[Comparison of addition of theophylline to inhaled steroid with doubling of the dose of inhaled steroid in asthma]

The anti-asthmatic effect of theophylline may supplement those of inhaled steroids in asthma. The aim of the present trial was to study how the addition of theophylline compares to doubling the dose of inhaled steroid in asthmatics who remain symptomatic on beclomethasone dipropionate (BDP) 400 micrograms/day. The trial was designed as a randomized, double-blind, parallel-group study in several European countries. 69 patients were treated for 6 weeks with theophylline plus BDP 400 micrograms/day, compared to 64 patients treated with BDP 800 micrograms/day. The mean +/- SD serum theophylline concentration was 10.1 +/- 4.2 mg/l. Lung function measurements were made throughout the study and patients kept daily records of peak expiratory flow rate (PEF), symptoms and salbutamol usage. Forced expiratory volume in one second and PEF at week 6 were significantly increased by both treatments (p < 0.01). PEF variability was reduced by about 30% in both groups. There were significant improvements in asthma symptoms and rescue medication use (p < 0.001). There were no significant differences between the treatment groups. The study demonstrated clinical equivalence of theophylline plus beclomethasone dipropionate 400 micrograms/day and beclomethasone dipropionate 800 micrograms/day in patients whose asthma is not controlled on beclomethasone dipropionate 400 micrograms/d. The results support the use of theophylline as steroid-sparing agent. The combination of low-dose inhaled steroid plus theophylline is a suitable treatment for moderate asthma.

5-Fluorouracil and leucovorin therapy in patients with hormone refractory prostate cancer: an Eastern Cooperative Oncology Group phase II study (E1889)

This report is a multi-institutional phase II study designed to obtain the response rate, survival, and toxicity profile for patients having hormone-refractory prostate cancer. Patients who had bidimensionally measurable prostate carcinoma in first or second remission after previous hormonal therapy but no history of chemotherapy were eligible. Patients were treated with leucovorin, 20 mg/m2 intravenously, followed by 5-fluorouracil (5-FU), 425 mg/m2 intravenously daily for 5 days, with cycles repeated every 28 days. Of 38 eligible patients, 3 (7.9%) had partial responses to therapy and 20 (52.6%) had stable disease. Median survival was 11.6 months for all 38 patients and median time to progression was 4.4 months. Most of the serious side effects were gastrointestinal or hematologic and overall, 23 of 38 patients (60.5%) experienced at least one grade 3 or 4 treatment-related toxicity of any type, as measured by the National Cancer Institute common toxicity criteria. Five patients (13.2%) withdrew from the study because of adverse reactions from chemotherapy. We conclude that treatment of hormone-refractory prostate cancer patients with 5-FU and leucovorin chemotherapy produced few responses at the cost of significant side effects. Further investigation of this combination is not warranted in this setting.

Revisions of endoprosthetic reconstructions after limb salvage in musculoskeletal oncology

Of 91 limb-salvage procedures using prosthetic reconstructions because of primary or metastatic bone and soft-tissue tumors 26 revisions were performed in 16 patients. Revision was due to polyethylene wear (9 cases), aseptic loosening (8 cases), recurrent hip dislocation (3 cases), prosthetic stem fracture (2 cases), infection (2 cases), leg length discrepancy (1 case), and traumatic dislocation of a saddle prosthesis (1 case). The follow-up period for tumor control varied from 1.5 to 22 years with a median of 13.5 years. The follow-up period after the last revision operation varied from 0.5 to 12 years with a median of 3 years. At the last follow-up, the functional results had deteriorated compared with after the primary operation in 5 patients and had improved in 2 patients. In the remaining patients, the results did not change.

