Arrhythmias in structural heart disease.

The presence of structural heart disease is often associated with the development of electrical abnormalities of the heart, manifesting as atrial and ventricular arrhythmias. These can occur in those with ischemic and nonischemic cardiomyopathies, congenital heart disease, and various acquired and intrinsic structural abnormalities of the myocardium. Treatment of these arrhythmias generally involves treatment of the underlying disorder first, if possible, such as with surgical or catheter-based intervention. Other therapies, including medical therapy with beta-blockers and anti-arrhythmic agents, pacemakers and implantable cardioverter-defibrillators (ICDs), and ablation may be offered both as prophylactic therapy or if arrhythmias have developed. In some instances, therapy is undertaken regardless of whether there are symptoms. ICDs provide support for those patients at risk for malignant, life-threatening arrhythmias, but appropriate patient and device selection are vital to improve mortality and to limit adverse events.

Sudden death in a patient newly diagnosed with diabetes having hyperosmolar non-ketotic acidosis with sickle cell trait.

Sickle cell trait (SCT) has a UK urban population rate estimated at 3.2%. The condition may remain unrecognised, but sudden death is a recognised feature. The sudden death of a 51-year-old man with SCT who presented with hyperosmolar non-ketotic acidosis (HONK) as his first presentation of diabetes is reported here. After admission to hospital, a rapid deterioration was seen in his condition, with loss of cardiac output, leading to death. He was found to have had acute-chest syndrome and hepatosplenic infarction on postmortem examination. The pathophysiology of sudden death in patients with SCT and the role of HONK in the patient's demise is discussed here.

Cortactin underpins CD44-promoted invasion and adhesion of breast cancer cells to bone marrow endothelial cells.

Using a validated tetracycline (tet)-regulated MCF7-founder (MCF7F) expression system to modulate expression of CD44 standard form (CD44s), we report the functional importance of CD44s and that of a novel transcriptional target of hyaluronan (HA)/CD44s signaling, EMS1/cortactin, in underpinning breast cancer metastasis. In functional experiments, tet-regulated induction of CD44s potentiated the migration and invasion of MCF7F cells through HA-supplemented Matrigel. EMS1/cortactin was identified by expression profiling as a novel transcriptional target of HA/CD44 signaling, an association validated by quantitative PCR and immunoblotting experiments in a range of breast cancer cell lines. The mechanistic basis underpinning CD44-promoted transcription of EMS1/cortactin was shown to be dependent upon a NFkappaB mechanism, since pharmacological inhibition of IkappaKinase-2 or suppression of p65 Rel A expression attenuated CD44-induced increases in cortactin mRNA transcript levels. Overexpression of a c-myc tagged murine cortactin construct in the weakly invasive, CD44-deficient MCF7F and T47D cells potentiated their invasion. Furthermore, the functional importance of cortactin to CD44s-promoted metastasis was demonstrated by selective suppression of cortactin in CD44-expressing MCF7F-B5 and MDA-MB-231 breast cancer cells using RNAi, which was shown to result in attenuated CD44-promoted invasion and CD44-promoted adhesion to bone marrow endothelial cells (BMECs).

Epidermal growth factor up-regulates CD44-dependent astrocytoma invasion in vitro.

CD44/hyaluronan interactions and epidermal growth factor (EGF) stimulation are both known to enhance tumour invasion in vitro. The frequent amplification of the EGF receptor (EGFR) in high-grade astrocytomas led to the examination of the hypothesis that CD44-dependent astrocytoma invasion is regulated by EGF. It has been shown that human astrocytoma cells express only the standard (haemopoietic) form of CD44 (CD44s) and that EGF up-regulates CD44 mRNA and protein in a time- and dose-dependent (10-100 ng/ml) manner. EGF stimulation did not result in induction of additional splice variants. No EGF-induced increase in CD44s was observed after treatment of cells with the wild-type EGFR tyrosine kinase inhibitor Tyrphostin AG1478 (30 nM). Up-regulation of CD44 by EGF is also prevented by the transcriptional inhibitor actinomycin D (5 microg/ml) and by blocking the MAP kinase (MAPK) pathway using the MEK inibitor U0126 (100 microM). CD44 up-regulation was associated with a 50% increase in invasion through hyaluronan-supplemented Matrigel(trade mark), which was abrogated by ligating CD44 with the specific antibody KM201. These results suggest that increased CD44 expression in response to EGF stimulation plays a significant role in astrocytoma invasion.

