Trends in intentional and unintentional poisonings among older adults - A national register-based study in Sweden

BACKGROUND

Among older people intentional poisoning outnumber unintentional ones. While there are indications that time trends differ by poisoning intent, studies are scarce. We assessed how the annual prevalence of intentional and unintentional poisoning changed over time, overall and by demographic groups.

METHODS

We conducted a national open cohort study of individuals aged 50-100 years, resident in Sweden during 2005-2016. Individuals were followed up in population-based registers for their demographic and health attributes from 2006-2016. Annual prevalence of hospitalization and death by poisoning intent (unintentional vs. intentional or undetermined; ICD-10 definitions) were compiled for the categories of four demographic attributes (age, sex, marital status, and birth cohort "baby boomers"). The time trends were assessed by multinomial logistic regression with year as an independent variable.

RESULTS

The annual overall prevalence of hospitalization and death by intentional poisonings consistently exceeded that of unintentional poisonings. There was a significant downward trend in intentional poisonings but not in unintentional ones. This difference in trends also applied when considering men and women separately, married and unmarried people, the young-old individuals (but not the older- or oldest-old ones), and the baby boomers and non-baby boomers. The largest demographic differences within intent were found between married and unmarried people, and the smallest one between men and women.

CONCLUSION

As expected, the annual prevalence of intentional poisonings considerably exceed that of unintentional ones among Swedish older people. The recent trends reveal a significant reduction of intentional poisonings, consistent across a range of demographic attributes. The scope for action regarding this preventable cause of mortality and morbidity remains considerable.

Peginterferon Lambda-1a Is Associated with a Low Incidence of Autoimmune Thyroid Disease in Chronic Hepatitis C

Peginterferon alfa (alfa) increases the risk of autoimmune disease. Peginterferon lambda-1a (Lambda) acts through a receptor with a more liver-specific distribution compared to the alfa receptor. In a phase-2b study, 525 treatment-naive patients with chronic hepatitis C virus (HCV) infection received ribavirin and Lambda interferon (120, 180, or 240 μg) or alfa interferon (180 μg) for 24 (genotypes 2 and 3) or 48 (genotypes 1 and 4) weeks. Retrospective analysis found that adverse events of MedDRA-coded thyroid dysfunction and abnormal levels of thyroid-stimulating hormone (TSH) were significantly more frequent with alfa versus Lambda (12% versus 2.6% and 15.2% versus 3.4%, respectively, both P<0.0001). Most Lambda recipients with abnormal TSH had levels below the lower limit of normal; the frequency of low and high TSH was similar in alfa recipients with abnormal TSH. Blinded review by an endocrinologist found that new-onset primary hypothyroidism or painless thyroiditis was less frequent with Lambda versus alfa (0.5% and 1.8% versus 5.3% and 7.5%, respectively, P<0.0001). Most TSH elevations reflected new-onset hypothyroidism requiring treatment, while most markedly suppressed TSH values reflected probable painless thyroiditis and resolved without sequelae. In conclusion, HCV-infected patients treated with Lambda/ribavirin experienced fewer adverse events of thyroid dysfunction compared with patients treated with alfa/ribavirin.

Efficacy and safety of treatment with an anti-m2e monoclonal antibody in experimental human influenza

BACKGROUND

The efficacy of TCN-032, a human monoclonal antibody targeting a conserved epitope on M2e, was explored in experimental human influenza.

METHODS

Healthy volunteers were inoculated with influenza A/Wisconsin/67/2005 (H3N2) and received a single dose of the study drug, TCN-032, or placebo 24 hours later. Subjects were monitored for symptoms, viral shedding, and safety, including cytokine measurements. Oseltamivir was administered 7 days after inoculation.

RESULTS

Although the primary objective of reducing the proportion of subjects developing any grade ≥2 influenza symptom or pyrexia, was not achieved, TCN-032-treated subjects showed 35% reduction (P = .047) in median total symptom area under the curve (days 1-7) and 2.2 log reduction in median viral load area under the curve (days 2-7) by quantitative polymerase chain reaction (P = .09) compared with placebo-treated subjects. TCN-032 was safe and well tolerated with no additional safety signals after administration of oseltamivir. Serum cytokine levels (interferon γ, tumor necrosis factor α, and interleukin 8 and 10) were similar in both groups. Genotypic and phenotypic analyses showed no difference between virus derived from subjects after TCN-032 treatment and parental strain.

CONCLUSIONS

These data indicate that TCN-032 may provide immediate immunity and therapeutic benefit in influenza A infection, with no apparent emergence of resistant virus. TCN-032 was safe with no evidence of immune exacerbation based on serum cytokine expression. Clinicaltrials.gov registry number. NCT01719874.

