Assessment of health risks due to hazardous air pollutant emissions from electric utilities

Hazardous air pollutant (HAP) emissions from electric utilities were evaluated. Cancer risks, as well as noncancer effects, due to inhalation exposure were assessed for 67 HAPs. Also, cancer risks due to multipathway exposure to radionuclide emissions were assessed. In addition, an assessment of the fate of mercury (Hg) through various environmental media was included. Results suggest arsenic, chromium, and nickel are the HAPs that present the highest cancer risk due to inhalation exposure. For noncancer effects due to inhalation exposure, hydrogen chloride appears to present the greatest potential concern. The risks due to multipathway exposure to radionuclides are estimated to be of similar magnitude to the risks posed by inhalation of arsenic and nickel. Mercury is of potential concern for multipathway exposures because it persists in the environmental and bioaccumulates in the aquatic food web. The study suggests there is a plausible link between Hg emissions from utilities and the Hg found in soil, water, and freshwater fish.

Myocardial phosphocreatine-to-ATP ratio is a predictor of mortality in patients with dilated cardiomyopathy

BACKGROUND

In patients with heart failure due to dilated cardiomyopathy, cardiac energy metabolism is impaired, as indicated by a reduction of the myocardial phosphocreatine-to-ATP ratio, measured noninvasively by 31P-MR spectroscopy. The purpose of this study was to test whether the phosphocreatine-to-ATP ratio also offers prognostic information in terms of mortality prediction as well as how this index compares with well-known mortality predictors such as left ventricular ejection fraction (LVEF) or New York Heart Association (NYHA) class.

METHODS AND RESULTS

Thirty-nine patients with dilated cardiomyopathy were followed up for 928+/-85 days (2.5 years). At study entry, LVEF and NYHA class were determined, and the cardiac phosphocreatine-to-ATP ratio was measured by localized 31P-MR spectroscopy of the anterior myocardium. During the study period, total mortality was 26%. Patients were divided into two groups, one with a normal phosphocreatine-to-ATP ratio (>1.60; mean+/-SE, 1.98+/-0.07; n=19; healthy volunteers: 1.94+/-0.11, n=30) and one with a reduced phosphocreatine-to-ATP ratio (<1.60; 1.30+/-0.05; n=20). At re-evaluation (mean, 2.5 years), 8 of 20 patients with reduced phosphocreatine-to-ATP ratios had died, all of cardiovascular causes (total and cardiovascular mortality, 40%). Of the 19 patients with normal phosphocreatine-to-ATP ratios, 2 had died (total mortality, 11%), one of cardiovascular causes (cardiovascular mortality, 5%). Kaplan-Meier analysis showed significantly reduced total (P=.036) and cardiovascular (P=.016) mortality for patients with normal versus patients with low phosphocreatine-to-ATP ratios. A Cox model for multivariate analysis showed that the phosphocreatine-to-ATP ratio and NYHA class offered significant independent prognostic information on cardiovascular mortality.

CONCLUSIONS

The myocardial phosphocreatine-to-ATP ratio, measured noninvasively with 31P-MR spectroscopy, is a predictor of both total and cardiovascular mortality in patients with dilated cardiomyopathy.

Inappropriate discharge of an implantable cardioverter defibrillator during atrial flutter and intermittent ventricular antibradycardia pacing

INTRODUCTION

Inappropriate discharges of an implantable cardioverter defibrillator (ICD) are troublesome to the patient and sometimes a difficult task for the physician trying to identify and treat the cause.

METHODS AND RESULTS

For the first time, we report a mechanism of inappropriate ICD discharges during episodes of atrial flutter with a slow ventricular response and intermittent antibradycardia pacing. The episodes occurred in two patients and were triggered by the unique sensing algorithm of the Ventritex Cadence V-100 in combination with the tripolar CPI Endotak 072 transvenous defibrillation lead, which provides integrated bipolar sensing.

CONCLUSION

Besides treatment of the underlying arrhythmia, reprogramming of the device, an electrode position far away from the atria, and true bipolar sensing will enhance the performance of ICD systems with respect to the episodes described here. In addition, more flexible sensing algorithms may, in the future, prevent this overall rare complication.

An outcome analysis of 100 women after explantation of silicone gel breast implants

A prospective outcome analysis was conducted on 100 consecutive women who requested explantation of their silicone gel breast implants from January 6, 1992 (the moratorium), through 1995. Eighteen patients were referred by rheumatologists with a diagnosis of autoimmune or rheumatic disease. Six had autoimmune disease (systemic lupus, 2 patients; rheumatoid arthritis, 2 patients; multiple sclerosis, 1 patient; and Raynaud's disease, 1 patient). Twelve had rheumatic disease (fibromyalgia, 10 patients; inflammatory arthritis, 2 patients). All of these 18 patients had developed symptoms of their disease after they had received implants. All 100 patients were extensively evaluated pre- and postoperatively by interviews, clinical assessment, and by assay of the following laboratory tests: rheumatoid factor, ESR, ANA, and anti-Ro/SSA, -La/SSP, -Sm, -RNP, -double-stranded deoxyribonucleic acid, -Scl-70, -centromere, and -cardiolipin. Patients were also evaluated by a questionnaire that was sent at a mean time of 2.7 years postexplantation (range, 1-5 years), which had a 75% response rate. Reasons for implants were augmentation, 75%; lifting, 11%; reconstruction, 12%; and congenital aplasia, 2%. The mean age at first implant was 28.9 years (range, 13-55 years) and at explantation was 41.5 years (range, 25-65 years). The mean duration of implantation was 12.0 years (range, 1-27 years). Thirty-six percent of the patients had undergone at least one closed capsulotomy and 54% at least one open capsulotomy. The mean reasons for explantation were suspected silicone-related health problems, 76%; suspected rupture, 59%; breast firmness, 36%; breast pain, 36%; and musculoskeletal pain, 23%. Before explantation 75% of the questionnaire respondees had lost some sensitivity in their nipples following their breast augmentation. In 36% of those 75 patients, that loss was almost complete. Loss of sensitivity was related to capsular contracture and to pain (p < 0.05). Following explantation there was significant improvement in nipple sensitivity in 38% of breasts in the 75 respondees. A total of 186 implants were removed. Fifty-seven percent had failed by rupturing or leaking. Only 3.2% demonstrated extravasation extracapsularly. Twenty-five percent of the capsules were calcified, demonstrating visible plaques of calcification on their inner surface. Forty-two percent were colonized by bacteria. The prevalence of class III-IV capsular contracture was 61% and it was related to implant location, duration in situ, and capsular calcification (p < 0.05), but not to capsular colonization or implant integrity (p > 0.05). Only 43 of the 100 patients elected to have saline implants inserted. Of the others, 56% felt that the shell of the saline implant could be associated with medical problems. The others felt that breast size was of minor importance to them at this time. There were few complications from the explantation procedure. Two "masses" were discovered-one was an occult carcinoma, the other a galactocele. There was one wound infection, which responded to antibiotics. Three patients developed decreased sensitivity and 3 developed increased breast pain. From the patient questionnaires, in those women who did not have saline implants inserted, 15% felt that their breast appearance was improved after explantation, 36% were "pleased," 33% were disappointed, and 13% felt "mutilated". In women who did have saline implants inserted, 18% felt that their breast appearance was now improved, 60% were "pleased," and 14% were disappointed, mainly because of wrinkling. At a mean time of 2.7 years (range, 1-5 years) after explantation, 45% of the 75 questionnaire respondees felt that their implants had caused permanent health problems and 56% felt that they had not been given adequate informed consent by their original surgeon (particularly regarding implant rupture and a possible relationship to medical disease). (ABSTRACT TRUNCATED)

