Comparative in vivo mucoadhesion studies of thiomer formulations using magnetic resonance imaging and fluorescence detection

The aim of this study was to compare different oral delivery systems based on the thiolated polymer polycarbophil-cysteine (PCP-Cys) and to provide evidence for the validity of the hypothesis that unhydrated polymers provide better mucoadhesion in vivo. To achieve dry polymer application, a new, experimental dosage form named Eutex (made of Eudragit L100-55 and latex) capsule has been developed. Magnetic resonance imaging was used to localize the point of release of the thiolated polymer from the application forms via the positive magnetic resonance signal from a gadolinium complex (Gd-DTPA). In vivo mucoadhesion was determined by ascertaining the residence time of the fluorescence-tagged thiomer on intestinal mucosa after 3 h. Results showed that in comparison to conventional application forms the Eutex capsules led to 1.9-fold higher mucoadhesive properties of PCP-Cys when compared to application with a conventional enteric-coated capsule, and to 1.4-fold higher mucoadhesion when compared to administration with an enteric-coated tablet of the thiomer. The findings of this study should contribute to the understanding of mucoadhesion and mucoadhesion influencing parameters in vivo and should therefore be of considerable interest for the development of future mucoadhesive oral drug delivery dosage forms.

[Pictorial essay: Ultrasound of tumours and tumour-like lesions of peripheral nerves]

High-resolution ultrasound is an excellent diagnostic modality for visualising peripheral nerves and differentiate tumours of the peripheral nerve. With high-frequency transducers (5-15 MHz), peripheral nerves can be visualised, the hypoechoic nerve fascicles, the surrounding tissue and tumourous lesions including the relation to their nerve of origin can be evaluated. By using colour Doppler sonography (CDS), it is possible to detect and assess vascularisation of tumours of the nerve. We present sonographic features of common and uncommon benign and malignant tumours of the peripheral nerve.

Building up of the liquid-ordered phase formed by sphingomyelin and cholesterol

The long-range and molecular orders and dynamics in codispersions of egg sphingomyelin-cholesterol have been investigated by synchrotron x-ray diffraction and electron spin resonance using phosphatidylcholine spin-labeled at several positions on the sn-2 chain. Mixtures containing 0, 17, 33, 41, 50 mol% cholesterol exhibited a single phase by x-ray diffraction methods. The temperature dependence of the d-spacing between 20 and 50 degrees C is attenuated with increasing proportions of cholesterol, becoming invariant for cholesterol contents of 41 and 50 mol% on completion of the liquid-ordered phase. Electron spin resonance revealed two sites for 17 and 33 mol% cholesterol. One site is highly ordered and the other is less ordered than the fluid phase of pure sphingomyelin as shown by the molecular and the intramolecular order parameters reflecting the segmental motions of the probe. The two-sites exchange rate indicates a mean lifetime of the sites of approximately 0.1 micros during which the lipid displacement is approximately 1 nm. The short lifetime of the sites probed by ESR and the single phase detected by x-ray diffraction support in this binary mixture, the building up of the Lo phase by a progressive accumulation of randomly distributed sphingomyelin-cholesterol condensed complexes rather than by diffusional exchange between extended domains.

Clinical significance and neuropathology of primary MADD in C34-T and G468-T mutations of the AMPD1 gene

OBJECTIVE

Primary myoadenylate deaminase deficiency (MADD) is probably the most frequent inborn metabolic myopathy with a prevalence of up to 2%. It is the result of mutations in the AMPDI gene, the most common of which is a C34-T transition in exon 2. The importance of the more rare mutation G468-T in exon 5 is uncertain. Primary objective was to elucidate the clinical significance of the enzyme disorder, which remains unclear since its first description in 1978. We further examined the existence of an association of MADD with other muscle disorders, such as malignant hyperthermia and rhabdomyolysis, as was suspected in earlier studies.

