Conduct of phase I trials in children with cancer

PURPOSE AND METHODS

Future progress in the care of children with cancer requires appropriate evaluations of promising new agents for pediatric indications, beginning with well-conducted phase I trials. This report summarizes current guidelines for the conduct of pediatric phase I trials and represents a consensus between American and European investigators. The primary objective of pediatric phase I trials is to define safe and appropriate doses and schedules of new agents that can subsequently be used in phase II trials to test for activity against specific childhood malignancies. Prioritization of agents for evaluation in children is critical, since many more investigational agents are evaluated in adult patients than can be systematically evaluated in children. Considerations used in prioritizing agents include activity in xenograft models, novel mechanism of action, favorable drug-resistance profile, and activity observed in adult trials of the agent.

RESULTS AND CONCLUSION

Distinctive characteristics of pediatric phase I trials, in comparison to adult phase I trials, include the necessity for multiinstitutional participation and their higher starting dose (typically 80% of the adult maximum-tolerated dose [MTD]), both of which reflect the relative unavailability of appropriate patients. The application of uniform eligibility criteria and standard definitions for MTD and dose-limiting toxicity (DLT) help to assure that pediatric phase I trials are safely conducted and reliably identify appropriate doses and schedules of agents for phase II evaluation. Where possible, pediatric phase I trials also define the pharmacokinetic behavior of new agents in children.

Sensitization to inhaled allergens as a risk factor for asthma and allergic diseases in Chinese population

BACKGROUND

Allergen sensitization is associated with asthma and allergic disease in children, but such a relationship has not been confirmed in Chinese populations.

OBJECTIVES

The objective of this study was to evaluate the effects of allergen sensitization and family history of atopy on asthma and allergic disease in Chinese schoolchildren from three southeast Asian populations.

METHODS

Written questionnaires on respiratory and allergic symptoms were completed by parents of children of secondary-school age (age range 12 to 18 years) in Hong Kong (n = 1062), Kota Kinabalu in eastern Malaysia (n = 409), and San Bu in southern China (n = 737). A subsample of school-children underwent skin prick testing to common inhalant allergens (Hong Kong 471 children, Kota Kinabalu 321, San Bu 647).

RESULTS

The prevalence of asthma and allergic disease in schoolchildren was highest in Hong Kong, intermediate in Kota Kinabalu, and lowest in San Bu. However, the overall rate of atopic sensitization was similar in the three populations (49% to 63%). House dust mite and cockroach were the two most common allergens causing sensitization and these gave rise to more than 95% of the positive skin test results in all three populations. By regression analysis, mite allergy was associated with rhinitis and asthma in all three populations, and a family history of asthma, rhinitis, or eczema was strongly associated with respective symptoms in the subjects. After adjusting for age, sex, atopic status, and family history of allergic disease, the place of residence remained a significant independent factor for asthma (odds ratio [OR] = 1.0 for Hong Kong, 0.57 for Kota Kinabalu, 0.15 for San Bu, p < 0.001), rhinitis (OR = 1.0 for Hong Kong, 0.59 for Kota Kinabalu, 0.15 for San Bu, p < 0.001), or eczema (OR = 1.0 for Hong Kong, 0.35 for Kota Kinabalu, 1.01 for San Bu, p < 0.001).

CONCLUSION

Sensitization to indoor allergens was a significant risk factor for asthma and allergic disease, and familial clustering of disease was common in the region. However, the marked difference in disease prevalence in the three southeast Asian populations of Chinese schoolchildren cannot be explained by atopic sensitization and family history alone, and the place of residence was an independent risk factor for asthma and allergies, which suggests an important environmental role in disease pathogenesis.

New drugs in non-Hodgkin's lymphoma

While novel agents designed to target molecular abnormalities involved in lymphoma pathogenesis are most likely to improve current therapeutic results, cytotoxic therapy remains the main-stay of therapy. Several new chemotherapy agents, including purine antimetabolites, taxanes, camptothecins, suramin, and protein kinase C inhibitors, are discussed. Other issues important in lymphoma drug development, including the limited patient population available for evaluation of investigational agents, are also considered.

Telomerase activity in hematopoietic cells is associated with self-renewal potential

It has been proposed that the biological clock underlying the limited division potential of eukaryotic cells is telomere length. We assayed telomerase activity in single cells of the hematopoietic and immune systems. We examined hematopoietic stem cells at four stages of differentiation, lineage-committed progenitors, and mature myeloid and lymphoid cells. The frequency of telomerase-expressing cells within each population was proportional to the frequency of cells thought to have self-renewal potential. Among bone marrow hematopoietic stem cells, 70% exhibited detectable telomerase activity. The telomerase-expressing somatic cells observed in this study are not thought to be immortal, and expression was not correlated with cell cycle distribution or differentiation state. This study demonstrates that the developmental characteristic most consistently associated with telomerase expression is self-renewal potential.

Pediatric phase I drug tolerance: a review and comparison of recent adult and pediatric phase I trials

PURPOSE

We evaluated the ratio of pediatric to adult maximum tolerated doses (MTDs) from 70 Phase I studies conducted between 1975 and 1995. The aim of this study was to determine whether previously observed differences in drug tolerance between adult and pediatric Phase I patients have persisted over the 20-year period of this analysis.

PATIENTS AND METHODS

Phase I trials of pediatric and adult patients with solid tumors as the predominant diagnosis and sharing similar dosing regimens were evaluated. For consistent comparison between Phase I studies, the MTD was defined as the drug dose one level below that yielding dose-limiting toxicity in >30% of patients. The ratio of pediatric to adult MTDs was calculated and plotted chronologically by year of pediatric study closure. Statistical evaluation of MTD ratios included regression and correlation analysis. The extent of therapy before Phase I study entry was also examined.

