Virtual Reality for the Management of Pain and Anxiety for IR Procedures: A Prospective, Randomized, Pilot Study on Digital Sedation

PURPOSE

To assess the analgesic and anxiolytic effects of virtual reality (VR) augmentation in patients undergoing peripherally inserted central catheter (PICC) placement or fine-needle aspiration thyroid biopsy.

MATERIALS AND METHODS

This is a prospective, single-center randomized controlled trial with 107 patients enrolled. Patients were randomly assigned to receive standard of care (SOC) or SOC+VR during PICC or thyroid biopsy procedures. Pain and anxiety were individually measured using the visual analog scale (VAS) before and after the procedure. Vital signs including heart rate and systolic and diastolic blood pressure were recorded. One-way analysis of variance test and Games-Howell post hoc analysis were used to assess effect size and statistical significance between SOC and SOC+VR measures.

RESULTS

The PICC cohort consisted of 59 patients (33 in SOC+VR and 26 in SOC), with a median age of 53.1 years (interquartile range [IQR], 38.3-62.7 years). The thyroid biopsy cohort consisted of 48 patients (26 in SOC+VR and 22 in SOC), with a median age of 60.1 years (IQR, 49.0-67.2 years). One-way analysis of individuals undergoing thyroid biopsies with adjunctive VR revealed an effect size of -1.74 points (SE ± 0.71; P = .018) on VAS pain scale when compared with SOC. Analysis of individuals undergoing PICC placements revealed an effect size of -1.60 points (SE ± 0.81; P = .053) on VAS anxiety when compared with SOC.

CONCLUSIONS

VR as a nonpharmacologic adjunct reduced some procedure-related pain and anxiety without increasing the procedural duration.

Motor unit properties do not correlate between MUNIX and needle EMG in remote polio in the biceps brachii muscle

Objective

To compare the utility of MUNIX (motor unit number index) with needle EMG in characterizing motor unit (MU) properties in the biceps brachii (BB) muscle in subjects with remote polio.

Methods

Thirty subjects suffering from remote polio were investigated with MUNIX and needle EMG, all with Macro EMG and 16 of these subjects with concentric needle EMG.

Results

Both MUNIX and the needle EMG methods showed abnormal results. Fiber density (FD) was the most sensitive parameter for showing signs of reinnervation. At a group level, the methods showed neurogenic findings, but there was no correlation between the results of the MUNIX and needle EMG investigations.

Conclusions

Both MUNIX and needle EMG are valuable methods for measuring neurogenic involvement in the BB muscle. However, there was a lack of correlation between the MUNIX and needle EMG findings. The cause for this missing correlation may be multifactorial as there are several differences between the methods.

Significance

The reason for the lack of correlation between the MUNIX and needle EMG results is discussed. By combining the needle and surface recorded methods one can obtain more information on the denervation and reinnervation process compared to using just one of the methods alone.

The impact of walk advice and exercise strategies on daily physical activity in patients with intermittent claudication - a randomized controlled trial

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Research and Development Council for Southern Gothenburg and Bohuslän and the Healthcare Board, Region Västra Götaland, Sweden.

The Swedish state under the agreement between the Swedish government and the county councils, the ALF agreement.

Introduction

Exercise is a first-line treatment in intermittent claudication (IC). However, as the real impact of exercise interventions on daily physical activity (PA) behaviour remains largely undetermined, it is important to include objectively measured PA as an additional endpoint in clinical trials.

Purpose

The aim of this study was to investigate the impact of unsupervised Nordic pole walk advice (WA) alone or in combination with hospital-based supervised exercise (SEP) or home-based structured exercise (HSEP) with 1year follow up, on daily PA in patients with IC.

Methods

In this pre-specified analysis from an RCT, a total of 166 patients with IC (mean age 72 (7.4), 41% women) were randomized to three IC-treatment strategies: WA, WA+SEP or WA+HSEP. All patients received Nordic poles and the advice to walk for 30 min, 3 times weekly (WA strategy). Patients allocated to HSEP, and SEP were offered to participate in an additional 6 month exercise program with muscle resistance and aerobic walking exercises. During the following 7-12 months, patients continued with the exercise program at home, with no further feedback.

PA was measured through wearable accelerometer recordings for 7-days consecutive periods at baseline, 3, 6, and 12 months. Studied PA outcomes were steps/day, time spent within a stepping cadence ≥100 steps/min, time spent in upright position (standing still and stepping), number of sit to stand transitions, number of sitting bouts of >30 min and >60 min. Intergroup comparisons were performed with one-way analysis of variances ANOVA and intragroup comparisons by paired sample t-test.

Results

No statistically significant intergroup differences were observed in steps/day over time. HSEP and SEP numerically improved in steps/day at 3 months (HSEP: +472 steps, 95% CI: -146 to 1090; SEP: +241 steps, 95% CI: -282 to 764) but again declined at 6 and 12 months, while WA improved in steps/day at 1year (+89 steps, 95% CI: -568 to 747). At 3 months, a significant improvement were observed in favour of HSEP vs. WA in time spent within a stepping cadence ≥100 steps/min (P=.01) and at 6 months, a significant decrease in favour of SEP vs. WA in number of sitting bouts (>60 min; P=.01).

