The ancient drug salicylate directly activates AMP-activated protein kinase

Salicylate, a plant product, has been in medicinal use since ancient times. More recently, it has been replaced by synthetic derivatives such as aspirin and salsalate, both of which are rapidly broken down to salicylate in vivo. At concentrations reached in plasma after administration of salsalate or of aspirin at high doses, salicylate activates adenosine monophosphate-activated protein kinase (AMPK), a central regulator of cell growth and metabolism. Salicylate binds at the same site as the synthetic activator A-769662 to cause allosteric activation and inhibition of dephosphorylation of the activating phosphorylation site, threonine-172. In AMPK knockout mice, effects of salicylate to increase fat utilization and to lower plasma fatty acids in vivo were lost. Our results suggest that AMPK activation could explain some beneficial effects of salsalate and aspirin in humans.

Aromatic hydroxylation as a potential measure of hydroxyl-radical formation in vivo. Identification of hydroxylated derivatives of salicylate in human body fluids

Attack by .OH radicals, generated by a Fenton system, upon salicylate produces 2,3-dihydroxybenzoate and 2,5-dihydroxybenzoate as major products and catechol as a minor product. H.p.l.c. separation combined with electrochemical detection was used to identify and quantify 2,3-dihydroxybenzoate and 2,5-dihydroxybenzoate in human plasma and synovial fluid. We propose that conversion of salicylate into 2,3-dihydroxybenzoate, or of other aromatic compounds into specific hydroxylated products, may be a useful assay for .OH formation in the human body.

A controlled therapeutic trial of long-term maintenance treatment of ulcerative colitis with sulphazalazine (Salazopyrin)

Sixty-four patients with proven ulcerative colitis who had been maintained on sulphasalazine as their sole form of treatment for a minimum period of one year were entered into a controlled trial of sulphasalazine versus dummy tablets for a period of six months. All the patients admitted were not only symptom-free but also showed no evidence of inflammation on sigmoidoscopy and rectal biopsy. A patient was judged to have relapsed when there was a recurrence of colitic symptoms accompanied by sigmoidoscopic and histological evidence of inflammation. The patients who received dummy tablets had more than four times the relapse rate of those receiving sulphasalazine. The results were similar in patients who had been on maintenance treatment with sulphasalazine for less than three years before entry into the trial and in those who had been on this treatment for more than three years. It is concluded that maintenance treatment of ulcerative colitis with sulphasalazine should be continued indefinitely unless contraindicated by side effects.

Suppression of thromboxane A2 but not of systemic prostacyclin by controlled-release aspirin

BACKGROUND

The antithrombotic efficacy of aspirin is attributed to its inhibition of the enzyme prostaglandin G/H synthase, which is necessary for the formation of thromboxane A2 in platelets. Thromboxane A2 is a potent vasoconstrictor and platelet agonist. However, the formation of prostacyclin by vascular endothelium also requires prostaglandin G/H synthase, and prostacyclin exerts opposite effects on platelet function and vascular tone. We wanted to see whether controlled-release aspirin would affect the formation of thromboxane A2 but not prostacyclin by reducing the aspirin concentration that reaches the posthepatic circulation.

METHODS

A controlled-release formulation containing 75 mg of aspirin, designed to release 10 mg per hour, was developed to inhibit prostaglandin G/H synthase in platelets in the prehepatic circulation. The effects of the controlled-release preparation on plasma levels of aspirin and salicylate, serum levels of thromboxane B2, and urinary dinor metabolites of prostacyclin and thromboxane B2 (measured by gas chromatography-mass spectrometry) were compared with those of conventional immediate-release aspirin in normal volunteers. Prostacyclin release was stimulated by intravenous bradykinin.

