Quantitative studies on the urinary metabolic fate of 2-chloro-4-trifluoromethylaniline in the rat using 19F-NMR spectroscopy and directly coupled HPLC-NMR-MS

1. The metabolism and urinary excretion of 2-chloro-4-trifluoromethylaniline has been studied in the rat using 19F-NMR spectroscopy and directly coupled HPLC-NMR-MS methods. The compound was dosed to three male Sprague-Dawley rats (50 mg kg(-1) i.p.) and urine collected over 0-8, 8-24 and 24-48 h post-dosing. 2. A total urinary recovery of 56.3+/-2.2% of the dose was achieved up to 48 h after dosing. The major metabolite in the urine was identified as 2-amino-3-chloro-5-trifluoromethylphenylsulphate accounting for a total of 33.5+/-2.2% of the dose. 3. Further metabolites detected and characterized included 2-chloro-4-trifluoromethylphenylhydroxylamine glucuronide (13.2+/-0.5% of the dose), 2-amino-3-chloro-5-trifluoromethylphenylglucuronide (3.8+/-0.4% of the dose) and 2-chloro-4-trifluoromethylaniline-N-glucuronide (3.6+/-0.1% of the dose). Several minor metabolites were also found and identified, including 2-chloro-4-trifluoromethylphenylsulphamate, which together accounted for 2.1+/-0.4% of the dose. 4. Directly coupled HPLC-NMR-MS and 19F-NMR spectroscopy is shown to provide an efficient approach for the unequivocal and rapid determination of the quantitative urinary metabolic fate and excretion balance of a fluorinated xenobiotic without the necessity for specific radiolabelling.

Assessment of treatment for patients with primary ductal carcinoma in situ in the breast

BACKGROUND

Current mammographic technology has resulted in increased detection of ductal carcinoma in situ (DCIS). It is necessary to assess which patients presenting with DCIS are good candidates for breast conservation and which of these patients should receive adjuvant radiation.

METHODS

We accrued clinical data for 124 patients with a primary diagnosis of DCIS from 1979 through 1994. Primary therapy was a mastectomy for 18 patients, and a lumpectomy for 106 patients. Only 18 of the latter group of patients received adjuvant radiotherapy. For the 88 lumpectomy-alone patients (median follow-up, 5.2 years), we evaluated the effects of clinical (age and initial presentation) and pathologic (nuclear grade, architecture, parenchymal involvement, calcifications, and measured margins) factors on recurrence of DCIS or the development of invasive breast cancer.

RESULTS

Patients who underwent lumpectomy with or without adjuvant radiotherapy (median follow-up, 5.0 years) were significantly more likely to have recurrence of DCIS (P=.05) than those who underwent mastectomy (median follow-up, 6.7 years): 18% (19/106) versus 0% (0/18), respectively; lumpectomy-alone patients experienced a 19% (17/88) rate of DCIS recurrence. All recurrent DCIS was ipsilateral. For lumpectomy-alone patients, the factors associated with ipsilateral recurrence of DCIS were extent of involvement of the parenchyma (P=.01, for univariate; P=.07, for multivariate) and initial presentation (P=.05, for univariate; P=.07, for multivariate). Eleven lumpectomy-alone patients developed invasive breast cancer (6 ipsilateral, 5 contralateral); none of the 18 lumpectomy patients who received adjuvant radiation developed invasive disease. None of the factors investigated, including primary surgery and adjuvant radiotherapy, were associated with a significant effect on the development of invasive disease.

CONCLUSIONS

Longer follow-up is required to determine if the benefits of either mastectomy or radiotherapy following lumpectomy persist. There is a suggestion that patients under 40 years of age or women who present with nipple discharge might be considered for either adjuvant radiotherapy following lumpectomy or a simple mastectomy.

Periodic limb movement in sleep in children with Williams syndrome

OBJECTIVE

Williams syndrome (WS) is associated with neurobehavioral abnormalities that include irritability and attention-deficit/hyperactivity disorder. Parents often report children having difficulties initiating and maintaining sleep because of restlessness and arousals. Therefore we evaluated a group of children with WS for the presence of a movement arousal sleep disorder.

