A prospective, pragmatic non-inferiority study of emergency intubation success with the single-use i-view versus standard reusable video laryngoscope

INTRODUCTION

Video laryngoscope (VL) technology improves first-pass success. The novel i-view VL device is inexpensive and disposable. We sought to determine the first-pass intubation success with the i-view VL device versus the standard reusable VL systems in routine use at each site.

METHODS

We performed a prospective, pragmatic study at two major emergency departments (EDs) when VL was used. We rotated i-view versus reusable VL as the preferred device of the month based on an a priori schedule. An investigator-initiated interim analysis was performed. Our primary outcome was a first-pass success with a non-inferiority margin of 10% based on the per-protocol analysis.

RESULTS

There were 93 intubations using the reusable VL devices and 81 intubations using the i-view. Our study was stopped early due to futility in reaching our predetermined non-inferiority margin. Operator and patient characteristics were similar between the two groups. The first-pass success rate for the i-view group was 69.1% compared to 84.3% for the reusable VL group. A non-inferiority analysis indicated that the difference (-15.1%) and corresponding 90% confidence limits (-25.3% to -5.0%) did not fall within the predetermined 10% non-inferiority margin.

CONCLUSIONS

The i-view device failed to meet our predetermined non-inferiority margin when compared to the reusable VL systems with the study stopping early due to futility. Significant crossover occurred at the discretion of the intubating operator during the i-view month.

An Assessment of Clinical Accuracy of Vital Sign-based Triage Tools Among U.S. and Coalition Forces

INTRODUCTION

Early appropriate allocation of resources for critically injured combat casualties is essential. This is especially important when inundated with an overwhelming number of casualties where limited resources must be efficiently allocated, such as during mass casualty events. There are multiple scoring systems utilized in the prehospital combat setting, including the shock index (SI), modified shock index (MSI), simple triage and rapid treatment (START), revised trauma score (RTS), new trauma score (NTS), Glasgow Coma Scale + age + pressure (GAP), and the mechanism + GAP (MGAP) score. The optimal score for application to the combat trauma population remains unclear.

MATERIALS AND METHODS

This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry from January 1, 2007 through March 17, 2020. We constructed univariable analyses to determine the area under the receiving operator characteristic (AUROC) for the scoring systems of interest. Our primary outcomes were early death (within 24 hours) or early massive transfusion, as defined by ≥3 units.

RESULTS

There were 12,268 casualties that met inclusion criteria. There were 168 (1%) who died within the first 24 hours and 2082 (17%) that underwent significant transfusion within the first 24 hours. When assessing the predictive capabilities for death within 24 hours, the AUROCs were 0.72 (SI), 0.69 (MSI), 0.89 (START), 0.90 (RTS), 0.83 (NTS), 0.90 (GAP), and 0.91 (MGAP). The AUROCs for massive transfusion were 0.89 (SI), 0.89 (MSI), 0.82 (START), 0.81 (RTS), 0.83 (NTS), 0.85 (MGAP), and 0.86 (GAP).

CONCLUSIONS

This study retrospectively applied seven triage tools to a database of 12,268 cases from the Department of Defense Trauma Registry to evaluate their performance in predicting early death or massive transfusion in combat. All scoring systems performed well with an AUROC >0.8 for both outcomes. Although the SI and MSI performed best for predicting massive transfusion (both had an AUROC of 0.89), they ranked last for assessment of mortality within 24 hours, with the other tools performing well. START, RTS, NTS, MGAP and GAP reliably identified early death and need for massive transfusion, with MGAP and GAP performing the best overall. These findings highlight the importance of assessing triage tools to best manage resources and ultimately preserve lives of traumatically wounded warfighters. Further studies are needed to explain the surprising performance discrepancy of the SI and MSI in predicting early death and massive transfusion.

A Market Assessment of Introducer Technology to Aid With Endotracheal Intubation

INTRODUCTION

Endotracheal intubation is a potentially lifesaving procedure. Previously, data demonstrated that intubation remains the most performed airway intervention in the Role 1 setting. Additionally, deployed data demonstrate that casualties intubated in the prehospital setting have worse survival than those intubated in the emergency department setting. Technological solutions may improve intubation success in this setting. Certain intubation practices, including the use of endotracheal tube introducer bougies, facilitate intubation success especially in patients with difficult airways. We sought to determine the current state of the market for introducer devices.

MATERIALS AND METHODS

This market review utilized Google searches to find products for intubation. The search criteria aimed to identify any device ideal for intubation in the emergency setting. Device data retrieved included manufacturer, device, cost, and design descriptions.

RESULTS

We identified 12 introducer-variants on the market. Devices varied with regards to composition (latex, silicone, polyethylene, combination of several materials, etc.), tip shape, special features for ease of intubation (markings for depth and visibility, size, etc.), disposability/reuse capability, measurements, and prices. The cost of each device ranged from approximately $5 to $100.

CONCLUSIONS

We identified 12 introducer-variants on the market. Clinical studies are necessary to determine which devices may improve patient outcomes in the Role 1 setting.

Ketamine during resuscitation - Is it as hemodynamically perfect as we think?

INTRODUCTION

Ketamine administration in patients experiencing or at risk for hypotension is common based upon the presumption of this agent's favorable hemodynamic profile. The Compensatory Reserve Measurement (CRM) is a novel algorithm that accurately tracks systemic adequacy for delivery of oxygen (DO2) to the tissues. We present a case series of trauma patients receiving ketamine with CRM measurements to offer insight into the DO2 during resuscitation.

METHODS

We captured vital signs along with analog arterial waveform data from trauma patients meeting major activation criteria using a prospective study design. Study team members tracked interventions and vital signs including systolic blood pressure (SBP), mean arterial pressure (MAP), and heart rate (HR) throughout their emergency department stay.

RESULTS

Our study included 8 patients who received ketamine for intubation or analgesia (20-300 mg) and had adequate data for analysis. Most were male (88%) with a median age of 28. The most common mechanisms of injury were motor vehicle collisions (MVCs) (38%) and gunshot wounds (38%). After ketamine administration SBP, MAP, and HR all increased while the CRM exhibited minimal change.

CONCLUSIONS

SBP, MAP, and HR generally appeared to increase while the CRM remained unchanged. Our findings suggest that while standard vital sign measurements appear to increase, ketamine may not improve delivery of oxygen to the tissues. This warrants further study to better understand the effects of ketamine on hemodynamics.

Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults

BACKGROUND

Whether video laryngoscopy as compared with direct laryngoscopy increases the likelihood of successful tracheal intubation on the first attempt among critically ill adults is uncertain.

METHODS

In a multicenter, randomized trial conducted at 17 emergency departments and intensive care units (ICUs), we randomly assigned critically ill adults undergoing tracheal intubation to the video-laryngoscope group or the direct-laryngoscope group. The primary outcome was successful intubation on the first attempt. The secondary outcome was the occurrence of severe complications during intubation; severe complications were defined as severe hypoxemia, severe hypotension, new or increased vasopressor use, cardiac arrest, or death.

