"Worn out": Coping strategies for managing antiretroviral treatment fatigue among urban people of color living with HIV who were recently disengaged from outpatient HIV care

Antiretroviral-related treatment fatigue is inconsistently defined in the literature on barriers to ART adherence. Research suggests that treatment fatigue is a salient challenge for people struggling with antiretroviral therapy adherence, but little is known about how people living with HIV attempt to manage this fatigue. Twenty-seven semi-structured interviews were conducted with low-income people of color living with HIV in NYC that were currently, or recently, disengaged from HIV care. The findings from this exploratory study suggest that treatment fatigue was common and that participants devised personal strategies to overcome it. These strategies included using reminder programs, requesting weekly rather than monthly pill quantities, and taking "pill holidays". The varied nature- and varying levels of effectiveness- of these strategies highlight the need for specific programming to provide tailored support. Future research should examine treatment fatigue as a specific subtype of adherence challenge, and aim to define pill fatigue clearly.

Performance of Edmonton Frail Scale on frailty assessment: its association with multi-dimensional geriatric conditions assessed with specific screening tools

BACKGROUND

The aim of this study was to evaluate the performance of Edmonton Frail Scale (EFS) on frailty assessment in association with multi-dimensional conditions assessed with specific screening tools and to explore the prevalence of frailty by gender.

METHODS

We enrolled 366 hospitalised patients (women\men: 251\115), mean age 81.5 years. The EFS was given to the patients to evaluate their frailty. Then we collected data concerning cognitive status through Mini-Mental State Examination (MMSE), health status (evaluated with the number of diseases), functional independence (Barthel Index and Activities Daily Living; BI, ADL, IADL), use of drugs (counting of drugs taken every day), Mini Nutritional Assessment (MNA), Geriatric Depression Scale (GDS), Skeletal Muscle Index of sarcopenia (SMI), osteoporosis and functionality (Handgrip strength).

RESULTS

According with the EFS, the 19.7% of subjects were classified as non frail, 66.4% as apparently vulnerable and 13.9% with severe frailty. The EFS scores were associated with cognition (MMSE: β = 0.980; p < 0.01), functional independence (ADL: β = -0.512; p < 0.00); (IADL: β = -0.338; p < 0.01); use of medications (β = 0.110; p < 0.01); nutrition (MNA: β = -0.413; p < 0.01); mood (GDS: β = -0.324; p < 0.01); functional performance (Handgrip: β = -0.114, p < 0.01) (BI: β = -0.037; p < 0.01), but not with number of comorbidities (β = 0.108; p = 0.052). In osteoporotic patients versus not-osteoporotic patients the mean EFS score did not differ between groups (women: p = 0.365; men: p = 0.088), whereas in Sarcopenic versus not-Sarcopenic patients, there was a significant differences in women: p < 0.05.

CONCLUSIONS

This study suggests that measuring frailty with EFS is helpful and performance tool for stratifying the state of fragility in a group of institutionalized elderly. As matter of facts the EFS has been shown to be associated with several geriatric conditions such independence, drugs assumption, mood, mental, functional and nutritional status.

Introduction of the chronic care model into an academic rheumatology clinic

BACKGROUND

While the chronic care model has been extensively used for the management of patients with diabetes in non-academic, primary care settings, it is not clear whether this model can be used effectively in academic, specialty clinics for other chronic disorders.

METHODS

Through the Academic Chronic Care Collaborative, the chronic care model was introduced to help manage patients with osteoarthritis in an academic rheumatology service with seven prespecified goals. These goals included measurements of Western Ontario MacMaster (WOMAC) osteoarthritis scores, self-efficacy scores and exercise time.

RESULTS

Five a priori goals were achieved in this study: average WOMAC scores less than 1000 mm as measured on a visual analogue scale, average self-efficacy score of less than 5 mm, average exercise time greater than 90 min, more than 40% of patients exercising at least 60&emsp14;min per week and a 20% improvement in self-efficacy scores. However, a 20% improvement in WOMAC scores and a 60% completion of documented self-management goals in our patients were not achieved. Our inability to achieve our self-management goal underscores the fact that we have not yet fully implemented the chronic care model into our practice. The inability to detect a 20% improvement in WOMAC scores in the context of having reached our absolute WOMAC goal at baseline suggests a probable ceiling effect for this measure.

CONCLUSIONS

The chronic care model can be effectively introduced into an academic specialty service and can be used effectively in the management of patients with non-diabetic disorders, in this case osteoarthritis.

Health care quality in the 21st century

The concepts of healthcare quality have evolved over the years. Many stakeholders have become quite engaged in the movement towards improvement in healthcare quality and safety. The standardization and national endorsement of performance measures, the assessment of outcomes, and the reporting for accountability are now being coupled with more transparency, and technological innovation. As the quality landscape changes to evaluation of episodes of care and performance at the individual clinician level measures (primary and specialty care), collaboration is critical among consumers, purchasers, measure developers, implementers of measures to identify and adopt national standards to tell a clear story of healthcare quality.

