Prenatal substance abuse in California: findings from the Perinatal Substance Exposure Study

This article reports the overall statewide findings of an epidemiological study that included 29,494 pregnant women who had been admitted for delivery in more than 200 hospitals in California and who were tested for alcohol and other drugs via blind urine toxicology screens. Results were matched to demographic data. The article includes analysis and discussion of four major variables: race/ethnic group differences, acculturation, source of payment for birth, and prenatal care status. Regional results are also discussed. The authors emphasize the high rate of alcohol use and self-reported tobacco use in comparison to relatively low rates of illicit drug use. Alcohol use rates were fairly stable, while use of illicit drugs and tobacco tended to vary according to social and demographic variables. The findings establish the need for both broad-based and targeted prevention and intervention programs to better disseminate the risks involved in drinking alcohol, smoking tobacco, and using drugs during pregnancy.

Perinatal drug use among immigrant and native-born Latinas

Perinatal drug exposures pose a significant health hazard for women and imperil normal fetal and neonatal development. Little is known about patterns of drug exposure among pregnant immigrant and native-born Latinas in the United States. We present multivariate risk factor analyses for alcohol and illicit drug use from the California Perinatal Substance Exposure Study using a statistical probability sample (N = 11,002) of Latinas who were tested anonymously using urine toxicology screening techniques. Alcohol use during pregnancy was pervasive among both immigrant and United States-born Latinas (7%) with little variation on risk factors. Illicit drug use was found primarily in a high risk group of United States-born Latinas between 25 and 34 years of age who received no prenatal care (prevalence 50%, odds ratio of 185). Increased general awareness of perinatal alcohol risk by medical providers and public health practitioners serving this population is needed. The potential isolation of United States-born Latinas who are at risk using illicit drugs during pregnancy requires effective communication and outreach.

Prevalence of markers for hepatitis B virus and HIV-1 among drug injectors in London: injecting careers, positivity and risk behaviour

Concerns about the risks of HIV infection among drug injectors have eclipsed concerns about the prevalence and transmission of hepatitis, and in particular hepatitis B virus infection. Findings are reported from surveys undertaken with two separate community-recruited samples of drug injectors in London collected in 1992 (n = 505) and in 1993 (n = 507). Anonymized confirmed testing of saliva shows 51.5% of drug injectors in 1992 and 47.9% in 1993 to be antibody positive to the core antigen of hepatitis B virus (anti-HBc). Approximately half of the drug injectors confirmed as anti-HBc positive were unaware that they had been infected with hepatitis. Anti-HIV-1 prevalence was considerably lower at 7.0% in 1992 and 6.9% in 1993. Multivariate analyses showed anti-HBc positivity to be most likely among older injectors with longer injecting careers who had a history of having shared used needles and syringes. HIV-1 positivity was also associated with a history of having shared injecting equipment as well as with recent sharing (i.e. in the last 6 months). Unlike anti-HBc positivity, there were no associations between HIV-1 positivity and age or length of injecting career. Younger injectors with shorter injecting careers were more likely to report recent sharing of used injecting equipment than older injectors with longer injecting careers. We note the potential for continued transmission of HBV and HIV-1, particularly among younger injectors. We recommend an integrated strategy to maximize the health of drug injectors, of which HIV and HBV prevention is a part. There is a need to widen the availability of HBV vaccinations for HBV negative drug injectors and their sexual partners and for clear guidelines to drug injectors about the relative efficacy of bleach to disinfect injecting equipment of HBV and HIV.

[Transrectal endoscopic ileal decompression as treatment of small intestine pseudoobstruction. Report of a case]

BACKGROUND

Intestinal pseudo-obstruction is a syndrome characterized by recurrent signs and symptoms of intestinal pseudo-obstruction or dilation without any evidence of mechanical pseudo-obstruction. Its cause is unknown, and it is associated with severe alterations of gastrointestinal motility.

AIMS

To report the transendoscopic treatment in a case of intestinal pseudo-obstruction as an alternative to a poor response to medical treatment.