RESULTS

Ninety-three Phase I studies were reviewed. Twenty-one drugs (70 studies) met our criteria for paired review of MTDs and analysis of the variation of ratio with time. The pediatric to adult MTD ratios ranged from 0.4 to 2.8, with a median of 1.2. Regression analysis of the ratio of MTD versus date of pediatric study closure supports a linear relationship of decreasing ratio with time (p<0.01). Analysis of the regression line predicts MTD ratios of 2.02 and 0.76 for 1974 and 1995, respectively. Of patients included in this analysis, 37.1% and 68.6% of adult and pediatric patients, respectively, were considered to have been heavily pretreated before study entry. A significant (p<0.001) downward trend with time was observed in the proportion of adult patients entering Phase I studies who had received both radiation and chemotherapy.

CONCLUSIONS

The results of this review continue to show an equal or greater drug tolerance in the pediatric population when compared with adult patients for most drugs studied during Phase I trials. However, there appears to be significant trend of decreasing differences in drug tolerance between pediatric and adult Phase I patients with time, as defined by the descent of the MTD ratio toward values <1.0. Mechanisms to explain greater drug tolerance in children and the observation of decreasing maximum tolerated dose ratios with time are discussed. Limited data suggest that changes in degree of therapy before Phase I study entry may be influencing the MTD ratio.

A rare case of multiple intussusceptions: intense segmentary lipomatosis of the ileum

We report a patient who presented with intestinal obstruction; his small intestine showed intense segmentary lipomatosis associated with unusually situated multiple intussusceptions. Preoperatively, we diagnosed intussusceptions in the ileocecal region by ultrasonography and computed tomographic scan. During surgery, the ileum was dilated and contained numerous movable polypoid masses. One reducible intussusception was encountered in the ileocecal region. In addition, an ileoileal intussusception that could not be reduced was resected with an end-to-end anastomosis. At histological examination, more than 150 submucosal lipomas were found.

Changing patterns of susceptibilities of blood, urinary and respiratory pathogens in Hong Kong

The incidence and antimicrobial susceptibility of organisms isolated from blood, urine and respiratory specimens at a teaching hospital in Hong Kong were studied retrospectively from 1986-1993. The incidence of Gram-positive bacteraemia, particularly coagulase-negative staphylococci (CNS), increased significantly from 33.6 to 47.3% (P < 0.001) while that of Gram-negative bacteraemia fell from 60.0 to 47.0% (P < 0.001). Among blood isolates, methicillin resistance of CNS increased from 17.0 to 58.0% (P < 0.001) and cefuroxime resistance of Enterobacter spp. increased from 21.0 to over 50% (P < 0.01). Among urinary isolates, cefuroxime resistance of Klebsiella spp. (11.0 to 24.0%, P < 0.001) and Enterobacter spp. (32.0 to 75.0%, P < 0.001) increased. Nalidixic acid resistance among Gram-negative urinary isolates, except Proteus mirabilis, rose by three- to sixfold. For Streptococcus pneumoniae, isolated from the respiratory tract, penicillin resistance increased dramatically (2 to 18%, P < 0.001). For respiratory isolates of Haemophilus influenzae, ampicillin resistance increased from 17.0 to 29.0% (P < 0.001). These data are useful in guiding empirical treatment of nosocomial infections.

Asthma, allergy, and atopy in three south-east Asian populations

BACKGROUND

Whilst many recent reports have suggested a rise in the prevalence of asthma and allergic disease in Western countries, little is known about the epidemiology of these common conditions in south-east Asia. This study compared the prevalence of asthma and allergic disease amongst secondary school students in three south-east Asian populations--Hong Kong, Kota Kinabalu in Malaysia, and San Bu in China--and investigated the associations with atopy and family history.

METHODS

Secondary school students were given standard questionnaires on respiratory and allergic symptoms for completion by parents with response rates of 89.2% in Hong Kong (611 male, 451 female; mean (SD) age = 13.9 (1.8 years), 87.6% in Kota Kinabalu (134 male, 275 female; 15.5 (2.1) years), and 98.6% in San Bu (492 male, 245 female; 16.4 (1.8) years). Skin tests were performed in a subsample of students to determine atopic status.

RESULTS

The respective prevalence (and 95% CI) for hayfever, eczema, and wheeze or asthma were 15.7% (13.5, 17.9), 20.1% (17.7, 22.5), 11.6% (9.3, 13.9) in Hong Kong, 11.2% (8.2, 14.3), 7.6% (5.0, 10.1), 8.2% (5.5, 10.9) in Kota Kinabalu, and 2.1% (1.2, 3.1), 7.2% (5.4, 9.1), 1.9% (0.7, 3.1) in San Bu. Atopy was common and was present in 49.0-63.9% of subjects in the three populations. Dust mite and cockroach were the commonest allergens that gave positive reactions in 42.8-60.5% and 25.7-35.9% of students respectively. A higher proportion of students in Hong Kong had severe degree of reactivity on skin test than the other two populations. Family history was associated with asthma and allergic symptoms in the three populations conferring a 3-80-fold increase in risk to family members and was a stronger predictor for asthma and allergy than atopy.

CONCLUSIONS

Prevalence of asthma and allergic disease is low compared with Western countries, but considerable differences exist between the three south-east Asian populations despite similar rates of atopy. Asthma and allergic disease are more strongly associated with family history than atopy, which suggests that genetic and environmental factors common to the family, other than aeroallergen sensitisation, are important in the pathogenesis of asthma and allergy in the region.

