Histamine, antihistamines and atopic eczema

Histamine is known to be a classical inducer of pruritus. In atopic eczema, itch is a prominent feature (regarded by some even as a 'primary lesion'!). One of the most potent chemical mediators of itch is histamine. Histamine, together with other mediators may play a role in the pathophysiology of atopic eczema: the increased release of histamine from basophil leucocytes of atopic patients has been described, as well as elevated histamine levels in plasma and skin during acute exacerbations of eczematous lesions. Therefore, application of H1 antagonists seems to be a rational regime in the symptomatic treatment of atopic eczema. Nevertheless, some controversy exists regarding the clinical efficacy of orally applied H1 antagonists in this disease, especially with regard to the newer non-sedating compounds such as terfenadine, astemizole, loratadine and cetirizine. Review of the literature shows that there are studies demonstrating a clear-cut antipruritic effect of non-sedating H1 antagonists. Thus the sedative action does not seem necessarily to be connected with therapeutic efficacy in treating itch in atopic eczema. Newer studies show that cetirizine exerts an additional inhibitory effect on eosinophils. This may broaden the therapeutic spectrum of this H1 antagonist in diseases with eosinophil involvement.

[Disseminated tuberculosis cutis colliquativa caused by hematogenous dissemination of Mycobacterium tuberculosis]

We report on a female patient suffering from tuberculosis cutis colliquativa. The skin lesions were caused by hematogenic dissemination of mycobacteria tuberculosis spreading from the affected urogenital tract. The diagnosis was confirmed by culturing. Combined treatment with tuberculostatic agents for 5 months resulted in complete remission of the tuberculosis.

H1- and H2-antagonists in allergic and pseudoallergic diseases

Although known for more than 80 years, histamine still remains a fascinating substance for allergy research. Histamine antagonists have been in clinical use since 1942. The classical H1-antagonists with sedative side-effects have been more or less replaced by newer non-sedating H1-antagonists; the role of H2-receptors in allergic diseases is still controversial. There, are however, increasing reports of beneficial effects of H2-antagonists, mostly in combination with H1-antagonists, in a variety of allergic and pseudoallergic conditions such as chronic urticaria, anaphylactoid reactions due to colloid volume substitutes, opioid analgesics and radiographic contrast media. The combined use of H1- and H2-antagonists might not only act as specific histamine antagonism but exert a mast cell stabilizing effect, as demonstrated in animal experiments and some clinical studies. Future research will show whether the combined use of H1- and H2-antagonists will become a routine therapeutic procedure in allergy therapy.

Levels of itraconazole in skin blister fluid after a single oral dose and during repetitive administration

Oral itraconazole is effective in the treatment of mycoses. To measure its concentrations in the tissue, levels of total and non-protein-bound itraconazole were determined in serum, suction-induced blister fluid, and cantharides-induced blister fluid. Six healthy subjects received 200 mg as a single dose, followed by 100 mg/day for 10 days. Itraconazole binding in suction-induced blister fluid (99.54%) and cantharides-induced blister fluid (99.77%) was calculated from plasma protein binding (99.8%). The single-dose study showed the drug levels in blister fluid to increase more slowly than those in serum. The terminal half-life of itraconazole in serum was 22.5 +/- 3.2 hours. Suction- and cantharides-induced blister fluid levels declined in parallel. After the final dose, itraconazole penetration into cantharides-induced blister fluid was only 70%. Moreover, trough levels of unbound itraconazole in suction- and cantharides-induced blister fluid were 0.239 +/- 0.115 and 0.334 +/- 0.101 ng/ml and thus were significantly lower than free itraconazole levels in serum (0.422 +/- 0.125 ng/ml). Thus a distribution equilibrium between serum and blister fluids was not obtained. Free drug concentrations in suction- and cantharides-induced blister fluid were far lower than the minimal inhibitory concentration values for Candida ssp. and dermatophytes.

