Over-the-counter and out-of-control: legal strategies to protect youths from abusing products for weight control.

Abuse of widely available, over-the-counter drugs and supplements such as laxatives and diet pills for weight control by youths is well documented in the epidemiological literature. Many such products are not medically recommended for healthy weight control or are especially susceptible to abuse, and their misuse can result in serious health consequences. We analyzed the government's role in regulating these products to protect public health. We examined federal and state regulatory authority, and referred to international examples to inform our analysis. Several legal interventions are indicated to protect youths, including increased warnings and restrictions on access through behind-the-counter placement or age verification. We suggest future directions for governments internationally to address this pervasive public health problem.

Mild hyperoxia limits hTR levels, telomerase activity, and telomere length maintenance in hTERT-transduced bone marrow endothelial cells.

Reactivation of telomerase in endothelial cells (ECs) may be an effective approach to the treatment of vascular disorders associated with telomere attrition and EC senescence. However, overexpression of human telomerase reverse transcriptase (hTERT) does not prevent net telomere loss in ECs grown in standard culture medium with exposure to atmospheric oxygen (21% O(2)). Since these culture conditions are hyperoxic relative to normal tissue in vivo, where oxygen tension is estimated to be 1%-6%, we examined the effects of reduced exposure to oxidative stress (OS) on telomere length maintenance in hTERT-transduced bone marrow endothelial (BMhTERT) cells. Propagation of BMhTERT cells in the free radical scavenger, tert-butylhydroxylamine (tBN), and/or in 5% O(2) increased telomerase enzyme activity and facilitated telomere length maintenance. The enhancement of telomerase activity correlated with higher levels of the telomerase RNA component (hTR). We also investigated the role of the telomere binding protein, TRF1, in telomere length regulation under alternate OS conditions. Inhibition of TRF1 function had no effect on telomere length in BMhTERT cells grown under standard culture conditions. However, alleviation of OS by growth in tBN plus 5% O(2), elevated hTR levels, enhanced telomerase enzyme activity, and enabled progressive telomere lengthening. The direct impact of hTR levels on telomerase-mediated telomere lengthening was demonstrated by overexpression of hTR. BMhTERT cells transduced with hTR exhibited very high telomerase enzyme activity and underwent dramatic telomere lengthening under standard culture conditions. Overall, these results demonstrate that hTR levels are reduced by mild hyperoxia and limit telomerase-mediated telomere lengthening in hTERT-transduced ECs.

Hypertonic saline treatment of cystic fibrosis.

OBJECTIVE: To review the literature concerning the use of hypertonic saline (HS) in patients with cystic fibrosis and explain the rationale for its use. DATA SOURCES: A MEDLINE search was conducted through February 2007. Search terms included hypertonic saline, mucociliary clearance, cystic fibrosis, and human DNASE 1 protein. Additional data were identified through subsequent bibliographic reviews. STUDY SELECTION AND DATA EXTRACTION: All articles in English identified from the data sources were evaluated. Pertinent studies using HS in patients with cystic fibrosis were included in the analysis. DATA SYNTHESIS: Cystic fibrosis is caused by a deficiency in the cystic fibrosis transmembrane regulator gene, resulting in reduced chloride secretion and excessive sodium absorption. The most significant changes are seen in the airway lumen of the lungs. HS has been shown to improve mucociliary clearance versus placebo. A short-term efficacy trial showed a modest and variable increase in forced expiratory volume in 1 second (FEV(1)) over a 2 week period (15.0 +/- 16.0% from baseline vs 2.8 +/- 13.1% with HS 6% and NaCl 0.9%, respectively; p = 0.004). A long-term efficacy trial of either HS 7% or NaCl 0.9% twice daily for 48 weeks has shown a modest sustained improvement in FEV(1) and a significantly increased exacerbation-free survival rate (76% vs 62% for HS 7% and NaCl 0.9%, respectively; p = 0.03). CONCLUSIONS: HS preceded by a bronchodilator is an inexpensive, safe, effective additional therapy in cystic fibrosis patients with stable lung function. Its use has been associated with a modest improvement in lung function and reduced frequency of pulmonary exacerbations.

