An effective therapy for both undifferentiated (including Burkitt's) lymphomas and lymphoblastic lymphomas in children and young adults

We have used a single intensive chemotherapy regimen in the treatment of young patients with diffuse, aggressive, malignant lymphomas. There were two major histologic types of lymphoma in our series: lymphoblastic lymphomas, which presented most often with mediastinal tumor (64%), and undifferentiated lymphomas (mostly Burkitt's lymphomas), which occurred predominantly in the abdomen (86%). Our objective was to examine the determinants of prognosis in a uniformly treated patient group that included 31 children (2-16 yr) and 34 young adults 17-35 yr). Patients with extensive bone marrow involvement (greater than 50% replacement by tumor cells) were included in the study. Treatment consisted essentially of a 4-drug combination (cytoxan, adriamycin, vincristine, and prednisone) alternating with a 42-hr methotrexate infusion, followed by leukovorin rescue, and included intrathecal prophylactic therapy against central nervous system (CNS) disease. Patients with localized or resected undifferentiated lymphoma received 6 therapy cycles; all other patients received 15 cycles. Radiation therapy was used only in exceptional circumstances. Fifty-eight of 65 patients (89%) achieved complete remission: 97% of children and 82% of adults. The estimated 3-yr survival was 60% (SE 6.4%) with a median follow-up of 3 yr. Analysis of factors associated with remission duration and survival indicated that bone marrow involvement at referral and extensive disease were poor prognostic variables. Patients with lymphoblastic lymphomas and patients with completely resected undifferentiated lymphomas had the best prognosis (81% +/- 12% and 94% +/- 6% estimated 3-yr survival, respectively). Patients with extensive intraabdominal undifferentiated lymphoma (stage D) had the worst prognosis (33% +/- 11% estimated 3 yr survival), but even in this subgroup, bone marrow involvement was an adverse factor (estimated survival in stage D patients with and without bone marrow involvement was 14% +/- 13% and 43% +/- 15%, respectively). Elevated uric acid and/or lactic dehydrogenase (LDH) were also of prognostic significance, but predominantly reflected state, i.e., extent of disease. Age did not significantly influence prognosis. In the undifferentiated lymphoma subgroup, histology (i.e., Burkitt's lymphoma versus non-Burkitt's lymphoma) was not of prognostic significance. Total white count was below 1,000/cu mm in 39% of cycles, and fever associated with granulocytopenia occurred in 17% of cycles. Stomatitis of moderate to severe extent occurred in 50% of cycles.(ABSTRACT TRUNCATED AT 400 WORDS)

Effects of RS 86, an orally active cholinergic agonist, on sleep in man

The effect of four oral doses of RS 86, a direct-acting cholinergic agonist, on polygraphic sleep parameters was studied in two groups of 12 healthy male volunteers. Subjects received placebo, 0.25 and 0.50 mg (Study I), or placebo, 0.75 and 1.50 mg (Study II), in a double-blind, balanced, crossover design. While 0.25 and 0.50 mg RS 86 had no effect on electrophysiological correlates of sleep, 0.75 and 1.50 mg altered polygraphic sleep parameters in a dose-dependent fashion: the latency of rapid eye movement (REM) sleep was shortened, REM sleep duration in the first third of the sleep period increased, and slow wave sleep reduced in the first and second thirds of the sleep period. Pulse rate was dose-dependently and significantly increased after RS 86. Subjective sleep experience and the subjects' condition in the morning were not altered. These results suggest that RS 86, in well-tolerated oral doses, has central effects that are partly similar to and partly different from those of other cholinomimetic agents.

A long-term study with co-dergocrine mesylate (Hydergine) in healthy pensioners. Results after 3 years

