In vivo modulation of benzodiazepine receptor function after inhibition of endogenous gamma-aminobutyyric acid synthesis

The influence of decreased endogenous gamma-aminobutyric acid (GABA) concentration on benzodiazepine receptor function was studied in the brain of living baboons. Positron emission tomography and the radiotracer [11C]flumazenil combined with electroencephalography were used to determine the pharmacological properties of two bezodiazepine receptors agonists, diazepam and bretazenil, in baboons pre-treated or not with DL-allylglycine (an inhibitor of GABA synthesis). Our results show that, in vivo, DL-allylglycine reduces the affinity of benzodiazepine receptors for their agonists without altering the intrinsic capability of agonists to allosterically modulate GABAergic transmission.

[Chondrocalcinosis and Bartter syndrome]

A patient presenting with acute left-knee arthritis was diagnosed as having articular chondrocalcinosis. Routine laboratory tests motivated by a history of muscular cramps and weakness revealed hypokalemia and hypomagnesemia. Further investigations showed Bartter's syndrome. The characteristics of Bartter's syndrome and chondrocalcinosis and the relationship between the two diseases are developed.

Pharmacological characterization and positron emission tomography evaluation of 4-[76Br]bromodexetimide and 4-[76Br]bromolevetimide for investigations of central muscarinic cholinergic receptors

4-[76Br]bromodexetimide and its inactive enantiomer 4-[76Br]bromolevetimide were prepared via electrophilic bromodesilylation using chloramine-T and no-carrier-added (NCA) [76Br]NH4. In vitro, Bmax measured on rat cortex membranes were 3.7 +/- 0.2 and < 0.07 pmol/mg protein for 4-[76Br]bromodexetimide and 4-[76Br]bromolevetimide, respectively. The kD of 4-[76Br]bromodexetimide was 1.9 +/- 0.3 nM. In vivo studies in rats showed specific uptake of 4-[76Br]bromodexetimide in cortex, striatum, thalamus and hippocampus. No specific uptake was observed with 4-[76Br]bromolevetimide. With [76Br]bromodexetimide, positron emission tomography (PET) studies in primates demonstrated a preferential accumulation of the radioactivity in the cortex and striatum which was displaced to the level of cerebellum by dexetimide. With 4-[76Br]bromolevetimide, the radioactivity concentrations in the cortex and striatum were similar to that of cerebellum.

Vigabatrin modulates benzodiazepine receptor activity in vivo: a positron emission tomography study in baboon

The influence of increased endogenous gamma-aminobutyric acid (GABA) concentrations on benzodiazepine receptor (BZR) function was studied in the living baboon brain. By using positron emission tomography and the radiotracer [11C] flumazenil combined with electroencephalography, the anticonvulsant/proconvulsant activity and the potency of the BZR agonist diazepam and the inverse agonist methyl-beta-carboline-3-carboxylate (beta-CCM), a beta-carboline, were determined in baboons pretreated or not with 500mg/kg of vigabatrin (irreversible inhibitor of the GABA-aminotransferase which increases GABA concentrations in vivo). Pretreatment with vigabatrin increased the threshold of paroxysmal pentylenetetrazol-induced seizure. In both vigabatrin-treated and -untreated animals, the threshold dose of pentylenetetrazol increased with increasing doses of diazepam; it decreased with increasing doses of beta-CCM. The proconvulsant activity of beta-CCM was at all doses reduced in vigabatrin-treated animals compared to untreated animals, whereas, surprisingly, the anticonvulsant activity of high doses of diazepam was reduced after vigabatrin. The potency of diazepam in displacing [11C] flumazenil was enhanced in vigabatrin-pretreated animals, contrasting with the reduced anticonvulsant effects of diazepam in those animals. We determined the linear relationship between the fractional receptor occupancy and the anticonvulsant/proconvulsant effect. The slope, an estimate of the intrinsic efficacy of a BZR ligand, was reduced markedly for diazepam after vigabatrin pretreatment, whereas that for beta-CCM was unmodified. This indicates that increasing GABA levels in vivo reduce the anticonvulsant activity of the BZR agonist diazepam by decreasing its intrinsic efficacy, whereas the intrinsic efficacy of the inverse agonist beta-CCM remains essentially unaltered.

