Dataset on renal tumor diameter assessment by multiple observers in normal-dose and low-dose CT

Computed tomography-based active surveillance is increasingly used to manage small renal tumors, regardless of patient age. However, there is an unmet need for decreasing radiation exposure while maintaining the necessary accuracy and reproducibility in radiographic measurements, allowing for detecting even minor changes in renal mass size. In this article, we present supplementary data from a multiobserver investigation. We explored the accuracy and reproducibility of low-dose CT (75% dose reduction) compared to normal-dose CT in assessing maximum axial renal tumor diameter. Open-access CT datasets from the 2019 Kidney and Kidney Tumor Segmentation Challenge were used. A web-based platform for assessing observer performance was used by six radiologist observers to obtain and provide data on tumor diameters and accompanying viewing settings, in addition to key images of each measurement and an interactive module for exploring diameter measurements. These data can serve as a baseline and inform future studies investigating and validating lower-dose CT protocols for active surveillance of small renal masses.

Ultra-low-dose non-contrast CT and CT angiography can be used interchangeably for assessing maximal abdominal aortic diameter

Background

Routine CT scans may increasingly be used to document normal aortic size and to detect incidental abdominal aortic aneurysms.

Purpose

To determine whether ultra-low-dose non-contrast CT (ULDNC-CT) can be used instead of the gold standard CT angiography (CTA) for assessment of maximal abdominal aortic diameter.

Materials and Methods

This retrospective study included 50 patients who underwent CTA and a normal-dose non-contrast CT for suspected renal artery stenosis. ULDNC-CT datasets were generated from the normal-dose non-contrast CT datasets using a simulation technique. Using the centerline technique, radiology consultants (n = 4) and residents (n = 3) determined maximal abdominal aortic diameter. The limits of agreement with the mean (LOAM) was used to access observer agreement. LOAM represents how much a measurement by a single observer may plausibly deviate from the mean of all observers on the specific subject.

Results

Observers completed 1400 measurements encompassing repeated CTA and ULDNC-CT measurements. The mean diameter was 24.0 and 25.0 mm for CTA and ULDNC-CT, respectively, yielding a significant but minor mean difference of 1.0 mm. The 95% LOAM reproducibility was similar for CTA and ULDNC-CT (2.3 vs 2.3 mm). In addition, the 95% LOAM and mean diameters were similar for CTA and ULDNC-CT when observers were grouped as consultants and residents.

Conclusions

Ultra-low-dose non-contrast CT exhibited similar accuracy and reproducibility of measurements compared with CTA for assessing maximal abdominal aortic diameter supporting that ULDNC-CT can be used interchangeably with CTA in the lower range of aortic sizes.

Pharmacological monitoring of azathioprine therapy

BACKGROUND

Studies on azathioprine (Aza) treatment in Crohn disease have indicated a positive correlation between clinical remission and a concentration in erythrocytes of the metabolites 6-thioguanine nucleotides (E-6-TGN) above 230 pmol/8 x 10(8) RBC. A concentration of the methylated Aza metabolites (E-6-MMP) above 5000 pmol/8 x 10(8) RBC has been correlated to hepatotoxicity. Thiopurine methyltransferase (TPMT) is responsible for the formation of methylated metabolites and lower E-TGN levels, and TPMT genotyping has been proposed as guidance for dosage. In a cross-sectional study we investigated relationships between the clinical outcome and Aza dose, the TPMT genotype and the Aza metabolite levels among patients with Crohn disease.

METHODS

TPMT genotype (PCR assay), azathioprine metabolite levels (HPLC analysis) and xanthine oxidase (XO) activity were determined once in 71 randomly selected Crohn patients on an unaltered Aza dose for at least 3 months.

RESULTS

None of the doses of Aza, TPMT genotype, E-6-TGN-, E-6-MMP levels or XO activity were significantly related to disease activity (H-B score), (P = 0.18, P = 0.69, P = 0.90, P = 0.54, P = 0.29, respectively). Leucopenia and/or hepatotoxicity were not demonstrated in any patient. Four patients had a heterozygous TPMT genotype (6.1%; 95% CI: 1.68%-14.80%). The 4 TPMT heterozygous patients had higher E-6-TGN levels than did the 67 remaining patients (P = 0.008).

CONCLUSIONS

To explore the applicability of TPMT genotyping, E-6-TGN and E-6-MMP levels for therapeutic drug monitoring, large prospective studies with patient entry at the start of Aza therapy are needed. Until the results of such studies are available, the dose adjustments of Aza should be guided primarily by clinical response and blood counts; metabolite level measurements can only be applied to identify therapeutic non-compliance.

High serum enalaprilat in chronic renal failure

BACKGROUND

Most angiotensin-converting enzyme (ACE) inhibitors and their metabolites are excreted renally and doses should hence be reduced in renal insufficiency. We studied whether the dosage of enalapril in daily clinical practice is associated with drug accumulation of enalaprilat in chronic renal failure.

METHODS

Fifty nine out-patients with plasma creatinine >150 micromol/L and chronic antihypertensive treatment with enalapril were investigated, in a cross-sectional design.

RESULTS

Median glomerular filtration rate (GFR) was 23(range 6-60) ml/minute/1.73 m2. The daily dose of enalapril was 10 (2.5-20) mg and the trough serum concentration of enalaprilat was 31.8 (<2.5-584.7)ng/ml. Ninety percent of the patients had higher serum concentrations of enalaprilat than has been reported in subjects with normal kidney function, and a marked elevation of serum enalaprilat was observed in patients with GFR <30 ml/minute. All but three patients had serum ACE activity below the reference range. The ACE genotype did not influence the results. Additional pharmacokinetic studies were done in nine patients in whom GFR was 23 (10-42)ml/minute/1.73 m2. The median clearance of enalaprilat was 28 (16-68) ml/minute and correlated linearly with GFR (r=0.86, p=0.003). Intra-subject day-to-day variation in trough concentrations was 19.7%.