METHODS

Twenty-eight families of children with WS participated in a telephone survey aimed to screen for a movement arousal disorder. Of the 16 children identified as having such a disorder, 7 (mean age, 3.9 +/- 2.2 years) underwent polysomnography. Their studies were compared with those of 10 matched control subjects (mean age, 5.3 +/- 2.0 years).

RESULTS

The 7 subjects with WS who were screened by the survey had sleep latency, total sleep time, arousals, and awakenings that were similar to those of control subjects. However, they presented with a disorder of periodic limb movement in sleep (PLMS). The PLMS index in the subjects with WS was 14.9 +/- 6.2 versus 2.8 +/- 1.9 in control subjects (P < .0001). In addition, arousal and awakening in subjects with WS were strongly associated with PLMS. Moreover, children with WS spend more time awake during sleep periods than control subjects (10.0% +/- 7.0% vs 4.4% +/- 4.7%; P < .05). Five children were treated with clonazepam, and in 4 a significant clinical response was noted.

CONCLUSION

We report an association between WS and PLMS. Clonazepam may reduce the clinical symptoms of PLMS in some of these children.

A cross-national study of self-evaluations and attributions in parenting: Argentina, Belgium, France, Israel, Italy, Japan, and the United States

This study investigated and compared ideas about parenting in Argentine, Belgian, French, Israeli, Italian, Japanese, and U.S. mothers of 20-month-olds. Mothers evaluated their competence, satisfaction, investment, and role balance in parenting and rated attributions of successes and failures in 7 parenting tasks to their own ability, effort, or mood, to difficulty of the task, or to child behavior. Few cross-cultural similarities emerged; rather, systematic culture effects for both self-evaluations and attributions were common, such as varying degrees of competence and satisfaction in parenting, and these effects are interpreted in terms of specific cultural proclivities and emphases. Child gender was not an influential factor. Parents' self-evaluations and attributions help to explain how and why parents parent and provide further insight into the broader cultural contexts of children's development.

The effects of hyperoxia on the biosynthesis of cyclooxygenase products and haemodynamic response to nitric oxide synthase inhibition with L-NAME in endotoxaemic pigs

The interaction between constitutive nitric oxide and oxygen may depend on the degree of tissue oxygenation and may play a critical role in the pathophysiological response to endotoxaemia. We investigated if hyperoxia (100% O2) attenuated the systemic and pulmonary vasoconstriction and increased biosynthesis of thromboxane B2 (TXB2) and 6-keto-prostaglandin (PG) F1alpha induced by inhibition of nitric oxide synthase with NG-nitro-L-arginine-methyl-ester (L-NAME) in a porcine model of endotoxaemia. Twenty-two domestic, random source pigs, weighing 15.4 +/- 2.7 kg (mean +/- standard deviation) were the subjects of this study. Pigs were anaesthetized with isoflurane in 100% O2, orotracheally intubated and ventilated to maintain normocapnia, and then instrumented for haemodynamic monitoring. Following instrumentation, pigs were maintained at an end-tidal isoflurane concentration of 2%. Pigs were randomly assigned to treatment groups: saline + 30% O2 (Control, n = 6); Escherichia coli lipopolysaccharide (5 microg/kg/h from 1 to 2 h followed by 2 microg/kg/h from 2 to 5 h) + 30% O2 (LPS, n = 4); L-NAME (0.5 mg/kg/h, from 0 to 5 h) + LPS + 100% O2 (n = 6); and L-NAME + LPS + 30% O2 (n = 6). L-NAME and endotoxin significantly (P < 0.05) increased mean arterial pressure, mean pulmonary arterial pressure, and systemic and pulmonary vascular resistance index beginning at 90 min. When results were pooled across all time periods, mean arterial pressure and mean pulmonary arterial pressure were significantly higher in the L-NAME + LPS + 30% O2 group than all other groups, reflecting pulmonary and systemic vasoconstriction. Hyperoxia attenuated the L-NAME + LPS-induced increases in TXB2 and 6-keto-PGF1alpha concentrations at 90 and 120 min and 120 min, respectively, although the differences were not statistically significant. These results support the observation that nitric oxide synthase inhibition with L-NAME has deleterious haemodynamic effects in this model of endotoxaemia. The temporal attenuation of L-NAME-induced pulmonary and systemic vasoconstriction by hyperoxia suggested that the haemodynamic effects of acute endotoxaemia were in part influenced by the relative amounts of nitric oxide and oxygen present.