[Implantation of a transvenous defibrillation system in isolated persistent left superior vena cava]

HISTORY AND CLINICAL FINDINGS

A 49-year-old man, an alcoholic for the past 7 years, complained of dizziness, palpitations and exertional dyspnoea (NYHA stage III). Physical examination revealed peripheral cyanosis, slightly raised jugular venous pressure, râles in the lung bases, a loud systolic murmur, maximal over the apex, and an enlarged palpable liver.

INVESTIGATIONS

Results of biochemical tests were unremarkable. The ECG showed sinus rhythm, 1 degree AV block and signs of left ventricular hypertrophy. Chest radiogram demonstrated cardiac dilatation and probably absent right superior vena cava (SVC). Long-term ECG monitoring during episodes of dizziness and one syncope revealed self-limited periods of unifocal ventricular tachycardia. Echocardiography and angiography showed bilateral ventricular dilatation with an ejection fraction reduced to 20%, as well as mild mitral and moderate tricuspid regurgitation but normal cardiac valves, suggesting a dilated cardiomyopathy. Coronary angiography was normal. No myocarditis was revealed on myocardial biopsy. The patient declined electrophysiological investigation.

TREATMENT AND COURSE

Amiodarone caused higher degree AV block. A temporary pacemaker lead was inserted via the persistent left SVC, amiodarone discontinued and later a pacemaker-defibrillator system (ICD) implanted, previous digital subtraction angiography having demonstrated a left SVC and absent right SVC. The transvenous electrode had been placed via the left subclavian vein, left SVC (anode), coronary sinus, right atrium into the right ventricle (cathode), and the pacemaker-defibrillator implanted subpectorally. Stable electrode position and correct ICD function has been documented over 2 years. 4 months after implantation bursts of ventricular tachycardia recurred every few minutes that responded to renewed amiodarone administration.

CONCLUSION

Good long-term results can be obtained with ICD electrodes implanted via a persistent LSVC.

Antimalarial activity of the bisquinoline trans-N1,N2-bis (7-chloroquinolin-4-yl)cyclohexane-1,2-diamine: comparison of two stereoisomers and detailed evaluation of the S,S enantiomer, Ro 47-7737

The S,S enantiomer of the bisquinoline trans-N1,N2-bis(7-chloroquinolin-4-yl)cyclohexane-1,2-diamine, Ro 47-7737, is significantly more potent against chloroquine-resistant Plasmodium falciparum than the R,R enantiomer and the previously described racemate. Both the enantiomers and the racemate are more potent inhibitors of heme polymerization than chloroquine, and their activities are probably mediated by inhibition of this parasite-specific process. The S,S enantiomer, Ro 47-7737, was studied in more detail and proved to be a potent antimalarial in the treatment of P. vivax ex vivo and P. berghei in vivo. Its suppression of P. berghei growth in a mouse model (50% effective dose, 2.3 mg/kg of body weight) was equal to that of chloroquine and mefloquine, and Ro 47-7737 was found to be more potent than these two drugs in the Rane test, in which the curative effect of a single dose is monitored. The dose at which 50% of animals were permanently cured (34 mg/kg) was markedly superior to those of chloroquine (285 mg/kg) and mefloquine (> 250 mg/kg). When administered orally at 50 mg/kg, Ro 47-7737 also showed a faster clearance of parasites than either chloroquine or mefloquine, and unlike the other two compounds, Ro 47-7737 showed no recrudescence. In a study to compare prophylactic efficacies of oral doses of 50 mg/kg, Ro 47-7737 provided protection for 14 days compared to 3 days for mefloquine and 1 day for chloroquine. The good curative and prophylactic properties of the compound can be explained in part by its long terminal half-life. The ability to generate parasite resistance to Ro 47-7737 was also assessed. With a rodent model, resistance could be generated over eight passages. This rate of resistance generation is comparable to that of mefloquine, which has proved to be an effective antimalarial for many years. Toxicity liabilities, however, ruled out this compound as a candidate for drug development.

The chemotherapy of rodent malaria. LV. Interactions between pyronaridine and artemisinin

Two interactions of two potent blood schizontocides, pyronaridine and artemisinin, were assessed in mice infected with chloroquine-resistant Plasmodium yoelii ssp. NS or one of two lines derived from it, namely ART, which is resistant to artemisinin and SPN, which is resistant to pyronaridine. While the drug combination proved to be only additive in its action against P. yoelii ssp. NS, a marked potentiation between the two compounds was observed against the ART and SPN lines. The implications of the findings in terms of the impeding of drug resistance when these compounds are deployed for the treatment of multi-drug-resistant P. falciparum are discussed.

