Traditional Chinese medicine for the treatment of dermatologic disorders

Traditional Chinese medicine (TCM) is an alternative method of therapy that can be administered in oral, topical, or injectable forms. It emphasizes the importance of using many herbs that are combined in different formulations for each individual patient. Among some segments of the patient population, it has become increasingly popular as a mode for treating dermatologic diseases. As a result, it is now worthwhile for dermatologists throughout the West to gain some familiarity with this method. Yet, dermatologists are largely unfamiliar with TCM and may possess some misconceptions. We attempt to give a general overview of TCM through the discussion of different clinical studies involving various TCMs. Some proposed mechanisms of action of TCM are also presented. A discussion of adverse effects, including hepatotoxic effects and the need for close monitoring is discussed. A warning regarding the possible contamination of TCMs is also included. Since it is not possible to discuss the application of TCM for every skin disorder, psoriasis and atopic dermatitis are used as the prototype in illustrating the use of TCM. In the future, perhaps a better understanding of TCM will be gained through more systematic analysis and controlled studies with a placebo arm. It is our hope that this article will provide an overview of the efficacy, mechanism of action, as well as adverse effects of TCM.

Cyclosporine consensus conference: with emphasis on the treatment of psoriasis

Cyclosporine has been in worldwide use for 15 years for patients who have undergone transplantation operations and is now being used to control inflammatory reactions in other organs (eg, joints, bowel, and skin). Neoral, a more consistently absorbed form of cyclosporine, has recently been approved by the Food and Drug Administration for the treatment of psoriasis. This report outlines the indications, contraindications, dosage recommendations, monitoring requirements, adverse events, drug interactions, interactions with other psoriasis treatments, and suggestions for cyclosporine's use in rotational therapy.

A randomized, double-blind study comparing the efficacy, safety and optimal dose of two formulations of cyclosporin, Neoral and Sandimmun, in patients with severe psoriasis. OLP302 Study Group

This study compared the efficacy, safety and optimal dose of two formulations of cyclosporin, Sandimmun and Neoral, in patients with severe, chronic plaque-type psoriasis. Patients were randomized on a 1:1 basis to 24 weeks of treatment with Neoral (n = 152) or Sandimmun (n = 157). The starting dose of each formulation was 2.5 mg/kg per day. Dose increases to maintain efficacy were allowed after 4 weeks. In patients who achieved remission, the dose was down-titrated at 4-week intervals from week 16. The maximum permitted dose for each formulation was 5.0 mg/kg per day. Neoral produced a more rapid response than Sandimmun: remission rates were higher for Neoral during the first 8 weeks of treatment. The number of dose reductions for safety was similar in both treatment groups, but there were more dose increases to maintain efficacy in the Sandimmun group (198) than the Neoral group (146). The number of patients with dose reductions after week 16 was higher for Neoral (n = 83) than for Sandimmun (n = 73). The frequency and nature of adverse events were similar for both treatment groups. The mean dose required to control the disease was approximately 10% lower with Neoral and fewer dose changes were needed. The increased bioavailability and reduced pharmacokinetic variability of cyclosporin provided by the Neoral formulation may facilitate short-course, intermittent therapy.

Random population-wide genetic damage induced in replicating cells treated with methotrexate

Low lethality treatment of the NIH 3T3 mouse cell line with methotrexate (MTX) during exponential multiplication results in heterogeneous, heritable reduction in growth rate of most if not all the replicatively surviving cells. The effective concentrations of MTX are 10 to 100 times higher in molecular, cellular and developmental biology medium 402 (MCDB 402) than in Dulbecco's modification of Eagle's medium (DMEM) medium because of the folate-sparing presence of adenine, thymidine and, particularly, of folinic acid in MCDB 402 medium. The reduced growth rates are detectable during early passages of surviving populations before the faster growing cells dominate them. The heritable effect is most clearly demonstrated by sequestered cloning of many individual cells immediately after drug treatment, and repeatedly measuring the growth rates of the clones in serial passages. After 7-10 passages of the clones, there is an increase in growth rate of some of the slow growing clones presumably due to the generation and selection of faster growing cells. Evidence from mutagenic studies at a single genetic locus in other cell lines suggests that heritable reductions in growth rate arise from chromosome aberrations although point mutations may also contribute to the effect. Clastogenic changes can be induced by a wide variety of mutagens and carcinogens, many of which are used in chemotherapy of cancer and other chronic diseases. The population-wide, heritable damage to cells may be the source of, or may contribute to, late-occurring side effects of treatment in cancer and other chronic diseases.

Mometasone furoate 0.1%-salicylic acid 5% ointment versus mometasone furoate 0.1% ointment in the treatment of moderate-to-severe psoriasis: a multicenter study

Topical corticosteroids and keratolytics are both used widely in the management of patients with psoriasis. A combination of the two types of agents may provide enhanced relief. The purpose of this study was to compare the efficacy and safety of the combination ointment mometasone furoate 0.1% plus salicylic acid 5% with that of mometasone furoate 0.1% ointment in the treatment of moderate-to-severe psoriasis vulgaris. A total of 408 patients were enrolled in this controlled, randomized, double-masked, parallel-group, multicenter comparison. Patients applied either mometasone furoate-salicylic acid ointment or mometasone furoate ointment alone to target lesions twice daily for 21 days. Severity of erythema, induration, and scaling were scored at baseline and at days 4, 8, 15, and 22. An evaluation of overall change in disease status of all treated lesions was performed at each follow-up visit. Adverse events were also monitored and scored, including signs of skin atrophy. Beginning on day 8, the combination of mometasone furoate-salicylic acid was significantly more effective than mometasone furoate alone, as indicated by the mean percentage of improvement in total disease scores, mean total disease sign scores, and the individual score for scaling. Similarly, the combination was more effective beginning on day 15, as indicated by the global evaluation of overall clinical response and individual scores for erythema and induration. Both treatments were well tolerated. Mometasone furoate-salicylic acid ointment provides more effective treatment of moderate-to-severe psoriasis than does mometasone furoate ointment alone and is safe and well tolerated.

