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.

Phase II trial of irinotecan in patients with progressive or rapidly recurrent colorectal cancer

PURPOSE

To evaluate irinotecan (CPT-11; Yakult Honsha, Tokyo, Japan) in patients with metastatic colorectal carcinoma that had recurred or progressed following fluorouracil (5-FU)-based therapy.

PATIENTS AND METHODS

Patients were treated with irinotecan 125 to 150 mg/m2 intravenously (IV) every week for 4 weeks, followed by a 2-week rest. Forty-eight patients were entered onto the study and all were assessable for toxicity. Forty-three patients completed one full course of therapy and were assessable for response.

RESULTS

One complete and nine partial responses were observed (response rate, 23%; 95% confidence interval [CI], 10% to 36%). The median response duration was 6 months (range, 2 to 13). The median survival time was 10.4 months and the 1-year survival rate was 46% (95% CI, 39% to 53%). Grade 4 diarrhea occurred in four of the first nine patients (44%) treated on this study at the 150-mg/m2 dose level. The study was amended to reduce the starting dose of irinotecan to 125 mg/m2. At this dose, nine of 39 patients (23%) developed grade 4 diarrhea. Aggressive administration of loperamide also reduced the incidence of grade 4 diarrhea. Grade 4 neutropenia occurred in eight of 48 patients (17%), but was associated with bacteremia and sepsis in only case.

CONCLUSION

Irinotecan has significant single-agent activity against colorectal cancer that has progressed during or shortly after treatment with 5-FU-based chemotherapy. The incidence of severe diarrhea is reduced by using a starting dose of irinotecan 125 mg/m2 and by initiating loperamide at the earliest signs of diarrhea. These results warrant further clinical evaluation to define the role of irinotecan in the treatment of individuals with colorectal cancer.

Depression and multiple sclerosis

The objective of the present study were (1) to ascertain the lifetime risk of a depression in a representative group of multiple sclerosis (MS) patients, (2) to assess the morbidity risks for depression among first-degree relatives of these MS patients, and (3) to compare these familial risks for first-degree relatives of MS patients with those for first-degree relatives of a primary depression population, i.e., depression but no MS. We psychiatrically evaluated 221 MS patients (index cases) using a structured clinical interview for the DSM-III-R and calculated the rate and lifetime risk of depression for these index cases using the product limit estimate of survival function. We obtained psychiatric histories for all first-degree relatives of index cases, and we calculated morbidity risks for depression for these relatives using the maximum likelihood approach and compared the risks using the likelihood ratio tests. Index cases had a 50.3% lifetime risk of depression. Morbidity risks for depression among first-degree relatives of index cases were decidedly lower when compared with morbidity risks among first-degree relatives of the reference population. Although there appears to be a very high rate of depression among MS patients, the data for their first-degree relatives do not support a clear genetic basis for this depression, or at least the same genetic basis that probably operates within families when depression occurs in the absence of MS.

Tyrosine kinase inhibitors. 9. Synthesis and evaluation of fused tricyclic quinazoline analogues as ATP site inhibitors of the tyrosine kinase activity of the epidermal growth factor receptor

Following the discovery of 4-[(3-bromophenyl)amino]-6,7-dimethoxyquinazoline (4; PD 153035) as an extremely potent (IC(50) 0.025 nM) inhibitor of the tyrosine kinase activity of the epidermal growth factor receptor (EGFR), several fused tricyclic quinazoline analogues have been prepared and evaluated for their ability to inhibit the enzyme. The most potent compound was the linear imidazo[4,5-g]quinazoline (8), which exhibited an IC(50) of 0.008 nM for inhibition of phosphorylation of a fragment of phospholipase C-gamma-1 as substrate. While N-methyl analogues of 8 showed similar potency, analogous N-[2-(dimethylamino)ethyl] derivatives were less effective. The next most potent compounds were the linear pyrazoloquinazolines (19 and 20) (IC(50)s 0.34 and 0.44 nM) and pyrroloquinazoline (21) (IC(50) 0.44nM), while several other linear tricyclic ring systems of similar geometry to 8 (triazolo-, thiazolo-, and pyrazinoquinazolines) were less effective. In the imidazo[4,5-g]quinazoline and pyrroloquinazoline series, the corresponding angular isomers were also much less effective than the linear ones. These results are consistent with structure-activity relationship studies previously developed for the 4-[(3-bromophenyl)amino] quinazolines, which suggested that small electron-donating substituents at the 6- and 7-positions were desirable for high potency. Cellular studies of the linear imidazoloquinazoline 8 show that it can enter cells and rapidly and very selectively shut down EGF-stimulated signal transmission by binding competitively at the ATP site of the EGFR.