Historical perspectives on the clinical development of bisphosphonates in the treatment of bone diseases

Bisphosphonates (formerly termed diphosphonates) were first synthesized in the late 1800s; however, their clinical use has been relatively recent. The bisphosphonates' affinity for hydroxyapatite crystal surface led Procter and Gamble to test these compounds in dental, then medical applications. With key input from university researchers, this led to the medical use of the first bisphosphonate, etidronate disodium in 1968 to treat a young patient with myositis ossificans progressiva. Further clinical research led to widespread medical application for the bisphosphonate class including use as a diagnostic in radionuclide bone imaging agents, treatment of osteoporosis, Paget's disease of bone, hypercalcemia of malignancy and metastatic bone disease. The historical development of bisphosphonates provides an excellent example of how observations and knowledge obtained at the basic science level were applied and successfully tested in the clinic. The end result of these efforts has provided health care professionals with diagnostic and therapeutic tools to improve the lives of patients.

The DNA sequence and analysis of human chromosome 6

Chromosome 6 is a metacentric chromosome that constitutes about 6% of the human genome. The finished sequence comprises 166,880,988 base pairs, representing the largest chromosome sequenced so far. The entire sequence has been subjected to high-quality manual annotation, resulting in the evidence-supported identification of 1,557 genes and 633 pseudogenes. Here we report that at least 96% of the protein-coding genes have been identified, as assessed by multi-species comparative sequence analysis, and provide evidence for the presence of further, otherwise unsupported exons/genes. Among these are genes directly implicated in cancer, schizophrenia, autoimmunity and many other diseases. Chromosome 6 harbours the largest transfer RNA gene cluster in the genome; we show that this cluster co-localizes with a region of high transcriptional activity. Within the essential immune loci of the major histocompatibility complex, we find HLA-B to be the most polymorphic gene on chromosome 6 and in the human genome.

An SNP map of human chromosome 22

The human genome sequence will provide a reference for measuring DNA sequence variation in human populations. Sequence variants are responsible for the genetic component of individuality, including complex characteristics such as disease susceptibility and drug response. Most sequence variants are single nucleotide polymorphisms (SNPs), where two alternate bases occur at one position. Comparison of any two genomes reveals around 1 SNP per kilobase. A sufficiently dense map of SNPs would allow the detection of sequence variants responsible for particular characteristics on the basis that they are associated with a specific SNP allele. Here we have evaluated large-scale sequencing approaches to obtaining SNPs, and have constructed a map of 2,730 SNPs on human chromosome 22. Most of the SNPs are within 25 kilobases of a transcribed exon, and are valuable for association studies. We have scaled up the process, detecting over 65,000 SNPs in the genome as part of The SNP Consortium programme, which is on target to build a map of 1 SNP every 5 kilobases that is integrated with the human genome sequence and that is freely available in the public domain.

Bradykinin antagonists in human systems: correlation between receptor binding, calcium signalling in isolated cells, and functional activity in isolated ileum

The determination of the relationship between ligand affinity and bioactivity is important for the understanding of receptor function in biological systems and for drug development. Several physiological and pathophysiological functions of bradykinin (BK) are mediated via the B2 receptor. In this study, we have examined the relationship between B2 receptor (soluble and membrane-bound) binding of BK peptidic antagonists, inhibition of calcium signalling at a cellular level, and in vitro inhibition of ileum contraction. Only human systems were employed in the experiments. Good correlations between the studied activities of BK antagonists were observed for a variety of different peptidic structures. The correlation coefficients (r) were in the range of 0.905 to 0.955. In addition, we analyzed the effect of the C-terminal Arg9 removal from BK and its analogs on B2 receptor binding. The ratios of binding constants (Ki(+Arg)/Ki(-Arg)) for the Arg9 containing compounds and the corresponding des-Arg9 analogs varied from about 10 to 250,000. These ratios strongly depend on the chemical structures of the compounds. The highest ratios were observed for two natural agonist pairs, BK/des-Arg9-BK and Lys0-BK/des-Arg9-Lys0-BK.

A quantitative one-dimensional magnetic resonance imaging technique in adjuvant arthritis: the assessment of disease progression and indomethacin efficacy

OBJECTIVE

To demonstrate the use of a one-dimensional proton (1H) nuclear magnetic resonance (NMR) imaging technique to noninvasively monitor the progression of adjuvant arthritis and its response to indomethacin treatment in Lewis rat leg joints.

METHODS

The total hydrogen content of a defined volume of the joint was quantitated at selected time points. The differences in proton T2 relaxation times allowed for characterization and quantitative separation of the fluid (relatively long T2) and nonfluid (relatively short T2) components of hydrogen content in the defined volume. The estimates of hydrogen content of both long and short T2 tissue components were used to assess the severity of the disease and its regression with indomethacin treatment.

RESULTS

A progressive increase of the 2 components of hydrogen content in saline treated arthritic rats is consistent with histological examinations. After 19 days of treatment, 0.1 mg/kg/day and 0.5 mg/kg/day of indomethacin reduced the fluid component (primarily from inflammatory edema) in arthritic leg joints by 39 and 77% respectively, compared to the saline treated arthritic rats. The higher dose of indomethacin also significantly reduced the nonfluid component (primarily from cellular content) suggesting a reduced influx of inflammatory cells into the affected areas. The paw volume measurements, radiologic changes, and histopathology also showed the regression of adjuvant arthritis on treatment.

