Pregnancy outcome in four women with inflammatory bowel disease treated with budesonide MMX

BACKGROUND

Maintaining disease remission throughout pregnancy in women with inflammatory bowel disease is of the utmost importance to decrease the risk of adverse outcome. In general, corticosteroids are safe to use during pregnancy, but no data exist in the specific use of budesonide MMX. We report four cases of budesonide MMX in pregnancy and pregnancy outcome.

METHODS

Four women with inflammatory bowel disease experienced disease activity during pregnancy. They were treated with budesonide MMX in an attempt to obtain clinical remission. Disease activity was assessed through physician's global assessment as well as lower endoscopy.

RESULTS

Budesonide MMX proved effective in achieving remission in three out of four women. One woman had an uncomplicated colectomy in the second trimester. All children were born normal for gestational age, with no congenital abnormalities and have reached all their developmental milestones. The four children have received vaccines according to the national immunization program without complications.

CONCLUSION

No adverse pregnancy outcomes were reported after the use of budesonide MMX. To our knowledge, this is the first report on the safety of budesonide MMX treatment in pregnant women with inflammatory bowel disease.

Regional gastrointestinal transit times in severe ulcerative colitis

BACKGROUND

Gastrointestinal (GI) dysmotility may present secondary to inflammatory bowel disease. The main aim of this study was to investigate GI motility in ulcerative colitis (UC) patients during severe disease activity.

METHODS

Twenty patients with severe UC were studied with a novel telemetric capsule system (3D-Transit) designed for minimally invasive, ambulatory assessment of total and regional GI transit times. Ten patients were available for follow-up during remission. Data were compared to those of 20 healthy subjects (HS).

KEY RESULTS

Total GI transit time was significantly longer in patients with severe UC (median 44.5 h [range 9.9-102.7 h]) than in HS (median 27.6 h [range 9.6-56.4 h]) (p = 0.032). Additionally, during severe UC, transit time was prolonged through the proximal colon (p = 0.003) and there were strong trends toward longer than normal small intestinal transit time (HS: median 4.9 h [range 3.4-8.3 h] vs severe UC patients: median 5.9 h [range 3.9-11.9 h]; p = 0.053) and colorectal transit times (HS: median 18.2 h [range 1.5-43.7] vs severe UC patients: median 34.9 h [range 0.4-90.9 h]; p = 0.056). Our data further indicate that total GI and colorectal transit times may be prolonged in UC during early remission.

CONCLUSIONS & INFERENCES

Total GI transit times are significantly prolonged during severe UC.

Clinical trial: vitamin D3 treatment in Crohn's disease - a randomized double-blind placebo-controlled study

BACKGROUND

Vitamin D has immune-regulatory functions in experimental colitis, and low vitamin D levels are present in Crohn's disease.

AIM

To assess the effectiveness of vitamin D3 treatment in Crohn's disease with regard to improved disease course.

METHODS

We performed a randomized double-blind placebo-controlled trial to assess the benefits of oral vitamin D3 treatment in Crohn's disease. We included 108 patients with Crohn's disease in remission, of which fourteen were excluded later. Patients were randomized to receive either 1200 IU vitamin D3 (n = 46) or placebo (n = 48) once daily during 12 months. The primary endpoint was clinical relapse.

RESULTS

Oral vitamin D3 treatment with 1200 IU daily increased serum 25OHD from mean 69 nmol/L [standard deviation (s.d.) 31 nmol/L] to mean 96 nmol/L (s.d. 27 nmol/L) after 3 months (P < 0.001). The relapse rate was lower among patients treated with vitamin D3 (6/46 or 13%) than among patients treated with placebo (14/48 or 29%), (P = 0.06).

CONCLUSIONS

Oral supplementation with 1200 IE vitamin D3 significantly increased serum vitamin D levels and insignificantly reduced the risk of relapse from 29% to 13%, (P = 0.06). Given that vitamin D3 treatment might be effective in Crohn's disease, we suggest larger studies to elucidate this matter further. ClinicalTrial.gov(NCT00122184).

Perforated peptic ulcer--a complication in acute salicylate intoxication

A patient with perforated peptic ulcer following acute salicylate intoxication is presented. The patient had reversible renal failure requiring dialysis therapy, but no abdominal symptoms were noticed until six days after arrival. At this time haematemesis and melaena were observed. Symptoms and objective findings were vague, but further investigations revealed a perforated prepyloric ulcer, which was successfully treated with cimetidine, The delay from intoxication to symptoms has previously been described and might be due to the analgetic properties of salicylates.

Long-term budesonide treatment of collagenous colitis: a randomised, double-blind, placebo-controlled trial

OBJECTIVE

To evaluate the efficacy and safety of long-term budesonide therapy for the maintenance of clinical remission in patients with collagenous colitis.

DESIGN

Randomised, placebo-controlled study with a 24-week, blinded follow-up period without any treatment.

SETTING

Three gastroenterology clinics in Denmark.

PATIENTS

Forty-two patients with histologically confirmed collagenous colitis and diarrhoea (more than three stools/day).

