An Objective Computer-Assisted Measurement of Sonographic Renal Cortical Echogenicity: The Splenorenal Index

ABSTRACT

Renal cortical echogenicity represents a marker of renal function. However, evaluation of the renal echotexture is subjective and thus disposed to error and interrater variability. Computer-aided image analysis may be used to objectively assess renal cortical echogenicity by comparing the echogenicity of the left kidney to that of the spleen; the resultant ratio is referred to as the splenorenal index (SRI). We performed a retrospective review of all adult patients who received a renal ultrasound over a 45-day period at our institution. Demographic data and kidney function laboratory values were documented for each patient. Regions of interest (ROIs) were selected in the left renal cortex and spleen using ImageJ software. The SRI was calculated as a ratio of the mean pixel brightness of the left kidney cortex ROI to the mean pixel brightness of the spleen ROI. The SRI was then correlated with serum creatinine, blood urea nitrogen, and estimated glomerular filtration rate. We found that among the 94 patients included in the study, the SRI had a significant positive correlation with serum creatinine ( r = 0.43, P < 0.001) and serum blood urea nitrogen ( r = 0.45, P < 0.001) and negative correlation with estimated glomerular filtration rate ( r = -0.47, P < 0.001). Our data indicate that SRI may serve as a valuable tool for sonographic evaluation of renal parenchymal disease.

Work-Life Experience of Academic Radiologists: Food for Thought

RATIONALE AND OBJECTIVES

Work-life experience of physicians is a driver of work engagement vs. burnout. We aimed to determine individual and institutional factors affecting work-life experience of the clinical faculty at a large tertiary care academic medical center.

MATERIALS AND METHODS

The Department of Radiology clinical faculty (n = 62) were surveyed electronically in October 2022. Twenty-three questions, consisting of multiple choice, Yes/No, and Likert scale ratings were administered to obtain demographic information and data for life outside of work, life at work, and work-life integration for the prior 12 months. Work engagements in terms of clinical, research, administrative, and education; work practices including engagement in extra work and remote work; life responsibilities; and utilization of work-life balance strategies were analyzed for percentages and differences in seniority levels and genders. Ratings of faculty work engagement and life integration strategies were assessed utilizing a 1-5 Likert scale. Descriptive statistics were utilized to report mean, standard deviation, median, Q1 and Q3 for continuous measurements, while count and percentage for categories measurements. Comparisons between seniority and gender categories were conducted using independent t-test or Wilcoxon rank sum test depending on data normality assessed through histogram analysis. Chi-square test was used to make comparisons for categorical data. When encountered with small cell (category with <5 count), Fisher's exact test was used for 2 × 2 table analysis and Freeman-Halton test was used for comparisons with more than two categories. SAS 9.4 was used for the data analysis.

RESULTS

Twenty-eight faculty (M:F = 17:11) responded to the survey (survey response rate 45%). The vast majority of faculty reported working extra hours, with 40% working at least 10 hours extra per week. Total of 42.9% reported performing clinical work in the extra hours worked. Total 70.4% of faculty had caregiver responsibilities and 64.3% reported other individual stresses (e.g., financial, family/social, health-related), which required consistent demand of time and effort. A total of 35.7% of faculty reported not being able to balance competing life and work demands. A total of 21.4% respondents reported not utilizing any individual healthy lifestyle choices on a consistent basis over the prior 12 months. Protected time off work and remote work were perceived as effective strategies to provide adequate work-life balance; however, remote work engagement was relatively minor and 35.7% bought back vacation. Total 53.6% respondents reported a level 4 (out of 5) rating for work being meaningful and being positively engaged in their work.

CONCLUSION

Institutions should invest in providing the infrastructure for physician work-life balance and in facilitating healthy lifestyle choices for physicians.

Detected prenatal perfluorooctanoic acid (PFOA) exposure is associated with decreased fetal head biometric parameters in participants experiencing higher perceived stress during pregnancy in the MADRES cohort

BACKGROUND

Perfluoroalkyl substances (PFAS) are ubiquitous synthetic chemicals with long half-lives and are known to cross the placenta during pregnancy. We examined the influence of maternal PFAS levels on in utero fetal growth trajectories and assessed whether maternal stress modified these associations.

METHODS

Blood serum concentrations of five PFAS (PFOS, PFHxS, PFNA, PFOA, PFDA) were measured in 335 prenatal specimens (mean gestational age (GA): 21±9 weeks) in the MADRES cohort. Fetal growth outcomes (head circumference (HC), abdominal circumference (AC), biparietal diameter (BPD), femur length (FL), and estimated fetal weight (EFW)) were abstracted from ultrasound medical records and measured at the 3rd trimester study visit (N = 833 scans, GA range 10-42 weeks, mean 2.4 scans/participant). Adjusted linear mixed models with a GA quadratic growth curve were used for each PFAS exposure and growth outcome. PFOS and PFHxS were modeled continuously (100% sample detection), while PFOA, PFNA, and PFDA were modeled categorically (57-70% sample detection). Scores on the Perceived Stress Scale (PSS) measured in pregnancy were dichotomized at the median (<13 vs. ≥ 13) in stratified models.

RESULTS

Participants were on average 29±6 years old and predominately Hispanic (76%). Median serum concentrations of PFOS, PFHxS, PFNA, PFOA and PFDA were 1.34, 1.10, 0.07, 0.12, and 0.04 ng/mL, respectively. Participants with detected PFOA concentrations had fetuses with -2.5 mm (95% CI -4.2, -0.8) smaller HC and-0.7 mm (95% CI -1.3, -0.2) smaller BPD on average for a fixed GA than those without detected PFOA concentrations. In models stratified by PSS level, the effects of PFOA on fetal growth parameters were stronger and only significant in participants with higher stress levels (HC: β= -3.5, 95% CI -5.8, -1.4; BPD: β = -0.8, 95% CI -1.6, -1.1).

CONCLUSIONS

Prenatal PFOA exposure adversely impacted fetal head biometric parameters in participants experiencing higher stress during pregnancy.

Prenatal Perfluorooctanoic Acid (PFOA) Exposure Is Associated With Lower Infant Birthweight Within the MADRES Pregnancy Cohort

Introduction

Perfluoroalkyl and polyfluoroalkyl substances (PFAS) are persistent synthetic chemicals found in household products that can cross the placenta during pregnancy. We investigated whether PFAS exposure during pregnancy was associated with infant birth outcomes in a predominantly urban Hispanic population.

Methods

Serum concentrations of perfluorooctanoic acid (PFOA), perfluorooctanesulfonic acid (PFOS), perfluorohexanesulfonic acid (PFHxS), perfluorononanoic acid (PFNA), and perfluorodecanoic acid (PFDA) were measured in 342 prenatal biospecimens (mean gestational age: 21 ± 9 weeks) from participants in the ongoing Maternal And Developmental Risks from Environmental and Social Stressors (MADRES) cohort. PFAS compounds were modeled continuously or categorically, depending on the percentage of samples detected. The birth outcomes assessed were birthweight, gestational age at birth, and birthweight for gestational age (BW-for-GA) z-scores that accounted for parity or infant sex. Single pollutant and multipollutant linear regression models were performed to evaluate associations between PFAS exposures and birth outcomes, adjusting for sociodemographic, perinatal, and study design covariates.