Bone marrow relapse occurring as first relapse in children with acute lymphoblastic leukemia

In a retrospective review which covered the whole Dutch childhood population of approximately 3 million children we studied the prognosis in 164 children with acute lymphoblastic leukemia (ALL) who were initially treated between 1973 and 1983, and who had an isolated bone marrow relapse occurring as first relapse. Until their first relapse, the patients were initially treated according to standard protocols, while treatment for relapse was heterogeneous, and not intensive. Second complete remission (CR) was attained by 78% of the patients. The median duration of second CR was 9 months, the median survival 13 months. Multivariate analysis showed that the duration of the first CR was the most significant variable with regard to prognosis. None of the patients who developed their bone marrow relapse during initial treatment, i.e., within 24 months from diagnosis, survived. Among the 73 patients who relapsed after cessation of the initial treatment there were 19 long-term disease-free survivors, 14 of whom had not developed subsequent relapses after 48(+)-125 + months. From this study we conclude that treatment in children with first bone marrow relapse has to be intensified.

Experimental evidence for amide hydrolysis of indomethacin in rabbit skin

Amide hydrolysis of indomethacin was investigated in rabbit skin using the isolated perfused rabbit ear model. Indomethacin was applied topically on the surface area of 4 rabbit ears using a 1% alcoholic solution (Elmetacin). Indomethacin and its hydrolytic product N-deschloro-benzoyl-indomethacin (DBI) were determined in the venous efflux. The concentrations of indomethacin and DBI increased during the first 160 min and remained constant thereafter, the concentrations amounting from 0.041 +/- 0.001 to 0.497 +/- 0.018 nmol/min/cm2 (indomethacin) and from 0.84 +/- 0.03 to 3.24 +/- 0.31 pmol/min/cm2 (DBI). Thus steady state was reached with both substances, indicating a formation of DBI in the range of 0.65-2.01%. Considering the low hydrolytic turnover rate, the limited efficacy of topically applied indomethacin in the treatment of skin diseases does not seem to be due to extensive metabolic inactivation via amide hydrolysis in this target organ.

[A clinical trial of desired and unwanted effects of topically applied glucocorticosteroids in the human]

Several methods are available for testing the clinical efficacy of topical glucocorticosteroids, some of which only check single parameters relevant to the inhibition of inflammation. These methods include the vasoconstriction assay, the erythema inhibition assays, the psoriasis-plaque assay and the contact sensitization inhibition assay. The methods of testing side-effects include the Duhring chamber assay, the ammonium hydroxide blister assay and the corticoid stratum corneum assay. Provided the most appropriate of these methods are carefully selected, reliable data on the efficacy of topical glucocorticosteroids can be obtained.

[Osteomyelitis in newborn infants]

This article describes 12 patients (aged 1-28 days) suffering from neonatal osteomyelitis diagnosed between 1975 and 1987. Complications had occurred during 5 pregnancies, 9 patients had problems in the perinatal period (5 infections). In 9 cases (75%) only local symptoms existed, of which localized swelling, erythema, and loss of function were the most common. Deep soft-tissue swelling was the most common initial radiographic finding. Staphylococcus aureus (penicillin-resistant in all cases) was the most important aetiological organism (66%). Haemolytic streptococci occurred in 3 patients (group B twice, group A once). Six of 12 patients showed multifocal lesions, in 7 out of 12 patients concomitant septic arthritis existed. All patients received antibiotics (at least 2 weeks parenterally, total duration 6 weeks), while surgical intervention (exploration and drainage) took place in 8 patients. On follow-up (8 months-13 years) 4 patients showed deformity of the affected limb, leading to impaired function in 2 cases. Patients suffering from neonatal osteomyelitis require fast and properly directed therapy in order to prevent serious sequelae. Early surgical intervention is necessary if joint involvement exists.

The significance of an isolated central nervous system relapse, occurring as first relapse in children with acute lymphoblastic leukemia