INTERVENTIONS

Patients in clinical remission after 6 weeks' open-label therapy with oral budesonide (Entocort CIR capsules, 9 mg/day) received 24 weeks' double-blind maintenance therapy with budesonide 6 mg/day or placebo. Thereafter, patients entered the 24-week, blinded follow-up period.

MAIN OUTCOME MEASURE

The proportion of patients in clinical remission (three or fewer stools/day) at the end of maintenance therapy.

FINDINGS

A total of 34 patients in remission at week 6 were randomly assigned to budesonide 6 mg/day (n = 17) or placebo (n = 17). After 24 weeks' maintenance treatment, the proportions of patients in clinical remission were 76.5% (13 of 17) with budesonide and 12% (2 of 17) with placebo (p<0.001). At 48 weeks (the end of the follow-up period, without any treatment) these values were 23.5% (4 of 17) and 12% (2 of 17), respectively (p = 0.6). The median times to relapse after stopping active treatment (6 plus 24 weeks in the budesonide group; 6 weeks in the placebo group) were 39 and 38 days, respectively. Long-term treatment with budesonide was well tolerated.

CONCLUSIONS

Long-term maintenance therapy with oral budesonide is efficacious and well tolerated for preventing relapse in patients with collagenous colitis. The risk of relapse after 24 weeks' maintenance treatment is similar to that observed after 6 weeks' induction therapy.

Azathioprine treatment during lactation

BACKGROUND

Thiopurines are widely used to maintain remission in inflammatory bowel disease. Treatment during pregnancy is generally recommended to improve the chance of a normal birth outcome, but advice concerning breastfeeding is conflicting. Aim To estimate the exposure of breastfed infants to 6-mercaptopurine, as a metabolite of azathioprine, from maternal milk.

METHODS

Eight lactating women with inflammatory bowel disease receiving maintenance therapy with azathioprine 75-200 mg daily were studied. Milk and plasma samples were obtained 30 and 60 min after drug administration and hourly for the following 5 h.

RESULTS

The variation in the bioavailability of the drug was reflected in a wide range of peak plasma values of 6-mercaptopurine within the first 3 h. A similar curve, but with an hour's delay and at significantly lower concentrations varying from 2-50 microg/L, was seen in maternal milk. After 6 h an average of 10% of the peak values were measured.

CONCLUSIONS

The major part of 6-mercaptopurine in breast milk is excreted within the first 4 h after drug intake. On the basis of maximum concentration measured, the infant ingests mercaptopurine of <0.008 mg/kg bodyweight/24 h. The findings confirm that breastfeeding during treatment with azathioprine seems safe and should be recommended, considering the extensive beneficial effects.

5-Aminosalicylic acid containing drugs. Delivery, fate, and possible clinical implications in man

Since the beginning of the 1940s salazosulfapyridine (SASP) has been used in the treatment of chronic inflammatory bowel disease (CIBD). Almost 40 years later 5-aminosalicylic acid (5-ASA), which is split off by azo-reducing enzymes in the colon, was identified as the therapeutically active moiety of SASP. Thus different 5-ASA containing drugs were produced from which 5-ASA is released in the small and large intestine in a pH-dependent manner. Since there is a firm clinical indication that the 5-ASA concentration in the gut lumen is decisive for the therapeutic effect, a method was developed to evaluate the 5-ASA concentration at different levels in the intestine. The method was subsequently used to clarify factors of importance for the release of 5-ASA from the preparations. Ileostomy patients and healthy volunteers were investigated during continuous treatment with the three 5-ASA containing drugs with pH-dependent 5-ASA release: Asacol, Mesasal (Salofalk, Claversal), and Pentasa. The study confirmed release of 5-ASA in the small intestine from all preparations, but at different levels and speeds. Despite similar peroral dosage, very different 5-ASA concentration profiles were found in the ileostomy effluents, reflecting not only the difference in the release pattern of the preparations, but also the influence of the gastric residence time for larger sized tablets. The 5-ASA concentrations increased in the faeces of healthy volunteers. Furthermore the systemically absorbed fraction of 5-ASA was larger than previously found after SASP. The 5-ASA release from the preparation with the most proximal release, Pentasa, was less influenced by acceleration of the intestinal transit time than previously demonstrated after SASP in a similar study design. A comparative study of children given SASP and Pentasa showed similar results as in adults: a tendency for smaller 5-ASA concentration at rectal level after Pentasa than after SASP, and also larger systemic absorption. Despite higher 5-ASA dose per kg body weight, lower 5-ASA concentrations were seen in the faeces after both preparations, compared with adults. A peroral dose increase of Pentasa in healthy adults resulted in higher intraluminal 5-ASA concentration in the gut lumen, but also in saturation of the local and probably also systemic acetylation capacity, demonstrated by higher plasma concentrations and larger urinary excretion of 5-ASA. Similar faecal water concentrations were found after Pentasa 4 g and the azo-bond preparation with colonic 5-ASA release, Dipentum (olsalazine) 2 g, confirming the substantial 5-ASA release from Pentasa in the small intestine. Investigation of pregnant patients treated with different 5-ASA containing drugs showed a similar pattern to SASP treatment: small amounts of 5-ASA cross the placenta, whereas the concentration of the metabolite Ac-5-ASA is similar in the maternal and fetal circulations. Only minute amounts of 5-ASA were found in milk from nursing mothers, while the concentrations of Ac-5-ASA were considerably higher. The decrease in the semen quality during SASP treatment was improved by changing to a controlled-release 5-ASA drug. The concentrations of 5-ASA in seminal plasma were similar during the two treatment periods, but higher of its metabolite Ac-5-ASA during treatment with the controlled-release preparation. That indicates that the toxic effect after SASP is not caused by the 5-ASA or Ac-5-ASA moiety. All the preparations have proved effective in the treatment of ulcerative colitis, but data concerning the 5-ASA treatment of Crohn's disease are conflicting. Knowledge of the demonstrated differences in the release profiles of the 5-ASA containing drugs is therefore important when designing future clinical trials.

