Death due to asphyxia linked to antipsychotic drugs

A 46-year-old man with schizophrenia, died in hospital. Autopsy revealed numerous facial injuries and the direct cause of death was apparently asphyxia as a large amount of coagulated blood was present in the lower part of the trachea and bronchi. The blood derived from a lacerated wound of the mouth. The question was raised as to why expectoration was impossible and a toxicological analysis was directed to the antipsychotic drugs allegedly prescribed by doctors at the hospital. Using gas chromatography and gas chromatography/mass spectrometry, four different antipsychotic drugs including chlorpromazine, levomepromazine, zotepine and haloperidol were identified in the whole blood and tissues with concentrations being 1.91, 0.75, 0.61 and 0.48 micrograms/g in the blood, respectively. These levels were toxic to the extent that he could not expectorate and blood accumulating in the airway led to asphyxia and death.

[Influence of splenectomy on drug therapy for acute liver failure induced by D-galactosamine and lipopolysaccharide in rats]

We studied protective effects of dibutyryl cyclic AMP (DBcAMP 15 mg/kg i.p.) and OK-432 (5 KE/body), and the role of the spleen on D-galactosamine (D-Gal 500 mg/kg i.p.) and lipopolysaccharide (endotoxin: Et 0.5 mg/kg i.p.) induced acute liver failure. The survival rates were 10% in the control group (D-Gal+Et), 53% in the group I A (DBcAMP was administered at 1 hour before D-Gal administration), 79% in the group I B (Splenectomy was performed at 24 hours before D-Gal administration on the group I A), 87% in the group II A (OK-432 was administered at 24 hours before D-Gal administration), and 64% in the group II B (Splenectomy was performed at 24 hours before D-Gal administration on the group II A). GOT activities and TNF activities were significantly improved in the treatment groups, and in the group I B and group II A, they were more improved than in the group I A and group II B. In conclusion, spleen had the positive effect for OK-432 treatment, and also had the negative effect for DBcAMP treatment on acute liver failure induced by D-Gal and Et.

Brain death diagnosed by forensic analysis of drug distribution in human tissues

Brain death was diagnosed by analyzing drug distribution in human tissues. Concentrations of diazepam and phenobarbital in human tissues, administered therapeutically to 3 patients in a critical condition, were determined by gas chromatography with a nitrogen phosphorus detector and gas chromatography-mass spectrometry. In 2 patients administered drugs while the brain was functioning, drug concentrations in the brain were high compared with those in the other tissues. In the other patient given the drugs after vital signs of the brain ceased, the level of drugs in the brain was much lower than seen in other tissues. We propose that a forensic diagnosis of patients who are brain dead can be made by comparing the concentrations of drugs in the brain given at the time of critical condition with concentration of these agents in other tissues. When cerebral function ceased can be roughly estimated by the variable distribution patterns of drugs and time of administration of these drugs.

Detection of neuroblastoma cells in bone marrow and peripheral blood at diagnosis by the reverse transcriptase-polymerase chain reaction for tyrosine hydroxylase mRNA

BACKGROUND

Bone marrow metastasis often occurs in patients with neuroblastoma; therefore, a sensitive assay to detect occult neuroblastoma cells in bone marrow (BM) and peripheral blood (PB) is needed. The feasibility and clinical value of using the reverse transcriptase-(RT) polymerase chain reaction (PCR) to amplify mRNA for tyrosine hydroxylase (TH), the first enzyme of catecholamine synthesis, was evaluated to detect neuroblastoma cells in patient samples.

METHODS

Thirty-eight patients with Stages I to IV neuroblastoma and eight healthy donors were included in this study. Bone marrow and PB samples obtained at diagnosis were examined for TH mRNA. After preparation of complementary DNA, the PCR was performed to amplify the TH gene.

