Mastectomy or lumpectomy? Helping women make informed choices

PURPOSE

To develop an instrument to help clinicians inform their patients about surgical treatment options for the treatment of breast cancer and to evaluate the impact of the instrument on the clinical encounter.

METHODS

We developed an instrument, called the Decision Board, to present information regarding the benefits and risks of breast-conserving therapy (lumpectomy plus radiation therapy) and mastectomy to women with early-stage breast cancer to enable them to express a preference for the type of surgery. Seven surgeons from different communities in Ontario administered the instrument to women with newly diagnosed clinical stage I or II breast cancer over an 18-month period. Patients and surgeons were interviewed regarding acceptability of the instrument. The rates of breast-conserving surgery performed by surgeons before and after the introduction of the instrument were compared.

RESULTS

The Decision Board was administered to 175 patients; 98% reported that the Decision Board was easy to understand, and 81% indicated that it helped them make a decision. The average score on a true/false test of comprehension was 11.8 of 14 (84%) (range, 6 to 14). Surgeons found the Decision Board to be helpful in presenting information to patients in 91% of consultations. The rate of breast-conserving surgery decreased when the Decision Board was introduced (88% v 73%, P =.001)

CONCLUSION

The Decision Board is a simple method to improve communication and facilitate shared decision making. It was well accepted by patients and surgeons and easily applied in the community.

The PPVT-R: validity as a quick screen of intelligence in a postacute rehabilitation setting for brain-injured adults

The utility of the Peabody Picture Vocabulary Test-Revised (PPVT-R) as a surrogate for the Wechsler Adult Intelligence Test-Revised (WAIS-R) was investigated in 61 brain-injured adult participants in a postacute rehabilitation setting. Idiographic comparison revealed substantial disagreement in clinical classification between the two instruments, and it is concluded that the PPVT-R is not a good surrogate for the WAIS-R for this purpose. In contrast, the PPVT-R was judged an adequate surrogate for the WAIS-R for the purpose of group comparison, as is common in biomedical research. Finally, contrary to prior report, the PPVT-R was demonstrated to measure more than simply Vocabulary. As such, in the absence of independent validation research, perhaps the most parsimonious conclusion regarding what the PPVT-R is measuring is that like each of the various subtests of the WAIS-R, the PPVT-R shares some of the variance of the construct termed intelligence, as well as demonstrates some unique variance that is likely comprised of error and, perhaps, a unique or different facet of intelligence.

Nortriptyline versus amitriptyline in postherpetic neuralgia: a randomized trial

OBJECTIVE (BACKGROUND): Amitriptyline (AT) is a standard therapy for postherpetic neuralgia (PHN). Our hypothesis was that nortriptyline (NT), a noradrenergic metabolite of AT, may be more effective.

METHODS

A randomized, double-blind, crossover trial of AT versus NT was conducted in 33 patients.

RESULTS

Thirty-one patients completed the trial. Twenty-one of 31 (67.7%) had at least a good response to AT or NT, or both. We found no difference with regard to relief of steady, brief, or skin pain by visual analog scales for pain and pain relief; mood; disability; satisfaction; or preference between the two drugs. Intolerable side effects were more common with AT. Most patients (26/33) were not depressed, and most responding showed no change in rating scales for depression despite the occurrence of pain relief.

CONCLUSIONS

We concluded that this study provides a scientific basis for an analgesic action of NT in PHN because pain relief occurred without an antidepressant effect, and that although there were fewer side effects with NT, AT and NT appear to have a similar analgesic action for most individuals.

Effectiveness of patient delivered partner medication for preventing recurrent Chlamydia trachomatis

OBJECTIVE

To determine if providing Chlamydia trachomatis infected women with medication to deliver to their sex partner(s) could reduce recurrent chlamydia infections compared with the standard partner referral method.

STUDY DESIGN

A observational cohort study of 178 women, 14-39 years old attending a family planning clinic, diagnosed and treated for C trachomatis between October 1993 and December 1994 was conducted (43 received patient delivered partner medication (PDPM) and 135 received partner referral cards). Women were retested before or at their annual visit.

RESULTS

The mean time of follow up was 17.7 months (SD 7.7). The PDPM group (n = 43) was similar to partner referral group (n = 135) for age, race, contraceptive method, history of an STD, and follow up time. The annual recurrent infection rate was lower among the PDPM group compared with the partner referral group (11.5% v 25.5%, p < 0.05). After adjusting for age in logistic regression, women in the PDPM group were less likely than women in the partner referral group to have an incident C trachomatis infection (OR 0.37, 95% CI 0.15-0.97, p < 0.05).

CONCLUSION

These findings suggest that patient delivered partner medication can protect women from recurrent C trachomatis infection compared with the standard partner referral approach. Prospective studies with larger sample sizes are under way.

Determinants of interindividual variability and extent of CYP2D6 and CYP1A2 inhibition by paroxetine and fluvoxamine in vivo

