A study of the feasibility and accuracy of pharmacokinetically guided etoposide dosing in children

Pharmacokinetically guided dosing was performed in nine paediatric patients receiving etoposide. Doses on day 2 of a 2- or 3-day schedule were adapted on the basis of the day-1 area under the plasma etoposide concentration vs time curve (AUC). The day-1 AUC was estimated using a limited sampling model and the day-2 target AUC defined by the etoposide dose-AUC relationship observed in 33 children. Target AUC values (4.6-8.2 mg ml(-1) x min) were achieved with a high degree of precision and with little bias (mean error 11% and root mean squared error 15% respectively). Pharmacokinetic parameters were similar to those reported previously in children, although interpatient pharmacokinetic variability was less than that observed previously: plasma clearance, 23 (18-26) ml min(-1) m(-2); volume of distribution at steady state (Vdss), 6.0 (3.9-8.9) l m(-2); t(1/2) 254 (127-550) min (median and range). This study has demonstrated that pharmacokinetically guided dosing with etoposide is feasible. However, pharmacokinetically guided dosing is likely to be of most benefit in patients with abnormalities of renal or hepatic function, or in children with prior exposure to cisplatin.

Neonatal alcohol exposure reduces NMDA induced Ca2+ signaling in developing cerebellar granule neurons

Glutamatergic neurotransmission through NMDA receptors is critical for both neurogenesis and mature function of the central nervous system (CNS), and is thought to be one target for developmentally-induced damage by alcohol to brain function. In the current study we examined Ca2+ signaling linked to NMDA receptor activation as a potential site for alcohol's detrimental effects on the developing nervous system. We compared Ca2+ signals to NMDA in granule neurons cultured from cerebella of rat neonates exposed to alcohol (ethanol) during development with responses to NMDA recorded in separated control groups. Alcohol exposure was by the vapor chamber method on postnatal days 4-7. An intermittent exposure paradigm was used where the pups were exposed to alcohol vapor for 2. 5 h/day to produce peak BALs of approximately 320 mg%. Control pups were placed in an alcohol-free chamber for a similar time period or remained with their mother. After culture under alcohol-free conditions for up to 9 days, Ca2+ signaling in response to NMDA was measured using fura-2 Ca2+ imaging. Results show that the peak amplitude of the Ca2+ signal to NMDA was significantly smaller in cultured granule neurons obtained from alcohol-treated pups compared to granule neurons from control pups. In contrast, the Ca2+ signal to K+ depolarization was not depressed by the alcohol treatment. Resting Ca2+ levels were also altered by the alcohol treatment. These results show that intermittent alcohol exposure during development in vivo can induce long-term changes in CNS neurons that affect the Ca2+ signaling pathway linked to NMDA receptors and resting Ca2+ levels. Such changes could play an important role in the CNS dysfunction associated with alcohol exposure during CNS development.

Effectiveness of treatments of depression in older ambulatory patients

OBJECTIVE

To determine the effectiveness of acute-phase pharmacological and psychological treatments of depression in older ambulatory patients by systematically reviewing original research relevant to this topic.

METHODS

Searches in MEDLINE and PsycINFO and manual reviews of bibliographies located 233 articles. Of these, 40 (37 different studies) met our 8 inclusion criteria: original research, written in English or French, subjects 55 years and older, diagnosis of depression, outpatient or community setting, prospective controlled study design, acute-phase pharmacological or psychological treatment, and outcome measure of depression. Two independent reviewers assessed the methodological quality of each article using a standard form and a quality score was computed. Quantitative data on levels of depression at the end of treatment were abstracted. Results were grouped by specific treatment comparison (type of treatment and type of control group). For comparisons that used the Hamilton Depression Rating Scale, we computed mean posttreatment differences. Effect sizes were computed from the Hamilton Depression Rating Scale or an alternative scale.

RESULTS

In studies that compared active drugs with placebo, the heterocyclic drugs significantly reduced the posttreatment Hamilton Depression Rating Scale score (mean difference, -5.78; 95% confidence interval, -8.31 to -3.25); other drugs had smaller effects. In studies that compared active drugs, there were no significant differences overall between different classes of drugs; selective serotonin reuptake inhibitors appeared to be as effective as heterocyclic drugs. Rational psychological treatments performed significantly better than no treatment (mean posttreatment Hamilton Depression Rating Scale difference, -7.25; 95% confidence interval, -10.10 to -4.40) but not significantly better than that for controls who received similar attention. Adjustment for the study quality score did not affect these results.

