Prospective identification of variables as outcomes for treatment (PIVOT): study protocol for a randomised, placebo-controlled trial of hydroxyurea for Ghanaian children and adults with haemoglobin SC disease

BACKGROUND

Haemoglobin SC (HbSC) is a common form of sickle cell disease (SCD), especially among individuals of West African ancestry. Persons with HbSC disease suffer from the same clinical complications and reduced quality of life that affect those with sickle cell anaemia (HbSS/Sβ0). Retrospective anecdotal data suggest short-term safety and benefits of hydroxyurea for treating HbSC, yet rigorous prospective data are lacking regarding optimal dosing, clinical and laboratory effects, long-term safety and benefits, and appropriate endpoints to monitor. Prospective Investigation of Variables as Outcomes for Treatment (PIVOT) was designed with three aims: (1) to measure the toxicities of hydroxyurea treatment on laboratory parameters, (2) to assess the effects of hydroxyurea treatment on sickle-related clinical and laboratory parameters, and (3) to identify study endpoints suitable for a future definitive phase III trial of hydroxyurea treatment of HbSC disease.

METHODS

PIVOT is a randomised, placebo-controlled, double blind clinical trial of hydroxyurea. Approximately 120 children and 120 adults ages 5-50 years with HbSC disease will be enrolled, screened for 2 months, and then randomised 1:1 to once-daily oral hydroxyurea or placebo. Study treatment will be prescribed initially at 20 ± 5 mg/kg/day with an opportunity to escalate the dose twice over the first 6 months. After 12 months of blinded study treatment, all participants will be offered open-label hydroxyurea for up to 4 years. Safety outcomes include treatment-related cytopenias, whole blood viscosity, and adverse events. Efficacy outcomes include a variety of laboratory and clinical parameters over the first 12 months of randomised treatment, including changes in haemoglobin and fetal haemoglobin, intracranial arterial velocities measured by transcranial Doppler ultrasound, cerebral oxygenation using near infrared spectrometry, spleen volume and kidney size by ultrasound, proteinuria, and retinal imaging. Exploratory outcomes include functional erythrocyte analyses with ektacytometry for red blood cell deformability and point-of-sickling, patient-reported outcomes using the PROMIS questionnaire, and 6-min walk test.

DISCUSSION

For children and adults with HbSC disease, PIVOT will determine the safety of hydroxyurea and identify measurable changes in laboratory and clinical parameters, suitable for future prospective testing in a definitive multi-centre phase III clinical trial.

TRIAL REGISTRATION

PACTR, PACTR202108893981080. Registered 24 August 2021, https://pactr.samrc.ac.za.

Hydroxyurea with dose escalation for primary stroke risk reduction in children with sickle cell anaemia in Tanzania (SPHERE): an open-label, phase 2 trial

BACKGROUND

Transcranial Doppler screening with chronic transfusions reduces stroke risk in children with sickle cell anaemia but is not feasible in low-resource settings. Hydroxyurea is an alternative treatment to decrease stroke risk. We aimed to estimate stroke risk in children with sickle cell anaemia in Tanzania and to determine the efficacy of hydroxyurea to decrease and prevent stroke.

METHODS

We did an open-label, phase 2 trial (SPHERE) at Bugando Medical Centre, Mwanza, Tanzania. Children aged 2-16 years with a diagnosis of sickle cell anaemia confirmed by haemoglobin electrophoresis were eligible for enrolment. Participants had transcranial Doppler ultrasound screening by a local examiner. Participants with elevated Doppler velocities, either conditional (170-199 cm/s) or abnormal (≥200 cm/s), received oral hydroxyurea starting at 20 mg/kg once daily and escalated every 8 weeks by 5 mg/kg per day to the maximum tolerated dose. Participants with normal Doppler velocities (<170 cm/s) received usual care from the sickle cell anaemia clinic and were rescreened after 12 months to determine whether they qualified for treatment on trial. The primary endpoint was change in transcranial Doppler velocity from the baseline visit to after 12 months of hydroxyurea treatment, analysed in all patients who had paired baseline and follow-up measurements collected after 12 months of treatment. Safety was analysed in the per-protocol population (all participants who received study treatment). This study is registered with ClinicalTrials.gov, NCT03948867.