Major depression may require antidepressant treatment for several years. This necessitates consideration of the long-term effects of antidepressants on multiple clinical endpoints. The antidepressants paroxetine and fluvoxamine are potent in vitro inhibitors of CYP2D6 and CYP1A2 isozymes, respectively. CYP2D6 and CYP1A2 are important for the clearance of 30 or more frequently used medications. Moreover, CYP1A2 also contributes to metabolism of 17beta-estradiol and metabolic activation of environmental procarcinogens (e.g., arylamines in cigarette smoke). The aim of this study was to assess the determinants of interindividual variability and extent of CYP2D6 and CYP1A2 inhibition during paroxetine and fluvoxamine treatment. Healthy volunteers and patients received caffeine (100 mg) and dextromethorphan (30 mg) at baseline and at steady state of paroxetine (10-20 mg/day, 5-74 days, N = 13) or fluvoxamine (50-100 mg/day, 5-43 days, N = 8). The caffeine metabolic ratio (CMR) and the log O-demethylation ratio (ODMR) of dextromethorphan in overnight urine were used as in vivo indices of the CYP1A2 and CYP2D6 isozyme activities, respectively. All subjects had an extensive metabolizer phenotype for CYP2D6. After fluvoxamine treatment, baseline CMR 5.1 +/- 1.4 (mean +/- SD) decreased to 2.7 +/- 1.1 (p < 0.01). Paroxetine did not have a significant effect on CMR (p > 0.05). In seven of eight subjects in the fluvoxamine group, posttreatment CMR was comparable with the minimum CMR value (2.0) attainable in nonsmoking healthy volunteers. After paroxetine treatment, log ODMR changed from a baseline value of -2.28 +/- 0.37 to -1.13 +/- 0.44, indicating significant inhibition of CYP2D6 (p < 0.001). Subjects' CYP2D6 phenotype did not change after paroxetine treatment. Fluvoxamine had no significant effect on log ODMR (p > 0.05). The extent of inhibition of CYP2D6 and CYP1A2 by paroxetine and fluvoxamine, respectively, displayed a positive correlation with baseline enzyme activity (p < 0.05). In addition, a negative association was found between the plasma paroxetine concentration and the CYP2D6 activity after paroxetine treatment (r = -0.47, p < 0.05). These data indicate that paroxetine and fluvoxamine treatment with minimum clinically effective doses significantly inhibit CYP2D6 and CYP1A2, respectively. The extent of inhibition of CYP2D6 by paroxetine and of CYP1A2 by fluvoxamine is dependent in part on the baseline enzyme activity. The interindividual variability in CYP2D6 inhibition by paroxetine can also be explained by variability in plasma paroxetine concentration. Most patients treated with fluvoxamine (50-100 mg/day) will reach population minimums for CYP1A2 activity. These results have potential implications for interindividual variability in the risk for drug-drug interactions mediated by CYP2D6 and CYP1A2 as well as for the disposition of 17beta-estradiol and environmental procarcinogens.

Maternal serum dehydroepiandrosterone sulfate levels and successful labor induction

OBJECTIVE

To evaluate the maternal serum dehydroepiandrosterone (DHEA) sulfate level as a factor associated with the outcome of labor induction.

METHODS

Venous blood was collected from 161 women at the initiation of labor induction. Pregnancies complicated by maternal corticosteroid use, antepartum chorioamnionitis, or cesarean delivery for indications other than arrest disorders were excluded from analysis. In 155 women meeting inclusion criteria, induction followed established protocols. Serum DHEA sulfate levels were measured by radioimmunoassay and correlated with the outcome of each induction attempt. A success was defined as progression to active labor. The Welch approximate t test, Mann-Whitney test, Fisher exact test, simple regression, and multiple regression were used for statistical analysis, with P < .05 considered significant.

RESULTS

The mean (+/- standard error) DHEA sulfate level was higher in women who progressed to active labor (n = 147) than in those with unsuccessful attempts (n = 8), (109.01 +/- 5.19 microg/dL versus 58.78 +/- 15.83 microg/dL, respectively; P = .02). Compared with women with DHEA sulfate levels above 70 microg/dL, women with lower levels had an unsuccessful induction odds ratio (OR) of 4.46 (95% confidence interval, 1.12, 17.67; P = .04). The OR increased as DHEA sulfate levels decreased.

CONCLUSION

Dehydroepiandrosterone sulfate may be an important factor in successful labor induction.

Pigmented ("black") extraadrenal paraganglioma

A pigmented ("black") extraadrenal paraganglioma was discovered incidentally in a 57-year-old woman during ultrasonography. The tumor was located in the retroperitoneum near the superior border of the right kidney. Results of preoperative fine-needle aspiration and intraoperative frozen sectioning of the resected jet-black tumor (13 cm in diameter, 225 g) were both interpreted as suspicious for malignant melanoma. Histomorphology and immunohistochemistry were diagnostic for paraganglioma. Electron microscopy showed numerous dense-core neurosecretory-type granules, as well as abundant, larger pleomorphic electron-dense granules; most were consistent with lipofuscin or neuromelanin. No melanosomes or premelanosomes were identified. Histochemical stains showed that the pigment most likely is neuromelanin, a nonenzymatic or oxidative waste product of catecholamine metabolism. Eighteen other examples of pigmented paragangliomas have been reported in various sites in the English literature during the last 12 years; most indicate the presence of melanosomes or premelanosomes using electron microscopy, whereas in a minority of cases the pigment has not been characterized rigorously. Common embryogenesis from neural crest may help explain the overlapping phenotype of melanocytes and cells of paraganglioma.

The extent and determinants of changes in CYP2D6 and CYP1A2 activities with therapeutic doses of sertraline

The extent of changes in CYP2D6 and CYP1A2 activities with higher therapeutic dosages (>50 mg/day) of sertraline is not well established in vivo. This study assessed the extent and determinants of changes in CYP2D6 and CYP1A2 isozyme activities after treatment with clinically relevant doses of sertraline. Patients and healthy volunteers aged 19 to 85 years (N = 21) were treated with sertraline for 5 to 55 days. The dosage of sertraline ranged from 25 to 150 mg/day (93.5+/-26.4 mg/day; mean +/- SD). All subjects had an extensive metabolizer phenotype for CYP2D6 and received a single oral dose of dextromethorphan (30 mg) and caffeine (100 mg) before and after sertraline treatment. The log O-demethylation ratio (ODMR) of dextromethorphan and the caffeine metabolic ratio (CMR) in overnight urine were used as in vivo indices of the CYP2D6 and CYP1A2 isozyme activities, respectively. Concurrent medications and lifestyle habits (e.g., smoking and diet) were monitored during the study. Baseline log ODMR (-2.33+/-0.45) but not CMR (5.1+/-1.9) (mean +/- SD) significantly changed after sertraline treatment (-2.19+/-0.62; 4.5+/-1.6, respectively) (p: ODMR = 0.04, CMR = 0.10). There was no significant effect of age, dose, duration of treatment, gender, sertraline and/or desmethylsertraline plasma concentration, subject type (patient or volunteer), and weight on the extent of changes in log ODMR or CMR (p > 0.05). In conclusion, sertraline treatment at a mean daily dosage of 94.0 mg did not significantly change CYP1A2 activity and resulted in a modest inhibition of CYP2D6 activity.

