Intellectual disability and autism in propionic acidemia: a biomarker-behavioral investigation implicating dysregulated mitochondrial biology

Propionic acidemia (PA) is an autosomal recessive condition (OMIM #606054), wherein pathogenic variants in PCCA and PCCB impair the activity of propionyl-CoA carboxylase. PA is associated with neurodevelopmental disorders, including intellectual disability (ID) and autism spectrum disorder (ASD); however, the correlates and mechanisms of these outcomes remain unknown. Using data from a subset of participants with PA enrolled in a dedicated natural history study (n = 33), we explored associations between neurodevelopmental phenotypes and laboratory parameters. Twenty (61%) participants received an ID diagnosis, and 12 of the 31 (39%) who were fully evaluated received the diagnosis of ASD. A diagnosis of ID, lower full-scale IQ (sample mean = 65 ± 26), and lower adaptive behavior composite scores (sample mean = 67 ± 23) were associated with several biomarkers. Higher concentrations of plasma propionylcarnitine, plasma total 2-methylcitrate, serum erythropoietin, and mitochondrial biomarkers plasma FGF21 and GDF15 were associated with a more severe ID profile. Reduced 1-13C-propionate oxidative capacity and decreased levels of plasma and urinary glutamine were also associated with a more severe ID profile. Only two parameters, increased serum erythropoietin and decreased plasma glutamine, were associated with ASD. Plasma glycine, one of the defining features of PA, was not meaningfully associated with either ID or ASD. Thus, while both ID and ASD were commonly observed in our PA cohort, only ID was robustly associated with metabolic parameters. Our results suggest that disease severity and associated mitochondrial dysfunction may play a role in CNS complications of PA and identify potential biomarkers and candidate surrogate endpoints.

Biomarkers to predict disease progression and therapeutic response in isolated methylmalonic acidemia (MMA)

Methylmalonic Acidemia (MMA) is a heterogenous group of inborn errors of metabolism caused by a defect in the methylmalonyl-CoA mutase (MMUT) enzyme or the synthesis and transport of its cofactor, 5'-deoxy- adenosylcobalamin. It is characterized by life-threatening episodes of ketoacidosis, chronic kidney disease, and other multiorgan complications. Liver transplantation can improve patient stability and survival and thus provides clinical and biochemical benchmarks for the development of hepatocyte-targeted genomic therapies. Data are presented from a US natural history protocol that evaluated subjects with different types of MMA including mut- (N=91), cblB- (15), and cblA-type MMA (17), as well as from an Italian cohort of mut- (N=19) and cblB-type MMA (N=2) subjects, including data before and after organ transplantation in both cohorts. Canonical metabolic markers, such as serum methylmalonic acid and propionylcarnitine, are variable and affected by dietary intake and renal function. We have therefore explored the use of the 1-¹³ C-propionate oxidation breath test (POBT) to measure metabolic capacity and the changes in circulating proteins to assess mitochondrial dysfunction (fibroblast growth factor-21, FGF-21 and growth differentiation factor-15, GDF-15) and kidney injury (lipocalin-2, LCN2). Biomarker concentrations are higher in patients with the severe mut⁰ - and cblB-type MMA, correlate with a decreased POBT, and show a significant response post-liver transplant. Additional circulating and imaging markers to assess disease burden are necessary to monitor disease progression. A combination of biomarkers reflecting disease severity and multisystem involvement will be needed to help stratify patients for clinical trials and assess the efficacy of new therapies for MMA. This article is protected by copyright. All rights reserved.

Systemic gene therapy for methylmalonic acidemia using the novel adeno-associated viral vector 44.9

Methylmalonic acidemia (MMA) is a severe and potentially lethal autosomal recessive inborn error of metabolism most frequently caused by mutations in the methylmalonyl-CoA mutase (MMUT) gene. Proof-of-concept adeno-associated virus (AAV) gene therapy studies using mouse models of MMA have demonstrated promise for this therapeutic approach but translation to the clinic could be limited by preexisting capsid immunity and vector potency. Here we explore the efficacy of a novel clade E capsid, 44.9, as a serotype for systemic AAV gene therapy for MMA. An anti-AAV44.9 neutralizing antibody (NAb) survey in adult volunteers (n = 19) and a large cohort of MMA patients (n = 48) revealed a seroprevalence rate of ∼26% and 13%, respectively. The efficacy of AAV44.9 gene delivery was examined in two murine models of MMA, representing neonatal lethal and juvenile phenotypes of MMA. Systemic delivery of the AAV44.9-Mmut vector prevented lethality and lowered disease-related metabolites in MMA mice. Tissue biodistribution and transgene expression studies in treated MMA mice showed that AAV44.9 was efficient at transducing the liver and heart. In summary, we establish that AAV44.9 exhibits a low prevalence of preexisting NAb in humans, is highly efficacious in the treatment of clinically severe MMA mouse models and is therefore a promising vector for clinical translation.