RESULTS

The trial was stopped for efficacy at the time of the single preplanned interim analysis. Among 1417 patients who were included in the final analysis (91.5% of whom underwent intubation that was performed by an emergency medicine resident or a critical care fellow), successful intubation on the first attempt occurred in 600 of the 705 patients (85.1%) in the video-laryngoscope group and in 504 of the 712 patients (70.8%) in the direct-laryngoscope group (absolute risk difference, 14.3 percentage points; 95% confidence interval [CI], 9.9 to 18.7; P<0.001). A total of 151 patients (21.4%) in the video-laryngoscope group and 149 patients (20.9%) in the direct-laryngoscope group had a severe complication during intubation (absolute risk difference, 0.5 percentage points; 95% CI, -3.9 to 4.9). Safety outcomes, including esophageal intubation, injury to the teeth, and aspiration, were similar in the two groups.

CONCLUSIONS

Among critically ill adults undergoing tracheal intubation in an emergency department or ICU, the use of a video laryngoscope resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope. (Funded by the U.S. Department of Defense; DEVICE ClinicalTrials.gov number, NCT05239195.).

Protocol and statistical analysis plan for the PREOXI trial of preoxygenation with noninvasive ventilation vs oxygen mask

Background

Hypoxemia is a common and life-threatening complication during emergency tracheal intubation of critically ill adults. The administration of supplemental oxygen prior to the procedure ("preoxygenation") decreases the risk of hypoxemia during intubation.

Research Question

Whether preoxygenation with noninvasive ventilation prevents hypoxemia during tracheal intubation of critically ill adults, compared to preoxygenation with oxygen mask, remains uncertain.

Study Design and Methods

The PRagmatic trial Examining OXygenation prior to Intubation (PREOXI) is a prospective, multicenter, non-blinded randomized comparative effectiveness trial being conducted in 7 emergency departments and 17 intensive care units across the United States. The trial compares preoxygenation with noninvasive ventilation versus oxygen mask among 1300 critically ill adults undergoing emergency tracheal intubation. Eligible patients are randomized in a 1:1 ratio to receive either noninvasive ventilation or an oxygen mask prior to induction. The primary outcome is the incidence of hypoxemia, defined as a peripheral oxygen saturation <85% between induction and 2 minutes after intubation. The secondary outcome is the lowest oxygen saturation between induction and 2 minutes after intubation. Enrollment began on 10 March 2022 and is expected to conclude in 2023.

Interpretation

The PREOXI trial will provide important data on the effectiveness of noninvasive ventilation and oxygen mask preoxygenation for the prevention of hypoxemia during emergency tracheal intubation. Specifying the protocol and statistical analysis plan prior to the conclusion of enrollment increases the rigor, reproducibility, and interpretability of the trial.

Clinical trial registration number

NCT05267652.

DirEct versus VIdeo LaryngosCopE (DEVICE): protocol and statistical analysis plan for a randomised clinical trial in critically ill adults undergoing emergency tracheal intubation

INTRODUCTION

Among critically ill patients undergoing orotracheal intubation in the emergency department (ED) or intensive care unit (ICU), failure to visualise the vocal cords and intubate the trachea on the first attempt is associated with an increased risk of complications. Two types of laryngoscopes are commonly available: direct laryngoscopes and video laryngoscopes. For critically ill adults undergoing emergency tracheal intubation, it remains uncertain whether the use of a video laryngoscope increases the incidence of successful intubation on the first attempt compared with the use of a direct laryngoscope.

METHODS AND ANALYSIS

The DirEct versus VIdeo LaryngosCopE (DEVICE) trial is a prospective, multicentre, non-blinded, randomised trial being conducted in 7 EDs and 10 ICUs in the USA. The trial plans to enrol up to 2000 critically ill adults undergoing orotracheal intubation with a laryngoscope. Eligible patients are randomised 1:1 to the use of a video laryngoscope or a direct laryngoscope for the first intubation attempt. The primary outcome is successful intubation on the first attempt. The secondary outcome is the incidence of severe complications between induction and 2 min after intubation, defined as the occurrence of one or more of the following: severe hypoxaemia (lowest oxygen saturation <80%); severe hypotension (systolic blood pressure <65 mm Hg or new or increased vasopressor administration); cardiac arrest or death. Enrolment began on 19 March 2022 and is expected to be completed in 2023.

ETHICS AND DISSEMINATION

The trial protocol was approved with waiver of informed consent by the single institutional review board at Vanderbilt University Medical Center and the Human Research Protection Office of the Department of Defense. The results will be presented at scientific conferences and submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05239195).

A Conceptual Framework for Non-Military Investigators to Understand the Joint Roles of Medical Care in the Setting of Future Large Scale Combat Operations

As the wars in Iraq and Afghanistan end, the US military has begun to transition to the multi-domain operations concept with preparation for large scale combat operations against a near-peer adversary. In large scale combat operations, the deployed trauma system will likely see challenges not experienced during the Global War on Terrorism. The development of science and technology will be critical to close existing capability gaps and optimize casualty survival. This review comprises a framework of deployed trauma care to provide nonmilitary investigators a general understanding of our deployed trauma care system. Trauma care begins at the Role 1 which encompasses all care from the point of injury and the battalion aid station, through transport to the Role 2 or forward staged mobile surgical team such as a Forward Resuscitative Surgical Detachment. Role 1 point of injury care approximates the care delivered by Emergency Medical Services (EMS) personnel. The Battalion Aid Station approximates the care available at a freestanding emergency center with significant differences in training level of the providers, number of beds, and diagnostic capabilities. Role 2 medical care is part of an area support medical company with surgical capabilities. The Role 2 represents the first role of care which provides damage control surgery. This capability approximates a small community hospital with the primary difference being limited patient holding capacity and reduced diagnostic equipment. The Role 3 field hospital is the largest military treatment facility in the deployed setting. The Role 3 approximates a civilian level 2 trauma center with smaller holding capabilities and diagnostic abilities limited to that of a computed tomography (CT) scanner and less.

A Comparison of Injury Patterns and Interventions among US Military Special Operations Versus Conventional Forces Combatants

BACKGROUND

Over the course of the US' Global War on Terrorism, its military has utilized both conventional and special operations forces (SOF). These entities have sustained and treated battlefield casualties in the prehospital, Role 1 setting, while also making efforts to mitigate risks to the force and pursuing improved interventions. The goal of this study is to compare outcomes and prehospital medical interventions between SOF and conventional military combat casualties.

METHODS

This is a secondary analysis of previously published data from the Department of Defense Trauma Registry. The casualties were categorized as special operations if they were 18-series, Navy SEAL, Pararescue Jumper, Tactical Air Control Party, Combat Controller, and Marine Corps Force Reconnaissance. The remainder with a documented military occupational specialty (MOS) were classified as conventional forces.