CONCLUSION

Patients with chronic renal failure given small or moderately high doses of enalapril may thus have markedly elevated levels of serum enalaprilat. Whether this affords extra renoprotection, or on the contrary may inappropriately impair renal function, is not known, and should be investigated in prospective, controlled studies.

Postoperative analgesia is not different after local vs systemic administration of meloxicam in patients undergoing inguinal hernia repair

PURPOSE

To distinguish between local and systemic drug effects, we compared pain scores, analgesic consumption and plasma concentrations after local vs i.v. administration of meloxicam 7.5 mg in patients with inguinal hernia repair.

METHODS

In a double-blind, randomized study 56 patients received either local or i.v. meloxicam 7.5 mg. Postoperative pain was assessed with a visual analogue scale (VAS) at rest, on mobilization, and on coughing, the need for supplementary analgesics (fentanyl i.v. and/or acetaminophen-codeine tablets) was recorded, and blood samples were drawn during 24 hr after meloxicam administration.

RESULTS

No significant differences were found between groups with respect to pain scores, or in the consumption of supplementary analgesics. Following local application of meloxicam, the peak plasma concentration (C(max)) of 0.5 +/- 0.2 mg*L(-1) achieved after 1.8 +/- 0.5 hr was much lower than the C(max) of 2.5 +/- 0.9 mg*L(-1) achieved immediately after i.v. administration (P <0.05). Mean meloxicam plasma concentration after infiltration was significantly lower than after i.v. doses for the first three hours after administration (P <0.05).

CONCLUSION

We showed no differences in pain scores and analgesic consumption between local and i.v. administration of meloxicam 7.5 mg during the first 24 hr after herniorrhaphy, while plasma concentration of meloxicam was lower after local administration. These results indicate a lack of difference in pain relief after concentrating meloxicam at the hernia wound or after achieving high blood levels rapidly (i.v.). Local administration of meloxicam may confer an advantage over systemic administration by eliciting lower incidences of systemic adverse effects.

[Severe neonatal hyperparathyroidism in a family with familial hypocalciuric hypercalcemia]

Familial hypocalciuric hypocalcaemia (FHH) is a rare disorder, inherited in an autosomal dominant manner. It has earlier been believed that neonatal severe hyperparathyroidism (NSHPT) is the homozygous form of FHH, but in this case story we show that it is not always like that. We describe a girl who presents with a calcium metabolic disorder from birth. Genetic examination of the girl and her family shows a single abnormal allele in the calcium ion sensitive receptor. We discuss why some heterozygotic inactivating calcium receptor mutations cause NSHPT, while the majority of other mutations only cause mild, asymptomatic hypercalcaemia as in FHH.

Familial hypocalciuric hypercalcemia and neonatal severe hyperparathyroidism associated with mutations in the human Ca2+-sensing receptor gene in three Danish families

We screened three unrelated Danish families with familial hypocalciuric hypercalcemia (FHH) for mutations in the Ca2+-sensing receptor (CASR) gene by polymerase chain reaction amplification and DNA sequencing of exons 2-7, which include the entire coding region of the gene. In one family the affected individuals have a T-->C mutation that changes the normal arginine at codon 220 to a tryptophan. In the other two FHH families, affected individuals have the same A-->G mutation, leading to conversion of the normal glycine at codon 552 to an arginine. These results confirm that FHH can be caused by non-conservative missense mutations in the CASR gene leading to abnormal calcium homeostasis. Both mutations are located in the amino-terminal extracellular domain of the receptor, which contains the binding site for extracellular Ca2+, the CASR's principal physiological agonist.

An analysis of seven different methods to diagnose Helicobacter pylori infections

BACKGROUND

It has been debated which diagnostic test should be preferred for the diagnosis of Helicobacter pylori in patients with gastroduodenal diseases.

METHODS

The H. pylori infection was diagnosed prospectively in 97 untreated patients. H. pylori was diagnosed by means of tests based on five different principles: 1) culture, 2) microscopy (HLO), 3) urease activity (urea breath test (UBT) and urease test on biopsy specimens (CLO test)), 4) DNA detection (polymerase chain reaction (PCR)), and 5) IgG antibody detection (enzyme-linked immunosorbent assay (EIA) and Western blotting (WB)).

RESULTS

This study showed that two positive tests out of five tests, based on different principles, were most reliable for predicting the H. pylori infection. Most tests had specificities and predictive values for a negative result greater than 90%. The most important difference between the tests was the sensitivity and the predictive value for a positive result (PPV). WB, HLO, UBT, and PCR had sensitivities and PPV greater than 75%.

CONCLUSIONS

The non-invasive tests UBT and WB are reliable, both alone and in combination, and they are recommended for the pre-endoscopic diagnosis of H. pylori. WB is recommended as a confirmative test for antibody detection by EIA. When patients have an upper endoscopy, we recommend taking biopsy specimens for culture and histology because of the additional information obtained about susceptibility, virulence determinants, and morphology, including the degree of inflammation.

Fluctuation of serum zuclopenthixol concentrations in patients treated with zuclopenthixol decanoate in viscoleo

Zuclopenthixol serum concentrations were measured in 58 psychiatric patients referred for routine therapeutic drug monitoring (TDM). Patients were treated for prolonged time with zuclopenthixol decanoate in viscoleo in doses of 50-500 mg, administered intramuscularly at 14-day intervals. The serum concentration was determined at days 7 (C7) and 14 (C14) following injection. The mean ratio C7/C14 was 2.0 and was independent of the dosage given. In 14 patients, additional blood samples were drawn at day 3 (C3) following injection. The mean ratio C3/C14 of this group was 3.2. An almost log-linear decline of the serum concentration from day 3 to 14 appeared, which corresponds to an apparent half-life of zuclopenthixol in this dosage form of 7.4 days. The marked fluctuations of serum concentrations of zuclopenthixol from peak to trough levels in patients given fortnightly injections of the depot preparation indicate that shorter intervals between injections should be considered in many cases in order to diminish side effects.