Lifestyle change for coronary artery disease. What to tell patients

Heart-healthy living is a wise choice for anyone, but it assumes even greater importance in persons who have or are at risk for coronary artery disease. Such patients need to know which measures have proved most effective in the prevention and treatment of the disease. This article reviews the data regarding risk factor reduction and offers recommendations for effective lifestyle modifications.

Screening for coeliac disease as a possible maternal risk factor for neural tube defect

Coeliac disease is an important cause of malabsorption, particularly of folic acid, in adults. We investigated the possibility that it might be a maternal risk factor for neural tube defect (NTD)-associated pregnancy by screening affected mothers using serum endomysial antibody (EmA) which has high sensitivity and specificity for coeliac disease. One (1.6%) of 60 patients was EmA positive and had a diagnosis of coeliac disease confirmed by the finding of villous atrophy on jejunal biopsy. In conclusion, the majority of NTD-associated pregnancies are not associated with maternal coeliac disease and our study is additional evidence that abnormalities of folic acid metabolism rather than absorption are the most important risk factors for NTD. Further studies are needed to determine whether the coeliac disease prevalence among women with NTD-affected pregnancy is higher than that of the general population.

Reactions of nitric oxide and peroxynitrite with organic molecules and ferrihorseradish peroxidase: interference with the determination of hydrogen peroxide

Endothelial, inflammatory, and other cell types, in addition to forming reactive oxygen species, under proper stimulation release free radicals such as nitric oxide (.NO) and strong oxidants such as peroxynitrite (ONOO-), which is the product of the reaction of nitric oxide with superoxide. Several methods for the detection of H2O2 are based on the ferrihorseradish peroxidase catalyzed oxidation of organic molecules. We investigated the reactions of nitric oxide and peroxynitrite with organic molecules as well as with ferrihorseradish peroxidase and examined the potential interference with the detection of H2O2. Peroxynitrite at low concentrations (0-10 microM) induced a concentration-dependent oxidation of 1,2 phenylenediamine, 3-3' dimethoxybenzidine (o-dianisidine) and para-hydroxyphenylacetic acid (pHPA). With the exception of pHPA, the oxidation of the above compounds by peroxynitrite was not affected by the presence of ferrihorseradish peroxidase. The yield of HPA-dimmer, the oxidation product of pHPA by peroxynitrite, was decreased because ferrihorseradish peroxidase catalyzed the formation of a different product, 3-nitro-HPA. Nitrogen oxides, formed by the reaction of nitric oxide with oxygen, oxidized the aromatic amines o-phenylenediamine and o-dianisidine. A 10-fold excess of nitric oxide over H2O2 decreased the yield of pHPA and dihydrorhodamine 123 (DHR123) by 58 and 72%, respectively, as compared to H2O2 plus ferrihorseradish peroxidase. The inhibition of pHPA oxidation by nitric oxide was in part to the reaction of nitric oxide with compound I and compound II and in part due to the reaction with the phenoxyl radical. These data suggest that the simultaneous generation of nitric oxide and peroxynitrite can interfere with the detection of H2O2. The overestimation or underestimation of the H2O2 detected is dependent upon the organic molecule utilized for detection and by the relative rate of nitric oxide, superoxide, and peroxynitrite generation.

