Saturation of 1-beta-D-arabinofuranosylcytosine 5'-triphosphate accumulation in leukemia cells during high-dose 1-beta-D-arabinofuranosylcytosine therapy

Twenty-seven patients with refractory leukemia were treated with 1-beta-D-arabinofuranosylcytosine (ara-C), 0.3 to 3.0 g/m2 as i.v. infusions over 1, 2, 4, or 24 h. The pharmacokinetics of ara-C in plasma and its 5'-triphosphate (ara-CTP) in leukemic cells from peripheral blood were studied after a single infusion of 3 g/m2 over 2 h in 13 patients. Accumulation of ara-CTP in leukemic cells remained linear until 1 to 2 h after the infusion. At the time when the rate of ara-CTP accumulation deviated from linearity, the plasma concentration of ara-C was 5- to 20-fold lower [8.1 +/- 4.4 (SD) microM] than the steady-state level during the infusion. Plasma ara-C and cellular ara-CTP pharmacokinetics were studied after two serial infusions in 14 additional patients. Varying the duration of infusion of an ara-C dose between 1, 2, and 4 h (corresponding to infusion rates of 3000, 1500, and 750 mg/m2/h) did not substantially change the rate of ara-CTP accumulation by leukemic cells. The peak ara-CTP concentration and the area under the concentration times time curve (AUC) of ara-CTP in leukemic cells increased with prolongation of the infusion. Although steady-state concentration of ara-C and AUC of ara-C in plasma were proportionally reduced by 1.0 or 0.5 g/m2 infusion over 2 h, ara-CTP accumulation rate and AUC in leukemic cells did not change compared with administration of 3 g/m2 over 2 h. However, when the infusion rate was further reduced to 0.4 or 0.3 g/m2 over 2 h, resulting in steady-state plasma ara-C concentrations of less than 7 microM, the accumulation rate of ara-CTP was substantially reduced as was the ara-CTP intracellular AUC. The cellular elimination rate of ara-CTP remained constant under all infusion conditions. These findings support the conclusion that high-dose ara-C therapy, as currently administered, results in plasma ara-C concentrations that saturate the accumulation of ara-CTP by circulating leukemic cells. We recommend that intermediate dose rates, 200 to 250 mg/m2/h, be evaluated in future studies as an alternative to the substantially higher ara-C dose rates currently in use.

Effect of amsacrine on ara-CTP cellular pharmacology in human leukemia cells during high-dose cytarabine therapy

The combination of high-dose cytarabine (ara-C) and amsacrine (m-AMSA) is effective treatment for relapsed adult acute leukemia. Studies were performed to determine if m-AMSA affected the pharmacokinetics of the active triphosphate ara-CTP in HL-60 and K562 cells in culture. No significant differences were observed in accumulation, rate of elimination, or total intracellular exposure to ara-CTP in cultures treated with 100 microM ara-C alone or in combination with 1 microM m-AMSA. In clinical investigations, the accumulation and retention of ara-CTP in circulating leukemic cells were studied in five patients after two serial doses of ara-C (3 g/m2 infused over 2 hours) and in six additional patients in whom the second dose of ara-C was accompanied by an infusion of m-AMSA (30 mg/m2 infused over 1 hour). While substantial differences were observed in the cellular pharmacokinetics of ara-CTP among patients, the rate of ara-CTP elimination and the total intracellular exposure to ara-CTP in individuals were remarkably similar after each ara-C infusion. Infusion of m-AMSA with the second dose of ara-C did not significantly affect the cellular pharmacokinetics of ara-CTP. These studies demonstrate the feasibility and utility of conducting investigations of the cellular pharmacology of drug-drug interactions in human leukemic cells during therapy.

