Unprecedented oxidation of a phenylglycinol-derived 2-pyridone: enantioselective synthesis of polyhydroxypiperidines

[reaction: see text]. The phenylglycinol-derived 2-pyridone 1 undergoes m-CPBA oxidation steroselectively leading to the chiral nonracemic unsaturated bicyclic hydroxylactam 2, from which the enantioselective synthesis of (3R,5R)-3,4,5-trihydroxypiperidine (16) and the formal synthesis of the azasugar epiisofagomine are described. The enantioselective synthesis of (S)-N-Boc-3-hydroxypiperidine and (3R,4S)-3,4-dihydroxypiperidine is also reported.

The value of endorectal MR imaging to predict positive biopsies in clinically intermediate-risk prostate cancer patients

The aim of this study was to assess the effectiveness of endorectal MR imaging in predicting the positive biopsy results in patients with clinically intermediate risk for prostate cancer. We performed a prospective endorectal MR imaging study with 81 patients at intermediate risk to detect prostate cancer between January 1997 and December 1998. Intermediate risk was defined as: prostatic specific antigen (PSA) levels between 4 and 10 ng/ml or PSA levels in the range of 10-20 ng/ml but negative digital rectal examination (DRE) or PSA levels progressively higher (0.75 ng/ml year(-1)). A transrectal sextant biopsy was performed after the endorectal MR exam, and also of the area of suspicion detected by MR imaging. The accuracies were measured, both singly for MR imaging and combined for PSA level and DRE, by calculating the area index of the receiver operating characteristics (ROC) curve. Cancer was detected in 23 patients (28%). Overall sensitivity and specificity of endorectal MRI was 70 and 76%, respectively. Accuracy was 71% estimated from the area under the ROC curve for the total patient group and 84% for the group of patients with PSA level between 10-20 ng/ml. Positive biopsy rate (PBR) was 63% for the group with PSA 10-20 ng/ml and a positive MR imaging, and 15% with a negative MR exam. The PBR was 43% for the group with PSA 4-10 ng/ml and a positive MR study, and 13% with a negative MR imaging examination. We would have avoided 63% of negative biopsies, while missing 30% of cancers for the total group of patients. Endorectal MR imaging was not a sufficient predictor of positive biopsies for patients clinically at intermediate risk for prostate cancer. Although we should not avoid performing systematic biopsies in patients with endorectal MR imaging negative results, as it will miss a significant number of cancers, selected patients with a PSA levels between 10-20 ng/ml or clinical-biopsy disagreement might benefit from endorectal MR imaging.

[Myocardial perfusion scintigraphy with 99mTC-sestamibi and gated SPECT and myocardial perfusion scintigraphy with reinjection of 201Tl at 24 hours. Are the techniques comparable?]

AIM

To compare the results obtained with 99mTc-sestamibi and gated-SPECT (gated SPECT in stress and rest) with 201Tl (stress, redistribution, and 24 hour reinjection SPECT).

METHODS

Twenty patients underwent two SPECT studies, one with 201Tl and the other with 99mTc-sestamibi.

RESULTS

Using 201Tl as a reference, 177 segments were considered normal, 31 viable and 32 with myocardial necrosis. The overall concordance with 99mTc-sestamibi was 84.2%. In the subgroup of defects that improved after reinjection of 201Tl, it was much less (45%), even after wall thickness and movement (55%) were analyzed.

CONCLUSION

The overall concordance between 201Tl scintigraphy compared to 99mTc-sestamibi is acceptable. Correlation is low in the viable segments with 99mTc-sestamibi, even after analyzing the Gated-SPECT.

[Acute myopericarditis following laparoscopic treatment of gastroesophageal reflux]

A 32-year-old patient experienced a postoperative acute myopericarditis following laparoscopic surgery for gastro-oesophageal reflux (Toupet's fundoplication). His medical history was unremarkable, apart from controlled arterial hypertension. Peroperative circulation was stable, except a short hypertensive episode at CO2 insufflation, controlled with nicardipine. A myopericarditis occurred at the fourth postoperative hour, with apical and inferior hypokinesia at ventriculography, ST-segment elevation with unremarkable coronary arteriography. The patient was discharged at day seven, with a NSAIDs treatment. Echocardiography three and nine months later postoperatively, showed an apical akinesia and persistence of the ST-segment modification, without clinical symptoms. Complications of laparoscopic fundoplication is either specific to surgery (gastro-oesophageal injury, diaphragmatic injury, mediastinitis, stenosis) or secondary to pneumoperitoneum (pneumothorax, carbon dioxide embolism). In this case, following an apparently uncomplicated laparoscopy and, except a direct cardiac trauma from a laparoscopic instrument, either coronary artery spasm, or pneumopericardium with CO2, or delayed gas embolism, or preoperative "silent" myopericarditis could be the potential cause of this cardiac complication.