Functional organization of rat olfactory bulb glomeruli revealed by optical imaging

The functional organization and synaptic physiology of olfactory bulb glomeruli were studied in rat in vitro slice preparations stained with the voltage-sensitive dye RH-155. Optical signals were recorded with a 100-element photodiode array at high temporal resolution. Pharmacological and ionic manipulations were used to investigate synaptic responses to stimulation of the olfactory nerve layer (ONL). ONL stimulation evoked a sodium-mediated compound action potential that propagated across the ONL and invaded individual glomeruli. This presynaptic volley evoked calcium-dependent synaptic responses the amplitudes of which were largest within the glomerular layer (GL); smaller amplitude responses were recorded in deeper layers of the olfactory bulb. Synaptic responses in the GL were attenuated by the non-NMDA ionotropic glutamate receptor antagonist CNQX; the residual component was suppressed by the NMDA glutamate receptor antagonist AP-5. The GABAA receptor antagonist bicuculline methiodide had little effect, whereas the GABAB receptor agonist baclofen dramatically attenuated ONL-evoked synaptic responses. The effects of baclofen were reversed by the GABAB receptor antagonist CGP35348. Paired-pulse depression of ONL-evoked synaptic responses in the GL was partially reversed by CGP35348. These findings suggest that olfactory nerve axons release glutamate to activate both NMDA and non-NMDA receptors on GL neurons, that GABAA receptor-mediated inhibition has little effect on these responses, and that GABAB receptor-mediated inhibition may act presynaptically on olfactory nerve axons to modulate their inputs to olfactory bulb neurons.

Internal jugular vein thrombosis following modified neck dissection: implications for head and neck flap reconstruction

BACKGROUND

The incidence of internal jugular vein thrombosis (IJVT) following a modified neck dissection remains uncertain. The effect of, or consequences following, IJVT upon pedicled and free flap head and neck reconstructions remains unexplored.

METHODS

Twenty-nine preserved internal jugular veins in 24 patients undergoing modified neck dissection were available for prospective study. All patients required a pedicled or free flap reconstruction and received a modified, unilateral or bilateral cervical lymphadenectomy. The patency of all jugular veins was determined preoperatively and postoperatively using a combination of computed tomography (CT) scanning, high-resolution ultrasound, and color-flow Doppler (CFD).

RESULTS

The IJVT rate was 14%. The presence of a pedicled myocutaneous flap and left-sided jugular dissections may represent risks to the postoperative patency of the internal jugular vein. Preoperative radiotherapy did not appear to impact negatively upon the thrombosis rate.

CONCLUSIONS

Thrombosis of the internal jugular vein may result in significant morbidity for the postoperative oncologic patient. An internal jugular-dependent-free-tissue transfer may risk venous compromise of the flap, whereas the use of a pedicled flap may place the jugular at increased risk for thrombosis. Strategies for deep venous system microvascular recipient recruitment in the head and neck are discussed. Wherever possible, we employ two deep venous systems, the internal jugular, and subclavian (via the external jugular) for flap drainage.

Asthma management: the challenge of equivalence

Increasing prevalence and severity of asthma worldwide encourage the development of new antiasthmatic drugs, alternative treatment regimens and improved formulations of established drugs. Whereas the efficacy of new chemical entities (NCEs) is usually demonstrated by superiority over placebo or a subtherapeutic dose of the active drug, equivalence concepts have to be used in the following situations: the need to replace chlorofluorocarbon (CFC) propellants for inhalative asthma medications by suitable alternatives, and the need to demonstrate that an alternative treatment regimen is not clinically inferior to an established reference treatment. To cover both situations, the recent ICH guidance on biostatistics clearly distinguishes between two-sided equivalence trials and one-sided non-inferiority trials. In this context, non-inferiority always means "not inferior by a clinically relevant amount". After having confirmed non-inferiority, superiority of the alternative test treatment over the reference treatment can additionally be tested without the need to adjust the significance level. The definition of equivalence acceptance limits becomes crucial, particularly in studies conducted in the flat range of the dose-response curve of inhaled steroids. In order to assess the non-inferiority of steroid sparing add-on treatments we propose a one-sided test based on post-/pre-ratios which have substantially reduced coefficients of variation compared to the post-treatment values themselves. The non-inferiority acceptance limit of 0.90 - as opposed to 0.80 in bioequivalence assessment - reflects clinically irrelevant changes of lung function variables. The proposed methodology is illustrated by 2 examples from randomized, double-blind, parallel-group studies comparing inhaled steroid plus theophylline versus doubling the steroid dose in asthmatics who are symptomatic on low-dose inhaled steroid.

Long-term pamidronate treatment of advanced multiple myeloma patients reduces skeletal events. Myeloma Aredia Study Group

PURPOSE

To determine the efficacy and safety of 21 monthly cycles of pamidronate therapy in patients with advanced multiple myeloma.

