Randomised, double-blind, placebo controlled pilot study assessing nitroglycerin as a tocolytic

Thirty-three women in preterm labour were randomised in a double-blind fashion to receive either transdermal nitroglycerin (n = 17) or placebo (n = 16). Both groups had significant (P < 0.001) change in the cervix prior to randomisation. The primary outcome measure was delivery within 48 hours of randomisation. Fewer women randomised to nitroglycerin treatment (6/17) were delivered within 48 hours, compared with the placebo treatment (10/16) (RR 0.56, 95% CI 0.27 to 1.19). This pilot study lends support to two case series published that suggest that transdermal nitroglycerin may be promising as a safe, effective means for tocolysis.

Specificity of inhibition of matrix metalloproteinase activity by doxycycline: relationship to structure of the enzyme

OBJECTIVE

To investigate the inhibition of matrix metalloproteinase 1 (MMP-1), MMP-8, and MMP-13 by doxycycline, and to determine whether the variable hemopexin-like domain of each MMP was responsible for the differences in susceptibility to doxycycline inhibition among these collagenases.

METHODS

Recombinant human MMP-1 (collagenase 1), MMP-8 (collagenase 2), and MMP-13 (collagenase 3), truncated forms of MMP-8 and MMP-13 lacking the hemopexin-like domain, and a mutant form of truncated MMP-13 were used in these studies. The activity of the full-length MMP in the presence of doxycycline was tested against type II collagen, a natural substrate for the enzymes. A small peptolide substrate was used to determine which structural features of the MMPs were related to sensitivity to doxycycline inhibition.

RESULTS

The activity of MMP-13 and MMP-8 against type II collagen was inhibited by 50-60% by 30 microM doxycycline, while that of MMP-1 was inhibited only 18% by 50 microM doxycycline. In contrast, in experiments with the peptolide substrate, neither full-length nor truncated MMP-13 was inhibited until the concentration of the drug exceeded 90 microM. MMP-8 and truncated MMP-8 were sensitive to inhibition by 30 microM doxycycline, while MMP-1 was slightly inhibited (14%) by 90 microM doxycycline. For MMP-8, inhibition was reversible upon dilution and was independent of the order in which the reagents were added. Kinetic analysis of the inhibition constant (K(i)) of MMP-8 (K(i) = 36 microM) and truncated MMP-8 (K(i) = 77 microM) indicated that inhibition was noncompetitive.

CONCLUSION

Significant inhibition of MMP-13 and MMP-8 activity against collagen occurred in vitro at concentrations that were near the concentrations achieved in serum after oral dosing. Studies with truncated enzymes and 2 substrates suggest that doxycycline disrupts the conformation of the hemopexin-like domain of MMP-13 and the catalytic domain of MMP-8.

Differential patterns of response to doxycycline and transforming growth factor beta1 in the down-regulation of collagenases in osteoarthritic and normal human chondrocytes

OBJECTIVE

To investigate the ability of doxycycline, transforming growth factor beta1 (TGFbeta1), and phorbol myristate acetate (PMA) to modulate collagenase synthesis in osteoarthritic (OA) chondrocytes.

METHODS

Levels of fibroblast collagenase (matrix metalloproteinase 1 [MMP-1]), neutrophil collagenase (MMP-8), and collagenase 3 (MMP-13) proteins and messenger RNA (mRNA) were measured in chondrocytes isolated from involved and uninvolved areas of OA cartilage and from normal human chondrocytes, after treatment with doxycycline, TGFbeta1, and PMA.

RESULTS

Chondrocytes isolated from cartilage immediately adjacent to the OA lesion had, on average, 1.8-3.9-fold higher basal levels of MMP mRNA. These cells down-regulated collagenase proteins and mRNA upon incubation with TGFbeta1. In contrast, chondrocytes from areas located more distant from the macroscopic lesion increased MMP-13 mRNA, while MMP-1 and MMP-8 decreased after stimulation with TGFbeta1. Discoordinate regulation was observed after stimulation with PMA, with an increase in MMP-1 and MMP-8 but a decrease in MMP-13. Incubation of OA chondrocytes with doxycycline (1-10 microg/ml), at pharmacologically achievable levels, decreased levels of mRNA of all 3 collagenases, but not G3PDH. In addition, doxycycline inhibited the increase in mRNA for these enzymes in normal chondrocytes stimulated with tumor necrosis factor alpha.

