Single and multiple test repetition priming in implicit memory

Using a picture naming task, we compared the magnitude of repetition priming after one prior study episode (single test priming) versus multiple prior study presentations (multiple test priming). Pictures were repeated either one, two, or three times, and the interval between tests was either several minutes (blocked test) or one week (spaced test). Priming increased with additional prior presentations (beyond one) in the multiple test format. In addition, single test priming decreased within one hour after initial exposure, with little change from one hour to two weeks. Priming was unaffected by a simultaneous recognition task, suggesting that picture naming is an implicit task relatively immune from explicit memory contamination.

Planning for the future: moving to the multispecialty group organizational structure

Physicians in a Southeastern community were finding themselves ill equipped to deal with many of the requirements of insurance companies, state governments and managed care organizations. One medical practice was considering moving toward becoming a multispecialty group and adding physicians to keep with their objective of having a "growing practice." This case study is centered around the efforts of the physicians' involvement in the strategic planning process of growing their practice.

The effect of granulocyte-macrophage colony stimulating factor (rGM-CSF) on macrophage function in microbial disease

The haematopoietic growth factor, GM-CSF, has well-documented stimulatory effects on monocyte and macrophage functions. These effects include enhanced proliferation on their progenitor cells, increased endocytosis and metabolism of mature cells, increased function as antigen-presenting cells, and increased inhibition or killing of intracellular fungi, bacteria, protozoa and viruses. The major effect of GM-CSF on monocytes and macrophages is to enhance phagocytic and metabolic functions, including increased synthesis of molecules toxic to microbes, and to release other proinflammatory cytokines. This results in inhibition and/or killing of Candida albicans, Aspergillus, Cryptococcus, Pneumocystis, Leishmania, Mycobacteria, as well as other intracellular pathogens. GM-CSF also enhances the intracellular effectiveness of antiviral and antibacterial drugs. Viral replication may be increased in activated cells, therefore, when GM-CSF is used, a combination with appropriate antiviral drugs is recommended. Several reports in patients of successful management of microbial diseases which depend on macrophage function are now reviewed. These reports support the clinical value of GM-CSF in the management of patients with cancer and chemotherapy related monocyte/macrophage dysfunction and presumed or documented microbial disease.

Present status of the use of cytokines as adjuvants with vaccines to protect against infectious diseases

Vaccine adjuvants are expected to play an important role in enhancing the immunogenicity of existing and new-generation vaccines against infectious diseases. In particular, adjuvants should direct the immune response in the most appropriate manner--furthering, for example, an expanded B-cell response, a cytotoxic T-cell response, or a T-helper 1 or 2 subset response. While some noncytokine adjuvants have exerted potent effects, their modes of action are most likely mediated by cytokines. Several cytokines have already been shown to be efficient adjuvants in animal models and/or in clinical trials. The mechanisms of cytokine function must be better understood and the techniques for the use of cytokines improved if the full potential of these substances as vaccine adjuvants is to be realized. When used to best advantage, such adjuvants enhance the immunity induced by viral, bacterial, and parasitic vaccines and thereby promote efficient protection or even cure.

Overview of the use of terbinafine (Lamisil) in children

This review summarizes the efficacy and tolerability of terbinafine (Lamisil) in the treatment of dermatophytoses in children. In six clinical studies, 152 children who received terbinafine were evaluable for efficacy and 196 were evaluable for tolerability. In these studies, terbinafine was used for between 1 and 28 weeks. The median treatment was 4 weeks, the duration of treatment in the tinea capitis studies. As a result of extensive experience in adults at doses of 10 mg/kg and less, and the overall pharmacokinetic profile in children, including the lower volume of distribution of terbinafine into lipophilic tissue, the use of a dose of 125 mg/day for children weighing 20-40 kg, and 62.5 mg/day in children weighing less than 20 kg, has been proposed. This dose was shown to be well tolerated and effective. For children weighing > 40 kg, the adult dose of 250 mg is appropriate. Terbinafine was shown to be very effective (93% cured), in the treatment of children with tinea capitis, using a shorter treatment duration (4 weeks) than that usually employed with presently available antifungal drugs. It is also effective in children with various dermatophyte infections of the skin, with a cure rate of more than 90%. Terbinafine was shown to be well tolerated in children aged between 2 and 17 years. The recommended duration of treatment for tinea capitis is 4 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

