Correlation of haemophagocytosis with clinical criteria of haemophagocytic lymphohistiocytosis and recommendations for bone marrow reporting.

Haemophagocytic lymphohistiocytosis (HLH) is a rare condition resulting from a dysregulated inflammatory response. Currently there are no guidelines on the reporting of haemophagocytosis on bone marrow biopsy (BM) and lack of evidence on correlation between haemophagocytosis with the clinical diagnostic criteria for HLH. We aimed to assess if the amount of haemophagocytosis identified in the BM correlates with HLH-2004 criteria. Secondary aims were to evaluate inter-observer variability in reporting haemophagocytosis, and to formulate recommendations for screening in bone marrow specimens. A retrospective review of bone marrow biopsies from adult patients under investigation for HLH was undertaken independently by two haematopathologists who were blinded to the original biopsy report. The average number of actively haemophagocytic cells in each slide were quantified. Cases with discordance pertaining to the degree of haemophagocytosis were reviewed by both assessors to reach a consensus. Sixty-two specimens from 59 patients were available for assessment. An underlying haematological condition was identified in 34 cases (58%). There was a significant association between the amount of haemophagocytosis identified on the aspirate samples and the number of HLH-2004 criteria met (p<0.0001). In patients where haemophagocytosis was present (n=31), there was a correlation between the amount of haemophagocytosis and ferritin (p=0.041). Based on our review, we have made recommendations for the reporting of BM haemophagocytosis. Our findings indicate that the amount of haemophagocytosis present on BM samples correlates with the number of HLH-2004 criteria. We found marked interobserver variability which we anticipate can be rectified with our recommendations for reporting.

Efflux pump gene expression study using RNA-seq in multidrug-resistant TB.

BACKGROUND: The mechanism underlying kanamycin (KM) resistance in Mycobacterium tuberculosis is not well understood, although efflux pump proteins are thought to play a role. This study used RNA-seq data to investigate changes in the expression levels of efflux pump genes following exposure to KM.METHODS: RNA expression of efflux pump and regulatory genes following exposure to different concentrations of KM (minimum inhibitory concentration MIC 25 and MIC50) in rrs wild-type strain and rrs A1401G mutated strain were compared with the control group.RESULTS: The selected strains had differential RNA expression patterns. Among the 71 putative efflux pump and regulatory genes, 46 had significant fold changes, and 12 genes (Rv0842, Rv1146, Rv1258c, Rv1473, Rv1686c, Rv1687c, Rv1877, Rv2038c, Rv3065, Rv3197a, Rv3728 and Rv3789) that were overexpressed following exposure to KM were thought to contribute to drug resistance. Rv3197A (whiB7) showed a distinct fold change based on the concentration of KM.CONCLUSION: The significant changes in the expression of the efflux pump and regulatory genes following exposure to KM may provide insights into the identification of a new resistance mechanism.

Immunologic assessment and KMT2D mutation detection in Kabuki syndrome.

Kabuki or Niikawa-Kuroki syndrome (KS) is a rare disorder with multiple malformations and recurrent infections, especially otitis media. This study aimed to investigate the genetic defects in Kabuki syndrome and determine if immune status is related to recurrent otitis media. Fourteen patients from 12 unrelated families were enrolled in the 9-year study period (2005-2013). All had Kabuki faces, cleft palate, developmental delay, mental retardation, and the short fifth finger. Recurrent otitis media (12/14) and hearing impairment (8/14) were also more common features. Immunologic analysis revealed lower memory CD19+ cells (11/13), lower memory CD4+ cells (8/13), undetectable anti-HBs antibodies (7/13), and antibody deficiency (7/13), including lower IgA (4), IgG (2), and IgG2 (1). Naïve emigrant lymphocytes, lymphocyte proliferation function, complement activity, and superoxide production in polymorphonuclear cells were all normal. All the patients had KMT2D mutations and 10 novel mutations of R1252X, R1757X,Y1998C, P2550R fs2604X, Q4013X, G5379X, E5425K, R5432X, R5432W, and R5500W. Resembling the phenotype of common variable immunodeficiency, KS patients with antibody deficiency, decreased memory cells, and poor vaccine response increased susceptibility to recurrent otitis media. Large-scale prospective studies are warranted to determine if regular immunoglobulin supplementation decreases the frequency of otitis media and severity of hearing impairment.

