Benzodiazepines preferentially affect mesolimbic dopamine turnover in rats. Withdrawal of benzodiazepines in man may induce hallucinatory symptoms and can evoke delusional depressions, which can be treated with dopamine-antagonistic drugs. Withdrawal of benzodiazepines in rats induces a strong hyperactivity during daytime, leaving the nighttime activity relatively undisturbed. This hyperactivity may be related to an enhanced dopaminergic activity in the mesolimbic area, especially in the nucleus accumbens. Mesolimbic dopaminergic activity may be specifically involved in the development of benzodiazepine withdrawal. Acute administration of benzodiazepines in otherwise non-treated rats, has been described not to affect the dopamine-turnover in the nucleus accumbens, measured by synthesis inhibition. However, activation by administration of haloperidol (feedback activation) can be suppressed by benzodiazepines effectively. Five different benzodiazepines viz. desmethyldiazepam (DMD), lorazepam (LRZ), brotizolam (BTZ), triazolam (TRZ) and flunitrazepam (FNZ) have been compared with respect to their acute effects. Using a 3-fold increase in dopamine turnover (determined by measuring the DOPAC-concentration), benzodiazepines were capable to reduce this increase maximally for 70-80% in the nucleus accumbens. The results point to a selective effect of benzodiazepines in the nucleus accumbens. The increase induced by haloperidol in the corpus striatum was found to be much less sensitive to benzodiazepines. In contrast to the other compounds lorazepam appeared to have no effect on haloperidol-induced increase in DOPAC concentration. Flunitrazepam and brotizolam did affect not only the haloperidol-induced DOPAC increase but also the basal DOPAC concentrations. Linear dose-response curves could not be obtained for the compounds, but minimal effective doses could be assessed. Flunitrazepam and triazolam appeared to be the most active compounds.(ABSTRACT TRUNCATED AT 250 WORDS)


Mode of action of the triazolobenzodiazepines in the treatment of panic attacks: a hypothesis. Alprazolam (Xanax) or 8-chloro-1-methyl-6-phenyl-4H-S-triazolobenzodiazepine is a potent drug for the treatment of anxiety disorders. The chemical structure differs from the classical benzodiazepines by incorporation of the triazoloring. Due to the triazolo ring, the drug can have additional modes of action than the normal benzodiazepines. The triazolobenzodiazepines are potent inhibitors of the platelet-activating factor. This factor is a potent stimulator of the corticotropin-releasing hormone. This hormone has an effect on the hypothalamo-pituitary-adrenal axis but the corticotropin-releasing hormone is also known to be a stimulator of the locus coeruleus. The corticotropin-releasing hormone in patients with panic attacks is elevated. This could be a result of the hyperactive metabolism which is observed by positron emission tomographic (PET) studies of the right parahippocampal area.


Expression of glutathione transferase pi in benign and malignant lesions of the melanocyte lineage. Intrinsic and acquired resistance to chemotherapeutic agents represents the major clinical obstacle in the control of most tumours. In vitro studies have established that multiple mechanisms, including changes in drug uptake and efflux and in detoxifying enzymes, are responsible for drug resistance. Among the latter, glutathione S transferases (GST) have been recognized to play a relevant role. In the present study we have evaluated GST pi immunohistochemically as well as enzymatically in benign and malignant primary and metastatic lesions of the melanocyte lineage. A parallel analysis of the multiple drug resistance (MDRI) gene product was performed in a representative number of specimens. Results of this study demonstrate that while GST pi is constitutively expressed by the melanocyte lineage, independently from the transformed stage, MDRI p-glycoprotein is detected with a significantly lower frequency. These findings clearly indicate that GST pi represents the major detoxifying metabolic pathway of the melanocyte lineage and may be responsible for the high degree of inherent resistance of malignant melanoma to available cytostatic treatments.


Factors predicting early response to treatment with recombinant interferon alpha-2a in chronic non-A, non-B hepatitis. Preliminary report of a long-term trial. To evaluate cost-effectiveness and response predictors of treatment with recombinant interferon alpha-2a in chronic non-A, non-B hepatitis, 263 consecutive patients were enrolled in a multicenter long-term study. A pre-planned analysis aimed at identifying predictors of early response was carried out when all patients had completed the initial 3 months of treatment with 6 MU thrice weekly. Sixty-three percent of the patients enrolled were classified as responders. At multivariate logistic regression analysis, baseline gamma-glutamyltranspeptidase levels and cirrhosis were the only independent variables significantly associated with response. The risk of no response after 3 months of treatment was 3.9 times higher (95% confidence interval, 1.6 to 7.2) in patients with high baseline levels of gamma-glutamyltranspeptidase as compared with patients showing low baseline levels, and it was 2.0 times higher (1.1 to 3.8) in patients with cirrhosis as compared with those without it. We expect that results from this and other studies on large patient populations may help to select those patients who are more likely to benefit from interferon administration.


Combined cornual pregnancy and intrauterine twin pregnancy after in vitro fertilization and embryo transfer: report of a case. A case of combined cornual pregnancy and intrauterine twin pregnancy after in vitro fertilization (IVF) and transfer of six embryos is presented. The case was diagnosed as intrauterine triplets ultrasonographically at seven weeks of gestation. Unfortunately, the patient suffered from severe lower abdominal pain and hypovolemic shock at 10 weeks of gestation, and an emergent laparotomy was done. During the operation, a ruptured cornual pregnancy with accompanying hemoperitoneum was found. Because fetal heart beats were not detected by intraoperative ultrasonography in the other two intrauterine fetuses, evacuation of the gestational contents through the uterine defect was done, and the rupture site was repaired. The incidence, mechanism and management of heterotopic pregnancies after in vitro fertilization and embryo transfer are discussed.


Bizarre parosteal osteochondromatous proliferation of the phalanx: report of a case. The bizarre parosteal osteochondromatous proliferation of the hand and foot is a benign lesion which occasionally may mimic osteochondromas, chondrosarcomas or osteosarcomas clinically, radiologically and histopathologically. This rare benign entity should be recognized in order to avoid unwarranted destructive therapy. The authors report a case of this disease and discuss the differential diagnosis and the relevant features of this disease entity. A 27-year-old female patient suffered from a painful swelling at the proximal middle phalanx of the right middle finger for five months. The lesion was excised but the residual lesion developed a distinct parosteal growth by radiologic studies one-and-a-half years later. The patient underwent reexcision of the lesion twice. No recurrence was noted 11 months following the last excision. Histopathologically, the first specimen contained bizarre chondrocytes. The recurrent nodular tumors, submitted in the second and third operations, were composed of cancellous bone with fatty marrow and a few marrow elements, and focally capped by cartilage. The adjacent soft tissue contained proliferating fibrous tissue. The osteochondral junctions in the latter two specimens were irregular. We believe that the documentation of this tumor at different stages of development has helped in the further understanding of this rare entity.


Solitary cerebellar metastases: analysis of 11 cases. Solitary cerebellar metastatic tumors are rarely reported in the literature. We reviewed 240 posterior fossa tumors treated in the past eight years. There were 11 cases of solitary metastases in the cerebellum. The primary tumor was lung cancer in five cases and breast carcinoma in two cases; the remaining three cases had colon cancer, nasopharyngeal carcinoma (NPC) and Ewing's sarcoma, respectively. All patients underwent craniectomy and gross total excision of the tumor. Seven patients survived less than one year, two cases died in the second year, and one case of NPC survived for more than two years. The only survival is a case of Ewing's sarcoma who underwent surgery 14 months ago. The symptoms and signs of all patients improved satisfactorily after surgery. Four patients received postoperative irradiation to the posterior fossa and two cases of lung cancer had a thoracotomy for the primary lung lesion; however, the survival period was not prolonged. We suggest that a cancer patient or a patient in the fifth to seventh decades of life presenting headache, gait disturbance and vomiting should promptly undergo a computed tomography (CT) scan of the head. In selected cases, surgical intervention for solitary metastatic tumors in the tiny posterior fossa may be the best initial treatment. Adjuvant therapies should then be added according to the type of tumor.


Delayed-onset dystonia following recovery from central pontine myelinolysis. We report on a 47-year-old female patient with Sheehan's syndrome who developed delayed-onset dystonia following recovery from central pontine myelinolysis. The dystonia was observed in the head, neck and limbs during active movement. MRI scan demonstrated a discrete lesion in the central pons without involving the basal ganglia. The action dystonia was markedly improved by giving trihexyphenidyl. The patient showed that generalized dystonia can be induced by an isolated pontine myelinolysis. There have been four other cases reported in the literature. On reviewing all five cases, we conclude that delayed-onset dystonia following central pontine myelinolysis usually presents with generalized action dystonia and has a beneficial response to trihexyphenidyl.


Hypothalamic hamartoma and precocious puberty: report of a case. Hypothalamic hamartoma is reported to be associated with precocious puberty. Here, the authors present a seven-year-old girl whose onset of puberty occurred at the age of two. Under the impression of idiopathic precocious puberty, cyproterone acetate was initially tried. Since the effect of her medication was not satisfactory, it was discontinued at the age of five years and 11 months. However, rapid advance of bone age and vaginal spotting recurred after the withdrawal of treatment. She was re-evaluated at the age of six, and a magnetic resonance image (MRI) study of the head revealed a hypothalamic hamartoma. At that time, a long-acting analog of luteinizing hormone-releasing hormone (LHRHa), leuprolide acetate, was prescribed. Her secondary sex characteristics regressed and her hypothalamic-pituitary-gonad axis was suppressed after treatment. The clinical presentation, mechanism and treatment of precocious puberty caused by hypothalamic hamartomas are fully discussed in this report.


Simultaneous presence of three or more creatine kinase isoenzymes in patient serum. Samples of sera from 1,508 consecutive patients, which were sent to the clinical laboratories of Chang Gung Medical College for creatine kinase (CK) isoenzyme determination, were examined for the simultaneous presence of various patterns of three or more usual or atypical isoenzymes. Of these samples, a total of 29 cases (1.9%) exhibited this abnormal isoenzyme condition. Nineteen (66%) of these 29 cases were patients with cancer of various types. Furthermore, five (26%) of these 19 cases had the same pattern of four isoenzymes, and 17 (89%) of these 19 cases showed the cathodic CK variant (macro CK type II). Eleven (58%) of these 19 cancerous cases also showed a CK-MB variant, evidently of nonmyocardial origin.


Cancer of the colon during pregnancy: report of a case and review of the literature. A case of adenocarcinoma of the sigmoid colon during pregnancy is reported. The patient presented with anemia and a painless mass over the left abdomen without gastrointestinal discomfort, making this case different from 25 previously reported cases of colon carcinoma above the peritoneal reflection associated with pregnancy.


