Pharmacokinetics and dose proportionality of beclomethasone from three strengths of a CFC-free beclomethasone dipropionate metered-dose inhaler

As part of a development program to offer alternatives to chlorofluorocarbon (CFC) containing metered-dose inhalers, beclomethasone dipropionate has been formulated in a CFC-free system at three strengths: 50, 100, and 200 micrograms/actuation ex valve. To measure serum levels and dose proportionality of the beclomethasone derived from beclomethasone dipropionate, 13 mild to moderate asthmatic patients received a single dose of eight inhalations from each strength according to a double-blind crossover design. Seven patients were studied over 4 h and six patients over 12 h. For the total doses of 400, 800, and 1600 micrograms studied over 12 h, Cmax and AUC increased in a ratio of 1:1.8:3.1. A good correlation was seen between the fine-particle mass delivered and the in vivo performance of the three strengths. From a clinical point of view, the predictable increases in serum levels with an increase in dose will permit the clinician to effectively titrate a patient with this product.

Childhood-onset schizophrenia. Progressive ventricular change during adolescence

BACKGROUND

There is controversy about progression in brain abnormalities in later-onset schizophrenia. This study looked for more striking progression in brain abnormalities during adolescence in a chronically ill, treatment-refractory sample of patients with childhood-onset schizophrenia who had had more prepsychotic developmental disturbance, but clinical and neurobiological characteristics similar to those of patients with treatment-refractory adult-onset schizophrenia who have poor outcome.

METHODS

Anatomic brain magnetic resonance images were obtained for 16 children and adolescents with onset of schizophrenia by 12 years of age and 24 temporally yoked, age- and sex-matched healthy controls. Subjects were scanned on initial admission and rescanned after 2 years with the identical equipment and measurement methods.

RESULTS

Childhood schizophrenics showed a significantly greater increase in ventricular volume than did controls, for whom ventricles did not increase significantly (analysis of variance, diagnosis x time, F = 16.1, P < .001). A significant decrease in midsagittal thalamic area was also seen for the schizophrenics (P = .03), which was unchanged at rescan for controls. These differential brain changes correlated significantly with each other and tended to be predicted by both prepsychotic developmental abnormality (Premorbid Assessment Scale, P = .06) and Brief Psychiatric Rating Scale at follow-up (P = .07).

CONCLUSIONS

More consistent progressive ventricular enlargement was seen during adolescence for this childhood-onset sample than has been reported for adult-onset populations. The brain imaging results support other clinical data showing both early and late deviations in brain development for at least this rare subgroup of treatment-refractory, very-early-onset schizophrenic patients.

Consanguineous marriage and its clinical consequences in migrants to Australia

Marriage between close biological relatives is strongly favoured in many countries in Asia and Africa. Although substantial numbers of migrants from these regions are now living in Australia, little information is available either on the prevalence of consanguineous unions among migrants or on their clinical outcome. Data are presented on a range of generally rare autosomal recessive genetic disorders diagnosed in the children of parents of Eastern Mediterranean origin who attended Westmead Hospital, Sydney for genetic counselling during the period 1990 to 1994. The effects of parental consanguinity are assessed both in terms of the specific recessive disorders detected, and the perceived role of consanguineous marriage in the communities investigated.

Gillespie syndrome: a report of two further cases

We describe two unrelated patients with Gillespie syndrome (partial aniridia, cerebellar ataxia, and mental retardation). The typical presentation is the discovery of fixed dilated pupils in a hypotonic infant. The iris abnormality is specific and seems pathognomonic of Gillespie syndrome. It can be distinguished clinically from other forms of aniridia and a presumptive diagnosis of Gillespie syndrome can be made in the first months of life on the basis of the ocular findings. Neurological involvement includes marked motor delay, hypotonia, disabling ataxia, and usually mental retardation. Cerebral and cerebellar atrophy with white matter changes on MRI scan were present in our second patient suggesting that patients with Gillespie syndrome may have more extensive CNS involvement than previously described. The parents of this child were first cousins; thus Gillespie syndrome may be heterogeneous with autosomal recessive and autosomal dominant forms.