Aspects of motivation of a volunteer AIDS care team program

The South Carolina AIDS Care Team Program, directed by The Ecumenical AIDS Ministry, a component of the South Carolina Christian Action Council, provides emotional and supportive services to people living with HIV and AIDS. A sample of volunteer care team members participated in five focus groups as part of a process evaluation. Care teams were asked to participate based on years since training (new vs. experienced), race (white vs. African American), and location (urban vs. rural). Volunteers were motivated to become involved in a care team through previous contact with a person with AIDS, a general sense of altruism, and influences from their faith community. Due to the emotionally demanding nature of the work, motivation to remain a volunteer was also examined. It was discovered that a support system, the expression of faith, support of their faith community, and coping with the death of a care partner were essential elements for sustaining care team involvement. The implications of this study are useful to volunteer programs through faith communities to meet the growing need of people living with HIV and AIDS.

Antiviral therapy in a child with pediatric human immunodeficiency virus (HIV): case study of audiologic findings

Over the past decade, much research has been conducted to determine the auditory consequences of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS). This research, primarily using adult patients, has focused on the involvement of the central auditory nervous system (CANS). Measures of auditory evoked potentials, particularly the auditory brainstem response (ABR), can document changes in the CANS as the disease progresses and during treatment with antiviral therapies such as zidovudine (AZT) and didanosine (ddI). This case study presents the audiologic findings for a child with HIV infection. Evaluations were performed over a 2-year period prior to the initiation of antiviral therapy and following treatment. Audiologic measures included behavioral audiometry, tympanometry, otoacoustic emissions, and ABR latency/intensity functions and rate studies. Findings indicated a gradual shortening of all ABR component latencies following the initiation of antiviral therapy. In addition, a high-frequency hearing loss was detected during the final evaluation subsequent to 19 months of treatment with AZT and ddI.

Identification of multidimensional stimuli containing speech cues and the effects of training

The purpose of this study was to determine how listeners with normal hearing make use of cues from multiple, independent stimulus dimensions when classifying synthesized stimuli containing acoustic cues found in speech. Listeners classified synthesized stimuli that differed on three independent and discriminable dimensions. The three dimensions of the stimuli included: (1) the fricative spectrum center frequency; (2) the slope of the frequency transition; and (3) the duration of the temporal gap. Each of the three dimensions could take on one of three possible values. Twenty-seven stimuli were synthesized using all possible combinations of the values on the three dimensions. Multidimensional scaling of paired-comparison similarity judgments confirmed the existence of three perceptual dimensions. Listeners were then trained to classify three exemplar stimuli as "circle," "triangle," and "square," respectively. Following this training, subjects classified all 27 stimuli as "circle," "triangle," and "square." From this it was determined how each listener's attention was distributed among the dimensions. Results indicated the listeners did not pay equal attention to the three stimulus dimensions. In addition, it was demonstrated that it was possible to train a listener to attend to a dimension that was not previously used to classify the stimuli.

A comparison of the benefit provided by well-fit linear hearing aids and instruments with automatic reductions of low-frequency gain

In this clinical study, 110 patients seen at three different clinical facilities were fit binaurally with linear, in-the-canal (ITC) hearing aids. All patients were new hearing aid users. Each of the hearing aids was equipped with an adjustable control that could be set by one of the audiologists (Audiologist A) at each site to convert it from a linear instrument to an experimental nonlinear one with automatic reduction of low-frquency gain at high input levels (or base increase at low levels, BILL). Both the patient and the audiologist performing the outcome testing at each site (Audiologist B) were blind as to the present setting of the hearing aid. Each participant was enrolled in the study for a total of 12 weeks, with the hearing aid set to either the linear or BILL-processing mode of operation for the first 8 weeks and the opposite setting for a subsequent 4-week period. In summary, this was a prospective, doubleblind, crossover study of 110 new hearing aid users. Outcome measures focused on hearing-aid benefit and included both objective and subjective measures. Objective measures were derived from scores on the Northwestern University Auditory Test NO. 6 (NU-6) and the Connected Speech Test (CST) obtained for all possible combinations of two speech presentation levels (60 and 75 dB SPL) two types of background noise (cafeteria noise and multitalker babble), and two signal-to-noise ratios (+5 and +10 dB). Subjective outcome measures included magnitude estimation of listening effort (MELE), the abbreviated form of the Hearing Aid Performance Inventory (HAPI), and estimations of hearing-aid usage based on daily-use logs kept by the participants. All of these measures were used to evaluate the benefit provided by linear amplification and the benefit resulting from the experimental BILL processing. Participant preferences for the experimental BILL-processing scheme or linear processing were also examined by using a paired-comparison task at the end of the study. Results were analyzed separately for three subgroups of patients (mild, moderate, severe) formed on the basis of their average hearing loss at 500, 1000, 2000, and 4000 Hz. In all three subgroups, significant improvement in performance was observed for linear amplification and for BILL processing when compared to unaided performance. There were no significant differences in aided performance, however, between linear processing and the experimental BILL processing.