Ventilation scintigraphy of the middle ear

In this study, an attempt was made to administer radioactive gas into the tympanic cavity to measure initial gas trappings as well as clearance from the middle ear to evaluate eustachian tube function.

METHODS

Twenty-eight patients were administered 50 MBq 133Xe gas. Three different methods for gas application were tested: (a) direct injection through a tympanostomy tube in two patients, (b) administration through a nasopharyngeal catheter combined with Valsalva maneuvers in six subjects without middle ear dysfunction and (c) insufflation into the pharyngeal space through a nose olive performed in 12 patients with normal eustachian tube function and in eight patients with one-sided tube dysfunction.

RESULTS

All three approaches were successful in visualizing middle ear ventilation, demonstrating tracer trapping within the tympanic cavities in 20 of 28 patients. Semiquantitative evaluation by region of interest techniques revealed a left-to-right uptake ratio of 48.4%-51.6% in 13 patients without tube dysfunction. Five patients with one-sided tube dysfunction showed a significantly lower median uptake of 31.6% (p = 0.01). The clearance half-lives ranged from 9 to 283 min in normal subjects and 37-64 min in patients with one-sided tube malfunction, demonstrating no statistically significant difference between the two groups and a trend towards increased washout in patients with tympanic dysfunction.

CONCLUSION

Middle ear ventilation scintigraphy with 133Xe through a nose olive is an easy-to-perform test to evaluate eustachian tube function and has a success rate of about 70%, thus, reflecting the complex physiological mechanisms involved.

The chemotherapy of rodent malaria. LIV. Combinations of 'Fenozan B07' (Fenozan-50F), a difluorinated 3,3'-spirocyclopentane 1,2,4-trioxane, with other drugs against drug-sensitive and drug-resistant parasites

Fenozan B07, a 1,2,4-trioxane endoperoxide with potent blood schizontocidal activity against drug-sensitive and drug-resistant rodent malaria parasites, exerted a modest potentiating action when administered with chloroquine (CQ) to mice infected with parasites of the CQ-resistant P. yoelii ssp. NS, but not when given to mice infected with the CQ-sensitive P. berghei N strain. The reason why this potentiation may be of particular value in the treatment of severe falciparum malaria is discussed. Mefloquine and halofantrine displayed a similar level of potentiation with Fenozan B07 against the CQ-resistant parasites. However, antagonism was shown by combinations of Fenozan B07 with pyronaridine or the 8-aminoquinoline WR 238 605 when used against CQ-resistant parasites. Mefloquine with Fenozan B07 is also antagonistic against a highly mefloquine-resistant line of P. yoelii ssp. NS. The reasons behind such antagonism are not known. The importance is stressed of using carefully selected drug combinations of novel antimalarials, rather than single drugs, in order to impede the selection of drug-resistant parasites, but only after adequate, preclinical, toxicity testing.

Modifications in the rhythm of schizogony in Plasmodium chabaudi chabaudi associated with the selection of chloroquine resistance

A high level of drug resistance was obtained with a line of Plasmodium chabaudi maintained under intense chloroquine selection pressure according to the protocols established for P. berghei. The main objective of this work was to verify if the characteristic asynchronous schizogonic rhythm of naturally resistant rodent malaria parasites was also found when the drug resistance was induced experimentally. The degree of resistance was evaluated through the use of the "2% delay test" (DT) and the schizogonic rhythm, by reference to the synchronicity index (SI). The strain had originally a DT of 4.26 and an SI of 0.52. Following the application of 80 mg/kg chloroquine at each passage, as early as at the 8th passage the parasites rapidly became resistant and asynchronous. At the 17th passage the DT was 3.32 and the SI, 0.20. In the drug-resistant line the original indices, both the DT and the SI, were restored after deep-freezing, sporogony, or passage through a Percoll gradient, or simply by repeated intravenous subinoculations of blood. The clear correlation between asynchronicity and drug resistance is easily explained by the action of chloroquine, which favours the schizogonic cycles initiated by latent merozoites.

The chemotherapy of rodent malaria. LIII. 'Fenozan B07' (Fenozan-50F), a difluorinated 3,3'-spirocyclopentane 1,2,4-trioxane: comparison with some compounds of the artemisinin series

Fenozan B07, a difluorinated 3,3'-spirocyclopentane, 1,2,4-trioxane, is a novel, second-generation antimalarial endoperoxide which is a potent blood schizontocide against strains of rodent malaria that are highly resistant to a wide spectrum of classical antimalarials. Like compounds of the artemisinin series, its action is limited to the intra-erythrocytic stages, both asexual and sexual, and it is devoid of causal prophylactic activity. Both Fenozan B07 and the artemisinins are potent gametocytocides. In contrast to arteether, in a model using synchronous infection with Plasmodium vinckei petteri, Fenozan B07 inhibits the development of all asexual stages except preschizonts, as well as gametocytes. The activity of the artemisinin series in rodent-malaria models is limited to the rings and young trophozoites. The combined effect of Fenozan B07 with artesunate against P. v. petteri was only additive. A slight degree of potentiation was found in mice infected with asynchronous, drug-sensitive P. berghei but the combination was only additive against CQ-resistant P. yoelli ssp. NS. On the other hand, a significant degree of synergism was observed when mice infected with the artemisinin-resistant ART line of P. yoelii ssp. NS received combinations of Fenozan B07 with artemisinin. The conclusion is drawn from these and other data that there are significant differences between the blood schizontocidal actions of Fenozan B07 and the artemisinins. The basis of these differences remains to be determined.