Results

Maternal participants (n = 342) were on average 29 ± 6 years old at study entry and were predominantly Hispanic (76%). Infants were born at a mean of 39 ± 2 weeks of gestation and weighed on average 3,278 ± 522 g. PFOS and PFHxS were detected in 100% of the samples while PFNA, PFOA, and PFDA were detected in 70%, 65%, and 57% of the samples, respectively. PFAS levels were generally lower in this cohort than in comparable cohorts. Women with detected levels of PFOA during pregnancy had infants weighing on average 119.7 g less (95% CI -216.7, -22.7) than women with undetected levels of PFOA in adjusted single pollutant models. PFOA results were also statistically significant in BW-for-GA z-score models that were specific for sex or parity. In models that were mutually adjusted for five detected PFAS compounds, PFOA results remained comparable; however, the association was only significant in BW-for-GA z-scores that were specific for parity (β = -0.3; 95% CI -0.6, -0.01). We found no significant adjusted associations with the remaining PFAS concentrations and the birth outcomes assessed.

Conclusion

Prenatal exposure to PFOA was associated with lower birthweight in infants, suggesting that exposure to these chemicals during critical periods of development might have important implications for children's health.

Indicators of successful implementation of programs to promote healthy weight among women

Obesity rates have steadily increased over the past two decades. To address the epidemic in women, the Health Resources and Services Administration's Maternal and Child Health Bureau, Division of Healthy Start and Perinatal Services (HRSA/MCHB/DHSPS) awarded 14 demonstration grants to community health centers, health departments, universities and community-based organizations in 12 states to develop innovative approaches aimed at reducing the prevalence of overweight and obesity, specifically in women of childbearing age. Grantees implemented modified or existing evidence-based programs (EBP) or promising practices tailored to the geographic locations, cultures and traditional values of the communities. A review of the 15 programs implemented from 2004 to 2007 was conducted using the methodology outlined in the Transparent Reporting of Evaluations with Nonrandomized Designs Statement to identify indicators of successful program implementation. The six indicators identified were: (1) supportive organizational culture with adequate resources and appropriate staff; (2) attention to the needs of the service population; (3) a referral system that links participants to appropriate services; (4) flexible schedules; (5) support for child care and transportation; and (6) formal and informal support systems to keep participants engaged and motivated. Two of the programs that reported improved participant outcomes are available for replication: La Vida Sana, La Vida Feliz in Illinois was designated as a promising practice by the Association of Maternal and Child Health Programs and Sisters in Action in Michigan was rated as a moderate evidence-based program by the Agency for Healthcare Research and Quality.

Ruggedness and reproducibility of the MBEC biofilm disinfectant efficacy test

The MBEC™ Physiology & Genetics Assay recently became the first approved ASTM standardized biofilm disinfectant efficacy test method. This report summarizes the results of the standardization process using Pseudomonas aeruginosa biofilms. Initial ruggedness testing of the MBEC method suggests that the assay is rugged (i.e., insensitive) to small changes to the protocol with respect to 4 factors: incubation time of the bacteria (when varied from 16 to 18h), treatment temperature (20-24°C), sonication duration (25-35min), and sonication power (130-480W). In order to assess the repeatability of MBEC results across multiple tests in the same laboratory and the reproducibility across multiple labs, an 8-lab study was conducted in which 8 concentrations of each of 3 disinfectants (a non-chlorine oxidizer, a phenolic, and a quaternary ammonium compound) were applied to biofilms using the MBEC method. The repeatability and reproducibility of the untreated control biofilms were acceptable, as indicated by small repeatability and reproducibility standard deviations (SD) (0.33 and 0.67 log10(CFU/mm(2)), respectively). The repeatability SDs of the biofilm log reductions after application of the 24 concentration and disinfectant combinations ranged from 0.22 to 1.61, and the reproducibility SDs ranged from 0.27 to 1.70. In addition, for each of the 3 disinfectant types considered, the assay was statistically significantly responsive to the increasing treatment concentrations.

Soy-dairy protein blend and whey protein ingestion after resistance exercise increases amino acid transport and transporter expression in human skeletal muscle

Increasing amino acid availability (via infusion or ingestion) at rest or postexercise enhances amino acid transport into human skeletal muscle. It is unknown whether alterations in amino acid availability, from ingesting different dietary proteins, can enhance amino acid transport rates and amino acid transporter (AAT) mRNA expression. We hypothesized that the prolonged hyperaminoacidemia from ingesting a blend of proteins with different digestion rates postexercise would enhance amino acid transport into muscle and AAT expression compared with the ingestion of a rapidly digested protein. In a double-blind, randomized clinical trial, we studied 16 young adults at rest and after acute resistance exercise coupled with postexercise (1 h) ingestion of either a (soy-dairy) protein blend or whey protein. Phenylalanine net balance and transport rate into skeletal muscle were measured using stable isotopic methods in combination with femoral arteriovenous blood sampling and muscle biopsies obtained at rest and 3 and 5 h postexercise. Phenylalanine transport into muscle and mRNA expression of select AATs [system L amino acid transporter 1/solute-linked carrier (SLC) 7A5, CD98/SLC3A2, system A amino acid transporter 2/SLC38A2, proton-assisted amino acid transporter 1/SLC36A1, cationic amino acid transporter 1/SLC7A1] increased to a similar extent in both groups (P < 0.05). However, the ingestion of the protein blend resulted in a prolonged and positive net phenylalanine balance during postexercise recovery compared with whey protein (P < 0.05). Postexercise myofibrillar protein synthesis increased similarly between groups. We conclude that, while both protein sources enhanced postexercise AAT expression, transport into muscle, and myofibrillar protein synthesis, postexercise ingestion of a protein blend results in a slightly prolonged net amino acid balance across the leg compared with whey protein.

Beyond hemostasis: spectrum of gynecologic and obstetric indications for transcatheter embolization

Percutaneous vascular embolization is a useful therapeutic option for a wide range of gynecologic and obstetric abnormalities. Transcatheter embolization procedures performed with the use of radiologic imaging for guidance are minimally invasive and may obviate surgery, thereby decreasing morbidity and mortality and safeguarding the patient's future fertility potential. To integrate this treatment method optimally into patient care, knowledge is needed about the clinical indications for therapeutic embolization, the relevant vascular anatomy, technical considerations of the procedure, and the potential risks and benefits of embolization. The most well-known and well-studied transcatheter embolization technique for treating a gynecologic-obstetric condition is uterine fibroid embolization. However, the clinical indications for transcatheter embolization are much broader and include many benign gynecologic conditions, such as adenomyosis and arteriovenous malformations, as well as intractable bleeding due to inoperable advanced-stage malignancies. Uterine artery embolization may be performed to prevent or treat bleeding associated with various obstetric conditions, including postpartum hemorrhage, placental implantation abnormality, and ectopic pregnancy. Embolization of the uterine artery or the internal iliac artery also may be performed to control pelvic bleeding due to coagulopathy or iatrogenic injury, and ovarian vein embolization has been shown to be effective for the management of pelvic congestion syndrome. The article discusses these and other gynecologic and obstetric indications for transcatheter embolization, provides detailed descriptions of imaging findings before and after embolization, and reviews procedural techniques and outcomes.

Evidence of heterogeneity within bovine satellite cells isolated from young and adult animals

Satellite cells are a heterogeneous population of myogenic precursors responsible for muscle growth and repair in mammals. The objectives of the experiment were to examine the growth rates and degree of heterogeneity within bovine satellite cells (BSC) isolated from young and adult animals. The BSC were harvested from the semimembranosus of young (4.3 ± 0.5 d) and adult (estimated 24 to 27 mo) cattle and cultured en masse. Young animal BSC re-enter the cell cycle sooner and reach maximal 5-ethynyl-2'-deoxyuridine (EdU) incorporation earlier (P < 0.05) than adult contemporaries. Adult BSC contain fewer (P < 0.05) MyoD and myogenin immunopositive nuclei than BSC isolated from young animals after 3, 4, and 5 d in culture. These results indicate that BSC from young animals activate, proliferate, and differentiate sooner than isolates from adult animals. Lineage heterogeneity within BSC was examined using antibodies specific for Pax7 and Myf5, lineage markers of satellite cells, and myoblasts. Immunocytochemistry revealed the majority of Pax7-expressing BSC also express Myf5; a minor population (~5%) fails to exhibit Myf5 immunoreactivity. The percentage of Pax7:Myf5 BSC from young animals decreases sooner (P < 0.05) in culture than adult BSC, indicating a more rapid rate of muscle fiber formation. A subpopulation immunopositive for Myf5 only was identified in both ages of BSC isolates. The growth kinetics and heterogeneity of young BSC was further evaluated by clonal analysis. Single cell clones were established and analyzed after 10 d. Colonies segregated into 2 groups based upon population doubling time. Immunostaining of the slow-growing colonies (population doubling time ≥ 3 d) revealed that a portion exhibited asymmetric distribution of the lineage markers Pax7 and Myf5, similar to self-renewable mouse muscle stem cells. In summary, these results offer insight into the heterogeneity of BSC and provide evidence for subtle differences between rodent and bovine myogenic precursors.

