Non-vision adverse events with vigabatrin therapy.

Vigabatrin is an effective antiepileptic drug (AED) for the treatment of refractory complex partial seizures (rCPS) and infantile spasms (IS). In clinical trials, vigabatrin was generally well-tolerated with an adverse event profile similar to that of other AEDs. The most common treatment-related adverse events were central nervous system effects, including drowsiness, dizziness, headache, and fatigue, with adjunctive vigabatrin in adults with rCPS, and sedation, somnolence, and irritability with vigabatrin monotherapy in infants with IS. Vigabatrin had little effect on cognitive function, mood, or behavior in a battery of neuropsychologic tests for rCPS. In placebo-controlled clinical trials, the incidence of depression and psychosis, but not other psychiatric adverse events, was greater with vigabatrin than placebo. Intramyelinic edema (IME) was initially identified in rats and dogs and led to a temporary suspension of clinical trials in the United States. IME was subsequently correlated with delays in evoked potential (EP) and increased T(2) -weighted signals on magnetic resonance imaging (MRI). Clinical trials of vigabatrin were allowed to resume after IME was not detected by neuropathologic assessments of autopsy and neurosurgical specimens or by serial EP or MRI assessments in older children and adults receiving vigabatrin. Subsequently, MRI abnormalities characterized by increased T(2) intensity and restricted diffusion were identified in infants treated with vigabatrin for IS. These abnormalities generally resolved with discontinuation of vigabatrin and, in some cases, during continued therapy. The benefit of improved seizure control must be balanced against the potential risks associated with vigabatrin, including abnormal MRI changes and other vigabatrin-related safety issues.

Evidence for a differential cellular distribution of inward rectifier K channels in the rat isolated mesenteric artery.

The distribution of functionally active, inwardly rectifying K (K(IR)) channels was investigated in the rat small mesenteric artery using both freshly isolated smooth muscle and endothelial cells and small arterial segments. In Ca(2+)-free solution, endothelial cells displayed a K(IR) current with a maximum amplitude of 190 +/- 16 pA at -150 mV and sensitivity to block with 30 microM Ba(2+) (n = 7). In smooth muscle cells, outward K current was activated at around -47 +/- 3 mV, but there was no evidence of K(IR) current (n = 6). Furthermore, raising extracellular [K(+)] to either 60 or 140 mM, or applying the alpha(1)-adrenoceptor agonist phenylephrine (PE; 30 microM), failed to reveal an inwardly rectifying current in the smooth muscle cells, although PE did stimulate an iberiotoxin-sensitive outward K current (n = 4). Exogenous K(+) (10.8-16.8 mM) both relaxed and repolarized endothelium-denuded segments of the mesenteric artery contracted with PE. These effects were depressed by 100 microM ouabain but unaffected by either 30 microM BaCl(2) or 3 microM glibenclamide. These data suggest that functional, inwardly rectifying Ba(2+)-sensitive channels are restricted to the endothelial cell layer in the rat small mesenteric artery.

First Report of Sudden Death Syndrome of Soybean in Delaware and Eastern Shore of Maryland.