Hylan gel biomaterial: dermal and immunologic compatibility

Hylan, a hyaluronan derivative, was chemically cross-linked with divinyl sulfone to produce a water-insoluble gel. This gel was fragmented into a gel slurry and evaluated for particle size, biocompatibility, and residence times in selected tissues. Hylan gels used in this study are made up of pseudoplastic, deformable gel particles with greater elasticity (at all frequencies) and greater viscosity (shear rates, 0.01 sec-1) than the water soluble hylan polymer. Hylan gel was injected intradermally and subdermally in mice and was found to produce a minimal reaction at 24 h; thereafter (up to 7 weeks) there was no significant tissue reaction. Intradermal injection of [3H]-hylan gel in guinea pigs revealed a minimal tissue reaction after 1 week, and measurement of radioactivity in the tissue at 1, 2, and 4 weeks revealed only a slight decrease in the total amount of injected radioactivity. The immunogenic activity of hylan gel was evaluated in rabbits; unmodified hylan gel, degraded hylan gel, and hylan gel ovalbumin conjugate were used to immunize rabbits. No antibody production to any hylan gel sample was detected, although control rabbits immunized with ovalbumin developed titers > 400 of antiovalbumin antibodies by day 21, as measured by the passive cutaneous anaphylaxis assay (PCA). Last, serum from owl monkeys (Aotus trivirgatus) in which hylan gel had been placed intravitreally for up to 3 years contained no detectable anti-hylan gel antibodies (PCA assay). Skin tests on these monkeys were also negative.

Computer-assisted alignment of standard serial sections without use of artificial landmarks. A practical approach to the utilization of incomplete information in 3-D reconstruction of the hippocampal region

An algorithm for the alignment of stained serial sections without the support of artificial landmarks is described. Four-hundred-thirty serial sections of the rabbit hippocampal region were digitized, and computer-based alignment was performed without use of artificial markers, resulting in a consistent matrix. Following proper filtration, artificial sections were cut through the matrix. In a second experiment every second image was deleted and reconstructed by interpolation with a minor loss of biological information. In a third experiment every second image was deleted and the rest of the images were 'disordered', realigned and the missing planes reconstructed by interpolation. Under these circumstances the matrix was reconstructed with some loss of information. These results may widen the limits of 3-dimensional (3-D) reconstruction, as routine histological preparations normally include only every second or every third section without artificial landmarks.

Effect of hylan on cartilage and chondrocyte cultures

The protective role of hylan, a hyaluronan [hyaluronic acid (HA)] derivative, was studied in explanted bovine cartilage and isolated chondrocytes. Cartilage and chondrocytes were exposed to degradative enzymes (lysate from activated polymorphonuclear leukocytes), oxygen-derived free radicals (ODFR), conditioned media from mononuclear cells (MCCM), and interleukin-1 (IL-1), in the presence and absence of hylan. The effect of HA was also studied. In cartilage explants susceptibility to pertubation was evaluated in terms of 35S release and proteoglycan depletion and was compared to control cultures; high viscosity hylan was found to reduce 35S release in cartilage explants caused by degradative enzymes, ODFR, MCCM, and IL-1. The hylan effect was reversible and viscosity-dependent. In chondrocyte cultures, high viscosity hylan was effective in reducing cell injury caused by degradative enzymes and ODFR. The data suggest that the glycosaminoglycan hylan, as well as native HA, may mediate exposure to and/or response to stimuli associated with initiation of degenerative processes in cartilage tissues.

Scintigraphic determination of gastrointestinal transit times. A comparison with breath hydrogen and radiologic methods

A scintigraphic method for determination of gastrointestinal transit times was compared with the breath hydrogen test and a multiple-bolus, single-radiograph technique. A close temporal association was found between the caecal appearance of radioactivity and the onset of breath hydrogen excretion in eight healthy subjects. Neither mean small-intestinal nor mean orocaecal transit times of the radiolabelled marker were correlated with the magnitude of hydrogen peak, hydrogen peak time, or the area under hydrogen curve. No correlation was noted between whole-gut transit time of the radiolabelled marker and mean whole-gut transit time calculated from a 6-day administration of the radiopaque marker in 16 healthy subjects. The stool weight was inversely correlated with the mean colonic (r = -0.46, p = 0.009) and the mean whole-gut (r = -0.45, p = 0.011) transit times of the radiolabelled marker. In conclusion, inadequate delineation of the caecal region seems to be an unimportant drawback of the scintigraphic measurements, whereas day-to-day variation in gastrointestinal transit rates may influence the reliability of the assessments. Probably, quantitative transit data cannot be obtained from the breath hydrogen concentration profiles.

[Therapy control of perphenazine. 2. Clinical aspects]

Rational use of serum concentration monitoring of the neuroleptic, perphenazine, was evaluated in a prospective investigation. A total of 141 hospitalized patients with paranoid symptoms (excluding mania) requiring treatment were included during the investigation period (one year). Perphenazine was administered (fixed doses) orally (92 patients) and parenterally (depot, decanoate, 45 patients) in a six-week treatment period. Serum concentrations of perphenazine were monitored after 10-14 days oral treatment, on the 14th and 21st days after the commencement of depot treatment. The patients were steered on to the recommended therapeutic range for perphenazine (1.5-6 nmol), according to the serum level measured. Global clinical assessment was carried out by the departmental physicians. Therapy control of perphenazine by serum monitoring was an important supplement to the clinical evaluation of therapeutic effect. Fifteen (65%) out of 23 patients who were treated orally with insufficient therapeutic effect, showed non-compliance or elevated metabolism. On the basis of a single serum concentration measurements (12 hours values), it proved possible to steer the majority of patients onto the recommended therapeutic level. In this way, the individual patient reached optimal therapeutic effect with a minimum of side-effects.