CONCLUSIONS

Based on comparisons with untreated controls, heterocyclic antidepressants and rational psychological therapies appear to be the most effective treatments for older ambulatory patients with mild to moderate depression. Based on drug-drug comparisons, selective serotonin reuptake inhibitors appear to be as effective as heterocyclic drugs. However, overall, the magnitude of the treatment effects is modest. Limitations in the quantity and quality of appropriate studies suggest a sober approach to treatment in this population.

Increased soluble interleukin 2 receptor levels in schizophrenia

Immunological mechanisms have been implicated in schizophrenia, but laboratory results have been variable. We evaluated soluble interleukin 2 receptor (sIL2R alpha) levels in sera of Irish patients with schizophrenia. Twenty-seven patients, 12 females and 15 males, with schizophrenia or schizophreniform psychosis, were sampled, along with 32 controls. Diagnosis was made using the Structured Clinical Interview for DSM IIIR. All but one of the patient group were in the first fortnight of an acute hospital admission. Soluble IL2R alpha levels were measured by ELISA. Soluble IL2R alpha levels were significantly higher (two-tailed p = 0.0019) in patients (median = 1010.4 pg/ml, range = 748.7-5673.3 pg/ml) than in controls (median = 792.3 pg/ml, range = 399.6-1479.5 pg/ml). The elevated sIL2R alpha levels in an Irish population with schizophrenia are consistent with other reports and support the implication of immunological mechanisms in this disorder.

Neonatal vitamin K administration and childhood cancer in the north of England: retrospective case-control study

OBJECTIVE

To explore the possible association between intramuscular vitamin K given to neonates and the subsequent development of childhood cancer.

DESIGN

Retrospective case-control study on the basis of hospital records.

SETTING

The former Northern Health region of England.

SUBJECTS

685 children who were born and lived in the region and who developed cancer before their 15th birthday, and 3442 controls also born between 1960 and 1991 and matched only for date and hospital of birth. The notes of a further 701 index cases were untraceable.

MAIN EXPOSURE MEASURE

Administration of intramuscular vitamin K versus no exposure to vitamin K.

RESULTS

There was no association between the administration of vitamin K and the development of all childhood cancers (unadjusted odds ratio 0.89; 95% confidence interval 0.69 to 1.15) or for all acute lymphoblastic leukaemia (1.20; 0.75 to 1.92), but there was a raised odds ratio for acute lymphoblastic leukaemia developing 1-6 years after birth (1.79; 1.02 to 3.15). No such association was seen in a separate cohort-based study not dependent on case note retrieval in which the rates of acute lymphoblastic leukaemia in children born in hospital units where all babies received vitamin K were compared with those born in units where less than a third received prophylaxis.

CONCLUSIONS

It is not possible, on the basis of currently published evidence, to refute the suggestion that neonatal intramuscular vitamin K administration increases the risk of early childhood leukaemia. Any association may have been masked in earlier studies that did not use controls matched for time and locality by other unidentified factors affecting the spatiotemporal variations in incidence of leukaemia.

Alcohol metabolism in Asian-American men with genetic polymorphisms of aldehyde dehydrogenase

BACKGROUND

About half of certain Asians have a deficiency of the low-Km aldehyde dehydrogenase (ALDH2) isoenzyme. This deficiency results from inheritance of a mutant ALDH2*2 allele.

OBJECTIVE

To determine whether Asian Americans with ALDH2*2 alleles differ from Asian Americans without this mutation in terms of blood levels of alcohol and acetaldehyde after ingestion of a moderate amount of alcohol.

DESIGN

Double-blind, crossover study.

SETTING

Private research institute.

PARTICIPANTS

35 healthy Asian-American men. Three men who became ill after alcohol ingestion and one who had outlying data were excluded.

INTERVENTION

Alcoholic beverage, containing 0.56 g of alcohol per kg of body weight, or placebo beverage, containing 3 mL of alcohol, given orally on separate occasions.

MEASUREMENTS

Blood levels of alcohol and acetaldehyde measured before and several times after ingestion of the alcoholic or placebo beverage.

