevented endotoxin-induced diaphragm caspase-8 activation (P < 0.01) and diaphragm weakness (P < 0.001). Inhibition of PKR with either 2-aminopurine or transfection with dominant-negative PKR blocked caspase-8 activation in isolated cytokine-treated C₂C₁₂ cells. These data implicate PKR activation as a major factor mediating cytokine-induced skeletal muscle caspase-8 activation and weakness.

Caspase and calpain activation both contribute to sepsis-induced diaphragmatic weakness

The cecal ligation perforation (CLP) model of sepsis is known to induce severe diaphragm dysfunction, but the cellular mechanisms by which this occurs remain unknown. We hypothesized that CLP induces diaphragm caspase-3 and calpain activation, and that these two enzymes act at the level of the contractile proteins to reduce muscle force generation. Rats (n = 4/group) were subjected to 1) sham surgery plus saline (intraperitoneal); 2) CLP; 3) CLP plus administration of calpain inhibitor peptide III (12 mg/kg ip); or 4) CLP plus administration of a caspase inhibitor, zVAD-fmk (3 mg/kg). At 24 h, diaphragms were removed, and the following were determined: 1) calpain and caspase-3 activities by fluorogenic assay; 2) caspase-3 and calpain I protein levels; 3) the intact diaphragm force-frequency relationship; and 4) the force generated by contractile proteins of single, permeabilized diaphragm fibers in response to exogenous calcium. CLP significantly increased diaphragm calpain activity (P < 0.02), caspase-3 activity (P < 0.02), active calpain I protein levels (P < 0.02), and active caspase-3 protein (P < 0.02). CLP also reduced the force generated by intact diaphragm muscle (P < 0.001) and the force generated by single-fiber contractile proteins (P < 0.001). Administration of either calpain inhibitor III or zVAD-fmk markedly improved force generation of both intact diaphragm muscle (P < 0.01) and single-fiber contractile proteins (P < 0.001). CLP induces significant reductions in diaphragm contractile protein force-generating capacity. This force reduction is mediated by the combined effects of activated caspase and calpain. Inhibition of these pathways may prevent diaphragm weakness in infected patients.

MitoQ administration prevents endotoxin-induced cardiac dysfunction

Sepsis elicits severe alterations in cardiac function, impairing cardiac mitochondrial and pressure-generating capacity. Currently, there are no therapies to prevent sepsis-induced cardiac dysfunction. We tested the hypothesis that administration of a mitochondrially targeted antioxidant, 10-(6'-ubiquinonyl)-decyltriphenylphosphonium (MitoQ), would prevent endotoxin-induced reductions in cardiac mitochondrial and contractile function. Studies were performed on adult rodents (n = 52) given either saline, endotoxin (8 mg x kg(-1) x day(-1)), saline + MitoQ (500 microM), or both endotoxin and MitoQ. At 48 h animals were killed and hearts were removed for determination of either cardiac mitochondrial function (using polarography) or cardiac pressure generation (using the Langendorf technique). We found that endotoxin induced reductions in mitochondrial state 3 respiration rates, the respiratory control ratio, and ATP generation. Moreover, MitoQ administration prevented each of these endotoxin-induced abnormalities, P < 0.001. We also found that endotoxin produced reductions in cardiac pressure-generating capacity, reducing the systolic pressure-diastolic relationship. MitoQ also prevented endotoxin-induced reductions in cardiac pressure generation, P < 0.01. One potential link between mitochondrial and contractile dysfunction is caspase activation; we found that endotoxin increased cardiac levels of active caspases 9 and 3 (P < 0.001), while MitoQ prevented this increase (P < 0.01). These data demonstrate that MitoQ is a potent inhibitor of endotoxin-induced mitochondrial and cardiac abnormalities. We speculate that this agent may prove a novel therapy for sepsis-induced cardiac dysfunction.