Calcipotriol/calcipotriene (Dovonex/Daivonex) in combination with phototherapy: a review

BACKGROUND

Calcipotriol/calcipotriene (Dovonex/Daivonex) ointment plus phototherapy has been used in the treatment of psoriasis.

OBJECTIVE

We will attempt to clarify two issues: First, is there any benefit to combining the above treatment modalities? Second, is there any increased risk associated with the use of the combination?

METHODS

A complete review of the literature revealed four studies dealing with the combination of calcipotriol with UVB phototherapy and three studies dealing with the combination of calcipotriol with PUVA phototherapy.

RESULTS

These studies showed an advantage to the use of the combination compared with the use of either treatment alone.

CONCLUSION

Topical calcipotriol enhances the effect of UVB and PUVA phototherapy.

Enteric duplication in the adult, derived from the foregut, midgut and hindgut: presentation, patterns and literature review

Duplication of the alimentary tract may affect patients of all ages. Although they are relatively rare, the importance of these congenital lesions lies in the fact that they readily mimic other surgical disease processes and may result in significant morbidity if left untreated. Prompt recognition and treatment using combined radiologic and surgical management are generally associated with an excellent outcome. Three patients who presented with intestinal duplication arising from each of the major embryologic origins are reported. Their clinical histories reveal the spectrum of presentation associated with these lesions and provide a framework for a discussion of current management strategies.

Cyclosporine as maintenance therapy in patients with severe psoriasis

BACKGROUND

Low-dose cyclosporine therapy for severe plaque psoriasis is effective. Most side effects can be controlled by patient monitoring, with appropriate dose adjustment or pharmacologic intervention, or both, if indicated. Prevention or reversibility of laboratory and chemical abnormalities may be achieved by discontinuation of therapy after the induction of clearing. However, relapse occurs rapidly on discontinuation. Maintenance therapy with cyclosporine after induction has not been fully evaluated.

OBJECTIVE

Our purpose was to compare a regimen of 3.0 mg/kg per day of oral cyclosporine with placebo in maintaining remission or improvement in patients with psoriasis.

METHODS

After a 16-week unblinded induction phase in which 181 patients received cyclosporine, 5.0 mg/kg per day (an increase up to 6.0 mg/kg per day and a decrease to 3.0 mg/kg per day were allowed, if required, to achieve efficacy or tolerability, respectively), those patients showing a 70% decrease or more in involved body surface area (BSA) entered the 24-week maintenance phase and were randomly assigned to either placebo, cyclosporine, 1.5 mg/kg per day, or cyclosporine, 3.0 mg/kg per day. Patients were considered to have had a relapse when BSA returned to 50% or more of the prestudy baseline value. Clinical efficacy, adverse effects, and laboratory values were monitored regularly throughout both study phases.

RESULTS

During induction, cyclosporine at approximately 5.0 mg/kg per day produced a reduction in BSA of 70% or more in 86% of the patients. During maintenance, the median time to relapse was 6 weeks in both the placebo and cyclosporine 1.5 mg/kg per day groups, but was longer than the 24-week maintenance period in the 3.0 mg/kg per day group (p < 0.001 vs placebo). By the end of the maintenance period, 42% of the patients in the 3.0 mg/kg per day cyclosporine group had a relapse compared with 84% in the placebo group. Changes in laboratory values associated with the higher induction dosage generally exhibited partial or complete return toward mean prestudy baseline values during the maintenance phase, with the greatest degree of normalization in the placebo group.

CONCLUSION

Cyclosporine, 3.0 mg/kg per day, adequately and safely maintained 58% of patients with psoriasis for a 6-month period after clearing of their psoriasis with doses of approximately 5.0 mg/kg per day.

Comparison of once-daily versus pharmacokinetic dosing of aminoglycosides in elderly patients

PURPOSE

Once-daily dosing has been suggested as an alternative method of dosing aminoglycosides that would reduce their toxicity while maintaining efficacy. There have been no studies published to date comparing once-daily dosing and pharmacokinetic dosing of aminoglycosides. We conducted a randomized controlled trial comparing the safety and effectiveness of 4 mg/kg IV once-daily dosing of gentamicin or tobramycin with a pharmacokinetic dosing method using an initial dose of 2 mg/kg IV every 12 hours.

PATIENTS AND METHODS

Ninety-six patients were randomly assigned to either the once-daily dosing group (4 mg/kg) or the pharmacokinetic dosing group (initial dose of 2 mg/kg every 12 hours). In the once-daily dosing group, the dosing interval was extended by 12 to 24 hours to maintain a serum trough concentration < 1.5 mg/L regardless of the peak concentration. Dosing in the other group was adjusted based on the individual pharmacokinetic data to achieve a serum peak concentration of 6 to 10 mg/L and a trough concentration below 1.5 mg/L. The patients studied were predominantly elderly males (mean age 69 years). All patients were assessed for treatment efficacy and nephrotoxicity.

