Characterization of radioactive metabolites of 5-HT2A receptor PET ligand [18F]altanserin in human and rodent

This study was performed to identify and characterize the radiometabolites of the serotonin 5-HT2A receptor ligand [18F]altanserin in supporting quantification of the target receptors by positron emission tomography. In analogy to its analog ketanserin, we postulated 4-(4-fluorobenzoyl)piperidine (FBP) and altanserinol for the previously observed two polar radiometabolites, corresponding to dealkylation at the piperidine nitrogen and reduction at the ketone, respectively. To test this hypothesis and characterize the in vivo and in vitro behavior of the radiometabolites, we synthesized nonradioactive authentic compounds altanserinol, 1-(4-fluorophenyl)-1-(piperidin-4-yl)methanol (FBPOH), and isolated nonradioactive FBP metabolite from monkey plasma. [18F]Altanserinol was obtained by NaBH4 reduction of [18F]altanserin, followed by acid hydrolysis. Identification of radiometabolites was carried out by high performance liquid chromatography and thin layer chromatography comparison of the radioactive plasma after injection of tracers with five authentic compounds. Human studies revealed that at least four radiometabolites, one identified as [18F]altanserinol, resulted from reduction of the ketone functionality. The N-dealkylation product [18F]FBP was not detectable; however, a radiometabolite of FBP was present in plasma after administration of [18F]altanserin. Monkey studies showed nonradioactive FBP was converted rapidly to a less polar metabolite. In rat, altanserin and altanserinol were converted to each other in vivo, and all the radiometabolites likely penetrated the blood-brain barrier and entered the brain. Displacement binding of altanserin to cloned serotonin 5-HT2A, 5-HT2C, 5-HT6, and 5-HT7 receptors showed Ki values of 0.3, 6.0, 1,756, and 15 nM; the binding of FBP and altanserinol to these four 5-HT subtypes was negligible. We conclude from these studies that the radiometabolites of [18F]altanserin from N-dealkylation and ketone reduction should not interfere with specific receptor quantification in an equilibrium paradigm.

Scrofuloderma of the lower extremity treated with wide resection: a case report and review of the literature

Scrofuloderma is tuberculosis of subcutaneous tissue that ulcerates and drains through the overlying skin. It most commonly occurs in the neck from a cervical lymph node source. Although such lymphatic spread is the usual clinical picture, there are sporadic reports in the literature of direct hematogenous seeding of subcutaneous tissue forming a tuberculoma, or "cold abscess." Definitive diagnosis requires the identification of Mycobacterium tuberculosis within the suspect lesion. Surgical intervention is necessary in any draining lesion and should be accompanied by appropriate antituberculous chemotherapy. Accounts of bone and joint involvement are numerous, but the orthopedic surgeon must also be aware of the soft-tissue manifestations of tuberculosis and the indications for surgery. We report on an immunocompromised patient who presented with a rare case of scrofuloderma of the lower extremity, which was treated with wide resection.

[Foster care for adolescents with severe psychic disorders]

An introduction to the concept and practical implementation of a project entitled "Care in families for young people with mental disorders" is presented. In a project five adolescents were placed in fostering families. Continuous care is provided by a professional family care team and the treatment as out-patients at the Department of Child und Adolescent Psychiatry and Psychotherapy, in which they were previously treated, is continued.

Esophageal motility patterns in patients with and without coronary heart disease and healthy controls

BACKGROUND/AIMS

The aim of the study was to evaluate esophageal motility patterns in patients with chest pain with and without coronary artery disease, in order to elucidate the question: Does "non-cardiac" chest pain really exist?

METHODOLOGY

Patients with chest pain and normal coronary angiograms, patients with chest pain and coronarographically diagnosed coronary artery disease and controls were prospectively studied with long-term manometry.

RESULTS

The pressure amplitudes were 38.3 (NCA)/39.82(CAD) and 30 (CG) mmHg (p<0.02, p<0.02) distally and 30/28.1 and 25.5 mmHg (p<0.02) proximally. The percentage of propulsive contractions were 51.5%/45% and 53.5% (p<0.05) and of simultaneous contractions were 18.5%/23% and 10% (p<0.0005, p<0.0001).