Effect of proteasome inhibitors on endotoxin-induced diaphragm dysfunction

Infections produce severe respiratory muscle dysfunction. It is known that the proteasome proteolytic system is activated in skeletal muscle in sepsis, and it has been postulated that this degradative pathway is responsible for inducing skeletal muscle weakness and wasting. The objective of this study was to determine if administration of proteasomal inhibitors (MG132, epoxomicin, bortezomib) can prevent sepsis-induced diaphragm weakness. Rats were given either 1) saline (0.5 ml ip), 2) endotoxin (12 mg/kg ip), 3) endotoxin plus MG132 (2.5 mg/kg), 4) endotoxin plus epoxomicin (1 micromol/kg), or 5) endotoxin plus bortezomib (0.05 mg/kg). Animals were killed either 48 or 96 h after injections, and assessments were made of diaphragm proteolysis, force-frequency relationships, mass, protein content, and caspase activation. Endotoxin increased proteolysis (P <0.001). MG132, epoxomicin, and bortezomib each prevented the endotoxin-induced increase in proteolysis (P <0.01). Endotoxin induced severe reductions in diaphragm force generation by 48 h (P <0.01); none of the proteasomal inhibitors prevented loss of force. Endotoxin induced significant reductions in diaphragm mass and protein content by 96 h (P <0.01); neither MG132 nor epoxomicin prevented loss of mass or protein, but bortezomib attenuated the reduction in protein content (P <0.05). Endotoxin increased diaphragm caspase-3 activity (P <0.01); caspase-3 activity remained high when either MG132, epoxomicin, or bortezomib were given. These data suggest proteasomal inhibitors are not an adequate treatment to prevent endotoxin-induced diaphragmatic dysfunction.

Exercise in sickle cell anemia: effect on inflammatory and vasoactive mediators

The aim of this study was to determine the response of inflammatory and vasoactive mediators to 3 consecutive days of exercise in African-American women with and without sickle cell anemia (SCA). Circulating inflammatory mediators [C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor alpha (TNFalpha)] were measured before, and vasoactive mediators [endothelin-1 (ET-1), nitric oxide metabolites (NOx)] before and after each exercise bout in ten subjects with SCA and ten controls. Exercise did not affect ET-1, IL-6 or CRP concentrations (p >.05). TNFalpha was higher in SCA than controls (p < or = .0005) at all times; however, the response pattern was similar for the groups: no change from day 1 to day 2, but a decrease from day 2 to day 3 (p < or = .05). NOx increased significantly after exercise (p < or = .0001) but returned to baseline by 24 h afterward. On the 3rd day, NOx increased after exercise in SCA but not in the controls (p < or = .05). In conclusion, exercise did not cause a harmful inflammatory response in these individuals with SCA. However, NOx increased after exercise on all 3 days in SCA but appeared attenuated after 2 days in controls.

Impact of endovascular-assisted in situ saphenous vein bypass technique on hospital costs

Our initial experience with endovascular-assisted in situ saphenous vein bypass (EISVB) showed patency rates to be comparable to those with conventional in situ bypass, and resulted in a significant reduction in wound-related complications and hospital length of stay (LOS). Here we evaluate the relative costs of these two approaches. Forty-four patients underwent 46 EISVB procedures using endovascular cannulation and coil occlusion of the saphenous vein side branches. Costs for each patient for the operation, the associated hospital stay, and any postoperative care were assessed. These costs were compared to those of the last 46 conventional open in situ bypass procedures as an historical comparison group. The two groups were statistically similar for all parameters except distal outflow target, with the comparison group having statistically more pedal bypasses (p = 0.004). Subset analysis was performed by subdividing each operative group, into those with popliteal and those with distal bypasses. The results of our analysis led us to conclude that the shorter LOS following EISVB more than compensates for the initial cost incurred by the side branch occlusion system. This shorter stay translates into an overall cost savings for EISVB compared to the cost of conventional in situ bypass. The reductions in wound-related morbidity and recovery time postoperatively with EISVB add an additional long-term cost benefit.

Body composition in women with sickle cell disease

INTRODUCTION

Adults with sickle cell disease (SCD) have increased morbidity and low perceived health status, similar to patients with other chronic conditions. These patients may be sedentary due to exercise intolerance, physical incapacity due to sickle cell-related complications or medical conservatism. Obesity is an indicator of low health status and overall well-being in the general population, and we hypothesize that adults with SCD will have a high total body fat (%BF). The purpose of this study was to assess body composition in women with SCD using dual-energy X-ray absorptiometry (DXA).

METHODS

Baseline medical examination, laboratory assessments, and seven-day activity recall to estimate energy expenditure (EE) were obtained for 22 women with SCD. BMI was calculated and whole body DXA was performed [fat mass (FM), fat-free soft tissue (FFST), and bone mineral content (BMC)]. Descriptive statistics were obtained and associations between body composition indices, total hemoglobin (Hb), treatment with hydroxyurea (HU), and EE were determined.