Synthesis and in vivo studies of a specific monoamine oxidase B inhibitor: 5-[4-(benzyloxy)phenyl]-3-(2-cyanoethyl)- 1,3,4-oxadiazol-[11C]-2(3H)-one

We report the radiochemical synthesis of a specific MAO B inhibitor, namely 5-[4-(benzyloxy)phenyl]-3-(2-cyanoethyl)-1,3,4-oxadiazol-[11C]-2(3 H)-one (2b) (in vitro IC50=4nM and selectivity over 71000 for MAO B), by cyclization of its hydrazide precursor 1 with [11C]phosgene. The reaction occurred within 2 min. The product obtained after HPLC purification, 2b, had a high specific activity (11.1-22.2 GBq/micromol), allowing its use in experiments as a radiotracer in vivo. Biodistribution of 2b in the CNS and in the peripheral organs of the rat, and positron emission tomography (PET) studies in the living baboon brain, pretreated or not with L-deprenyl (1mg/kg, 1h), an irreversible MAO B-specific inhibitor, were undertaken. The results showed a good uptake of 2b in all organs of the rat, with a rapid clearance from the blood (10 min). Metabolite analyses in plasma and in the diencephalon of the rat showed that 2b was the only radioactive compound in brain structure whereas in plasma three other radioactive products appeared. PET experiments show that in the L-deprenyl-pretreated baboon brain, specific binding of 2b represents around 70% of total radioactivity, whereas in the blood and plasma the radioactivity cleared rapidly (15 min).

Zolpidem displays heterogeneity in its binding to the nonhuman primate benzodiazepine receptor in vivo

The distinctive pharmacological activity of zolpidem in rats compared with classical benzodiazepines has been related to its differential affinity for benzodiazepine receptor (BZR) subtypes. By contrast, in nonhuman primates the pharmacological activity of zolpidem was found to be quite similar to that of classical BZR agonists. In an attempt to explain this discrepancy, we examined the ability of zolpidem to differentiate BZR subtypes in vivo in primate brain using positron emission tomography. The BZRs were specifically labeled with [11C]flumazenil. Radiotracer displacement by zolpidem was monophasic in cerebellum and neocortex, with in vivo Hill coefficients close to 1. Conversely, displacement of [11C]flumazenil was biphasic in hippocampus, amygdala, septum, insula, striatum, and pons, with Hill coefficients significantly smaller than 1, suggesting two different binding sites for zolpidem. In these cerebral regions, the half-maximal inhibitory doses for the high-affinity binding site were similar to those found in cerebellum and neocortex and approximately 100-fold higher for the low-affinity binding site. The low-affinity binding site accounted for < 32% of the specific [11C]-flumazenil binding. Such zolpidem binding characteristics contrast with those reported for rodents, where three different binding sites were found. Species differences in binding characteristics may explain why zolpidem has a distinctive pharmacological activity in rodents, whereas its pharmacological activity in primates is quite similar to that of classical BZR agonists, except for the absence of severe effects on memory functions, which may be due to the lack of substantial zolpidem affinity for a distinct BZR subtype in cerebral structures belonging to the limbic system.

[Is the assessment of prothrombin fragment F1+2 for monitoring of heparin therapy in patients with deep vein thrombosis useful?]

Prothrombin fragments (F1+2) can be used to monitor oral anticoagulation; their generation is also suppressed by heparin. We studied the course of F1+2, aPTT, heparin doses administered and heparin concentrations, as well as prothrombin time, during the first 7 days of heparin therapy (target aPTT 70 s) and overlapping oral anticoagulation (target INR 2-3) in 26 patients routinely treated for deep venous thrombosis (deep venous thrombosis +/- pulmonary embolism, 23 patients) or pulmonary embolism with a history of recurring deep venous thrombosis (3 patients). Although we found significant suppression of F1+2 between all pre- and post-treatment values, a transient, significant increase was seen on days 2-4. The amount of heparin given was stable from day 1-5; the fact of a transient increase in F1+2 might thus indicate that heparin doses routinely used are too low for the treatment of hypercoagulability in deep venous thrombosis in patients. We also found a decrease in heparin concentration on day 2, which may be explicable by changed pharmacokinetics of heparin in individuals with deep venous thrombosis. In conclusion, F1+2 may be useful for monitoring heparin treatment and oral anticoagulation in deep venous thrombosis patients from a laboratory point of view. However, larger studies are necessary to confirm these results. It remains to be clarified whether monitoring of anticoagulation by molecular markers might improve therapy of deep venous thrombosis. Such studies are in progress.

