Establishment of cell lines from B-cell precursor acute lymphoblastic leukemia

In an attempt to establish permanent cell lines from children with B-cell precursor acute lymphoblastic leukemia (BCP-ALL), 123 clinical samples from 117 patients were cultured in vitro. Using a method which was successful for the growth of ALL with T-cell phenotype, 3% (2/74) of BCP-ALL samples from patients at diagnosis and 31% (9/29) of BCP-ALL samples from patients at relapse were established as cell lines. However, in most cultures, leukemic cells survived for only a few weeks and the majority of viable cells present after 28 days of culture were esterase-positive mononuclear cells. Based on the hypothesis that mononuclear cells inhibited leukemic cell growth, we evaluated the effect of a monocyte toxin, L-leucine methyl ester (Leu-OMe), on the growth of four frozen BCP-ALL samples. Thawed leukemic cells treated with Leu-OMe, but not untreated control cells, proliferated in three samples and one new cell line was established. Subsequently, when Leu-OMe was added to fresh leukemia cells in culture, leukemic cell lines were grown from 29% (4/14) of samples at diagnosis and 66% (4/6) of relapse samples. Overall, 20 BCP-ALL cell lines were established, all were Epstein-Barr virus (EBV)-negative, and authenticity of each cell line was verified by a direct comparison of the immunophenotype, karyotype, and genotype with the patient's tumor cells. This improved method of cell culture permits a higher success rate of cell line establishment from patients with BCP-ALL thereby aiding in analysis of B-lymphocyte transformation and neoplasia.

Sexualization and desexualization

This paper is a reconsideration of the role of sexualization in psychoanalysis. After a review of the accepted definitions of sexualization as defense and/or part of normal sexuality, a new explanation is offered. This posits sexualization as a psychological manifestation of a structural deficit and suggests analytic treatment as a process of structuralization. These terms are defined and illustrated. A case example demonstrates the thesis, and some implications of this concept are discussed.

Once-daily, extended-release gemfibrozil in patients with dyslipidemia. The Lopid SR Work Group I

This randomized, parallel-group, multicenter clinical trial compared a newly developed, once-daily, extended-release formulation of gemfibrozil (Lopid SR) and gemfibrozil twice daily (Lopid) in terms of lipid-regulating effects and toxicity. Patients were men and women with elevations of low-density lipoprotein cholesterol and low levels of high-density lipoprotein cholesterol. The trial consisted of a 1-week screening period, an 8-week diet baseline period (Step One Diet), and a 24-week double-blind treatment period (extended-release gemfibrozil 1,200 mg once daily vs gemfibrozil 600 mg twice daily). At the end of the trial, the 2 treatment groups showed comparable improvements in all primary lipid factors: mean percent changes in triglyceride, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol were -32, +10 and -10% for extended release (n = 325) and -36, +11 and -10% for twice daily (n = 330). The 90% confidence interval for the relative difference between the treatment means fell within the equivalence bounds of +/- 35% for all 3 factors, demonstrating equivalence of efficacy. Adverse events were reported at low rates and were similarly distributed in frequency and intensity between treatment groups; they were preponderantly mild or moderate, and gastrointestinal effects were the most frequent. The once-daily formulation of gemfibrozil may afford better control of dyslipidemia through improved compliance by patients who have this asymptomatic disease.

Nedocromil sodium inhibits T-cell function in vitro and in vivo

Nedocromil sodium, a topical antiinflammatory agent recommended as a prophylactic regimen for asthma, is known to inhibit both allergic and nonallergic inflammatory processes in which an essential role for T cells has been implicated. Therefore the direct effects of this drug on several aspects of T-cell activity were analyzed in the present study. By using murine lymphocytes we found that NS at concentrations of 10(-8) to 10(-6) mol/L inhibited the mitogen- or antigen-induced proliferative responses of these cells. It is interesting to note that higher concentrations were ineffective. Preincubation of immune lymph node cells from contact sensitized mice with the drug abrogated their ability to transfer contact sensitivity to naive recipients, an effect that was found to be specific for the treated cells. Nedocromil sodium also interfered with the mitogen-induced interleukin-2 and tumor necrosis factor production by T cells and with their ability to adhere to the bound protein components of the extracellular matrix laminin and fibronectin. All these effects may be attributed to the inhibition of the increase of cytosolic calcium, which accompanies the early phase of T-cell activation and which is an essential step in inducing the aforementioned phenomena.