Hylan gel composition for percutaneous embolization

Viscoelastic, pseudoplastic, radiopaque injectable hylan gel for percutaneous embolization was developed and evaluated by in vitro and in vivo tests. The embolization gel is composed of cross-linked hylan (hyaluronan, hyaluronate), tantalum, microcrystalline cellulose, hexamethonium chloride, and thrombin. Upon delivery through small-lumen catheters to the appropriate vascular site, the gel induces formation of a solid blood/gel coagulum. Results from animal studies (rat aorta, rabbit auricular artery) demonstrate that formation of complete and long-lasting arterial blockage is readily achievable without complications due to blood flow, partial vessel obstruction, uncontrolled polymerization, or movement of the gel or its components (specifically thrombin and hexamethonium chloride) into the circulation. Microscopic evaluation indicates that arterial occlusion initially occurs as a result of the injected gel and formed fibrin; at 7 weeks and beyond, arteries are occluded by injected gel, inflammatory cells and fibrosis (scar tissue).

Computer-assisted three-dimensional reconstruction of the hippocampal region based on serial sections

A large series of rabbit hippocampal Neo-Timm stained sections were manually aligned, digitized, and by a modified median filtration noise reduced and reconstructed into a three-dimensional object. From the presented simulated grey tone cuts of this object, the reader may assemble a rabbit hippocampal model, that spatially illustrates its anatomy.

Matrix engineering

Matrix engineering is a technology that utilizes hyaluronan (HA, hyaluronic acid) based matrices to control, direct or augment tissue regenerative processes. Hyaluronan and the concept of matrix engineering have become established tools in ophthalmic and orthopaedic medicine. The clinical indications for HA are limited by the physical properties and short residence time of the natural HA molecule. To expand and improve upon its current medical applications, a family of HA derivatives was prepared by chemical modification and cross-linking. Relative to the non-modified HA molecule, the hylan family of polymers provides more versatile physical forms, improved mechanical properties and an extended residence time. Hylan can also be used as a surface coating to improve blood compatibility. The chemical, physical and biological properties of hylans will be reviewed, focusing on the specific therapeutic indications they enable.

Perphenazine decanoate and cis(z)-flupentixol decanoate in maintenance treatment of schizophrenic outpatients. Serum levels at the minimum effective dose

Two groups of schizophrenic outpatients were treated with perphenazine decanoate (N = 20) and cis(z)-flupentixol decanoate (N = 24) respectively. Every 3 months the dose was gradually reduced until symptoms appeared that were suggestive of a prodromal phase of a psychotic episode. A slightly higher dose was then promptly reinstituted (the minimum effective dose). At each dose level, two blood samples were drawn for determination of serum concentration. The mean minimum effective dose of perphenazine decanoate was 99.3 mg/2 weeks (range 21.6-270.5), while the mean minimum effective dose of cis(z)-flupentixol decanoate was 60 mg/2 weeks (range 20-250). The corresponding mean serum level of perphenazine decanoate was 7.3 nmol/l (range 2.0-18.1) and of cis(z)-flupentixol decanoate 7.8 nmol/l (range 1.2-37.0). There was a significant correlation between the administered doses and the corresponding serum levels for both drugs (r = 0.87, P less than 0.01). A weak positive correlation was found between serum levels at the minimum effective dose and symptom intensity (BPRS total score) (r = 0.53, P less than 0.02) for perphenazine, but not cis(z)-flupentixol. No correlation was found between serum levels and side effects or length of neuroleptic treatment. It is concluded that the serum drug concentrations corresponding to the lowest effective dose are so variable that routine serum level monitoring may be of limited value in the long-term maintenance treatment of schizophrenia.

ALMA, an editor for large sequence alignments

A dedicated sequence editor, ALMA, was developed for aligning many sequences of proteins or RNA molecules or longer DNA fragments. Like previously published editors, ALMA is menu directed, screen oriented, and offers similarity and consensus display. ALMA has the additional features of collective movement of sequences, acceptance of input from many sources including structure files and databases, secondary structure display, and easy merging of alignments. In order to maintain sequence integrity and save disk space, gaps and sequences are stored separately. Automatic recovery of a session is possible. Finally, the program allows interaction between manual and automatic alignment.

Prediction of the optimal perphenazine decanoate dose based on blood samples drawn within the first three weeks

During a 3-month period, 52 paranoid psychotic inpatients were treated with perphenazine decanoate (Trilafon decanoate) in order to determine a treatment schedule ensuring perphenazine serum levels within the optimal range (2-6 nmol/L). All patients received 1 ml (108 mg) perphenazine decanoate on days 0, 7 and 21, after which the doses and intervals were individually adjusted according to the clinical condition. It was shown that the sum of 2 measurements of perphenazine concentration early during treatment, viz., on days 14 and 21, correlates strongly (r = 0.96) with the steady-state level obtained after 3 months. Consequently, a nomogram for dose and length of interval could be elaborated giving steady-state serum levels of perphenazine of about 4 nmol/L, i.e., in the middle of the optimal concentration range.

The relationship between perphenazine plasma levels and clinical response in acute schizophrenia

1. Twelve patients with schizophrenia according to RDC participated in a double-blind study, comparing two dose levels of perphenazine, 16 or 32 mg, during four weeks. 2. The patients were assessed with a subscale to CPRS and global scores, measuring improvement of regular intervals during four weeks. 3. Blood samples for assay of plasma perphenazine were collected once a week. 4. These results are in many respects in accordance with earlier published data with perphenazine, that is a good clinical response is achieved with a plasma concentration of perphenazine between 1-5 nmol/L. 5. No incidence of severe adverse symptoms were observed.