Endogenous dopamine regulates phosphate reabsorption but not NaK-ATPase in spontaneously hypertensive rat kidneys

Dopamine's modulatory actions on signal transduction in the spontaneously hypertensive rat (SHR) proximal tubule are blunted; therefore, it was predicted that dopamine does not regulate phosphate (Pi) reabsorption in SHR. To test this hypothesis, dopamine production was inhibited with carbidopa (10 mg/kg ip) 18 h before and during clearance measurements of chronically denervated SHR and Wistar-Kyoto (WKY) rat kidneys. Dopamine excretion decreased 80% from SHR and 85% from WKY rats. Pi excretion decreased 60 to 67%. Plasma Pi and calcium, inulin clearance, and Na excretion did not change. Citrate excretion, which reflects proton secretion by proximal tubules, decreased 72% from WKY rats. Citrate excretion was significantly lower from SHR (5 +/- 10 pmol/min) than from WKY rats (73 +/- 11 pmol/min) and was not altered by carbidopa. Carbidopa, injected 18 and 1 h before kidneys were collected, increased NaK-ATPase in cortical basolateral membranes from WKY rats (27%) but not in membranes from SHR. After the incubation of renal cortical minceates for 15 min with L-DOPA (10(-5) M), there was no change in brush border membrane vesicle uptake of 32Pi, (3H)glucose, or (14C)citrate. Incubation with carbidopa (10(-4) M) increased 32Pi uptake by 11% (P < 0.001) and (3H)glucose uptake by 9% (P = 0.02). (14C)citrate uptake was not increased by carbidopa but was higher in SHR (977 +/- 2 pmol/10 s.mg) than in WKY rats (823 +/- 43 pmol/10 s.mg; P = 0.04). In summary, dopamine produced in WKY rat and SHR proximal tubules decreases Pi uptake by using a signaling process distinct from those that regulate NaK-ATPase and the antiporter.(ABSTRACT TRUNCATED AT 250 WORDS)

Endogenous renal dopamine production regulates phosphate excretion

We examined the effect of endogenous dopamine production on Pi and citrate excretion by Wistar rats. Carbidopa (20-40 mumol/kg ip) decreased dopamine, Pi, and citrate excretion within 20 min (86%, 47%, and 38%, respectively); Pi reabsorption increased 11 +/- 4% (P = 0.03). The decreases were sustained for at least 18 h. 3-Hydroxybenzylhydrazine (45 mumol/kg ip) reduced Pi excretion 24%. Benserazide (40 mumol/kg ip and 0.1 mumol/min iv) reduced dopamine excretion (94%) and blocked the effect of carbidopa on Pi and citrate excretion. In isolated perfused kidneys benserazide, carbidopa, and 3-hydroxybenzylhydrazine all decreased Pi excretion. Dopamine (1 mumol/l) added to cortical minceates reduced brush-border membrane vesicle (BBMV) 32P uptake by 8% (P < 0.02) and amiloride-inhibitable 22Na uptake by 19%. Carbidopa added to minceates increased 32P uptake by 12%. Carbidopa pretreatment increased (75%) amiloride-sensitive 22Na uptake into BBMV of rats fed a high-salt diet. Uptake was not increased into BBMV from rats fed a low-salt diet. Carbidopa increased (17%) basolateral membrane Na(+)-K(+)-adenosinetriphosphatase (Na(+)-K(+)-ATPase) gradually over 4 h. Na(+)-K(+)-ATPase did not increase in rats fed a low-phosphorous diet, but did increase when dopa was added to the diet. Thus endogenous dopamine appears to directly control Na(+)-Pi and Na+/H+ transport and secondarily alter basolateral membrane Na(+)-K(+)-ATPase.

[Anaphylactic reaction with coronary spasm following coronarography]

The authors report a case of anaphylactic shock following the injection of iodinated contrast medium for coronary angiography and complicated by two spasms affecting segments II and III of the right coronary. Vasospasm was relieved by the injection of linsidomine, revealing an angiographically healthy segment III. Such complications associated with various substances, notably iodinated contrast media, are rare. They should nevertheless always be borne in mind when evaluating anaphylactic type reactions. Vasoactive mediators (histamine, serotonin, arachidonic acid metabolites) released by the allergic reaction appear to play a major role. Treatment based upon pathogenesis can be proposed.

A radiation hybrid map of the BRCA1 region of chromosome 17q12-q21

The chromosomal region 17q12-q21 contains a gene (BRCA1) conferring susceptibility to early-onset familial breast and ovarian cancer. An 8000-rad radiation-reduced hybrid (RH) panel was constructed to provide a resource for long-range mapping of this region. A large fraction of the hybrids (approximately 90%) retained detectable human chromosome 17 sequences. The complete panel of 76 hybrids was scored for the presence or absence of 22 markers from this chromosomal region, including 14 cloned genes, seven microsatellite repeats, and one anonymous DNA segment. Statistical analysis of the marker retention data employing multipoint methods provided both comprehensive and framework maps of this chromosomal region, including distance estimates between adjacent markers. The comprehensive RH map includes 17 loci and spans 179 cRays(8000). Likelihood ratios of at least 1000:1 support the 10-locus framework order: cen-D17S250-ERBB2-(THRA1, TOP2A)-D17S855-PPY-D17S190-MTBT1-GP3A++ +-BTR-D17S588-tel. The order obtained from RH mapping, when used in conjunction with other methods, will be useful in linkage analysis of breast cancer families and will facilitate the development of a physical map of this region.

