A family with pheochromocytoma-paraganglioma inherited tumour syndrome. Serial 18F-DOPA PET/CT investigations.

AIM: Hereditary pheochromocytoma-paraganglioma syndromes are characterized by multiple pheochromocytomas (PCC) and paragangliomas (PGLs), inherited in an autosomal dominant manner. Early detection and removal of tumours may prevent or minimize complications related to mass effects and malignant transformation. Having confirmed the diagnosis, it is important to localize the tumours and reveal their extent preoperatively. This study aimed to introduce 18F-DOPA PET/CT as a highly sensitive non-invasive diagnostic tool for early detection of mass lesions in patients with pheochromocytoma-paraganglioma inherited tumour syndrome and to report about its impact on patient management. PATIENTS, METHODS: We are currently supervising one of the largest documented families in Germany with genetically determined SDHD gene mutation. We performed 18F-DOPA PET/CT in order to detect tumours in asymptomatic gene carriers and enable subsequent surgical therapy. RESULTS: In seven patients undergoing 12 18F-DOPA PET/CT scans 17 lesions have been detected. Three of these lesions, located in the head and neck region, have had no morphologic correlate in CT and one had also no morphologic correlate in MRI. Of the six histologically analyzed lesions five have been tumors (PGL or PCC) and one has been a nodular hyperplasia. This means the 18F-DOPA PET/CT scan in our study group had a sensitivity of 83%. 18F-DOPA PET/CT investigations lead to change in the management in 5/7 studied patients (70%). CONCLUSION: The benefits of PET/CT in detection of pheochromocytoma and paraganglioma are well documented, but we are the first to use this technique for screening of a rare hereditary disease (estimated prevalence 0.3/100 000).

The effects of cocaine and nicotine on amino acid transport across the human placental cotyledon perfused in vitro.

The inhibitory effects of cocaine and nicotine on placental amino acid transport, as a mechanism contributing to intrauterine growth restriction, were investigated in the in vitro placental perfusion model. Amino acids that represent substrates for known placental transporters were selected: alanine (system A), glutamine (system N), phenylalanine and valine (system l), and arginine (system y(+)). Amino acid accumulation on the fetal side was measured in the absence of cocaine or nicotine (n = 7) and in the presence of 1.2 microg/ml cocaine (n = 6), 120 ng/ml nicotine (n = 6), or both (n = 6). Neither cocaine nor nicotine alone significantly inhibited alanine transport, whereas their combination did (P =.02). Significant inhibition of arginine transport was detected with nicotine (P =.007), cocaine (P =.01), and their combination (P =.01), whereas phenylalanine (P =.03, P =.04) and valine (P =.03, P =.04) transport was affected by cocaine and the combination of cocaine and nicotine, respectively. For glutamine, neither cocaine, nicotine, nor their combination had a statistically significant inhibitory effect. In conclusion, both cocaine and nicotine may contribute to fetal growth restriction by interfering with the activity of amino acids transporters that are necessary to maintain the nutrient gradients associated with normal fetal growth.

Transfer of morphine across the human placenta and its interaction with naloxone.

The purpose of this investigation was to measure the transfer rate and clearance of morphine across the placenta with and without naloxone. Term human placental cotyledons were perfused in vitro. The placenta was perfused with 50 ng/mL of morphine in the absence (n=4) and presence (n=5) of 100 ng/mL of naloxone. Maternal and fetal samples were collected. Student's t-test or one-way repeated measures ANOVA were used for all comparisons. The maternal-to-fetal morphine transfer rate was 0.73+/-0.44 ng/mL/min in the morphine and 0.69+/-0.26 ng/mL/min in the morphine-naloxone experiments (p=0.89). The clearance of morphine was 0.89+/-0.39 mL/min without naloxone and 0.87+/-0.27 mL/min with naloxone (p=0.92). Final morphine concentrations in the morphine experiments were 9.78+/-6.17 ng/mL (maternal) and 3.43+/-2.14 ng/mL (fetal) and 10.04+/-3.89 ng/mL (maternal) and 4.16+/-1.64 ng/mL (fetal) in the morphine-naloxone experiments. Morphine readily crosses the term human placenta. Naloxone does not alter placental transfer or clearance of morphine, suggesting that transfer across the placental barrier is not altered by changes in vascular resistance. Placental retention of morphine prolongs fetal exposure to morphine.