Hydroxyproline/creatinine ratios as estimates of bone resorption in early postmenopausal women. Fasting and 24-h urine samples compared

Ratio of urinary hydroxyproline/creatinine excretion is often used as an index of bone resorption. To establish the difference between the fasting urinary content (FU-HPR/CR) and the 24-h urinary excretion (24 h-U-HPR/CR) we determined hydroxyproline and creatinine in specimens from a group of early postmenopausal women. One hundred and eighty-six early postmenopausal women were randomized into 10 groups receiving various doses of sequential female sex hormones and/or 1,25(OH)2D3, 0.25 microgram per day, or placebo. In all groups there were parallel changes of FU-HPR/CR and 24 h-U-HPR/CR, and in all groups treated with oestrogens the values decreased significantly. The changes in FU-HPR/CR were more pronounced than in the 24-h-U-HPR/CR, which indicates that FU-HPR/CR is a more sensitive marker of changes in bone resorption. The strong correlation between the mean values of 24-h-U-HPR/CR and those of FU-HPR/CR suggests that both methods are convenient for evaluating changes during long-term studies in groups of patients. The correlation on an individual basis is weak. The substantial intraindividual variation in 24-h-U-HPR/CR, (34.6%) indicates that FU-HPR/CR (CV = 17.0%) is the more valid variable for individual patients.

Development of cimetidine resistance in the Zollinger-Ellison syndrome

A patient with the Zollinger-Ellison syndrome was followed with multiple gastric secretion tests and serum gastrin analyses for six years. During this period cimetidine requirement increased to a daily dose of 8 g, but it reversed spontaneously after two years. The altered cimetidine effectiveness was not associated with reduced oral bioavailability and serum calcium was unchanged. Total serum gastrin was very high at all times, and fractionation of gastrins in serum by gel filtration showed varying proportion of big to small gastrins, but not in a mode which explained the parietal cell resistance to cimetidine.

Pharmacokinetic implications of different oil vehicles used in depot neuroleptic treatment

On separate occasions two male schizophrenic inpatients were given intramuscular injections of equal amounts of perphenazine decanoate dissolved in sesame oil and Viscoleo, respectively. Substantially more even, but also lower perphenazine plasma concentrations were found within the dose intervals following the injections of perphenazine decanoate dissolved in sesame oil compared to the intervals following the Viscoleo-preparation. The occurrence of extrapyramidal side effects were consistent with the magnitude of the perphenazine plasma concentrations. The results support the importance of selecting an appropriate oil vehicle in a depot neuroleptic.

Effect of bacterial endotoxin on the transmembrane electrical potential and plasma membrane fluidity of human monocytes

In order to gain insight into the physical interaction between bacterial endotoxins and the surface of human monocytes, we investigated the effects of Salmonella typhi endotoxin and lipid A on two functional properties of the plasma membrane of these cells: (1) the transmembrane electrical potential and (2) the fluidity of the lipid bilayer. Using the fluorescent lipophilic cationic probe 3,3'-dipropylthiodicarbocyanine (di-S-C3(5] to monitor the transmembrane electrical potential, we found that neither endotoxin nor lipid A induced depolarization of the monocyte's plasma membrane or impeded its ability to undergo depolarization in response to phorbol myristate acetate. When the resting transmembrane potential of the monocyte was analyzed by exposing di-S-C3(5)-labeled cells suspended in media containing incremental concentrations of potassium ion (K+) to valinomycin, no difference between the response of control cells and cells pretreated with endotoxin was noted. We next examined the effect of endotoxin and lipid A on the fluidity of the monocyte's plasma membrane by monitoring the intensity of the fluorescence of 1,6-diphenyl-1,3,5-hexatriene. By quantifying the intensity of parallel and perpendicular polarized light emitted by this membrane-embedded probe between 8 and 56 degrees C, measurements of molecular anisotropy were used to identify temperature-dependent phase transitions within the hydrocarbon region of the plasma membrane and to estimate the relative microviscosity of the lipid bilayer before and after exposing the cells to endotoxin or lipid A. Although the temperature at which phase transitions occurred was the same in all experimental groups of cells, preincubation of monocytes with either endotoxin or lipid A appeared to increase both the apparent microviscosity of the cell membrane and the order of the lipid bilayer as reflected by a decrease in its flow-activation energy. Our data indicate that when endotoxin molecules contact the surface of the monocyte, the lipid A moiety appears to become incorporated into the plasma membrane, increasing the microviscosity of the lipid bilayer without significantly altering its ionic permeability. We therefore conclude that the metabolic activation of monocytes by endotoxin is not coupled to, or initiated by, membrane depolarization.

Dextropropoxyphene kinetics after single and repeated oral doses in man

The kinetics of dextropropoxyphene (DP) and its main metabolite norpropoxyphene (NP) were studied in 6 healthy male subjects after a single oral dose of 195 mg DP HCl, and during and after 12 daily single oral doses of 195 mg DP HCl. The kinetics varied up to five-fold between individuals after the single dose, the apparent mean elimination half-life (t1/2) was 16 h for DP and 29 h for NP. The mean apparent overall plasma clearance (CL) for DP was 2.61/min. There was no systematic difference in DP clearance between the single and multiple doses, but the accuracy of individual predictions from single to multiple doses was poor, probably because of imprecise determinations of the AUC and t1/2 in the single dose experiments. The individual correlation between single and multiple dose kinetics was good for NP, although the predicted plasma levels during steady state were significantly higher than the observed levels (mean AUCss/AUCsd: 0.81). There was no sign of saturation kinetics on repeated administration. In fact, autoinduction, resulting in significantly lower plasma concentrations after treatment for 1 week was found for NP and was indicated for DP. On discontinuing DP after 12 days of treatment, the apparent mean t1/2 of DP was 23 h and of NP 25 h.