In August and September of 2000, soybean (Glycine max (L.) Merr.) plants from two fields in Sussex County, Delaware, and one field from Somerset County on the eastern shore of Maryland exhibited typical symptoms of sudden death syndrome. The season had been wetter and cooler than normal. Leaf symptoms ranged from small chlorotic spots to elongated regions of interveinal necrosis. Leaflets dropped leaving attached petioles in the upper canopy. Severely infected plants were easily pulled from the soil and had taproots with blue sporodochia, necrotic cortical tissue, and necrosis of secondary roots (2). Initial isolations from the infected plants were made from the basal stems, discolored taproots, vascular tissue, and directly from blue sporodochia. Sections were plated on water agar (WA) amended with neomycin and streptomycin, WA with antibiotics and chloramphenicol, and acidified potato dextrose agar (PDA). The isolates were slow growing on PDA, often staining agar dark maroon, produced little aerial mycelium, and formed macroconidia in blue sporodochia. The fungus was identified as Fusarium solani (Mart.) Sacc. based on spore morphology. Plugs (5 mm) of the fungus from 14-day-old cultures were placed next to the stem just below the soil line of 14-day-old plants of soybean cvs. Essex and Lee 74. Eighteen plants of each cultivar (three per pot) were inoculated and placed on a greenhouse bench for 43 days at 21°C (±2°C). Six noninoculated control plants were also included. Plants were rated for the presence of stem lesions and foliar symptoms. Of the inoculated plants, 70% had mottling, rugosity, and leaf cupping, 6% had severe interveinal leaf necrosis, and 52% had distinct stem lesions at the soil line. Control plants were symptomless. F. solani was recovered from all symptomatic plants and presumed to be F. solani f. sp. glycines based on spore morphology, color, lack of microconidia, and symptoms (1). A more extensive test was conducted to confirm Koch's postulates. Eleven isolates of F. solani f. sp. glycines were grown as before and used to inoculate Essex soybeans as previously described. Inoculated and control plants were randomized on the greenhouse bench and watered using an individual pot irrigation system. Fifty-six days after inoculation plant height was reduced 12% compared with the noninoculated controls. Lesions produced on the lower stem and taproot of the inoculated plants averaged 4.5 cm long. Most plants had mild foliar symptoms that included mottling, rugosity, and leaf cupping. Only three plants had severe foliage symptoms. F. solani f. sp. glycines was recovered from 56% of inoculated plants, completing Koch's postulates for all 11 isolates. Noninoculated controls were symptomless. Sudden death syndrome was not observed in 2001. Soybean is an important crop in the region; 250,000 ha were harvested in 2000 on the Delmarva Peninsula, which includes the three counties of Delaware, nine eastern shore counties of Maryland, and two counties of Virginia. Sudden death syndrome could be a serious threat to profitable soybean production. To our knowledge, this is the first report of sudden death syndrome from this area and represents the most eastern occurrence of this disease reported in the United States. References: (1) K. W. Roy. Plant Dis. 81:259, 1997. (2) K. W. Roy et al. Plant Dis. 81:1100, 1997.

Activation of endothelial cell IK(Ca) with 1-ethyl-2-benzimidazolinone evokes smooth muscle hyperpolarization in rat isolated mesenteric artery.

1. In rat small mesenteric arteries contracted with phenylephrine, 1-ethyl-2-benzimidazolinone (1-EBIO; 3-300 microM) evoked concentration-dependent relaxation that, above 100 microM, was associated with smooth muscle hyperpolarization. 2. 1-EBIO-evoked hyperpolarization (maximum 22.1+/-3.6 mV with 300 microM, n=4) was endothelium-dependent and inhibited by charybdotoxin (ChTX 100 nM; n=4) but not iberiotoxin (IbTX 100 nM; n=4). 3. In endothelium-intact arteries, smooth muscle relaxation to 1-EBIO was not altered by either of the potassium channel blockers ChTX (100 nM; n=7), or IbTX (100 nM; n=4), or raised extracellular K(+) (25 mM). Removal of the endothelium shifted the relaxation curve to the right but did not reduce the maximum relaxation. 4. In freshly isolated mesenteric endothelial cells, 1-EBIO (600 microM) evoked a ChTX-sensitive outward K-current. In contrast, 1-EBIO had no effect on smooth muscle cell conductance whereas NS 1619 (33 microM) stimulated an outward current while having no effect on the endothelial cells. 5. These data show that with concentrations greater than 100 microM, 1-EBIO selectively activates outward current in endothelial cells, which presumably underlies the smooth muscle hyperpolarization and a component of the relaxation. Sensitivity to block with charybdotoxin but not iberiotoxin indicates this current is due to activation of IK(Ca). However, 1-EBIO can also relax the smooth muscle by an undefined mechanism, independent of any change in membrane potential.

An indirect influence of phenylephrine on the release of endothelium-derived vasodilators in rat small mesenteric artery.

