Rapid and slow release phenytoin in epileptic patients at steady state: Comparative plasma levels and toxicity

Phenytoin plasma level and toxicity data were compared in a three-way crossover study performed in 18 patients at steady state. Formulations compared were a rapid and a slow release capsule and an oral solution. Plasma concentration-time integrals and maximum plasma phenytoin levels were significantly greater for the rapid release capsule and solution than for the slow release capsule. The incidence of nystagmus and toxicity did not differ for the three treatments,but the occurrence of mental symptoms was more frequent for the oral solution, possibly because of the solvent used in this formulation.     

Effects of docosahexaenoic acid supplementation on blood lipids, estrogen metabolism, and in vivo oxidative stress in postmenopausal vegetarian women

BACKGROUND: Vegetarians are generally deficient in long-chain n-3 fatty acids. Long-chain n-3 fatty acids have a beneficial effect on plasma lipid levels, and some studies showed that they had breast cancer suppression effect. One of the biomarkers of breast cancer risk is the ratio of urinary 2-hydroxyestrone (2-OHE(1)) to 16alpha-hydroxyestrone (16alpha-OHE(1)). OBJECTIVE: To investigate the effect of docosahexaenoic acid (DHA, 22:6n-3) supplementation on blood lipids, estrogen metabolism and oxidative stress in vegetarians. DESIGN: Single-blind, randomized, placebo-controlled trial. INTERVENTIONS: Twenty-seven postmenopausal vegetarian women were recruited. After a 2-week run-in period with 6 g placebo corn oil, the subjects were subsequently randomized to receive either 6 g corn oil (n=13) or 6 g DHA-rich algae oil (2.14 g of DHA/day) (n=14) for 6 weeks. Two subjects in corn oil group withdrew before completion. MAIN OUTCOME MEASURES: Plasma lipids, urinary 2-OHE(1) and 16alpha-OHE(1), urinary F(2)-isoprostanes and plasma alpha-tocopherol. RESULTS: Plasma LDL-DHA and EPA level increased significantly by DHA supplementation. DHA decreased plasma cholesterol (C) levels (P=0.04), but did not influence the levels of plasma TG, LDL-C and HDL-C, alpha-tocopherol, urinary F(2)-isoprostanes, 2-OHE(1), 16alpha-OHE(1) and ratio of 2-OHE(1) to 16alpha-OHE(1) as compared to corn oil. CONCLUSION: DHA supplementation at a dose of 2.14 g/day for 42 days decreases plasma cholesterol but neither does it show beneficial effects on estrogen metabolism, nor does it induce deleterious effects on the observed in vivo antioxidant or oxidative stress marker in postmenopausal vegetarian women. SPONSORSHIP: A grant (# DOH89-TD-1062) from Department of Health, Executive Yuan, Taiwan.     

The universal influenza vaccine M2e-HBc administered intranasally in combination with the adjuvant CTA1-DD provides complete protection

Mucosal vaccination requires effective and safe adjuvants. We have evaluated the non-toxic adjuvant CTA1-DD for mucosal vaccination against influenza. CTA1-DD contains the enzymatically active CTA1 subunit of cholera toxin (CT) genetically fused to a gene encoding a dimer of the D-fragment from Staphylococcus aureus protein A. CTA1-DD only binds to Ig-receptor carrying cells of the immune system. Nasal administration of the universal influenza vaccine M2e-HBc in combination with CTA1-DD completely protected mice from a potentially lethal infection and significantly reduced morbidity. Sera of mice immunized with M2e-HBc + CTA1-DD revealed IgG subclass profiles consistent with an enhanced Th1-type immunity. When the vaccine was administered intraperitoneally, the adjuvant improved the M2e antibody titer in circulation, but did not significantly reduce the morbidity.     

