A dual CysLT1/2 antagonist attenuates allergen-induced airway responses in subjects with mild allergic asthma

BACKGROUND

The cysteinyl leukotrienes (cysLTs) play a key role in the pathophysiology of asthma. In addition to functioning as potent bronchoconstrictors, cysLTs contribute to airway inflammation through eosinophil and neutrophil chemotaxis, plasma exudation, and mucus secretion. We tested the activity of the dual cysLT_1/2 antagonist, ONO-6950, against allergen-induced airway responses.

METHODS

Subjects with documented allergen-induced early (EAR) and late asthmatic response (LAR) were randomized in a three-way crossover study to receive ONO-6950 (200 mg) or montelukast (10 mg) or placebo q.d. on days 1-8 of the three treatment periods. Allergen was inhaled on day 7 two hours postdose, and forced expiratory volume in 1 s (FEV₁ ) was measured for 7 h following challenge. Sputum eosinophils and airway hyperresponsiveness were measured before and after allergen challenge. The primary outcome was the effect of ONO-6950 vs placebo on the EAR and LAR.

RESULTS

Twenty-five nonsmoking subjects with mild allergic asthma were enrolled and 20 subjects completed all three treatment periods per protocol. ONO-6950 was well tolerated. Compared to placebo, ONO-6950 significantly attenuated the maximum % fall in FEV₁ and area under the %FEV₁ /time curve during the EAR and LAR asthmatic responses (P < 0.05) and allergen-induced sputum eosinophils. There were no significant differences between ONO-6950 and montelukast.

CONCLUSIONS

Attenuation of EAR, LAR, and airway inflammation is consistent with cysLT₁ blockade. Whether dual cysLT_1/2 antagonism offers additional benefit for treatment of asthma requires further study.

Airway responsiveness to mannitol 24 h after allergen challenge in atopic asthmatics

BACKGROUND

Airway responsiveness to indirect stimuli correlates positively with airway inflammation. In atopic asthmatics, allergen inhalation is associated with an influx of inflammatory cells and increased responsiveness to the direct-acting stimuli methacholine at 3 and 24 h after exposure. We have shown mannitol responsiveness decreases 3 h after allergen inhalation. The current investigation assessed mannitol responsiveness 24 h after allergen challenge.

METHODS

Eleven mild atopic asthmatics completed allergen challenges on two separate occasions. In random order, methacholine or mannitol challenges were performed 24 h pre- and post-allergen challenge. Levels of fractional exhaled nitric oxide were also measured.

RESULTS

Allergen challenge increased airway responsiveness to methacholine 24 h postchallenge; the geometric mean (95% CI) methacholine PC20 decreased from 5.9 mg/ml (1.8-19.4) to 2.2 mg/ml (0.81-5.89); P = 0.01. This coincided with a significant increase (P = 0.02) in FeNO levels. Conversely, allergen challenge decreased airway responsiveness to mannitol; geometric mean (95% CI) dose-response ratio was significantly higher after allergen exposure (57 mg/% FEV1 fall [27-121] to 147 mg/% FEV1 fall [57-379]; P = 0.03), and FeNO levels were not significantly increased (P = 0.054).

CONCLUSION

Allergen-induced changes in airway responsiveness to direct and indirect stimuli are markedly different. The loss in responsiveness to mannitol is likely not explainable by a refractory state. The effect(s) of allergen exposure on airway responsiveness to indirect-acting stimuli require further investigation.

OX40L blockade and allergen-induced airway responses in subjects with mild asthma

Background

The OX40/OX40L interaction contributes to an optimal T cell response following allergic stimuli and plays an important role in the maintenance and reactivation of memory T effector cells.

Objective

We tested whether treatment with an anti-OX40L monoclonal antibody (MAb) would inhibit allergen-induced responses in subjects with asthma.

Methods

Twenty-eight mild, atopic asthmatic subjects were recruited for a double-blind, randomized, placebo-controlled, parallel-group trial (ClinicalTrials.gov identifier NCT00983658) to compare blockade of OX40L using a humanized anti-OX40L MAb to placebo-administered intravenously in 4 doses over 3 months. Allergen inhalation challenges were carried out 56 and 113 days after the first dose of study drug. The primary outcome variable was the late-phase asthmatic response. Other outcomes included the early-phase asthmatic response, airway hyperresponsiveness, serum IgE levels, blood and sputum eosinophils, safety and tolerability.

Results

Treatment with anti-OX40L MAb did not attenuate the early- or late-phase asthmatic responses at days 56 or 113 compared with placebo. In the anti-OX40L MAb treatment group, total IgE was reduced 17% from pre-dosing levels, and sputum eosinophils decreased 75% by day 113 (both P = 0.04). There was no effect of anti-OX40L MAb on airway hyperresponsiveness or blood eosinophils. The frequency of AEs was similar in both groups.

Conclusion and Clinical Relevance

Pharmacological activity of anti-OX40L MAb was observed by decreases in serum total IgE and airway eosinophils at 16 weeks post-dosing, but there was no effect on allergen-induced airway responses. It is possible that the treatment duration or dose of antibody was insufficient to impact the airway responses.

Comparison of primary closure of incisional hernias in horses with and without the use of prosthetic mesh support

REASONS FOR PERFORMING STUDY

Repair of incisional hernias in horses has been described previously; however, this report describes the outcome of primary closure of incisional hernias in a large number of horses and compares these results with those of mesh implantation.

OBJECTIVE

To report the perioperative care, complications and long-term outcome of primary closure of incisional hernias in horses and to compare these results with a second population of horses in which prosthetic mesh was used.