CONCLUSIONS

Esophageal motility patterns of patients with chest pain and normal coronary angiograms and coronary artery disease differ significantly from controls. Both patient groups show a considerable overlap in motility disturbances. These data indicate that the term "non-cardiac" chest pain in fact does not sufficiently characterize patients' status.

Early metabolic acidosis and coma after acetaminophen ingestion

Metabolic acidosis and coma may develop in patients who experience severe hepatic injury after acetaminophen poisoning. The onset of acidosis and coma soon after acetaminophen overdose, but preceding manifest hepatic injury, contrasts with the typical course of poisoning. This pattern has been reported in a limited number of cases. Coingestions and the rare occurrence of these findings after an overdose have engendered controversy as to whether acetaminophen alone is the cause of early coma and acidosis. We describe 4 separate overdoses among 3 patients who arrived at the emergency department comatose with a metabolic acidosis soon after ingesting large amounts of acetaminophen without evidence of toxic liver injury. Our cases support the view that early metabolic acidosis with coma does indeed occur after acetaminophen poisoning, independent of hepatic failure or its complications.

Hydroxylated metabolites of thalidomide: formation in-vitro and in-vivo in man

There is renewed interest in the clinical use of thalidomide, because of its unique immunomodulating action. Because data on the metabolism of thalidomide in man are very sparse, the aim of this study was to develop HPLC assays for the 5-hydroxy, 5,6-dihydroxy, 4,5-dihydroxy and 5'-hydroxy metabolites of thalidomide and to investigate their possible formation in man-in-vitro in liver homogenates and in-vivo in healthy volunteers. Reversed-phase HPLC assays with UV detection were developed for quantification of the metabolites in the low ng mL(-1) range in plasma and incubate samples. The stability of the metabolites was investigated and degradation was avoided by rapid chilling and acidification of the samples. After incubation of thalidomide with fraction S9 from human liver, formation of the 5-hydroxy and 5'-hydroxy metabolites could be demonstrated. The 5'-hydroxy metabolite was found, in low concentrations, in plasma samples from eight healthy male volunteers who had received thalidomide orally. The other three metabolites could not be found by HPLC with detection limits of 1-2 ng mL(-1). Thus the formation of two hydroxylated metabolites of thalidomide in the liver in man was demonstrated, but only one of these could be detected in the circulation.

Jaw lift--a simple and effective method to open the airway in children

Assessment of breathing during resuscitation of children is important. Misjudgement due to failure to open the airway may lead to mouth-to-mouth ventilation in unconscious children who have retained spontaneous breathing efforts, and might lead to completely ineffective ventilation with gastric distension. The efficiency of the standard head tilt-chin lift manoeuvre (HT-CL) and the jaw lift manoeuvre (JL) for opening of the airway in children was investigated. Fifty children between 1 and 9 years of age breathing spontaneously during deep anaesthesia were studied. Both manoeuvres were randomly performed in all children by nurse anaesthetists. The time for opening and the quality of the airway was determined by a blind folded anaesthesiologist listening to the breathing sounds. The standard HT-CL manoeuvre was insufficient in 12% of the children. JL was more effective than HT-CL in opening the airway in unconscious children who had retained attempts at spontaneous breathing. The JL manoeuvre may, therefore, be recommended in situations when the HT-CL manoeuvre is insufficient.

Proton MR spectroscopy in infants with cerebral energy deficiency due to hypoxia and metabolic disorders

PURPOSE

To investigate the similarities and differences of cellular energy deficiencies due to asphyxia and to impaired oxidative phosphorylation caused by enzyme deficiencies using localized 1H-MR spectroscopy of the brain.

MATERIAL AND METHODS

In 35 neonates and infants with a postconceptional age of 36.4-153 weeks, 1H-MR spectra were obtained from the basal ganglia. Of the 35 children, 14 served as a control group, 12 suffered from hypoxic-ischemic disease (HIE), and 9 had congenital enzymatic disorders.