The use of C(av) rather than AUC in safety assessment

Toxicokinetic data have traditionally been presented as maximum observed plasma concentrations (C(max)) and area under the concentration time curve (AUC) values. These values have been used to compare exposures across studies and species to provide valuable interpretation of drug safety data. Increasingly, questions are asked of toxicology studies to more accurately describe the concentration effect relationships in terms of compound affinity for target and off-target receptors. C(max) values can immediately be referenced to known pharmacological activities, particularly when the extent of plasma protein binding is taken into account. This provides a measure of the more pharmacologically relevant free drug exposure. AUC values on the other hand contain the component of time, which means that direct comparison to pharmacological activity values are not immediately possible. Conversion of AUC to average plasma concentration (C(av)) provides a simple and convenient means to allow such a comparison without losing any information imparted by AUC values. In this paper, the benefit and advantage of applying C(av) values is illustrated using examples taken from the literature.

Effects of steroidal implantation and ractopamine-HCl on nitrogen retention, blood metabolites and skeletal muscle gene expression in Holstein steers

Six Holstein steers (231 +/- 17 kg) housed in metabolism crates were used in a randomized complete block design with three blocks of two steers based on previous serum insulin-like growth factor (IGF)-I concentrations. One of the two steers in each block was implanted with 120 mg trenbolone acetate and 24 mg oestradiol-17beta on day 0. None of the steers was fed ractopamine-HCl in the initial 28 days, and then all steers were fed 200 mg of ractopamine-HCl per steer daily from day 28 until the end of the trial. Steers were fed a corn-based diet (62% rolled corn, 20% expeller soya bean meal and 15% alfalfa hay) twice daily with an average dry matter intake of 4.8 kg/day. Blood and M. longissimus biopsy samples were collected prior to implantation and on days 14, 28, 42 and 56. There was an implant x ractopamine interaction for retained nitrogen (p < 0.05); ractopamine feeding led to only small improvements in nitrogen retention for implanted steers (45.9 g/day vs. 44.5 g/day), whereas ractopamine led to larger increases in nitrogen retention for non-implanted steers (39.0 g/day vs. 30.4 g/day). Implantation increased (p < 0.05) and ractopamine tended to decrease (p = 0.06) serum IGF-I concentrations. Implantation tended to increase (p = 0.16) and ractopamine decreased (p < 0.05) mRNA expression of IGF-I in the M. longissimus. Ractopamine decreased mRNA expression of beta(1)- and beta(2)-receptors in M. longissimus (p </= 0.02). The steroidal implant and the feeding of ractopamine both increased nitrogen retention in steers, but the combination did not yield an additive response. The two growth promotants had opposite effects on serum concentrations of IGF-I and mRNA expression of IGF-I in M. longissimus.

Effects of ractopamine and protein source on growth performance and carcass characteristics of feedlot heifers1

An experiment was conducted to determine the relationship between feeding ractopamine and different amounts of MP on growth and carcass characteristics of feedlot heifers. Seventy-two crossbred heifers (475 kg of initial BW) were fed individually a diet based on steam-flaked corn for ad libitum intake for 29 d. Heifers were implanted with 140 mg of trenbolone acetate and 14 mg of estradiol-17beta 60 d before the experiment. Treatments were arranged as a 2 x 3 factorial and included 0 or 200 mg of ractopamine-HCl (23 ppm)/ d, and urea, solvent soybean meal, or expeller soybean meal (ESBM) as the predominant protein supplement. The amounts of MP supplied by the urea, solvent soybean meal, and ESBM diets were 688, 761, and 808 g/ d, respectively, calculated according to level 1 of the NRC model. Body weights were obtained 1 d before ractopamine feeding and at slaughter. Blood samples were obtained 1 d before starting the experiment and 13 d later. Ractopamine improved ADG, efficiency of gain, carcass-adjusted ADG, and carcass-adjusted efficiency of gain (P < 0.01). For ADG, heifers demonstrated a ractopamine x protein source interaction (P < 0.05); heifers not fed ractopamine had greater ADG when fed ESBM than when fed urea, whereas for heifers fed ractopamine there were no differences (P > or = 0.10) among protein supplements. This interaction was not observed for carcass-adjusted ADG (P = 0.60). Final live weights (P = 0.02) and carcass weights (P = 0.01) were greater with ractopamine feeding. Carcass marbling scores and yield grades were not affected by ractopamine or protein source (P > or = 0.39). Plasma total alpha-amino N and glucose concentrations decreased more from pretreatment concentrations when heifers were fed ractopamine (P < 0.05). Feeding ractopamine to heifers for 28 d before slaughter improved ADG and efficiency of gain without any large effects on carcass characteristics. The MP supply does not need to be increased from that provided by finishing diets based on steam-flaked corn with urea as the primary N supplement to allow the maximal response to ractopamine by finishing heifers.

Effects of dietary ruminally protected l-carnitine on plasma metabolites in sheep following a sub-lethal ammonia challenge

In Experiment 1, lambs were randomly assigned to 0.25, 1.00, 2.50, 5.00 and 10.00 g/day of dietary ruminally protected L-carnitine (RPLC) and were allowed to adapt for 20 days. Plasma samples were obtained at 0, 120 and 240 min after RPLC feeding. Plasma L-carnitine (LC) concentrations increased (p<0.01) for all levels of RPLC treatment, however, no differences were observed due to level of RPLC or time. Plasma LC concentrations were 27.05 and 57.83 micromol/l for baseline and pooled RPLC treated sheep, respectively. In Experiment 2, lambs were randomly assigned to 0, 0.125, 1.06 and 2.0 g/day of RPLC and were adapted as in Experiment 1. Plasma was collected at 0, 15, 30, 60, 90, 180, 240 and 360 min after oral ammonia challenge (300 mg/kg BW urea). Plasma LC concentrations increased with treatment relative to control (p<0.01). Plasma LC concentrations were 35.7, 44.2, 60.5 and 65.7 micromol/l for the 0, 0.125, 1.06 and 2.0 g/day treatments, respectively. RPLC tended to decrease plasma ammonia at some time points (time x treatment; p=0.10). We conclude that RPLC increased plasma LC concentrations, but had only modest effects on plasma ammonia concentrations and had no effect on plasma urea or glucose concentrations.