RESULTS

Within our dataset, a MOS was categorizable for 1806 conventional and 130 special operations. Conventional forces were younger age (24 versus 30, p is less than 0.001). Conventional forces had a higher proportion of explosive injuries (61% versus 44%) but a lower proportion of firearm injuries (22% versus 42%, p is less than 0.001). The median injury severity scores were similar between the groups. Conventional forces had lower rates of documentation for all metrics: pulse, respiratory rate, blood pressure, oxygen saturation, Glasgow Coma Scale, and pain score. On adjusted analyses, SOF had higher odds of receiving an extremity splint, packed red blood cells, whole blood, tranexamic acid, ketamine, and fentanyl.

CONCLUSION

SOF had consistently better medical documentation rates, more use of ketamine and fentanyl, less morphine administration, and lower threshold for use of blood products in both unadjusted and adjusted analyses. Our findings suggest lessons learned from the SOF medics should be extrapolated to the conventional forces for improved medical care.

A Comparison of Injury Patterns and Interventions among US Military Special Operations Versus Conventional Forces Combatants

BACKGROUND

Over the course of the US' Global War on Terrorism, its military has utilized both conventional and special operations forces (SOF). These entities have sustained and treated battlefield casualties in the prehospital, Role 1 setting, while also making efforts to mitigate risks to the force and pursuing improved interventions. The goal of this study is to compare outcomes and prehospital medical interventions between SOF and conventional military combat casualties.

METHODS

This is a secondary analysis of previously published data from the Department of Defense Trauma Registry. The casualties were categorized as special operations if they were 18-series, Navy SEAL, Pararescue Jumper, Tactical Air Control Party, Combat Controller, and Marine Corps Force Reconnaissance. The remainder with a documented military occupational specialty (MOS) were classified as conventional forces.

RESULTS

Within our dataset, a MOS was categorizable for 1806 conventional and 130 special operations. Conventional forces were younger age (24 versus 30, p is less than 0.001). Conventional forces had a higher proportion of explosive injuries (61% versus 44%) but a lower proportion of firearm injuries (22% versus 42%, p is less than 0.001). The median injury severity scores were similar between the groups. Conventional forces had lower rates of documentation for all metrics: pulse, respiratory rate, blood pressure, oxygen saturation, Glasgow Coma Scale, and pain score. On adjusted analyses, SOF had higher odds of receiving an extremity splint, packed red blood cells, whole blood, tranexamic acid, ketamine, and fentanyl.

CONCLUSION

SOF had consistently better medical documentation rates, more use of ketamine and fentanyl, less morphine administration, and lower threshold for use of blood products in both unadjusted and adjusted analyses. Our findings suggest lessons learned from the SOF medics should be extrapolated to the conventional forces for improved medical care.

A Retrospective Review of Emergency Department Visits That May Be Appropriate for Management in Non-Emergency Settings

Background

Emergency departments (EDs) continue to struggle with overcrowding, increasing wait times, and a surge in patients with non-urgent conditions. Patients frequently choose the ED for non-emergent medical issues or injuries that could readily be handled in a primary care setting. We analyzed encounters in the ED at the Brooke Army Medical Center—the largest hospital in the Department of Defense—to determine the percentage of visits that could potentially be managed in a lower cost, appointment-based setting.

Materials and Methods

We conducted a retrospective chart review of patients within our electronic medical record system from September 2019 to August 2020, which represented equidistance from the start of the COVID-19 pandemic, resulting in a shift in ED used based on previously published data. Our study also compared the number of ED visits pre-covid vs. post-covid. We defined visits to be primary care eligible if they were discharged home and received no computed tomography imaging, ultrasound, magnetic resonance imaging, intravenous medications, or intramuscular-controlled substances.

Results

During the 12 month period, we queried data on 75,205 patient charts. We categorized 56.7% (n = 42,647) of visits as primary care eligible within our chart review. Most primary-care-eligible visits were ESI level 4 (59.2%). The largest proportion of primary-care-eligible patients (28.3%) was seen in our fast-track area followed by our pediatric pod (21.9%). The total number of ED visits decreased from 7,477 pre-covid to 5,057 post-covid visits. However, the proportion of patient visits that qualified as primary care eligible was generally consistent.

Conclusions

Over half of all ED visits in our dataset could be primary care eligible. Our findings suggest that our patient population may benefit from other on-demand and appointment-based healthcare delivery to decompress the ED.

Trends in Prehospital Blood, Crystalloid, and Colloid Administration in Accordance With Changes in Tactical Combat Casualty Care Guidelines

INTRODUCTION

Hemorrhage is the leading threat to the survival of battlefield casualties. This study aims to investigate the types of fluids and blood products administered in prehospital trauma encounters to discover the effectiveness of Tactical Combat Casualty Care (TCCC) recommendations.

MATERIALS AND METHODS

This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry with a focus on prehospital fluid and blood administration in conjunction with changes in the TCCC guidelines. We collected demographic information on each patient. We categorized receipt of each fluid type and blood product as a binary variable for each casualty and evaluated trends over 2007-2020 both unadjusted and controlling for injury severity and mechanism of injury.

RESULTS

Our original dataset comprised 25,897 adult casualties from January 1, 2007 through March 17, 2020. Most (97.3%) of the casualties were male with a median age of 25. Most (95.5%) survived to hospital discharge, and 12.2% of the dataset received fluids of any kind. Medical personnel used crystalloids in 7.4% of encounters, packed red blood cells in 2.0%, and whole blood in 0.5% with very few receiving platelets or freeze-dried plasma. In the adjusted model, we noted significant year-to-year increases in intravenous fluid administration from 2014 to 2015 and 2018 to 2019, with significant decreases noted in 2008-2009, 2010-2012, and 2015-2016. We noted no significant increases in Hextend used, but we did note significant decreases in 2010-2012. For any blood product, we noted significant increases from 2016 to 2017, with decreases noted in 2009-2013, 2015-2016, and 2017-2018. Overall, we noted a general spike in all uses in 2011-2012 that rapidly dropped off 2012-2013. Crystalloids consistently outpaced the use of blood products. We noted a small upward trend in all blood products from 2017 to 2019.

CONCLUSIONS

Changes in TCCC guidelines did not immediately translate into changes in prehospital fluid administration practices. Crystalloid fluids continue to dominate as the most commonly administered fluid even after the 2014 TCCC guidelines changed to use of blood products over crystalloids. There should be future studies to investigate the reasons for delay in guideline implementation and efforts to improve adherence.