Predictive value of 99Tcm-sestamibi gated SPET for long-term myocardial perfusion and functional recovery after an acute myocardial infarction

We assessed the predictive value of 99Tcm-sestamibi gated single photon emission tomography (SPET) for changes in perfusion and functional outcome after an acute myocardial infarction and compared the findings on functional recovery with echocardiography using low-dose dobutamine. Gated 99Tcm-sestamibi SPET and radionuclide angiocardiography were performed in 17 patients 4-10 days after an acute myocardial infarction. Six months later, both isotopic studies and rest-dobutamine echocardiography were performed to assess outcome. Perfusion improved in six of seven severely hypoperfused segments (positive predictive value = 85.7%) that showed wall thickening but not in any of 28 segments (negative predictive value = 100%) without wall thickening. The mean ejection fraction improved from 47.7 to 52.3% (P = 0.018). Furthermore, there was a greater improvement in ejection fraction in the group of patients in whom wall thickening predicted a recovery in perfusion (9.0 vs 3.7%, P = 0.01). A comparison of the assessment of functional recovery between gated SPET and dobutamine echocardiography showed good agreement (81.4%). We conclude that the presence of wall thickening in severely hypoperfused segments on 99Tcm-sestamibi gated SPET is predictive of changes in perfusion and functional recovery after acute myocardial infarction, thus identifying the presence of viable myocardium. In contrast, segments showing hypoperfusion and dysfunction after an acute myocardial infarction probably contain scar tissue only.

Eutectic mixture of local anesthetics in adult urology patients: an observational trial

BACKGROUND AND OBJECTIVES

The effectiveness of EMLA eutectic mixture of local anesthetics, (ASTRA Co, France) cream in minor surgery on the penis and its acceptability in unpremedicated outpatients were assessed.

METHODS

EMLA cream was applied 1 hour before surgery (fremulum plasty, circumcision or dorsal section for phimosis, and condyloma accuminatum) in addition to a subcutaneous infiltration of lidocaine 1%, just before incision in cases of circumcision. Verbal Rating Scale (VSR) was assessed during the surgery and the acceptance 15 days later by a questionnaire.

RESULTS

Thirty-two patients included. In all of the cases, the application of EMLA cream was sufficient, with the exception of one (fremulum plasty). General anesthesia was used for this patient unable to tolerate the proprioceptive sensations (VRS = 0). In cases of circumcision, the subcutaneous infiltration was not experienced as painful. Eighty-eight percent of patients who answered the questionnaire confirmed that if they had to be reoperated on, they would opt for this technique of anesthesia.

CONCLUSION

EMLA cream is effective in minor penile surgery in adult patients, and it is associated with subcutaneous infiltration of local anesthetic in the case of circumcision.

CD4 masking during human immunodeficiency virus type 1 infection, quantified on peripheral blood lymphocytes, is a potential marker of disease progression

In human immunodeficiency virus type 1 (HIV-1)-infected adults, the proportion of gp120-free CD4 molecules on the surface of T lymphocytes was measured by double-epitope EIA and expressed as a CD epitope concentration ratio. In 51% of these patients (n=81), CD4 T cells showed a significant decrease (up to 100%) in the accessibility of the CD4 epitope in the D1 domain remained accessible. Of interest, a significant increase in the CD4 gp120 binding site concentration, without a change in T cell counts, was observed within 10 days after initiation of zidovudine treatment. Furthermore, CD4 masking by gp120 was associated with a poor clinical patient status. The assessment of the CD4 epitope concentration ratio is proposed as a surrogate marker of disease progression in HIV-1-infected patients.

Improvement of exercise-induced ischaemia and myocardial perfusion after aminophylline

BACKGROUND

Previous studies have suggested that aminophylline improves exercise-induced ischaemia by preventing the redistribution of the coronary flow from ischaemic to non-ischaemic myocardium. The purpose of the study was to assess whether aminophylline improves myocardial perfusion in zones supplied by collateral circulation.

