Therapeutic monitoring of continuous infusion etoposide in small-cell lung cancer

PURPOSE

To investigate the feasibility of therapeutic monitoring of etoposide at different plasma concentrations of the drug, and the resulting pharmacodynamic effects of such an approach.

PATIENTS AND METHODS

Forty-nine previously untreated small-cell lung cancer (SCLC) patients received single-agent etoposide every 3 weeks by continuous infusion over 5 days. Plasma etoposide concentrations were monitored 18 and 66 hours into the infusion to permit dose modification. The first cohort of 15 patients began treatment with etoposide 2 micrograms/mL, with dose escalation to 3 micrograms/mL for cycles 3 and 4 and 4 micrograms/mL for cycles 5 and 6, toxicity permitting. The second cohort of 34 patients commenced at 3 micrograms/mL, with dose escalation to 4 and 5 micrograms/mL on cycles 3 and 5, respectively.

RESULTS

Mean plasma etoposide concentration during the first treatment cycle was 93.4% +/- 26.6% of the target level at 18 hours (57% of patients within +/- 20% of the target) and 98.9% +/- 14.5% of the target level at 66 hours (82% of patients within +/- 20%). Hematologic toxicity was more pronounced in those treated with 3 micrograms/mL versus 2 micrograms/mL (median nadir neutrophil count, 1.3 v 2.6 x 10(9)/L, P = .032). Tumor responses, typically documented by the third cycle, were similar in each cohort (71% in patients commenced at 2 micrograms/mL and 70% at 3 micrograms/mL). Treatment cohort was not independently predictive of survival.

CONCLUSION

Therapeutic monitoring of infusional etoposide is feasible and dramatically reduces interpatient pharmacokinetic variability. Although this was a small nonrandomized trial, the observation of different hematologic toxicity at the two starting concentrations but similar antitumor activity further suggests that these effects may be associated with different plasma etoposide concentrations.

Allelic association between a Ser-9-Gly polymorphism in the dopamine D3 receptor gene and schizophrenia

We examined a Ser-9-Gly polymorphism in the dopamine D3 receptor gene for allelic association with schizophrenia in 133 patients currently treated with clozapine and 109 controls. Allele 1 (Ser-9) was significantly more frequent in the patients (69%) than in the controls (56%) (P = 0.004). The 1-1 genotype was more common (43% vs 30%) and the 2-2 genotype less common (5% vs 18%) in patients than in controls. When the patient group was subdivided on the basis of clinical response to clozapine, using a 20-point improvement in the global assessment scale as cut-off, genotype 1-1 was found to be more frequent among the non-responders (53% vs 36%, P = 0.04). To place our results in the context of previous studies of this polymorphism and schizophrenia, we performed a meta-analysis of all published data including the present sample. The combined analysis shows evidence for a modest association between genotype 1-1 and schizophrenia (odds ratio 1.25, 95% confidence interval 1.05-1.49, P = 0.01). These results suggest that the Ser-9 allele, or a nearby polymorphism in linkage disequilibrium, results in a small increase in susceptibility to schizophrenia.

The influence of smoking cessation and hypertriglyceridaemia on the progression of peripheral arterial disease and the onset of critical ischaemia

OBJECTIVE

To investigate whether smoking and other cardiovascular risk factors were associated with deterioration of ankle/brachial pressure index or onset of critical ischaemia in patients with mild to moderate intermittent claudication.

DESIGN AND SETTING

Longitudinal study in a London teaching hospital.

SUBJECTS

415 consecutive smokers, with symptoms of intermittent claudication and an ankle/brachial pressure index of <0.9, referred for a surgical opinion between April 1985 and December 1990, who were not considered for an immediate surgical procedure.

MAIN OUTCOME RESULTS

Reduction in ankle/brachial pressure index of >0.14, onset of critical limb ischaemia.