Interrater Agreement and Reliability of Burn Size Estimations Between Emergency Physicians and Burn Unit

The initial approach to burn injuries has remained relatively unchanged over the past several decades and revolves around trauma assessment and fluid resuscitation, frequently initiated in the emergency department (ED). While previous research suggests that emergency physicians (EP) are poor estimators at total body surface area (TBSA) affected, we believe that estimation differences are improving, specifically at academic centers with co-located burn units that emphasize burn injury education. This study investigated the interrater agreement and reliability of burn size estimations at an academic ED and its co-located burn unit. This single-center, retrospective study was conducted at a large academic ED with a co-located burn unit. The study included adult patients admitted to the burn unit after receiving paired burn size estimations from EPs and the burn unit. The primary endpoint was the interrater agreement, measured by the kappa coefficient, κ, of 10% TBSA estimation intervals. The secondary endpoint was the intraclass correlation coefficient (ICC), evaluating the reliability of exact, nonranged, and TBSA estimations. A chart review was performed for patients evaluated from November 1, 2016 to July 31, 2019. One thousand one hundred and eighty-four patients were admitted to the burn unit, 1176 of which met inclusion criteria for the primary endpoint. The κ of TBSA between EPs and the burn unit was 0.586, while the weighted κ was 0.775. These values correlate with moderate and substantial agreements, respectively. Additionally, 971 patients had exact TBSA estimations from paired EPs and the burn unit which were used for the secondary endpoint. The ICC between EPs and the burn unit was 0.966, demonstrating an excellent reliability. Further sub-analysis was performed, revealing mean over- and underestimation differences of exact TBSA estimations of 3.93 and 2.93, respectively. EPs at academic institutions with co-located burn units are accurate estimators of TBSA in the assessment of burn injuries. We believe that burn education, to include core rotations within the burn unit, plays a major role in improved burn size estimations.

Plastic Surgery Complications: A Review for Emergency Clinicians

The number of aesthetic surgical procedures performed in the United States is increasing rapidly. Over 1.5 million surgical procedures and over three million nonsurgical procedures were performed in 2015 alone. Of these, the most common procedures included surgeries of the breast and abdominal wall, specifically implants, liposuction, and subcutaneous injections. Emergency clinicians may be tasked with the management of postoperative complications of cosmetic surgeries including postoperative infections, thromboembolic events, skin necrosis, hemorrhage, pulmonary edema, fat embolism syndrome, bowel cavity perforation, intra-abdominal injury, local seroma formation, and local anesthetic systemic toxicity. This review provides several guiding principles for management of acute complications. Understanding these complications and approach to their management is essential to optimizing patient care.

Author Correction: Toxic alcohol diagnosis and management: an emergency medicine review

Toxic alcohols are a group of substances containing a hydroxyl group not meant to be ingested. They are the cause of a significant number of accidental and non-accidental exposures. Toxic alcohol poisoning can be associated with a significant degree of morbidity and mortality if not promptly recognized and treated. This review describes the clinical presentation and an approach to the recognition and management for toxic alcohol poisoning. Toxic alcohols classically refer to a group of alcohols not meant for ingestion. Methanol, ethylene glycol, and isopropyl alcohol are readily available in common hardware and household materials. Toxic alcohols are ingested for a variety of reasons including accidental exposures, intentional inebriation, homicide and suicide. The patient with an altered mental status or concerning history warrants consideration of this potentially deadly ingestion. Treatment considerations include alcohol dehydrogenase blockade and hemodialysis. Toxic alcohol poisoning can be an elusive diagnosis. This review evaluates toxic alcohol poisoning signs and symptoms and an approach to diagnosis and management.

Toxic alcohol diagnosis and management: an emergency medicine review

Toxic alcohols are a group of substances containing a hydroxyl group not meant to be ingested. They are the cause of a significant number of accidental and non-accidental exposures. Toxic alcohol poisoning can be associated with a significant degree of morbidity and mortality if not promptly recognized and treated. This review describes the clinical presentation and an approach to the recognition and management for toxic alcohol poisoning. Toxic alcohols classically refer to a group of alcohols not meant for ingestion. Methanol, ethylene glycol, and isopropyl alcohol are readily available in common hardware and household materials. Toxic alcohols are ingested for a variety of reasons including accidental exposures, intentional inebriation, homicide and suicide. The patient with an altered mental status or concerning history warrants consideration of this potentially deadly ingestion. Treatment considerations include alcohol dehydrogenase blockade and hemodialysis. Toxic alcohol poisoning can be an elusive diagnosis. This review evaluates toxic alcohol poisoning signs and symptoms and an approach to diagnosis and management.

Computerized Diagnostic Assistant for the Automatic Detection of Pneumothorax on Ultrasound: A Pilot Study

INTRODUCTION

Bedside thoracic ultrasound (US) can rapidly diagnose pneumothorax (PTX) with improved accuracy over the physical examination and without the need for chest radiography (CXR); however, US is highly operator dependent. A computerized diagnostic assistant was developed by the United States Army Institute of Surgical Research to detect PTX on standard thoracic US images. This computer algorithm is designed to automatically detect sonographic signs of PTX by systematically analyzing B-mode US video clips for pleural sliding and M-mode still images for the seashore sign. This was a pilot study to estimate the diagnostic accuracy of the PTX detection computer algorithm when compared to an expert panel of US trained physicians.

METHODS

This was a retrospective study using archived thoracic US obtained on adult patients presenting to the emergency department (ED) between 5/23/2011 and 8/6/2014. Emergency medicine residents, fellows, attending physicians, physician assistants, and medical students performed the US examinations and stored the images in the picture archive and communications system (PACS). The PACS was queried for all ED bedside US examinations with reported positive PTX during the study period along with a random sample of negatives. The computer algorithm then interpreted the images, and we compared the results to an independent, blinded expert panel of three physicians, each with experience reviewing over 10,000 US examinations.

RESULTS

Query of the PACS system revealed 146 bedside thoracic US examinations for analysis. Thirteen examinations were indeterminate and were excluded. There were 79 true negatives, 33 true positives, 9 false negatives, and 12 false positives. The test characteristics of the algorithm when compared to the expert panel were sensitivity 79% (95 % CI [63-89]) and specificity 87% (95% CI [77-93]). For the 20 images scored as highest quality by the expert panel, the algorithm demonstrated 100% sensitivity (95% CI [56-100]) and 92% specificity (95% CI [62-100]).

CONCLUSION

This novel computer algorithm has potential to aid clinicians with the identification of the sonographic signs of PTX in the absence of expert physician sonographers. Further refinement and training of the algorithm is still needed, along with prospective validation, before it can be utilized in clinical practice.

Aromatase and COX-2 expression in human breast cancers

We have investigated aromatase and the inducible cyclooxygenase COX-2 expression using immunocytochemistry in tumors of a series of patients with advanced breast cancer treated with aromatase inhibitors. Aromatase was expressed in 58/102 breast cancers. This is similar to the percentage previously reported for aromatase activity. Interestingly, aromatase was expressed in a variety of cell types, including tumor, stromal, adipose, and endothelial cells. Since prostaglandin E2 is known to regulate aromatase gene expression and is the product of COX-2, an enzyme frequently overexpressed in tumors, immunocytochemistry was performed on the tissue sections using a polyclonal antibody to COX-2. Aromatase was strongly correlated (P<0.001) with COX-2 expression. These results suggest that PGE2 produced by COX-2 in the tumor may be important in stimulating estrogen synthesis in the tumor and surrounding tissue. No correlation was observed between aromatase or COX-2 expression and the response of the patients to aromatase inhibitor treatment. However, only 13 patients responded. Nine of these patients were aromatase positive. Although similar to responses in other studies, this low response rate to second line treatment suggests that tumors of most patients were no longer sensitive to the effects of estrogen. Recent clinical studies suggest that greater responses occur when aromatase inhibitors are used as first line treatment. In the intratumoral aromatase mouse model, expression of aromatase in tumors is highly correlated with increased tumor growth. First line treatment with letrozole was effective in all animals treated and was more effective than tamoxifen in suppressing tumor growth. Letrozole was also effective in tumors failing to respond to tamoxifen, consistent with clinical findings. In addition, the duration of response was significantly longer with the aromatase inhibitor than with tamoxifen, suggesting that aromatase inhibitors may offer better control of tumor growth than this antiestrogen.