CONCLUSION

The study demonstrated that the NMR method has the sensitivity required to assess the treatment efficacy in adjuvant arthritis and suggests its possible utility in early diagnosis and monitoring of therapy in clinical arthritis on human extremities.

Retention of etidronate in human, dog, and rat

The retention of radioactivity in human, rat, and dog following a single injected dose of radiolabeled etidronate disodium (EHDP) is shown to follow power-law decay curves with similar slopes for times up to 4, 60, and 80 days, respectively. During this period retention declines with time according to a weak inverse power of the time since dosing, with an exponent ranging from -0.05 (dog) to -0.09 (human and rat). Direct analyses of dog bones either 90 days after a single dose or 365 days after cessation of chronic dosing indicate a more rapid bone clearance of EHDP than predicted by the initial power law. Direct skeletal analysis also shows a more rapid loss of radioactivity in the rat between 60 and 365 days, indicative of either a second power law or a terminal exponential phase in the retention function occurring after 60 days. These data are used to estimate the minimum and maximum amounts of drug that would remain in the body following long-term treatment in humans. For the intermittent cyclic EHDP treatment (ICT) regimen for osteoporosis (repeated cycles of 14 daily doses of 400 mg orally followed by 76 days drug free), the projected retention of EHDP after 3 years of treatment is 25-50 times the daily absorbed dose. Thus, for a 60 kg woman with a daily absorbed dose of 12 mg, the retained mass of EHDP would be about 300-600 mg.(ABSTRACT TRUNCATED AT 250 WORDS)

Theoretical physical chemical studies of the cause of fluoride-induced osteomalacia

In this study we investigated the possibility of the formation of a calcium fluoride surface film on the new bone matrix in patients undergoing fluoride treatment for osteoporosis. This calcium fluoride film could interfere with the normal mineralization process and lead to hyperosteoidosis (osteomalacia), a well-documented complication seen in fluoride-treated patients. During treatment, fluoride circulating in the blood and extracellular fluid of patients, could interact with the components of the serum, but particularly calcium and magnesium ions. The interrelationships among serum components in the presence of fluoride ion may result, at thermodynamic equilibrium, in deposition on the apatitic bone surface of phases such as calcium fluoride, fluorapatite, or fluorhydroxyapatite. Differences in the phase deposited among patients could result in differences in response to fluoride treatment. A computer program based on equilibrium thermodynamic data was utilized to study the physicochemical calcium, fluoride, and phosphate interrelationships in serum. In all the computer calculations, fluorhydroxyapatite (FHAP), alone or in combination with hydroxyapatite (HAP), was determined to be the thermodynamically stable precipitating surface phase. These data strongly suggest that calcium fluoride surface film is not the reason for the delay of mineralization of fluoride-stimulated new bone. Based on these calculations, we now advance the hypothesis that the effect of fluoride to cause osteomalacia is due to an effect on osteoblasts and also on osteocytes.(ABSTRACT TRUNCATED AT 250 WORDS)

Synthesis of human progesterone receptors in T47D cells. Nascent A- and B-receptors are active without a phosphorylation-dependent post-translational maturation step

Human progesterone receptors (PR) are structurally complex. At basal states there are two forms: A-receptors of approximately 94 kDa and B-receptors which are triplets of approximately 114, 117, and 120 kDa. All the proteins bind hormone and are phosphorylated. By using PR-rich T47Dco human breast cancer cells, pulse-labeling with [35S]methionine, and receptor immunopurification with anti-PR monoclonal antibodies, we show that PR are synthesized as single B-proteins of 114 kDa and single A-proteins of 94 kDa. The mature B-triplets form 6-10 h later by post-translational phosphorylation at sites restricted to the B-proteins. This slow maturation is not required for PR activation to hormone binding states, however, since A- and B-receptors that are less than 15 min old respond to progestins by undergoing transformation and nuclear binding accompanied by a rapid secondary phosphorylation common to both proteins. These studies explain the complex structure of the mature human B-receptors and the transformed A- and B-receptors, and address issues dealing with A- and B-proreceptor synthesis and receptor activation rates.

Human progesterone A-receptors can be synthesized intracellularly and are biologically functional

In order to investigate the origin and functional independence of the human progesterone receptor A binding protein, we have expressed a truncated human progesterone receptor cDNA in both gene transfer and in vitro translation assays. Proteins identical in size and antigenicity to the A-receptors found naturally in human progesterone target cells are synthesized from this cDNA that lacks the putative B receptor initiator methionine codon of the complete cDNA. The functional independence of A-receptors is suggested by their ability to bind hormone and to stimulate transcription from the progestin responsive mouse mammary tumor virus promoter.