Registered Replication Report: Schooler and Engstler-Schooler (1990)

Trying to remember something now typically improves your ability to remember it later. However, after watching a video of a simulated bank robbery, participants who verbally described the robber were 25% worse at identifying the robber in a lineup than were participants who instead listed U.S. states and capitals-this has been termed the "verbal overshadowing" effect (Schooler & Engstler-Schooler, 1990). More recent studies suggested that this effect might be substantially smaller than first reported. Given uncertainty about the effect size, the influence of this finding in the memory literature, and its practical importance for police procedures, we conducted two collections of preregistered direct replications (RRR1 and RRR2) that differed only in the order of the description task and a filler task. In RRR1, when the description task immediately followed the robbery, participants who provided a description were 4% less likely to select the robber than were those in the control condition. In RRR2, when the description was delayed by 20 min, they were 16% less likely to select the robber. These findings reveal a robust verbal overshadowing effect that is strongly influenced by the relative timing of the tasks. The discussion considers further implications of these replications for our understanding of verbal overshadowing.

An international, randomized, placebo-controlled, double-blind phase III study (MONET1) of motesanib plus carboplatin/paclitaxel (C/P) in patients with advanced nonsquamous non-small cell lung cancer (NSCLC)

LBA7512

Background: This study evaluated whether motesanib (a selective oral inhibitor of VEGFR 1, 2 and 3; PDGFR and Kit) plus C/P improved overall survival (OS) compared with placebo + C/P in patients (pts) with nonsquamous NSCLC and in a subset of pts with adenocarcinoma. Methods: Pts had stage IIIB/IV or recurrent nonsquamous NSCLC and no prior systemic therapy for advanced NSCLC. The study initially enrolled all histologies but was amended to exclude pts with squamous NSCLC owing to a high rate of hemoptysis. Pts were randomized 1:1 to receive up to six 3-wk cycles of C (AUC 6 mg/mL·min) and P (200 mg/m2) with either motesanib 125 mg QD (Arm A) or placebo QD (Arm B) orally continuously. The primary endpoint was OS; secondary endpoints included progression-free survival (PFS), adverse events (AEs), objective response rate (ORR) and association between placental growth factor (PLGF) change and OS. OS was evaluated using a stratified Cox model and 2-sided log-rank test (α=0.03 for nonsquamous pts and α=0.02 for adenocarcinoma pts). Results: 1090 pts with nonsquamous NSCLC were randomized (Arm A/B, n=541/549); 890 had adenocarcinoma (n=448/442). 61% were men; median age was 60 years (range 21–87); 83% had stage IV disease. At the time of analysis, 753 pts had died (608 pts with adenocarcinoma). Median follow-up was 10.6 mo. OS was not significantly improved in Arm A compared with Arm B (Table). In Arm A, PLGF analysis did not show an association with OS. The incidence of grade ≥3 AEs in Arms A/B was 73/59%. Grade ≥3 AEs occurring more frequently in Arm A than B included neutropenia (22/15%), diarrhea (9/1%), hypertension (7/1%) and cholecystitis (3/0%). The incidence of grade 5 AEs was 14/9% in Arms A/B. Conclusions: In pts with advanced nonsquamous NSCLC, treatment with motesanib + C/P did not significantly improve OS compared with C/P alone.

[Table: see text]

Safety and pharmacokinetics (PK) of AMG 706 in combination with gemcitabine for the treatment of patients (pts) with solid tumors

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Background: AMG 706 is an oral, investigational multikinase inhibitor (MKI) with antiangiogenic and direct antitumor activity achieved by selectively targeting VEGF, PDGF and Kit receptors. Methods: This is a fully enrolled, phase 1b, open-label, dose- finding study. The objectives are to determine the maximum tolerated dose and to assess safety and PK of AMG 706 in pts with solid tumors receiving AMG 706 plus gemcitabine. Pts =18 years with ECOG 0–2 and no prior treatment with bevacizumab or VEGFr MKIs were assigned to cohorts receiving escalating doses of AMG 706 (50mg QD, 125mg QD or 75mg BID continuously from day 2 of cycle 1) plus gemcitabine (1000mg/m2 weekly for 7/8 wks, then 3/4 wks per cycle) for up to 11 cycles. Assessments include dose-limiting toxicities (DLT) (weeks 1–4) and tumor response (every 3 months). Results: 26 pts were enrolled and received at least 1 dose of AMG 706 (50mg QD n=11; 125mg QD n=6; 75mg BID n=9). All but 2 pts have completed the study. Median (range) age was 57 (25–77) yrs. 65% of pts received prior chemotherapy; 4 pts received prior gemcitabine (50mg QD n=2; 125mg QD n=1; 75mg BID n=1). There were 2 DLTs: grade 4 neutropenia (125mg QD), grade 3 deep vein thrombosis (75mg BID). Treatment-related adverse events (AE) occurring in = 10% of pts are shown in the table . The mean AMG 706 PK profiles were not markedly different when AMG 706 was dosed on the same day or 24 hours after gemcitabine administration. Objective tumor responses per RECIST for 26 evaluable pts were: 2 unconfirmed PR (50mg QD n=1; 125mg QD n=1), 7 SD (50mg QD n=3; 125mg QD n=1; 75mg BID n=3), 11 PD (50mg QD n=7; 125mg QD n=3; 75mg BID n=1), and 6 not available (125mg QD n=1; 75mg BID n=5). Conclusions: These preliminary data suggest that, in pts with solid tumors, AMG 706 combined with gemcitabine had an expected AE profile at the target once-daily dose of 125mg QD, with little effect on AMG 706 PK. The data provide a foundation for conducting further trials, potentially including biliary tumors. Final data will be presented.

