Correlation of Nabiximols Dose to Steady-State Concentrations of Cannabinoids in Urine Samples from Patients with Multiple Sclerosis.

Therapeutic drug monitoring of Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) is based on a complex procedure and is therefore not possible in most laboratories, especially in emergency cases. This work addresses the question of whether therapeutic drug monitoring of nabiximols can be performed using an immunological urine-based test system for cannabinoid abuse. Seventeen patients with multiple sclerosis were included in this study. Administered doses of nabiximols were correlated with immunologically determined urine concentrations of cannabinoids using the DRITM Cannabinoid (THC) Assay. Significant correlations with the administered nabiximols doses were found for creatinine-normalized urine concentrations of cannabinoids without (r = 0.675; p = 0.0015) and after (r = 0.650; p = 0.0044) hydrolysis, as well as for gas-chromatography-coupled mass spectrometry (GC/MS)-measured concentrations of the THC metabolite 11-nor-9-carboxy-Δ9-THC (THC-COOH) in urine samples (r = 0.571; p = 0.0084) by Pearson's correlation. In addition, doses were significantly correlated with plasma THC-COOH concentrations (r = 0.667; p = 0.0017) measured by GC/MS. Simple immunological cannabinoid measurements in urine samples could provide an estimate of nabiximols dosage, although the correlations obtained here were weak because of the small number of patients observed. Longitudinal monitoring of individual patients is expected to exhibit good results of therapeutic drug monitoring of nabiximols.

Influence of Test Specimen Geometry and Water Soaking on the In Vitro Cytotoxicity of Orthocryl®, Orthocryl® LC, Loctite® EA 9483 and Polypropylene.

Depending on their composition, plastics have a cytotoxic potential that needs to be evaluated before they are used in dentistry, e.g., as orthodontic removable appliances. Relevant guidelines set out requirements that a potential new resin in the medical field must meet, with a wide scope for experimental design. In the present study, test specimens of different geometries consisting of varying polymers (Orthocryl®, Orthocryl® LC, Loctite® EA 9483, Polypropylene) were soaked for different periods of time, then transferred to cell culture medium for 24 h, which was subsequently used for 24-h cultivation of A549 cells, followed by cytotoxicity assays (WST-1, Annexin V-FITC-propidium iodide (PI) flow cytometry). In this context, a reduction in the cytotoxic effect of the eluates of test specimens prepared from Orthocryl® LC and Loctite® EA 9483 was particularly evident in the Annexin V-FITC-PI assay when the soaking time was extended to 48 h and 168 h, respectively. Consistent with this, a reduced release of potentially toxic monomers into the cell culture medium, as measured by gas chromatography-mass spectrometry, was observed when the prior soaking time of test specimens of all geometries was extended. Remarkably, a significant increase in cytotoxic effect was observed in the WST-1 assay, which was accompanied by a higher release of monomers when the thickness of the test sample was increased from 0.5 to 1.0 mm, although an elution volume adapted to the surface area was used. However, further increasing the thickness to 3.0 mm did not lead to an increase in the observed cytotoxicity or monomer release. Test specimens made of polypropylene showed no toxicity under all test specimen sizes and soaking time conditions. Overall, it is recommended to perform toxicity studies of test specimens using different geometries and soaking times. Thereby, the influence of the different specimen thicknesses should also be considered. Finally, an extension of the test protocols proposed in ISO 10993-5:2009 should be considered, e.g., by flow cytometry or monomer analysis as well as fixed soaking times.

Non-Invasive O-Toluidine Monitoring during Regional Anaesthesia with Prilocaine and Detection of Accidental Intravenous Injection in an Animal Model.

Regional anaesthesia is well established as a standard method in clinical practice. Currently, the local anaesthetics of amino-amide types such as prilocaine are frequently used. Despite routine use, complications due to overdose or accidental intravenous injection can arise. A non-invasive method that can indicate such complications early would be desirable. Breath gas analysis offers great potential for the non-invasive monitoring of drugs and their volatile metabolites. The physicochemical properties of o-toluidine, the main metabolite of prilocaine, allow its detection in breath gas. Within this study, we investigated whether o-toluidine can be monitored in exhaled breath during regional anaesthesia in an animal model, if correlations between o-toluidine and prilocaine blood levels exist and if accidental intravenous injections are detectable by o-toluidine breath monitoring. Continuous o-toluidine monitoring was possible during regional anaesthesia of the cervical plexus and during simulated accidental intravenous injection of prilocaine. The time course of exhaled o-toluidine concentrations considerably differed depending on the injection site. Intravenous injection led to an immediate increase in exhaled o-toluidine concentrations within 2 min, earlier peak and higher maximum concentrations, followed by a faster decay compared to regional anaesthesia. The strength of correlation of blood and breath parameters depended on the injection site. In conclusion, real time monitoring of o-toluidine in breath gas is possible by means of PTR-ToF-MS. Since simulated accidental intravenous injection led to an immediate increase in exhaled o-toluidine concentrations within 2 min and higher maximum concentrations, monitoring exhaled o-toluidine may potentially be applied for the non-invasive real-time detection of accidental intravenous injection of prilocaine.