Paroxetine potentiates the central nervous system side effects of perphenazine: contribution of cytochrome P4502D6 inhibition in vivo

BACKGROUND

Paroxetine is a frequently used antidepressant and a potent inhibitor of the CYP2D6 isozyme in vitro (inhibition constant [Ki] = 0.15 micromol/L). Most classic antipsychotic agents such as perphenazine are metabolized by the CYP2D6 isozyme and are often coadministered with antidepressant agents. This study assessed the extent of changes in CYP2D6 isozyme activity in vivo after pretreatment with paroxetine and its consequences on perphenazine kinetics and central nervous system effects.

METHODS

Eight extensive metabolizers for CYP2D6 were administered a single dose of perphenazine (0.11 mg/kg orally) or placebo following a randomized double-blind design. Perphenazine plasma concentrations and effects were assessed for a period of 8 hours. Subsequently, subjects were treated with a standard therapeutic dose of paroxetine (20 mg/day orally) for 10 days and test sessions with perphenazine and placebo were repeated.

RESULTS

Paroxetine treatment resulted in a twofold to 21-fold decrease in CYP2D6 activity (p < 0.001). After pretreatment with paroxetine, perphenazine peak plasma concentrations increased twofold to 13-fold (p < 0.01). This was associated with a significant increase in central nervous system side effects of perphenazine, including oversedation, extrapyramidal symptoms, and impairment of psychomotor performance and memory (p < 0.05).

CONCLUSION

Coadministration of perphenazine after pretreatment with a standard therapeutic dose of paroxetine increased the plasma concentration and central nervous system side effects of perphenazine, primarily as a result of inhibition of the CYP2D6 isozyme. In patients who are at steady state with paroxetine, a reduction of perphenazine dose may be required to prevent central nervous system side effects.

Relationship between negative symptoms in chronic schizophrenia and neuroleptic dose, plasma levels and side effects

The negative symptoms of schizophrenia are often difficult to distinguish from the side effects of antipsychotic medication. In this study, we tried to clarify this issue by studying a group of patients in a clinic setting where a wide range of antipsychotic doses were being prescribed. Thirty-one patients meeting DSM-III-R criteria for schizophrenia or schizoaffective disorder were studied. Clinical ratings were carried out to assess the positive and negative symptoms of schizophrenia, parkinsonism, akathisia and tardive dyskinesia. Plasma levels were also measured for the majority of patients. Antipsychotic plasma levels were found to be highly correlated with dose. Antipsychotic dose and plasma levels were not correlated with the severity of negative symptoms, akathisia or parkinsonism. However, the severity of positive symptoms and tardive dyskinesia were positively correlated with both dose and plasma level. These findings do not support the hypothesis that higher doses of antipsychotic medication are associated with more severe negative symptoms.

The relationship between D2 receptor occupancy and plasma levels on low dose oral haloperidol: a PET study

The purpose of this study was to determine the relationship between dopamine D2 receptor occupancy and plasma haloperidol. Twelve patients treated with 1-5 mg/day of haloperidol had their D2 occupancy measured using [11C]-raclopride and positron emission tomography and haloperidol plasma levels measured using gas chromatograph mass spectrophotometer. The patients exhibited haloperidol plasma levels ranging from 0.5 to 5.8 ng/ml and D2 occupancy from 53 to 88%. The D2 occupancy was related to the plasma level as a saturating rectangular hyperbola relationship (r2 = 0.84) and it showed that, on average, 50% D2 occupancy was achieved with 0.51 ng/ml and 80% D2 occupancy with 2.0 ng/ml. Our findings demonstrate that 2-5 mg/day of haloperidol, which usually leads to plasma levels of 1-2 ng/ml, would be expected to induce 60-80% dopamine D2 receptor occupancy. If, as has been claimed, 70% D2 occupancy is adequate for typical neuroleptic response, then the conventional use of > 10 mg/day may have been too high, since 70% occupancy can be achieved in most patients by 2-5 mg/day. On the other hand, if as others have suggested, 8-12 ng/ml of haloperidol is the correct therapeutic window for plasma levels, then the required therapeutic D2 occupancy is closer to 90%, not 70%. The implications of the D2 occupancy findings for the optimal dosing of neuroleptics are discussed.

Employee reactions to ergonomic job design: the moderating effects of health locus of control and self-efficacy

A field survey of 180 municipal government office employees (82% women, 21-75 years old) investigated the potential moderating effects of internal health locus of control (HLOC) and self-efficacy on employees' reactions to ergonomic job design. Internal HLOC moderated the associations between ergonomic job design and somatic complaints and turnover intentions, and, to a lesser extent, job satisfaction. Self-efficacy moderated the associations between job design and job satisfaction, somatic complaints, and, to a lesser extent, persistent pain. Employees with low self-efficacy or low internal HLOC were influenced more by their physical job conditions than those with high self-efficacy or high internal HLOC. Implications for the ergonomic design of offices are discussed.

Maternal serum dehydroepiandrosterone sulfate levels and the efficiency of labor in young nulliparas

OBJECTIVE

To evaluate the maternal serum dehydroepiandrosterone (DHEA) sulfate level as a factor influencing labor "efficiency" at term.

METHODS

On admission to the labor and delivery unit, blood was collected from 55 term nulliparous women up to 25 years of age in active labor. Following delivery, umbilical venous cord blood was also collected. Pregnancies complicated by diabetes mellitus, hypertension, fetal growth restriction, tobacco use, corticosteroid use, or chorioamnionitis were excluded. Serum DHEA sulfate levels were measured by radioimmunoassay. Dehydroepiandrosterone sulfate levels and other obstetric variables were correlated retrospectively with the clinically determined requirement for oxytocin augmentation of labor. The unpaired Student t test, Mann-Whitney test, and linear correlation were used for statistical analysis. P < .05 was considered statistically significant.

