Investigation of the effect of oral metformin on dipeptidylpeptidase-4 (DPP-4) activity in Type 2 diabetes

AIMS

Glucagon-like peptide-1 (GLP-1) is an insulinotropic hormone and major component of the enteroinsular axis. Its therapeutic potential in human diabetes is limited by rapid degradation and inactivation by the enzyme dipeptidylpeptidase-4 (DPP-4). We investigated the acute effects of metformin with and without food on DPP-4 activity in Type 2 diabetes.

METHODS

Ten subjects with Type 2 diabetes (6 male/4 female, age 65.8 +/- 2.6 years, body mass index 30.0 +/- 1.2 kg/m2, glycated haemoglobin (HbA(1c)) 6.3 +/- 0.2%, mean +/- SEM) received metformin 1 g orally or placebo together with a standard mixed meal (SMM) in a random crossover design. Six subjects re-attended fasting and received metformin 1 g without a SMM.

RESULTS

Following SMM (n = 10), DPP-4 activity was not suppressed by metformin compared with placebo [area under curve (AUC)(0-4 h) 1574 +/- 4 vs. 1581 +/- 8 micromol/ml/min, respectively]. Plasma glucose, insulin and active GLP-1 were not different. However, DPP-4 activity was suppressed with metformin following fasting compared with a SMM (n = 6) (AUC(0-4 h) 1578 +/- 4 vs. 1494 +/- 9 micromol/min, P < 0.02). Metformin serum levels were significantly lower (P < 0.001) after SMM than fasting (AUC(0-4 h) 350 +/- 66 vs. 457 +/- 55 mg/ml/min).

CONCLUSION

Metformin inhibits DPP-4 activity in Type 2 diabetic patients in the fasting state but not when taken with a standard mixed meal. Metformin serum concentrations are lower if the drug is taken with food. These findings should be taken into account in establishing how to maximize efficacy of the drug.

The plasma protease inhibitor system (Pi) of Standardbred horses

The plasma protease inhibitor system (Pi) of Standardbred horses was studied by thin-layer, high-voltage, acid polyacrylamide gel electrophoresis (pH 4.6) followed by protein staining and staining for trypsin and chymotrypsin inhibition. In addition to the eight Thoroughbred alleles (PiF, G, I, L, N, S1, S2, U), another 10 alleles, designated PiH, J, K, O, P, Q, R, V, X, Z, were postulated to account for the 98 Pi types which were observed in Standardbreds. Detailed inhibitory spectra of the 'new' alleles were determined and further exceptions to the Pi1, Pi2 classification of Juneja et al. (1979) were found. Limited family data demonstrated the genetic nature of the 'new' variants and confirmed the allelic inheritance of the 'new' Pi variants.

Rationale and design of CAPITA: a RCT of 13-valent conjugated pneumococcal vaccine efficacy among older adults

The burden of community-acquired pneumonia (CAP) among the elderly is high and has increased over the last decades. Streptococcus pneumoniae is the most common cause of CAP and in 10% the infection may be fatal. Although the 23-valent polysaccharide pneumococcal vaccine (23vPS) is considered effective in the prevention of invasive pneumococcal disease in the elderly population, the evidence is mainly from nonrandomised observational studies and effects on the occurrence of pneumonia have not been demonstrated. Conjugated pneumococcal vaccines which also stimulate T-cell dependent immune responses induced antibody responses in elderly persons which are similar to those induced by a primary series of 7-valent conjugated pneumococcal vaccine (7vPnC) in infants, and the response appeared similar or superior for all vaccine serotypes to that induced by 23vPS. The primary objective of the planned trial entitled CAPITA (Community Acquired Pneumonia Immunization Trial in Adults) is to establish the efficacy of a 13-valent PnC vaccine in the prevention of a first episode of vaccine-serotype specific pneumococcal CAP in 85,000 community-dwelling adult persons aged 65 years and older. This is a parallel group, randomised, placebo-controlled trial, with a 1:1 random allocation to vaccine or placebo vaccine. The occurrence of the primary outcome of vaccine-serotype specific (VT)-CAP will be established in hospitals on the basis of three sets of criteria: (1) a clinical definition of CAP; (2) independent interpretation of chest radiograph consistent with pneumonia: and (3) determination of S. pneumonia serotype. the trial will be critical to determine the position of conjugate pneumococcal vaccines in the prevention of pneumococcal disease.

Targeting invasion and egress: from tools to drugs?

A recent resurgence in the use of compounds to study essential biological processes raises important questions concerning the link between fundamental research and drug development. This article discusses many of the issues involved, in the context of host cell invasion and egress by parasites of the Phylum Apicomplexa. In addition, an overview of the key steps in invasion and egress is provided with a particular emphasis on potential parasite protein drug targets.

The nutritional vulnerability of older Guyanese in residential homes

OBJECTIVE

To assess the nutritional status, functional ability and food intake of older Guyanese in residential care.

METHODS

Eighty-four residents of one public and two private homes underwent an anthropometric and functional ability assessment including height, weight, armspan, arm and calf circumferences and handgrip strength. Food intake in two private homes was measured over seven days by direct weighing and the use of consumption units.

RESULTS

The overall prevalence of underweight was 26.2% and of overweight was 17.8% but the prevalence of underweight was higher in the public home (29.3% underweight and 17.2% overweight in the public home, and 19.2% underweight and 19.2% overweight in the private home). Mean handgrip strength was 26 kg in males and 17.7 kg in females. The nutritional adequacy of the diet provided by one of the homes was poor with the food providing less than 50% of the required amount of zinc and vitamins A, D and C. Neither home met the requirement for energy.

CONCLUSION

A high prevalence of malnutrition exists in a public home for the elderly and, to a lesser degree, in two private homes. In the context of a rapidly ageing population and tight financial constraints, the challenge of providing an adequate diet must be given priority.