A red flag for diagnosing brain death: decompressive craniectomy of the posterior fossa.

PURPOSE: Brain death/death by neurologic criteria (BD/DNC) may be determined in many countries by a clinical examination that shows coma, brainstem areflexia, and apnea, provided the conditions causing reversible loss of brain function are excluded a priori. To date, accounts of recovery from BD/DNC in adults have been limited to noncompliance with guidelines. CLINICAL FEATURES: We report the case of a 72-yr-old man with a combined primary infratentorial (hemorrhagic) and secondary global (anoxic) brain lesion in whom decompressive craniectomy of the posterior fossa and six-hour therapeutic hypothermia (33-34°C) followed by 8-hour rewarming to ≥ 36°C were conducted. Thirteen hours later, clinical findings of brain function loss were documented in addition to guideline-compliant exclusion of reversible causes (arterial hypotension, intoxication, depressant drug effects, relevant metabolic or endocrine disequilibrium, chronic hypercapnia, neuromuscular disorders, and administration of a muscle relaxant). Since a primary infratentorial brain lesion was present, German guidelines required further ancillary testing. Doppler ultrasonography revealed some preserved cerebral circulation, and BD/DNC was not diagnosed. Approximately 24 hr after rewarming to ≥ 36°C, the patient exhibited respiratory efforts. He continued with assisted respiration until final asystole/apnea, without regaining additional brain function other than mild signs of hemispasticity. Follow-up computed tomography showed partial herniation of the cerebellum through the craniectomy gap of the posterior fossa, alleviating caudal brain stem compression. CONCLUSIONS: Therapeutic decompressive craniectomy of the posterior fossa may allow for delayed reversal of apnea. In these patients, proof of cerebral circulatory arrest should be mandatory for diagnosing BD/DNC.

RéSUMé: OBJECTIF: Dans de nombreux pays, la mort cérébrale / décès déterminé par des critères neurologiques (MC / DDN) peut être déterminée par un examen clinique qui montre le coma, l'aréflexie du tronc cérébral et l'apnée, sous réserve que les conditions causant une perte réversible de la fonction cérébrale soient exclues a priori. À ce jour, les comptes rendus décrivant un rétablissement après une MC / DDN chez les adultes ont été limités en raison d'un non-respect des lignes directrices. CARACTéRISTIQUES CLINIQUES: Nous rapportons le cas d'un homme de 72 ans atteint d'une lésion cérébrale sous-tentorielle primaire (hémorragique) et secondaire globale (anoxique) chez qui une craniectomie décompressive de la fosse postérieure et une hypothermie thérapeutique de six heures (33-34 °C), suivie d'un réchauffement de 8 heures à ≥ 36 °C, ont été réalisés. Treize heures plus tard, les résultats cliniques de la perte de la fonction cérébrale ont été documentés, en plus de l'exclusion conforme aux lignes directrices des causes réversibles (hypotension artérielle, intoxication, effets des médicaments dépresseurs, déséquilibre métabolique ou endocrinien pertinent, hypercapnie chronique, troubles neuromusculaires et administration d'un relaxant musculaire). Étant donné qu'une lésion cérébrale sous-tentorielle primaire était présente, les directives allemandes exigeaient la réalisation d'autres tests auxiliaires. L'échographie Doppler a révélé la préservation d'une certaine circulation cérébrale, et la MC / DDN n'a pas été diagnostiquée. Environ 24 heures après le réchauffement du patient à ≥ 36 °C, le patient a manifesté des efforts respiratoires. Il a continué à respirer avec assistance jusqu'à l'asystole / l'apnée finale, sans retrouver de fonction cérébrale supplémentaire autre que de légers signes d'hémispasticité. La tomodensitométrie de suivi a montré une hernie partielle du cervelet à travers l'espace de craniectomie de la fosse postérieure, soulageant la compression caudale du tronc cérébral. CONCLUSION: La craniectomie décompressive thérapeutique de la fosse postérieure peut permettre une inversion retardée de l'apnée. Chez ces patients, la preuve d'un arrêt circulatoire cérébral devrait être obligatoire pour diagnostiquer une MC / DDN.

