Effect on cell kill of addition of multidrug resistance modifiers cyclosporin A and PSC 833 to cytotoxic agents in acute myeloid leukaemia

Multidrug resistance (MDR) mediated by the drug efflux pump P-glycoprotein (Pgp), may cause remission failure and relapse in patients with acute myeloid leukaemia (AML) by extruding cytotoxic agents such as anthracyclines from leukaemic cells thus allowing them to survive. Cell line data suggest that reversal of MDR is possible using modifying drugs such as cyclosporin A (CSA) and its analogue PSC 833. We have investigated the effects on cell kill of the addition of CSA and PSC 833 to daunorubicin, idarubicin, mitozantrone, etoposide and cytarabine in 52 fresh cell samples from AML patients using an MTT assay. Pgp status was determined by using monoclonal antibodies JSB-1 and MRK-16 and by assessment of rhodamine efflux. Although overall each cytotoxic-modifier combination produced significant improvements in cell kill compared to cytotoxic alone (P values ranged from P < 0.001 to P = 0.017), modifiers also produced significant cytotoxicity in their own right, and no consistent difference was seen between responses in Pgp-positive and negative groups. Up to one in three Pgp-positive samples failed to show any improvement in cell kill with the addition of CSA or PSC 833, possibly owing to co-expression of alternative resistance mechanisms not affected by the MDR modifiers. The best responses were seen when PSC 833 was added to idarubicin, with 7 out of 22 Pgp-positive cases (32%) showing five-fold improvements in cell kill or better compared to idarubicin alone. Comparison of equimolar concentrations of the two modifiers in the Pgp positive group failed to show a significant difference in cell kill, though PSC 833 was markedly superior to CSA in a minority of highly responsive samples which demonstrated clear evidence of MDR reversal. Our in vitro data suggest that MDR modifiers such as CSA and PSC 833 could play an important role in the therapy of AML and indicate the need for prospective randomised trials to assess their clinical efficacy.

Structure and variation of mood in individuals with Parkinson's disease: a dynamic factor analysis

Mood structure was examined among individuals diagnosed with Parkinson's disease. Twelve individuals completed a measure of positive and negative affect for 70 consecutive days. Mood structure was determined by using dynamic factor analysis (DFA) models that account for both concurrent and lagged relationships in repeated measurements. Five individuals had sufficient variability in positive and negative affect to conduct DFA on both sets of variables. Results showed the presence of 2 2-factor 1-lag models, 2 1-factor 1-lag models, and a P-technique model. There was sufficient variability in positive affect to conduct DFA on positive affect for the entire sample. Two individuals displayed 2-factor 1-lag models, 6 individuals had 1-factor 1-lag models, and 4 individuals showed P-technique models. Implications of lagged relationships are discussed from substantive and methodological perspectives.

Structure and variation of mood in individuals with Parkinson's disease: a dynamic factor analysis

Mood structure was examined among individuals diagnosed with Parkinson's disease. Twelve individuals completed a measure of positive and negative affect for 70 consecutive days. Mood structure was determined by using dynamic factor analysis (DFA) models that account for both concurrent and lagged relationships in repeated measurements. Five individuals had sufficient variability in positive and negative affect to conduct DFA on both sets of variables. Results showed the presence of 2 2-factor 1-lag models, 2 1-factor 1-lag models, and a P-technique model. There was sufficient variability in positive affect to conduct DFA on positive affect for the entire sample. Two individuals displayed 2-factor 1-lag models, 6 individuals had 1-factor 1-lag models, and 4 individuals showed P-technique models. Implications of lagged relationships are discussed from substantive and methodological perspectives.

Defence against the immune barrage: helminth survival strategies

Parasites have generated a range of countermeasures against the host immune system which allows their survival long enough for reproduction to occur. Parasite subsistence is enhanced by evasion of the immune response utilizing mechanisms such as antigenic variation of exposed immunogenic proteins, shedding of surface proteins which are the target of an immune response, and protease production to neutralise specific anti-parasite immune components. Recent advances in the fields of immunology and parasitology have highlighted a range of mechanisms by which the parasite actively modulates the immune response to allow survival. Parasite factors can directly suppress the function of certain subsets of immune cells as well as stimulating other cell populations which have suppressive activity. Strategies such as the skewing of the type 1-type 2 cytokine profile to that of a less appropriate response, and the mimicry of host immune regulatory proteins are becoming more widely acknowledged as means by which helminths enhance their survival. An illustration of the extent by which parasites can exploit host immune components is emphasized by the use of host cytokines as parasite growth factors. This review will examine some of the strategies developed by helminths which enables them not only to survive in the host, but also to prosper.