RESULTS

There was no significant difference between the two groups with regard to clinical and bacteriologic efficacy. Incidence of nephrotoxicity was 24% in the once-daily group and 14% in the pharmacokinetic dosing group but the difference was not statistically significant (P = 0.13). Unlike previous studies, we found a correlation between high serum peak concentration and incidence of nephrotoxicity in the once-daily dosing group. Nephrotoxicity developed in six out of 10 patients (60%) with an initial serum peak concentration greater than 12.0 mg/L compared to two out of 24 patients (8.3%) with an initial peak concentration less than 12.0 mg/L (P < 0.001) in the once-daily group. Serum peak concentrations in the pharmacokinetic dosing group were not correlated with nephrotoxicity.

CONCLUSIONS

Once-daily dosing and pharmacokinetic dosing of aminoglycosides appear to have equal efficacy and toxicity. However, in the elderly population, high serum peak concentrations that occur with once-daily aminoglycoside dosing may increase the risk of nephrotoxicity.

Cutaneous sensory disorder

Some patients only present with a cutaneous sensory complaint such as itching, burning, stinging, or other disagreeable sensations of unknown etiology. Frequently, these patients may not have any diagnosable dermatologic, neurologic, medical, or psychiatric diagnosis. Their suffering, however, is real. This article explains a practical approach to the treatment of patients with pure cutaneous sensory disorders.

Delusions of parasitosis and other forms of monosymptomatic hypochondriacal psychosis. General discussion and case illustrations

In this article, the epidemiology and differential diagnosis of monosymptomatic hypochondriacal psychosis are discussed in detail. The use of pimozide is also discussed and illustrated with case reports. Delusional patients are some of the most challenging cases based in dermatologic practice. This challenge is so much easier to meet if one knows how to approach these patients and feels comfortable in the use of pimozide.

Psychopharmacology for dermatologic patients

In the recent past, there has been great progress made in making psychopharmacologic agents both more efficacious and more user friendly. If dermatologists are to more effectively treat psychodermatologic patients who refuse to see a mental health professional, judicious and responsible use of psychopharmacology is still the most feasible way to treat many of these patients. This article illustrates the use of several commonly used psychopharmacologic agents. Even for psychiatrists, it is not realistic to try to master all psychopharmacologic agents that are on the market. Familiarity with the use of medications discussed in this article is likely to add significantly to the therapeutic armamentarium of a dermatologic practitioner.

Pseudopsychodermatologic disease

Just as psychodermatologic disorders can mimic real dermatologic conditions, real dermatologic or other bona fide physical problems such as neurologic disorders can also mimic psychodermatologic disorders. This article illustrates several cases of pseudopsychodermatologic disorders. When faced with a difficult patient or baffling case, sometimes there is a tendency to "jump to conclusions" with regard to the psychogenic origins of the case. It is important to be cognizant of the possibility that one may be missing a real organic disorder if one does not keep an open mind with regard to diagnosis of the patient's skin condition.

Population-based epidemiologic study of psoriasis with emphasis on quality of life assessment

With the changing health care scene in the United States, it is important to have up-to-date epidemiological data with regard to the prevalence of psoriasis in the United States. It is also becoming more important to develop a psychometric instrument that is useful in assessing quality of life issues among psoriasis patients. The Psoriasis Disability Index, which was developed in England, may not be optimally applicable in assessing quality of life issues among psoriasis patients seen by American dermatologists. In this article, the latest nationwide population-based epidemiologic data on psoriasis are presented, along with the use of a new psychometric questionnaire that emphasizes the assessment of quality of life rather than disability.

The severity of nauseogenic effect of cross-coupled rotation is proportional to gyroscopic angular acceleration

METHOD AND RESULTS

Subjects underwent cross-coupled rotation of the head (i.e., Coriolis stimuli) during which the upper body was tilted from side to side during horizontal rotation of the whole body about the Earth-vertical axis. In Experiment 1, the angle between the two axes of cross-coupled rotation was changed to vary the magnitude of gyroscopic angular acceleration without wide variations in Coriolis linear acceleration. The severity of nausea evoked by cross-coupled rotation stimuli varied relative to the magnitude of gyroscopic angular acceleration. It is noteworthy that nausea was not evoked unless gyroscopic angular acceleration was generated, even though Coriolis linear acceleration was equally induced. In Experiment 2, subjects tilted the upper body with or without restriction of head movement to a vertical plane during Earth-vertical axis rotation of the body at various angular velocities. The severity of evoked nausea was in direct proportion to angular velocity of body rotation irrespective of the restriction.

CONCLUSION

These results indicated that the severity of nauseogenic effect of cross-coupled rotation is directly proportional to gyroscopic angular acceleration.