MATERIAL AND METHODS

In a large collection of 1673 muscle biopsies that had been stored deep frozen we identified 33 cases of primary MADD, 12 of which without any other coinciding muscle diseases, by histochemical, biochemical and molecular genetic examinations. Clinical and laboratory data was collected. By additional examination of randomly chosen blood samples we identified one person carrying the rare compound heterozygosity C34-T/ G468-T, who was examined in clinical respects and a muscle biopsy was taken.

RESULTS

As underlying mutation, the most common transition C34-T/C 143-T was detected in 33 cases. One patient carried the compound heterozygosity C34-T/G468-T. The overall frequency of MADD in the contingent was 1.8%. Only three patients out of 12 with isolated primary MADD suffered from muscle complaints, one of whom did not experience the typical symptoms of exercise related myalgia, muscle cramps and weakness as described by Fishbein. The patient carrying C34-T/G468-T was a fully healthy female. She had never experienced any muscle complaints. Any association with other neuromuscular disorders, if not completely ruled out, was found to be very unlikely.

CONCLUSION

The results suggest that MADD itself is unlikely to be solely responsible for the manifestation of muscular symptoms. It is probable that either the loss of a compensation mechanism or coexistent disturbances in muscle metabolism which are unidentified so far are required for the emergence of complaints.

Malignes Melanom der Uvula und des weichen Gaumens

Malignant melanoma of the uvula and soft palate is very rare. We describe a case demonstrating the typical aggressive behavior of mucosal melanoma in contrast to cutaneous melanoma. Regional lymph node and distant metastases often develop rapidly in this type of melanoma. Despite aggressive surgical approaches, other treatment options are often limited and usually palliative. Therefore, early diagnosis is critical in patients with mucosal melanoma.

Dynamics of the self-assembly of unilamellar vesicles

We have studied the transient stages in the formation of unilamellar vesicles with millisecond time resolution. The self-assembly was initiated by rapid mixing of equimolar amounts of anionic and zwitterionic micelles and the transient micellar entities were probed by time-resolved small-angle x-ray scattering. Within the mixing time, original micelles transformed to disklike micelles which evolved further to a critical size and then closed to form monodisperse unilamellar vesicles within a second. Subsequent growth led to an unexpected broadening of the vesicle size distribution.

Sterol profiling of amniotic fluid: a routine method for the detection of distal cholesterol synthesis deficit

OBJECTIVES

Smith Lemli Opitz syndrome (SLOS) caused by a deficit of 3beta-hydroxysterol-Delta7 reductase was the first sterol deficit described with multiple malformations. The lack of specificity of many morphological abnormalities detected by ultrasound and their frequency have justified routine screening of amniotic fluid (AF) for sterols by GC-MS. The examination contributes to an improved knowledge of the sterol status in the fluid.

METHODS

A series of sterol profiles is collated here. Accumulation of 7- and 8-dehydrocholesterol are diagnostic for SLOS. However, a number of other sterols have also been detected by GC-MS in control AF and their presence may be confusing.

RESULTS AND CONCLUSIONS

In addition to cholesterol, the level of which varies as function of the gestational age, lathosterol is present together with trace amounts of 7- and 8-dehydrocholesterol and other precursors such as desmosterol, lanosterol, and dimethylsterol. Phytosterols are also present in 70% of AF samples that have been tested. Besides SLOS, GC-MS examination of amniotic fluid can detect various sterol deficits associated with malformations (lathosterolosis, desmosterolosis, X-linked chondrodysplasia, and particular Antley-Bixler syndrome). Practical conclusions support GC-MS as a routine method to investigate skeletal and central nervous system malformations.

Introductory Experience with the Continuous Glucose Monitoring System (CGMS®; Medtronic Minimed®) in Detecting Hyperglycemia by Comparing the Self-Monitoring of Blood Glucose (SMBG) in Non-Pregnant Women and in Pregnant Women with Impaired Glucose Tolerance and Gestational Diabetes

OBJECTIVE

To assess the detection rate of hyperglycemia with a continuous glucose monitoring system compared to a self-monitoring blood glucose profile in non-pregnant, non-diabetic pregnant women, and patients with impaired glucose tolerance or gestational diabetes..