RESULTS

Steady-state inhibition of serum thromboxane B2 required two to four days and appeared slower with 75 mg of controlled-release than with the same amount of immediate-release aspirin. Maximal inhibition was achieved rapidly by adding a single loading dose of 162.5 mg of immediate-release aspirin to the regimen. Over a 28-day period, suppression of thromboxane A2 with this regimen was comparable to that with immediate-release aspirin taken either as 162.5 mg daily or as 325 mg on alternate days, despite the minimal systemic bioavailability of controlled-release aspirin. Bleeding time was prolonged to a similar degree with each of the three regimens. The five- to sixfold increase in the prostacyclin metabolite induced by bradykinin was depressed by pretreatment for four days with 75 mg of immediate-release aspirin, but not by 75 mg of controlled-release aspirin.

CONCLUSIONS

Maximal inhibition of platelet thromboxane A2 production was sustained during long-term dosing with controlled-release aspirin, whereas basal prostacyclin biosynthesis fell only slightly and systemic synthesis of prostacyclin stimulated by bradykinin was preserved. Controlled-release aspirin may facilitate determination of the clinical importance of preserving prostacyclin during platelet inhibition in humans.

Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study

OBJECTIVE

To evaluate the effects on suicidal behaviour of legislation limiting the size of packs of paracetamol and salicylates sold over the counter.

DESIGN

Before and after study.

SETTING

UK population, with detailed monitoring of data from five liver units and seven general hospitals, between September 1996 and September 1999.

SUBJECTS

People who died by suicidal or accidental overdose with paracetamol or salicylates or who died of undetermined causes; patients admitted to liver units with hepatic paracetamol poisoning; patients presenting to general hospitals with self poisoning after taking paracetamol or salicylates.

MAIN OUTCOME MEASURES

Mortality from paracetamol or salicylate overdose; numbers of patients referred to liver units or listed for liver transplant; numbers of transplantations; numbers of overdoses and tablets taken; blood concentrations of the drugs; prothrombin times; sales to pharmacies and other outlets of paracetamol and salicylates.

RESULTS

Numbers of tablets per pack of paracetamol and salicylates decreased markedly in the year after the change in legislation on 16 September 1998. The annual number of deaths from paracetamol poisoning decreased by 21% (95% confidence interval 5% to 34%) and the number from salicylates decreased by 48% (11% to 70%). Liver transplant rates after paracetamol poisoning decreased by 66% (55% to 74%). The rate of non-fatal self poisoning with paracetamol in any form decreased by 11% (5% to 16%), mainly because of a 15% (8% to 21%) reduction in overdoses of paracetamol in non-compound form. The average number of tablets taken in paracetamol overdoses decreased by 7% (0% to 12%), and the proportion involving >32 tablets decreased by 17% (4% to 28%). The average number of tablets taken in salicylate overdoses did not decrease, but 34% fewer (2% to 56%) salicylate overdoses involved >32 tablets. After the legislation mean blood concentrations of salicylates after overdose decreased, as did prothrombin times; mean blood concentrations of paracetamol did not change.

CONCLUSION

Legislation restricting pack sizes of paracetamol and salicylates in the United Kingdom has had substantial beneficial effects on mortality and morbidity associated with self poisoning using these drugs.

Sensing of Antipyretic Carboxylates by Simple Chromogenic Calix[4]pyrroles

We present a simple, two- or three-step method for the synthesis of chromogenic octamethylcalix[4]pyrrole-based (OMCP) sensors for anions. Electrophilic aromatic substitution allows for converting the pyrrole moieties of OMCP into a dye. The formation of a sensor-anion complex results in partial charge transfer and a dramatic change in color. The absorption (UV-vis) and NMR titration experiments show that the chromogenic OMCPs sense anions administered as aqueous solutions, even at high ionic strength ( approximately 0.1 M NaCl), while displaying selectivity for pyrophosphate and carboxylate anions. The experiments with polyurethane sensor films show a strong response for aqueous carboxylates, such as antipyretics naproxen approximately ibuprofen > salicylate, without being biased by bicarbonate or carboxy termini of blood plasma proteins.