RESULTS

Eleven of the 12 children with HIE showed low N-acetyl aspartate (NAA) to trimethylamine (TMA) ratios, indicating neuronal damage. Lactate (Lac) to TMA ratios correlated with the HIE grade. Children with congenital disorders of energy metabolism had NAA/TMA ratios ranging from severely decreased to normal, but 7 of the 9 had high Lac signals, even in brains with normal NAA/TMA.

CONCLUSION

High Lac/TMA even with normal NAA/TMA in children with enzyme deficiencies, in contrast to Lac/TMA that correlates with clinical grade and low NAA/TMA in asphyxic children, hints at different mechanisms of cell damage in the two disease groups.

Attenuated hematopoietic response to granulocyte-macrophage colony-stimulating factor in patients with acquired pulmonary alveolar proteinosis

The pathogenesis of acquired pulmonary alveolar proteinosis (PAP), a rare lung disease characterized by excessive surfactant accumulation within the alveolar space, remains obscure. Gene-targeted mice lacking the hematopoietic growth factor granulocyte-macrophage colony-stimulating factor (GM-CSF) or the signal-transducing beta-common chain of the GM-CSF receptor have impaired surfactant clearance and pulmonary pathology resembling human PAP. We therefore investigated the hematopoietic effects of GM-CSF in patients with PAP. The hematologic response of 5 infants with congenital PAP to 5 microgram/kg/d was of normal magnitude. By contrast, despite normal expression of GM-CSF receptor alpha- and beta-common chains on peripheral blood myelomonocytic cells (n = 6) and normal binding affinity of bone marrow mononuclear cells for GM-CSF (n = 3), each of the 12 patients with acquired PAP treated displayed impaired responses to GM-CSF; 5 microgram/kg/d produced only minor eosinophilia, and doses of 7.5 to 20 microgram/kg were required to induce >/=1.5-fold neutrophil increments in the 3 patients who underwent dose-escalation. However, neutrophilic responses to 5 microgram/kg granulocyte colony-stimulating factor (G-CSF) were normal (n = 4). In vitro, the proportion of hematopoietic progenitors responsive to GM-CSF (16.1% +/- 8.9%; P = .042) or interleukin-3 (IL-3; 19.3% +/- 7.7%; P = .063), both of which utilize the beta-common chain of the GM-CSF receptor complex, were reduced among patients with acquired PAP (n = 4) compared with normal bone marrow donor controls (47.2% +/- 25.9% and 40.9% +/- 18.6%, respectively). In the one individual who had complete resolution of lung disease during the period of study, this was temporally associated with correction of this defective in vitro response to GM-CSF and IL-3 on serial assessment. These data establish that patients with acquired PAP have an associated impaired responsiveness to GM-CSF that is potentially pathogenic in the development of their lung disease. Based on these observations, we propose a model of the pathogenesis of acquired PAP that suggests the disease arises as a consequence of an acquired clonal disorder within the hematopoietic progenitor cell compartment.

Oxalate, citrate, and sulfate concentration in human milk compared with formula preparations: influence on urinary anion excretion

BACKGROUND

Nephrocalcinosis is not uncommon in preterm infants, and elevated urinary oxalate excretion is known to be one of the main risk factors. When oxalate excretion was found to be higher in formula-fed than in human milk-fed infants, the formulas' oxalate content was thought to be responsible.

METHODS

The oxalate concentration in human milk (21 samples obtained during lactogenesis; 17 samples obtained during established lactation) and of 16 formula preparations was examined. Citrate and sulfate concentrations were also measured, because both anions influence urinary saturation.

RESULTS

The mean (+/- SE) oxalate content of human milk increased approximately 27% from early lactogenesis (70.4 +/- 6.4 micromol/1) to established lactation (96.4 +/- 9.5 micromol/l; p < 0.05). The latter was not different from the mean oxalate concentration of formula (98.2 +/- 11.4 micromol/l), however a fourfold range of measurements was recorded in both groups. The mean citrate content of human milk increased only slightly after early lactogenesis (2.66 +/- 0.22 mmol/l), but remained significantly lower than in formula (3.34 +/- 0.23 mmol/l; p < 0.05). The mean sulfate concentration did not increase and was 13 times lower in human milk (52.1 +/- 9.5 micromol/l) than in formula (688.7 +/- 95.4 micromol/l; p < 0.0001).