Multiple human progesterone receptor messenger ribonucleic acids and their autoregulation by progestin agonists and antagonists in breast cancer cells

We have used AB-52, a monoclonal antibody which recognizes both the A (94,000 daltons) and B (120,000 daltons) proteins of human progesterone receptors (hPR), and hPR-50, a PR complementary DNA probe isolated from a T47D-pcD library, to study the structure and hormonal regulation of the hPR mRNAs and proteins in human breast cancer cells. RNA blot hybridization analysis of poly(A+) RNA shows that T47DCO, an estrogen resistant human breast tumor cell line in which PR are constitutively expressed, contain at least six PR mRNAs ranging in size from 2.5 to 11.4 kilobases. All six are mature cytoplasmic messages that are also present in normal human endometrium and in PR-positive MCF-7 breast cancer cells, but not in PR-negative cells. Using hPR-50 RNA synthesized in vitro as a 1.3 kilobase standard, we calculate that MCF-7 cells contain approximately 16 message molecules per cell which are increased to approximately 45 by estradiol treatment; T47DCO cells contain approximately 90 message molecules per cell constitutively expressed. Treatment of T47DCO cells with progesterone leads to down-regulation of immunoreactive A- and B-receptors in the first 8-12 h, followed by their replenishment during the next 48 h. In parallel, hPR message levels initially decrease and then return to pretreatment levels. The synthetic progestin R5020 chronically down-regulates A- and B-receptors; the proteins are profoundly suppressed for at least 48 h, while PR mRNAs fall to less than 15% of control. However, with both hormones, parallel changes in protein and message levels are observed, suggesting that progestational agonists autoregulate the levels of their own receptors by inhibiting transcription of the PR gene. Antagonists appear to have different effects. With the antiprogestin RU 486 there is discordance between hPR protein and message levels which may be due to an ineffective inhibitory interaction between the antagonist-occupied receptors and PR genes, thereby disrupting the negative feedback loop.

Immunologic analysis of human breast cancer progesterone receptors. 2. Structure, phosphorylation, and processing

We have used a monoclonal antibody (MAb) directed against chick oviduct progesterone receptors (PR), that cross-reacts with human PR, to analyze PR structure and phosphorylation. This MAb, designated PR-6, interacts only with B receptors (Mr 120,000) of T47D human breast cancer cells; it has no affinity for A receptors (Mr 94,000) or for proteolytic fragments from either protein. The antibody immunoprecipitates native B receptors and was used to study the structure of native untransformed 8S and transformed 4S receptors, using sucrose density gradient analysis, photoaffinity labeling, and gel electrophoresis. On molybdate-containing low-salt gradients, PR-6 complexes with 8S B receptors, causing their shift to the bottom of the gradient while A receptors remain at 8 S. Therefore, A and B receptors form separate 8S complexes, and we conclude that A and B do not dimerize in the holoreceptor. Similar gradient studies using salt-containing, molybdate-free buffers show that there are two forms of salt-transformed 4S receptors, comprising either A proteins or B proteins, suggesting that A and B are also not linked to one another in transformed PR. The independence of A- and B-receptor complexes was confirmed by the finding that purified, transformed B receptors bind well to DNA-cellulose. Since PR-6 cross-reacts with nuclear PR, it was used to analyze nuclear PR processing--a down-regulation step associated with receptor loss as measured by hormone binding. Insoluble nuclear receptors and soluble cytosol receptors were measured by immunoblotting following treatment of T47D cells for 5 min to 48 h with either R5020 or progesterone. From 8 to 48 h after R5020 treatment, immunoassayable receptors decreased in nuclei and were not recovered in cytosols. Nuclear receptors also decreased after progesterone treatment but replenished in cytosols between 8 and 24 h after the start of treatment. Thus, processing involves a true loss of nuclear receptor protein, and not just loss of hormone binding activity, and occurs after progesterone or R5020 treatment. This loss is chronic, however, only in R5020-treated cells. Additional studies focused on the covalent modifications of receptors. We previously described shifts in apparent molecular weight of nuclear PR following R5020 treatment using in situ photoaffinity labeling. To show whether these shifts can be explained by receptor phosphorylation, untreated cells and hormone-treated cells were metabolically labeled with [32P]orthophosphate, and the B receptors were isolated by immunoprecipitation with PR-6 and analyzed by sodium dodecyl sulfate (SDS) gel electrophoresis.(ABSTRACT TRUNCATED AT 400 WORDS)

Structural analyses of progesterone receptors

Progesterone receptors of T47Dco human breast cancer cells consist of two equimolar hormone-binding proteins of mol. wt approximately 85,000 (A protein) and 115,000 (B protein). Both proteins can be demonstrated in intact cells by in situ photoaffinity labeling; that is, in cells treated with the synthetic progestin [3H]R5020, irradiated 2 min with 300 nm u.v., solubilized directly in SDS and subjected to electrophoresis under denaturing conditions. These proteins are 6000-10,000 dalton heavier than the corresponding proteins of chick oviducts. This difference has been measured by direct comparison of photolabeled chick and human receptors on SDS-PAGE and by immunoblotting with the 9G10 antibody prepared against chick protein B. The antibody binds to a protein of mol. wt approximately 106,000 in human cells that is smaller than the hormone-bound B protein and larger than the hormone-bound A. In T47Dco cells, in situ photolabeled, untransformed receptors, as well as transformed nuclear-bound receptors, have equimolar amounts of A and B proteins. This ratio remains stable during a 1 h 37 degrees C in vitro incubation. Analysis of the in situ labeled receptors on gradient gels shows that the untransformed B protein exists as a doublet of mol. wt approximately 115,000 and 119,000 while the A protein is a singlet. After [3H]R5020 treatment, nuclear receptors change further: during the first 30 min in the nucleus the B protein shifts entirely to the heavier, mol. wt = 119,000 form. Between 30 and 60 min after nuclear binding, the A protein first becomes a doublet of 85,000 and 89,000 dalton then shifts entirely to the 4000 dalton heavier form. Later, nuclear processing leads to the simultaneous disappearance of both proteins without generation of smaller molecular weight fragments. Cleveland mapping studies show that the A and B proteins are closely related; despite the initial difference in the molecular weight of A and B, digestion with S. aureaus V8 protease yields identical fragmentation patterns for each, with sequential peptides of mol. wt approximately 49,000, 39,000, 26,000 and 14,000.(ABSTRACT TRUNCATED AT 400 WORDS)