Clinical utility of a continuous intravenous infusion of valproic acid in pediatric patients.

STUDY OBJECTIVE: To describe the dose-concentration relationship of a continuous intravenous infusion of valproic acid (VPA) in pediatric patients when a dosing protocol is used. DESIGN: Retrospective and concurrent chart review. SETTING: Tertiary care, 473-bed, academic medical center with a 120-bed, dedicated children's hospital. PATIENTS: Twenty-six pediatric patients (< 18 yrs old) who received VPA according to the protocol for continuous intravenous infusions between January 1, 2004, and March 31, 2006, identified by using a pharmacy order-entry system. MEASUREMENTS AND MAIN RESULTS: Patient demographics, VPA treatment regimens, clinical responses, and safety data were recorded and analyzed. Median patient age was 8.5 years (range 1.4-16 yrs). Approximately two thirds received VPA for seizures, and one third for migraines. Patients were given a mean +/- SD VPA loading dose of 28.5 +/- 5.2 mg/kg followed by a continuous infusion rate of 1 +/- 0.2 mg/kg/hour. Mean +/- SD serum concentration measured 4.5 +/- 1.6 hours after the loading dose was 83.3 +/- 22.8 microg/ml. Steady-state concentration at 23.3 +/- 3.0 hours after the start of the continuous infusion was 80.0 +/- 26.0 microg/ml. Postload and steady-state serum concentrations were within the target concentration of 50-100 microg/ml in 77% and 69% of patients, respectively. On further analysis, when the target range was expanded to 50-125 microg/ml (125 microg/ml was deemed acceptable if no adverse effects were noted), 89% and 92% of patients, respectively, had postload and steady-state VPA serum concentrations within this range. The response rate was excellent, with nearly 85% of patients achieving a complete or partial response to therapy. Adverse effects were generally mild and uncommon. CONCLUSIONS: The continuous-infusion protocol permitted rapid intravenous loading of VPA in pediatric patients while minimizing adverse events and achieving concentrations in the upper region of the therapeutic range.

The paradox of heparin-induced thrombocytopenia: the initial management.

The potential risk for heparin-induced thrombocytopenia should be suspected in postoperative patients who develop thrombocytopenia in the presence of heparin and low-molecular weight heparin agents.

The paradox of heparin-induced thrombocytopenia: future anticoagulation.

Heparin and low molecular weight heparin agents are frequently administered to postoperative orthopedic patients. In patients with a history of heparin-induced thrombocytopenia, alternative anticoagulant agents to heparin for prophylaxis and treatment must be considered. Unfortunately, the data is limited in this patient population. Upon transitioning from heparin-induced thrombocytopenia treatment with direct thrombin inhibitors, argatroban, or lepirudin, careful consideration must be taken to avoid further thrombotic complications.

Inactivation of p16INK4a, with retention of pRB and p53/p21cip1 function, in human MRC5 fibroblasts that overcome a telomere-independent crisis during immortalization.