Transformation of essential thrombocythaemia to T cell acute lymphoblastic leukaemia

Leukaemic transformation of essential thrombocythaemia is a rare event and is usually associated with previous treatment with either alkylating agents or radioactive phosphorous. We describe a patient with essential thrombocythaemia who developed an acute leukaemia of T cell phenotype following hydroxyurea therapy. The T cell phenotype of the blasts suggests the target cell for leukaemic transformation was a pluripotential stem cell.

Insensitivity to anti-müllerian hormone due to a mutation in the human anti-müllerian hormone receptor

Anti-Müllerian hormone (AMH) and its receptor are involved in the regression of Müllerian ducts in male fetuses. We have now cloned and mapped the human AMH receptor gene and provide genetic proof that it is required for AMH signalling, by identifying a mutation in the AMH receptor in a patient with persistent Müllerian duct syndrome. The mutation destroys the invariant dinucleotide at the 5' end of the second intron, generating two abnormal mRNAs, one missing the second exon, required for ligand binding, and the other incorporating the first 12 bases of the second intron. The similar phenotypes observed in AMH-deficient and AMH receptor-deficient individuals indicate that the AMH signalling machinery is remarkably simple, consisting of one ligand and one type II receptor.

Massive overdose of sustained-release verapamil: a case report and review of literature

Verapamil 99 is a commonly prescribed medicine for treatment of hypertension, angina, and migraine headache. Toxicity with sustained-release verapamil may be prolonged, and manifest with hypotension, bradycardia, metabolic acidosis, and hyperglycemia. Currently, because of the lack of a specific antidote management of verapamil, toxicity is mainly supportive. Treatment with inotropic support, glucagon, calcium, and cardiac pacing may be effective in some cases. A review of 20 cases and a case report of sustained-release verapamil overdose are described. The authors describe a patient who ingested 24 g of slow-release verapamil. This is the largest overdose of sustained-release verapamil reported in English literature. The patient was managed aggressively with gastric lavage, inotropic support, and continuous infusion of calcium and glucagon. The patient's survival may have been due to the continuous intravenous calcium gluconate and glucagon infusion. Both of these treatment modalities should be considered in patients with moderate to severe calcium channel blocker overdose.

Epidural administration of methylprednisolone and morphine for pain after a spinal operation. A randomized, prospective, comparative study

The results of postoperative epidural administration of saline solution (a placebo), morphine, methylprednisolone, and a combination of morphine and methylprednisolone for the reduction of pain after an operation for spinal stenosis or a herniated intervertebral disc were compared in a prospective, randomized blinded study. Epidural administration of morphine and methylprednisolone--either alone or in combination--significantly reduced the need for analgesia after an operation for spinal stenosis (p < 0.05) but not after an operation for a herniated intervertebral disc. Morphine and methylprednisolone did not have an addictive effect on the reduction of pain. Itching was significantly more common in the patients who had received morphine than in those who had received the placebo (p = 0.04). Although urinary retention was more frequent after the use of morphine than after the use of the placebo, the difference was not significant with the size of the sample that was analyzed (p = 0.25).

Delayed density-dependence in a small-rodent population

The role of delayed density-dependent processes in the dynamics of animal populations poses a problem for ecologists; although generally assumed important in populations that show cyclic or chaotic fluctuations, little experimental evidence for such processes exist. Through manipulation of vole densities within enclosed areas it was shown that reproduction, recruitment, and body growth rate in introduced populations were negatively affected by high previous density. In addition, female movement patterns shifted, and territoriality as well as home-range size was increased after high density. The observed changes in female spacing-behaviour suggested that negative effects of previous density were partly mediated by social interactions, and agreed with the finding that smaller (less competitive) females were the ones suffering most from increased competition. Contrary to expectations from recent work, predation could be excluded as the cause of delayed density-dependence in this study. Instead, chemical analyses of a dominating food plant suggested that herbivory at high vole-density had delayed negative effects on food quality.