Epidemiological relatedness and clonal types of natural populations of Escherichia coli strains producing Shiga toxins in separate populations of cattle and sheep.

Two separate animal populations consisting of a herd of cattle (19 animals) and a flock of sheep (25 animals) were investigated for strains of Escherichia coli producing Shiga toxins (STEC) over a time period of 6 months. Thirty-three STEC were isolated from 63.2% of cattle and grouped into 11 serotypes and eight electrophoretic types (ETs) by multilocus enzyme analysis. In sheep, 88% of the animals excreted STEC (n = 67 isolates) belonging to 17 different serotypes and 12 different ETs. STEC from cattle and sheep differed with respect to serotype, and only 4 of the 16 ETs occurred in both animal populations. In cattle, ET14 (O116:H21) strains predominated, whereas other STEC serotypes occurred only sporadically. The predominating STEC types in sheep were ET4 (O125 strains), ET11 (O128:H2 and others), and ET14 (O146:H21). In contrast to their diversity, STEC originating from the same animal population were similar with respect to Shiga toxin (stxy genes. Almost all STEC isolated from cattle were positive for stx2 and stx2c; only one was positive for stx1. In sheep, almost all STEC isolated were positive for stx1 and stx2, whereas stx2c was not found. XbaI-digested DNAs of genetically closely related O146:H21 strains have different restriction profiles which were associated with size alterations in XbaI fragments hybridizing with stx1- and stx2-specific DNA probes. Our results indicate that stx-encoding bacteriophages might be the origin of the genetic heterogeneity in STEC from animals.

Brain glucose metabolism in chronic marijuana users at baseline and during marijuana intoxication.

Despite the widespread abuse of marijuana, knowledge about its effects in the human brain is limited. Brain glucose metabolism with and without delta 9 tetrahydrocannabinol (THC) (main psychoactive component of marijuana) was evaluated in eight normal subjects and eight chronic marijuana abusers with positron emission tomography. At baseline, marijuana abusers showed lower relative cerebellar metabolism than normal subjects. THC increased relative cerebellar metabolism in all subjects, but only abusers showed increases in orbitofrontal cortex, prefrontal cortex, and basal ganglia. Cerebellar metabolism during THC intoxication was significantly correlated with the subjective sense of intoxication. The decreased cerebellar metabolism in marijuana abusers at baseline could account for the motor deficits previously reported in these subjects. The activation of orbitofrontal cortex and basal ganglia by THC in the abusers but not in the normal subjects could underlie one of the mechanisms leading to the drive and the compulsion to self-administer the drug observed in addicted individuals.

Brain glucose metabolism in violent psychiatric patients: a preliminary study.

Positron emission tomography with 18F-deoxyglucose was used to evaluate regional brain glucose metabolism in eight normal subjects and eight psychiatric patients with a history of repetitive violent behavior. Seven of the patients showed widespread areas of low brain metabolism. Although the location of the abnormal regions varied among patients, they showed significantly lower relative metabolic values in medial temporal and prefrontal cortices than did normal comparison subjects. These regions have been implicated as substrates for aggression and impulsivity, and their dysfunction may have contributed to the patients' violent behavior.

The effect of haloperidol on aldosterone secretion.

Haloperidol (0.02 mg/kg, intravenous) did not stimulate aldosterone secretion in six normal controls or in six schizophrenic subjects. This is contrary to our hypothesis, which was based on the finding that peripheral D2 receptor antagonists stimulate aldosterone secretion, including haloperidol in rats and chlorpromazine in man. We speculated that a different dose of haloperidol would stimulate aldosterone in man. As expected, prolactin release was markedly stimulated in both groups of subjects, but no difference was found between groups.

Cerebellar metabolic activation by delta-9-tetrahydro-cannabinol in human brain: a study with positron emission tomography and 18F-2-fluoro-2-deoxyglucose.

We investigated the effects of acute i.v. administration of 2 mg of delta 9-tetrahydrocannabinol (THC) on regional brain glucose metabolism using 18F-2-fluoro-2-deoxyglucose and positron emission tomography (PET) in eight normal subjects. Subjects were tested twice: during baseline conditions and 30-40 min after THC administration. Changes in global cerebral glucose metabolism in response to THC were variable: three subjects showed an increase, three showed a decrease, and two showed no change. In contrast, all subjects showed an increase in normalized metabolism in the cerebellum following THC administration. Cerebellar changes were the only significant regional metabolic changes due to THC administration. The increase in metabolic activity in the cerebellum was correlated with the subjective sense of THC intoxication and with plasma THC concentration. Cerebellar localization of metabolic effects due to THC administration corresponds well with the high density of cannabinoid receptors known to be in this area.