RESULTS

Oxytocin augmentation followed standard indications in 29 of the 55 patients. The mean (+/- standard error) maternal serum DHEA sulfate level was significantly lower in these patients than in the remaining 26 who progressed spontaneously through labor (99.31 +/- 8.92 versus 135.05 +/- 12.30 micrograms/dL, respectively; P = .02). With the exception of cervical dilation on admission, no significant demographic differences were identified between the two groups. The maternal serum DHEA sulfate level did not correlate significantly with cervical dilation on admission (r = 0.03, P = .81).

CONCLUSION

Among term nulliparous women, maternal serum levels of DHEA sulfate are significantly lower in those clinically requiring pharmacologic augmentation than in those progressing spontaneously through labor. Dehydroepiandrosterone sulfate may be an important factor in efficient labor.

Rapid identification of Acremonium lolii and Acremonium coenophialum endophytes through arbitrarily primed PCR

Using a random decamer 5'-CCGAGGTGAC-3' in an arbitrarily primed PCR, similar band patterns were observed between Acremonium lolii and A. coenophialum DNA, which were somewhat different from those formed by other fungal DNA. Despite sharing bands of around 0.7, 0.9 and 2.1 kb, A. lolii can be distinguished from A. coenophialum by the presence of an additional band at around 0.5 kb in the arbitrarily primed PCR.

24-hour immunologic assessment of CD4+ and CD8+ lymphocytes in renal transplant recipients receiving chronic methylprednisolone

Glucocorticoids are commonly prescribed in the post transplant period as a component of combination immunosuppressive regimens. However, the daily 24-hour pattern of helper lymphocytes (CD4+) and suppressor cells (CD8+) during chronic methylprednisolone therapy has not been examined in renal transplant recipients in relation to glucocorticoid exposure and time post-transplant. The response of total lymphocytes, CD4+ and CD8+ lymphocytes was examined in 23 stable renal transplant recipients who received methylprednisolone for at least 8 months post-transplant. The patient's prescribed oral methylprednisolone dose (mean daily dose = 9.7 +/- 2.6 mg) was given intravenously and whole blood was sampled periodically over 24 h for lymphocyte counts and methylprednisolone concentrations. A complete blood count with differential was determined via an automated hemocytometer with CD4+ and CD8+ lymphocytes determined using flow cytometry. Methylprednisolone area under the concentration versus time curve (AUC) was determined and normalized for each patient's respective dose. A general lymphopenia resulted in all patients with a mean decrease of 61 +/- 15% and an average nadir time occurring at 6 h. The decline from baseline was 76 +/- 17% for absolute number of CD4+ and 59 +/- 18% for CD8+ lymphocytes with an average nadir time at 6 h. Twelve patients exhibited a baseline CD4+ count to be less than 688 cells/mm3 (the low end of the reference range) and the lymphocyte count of all the patients fell below this value at the nadir. Six patients had a CD8+ lymphocyte count below 380 cells/mm3 (low end of the reference range) at baseline with 21 of the 23 patients exhibiting less than 380 cells/mm3 at the nadir time. At the time of nadir, the mean CD4+ and CD8+ counts were 156 +/- 105 cells/mm3 and 256 +/- 270 cells/mm3, respectively. In 17 of the 23 patients, the CD4+ count was below 200 cells/mm3 at the time of nadir. The dose-normalized AUC of methylprednisolone ranged from 22.6 to 113.5 ng.h/ml with 48% of patients exhibiting morning cortisol concentrations greater than 60 ng/ml. No correlation was noted between daily methylprednisolone exposure and the extent of lymphocyte decline. Lymphocyte response patterns are not clinically recognized in renal transplant recipients, as a means of monitoring immunosuppression. The absolute CD4+ and CD8+ lymphocyte count and the timing of these sample collections post-steroid administration, may have clinical relevance when serially assessed as is done in other immunologic diseases. Prospective evaluation of lymphocyte subset patterns and correlation with susceptibility to overimmunosuppressive (i.e. opportunistic infections) is necessary to help determine if these complications can be minimized by more individualized steroid dose modification.

Perinatal regionalization versus hospital competition: the Hartford example

OBJECTIVES

The increasingly competitive health care environment may undermine effective traditional regional organizations. It is urgent to document the benefits of perinatal regionalization for the emerging health care system. We present a case study that illustrates many of the challenges to and benefits of perinatal regionalization in the 1990s.

BACKGROUND

The controversy in Hartford was sparked by a proposed merger of two major pediatric services into a full-service children's hospital. Community hospitals reacted with plans to upgrade their obstetrics/neonatal facilities toward level II (intermediate) or II+ (intensive) neonatal intensive care units (NICUs). The fear that unrestricted competition would drive up overall health care costs prompted the hospital association and Chamber of Commerce to retain consultants to evaluate the number and location of regional NICU beds.

METHODS

The consultant team interviewed stake-holders in area hospitals, health maintenance organizations, insurance companies, businesses, state agencies, and community groups, and analyzed quantitative data on newborn discharges.

RESULTS

The existing system worked remarkably well for clinical care, training, referrals, and provider and patient satisfaction. There was a high level of inter-hospital collaboration and regional leadership in obstetrics and pediatrics, but strong and growing competition between their hospitals. Hospital administrators enumerated the competitive threats that obligated them to compete and the financial disincentives to support the regional structures. Business leaders and insurance executives emphasized the need to control costs. Analysis of discharge data showed marginal adequacy of NICU beds but maldistribution between NICUs, particularly between level III and level II units. The consultants recommended no new beds based on population projections, declining lengths of stay nationally, and substantial gains available from aggressive back-transport of convalescing infants. The consultants emphasized the need for all stakeholders to support the regional infrastructure (referral, transport, education, evaluation, quality assurance) and to modify competition when it impaired effective regionalization.