Treatment of mediastinal immature teratoma in a child with precocious puberty and Klinefelter's syndrome

Teratoma is the most common germ cell tumor, which can be divided into the mature and the immature histologically. Concurrent Klinefelter's syndrome may be overlooked in a patient with a germ cell tumor. This is because the tumor that secrets alpha-fetoprotein and beta human chorionic gonadotropin can mimic puberty in a patient with Klinefelter's syndrome, masking the usual clinical signs. In reviewing the literature on the subject, the role of neoadjuvant and adjuvant chemotherapy remains ill-defined for the immature teratoma. Age-dependent prognosis seems to demonstrate that children with immature teratomas have a better outcome. We share the experience of treating a child with immature teratoma with surgical excision alone, and it ended in a local recurrence.     

Intraarterial infusion chemotherapy as a primary treatment in cancer of uterine cervix limited to the pelvis

Percutaneous intraarterial infusion chemotherapy via the internal iliac arteries was performed as a primary treatment in 14 patients with invasive cancer of the uterine cervix. The drugs used were Mitomycin-C, Bleomycin and Cis-Platinum in cycles of 52 hours which were repeated, in some cases, 21 days apart. Complete responses were observed in two patients. Partial responses were seen in 10 patients and no response in two patients. 5 patients were treated surgically and 8 patients received radiotherapy after the infusion. The effect of chemotherapy was more evident in exophytic tumors with less effect on the parametria. Tumor masses can be reduced and patients can then be treated by surgery or radiotherapy. 6 patients died from sepsis.     

Clinical features, prognostic factors, and their relationship with antiplatelet antibodies in children with immune thrombocytopenia

We investigated and evaluated the demographics, clinical and laboratory features, treatment responses, and disease duration of 25 children with immune thrombocytopenia (ITP) eligible for detection of antiplatelet antibodies. We found that patients without antecedent of preceding infection (API) were more likely to have anti-GPIa/IIa than those with API (42.9% vs. 5.5%, P=0.048). Age groups of <2 years and 2 to 10 years were more likely to show response (R) or complete response (CR) to given treatments, whereas none of the patients whose onset age >10 years showed R or CR to given treatments (88.9% and 100% vs 0%, P=0.001). The percentage of newly diagnosed ITP was higher in age groups of <2 years (100%) and in 2 to 10 years (90%) than the age group of >10 years (16.7%, P=0.001). Patients without API (71.4%) were more likely to develop chronic ITP than those with API (5.6%, P=0.002). In conclusion, younger age was a favorable prognostic factor, especially in patients <2 years of age with respect to treatment responses and disease duration. In addition, API was associated with a short disease course as well as absence of anti-GPIa/IIa.     

Correlation of digital sensibility and precision of pinch force modulation in patients with nerve repair

The outcome measures for patients following peripheral nerve repairs commonly include muscle strength and sensory assessments. However, no significant discussion exists on the impact of nerve injury on sensorimotor control. The objective of this longitudinal study was to explore the effects of nerve regeneration on the control of pinch force in executing functional tasks. Seven patients with digital or median nerve repairs were assessed by a custom‐designed pinch device and conventional sensory tools at monthly intervals following nerve repair. These tools measured sensibility, maximum pinch strength, and anticipated pinch force adjustments to movement‐induced load fluctuations in a pinch‐holding‐up activity (PHUA). Six force‐related and temporal parameters for sensory measurement were used to determine improvements in pinch performance over time following sensory recovery. The results revealed significant differences in the parameters of peak pinch force, baseline pinch force, force ratio, and the percentage of maximal pinch force output at different points in the course of nerve regeneration. A strong relationship was also found between kinetic data from the PHUA test and the traditional sensibility tests for the nerve repair patients in the present study. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29: 1210–1215, 2011     

Single-Nucleotide Polymorphism in the fadD28 Gene as a Genetic Marker for East Asia Lineage Mycobacterium tuberculosis