Dependence and perceived difficulty in daily activities in community-living stroke survivors 2 years after stroke: a study of instrumental structures

BACKGROUND AND PURPOSE

There is a need for better understanding of the structure of instruments for functional outcome assessment after discharge from rehabilitation. One purpose of the study was to contribute to the analysis of instrumental dimensionality. Another purpose was to compare disability in stroke patients within the younger age range 2 years after onset of stroke with that at discharge with respect to both dependence and patients' perceived difficulty and to extend the assessments with instrumental activities.

METHODS

We studied 68 stroke survivors aged 18 to 71 years at onset (59% aged <55 years) by means of interviews in their home, using activities from the Functional Independence Measure (FIM) and Instrumental Activity Measure (IAM) for ratings of dependence and perceived difficulty. Rasch analysis was used to construct calibrated linear measures and to evaluate the level of fit.

RESULTS

Acceptable models for comparison of dependence between discharge and follow-up were found for the physical and the social-cognitive items in FIM. However, personal care and social-cognitive items showed an increased level of dependence at follow-up compared with at discharge. A combination of physical activities from FIM and IAM also gave acceptable models for both dependence and perceived difficulty, and the hierarchical orders of activities are presented. In general, there was agreement between the ratings of dependence and perceived difficulty, but with some discrepancies. Men found it harder to be independent in such instrumental activities as cooking and cleaning than women; the opposite was true for small-scale shopping and locomotion outdoors. Subjects aged > or =55 years had slightly higher level of dependence and perceived difficulty in IAM activities than those below that age.

CONCLUSIONS

Changes in the hierarchical order of activities should be taken into account in follow-up studies. Differences in the environment between hospital and home, as well as differences in support and motivation, might explain the relatively larger degree of dependence at follow-up compared with at discharge and indicate the need for further rehabilitation efforts. Instrumental activities could be combined with FIM activities in a model. For individual items, ratings of both dependence and perceived difficulty may provide further insight into the disablement process.

A cross-national study of self-evaluations and attributions in parenting: Argentina, Belgium, France, Israel, Italy, Japan, and the United States

This study investigated and compared ideas about parenting in Argentine, Belgian, French, Israeli, Italian, Japanese, and U.S. mothers of 20-month-olds. Mothers evaluated their competence, satisfaction, investment, and role balance in parenting and rated attributions of successes and failures in 7 parenting tasks to their own ability, effort, or mood, to difficulty of the task, or to child behavior. Few cross-cultural similarities emerged; rather, systematic culture effects for both self-evaluations and attributions were common, such as varying degrees of competence and satisfaction in parenting, and these effects are interpreted in terms of specific cultural proclivities and emphases. Child gender was not an influential factor. Parents' self-evaluations and attributions help to explain how and why parents parent and provide further insight into the broader cultural contexts of children's development.

Effect of diet on the urinary excretion of hippuric acid and other dietary-derived aromatics in rat. A complex interaction between diet, gut microflora and substrate specificity

1. A combined in vivo and in vitro study has been devised to investigate an observation, obtained by 1H NMR of urine, that Alp:AprSD (Wistar derived) rats kept under standard husbandry conditions did not excrete urinary hippuric acid (HA). meta-(hydroxyphenyl)-propionic acid ¿m-HPPA¿ was identified as the major aromatic component in urine samples lacking HA. 2. Examination of urine from Alp:APrSD and Zücker (obese negative) rats fed various diets showed that the lack of HA/presence of m-HPPA was due to diet and not to the strain of animal. This observation was reinforced by the demonstration that the administration of benzoic acid (BA) to rats not previously excreting urinary HA resulted in the return of this component to the urinary excretion profile. Thus rats receiving the standard diet were still capable of glycine conjugation. 3. Changing the diet of rats excreting m-HPPA led to the cessation of m-HPPA excretion and the return of HA urine excretion. Interestingly, switching back to the original diet did not cause the loss of HA and the re-emergence of m-HPPA. 4. In vitro studies on the two enzyme systems responsible for glycine conjugation (benzoyl CoA:synthetase and benzoyl CoA:glycine N-acyltransferase) in isolated liver mitochondria showed that m-HPPA did not inhibit either enzyme. However, m-HPPA was not found to be a substrate for the first reaction step explaining why it was found in the urine as the free acid and not as a glycine conjugate. 5. The absence and presence of m-HPPA and hippuric acid is suggested to be due to a combination of differences in dietary precursors of substrates for glycine conjugation and a dietary dependent redistribution of the intestinal microflora responsible for breakdown of plant phenolics and aromatic amino acids. Taken collectively this study emphasises how a simple diet change can cause a profound change in metabolism.