Evolution of late potentials during the first 8 hours of myocardial infarction treated with thrombolysis

It has been demonstrated that successful thrombolytic therapy is associated with a reduction of late potentials in the signal-averaged electrocardiogram (SAECG) recorded within 48 hours after hospital admission. This study extends these observations, using for the first time a longitudinal design investigating whether ischemia and its potential reversal by thrombolytic therapy are associated with dynamic changes in SAECG recordings obtained continuously for 8 hours after the start of therapy in patients with acute myocardial infarction (MI). SAECGs were obtained from 12 patients (2 women and 10 men; ages 63 +/- 13 years) with acute MI. The SAECG (X2 + Y2 + Z2)1/2 was generated with a high pass filter of 40 Hz, noise < or = 0.3 microV. Comparing the SAECG recordings during the first and eighth hours, there was a significant decrease in filtered QRS duration (fQRS; 119.5 +/- 17.1 vs 106.3 +/- 15.3 ms) and duration of the low amplitude signals < or = 40 microV of the terminal QRS (LAS40; 48.8 +/- 18 vs 34.2 +/- 14.2 ms), and increase of root mean square voltage of the last 40 ms of the QRS (t-RMS; 14.8 +/- 9.3 vs 37.8 +/- 34.4 microV) (rank test, P < or = 0.05). In this patient series, there was a significant improvement of fQRS, t-RMS, and LAS40 during the first 8 hours of acute MI, perhaps indicating reversal of ischemia with thrombolysis. Even during acute MI, these markers of delayed conduction allow investigation of intervention induced changes in myocardial conduction and possibly prediction of the patency of the infarct related artery using signal-averaging techniques.

4-aminoquinoline analogs of chloroquine with shortened side chains retain activity against chloroquine-resistant Plasmodium falciparum

We have synthesized several 4-aminoquinolines with shortened side chains that retain activity against chloroquine-resistant isolates of Plasmodium falciparum malaria (W. Hofheinz, C. Jaquet, and S. Jolidon, European patent 94116281.0, June 1995). We report here an assessment of the activities of four selected compounds containing ethyl, propyl, and isopropyl side chains. Reasonable in vitro activity (50% inhibitory concentration, < 100 nM) against chloroquine-resistant P. falciparum strains was consistently observed, and the compounds performed well in a variety of plasmodium berghei animal models. However, some potential drawbacks of these compounds became evident upon in-depth testing. In vitro analysis of more than 70 isolates of P. falciparum and studies with a mouse in vivo model suggested a degree of cross-resistance with chloroquine. In addition, pharmacokinetic analysis demonstrated the formation of N-dealkylated metabolites of these compounds. These metabolites are similarly active against chloroquine-susceptible strains but are much less active against chloroquine-resistant strains. Thus, the clinical dosing required for these compounds would probably be greater for chloroquine-resistant strains than for chloroquine-susceptible strains. The clinical potential of these compounds is discussed within the context of chloroquine's low therapeutic ratio and toxicity.

Silicon and silicone levels in patients with silicone implants

Although a potential link between silicone gel breast implants and autoimmune connective tissue disease has been suggested, none has been proven. The potential role of silicone as an immune adjuvant remains very controversial. Currently available techniques do not easily allow precise measurements of silicone in tissues. However, all compounds containing silicon (which would include silicone) can be measured accurately. The present study was designed to measure silicon levels in the fibrous capsules of patients with silicone-gel breast implants, saline breast implants and silicone inflatable penile prostheses. Baseline control silicon levels were obtained from the breast tissue of patients undergoing breast reduction, who had no exposure to breast implants. All silicon measurements were carried out using atomic absorption spectrometry with a graphite furnace. The mean silicon levels in 16 breast tissue control samples from 8 patients undergoing breast reduction varied from 0.046 to 0.742 micrograms/g dry weight, with the median mean being 0.0927. The median silicon level in capsules from 6 patients with saline implants was 7.7 micrograms/g (range 36.6). The median silicon level in capsules from 5 patients with silicone inflatable penile prostheses was 19.5 micrograms/g (range 34.8). Although the levels of silicon in capsules of patients with saline breast prostheses and penile implants were higher than in control samples, they were much lower than those from the capsules of the 58 gel implants (median 9979 micrograms/g). Of the 58 silicone gel breast implants (from 20 patients with bilateral implant removal and 18 patients with unilateral removal) which had been inserted from 1974 to 1990, 28 were intact, 8 had pinhole leaks, and 22 were ruptured. Median capsule silicon levels and ranges for all 58 implants, for intact only, for leaking, and for ruptured were: 9979 (152,000), 10,477 (88,703), 6592 (65,396), and 9922 (152,387) micrograms/g respectively. There were no significant differences in silicon levels associated with implant status, duration in situ, or year of implantation. Capsule contracture was not associated with higher levels of capsule silicon. Capsule silicon levels were about 10(6) times higher than previously assayed blood silicon levels. This may be because silicone released from implants remains localized in capsular tissue, or because blood-borne silicone is quickly excreted. Using 29Si nuclear magnetic resonance spectroscopy, no detectable silicone was found in the blood of 7 control women and 7 women with silicone-gel implants (5 with known implant rupture).

Co-localization and functional coupling of creatine kinase B and gastric H+/K(+)-ATPase on the apical membrane and the tubulovesicular system of parietal cells

Immunogold labelling of creatine kinase B (BB-CK) and gastric H+/K(+)-ATPase in the parietal cells of the stomach revealed colocalization of these two enzymes on the apical membrane and the membranes of the tubulovesicular system. Upon fractionation of hog parietal cells, a specific fraction of the BB-CK proteins remained associated with the purified vesicles, in which gastric H+/K(+)-ATPase is highly enriched. The BB-CK present in this highly purified preparation was able to support pronounced H+/K(+)-ATPase activity in K(+)-loaded vesicles in the presence of phosphocreatine and ADP, although only low levels of ATP were measured. In contrast, when pyruvate kinase, phosphoenolpyruvate and ADP were used as an ATP-generating system to sustain similar levels of H+/K(+)-ATPase activity, ATP levels were more than 10-fold higher. Changing the experimental conditions such that ATP levels were the same for both systems resulted in significantly elevated H+/K(+)-ATPase activities in the BB-CK/phosphocreatine system in comparison with the pyruvate kinase/phosphoenolpyruvate system. These results indicate that gastric H+/K(+)-ATPase has preferential access to ATP generated by creatine kinase co-localized on the membranes of the vesicles.