Mixed-linked beta-glucan from breads of different cereals is partly degraded in the human ileostomy model

The purpose of this investigation was to study the degradation of beta-glucan in the small intestine and the molecular weight of beta-glucan in the excreta of nine ileostomy subjects after consumption of different diets based on bread made with oat bran (oat bread), a fiber-rich barley fraction (barley bread), or wheat flour (wheat bread) as the main ingredients. Oat bread with enzymatically degraded beta-glucan was also used (oat + enzyme bread). The beta-glucan intake from the four diets was 12.5, 12.9, 1.1, and 4.0 g/d, respectively. On the basis of dry matter, the night effluents accounted for approximately 15% of the total amount of the excreta, with the highest proportion (22%) being for the wheat-bread diet. A notable loss of beta-glucan (0.7-2.4 g/d, or 13-64%) was found when intake was compared with excretion. In vitro, a higher viscosity development with time for dispersions of oat bread compared with barley bread was noted, which could be related to the higher molecular weight of the beta-glucan in this bread. There seemed to be a depolymerization of the beta-glucan both during bread making and transit through the upper gastrointestinal tract.

Cytokines and their inhibitors in orf virus infection

The epitheliotropic parapoxvirus, orf virus, can repeatedly infect sheep skin. A specific immune response is generated as reinfections induce smaller lesions with quicker resolution times than primary lesions. Cyclosporin-A treatment abrogates this partial immunity. Cytokine mRNAs detected in lesion biopsies include the transcripts for IL-1 beta, IL-3 GM-CSF, TNF-alpha and, less reproducibly, IFN-gamma. CD4+ T-cells predominate in afferent lymph draining the site of infection, and are the major source of GM-CSF and IFN-gamma. IL-1 beta and IL-8 are also detected. The orf virus genome contains a homologue of mammalian vascular endothelial growth factor that may enhance virulence and a vaccinia virus E3L-like gene which may inhibit the anti-viral effect of the interferons. A GM-CSF inhibitory activity has also been discovered and has been 'chased' into a 10 kb DNA segment of the orf virus genome. These studies indicate that orf virus may temporarily avoid host immunity by a combination of acute, rapid infection and replication in the epidermis and by producing virulence factors that inhibit protective proteins of the host immune and inflammatory response.

A Novel Strategy for Control of Microbial Biofilms through Generation of Biocide at the Biofilm-Surface Interface

Biofilms of a mucoid clinical isolate of Pseudomonas aeruginosa (24 h; ca. 10(sup6) CFU/cm(sup2)) were established by immersion of polymer discs in nutrient broth cultures at 37(deg)C. Biofilms exposed for 30 min to various concentrations (0 to 3 mg/ml) of hydrogen peroxide or potassium monopersulfate were rinsed and shaken vigorously in sterile saline to detach loosely associated cells, and the residual viable attached population was quantified by a blot succession method on agar plates. Incorporation of copper and cobalt phthalocyanine catalysts within the polymers significantly enhanced the activity of these oxidizing biocides towards biofilm bacteria by several orders of magnitude. Biofilms established on the control discs resisted treatment with concentrations of either agent of up to 3 mg/ml. Enhancement through incorporation of a catalyst was such that concentrations of potassium monopersulfate of as low as 20 (mu)g/ml gave no recoverable survivors either on the discs or within the washings. Catalysts such as these will promote the formation of active oxygen species from a number of oxidizing agents such as peroxides and persulfates, and it is thought that generation of these at the surface-biofilm interface concentrates the antimicrobial effect to the interfacial cells and generates a diffusion pump which further provides active species to the biofilm matrix. The survivors of low-concentration treatments with these agents were more readily removed from the catalyst-containing discs than from the control discs. This indicated advantages gained in hygienic cleansing of such modified surfaces.

Identification of Gas6 as a growth factor for human Schwann cells

Schwann cells are one of the principal components of the peripheral nervous system. They play a crucial role in nerve regeneration and can be used clinically in the repair of injured nerves. We have established serum-free, defined culture conditions that rapidly expand adult human Schwann cells without fibroblast growth. We find that Gas6, a ligand for the Axl and Rse/Tyro3 receptor protein tyrosine kinase family, stimulates human Schwann cell growth, increasing both cell number and thymidine incorporation. Gas6 has synergistic effects with the other known human Schwann cell mitogens, heregulin/glial growth factor and forskolin. Addition of Gas6 causes phosphorylation of Axl and Rse/Tyro3 simultaneously and results in ERK-2 activation. A combination of Gas6 with heregulin and forskolin, on a defined background, supports maximal Schwann cell proliferation, while preserving the typical Schwann cell morphology and expression of the Schwann cell markers S-100, glial fibrillary acidic protein, and low-affinity nerve growth factor receptor. Gas6 mRNA is present in both spinal motor neurons and large neurons of the dorsal root ganglia, and neural injury has been reported to upregulate Rse/Axl in the schwann cell. This is the first demonstration of a potentially important biological role for the human Gas6/Rse-Axl system.