The Missouri Cardiovascular Health Plan: a focus on prevention

The authors describe a framework for planning, implementing, and evaluating cardiovascular health programs in Missouri. Populations targeted for intervention are identified, and the role of the physician in supporting community-based cardiovascular health promotion is explored.

Intranasal absorption of flurazepam, midazolam, and triazolam in dogs

Intranasal delivery of flurazepam, midazolam, and triazolam was studied in a dog model as a possible alternate route of drug administration for treatment of insomnia. Four beagles received each hypnotic by both intranasal and oral routes on two separate occasions. Plasma concentrations for each hypnotic after dosing were measured by electron-capture gas-liquid chromatography. The mean intranasal absorption rates (tmax) of flurazepam, midazolam, and triazolam were 1.7, 2.0, and 2.6 times faster, respectively, compared with oral dosing. The mean dose-normalized peak concentrations (Cmax) after intranasal delivery were 16.4, 2.9, and 3.4 times higher, respectively, versus oral administration. The mean dose-normalized AUCs estimated for these compounds after nasal administration were 2.4-, 2.5-, and at least 2-fold larger than after oral administration for midazolam, triazolam, and flurazepam, respectively. If these observations can be extrapolated to humans, the faster absorption achieved by the intranasal route would appear to benefit insomniacs characterized by difficulty in falling asleep because of an anticipated faster sedative effect onset. The higher peak concentrations and larger amounts absorbed in the case of intranasal midazolam and triazolam delivery may lead to dose reduction.

Cutaneous responses to histamine, compound 48/80, and codeine in patients with chronic renal failure

Pruritus is a common symptom associated with chronic renal failure (CRF). But increased plasma histamine levels and skin mast cell proliferation previously reported in these patients did not correlate with the intensity of the pruritus. Since increased mast cell releasability was described in chronic idiopathic urticaria, we attempted to examine whether this mechanism could explain pruritus in patients with CRF. Twenty-five patients with end stage renal failure were skin tested with histamine, codeine, and compound 48/80. There were nine patients on continuous ambulatory peritoneal dialysis, eight patients on hemodialysis, (tested both before and after dialysis) and eight patients with advanced CRF. Wheal area after intradermal injection of three concentrations of the above substances was measured. In general, the wheal areas in all patients with CRF were either similar to or smaller than those of the control group who were without renal impairment. In conclusion, patients with CRF with or without dialysis therapy demonstrated unchanged or decreased skin test responses to histamine, codeine, and compound 48/80. Increased mast cell releasability cannot explain the pruritus in patients with CRF.

Appearance of macrophage migration inhibition factor in patients with systemic reactions to bee venom

Cellular responses in bee venom (BV) allergy is a controversial issue. Previous studies could not reach an agreement whether this mechanism is activated as a result of allergic sensitization to bee venom. All previous works have used lymphocyte proliferation as their method to analyze cell-mediated immunity. In the present work, we tried to explore whether the production of macrophage migration inhibition factor (MIF), which is another in vitro correlate with cellular responses, is increased in these patients. We also examined which of the major antigenic components of BV played a significant role in the cellular response. Peripheral blood lymphocytes from 10 patients with systemic allergic reactions to bee sting and 9 healthy volunteers were examined for their ability to induce positive MIF responses. Macrophage inhibition was significantly increased in allergic patients when tested with BV, phospholipase A2 (PLA2) and with melittin. Positive MIF responses to other components were also more common in allergic patients than in the control group. Our results indicate that cellular response to BV is expressed in patients with systemic allergic reaction to BV. When major antigenic components of BV are examined, PLA2 seems to play the major role in inducing this response.

Elevation of blood lactate and pyruvate levels in acute intermittent porphyria--a reflection of haem deficiency?

Blood lactate concentrations after glucose loading were significantly higher in 6 patients with acute intermittent porphyria in clinical remission than in 6 control subjects and the percentage rise in glucose pyruvate and lactate concentrations were greater in the porphyric subjects than in the control group. It is postulated that the raised lactate levels in the porphyric patient group may reflect haem deficiency affecting the cytochromes of the terminal respiratory chain.