Snus (Swedish smokeless tobacco) use and risk of stroke: pooled analyses of incidence and survival

BACKGROUND

Snus is a moist smokeless tobacco product with high nicotine content. Its use has a short-term effect on the cardiovascular system, but the relationship between snus use and stroke is unclear.

OBJECTIVE

The aim of this study was to assess the associations between use of snus and incidence of and survival after stroke, both overall and according to subtypes.

METHODS

Pooled analyses of eight Swedish prospective cohort studies were conducted, including 130 485 men who never smoked. We estimated hazard ratios (HRs) with 95% confidence intervals (CIs) of incidence and death after diagnosis using Cox proportional hazard regression models and case fatality and survival using logistic regression and Kaplan-Meier methods, respectively.

RESULTS

No associations were observed between the use of snus and the risk of overall stroke (HR 1.04, 95% CI 0.92-1.17) or of any of the stroke subtypes. The odds ratio (OR) of 28-day case fatality was 1.42 (95% CI 0.99-2.04) amongst users of snus who had experienced a stroke, and the HR of death during the follow-up period was 1.32 (95% CI 1.08-1.61).

CONCLUSION

Use of snus was not associated with the risk of stroke. Hence, nicotine is unlikely to contribute importantly to the pathophysiology of stroke. However, case fatality was increased in snus users, compared with nonusers, but further studies are needed to determine any possible causal mechanisms.

School performance and the risk of suicide attempts in young adults: a longitudinal population-based study

BACKGROUND

Poor school performance is strongly associated with attempted suicide, but the mechanisms underlying this association are uncertain. We examined this relationship and the extent to which it is explained by (i) adult health behaviours and (ii) social conditions. Furthermore, we examined the potential modifying role of previous suicidal thoughts in the relationship.

METHOD

We conducted a longitudinal cohort study of 6146 individuals aged 18-33 years, recruited in 2002 and 2006 in Stockholm and resurveyed in 2007 and 2010 respectively. We estimated the risk of reported lifetime suicide attempts at follow-up among individuals without a history of suicide attempts at baseline and in relation to compulsory school-leaving grades, controlling for possible confounders and mediators.

RESULTS

There were 91 cases of self-reported suicide attempts during the follow-up (5-year incidence of 1.5%). ORs ranged from 3.35 [95% confidence interval (CI) 1.88-5.96] for those in the lowest grade quartile to 2.60 (95% CI 1.48-4.57) and 1.76 (95% CI 0.99-3.13) for those in the second and third quartiles respectively. The relationship between school performance and risk of suicide attempts did not differ by sex. Adult health behaviours and social conditions marginally attenuated, but did not explain, the relationship. The gradient varied with baseline history of suicidal thoughts, and was found only among individuals without such a history.

CONCLUSIONS

Poor school performance was found to predict suicide attempts among young adults without a history of suicidal thoughts. Adult health behaviours and social conditions did not explain this relationship. Instead, other factors linked with poor school performance, such as poor coping ability, may increase the risk of suicide attempts.

A phase I dose-escalation study of TKM-080301, a RNAi therapeutic directed against polo-like kinase 1 (PLK1), in patients with advanced solid tumors: Expansion cohort evaluation of biopsy samples for evidence of pharmacodynamic effects of PLK1 inhibition

TPS2621

Background: TKM-080301 is a lipid nanoparticle formulation of a small interfering RNA (siRNA) directed against PLK1, a serine/threonine kinase that regulates multiple critical aspects of cell cycle progression and mitosis. Anti-tumor activity, RNA interference and pharmacodynamic effects of PLK1 inhibition have been conclusively demonstrated in preclinical models. Demonstration of pharmacodynamic effects of PLK1 inhibition in patient biopsy samples is an exploratory objective of this first-in-human study. Methods: TKME080301 is being evaluated in an open-label, non-randomized, dose-escalation study in patients with advanced solid tumors or lymphoma. Sequential cohorts of 3 to 6 patients receive TKME080301 as a 30-minute intravenous infusion on Days 1, 8 and 15 of a 28-day cycle. Treatment can continue until disease progression, based on overall clinical benefit. Tumor response is determined according to RECIST criteria. Primary study objectives include determination of safety, maximum tolerated dose and dose limiting toxicities. Secondary objectives include characterization of pharmacokinetics and the preliminary assessment of anti-tumor activity. Five cohorts have been enrolled and a tentative Phase 2 dose has been identified. An expansion cohort of 10 patients began enrolling in February, 2013. The focus of the expansion cohort will be to collect additional safety and pharmacokinetic data at the tentative Phase 2 dose, as well as pharmacodynamic data from mandatory biopsy samples. Pre- and post-dose biopsy samples will be evaluated for potential evidence of PLK1 inhibition using 5’ RACE (rapid amplification of cDNA ends) polymerase chain reaction (to identify the predicted PLK1 mRNA cleavage product), histology (to assess for the presence of aberrant mitotic figures) and immunohistochemistry. An update on enrollment and pharmacodynamic evaluations will be presented. Clinical trial information: NCT01262235.