METHODS

The diagnosis of intestinal pseudo-obstruction was made in a 34-year old male patient who had not responded to conservative treatment; therefore, a colonoscopy was performed and an ileal drainage was introduced with its distal end 50 cm beyond the ileocecal valve.

RESULTS

Twenty-four hours after the procedure was performed clinical and radiological improvement was evident. Such improvement was completed at 72 hours when the patient tolerated oral ingestion.

CONCLUSIONS

Transrectal ileal drainage could be an alternative to consider in those patients that do not respond to conservative treatment.

Leeds Undergraduate Medical Education Conference, 7-8 July 1995

The Leeds Undergraduate Medical Education Conference (LUMEC) was held on 7-8 July 1995. This conference, devoted entirely to undergraduate medical education, was unique in that it was organized entirely by four medical students. It attracted a wide and enthusiastic audience and excellent speakers. Professor Charles George (Chairman, Education Committee, General Medical Council) spoke about Tomorrow's Doctors, Dr Mark Bailey (Part-chairman, Medical Students' Committee of the British Medical Association) responded with 'Today's Students on Tomorrow's Doctors', and Dr Fleur Fisher (Ethics, Science and Information Division, British Medical Association) focused on the central place of ethics and communication skills in medicine. Professor Sam Leinster (Director of Medical Studies, Liverpool University) and Professor Tim de Dombal (Director, Clinical Information Science Unit, Leeds University) debated the need for new technology and radical change in the curriculum. Finally, Dr Stella Lowry (International Division, British Medical Association) considered the assessment of staff and Mrs Joy Crosby (Curriculum Facilitator, Dundee Medical School) discussed the assessment of students. Discussions focused on a variety of areas, including the need for change, the control of the money available for teaching and the problems of assessment.

Linkage studies of non-syndromic recessive deafness (NSRD) in a family originating from the Mirpur region of Pakistan maps DFNB1 centromeric to D13S175

Autosomal recessive non-syndromal hearing impairment (NSRD) is genetically heterogeneous. Five loci have been identified to date which map to chromosomes 13 (DFNB1), 11 (DFNB2), 17 (DFNB3), 7 (DFNB4) and 14 (DFBN5). We report definite linkage of NSRD to the locus DFNB1 in a single family of 27 families studied of Pakistani origin. Haplotype analysis of markers in the pericentromeric region of chromosome 13q revealed a recombination event which maps DFNB1 proximal to the marker D13S175 and in the vicinity of D13S143.

IFN-gamma and IL-4 regulate the growth and differentiation of CD8+ T cells into subpopulations with distinct cytokine profiles

In this study, we have investigated the effects of IL-4 and IFN-gamma on the growth and differentiation of CD8+ T cells in vitro. Rat splenic CD8+ T cells expressed higher levels of IL-4, IL-5, IL-10, and IFN-gamma mRNA, as measured by reverse-transcription PCR, than CD4+ T cells from the same source, whereas CD4+ T cells expressed more IL-2 and IL-6 mRNA. CD8+ T cells were cultured for 6 days with PMA, ionomycin, and IL-2, and their ability to proliferate, to express mRNA for IL-2, IL-4, IL-5, IL-6, IL-10, and IFN-gamma, and to secrete IFN-gamma and IL-2 was determined. IL-4 could act as a growth factor for CD8+ T cells during primary stimulation, but inhibited proliferation of the restimulated 6-day-cultured CD8+ T cells. The highest levels of mRNA for IL-2 and IL-6 were detected in control cultures in which little mRNA for IL-4, IL-5, or IL-10 was detected. Addition of IL-4 to the primary cultures reduced the capacity of the restimulated cells to express mRNA for IL-2, and for IL-6, but enhanced expression of mRNA for IL-4 and IL-5. Addition of IFN-gamma to the cultures, alone or in conjunction with IL-4, or addition of IFN-gamma-specific neutralizing Ab, had little effect. However, in conjunction with IL-4, anti-IFN-gamma enhanced expression of mRNA for IFN-gamma, and for IL-10. These results indicate that IL-4 and IFN-gamma regulate the differentiation of CD8+ T cells and the growth of cytotoxic and other types of CD8+ T cells, and suggest pathways through which CD8+ T cells may interact with other immune cells.