RESULTS

Participants with ALDH2*2 alleles had significantly higher blood acetaldehyde levels after ingesting alcoholic and placebo beverages than did participants with ALDH2*1 alleles, despite similar blood alcohol concentrations.

CONCLUSIONS

Blood acetaldehyde levels rather than blood alcohol concentration may mediate enhanced alcohol sensitivity among Asians with ALDH2*2 alleles.

Stress in medical students

The object of this study was to examine the main stressors experienced by students in an Irish medical school and their effects on the attitude of the students towards their training. It also determined the students' knowledge of how they could receive help and their attitudes towards seeking such help. Data was collected by an anonymous self-report questionnaire distributed to a fifth year medical school class in the Hilary Term of the academic year. These 63 students had chosen medicine as a career mainly because of vocational and academic factors and almost two thirds of them had always wanted to do medicine. However four were no longer happy with that choice. Fifty-four percent of them had felt like making a complaint on at least one occasion, but did not do so. The perceived problems were mainly verbal in nature. 41% said that this had affected their attendance. The main source of perceived mistreatment was consultant staff. Rates of perceived racial and sexual discrimination were low. Other stressors included examinations, financial issues and family issues. 52% of students did not know the process by which they could make a complaint and 30% felt that seeking help or advice from staff would be damaging to their future career. This study analyses these issues and suggests ways of addressing them.

A C. elegans E/Daughterless bHLH protein marks neuronal but not striated muscle development

The E proteins of mammals, and the related Daughterless (DA) protein of Drosophila, are ubiquitously expressed helix-loop-helix (HLH) transcription factors that play a role in many developmental processes. We report here the characterization of a related C. elegans protein, CeE/DA, which has a dynamic and restricted distribution during development. CeE/DA is present embryonically in neuronal precursors, some of which are marked by promoter activity of a newly described Achaete-scute-like gene hlh-3. In contrast, we have been unable to detect CeE/DA in CeMyoD-positive striated muscle cells. In vitro gel mobility shift analysis detects dimerization of CeE/DA with HLH-3 while efficient interaction of CeE/DA with CeMyoD is not seen. These studies suggest multiple roles for CeE/DA in C. elegans development and provide evidence that both common and alternative strategies have evolved for the use of related HLH proteins in controlling cell fates in different species.

Hsp30, the integral plasma membrane heat shock protein of Saccharomyces cerevisiae, is a stress-inducible regulator of plasma membrane H(+)-ATPase

Saccharomyces cerevisiae has a single integral plasma membrane heat shock protein (Hsp). This Hsp30 is induced by several stresses, including heat shock, ethanol exposure, severe osmostress, weak organic acid exposure and glucose limitation. Plasma membrane H(+)-ATPase activities of heat shocked and weak acid-adapted, hsp30 mutant and wild-type cells, revealed that Hsp30 induction leads to a downregulation of the stress-stimulation of this H(+)-ATPase. Plasma membrane H(+)-ATPase activity consumes a substantial fraction of the ATP generated by the cell, a usage that will be increased by the H(+)-ATPase stimulation occurring with several Hsp30-inducing stresses. Hsp30 might therefore provide an energy conservation role, limiting excessive ATP consumption by plasma membrane H(+)-ATPase during prolonged stress exposure or glucose limitation. Consistent with the role of Hsp30 being energy conservation, Hsp30 null cultures give lower final biomass yields. They also have lower ATP levels, consistent with higher H(+)-ATPase activity, at the glucose exhaustion stage of batch fermentations (diauxic lag), when Hsp30 is normally induced. Loss of Hsp30 does not affect several stress tolerances but it extends the time needed for cells to adapt to growth under several stressful conditions where the maintenance of homeostasis will demand an unusually high usage of energy, hsp30 is the first yeast gene identified as both weak organic acid-inducible and assisting the adaptation to growth in the presence of these acids.

Biparous: a novel bHLH gene expressed in neuronal and glial precursors in Drosophila

Genetic studies have uncovered many genes that are involved in the first steps of neuronal development in Drosophila. Less is known about the intermediate steps during which individual precursor cells follow either the neuronal pathway or the glial pathway. We report the identification of a novel bHLH gene, biparous, expressed in neuronal and glial precursors in Drosophila. Unlike most bHLH genes, biparous expression continues to the final stages of neurogenesis in the embryo. Expression of biparous is not observed in end stage postmitotic neurons and precedes the expression of repo, a gene activated in later stages of glial differentiation. The bHLH domain is sufficiently different from previously described bHLH domains to imply a novel function.