Recombinant human thrombin: safety and immunogenicity in pediatric burn wound excision

BACKGROUND

Previous studies of recombinant human thrombin (rThrombin) enrolled adult and adolescent patients. This phase 4, open-label, single-group study was conducted in pediatric patients undergoing synchronous burn wound excision and skin grafting to provide information regarding the safety and immunogenicity of rThrombin (primary and secondary endpoints) in this population.

METHODS

Topical rThrombin was applied as a hemostatic aid during a surgical procedure (day 1). Adverse events and clinical laboratory abnormalities were recorded during the study. Immunogenicity samples were collected on days 1 and 29 (study end). Study results were summarized with descriptive statistics.

RESULTS

Thirty patients enrolled and 28 completed the study. Mean age was 6.9 years (range, 0.9-17.8 years); 40.0% of patients were girls. Flame and scald were the most common burn types (33.3% each, n = 10/30). Mean graft size was 3.6% total body surface area. Procedural pain (50.0% patients), pruritus (43.3%), and anemia (30.0%) were the most commonly reported adverse events. All adverse events and clinical laboratory abnormalities were considered unrelated to treatment. No patients developed anti-rThrombin product antibodies at day 29.

CONCLUSIONS

In pediatric patients undergoing burn wound excision and skin grafting, rThrombin was well tolerated and did not lead to the formation of anti-rThrombin product antibodies.

Steroid-sparing properties of sargramostim in patients with corticosteroid-dependent Crohn's disease: a randomised, double-blind, placebo-controlled, phase 2 study

OBJECTIVE

Although treatment with corticosteroids induces remission in Crohn's disease, prolonged exposure to corticosteroids is undesirable. This randomised clinical trial evaluated the efficacy of recombinant human granulocyte-macrophage colony-stimulating factor (sargramostim), an activator of innate immunity, in corticosteroid-dependent patients with Crohn's disease.

DESIGN

Patients were randomised in a 2:1 ratio, to sargramostim 6 microg/kg subcutaneously once daily or placebo for up to 22 weeks. The study consisted of (1) an adjunctive phase (weeks 1-4) in which patients received study drug plus corticosteroid therapy; (2) a forced corticosteroid tapering phase (weeks 4-14); and (3) an observation phase (4 weeks) in which patients received study drug plus prednisone < or =7.5 mg. The primary endpoint was corticosteroid-free remission (Crohn's Disease Activity Index (CDAI) < or =150) 4 weeks after corticosteroid elimination. Secondary endpoints were corticosteroid-free response (CDAI decreased by > or =100) and induction of remission in patients who reduced the dose of corticosteroid to 2.5-7.5 mg.

RESULTS

Eighty-seven patients were randomised to sargramostim and 42 to placebo. Significantly more sargramostim-treated patients than placebo patients achieved corticosteroid-free remission (18.6% vs 4.9%; p = 0.03). Similar differences were seen for corticosteroid-free response and in patients who tapered corticosteroids to 2.5-7.5 mg/day. Sargramostim treatment was also associated with significant improvements in health-related quality of life. Patients who received sargramostim were more likely to experience musculoskeletal pain, injection site reactions and dyspnoea.

CONCLUSIONS

Sargramostim was more effective than placebo for inducing corticosteroid-free remission in patients with Crohn's disease with corticosteroid dependence. Sargramostim may provide significant benefit in this population if these findings are confirmed.

Efficacy, safety, and treatment satisfaction of tadalafil versus placebo in patients with erectile dysfunction evaluated at tertiary-care academic centers

OBJECTIVES

To determine the efficacy, safety, and treatment satisfaction of tadalafil 20 mg for erectile dysfunction (ED) in patients evaluated at tertiary-care academic centers.

METHODS

In this randomized, double-blind, placebo-controlled trial, patients were randomly allocated to receive fixed-dose tadalafil 20 mg (n = 146) or placebo (n = 49) for 12 weeks. Efficacy was assessed by the International Index of Erectile Function (IIEF), Sexual Encounter Profile (SEP), and Global Assessment Question (GAQ); patient and partner treatment satisfaction by the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) and SEP; and safety by adverse events, laboratory values, and vital signs.

RESULTS

Mean baseline IIEF erectile function (EF) domain was 12.98. Fifty-one percent of enrolled patients had severe baseline ED, and 82% had organic ED. Pre-existing, ED-associated comorbid conditions were common. When compared with patients treated with placebo, those receiving tadalafil reported significant improvement from baseline in the IIEF EF domain (P <0.001), successful penetration attempts (SEP question 2; P <0.001), successful intercourse (SEP question 3; P <0.001), and all secondary efficacy outcomes (P <0.001). Patients and their sexual partners were also significantly more satisfied with tadalafil treatment (P <0.001), including overall satisfaction (P <0.001) and length of time the treatment worked (P <0.001). Mild or moderate headache, dyspepsia, and myalgia were the most frequent treatment-emergent adverse events reported.