Phase II study of FK228 in patients with hormone refractory prostate cancer (HRPC)

14554

Background: FK228 is a bicyclic depsipeptide that inhibits histone deacetylase (HDAC). HDAC inhibition results in accumulation of hyperacetylated histone proteins resulting in G1 and G2/M arrest, differentiation of transformed cells and apoptosis. FK228 can also inhibit HSP90, ablating androgen receptor expression. Methods: FK228 was administered intravenously at 13mg/m2 on days 1, 8 and 15 of a 28-day schedule for up to 6 cycles. Sixteen patients were treated in stage 1. If ≥ 1 response was seen, an additional 9 patients were to be recruited. Eligibility criteria included: no prior chemotherapy, metastatic disease, ≤3 lines of hormonal therapy, QTcB <500 msec, Karnofsky PS ≥80. The primary endpoint was to measure rate of disease control (complete response [CR], partial response [PR], stable disease [SD] for 6 months). Secondary endpoints were PSA response rate, time to PSA and objective disease progression, safety profile, effect on disease related symptoms and pharmacokinetics (PK) of FK228. Results: Interim results are available after 16 patients were enrolled in stage 1 and 5 patients in stage 2. Median age (n = 21): 65 years (range 43–77). 3 patients have completed 6 cycles of treatment, 4 are ongoing and 14 have discontinued. 16 patients are evaluable for radiological response and 18 for PSA response: 1 has achieved a confirmed radiological PR (6 months [m]), and 6 have confirmed SD (2 for 6m, 1 for 5 m, 1 for 4 m+, 1 for 3 m+). 2 of 18 have had a 50% fall in PSA (6 m, 4 m+) and another a 40% fall (5m). Most common drug related adverse events are (grade [gr],%): fatigue (gr 1–2, 88%), nausea (gr 1–2, 77%; gr 3, 10%), anorexia (gr 1–2, 72%), vomiting (gr 1–2, 55%; gr 3, 10%), non-specific asymptomatic ECG changes (gr 1–3, 44%), diarrhoea (gr 1–2, 38%), thrombocytopaenia (gr 1–2, 33%) and weight loss (gr 1, 20%). Conclusions: Interim results of treatment with FK228 suggest clinically relevant antitumor activity with an 18% disease control rate and a 11% PSA response rate. Toxicity is manageable. Accrual into the study continues.

[Table: see text]

Detrimental actions of metabolic syndrome risk factor, homocysteine, on pancreatic beta-cell glucose metabolism and insulin secretion

Elevated plasma homocysteine has been reported in individuals with diseases of the metabolic syndrome including vascular disease and insulin resistance. As homocysteine exerts detrimental effects on endothelial and neuronal cells, this study investigated effects of acute homocysteine exposure on beta-cell function and insulin secretion using clonal BRIN-BD11 beta-cells. Acute insulin release studies in the presence of various test reagents were performed using monolayers of BRIN-BD11 cells and samples assayed by insulin radioimmunoassay. Cellular glucose metabolism was assessed by nuclear magnetic resonance (NMR) analysis following 60-min exposure of BRIN-BD11 cell monolayers to glucose in either the absence or presence of homocysteine. Homocysteine dose-dependently inhibited insulin release at moderate and stimulatory glucose concentrations. This inhibitory effect was reversible at all but the highest concentration of homocysteine. 13C-glucose NMR demonstrated decreased labelling of glutamate from glucose at positions C2, C3 and C4, indicating that the tricarboxylic acid (TCA) cycle-dependent glucose metabolism was reduced in the presence of homocysteine. Homocysteine also dose-dependently inhibited insulinotropic responses to a range of glucose-dependent secretagogues including nutrients (alanine, arginine, 2-ketoisocaproate), hormones (glucagon-like peptide-1 (7-36)amide, gastric inhibitory polypeptide and cholecystokinin-8), neurotransmitter (carbachol), drug (tolbutamide) as well as a depolarising concentration of KCl or elevated Ca2+. Insulin secretion induced by activation of adenylate cyclase and protein kinase C pathways with forskolin and phorbol 12-myristate 13-acetate were also inhibited by homocysteine. These effects were not associated with any adverse action on cellular insulin content or cell viability, and there was no increase in apoptosis/necrosis following exposure to homocysteine. These data indicate that homocysteine impairs insulin secretion through alterations in beta-cell glucose metabolism and generation of key stimulus-secretion coupling factors. The participation of homocysteine in possible beta-cell demise merits further investigation.

Paclitaxel for anthracycline-resistant AIDS-related Kaposi's sarcoma: clinical and angiogenic correlations

BACKGROUND

Murine data indicate that angiogenesis is central to the aetiopathogenesis of Kaposi's sarcoma (KS). Therefore, we measured angiogenic cytokines and growth factors in patients with AIDS-related KS during treatment with both antiretrovirals and second-line paclitaxel chemotherapy. Cytokines measured included tumour necrosis factor-alpha (TNF-alpha), basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF) and the interleukins IL-2, -6 and -12.

PATIENTS AND METHODS

Enzyme-linked immunosorbent assays (ELISAs) were carried out to measure plasma cytokine levels in 17 patients with AIDS-related KS who had progressed within 6 months of receiving liposomal anthracyclines and were treated with paclitaxel 100 mg/m(2) every 2 weeks. Measurements were carried out before progression, at commencement and at the completion of paclitaxel.

RESULTS

The objective response rate to paclitaxel was 71% (95% confidence interval 60% to 81%). In 17 patients with AIDS-related KS, we observed eight partial responses and four complete responses. Patients with AIDS Clinical Trial Group stage T1 disease had higher plasma VEGF (P = 0.05) and lower plasma TNF-alpha levels (P = 0.05) than patients with earlier stage T0 KS. There were no correlations between plasma cytokines (bFGF, VEGF, TNF-alpha, and IL-2,-6 and -12) and the CD4 and CD8 cell counts or HIV-1 RNA viral load. Response to paclitaxel was associated with a fall in plasma IL-6 levels (P = 0.04) but no change in other cytokines. There were no significant changes in CD4, CD8, CD16/56, CD19 cell counts and HIV-1 viral loads during chemotherapy.