Started in 1976, a long-term study in healthy pensioners is now in progress in Basel, Switzerland, to investigate medical, psychological, and electrophysiological aspects of the normal aging process and to establish whether these can be influenced by drug treatment. The subjects are receiving co-dergocrine mesylate (Hydergine) 1.5 three times daily or placebo orally under double-blind conditions. At 1-year intervals each subject's case history is reviewed, a clinical examination and laboratory tests are carried out, an ECG and an EEG are recorded, and a shortened form of the Hamburg-Wechsler Intelligence Test for Adults (German version of the WAIS, i.e., the Wechsler Adult Intelligence Scale), the Raven Coloured Progressive Matrices Test, and the Maudsley Personality Inventory are administered. Treatment compliance is being monitored by pill counting and determination of drug plasma levels. The results after 3 years of the study are presented. The subjects included in this evaluation are those who have undergone all examinations under double-blind conditions (n = 99). During the 3-year period, 27 of the 148 subjects (64 women and 84 men, mean age 63 years) initially recruited for the study have withdrawn, mainly because serious illness has supervened. Three subjects in the placebo group and 1 in the co-dergocrine mesylate group have died. The double-blind code has been broken for medical reasons in 18 cases; these subjects have continued to participate under open conditions. During this 3-year period, the following changes have been observed: A slight but statistically significant rise in systolic and diastolic blood pressure in the sample as a whole (mean increase 12 mm Hg). A decrease in systolic blood pressure in subjects with high initial values (mean decrease 6 mm Hg in the placebo group, and 18 mm Hg in the co-dergocrine mesylate group). An increase in systolic blood pressure in subjects with low initial values (mean increase 17 mm Hg in the placebo group and 16 mm Hg in the co-dergocrine mesylate group). A significant decrease in pulse rate in all subjects (mean decrease 7 beats/min). An increase in the number of subjects with pathological ECGs. A significant decrease in mean serum creatinine and lipid levels (all subjects) and a decrease of about 70% in the number of subjects with pathologically raised values. A decrease in the number of subjects from both groups with pathological signs in the EEG.(ABSTRACT TRUNCATED AT 400 WORDS)

Clinical trials with the cholinergic drug RS 86 in Alzheimer's disease (AD) and senile dementia of the Alzheimer type (SDAT)

The muscarinic agonist RS 86 was administered to patients with Alzheimer's disease (AD) and senile dementia of the Alzheimer type (SDAT) in a series of controlled clinical trials. Daily doses were up to 3.0 mg orally for a maximum duration of 18 weeks. RS 86 produced typical peripheral cholinergic effects, but appeared to be better tolerated than similar drugs, such as physostigmine and arecoline. Positive clinical changes with regard to cognitive functions, mood, and social behavior were seen in a minority of AD and SDAT patients. Psychometric tests suggested improvement of functions entailing a speed component. RS 86 is a suitable drug for further clinical experiments in AD and SDAT.

A controlled long-term study with ergoloid mesylates (Hydergine) in healthy, elderly volunteers: results after three years

A long-term clinical comparison of the effects of ergoloid mesylates and placebo on 148 healthy elderly volunteers of both sexes was analyzed after three years of study. At that point, 99 subjects (53 receiving ergoloid mesylates and 46, placebo) were still being treated under double-blind conditions, while the remainder either had dropped out or continued to participate under open conditions. Many subjects in both groups were healthier after the three years than they had been at the onset of the study: subjective symptoms such as tiredness and dizziness were reduced, performances on tests of intelligence were improved, and some abnormal laboratory values had normalized. Blood pressures increased on the average during the investigational period and pulse rates became slower. The ergoloid mesylate regimen was well tolerated objectively and subjectively. Additional medical and psychologic improvements were noted in the group treated with ergoloid mesylates concerning cardiovascular parameters, cholesterol levels, subjective symptoms, and performances on tests of intelligence. These intermediate findings are interpreted as showing a preventive effect of ergoloid mesylates against some of the debilitating physical and psychologic concomitants of aging.

EEG and sleep in aged hospitalized patients with senile dementia: 24-h recordings

Polygraphic recordings of wake and sleep were performed on 10 partly bed-ridden, severely deteriorated patients with senile dementia. Compared with healthy elderly persons these subjects showed less SWS (slow wave sleep, characterized by high amplitude, slow EEG waves), less REM sleep (rapid eye movement sleep, usually accompanied by dream activity) and poorly organized stage 2 sleep (no sleep spindles, i.e. phasic EEG activity with a frequency of 12-14 Hz). Six of the 10 patients had no dominant alpha rhythm during wakefulness; this seemed to be related to their more deteriorated clinical state, to still less SWS and REM sleep and more time spent in stage 2. The basic NREM-REM cycle of sleep, i.e. the regular alternation between non-REM- and REM-periods, could still be distinguished, however, and showed similar average temporal characteristics as in healthy old and younger people. Similarly, although sleep was severely fragmented in most patients and many sleep episodes occurred during the day, the day-night alternation of wakefulness and sleep was maintained in the sample as a whole.