Hormone-dependent covalent modification and processing of human progesterone receptors in the nucleus

In situ photoaffinity labeling, which minimizes in vitro incubations and proteolytic artifacts, was used to study the structure of progesterone receptors (PR) in intact T47D human breast cancer cells. These cells, rich in PR, were incubated with the photoreactive progestin [3H]R5020 at 0 degrees C for 3 hr to keep PR in their untransformed state, or at 37 degrees C for 5 min to transform PR and convert them to tight chromatin-binding proteins. The cells, still intact, were then irradiated with 300-nm UV light to link the hormone covalently to receptors at any intracellular location. In T47D cells, untransformed PR, as well as transformed nuclear-bound PR, have equimolar amounts of proteins A (Mr approximately 94,000) and B (Mr approximately 120,000). The quantitative relationship between these is stable--no degradation of B to A is seen even if in situ photolabeled receptors are incubated in vitro at 37 degrees C for as long as 1 hr. Analysis of the in situ labeled receptors on gradient NaDodSO4-polyacrylamide gels shows that the untransformed B protein is a doublet of Mr approximately 117,000 and 120,000, while the A protein is a singlet. After R5020 treatment, transformed hormone-receptor complexes rapidly (5 min) translocate to nuclei. During the next 30 min the B protein becomes modified and shifts entirely to the heavier, Mr approximately 120,000 form. Between 30 and 60 min after nuclear binding, the A protein first splits, and then also becomes approximately 3000 daltons heavier. These changes are consistent with asynchronous modification--occurring first in protein B and then in protein A. Four to 8 hr after nuclear residence, receptor "processing" leads to the simultaneous disappearance of both proteins without generation of smaller molecular weight fragments. Peptide mapping shows that proteins A and B are closely related: despite the initial difference in molecular weight of A and B, digestion with Staphylococcus aureus V8 protease yields identical fragmentation patterns for each, with sequential peptides of Mr approximately 49,000, 39,000, 26,000, and 14,000. These data are consistent with the hypothesis that B and A are closely related integral intracellular proteins; that in their untransformed state only B is phosphorylated; that hormone treatment leads to their rapid (5 min) transformation to nuclear and DNA binding states; and that a nuclear phosphoprotein kinase(s) then modifies both proteins further to influence their gene regulatory activities.

Platelet deposition on and calcification of bovine pericardial valve

Platelet deposition on bovine pericardial mitral valves was quantified in healthy adult mongrel dogs at 1, 14 and 30 days post-implantation and 24 h after i.v. injection of 400-500 microCi of autologous 111In-platelets. In vitro quantitation of platelet deposition on components of the prosthesis indicated maximal activity at one day with a successive decrease in activity at 14 and 30 days. At one day, platelet-associated radioactivity on the sewing ring was 3-4 times as great as on the leaflets, but at 14 and 30 days this had dropped to approximately half of the value on the leaflets. Calves underwent mitral valve replacement with a bovine pericardial valve. Thirty days post-operatively, 111Indium labeled labeled platelets were administered i.v.; 24 h later, calves were sacrificed and sections of each valve leaflet were analyzed for platelet and calcium deposition. Platelet deposition per mm2 of surface was greatest at the free edge of the leaflet, followed by the central zone and flexion point. Calves treated with sodium hydroxyethylene diphosphonate (5 mg kg-1 day-1 s.c.) had reduced platelet deposition but no reduced calcium content on the valves after 30 days compared with untreated calves. In flow chamber studies, platelet deposition from the heparinized blood of normal calves was significantly less on the smooth (inner) than on the rough (outer) surface of fixed bovine pericardium.

Acute intravenous infusion of disodium dihydrogen (1-hydroxyethylidene)diphosphonate: mechanism of toxicity

The acute intravenous toxicity of disodium dihydrogen (1-hydroxyethylidene)diphosphonate (etidronate disodium; I) and the mechanism of this toxic response have been investigated in 40 beagle dogs. The intravenous toxicity of I is dependent on the total dose administered and the length of the infusion interval. The toxicity of I is directly related to the ability of the drug to bind or complex with the circulating calcium in the blood. Maximum depressions in ionized calcium coincide in time with peak blood levels of I, and at lethal doses electrocardiographic changes indicative of hypocalcemia are observed. For a 2-min infusion of 2 mg of I/kg, no effect is observed on ionized calcium levels, and the electrocardiogram remains normal. At doses of 16 and 32 mg/kg, coincident with an immediate fall in ionized calcium levels, there is a transient rise in total calcium and a fall in phosphorus levels. The ionized calcium level rises, and total calcium level falls and stabilizes at baseline levels within 30 min after the infusion. However, the phosphorus level rises and exceeds the baseline value, reaching 3-4 times normal by 72 h after the infusion. With proven lethal doses of I (60 mg/kg infused over 2 min) and the simultaneous infusion of an ionized calcium salt such as calcium gluconate (20 mg of Ca2+/kg), electrocardiograms remain normal and death is prevented. Thus, an effective antidote in the event of an overdose or too rapid an infusion of I can be employed to prevent acute toxic effects.