CONCLUSIONS

The higher oxalate excretion in formula-fed infants is not because of the milk's oxalate concentration. Urinary citrate and sulfate excretion may be influenced by their higher concentrations in formula preparations, which may be of clinical importance in the population that is at risk for development of nephrocalcinosis.

Epidemiology and etiology of acquired hearing disorders in childhood in the Cologne area

Because of their serious consequences for all aspects of development, severe hearing disorders in children are an important clinical entity. A better understanding of the epidemiology and etiology of acquired hearing disorders may potentially lead to more effective prevention. Marked differences in the epidemiology of acquired hearing disorders are reported in the literature. In order to illuminate the problem of acquired disorders and to define current etiological causes with special regard to ethnological factors in the Cologne area, we started a retrospective study. A total of 314 children in residence at the school for hearing impaired children in Cologne were investigated. We also obtained concise data on the structure of the population in order to determine prevalence of acquired hearing disorders in the German and immigrant portions of the population. We found an overall prevalence of 0.43 per thousand for severe hearing disorders and deafness. German children were most frequently affected by acquired, and non-German children by hereditary hearing disorders. The most common causes of acquired severe hearing disorder were the perinatal complex of premature delivery, anoxia and hyperbilirubinuria or kernicterus. Other causes were congenital rubella infections and meningitis in early childhood. The accumulation of perinatal etiologies seems to be the reason for the remarkable majority of acquired hearing disorders among German children. One reason might be progress in neonatology which exerts two effects. It decreases perinatal mortality but increases perinatal complications like acquired hearing impairment. The incidence of congenital rubella in Germany has decreased during recent years, reaching a low level.

A 12-year-old boy with fatal hemolytic-uremic-syndrome, excessive neutrophilia and elevated endogenous granulocyte-colony-stimulating-factor serum concentrations

We report the case of a 12-year-old boy with fatal enteropathic hemolytic-uremic syndrome who developed excessive neutrophilia in the course of his disease, his leukocyte count exceeding 200,000/mm3. Neutrophilia, as it was observed in this case, is an extreme manifestation of a phenomenon, that is commonly observed in hemolytic-uremic syndrome [Salzmann et al. 1991]. Neutrophilia is suspected to be correlated with a bad prognosis [Walters et al. 1989], but further explanation of this phenomenon is needed. Other underlying diseases related with neutrophilia, especially hematologic malignancies, could be ruled out by far. We examined endogenous G-CSF serum concentrations of the HUS patient from day 6 to 13 in the course of the disease. The assayed concentrations were found to be elevated in the first two samples taken (peak level 340 pg/ml). In the samples taken after plasmapheresis had started, G-CSF concentrations were not found to be elevated. The peak of neutrophilia was reached short before death on day 13 of the disease. We also measured the serum G-CSF concentrations of 28 children aged 3 months to 12 years, who were treated with various infectious and noninfectious diseases in our hospital. In none of the examined samples was there a G-CSF serum concentration exceeding 50 pg/ml. The reported case shows evidence that the commonly observed coincidence of leukocytosis and HUS may reflect the role of G-CSF (and other cytokines) in the inflammatory process underlying the HUS.

Biochemical and ultra-structural reactions to parenteral nutrition with two different fat emulsions in rats

OBJECTIVE

To compare the effects on fat metabolism and Kupffer cell morphology by total parenteral nutrition (TPN) with two different fat emulsions.

DESIGN

Thirty-two male Sprague-Dawley rats, divided into three groups, were investigated. Rats fed orally were used as a reference group, and a group of rats receiving TPN with fat emulsions containing pure long-chain triglycerides (LCT) was compared to a group of rats receiving fat emulsions containing both long-chain triglycerides and medium-chain triglycerides (MCT/LCT). The TPN regimens were equicaloric and administered continuously via a jugular catheter for 10 days.

INTERVENTIONS

After suffocation, blood of the rats was collected for the determination of serum lipids. Epididymal fat and heart were collected for the analysis of lipoprotein lipase (LPL) activities, and liver specimens were saved for analyses of hepatic triglyceride concentration, as well as activities of hepatic lipase (HL) and lysosomal enzymes. Light and electron microscopy were used for examination of the Kupffer cell reaction.