Pen injector for insulin-requiring diabetic patients. To compare the metabolic control and acceptability of a pen injector to the traditional syringe used in diabetes, 12 non-insulin-dependent diabetes mellitus (NIDDM) patients and six insulin-dependent diabetes mellitus (IDDM) patients were followed-up at the outpatient clinic of the Taipei Municipal Yang-Ming Hospital. All patients participated in a four-week run-in period and 24-week randomized cross-over design study. Human NPH insulin (Protaphane HM) in vials and in penfills were used in each 12-week experimental period, respectively. Metabolic control was assessed by a biochemical examination (before and after seven months of treatment) and HbA1c levels (at Weeks 1, 4, 16 and 28) and was found to be unchanged. The overall mean blood glucose declined slightly in both treatment modalities but not to a significant level (mean +/- SE; run-in: 175 mg/dL +/- 10 mg/dL; pen: 159 mg/dL +/- 8 mg/dL; syringe: 156 mg/dL +/- 7 mg/dL). The number of hypoglycemic episodes and self-adjustments of insulin dosage did not differ significantly between pen and syringe treatments. At the end of the study, a questionnaire revealed that eight patients would choose pen injectors, nine patients syringes and one was unsure of what to use as a future preference. The limitation of 36 units per injection of insulin is a drawback for those NIDDM patients with insulin resistance. An insulin delivery device that would allow an injection of a larger quantity of insulin is desirable for some patients.


Epidemiologic investigation of nosocomial outbreak of methicillin-resistant Staphylococcus aureus by plasmid pattern analysis. Nosocomial infections caused by methicillin-resistant Staphylococcus aureus (MRSA) have become an important problem with increasing frequency. In order to learn if plasmid pattern analysis can be used in epidemiologic investigations of MRSA infections, the authors did plasmid extractions of 70 MRSA stock isolates using a rapid lysostaphin lysis method. All isolates carried at least one plasmid. Most of the isolates had one large plasmid of 24-28 megadaltons (Md). Many also carried one or two small plasmids. Accordingly, 12 different patterns were identified. From these background results, we applied this method to the investigation of two small nosocomial outbreaks of MRSA infection. It was found that the analysis of plasmid pattern and restriction endonuclease analysis are more discriminative than antibiograms. Strains with the same antibiograms can be different by plasmid analysis. It is concluded that the plasmid pattern with a restriction endonuclease analysis study is a reliable method for epidemiologic study of MRSA infections.


Dystrophin gene deletion in Chinese Duchenne/Becker muscular dystrophy patients via multiplex DNA amplification. Duchenne/Becker muscular dystrophy (DMD/BMD) is a progressive muscle-wasting disease. The dystrophin gene responsible for the disease is the largest human gene ever cloned and is prone to gross gene deletion in two "hot spot" regions. Using nine pairs of oligonucleotide primers deduced from the two regions, we have screened 23 unrelated Chinese DMD/BMD patients by multiplex polymerase chain reaction. Nine (39%) patients were noted to have gene deletion, one in the 5' terminus and eight in the distal half of the gene. The incidence is similar to that reported in other large series mainly on Caucasian patients. The "hot-spot" regions also seem to be present in Chinese patients. Multiplex gene amplification for deletion analysis is useful in the diagnosis of patients with neuromuscular diseases and is an important aid in the prenatal diagnosis and genetic counseling of at-risk families.


Role of platelets in microembolism-induced acute lung injury. The role of platelets in acute lung injury has not been well defined. In the present study of isolated perfused rat lungs, a significant increase in pulmonary arterial pressure (PAP), lung weight and the lung lavage fluid protein concentration occurred when 3 mL of a CaCl2 suspension (25 mg/mL) was mixed with blood-KHB (Krebs-Henseleit Buffer) perfusate; or when platelets were added instead of blood. However, such an increase was not observed (p > 0.05) when only KHB was used. When a comparatively small amount (0.75 mL) of the CaCl2 suspension (50 mg/mL) was added to the KHB perfusate, PAP, lung weight and the lung lavage protein concentration increased only when PAF (platelet activating factor) and platelets were both added before, but not separately. The above phenomena show that platelets are actively involved in the mechanism of acute lung injury and play an extremely important role in this microembolic model.


Experience of desmopressin (DDAVP) administration in patients with congenital and acquired bleeding disorders. Desmopressin (DDAVP) 0.3 micrograms/kg was administered intravenously to three normal volunteers and 12 patients with von Willebrand's disease (vWD), congenital or acquired platelet function defect, or uremic bleeding to assess its effects and side effects. DDAVP significantly shortened the bleeding time as compared with basal values. The mean peak post-DDAVP level of factor VIII coagulant activity increased 5.9 +/- 0.5 (mean +/- SEM) fold, von Willebrand factor antigen increased 3.7 +/- 0.3 fold, von Willebrand factor ristocetin cofactor activity increased 4.6 +/- 0.6 fold and the tissue-type plasminogen activator antigen increased 3.4 +/- 0.6 fold. Analysis of the multimeric structure of the von Willebrand factor revealed that type I vWD had complete correction after DDAVP infusion transiently. Except for a mild drop in both systolic and diastolic blood pressures, few side effects were noted. By concomitant intravenous infusion of DDAVP and oral administration of tranexamic acid, we successfully treated two cases of type I vWD undergoing tooth extraction, and one case of acquired bleeding disorder undergoing a biopsy of a mandibular mass, and a uremic patient complicated by intractable traumatic hematuria. Our experiences confirmed that most patients with vWD and some patients with congenital or acquired bleeding disorders can be treated effectively by DDAVP infusion without the need for plasma product replacement. In this study we found that a patient with a variant form of type I vWD had prolongation of the bleeding time, thrombocytopenia and platelet aggregation after DDAVP infusion.


Prevalence of goiters in school children residing in villages where underground water is used. A representative of Fuder village in Taichung County complained that many residents had a goiter problem, which he felt might be related to pollution from the nearby Youshi industrial area. The purpose of this study was to determine whether school children in the Fuder area have a high prevalence of goiters. We chose children of the Schichi elementary school in the Fuder area as the study population, and children of the Goumei elementary school, far from the Youshi industrial area, as controls. Both groups were from a similar geographic location (near the sea), had similar socioeconomic status, and both drank underground water. Thyroid enlargement was examined by palpation as recommended by the World Health Organization. Thyroid antibodies and hormones were determined in school children with a goiter and age-sex-matched normal control children using the particle agglutination method and radioimmunoassay, respectively. In total, 1,692 school children were examined, including 875 males and 817 females. Of these, 126 school children (7.4%) had a goiter of Grade I or above. The prevalence of goiters in Shichi and Goumei were 8.8% (59/671) and 6.6% (67/1,021), respectively. There was no significant difference between these two areas. We compared the prevalence of goiters in these two schools where underground water is drunk with another previous study in Peimen and Putai where tap water is used. There was a statistically significant difference (7.4% vs 2.6%, p < 0.0001). This suggests that the higher prevalence rate of goiters in Shichi and Goumei is related to the drinking of underground water. We recommend that the use of tap water and continued salt iodization is the way to prevent endemic goiter in these areas. A further comprehensive study is needed to determine the nature of the goitrogen in the underground drinking water of the Fuder area.


Multiplanar gradient recalled images of the knee: comparison of different flip angles and echo times. To determine the most appropriate combination of echo time (TE) and flip angle in gradient echo images of the knee, the authors used different TEs (10, 20 and 30 msec) and flip angles (10, 30, 50, 70, 90, 120 and 150 degrees) to perform a systematic study of MRI on 10 volunteer knees. Contrast-to-noise ratios of cartilage-fat, fluid-cartilage, fluid-fat and fluid-ligament were calculated and compared. Images with a 30-degree flip angle combined with 20 msec of TE were found to have the best contrast-to-noise ratios in both objective data analysis and subjective observation. Hyaline cartilage of the knee was hyperintense and was well delineated on this pulse sequence, appearing distinct in contrast to the intra-articular fluid. It is concluded that this T2-weighted gradient echo pulse sequence is an alternative to conventional spin echo T2-weighted imaging of the knee.


Staging of cervical cancer: comparison between magnetic resonance imaging, computed tomography and pelvic examination under anesthesia. A prospective study was undertaken to compare magnetic resonance imaging (MRI) with computed tomography (CT) and examination under anesthesia (EUA) in staging cervical carcinoma, with special emphasis on parametrial status. Twenty patients with carcinoma of the cervix, in whom the extent of the disease was surgically confirmed, were analyzed by MRI, CT and EUA. The tumor size estimated by MRI correlated well (r = 0.79, p < 0.001) with those obtained by histopathologic measurement of the surgical specimen. Neither clinical examination nor CT could precisely estimate tumor size. The overall accuracy rate of MRI in staging carcinoma of the cervix was 75%, compared with 32% for CT staging and 55% for clinical staging. The accuracy rate of these modalities for parametrial status was 90% for MRI, 55% for CT and 82.5% for EUA. MRI accurately excluded all 20 patients with pelvic side wall, bladder and rectal involvement. In conclusion, MRI is superior to CT and EUA in assessment of the parametrium (90% vs 55% vs 82.5%, p < 0.005). From MRI, tumor size can be estimated precisely. Although a larger scale study comparing MRI and CT is needed to determine their roles, both should help in the diagnosis and selection of proper treatment for cervical carcinoma. Our preliminary report agrees with previous reports that MRI is promising and indispensable. MRI should be routinely used in conjunction with clinical staging to determine appropriate therapy in patients with cervical carcinoma.


Surgery for malignant involvement of the superior vena cava. This study reviews surgical operations on seven patients with intrathoracic tumors involving the superior vena cava (SVC). Among these patients, five were found to have advanced bronchogenic carcinoma; one was found to have thyroid carcinoma; and another was found to have thymic carcinoma. The incidence of SVC involvement in resectable lung cancer patients at the National Cheng-Kung University Hospital was 5.8% (5/85). Total excision of SVC was done in three patients and three different prostheses (ringed GoreTex, woven Dacron and pericardial tube graft) were interposed. Four patients underwent partial excision and repair: one by direct suture and three by autologous pericardial patch. A temporary SVC-right atrium internal shunt was used in two of these seven patients. The mean time of SVC cross-clamping in five patients was 20 minutes (10-28 minutes), and the mean value of the central venous pressure at the time of SVC cross-clamping was 34 mmHg (18-54 mmHg). There were no operative deaths or neurologic sequels. Venography or computed tomography obtained 7-100 days after surgery demonstrated all but one to be patent. In conclusion, SVC reconstruction with concomitant tumor resection can be performed if a patient fulfills the following criteria: 1) there is no distant metastasis; 2) a radiosensitive or chemotherapy-effective tumor has been ruled out; and 3) total SVC occlusion or prominent collateral circulation should be avoided.


Successful treatment of cytomegalovirus pneumonitis with ganciclovir and high-dose intravenous immunoglobulin in a bone marrow transplant recipient. A 35-year-old man with acute lymphoblastic leukemia in second remission received an allogeneic bone marrow transplant from an HLA-compatible sibling donor. Unfortunately, cytomegalovirus (CMV) pneumonitis was histologically documented on Day +72. Combination therapy with ganciclovir (9-[2-hydroxy-1-(hydroxy-methyl) ethoxymethyl] guanine) and high-dose intravenous immunoglobulin (IVIG) was started immediately. The treatment comprised a three-week induction course (ganciclovir, 2.5 mg/kg q8h and IVIG, 500 mg/kg qod) and a seven-week fixed-dose maintenance course (ganciclovir 5 mg/kg thrice a week for 20 doses and IVIG 500 mg/kg twice a week for eight doses). The pneumonia resolved gradually, and he was free from symptoms within two weeks. The only significant side effect was moderately severe myelosuppression which was reversible after discontinuation of ganciclovir. The patient had a relapse of leukemia on Day +186, but there was no recurrence of CMV pneumonitis. This result confirms that such combination therapy is effective in the treatment of CMV pneumonitis in a patient with a bone marrow transplant.