Penetration and effect of topically applied dimethylsulfoxide or indomethacin on adjuvant arthritis in the rat

The present study, using 14C-DMSO, established the systemic and local load and distribution of topically applied DMSO in adjuvant arthritic rats. Under equivalent conditions, the antiinflammatory effects (systemic and local) of topical DMSO treatments were compared with a topical treatment of a control vehicle or of indomethacin, a known effective antiinflammatory agent. No significant systemic or local antiinflammatory effect of topical DMSO was seen in the adjuvant arthritic rats. Indomethacin, applied topically, had a significant systemic antiinflammatory effect; however, no significant local antiinflammatory effect of indomethacin was observed.

A comparison of skeletal uptakes of three diphosphonates by whole-body retention: concise communication

Twenty normal volunteers had measurements of 24-hr whole-body retention (WBR) of three structurally related Tc-99m-labeled phosphonate skeletal imaging agents: (1-hydroxyethylidene) diphosphonate (HEDP), methylene diphosphonate (MDP), and hydroxymethylene diphosphonate (HMDP). The average WBR values, reflecting skeletal uptake, were 18.4, 30.3, and 36.6%, respectively. These results clearly illustrate that slight alterations in diphosphonate molecular structure have a significant effect upon specificity for osseous tissue, and thus may affect skeletal image quality and the usefulness of the WBR technique in diagnosing metabolic bone disease.

Comparative evaluation of three diphosphonates: in vitro adsorption (C- 14 labeled) and in vivo osteogenic uptake (Tc-99m complexed)

We have investigated the in vitro adsorption of three C-14-labeled diphosphonates on calcium phosphate. The three are 1-hydroxy[1-14C]ethylidene diphosphonate (C-14 HEDP), [14C]methylenediphosphonate (C-14 MDP), and hydroxy[14C]methylenediphosphonate (C-14 HMDP). All three adsorbed significantly more, per mole of calcium, on amorphous calcium phosphate than on crystalline hydroxyapatite. Among the three diphosphonates, C-14 HMDP adsorbed--on both amorphous and crystalline calcium phosphate--to a greater degree than did the other two bone-seeking agents. Moreover, when HMDP was complexed with Sn(II) and Tc-99m, it produced a significantly higher uptake of Tc-99m, per mg of calcium, in an isolated in vivo site of osteogenesis. The mechanisms of adsorption are discussed relative to the hydroxyl group on the diphosphonate, to the solubility of the calcium salts to the diphosphonates, and to the form of the calcium phosphate. These studies form a working rationale for the clinically observed high contrast obtained with Tc-99m HMDP between normal bone and soft tissue, and between normal and abnormal bone.

Tc-99m HMDP (hydroxymethylene diphosphonate): a radiopharmaceutical for skeletal and acute myocardial infarct imaging. I. Synthesis and distribution in animals

Technetium-99m hydroxymethylene diphosphonate (Tc-99M HMDP) is a new diphosphonate skeletal imaging agent. Animal studies show that Tc-99m HMDP has a higher uptake on bone and a more rapid clearance from the blood than any of the three technetium-labeled bone imaging agents in current use: Tc-99m methylene diphosphonate (DMP), Tc-99 (1-hydroxyethylidene) diphosphonate (HEDP), and Tc-99m pyrophosphate (PPi). On the basis of these animal studies, Tc-99m HMDP is a highly promising candidate for skeletal imaging.

Tc-99m HMDP (hydroxymethylene diphosphonate): a radiopharmaceutical for skeletal and acute myocardial infarct imaging. II. Comparison of Tc-99m hydroxymethylene diphosphonate (HMDP) with other technetium-labeled bone-imaging agents in a canine model

Technetium-99m hydroxymethylene diphosphate (Tc-HMDP) was compared with the two other diphosphonates (Tc-MDP and Tc-HEDP) and Tc-99m pyrophosphate (Tc-PPi) in a canine model of acute myocardial infarction. The TC-HMDP showed higher uptake in infarcted myocardium than the other two diphosphonates, and uptake equivalent to that of Tc-PPi.