[Encephalopathy and memory disorders during treatments with mefloquine]

Benign psychiatric side effects have been frequently associated with mefloquine therapy. On the other hand, severe psychiatric disorders due to mefloquine are rare but must be detected by physicians. Two such cases are reported. In the first case, excessive curative mefloquine therapy caused an acute psychotic state which ultimately regress without treatment. The second report concerns a transient memory failure following prophylactic mefloquine treatment. The causative role of this compound is being discussed and the importance of a differential diagnosis of neuropsychiatric disorders from toxic or parasitic origin is underlined. Circumstances aggravating such neuropsychiatric side effects and actual recommendations concerning the prescription of mefloquine are recalled.

Percutaneous hepaticoneojejunostomy and choledochocholedochal reanastomosis using metallic stents: technical note

A new, nonsurgical approach to biliary duct reconstruction in two high-operative risk patients is presented. The first patient with an obstructed hepaticojejunostomy underwent such reconstruction by placement of Wallstent, which remained patent 9 months until death from recurrent tumor. The second patient with an inadvertently ligated common bile duct underwent a combined percutaneous transhepatic-retrograde endoscopic reconstruction with placement of a Gianturco-Rösch (GR) stent. Because of occlusion by granulation tissue 5 months later, a new GR stent covered with a silicone membrane was placed within the initial stent. Nine months after the second GR stent placement there is no evidence of obstruction.

Proximal tubular dopamine production regulates basolateral Na-K-ATPase

Regulation of proximal tubular Na-K-adenosine-triphosphatase (ATPase), brush-border membrane Na(+)-H+ antiporter and Na(+)-Pi symporter activity by endogenously produced dopamine was examined in Wistar rats. Na-K-ATPase was measured in basolateral membrane (BLM) fractions permeabilized with alamethicin or sodium dodecyl sulfate (SDS). Carbidopa (5 mg/kg) injected 18 h before removal of kidneys increased maximal activity (Vmax) noncompetitively in cortical BLM but not in other membrane fractions or outer medullary BLM (-2 +/- 4%). Chronic renal denervation did not alter the response. Carbidopa stimulated Na-K-ATPase in cortical BLM from rats eating a normal salt diet with and without 1% saline to drink (+18 +/- 4% and +22 +/- 4%, respectively; P greater than 0.001). Carbidopa did not increase Vmax of BLM Na-K-ATPase from rats eating a low-salt diet (+1.5 +/- 4%); however, when the low-salt diet was supplemented with 1 mM dihydroxyphenylalanine (dopa) to drink for 1 day carbidopa, increased Vmax by 18 +/- 3% (P = 0.018). Carbidopa did not alter the Michaelis constant (Km) for Na or K or inhibitory constant (Ki) for ouabain. Injection of the DA1 antagonist Sch 23390 (2 mg/kg) also increased Na-K-ATPase (18 +/- 4%; P = 0.014). Western blots using a monoclonal alpha-subunit antibody revealed a 22 +/- 8% increase following carbidopa treatment (P = 0.033; n = 19 pairs). Carbidopa had no effect on Na(+)-H+ antiporter activity (22Na uptake) or on Na(+)-32Pi cotransport in brush-border membrane vesicles. These results indicate that dopamine produced in proximal tubules tonically reduces Na-K-ATPase Vmax by decreasing the number of alpha-subunits associated with the BLM.

Parathyroid hormone-related protein: elevated levels in both humoral hypercalcemia of malignancy and hypercalcemia complicating metastatic breast cancer

A RIA for PTH-related protein (PTHrP) is described, using a polyclonal goat antiserum against synthetic PTHrP-(1-40) and recombinant PTHrP-(1-84) as standard. The detection limit is 2 pmol/L, and intra- and interassay coefficients of variation are 4.8% and 13.6%, respectively. This assay does not detect PTH even at concentrations of up to 2000 pmol/L. Cross-reactivity studies using various synthetic PTHrP peptides localize the antibody-binding epitope between residues 20 and 29. Hypercalcemic patients with a range of solid tumors and no evidence of bone metastases on radionuclide scanning (n = 27) all had detectable PTHrP levels (range, 2.8-51.2 pmol/L). Of 17 patients with solid tumors (other than breast) and bone metastases, 11 (64%) also had detectable PTHrP levels (range, 4.9-47.5 pmol/L). Twenty samples from breast cancer patients with hypercalcemia, 19 with evidence of bone metastases, and 1 with a negative bone scan were assayed, and detectable PTHrP levels were found in 13 (65%; range, 3.8-61.6 pmol/L). Patients with squamous cell carcinomata and normal serum calcium levels (n = 11) had no detectable PTHrP or levels close to the detection limit of the assay (range, less than 2 to 3.7 pmol/L). Plasma levels in normal volunteers were below the detection limit of the assay in all but 1 of 38 normal subjects. Patients with chronic renal failure on hemodialysis (n = 18) and patients with primary hyperparathyroidism (n = 14) all had undetectable PTHrP in this assay. This assay allows positive identification of patients with PTHrP-mediated hypercalcemia and, therefore, should be useful in the clinical investigation of the hypercalcemic patient. Furthermore, it has allowed detection of circulating PTHrP in hypercalcemic breast cancer patients with bone metastases, indicating a significant role for PTHrP in this disease.