CONCLUSIONS

Tadalafil significantly improved erectile function and patient and partner satisfaction and was well tolerated. These results were observed in a tertiary-care, academic center population with a high incidence of severe, organic ED, and comorbid medical conditions, factors known to compromise erectile function and treatment outcome.

A three-part study to investigate the incidence and potential etiologies of tadalafil-associated back pain or myalgia

The potential mechanisms underlying back pain and/or myalgia experienced by men taking tadalafil were investigated. An integrated analysis of 10 placebo-controlled tadalafil clinical trials (N=1846) showed that the incidence of back pain and/or myalgia was 9.4% in patients receiving tadalafil 10 mg (N=394), 8.3% in patients receiving tadalafil 20 mg (N=883) and 3.7% in placebo-treated patients (N=569). One (0.3%) patient receiving tadalafil 10 mg, six (0.7%) patients receiving tadalafil 20 mg, and no patients receiving placebo discontinued treatment due to back pain and/or myalgia. In a prospective study in healthy volunteers, no substantial changes were observed in laboratory markers indicative of inflammation or muscle damage, and tadalafil did not affect renal plasma flow nor produce lumbar or gluteal myositis by positron emission tomography scan or magnetic resonance imaging. Although the mechanism of back pain and/or myalgia remains unknown, these events appear to be self-limiting and a general effect of phosphodiesterase 5 inhibition.

A 6-month study of the efficacy and safety of tadalafil in the treatment of erectile dysfunction: a randomised, double-blind, parallel-group, placebo-controlled study in Australian men

The efficacy and safety of tadalafil for the treatment of erectile dysfunction (ED) were assessed in a 6-month, randomised, double-blind, placebo-controlled study. Australian men with mild, moderate or severe ED of organic, psychogenic or mixed aetiology were randomised to tadalafil 20 mg as needed (n = 93) or placebo (n = 47). Efficacy assessments included the international index of erectile function (IIEF) and the sexual encounter profile (SEP) diary. Tadalafil significantly improved erectile function compared with placebo (p < 0.001, all measures). At the end of the study, the mean per-patient proportion of successful sexual intercourse attempts (SEP question three) was 73.5% for patients treated with tadalafil and 26.8% for placebo-treated patients. Improved erections were reported by 78% of tadalafil-treated patients compared to 12.8% of placebo-treated patients. The most common treatment-emergent adverse events--headache and dyspepsia--were generally mild or moderate. Tadalafil was effective and well tolerated in Australian men with mild to severe ED.

Impact of diabetes mellitus on the severity of erectile dysfunction and response to treatment: analysis of data from tadalafil clinical trials

AIMS/HYPOTHESIS

A retrospective analysis of pooled data from twelve placebo-controlled trials was conducted to characterise the efficacy and safety of tadalafil for the treatment of erectile dysfunction in men with diabetes compared with that in men without diabetes.

METHODS

Patients were randomly allocated to tadalafil 10 mg, 20 mg, or placebo, taken as needed for 12 weeks. The study population comprised 637 men with diabetes (mean age 57 years) and 1681 men without diabetes (mean age 56 years).

RESULTS

At baseline, patients with diabetes had more severe erectile dysfunction than patients without diabetes, with mean International Index of Erectile Function (IIEF) erectile function domain scores of 12.6 and 15.0 respectively (p<0.001). Compared with placebo, tadalafil 10 mg and 20 mg improved all primary efficacy outcomes in both patient groups (p<0.001). Men with diabetes receiving tadalafil 20 mg experienced a mean improvement of 7.4 in their IIEF erectile function domain score against baseline versus 0.9 for placebo (p<0.001). This group reported on average that 53% of their attempts at intercourse were successful, compared with 22% for placebo (p<0.001 for the change from baseline). Baseline IIEF erectile function domain scores correlated inversely with baseline HbA(1)c levels. The responses to tadalafil were similar regardless of levels of baseline glycaemic control, diabetic therapy received, or previous use of sildenafil.

CONCLUSIONS/INTERPRETATION

Despite more severe baseline erectile dysfunction in men with diabetes, tadalafil was efficacious and well tolerated in this population. As reported for other phosphodiesterase 5 inhibitors, the response to tadalafil was slightly lower in men with diabetes than in men without diabetes.

