Clinical issues related to the costs of alcoholism.

Alcohol (ethanol) use disorders are prevalent in many countries and are associated with significant social and health costs. Little is known, however, about the comparative cost effectiveness of treatments for alcoholism. Pharmacoeconomic evaluations are largely (if not wholly) absent from the alcoholism treatment outcome database. We discuss pharmacological approaches to the treatment of alcohol withdrawal and dependence, describing agents that ameliorate withdrawal symptoms, deter alcohol consumption, reduce alcohol craving and produce conditioned alcohol aversion. Cost-relevant clinical considerations are elucidated and recommendations for cost-conscious pharmacological treatment of alcohol dependence are proffered.

Conversion of the human 5-HT1D beta serotonin receptor to the rat 5-HT1B ligand-binding phenotype by Thr355Asn site directed mutagenesis.

The human 5-HT1D beta serotonin receptor and its rat homolog (also called the 5-HT1B receptor) share 93% amino acid identity, yet display markedly different pharmacological specificities. Comparison of deduced amino acid sequences among these and other recently cloned receptors suggested that this phenotypic difference might be attributable to a single human threonine355/rat asparagine351 amino acid difference in the putative seventh membrane spanning regions. We now report that Thr355Asn mutagenesis of the human 5-HT1D beta receptor alters the binding characteristics of the recombinant receptor in [3H]5-HT binding assays to a profile very similar to that of the rat 5-HT1B binding site. These results confirm that this single amino acid difference is responsible for the majority of the known pharmacological discrepancies between human and rat observed for 5-HT1D beta (5-HT1B) receptors.

Molecular cloning and functional characterization of a human 5-HT1B serotonin receptor: a homologue of the rat 5-HT1B receptor with 5-HT1D-like pharmacological specificity.

We describe a genomic clone encoding the human 5-HT1B receptor. This apparently intronless gene encodes a 390 amino acid polypeptide homologous to the rat 5-HT1B serotonin receptor, with which it shares 93% amino acid sequence identity. Remarkably, [3H]5-hydroxytryptamine binding studies with transfected HeLa cells show that the human 5-HT1B receptor has a pharmacological profile that is markedly different from that of the corresponding rat receptor. Instead, human 5-HT1B drug specificity is highly similar to that of the human 5-HT1D receptor, with which it shares 59% amino acid sequence identity. The human 5-HT1B receptor, like the 5-HT1D receptor, can couple to Gi proteins. The presence of the threonine355 in the human receptor rather than an asparagine, as found in the corresponding rat gene product, may explain much of the marked pharmacological difference between the human and rat 5-HT1B receptors.

Distinct 5-HT(1B) and 5-HT(1D) serotonin receptors in rat: Structural and pharmacological comparison of the two cloned receptors.

We and others have recently cloned the genes encoding the human 5-HT(1D) (5-HT(1Dalpha)) and 5-HT(1B) (5-HT(1Dbeta)) serotonin receptors. Because of the history of profound species differences in the pharmacology of these receptor subtypes, we also cloned the homologous genes for these two receptors in rat. The rat 5-HT(1D) receptor gene, like that of the rat 5-HT(1B) receptor, is intronless, encoding a 374-amino acid polypeptide 90% identical to its human homologue. The rat 5-HT(1D) and rat 5-HT(1B) receptors are 61% identical in their deduced amino acid sequences. The availability of both the rat 5-HT(1B) and 5-HT(1D) genes allowed direct comparison of the pharmacological properties of the two receptors expressed in transfected cells as assessed using 5-[(3)H]HT binding assays. Unlike the rat 5-HT(1B) receptor, which is pharmacologically dimorphic with respect to its human homologue, the rat 5-HT(1D) receptor has an almost identical profile compared to the human 5-HT(1D) receptor. (+/-)-Cyanopindolol and (-)-propranolol are more than 100-fold selective for the rat 5-HT(1B) receptor over the rat 5-HT(1D) receptor, while mianserin is more than 100-fold selective for the rat 5-HT(1D) receptor. The rat 5-HT(1D) receptor is expressed in cells of the dorsal raphe and thus may serve as an additional type of serotonin autoreceptor. This constitutes the first unambiguous characterization of a 5-HT(1D) receptor in rat and demonstrates its relationship to the 5-HT(1B) receptor in rat as well as to the 5-HT(1D) and 5-HT(1B) receptors in human.

Prophylactic use of human leukocyte interferon after allogeneic marrow transplantation.