Smoking cession decreases mean platelet volume in healthy Korean populations.

BACKGROUND: Smoking is considered as a major modifiable risk factor for cardiovascular diseases. It has been shown that smoking cessation drops the risk of cardiovascular diseases such as myocardial infarction and also improves platelet function. Because mean platelet volume (MPV) is a simple and convenient indicator for platelet activation, we planned to investigate the effect of smoking status on MPV in healthy populations. METHODS: This study was conducted on 398 individuals who visited our hospital for regular medical check-ups and were confirmed not to have diabetes or hypertension. MPV was measured using EDTA blood on an Advia 2120 (Siemens Healthcare Diagnostics Inc., Tarrytown, NY, USA) within 2 hours. RESULTS: Present smokers showed higher MPV levels than present non-smokers. When MPV was compared by taking previous smoking history and present smoking status into account, the smoking cessation group showed significantly lower MPV levels than other groups. CONCLUSIONS: Because this finding was significant only in the female group, the change in MPV according to smoking status was found to be different by gender. We carefully suggest that smoking cessation can lower the risk of cardiovascular diseases through the change in MPV, which can be more effective for women than men.

The outcome of patients with renal involvement in pediatric-onset systemic lupus erythematosus--a 20-year experience in Asia.

Systemic lupus erythematosus (SLE) predominantly affects women of childbearing age, but 15-20% of cases are diagnosed during childhood. It is important for physicians to understand the epidemiology and clinical presentation for early detection and diagnosis of this disease in difference races. The aim of this retrospective review was to provide a 20-year experience for initial clinical and laboratory manifestations and outcomes in pediatric-onset SLE (pSLE) in a medical center in Asia. We reviewed medical records between April 1990 and June 2012 of patients with a diagnosis of International Classification of Diseases, Ninth Revision (ICD-9) code 710.0 (SLE), who admitted or received follow-up in the Department of Pediatrics at Chang Chung Memorial Hospital. Patients with a diagnosis of SLE prior to their 18th birthday and followed up at our hospital were eligible for inclusion in this study. Medical records regarding age, gender, date of birth and diagnosis, clinical manifestations at diagnosis, laboratory results, image studies and the classification criteria were reviewed. Patients received regular outpatient department follow-up and laboratory survey every 1-6 months. The study cohort consisted of 189 patients; 164 females (86.87%) and 25 males (13.23%). The overall mean age at pSLE diagnosis was 12.62 ± 2.77 years. The most common clinical symptom was malar rash, followed by arthritis and oral ulcers. There was no significant difference in clinical and laboratory manifestations between females and males. More than half of the patients presented with renal involvement initially. The most common histological finding was Class IV lupus nephritis (LN), especially in males (p = 0.034) and young age. Even with severe LN, the rate of end-stage renal disease (ESRD) was low if adequate treatment was initiated. The 5, 10 and 15-year ESRD-free survival rates were 95.4%, 94.0% and 89.9% in patients with biopsy-proven LN. However, infection was the leading cause of mortality. Therefore, aggressive treatment for major organ involvement is important, but physicians must also be aware of fatal infection. The overall survival rates were 5 years: 93.4% and 10-20 years: 89.6%.

Impaired phagocytosis and susceptibility to infection in pediatric-onset systemic lupus erythematosus.

OBJECTIVES: Impaired function of polymorphonuclear cells (PMNs) in systemic lupus erythematosus (SLE) leads to severe gram-positive and gram-negative bacterial infection, and to major morbidity and mortality. Few studies have focused on the association of impaired function of PMNs and SLE patients' susceptibility to infection. This study aimed to analyze function of PMNs in peroxidase production, chemotaxis, and phagocytosis in pediatric-onset SLE with severe infection. METHODS: This study compared function of PMNs among pediatric-onset SLE patients with and without histories of severe infection and in normal control subjects. Human peripheral blood PMNs were isolated from patients and controls. Function of PMNs was measured by analyzing peroxidase, chemotaxis, and phagocytic activities. Different disease activity and severity, and drug use in newly diagnosed SLE patients were also compared. RESULTS: In total, 34 SLE patients (12 patients with severe infection, 22 patients without infection) and 25 healthy controls were analyzed. There were no differences in function of PMNs between SLE patients with or without severe infection. Regardless of infection status, medication, and disease activity, SLE patients had impaired phagocytic ability against Salmonella-specific lipopolysaccharides (LPS) compared with normal controls (p < 0.01). The use of immunosuppressants did not influence phagocytic ability against Salmonella-derived LPS. CONCLUSIONS: Immunosuppressant agents do not influence phagocytic ability against Salmonella in SLE subjects. Impaired phagocytosis against Salmonella is prominent in pediatric-onset SLE subjects, which may result in the high prevalence of Salmonella infection. There is no deficiency of peroxidase production and chemotaxis activity among SLE subjects.