CONCLUSIONS

Angiogenic cytokines may correlate with KS disease extent but not with cellular immune function or HIV viraemia. Response to paclitaxel therapy correlates with a fall in plasma IL-6 levels and recent data indicate this may be a surrogate marker of KS-associated herpesvirus viral load. Overall, clinical response in KS correlates poorly with known angiogenic cytokines.

Analysis of full-length HIV type 1 env genes indicates differences between the virus infecting T cells and dendritic cells in peripheral blood of infected patients

Dendritic cells (DC) are targets for HIV-1 infection and may harbor distinct populations of virus variants. To test this hypothesis full length env genes have been amplified and sequenced from DC and T cells purified from the blood of five symptomatic HIV-1-infected patients. For three of the patients, showing slow and slow/standard disease progression, distinct subsets of HIV variants infected DC and T cells, and the diversity of the DC-derived env genes was less than that observed in T cells. Amino acid substitutions differentiating DC and T cell variants were dispersed throughout the length of the glycoproteins and were patient/HIV-1 strain specific. However, the V1 and V2 domains of T cell-derived clones were generally shorter than those from DC. These findings suggest that there may be distinct populations of HIV-1 variants infecting blood DC and T cells in patients showing slow and slow/standard disease progression.

Idiopathic recurrent stupor: a warning

A proposal that an endogenous benzodiazepine-like agent named endozepine-4 might be responsible for presentations of recurrent stupor has gained wide acceptance. A case of recurrent stupor over two decades is presented with many similarities to previous cases of "endozepine stupor". This case, however, was caused by exogenous benzodiazepine administration and serves as a warning to clinicians to beware of this diagnosis.

Model-Based Inference of Recombination Hotspots in a Highly, Variable Oncogene

An emergent problem in the study of pathogen evolution is our ability to determine the extent to which their rapidly evolving genomes recombine. Such information is necessary and essential for locating pathogenicity loci using association studies, and it also directs future screening, therapeutic and vaccination strategies. Recombination also complicates the use of phylogenetic approaches to infer evolutionary parameters including selection pressures. Reliable methods that identify the presence of regions of recombination are therefore vital. We illustrate the use of an integrated model-based approach to inferring recombination structure using all available sequences of the highly variable, transforming Kaposi's sarcoma-associated herpesviral gene, ORF-K1. This technique learns the parameters of a statistical model that takes recombination hotspots, population genetic effects, and variable rates of mutation into account. As there are no known mechanisms to explain the high mutation rate in this DNA viral gene, recombination may account for some of the variability observed. We infer recombination hotspots in conserved sites such as the tyrosine kinase signaling motif, referred to here as recombination drift, as well as in nonconserved sites, a process described as recombination shift.

Radiation after mastectomy in high-risk patients: is it necessary?

A retrospective review of cases from 1988 through 1992 was performed examining high-risk breast cancer patients treated with modified radical mastectomy without postoperative radiation at a single institution. Locoregional recurrence, distant metastases, overall survival, and number of lymph nodes removed were examined. This was compared with recent Danish and Canadian studies. Thirty-three premenopausal node-positive breast cancer patients had a 9 per cent locoregional recurrence rate. In the Danish and Canadian studies the locoregional recurrence rates were 32 and 21 per cent. These were reduced to 9 per cent and 10 per cent respectively in the radiated arms. Our locoregional recurrence in nonradiated patients was similar to that in the radiated arms of the studies and improved when compared with recurrence in their non-radiated controls. The adequacy of the axillary lymph node dissection was examined. In the current study a median of 18 lymph nodes were recovered with only 3 per cent containing less than 12 nodes. In the Danish study a median of seven lymph nodes were removed. Similarly in the Canadian trial a median of 11 nodes were removed. With complete axillary dissection results equivalent to those of postoperative adjuvant radiation is achieved. Further randomized controlled studies with standard axillary dissections are needed before the recommendation of routine postoperative radiotherapy.

Evaluation of the cervical cytobrush sampling technique for the preparation of CD45+ mononuclear cells from the human cervix

A cytobrush technique developed to prepare mononuclear cells from the intraepithelial layer of the endocervix has been evaluated. Specimens yielded approximately 4-6x10(6) cells, of which 10-15% were CD45+. Between 10% and 15% of these CD45+ cells were mononuclear leukocytes. The non-leukocyte cell fraction exhibited high levels of autofluorescence and for flow cytometry analysis, it was necessary to exclude these cells by gating. Macrophages constituted approximately 60% and T lymphocytes, 40% of the mononuclear cells in cytobrush samples. The CD4/CD8 T-cell ratio was similar to that observed in blood. In 9 of 13 specimens, B lymphocytes constituted less than 1% of the mononuclear cell fraction suggesting that the mononuclear cells were derived from the intraepithelial compartment rather then the deeper lamina propria. Lack of B lymphocytes also indicates minimal blood contamination in these samples, a conclusion supported by labelling for the red blood cell (RBC) glycoprotein glycophorin A. However, the need to monitor all samples for possible blood contamination was indicated by 4 of 13 samples in which B lymphocytes accounted for 2-8% of the mononuclear cells.

Loss of blood CD11c(+) myeloid and CD11c(-) plasmacytoid dendritic cells in patients with HIV-1 infection correlates with HIV-1 RNA virus load

Human blood contains at least 2 subpopulations of antigen-presenting dendritic cells (DCs) that can be differentiated by their expression of CD11c. Myeloid DCs (myDCs), which are CD11c(+), trap invading pathogens in the tissues and then migrate to lymphoid tissues where they stimulate pathogen-specific T-cell responses. Plasmacytoid DCs (pcDCs), which are CD11c(-), secrete interferon-alpha in response to viral infections. This study reports that in HIV-1 infection there is a progressive depletion of both these DC populations and that this correlates with an increasing HIV-1 plasma virus load. The median numbers of myDCs and pcDCs were 6978/mL and 9299/mL, respectively, in healthy male controls and 2298/mL and 1640/mL, respectively, in patients with more than 10(5) HIV-1 RNA copies/mL. Both DC populations expressed CD4, CCR5, and CXCR4. The findings suggest that loss of DCs in HIV infection may contribute to disease progression.