CONCLUSIONS

Regionalization permits better care at lower cost, yet competition may disrupt this effective system. Active cooperation by stakeholders is vital. Substantial new research is required to define optimal regional organization.

Pharmacokinetics of methylprednisolone during acute renal allograft rejection

High dose methylprednisolone is administered empirically by fixed daily boluses to renal transplant recipients who are experiencing acute rejection episodes. Little information is available characterizing the pharmacokinetics of high-dose methylprednisolone in these individuals, who are often acutely ill. Therefore, 5 renal transplant recipients (2 men; 3 women) were studied during an acute rejection episode (mean serum creatinine = 2.6 +/- 0.7 mg/dl) which occurred within the first 8 months post-transplantation. The rejection episode was characterized clinically by at least two of the following: fever, leukocytosis, graft tenderness and an increase in serum creatinine. All patients received bolus doses of methylprednisolone for 3 consecutive days during the rejection episode. All patients were studied on the 3rd day of bolus dosing and received 250 mg methylprednisolone by an i.v. infusion. In phase II, 4 patients were studied during a period of stable renal function when the methylprednisolone was given at lower chronic immunosuppressive doses. Serum samples were taken prior to infusion and serially over the following 24 hours. The serum samples were analyzed for methylprednisolone with high-performance liquid chromatography (HPLC) and pharmacokinetic parametes were generated. During rejection episodes, the methylprednisolone clearance values were 523 +/- 154 ml/h/kg with a corresponding mean volume of distribution of 1.89 +/- 0.72 l/kg. The mean methylprednisolone half-life was 2.61 +/- 0.62 h. During Phase II, the methylprednisolone clearance was 358 +/- 95 ml/h/kg with a half-life of 3.05 h. This observation indicates that methylprednisolone metabolism is increased during acute rejection compared to that seen during chronic immunosuppressive dosing with this agent.

Methylprednisolone pharmacokinetics, cortisol response, and adverse effects in black and white renal transplant recipients

It is generally assumed that chronic glucocorticoid therapy is similar pharmacologically when administered to either black or white renal transplant recipients, resulting in adrenal suppression, low circulating plasma cortisol concentrations, and a similar degree of drug exposure and toxicity. To examine this theory and to investigate the relationship of glucocorticoid metabolism to steroid-induced adverse effects among specific ethnic groups of renal transplant recipients, 9 black and 9 white male patients chronically receiving methylprednisolone were enrolled. All patients had stable renal function and were matched for age, weight, and time since transplant. Standard pharmacokinetic parameters for methylprednisolone were determined and cortisol responses were characterized by total cortisol area under the concentration curve (AUC), return cortisol AUC, and cortisol suppression half-life. All patients received their daily oral dose of methylprednisolone (mean daily dose = 11 mg for blacks and 11 mg for whites) as an intravenous infusion with serial plasma samples obtained over 24 h. The patients were assessed for the presence of specific cushingoid manifestations (buffalo hump, moon facies) and steroid-associated diabetes. Methylprednisolone and cortisol were analyzed via HPLC. In the black patients, the mean clearance of methylprednisolone (206 +/- 70 ml/hr/kg) was significantly slower with a smaller volume of distribution (0.95 +/- 0.32 L/kg) when compared with the white group (327 +/- 129 ml/hr/kg, P = 0.03; volume of distribution = 1.33 +/- 0.27 L/kg, P = 0.015). Despite chronic methylprednisolone therapy, a definite 24-hr cortisol response pattern was noted in 15 of the 18 patients with a mean total cortisol AUC of 732 +/- 443 ng.hr/ml in blacks and 539 +/- 361 ng.hr/ml in whites (P = 0.17, black vs. white). The mean cortisol suppression half-life was 4.31 +/- 1.54 hr in black recipients and 4.11 +/- 1.49 hr in whites (P = 0.48). The mean return cortisol AUC for the black patients was 327 +/- 279 ng.hr/ml and 370 +/- 207 ng.hr/ml for white patients (P = 0.28). The serum cortisol nadir for black patients was 12.3 +/- 7.2 ng/ml, which was significantly higher than the cortisol nadir in white patients (6.4 +/- 4.4 ng/ml; P = 0.03). A majority (94%) of patients (9 black, 8 white) had moon facies and 27% of patients (3 black, 1 white) had a buffalo hump. While 5 of 9 black patients had steroid-associated diabetes, no white patients manifested this adverse effect. The black patients with diabetes had higher cortisol AUCs with lower methylprednisolone clearances than the white group.(ABSTRACT TRUNCATED AT 400 WORDS)

Cortisol pharmacodynamic response to long-term methylprednisolone in renal transplant recipients

STUDY OBJECTIVE

To examine the pharmacodynamic patterns of cortisol and pharmacokinetic values of long-term methylprednisolone in renal transplant recipients.

DESIGN

Twenty-four-hour pharmacokinetic and pharmacodynamic evaluation of patients who participated in a glucocorticoid-monitoring program.

SETTING

University-based renal transplant clinic.

PATIENTS

Fourteen renal transplant recipients studied during a clinically stable period.

INTERVENTIONS

The daily oral methylprednisolone dose for each patient was administered intravenously, and serial plasma cortisol and methylprednisolone samples were obtained over 24 hours.

MEASUREMENTS AND MAIN RESULTS

Methylprednisolone was analyzed by high-performance liquid chromatography. The baseline morning cortisol serum concentrations ranged from 9.8-210.7 ng/ml. After the drug was administered, cortisol declined in a linear fashion with a mean suppression half-life of 2.4 +/- 0.9 hours. The cortisol nadir was reached at 12-16 hours in 11 of 14 patients. The return cortisol area under the curve (AUC-Cret) was noted in all patients and ranged from 57-987 ng.hr/ml. The total cortisol area under the curve was greater in patients who had been transplanted for longer than 2 years (1676 +/- 252 vs 836 +/- 405 ng.hr/ml; p < 0.05) compared with more recently transplanted patients. Methylprednisolone clearance ranged from 100-1181 ml/hr/kg with a mean volume of distribution of 1.3 +/- 0.6 L/kg. The methylprednisolone half-life ranged from 1.2-4.7 hours. The correlation between AUC-Cret and methylprednisolone AUC was -0.64 (p < 0.05).