STUDY OBJECTIVE: To determine the efficacy of prophylactic interferon for prevention of cytomegalovirus infection and relapse of leukemia after allogeneic marrow transplantation. DESIGN: Randomized trial with intermittent interferon administration to day 80 after transplantation. SETTING: Marrow transplantation units of a cancer research center. PATIENTS: Consecutive patients with acute lymphocytic leukemia in remission at the time of transplantation. Thirty-nine patients received interferon, and 40 were control patients. INTERVENTIONS: Partially purified human leukocyte interferon given every 3 days beginning after marrow engraftment and continuing to day 80 after transplantation. After initial safety testing, the starting and minimum dose was 6 X 10(4) units/kg of body weight, with dose escalations determined by the circulating neutrophil count. Transplant conditioning and post-transplantation prophylaxis of graft-versus-host disease with methotrexate followed standard procedures. MEASUREMENTS AND MAIN RESULTS: No difference was observed in the probability or severity of cytomegalovirus infection or in the probability or severity of graft-versus-host disease. Relapse of leukemia occurred in 9 interferon recipients and 21 control patients, with a minimum follow-up of 4 years among surviving patients. The probability of relapse among all interferon recipients was 0.36 (95% confidence interval [Cl], 0.56 to 0.17) and among all control patients was 0.74 (95% Cl, 0.91 to 0.58) (p = 0.04 by log-rank test). Among patients who received transplants in first or second remission, the probability of relapse among interferon recipients was 0.19 (95% Cl, 0.37 to 0.02) compared with 0.71 (95% Cl, 0.97 to 0.51) among control patients (p = 0.008 by log-rank test). Survival rates did not differ between interferon recipients and control patients. Transient decreases in leukocyte count and anorexia and nausea occurred among interferon recipients. Six interferon recipients, all of whom had received chemoradiotherapy of the central nervous system before transplantation, developed leukoencephalopathy after transplantation. CONCLUSIONS: These data suggest that interferon given after transplantation reduces the risk for subsequent relapse of leukemia. The effect of longer administration and of administration in patients with other underlying diseases will require additional trials. No effect was observed on cytomegalovirus infection, either because interferon was not initiated until a median of 18 days after transplantation or because of a lesser effect among marrow allograft recipients.

Bone marrow transplantation in a patient with myelodysplasia associated with diffuse eosinophilic fasciitis.

A 34-year-old man with diffuse eosinophilic fasciitis and a hypocellular myelodysplastic syndrome underwent marrow transplantation from an HLA-identical brother. Prompt hematopoietic reconstitution was observed, strongly suggesting that the marrow hypocellularity was caused by neither a serum inhibitory factor nor a microenvironmental disorder. The patient died of disseminated cytomegalovirus infection too early to evaluate the impact of hematopoietic reconstitution on the eosinophilic fasciitis. Nevertheless, marrow transplantation may offer a therapeutic option for those patients with this disorder who develop severe hematopoietic dysfunction and who have a suitable marrow donor.

The effects of splenectomy on engraftment and platelet transfusion requirements in patients with chronic myelogenous leukemia undergoing marrow transplantation.

Granulocyte and platelet recovery as well as platelet transfusion requirements following allogeneic marrow transplantation were analyzed in 67 patients with chronic myelogenous leukemia in the chronic phase. Twenty patients had splenectomy prior to transplantation. Forty-seven patients were transplanted without splenectomy, 21 of whom had splenic enlargement by physical examination. There were no differences in the proportion of patients with granulocyte recovery, but the recovery of peripheral granulocytes to levels of 200, 500 and 1,000/mm3 occurred more rapidly in the splenectomy group than in the no-splenectomy group. Patients with splenectomy received platelet transfusions for a mean of 10 (2-36) days as compared to 20 (3-82) days for patients without splenectomy (p less than .001). Eighteen (90%) patients with splenectomy became platelet transfusion independent at a median of 16 (2-32) days after transplantation as compared to 40 (85%) patients without splenectomy who became transfusion independent at a median of 28 (15-86) days (p less than .001). The proportion of patients achieving platelet levels of 50 and 100 X 10(3)/mm3 did not differ between the two groups (p = .07), but patients in the splenectomy group achieved these levels more rapidly following transplant (p less than .001). One of 17 evaluable patients in the splenectomy group and 31 of 46 in the no-splenectomy group became refractory to random platelets (p less than .001) and required platelets from family members or unrelated completely or partially HLA matched donors. In the no-splenectomy group, splenic size did not affect the speed of granulocyte or platelet recovery or platelet transfusion requirements.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of I-131 labeled, murine Fab against a high molecular weight antigen of human melanoma: preliminary experience.