RESULTS

After one year of follow up 183 patients (44%) had stopped smoking (as evaluated by biochemical markers). With longer follow up only 110 patients (27%) had maintained smoking cessation. There were no differences in age, sex, and previous tobacco exposure between stoppers and smokers, but the proportion of diabetics among stoppers (20%) was greater than among those who continued smoking (10%) [p=0.01]. The annual rate of deterioration of ABPI was 21, 16 and 17% respectively in the first, second and third year of follow-up and the onset of critical ischaemia was observed in 52 patients (12.5%) during the period of follow-up. In univariate analyses, continued smoking, diabetes and presence of ischaemic heart disease were not associated with an increased risk of deterioration of ABPI, but hypertriglyceridaemia (> or = 2.2 mmol/l) was, [relative risk 1.7(95% CI 1.21-2.37), p=0.003], and patients having systolic blood pressure in the middle tertile (153-170 mmHg had a reduced risk of deterioration of ABPI, p=0.026. Hypertriglyceridaemia (> or = 2.2mmol/l) was the only independent factor associated with deterioration of ABPI in multivariate analysis [relative risk 1.8(95% CI:1.23-2.59), p=0.003] and also was associated with a relative risk of onset of critical ischaemia of 1.9 [(95% CI: 1.08-2.87), p=0.035], compared with triglyceride levels of <2.2mmol/l.

CONCLUSION

For those with mild to moderate claudication, the lack of immediate benefit from cessation of smoking appears to be associated with a gradual return to smoking. Hypertriglyceridaemia was identified as the most important independent factor associated with the progression of peripheral arterial disease and onset of critical ischaemia.

Pharmacokinetic study of oral and bolus intravenous 2-chlorodeoxyadenosine in patients with malignancy

PURPOSE

This study was designed to evaluate the absolute bioavailability (F value) of 2-chlorodeoxyadenosine (cladribine; 2-CdA) after multiple oral administrations, and the intersubject variability after oral and 2-hour intravenous (IV) administration schedules in patients with malignancy.

PATIENTS AND METHODS

Patients with advanced malignancies were eligible. There were two treatment cycles; during cycle 1, patients received 2-CdA solution at 0.28 mg/kg/d orally under fasting conditions for 5 consecutive days concomitantly with omeprazole, and 4 weeks later during cycle 2 patients received 2-CdA as a 2-hour IV infusion of 0.14 mg/kg/d for 5 consecutive days. Serial blood samples for 2-CdA plasma levels were obtained after drug administrations on days 1 and 5 during each treatment cycle.

RESULTS

Ten patients completed cycles 1 and 2. The F value of oral 2-CdA measured on days 1 and 5 was 37.2% and 36.7%, respectively. For both oral and IV multiple administrations, there was no significant accumulation in maximum concentration (Cmax), and the intersubject variabilities (coefficient of variation [CV], approximately 40%) in Cmax and area under the concentration-time curve from 0 to 24 hours [AUC(0-24)] values were comparable for both routes on days 1 and 5. A three-compartment open model was applied to the plasma concentration data after oral and IV administrations and resulted in good agreement between observed and simulated concentration-time profiles. Neutropenia was the principal adverse event observed when 2-CdA was administered orally and IV.

CONCLUSION

The F value of 2-CdA after oral administration was approximately 37% and there were no cumulative differences in bioavailability observed on multiple dosing of the drug. The absorption and disposition characteristics of oral 2-CdA were linear and predictable with this dosing regimen.

Acute psychiatric problems in an A&E Department

A study of patients with psychiatric problems attending the Accident & Emergency Department at the Western Infirmary, Glasgow was performed over a four month period. Those requiring admission to other specialties for treatment were excluded (e.g. overdoses). Forty-seven patients presented during the study period and all were self-referred. Seventy-seven per cent had a past history of psychiatric illness. Sixty-six per cent of cases presented with self harm. Eighty-one per cent of cases presented after normal working hours. Alcohol intoxication was a contributing factor in only one quarter of patients presenting. Of all cases seen, 62% were referred to a duty psychiatrist. In this group 38% were admitted and 45% were discharged with psychiatric follow-up, three absconded and two were referred back to their general practitioners. Results indicated that the majority of patients referred to the psychiatric services from Accident & Emergency needed some form of psychiatric input. In the self harm group results showed a correlation between known risk factors for suicide and a need for admission or follow up. Due to local psychiatric referral policies, patients were referred to four different psychiatric hospitals in the area. After initial assessment by the duty psychiatrist, 52% of these patients were subsequently discharged with or without psychiatric follow up. Availability of an on site psychiatrist would alleviate many of the present delays in obtaining definitive management.

