Parkinsonism Treatment: Part III—Update

OBJECTIVE:

The purpose of this review is to update clinicians with recent advances in the management of parkinsonism, including drug therapy, transplantation, and diet.

DATA SOURCES:

Pertinent articles were obtained from an English-language literature search using MEDLINE (1970–1991), Index Medicus (1987–1991), Current Contents (1990), and bibliographic reviews of review articles. Index terms included parkinsonism, selegiline, pergolide, vitamin E, and transplantation. Fifty-five articles (representing 85 percent of the complete literature search) were selected by multiple reviewers for their contribution to the stated purpose. Emphasis was placed on double-blind, placebo-controlled, and randomized studies. Data from cited articles were examined by multiple reviewers for support of their stated hypothesis and were included as background for justification of major points in this article; critical studies were abstracted in more detail.

RESULTS:

New therapeutic measures have been added to the treatment of parkinsonism. Selegiline, a monoamine oxidase inhibitor type B, has shown beneficial results, especially in early stages. Pergolide, a dopamine agonist, may be an efficacious alternative to bromocriptine resistance or intolerable adverse effects. Vitamin E may have protective antioxidant properties, but very few clinical data are available. Fetal tissue transplantation needs continued research and remains very controversial. Diet modification may maximize the results of therapy with exogenous dopamine therapy.

CONCLUSIONS:

Clinicians should familiarize themselves with new alternatives for the management of parkinsonism in order to be reliable consultants for both professional and lay persons.

Fat necrosis of the breast: a cytological and clinical study

Fat necrosis of the breast is a sterile condition that usually results from trauma to the breast. It may present with a breast lump that, on clinical and mammographic examination, can mimic malignancy. The literature suggests that fat necrosis of the breast can only be diagnosed accurately by histological examinations of breast biopsies. In this paper, we review the findings of a series of 35 patients in whom fat necrosis was diagnosed on fine needle aspiration cytology. Repeated fine needle aspiration cytology with close follow-up have proven to be a reliable method of establishing the diagnosis of fat necrosis of the breast, thereby reducing the necessity for open biopsy.

Omeprazole pharmacodynamics and gastric acid suppression in critically ill pediatric transplant patients

OBJECTIVE: To characterize the pharmacodynamics and pharmacokinetics of omeprazole suspension in critically ill pediatric liver/intestinal transplant patients. DESIGN: Open-label pharmacodynamic and pharmacokinetic study. SETTING: Pediatric intensive care unit of an academic medical center. PATIENTS: Eleven pediatric liver and/or intestinal transplant patients. INTERVENTIONS: Extemporaneously prepared 0.5 mg/kg omeprazole suspension every 12 hrs via nasogastric tube before sequential measurements of omeprazole serum concentration and gastric pH monitoring. Gastric pH was monitored continuously for 48 hrs and plasma omeprazole concentrations were determined upon first and multiple dosing. MEASUREMENTS AND MAIN RESULTS: Mean onset of action of omeprazole in a sodium bicarbonate vehicle was 62 +/- 82 mins (range, 2-226 mins). Subjects <4 yrs of age exhibited a more variable onset of omeprazole action (range, 3-226 mins) when compared with older subjects (onset of action, 2-40 min). Omeprazole maximum concentration and area under the concentration-time curve for the dosage interval were significantly greater upon multiple dosing when compared with the first dose. Mean baseline gastric pH in this study population was 1.0 +/- 0.8. Gastric pH remained >4.0 for 78.8% +/- 18.9% of the first dosage interval and 97.8% +/- 5.4% of multiple dosage intervals regardless of age when administered twice daily as a suspension. CONCLUSION: These results support the use of omeprazole administered twice daily as a suspension to maintain gastric pH of >4.0 and to achieve maximal pharmacodynamic effect in pediatric liver and/or intestinal transplant patients.

Extracorporeal liver perfusion using human and pig livers for acute liver failure

BACKGROUND

Patients with fulminant hepatic failure (FHF) often die awaiting liver transplantation. Extracorporeal liver perfusion (ECLP) has been proposed as a method of "bridging" such patients to transplantation. We report the largest experience to date of ECLP using human and porcine livers in patients with acute liver failure.