In a retrospective study, which comprised the whole Dutch childhood population of approximately 3 million children, the authors assessed the influence of an isolated meningeal relapse, occurring as first relapse, together with some patient and treatment characteristics on prognosis in 142 children with acute lymphoblastic leukemia (ALL). Until their first relapse, patients were initially treated according to standard protocols, whereas the treatment for relapse was heterogeneous. Concerning the probability of achieving a second complete remission (CR) it appears that the duration of the first CR is the single most important prognostic factor. The duration of the first CR is also the most important factor with regard to the duration of the second CR, upon which also age and sex have a significant influence. Concerning the survival from the time of central nervous system (CNS) relapse, again the duration of the first CR appears to be the most important prognostic factor, followed by age and the institution of systemic reinduction treatment. Other factors, such as initial leukocyte count, attainment of first CR within 48 days, type of reinduction treatment, and the cerebral spinal fluid (CSF) blast count at the time of relapse, have a less important, but nevertheless significant influence on survival. The median survival from the time of CNS relapse is 25 months, the 5-year survival is 25%, whereas the ultimate survival will be less than 20%. From 90 patients who developed second or subsequent relapses, 75% experienced a bone marrow relapse during the follow-up period. From this study the authors conclude that CNS relapse in children with ALL carries a grave prognosis, which requires the institution of intensive retreatment programs.

[Prevention of oral side effects in children receiving chemotherapy]

Especially in children the frequency of oral complications associated with cancer chemotherapy is high. The dentist plays an important role in preventing or reducing these sometimes life-threatening problems. Oral symptoms of the underlying disease, oral sequelae from chemotherapy, patient-related factors and a preventive oral care program will be discussed.

Absorption and ester cleavage of methyl salicylate by skin of single-pass perfused rabbit ears

1. Rabbit ears were single-pass perfused with a cell-free medium. Arterial pressure, oxygen consumption, and lactate production increased with flow rate. 2. Methyl salicylate was hydrolysed with an apparent Vmax of 1.5 nmol/min per cm2 surface area, a rate about 25 times greater than after arterial administration. 3. Estimation of the Km was not possible, due to oedema developing at arterial concentrations greater than 100 microM methyl salicylate. 4. The model appears suitable to compare absorption, as well as metabolic rates, of xenobiotics in rabbit skin.

Skin blister fluid levels of ketoconazole during repetitive administration in healthy man

Ketoconazole administered orally is used in the treatment of superficial and deep mycoses. To evaluate its active concentrations in skin tissue, serum, suction blister fluid (SBF), and cantharides blister fluid (CBF) levels of total and non-protein bound ketoconazole were determined. In general, only the free drug is considered to be the active one. Six healthy subjects received 200 mg once daily for 5 days. Total ketoconazole concentrations were determined by HPLC. The unbound fractions of ketoconazole in SBF (2.3%) and CBF (1.2%) were calculated from plasma protein binding (99.0%). Before the ultimate dose, levels of unbound ketoconazole in SBF and CBF were 0.64 +/- 0.16 and 0.70 +/- 0.25 ng/ml and were thus in accordance with free ketoconazole serum levels (0.52 +/- 0.24 ng/ml; p greater than 0.05). Furthermore, following the ultimate dose, the areas under the blister fluid level-time curves of unbound ketoconazole did not differ from the respective areas under the serum level time curves, thus distribution equilibrium between serum and skin blister fluid was obtained. Peak concentrations of free ketoconazole were (SBF) 8.6 +/- 2.9 ng/ml and (CBF) 8.9 +/- 2.3 ng/ml. Free concentrations in SBF and CBF were far below the MIC values for dermatophytes and Candida ssp. reported in the literature, leaving the concentration-effect relationship of ketoconazole still open for discussion.

[Metabolism of drugs in the skin]

The principle metabolic pathways in the skin and their practical implications are still largely unknown. Some insight has already been gained from a few in vivo methods (application of radiolabelled substances in animal and man) and several in vitro methods (skin slice models, use of skin homogenates, skin perfusion models). Most of the drugs investigated with these methods have been glucocorticosteroids: cortisol (oxidation to cortisone, reduction at C-20 and delta 4), diflucortolonvalerate, fluocortinbutylester (ester cleavage). Estradiol (oxidation to estrone) and vidarabine-5-valerate (ester cleavage) are drugs of a different type that have been examined.