Mild impairment of neuro-otological function in early treated congenital hypothyroidism

Pure tone audiometry, tympanometry, acoustic stapedial reflex thresholds (ASRTs), and auditory evoked brain stem responses (AEBRs) were carried out in 38 children with early treated congenital hypothyroidism aged 10-12 years, together with tests of vestibular function (electronystagraphy, rotational, and caloric tests). Sensorineural hearing loss with thresholds of greater than 15 dB was detected in 18 children (10 at 8 kHz only); only two children had more than 40 dB hearing loss, each in one ear. Raised ASRTs were found in eight children and two children had abnormal AEBRs. Of the 29 children tested, 12 had an abnormality of vestibular function. Although not significant at the 5% level, there was a tendency for the abnormalities to be more prevalent and severe in the children with more severe hypothyroidism, as judged by pretreatment plasma thyroxine. It is concluded that (i) mild abnormality of hearing is still common in children with congenital hypothyroidism despite early treatment but this is much less severe than that found before neonatal screening and (ii) mild abnormalities of vestibular function may be common in early treated congenital hypothyroidism.

Neurochemical effects following peripheral administration of tetrahydropterin derivatives to the hph-1 mouse

The hph-1 mouse which displays tetrahydrobiopterin deficiency and impaired dopamine and serotonin turnover, has been used to study cofactor replacement therapy for disorders causing brain tetrahydrobiopterin deficiency. Subcutaneous administration of 100 mumol/kg (30 mg/kg) of tetrahydrobiopterin resulted in a twofold increase in brain cofactor concentration 1 h after administration. Concentrations remained above the endogenous level for at least 4 h but returned to normal by 24 h. The lipophilic tetrahydrobiopterin analogue 6-methyltetrahydropterin entered the brain five times more efficiently than tetrahydrobiopterin but was cleared at a faster rate. Tetrahydropterins linked to the lipoidal carrier N-benzyl-1, 4-dihydronicotinoyl did not result in a detectable increase in levels of brain pterins over the period of the study (1-4 h). Stimulation of monoamine turnover was not observed at any time point with either natural cofactor or the methyl analogue. Increasing the amount of tetrahydrobiopterin to 1,000 mumol/kg resulted in elevation of cofactor concentrations, a brief increase in the activity of tyrosine and tryptophan hydroxylase 1 h postadministration, and increased turnover of dopamine and serotonin metabolites lasting 24 h. However, 2 of 12 (17%) mice died following administration of this dose of cofactor. Our findings suggest that acute peripheral tetrahydrobiopterin administration is unlikely to stimulate brain monoamine turnover directly unless very large and potentially toxic doses of cofactor are used.

Prolonged metabolic correction in adult ornithine transcarbamylase-deficient mice with adenoviral vectors

A murine model of ornithine transcarbamylase (OTC) deficiency was used in this study to evaluate the efficacy of recombinant adenoviruses for correcting the metabolic defect in liver. Recombinant adenoviruses deleted in E1 and containing a human OTC cDNA expressed little functional OTC enzyme in vivo and had no observable impact on the underlying metabolic abnormalities of the OTC-deficient mouse (i.e. elevated urinary orotate and serum glutamine). E1-deleted vectors were improved through the use of the strong constitutive promoter from cytomegalovirus driving the normal murine homolog of OTC cDNA and the ablation of E2a with a temperature-sensitive mutation. Infusion of this improved vector into the mouse model was associated with a complete normalization of liver OTC enzyme activity that persisted for at least 2 months with complete but transient correction in serum glutamine and urine orotic acid. These studies illustrate the utility of improved adenoviral vectors in the treatment of liver metabolic disease.

'Tomudex' (ZD1694): a novel thymidylate synthase inhibitor with clinical antitumour activity in a range of solid tumours. 'Tomudex' International Study Group

BACKGROUND

Anti-metabolites such as methotrexate (MTX) and 5-fluorouracil (5-FU) have been used clinically for many years. Although their effects are partly due to thymidylate synthase (TS) inhibition, they also have non-specific, non TS effects on RNA and purine synthesis. Direct and specific TS inhibitors therefore presented an attractive research target. Collaborative research between the Institute of Cancer Research and Zeneca Pharmaceuticals led to the design of specific folate based quinazoline TS inhibitors. ZD1694 ('Tomudex'), the first of these drugs reaching advanced clinical development, is currently completing phase III studies.