Identification of multidimensional complex sounds having parallel dimension structure

The present series of experiments examined the ability of normal-hearing listeners to make use of cues from multiple, independent stimulus dimensions when classifying multidimensional complex sounds. Ten listeners classified complex sound pulses that differed along three independent dimensions. The stimuli were 100 ms in duration and were synthesized using five simultaneous sinusoids. The three dimensions of the complex stimuli manipulated in this experiment were harmonicity, spectral shape, and amplitude envelope. Each stimulus dimension could take on one of two values, referred to here as target or nontarget. Eight stimuli were synthesized using all possible combinations of the dimension values. Subjects were trained to label two stimuli, the two having either all-target or all-nontarget values, as "+" and "0," respectively. Following this training, subjects were asked to classify all eight stimuli as either "+" or "0." Results of this experiment indicated that listeners preferred to classify these stimuli on the basis of one stimulus dimension. However, the preferred dimension was not the same for all of the listeners. In addition, it was demonstrated that it was possible to train an individual to use a dimension other than the one or two initially preferred when classifying the stimuli.

Influence of anesthetics on the peripheral blood microfilaremia of Brugia malayi in the Mongolian jird, Meriones unguiculatus

The effects of anesthetics on the peripheral blood microfilaremia of Brugia malayi in Meriones unguiculatus were investigated. Microfilaremias were assessed by orbital puncture prior to and following the use, either individually or in tandem, of ether, Rompun, Ketaset, and sodium pentobarbital. Results indicate that the peripheral microfilaremia varied dramatically, depending on the anesthetic administered. Although microfilaremias were not affected by an initial ether exposure, counts of microfilariae increased significantly when jirds received Rompun and Ketaset, or Ketaset alone. Administration of sodium pentobarbital did not increase the number of microfilariae observed in the peripheral blood. The mode of action differs between these drugs and is likely responsible for the different effects observed. Consequently, studies involving vector-parasite interactions should take precautions to prevent parasite-induced vector mortality due to the ingestion of large numbers of microfilariae induced in the peripheral bloodstream by certain anesthetics.

Effect of olsalazine and mesalazine on intraluminal pH of the duodenum and proximal jejunum in healthy humans

BACKGROUND

Treatment of inflammatory bowel disease with olsalazine causes diarrhoea in 10% of patients. This is claimed to be caused by a drug effect on mucosal transport in the small intestine, which might be reflected in the intraluminal pH. We aimed to study the effect on jejunal pH of olsalazine (Dipentum) and an alternative preparation, slow-release mesalazine (Pentasa).

METHODS

Thirteen healthy volunteers, seven male and six female, participated in a randomized, crossover study. Steady-state conditions were obtained after ingestion of 2 g or 6 g mesalazine daily or 2 g olsalazine daily for 1 week. The pH of the duodenum and proximal jejunum was measured by using pH-sensitive, radiotransmitting capsules, the location of which was confirmed by fluoroscopy.

RESULTS

No effect of either drug on duodenal pH was detected. Mean duodenal pH ranged from 6.18 to 6.22. The mean pH of the pre-medication proximal jejunum was 6.02. Mesalazine had no significant effect, but olsalazine significantly increased the pH of the proximal jejunum (mean pH, 6.47).

CONCLUSIONS

Our results indicate that the effect of olsalazine on jejunal transport of electrolytes and water, observed in experimental studies, also applies to human subjects in steady-state conditions, and adaptation does not occur within 6 days.

Comparative bioavailability of 5-aminosalicylic acid from a controlled release preparation and an azo-bond preparation

BACKGROUND

Knowledge of the bioavailability of 5-aminosalicylic acid (5-ASA, mesalazine) from the different 5-ASA-containing drugs is important for rational therapy of inflammatory bowel diseases.

METHODS

The local and systemic bioavailability of 5-ASA from a controlled release 5-ASA preparation (Pentasa--2, 4 or 6 g/day) was investigated and compared with the azo-bond 5-ASA preparation olsalazine (Dipentum--2 g/day) in 13 healthy volunteers during steady state conditions.