Conclusion

Compared to WA alone, receiving additional exercise strategies resulted in a trend toward increased steps/day and time spent within a stepping cadence ≥100 steps/min at 3 months. The opposite pattern occurred at 1year follow-up with a trend for WA to increase in steps/day, while the exercise strategies declined. No firm conclusions can be drawn on the impact of HSEP, SEP and WA strategies on daily PA, and future studies should focus on elaborating on factors that increase daily PA levels in patients with IC. Such studies also need to attach a high priority to develop exercise interventions that translate to more sustainable improvements in daily PA levels in this target population.

Radiosynthesis, In Vitro and In Vivo Evaluation of [18F]CBD-2115 as a First-in-Class Radiotracer for Imaging 4R-Tauopathies

CBD-2115 was selected from a library of 148 compounds based on a pyridinyl-indole scaffold as a first-in-class 4R-tau radiotracer. In vitro binding assays showed [³H]CBD-2115 had a K_D value of 6.9 nM and a nominal B_max of 500 nM in 4R-tau expressing P301L transgenic mouse tissue. In binding assays with human brain tissue homogenates, [³H]CBD-2115 has a higher affinity (4.9 nM) for progressive supranuclear palsy specific 4R-tau deposits than [³H]flortaucipir (45 nM) or [³H]MK-6240 (>50 nM). [¹⁸F]CBD-2115 was reliably synthesized (3-11% radiochemical yield with molar activity of 27-111 GBq/μmol and >97% radiochemical purity). Dynamic PET imaging was conducted in mice, rats, and nonhuman primates, and all species showed initial brain uptake of 0.5-0.65 standardized uptake value with fast clearance from normal tissues. [³H]CBD-2115 could be a useful lead radioligand for further research in 4R-tauopathies, and PET radiotracer development will focus on improving brain uptake and binding affinity.

Fibrillation and molecular characteristics are coherent with clinical and pathological features of 4-repeat tauopathy caused by MAPT variant G273R

Microtubule Associated Protein Tau (MAPT) forms proteopathic aggregates in several diseases. The G273R tau mutation, located in the first repeat region, was found by exome sequencing in a patient who presented with dementia and parkinsonism. We herein return to pathological examination which demonstrated tau immunoreactivity in neurons and glia consistent of mixed progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD) features. To rationalize the pathological findings, we used molecular biophysics to characterize the mutation in more detail in vitro and in Drosophila. The G273R mutation increases the aggregation propensity of 4-repeat (4R) tau and alters the tau binding affinity towards microtubules (MTs) and F-actin. Tau aggregates in PSP and CBD are predominantly 4R tau. Our data suggest that the G273R mutation induces a shift in pool of 4R tau by lower F-actin affinity, alters the conformation of MT bound 4R tau, while increasing chaperoning of 3R tau by binding stronger to F-actin. The mutation augmented fibrillation of 4R tau initiation in vitro and in glial cells in Drosophila and showed preferential seeding of 4R tau in vitro suggestively causing a late onset 4R tauopathy reminiscent of PSP and CBD.

Intramolecular Proton and Charge Transfer of Pyrene-based trans-Stilbene Salicylic Acids Applied to Detection of Aggregated Proteins

Two analogues to the fluorescent amyloid probe 2,5-bis(4'-hydroxy-3'-carboxy-styryl)benzene (X-34) were synthesized based on the trans-stilbene pyrene scaffold (Py1SA and Py2SA). The compounds show strikingly different emission spectra when bound to preformed Aβ1-42 fibrils. This remarkable emission difference is retained when bound to amyloid fibrils of four distinct proteins, suggesting a common binding configuration for each molecule. Density functional theory calculations show that Py1SA is twisted, while Py2SA is more planar. Still, an analysis of the highest occupied molecular orbitals (HOMOs) and lowest unoccupied molecular orbitals (LUMOs) of the two compounds indicates that the degree of electronic coupling between the pyrene and salicylic acid (SA) moieties is larger in Py1SA than in Py2SA. Excited state intramolecular proton transfer (ESIPT) coupled-charge transfer (ICT) was observed for the anionic form in polar solvents. We conclude that ICT properties of trans-stilbene derivatives can be utilized for amyloid probe design with large changes in emission spectra and decay times from analogous chemical structures depending on the detailed physical nature of the binding site.

Many Analysts, One Data Set: Making Transparent How Variations in Analytic Choices Affect Results

Twenty-nine teams involving 61 analysts used the same data set to address the same research question: whether soccer referees are more likely to give red cards to dark-skin-toned players than to light-skin-toned players. Analytic approaches varied widely across the teams, and the estimated effect sizes ranged from 0.89 to 2.93 ( Mdn = 1.31) in odds-ratio units. Twenty teams (69%) found a statistically significant positive effect, and 9 teams (31%) did not observe a significant relationship. Overall, the 29 different analyses used 21 unique combinations of covariates. Neither analysts’ prior beliefs about the effect of interest nor their level of expertise readily explained the variation in the outcomes of the analyses. Peer ratings of the quality of the analyses also did not account for the variability. These findings suggest that significant variation in the results of analyses of complex data may be difficult to avoid, even by experts with honest intentions. Crowdsourcing data analysis, a strategy in which numerous research teams are recruited to simultaneously investigate the same research question, makes transparent how defensible, yet subjective, analytic choices influence research results.

A utility valuation study assessing the impact of postprandial glucose control on quality of life of individuals with type 1 or type 2 diabetes

Background

Consideration of health-related quality of life (HRQOL) in diabetes has been associated with long-term and short-term complications such as hypoglycaemia, but not with short-term glucose control. This study aimed to collect health utilities related to different degrees of poorly controlled postprandial glucose (PPG) and its impact on HRQOL in the UK and in Sweden.

