Anabolic and catabolic function of chondrocyte ex vivo is reflected by the metabolic processing of type II collagen

OBJECTIVE

The aim of the present study was to investigate collagen metabolism after anabolic and catabolic stimulation of chondrocytes ex vivo.

DESIGN

Metabolic activities in ex vivo bovine cartilage explants were stimulated with insulin-like growth factor I (IGF-I) or a combination of tumor necrosis factor alpha (TNFalpha) and oncostatin M (OSM). Supernatants were assessed for changes in biochemical markers, N-terminal propeptide of type II (PIINP) collagen and fragments of C-telopeptide of type II collagen (CTX-II). Matrix metalloproteinases (MMP) were added to metabolic inactivated cartilage and evaluated by the two biochemical markers for formation or degradation, respectively. Finally, urinary CTX-II and PIINP were evaluated for assessment of type II collagen turnover in patients with rheumatoid arthritis (RA).

RESULTS

In the bovine articular cartilage explants, IGF-I induced an increase in PIINP level up to 4.8+/-1.1[ng/ml]/mg cartilage whereas CTX-II remained below 0.1+/-0.1[ng/ml]/mg cartilage. In the catabolic stimulated explants both PIINP and CTX-II were released to the supernatant, reaching concentrations of 9.0+/-1.4 and 9.1+/-2.2[ng/ml]/mg cartilage, respectively. RA patients had significantly lower serum concentrations of PIINP (3.4+/-3.7 ng/ml) compared with those healthy individuals (18.7+/-12.41 ng/ml, P<0.001). In contrast, RA patients had significantly higher urinary CTX-II (0.8+/-0.8 mg/mmol) compared to the healthy controls (0.1+/-0.08 mg/mmol, P=0.004).

CONCLUSIONS

This study is the first to demonstrate that precursors and degradation products of type II collagen released into the supernatant can effectively reflect the anabolic and catabolic activities of stimulated cartilage explants.

PET evaluation of the uptake of N-[11C]methyl CP-643,051, an NK1 receptor antagonist, in the living porcine brain

Antagonists of neurokinin receptors such as CP-643,051 are presently under investigation as potential antidepressants, but little is known about the brain uptake and distribution of these agents. We developed a method for the efficient N-[11C]methylation of CP-122,721, yielding the NK1 antagonist N-[11C]methyl CP-643,051. The brain uptake and distribution of N-[11C]methyl CP-643,051 were studied by positron emission tomography (PET) in the anaesthetized pig, first in a baseline condition, and again after displacement of specific binding with the NK1 receptor antagonist L-732,138 (0.6 mg/kg, i.v.). In order to validate this displacement procedure, we tested the effects of L-732,138 on cerebral blood flow (CBF) in one pig. We found that N-[11C]methyl CP-643,051 had a distribution volume close to 3 ml g(-1), and a binding potential (pB) of 0.3 in the pig striatum; this binding was displaceable by the L-732,138 pre-treatment, which evoked a small (10-20%) global increase in CBF. We conclude that of N-[11C]methyl CP-643,051 may serve as a lead structure for the development of PET NK-1 ligands of higher specific binding in vivo.

A volumetric screening procedure for the Göttingen minipig brain

A screening procedure was developed to provide quantitative estimates of structural parameters, regional volumes and neuron number, in a neurotoxicologic study of the Göttingen minipig brain. The study material consisted of normal controls and brains collected from young minipigs which had been exposed in utero to the mitotic inhibitor methylazoxymethanol acetate (MAM). Based on stereological principles and systematic sampling techniques, volumetric data from pre-selected regions of the pig brain was obtained using Cavalieri's principles and point-counting. Secondarily, estimates of total hemispheric neocortical cell numbers were obtained from pre-selected groups to test the potential effect of MAM on neuron number. No significant differences were observed in volume of the pre-selected regions of MAM intoxicated pigs nor in estimates of total neocortical neuron number.