FINDINGS

Between April 24, 2019, and April 9, 2020, 202 children were enrolled and had transcranial Doppler screening. Sickle cell anaemia was confirmed by DNA-based testing in 196 participants (mean age 6·8 years [SD 3·5], 103 [53%] were female, and 93 [47%] were male). At the baseline screening, 47 (24%) of 196 participants had elevated transcranial Doppler velocities (43 [22%] conditional, four [2%] abnormal); 45 initiated hydroxyurea at a mean dose of 20·2 mg/kg per day (SD 1·4) with escalation to a mean dose of 27·4 mg/kg per day (5·1) after 12 months. Treatment response was analysed after 12 months (± 1 month; median 11 months, IQR 11-12) and 24 months (±3 months; median 22 months, 22-22). Transcranial Doppler velocities decreased to a mean of 149 cm/s (SD 27) compared with 182 cm/s (12) at baseline, which was significantly lower than baseline (p<0·0001), with an average decline of 35 cm/s (SD 23) after 12 months of treatment in 42 participants with paired results available at baseline and 12 months. No clinical strokes occurred, and 35 (83%) of 42 participants reverted to normal transcranial Doppler velocities. Clinical adverse events were mild, and dose-limiting toxicities were uncommon. The most common grade 3 adverse events were malaria (12 [29%] episodes in 45 patients) and sepsis (13 [32%] episodes). There were three serious adverse events, none of which were treatment-related, and no treatment-related deaths occurred.

INTERPRETATION

Children with sickle cell anaemia in Tanzania have a high baseline stroke risk. Hydroxyurea at the maximum tolerated dose significantly lowers transcranial Doppler velocities and reduces primary stroke risk. Transcranial Doppler screening plus hydroxyurea at the maximum tolerated dose is an effective stroke prevention strategy, supporting wider hydroxyurea access for patients with sickle cell anaemia across sub-Saharan Africa.

FUNDING

American Society of Hematology, National Institutes of Health, Cincinnati Children's Research Foundation.

Intracellular cytokine production by human CD4+ and CD8+ T cells from normal and immunodeficient donors using directly conjugated anti-cytokine antibodies and three-colour flow cytometry

Using three-colour flow cytometry, we have measured intracellular IL-2, interferon-gamma (IFN-gamma) and tumour necrosis factor-alpha (TNF-alpha) induced in human CD4+ and CD8+ T cells from normal donors and patients with common variable immunodeficiency (CVID). Since a new range of directly FITC-conjugated anti-cytokine antibodies was used, conditions were optimized for the concentration of antibody, for cell permeabilization and fixation, and for the time of exposure to monensin to retain the cytokines within the cell. Kinetics of intracellular cytokine production were measured for up to 20 h in culture with phorbol myristate acetate (PMA) and ionomycin, or with phytohaemagglutinin (PHA). Kinetic studies of activation with PMA and ionomycin show that a higher proportion of normal CD4+ cells can make IL-2 than the other two cytokines, and that there are more TNF-alpha-positive CD4+ cells than cells with IFN-gamma. For normal CD8+ cells the highest production of cytokine is of IFN-gamma (up to 50% of the cells) especially at longer times (10-20 h) of stimulation. For CD8+ cells, IL-2-positive cells exceed those with TNF-alpha. The other mitogenic stimulus used (PHA) was grossly inferior to PMA and ionomycin in its ability to induce intracellular cytokines. The time of exposure to monensin was also examined. Its continuous presence in the cultures (up to a maximum of 20 h) increased the detection of IL-2-positive cells without apparently reducing the percentage of cytokine-positive CD4+ or CD8+ cells. Finally, using optimal conditions, we compared cytokine production in cells from patients with the disease CVID and showed normal cellular levels of ability to produce IL-2 and TNF-alpha but significantly raised levels of production of IFN-gamma in both CD4+ and CD8+ lymphocytes. This suggests that the pathology of this disease may involve an excessive Th1-type response.