Preovulatory sonographic uterine receptivity index (SURI): usefulness as an indicator of pregnancy in women undergoing assisted reproductive treatments

To evaluate the uterine component as a determinant variable in the probability of establishing a pregnancy after assisted reproductive treatments, we introduced a mathematical formula derived from standard endovaginal uterine monitored color Doppler imaging parameters. We analyzed 102 cycles of ovarian stimulation with leuprolide acetate and exogenous gonadotropins resulting in 52 clinical pregnancies by stepwise logistic regression analysis. Sonographic endometrial pattern, thickness, diastolic blood flow, and resistive index variables were transformed into categorical variables and forced to yield a regression equation. Sonographic uterine receptivity index was calculated as a summation of four times endometrial pattern, five times resistive index, and two times diastolic blood flow. This index yielded values for each patient in a range of 0 to 15. Scores > or = 13 were associated with a successful outcome in 79.4% of the patients, whereas scores between 8 and 12 were accompanied by 45.8% pregnancy rates (P = 0.01), and scores < or = 7 had successful treatment outcome in only 7.7% (P = 0.0001). The scores obtained by this mathematical equation provide the ability to make reliable predictions about the outcome of assisted reproductive treatments in women undergoing ovulation induction with leuprolide acetate and human menopausal gonadotropins.

Effects of pravastatin with niacin or magnesium on lipid levels and postprandial lipemia

This study was designed to evaluate the therapeutic effectiveness of 3 different pharmacologic lipid-lowering regimens in the treatment of patients with clustered lipid risk factors. Sixty-five patients with low high-density lipoprotein (HDL) levels and hypertriglyceridemia were randomized to 1 of 3 treatment arms: pravastatin/niacin, pravastatin/magnesium, or pravastatin/placebo. After 18 weeks, patients in the pravastatin/niacin group had a -41% change in the total cholesterol/HDL ratio compared with -13% in the pravastatin/magnesium arm and -16% in the pravastatin/placebo group. The HDL2 and HDL3 subfractions, as well as the apolipoprotein A-I levels, were increased significantly only in the pravastatin/niacin arm. The levels of small dense low-density lipoprotein (LDL) cholesterol (LDL3) were decreased to a greater extent in the pravastatin/niacin arm (-43%) than in either the pravastatin/magnesium (-13%) or the pravastatin/placebo (-20%) arm. Only the pravastatin/niacin regimen significantly diminished postprandial lipemia (-32% change in the remnant particle triglyceride concentration and decreased very-low-density lipoprotein remnant levels). Thus, in this group of patients with clustered risk factors, the combination of pravastatin and niacin resulted in significant improvements in HDL and triglyceride levels, total cholesterol to HDL ratio, small dense LDL levels, and postprandial lipemia. Pravastatin alone or in combination with magnesium resulted in less significant changes that were largely limited to LDL cholesterol reduction.

Murine epidermal growth factor (EGF) fragment (33-42) inhibits both EGF- and laminin-dependent endothelial cell motility and angiogenesis

Laminin, murine epidermal growth factor (mEGF), and the synthetic laminin peptide Lam.B1(925-933) (a linear peptide from the B1 chain of murine laminin, CDPGY1GSR-amide) all stimulate endothelial cell motility above basal rates, whereas a synthetic mEGF fragment, mEGF33-42 (a linear peptide from the C-loop of mEGF, acetyl-C-[S-Acm]-VIGYSGDR-C-[S-Acm]-amide), inhibits motility. In both human SK HEP-1 and embryonic chick endothelial cells, mEGF33-42 blocks both EGF- and laminin-stimulated locomotion of endothelial cells. In vivo, mEGF33-42 also blocks both laminin- and mEGF-induced angiogenesis in the chick. In the human cell line. Lam.B1(925-933) has an additive effect in coincubation with either laminin or mEGF, but it blocks their effects in the chick cells. Lam.B1(925-933) alone stimulates angiogenesis in the chick but blocks laminin-induced angiogenesis. Thus, mEGF33-42 acts as a general laminin antagonist, whereas Lam.B1(925-933) acts as a laminin agonist in human cells, but in chick cells it acts as a partial antagonist. We propose that the presence of an anionic group at the eighth residue of mEGF33-42 may be the source of the antagonistic effects seen with this peptide as compared with the laminin fragment. These findings have important implications in the design of human antiangiogenic agents, and also in the use of chick models in the study of human disease.

