Comparing dose prediction software used to manage gentamicin dosing.

BACKGROUND: Current Australian guidelines recommend initiating directed therapy of gentamicin if administration exceeds 48 h. Directed doses of gentamicin require the monitoring of plasma concentrations of gentamicin to determine the 24-h area under the time course of plasma gentamicin concentrations (AUC) and a dosage prediction program, for example TCIWorks or Aladdin. However, doses calculated by such programs have not been compared with an established program. AIM: To compare the directed dosage of gentamicin calculated by TCIWorks, Aladdin and an Excel-based program, with an established program, Abbottbase. METHODS: Peak and trough plasma concentrations after the first and second administered doses of gentamicin were available from three patient groups (n = 20-23) with varying creatinine clearances (<40, 40-80, >80 mL/min). The directed dose needed to produce 24-h AUC values of 80 mg.h/L was calculated using each program. RESULTS: There was a strong correlation between the directed doses predicted by each of the three programs compared with Abbottbase, following the first administered dose (r(2) > 0.97, P < 0.0001). The mean ratio (90% confidence intervals) of these directed doses of the gentamicin were: TCIWorks/Abbottbase 106% (105-107%), Aladdin/Abbottbase 102% (101-103%) and Excel/Abbottbase 108% (106-109%). The correlations and dose ratios were also similar when comparisons were made following the second administered dose. For each of the three renal function groups, all programs yielded similar directed doses. CONCLUSIONS: The four programs used in the calculation of directed doses of gentamicin yielded similar results. Any would be suitable for use in clinical practice.

Mtd/Bok takes a swing: proapoptotic Mtd/Bok regulates trophoblast cell proliferation during human placental development and in preeclampsia.

We have previously reported that matador/Bcl-2 ovarian killer (Mtd/Bok), a proapoptotic member of the Bcl-2 family, regulates human trophoblast apoptosis and that its levels are elevated in severe preeclamptic pregnancy. Herein, we show that Mtd is also involved in the regulation of proliferation in normal and pathological placentae. Mtd was found in proliferating trophoblast cells during early placental development and in preeclampsia (PE). The main isoform of Mtd associated with trophoblast proliferation was Mtd-L, the full-length isoform, which preferentially localized to the nuclear compartment in proliferating cells, whereas during apoptosis it switched localization to the cytoplasm where it associated with mitochondria. Mtd expression in proliferating cells colocalized with cyclin E1, a G(1)/S phase cell cycle regulator. MtdL-specific knockdown in the early first trimester villous explants and in HEK293 revealed a direct effect of Mtd-L on cyclin E1 expression and cell cycle progression. We conclude that Mtd-L functions to regulate trophoblast cell proliferation during early placentation and that the elevated levels of Mtd found in PE may contribute to increased trophoblast proliferation accompanying this devastating disorder of pregnancy.

Structures of three inhibitor complexes provide insight into the reaction mechanism of the human methylenetetrahydrofolate dehydrogenase/cyclohydrolase.

Enzymes involved in tetrahydrofolate metabolism are of particular pharmaceutical interest, as their function is crucial for amino acid and DNA biosynthesis. The crystal structure of the human cytosolic methylenetetrahydrofolate dehydrogenase/cyclohydrolase (DC301) domain of a trifunctional enzyme has been determined previously with a bound NADP cofactor. While the substrate binding site was identified to be localized in a deep and rather hydrophobic cleft at the interface between two protein domains, the unambiguous assignment of catalytic residues was not possible. We succeeded in determining the crystal structures of three ternary DC301/NADP/inhibitor complexes. Investigation of these structures followed by site-directed mutagenesis studies allowed identification of the amino acids involved in catalysis by both enzyme activities. The inhibitors bind close to Lys56 and Tyr52, residues of a strictly conserved motif for active sites in dehydrogenases. While Lys56 is in a good position for chemical interaction with the substrate analogue, Tyr52 was found stacking against the inhibitors' aromatic rings and hence seems to be more important for proper positioning of the ligand than for catalysis. Also, Ser49 and/or Cys147 were found to possibly act as an activator for water in the cyclohydrolase step. These and the other residues (Gln100 and Asp125), with which contacts are made, are strictly conserved in THF dehydrogenases. On the basis of structural and mutagenesis data, we propose a reaction mechanism for both activities, the dehydrogenase and the cyclohydrolase.

Novel cryptophycin antitumor agents: synthesis and cytotoxicity of fragment "B" analogues.