RESULTS

Tyrosine hydroxylase mRNA was detected in neuroblastoma samples including a cell line and tumor tissues, but was not detected in normal BM or PB mononuclear cells. Neuroblastoma cells were detected at a level of 1 per 10(5-6) normal PB mononuclear cells by this method. Tyrosine hydroxylase mRNA was detected in 18 of 38 BM samples, and all 12 BM samples with cytologic evidence of tumor cells were positive for TH mRNA by the RT-PCR. Six of 26 patients without cytologic evidence of tumor cells in the BM were also positive for TH mRNA. TH mRNA was detected in BM samples from 1 of 14 patients with Stage I disease, 2 of 7 patients with Stage II disease, 1 of 3 patients with Stage III disease and all patients with Stage IV (11 patients) and IVS (3 patients) diseases. Tyrosine hydroxylase mRNA also was detected in 8 of 14 PB samples (one of five patients in Stages I, II or III, and 7 of 9 in Stage IV or IVS).

CONCLUSIONS

Reverse transcriptase-polymerase chain reaction amplification of TH mRNA was a sensitive and specific method of detecting occult neuroblastoma cells in BM and PB samples. Neuroblastoma cells could be detected by this method in some BM samples that had no cytologic evidence of tumor cells and in some PB samples at the time of diagnosis. The clinical significance of these very low levels of neuroblastoma cells detected by RT-PCR requires further investigation.

Ginseng saponins reduce acetylcholine-evoked Na+ influx and catecholamine secretion in bovine adrenal chromaffin cells

The effects of various ginseng saponins (ginsenosides Rb1, Rb2, Rb3, Rc, Rd, Re, Rf, Rg1, Rg2, Rh1, Ro and Rs1), which are isolated from the root of Panax ginseng, on the catecholamine secretion from bovine adrenal chromaffin cells stimulated by ACh were examined. Most of the ginsenosides (1-100 microM) had a tendency to reduce the ACh-evoked secretion of catecholamines. The order of inhibitory potency (at the concentration of 10 microM) was as follows: Rg2 > Rf > Re > Rh1 > Rb2, Rg1 > Rb1 > Rc > Rb3, Rd, Ro, Rs1. The inhibition of ginseoside Rg2 at 10 microM was 72%, but ginsenosides Rb3, Rd, Ro and Rs1 did not show the inhibitory effect. On the other hand, ginsenoside Rg2 (1-100 microM) did not at all affect the secretion induced by high K+ or veratridine, a potent specific activator of voltage-sensitive Na+ channels. Ginsenoside Rg2 (1-100 microM) also inhibited both ACh-induced Na+ and Ca++ influxes into the cells in a concentration-dependent manner. The concentration-response curves for ginsenoside Rg2 inhibition of Na+ influx, of Ca++ influx and of catecholamine secretion were quite similar. The inhibitory effect of ginsenoside Rg2 on the secretion was not overcome by increasing ACh or external Ca++ concentrations. These results strongly suggest that the ginseng saponins, especially ginsenoside Rg2, block the nicotinic ACh receptors or the receptor-operated Na+ channels (but not voltage-sensitive Na+ and Ca++ channels), inhibit Na+ influx through the channels and consequently reduce both Ca++ influx and catecholamine secretion in bovine adrenal chromaffin cells.(ABSTRACT TRUNCATED AT 250 WORDS)

[Legionella pneumonia diagnosed by urinary antigen detection]

A 63-year-old man with dyspnea and high fever was admitted to the hospital. A pneumonic shadow in the right lower lung field was observed. After administration of rifampicin and clarithromycin, his symptoms were gradually alleviated. Although Legionella pneumonia was highly suspected, Legionella pneumophila was not isolated from his sputum specimens and the serum level of indirect immunofluorescent antibody titer was not significantly elevated. However, we believe it is very likely that he had Legionella pneumonia, because we detected a high density of urinary Legionella pneumophila serogroup 1 antigen by antigen capture EIA.