Intracellular aromatase and its relevance to the pharmacological efficacy of aromatase inhibitors

An important feature of the pharmacological profile of aromatase inhibitors is the ability of the various inhibitors to inhibit intracellular aromatase. It is now well documented that a large proportion of breast tumors express their own aromatase. This intratumoral aromatase produces estrogen in situ and therefore may contribute significantly to the amount of estrogen to which the cell is exposed. Thus it is not only important that aromatase inhibitors potently inhibit the peripheral production of estrogen and eliminate the external supply of estrogen to the tumor cell, but that they in addition potently inhibit intratumoral aromatase and prevent the tumor cell from making its own estrogen within the cell. To study the inhibition of intracellular aromatase we have compared the aromatase-inhibiting potency of the non-steroidal aromatase inhibitors, letrozole, anastrozole and fadrozole in a variety of model cellular endocrine and tumor systems which contain aromatase. We have used hamsters ovarian tissue fragments, adipose tissue fibroblasts from normal human breast, the MCF-7Ca human breast cancer cell line transfected with the human aromatase gene and the JEG-3 human choriocarcinoma cell line. Although letrozole and anastrozole are approximately equipotent in a cell-free aromatase system (human placental microsomes), letrozole is consistently 10-30 times more potent than anastrozole in inhibiting intracellular aromatase in intact rodent cells, normal human adipose fibroblasts and human cancer cell lines. Whether these differences between letrozole and anastrozole are seen in the clinical setting will have to await the results of clinical trials which are currently in progress.

Pregnenolone stimulates LNCaP prostate cancer cell growth via the mutated androgen receptor

Pregnenolone (P(5)), a common precursor of many steroids, is present in the blood of normal adult men at concentrations of 1-3 nM. In vitro, P(5) was found to stimulate LNCaP-cell proliferation 7-8-fold at a physiological concentration (2 nM), and 3-4-fold at a subphysiological concentration (0.2 nM). Growth stimulation at the 2-nM concentration was comparable with that of the androgen, dihydrotestosterone at its physiological concentration (0.5 nM; 9-10-fold increase in cell number). To determine whether P(5) or its metabolites were mediating this growth response, LNCaP cells were incubated with [3H]P(5) and high-performance liquid chromatography (HPLC) was performed. After a 48-h exposure, two unidentified metabolites were detected. Although, the P(5) metabolites slightly increased LNCaP-cell growth in vitro, their effect was significantly less than P(5) alone, suggesting that the growth stimulation was mediated by P(5) itself. We further showed that P(5) sustained its proliferative activity in vivo and stimulated the growth of LNCaP-tumor xenografts in intact male SCID mice as well as in castrated animals. In order to determine whether P(5) was binding to a specific site in LNCaP cells, receptor binding studies were performed. Scatchard analysis predicted for a single class of binding sites with K(d)=1.4 nM. Studies were performed to determine the effects of P(5) on transcription mediated by wild-type and LNCaP androgen receptors. P(5) was shown to activate transcription through the LNCaP androgen receptor (AR), but not the wild-type AR. This implies that P(5) most likely stimulates LNCaP-cell proliferation through binding to the cellular mutated AR present in LNCaP cells. We have also demonstrated that drugs designed to be antagonists of the androgen, progesterone and estrogen receptors, and one of our novel compounds designed to be an inhibitor of androgen synthesis, were potent inhibitors of the AR-mediated transcriptional activity induced by P(5), and were able to inhibit LNCaP-cell proliferation. These findings suggest that some prostate cancer patients who appear to become hormone-independent may have tumors which are stimulated by P(5) via a mutated AR and that these patients could benefit from treatment with antiestrogens, antiprogestins, or with some of our novel androgen synthesis inhibitors.

Antiandrogenic effects of novel androgen synthesis inhibitors on hormone-dependent prostate cancer

We have found that in addition to being potent inhibitors of 17alpha-hydroxylase/C17,20-lyase and/or 5alpha-reductase, some of our novel androgen synthesis inhibitors also interact with the mutated androgen receptor (AR) expressed in LNCaP prostate cancer cells and the wild-type AR expressed in hormone-dependent prostatic carcinomas. The effects of these compounds on the proliferation of hormone-dependent human prostatic cancer cells were determined in vitro and in vivo. L-2 and L-10 are delta4-3-one-pregnane derivatives. L-35 and L-37 are delta5-3beta-ol-androstane derivatives, and L-36 and L-39 are delta4-3-one-androstane-derived compounds. L-2, L-10, and L-36 (L-36 at low concentrations) stimulated the growth of LNCaP cells, indicating that they were interacting agonistically with the mutated AR expressed in LNCaP cells. L-35, L-37, and L-39 acted as LNCaP AR antagonists. To determine whether the growth modulatory effects of our novel compounds were specific for the mutated LNCaP AR, competitive binding studies were performed with LNCaP cells and PC-3 cells stably transfected with the wild-type AR (designated PC-3AR). Regardless of AR receptor type, all of our novel compounds were effective at preventing binding of the synthetic androgen methyl-trienolone[17alpha-methyl-(3H)-R1881 to both the LNCaP AR and the wildtype AR. L-36, L-37, and L-39 (5.0 microM) prevented binding by >90%, whereas L-35 inhibited binding by 30%. To determine whether the compounds were acting as agonists or antagonists, LNCaP cells and PC-3AR cells were transfected with the pMAMneoLUC reporter gene. When luciferase activity was induced by dihydrotestosterone, all of the compounds were found to be potent inhibitors of transcriptional activity, and the pattern of inhibition was similar for both receptor types. However, L-2, L-10, and L-36 were determined to be AR agonists, and L-35, L-37, and L-39 were wild-type AR antagonists. When tested in vivo, L-39 was the only AR antagonist that proved to be effective at inhibiting the growth of LNCaP prostate tumor growth. L-39 slowed tumor growth rate in LNCaP tumors grown in male SCID mice to the same level as orchidectomy, significantly reduced tumor weights (P < 0.05), significantly lowered serum levels of prostate-specific antigen (P < 0.02), and significanty lowered serum levels of testosterone (P < 0.05). L-39 also proved to be effective when tested against the PC-82 prostate cancer xenograft that expresses wild-type AR. These results show that some of our compounds initially developed to be inhibitors of androgen synthesis also interact with the human AR and modulate the proliferation of hormone-dependent prostatic cancer cells. Therefore, compounds such as L-39, which have multifunctional activities, hold promise for the treatment of androgen-dependent prostate tumors.