Human EEG slow-wave sleep increased by a serotonin antagonist

Serotonin has been held to play a necessary role in EEG slow-wave sleep. A central serotonin antagonist, known as FU 29-245, 200 mg, was taken nightly for 6 nights by 10 volunteers, mean age 59 years. Compared with baseline sleep the drug significantly increased the duration of slow-wave sleep, with a significant rebound decrease below baseline after withdrawal. The drug also caused fewer transitions into stage 1 and less time in stage 1 and less time in stage 2. There were significant tolerance effects by the fifth and sixth nights. No subjective effects were present.

Aspects of sleep, daytime vigilance, mental performance and psychotropic drug treatment in the elderly

As people grow older, their subjective and objective sleep patterns change: sleep is often experienced as less deep, more broken, less refreshing - and these alterations find their objective correlate in polygraphic sleep recordings. Reductions in high amplitude slow wave sleep, rapid eye movement (REM) sleep and sleep maintenance are the best documented of these. Besides, there are changes in the EEG pattern during sleep (fewer and slower sleep spindels, fewer K-complexes and other phasic events). Daytime EEG recordings in the elderly are characterized by slowing of the dominant alpha rhythm, diffuse or localized slow waves and reduced reactivity to stimuli. Only few studies, however, have addressed the question of how daytime EEG alterations are related to changes of the sleep polygram, and how these electrophysiological parameters relate to measures of mental performance which also undergo changes with aging. A review of published results and data from our own studies suggest that, within the non-pathological range, few correlations exist between polygraphic sleep, daytime EEG and mental performance data if age as an independent factor is kept constant. The only relations that were significant in some of the studies had opposite directions in different subjects' samples. Thus, until more is known, these 3 areas of assessment should be studied and conceptualized separately. Our lack of understanding in this field is further illustrated by results of drug studies: compounds with confirmed effects on mental performance and mood in young subjects, such as amphetamine, fail to be useful stimulants or antidepressants in the elderly, and drugs like co-dergocrine mesylate ((Hydergine) which are of use in mentally deteriorating old persons have no effects on vigilance and mental performance in young, healthy subjects. Therefore, extrapolations from one level of assessment to another and from experiments in young subjects to studies in the elderly appear unwarranted at the present time.

Action of lysine-vasopressin on human electroencephalographic activity. Night sleep pattern, auditory evoked potential, contingent negative variation

This study is an investigation of the central effects of vasopressin in man, as this hormone proved able to modify learning processes in animals and was applied successfully to post-traumatic, amnesic patients. Electrophysiological techniques were used to assess the effects of lysine-vasopressin (LVP) given by nasal spray (7 and 14 IU) on night sleep pattern (12 subjects), auditory evoked potentials (AEP; 26 subjects), and contingent negative variation (CNV; 26 subjects). Night sleep EEG was not modified to a great extent: in particular REM sleep did not undergo any change after LVP. Nor were AEPs modified, either in the 6-hour period following drug administration or 1 week after; CNV, however, reacted in a significant manner 6 h after drug intake, and the modifications were still present after 1 week. LVP did not affect CNV amplitude itself but its evolution through time, as CNV habituation was prevented. Such effects are discussed with regard to the neurochemical mechanisms of vasopressin action and CNV genesis.

Induction of complement receptor expression in cell lines derived from human undifferentiated lymphomas. II. Characterization of the induced complement receptors and demonstration of the simultaneous induction of EBV receptor

We have studied the specificity of complement receptors induced by theophylline in 2 cell lines derived from undifferentiated lymphomas, one of Burkitt's type, and compared it to that of complement receptors in other cell types. Both C3b and C3d receptors were induced. The induced C3b receptor differed from the C3b receptor of mature normal lymphocytes, polymorphonuclear leukocytes and the cells of a nodular lymphoma in 2 respects. Firstly, it bound C3b much less avidly (by a factor of several hundred-fold) and secondly, we were unable to demonstrate C4b binding. EBV receptors were induced at the same time as complement receptors, and permitted the conversion of a greater fraction of cells to EBNA positivity after experimental infection with EBV. The induction of receptors was not associated with a change in the fluidity of the plasma membranes and our data do not favor a different orientation of induced receptors within the membrane as compared to receptors of other cell types--a potential explanation for the different specificities. Our findings are consistent with the possibility that the complement receptors of lymphocyte precursors differ from these of mature lymphocytes.