PATIENTS AND METHODS

Patients with stage III myeloma and at least one lytic lesion received either placebo or pamidronate 90 mg intravenously administered as a 4-hour infusion monthly for 21 cycles. At study entry, the patients were stratified according to whether they were to receive first-line (stratum 1) or second-line (stratum 2) antimyeloma chemotherapy. Skeletal events (pathologic fracture, radiation or surgery to bone, and spinal cord compression) and hypercalcemia were assessed monthly.

RESULTS

The results of the first nine previously reported cycles are extended to 21 cycles. Of the 392 randomized patients, efficacy could be evaluated in 198 who received pamidronate and 179 who received placebo. After 21 cycles, the proportion of patients who developed any skeletal event was lower in the pamidronate-group (P = .015). The mean number of skeletal events per year was less in the pamidronate-group (1.3) than in placebo-treated patients (2.2; P = .008). Although survival was not different between the pamidronate-treated group and placebo patients overall, stratum 2 patients who received pamidronate lived longer than those who received placebo (14 v 21 months, P = .041). Pamidronate was safe and well tolerated during the 21 cycles of therapy.

CONCLUSION

Long-term monthly infusions of pamidronate as an adjunct to chemotherapy are superior to chemotherapy alone in reducing skeletal events in stage III multiple myeloma patients, and may improve the survival of patients on salvage therapy.

Differential distribution of inositol 1,4,5-triphosphate receptors in the rat olfactory bulb

The inositol 1,4,5-triphosphate receptor (IP3R) regulates the release of calcium from intracellular stores. In the present study, the distribution of IP3R in the rat main olfactory bulb was determined by immunohistochemistry. Immunofluorescence was used to double label for IP3R and for gamma-aminobutyric acid (GABA) or for projection neurons, which were retrogradely labeled following dextran injection into the lateral olfactory tract (LOT). The expression profile of IP3R changes dramatically during development. In the glomerular layer of adults, many juxtaglomerular neurons are IP3R immunoreactive [IP3R(+)]; the majority of these cells are also GABA immunoreactive [GABA(+)]. Scattered sparsely throughout the external plexiform layer are small numbers of IP3R(+) neurons, a small number of which are LOT-projecting tufted cells. Significant numbers of IP3R(+) neurons are in the granule cell layer; however, most of these cells are GABA(-). The vast majority of mitral cells contain little or no IP3R immunoreactivity. These findings indicate that, in the olfactory bulb of adult rats, IP3R is preferentially localized in specific classes of intrinsic neurons and that it is rarely expressed in projection neurons. In contrast, during the first postnatal week, the receptor is detected almost exclusively in mitral cells. Expression of IP3R in subclasses of intrinsic neurons begins during the second and third weeks, concomitant with a decrease in immunostaining of mitral cells. Adult patterns of IP3R immunostaining are apparent by the fourth postnatal week. These observations raise the possibility that the expression of IP3R in specific classes of neurons during development is activity dependent.

Comparison of addition of theophylline to inhaled steroid with doubling of the dose of inhaled steroid in asthma

The anti-asthmatic effects of theophylline may supplement those of inhaled steroids in asthma. The aim of the present trial was to study how the addition of theophylline compares to doubling the dose of inhaled steroid in asthmatics who remain symptomatic on beclomethasone dipropionate (BDP) 400 microg x day(-1). The trial was designed as a randomized, double-blind, parallel-group study in several European countries. Sixty nine patients were treated for 6 weeks with theophylline plus BDP 400 microg x day(-1), compared to 64 patients treated with BDP 800 micro x day(-1). The mean+/-SD serum theophylline concentration was 10.1+/-4.2 mg x L(-1). Lung function measurements were made throughout the study and patients kept daily records of peak expiratory flow (PEF), symptoms and salbutamol usage. Forced expiratory volume in one second and PEF at week 6 were significantly increased by both treatments (p<0.01). PEF variability was reduced by about 30% in both groups. There were significant improvements in asthma symptoms and rescue medication use (p<0.001). There were no significant differences between the treatment groups. The study demonstrated clinical equivalence of theophylline plus beclomethasone dipropionate 400 microg x day(-1) and beclomethasone dipropionate 800 microg x day(-1) in patients whose asthma is not controlled on beclomethasone dipropionate 400 microg x day(-1). The results support the use of theophylline as a steroid-sparing agent. The combination of low-dose inhaled steroid plus theophylline is a suitable treatment for moderate asthma.