A prospective study of fatal occupational accidents -- relationship to sleeping difficulties and occupational factors

Very little is known about the association between sleep and (fatal) occupational accidents. This study investigated this relationship using register data of self-rated sleep difficulties, together with occupational and demographic characteristics. The variables were related to subsequent occupational fatal accidents. A national sample of 47,860 individuals was selected at regular intervals over a period of 20 years, and interviewed over the phone on issues related to work and health. The responses were linked to the cause of death register (suicides excluded) and the data set was subjected to a (multivariate) Cox regression survival analysis. One hundred and sixty six fatal occupational accidents occurred, and the significant predictors were: male vs. female: relative risk (RR)=2.30 with a 95% confidence interval (CI) of 1.56-3.38; difficulties in sleeping (past 2 weeks): RR=1.89 with CI=1.22-2.94; and non-day work: RR=1.63 with CI=1.09-2.45. No significant effect was seen for age, socio-economic group, hectic work, overtime (>50 h per week), or physically strenuous work. It was concluded that self-reported disturbed sleep is a predictor of accidental death at work, in addition to non-day work and male gender.

Self rated health: Is it as good a predictor of subsequent mortality among adults in lower as well as in higher social classes?

STUDY OBJECTIVE

To analyse the predictive power of self rated health for mortality in different socioeconomic groups.

DESIGN, SETTING, PARTICIPANTS

Analysis of mortality rates and risk ratios of death during follow up among 170 223 respondents aged 16 years and above in the Swedish Survey of Living Conditions 1975-1997, in relation to self rated health stated at the interview, by age, sex, socioeconomic group, chronic illness and over time.

MAIN RESULTS

There was a strong relation between poor self rated health and mortality, greater at younger ages, similar among men and women and among persons with and without a chronic illness. The relative relation between self rated health and subsequent death was stronger in higher than in lower socioeconomic groups, possibly because of the lower base mortality of these groups. However, the absolute mortality risk differences between persons reporting poor and good self rated health were similar across socioeconomic groups within each sex. The mortality risk difference between persons reporting poor and good self rated health was considerably higher among persons with a chronic illness than among persons without a chronic illness. The mortality risk among persons reporting poor health was increased for shorter (<2 years) as well as longer (10+ years) periods of follow up.

CONCLUSIONS

The results suggest that poor self rated health is a strong predictor of subsequent mortality in all subgroups studied, and that self rated health therefore may be a useful outcome measure.

Decision latitude, job strain, and myocardial infarction: a study of working men in Stockholm. The SHEEP Study Group. Stockholm Heart epidemiology Program

OBJECTIVES

This study examined the role of decision latitude and job strain in the etiology of a first myocardial infarction.

METHODS

Eligible case patients were all full-time working men 45 to 64 years of age who suffered a first myocardial infarction during the period January 1992 to January 1993 in the greater Stockholm region. Referents were selected from the general population. Participation rates were 82% (case patients) and 75% (referents).

RESULTS

Both inferred and self-reported low decision latitude were associated with increased risk of a first myocardial infarction, although this association was weakened after adjustment for social class. A decrease in inferred decision latitude during the 10 years preceding the myocardial infarction was associated with increased risk after all adjustments, including chest pain and social class. The combination of high self-reported demands and low self-reported decision latitude was an independent predictor of risk after all adjustments.

CONCLUSIONS

Both negative change in inferred decision latitude and self-reported job strain are important risk indicators in men less than 55 years of age and in blue-collar workers.

Long-term psychosocial work environment and cardiovascular mortality among Swedish men

OBJECTIVES

This study examined the effect of cumulative exposure to work organization--psychological demands, work control, and social support on prospectively measured cardiovascular disease mortality risk.

METHODS

The source population was a national sample of 12517 subjects selected from the Swedish male population by Statistics Sweden in annual surveys between 1977 and 1981. Over a 14-year follow-up period, 521 deaths from cardiovascular disease were identified. A nested case-control design was used. Work environment exposure scores were assigned to cases and controls by linking lifetime job histories with a job exposure matrix.

RESULTS

Conditional logistic regression analysis was used in examining cardiovascular mortality risk in relation to work exposure after adjustment for age, year last employed, smoking, exercise, education, social class, nationality, and physical job demands. In the final multi-variable analysis, workers with low work control had a relative risk of 1.83 (95% confidence interval [CI] = 1.19, 2.82) for cardiovascular mortality. Workers with combined exposure to low control and low support had a relative risk of 2.62 (95% CI=1.22, 5.61).

CONCLUSIONS

These results indicate that long-term exposure to low work control is a risk factor for cardiovascular disease mortality.