[Clinical evaluation of cefpodoxime proxetil, a new oral cephem, in the treatment of respiratory tract infections with the special reference to community-acquired Streptococcus Pneumoniae infections]

The clinical usefulness of cefpodoxime proxetil (CPDX-PR) was investigated in the treatment of pneumonia and chronic airway infections occurring in patients first visiting our outpatient clinic or those being treated at the outpatient clinic. CPDX-PR was orally administered twice a day after meals at a dose of 100-200 mg for acute respiratory tract infections and at a dose of 200 mg for chronic respiratory tract infections. Excellent, good, fair, and poor responses were observed in 20, 33, 10, and 3 of 66 patients (4 with acute bronchitis, 27 with pneumonia, and 35 with acute exacerbation of chronic airway infection), respectively, demonstrating an 80.3% efficacy rate (53/66). Causative organisms, including Streptococcus pneumoniae, were all eradicated from the patients whose causative organisms were examined over time, although 2 of the patients were superinfected with Pseudomonas aeruginosa. There were no serious adverse reactions or abnormal changes in laboratory test results. It was concluded that CPDX-PR could be used as a first-choice drug for the treatment of respiratory tract infections at an outpatient clinic, and that this drug should acquire greater importance in particular consideration of recent increases in infections with S. pneumoniae.

Sensitive determination of delta 9-tetrahydrocannabinol in human tissues by GC-MS

A reliable, simple, and sensitive method was devised to determine the levels of delta 9-tetrahydrocannabinol (THC) in human solid tissues. THC was effectively extracted with acetonitrile, and interfering compounds were removed by washing with a solution of sodium hydroxide and hydrochloric acid. THC was then derivatized by methylation and subjected to gas chromatography-mass spectrometry. Deuterated methyl THC (THC-CD3) was used as an internal standard. The calibration curves were linear in the concentration range from 1 to 100 ng/g, and the lower limit of detection was 1 ng/g in all samples examined. The accuracy and precision of the method were evaluated in every tissue sample at two different concentrations, 5 and 50 ng per sample. The coefficient of variation ranged from 3.4 to 11.6%. We used this method to identify THC in tissues from an autopsied individual, and the distribution of this drug in the tissues was evaluated based on medico-legal criteria.

[Angiotrophic lymphoma in the paranasal sinuses]

Angiotrophic lymphoma (neoplastic angioendotheliosis) is a peculiar disease which increases large extraordinary sized cells originating from B lymphocytes, in the small blood vessels and the capillary vessels of each viscera of the whole body, including brain. This disease, which was first reported by Pfleger and Tappeiner in 1959, has many clinical manifestations. CNS, skin, lung, kidney, and adrenal gland are often damaged by the disease. A case of this disease appearing in the paranasal sinus with successful remission following chemotherapy is reported. The patient was a 78-year-old woman with bilateral occulomotor nervous paralysis. Ethmosphenoidectomy was conducted under a working diagnosis of pansinusitis following CT. The surgical specimens were studied histopathologically and diagnosed as angiotrophic lymphoma. Six courses of chemotherapy (THP-COP) were applied. This disease is not necessarily rare, but the possibility of its being overlooked without enough diagnosis and treatment is very high. If we detect and treat it at an early stage, recovery of the disease can be expected, as in the case described above.

Subtle increase in leukocyte counts in association with drinking and smoking habits

Peripheral leukocyte counts were examined in venous blood of more than 800 male workers exposed to toluene, xylenes, a combination of the two, or neither. Information on the social habits of smoking and drinking was obtained in an occupational health interview. The analysis showed that smoking (15 cigarettes/day on average) induced a significant increase (by 7%) in leukocyte counts, and that an additional increase was induced when the drinking habit was coupled with smoking. Drinking alone tended to increase the leukocyte counts but the effect was statistically nonsignificant, possibly because the number of nondrinking smokers was limited. The study stresses the importance of paying attention to smoking and drinking habits when evaluating hematological parameters such as peripheral leukocyte counts in solvent-exposed workers.