Transplacental transfer and biotransformation studies of nicotine in the human placental cotyledon perfused in vitro.

Our objective was to study the characteristics of transfer and biotransformation of nicotine in the human term placenta. Nicotine transfer was studied by dually perfusing an isolated cotyledon of the human placenta in vitro. Nicotine metabolism to cotinine was investigated in intact tissue during perfusion and in placental microsomal fractions. Following the addition of nicotine (40 ng/ml) to the maternal side of the placenta, distribution into placental tissue (0.43 +/- 0.13 ng/ml/min) was three times higher than transfer to the fetal side of the placenta (0.15 +/- 0.01 ng/ml/min). The steady-state maternal-to-fetal transfer of nicotine was approximately 90% that of antipyrine (a marker of flow-dependent transfer). There was no evidence of nicotine metabolism to cotinine by intact placental tissue or in microsomal fractions. The observation that nicotine readily crosses the human placenta with no evidence of metabolism suggests that nicotine has the potential to cause adverse affects on the developing fetus.

Arylamine N-acetyltransferase activity of the human placenta.

The fetus is exposed to almost all of the substances found in the maternal circulation whether nutrients or foreign chemicals ("xenobiotics"). The main route of exposure is the placenta. The placenta is metabolically active toward xenobiotics and the nature of the compounds reaching the fetal circulation will, in part, depend on placental biotransformation reactions. Arylamine N-acetyltransferase (NAT) catalyzes the acetyl CoA-dependent N-acetylation of primary arylamine and hydrazine substrates such as sulfamethazine, isoniazid, p-aminobenzoic acid as well as arylamine carcinogens such as 2-aminofluorene and benzidine. NAT activity is multigenically determined and can be attributed to two independently expressed proteins: NAT1 and NAT2. The acetylation capacity of the human placenta has not been investigated extensively. In the current study we identified and characterized the NAT activity of human term placenta. The kinetic data show that the activity of NAT in human placenta predominantly reflects the NAT1 enzyme. The apparent affinity (19.1 +/- 0.97 microM; mean +/- S.E.M., n = 22) and maximal velocity (3.84 +/- 0.32 nmol/min/mg; mean +/- S.E.M., n = 22) of p-aminobenzoic acid N-acetylation are similar to those measured in other tissues such as liver, blood lymphocytes, neutrophils and monocytes. In addition, there is evidence of NAT2 activity in some of the placental samples assayed, although the contribution of a small amount of NAT2 activity to the overall acetylation capacity of the placenta is likely to be small.

Human placental transfer and metabolism of p-aminobenzoic acid.

Studies in our laboratory have shown that the N-acetylation activity of the human term placenta is a predominantly attributable to the NAT1 form of arylamine N-acetyltransferase (NAT). To further assess the acetylation capacity of the placenta, the N-acetylation of the prototype NAT1-selective substrate, p-aminobenzoic acid (PABA), was studied using the in vitro human placental perfusion model. This study compared the net N-acetylation of PABA in intact placental tissue with the PABA acetylation activity observed in a subcellular fraction (cytosol). Such studies with intact tissue can permit assessment of the exposure of the fetus in vivo to drugs and their metabolites. Acetylated metabolite (N-acetyl-p-aminobenzoic acid) was detectable in fetal and maternal venous samples taken less than 5 min from the start of perfusion with PABA. In a closed recirculating system, the rate of placental PABA transfer decreased as PABA concentrations equilibrated across the placenta. In contrast, the rate of N-acetyl-p-aminobenzoic acid formation continued to increase throughout the entire time of perfusion. Kinetic parameters of PABA N-acetylation measured in cytosol prepared from perfused placental tissue show that the placenta retains its ability to N-acetylate PABA at fresh tissue levels even after 6 hr of in vitro perfusion (Vmax = 5.75 +/- 0.42 nmol/min/mg (fresh) vs. Vmax = 7.24 +/- 0.31 nmol/min/mg (perfused); mean +/- S.E.M., n = 6). These studies indicate that the human placenta has a significant capacity to N-acetylate NAT1-selective substrates of NAT and that it maintains its ability to metabolize xenobiotics during in vitro perfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Transfer of cocaine and benzoylecgonine across the perfused human placental cotyledon.