IFN-gamma and IL-4 regulate the growth and differentiation of CD8+ T cells into subpopulations with distinct cytokine profiles

In this study, we have investigated the effects of IL-4 and IFN-gamma on the growth and differentiation of CD8+ T cells in vitro. Rat splenic CD8+ T cells expressed higher levels of IL-4, IL-5, IL-10, and IFN-gamma mRNA, as measured by reverse-transcription PCR, than CD4+ T cells from the same source, whereas CD4+ T cells expressed more IL-2 and IL-6 mRNA. CD8+ T cells were cultured for 6 days with PMA, ionomycin, and IL-2, and their ability to proliferate, to express mRNA for IL-2, IL-4, IL-5, IL-6, IL-10, and IFN-gamma, and to secrete IFN-gamma and IL-2 was determined. IL-4 could act as a growth factor for CD8+ T cells during primary stimulation, but inhibited proliferation of the restimulated 6-day-cultured CD8+ T cells. The highest levels of mRNA for IL-2 and IL-6 were detected in control cultures in which little mRNA for IL-4, IL-5, or IL-10 was detected. Addition of IL-4 to the primary cultures reduced the capacity of the restimulated cells to express mRNA for IL-2, and for IL-6, but enhanced expression of mRNA for IL-4 and IL-5. Addition of IFN-gamma to the cultures, alone or in conjunction with IL-4, or addition of IFN-gamma-specific neutralizing Ab, had little effect. However, in conjunction with IL-4, anti-IFN-gamma enhanced expression of mRNA for IFN-gamma, and for IL-10. These results indicate that IL-4 and IFN-gamma regulate the differentiation of CD8+ T cells and the growth of cytotoxic and other types of CD8+ T cells, and suggest pathways through which CD8+ T cells may interact with other immune cells.

Interleukin-4 enhances interferon-gamma synthesis but inhibits development of interferon-gamma-producing cells

Interleukin-4 (IL-4) is antagonistic for many of the activities of interferon-gamma (IFN-gamma) and, as well as suppressing the development of T-helper type-1 (Th1) cells, has been reported to block directly the synthesis of IFN-gamma in human lymphocytes. However, IL-4 transgenic mice produce increased amounts of IFN-gamma as well as IL-4. We have compared the ability of rat IL-4 to regulate IFN-gamma secretion in short-term cultures of spleen cells with its effect on the differentiation of T lymphocytes into IFN-gamma-producing, or Th1-type, cells. Normal rat spleen cells were stimulated using a variety of mitogens and ovalbumin antigen, with or without IL-4, for 12-24 hr and the levels of IFN-gamma in the supernatants measured by enzyme-linked immunosorbent assay (ELISA). The results show that when normal rat splenocytes were stimulated with phytohaemagglutinin (PHA) or concavalin A (Con A), IL-4 enhanced secretion of IFN-gamma after 12-24 hr. This enhancement was also apparent when splenocytes from animals immunized 10 days previously with alum-precipitated ovalbumin were stimulated with ovalbumin in vitro, and appeared to be mediated primarily via CD+ T cells. In contrast, when spleen cells were maximally stimulated with phorbol myristate acetate (PMA) and ionomycin, addition of IL-4 had no effect on the amount of IFN-gamma secreted. When splenocytes were stimulated with Con A for 4 days in the presence of IL-4, and restimulated with PMA and ionomycin, IFN-gamma secretion was greatly suppressed. Our results indicate that IL-4 exerts differential effects on IFN-gamma secretion and on the development of IFN-gamma-producing lymphocytes.