A general synthetic approach to novel cryptophycin analogues 6 is described. N-Hydroxysuccinimide active ester 15, a key common intermediate, was converted to beta-epoxide 6 in three steps, via initial coupling with unprotected amino acid 9, followed by deprotection/macrolactamization of acyclic precursor 16, and final oxidation of styrene 7 to install the C7-C8 beta-epoxide. Cryptophycin styrenes 7 and beta-epoxides 6, bearing diverse side chains in fragment "B", were evaluated for cytotoxic activity. beta-Epoxides 6, in general, were significantly more potent than the corresponding alpha-epoxides 17 and styrenes 7. A benzyl side chain was required for potent activity, with beta-epoxide 6u, possessing a 3-Cl,4-(dimethylamino)benzyl moiety, as the most potent cytotoxic agent prepared, with an IC(50) = 54 pM, only 2-fold less than that of Cryptophycin-52 (3).

Disposition and metabolism of the sulfonylurea oncolytic agent LY295501 in mouse, rat, and monkey.

The disposition and metabolism of LY295501 was studied in mice, rats, and monkeys. This novel diaryl sulfonylurea oncolytic agent is structurally related to sulofenur and shows excellent activity in a broad range of mouse antitumor models. The compound is well absorbed, giving plasma concentrations greater than 200 micrograms/ml after oral doses of 30-100 mg/kg, where it appears to be completely bound (> 99.9%) to plasma proteins. The high degree of protein binding may be a factor in its relatively long half-life, which ranges from about 8 hr in rats and 15 hr in mice to 50 hr in monkeys. While more material was excreted in feces than in urine from mice and rats given single oral doses of [14C]LY295501, urine was the major route of elimination in monkeys. Three major metabolites-all formed via oxidation of the saturated part of the benzodihydrofuran moiety-were characterized in the urine of mice, rats, and monkeys. It is interesting that two of these metabolites are derived from opening of this saturated ring, an unusual metabolic process which represents a significant part of the metabolism of LY295501. As with sulofenur, metabolites of 3,4-dichloroaniline formed after metabolic cleavage of the sulfonylurea linkage were also found in urine. Unlike sulofenur, these do not seem to have major toxicological significance, but their formation does explain the minor methemoglobinemia observed in toxicology studies of LY295501. Even though only trace amounts of LY295501 were found in urine, LY295501 is the predominant drug-related material in plasma, along with small amounts of other, relatively nonpolar, metabolites.

Sulfonimidamide analogs of oncolytic sulfonylureas.

A series of sulfonimidamide analogs of the oncolytic diarylsulfonylureas was synthesized and evaluated for (1) in vitro cytotoxicity against CEM cells, (2) in vivo antitumor activity against subaxillary implanted 6C3HED lymphosarcoma, and (3) metabolic breakdown to the o-sulfate of p-chloroaniline. The separated enantiomers of one sulfonimidamide analog displayed very different activities in the in vivo screening model. In general, several analogs demonstrated excellent growth inhibitory activity in the 6C3HED model when dosed orally or intraperitoneally. A correlative structure-activity relationship to the oncolytic sulfonylureas was not apparent.

Studies on the mechanism of phosphatidylinositol 3-kinase inhibition by wortmannin and related analogs.

Wortmannin, a fungal metabolite, was identified as a potent inhibitor (IC50 = 4.2 nM) of phosphatidylinositol 3-kinase (PI 3-kinase). Due to the importance of PI 3-kinase in several intracellular signaling pathways, structure-activities studies on wortmannin analogs were performed in an effort to understand the structural requirements necessary for PI 3-kinase inhibition. Since wortmannin is an irreversible inhibitor of PI 3-kinase, it was postulated that covalent attachment at the electrophilic C-21 site was a possible mode of action for PI 3-kinase inhibition. We have prepared various wortmannin analogs which address the possibility of this mechanism. Of particular interest are compounds which affect the C-21 position of wortaminnin either sterically or electronically. Our results support the conclusion that nucleophilic addition by the kinase onto the C-21 position of wortmannin is required for inhibition of PI 3-kinase by wortmannin analogs. Additionally, we have prepared several D-ring analogs of wortmannin, and their activities are reported herein. We conclude that the wortmannin D ring is an important recognition site since modifications have such a dramatic effect on inhibitor potency. Finally, the identification of 17beta-hydroxywortmannin represents the first reported subnanomolar inhibitor of PI 3-kinase. These studies, along with in vivo antitumor experiments, suggest that the mechanism of PI 3-kinase inhibition correlates to the associated toxicity observed with wortmannin-based inhibitors of PI 3-kinase.