METHODS

Medical records of horses undergoing an incisional herniorrhaphy between 1998 and 2009 were reviewed. Information obtained included case details, factors from the initial surgery that contributed to the hernia formation, method of hernia repair and outcome. Comparisons between horses with and without mesh were made using logistic regression.

RESULTS

Thirty-eight horses with primary closure and 9 horses with mesh implantation met inclusion criteria. Long-term follow-up for cases in which a mesh was not used was available for 25 cases; of these, 21 horses (84%) had a normal cosmetic appearance and 4 (16%) had a visible defect. There was no significant difference between the 2 repair methods in terms of age, sex, breed, weight, size of the hernia, number of defects, timing of the repair or cosmetic outcome. Horses in which a mesh was used had significantly longer duration of surgery and hospitalisation, and were significantly more likely to develop post operative complications while having a longer duration of convalescence prior to return to use.

CONCLUSIONS

Primary apposition of incisional hernias in horses without the use of mesh support appears to result in a good cosmetic outcome while avoiding the complications associated with mesh implantation in this population of horses.

POTENTIAL RELEVANCE

Surgical time, duration of hospitalisation, and post operative complications may be reduced by using this technique of primary repair and avoiding mesh implantation.

Single-dose desloratadine and montelukast and allergen-induced late airway responses

Montelukast and desloratadine synergistically inhibit the allergen-induced early asthmatic response. Montelukast also suppresses the allergen-induced late asthmatic response, but there are no reports on the effect of desloratadine or the combination on the allergen-induced late asthmatic response. Atopic asthmatics (n = 10) completed a multicentric randomised double-blind crossover study comparing single-dose placebo, 5 mg desloratadine, 10 mg montelukast and the combination administered 2 h prior to allergen inhalation challenge. Methacholine challenges were performed 24 h before and after allergen challenge. Exhaled nitric oxide measurements and sputum inflammatory cell counts were also carried out. All active treatments significantly decreased the late asthmatic response area under the curve. Combination therapy provided the greatest inhibition compared to desloratadine and montelukast. Montelukast was nonsignificantly better than desloratadine but not as effective as the combination. There was a trend towards a decrease in airway responsiveness following montelukast and combination. Montelukast, but not desloratadine or the combination, decreased exhaled NO levels 24 h after allergen. The allergen-induced increase in sputum eosinophil numbers was significantly suppressed at 7 h with desloratadine and combination therapy, and at 24 h with montelukast and combination therapy. Single-dose co-administration of desloratadine and montelukast 2 h prior to allergen inhalation clinically abolished the late asthmatic response and eosinophil recruitment.

The links between allergen skin test sensitivity, airway responsiveness and airway response to allergen

BACKGROUND

The allergen-induced early asthmatic response [provocation concentration (PC)20, the concentration causing a 20% forced expiratory volume in 1 s (FEV)1 fall] depends on the level of IgE sensitivity and the degree of nonallergic airway hyperresponsiveness (AHR) and can be predicted from histamine PC20 and allergen skin test endpoint.

OBJECTIVES

We examined the relationships between allergen PC20, methacholine PC20, and allergen skin test endpoint and assessed the accuracy of both the histamine PC20-based prediction of allergen PC20 (using methacholine) and a new methacholine PC20-based prediction equation.

METHODS

From 158 allergen challenges, the allergen PC20, the methacholine PC20, and the skin test endpoint were recorded and relationships between these three were sought. We compared the measured allergen PC20 to that predicted from the previous histamine PC20-based and the new methacholine-based formulae.

RESULTS

In single regressions, allergen PC20 correlated with both methacholine PC20 (r=0.25, P=0.0015) and skin test endpoint (r=0.52, P <0.00005). The relationship was improved by multiple regression of log-allergen PC20vs. log-methacholine PC20 and log-endpoint (r=0.61, P <0.00005). The histamine-based formula predicted allergen PC20 to within 2 doubling concentrations in 80% and within 3 in 92%. The new methacholine-based formula to within 2 and 3 concentrations in 81% and 94%, respectively; only nine of 158 subjects were outside the 3 concentrations.

CONCLUSIONS

We have confirmed the dependence of the allergen-induced early asthmatic response upon the level of allergic sensitivity and the degree of AHR, the latter as assessed by methacholine challenge. The allergen PC20 can be predicted to within 3 doubling concentrations in 94% of cases.

Regular salbutamol use increases CXCL8 responses in asthma: relationship to the eosinophil response

Regular salbutamol use can exacerbate allergen-induced airway eosinophilia in asthmatics, but its effect on airway eosinophil chemokine responses is unknown. Asthmatic subjects (n=14) were treated for 10 days with placebo or salbutamol in a double-blind, cross-over study, then given same-dose allergen challenges. Their sputa were then analysed 1 and 7 h later for a panel of eosinophil-related cytokines. Eosinophils from five test and three control subjects were tested for expression of CXCL8/interleukin (IL)-8, and its receptors and responsiveness to CCL11/eotaxin and CXCL8/IL-8. Sputum CXCL8/IL-8, but not IL-5, CCL5/regulated on activation, T-cell expressed and secreted, CCL7/monocyte chemotactic protein-3, CCL11/eotaxin, granulocyte-macrophage colony-stimulating factor or tumour necrosis factor levels, were increased (42%) by the salbutamol treatments. The CXCL8/IL-8 levels correlated with the proportions of sputum eosinophils and these cells, but not other sputum cells, stained strongly for CXCL8/IL-8. The circulating eosinophils of the tested subjects (n=5) expressed CXCL8/IL-8 receptors and secreted high levels of this chemokine. Neutralisation of sputum CXCL8/IL-8 reduced eosinophil chemotactic responses to these samples by 19 +/- 5%. These data suggest that regular use of salbutamol can augment airway CXCL8/interleukin-8 responses to allergen challenge and that this CXCL8/interleukin-8 could contribute to the airway inflammatory response.