[Two-dimensional echocardiography in the quantification of severe mitral stenosis]

The aim of the study was to evaluate the accuracy of echocardiographic quantification of mitral valve opening area in severe mitral stenosis. 31 consecutive patients with severe mitral stenosis were studied with two-dimensional echocardiography before they had complete resection of the mitral valve. The valves were examined for calcifications by x-ray. Each specimen was tensionlessly suspended in a glass cylinder, with 10 to 15 l of warm water (37 degrees C) running through it until maximal opening of the valve. Then the valvular orifice was photographed for planimetry. Now the echocardiographic results were checked again to analyse the errors of the initial assessment. In 6 out of 31 patients the size of the valvular opening area could not be assessed echocardiographically due to poor echo quality. The mean mitral opening area of the specimens was 0.92 +/- 0.32 cm2. With 1.27 +/- 0.52 cm2, the results achieved by echocardiography reached a correlation of only r = 0.44. In 9 out of 25 patients the area was assessed precisely in terms of size and anatomy. The difference between the values calculated from the specimens and echocardiograms was below 0.5 cm2 in 19 out of 25 (76%) patients and below 1 cm2 in another 4 (16%) patients. A larger difference in two patients was due to incorrect beam direction. Otherwise, false results in 10 out of 25 patients were caused by multiple inner echoes and in 2 out of 25 patients by bright reflections due to calcifications. Although the echocardiographically assessed mitral valve opening area does not correlate with the real opening area, it is possible to distinguish in most patients between severe and mild stenosis. Furthermore the valvular opening area can be exactly determined up to 0.5 cm2 in 90 percent of patients, provided that the echo beam is correctly positioned.

[In vitro study of transvenous commissurotomy in severe mitral valve stenoses using the balloon catheter]

To answer the question whether mitral commissurotomy with a balloon catheter is possible, the following in vitro study was performed. In 12 patients who were operated due to severe mitral stenosis the fibrotic (n = 8) or calcified (n = 4) valves were excised and mounted in a glass cylinder. In a first step a valvuloplasty was performed with a balloon catheter (size 20 mm). Mitral valve area increased by about 40%. With simultaneous inflation of a second balloon catheter (size 15 mm) valve area increased more than 100% and reached 1.63 cm2 in the mean. Valvuloplasty was successful (increase of at least 0.5 cm2) in 11/12 cases. In 9 valves the rupture occurred within the commissures, twice within the leaflets and once the opening area increased due to dilatation. Commissurotomy with a balloon catheter seems to be possible even in calcified mitral valves although in most cases a mild to moderate stenosis will remain.

Physical mapping of human cytomegalovirus genes: identification of DNA sequences coding for a virion phosphoprotein of 71 kDa and a viral 65-kDa polypeptide

Polyadenylated RNA was isolated from fibroblast cultures infected with human cytomegalovirus (HCMV) strain AD169 during the late phase of viral replication. The RNA was selected by hybridization to a series of cosmid clones containing the entire viral genome in partially overlapping segments. Translation of this RNA in a reticulocyte cell-free system allowed the mapping of virus specific polypeptides. Nine polypeptides synthesized in vitro comigrated with major virion structural proteins. An in vitro-translated protein of 71 kDa was precipitated by a monoclonal antibody directed against the phosphorylated internal envelope protein of 71 kDa. The map coordinates of viral DNA coding for this phosphoprotein were localized by hybrid selection with subcloned DNA fragments, and the direction of transcription was determined by hybrid selection with single-stranded DNA cloned in bacteriophage vector M13mp9. An in vitro translation with size-fractionated RNA, combined with immunoprecipitation and Northern blot analyses, indicated that an mRNA of 4 kb encodes the 71-kDa phosphoprotein. An mRNA of the same size, map coordinates, and orientation was translated into an abundant 65-kDa polypeptide which had the same size as the major structural phosphoprotein of HCMV.