Distribution and activation of intracellular Ca2+ stores in cultured olfactory bulb neurons

The presence and distribution of intracellular Ca2+ release pathways in olfactory bulb neurons were studied in dissociated cell cultures. Histochemical techniques and imaging of Ca2+ fluxes were used to identify two major intracellular Ca2+ release mechanisms: inositol 1, 4,5-triphosphate receptor (IP3R)-mediated release, and ryanodine receptor-mediated release. Cultured neurons were identified by immunocytochemistry for the neuron-specificmarker beta-tubulin III. Morphometric analyses and immunocytochemistry for glutamic acid-decarboxylase revealed a heterogeneous population of cultured neurons with phenotypes corresponding to both projection (mitral/tufted) and intrinsic (periglomerular/granule) neurons of the in vivo olfactory bulb. Immunocytochemistry for the IP3R, and labeling with fluorescent-tagged ryanodine, revealed that, irrespective of cell type, almost all cultured neurons express IP3R and ryanodine binding sites in both somata and dendrites. Functional imaging revealed that intracellular Ca2+ fluxes can be generated in the absence of external Ca2+, using agonists specific to each of the intracellular release pathways. Local pressure application of glutamate or quisqualate evoked Ca2+ fluxes in both somata and dendrites in nominally Ca2+ free extracellular solutions, suggesting the presence of IP3-dependent Ca2+ release. These fluxes were blocked by preincubation with thapsigargin and persisted in the presence of the glutamate receptor antagonist 6-cyano-7-nitroquinoxaline-2,3-dione. Local application of caffeine, a ryanodine receptor agonist, also evoked intracellular Ca2+ fluxes in the absence of extracellular Ca2+. These Ca2+ fluxes were suppressed by preincubation with ryanodine. In all neurons, both IP3- and ryanodine-dependent release pathways coexisted, suggesting that they interact to modulate intracellular Ca2+ concentrations.

Intrinsic circuitry and physiological properties of pyramidal neurons in rat barrel cortex

Pyramidal neurons in the rat posteromedial barrel subfield (PMBSF) were characterized physiologically and filled with biocytin in in vitro brain slices. Intrinsic axons belonging to supragranular neurons projected horizontally and vertically, arborizing in layers II/III and V, but had few or no projections to layers IV or VI. These axons projected horizontally for up to 2 mm, spanning two to seven barrel columns. Layer V neurons had more diffuse axon arbors that projected either vertically, arborizing in layers III to V, or horizontally, branching profusely in layers V and VI. The basal dendritic trees of neurons in layers II/III, V and VI spanned one or two barrel columns without being skewed toward particular barrel columns. Physiologically, regular-spiking neurons were classified as "RS1" or "RS2" according to their degree of late spike frequency adaptation. RS1 neurons were found in superficial and deep layers, whereas RS2 neurons were significantly more prevalent in the latter. Infragranular, but not supragranular neurons showed slow, inward rectification at hyperpolarized potentials. All neurons generated fast and medium afterhyperpolarizations following individual spikes; however, only infragranular pyramids had depolarizing afterpotentials interposed between the two afterhyperpolarizations. RS1 neurons had larger cell bodies, longer total basal dendritic lengths, and more densely branched proximal dendritic trees than RS2 neurons. These findings indicate that pyramidal neurons in the deep and superficial layers of the rat PMBSF have distinct patterns of intracortical axon arbors and distinct physiological properties. These features are probably involved in shaping and modulating the response properties of PMBSF neurons.