Recombinant human granulocyte-macrophage colony-stimulating factor reverses neutropenia and reduces secondary infections in visceral leishmaniasis

Twenty-four patients with acute visceral leishmaniasis and leukopenia (< 1500 neutrophils/mm3) due to Leishmania chagasi were studied, 4 in an open-label pilot study and 20 in a double-blind, placebo-controlled trial. Patients received granulocyte-macrophage colony-stimulating factor (GM-CSF), 5 micrograms/kg daily, or placebo for 10 days, plus 10-20 mg/kg pentavalent antimony daily for 20 days. In GM-CSF recipients, neutrophil counts increased threefold and fourfold over baseline at 5 and 10 days, respectively, and were significantly higher than those in placebo recipients (P < .02). Eosinophil and monocyte counts were significantly increase in GM-CSF recipients at 10 days (P < or = .03). Secondary infections occurred in 3 GM-CSF and in 8 placebo recipients (P = .04). All patients had complete resolution of their leishmaniasis at 3 months. Few adverse events were recorded. GM-CSF, 5 micrograms/kg daily for 10 days, was safe, rapidly reversed neutropenia, and reduced the number of secondary infections in patients with leishmaniasis.

Future uses of granulocyte-macrophage colony-stimulating factor (GM-CSF)

Granulocyte-macrophage colony-stimulating factor (GM-CSF) has been used extensively to restore hematopoietic system function after damage by diseases such as myelodysplastic syndrome or by cytotoxic anti-cancer agents used during cancer chemotherapy or prior to bone marrow transplantation. The clinical benefits of this approach have included fewer infections, fewer hospital days and less antibiotic use. In the future, the use of GM-CSF will be focused on special situations within these general areas, plus new directions that were not previously given sufficient attention. Examples of focused approaches include the use of GM-CSF in the control of fungal or protozoal disease and to take advantage of anti-tumor effects of myeloid cell activation. The anti-microbial effects will also be explored in patients who are not neutropenic but have serious infections which may be benefited by increased stimulation to myeloid cell function. The use will also be focused on mobilization of peripheral blood progenitor cells and in cycling of normal hematopoietic and malignant cells. The new directions will include use of GM-CSF by local application in healing of cutaneous ulcers, rapid wound closure and skin grafting. Because of its potent effects on immunologic mechanisms of antigen presentation, it will be used in several ways as a vaccine adjuvant. This adjuvant action will be directed at enhancing immunologic responses to antimicrobial antigens and anti-tumor antigens. The future of GM-CSF as a tool for hematopoietic and immunologic stimulation with resulting important clinical benefits is clear.

Granulocyte-macrophage colony-stimulating factor in combination with pentavalent antimony for the treatment of visceral Leishmaniasis

The efficacy of GM-CSF was investigated in 20 neutropenic patients (< 1500 neutrophils/microliters) with acute visceral leishmaniasis due to Leishmania chagasi. Patients were randomized to receive either GM-CSF, 5 micrograms/kg daily (intravenously or subcutaneously), or placebo for ten days, in combination with pentavalent antimony, 10-20 mg/kg daily for 20 days. Neutrophil counts were significantly greater on days 5 and 10 of treatment in the GM-CSF group compared with the placebo group (p < 0.02). Eosinophil and monocyte counts were also significantly increased in the GM-CSF group at day 10 (p < or = 0.03). Interestingly, at day 30, platelet counts were significantly increased in the GM-CSF group on days 5 and 10 (p = 0.04 and 0.02, respectively). Patients in the GM-CSF group experienced fewer secondary bacterial or viral infections than placebo patients. Infections occurred in only three patients given GM-CSF compared with eight patients given placebo (p < 0.04). All patients had complete resolution of disease symptoms at three months. Few adverse events were recorded. GM-CSF given subcutaneously at a dose of 5 micrograms/kg daily for ten days was well tolerated, reversed neutropenia rapidly and reduced the number of secondary infections in patients with leishmaniasis.