1. The possibility that stimulation of smooth muscle alpha(1)-adrenoceptors modulates contraction via the endothelium was examined in rat small mesenteric arteries. 2. N(omega)-nitro-L-arginine methyl ester, (L-NAME, 100 microM to inhibit NO synthase) increased contraction to single concentrations of phenylephrine (1 - 3 microM) by approximately 2 fold (from a control level of 14.2+/-3.0 to 34. 1+/-4.2% of the maximum contraction of the artery, n=20). The action of L-NAME was abolished by disrupting the endothelium. 3. The subsequent addition of apamin (to inhibit small conductance Ca(2+)-activated K(+) channels, 50 nM) further augmented phenylephrine contractions, in an endothelium-dependent manner, to more than 3 fold above control (50.4+/-5.3% of the maximum contraction, n=11). 4.Charybdotoxin (non-selective inhibitor of large conductance Ca(2+)-activated K(+) channels, BK(Ca), 50 nM) plus L-NAME augmented the level of phenylephrine contraction to 4 - 5-fold above control (64.1+/-3.1%, n=5), but this effect was independent of the endothelium. The potentiation of contraction by charybdotoxin could be mimicked with the selective BK(Ca) inhibitor, iberiotoxin,. 5. Apamin together with L-NAME and charybdotoxin further significantly increased the phenylephrine contraction by 5 - 6-fold, to 79.9+/-3.5% of the maximum contraction of the artery (n=13). 6. Phenylephrine failed directly to increase the intracellular Ca(2+) concentration in endothelial cells freshly isolated from the small mesenteric artery. 7. Stimulation of smooth muscle alpha(1)-adrenoceptors in the mesenteric artery induces contraction that is markedly suppressed by the endothelium. The attenuation of contraction appears to reflect both the release of NO from the endothelium and the efflux of K(+) from both endothelial and smooth muscle cells. This suggests that the release of NO and endothelium-derived hyperpolarizing factor can be evoked indirectly by agents which act only on the smooth muscle cells.

External alkalinization decreases intracellular Ca++ and spontaneous contractions in pregnant rat myometrium.

OBJECTIVES: As plasma pH rises during pregnancy, the effect of raising external pH on spontaneous contractions in pregnant rat myometrium was investigated to test the hypothesis that elevated external pH depresses contraction. STUDY DESIGN: Strips of longitudinal myometrium were loaded with SNARF (seminaphthorhodafluor) or Indo-1 for simultaneous intracellular pH or Ca++ and force measurements. Results were obtained from a minimum of five animals in each group, and significant differences were tested for by paired Student t tests. RESULTS: Raising the external pH significantly reduced spontaneous force and calcium transient in the pregnant uterus. Raising the external pH led to a slow rise in intracellular pH, but this could not account for the functional effect. K+ rubidium 86-labeled efflux rates were unaffected by external pH, suggesting no hyperpolarization. The Ca++ channel agonist Bay K8644 (5 mumol/L) restored contractions abolished by raised external pH. CONCLUSIONS: Raised external pH reduces spontaneous contractions in the pregnant rat uterus, probably by an external effect on Ca++ entry. This effect may contribute to uterine quiescence before term.

Modulation of membrane currents and mechanical activity by niflumic acid in rat vascular smooth muscle.

The effects of niflumic acid on whole-cell membrane currents and mechanical activity were examined in the rat portal vein. In freshly dispersed portal vein cells clamped at -60 mV in caesium (Cs+)-containing solutions, niflumic acid (1-100 microM) inhibited calcium (Ca2+)-activated chloride currents (IC1(Ca)) induced by caffeine (10 mM) and by noradrenaline (10 microM). In a potassium (K+)-containing solution and at a holding potential of - 10 mV, niflumic acid (10-100 microM) induced an outward K+ current (IK(ATP)) which was sensitive to glibenclamide (10-30 microM). At concentrations < 30 microM and at a holding potential of -2 mV, niflumic acid had no effect on the magnitude of the caffeine- or noradrenaline-stimulated current (IBK(Ca)) carried by the large conductance, Ca(2+)-sensitive K+ channel (BKCa). However, at a concentration of 100 microM, niflumic acid significantly inhibited IBK(Ca)) evoked by caffeine (10 mM) but not by NS1619 (1-(2'-hydroxy-5'-trifluoromethylphenyl)-5-trifluoromethyl-2(3 H) benzimidazolone; 20 microM). In Cs(+)-containing solutions, niflumic acid (10-100 microM) did not inhibit voltage-sensitive Ca2+ currents. In intact portal veins, niflumic acid (1-300 microM) inhibited spontaneous mechanical activity, an action which was partially antagonised by glibenclamide (1-10 microM), and contractions produced by noradrenaline (10 microM), an effect which was glibenclamide-insensitive. It is concluded that inhibition of ICl(Ca) and stimulation of IK(ATP) both contribute to the mechano-inhibitory actions of niflumic acid in the rat portal vein.