[Table: see text]

No significant financial relationships to disclose.

Phase II trial of depsipeptide (NSC-630176) in colorectal cancer patients who have received either one or two prior chemotherapy regimens for metastatic or locally advanced, unresectable disease: A Southwest Oncology Group study

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The treatment for metastatic colorectal cancer has markedly improved but the disease is still not curable, and additional active agents need to be found. Depsipeptide is a histone deacetylase inhibitor that has shown activity against human solid tumor cell lines and promising results in murine model systems. This phase II trial was undertaken to determine its activity in patients with advanced colorectal cancer. Eligibility requirements included measurable disease, either metastatic or locally advanced and not surgically resectable, Zubrod performance status of 0–1, and adequate renal, hepatic, hematologic and cardiac function. Prior surgery or radiation therapy was allowed and patients were required to have received either one or two prior chemotherapy regimens for advanced disease. A two-stage design was used designed to detect a difference in the null hypothesis of 5% response vs. an alternative 20% response, with 20 eligible patients to be accrued initially followed by an additional 20 patients if one or more confirmed responses were observed. The study closed after the first stage, with 28 patients registered. Three patients are ineligible, two who did not meet requirements for serum magnesium level, and one whose baseline labs were performed more than 14 days prior to registration. One eligible patient never received treatment and is not analyzable for any endpoint. For the 24 eligible and analyzable patients, median age was 58.6 years (range 31–84) with 14 males. Performance status was 0 in 16 patients and 1 in 8. Ten patients received 1 prior chemotherapy regimen and 14 received 2 prior regimens. There were no grade 4 or higher toxicities. The most common grade 2 or 3 toxicities were anorexia, fatigue, nausea, and dehydration. No objective responses were observed. Four patients had stable disease, 15 showed increasing disease, 3 had symptomatic deterioration, and 2 had assessment inadequate. The current Kaplan-Meier estimate of 6 month overall survival is 69% (95% CI 50%-88%) with a median survival of 8.4 months. Depsipeptide does not show significant anti-tumor activity in previously treated patients with advanced colorectal cancer.

No significant financial relationships to disclose.

SWOG S0202: A phase II trial of gemcitabine and capecitabine in patients (pts) with unresectable or metastatic gallbladder cancer or cholangiocarcinoma

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Background: Pts with gallbladder cancer or cholangiocarcinoma usually present with advanced disease and limited treatment options. Based on data demonstrating effectiveness of gemcitabine in pancreatic carcinoma and the common embryologic origin of the exocrine pancreas and gallbladder, this trial was pursued. The primary objective of this study was to assess the response rate (confirmed complete and partial responses). Secondary objectives included overall survival and toxicities for gemcitabine and capecitabine. Methods: A two-stage design was used to detect a difference in the null hypothesis of 5% response probability and the alternative 20% response probability. If at least one response occurred after the first 20 pts, another 20 were to be accrued. The combination of gemcitabine 1,000 mg/m2 IV over 100 minutes days 1, 8 and capecitabine 650 mg/m2 BID PO days 1–14, was administered every 21 days. Results: The study accrued 57 pts from September 2003 until April 2005. Three patients were ineligible, and two others received no treatment. Characteristics of analyzable pts: 35 (73%) cholangiocarcinoma, 17 (32%) gallbladder cancer; PS 0 (18 pts), 1 (26 pts), 2 (8 pts); 26 (50%) male; median age 58.8 years (29.5–85.6). Among 51 pts evaluated for toxicity, 6 experienced grade 4 toxicities: 1 thrombosis/embolism and muscle pain, 1 fatigue and 4 neutropenia, one of whom also had grade 4 leukopenia and grade 4 anemia. Among 52 pts, there were 5 confirmed partial responses for a confirmed response probability of 10% (95% CI 3% to 21%). Four pts had an unconfirmed partial response for an overall response probability of 18% (95% CI 8% to 30%). Fourteen patients (27%) stable disease. The 6 month overall survival was 56% (95% CI 42%–70%) and median survival was 7.0 months. Conclusions: Gemcitabine and capecitabine is a well tolerated regimen with activity in pts with advanced gallbladder cancer and cholangiocarcinoma. Correlative analyses are ongoing.