The Göttingen minipig as a model for postprandial hyperlipidaemia in man: experimental observations

Postprandial hyperlipidaemia is believed to be atherogenic. This study aimed to establish a minipig model to investigate determinants of postprandial lipid metabolism. In a randomized cross-over design seven minipigs were subjected to six different feeding regimens: intragastric fat loads of 1, 2, and 4 g fat (Intralipid, 20%) kg(-1) in two fractions 1.5 h apart (1/3 first, 2/3 second), 2 g fat (Intralipid kg(-1) in one fraction, and 2 g olive oil kg(-1) in two fractions, all after pre-feeding with standard diet, and finally 2 g fat (Intralipid kg(-1) in two fractions without pre-feeding. Blood was sampled before and hourly for 7 h after gavaging, and plasma triglycerides were measured. Triglycerides increased significantly in all the feeding regimens (P < 0.001), except when olive oil was used as the fat source. A borderline significant dose-response effect of the Intralipid dose on the triglyceride response was observed. We found no significant differences in triglyceride response whether 2 g fat (Intralipid kg(-1) was given in one or two fractions, with or without pre-feeding. We conclude that postprandial hyperlipidaemia in minipigs can be induced by gavaging an emulgated lipid solution (1-4 g fat/kg, Intralipid, while olive oil is not applicable. There is no need to administer the fat fractionated or to withhold food prior to administration.

Characterization of mixtures of recombinant human cytochrome p450s as a screening model for metabolic stability in drug discovery

1. Recombinant human cytochrome p450 (rhCYP) has become an important screening model in drug metabolism studies due to the high cost of human and animal hepatic tissue. Until now, rhCYPs have been evaluated and used as separate forms, but a mixture of CYP forms comparable with the human liver could be of value in early drug discovery. 2. In the present study, rhCYP2C9, rhCYP2D6 and rhCYP3A4 co-expressed with reductase in Escerichia coli were mixed and evaluated with regards to kinetic properties (K(m) and V(max)). Furthermore, antioxidant was added to investigate whether a free radical scavenger would affect the kinetic parameters. Results were compared with data obtained in human liver microsomes (HLM). 3. Results showed a good correlation between mixed rh CYP data and HLM data for K(m) and V(max). K(m) varied < 3-fold between matrices for CYP2C9 and CYP3A4, whereas the K(m) for CYP2D6 varied up to 4.5-fold. V(max) differed up to 3-fold between matrices for the CYP forms investigated. However, the discrepancy in V(max) may depend on the anticipated level of each form in HLM. The addition of antioxidant increased V(max) for CYP2C9 and CYP2D6 by 75 and 50%, respectively, whereas V(max) for CYP3A4 was unchanged. 4. In conclusion, the rhCYP mixture shows promising results as a predictor of CYP kinetic parameters. Furthermore, addition of antioxidant can in certain cases increase catalytic activity.

Symptomatology of cancer patients in palliative care: content validation of self-assessment questionnaires against medical records

To elucidate which symptoms or problems to measure when evaluating palliative care, we assessed the content validity of selected patient self-assessment questionnaires used to evaluate palliative care: the European Organization for Research and Treatment of Cancer-Quality of Life-Core 30 (EORTC QLQ-C30), the Edmonton Symptom Assessment System (ESAS), the Palliative Care Outcome Scale (POS), the McGill Quality of Life Questionnaire (MQOL) and the Memorial Symptom Assessment Scale (MSAS). The content of the questionnaires was compared against the symptoms and problems noted in the medical records of 171 consecutive cancer patients on their first admission to a department of palliative medicine. From the records, 63 different symptoms were listed. Two questionnaires covered almost all of the prevalent symptoms/problems: the EORTC QLQ-C30 covered 10 and the MSAS 11 of the 12 most frequent problems. Researchers selecting instruments for evaluating palliative care may use the present study and other reviews to examine to what degree a given selection of instruments cover the symptoms/problems targeted by palliative care physicians.

Early postoperative erythromycin breath test correlates with hepatic cytochrome P4503A activity in liver transplant recipients

BACKGROUND

Interindividual variation in the pharmacokinetics of the immunosuppressive agents cyclosporine (INN, ciclosporin) and tacrolimus may result from differences in the activity of cytochrome P4503A (CYP3A). The erythromycin breath test is an in vivo assay of hepatic CYP3A activity, but the method has never been directly validated. The aim of the study was to investigate whether an early postoperative erythromycin breath test correlated with the hepatic CYP3A protein level and catalytic activity in liver transplant recipients.

METHODS

In 18 liver transplant recipients, the erythromycin breath test was performed within 2 hours after transplantation. A graft biopsy was obtained during surgery and analyzed for the CYP3A protein level by Western blotting and for CYP3A activity with erythromycin demethylation and testosterone 6beta- hydroxylation assays.