Biochemical characterization of the mouse muscle-specific enolase: developmental changes in electrophoretic variants and selective binding to other proteins

The glycolytic enzyme enolase (EC 4.2.1.11) is active as dimers formed from three subunits encoded by different genes. The embryonic alphaalpha isoform remains distributed in many adult cell types, whereas a transition towards betabeta and gammagamma isoforms occurs in striated muscle cells and neurons respectively. It is not understood why enolase exhibits tissue-specific isoforms with very close functional properties. We approached this problem by the purification of native betabeta-enolase from mouse hindlimb muscles and by raising specific antibodies of high titre against this protein. These reagents have been useful in revealing a heterogeneity of the beta-enolase subunit that changes with in vivo and in vitro maturation. A basic carboxypeptidase appears to be involved in generating an acidic beta-enolase variant, and may regulate plasminogen binding by this subunit. We show for the first time that pure betabeta-enolase binds with high affinity the adjacent enzymes in the glycolytic pathway (pyruvate kinase and phosphoglycerate mutase), favouring the hypothesis that these three enzymes form a functional glycolytic segment. betabeta-Enolase binds with high affinity sarcomeric troponin but not actin and tropomyosin. Some of these binding properties are shared by the alphaalpha-isoenolase, which is also expressed in striated muscle, but not by the neuron-specific gammagamma-enolase. These results support the idea that specific interactions with macromolecules will address muscle enolase isoforms at the subcellular site where ATP, produced through glycolysis, is most needed for contraction. Such a specific targeting could be modulated by post-translational modifications.

Correspondence between the effect of zidovudine plus lamivudine on plasma HIV level/CD4 lymphocyte count and the incidence of clinical disease in infected individuals. North American Lamivudine HIV Working Group

OBJECTIVES

To investigate whether apparently beneficial changes in plasma HIV RNA level and CD4 lymphocyte count that are induced by antiretroviral therapy are associated with a corresponding clinical benefit.

METHODS

For 620 patients in two randomized, double-blind trials of lamivudine (3TC) and zidovudine (ZDV) plasma HIV RNA and CD4 lymphocyte count changes were compared in patients randomized to 3TC plus ZDV and patients randomized to other treatment arms. The effect of therapy on the HIV RNA level and CD4 count was compared with the effect of therapy on clinical endpoints over the same time period.

RESULTS

Median baseline values for all subjects were 42 420 copies/ml for HIV RNA and 277 x 10(6)/l for CD4 count. During the trial a significantly lower HIV RNA level and higher CD4 count was sustained in the ZDV/3TC group compared with the other group, with a difference in the median area under the curve from baseline per month of follow-up of 0.38 log10 copies/ml HIV RNA and 0.18 log2 x 10(6)/l CD4 cells (P < 0.001 in each case). For patients who were initially asymptomatic or in CDC stage B, the adjusted relative hazard (RH) of AIDS for a twofold lower CD4 count was 3.14 [95% confidence interval (CI), 1.44-6.83] and for a 10-fold higher HIV RNA level was 3.22 (1.20-8.59). The RH progression to AIDS expected with ZDV/3TC compared with the control treatments, given the observed effects of treatment on CD4 cell counts and HIV RNA levels, is 0.52, whereas the observed value was 0.16 (0.03-0.74). After adjustment for HIV RNA and CD4 changes over time the observed RH of progression to AIDS for ZDV/3TC treatment compared with controls was increased to 0.36 and was no longer significant (95% CI, 0.07-1.85).

CONCLUSION

In this analysis of two trials, the effects of ZDV/3TC in reducing plasma HIV RNA and raising peripheral blood CD4 counts were associated with concurrent clinical benefits and the effect of treatment on these markers could account for at least part of the clinical benefits of therapy that were observed.

[Iatrogenic hepatitis B, non-A non-B, and C virus infections acquired in health service institutions of the Gdansk province in 1986-1995]

The aim of this study is estimation of the frequency of nosocomial infections caused by HBV, NANB virus, HCV in health service institutions of Gdańsk province. Relationship between medical procedures and acute viral hepatitis was examined among 4268 patients hospitalized in Clinic of Infectious Diseases and Provincial Hospital of Infectious Diseases in Gdańsk, from 1986 to 1995. The analysis of results showed that 1915 (44.9%) cases of viral hepatitis caused by HBV, NANB virus, HCV were probably connected with diagnostic or therapeutic procedures. Within ten years number of HBV, NANB, HCV infections decreased but at the same time relative increase of nosocomial infections caused by those pathogens was observed. Transfusion anamnesis was noted among 129 patients (8.5% of all persons with acute viral hepatitis probably infected in hospitals).