Childhood stroke at three years of age with transient protein C deficiency, familial antiphospholipid antibodies and F. XII deficiency--a family study

The unusual case of a boy with a stroke occurring at three years of age, transient reduction in protein C activity and high concentrations of antiphospholipid antibodies (APA) is described. APA or Lupus Anticoagulant (LA) were found in 7 of 11 relatives studied out of three different generations. In addition, antigenic Factor (F) XII deficiencies or borderline values were found in the propositus and 2 relatives. Evidence for F. XII inhibitors was found in the propositus, one of his brothers and both of his parents. Whether F. XII inhibitors in patients with APA and/or LA are pathophysiologically relevant in vivo or if they are only an in vitro phenomenon remains to be elucidated. It is reasonable to believe that the main laboratory pathology (APA and/or LA activity) in antiphospholipid syndrome is related to the clinical picture of a hypercoagulable state. There is evidence from the literature that deficiency or inhibition of F. XII might contribute to a prothrombotic state through impairment of the fibrinolytic system. There is also evidence that APA are able to reduce protein C activation. From a clinical point of view, it seems that hypercoagulability in our patient was controlled by low-dose aspirin therapy (75 mg/d). In conclusion, this case seems to support the idea of a genetic predisposition for the development of APA and/or LA. The related disturbances of the coagulatory, anticoagulatory and fibrinolytic systems might contribute in different ways to the prothrombotic state seen in patients with "antiphospholipid syndrome", eventually resulting in possible venous thrombosis or arterial thrombosis with corresponding ischaemic lesions.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased thrombin generation during fibrinogen and platelet recovery as an explanation for hypercoagulability in children with L-asparaginase therapy for ALL or NHL: a preliminary report

Three out of 21 patients treated at the Children's Hospital of Eastern Switzerland for ALL or NHL with the respective BFM-90 protocols experienced thrombotic complications during Erwinia L-asparaginase therapy. We therefore investigated the development of the haemostatic imbalance in six children during the induction phase of both protocols. In the average, elevated thrombin generation was found simultaneously to an increase in fibrinogen, cross-linked fibrin degradation products and platelet counts between protocol days 28 to 35. This period thus seems to harbour an increased potential of hypercoagulability which could explain the accumulation of thrombotic complications described by Sutor et al. Moreover, day to day investigations just before and one day after L-asparaginase administration did not show any relevant change in the above named parameters, thus rather indicating a cumulative than a single dose effect of Erwinia L-asparaginase therapy on the coagulation system. These findings lead to the question if the prophylactic use of anticoagulants might reduce the hypercoagulability seen during L-asparaginase therapy, which is currently under investigation in our institutions.

In vivo high intrinsic efficacy of triazolam: a positron emission tomography study in nonhuman primates

The triazolobenzodiazepine triazolam is a central-type benzodiazepine receptor (BZR) ligand that is widely prescribed as a hypnotic agent. Triazolam produces its effects through potentiation of gamma-aminobutyric acid-mediated neurotransmission. Findings reported from in vitro binding studies showed some discrepancies concerning the pharmacological characteristics of triazolam. The present study aims to characterize in vivo the biochemical properties of triazolam, i.e., cerebral pharmacokinetics, interaction with BZR, potency, and intrinsic efficacy. Triazolam was studied in living nonhuman primates using positron emission tomography. Two different studies were carried out: (a) a direct study using [11C]triazolam and (b) an indirect competition study using the radiolabeled BZR antagonist 1C]flumazenil. Results showed that, in the brain in vivo, triazolam binds specifically and competitively to the BZR. Its rapid cerebral kinetics is consistent with a hypnotic profile (maximal binding after 23 min, elimination half-life of 202 min). Triazolam is very potent in displacing [11C]flumazenil (ID50 = 28 +/- 6 micrograms/kg). Hill analysis of the displacement curve does not show obvious binding-site heterogeneity. Triazolam is 20 times more potent in displacing [11C]flumazenil and 50 times more potent in inhibiting pentylenetetrazol-induced paroxysmal activity than the full benzodiazepine agonist diazepam. Interestingly, the simultaneous use of positron emission tomography and EEG recording allowed us to show that triazolam-positive intrinsic efficacy is slightly higher (20%) than that of diazepam. An attractive hypothesis proposes that the severity of side effects of BZR ligands is proportional to their intrinsic efficacy. Therefore, our study shows that triazolam side effects, as for other benzodiazepines, may be related to its high intrinsic efficacy in vivo.