CONCLUSION

These findings suggest that regulation of MMP-1, MMP-8, and MMP-13 in OA chondrocytes, although mediated by differing pathways, can be decreased by treatment with doxycycline at low concentrations. Our data provide a rationale for the use of doxycycline in the treatment of OA.

Diacerhein treatment reduces the severity of osteoarthritis in the canine cruciate-deficiency model of osteoarthritis

OBJECTIVE

To determine if diacerhein protects against the early stages of joint damage in a canine model of osteoarthritis (OA).

METHODS

OA was induced in 20 adult mongrel dogs by transection of the anterior cruciate ligament of the left knee. Beginning the day after surgery, dogs in the active treatment group were dosed twice a day with capsules of diacerhein, providing a total daily dose of 40 mg/kg, for 32 weeks. Dogs in the control group received placebo capsules on the same schedule. Pathology in the unstable knee was assessed arthroscopically 16 weeks after surgery and by direct observation when the dogs were killed 32 weeks after surgery. The severity of gross joint pathology was recorded, and samples of the medial femoral condyle cartilage and the synovial tissue adjacent to the central portion of the medial meniscus were collected for histologic evaluation. Water content and uronic acid concentration of the articular cartilage from the femoral condyle were determined, and collagenolytic activity in extracts of cartilage pooled from the medial and lateral tibial plateaus was assayed against 14C-labeled collagen fibers.

RESULTS

Diacerhein treatment slowed the progression of OA, as measured by grading of gross changes in the unstable knee at arthroscopy 16 weeks after cruciate ligament transection (P = 0.04) and at the time the animals were killed, 32 weeks after surgery (P = 0.05). However, 32 weeks after ACL transection, the mean proteoglycan concentration and water content of the OA cartilage and the level of collagenolytic activity in extracts of the cartilage were not significantly different in the diacerhein treatment group than in the placebo treatment group.

CONCLUSION

Diacerhein treatment significantly reduced the severity of morphologic changes of OA compared with placebo. These findings support the view that diacerhein may be a disease-modifying drug for OA.

Changes in homocysteine levels during normal pregnancy

OBJECTIVE

The objective of this study was to determine the changes in total plasma homocysteine concentration that occur during normal pregnancy.

STUDY DESIGN

In this cross-sectional study homocysteine was measured in 155 normal women in the first, second, and third trimesters and in nonpregnant controls. In addition, albumin, serum B12, serum folate, and red blood cell folate concentrations were measured and correlated to homocysteine values.

RESULTS

The mean homocysteine concentration (in micromoles per liter) was 5.6 (95% confidence interval 3.9-7.3) at 8-16 weeks' gestation, 4.3 (95% confidence interval 3.5-5.3) at 20-28 weeks' gestation, 5.5 (95% confidence interval 3.3-7.5) at 36-42 weeks' gestation, and 7.9 (95% confidence interval 6.2-9.6) in the nonpregnant control group. Homocysteine was significantly lower in all 3 trimesters of pregnancy compared with nonpregnant controls (P <.001). Homocysteine levels were directly correlated with albumin levels, which decreased during pregnancy. Homocysteine concentrations were decreased in subjects taking folic acid supplementation.

CONCLUSION

Serum concentrations of homocysteine decrease during pregnancy. This occurs in association with the physiologic fall in albumin during pregnancy, as well as with folic acid supplementation.

Use of nitroglycerin for uterine relaxation

Data from human and experimental animal research indicate that nitric oxide (NO), a novel messenger, formed during the nitric oxide synthase-catalyzed oxidation of L-arginine to L-citrulline, is involved in maintaining normal uterine tone during gestation. There are demonstrated and potential benefits of manipulating the L-arginine-NO system during pregnancy. Several recent case reports and case series have described the effective use of nitroglycerin (GTN), a NO donor compound, antenatally, intrapartum, and postpartum for acute uterine relaxation. Therapeutic indications for GTN range from facilitating external cephalic version, difficult vaginal or cesarean section delivery, and manual exploration of the uterus, to its use as a tocolytic. The intravenous regimen of GTN required to obtain the desired degree of uterine relaxation is extremely variable; intravenous bolus doses of 50 micrograms to 500 micrograms GTN with up to three repeated injections of 50 micrograms to 250 micrograms have been reported. Other methods of GTN administration include transdermal patches and sublingual spray. GTN, when used in low doses, may provide safe and effective uterine relaxation with no clinically apparent fetal or maternal adverse effects. However, clinical trials with use of objective methods of evaluating uterine tone and comparing GTN to other tocolytic agents are required before widespread use in advocated.