Cytokine production by highly purified human CD8+ T cells

We have systematically investigated the capacity of highly purified human peripheral CD8+ T cells to produce interleukin (IL)-4 and interferon (IFN)-gamma when triggered by different stimuli. CD8+ T cells were isolated from peripheral blood by positive selection to > 99% purity and stimulated with one of three different stimuli: phytohaemagglutinin (PHA) and IL-2, phorbol myristate acetate (PMA) and ionomycin, and plate-bound anti CD3 and PMA. On their own, ionomycin and IL-2 failed to stimulate significant CD8+ T cell proliferation while PHA, plate-bound anti-CD3 and PMA induced weak proliferation. A combination of PHA and IL-2, PMA and ionomycin, or plate-bound anti-CD3 and PMA all induced vigorous CD8+ T cell proliferation. IFN-gamma was produced following all three stimuli, but was greatest from cells cultured with PMA and ionomycin. However, IL-4 secretion was only detected in cell cultures stimulated with PMA and ionomycin. These results indicate that, with sufficient stimulation, human CD8+ T cells have the potential to produce Th2 as well as Th1 cytokines.

Interleukin-4 and interferon-gamma regulate differentiation of CD8+ T cells into populations with divergent cytokine profiles

The ability of CD8+ T cells to synthesise and secrete cytokines before and after culture with interleukin (IL)-4 and anti-interferon (IFN)-gamma was investigated. Purified rat splenic CD8+ and CD4+ T cells and CD4-CD8- cells were stimulated with phorbol myristate acetate (PMA) and ionomycin for 6 h and expression of mRNA for IL-2, IL-4, IL-5, IL-6, IL-10 and IFN-gamma determined using a quantitative PCR technique. Secreted IFN-gamma and IL-2 were measured by ELISA and bioassay, respectively, 24 h after restimulation. The highest levels of IL-4, IL-5 and IFN-gamma mRNA were expressed by CD8+ T cells, the highest levels of message for IL-2 were expressed by CD4+ T cells and the highest levels of message for IL-6 and IL-10 by CD4-CD8- splenocytes. Purified rat splenic CD8+ T cells were cultured for 6 days with PMA, ionomycin and IL-2 with or without IL-4 or anti-IFN-gamma and restimulated with PMA and ionomycin. Those CD8+ T cells cultured with IL-4 expressed increased levels of IL-4, IL-5 and reduced levels of IL-2 and IL-6 mRNA, while CD8+ T cells cultured with IL-4 and anti-IFN-gamma expressed increased levels of mRNA for IL-10 and IFN-gamma. Comparable effects were seen for secreted IFN-gamma and IL-2. These results indicate that CD8+ T cells have the potential to produce large amounts of Th2 cytokines and are able to differentiate into different subpopulations with distinct cytokine profiles under the control of IL-4 and IFN-gamma.

Pharmacokinetics and metabolism of pirarubicin in humans: correlation with pharmacodynamics

The pharmacokinetic monitoring of anthracycline-containing regimens is warranted because of the important toxicity of these drugs and because pharmacokinetic-pharmacodynamic relationships have been clearly established. We studied the pharmacokinetics of the new anthracycline pirarubicin in 80 courses of treatment performed in 27 patients, using a limited sampling protocol we had previously validated. We observed (for 47 of these courses) a significant correlation between the leucocyte cell kill and the pirarubicin area under the time x concentration curve, but the most significant correlation was obtained using the plasma concentration of doxorubicin, a metabolite of pirarubicin, at the end of the infusion. On the basis of this value, it is possible to predict for pirarubicin haematological toxicity in a way that can help the clinician in identifying patients at risk for toxicity.

A limited sampling strategy for the study of pirarubicin pharmacokinetics in humans

Pirarubicin (4'-O-tetrahydropyranyldoxorubicin, THP-Adriamycin) is a new anthracycline antibiotic that has recently been developed because its reduced cardiac toxicity is associated with an antitumour efficacy similar to that of doxorubicin. Pirarubicin is characterised by strong haematological toxicity, which has been shown to be correlated with pharmacokinetic parameters, especially the area under the time-concentration curve. To obtain routine pharmacokinetic evaluations of pirarubicin for dose monitoring we developed a limited sampling strategy relying on three blood samples taken at the end of the infusion and at 12 and 24 h post-infusion. The characteristics of interindividual variability were assessed on the first courses of treatment performed in 18 patients; the model was then validated on 10 independent first courses of treatment performed in 10 other patients. The main pharmacokinetic parameters (half-lives, total volume of distribution, total plasma clearance) were estimated in the test group by maximum-likelihood estimation using all samples and by Bayesian estimation using three samples. The concordance between the two estimates was correct (the bias and precision for clearance were 2.3% and 12.1%, respectively), which shows that this limited sampling strategy can be used in routine drug monitoring.