Induction of complement receptor expression in cell lines derived from human undifferentiated lymphomas. II. Characterization of the induced complement receptors and demonstration of the simultaneous induction of EBV receptor

We have studied the specificity of complement receptors induced by theophylline in 2 cell lines derived from undifferentiated lymphomas, one of Burkitt's type, and compared it to that of complement receptors in other cell types. Both C3b and C3d receptors were induced. The induced C3b receptor differed from the C3b receptor of mature normal lymphocytes, polymorphonuclear leukocytes and the cells of a nodular lymphoma in 2 respects. Firstly, it bound C3b much less avidly (by a factor of several hundred-fold) and secondly, we were unable to demonstrate C4b binding. EBV receptors were induced at the same time as complement receptors, and permitted the conversion of a greater fraction of cells to EBNA positivity after experimental infection with EBV. The induction of receptors was not associated with a change in the fluidity of the plasma membranes and our data do not favor a different orientation of induced receptors within the membrane as compared to receptors of other cell types--a potential explanation for the different specificities. Our findings are consistent with the possibility that the complement receptors of lymphocyte precursors differ from these of mature lymphocytes.

CT of American Burkitt lymphoma

One hundred abdominal and chest CT scans in 29 patients with American Burkitt lymphoma were reviewed. Abdominal and/or pelvic masses were the most common finding and were detected in 13 (45%) patients. Masses indicating relapse were noted in three (10%) additional patients. Ascites and retroperitoneal involvement were noted in seven and five patients, respectively. Other findings included hepatic lesions, splenomegaly, gastric wall abnormalities, renal enlargement, urate nephropathy, and bony involvement. Pleural effusions and two mediastinal masses were noted on chest scans. CT was found to be a rapid screening procedure and especially useful in delineating the size and intrathoracic extension of abdominal masses, defining deep pelvic diseases, assessing the response to therapy, and defining areas of relapse. Lack of retroperitoneal fat and inadequate opacification of bowel loops were frequent problems that limited the value of CT scans.

Characterization of ergot and non-ergot serotonin antagonists by prolactin and growth hormone profiles during wakefulness and sleep

In order to further clarify the involvement of serotonin in the control of secretion of pituitary lactogens, diurnal and sleep prolactin (PRL) and growth hormone (GH) profiles were investigated in healthy subjects treated with ergot and non-ergot serotonin antagonists. A group of 10 subjects received a single oral dose of 2 mg each of pizotifen, methysergide, and the dopaminergic drug bromocriptine as reference substance, in comparison with placebo. Blood was collected at hourly intervals for 6 h. Another group of 10 individuals received either a placebo, 2.5 mg bromocriptine (n = 6) twice daily for 4 days or pizotifen (n = 10) 0.5 mg 3 times daily for 12 days before undergoing EEG recording and blood sampling during night sleep. The diurnal plasma profiles of PRL and GH were not modified by pizotifen, a non-ergot drug. Methysergide and bromocriptine, two ergot derivatives, significantly (P < 0.01 and P < 0.001 respectively) suppressed the basal secretion of PRL throughout the trial and increased plasma GH significantly (P < 0.01). The sleep profile of PRL was not modified by pizotifen but there was a moderate reduction in GH reaching the level of significance (P < 0.02) between hours 1 and 2 of sleep. Bromocriptine suppressed completely PRL secretion throughout the entire sleep period and significantly (P < 0.05) prolonged the secretory profile of GH. The results indicate the presence in the ergot molecule of a dopaminergic moiety responsible for PRL inhibition and GH stimulation. This effect is independent of the serotonin active component of the drug.

[Effect of high single doses of bromocriptine in schizophrenic patients with elevated serum prolactin levels and extrapyramidal side effects associated with neuroleptic treatment (author's transl)]

The purpose of the present study was to investigate the effect of bromocriptine in single doses of 20 and 30 mg on the unwanted effects most frequently caused by neuroleptics: elevated prolactin levels and extrapyramidal disturbances. 111 chronic schizophrenics were included in the investigations, 58 of them being treated with haloperidol and 53 with chlorpromazine. It was found that a single dose of 30 mg bromocriptine brought about a statistically significant decrease in the prolactin levels of patients treated with haloperidol but produced no more than a downward tendency in patients receiving chlorpromazine (the initial prolactin levels of both groups of patients were equal.) The effect of bromocriptine on EPS disturbances was more marked in the chlorpromazine group, but side effects such as nausea and agitation also occurred more frequently in this group. These results show that there is no correlation between the reduction in prolactin levels produced by bromocriptine and an improvement in unwanted EPS effects. This supports the hypothesis that the effect of neuroleptics on the prolactin secreting cells of the anterior pituitary and their effect on the EPS are mediated by different sets of receptors.