Lovastatin lactone elicits human lung cancer cell apoptosis via a COX-2/PPARγ-dependent pathway.

Statins (3-hydroxy-3-methylglutaryl coenzyme A [HMG-CoA] reductase inhibitors) are well-established agents to treat hyperlipidemic states. Experimental and epidemiological evidence further implies an anticancer effect of these substances. This study investigates the mechanism underlying human lung cancer cell death by lovastatin and the role of the prostaglandin (PG)-synthesizing enzyme cyclooxygenase-2 (COX-2) in this process. In A549 and H358 lung carcinoma cells the lipophilic prodrug lovastatin lactone led to a concentration-dependent decrease of viability and induction of DNA fragmentation, whereas its HMG-CoA-inhibitory, ring-open acid form was inactive in this respect. Apoptotic cell death by lovastatin was accompanied by high intracellular levels of the lactone form, by upregulation of COX-2 mRNA and protein, as well as by increased formation of peroxisome proliferator-activated receptor γ (PPARγ)-activating PGD2 and 15-deoxy-Δ12,14-PGJ2. Cells were significantly less sensitive to lovastatin-induced apoptotic cell death, when the expression or activity of COX-2 was suppressed by siRNA or by the COX-2 inhibitor NS-398. Apoptosis by lovastatin was likewise reversed by the PPARγ antagonist GW9662. Fluorescence microscopy analyses revealed a lovastatin-induced cytosol-to-nucleus translocation of PPARγ that was inhibited by NS-398. Collectively, this study demonstrates COX-2 induction and subsequent COX-2-dependent activation of PPARγ as a hitherto unknown mechanism by which lovastatin lactone induces human lung cancer cell death.

Pro-oxidative toxicity of cells in suspension does not point to a cell cultural artefact as an explanation of the increased susceptibility of alveolar epithelial-like cells after glucocorticoid pretreatment.

The influence of cell numbers on peroxide-(tertiary butylhydroperoxide (tBHP) or hydrogen peroxide-(HP)) or zinc-(zinc chloride) induced oxidative stress was assessed in alveolar epithelial-like cell lines in this work. Differences in cell numbers change the cellular glutathione and glutathione reductase activity as well as the amount of exported glutathione and therefore might influence susceptibility against oxidative stress. Toxicity due to zinc decreased, toxicity due to HP increased, while tBHP-mediated toxicity was unchanged in our experiments when cells were exposed in suspension as compared to monolayers. Toxicity of HP correlated to the glutathione content in monolayers and in cell suspensions, while zinc- or tBHP-mediated toxicity did not correlate towards glutathione. Decreasing cellular glutathione and the activity of some antioxidative enzymes by glucocorticoid pretreatment had no effect on toxicity of zinc or tBHP in L2 cells in suspensions, while toxicity in monolayers was increased. Glucocorticoid pretreatment seems to increase toxicity of HP in A549 monolayers according to the lowered protein content, while toxicity might be changed by a different way when cells are incubated as cell suspensions. No explanation as a cell culture artificial effect was observed, therefore we assume the increased toxicity after glucocorticoid pretreatment occurs in vivo as well.

Induction but not inhibition of COX-2 confers human lung cancer cell apoptosis by celecoxib.