RESULTS

The erythromycin breath test values ranged from 0.14% to 1.65% of carbon 14 per hour, and the CYP3A protein level ranged from 732 to 7822 as measured by optical density. The in vitro catalytic activity determined by the erythromycin demethylation assay ranged from 94 to 902 disintegrations per minute per 5 minutes per milligram of protein, and the activity determined by testosterone 6beta-hydroxylation ranged from 0.030 to 0.627 nmol per minute per milligram of protein. Significant correlation was demonstrated between the erythromycin breath test and both the erythromycin demethylation (Spearman correlation coefficient: R = 0.76, R (2) = 0.57; P =.0004) and the testosterone 6beta-hydroxylation (Spearman correlation coefficient: R = 0.79, R (2) = 0.63; P =.0001) assays. The erythromycin breath test also correlated with the CYP3A protein level (Spearman correlation coefficient: R = 0.60, R (2) = 0.36; P =.01).

CONCLUSION

Our data support the erythromycin breath test as a specific in vivo assay of CYP3A activity in humans. The test is applicable in liver transplant recipients in the early postoperative phase. Future studies should evaluate the clinical usefulness of an early postoperative erythromycin breath test as a predictor of cyclosporine-tacrolimus pharmacokinetics in liver transplantation.

[Therapeutic results in chronic, non-malignant pain in patients treated at a Danish multidisciplinary pain center compared with general practice. A randomized controlled clinical trial]

INTRODUCTION

Multidisciplinary pain treatment (MPT) is generally considered to be the most effective treatment of chronic pain, but its long-term effect has not yet been firmly established.

METHODS

This randomised controlled study compared the effect of outpatient MPT with that of treatment by general practitioners after initial supervision by a pain specialist (GP group) and with a six-month waiting list group (WL group). The participants were 189 patients with chronic non-malignant pain. On referral and at three and six months, the patients filled in questionnaires evaluating pain intensity, health-related quality of life (HRQL), and the use of analgesics.

RESULTS

At six months, the patients allocated to MPT (N = 63) reported a reduction in pain intensity (p < 0.001), and an improvement in psychological well-being (p < 0.001), quality of sleep (p < 0.05), and physical functioning (p < 0.05). The WL group (N = 63) had a statistically significant deterioration in most of the HRQL measures. The only effect of treatment found in the GP group was a reduction in the use of short-acting opioids. In the MPT group, the use of opioids administered on demand and short-acting opioids was decreased (p < 0.001). No change in the use of analgesics was seen in the WL group.

DISCUSSION

The study showed that (i) in the MPT group there was a significant reduction in pain intensity and an improvement in HRQL compared to the WL group, and (ii) the mere establishment of a pain diagnosis and management plan by a specialist was not sufficient to enable the referring GP to manage patients with severe chronic pain.

Highly efficient base excision repair (BER) in human and rat male germ cells

The quality of germ cell DNA is critical for the fate of the offspring, yet there is limited knowledge of the DNA repair capabilities of such cells. One of the main DNA repair pathways is base excision repair (BER) which is initiated by DNA glycosylases that excise damaged bases, followed by incision of the generated abasic (AP) sites. We have studied human and rat methylpurine-DNA glycosylase (MPG), uracil-DNA glycosylase (UNG), and the major AP endonuclease (HAP1/APEX) in male germ cells. Enzymatic activities and western analyses indicate that these enzymes are present in human and rat male germ cells in amounts that are at least as high as in somatic cells. Minor differences were observed between different cellular stages of rat spermatogenesis and spermiogenesis. Repair of methylated DNA was also studied at the cellular level using the Comet assay. The repair was highly efficient in both human and rat male germ cells, in primary spermatocytes as well as round spermatids, compared to rat mononuclear blood cells or hepatocytes. This efficient BER removes frequently occurring DNA lesions that arise spontaneously or via environmental agents, thereby minimising the number of potential mutations transferred to the next generation.

Nucleotide excision repair in rat male germ cells: low level of repair in intact cells contrasts with high dual incision activity in vitro

The acquisition of genotoxin-induced mutations in the mammalian germline is detrimental to the stable transfer of genomic information. In somatic cells, nucleotide excision repair (NER) is a major pathway to counteract the mutagenic effects of DNA damage. Two NER subpathways have been identified, global genome repair (GGR) and transcription-coupled repair (TCR). In contrast to somatic cells, little is known regarding the expression of these pathways in germ cells. To address this basic question, we have studied NER in rat spermatogenic cells in crude cell suspension, in enriched cell stages and within seminiferous tubules after exposure to UV or N-acetoxy-2-acetylaminofluorene. Surprisingly, repair in spermatogenic cells was inefficient in the genome overall and in transcriptionally active genes indicating non-functional GGR and TCR. In contrast, extracts from early/mid pachytene cells displayed dual incision activity in vitro as high as extracts from somatic cells, demonstrating that the proteins involved in incision are present and functional in premeiotic cells. However, incision activities of extracts from diplotene cells and round spermatids were low, indicating a stage-dependent expression of incision activity. We hypothesize that sequestering of NER proteins by mispaired regions in DNA involved in synapsis and recombination may underlie the lack of NER activity in premeiotic cells.