Effect of intraarticular hyaluronan injection in experimental canine osteoarthritis

OBJECTIVE

To determine if intraarticular injections of hyaluronan (HA) protect against the early stages of joint damage in a canine model of osteoarthritis (OA).

METHODS

OA was induced in adult mongrel dogs by transection of the anterior cruciate ligament of the left knee. One group of dogs (n=7) was treated with 5 weekly injections of HA (MW 1,500,000) into the operated knee beginning 1 day after ligament transection. The control group (n=6) was injected with saline on the same schedule. Twelve weeks after surgery, all dogs were killed, the severity of pathologic changes of OA was graded, and composition of the cartilage and extent of aggregation of proteoglycans (PGs) synthesized in vitro by cartilage slices were determined.

RESULTS

All dogs showed gross morphologic changes typical of OA in the unstable knee. The severity of joint pathology in HA-treated dogs was comparable with that in the saline-injected controls. In OA cartilage from the saline-treated group, the mean uronic acid concentration was 30-60% greater than that in the contralateral knee. In sharp contrast, the uronic acid concentration in OA cartilage from the HA-treated dogs was 10-30% lower than that in cartilage from the contralateral knee (P=0.02 and P=0.03, respectively, for samples from the medial and lateral femoral condyle). The extent of aggregation of PG synthesized in vitro by cartilage from HA-injected animals was similar to that synthesized by cartilage from the saline-injected dogs.

CONCLUSION

In this canine model of OA, the series of intraarticular injections of HA did not alter development of osteophytosis or fibrillation. However, the PG concentration of cartilage in the OA knee was significantly reduced by this treatment, suggesting that HA therapy might adversely affect the biomechanical properties of the cartilage.

Obstetric complications, treatment response and brain morphology in adult-onset and early-onset males with schizophrenia

BACKGROUND

Substantial variability in age at onset of illness and course of illness exists between patients with schizophrenia. Recent studies suggest that age at illness onset may be useful in defining biologically and clinically distinct subgroups of patients.

METHODS

Two hundred and ten males with schizophrenia were classified as early-onset or adult-onset according to their age at first hospitalization. Birth history, clinical functioning and treatment response was assessed in a subgroup of patients. Brain anatomy was assessed from CT scans in all patients and in 32 non-psychiatric control subjects.

RESULTS

Patients with an early-onset were likely to have a history of obstetric complications, a poor response to neuroleptic treatment, and showed no relationship between ventricle size and duration of illness. Adult-onset patients were less likely to have obstetric complications, more likely to respond to treatment in the first years of illness, and showed an association between brain structure and duration of illness.

CONCLUSIONS

The distinction between early- and adult-onset patients may have important aetiological and treatment implications.

Oral administration of doxycycline reduces collagenase and gelatinase activities in extracts of human osteoarthritic cartilage

OBJECTIVE

To determine whether oral administration of doxycycline in clinically relevant doses will suppress activities of collagenase and gelatinase in extracts of human osteoarthritic (OA) cartilage.

METHODS

Femoral heads were obtained from 21 patients undergoing arthroplasty for endstage hip OA. Activities of collagenase and gelatinase were measured in extracts of the OA cartilage from patients who received doxycycline, 100 mg bid or qam for 5 days before surgery (n = 5 and n = 6, respectively), 200 mg as a single dose 3 days before surgery (n = 4); or no doxycycline (n = 6).

RESULTS

Five days of doxycycline treatment, in a dose of either 100 mg bid or 100 mg qam, inhibited gelatinase activity in the cartilage extracts (p = 0.003, 0.008, respectively). The bid dose also inhibited collagenase activity (p = 0.002), but inhibition of collagenase with 100 mg qam did not quite reach statistical significance (p = 0.055), in comparison with the values for the untreated OA controls. The single 200 mg dose, given 3 days before procurement of the cartilage, was ineffective in inhibiting metalloproteinase activity.