Salicylate-induced abnormal activity in the inferior colliculus of rats

The evaluation of the spontaneous activity of 471 units from the external nucleus of the IC revealed that salicylate induces an increase of the spontaneous activity and the emergence of a bursting type of activity longer than 4 spikes. For sharply tuned units, the affected cells were from the frequency range of 10-16 kHz, which corresponds to the behaviorally measured pitch of salicylate-induced tinnitus in rats. An exogenous calcium supplement, provided under the conditions shown to attenuate the behavioral manifestation of salicylate-induced tinnitus, abolished the modification of the spontaneous activity induced by salicylate. Finally, profound changes of activity were observed for cells not responding to contralateral sound. We propose that the observed long bursts of discharges represent tinnitus-related neuronal activity. The results are consistent with the hypothesis that GABA-mediated disinhibition is involved in the processing of tinnitus-related neuronal activity.

Reye's syndrome in the United States from 1981 through 1997

BACKGROUND

Reye's syndrome is characterized by encephalopathy and fatty degeneration of the liver, usually after influenza or varicella. Beginning in 1980, warnings were issued about the use of salicylates in children with those viral infections because of the risk of Reye's syndrome.

METHODS

To describe the pattern of Reye's syndrome in the United States, characteristics of the patients, and risk factors for poor outcomes, we analyzed national surveillance data collected from December 1980 through November 1997. The surveillance system is based on voluntary reporting with the use of a standard case-report form.

RESULTS

From December 1980 through November 1997 (surveillance years 1981 through 1997), 1207 cases of Reye's syndrome were reported in patients less than 18 years of age. Among those for whom data on race and sex were available, 93 percent were white and 52 percent were girls. The number of reported cases of Reye's syndrome declined sharply after the association of Reye's syndrome with aspirin was reported. After a peak of 555 cases in children reported in 1980, there have been no more than 36 cases per year since 1987. Antecedent illnesses were reported in 93 percent of the children, and detectable blood salicylate levels in 82 percent. The overall case fatality rate was 31 percent. The case fatality rate was highest in children under five years of age (relative risk, 1.8; 95 percent confidence interval, 1.5 to 2.1) and in those with a serum ammonia level above 45 microg per deciliter (26 micromol per liter) (relative risk, 3.4; 95 percent confidence interval, 1.9 to 6.2).

CONCLUSIONS

Since 1980, when the association between Reye's syndrome and the use of aspirin during varicella or influenza-like illness was first reported, there has been a sharp decline in the number of infants and children reported to have Reye's syndrome. Because Reye's syndrome is now very rare, any infant or child suspected of having this disorder should undergo extensive investigation to rule out the treatable inborn metabolic disorders that can mimic Reye's syndrome.

Salicylate-selective membrane electrode based on tin(IV) tetraphenylporphyrin

The response properties of a new solvent/polymeric membrane electrode with unique selectivity toward anionic salicylate are reported. The electrode is prepared by incorporating 5, 10, 15, 20-tetraphenyl(porphyrinato)tin(IV) dichloride (Sn[TPP]Cl2) into a plasticized poly(vinyl chloride) membrane. The resulting sensor exhibits an anti-Hofmeister selectivity pattern, with high specificity for salicylate over lipophilic inorganic anions (perchlorate, periodate, thiocyanate, iodide, etc.) and biological organic anions (citrate, lactate, acetate). Moderate selectivity over structural analogues of salicylate (3- and 4-hydroxybenzoate, benzoate) is also observed. Radiotracer uptake experiments using [14C]salicylate clearly show that the metal center of the metalloporphyrin is critical for selective salicylate transport in the membrane phase. Minimal response to chloride ions makes the new electrode potentially useful for estimating salicylate levels in biological samples.

Pharmacokinetics of aspirin and salicylate in relation to inhibition of arachidonate cyclooxygenase and antiinflammatory activity