CONCLUSIONS

The pharmacodynamic response of cortisol in renal transplant recipients may be associated in part with long-term steroid exposure. However, the interrelationship between the endocrine and immune system may also affect cortisol's disposition and subsequent recovery patterns in this population. Considerable interpatient variability was apparent in both the cortisol pharmacodynamic response as well as the pharmacokinetics of methylprednisolone. These findings suggest a more individualized dosing method may be necessary to optimize the immunosuppressive effect of glucocorticoids and minimize clinical toxicity.

Acutely psychotic patients receiving high-dose haloperidol therapy

Despite the trend towards lower neuroleptic dosing in the treatment of psychosis, there continue to be patients who are administered doses that are higher than recommended. Thirty-six acutely psychotic patients receiving parenteral haloperidol were evaluated by the Brief Psychiatric Rating Scale, the Schedule for Affective Disorders and Schizophrenia-Change Version, and the Nurses' Observation Scale for Inpatient Evaluation, as well as by drug levels in plasma. Patients were compared on the basis of total haloperidol dose in the first 24 hours: regular dose (RD: 10-30 mg) and high dose (HD: 40-80 mg). At baseline, patients in the HD group scored significantly higher on the Brief Psychiatric Rating Scale factor Hostile-Suspiciousness and the Nurses' Observation Scale for Inpatient Evaluation factor Irritability. Assignment to regular-dose and HD groups could not be accounted for on the basis of age, gender, weight, or duration of illness. Moreover, drug levels in plasma indicated that the HD patients did not require higher doses on the basis of differences in haloperidol levels.

Measles epidemic: impact on pediatric oncology patients

Measles, a preventable disease, is again epidemic in the United States and is a threat to the immunocompromised pediatric oncology patient. In response to this latest epidemic, the Immunization Practices Advisory Committee has revised its recommendations for controlling an outbreak and has changed childhood immunization to a two-dose schedule. Full understanding of measles management is needed to effectively protect the pediatric oncology patient during the current epidemic. This article reviews the epidemiology, clinical presentation and management of measles, including recommendations for vaccinations, exposures, isolation, and patient and family education.

Oral tocolysis with magnesium chloride: a randomized controlled prospective clinical trial

A prospective randomized clinical trial was conducted to assess the efficacy and safety of enteric-coated magnesium chloride (SLOW MAG) as an oral tocolytic agent. Seventy-five patients between 24 and 34 weeks' gestation who were treated with intravenous magnesium sulfate for a first episode of preterm labor were enrolled. After a 12-hour contraction-free period on intravenous therapy, patients were randomized by sealed envelope to one of three groups: group 1, SLOW MAG (535 mg every 4 hours); group 2, oral ritodrine (20 mg every 4 hours); or group 3, no therapy (control). Patients receiving oral therapy were treated until delivery or completion of 36 weeks' gestation. No difference was found between groups with respect to time gained with the use of oral therapy or number completing 36 weeks' gestation. Therapy with enteric-coated magnesium chloride was associated with significantly fewer side effects (20%) as compared with ritodrine (48%) (p less than 0.01). Our results suggest that compared with ritodrine, enteric-coated magnesium chloride is as effective in prolonging pregnancy and preventing recurrent preterm labor. However, neither enteric-coated magnesium chloride nor ritodrine appeared to be any more effective in the prevention of preterm delivery than observation alone.

Cloning and expression of a rat cardiac delayed rectifier potassium channel

We have cloned a cDNA (designated RAK) coding for a delayed-rectifier K current (IRAK) from adult rat heart atrium and expressed it in Xenopus oocytes. RAK differs from the cloned rat brain K current, BK2 [McKinnon, D. (1989) J. Biol. Chem. 264, 8230-8236], by one amino acid at residue 411. RAK expressed in oocytes compares closely to the intrinsic adult rat atrial delayed-rectifier current measured by using whole-cell recording of single isolated cells. Northern blot analysis confirmed the presence of the channel in adult rat atrium, and to a lesser extent, in rat ventricle. IRAK activates with time constants ranging from 58 ms at -20 mV to 6 ms at +60 mV and does not show significant inactivation over 800 ms. It is blocked by 4-aminopyridine greater than barium much greater than tetraethylammonium chloride, which is similar to the relative potencies of these blockers on the native delayed rectifier current. We conclude that the main delayed rectifier K current in adult rat atria is virtually identical to a neuronal delayed rectifier, BK2.

A comparison of adinazolam and desipramine in the treatment of major depression

Thirty-one patients with a DSM-III (R) diagnosis of Major Depression received adinazolam (n = 16) or desipramine (n = 15) during a 6 week double-blind randomized controlled trial. Both groups showed a significant decline in Hamilton Rating Scale for Depression scores (21.8 +/- 4.5 to 10.7 +/- 8.5 for adinazolam and 23.5 +/- 5.5 to 12.9 +/- 8.6) for desipramine. Melancholic and anxiety symptoms were reduced equally by both drugs. Initial sedation was the most common side-effect with adinazolam. Plasma levels of desipramine and hydroxy-desipramine correlated highly with oral dose after 3 weeks of treatment.