Reference values of exhaled nitric oxide in healthy Asian children aged 5 to 18 years.

This study was undertaken to establish reference values of exhaled nitric oxide fraction (F(eNO)) and its determinants in healthy Asian children. 693 healthy Asian children aged 5-18 yrs were assessed using a single-breath online F(eNO) measurement (exhaled flow 50 mL·s(-1)), questionnaires, anthropometric measurements, spirometry and total and specific immunoglobulin (Ig) E. Geometric mean F(eNO) and the upper 95% CI were 13.7 ppb and 49.7 ppb, respectively, for healthy children, and 11.2 ppb and 30.2 ppb, respectively, for those without allergic sensitisation. F(eNO) was positively associated with age, allergic sensitisation, total IgE, ambient nitric oxide, measurement in the afternoon, and drinking water within 1 h before testing, and was negatively associated with weight. In healthy children without allergic sensitisation, age was the single best explanatory variable. The F(eNO) predicted values were 1-2 ppb higher in Asian than in Caucasian children in earlier studies, while the upper 95% CI were 9-10 ppb higher. In conclusion, the upper limits of normal F(eNO) in Asian children depend on age, from 21 ppb in young children to 39 ppb in adolescents. Ethnicity, age, allergic sensitisation, total IgE, ambient nitric oxide, time of testing, drinking water and weight are important determinants.

Exhaled nitric oxide discriminates children with and without allergic sensitization in a population-based study.

BACKGROUND: Fraction of exhaled nitric oxide (FeNO) as a biomarker of airway inflammation in children warrants better clarification. OBJECTIVE: To identify the determinants of FeNO in children and assess the validity of FeNO as a discriminative tool for asthma, rhinitis or allergic sensitization in a population setting. METHODS: Children aged 5-18 years (N=1717) were evaluated using online FeNO measurements, questionnaires, anthropometric measurements, pulmonary function tests and total and specific serum IgE. RESULTS: FeNO levels were age-dependent, with an average increase of 7.4% per year of age. It decreased with increasing body mass index (BMI), estimated at 1.5% decrease per kg/m(2) . Children with allergic sensitization had elevated FeNO independent of allergic symptoms. In the combined analyses of asthma, rhinitis and allergic sensitization, elevated FeNO levels were confined mainly to children having allergic sensitization. After adjusting for allergic sensitization, a significant association between rhinitis and FeNO remained, but no such association was seen with asthma. The sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) of FeNO at the optimum cut-off of 28 p.p.b. for diagnosing asthma were 64.3%, 69.9%, 8.8%, and 97.7%, respectively (area under the ROC curve [AUC] 0.67), and were slightly better for diagnosing allergic asthma: 70.0%, 70.4%, 9.0%, 98.3%, respectively (AUC 0.71). FeNO had modest accuracy in discriminating rhinitis with an AUC value of 0.70, and performed better in discriminating allergic rhinitis (AUC 0.78). FeNO was a robust discriminator of allergic sensitization independent of symptoms at a cut-off of 15.4 p.p.b. (AUC 0.80; sensitivity 72.2%; specificity 71.2%; PPV 76.9%; NPV 65.8%). CONCLUSION AND CLINICAL RELEVANCE: FeNO measurement discriminates children with and without allergic sensitization independent of allergic symptoms. On the other hand, low FeNO levels in children may help exclude allergic asthma but high levels may be caused by allergic sensitization, older age, rhinitis, and lower BMI, in addition to asthma.

Safe and effective gene transfer by adeno-associated virus of neonatal thymus-derived mesenchymal stromal cells.