Immunophenotyping in presumed ocular histoplasmosis like retinopathy

Four cases of presumed ocular histoplasmosis like retinopathy are presented. A detailed immunological assessment was carried out on the patients and a control group: lymphocyte immunophenotyping; flow cytometric analysis; HLA typing and T cell receptor variable region (TCR V region) expression were assessed. Analysis of TCR V region expression revealed no significant preferential expression. HLA typing also failed to reveal any links. All lymphocyte markers analysed were unremarkable, with the exception of CD38 which was significantly raised compared with controls (p < 0.01). This finding was confirmed by the use of two different CD38-specific monoclonal antibodies. The raised CD38 in our cases was shown to be persistent when the patients were retested after an interval of several months. Significantly, this may correlate with poor T cell function, as in Common Variable Immunodeficiency, making these patients more susceptible to various stimuli.

Altered T lymphocyte phenotype at birth in babies born to atopic parents

Flow cytometry was used to analyse the cord blood T cells of 33 babies at high risk 'HR' for developing allergy (born to at least one atopic, asthmatic parent), and 10 low risk 'LR' babies (born to non-atopic parents), following normal term deliveries. Significantly lower numbers of CD25+, (activated) T cells (p < 0.005) were seen in the cord blood of the HR babies who had developed both allergic symptoms and positive skin prick tests by one year of age when compared with the LR group. CD45RO+ (memory) T cells were detected in both HR and LR babies with a trend for lower numbers of memory cells to be detected in HR infants who later developed allergic symptoms and/or positive skin prick tests. Significantly lower numbers of CD4+/CD45RO+ were seen in the cord blood of HR babies who developed allergic symptoms compared to HR babies who showed no sign of allergy by one year and to the LR babies (p < 0.05 and p < 0.005). The presence of activated and memory T cells at birth implies intra-uterine priming. The significantly lower numbers of memory T cells in the HR babies suggests a suppression of T cell activation or lack of antigenic priming in this group. This prenatal influence on babies born to atopic parents may have important implications with regard to the mechanisms underlying atopic sensitisation.

Automated HLA-B27 testing using the FACSPrep/FACScan system

Tissue typing can help in the diagnosis of the seronegative arthropathy ankylosing spondylitis. Using an automatic sample preparation system and flow cytometry (FACSPrep/FACScan) we have developed a test for HLA-B27 screening using whole blood which is both rapid, reproducible, and permits simultaneous screening of large numbers of samples. We have used both indirect (248 cases) and direct (126 cases) monoclonal antibody staining techniques. Results were assessed using median channel shift (CS) from the negative control and relative fluorescence intensity. There is known cross-reactivity between HLA-B27 and HLA-B7 with the monoclonal antibody (MoAb) HLA-ABC-m3. Using this antibody and indirect staining, HLA-B7 samples had a significantly lower CS value than HLA-B27 samples. In 60% of these cases there was a clear distinction between HLA-B27 and HLA-B7. All HLA-B27 and HLA-B7 negative samples had a CS of 0 (P < 0.001). Using direct dual staining with CD3 and HLA-B27, all HLA-B27 and HLA-B7 negative samples had a low CS value (15 maximum), HLA-B7 samples had an intermediate CS value (20-85), and HLA-B27 samples had the highest CS values (70 upward). This system permits large scale rapid negative screening of samples with the elimination of over 60% as negatives (CS < 15). Limitations as a definitive test for HLA-B27 are due to MoAb cross-reactivity with HLA-B7 which necessitates other confirmatory techniques. The substitution of the HLA-ABC-m3 with the recently available HLA-B27 specific MoAb FD705 would substantially increase the value of this technique for routine HLA-B27 typing.

A simple technique for the determination of kappa and lambda immunoglobulin light chain expression by B cells in whole blood

This article describes the development of a simple technique by which the numbers of surface immunoglobulin expressing cells can be analysed by dual fluorescence flow cytometry in samples of whole blood. We have compared the results obtained using this procedure with those obtained using samples prepared by traditional density gradient centrifugation, and demonstrate an excellent correlation between the two techniques. The method is applicable both to blood samples from normal individuals and from patients with B cell malignancies such as B-CLL and B-NHL. We have also confirmed previous findings that density gradient centrifugation may preferentially deplete certain lymphocyte subsets. This technique offers the following advantages: (i) it is rapid, (ii) it is accurate, (iii) it is reliable, (iv) it is useful in cases of lymphopenia, and (v) it requires only a small volume of blood. It is likely to be applicable to other situations in which the presence of serum factors interfere with antibody staining in whole blood.