CONCLUSION

Oral administration of doxycycline significantly inhibited collagenase and gelatinase activity in human OA cartilage. The effective dose is likely to be well tolerated during chronic administration, e.g., in a clinical trial to assess the potential of the drug to modify cartilage breakdown in OA.

An open comparison of clozapine and risperidone in treatment-resistant schizophrenia

BACKGROUND

Clozapine and risperidone are used in treatment-resistant schizophrenia. At present, there are few reported comparisons of these drugs in this population. We report on a consecutive series of treatment-resistant schizophrenics given either clozapine or risperidone in open clinical trials.

METHOD

Subjects were treated with clozapine (n = 57) or risperidone (n = 29). Pretreatment GAF, CGI, and PANSS scores did not differ between the groups, nor did demographic variables including age, age at first hospitalization, years ill, number of previous hospitalizations, or gender. The mean treatment trial was 12.1 weeks, with mean doses of clozapine 420 mg, and risperidone 7.75 mg. The length of the trial did not differ significantly between the groups. Response was taken to be a 20% decrease in the PANSS score.

RESULTS

Using repeated measures ANOVA, PANSS total scores (F = 5.3, p = 0.02) and positive subscore (F = 7.4, p = 0.008) showed greater improvement in the clozapine group than the risperidone group, while other PANSS subscores showed a trend toward greater improvement with clozapine. The PANSS-derived factors of excitement (F = 6.7, p = 0.01), psychosocial withdrawal (F = 3.8, p = 0.05), and psychomotor retardation (F = 3.9, p = 0.05) improved more in the group treated with clozapine. The GAF (F = 10.9, p = 0.0014), CGI (F = 11.5, p = 0.0011), and CGI improvement (p = 0.0001) scores also improved more in the clozapine group. Of the clozapine group, 25 (44%) responded, while 8 (28%) of the risperidone group responded to treatment.

DISCUSSION

Clozapine had better efficacy in subjects with treatment-resistant schizophrenia compared to risperidone, although risperidone appears to yield better response rates than those previously reported for typical antipsychotics. Double-blind, controlled trials of risperidone are needed to establish its efficacy in treatment-resistant schizophrenia.

A comprehensive method of assessing routine CT scans in schizophrenia

Morphological brain abnormalities are common in schizophrenia, although the aetiological and clinical significance of these findings is largely unknown. Substantial between-subject variability suggests that large samples are needed to study the full implications of brain pathomorphology. Computerized tomography (CT) is frequently used routinely in schizophrenia, and large numbers of scans are available for study. This article describes the development and statistical properties of a rapid and simple method of assessing CT scans. The CT Rating Scale for Schizophrenia (CTRSS) is minimally affected by variability in scanning procedures, is reliable, and accurately estimates area and volumetric measures of brain spaces. By promoting the comprehensive assessment of large numbers of routinely obtained scans, the CTRSS would allow the investigation of variables that may systematically affect results (e.g. gender and age) and variables with low prevalence. The CTRSS provides a useful adjunct to technologically more sophisticated methods of assessment such as magnetic resonance imaging (MRI).

Inhibition of recombinant human neutrophil collagenase by doxycycline is pH dependent

OBJECTIVE

To examine, as part of an evaluation of the role of matrix metalloproteinase (MMP) inhibition in the amelioration of cartilage damage by doxycycline, the effect of pH on the inhibition of activity and reduction in stability of recombinant human neutrophil collagenase (rhMMP-8) by doxycycline in vitro.

METHODS

After activation with trypsin, rhMMP-8 was assayed using a peptolide substrate and a colorimetric assay. The rate of hydrolysis in the presence and absence of 30 microM doxycycline was measured over a pH range of 6.5-7.9. The molecular weight changes that accompanied activation of the proenzyme by acetylphenylmercuric acetate (APMA) in the presence and absence of doxycycline at pH 6.9 and 7.5 were studied by Western blotting.