Higher levels of activation markers and chemokine receptors on T lymphocytes in the cervix than peripheral blood of normal healthy women

Heterosexual transmission of human immunodeficiency virus (HIV-1) is the predominant mode of infection world-wide. To better understand sexual transmission of HIV-1 in women we have analysed virus co-receptor and cellular activation marker expression on T lymphocyte subsets from the cervical epithelium and have made comparisons with peripheral blood T cells. Intraepithelial cervical T lymphocytes were obtained with a cytobrush, immunolabelled and analysed by flow cytometry. Activation markers (CD69, CD25 and HLA-DR) were found to be more highly expressed on cervical than on blood T lymphocytes. These higher levels of activation on cervical T lymphocyte subsets could facilitate HIV-1 infection. CXCR4 was expressed at marginally higher levels than CCR5 on T cells from the cervical epithelium and peripheral blood. Thus, the preferential transmission of macrophage tropic strains of HIV-1 following sexual contact cannot be explained solely on the expression of chemokine co-receptors by T lymphocyte subsets.

Macrophages are increased in cervical epithelium of women with cervicitis

BACKGROUND

Sexually transmitted diseases (STIs) are major causes of morbidity in women. The mechanisms involved in establishment of genital mucosal infection are poorly defined.

OBJECTIVE

To investigate changes in cervical epithelial (CE) CD45+ cell subpopulations in women with microscopic evidence of cervicitis (n=9) and those without (n=12).

METHODS

CE samples were obtained using cytobrush including matched venous blood. CE and peripheral blood (PB) mononuclear cells were analysed by flow cytometry for CD3+, CD4+, CD8+, CD14+,CD19+, and HLA-DR+ expression.

RESULTS

Women with cervicitis had increased CE macrophages compared with those without (p<0.05). MHC class II+ cells were predominant in all cervical samples. Considerably fewer B lymphocytes were found in cervical samples in both groups of women. No changes were observed in cervical T lymphocyte subsets. However, a relative CD8+ lymphocytosis in PB was noted in women with cervicitis.

CONCLUSION

The increased numbers of CE macrophages in women with cervicitis may have important implications for pathogenesis of STIs including human immunodeficiency virus infection.

Comparative loss and maturation of peripheral blood dendritic cell subpopulations in African and non-African HIV-1-infected patients

OBJECTIVES

To quantify the percentage of the two major subpopulations of blood dendritic cells (DC) in HIV-1-seropositive Ugandan individuals infected with non-clade B viruses and compare this with that seen in clade B HIV-1 infected non-African individuals. DC maturation/activation status was also investigated via the expression of CD86.

METHODS

The percentage of blood DC was quantified by using flow cytometry. DC were identified as the lineage (CD3, CD14, CD16, CD19, CD20, CD56)-negative, HLA-DR-positive population and the two major subpopulations were differentiated by CD11c expression.

RESULTS

The percentage of blood DC was reduced significantly in HIV-1-seropositive African individuals when compared with controls (0.21 and 0.39% respectively). A similar reduction was also seen in non-African patients residing in the UK (0.19% compared with 0.36% for controls). However, there was no selective loss in either CD11c-positive or CD11c-negative subpopulations. The percentage of blood DC expressing CD86 was significantly greater in HIV-1-seropositive individuals when compared with controls and the increased expression was largely confined to CD11c-negative DC.

CONCLUSIONS

Africans infected with non-clade B HIV-1 showed similar reductions in the percentage of blood DC to non-Africans infected with clade B viruses. There was no selective loss of either DC subpopulation, suggesting that the ability of DC to acquire and present antigens or to produce interferon-alpha may both be impaired in HIV-1 infection.

Plasmacytoid dendritic cells are highly susceptible to human immunodeficiency virus type 1 infection and release infectious virus

Plasmacytoid dendritic cells (pcDC) and myeloid dendritic cells (myDC) are shown to express CD4 and low levels of CCR5 and CXCR4, but only myDC express DC SIGN, a C-type lectin that binds human immunodeficiency virus but does not mediate virus entry. Both DC types were more susceptible to infection with a macrophage than a lymphotropic strain of human immunodeficiency virus type 1, but pcDC were more readily infected than myDC.

Easy-to-implement Bayesian methods for dose-escalation studies in healthy volunteers

In phase I clinical trials, experimental drugs are administered to healthy volunteers in order to establish their safety and to explore the relationship between the dose taken and the concentration found in plasma. Each volunteer receives a series of increasing single doses. In this paper a Bayesian decision procedure is developed for choosing the doses to give in the next round of the study, taking into account both prior information and the responses observed so far. The procedure seeks the optimal doses for learning about the dose-concentration relationship, subject to a constraint which reduces the risk of administering dangerously high doses. Individual volunteers receive more than one dose, and the pharmacokinetic responses observed are, after logarithmic transformation, treated as approximately normally distributed. Thus data analysis can be achieved by fitting linear mixed models. By expressing prior information as 'pseudo-data', and by maximizing over posterior distributions rather than taking expectations, a procedure which can be implemented using standard mixed model software is derived. Comparisons are made with existing approaches to the conduct of these studies, and the new method is illustrated using real and simulated data.To whom correspondence should be addressed.

Relationship between V3 sequences of HIV type 1 from plasma, T cells, and dendritic cells suggests that plasma virus may arise from different cell sources

Nucleotide sequences of HIV-1 from plasma virus RNA and proviral DNA extracted from blood dendritic cells (DCs) and from T cells were analyzed to determine whether blood DCs may harbor a restricted population of virus variants. The sequence of the V3 loop and 51 bases from the 3' flanking region were determined in four patients not receiving antiviral therapy. There was no evidence of a unique or more restricted population of variants in DCs for any of the four patients studied. However, for one patient there was evidence of differences between plasma virus and virus in the T cell population, with virus in the plasma showing a closer relationship to DC-derived sequences.