Intervention treatment of established neutropenia with human recombinant granulocyte-macrophage colony-stimulating factor (rhGM-CSF) in patients undergoing cancer chemotherapy

Recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) was given to 60 patients, in a double-blind, non-prophylactic study of already established chemotherapy-induced leucopenia, for 5 days by continuous intravenous infusion and twice or once daily by subcutaneous injection. Four patients were randomized to rhGM-CSF (3) or placebo (1) at each dose (1.3, 1.7, 5.5, 11, or 22 micrograms of protein/kg). Leucocyte recovery was significantly enhanced compared with controls, in a dose-dependent manner except for 22 micrograms/kg which was ineffective with a worse experience of side effects in some patients. Most adverse events occurred in equal proportions in the treated and placebo cases. Fourteen patients developed infection and were treated with antibiotics in addition to rhGM-CSF. They were joined by a further 18 febrile patients and treated with rhGM-CSF in a subsequent open-label trial. The survival from infection was related to white blood cell (WBC) count: 19 of 32 responded with increased numbers of leucocytes (WBC count above 1.5 x 10(9)/1) after 5 days of GM-CSF. Sixteen of the 19 leucocyte 'responders' recovered from infection, two died from the underlying disease and one from persistent infection. Six of the 13 patients who did not have a leucocyte response died with persistent infection. These data indicate that rhGM-CSF enhances the leucocyte count following chemotherapy and in this way saves critically ill neutropenic patients from fatal infections.

The effects of rhGM-CSF on macrophage function

Markers of monocyte/macrophage activity are numerous, and offer an insight on the potential effects of recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF). These include anti-microbial effects, anti-tumour effects, inflammation and wound healing enhancing effects, antigen presenting effects and effects on the haematopoietic microenvironment. The actions of rhGM-CSF on monocytes/macrophages relevant to enhanced antimicrobial activity include increased phagocytosis, increased oxidative metabolism, increased numbers of Fc receptors, release of chemotactic factors and stimulation of mechanisms for killing intracellular viruses, fungi, bacteria and protozoa. Markers of macrophage anti-tumour activities can be divided into two types: those associated with antitumour antibodies, antibody-dependent cell cytotoxicity (ADCC) and those associated with synthesis and secretion of cytolytic substances by activated macrophages. In addition, rhGM-CSF has actions on fibroblasts and kerotinocytes consistent with an important role in wound healing. Moreover, the clinical use of rhGM-CSF to enhance antibody responses in conditions of inadequate immunisation is currently being investigated. Furthermore, rhGM-CSF appears to have a role in stimulating haemopoietic recovery following cytotoxic chemotherapy or radiation damage to bone marrow tissue.

Clinical experience with Escherichia coli rHuGM-CSF

The use of rHuGM-CSF has resulted in patient benefit as shown by reduced infections (MDS and AA), reduced days in intensive care (ABM transplant), better adherence to cancer chemotherapy protocols, and the ability to use full doses of antiviral drugs in AIDS and cytomegalovirus retinitis. The adverse reactions are significant when high doses are used, therefore high doses should be avoided (there is a plateau in the dose-effective biological responses). At recommended doses, GM-CSF is well tolerated and is a valuable adjunctive therapy in the management of patients with conditions of dysmyelopoiesis and myeloid hypoplasia associated with myelotoxic therapy, or after bone marrow transplantation.

The side-effect profile of GM-CSF

Granulocyte-macrophage colony-stimulating factor (GM-CSF), a pleiotropic molecule which displays a broad range of haematopoietic activities, has become available for clinical evaluation in various patient groups. It has been shown to be effective in preventing or reversing neutropenia. Adverse effects of GM-CSF, however, are dose related. Appropriate dose, route and schedules for GM-CSF in various clinical settings have recently been defined, the usual range being 5-10 micrograms/kg/day either by 4-6 h intravenous infusion or by subcutaneous injection. At such doses, adverse effects are predominantly mild-to-moderate in nature, occur in 20-30% of patients and usually comprise fever, myalgia, malaise, rash and injection site reaction. Early trials using very high doses of GM-CSF were often associated with marked adverse effects, which in rare cases proved severe (pericarditis and thrombosis). Similarly, a so-called "first-dose reaction", defined as a syndrome of hypoxia and hypotension after the initial but not subsequent doses of GM-CSF, was observed in certain predisposed patients following doses above 10 micrograms/kg/day. Subsequent trials have established that intravenous bolus or short infusions of GM-CSF are more likely to promote adverse effects. Certain patient groups, for example those with myelodysplastic syndrome, acute myeloid leukaemia, inflammatory disease, autoimmune thrombocytopenia or malfunctional immunological responsiveness, require careful clinical monitoring in order to avoid potential complications following the administration of GM-CSF. With the current appropriate administration and doses of GM-CSF, the benefit:risk ratio has been greatly improved.