METHODS

Patients with FHF unlikely to survive without liver transplantation were identified. ECLP was performed with human or porcine livers. Patients underwent continuous perfusion until liver transplantation or withdrawal of support. Two perfusion circuits were used: direct perfusion of patient blood through the extracorporeal liver and indirect perfusion with a plasma filter between the patient and the liver.

FINDINGS

Fourteen patients were treated with 16 livers in 18 perfusion circuits. Nine patients were successfully "bridged" to transplantation. ECLP stabilized intracranial pressure (ICP) and cerebral perfusion pressure (CPP). Arterial ammonia levels fell from a median of 146 to 83 micromol/liter within 12 hr and this reduction was maintained at least 48 hr. Pig and human ECLP lowered ammonia levels equally. Serum bilirubin levels also fell from a median of 385 to 198 micromol/liter over the first 12 hr but the response was not sustained as well with porcine livers. There was no immunological benefit to using the the filtered perfusion circuit.

INTERPRETATION

These data demonstrate that ECLP is safe and can provide metabolic support for comatose patients with fulminant hepatic failure for up to 5 days. While labor and resource intensive, this technology is available to centers caring for patients with acute liver failure and deserves wider evaluation and application.

Circum-areolar mastectomy with immediate reconstruction (CAMIR)

AIMS

To develop an oncologically safe and aesthetically acceptable technique for mastectomy using a myocutaneous flap and tissue expander for patients with neoplastic involvement of the nipple.

METHODS

Fourteen consecutive patients (mean age 40 years) underwent a circum-areolar mastectomy with immediate reconstruction using a latissimus dorsi myocutaneous flap and tissue expander. Assessment of cosmesis was by review of pre- and post-operative photographs by an independent observer.

RESULTS

During a mean follow-up of 11.4 months there have been no local recurrences. There were two deaths: pulmonary embolus (one) and distant metastatic disease (one). Assessment of cosmesis gave a score of 47 out of 56 (84%).

CONCLUSIONS

In patients with tumours involving the nipple, mastectomy with immediate reconstruction may be used to achieve a good cosmetic result. The replacement nipple is fashioned from a circle of skin attached to the latissimus dorsi myocutaneous harvest.

Envelope mastectomy with immediate reconstruction (EMIR)

AIMS

To develop an oncologically safe and aesthetically acceptable technique for mastectomy, using a muscle flap and tissue expander through one incision.

METHODS

Twelve consecutive patients (mean age 40) underwent an envelope mastectomy (skin and nipple sparing), with immediate reconstruction with a latissimus dorsi muscle flap and tissue expander. Assessment of cosmesis was by review of pre- and post-operative photographs by an independent observer.

RESULTS

During follow-up there have been no recurrences. Assessment of cosmesis gave a score of 44 out of 48 (92%). One prosthesis was removed due to erosion of the prosthesis through the skin.

CONCLUSIONS

In patients with large lesions, multi-focal lesions (both invasive and in situ) and recurrent phyllodes tumours may undergo an oncologically safe mastectomy with immediate reconstruction through a single incision that is inconspicuous being in the mid-axillary line. Although follow up is only 8.5 months, long-term studies are being undertaken.

Effect of omeprazole, lansoprazole, and ranitidine on the DNA synthesis of mononuclear cells

OBJECTIVE

To examine and compare the effects of omeprazole, lansoprazole, and ranitidine on the DNA synthesis of peripheral blood mononuclear cells.

DESIGN

Ex vivo laboratory study.

SETTING

Clinical research laboratory of an academic medical center.