Anti-tumour effects and pharmacokinetic profile of 17-(5'-isoxazolyl)androsta-4,16-dien-3-one (L-39) in mice: an inhibitor of androgen synthesis

17-(5'-Isoxazolyl)androsta-4,16-dien-3-one (L-39), a novel androstene derivative, was synthesized and evaluated in vitro and in vivo. L-39 showed potent and non-competitive inhibition of human testicular microsomal 17alpha-hydroxylase/C(17,20)-lyase with an IC50 value of 59 nM and Ki of 22 nM. L-39 also showed potent and competitive inhibition of 5alpha-reductase in human prostatic microsomes with IC50 and Ki values of 33 and 28 nM respectively. L-39 (5 microM) has also been shown to manifest anti-androgenic activity in cultures of human prostate cancer cell lines (LNCaP) by preventing the labelled synthetic androgen R1881 (5 nM) from binding to the androgen receptors. Androgen-dependent human prostate cancer xenografts (PC-82) were grown in nude mice and the effects of L-39 (50 mg kg(-1) day(-1)) on tumour growth and prostate-specific antigen (PSA) levels were determined after 28 days. L-39 significantly (P < 0.01) diminished tumour growth and wet weights to a similar extent as castration or flutamide treatment. L-39 also significantly (P < 0.01) reduced serum PSA levels by more than 80% in the mice bearing human prostate cancer xenografts. Pharmacokinetic studies were also conducted in male Balb/c mice. After subcutaneous administration of a single bolus dose, L-39 was rapidly absorbed into the systemic circulation. Peak plasma levels occurred at 0.75 h and then declined with a t(1/2) of 1.51 h. The bioavailability of L-39 after subcutaneous administration was 28.5%. These results demonstrate that L-39 is a potent inhibitor of androgen synthesis and is effective in reducing the growth of human prostate cancer xenografts in nude mice. Although improvements in the bioavailability are necessary, L-39 is a potential lead compound with this profile as an inhibitor of prostate cancer growth.

Effects of new 17alpha-hydroxylase/C(17,20)-lyase inhibitors on LNCaP prostate cancer cell growth in vitro and in vivo

Our laboratory has been developing new inhibitors of a key regulatory enzyme of testicular and adrenal androgen synthesis 17alpha-hydroxylase/C(17,20)-lyase (P450c17), with the aim of improving prostate cancer treatment. We designed and evaluated two groups of azolyl steroids: delta5-non-competitive inhibitors (delta5NCIs), VN/63-1, VN/85-1, VN/87-1 and their corresponding delta4 derivatives (delta4NCIs), VN/107-1, VN/108-1 and VN/109-1. The human P450c17 gene was transfected into LNCaP human prostate cancer cells, and the resultant LNCaP-CYP17 cells were utilized to evaluate the inhibitory potency of the new azolyl steroids. VN/85-1 and VN/108-1 had the lowest IC50 values of 1.25 +/- 0.44 nM and 2.96 +/- 0.78 nM respectively, which are much lower than that of the known P450 inhibitor ketoconazole (80.7 +/- 1.8 nM). To determine whether the compounds had direct actions on proliferation of wild-type LNCaP cells, cell growth studies were performed. All of the delta5NCIs and VN/108-1 blocked the growth-stimulating effects of androgens. In steroid-free media, the delta5NCIs decreased the proliferation of LNCaP cells by 35-40%, while all of the delta4NCIs stimulated LNCaP cells growth 1.5- to 2-fold. In androgen receptor (AR) binding studies, carried out to determine the mechanism of this effect, all of the delta4NCIs (5 microM) displaced 77-82% of synthetic androgen R1881 (5 nM) from the LNCaP AR. The anti-androgen flutamide and the delta5NCIs displaced 53% and 32-51% of R1881 bound to AR respectively. These results suggested that the delta5NCIs may also be acting as anti-androgens. We further evaluated our inhibitors in male severe combined immunodeficient mice bearing LNCaP tumour xenografts. In this model VN/85-1 was as effective as finasteride at inhibiting tumor growth (26% and 28% inhibition, respectively) and the inhibitory effect of VN/87-1 was similar to that of castration (33% and 36% inhibition respectively). These results suggest that VN/85-1 and VN/87-1 may be potential candidates for treatment of prostate cancer.

The effect of combining aromatase inhibitors with antiestrogens on tumor growth in a nude mouse model for breast cancer

We have previously established a model for postmenopausal, hormone-dependent breast cancer in nude mice which is responsive to both antiestrogens and aromatase inhibitors. In this model, MCF-7 human breast carcinoma cells transfected with the aromatase gene (MCF-7CA) synthesize sufficient estrogen to form tumors in ovariectomized nude mice. In the present study we used this intratumoral aromatase model to investigate the effects on tumor growth of the new nonsteroidal aromatase inhibitors letrozole (CGS 20,267) and anastrozole (ZD 1033) and the antiestrogens tamoxifen (ICI 47,474) and faslodex (ICI 182,780). Furthermore, we determined whether the inhibition of estrogen synthesis together with inhibition of estrogen action would be more effective in controlling breast tumor growth. The results of our studies indicate that the aromatase inhibitors anastrozole and letrozole, as well as the new pure antiestrogen faslodex, have potent antitumor effects in the mouse model. In the treatment of mice with mammary tumors, letrozole was more effective in suppressing tumor growth than anastrozole. This was consistent with the Ki values of these inhibitors against placental aromatase and the IC50 values in cell culture (MCF-7CA), which indicated the greater potency of letrozole as an aromatase inhibitor. Letrozole also had greater antitumor effects than tamoxifen and faslodex. The antitumor effect of letrozole was substantial, making it difficult to detect any additional effect on the tumors when letrozole was combined with the antiestrogens. However, the combined treatment of anastrozole + tamoxifen and anastrozole + faslodex also did not increase efficacy compared to the aromatase inhibitor alone. In addition, combining the two antiestrogens did not suppress tumor growth more effectively than faslodex alone. Our results show that treatment with the combinations of aromatase inhibitors with either tamoxifen or faslodex are not more effective in blocking estrogen stimulation of tumor growth than the aromatase inhibitors alone.