T-cell receptor variable (V) gene usage by lymphoid populations in T-cell lymphoma

A panel of monoclonal antibodies specific for TcR V gene families was used to study TcR V region expression in 28 cases of malignant and reactive T-cell expansions including four cases of mixed cellularity Hodgkin's disease (HD) and five reactive cases. TcR V beta 5 gene products were represented in three cases of lymphoblastic malignancy (V beta 5.1, V beta 5.2) and two cases of peripheral T-cell lymphoma (PTCL) (V beta 5.1). In the PTCL cases, the expanded family was found in the absence of clonal TcR gene rearrangements and in one of these cases with Ig JH and Ck clonal gene rearrangements consistent with the presence of a phenotypically and histologically undetectable clonal B-cell population. In a third PTCL case not investigated for genotype, the TCR V alpha 12 family was overrepresented. Expanded TcR V alpha 2 and V beta 5.1 families were identified in HD and V beta 8 and V beta 5.2/V beta 5.3 families in a reactive lymph node and CD3 and CD8-positive blood lymphocytosis respectively. Further study of PTCL and related entities are needed to establish whether expanded TcR families are common in those cases that fail to exhibit clonal TcR gene rearrangement.

Lack of correlation between IgG T-lymphocyte flow cytometric crossmatches with primary renal allograft outcome

The flow cytometric crossmatch (FCXM) has been reported to be more sensitive and capable of detecting very low levels of antibodies than the normally used complement dependent cytotoxicity test. We studied both the two colour IgG T cell FCXM and CDC-XM in 146 renal allograft recipients, 111 primary and 35 regrafts, of which 26% (29/111) of 1st and 20% (7/35) of regrafts had a positive FCXM. There was no overall correlation between the FCXM results and early graft outcome in primary renal allografts. The FCXM did not appear to have any advantage over the CDC-XM in predicting graft outcome in unsensitized first grafts. In the small number of regrafts studied, a positive FCXM was associated with a higher degree of graft failure. FCXM can exhibit false negative results if sera are used solely neat although these prozone phenomena do not influence subsequent graft outcome.

Enhanced modulation of antibodies coating guinea pig leukemic cells in vitro and in vivo. The role of Fc gamma R expressing cells

We have investigated the antigenic modulation induced by a number of antibody fragments and derivatives directed against the idiotype of the surface Ig of the L2C guinea pig B lymphoblastic leukemia, and studied the effects upon such modulation of the simultaneous presence of cells expressing Fc gamma receptors (FcR). In vitro studies confirmed previous work showing that antibody bivalency is required to induce modulation in vitro in simple systems. However, in the presence of isolated Kupffer cells, Fc-containing univalent antibodies were found to induce significant antigenic modulation, and the modulation induced by intact IgG was also found to be more rapid and extensive. Fragments that did not contain Fc regions behaved similarly in the presence or absence of Kupffer cells. Further investigations demonstrated that all three classes of human FcR can mediate modulation enhancement, and suggest that the mechanism involves indirect cross-linking of cell surface Ag via the antibody and effector cell FcR. In vivo studies showed that univalent antibody derivatives containing Fc regions did induce antigenic modulation, but that this was significantly reduced in comparison with bivalent antibodies, confirming their potential advantage for immunotherapy.