Therapeutic advantages of monitoring plasma concentrations of perphenazine in clinical practice

Two hundred and twenty-eight acute paranoid psychotic in-patients received continuous treatment with perphenazine for a period of at least 5 weeks, before blood samples were taken to determine perphenazine plasma levels and conclusions regarding therapeutic efficacy and motor side effects. Patients with plasma concentrations within the range of 2-6 nmol/l showed an excellent antipsychotic response, concomitantly with a low incidence of extrapyramidal side effects. However, patients with plasma levels below or above this range either demonstrated a poor therapeutic response or a high degree of side effects respectively. The results indicate that with increasing age significantly lower doses of perphenazine are required to ensure an optimal clinical response. No difference, however, was seen between sexes with regard to dose response.

The effects of tumor-promoting phorbol esters on human granulopoiesis in vitro

In order to determine whether the tumor-promoting phorbol esters are capable of inducing normal human committed granulocytic-monocytic progenitor cells (CFUc) to proliferate and differentiate in the absence of granulocyte-monocyte colony-stimulating activity (CSA), we studied the effects of these compounds on human granulopoiesis in vitro. We found that when light-density human marrow cells or peripheral blood leukocytes were depleted of adherent cells and then incubated in semisolid tissue culture medium under conditions optimal for CFUc growth, phorbol myristate acetate (PMA) and its congeners produced no measurable stimulatory effect on the proliferation of CFUc in the absence of added CSA. Likewise, when light-density marrow cells that had not been depleted of adherent cells were plated in the cultures, no stimulation of CFUc colony growth resulted from the addition of PMA. However, when light-density peripheral blood leukocytes were used as a target source of CFUc without first subjecting them to adherence separation, enhanced proliferation and differentiation of CFUc were noted in cultures that contained PMA. To investigate the possibility that CSA production by monocytes in these cultures in response to activation by PMA might account for the enhanced colony formation that we observed, we incubated isolated peripheral blood monocytes in short-term liquid suspension cultures and found that in the presence of PMA, large quantities of CSA were secreted into the surrounding medium. Finally, we noted that when marrow cell suspensions were suboptimally stimulated by low concentrations of CSA added to the cultures, the effects of PMA on CFUc proliferation were unpredictable, enhancing colony formation in some cases and inhibiting it in others. Our data indicate that although the tumor-promoting phorbol esters do not appear capable of directly stimulating the proliferation or differentiation of human CFUc in the absence of CSA, they may do so indirectly by causing auxiliary cells such as monocytes to secrete CSA.

Interaction of radiolabeled endotoxin molecules with human monocyte membranes

Radiolabeled and biologically active endotoxin molecules were prepared, and their binding to monocyte plasma membranes was studied. The binding of 3H-endotoxin and 51Cr-lipid A to isolated membranes was found to be less specific and of lower apparent affinity than that observed using whole cells. Plasma membranes isolated from intact, viable 51Cr-lipid A-pretreated monocytes were found to contain a significant portion of the cell-associated 51Cr-lipid A following Percoll density gradient fractionation of post-nuclear homogenates. When monocytes were pretreated with 3H-endotoxin under the same experimental conditions, all of the label was recovered in the extracellular medium, and subcellular fractionation revealed no fractions which contained tritium. Taken together, our results suggest that specific and high affinity interactions between monocyte membranes and endotoxin molecules are likely to depend on plasma membrane structures which are assembled in intact monocytes but which are disrupted when plasma membranes are isolated from these cells.

Interaction between endotoxin and human monocytes: characteristics of the binding of 3H-labeled lipopolysaccharide and 51Cr-labeled lipid A before and after the induction of endotoxin tolerance

Salmonella typhi endotoxin (lipopolysaccharide, LPS) was labeled with tritium and purified by gel filtration. Using this preparation, we found that binding of 3H-labeled LPS (3H-LPS) to isolated human monocytes consisted of a rapid (t1/2 less than 5 min), reversible, temperature-independent phase of surface adsorption that was followed by a slower (t1/2 greater than 20 min) period of binding that was irreversible and temperature-dependent. The interactions between 3H-LPS and monocytes that we measured were dependent both on the concentration of LPS and the cell number. We observed an apparent decrease in 3H-LPS surface binding after initial treatment of the cells with LPS, which was most likely due to an acquired reduction in the number of sites on the monocyte membrane available for the binding of LPS. Estimates of the parameters of the binding of 3H-LPS were calculated from a double-reciprocal plot (1/bound vs. 1/free) of the surface binding data and suggest that the relative binding affinity (Kd) for 3H-LPS was unchanged after pretreatment of the monocytes with LPS; however, the total number of LPS binding sites appeared to be reduced by this manipulation. The results of competition binding experiments also suggest that the binding affinity for 3H-LPS was the same before and after incubation of the cells with LPS. Lipid A, which we extracted from LPS and labeled with chromium-51, exhibited a binding affinity similar to that of 3H-LPS and, like 3H-LPS, could be displaced from the cells by competing concentrations of unfractionated LPS; however, the kinetics of binding of the two labeled ligands differed considerably. Our results suggest that exposure of monocytes to LPS may alter the ability of these cells to interact with, and consequently respond to, LPS.

Lack of interaction between cimetidine and carbamazepine

In order to investigate a possible interaction between cimetidine and carbamazepine (CBZ) 7 otherwise healthy epileptic patients on a long-term monotherapy with CBZ were given cimetidine (1 g daily) for 7 days. No significant alterations in steady-state plasma concentration of CBZ and the 10,11-epoxide metabolite (CBZ-E) were demonstrated.