[Table: see text]

Exercise in a hot environment: comparison of two different fluid intake patterns

AIM

Extensive research has been undertaken in the area of exercise and hydration. Most work has focused on prehydration. Less is known about different fluid intake patterns during exercise and its effect in thermoregulatory variables in hot environments. This study attempted to determine if ingesting fluid either in a single bolus or intermittently during exercise had different results in thermoregulatory parameters and thirst in a hot environment.

METHODS

Six moderately trained men and women (n=6, 5 male, 1 female; mean+/-SD: age 28.5+/-2.5 y; weight 74.4+/-3.3 kg, VO2max 45.9+/-3.7 ml.kg.min-1) completed 2 exercise sessions in a randomized, counterbalanced order. Treatment 1 (bolus) consisted of 60 minutes of bicycling at 50% of VO2max in a climatic chamber (dry bulb temperature, 35 degrees C, 45% relative humidity). Subjects consumed 1 000 ml of plain cool (22 degrees C) water immediately before exercise. During treatment 2 (intermittent) the same environmental conditions were present, but subjects consumed 250 ml of water immediately before exercise. During the bicycle ride, subjects consumed 250 ml of cool water at minutes 15, 30, and 45 of exercise for a total trial volume of 1,000 ml. Tympanic ear temperatures, heart rates, rating of perceived exertion (RPE), and thirst scale data were collected immediately before exercise and at minutes 10, 20, 30, 40, 50, and 60 of exercise.

RESULTS

No statistical differences were noted in temperature between treatments (P>0.05). Lower heart rates and thirst scores were noted for the bolus treatment at various time points (P<0.05). Little differences were noted between treatments for RPE during exercise.

CONCLUSIONS

These results suggest that consumption of water in a single bolus is more beneficial for some aspects of thermoregulatory control and delaying thirst during exercise in the heat. Additional mechanistic studies with larger sample sizes are warranted.

Utility of clinical swallowing examination measures for detecting aspiration post-stroke

The purpose of this investigation was to determine the utility of clinical swallowing examination (CSE) measures for detecting aspiration as defined by videofluoroscopic swallowing examination (VFSE). This study, involving 165 participants, is a follow-up to a previously published investigation of 60 participants. Findings are compared with that investigation as well as with other research on CSEs. The results suggest that clinicians can make an accurate judgment of the occurrence of aspiration in most post-stroke patients. However, ruling out aspiration when it is absent appears more problematic. More work needs to be done if data collected from non-instrumented examinations are to be strongly predictive of the presence and absence of aspiration on VFSE. At present, there are no data to suggest that CSEs can be used to quantify aspiration or make adequate recommendations regarding patient care.

A comparison of visual analogue and numerical rating scale formats for the Lung Cancer Symptom Scale (LCSS): does format affect patient ratings of symptoms and quality of life?

PROBLEM AND PURPOSE

The Lung Cancer Symptom Scale (LCSS), a site-specific health-related quality of life measure for patients with lung cancer, was originally developed using a Visual Analogue Scale (VAS) format. However, the VAS format is not readily compatible with data management and software programs using scanning. The primary aim of this study was to evaluate the convergence of ratings obtained with a Numerical Rating Scale (NRS), with an 11-pt response category format, to those obtained with a VAS format. The intent was to determine the degree of agreement between two formats to generalize the existing psychometric properties for the original measure to the new presentation.

DESIGN/SETTING

This methodological study evaluated the feasibility, reliability, and validity of a NRS format for the LCSS. The study was conducted at two cancer centers in New York City. PATIENTS/PROCEDURES: Sixty-eight patients with non-small cell lung cancer (NSCLC) completed both versions of the LCSS along with demographic and feasibility questions on a single occasion. The VAS form was administered first, followed by the NRS form to prevent bias. The intraclass correlation coefficient (ICC), Lin's concordance correlation coefficient (CCC), and Bland-Altman plots were used to evaluate agreement and to characterize bias.

RESULTS

Cronbach's alpha for the NRS format total score was 0.89 for the 68 patients with NSCLC. Agreement was excellent, with both the ICC and CCC > or = 0.90 for the two summary scores (total score and average symptom burden index) for the LCSS. Only five of the nine individual items showed this level of strict agreement. An agreement criterion of > or = 0.80 (representing excellent) was observed for seven of the nine individual items (all but appetite loss and hemoptysis). Mean differences tended to be slightly lower for the VAS format compared to the NRS format (more so for the appetite and hemoptysis items), with evidence of scale shift for the same two items. The summary measures showed good concordance as measured by the ICC and CCC, but did display mean differences (VAS - NRS) of -2.7 and -3.1, respectively.

CONCLUSIONS

Overall, the NRS format for the LCSS suitable for scanning has good feasibility, reliability (internal consistency), and convergent validity. The complete set of concordance evaluation measures supports the reproducibility of VAS scores by NRS scores, particularly for the two summary scores.