Inhalation hazards from airborne particulates evaluated by in vitro cyto- and genotoxicity testing: a long-term study over a period of 14 years (1975-1988) from a highly industrialized area

26 samples of airborne particulates collected between 1975 and 1988 in the highly industrialized Rhine-Ruhr region were analyzed for cytotoxic and genotoxic activity. Samples were extracted by organic solvents and quantitatively transferred to dimethyl sulfoxide for tissue culture experiments. Cytotoxicity testing of samples revealed a dose related loss of cell viability of mouse and human macrophages as well as an impairment of phagocytosis. We observed a reduction of "plating efficiency" of rodent and human lung cell lines induced by extracts. In the presence of extracts we found an inhibition of DNA synthesis, alterations of cell cycle progression and diminished cell growth of rodent, primate and human tissue culture cells. Genotoxic potency of extracts caused dose dependently an induction of "sister chromatid exchanges" in human lymphocyte cultures, Chinese hamster cell line V 79 and human type II pneumocytes of line A 549. Furthermore, we observed by extracts "chromosomal aberrations" in human lymphocyte cultures and a strong "enhancement" of malignant cell transformation of SV40-infected Syrian hamster kidney cells.

[Significance of recurrence in children with acute lymphatic leukemia]

Relapse is the main obstacle on the way to cure in children with acute lymphoblastic leukemia. In a retrospective study the influence of some prognostic factors and the prognosis have been evaluated in children with an isolated bone marrow relapse and an isolated CNS relapse. The median survival in 152 children with an isolated bone marrow relapse was 13.3 months. Favourable prognostic factors were: duration of first complete remission (CR) longer than 24 months, age at diagnosis between 2 and 6 years, initial leucocyte count below 50 X 10(9)/l, re-induction treatment with four drugs and the institution of a second central nervous system (CNS) prophylaxis. The most important prognostic factor was the duration of the first CR. The median survival in 140 children with a CNS relapse was 25 months. Favourable prognostic factors were: duration of first CR more than 24 months, age at diagnosis between 2 and 10 years, initial leucocyte count below 10 X 10(9)/l and a low blast count at the time of diagnosis of CNS relapse. The estimated survival in children with bone marrow relapse as well as in children with CNS relapse is less than 20%.

IN CONCLUSION

with current treatment regimens both bone marrow and CNS relapse have a very poor prognosis in children with acute lymphoblastic leukemia.

[Drainage of cerebrospinal fluid into the renal pelvis system as a rare variant in therapy of occlusive hydrocephalus]

On the basis of two case reports it is shown that circumstances a transitory or permanent ventriculopyeloureteral CSF shunt may be indicated in the treatment of hydrocephalus. The technique is explained. The examination methods for controlling the function during the postoperative period are explained.

[Ventriculo-renal shunt in the therapy of hydrocephalus]

Ventriculo-atrial shunt has proved to be an effective therapy for hydrocephalus. We report about two patients, in whom due to different causes this therapy was not possible. Both of them were treated with ventriculo-pyeloureterostomy for liquor drainage. The shunt functioned well and without renal damage for four weeks in one patient and for 1 1/2 year in the other patient. The reported method is an alternative procedure when the usual type of liquor drainage is impossible.

Treatment of Hodgkin's disease in children with or without radiotherapy

From 1975 until 1984 37 children with newly diagnosed Hodgkin's disease were treated with six mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) courses with or without involved field radiotherapy (25 Gy) independent of the stage of their disease. Patients with small lymph node tumors (less than 4 cm) received only six MOPP-courses. Patients with large lymph node tumors (greater than 4 cm) received involved field radiotherapy, 25 Gy to the large tumor masses, between the third and fourth MOPP-course. For the 21 patients with "small" tumors, the disease-free survival (DFS) rate is 90%. In this group two patients with clinical stage (CS) III disease have relapsed but both are alive after successful salvage treatment. The median follow-up time is 69.7+ months. For the 16 patients with larger tumor masses (greater than 4 cm) the DFS rate is 87.5%. In this group one patient with CS II relapsed and died of Hodgkin's disease, and one with CS III relapsed after 37 months, but is now without evidence of disease, 61 months from diagnosis. The median follow-up time is 62+ months. Most of the children with Hodgkin's disease diagnosed before or during puberty can be cured with chemotherapy alone, and thus will not suffer from the damaging late effects of radiotherapy.