Involvement of tyrosine kinases in the activation of human peripheral blood neutrophils by granulocyte-macrophage colony-stimulating factor

The aim of the present study is to evaluate the involvement of human neutrophil tyrosine kinase(s) in the signal transduction mechanism of granulocyte-macrophage colony-stimulating factor (GM-CSF). Stimulation of neutrophils with GM-CSF resulted in a time- and dose-dependent phosphorylation of several proteins having estimated molecular weights of approximately 40, 55, 74, 97, 118, and 155 Kd, detected by immunoblot using a monoclonal antibody directed against phosphotyrosine. GM-CSF-induced tyrosine phosphorylation was inhibited in a dose- and time-dependent manner by the tyrosine kinase inhibitor erbstatin. Using this inhibitor, we were able to correlate tyrosine phosphorylation with several functional effects of GM-CSF on human neutrophils. Pretreatment of neutrophils with erbstatin before incubation with GM-CSF completely inhibited the GM-CSF-induced intracellular alkalinization, downregulation of the leukotriene B4 receptor, enhancement of fMet-Leu-Phe-induced intracellular calcium mobilization, as well as the accumulation of mRNA for the proto-oncogene c-fos. Taken together, these data suggest that tyrosine kinase activation in human neutrophils plays a critical regulatory role in both the stimulation and priming of neutrophil function by GM-CSF.

Activation of MAP-2 kinase activity by the CD2 receptor in Jurkat T cells can be reversed by CD45 phosphatase

We have recently characterized a serine kinase in T lymphocytes which phosphorylates microtubule-associated protein-2 (MAP-2) in vitro. This kinase is activated in a rapidly reversible fashion during ligation of CD3/Ti by a process which involves tyrosine phosphorylation of the enzyme itself. We show that the stimulatory anti-CD2 mAb combination, anti-(T11(2) + T11(3), stimulates MAP-2K activity in Jurkat cells with kinetics that are more prolonged than during anti-CD3 treatment. The principal difference is not in the rate of response induction, but in the decline of the response beyond the peak, to which end anti-CD2 stimulation resembles the sustained phytohaemagglutin (PHA) response. Parallel immunoblotting, utilizing anti-phosphotyrosine antibodies, also revealed differences in the rate at which tyrosine phosphorylation of pp43 (MAP-2K) disappears after induction. In spite of these differences, CD2 was absolutely dependent on the presence of CD3 for inducing a MAP-2K response in Jurkat cells. These results indicate that, even though CD2 and CD3 are using a common signalling pathway in Jurkat cells, additional differences such as the involvement of a tyrosine phosphatase may have to be considered in response generation. We also demonstrate that the common CD45 isoform, when cross-linked to CD2 by mAb, could inhibit the MAP-2K response during both induction as well as the disappearing phase of the response.

Diacylglycerol and protein kinase mediated noradrenergic responses in perfused rat kidneys

The role of protein kinases in renal noradrenergic stimulation was examined using sphingosine, 1-(5-isoquinolinylsulfonyl)-2-methyl-piperizine (H7), using sphingosine, 1-(5-isoquinolinylsulfonyl)-2-methyl-piperizine (H7), or staurosporine to inhibit the responses to norepinephrine (NE, 60 nM) in isolated perfused rat kidneys. Sphingosine (20 mumol/L) increased the noradrenergic vasoconstrictor response. H7 (10 mumol/L) partially blocked the immediate vasoconstrictor response and completely inhibited it after 2 min without altering the antinatriuretic and antilithuretic responses. H7 also blocked the increase in free water produced by NE, which is consistent with the inhibition of protein kinase A linked to beta-adrenergic stimulation. Staurosporine (10 nmol/L) partially inhibited noradrenergic vasoconstriction and antinatriuresis, and it completely blocked the depression of gluconeogenic responses to NE in pyruvate-perfused kidneys. To examine the role of diacylglycerol and protein kinase C in the renal responses to NE, we used oleoyl-acetyl-glycerol (OAG, 50-100 microM) or phorbol-12-myristyl-13-acetate (TPA, 5-50 nM). TPA slowly vasoconstricted the kidney and reduced GFR and fractional Na+, Li+, and free water excretion. Amiloride (1 mM) prevented the TPA responses. OAG mimicked the effects of TPA except that vasoconstriction occurred more rapidly and was brief. Both TPA and OAG acted like alpha 1-adrenergic agonists. These results indicate that diaclyglycerol and protein kinase are involved in the prolonged effects of NE on vasoconstriction. GFR, and proximal tubular reabsorption.

Mechanisms of perfused kidney cytoprotection by alanine and glycine

We examined the cytoprotective action of individual amino acids in isolated perfused kidneys during perfusion with either 10 mM lactate or 5 mM glucose. In the absence of amino acids inulin clearance fell rapidly, whereas fractional excretion of phosphate, lactate, or glucose increased to more than 30%; lactate dehydrogenase was released into perfusate and alkaline phosphatase into the urine. Functional deterioration was less in kidneys from rats rendered chronically water diuretic by drinking 5% glucose. Adding 5 mM glycine, L-alanine, beta-alanine, or D-alanine to the perfusate also prevented functional deterioration and release of enzymes. Glycine perfusion increased total phospholipid per microgram DNA by 6%. Aspartate, glutamate, glutamine, taurine, isoleucine, leucine, and valine were not protective. Serine, proline, and alpha-aminoisobutyric acid had small protective effects. Micropuncture measurements of proximal tubular free- and stop-flow pressures showed no effect of L-alanine on glomerular hemodynamics. L-Alanine increased oxygen consumption by both glucose- and lactate-perfused kidneys and increased gluconeogenesis by lactate-perfused kidneys but did not alter renal ATP content or energy charge. L-Alanine was not consumed during 70 min of perfusion and its protective action was not inhibited by blocking transamination with 0.5 mM amino-oxyacetate. The protective action of glycine was not inhibited by blocking glycine metabolism with 0.1 mM cysteamine. Thus the beneficial effects of L-alanine and glycine do not require their metabolism. These observations suggest that small neutral amino acids prevent tubular disruption through their physicochemical effects, which can stabilize membrane protein tertiary structure.