Methods

Three health state descriptions were developed based on literature reviews and interviews with people with diabetes and healthcare professionals, characterising mild, moderate and severe impact of postprandial hyperglycaemic symptoms on HRQOL. Time Trade-Off (TTO) interviews with a 10-year trade-off period were conducted with samples of the UK general public and of Swedish people with diabetes. Mean TTO-derived health state values were expressed on a scale from 0 (death) to 1 (full health).

Results

One hundred fifty participants from the general population were interviewed in the UK (57% female, mean age 35 years) and 150 participants with diabetes in Sweden (64% female, mean age 51 years, 42% type 1 and 58% type 2 diabetes). The mean TTO-derived health state values were for the UK and Swedish participants: mild impact of poorly PPG control (0.89/0.76); moderate (0.75/0.71); severe (0.56/0.58).

Conclusions

Glucose lowering treatments associated with improved control over PPG levels could have important benefits to people with type 1 and type 2 diabetes since findings suggest that increasing severity in postprandial hyperglycaemic symptoms is perceived as having significant negative impact on HRQOL of individuals with type 1 or type 2 diabetes.

Aggregated Aβ1-42 Is Selectively Toxic for Neurons, Whereas Glial Cells Produce Mature Fibrils with Low Toxicity in Drosophila

The basis for selective vulnerability of certain cell types for misfolded proteins (MPs) in neurodegenerative diseases is largely unknown. This knowledge is crucial for understanding disease progression in relation to MPs spreading in the CNS. We assessed this issue in Drosophila by cell-specific expression of human Aβ1-42 associated with Alzheimer's disease. Expression of Aβ1-42 in various neurons resulted in concentration-dependent severe neurodegenerative phenotypes, and intraneuronal ring-tangle-like aggregates with immature fibril properties when analyzed by aggregate-specific ligands. Unexpectedly, expression of Aβ1-42 from a pan-glial driver produced a mild phenotype despite massive brain load of Aβ1-42 aggregates, even higher than in the strongest neuronal driver. Glial cells formed more mature fibrous aggregates, morphologically distinct from aggregates found in neurons, and was mainly extracellular. Our findings implicate that Aβ1-42 cytotoxicity is both cell and aggregate morphotype dependent.

Purification and Fibrillation of Recombinant Human Amyloid-β, Prion Protein, and Tau Under Native Conditions

Protein misfolding, aggregation, and amyloid formation is involved in a large number of diseases. Recombinantly expressed proteins to study the amyloid fibril formation process are important for mechanistic studies. We here report protocols for production, purification, and fibrillation of three different proteins commonly found in cerebral amyloid; Aβ and Tau found in Alzheimer's disease, Chronic traumatic brain injury, Corticobasal degeneration, and Progressive Supranuclear Palsy and human prion protein found in Creutzfeldt-Jakob's disease. The three protocols have in common that the protein is in a pH-neutral phosphate saline buffer during fibrillation to mimic their endogenous near physiological environment.

trans-Stilbenoids with Extended Fluorescence Lifetimes for the Characterization of Amyloid Fibrils

It was previously reported that two naphthyl-based trans-stilbene probes, (E)-4-(2-(naphthalen-1-yl)vinyl)benzene-1,2-diol (1) and (E)-4-(2-(naphthalen-2-yl)vinyl)benzene-1,2-diol (3), can bind to both native transthyretin (TTR) and misfolded protofibrillar TTR at physiological concentrations, displaying distinct emission maxima bound to the different conformational states (>100 nm difference). To further explore this amyloid probe scaffold to obtain extended fluorescence lifetimes, two new analogues with expanded aromatic ring systems (anthracene and pyrene), (E)-4-(2-(anthracen-2-yl)vinyl)benzene-1,2-diol (4) and (E)-4-(2-(pyren-2-yl)vinyl)benzene-1,2-diol (5), were synthesized employing the palladium-catalyzed Mizoroki-Heck reaction. (E)-4-Styrylbenzene-1,2-diol (2), 3, 4, and 5 were investigated with respect to their photophysical properties in methanol and when bound to insulin, lysozyme, and Aβ1-42 fibrils, including time-resolved fluorescence measurements. In conclusion, 4 and 5 can bind to both native and fibrillar TTR, becoming highly fluorescent. Compounds 2-5 bind specifically to insulin, lysozyme, and Aβ1-42 fibrils with an apparent fluorescence intensity increase and moderate binding affinities. The average fluorescence lifetimes of the probes bound to Aβ1-42 fibrils are 1.3 ns (2), 1.5 ns (3), 5.7 ns (4), and 29.8 ns (5). In summary, the variable aromatic moieties of the para-positioned trans-stilbenoid vinyl-benzene-1,2-diol with benzene, naphthalene, anthracene, and pyrene showed that the extended conjugated systems retained the amyloid targeting properties of the probes. Furthermore, both the anthracene and pyrene moieties extensively enhanced the fluorescence intensity and prolonged lifetimes. These attractive probe properties should improve amyloid detection and characterization by fluorescence-based techniques.

Real-life treatment patterns, compliance, persistence, and medication costs in patients with hypertension in Germany

OBJECTIVE

This retrospective patient data analysis was initiated to describe current treatment patterns of patients in Germany with arterial hypertension, with a special focus on compliance, persistence, and medication costs of fixed-dose and unfixed combinations of angiotensin receptor blockers (ARBs), amlodipine (AML) and hydrochlorothiazide (HCT) in Germany.