Protein kinase C chimeras: catalytic domains of alpha and beta II protein kinase C contain determinants for isotype-specific function.

Protein kinase C (PKC) is involved in the proliferation and differentiation of many cell types. In human erythroleukemia (K-562) cells, the PKC isoforms alpha and beta II play distinct functional roles. alpha PKC is involved in phorbol 12-myristate 13-acetate-induced cytostasis and megakaryocytic differentiation, whereas beta II PKC is required for proliferation. To identify regions within alpha and beta II PKC that allow participation in these divergent pathways, we constructed chimeras in which the regulatory and catalytic domains of alpha and beta II PKC were exchanged. These PKC chimeras can be stably expressed, exhibit enzymatic properties similar to native alpha and beta II PKC in vitro, and participate in alpha and beta II PKC isotype-specific pathways in K-562 cells. Expression of the beta/alpha PKC chimera induces cytostasis in the same manner as overexpression of wild-type alpha PKC. In contrast, the alpha/beta II PKC chimera, like wild-type beta II PKC, selectively translocates to the nucleus and leads to increased phosphorylation of the nuclear envelope polypeptide lamin B in response to bryostatin-1. Therefore, the catalytic domains of alpha and beta II PKC contain determinants important for alpha and beta II PKC isotype function. These results suggest that the catalytic domain represents a potential target for modulating PKC isotype activity in vivo.

Treatment of bleb infection after glaucoma surgery.

OBJECTIVE: To assess the history, clinical course, and response to treatment of 14 patients with a bleb infection (blebitis) following glaucoma surgery. DESIGN: Retrospective study. SETTING: A university referral center in Atlanta, Ga. PATIENTS: Fourteen patients developed a bleb infection that ranged from 1 month to 22 years after glaucoma surgery. Infections were characterized by pain, a whitened bleb surrounded by intense conjunctival injection, marked anterior chamber reaction (hypopyon in six eyes), and a clear vitreous. Before infection, most blebs were described as thin. The results of Seidel's test were positive in six patients, and most patients had a low intraocular pressure without the use of any glaucoma medication. INTERVENTION: Treatment consisted of hospitalization, intravenous antibiotic therapy, and hourly topical fortified cefazolin sodium and gentamicin sulfate. RESULTS: The visual acuity in most patients improved to the level before the bleb infection, with only three eyes losing 2 or more lines of vision. CONCLUSIONS: Bleb infection without vitreous involvement (blebitis) may be a precursor of endophthalmitis. With aggressive treatment, bleb infection appears to have a much better prognosis for visual recovery than endophthalmitis.

Fatal disseminated Conidiobolus coronatus infection in a renal transplant patient.

A case of fatal disseminated fungal infection due to Conidiobolus coronatus in a patient with a renal transplant is described. This organism, known to cause localized infections in otherwise healthy individuals in the tropics, is now recognized as a cause of fatal infection in immunosuppressed hosts. Histologically, localized infections are characterized by lack of vessel invasion and the presence of an eosinophilic sleeve around fungal elements, called the Splendore-Hoeppli phenomenon. The histologic findings in the present case were more typical of mucormycosis, and the correct diagnosis was established only after the organism was isolated and identified in culture.

Anesthetic and respiratory gas measurements by infrared technology.

Infrared systems for measuring respiratory gas are accurate, stable, and reliable, and cover most respiratory gases. Their most serious limitations (requiring complementary analyzers) are their inabilities to measure O2 (to assure a safe inspired O2) and nitrogen (for clinical N2 washout and detection of air emboli). Properly designed IR systems can monitor higher breath rates, are smaller, require less power, and are less costly than time-shared mass spectrometers. IR systems have a multitude of interfering factors that affect absorption, but control and analysis systems can compensate for them. IR technology continues to advance, with its most recent enhancement being the ability to identify the anesthetic agent in use. Mass spectrometers and Raman analyzers, which have more comprehensive capabilities, will not render IR technology obsolete until they can meet IR technology levels for cost, size, and reliability.

Evaluation and assessment of high sensitivity thyrotropin methods as an index for thyroid function.