RESULTS

Directly after termination of parenteral feeding, the levels of serum triglycerides and high density lipoprotein (HDL) triglycerides were higher in the MCT/LCT group than in the LCT group, while no differences concerning cholesterol and phospholipid concentrations were found. No significant difference in liver steatosis was found between the two TPN groups. Comparison of the TPN groups showed that the MCT/ LCT group had significantly decreased LPL activity in adipose tissue, while the LCT group had significantly increased LPL activity in the heart. The activity of HL was low in both groups, but significantly lower in the LCT group. Lipid accumulation and an increased number of lysosomes were found in all Kupffer cell when TPN with LCTemulsions was used. Moreover, TPN induced a pronounced increase in various liver lysosomal enzyme activities, but there was no notable difference between LCT and MCT/LCT effects.

CONCLUSIONS

Compared to treatment with pure LCTemulsions, treatment with MCT/LCT emulsions evoked weaker biochemical reactions in terms of lower activity of lipoprotein lipase in fat and heart together with higher serum and HDL triglyceride levels. Morphological signs of increased Kupffer cell activity such as the appearance of multiple lysosomes and fat vacuoles in the cytoplasm followed treatment with pure LCT emulsions. However, both TPN groups showed a marked increase in activities of liver lysosomal enzymes.

Enantiomers of thalidomide: blood distribution and the influence of serum albumin on chiral inversion and hydrolysis

The aim of this investigation was to elucidate the distribution and reactions of the enantiomers of thalidomide at their main site of biotransformation in vivo, i.e., in human blood. Plasma protein binding, erythrocyte: plasma distribution, and the kinetics of chiral inversion and degradation in buffer, plasma, and solutions of human serum albumin (HSA) were studied by means of a stereospecific HPLC assay. The enantiomers of thalidomide were not extensively bound to blood or plasma components. The geometric mean plasma protein binding was 55% and 66%, respectively, for (+)-(R)- and (-)-(S)-thalidomide. The corresponding geometric mean blood:plasma concentration ratios were 0.86 and 0.95 (at a haematocrit of 0.37) and erythrocyte:plasma distributions were 0.58 and 0.87. The rates of inversion and hydrolysis of the enantiomers increased with pH over the range 7.0-7.5. HSA, and to a lesser extent human plasma, catalysed the chiral inversion, but not the degradation, of (+)-(R)- and (-)-(S)-thalidomide. The addition of capric acid or preincubation of HSA with acetylsalicylic acid or physostigmine impaired the catalysis to varying extents. Correction for distribution in blood enhances previously observed differences between the pharmacokinetics of the enantiomers in vivo. The findings also support the notion that chiral inversion in vivo takes place mainly in the circulation and in albumin-rich extravascular spaces while hydrolysis occurs more uniformly in the body. In addition, the chiral inversion and hydrolysis of thalidomide apparently occur by several different mechanisms.

[Etiology of moderate and profound deafness in childhood]

The present study sought to determine the etiology of bilateral profound hearing losses in children living in Germany. Additionally, a comparison with the data of previous investigations in the available literature was used to update causes now known through medical progress.

PATIENTS AND METHODS

The medical charts of 314 profoundly hearing-impaired pupils at schools for the deaf in Cologne, Germany, were reviewed. All available data on possible etiological factors were collected. In addition, the families of these children were interviewed using a standardized questionnaire.

RESULTS

Sixty children were found to have bilateral sensorineural hearing losses averaging 30 to 60dBHL within the frequency ranges of 500-2000 HZ, while 254 had bilateral hearing impairments of 60 dBHL or greater. The etiology of the hearing disorder could be determined in 218 of the children. Eighty-two children suffered from hereditary deafness and 136 from acquired hearing losses. The etiology could not be determined in 96 children. Hereditary causes included 34 children with mendelian autosomal dominant losses, 46 with autosomal recessive losses and two children with genetic but non-mendelian causes. Immigrants to Germany (mostly from Turkey and the former Soviet Union) were found significantly more frequently among the students of these schools, than among the total population of the Cologne area. In this group of students, autosomal recessive deafness was particularly common as compared to the overall native population. Acquired hearing disorders were broken down into three subgroups: prenatal, perinatal and postnatal disorders. A prenatal etiology was considered in 32 children, 21 of whom had known congenital rubella infection. This entity was significantly less common among younger children. A perinatal etiology was considered in 60 children. Causative factors were birth asphyxia, apnea and/or hyperbilirubinemia. Forty-four children had deafness attributed to postnatal causes, with bacterial meningitis (n = 31) being the most important single factor. The findings reported indicate changing trends for causes of hearing loss in children with severe hearing impairment in Germany.