Increase of a urokinase receptor-related low-molecular-weight molecule in colorectal adenocarcinomas

Proteolytic activity is important for tumor growth and metastasis. Plasminogen and urokinase-type plasminogen activator (u-PA) constitute one of the most extensively studied proteolytic systems believed to participate in these processes. u-PA cleaves plasminogen to plasmin, which in turn degrades surrounding extracellular matrix and allows tumor cells to migrate to other areas. The specific receptor for u-PA (u-PAR) has also been implicated as an essential modulator in this pathway. Eleven paired samples of colorectal cancers and normal mucosal tissues from the same patients were removed at surgery. The tissues were homogenized and the supernatants assayed for u-PAR immunoreactivity, u-PAR antigen concentration, u-PAR binding activity and u-PA activity. Immunoblot analysis showed that a major u-PAR species of approximately 55 kDa was present in all tissues. In addition, a protein band of approximately 41 kDa, which crossreacted with anti-u-PAR antibodies, was also found in the tumors. This protein band was either absent, or present in relatively small amounts in the normal colorectal tissues. Cross-linking experiments showed that the approximately 55 kDa band only, and not the approximately 41 kDa band, was able to bind either single chain urokinase-type plasminogen activator (scu-PA) or the amino terminal fragment of urokinase (ATF). The tumor samples also exhibited highly elevated u-PA activity and u-PAR antigen relative to the corresponding normal tissues. Elevated u-PA activity appeared to correlate with elevated u-PAR antigen in colorectal cancers, but not in the normal tissues. These increases were also associated with increase of the u-PAR-related, low-molecular-weight protein in the tumor samples. The measurement of u-PAR and the u-PAR-related protein, in addition to u-PA activity, could have diagnostic or prognostic value in this type of cancer.

Cyclosporine: what clinicians need to know

Cyclosporine is known to be highly efficacious for the treatment of psoriasis as well as several other dermatologic conditions. Because of its profound anti-inflammatory properties and a side-effect profile that differs from other agents, such as methotrexate, the availability of cyclosporine confers certain advantages in meeting the challenges of treating recalcitrant psoriasis. In short-term use, cyclosporine can induce dramatic improvements in psoriasis, especially patients who present with intense inflammation. Because of nephrotoxicity and the possible development of hypertension, however, its utility in long-term usage, especially continuous usage beyond 1 year, is still to be defined. With contemporary attempts to use combination and rotational therapies to maximize therapeutic efficacy and minimize risk of long-term side effects, cyclosporine is definitely a welcome addition to our current armamentarium in the treatment of psoriasis.

The effect of extended lymphadenectomy on survival in patients with gastric adenocarcinoma

BACKGROUND

In the United States of America, the five-year survival rate among patients surviving curative resection for gastric carcinoma will range between 20 and 25 percent. In Japan, early diagnosis and an aggressive surgical approach including planned lymph node dissection has resulted in the five-year survival rate exceeding 50 percent for all patients with newly diagnosed gastric carcinoma. This report is a retrospective review evaluating the effect of extended lymph node dissection (D2) on overall survival in 101 patients with gastric adenocarcinoma who underwent a potentially curative gastric resection from 1975 to 1990 at Roswell Park Cancer Institute.

STUDY DESIGN

Gastric carcinomas were staged according to the revised 1987 TNM classification. Lymph node dissections were defined according to the General Rules of the Japanese Research Society for Gastric Cancer. Gastric resections in this study were classified as D2.5, D2, D1.5, and D1 and divided into two groups, the extended resection group (D2, D2.5) and the limited resection group (D1, D1.5).

RESULTS

The median follow-up period was 33 months. The entire group (n = 101) had an estimated five-year survival rate of 36 percent with a median survival rate of 33 months. The estimated five-year survival rate for the extended resection group (n = 46) was 49 percent with a median of 50 months compared with 27 percent and 25.7 months, respectively, for the limited resection group (n = 55, p = 0.01). Following extended resection, 74 percent of patients with stage I gastric carcinoma survived five years, 75 percent of patients with stage II carcinoma were alive at five years as were 13 percent with stage IIIA, and 30 percent with stage IIIB. Patients whose tumors fell into the classifications of T2-4, N0-1, M0 and required a total or proximal gastrectomy enjoyed a significant survival advantage undergoing an extended resection, with 44 percent surviving five years with a median of 43 months compared with 16 percent and 25 months, respectively, for patients undergoing a limited resection (p = 0.05). Of 13 patients treated with a D2 or greater resection whose gastric carcinomas metastasized to N2 lymph nodes, four patients (31 percent) survived at least five years. Only the extent of lymph node dissection and type of gastric resection proved to be significant independent predictors of overall survival.

CONCLUSIONS

Patients treated by extended resection (D2, D2.5) were more likely to survive five years and had prolonged median survival times when compared with patients treated with limited resection (D1, D1.5). For patients with T2-4, N0-1, M0 gastric carcinomas treated with extended resection, their differences reached levels at or approaching statistical significance.

Cyclic compressive loading results in fatigue cracks in ultra high molecular weight polyethylene

Wear damage to the articulating surfaces of total joint components made of ultra high molecular weight polyethylene is associated with a fatigue fracture mechanism, despite the fact that these surfaces are subjected to primarily compressive and compressive-tensile cyclic stresses. The question arises as to whether fatigue cracks will form under such loading conditions. In this study, we experimentally demonstrated that fatigue cracks could be initiated and propagated in notched ultra high molecular weight polyethylene specimens subjected to fully compressive and compressive-tensile cyclic loading. Under these loading conditions, growth of fatigue cracks was limited: the cracks arrested without catastrophic failure of the test specimens. The final length of the crack was dependent on the load ratio of the fatigue cycle; fatigue cracks propagated to greater lengths as the load ratio was increased.