Effect of pre-analytical handling on haematological variables in minipigs

Pre-analytical handling may be an important determinant of haematological variables, if analysis is delayed. We investigated the effect of anticoagulants, i.e. tripotassium ethylenediamine-tetraacetic acid (EDTA) and citric acid, theophylline, adenosine, dipyridamole (CTAD), storage time (0.5, 1.5, 3.5, 5.5, 7.5, 25.5 and 27.5 h after blood sampling), and storage temperature (5 degrees C and 20 degrees C) on the variation in haemoglobin (HGB), red blood cell count (RBC), haematocrit (HCT), white blood cell count (WBC), and platelet count (PLT) in minipigs. Medians of HGB, RBC, HCT, WBC and PLT were significantly higher in EDTA tubes than in CTAD tubes due to the dilution effect of the anticoagulant. We found a minor significant increase in HCT after 25.5 h in blood stored at 20 degrees C, and at the same time a minor significant increase in WBC in EDTA tubes stored at 20 degrees C. We found a significant decrease in PLT in blood stored at 5 degrees C, especially in EDTA tubes. Minor variations were also observed in HGB and RBC. Our results indicate that PLT should only be measured in tubes placed at room temperature. If HCT or WBC analyses are to be performed on the day after blood sampling, the samples must be stored in a refrigerator until analysis. Our studies underline that time delay before analysis of haematological variables can cause increased variation, and should therefore be limited as far as possible in order to reduce the number of animals needed to make reliable conclusions.

Does the medical record cover the symptoms experienced by cancer patients receiving palliative care? A comparison of the record and patient self-rating

The aim of this study was to investigate the extent to which the symptoms experienced by advanced cancer patients were covered by the medical records. Fifty-eight patients participated in the study. On the day of first encounter with our palliative care department, a medical history was taken, and on this or the following day, the patients completed the EORTC Quality of Life Questionnaire (EORTC QLQ-C30), Edmonton Symptom Assessment System (ESAS), and Hospital Anxiety and Depression Scale (HADS). The symptomatology reported in the patient-completed questionnaires was compared with the symptomatology mentioned by the physician in the medical record. The analysis revealed good concordance concerning pain, but most other symptoms or problems were reported much more often by patients than by their doctors. Reasons for these discrepancies are discussed. It is suggested that the doctor's knowledge of the patient's symptomatology might gain from more systematic screening and transfer of information from patient self-assessment questionnaires to the medical records.

A high-fat meal does not activate blood coagulation factor VII in minipigs

It is a matter of debate whether postprandial activation of blood coagulation factor VII (FVII) is associated with an increased risk of thrombosis. To clarify this question, an animal model in which consequences of dietary FVII activation can be studied in a more detailed way would be an important tool. We studied postprandial FVII activation in seven non-fasting Göttingen minipigs. Intralipid (4 g/kg) was administered through a gastric tube in two fractions at 9.00 a.m. (one-third of total dose) and 10.30 a.m. (two-thirds of total dose). Blood samples were drawn 0.5 h before (baseline) and 2, 3, 3.5, 4, 5, and 6 h after the first fat load. Triglycerides, activated FVII (FVIIa), FVII coagulant activity (FVIIc), FVII amidolytic activity (FVIIam) and prothrombin fragment I + 2 (F1 + 2) were analysed in plasma samples. Median plasma triglycerides were significantly raised from 0.67 mmol/l (baseline) to 2.56 mmol/l 5 h postprandially (P < 0.001). There were no significant changes in FVIIa (9.6 U/l at baseline), FVIIam (142% at baseline) and F1 + 2 (0.13 nmol/l at baseline). FVIIc decreased from 141% at baseline to 114% 6 h postprandially (P < 0.001). As a high-fat meal does not seem to activate blood coagulation FVII in minipigs, the pig is apparently not a relevant model for the study of dietary FVII activation and thrombin generation.