Unchanged biochemical indices of bone turnover despite fluctuations in 1,25-dihydroxyvitamin D during the menstrual cycle

To examine the effect of endogenous oestrogens on calcium metabolism during the menstrual cycle, fasting blood and urinary samples were obtained every day throughout the menstrual cycle in 5 young women. Bone turnover was estimated by serum alkaline phosphatase and fasting urinary excretions of hydroxyproline and calcium. Serum levels of oestradiol (E2), oestrone (E1), and androstenedione (A) showed the well known cyclic fluctuations, the serum 1,25-dihydroxyvitamin D (1,25(OH)2D) nearly doubled from the early follicular phase to the time of ovulation, although 25-hydroxyvitamin D (25OHD) and 24,25-dihydroxyvitamin D (24,25(OH)2D) were almost unchanged. No correlation between the rise in the serum 1,25(OH)2D level and the measured parameters of calcium metabolism was observed. In view of these findings, the 1,25(OH)2D3 serum concentration measured in women with functioning ovaries can only be interpreted in the context of the menstrual cycle. The published normal range in women for the metabolite may also require reinterpretation.

Pharmacokinetics of cimetidine in patients undergoing hemodialysis

In order to establish improved guidelines for dosage adjustments of cimetidine before and during hemodialysis, the kinetics of this drug was investigated in 7 uremic patients undergoing regular hemodialysis. The absorption fraction was found to be 0.75 (range 0.61-0.86), the terminal half-life in plasma between 138 and 238 min, the total body clearance (Cltotal) between 178 and 337 ml/min, and the apparent volume of distribution about 1 l/kg. During hemodialysis no excess amounts of cimetidine were removed from serum. In 3 patients a weak rebound phenomenon was seen after hemodialysis. Based on the Cltotal obtained in this study, dosage schemes producing a 24-hours mean steady state concentration from 0.60 (2.38) to 1.20 (4.76) mg/l (mumol/l) are suggested.

Protection of opiate receptors in NG108-15 against modification by N-ethylmaleimide

Two different -SH groups associated with the opiate receptors of the mouse neuroblastoma X rat glioma hybrid NG108-15 have been identified. Modification of these by N-ethylmaleimide (NEM) (presumed to be via alkylation) or by para-chloromercuribenzoic acid (presumed to be via formation of mercury adducts) decreases the binding of both opiate agonists and antagonists to these receptors. Agonist binding is more sensitive than antagonist binding to modification by NEM. Losses in antagonist binding are accounted for totally by decreases in the number of binding sites; there are no corresponding losses in antagonist affinity. Losses of antagonist binding exhibit a pseudo-first order rate constant; the modification of only one such group completely destroys the binding site. Both agonists and antagonists protect against modification of this group by NEM. Sodium and lithium, but not GTP, also protect this group, indicating that the action of these monovalent cations is directly on the receptor moiety. Losses in agonist binding stem not only from decreases in receptor number but also from selective losses in affinity. This -SH group appears to be different from the one at the binding site as sodium, GTP, and antagonist ligands do not protect against losses in agonist affinity. Agonist high affinity also is lost in a pseudo-first order fashion indicating that an alteration of only one -SH group per receptor complex is sufficient to produce this effect. The possible roles of two sulfhydryls in opiate receptor function are discussed.

Pathophysiological mechanisms of estrogen effect on bone metabolism. Dose-response relationships in early postmenopausal women

Dose-response relationships of estrogen (E) on indices of calcium balance and bone activity were studied in normal early postmenopausal women. Calcium balance was estimated by changes in forearm bone mineral content, measured by photon absorptiometry. Bone activity was estimated by serum alkaline phosphatases (S-aPh), indicating bone formation, and by fasting urinary excretion of hydroxyproline (U-HyPro) and calcium (U-Ca), indicating bone resorption. A total of 92 female volunteers were randomized to 12 months' treatment with placebo or one of three different doses (high, medium, or low) of natural estrogens (17 beta-estradiol and estriol, 4/2, 2/1, and 1/0.5 mg, respectively), sequentially combined with the same dose (1 mg) of norethisterone acetate for 10 of the 28 cycle days. The trial was completed by 79 women. Bone mineral content declined by 2% (P less than 0.001) in the placebo group, remained constant in the low hormone group and increased by 0.8% (P less than 0.05) and 1.5% (P less than 0.01), respectively, in the medium and high hormone groups. S-aPh decreased gradually and equally by 20-25% in the three hormone groups and U-HyPro and U-Ca decreased by 30-40% during 1-yr hormone treatment, irrespective of dose. The decrease in these three indices occurred practically without exceptions. Compared to the values found in 48 normal premenopausal women the untreated postmenopausal women had increased values of S-aPh (P less than 0.001), U-HyPro (P less than 0.01), and U-Ca (P less than 0.001), and no pretreatment values were below the normal premenopausal range. After treatment the mean values of S-aPh and U-HyPro were slightly lower than the premenopausal mean values (P less than 0.01). These data strongly support the major importance of E deficiency for early postmenopausal bone loss, which is prevented by even a small substitution dose of E.

Measurement of goal attainment in clinical and health care programs

Goal attainment scaling (GAS) is a method of measurement that attempts to tailor measures to the relevant and often unique characteristics of an event, individual, program, or organization. The general approach is common in industry, management, service delivery, and most forms of contractual arrangements or agreements. GAS has quantification characteristics that make it useful in a variety of research and management areas, and it is popularly used as a clinical and educational facilitator. This article describes the method within a recent historical context, relating the method to current thinking and problems in evaluation, and attempts to make the method accessible to potential users. Special emphasis is placed on the use of analyses that assess readiness to change or adopt new practices.