METHODS

Eight non-pregnant (NP) and 56 pregnant women (17 dietary-treated gestational diabetics (GDM), 15 women with impaired glucose tolerance (IGT), and 24 non-diabetic pregnant women (NDP)) underwent a 72-hour measurement with the CGMS (Medtronic Minimed, Northridge, CA, USA). Self-monitored blood glucose measurements, performed 30 minutes before and 120 minutes after each meal, were compared to the duration of hyperglycemia monitored by the continuous glucose monitoring system.

RESULTS

No clinically observable infection was found at the subcutaneous tissue where the electrode was placed. A statistically significant difference was found between the groups in body mass index, HbA1c, and in gestational age, but not in age or parity. Using the self-monitored blood glucose (SMBG), 88 % (7/8) of the NP and 54 % (13/24) of the NDP had no measurement above 6.7 mmol/l. However, 17 % (4/24) of the NDP and 40 % (6/15) of the IGT showed more than two measurements above 6.7 mmol/l compared to 24 % (4/17) of the dietary-treated GDM. The differences between these groups were not significant (p = 0.21). The mean durations (+/- SD) of hyperglycemia above 6.7 mmol/l/24 h were: NP 111 +/- 120 min, NDP 138 +/- 120 min, IGT 381.8 +/- 295 min, and GDM 190 +/- 155 min, p = 0.017; above 7.8 mmol/l/24 h NP 24 +/- 49 min, NDP 38 +/- 47 min, IGT 170.7 +/- 190 min, and GDM 64 +/- 88 min, p = 0.016; and above 8.9 mmol/l/24 h NP 9.3 +/- 25 min, NDP 7.5 +/- 14 min, IGT 59 +/- 77 min, and GDM 14 +/- 21 min, p = 0.026. There was no significant difference in the fetal outcome or rate of birth percentiles using the sensor data.

CONCLUSIONS

The use of the sensor in pregnant women is unproblematic. a) The CGMS detected more frequent and longer durations of hyperglycemia in GDM compared to non-diabetic pregnant women than the SMBG. b) Women with an IGT exhibited higher glucose levels than patients with gestational diabetes. c) The clinical importance of these hyperglycemic intervals, e.g. with respect to the risk for macrosomia, must be assessed in larger trials.

Extracorporeal photochemotherapy for the treatment of exanthematic pityriasis rubra pilaris

Pityriasis rubra pilaris (PRP) is a rare papulosquamous skin disease of unknown aetiology that has been categorized into five clinical types based on age at onset, cutaneous features and prognosis. We present a patient with chronic exanthematic type II atypical adult PRP, whose skin status was significantly improved with monthly extracorporeal photochemotherapy (ECP). Various therapeutic regimens including narrow-band UV-B, bath PUVA therapy, systemic fumaric acid esters and systemic cyclosporin had failed. Oral retinoids could not be administered due to a type IIa hyperlipoproteinemia with profound hepatic steatosis and elevated liver transaminases. The observed clinical benefit may encourage future clinical studies analysing the effectiveness of ECP in otherwise unresponsive cases of type II PRP.

Localized radiation increases morbidity and mortality after TBI-containing autologous stem cell transplantation in patients with lymphoma

The purpose of this study is to assess the relationship between involved field radiation therapy (IFRT) and treatment-related morbidity and mortality in patients receiving high-dose chemotherapy (HDC), total body irradiation (TBI) and autologous peripheral stem cell transplant (PSCT) for Hodgkin's and non-Hodgkin's lymphoma. Between January 1994 and May 2002, 156 patients underwent HDC, TBI and autologous PSCT. Localized external beam radiation therapy was given to 21 patients for consolidation, or to achieve control of symptomatic or active disease prior to or after transplant. Among patients who had IFRT prior to autologous PSCT, five treatment-related deaths were observed, compared to seven deaths in 135 patients who had autologous PSCT without IFRT (P<0.01). Most deaths were attributable to sepsis and multiorgan failure. A higher incidence of pneumonitis was also noted in patients exposed to mediastinal irradiation. No adverse impact on long-term survival could be demonstrated. Involved field radiation prior to TBI is associated with higher treatment-related mortality in lymphoma patients undergoing autologous peripheral stem cell transplant, necessitating careful monitoring.