METHODS

Twenty-three patients with an occluded coronary artery and collateral circulation from a non-diseased vessel underwent two symptom-limited exercise 99mTc-MIBI, single-photon emission computed tomography (SPECT) myocardial scintigraphy experiments, which were preceded by an intravenous infusion of either aminophylline (5 mg/kg over 20 min) or saline solution in a randomized double-blind control procedure. The MIBI SPECT images were analysed by two experienced observers who were blinded to each other's data.

RESULTS

All patients underwent cardiac catheterization. For 16 patients this was because of stable angina and the remaining eight were post-myocardial infarction patients with a positive exercise test. Aminophylline significantly increased the time to the onset of ischaemia in the 15 patients with a positive exercise test (mean +/- SD, 6.5 +/- 1.9 compared with 5.3 +/- 1.8 min, P < 0.005); and ischaemia occurred at higher rate-pressure product (230 +/- 68 compared with 195 +/- 68 HB x mmHg, P < 0.03). After aminophylline, exercise ST-segment depression was 1.1 +/- 0.5 mV, compared with 1.5 +/- 0.8 mV after placebo (P < 0.01). All patients had perfusion defects that resolved partially or completely in the rest images. The imaging score was significantly lower after aminophylline infusion than after placebo (9.7 +/- 9 compared with 12.1 +/- 10, P < 0.01).

CONCLUSIONS

Aminophylline significantly delayed the time to onset of exercise-induced ischaemia and improved perfusion in zones supplied by collateral circulation. Aminophylline-like drugs may be useful in the treatment of selected patients with ischaemic heart disease.

Identification of coronary artery disease by 99mTc-MIBI myocardial perfusion single photon emission computed tomography: evaluation using Diamond's method and segmental score system

Three hundred and eighty-one consecutive patients referred to our Nuclear Medicine Service from the Cardiology Department during a period of two years have been studied to evaluate Coronary Artery Disease (CAP) using 99mTc-MIBI single photon emission computed tomography (SPECT). The sensitivity and specificity for detecting CAD in the whole group of patients, referred (n = 161) or not (n = 220) for coronary angiography, were calculated following Diamond's method, and were found to be 87% and 92%, respectively. Diamond's method estimates these values from those obtained in the subset of patients with angiography referral (sensitivity 91% and specificity 85%) and the pattern of SPECT responses of both groups (69% and 52%, respectively). A new segmental score system was used to evaluate the location and extent of CAD in the catheterized group. The sensitivity for detecting individual artery disease was 69% and specificity was 81%. The sensitivity in patients with single, double and triple-vessel disease was 90%, 96% and 89%, respectively. In the subgroup of patients without infarction (n = 66) the sensitivity and specificity were 76% (19/25) and 90% (37/41).

The effect of systemic lupus erythematosus and long-term steroid therapy on bone mass in pre-menopausal women

The aim of our study was to assess bone mineral density (BMD) in pre-menopausal women with systemic lupus erythematosus (SLE) and the influence of disease activity and use of corticosteroids. Lumbar and femoral BMD were measured in 43 patients with SLE (28 on regular steroid therapy, 15 with recent onset, non-treated) and compared with 43 healthy women matched for age. In addition, 21 SLE patients treated with corticosteroids were followed-up with a mean of 36.6 +/- 12.7 months. BMD was significantly lower in SLE patients with prednisone doses > or = 7.5 mg/day than those of recent onset (lumbar: 1.07 +/- 0.11 vs 1.15 +/- 0.13, P = 0.039; femur: 0.85 +/- 0.13 vs 0.98 +/- 0.21, P = 0.034) and the control group (lumbar: 1.07 +/- 0.11 vs 1.13 +/- 0.10, P = 0.040; femur: 0.85 +/- 0.13 vs 0.93 +/- 0.10, P = 0.028). In addition, 18% of SLE steroid users had osteoporosis. Lumbar and femoral BMD were inversely correlated with the time of treatment and the cumulative doses of prednisone. There were no significant BMD changes during the 3-yr follow-up period. In conclusion, in SLE pre-menopausal patients lumbar and femoral BMD is decreased and related to long-term corticosteroid therapy.