Caffeine as an analgesic adjuvant. A double-blind study comparing aspirin with caffeine to aspirin and placebo in patients with sore throat

Despite its frequent clinical use in analgesic agents, caffeine has not been accepted unequivocally as an analgesic adjuvant. To evaluate this activity of caffeine, we used new study methods in a randomized controlled trial on patients with acute sore throat due to tonsillopharyngitis. Patients were randomly assigned to receive a single dose of one of three treatments: 800 mg of aspirin with 64 mg of caffeine (n = 70), 800 mg of aspirin (n = 68), or placebo (n = 69). Under double-blind conditions, during a 2-hour evaluation period, patients used different rating scales to assess pain intensity, change in pain, relief, and two qualities of throat pain, how swollen the throat felt, and difficulty swallowing. Aspirin with caffeine and aspirin alone were significantly more effective than placebo for all efficacy measurements from 30 minutes through 2 hours and overall. The aspirin-caffeine combination also showed evidence of activity at 15 minutes on the relief scale. Aspirin with caffeine was more effective than aspirin alone after 30 minutes and over the entire study period. For patients with fever, both active treatments were equally effective antipyretic agents. We conclude, therefore, that 800 mg of aspirin, given alone or with 64 mg of caffeine, is an effective analgesic and antipyretic agent. Because the aspirin-caffeine combination is significantly more effective than aspirin alone as an analgesic, we also conclude that 64 mg of caffeine is an analgesic adjuvant.

Enhanced modulation of antibodies coating guinea pig leukemic cells in vitro and in vivo. The role of Fc gamma R expressing cells

We have investigated the antigenic modulation induced by a number of antibody fragments and derivatives directed against the idiotype of the surface Ig of the L2C guinea pig B lymphoblastic leukemia, and studied the effects upon such modulation of the simultaneous presence of cells expressing Fc gamma receptors (FcR). In vitro studies confirmed previous work showing that antibody bivalency is required to induce modulation in vitro in simple systems. However, in the presence of isolated Kupffer cells, Fc-containing univalent antibodies were found to induce significant antigenic modulation, and the modulation induced by intact IgG was also found to be more rapid and extensive. Fragments that did not contain Fc regions behaved similarly in the presence or absence of Kupffer cells. Further investigations demonstrated that all three classes of human FcR can mediate modulation enhancement, and suggest that the mechanism involves indirect cross-linking of cell surface Ag via the antibody and effector cell FcR. In vivo studies showed that univalent antibody derivatives containing Fc regions did induce antigenic modulation, but that this was significantly reduced in comparison with bivalent antibodies, confirming their potential advantage for immunotherapy.

Sore throat pain in the evaluation of mild analgesics

A double-blind, single-dose parallel study was conducted to assess refinements of a previously tested model for evaluating treatment of sore throat pain. Patients with tonsillopharyngitis randomly received either 400 mg ibuprofen (n = 39), 1000 mg acetaminophen (n = 40), or placebo (n = 41). At hourly intervals for 6 hours the patients reported pain intensity and pain relief on conventional scales and two sensory qualities of throat pain ("swollen throat" and "difficulty swallowing") on two new visual analog scales. Both active agents were significantly more effective than placebo for all efficacy measurements (p less than 0.01). Ibuprofen, 400 mg, was more effective than acetaminophen, 1000 mg, on all rating scales, conventional and new, at all time points after 2 hours and overall (p less than 0.01). There were no side effects. We conclude that sore throat is a pain model that can be used to discriminate between active medication and placebo, as well as between two effective over-the-counter analgesics.

Indoline analogues of idazoxan: potent alpha 2-antagonists and alpha 1-agonists

The synthesis and alpha-adrenergic activity of a series of substituted 2-imidazolinylindolines are described. Substitution in the indoline ring generated compounds with a spectrum of adrenoceptor antagonist/agonist profiles that proved sensitive to both the nature and position of the substituent. Many of the derivatives possess greater presynaptic antagonist potency than the corresponding benzodioxan 1, dihydrobenzofuran 2, and indan 3 analogues; however, this alpha 2-antagonism is often accompanied by alpha 1-agonist activity. It was not possible to separate alpha 2-antagonist from alpha 1-agonist properties in this series. Compounds of most interest proved to be the N-ethyl 6, 5-chloro-N-methyl 18, and 5-chloro-N-ethyl 23 derivatives, all being potent alpha 2-antagonists and alpha 1-agonists. Substitution at the 4- and 7-position of the indoline ring generally gave compounds with nonselective agonist properties.