19F-NMR and directly coupled HPLC-NMR-MS investigations into the metabolism of 2-bromo-4-trifluoromethylaniline in rat: a urinary excretion balance study without the use of radiolabelling

1. The metabolic fate and urinary excretion of 2-bromo-4-trifluoromethylaniline has been studied in rat using 19F-NMR spectroscopic and directly coupled HPLC-NMR-MS methods. The compound was dosed to Sprague-Dawley rats (50 mg kg-1, i.p.) and urine collected over 0-8, 8-24 and 24-48 h post-dosing. 2. A total urinary recovery of 53.5 +/- 7.0% of the dose was achieved up to 48 h after dosing. The major metabolite in the urine was identified as 2-amino-3-bromo-5-trifluoromethylphenylsulphate accounting for a total of 35.7 +/- 6.2% of the dose. 3. Further metabolites detected were 2-bromo-4-trifluoromethylphenylhydroxylamine-1V-glucuronide (9.7 +/- 0.2% of the dose), 2-bromo-4-trifluoromethylaniline-N-glucuronide (3.0 +/- 0.3%) and 2-amino-3-bromo-5-trifluoromethylphenylglucuronide (2-St 0-4). Minor metabolites, including 2-bromo-4-trifluoromethylphenylhydroxylamine-O-glucuronide, 2-amino-3-bromo-5-trifluoromethylphenol and 2-bromo-4-trifluoromethylphenylsulphamate, in total accounted for 2.3 +/- 0.9% of the dose. 4. Directly coupled HPLC-NMR-MS and 19F-NMR spectroscopy proved to be efficient techniques for the unequivocal and rapid determination of the urinary metabolic fate and excretion balance of fluorinated xenobiotics without the need for radiolabelling.

The Development of Critical Pathways in Home Infusion

Critical paths have been used successfully in the acute care facility to manage resources with satisfactory patient outcomes since 1985. Clinical pathways exhibiting significant impact in length of stay and cost savings have included home care. Organizations are also beginning to implement clinical pathways in home health agencies. Many include pathways for home infusion. This article reviews the evolution of clinical pathways in the acute care facility, home care, and home infusion. The benefits and barriers in each environment are included. Recommendations on the developing critical pathways are, detailed.

Perceived adequacy of tangible social support and health outcomes in patients with coronary artery disease

OBJECTIVE

Health outcomes of patients with chronic disease might be influenced by assistance from others in performing daily activities. We examined whether perceived adequacy of such tangible support was associated with prognosis in a cohort of patients with coronary artery disease.

DESIGN

Longitudinal cohort study.

SETTING/PARTICIPANTS

In spring 1993, a cohort of 1,468 patients with chronic artery disease was identified using claims data. The cohort consisted of all surviving residents of Manitoba, Canada, who had been hospitalized for acute myocardial infarction from 1991 to 1992: 820 patients completed the initial survey, and 734 completed a follow-up survey approximately 1 year later.

MEASUREMENTS AND MAIN RESULTS

Adequacy of tangible support was assessed by asking if respondents needed help at home because of health problems, and whether these needs were met. We examined the association between perceived adequacy of tangible support and health outcomes at 1 year (mortality, physical function). Of 820 participants, 74% perceived no need for help, 13% had sufficient help, 9% needed more help, and 5% needed much more help; 31 patients died during follow-up. After adjustment for age and initial health status, odds ratios (95% confidence interval) for death were: sufficient help 1.8 (0.61, 5.8); need more help 3.2 (1.1, 9.4); and need much more help 6.5 (2.0, 21.6) compared with respondents with no perceived need. Decline in physical function was also linearly related to perceiving less-adequate tangible support. Sensitivity analyses indicated it is highly improbable that results were due to selection bias.