Anteroposterior versus lateral bone mineral density of spine assessed by dual X-ray absorptiometry

Recently, it has been suggested that lateral (LAT) spine bone mass measurements by absorptiometry may be more sensitive for detecting bone loss than the standard anteroposterior (AP) projection. The aim of this study was to evaluate the precision of LAT spine dual-energy X-ray absorptiometry (DEXA) and its diagnostic sensitivity. A group of 1554 subjects with no risk factors that might affect bone metabolism and 185 osteoporotic patients with vertebral fractures were studied. Bone mineral density (BMD) was measured in the lumbar spine (standard AP and LAT projections) and proximal femur with a DEXA absorptiometer. The precision of the measurements was assessed in 15 volunteers. Diagnostic sensitivity was evaluated by the Z-score method. Comparing young people and the elderly, spine bone loss in the latter was similar for AP and LAT projections, when it was evaluated in absolute values (glcm2). However, when it was evaluated in percentage terms, bone loss was about twice as high in the LAT projection. LAT spine BMD correlated significantly with all the other areas assessed. The best correlation was found with the standard AP projection (r = 0.67, P < 0.0001). The precision in the LAT projection was found to be within an acceptable range (1.6% in normal subjects, 2% in osteoporotic patients), even though it was about twice that obtained in the AP projection. Diagnostic sensitivity was also better with the AP projection. It is concluded that LAT spine BMD measurements can be assessed with acceptable precision although it is about twice as high as for AP spine measurements.(ABSTRACT TRUNCATED AT 250 WORDS)

Tc-99m galactosyl-neoglycoalbumin hepatic scintigraphy in fulminant hepatic failure

Tc-99m galactosyl-neoglycoalbumin (NGA) is a new liver imaging agent that specifically binds to a hepatocyte specific membrane receptor, the hepatic binding protein. Scintigraphy with Tc-99m NGA is a noninvasive method that provides functional images of the liver. This report deals with one case of fulminant hepatic failure in which hepatic scintigraphy with Tc-99m NGA predicted hepatic recovery before clinical and biochemical parameters, being a prognostic index in this patient.

Myocardial uptake of antimyosin antibody in idiopathic dilated cardiomyopathy and its relation to functional and morphological parameters

Monoclonal 111In antimyosin (AMS) uptake indicates the presence of ongoing myocyte damage. In idiopathic dilated cardiomyopathy (IDC), there is diffuse myocyte damage. We have attempted to find a correlation between AMS uptake and functional myocardial parameters. With this purpose in mind, we studied two groups of subjects: group 1 comprised 19 subjects with IDC and group 2 comprised 6 control subjects. In all subjects, an antimyosin scan was performed. Among the subjects with IDC, two-dimensional echocardiography was carried out to determine the left ventricular ejection fraction (LVEF) and left ventricular dimensions, and a gated blood pool study was undertaken to assess the LVEF at rest and end-diastolic and end-systolic volumes. Three months later, repeat antimyosin scintigraphy and equilibrium gated blood pool were performed on 13 of the patients. The mean heart to lung (H/L) ratio in the IDC subjects was 1.82 +/- 0.25 (range 1.42-2.25), a value significantly higher than that obtained in the controls: 1.41 +/- 0.12 (range 1.26-1.58) (P < 0.001). Linear regression analysis did not find a statistically significant correlation between H/L and gated blood pool or echocardiography measures. No marked changes in ejection fraction and antimyosin uptake were found between baseline and follow-up studies. Subjects with IDC have a high incidence of positive antimyosin scans, but antimyosin uptake is not related to any functional or morphological parameters.

Three-dimensional realignment of activation brain single-photon emission tomographic studies

Two methods for 3D realignment of activation brain single-photon emission tomographic (SPET) studies are analyzed. The first is based on principal axes transformation (PAT). The second uses the results of the first method as initial values to start a least-squares iterative process (LS) to search for the maximum value of the correlation function. Both methods were tested with simulated and real studies. The results of the PAT method showed a maximum translation error of 0.3 +/- 0.1 pixels and a rotational error of 1.2 +/- 0.7 degrees in a total of 100 runs. For the LS method these errors were 0.2 +/- 0.1 and 0.6 +/- 0.3. The realignment for 34 real studies was assessed by three expert observers. The alignment was found to be satisfactory in all cases for the LS method, and in 18 cases (53%) for the PAT method. From the results we conclude that a combination of both methods allows the accurate realignment of SPET neuroactivation studies.