Purification of dendritic cells from peripheral blood

It is well established that dendritic cells (DC) exhibit different phenotypes and functions as they progress down the developmental pathway toward interdigitating DC that stimulate T cells in the secondary lymphoid tissue (1). In the blood, two populations of DC can be identified based on the expression of the β-intergrin, CD1 1c. For most individuals, the proportion of DC that are CD1 1c(+) ranges from 30% to 70%. The CD11c(-) population was originally proposed to be the precursor of the CD1 1c(+)cells, but there is now good evidence that they constitute a distinct population of DC that have a separate developmental pathway (2 ,3). The CD11c(+)blood DC give rise to the Langerhans cells located in the epidermal layers of the skin and mucosal tissue, where their function is to capture and process antigens from invading pathogens for presentation. Dermal and interstitial DC are also derived from CD1 1c(+)blood DC. CD1 1c- DC, on the other hand, are thought to migrate directly to secondary lymphoid tissue and not to take up residence in the tissues. CD11c(+)and CD11c(-) DC were claimed to stimulate Th1 and Th2 types of immune responses, respectively, and hence were termed DC1 and DC2 (2). However, other reports suggest that both cell populations can stimulate Th1 and Th2 responses (4). The role of the CD11c(-) DC is currently unclear but they are potent producers of interferon-α (4,5) and could therefore be important in antiviral immunity. Elucidating the function of these cells and comparing them with the CD1 1c(+)population will be a major aim of DC research groups in the future. There is thus a need for techniques to purify these two cell populations.

Microfluorometric analysis of Cl- permeability and its relation to oscillatory Ca2+ signalling in glucose-stimulated pancreatic beta-cells

The cytoplasmic concentrations of Cl-([Cl-]i) and Ca2+ ([Ca2+]i) were measured with the fluorescent indicators N-(ethoxycarbonylmethyl)-6-methoxyquinilinum bromide (MQAE) and fura-2 in pancreatic beta-cells isolated from ob/ob mice. Steady-state [Cl-]i in unstimulated beta-cells was 34 mM, which is higher than expected from a passive distribution. Increase of the glucose concentration from 3 to 20 mM resulted in an accelerated entry of Cl- into beta-cells depleted of this ion. The exposure to 20 mM glucose did not affect steady-state [Cl-]i either in the absence or presence of furosemide inhibition of Na+, K+, 2 Cl- co-transport. Glucose-induced oscillations of [Ca2+]i were transformed into sustained elevation in the presence of 4,4' diisothiocyanato-dihydrostilbene-2,2'-disulfonic acid (H2DIDS). A similar effect was noted when replacing 25% of extracellular Cl- with the more easily permeating anions SCN-, I-, NO3- or Br-. It is concluded that glucose stimulation of the beta-cells is coupled to an increase in their Cl- permeability and that the oscillatory Ca2+ signalling is critically dependent on transmembrane Cl- fluxes.

Rosiglitazone does not affect the steady-state pharmacokinetics of digoxin

Rosiglitazone is a potent insulin-sensitizing oral hypoglycemic agent of the thiazolidinedione class that works through activation of the peroxisome proliferator-activated receptor-gamma (PPAR-gamma) nuclear receptor and improves glycemic control in patients with non-insulin-dependent diabetes mellitus. The potential for a drug-drug interaction with oral digoxin was investigated. Subjects received both of the study regimens in a random sequence: digoxin 0.375 mg plus matching placebo for rosiglitazone orally each morning for 14 days or digoxin 0.375 mg plus 8 mg rosiglitazone orally each morning for 14 days. There was a 14-day washout period between sessions. Blood and urine were collected over 24 hours beginning on the morning of day 14 for measurement of digoxin concentrations. An equivalence statistical approach was used, with rosiglitazone considered to have no effect on the pharmacokinetics of digoxin if the 90% confidence interval (CI) for the ratio of digoxin plus rosiglitazone relative to digoxin plus placebo was completely contained within the range (0.80, 1.25) for the primary end points, AUC(0-24), and C24. Digoxin AUC(0-24) and C24 values were similar for digoxin 0.375 mg plus matching placebo (18.5 ng.h/mL and 0.579 ng/mL, respectively) and digoxin 0.375 mg plus rosiglitazone (19.1 ng.h/mL and 0.594 ng/mL, respectively). Point estimates were 1.05 (90% CI: 1.01, 1.10) for AUC(0-24) and 1.04 (90% CI: 0.98, 1.11) for C24. Oral and renal clearance were also similar between regimens. Digoxin alone or in combination with rosiglitazone was safe and well tolerated. The most common adverse experience was headache. Coadministration of digoxin with rosiglitazone had no significant effect on the safety or steady-state pharmacokinetics of digoxin.

The effect of celecoxib, a cyclooxygenase-2 inhibitor, in familial adenomatous polyposis

BACKGROUND

Patients with familial adenomatous polyposis have a nearly 100 percent risk of colorectal cancer. In this disease, the chemopreventive effects of nonsteroidal antiinflammatory drugs may be related to their inhibition of cyclooxygenase-2.

METHODS

We studied the effect of celecoxib, a selective cyclooxygenase-2 inhibitor, on colorectal polyps in patients with familial adenomatous polyposis. In a double-blind, placebo-controlled study, we randomly assigned 77 patients to treatment with celecoxib (100 or 400 mg twice daily) or placebo for six months. Patients underwent endoscopy at the beginning and end of the study. We determined the number and size of polyps from photographs and videotapes; the response to treatment was expressed as the mean percent change from base line.

RESULTS

At base line, the mean (+/-SD) number of polyps in focal areas where polyps were counted was 15.5+/-13.4 in the 15 patients assigned to placebo, 11.5+/-8.5 in the 32 patients assigned to 100 mg of celecoxib twice a day, and 12.3+/-8.2 in the 30 patients assigned to 400 mg of celecoxib twice a day (P=0.66 for the comparison among groups). After six months, the patients receiving 400 mg of celecoxib twice a day had a 28.0 percent reduction in the mean number of colorectal polyps (P=0.003 for the comparison with placebo) and a 30.7 percent reduction in the polyp burden (the sum of polyp diameters) (P=0.001), as compared with reductions of 4.5 and 4.9 percent, respectively, in the placebo group. The improvement in the extent of colorectal polyposis in the group receiving 400 mg twice a day was confirmed by a panel of endoscopists who reviewed the videotapes. The reductions in the group receiving 100 mg of celecoxib twice a day were 11.9 percent (P=0.33 for the comparison with placebo) and 14.6 percent (P=0.09), respectively. The incidence of adverse events was similar among the groups.