Inhibition of androgen synthesis in human testicular and prostatic microsomes and in male rats by novel steroidal compounds

The C(17,20)-lyase and 5alpha-reductase are key enzymes in the biosynthesis of androgens. The effects of novel steroidal compounds were evaluated as inhibitors against both human C(17,20)-lyase and 5alpha-reductase in vitro. The concentrations of testosterone (T) and dihydrotestosterone (DHT) in the prostate, testis and serum and changes in the tissue weights were also determined in rats treated with the novel inhibitors. L-12 and L-26 showed potent inhibition of human testicular C(17,20)-lyase with IC50 values of 50 and 25 nM, respectively. L-12, L-38, and I-47 showed moderate inhibition of human testicular C(17,20)-lyase with IC50 values of 75, 108, and 70 nM, respectively similar to ketoconazole (78 nM). Interestingly, L-6, L-26, and L-38 also showed some inhibitory activity against 5alpha-reductase with IC50 values of 75, 125, and 377 nM, respectively. Finasteride, an inhibitor of 5alpha-reductase had an IC50 value of 33 nM. However, ketoconazole did not inhibit 5alpha-reductase nor did finasteride inhibit C(17,20)-lyase. Treatment of normal male rats with several of these novel inhibitors (50 mg/kg x day, s.c., for 14 consecutive days) caused about 45-91% decrease in serum, testicular and prostatic T concentration. Similarly, serum and prostatic DHT concentration were significantly decreased in rats treated with these novel compounds by 50-90% compared with controls. Surgical castration caused almost complete elimination of circulating T and DHT concentration in rat tissues. L-6 and L-12 were the most effective and reduced the wet weight of the prostate by 50%. Although future improvements in their bioavailability are necessary, these novel steroidal compounds show promise as potential agents for reducing T and DHT levels in patients with androgen dependent diseases.

Comparison of once-daily and twice-daily dosing of 0.75% metronidazole gel in the treatment of bacterial vaginosis

BACKGROUND AND OBJECTIVES

Bacterial vaginosis is the most common cause of vaginal symptoms in women and has potential complications. Efforts to improve treatment of this disease process are warranted.

GOAL OF THIS STUDY

The goal of this study was to compare the safety and efficacy of once-daily intravaginal administration of 0.75% metronidazole gel for 5 days to the established twice-daily regimen in the treatment of bacterial vaginosis.

STUDY DESIGN

Nonpregnant women with bacterial vaginosis diagnosed by accepted clinical criteria at 14 geographically diverse general gynecology clinics were enrolled in this prospective, randomized, investigator-blind, parallel study. They were treated with either once-daily or twice-daily 0.75% metronidazole gel 5 g intravaginally for 5 days and were reevaluated at 7 to 12 days and 28 to 35 days after completing treatment. Efficacy was determined by clinical criteria. Adverse drug reactions were monitored.

RESULTS

Of the 514 evaluable women enrolled, bacterial vaginosis was cured at the first return visit among evaluable patients in 153 of 199 (77%) of those who received the once-daily and in 157 of 196 (80%) of those who received the twice-daily administration. Bacterial vaginosis was cured among evaluable patients at the final visit in 104 of 180 (58%) of those who received once-daily and 109 of 178 (61%) of those who received the twice-daily regimen. Intent-to-treat analysis showed cure at 1 month in 118 of 207 (57%) of those treated once daily and 129 of 209 (62%) of those treated twice daily. Side effects were mild, and none caused treatment discontinuation.

CONCLUSIONS

Once-daily dosing of 0.75% metronidazole gel 5 g for 5 days yields efficacy, safety, and tolerance equivalent to the currently used twice-daily dosing in the treatment of bacterial vaginosis, adding another competitive choice to the available therapeutic options for this condition.

Cytochrome P450c17-expressing Escherichia coli as a first-step screening system for 17alpha-hydroxylase-C17,20-lyase inhibitors

We have designed and synthesized a number of cytochrome P450 17alpha-hydroxylase-C17,20-lyase (P450c17) inhibitors with the aim of inhibiting androgen synthesis. To select the most potent inhibitors, we initially used human testicular microsomes, which have a high level of expression of this enzyme. However, due to lack of availability of human tissue and variability among the samples, we utilized recombinant human enzyme expressed in Escherichia coli. We designed a simple and economical protocol based on the report that recombinant bovine P450c17 can be functionally active in live bacteria. In the assay we report here, we substituted high-performance liquid chromatography product isolation with a rapid biochemical acetic acid releasing assay and utilized intact P450c17-expressing E. coli for the source of the enzyme. Enzymatic parameters of the bacterial system (Km = 5.1 x 10(-7) M, Vmax = 15.0 pmol/min/mg) were similar to those of human testicular microsomes (Km = 4.8 x 10(-7) M, Vmax = 40.0 pmol/min/mg), and our compounds displayed a similar pattern of inhibition in both systems. This new system is a fast, reliable, and reproducible method for screening P450c17 inhibitors. Furthermore, it eliminates our dependence on human tissue and potential data fluctuations caused by variations in enzymatic activity between donors.

The steroidal antiestrogen ICI 182,780 is an inhibitor of cellular aromatase activity

Two types of endocrine therapy that have been successfully applied to patients with hormone-dependent breast cancer are the non-steroidal antiestrogen tamoxifen, and inhibitors of aromatase, the enzyme that synthesizes estrogens. The major drawback with tamoxifen is that it acts as a partial estrogen-agonist and this is believed to mediate, at least in part, acquired tumor resistance to the drug as well as endometrial hyperplasia and carcinoma in some patients. The newer and more potent antiestrogen ICI 182,780 is a steroidal molecule that is devoid of estrogenic activity. We now report that ICI 182,780 is also an inhibitor of aromatase activity in fibroblasts isolated from the normal human breast as well as other carcinoma cell lines that express aromatase (MCF-7Ca breast cancer and JEG-3 choriocarcinoma). ICI 182,780 (1 microM) did not affect aromatase activity levels in human placental microsomes and only inhibited aromatase activity in each of the cell lines following a prolonged incubation period. In the fibroblasts, inhibition of aromatase activity by ICI 182,780 was shown to be time and dose-dependent. In contrast, tamoxifen and 17beta-estradiol were shown to have no effect on aromatase activity levels. ICI 182,780 inhibited aromatase activity levels with IC50 values of 16.80 nM in MCF-7Ca cells, 125.50 nM in JEG-3 cells and 386.1 nM in breast fibroblasts. These values were compared to those for known aromatase inhibitors, and in each of the cell lines the order of potency was letrozole>4-OHA>anastrozole>ICI 182,780. The inhibition of aromatase activity by ICI 182,780 was sustained even after the antiestrogen was removed from the cells indicating that ICI 182,780 may be remaining bound to the enzyme. Although ICI 182,780 had no effect on the proliferation of the fibroblasts, or JEG-3 cells, it significantly inhibited the growth of MCF-7Ca cells. This growth inhibition appeared to be due to the antiestrogenic activity of ICI 182,780 and not to its aromatase inhibiting effects. ICI 182,780 did not inhibit aromatase activity by down-regulating levels of the aromatase transcript. These results show that in addition to being a potent antiestrogen, ICI 182,780 is also an inhibitor of cellular aromatase activity, and suggest that by interfering with the actions of estrogen by two distinct mechanisms, ICI 182,780 may be a suitable drug for treating patients with hormone-dependent breast cancer.