RESULTS

Patient age was 30.5+/-9.3 years and total Hb was 8.85+/-1.92 g/dL (mean+/-SD). Mean body mass index (BMI) (22.6 kg/m2) was in the 'acceptable' range, while DXA measurement of mean % fat (32.6%) indicated obesity. Fat-free mass (FFM) was 40.0+/-5.62 and bone mineral density (BMD) was 1.13+/-0.14 g/cm2 (mean+/-SD). There were no correlations between body composition indices and total Hb, HU, or EE.

CONCLUSIONS

This is the first report of high levels of adiposity, low FFM, and low BMD in normal weight women with SCD. The findings were not affected by total Hb, EE, HU. Further studies are needed to better define body composition, body composition determinants, and their impact on overall health status in adults with SCD.

Free radical-induced contractile protein dysfunction in endotoxin-induced sepsis

Recent studies have indicated that sepsis is associated with enhanced generation of several free-radical species (nitric oxide [NO], superoxide, hydrogen peroxide) in skeletal muscle. It is also known that this enhanced free-radical generation results in reductions in skeletal muscle force-generating capacity, but the precise mechanism(s) by which free radicals exert this effect in sepsis has not been determined. We postulated that free radicals might react directly with the contractile proteins in this condition, altering contractile protein force-generating capacity. To test this theory, we compared the force generation of single Triton-skinned diaphragmatic fibers (Triton skinning exposes the contractile apparatus, permitting direct assessment of contractile protein function) from the following groups of rats: (1) control animals; (2) endotoxin-treated animal; (3) animals given endotoxin plus polyethylene glycol- superoxide dismutase (PEG-SOD), a superoxide scavenger; (4) animals given endotoxin plus N(omega)-nitro-L-arginine methylester (L-NAME), a NO synthase inhibitor; (5 ) animals given only PEG-SOD or L-NAME; and (6 ) animals given endotoxin plus denatured PEG-SOD. We found that endotoxin administration produced both a reduction in the maximum force-generating capacity (Fmax) (i.e., a decrease in Fmax) of muscle fibers and a reduction in fiber calcium sensitivity (i.e., an increase in the Ca2+ concentration required to produce half-maximal activation [Ca50]). L-NAME and PEG-SOD administration preserved Fmax and Ca50 in endotoxin-treated animals; neither drug affected these parameters in non-endotoxin treated animals. Denatured PEG-SOD failed to inhibit endotoxin-related alterations in contractile protein function. Sodium dodecyl sulfate polyacrylamide gel electrophoresis of skinned fibers from endotoxin-treated animals revealed a selective depletion of several proteins; administration of L-NAME or PEG-SOD to endotoxin-treated animals prevented this protein depletion, paralleling the effect of these two agents to prevent a reduction in contractile protein force-generating capacity. These data indicate that free radicals (superoxide, NO, or daughter species of these radicals) play a central role in altering skeletal muscle contractile protein force-generating capacity in endotoxin-induced sepsis.

Superoxide, hydroxyl radical, and hydrogen peroxide effects on single-diaphragm fiber contractile apparatus

Reactive oxygen species contribute to diaphragm dysfunction in certain pathophysiological conditions (i.e., sepsis and fatigue). However, the precise alterations induced by reactive oxygen species or the specific species that are responsible for the derangements in skeletal muscle function are incompletely understood. In this study, we evaluated the effect of the superoxide anion radical (O(2)(-).), hydroxyl radical (.OH), and hydrogen peroxide (H(2)O(2)) on maximum calcium-activated force (F(max)) and calcium sensitivity of the contractile apparatus in chemically skinned (Triton X-100) single rat diaphragm fibers. O(2)(-). was generated using the xanthine/xanthine oxidase system;.OH was generated using 1 mM FeCl(2), 1 mM ascorbate, and 1 mM H(2)O(2); and H(2)O(2) was added directly to the bathing medium. Exposure to O(2)(-). or.OH significantly decreased F(max) by 14.5% (P < 0.05) and 43.9% (P < 0. 005), respectively.OH had no effect on Ca(2+) sensitivity. Neither 10 nor 1,000 microM H(2)O(2) significantly altered F(max) or Ca(2+) sensitivity. We conclude that the diaphragm is susceptible to alterations induced by a direct effect of.OH and O(2)(-)., but not H(2)O(2), on the contractile proteins, which could, in part, be responsible for prolonged depression in contractility associated with respiratory muscle dysfunction in certain pathophysiological conditions.