In search of psychiatric performance measures

The purpose of this article is to relate the experiences of a panel of industry experts and Maryland Hospital Association (MHA) staff who worked together to develop and pilot test a set of comparative performance indicators for psychiatric care. MHA's experiences with the Quality Indicator Project served to provide a sound structure for indicator development and testing. This paper explores the premise on which the indicator set was developed, the work of the expert panel, and the participation and contribution of the pilot sites.

Concentration dependent cardiotoxicity of terodiline in patients treated for urinary incontinence

OBJECTIVE

Terodiline, an antimuscarinic and calcium antagonist drug, was used to treat detrusor instability but was withdrawn in 1991 after provoking serious ventricular arrhythmias associated with increases in the corrected QT interval (QTc). This research was performed to relate drug induced electrocardiographic changes in asymptomatic recipients to plasma concentrations of the R(+) and S(-) terodiline enantiomers.

SETTING

Urological and geriatric clinics and wards.

SUBJECTS

Asymptomatic patients taking terodiline in stable dose.

METHODS

Electrocardiograms (50 mm/s) were collected from patients while they were taking terodiline and compared with ECGs obtained before or after terodiline. QT interval, heart rate corrected QT interval (QTc), and QT dispersion (QTd) were measured. Drug induced electrocardiographic changes were related to plasma concentrations of R(+) and S(-) terodiline.

RESULTS

During terodiline treatment mean QTc and QTd were prolonged (491(43) and 84 (35) ms 1/2) compared with measurements made off therapy (443 (33) and 42 (17) ms 1/2, paired t tests, P < 0.002 and P < 0.01 respectively) in the 12 patients in sinus rhythm. The mean (95% confidence interval) drug induced increases were 48 (23 to 74) ms 1/2 for QTc and 42 (13 to 70) ms 1/2 for QTd. These increases correlated with total plasma terodiline (QTc: r = 0.77, P < 0.006, QTd: r = 0.68, P < 0.025) and with plasma concentrations of both terodiline enantiomers.

CONCLUSIONS

Terodiline increases QTc and QTd in a concentration dependent manner. It is not clear whether this is a stereoselective effect and, if so, which enantiomer is responsible. The results suggest that drug induced torsade de pointes is a type A (concentration dependent) adverse drug reaction.

Beta 2-adrenergic receptor density and cardiovascular response to mental stress

In this study we evaluated effects of an acute experimental stressor on beta 2-adrenoceptor density and examined the relationships of baseline receptor density to cardiovascular reactions induced by stress. In addition, we investigated whether any observed alterations in receptor density were associated with concomitant redistribution of circulating lymphocyte populations. Receptor density and lymphocyte subsets were determined before and immediately following performance of a frustrating laboratory task in 22 male volunteers. Blood pressure, heart rate (HR), and plasma catecholamine concentrations were also assessed at baseline and during task performance. Parallel measurements were obtained among 11 unstressed control subjects. Receptor density increased significantly between baseline and posttask measurements, but equally so in experimental and control subjects. Numbers of T suppressor/cytotoxic and natural killer cells increased selectively among subjects assigned to the experimental (stress) condition. However, there was no association between lymphocyte subset distribution and receptor density. Interindividual variability in pretask receptor density correlated significantly with heart rate and systolic blood pressure (SBP) reactivity during the initial 3 min of mental stress, but not over the entire task period. In addition, baseline receptor density correlated with SBP (but not HR) reactivity after covariance adjustment for the concomitant change in plasma catecholamine concentrations.

The pharmacokinetics and neuromuscular effects of rocuronium bromide in patients with liver disease

To determine the effect of liver disease on the pharmacokinetics of rocuronium, the authors administered 0.6 mg/kg (twice the ED95) to 10 patients with liver disease and compared these results to values in 10 healthy surgical patients. Anesthesia was induced with thiopental and maintained with isoflurane (0.9%-1.1% end-tidal concentration) and nitrous oxide (60%). Venous blood samples were obtained for 6 h after rocuronium injection and plasma concentrations were measured using gas chromatography. Pharmacokinetic differences between groups were determined using a population-based pharmacokinetic analysis (NONMEM). Hepatic impairment did not alter the plasma clearance of rocuronium (217 +/- 21.8 mL/min, mean +/- SE, for both groups), but did increase the volume of the central compartment (5.96 +/- 1.01 L for controls, 7.87 +/- 1.33 L for patients with liver disease) and volume of distribution at steady state (16.4 L for controls, 23.4 L for patients with liver disease). In turn, elimination half-life was longer in patients with liver disease (111 min) compared to controls (75.4 min). The authors conclude that liver disease alters the pharmacokinetics of rocuronium by increasing its volume of distribution. The longer elimination half-life might result in a longer duration of action of rocuronium in patients with liver disease, particularly after prolonged administration.