Coincidence of familial platelet glycoprotein Ib/IX deficiency (Bernard-Soulier syndrome), idiopathic autoantibody against platelet glycoprotein Ib/IX, familial appearance of antiphospholipid antibodies, and familial factor XII deficiency

The case of an 8-year-old boy with apparently homozygous Bernard-Soulier syndrome (platelet GP Ib/IX complex deficiency) and a transient idiopathic autoantibody against GP Ib/IX is described. He had been diagnosed with chronic autoimmune thrombocytopenia (due to the detection of antiplatelet autoantibodies) before Bernard-Soulier syndrome was proven. Both parents and his brother displayed intermediate deficiency of GP Ib/IX, thus indicating a heterozygote state for Bernard-Soulier syndrome. Alloimmunization as an explanation for the appearance of GP Ib/IX antiplatelet antibodies in the propositus can be excluded. A so-called pseudo Bernard-Soulier syndrome due to selective antibodies was also excluded. Flow cytometric analysis revealed residual expression of 2% GP Ib and 13% GP IX on the propositus' platelets. It seems that the propositus showed an idiopathic autoantibody against a platelet glycoprotein in which he is genetically deficient (but which is not completely lacking). Thus, in patients with untypical behavior upon therapy of "autoimmune thrombocytopenia", other differential diagnoses should also be considered even if antiplatelet antibodies are detected. In addition, all family members displayed elevated concentrations of antiphospholipid antibodies. These findings raise the question of a genetic predisposition for the development of autoantibodies. Moreover, an F. XII deficiency was found in all family members except the mother.

Assessing intervention effects in the Minnesota Heart Health Program

The Minnesota Heart Health Program is a 13-year research and demonstration project to reduce morbidity and mortality from coronary heart disease in whole communities in the upper Midwest. Six communities were selected for the study: three intervention and three comparison sites, matched to increase baseline comparability. After 2-4 years of baseline observations, a 5- to 6-year program of intensive intervention was introduced in the three intervention communities. Periodic cross-sectional and cohort surveys provided data on risk factors and related behaviors. Regression adjustments within and between communities reduced the confounding influences of important covariates and the variance inflation associated with the nesting of individuals within communities and surveys. Post hoc stratification allowed exploration of the main and strata-specific effects of the intervention program. Finally, the intervention effect was modeled as a departure from the trend line fit to the nonintervention city-year means. Together, these procedures explicitly acknowledged the component of variance associated with communities, and so avoided a major source of bias created in the usual analysis when that variation is ignored. They also increased the interpretability of the analyses and reduced the mean square errors used to assess the treatment effects.

Unstable distal radius fractures treated by modified Kirschner wire pinning: anatomic considerations, technique, and results

A modified technique of percutaneous Kirschner-wire pinning for unstable distal radius fractures is presented. Three to four pins are placed from the radial styloid process toward and through the dorsal, volar, and ulnar cortices of the proximal fracture fragment, respectively. Rotational stability is achieved by bending and counterblowing of the wire ends in the styloid process. Anatomic studies of cadaver wrists revealed possible lesions of the superficial radial nerve, the cephalic vein, and the tendons of the brachioradialis muscle or the thumb and wrist extensors, respectively. Nevertheless, in a follow-up of 80 patients after 1 year, no tendinous lesions nor any other serious complications were seen. Using the criteria of Green and O'Brien, the results were excellent in 66.25%, good in 20%, and fair in 8.75%.

A crook plate for treatment of acromioclavicular joint separation: indication, technique, and results after one year

From 1987 through 1991 thirty-five patients underwent surgical repairs with Wolter's crook plates for acromioclavicular joint rupture. Sixteen of the patients had Post type IV lesions: another 19 patients had the same procedure for Tossy type III lesions. Active shoulder motion up to 90 degrees of abduction and forward flexion was allowed 48 hours postoperatively. All but one patient regained full range of motion at 8 weeks. Precise bending of the plate before insertion and an accurate drill hole for the crook in the acromion were essential to prevent impingement and also precluded ventral or cranial subluxation in the joint. Using the shoulder evaluation method proposed by Constant and Murley, after 1 year 94.28% (33 of 35) of the patients had excellent results.

[Kasabach-Merritt syndrome. Intraoperative heparin therapy with follow-up combination therapy of heparin and ticlopidine for the control of intravascular coagulation]

A 39-year-old woman with Kasabach-Merritt syndrome (cavernous vascular malformations with disseminated intravascular coagulation) sustained a displaced fracture of the femoral shaft. Despite pronounced hypofibrinogenemia (< 0.1 g/l) there was no significant bleeding. The concentration of D dimer was raised to > 32 < 64 mg/l and that of prothrombin fragments F1 and F2 to > 10 nmol/l. The platelet count was 102,000/microliters and other coagulation parameters were normal or only slightly abnormal. The consumption coagulopathy was successfully controlled by continuous intravenous infusion of heparin (17,000 I.U./d) without need for clotting factor replacement, and was subsequently stabilized by combined treatment with low molecular weight heparin (5,000 I.U./d s.c.) and ticlopidine (250 mg twice daily by mouth). Oral therapy with acetylsalicylic acid alone or in combination with ticlopidine proved insufficient, being rapidly followed by a renewed fall in fibrinogen level and platelet count. The findings suggest that fibrin formation in the abnormal vascular territories was the principal pathogenetic factor in this case.