Among the nonsteroid antiinflammatory drugs there is generally a close correlation between the potency of their inhibition of arachidonate cyclooxygenase, and thus prostaglandin production, and their antiinflammatory activity. One anomaly in this generalization is that whereas aspirin and salicylate are equipotent as antiinflammatory agents, salicylate is less active than aspirin in inhibiting prostaglandin production in vitro. Using rats, we have now measured the concentrations of aspirin and salicylate in plasma and in inflammatory exudates after their oral administration and determined their effects on thromboxane B2 production in clotting blood and prostaglandin (PG) E2 concentrations in the exudates. We have also investigated the effects of both drugs, at concentrations achieved in the exudates, on PGE2 production by nonproliferative explants of acutely inflamed tissues. Aspirin is rapidly metabolized, resulting in peak concentrations of salicylate in the plasma and exudate that exceeded peak concentrations of aspirin by 30- to 50-fold. Furthermore, concentrations of aspirin rapidly declined, whereas high concentrations of salicylate persisted in the plasma and in the exudate for up to 6 hr after a single administration of aspirin. Both drugs reduced PGE2 concentrations in inflammatory exudates by 50-70%, but aspirin was considerably more potent than salicylate in inhibiting thromboxane B2 production in clotting blood. The concentration of salicylate found in inflammatory exudates 6 hr after the administration of aspirin was sufficient to reduce PGE2 production in explants by more than 50%. We conclude that the antiinflammatory action of both drugs depends on the inhibition of PGE2 synthesis by salicylate.

Effect of Sunscreen Application on Plasma Concentration of Sunscreen Active Ingredients: A Randomized Clinical Trial

IMPORTANCE

A prior pilot study demonstrated the systemic absorption of 4 sunscreen active ingredients; additional studies are needed to determine the systemic absorption of additional active ingredients and how quickly systemic exposure exceeds 0.5 ng/mL as recommended by the US Food and Drug Administration (FDA).

OBJECTIVE

To assess the systemic absorption and pharmacokinetics of the 6 active ingredients (avobenzone, oxybenzone, octocrylene, homosalate, octisalate, and octinoxate) in 4 sunscreen products under single- and maximal-use conditions.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial at a clinical pharmacology unit (West Bend, Wisconsin) was conducted in 48 healthy participants. The study was conducted between January and February 2019.

INTERVENTIONS

Participants were randomized to 1 of 4 sunscreen products, formulated as lotion (n = 12), aerosol spray (n = 12), nonaerosol spray (n = 12), and pump spray (n = 12). Sunscreen product was applied at 2 mg/cm2 to 75% of body surface area at 0 hours on day 1 and 4 times on day 2 through day 4 at 2-hour intervals, and 34 blood samples were collected over 21 days from each participant.

MAIN OUTCOMES AND MEASURES

The primary outcome was the maximum plasma concentration of avobenzone over days 1 through 21. Secondary outcomes were the maximum plasma concentrations of oxybenzone, octocrylene, homosalate, octisalate, and octinoxate over days 1 through 21.

RESULTS

Among 48 randomized participants (mean [SD] age, 38.7 [13.2] years; 24 women [50%]; 23 white [48%], 23 African American [48%], 1 Asian [2%], and 1 of unknown race/ethnicity [2%]), 44 (92%) completed the trial. Geometric mean maximum plasma concentrations of all 6 active ingredients were greater than 0.5 ng/mL, and this threshold was surpassed on day 1 after a single application for all active ingredients. For avobenzone, the overall maximum plasma concentrations were 7.1 ng/mL (coefficient of variation [CV], 73.9%) for lotion, 3.5 ng/mL (CV, 70.9%) for aerosol spray, 3.5 ng/mL (CV, 73.0%) for nonaerosol spray, and 3.3 ng/mL (CV, 47.8%) for pump spray. For oxybenzone, the concentrations were 258.1 ng/mL (CV, 53.0%) for lotion and 180.1 ng/mL (CV, 57.3%) for aerosol spray. For octocrylene, the concentrations were 7.8 ng/mL (CV, 87.1%) for lotion, 6.6 ng/mL (CV, 78.1%) for aerosol spray, and 6.6 ng/mL (CV, 103.9%) for nonaerosol spray. For homosalate, concentrations were 23.1 ng/mL (CV, 68.0%) for aerosol spray, 17.9 ng/mL (CV, 61.7%) for nonaerosol spray, and 13.9 ng/mL (CV, 70.2%) for pump spray. For octisalate, concentrations were 5.1 ng/mL (CV, 81.6%) for aerosol spray, 5.8 ng/mL (CV, 77.4%) for nonaerosol spray, and 4.6 ng/mL (CV, 97.6%) for pump spray. For octinoxate, concentrations were 7.9 ng/mL (CV, 86.5%) for nonaerosol spray and 5.2 ng/mL (CV, 68.2%) for pump spray. The most common adverse event was rash, which developed in 14 participants.