Do clerkship experiences affect medical students' attitudes toward chronically ill patients?

PURPOSE

To measure changes in medical students' attitudes toward chronically ill patients, and to identify experiences, specifically during clerkships, that contributed to students' attitudes.

METHOD

A cohort of students from five U.S. medical schools voluntarily participated in three surveys longitudinally administered before and after required clinical rotations. The first two questionnaires were identical and asked for demographic information and pre-matriculation experiences with chronically ill patients. The third was modified to include questions about clinical experiences with chronically ill patients. Responses from the first and third questionnaires were linked for analysis.

RESULTS

A total of 502 of 695 students (69%) completed both the first and the third questionnaires. Many students (36%) had had pre-matriculation experiences with chronic illness. After clinical training, 25% of the respondents stated that they would seek another career specialty if the incidence of chronically ill patients increased in their chosen field, compared with the 9% who responded so before clinical training (p <.001). While 73% of the students had favorable perceptions toward chronically ill patients, and 91% felt involved in care, significantly fewer students (p <.01) had had positive patient care experiences when working with residents (57%) and attendings (59%). Gender, age, prior experiences, and school site were not associated with attitudinal changes.

CONCLUSION

Students begin medical school with positive attitudes toward caring for chronically ill patients, but this perception depreciates with clinical experience, which may affect specialty decisions. Contributing factors may include adequate role modeling by residents and attendings and a perceived discrepancy in the quality of care patients receive.

Regular inhaled salbutamol : effect on airway responsiveness to methacholine and adenosine 5'-monophosphate and tolerance to bronchoprotection

OBJECTIVE

Regular treatment with inhaled beta(2)-agonists increases airway responsiveness consistently to indirect bronchoconstrictors (allergen, exercise, hypertonic saline solution, etc) and inconsistently to direct bronchoconstrictors (histamine, methacholine). Studies demonstrating tolerance to beta(2)-agonist bronchoprotection against the indirect bronchoconstrictor adenosine 5'-monophosphate (AMP) have not examined changes in baseline AMP responsiveness. This study assessed the effect of regular salbutamol on AMP and methacholine responsiveness and on tolerance to bronchoprotection.

DESIGN

Double-blind, randomized, crossover study.

SETTING

University hospital bronchoprovocation laboratory.

PATIENTS

Fourteen atopic asthmatic subjects with FEV(1) > 65% predicted, and methacholine provocative concentration causing a 20% fall in FEV(1) (PC(20)) < 8 mg/mL.

INTERVENTIONS

Salbutamol, 100 microg, and placebo inhalers, two puffs qid, each for 10 days.

MEASUREMENTS

Methacholine PC(20) and AMP PC(20) measured 12 h after blinded inhaler after each treatment period. Methacholine PC(20) and AMP PC(20) repeated 10 min after salbutamol, 200 microg (eight subjects).

RESULTS

There was no difference between placebo and salbutamol treatment in geometric mean methacholine PC(20) (0.85 mg/mL vs 0.82 mg/mL, p = 0.86) or AMP PC(20) (22 mg/mL vs 17.4 mg/mL, p = 0.21; n = 14). The acute bronchoprotective effect of salbutamol was greater vs. AMP than vs methacholine (5.1 doubling concentrations vs. 3.5 doubling concentrations, p = 0.06) and loss of protective effect of salbutamol (mean +/- SD) was greater vs AMP than vs. methacholine (2.4 +/- 0.33 doubling concentration loss vs 0.8 +/- 0.21 doubling concentration loss, p = 0.008; n = 8).

CONCLUSION

Regular salbutamol (mean +/- SD) treatment did not enhance airway responsiveness to either the indirect bronchoconstrictor AMP or the direct bronchoconstrictor methacholine. Compared to its effect on methacholine, salbutamol had a greater acute protective effect vs AMP and produced greater loss of protection vs AMP when used regularly.

Periurethral transurethral microwave thermotherapy for the treatment of benign prostatic hyperplasia: an interim 1-year safety and efficacy analysis using the thermatrx TMx-2000

Transurethral microwave thermotherapy (TUMT) represents an accepted minimally invasive approach to the management of patients with benign prostatic hyperplasia (BPH). The TherMatrx TMx-2000 represents a further evolution in TUMT technique. This device uses periurethral transurethral microwave thermotherapy (P-TUMT) technology to directly target the BPH tissue adjacent to the prostatic urethra by using a catheter without a urethral-cooling surface. This article provides a technical review of the device and describes the results of a randomized, controlled multicenter study of P-TUMT for the treatment of symptomatic BPH. A discussion of the physiologic effects of P-TUMT is presented and compared to conventional TUMT. A comparison of P-TUMT to contemporary TUMT series in relation to efficacy and complications is also described. This study concludes that P-TUMT using the TherMatrx TMx-2000 device represents a minimally invasive, efficacious, and well-tolerated treatment for symptomatic BPH.