The use of pharmacokinetic and pharmacodynamic data in the assessment of drug safety in early drug development

The pharmaceutical industry continues to look for ways to reduce drug candidate attrition throughout the drug discovery and development process. A significant cause of attrition is due to safety issues arising either as a result of animal toxicity testing or in the clinical programme itself. A factor in the assessment of safety during early drug development is the pharmacokinetic profile of the compound. This allows safety data to be considered in the light of systemic drug exposure and therefore permits a quantitative assessment. This is particularly applicable when assessing the risk of a new chemical entity (NCE) in relation to safety parameters such as QT interval prolongation, where free plasma concentrations have been shown to be predictive of this property in relation to potency in preclinical testing. Prior to actual human exposure it is therefore important to be able to predict reliably the pharmacokinetic behaviour of an NCE in order to place such safety findings into a quantitative risk context. The emerging science of pharmacogenetics is likely to further our ability to assess the risk of NCEs to populations and individuals due to genetic variance. The drug metabolizing enzyme CYP2D6 has been recognized as providing the potential to result in widely differing systemic drug exposure in the patient population due to polymorphic expression. Further knowledge is likely to add to our understanding of population differences in exposure and response and aid in the identification of risk factors. One potential strategy for improving the effectiveness of the drug discovery process is to obtain clinical pharmacokinetic data more rapidly in order to assess more accurately the potential for both efficacy and safety of an NCE. Whilst procedures and technologies are available that allow this on the microdose scale, it is important that we recognize potential limitations of these approaches in order that they can be applied beneficially.

The disposition of voriconazole in mouse, rat, rabbit, guinea pig, dog, and human

Voriconazole is a new triazole antifungal agent with potent, wide-spectrum activity. Its pharmacokinetics and metabolism have been studied in mouse, rat, rabbit, dog, guinea pig, and humans after single and multiple administration by both oral and intravenous routes. Absorption of voriconazole is essentially complete in all species. The elimination of voriconazole is characterized by non-linear pharmacokinetics in all species. Consequently, pharmacokinetic parameters are dependent upon dose, and a superproportional increase in area under the curve is seen with increasing dose in rat and dog toxicology studies. Following multiple administration, there is a decrease in systemic exposure. This is most pronounced in mouse and rat, less so in dog, and not observed in guinea pig or rabbit. Repeat-dose toxicology studies in mouse, rat, and dog have demonstrated that induction of cytochrome P450 by voriconazole (autoinduction of metabolism) is responsible for the decreased exposure in these species. Autoinduction of metabolism is not observed in humans, and plasma steady-state concentrations remain constant with time. Voriconazole is extensively metabolized in all species. The major pathways in humans involve fluoropyrimidine N-oxidation, fluoropyrimidine hydroxylation, and methyl hydroxylation. Also, N-oxidation facilitates cleavage of the molecule, resulting in loss of the fluoropyrimidine moiety and subsequent conjugation with glucuronic acid. Major pathways are represented in animal species. The major circulating metabolite in rat, dog, and human is the N-oxide of voriconazole. It is not thought to contribute to efficacy since it is at least 100-fold less potent than voriconazole against fungal pathogens in vitro.

Pharmacokinetics of selamectin following intravenous, oral and topical administration in cats and dogs

The pharmacokinetics of selamectin were evaluated in cats and dogs, following intravenous (0.05, 0.1 and 0.2 mg/kg), topical (24 mg/kg) and oral (24 mg/kg) administration. Following selamectin administration, serial blood samples were collected and plasma concentrations were determined by high performance liquid chromatography (HPLC). After intravenous administration of selamectin to cats and dogs, the mean maximum plasma concentrations and area under the concentration-time curve (AUC) were linearly related to the dose, and mean systemic clearance (Clb) and steady-state volume of distribution (Vd(ss)) were independent of dose. Plasma concentrations after intravenous administration declined polyexponentially in cats and biphasically in dogs, with mean terminal phase half-lives (t(1/2)) of approximately 69 h in cats and 14 h in dogs. In cats, overall Clb was 0.470 +/- 0.039 mL/min/kg (+/-SD) and overall Vd(ss) was 2.19 +/- 0.05 L/kg, compared with values of 1.18 +/- 0.31 mL/min/kg and 1.24 +/- 0.26 L/kg, respectively, in dogs. After topical administration, the mean C(max) in cats was 5513 +/- 2173 ng/mL reached at a time (T(max)) of 15 +/- 12 h postadministration; in dogs, C(max) was 86.5 +/- 34.0 ng/mL at T(max) of 72 +/- 48 h. Bioavailability was 74% in cats and 4.4% in dogs. Following oral administration to cats, mean C(max) was 11,929 +/- 5922 ng/mL at T(max) of 7 +/- 6 h and bioavailability was 109%. In dogs, mean C(max) was 7630 +/- 3140 ng/mL at T(max) of 8 +/- 5 h and bioavailability was 62%. There were no selamectin-related adverse effects and no sex differences in pharmacokinetic parameters. Linearity was established in cats and dogs for plasma concentrations up to 874 and 636 ng/mL, respectively. Pharmacokinetic evaluations for selamectin following intravenous administration indicated a slower elimination from the central compartment in cats than in dogs. This was reflected in slower clearance and longer t(1/2) in cats, probably as a result of species-related differences in metabolism and excretion. Inter-species differences in pharmacokinetic profiles were also observed following topical administration where differences in transdermal flux rates may have contributed to the overall differences in systemic bioavailability.

Absorption, distribution, metabolism, and excretion considerations in selection of orally active indole-containing endothelin antagonist

A series of potent indole-containing endothelin antagonists were evaluated in rat pharmacokinetic studies as part of a rational drug design program. Early compounds in this series were found to show poor gastrointestinal absorption, limiting their utility as oral agents. Structural modifications and pharmacokinetic studies indicated that reducing the overall H-bonding potential, through a reduction in the number of H-bond donors and acceptors, could increase absorption of the molecules. There was a correlation between calculated H-bonding capacity and rate of permeability across Caco-2 monolayers for this series of compounds. Caco-2 permeability was also shown to be indicative of the estimated extent of absorption in rats. Balancing the requirements of absorption and systemic clearance lead to the selection of an alcohol-containing compound, compound 7a (single enantiomer of compound 7) that was moderately absorbed after oral administration and converted to an active acid metabolite, which itself was of low intrinsic clearance. Species differences were observed between the absorption of compound 7a in rat and dog and also in the extent of conversion to the acid metabolite. Absorption was estimated at 30% in rat and 100% in dog. Approximately 30% of the absorbed drug was converted to systemically available acid metabolite in rat, compared with only 3% in dog.

Potential role for P-glycoprotein in the non-proportional pharmacokinetics of UK-343,664 in man

1. UK-343,664 is a potent and specific PDE5 inhibitor. Following single oral doses to human volunteers, it exhibited non-proportional pharmacokinetics over the dose range 30-800 mg. Over this 27-fold dose range, Cmax and AUCt increased 247- and 287-fold respectively. The half-life (4-6 h) was similar at all doses. No systemic exposure was quantifiable at doses <10 mg. 2. UK-343,664 is a lipophilic molecule (log D7.4 = 3.1) and as such is expected to be cleared mainly by metabolism. Based on studies with expressed human P450 enzymes it was concluded that the metabolism of UK-343,664 was predominantly mediated by CYP3A4. With a moderate Km = 76 microM for this enzyme, saturation of first-pass metabolism alone was considered unlikely to account for the non-proportional pharmacokinetics. 3. UK-343,664 showed high affinity for P-glycoprotein in vitro, with a Km = 7.3 microM. In transport studies in LLC-PK1 cell monolayers transfected with P-glycoprotein, UK343,664 showed marked polarized transport which was concentration dependent. 4. The high affinity of UK-343,664 for P-glycoprotein is considered to be the primary source of the non-proportional pharmacokinetic profile observed in man.