Prognostic implication of hyperdiploidy as based on DNA flow cytometric measurement in childhood acute lymphocytic leukemia--a multicenter study

The pretreatment distribution of DNA content was determined in the leukemic blasts of 114 children with standard risk acute lymphocytic leukemia. The patients were admitted to four different centers for pediatric oncology, participating in a national study ALL-V. In 39 of 107 evaluable patients (36.4%), a single aneuploid leukemic line was detected with a median DNA Index of 1.22 (range 1.10-1.40). These hyperdiploid patients did not differ from those with diploid disease for the presenting features of age, sex, FAB classification, immunophenotype, or white blood cell count. However, patients with hyperdiploid acute lymphocytic leukemia had a significantly longer (p = 0.021) disease-free survival after a median observation period of 52 months. These observations indicate that routinely applied flow cytometry of DNA content can identify a fairly large subgroup of children with standard risk acute lymphocytic leukemia who have a low probability of relapse. It may be considered to exempt these patients from more intensive treatment regimens.

Characterization of the blast cells in acute leukemia with translocation (4;11): report of eight additional cases and of one case with a variant translocation

Eight new cases (five adults and three children) of acute leukemia characterized by the presence in bone marrow cells of a t(4;11)(q21;q23)and one similar case, a child, with a t(1;11)(p32;q23) are reported. All patients were diagnosed as having acute lymphoblastic leukemia (ALL) with high-risk features. Immunologically the blast cells of the nine cases showed a strikingly consistent immature lymphoid phenotype, i.e., TdT+, HLA-DR+, B4(CD19)+, CALLA(CD10)-, Smlg-, cmu-, BA-2(CD9)+ corresponding to a "null ALL." In addition, six of nine cases expressed the myeloid marker VIM-D5(CD15). By double immunofluorescence staining it was determined that the VIM-D5(CD15) antigen was expressed by terminal deoxynucleotidyl transferase-positive blast cells, excluding the possibility of double leukemia. In five cases investigation of the Ig heavy chain genes by Southern blot analysis showed clonal rearrangement of both Ig heavy chain gene alleles. These data suggest that the blast cells involved in t(4;11) leukemia represent early B-cell progenitors with "aberrant" expression of myelomonocytic features, possibly related to the 11q23 breakpoint.

Eosinophilic meningitis preceding meningeal relapse in a child with acute lymphoblastic leukemia: abnormal nucleotide content of eosinophils

A case of eosinophilic meningitis 2 months before the appearance of lymphoblasts in the cerebrospinal fluid is described in a child with acute lymphoblastic leukemia (ALL). The peripheral blood showed no simultaneous eosinophilia. The child was successfully treated for her CNS relapse, and complete remission was easily obtained. The eosinophils and lymphoblasts disappeared quickly after the administration of intrathecal methotrexate. However, 3 1/2 years later hypereosinophilia developed in the blood and bone marrow, heralding bone marrow relapse. Simultaneously, meningeal relapse was diagnosed and this time the cerebrospinal fluid showed a mixture of lymphoblasts and eosinophils. Treatment was reinstituted and complete remission was again obtained. Analysis of the blood eosinophils showed abnormal nucleotide patterns. Similar patterns were previously found in the lymphoblasts from other ALL patients.

Time-course of IgE binding to rat peritoneal cells after sensitization with alum-adsorbed ovalbumin and Bordetella pertussis

High IgE responder rats were sensitized intraperitoneally with alum-adsorbed ovalbumin and Bordetella pertussis organisms. At day 0, 7, 14, 21 and 28 following sensitization the peritoneal cells were harvested and further processed for light and immunoelectron microscopical investigations using a specific anti-rat IgE immunogold sandwich method. The results obtained show that the number of peritoneal mast cells increase significantly during the course of sensitization. There is a time-dependent increase in the amount of immunogold particles on mast cell surfaces together with a shift of particle distribution towards the surface folds. Sensitized mast cells exhibit altered releasability as is indicated by slightly degranulated cells at day 21 and day 28 postsensitization. Additionally, about 25% of small lymphocytes which had entered the peritoneal cavity between day 7 and day 14 are heavily stained with the immunogold complex between day 14 and day 28 postsensitization. This is not so for macrophages (less than or equal to 0.2% positive cells) nor for eosinophils which do not show any staining activity at all despite they are present in high numbers.