Lung dysfunction in animal confinement workers--chairman's report to the Scientific Committee of the Third International Symposium: issues in health, safety and agriculture, held in Saskatoon, Saskatchewan, Canada, May 10-15, 1992. The session traced the course of health hazards in livestock confinement from anticipation of an emerging health hazard in 1974 to its full recognition as a significant health hazard in 1992. The session documented the major health hazards including hydrogen sulfide toxicity, bronchitis, non-allergic asthma, organic dust toxic syndrome, and mucus membrane irritation. In regard to exposures, bioaerosols seem to be the most significant hazard, with endotoxin evident as at least one of the major specific atiologic agents. Other agents were suspected, as newly recognized agents, specifically 1,3 beta-glucan. Previous epidemiological studies have revealed mild decrements in pulmonary function, however symptoms have always been excessively prevalent relative to controls. Recent results of a longitudinal observation showed a 12% drop out of workers with profound decrement in pulmonary function. In summary, the health hazard of livestock confinement workers is now well substantiated in North America and Europe and further work regarding prevention is highly indicated.


The pathogenesis of AIDS lymphomas: a foundation for addressing the challenges of therapy and prevention. The association between AIDS and a spectrum of malignancies relates to chronic, profound defects in both cellular and humoral mechanisms of immune surveillance. Ironically, as AIDS patients live longer in response to increasingly effective antiretroviral therapies, the incidence of AIDS-related malignancies will continue to rise. The emergence of non-Hodgkin's lymphomas (NHL) as a major sequela of HIV infection bears a striking relationship to depletion of CD4 lymphocytes, particularly below 50/mm3. The ability to interfere early in the course of active HIV infection with additional mechanisms that may promulgate transformed cell hyperproliferation and clonal expansion--growth factors, HIV itself or other viruses (Epstein-Barr, in particular), aberrant oncogene or tumor suppressor genes expression, factors that induce genetic instability or DNA damage or alter host or viral genome repair--might decrease the occurrence or prolong the time to development of AIDS-related malignancies. The development of antiretroviral strategies that confer long-term suppression of HIV activity and relative preservation of immune function are essential to the ultimate prevention of malignancies that arise as a consequence of HIV-induced immunosuppression.


Ligation-mediated PCR of restriction fragments from large DNA molecules. A general method is described for PCR amplification of single restriction fragments from large DNA molecules. The method involves sequence-specific ligation of synthetic oligonucleotides to ambiguous 4-base 5' overhangs produced by type IIS restriction endonucleases. Such "adapter-tags" provide one target for primer annealing in subsequent PCR reactions. The second target for primer annealing is provided by a universal "bubble-tag" ligated to blunt ends produced with another endonuclease. The key advantage of this approach is that specific fragments can be isolated without any prior knowledge of the nucleotide sequence of the target. Using bacteriophage lambda DNA as a test system, unique PCR products could be generated consistently. Conditions of temperature, ionic strength, and substrate concentration in the adapter-tag ligations--which affect sequence specificity--were found to have a major influence on the purity of PCR-generated fragments. In principle, the method permits the amplification of virtually any sequence from purified cosmid or YAC DNA using a library of only 240 adapter-tags.


Amplification and cloning of sugarcane sucrose synthase cDNA by anchored PCR. We have used a strategy based on the polymerase chain reaction (PCR) to amplify and construct full-length sucrose synthase (SS) cDNA of sugarcane. Two SS-specific internal primers were synthesized based on their complementarity to published consensus sequences of the SS gene of maize and wheat. Amplification of full-length cDNA was achieved by an anchored PCR method utilizing primers which extend to 5' and 3' ends of specific cDNA. In the first step, a homopolymeric oligo(dC) tail was added to the 3' end of single-stranded cDNAs. The two SS cDNAs were amplified, one with a 5' end (SSp1) and the other with a 3' end (SSp2) using one internal SS primer and the other anchored end primer. Finally, overlapping fragments were identified by restriction mapping, and the non-overlapping fragments were excised and religated to reconstruct full-length cDNA. Partial sequences of the reconstructed cDNAs (SS-5' and SS-3') were compared with the published SS sequences to confirm that the amplified DNA was a copy of the SS transcript.


Cutaneous toxicity of high-dose carboplatin, etoposide and ifosfamide followed by autologous stem cell reinfusion. Forty patients with germ cell tumors were treated with carboplatin 1500-2000 mg/m2, etoposide 1200-1600 mg/m2 and ifosfamide 0-10 g/m2 plus mesna followed by autologous stem cell reinfusion. A pruritic maculopapular rash was observed in 10 patients usually starting on the last day of chemotherapy. Lesions remained localized to the extremities in four patients. In six they became confluent and progressed also involving the trunk and face. Facial edema and painful swelling of hands and feet also occurred in this latter group. No ulcerations or bullae formation were seen and changes resolved spontaneously in all patients within 3 weeks leaving marked hyperpigmentation in involved areas. Renal function declined in nine of 10 patients concomitantly with evolving cutaneous changes, but recovered in all except one. Cutaneous side effects were more frequent with increasing doses of etoposide and carboplatin and in patients with deteriorating renal function. Plasma concentrations during high-dose chemotherapy should be monitored to avoid excessive serum levels and toxicity, especially in patients at risk of renal dysfunction.


Long-term acyclovir prophylaxis for prevention of varicella zoster virus infection after autologous blood stem cell transplantation in patients with acute leukemia. Twenty-one adult patients with acute leukemia who underwent autologous blood stem cell transplantation (ABSCT) and who received acyclovir during the first 6 months after transplant to prevent varicella zoster virus (VZV) infection were studied retrospectively to determine the incidence and outcome of VZV infection after ABSCT. The cumulative risk of VZV infection was 32% by 1 year after transplant. No patient developed VZV while on prophylactic acyclovir but five (24%) had localized herpes zoster within 1 month of acyclovir withdrawal. There were no deaths related to VZV infection and only one patient had disseminated disease and post-herpetic neuralgia. These preliminary results suggest that the incidence and outcome of VZV infection after ABSCT largely parallel those reported in marrow transplant patients and that long-term acyclovir prophylaxis delays but does not prevent VZV infection. Prophylaxis of VZV infection after ABSCT requires new therapeutic approaches.


Non-haematological toxicity limiting the application of sequential high dose chemotherapy in patients with advanced breast cancer. A programme of repeated high dose chemotherapy for advanced breast cancer was developed using (1) cyclophosphamide 4 g/m2 followed by autologous peripheral blood stem cell (PBSC) collection; (2) three cycles of conventional dose chemotherapy; (3) high dose cyclophosphamide, cisplatin, and carmustine with PBSC rescue; and (4) high dose etoposide and melphalan with PBSC rescue. Fifteen eligible patients had advanced poor prognosis breast cancer either at initial diagnosis (one patient) or at relapse (14 patients). During the course of the protocol, there were three treatment related deaths, two patient withdrawals due to debilitating toxicity, five patient withdrawals due to disease progression, and one patient withdrawal due to inadequate collection of PBSC. The remaining four patients did not complete the planned protocol as the programme was terminated because of the unacceptable morbidity and mortality. They were treated with an alternative high dose chemotherapy protocol which was well tolerated. This study highlights the significant problems associated with a complex sequential high dose chemotherapy regimen. Cyclophosphamide mobilized PBSC infused following high dose chemotherapy enables rapid haematological recovery. However the non-haematological toxicity following high dose chemotherapy regimens is often severe and may limit the application of certain sequential high dose chemotherapy combinations in patients with breast cancer.


A case of affective disorder associated with the misuse of 'anabolic steroids'. In the pursuit of gains in muscle size and strength, body-builders may mistakenly use illicit drugs believing them to be anabolic steroids. The case described illustrates the physical and psychological dangers of such behaviour.


Differential sensitivities of the sphincter of Oddi and gallbladder to cholecystokinin in the guinea pig: their role in transsphincteric bile flow. Cholecystokinin (CCK) is considered to simply contract the gallbladder and relax the sphincter of Oddi with meals. In this study, we examined this hypothesis by investigating the action of CCK on the sphincter of Oddi and gallbladder of the guinea pig. The experimental design used an in vitro preparation of the sphincter of Oddi to measure contraction of the circular muscle. CCK increased tone in both the gallbladder and the sphincter of Oddi in a concentration-dependent manner. The normalized concentration-response curves for CCK, however, revealed that the gallbladder had a greater sensitivity to CCK (ED50 7 nM) than the sphincter of Oddi (ED50 22 nM; p < 0.01). Conversely, the sphincter was more sensitive to bethanechol than was the gallbladder. When the sphincter of Oddi was stimulated maximally with CCK in the presence of atropine (10(-6) M) or tetrodotoxin (10(-6) M), the contractile response was significantly reduced (p < 0.05) although not abolished. Conversely, atropine completely abolished the responses to bethanechol (10(-3) M) and transmural field stimulation (70 V, 10 Hz, 1 ms, for 20 s). Transmural field stimulation of the sphincter that had been precontracted with CCK (26 nM) caused a transient, initial relaxation followed by contraction. Pretreatment with atropine augmented the duration of this relaxation, which could be completely abolished by tetrodotoxin. Thus, CCK contracts the sphincter of Oddi in the guinea pig by a direct (myogenic) and a neural (likely cholinergic) mechanism. Relaxation of the sphincter of Oddi also occurs in the guinea pig via noncholinergic inhibitory nerves.(ABSTRACT TRUNCATED AT 250 WORDS)


Impact of enalapril therapy on in vitro coronary artery responsiveness in pacing-induced heart failure. In vitro coronary artery responsiveness to angiotensin I, angiotensin II, noradrenaline, phenylephrine, BHT 920, and potassium chloride together with functional relaxation to acetylcholine was investigated in dogs with pacing-induced heart failure treated with enalapril (oral administration of 10 mg.day-1) for a mean duration of 26 days. Although maximal responses generated to both angiotensin I and angiotensin II were unaltered in the enalapril-treated group, angiotensin II became more potent following enalapril treatment: the EC50 for angiotensin II following placebo treatment was 2.4 (0.6-5.8; 95% confidence limits) nM and following enalapril treatment was 0.03 (0.007-0.1; 95% confidence limits) nM. In addition to the above changes, coronary artery rings from dogs treated with enalapril developed significantly less tension to noradrenaline, phenylephrine, and BHT 920. In contrast, responses to potassium chloride were unaltered following enalapril treatment. However, the relaxation to acetylcholine was enhanced from 38.9 +/- 3.0 to 50.4 +/- 3.5% (placebo versus enalapril, p < 0.05). These findings indicate that enalapril may possess alpha-blocking properties and enhance the relaxation response to acetylcholine through an endothelial-dependent mechanism in addition to inhibiting converting enzyme.