DESIGN

Eight phase II trials were carried out using 'Tomudex', 3.0 mg/m2, given as a short 15-minute infusion 3-weekly.

RESULTS

'Tomudex' demonstrates activity in a range of tumour types, most notably advanced colorectal and breast cancer (objective response rate 26%) and has acceptable toxicity: the most common WHO grade 3 and 4 adverse events were self-limiting reversible increases in liver transaminases, transient leucopenia, diarrhoea, nausea and vomiting and tiredness or malaise. Mucositis/stomatitis, alopecia and skin toxicity were notable for their low incidence and mild intensity.

CONCLUSIONS

'Tomudex' represents the successful culmination of a rational drug design programme, and shows promise as a new cytotoxic for the treatment of colorectal cancer. Further studies in other tumour types are planned.

Assessment of pre-operative investigations of thyroglossal cysts

The appropriate degree of investigation of thyroglossal cysts is uncertain. This retrospective study analyses the pre-operative investigations and correlates this with the post-operative results. The conclusion is that only radio-isotope studies are useful, but there is a limitation regarding the age of the patient and the authors only recommend this in patients over 10 years of age.

Crystallisation of the Bacillus subtilis sporulation inhibitor SinR, complexed with its antagonist, SinI

The transcription factor SinR, a pleiotropic regulator of late growth processes in Bacillus subtilis, has been crystallised as a complex with its antagonist SinI, in a form suitable for structural analysis. The SinI:SinR crystals diffract X-rays generated from a rotating copper anode source to 2.3 A spacing and a complete native dataset has been collected to this resolution limit. The space group of the crystals is P3(1)21 (or its enantiomorph P3(2)21) with cell dimensions a = b = 60.76 A, c = 87.79 A. Assuming that there is a single SinI:SinR heterodimer in the asymmetric unit, the crystals have a Vm of 2.53 A3.Da-1.

Phase I trial and tumour localisation of the anti-EGFR monoclonal antibody ICR62 in head and neck or lung cancer

The purpose of this study was to determine the effect of the first rat monoclonal antibody (MAb ICR62) to the epidermal growth factor receptor (EGFR) in a phase I clinical trial in patients with unresectable squamous cell carcinomas. This antibody effectively blocks the binding of EGF, transforming growth factor (TGF)-alpha and HB-EGF to the EGFR, inhibits the growth in vitro of tumour cell lines which overexpress the EGFR and eradicates such tumours when grown as xenografts in athymic mice. Eleven patients with squamous cell carcinoma of the head and neck and nine patients with squamous cell carcinoma of the lung, whose tumours expressed EGFR, were recruited. Groups of three patients were treated with 2.5 mg, 10 mg, 20 mg or 40 mg of ICR62 and a further eight patients received 100 mg. All patients were evaluated for toxicity using WHO criteria. Patients' sera were tested for the clearance of MAb ICR62 and the development of human anti-rat antibodies (HARA). No serious (WHO Grade III-IV) toxicity was observed in patients treated with up to 100 mg of antibody ICR62. Antibody ICR62 could be detected at 4 h and 24 h in the sera of patients treated with 40 mg or 100 mg of ICR62. Only 4/20 patients showed HARA responses (one at 20 mg, one at 40 mg and two at 100 mg doses) and of these only the former two were anti-idiotypic responses. In four patients receiving doses of ICR62 at 40 mg or greater, biopsies were obtained from metastatic lesions 24 h later and examined for the localisation of ICR62 using anti-rat antibody reagent. In these patients we showed the localisation of MAb ICR62 to the membranes of tumour cells; this appeared to be more prominent at the higher dose of 100 mg. On the basis of these data we conclude that MAb ICR62 can be administered safely to patients with squamous cell carcinomas and that it can localise efficiently to metastases even at relatively low doses.