METHODS

The study analyzed prescription data collected by general practitioners, using the IMS Disease Analyzer database. The database was searched for patients with the diagnosis hypertension (ICD-10 code I10) and treatment data in the period 09/2009 to 08/2010. Compliance was measured indirectly based on the medication possession ratio (MPR), and persistence was defined as the duration of time from initiation to discontinuation of therapy. Medication costs were assessed from the statutory health insurance perspective in Germany.

RESULTS

In the IMS DA 406,888 observable patients in Germany were encoded with the diagnosis I10 essential hypertension. In total, 88,716 patients received prescriptions including ARBs, monotherapy (18.6%) or unfixed combinations with other anti-hypertensives (19.3%). The compliance with fixed-dose combinations of ARB with HCT, either dual or with one other anti-hypertensive drug, was significantly better, compared to unfixed combinations (mean compliance 78.1% for fixed-dose vs 71.5% for unfixed combinations of ARB with HCT, p < 0.0001; mean compliance 79.4% vs 72.0%, p < 0.0001 if an additional anti-hypertensive medication was added). Fixed-dose combinations of ARB with HCT, ARB with AML, dual only or prescribed with another anti-hypertensive medication resulted in a substantial increase of persistence, especially for patients on fixed-dose dual combinations (225.7 vs 163.6 days for ARB with HCT; 232.9 vs 178.4 days for ARB with AML, respectively). Fixed-dose combinations (varying from €1.38 to €2.20 per patient and day) were on average cheaper than unfixed combinations.

LIMITATIONS

Persistence and compliance could be under- or over-estimated because their assessment was based on prescription information. For two thirds of 69,060 patients, data on compliance and persistence was missing.

CONCLUSION

The study shows considerable variations in ARB treatment patterns among patients, with the majority of patients treated with fixed-dose or semi-fixed combination therapy. Fixed-dose combinations of ARBs with HCT and/or AML seem to result in better compliance and persistence compared to unfixed regimes of these drug classes, leading to reduction in all-cause hospitalizations, emphasizing the benefit and potential cost-savings of using fixed-dose regimes in a real-life general practice setting in Germany.

Sleep better than medicine? Ethical issues related to "wake enhancement"

This paper deals with new pharmacological and technological developments in the manipulation and curtailment of our sleep needs. While humans have used various methods throughout history to lengthen diurnal wakefulness, recent advances have been achieved in manipulating the architecture of the brain states involved in sleep. The progress suggests that we will gradually become able to drastically manipulate our natural sleep-wake cycle. Our goal here is to promote discussion on the desirability and acceptability of enhancing our control over biological sleep, by illustrating various potential attendant ethical problems. We draw attention to the risks involved, possible conflicts of interests underlying the development of wake enhancement, and the potential impact on accountability for fatigue related errors.

A working memory model based on fast Hebbian learning

Recent models of the oculomotor delayed response task have been based on the assumption that working memory is stored as a persistent activity state (a 'bump' state). The delay activity is maintained by a finely tuned synaptic weight matrix producing a line attractor. Here we present an alternative hypothesis, that fast Hebbian synaptic plasticity is the mechanism underlying working memory. A computational model demonstrates a working memory function that is more resistant to distractors and network inhomogeneity compared to previous models, and that is also capable of storing multiple memories.

A Bayesian attractor network with incremental learning

A realtime online learning system with capacity limits needs to gradually forget old information in order to avoid catastrophic forgetting. This can be achieved by allowing new information to overwrite old, as in a so-called palimpsest memory. This paper describes an incremental learning rule based on the Bayesian confidence propagation neural network that has palimpsest properties when employed in an attractor neural network. The network does not suffer from catastrophic forgetting, has a capacity dependent on the learning time constant and exhibits faster convergence for newer patterns.

NIH symposium summary: organ preservation therapies for squamous cancers of the head and neck

This symposium, sponsored by the NIH Office of Rare Diseases, the National Cancer Institute, the National Institute of Deafness and Other Communication Disorders, and the National Institute of Dental and Craniofacial Diseases, reviewed the current status of organ preservation therapies for head and neck cancers, as well as promising newer approaches for therapy and for toxicity amelioration.

Electrophysiologic evaluation of muscle fatigue development and recovery in late polio

OBJECTIVES

To study aspects of fatigue in late-polio patients and healthy controls. We hypothesized that late-polio subjects would develop more peripheral fatigue, assessed with surface electromyography (EMG), and that no major differences would exist between the two groups in neuromuscular junction transmission.

DESIGN

Case-control study.

SETTING

University hospital laboratory.

SUBJECTS

Ten patients with a history of polio (mean age, 54 yrs, SD = 5; mean time since polio onset, 49 yrs, SD = 7) and a matched control group (mean age, 52 yrs, SD = 8).

METHODS

A protocol with a stepwise force increase up to 80% of maximal voluntary contraction ending with an 8-minute recovery period was performed twice, first with surface EMG and then with electrical stimulation and surface-recorded evoked M-response.

MAIN OUTCOME MEASURES

Surface EMG analysis of voluntary activity and evoked M-response.

RESULTS

No significant differences existed between groups in the relative decrease during the fatigue protocol. The recovery of force was slower in the late-polio subjects. A reduction in the root mean square (RMS) value during recovery was seen in the polio group, although a normalization of the mean power frequency (MPF) was seen in both groups.