[Circumvention of cisplatin resistant ovarian cancer cells by antiestrogens]

Antiestrogens (AEs) have been considered to elicit antitumor effects via estrogen receptor. However, recent reports have demonstrated that AEs had an antitumor effect even in cases without estrogen receptor, and that AEs caused various kinds of biological behavior such as a chemosensitizing effect. We therefore investigated the possibility of circumvention of cisplatin (CDDP) resistance due to the chemosensitizing effect of AEs by using 5 ovarian cancer cell lines. They were named KF, MH, KK, KFra and KFrb cell lines. KF and MH were derived from serous cystadenocarcinomas, and KK from a clear cell carcinoma. KFra and KFrb were CDDP-resistant cell lines developed from the KF cell line. MCF-7 cell line derived from breast cancer was used as a control. The study of a 50% inhibitory concentration (IC50) revealed that clomiphene (CLO) had the most potent antiproliferative effect among the AEs used, and was followed by tamoxifen (TAM) and toremifene (TOR) with a similar effect. On the whole, the degree of CDDP sensitivity was not correlated with the degree of AE sensitivity. KFra cell line which had the highest CDDP-resistance among the 5 ovarian cancer cell lines used was the most sensitive to AEs, especially to CLO. In the study on the combined administration of CDDP and AEs, 1 microM of CLO significantly reduced the IC50 of CDDP to KFrb, KK and MCF-7 cell lines. Similarly, 1 microM of TAM significantly reduced the IC50 of CDDP to KF, KFra and MCF-7 cell lines, and 1 microM of TOR significantly reduced it to KFra, KK and MCF-7 cell lines.(ABSTRACT TRUNCATED AT 250 WORDS)

How to diagnose polysulphide poisoning from tissue samples

We carried out animal experiments to toxicologically verify polysulphide poisoning by analyzing tissue samples. A bathing agent containing calcium polysulphides was administered orally to rats, and then polysulphides and sulphide, the decomposed product of polysulphides, were analyzed by GC and GC/MS. The concentrations of polysulphides (mumol/ml or g) were found to be highest in blood (0.196), followed by the liver (0.051), the lungs (0.018) and kidneys (0.013), but were below the detection limit (0.005 mumol/g) in the other tissues tested. Sulphide was detected in all the tissue samples and was found to be highest in the blood (0.518 mumol/ml), this being 40 times higher than that required for fatal poisoning in the case of hydrogen sulphide. Polysulphide poisoning was considered to be confirmatively diagnosed by detecting and measuring polysuphides and supplementarily sulphide in body tissues, most pertinently in the blood. Two practical cases of suspected poisoning by polysulphides are briefly described.

Simultaneous determination of nicotine and cotinine in various human tissues using capillary gas chromatography/mass spectrometry

A reliable and sensitive method for the simultaneous determination of nicotine and cotinine concentrations in various human tissues was developed using capillary gas chromatography/mass spectrometry. Nicotine and cotinine were extracted using a 3-step solvent extraction procedure and quinoline as an internal standard. Quantification was carried out by single ion monitoring using ions of m/z 133 for nicotine, m/z 176 for cotinine and m/z 129 for quinoline. The lower limit of detection was 5 ng/g for nicotine and 10 ng/g for cotinine, in each tissue sample. The calibration curves of various tissues were linear in the concentration range from 5-1,200 ng/g for nicotine and 10-1,500 ng/g for cotinine. The accuracy and precision of this method were examined using human tissues and the results were satisfactory. The distribution of nicotine and cotinine was measured in tissues from 10 human autopsies. Nicotine was detected in every tissue examined at a level seen in habitual smokers. The nicotine concentration was high in the liver, kidney, spleen and lung, and low in adipose tissue. The cotinine level was highest in the liver. The tissue/blood concentration ratios of nicotine and cotinine were most stable in skeletal muscle, where the level of these drugs was close to that in whole blood. Skeletal muscle is, therefore, considered to be the most suitable tissue sample for toxicological examination, when acquisition of blood samples is not feasible.