Coriolis effects are principally caused by gyroscopic angular acceleration

A cause of nausea evoked by cross-coupled rotation (termed Coriolis stimulus) was determined. Subjects were provided with two types of cross-coupled rotations: neck-forward flexion (Neck Flx) and upper body-forward flexion (Body Flx) during horizontal whole body rotation at a constant angular velocity. These Coriolis stimuli were given alternatively in an experimental sequence, and the severity of the nausea they evoked was compared by the subjects. The results indicated that the same quality of nausea was evoked by a slightly higher angular velocity during Body Flx (100.5 degrees/s) than during Neck Flx (90 degrees/s). While Body Flx generated Coriolis linear acceleration several times larger than Neck Flx, both the stimuli generated a similar magnitude of gyroscopic angular acceleration in this condition. Therefore, it was inferred that the nausea evoked by a Coriolis stimulus is principally caused by gyroscopic angular acceleration.

Solubility of calcium salts and carrageenan used in infant formulas did not influence calcium absorption in rats

Calcium absorption from tricalcium phosphate (TCP) was compared to that from calcium chloride, CaCl2, in the presence and absence of carrageenan in the rat model. There was no difference in percent calcium absorption as indicated by femur uptake of TCP or CaCl2 intrinsically labeled with 45Ca given by gavage (78.4 +/- 9.6 vs. 80.0 +/- 5.9, respectively). Thus, the difference in solubility of the two salts did not influence calcium absorption. When TCP was delivered by gavage in a solution containing 1% carrageenan, calcium absorption was not decreased compared to that of a control without carrageenan. In this model, calcium from TCP in the presence of up to 1% carrageenan is well absorbed.

Secretion of erythropoietin from microencapsulated rat kidney cells: preliminary results

Rat kidney epithelial cells were microencapsulated within alginate-poly(L)lysine-alginate membrane. The microencapsulated cells were incubated using a culture media containing cobalt and another without cobalt. The viability was measured by trypan blue exclusion test. Secretion of erythropoietin (EPO) was measured by radioimmunoassay (RIA). Viability of free cells was 53%. The viability of microencapsulated cells increased to 72% after 12 days of incubation and remained at this level. Samples of the culture media were collected every 2 days for RIA. Samples within the microcapsules were collected by breaking the microcapsules open. RIA of these samples showed the following for the media containing cobalt. Between day 16 and day 32 the concentrations of EPO were 5.3 mU/ml inside and 18.3 mU/ml outside the microcapsule. The medium from the same number of free cells contained 21.2 mU/ml of EPO. Culture media without cobalt collected during the same period contained 1.8 mU/ml inside and 9.9 mU/ml outside the microcapsules. The free cell culture with this media during the same period contained 8.3 mU/ml.

Ongoing ischemic pain as a workload indexed by P3 amplitude and latency in real-versus feigned-pain conditions

We tested four independent groups: real pain, real pain/tracking, feigned pain, and feigned pain/tracking. After baseline (auditory oddball task only, .8/.2), the real pain groups had an ischemia cuff applied, which generated intense pain after 14 min. The pain feigners were instructed to simulate pain. The oddball task was repeated during low pain (6 min following cuff application) and during high pain (7-15 min following application). Real pain ratings were affected by low versus high pain and by tracking (reporting pain regularly), which elevated ratings. Nontracking feigned- and real-pain subjects differed in oddball-evoked P3 amplitude and latency during high pain. Oddball P3 amplitude decreased and latency increased from real low pain to high pain. Tracked but not untracked real low pain affected oddball P3 amplitude. Real and feigned pain-tracking subjects did not differ in P3 amplitude. P3 latency differed between real-pain and feigning subjects during low-pain tracking. A 91% individual hit rate (real vs. feign) obtained.

Human pharmacokinetics of ibuprofen enantiomers following different doses and formulations: intestinal chiral inversion

The influences of absorption rate and dosage size on the pharmacokinetics of ibuprofen (IB) enantiomers were studied in six healthy subjects. Rapidly absorbed solutions (50, 100, 200, 400, 600, and 1200 mg) and regular 600-mg tablets of racemic IB were given orally, and plasma concentration-time courses of the enantiomers were followed. Solutions were absorbed faster (tmax less than 0.25 h) than the tablet (tmax = 2.17 +/- 1.17 h). While the S:R AUC ratios were unaffected by increasing the dose, they were significantly greater after the tablet (1.35 +/- 0.14) as compared with the solutions (1.15 +/- 0.16 to 1.24 +/- 0.26). This indicates a greater extent of chiral inversion for the tablet, perhaps due to a longer residence time in the gut, thereby allowing more presystemic inversion. To test this hypothesis, R-IB was incubated at 37 degrees C in the presence of excised segments of human ileum and colon obtained from three patients. Chiral inversion was evident in all segments. After 3 h, the extent of inversion ranged from 20.0 to 33.0%. In addition, incubation resulted in the formation of up to 23.3 and 13.0% of acylglucuronides of S- and R-IB, respectively. In all subjects, the AUC-dose relationships were nonlinear, indicating a gradual increase in the clearance of both enantiomers due, perhaps, to a parallel saturation of plasma protein binding sites. In humans, the chiral inversion of IB is not influenced by the dosage size but is enhanced by prolongation of the residence time in the intestine.