Role of diacylglycerol in adrenergic-stimulated 86Rb uptake by proximal tubules

We used rat proximal tubule fragments purified by Percoll centrifugation to examine the role of diacylglycerol (DAG) in noradrenergic-stimulated Na+ reabsorption. Tubular DAG concentration and ouabain-inhibitable 86Rb uptake increased within 30 s after adding norepinephrine (NE) and remained elevated for at least 5 min. NE (1 microM) increased DAG content 17% and ouabain-inhibitable 86Rb uptake 23%. Cirazoline-stimulated 86Rb uptake was not inhibited by BaCl, quinidine, or bumetanide (1-10 microM) or by the omission of HCO3- or Cl- from the medium, but it was completely inhibited by ouabain and furosemide. Oleoyl-acetyl glycerol, L-alpha-1,2-dioctanoylglycerol, and L-alpha-1,2-dioleoylglycerol (DOG) increased total 86Rb uptake 8-11%. 12-O-tetradecanoylphorbol-13-acetate (TPA) (5 nM) increased uptake by only 4%. Staurosporine at 5 nM inhibited DOG stimulation completely, whereas 50 nM staurosporine was required to inhibit NE stimulation completely. Sphingosine inhibited DOG stimulation by 66% but did not inhibit NE stimulation. Amiloride (1 mM) completely blocked DOG stimulation. Monensin increased 86Rb uptake 31% and completely blocked the DOG effect but reduced the NE effect by only 26% (P = 0.08). In tubules from salt-loaded rats, NE did not increase DAG concentration, but NE-stimulated 86Rb uptake was reduced by only 23% (P = 0.15). Thus DAG released by NE may stimulate Na+ entry through Na(+)-H+ exchange. NE predominantly stimulates Na(+)-K(+)-adenosinetriphosphatase (ATPase) by activating a protein kinase that is insensitive to DAG and TPA and is inhibited by staurosporine but not by sphingosine. NE may also stimulate K+ efflux through a BaCl-insensitive K+ channel that is inhibited by millimolar furosemide.(ABSTRACT TRUNCATED AT 250 WORDS)

Eight-month longitudinal study of urinary excretion of albumin and tubular proteins in diabetic subjects

To evaluate the importance of tubular proteinuria in diabetic nephropathy, we studied the serial changes of micro-albuminuria, microproteinuria and protein patterns by sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) in 38 diabetic patients over 8 months. There was a significant correlation between the amount of micro-albuminuria measured by radio-immunoassay and the amount of microproteinuria quantitated by the Coomassie brilliant blue dye binding method (r = 0.976; p less than 0.0001). Micro-albuminuria of 50 mg/day was equivalent to microproteinuria of 190 mg/day. Among the 38 diabetic patients, 26 had micro-albuminuria above 50 mg/day, while 12 had micro-albuminuria below this level. There was a significant correlation between the amount of microproteinuria and haemoglobin A1, showing that the quantity of microproteinuria was affected by metabolic control. Diabetic patients with micro-albuminuria of above 50 mg/day have a significantly higher diastolic blood pressure than those below this level. Among the diabetic patients with micro-albuminuria of less than 50 mg/day, the amount of micro-albuminuria and microproteinuria remained constant, whereas progressive increases in micro-albuminuria and microproteinuria were observed among the 12 diabetic subjects with micro-albuminuria above 50 mg/day. These support the prognostic importance of this quantity of micro-albuminuria. The protein patterns as revealed by SDS-PAGE with Coomassie blue staining show a significant loss of low-molecular-weight proteins in 7 patients, which may therefore suggest tubular damage. The loss of tubular proteins persisted over a period of 8 months in all 7 subjects, and the amount gradually increased over this period.(ABSTRACT TRUNCATED AT 250 WORDS)

A Canadian multicenter study with Zaditen (ketotifen) in the treatment of bronchial asthma in children aged 5 to 17 years

One hundred thirty-eight children with chronic asthma, requiring daily treatment with bronchodilators, took part in a 7-month, double-blind, multicenter clinical study. Patients were randomized into two groups, and after a 1-month baseline, were administered Zaditen (ketotifen), 1.0 mg twice daily, or an identical placebo for a period of 6 months. After 10 weeks of receiving the study medication, bronchodilator use was reduced or stopped. In the Zaditen-treated group, 60% of the children taking theophylline were able to stop its use completely, compared to 34% of the patients taking placebo (p less than 0.05). Of the patients who were unable to stop taking theophylline, the Zaditen-and placebo-treated groups recorded average dosage reductions of 62% and 26%, respectively. These differences were statistically significant (p less than 0.05). Thus, a high percentage of patients in the placebo-treated group maintained asthma symptom control with theophylline, whereas most of the Zaditen-treated patients could stop using this medication. Although pulmonary function readings improved in both groups, those patients taking Zaditen demonstrated earlier improvement and greater changes from baseline. Significant differences (p less than 0.05) in favor of Zaditen were found for reduction of concomitant medications, patient's global evaluation, physician's clinical evaluations, incidence of emergency room visits for asthma, and upper respiratory tract infections. No unexpected side effects were observed. It is concluded that Zaditen is an effective medication for long-term control of asthma in children.

Gas chromatographic determination of gallopamil and norgallopamil in human plasma

A highly sensitive gas chromatographic assay is described for the simultaneous determination of gallopamil, a calcium channel blocking agent, and its major metabolite, norgallopamil. A multi-step extraction procedure is employed followed by on-column capillary gas chromatographic analysis using nitrogen-selective detection. Acetylation of norgallopamil is performed to enable accurate quantification of the metabolite. Linearity was achieved over the range 1-50 ng/ml for both analytes. Assay specificity, precision and accuracy were investigated.