Lipid lowering through work stress reduction

Swedish civil servants, who reported considerable stress while working in larger government authorities, were randomized into either a work stress reduction intervention or a control group. Four work units constituted the intervention group (n = 94). and one unit formed the control group (n = 35). Participants in the two groups were of similar age and two thirds were women. Psychosocial, lifestyle, and physiological assessments were made before, during, and after the 8-month intervention period. A significant decrease in apolipoprotein B/apolipoprotein A I ratio (p < 0.05) occurred in the intervention group but not in the control group. No changes were seen in either group in smoking, eating. exercise, relative weight, or other lifestyle factors. which could explain the lipid profile changes. Stimulation from and autonomy over work increased in the intervention group (p < 0.01) hut remained the same in the control group. Results have implications for the efficacy of work stress interventions in decreasing coronary risk.

Surveillance colonoscopy and biopsy in patients with ureterosigmoidostomy

Colonoscopy with biopsy was included in the surveillance of 19 patients with ureterosigmoidostomy, because of the high incidence of colonic carcinoma reported in such cases. The patients were examined 1-6 times, at intervals of 1-2 years, 4-36 years after the urinary diversion. Random biopsies from the distal colon and rectum showed only discrete changes, and no dysplasia. Polyps with dysplastic changes were found close to ureteral anastomoses in three patients. For routine check-up of the rectosigmoid region and the ureteral implantation sites, examination with a flexible sigmoidoscope seems to be adequate and preferable, giving easy access to the risk zone for the development of cancer. Caution should be exercised, however, when performing biopsy close to the ureteral orifices.

Continent ileostomy. A follow-up study of 60 patients

Sixty patients underwent proctocolectomy and received a continent ileostomy because of ulcerative colitis (50 cases) familial polyposis (7) or Crohn's disease (3), with no deaths at surgery or during follow-up (mean 4.5 years, range 3 months-10 years). Early complications were few and insignificant. Late complications (nipple-valve sliding and pouch ileitis) were more common, and 15 patients with valve sliding causing leakage had to undergo altogether 22 reoperations. Three reservoirs had to be removed because of refractory pouch ileitis. Modifications in nipple-valve construction in the last 40 cases diminished the problem of sliding. More than 90% of the patients reported improved quality of life after conversion of conventional to continent ileostomy. Continent ileostomy remains an excellent alternative to ileoanal anastomosis with proximal reservoir for patients who cannot accept conventional ileostomy or when an ileoanal anastomosis with reservoir functions unsatisfactorily or is otherwise unsuitable.

Protective colostomy in low anterior resection of the rectum using the EEA stapling instrument. A randomized study

The need for protective transverse colostomy in low anterior resection using the EEA stapler was tested in a randomized series of 50 patients, half of whom received peroperative protective colostomy. Gastrografin enema on the tenth postoperative day showed a leakage frequency of 30 per cent in both groups. Clinical leakage was noted in 4 per cent (one patient) in the colostomy group and 12 per cent (three patients) in the noncolostomy group. Protective colostomy was followed by stenosis in nine instances, compared with only two in the noncolostomy group (2 alpha = 0.05). Routine protective colostomy should not be used in low anterior resection when the EEA stapling instrument is used. The occasional clinical leakage, which may appear in the postoperative period, can be revealed by close observation and successfully treated by an emergency colostomy. The majority of patients with anterior resection of the rectum, therefore, can be spared the inconvenience and cost of temporary colostomy.

Angiography after temporary inhibition of blood flow followed by intraarterial 5-FU infusion in the treatment of liver metastases

Temporary inhibition of the blood flow to the liver was performed in 20 patients with metastases by tightening slings around the hepatic artery for 16 hours. Infusion of 5-FU started two days later through a catheter in the gastroduodenal artery. The response to the treatment as revealed by angiography was swelling of the liver and necrosis of the metastases. Thirteen patients responded favourably to the treatment. Complications such as abscess formation, 5-FU leakage, thrombosis of the hepatic artery and development of aneurysm at the entry of the infusion catheter occurred in some patients.

Evaluation of aggressive surgery for carcinoma of the extrahepatic bile ducts

The records of 80 consecutive patients with extrahepatic bile duct cancer, 45 women and 35 men, median age 70 years (33-89 years), were reviewed. The histologic diagnoses were adenocarcinoma in 45 patients, 34 cholangiocarcinoma and one squamous cell carcinoma. In 34 patients the tumor was located to the confluence, the right or left hepatic duct, in 16 to the middle and in four to the distal portion of the bile duct. In the remaining 26 patients the tumor comprised more than one of these locations (mixed location). Twenty-seven of the 80 patients (34%) were operated on with resection of the tumor. Among patients 70 years of age and younger the resectability rate was 57%. In nine patients the main surgical procedure was bile duct resection, in 15 patients bile duct resection and liver lobe resection, in 2 patients total pancreatectomy and in one local excision were performed. The resection of the tumor was regarded as radical in 12 patients and palliative in 15. The mortality rate was 11% after resection as compared to 30% in patients with nonresectable tumors. The most common postoperative complication was insufficiency of the anastomosis which occurred in seven patients. Three of these patients required reoperation. The median survival time in patients operated on with radical resection was 20 months, palliative resection 7(1/2) months and in patients with nonresectable tumors 2(1/2) months. The quality of life was estimated according to a special schedule and was found to be improved after resection as compared to nonresection. Patients operated with radical resection spent significantly less of their remaining life at hospital as compared to palliatively resected patients or patients with nonresectable tumors.