CONCLUSIONS AND RELEVANCE

In this study conducted in a clinical pharmacology unit and examining sunscreen application among healthy participants, all 6 of the tested active ingredients administered in 4 different sunscreen formulations were systemically absorbed and had plasma concentrations that surpassed the FDA threshold for potentially waiving some of the additional safety studies for sunscreens. These findings do not indicate that individuals should refrain from the use of sunscreen.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03582215.

Unrecognized adult salicylate intoxication

Adult salicylate intoxication has been considered to be easily recognized and assciated with low morbidity and mortality. In the present study of 73 consecutive adults hospitalized with salicylate intoxication, 27% of patients were undiagnosed for as long as 72 h after admission. The initial physical findings and laboratory data in patients not diagnosed on admission did not markedly differ from the findings in patients diagnosed on admission, and included tachypnea and acid-based disturbances as well as the frequent occurrence of neurologic abnormalities. However, patients with a delayed diagnosis of salicylate intoxication were older, rarely had a previous history of drug overdose, and more often became accidentally intoxicated while ingesting salicylate for associated medical illnesses when compared with patients diagnosed on admission. Moratlity was encountered with significantly greater frequency in patients with delayed diagnosis, and, consequently, delayed therapy, when compared with patients diagnosed on admission.

Gastrointestinal safety of nitric oxide-derived aspirin is related to inhibition of ICE-like cysteine proteases in rats

BACKGROUND & AIMS

Caspases, a class of cysteine proteases, modulate apoptosis. Nitric oxide (NO)-releasing nonsteroidal anti-inflammatory drugs (NSAIDs) are a new class of NSAID derivatives with reduced gastrointestinal toxicity. The aim of this study was to investigate whether cysteine endoproteases are involved in the pathogenesis of NSAID gastropathy and are target for NO-aspirin (NCX-4016).

METHODS

Rats were treated orally with aspirin or equimolar doses of NCX-4016. Caspase activities were measured by fluorometric assay. Apoptosis was quantified by an enzyme-linked immunosorbent assay for histone-associated DNA, DNA ladder on agarose gel, and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling assay. A primary culture of gastric chief cells was used to investigate whether NCX-4016 modulates guanosine 3',5'-cyclic monophosphate (cGMP)-dependent pathways.

RESULTS

Short- and long-term (7 days) aspirin administration resulted in a time- and dose-dependent gastric injury that was associated with apoptosis and caspase up-regulation. Z-VAD.FMK, a pancaspase inhibitor, and NO donors protected from acute damage induced by aspirin. NCX-4016 spared the gastric mucosa and caused caspase inactivation by S-nitrosylation. Inhibition of tumor necrosis factor (TNF)-alpha release or activity by TAPI-2 or anti-TNF-alpha receptor monoclonal antibodies protected against mucosal damage and caspase activation. NCX-4016 protected gastric chief cells from toxicity induced by TNF-alpha by activating cGMP-dependent pathways.

CONCLUSIONS

Aspirin administration leads to a TNF-alpha-dependent activation of gastric caspases. NO-aspirin spares the gastric mucosa and inhibits caspase activity through cGMP-dependent and -independent pathways.

Fetal effects of regular salicylate ingestion in pregnancy

The babies of 144 mothers who took salicylates regularly in pregnancy are described. These babies had a significantly reduced birth-weight compared with controls; many of them had a raised cord-blood salicylate level but had no clinical evidence of bleeding or hypoglycaemia. Their perinatal mortality was increased, but the incidence of congenital anomalies was not significantly raised.