Gross and histologic effects of topical misoprostol on canine gastric mucosa

This study reports the histological effects of topical misoprostol, a synthetic PGE1 analog, administered in varying dosages on the resting canine gastric mucosa. Misoprostol did not macroscopically or microscopically damage the mucosa but its presumed permeability effects on the gastric vasculature induced marked edema of the mucosa and submucosa. Consistent features included increased thickness of both layers, dilated interglandular regions of the lamina propria, marked subepithelial edema, reduced depth and width of gastric foveolae, vasodilation of the vascular channels, reduced height of surface epithelial cells, swelling of their basolateral intercellular spaces, and increased amounts of surface adherent mucus. It is speculated that the mucosal edema, in addition to an increased mucus layer, may be important in the mechanism of gastric cytoprotection by increasing the distance of penetration or absorption for a mucosal-damaging agent, diluting its concentration, and disseminating any focal accumulations of red blood cells.

A controlled study of human resting gastric mucosal blood flow by endoscopic laser-Doppler flowmetry

We investigated regional variation in resting focal gastric mucosal blood flow obtained by endoscopic laser-Doppler flowmetry in patients with symptoms of dyspepsia or peptic ulcer (N = 12) and asymptomatic healthy volunteers (N = 6). Mucosal blood flow was measured for 1 min at the duodenum (first part), prepylorus, antrum and body (anterior and posterior walls), angularis, mid-greater curvature, fundus, and distal esophagus. At all sites, mean +/- SE blood flow in patients was 71.88% of the corresponding value in volunteers (1.15 +/- 0.10 and 1.60 +/- 0.13 volts, p less than 0.02, t test). In both groups, blood flow was highest in the fundus, followed by the body and lowest in the antrum; the angularis had a high blood flow, second only to the fundus. There was no correlation between age and blood flow. We conclude that regional variation in resting gastric mucosal blood flow exists in health and disease.

Cobalt as a gastric juice volume marker: comparison of two methods of estimation

We investigated the use of cobalt-EDTA, a novel, nonabsorbable liquid phase marker, in the estimation of secretory volumes during topical misoprostol (synthetic PGE, analog) administration in the canine chambered gastric segment. We compared atomic absorption spectrophotometry (AAS) and instrumental neutron activation analysis (INAA) in the estimation of [Co]. Mucosal bathing solutions containing cobalt-EDTA were instilled into and recovered from the chamber by gravity every 15-min period as follows: (i) basal--60 min; (ii) misoprostol periods--150 min (plus 0.1-, 1-, 10-, 100-, and 1000-micrograms doses of misoprostol for two periods per dose). The recovered solutions were analyzed for [Co] by AAS and INAA. Total cobalt recovery by AAS after chamber washout was 102.97 +/- 0.98%. Mean +/- SE volumes (12.14 +/- 0.33 and 13.24 +/- 0.60 ml/15 min) obtained respectively from AAS and INAA were significantly higher (P less than 0.001) than the recovered mean volumes (10.51 +/- 0.17 ml/15 min). The percentage error in volume collection increased (range: 9.3-52.7%) with the volume of secretion. Values of [Co] obtained by the two techniques were comparable and not significantly different from each other (P greater than 0.05). INAA-estimated mean +/- SE [Co] showed consistently higher coefficients of variation. Spectra obtained for all samples during INAA measurements showed significant Compton background activity from 24Na and 38Cl. Cobalt-EDTA did not grossly or histologically damage the gastric mucosa. We conclude that cobalt is not adsorbed, absorbed, or metabolized, and is a suitable and reliable volume marker in this model.(ABSTRACT TRUNCATED AT 250 WORDS)

The dose-response of canine focal gastric mucosal blood flow to misoprostol

We studied the dose-response of focal gastric mucosal blood flow measured simultaneously by laser-Doppler flowmetry and hydrogen gas clearance in the canine chambered gastric segment to topical misoprostol (0.1, 1.0, 10, 100, and 1000 micrograms in 10 ml of 150 mM NaCl for two 15-min periods per dose). Simultaneously obtained mucosal blood flow values showed a highly significant linear correlation (r = 0.63, n = 20, p less than 0.01) in the basal but not misoprostol periods between the two techniques. Laser-Doppler flowmetry measured a dose-dependent increase in blood flow (Emax = 6.4 +/- 2.8 V at the 100-micrograms dose; equivalent to 92.8% increase above the basal mean blood flow value; ED50 = 1.0 micrograms). Peak increase in blood flow by laser-Doppler flowmetry after dosing was attained in 6.1 +/- 0.7 min and maintained for 1.9 +/- 0.3 min. In contrast, hydrogen gas clearance showed a gradual decline in blood flow after misoprostol administration throughout all experiments. The duration of each hydrogen gas clearance measurement was 13.1 +/- 0.1 min. In conclusion, misoprostol dose-dependently and transiently increases focal gastric mucosal blood flow. However, only laser-Doppler flowmetry is sensitive enough to detect it. Although it can measure steady-state blood flow, owing to the duration of one measurement, hydrogen gas clearance is incapable of detecting rapid flow changes.