Pharmacokinetics and metabolism of a selective PDE5 inhibitor (UK-343,664) in rat and dog

1. UK-343,664 is a novel potent and selective PDE5 inhibitor. Plasma clearances in the male and female rat were high (120 and 54 ml min(-1) kg(-1)), giving rise to short elimination half-lives (0.2 and 0.3h respectively). Lower clearance in dog (14 ml min(-1) kg(-1)) was the primary factor resulting in a longer elimination half-life (3.7 h). The higher clearance in rat than dog was in agreement with in vitro metabolism rates in hepatic microsomes. 2. The volume of distribution was lower in rat (1.3-2.11 kg(-1)) compared with dog (4.61 kg(-1)) probably due to increased plasma protein binding in rat (96 versus 81% in dog). 3. Oral bioavailabilities were 2, 12 and 70% in the male and female rat and dog respectively. Tmax < or = 0.5 h in all animals. 4. In multiple oral dose studies, increased systemic exposure was seen with increasing dose up to doses of 200 mg kg(-1) in rat and 150 mg kg(-1) in dog. A marked super-proportional increase in the male rat indicated a capacity-limited clearance at high doses. 5. At the maximal dose of 200 mg kg(-1) in the female rat, no clinical signs were observed after 14 days of treatment. Only minimal signs were recorded in the male rat and dog at the highest dose levels investigated. 6. After single oral or intravenous doses of [14C]-UK-343,664, the majority of radioactivity was excreted in the faeces of both species. 7. UK-343,664 was extensively metabolized in both rat and dog. The major primary pathways in dog involved piperazine N-deethylation and loss of a two carbon fragment from the piperazine ring (N,N'-de-ethylation). More extensive metabolism in the rat included additional notable metalbolites arising from hydroxylation and lactamization of the piperazine ring, which were only minor metabolites in the dog.

A sensitive method for the measurement of the novel pet endectocide, selamectin (UK-124,114), in dog and cat plasma by chemical derivatisation and high-performance liquid chromatography with fluorescence detection

An analytical method has been developed for the novel pet endectocide, selamectin (USAN, UK-124, 114), in dog and cat plasma to facilitate pharmacokinetic profiling for this compound. The method involves solid phase extraction of the compound and internal standard from plasma followed by chemical derivatisation using triethylamine and trifluoroacetic anhydride. This reaction yields a highly fluorescent product and thus provides a sensitive assay. Using a sample volume of 1.0 ml for dog plasma the assay has been validated over a concentration range of 0.2-40 ng/ml. Due to smaller plasma volumes for cat plasma samples, the assay was validated over a concentration range of 1.0- 200 ng/ml using a sample volume of 0.2 ml. The analyte has been shown to be stable for 48 h at room temperature and through three freeze thaw cycles in dog plasma. The analytical method is highly specific and proved suitable for the analysis of selamectin in dog and cat plasma samples following doses of compound by parenteral and non-parenteral routes.

How well does the questionnaire for identifying children with chronic conditions identify individual children who have chronic conditions?

BACKGROUND

The Questionnaire for Identifying Children With Chronic Conditions (QuICCC) is an instrument based on a conceptual noncategorical definition that uses parental responses to identify children with chronic conditions for epidemiological purposes.

OBJECTIVES

To determine whether the QuICCC is sufficiently valid, sensitive, and specific to be used to identify individual children as having a chronic condition or disability; whether parents are accurate enough that their answers to QuICCC items can be accepted as valid; and what kinds of errors in classification occur when the QuICCC is used to identify children with chronic conditions.

METHODS

The sample consisted of 424 children who were patients of 9 physicians in separate practice settings throughout New England. Each physician was briefly trained in the conceptual definition on which the QuICCC is based and then was asked to identify 25 children in his or her practice who met the definition and 25 children who did not meet the definition. The QuICCC was administered to the parents of these children by blinded interviewers via telephone. The QuICCC classification was compared with physician categorization. Discrepant cases were then followed up by asking physicians and parents to answer the original questions a second time.

RESULTS

Complete data were available on 379 (89.4%) of 424 children. There was agreement on 89% (kappa = 0.78). The sensitivity was 94%; specificity, 83%; positive predictive value, 86%; and negative predictive value, 92%. Of the 42 discordant cases, 30 parent reports on the QuICCC qualified the child as having a chronic condition when the physician classified the child as being without such a condition. Fewer (n = 12) discrepancies occurred because physicians identified children with chronic conditions that the QuICCC failed to identify. When the questions were readministered at follow-up, physicians corrected errors in rating in 9 cases; mothers changed their answers in 5 instances. In 13 instances the issues were known to both parties and appeared to arise in the "gray zone" or boundary area, where there was disagreement over whether a particular child qualified using the theoretical definition. For 11 children identified as having a chronic condition only by the parent's responses to the QuICCC, physician report appeared to be inaccurate primarily due to the physician's lack of information. In 3 cases where the physician reported the child to have a chronic condition, but the parent did not, the physician appeared to be correct. Follow-up data were incomplete on 1 child.

CONCLUSIONS

These data support the validity of parent-generated information for the evaluation of health status. Although these findings should be replicated, this study suggests that the QuICCC may be applicable also as a screening tool for individual child identification, provided that several sources of error are considered.

The new St. Jude Medical regent mechanical heart valve: laboratory measurements of hydrodynamic performance

BACKGROUND AND AIM OF THE STUDY

The St. Jude Medical (SJM) mechanical heart valve was the first bileaflet valve with leaflets and orifice all fabricated from pyrolytic carbon. In 1992, a supra-annular cuff configuration, the SJM mechanical heart valve Hemodynamic Plus Series (HP), was introduced, which gave a one-size gain in orifice area over the standard valve. In a continuing effort to improve hydrodynamic performance, a new enhanced configuration of the mechanical valve - the SJM Regent valve - has been developed. The blood-contacting components of the SJM Regent valve have the same design features as those of the standard or HP valve, but the orifice lumen area has been increased, without compromising structural integrity, by a shift in the cuff-retaining orifice rims.

METHODS

Valve performance has been measured using a laboratory simulation of the left heart system. Three samples of both valve types (SJM Regent, HP) for sizes 17 mm to 27 mm, were tested at a cardiac output of 5 l/min. Supplementary steady-flow measurements were made at flow rates between 5 and 30 l/min. Pressure and flow signals were recorded and several performance parameters, including pressure gradient, effective orifice area (EOA), insufficiency (regurgitant volume as a percent of forward flow volume) and energy loss, were computed.

RESULTS

All sizes of the SJM Regent valve showed improved hydrodynamic performance compared with the HP valve. For the small sizes (17, 19, 21 mm), the pressure gradient of the SJM Regent decreased by 37%, 36% and 39%, respectively; the EOA increased by 22%, 22% and 21%; and the total transaortic energy loss decreased by 33%, 31% and 31% compared with the HP valve. The regurgitation for both valves ranged between 4% and 8% of forward flow volume over the 17-27 mm size range.

CONCLUSIONS

Hydrodynamic measurements confirm the gain of the SJM Regent valve over the HP valve that is expected based on the increased geometric orifice area. Given its basic similarity of design, but with an increased EOA as demonstrated in vitro, the SJM Regent valve is anticipated to provide an increased level of clinical benefit.

Pharmacokinetics and metabolism of sildenafil in mouse, rat, rabbit, dog and man

1. Pharmacokinetics were studied in mouse, rat, rabbit, dog and man after single intravenous and/or oral doses of sildenafil or [14C]-sildenafil (Viagra). 2. In man, absorption from the gastrointestinal tract was essentially complete. With the exception of male rat, Tmax occurred at approximately 1 h or less. Bioavailability was attenuated by pre-systemic hepatic metabolism in all species. 3. The volume of distribution was similar in rodents and humans (1-2 l/kg) but was greater in dog (5.2 l/kg), due to lower plasma protein binding (84 versus 94-96% respectively). 4. High clearance was the principal determinant of short elimination half-lives in rodents (0.4-1.3 h), whereas moderate clearance in dog and man resulted in longer half-lives (6.1 and 3.7 h respectively). Clearances were in agreement with in vitro metabolism rates by liver microsomes from the various species. 5. After single oral or intravenous doses of [14C]-sildenafil, the majority of radioactivity was excreted in the faeces of all species. No unchanged drug was detected in the excreta of man. 6. Five principal pathways of metabolism in all species were piperazine N-demethylation, pyrazole N-demethylation, loss of a two-carbon fragment from the piperazine ring (N,N'-deethylation), oxidation of the piperazine ring and aliphatic hydroxylation. Additional metabolites arose through combinations of these pathways. 7. Sildenafil was the major component detected in human plasma. Following oral doses, AUC(infinity) for the piperazine N-desmethyl and piperazine N,N'-desethyl metabolites were 55 and 27% that of parent compound respectively.