CONCLUSIONS

In patients with familial adenomatous polyposis, six months of twice-daily treatment with 400 mg of celecoxib, a cyclooxygenase-2 inhibitor, leads to a significant reduction in the number of colorectal polyps.

Phase variable switching of in vivo and environmental phenotypes of Salmonella typhimurium

Previously it was shown that S. typhimurium strain 798, which is known to cause persistent asymptomatic infections in pigs, exists in two phenotypes. One phenotype, which is called adhesive, was shown to produce pili, is adhesive to porcine enterocytes, is readily phagocytized, and then survives intracellularly in phagocytes. The other phenotype, termed non-adhesive, does not produce pili, does not attach to enterocytes, is phagocytized less efficiently, and does not survive within the phagocyte. Cells in each phenotype can freely switch to the other phenotype at a fairly high frequency and thus the shift between each phenotype is phase variation. Further analysis of these phenotypes identified 4 additional characteristics that were co-regulated by phase variation. The first is the enterocyte-specific adhesin, which was shown to be type 1 fimbriae. Mutations in fimA, the major pilin molecule, led to a decreased ability to colonize the gut of pigs and mice. The second characteristic is O-antigen production. Adhesive cells produce a long O-antigen (up to 18 subunits) while non-adhesive cells do not (only 1-2 subunits). The long O-antigen produced by the adhesive cells leads to resistance to serum and appears to be the result of phase variable expression of rfaL. A third locus, ebu, has been identified based on differential color production of colonies growing on Evans blue-Uranine plates. The relationship of this trait to in vivo survival or virulence is not known but ebu is genetically related to a family of transcriptional activators. The fourth locus, prv is located on the virulence plasmid and a mutation in prv results in delayed time to death in mice. It is hypothesized that the adhesive phenotype is the in vivo, virulent form, while the non-adhesive phenotype is the environmental, avirulent form. By modulating the fraction of cells in each phase, persistent asymptomatic infections can be promoted.

Unifying organizational approaches to measuring and managing patient outcomes

Information about patient outcomes is increasingly available to guide consumers in their selection of healthcare. By unifying the traditionally separate programs of performance improvement, case management, and research, nurse executives can take control of care processes and outcomes. This article provides four case examples of patient care improvements achieved using performance improvement, case management, and research approaches. The use of the technologies outlined in the Johnson and Nolan article in this issue, "A Guide to Choosing Technology to Support the Measurement of Patient Outcomes", also is described.

Rosiglitazone has no clinically significant effect on nifedipine pharmacokinetics

To examine the effects of repeat oral dosing of rosiglitazone on the pharmacokinetics of nifedipine, a prototype CYP3A4 substrate, a randomized, open-label, crossover study was performed with two treatment phases separated by a washout period of at least 14 days. Twenty-eight healthy male volunteers received either a single 20 mg oral nifedipine dose or rosiglitazone 8 mg orally once daily for 14 days with a single 20 mg oral nifedipine dose administered on day 14. Plasma nifedipine concentrations were determined over the 24-hour period following administration of the nifedipine doses. Lack of effect was defined as the demonstration that the 90% CI was contained entirely within a symmetrical 30% range either side of unity on the loge-scale. Following rosiglitazone + nifedipine administration, the area under the nifedipine concentration-time curve from time zero to infinity (AUC(0-infinity)) was 13% lower than that after administration of nifedipine alone. This difference in nifedipine AUC(0-infinity) was not deemed to be clinically significant since the 90% CI was contained within the protocol-defined 30% range (point estimate for ratio of geometric means 0.87; 90% CI: 0.79, 0.96). Rosiglitazone had no marked effect on nifedipine peak plasma concentration (point estimate: 0.99; 90% CI: 0.73, 1.34) or time to peak concentration compared with nifedipine alone. Rosiglitazone coadministration produced a small decrease in the mean nifedipine half-life (point estimate: -0.77; 90% CI: mean difference -1.29 h, -0.25 h). Both treatment regimens were well tolerated and associated with a favorable safety profile. Rosiglitazone, at the highest dose used in clinical studies, produced a small, clinically insignificant decrease in nifedipine exposure. The very small effect on nifedipine pharmacokinetics suggests that rosiglitazone is an extremely weak inducer of CYP3A4, a characteristic that distinguishes rosiglitazone from troglitazone.

A novel Bayesian decision procedure for early-phase dose-finding studies

Phase I first-in-man studies in normal, healthy volunteers are performed to define a maximum safe dose and to identify a range of acceptable doses for later drug development studies in patients. Analysis of pharmacokinetic and pharmacodynamic data using mixed-effects modeling can be used to fit an overall dose-response relationship. By expressing prior information as pseudodata, the same methodology can be used to perform a Bayesian analysis and to determine posterior modal estimates for the model parameters. Decision theory can then be applied to maximize a chosen gain function, utilizing real-time data capture for choosing safe doses in a way that will provide more informative responses, thus accelerating study completion. The methodology is introduced elsewhere (1). The purpose of this paper is to describe software currently in development and to illustrate the method using an example from a recent study.

Human peripheral blood contains two distinct lineages of dendritic cells

Human peripheral blood contains two populations of dendritic cells (DC) but their developmental relationship has not been established. Freshly isolated CD11c- DC possessed a lymphoid morphology, lacked myeloid markers but expressed lymphoid markers (CD4+ CD10+) whilst the CD11c+ DC were monocytoid in appearance and expressed myeloid markers. Although both populations were allostimulatory, only the CD11c+ DC were able to take up antigen. Irrespective of the culture conditions the CD11c- cells developed into CD11c- CD13- CD33- CD4+ CD1a- CD83+/- DC. In contrast, cultured CD11c+ cells developed the phenotype CD11c+ CD13+ CD33+/- CD4- CD1a+ CD83+ CD9+. Only the CD11c+ DC expressed macrophage colony-stimulating factor (M-CSF) receptor and gave rise to CD14+, esterase+, phagocytic macrophages when cultured in M-CSF. These data suggest that these two populations of DC represent distinct lineages of antigen-presenting DC.