Ionic fluxes induced by topical misoprostol in canine gastric mucosa

We studied the dose response of ionic fluxes in canine chambered gastric segment mucosa to increasing doses of topical misoprostol (0.1, 1, 10, 100, and 1000 micrograms). The fluxes were also correlated with the simultaneous changes in focal gastric mucosal blood flow measured by laser-Doppler flowmetry. After misoprostol administration, there was a dose-dependent increase in focal gastric mucosal blood flow (Emax = 8.23 +/- 3.25 V at 10 micrograms; ED50 = 1.05 micrograms), pH, and the outputs of ions (Na+, K+, Cl-, and HCO3-) and fluid (Emax for pH and fluxes greater than or equal to 1000 micrograms). ED50 values for these outputs ranged from 215.40 to 340 micrograms (mean +/- SE = 279.08 +/- 24.27 micrograms). H+ output showed a dose-dependent decrease to zero at the 10-micrograms dose, the dose at and after which net HCO3- secretion became obvious. The slopes of the dose-response curves for the fluxes of fluid, Na+, K+, Cl-, and HCO3- were significantly different (p less than 0.01) from the slope of the curve for mucosal blood flow changes. There were no correlations between the changes in these fluxes and blood flow changes. Na+ and Cl- were the predominant cation (98.84%) and anion (98.19%), respectively, in the misoprostol-induced secretion. Misoprostol stimulates a composite alkaline gastric nonparietal secretion, predominantly Na+ and Cl-, but also containing K+ and HCO3-. Our results suggest different mechanisms for the effects on nonparietal secretion and focal gastric mucosal blood flow.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiostrongylus (Parastrongylus) eosinophilic meningitis

Angiostrongylus (Parastrongylus) cantonensis is the commonest cause of eosinophilic meningitis in the world. Infective third-stage larvae develop in slugs and snails. Humans are infected primarily in the central nervous system after ingesting an infected intermediate host. Damage by motile worms, inflammatory responses to foreign bodies, and possible toxicity of worm substances work in concert to produce the pathologic and clinical picture of neurologic angiostrongyliasis. This disease manifests itself by headache, paresthesias, generalized weakness, and occasionally visual disturbances and extraocular muscular paralysis. Eosinophilic pleocytosis is the major laboratory finding. Although the diagnosis of neurologic angiostrongyliasis is usually made clinically, serologic methods such as ELISA (enzyme-linked immunosorbent assay) can be helpful. Occasionally, living larvae can be identified histologically in the CSF, eye, or other tissue. There is no specific treatment for this disease. Corticosteroids may be useful to relieve increased intracranial pressure. The role of anthelmintic drugs, such as thiabendazole and ivermectin, is not yet known. The prognosis of neurologic angiostrongyliasis is usually good; however, fatal and chronic cases do occur. Appropriate preparation of food, control of mollusks and planarians, and elimination of rodents are important measures in limiting the further spread of eosinophilic meningitis caused by A. cantonensis.

Gastric mucosal blood flow in misoprostol pretreated aspirin-induced ulceration

To determine whether topical misoprostol (a synthetic PGE analog) pretreatment will increase or prevent a decrease in gastric mucosal blood flow (GMBF) during topical aspirin administration, we studied focal GMBF simultaneously by hydrogen gas clearance in a split canine gastric chamber model with one side as control. In the test chamber, immediately after topical misoprostol, there was a transient and significant increase (18%) in GMBF (55.71 +/- 7.80 to 65.84 +/- 6.12 mL/min/100 g; p less than 0.05). After 15 minutes, GMBF returned to premisoprostol levels and then showed a graded drop throughout the aspirin and postaspirin periods. No grossly visible mucosal lesions were observed. In the control chamber, mucosal lesions were observed 45 minutes after aspirin administration accompanied by a graded drop in GMBF throughout the experiments. Misoprostol neither produced a sustained increase in GMBF nor prevented the subsequent reduction in GMBF induced by aspirin. Therefore, maintenance of GMBF may not be important in cytoprotection by misoprostol. The sustained nonparietal secretion induced by this synthetic PGE1 analog may be important in gastric cytoprotection.

Focal gastric mucosal blood flow by laser-Doppler and hydrogen gas clearance: a comparative study

We compared focal gastric mucosal blood flow (GMBF) values simultaneously obtained by laser-Doppler flowmetry (LDF) and hydrogen gas clearance (HGC) from the same point in a chambered segment model of the gastric corpus in two sets of experiments (Experiments 1 and 2) involving nine anesthetized dogs (weighing 20-30 kg). We also investigated the feasibility of obtaining a conversion factor for LDF signal to absolute flow values. The GMBF values showed a highly significant linear correlation within individual experiments and for the combined data in experiments 1 (r = 0.7132, P less than 0.0001, n = 37) and 2 (r = 0.5660, P less than 0.0001, n = 61). The combined data did not corroborate a common regression line hypothesis in both experiments (Experiment 1: F = 6.59, P less than 0.0005; Experiment 2: F = 10.57, P less than 0.0005). There was a statistically significant difference between the slopes of the 5 and 4 linear regression lines obtained in Experiments 1 (F = 13.15, P less than 0.0005) and 2 (F = 21.14, P less than 0.0005), respectively. The LDF signal was stable and optical coupling is not a problem in this experimental model. HGC and GMBF values were reliable and highly reproducible within dog measurements. We conclude that LDF and HGC are comparable in the measurement of focal GMBF. Our data, however, did not suggest the existence of a conversion factor for LDF signal to absolute flow values from experiment to experiment. Conversion will have to be within individual experiments. Thus, LDF may only be useful in situations where qualitative changes in focal blood flow are investigated.

Skin potential reflex corresponding to transient motion discomfort

The qualitative and quantitative correspondence between the degree of motion discomfort and the skin potential reflex (SPR) was examined in four subjects. Head movement was provided three times during body rotation at three different angular velocities (Coriolis stimulus) to induce motion discomfort, and at rest as a control. SPRs were caused in the arousal sweat area by head movement. The wave form, latency, time-to-peak, and amplitude of SPR were analyzed. The amplitude of the depolarizing response (P response) of SPR increased proportionally to the angular velocity of body rotation and decreased in the course of repetitive Coriolis stimulation. It was revealed that the amplitude of P response of SPR in the arousal sweat area corresponds to the degree of transient motion discomfort.