The significance of oncometry for infusion therapy during pediatric heart surgery

BACKGROUND

The colloid osmotic pressure (COP) is not routinely assessed during pediatric heart surgery. Two cases of unrecognized hyperoncotic states associated with renal failure have been observed after pediatric heart surgery. We studied the hypothesis that the COP cannot be estimated from the total plasma protein (TPP) or albumin level.

METHODS

The course of COP and its correlation to the TPP and albumin level were investigated in 25 children undergoing elective heart surgery. Infusion therapy was performed solely on the basis of clinical parameters and TPP/albumin levels. COP values were determined in a blinded fashion at the end of the study.

RESULTS

No correlation between TPP/albumin and the COP could be determined preoperatively. On arrival at the ICU correlation was strong. A weak correlation was observed at 24 hours and 48 hours after surgery. However, the observed wide range of the confidential bands indicates that the COP cannot be estimated correctly, neither from the TPP, nor from the albumin level. Due to colloidal oversubstitution COP was significantly increased compared to preoperative level at 48 hrs following surgery.

CONCLUSIONS

As estimation of COP from TPP or albumin level is inaccurate, oncometry should be performed during pediatric heart surgery.

A prospective, randomized, multicenter trial of high-frequency oscillatory ventilation compared with conventional ventilation in preterm infants with respiratory distress syndrome receiving surfactant

OBJECTIVES

To compare high-frequency oscillatory ventilation (HFOV) and intermittent positive pressure ventilation (IPPV) as a primary ventilation mode in preterm infants with respiratory distress syndrome. Primary end points were survival and maintenance of the randomized ventilation mode.

STUDY DESIGN

Prospective, multicenter, randomized clinical trial.

SETTING

Level III neonatal intensive care units at three university children's hospitals.

PATIENTS

Ninety-six premature infants (gestational age < 32 weeks) randomly assigned to HFOV or IPPV within the first 2 hours of life. All patients received a natural surfactant. No differences were found between the study groups with respect to the demographic data or the severity of respiratory distress syndrome. Infants were stratified at randomization, by birth weight, into two groups: 750 to 1000 gm (n = 32) and 1001 to 1500 gm (n = 64). The centers involved complied with a study protocol that planned a reduction in respiratory pressures when the infant's oxygen requirement had reached a fractional concentration of inspired oxygen of 0.6.

RESULTS

Five patients in the HFOV group died, and eight patients did not respond to the randomized ventilation mode; whereas four patients in the IPPV group died, and nine were switched to HFOV. No differences were found in gas exchange or ventilator support over the first 72 hours. Premature infants with a birth weight < 1000 gm had a significantly shorter course to reach fractional concentration of inspired oxygen of 0.21 while receiving IPPV than those receiving HFOV (9.3+/-4.5 days vs 27.5+/-10.2 days, p = 0.01). No differences were found between the groups in extraalveolar air (HFOV seven; IPPV, seven) and intracranial bleeding (HFOV, nine; IPPV, eight).

CONCLUSION

After surfactant treatment, HFOV, as a primary ventilation mode in premature infants with respiratory distress syndrome, is as safe and efficacious as conventional ventilation.

[Pregnancy-saving measures in premature rupture of fetal membranes in the 22nd week of pregnancy]

The obstetric-perinatologic problems raised by premature rupturing of the membranes in the 22nd gestational week is presented in the form of a case report from the Perinatal Centre of the University of Cologne. By close ultrasonic monitoring of the course of development, measurement of parameters of inflammation and administration of prophylactic antibiotics pregnancy could be prolonged by 9 weeks with good fetal outcome.