The antitumorigenic mechanism of the selective cyclooxygenase-2 (COX-2) inhibitor celecoxib is still a matter of debate. Among different structurally related COX-2 inhibitors, only celecoxib was found to cause apoptosis and cell death of human lung cancer cells (IC50 values of 19.96 µM [A549], 12.48 µM [H460], and 41.39 µM [H358]) that was paralleled by a time- and concentration-dependent upregulation of COX-2 and peroxisome proliferator-activated receptor γ (PPARγ) at mRNA and protein levels. Apoptotic death of celecoxib-treated cancer cells was suppressed by the PPARγ antagonist GW9662 and by siRNA targeting PPARγ and, surprisingly, also by the selective COX-2 inhibitor NS-398 and siRNA targeting COX-2. NS-398 (1 µM) was shown to suppress celecoxib-induced COX-2 activity. Among the COX-2-dependent prostaglandins (PG) induced upon celecoxib treatment, PGD2 and 15-deoxy-Δ¹²,¹4-PGJ2 were found to induce a cytosol-to-nucleus translocation of PPARγ as well as a PPARγ-dependent apoptosis. Celecoxib-elicited PPARγ translocation was inhibited by NS-398. Finally, a COX-2- and PPARγ-dependent cytotoxic action of celecoxib was proven for primary human lung tumor cells. Together, our data demonstrate a proapoptotic mechanism of celecoxib involving initial upregulation of COX-2 and PPARγ and a subsequent nuclear translocation of PPARγ by COX-2-dependent PGs.

Metabolism of TEGDMA and HEMA in human cells.

Previous in vivo studies have shown that the comonomers triethylene glycol dimethacrylate (TEGDMA) and 2-hydroxyethyl methacrylate (HEMA) from dental materials can be metabolised to CO(2) by two postulated pathways: an epoxide and a valine pathway. In the epoxide pathway the formation of pyruvate is postulated and in valine pathway the formation of l-malate. The aim of this investigation was to quantify the formation of the intermediates pyruvate and l-malate to show which pathway may be preferred in A549 cells. Therefore A549 cells were incubated with TEGDMA or HEMA (with a tracer dose 14C-TEGDMA or 14C-HEMA) and afterwards 14C-TEGDMA or 14C-HEMA, 14C-methacrylate, 14C-l-malate and 14C-pyruvate were identified and quantified by thin layer chromatography at different time intervals from the extracellular and intracellular fluid. Our results show that in the metabolism of both comonomers more 14C-pyruvate was formed compared to 14C-l-malate for 14C-HEMA metabolisation during 0.5 up to 6h after 14C-HEMA exposure and for 14C-TEGDMA metabolisation >4h after 14C-TEGDMA exposure. Therefore the epoxide pathway with formation of the epoxy-intermediate 2,3-epoxymethacrylic acid is the main route of metabolisation of HEMA and TEGDMA.

Glutathione synthesis against oxidant injury by peroxides in two alveolar epithelial cell lines.

The D- and L-forms of N-acetylcysteine (NADC, NAC) were tested in antagonizing the toxicity mediated by hydrogen peroxide (H(2)O(2)) or tertiary butyl hydroperoxide (tBHP) in two lung cell lines to assess the effectivity of glutathione synthesis against peroxides. Toxicity was assessed by methionine incorporation, total glutathione content, and glutathione disulfide to glutathione ratio. NAC or NADC, at 2 mmol/L, increased cellular glutathione to about 1.5- or 3-fold (NAC) and 1.1- or 1.2-fold (NADC) in A549 or L2 cells, respectively, as compared to naive cells. H(2)O(2)-mediated toxicity was decreased by NADC (as compared to controls), but increased slightly with NAC, whereas tBHP-mediated toxicity was decreased both by NAC and NADC. However, when compared to controls, NADC was an effective antidote against tBHP in L2 cells only. Dexamethasone pretreatment increased toxicity of H(2)O(2) and tBHP in L2 cells, but did not affect the antioxidative efficacy of NAC/NADC. Antidotal properties of NAC/NADC were similar in both cell lines, despite significant differences of the glutathione redox system in both situations. Hence, it is concluded that direct antioxidative properties of NAC and NADC is a main antagonizing factor in H(2)O(2)-based toxicity but not in tBHP-mediated toxicity. Enhancement of glutathione biosynthesis decreased toxicity of tBHP, but not of H(2)O(2) in 2 pulmonary cell lines.

Glucocorticoid pretreatment increases toxicity due to peroxides in alveolar epithelial-like cell lines.

In previous experiments an increase in zinc-mediated toxicity was found after pretreatment of alveolar epithelial type II-like cells with glucocorticoids. In this work toxicity of two peroxides (tertiary butyl hydroperoxide [tBHP], hydrogene peroxide [HP]) was assessed in L2 and A549 cells compared to dexamethasone (DEX) pretreated cells. Pretreatment of cells with 7.5micromol/l DEX for 72h decreased cellular glutathione content in both cell lines. Furthermore compared to not pretreated cells toxicity of both peroxides was increased in A549 cells, while in L2 cells only toxicity of tBHP was significantly increased by the glucocorticoid pretreatment. HP toxicity only showed a tendency to be increased in L2 cells after DEX pretreatment. The results point to a glucocorticoid-dependent increased oxidative stress of alveolar epithelial type II cells as antagonised by antioxidative enzymes such as catalase and/or preferentially by the glutathione system. This furthermore should be considered for all glucocorticoid applications in vivo as well.