Ototoxic effects of salicylates on the responses of single cochlear nerve fibres and on cochlear potentials

Anaesthetized cats were given 400 mg/kg sodium salicylate i.v. producing blood levels in excess of 300-400 mg/kg. Within 10 min of injection, thresholds of fibers had risen by values ranging from 13 to 21 dB. The elevation in thresholds progressed rapidly over the subsequent 5 or so hours, reaching a plateau in about 10 h. The Q10 dB values for tuning of the cochlear fibres decreased by a factor of 3-4 on average over the same period. Likewise, the dynamic range of response was significantly reduced. These effects on the cochlear fibres were reflected in the elevation of the gross cochlear action potential thresholds. In contrast to the findings with other types of cochlear pathology, the mean discharge rate of the subpopulation of cochlear fibres having discharge rates above 20 sp/s was significantly increased by an average of 10-20 sp/s. There was a tendency for this increase to be more marked for fibres with higher characteristic frequencies and to be inversely related to threshold. In addition, 63% of fibres had anomalous temporal patterns of spontaneous activity. In view of the relevance of these data on the ototoxic effects of salicylates for our understanding of tinnitus, the effects of direct electrical current stimulation via the round window have been studied. Positive currents up to at least 600 microA suppressed the spontaneous and evoked activity of all cochlear fibres studied in the normal cochlea. These findings are consistent with the effects of such current stimulation in patients with tinnitus of peripheral origin and support the hypothesis that the neural correlate of such tinnitus is hyperactivity at the cochlear nerve level.

Disappearance kinetics of solutes from synovial fluid after intra-articular injection

1. Five rheumatoid patients with a knee joint effusion participated in the study. An aqueous solution (0.1 to 0.2 ml) containing paracetamol, salicylate, diclofenac and [125I]-albumin was injected into a given joint to yield target concentrations of approximately 20 micrograms ml-1 for diclofenac, salicylate and paracetamol and 10(8) counts ml-1 for [125I]-albumin. 2. Paracetamol, salicylate and diclofenac were analysed in synovial fluid by h.p.l.c. [125I]-albumin was analysed using gamma counting. 3. The clearances (+/- s.d.) obtained for the solutes were [125I]-albumin (0.0053 +/- 0.0019 l h-1), diclofenac (0.0096 +/- 0.0061 l h-1), salicylate (0.024 +/- 0.022 l h-1) and paracetamol (0.055 +/- 0.041 l h-1). The corresponding fractions unbound of these solutes in synovial fluid were 0.0, < or = 0.01, 0.34 +/- 0.09 and 0.85 +/- 0.10, respectively. 4. Diffusion of unbound solute through the synovium is estimated to account for (+/- s.d.) 0.52 +/- 0.08, 0.87 +/- 0.06 and 0.99 +/- 0.01 of the total clearance of diclofenac, salicylate and paracetamol from the joint space, respectively. The remaining proportion of clearance is accounted for by efflux of solute bound to albumin. 5. An expression for the ratio of synovial fluid to total plasma concentrations after systemic administration was developed to include both diffusion of unbound solute and albumin flux. Most solutes appear to satisfy the conditions in which this expression reduces to the limiting case where the unbound concentration of the solute is identical in the synovial fluid and plasma under steady state conditions.

Prevalence of Helicobacter pylori in peptic ulcer patients in greater Rochester, NY: is empirical triple therapy justified?

OBJECTIVES

Among patients with peptic ulcer disease, the prevalence of Helicobacter pylori has been reported to range from 80% to 90%. Thus empirical cost-effective therapy has been suggested. We surveyed patients with peptic ulcer disease in Rochester, NY.

METHODS

From two teaching hospitals all patients who had duodenal ulcers (DU) and/or gastric ulcers (GU) on esophagogastroduodenoscopy (EGD) with antral biopsy for histology for H. pylori and for rapid urease (CLO) test were included in the study. We examined a total of 160 patients with DU and 145 patients with GU, age range 18-92 yr, obtaining clinical data, race, medication profile, and history of use of nonsteroidal antiinflammatory drugs (NSAIDs). An ulcer was defined if the lesion with loss of mucosal integrity was > or = 0.5 cm, with apparent depth. H. pylori was considered present if CLO test and/or histology were positive for H. pylori. To confirm the reliability of nonuse of NSAIDs, we randomly checked blood samples of 90 such patients from the ambulatory clinic for the presence of salicylates. To identify the sensitivity of the CLO test, we performed a serology test for H. pylori antibody in 100 subjects to compare the CLO test results. Also, 500 CLO test results were compared to the histology results for H. pylori.