Decrease in hypothalamic vasopressin mRNA poly(A) tail length following physiological stimulation. 1. The vasopressin mRNA in the adult male rat hypothalamus is modulated in two distinct ways by a dehydration stimulus. In addition to the well-established increase in transcript abundance, it has recently been demonstrated that the vasopressin mRNA poly(A) tail increases in length. 2. We have studied the ontogeny of poly(A) tail length modulation in neonates in response to milk deprivation and found that poly(A) tail length changes are age dependent. In neonates older than 12 days of age, the vasopressin mRNA poly(A) tail length increased with milk deprivation and this effect became more marked in older animals. However, in rats 5 to 9 days old, milk deprivation resulted in a detectable though not significant decrease in vasopressin mRNA poly(A) tail length. 3. As milk deprivation is a combination of dehydration and starvation, we investigated the effect of the latter stimulus in more mature animals. We found that starvation modifies the length of the vasopressin mRNA poly(A) tail in a manner opposite that due to dehydration. 4. Our data indicate a novel mode of regulation of the vasopressin mRNA, namely, poly(A) tail shortening. This system provides a model for future studies concerning the adaptive role of poly(A) tail length modulation in response to physiological stimuli.


Differential expression of tyrosine hydroxylase mRNA in the developing rat mesencephalon. 1. With respect to the mesostriatal projection, the mesencephalon is composed of two dopaminergic (DA) cell populations, called dorsal tier and ventral tier. Strong evidence suggests differences in both the spatial and the temporal sequence of the innervation of the striatum between the two groups, with the ventral tier neurons innervating striatal patches prenatally and dorsal tier cells innervating striatal matrix postnatally. 2. Using in situ hybridization, we have examined the expression of the gene coding for tyrosine hydroxylase (TH) in mesencephalic DA neurons with respect to their postnatal development. Two ontogenic patterns of expression were observed: (a) dorsal tier neurons of the medial mesencephalon exhibited a sharp increase in expression beginning after birth, peaking on day 14, then decreasing and, finally, stabilizing; and (b) ventral tier neurons and dorsal tier cells from the lateral and the medial-dorsal mesencephalon showed only a slight increase in TH mRNA, reaching a plateau at P10. 3. The time course of the observed increase in TH gene expression in the first group, generally parallels the innervation of their target cells in the striatal matrix, suggesting that TH gene expression in these cells may be influenced by their postsynaptic cells or by the innervation process.


[Histologic evaluation of potential new beta-adrenolytics]. The present paper investigated histological changes in the myocardium in two potential beta-adrenolytic agents, 4-[3-isopropylamino-2-hydroxypropoxy]-3-[propoxymethyl]acetophenone and 4-[3-isopropylamino-hydroxypropoxy]-3-[pentyloxymethyl]acetophenon e after intravenous administration in doses of 8 mg/kg and 24 mg/kg. It results from the found data that in both agents in the doses used there are no necrotic changes in the myocardium and the values of the impairment range within the 1st degree of Zbinden's classification, comparable to the standard metipranolol.


Lipid parameters and apolipoprotein B RFLP studies: comparison of normal and coronary heart disease groups as defined by angiography. We have compared the lipid and apolipoprotein values and the frequency of DNA polymorphisms of the apolipoprotein B gene detected with the restriction enzymes, Xba I and Eco RI in 122 patients with coronary heart disease (CHD) and 80 control subjects. The patients with coronary heart disease (CHD) were defined by > 70% stenosis in at least one major coronary artery whereas the controls showed no signs of coronary artery narrowing at angiography. When males and females were considered separately, differences in triglyceride, total cholesterol and high density lipoprotein-cholesterol (HDL-cholesterol) between CHD and control subjects were significant only for females. The polymorphism studies showed no significant differences between the control and CHD subjects except for a difference in the frequency in the females of the Xba I polymorphism (p < 0.05). The X1 allele (absence of the restriction enzyme cutting site) occurred significantly more often in the patient group than in the controls. Individuals with the X1X2 genotype had the highest serum total cholesterol whereas those with the X1X1 genotype had the lowest HDL-cholesterol value. Generally, the associations between the Xba I and Eco RI alleles and serum lipid levels were weak and inconsistent. Furthermore, even after careful selection of disease and control groups, a useful role for restriction fragment length polymorphism studies in assessing CHD risk in individual patients was not demonstrated.


Aggressive cancer pain management--where does the buck stop? A comprehensive cancer pain management consultative service sponsored by a department of anesthesia at a moderately sized community hospital is described. Medical records of 111 patients from 1986 to 1990 were reviewed. Different therapies utilized and patient populations are described. It is suggested that trained anesthesiologists who are committed to a multidisciplinary approach to alleviating cancer pain can provide similar support.


Prompt diagnosis of 'acute groin' conditions in infants. Urgent sonographic examination of the groin was performed in 58 patients under the age of two years. Accurate diagnosis was done in conditions such as: incarcerated inguinal hernia, twisted undescended testis, incarcerated ovary in inguinal hernia and others. Ultrasonography facilitated decision-making and differentiation between surgical and non-surgical conditions.


Changes on distribution of CD4+/CD45RA- and CD8+/CD11- cells in tumor-infiltrating lymphocytes of renal cell carcinoma associated with tumor progression. To study the distribution of subsets of T cells in renal cell carcinoma, peripheral blood lymphocytes (PBL) and tumor-infiltrating lymphocytes (TIL) were analyzed in 43 untreated patients using two-color flow cytometry. An increase in the relative number of CD4+/CD45RA-, CD8+/CD11- and HLA-DR+/CD3+ cells was shown in TIL when compared with PBL. When the influence of various tumor factors on subsets of TIL was examined, a decrease in CD4, CD4+/CD45RA- and CD16+/CD57- cells and an increase in CD8+ and CD8+/CD11- cells was observed along with the aggravation of tumor stage and grade. In TIL of stage III/IV and grade III/IV disease, most patients showed an increase in CD8+/CD11- associated with a decrease in CD4+/CD45RA- cells, or the reverse, resulting in changes of the CD4+/CD45RA- to CD8+/CD11- ratio. The prognosis for these patients was poor, suggesting that changes in the ratio were a sign of the impairment of local immune status associated with disease progression.


A-77636: a potent and selective dopamine D1 receptor agonist with antiparkinsonian activity in marmosets. A-77636, ((1R,3S) 3-(1'-adamantyl)-1-aminomethyl-3,4-dihydro-5,6-dihydroxy-1H-2-benz opyran hydrochloride), is a selective dopamine D1 receptor agonist. In a battery of receptor binding assays, A-77636 shows the highest affinity (pKi = 7.40 +/- 0.09; Ki = 39.8 nM) for the dopamine D1 receptor. A-77636 is an agonist at the dopamine D1 receptors in the fish retina (pEC50 = 8.13; EC50 = 1.1 nM; intrinsic activity = 102% of dopamine) and the rat caudate-putamen (pEC50 = 8.97; intrinsic activity = 134% of dopamine). The compound is functionally inactive at dopamine D2 receptors (EC50 > 10 microM). In rats with unilateral 6-OHDA (6-hydroxydopamine) lesions of the nigro-striatal dopaminergic pathway, A-77636 elicits prolonged (> 20 h) contralateral turning that is blocked by SCH 23390, a D1 receptor antagonist, but not by haloperidol at doses selective for the dopamine D2 receptor. Higher doses of A-77636 produce forelimb clonus in rats and mice. When tested in marmosets treated with MPTP to induce a parkinsonian-like state, A-77636 increases locomotor activity and decreases the severity of the parkinsonian-like symptoms: the compound is active after either subcutaneous or oral administration. A-77641, the optical antipode of A-77636, has a lower affinity towards the dopamine D1 receptor (pKi = 5.14, Ki = 7200 nM), is less potent as a dopamine D1 receptor agonist (pEC50 = 5.65; EC50 = 2200 nM), fails to elicit turning in the 6-OHDA-lesioned rat, and lacks antiparkinsonian efficacy in the MPTP-treated marmoset.(ABSTRACT TRUNCATED AT 250 WORDS)


Sensitization, response fluctuation and long-term effect of SKF-82958 and bromocriptine in the hemi-parkinsonian rat. Rats with a unilateral 6-hydroxydopamine lesion of substantia nigra were treated with the dopamine agonists SKF-82958 (D1 receptor selective) or bromocriptine (D2 receptor-selective) and their circling response recorded. Both of the compounds induced an acute episode of rotation directed away from the lesioned side. Consecutive daily treatments with either compound usually resulted in a significantly increased average response (sensitization) over a 3- to 6-day treatment period. But nearly all animals treated with low doses of either SKF-82958 or bromocriptine exhibited one or more days when they were totally unresponsive to drug treatment. Response fluctuations thus were not exclusively associated with D1 or D2 receptor agonist treatment. When subsequently tested, undrugged, in the drug-associated environment, 2, 4 and 10 weeks after their last drug treatment, rats that had previously been treated with SKF-82958 exhibited rapid contralateral rotation while rats that had previously been treated with bromocriptine showed no such undrugged rotation. This result is consistent with previous findings that the D1 receptor agonist, SKF-38393, but not the D2 receptor agonist, quinpirole, had long-term behavioral effect in nigral rats, and suggests that persistent motor consequences of limited treatment with dopamine receptor agonists are D1 receptor-related.


Central alpha-adrenoceptor subtypes involved in the emetic pathway in cats. The intracerebroventricular (i.c.v.) injection of clonidine, xylazine, adrenaline and methoxamine elicited dose-dependent vomiting in cats in that order of potency. The vomiting induced by clonidine, xylazine and adrenaline was antagonized by i.c.v. yohimbine and phentolamine possessing alpha 2-adrenoceptor-blocking activity, but not by prazosin showing alpha 1-adrenoceptor-blocking activity. In contrast, methoxamine-induced vomiting was antagonized by prazosin, but not by yohimbine. The vomiting induced by xylazine and adrenaline was not prevented by i.c.v. 6-hydroxydopamine treatment, but was prevented by i.c.v. reserpine treatment. Ablation of the area postrema with some damage to extremely adjacent areas abolished the vomiting induced by each alpha-adrenoceptor agonist. These results indicate that both central alpha 1- and alpha 2-adrenoceptors are involved in the emetic pathway in cats, although alpha 2-adrenoceptors seem to have the main role. It is also suggested that monoamines, and in particular 5-hydroxytryptamine in the brain, are involved in the regulation of alpha-adrenoceptor-mediated vomiting.


Stereoselective binding of tertatolol and of 4-hydroxytertatolol to human plasma proteins. The binding of racemic tertatolol and 4-hydroxytertatolol and of their enantiomers was compared in alpha 1-acid glycoprotein and albumin solutions. The binding rate of S(-)tertatolol to alpha 1-acid glycoprotein was much greater than that of R(+)tertatolol, the binding of the racemate being intermediate. It was the reverse for the binding to albumin, although the differences were slight. The binding of 4-hydroxytertatolol racemate and enantiomers was very low as compared to the binding of tertatolol, and there were no statistically significant differences in the binding of the 4-hydroxytertatolol enantiomers to either alpha 1-acid glycoprotein or albumin.