RESULTS

The therapeutically relevant parameter of 5-ASA at the rectal level, expressed as the mean concentration in faecal water, showed a significant trend towards higher concentrations with increasing Pentasa dose: 9.2 mmol/L, 19.0 mmol/L and 24.4 mmol/L, respectively. The concentration of olsalazine 2 g/day was 16.0 mmol/L. The concentration of the metabolite N-acetyl-5-aminosalicylic acid (Ac-5-ASA) did not rise with increasing Pentasa dose, indicating saturable presystemic acetylating capacity of 5-ASA. Total urinary excretion of 5-ASA and Ac-5-ASA, as a percentage of the daily ingested 5-ASA dose, remained constant on the three Pentasa doses, but there was a significant increase in the 5-ASA fraction. Mean steady state plasma concentrations of 5-ASA and Ac-5-ASA were significantly higher on Pentasa 4 g/day and 6 g/day than on 2 g/day. Values on Pentasa 2 g/day were comparable with those on olsalazine 2 g/day.

CONCLUSIONS

The study confirmed that 5-ASA is released from Pentasa in a predictable manner, the amount released increasing with dose. Olsalazine is an excellent generator of 5-ASA in the colon.

Disposition of 5-aminosalicylic acid and N-acetyl-5-aminosalicylic acid in fetal and maternal body fluids during treatment with different 5-aminosalicylic acid preparations

STUDY OBJECTIVE

To determine the concentration of 5-aminosalicylic acid (5-ASA) and the metabolite N-acetyl-5-aminosalicylic acid (Ac-5-ASA) in the maternal and fetal plasma at delivery and in the maternal milk post partum.

DESIGN AND STUDY SUBJECTS

Pregnant and lactating women with chronic inflammatory bowel disease, treated with different pure 5-ASA preparations participated in the study. At delivery, samples of fetal and maternal plasma were obtained from nine women. The excretion in milk was measured and the time of medicine intake was registered during a 24 h period 2-4 weeks after delivery in 13 women.

RESULTS

Concentrations of 5-ASA in the fetal plasma were lower than in maternal plasma. Plasma concentrations of Ac-5-ASA were detectable in all the nine samples and similar levels in the mother and the fetus were found at the time of delivery. In three women 5-ASA was detected in the milk in low concentrations. The concentration of Ac-5-ASA in the milk varied considerably during the 24 h collection period, and also between individuals; its concentration tended to be higher than in the plasma. No time relation between medicine intake and maximal concentration in the milk was found. Based on the maximal Ac-5-ASA concentration and a milk intake of one liter/daily, the newborn receives less than 15 mg Ac-5-ASA daily.

CONCLUSION

The study indicates that treatment with pure 5-ASA preparations in conventional doses is without risk to the fetus and the newborn.

Factors associated with individual differences in clinical measures of speech recognition among the elderly

In the present study, the speech-recognition performance of 50 subjects aged 63 to 83 years was measured for a wide range of materials (nonsense syllables, monosyllabic words, sentences) and listening conditions (presentation levels of 70 and 90 dB SPL, both in quiet and in a noise background). In addition to complete audiologic evaluations, measures of auditory processing (the Test of Basic Auditory Capabilities [TBAC], Watson, 1987) and cognitive function (Wechsler Adult Intelligence Scale-Revised [WAIS-R], and the Wechsler Memory Scale-Revised [WMS-R], Wechsler, 1981, 1987) were obtained from all subjects. Principal component analyses were applied to each of the three sets of measures (speech-recognition, auditory, and cognitive) prior to examining associations among the sets using canonical analyses. Two principal components captured most of the systematic variation in performance sampled by the set of 20 speech-recognition measures. Hearing loss emerged as the single largest factor associated with individual differences in speech-recognition performance among the elderly, accounting for 70-75% of the total variance in speech-recognition performance, with the measures of auditory processing and cognitive function accounting for little or no additional variance.

Very low intraluminal colonic pH in patients with active ulcerative colitis

Intraluminal gastrointestinal pH was measured in seven patients with active ulcerative colitis (four male, three female). A radiotelemetry capsule was used, and its location was determined by fluoroscopy. Satisfactory measurements were obtained from six, in all of whom pH levels were normal in the stomach and small intestine. Three patients also had normal pH values in the colon. However, in the remaining three patients very low pH levels (lowest values 2.3, 2.9, and 3.4) were found in the proximal parts of the colon. Five of the seven patients, including the three with low pH in the colon, underwent colectomy. The mechanism behind the low intraluminal pH in some patients with ulcerative colitis is speculative. Increased fecal concentrations of lactate occur in active disease, but some of the pH values measured in our study were below the pKa value of lactate. The study demonstrates that very low intraluminal pH levels in the colon occur in some patients with active ulcerative colitis. This might be an indicator of severe activity of the disease.

Bioavailability of 5-aminosalicyclic acid from slow release 5-aminosalicyclic acid drug and sulfasalazine in normal children

The bioavailability of a controlled release 5-aminosalicyclic acid preparation (Pentasa) was investigated in nine healthy children after a medication period of six days (1000 mg/day) and compared with sulfasalazine (Salazopyrin) (2000 mg/day). The local bioavailability in the distal gut lumen, reflected by the 5-aminosalicylic acid concentration in the fecal water, showed comparable values after Pentasa (4.44 mmol/liter) and Salazopyrin (6.25 mmol/liter). The concentration of N-acetyl-5-ASA was significantly higher after Pentasa, reflecting the more proximal release of 5-aminosalicyclic acid compared with Salazopyrin. No relation was found between the 5-aminosalicylic acid fecal water concentration water concentration and the 5-aminosalicylic acid dose per kilogram of body weight. The urinary excretion of 5-aminosalicylic acid and N-acetyl-5-aminosalicylic acid was higher after Pentasa than after Salazopyrin (32% vs 25%). Dose interval plasma concentration curves showed low values after both preparations. Based on the concept that the fecal water concentration is decisive for the efficacy of 5-aminosalicylic acid in distal inflammatory bowel disease, Pentasa treatment offers a relevant alternative in cases of Salazopyrin intolerance or allergy in children. The higher systemic bioavailability from Pentasa warrants monitoring of the renal function.

