Familial juvenile polyposis coli with APC gene mutation

Familial juvenile polyposis has been known to have malignant potential, but their genetic relation to familial adenomatous polyposis has not been proven yet. Two young brothers with intermittent rectal bleeding revealed multiple juvenile polyposis. Their father had a history of rectal cancer with multiple colonic polyps. Four frequent exons of APC gene mutation were tested from these patients' white blood cells by polyacrylamide gel electrophoresis and sequencing. The 21-yr-old brother had a missense mutation (GAA-->GGA) at codon 1309, whereas the 18-yr-old brother showed a missense mutation (ATA-->GTA) at codon 1304 in exon 15 of APC gene. Three of four first-degree relatives were affected with familial juvenile polyposis, familial juvenile polyposis with adenomatous change, and rectal cancer with multiple polyps. The APC gene mutation of familial juvenile polyposis in this case suggests a genetic relationship with familial adenomatous polyposis.

Spine surgery in geriatric patients

AIM

Many elderly patients are crippled by degenerative spine conditions. Operative treatment is often not offered due to fear of complications and consideration of life span. The objective of this study was to look at the diagnosis, surgical results and post-operative complications of elderly patients who underwent spinal surgery.

METHODS

A cohort of 44 patients, 65 years and older, who had surgery in Tan Tock Seng Hospital from January 1990-August 1995 were reviewed. Twenty-five of them had spinal stenosis, II had tumour and 9 had traumatic fracture/dislocation/subluxation. There were 3 patients each with disc herniation, infection and spondylolisthesis. Nine patients had more than one diagnosis. All patients were investigated post-operatively. The data was entered into a computer-coded protocol. The diagnosis was determined intraoperatively. Type of surgery, co-morbid conditions and results were looked into. Patient's opinion on relief symptoms was graded on a 5-point scale. Functional improvement was tabulated as the patient's ambulatory status.

RESULTS

The analysis of results was divided into two groups, patients with tumour and those without tumour. Twenty-seven of the 33 patients without tumour were alive at follow-up. Twenty-six of these patients had improvement of symptoms and 18 of 27 had improved functional status post-operatively. In the group with tumours, 2 had worsening symptoms and 3 had decreased function.

CONCLUSION

Surgical intervention should be a treatment option in elderly patients with spinal disease.

Results of minor foot amputations in diabetic mellitus

The aim of this retrospective study is to study the outcome of surgery in diabetic patients with foot infections. The results of 54 local amputations performed by surgeons of different levels of experience for gangrene and/or deep infection confined to the toes in diabetic patients were studied. Failure of surgery is defined as any case that requires subsequent surgery. Twenty-two of the initial local amputations subsequently required higher amputations. The majority of these cases that failed were done by junior officers of Medical Officer and Registrar grade. In contrast, the cases done by senior surgeons are more likely to heal. Fifty-six percent of the initial operations done by Medical Officers failed. A similar pattern is also seen in repeat operations done by junior officers. Based on our findings, it is recommended that the decision making must be made by senior staff of at least Registrar grade. Repeat surgery should also be done by senior staff. Finally, continued training and supervision of junior staff are necessary to improve their technical expertise, judgment and knowledge.

Perioperative nutrition and postoperative complications in patients undergoing spinal surgery

STUDY DESIGN

The authors undertook a three-part study to better understand the impact of perioperative nutritional status on postoperative complications in patients undergoing spinal surgery. In preliminary Parts I and II, the authors targeted two groups of patients who are particularly nutritionally challenged. In Part III, they studied a large group of consecutive patients undergoing routine lumbar spinal fusion.

OBJECTIVES

To determine whether preoperative nutritional status was a significant predictor of postoperative complications in patients undergoing elective lumbar spinal fusion.

SUMMARY OF BACKGROUND DATA

In Part I, 27 patients treated surgically for vertebral osteomyelitis were divided into two groups based on their preoperative nutritional status. Twenty-four of the 26 postoperative complications were in the malnourished group (P < 0.001). In Part II, 15 (75%) of 20 patients treated surgically for spinal cord injury were found to become malnourished in the postoperative period. Seventeen complications were noted, all in the malnourished group (P = 0.001).

METHODS

One hundred fourteen consecutive patients undergoing selective lumbar decompression and fusion were identified and their records reviewed. In addition to preoperative nutritional status, data gathered included age, sex, height, weight, past medical history, steroid use, alcohol use, tobacco use, type of bone graft (allograft vs. autograft), history of previous lumbar surgery, number of levels fused, and use of spinal instrumentation.