Prospective study of adenovirus antigen detection in eye swabs by radioimmune dot-blot

Rapid laboratory diagnosis of ocular adenovirus infection is crucial in the containment of nosocomial transmission of the virus. In a large prospective study of adenovirus assay in eye swabs, antigen detection by radioimmune dot-blot (turnaround time 72 hours) achieved a sensitivity of 67% (239/355) and a specificity of 93% (3065/3285) in comparison with virus culture (median turnaround time 14 days). When specimens weakly reactive for adenovirus antigen, or equally reactive for both adenovirus antigen and Chlamydia trachomatis antigen, were considered falsely reactive in the adenovirus test, the sensitivity of the latter was reduced and false positive reactions were only marginally less frequent. The radioimmune dot-blot provides a more rapid diagnosis of ocular adenovirus infection than virus culture, but the high risk of false negative and in particular false positive results limits its clinical utility.

Small patella syndrome

We report on 2 sporadic cases of small patella syndrome (coxo-podo-patellaire syndrome) most probably representing new mutations. Both children showed retarded patellar bone age (small patellae in Patient 1 and absent patellae in Patient 2) and pelvic abnormalities. Patient 1 who was fully investigated had an unusual facies with characteristic morphological abnormalities of the forefoot and generalized bone changes. Patient 2 was not available for examination and only X-ray films of his knees, pelvis, and chest were available. These were all abnormal. He was said to have an "unusual facies" with flattened nose and prominent forehead but no further information was available. We think that small patella syndrome (coxo-podo-patellaire syndrome) is a generalized bone dysplasia with morphological and diagnostic radiographic appearances.

Value of screening for oro-pharyngeal Chlamydia trachomatis infection

AIMS

To determine whether oro-pharyngeal colonisation by Chlamydia trachomatis occurs in patients at risk of genital chlamydia infection; to determine whether screening pharyngeal specimens by polymerase chain reaction (PCR) increases detection of C trachomatis compared with isolation and the immune dot blot test; and to correlate the detection of C trachomatis and Neisseria gonorrhoeae in the pharynx with a history of oro-genital contact.

METHODS

Thirteen homosexuals and 11 heterosexuals were included in the study. Urogenital and pharyngeal specimens were tested for C trachomatis and N gonorrhoeae using standard clinical diagnostic procedures. Two different PCR methodologies were also used to detect C trachomatis in the pharyngeal specimens. Results were correlated with the mode of sexual practice.

RESULTS

Oro-genital sexual contact was practised by 64.9% (72/111) of heterosexuals in addition to penetrative penovaginal intercourse. Additionally, 62.1% (77/124) of all patients did not use any form of barrier protection. Of those who admitted to oro-genital sexual contact, 17.6% of patients with a genital chlamydial infection and 36.4% of those with genital gonorrhoea also had asymptomatic pharyngeal colonisation. C trachomatis was detected in three of 124 (2.4%) pharyngeal specimens by PCR which were reported as negative by chlamydial culture; one was positive by the immune dot blot test.

CONCLUSION

The majority of patients practised unprotected oro-genital contact and significant pharyngeal colonisation by C trachomatis and N gonorrhoeae occurred if genital infection was present. Despite the use of PCR in a population at high risk of sexually transmitted disease, the prevalence of chlamydia in the pharynx was very low. This indicates that transmission of C trachomatis to the oro-pharynx does not pose a serious health risk and that screening of patients for oro-pharyngeal C trachomatis is not worthwhile.