Focal gastric mucosal blood flow in aspirin-induced ulceration

Focal gastric mucosal blood flow was studied during aspirin injury by hydrogen gas clearance in a chambered segment model of canine gastric corpus. Measurements were made simultaneously every 15 minutes at ulcerated and nonulcerated areas 1.5 hours before, during (20 mM of aspirin in 150 mM of HCl for 1 hour), and 2 hours after exposure of the mucosa to topical aspirin. There was a highly significant decrease (p less than 0.001) in flow at the ulcerated areas 30 minutes after exposure to aspirin, coinciding with the appearance of focal mucosal pallor followed by subsequent hemorrhagic foci and ulceration. This was not followed by recovery to basal flow values. Blood flow to the non-ulcerated areas was significantly but less severely reduced than in the ulcerated areas (p less than 0.05) 90 minutes after exposure to aspirin. This was followed by recovery to basal levels. It is proposed that aspirin induces reduction of focal mucosal blood flow of varying degrees and that mucosal areas with flow reduced to below a "critical value" develop gross damage.

Changes of skin potential level and of skin resistance level corresponding to lasting motion discomfort

The qualitative correspondence between degree of motion discomfort and electrodermal activity was investigated. Skin potential level (SPL) and skin resistance level (SRL) in the arousal sweat area and the thermal sweat area were recorded. In order to induce motion discomfort, Coriolis stimulation and/or horizontal body rotation were provided by using a rotatory chair. The degree of discomfort was evaluated according to reports by the subjects. It was observed that SPL depolarized in the arousal sweat area as well as in the thermal sweat area and SRL lowered in the thermal sweat area coincidentally with lasting motion discomfort. SPL showed better correspondence the recovery period from the motion discomfort.

Immunological aspects in patients with chronic active hepatitis--cellular immune responses

We studied host immune parameters which might be related to the activity and the pathogenetic mechanism of chronic active hepatitis. The subjects consisted of 45 cases with hepatitis B virus surface antigen (HBsAg)-positive chronic active hepatitis (CAH), 44 HBsAg-negative CAH, 22 with inactive chronic hepatitis, and 45 cases of normal persons, hepatitis B virus (HBV) carriers, or the patients with acute myocardial infarction. The in vitro assay for the in vivo activated lymphocytes was performed by measuring spontaneous thymidine uptake (SLT) of lymphocytes isolated from peripheral blood. SLT was significantly (p < 0.001) elevated in cases with HBsAg-positive (1227 +/- 806 cpm) and-negative CAH (1017 +/- 559 cpm) compared to the patients with inactive chronic hepatitis (347 +/- 79 cpm) and to the control group (320 +/- 106 cpm). SLT values observed in 7 cases with active disease (group I and II), in which remission and relapsing phase could be assessable, were elevated from 648 +/- 121 cpm in remission phase to 1548 +/- 606 cpm one to two weeks before the appearance of biochemical evidence (SGPT) of relapse. This pattern of SLT elevation, however, was not observed in patients with inactive hepatitis. Neither the abnormal distribution of T-cell subsets nor the presence of conventional HBV markers were related to the elevated SLT value. Our findings may therefore indicate that SLT might be useful in assessment of the disease activity in patients with CAH.(ABSTRACT TRUNCATED AT 250 WORDS)

Health care of the aged in Korea

Korea's population is now aging very rapidly, but the country has not yet shifted its priorities nor instituted programs to meet the needs of an aging population. While the death rate has already achieved low modern levels, there are still traces of malnutrition and other debilitative conditions among the elderly and ill health is generally believed to be an inevitable accompaniment of old age. This leads to resignation and stoicism rather than active steps to deal with the growing problems. Furthermore, care of the aged is still viewed as a private matter to be handled by the person's family and the state plays a very minor role. Medical practice is largely private with physicians drawing their financial support chiefly from fees of their patients. Only one-fourth of the elderly population is presently served to any significant degree by modern medical practitioners. The basic reason for the general lack of skilled care is economic, although folk medicine still plays a role. Only civil servants are covered by any type of health insurance and only 9% of the elderly receive any health care as social welfare recipients. Ninety-five percent of the elderly live in families, three-fourths of them with children and financially dependent upon the children. Bedfast patients are cared for by spouses or daughters-in-law. But fundamental changes are under way in the structure of families which make home care of incapacitated members impractical and burdensome.(ABSTRACT TRUNCATED AT 250 WORDS)

Pyloric function five to eleven years after Ramstedt's pyloromyotomy

Pyloric function after Ramstedt's pyloromyotomy was assessed in seven patients aged five to eleven years and compared to that in sixteen normal children. Gastric emptying (T 1/2) of liquid, as measured by the double sampling test, was faster in patients than in normal children. Duodenal reflux was calculated from the sodium content in gastric aspirates. At rest, it was greater in patients than in normal children. In the poststimulatory state, there was no difference. Gastric acid secretion was similar in both groups. Rapid gastric emptying might explain the high incidence of peptic ulcer reported in several series of long-term follow-up patients. Increased duodenal reflux at rest might account for a similar increased incidence in gastritis and dyspepsia.