RESULTS

At pH values above 7.1, doxycycline inhibited the activity of the enzyme. At pH values below 7.1, no inhibition was observed. When doxycycline was present during activation with APMA at pH 7.5, significant amounts of small (< 30 kDa) fragments were generated. In contrast, when doxycycline was present during activation with APMA at pH 6.9, no small fragments were detected.

CONCLUSION

The ability of doxycycline to inhibit matrix rhMMP-8 activity or to promote its degradation is lost at pH values lower than 7. Although relatively high pH values may exist in adult articular in some pathological situations, at lower pH the effect of doxycycline on proenzyme levels in the extracellular matrix may be due to an effect on the regulation of synthesis of the proenzyme, rather than to direct inhibition of the active enzyme or reduction in the level of enzyme by proteolysis.

Increased incidence of preeclampsia in women conceiving by intrauterine insemination with donor versus partner sperm for treatment of primary infertility

OBJECTIVE

Reports suggest that there is an increased incidence of preeclampsia after a previously normal pregnancy if there is a change in paternity. We hypothesize that there is a higher incidence of preeclampsia (proteinuric hypertension) in women conceiving by intrauterine insemination with donor sperm versus intrauterine insemination with partner sperm.

STUDY DESIGN

This was a retrospective cohort study. In women with primary infertility all pregnancies achieved by either partner or donor intrauterine insemination carried to birth of a fetus (> 20 weeks) were identified. The medical records were examined for the maternal and pregnancy outcome data. The relative risk and 95% confidence interval were calculated for the risk of preeclampsia. The baseline data were compared with t tests, chi 2 analysis and Fisher's exact test where appropriate.

RESULTS

Forty-four patients in the partner intrauterine insemination group and 37 in the donor insemination group were identified as having primary infertility. Three cases of mild preeclampsia were found in the partner insemination program and nine cases of preeclampsia (five severe, four mild) in the donor insemination program (relative risk 1.85, 95% confidence interval 1.20 to 2.85).

CONCLUSIONS

There is a higher incidence of preeclampsia in women conceiving by intrauterine insemination with washed donor sperm compared with intrauterine insemination with washed partner sperm. This supports, indirectly, an immunologic basis for preeclampsia. The antigenic factor would appear to be located on the sperm as opposed to the seminal fluid itself.

Obstetric complications and age-related changes in brain morphology in schizophrenia

Birth problems can lead to changes in brain morphology in the general population and an increased prevalence of both birth problems and altered brain morphology are found in patients with schizophrenia. The purpose of this study was to test the hypothesis that these two findings are related. Birth history and the size of ventricular and sulcal spaces from nine regions of the brain were assessed in 80 male subjects with schizophrenia. No differences were found between patients with and those without a history of birth problems for the size of any brain space; however, ventricular size increased significantly with age in patients who had no birth complications but not in patients with a history of birth problems. The size of cortical sulci increased with age in patients with and those without a history of birth problems. These results suggest that region-specific rates of change in size may identify clinically meaningful patients subgroups.

The sonographic finding of persistent umbilical cord cystic masses is associated with lethal aneuploidy and/or congenital anomalies

Advancements in sonographic technology have led to improved prenatal detection of fetal anomalies. Umbilical cord cystic masses are being detected prenatally and several case reports have appeared in the literature. We report three new cases in which umbilical cord cystic masses were detected prenatally; two cases in the later half of pregnancy and one case in the first trimester. The literature was reviewed and summaries of the 23 reported cases of persistent second- and third-trimester umbilical cord cystic masses and their implications are discussed. There is a high association (18 of 23 cases) with lethal chromosomal anomalies and/or congenital malformations suggesting that the finding of an isolated umbilical cord cystic mass should lead to further detailed sonographic evaluation.

Activation of recombinant human neutrophil procollagenase in the presence of doxycycline results in fragmentation of the enzyme and loss of enzyme activity

OBJECTIVE

To determine if reduction of collagenase activity in vitro by doxycycline (doxy) is related to activation of the proenzyme, and to determine how exogenous Ca++ and Zn++ affect the reduction.

METHODS

Recombinant human neutrophil procollagenase was activated with trypsin or APMA. Activity was assayed on a small peptolide substrate or on 14C-acetylated collagen fibers. The molecular weight of the proenzyme, active enzyme, and enzyme fragments was determined by Western blotting, using a polyclonal antiserum raised against the recombinant proenzyme. Similar experiments were performed in the presence of EDTA, EGTA, 1,10-phenanthroline, or doxy. The effects of exogenous Ca++ and Zn++ were also tested.