Insulin stimulates NaCl transport in isolated perfused MTAL of Henle's loop of rabbit kidney

To elucidate the mechanism of Na+ retention by insulin in vivo, the direct tubular effect of insulin on NaCl transport in the in vitro microperfused medullary thick ascending limb of Henle (MTAL) was examined. Insulin at 10(-6) mol/l in the bath increased transepithelial voltage (Vte) from 3.1 +/- 0.3 to 5.7 +/- 0.3 mV (n = 12, P < 0.0001). The effect of insulin on Vte was dependent on its concentration, and the half-maximal effect of insulin was observed at 5 x 10(-9) mol/l. Insulin at 10(-6) mol/l also caused a significant decrease of luminal Cl- concentration from 85.4 +/- 5.0 to 62.8 +/- 3.0 mmol/l (n = 5, P < 0.002) when the lumen was microperfused constantly at less than 1 nl/min. Insulin at 10(-6) mol/l also increased net lumen-to-bath Cl- flux (JCl) from 143 +/- 15 to 292 +/- 37 pmol.mm-1.min-1 (n = 5, P < 0.004). When the Na(+)-K(+)-adenosinetriphosphatase (Na(+)-K(+)-ATPase) in the basolateral membrane was blocked by 10(-4) mol/l ouabain, the insulin-mediated increase in Vte was completely suppressed. When the Na(+)-K(+)-2Cl- cotransporter in the luminal membrane of the MTAL was blocked by 10(-4) mol/l furosemide, the insulin-mediated increase in Vte was also abolished. To test whether adenosine 3',5'-cyclic monophosphate (cAMP) contributes to the action of insulin, we examined the effect of cAMP analogue and cAMP-dependent protein kinase inhibitor on the action of insulin. A maximal concentration (5 x 10(-4) mol/l) of dibutyryl-cAMP (DBcAMP) increased Vte and JCl.(ABSTRACT TRUNCATED AT 250 WORDS)

[Outcome of treatment protocol 8704T for childhood T cell leukemia and lymphoma]

We reported the treatment outcome of Protocol 8704T, which included repeated L-asparaginase, for childhood T cell malignancies. Fifteen cases of acute lymphoblastic leukemia (T-ALL) and 11 cases of non-Hodgkin's lymphoma (T-NHL), aged 3 to 14 yrs (median 6 yrs), were enrolled. Twelve T-ALL had mediastinal mass. Murphy's stages of T-NHL were 6 with III and 5 with IV. Types of histology consisted of 8 lymphoblastic and 3 large cell. Treatment was performed for 2 years. Observation periods were from 14 months to 78 months (median 42 months). Twenty-three achieved remission and 6 of them were transplanted with bone marrow or peripheral stem cells in the first remission. The protocol was continued in 17 cases. Fourteen of them remain in first remission, but one died of measles and 2 died of relapse. The 5-year event-free survival was 76.1% for ALL and 65.5% for NHL. In terms of histology, it was 87.5% for lymphoblastic NHL and 33.3% for large cell NHL (p = 0.19). In terms of phenotypes in ALL, it was 88.7% for ALL positive to CD2, 5 and 7, while 2 ALL positive to CD7 alone both failed. Therefore, it was shown that this treatment protocol is very effective for T-lymphoblastic leukemia and lymphoma.

[Locus of the retention benefits of variable practice in the motor learning]

Shea and Kohl (1990) reported that acquisition practice with variations of the criterion task leads to better retention than practice on the criterion task alone. The purpose of this study was to determine the locus of this retention benefits. Experimental task was the speed reproduction task. Eighty undergraduate male students were randomly assigned to eight practice conditions differing in the activities performed during the intertrial intervals. All subjects were administered retention test immediately and twenty-four hours after the practice. Results indicated that the retention benefits demonstrated by subjects provided variable practice was produced by the contextual interference effect not by the formation of motor response schema. Results also suggested that both of reconstruction of action plan and elaborative processing resulted in the retention benefits.