Histological study of hair follicles treated with a 3-msec pulsed ruby laser

BACKGROUND AND OBJECTIVE

Ruby laser energy at 694 mn is moderately absorbed by melanin and minimally absorbed by other skin chromophores. This property and its depth of penetration into dermis permit absorption into pigmented hair follicles, thus making it suited to photothermolysis of these appendages. Clinical reports of the efficacy of such lasers for removal of unwanted hair are emerging in large numbers, but scientific data regarding the exact mechanism of action is still lacking. This study aims to evaluate and define further the histological responses of hair follicles to 3-msec pulsed ruby laser light.

STUDY DESIGN/MATERIALS AND METHODS

Twenty-four patients with brown or black axillary or groin hair were treated with a 3-msec ruby laser at fluences from 10 to 40 J/cm2 on one, two, or three occasions. Biopsies were taken at various intervals from immediately to 8 weeks after treatments. Biopsies were fixed and stained with either nitroblue tetrazolium chloride or hematoxylin and eosin for histological examination.

RESULTS

One treatment induced changes typical of catagen followed by telogen at all fluences. The papillae always remained viable. Two and three treatments resulted in atypical telogen, with infundibular dilatation and plugging, and marked proliferation of the stem outer sheath. New anagen follicles were evident even after three treatments at 12- and then 8-week intervals and were biopsied 6 weeks later, but there were no hairs extending to or through the epidermis.

CONCLUSION

There was no evidence of permanent follicle death after one ruby laser treatment. However, despite evidence of persistence of follicular elements after two and three treatments, it is possible that laser-induced damage to the isthmus and upper stem may interfere with the interaction between dermal and epidermal germinative cells, thus inhibiting or altering the normal hair cycle.

Sclerotherapy for leg telangiectasia--a blinded comparative trial of polidocanol and hypertonic saline

BACKGROUND

Hypertonic saline (HS) and polidocanol (POL) have been in use around the world for sclerotherapy of telangiectasia for many years. However, despite numerous articles in the literature extolling the virtues of their individual use, few studies scientifically compare their relative efficacies.

OBJECTIVE

To compare, in a statistically significant number of female patients, the relative efficacy of hypertonic saline and polidocanol as sclerosants of leg telangiectasia and reticular feeding veins, using each patient as her own control.

METHODS

Eighty-one women with roughly matching leg telangiecasia were treated with sclerotherapy. One leg was injected with 20% saline/2% lignocaine, the other with 1% polidocanol, with the patients blinded as to the sclerosant used for each leg. Assessment of percent reduction of vessels, and the complications of matting and hemosiderin staining was conducted at 2 months by 3 methods: the patient's satisfaction, the treating physician's evaluation, and blinded assessment of before and after photographs.

RESULTS

There was no statistically significant difference between HS and POL treated legs when assessed clinically or photographically. However, POL caused more staining and matting, and despite patients finding HS more painful at injection, patient satisfaction at follow-up was higher with the HS treated leg.

CONCLUSION

20% HS and 1% POL have equal efficacy in sclerosing leg telangiectasia and reticular feeding veins. POL causes more adverse sequelae, although these may be related to the solution concentration.

Using multiple pharmacoeconomic methods to conduct a cost-effectiveness analysis of histamine H2-receptor antagonists

A formulary decision at a health care institution was studied by using two pharmacoeconomic methods. A pharmacoeconomic study was undertaken to assess the impact of a 1995 formulary decision to designate cimetidine as the primary histamine H2-receptor antagonist (H2RA) and to restrict the use of famotidine. Consecutive patients receiving either i.v. cimetidine or famotidine for stress ulcer prophylaxis were reviewed during a two-month period in 1997, and information on demographics, dosage and duration of H2RA therapy, admission date, laboratory test values, and adverse drug reactions was collected. Data for 62 patients (43 cimetidine recipients and 19 famotidine recipients) were evaluated. Therapy was categorized as successful or failed, and the data were then evaluated by decision analysis to evaluate the cost-effectiveness of the agents and by multiattribute utility theory (MAUT) to incorporate a humanistic evaluation of the treatments, namely, the number of doses administered and the number of times dosages were changed. The decision tree revealed that the average cost of receiving cimetidine was $82.01 and the average cost of famotidine therapy was $92.45. The MAUT analysis showed that cimetidine was the preferred agent as long as cost was valued at greater than 60% of the decision-making process and efficacy remained equal between the two agents. Two pharmacoeconomic methods lent support to a formulary decision at a health care institution.

Perspectives on the nursing management of osteoarthritis

Osteoarthritis is a daily presence in the lives of almost 16 million older people. Without expert nursing care, functional health status and the ability to manage independently may be dramatically altered. Nursing parameters include pain control, medication assessment, use of exercise, diet, joint protection, and attention to the psychosocial factors that affect both pain and disability. Patient education with regular, periodic follow-up is a vital part of successful long-term management.