Sevoflurane versus desflurane for outpatient anesthesia: a comparison of maintenance and recovery profiles

The recovery characteristics of desflurane and sevoflurane were compared when used for maintenance of ambulatory anesthesia. After obtaining informed consent, 42 healthy, unpremedicated women undergoing laparoscopic sterilization procedures were studied. Anesthesia was induced with propofol, 1.5-2.0 mg/kg, and maintained with either desflurane 3%-6% (n = 21) or sevoflurane 1%-2% (n = 21) with 60% nitrous oxide in oxygen. Intraoperative analgesia and neuromuscular block was achieved using fentanyl and vecuronium, respectively. The inhaled anesthetics were titrated to achieve an adequate clinical "depth of anesthesia" and to maintain mean arterial pressure (MAP) within 20% of the preinduction baseline values. Visual analog scales (VAS) and the digit-symbol substitution test (DSST) were performed preoperatively and at 30-min intervals during the recovery period. There were no differences between the two groups in the total doses of propofol, fentanyl, or vecuronium. Heart rate (HR) values were lower in the sevoflurane group during the induction-to-incision period. However, HR and MAP were otherwise similar during the maintenance and recovery periods. Use of desflurane led to a more rapid emergence (4.8 +/- 2.4 vs 7.8 +/- 3.8 min) and shorter time to extubation (5.1 +/- 2.2 vs 8.2 +/- 4.2 min) compared to sevoflurane (mean values +/- SD). Intermediate recovery times, postoperative VAS and DSST scores, and side effects were similar in the two treatment groups. Although sevoflurane was associated with a slower emergence from anesthesia than desflurane after laparoscopic surgery, recovery of cognitive function and discharge times were similar in the two anesthetic groups. Thus, it would appear that sevoflurane is an acceptable alternative to desflurane for maintenance of outpatient anesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of sevoflurane in outpatient anesthesia

Sevoflurane appears to have several properties that make it an attractive alternative to the currently available anesthetics for outpatient anesthesia. The relative low solubility of sevoflurane, as well as an impressive lack of airway irritation, makes it a very useful anesthetic for inhalation induction of anesthesia. This feature is likely to make sevoflurane a population choice for pediatric outpatient anesthesia. For adult outpatients, the relatively low solubility of sevoflurane permits rapid alterations in alveolar concentration during the maintenance period (even when administered at relatively low flow rates of 2-3 L/min), thereby improving control of the depth of anesthesia. Low solubility should also allow for a more predictable emergence from anesthesia (versus isoflurane), thereby facilitating patient turnover in a busy ambulatory surgery center. The commercial development of sevoflurane has been slow because of concerns regarding the potential toxicity of its metabolites and breakdown products (24). However, the large body of clinical experience from Japan and the worldwide Phase II and III clinical development programs suggests that these concerns may be unfounded. The short duration of exposure in the outpatient setting should further decrease the risk of nephrotoxicity. The relatively low solubility of sevoflurane will facilitate its use with total gas flow rates of 2-3 L/min. In the final analysis, clinicians will have to balance the cost of sevoflurane (versus halothane, enflurane, isoflurane, and desflurane) against its potential advantages in the ambulatory surgery population. Although the search for anesthetics that are more ideally suited for use in the outpatient setting will continue, sevoflurane clearly represents a step in the right direction (3).

Genomic organization of the mycobacterial sigma gene cluster

We have previously described sigma A and sigma B and their structural genes, mysA and mysB, respectively, in Mycobacterium smegmatis. We have now sequenced the corresponding regions in the M. tuberculosis and M. leprae chromosomes, and have found the two homologous genes. The chromosomal linkage and the deduced amino acid (aa) sequences of the two genes show very high similarity in the three species of mycobacteria. We also report the finding of two other open reading frames (ORF) in these clusters. orfX, which has an unknown function, is located between mysA and mysB. The other ORF, located downstream from mysB, encodes a homolog of DtxR, the iron regulatory protein from Corynebacterium diphtheriae (Cd).