Influence of nutrition on urinary oxalate and calcium in preterm and term infants

Few data for normal urinary oxalate (Ox) and calcium (Ca) excretion related both to gestational age and nutritional factors have been reported in preterm or term infants. We therefore determined the molar Ox and Ca to creatinine (Cr) ratios in spot urines from 64 preterm and 37 term infants aged 1-60 days, either fed formula or human milk (HM). Only vitamin D was supplemented; renal or metabolic diseases were excluded. Urinary Ox/Cr ratio was higher in preterm than in term infants, both when formula fed (1st month 253 vs. 180 mmol/mol and 2nd month 306 vs. 212 mmol/mol; P<0.05) or HM fed (206 vs. 169 mmol/ mol and 283* vs. 232 mmol/mol; *P<0.05). Ox/Cr was also higher in formula- than HM-fed preterm infants. The ratio increased during the first 2 months of life irrespective of nutrition. Urinary Ca/Cr ratio was comparable in all groups during the 1st month of life, except for a lower (P < 0.05) value in term infants fed HM (0.10 mol/mol). It increased in all groups during the 2nd month of life, being highest in HM-fed preterm infants (1.86 mol/mol). In conclusion, urinary Ox and Ca excretion is influenced by both gestational age and nutrient intake in preterm and term infants.

Phase II study of single-agent gemcitabine in previously untreated patients with metastatic urothelial cancer

PURPOSE

To determine the activity of single-agent gemcitabine in previously untreated patients with metastatic transitional cell cancer.

METHODS

Forty patients with measurable disease and a Karnofsky performance status > or = 60% were enrolled at five institutions between March 1994 and October 1995. Treatment consisted of gemcitabine (1,200 mg/m2) administered weekly times three on a 4-week cycle. One patient was ineligible for response evaluation because pathology review showed a metastatic melanoma. Responses were confirmed by all investigators and an independent radiologist and were maintained for at least 4 weeks.

RESULTS

There were four complete and seven partial responses, for an overall response rate of 28%. Responses were seen at all sites, including liver. Median progression-free and overall survival times were 20 and 54 weeks, respectively. Toxicity was mild, with only two grade 4 toxicities. Twenty-five percent of patients experienced grade 3 neutropenia or thrombocytopenia that was rapidly reversible.

CONCLUSION

Gemcitabine exhibits significant activity in metastatic transitional cell cancer with minimal toxicity, but survival remains short. Trials of gemcitabine in combination with other active agents are thus suggested.

Disposable CO2-detector, a reliable tool for determination of correct tracheal tube position during resuscitation of a neonate

Undetected displacement of the endotracheal tube may lead to death of the patient. The present report illustrates the benefits of using a disposable carbon dioxide detector, designed for adults, also in a new-nate during resuscitation. The infant had asystole after delivery by caesarean section. The trachea was intubated, but the tube was displaced soon after return of spontaneous circulation. The oesophageal position of the tube was, however, discovered before bradycardia had occurred, thanks to the use of the CO2 detector.

A staged protocol for the treatment of persistent pulmonary hypertension of the newborn

The purpose of this report is to propose a staged therapeutic protocol for the treatment of persistent pulmonary hypertension of the newborn (PPHN) based on retrospective clinical experience. We analysed the clinical course of 19 term and near-term neonates with severe PPHN treated between 1991 and 1993, before the introduction of inhalational nitric oxide (NO) therapy. Basic therapy consisted of continuous sedation, and analgesia, circulatory support with dobutamine, dopamine and substitution of 5% albumin or packed red blood cells, mechanical hyperventilation, alkalisation with sodium bicarbonate and surfactant instillation. Consecutive therapy included the administration of norepinephrine, high frequency oscillatory ventilation (HFOV), Prostacyclin (PGI2) and extracorporeal membrane oxygenator (ECMO) therapy with entry criteria for each stage of treatment. From our observations we suggest that firstly, an early increase in systemic mean arterial pressure due to norepinephrine and secondly, HFOV trials are beneficial in patients with PPHN. The staged protocol shall be applicable in most neonatal intensive care units in which inhalational NO and ECMO therapies are not available and includes our present entry criteria for both therapies.