SUBJECTS

Healthy volunteers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Venous blood was collected from normal subjects and peripheral blood mononuclear cells (PBMCs) were isolated using centrifugation techniques over a Ficoll-Hypaque density gradient. PBMCs were added to 12-well culture plates in four groups of media: a) control; b) control plus lansoprazole (25 microg/mL); c) control plus omeprazole (0.35 microg/mL); and d) control plus ranitidine (50 microg/mL). PBMCs were exposed to the drug for 96 hrs, with addition of phytohemagglutinin (2.5 microg/ mL) for the last 48 hrs, and 3H-thymidine (1 microCi) during the final 6 hrs. PBMCs were filtered onto glass-fiber filter paper and the radioactivity was determined by scintillation counting. Since radioactivity is measured only in those cells undergoing DNA synthesis or cell division, results are expressed as quantification of 3H-thymidine uptake. Median disintegrations per min (DPM)/number of PBMCs per well+/-SEM are reported: control 68.3+/-37.8; ranitidine 38.4 +/-94.2; lansoprazole 14.6+/-84.4; and omeprazole 15.1+/-48.9. There was a significant difference between lansoprazole vs. ranitidine (p< .01), and omeprazole vs. ranitidine (p< .05), and no significant difference between lansoprazole and omeprazole.

CONCLUSIONS

This is the first study to compare the potential immunomodulating effects of these commonly used agents. Ranitidine caused increased DNA synthesis in PBMCs when compared with lansoprazole and omeprazole. This phenomenon may be an important, often disregarded, effect of histamine-2-receptor antagonists when used in postsurgical or trauma patients who have T-lymphocyte-mediated immune suppression.

Use of disodium pamidronate in children with hypercalcemia awaiting liver transplantation

We report four children with advanced liver disease awaiting liver transplantation who developed moderately severe hypercalcemia (range: 1.65-2.40 mmol/L) while receiving total parenteral nutrition. Hypercalcemia had been unresponsive to cessation of calcium intake and therapy with loop diuretics and calcitonin. One or two intravenous doses of disodium pamidronate (35-50 mg/m2) resulted in normalization of plasma calcium concentration within 2-4 d in all four children. Pamidronate may be useful for children with hypercalcemia associated with liver disease.

Evaluation of the pharmacokinetic interaction between cimetidine or famotidine and cyclosporine in healthy men

OBJECTIVE

To investigate the potential interaction between cimetidine or famotidine and cyclosporine in healthy men.

DESIGN

All subjects received oral cyclosporine at baseline, after the first week of 1 histamine2 (H2)-blocker, and a third time after a 1-week washout plus 1 week of the second H2-blocker. Blood samples were collected just before each dose of cyclosporine and for up to 36 hours afterward for pharmacokinetic analysis.

SETTING

A college of pharmacy in a university teaching hospital.

PARTICIPANTS

The study population consisted of 8 healthy men at least 19 years of age.

MAIN OUTCOME MEASURES

Cyclosporine concentrations in whole blood were measured using a polyclonal fluorescence polarization immunoassay. Cyclosporine pharmacokinetic parameters during each of the 3 treatment periods were compared.

RESULTS

The average times to maximum cyclosporine concentrations were similar between baseline (3.2 h), cimetidine (2.9 h), and famotidine (3.6 h) dosing periods. There were no significant differences in area under the curve, half-life, or maximum concentration during the 3 dosing periods.

CONCLUSIONS

Neither cimetidine or famotidine produced a significant change in the pharmacokinetics of single-dose oral cyclosporine in healthy men.

Intraperitoneal rupture of an infected urachal cyst in an infant. Case report

Peritonitis due to intraperitoneal rupture of an infected urachal cyst is a life-threatening condition, not previously reported in an infant. We report this condition in an 8-month-old infant. The child underwent complete excision of the urachal remnant and made an uneventful recovery; bacterial culture grew Staphylococcus aureus. Subsequent investigations did not reveal any other renal tract abnormalities.

Occult blood loss from small bowel tumours. Case report

We report 4 patients who presented with occult blood loss, from a small bowel adenocarcinoma, in whom there was considerable delay in diagnosis. The difficulty in diagnosis and the role of CT scanning is discussed. We recommend a careful laparotomy when endoscopic and radiological investigations fail to reveal the source of blood loss.