CONCLUSION

The weakness during the fatigue procedure was not caused by neuromuscular blockade, because electrical nerve stimulation evoked a normal response. The weakness after exercise was the result of a slow recovery that may reflect both central and peripheral fatigue.

Comparison between concentric needle EMG and macro EMG in patients with a history of polio

OBJECTIVES

Acute poliomyelitis causes degeneration of anterior horn cells, followed by denervation. Reinnervation and muscle fibre hypertrophy are mechanisms that compensate this loss of neurones. Concentric needle EMG (CNEMG) and macro EMG are two methods to assess the magnitude of initial involvement and the compensatory reinnervation. The aim of this study is to explore the difference between CNEMG and macro EMG describing the status of the motor unit in patients previously affected by polio.

METHODS

Macro and concentric needle EMG investigations were performed in 261 muscles in 121 patients with a remote history of polio.

RESULTS

CNEMG was abnormal in 211 muscles, macro EMG was abnormal in 246 muscles. The macro amplitude was 3-4 times 'more abnormal' than CNEMG amplitude relative to the reference values. CNEMG duration was less abnormal and showed only weak correlation with macro amplitudes. The most likely explanation for the difference in magnitude of deviation from reference values for CNEMG and macro EMG, is a more pronounced 'phase cancellation' between single fibre action potentials in CNEMG. This is supported by simulation studies reported here.

CONCLUSIONS

In conclusion macro EMG better reflects the size of the motor unit than the CNEMG. For detection of concomitant disorders, CNEMG is the method of choice.

An 8-year longitudinal study of muscle strength, muscle fiber size, and dynamic electromyogram in individuals with late polio

Twenty-one subjects with polio 24 to 51 years prior to the first examination were studied on three occasions, each 4 years apart with measurements of muscle strength and endurance for knee extension, macro EMG, and muscle biopsy from vastus lateralis. On average the muscle strength decreased during the 8-year follow-up by 9-15%. Endurance decreased during the observation period. The muscle fiber area was markedly increased in most subjects. There was a decrease in the capillarization during the follow-up. Macro EMG was increased in all subjects (range 3-42 times control) and increased in 20 legs during the 8-year follow-up, but showed a decrease in 8 of 9 legs with an approximative breakpoint when macro MUPs were around 20 times the normal size. Thus, evidence of on-going denervation/reinnervation as well as of failing capacity to maintain large motor units was demonstrated. SFEMG showed a moderate degree of disturbed neuromuscular transmission.

Motor unit size estimation of enlarged motor units with surface electromyography

Surface EMG is hardly used to estimate motor unit (MU) characteristics, while its non-invasiveness is less stressful for patients and allows multi-electrode recordings to investigate different sites of the muscle and MU. The present study compares motor unit potentials (MUPs) obtained with surface EMG and macro EMG during voluntary contraction of the biceps brachii muscle of patients with enlarged MUs caused by prior poliomyelitis. Averaged surface MUPs were obtained by means of needle EMG (SMUP1) and surface EMG (SMUP2) triggering. The MUPs area and peak amplitudes correlated well when comparing the macro MUP and SMUP1 of the same MUs. When MU populations of different patients were compared, the SMUP1s and SMUP2s were equally sensitive to pathology as macro MUPs. In this, the late non-propagating positive wave (only present in unipolar recordings) is more robust than the triphasic propagating wave. Therefore, surface EMG can be used for detecting enlarged MUs.

Pre-clinical evaluation of probes to detect t(8;21) AML minimal residual disease by fluorescence in situ hybridization

The 8;21 translocation in acute myeloid leukemia (AML) results in a consistent fusion transcript, AML1/ETO. Long-term clinical remission occurs in some patients despite incomplete eradication of AML1/ETO as demonstrated by RT-PCR, thus limiting the usefulness of this assay. An important future goal will be to determine if there is a level of minimal residual disease (MRD) in patients below which relapse is unlikely. For the detection of MRD, we have developed reagents for fluorescence in situ hybridization (FISH) that identify both derivative 8 and 21 chromosomes with a high analytical sensitivity. In t(8;21) AML cells, two fused signals were detected in addition to the normal 8 and 21 alleles. The sensitivity and specificity of this probe mixture were analyzed in cell lines and patient bone marrows. One and two randomly juxtaposed signals were observed in 2.4 and 0.04% of normal cells, respectively. However, these were easily differentiated from t(8;21) cells by the absence of signals from the normal alleles. Using as criteria the presence of two fused signals plus the normal alleles, we observed no false positives among 5,000 normal cells. The probe correctly identified 20/20 patients with t(8;21) AML and 10/10 non-t(8;21) patients. In cell dilution experiments, the analytical sensitivity of this reagent was equal to that of the X chromosome and Y chromosome alpha-satellite probes. These optimized probes should facilitate the quantitative assessment and study of MRD in t(8;21) AML.

Cancer cytogenetics and molecular-genetics - clinical implications (review)

Cancer genetics has become a burgeoning area of both cytogenetic and molecular genetic research and practical clinical application of the findings of such research in human cancer and leukemia. This review summarizes the specific types of chromosomal and associated molecular genetic alterations in leukemia and cancer. The primary objective is to acquaint physicians of various disciplines with the application of cytogenetics and molecular genetics as diagnostic, prognostic and therapeutic indices, as approaches to the evaluation of minimal residual disease and as guides for differentiation therapy and the molecular localization of oncogenes and tumor suppressor genes related to gene therapy in leukemias and cancers.