Comparison of hypertension treatment on and off the worksite

A survey was carried out in two plants in Haifa, Israel on the prevalence of treated and controlled hypertension. In both plants hypertension treatment was being carried out by family physicians at regular family clinics. In factory A, after screening, a programme of follow-up and treatment by the plant doctor and nurse was introduced. In factory B all hypertensives continued to be referred to their family physician for treatment and follow-up. One year later all previously detected hypertensives were reassessed. The percentage of treated hypertensives had increased from 70.9% to 100% in factory A, and from 55.0% to 62.1% in factory B. The percentage of controlled hypertensives among those treated had increased from 52.7% to 83.7% in factory A, and from 28.0% to 38.9% in factory B. Thus, the percentage of all hypertensives who were controlled increased from 37.3% to 83.7% in Factory A and from 15.4% to 24.1% in Factory B. The introduction of on-site treatment and follow-up of hypertension by a doctor-nurse team was associated with marked improvement of all aspects of hypertensive care.

DNA fingerprints of chickens selected for high and low body weight for 31 generations

Two lines of White Plymouth Rock chickens that have been divergently selected for 8-week body weight for 31 generations were compared for patterns of DNA fingerprints (DFP). Digestion of DNA with HinfI and hybridization to Jeffreys' minisatellite probe 33.6 resulted in DFPs that were relatively similar within lines (bandsharing = 0.50) and less similar between lines (bandsharing = 0.22). Analyses of scorable DFP bands produced by mixing DNA from individuals within lines indicated that 48% were line-specific. Causes for the differences in DFP patterns between lines and for occurrence of line-specific bands for the two lines divergently selected for body weight are discussed.

LHRH analogue treatment for the prevention of premenstrual attacks of acute porphyria

We have assessed the value of suppressing ovulation with the luteinizing hormone releasing hormone (LHRH) analogue buserelin in seven patients experiencing crises of acute intermittent porphyria related to the menstrual cycle. Clinical course, plasma oestradiol and progesterone levels, and urinary porphyrin and precursor excretion were monitored over a baseline period of approximately one year, and then for a similar period on buserelin treatment. There was a trend towards clinical improvement on buserelin therapy. The median number of attacks fell from seven during the baseline period to three on treatment (p = 0.06). The response to buserelin varied considerably, with those patients in whom the association between baseline attacks and the menstrual cycle was strongest gaining the most benefit. All patients became amenorrhoeic with suppression of plasma oestradiol and progesterone levels. Urinary delta-aminolaevulinic acid and total porphyrin excretion fluctuated widely both before and during treatment. Our experience indicates that ovulation suppression may be of value in the management of young women in whom recurrent attacks of porphyria are related to the menstrual cycle.

Elevation of hormone-binding globulins in acute intermittent porphyria

Sex hormone-binding globulin (SHBG), thyroxine-binding globulin (TBG) and cortisol-binding globulin (CBG) were measured in plasma of 26 patients with acute intermittent porphyria (AIP). Twelve patients had clinically manifest disease and all had elevated SHBG levels. All but one of 14 patients with latent porphyria had normal SHBG levels. TBG was elevated in 9 of the patients with clinically manifest porphyria and CBG elevated in three. Levels of TBG and CBG were either normal or only slightly elevated in those with latent porphyria. In a prospective study of 30 attacks of AIP in 7 patients, SHBG levels fell between admission and discharge, the fall being significant in the group of 21 attacks treated with haem arginate (p less than 0.001). Our findings suggest that a close correlation exists between elevated SHBG and clinical expression of AIP.

Cutaneous responses to histamine, compound 48/80 and codeine in patients with hyperthyroidism

The regulatory effects of various endocrine factors on allergic processes have been widely studied. The clinical importance of hyperthyroidism in asthma and in chronic urticaria has been demonstrated in several cases. These observations may be attributed to modulatory effects of thyroid hormones on mast cell releasability and/or on other target organs as blood vessels. To evaluate the effects of thyroid hormones on mast cell releasability and on the cutaneous vasculature, we analyzed the wheal and flare response to compound 48/80, to codeine, and to histamine in patients with hyperthyroidism and in a control group. No significant difference was found between the two groups. We could not demonstrate any in vivo effect of the thyrotoxic state on the cutaneous response to these substances.