Spectral analysis of ventricular fibrillation and closed-chest cardiopulmonary resuscitation

This study was designed to assess the interference by closed-chest cardiopulmonary resuscitation (CPR) on the ventricular fibrillation (VF) ECG signal in a porcine model of cardiac arrest and to elucidate which variable of VF spectral analysis reflects best myocardial blood flow and resuscitation success during CPR. Fourteen domestic pigs were allocated to receive either 0.4 U/kg vasopressin (n = 7) or 10 ml saline (n = 7) after 4 min of VF and 3 min of CPR. Using radiolabeled microspheres, myocardial blood flow was determined during CPR before, and 90 s and 5 min after, drug administration. Using spectral analysis of VF, the median frequency, dominant frequency, edge frequency and amplitude of VF were determined simultaneously and before the first defibrillation attempt. Using filters in order to specify frequency ranges, stepwise elimination of mechanical artifacts resulting from CPR revealed that at a frequency bandpass of 4.3-35 Hz, median fibrillation frequency has a sensitivity, specificity, positive and negative predictive value of 100% to differentiate between resuscitated and non-resuscitated animals. The best correlation between myocardial blood flow and fibrillation frequency was found at a median frequency range of 4.3-35 Hz. We conclude that spectral analysis of VF can provide reliable information relating to successful resuscitation. In this model after elimination of oscillations due to mechanical CPR, median fibrillation frequency best reflects the probability of resuscitation success.

[Primary unrecognized gunshot wound in the frontal skull base]

BACKGROUND

Craniocerebral gunshot wounds demand a high degree of skill in clinical treatment. In addition to painstaking history, modern imaging techniques for preoperative diagnosis and interdisciplinary surgical treatment are important.

CASE REPORT

Diagnosis and therapeutic principles are discussed on the basis of a case study of a 21-year-old soldier with an unusual craniocerebral gunshot wound.

Cardiovascular function during the postresuscitation phase after cardiac arrest in pigs: a comparison of epinephrine versus vasopressin

OBJECTIVE

The administration of vasopressin during cardiopulmonary resuscitation (CPR) provides significantly more vital organ blood flow when compared with epinephrine during cardiac arrest in pigs. The effects of this potent vasoconstrictor on postresuscitation cardiovascular function remain unknown. The purpose of this study was to compare the effects of vasopressin and epinephrine on cardiovascular function in the postresuscitation phase after CPR.

DESIGN

Prospective, randomized, experimental study.

SETTING

University research laboratory.

SUBJECTS

Domestic pigs, 12 to 14 wks of age.

INTERVENTIONS

Sixteen pigs were randomly allocated to receive either 0.045 mg/kg of epinephrine or 0.4 U/kg of vasopressin after 4 mins of cardiac arrest.

MEASUREMENTS AND MAIN RESULTS

Hemodynamics, left ventricular contractility, and myocardial blood flow were measured for an interval of 240 mins after successful CPR. Differences between animals treated with epinephrine vs. vasopressin were most pronounced 15 mins after restoration of spontaneous circulation. At this time, mean aortic pressure was 64 +/- 6 (SEM) mm Hg in the epinephrine group and 84 +/- 6 mm Hg (p < .05) in the vasopressin group. Systemic vascular resistance was 1285 +/- 72 dyne.sec/cm5 in the epinephrine group and 2314 +/- 130 dyne.sec/cm5 (p < .001) in the vasopressin group. Cardiac index was 140 +/- 9 mL/min/kg in animals treated with epinephrine and 99 +/- 9 mL/min/kg (p < .01) in animals treated with vasopressin. Myocardial contractility (dp/ dtmax/P) was 52.8 +/- 3.4/sec with epinephrine as compared with 36.3 +/- 2.9 sec-1 (p < .01) with vasopressin. Left ventricular epicardial blood flow was 241 +/- 35 mL/min/100 g with epinephrine and 142 +/- 22 mL/min/100 g (p < .05) with vasopressin. Four hours after CPR, no significant differences were observed between groups.

CONCLUSIONS

In the early postresuscitation phase, vasopressin provided higher systemic blood pressures and there was a reversible depressant effect on myocardial function when compared with epinephrine. Overall cardiovascular function was not irreversibly or critically impaired after the administration of vasopressin in this pig model of cardiac arrest.