Longevity of patients born with myelomeningocele

There are limited data concerning the life expectancy for individuals born with myelomeningocele (MM), with and without hydrocephalus. To ascertain such data was our first purpose. We have selected all patients with MM in our computer database, The Patient Data Management System (PDMS/fx). Data were transferred to Excel for primary and SPSS/PC for final analysis by Kaplan-Meier life survival curves. Of the 1,054 patients with MM in the Birth Defects Clinic and the University of Washington Medical Center (UWMC) of Seattle, 505 are now over the age of 21 (391) or have died (114). Follow-up information was available since 1994 for 132, 62% of whom we have had contact within the past 2 years. The second purpose was to identify potential health factors associated with long-term outcome of patients with MM. Patient variables chosen as relevant to survival included hydrocephalus, treatment before or after 1975, and health maintenance determined by outcome for those receiving care within the last 5 years or those last seen before. Age at last appointment and reason for visit were determined in order to identify age-specific health care needs of the adult population. Survival and medical needs were obtained from the UWMC's computer database, Mindscape, and by telephone survey for adult patients not seen in the last 2 years. Death is more frequent earlier in life for those MM patients with hydrocephalus. Ordinary degenerative disorders affect MM patients earlier in life than normals. Our data extend life expectancy for patients with MM and hydrocephalus to age 40 years with some reliability for those treated from 1957 to 1974, but only 24 years for those treated with modern techniques after 1974. More data is needed to determine long-term survival.

Calculation of provocative concentration causing a 20% fall in FEV(1): comparison of lowest vs highest post-challenge FEV(1)

BACKGROUND

Considerable, unexamined controversy exists surrounding the use of the highest vs the lowest FEV(1) for calculating the provocative concentration causing a 20% fall in FEV(1) (PC(20)) during direct bronchoprovocation challenges.

OBJECTIVE

To compare the PC(20) calculated using the lowest FEV(1) post-diluent and post-histamine/methacholine vs the PC(20) calculated using the highest FEV(1) post-diluent and post-histamine/methacholine.

METHOD

Retrospective analysis of 225 challenges: 75 research methacholine challenges, 75 research histamine challenges, and 75 clinical methacholine challenges. For each test, the PC(20) was calculated twice, first using the lowest post-diluent FEV(1) to the lowest post-histamine/methacholine FEV(1), and then using the highest to the highest.

RESULTS

The intraclass correlation coefficients for methacholine research, histamine research, and methacholine clinic challenges were 0.99, 0.98, and 0.95, respectively. The PC(20) calculated using the lowest to lowest FEV(1) was slightly and significantly lower in all three groups (paired t test p < 0.0001).

CONCLUSIONS

The PC(20) values calculated using the highest FEV(1) are almost identical to the PC(20) values calculated using the lowest FEV(1). The difference, although clinically irrelevant, holds statistical significance.

Severe early onset preeclampsia secondary to bilateral ureteral obstruction reversed by stenting

BACKGROUND

Severe early onset preeclampsia might be reversed by correction of an underlying pathophysiologic condition.

CASE

A 22-year-old nullipara with a history of antivesicoureteral reflux surgery in childhood presented at 23 weeks' gestation with severe headaches, hypertension, proteinuria, edema, and acute renal failure. Severe preeclampsia was diagnosed, and bilateral distal ureteral obstruction was documented by cystoscopy, fluoroscopy, and retrograde pyelography. Bilateral ureteral stent placement completely resolved the preeclampsia and prolonged pregnancy until term.

CONCLUSION

Pregnant women with a history of antireflux surgery in childhood might be at risk for acute renal failure and severe preeclampsia caused by bilateral ureteral obstruction. Ureteral stent placement might reverse obstruction, renal failure, and preeclampsia.

Dose versus concentration of methacholine

BACKGROUND

The methacholine challenge test is a common investigation used to identify airway hyperresponsiveness. There has been recent debate as to whether the airway effect is due to the concentration or the dose of methacholine.

OBJECTIVE

To determine whether the airway response during a methacholine challenge test is due to the concentration or the dose of methacholine.

METHODS

Ten subjects with stable, mild asthma were enrolled in this study. Two methacholine challenge tests, one with 30-second inhalations of methacholine and the other with two minute inhalations of methacholine, were performed on each subject in a random order on 2 days within a 1-week period at approximately the same time each day.

RESULTS

The geometric mean 2-minute PC20 was 1.1 mg/mL and the geometric mean 30-second PC20 was 5.7 mg/mL, 5.2-fold greater than the mean 2-minute PC20. The paired t-test comparison of the 2-minute PC20 multiplied by 4 and the 30-second PC20 revealed no significant difference (P > .2).

CONCLUSIONS

The dose of methacholine is primarily responsible for the degree of bronchial response rather than the concentration.

Tolerance to the bronchoprotective effect of beta2-agonists: comparison of the enantiomers of salbutamol with racemic salbutamol and placebo

BACKGROUND

Regular use of racemic salbutamol results in the partial loss of its bronchoprotective effect. The 2 enantiomers of salbutamol, the bronchodilator R-salbutamol and nonbronchodilator S-salbutamol, are now available.

OBJECTIVE

We sought to compare the effect of regular use of S-salbutamol, R-salbutamol, racemic salbutamol, and placebo on the bronchoprotective effect of a single dose of racemic salbutamol against methacholine-induced bronchoconstriction.

METHODS

Eleven of 13 well-controlled beta2 -agonist-free asthmatic subjects completed a double-blind, randomized study comparing racemic salbutamol 2.5 mg, S-salbutamol 1. 25 mg, R-salbutamol 1.25 mg, and diluent placebo nebulized and inhaled 3 times daily for 6 days (>/=6-day washout period). Ten to 12 hours after the last dose, the subjects performed measurement of FEV1, methacholine PC20, and a repeat methacholine PC20 done 1 hour after the first methacholine test and 10 minutes after 2 puffs (200 microgram) of racemic salbutamol administered from a metered-dose inhaler. The primary endpoint was the methacholine PC20 dose shift (Deltalog PC20/log 2) from before to after administration of 200 microgram of racemic salbutamol.