[Management of acromioclavicular joint dislocation with the Wolter hook-plate. One year follow-up of 35 cases]

Wolter's hook-plate provides active abduction and forward-flexion of up to 90 degrees two days postoperatively. Prebending of the plate and a precise drill hole for the hook in the acromion prevents later impingement of the hook on the humeral head or subluxation in the acromioclavicular joint, respectively. According to the shoulder evaluation form of C.R. Constant, 33 of 35 patients operated on between 1987 and 1991 at the trauma departments in Schwaz/Tirol and Bad Ischl showed excellent results one year postoperatively.

A new approach to the subacromial space. Technique and 2-year results in 28 rotator-cuff repair cases

We present a new approach to the subacromial space, consisting essentially of an osseous detachment of the deltoid muscle from the anterior and lateral rim of the acromion including the osseous origin of the coraco-acromial ligament. After acromioplasty and an eventual reconstruction of a torn rotator cuff, Kessler-sutures provide stable transosseous repair of the deltoid muscle. This method generally allows immediate active shoulder motion. 25 of 28 patients with rotator cuff ruptures alone or in combination with an impingement syndrome had good results according to the UCLA-score 2 years postoperatively. No serious complications regarding the function of the deltoid muscle or any failure of the accompanying acromioplasty occurred.

[Anatomic studies of percutaneous bore wire osteosynthesis of the distal radius]

Modified percutaneous K-wire pinning has been used for unstable distal radius fractures groups A 2.2-3, A 3.1-3, B 1.1-2, B 2.1-2, B 3.3, C 1.1-3, C 2.1-3, and C 3.1-2 according to the ASIF-classification in 90 patients with good results. No tendinous rupture or any weakness respectively, infection or secondary dislocation either had occurred six months postoperatively. In five cadavers experimental anatomical studies had revealed possible lesions of the tendons of the brachioradialis muscle, the short and long wrist extensors, the long thumb abductor and his short extensor respectively as well as the superficial radial nerve and the cephalic vein. Abnormous sensations in the scar or in the region of distribution of the superficial radial nerve had occurred in every second patient but had subsided six months postoperatively. No permanent nerve lesion was found. There has been bleeding from the cephalic vein after the stab incision for exposure of the tip of the styloid process in every third patient but had healed uneventfully in every case.

The fates of Czechoslovak contestants in Olympic games

Since the Second Olympic Games of the new era up to the Games in 1988 on the whole 2031 Czechoslovak competitors participated in both Summer and Winter Games. The author succeeded in compiling items on the length of life and causes of decease of 265 Olympic participants who died up to the end of 1989. The study of those items revealed that the length of living of those athletes who died in the period 1950 till 1989 was 67.4 years. That indice may be compared with men in population with a mean length of life 67.7 years in 1988. It is however necessary to take into consideration that the studied sample of Olympic competitors represents a certain selection of men. The causes of natural death of Olympic competitors do not differ in principle from natural deceases of other former Czechoslovak athletes and also no expressive differences were found in comparison with natural causes of death of men in population.

Complications of interlocking nailing for lower leg fractures: a 3-year follow up of 102 cases

Of the 109 patients treated by interlocking nailing for lower leg fractures between 1985 and 1990 at the A.ö.KH Schwaz and the LKH Bad Ischl, Austria, 92 underwent follow-up examination. Data were analyzed using a personal computer. Special attention was paid to fracture pattern, level, complications, and length of sick leave. Compared with a previous study, an increasing number of compound fracture patterns were evaluated. Except for 14 misalignments and two late infections after new injuries, no other serious complications were detected. Interlocking nailing can be highly recommended even for open fractures up to the second degree at any level from the second fifth to the fourth fifth of the tibia.