Balancing science and practice in indicator development: the Maryland Hospital Association Quality Indicator (QI) project

This paper describes the technical and conceptual aspects in the development of an indicator project to measure hospital performance. Almost a decade ago, a research based--hence explorative, series of inpatient and ambulatory care indicators were developed. This paper describes some of the most fundamental technical and applied knowledge gleaned from the study and applicable to all quality assurance/quality improvement activities. These findings, and the resulting indicator development guiding principles, are based on more than 900 hospitals' experience in the US, Japan, and England. Although this paper presents the necessary scientific underpinning for a valid and reliable analysis, its principal emphasis is on the practical applicability of this decade old research project aimed at measuring select outputs of performance and identifying and explaining the determinants of these outputs.

The effect of gastritis on human gastric alcohol dehydrogenase activity and ethanol metabolism

BACKGROUND

Gastric mucosal alcohol dehydrogenase (ADH) may decrease the bioavailability of ingested ethanol. Because this enzyme is found in highest concentrations in the superficial gastric mucosa, diffuse abnormalities of this tissue could lead to a decrease in the first pass metabolism of ethanol.

METHODS

Thirty-three adult subjects undergoing routine upper gastrointestinal endoscopy had gastric biopsies performed for assessment of gastric histology and the measurement of gastric ADH activity. Twenty of these subjects underwent separate oral dosing and intravenous infusion of ethanol (0.15 g/kg body weight) in order to determine the first pass metabolism, and hence bioavailability, of ethanol.

RESULTS

Gastric histology was normal in 10 of the biopsies, showed chronic gastritis alone in 13 and significant glandular atrophy (i.e. atrophic gastritis) in a further 10. Gastric ADH activity in specimens with normal gastric histology was significantly higher than those with chronic gastritis (P = 0.02), and was further decreased in those specimens with significant atrophy (P < 0.00001). However, no correlation was found between gastric ADH activity and the first pass metabolism of ethanol (r = 0.09, P = 0.9).

CONCLUSIONS

These results suggest that although gastric ADH activity was decreased in individuals with abnormal gastric mucosa, ethanol bioavailability was not affected by gastric ADH activity. These data support the view that gastric ADH does not play a significant role in the first pass metabolism of alcohol.

Suppression of lymphocyte mitogenesis in different rat strains exposed to footshock during early diurnal and nocturnal time periods

The present study examined stressor interactions with genotype and light/dark cycle. Male Brown Norway (BN), Fischer 344 (F344), Lewis (from two different vendors: Lew/CR and Lew/H) and Sprague Dawley (SD) rats were exposed to footshock either in the early light or early dark circadian phase. Immediately after footshock, the spleen and whole blood proliferation to PHA and Con A was assessed. To provide endocrine indices of stress, serum was measured for corticosterone and interleukin-6 (IL-6). All rats showed significant increases in serum corticosterone and IL-6 following footshock either in the light or the dark. Rat strain differences were noted in the IL-6 response, while the corticosterone response was strong for all strains. The criterion for 'suppression' of lymphocyte proliferation was p < .05 (as determined by ANOVA) compared to non-shocked controls. Spleen: with the exception of BN rats, the other strains showed suppressed spleen cell proliferation to PHA and Con A both in the light and the dark. BN rats failed to show suppression of mitogenic activity to PHA when footshock was given in the light. Peripheral blood lymphocytes: suppression in Lew rats from either vendor, and in F344 and BN rats, did not vary with time of day nor with the type of mitogen tested. SD rats did not show suppression to PHA if shocked in the light. These results highlight the generality of stressor-induced mitogenic lymphocyte proliferation during the early diurnal and nocturnal periods of the day.

Pregnancy after treatment with hydroxyurea in a patient with primary thrombocythaemia and a history of recurrent abortion

A 28 year old patient with primary thrombocythaemia, who had had two stillbirths in the third trimester, is reported. She was successfully treated with hydroxyurea and delivered a healthy 6lb boy by elective caesarean section. The ease with which this treatment can be given, its high level of tolerance among patients, and its low cost are likely to increase its use as a safe and effective treatment in pregnant patients with primary thrombocythaemia.