RESULTS

Eleven of 13 postoperative infectious complications (10 deep wound infections) were noted in the malnourished group (P < 0.001). By stepwise logistic regression analysis, preoperative nutritional status was an extremely significant independent predictor of postoperative complications in patients undergoing elective lumbar spinal fusion (P = 0.0018).

CONCLUSIONS

The prevalence data in our study population suggest that a large number (25%) of patients undergoing elective lumbar spine surgery are nourished inadequately at surgery. This number is higher (42%) in older patients. The authors recommend that close attention be paid to the perioperative nutritional status of patients undergoing lumbar spinal surgery. Patients with suboptimal nutritional parameters should be supplemented and replenished before elective surgery.

Wide versus selective decompression in the operative treatment of lumbar spinal stenosis

The early post-operative results of wide versus selective decompression in a group of 64 patients with lumbar spinal stenosis were studied with the aim of ascertaining whether a more limited approach gives comparable results to the more traditional method of wide decompression. Wide decompression involved complete removal of a vertebral lamina at the stenotic level. Selective decompression refers to removal of the lower part of the superior lamina and the upper part of the inferior lamina at the stenotic level together with limited facetectomies. Patients were compared with respect to post-operative relief of back pain and sciatica/claudication as well as the ability to return to their pre-morbid level of functional activity. Follow up ranged from 4 months to 26 months. Results showed that both wide and selective decompression were able to achieve complete or considerable relief of symptoms and return to pre-morbid level of activity in 74% to 84% of patients. The results in the 2 groups were not statistically different. It appears that within the first 2 years of surgery, the vast majority of our post-decompression patients had good results regardless of whether wide or selective decompression was used.

A randomized trial on the effect of decreased dietary sodium intake on blood pressure in adolescents

A randomized crossover trial on the effect of salt restriction on blood pressure was carried out involving 124 adolescents (mean age 16 years). Dietary sodium was reduced from approximately 110 to 45 mEq/24 h for a period of 24 days. Blood pressure was non-significantly lower at the end of the experimental diet for all participants. A slight (0.7 kg), yet statistically significant fall in weight was observed (P less than 0.05). Subgroup analysis demonstrated that participants whose body mass index was below the median had a statistically significant fall in systolic blood pressure (P less than 0.05); fall in weight and increase in heart rate were also more pronounced in the less obese individuals. It would appear that moderate sodium reduction does not have an overall short-term effect on blood pressure in normotensive adolescents. However, body size as reflected in body mass index may influence blood pressure response to sodium reduction.

Methotrexate analogues. 21. Divergent influence of alkyl chain length on the dihydrofolate reductase affinity and cytotoxicity of methotrexate monoesters

n-Octyl, n-dodecyl, and n-hexadecyl alpha- and gamma-esters of methotrexate (MTX) were compared with the previously described alpha- and gamma-n-butyl esters and with MTX as inhibitors of dihydrofolate reductase (DHFR) and human leukemic lymphoblasts (CEM cells) in culture. The overall order of activity in both test systems was MTX greater than MTX gamma-esters greater than MTX alpha-esters. In the DHFR assay the activity of the alpha-esters followed the order C4 greater than C8 congruent to C12 greater than C16, whereas for the gamma-esters this order was C4 congruent to C8 greater than C12 greater than C16. On the other hand, the order of cytotoxic activity in culture in both series was C16 greater than C12 greater than C8 greater than C4. Increasing the alkyl chain length in the ester moiety therefore decreases DHFR affinity but increases cytotoxicity. The most potent member of the compounds tested was the gamma-n-hexadecyl ester, whose IC50 against CEM cells was 0.11 microM as compared with 0.025 microM for MTX. In a comparison of the effect of treatment with the gamma-n-hexadecyl ester (10(-5) M, 1 h) on DNA synthesis in CEM and CEM/MTX cells, the latter of which are 120-fold resistant to MTX by virtue of a transport defect, the ester produced only 4-fold less inhibition in the resistant line than in the parental line. These results suggest possible use of this compound or related derivatives in the treatment of MTX-resistant tumors with impaired transport.