CONCLUSIONS

Perceived lack of needed assistance was related to mortality and to decline in physical functioning. Adequacy of tangible support was an important prognostic factor for these patients with coronary artery disease and may be a determinant of health outcomes.

Bioanalysis of p-trifluoromethylmandelic acid and Mosher's acid by chiral gas chromatography and fluorine nuclear magnetic resonance to study chiral inversion: application to rat urine samples

Methods for the nuclear magnetic resonance and gas chromatographic analysis of the enantiomers of p-trifluoromethylmandelic acid (p-TFM) and Mosher's acid (alpha-methoxy-alpha-(trifluoromethyl)phenylacetic acid) present in rat urine samples are described. Gas chromartography was performed using cyclodextrin capillary columns with both compounds analysed following derivatisation with methanolic HCl. Nuclear magnetic resonance was performed directly on the untreated urine samples following addition of beta-cyclodextrin. The methods were suitable for the determination of the individual enantiomers of the analytes in urine. Analysis of the rat urine samples indicated that the p-TFM had undergone a unidirectional enantiomeric interconversion in vivo, while the enantiomers of Mosher's acid were excreted unchanged.

Treatment and health outcomes of women and men in a cohort with coronary artery disease

BACKGROUND

Women with coronary artery disease are treated differently than men. Although mortality has been studied, functional outcomes for women and men have not been prospectively compared.

METHODS

The Manitoba Health Reform Impact Study used hospital databases to identify all residents aged 45 years and older in Manitoba who were hospitalized for a myocardial infarction between October 1, 1991, and September 30, 1992. Cohort members were interviewed twice, an average of 16 and 25 months after hospitalization. Baseline and follow-up measures included treatments (eg, physician visits, diagnostic testing, revascularization, and cardiac medications), physical health status (physical component summary [PCS] score derived from the Medical Outcomes Study Short Form 36), reinfarction, and mortality.

RESULTS

Of the 820 patients who completed the initial survey, 31 died during the follow-up period, and 734 completed the follow-up survey. Data were complete for the primary outcome (PCS score) and all relevant covariates for the 677 patients who were included in this study Women constituted 34% of this cohort. Although women had more physician visits during follow-up, they were less likely to have undergone treadmill testing or angiography (odds ratio, 0.68; 95% confidence interval, 0.46-0.99). Women were equally likely to report taking beta-adrenergic blocking agents, but were less likely than men to report the use of aspirin (odds ratio, 0.69; 95% confidence interval, 0.48-0.98). After adjusting for baseline differences in PCS scores, age, income, social supports, and the levels of angina and dyspnea, the PCS score for women declined by 1.4 points, while the score for men improved by 0.2 points (P = .03). During the follow-up period, reinfarction and mortality rates were low overall, but were not different in men and women.

CONCLUSIONS

In this cohort of patients with known coronary artery disease, we found less aggressive treatment of coronary artery disease and less use of aspirin among women than among men during 1 year of observation. After controlling for baseline differences, women with coronary artery disease experienced a more rapid decline in physical health status than did men during 1 year of follow-up.

Depression in North India comparison of symptoms and life events with ocher patient groups

Cross-cultural studies of depression have raised interesting issues in terms of symptoms and diagnosis in patients seeking treatment. To understand the symptom patterns of depression in a clinic population in north India, we studied 75 consecutive patients diagnosed as suffering from depression. They were asked to describe their symptoms, life events in the year before the onset of depression, and family history. Sleep disturbances, low mood and irritability were common symptoms. Suicidal intent was reported by 54% of the sample, and guilt by 56%. Study of family history and life events suggests that in those with a negative family history, the onset of depression was more likely to be related to a significant life event the commonest being family conjunct. The symptoms of this patient group are compared with the symptoms of depression reported from clinical samples in south India, Bombay and the West. North Indian samples have low rates of delusions, whereas Bombay samples reveal low levels of hypochondriasis, agitation, guilt and suicidal thoughts. The roles of cultural factors, family responsibilities and expectations are discussed in relation to depression across cultures. These findings also have implications for the clinical management of patients from the North Indian diaspora presenting with depression.