Recently, human neonatal thymus-derived mesenchymal stromal cells (nTMSCs) have been recognized as a promising mesenchymal stem cell source for combined cell and gene therapy. While efficient gene transfer is crucial for optimizing therapeutic efficacy, almost no studies have yet reported on the characteristics of nTMSC in terms of genetic modification. The present study investigates and realizes the potential of self-complementary adeno-associated viruses (scAAVs) as an effective transduction tool for nTMSCs. Transduction efficiency (TE), cytotoxicity and functional characteristics were determined in nTMSCs isolated from thymic tissues and transduced with scAAV1-6 and -8 serotypes expressing GFP. Our study confirms MSC-typical characteristics in nTMSCs and additionally, suggests further therapeutic advantages of nTMSCs due to its particularities with lower levels of MHC class I protein and higher levels of CD31 and CD34 expression. Effective transduction by scAAV2 and scAAV5 was evident in the majority of nTMSCs that were GFP-positive at a multiplicity of infection (MOI) of 1000. TE was further improved by higher MOI treatments. Transduced cells also successfully maintained adipocyte and vessel-forming endothelial cell multi-potency and showed no evidence of gene delivery-related cytotoxicity. Collectively, the data strongly suggest that scAAVs are promising technical platforms for safe and effective transgene expression in nTMSCs.

Pediatric lupus in Asia.

Of all patients with systemic lupus erythematosus (SLE), 15-20% are diagnosed during childhood, with disease onset prior to the age of 16 years. Because disease expression in SLE is influenced by environment factors and differs between racial and ethnic groups. The aims of this review were to describe prevalence, clinical manifestations, common infectious complications, and outcome of pediatric-onset SLE in Asia. The prevalence of pediatric-onset SLE was 6.3-19.3 per 100,000 in Asia. The ratio of female to male was 4.7-6.2. The mean age at diagnosis of pediatric-onset SLE was 8.6-13.5 years. The most common clinical features of pediatric-onset SLE in Asia were cutaneous rashes, arthritis, hematological involvement and nephritis. The occurrence of nephritis varies from 29% to 81%. The most common histopathology of lupus nephritis was diffuse proliferative glomerulonephritis (WHO Class-IV) which occurred in 39.4-54% of case of lupus nephritis. Pediatric-onset SLE patients with infections have poor outcomes than uninfected patients. Gram-negative bacilli are the most common microorganisms responsible for bacteremia in Asian patients with SLE. Recurrent major infections predict poorer disease outcome and associated organ damage in pediatric-onset SLE. Improving the survival of SLE patients was reported in Asia in recent decades. The survival was 92% at the age of 5 years, 86% at 10 years and 79% at 15 years in children with SLE in Taiwan in 2008.

Carbon nanotube reservoirs for self-healing materials.

A novel nanoreservoir made of carbon nanotubes (CNTs) is proposed for realizing tougher and automated self-healing materials. The advantages of the approach are that CNTs have the potential to play the role of reinforcing elements prior to and after sealing a crack and that the number of voids is reduced after the material and the CNTs themselves are healed. The focus of this paper is on investigating the feasibility of using CNTs as a nanoreservoir by analyzing the dynamics of a fluid flowing out of a ruptured single-walled CNT (SWNT), where the fluid resembles an organic healing agent. With this in mind the escaping mechanism of organic molecules stored inside a cracked SWNT was investigated through a molecular dynamics study. The study shows that, when a SWNT wall suffers the formation of a crack, a certain amount of organic molecules, stored inside the SWNT, escape into space in a few picoseconds. This phenomenon is found to depend on the temperature and on the size of the cracks. The results of this study indicate that CNTs have the potential to be successfully used to realize the next generation of stronger, lighter and self-healing materials.

Quantitative measurement of BCR/abl transcripts using real-time polymerase chain reaction.

BACKGROUND: Quantitative real-time polymerase chain reaction (Q-Rt-PCR) is a new tool in the detection and quantification of the BCR/abl fusion transcripts in chronic myelogenous leukemia (CML). This study investigates its specificity, sensitivity and potential clinical usefulness. PATIENTS AND METHODS: Parallel analysis of Q-Rt-PCR and the conventional reverse transcription-mediated PCR (RT-PCR) were performed on 567 samples from 481 patients. Treatment response was monitored by Q-Rt-PCR at 6 and 12 months of 61 patients on STI-571 and 103 patients on interferon. RESULTS: The concordance rate between Q-Rt-PCR and RT-PCR was 96.3% (546/567), with 341 positives and 205 negatives. The positive equivalents ranged from 2 x 10(-6) to 1.2 microg of K562 cell RNA. Karyotyping in 372 samples revealed excellent correlation with Q-Rt-PCR measurements (P < 0.001). Setting residual BCR/abl < 0.01 as an early goal of molecular response, we observed that STI-571 induced a better response than interferon: 49% (20 of 41 patients) versus 35% (15 of 62 patients) at 6 months (P = 0.025) and 52% (32 of 61 patients) versus 34% (35 of 103 patients) at 12 months (P = 0.01), respectively. CONCLUSIONS: Q-Rt-PCR provides reliable measurements of BCR/abl fusion transcripts. It is potentially useful in assessing molecular residual disease after therapy.