The effect of different porosities in coral implants: an experimental study

Goniopora lobata and polyphyllia talpina were tested in 10 sheep with a follow-up of 12 months. The reference material was a glass ceramic CAP 42. Different implantation sites are used: craniofacial and orthopaedic. A macro and microscopic postoperative study was performed at 3, 6, 9 and 12 months. The results show: (1) biocompatibility with bone and soft tissues; (2) disappearance, without colonisation, of Goniopora Lobata associated with complete bone regeneration at 12 months and (3) later resorption of polyphyllia talpina with a fibrous colonisation, without osseous transformation. The possibility of using these materials in cranio-maxillo facial surgery is discussed.

[Drug consumption in diabetes mellitus (IV). The utilization of reactive material and systems for assessing blood glucose control from the viewpoint of primary care. The Group for the Study of Diabetes in Tarragona (GEDT)]

BACKGROUND

A study was performed to analyze the use of reactive material in the periodic follow up of diabetes. Likewise, the use of systems to assess glycemic control by primary care physicians was investigated.

METHODS

Analysis of the habits of use of reactive material was performed on the diabetic population of Tarragona (548,900 inhabitants) by randomized survey of prescription in 525 patients attended in 12 primary care centers. The estimation of amount was carried out by a counting of the public prescriptions made. Similarly the periodicity and the results of the applications of glucoproteins in the reference laboratories were studied.

RESULTS

A total of 253 diabetics (48%) were exclusively attended in the centers and 272 (52%) performed some type of home self-analysis; 26 (5%) in urine samples, and 246 (47%) in capillary blood. The estimated mean consumption was of 14 blood sugar strips per patient per month (168 strips/year) and 2.7 glucosuria-glucocetonuria strips (32.4 strips/year). The relative urine/blood ratio was 1/5.2. In 343 cases (65%) some glucoprotein measurement was reported within the last year, 330 (63%) corresponding to glucohemoglobin A1. The mean value was 8.3% (normal: 5-8%). The mean number of applications was 1.6 applications per patient per year.

CONCLUSIONS

An enormous increase was observed in the amount consumed at the province of reactive material in blood and in the measurement of glucoproteins as the system to assess carbohydrate control in diabetes. A significant reduction was found in the use of reactive strips in urine by the diabetic population.

[Consumption of drugs in diabetes mellitus II. Utilization and loss of insulin: epidemiologic and socioeconomic implications. Study Group for Diabetes in Tarragona (GEDT)]

BACKGROUND

With the aim of evaluating the real consumption on insulin an analysis of its loss with use in clinical practice was carried out. The influence of this loss was investigated in the calculations of prevalence of diabetes (DM) initiating from the consumption of medication, the presumable repercussion in public health costs and possible alternatives.

METHODS

Revision and analysis of the recipients used by a group of 58 insulin treated diabetics was carried out during a mean period of one month. The theoretic consumption, real consumption and the mean loss per each injection according to visual accuracy and the system employed were evaluated. A deduction was made of the autonomy by storing of insulin. A previous calculation concerning the prevalence of DM in Tarragona (548,900 inhabitants) according to consumption was corrected and an economic estimation of the loss demonstrated over public health costs of insulin during 1991 was made.

RESULTS

The mean dose prescribed was 39.7 IU/day supplied in 2.4 injections/patient/day. At 30 days (27-35) 310 recipients were evaluated (115 vials/195 boxes). The mean real dose consumed was 53.3 IU/day and the mean loss per injection was 5.6 (25.5% of all the insulin supplied, 4.5% as remnants at the bottom of the recipient). A greater loss was observed by injection a) in patients with reduced sight (6.4 +/- 7.3 IU/5.5 +/- 4.5; NS) and b) in the users of syringes with dead space (5.8 +/- 4.7) with respect to those using an injector insulin pen (4.4 +/- 2.9; p < 0.01). The autonomy by domiciliary storage of insulin was of 103.7 days/patient (prescribed doses) and 78.6 (real consumption). A total of 7 diabetics (12%) had unused expired recipients. The prevalence of insulin treated DM in Tarragona was estimated as around 4.3-4.8/1,000 (2,360-2,635 inhabitants). The expense of loss was 36 million pesetas/year; 6.4 as depreciated remnants of insulin in the bottom of recipients.

CONCLUSIONS

There is a great loss of insulin in clinical practice which may be avoidable and which influences the public health costs for diabetes. An adequate educative strategy and system of injection independent of user ability would reduce the costs.