Self psychology and the narcissistic personality disorders

This article is about the self psychological approach to narcissistic personality disorders. Starting from the vantage point of considering the growth and development of the self as crucial to understanding any and all disorders of narcissism, it describes the various forms of self development. These forms are felt to emerge and grow according to patterns seen in the transference of these patients in treatment. The transferences are called selfobject transferences and are based on the use of another person as part of the self, that is, as a part of the structure needed for growth. The three kinds of transferences that have been described are the mirror transference, the idealizing transference, and the twinship transference. These are considered to be expressions of childhood development that has gone awry and thus to be the focus for psychological intervention. Short-term treatment aims for repair of an injured or traumatized self. Long-term treatment or analysis aims for a reorganized self that pursues its own further development. Some factors involving etiology and the role of empathy in treatment are noted in the discussion.

Controlled trial of haem arginate in acute hepatic porphyria

A double-blind study comparing placebo and haem arginate was conducted in 12 patients with acute intermittent porphyria. 2 days after admission in attack patients were randomised to receive intravenous haem arginate 3 mg/kg per 24 h for 4 days or placebo. 9 patients were readmitted with a further attack and were given the alternative treatment. Before randomisation the paired attacks were of similar severity with respect to urinary porphobilinogen (PBG) excretion and clinical manifestations. With haem arginate the median PBG excretion of the 9 patients with two attacks (normal range 0-16 mumol per 24 h) fell significantly from 332 mumol per 24 h (range 137-722) on admission to a median lowest level of 40 (range 22-105). On placebo, median PBG excretion was 382 (range 196-542) on admission, falling to 235 (range 128-427). Median duration of admission after the start of treatment was 11 days (range 2-28) for placebo and 8 days (3-26) for haem arginate. Median total analgesic requirement between the start of treatment and discharge was 8150 mg pethidine equivalents (range 0-17,650) with placebo versus 6425 (range 50-20,650) with haem arginate. Phlebitis occurred in 5 patients on haem arginate and in 2 on placebo. Haem arginate effectively reduces porphyrin precursor overproduction in the acute porphyric attack but this reduction is not accompanied by striking resolution of the clinical manifestations of the attack.

Inhibition of delayed hypersensitivity reactions in mice by colchicine. I. Mechanism of inhibition of contact sensitivity in vivo

Colchicine has been recently shown to inhibit delayed hypersensitivity reactions (DHR). In the present study we investigated the effects of colchicine on contact sensitivity (CS) to dinitrofluorobenzene. Colchicine, at a dosage level of 15 micrograms/mouse, inhibited the elicitation of the contact response only when given on the day of ear challenge. Administration of the drug during the induction phase did not have any effect on the CS reaction. By using adoptive transfer experiments, we could demonstrate that CS was suppressed only when colchicine was given to the recipient mice, while treating the donors of immune lymph node cells (I-LNC) did not affect their ability to transfer a significant DHR. These findings were observed also when I-LNC were directly injected into the ears, a result which indicated that there was no effect of the drug on the ability of effector cells to migrate to the site of antigen challenge. Neither was there any effect on the distribution of T cell subsets in peripheral lymph nodes. The proliferative response of LNC to antigenic or mitogenic stimulation in vivo or in vitro was also not affected by colchicine pretreatment. These findings raise major questions about the mechanism of action of colchicine in vivo and suggest that more experimentation is required to probe the mechanism of colchicine-induced suppression of DHR.

Acute intermittent porphyria in two patients on anticonvulsant therapy and with normal erythrocyte porphobilinogen deaminase activity

1. Acute intermittent porphyria (AIP) is sometimes termed a 'pharmacogenetic' disease. patients with genetic deficiency of the enzyme porphobilinogen deaminase are liable to develop acute attacks of porphyria if exposed to a variety of drugs. 2. Two patients are reported who had no evidence of deficiency of erythrocyte porphobilinogen deaminase yet developed typical attacks of AIP while on anticonvulsant therapy. 3. Normal activity of erythrocyte porphobilinogen deaminase does not completely exclude porphyria. 4. Acute porphyria should be suspected if clinical deterioration occurs during therapy with anticonvulsants, or other porphyrinogenic drugs, even in the absence of an underlying genetic defect in haem synthesis in peripheral blood cells.