Cyclosporin A monitoring in Australia: consensus recommendations.

Cyclosporin-A (CsA) therapeutic drug monitoring plays an integral role in therapeutic management of immunosuppressed patients, including those with organ transplants. This communication, prepared by an Australian team, presents recommendations for the routine monitoring of CsA, including blood sampling methodological approaches and interpretation of results generated. The consensus approach described is intended to address the diversity of attitudes to CsA monitoring demonstrated in a recent national survey of Australian laboratories that provide CsA analyses.

Mucinous carcinoma--just another colon cancer?

The significance of mucinous carcinoma has been controversial since first described by Parham in 1923. Previous reports have suggested that mucinous tumors affect young patients, involve the more proximal colon, are more advanced at diagnosis, and have a poorer prognosis than nonmucinous colon carcinoma. More recent reports have refuted these results. In an effort to clarify the significance of mucinous histology, a retrospective review of cases of invasive colon cancer treated at the Ochsner Clinic between 1982 and 1985 was undertaken. Mucinous adenocarcinoma, as defined by > or = 50 percent mucin, was found in 52 patients. During the same period, 343 nonmucinous adenocarcinomas were resected. The mean age, distribution within the colon, stage at diagnosis, and survival of mucinous carcinoma patients were compared with those with nonmucinous tumors. Mucinous tumors presented at a statistically significant more advanced stage (38 percent vs. 22 percent Dukes C lesions; P < 0.01). No significant differences were seen in age at presentation, distribution within the colon, or stage-for-stage survival when the entire group was analyzed. Mucinous carcinomas of the rectum occurred at an advanced stage more frequently (P < 0.05) than nonmucinous rectal carcinomas and had a markedly worse five-year survival (11 percent vs. 57 percent; P < 0.002).

Ogilvie's syndrome: colonoscopic decompression and analysis of predisposing factors.

Forty-eight cases of Ogilvie's syndrome, colonic pseudo-obstruction, presenting between 1983 and 1989 were retrospectively reviewed to assess the results of colonoscopic decompression and to identify potential etiologic factors. Three patients had spontaneous resolution with medical treatment. Forty-five patients required 60 colonoscopic decompressions: 38 (84 percent) were successfully treated using colonoscopy; five (11 percent) required an operation; and two died within 48 hours of colonoscopy from medical causes. No complications or deaths were the result of colonoscopy. Twenty-nine patients (64 percent) were successfully treated with a single colonoscopy. One-third of patients required serial decompressions. Average cecal diameter in patients with successful colonoscopic decompression was 12.4 cm but was larger for patients requiring more than one colonoscopy (13.3 cm) and for those who failed colonoscopic therapy (13.4 cm). The spine or retroperitoneum had been traumatized or manipulated in 52 percent of patients. Patients with Ogilvie's syndrome were being treated with narcotics (56 percent), H-2 blockers (52 percent), phenothiazines (42 percent), calcium-channel blockers (27 percent), steroids (23 percent), tricyclic antidepressants (15 percent), and epidural analgesics (6 percent) at diagnosis. Electrolyte abnormalities included hypocalcemia (63 percent), hyponatremia (38 percent), hypokalemia (29 percent), hypomagnesemia (21 percent), and hypophosphatemia (19 percent). Colonoscopic decompression in Ogilvie's syndrome is safe and effective management. Multiple pharmacologic and metabolic factors, as well as spinal and retroperitoneal trauma, appear to alter autonomic regulation of colonic function, resulting in colonic pseudo-obstruction.

Rectal carcinoids: the most frequent carcinoid tumor.