RESULTS

The methacholine dose shift was 3.2 doubling doses (9-fold increase in methacholine PC20 after 200 microgram of racemic salbutamol) during the placebo treatment and was unaltered (3.2) after administration of S-salbutamol. The dose shift was significantly lower after both the R-salbutamol and racemic salbutamol treatments (2.2 and 2.6 doubling doses, respectively); there was no significant difference between R-salbutamol and racemic salbutamol. There was no treatment effect on baseline FEV1, baseline methacholine PC20, or bronchodilation.

CONCLUSION

Regular treatment with racemic salbutamol or R-salbutamol, but not S-salbutamol, results in a partial loss of bronchoprotection, without loss of bronchodilation, compared with placebo.

Prone infant sleeping despite the "Back to Sleep" campaign

OBJECTIVES

To determine sleep position variation during the first 6 months of life and to identify risk factors for prone sleeping.

DESIGN

Cohort study of healthy term newborns recruited from November 1995 to September 1996 and followed up to age 6 months. Pediatricians were surveyed about sleep position advice. At recruitment, all parents were instructed to avoid prone sleeping. Parents were telephoned at 1 week and then monthly to ensure that they recorded sleep position. Investigators were unaware of sleep position until the infant was 6 months of age, when sleep log data and reasons for sleep position choice were ascertained.

SETTING

Practice-based study conducted by the Children's National Medical Center Pediatric Research Network, Washington, DC.

PARTICIPANTS

A total of 402 consecutive healthy term newborns followed up by a Pediatric Research Network pediatrician were enrolled. Exclusion criteria were prematurity, a serious medical condition, and absence of a telephone. Of the 402 enrolled newborns, 348 (86.6%) completed the study.

RESULTS

Only 34.0% of infants maintained a consistent sleep position. Prone sleeping increased from 12.2% at birth to 32.0% at 6 months. One third of pediatricians discussed sleep position beyond the newborn period. The following were associated (P<.05) with prone sleeping: male sex, lower maternal education level, single marital status, having siblings, and black race. Perceived infant comfort was the main reason for prone sleeping.

CONCLUSIONS

Most newborns are placed by parents in nonprone sleep positions. Pediatricians need to consistently reinforce the "Back to Sleep" message when the infants are 2 to 4 months of age because this is the most likely time that they are switched to prone sleeping and the highest risk period of sudden infant death syndrome. Parents should not use prone sleeping as a means of comforting infants.

Clinical efficacy and safety of tolterodine compared to placebo in detrusor overactivity

PURPOSE

We evaluated the efficacy, patient acceptability and side effect profile of tolterodine, a new antimuscarinic agent for treating bladder overactivity.

MATERIALS AND METHODS

In our randomized, placebo controlled, parallel group study 123, 129 and 64 patients 18 years old or older with proved detrusor overactivity (idiopathic detrusor instability or detrusor hyperreflexia) were randomized to receive 1 or 2 mg. tolterodine, or placebo, respectively, twice daily for 12 weeks. Main outcome measures were number of voids per 24 hours, urine volume per void and episodes of urge incontinence per 24 hours on a frequency-volume chart with detailed recording of side effects.

RESULTS

After 12 weeks of treatment mean number of voids per 24 hours plus or minus standard deviation decreased from 11.2 +/- 3.1 to 9.0 +/- 2.6 with the 2 mg. dosage (p = 0.0045 versus placebo). At this dose mean urine volume per void increased from 155 +/- 52 to 190 +/- 70 ml. (p <0.0001 versus placebo), while mean number of incontinence episodes per 24 hours decreased from 3.6 +/- 4.0 to 1.8 +/- 3.1 (p = 0.19 versus placebo). Similar efficacy was observed in patients receiving the 1 mg. dose. Severe dry mouth was reported by only 2, 1 and 2% of patients given the 1 and 2 mg. dose, and placebo, respectively. There was no clinical or electrocardiographic evidence of significant cardiac adverse events.

CONCLUSIONS

Tolterodine administration resulted in a significant decrease in the frequency of voiding and improved voided volume but it was seldom associated with troublesome or severe side effects.

Effects of sleep position on infant motor development

BACKGROUND

As a result of the American Academy of Pediatrics' recommendation that healthy infants be placed on their side or back for sleep, the percentage of infants sleeping prone has decreased dramatically. With the increase in supine sleeping, pediatricians have questioned if there are differences in the rate of acquisition of early motor milestones between prone and supine sleeping infants.

METHODS

To examine this question, we performed a prospective, practice-based study of healthy term infants. Infants were recruited before the age of 2 months. Parents were asked to record infant sleep position and awake time spent prone until 6 months of age. A developmental log was used to track milestones from birth until the infant was walking. Age of acquisition of eight motor milestones was determined, and the mean ages of milestone attainment of prone and supine sleepers were compared.

RESULTS

Three hundred fifty-one infants completed the study. Prone sleepers acquired motor milestones at an earlier age than supine sleepers. There was a significant difference in the age of attainment of rolling prone to supine, tripod sitting, creeping, crawling, and pulling to stand. There was no significant difference in age when infants walked.

CONCLUSIONS

The pattern of early motor development is affected by sleep position. Prone sleepers attain several motor milestones earlier than supine sleepers. However, all infants achieved all milestones within the accepted normal age range. Pediatricians can use this information to reassure parents. This difference in milestone attainment is not a reason to abandon the American Academy of Pediatrics' sleep position recommendations.

Novel 2- and 5-azido-N-(diphenylcarbamoyl)proline methyl esters. Examples of a novel proline oxidation

The crystal structures of two azido-substituted proline derivatives are reported. Racemic 2-azido-1-(diphenyl-carbamoyl)proline methyl ester, (I), C19H19N5O3, is resolved upon crystallization from methylene chloride-diethyl ether. The azido moieties are nonlinear with N--N--N angles of 173 (1) and 170.3 (2) degrees for (I) and (II) [cis-5-azido-N-(diphenylcarbamoyl)proline methyl ester, C19H19N5O3], respectively. Close intramolecular contacts between the carbonyl O atom of the amide and the central N atom of the azido group are found. The contact distances between N7 and O14 are 2.780 (14) and 2.815 (2) A for (I) and (II), respectively.