Roentgen stereophotogrammetry for evaluation of liver volume and shape

Model experiments and tests on 2 patients were performed to probe the feasibility of roentgen stereophotogrammetry for evaluating variations in shape and volume of the liver. The surface of the object was marked with indicators, and the three-dimensional marker coordinates were determined. The model experiments demonstrate a good correlation between true volume and the volumes defined by the indicators, and also demonstrate the possibility of localizing an expansivity. The variability of the volume of a polyhedron defined by 15 liver indicators with stage of breathing is discussed.

Aldosterone production by isolated glomerulosa cells: modulation of sensitivity to angiotensin II and ACTH by extracellular potassium concentration

The influence of extracellular potassium concentration on adrenal sensitivity to angiotensin II and ACTH was studied in isolated canine adrenal glomerulosa cells. When potassium was absent from the incubation medium, the aldosterone response to angiotensin II or ACTH was completely abolished. At physiologic angiotensin II concentrations (2.5 x 10(-11) M), aldosterone formation increased 4-fold when potassium concentration was increased from 2.5 to 5.0 mM, and rose 6-fold as potassium was increased from 2.5 to 7.5 mM. In the absence of angiotensin II, the same changes in potassium concentration increased aldosterone production only to 2-fold and 3.5-fold, respectively. The effect of potassium concentration upon the aldosterone response to ACTH was similar but less marked. The concentration and binding affinity of angiotensin II receptor sites in glomerulosa cells were not changed by increasing potassium concentrations from 0 to 7.5 mM. These observations demonstrate that the aldosterone response to the glomerulosa cell to angiotensin II is potassium-dependent within the physiological range for each of these stimuli. Such an interaction suggests that the in vivo effect of potassium upon aldosterone secretion includes a significant modulating action upon adrenal sensitivity to angiotensin II, as well as a direct action of potassium upon the adrenal glomerulosa cell.

Receptor binding of angiotensin II and antagonists. Correlation with aldosterone production by isolated canine adrenal glomerulosa cells

The binding properties of the angiotensin II receptors of the adrenal cortex have been studied in isolated cells prepared by collagenase dispersion of the zona glomerulosa of the canine adrenal gland. Such cell preparations are responsive to physiological concentrations of angiotensin II, and permit correlation of binding of angiotensin II and its analogues with aldosterone production in vitro. Uptake of 125I-angiotensin II (5 X 10(-11) M) by glomerulosa cells at 37 degrees C reached a steady state at 45 minutes, with a subsequent plateau for at least 60 minutes. Angiotensin II binding was also dependent upon the hormone and cell concentrations employed during uptake studies. Bound angiotensin II was rapidly dissociated from canine adrenal cells after addition of the unlabeled octapeptide. High affinity sites with equilibrium association constant (Ka) of 3.3 X 10(9) M-1 comprised 25-33% of the receptor population and the remainder of the sites were of lower affinity, 2.5 X 10(8)M-1. Binding of angiotensin II analogues and antagonists was found to be consistent with their biological activities. The analogue most extensively evaluated was [Sar-1]angiotensin II, which exhibited enhanced binding activity when compared to angiotensin II, and had a higher equilibrium association constant by kinetic analysis and direct binding studies. Direct binding of labeled angiotensin II to the adrenal glomerulosa receptor has been correlated with a progressive response in aldosterone production. The steroidogenic response to angiotensin II was maximal when 25% of the receptor population was occupied; this fraction corresponds to the proportion of high affinity receptor sites measured by binding analysis. In addition, inhibition of angiotensin II binding to receptor sites by the competitive antagonist [Sar-1, Ala-8]angiotensin II has been correlated with inhibition of aldosterone production. These findings serve to demonstrate the biological significance of the angiotensin II binding sites of the adrenal cortex, and confirm their role as receptors which mediate the steroidogenic responses to angiotensin II.