An evaluation of the copper-bromide laser for treating telangiectasia

BACKGROUND

Copper bromide lasers, producing pulsed yellow and green light, have been developed for treating cutaneous lesions.

OBJECTIVE

A clinical trial was conducted to evaluate the role of this laser, using its yellow wavelength, to treat benign vascular ectasia and establish some clinical guidelines for therapy.

METHODS

Twenty-three informed consenting adults with facial telangiectasia, spider angiomas, or vascular nevi on the head, neck, or upper chest were treated with the laser. Assessment of results was performed by: blinded clinical evaluation, blinded comparison of "before" and "after" photographs, and patients' own reports of satisfaction levels.

RESULTS

Good to excellent results were obtained in most patients, except for a few suffering minor skin atrophy where very large vessels were treated.

CONCLUSIONS

The copper bromide laser was an effective tool in the treatment of certain cutaneous vascular lesions.

More uniform diurnal blood glucose control and a reduction in daily insulin dosage on addition of glibenclamide to insulin in type 1 diabetes mellitus: role of enhanced insulin sensitivity

Combination therapy with insulin and sulphonylurea has gained acceptance in management of subjects with Type 2 (non-insulin-dependent) diabetes mellitus. However, its role in management of Type 1 (insulin-dependent) diabetes mellitus remains controversial. In this study, the effect of combination therapy with insulin and glibenclamide on metabolic control, daily insulin dosage, and insulin sensitivity was assessed in subjects with Type 1 diabetes mellitus. Ten men with Type 1 diabetes mellitus participated in a randomized, double-blind, crossover, clinical trial with three treatment regimens, namely (1) insulin alone, (2) insulin and placebo, (3) insulin and glibenclamide, each lasting 3 months. Combination therapy induced: (1) reduction in daily insulin dosage; (2) more uniform blood glucose control as reflected by a lower average 24 h blood glucose level, a smaller difference between mean preprandial and 2 h postprandial blood glucose concentrations, decreased 24 h urine glucose excretion, and a decline in number of hypoglycaemic events; (3) improved insulin sensitivity as expressed by more rapid plasma glucose disappearance rate, without a significant alteration in fasting plasma glucagon and 1h postprandial serum C-peptide levels; when compared with treatment with either insulin alone or with insulin and placebo. Therefore, it is apparent that the addition of glibenclamide to insulin reduces daily insulin dosage and renders a greater uniformity to diurnal blood glucose control, most probably secondary to enhancement of insulin sensitivity.

Nonspecific laryngeal granuloma: a case study of a professional singer

A professional singer with laryngeal granuloma underwent surgery following failed response to conservative treatments. Two primary findings emerged. First, although a sizable lesion was present initially, presurgical voice measures were largely normal or superior. The exception was elevated phonatory effort during singing. Second, postsurgical voice functions were entirely normal or superior (including phonatory effort), despite demanding singing performances a few weeks following surgery. The results add to the limited corpus of quantitative, normative-referenced data on voice in patients with granulomas and are inconsistent with previous reports of voice abnormalities in such patients and poor functional response to surgery.

Perfluorocarbons as blood substitutes: the early years. Experience with Fluosol DA-20% in the 1980s

Clinical testing of perfluorocarbons (PFC) as blood substitutes began in the early 1980's in the form of Fluosol DA-20% (FDA), a mixture of perfluorodecalin and perfluorotripropylamine emulsified with Pluronic F68. We have treated 55 patients (Treatment (T) = 40; Control (C) = 15) with intravenous infusions of 30 cc/kg of FDA as part of either a randomized, clinical trial or a humanitarian protocol. All patients were Jehovah's Witnesses who refused blood transfusion and were severely anemic (mean hemoglobin = 4.6 g/d). FDA successfully increased dissolved or plasma oxygen content (P1O2 in ml/dl), but not overall oxygen content (T group: P1O2 baseline = 1.01 +/- .27, P1O2 12hrs = 1.58 +/- .47 [p = < .0001, t-test]; P1O2 12 hrs: T = 1.58 +/- .47, C = 1.00 +/- .31, p = < .0002, t-test). This effect persisted for only 12 hours post infusion, and had no apparent effect on survival. FDA is an ineffective blood substitute because of low concentration and short half-life. Improved emulsion design may resolve these problems, thereby producing a more effective agent. Our discussion will include a review of our data plus a summary of other reports of FDA efficacy as a blood substitute.

Effects of behavioral stimuli on plasma interleukin-1 activity in humans at rest

Interleukin-1 (IL-1) bioassays were done on 208 serum samples drawn from 7 volunteers, over several hours at 5-minute intervals, before, during, and after a relaxation-related behavioral stimulus. Individuals showed up to a 267% increase (t[29] = 7.750, p = 1 x 10(-7).) in IL-1, and for the group, a mean 48.1% elevation (t[5] = 4.128, p = .003) occurred, during the stimulus interval relative to baseline. When baselines were repeated, IL-1 activity rapidly returned toward baseline values. Suggestions to picture one's immune cells fighting illness appeared to have no uniform effect for all subjects. Such rapid changes in plasma IL-1, concomitant with stimuli, indicate a new way to alter immune function and further understand disease susceptibility.