Identification of oxidation products of 5-aminosalicylic acid in faeces and the study of their formation in vitro

The formation of three oxidant-derived products of 5-aminosalicylic acid (5-ASA) in vivo was demonstrated in patients with active ulcerative colitis as well as in healthy subjects. The products were isolated from faeces by preparative HPLC and their chemical structures were found to be oxidation products of 5-ASA using 1H-NMR spectroscopy and mass spectrometry. Reactions carried out in vitro between 5-ASA and oxidants suggested to be present in the inflamed bowel verified that the hypochlorite-mediated oxidation of 5-ASA as well as the haemoglobin-catalysed H2O2-dependent oxidation of 5-ASA resulted in the formation of a single oxidation product of 5-ASA. This product was similar to, but not identical to any of the products identified in faeces from patients receiving 5-ASA. Oxygen radical-mediated oxidation of 5-ASA gave several products, different from the products isolated. Finally, it was verified that the products formed in vivo are not formed as a result of autooxidation of 5-ASA either in faeces extract or in pharmaceuticals.

Availability of mesalazine (5-aminosalicylic acid) from enemas and suppositories during steady-state conditions

The local and systemic bioavailability of a mesalazine enema (Pentasa, Ferring A/S, Denmark) and a mesalazine suppository (Pentasa, Ferring) was assessed during steady-state conditions. Eleven healthy subjects took 1 g of the enema or the suppository twice daily for 1 week, with a drug-free period of at least 1 week in between. At the end of each treatment period the urine and faeces were collected for 48 h, and the concentrations of mesalazine and the metabolite acetyl-mesalazine were measured. Plasma concentrations of drug and metabolite were measured hourly during a 12-h dose interval. The faecal water concentration of mesalazine was significantly higher after suppository treatment (55.7 mmol/l) compared with enema treatment (31.7 mmol/l) (p less than 0.01). The systemic absorption was low; 15% of daily mesalazine dose was recovered in urine after enema treatment and 10% after suppositores (p less than 0.01). Plasma concentrations were low, and no accumulation of either mesalazine or acetyl-mesalazine occurred. In conclusion, the enema and the suppository can be continuously administered as 1 g of mesalazine twice daily, respectively, giving high faecal water concentrations of mesalazine and a low systemic absorption.

Topical and systemic availability of 5-aminosalicylate: comparisons of three controlled release preparations in man

The bioavailability of three pure 5-aminosalicylic (5-ASA) preparations (Asacol, Claversal, and Pentasa) was studied in 8 ileostomy patients and 12 normal subjects after 6 days of treatment with 2000 mg 5-ASA. The local bioavailability, reflected by the 5-ASA concentration was thereby measured at two clinically relevant areas of the gut: at the entrance to, and the exit from the colon. Estimates of the systemic bioavailability were obtained from the urinary excretions and the plasma values of 5-ASA and Acetyl-5-ASA (Ac-5-ASA) during the three regimens. The three preparations studied are designed to release 5-ASA at different levels in the intestine, but there was no significant difference in the 5-ASA concentrations in the ileostomy effluents (Asacol 1.8 mmol/L, Claversal 3.4 mmol/L, Pentasa 2.0 mmol/L, median values). However, we found a smaller urinary excretion of 5-ASA and Ac-5-ASA (5.2% vs Claversal 27.9% and Pentasa 23.0%, median values of ingested daily dose) and a lower concentration of Ac-5-ASA in the ileostomy effluents after Asacol treatment (0.8 mmol/L, median value) which indicates a more distal release from this preparation compared with Claversal (2.4 mmol/L, median value) and Pentasa (5.5 mmol/L, median value). In normal subjects a higher faecal water concentration of 5-ASA was found after Asacol (9.8 mmol/L, median value) compared with Claversal (5.0 mmol/L, median value), whereas no difference between the faecal water concentrations of Ac-5-ASA was found (Asacol 21.5 mmol/L, Claversal 21.6 mmol/L, median values). This can be explained by a larger systemic absorption of 5-ASA from Claversal, and accordingly Claversal treatment resulted in the largest urinary excretion of 5-ASA and Ac-5-ASA (43.7% vs Asacol 35.6% and Pentasa 31.6%, median values of ingested daily dose). The high Ac-5-ASA concentration in the ileostomy effluents and in the faeces after Pentasa, and the low plasma values, indicate a slow 5-ASA release from this preparation throughout the small and large intestine. The results of the study indicate that Asacol is released in the distal part of the small intestine, that Pentasa is gradually released in the small and large intestine, and that Claversal shows an intermediate release pattern.