Free radicals alter maximal diaphragmatic mitochondrial oxygen consumption in endotoxin-induced sepsis

Recent studies indicate that sepsis is associated with enhanced generation of several free radical species (nitric oxide, superoxide, hydrogen peroxide) in skeletal muscle. While studies suggest that free radical generation causes uncoupling of oxidative phosphorylation in sepsis, no previous report has examined the role of free radicals in modulating skeletal muscle oxygen consumption during State 3 respiration or inhibiting the electron transport chain in sepsis. The purpose of the present study was to examine the effects of endotoxin-induced sepsis on State 3 diaphragm mitochondrial oxygen utilization and to determine if inhibitors/scavengers of various free radical species would protect against these effects. We also examined mitochondrial protein electrophoretic patterns to determine if observed endotoxin-related physiological derangements were accompanied by overt alterations in protein composition. Studies were performed on: (a) control animals, (b) endotoxin-treated animals, (c) animals given endotoxin plus PEG-SOD, a superoxide scavenger, (d) animals given endotoxin plus L-NAME, a nitric oxide synthase inhibitor, (e) animals given only PEG-SOD or L-NAME, (f) animals given endotoxin plus D-NAME, and (g) animals given endotoxin plus denatured PEG-SOD. We found: (a) no alteration in maximal State 3 mitochondrial oxygen consumption rate at 24 h after endotoxin administration, but (b) a significant reduction in oxygen consumption rate at 48 h after endotoxin, (c) no effect of endotoxin to induce uncoupling of oxidative phosphorylation, (d) either PEG-SOD or L-NAME (but neither denatured PEG-SOD nor D-NAME) prevented endotoxin-mediated reductions in State 3 respiration rates, (e) some mitochondrial proteins underwent tyrosine nitrosylation at 24 h after endotoxin administration, and (f) SDS-page electrophoresis of mitochondria from endotoxin-treated animals revealed a selective depletion of several proteins at 48 h after endotoxin administration (but not at 24 h); (g) administration of L-NAME or PEG-SOD prevented this protein depletion. These data provide the first evidence that endotoxin-induced reductions in State 3 mitochondrial oxygen consumption are free radical-mediated.

PLA(2) dependence of diaphragm mitochondrial formation of reactive oxygen species

Contraction-induced respiratory muscle fatigue and sepsis-related reductions in respiratory muscle force-generating capacity are mediated, at least in part, by reactive oxygen species (ROS). The subcellular sources and mechanisms of generation of ROS in these conditions are incompletely understood. We postulated that the physiological changes associated with muscle contraction (i.e., increases in calcium and ADP concentration) stimulate mitochondrial generation of ROS by a phospholipase A(2) (PLA(2))-modulated process and that sepsis enhances muscle generation of ROS by upregulating PLA(2) activity. To test these hypotheses, we examined H(2)O(2) generation by diaphragm mitochondria isolated from saline-treated control and endotoxin-treated septic animals in the presence and absence of calcium and ADP; we also assessed the effect of PLA(2) inhibitors on H(2)O(2) formation. We found that 1) calcium and ADP stimulated H(2)O(2) formation by diaphragm mitochondria from both control and septic animals; 2) mitochondria from septic animals demonstrated substantially higher H(2)O(2) formation than mitochondria from control animals under basal, calcium-stimulated, and ADP-stimulated conditions; and 3) inhibitors of 14-kDa PLA(2) blocked the enhanced H(2)O(2) generation in all conditions. We also found that administration of arachidonic acid (the principal metabolic product of PLA(2) activation) increased mitochondrial H(2)O(2) formation by interacting with complex I of the electron transport chain. These data suggest that diaphragm mitochondrial ROS formation during contraction and sepsis may be critically dependent on PLA(2) activation.