Induction of type-IIA secretory phospholipase A2 in animal models of acute lung injury

The aim of this study was to evaluate the presence of type-II secretory phospholipase A2 (sPLA2-IIA) in alveolar space and its possible role in the destruction of surfactant in three rat models of acute lung injury. Alveolar instillation of either lipopolysaccaride or live Pseudomonas aeruginosa resulted in a significant increase in lung oedema and in a decrease in static compliance of the respiratory system together with alveolar-neutrophil influx as compared with healthy control rats. The upregulation of messenger ribonucleic acid and sPLA2-IIA by the lung was evident. This was associated with surfactant degradation and a decrease in large:small ratio of surfactant aggregates in bacteria-instilled rats. A negative correlation between compliance and sPLA2-IIA activity in bronchoalveolar lavage fluid was shown. By contrast, during alpha naphthylthiourea-induced injury, neither alveolar-neutrophil influx nor increase in sPLA2-IIA activity was observed. Additional experiments in rats treated with a specific inhibitor of type-II secretory phospholipase A2 activity (3 acetamine-1-benzyl-2 ethylindolyl-5 oxy; propane phosphonic acid (LY311727)) demonstrated no improvement in physiological parameters despite a biochemical effect, suggesting that its activity is only one of the multiple factors involved in the pathophysiology of lung injury.

Dysphagia in patients with acute cervical spinal cord injury

STUDY DESIGN

Longitudinal observational.

OBJECTIVES

(a) To establish a reliable and feasible method to indicate the presence and severity of dysphagia and (b) to establish a course of treatment in individuals presenting with cervical spinal cord injury (CSCI).

SETTING

Spinal Cord Injury Center, Werner Wicker Klinik, Bad Wildungen, Germany.

PATIENTS AND METHODS

This is a cross-sectional study of 51 patients consecutively admitted to the Intensive Care Unit of the SCI in-patient service. They were subjected to neurological and fiberoptic endoscopic examination of swallowing (FEES). Data concerning artificial respiration, presence of tracheostomy, oral or non-oral feeding were obtained from the medical charts. Statistics were carried out by a calculation of a nonparametric correlation (Spearman).

RESULTS

Five levels of dysphagia could be distinguished. At levels 1 and 2, patients presented with a severe impairment of swallowing, in level 3 aspiration was met by a powerful coughing reflex, level 4 comprised a laryngeal edema and/or a mild aspiration of fluids only and at level 5 laryngeal function was not compromised. On admission, 20 patients with CSCI presented with mild (level 4), eight with moderate (level 3) and 13 with severe dysphagia (levels 1 and 2). In 10 no signs of dysphagia could be detected. After treatment, level 1 was no longer detected, one patient showed level 2, two patients showed level 3, all other patients showed only mild or no signs of dysphagia any longer.

CONCLUSIONS

Dysphagia of various severities was present in the majority of these patients with CSCI together with respiratory insufficiency. FEES allows for the detection and classification of dysphagia as well as for an evaluation of the therapeutic management. Under interdisciplinary treatment the prognosis of dysphagia is good.

The implementation of the 'International Classification of Functioning, Disability and Health' (ICF) in daily practice of neurorehabilitation: an interdisciplinary project at the Kantonsspital of Lucerne, Switzerland

PURPOSE

The current paper describes the implementation of ICF as a standard language and framework for description of human functioning and disability for common use in every day work by the multiprofessional team.