Cocaine releases limbic acetylcholine through endogenous dopamine action on D1 receptors. Cocaine (10 and 20 mg/kg i.p.) enhanced the extracellular concentration of acetylcholine (ACh) in the ventral striatum of freely moving rats. The enhancement was prevented both by dopamine (DA) D1 receptor blockade with SCH 23390 (0.1 mg/kg s.c.) and by depletion of endogenous DA after coadministration of reserpine (5 mg/kg i.p.) and alpha-methyltyrosine (alpha-MT) (150 mg/kg i.p.). In contrast, blockade of DA D2 receptors with (-)-sulpiride (20 mg/kg i.p.) did not prevent the cocaine-induced increase in ACh release. These results indicate that the cocaine-induced stimulation of ACh release is mediated by an action of DA on D1 receptors, and suggest that the enhancement of ACh release might play a functional role in the central effects of cocaine. Moreover, DA depletion after reserpine + alpha-MT or D1 receptor blockade with SCH 23390 led to a comparable decrease of baseline ACh release, suggesting that striatal cholinergic interneurons are under D1 receptor-mediated facilitatory dopaminergic control.


Thermal regulation of fimA, the Escherichia coli gene coding for the type 1 fimbrial subunit protein. The effect of temperature on expression of fimA, the gene coding for the phase-variable type 1 fimbrial subunit protein of Escherichia coli K-12 was investigated. In a genetic background in which the orientation of the DNA fragment carrying the fimA promoter was determined by the activity of the 'orientationally unbiased' FimB recombinase, fimA transcription was consistently higher at 30 degrees C than at 37 degrees C. This apparent increase in fimA expression was found to be due to the fact that the fimA site-specific recombination system had become directionally biased at the lower temperature such that the bacterial population contained more cells in the ON phase than at 37 degrees C. When expression of fimA was studied in a strain genetically incapable of switching the fimA promoter to the OFF phase (i.e. all cells in the culture were phase-locked ON), fimA transcription was found to be higher at 37 degrees C than at 30 degrees C. Thus, transcription from the fimA promoter was subject to temperature control and the site-specific recombination system determining the orientation of the promoter DNA fragment was temperature-modulated. Furthermore, it was found that the thermosensitive fimA promoter was subject to transcriptional silencing by the HNS nucleoid protein, in a manner analogous to that described for other thermoregulated adhesins.


Establishment of three categories of P-fimbriated Escherichia coli strains that show different toxic phenotypes and belong to particular O serogroups. Eight hundred and nineteen strains of Escherichia coli isolated in Spain between 1986 and 1991 from extraintestinal infections and feces of healthy controls were investigated for expression of P-fimbriae using a particle agglutination test. Among strains causing urinary tract infections, sepsis and other extraintestinal infections, P-fimbriae were found in 31% (130/420) (P < 0.001), 25% (30/118) (P < 0.001) and 12% (11/92) (P < 0.5) respectively. In contrast, only 7% (14/189) of faecal isolates from healthy individuals carried P-fimbriae. According to two more common toxic markers detected in this study (alpha-haemolysin and cytotoxic necrotizing factor type 1), P-fimbriated E. coli strains were grouped into three categories: haemolysin+cytotoxic necrosing factor+ (Hly+CNF1+) (68/185; 37%), haemolysin+cytotoxic necrosing factor- (Hly+CNF1-) (61/185; 33%) and Hly-CNF1- (56/185; 30%). The 185 P-fimbriated strains belonged to 17 different O serogroups. However, 148 (80%) were of one of six serogroups (O1, O2, O4, O6, O7 and O18). The most frequent serogroups determined in the Hly+CNF1+ strains were the O4 and O6 (53/68; 78%), in the Hly+CNF1- strains it was the O18 (27/61; 44%) and in the Hly-CNF1- strains the O1, O2 and O7 (41/56; 73%). The majority (160/185; 86%) of P-fimbriated E. coli expressed the mannose-resistant haemagglutinin type IVa.


Satellite III DNA: regions of extreme endonuclease resistance and inter-individual polymorphism in the Mb size range. Southern analysis of within-gel digested and restricted human cells has revealed very large Satellite III restriction fragments which show clear inter-individual length polymorphism. The Mb and sub-Mb length of these fragments indicate that they arise from regions of heterochromatin which contain homogeneous Satellite III sequences of peculiar resistance to common endonucleases. Based on sequence alone, such regions would be little digested by endonuclease digestion of chromatin in metaphase, regardless of its method of preparation. Polymorphic regions such as these might be expected to stain as part of the C-banding seen in endonuclease treated metaphase chromosomes, and may in part account for inter-individual C-band heteromorphisms.


The effects of (+/-)-idazoxan and its stereoisomers on mouse vas deferens motility in vitro. A comparison with yohimbine. The effects of idazoxan (IDZ) and its stereoisomers were compared to that of a classical alpha 2-antagonist, yohimbine (YOH), on para-aminoclonidine (PAC)- and norepinephrine (NE)-mediated inhibition of the twitch response evoked in the mouse vas deferens by low-frequency (0.1 Hz) field stimulation. (+/-)-IDZ and (+)-IDZ antagonized the inhibitory effects of PAC, (+)-IDZ being twice as potent as (+/-)-IDZ; in contrast, antagonism by (-)-IDZ failed to meet Schild criteria for a competitive mechanism. YOH completely reversed the inhibition of twitch response induced by NE, but not that induced by PAC; in the latter case, residual inhibition was almost fully reversed by (+)-IDZ and to a lesser extent by (+/-)-IDZ, while (-)-IDZ proved ineffective. These results provide pharmacological evidence of alpha 2-receptor heterogeneity at the vas deferens level. A possible additional mechanism involving imidazoline binding sites is discussed.


Detection of thyroid-stimulating antibody in patients with inflammatory thyrotoxicosis. The detection of thyrotropin-binding inhibitory immunoglobulins (TBII) and/or thyroid-stimulating antibody (TSAb) has been reported in some patients with painless thyroiditis (PT) or subacute thyroiditis (SAT). However, its mechanism is unknown. TBII and TSAb measured using cultured FRTL-5 thyroid cells were evaluated in 18 patients with PT, 11 patients with SAT and a patient with SAT-like symptoms. In PT, we detected both TBII and TSAb activities in only 1 patient. This case had first come to our attention with subclinical hypothyroidism and had already had weakly positive TSAb activity (205.9%) 1 year before the present onset of PT. This patient had a transient thyrotoxicosis with a low uptake (24 h) of 123I (4.3%) and 821.0% TSAb activity, and subsequently developed a transient subclinical hypothyroidism. Even after 2 years, she still had positive TSAb activity (382.3%). In SAT, TBII and TSAb activities were not detected during the courses of any patients. A patient with transient thyrotoxicosis, who had a high uptake (30 min) of 99mTc (5.6%) and SAT-like symptoms (painful tenderness on right thyroid lobe and markedly accelerated erythrocyte sedimentation rate), showed positive activities of TBII (34.9%) and TSAb activity (1,366.9%). Histological findings by thyroid needle biopsy performed in the thyrotoxic phase showed coexistence of granulomatous inflammatory changes and hyperplasia with papillary folds of some residual follicular cells.(ABSTRACT TRUNCATED AT 250 WORDS)


Accelerated rejection of allografted rat liver perfused with anti-ICAM-1 monoclonal antibody. Infusion of mouse anti-rat ICAM-1 into the portal vein of ACI rat liver graft before transplantation resulted in accelerated rejection by LEW recipients (2.9 +/- 2.5 days), when compared to the ACI liver grafts perfused with either Lactate-Ringer's solution (9.8 +/- 1.3) or anti-human ICAM-1 mAb (9.8 +/- 3.1). Histologic features of anti-rat ICAM-1 perfused grafts were spotty ischemic necrosis, whereas those of control grafts were marked cellular infiltration. These combined survival and histologic data suggest that the accelerated rejection may be mediated by vascular deterioration.


Interferon-gamma-mediated suppression of erythroid progenitor growth by a HLA-DR- and CD4-positive subset of T lymphocytes in acute myeloid leukemia. In this study, we examined the effects of peripheral blood T lymphocytes from patients with acute myeloid leukemia (AML) on marrow-derived erythroid progenitors (BFU-DE and CFU-DE) growth in an in vivo culture by using the plasma clot diffusion chamber (DC) technique. The application of double-compartment chambers (each compartment separated by a membrane filter) makes the investigations of humoral effects of T lymphocytes upon marrow erythroid progenitors proliferation possible. T lymphocytes of AML-patients in the absence of a statistically significant number of monocytes suppressed the growth of BFU-DE and CFU-DE from T lymphocyte- and adherent cell-depleted marrows. The inhibition ability was restricted to the CD4-positive enriched fraction obtained from T cells by using the negative selection technique. In contrast, the CD8-positive enriched fraction had no effect on erythroid colony formation. Autologous and allogeneic BFU-DE and CFU-DE were similarly affected by the CD4-positive T cells. Treatment of T cells with monoclonal antibodies against HLA-DR before cocultures, completely abrogated the suppression of BFU-DE and CFU-DE-derived colony formation. Suppressive activity detected in the CD4-positive T cells was also totally abolished by treatment with anti-interferon-gamma antibodies; whereas the inhibition was retained after 30 Gy radiation. Under these experimental conditions, resting T lymphocytes from healthy subjects did not affect the erythroid colony formation. Our data show that in AML-patients, a circulating HLA-DR-positive, less radiosensitive subset within the CD4-positive T cells is capable of inducing an interferon-gamma-mediated suppression of erythropoiesis, at least in DC culture.


Failure to control AIDS-related CMV-retinitis with intravenous ganciclovir. Between January 1988 and May 1991 intravenous ganciclovir (GCV) treatment was administered to eight male AIDS-patients with unilateral cytomegalovirus (CMV)-retinitis. Despite of continuous therapy with at least the recommended dose of GCV, three patients developed slowly progressive CMV-retinitis in the fellow eye after 4 to 13 months. The progression could not be stopped by GCV and thus bilateral blindness resulted after 12 to 22 months. The number of CD4-lymphocytes in the blood was reduced in all patients, but particularly in patients with progressive disease. Treatment failure was partly related to the duration of CMV-retinitis and partly to the degree of immunodeficiency. Intravenous treatment with GCV alone can not stop the progression of CMV-retinitis in long-term survivors and in those with advanced immunodeficiency.


The first normal oral mucosa epithelium in which gamma-glutamyl transpeptidase activity has been detected. A portion of consistently gamma-glutamyl transpeptidase-positive epithelium in the normal oral mucosa of rats is described. This is the first normal oral mucosa epithelium reported to express activity of the transpeptidase. This enzyme has been used as a marker of malignant transformation in tissues such as epidermis and oral mucosa epithelium. Complementary studies of the enzyme-positive portion of oral mucosa and a neighbouring negative portion, suggest that, in this model, expression of gamma-glutamyl transpeptidase is linked to a terminally-differentiated epithelium.