[Histopathological studies on paranasal mucosa from patients treated with erythromycin]

Low-dose and long-term administration of erythromycin (EM therapy) has been reported to be very effective for patients with intractable chronic sinusitis including sinobronchial syndrome. However, we sometimes encounter patients whose sinusitis is extremely resistant to EM therapy. Therefore, the present study was carried out to determine the correlation between the clinical efficacy of EM therapy and the histopathological features of the ethmoidal mucosa and nasal polyps of patients treated with erythromycin. Patients with significant lymphocytic infiltration in the submucosal area responded well to EM therapy. Furthermore, patients with neutrophilic infiltration within and beneath the ciliary epithelium tended to show improvement with this therapy. On the other hand, EM therapy was minimally effective in patients whose subepithelial layer showed marked eosinophilic infiltration. In patients showing excellent and good clinical results, histological changes in the paranasal mucosa after therapy were as follows: a decrease in the number of inflammatory cells, reduced interstitial edema, increased fibrosis and normalization of the secretory glands. From these results, we conclude that erythromycin may suppress chronic inflammation except for an allergic reaction characterized by marked eosinophilic infiltration.

Pharmacokinetics and postmortem changes of cimetidine in body tissues

Cimetidine concentrations in body tissues were pharmacokinetically examined, together with their postmortem changes, to assess the toxicological effect of this drug from the aspect of forensic medicine. For the pharmacokinetic study, rats were pithed at 0.5, 1.0, 2.0, 4.0 or 8.0 hours after an intravenous injection of the drug (33.3 mg/kg), and their tissue samples were immediately collected to be analyzed by high-performance liquid chromatography (HPLC). The concentrations of cimetidine in the blood and muscle decreased below the lower detection limit at 8 hours after the injection, while the drug could still be detected in the brain, lung, liver, kidney, spleen and adipose tissue. The ratios of the cimetidine concentrations in the muscle, lung and spleen to that in the blood were nearly constant until 4 hours after the injection, while those in the liver, kidney and adipose tissue increased as time elapsed. Postmortem changes of cimetidine concentrations were examined using the tissue samples collected 0, 1 and 2 days after death. There was no statistical significance in the postmortem changes in cimetidine concentrations in the body tissues over the two-day period of examination. The experimental results indicated that the muscle, lung and spleen together can serve as samples for toxicological analysis to evaluate the effect of cimetidine, regardless of various postmortem factors, including the availability of blood.

Electrophysiological analysis of effect of propranolol in rabbit S2 proximal straight tubule

The effect of dl-propranolol on the basolateral membrane potential (Vb) of in vitro microperfused S2 proximal straight tubules of the rabbit kidney was examined using conventional microelectrode techniques. In the steady-state condition, the average of 23 measurements of Vb was -44.8 +/- 2.0 mV. Addition of 10(-4) mol/l of dl-propranolol to the basolateral solution rapidly depolarized Vb by 12.1 +/- 1.3 mV in 20 sec (n = 15). The same dose of d-isomer of propranolol, which has no beta-blocking effect, also depolarized Vb to a similar extent. The non-selective beta-blocker nadolol, which possesses no membrane stabilising activity, had no effect on Vb. Depolarization of Vb by dl-propranolol in 20 seconds (propranolol-induced delta Vb) occurred in a dose-dependent manner. In the presence of 1 mmol/l Ba++ in basolateral solution, propranolol-induced delta Vb was strongly inhibited. The stilbene derivative DIDS at 1 mmol/l did not change propranolol-induced delta Vb, whereas the elimination of Cl- from the ambient conditions increased propranolol-induced delta Vb. The minimization of the luminal Na(+)-coupled organic solute transporter by collapsing of the lumen did not inhibit propranolol-induced delta Vb, indicating the lack of effect of propranolol on luminal Na(+)-coupled transporters. Ouabain at 10(-3) mmol/l in the bath did not eliminate propranolol-induced delta Vb, indicating the presence of a target transporter other than Na+/K+ ATPase for propranolol. These results suggest the following; 1) propranolol has a depolarizing effect on Vb in proximal tubule; 2) the effect of propranolol is independent of Cl- transport or Na(+)-coupled transporters in the luminal membrane; 3) propranolol depolarizes Vb by inhibiting the K+ channel in the basolateral membrane of S2 proximal tubule.