METHOD

An interdisciplinary project team involving all rehabilitation specialities was constituted. The extensive original document of ICF was broken down to a simplified raster for body functions and structures, activities and participation, as well as for contextual factors. These rasters had to cover the most important aspects concerning the patients treated on our unit. Checklists on the basis of these rasters were worked out for use by the different specialized teams. Using these checklists, rehabilitation conferences, form and language of interdisciplinary communication, goal setting and documentation were introduced newly in every day work for the interdisciplinary rehabilitation team, structured strictly based on the ICF-criteria.

RESULTS

Since April 2002 the ICF-based processes are implemented in routine work for all members of the rehabilitation staff. First experiences show good acceptance by the team members, improvements in communication and documentation as well as substantial gains in content and handling of rehabilitation conferences. As a result of the implementation we observed, that participation, context and domiciliary interventions gained quite more influence in every day work at the unit.

CONCLUSION

Implementation improved considerably the quality of interdisciplinary work processes and contributed to a more systematic approach to rehabilitation tasks by the team members.

Diagnostic management of orthostatic intolerance in the workplace

OBJECTIVE

Orthostatic intolerance (OI) is a syndrome that is characterised by headache, concentration difficulties, palpitation of the heart, dizziness associated with postural tachycardia and plasma norepinephrine concentrations that are disproportionately high when the sufferer is in the upright posture. In contrast to other forms of orthostatic dysregulation - orthostatic hypotension (OH) and postural orthostatic tachycardia syndrome (POTS) - OI, hitherto, could be diagnosed only by a tilt table examination, with high expenditure. In this paper we examine the reliability and validity of a questionnaire as a screening instrument for OI.

METHODS

We studied 138 young men (mean age 21.6 years) who were undergoing military service. After a medical check and filling in the questionnaire, the participants underwent a tilt table test including monitoring of blood pressure, heart rate and plasma catecholamines, in the supine position and during 30 min of standing. The questionnaire consisted of ten items registering presence and frequency of typical OI symptoms.

RESULTS

Probands (104) showed normal tilt table test results. OI was diagnosed in 14 probands, OH in 6 and POTS in 14. The OI participants scored significantly higher in the questionnaire than the healthy subjects did: the mean score of the OI group was 22.6, the healthy participants had a mean score of 3.9. Participants with POTS had a mean score of 13.5 and subjects with OH had a mean score of 17.0. Reliability analysis showed a Cronbach's alpha of 0.888. Validity analysis showed that 93.5% of the probands with any kind of orthostatic dysregulation can be detected.

CONCLUSIONS

We were able to establish a short questionnaire as a reliable and valid screening instrument for OI. Usage of this questionnaire can simplify enormously the diagnostic management of patients with suspected OI.

[Clinical characteristics and diagnosis of Smith-Lemli-Opitz syndrome and tentative phenotype-genotype correlation: report of 45 cases]

INTRODUCTION

SLO (Smith-Lemli-Opitz) syndrome is an autosomal recessive multiple congenital malformations syndrome, including mental retardation, failure to thrive, craniofacial abnormalities, incomplete development of male genitalia, limb anomalies and various internal organ abnormalities. This syndrome is caused by a deficiency of cholesterol biosynthesis at the distal step of 7-dehydrocholesterol reductase (7DHCR).

PATIENTS AND METHODS

We have reviewed 45 cases of SLO syndrome and showed the large clinical spectrum of this syndrome.

RESULTS

The prenatal diagnosis should be considered when dealing with antenatal growth retardation and visceral malformations. At birth, a normal weight does not systematically exclude the diagnosis. Diagnosis was more difficult for older children especially for girls and should be suspected on the association of mental retardation, autism, short stature and microcephaly. We found a correlation between low plasmatic cholesterol measurement and clinical severity. Phenotype-genotype correlation was difficult to establish. However, homozygosity for IVS8-1G > C splice site mutation was associated with severe phenotype.

CONCLUSION

Better understanding of the 7DHCR gene regulation factors and of the compensatory mechanism of foeto-maternal cholesterol transfer are necessary to explain the wide clinical spectrum of the SLO syndrome.