We report the evaluation of four new commercially available sensitive assay kits for determination of thyrotropin (TSH) and their clinical utility in normal subjects and patients with thyroidal and non-thyroidal illnesses. The sensitivity for the reliable detection of serum TSH by these methods ranged from 0.1-0.4 mU/L and their decreasing order was : NML greater than Serono greater than Abbott EIA greater than Hybritech. The coefficient of variation ranged from 2.0-5.8% for intra-assay and 2.3-8.6% for interassay at different concentration levels. Patients studied (n = 130) were assigned into four groups on the basis of the serum thyroxine value and their clinical findings. In total, there were 17 discrepancies (five with Hybritech, three with NML, five with Abbott EIA, and four with Serono) in making the correct diagnosis using these sensitive TSH methods as a single diagnostic test. These discrepancies were mainly in the same patients who were clinically euthyroid but had subnormal TSH values. There were no discrepancies in making the correct diagnosis for patients with hyperthyroidism or hypothyroidism using these sensitive TSH methods. Our observations indicate that the sensitive TSH methods are reliable in measuring subnormal levels and may be used to detect hyperthyroidism without affecting in any way their value in detecting hypothyroidism.

Absence of rebound from diltiazem therapy in Prinzmetal's variant angina.

To determine the frequency of rebound anginal symptoms on abrupt withdrawal of calcium channel blocking agents, anginal symptoms were retrospectively examined in patients with Prinzmetal's variant angina abruptly withdrawn from diltiazem therapy as part of the design of a placebo-controlled multiple crossover trial. Rebound was defined as a return of anginal symptoms to levels exceeding those of the pretreatment baseline state. Values for daily frequency of angina were compared (after subtracting corresponding baseline values) between placebo periods following diltiazem periods and placebo periods following placebo periods. No intergroup differences existed between mean changes in daily frequency of angina from baseline value (-0.61 for placebo following diltiazem versus -1.10 for placebo following placebo) (p greater than 0.4). Furthermore, in 13 (28%) of 46 occurrences when placebo followed placebo, daily frequency of angina exceeded baseline value in the immediate 3 day period following placebo compared with 17 (21%) of 80 occurrences when placebo followed diltiazem. There was no increased rebound occurrence comparing high dose (240 mg/day) with low dose (120 mg/day) diltiazem therapy. No significant symptoms such as myocardial infarction or unstable angina occurred after withdrawal of diltiazem or placebo. The lack of difference in rebound after diltiazem or placebo withdrawal was consistent using paired and unpaired analyses. In conclusion, there appears to be no evidence that abrupt withdrawal of therapy with diltiazem results in rebound anginal symptoms.

Hypotony and aqueous humor dynamics in myotonic dystrophy.

A group of 26 subjects with myotonic dystrophy were studied with fluorophotometry to evaluate the relationship between aqueous humor dynamics and the hypotony found in this disorder. All 26 received topical fluorescein to determine the anterior chamber elimination coefficient; five received systemic fluorescein to evaluate the integrity of the blood-aqueous barrier. The group has a mean intraocular pressure of 7.1 mm Hg. The rate of clearance of fluorescein from the anterior chamber and the cornea-to-anterior chamber transfer coefficient for fluorescein were normal. An abnormally high level of fluorescence, three times normal, was observed in the anterior chambers of the myotonic subjects after oral administration of fluorescein. This finding could not be attributed to abnormal absorption and elimination of fluorescein or to abnormal plasma binding. This finding indicates that there is a defect in the blood-ocular barrier to fluorescein in myotonic subjects. Thus conclusions regarding aqueous humor flow cannot be made from the rate of clearance of topically applied fluorescein in myotonic subjects, since the clearance due to diffusion may represent a significantly large fraction of the total clearance.

Clinical experience with diltiazem in Japan.

In a cooperative postmarketing study, 3,913 Japanese patients received diltiazem, an orally administered calcium channel blocking agent, for 30 to over 360 days. Drug safety was assessed by monthly evaluations of subjective symptoms, electrocardiographic recordings, adverse experiences, vital signs, and biochemical profiles. Original case report forms were processed and analyzed in the United States. None of the observed adverse experiences were serious or life threatening. They occurred in 1.8% of the patients and primarily involved the gastrointestinal system; anorexia and nausea were the most common adverse effects. The majority of the other adverse experiences were extensions of the drug's pharmacologic effects. Diltiazem appears to cause relatively minor clinical toxicity at a low frequency.