Preparation and biological distribution of technetium diphosphonate radiotracers synthesized without stannous ion

Two HEDP complexes of technetium (either Tc-99 or a mixture of Tc-99 and Tc-99m) have been prepared without the use of stannous ion. The first, Tc(NaBH4)-HEDP, is synthesized by reduction of TcO4- with NaBH4 in the presence of excess HEDP; this is analogous to the preparation of Tc(Sn)-HEDP in commercial kits wherein SN(II) functions as the reductant. The second, Tc-HEDP, is prepared by substitution of HEDP onto the pre-formed, pre-reduced, technetium center TcBr62-. The HEDP-to-Tc ratio in Tc-HEDP was found to be 1.0 by double-labeling procedures (Tc-99 and [3H]HEDP), implying that in solution this material is polymeric or at least dimeric. Preparations of Tc(NaBH4)-HEDP and Tc-HEDP with Tc-99m are excellent bone-imaging agents in both rats and dogs. Tissue distribution studies in rats show that uptake of Tc(NaBH4)-HEDP and Tc-HEDP by the bone is at least equivalent to that achieved by Tc(Sn)-HEDP prepared in commercial kits with Sn(II) as the reductant. Tin is therefore not necessary for the bone-seeking properties of Tc(Sn)-HEDP, and the in vivo distribution of a given HEDP radiotracer seems to depend primarily on the presence of the HEDP ligand and not on the exact nature of the technetium complex itself. Synthesis of technetium radiotracers by a substitution route, rather than by redox, is practicable; this route has the potential of introducing hitherto unattainable flexibility and subtlety into the preparation of technetium radiotracers.

Gentisic acid: a new stabilizer for low tin skeletal imaging agents: concise communication

In vitro stabilization of low-tin bone-imaging agents has previously been achieved with ascorbic acid. In this study gentisic acid is shown to be an equally effective antioxidant for the (1-hydroxyethylidene) diphosphonate (HEDP) and hydroxymethylenediphosphonate (HMDP) skeletal agents. In vitro studies show less than 2% free sodium [99mTc] pertechnetate at 24 hr with the gentisic acid stabilizer. Studies in guinea pigs at 3 and 24 hr--whether with C-14 or H-3-labeled gentisic acid as stabilizer--show no alteration in the biodistribution of either skeletal imaging agent by the addition of the gentisic acid. Gentisic acid is a safe and effective stabilizer, and clinical studies have shown bioequivalency with ascorbic acid.

[32P] diphosphonate dose determination in patients with bone metastases from prostatic carcinoma

In an initial safety study, phosphorus-32 (as diphosphonate) was administered intravenously to five patients with painful bone metastases from prostatic carcinoma; two patients received 9 mCi and three were given 3 mCi. Hematological, biochemical, ECG, x-ray, bone-scan data, and clinical observation, were followed for 2 mo. At both dose levels, bone-marrow depression was noted. One of the patients, who received 9 mCi, had only a slight dip in the levels of circulating white blood cells and platelets. The other 9-mCi patient was the only one with discrete metastases by bone scan; he had bone-marrow depression, from which he recovered, and was the only one of the five who had relief of bone pain.

Sites and mechanisms of localization of technetium-99m phosphorus radiopharmaceuticals in acute myocardial infarcts and other tissues

This study was performed to elucidate the localization at the cellular level of technetium-99m phosphorus ((99m)Tc-P) radiopharmaceuticals in acute myocardial infarcts and the mechanisms responsible for (99m)Tc-P uptake in acute myocardial infarcts and other tissues. In 20 dogs with proximal left anterior descending coronary arterial ligation for 1-3 days, elevated calcium levels were measured at all sites of increased (99m)Tc-P uptake (acute myocardial infarcts, necrotic thoracotomy muscle, lactating breast, and normal bone); however, a consistent linear relationship between (99m)Tc-P and calcium levels was not observed. A strong correlation (r = 0.95 and 0.99, n = 2 dogs) was demonstrated between levels of (3)H-diphosphonate and (99m)Tc-P in infarcted myocardium. Autoradiographic studies with (3)H-diphosphonate revealed extensive labeling in the infarct periphery which contained necrotic muscle cells with features of severe calcium overloading, including widespread hypercontraction as well as more selective formation of mitochondrial calcific deposits. Autoradiography also demonstrated labeling of a small population of damaged border zone muscle cells which exhibited prominent accumulation of lipid droplets and focal, early mitochondrial calcification. Cell fractionation studies revealed major localization of both (99m)Tc-P and calcium in the soluble supernate and membrane-debris fractions of infarcted myocardium and less than 2% of total (99m)Tc-P and calcium in the mitochondrial fractions; however, electron microscopic examination showed that mitochondria with calcific deposits were not preserved in the mitochondrial fractions. In vitro studies evaluating the role of serum protein binding on tissue uptake of (99m)Tc-P agents demonstrated that, in spite of significant complexing with serum proteins, serum (99m)Tc-P activity retained the ability to adsorp to calcium hydroxyapatite and amorphous calcium phosphate. In vivo studies showed that concentration of human serum albumin (labeled with iodine-131) in infarcted myocardium reached a maximum of only 3.8 times normal after a circulation time of 96 h, whereas (99m)Tc-P uptake was at least 10 times normal after a circulation time as short as 1 h. It is concluded that: (a) (99m)Tc-P uptake in acutely infarcted myocardium, and possibly other types of soft tissue damage, is limited to necrotic and severely injured cells; (b) concentration of (99m)Tc-P results from selective adsorption of (99m)Tc-P with various forms of tissue calcium stores, including amorphous calcium phosphate, crystalline hydroxyapatite, and calcium complexed with myofibrils and other macromolecules, possibly supplemented by calcium-independent complexing with organic macromolecules; and (c) lack of a linear relationship between (99m)Tc-P and tissue calcium levels mainly results from local differences in composition and physicochemical properties of tissue calcium stores and from local variations in levels of blood flow for delivery of (99m)Tc-P agents.