Long term pulsatile growth hormone (GH)-releasing hormone therapy in children with GH deficiency

We treated seven GH-deficient children with 3-hourly 1 microgram/kg sc pulses of GHRH-(1-44) for 6 months and 2 micrograms/kg.pulse for another 6 months. Four patients had a serum GH response to iv GHRH before treatment, and an additional patient responded to iv GHRH after 1 month of pulsatile sc GHRH administration. The mean cumulative growth velocity increased from a pretreatment mean of 2.7 +/- 0.2 (+/- SE) to 8.4 +/- 2.5 and 5.4 +/- 0.7 cm/yr after 2 months and 1 yr of treatment, respectively. Low dose pulsatile GHRH therapy was effective in promoting growth in five of seven children, with height gain ranging from 4.4-7.5 cm at the end of 1 yr's therapy. Only one of the two patients who did not respond to GHRH had an improvement in linear growth when they were subsequently treated with synthetic GH. The other patient, a 16.5-yr-old pubertal girl who had both satisfactory GH and somatomedin-C responses during GHRH therapy, did not respond to either GHRH or, later, synthetic GH. The pretreatment serum GH response to iv GHRH, the serum somatomedin-C concentrations, and the peak serum GH response during sc GHRH therapy were not reliable predictors of clinical response.

Neural stimulation of gluconeogenesis in isolated pyruvate-perfused rat kidneys

To estimate peritubular norepinephrine concentration during renal nerve stimulation, we compared gluconeogenic responses in isolated pyruvate-perfused rat kidneys with electrical nerve stimulation and exogenous norepinephrine. During 2 and 4 Hz stimulation, venous norepinephrine was 1.7 +/- 0.4 and 2.7 +/- 0.9 nmol/L, respectively. Intra-arterial norepinephrine infusion of 60 pmol/min for 20 min (an amount corresponding to that released during 4 Hz stimulation) resulted in venous norepinephrine levels of 3.6 +/- 0.6 nmol/L. Electrical stimuli (1, 2, and 4 Hz) sustained increases in vascular resistance of 2, 5, and 11% during 20 min of stimulation, while the norepinephrine infusion increased resistance gradually by 8% and a bolus (12.5 nmol/L) transiently increased resistance by 2%. All electrical and norepinephrine interventions, except 1 Hz, decreased fractional Cl excretion. Decreased glomerular filtration rate was observed only during 4 Hz stimulation. Gluconeogenesis transiently increased during stimulation at 2 or 4 Hz (12% (p = 0.056) and 15% (p = 0.028]. The 5% increase in gluconeogenesis during norepinephrine infusion did not differ from the increase during 4 Hz stimulation (p = 0.45). An exogenous norepinephrine bolus (12.5 nmol/L) increased gluconeogenesis 60% for 15 min, four time more than the response to 4 Hz nerve stimulation (p = 0.012). Therefore, we conclude that nerve stimulation sufficient to produce sustained vasoconstriction and antinatriuresis raised norepinephrine concentration less than 12 nmol/L on the peritubular surface of the S1 proximal tubule, thus accounting for the small gluconeogenic response.

[Multiple sclerosis disclosed by spinal anesthesia]

A case is reported of an acute onset of previously undiagnosed multiple sclerosis, revealed by an oculomotor paralysis following spinal anaesthesia performed for minor orthopaedic surgery. The need for a complete preoperative physical examination is underlined by this case, looking for latent neuromuscular disorders before undertaking such techniques, and for a thorough neurological work-up should such a complication arise. The harmlessness of regional anaesthesia in multiple sclerosis patients is controversial; without entering into such a debate, the direct relationship between spinal anaesthesia and acute exacerbation of the disease in our patient seemed more than likely.

Neuroendocrine (Merkel cell) carcinoma of the vulva

The clinical, histopathologic, and ultrastructural features of a primary cutaneous vulvar neuroendocrine neoplasm (Merkel cell carcinoma) are presented. This recently described tumor arises in the dermis and is often aggressive with metastasis to regional lymph nodes. Ultrastructural study of this case reveals morphologic similarities to normal cutaneous Merkel cells, including peripherally located dense-core neurosecondary-like granules, and immunohistochemical studies revealed ACTH within neoplastic cells. By light microscopy this tumor is readily confused with other primary or metastatic cutaneous neoplasms; therefore, the importance of electron microscopic examination is emphasized for definitive diagnosis of this unusual tumor.

Alpha 1-adrenergic stimulation of renal Na reabsorption requires glucose metabolism

The effect of glucose on renal responses to alpha 1-adrenergic stimulation was examined in isolated rat kidneys perfused with 5 mM lactate, 5 mM alanine, 0.5 mM pyruvate, and 0.2 mM mercaptopicolinic acid. Adding 5 mM glucose to this perfusate vasodilated the kidneys and raised the glomerular filtration rate (GFR) and free water clearance without altering fractional sodium excretion. alpha 1-Adrenergic actions were evaluated with norepinephrine (NE, 60 nM), methoxamine (600 nM), and prazosin (1 microM). Glucose altered neither the vasoconstriction nor the reduction in GFR produced by NE and methoxamine but increased the antinatriuretic responses (P less than 0.001). Glucose was required for prazosin to inhibit the effect of NE on sodium and lithium excretion. The nonmetabolized glucose analogue, alpha-methyl-D-glucoside (5 mM), did not increase the antinatriuretic response to NE, therefore glucose metabolism and not Na cotransport stimulated the alpha 1-adrenergic response. Glucose did not alter alpha 1-adrenoceptor number or binding affinity for prazosin in renal cortical homogenates. We conclude that glucose metabolism in the proximal tubule is involved in the stimulation of sodium reabsorption by alpha 1-adrenoceptor agonists.