Linking the elderly to community services

Sometimes, the only contact elderly patients have with outside medical services is through the EMS network. Find out how one city uses prehospital providers to link these patients with community services tailored to their needs.

Altered regulation of atrial natriuretic peptide in essential hypernatremia

Hypothalamic osmoreceptor dysfunction resulting in hypodipsia and altered regulation of vasopressin secretion is well established as the pathogenetic mechanism in the syndrome of 'essential hypernatremia'. However, little is known about the secretory pattern of atrial natriuretic peptide (ANP) in this syndrome. Therefore, we assessed ANP regulation by determining ANP concentrations in a patient manifesting this syndrome of essential hypernatremia during several well-established experimental protocols. The serum ANP level was within normal limits despite severe euvolemic hypernatremia (serum Na+ 163 mEq/l) during one of the many admissions and remained unchanged following normalization of serum Na+. Furthermore, a decline in serum ANP instead of an appropriate rise was noted when hypernatremia (serum Na+ 152 mEq/l) was induced by either hypertonic (3%) saline infusion or following a high-Na+ (300 mEq/day) diet for several days (serum Na+ 161 mEq/l). Similarly, exogenous pitressin administration failed to cause a rise in ANP, although an appropriate fall in ANP concentration occurred following fluid deprivation. Therefore, it is apparent that ANP regulation may be significantly altered in essential hypernatremia. However, further studies are required to define whether it plays a role in the pathogenesis of hypernatremia in this syndrome.

Fluosol DA-20 in the treatment of severe anemia: randomized, controlled study of 46 patients

We evaluated the safety and efficacy of Fluosol DA-20% (FDA) as a blood substitute in the treatment of severe anemia. Thirty-six patients received either FDA (n = 21) or crystalloid/hydroxyethyl starch (CHS) (n = 15) as part of a randomized, controlled trial. Ten patients received FDA as part of a humanitarian protocol. All were Jehovah's Witnesses who refused transfusion, had bled recently, and had average Hgb levels of 4.3 g/dl. After pulmonary artery catheter insertion, each patient was infused with CHS to attain a pulmonary artery wedge pressure (WP) of 10 to 18 mm Hg. FDA was given as a one-time dose of 30 ml/kg. Data were collected at baseline, 12, 24, and 48 h. None of the patients with negative reactions to a 0.5-ml test dose of FDA had adverse reactions to the subsequent infusion. The plasma or dissolved component of oxygen content was significantly higher in the FDA group at 12 h (FDA group 1.58 +/- 0.47 ml/dl, control group 1.01 +/- 0.31 ml/dl, p less than .02, t-test). Nineteen patients died: 12 (37.5%) FDA, seven (46.6%) control. The difference was not significant. We conclude the following: a) FDA can be given safely to severely anemic patients in doses of 30 ml/kg; b) FDA significantly increased the dissolved component of oxygen content after 12 h but the effect did not persist; c) severely anemic patients can survive without transfusion although mortality is high. In this study, inability of FDA to sustain increased oxygen content was due in part to the rapid elimination of FDA and also to the limited amount given.(ABSTRACT TRUNCATED AT 250 WORDS)

Elective surgery without transfusion: influence of preoperative hemoglobin level and blood loss on mortality

To clarify the widespread practice of preoperative transfusion to attain a 10 g/dL level of hemoglobin, the relationship between preoperative hemoglobin level, operative blood loss, and mortality was studied by analyzing the results of 113 operations in 107 consecutive Jehovah's Witness patients who underwent major elective surgery. Ninety-three patients had preoperative hemoglobin values greater than 10 g/dL; 20 had preoperative hemoglobin levels between 6 to 10 g/dL. Mortality for preoperative hemoglobin levels greater than 10 g/dL was 3 of 93 (3.2%); for preoperative hemoglobin levels between 6 to 10 g/dL, mortality was 1 of 20 (5%). Mortality was significantly increased with an estimated blood loss of greater than 500 mL, regardless of the preoperative hemoglobin level (p less than 0.025). More importantly, there was no mortality if estimated blood loss was less than 500 mL, regardless of the preoperative hemoglobin level. From these data, we conclude that: (1) Mortality in elective surgery appears to depend more on estimated blood loss than on preoperative hemoglobin levels; and (2) Elective surgery can be done safely in patients with a preoperative hemoglobin level as low as 6 g/dL if estimated blood loss is kept below 500 mL.