An in vitro and in vivo investigation of mellitate and ethane-1-hydroxy-1,1-diphosphonate in calcium phosphate systems

Comparisons of mellitate (MA) and ethane-1-hydroxy-1,1-diphosphonate (EHDP) have been carried out in studies of enamel etching, calcium phosphate crystal growth and animal calculus deposition. In enamel etch studies at pH 5, 6, or 7 and after treatment times of 5 or 170 min, EHDP was less damaging to enamel surfaces than MA as determined by scanning electron microscopy, grazing angle electron diffraction, and quantitative etch solution analyses. Both MA and EHDP inhibited hydroxyapatite crystal growth, although EHDP was more effective than MA. The formation of a tricalcium mellitate surface phase is suggested as the basis of the MA crystal growth effect on apatite. Both MA and EHDP also inhibited rat calculus formation, but EHDP was more effective than MA. The relation between crystal growth inhibition, surface phase solubility, and anti-calculus activity is discussed and a generalized principal for determining an effective inhibitor of calculus is suggested.

In vitro stabilization of a low-tin bone-imaging agent (99mTc-Sn-HEDP) by ascorbic acid

The presence of oxidants in the 99mTc-pertechnetate and of oxygen in diagnostic kits containing low concentrations of Sn(II) has a detrimental effect upon in vitro and in vivo stability. Maintaining a nitrogen atmosphere or increasing the Sn(II) concentration inhibits the formation of 99mTcO4-. However, the latter remedy is likely to cause uptake in the reticuloendothelial system and has been associated with false positive or negative brain scans. We used ascorbic acid (an antioxidant) to ensure the in vitro stability with the low-Sn(II) bone agent disodium etidronate. In vitro stability studies by instant thin-layer chromatography, using high-acitivity generators and "instant pertechnetate," yielded less than 2% free pertechnetate at 24 hr after preparation. Distribution studies in guinea pigs show neither altered distribution of the bone agent nor abnormal distribution of ascorbic acid, suggesting its sole function as a noncomplexing stabilizer.

Factors affecting uptake and retention of technetium-99m-diphosphonate and 99m-pertechnetate in osseous, connective and soft tissues

The bone scanning complex, 99mTc-Sn-EHDP, consisting of the nuclide technetium-99m, stannous ion and ethane-1-hydroxy-1,1-diphosphonate, administered intravenously is retained in soft tissues in proportion to increasing calcium content of the tissues. Within bone tissue, the retention is proportional to vascularity and to surface area of calcium phosphate in bones and not necessarily to calcium and phosphate concentration. The nuclidic agent 99mTcO4-BUT NOT THE 99MTc-diphosphonate is selectively taken up by the thyroid and this uptake can be blocked by administering sodium perchlorate. Among the connective tissues studied, the tracheal cartilage seems to have the greatest potential to calcify with increasing age of the animal and man. Soft tissue does not retain the bone scanning complex 99mTc-Sn-EHDP but does retain 99mTcO4-.

Bone scanning: radionuclidic reaction mechanisms

One of the major successes of nuclear medicine in recent years has been the clinical utility of the 99mTc-labeled bone-imaging agents. This article is concerned with the evidence available for the mechanisms by which these and other such radiopharmaceuticals localize at sites in the skeleton.

Correlation of neoplasms with incidence and localization of skeletal metastases: An analysis of 1,355 diphosphonate bone scans

A total of 1,355 patients from clinical trails with the 99mTc-labeled bone agent, Osteoscan (99mTc-Sn -EHDP), has shown a higher incidence of skeletal abnormalities than previously reported. Overall in this study, 60% of bone scans were abnormal in patients with nonosseous neoplasms. Carcinoma of breast, lung, and prostate yielded 67%, 64%, and 62% skeletal involvement, respectively. Over 50% of all the skeletal abnormalities for the neoplastic indications were detected in the thorax and vertebra while the skull, pelvis, and extremities accounted for 22%, 38%, and 34%, respectively.

Distribution of 99mTc-Sn diphosphonate and free 99mTc-pertechnetate in selected soft and hard tissues

Because increased uptake of 99mTc-diphosphonate (ethane-hydroxy-1, 1-diphosphonate) occasionally occurs in the anterior neck region, the possible increased affinity of the diphosphonate bone-scanning agent for cartilage was investigated. In vivo scintigraphic studies and organ analyses from rats and rabbits injected with this bone scintigraphic agent were performed. Trachea-to-muscle uptake ratios were a high 45:1 in adult Sprague-Dawley rats and approached the femur-to-muscle ratio of 93:1. Technetium-99m-diphosphonate uptake was also increased, but to a lesser extent, in xiphoid cartilage, tendon, and ear cartilage; this was proportional to the calcium content of the organ. The thyroid showed a high affinity for free pertechnetate but not 99mTc-diphosphonate, providing further evidence that the increased neck uptake of this 99mTc-diphosphonate is due to tracheal, not thyroid activity. In addition, premedication of three patients with 200 mg of potassium-perchlorate did not block this neck uptake. Interpretation of scintigraphs performed with 99mTc-diphosphonate that show lesions in the cervical spine should take into account the potential for false-positive readings caused by this increased tracheal uptake.