Sorbents used for removal of urea in the system of artificial kidney

Three copolymers were made from the suspension polymerization of methyl acrylate, divinyl benzene and triallyl isocyanurate; acrylamide and N,N'-methylene-bis-acrylamide; and styrene and divinyl benzene. These copolymers were then converted into derivatives of hydrazides through several steps. They were used as polymeric sorbents. They sorbed in situ a little bit less than 40 mg. of urea per gram of sorbent at 37 degrees C, pH = 7.0-7.4 and the percentage of urea in the buffer solution being 130 mg%. The sorption of urea was related to the specific surface area of the sorbent, temperature of sorption and time of sorption, concentration of urea, pH value of solution etc. In order to find out whether the above-prepared derivatives of hydrazide can be used clinically as polymeric sorbents in artificial kidney system, the junior author carried out experiments with patient's dialysate as imitated to hemodialysis. From the results, it indicates the sorbents might be used in artificial kidney system because they sorbed the urea from hemodialysate as much as that of the pure urea in a buffer solution.

Specific alpha 1-, alpha 2-, and beta-responses to norepinephrine in pyruvate-perfused rat kidneys

We compared the effects of alpha- and beta-adrenergic agonists on vascular resistance, gluconeogenesis (GNG), and electrolyte excretion in pyruvate-perfused rat kidneys. Norepinephrine (NE) (15-60 nM) increased vascular resistance (2-19%) and GNG (42-49%) and decreased fractional excretion of Na (18-34%), Cl (38-48%), and K (13-27%). Prazosin and yohimbine blocked the vasoconstrictor but not the antinatriuretic response. Prazosin revealed an antiphosphaturic and inhibited the gluconeogenic response. Propranolol blocked the effect on Na and Cl (66%) and K excretion (100%). Methoxamine (0.6-1 microM) maximally increased GNG (40-52%) with little effect on vascular resistance (+0-9%) and NaCl excretion (-0-11%). Adding glucose to the perfusate increased methoxamine's effects on electrolyte excretion and vascular resistance. Mercaptopicolinate did not alter methoxamine's effects during pyruvate perfusion. Clonidine (0.1 microM) decreased phosphate excretion without vasoconstriction or antinatriuresis; 0.5-1 microM vasoconstricted and decreased NaCl excretion. Isoproterenol (0.1 microM) vasodilated and decreased Na (25%), Cl (40%), and K excretion (20%). Thus alpha 1- and beta-receptors could account for the effect of NE on GNG and K reabsorption, respectively. Synergism of alpha 1, alpha 2, and beta were required for full antinatriuresis. Glucose increased alpha 1-stimulated vasoconstriction and antinatriuresis. Blocking alpha 1-receptors revealed an alpha 2-like antiphosphaturic response.

Assessment of habitual physical activity by a seven-day recall in a community survey and controlled experiments

Assessment of habitual physical activity in epidemiologic and health education studies has been difficult. A seven-day physical activity recall interview was developed and administered in a community health survey, a randomized clinical trial, and two worksite health promotion programs during 1979-1982. These studies were conducted in several populations in California, Texas, Pennsylvania, and New Jersey. Energy expenditure estimates from the physical activity recall conformed to expected age- and sex-specific values in the cross-sectional community survey. Estimates of energy expenditure were also congruent with other questions on physical activity and job classification. In a randomized, one-year exercise trial, the physical activity recall detected increases in energy expenditure in the treated group and was positively associated with miles run during training (p less than 0.05). Changes in energy expenditure were associated with changes in maximal oxygen uptake (VO2max (r = 0.33, p less than 0.05) and body fatness (r = -0.50, p less than 0.01) at six months, and in high density lipoprotein-cholesterol (r = 0.31, p less than 0.05) and triglyceride (r = -0.41, p less than 0.01) at one year. The physical activity recall detected significant (p less than 0.01) increases in energy expenditure in treatment groups in two worksite health promotion projects. These data suggest that the physical activity recall provides useful estimates of habitual physical activity for research in epidemiologic and health education studies.

Metabolic control of renal vascular resistance and glomerulotubular balance

Renal vascular resistance (RVR) and glomerulotubular balance were examined in isolated rat kidneys perfused at 100 mm Hg with 10 mM lactate (L) or 10 mM pyruvate (P) or 5 mM glucose (G) either alone or with a mixture of 20 amino acids (13.5 mM, AA); albumin oncotic pressure 24 +/- 1 mm Hg. RVR was L greater than P greater than G = AA. Vasodilation by G and AA was additive. Proximal tubular sodium-cotransport was evaluated from fractional reabsorption (FR) of phosphate (Pi), G, and L. FR Pi was 91% in AA, 86% in P, 72% in L, and 67% in G. Combining AA or P with L or G increased FR Pi to 89 to 90%. FRs of G and L by G and L perfused kidneys were 83 and 78%, respectively, and were increased to 97 to 99% by combining G or L with AA or P. P and AA also increased FR sodium and FR water when combined with L or G or when combined with each other. GFR correlated positively with FR sodium and FR water. AA combined synergistically with L to increase gluconeogenesis. These results indicate that, compared with pyruvate or AA, neither glucose nor lactate alone is a good energy source for proximal tubular reabsorption, that synergistic interactions between AA or pyruvate and lactate or glucose augment GFR by increasing proximal tubular reabsorption, and that the vasodilating effects of glucose and AA are not related directly to their effects on GFR.