Enhancing glutathione synthesis can decrease zinc-mediated toxicity.

Zinc toxicity has been linked to cellular glutathione: A decrease in glutathione is followed by an increase in zinc-mediated toxicity. The question arises whether an increase in glutathione synthesis might decrease zinc-mediated cytotoxicity. We incubated five cell lines (hepatoma and lung-derived) with zinc chloride and 2 mmol/l N-acetyl-L-cysteine (NAC) to support glutathione synthesis. In all but one hepatic cell line, the glutathione content was increased by NAC as compared to the D-enantiomere NADC, whereas NADC did not increase GSH content as compared to not treated controls. In both alveolar epithelial cell lines, an increase in zinc tolerance was observed due to NAC as compared to NADC. In native fibroblast-like and the hepatoma cell lines, no changes in zinc tolerance were found due to NAC. In the fibroblast-like cells, zinc tolerance was increased due to NAC only after cellular glutathione had been previously decreased (by lowered cysteine concentrations in the medium). Enhancing glutathione synthesis can antagonize zinc-mediated toxicity in the alveolar epithelial cell lines, whereas some other characteristics than glutathione synthesis might be more important in other cell types. Furthermore, NAC acted as a GSH precursor only at cysteine medium concentrations of 10 micromol/l or below and therefore might be described as a poor cysteine repletor for glutathione synthesis.

Changes in the glutathione system of lung cell lines after treatment with hydrocortisone.

Administration of anti-inflammatory glucocorticoids is a drug option in the therapy of acute respiratory distress syndrome (ARDS), according to present pathophysiological concepts. Surprisingly, glucocorticoids failed to show beneficial effects. This failure is not understood. In this investigation changes in the glutathione system due to hydrocortisone were found to consist of glutathione depletion and lowered glutathione reductase activities in alveolar epithelial type II cells, contrasted with unchanged activities in a fibroblast-like lung cell line. The glutathione system is thought to be the most important cellular antioxidative system and therefore alveolar epithelial type II cells might be more susceptible to oxidative stress after glucocorticoid treatment. As alveolar epithelial type II cells may be important targets in ARDS, because of their functions (stem cells of type I epithelial cells; surfactant synthesis), these changes might provide an explanation for the failure of glucocorticoids. In the present experiments the capability of hydrocortisone-treated alveolar epithelial type II cells to synthesise glutathione was found to be cysteine dependent at physiological concentrations. Transposing this observation to the in vivo situation, it might be expected that glucocorticoid efficacy in ARDS therapy requires co-administration of substances that increase glutathione synthesis, e.g. N-acetylcysteine.

Uptake, clearance and metabolism of TEGDMA in guinea pigs.

OBJECTIVE: The resin monomer triethyleneglycoldimethacrylate (TEGDMA) is used as a diluent in many resin-based bonding, cementing and direct tooth filling materials. METHODS: In the present study the uptake and the clearance of 14C-TEGDMA applied via different routes were examined in vivo in guinea pigs. TEGDMA (0.02 mmol/kg by weight labeled with a tracer dose 14C-TEGDMA 0.7Bq/g by weight) was administered by gastric tube or by subcutaneous injection. Urine, feces, and exhaled carbon dioxide were collected for 24h after administration. The animals were killed 24h after the beginning of the experiment and various organs removed and 14C-radioactivity measured. RESULTS: It was apparent that 14C-TEGDMA was taken up rapidly from the stomach and small intestine after gastric administration and was widely distributed in the body following administration by each of the routes. Clearance from most tissues following gastric and intradermal administration was essentially complete within one day. Low fecal 14C-levels (<1% of the administered dose) and urinary levels of about 15% after 24h were noted with each route of administration. Direct measurement of exhaled carbon dioxide showed that 60-65% of the administered dose of 14C left the body via the lungs during 24h. It is likely that 14C-pyruvate is formed in vivo resulting possibly in the formation of toxic 14C-TEGDMA-intermediates. SIGNIFICANCE: Despite using a high administered dose, the peak TEGDMA levels in all tissues examined after 24h were at least 100,000-fold less than known toxic levels.