Gastrointestinal pH and transit times in healthy subjects with ileostomy

Gastrointestinal pH in 11 healthy subjects with ileostomy was determined with a pH-sensitive, radiotransmitting capsule. Median pH was 7.0 in duodenum, dropped to pH 6.3 in the proximal part, but rose to 7.3 in the distal part of the small intestine. In five subjects the pH of the ileostomy effluents was determined with the pH capsule as well as with a pH meter. Median pH was 7.2 measured with the capsule and 7.4 with the pH meter. The difference between the results obtained with the two methods ranged from 0.1 to 0.3 pH units. The median gastrointestinal transit time of the capsule was 10.5 h (range 6.2-12.8 h). Gastric residence time was 0.6 h (range 0.2-3.8 h), and small intestinal transit time was 10.3 h (range 5.6-11.9 h). Thus the small intestinal transit time in ileostomates is slightly increased compared with values reported from studies on subjects with intact gut. However, no statistically significant correlation was found between the small intestinal transit time and the time elapsed after the creation of the ileostomy. We conclude that colectomy does not alter small intestinal pH but seems to increase the small intestinal transit time of single units.

pH-profile and regional transit times of the normal gut measured by a radiotelemetry device

The pH of the gut lumen was measured in 39 healthy persons using a pH-sensitive, radiotransmitting capsule. Thirteen persons were studied twice. The location of the capsule was determined by X-ray. The pH rose from 6.4 in the duodenum to 7.3 in the distal part of the small intestine. In 17 persons the pH dropped by 0.1-0.8 pH units during the last hours of the small intestinal transit. The pH was 5.7 in the caecum, but rose to 6.6 in the rectum. Gastric residence time was 1.1 h, small intestinal transit was 8 h, and colonic transit time was 17.5 h (median values). The results provide a firmer basis for prediction of the level, and the rate of release of active substance from pH-dependent sustained-release oral preparations.

Effects of mesalazine substitution on salicylazosulfapyridine-induced seminal abnormalities in men with ulcerative colitis

Some semen characteristics of eight male patients with clinically inactive ulcerative colitis were investigated. Semen analysis was carried out twice during salicylazosulfapyridine (SASP) treatment and repeated twice after at least 3 months' treatment with mesalazine. The motility variables all showed significant improvement during mesalazine treatment: the graded motility (p less than 0.05), motility in percentage (p less than 0.01), and the penetration in egg white (p less than 0.05). The semen plasma was analyzed for mesalazine and the metabolite Ac-mesalazine during both regimens. There was no difference in the semen plasma concentration of mesalazine during the two regimens, whereas Ac-mesalazine was significantly higher during mesalazine treatment than during SASP treatment, indicating that other SASP metabolites, most likely sulfapyridine, are the agent causing the abnormal sperm characteristics. We suggest that pure mesalazine preparations are a safer alternative in young men with chronic inflammatory bowel disease.

5-Aminosalicylic acid derivatives. Clinical and pharmaceutical evaluation

Several new 5-aminosalicylic acid (5-ASA) derivatives have been introduced for the treatment of chronic inflammatory bowel disease (CIBD). In azo-bond preparations, 5-ASA is linked to an inert carrier (Balsalazide) or to another 5-ASA molecule (Dipentum). The pharmacokinetic profile is similar to salazosulphapyridine (SASP) and the preparations are as effective as SASP in treatment of ulcerative colitis (UC) and with fewer side effects. In controlled release preparations (Asacol, Pentasa, Salofalk), 5-ASA is coated with compounds resistant to low pH, but which deliver 5-ASA to the intestines at various rates at higher pH values. The drugs are as effective as SASP in maintenance of remission and in the treatment of mild to moderate flare ups in UC. A larger systemic absorption is found for the three preparations compared to SASP. The controlled release preparations seem promising in the treatment of Crohn's disease, but further studies are needed. The controlled release preparations should be the drugs of choice in patients with UC allergic to or intolerant of SASP and to males who wish to have children.

Hemocyte population changes during the immune response of Aedes aegypti to inoculated microfilariae of Dirofilaria immitis

Ultrastructural and lectin-binding studies have established that the melanotic encapsulation reaction of Aedes aegypti Liverpool strain against inoculated Dirofilaria immitis microfilariae (mff) is a hemocyte-mediated reaction. Total hemocyte counts from mff-inoculated (= immune-activated), saline-inoculated, and uninoculated female A. aegypti were determined using a hemocoel perfusion technique. Total hemocyte populations in uninoculated mosquitoes were significantly larger in younger mosquitoes, but no significant change was noted as mosquitoes aged beyond 14 days. Hemocyte populations in immune-activated mosquitoes increased from 1 to 3 days postinoculation (PI) and decreased on days 4 and 5 PI. Hemocyte populations at 1 to 4 days PI were significantly elevated in mff-inoculated A. aegypti as compared with saline-inoculated controls. Saline-inoculated mosquitoes displayed little change in total hemocyte numbers from 1 to 5 days PI, and their hemocyte populations were similar to those seen in uninoculated insects of the same age. Experiments involving the inoculation of [3H]thymidine along with mff or saline alone and studies involving the administration of colchicine suggest that increased hemocyte populations in immune-activated A. aegypti are a result of mitotic division of circulating blood cells.