Action of lead on neurotransmission in rats

1. The neurotoxic effect of lead on the catecholaminergic and cholinergic nervous systems has been investigated using a rat model of lead exposure. 2. This model of lead exposure resulted in significant quantities of lead accumulating in the blood, brain and femur of the lead-exposed animals. 3. The biochemical effect of lead on brain neurochemistry was dependent on the degree and duration of lead exposure. However, the data points to a selective action of lead, with the midbrain and diencephalon being prime targets while very few lead-related alterations were observed in the cerebellum or the telencephalon. 4. Within the catecholaminergic nervous system, lead exposure resulted in alterations in the concentrations of the transmitters, noradrenaline and dopamine, in addition to changes in the activities of the enzymes tyrosine hydroxylase and phenylethanolamine-N-methyl transferase. The activity of the cholinergic biosynthetic enzyme, choline acetyltransferase was also noted to be altered by lead exposure.

Prolonged interval maintenance venom immunotherapy

Current guidelines recommend indefinite administration of venom immunotherapy at 4-week intervals. To simplify this therapy, we examined the clinical and immunologic response after extending the interval between maintenance venom injections to 6, 8, and 12 weeks. Twenty-six patients who had had sting anaphylaxis and positive skin tests received maintenance bee or yellow jacket venom immunotherapy at greater or equal to 6-week intervals. This extended interval was started after a prior average 4-week maintenance interval of 2.3 years. Injections were given at 6-week intervals to all 26 patients and extended to 8-week intervals in 10, and 12-week intervals in 3 patients. Following venom injections, there were 14 mild local reactions and no systemic reactions. No adjustment in dosing was necessary. While on prolonged interval maintenance venom immunotherapy, there were 17 re-stings in 12 patients with no systemic reactions. During prolonged interval maintenance venom immunotherapy, either the serum venom-specific IgG increased or the already elevated titers remained the same in 18 patients and decreased in 2. In the others, preexisting titers were low and unchanged. Serum venom-specific IgE tended to slowly decrease. These clinical and immunologic data suggest that a 4-week maintenance interval may be safely extended.

Magnetic resonance imaging in acute spinal cord trauma

Magnetic resonance imaging (MRI) has proven to be an invaluable tool for evaluating neoplastic, congenital, and degenerative conditions of the spine and spinal cord. Because of various technical limitations, however, the use of MRI in acutely spinal cord-injured patients has not been fully explored. Sixty-two spinal cord-injured patients underwent MRI within the first 36 hours of injury. A variety of pathological findings were detected on the MRI scans: anatomical cord transection (7 cases), spinal cord deformity secondary to extrinsic compression (28), focal cord enlargement/swelling (21), hyperintense intramedullary lesions (17), and disc herniations (2). MRI may be a useful adjunct in the evaluation of acute spinal cord injury.

Effect of haem arginate therapy on porphyrin metabolism and mixed function oxygenase activity in acute hepatic porphyria

The effect of haem arginate on porphyrin metabolism and haemoprotein function was studied during seven attacks of acute hepatic porphyria in 5 patients. In each attack it greatly reduced the overproduction of porphyrin precursors and repressed the overactivity of the rate-controlling enzyme of haem synthesis delta-aminolaevulinic acid (ALA) synthase measured in leucocytes. Antipyrine clearance, an index of the oxidative function of cytochromes P-450, the major group of hepatic haemoproteins, was increased during haem therapy. Thus, haem arginate not only suppresses the overproduction of haem precursors but also improves hepatic oxidative metabolism in acute porphyria.

An assessment of preoperative coagulation screening for tonsillectomy and adenoidectomy

Preoperative coagulation studies are commonly employed in order to try to identify the 2-4% of all patients undergoing tonsillectomy/adenoidectomy surgery who experience hemorrhagic complications. In an atmosphere of increasing cost consciousness, evaluation of the efficacy of screening tests is warranted. The records of 994 out of 1050 patients consecutively scheduled for tonsillectomy, adenoidectomy or T&A over a 2.5-year period were retrospectively reviewed in order to determine the usefulness of partial thromboplastin (PTT) and prothrombin time (PT) screening in predicting surgical and postsurgical bleeding. For patients with no history or clinical signs indicating possible bleeding disorder, preoperative PT and PTT failed to predict bleeding as an outcome. Also no patients were identified in this series to have previously undiagnosed coagulopathies on the basis of screening PT/PTT. The purpose of any screening test is to identify disease early enough for therapeutic intervention to be effective. Although preoperative PT/PTT will occasionally identify an unsuspected von Willebrand's or other coagulopathy, the prevalence of bleeding disorders in patients with negative history and examination is low enough that PT/PTT has essentially a zero predictive value for surgical bleeding. Screening PT/PTT should therefore be reserved for patients with known or suspected coagulopathies.