Neurocognitive impairment in human immunodeficiency virus infection is correlated with sexually transmitted disease history

BACKGROUND AND OBJECTIVES

Neurocognitive impairment is common in human immunodeficiency virus (HIV)-infected subjects. The relationship of sexually transmitted diseases to neurocognitive changes is unknown.

GOAL

To establish whether HIV-infected patients with a history of syphilis or gonorrhea have a higher rate of neurocognitive dysfunction.

STUDY DESIGN

Neurocognitive function was measured by a battery of quantitative tests in a 453-person HIV-infected cohort and a 219-person HIV-seronegative control group. Neurocognitive function was then correlated with histories of either syphilis or gonorrhea to assess for possible relationships between these sexually transmitted diseases and neurologic impairment.

RESULTS

Human immunodeficiency virus-infected subjects with a history of either syphilis or gonorrhea tended to perform worse on neurocognitive testing than their counterparts. This difference could not be explained by educational attainment, age, race or CD4 cell count, and was not noted in the HIV-uninfected control subjects.

CONCLUSIONS

Sexually transmitted diseases in HIV-infected subjects are correlated with neurocognitive impairment through an unidentified mechanism.

Results of a phase I clinical trial of a T-cell receptor peptide vaccine in patients with multiple sclerosis. I. Analysis of T-cell receptor utilization in CSF cell populations

To identify a panel of multiple sclerosis patients (MS) for a phase I clinical trial of a T-cell receptor (TCR) peptide vaccine we characterized the T-cell populations present in the cerebrospinal fluids (CSF) of a large group of patients with respect to surface phenotype and state of activation, TCR beta chain utilization, features of the CDR3 junctional region, the extent of clonality and persistence of selected clonotypes over time. These CSF cell populations consist of approximately 60% CD4+ T-cells, half of which bear IL-2 receptors, indicating these activated T-cells may be part of the pathogenic process in MS. When these activated CD4+ T-cells were selectively expanded in IL-2/IL-4 supplemented cultures, an over-representation of several TCRV beta families was noted in 39/47 patients, the most frequent being V beta 6.5, V beta 6.7, V beta 2, V beta 5 and V beta 4. Biased expression of various members of the V beta 6 family was seen in 21 of this group of 39 patients. Clonal analysis of TCR beta 6 CDR3 sequences, revealed two notable features: clonal dominance and clonal persistence. CSF cells from two-thirds of MS patients contained a dominant clone comprising 50% or more of sequences and the same patient-specific clone could be shown to persist for up to 18 months. This clonal prevalence and over representation of V beta 6+TCR raises the possibility that immunization with a V beta 6 peptide vaccine may produce a regulatory immune response leading to a clinical benefit.

Results of a phase I clinical trial of a T-cell receptor vaccine in patients with multiple sclerosis. II. Comparative analysis of TCR utilization in CSF T-cell populations before and after vaccination with a TCRV beta 6 CDR2 peptide

We report here the results of a phase I trial of a T-cell receptor (TCR) V beta 6 CDR2 region peptide vaccine in 10 patients with multiple sclerosis who showed biased over-representations of V beta 6 mRNA among T-cells in their cerebrospinal fluids (CSF). One group of 5 patients was immunized twice during a four week period with 100 micrograms of the TCRV beta 6 peptide 39-LGQGPEF LTYFQNEAQLEKS-58 emulsified in incomplete Freund's adjuvant (IFA); the second group of 5 MS patients received 300 micrograms of the same peptide in IFA over a similar time period. Patients were monitored for adverse events, immunogenicity of the peptide and changes in their CSF T-cell populations. The results indicate that this peptide was immunogenic (T-cell proliferation assays and recall DTH responses) in some of the patients, although none of the immunized patients produced detectable anti-peptide antibodies. More importantly, we show that the 5 patients treated with higher doses of the vaccine displayed a slight decrease in CSF cellularity, a lack of growth of CSF cells in cytokine supplemented expansion cultures that implies a significant absence of a subset of activated CD4 T-cells and a marked diminution in V beta 6 mRNA levels among T-cells in these cultures. By comparison, in 5 patients receiving the lower dosage of the vaccine, CSF cellularity was the same or slightly increased over pre-vaccination levels, CSF cells from 1 patient failed to grow in expansion cultures and cultured CSF cells from 2 patients underwent a change from an oligoclonal V beta 6 pattern to one that was more polyclonal. These results justify a more through exploration of the use of TCR peptide vaccines as a possible therapeutic treatment for MS.