Immune regulation: a new role for the CD8+ T cell

During an immune response, peripheral T cells develop into functionally distinct subpopulations that effect cell-mediated immunity and regulate humoral immune responses through the secretion of specific cytokines. Recent data suggest that CD8+ T cells, which have long been regarded simply as cytotoxic cells, play a more active role in the regulation of the immune response. In this article, Mike Kemeny and colleagues suggest that there are functionally distinct subsets of CD8+ T cells that produce different combinations of cytokines and appear to play an important part in determining the pattern of cytokines produced by CD4+ T cells and the isotype of immunoglobulins expressed by B cells.

A double-blind, randomised, crossover comparison of granisetron and ondansetron in 5-day fractionated chemotherapy: assessment of efficacy, safety and patient preference. The Granisetron Study Group

We report the first double-blind, randomised, crossover study comparing granisetron and ondansetron as antiemetics in cancer chemotherapy. Patients receiving two cycles of identical chemotherapy fractionated over 5 days were given either granisetron (3 mg/day) or ondansetron (24 mg/day) on each day of chemotherapy, using a double-dummy technique to preserve study blindness. Patients then crossed over to the other therapy. 309 patients (237 male) completed the crossover: 260 received cisplatin (mean dose 19.2 mg/m2/day) and 49 received ifosfamide (mean dose 1415 mg/m2/day). Primary efficacy variables were prospectively defined as complete response (no vomiting and mild or absent nausea) over 5 days, and patient preference. Both agents achieved good control of emetic symptoms with 5-day complete response rates of 44.0% on granisetron and 39.8% on ondansetron [95% confidence interval (CI) for odds ratio 0.8, 1.9]. Complete response rates were very similar in patients receiving either cisplatin (40.8% granisetron, 37.6% ondansetron) or ifosfamide (61.2% granisetron, 51.0% ondansetron). There was a statistically significant difference in patient preference in favour of granisetron, 105 patients preferred granisetron, 79 preferred ondansetron, 121 had no preference (P = 0.048: 95% CI for odds ratio 1.00, 1.84). Single daily doses of granisetron (3 mg/day) appeared similarly effective and well tolerated to three daily doses of ondansetron (8 mg three times daily) in prevention of emesis induced by 5-day fractionated chemotherapy, however, significantly more patients preferred granisetron.

Elimination of IgE regulatory rat CD8+ T cells in vivo increases the co-ordinate expression of Th2 cytokines IL-4, IL-5 and IL-10

Immunization of rats with soluble antigen (ovalbumin) and the castor bean toxin, ricin, eliminates a subpopulation of CD8+ T cells which suppress IgE responses in vivo. This treatment also reduces the ability of splenic T cells to produce interferon-gamma (IFN-gamma) and enhances their capacity to make interleukin-4 (IL-4). In this report we describe the effect of immunization with ricin and antigen on the expression of mRNA for other T-helper type 2 (Th2) cytokines--IL-5 and IL-10--and their relationship to serum IgE and IL-4 mRNA expression. Splenocytes were taken from rats at different times after immunization with antigen or ricin and antigen and activated in vitro with phorbol myristate acetate (PMA) and ionomycin for 6 hr and total RNA extracted and reverse transcribed. Cytokine gene expression was detected using a quantitative polymerase chain reaction (PCR). Expression of IL-4, IL-5, and IL-10 was increased 7-20-fold 11 days after immunization with ricin and antigen (from 0.107% to 0.769% beta-actin for IL-4, from 0.0167% to 0.381% beta-actin for IL-5, and from 0.0581% to 0.954% beta-actin for IL-10), and preceded maximum serum IgE levels by 4-5 days. There was no increase in IgE or mRNA for these cytokines in rats immunized with antigen alone. The level of IL-4, IL-5, and IL-10 expression declined rapidly after 12 days. Our results suggest that immunization with antigen and ricin preferentially induces a Th2 response, and that CD8+ T cells may play a part in down-regulating the development of Th2 T cells.