[Initial experiences with the humerus interlocking nail]

A preliminary report is given on the good results of eleven patients, who had been treated with a locking nail for a fracture of the humerus at three different trauma departments. No non-union, infection or radial palsy has been seen nor was there any neurovascular complication intraoperatively. Four patients had misalignments of up to 15 degrees, whereof three of them had combined varus-recurvation-angulations without functional or cosmetic sequelae. All but one had excellent functional results six months postoperatively. Bone healing could be confirmed three months postoperatively. Only transverse and spiral fractures of the second to fifth sixth had been treated until now, though open fractures up to the second degree can be managed too. Finally, some technical issues are considered, which include a better guiding device, the use of cancellous screws for proximal looking, a more oblique position of one of the proximal screwholes to obtain some kind of interfragmentary compression for appropriate fractures, and the use of a Williams-screwdriver.

[Technique and results of modified percutaneous bore wire osteosynthesis of the distal radius]

A modified technique for percutaneous K-wire pinning of distal radius fractures is presented. With this method, three to four K-wires are introduced from the radial styloid process towards and through the dorsal, volar and ulnar proximal cortical wall, respectively. After the fracture fragments have been demonstrated to be stable, the wires are cut, bent over and fixed. Then a dorsal plaster splint is applied, which should be worn for 4-6 weeks, depending on whether or not there is a dorsal comminution zone. Fifty-five patients have been operated on by this method. At follow-up 6 months after the operation, no secondary dislocation, wire migration, infection, Sudeck syndrome or functional disturbance was seen. The advantage of this method is emphasized as compared with the usual, previously published method.

Results from a statewide approach to adolescent tobacco use prevention

BACKGROUND

The 1985 Minnesota Legislature established guidelines for school-based tobacco-use prevention programming and provided financial incentives to school districts to encourage them to adopt a broad range of preventive measures. The Minnesota-Wisconsin Adolescent Tobacco-Use Research Project was funded by the National Cancer Institute in 1986 to evaluate the Minnesota initiative through two parallel studies.

METHODS

The Four Group Comparison Study was a prospective study of 48 school "units" which were randomly assigned to one of four conditions in 1987. Baseline observations were taken in the sixth grade in 1987, interventions were delivered in the seventh grade, and follow-up observations were taken in the seventh, eighth, and ninth grades. The Four Group Comparison Study was designed to evaluate the three middle-school interventions that were most widely adopted by Minnesota school districts as a result of the 1985 legislation. The Two State Comparison Study was a serial cross-sectional study of representative districts in Minnesota and Wisconsin. Annual surveys of ninth graders were conducted from 1986-1990. The Two State Comparison Study was designed to determine whether tobacco-use patterns changed in Minnesota relative to Wisconsin following the Minnesota legislation.

RESULTS

The prospective study indicated that none of the interventions was more effective in reducing adolescent tobacco use compared with a randomized control group. The serial cross-sectional study revealed that there was a modest net decline in Minnesota relative to Wisconsin from 1986 to 1990, but that it was within the range of chance variation.

CONCLUSIONS

Taken together, these results indicate that this legislative initiative was insufficient to reduce adolescent tobacco use statewide during the 5-year study period. Together with results from other recent studies, they suggest that even more intensive efforts may be required to effect widespread reductions in adolescent tobacco use.

[Differentiation antigens on normal bone marrow cells and following culture with growth factors in patients with acute myeloid leukemia (AML)]

In an attempt to detect residual leukemic cells during complete remission (CR), we used 4 monoclonal antibodies detecting markers at different stages of myeloid maturation. Bone marrow cells of AML patients at diagnosis/relapse or in CR were compared with normal controls at day 0 and 7, after incubation with colony stimulating factors, by the alkaline phosphatase/antialkaline phosphatase method. In AML patients at diagnosis/relapse, the expression of the early differentiation markers (CD34, HLA DR) was significantly increased and that of the late marker CD15 significantly decreased at day 0. After day 7 liquid cultures, the markers HLA DR and CD13 were significantly increased and CD15 significantly decreased. During CR a significant increase in day 7 liquid cultures of the markers HLA DR and CD13 was found compared to normal controls. These results may reflect the proliferation in culture of residual leukemic cells in CR patients.

A new technique for anterior acromioplasty

A new approach to anterior acromioplasty is presented. Using the oscillating saw of the ASIF-miniset, the deltoid muscle is detached off the acromion together with an osseous slice. This technique provides a stable reduction of the muscle at the end of the operation and avoids painful periostitis postoperatively. In so far, early functional recovery can be undertaken as soon as three weeks postoperatively.