Human urinary excretion profile after smoking and oral administration of [14C]delta 1-tetrahydrocannabinol.

The urinary excretion profiles of delta 1-tetrahydrocannabinol (delta 1-THC) metabolites have been evaluated in two chronic and two naive marijuana users after smoking and oral administration of [14C]delta 1-THC. Urine was collected for five days after each administration route and analyzed for total delta 1-THC metabolites by radioactivity determination, for delta 1-THC-7-oic acid by high-performance liquid chromatography, and for cross-reacting cannabinoids by the EMIT d.a.u. cannabinoid assay. The average urinary excretion half-life of 14C-labeled delta 1-THC metabolites was calculated to be 18.2 +/- 4.9 h (+/- SD). The excretion profiles of delta 1-THC-7-oic acid and EMIT readings were similar to the excretion profile of 14C-labeled metabolites in the naive users. However, in the chronic users the excretion profiles of delta 1-THC-7-oic acid and EMIT readings did not resemble the radioactive excretion due to the heavy influence from previous Cannabis use. Between 8-14% of the radioactive dose was recovered in the urine in both user groups after oral administration. Lower urinary recovery was obtained both in the chronic and naive users after smoking--5 and 2%, respectively.

The benzodiazepine receptor antagonist, flumazenil does not block clinical effects of delta-9-tetrahydrocannabinol.

Fifteen normal volunteer men were given intravenous doses of 2 mg of delta-9-tetrahydrocannabinol (THC) and 3 were given doses of 0.5 mg. Five, 15 and 30 minutes later, they were given intravenous doses of the benzodiazepine receptor antagonist, flumazenil. Doses of this compound ranged between 0.1 and 3.2 mg for single doses and 0.7 and 6.4 mg for total doses, being increased progressively with each successive subject, until dose-ranging was completed in 10 subjects. After that 5 subjects were given doses of 2 mg of THC on two occasions, followed by either doses of 3.2 or 6.4 mg flumazenil or placebo, administered under blind conditions. Three subjects were treated with 0.5 mg doses of THC followed by 3.2 mg of flumazenil or placebo under similar conditions. Despite doses of the antagonist which would have been adequate to reverse the effects of substantial doses of benzodiazepines, little ameliorative action was observed on the level of intoxication or the degree of conjunctival injection, two quite reliable clinical indicators of THC action. The benzodiazepine receptor does not seem to play any significant role in the psychoactive actions and conjunctival injection produced by THC.

Terminal elimination plasma half-life of delta 1-tetrahydrocannabinol (delta 1-THC) in heavy users of marijuana.

The terminal elimination half-life of delta 1-tetrahydrocannabinol (delta 1-THC) was investigated in eight men who were heavy users of marijuana. A stable isotope assay, following smoking deuterium-labeled delta 1-THC, was used to determine plasma concentrations. In two additional users plasma levels were followed after administration of unlabeled delta 1-THC. The subjects were asked to smoke a "loading dose" of 56 mg delta 1-THC during two days and then abstain from all marijuana use for 4 weeks. The pharmacokinetic behavior was consistent with a multicompartment model with a mean plasma elimination half-life of delta 1-THC of 4.3 days when concentrations were followed for 10-15 days after smoking. In the two subjects with detectable plasma levels during 4 weeks, half-lives of 9.6 and 12.6 days was obtained.

Single-dose kinetics of deuterium-labelled cannabinol in man after intravenous administration and smoking.

The single dose pharmacokinetics of deuterium-labelled cannabinol (2H2-CBN) were evaluated in six male cannabis users with different degree of abuse after smoking an average dose of 19 mg and after intravenous administration of 20 mg CBN. Plasma levels were measured for up to 72 h with selected ion monitoring by GC/MS using 2H7-CBN as internal standard. The systemic availability of smoked CBN was found to be 39 +/- 26% (min-max 6-65%). The mean plasma clearance was 19.1 +/- 2.6 ml min-1 kg-1 and the volume of distribution was determined to 50 +/- 23 l kg-1. The apparent terminal half lives for CBN were 32 +/- 17 h and 43 +/- 29 h after intravenous administration and smoking, respectively.