Special features of the clinical use of oral terbinafine in the treatment of fungal diseases

Terbinafine (Lamisil) is an antifungal drug, belonging to a class of drugs called the allylamines, which has recently become available for clinical use. This is a report of four special features which emerged during evaluation of the systemic use of orally administered terbinafine in the treatment of 2500 patients during the last 5 years. These features include: (i) distribution of terbinafine in skin, hair and nail tissue; (ii) use in short-duration treatment of chronic tinea pedis and onychomycosis; (iii) use in patients with serious infections often associated with local or generalized immunological defects; and (iv) tolerability and safety of the drug. The diffusion of terbinafine into thickened, chronically infected tissue and into nails, and its recognized fungicidal action are the most likely features responsible for its success in the treatment of chronic fungal diseases, including those with immunological defects. Terbinafine is well tolerated, particularly when compared with other available systemic antifungal drugs.

Carboxyl-terminal truncation of apolipoprotein B results in gradual loss of the ability to form buoyant lipoproteins in cultured human and rat liver cell lines

Apolipoprotein B has an obligatory role in the production of chylomicrons, VLDL, and LDL. Familial hypobetalipoproteinemia is a codominant disorder characterized by reduced levels of apo B containing lipoproteins in plasma. We have previously described mutations of the apo B gene in persons with hypobetalipoproteinemia that predict truncated forms of apo B designated apo B29 (1305 amino acid residues) and apo B39 (1799 residues). Apo B39 was present in the VLDL and LDL fractions of plasma, but apo B29 was not detected in the lipoprotein or infranatant fractions of plasma. Here we have investigated the regions of apo B necessary for apo B containing lipoprotein secretion by expression of constructs designed to express truncated forms of apo B. Apo B13 (583 residues), apo B17 (784 residues), apo B23 (1084 residues), apo B29 (1306 residues), and apo B41 (1880 residues) were transiently expressed in HepG2 cells, and apo B23 and apo B41 were stably expressed in McArdle 7777 cells. Lipoprotein (d less than 1.25 g/mL) and infranatant (d greater than 1.25 g/mL) fractions of conditioned medium were analyzed by immunoprecipitation and SDS-PAGE. The distribution between lipoprotein and infranatant fractions varied: apo B41 was found solely in the lipoprotein fraction; apo B29, apo B23, and apo B17 were present in both fractions, but with stepwise truncation, progressively more apo B was recovered in the infranatant; apo B13 was only in the infranatant. These results demonstrate that deletion from the carboxyl terminal of apo B41 results in a gradual loss of the ability of the truncated proteins to form buoyant lipoprotein particles.

Transfer of processing in repetition priming: Some inappropriate findings

Transfer effects in repetition priming were found with both picture and word naming, but varied with the type of prime list. Unmixed lists of word or picture primes produced equivalent intra-modal and cross-modal repetition priming in both picture-naming (Experiment 1) and word-naming (Experiment 5) tasks. However, mixing word and picture primes resulted in greater intra-modal than cross-modal priming for both picture-naming (Experiment 2) and word-naming (Experiment 6) tasks. This mixed-list difference between intra-modal and cross-modal priming was reduced by blocking prime types at input (Experiment 3). These findings suggest that differences in priming as a function of prime stimulus format should be cautiously interpreted when mixed prime lists are used.

Role of human recombinant GM-CSF in the prevention and treatment of leukopenia with special reference to infectious diseases

Recombinant human GM-CSF has been shown to be effective in reversing severe neutropenic states associated with the underlying disease or caused by cytotoxic drugs, and during engraftment after bone marrow transplantation. Preliminary evidence supports the view that restoration of adequate myelopoiesis results in better control of infection. The use of rhGM-CSF in special infectious diseases to activate cell function is currently being studied. Preliminary in vitro and in vivo data allow high expectations for the usefulness of rhGM-CSF in contributing to the control of these diseases.

Long-term follow-up of patients with Leishmania (Viannia) braziliensis infection and treated with Glucantime

Seventy-nine patients with cutaneous (62) or mucosal (17) infection with Leishmania (Viannia) braziliensis in Três Braços, Bahia, Brazil, were followed for at least 4 years after initiating treatment with antimony. Cutaneous relapses occurred in 6/62 (10%), mucosal relapse after cutaneous infection in 2/62 (3%), and mucosal relapse after mucosal disease in 2/17 (17%). It is concluded that relapse (cutaneous and mucosal) is rare after adequate antimony therapy and that no definite prediction of relapse (clinical, serological or by skin reaction) is possible.