The efferent modulation of mammalian inner hair cell afferents. The results of immunocytochemical, enzymatic and electrophysiological studies have indicated that acetylcholine and GABA may act as neurotransmitters in lateral olivocochlear efferent endings on inner hair cell afferent dendrites. Since spike activity can be recorded in the dendritic region of inner hair cells, microiontophoretic techniques were used testing the possible neurotransmitter candidates, acetylcholine and GABA, on spontaneous and induced firing of the afferent dendrites. The experiments were carried out in anaesthetised guinea-pigs, the third and fourth turns of the cochlea being exposed for electrode penetration. Ejection of acetylcholine resulted in a pronounced dose-dependent increase in subsynaptic spiking activity. Furthermore, acetylcholine enhanced glutamate-induced activity. In contrast, even at high doses, GABA had very little effect on the spontaneous cochlear firing rate. When the firing rate had first been enhanced by glutamate or N-methyl-D-aspartate, however, this activation could be reduced by the ejection of GABA. A similar reduction was observed when the firing rate had been enhanced with acetylcholine. The results of our studies support the hypothesis that these substances are involved in efferent neurotransmission on inner hair cell afferent fibres. It should be pointed out, however, that besides acetylcholine and GABA, several opioids such as enkephalins and dynorphins seem to be involved in efferent cochlear innervation.


N omega-nitro-L-arginine influences cerebral metabolism in awake sheep. Cerebral vasodilation in hypoxia may involve endothelium-derived relaxing factor-nitric oxide (NO). An inhibitor of NO formation, N omega-nitro-L-arginine (LNA, 100 micrograms/kg i.v.), was given to conscious sheep (n = 6) during normoxia and again in hypocapnic hypoxia (arterial PO2 approximately 38 Torr). Blood samples were obtained from the aorta and sagittal sinus, and cerebral blood flow (CBF) was measured with 15-microns radiolabeled microspheres. During normoxia, LNA elevated (P < 0.05) mean arterial pressure from 82 +/- 3 to 88 +/- 2 (SE) mmHg and cerebral perfusion pressure (CPP) from 72 +/- 3 to 79 +/- 3 mmHg, CBF was unchanged, and cerebral lactate release (CLR) rose temporarily from 0.0 +/- 1.9 to 13.3 +/- 8.7 mumol.min-1 x 100 g-1 (P < 0.05). The glucose-O2 index declined (P < 0.05) from 1.67 +/- 0.16 to 1.03 +/- 0.4 mumol.min-1 x 100 g-1. Hypoxia increased CBF from 59.9 +/- 5.4 to 122.5 +/- 17.5 ml.min-1 x 100 g-1 and the glucose-O2 index from 1.75 +/- 0.43 to 2.49 +/- 0.52 mumol.min-1 x 100 g-1 and decreased brain CO2 output, brain respiratory quotient, and CPP (all P < 0.05), while cerebral O2 uptake, CLR, and CPP were unchanged. LNA given during hypoxia decreased CBF to 77.7 +/- 11.8 ml.min-1 x 100 g-1 and cerebral O2 uptake from 154 +/- 22 to 105.2 +/- 12.4 mumol.min-1 x 100 g-1 and further elevated mean arterial pressure to 98 +/- 2 mmHg (all P < 0.05), CLR was unchanged, and, surprisingly, brain CO2 output and respiratory quotient were reduced dramatically to negative values (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)


Inhibitory NANC nerves in human tracheal smooth muscle: a quest for the neurotransmitter. Inhibitory nonadrenergic noncholinergic (i-NANC) nerves are the only neural bronchodilator pathway in human airways. Possible candidates for the neurotransmitter include vasoactive intestinal peptide (VIP) and nitric oxide (NO) and purines such as ATP. We have investigated the potential role of these neurotransmitters. Phosphoramidon (10(-5) M) significantly potentiated relaxations to low doses of VIP with no effect on i-NANC responses. Relaxations induced by VIp were abolished with alpha-chymotrypsin (2 U/ml), but i-NANC responses were unaffected. Reactive blue 2 had no effect on i-NANC neural responses, indicating that endogenous ATP was not involved. The NO synthase inhibitor L-NG-nitroarginine methyl ester (L-NAME, 10(-4) M) produced a concentration-dependent inhibition of the i-NANC response, producing almost complete inhibition at every frequency studied (0.5-40 Hz), whereas L-NG-monomethyl arginine was effective only at low stimulation frequencies. The inhibitory effect of L-NAME was partially reversed by L- but not D-arginine, and D-NAME was without effect. These results suggest that in human tracheal segments the neural bronchodilator response is mediated by NO, and there is no functional evidence for implicating VIP in this response.


Histamine decreases left ventricular contractility in normal human subjects. To determine whether histamine alters human left ventricular contractility we measured heart rate, calibrated carotid arterial pressure, and left ventricular dimensions (echocardiogram) in nine healthy volunteers. We assessed baseline contractility using the end-systolic pressure-dimension relationship and the end-systolic meridional wall stress-rate-corrected velocity of circumferential fiber shortening relationship determined over a wide range of afterloads using phenylephrine and nitroprusside infusions. We then infused histamine for 3-5 min at a dose predetermined to decrease mean arterial pressure by 20%, both before and after H1 receptor antagonist pretreatment (diphenhydramine 50 mg i.v.). Histamine decreased end-systolic pressure but, unlike an equally hypotensive infusion of nitroprusside, did not decrease end-systolic dimension or increase fractional shortening. Histamine also decreased velocity of circumferential fiber shortening at the same end-systolic meridional wall stress as controls (P < 0.05). These effects of histamine were inhibited by H1 antagonist pretreatment. We conclude that the dominant effect of histamine on the human heart is to decrease left ventricular contractility and that this decrease in contractility is dependent, at least partially, on H1-receptor activation.


Brain glutamate metabolism during metabolic alkalosis and acidosis. Glutamate modifies ventilation by altering neural excitability centrally. Metabolic acid-base perturbations may also alter cerebral glutamate metabolism locally and thus affect ventilation. Therefore, the effect of metabolic acid-base perturbations on central nervous system glutamate metabolism was studied in pentobarbital-anesthetized dogs under normal acid-base conditions and during isocapnic metabolic alkalosis and acidosis. Cerebrospinal fluid transfer rates of radiotracer [13N]ammonia and of [13N]glutamine synthesized de novo via the reaction glutamate+NH3-->glutamine in brain glia were measured during normal acid-base conditions and after 90 min of acute isocapnic metabolic alkalosis and acidosis. Cerebrospinal fluid [13N]ammonia and [13N]glutamine transfer rates decreased in metabolic acidosis. Maximal glial glutamine efflux rate jm equals 85.6 +/- 9.5 (SE) mumol.l-1 x min-1 in all animals. No difference in jm was observed in metabolic alkalosis or acidosis. Mean cerebral cortical glutamate concentration was significantly lower in acidosis [7.01 +/- 0.45 (SE) mumol/g brain tissue] and tended to be larger in alkalosis, compared with 7.97 +/- 0.89 mumol/g in normal acid-base conditions. There was a similar change in cerebral cortical gamma-aminobutyric acid concentration. Within the limits of the present method and measurements, the results suggest that acute metabolic acidosis but not alkalosis reduces glial glutamine efflux, corresponding to changes in cerebral cortical glutamate metabolism. These results suggest that glutamatergic mechanisms may contribute to central respiratory control in metabolic acidosis.


The kinetics and temporal expression of T-cell activation-associated antigens CD15 (LeuM1), CD30 (Ki-1), EMA, and CD11c (LeuM5) by benign activated T cells. Cell surface antigens, including CD71 (T9), CD38 (T10), HLA-DR, CD25 (IL2-R), CD15 (LeuM1), CD30 (Ki-1), epithelial membrane antigen (EMA), and CD11c (LeuM5), have been identified on the surface of neoplastic T-cells. The significance of this expression is unknown since the expression of these antigens by benign T cells has not been fully investigated. In this study the kinetics, temporal relation and hierarchy of expression of these eight cell surface antigens by purified normal peripheral blood T cells following activation with phytohemagglutinin (PHA) were investigated using one- and two-color flow cytometry. All eight antigens were expressed in a hierarchical manner following activation of normal peripheral blood T cells with PHA. The sequence of antigen expression and the initial time point of this expression was: CD38, < 24 h; CD71, CD25, 24 h; EMA, HLA-DR, CD15, 48-72 h; CD30, 72 h; and CD11c, 96-120 h. The maximum percentage of T cells expressing each antigen and the time point of maximum expression was: CD38 96% at 14 and 17 days; CD71 88%, CD25 94%, EMA 55%, and CD30 31% at 96 h; CD15 56% at 120 h; HLA-DR 30% at 168 h; and CD11c 42% at 240 h. The expression of these 8 antigens clustered into six distinct immunophenotypic constellations: Group I: None; Group II: CD38 with CD71 and/or CD25; Group III: CD38, CD71, CD25 with HLA-DR, CD15 and/or EMA; Group IV: CD38, CD71, CD25, EMA, HLA-DR with CD15, CD30 and/or CD11c; Group V: CD38, CD25, CD11c with CD71, EMA and/or HLA-DR; Group VI: CD38 with CD25 and/or CD11c. Finally, EMA and CD11c were preferentially expressed by CD4 and CD8 T cells, respectively. In summary, these results demonstrate that all eight antigens (1) are associated with T-cell activation, (2) are expressed in a hierarchical manner following activation, and (3) that this expression clusters into distinct immunophenotypic constellations.


Minor BCR (m-bcr) rearrangements may appear in major BCR (M-bcr)-positive CML cases. The chromosome 22 derivative, the Philadelphia (Ph) chromosome, results from the reciprocal translocation t(9;22) (q34;q11). On DNA level a BCR/ABL rearrangement involving the so-called major BCR (Mbcr) from chromosome 22 has been associated with chronic myeloid leukemia (CML). For Ph+ ALL a site of rearrangements in the 5' part of the BCR (breakpoint cluster region) gene on chromosome 22, the so-called minor bcr region (mbcr) has been described within the first intron in a 10.8 kb region (=bcr2 or m-BCR1). The BB1 probe detects two Eco fragments of 8.5 and/or 11 kb, which may appear as monomorphic or heteromorphic alleles, both covering bcr2. We have analyzed EcoRI restriction polymorphisms within bcr2 in 42 patients with a rearrangement in M-bcr (including 39 Philadelphia chromosome-positive (Ph+) CML patients and 3 ALLs) and in 18 healthy unrelated volunteers. Of the 42 patients tested, 52.4% (22) had the 8.5 kb bcr2 allele, 21.4% (9) had the 11 kb bcr2 allele, and 26.2% (11) had both the 8.5 and the 11 kb allele. In addition to normal allelic polymorphisms in bcr2, rRFs (rearranged bcr2 restriction fragments) were found in bcr2 as shown in 33% (14 of 42) of our patients. By contrast, no rRFs were found in 18 healthy volunteers. Our results indicate, that heterogeneous rearrangements in bcr2 may appear in addition to BCR/ABL rearrangements involving M-bcr in Ph+CML.


Determination of Taxotere in human plasma by a semi-automated high-performance liquid chromatographic method. A rapid, selective and reproducible high-performance liquid chromatographic (HPLC) method with ultraviolet detection was developed for the determination of the anti-cancer agent Taxotere in biological fluids. The method involves a solid-phase extraction step (C2 ethyl microcolumns) using a Varian Advanced Automated Sample Processor (AASP) followed by reversed-phase HPLC. The validated quantitation range of the method is 10-2500 ng/ml in plasma with coefficients of variation < or = 11%. The method is also suitable for the determination of Taxotere in urine samples under the same conditions. The method was applied in a phase I tolerance study of Taxotere in cancer patients, allowing the pharmacokinetic profile of Taxotere to be established.