Recent investigations, including our own, have shown that specific strains of fibroblasts expressing telomerase reverse transcriptase (hTERT) have an extended lifespan, but are not immortal. We previously demonstrated that hTERT-transduced MRC5 fetal lung fibroblasts (MRC5hTERTs) bypassed senescence but eventually succumbed to a second mortality barrier (crisis). In the present study, 67 MRC5hTERT clones were established by limiting dilution of a mass culture. Whereas 39/67 clones had an extended lifespan, all 39 extended lifespan clones underwent crisis. 11 of 39 clones escaped crisis and were immortalized. There was no apparent relationship between the fate of clones at crisis and the level of telomerase activity. Telomeres were hyperextended in the majority of the clones analyzed. There was no difference in telomere length of pre-crisis compared with post-crisis and immortal clones, indicating that hyperextended telomeres were conducive for immortalization and confirming that crisis was independent of telomere length. Immortalization of MRC5hTERT cells was associated with repression of the cyclin-dependent kinase inhibitor p16INK4a and up-regulation of pRB. However, the regulation of pRB phosphorylation and the response of the p53/p21cip1/waf1 pathway were normal in immortal cells subject to genotoxic stress. Overexpression of oncogenic ras failed to de-repress p16INK4a in immortal cells. Furthermore, expression of ras enforced senescent-like growth arrest in p16INK4a-positive, but not p16INK4a-negative MRC5hTERT cells. Immortal cells expressing ras formed small, infrequent colonies in soft agarose, but were non-tumorigenic. Overall, these results implicate the inactivation of p16INK4a as a critical event for overcoming telomere-independent crisis, immortalizing MRC5 fibroblasts and overcoming ras-induced premature senescence.

UV filter instability: consequences for the human lens.

Human lenses appear to become coloured with age primarily due to the covalent binding of UV filter compounds to lens proteins. These crystallin modifications result from the inherent instability of the kynurenine UV filters. Here we investigate this decomposition, the role this may have in the formation of other primate UV filters, and the interaction of the intermediates (alpha,beta-ketoalkenes) with lens components. The UV filters kynurenine, 3-hydroxykynurenine and 3-hydroxykynurenine glucoside were incubated at neutral pH in the presence or absence of NADH or NADPH. The three UV filters underwent spontaneous deamination, such that at pH 7 less than half of the starting materials (kynurenine (42%), 3-hydroxykynurenine glucoside (30%) and 3-hydroxykynurenine (21%)) remained after 7 days. In the presence of NAD(P)H, the double bond of the UV filter-derived deamination compounds, were reduced. Deamination of 3-hydroxykynurenine glucoside, followed by reduction with NAD(P)H, could thus account for the formation of the major lens UV filter 4-(2-amino-3-hydroxyphenyl)-4-oxobutanoic acid glucoside. beta-Benzoylacrylic acid, which possesses the same alpha,beta-ketoalkene sidechain as the deaminated kynurenine UV filters, underwent Michael addition with glutathione, was reduced (hydrogenated) by NAD(P)H, however was unreactive with ascorbate. Surprisingly, at pH 7 the UV filter-derived alpha,beta-ketoalkene intermediates, do not readily undergo intramolecular cyclization. This feature makes the double bond more available for reaction with protein nucleophilic residues and other lens components such as glutathione. On the basis of these data it is likely that glutathione and NAD(P)H, but not ascorbate, protect proteins in the lens from modification by UV filters.

Glutathione and NADH, but not ascorbate, protect lens proteins from modification by UV filters.

Age-dependent human lens colouration and fluorescence may stem primarily from the covalent binding of UV filters to crystallins. The tendency of the kynurenine (Kyn) UV filters to deaminate at neutral pH, with the generation of reactive alpha,beta-ketoalkenes, underlies this phenomenon. In this study the authors examined the ability of small molecular weight antioxidants, which are known to be present in the lens, to inhibit this process. Crystallins were incubated with Kyn at pH 7 in the presence of glutathione (GSH), ascorbate or NADH. Ascorbate, even at high (15 m M) levels, was not found to significantly retard the time-dependent covalent binding of Kyn to the proteins. GSH, and to a lesser extent NADH, however, had a major impact in preventing this modification. The increase in protein UV absorbance and fluorescence was inhibited by GSH intercepting the reactive ketone intermediate, to form a GSH-Kyn adduct. NADH seemed to protect by both reduction of the reactive ketone intermediate and by competing with Kyn for presumably hydrophobic sites on the crystallins. This may indicate that the covalent attachment of aromatic Kyn molecules could be facilitated by initial hydrophobic interactions. Since GSH is present at far greater concentrations than NADH, these results show that in primate lenses, GSH is the key agent responsible for protecting the crystallins from covalent modification.