Small bowel obstruction: computer-assisted prediction of strangulation at presentation

A multivariate computer analysis has been performed on the presenting data of patients with simple small bowel obstruction that settled with conservative treatment (n = 120) and of patients with viable strangulation small bowel obstruction (n = 38) and non-viable strangulation small bowel obstruction (n = 39) found at operation. Initially only 66 per cent of patients with viable strangulation and 46 per cent of those with non-viable strangulation had been treated by immediate surgery after resuscitation. The remainder had been treated conservatively for a median of 3.8 and 2.2 days respectively before undergoing surgery. The computer predicted on the basis of presenting symptoms and signs that 82 per cent of patients with viable strangulation and 97 per cent of those with non-viable strangulation had or would develop strangulation and should have undergone immediate surgery. We advocate that the computer can assist in the management of patients with small bowel obstruction.

Leiomyosarcoma of the scrotum

A case of leiomyosarcoma arising from the dartos muscle of the scrotum is described. Review of the literature reveals only eight other cases, and aspects of management of these and our case are discussed.

Reticuloendothelial system phagocytic function in obstructive jaundice and its modification by a muramyl dipeptide analogue

Measurement of reticulo-endothelial system (RES) phagocytic function by clearance of intravenous micro-aggregated human albumin (HMAA) showed prolonged clearance in both patients (p less than 0.001) and rats (p less than 0.001) with extrahepatic biliary tract obstruction compared with non-jaundiced controls. After the administration of the immune stimulator, N-acetyl-L-alpha-aminobutyryl-D-isoglutamine, the mean HMAA clearance rate in jaundiced animals was similar to that of non-jaundiced controls. The implications of modifying RES phagocytic function to prevent overspill of endotoxins from the portal to systemic circulation in obstructive jaundice are discussed.

The Kupffer cell in experimental extrahepatic cholestasis in the rat--a light microscopy, immunohistochemical and electron microscopy study

Kupffer cell phagocytic function is reduced in the presence of obstructive jaundice. To investigate possible mechanisms we report a study of the rat liver in extrahepatic cholestasis, using light microscopy, immunohistochemistry and electron microscopy, Immunohistochemistry was performed with monoclonal antibodies specific for rat Kupffer cells ED 1, ED 2 and ED 3 and monoclonal antibodies directed against class II antigens of the rat major histocompatibility complex Ox 3 and Ox 6. Extrahepatic cholestasis was produced by bile duct ligation. In bile duct ligated animals light microscopy showed proliferation of bile ductules and an increase in sinusoidal cells. Immunohistochemistry with ED 1, ED 2 and ED 3 demonstrated a marked increase in the number of positive cells, but few of these cells were positive with Ox 3 and Ox 6, whereas the proliferating bile ductules were strongly positive. Electron microscopy revealed two homogeneous granular substances within the sinusoidal lumen and loss of the space of Disse. Despite a reduction in Kupffer cell phagocytic function in obstructive jaundice there is an increase in Kupffer cells, but these cells appear to be in an inactivated state as few express class II antigens on their surface. Furthermore the granular substance within the space of Disse may interfere with function.

Malignant melanoma of a parotid lymph gland. An unusual case

A case of malignant melanoma in an intra-parotid lymph gland treated by excision is reported. The patient remains disease-free 9 years after surgical treatment, and no primary lesion has been found.

A simple and economic technique for long-term continuous intravenous infusion in the unrestrained rat

A reliable, inexpensive and ethically acceptable method for long-term intravenous infusion in unrestrained rats is described. This system absorbs rotational forces produced by the animal turning without kinking of the tube.

Non-steroidal anti-inflammatory drugs and peptic ulcer perforation

A retrospective study is reported in which the ingestion of non-steroidal anti-inflammatory drugs (NSAID) in 269 patients with perforated peptic ulceration and 269 age/sex matched controls admitted between 1973-1982 was compared. A highly significant statistical difference was found (p less than 0.001) in those aged over 65. There was no statistical difference, however, in those aged under 65. Furthermore we have shown a highly statistically significant correlation (p less than 0.0001) between the annual number of patients aged over 65 with perforated peptic ulcers taking NSAID and the annual number of prescriptions issued for these drugs in the region. No such correlation was found for patients aged under 65 years. We suggest that the elderly especially women are unduly susceptible to NSAID associated peptic ulcer perforation, and discuss factors that may account for this.