High molecular weight antigen (HMWA) is a tumor-associated proteoglycan of human malignant melanoma. I-131 labeled Fab fragments of these specific antibodies were used for preliminary feasibility studies for radioimmunodetection and therapy of human subjects who had inoperable metastatic melanoma. Ten patients received tracer doses of 5-13 mCi (185-481 MBq) of I-131 (anti-HMWA) Fab. All patients (8/8) who had melanoma lesions greater than 1 cm by correlative diagnostic methods had one or more lesions that had localization to tumor of the radiolabeled Fab. In all, 17 of 23 (74%) documented metastases were seen. There were no false positives in this series. Two patients who had avid uptake received potentially radiotherapeutic doses of 142 mCi (5,254 MBq) (one patient) and 181 mCi (6,697 MBq) and 193 (7,141 MBq) (total: 374 mCi or 13,838 MBq) (one patient). For both of these patients, whole body imaging studies showed that the localization of the high dose I-131 Fab was predominantly in tumor. The patient who received the larger dose showed a greater than 50% reduction in the size of pelvic and pericaval nodes, with stabilization of disease at the smaller nodal size for a period of three months. On whole body images, the anti-Fab HMWA appears to be more tumor selective than Fab preparations that target the p97 antigen for melanoma, and there is less uptake in liver.

Diagnosis of and therapy for solid tumors with radiolabeled antibodies and immune fragments.

Antibodies which are directed against human tumor-associated antigens can potentially be used as carriers of radioactivity for in vivo diagnosis (radioimmunodetection) or treatment (radioimmunotherapy) of solid tumors, including colon, hepatoma, cholangiocarcinoma, and melanoma. Murine monoclonal antibodies (MOAB), produced by the hybridoma technique of Kohler and Milstein, are replacing conventional heterosera as sources of antibodies, because MOAB can be produced in large quantities as reproducible reagents with homogeneous binding properties. We have studied human melanoma using MOAB IgG and Fab fragments that recognize the human melanoma-associated antigens p97 and "high-molecular-weight antigen." Both antigens are found in the membrane of melanomas at much larger concentrations than in normal adult tissues. We have performed radioimmunodetection studies with whole immunoglobulin and have detected 88% of lesions greater than 1.5 cm. We have used Fab fragments for radioimmunotherapy and have found that large doses of radiolabeled antibodies (up to 342 mCi) can be repetitively given to patients without excessive end-organ toxicity. Two of three patients treated with high-dose radiolabeled antimelanoma Fab showed an effect from the treatment. Although both technical and biologic problems remain, the use of radiolabeled antibodies that are directed against tumor-associated antigens holds future promise as a new therapeutic approach to solid tumors that are resistant to conventional therapy.

Localization of 131I-labeled p97-specific Fab fragments in human melanoma as a basis for radiotherapy.

33 patients with advanced malignant melanoma were studied after intravenous administration of 131I-labeled Fab fragments specific for p97, an oncofetal glycoprotein of human melanoma. In all, 47 gamma camera imaging studies were performed for the purpose of localization of metastatic deposits. In addition to tumor, 131I-Fab uptake was also seen in liver and kidney. 20 of these studies included simultaneous administration of both an 131I-labeled Fab specific for p97, and an 125I-labeled Fab not specific for p97. Blood clearance of p97-specific Fab was significantly more rapid than for nonspecific Fab. Eight of these patients had biopsies of subcutaneous nodules at 48 and 72 h postinjection in order to assess whether localization of radioactivity was antigen specific. Antigen-specific localization was observed with average ratios of specific/nonspecific uptake of 3.7 (48 h) and 3.4 (72 h); uptake was strongly correlated with tumor p97 concentration (r = 0.81, P less than 0.01). Also, imaging studies of the bio-distribution of 131I-labeled anti-p97 Fab in patients selected for high p97 tumor concentration showed avid tumor uptake and more prolonged retention of labeled Fab in tumor than in normal tissues. Based on these studies, we estimated that total 131I doses of 500 mCi could be safely given to patients before dose-limiting toxicity would be observed. Accordingly, in seven selected patients, phase I radiotherapeutic trials were begun. For improved radiation safety, we developed automated methods to label Fab fragments with up to 200 mCi of 131I. So far, a total of 12 individual therapeutic doses, ranging from 34 to 197 mCi of 131I-labeled to 5 to 10 mg of Fab, have been administered with excellent tumor localization and without major target organ toxicity. Cumulative doses ranged from 132 to 529 mCi 131I. Side effects attributable to the radiation were mild, with a transient drop slightly greater than 50% in platelet and absolute neutrophil counts being observed in the two patients who received cumulative doses greater than 500 mCi. In the combined series of 47 diagnostic and 12 therapeutic studies, four acute reactions were observed: one episode each of transient chills and fever; flushing and hypotension; and two skin rashes. All of these reactions responded promptly to symptomatic therapy. After multiple administrations of 131I-(anti-p97) Fab (IgG1), isotype-specific immunity was observed in three patients. In two of these patients it was possible to successfully reinfuse after immunity had developed with 131I-(anti-p97) Fab of a different isotype (IgG2a). Dosimetry estimates were performed based on the biodistribution of (131)I-Fab in these patients,and for every 100 mCi of (131)I-Fab given, tumor receives 1,040 rads; liver. 325 rads; and bone marrow, 30 rads. Marrow would be expected to be the critical organ, if doses >500 mCi (131)I-Fab are given. These studies demonstrated that, with proper precautions, large doses (of an (131)I-labeled murine Fab fragments immunologically specific for a human melanoma-associated antigen) could be safely given to humans by using repetitive intravenous injections.