Release of 5-aminosalicylic acid from Pentasa during normal and accelerated intestinal transit time

The influence of intestinal transit time on the release of 5-aminosalicylic acid (5-ASA) from a peroral, slow-release preparation (Pentasa) was studied at steady state in seven healthy volunteers. Daily dose was 1500 mg Pentasa, normal transit time (NTT) was 24 h (16-26 h) and accelerated transit time (ATT), caused by a laxative, was 5 h (4-9 h). Median total recovery (24 h, 5-ASA + acetyl-5-ASA) was 87% (61-129%) (NTT) and 81% (56-100%) (ATT), respectively, (P greater than 0.10). The total faecal excretion of 5-ASA (per cent of dose) increased from 16%, (9-21%) (NTT) to 29%, (16-38%) (ATT) (P less than 0.02). Free 5-ASA rose from 12% (4-19%) to 17% (10-25%), the retained part (in granules) from 4% (2-5%) to 12% (4-24%). Urinary excretion decreased correspondingly from 32% (19-59%) to 21% (11-38%), predominantly as Ac-5-ASA (P less than 0.05). Mean plasma Ac-5-ASA concentration decreased from 1.42 micrograms ml-1 to 0.86 microgram ml-1 (P less than 0.05). An almost complete release of 5-ASA from Pentasa takes place during NTT. At ATT conditions about 88% is released, indicating Pentasa to be an acceptable source of 5-ASA in diarrhoeal states.

Defense reactions of mosquitoes to filarial worms: effect of host age on the immune response to Dirofilaria immitis microfilariae

The melanization response of Aedes aegypti black-eyed Liverpool strain (LVP) and Aedes trivittatus against intrathoracically inoculated Dirofilaria immitis microfilariae (mff) was assessed in mosquitoes less than 1, 14, 21, and 28 days after adult ecdysis. There was a significant decrease in the melanization response of A. aegypti 14 days of age and older at 1, 3, and 5 days postinoculation (PI) compared to less than 1-day-old mosquitoes. The response also was reduced significantly in 14- to 28-day-old A. trivittatus on days 1 and 3 PI. Although essentially 100% of recovered mff were melanized by day 5 PI in A. trivittatus, the amount of melanin deposited was much less than that seen in 0-day-old mosquitoes. Potential mechanisms responsible for a reduced immune competence in older mosquitoes and the possible relationship to vector potential are discussed.

Microscopic appearance of the esophageal mucosa in a consecutive series of patients submitted to upper endoscopy. Correlation with gastroesophageal reflux symptoms and macroscopic findings

The histologic finding of basal-layer hyperplasia and papillosis as consequences of gastroesophageal reflux still constitute an area of controversy. Consequently, a prospective study of symptoms and endoscopy and biopsy interpretation was undertaken in 200 patients consecutively submitted to upper endoscopy, whereof 12 were excluded. Complete agreement among all three variables was found in half of the patients and harmony between two of the variables in one fourth. In the last fourth the outcome was positive in one variable only, equally distributed among the symptoms, endoscopy, and histology. It is concluded that histology is of considerable value in gastroesophageal reflux disease.

Abnormal duodenal loop in patients with irritable bowel syndrome

The frequency of an abnormal duodenal loop (AD) was investigated in 36 patients with irritable bowel syndrome (IBS) and in a sex- and age-matched control group of patients with Crohn's disease. The frequency was significantly higher in the patients with IBS than in the control group (41% versus 18%; p less than 0.02). Among IBS patients with AD, the frequency of food-provoked pain was higher than in IBS patients with a normal duodenum (65% versus 21%; p less than 0.01). We conclude that AD may be one of the reasons for complaints in IBS.

Agar disk elution method for susceptibility testing of Mycobacterium marinum and Mycobacterium fortuitum complex to sulfonamides and antibiotics

An agar disk elution method using round well plates, supplemented Mueller-Hinton agar, and commercial drug disks is described for susceptibility testing of Mycobacterium marinum and the rapidly growing mycobacteria to antibiotics and sulfonamides. By this method, 14 of 14 strains of M. marinum were susceptible to rifampin, doxycycline, minocycline, and trimethoprim-sulfamethoxazole. Identical results were obtained with Middlebrook 7H10 agar and drugs prepared from standard powders. With 58 isolates of Mycobacterium fortuitum and Mycobacterium chelonei, this method had a 92% correlation with broth minimal inhibitory concentration determinations for cefoxitin and greater than 98% for doxycycline, kanamycin, amikacin, and the sulfonamides. Sixty-nine percent of isolates of M. chelonei susceptible to amikacin on supplemented Mueller-Hinton agar were resistant on 7H10 agar, and 15 of 16 M. chelonei isolates susceptible to erythromycin in broth were resistant by disk elution when an endpoint of no growth was used with either agar. The agar disk elution method offers a practical method for testing of most antibacterial agents against these mycobacterial species.