Failure of 29Si NMR to detect increased blood silicon levels in silicone gel breast implant recipients

We have compared directly the results of atomic absorption (AA) spectroscopy and a 29Si magic angle spinning (MAS) nuclear magnetic resonance (NMR) technique reported in the literature by Garrido et al. (Garrido, L.; et al. Magn. Reson. Med. 1994, 31, 328-330) for analyzing blood silicon levels in control patients versus patients with silicone gel breast implants. AA spectroscopy yielded blood silicon levels in the nanogram per milliliter range for control patients, while somewhat higher values were found in patients with implants. The 29Si MAS NMR technique applied to the identical blood samples was unable to detect silicon in any of the samples. Sensitivity calculations demonstrate that 29Si MAS NMR should not be expected to detect silicon at the levels determined by AA spectroscopy under the spectroscopic conditions employed and that the concentration of silicon-containing compounds would need to 10(4) times the level detected by AA in order to be detected by this NMR method.

The chemotherapy of rodent malaria. LII. Response of Plasmodium yoelii ssp. NS to mefloquine and its enantiomers

A comparison was made between the blood schizontocidal action in mice of racemic mefloquine hydrochloride and the free bases of its (+)- and (-)-enantiomers (Ro 13-7224 and Ro 13-7225) against chloroquine-resistant Plasmodium yoelii ssp. NS. The racemic hydrochloride was two to three times as active against this parasite in mice as either of the enantiomer free bases, which were of similar activity to each other. Under drug selection pressure, the parasites acquired resistance in approximately the same time for each of the three compounds.

Mouse ubiquitous mitochondrial creatine kinase: gene organization and consequences from inactivation in mouse embryonic stem cells

Individual members of the creatine kinase isoenzyme family (CK; EC 2.7.3.2), which play a prominent role in energy homeostasis, are encoded by four separate nuclear genes. We have isolated and characterized the complete mouse UbCKmit gene, the product of which is ubiquitously expressed and is located in the intermembrane space of mitochondria. Transcription of this gene is initiated at multiple adjacent positions and the region immediately upstream of these sites shares many features with genes encoding housekeeping proteins. These include a high G/C content, absence of TATA and CCAAT motifs, and presence of SP1 and AP2 recognition sequences. In addition, a binding site for HIP1, hormone-responsive elements, and three Mt-motifs, known as boxes shared between nuclear genes encoding mitochondrial proteins, were identified. To study the functional role of the UbCKmit protein, we have inactivated both UbCKmit alleles in mouse embryonic stem (ES) cells. UbCKmit-deficient cells, obtained by consecutive rounds of gene targeting using homologous recombination and drug selection-driven gene conversion events, show no obvious growth disadvantage or abnormal differentiation potential. Activities of mitochondrial cytochrome c oxidase and citrate synthase, as well as the rate of pyruvate oxidation, showed values equal to wild-type cells, indicating a normal aerobic metabolism. Mitochondria of in vivo differentiated knock-out cells were structurally intact, as demonstrated by electron microscopy. Approaches to study the role of the UbCKmit gene further are discussed.

Analysis of silicon levels in capsules of gel and saline breast implants and of penile prostheses

Although a potential link between silicone-gel breast implants and autoimmune connective tissue disease has been suggested, none has been proven. The potential role of silicone as an immune adjuvant remains very controversial. Currently available techniques do not allow precise measurements of silicone in tissues. However, all compounds containing silicon (including silicone) can be measured accurately. The present study was designed to measure silicon levels in the fibrous capsules of patients with silicone-gel breast implants, saline breast implants, and silicone inflatable penile prostheses. Baseline control silicon levels were obtained from the breast tissue of patients undergoing breast reduction, who had no exposure to breast implants. All silicon measurements were carried out using atomic absorption spectrometry with a graphite furnace. Silicon was measured in a normal heptane extract of silicone from dried tissue. The mean silicon levels in 16 breast tissue control samples from 8 patients undergoing breast reduction varied from 0.025 to 0.742 micrograms/gm with the median mean being 0.0927. The median silicon level in capsules from six patients with saline implants was 7.7 micrograms/gm (range, 1.9-36.6 micrograms/gm). The median silicon level in capsules from five patients with silicone inflatable penile prostheses was 19.5 micrograms/gm (range, 1.9-34.8 micrograms/gm). Although the levels of silicon in capsules of patients with saline breast prostheses and penile implants were higher than in control samples, they were much lower than those from the capsules of the 58 gel implants (median, 9,979 micrograms/gm; range, 371-152,000 micrograms/gm).(ABSTRACT TRUNCATED AT 250 WORDS)

Tissue- and cell-specific distribution of creatine kinase B: a new and highly specific monoclonal antibody for use in immunohistochemistry

A synthetic 17-mer peptide corresponding to an unique sequence in the amino-terminal region of human creatine kinase B was used to raise a new and highly B-subunit-specific monoclonal antibody, CK-BYK/21E10. We show here that the monoclonal antibody is suitable for immunohistochemistry of unfixed frozen sections as well as formaldehyde- or Bouin-fixed, paraffin-embedded sections of human, rabbit, and mouse tissues. Moreover, in the study of cell- and tissue-specific distribution patterns, parallel Western blot analysis and immunoelectron microscopy is possible using this antibody. Our analyses demonstrate that creatine kinase B expression is restricted to a specific subset of cell types in various tissues. In brain, the B-subunit was found only in neurocytes, but not in glia cells. High expression was also observed in inner segments of photoreceptor cells and the outer plexiform layer of the retina, in the parietal cells of the stomach and in gut enterocytes, gallbladder and epithelial cells of the urogenital system. The possible roles of the creatine kinase/phosphocreatine-ATP system in these tissues are discussed.