Differential interactions of nitric oxide donors with rat oxyhemoglobin.

To estimate the reaction of two primary redox-related species of nitric oxide (i.e. NO+ vs NO*) from a variety of NO donors, we employed the differential interactions of these NO forms with oxyhemoglobin (oxyHb) as a chemical assay. NO+ formation was estimated by the S-nitrosation reaction with oxyHb, and NO* formation via its reaction with the oxygen-heme complex of oxyHb. Under the conditions employed, all NO donors caused concentration-dependent formation of methemoglobin, indicative of NO* liberation. However, the extent of S-nitrosation was substantially different among the NO donors studied. A representative S-nitrosothiol, S-nitroso-N-acetyl-penicillamine, caused significantly more S-nitrosation than nitroglycerin, isobutyl nitrite, sodium nitroprusside, and 3-morpholino-sydnonimine (ANOVA, P < 0.05). These results indicated that NO donors can differ in their interactions with oxyHb, and possibly with other target proteins, in part because they liberate or transfer different ratios of NO redox forms. This difference may contribute, in part, to the diversity of pharmacological effects elicited by NO donors.

PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitis).

This paper aims to remind paediatric clinicians to suspect and confirm 'PFAPA' syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis and cervical Adenitis syndrome). We report two cases of PFAPA syndrome: a 3-year-old healthy boy with atopic rhinitis and a boy aged 8 years 5 months who simultaneously had lymphocytic vasculitis syndrome treated with immunosuppressive drugs. Both met Marshall's criteria. The literature regarding PFAPA syndrome was complied using a Medline search for articles published between 1963 and 1998 and we then reviewed the reference lists of the articles. The Medline search revealed 28 cases with available clinical manifestations, management and prognosis. Our study describes two additional cases. We divided the cases into typical (28 cases) and atypical (two cases) PFAPA syndrome. In typical PFAPA, the age of onset was less than 5 years in most cases and the patients presented 4.9 +/- 1.4 days of fever (100%), pharyngitis (89.3%), cervical adenitis (72.1%), stomatitis (71.4%), malaise (64.3%), headache (60.7%), abdominal pain (53.6%) and nausea/vomiting (17.9%). Afebrile intervals were 3.2 +/- 2.4 months and increased with age. The time from initial onset to final episode was 3 years 7 months +/- 3 years 6 months. The total number of episodes was 8.3 +/- 2.5 (range 6-14). Effective treatment included steroids, tonsillectomy/adenoidectomy and cimetidine. The general outcome was good. In atypical PFAPF, the clinical manifestations were similar to those of typical PFAPA except that the age of onset was more than 5 years, and life-threatening intestinal perforation happened once in a patient with underlying Fanconi's anaemia. It was concluded that typical PFAPA syndrome is benign and can be diagnosed by detailed history-taking and from physical findings during repeated febrile episodes with tests to rule out other periodic fever syndromes. A review of the literatures since the first report in 1987 has shown that typical PFAPA syndrome is not associated with significant long-term sequelae and has a good response to steroids. One patient with atypical PFAPA, who received low-dose steroids for over 1 year, developed intestinal perforation after an increment of the 7-day steroid dose. If an underlying problem requires long-term immunosuppressive medication, it is wiser to choose cimetidine rather than increasing the steroid dosage to resolve atypical PFAPA.

Intraarticular triamcinolone hexacetonide injection in children with chronic arthritis: a survey of clinical practice.