Problems and prospects in the use of lymphoma idiotypes as therapeutic targets

The infusion of anti-idiotypic antibody in patients with lymphoma has proved a relatively innocuous procedure, but in general had yielded only partial, short-lived remissions of disease. A major problem is that xenogeneic antibody is simply not well-fitted to destroying mammalian cells: complement and cellular effectors (K cells and phagocytes) are not efficiently recruited, and the target cells in any case present some excellent defense mechanisms. Antigenic modulation is particularly prominent among these defenses, and we present evidence here for modulation of idiotype being much more efficient in vivo than in vitro. Two broad types of antibody derivative are under development to improve the killing of neoplastic targets. One type relies on recruiting natural effectors, and is exemplified by univalent chimeric antibody. The other relies on delivering an exogenous effector such as a drug or toxin, and is exemplified by bispecific anti-Id/anti-saporin F(ab'gamma)2 antibody. Both types of derivative have been able to suppress animal lymphoma to the extent that tumor escape occurs largely through the emergence of idiotype-negative mutants.

Determination of idazoxan in plasma by radioreceptor assay

A radioreceptor assay to determine the plasma concentration of idazoxan, a potent, highly selective antagonist for the alpha(2)-adrenoreceptor, is described. The assay is based upon a technique in which plasma extracts containing idazoxan compete with radiolabelled ligand for binding sites on receptor-rich tissue prepared from beef brain cortex. Using a logistic data-fit the limit of detection is of the order of 1 ng ml(-1) and represents a 10-fold increase in sensitivity over that from an established HPLC procedure. Comparison of human plasma data from the two assays indicates a correlation coefficient of 0.92 (N = 27) although the chromatographic method gave consistently higher values than the binding assay. The binding assay requires no sample extraction or pretreatment of plasma and its accuracy, precision and inherent specificity are such that the method represents a useful alternative to HPLC for therapeutic drug monitoring.

Alpha-adrenoreceptor reagents. 4. Resolution of some potent selective prejunctional alpha 2-adrenoreceptor antagonists

The resolution of three 2-substituted derivatives of idazoxan is described. The enantiomers show large separations in activity in a variety of in vitro and in vivo tests, and the active isomers are all potent and selective antagonists at the alpha 2-adrenoreceptor. The significance of these results in relation to those published on the enantiomers of idazoxan and to those on optically active alpha 2-adrenoreceptor agonists is discussed.

The mode of antifungal action of tolnaftate

The anti-dermatophyte agent tolnaftate was compared with the allylamine antifungal compounds naftifine and terbinafine. Tolnaftate was shown to inhibit sterol biosynthesis at the level of squalene epoxidation and squalene was shown to accumulate in dermatophytes grown in its presence. Biochemical studies in whole and broken cells supported this conclusion and showed that the compound was active against squalene epoxidation in broken C. albicans cells, but was much less potent against whole cells. These results suggested there was a barrier to penetration in these yeasts.

2-Alkyl analogue of idazoxan (RX 781094) with enhanced antagonist potency and selectivity at central alpha 2-adrenoceptors in the rat

Four 2-alkyl (methyl, ethyl, n-propyl and isopropenyl) analogues of idazoxan (RX 781094) have been synthesized and assessed in terms of their central alpha 2/alpha 1-adrenoceptor selectivity and alpha 2-adrenoceptor antagonist potency using both in vitro and in vivo tests in the rat. In cortical binding assays using [3H]-idazoxan and [3H]-prazosin, idazoxan had a 5 times greater alpha 2/alpha 1-selectivity than yohimbine. The 2-alkyl substituted analogues all showed improved selectivity, being between 17 and 29 times more selective than yohimbine for [3H]-idazoxan binding sites. In terms of central antagonist potency in vivo, the most favourable substitutions were 2-ethyl (RX 811033) and 2-n-propyl (RX 811054). Compared with yohimbine, these analogues were, respectively, 36 and 18 times more potent intravenously and 5 and 7.5 times more potent orally in their antagonism of guanoxabenz-induced mydriasis in the pentobarbitone-anaesthetized rat. All the analogues had a duration of action similar to that of idazoxan, which was significantly shorter than that of yohimbine. The results indicate that introduction of alkyl groups in the 2-position of idazoxan greatly increases the alpha 2/alpha 1-adrenoceptor selectivity as measured in binding studies. Improved alpha 2-adrenoceptor affinity and antagonist potency were particularly associated with the 2-ethyl and 2-n-propyl analogues.