Two [7.3.1]azabicyclo-z-3-ene-1,5-diyne analogues of dynemicin A

The crystal structures of methyl 6-methoxy-17-oxo-2-azatricyclo[7.7.1.0(3,8)]heptadeca-3(8),4 ,6,13-tetraene- 11,15-diyne-2-carboxylate ethyl acetate solvate, (1), 2C19H15NO4.0.5C4H8O2, and tricyclo[3.3.1.1(3,7)]decyl 6-methoxy-17-oxo-2-azatricyclo[7.7.1.0(3,8)]heptadeca-3(8),4 ,6,13-tetraene- 11,15-diyne-2-carboxylate ethyl acetate solvate, (2), C28H27NO4.0.5C4H8O2, are reported. For compound (1), two crystallographically independent molecules are observed. Interestingly, for both compounds (1) and (2), a molecule of ethyl acetate is found in the crystal lattice disordered about an inversion center. The azabicyclo[7.3.1]enediyne core appears to be fairly rigid. Only minor differences are observed in the ring conformation between the two independent molecules in (1) and between compounds (1) and (2) themselves. The conformation is also similar to that found in deoxydynemicin A [Shiomi, Iinuma, Naganawa, Hamada, Hattori, Nakamura, Takeuchi & Iitaka (1990). J. Antibiot. 43, 1000-1005] and triacetyldynemicin A [Konishi, Ohkuma, Tsuno, Oki, Van Duyne & Clardy (1990). J. Am. Chem. Soc. 112, 3715-3716]. The transannular diyne distance (C3...C8) averages 3.428 (2) A for compound (1) and is 3.403 (3) A for compound (2).

4,7-Dimethoxybenzo[c]furan

The title compound, C10H10O3, is nearly planar with a maximum deviation from planarity of 0.140 (2) A for methoxy atom C11. The geometry of the benzo[c]furan moiety is indicative of a non-aromatic ring system. The bond lengths more closely resemble those of two non-interacting diene systems than those of an aromatic one. There are alternating long and short bond lengths around the ring skeleton with the long and short C-C bonds averaging 1.437 (2) and 1.354 (2) A, respectively. There are close C-H ... O intermolecular contacts which may help stabilize the molecule in the solid state.

A novel dioxabicyclo[3.3.1]nonane, a key intermediate in the synthesis of erythronolide B seco-acid

In the title compound, (1R,4S,5R,6R,8R)-1-ethyl-4,6,8-trimethyl-2,9-dioxabicyclo[3.3.1]++ +nonan-6-yl 1-imidazolecarboxylate, C16H24N2O4, the 2,9-dioxabicyclo[3.3.1]nonane ring system assumes a double-chair conformation. Bond angles around the ring are enlarged compared to normal tetrahedral values to alleviate some of the overcrowding which results from close intramolecular H...H and C...C contacts. The N-imidazolylcarbonyloxy group is nearly planar with dihedral angles of 5.2 (2) and 6.0 (2) degrees between the imidazole and carbonyl groups for molecules 1 and 2, respectively.

The management of patients with nonseminomatous germ cell tumors of the testis with serologic disease only after orchiectomy

Management of patients with nonseminomatous germ cell tumors of the testis who have persistently elevated serum tumor marker levels (alpha-fetoprotein and/or human chorionic gonadotropin) following orchiectomy and no clinical evidence of disease is controversial. We reviewed our experience with 15 such patients at our cancer center between March 1977 and November 1991. Group 1 (11 patients) underwent initial retroperitoneal lymph node dissection and group 2 (4 patients) received primary chemotherapy. All group 1 patients required subsequent chemotherapy for retroperitoneal disease or persistent marker elevation, whereas only 1 of the 4 who received primary chemotherapy required later surgery. We conclude that tumor marker elevation in this setting is usually indicative of systemic tumor, which is best treated primarily by initial chemotherapy.

Association of primary germ cell tumor of the testis and renal cell carcinoma

The combined presentation of 2 separate neoplasms is rare. We report 3 cases of primary testicular cancer that were associated with renal cell carcinoma and discuss their management.

Serum soluble interleukin 2 receptor levels in erythrodermic cutaneous T-cell lymphoma correlate with response to photopheresis-based treatment

BACKGROUND

Cutaneous T-cell lymphoma (CTCL) comprises a spectrum of presentations, including erythroderma, pruritus, lymphadenopathy, and circulating atypical lymphocytes. Photopheresis is an extracorporeal treatment in which white blood cell concentrates are subjected to UV irradiation when the serum methoxypsoralen level is above 50 ng/mL. Of patients with CTCL, those with erythroderma have been most responsive to this therapy. In some conditions, including certain malignant hematologic neoplasms, serum soluble interleukin 2 receptor levels (SIL2R) correlate with disease activity. We sought to determine whether serum SIL2R levels correlated with disease activity in six erythrodermic patients with CTCL treated primarily with photopheresis. We measured SIL2R levels in five patients with stage III or greater erythrodermic CTCL and one with stage IIa CTCL. We compared SIL2R values with clinical course, skin scores, CD4/CD8 ratios, peripheral white blood cell counts, and Sézary cell counts, using Pearson correlation coefficients.

OBSERVATIONS

The SIL2R levels correlated with clinical course and skin scores, even when controlled for other factors noted above.

CONCLUSION

Data preliminarily suggest that serum SIL2R levels may be useful indicators of disease activity in erythrodermic CTCL patients treated with photopheresis.