[Intraoperative ultrasonography in laparoscopic cholecystectomy]

BACKGROUND

Laparoscopic ultrasonography has been increasingly used over the last several years as a new imaging modality. This study assessed the effectiveness of laparoscopic ultrasonography in detecting main biliary duct stones during laparoscopic cholecystectomy.

MATERIAL AND METHODS

During the eight-year period 1991-98, 441 patients treated by laparoscopic cholecystectomy were at the same time included in laparoscopic ultrasonography. After port placement and dissection of the gallbladder, laparoscopic ultrasonography of the extrahepatic common bile duct was performed in the longitudinal plane.

RESULTS

Laparoscopic ultrasonography failed to recognise the intrapancreatic part of the common bile duct in 64 cases (14%). The time used for sonography was approximately eight minutes. In this study, common bile duct stones were found in 29 cases (7%). One false negative result was recognised.

INTERPRETATION

Laparoscopic ultrasonography is a safe, repeatable, noninvasive and cost-effective procedure, but a considerable learning curve is necessary in order to optimise its efficacy. Once learned, however, the method can be used as a primary screening procedure for bile duct calculi.

Neuropsychological performance in cancer patients: the role of oral opioids, pain and performance status

The aim of the present study was to evaluate the possible influence of oral opioids, pain and performance status on some aspects of psychomotor function and cognition in cancer patients. One hundred and thirty cancer patients between 40 and 76 years of age were consecutively included in the study. In order to separate the impact of performance status, pain and oral opioids on neuropsychological functioning the patients were allocated in a cross-sectional design to five different groups. Group 1 (N=40), which was considered the control group, was characterized by being in Karnofsky Performance Status (KPS) A ('Able to carry on normal activity and work. No special care is needed'), had no pain and received no oral opioid medication. Group 2 (N=19) was characterized by being in KPS B ('Unable to work. Able to live at home and care for most personal needs. A varying degree of assistance is needed'), had no pain and received no oral opioid medication. Group 3 (N=19) was characterized by being in KPS B, had pain, but received no oral opioid medication. Group 4a (N=31) was characterized by being in KPS B, had pain and received stable doses of oral opioids. Group 4b (N=21) was characterized by being in KPS B, had no pain and received stable doses of opioids. Assessments comprised pain intensity, sedation, opioid doses, time from ingestion of last opioid dose to testing and opioid side effects. The neuropsychological tests used were continuous reaction time (CRT), finger tapping test (FTT) and paced auditory serial addition task (PASAT). Regarding the neuropsychological tests group 1 was compared with each of the other groups and respecting the hierarchy of increasing numbers of stigmatizing factors group 1 was compared with group 2, group 2 with group 3 and so forth. Concerning CRT, group 1 performed statistically significantly faster than groups 2, 4a and 4b. Concerning FTT, group 1 performed statistically significantly faster than groups 3 and 4a. Concerning PASAT, groups 1 and 4b performed statistically significantly better than group 4a. Furthermore, the pain-relieved groups 2 and 4b performed statistically significantly better in PASAT than the pain-suffering groups 3 and 4a. We conclude that in cancer patients the impact of stigmatizing factors (oral opioids, pain and reduced performance status) seems to impair some important aspects of neuropsychological performance, but more specifically our results indicate that (1) the use of long-term oral opioid treatment in cancer patients per se did not affect any of the neuropsychological tests used in the present study, (2) cancer patients being in KPS B had statistically significantly slower CRT than patients being in KPS A and (3) pain itself may deteriorate the performance of PASAT more than oral opioid treatment.

Impaired neuropsychological performance in chronic nonmalignant pain patients receiving long-term oral opioid therapy

The study investigated neuropsychological performance in chronic nonmalignant pain patients receiving long-term oral opioid therapy. Forty patients treated solely with regular and stable doses of an oral opioid were compared with 40 healthy volunteers. The patients received daily opioid doses of 15-300 mg of oral morphine (median: 60 mg) or equianalgesic doses of other opioids. The neuropsychological tests consisted of continuous reaction time (CRT), which measured vigilance/attention; finger tapping test (FTT), which measured psychomotor speed; and paced auditory serial addition task (PASAT), which measured working memory. Three months after the study had been carried out, 14 of the controls were retested in order to determine the reliability of the three tests. The patients performed statistically significantly poorer than the controls in all the tests. Significantly positive correlations were found between the PASAT and pain visual analogue scales (VAS). In the retesting of 14 controls, it was found that the tests showed high reliability. Vigilance/attention, psychomotor speed, and working memory were significantly impaired in chronic nonmalignant pain patients. The present study cannot determine which factors influenced the test results, but pain itself seemed to have an arousal effect on working memory.