Fragmentation, Concentration, and Local Government Structure: Top-Tier Authorities in England and Wales, 1831–1996

The structure of local government in England and Wales is evaluated on the basis of public-choice theories concerning structural effects on performance. The concepts of fragmentation and concentration are applied to changes in the pattern of top-tier units since 1831. For most of this period the structure of this set of authorities became much less fragmented and more concentrated. Public-choice theory suggests that the net effect of these changes is likely to have been a reduction in the allocative and technical efficiency of service provision.

Intra-amygdala muscimol decreases operant ethanol self-administration in dependent rats

Dependence is an important factor motivating continued alcohol use in human alcoholics. Development of a model of ethanol (EtOH) consumption in dependent animals would advance the understanding of reinforcement after chronic EtOH exposure and allow for the investigation of the neuropharmacological mechanisms mediating reinforcement in dependent versus nondependent animals. In the present study, rats were trained to lever press for 10% EtOH, surgically implanted with bilateral guide cannulae in the amygdala, and either made dependent on EtOH by exposure for 2 weeks to EtOH or exposed to air in identical vapor chambers. Upon removal, the rats were placed in operant boxes and allowed to respond on levers for 10% EtOH or water during a 12-hr period. Rats were removed briefly at approximately 6.5 hr for intra-amygdala injections of saline or the GABAA receptor agonist muscimol. After the test period, rats were returned to the vapor chambers for 4 days before retest. EtOH-dependent animals responded more for EtOH across the 12-hr test period than did air control nondependent rats; this difference became more pronounced with repeated test sessions. Intra-amygdala muscimol significantly decreased responding for EtOH in EtOH-dependent rats, but had no effect in nondependent controls. These data suggest that the reinforcing effects of EtOH and neurotransmitter pathways mediating reward are altered after the development of dependence, and they support the use of this paradigm for further investigations into the neuropharmacology of EtOH dependence.

Alcohol elimination in Native American Mission Indians: an investigation of interindividual variation

The high prevalence of alcohol abuse and alcohol dependence among Native Americans may be mediated by unique environmental and genetic factors in this population. One factor that may influence the development of alcoholism is variability in alcohol metabolism. To determine factors that contribute to differences in alcohol elimination rates within a Native American population, this study evaluated healthy southern California Mission Indian men between the ages of 18 and 25 years. Each man drank a dose of alcohol, 0.56 g/kg of body weight as a 20% by volume solution, at approximately 9:00 AM after eating a low-fat breakfast and having fasted overnight. The drink was consumed within 7 min, and the concentrations of alcohol in blood were determined before and at 15, 30, 60, 90, 120, and 150 min after beverage ingestion. Rates of alcohol elimination were calculated from the pseudolinear slope of the blood alcohol versus time curve. The influences of estimated body water, recent drinking history, recent smoking history, polymorphism at the ADH2 and ADH3 loci, family history of alcoholism, and percentage Native American heritage on alcohol elimination rate were determined using multiple regression analyses. Estimated body water accounted for a significant proportion of the variance in alcohol elimination rate. There was also a nonsignificant trend for subjects with an ADH2*3 allele (n = 6) to have faster rates of alcohol elimination than those with ADH2*1 alleles only (n = 33). Given the high prevalence of alcoholism and alcohol-related health problems among Native Americans, the results from this study suggest that evaluation of alcohol metabolism and genotypes of the alcohol-metabolizing enzymes in Native American populations merits further study.

Cyclophosphamide pharmacokinetics in children

1. Cyclophosphamide pharmacokinetics were measured in 38 children with cancer. 2. A high degree of inter-patient variation was seen in all pharmacokinetic parameters. Cyclophosphamide half-life varied between 1.1 and 16.8 h, clearance varied between 1.2 and 10.61 h-1 m-2 and volume of distribution varied between 0.26 and 1.48 1 kg-1. 3. The half-life of cyclophosphamide was prolonged at high dose levels (P = 0.008). 4. Children who had received prior treatment with dexamethasone showed a mean increase in clearance of 2.51 h-1 m-2 (P = 0.001) presumably as a result of CYP450 enzyme induction. 5. Treatment with allopurinol or chlorpromazine was associated with a significant increase in cyclophosphamide half-life (P < 0.001 in both cases). 6. Dose and concurrent treatment may influence cyclophosphamide metabolism in vivo and thus potentially alter the drugs therapeutic effect.