Post-decision consolidation, as a function of the instructions to the decision maker and of the decision problem

The effects of instructions and decision problems on post-decision processes were studied by varying the instructions to subjects. Subjects made a medical policy decision based on information on four attributes in Experiments 1-2. The subjects were given different instructions: (1) no instruction at all about a second session, (2) instruction to remember his/her decision until a session a week later, and (3) instruction to justify the decision at a later occasion one week later. The results indicated post-decision consolidation in the first group, as predicted by the Differentiation and Consolidation Theory (Svenson, 1992). The effect showed up in attractiveness restructuring in support of the chosen alternative on the most important attributes. The instruction to remember the decision until a later time increased the consolidation effect. Contrary to our expectations, the instruction to later justify the decision did not produce any consolidation. This effect was replicated in the second experiment and could not be interpreted as a random result. In a third experiment the decision problem was framed as an environmental pollution problem and it was preceded by a carefully designed booklet presenting arguments for and against different materials used in manufacturing packages for coffee. Subjects were then asked to make a choice of the same coffee in two different packages. The data indicated no difference in structural consolidation as a result of the instruction to justify or not. The paper concludes with a discussion pointing out the importance of the involvement in a decision task for decision differentiation and consolidation.

Steady-state bioavailability and day-to-day variability of a multiple-unit (CR/ZOK) and a single-unit (OROS) delivery system of metoprolol after once-daily dosing

Steady-state bioavailability and day-to-day variability of plasma levels were evaluated in 18 healthy male subjects in a crossover study of multiple once-daily administration of two novel oral drug delivery systems of metoprolol and an immediate-release tablet (100 mg metoprolol tartrate). Data were collected over two consecutive 24-hr dosing intervals on treatment days 6 and 7. The two extended-release formulations investigated were metoprolol CR/ZOK (95 mg metoprolol succinate), a multiple-unit system consisting of several hundred membrane-coated delivery units, and metoprolol OROS (95 mg metoprolol fumarate), a single-unit osmotic delivery system. The extended drug release and absorption observed after administration of metoprolol CR/ZOK and metoprolol OROS resulted in similar steady-state plasma concentrations after once-daily dosing. Compared to the immediate-release tablet, they produced considerably lower plasma peaks, three- to fourfold higher trough concentrations, 8-9 hr longer mean residence times, and 20% lower relative bioavailability. Moreover, the two once-daily metoprolol products were found bioequivalent in Cmax and AUC based on 90% confidence intervals for the mean ratio CR/OROS. Repeated plasma concentration measurements on two consecutive 24-hr periods suggested that all three metoprolol treatments produced reproducible and consistent plasma concentrations from day to day at steady state. Assessment of day-to-day variability, however, resulted in significantly lower variation in AUC for the multiple-unit CR/ZOK formulation compared to the single-unit OROS tablet. These results imply that there may be formulation-related differences in the in vivo behavior of the two products despite their being bioequivalent in extent and rate of absorption.

The usefulness of cytogenetic findings in differential-diagnosis of metastases of unknown origin

Chromosomal abnormalities can be applied in the diagnosis and classification of some metastases of unknown origin. A selective search is most appropriate for treatable tumors, such as prostate, ovary, breast, small-cell lung cancer and germ cell tumors. Cytogenetic analysis may be particularly useful in these cases, since some of these tumors have been found to have specific chromosomal changes that are generally retained in the metastases. We discuss the usefulness of cytogenetic analysis in differentiating the origin of metastases and review the few cases reported in the literature.

Controlled release metoprolol. Clinical pharmacokinetic and therapeutic implications

Metoprolol is a relatively beta 1-selective beta-blocker used extensively to treat hypertension and angina and as a prophylaxis after myocardial infarction. Conventional formulations are usually administered twice daily and the drug has a tendency to lose its selectivity of action at higher plasma concentrations. Two controlled release formulations, metoprolol CR and metoprolol 'Oros', have made it possible to achieve sustained beta 1-blockade over an entire 24h period and to minimise the loss of selectivity associated with higher plasma concentrations. The CR formulation has been extensively investigated and is the major subject of this review. The 'Oros' formulation is pharmaceutically different from the CR, yet both produce similar plasma concentration profiles and comparable beta 1-blocking effects. The availability of these preparations occurs at a time when increasingly persuasive data are becoming available on the cardioprotective or coronary preventive action of metoprolol.

Pharmacokinetic and pharmacodynamic evaluation of metoprolol controlled release (CR/ZOK) 50 mg in young subjects