Maternal perception of preterm labor: is it reliable?

The objective of this study was to determine the reliability of maternal perception of uterine contractions and the influence of gestational age and maternal training on the perception level. Three hundred fifty patients at high risk for preterm delivery were followed from 20 to 35 weeks of gestation. The average maternal perception (79%) of contractions did not significantly vary as a function of gestational age. Four groups of women were identified according to the perception index (PI) defined as the ratio of contractions felt by the mother and the contractions documented by tocodynamometer. Within each group, the PI did not significantly vary during consecutive monitoring sessions, as the women become more familiar with self detection of uterine contractions (R < .65, P > .95). Twenty-one percent (+/-5%) of all preterm uterine contractions were not perceived by the pregnant women from 21 to 35 weeks. Thirty-two patients (9.1%) fail to perceive most or all uterine contractions while 189 (54%) detect most or all at any time during the study period.

Federal Nursing Service Award. Rhythms of War: activation experiences during the Persian Gulf War

Reserve military members and families require family support; however, support needs may increase in war. Stress may stem from entering active duty or change in family situations. This ethnographic study illuminates patterns of activation through deactivation of reserve military members, their families, family support personnel, and commanders during the Persian Gulf War. The sample included 59 individuals. Five themes were uncovered: (1) staying connected, (2) living with war, (3) fluctuating emotions, (4) refocus your sense of life, and (5) challenges of living the day-to-day. This study contributes to understanding family support experience from activation through deactivation. Recommendations are offered.

Porcine and bovine cartilage transplants in cynomolgus monkey: I. A model for chronic xenograft rejection

Transplantation of discordant xenograft tissues usually results in antibody-mediated hyperacute rejection response. It has been speculated that because cartilage has a limited vascular, neural, and lymphatic supply, it might be immunologically privileged and may not undergo hyperacute or chronic rejection. Moreover, porcine and bovine cartilage were found to express very low amounts of alpha-galactosyl epitopes (Gal alpha1-3Gal beta1-4GlcNAc-R). To evaluate animal cartilage for possible human transplantation, xenograft meniscal cartilage was transplanted from pigs and cows into the suprapatellar pouches of six cynomolgus monkeys (group 1). In a second group of six monkeys (group 2), porcine meniscal cartilage and porcine articular cartilage plugs were evaluated. During the 2-month evaluation period in group 1, all monkeys displayed an extensive humoral response to the xenograft, as indicated by the increase in production of antibodies against bovine and porcine cartilage. Upon explant, all meniscal cartilage samples in this group demonstrated histological evidence of chronic rejection, including fibroplasia, encapsulation, mononuclear infiltrates, foreign body giant cells, and eosinophilic infiltrates. There was no difference between the response seen in untreated tissues and that seen in tissues treated with UV irradiation or ozone oxidation. In group 2, the menisci explanted after 1 month displayed extensive infiltration of eosinophils alone or eosinophils mixed with mononuclear cells. The mononuclear infiltrates consisted primarily of CD4+ and CD8+ T cells and of macrophages. The articular cartilage plugs demonstrated only a small area of fibrous encapsulation and leukocyte infiltration at the periphery. This study suggests that xenograft cartilage tissue does not appear to be immunoprivileged and is unsuitable for human implantation due to a chronic rejection mechanism, which is evident already within 1 month after transplantation. In addition, this study may serve as a general model for the primate immune response against xenografts in the absence of hyperacute rejection.