Effects of idazoxan on catecholamine systems in rat brain

Experiments have been performed to assess the potency of idazoxan (RX 781094) at alpha and beta-adrenoceptors and dopamine receptors and on catecholamine uptake processes in rat brain. The effects of idazoxan on the turnover rates of noradrenaline and dopamine have been determined. Radioligand binding studies with cerebral cortex membranes have demonstrated that idazoxan exhibits 46-fold selectivity for alpha 2-adrenoceptors labelled by (3H)-idazoxan (Mean Ki +/- S.E.M. = 3.1 +/- 0.4 nM) compared with alpha 1-adrenoceptors labelled by (3H)-prazosin (Mean Ki +/- S.E.M. = 142 +/- 27 nM). Under the same conditions, yohimbine showed 6-fold selectivity for alpha 2-adrenoceptors. Idazoxan had low affinity for beta-adrenoceptors labelled by (3H)-dihydroalprenolol (IC50 value greater than 10 microM), for dopamine receptors labelled by (3H)-domperidone (IC50 value greater than 20 microM), for the (3H)-noradrenaline uptake site in rat hypothalamus (IC50 = 31 microM) and for the (3H)-dopamine uptake site in rat striatum (IC50 value approximately 800 microM). In rats treated with alpha-methyl-p-tyrosine, idazoxan (10-80 mg/kg, po) produced a marked increase (63% at 10, 217% at 20 mg/kg, po) in the apparent rate of turnover of noradrenaline in rat cortex/striatum, without affecting the rate of turnover of dopamine. This was in contrast to yohimbine (5-20 mg/kg, po) which increased the turnover rates of both catecholamines. In the absence of alpha-methyl-p-tyrosine, idazoxan (5-40 mg/kg, po) produced a dose related increase in the MHPG concentration and a small (20-30%) reduction in the steady state concentration of NA; the duration of the reduction was dose-related. DA steady state concentrations were unaffected. Idazoxan is a new selective alpha 2-adrenoceptor antagonist which should prove a valuable investigative tool in neurochemical studies and which may be a useful clinical agent in the management of the affective disorders.

Subjective and objective features of sore throat

This study examines the relationship between the symptom of sore throat and the signs of pharyngitis. Patients seeking medical attention for sore throat were examined by their physician, who documented findings on a Tonsillopharyngitis Score (TPS) and obtained a throat culture. Each patient was then instructed by the physician's assistant to characterize the severity of throat pain on a Sore Throat Pain Intensity Scale (STPIS) and Sore Throat Questionnaire. A high positive correlation was found for the STPIS and TPS but not for these findings and the cause of pharyngitis. A similar association was found between the relative severity of throat pain and the words patients use to describe it. This new method objectively confirms the subjective rating of sore throat pain.

Comparison of the alpha-adrenoceptor antagonist profiles of idazoxan (RX 781094), yohimbine, rauwolscine and corynanthine

In the present studies the potency and selectivity of idazoxan (RX 781094) were compared with yohimbine and its diastereoisomers rauwolscine and corynanthine in both functional studies and radioligand binding experiments. Prejunctional alpha 2- and postjunctional alpha 1-adrenoceptor antagonist potencies were assessed by determining pA2 values against clonidine on the stimulated rat was deferens and noradrenaline on the anococcygeus muscle, respectively. The rank order of prejunctional alpha 2-adrenoceptor antagonist potency was idazoxan greater than yohimbine greater than rauwolscine much greater than corynanthine. At postjunctional alpha 1-adrenoceptors the rank order of antagonist potency was rauwolscine greater than corynanthine greater than yohimbine greater than idazoxan. The selectivity values (alpha 2/alpha 1) for idazoxan, yohimbine, rauwolscine and corynanthine were 245, 45, 3 and 0.03 respectively. The selectivity and potency profiles established for these antagonists in functional studies were confirmed in radioligand binding studies utilising 3H-idazoxan (alpha 2) and 3H-prazosin (alpha 1) in rat cerebral cortex. In pithed rats intravenously administered idazoxan, yohimbine and rauwolscine fully reversed the inhibitory effects of clonidine on electrically-induced contractions of the vas deferens; idazoxan was approximately ten times more potent than both yohimbine and rauwolscine. Corynanthine was inactive. Idazoxan and yohimbine also fully antagonised the inhibitory effects of guanabenz on electrically-induced contractions of the anococcygeus muscle; idazoxan again was more than ten times more potent than yohimbine in this model. The inhibitory effects of guanabenz were less readily antagonised by rauwolscine indicating that the selectivity of this compound is less than that of yohimbine in this tissue. Corynanthine was again inactive.(ABSTRACT TRUNCATED AT 250 WORDS)