In this steady state, cross-over study, the bioavailability and beta 1-blocking effects of metoprolol CR/ZOK 50 mg, conventional metoprolol 50 mg tablets and placebo were evaluated in 12 healthy male subjects (mean age 25 years) after once daily treatment in 5 days. The drugs were administered in a randomized order. The beta 1-blocking effect was defined as percent reduction from baseline in exercise heart rate. The plasma concentration-time profile following metoprolol CR/ZOK 50 mg administration was more even compared to conventional metoprolol tablets, with significantly lower Cmax (mean: 71 vs 221 nmol/L) and significantly higher Cmin (mean: 39 vs 6 nmol/L) for the CR/ZOK formulation. This difference in plasma concentrations was also well reflected by a significantly lower fluctuation index for metoprolol CR/ZOK 50 mg compared with the conventional 50 mg tablet (mean: 69 vs 529%). There was, however, no difference in systemic bioavailability between the two metoprolol formulations (90% confidence limits: 86-106%). The beta 1-blockade was also more even after metoprolol CR/ZOK 50 mg compared to conventional tablets with a significantly lower Emax (mean: 14 vs 19%) and higher Emin (mean: 9 vs 0%) for CR/ZOK. The total effect over a dosage interval, defined as area under the effect curve, was significantly higher for metoprolol CR/ZOK compared to conventional tablets (90% confidence limits: 123-213%). In conclusion, once daily administration of metoprolol CR/ZOK 50 mg to young healthy subjects resulted in smooth plasma concentration and produced a significant beta 1-blocking effect for 24 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetic and biopharmaceutic aspects of once daily treatment with metoprolol CR/ZOK: a review article

In the development of a new controlled release preparation and its subsequent assessment there are a number of factors that need to be considered both related to the drug itself and to the pharmaceutical preparation. This review describes the biopharmaceutical and pharmacokinetic properties of metoprolol CR/ZOK, a recently introduced formulation of a widely used beta 1-selective adrenoceptor antagonist intended for once daily usage. The metoprolol CR/ZOK preparation provides reproducible dissolution and absorption properties resulting in stable plasma concentrations with minimum fluctuations over a 24-hour dosage interval. This has been shown in extensive studies comprising over 200 healthy volunteers. Considerations for a new drug preparation such as bioavailability and variability in relation to a standard treatment and the clinical significance of taking the drug with food and in increasing doses, are potential concerns that do not seem to be a problem for the therapeutic use of metoprolol CR/ZOK. Furthermore, the pharmacokinetic data achieved in young healthy subjects appear to be relevant for the treatment of patients, as shown by the consistent plasma concentration profiles obtained in elderly and in hypertensive patients.

The relationship between metoprolol plasma concentration and beta 1-blockade in healthy subjects: a study on conventional metoprolol and metoprolol CR/ZOK formulations

Four studies using different daily doses (100 mg, 200 mg, 300 mg and 400 mg) have examined the bioequivalence of the once daily formulation metoprolol CR/ZOK and conventional metoprolol tablets (CT). These studies showed metoprolol CR/ZOK to have a similar beta 1-blocking activity to metoprolol CT but that the bioavailability of the new formulation was lower. This paper presents the analysis of data from all four studies, looking at the relationship between plasma concentrations and beta 1-blockade measured as reduction of exercise induced tachycardia. The log linear pharmacodynamic model was used for each of the four doses to compare the two formulations. Mean slopes and intercepts in the linear regression analysis of log plasma concentration of metoprolol versus beta 1-blockade did not differ significantly between CR/ZOK and CT in any of the four studies. After having shown lack of influence of the absorption rate of the plasma concentration-effect relationship, data for CR/ZOK and CT formulations from the 200 mg study were pooled for each individual subject and fitted to an Emax model. The maximal beta 1-blocking effect (Emax) was 28% (95% confidence interval: 25-31%) and the plasma concentration for obtaining 50% of Emax (C50) was 105 nmol/L (95% confidence interval: 74-135 nmol/L). The plasma concentration-effect data from the 100 mg, 300 mg and 400 mg studies were reasonably well within the 95% prediction interval based on the 200 mg study, which showed the validity of the obtained relationship.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetic and pharmacodynamic properties of a new controlled-release formulation of metoprolol: a comparison with conventional tablets

The pharmacokinetic and pharmacodynamic properties of a new multiple-unit, controlled-release (CR) formulation of metoprolol (metoprolol succinate, 95 mg once daily), which has almost constant (zero-order) release properties over most of a 24-h dose interval, have been compared with those of conventional metoprolol tablets (metoprolol tartrate, 100 mg once daily and 50 mg twice daily), in 12 healthy male volunteers. The steady-state plasma concentrations of metoprolol after five days of treatment varied less throughout the day with the CR than with the conventional formulation. This was associated with a considerably lower peak plasma concentration and the achievement of a significantly higher plasma concentration at the end of the dose interval. Similarly, the effect on exercise-induced tachycardia was maintained at a relatively constant level throughout the day after treatment with the CR formulation. A significantly greater effect 24 h after administration was achieved with the CR formulation, when compared with once-daily dosing with metoprolol tablets, 100 mg. Twice-daily dosing with metoprolol tablets, 50 mg, produced a similar beta 1-blocking effect at the end of the dose interval to that observed with metoprolol CR. Although the steady-state plasma concentrations indicated significantly lower systemic availability for the CR formulation, compared with both regimens of metoprolol tablets, the total effect over the dose interval, expressed as the area under the efficacy curve (AUEC), was similar for the three treatments. The relationship between steady-state plasma concentrations and the pharmacodynamic efficacy at corresponding times, indicated that plasma concentrations were more effectively utilized after the administration of the CR formulation than after the conventional tablet regimens.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetics and pharmacodynamics of controlled-release metoprolol: a comparison with atenolol

Pharmacokinetic and pharmacodynamic properties of a new controlled-release (CR) formulation of metoprolol have been compared with those of atenolol. Metoprolol CR (100 mg and 200 mg), atenolol (50 mg and 100 mg) and placebo were each given once daily for four days in a double-blind, cross-over study to ten healthy men. The plasma concentration-time profiles were more even with metoprolol CR than with atenolol over the 24-h dose interval, shown by the lower fluctuation ratio and the longer time period during which the plasma concentration exceeded 50% of the maximum concentration. All four active treatment regimens reduced exercise heart rate over the 24-h period compared with placebo. However, the reduction in both exercise heart rate and systolic blood pressure (SBP) was more even with metoprolol CR than with atenolol. The remaining beta 1-blockade after 24 h, expressed as the percentage reduction in exercise heart rate in relation to placebo, was significantly greater after the administration of metoprolol CR, 200 mg, than after either dose of atenolol. At this time the beta 1-blockade with metoprolol CR, 100 mg, was similar to that with atenolol, 100 mg. At peak plasma concentrations, 4 h after the dose, the subjects experienced less fatigue during exercise with metoprolol CR than with atenolol.