Assessing managed care for children with chronic conditions

This paper reviews opportunities to monitor managed care for children and adolescents with chronic conditions and considers how well the Health Plan Employer Data and Information Set, version 3.0 (HEDIS 3.0), assesses care for these children. We propose four steps to strengthen the applicability of HEDIS to children with chronic conditions: (1) develop methods of identifying and monitoring groups of children with chronic conditions; (2) report HEDIS indicators for these children separately from those for other children; (3) develop and implement consumer and provider surveys that elicit information specific to these populations; and (4) develop specific structure, process, and outcomes indicators for children with chronic conditions.

Automated 96-well solid phase extraction for the determination of doramectin in cattle plasma

Automated standard and sample preparation have been coupled with 96-well solid phase extraction (SPE) technology to produce a cost effective, high throughput system for the analysis of drugs in biological media. The system was originally designed using the Packard Multiprobe 104DT robotic sample processor (RSP) to improve throughput for the assay of doramectin in cattle plasma, and the assay has since been validated (0.5-100 ng ml[-1]) using the Tecan Genesis RSP 150/8. The robotic processor conducts all liquid handling procedures involved in sample extraction. These comprise preparation of calibration standards in plasma, dispensing and diluting of plasma samples and addition of internal standard. In addition, the robot primes the 96-well SPE block, applies calibration standards and samples, draws the mixtures through the 96-well SPE block, and finally washes the block ready for manual elution. The doramectin assay involves high-performance liquid chromatography (HPLC) with fluorescence detection, and requires the sample extracts to be derivatised prior to analysis. The derivatisation procedure is performed manually in situ in the polypropylene deep 96-well block into which the samples have been eluted from the SPE-block. The derivatised samples are taken directly from the deep well block and injected into the HPLC for analysis. This type of batch processing keeps sample transfer to a minimum. Automated sample preparation, in combination with the use of 96-well technology, has reduced both cost and effort required in the analysis of doramectin in cattle plasma samples, and has resulted in improved sample throughput.

Monitoring health care for children with chronic conditions in a managed care environment

OBJECTIVE

Children with chronic health conditions face special issues in their interactions with managed care. These children often require additional and more varied services than do other children. Managed care plans increasingly include these children, especially with the growth of Medicaid managed care. This article examines the special issues facing children with chronic conditions and develops strategies for monitoring their care in managed care settings.

METHODS

The project staff conducted an extensive review of the research and policy literature related to managed care and the special needs of families with children with chronic conditions. The project also reviewed current and proposed plans of federal, state, and private groups for monitoring and, working with parents and other outside groups, identified key issues to consider in developing monitoring plans.

RESULTS

The relative rarity of many childhood conditions and the complex interactions among child, family, and community over time make assessment of their care difficult. We describe these child and family characteristics, outline essential features and domains for monitoring systems, and describe population-based and plan-based monitoring systems to assess managed care for these children and their families.

CONCLUSIONS

Monitoring for children with chronic conditions in managed care arrangements will require public health agencies and health providers to define populations systematically, assess across a variety of conditions, and monitor several domains central to the health of these families.

Monitoring and evaluating managed care for children with chronic illnesses and disabilities

OBJECTIVE

Children with chronic illnesses and disabilities are increasingly enrolling in managed care arrangements. Yet, the rapid expansion of managed care has unknown consequences for children with chronic conditions and disabilities. As managed care is likely to become the predominant mode of medical practice for children with chronic health problems, information gained from a thorough assessment of existing managed care models could be helpful in indicating adjustments and modifications that could result in improved outcomes for this population. the purpose of this article is to outline a new strategy for collecting needed information on the effects of managed care on children with chronic health problems.

METHODS

We reviewed the literature on the effects of managed care on children with chronic conditions and disabilities. We identified key domains relevant to monitoring and evaluating managed care for this population.

RESULTS

Two research approaches can provide helpful information for assessing the effects of managed care on children with chronic conditions. First, a monitoring strategy could be pursued in which enrollment trends in managed care, enrollee perceptions of access and satisfaction with care, and other general indicators of outcomes would be tracked over time using inexpensive and rapid turnaround data sources. Second, an evaluative strategy could be pursued using experimental or quasiexperimental designs, in which outcomes across a variety of domains for children with chronic conditions in managed care are compared with: (a) outcomes for the same children before enrollment in managed care; or (b) outcomes for similar children remaining in traditional fee-for-service settings. Evaluation and monitoring strategies should focus on outcomes in a number of domains including: (1) access to care; (2) utilization of services; (3) quality of care; (4) satisfaction with care; (5) expenditures for care; (6) health outcomes; and (7) family impact.

CONCLUSION

Assessing outcomes that result from enrollment in managed care for children with chronic health problems presents a formidable challenge. The research strategy outlined in this article presents one approach to meeting that challenge. The monitoring and evaluation strategies described here would require commitment of additional resources on the part of government, private foundations, and/or health plans. Given the paucity of existing information and the stakes for children with chronic conditions and their families, investment of added resources in a comprehensive monitoring and evaluation strategy is essential.

Pharmacokinetics of a series of bis(methanesulphonamido-arylalkyl)amines in the beagle dog

1. The pharmacokinetics of three closely related analogues of dofetilide have been investigated in the beagle dog. These have been compared with those of dofetilide and related to physicochemical properties and structural features of the molecules. 2. Following intravenous administration, the four compounds exhibit elimination half-lives ranging from 4.6 to 19 h. This range is due to changes in both volume of distribution and plasma clearance across the series. 3. In vitro plasma protein shows a relationship to lipophilicity within this series. Protein binding increasing from 54% for dofetilide, the least lipophilic compound (log D7.4 = 0.73) to 92% for the most lipophilic analogue (log D7.4 = 2.07). There is a trend for a decrease in the volume of distribution with increased plasma protein binding. 4. Plasma clearance values range from 2.4 to 10.2 ml/min/kg and are comprised of renal and non-renal components. Renal clearance ranges fro 0.11 to 2.9 ml/min/kg and shows an inverse correlation with and lipophilicity of the compounds. Values for the renal clearance of unbound drug suggest that only the most lipophilic derivative (III), has sufficient membrane affinity to undergo tubular reabsorption. 5. Non-renal clearance of either total or free drug shows no relationship with lipophilicity. Highest values are observed for the two compounds with a methyl substituent on the tertiary amine and lowest values for the two compounds in which the tertiary amine is incorporated into a 7-membered ring. In vitro metabolism in dog liver microsomes also shows increased lability for the two N-methyl compounds. The N-desmethyl metabolite is the major product in both cases.

Design of drugs involving the concepts and theories of drug metabolism and pharmacokinetics

Drug metabolism input to the discovery process had historically been on an empirical case-by-case basis, since, detailed descriptors of the effect on pharmacokinetics of a change in structure or physicochemical property were not available. Considerable advances have been made in recent years, such that basic rules can be applied to predict the behavior of a compound in man based on physicochemistry and structure. This is particularly true in the areas of absorption, distribution, and clearance. In particular, knowledge of the reactions catalyzed by the enzymes of drug metabolism, including the cytochrome P450 super family, can be used in the design of new chemical entities, together with the usual pharmacological-derived SAR. The combination of both pharmacokinetics and pharmacodynamics at the discovery stage leads to drugs with optimum performance characteristics. Such drugs are easier to develop, representing a huge saving in resources. Moreover, the marketed compound is much more likely to find high clinical utilization. This review uses dofetilide, fluconazole, and amlodipine to highlight the multifaceted consequences of changing chemical structure, in terms of drug disposition, and reinforces these principles with examples from the literature.