Public pensions, family allowances and endogenous demographic change

"A tax-transfer system deals with redistribution a PAYGmong generations and corrective taxation a PAYGt the same time. Since such a policy is a government's task, we take a normative approach and pose the question: Which tax-transfer system should a government apply to maximize social welfare? The framework we consider allows for endogenous demographic aspects...: first, fertility has a great impact on a PAYG [pay-as-you-go] financed pension insurance; and second, through education human capital is accumulated.... We analyzed the optimal extent of a public pension scheme in the presence of external effects of fertility and education on the net domestic product." Pension schemes in Germany and the United States are compared.

[An unusual series of complications in therapy with implantable cardioverter-defibrillator]

A 48-year-old man with dilative cardiomyopathy and a history of resuscitation due to ventricular fibrillation received an implantable cardioverter-defibrillator (ICD) with epicardial sensing and defibrillation electrodes in March 1990. An early battery depletion due to increased electrical leakage of a filter capacitor necessitated a generator exchange in July 1990. Subsequent inappropriate discharges occurred, but no underlying cause could be documented by history, clinical examination, Holter monitoring, and beepograms. Only 3 months later was it possible to demonstrate oversensing by repeated beepograms, and a new generator and transvenous sensing electrode were implanted in October 1991. Four months later, inappropriate shocks were suspected again. Once more, history, clinical examination, Holter monitoring, and beepograms were without pathological result. At follow-up, repeated beepograms during exercise demonstrated an oversensing, and an insulation defect of the newly implanted sensing electrode close to the edge of the generator could be documented on x-ray. Since replacement of generator and sensing electrode in July 1992 the patient is doing well. He received two appropriate shocks which were associated with presyncope. ICD therapy is very complex and therefore should only be performed in centers providing the necessary personal, apparative and logistic conditions.

Do patients with silicone-gel breast implants have elevated levels of blood silicon compared with control patients?

Whole blood silicon levels in 30 patients with silicon-gel implants (inserted between 1973 and 1991) were compared with those of 24 healthy, age-matched, female patients without breast implants using atomic absorption spectrometry with a graphite furnace. The blood silicon levels in the implant patients were significantly higher than those of controls (medians 33.45 vs 17.05 ng/ml; p = 0.005). Of the 30 patients with implants, 15 had received their implants between 1973 and 1985, and 15 had received implants between 1986 and 1991. Implants made between 1973 and 1985 have been shown to be weaker and to have higher silicone "bleed" levels than those made from 1986 onward. However, there were no significant differences in the blood silicone levels between these two groups of patients.

On the effect of garlic on plasma lipids and lipoproteins in mild hypercholesterolaemia

The ingestion of garlic has been reported to have many cardiovascular effects, including a reduction in plasma cholesterol concentration and the susceptibility of LDL to oxidation. A double-blind, placebo-controlled, randomised crossover study was conducted in subjects with mild to moderate hypercholesterolaemia who were subject to strict dietary supervision and assessment. After a baseline dietary period of 28 days, subjects took Kwai garlic powder tablets 300 mg three times daily or matching placebo for 12 weeks, followed by 28 days washout, followed by a 12 weeks crossover on the alternative preparation. In the analysis hypercholesterolaemia was defined as those subjects in the range 5.5-8.05 mmol/l. Three subjects were withdrawn, one allocated to garlic and complaining of garlic body odour, one using placebo having intercurrent health problems, and one with a baseline cholesterol below 5.5 mmol/l, yielding analysable results in 28 subjects. Comparing the period on garlic with that on placebo, there were no significant differences in plasma cholesterol, LDL cholesterol, HDL cholesterol, plasma triglycerides, lipoprotein(a) concentrations, or blood pressure. Mean LDL cholesterol concentration was 4.64 +/- 0.52 mmol/l on garlic and 4.60 +/- 0.59 mmol/l on placebo. There was no demonstrable effect of garlic on oxidisability of LDL, on the ratio of plasma lathosterol/cholesterol (a measure of cholesterol synthesis), nor on LDL receptor expression in lymphocytes. This study found no demonstrable effect of garlic ingestion on lipids and lipoproteins.

A phase II trial of zeniplatin in metastatic melanoma

A third-generation platinum analogue, zeniplatin, was administered at a dose of 145 mg/m2 intravenously over 60-90 minutes every 21 days as the initial chemotherapy to 21 patients with metastatic melanoma. Prehydration and mannitol diuresis was introduced after the first 7 patients. There were 17 males and 4 females. The median age was 52 (range: 29-81). ECOG performance status was 0 in 10 patients, 1 in 8 patients and 2 in 3 patients. Major disease sites were lymph nodes, skin, lung, liver, and bone. Patients received a median of 2 cycles (range: 1-7). Two patients achieved partial responses. One with nodal disease progressed after 166 days and the other with buccal mucosal disease after 142 days. A third patient showed partial regression of nodal disease but developed cerebral metastases. Gastrointestinal toxicity included WHO grade 3 vomiting in 8 patients and nausea in 2. Antiemetics were used, but ondansetron was not available. WHO grade 3 hematologic toxicities included neutropenia in 8 patients and anemia and thrombocytopenia in 1 patient. Thrombocytosis was seen in 35% of courses. Dosage reduction was required in 15% of courses and escalation in 5% of courses. Three patients developed phlebitis related to the infusion. One patient developed a reversible rise in serum creatinine, but, unlike other studies, no severe nephrotoxicity was reported. Zeniplatin demonstrated only modest activity in melanoma with significant gastrointestinal and hematologic toxicity.

Analog-digital recording of current and voltage during high voltage DC shocks

Efficient on-line digitization is the prerequisite for computerized analysis of the electrical phenomena occurring during defibrillation. Conventional hardware presently provides only limited time resolution. The performance of various digitization rates for recording of voltage, current, and calculation of derived quantities like impedance, energy, and defibrillator capacitance was investigated. It was assessed both experimentally and by computer simulation of a trapezoidal discharge (of 9 msec duration into a constant resistive load of 50 omega with a defibrillator capacitance of 132 microF). The accuracy achieved with different digitization rates is given. For example, an accuracy of 1% for analog-digital conversion for impedance calculation during this kind of DC shock requires a sampling rate of 8 kHz without, and a rate of 1 kHz with linear interpolation to correct for the hardware dependent error due to sequential sampling.