Design of a new multiple-unit controlled-release formulation of metoprolol--metoprolol CR

A new controlled-release (CR) formulation of the beta 1-selective adrenoceptor antagonist metoprolol has been developed, aiming at an even 24-h pharmacological effect. In order to achieve this, using a once-daily dose, factors such as absorption characteristics, physicochemical properties, and technological aspects had to be considered. The new formulation, called metoprolol CR, is a disintegrating tablet consisting of several hundred coated pellets of metoprolol succinate, each pellet being its own CR delivery unit. In vitro testing and in vivo studies in healthy volunteers show that the new CR formulation gives continuous delivery of metoprolol throughout the day, resulting in smooth plasma concentration profiles, without peaks and troughs. The release of the drug is independent of pH and other physiological variables, such as food intake, which do not seem to alter the biopharmaceutical properties of the formulation.

Intensive remission consolidation therapy in the treatment of acute nonlymphocytic leukemia

A pilot study was conducted to determine the possible efficacy and the toxicities associated with the administration of four courses of intensive consolidation chemotherapy to patients with acute nonlymphocytic leukemia in remission. All therapy was completed within 6 months. The median duration of remission was 22 months, with 45+% of patients in remission at 3 years and few relapses to date thereafter. Sixty percent of patients experienced significant side effects after each course of therapy. The therapy appeared to be particularly efficacious for patients less than 45 years of age, since 65% are alive at 3 years and there is no projection for a median duration of remission as yet. The cytogenetic characteristics of the leukemic cells, the percentage of S phase cells, and the height of the WBC count were the most important prognostic characteristics at diagnosis.

Oesophageal ulcerations and plasma levels of different alprenolol salts: potential implications for the clinic

The ulcerogenic effect of five different salts of alprenolol were tested against placebo in a porcine oesophageal test model. The salts with high water solubility, such as the hydrochloride and the fumarate, gave rise to the highest plasma concentrations of alprenolol and evoked serious oesophageal lesions, while the salts with low solubility-the benzoate, maleate and sebacate-had no irritative effect on the oesophagus. The plasma levels of alprenolol were much higher following administration of alprenolol hydrochloride in the oesophagus than after an identical intraduodenal dose of the same salt possibly because of the avoidance of the first-pass degradation during oesophageal absorption.

Coexistence of myeloid metaplasia with myelofibrosis and hairy-cell leukemia

A 42-year-old man with severe pancytopenia and myelofibrosis underwent splenectomy seven months after onset of his symptoms; the leukocyte, platelet, and hematocrit levels became normal. Myeloid metaplasia was identified in the liver and spleen. Progressive lymphocytosis started eight months after splenectomy, and after 66 months a florid hairy-cell leukemia was diagnosed; the circulating cells were B type with micro K surface markers. Anemia and thrombocytopenia reappeared and were controlled initially with daily prednisone; chlorambucil was later added. At that time, the peripheral blood had more than 150 megaloblastoid-appearing normoblasts per 100 leukocytes. The PAS stain was positive in 95% to 100% of these cells; the B-cell surface markers were no longer identified. Further treatment failed to control the lymphoproliferative and myeloproliferative syndromes; the patient died 99 months after splenectomy. On autopsy, infiltration by hairy-cell leukemia cells and erythroid precursors was observed in the bone marrow, liver, lymph nodes, and other organs.

Prostatic cancer--II. Inhibitors of rat prostatic 4-ene-3-ketosteroid 5 alpha-reductase derived from 6-methylene-4-androsten-3-ones

The studied 6-methylene-4-androsten-3-ones proved to be significantly inferior to 6-methylene-4-pregnene-3,20-dione and its 17-acetoxy derivative described in Part 1 as inhibitors of 4-ene-3-ketosteroid 5 alpha-reductase [1] in vitro. Surprisingly, the 6-methylene derivative of testosterone was only weakly active until acetylated, when an effective inhibitor was obtained. Etherification of the hydroxyl-group, its replacement by a hydrocarbon chain, or introduction of a substituent at C17 or on the methylene group led to virtual loss of activity. 17 alpha-Chloro-6-methylene-4-androstene-3-one had ca 60-70% of the potency of progesterone, but was inactive as enzyme inhibitor in explants of rat prostate in tissue culture and in in vivo studies. 6-Methylenetestosterone acetate was weakly active as enzyme inhibitor in explants of human prostate in tissue culture and produced a histological picture closely resembling testosterone and differing from that of cyproterone acetate. In vivo in the rat it had 80% of the androgenic activity of testosterone propionate. The foregoing data have been used to define some structural characteristics necessary for enzyme inhibition and to draw some conclusions regarding the architecture of the androgen and progesterone receptors and of the enzyme active site.