Treatment outcome of chronic non-malignant pain patients managed in a danish multidisciplinary pain centre compared to general practice: a randomised controlled trial

This randomised controlled study investigated the effect of outpatient multidisciplinary pain centre treatment (MPT) compared with treatment by a general practitioner after initial supervision by a pain specialist (GP-group) and with a group of patients waiting for 6 months before treatment was initiated (WL-group). One-hundred-and-eighty-nine chronic non-malignant pain patients were studied. At referral, and after 3 and 6 months patients filled in questionnaires evaluating pain intensity, health related quality of life (HRQL) and use of analgesics. HRQL was evaluated using the Medical Outcome Study-Short Form (SF-36), the Hospital Anxiety and Depression scale (HAD) and the Psychological General Well-being Scale (PGWB). After 6 months patients allocated to MPT (n=63) reported statistically significant reduction in pain intensity (VAS-score, P<0.001), improvement in psychological well-being (PGWB, P<0.001), quality of sleep (P<0.05) and physical functioning (SF-36-Phycical Functioning, P<0.05). No improvements were seen in the GP-group (n=63). In the WL-group (n=63) a statistically significant deterioration was observed in PGWB-scores, HAD-scores and in 6 of 8 SF-36-subscores (P </= 0.05). A reduction in use of opioids administered on demand was obtained in the group receiving MPT (P<0.001). In the MPT- and GP-groups a decrease in the use of short acting opioids was observed (P<0.01). No change in use of analgesics was seen in the WL-group. The study showed that (i) in the MPT-group there was a significant reduction in pain intensity and improvement of HRQL compared to the WL-group, and (ii) the mere establishment of a pain diagnosis and a pain management plan by a pain specialist was not sufficient to enable the referring GP to manage severely chronic pain patients.

Laparoscopic ultrasound (LUS) in gastrointestinal surgery

Intraoperative ultrasonography during abdominal surgery became widespread by availability of high-frequency, high-resolution transducers. It's usefulness has particularly been proven in biliar and gastrointestinal surgery. Our objective was to examine the method in laparoscopic cholecystectomy and in laparoscopic staging of malignancies of the upper gastrointestinal tract as well. Lapaoscopic ultrasound (LUS) examination was performed in 567 patients operated on because of biliary stones and in 12 patients with carcinoma in the upper part of the gastrointestinal tract. In accordance to the known criteria endoscopic retrograde cholangiopancreatography (ERCP) was performed in 89 patients, and additionally, ERCP was performed in 58 patients because of dilated common bile duct. Choledochal stones were demonstrated in 72 of the 147 patients. Laparoscopic ultrasonography demonstrated preoperatively undetected bile duct stones in 18 of these patients (12%). In 294 other patients without any criteria of bile duct stones, laparoscopic ultrasonography demonstrated bile duct stones in 11 patients (4%). Laparoscopic ultrasonography in 12 patients with proximal gastrointestinal malignancies demonstrated inoperability in all of the patients. Laparotomy could thereby be avoided. LUS examination is an ideal operative tool as it is safe, reproducible and requires no special patient preparation or positioning. The method of imaging is therefore justified for patients undergoing laparoscopic surgery because of biliary stones and gastrointestinal surgery.

Oral glycopyrrolate alleviates drooling in a patient with tongue cancer

Although sialorrhea and drooling are uncommon symptoms in cancer patients, they can cause considerable discomfort, inconvenience and social embarrassment. In this article we describe a patient with tongue cancer who was successfully treated with oral glycopyrrolate 0.4 mg 3 times daily. Glycopyrrolate is a quaternary ammonium compound. In contrast to the recommended treatment with scopolamine, glycopyrrolate is virtually without side effects to the central nervous system because it penetrates the blood-brain barrier poorly. Glycopyrrolate has a slow and erratic absorption from the gastrointestinal system, but even low plasma levels are associated with a distinct and long-lasting antisialogic effect.