OBJECTIVE: Our aim was to measure the transfer of cocaine and its major metabolite benzoylecgonine across the human term placenta. STUDY DESIGN: By means of in vitro perfusion of the human term placental cotyledon the transfer of these compounds was measured. RESULTS: The steady-state maternal-to-fetal transfer of cocaine (0.18 +/- 0.05 microgram/ml/min) was significantly greater than benzoylecgonine transfer (0.02 +/- 0.01 microgram/ml/min) (p < 0.05). When the perfused tissue was analyzed 32% +/- 7% of the maternal cocaine dose was retained by the placental tissue, whereas only 12% +/- 12% of the maternal benzoylecgonine dose was retained by the placental compartment. CONCLUSIONS: These results suggest (1) the placenta may serve as a depot for large amounts of cocaine, thus offering some degree of fetal protection after bolus administration; (2) fetal exposure may be prolonged by placental retention and subsequent release of cocaine and benzoylecgonine; and (3) benzoylecgonine does not cross the placenta as readily as does cocaine. Variability in placental handling of cocaine and benzoylecgonine may therefore determine fetal exposure to these agents.

Acetylcholinesterase and butyrylcholinesterase activity in the human term placenta: implications for fetal cocaine exposure.

The characterization of the enzymes responsible for drug metabolism in the human placenta is of great importance in determining the possible role the placenta plays in protecting the fetus from potentially fetotoxic drugs. We speculate that the placenta metabolizes cocaine, serving to protect the fetus from the drug's ill effects. Cholinesterase, the principle enzyme that metabolizes cocaine, has been hypothesized to be present yet is not well characterized in the human placenta. The purpose of this study was to quantify human placental acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) activity. Human placentas were obtained from elective cesarean sections, and several lobules were thoroughly perfused with cold buffer to ensure minimal contamination from erythrocyte AChE. Subcellular fractions were then prepared from these lobules by using standard differential centrifugation techniques. Microsomes and cytosol were assayed for AChE and BChE activity by using a spectrophotometric assay. BChE activity was found in the cytosolic fraction of the placental villous tissue, whereas AChE activity was measured in the microsomal fraction. By demonstrating that BChE activity is present in human term placenta we have shown that this organ has the capacity to metabolize cocaine and may therefore serve as a metabolic barrier to fetal exposure to cocaine.

Hair concentrations of nicotine and cotinine in women and their newborn infants.

BACKGROUND: To date, no biological markers have been identified that can predict the extent of fetal exposure to the toxic constituents of cigarette smoke. A variety of xenobiotic agents have been shown to accumulate in growing hair. PATIENTS AND METHODS: We measured maternal and neonatal hair concentrations of nicotine and cotinine in 94 mother-infant pairs. Mothers who were active smokers, nonsmokers, and passive smokers and their infants were included. RESULTS: Mothers who were active smokers (n = 36) had mean (SEM) hair concentrations of 19.2 (4.9) ng/mg for nicotine and 6.3 (4.0) ng/mg for cotinine, significantly higher than concentrations in nonsmokers (n = 35) (1.2 [0.4] ng/mg for nicotine and 0.3 [0.06] ng/mg for cotinine, P < .0001). Infants of smokers had mean hair concentrations of 2.4 (0.9) ng/mg for nicotine (range, 0 to 27.3 ng/mg) and 2.8 (0.8) ng/mg for cotinine (range, 0 to 12.2 ng/mg), significantly higher than concentrations in infants of nonsmokers (0.4 [0.09] ng/mg for nicotine and 0.26 [0.04] ng/mg for cotinine, P < .01). Mothers with passive smoke exposure and their infants (n = 23) had significantly higher hair concentrations of nicotine (3.2 [0.8] ng/mg for mothers and 0.28 [0.05] ng/mg for infants) and cotinine (0.9 [0.3] ng/mg for mothers and 0.6 [0.15] ng/mg for infants) than nonsmoking mothers and their infants (P < .01). There was a significant correlation between maternal and neonatal hair concentrations of nicotine (r = .49, P < .001) or cotinine (r = .85, P = .0001). CONCLUSIONS: This is the first biochemical evidence that infants of passive smokers are at risk of measurable exposure to cigarette smoke. Hair accumulation of cigarette smoke constituents reflects long-term systemic exposure to these toxins and therefore may be well correlated with perinatal risks.