A unique form of proliferating cell nuclear antigen is present in malignant breast cells

Despite extensive research efforts to identify unique molecular alterations in breast cancer, to date, no characteristic has emerged that correlates exclusively with malignancy. Recently, it has been shown that the multiprotein DNA replication complex (synthesome) from breast cancer cells has a significantly decreased replication fidelity compared to that of nonmalignant breast cells. Proliferating cell nuclear antigen (PCNA) functions in DNA replication and DNA repair and is a component of the synthesome. Using two-dimensional PAGE analysis, we have identified a novel form of PCNA in malignant breast cells. This unique form is not the result of a genetic alteration, as demonstrated by DNA sequence analysis of the PCNA gene from malignant and nonmalignant breast cells. This novel form is most likely the result of an alteration in the post-translational modification of PCNA in malignant breast cells. These findings are significant in that it is now possible to link changes in the fidelity of DNA replication with a specific alteration of a component of the DNA synthetic apparatus of breast cancer cells. The novel form of PCNA may prove to be a new signature for malignant breast cells.

Human breast cancer cells contain an error-prone DNA replication apparatus

The mechanisms responsible for creating genetic errors and genomic instability in cancer cells have not been fully defined. Recently, it has been shown that human cells contain a highly organized complex of proteins, termed the DNA synthesome, that is fully competent to carry out all phases of SV40 in vitro DNA replication (J. M. Coll et al, Oncol. Res., 8: 435-447, 1996; L. H. Malkas et al., Biochemistry, 29: 6362-6374, 1990; Y. Wu et al., J. Cell. Biochem., 54: 32-46, 1994; N. Applegren et al., J. Cell. Biochem., 54: 32-46, 1994). DNA replication fidelity analyses of the DNA synthesome derived from malignant and nonmalignant human breast cells demonstrate that the malignant cell synthesome is mutagenic. The decrease in tumor cell replication fidelity was not due to an increased proliferative capacity of the tumor cells or an increase in the synthetic activity of their DNA synthesome. The ratios of insertions, deletions, and mismatches created by the synthesome from malignant and nonmalignant breast cells were essentially identical, despite the greater overall number of mutations made by the breast cancer cell synthesome. These data define, for the first time, a mechanism unique to cancer cells that contributes to the observed increase in genetic mutation in cancer cells.

Novel 17-azolyl steroids, potent inhibitors of human cytochrome 17 alpha-hydroxylase-C17,20-lyase (P450(17) alpha): potential agents for the treatment of prostate cancer

A new synthetic route to a variety of novel delta 16-17-azolyl steroids is described: it involves the nucleophilic vinylic "addition-elimination" substitution reaction of 3 beta-acetoxy-17-chloro-16-formylandrosta-5,16-diene (2) and azolyl nucleophiles. Some of these novel delta 16-17-azolyl steroids, 6, 17, 19, and 27-29, prepared in good overall yields, are very potent inhibitors of human and rat testicular P450(17) alpha. They are shown to be noncompetitive and appear to be slow-binding inhibitors of human P450(17) alpha. The most potent compounds are 3 beta-hydroxy-17-(1H-imidazol-1-yl)androsta-5,16-diene (17), 3 beta-hydroxy-17-(1H-1,2,3-triazol-1-yl)androsta-5,-16-diene (19), and 17-(1H-imidazol-1-yl)androsta-4,16-dien-3-one (28), with Ki values of 1.2, 1.4, and 1.9 nM, respectively, being 20-32 times more potent than ketoconazole (Ki = 38 nM). Spectroscopic studies with a modified form of human P450(17) alpha indicate that the inhibition process involves binding of steroidal azole nitrogen to the heme iron of the enzyme. Furthermore, some of these potent P450(17) alpha inhibitors (27-29) are also powerful inhibitors of steroid 5 alpha-reductase, and others (17 and 19) appear to exhibit strong antiandrogenic activity in cultures of the LNCaP human prostatic cancer cell line. These novel compounds with impressive dual biological activities make them strong candidates for development as therapeutic agents for treatment of prostate cancer and other disease states which depend on androgens.

A controlled trial of physician counseling to promote the adoption of physical activity

BACKGROUND

In accordance with one of the Year 2000 Health Objectives, the current study tests the efficacy of brief physician-based counseling to increase physical activity in sedentary patients in a nonrandomized controlled trial.

METHODS

Control and intervention physicians were matched on medical practice variables. Two hundred fifty-five apparently healthy, sedentary, adult patients were recruited from 17 physician offices (mean age = 39 years, 84% female, 28% ethnic minority). Intervention physicians delivered 3 to 5 min of structured physical activity counseling during a well visit or follow-up for a chronic condition. A health educator made a brief booster phone call to patients 2 weeks after receiving physician counseling. Self-reported physical activity and stage of change (i.e., behavioral readiness to adopt or maintain activity) were collected at baseline and at 4- to 6-week follow-up. Objective activity monitoring was conducted on a subsample.

RESULTS

Intervention patients reported increased walking more than control patients (+37 min/week vs. +7 min/week). There was a significant intervention effect on the activity monitor. Intervention participants also demonstrated a greater increase in readiness to adopt activity than control subjects.

CONCLUSIONS

Physician-based counseling for physical activity is efficacious in producing short-term increases in moderate physical activity among previously sedentary patients.

Reduced levels of cathepsin D associated with tamoxifen resistance and estrogen independence in the ZR-75-1 human breast cancer cell line

The expression and secretion of cathepsin D by ZR-75-1 human breast cancer cells, and tamoxifen-resistant (ZR-75-9a1) and estrogen-independent (ZR-PR-LT) variants was examined by electrophoresis of labeled proteins and Western blotting. Secreted proteins of 160 kDa, 52 kDa and 34 kDa were identified, and in ZR-75-1 cells, they were shown to be estrogen-inducible. Treatment of ZR-75-9a1 cells with 17 beta-estradiol (E2) and the progestin ORG 2058 increased secretion of the 52 kDa protein; ZR-PR-LT cells were unaffected. Western blotting showed that each cell line expressed high levels of the 52 kDa and 34 kDa forms of cathepsin D but that relatively little was being secreted. Each cell line secreted 52 kDa procathepsin D, but 34 kDa mature-cathepsin D was not detected as a secreted protein. ZR-75-1 cells expressed and secreted the highest levels of cathepsin D while ZR-75-9a1 cells expressed and secreted the least.

Invasive capacity and regulation of urokinase-type plasminogen activator in estrogen receptor (ER)-negative MDA-MB-231 human breast cancer cells, and a transfectant (S30) stably expressing ER

We assessed the invasive capacities and expression of urokinase-type plasminogen activator (uPA) in the estrogen receptor (ER) negative MDA-MB-231 cell line, and the same cell transfected with an ER expression vector (S30 cells) in response to 17 beta-estradiol (E2; 1 nM) and epidermal growth factor (EGF; 1 ng/ml and 10 ng/ml). The invasive potential of S30 cells was only 50% that of MDA-MB-231 cells and was further reduced by E2. EGF increased the invasiveness of S30 cells, but was unable to reverse the inhibitory effects of E2. Invasion of MDA-MB-231 cells was unaffected by E2 or EGF. EGF increased uPA secretion from both cell lines, as determined by ELISA and zymography, and this correlated with increased expression of uPA mRNA. uPA expression in MDA-MB-231 cells was unaffected by E2; however, S30 cells responded to E2 with downregulation of uPA at both the protein and mRNA levels.