Significance of metabolism in the disposition and action of the antidysrhythmic drug, dofetilide. In vitro studies and correlation with in vivo data

Dofetilide, a class III antidysrhythmic agent, undergoes both renal and metabolic clearance. Characterization of the metabolism in vitro allows explanation of species differences, whereas identification of the human enzymes involved permits assessment of potential drug interaction. In liver microsomes, the rate of oxidative metabolism of dofetilide is in the order: male rat > female rat > dog > humans, which correlates with the metabolic clearance seen in vivo. In vitro products of oxidative metabolism, formed by N-dealkylation, are the same as those formed in vivo, with the N-desmethyl being the major product. This route of dofetilide metabolism is mediated by cytochrome P450 (CYP). In humans, N-demethylation has a high KM of 657 +/- 116 microM, indicating low affinity for the enzyme's active site. In a number of human liver microsomal preparations, this rate correlated (r = 0.903) with the activity of CYP3A4. There was no correlation with the activities of other isozymes. Specific isozyme inhibitors also indicated the involvement of CYP3A4, with partial inhibition being observed with ketoconazole and troleandeomycin, whereas the activator, alpha-naphthaflavone, caused increased turnover. No inhibition was observed with specific inhibitors or competing substrates for other isozymes. Dofetilide did not significantly inhibit CYP2C9, CYP2D6, or CYP3A4 at concentrations up to 100 microM in vitro. In contrast, amiodarone (IC50, 25 microM) and flecainide (49 microM) inhibited CYP2C9 and quinidine (0.26 microM), and flecainide (0.44 microM) inhibited CYP2D6. Many antidysrhythmic drugs have active, circulating metabolites, complicating the relationship of dose and clinical response. In vitro pharmacology studies allow assessment of the potential contribution to the pharmacological profile by metabolites. Potency of dofetilide and metabolites has been compared for class III (K+ channel blockade) and class I (Na+ channel blockade) antidysrhythmic activities. Three of the metabolites of dofetilide displayed class III activity, but at concentrations at least 20-fold higher than dofetilide. Dofetilide N-oxide showed class I activity, but only at high concentration. Neither resting membrane potential or action potential amplitude were affected by any metabolite. This lack of biologically relevant activity is in accord with the close correlation between plasma concentrations of dofetilide and pharmacological response.

Effects of streptozotocin-induced diabetes and insulin treatment on substance P of the rat arterial wall

Substance P (SP) is present in perivascular nerves throughout the mammalian vasculature. Reports of diminished SP levels in nerve and gastrointestinal tissues of diabetic rats led us to examine SP-like immunoreactivity (SP-LI) in large arteries by RIA. Six weeks after inducing diabetes with streptozotocin (STZ), SP-LI was measured in the thoracic aorta, abdominal aorta, and the proximal superior mesenteric artery. In diabetics we measured a doubling (P<0.01) of SP-LI in all three artery wall preparations. This finding was verified in a second experiment which included a subset of diabetics treated daily with insulin for the sixth week of the holding period. Again, we measured a two-fold or greater increase of SP-LI (P<0.01-0.05) in arteries from the diabetics and found that insulin treatment significantly reduced SP-LI (P<0.05). In contrast to reports of diminished SP content in other tissues of diabetic rats, our findings demonstrate that the artery wall experiences at least a two-fold increase of SP-LI in the diabetic state. Furthermore, this elevation of SP-LI is reduced by insulin. We speculate that these changes of arterial wall SP-LI may contribute to altered regulation of the vascular system in the diabetic state.

The perceived long-term impact of a psychiatry clerkship on personal growth and clinical skills

The authors investigated the effects of a psychiatry clerkship that over 14 years has had a constant training philosophy and faculty and has been located in the same acute general hospital setting. In the study, 169 graduates completed a questionnaire on the effects of the clerkship on their knowledge of psychiatry, management of emotional problems in their patients, and personal development. Based on the graduates' responses, the results reveal that the clerkship indeed has had a lasting impact on its former students. Possible implications for recruitment of students into psychiatry are discussed.

Comparison of the disposition of two novel combined thromboxane synthase inhibitors/thromboxane A2 receptor antagonists in the isolated perfused rat liver

1. The pharmacokinetics of two combined thromboxane synthase inhibitor/thromboxane A2 receptor antagonists were investigated in an isolated perfused rat liver preparation. 2. The clearance of both UK 101613 (15.4 +/- 1.9 ml/min) and UK 102333 (14.9 +/- 1.6 ml/min) was limited by hepatic bloodflow. Both hepatic uptake and biliary excretion of UK 101613 appeared to be active processes. The apparent biliary clearance of UK 101613 (10.3 +/- 2.3 ml/min) was less than perfusate clearance, indicating accumulation within the hepatocytes. 3. The efficiency of the active hepatic uptake of UK 101613 and UK 102333 explains the rapid removal of these compounds from the systemic circulation. The processes of biliary and/or metabolic clearance of UK 101613 and UK 102333 appear to be subsequent to and independent of perfusate clearance. 4. Although the compounds are of similar structure and have a similar hepatic extraction (> 0.9), UK 101613 had an apparent biliary clearance approximately twice that of UK 102333. This is due to the formation of a metabolite of UK 102333 which reduces the amount of parent compound available for biliary excretion. 5. Inhibition of this latter metabolism by ketoconazole (10 microM) resulted in the two compounds having comparable apparent biliary clearances.

Overview of causes and costs of injuries in Massachusetts: a methodology for analysis of state data

Massachusetts has developed the first State profile of the causes and costs of injury based on the national study, "Cost of Injury in the United States: A Report to Congress." Incidence of fatal injuries is based on Massachusetts data; nonfatal hospitalized injuries, on Massachusetts age and sex rates and U.S. cause data; and nonhospitalized injuries, on U.S. rates applied to Massachusetts census data. Lifetime costs per injured person are based on national data adjusted for higher personal health care expenditures and for higher mean annual earnings in Massachusetts. The estimated total lifetime cost for the 1.4 million injuries that occurred in 1989 is $4.4 billion--$1.7 billion for health care and $2.7 billion for lost earnings. Injuries attributed to motor vehicles and falls account for more than half of the total cost. The other cause categories are poisonings, fire-burns, firearms, drowings-near drownings, and other. For every person who dies from an injury, 17 people are hospitalized, and an estimated 535 people require outpatient treatment, consultation, or restricted activity. Development of a State-based cost report can be useful in monitoring the contribution of injuries to health status and in planning effective injury prevention strategies in a community-based health care system. The methodology described in this paper can be replicated by other States through accessing their State-specific mortality and hospital discharge data bases.

A database obtained from in vitro function testing of mechanical heart valves

The in vitro function of the CarboMedics, Medtronic Hall, Omniscience, Starr-Edwards, St. Jude and Sorin (formerly Shiley) Monostrut heart valves have been compared using a pulsatile flow model left heart and load system. A wide range of flows and heart rates were used. The above valves in all sizes and in both aortic and mitral positions were tested. Results for transvalvular pressure, regurgitation and effective orifice area are presented. The small size St. Jude valves showed the least transvalvular pressure and largest effective orifice area. For large valves, the least regurgitation was exhibited by the Starr-Edwards valve. The data provides a reference for the range of normal performance that can be expected of mechanical prosthetic heart valves.