Comparison of methods for the estimation of carboplatin pharmacokinetics in paediatric cancer patients

The antitumour and toxic effects of platinum drugs, in particular carboplatin, have been related to their plasma concentration and this has led to the concept of a target area under the plasma concentration-time curve (AUC) for carboplatin dosing. A formula based on renal function has been successfully applied to carboplatin dosing in adults and modified versions have also been proposed for paediatric patients. In order to monitor carboplatin AUC with maximum efficiency and minimum patient inconvenience, limited sampling strategies are desirable. A population method with Bayesian estimation is described, based on one or two samples taken following a dose of carboplatin. Population data were obtained from 22 paediatric patients treated with 200-1000 mg/m2 carboplatin as a 60-90 min infusion. Ultrafilterable carboplatin was determined by atomic absorption spectrophotometry. A two compartment model was fitted to each data set using the Maximum Likelihood estimator of the ADAPT programme. These parameter estimates provided the prior means and covariance matrix for the Bayesian estimator using a lognormal distribution. The test data sets consisted of ultrafilterable carboplatin concentrations in 23 patients (aged 1 month-18 years) who received similar treatment. The two compartment model was fitted to data sets containing one or two points, using the Bayesian maximum a posteriori (MAP) estimator and an error model derived from the population error model parameters. Results from the Bayesian analysis and other methods for the estimation of AUC, including relating clearance to surface area or to renal function, were evaluated by comparing the AUC estimate with the AUC determined by model-independent analysis. Overall, the optimal sampling strategy performed better than estimates based on renal function, which had a median bias of 5% and precision of 22%. With one data point at 60 min postinfusion, the median bias and precision were 3 and 6%, respectively. Addition of a second data point at 30 min during the infusion improved the estimate slightly (median bias -2%, precision 3%). Bayesian estimation produced more reliable estimates of AUC compared to values based on renal function, which in turn was slightly better than using surface area. A technique, developed in adult patients, for estimating AUC from a measurement of 24 h total plasma platinum was comparable to estimates based on renal function, but was less reliable. The estimation of carboplatin AUC can be performed using only one or two plasma samples and Bayesian analysis. This approach is less biased and more precise than methods based on surface area, renal function or total platinum at 24 h postdose, but is probably best used in combination with dosing based on renal function.

An anti-murine CD3 monoclonal antibody with a low affinity for Fc gamma receptors suppresses transplantation responses while minimizing acute toxicity and immunogenicity

145-2C11, a hamster mAb directed against the mouse CD3 complex, is a potent immunosuppressive agent. Upon initial treatment, 145-2C11 triggers a systemic release of multiple cytokines that is responsible for the acute toxicity of the mAb. This cellular activation is a consequence of the cross-linking between T lymphocytes and Fc gamma R-bearing cells, mediated by the high affinity of the hamster mAb for murine Fc gamma Rs. Repeated mAb injections result in the onset of a neutralizing humoral response. Therefore, there has been an increased interest in developing nonmitogenic forms of anti-CD3 mAbs, although it is not clear whether these Abs will retain immunosuppressive properties. To determine whether the initial cytokine production is necessary for the immunosuppressive properties and the immunogenicity of anti-CD3 mAbs in vivo, we have generated chimeric (hamster 145-2C11 F(ab')2 region/mouse Fc gamma portion) mAbs using murine isotypes with different affinities for Fc gamma Rs. The 145-2C11 and a chimeric IgG2a isotype, both of which bind murine Fc gamma Rs avidly, had similar activating, immunogenic, and immunosuppressive properties in mice. The administration of a chimeric IgG3 isotype with a very low affinity for murine Fc gamma Rs did not result in cytokine production, a humoral response against the mAb, or TCR desensitization. Nevertheless, prolongation of skin graft survival was similar in the IgG3, IgG2a, and 145-2C11-treated mice, indicating that Fc gamma R nonbinding anti-CD3 mAbs retain potent immunosuppressive properties in vivo while not being immunogenic. This enhanced therapeutic to toxic profile may be beneficial in clinical transplantation.