RESULTS

Among 160 DU patients, 16 were NSAID users with negative H. pylori and excluded from the prevalence study. Of the remaining 144 patients with DU, H. pylori was present in 88 patients (61%). When these data were analyzed according to race, H. pylori was present in 54 (52%) of 104 whites compared to 34 of 40 (85%) nonwhites (blacks, Hispanics, Asians) (p < 0.01). Among 145 GU patients 18 were NSAID users with negative H. pylori and excluded from the prevalence analysis. Of the remaining 127 patients with GU, H. pylori was present in 87 patients (61%). Among them, H. pylori was present in 46 of 87 (53%) whites, whereas 31 of 40 nonwhites (78%) were H. pylori-positive (p < 0.01). Antral histology and CLO test for H. pylori were in agreement in 92% of cases. Serology and CLO test for H. pylori were in agreement in 87% of cases. None of the randomly screened patients, including 16 ulcer patients with negative H. pylori, showed presence of salicylate in blood.

CONCLUSION

In greater Rochester, NY, where the majority of our patients with EGD were whites, the prevalence of H. pylori among ulcer patients was lower compared to other regions, particularly among whites. This suggests that an additional causative factor or factors for peptic ulcers may be present. Hence, empirical antibiotic therapy of ulcer patients without confirming the presence of H. pylori may not be justified.

Effects of aspirin and acetaminophen on the liver

The mechanism for aspirin-caused liver injury is not clear. Aspirin produces hepatotoxic reactions as a cumulative phenomenon, requiring days or weeks to develop. Patients with active rheumatic or collagen disease, as well as children, are especially susceptible. Blood levels of salicylate higher than 25 mg/dL are particularly likely to lead to hepatic injury. Levels lower than 15 mg/dL rarely do. The mechanism for acetaminophen liver damage is quite clear. It produces hepatic injury as a result of a large single overdose, usually suicidal in intent. Patients with acetaminophen blood levels higher than 300 mg/dL at four hours after intake are most likely to develop hepatic damage; when N-acetylcysteine is used within the first ten hours after ingestion of an overdose, the recovery rate is reported to be virtually 100%. The conditions of patients receiving long-term full doses of either aspirin or acetaminophen should be intermittently monitored for hepatic injury.

Factors affecting drug binding in plasma of elderly patients

The binding of salicylate, sulphadiazine and phenylbutazone to plasma proteins has been studied in young and elderly subjects. Elderly patients had significantly reduced concentrations of plasma albumin, compared with subjects under 40 years of age. Sifnificant increases in free levels of all three drugs were found in elderly patients receiving multiple drug therapy, and a correlation obtained with the number of drugs being taken. It is suggested that because of their low albumin levels, elderly patients may be more susceptible to the effects of multiple drug therapy on drug binding. The clinical implications of these observations are discussed.

Comparison of the effects of regular and enteric-coated aspirin on gastroduodenal mucosa of man

To determine whether the topical or systemic effects of aspirin are of greater importance in the production of gastroduodenal mucosal damage, the effects of regular and enteric-coated aspirin were compared in 9 healthy volunteers in a 2-week crossover endoscopic study. All subjects developed multiple gastric erosions while taking regular aspirin; 2 subjects developed one gastric erosion each while taking enteric-coated aspirin. 5 subjects developed duodenal erosions while taking regular aspirin, whereas none developed an erosion while taking enteric-coated aspirin. Mean fasting salicylate levels were similar in the two groups. It is concluded that regular aspirin causes a greater amount of gastroduodenal mucosal damage than does enteric-coated aspirin despite similar serum-salicylate levels. This suggests that the topical effects of aspirin are of greater importance than the systemic effects in the production of gastroduodenal mucosal damage in healthy subjects.