Actions of angiotensin II antagonists upon aldosterone production by isolated adrenal glomerulosa cells

The biological activities of angiotensin II antagonists upon basal and angiotensin II-stimulated aldosterone production were evaluated in an isolated canine glomerulosa cell preparation. The most potent competitive antagonist of angiotensin II-stimulated aldosterone production was the [Sar1, Ile8]derivative of angiotensin II. However, this peptide was also a partial agonist at concentrations required to inhibit the steroidogenic effect of angiotensin II on dog adrenal cells, and never reduced aldosterone production to basal levels. On a molar basis, the [Sar1, Ala8] and [Sar1, Gly8]derivatives of angiotensin II were relatively less potent as competitive inhibitors of angiotensin II-stimulated aldosterone production. However, the [Ala8] and [Gly8]-analogues did not exhibit significant agonist activity and were therefore more effective antagonists of angiontensin II-stimulated aldosterone production. These results suggest that increased length of the aliphatic side chain at the C-terminus of angiotensin II antagonists is accompanied by enhanced affinity for the receptor site, but also by increased agonist activity upon aldosterone synthesis. The actions of angiotensin II and [Des-Asp1]angiotensin II upon aldosterone production were inhibited identically and completely by [Sar1, Ala8]angiotensin II, and identically, though incompletely, by lower concentrations of [Sar1, Ile8]angiotensin II. The heptapeptide antagonist [Des-Asp1, Ile8]angiotensin II was much less potent than [Sar1, Ile8]angiotensin II as an inhibitor of the actions of both the heptapeptide and octapeptide agonists. The antagonist activity of six angiotensin II analogues at the adrenal level, determined by the concentration required for 50% inhibition of maximum aldosterone secretion, correlated well with their antagonist activity measured upon isolated smooth muscle. These observations demonstrate that the octapeptide antagonists are more effective than the heptapeptide antagonists upon angiotensin II-stimulated aldosterone production, and that angiotensin II receptors in smooth muscle and adrenal cortex exhibit generally similar responses to angiotensin II antagonists. Also, these results do not support the proposal that the [Des-Asp1]heptapeptide is an important intermediate in the action of angiotensin II upon adolesterone production in the adrenal glomerulosa cells. The production of aldosterone by dispersed zona glomerulosa cells in vitro provides a highly sensitive and biologically appropriate response for evaluation of the agonist and antagonist properties of angiotensin II analogues upon the adrenal gland.

Aldosterone production by isolated adrenal glomerulosa cells: stimulation by physiological concentrations of angiotensin II

The production of aldosterone by isolated canine zona glomerulosa cells was measured after the incubation of cell suspensions with angiotensin II and ACTH, and during changes in extracellular potassium concentration. Adrenal cell suspensions were prepared by collagenase digestion and physical dispersion of the capsular layer of the dog adrenal cortex, and aldosterone production was determined by direct radioimmunoassay of cell incubation media. The isolated dog adrenal cells were highly responsive to angiotensin II, with aldosterone production significantly stimulated by concentrations of the octapeptide as low as 10(-11)M. Thus, the steroidogenic response of zona glomerulosa cells was consistently observed at peptide concentrations within the physiological range of angiotensin II in dog plasma, i.e., 2.0-5.0 X 5.0 X 10(-11)M. The maximum aldosterone response of 3-8 times the basal level of steroid production was induced by 3 X 10(-10)M angiotensin II, and a decrease in aldosterone production occurred at peptide concentrations above 10(-9)M. The aldosterone response of isolated adrenal cells to ACTH was consistently less sensitive than their response to angiotensin II, by a factor of 10-20 fold. Aldosterone production was significantly increased by 10(-10)M ACTH, and reached a maximum at 10(-8)M ACTH. By contrast with angiotensin II, ACTH usually evoked a higher maximal level of aldosterone production, and did not produce a decline in steroidogenesis at peptide concentrations above the level which caused maximum stimulation of aldosterone formation. Changes in the potassium concentration of cell incubation media were also accompanied by marked effects upon aldosterone synthesis which was abolished in the absence of potassium and became detectable in the presence of 0.5 mM K+. After remaining constant between 2.5 and 4.0 mM K+, aldosterone production rose sharply above 4.5 mM K+ and reached a maximum at 8 mM K+. These observations provide direct evidence that aldosterone production by zona glomerulosa cells is influenced by changes in angiotensin II levels within the normal plasma range.

Stimulation of aldosterone production by angiotensin II peptides in vitro: enhanced activity of the (1-sarcosine) analogue

The biological activity of angiotensin agonists has been determined in a highly sensitive in vitro assay system, based upon aldosterone production by isolated dog adrenal cells. The responses to angiotensin II and the heptapeptide [Des-Asp-1]-angiotensin II are identical, while the [Des-Asp-1, Des-Arg-2]-hexapeptide and the [Des-Phe-8]-heptapeptide are almost completely inactive. By contrast, [Sar-1]-angiotensin II, a potent agonist upon vascular smooth muscle, is also about 10 times more active than angiotensin II in stimulating the production of aldosterone by dog adrenal cells. The increased agonist activity of [Sar-1]-angiotensin II is attributable to increased binding affinity as well as increased efficacy at the adrenal receptor site. These results also suggest that conversion to the [Des-Asp-1] heptapeptide is not an important intermediate step in the action of angiotensin II upon the zona glomerulosa.