[Pain epidemiology and health-related quality of life in patients with chronic non-malignant pain]

This paper presents the results of a detailed study of the pain epidemiology and health related quality of life (HRQL) in 150 chronic non-malignant pain patients referred to a Danish multidisciplinary pain centre. Mean pain intensity was 71.6 (SD 18.5) on the VAS scale. HRQL was evaluated using the questionnaires: SF-36, HAD and PGWB. Compared with the normal population (NP) both physical, psychological and social well-being was severely reduced, and 58% were found to have a depressive or anxiety disorder. Sixty-three percent of the patients had neurogenic pain conditions. Of these, only 25% were treated with antidepressants or anticonvulsants. At referral 73% were treated with opioids. Mean opioid consumption was 64 mg of morphine per day. Patients had used the health care system five times more often than the NP (p < 0.001). The study showed that HRQL of chronic non-malignant pain patients is among the lowest observed for any medical condition.

Pig hepatocytes as an in vitro model to study the regulation of human CYP3A4: prediction of drug-drug interactions with 17 alpha-ethynylestradiol

The objective of this study was to provide evidence of the validity of pig hepatocytes as a model to study the regulation of human CYP3A4 with special emphasis on drug-drug interactions. Thirteen different drugs were incubated with primary monolayer cultures of pig hepatocytes (n = 4). The study included both drugs reported to cause drug interactions in the clinic with 17 alpha-ethynylestradiol (EE2), other drugs metabolized by CYP3A4, and drugs not reported to cause any problems. Effect of the drug exposure to pig hepatocytes was determined by immunodetection using a monoclonal human CYP3A4 antibody and measurement of 6 beta-hydroxylation of testosterone and 2-hydroxylation of 17 alpha-ethynylestradiol (EE2), both reactions known to be catalyzed by CYP3A4 in humans. Data were compared to data from human hepatocytes and to reported observations of drug-drug interactions in the clinic. The drugs known to be inducers of CYP3A4 in humans significantly increased a CYP isoform in pigs catalyzing 6 beta-hydroxylation of testosterone and 2-hydroxylation of EE2, whereas drugs not reported to have clinical interactions with EE2 had no or only marginal effect. Induction by the drugs known to be inducers of CYP3A4 increased with drug exposure time and the CYP3A4 activity, represented by testosterone 6 beta-hydroxylation, was highest at 72 h for the investigated induction periods (24, 48 and 72 h), except for dexamethasone where the effect peaked after 24 h. Induction of the 2-hydroxylation of EE2 correlated well with the increase in 6 beta-hydroxylation of testosterone (except for sulphinpyranzone) and the increase in the protein level of CYP3A detected by a monoclonal human CYP3A4 antibody, thus confirming the 2-hydroxylation of EE2 in pigs as being biotransformed by a CYP isoform presumably belonging to the CYP3A subfamily as in humans. In conclusion, these results indicate that pig hepatocytes may be a valuable model to mimic the regulation of human CYP3A4.

[Continuous subcutaneous infusion of opioids in cancer patients]

This review article describes pharmacokinetics, pharmaco-dynamics, side effects and the practical use of continuous subcutaneous infusion of opioids in cancer patients with pain. Clinical studies have shown that the analgesic effects of continuous subcutaneous infusion of morphine are comparable to continuous intravenous morphine, and that the treatment modality is associated with a low frequency of side-effects and complications. Continuous subcutaneous infusions of morphine are therefore recommended as the treatment of choice for cancer patients with pain, when oral analgesic treatment is no longer possible.

[Inhalation of levopromazine (Nozinan) in the treatment of status asthmaticus]

Levomepromazine reduces histamine-induced bronchial hyperresponsiveness in asthmatics without significant sedation. We present two patients with acute asthma refractory to conventional therapy, who were treated with inhalation of 2.5 mg levomepromazine. Until controlled studies have been done, we suggest that inhalation of levomepromazine be restricted to patients with asthma refractory to conventional therapy.

[Morphine-induced hyperalgesia, allodynia and myoclonus--new side-effects of morphine?]

During the last ten years hyperalgesia (H), allodynia (A) and myoclonia (M) has been reported at an increased frequency in human beings treated with morphine. The side effects are most common in cancer patients treated with high dose morphine, and has been reported for all routes of administration. The mechanisms are unknown, but human cases and experimental works have resulted in the following theories: 1) Morphine and morphine metabolites change the postsynaptic pain-transmission in dorsal horn neurones via non opioid-receptors (glycine and/or N-methyl-D-aspartate). 2) Morphine and morphine metabolites activate other opioid receptor populations. 3) Supplemental drugs in cancer management. 4) An abnormal metabolism of morphine or morphine metabolites. 5) A combination of one or more of the above-mentioned theories. The first mentioned theory is the most likely. The treatment of morphine induced H, A, and M seems to be to discontinue morphine administration and to initiate therapy with other opioids (fentanyl, sufentanyl, methadone or ketobemidone).