Endotoxin administration alters the force vs. pCa relationship of skeletal muscle fibers

Recent work indicates that endotoxemia elicits severe reductions in skeletal muscle force-generating capacity. The subcellular alterations responsible for these decrements have not, however, been fully characterized. One possibility is that the contractile proteins per se are altered in endotoxemia and another is that the mechanism by which these proteins are activated is affected. The purpose of the present study was to assess the effects of endotoxin administration on the contractile proteins by examining the maximum calcium-activated force (F(max)) and calcium sensitivity of single Triton-skinned fibers of diaphragm, soleus, and extensor digitorum longus (EDL) muscles taken from control and endotoxin-treated (8 mg/kg) rats. Fibers were mounted on a force transducer and sequentially activated by serial immersion in solutions of increasing Ca(2+) concentration (i.e., pCa 6.0 to pCa 5.0); force vs. pCa data were fit to the Hill equation. All fibers were typed at the conclusion of studies using gel electrophoresis. F(max), the calcium concentration required for half-maximal activation (Ca(50)), and the Hill coefficient were compared as a function of muscle and fiber type for the control and endotoxin-treated animals. Control group F(max) was similar for diaphragm, soleus, and EDL fibers, i.e., 112.34 +/- 2.64, 111.55 +/- 3.66, and 104.05 +/- 4.33 kPa, respectively. Endotoxin administration reduced the average F(max) for fibers from all three muscles to 80.25 +/- 2.30, 72.47 +/- 2.97, and 78.32 +/- 2.43 kPa, respectively (P < 0.001 for comparison of each to control). All fiber types in diaphragm, soleus, and EDL muscles manifested similar endotoxin-related reductions in F(max). The Ca(50) and the Hill coefficient for all fiber types and all muscles were unaffected by endotoxin administration. We speculate that these alterations in the intrinsic properties of the contractile proteins represent a major mechanism by which endotoxemia reduces muscle force-generating capacity.

Effects of protein kinase A inhibition on rat diaphragm force generation

Although protein kinases are known to play a role in modulating a variety of intracellular functions, the direct effect of inhibition of these enzymes on skeletal muscle force production has not been studied. The purpose of the present study was to examine this issue by determining the effects produced on diaphragm force generation by two protein kinase inhibitors: (a) H7, an inhibitor of both cAMP-dependent protein kinase (PKA) and of protein kinase C, and (b) H89, a selective inhibitor of PKA. Experiments (n=15) were performed using isolated, arterially perfused, electrically stimulated rat diaphragms. Perfusate temperature was adjusted to maintain muscle temperature at 27 degrees C and arterial pressure was kept at 150 Torr. Animals were divided into three groups: (a) a control group perfused with Krebs-Henselheit solution equilibrated with 95% O(2)/5% CO(2), (b) a group in which H7 (2 microM) was added to the perfusate, and (c) a group perfused with solution containing H89 (4 microM). In all three groups, we assessed diaphragm twitch kinetics, force-frequency relationships and in vitro fatiguability. We found that both H7 and H89 administration slowed twitch relaxation, augmented force generation in response to low frequency stimulation, and increased the rate of development of fatigue. Specifically, for control, H7 and H89 groups, respectively, we found: (a) 1/2 relaxation time averaged 64+/-2 S.E.M., 87+/-6 and 90+/-2 ms, P<0. 003, (b) force production during 10-Hz stimulation averaged 12.6+/-1. 1, 20.1+/-2.3, and 20.3+/-2.1 N/cm(2), P<0.035, and (c) force fell to 14.3+/-2.0, 9.5+/-0.5 and 8.7+/-0.2% of its initial value after 20 min of fatiguing stimulation, P<0.035. These data show that it is possible to produce large increases in low frequency skeletal muscle force generation by directly inhibiting PKA. We speculate that it may be possible to pharmacologically augment respiratory muscle force and pressure generation in clinical medicine by administration of PKA inhibitors.