Management of abdominal aortic aneurysm and invasive transitional cell carcinoma of bladder

Between January 1980 and June 1990 we treated 21 patients with invasive carcinoma of the bladder and abdominal aortic aneurysm. Three distinct groups of patients were identified. Group 1 comprised 8 patients who were initially diagnosed with invasive bladder cancer and during cancer staging a concomitant abdominal aortic aneurysm was found. Group 2 consisted of 10 patients previously treated for invasive bladder cancer who had aneurysmal disease at a later date. Group 3 included 3 patients who underwent a previous aneurysm repair and subsequently had invasive carcinoma of the bladder. Total survival was 9 of 21 patients (43%) with a mean of 84 months of followup after initial diagnosis. This finding is comparable to long-term (greater than 5 years) survival in patients with invasive carcinoma of the bladder alone. In fact, none of the 21 patients studied experienced rupture of the aneurysm and/or died of aneurysmal disease. We found that patients with abdominal aortic aneurysm and invasive bladder cancer have a poor overall prognosis. Although aneurysm repair presents technical challenges, mortality is dependent upon the carcinoma and other vascular or medical diseases, and does not bear direct relationship to abdominal aortic aneurysm.

Combined cholecystectomy and radical genitourinary cancer surgery

We have routinely performed simultaneous cholecystectomy in patients with cholelithiasis undergoing selected radical genitourinary cancer surgery. A total of 31 patients have undergone cholecystectomy at the time of radical nephrectomy (25), radical cystectomy (5), and radical prostatectomy (1). Operative time was increased twenty-five to forty-five minutes. There was no significant increase in blood loss, postoperative total bilirubin, or number of complications. No complications were directly attributable to the cholecystectomy except for 1 patient who had prolonged drainage from a closed suction drain in the gallbladder fossa. We conclude that concomitant cholecystectomy at the time of radical genitourinary cancer surgery does not significantly increase morbidity and recommend that it be performed in the presence of cholelithiasis.

Structure of a chiral intermediate in the synthesis of (+)-19-epiajmalicine

[2S*-(2 beta,3 alpha,6 alpha,12b beta)]-Methyl 3-acetyl-1,2,3,4,6,7,12,12b-octahydro-6-methoxycarbonyl-indolo+ ++[2,3-a] quinolizine-3-ethanoate, C22H26N2O5, M(r) = 398.46, orthorhombic, P2(1)2(1)2(1), a = 9.463 (2), b = 11.251 (3), c = 18.871 (6) A, V = 2009.2 (9) A3, Z = 4, Dx = 1.32 g cm-3 (178 K), lambda(Mo K alpha) = 0.7107 A, mu = 0.8762 cm-1, F(000) = 848, T = 178 K, R = 0.0536 for 1673 reflections [Fo > or = 6 sigma (Fo)]. Molecules are hydrogen bonded along the 2(1)-screw axis parallel to a. The hydrogen-bond geometric parameters for N12-H12...O19 (related by 0.5 + x, 1.5 - y, 1 - z) are N...O 2.986 (6), H...O 2.30 (5) A, N-H...O 161 (5) degrees. The C and D rings are trans fused with ring-junction torsion angles of -39.6 (5) and 63.8 (5) degrees for C12a-C12b-N5-C6 and C1-C12b-N5-C4, respectively. The conformation of the C ring is half chair with N5 and C6 -0.168 (4) and 0.552 (5) A, respectively, out of the plane defined by the remaining four atoms of the ring. The D ring is in the chair conformation.

Management of preexisting inflatable penile prosthesis during radical retropubic prostatectomy

A potentially difficult technical situation exists when a man with a functioning inflatable penile prosthesis elects radical prostatectomy as treatment for localized prostate cancer. Between February 1988 and June 1991 we encountered 8 men with a preexisting inflatable penile prosthesis who subsequently underwent radical retropubic prostatectomy. In 2 patients the reservoir portion of the prosthesis was in the perivesical space such that radical prostatectomy could be performed without difficulty. However, in 6 patients removal of the reservoir was necessary to complete the prostatectomy. In 3 of these 6 patients the reservoir was replaced at 3 to 6 months after radical prostatectomy and all 3 systems function well. The remaining 3 patients have not yet elected replacement of the reservoir. Only 1 patient had an infection and a complication attributable to the prosthesis. We believe that a preexisting inflatable penile prosthesis should not preclude successful radical retropubic prostatectomy, although temporary removal of the reservoir may be required.

Structure of a tricyclic subunit of manzamine A

(4a alpha,7a beta,10a beta)-2-Benzyl-1,2,3,4,4a,7,7a,8,9,10-decahydro-8,8- dimethylpyrrolo[2,3-i]isoquinolinium iodide, C20H29N2+.I-, M(r) = 424.37, monoclinic, P2(1)/n, a = 9.441 (4), b = 10.378 (4), c = 20.023 (9) A, beta = 91.56 (3) degrees, V = 1961 (1) A3, Z = 4, Dx = 1.44 g cm-3 (188 K), lambda(Mo K alpha) = 0.7107 A, mu = 16.16 cm-1, F(000) = 864, T = 188 K, R = 0.0288 for 3070 reflections [Fo greater than or equal to 4 sigma(Fo)]. The crystal structure determination was undertaken in order to establish the configuration around C10a. The rings of the isoquinoline group are trans, with the pyrrole moiety cis fused. The A ring is in the chair conformation, while the cyclohexene ring, B, is in the boat conformation owing to the cis fusion of the five-membered pyrrole ring. The pyrrole ring, C, assumes the half-chair conformation. The C-N bonds of the quaternary N atom, N8, are longer than those of the tertiary N atom, N2 [1.517 (2) for N8 and 1.463 (2) A for N2].