Human peripheral blood contains two distinct lineages of dendritic cells

Human peripheral blood contains two populations of dendritic cells (DC) but their developmental relationship has not been established. Freshly isolated CD11c- DC possessed a lymphoid morphology, lacked myeloid markers but expressed lymphoid markers (CD4+ CD10+) whilst the CD11c+ DC were monocytoid in appearance and expressed myeloid markers. Although both populations were allostimulatory, only the CD11c+ DC were able to take up antigen. Irrespective of the culture conditions the CD11c- cells developed into CD11c- CD13- CD33- CD4+ CD1a- CD83+/- DC. In contrast, cultured CD11c+ cells developed the phenotype CD11c+ CD13+ CD33+/- CD4- CD1a+ CD83+ CD9+. Only the CD11c+ DC expressed macrophage colony-stimulating factor (M-CSF) receptor and gave rise to CD14+, esterase+, phagocytic macrophages when cultured in M-CSF. These data suggest that these two populations of DC represent distinct lineages of antigen-presenting DC.

Human peripheral blood contains two distinct lineages of dendritic cells

Human peripheral blood contains two populations of dendritic cells (DC) but their developmental relationship has not been established. Freshly isolated CD11c- DC possessed a lymphoid morphology, lacked myeloid markers but expressed lymphoid markers (CD4+ CD10+) whilst the CD11c+ DC were monocytoid in appearance and expressed myeloid markers. Although both populations were allostimulatory, only the CD11c+ DC were able to take up antigen. Irrespective of the culture conditions the CD11c- cells developed into CD11c- CD13- CD33- CD4+ CD1a- CD83+/- DC. In contrast, cultured CD11c+ cells developed the phenotype CD11c+ CD13+ CD33+/- CD4- CD1a+ CD83+ CD9+. Only the CD11c+ DC expressed macrophage colony-stimulating factor (M-CSF) receptor and gave rise to CD14+, esterase+, phagocytic macrophages when cultured in M-CSF. These data suggest that these two populations of DC represent distinct lineages of antigen-presenting DC.

Intratester and intertester reliability of goniometric measurement of passive lateral shoulder rotation

Measurement of lateral rotation range of motion (ROM) is frequently performed during shoulder evaluation. The purpose of this study was to determine the intratester and intertester reliability of goniometric measurement of passive lateral rotation ROM of the shoulder. Two experienced PTs performed the testing in a randomized block design. They were blinded to all clinical information and to their goniometric readings. Passive lateral rotation ROM of the shoulder was assessed in 34 patients with a variety of shoulder pathologies. Patients were placed in the supine position with the arm abducted approximately 20 degrees to 30 degrees. A standard goniometer, placed along the joint axis by the therapist, was red by an independent assistant. Intraclass correlation coefficients (ICCs) and their associated 95% confidence intervals were calculated. Intratherapist ICCs (0.88 and 0.93) and intertherapist ICCs (0.85 and 0.80) were high. These findings suggest that reliable measures of passive lateral rotation ROM of the shoulder can be obtained from patients with shoulder pathology using standard goniometry and by placing the patient in a supine position.

Subpopulations of peripheral blood dendritic cells show differential susceptibility to infection with a lymphotropic strain of HIV-1

Blood dendritic cells (DC) express CD4 and are susceptible to HIV infection. By electron microscopy two morphologically distinct types of DC were identified in peripheral blood. Only one of these two types was susceptible to infection with a lymphotropic strain of HIV-1. By FACS two populations could be defined based on the expression of CD11c. The morphology of cultured FACS-purified CD11c negative DC was similar to that DC population shown to be susceptible to infection with the lymphotropic strain of HIV. Furthermore after several hours in culture CXCR4, the co-receptor for lymphotropic strains of HIV-1, was expressed at a significantly higher level on the CD11c negative DC than on the CD11c positive cells. This study suggests that there are subpopulations of DC that show differences in susceptibility to infection with some strains of HIV-1.

Dental screenings using telehealth technology: a pilot study

BACKGROUND

This pilot study compared data obtained using traditional methods of visual dental screenings in a school setting with data obtained using an intraoral camera and transmitted to a distant location via telehealth technology.

METHODS

For the study, 137 schoolchildren were screened using traditional methods. Two months later, 32 children were randomly selected and rescreened in a single day using the intraoral camera and the telehealth system. The measurement indices used were deft/DMFT.

RESULTS

A comparison revealed no significant difference in the data collected by the two screening methods. The percentage agreement between the methods ranged from 89% to 100%.

CONCLUSION

In under-serviced or remote areas, the telehealth system may allow for accurate identification of oral conditions and act as a means of consultation at a distance between specialists, general dental practitioners, dental hygienists and individual patients.

Idiopathic intracranial hypertension without papilledema: a case-control study in a headache center

OBJECTIVE

To compare the clinical features of patients with chronic daily headache (CDH) with idiopathic intracranial hypertension without papilledema (IIHWOP) to those with normal CSF pressure.

METHODS

A case-control study was conducted at a tertiary headache center. Cases consisted of 25 consecutive patients (24 women, 1 man, 38 +/- 6 years) with IIHWOP diagnosed between June 1989 and June 1996. IIHWOP was diagnosed if pressure was 200 mm CSF on two occasions and there was no papilledema. Control subjects consisted of patients with refractory CDH who had normal CSF pressure on lumbar puncture performed between June 1992 and June 1996 (n = 60, 50 women, 10 men, 36 +/- 11 years). A structured telephone follow-up was done from July 1996 to March 1997. Comparisons made between the two groups included demographics and headache profiles, both at the initial evaluation and at follow-up.