Modulation of release of reactive oxygen species by the contracting diaphragm

Recent reports have demonstrated that superoxide is released by the contracting diaphragm. Moreover, extracellular scavengers of superoxide (i.e., exogenously administered superoxide dismutase) reduce diaphragm fatigue rate, arguing that superoxide released from contracting muscles may have functionally significant effects. The mechanism by which free radical formation and release occurs has not, however, been determined, and all past studies of this phenomenon have been conducted at a single muscle length (the length of maximum force generation, Lo) and at a single level of carbon dioxide. The purpose of the present study was twofold: (1) to examine the effect of blockade of two free radical-generating pathways (i.e., to block cyclooxygenase with indomethacin and xanthine oxidase with oxypurinol) on superoxide release by the contracting diaphragm, and (2) to examine the effect of altering muscle length, carbon dioxide levels, and stimulation frequency on superoxide release during contraction. Studies were performed using an isolated, arterially perfused, rat diaphragm preparation in which superoxide release was assessed in real time by measuring arteriovenous cytochrome c reduction gradients across this muscle. We found that superoxide release during contraction was: (1) not altered by indomethacin administration, (2) partially reduced by oxypurinol administration, (3) reduced by decreasing muscle length, (4) reduced by increasing carbon dioxide concentrations, and (5) reduced by decreasing stimulation frequency. The first two findings indicate that xanthine oxidase pathways contribute to free radical formation under these circumstances but cyclooxygenase does not. The last three findings suggest that these common physiologic alterations have significant effects on free radical release by contracting muscle.

Peroxynitrite induces contractile dysfunction and lipid peroxidation in the diaphragm

Peroxynitrite may be generated in and around muscles in several pathophysiological conditions (e.g., sepsis) and may induce muscle dysfunction in these disease states. The effect of peroxynitrite on muscle force generation has not been directly assessed. The purpose of the present study was to assess the effects of peroxynitrite administration on diaphragmatic force-generating capacity in 1) intact diaphragm muscle fiber bundles (to model the effects produced by exposure of muscles to extracellular peroxynitrite) and 2) single skinned diaphragm muscle fibers (to model the effects of intracellular peroxynitrite on contractile protein function) by examining the effects of both peroxynitrite and a peroxynitrite-generating solution, 3-morpholinosydnonimine, on force vs. pCa characteristics. In intact diaphragm preparations, peroxynitrite reduced diaphragm force generation and increased muscle levels of 4-hydroxynonenal (an index of lipid peroxidation). In skinned fibers, both peroxynitrite and 3-morpholinosydnonimine reduced maximum calcium-activated force. These data indicate that peroxynitrite is capable of producing significant diaphragmatic contractile dysfunction. We speculate that peroxynitrite-mediated alterations may be responsible for much of the muscle dysfunction seen in pathophysiological conditions such as sepsis.

Factors associated with the conditional release of persons acquitted by reason of insanity: a decision tree approach

Most NGRI (not guilty by reason of insanity) acquitties are hospitalized for some period of time following acquittal, which raises the question of when an individual can be safely released into the community. The conditional release (CR) of persons acquitted by reason of insanity, therefore, provokes the question of public safety. This study examines the CR systems in four states--Connecticut, Maryland, New York, and Ohio. A study sample of 529 persons acquitted as NGRI from 1985 to 1987 was followed up for at least five years to determine who is conditionally released. Following a description of the CR systems, findings suggestive of the role of dangerousness and diagnosis as predictors of CR are presented. Personal characteristics are also significant factors in predicting who will be released. The length of hospitalization for this population and other descriptive factors such as history of hospitalization, arrests, substance abuse, family violence, and living arrangements are also addressed.

Increased superoxide production during fatigue in the perfused rat diaphragm

This study test the hypothesis that a temporal relationship exists between the production of superoxide anion (O2-) and the contractile activity of perfused rat diaphragm. O2- levels were determined minute to minute by measuring the reduction of cytochrome c in the perfusate as the diaphragms were subjected to various levels of contractile activity. After equilibrating at low contractile rates (one 500 ms 80 Hz train/min), diaphragms were fatigued by increasing their contractile activity for 5 min (one 500 ms 80 Hz train/s) and then allowed to recover for 30 min (one 500 ms 80 Hz train/min). During equilibration, diaphragms did not produce O2- above the background level measured in the presence of superoxide dismutase (SOD). Within the first minute of fatigue-inducing stimulation, however, the rate of O2- production increased to 0.70 +/- 0.17 nmol/min and remained elevated until the recovery period when production returned towards baseline. SOD blocked this stimulation-related increase of O2-. Tension (+/-SOD) fell to 12% of the control value during the fatigue-inducing stimulation. During recovery the contractile response returned to 51% of control, indicating long-lasting effects on the contractile machinery. SOD did not limit fatigue or improve recovery, probably because it is a large protein that cannot cross cell membranes and protect the cells by scavenging O2- at its site of production.