Evidence for pharmacological similarity between alpha 2-adrenoceptors in the vas deferens and central nervous system of the rat

Seven alpha 2-adrenoceptor antagonists with diverse chemical structures have been examined for their effects at alpha 2-adrenoceptors in the vas deferens and central nervous system of the rat. Antagonist potency assessed against the presynaptic alpha 2-adrenoceptor agonist action of clonidine in the isolated vas deferens (RX 781094 greater than Wy 26703 greater than yohimbine greater than rauwolscine greater than piperoxan greater than mianserin greater than RS 21361) was highly correlated with the ability of these drugs to displace saturable [3H]-RX 781094 binding from cerebral cortex membranes. Similarly, antagonist potency in the vas deferens was highly correlated with antagonist activity in reversing the centrally-mediated mydriasis induced by the selective alpha 2-adrenoceptor agonist, guanoxabenz, in pentobarbitone-anaesthetized rats. The results indicate that the presynaptic alpha 2-adrenoceptors in the vas deferens are pharmacologically similar to characterized these alpha 2-adrenoceptors in the central nervous system of the rat.

Common anionic receptor site hypothesis: its relevance to the antagonist action of naloxone

Appropriate modification of 14 beta-methoxy- and 14 beta-ethoxycodeinone (prepared by alkylation of 14 beta-hydroxycodeinone) has generated four alkoxy analogues (3a-d) of naloxone and naltrexone. These agents were pure narcotic antagonists in contradiction to the predictions of the common anionic receptor site hypothesis, postulated to be of importance in the enhanced antagonism of naloxone. The molecular change from allyl to cyclopropylmethyl on the N atom increased selectivity of these antagonists for the mu receptor to the same extent as found for naloxone. Increase in the length of the C14 O-substituent had no effect on receptor selectivity, and either formation in most cases did not significantly alter oral/parenteral ratios of durations of action.

[Transport and mode of action of sennosides]

Prior to attempting to develop a new laxative, pharmacodynamic studies were conducted on the individual active constituents of senna. Sennoside A, sennoside B and rhein were injected intravenously and were introduced into the isolated stomach, small bowel and large bowel of the anaesthetised pig. Blood, urine and bile, collected over 6 hours, were assayed by a novel fluorometric technique. Recoveries and measured oil water partition coefficients indicate that the sennosides are virtually non-absorbed in the stomach and small bowel. Following administrations outside the large bowel, anthracene derivative concentrations in the lumen and wall of the colon were below the limits of detection. Thus, a transport theory involving absorption and resecretion of sennosides into the large bowel is discounted. The results support a mode of action involving direct transport through the alimentary canal to the large bowel where micro-organism break the sugar-anthracene bonds. Derivatives of the liberated lipophilic aglycones are absorbed into the wall of the colon and stimulate the nerve plexuses thereby leading to defaecation. The "colon-specific" mode of action of the natural anthrone glycosides appears to be an ideal method of stimulating bowel action.

Inhibition of enzymes by alkylsalicylic acids

5-n-Alkylsalicylates inhibited a variety of enzymes that transform acidic substances, viz. glucose-6-phosphate dehydrogenase, glyoxalase, xanthine oxidase, carbonic anhydrase and D-amino-acid oxidase. Inhibitory potency rose to a peak at the n-nonyl derivative. None of the tests were of value, either singly or in combination, as screening processes for anti-inflammatory activity. The comparable results with a trinitrobenzaldehyde reagent suggest that the various inhibitions arise by non-specific association of the drugs with arginine and lysine residues in proteins.