Characterization of an iron-dependent regulatory protein (IdeR) of Mycobacterium tuberculosis as a functional homolog of the diphtheria toxin repressor (DtxR) from Corynebacterium diphtheriae

The DtxR protein from Corynebacterium diphtheriae is an iron-dependent repressor that regulates transcription from the tox, IRP1, and IRP2 promoters. A gene from virulent Mycobacterium tuberculosis H37Rv was recently shown to encode a protein, here designated iron-dependent regulator (IdeR), that is almost 60% homologous to DtxR from C. diphtheriae. A 750-bp PCR-derived DNA fragment carrying the M. tuberculosis ideR allele was subcloned to both high- and low-copy-number vectors. In Escherichia coli, transcription from the C. diphtheriae tox, IRP1, and IRP2 promoters was strongly repressed by ideR under high-iron conditions, and ideR restored normal iron-dependent expression of the corynebacterial siderophore in the C. diphtheriae dtxR mutant C7(beta)hm723. The M. tuberculosis IdeR protein was overexpressed in E. coli and purified to near homogeneity by nickel affinity chromatography. Gel mobility shift experiments revealed that IdeR bound to a DNA fragment that carried the C. diphtheriae tox promoter/operator sequence. DNAse I footprint analysis demonstrated that IdeR, in the presence of Cd2+, Co2+, Fe2+, Mn2+, Ni2+, or Zn2+, protected an approximately 30-bp region on DNA fragments carrying the tox, IRP1, or IRP2 promoter/operator sequences. IdeR reacted very weakly in Western blots (immunoblots) with antiserum against the C. diphtheriae DtxR protein, suggesting that the immunodominant epitopes of DtxR may be located in its poorly conserved carboxyl-terminal domain.

No reduction in birth weight in phenylketonuria

Birth weight in a total of 1886 British infants with phenylketonuria (PKU) born between 1964 and 1992 was examined in relation to sex, social class, gestational age, disease severity and birth year. Comparisons were made with two national surveys (British births 1970 and Office of Population Censuses and Surveys 1981). In contrast to a recent Dutch study, birth weight in British infants with PKU (mean 3307 g, median 3337 g) showed a similar distribution to population norms. Birth weight showed no temporal trends and no trends with disease severity. CONCLUSION. Birth weight is not reduced in British infants with PKU.

No association between the c2 allele at the cytochrome P450IIE1 gene and alcohol induced liver disease, alcohol Korsakoff's syndrome or alcohol dependence syndrome

Cytochrome P450IIE1 metabolises, and is induced by ethanol. The 5' regulatory sequence of the gene is polymorphic; that identified by the c2 allele has been shown by transfection studies to confer an increased rate of transcription. A recent report indicating an association between this allele and alcohol induced cirrhosis suggests that it may contribute to the genetic vulnerability to this disease. We have examined this polymorphism in patients of western European origin with alcohol induced cirrhosis, alcohol Korsakoff's syndrome and alcohol dependence syndrome. We were unable to detect any association between this allele and any of these diseases.

Sevoflurane for outpatient anesthesia: a comparison with propofol

Three different anesthetic techniques were compared in 146 healthy outpatients undergoing ambulatory surgery. In Groups I and II, anesthesia was induced with propofol (1.5-2.0 mg/kg, intravenously [iv]) and maintained with nitrous oxide (N2O) 60% in oxygen and either a propofol infusion, 75-160 micrograms.kg-1.min-1 IV, or sevoflurane, 1%-2% end-tidal, respectively. In Group III, anesthesia was induced and maintained with sevoflurane, 1%-4% end-tidal and N2O 60% in oxygen. In addition to 60% N2O in oxygen at a total gas flow of 3 L/min, all patients received fentanyl, 2-3 micrograms/kg IV, and vecuronium, 0.1 mg/kg IV. IV induction of anesthesia with propofol (90 +/- 53 s and 94 +/- 48 s in Groups I and II, respectively) was significantly faster than inhalation induction with sevoflurane (153 +/- 100 s). There were no significant differences in the incidence of coughing, airway irritation, or laryngospasm during induction of anesthesia. Although the mean arterial blood pressure values were similar in all three groups, the use of sevoflurane was associated with consistently lower heart rate values during the early maintenance period. Early and intermediate recovery times were the same in all three treatment groups. The use of sevoflurane for induction and/or maintenance of anesthesia was associated with a higher incidence of postoperative emetic sequelae compared with propofol. Finally, the times at which patients were considered "fit for discharge" and the actual discharge times were similar in all three groups. Sevoflurane is an acceptable alternative to propofol for induction and maintenance of outpatient anesthesia.