Importance of metabolic stability and hepatic distribution to the pharmacokinetic profile of amlodipine

1. In an isolated perfused rat liver (IPRL) model, the extensive hepatic uptake and subsequent slow redistribution of amlodipine into the perfusate have been demonstrated. The apparent liver volume for amlodipine was 920 ml compared with 38ml for nitrendipine. 2. Metabolism is the major clearance mechanism of amlodipine and nitrendipine in animals and man. In the IPRL, the intrinsic (metabolic) clearance and first-pass extraction values for amlodipine are similar to those of nitrendipine. This is in contrast with in vitro metabolic stability data in rat liver microsomes which indicate about 40-fold greater metabolic stability for amlodipine. 3. The discrepancy between relative clearance rates for the two preparations may be explained by consideration of the hepatic volume of the two compounds, with the higher liver volume of amlodipine amplifying the whole organ clearance.

Prevalence of medical technology assistance among children in Massachusetts in 1987 and 1990

In 1987 and 1990 in Massachusetts, surveys were conducted to determine the size, pattern of distribution, and trends in the population of children assisted by medical technology. The authors obtained an unduplicated count of all Massachusetts children from 3 months to 18 years of age who used one or more of the following: tracheostomy, respirator, oxygen, suctioning, gastrostomy, jejunal or nasogastric feedings, ostomies, urethral catheterization, ureteral diversion, intravenous access, or dialysis. By comparing counts obtained from medical and educational sources, the authors were able to perform a capture-recapture analysis to estimate the overall number of children dependent upon these technologies. The number of children identified in our surveys increased from 1,085 in 1987 to 1,540 in 1990. However, the capture-recapture analysis yielded estimates of 2,147 plus or minus 230 for 1987 and 2,237 plus or minus 131 for 1990. This suggests that the population of children dependent upon medical technology was essentially stable during this period, and that the 42 percent increase in the number of children identified in our survey reflected improved sampling techniques. During the 3 years, shifts in the pattern of technology use were noted, however. Use of oxygen and gastrostomy increased, and urostomy use declined. A change in the age distribution of the children was also documented, with a shift in the preponderence of technology use from 12 to 24 months in 1987 to children in the first year of life in 1990. Using the 1990 estimate and the 1990 U.S. census figures, an overall prevalence estimate of 0.16 percent was calculated. Applying this to the U.S.child population yields an estimate of 101,800 children assisted by medical technology nationwide(assuming comparable technology use in other States). This information will facilitate policy analysis and program planning on regional and national levels for this medically complex group of children.

Issues involved in the definition and classification of chronic health conditions

The need for a widely applicable definition of chronic conditions for research, policy, and program development has led to an extensive review of the development of such definitions, the considerations involved in their use, and some recommendations for a new approach. This paper examines some of the methodologic and conceptual issues related to defining and classifying chronic conditions and describes some consequences resulting from decisions made about these issues. While most examples are taken from child health applications, the basic concepts apply to all age groups. The dominant method for identifying and classifying children as having a chronic condition has relied on the presence of an individual health condition of lengthy duration. This condition-specific or "categorical" approach has increasingly seemed neither pragmatically nor conceptually sound. Thus, the development of a "generic" approach, which focuses on elements that are shared by many conditions, children, and families, is recommended. Such a definition might reflect the child's functional status or ongoing use of medical services over a specified time period. In addition, it is suggested that conditions be classified based on the experience of individual children, thus emphasizing the tremendous variability in expression of seemingly similar conditions.

Relationship among bile tolerance, bile salt deconjugation, and assimilation of cholesterol by Lactobacillus acidophilus

The relationships among growth in the presence of bile, deconjugation of sodium taurocholate, and assimilation of cholesterol by 19 cultures of Lactobacillus acidophilus were examined. Cultures of L. acidophilus were grown at 37 degrees C in lactobacilli MRS broth supplemented with sodium thioglycollate, sodium taurocholate, and cholesterol (cholesterol phosphatidyl choline micelles). Deconjugation activity was maximum in the late exponential phase of growth, which also coincided with maximum assimilation of cholesterol. Considerable variation existed among cultures in their ability to grow in the presence of bile, to deconjugate sodium taurocholate, and to assimilate cholesterol. However, statistical analyses revealed no significant correlations.

Bioanalytical data in decision making: discovery and development

1. Bioanalysis is traditionally associated with the development phase of drugs; its use in discovery programmes is often ignored but can have a major impact. 2. Pharmacokinetic studies conducted in conjunction with pharmacology screening can provide additional information to that considered in conventional structure activity relationships. Such factors as half-life and bioavailability can be critical in designing improved drugs. 3. Analytical methods in discovery programmes may differ from those used in later development work: for instance bioassay allows a common assay system for a large number of project compounds. Moreover its use, when combined with conventional methods, such as h.p.l.c., allows active metabolites to be readily detected. 4. Bioanalytical data generated in discovery and pre-clinical programmes are a valuable guide to early clinical programmes. Plasma concentration-response data from these programmes can be compared with those obtained in man. Such comparisons are particularly valuable during the phase one-initial dose escalation study. To maximize this it is our practice to generate pharmacokinetic data between each dose increase.

Pharmacokinetics and metabolism of dofetilide in mouse, rat, dog and man

1. Pharmacokinetics of dofetilide were studied in man, dog, rat and mouse after single i.v. and oral doses of dofetilide or 14C-dofetilide. 2. Dofetilide was absorbed completely in all species. Low metabolic clearance in man resulted in complete bioavailability following oral administration. Higher metabolic clearance in rodents, and to a lesser extent dogs, resulted in decreased bioavailability because of first-pass metabolism. 3. Following i.v. administration, the volume of distribution showed only moderate variation in all species (2.8-6.3 l/kg). High plasma clearance in rodents resulted in short half-life values (mouse 0.32, male rat 0.5 and female rat 1.2 h), whilst lower clearance in dog and man gave longer terminal elimination half-lives (4.6 and 7.6 h respectively). 4. After single i.v. doses of 14C-dofetilide, unchanged drug was the major component excreted in urine of all species with several metabolites also present. 5. Metabolites identified in urine from all species were formed by N-oxidation or N-dealkylation of the tertiary nitrogen atom of dofetilide. 6. After oral and i.v. administration of 14C-dofetilide to man, parent compound was the only detectable component present in plasma and represented 75% of plasma radioactivity. No single metabolite accounted for greater than 5% of plasma radioactivity.

Discrimination in vitro between the acoustic emissions from Bjork-Shiley convexo-concave valves with and without a broken minor strut

A statistical pattern recognition technique is used to learn and recognise the frequency spectra of the closing sounds emitted by Bjork-Shiley convexo-concave heart valves, with and without fractured minor struts, when operating in vitro. The sounds are generated with test valves operating under a variety of conditions in a model left ventricle. It is found in the learning stage that the discriminant functions generated correctly classified almost all of the cases within the learning set. When applied to cases outside the learning set, including a recording of a clinically implanted valve, the functions correctly classify the valves. These preliminary results, for a limited number of valves, lead us to believe that the discriminant analysis of heart valve sounds is a promising noninvasive method for screening patients with implanted Bjork-Shiley convexo-concave valves.

Liquid-liquid extraction and high-performance liquid chromatography for the determination of a novel antidysrhythmic agent (UK-68,798) in human urine

A routine method for the determination of a novel class III antidysrhythmic agent, 1-(4-methanesulphonamidophenoxy)-2-[N-(4-methanesulponamidophen ethyl)- N-methylamino]ethane, in human urine has been developed. The method involves solvent extraction followed by high-performance liquid chromatography on an unmodified silica column with ultraviolet detection. Despite a low recovery of drug through the three-stage extraction procedure a reliable assay with high precision (coefficient of variation less than 6%) and a limit of determination of 2.5 ng/ml was achieved. The method has been applied to the analysis of samples following single oral and intravenous doses of 1-12.5 micrograms/kg of the drug to human volunteers.