To assess the efficacy of the intraarticular steroid(IAS) injection in the management of arthritis and the possible related complications in children with chronic arthritis. We evaluated 11 children of chronic arthritis (4 girls and 7 boys), age of onset ranged from 2-13.6 years, who had persistent arthritis treated with IAS from November 1994 to June 1997. The results of injections showed that the beneficial effect was noted within one day to 2 weeks without significant adverse reactions, remission exceeding 6 months was seen in 10 of 11 patients (in 14 of 18 joints). According to subgroups of chronic arthritis, the remission rate of IAS injection in children with pauciarticular arthritis reached 100%. A significant fall in C-reactive protein (CRP) between pre- and post-IAS injection (p = 0.03), but there were no differences in hemoglobin (Hb), white blood cells (WBCs), thrombocytes (Plts), erythrocyte sedimentation rate (ESR) and osteocalcin level. No injection-related complications were found. In conclusion, the IAS injection was an effective and safe treatment in children with chronic arthritis with no obvious complications especially in pauciarticular arthritis.

Pharmacokinetic and pharmacodynamic changes of furosemide after intravenous and oral administration to rats with alloxan-induced diabetes mellitus.

Because some physiological changes occurring in diabetes mellitus patients could alter the pharmacokinetics and pharmacodynamics of the drugs to treat the disease, the pharmacokinetics and pharmacodynamics of furosemide were investigated after intravenous (i.v.) and oral administration of the drug (6 mg per whole body weight) to control rats and alloxan-induced diabetes mellitus rats (AIDRs). After i.v. administration, the total body clearance (5.47 versus 7.05 mL min(-1) kg(-1)) was significantly slower in AIDRs and this was due to significantly slower renal clearance (2.35 versus 4.33 mL min(-1) kg(-1)) because the nonrenal clearance was comparable between two groups of rats. The 8 h urinary excretion of furosemide after i.v. administration decreased significantly (2280 versus 3760 microg) in AIDRs due to impaired kidney function; the glomerular filtration rate measured by creatinine clearance was significantly slower (2.86 versus 4.33 mL min(-1) kg(-1)) and both the plasma urea nitrogen (43.5 versus 17.3 mg dL(-1)) and kidney weight (0.953 versus 0.749% of body weight) increased significantly in AIDRs. This resulted in a significant decrease in the 8 h urine output per g kidney (17.8 versus 43.6 mL) in AIDRs. However, the 8 h diuretic efficiency was not significantly different between two groups of rats. After oral administration, the area under the plasma concentration-time curve from time 0 to 8 h decreased significantly in AIDRs (1200 versus 1910 microg x min mL(-1)) due to considerably decreased absorption of furosemide from gastrointestinal tract of AIDRs. After oral administration, the 8 h urine output per g kidney (18.6 versus 36.4 mL) also decreased significantly in the AIDRs due to significantly decreased 8 h urinary excretion of furosemide (405 versus 2210 microg), however, the 8 h diuretic efficiency increased significantly (127 versus 35.2 mL mg(-1)) in AIDRs.

Pharmacokinetics and pharmacodynamics of furosemide after direct administration into the stomach or duodenum.

The pharmacokinetics and pharmacodynamics of furosemide were compared after an oral administration or a direct administration of Lasix into the duodenum in humans (40 mg). Furosemide was absorbed quickly after a direct administration of Lasix into the duodenum; the peak plasma concentration of furosemide was reached within 1 h in both routes of administration, and the peak concentration was higher in all four subjects after a direct administration into the duodenum than after an oral administration. Furosemide was absorbed considerably after a direct administration of Lasix into the duodenum; the values of the area under the plasma concentration-time curves of furosemide from time zero to 4 h (AUC0-4 h, 93.6 versus 122 micrograms min mL-1, p < 0.123) and the cumulative amounts of the dose excreted in 8 h (10,600 versus 15,000 micrograms, p < 0.0185) and 24 h (11,300 versus 15,400 micrograms, p < 0.0192) urine as unchanged furosemide were significantly higher after a direct administration into the duodenum than after an oral administration. However, the amounts excreted in urine as glucuronide conjugates, a metabolite of furosemide, tended to increase after an oral administration (4030 versus 1670 micrograms as expressed in terms of furosemide, p < 0.0858) when compared to a direct administration into the duodenum, possibly due to the increased gastric first-pass metabolism of furosemide. The 8 h urine output and 8 h urinary excretion of sodium did not increase significantly after a direct administration of Lasix into the duodenum, despite the significantly greater amount of the drug delivered to the active site after a direct administration into the duodenum. This could be explained by the fact that the urinary excretion rates of furosemide after a direct administration into the stomach were closer to the values of maximally efficient urinary excretion rate of furosemide during the 8 h experimental period than after a direct administration into the duodenum.