Ceftriaxone and amikacin versus ceftazidime and amikacin in febrile granulocytopenia

The efficacy and safety of the two antibiotic combinations, ceftazidime plus amikacin and ceftriaxone plus amikacin were compared in an open randomized trial. 100 episodes of neutropenia caused by malignant diseases and/or cytostatic drugs were evaluated in 66 males and 34 females with a mean age of 49.4 years. The types of infections treated were: septicemia 38, fever of undetermined origin 26, pneumonia 13, ear, nose and throat infections 11 and others 12. 17 episodes were not evaluable (6 protocol violations, 6 doubtful infections and 5 non-bacterial infections). The overall results were comparable, with a 74% success rate for ceftazidime and a 70% rate for ceftriaxone (criteria of the European Organization for Research and Treatment of Cancer). In the patients with septicemia, the success rate was 64% in the ceftriaxone and 57% in the ceftazidime group. Eight patients died during the treatment, in 5 cases due to infectious complications. There were no differences between the two groups in respect of efficacy or toxicity.

[BEP-chemotherapy in patients with testicular tumors--is it worthwhile?]

Since 1985 44 consecutive patients with testicular cancer have been treated with a modified BEP regimen. 70% had metastatic disease and 30% received adjuvant therapy. After mean follow-up of 26 (8-56) months, 91% of patients are alive and all are in remission. Chemotherapy-related side effects were alopecia (100%), myelosuppression (100%), nausea/vomiting (89%) and fever (66%). Patients reported nausea has been rare. It is concluded that BEP chemotherapy is a highly effective treatment which secures complete remission or cure even in patients with advanced metastatic disease. In retrospect the patients considered the treatment worthwhile despite the stress involved.

Major depression and agoraphobia in patients with angiographically normal coronary arteries and panic disorder

Patients with panic disorder and/or agoraphobia appearing in psychiatric settings report rates for lifetime major depression between 24% and 91%. Between 40% and 90% of patients with panic disorder in psychiatric populations report concomitant agoraphobia. A recent study of panic disorder subjects appearing in an outpatient cardiology clinic confirmed the strong link between panic and depression but found only a weak association between panic disorder and agoraphobia. In order to test the reliability of these outpatient cardiology findings, the authors studied major depression and agoraphobia in patients with angiographically normal coronary arteries and panic disorder. Twelve of the 32 (37.5%) panic disorder subjects reported a lifetime history of major depression (nine current, three past only). Only two of the 32 (six percent) reported any phobic avoidance. This study confirms the previous findings which suggest that major depression is common in cardiology populations with panic disorder and that phobic avoidance is uncommon in this group.

Use of a fully implantable drug delivery system in the treatment of acute leukemias and disseminated lymphomas

In an open study, 42 venous Port-A-Cath systems (PAC) were implanted in 40 patients with AML (12), ALL/AUL (11), NHL with bone marrow infiltration (8), Hodgkin's lymphoma (3), solid tumors (5) and severe aplastic anemia (1). Mean duration of system use was 212 days. The cumulated duration of use of all systems was 8.883 days. 1,627 blood samples were taken from the PAC. Blood sampling was possible on 8,696 of 8,883 days of cumulated access (98%). A total of 522 blood transfusions were administrated. Fifty-two episodes of neutropenia (granulocyte counts less than 0.5 x 10(9)/l) with a mean duration of 17 days were observed in the group of the 23 patients with acute leukemias. A total of 25 complications were registered. The incidence was 2.8/1,000 days of access. Twelve complications were regarded as severe. Venous thrombosis was observed in 3 cases. In addition, there were 2 disruptions of the catheter, 1 disconnection, 1 looping and 4 local infections. The rate of systemic infection could not be accurately estimated because the catheter was always left in place and antibiotic treatment was started immediately in case of fever with or without bacteriemia. The overall rate of catheter-related complications in patients with acute leukemia was not higher than in patients with solid tumors.

Patterns of self-initiated smoking cessation among young adults

Prochaska and DiClemente's (1984) cyclic-stage model of self-initiated smoking cessation divides the cessation process into five stages. This model was applied to a young adult population to determine the cross-sectional distribution of stages and the frequency and pattern of changes among stages over time. Compared to older adults, the distribution of the stages differed substantially: There were twice as many relapsers and only half as many maintainers among young adults. One-year changes in stages were examined using a static model, which did not take into account the cyclic nature of the change process, and a more realistic dynamic model, which did. Both models, especially the dynamic model, suggested substantially more movement among stages in younger than in older adults.