Office evaluation of pulmonary function: beyond the numbers

Pulmonary function testing is useful in evaluating dyspnea, wheezing and cough, determining the severity of pulmonary disease, monitoring the response to therapy and assessing preoperative pulmonary risk. Accurate office spirometry requires routine preventive maintenance, cleaning and calibration of equipment and quality control measures. To obtain a flow-volume loop, the seated or standing patient is instructed to inspire maximally to total lung capacity, exhale as hard, fast and completely as possible (forced vital capacity [FVC]), and inhale quickly and deeply to total lung capacity (TLC). Spirometry reveals both obstructive and restrictive airway disease. Obstruction is characterized by reduced forced expiratory volume in one second (FEV1) and FEV1/forced vital capacity (FEV1/FVC%), and normal to increased TLC and residual volume. Restriction is characterized by reduced TLC and residual volume and normal FEV1/FVC%. Spirometry may also reveal abnormalities of the upper airway, including the nasopharynx, vocal cords, trachea and proximal large airways.

The hidden effects of Montana's "abolition" of the insanity defense

Montana abolished the affirmative insanity defense in 1979. In this article we examine the effect of this change by focusing on all defendants who raised mental health in his/her defense from 1976 to 1985. We found that while post-reform insanity acquittals did dramatically decline, there was a corresponding rise in findings of incompetent to stand trial with charges dismissed, perhaps negating the desired impact. We also compared the defendants and the legal process, finding no significant differences pre to post reform.

The negligible effects of California's 1982 reform of the insanity defense test

OBJECTIVE

The authors' goal was to determine whether changing the insanity test in California in 1982 actually affected use of the insanity defense.

METHOD

They gathered information on all individuals who entered the insanity plea (N = 1,300) and all those acquitted by reason of insanity (N = 665) in seven counties in California 3 years before and 3 years after the change in the test of insanity. They focused on whether California's revision of the insanity test affected the number and rate of insanity pleas, the number and rate of insanity acquittals, the characteristics of individuals using the defense, the target offenses, and the length of stay of insanity acquittees.

RESULTS

The reform did not affect the rate of insanity pleas or acquittals, the characteristics of those using the defense, or their length of confinement.

CONCLUSIONS

Although the reform had no direct effects on the use of the insanity defense, the authors hypothesize that an indirect change in criminal sentencing practices led to a decrease in the number and rate of insanity pleas and acquittals.

Maintenance of an insanity defense under Montana's "abolition" of the insanity defense

In 1979, Montana's insanity defense was replaced with the more restrictive mens rea defense, a change that has been described as an example of "abolition" of the insanity defense. The authors identified cases in which mental health was an issue in seven Montana counties for 3 years before and 3 years after the 1979 reform. They found that acquittals based on the insanity plea markedly declined, but that dismissals based on incompetence to stand trial increased substantially following the reform. They conclude that dismissal based on incompetence to stand trial became a substitute for acquittal based on the insanity plea under mens rea.

Thought disorder and associative cognitive dysfunction in the first-degree relatives of adult schizophrenics. A reply to Romney

Contrary to both theoretical and empirical findings, Romney equates associative cognitive dysfunction with other manifestations of thought disorder. Moreover, he overstates the case for the documentation of thought disorder in the families of schizophrenics. We discuss his reaction to Callahan and Saccuzzo in the context of four major issues. We conclude that the evidence for thought disorder in the families of schizophrenics is weak and inconclusive. We call for more rigorous research as well as the exploration of viable alternatives.

Associative intrusions in the verbal behavior of the first-degree relatives of adult schizophrenics. A preliminary study

The first-degree blood relatives of schizophrenics were compared to a matched control group on a psychometrically matched test of responsiveness to associative intrusions. The groups differed on the subtest containing an associative alternative but not on the equally difficult subtest free of associative distractors. Results were consistent with the hypothesis that an overresponsiveness to associative distractors, well documented in schizophrenics, may also be a characteristic of their nondisturbed first degree blood relatives. The possible existence of cognitive markers in the relatives of schizophrenic patients that might indicate familial psychopathology was supported. Limitations of the present preliminary findings, as well as the case for additional investigation of the cognitive behavior of the first-degree relatives of schizophrenics, are discussed.