Clinical efficacy and tolerability of terbinafine (Lamisil)--a new topical and systemic fungicidal drug for treatment of dermatomycoses

Terbinafine (Lamisil) is the newest compound within a class of antimycotic drugs called allylamines. It is active against a broad range of dermatophytes and yeasts and exerts its fungicidal action by inhibiting squalene epoxidation during sterol synthesis in fungal membranes. Effective therapy (complete cure or mycological cure with minimal signs and symptoms) has been observed in 70-90% of 1200 patients treated topically with 1% cream for tinea corporis/cruris, tinea pedis, cutaneous candidiasis and pityriasis versicolor. Cure in patients treated systemically (125 mg b.i.d. orally) has been documented to be 75-90% in tinea corporis and chronic tinea pedis (plantar type), 60-70% in cutaneous candidiasis, and 90-100% in onychomycosis. Particularly noteworthy is the low rate of relapse of infection after cure of chronic dermatophyte infections, since frequent relapse is a recognized problem with presently available antifungal drugs. Terbinafine is ineffective when used systemically for pityriasis versicolor. Side-effects following oral administration of the recommended dose of 125 mg b.i.d. include gastrointestinal symptoms (3-4%), allergy (1%), and miscellaneous mild non-specific symptoms (1%). No significant haematological, hepatic or renal effects have been observed. Based on the drug's fungicidal action and the early appearance of negative cultures in these studies, a short duration therapy is predicted to be effective.

The effect of intracellular Chlamydia psittaci on lysosomal enzyme activities in mouse peritoneal macrophages

Live or heat killed (30 min at 56 degrees C) Chlamydia psittaci elementary bodies (EB) were phagocytosed by mouse peritoneal macrophages. Inoculation with killed Chlamydia caused rises in three lysosomal enzyme activities tested, especially in acid phosphatase activity. In contrast, after infection with live Chlamydia, only a negligible increase was seen in acid phosphatase activity, and no change in the activities of beta-glucuronidase and cathepsin D was observed. It was concluded that regulation of lysosomal enzyme synthesis in macrophages may be linked to signals mediated by phago-lysosome fusions.

Epidemiology of American cutaneous leishmaniasis due to Leishmania braziliensis braziliensis

A five-year prospective study of cutaneous leishmaniasis in an endemic area of Brazil revealed an annual incidence of disease of 8.1 per 1000 inhabitants and a prevalence of 14.9%. The disease fluctuated as a series of mini-epidemics. Most disease occurred in individuals who were 10-30 years of age. Mucosal disease occurred in 2.7% of patients with primary lesions and occurred a median of six years after this lesion. Disease was more common in males, in those with either large or multiple antecedent skin lesions, and in those with incomplete antimony therapy for the primary lesions. An ELISA was positive in 85% of those tested during the first two years after the primary lesion and remained positive for five to 40 years in 27% of patients. Skin testing was positive in 96% of patients with recent lesions and remained positive in 70% of patients. All patients with mucosal disease had positive serological and skin tests.

Murine spleen and lymph node cellular composition and function during cyclophosphamide and splenectomy induced resistance to Toxoplasma gondii

Murine toxoplasmosis caused by a low virulence, cyst-forming strain of Toxcoplasma gondii (Pe strain) is characterized by splenomegaly, lymphadenopathy, decreased delayed-type hypersensitivity (DTH), and the presence of toxoplasma cysts in brain tissue. Cyclophosphamide (CY) in a single dose of 100 mg/kg injected 3 days before infection, or splenectomy 3 weeks before infection, augmented DTH and decreased the number of toxoplasma brain cysts. CY-induced augmentation of resistance during the first 3 weeks of murine toxoplasmosis was associated with: (1) an increase in mononuclear phagocytes and a decrease in T lymphocytes (including Lyt2+ cells) in spleens and lymph nodes; (2) suppressed toxoplasma antigen induced proliferation of cultured spleen cells: (3) augmentation of antigen induced proliferation of cultured lymph node cells; and (4) low levels of interferon-gamma production in both spleen and lymph node cultures. The best correlate of the enhanced in-vivo effects of CY was proliferation of nylon wool-purified lymph node cells to toxoplasma antigen. The presence of Lyt2+ cells in lymph nodes of toxoplasma infected mice inhibited maximal proliferation.