The transport of digoxin across the perfused human placental lobule.

The cardiac glycoside, digoxin, is clinically used to treat fetal tachyarrhythmias and congestive heart failure. The time course of digoxin transfer across the human placenta was studied by dually perfusing an isolated lobule of the human placenta in vitro. Viability of the placental preparation was validated by measuring the rates of glucose and oxygen consumption, lactate production and synthesis of the protein hormone, chorionic gonadotropin. Following administration of 5 ng/ml digoxin to the maternal circulation, digoxin appeared in the fetal circulation within 5 min. The disappearance of digoxin from the maternal circulation was biexponential and best fit a two-compartment pharmacokinetic model. Mean calculated volume of the central compartment (257 +/- 6.3 ml) was consistent with the actual volume of the in vitro maternal circulation (246 +/- 7.4 ml). The half-life of the distribution phase was 9.7 +/- 3.3 min, and half-life of the terminal elimination phase was 362 +/- 83 min. After 30 min of perfusion, the amount of digoxin leaving the maternal circulation and appearing in the fetal circulation was constant at a fetomaternal mass ratio of 0.36 +/- 0.04. This ratio was maintained through to the end of the 3-hr experiment. All of the digoxin leaving the maternal circulation could be accounted for either in the fetal circulation or bound to placental tissue. The time to achieve equal concentrations on both sides of the placenta was estimated to be 268 +/- 34 min. These data are consistent with in vivo data obtained in humans, and support the relevance of using the in vitro placental perfusion model to obtain information regarding placental drug transfer in humans.

Controlled trial of ceftazidime vs. ticarcillin and tobramycin in the treatment of acute respiratory exacerbations in patients with cystic fibrosis.

A randomized controlled trial was undertaken to compare ceftazidime vs. the combination of ticarcillin and tobramycin in the treatment of acute respiratory exacerbations of mild to moderate severity in patients with cystic fibrosis. The two antibiotic regimens were equally effective in terms of clinical improvement: 16 of 17 in the ceftazidime group and 11 of 13 in the ticarcillin/tobramycin group were judged to be improved by the patients and attending physicians and were observed to show improvement in symptom scores, vital signs, body weight and pulmonary function. Ceftazidime was more effective bacteriologically in reducing colony counts of Pseudomonas aeruginosa in the sputum. Neither regimen affected Pseudomonas cepacia. Resistance to multiple antibiotics developed in six of 12 isolates of nonmucoid P. aeruginosa in patients receiving ticarcillin/tobramycin, which was significantly more than occurred in the ceftazidime group. There was no correlation between clinical and bacteriologic outcomes in either treatment group. No clinically important adverse effects were observed.

Activity of ceftazidime against Pseudomonas aeruginosa from bacteraemic and fibrocystic patients.

Minimum inhibitory and bactericidal levels of ceftazidime were determined for 337 isolates of Pseudomonas aeruginosa (135 mucoid, 202 non-mucoid) derived from fibrocystic patients, and 102 isolates of Ps. aeruginosa from blood or CSF. Fifty per cent of isolates of Pq. aeruginosa from all sources were inhibited by 2 mg/l of ceftazidime using inocula of 10(5)-10(6) colony forming units. Ninety per cent of the blood-culture and mucoid isolates were inhibited by 4 mg/l of ceftazidime, but more than 10 mg/l was required to inhibit 90% of the non-mucoid organisms. Bactericidal levels were close to the inhibitory levels. Of 30-isolates of Ps. cepacia, 50% were inhibited by 2 mg/l, and 90% by 4 mg/l of ceftazidime. Strains of pseudomonas derived from patients with fibrocystic disease were less susceptible than the strains from bacteraemic patients. Of the former, the mucoid strains were more susceptible than the non-mucoid strains. The patients with cystic fibrosis had been exposed to beta-lactam drugs for many years.