Human pharmacology of 1S and 1R enantiomers of delta-3-tetrahydrocannabinol.

Two enantiomers (1S and 1R) of delta-3-tetrahydrocannabinol were assayed in man for psychoactivity. The 1S enantiomer had definite psychic actions, qualitatively similar to those of delta-1-tetrahydrocannabinol, but quantitatively less potent (1:3 to 1:6). Adding the two enantiomers together did not increase the effect, confirming that activity was solely in the one enantiomer and that there was no interaction between them.

Single-dose kinetics of deuterium-labelled cannabidiol in man after smoking and intravenous administration.

The disposition of deuterium-labelled cannabidiol, 2H2-CBD, was studied in five young men who were marihuana smokers. The pattern of use ranged from infrequent to frequent use of the drug. Plasma concentrations, determined by mass fragmentography, were followed for 72 h after both intravenous administration of 20 mg 2H2-CBD and smoking of an estimated amount of 18.8-19.4 mg 2H2-CBD. Systemic availability after smoking was determined by comparing the areas under the plasma concentration versus time curves for the two treatments and was found to be 31 +/- 13%. A four-fold difference in the availability of the compound was noted for the five subjects. Based on the area under the curve and the dose after intravenous administration, a plasma clearance of 960-1560 ml min-1 was calculated. A terminal elimination phase was not reached at 72 h, but the kinetic parameters were estimated from the 72 h beta-elimination. A half-life of 31 +/- 4 h after smoking and 24 +/- 6 h after injection was estimated as well as a distribution volume of 2520 +/- 470 l (32.7 +/- 8.61 kg-1).

Clinical evaluation of a naltrexone sustained-release preparation.

A clinical evaluation of the naltrexone bead, a biodegradable sustained-release dosage form of 3.0 mg in weight containing 70% naltrexone in a copolymer of lactic and glycolic acids, was carried out in 4 healthy normal males. Subjects were given an intravenous dose of 10 mg naltrexone and approx. 1 week later a 63-mg dose of naltrexone by subcutaneous administration of the beads. Challenge doses of 15 mg morphine were given to each subject during the study for the assessment of narcotic blockade effects of naltrexone. For a 2-4-week period after bead administration, relatively constant plasma levels were maintained at 0.30-0.46 ng/ml for naltrexone and were 0.64-1.07 ng/ml for naltrexol. Urine levels for unchanged and conjugated naltrexone were 79-215 ng/ml and for naltrexol were 315-500 ng/ml. From kinetic analysis, an average of 2.4-2.7% of implanted dose was absorbed each day from the administration of the beads. Opiate effects of morphine challenges were mitigated during the 2-4-week period after administration of naltrexone beads.

Mood alteration following oral and intravenous haloperidol and relationship to drug concentration in normal subjects.

Haloperidol was administered to 12 subjects intravenously (0.125 mg/kg) and to nine subjects orally (0.5 mg/kg). These doses produced sedation in most subjects. A minimal decrease in orthostatic blood pressure was observed. Administration of the Profile of Mood States to these subjects revealed effects on factor 4, vigor-activity, and factor 6, confusion-bewilderment, but many subjects could not complete testing due to excessive sedation. Haloperidol concentrations were obtained during testing and correlated moderately with scores of these subscales. Correlation was also noted between haloperidol concentration and chlorpromazine effect as measured by the Addiction Research Center Inventory. Extrapyramidal reactions, mainly acute dystonic reactions and akathisia, were common. Dystonia occurred in four subjects after intravenous, and three subjects, after oral administration. Akathisia occurred in eight subjects after intravenous, and three subjects after oral administration. Extrapyramidal reactions tended to occur relatively early or relatively late, at times when drug concentrations were far less than peak values.

Yohimbine and the model anxiety state.

Ten subjects were treated with 30 and 60 mg oral doses of yohimbine hydrochloride or placebo under controlled clinical conditions to determine if such doses would create a "model anxiety state." Some evidence of anxiety was found on various rating scales, especially after the 60 mg dose. However, maximum anxiety produced by this dose of the drug exceeded that which occurred during placebo testing in only 5 of the 10 subjects. The 60 mg dose produced substantial increases in systolic blood pressure and less increase in diastolic blood pressure and pulse rate. It was concluded that yohimbine does not produce a very good model of anxiety.