The effects of a beta-2 selective adrenergic agonist and a beta-nonselective antagonist on theophylline clearance

Beta-adrenergic agonists and antagonists have been shown to alter theophylline pharmacokinetics. It was the purpose of this study to characterize further the effects that terbutaline and propranolol have on theophylline disposition. In nine healthy male volunteers, mean parameters for theophylline disposition did not change after four days of terbutaline (5 mg q8h). Theophylline clearance, however, did change within the subjects. Clearance increased in five subjects, decreased in three, and remained unchanged in one volunteer. Pretreatment with four days of terbutaline (5 mg q8h) and propranolol (60 mg q8h) significantly decreased mean theophylline clearance (60.1 +/- 12.9 vs 40.6 +/- 9.9 mL/min/1.73m2; P less than .01) increased half-life (8.37 +/- 1.77 vs 12.32 +/- 2.70 hours; P less than .05), and increased postinfusion theophylline concentration (13.5 +/- 2.7 vs 18.95 +/- 2.5 micrograms/mL; P less than .001). In five subjects theophylline clearance increased after terbutaline pretreatment (64.6 +/- 13.0 vs 75.0 +/- 13.9 mL/min/1.73m2). The percentage increase ranged from 3.9 to 28.5%. These subjects were restudied after receiving propranolol alone (60 mg q8h). Comparison between the propranolol and terbutaline study and the propranolol alone study indicated no mean change in clearance in these five subjects (41.8 +/- 12.7 vs 36.1 +/- 5.1 mL/min/1.73m2). Thus it appears that the changes observed in these five subjects after terbutaline pretreatment may have been random in occurrence as has been shown to occur with theophylline disposition and are not related to terbutaline pretreatment. It is concluded that beta-2 adrenergic stimulation does not alter theophylline pharmacokinetics, whereas nonselective beta-adrenergic antagonism profoundly affected theophylline disposition. This is an additional reason not to use propranolol in patients who receive theophylline.

Intraindividual variability in theophylline pharmacokinetics in subjects with mild/moderate asthma

Intrasubject variability in theophylline pharmacokinetics was assessed in six subjects with mild/moderate asthma. On four occasions, each separated by a minimum of 3 weeks, a 6 mg/kg intravenous aminophylline dose was infused during 30 minutes, and multiple blood samples were obtained thereafter. The pharmacokinetic parameters of clearance (Cl), volume of distribution, and half-life were determined by noncompartmental analysis. There was evidence for within-subject variability in these parameters. In comparison to the first study day, Cl changed by greater than 15% in all but one subject and by greater than 25% in two of six subjects. Changes in half-life exceeding 25% of the value observed on the first study day occurred in three of six subjects. Within-subject coefficient of variation for Cl was 14.9% (range 3.9% to 33.3%) and 14.4% (range 5.8% to 24.3%) for half-life. Volume of distribution, however, was a more stable parameter with a within-subject coefficient of variation of 7.2% (range 2.3% to 11.1%). Thus, within-subject changes in the pharmacokinetics of theophylline do exist over time. These data suggest that close monitoring of patients receiving theophylline is warranted, particularly when theophylline concentrations are maintained at either extreme of the therapeutic range.

Pathogenesis of acute porphyria

The pathogenesis of the clinical manifestations of acute porphyria has been considered in the light of their pathological changes and their aberrations of the haem biosynthetic pathway. These manifestations may be explained almost entirely upon a neurogenic basis. A number of hypotheses have been considered to explain the clinical, pathological and biochemical features. Of these hypotheses two seem more impressive: (i) the neurological manifestations may be explained by a deficiency of haem in neural tissues; (ii) the porphyrin precursor 5-aminolaevulinic acid (ALA) may have in addition specific pharmacological activity.