Dose-response relationships of perphenazine in the treatment of acute psychoses

A group of 26 acute psychotic patients received continuous oral treatment with perphenazine for a period of 5 weeks. Once-weekly blood samples were drawn for measurements of perphenazine levels and, simultaneously, the therapeutic outcome was registered. Another 26 acute psychotic patients received continuous oral treatment with perphenazine for a period of up to 4 weeks. A single blood sample was drawn and the perphenazine concentration was related to the appearance of extrapyramidal side effects. The following conclusions were made: (1) a high risk of provoking extrapyramidal side effects was associated with plasma levels of perphenazine above 3 nmol/l; (2) plasma levels below 2 nmol/l were associated with a poor therapeutic outcome; (3) a 'therapeutic window' between 2 and 3 nmol/l gives maximal therapeutic effect with a low risk of provoking extrapyramidal side effects.

Preparation and application of a photoreactive thrombin analogue: binding to human platelets

alpha-Thrombin has previously been shown to bind to specific, saturable glycoproteins on the platelet surface. Modification of the thrombin active site with tosyllysyl chloromethyl ketone (TosLysCH2Cl) does not alter thrombin's binding characteristics. Interaction of alpha-thrombin with high-affinity binding sites (KD = 10(-9) M) initiates the platelet response which involves proteolytic hydrolysis of this glycoprotein. Although TosLysCH2Cl--thrombin binds to and competes for the same sites as alpha-thrombin, it cannot induce platelet stimulation because it is enzymatically inactive. In this study, we describe the preparation and application of photoreactive tritium-labeled thrombin analogues. The alpha-thrombin derivative retains its platelet-stimulating and enzymatic activities and, upon photoactivation, covalently binds to specific platelet membrane components. When freshly washed human platelets are exposed to less than saturation doses (less than or equal to 2 nM) of the thrombin derivatives in the dark and photoactivated, a single labeled complex is detected. The same experiment with greater than saturating doses (greater than or equal to 20 nM) of the thrombin derivative yields a similar complex as well as two additional ones. Molecular weight estimates of these thrombin-bound complexes were obtained by gel filtration and NaDodSO4--polyacrylamide gel electrophoresis. The low dose (high affinity) complex with TosLysCH2Cl--thrombin has an approximate molecular weight of 200 000, while that with active alpha-thrombin is smaller, approximately 120 000, due to enzymatic cleavage. The additional complexes detected with the high thrombin dose had estimated molecular weights of 400 000 and 46 000, respectively, and appeared to be the same for TosLysCH2Cl--thrombin and for the alpha-thrombin coupled platelets. These isolated complexes appear to correspond to the two previously detected populations of thrombin binding sites on the platelet.

Saliva secretion following long-term antidepressant treatment with nortriptyline controlled by plasma levels

Eight patients undergoing antidepressant therapy with nortriptyline for 1--4 years were investigated. The period of the investigation was 7 weeks and included a 2-week placebo period, blind for the patients. Total saliva secretion measurement, the nortriptyline plasma level, and signs and symptoms of depression and side effects were obtained once a week during the study. The results of the investigation were: (1) long-term treatment with nortriptyline is followed by hyposecretion or xerostomia, (2) the reduction of the secretion is reversible, (3) re-establishment of treatment with dosage leading to the same serum level of nortriptyline is immediately followed by a drop in saliva secretion, and (4) the changes in salivary secretion are useful as an indicator of side effects. The practical importance of the investigation is discussed.

Cimetidine clearance and bioavailability in hepatic cirrhosis

Nine patients with compensated alcoholic and nonalcoholic cirrhosis of the liver and 11 patients with peptic ulcer received 200 mg of cimetidine orally and intravenously. No differences were observed in cimetidine clearance between the group with peptic ulcer (556 +/- 44 ml/min, mean +/- SEM) and the group with cirrhosis (606 +/- 64 ml/min). The bioavailability of cimetidine was unchanged (84 +/- 4% and 97 +/- 7%). In the patients with cirrhosis, cimetidine clearance did not correlate with galactose elimination capacity or antipyrine clearance. Cimetidine clearance was related to creatinine clearance only when both groups were considered. A reduction of cimetidine dose in patients with compensated cirrhosis appears unwarranted.

Plasma levels of perphenazine (Trilafon) related to development of extrapyramidal side effects

Thirteen acute psychotic patients received continuous oral treatment with perphenazine for a period of 8 weeks. Blood samples for quantification of perphenazine, perphenazine sulphoxide and prolactin were drawn twice weekly. Simultaneously, the therapeutic outcome and the degree of extrapyramidal side effects were recorded. The following conclusions were made: 1. In accordance with results achieved in one of our earlier investigations, a high risk of provoking extrapyramidal side effects was associated with plasma levels of perphenazine exceeding about 3 nmol/l. 2. An excellent therapeutic outcome was associated with plasma concentrations of perphenazine above 1.5 nmol/l. 3. Plasma concentrations of perphenazine and prolactin were poorly correlated to each other (R = 0.49). 4. A significant correlation (R = 0.85) was shown between the scores for the Brief Psychiatric Rating Scale and the Comprehensive Psychopathological Rating Scale.

Factors influencing nortriptyline steady-state kinetics: plasma and saliva levels

Proportionality between dose and steady-state nortriptyline (NT) plasma levels was found both during initial treatment and after long-term treatment (years) within the NT Plasma level range of 20 to 296 ng/ml. There were day-to-day variations of 10% to 20% (coefficient of variation) but no systematic changes in plasma levels over time. A significant age variation in NT plasma levels was found in 116 patients. Patients over 70 yr of age (n = 23) had higher levels than other age groups (p < 0.001) dose corrected; p < 0.0001 dose and weight corrected). It was found that during episodes of acute inflammatory diseases NT steady-state plasma levels rose after a change in sedimentation rate. Our data show that the use of saliva rather than plasma in therapeutic drug level monitoring of NT cannot be recommended because the saliva/plasma ratio varied both intra- and interindividually by factors of from 2 to 4.