The effect of glutathione monoethyl ester on the potentiation of the acute toxicity of methyl parathion, methyl paraoxon or fenitrothion by diethyl maleate in the mouse

Depletion of hepatic glutathione in the mouse by pretreatment with diethyl maleate (DEM) is known to potentiate the acute toxicities of many dimethyl-substituted organothiophosphate insecticides. However, certain studies have raised doubts regarding the participation of glutathione in the detoxification of methyl parathion in the mouse, and hence the putative mechanism of action of DEM-induced potentiation of this insecticide. The present study evaluates the hypothesis that DEM potentiates the acute toxicities of methyl parathion, methyl paraoxon, and fenitrothion by a mechanism other than glutathione depletion. One hour following pretreatment of mice with DEM (0.75 ml/kg i.p.), glutathione was markedly depleted and the acute toxicities of methyl parathion, methyl paraoxon and fenitrothion were potentiated. Administration of glutathione monoethyl ester (20 mmol/kg p.o.) to DEM-pretreated mice attenuated DEM-depletion of hepatic glutathione, or maintained glutathione at or above control levels. However, glutathione monoethyl ester did not alter the DEM-induced potentiation of the lethality of these insecticides. Furthermore, administration of glutathione monoethyl ester to naive mice increased hepatic glutathione levels, but did not affect the percentage of animals succumbing to a challenge dose of methyl parathion, methyl paraoxon, or fenitrothion. These data indicate that DEM potentiates the toxicity of methyl parathion, methyl paraoxon or fenitrothion by a mechanism unrelated to hepatic glutathione content.

Prevalence of neuroleptic-induced dystonia in mania and schizophrenia

In a prospective study of 41 acutely psychotic patients, neuroleptic-induced dystonic reactions occurred in 62.5% of the manic patients (10 of 16) and 66.7% of the schizophrenic patients (10 of 15), a nonsignificant difference. These findings contradict a recent report suggesting a higher risk for this side effect in mania.

Influence of age and parity on the emotional care given to women experiencing miscarriages

Obstetrical nurses (N = 309) participated in a study of the hypothetical influence of patients' age and parity status on nurses' emotional care for women who had experienced miscarriage. Vignettes in which age and parity were varied were mailed to the sample along with a questionnaire. After factor analysis, three measures of emotional care were used as the dependent variables: emotional seriousness, priority of care, and emotional support. Analysis of variance showed that the parity status of the woman was a significant variable in the nurses' perceptions of emotional seriousness and priority of care, but did not affect the nurses' perceptions of the need for emotional support. Age was not a significant variable in the three measures of emotional care.

A prospective evaluation of the Port-A-Cath implantable venous access system in chronically ill adults and children

Totally implantable venous access systems are presently widely used, but large-scale, prolonged studies are lacking in evaluating adequately these systems. We prospectively evaluated 198 systems in 191 patients (ages from two months to 80 years) during a three year period, with a median follow-up time of 330 days (a range of two to 1,088 days). Withdrawal of blood was consistently successful in 91 per cent of the systems. Complication rates for infection and thrombosis were 0.04 and 0.03 per 100 days of catheterization, respectively. No episodes of migration of the catheter or embolization were noted. This was thought to be the result of the placement of all catheters by a cutdown technique rather than percutaneously. Five systems were removed because of thrombosis and 22, because of infection. Implantable venous access devices are reliable and have a low complication rate in adult and pediatric patients who require repetitive venous access.

Leiomyomas of the gastrointestinal tract

Sixteen patients with leiomyoma of the gastrointestinal tract underwent operation and removal of their tumor during a four- and one-half-year period from January 1980 to July 1984. There were three esophageal, five gastric, two small bowel, four colon, and two anorectal leiomyomas. The majority of gastric leiomyomas presented with bleeding, as did half of the small bowel and colon cases. All were treated by excision without mortality. The various clinical presentations, evaluations, and choice of operative approach for this uncommon tumor are discussed.

Role of radionuclide imaging in the evaluation of wrist pain

The cause of hand and wrist pain can be difficult to determine, especially when standard radiographs are normal or show only nonspecific changes. This study reports the effectiveness of radionuclide imaging in the evaluation of patients with hand and wrist pain of uncertain cause. Eighty-eight patients with hand and wrist pain and initially normal standard radiographs were evaluated prospectively by additional radiographic methods including the following: routine tomography, wrist arthrography, computerized tomography, or magnetic resonance imaging. Each patient also had bone scintigraphy. The diagnosis established by clinical assessment and by other imaging methods was then compared with the scintigraphic findings. The presence or absence of focal scintigraphic abnormalities correlated with the presence or absence of focal pathology definable by the conventional methods in 88% of patients. As expected, scintigraphy was chiefly of value in defining the locus of an injury or other process in the wrist, rather than the nature of an abnormality. The scintigrams were abnormal in 95% of cases involving complete intrinsic ligament ruptures and fractures and were normal in 96% of patients with no definable injury. Scintigraphic findings correlated poorly with partial intrinsic ligament injuries and in cases of synovitis. Radionuclide imaging is a sensitive means of detecting focal lesions in patients with hand and wrist pain of unknown cause.

Changes in plasma catecholamines and plasma renin activity during hypotension in conscious rats with lesions of the nucleus tractus solitarii

The purpose of the present study was to examine the effects of lesions of the nucleus tractus solitarii on the reflex control of sympathetic activity and renin release in the conscious rat. Two doses of the arteriolar vasodilator hydralazine (0.3 and 1 mg/kg, i.v.) were used to activate reflexively the sympathetic nervous system in nucleus tractus solitarii lesion and control rats. Administration of 1 mg/kg of hydralazine to the control rats caused mean arterial pressure to fall from 120 +/- 2 mm Hg to 84 +/- 2 mm Hg and elicited an 11.2-fold increase in plasma renin activity and a 2.7-fold increase in plasma norepinephrine concentration. Administration of 0.3 mg/kg of hydralazine caused the arterial pressure of the lesion group to fall from 118 +/- 3 mm Hg to a comparable value of 85 +/- 4 mmg Hg, but plasma renin activity and plasma norepinephrine concentration did not rise significantly. However, administration of 1 mg/kg of hydralazine to the lesion group caused arterial pressure to fall from 128 +/- 6 mm Hg to 64 +/- 2 mm Hg, in association with a 12.4-fold increase in plasma renin activity and a 1.6-fold elevation in plasma norepinephrine concentration. Atenolol, a beta 1-adrenoceptor antagonist, blocked 70% of the rise in plasma renin activity caused by 1 mg/kg of hydralazine in both groups of rats. In addition, prior renal denervation also markedly attenuated the rise in plasma renin activity caused by hydralazine in the lesion group. Finally, electrical stimulation of the vagus nerves, which caused a large vasodepressor response in the control group, failed to lower the arterial pressure of the lesion group. Based on these observations, we conclude that in the conscious rat (1) nucleus tractus solitarii lesions eliminate the arterial baroreflexes as well as the cardiopulmonary baroreflex, and (2) severe hypotension induces sympathetically mediated renin release in the apparent absence of arterial and cardiopulmonary baroreflex function.