Expression of D2 dopamine receptor mRNA in the arterial chemoreceptor afferent pathway. Dopamine is a major neurotransmitter in the arterial chemoreceptor pathway. In the present study we wished to determine if messenger RNAs for dopamine D1 and D2 receptor are expressed in carotid body (type I cells), in sensory neurons of the petrosal ganglion which innervate the carotid body and in sympathetic neurons of the superior cervical ganglion. We failed to detect D1 receptor mRNA in any of these tissues. However, we found that D2 receptor mRNA was expressed by dopaminergic carotid body type I cells. D2 receptor mRNA was also found in petrosal ganglion neurons that innervated the carotid sinus and carotid body. In addition, a large number of sympathetic postganglionic neurons in the superior cervical ganglion expressed D2 receptor mRNA.


Fast inhibitory postsynaptic potentials and responses to inhibitory amino acids of sympathetic preganglionic neurons in the adult cat. Intracellular recordings were obtained from sympathetic preganglionic neurons (SPNs) of the intermediolateral nucleus (IML) in slices of upper thoracic spinal cord of the anesthetized cat. A total of 44 neurons was studied. Single shock stimulation of an area of white matter dorsolateral to the IML, close to the recording electrode (< 0.5 mm), evoked fast IPSPs with rise time of 3.8 ms and 1/2 decay time of 14.7 ms (n = 12). In 17 other cells only fast EPSPs were recorded but, after suppression of the EPSPs by the excitatory amino acid receptor antagonists CNQX (20 microM) and APV (100-250 microM), fast IPSPs were unmasked. The IPSP reversed polarity at -63 mV (-67 mV in the presence of CNQX and APV). The reversal potential shifted to a less negative value when the extracellular chloride concentration was reduced. The IPSP was reversibly abolished by the GABAA receptor antagonist bicuculline in 32% of the cells, by the glycine receptor antagonist strychnine in 47% of the cells and by the combination of the two in 21% of the cells. The IPSP was abolished by TTX (0.5 microM), had constant latency and showed no failures during high frequency stimulation. The IPSP presumably resulted from the excitation of inhibitory axons and/or inhibitory neuron somata with monosynaptic connections to the SPN. Glycine and GABA (1-3 mM) produced hyperpolarization associated with decreased membrane resistance. Sixty-nine percent of cells responded to both agonists, 19% to glycine only and 12% to GABA only. The GABAB agonist baclofen (5 microM) had no effect.(ABSTRACT TRUNCATED AT 250 WORDS)


Central action of alpha-adrenoceptor agents on the baroreceptor reflex. In chloralose-anaesthetized cats the effects of intravenous application of the alpha 1- and alpha 2-adrenoceptor agonistic and antagonistic agents methoxamine, prazosin, B-HT 933 and rauwolscine were tested on baroreceptor reflex, sympathetic background activity and blood pressure. Sympathetic activity was recorded from the renal nerve and the efficacy of the central transmission of the baroreceptor reflex was measured by the duration of the complete inhibition of renal nerve activity during electrical stimulation of the left carotid sinus nerve. All baroreceptors were denervated by sectioning both carotid sinus and vagal nerves. The alpha 1-agonist methoxamine increased baroreceptor-induced sympatho-inhibition, sympathetic background activity and blood pressure. The alpha 1-antagonist prazosin had the opposite effects. The alpha 2-agonist B-HT 933 was most effective in augmenting the inhibitory response in sympathetic activity to baroreceptor stimulation; sympathetic background activity and blood pressure were also decreased. At low doses (50 micrograms/kg) the alpha 2-antagonist rauwolscine reduced the baroreceptor sympathetic reflex inhibition and increased sympathetic activity and blood pressure. The effect of B-HT 933 upon the baroreceptor reflex could be completely antagonized by rauwolscine. These findings demonstrate a very effective facilitation of the baroreceptor reflex transmission by stimulation of central alpha 2-adrenoceptors. Through such humoral-neuronal interaction circulating catecholamines are likely to modulate cardiovascular control.


Growth hormone therapy in normal short children induces a transitory decrease in plasma growth hormone releasing hormone levels and in human growth hormone responsiveness to exogenous growth hormone releasing hormone. A three-month study of the effect of growth hormone (hGH) therapy (0.1 U/kg/day sc) on plasma levels of GH releasing hormone (GHRH), somatostatin and insulin-like growth factor I (IGF-I) and on the hGH responsiveness to exogenous GHRH was carried out in 32 prepubertal short-stature children with normal GH secretion. Blood samples were collected prior to initiation of therapy, and at 5, 30 and 90 days of onset of therapy, as well as 2 and 90 days after termination of therapy. The nonconventional hGH therapy induced an increase in serum IGF-I levels which lasted as long as therapy was continued. Plasma GHRH levels showed an early transitory decrease after five days of therapy, whereas plasma somatostatin levels were unaltered. A slight suppression in hGH responsiveness to exogenous GHRH was found at 2 but not at 90 days after termination of hGH therapy. It is concluded that nonconventional hGH treatment does not cause permanent changes in physiological hGH secretion.


[Takayasu's disease and pregnancy].

[Takayasu's disease and pregnancy]. We report one case of pregnancy in a non-oriental woman who had Takayashu's disease. Pregnancy was characterised by toxemia and caesarean section had to be carried out at 31 weeks because of fetal distress. The disease did not worsen and nor were there any maternal complications but the child died on the 7th day.


Septicaemia in paediatric intensive-care patients at the Hospital for Sick Children, Great Ormond Street. A review of nosocomial septicaemia in paediatric intensive care in a tertiary referral setting was undertaken for a 33-month period (1988-90). This involved six units: Cardiothoracic surgery; Neonatal surgery; general medical; Renal dialysis/transplant; Haematology/Oncology and Infectious disease/Immunology. The latter two units undertake bone marrow transplantation. During the study period, 10,719 admissions were made to these areas and 624 episodes of septicaemia were documented in 464 children. The frequency of septicaemia per 100 admissions ranged from 1.5 in the Renal Transplant Unit to 17.3 in the Haematology/Oncology unit. Over 60% of all septicaemic episodes occurred in children in the Haematology/Oncology and Cardiac Units. Gram-positive organisms were responsible for 66% of episodes, Gram-negative organisms for 17% and fungi for 3%. Polymicrobial episodes accounted for 13%. Coagulase-negative staphylococci were the most frequent isolates overall (43% of episodes in pure culture, and a further 6% in combination with other organisms). Staphylococcus aureus was associated with 10% of episodes, Enterobacteriaceae with 9% and Pseudomonas spp. 6% among which environmental pseudomonads predominated. Anaerobes and Haemophilus influenzae were each isolated in less than 1% of episodes.


Multiresistant Klebsiella pneumoniae in a neonatal nursery: the importance of maintenance of infection control policies and procedures in the prevention of outbreaks. During a 3-week period, nine babies in the neonatal unit of a large teaching hospital in Durban were infected or colonized with Klebsiella pneumoniae resistant to a range of antimicrobial agents including amikacin and cefotaxime. Resistance to cefotaxime was reduced by clavulanic acid in vitro suggesting production of extended-spectrum beta-lactamase activity. All the isolates had the same antibiotic resistance profile, belonged to the same serotype (K17), were non-typable with bacteriophages, and had identical plasmid profiles indicating that they belonged to the same strain. During a 1-day microbiological survey of the ward, the outbreak strain was isolated from the nose and hands of a doctor based in the nursery and from the hands of a nurse and the mother of an infected baby. The strain was also isolated from nine of 67 environmental samples. Investigation revealed that infection control practices which had been instituted following a previous outbreak in the nursery with multi-resistant methicillin-resistant Staphylococcus aureus (MRSA) were not being adhered to. The re-introduction and strict enforcement of these procedures under the supervision of an Infection Control Nurse resulted in the abrupt end of the outbreak.


Long-term carriage, and transmission of methicillin-resistant Staphylococcus aureus after discharge from hospital. The purpose of this study was to determine whether patients who become carriers of methicillin-resistant Staphylococcus aureus (MRSA) during their stay in hospital, remain colonized after discharge. Thirty-six patients colonized with MRSA during one of three outbreaks at Utrecht University Hospital (1986-89) were screened 2 or 3 years after they had become carriers. Patients were also interviewed to determine factors contributing to persistent carriage, such as antibiotics, re-admissions to the hospital, presence of skin lesions and chronic diseases. At the same time transmission of MRSA to family members was determined. The epidemic MRSA strain was still found in three patients (8%). One was a cystic fibrosis patient who had had frequent re-admissions to the hospital and had received several course of antibiotic treatment. Both of the other patients had skin lesions: a fistula and a colostomy respectively. None of the 44 family members of the patients was colonized or infected with MRSA. We conclude that long-term MRSA carriage occurs with low frequency and is comparable to persistent carriage of methicillin-sensitive Staphylococcus aureus (MSSA). Transmission of MRSA to healthy individuals in an antibiotic-free environment is a rare event.


A study of coagulase-negative staphylococci with reference to slime production, adherence, antibiotic resistance patterns and clinical significance. Two hundred and fifty-one strains of coagulase-negative staphylococci (CNS) isolated from patients in hospital and the community were investigated for slime production and adherence as indicators of pathogenicity. Staphylococcus epidermidis formed 68.5% (126) of the isolates of CNS from blood and central venous catheter (CVC) tips, of which 46.0% (58) were slime-positive and adherent. Clinically significant infections were associated with 55.2% (32) of the slime-positive adherent strains isolated and 11.1% (four) of slime-negative non-adherent strains of S. epidermidis. For other species of CNS isolated from blood and CVC tips 74.1% (43) were slime negative non-adherent and 18.6% (eight) of these were considered clinically significant isolates while none of the slime positive adherent strains were associated with a clinically significant infection. Slime production and adherence were not characteristic properties of CNS causing community-acquired urinary tract infection or colonizing the nasal mucosa. It is concluded that slime production and adherence had a limited role in the differentiation between clinically significant and contaminant strains isolated from blood cultures; however, the absence of slime and adherence in isolates of S. epidermidis suggested a lack of pathogenicity.


beta-Lactamase substrate profiles of coagulase-negative skin staphylococci from orthopaedic inpatients and staff members. Three different beta-lactamase substrate profiles were identified in 95 isolates of coagulase-negative staphylococci (CNS), of 57 different phenotypes, from 16 orthopaedic inpatients and staff members in one ward, by applying a bacterial whole-cell assay based on the hydrolysis of cefazolin, cephaloridine and nitrocefin. The typability of the assay was 93%, and 91% of the CNS isolates could be classified. To assess the discrimination between the beta-lactamase profiles obtained in the whole-cell assay, beta-lactamase extracts from 19 of the CNS isolates were used for estimation of their relative beta-lactamase substrate affinity index (RSAI). The RSAI assay was able to type previously unclassifiable or nontypable isolates. Two of the profiles obtained with the whole-cell assay were similar to those of the Staphylococcus aureus controls producing A or D and B or C beta-lactamases respectively. The distribution of beta-lactamase substrate profiles among the CNS isolates indicated an efficient spread of these drug resistance genes.