Topical levocabastine compared with orally administered terfenadine for the prophylaxis and treatment of seasonal rhinoconjunctivitis

BACKGROUND

This study was designed to compare the efficacy and tolerability of a new topical (nasal spray and eye drops) H1-receptor antagonist, levocabastine, with that of orally administered terfenadine for the prophylaxis and treatment of seasonal allergic rhinoconjunctivitis.

METHODS

A total of 115 patients with documented birch pollen allergy were enrolled in this randomized, double-blind, double-dummy, parallel-group trial. Treatment was initiated immediately before the birch pollen season started and continued for a total of 8 weeks. Xylometrazoline (Otrivin) nasal spray was permitted as rescue medication.

RESULTS

The investigator's evaluation of symptoms showed similar effects for levocabastine and terfenadine. Both the patients' and the investigator's global evaluations of ocular and nasal symptoms disclosed a somewhat higher percentage of good or excellent results for levocabastine, but the differences were not statistically significant. Visual analog scale ratings from the patients' diaries showed better results for levocabastine. Levocabastine was significantly more effective than terfenadine in relieving sneezing, rhinorrhea, lacrimation, itch, and burning sensation (p < 0.05). For some symptoms, levocabastine was significantly more effective than terfenadine on days when the pollen count was high. There were no statistically significant differences in the use of rescue medication or in the incidence of adverse reactions reported in each treatment group.

CONCLUSIONS

In the present study topical levocabastine was frequently more effective than orally administered terfenadine for the treatment of seasonal allergic rhinoconjunctivitis. Both drugs were well-tolerated.

A comparison of topical levocabastine and sodium cromoglycate in the treatment of pollen-provoked allergic conjunctivitis

A total of 71 patients with documented birch and grass pollen allergy participated in this randomized, double-blind, parallel-group study initiated to compare the long-term therapeutic efficacy of twice daily levocabastine, a new topical H1-receptor blocker, with that of sodium cromoglycate four times daily in the treatment of pollen-provoked conjunctivitis. There was no statistically significant difference in therapeutic efficacy between the two treatment groups, although a positive trend in favour of levocabastine was observed. Global evaluations of therapeutic efficacy were similar in both treatment groups. A total of 94% of levocabastine-treated patients rated treatment to be excellent or good compared with 86% of patients in the sodium cromoglycate group. Moreover, there were no significant differences in the severity of allergic symptoms reported on the patient diary cards. Patients were permitted to use rescue medication (oral terfenadine and betamethasone nasal spray) if symptoms became severe. The use of rescue medication was lower in the levocabastine group than in the sodium cromoglycate group. The mean number of days on which rescue medication was used was 12.8 and 26.9 in the two groups, respectively. The incidence, and type, of adverse reactions was similar in both patient groups. Levocabastine is well-tolerated and at least as effective as sodium cromoglycate in the treatment of pollen-provoked conjunctivitis.

Intraoperative ultrasonography and the detection of liver metastases in patients with colorectal cancer

A total of 213 patients with carcinoma of the colon and rectum were examined to detect liver metastases. The study compared preoperative ultrasonography and inspection and palpation of the liver during surgery with intraoperative ultrasonography. Preoperative ultrasonography, inspection and palpation identified 238 metastases in 42 patients. Intraoperative ultrasonography detected 116 previously unrecognized metastatic tumours during 40 surgical procedures (P less than 0.01). High resolution intraoperative ultrasonography is safe and more accurate than preoperative imaging and surgical exploratory methods. The examination is simple to perform and success appears to be related to careful attention to detail.

Severe toxic reaction to tinidazole

A physician aged 44 years participated as a volunteer in pharmacokinetic studies with tinidazole (FASIGYN, Pfizer). He received 1600 mg of the drug as an intravenous infusion over 80 min. Shortly afterwards, he fainted and was unconscious for about 10 s. The attack was followed by low blood pressure, nausea and tiredness for several h. The serum concentration of tinidazole was 35.4 mg/l when the attack started. Blood tests showed a normal immunoglobulin E level, and a transient fall in the concentration of complement factor C3 after the infusion. It is concluded that tinidazole caused an acute toxic reaction with subsequent activation of complement factors.