Prevalence and magnitude of perinatal substance exposures in California

BACKGROUND

Perinatal substance exposure has been linked to many neonatal and obstetrical complications. There have been few population-based epidemiologic studies to identify the prevalence and demographic profiles associated with drugs, alcohol, and smoking during pregnancy.

METHODS

We studied a fully probabilistic stratified-cluster sample to estimate the prevalence of perinatal substance exposures in California in 1992. Urine samples from 29,494 women presenting for delivery in 202 hospitals were coded and screened for toxins; the results of toxicology screening were later linked by code number to the subjects' demographic variables and their reported use of tobacco and prescribed drugs. Urinary toxicologic tests provide conservative estimates because they can detect only very recent substance use.

RESULTS

The weighted prevalence for perinatal substance exposure was 5.16 percent for the use of one or more drugs, 6.72 percent for alcohol (analyzed independently), and 8.82 percent for self-reported smoking. The percentage of women testing positive for any drug, including alcohol, was 11.35 percent. Estimates for racial and ethnic groups varied widely. Black women had the highest prevalence of total drug use (14.22 percent), alcohol use (11.58 percent), cocaine use (7.79 percent), and tobacco use (20.12 percent). Most drug exposures occurred among white non-Hispanic and Hispanic women. White non-Hispanic women had the second highest prevalence rate for the use of one or more drugs (6.79 percent) and self-reported tobacco use (14.82 percent). Hispanic women had the second highest prevalence rate for alcohol (6.87 percent).

CONCLUSIONS

In California in 1992, there were 67,361 estimated perinatal exposures to one or more drugs, including alcohol, and 52,346 self-reported exposures to tobacco. These findings have clinical and public health implications.

Generation of rat Th2-like cells in vitro is interleukin-4-dependent and inhibited by interferon-gamma

Differentiation of naive T cells into effector cells producing T helper type 1 (Th1) and Th2 cytokines is regulated by the presence of specific cytokines in the T-cell microenvironment. The effect of interferon-gamma (IFN-gamma) and interleukin-4 (IL-4) on Th1- and Th2-like cell development was investigated in cultures of mixed rat spleen cells. These cells were cultured for 4 days in medium containing concanavalin A (Con A) with or without additional IL-2, IFN-gamma or IL-4. The cells were then washed and their capacity to produce IL-4, IL-5 and IFN-gamma determined following stimulation with phorbol 12-myristate 13-acetate (PMA) and ionomycin. Freshly isolated cells stimulated with PMA and ionomycin expressed detectable levels of IL-4 and IL-5 mRNA as measured by a quantitative polymerase chain reaction (PCR) procedure and much higher levels of IFN-gamma mRNA. Cells cultured with Con A for 4 days, washed, and restimulated with PMA + ionomycin were unable to express detectable levels of IL-4 and IL-5 mRNA, but produced high levels of IFN-gamma mRNA. Addition of IL-4, or anti-IFN-gamma antibody, to Con A-driven splenocyte cultures restored the ability of restimulated cells to express IL-4 and IL-5. CD4+ T cells isolated from these cultures also showed an increased capacity to secrete IL-4 and IL-5 when anti-IFN-gamma and IL-4 were present in the culture medium. When cultured for 4 days with Con-A, IL-4 and anti-IFN-gamma splenocytes showed an increased capacity to proliferate in response to recombinant IL-2 and proliferated in response to IL-4 alone. IL-2 had no effect on cytokine production by cultured splenocytes. These results indicate that: (1) IL-4 is essential for the generation of Th2-like cells; (2) IFN-gamma inhibits IL-4 production by mixed spleen cells and suppresses generation of IL-4 responsive T cells; (3) in mixed spleen cell cultures mitogenic stimulation favours differentiation of naive rat T cells into effector cells expressing a Th1, and not Th2, cytokine profile.