CONCLUSION

Highly efficient analog-digital conversion of delivered voltage and current during DC shocks is available within the limits of conventional inexpensive hardware.

Silicone breast implants and autoimmune connective tissue disease

There is currently no proven cause-and-effect relationship between breast implants and autoimmune connective tissue disease. However, there is a growing concern that immunological sensitization to silicone could potentially develop in certain susceptible patients and that this could contribute to the development of autoimmune connective tissue disease. In this article I review the current status of this potential relationship. The following areas are discussed: chemistry of silicone, potential mechanisms for an immune response, implant failure, epidemiological and antibody studies of autoimmune connective tissue disease, and recent information on certain neurological findings in a group of patients with breast implants. Current large-scale epidemiological studies should help to define any potential relationship between breast implants and autoimmune connective tissue disease.

Calcification of breast implant capsules: incidence, diagnosis, and contributing factors

From January 1990 to August 1994, more than 6000 patients with silicone-gel breast implants were clinically assessed regarding their implant status. Of these, 82 patients requested removal of their implants (150 implants). Of the 150 implants that were removed, 24 (16%) demonstrated calcified capsules. All 12 patients with calcification demonstrated this finding bilaterally. All calcified capsules demonstrated discrete calcified plaques on their inner surface. All 12 patients presented with Baker class IV contractures, with pain as their chief complaint. One patient demonstrated calcification on a routine chest radiograph. One patient demonstrated a stippled appearance on xeromammogram. Capsular calcification was related to the duration of implantation. All 6 implants that had been in place for 23 to 26 years were associated with calcification. These implants were all of the thick-walled Dacron-backed type. All thick-walled Dacron-backed implants that were removed in this study were associated with calcification. Of the 69 implants that had been inserted for 11 to 20 years, 18 (26.1%) were associated with calcification. Fifteen of these 16 implants were ruptured. None of the implants that had been in place for 10 years or less demonstrated calcification.

Transmyocardial impedance during single and multiple internal ventricular defibrillation shocks

Pages H664–H693: W. Peters, S. Solingen, Y. Kobayashi, R. Scharf, W. J. Mandel, and E. S. Gang. “Transmyocardial impedance during single and multiple internal ventricular defibrillation shocks.” The following corrections should be noted.

Page H684, methods section, first paragraph: The analysis presented here is based on measurements during infusion with saline or lactated Ringer solution in the same dogs later treated with propafenone or lactated Ringer solution as described elsewhere (24).

Page H685, methods section, fourth paragraph: In dog 4, the same defibrillator-electrode combination was used to deliver 20 shocks of a damped half sine waveform as clinically used in external defibrillation (here C = 32 μF, inductance = 40 mH).

Page H686, Figure 2 legend: Typical graph of delivered voltage [V(t)] and transmyocardial impedance [Z(t)] during defibrillation with truncated trapezoidal pulse waveform [stored energy (Esto) = 20 J]. Pol, polarization.

Page H689, Table 6 title: Calculated defibrillator C according to Eq. 5 and relative difference in Edel and energy converted into heat (Eres by resistive part of transmyocardial impedance.

Preliminary experience using an optimized three-point transformation algorithm for spatial registration of coordinate systems: a method of noninvasive localization using frame-based stereotactic guidance systems

This study describes the use of an optimized three-point transformation algorithm to spatially cross-register a volumetric computerized tomographic scan or magnetic resonance image data set with the coordinate system of a stereotactic frame. This algorithm was tested for accuracy using a scanned phantom in which calculated targets, using the Brown-Roberts-Wells (BRW) frame picket-fence algorithm as a standard, could be compared to physical targets measured using a BRW arc and phantom. These target values were then compared to target values calculated with the optimized three-point algorithm. This method was used for target localization in 21 patients. Following this noninvasive localization method, the standard BRW stereotactic system was used for guidance. The application accuracy of this frameless localization technique was within the limits of the scan slice thickness in 16 of 21 cases, with an average error of 2.11 mm in an average scan slice thickness of 3.1 mm. Intracranial targets were successfully reached in all cases without morbidity or mortality. The algorithm can be customized to cross-register image data sets with the coordinate systems of a wide variety of stereotactic guidance systems. The method increases the convenience and flexibility of frame-based stereotactic guidance by providing a means of noninvasive localization that can be accomplished electively at a separate time from the guidance part of a stereotactic operative procedure.

Antimalarial activity of the bicyclic peroxide Ro 42-1611 (arteflene) in experimental models

The sesquiterpene peroxide Ro 42-1611 (arteflene), a synthetic derivative of yingzhaosu, was evaluated extensively against various drug-sensitive and drug-resistant lines of Plasmodium falciparum in vitro and P. berghei in vivo in mice. The potential therapeutic and prophylactic activities were studied comparatively with the standard antimalarials chloroquine, mefloquine and quinine, as well as qinghaosu and the derivatives artemether and artesunic acid. Experimentally arteflene proved to be a highly effective antimalarial drug. In vivo it is active at low doses against blood stages of P. berghei in mice after oral or parenteral administration. It has a rapid onset of drug action and a long lasting suppressive effect when given after infection, as well as a good potential for prophylactic activity when given before infection. The suppressive and prophylactic properties are comparable to chloroquine and superior to qinghaosu, artemether and artesunic acid. In vitro the compound showed no signs of cross-resistance with existing antimalarials. It was consistently rather more active against drug-resistant than against drug-sensitive strains of P. falciparum. Drug interaction studies in vitro and in vivo with chloroquine, mefloquine and quinine revealed an additive to synergistic effect with arteflene. Antagonism with these drugs was not observed. Compared with standard antimalarials the activity of arteflene in vitro is lower than would be expected from the in vivo results. This may be due to pharmacokinetic properties of the compound and the formation of an active metabolite which sustains the activity of arteflene in vivo.