On psychotherapy of patients with problems of hostility

Psychotherapy often involves the person's recognition of the hostility, the role of reaction formation to hurtful situations and relationships, and transferential expression--and for the therapist, countertransference. Generally, underlying hostility is the wish to be free of it, granted the difficulty of some paranoid patients. Ambulatory therapy may be inadequate, and other resources, including hospitalization, may be required. The ethical issue of social responsibility transcending the obligation of confidentiality may arise.

Central effects of guanfacine and clonidine during wakefulness and sleep in healthy subjects

1. Three double-blind studies in young normotensive male volunteers were carried out: a study in ten awake subjects, comparing guanfacine 2.0 and 4.0 mg with clonidie 0.15 and 0.30 mg and placebo; and two polygraphic sleep studies each with six subjects, comparing guanfacine 1.0 and 2.0 mg with placebo, and clonidine 0.15 and 0.30 mg with placebo, respectively. 2. In awake subjects, both drugs reduced systolic blood pressure without significantly altering diastolic blood pressure, pulse rate and objective performance parameters. 'Side-effects' such as tiredness, decreased inclination to work, and dryness of the mouth were somewhat more frequent after the higher clonidine dose than after both doses of guanfacine, and peaked 2 h after clonidine but only 4-6 h after guanfacine. 3. Clonidine 0.15 and 0.30 mg given in the evening was followed by a substantial and dose-dependent reduction in rapid eye movement (REM) sleep. Guanfacine 1.0 mg did not alter REM sleep and 2.0 mg of guanfacine had less effect than both doses of clonidine in this respect. Clonidine's effect on REM sleep began after about 2 h, whereas guanfacine's action on REM sleep began 5 h after the dose. 4. Guanfacine and clonidine possess a qualitatively similar pattern of activity with regard to the parameters studied; but the central effects are less pronounced and occur later after guanfacine than after clonidine in equiactive doses.

[A new geriatric battery test]

Both the clinical and the experimental field of geriatrics are in need of an instrument to test the cognitive abilities of people aged 60 and above. By means of a pre-test of the new geriatric test-battery, those abilities, which generally decrease with age, are tested first in order to obtain a testability rating for a particular patient. The geriatric test-battery, which is based on a theory of a 4 dimensional intelligence clearly delineating the differential development of specific cognitive abilities into old age, allows a precise, differentiated assessment of the cognitive abilities of the elderly. Considering the particular characteristics of the old person, the geriatric test-battery was given a new form which minimizes the feeling of being threatened by the test and at the same time maximizes motivation. The geriatric test-battery is pleasant for both the patient and the tester, it is simple to administer, can easily be given to physically impaired or bedridden patients, and is not time consuming.

Hypnotic efficacy of temazepam: a long-term sleep laboratory evaluation

1 Temazepam was evaluated in a strictly defined insomniac patient population under sleep laboratory conditions. Two protocols were used: a short-term (26-night) and a long-term (54-night) protocol evaluated the efficacy of the drug administered at night at 15 mg (short-term study) and 30 mg (long-term study), respectively. 2 Temazepam seemed to be both safe and effective at doses of 15 and 30 mg with up to 5 weeks of ingestion. 3 Suppression of slow wave sleep was observed at the high dose, but no suppression of REM sleep, found in studies with other benzodiazepines, was noted. 4 No evidence was found for development of tolerance or rebound effects.

Longitudinal mixing in pulmonary airways--normal subjects respiring at a constant flow

We have measured the impulse response of helium and sulfur hexafluoride in the airways of five normal human subjects at a respiratory flow of 400 ml/s. The longitudinal mixing of the inert gases was characterized by the increased volume variance of the expired concentration response. This parameter was measured over the largest possible range of airway penetrations, 30-290 ml. Employing a symmetrical model of the airway geometry, we have computed the values of a mean mixing coefficient from the volume variance data. This mixing coefficient is largest in the large airways and decreases rapidly with increasing penetration; it may be as much as 4,000 times greater than the molecular diffusivity; and it is relatively independent of the inert gas tested, at least up to an airway penetration of 180 ml. These observations are consistent with several preivously proposed mixing mechanisms including axial streaming, turbulent dispersion, and mixing by geometric asymmetry. However, the latter observation appears to rule out the importance of laminar dispersion since mixing by this mechanism is inversely dependent on the molecular diffusivity.

Selective renal artery embolization. Treatment of acute renovascular hypertension

A critically ill patient with severe renovascular hypertension following surgical repair of an aortic dissection was treated by percutaneous selective embolization of the ischemic kidney. Correction of the hypertension and subsequent complete recovery of the patient resulted.