Characterization of monoclonal antibodies and polyclonal immune sera directed against human cytomegalovirus virion proteins

Four classes of monoclonal antibody-producing cell lines have been obtained that detect human cytomegalovirus virion structural proteins. These antibodies react with (1) a major outer membrane virion glycoprotein(s) gp58-gp130, whose molecular weight varies between strains of cytomegalovirus, (2) a phosphoprotein, pp71, localized inside the virion membrane, (3) a phosphorylated nucleocapsid protein, pp155, and (4) a virion-associated phosphoprotein, pp29. Polyclonal immune human sera react with a large number of virion proteins including those detected by these monoclonal antibodies. These monoclonal antibodies were employed in a radioimmune assay to detect low levels (6 X 10(3) PFU/ml) of human cytomegalovirus in solution and human urine. These antibodies were also employed in a fluorescent antibody format to identify cytomegalovirus-infected cells obtained from human urine and nasopharyngeal aspirates. These reagents provide useful tools for studying the molecular biology of virus replication, for diagnosing cytomegalovirus infections, and for studying virus latency and activation.

Genome structure and virion polypeptides of the primate herpesviruses Herpesvirus aotus types 1 and 3: comparison with human cytomegalovirus

Two serologically distinguishable primate herpesviruses, Herpesvirus aotus type 1 and type 3, were examined with regard to their genomes and structural polypeptides. The duplex DNA genomes of these two viruses were found to be essentially identical in molecular weight (Mr approximately equal to 145 X 10(6)) and guanine plus cytosine composition (55%). Both contained unique and inverted repeat nucleotide sequences of the same size and arrangement, which, as judged by DNA-DNA hybridization and restriction enzyme analyses, were at least 95% homologous. In addition, no differences were observed in electrophoretic profiles of virion polypeptides. Because of their great similarity with respect to these criteria, the two viruses ought to be considered independent isolates (or strains) of a single virus, which should be designated H. aotus type 1. The elevated molecular weight and presence of two sets of inverted repeat sequences closely resemble the structure of the human cytomegalovirus genome. However, no sequence homology (less than 5%) nor similarity in virion polypeptides was detected between H. aotus type 1 and human cytomegalovirus.

Detection and characterization of multiple forms of simian virus 40 large T antigen

Subclasses of simian virus 40 large T antigen in simian virus 40-transformed and -infected cells separated by zone velocity sedimentation in sucrose density gradients have been characterized. Three forms of large T antigen were distinguished: a 5 to 6S form, a 14 to 16S form, and a 23 to 25S form. These forms appeared to differ biochemically and biologically. Differential labeling experiments suggested that the 5 to 6S form was less highly phosphorylated than the faster-sedimenting forms. The 23 to 25S form which was complexed with one or more host phosphoproteins, as reported recently (D. P. Lane and L. V. Crawford Nature [London] 268:261-263, 1979; F. McCormick and E. Harlow, J. Virol. 34: 213-224, 1980), was prominent in extracts of transformed cells, but was also detected in productively infected cells. Pulse-chase experiments suggested that the 5 to 6S large T antigen is a precursor of the more stable, faster-sedimenting forms of T antigen. Monkey cells infected with a tsA mutant of simian virus 40 at 41 degrees C contained only 5 to 6S large T antigen, implying that this form is not active in the initiation of simian virus 40 DNA replication. In pulse-chase, shift-down experiments, DNA replication resumed, and the 5 to 6S large T antigen which had accumulated at 41 degrees C was partially converted at 33 degrees C to a fast-sedimenting form. However, shift-up experiments demonstrated that the fast-sedimenting large T antigen, once formed, remained stable at 41 degrees C, although it was unable to function in initiation. These experiments suggest that different biological functions of large T antigen may be carried out by different subclasses of this protein.

Provocative testing for coronary arterial spasm: rationale, risk and clinical illustrations

Two cases of Prinzmetal's variant angina are presented in which coronary spasm was documented by electrocardiographic evidence obtained in the coronary care unit during provocative testing with ergonovine maleate after the arteriographic demonstration of anatomically normal coronary arteries. The rationale and risks of provocative testing for spasm in patients with chest pain and anatomically normal coronary arteries are reviewed. The advantages of performing provocative testing in the coronary care unit after arteriography rather than in the catheterization laboratory during coronary arteriography are discussed.