Treatment of cytomegaloviral pneumonia with high-dose acyclovir and human leukocyte interferon.

Thirteen recipients of bone marrow transplants were given high-dose acyclovir and alpha-interferon (Cantell interferon) for the treatment of biopsy-proven cytomegaloviral pneumonia. Three patients survived. Doses of acyclovir between 500 and 1,000 mg/m2 of body surface area (peak plasma levels, 7-86 micrograms/ml) and doses of interferon between 2 X 10(4) and 40 X 10(4) units/kg per day (peak serum levels, 5-608 units/ml) were given. No consistent antiviral effect was seen despite the large doses employed. Possible marrow toxicity associated with this regimen occurred in five patients, neurologic symptoms in two, and nephrotoxicity in one. Thus, treatment with high-dose acyclovir plus alpha-interferon was moderately toxic but ineffective against cytomegaloviral pneumonia after bone marrow transplantation.

The use of acyclovir for cytomegalovirus infections in the immunocompromised host.

Despite the lack of virus-specified thymidine kinase activity, human cytomegalovirus may be sensitive to acyclovir in vitro at concentrations between 10 and 25 mg/l. The inhibitory effect of acyclovir can be further increased by the presence of small amounts of human alpha or beta interferon. Twenty-one allogeneic marrow graft recipients with biopsy-proven cytomegalovirus pneumonia were treated with either high doses of acyclovir (eight patients) or the combination of acyclovir and human alpha (leukocyte) interferon (13 patients). Acyclovir doses of 400 to 1200 mg/m2/dose and interferon doses of 2 to 40 X 10(4) units/kg/day were used. There was no consistent effect of treatment on the likelihood or duration of survival, titre of virus in paired lung specimens, or shedding of virus. However, four patients survived and four others had 2-log or greater decreases in the amount of virus in paired lung specimens, suggesting a possible effect on cytomegalovirus strains with increased sensitivity to these agents. Acyclovir treatment of cytomegalovirus infection may be more effective in patients with lesser degrees of immunosuppression, but was not effective in the treatment of marrow transplant patients with cytomegalovirus pneumonia.

Toxicity of amphotericin B, miconazole, and ketoconazole to human granulocyte progenitor cells in vitro.

Granulocyte progenitor cells were grown in culture with amphotericin B, miconazole, and ketoconazole. Significant suppression of progenitor cell growth could be demonstrated with all three drugs at increasing concentrations. No additive suppression was seen when amphotericin B and ketoconazole were combined.

Treatment of cytomegalovirus pneumonia after marrow transplant with combined vidarabine and human leukocyte interferon.

Seven marrow transplant recipients were treated with human leukocyte interferon and vidarabine for cytomegalovirus pneumonia. Although the mean virus titer in biopsy and autopsy lung specimens from five patients decreased from 5 x 10(4) to 1 x 10(2) 50% tissue culture infective doses, there was little clinical evidence of efficacy and only one patient survived. Treatment was stopped in four patients because of declining neutrophil counts, and two of these four patients also showed severe neurotoxicity. The combination of these agents was neither safe nor effective for the treatment of cytomegalovirus pneumonia after marrow transplantation.

Lack of toxicity of acyclovir to granulocyte progenitor cells in vitro.

Granulocyte progenitor cells were grown with acyclovir to study potential marrow toxicity. Concentrations of up to 220 microM had little effect on progenitor cell growth.

Philadelphia chromosome (Ph1)-negative chronic myelogenous leukemia (CML): a clonal disease with origin in a multipotent stem cell.

It has been shown with glucose 6-phosphate dehydrogenase (G-6-PD) mosaicism that Ph1-positive chronic myelogenous leukemia (CML) is a clonal disease that involves multipotent hematopoietic stem cells. We now report G-6-PD studies of a 79-yr-old woman with Ph1-negative CML. Equal amounts of B and A-type activities were found in nonhematopoietic tissues, indicating that the patient was heterozygous for G-6-PD. In contrast, only A-type G-6-PD was found in marrow cells, blood erythrocytes, leukocytes, and platelets and in granulocyte-monocyte and eosinophil colonies grown from blood mononuclear cells. Unlike most cases of PH1-positive CML, colony growth in this patient increased during blastic transformation and the colonies contained only immature monocytic cells. The data indicate that in this patient, Ph1-negative CML is similar to the Ph1-positive form of the disease in involvement of multipotent stem cells and probable clonal origin, but the two disorders differ in the rapidity with which they enter blastic transformation and in the pattern of granulocyte-monocyte colony growth at that time.