One hundred seventy patients with gastrointestinal carcinoid tumors were treated at Ochsner Clinic from 1958 to 1990. Ninety-four rectal carcinoid tumors were diagnosed and treated during this time. Carcinoid tumors of the rectum represented the most frequent primary site (55 percent), followed by carcinoids of the ileum (12 percent), appendix (12 percent), colon (6 percent), stomach (6 percent), jejunum (2 percent), pancreas (2 percent), and other (5 percent). One-half of rectal carcinoids were discovered during anorectal examination of asymptomatic patients. The remainder were found primarily by examination of patients for symptoms of benign anorectal conditions. The diagnosis of rectal carcinoid was made at the time of initial examination in 61 patients. This allowed definitive treatment in a single session by local excision and fulguration in 48 patients. The remainder were treated by repeat biopsy and fulguration (25 patients) or by transanal excision (12 patients). Overall, 85 carcinoid tumors of the rectum measuring less than 2 cm were treated by local excision and fulguration or by transanal excision, with an average five-year follow-up. There were no local recurrences. Ten patients with metastasizing rectal carcinoids averaging 4 cm were treated. All were symptomatic at presentation and fared poorly despite radical surgery. Three were alive at three years but only one survived five years. At our institution, rectal carcinoids were the most frequently detected carcinoid tumor. Small carcinoids of the rectum were adequately treated by local excision and fulguration or by transanal excision, with no local recurrence. The true incidence of rectal carcinoids is detected only with careful and complete rectal examination of the asymptomatic screening population by experienced surgeons. With more widespread screening of the well population, rectal carcinoids may become recognized as the most frequent human carcinoid tumor.

Improved high-performance liquid chromatographic method for the determination of indomethacin in plasma.

Indomethacin is an inhibitor of prostaglandin synthesis and has several uses, including the ability to encourage closure of a patent ductus in premature neonates. A rapid, accurate, and sensitive high-performance liquid chromatographic (HPLC) method is described for measuring plasma concentrations of indomethacin. An acidic buffer (citrate, pH 3.0) was employed to alter the pH of the aqueous phase prior to extraction to minimise interference interference from endogenous compounds. Extraction of indomethacin from plasma was optimally achieved with petroleum ether (boiling fraction of 40-60 degrees C):dichloromethane (50:50). However, separation of indomethacin from plasma proteins was attempted unsuccessfully using acetonitrile precipitation; severe band broadening occurred due to injected sample solvent problems. The absolute recoveries for indomethacin and internal standard (mefenamic acid) were over 90% (n = 3). Precision was expressed as the coefficient of variation (n = 4), which was less than or equal to 8% at each of six indomethacin concentrations in the range 50-2,000 ng/ml. The limit of quantitation of indomethacin in plasma was 50 ng/ml (0.5 ml of plasma injected). We report an HPLC method for the quantitation of indomethacin in plasma that may have widespread applicability for routine drug assay laboratories.

Diminutive colonic polyps: an indication for colonoscopy.

A prospective study investigated the significance of solitary diminutive colonic polyps discovered during screening flexible sigmoidoscopy. Eighty-two patients with a solitary diminutive polyp (less than or equal to 5 mm) underwent colonoscopy after cold biopsy of the index polyp. Of the patients with adenomatous index polyps, 42.5 percent had proximal neoplastic polyps. Of the patients with hyperplastic index polyps, proximal neoplastic polyps were found in 38.9 percent. These data suggest that diminutive polyps identified during flexible sigmoidoscopy, whether adenomatous or hyperplastic, place the patient in the intermediate risk group for colorectal neoplasia. We recommend that any patient with polyps seen during screening sigmoidoscopy, regardless of histopathology, should undergo colonoscopy.

Complications associated with ileal pouch-anal anastomosis.

Seventy-three patients underwent total colectomy, rectal mucosectomy, creation of J or S ileal reservoir, and ileal pouch-anal anastomosis from 1982 to 1989. Mean follow-up was 38 months, with a minimum of 3 months in 15 patients being followed long-term at another institution. Forty-eight (66%) patients had histologically proven ulcerative colitis and 25 (34%) patients had familial polyposis. Thirty-eight J reservoirs and 35 S reservoirs were constructed. There were no perioperative deaths. The failure rate (loss of pouch) was 3%. Thirty-six complications in 34 (47%) patients were reported, 14 (19%) patients required surgery. Bowel obstruction was the most common postoperative complication (16%), followed by pouchitis (15%), and cuff infection (5%). Seventy-eight percent of the complications were associated with the J pouch. Average stool frequency at 1 year was 4 per 24-hour period. Other complications included postoperative pneumonia (1), peroneal nerve palsy (1), and temporary sexual dysfunction (1). Seven of 15 complications requiring surgical intervention occurred in the first 2 years of the study period, illustrating the learning curve associated with the procedure. Blood loss, transfusion requirements, and length of operation were not associated with higher complication rates. Use of the J pouch and experience of the individual surgeon affected morbidity.

Calcified mucocele of the appendix presenting as ureteral obstruction.