Effects of the combination of skin cooling and hyperpnea of frigid air in asthmatic and normal subjects

To investigate whether reducing integumental temperature influences pulmonary mechanics and interacts with inhaling cold air, 10 normal and 10 asthmatic subjects participated in a three-part trial in which cooling the skin of the head and thorax and isocapnic hyperventilation of frigid air were undertaken as isolated challenges and then administered in combination. Integumental cooling for 30 min caused airway obstruction to develop in both populations [change in 1-s forced expiratory volume (delta FEV1) asthmatic subjects = 10% ; normal subjects = 6%)]. Hyperventilation, however, only affected the asthmatic subjects (delta FEV1 asthmatic subjects = 18%; normal subjects = 3%). In contrast to expectations, the combined challenge did not produce a summation effect (delta FEV1 asthmatic subjects = 21%; normal subjects = 7%). These data demonstrate that the skin of the trunk and head is cold sensitive and when stimulated causes similar degrees of bronchial narrowing in both normal subjects and patients with airway disease independent of any ventilatory effect. They also indicate that cooling of the skin does not add to the obstructive consequences of hyperpnea.

Development of hearing and vocalization in a marsupial, the Northern Quoll, Dasyurus hallucatus

The development of hearing was studied in the Northern Quoll, a nocturnal marsupial carnivore whose young are born into a pouch in an immature state after about 21 days in utero. Startle responses to noise bursts of 105 dB sound pressure level first appeared at 60 days after arrival in the pouch, but only to occasional stimuli; forelimb rather than whole body twitches were evoked. The latter were elicited regularly at 67 days onward. Auditory brainstem response (ABR) audiograms were measured during the period when startle responses first appeared. At 68 days responses were elicited between 1 and 16 kHz with thresholds in excess of 55 dB. At 81-88 days responses occurred over the adult range at lower thresholds than observed in the adult. The waveform of the ABR increased in complexity and decreased in latency during development. Pouch-young emitted acoustically well-defined isolation cells when separated from their mothers. Fourier analysis of these calls revealed peak energy at 8-11 kHz irrespective of the sex of the pouch-young. The isolation call first became evident at about 35 days, when the young were deliberately removed from the nipple, and ceased being emitted beyond about 80 days, some 5 or so days after the eyes open, when the young leave the pouch for substantial amounts of time. The spectrum of the call was similar at all ages within this 45 day period, and its peak frequency correlated closely with the best frequency in the adult quoll's ABR audiogram. At approximately 80 days of age the calls developed major low frequency components, similar to those measured in adult vocalizations, and the contributions of frequencies between 8-11 kHz waned in importance. The results indicate that the onset of hearing in quolls occurs at a relatively early time in the course of their development, but prior to this time the pouch-young emit characteristic isolation calls easily detectable by the mother.

Features of the structural development of the inferior colliculus in relation to the onset of hearing in a marsupial: the northern quoll, Dasyurus hallucatus

The time course of synaptogenesis and the arrival and myelination of afferent connections were studied in the developing inferior colliculus (IC) of a marsupial, the Northern Quoll, and related to the onset of hearing and patency of peripheral auditory structures in that species. The quoll is born after 3 weeks of intrauterine growth and completes its development in a pouch for a further 80 days before weaning. Synaptic terminals in the IC at 9 days after arrival in the pouch were extremely rare and were associated with very low vesicle numbers. The number of synapses increased smoothly during pouch life, whereas the number of neurons with nucleoli fell over the same time period. The ratio of synapses to cells steadily increased from day 9 to day 63, then rapidly accelerated to day 73; a similar high ratio was observed in adults. Retrograde labeling from the IC of fibers projected from the medullary auditory nuclei, first observed on day 36, became progressively denser during pouch life. Myelination of lateral lemniscal fibers was absent on day 45, extremely sparse on day 54, and clear on day 63. Myelin sheaths were not observed within the IC electron microscopically until day 73. Examination of the peripheral auditory system revealed that until about day 40 the middle ear was fluid-filled, and middle ear structures were spongy. Between days 51 and 63 the middle ear cleared, the eardrum became shiny, and the ear canal became patent. The structural development of the IC is therefore very mature at the time hearing begins (67 days), and the last major anatomical change preceding hearing appears to be the opening of the external ear canal.