Rapid, inexpensive confirmation of chlamydial infection

This article will hopefully make all optometrists aware of a rapid, direct method for confirming a diagnosis of chlamydial (inclusion) conjunctivitis. The Micro-Trak test from Syva is inexpensive, highly specific, and very sensitive for all human serovars of Chlamydia trachomatis. The current regimens for chlamydial conjunctivitis are also described.

PvO2 changes in cutaneous veins during regression of spinal anaesthesia

Following transurethral resection of the prostate under spinal anaesthesia, 26 patients were divided into two groups according to the sensory levels measured in the recovery room: Group A: 20 patients with sensory level T10 or above, and Group B: six patients with sensory level T11 or T12. Through an intravenous catheter placed preoperatively in a superficial vein of the foot, serial blood samples were drawn to measure the PvO2. In Group A, the PvO2 increased significantly after spinal anaesthesia compared with preoperative control values, then decreased when the sensory level receded to T11 or T12. In Group B, the changes in PvO2 from control to postspinal and to motor recovery were not significant. The authors postulate that sympathetic denervation induced by spinal anaesthesia increases the PvO2 by the opening of arteriovenous anastomoses in the cutaneous circulation, and the PvO2 decreases with sympathetic recovery. These findings confirm that significant sympathetic denervation of the lower limbs can be expected at a sensory level of T10 or above, and sympathetic recovery begins when the sensory level recedes below T10.

Adrenoleukodystrophy: imaging with CT, MRI, and PET

A patient with adrenoleukodystrophy (ALD) was tested with a series of CT scans, magnetic resonance imaging (MRI), and positron emission tomographic (PET) images. The computed tomographic (CT) scan revealed the classical pattern described in ALD but showed little relation to the clinical presentation and the evolution of the disease. The MRI showed a larger area of abnormality than the one detected with the CT scan and was more sensitive to progression of the disease process. The PET scan done for cerebral blood flow and glucose metabolism showed derangements on gray matter that were not detected with either of the previous tests.

Doppler echocardiographic observations of pulmonary and transvalvular velocity changes after birth and during the early neonatal period

To evaluate the qualitative and quantitative changes in Doppler velocities in the normal fetus and newborn, 61 echo Doppler studies were performed in 18 neonates, nine of whom were also studied as fetuses. Four studies were inadequate in fetuses (one pulmonary artery, two mitral, and one tricuspid) and some post natal studies were inadequate due to inability to separate atrioventricular valve E and A velocity component waveforms (one tricuspid, three mitral). Heart rates for fetuses and newborns more than 24 hours of age and less than 24 hours of age were similar. Pulmonary artery diastolic velocities consistent with patent ductus arteriosus were present in 11 of 12 examinations at less than 6 hours of age, in 5 of 13 examined at 6 to 24 hours of age, and in 2 of 27 examined after 24 hours of age. Pulmonary artery times to peak velocity were similar in fetuses, m = 46, SD = 3 msec, and in neonates less than 6 hours of age, m = 51, SD = 13 msec, but lengthened significantly, p less than 0.05, at 6 to 24 hours (m = 69, SD = 14 msec). These changes are probably due to the dramatic changes in pulmonary vascular pressure that occur after birth. Data from 6 to 24 hours and greater than 24 hours (m = 78, SD = 13 msec) were similar. Significant differences existed for transmitral valve E/A ratios, which increased from m = 0.85 in utero to m = 1.17 (p less than 0.05) after birth, with no significant change thereafter.(ABSTRACT TRUNCATED AT 250 WORDS)

Factor VIII-associated antigen in human lymphatic endothelium

Lymphatic vascular endothelium both on tissue section and in culture exhibits positivity for Factor VIII-associated antigen although staining is generally less intense and more spotty than in comparable blood vascular endothelium. Lymphatic endothelium also exhibits Weibel-Palade bodies. Neither marker, therefore, reliably distinguishes blood vascular endothelium from lymphatic endothelium.

Plasma levels and effects of nortriptyline in geriatric depressed patients

Pharmacokinetic, therapeutic effects, and side effects of nortriptyline were studied in geriatric depressed patients treated with a standard dose of 150 mg/day. Plasma levels and elimination half-life of nortriptyline were no different in geriatric patients than younger patients. The antidepressant therapeutic effects of nortriptyline appeared to be similar in geriatric patients as in younger depressed patients. Geriatric patients experienced few subjective side effects of nortriptyline. Overall, the drug produced no clinically significant changes in several parameters of the EKG, and no geriatric patient experienced tachycardia on nortriptyline. Nortriptyline did induce significant orthostatic hypotension in the systolic component, but not in the diastolic component. However, the orthostatic hypotension produced by nortriptyline was not greater in geriatric patients than in younger patients treated with the same dose.

Desipramine plasma concentration and therapeutic response in elderly depressives: a naturalistic pilot study

This naturalistic pilot study of desipramine hydrochloride treatment in elderly DSM III diagnosed depressives demonstrated that therapeutic response was related to desipramine plasma levels and that a desipramine plasma concentration of 200 nmol/l significantly differentiated responders from non-responders. Plasma concentrations of 2-Hydroxydesipramine were not related to therapeutic response. This finding suggests that monitoring of desipramine plasma levels has utility in certain clinical situations. Further fixed dosage studies are necessary to confirm these initial results.