Mucocele of the appendix, a rare lesion, occurs in 0.3% of patients undergoing appendectomy. Only 46 cases of calcified mucocele have been reported. Complications reported include appendiceal intussusception, rupture resulting in acute abdomen, and infection. We report the case of a 74-year-old man with a calcified mucocele of the appendix that was discovered in the evaluation of a ureteral obstruction. During exploratory surgery, the patient was found to have a 6 x 5 cm appendiceal tumor and underwent a right ileocolectomy. Pathologic examination showed calcified mucous cystadenoma of the appendix. Calcification of a mucocele is believed to denote chronicity. Our case is the first report of ureteral obstruction secondary to calcified mucocele and the second calcified mucocele to be seen on computerized tomography. Calcified mucocele should be included in the differential diagnosis of any calcified tumor in the right lower quadrant.

Digoxin-like immunoreactivity in serum from neonates and infants reduced by centrifugal ultrafiltration and fluorescence polarization immunoassay.

We evaluated the TDx Digoxin II (Abbott) modified procedure for interference from digoxin-like immunoreactive factors (DLIF) in pediatric patients. The effectiveness of centrifugal ultrafiltration as a means of removing DLIF interference from the serum of such patients was assessed. We used sera from 40 patients who had not received digoxin, whom we divided into two age groups: 30 neonates (less than 34 days postpartum) and 10 infants (younger than six months). Digoxin-like immunoreactivity was detected in 34 of 41 (83%) neonatal specimens (range 0.2-1.0 micrograms/L) and 16 of 25 (60%) infants' specimens (range 0.2-1.3 micrograms/L). Centrifugal ultrafiltration of serum specimens from these patients reduced but did not eliminate the DLIF interference in some specimens. A comparison of concentrations of DLIF in serum with various other patients' characteristics demonstrated a strong correlation (r = 0.915; P = 0.0001) between DLIF and serum bilirubin in the infants. Apparent digoxin concentrations from 19 serum and serum ultrafiltrate samples collected from 13 patients (four neonates and nine infants) who were treated with digoxin showed a good correlation (r = 0.97); however, the serum samples showed a positive bias of 0.39 microgram/L. We conclude that the TDx Digoxin II modified procedure is still subject to considerable DLIF interference in these two pediatric populations. This interference can be reduced in some serum specimens, but cannot be eliminated completely as others reported.

Colonoscopic screening of asymptomatic patients with a family history of colon cancer.

The records of 201 asymptomatic patients who underwent colonoscopy based solely on a family history of colon cancer were reviewed. Eighty-five patients (42 percent) had a total of 166 lesions. Fifty-four (27 percent) patients of the screened population had neoplastic lesions, while 31 (15 percent) patients had nonneoplastic polyps. Four carcinomas were found. Twenty-five of the patients with polyps (29 percent) had no polyps distal to the splenic flexure; these proximal polyps (and two carcinomas) would have been missed on screening with fiberoptic sigmoidoscopy. Nineteen of these 25 patients had polyps smaller than 0.5 cm, which likely would have been missed with contrast enemas. Almost one half (47 percent) of all polyps discovered at screening colonoscopy were proximal to the descending colon. Only one patient younger than 40 years old had adenomas. The yield of polyps and cancer in patients with familial risk indicates screening colonoscopy should be considered after age 40.

Usefulness of performing colonoscopy one year after endoscopic polypectomy.

This retrospective study defines a population with neoplastic colonic polyps who have had colonoscopic polypectomy and, in follow-up within one year, a repeat colonoscopic evaluation. The population was broken down into two groups, one group that had polyps at the second examination and one group that did not. This study determined which factor(s) were significant among this population in distinguishing whether new polyps would be found at one year follow-up. The authors found that among the many variables studied, only polyp multiplicity was significant in predicting polyp recurrence. More than one polyp found at index colonoscopy led to a significant chance of having a new polyp after only one year. Also, it was demonstrated that these "new" polyps were unlikely to have been "missed" polyps from the initial colonoscopy. Because of the shifting location, smaller size, and fewer instances of histologic atypia in these polyps compared with those at index examination, the authors believe that polyps found after one year may be assumed to have arisen de novo. Finally, the authors show that a significant number of polyps occur beyond the reach of the flexible sigmoidoscope (approximately 60 cm). The authors recommend that patients who have polyps undergo a colonoscopic examination. When patients are re-evaluated after having colonoscopic neoplastic polypectomy, they should undergo repeat colonoscopy.