Murine epidermal growth factor peptide (33-42) binds to a YIGSR-specific laminin receptor on both tumor and endothelial cells

A laminin-antagonist peptide, comprising amino acids 33-42 of murine epidermal growth factor (mEGF-(33-42)), interacts with a breast cancer- and endothelial cell-associated receptor, which is specific for the laminin B1 chain sequence, CDPGYIGSR-NH2 (Lam.B1-(925-933)), and is immunologically similar to a previously described 67-kDa laminin receptor. In whole cell receptor assays, mEGF-(33-42), Lam. B1-(925-933), and laminin all have IC50 values for displacement of 125I-laminin in the range 1-5 nM. Cell attachment to solid-phase laminin is also blocked by all three ligands, but in contrast to the receptor assays, mEGF-(33-42) or Lam.B1-(925-933), while equipotent with each other, were less effective than laminin. The concentrations of the peptides required to produce half-maximal inhibition of attachment were in the range 230-390 nM, but those for laminin were 1000-fold lower, in the range 0.2-0.3 nM. Like laminin, solid-phase mEGF-(33-42) supports cell attachment, and this ability is blocked by anti-67-kDa receptor antibodies. Modeling studies suggest that both peptides present a tyrosyl and an arginyl residue on the same face of a right-handed helical fold with elliptical cross-section.

Betaseron: a breakthrough treatment for multiple sclerosis

Multiple sclerosis (MS) is the most common cause of disability in young adults; in Canada, it affects 1 in 1,000 people. A chronic and complicated demyelinating autoimmune disorder of the central nervous system, MS has no known cure. Indeed, there has been no effective treatment until recently.

The effects of salinity change on the exercise performance of two Atlantic cod (Gadus morhua) populations inhabiting different environments

The objective of this study was to determine whether differences in exercise physiology between Atlantic cod (Gadus morhua) populations from different salinity environments could be changed by acclimating individuals of each population to the natural salinity of the comparison population. The exercise-associated blood chemistry of cod from the brackish Bras d'Or lakes, which had previously been shown to be quite different from that of 'open-ocean' cod, changed to resemble the blood chemistry of their oceanic relatives after only 2 months of acclimation to full-strength salinity. In contrast, the blood chemistry of cod from the Scotian Shelf of the Northwest Atlantic Ocean showed little change after 2 months of acclimation to brackish water. These results demonstrate that the degree of osmoconformity to changes in environmental salinity is a population-specific not a species-specific trait. The blood chemistry differences between populations and salinities did not translate into differences in exercise performance: i.e. critical swimming speeds were statistically uniform across all combinations of population and salinity, although performance was more varied in fish swimming in 'non-native' waters. Other 'whole-animal' physiological characteristics, such as metabolic rate and the aerobic cost of transport, were dependent upon both population origin and the environmental salinity. Vigorous swimming was more energetically expensive at full-strength salinity than at 20 salinity, yet estimates of standard (i.e. resting) metabolic rate were lower for full-strength salinity. Environmental salinity also influenced the relative appearance of lactate and metabolic acid in the extracellular fluid compartment, with full-strength salinity favouring the relative appearance of lactate in the blood. Multivariate statistical analyses of this data set showed that, in contrast to other fish species and studies, differences in blood oxygen transport appear to account for some of the swimming performance differences seen in Atlantic cod at 2 &deg;C. The two experimental populations were cleanly separated by a principal components analysis, regardless of the salinity to which they were acclimated, confirming our earlier contention that these cod populations are physiologically distinct. A key feature of that distinctness is the greater phenotypic plasticity exhibited by the population from the more euryhaline, more eurythermal environment.