RESULTS

Doxy inhibited activity of the enzyme against both substrates. If the drug was present during activation, the yield of activity was lower than when it was added after activation of the proenzyme. Western blotting showed that activation in the presence of doxy resulted in the appearance of lower molecular weight fragments and accumulation of less active enzyme. APMA generated prominent 28- and 26-kd fragments while trypsin cleavage yield 40- and 30-kd fragments. Fragmentation of the enzyme also occurred in the presence of EDTA or EGTA, but not 1,10-phenanthroline. It was prevented by Ca++ concentrations greater than 50 mM, but was not altered by addition of Zn++ in concentrations as high as 500 microM. Inhibition of collagenase activity by doxy could be overcome by 100 mM Ca++, but addition of Zn++ had no effect.

CONCLUSION

These data suggest that doxy alters the conformation of procollagenase or collagenase by binding enzyme-associated Ca++, rendering the proteins more susceptible to proteolysis and resulting in irreversible loss of enzyme protein.

The temporal lobes, reversed asymmetry and the genetics of schizophrenia

Mechanisms determining temporal lobe structural asymmetries may be involved in the pathogenesis of schizophrenia. To investigate the temporal lobes in familial schizophrenia, computed tomographic scans were obtained from 51 subjects (seven families). Enlargement of sylvian fissures and temporal lobe sulcal spaces was observed in family members with schizophrenia. The posterior one-third of the sylvian fissure was larger on the left side in subjects with schizophrenia, and larger on the right side in unaffected individuals. This disturbed pattern of posterior sylvian fissure asymmetry suggests that adjacent language regions may be affected in schizophrenia. An intermediate degree of disturbance in subjects who had schizophrenia-related illnesses or were obligate carriers suggests that genetic factors may be important determinants of temporal lobe asymmetries in familial schizophrenia.

Developmental abnormalities and cortical sulcal enlargement in psychosis

Neurodevelopmental abnormalities and cortical sulcal enlargement both occur in schizophrenia. To test the hypothesis that these abnormalities were related, CT scans from 164 psychotic patients (80 with schizophrenia) were reviewed. Neurodevelopmental abnormalities were observed in 11%. Abnormalities were equally prevalent in schizophrenia and other psychotic disorders. Cortical sulcal enlargement was observed in 39% of patients with schizophrenia, and was not associated with developmental abnormalities. Different mechanisms may contribute to distinct structural abnormalities.

Regional cortical anatomy and clozapine response in refractory schizophrenia

Regional measures of cortical sulcal and ventricular enlargement on computed tomography scan were studied in a clinical sample of patients treated with clozapine. Cortical sulci were significantly enlarged in clozapine nonresponders compared to responders. The Clinical Global Impressions score at discharge was related to the size of the posterior frontal and lateral temporal sulci, with large sulci predicting a poorer response to clozapine treatment.

Comparative study of sodium nitroprusside induced vasodilation of human placental veins from premature and full-term normotensive and preeclamptic pregnancy

The objective of this study was to determine whether nitrovasodilator (nitric oxide donor) drug induced relaxation is different between preeclamptic and normotensive pregnancy. Human placental veins were collected at the time of delivery from normotensive (n = 6 premature, n = 6 full term) and preeclamptic (n = 6 premature, n = 3 full term) women and cut into rings. Cumulative concentration-response curves were performed on 5-hydroxytryptamine-contracted rings for the nitrovasodilator agent, sodium nitroprusside (SNP). The EC50 values were determined from the SNP concentration-response curves of the individual subjects, and were compared across gestational age and between preeclamptic and normotensive pregnancy by two-way ANOVA. There was no difference in the SNP EC50 values for normotensive and preeclamptic human placental veins in either the premature or full-term study groups. However, for both normotensive and preeclamptic pregnancy, the SNP EC50 value for full-term placental vein was greater than that for premature tissue. The sensitivity of human placental veins to SNP is similar between preeclamptic and normotensive pregnancy at similar gestational ages, but is increased in premature compared with full-term pregnancy in both preeclamptic and normotensive pregnant women.