Methotrexate analogues. 18. Enhancement of the antitumor effect of methotrexate and 3',5'-dichloromethotrexate by the use of lipid-soluble diesters

Lipophilic methotrexate (MTX) and 3',5'-dichloromethotrexate (DCM) diesters were prepared by HCl-catalyzed esterification or by neutral esterification using cesium carbonate and an alkyl or aralkyl halide in Me2SO. The products were tested for in vivo antitumor activity against L1210 leukemia in mice to test whether all MTX and DCM diesters are therapeutically equivalent in this species. Contrary to what has been found with simple primary dialkyl esters, ortho-substituted dibenzyl esters of MTX produce longer survival on a q3dX3 schedule than does MTX itself and show a dose-sparing effect comparable to that of MTX at shorter treatment intervals. Thus, MTX bis(6-chloropiperonyl) ester at an MTX-equivalent dose of 5.5 mg/kg gave a +88% increase in median life span (ILS), whereas for MTX a +88% ILS required 30 mg/kg. When the MTX-equivalent dose of MTX bis(6-chloropiperonyl) ester was increased to 40 mg/kg, a +167% ILS was observed, as compared with a +100% ILS with 60 mg/kg of the parent drug. High activity (greater than 100% ILS) was likewise shown by the bis(2,5-dimethylbenzyl), bis(2,6-dichlorobenzyl), and di-3-picolyl esters of MTX and by the bis(1-methylbutyl) ester of DCM. The results of this study indicate that MTX and DCM esters are not therapeutically equivalent in mice, despite the high serum esterase activity in this species, and that an up to 10-fold reduction in total administered dose on the q3dX3 schedule is feasible by this approach.

Methotrexate analogues. 13. Chemical and pharmacological studies on amide, hydrazide, and hydroxamic acid derivatives of the glutamate side chain

Carbodiimide-mediated condensation of 4-amino-4-deoxy-N10-methylpteroic acid (APA) with several alkyl, aralkyl, and aryl amines, in the presence or absence of N-hydroxysuccinimide, was employed in order to prepare new lipid-soluble bis(amide) derivatives of methotrexate (MTX) as potential prodrugs. MTX dianilide was likewise prepared, in comparable yield, from APA and L-glutamic acid dianilide via the mixed carboxylic--carbonic anhydride method. Dihydrazide and bis(N-methylhydrazide) derivatives of MTX were formed readily from MTX diethyl ester. However, reaction with hydroxylamine led to MTX gamma-monohydroxamic acid as the sole isolated product. The bis adduct appears to form, but is unstable during workup. The identity of the product was confirmed by independent mixed anhydride synthesis from APA and the gamma-monohydroxamate of L-glutamic acid. Treatment of MTX dimethyl ester with N,N-dimethylhydrazine unexpectedly yielded MTX gamma-monomethyl ester. MTX dianilide was active against L1210 leukemia in mice, with a +155% increase in life span at a dose of 160 mg/kg given ip in 10% Tween 80 on a q3d X 3 schedule. The bis(p-chlorobenzylamide), bis(p-methoxybenzylamide), and dihydrazide were also active against L1210 leukemia in vivo, but to a lesser extent than the dianilide. The gamma-monohydroxamic acid derivative showed activity (+111% ILS at 40 mg/kg) similar to that of MTX and was found to bind to a partially purified dihydrofolate reductase preparation from L1210 cells with an ID50 of 0.005 microM as compared to 0.007 microM for MTX. In vivo experiments in mice indicated that the pharmacokinetic properties of this compound and of MTX are similar but failed to demonstrate any advantage over MTX in terms of selective uptake into tumor (sc implanted P388 leukemia) or improved penetration of the central nervous system. The activities of the dianilide, bis(benzylamide), and dihydrazide derivatives in vivo are of interest in view of their low toxicity relative to MTX against cells in culture, which suggests that these derivatives are probably acting as prodrugs in the intact animal.

Synthesis of lysophosphatidylethanolamine analogs that inhibit renin activity

A series of lysophosphatidylethanolamine analogs containing saturated and methylene-interrupted cis-olefinic fatty chains was synthesized by phosphorylation and phosphonylation of respective fatty alcohols. Arachidonyl- and linolenylphosphorylethanolamines (12, 13), arachidonyl (2-phthalimidoethyl)phosphonate (17), and arachidonyl (2-aminoethyl)phosphonate (18) were found to be effective inhibitors of the renin-renin substrate reaction in vitro; lysophosphatidylethanolamine analogs 14-16 of lesser unsaturation were either weakly active or inactive. In a preliminary study, intramuscular administration of 25 mg/kg/day of arachidonyl (2-aminoethyl)phosphonate (18) to the hypertensive rat caused pronounced reduction (50 mm) in blood pressure within 3 days; upon continued dosage (15 mg/kg/day) of 18 for an additional 4 days, plasma renin activity was found to be 16 ng/0.1 ml/15 hr as compared with 69 ng/0.1 ml/15 hr before initial drug administration. Arachidonic acid (3), arachidonyl alcohol (8), and several corresponding tetraenoid ester, amide, mesylate, and glyceryl ether derivatives (4-7, 10, 11), that are not phosphate or phosphonate esters, were found to exhibit negligible or modest inhibition of renin activity in vitro.