Molecular detection of human cytomegalovirus and determination of genotypic ganciclovir resistance in clinical specimens

The data presented in this article demonstrate how the polymerase chain reaction (PCR) can be used to detect human cytomegalovirus (HCMV) DNA in the plasma and cerebrospinal fluid (CSF) of infected individuals. Detection of HCMV DNA in plasma of transplant recipients and persons infected with human immunodeficiency virus identifies people with acute visceral disease and those at highest risk for development of HCMV disease. The detection of HCMV DNA in CSF is of particular help in identifying persons with HCMV-related central nervous system disease. In addition, specific mutations within the UL97 region, which encodes for a HCMV protein kinase, have been found to confer ganciclovir resistance and can be detected in plasma and CSF by direct sequencing of PCR products. These data will help provide tools for clinicians to better diagnose, manage, and treat persons with HCMV disease.

Use of analgesics during propofol sedation: a comparison of ketorolac, dezocine, and fentanyl

STUDY OBJECTIVE

To evaluate the comparative efficacy and side effect profile of ketorolac 60 mg, dezocine 6 mg, and fentanyl 100 micrograms when used as analgesic supplements to a propofol infusion during monitored anesthesia care (MAC).

DESIGN

Randomized, double-blind, placebo-controlled study.

SETTING

Ambulatory surgery facility at a university medical center.

PATIENTS

80 outpatients undergoing breast biopsy or inguinal herniorraphy procedures under MAC.

INTERVENTIONS

All patients received midazolam 2 mg intravenously (IV) followed by 1 ml of the study medication containing either dezocine 3 mg IV, ketorolac 30 mg IV, fentanyl 50 micrograms IV, or normal saline. A propofol infusion was initiated at 75 micrograms/kg/min and then varied to maintain a stable level of sedation (i.e., Observer Assessment of Alertness/Sedation scale score of 3). An additional 1 ml of the same study medication was administered IV 2 to 3 minutes prior to infiltration of the local anesthetic solution. During the operation, supplemental (rescue) medication consisted of fentanyl 25 micrograms IV, bolus injections in all four treatment groups.

MEASUREMENTS AND MAIN RESULTS

Propofol infusion and supplemental fentanyl dosage requirements, oxygen saturation values, respiratory rates, recovery times, and postoperative side effects were recorded. Visual analog scales were used to assess sedation, anxiety, pain, and nausea preoperatively (baseline), upon entry into the postanesthesia care unit, and at 30-minute intervals until discharge. The fentanyl and dezocine groups required lower average infusion rates of propofol to maintain a stable level of sedation than the control (saline) group. The saline and ketorolac groups required rescue analgesic medication more frequently and/or larger supplemental dosages of fentanyl than the two opioid analgesic treatment groups. Compared with the three analgesic treatment groups, postoperative pain scores were only marginally higher in the control group. Ketorolac-treated patients had consistently (but not significantly) shorter recovery times to oral intake, ambulation, and discharge than those in the dezocine or fentanyl groups. No postoperative nausea, vomiting, or pruritus was reported in the ketorolac group.

CONCLUSION

Compared with ketorolac 60 mg, fentanyl 100 micrograms and dezocine 6 mg produced a greater decrease in the propofol sedation requirement during MAC. However, the use of ketorolac in combination with propofol for MAC was associated with an improved recovery profile.

The Bacillus subtilis SinR protein is a repressor of the key sporulation gene spo0A

SinR is a pleiotropic DNA binding protein that is essential for the late-growth processes of competence and motility in Bacillus subtilis and is also a repressor of others, e.g., sporulation and subtilisin synthesis. In this report, we show that SinR, in addition to being an inhibitor of sporulation stage II gene expression, is a repressor of the key early sporulation gene spo0A. The sporulation-specific rise in spo0A expression at time zero is absent in a SinR-overproducing strain and is much higher than normal in strains with a disrupted sinR gene. This effect is direct, since SinR binds specifically to spo0A in vitro, in a region overlapping the -10 region of the sporulation-specific Ps promoter that is recognized by E-sigma H polymerase. Methyl interference and site-directed mutagenesis studies have identified guanine residues that are important for SinR recognition of this DNA sequence. Finally, we present evidence that SinR controls sporulation through several independent genes, i.e., sp0A, spoIIA, and possibly spoIIG and spoIIE.