RESULTS

The initial headache characteristics did not differ between the two groups: most had transformed migraine with analgesic overuse. Significant predictors of IIHWOP included pulsatile tinnitus (odds ratio [OR] = 13.0) and obesity (OR = 4.4). Visual symptoms did not differ significantly. The prognosis of the two groups of patients was similar.

CONCLUSIONS

Pulsatile tinnitus and obesity suggest possible IIHWOP in patients with CDH. Treatment of patients with increased intracranial pressure was not satisfactory.

Increase in dendritic cell numbers, their function and the proportion uninfected during AZT therapy

The effects of AZT treatment on the numbers, level of infection and function of peripheral blood dendritic cells (DC) were examined in patients with HIV infection. This was a cross-sectional study of patients before AZT treatment and up to 20 months after initiation of treatment. Numbers of DC separated by density gradients were below the normal range in patients before treatment, but increased between 3 and 12 months of treatment. The numbers of DC per provirus copy rose from around 100 cells to 5000 cells and this decrease in viral load in DC was significant between 3 and 20 months of treatment. The capacity of DC to stimulate allogeneic T cell proliferation was low before treatment and significantly higher between 6 and 12 months after the start of AZT. This study indicated that AZT treatment produced beneficial effects on DC by increasing their numbers, reducing the provirus load and increasing their function in stimulating T cells. These results support the thesis that the function of these potent antigen-presenting cells is important in development of immunological defects in AIDS, and that effects of AZT treatment on DC may provide a measure of its therapeutic effect.

Analysis of human immunodeficiency virus type 1 (HIV-1) variants and levels of infection in dendritic and T cells from symptomatic HIV-1-infected patients

Dendritic cells (DC) are required to initiate primary cellular immune responses. Human immunodeficiency virus type 1 (HIV-1) infection of DC may be central to transmission and persistence of virus and in the pathogenesis of AIDS. In symptomatic HIV-1-infected patients the proportion of DC in the mononuclear cell population was reduced. Provirus load in the T cells was 3-100 times higher than in DC and there was no correlation between the levels of infection in the two cell types. Phylogenetic analysis of amino acids in the V3 loop and flanking regions indicated intermingling of sequences and thus provides the first evidence for transfer of virus between DC and T cells in vivo. In one of three patients analysed there were significant differences in amino acid residues in the V3 region. This may reflect reduced interactions between DC and T cells in infected individuals and for the existence of variants with a stronger tropism for DC, which could play a role in transmission by initiating infection in mucosal DC.

Effect of hepatic disease on the pharmacokinetics and plasma protein binding of eprosartan

STUDY OBJECTIVE

To evaluate the pharmacokinetics and plasma protein binding of eprosartan in hepatic disease.

DESIGN

Single-dose, parallel-group study.

SETTING

Oklahoma Foundation for Digestive Research, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.

PATIENTS

Eight healthy subjects with normal hepatic function and eight patients with hepatic disease.

INTERVENTION

All subjects received a single oral dose of eprosartan 100 mg.

MEASUREMENTS AND MAIN RESULTS

Eprosartan plasma concentrations were quantified by high-performance liquid chromatography; plasma protein binding was determined by ultrafiltration. Using analysis of variance, point estimates (PE) and 90% CIs were calculated. Total and unbound maximum concentrations and degree of plasma protein binding were similar for both groups. Total area under the plasma concentration-time curve (AUC0-t) was approximately 40% higher for the group with hepatic disease (PE 1.42, 90% CI 0.94-2.14). Similarly, unbound AUC0-t was approximately 50% higher (PE 1.53, 90% CI 0.98-2.39).

CONCLUSION

Eprosartan was safe and well tolerated by both groups. Based on the increase in AUC in patients with hepatic disease compared with those with normal hepatic function, the dosage of eprosartan in patients with hepatic disease should be individualized based on tolerability and response.

Global regulatory considerations for unified assay specifications

When developing a biotechnology product for global registration, there are several aspects to evaluate in an effort to unify specifications. These include differences between the United States, Europe and Japan, and Rest-of-World (ROW) countries with regard to the respective regulatory guidelines and pharmacopoeias in force, the state-of-the-art of product testing analytical methods, and the interval between submitting a registration dossier to different countries. In terms of regulatory guidelines, one country may have a monograph or required specifications for particular tests, for example the potency that a product has to meet before clinical trials can be initiated. For pharmacopoeias, different assay methods are required for sterility, general safety, and pyrogen testing, so that one may have to test a specific lot of a product at two or three different times to evaluate the same parameter, because of specific testing differences required for each country's pharmacopoeia. In addition, the state of analytical methods is always evolving and better analytical techniques become available. Sometimes, from starting with one set of tests, and based on the time in development, new tests may be added to the existing list of release specifications, because new analytical techniques have become available. Examining the global registration approval process for Betaseron, (interferon beta-1b) illustrates when specifications were able to be unified and when they were not.

Lymphocyte subset redistribution during acute laboratory stress in young adults: mediating effects of hemoconcentration

Acute psychological stress is known to alter the distribution of circulating lymphocyte subsets and also to cause a reduction of plasma volume. Data were reanalyzed from 4 previously reported studies (E. A. Bachen et al., 1995; T. B. Herbert et al., 1994; A. L. Marsland, S. B. Manuck, T. V. Fazzari, C. J. Stewart, & B. S. Rabin, 1995; A. L. Marsland, S. B. Manuck, P. Wood, et al., 1995) to determine the extent to which changes in the concentration of lymphocyte subsets are attributable to such hemoconcentration. Meta-analytic procedures showed circulating concentrations of T-suppressor/cytotoxic (CD8) and natural killer (NK) cells to increase following acute laboratory challenge, whereas T-helper (CD4) and B- (CD19) cell populations did not change. Adjustments for concomitant hemoconcentration reduced the magnitude of stress-related increases in CD8 and NK cells significantly and revealed a decrease in CD4 and CD19 cell concentrations from baseline to stress measurements. These data provide evidence (a) that increases in circulating numbers of CD8 and NK cells following acute stress are partially attributable to hemoconcentration and (b) that CD4 and CD19 cell concentrations decrease during acute stress when hemoconcentration is taken into account.