P-glycoprotein expression on acute myeloid leukaemia blast cells at diagnosis predicts response to chemotherapy and survival

P-glycoprotein (Pgp) expression, which is associated with the multi-drug resistance (MDR) phenotype, has been reported to be a useful predictor of treatment outcome in acute leukaemia. We have examined the expression of Pgp on acute myeloid leukaemia (AML) cells in 54 newly diagnosed patients, using a novel streptavidin-biotin complex (ABC) technique. 55% of patients at diagnosis were positive for Pgp with JSB-1, a monoclonal antibody that binds to an internal epitope of Pgp. All patients received intensive induction chemotherapy. Post-remission treatment consisted of further chemotherapy +/- bone marrow transplantation. Complete remission (CR) rates were significantly lower in the Pgp positive group than in the Pgp negative group (60% v 92%; P = 0.02). The overall survival for Pgp-positive patients was significantly shorter (329 v 534d, P = 0.004), disease-free survival was also reduced but the difference was not statistically significant (median 277 v 522d, P = 0.16). In this study CD34 expression was not predictive of response to chemotherapy nor was it associated with Pgp expression. Our results confirm the prognostic value of Pgp expression in AML at diagnosis and we suggest that Pgp could be a useful therapeutic target for reversing multi-drug resistance. Furthermore, our simple and sensitive method of detecting Pgp should enable widespread testing to be performed.

Flumecinol for the treatment of pruritus associated with primary biliary cirrhosis

OBJECTIVE

To determine whether flumecinol (3-trifluoromethyl-alpha-ethylbenzhydrol, Zixoryn) is effective in ameliorating pruritus of cholestasis, particularly in primary bilary cirrhosis.

METHODS AND RESULTS

50 patients (46 with primary biliary cirrhosis, PBC) took oral flumecinol 600 mg or identical placebo once weekly for 3 weeks. Patients assessed pruritus by scoring a daily 100 mm visual analogue scale (VAS; 0 = no itch, 100 = severe, continuous, day and night intolerable itch). Quality of life was similarly measured. Patients scored the VAS daily for a 7-day baseline and for a further 21 days. Subjectively, pruritus improved in 13 of 24 on flumecinol and 10 of 26 on placebo (chi 2 = 1.24, P = 0.27). Median difference in fall in VAS pruritus score between baseline week (mean score for each individual used) and the last week was 8.0 [95% confidence interval (CI) -2.1 to 20.8] and for VAS quality of life was 5.0 (95% Cl 0.4 to 13.0) both in favour of flumecinol over placebo. Later, 19 patients (all PBC) were randomised to flumecinol 300 mg or placebo daily for 3 weeks. Subjectively, pruritus improved in 7 of 10 on flumecinol and 1 of 9 on placebo (Fisher's exact test, P = 0.02). Median difference in fall in VAS pruritus score was 19.8 mm (95% CI 3.3 to 40.7 mm) in favour of flumecinol over placebo and for quality of life was 3.5 mm (95% Cl -5.9 to 24.9 mm). Flumecinol did not significantly affect liver function tests, antipyrine clearance or serum total bile acids, and was not associated with any significant side-effects.

CONCLUSION

Flumecinol was safe at the above doses and short term treatment with 300 mg daily, significantly ameliorated pruritus in primary biliary cirrhosis.

The development of functional ovarian cysts during pituitary down-regulation

This study investigated the development of functional ovarian cysts during pituitary down-regulation prior to in-vitro fertilization (IVF), and identified 16 cases of cysts in 288 IVF cycles studied. Comparing the patients with functional ovarian cysts to the other 272 IVF cycles, there was no significant difference in age or incidence of endometriosis but significantly (P < 0.01) more patients with cysts had ovulatory dysfunction. The serum progesterone was < 5.7 nmol/l in all 16 patients with cysts on day 4 of the IVF cycle, and in eight of these patients the serum progesterone was < 5.7 nmol/l on the day buserelin was commenced. In 10 of the 16 patients with cysts, serum oestradiol concentrations remained elevated despite the prolonged use of buserelin, and the cysts were aspirated. The aspirate in all cases was clear without any suggestion of endometriosis. The cyst aspirates had significantly lower progesterone (P < 0.001), higher androstenedione (P < 0.01) and similar oestradiol concentrations to 10 follicular fluid samples collected at the time of oocyte retrieval. This study suggests that functional ovarian cysts may develop during pituitary down-regulation, and these cysts are follicular cysts rather than persistent corpora lutea or endometriomata.