Transmyocardial impedance during single and multiple internal ventricular defibrillation shocks

Little is known about the transmyocardial impedance during internal ventricular defibrillation. In a canine model, using high rate on-line digitization, random shock delivery, and titanium electrodes, we determined the relationship among voltage, current, and impedance, delivered energy, and defibrillation success within the individual and within successive defibrillation shocks. Impedance decreased with repeated defibrillation in 10 of 11 dogs. Impedance always increased during trapezoidal discharges, whereas voltage decreased. Impedance was lower with high energy-voltage shocks in all dogs. Visually, voltage and current waveform did not show a phase shift. There was no difference in the total energy delivered and the energy converted into heat by the resistive part of the impedance. With a formula valid only for resistive loads, the capacitance of the defibrillator was calculated to be within the measurement accuracy and tolerance of the factory-provided value of 132 microF. Polarization voltage was consistently observed. Thus the transmyocardial impedance during defibrillation is primarily resistive, nonlinear voltage dependent, and declines with successive shocks. Defibrillation success was not influenced by these phenomena.

Glutathione, glutathione-s-transferase and p-170 glycoprotein in metastases of malignant melanomas

P-170 glycoprotein, glutathione and glutathione S-transferases are important in in vitro drug resistance, but their clinical relevance is unclear. Therefore glutathione content, glutathione S-transferase enzyme activity, isoenzyme composition as well as P-170 glycoprotein level were studied in metastases of malignant melanomas of thirteen patients. P-170 glycoprotein and glutathione S-transferases were quantified by immunoblotting with monoclonal antibodies, glutathione S-transferase enzyme activity was measured with 1-chloro-2,4-dinitrobenzene as substrate, and glutathione was assayed by HPLC. Glutathione and glutathione S-transferase enzyme activity were measurable in all samples and mean values were 40+/-7 nmol/mg protein (mean+/-SEM; range: 13-98) and 310+/-72 nmol/min mg protein (range: 15-819), respectively. Glutathione S-transferases present were mainly of class pi (2817+/-402 ng/mg protein); class alpha enzymes were detectable only in one case in low amounts (71 ng/mg protein), and class mu transferases were present in 5 out of the 13 samples (38%; 391+/-206 ng/mg protein). The P-170 glycoprotein plasma membrane located drug efflux pump was found in 8 out of 12 samples (67%). In three samples values were much higher as compared to the other specimens. In the metastatic melanoma of one patient, both high levels of glutathione S-transferase and P-170 glycoprotein were found. Further studies are necessary to reveal whether melanoma tissues containing high levels of P-170 glycoprotein, glutathione S-transferases or a combination of both systems do respond differently towards anti-cancer drug treatment.

Radiation necrosis overlying the ankle joint after injection with yttrium-90

A 35-year-old woman with rheumatoid arthritis presented with radiation necrosis and an open wound overlying her ankle joint, 8 months after injection with yttrium-90 to facilitate radiosynovectomy. This problem was successfully treated by surgical excision of the area of radiation damage and closure with a fasciocutaneous flap.

Factors affecting the rupture of silicone-gel breast implants

Between January 1990 and April 1993, over 500 patients with silicone-gel breast implants were clinically assessed regarding their implant status. Of these, 57 patients requested implant removal. Reasons for removal were capsular contracture (39 patients), possible implant rupture, suggested by ultrasound testing or mammography (7 patients), "silicone phobia" (7 patients), and asymmetry (4 patients). Of the 102 implants that were removed, 60% were intact, 33% were ruptured, and 7% were leaking. There was a positive correlation between duration of implantation time and the number of ruptured and leaking implants. Of the 45 implants that had been in place for 5 years or less, 93% were intact. Of the 29 implants that had been in place for 6 to 10 years, only 31% were intact (59% were ruptured and 10% were leaking). Similar results were obtained in 20 implants after 11 to 15 years (30% were intact, 55% were ruptured, and 15% were leaking). Of 8 implants that were in place for 16 to 26 years, 50% were intact and 50% were ruptured. In this study, the integrity of breast implants was not related to the degree of capsular contracture.

Evaluation of 0.75% metronidazole gel in acne--a double-blind study

Metronidazole, an imidazole, is an antibiotic with established efficacy against anaerobic bacteria. To date, however, there are no published data concerning the efficacy of topical metronidazole in the treatment of acne. This randomized, double-blind prospective clinical study of 96 patients was performed to investigate the efficacy and tolerability of 0.75% metronidazole gel vs. placebo in the treatment of mild to moderate acne. The results of this study showed no significant benefit in using 0.75% metronidazole gel over placebo in reducing counts of inflamed and non-inflamed lesions of acne. There was also no statistically significant difference between the two groups at any stage in the trial when skin tolerability was assessed.

Clostridium septicum abscess in hepatic metastases: successful medical management

Clostridium septicum bacteremia is frequently associated with hematologic and colonic malignancies and neutropenia. It frequently produces 'metastatic' gangrene with excessive mortality. Standard therapy usually includes surgical debridement and antibiotics. We present a patient with metastatic breast cancer treated with high-dose chemotherapy and bone marrow transplantation. She was treated successfully with antibiotics alone despite developing Cl. septicum bacteremia and gas in hepatic metastases. The pathophysiology of this infection is reviewed.

Patient-controlled analgesia in burn patients: a critical review of the literature and case report

Although patient-controlled analgesia has been well documented as effective in various types of patients, it has not been adequately studied in burn patients. In this paper, the authors review the literature on PCA in burn patients and present two cases. Flaws in most published studies make it difficult to determine the efficacy of PCA in burn patients. Both the literature and experience indicate that many patients with acute burns are not suitable candidates for PCA. The cases illustrate the different methods patients may use to achieve adequate analgesia with PCA. Both patients and nurses face a steep learning curve in using PCA for management of procedural pain in burn care.