Antenatal phenobarbital therapy and neonatal outcome. II: Neurodevelopmental outcome at 36 months

OBJECTIVE

To evaluate the effect of antenatal phenobarbital (PB) therapy on neurodevelopmental outcome at 36 months.

DESIGN

Prospective, randomized, controlled trial.

SETTING

Single-institution study. SUBJECT AND INTERVENTIONS: Children born to women who participated in the study evaluating the effect of antenatal phenobarbital (PB) on neonatal intracranial hemorrhage were prospectively followed to 3 years of age.

OUTCOME MEASURES

Physical growth, neurologic examinations, and developmental testing (McCarthy Scales of Children's Abilities). Comparisons between groups were made on all children and those born to multiple gestations.

RESULTS

Forty-one children born to women who received 10 mg/kg PB before delivery and 55 children in the control group were evaluated. Three children, all in the control group, had growth parameters (height, weight, and head circumference) below the fifth percentile. The McCarthy General Cognitive Index (standard, 100 +/- 16) was 93 +/- 20 in the PB group and 85 +/- 18 in the control group. The subscores tended to be higher in the PB group than in the control group, with higher quantitative scores in the PB group (44 +/- 11 vs 39 +/- 8). Neurologic deficits were noted in 2 of 41 in the PB group and in 6 of 55 in the control group.

CONCLUSIONS

Infants born to women who received antenatal PB therapy had similar neurodevelopmental outcomes as infants born to women who did not receive PB. No adverse effects of PB exposure were detected.

Platelet I1-imidazoline binding sites are elevated in depression but not generalized anxiety disorder

Depressed patients have been reported to have a higher than normal density of platelet binding sites for 3H-clonidine, an alpha 2-adrenoceptor agonist. Paradoxically, other studies using 3H-alpha 2, antagonists have found no differences from controls. Because 3H-clonidine interacts with platelet alpha 2-adrenoceptors to form G-protein complexes, whereas 3H-alpha 2-antagonists bind with uncoupled receptors, an elevation in G-protein coupling might explain this paradox. Another possibility is that depression might be associated with increased non-adrenergic I1-imidazoline binding sites, which are also clonidine sensitive. To distinguish these possibilities, we utilized p125I-clonidine to measure density (Bmax) and affinity (KD) of platelet G-protein coupled alpha 2-adrenoceptors as well as platelet I1 binding sites, and compared diagnostic groups of major depressive disorder (MDD), generalized anxiety disorder (GAD) and healthy subjects. Specific inhibition of binding by norepinephrine (NE = 10 microM) was used to selectively quantify alpha 2-adrenoceptors, whereas inhibition by 10 microM moxonidine (a > 100-fold selective I1 ligand) quantified I1 binding sites under a NE mask. I1 sites were found to be markedly elevated by, on average, +136% in MDD patients (p = .0007), whereas there was only a marginal increase in alpha 2-adrenoceptor Bmax values in MDD patients (p = .08; GAD and healthy subjects did not differ). Treatment of MDD patients for 6-8 weeks with desipramine downregulated I1 sites as well as alpha 2-adrenoceptors. Positive correlations were also noted for both sites: (a) between Bmax values and the severity of depression (using the Hamilton Depression Rating Scale); and (b) between end-of-treatment plasma desipramine concentrations and the extent of downregulation in Bmax values when subject groups were pooled. None of the binding parameters was associated with plasma catecholamine concentrations. The results suggest that an increased density of platelet I1 binding sites may partially explain the utility of radiolabeled clonidine as a potential biological marker for depressive illness, although an additional increase in G-protein coupling cannot be excluded.