Panic disorder in patients with chest pain and angiographically normal coronary arteries

Although patients with angiographically normal or near normal coronary arteries are at low risk for cardiac disease, several follow-up studies have shown that many continue to report recurrent chest pain associated with social and work dysfunction. Three diagnostic entities have been proposed to explain the morbidity of this group: microvascular angina, esophageal motility disorders and panic disorder. The purpose of this study was to test the hypothesis that panic disorder is found frequently in patients with chest pain who have normal epicardial vessels. Ninety-four subjects with angiographically normal coronary arteries were interviewed according to a structured psychiatric protocol within 24 hours of their catheterizations. Thirty-two (34%) fit Diagnostic and Statistical Manual of Mental Disorders (third edition, revised) criteria for current panic disorder. Because panic disorder can be effectively treated, physicians should consider this diagnosis in this group of patients. Current research findings suggest that panic disorder, microvascular angina and esophageal disorders may each form the basis for chest pain in approximately 25% of these patients. Miscellaneous problems account for the other 25%.

Relapse cell population differs from acute onset clone as shown by absence of the initially activated N-ras oncogene in a patient with acute myelomonocytic leukemia

We have conducted a follow-up study of a patient with myelomonocytic leukemia exhibiting an N-ras mutation (Gln61----Lys61) using the polymerase chain reaction method and synthetic oligonucleotide hybridization probes. This method allowed us to detect as little as 3% of N-ras-mutated cells within a population. When the patient went into clinical remission, the mutation became undetectable. When a relapse occurred, the blasts did not carry the N-ras mutation. Analysis of M13 cloned amplified N-ras sequences from relapse DNA revealed exclusively the wild type allele of the N-ras gene. These findings suggest that the relapse cell population is derived from a different clone than the acute phase population. Furthermore, the data argue that N-ras mutation is not an initiating lesion in this case of acute myelomonocytic leukemia (AMML).

[Primary non-Hodgkin's lymphoma of the muscles]

On the basis of two personal observations and of 18 published cases, a review of primary non-Hodgkin lymphoma originating in the skeletal muscle is presented. The disease mainly affects persons in the seventh decade. Ninety-five percent of the tumors occur in the extremities, with 75% in the lower extremities. Most lymphomas were of low grade malignancy, with intermediate and high grade tumors accounting for 45% of cases. Reliable differentiation of NHL from other small round cell tumors of the soft tissues, such as rhabdomyosarcoma or Ewing sarcoma, and from metastatic carcinoma, is mandatory for therapeutic purposes. Diagnosis can be established by light microscopy alone in most patients. In doubtful cases immunohistochemistry may be required.

[Myeloproliferative syndrome and acute febrile neutrophilic dermatosis (Sweet's syndrome)--a rare association]

The case is reported of a 73-year-old man presenting with a history arthralgia, conjunctivitis, fever and typical lesions of acute febrile neutrophilic dermatosis (Sweet's syndrome). Due to massive leukocytosis, an unclassifiable myeloproliferative disorder was later diagnosed. The disease responded well to hydroxyurea but only partly to steroids. The case demonstrates the necessity of close hematologic follow-up in Sweet's syndrome, since some 10% of patients develop hematologic malignancies weeks or months later.

[Simultaneous occurrence of hemophilia A and acute lymphatic leukemia]

In this paper the case of a man with haemophilia A is presented. At the age of 18 years an acute lymphatic leukaemia was observed. The case report demonstrates that even in the presence of a severe plasmatic coagulopathy an acute lymphatic leukaemia can be successfully treated with intensive chemotherapy, if the monitoring of the coagulation values and the substitution of antihaemophilic globulin and thrombocytes are guaranteed. Only 4 cases of haemophilia and acute leukaemia in the same patient are described in the literature. So we believe that the association of these two rare disorders is merely accidental.

[Which studies are suitable for the diagnosis of recurrences in resectable breast carcinoma? A retrospective analysis of the OSAKO 06/74 adjuvant study]

113 patients with first relapse in the OSAKO 06/74 adjuvant chemotherapy trial for resectable breast cancer were investigated retrospectively. Based on history alone, 85% of the relapses could have been presumed. Physical examination alone was positive in 82% of relapses. Depending on the localization of relapse, the relative importance of different methods of examination differed. If history and physical examination were analyzed together, 96% of all relapses could be presumed. 45% of the patients did not see the doctor before the fixed time, although they suffered from symptoms associated with relapse. 26% of the women complained of symptoms during at least 4 months before diagnosis of relapse. We conclude that regular clinical controls, including careful history and scrupulous physical examination, represent the most efficient method for diagnosis of relapse in patients with resectable breast cancer.