Structure of a protected C3-C10 subunit of erythromycin and its C8 epimer

(1) (2S,3R,4R,6R)-3,4-O-Carbonyl-7,7-dimethylenedithio-2,4,6-trimet hylnonane-1,3,4-triol, C15H26O4S2, M(r) = 334.49, triclinic, P1, a = 6.460 (2), b = 8.917 (3), c = 15.616 (5) A, alpha = 83.60 (3), beta = 83.41 (2), gamma = 89.52 (2) degrees, V = 888.0 (5) A3, Z = 2, Dx = 1.25 g cm-3, mu = 2.980 cm-1, lambda (Mo K alpha) = 0.7107 A, F(000) = 360, T = 298 K, R = 0.0465 for 1832 reflections [Fo greater than or equal to 4 sigma (Fo)]. (2) (2S,3R,4R,6S)-3,4-O-Carbonyl-7,7-dimethylenedithio-2,4,6-trimet hylnonane-1,3,4-triol, C15H26O4S2, M(r) = 334.49, monoclinic, P21, a = 8.1849 (8), b = 8.9456 (14), c = 12.0258 (14) A, beta = 100.878 (8) degrees, V = 864.7 (2) A3, Z = 2, Dx = 1.28 g cm-3, mu = 3.060 cm-1, lambda (Mo K alpha) = 0.7107 A, F(000) = 360, T = 298 K, R = 0.0569 for 2001 reflections [Fo greater than or equal to 4 sigma (Fo)]. The two diastereomers differ in configuration at C6. For (1) there are two unique molecules in the unit cell. These two molecules differ in conformation by a rotation about the bond C7-C8. The molecules are hydrogen bonded into infinite chains along b. The hydroxyl O atom of molecule (2), O10', acts as both a donor and an acceptor in hydrogen-bonding interactions with the carbonyl O atom, O14, and the hydroxyl H atom, H10, of molecule (1).(ABSTRACT TRUNCATED AT 250 WORDS)

Simplified urinary diversion in patients with preexisting or imminent colostomy

The indications for urinary and fecal diversion often mirror each other and at times overlap. Between 1980 and 1990 we encountered 14 patients with preexisting or newly diagnosed rectosigmoid disease who required diverting colostomy and urinary diversion. We describe a simple method for managing urinary diversion in these patients, which avoids a bowel anastomosis. The preexisting or newly created colostomy is used as the urinary stoma for a colon conduit, while a proximal colostomy is created for fecal diversion. This technique has proved to be beneficial and should be considered for high risk patients who require urinary and fecal diversion, and for whom an abbreviated operation would be desired.

Initial experience with combined interferon-alpha 2B and carbon dioxide laser for the treatment of condylomata acuminata

The incidence of condylomata acuminata, a common sexually transmitted disease caused by certain types of human papillomaviruses, is increasing rapidly and treatment regimens presently are not consistently effective. One of the more popular and effective modes of treatment has been laser therapy. Because of the relatively high recurrence rate of condylomata acuminata with laser treatment alone and because laser treatment in some patients with confluent acetowhite lesions would render cosmetically unacceptable results in the entire area were treated, we believed that it was reasonable to use intralesional pretreatment. We present our preliminary data on 14 consecutive patients with the clinical diagnosis of condylomata acuminata who were treated with the combination of carbon dioxide laser and intralesional interferon-alpha 2B. We found the treatment regimen to be effective in decreasing the recurrence rate compared to laser treatment alone and it was well tolerated with only transient side effects in a minority of patients. We are encouraged by our result and have recently begun a randomized double-blind prospective study to provide more conclusive information regarding this treatment combination.

Structure of 18'-epivinblastine

Methyl (3aR-[3a alpha,4 beta,5 beta,5a beta,9(3R*,5S*,7R*,9R*), 10bR,13a alpha])-4-(acetyloxy)-3a-ethyl-9-[5-ethyl-1,4,5,6,7,8,9, 10-octahydro-5-hydroxy-9-(methoxycarbonyl)-2H-3,7- methanoazacycloundecino[5,4-b]indol-9-yl]-3a,4,5,5a,6,11,12, 13a-octahydro-5-hydroxy-8-methoxy-6-methyl-1H-indolizino-[8,1-c,d] carbazole- 5-carboxylate methanol solvate, C46H58N4O9. 2CH3OH (1), Mr = 875.07, monoclinic, P2(1), a = 10.2759 (12), b = 22.353 (3), c = 10.4051 (12) A, beta = 106.502 (9) degrees, V = 2291.6 (5) A3, Z = 2, Dx = 1.27 g cm-3, Mo K alpha radiation, lambda = 0.7107 A, mu = 0.8397 cm-1, F(000) = 940, T = 198 K, R = 0.0470 for 2751 reflections, Fo greater than or equal to 4 sigma(Fo). The C ring of the vindoline moiety is in the boat conformation with the hydroxy group and the tertiary N in the bowsprit positions resulting in a fairly short intramolecular hydrogen-bonding interaction. The relevant parameters for O3--H3...N9 are O...N 2.651 (6), H...N 1.94 (5) A and O--H...N 147 (5) degrees. The D and E rings are in the sofa and envelope conformations, respectively. The piperidine ring of the catharanthine portion of the molecule assumes the chair conformation while the conformation of the azacyclononene ring is a boat-chair. An intramolecular hydrogen bond between the indolino NH of the catharanthine moiety and methoxy O (O25) of the vindoline moiety is also observed. The relevant parameters for N16'--H16'...O25 are N...O 2.827 (6), H...N2.14 (6) A and O--H...N 136 (5) degrees.