Antipyrine metabolism in acute hepatic porphyria in relapse and remission

Antipyrine kinetics following a single oral dose were obtained in porphyric patients in attack and in remission and in controls. The clearance of antipyrine was significantly lower during an acute porphyric attack (median: 0.34 ml min-1 kg-1; range: 0.1-0.71, P less than 0.05) than in patients in remission (median: 0.53 ml min-1 kg-1; range: 0.28-0.87) or controls (median: 0.52 ml min-1 kg-1; range: 0.32-0.93). There was a significant negative correlation between weight-adjusted antipyrine clearance and the urinary excretion of the porphyrin precursors, delta-aminolaevulinic acid (r = 0.86, P less than 0.001) and porphobilinogen (r = 0.82, P less than 0.002). These data suggest that the more severe the porphyric attack, the greater the impairment of hepatic monooxygenase activity.

A case of watery diarrhoea syndrome due to an adrenal phaeochromocytoma secreting vasoactive intestinal polypeptide with coincidental autoimmune thyroid disease

A 40 year old woman presented with a 10 year history of watery diarrhoea and an acute quadriparesis. On clinical examination there was severe muscle weakness and a nodule was palpable in the thyroid gland. Biochemical testing revealed a hypokalaemia at 1.6 mmol/l. Plasma levels of VIP were raised at 202 pmol/l. CT scanning demonstrated a mass in the area of the left adrenal gland, and isotope scanning of the thyroid gland showed a 'cold' nodule. The plasma catecholamines and calcitonin were elevated. The patient also presented with psychiatric symptoms, and the relevance of these to her condition has been discussed. At operation a left adrenal tumour was removed. Post-operatively the patient's symptoms disappeared and the plasma hormone levels returned to normal values. Histological examination of the tumour revealed a well differentiated phaeochromocytoma which contained VIP and calcitonin. The thyroid nodule was excised and showed histological features of autoimmune thyroid disease. It is suggested that in all cases of the WDHA syndrome where the tumour is in an extra-pancreatic site patients should be screened for phaeochromocytoma.

Porphyrin metabolism and haem biosynthesis in Gilbert's syndrome

Studies in 14 patients with unconjugated hyperbilirubinaemia caused by Gilbert's syndrome have revealed abnormalities of the enzymes of haem biosynthesis measured in peripheral blood cells. The activity of the penultimate enzyme of haem biosynthesis protoporphyrinogen (PROTO) oxidase was reduced at 3.1 +/- 2.6 nmol PROTO/g protein/h (mean +/- ISD) compared with 8.2 +/- 5.1 in controls (p less than 0.005). This was associated with a compensatory increase in the activity of the initial and rate controlling enzyme of the pathway delta-aminolaevulinic acid (ALA) synthase at 866 +/- 636 nmol ALA/g/protein/h compared with 156 +/- 63 in controls (p less than 0.001). Unlike variegate porphyria in which there is a genetic deficiency of PROTO oxidase there was no increased excretion of porphyrins or their precursors in Gilbert's syndrome. Accentuation and subsequent correction of the unconjugated hyperbilirubinaemia with rifampicin produced reciprocal changes in PROTO oxidase activity indicating that bilirubin may be inhibiting the activity of this enzyme.

Psychoanalysis and negotiation

Somewhere between the image of psychoanalysis as suggestion and psychoanalysis as unearthing is that of analysis as negotiation. This is a picture of a mutual construction of reality by analyst and patient. Such an interaction allows for reciprocal input of the participants and a possible change in both. This paper sketches the role of negotiation throughout the entire process of treatment--from the initial rules, to the theory of the analyst, to the emergence of the transference, to the goal of the cure. The technique of psychoanalysis is said to lie in the process of negotiation.

Effect of serotonergic, corticostriatal and kainic acid lesions on the dopaminergic neurotoxicity of 1-methyl-4-phenyl-1,2,5,6-tetrahydropyridine (MPTP) in mice

In mice, prior destruction of striatal 5-hydroxytryptamine (5-HT) neurons by intrastriatal or intraventricular injections of 5,7-dihydroxytryptamine did not abolish or attenuate DA depletions produced in striatum by 1-methyl-4-phenyl-1,2,5,6-tetrahydropyridine (MPTP). This suggests that although they contain monoamine oxidase type B, the oxidative conversion of MPTP to 1-methyl-4-phenyl-pyridinium ion (MPP+) does not take place in 5-HT neurons. Likewise, decortication and kainic acid lesions did not prevent or enhance striatal MPTP-induced DA decrements suggesting that corticostriatal projections and striatal neurons are not involved in the mechanisms of MPTP neurotoxicity.