Pseudobacteraemia with multiply-resistant Klebsiella pneumoniae resulting from contamination from the blood gas machine on a neonatal unit. Klebsiella pneumoniae with an unusual antibiotic susceptibility pattern was isolated from blood cultures of seven unwell premature babies on the Special Care Baby Unit. Although the organism was sensitive to cefuroxime it was resistant to ceftazidime. It was also resistant to gentamicin, tobramycin, netilmicin, piperacillin and aztreonam but sensitive to ciprofloxacin, imipenem and amikacin. On extensive investigation to trace the source, a K. pneumoniae with the same susceptibility pattern as that obtained from blood cultures was isolated from the probe and probe cover on the blood gas machine but not from any other environmental samples or clinical specimens. Where clinically indicated, antibiotics were used to treat these babies, with success. The difficulty, however, of differentiating between true septicaemia and pseudobacteraemia could be enormous as withholding treatment will have disastrous consequences in genuine cases of bacteraemia.


Single-dose amoxycillin-clavulanic acid vs. cefotetan for prophylaxis in elective colorectal surgery: a multicentre, prospective, randomized study. The PRODIGE Group. A prospective, multicentre, randomized trial was carried out in 19 hospitals in order to compare the efficacy of amoxycillin-clavulanic acid with cefotetan as antibiotic prophylaxis in patients undergoing elective colorectal surgery. Since the main purpose of the study was to demonstrate equivalence between the two regimens, the protocol planned the inclusion of 200 patients. Eligible patients were randomly assigned to receive either amoxycillin-clavulanic acid (2.2 g) or cefotetan (2 g) in a single infusion on the induction of anaesthesia. Failure of prophylaxis was defined as occurrence of infection of intestinal origin, either minor (wound cellulitis) or major (abscess, peritonitis, septicaemia) within the 30-day postoperative period. Among 221 randomized patients, 208 (105 amoxycillin-clavulanic acid, 103 cefotetan) aged 66 +/- 12 years (mean +/- SD) were evaluated while 13 were withdrawn. Colorectal cancer was the indication for surgery in 73% of cases. Eleven (10 +/- 6%, 95% confidence interval) and 13 (13 +/- 7%) failures were observed in the amoxycillin-clavulanic acid and cefotetan groups (P = 0.63 chi-square test) respectively. Most infections occurred before the 10th postoperative day (8% failures at this time, estimated by the Kaplan-Meier method). The results of the trial demonstrate that amoxycillin-clavulanic acid and cefotetan have similar efficacy when used for prophylaxis of infection after elective colorectal surgery.


Prophylaxis and treatment of infections complicating abdominal surgery. The suitability of commonly used antimicrobial regimens for prophylaxis in abdominal surgery and treatment of intra-abdominal sepsis is discussed. These various therapies are often limited in their usefulness by the range of microorganisms against which they are effective and thus, to extend the antimicrobial cover, agents may be combined. Some forms of therapy may produce adverse effects in susceptible patients, thus limiting their use to certain groups, or there may be cost constraints. Beta-lactamase-inhibiting compounds appear to offer an optimal combination of a broad spectrum of activity against aerobic and anaerobic microorganisms, minimal toxicity and reasonable cost.


Prospective, randomized study comparing amoxycillin-clavulanic acid and cefamandole for the prevention of wound infection in high-risk patients undergoing elective biliary surgery. The efficacy of amoxycillin-clavulanic acid for prevention of postoperative wound infection was compared with that of cefamandole in 150 patients at risk for infected bile while undergoing elective biliary surgery in a prospective, randomized study. The two groups were comparable for age, sex, risk factors, operative procedures and positive bile cultures. Similar numbers of patients had an uncomplicated postoperative course (amoxycillin-clavulanic acid 70%; cefamandole 73%). Four patients in each group developed wound infection. The incidence of postoperative pneumonia, urinary tract infection and number of days (+/- SD) in hospital (amoxycillin-clavulanic acid 10.1 +/- 4.7; cefamandole 9.7 +/- 5.6) were similar. The efficacy of amoxycillin-clavulanic acid and cefamandole in preventing wound sepsis in high-risk patients undergoing biliary surgery was similar. Economic considerations may favour the use of amoxycillin-clavulanic acid.


Postoperative complications due to methicillin-resistant Staphylococcus aureus (MRSA) in an elderly patient: management and control of MRSA. An elderly lady was admitted to hospital for elective resection of an adenocarcinoma of the colon. Following an anastomotic leak she developed intra-abdominal sepsis and underwent abdominal drainage of pus. During recovery from her second operation, she developed pneumonia and a bacteraemia due to methicillin-resistant Staphylococcus aureus (MRSA). She was treated with vancomycin and co-trimoxazole and survived without further sequelae. Details of the development and treatment of this case are discussed. Procedures for the control and eradication of MRSA infections in hospitals are reviewed.


Community-acquired pneumonia.

Community-acquired pneumonia. The aetiology of community-acquired pneumonia is reviewed, and the identification of the most likely pathogens, based on clinical presentation, is discussed. By far the major pathogen in community-acquired pneumonia is Streptococcus pneumoniae; the relative frequency of other pathogens, and particularly the atypical pneumonias caused by Mycoplasma and Legionella spp., will depend on local epidemiological factors. The diagnostic tests to confirm diagnosis and subsequent treatment of these infections are reviewed.


Activity of amoxycillin-clavulanic acid against Legionella pneumophila in vitro and in an experimental respiratory infection model. Amoxycillin and clavulanic acid show good activity against Legionella pneumophila in vitro, and synergy has been observed between the two agents. However, in tissue culture studies, amoxycillin was inactive against intracellular legionellae, whereas clavulanic acid and amoxycillin plus clavulanic acid were as effective as erythromycin in preventing bacterial growth. These latter findings were reflected in the results of therapy of a L. pneumophila pneumonia in the neutropenic rat. Amoxycillin was ineffective in reducing bacterial counts in the lungs of infected animals, but clavulanic acid and amoxycillin-clavulanic acid produced bactericidal effects similar to those of erythromycin. The data illustrate the bactericidal activity of amoxycillin-clavulanic acid and clavulanic acid against intracellular L. pneumophila in contrast to the lack of activity of amoxycillin.


Comparative clinical and microbiological study of amoxycillin-clavulanic acid and ciprofloxacin in acute purulent exacerbations of chronic bronchitis. In a retrospective study, the clinical and microbiological efficacy of amoxycillin-clavulanic acid and ciprofloxacin were evaluated in outpatients observed within the previous year who were affected by acute purulent exacerbations of chronic bronchitis. Of the 95 patients included in the trial, 50 received amoxycillin 875 mg-clavulanic acid 125 mg 8-hourly for 10 days and 45 received ciprofloxacin 500 mg 12-hourly before meals for 10 days. Of the amoxycillin-clavulanic acid-treated patients, 90% showed clear clinical improvement and in 10% treatment failed. In the ciprofloxacin group, 75.5% of patients showed improvement and in 24.5% treatment failed. All pathogens isolated prior to therapy were susceptible to the antibiotic used for therapy. At the end of treatment, in the amoxycillin-clavulanic acid-treated group, 84% of strains were eradicated and 8% persisted; others were superinfections. In the ciprofloxacin group, 57.7% of strains were eradicated, 26.6% persisted and 15.5% were superinfections. No clinically significant side effects were observed in either group. Overall, amoxycillin-clavulanic acid demonstrated superior clinical and microbiological efficacy to ciprofloxacin, although this might be attributable to the higher proportion of aerobic Gram-negative pathogens in the ciprofloxacin group.


The management of acute, serous and chronic otitis media: the role of anaerobic bacteria. Otitis media (OM) is a common childhood disease and one which can cause significant morbidity. A knowledge of the pathogens responsible for OM enables the most appropriate treatment regimen to be selected and thus minimizes further complications which may require hospital admission and surgery. The microbiology of acute, serous and chronic OM is reviewed, with particular regard to the role of anaerobic bacteria. Anaerobes, mainly Gram-positive cocci, have been recovered from 25% of the ear aspirates of patients with acute otitis media. In a study of serous OM, anaerobic bacteria were recovered in 12% of the culture-positive aspirates. The predominant anaerobes were Gram-positive cocci and pigmented Prevotella. Several studies have reported the recovery of anaerobes from about 50% of patients with chronic OM and those with cholesteatoma. The predominant anaerobes were Gram-positive cocci, pigmented Prevotella, Porphyromonas sp., Bacteroides spp. and Fusobacterium spp. Many of these organisms produce beta-lactamase which might have contributed to the failure of the patients to respond to penicillins. The appropriate antimicrobial therapy for acute, serous and chronic otitis media is discussed.


In-vitro bactericidal activity of four oral antibiotics against pathogens responsible for acute otitis media in children. This study was designed to test the in-vitro activity of four oral antibiotics against the four microorganisms most frequently isolated in acute otitis media: beta-lactamase-positive Haemophilus influenzae (N = 10), beta-lactamase-positive Moraxella catarrhalis (N = 10), penicillin-sensitive Streptococcus pneumoniae (N = 11) and methicillin-sensitive Staphylococcus aureus (N = 10), by the bactericidal curve method. Bactericidal kinetics were determined for concentrations of antibiotic equivalent to those found in the middle ear after treatment: amoxycillin-clavulanic acid (2.5 mg l-1/0.6 mg l-1 and 2.5 mg l-1/1.2 mg l-1), cefaclor (1 mg l-1), erythromycin (0.5 mg l-1) and erythromycin/sulfisoxazole (0.2/3 mg l-1). The inoculum was of 10(6) colony-forming units (cfu) ml-1. The bacterial counts were performed after 5 h and 24 h using a spiral inoculator system. The results showed that amoxycillin-clavulanic acid had rapid bactericidal activity (< 24 h) on the tested organisms at each of the doses used (reduction < or = 3 log10 cfu ml-1) which was not observed with the other antibiotics at either 5 or 24 h. Erythromycin alone or combined with sulfisoxazole had a bacteriostatic effect on Moraxella catarrhalis and Streptococcus pneumoniae but not on Haemophilus influenzae or Staphylococcus aureus. Cefaclor had no bactericidal action under these conditions.


A meta-analysis of the use of amoxycillin-clavulanic acid in surgical prophylaxis. The efficacy of amoxycillin-clavulanic acid as antibiotic prophylaxis in surgery has been assessed in numerous clinical studies, chiefly in abdominal and gynaecological surgery. A meta-analysis of 21 trials covering 2685 patients given amoxycillin-clavulanic acid and 2220 patients given comparator regimens is presented. Monotherapy with amoxycillin-clavulanic acid was as effective as the comparators, including combination regimens utilizing gentamicin or metronidazole, in preventing wound infections (median wound infection rates were 6% and 10% respectively). The antibacterial activity of amoxycillin-clavulanic acid covers the broad range of aerobic Gram-negative and anaerobic organisms that have a major role in postoperative infections. In addition, amoxycillin-clavulanic acid may have benefits in terms of convenience, tolerance and cost.