Sera from HTLV-III/LAV antibody-positive individuals mediate antibody-dependent cellular cytotoxicity against HTLV-III/LAV-infected T cells

The causative agent of the acquired immunodeficiency syndrome (AIDS) has been shown to be a human retrovirus called human T lymphotropic virus (HTLV)-III or lymphadenopathy-associated virus (LAV). The nature of the protective immune response against this virus is currently unknown. We report here results using an antibody-dependent cellular cytotoxicity (ADCC) assay which has been developed for measuring a specific immune response against HTLV-III/LAV. Forty-four sera were examined for their ability to mediate ADCC against HTLV-III/LAV-infected T cells. Sera from healthy HTLV-III/LAV seropositive individuals in the presence of mononuclear cells from healthy HTLV-III/LAV seronegative donors exhibited significantly higher levels of ADCC activity compared to sera from patients with AIDS. Western blot analysis of serum samples indicated that antibody reactivity with the p24 protein of HTLV-III/LAV correlated with higher levels of ADCC activity than did reactivity with Gp120/160. The observation that sera from healthy HTLV-III/LAV seropositive individuals mediated higher levels of ADCC activity than did sera obtained from subjects with AIDS suggests that ADCC may represent a protective immune response to infection with HTLV-III/LAV.

Sera from HTLV-III/LAV antibody-positive individuals mediate antibody-dependent cellular cytotoxicity against HTLV-III/LAV-infected T cells

The causative agent of the acquired immunodeficiency syndrome (AIDS) has been shown to be a human retrovirus called human T lymphotropic virus (HTLV)-III or lymphadenopathy-associated virus (LAV). The nature of the protective immune response against this virus is currently unknown. We report here results using an antibody-dependent cellular cytotoxicity (ADCC) assay which has been developed for measuring a specific immune response against HTLV-III/LAV. Forty-four sera were examined for their ability to mediate ADCC against HTLV-III/LAV-infected T cells. Sera from healthy HTLV-III/LAV seropositive individuals in the presence of mononuclear cells from healthy HTLV-III/LAV seronegative donors exhibited significantly higher levels of ADCC activity compared to sera from patients with AIDS. Western blot analysis of serum samples indicated that antibody reactivity with the p24 protein of HTLV-III/LAV correlated with higher levels of ADCC activity than did reactivity with Gp120/160. The observation that sera from healthy HTLV-III/LAV seropositive individuals mediated higher levels of ADCC activity than did sera obtained from subjects with AIDS suggests that ADCC may represent a protective immune response to infection with HTLV-III/LAV.

Insulin effectiveness in hypovolemic dogs

The question addressed in this study was whether exogenous insulin can enhance the rate of assimilation of blood glucose after prolonged hypovolemia when homeostasis is waning. Twenty-three well-fed mongrel dogs were maintained at a mean arterial blood pressure of 50 mm Hg by bleeding. Periodic analyses were made of arterial and venous plasma concentration of glucose, femoral blood flow, arterial plasma concentration of insulin, and hematocrit. At the onset of physiologic deterioration signaled by the need to reinfuse 50 ml of shed blood to maintain 50 mm Hg blood pressure, dogs received either 10 ml saline (control; n=15) or 10 ml saline containing 2 units insulin (treated; n=8). Administration of 2 units of insulin to eight of the dogs caused a significantly faster decline of blood glucose than that observed in saline-treated animals. Despite the more rapid decline in plasma concentration of glucose in animals that received insulin, there was no significant difference in glucose uptake between the two groups of animals. The hemoconcentration reflected by a rising hematocrit that develops when hypovolemia persists was accentuated by the administration of insulin without supplementary fluids. The absence of any effect of insulin on glucose uptake in the hindlimb in the late phase of hypovolemic shock suggests that the accelerated decline in arterial glucose levels may be due to inhibitory effects of insulin on hepatic glucose release. These results are not consistent with the resistance of plasma glucose to insulin in the late phases of hypovolemic shock.

Aneurysm of the inferior mesenteric artery

Current diagnostic techniques make it possible to diagnose unsuspected aneurysms. Two unsuspected cases of aneurysms of the inferior mesenteric artery are reported. One was iatrogenic and represented a false aneurysm of the proximal end of the inferior mesenteric artery following resection of an abdominal aortic aneurysm. The second was an aneurysm of the proximal protion of the inferior mesenteric artery in a patient with occlusion of the celiac axis, superior mesenteric artery and left ileofemoral system. The authors believe this to be the first published aneurysm of the inferior mesenteric artery.

Determinants of blood amino acid concentration after hemorrhage

Many mechanisms, including alterations in muscle metabolism, cellular damage, decreased blood volume, and hepatic disfunction, are influential in producing the observed progressive rise in the concentration of amino acids in arterial and venous blood during persisting hypovolemic shock. The rapid rise of venous and arterial concentrations of amino acids and the increase in venoarterial concentration difference suggest that hypovolemia causes a net release from muscle of a potential substrate for energy metabolism. The blood flow through peripheral tissues, however, is reduced to such an extent during hypovolemic shock that the net rate of release of amino acids is not greater than preshock release and may be less. Therefore, the homeostatic advantages served by the alteration in protein metabolism during the more chronic stresses of starvation or after injury may not obtain during acute hypovolemia.