Mycobacterium tuberculosis isolates with a region of difference 105 (RD105) deletion, mainly Beijing family spoligotypes, were phylogenetically grouped into the East Asia lineage. We identified a single nucleotide polymorphism in codon 507, ATC to ATT, of the fadD28 gene as a robust marker and developed a rapid assay for East Asia lineage M. tuberculosis.Beijing family Mycobacterium tuberculosis has successfully disseminated worldwide (8). The Beijing family isolates were reported to be associated with drug-resistant tuberculosis and disease manifestations (14). In Taiwan, the Beijing family was the most prevalent (44.4%) spoligotype determined by spacer oligonucleotide typing (11) and was associated with isoniazid and ethambutol resistance (10). Furthermore, approximately 3% of our isolates (mostly shared type [ST] no. 523, 246, and 955) could not be classified into any spoligotype families (R. Jou et al., unpublished data). Both single nucleotide polymorphisms (SNPs) and large sequence polymorphisms, with deletions in regions of difference (RD) identified by comparative genomics (16), were robust phylogenetic markers of M. tuberculosis complex. We identified nine SNPs to classify the main lineages of M. tuberculosis and proved that spoligotype ST no. 523 (carrying all 43 spacers) might share the same common ancestor with the Beijing family (4). Analyses of SNPs and deletion of RD105 (including Rv0071, Rv0072, Rv0073, and partial Rv0074 genes of the H37Rv reference strain) provided evidence that not only the Beijing family but also several non-Beijing isolates—ST no. 523 (strain 94_M4241A), 955 (strain 98_1663), and 623 (strain 96_1548)—belonged to the East Asia lineage (lineage 2) (7, 9). The results inferred they should be genetically more similar than other lineages. The aim of this study is to identify a marker for rapid screening of East Asia lineage M. tuberculosis in regions of tuberculosis endemicity, especially if genotyping is not readily accessible, and to facilitate case treatment and public health management.The mycobacterial cell wall is the site of action of some first-line antimycobacterial agents, such as isoniazid, by inhibiting the biosynthesis of mycolic acids (12). We investigated several genes that mediated cell envelope processing of M. tuberculosis. In particular, we focused on one protein of the fatty-acyl AMP ligase (FAAL) family, FadD28. It is responsible for the attachment of mycocerosic acids to phthiocerol in the phthiocerol dimycocerosate (PDIM) synthesis pathway. PDIM is found only in the cell wall of pathogenic mycobacteria (1, 13, 15). We conducted analyses to explore unique SNP of the fadD28 gene in M. tuberculosis lineages.Initially, we interrogated a set of 95 representative and genetic diversified isolates with 95 different IS6110 restriction fragment length polymorphism (RFLP) profiles containing 28 distinct spoligotypes. These 95 isolates included 42 Beijing family isolates, 6 East-African-Indian (EAI) isolates, 30 Haarlem and Haarlem-like isolates (defined in our previous study) (5), 3 Latin American and Mediterranean (LAM) isolates, 1 S isolate, 9 T isolates, 2 H37Rv isolate, and 1 ST no. 523 M. tuberculosis isolate as well as 1 isolate of Mycobacterium bovis BCG (ST no. 482). The polymorphisms of the fadD28 gene were analyzed by PCR amplification and then sequenced with two sets of oligonucleotide primers: (i) forward primer 5′-GGCGACTGCGACAACTCC-3′ and reverse primer 5′-CCTGCAGATTGAAGCGAGC-3′ and (ii) forward primer 5′-GGTACAGGCCGCGACG-3′ and reverse primer 5′-GGGAGG ACTTTTTCAAACGGAT-3′. By comparing the sequencing results to that of the H37Rv strain (GenBank accession no. {"type":"entrez-nucleotide","attrs":{"text":"NC_000962","term_id":"448814763","term_text":"NC_000962"}}NC_000962), an SNP of fadD28 codon 507, ATC to ATT (Ile to Ile), was found in all 42 Beijing family isolates and 1 ST no. 523 isolate, but not in other spoligotypes. Therefore, we suggested that the SNP in fadD28 codon 507 might be a specific marker for the East Asia lineage. To confirm our finding, we performed PCRs to detect the deletion in RD105 with published primers (16). Nevertheless, the flanking region of RD105 was not amplified in the ST no. 523 isolate. We checked the sequence of 94_M4241A (ST no. 523) (http://www.broadinstitute.org/) and found not only Rv0071 to Rv0074 but also Rv0069c (sdaA, encoding l-serine dehydratase) and Rv0070c (glyA2, encoding serine hydroxymethyltransferase) were deleted (Fig. ​(Fig.1).1). Therefore, we redesigned primers 68F (5′-TTCGACGACCTCCAGTGGGAACG-3′) and 75R (5′-AACGGAATGCCAGGCGACAGC-3′), which were located in the Rv0068 and Rv0075 flanking regions, respectively, to recognize the larger deletion in RD105. A 606-bp PCR product was amplified in the ST no. 523 isolate and confirmed by sequencing. Interestingly, non-Beijing isolates belonging to the East Asia lineage harbored a larger deletion fragment in RD105 than Beijing ones. sdaA and glyA2 encoded proteins involved in serine catabolism and folate metabolism, respectively (2, 3). The relationship between gene expression and different sublineages in East Asia lineage needs to be further investigated.Open in a separate windowFIG. 1.Schematic diagram of deletion in RD105 in Beijing family (02_1987 and T85) and non-Beijing East Asia lineage (94_M4241A) strains. Open reading frames of H37Rv are corresponding to the annotation of Cole et al. (6). The annotation of 02_1987, T85, and 94_4241A strains were designated according to the Broad Institute database (http://www.broadinstitute.org/). Gray and white arrows indicate primers used to amplify flanking region of RD105 in Beijing strains (16) and larger deletion in RD105 in 94_4241A (ST no. 523) strain in this study, respectively. The deleted region in the Beijing and 94_4241A strains is indicated by dash lines.Consequently, we designed a real-time TaqMan SNP assay for assessing the rapid identification of East Asia lineage M. tuberculosis in routine practices. Primer-probe sets of fadD28 codon 507 were designed by Applied Biosystems for the ABI 7500 real-time PCR system. The following primers and probes were used: forward primer 5′-CGCAGCACCGAAAAGCT-3′, reverse primer 5′-CATCGCGTCCTGATCTGAGT-3′, 6-carboxyfluorescein (FAM) probe 5′-CTTGAGTTCAATAATG-3′, and VIC probe 5′-TTCTTGAGTTCGATAATG-3′. The SNP assay was performed following the manufacturer''s instructions and confirmed by sequencing. The diagram of the real-time TaqMan SNP assay demonstrated that fadD28 codon 507 wild-type (ATC), SNP (ATT), and mixed genotypes could be distinctly determined (Fig. ​(Fig.2).2). Of the 232 culture-positive M. tuberculosis clinical isolates tested, all 155 East Asia lineage isolates, including 151 Beijing family isolates and 4 non-Beijing isolates (ST no. 246, 623, 955, and 1226), harbored the SNP in fadD28 codon 507. Conversely, 75 other non-Beijing isolates (15 EAI isolates, 24 Haarlem isolates, 24 T isolates, 2 LAM isolates, 2 S isolates, and 1 MANU isolate, as well as 7 isolates including ST no. 124, 238, 374, 602, 775, 780, and 1570) showed the wild-type allele. Notably, two cultures were clearly determined to be mixed-genotype isolates. Four non-Beijing isolates possessing SNP in fadD28 codon 507 had a concurrent larger deletion in RD105 detected by primers 68F and 75R. In addition, seven non-Beijing isolates (ST no. 124, 238, 374, 602, 775, 780, and 1570) harboring no SNP in fadD28 codon 507 while having an SNP in pimB codon 107 (GGC to GGT) recognized by an SNP assay with forward primer 5′-CGATCCGGATGTCGTGCAT-3′, reverse primer 5′-CCGTAGCTGGACGCGAAA-3′, FAM probe 5′-ATGGAGTCCGCCGTAG-3′, and VIC probe 5′-CATGGAGTCCACCGTAG-3′ (Applied Biosystems) were classified into the lineage “Europe and the Americas” (lineage 4) (4).Open in a separate windowFIG. 2.Diagram of the fadD28 TaqMan SNP assay. Circles, diamonds, triangles, and rectangle represent the fadD28 wild-type (ATC), SNP (ATT), mixed genotypes, and negative control (NTC), respectively.In conclusion, the SNP in the fadD28 codon 507 is an informative marker to recognize M. tuberculosis isolates of the Beijing family and genetically similar non-Beijing East Asia lineage isolates. Due to the redesign of primers 68F and 75R, we have revealed the absence of sdaA and glyA2 gene expression in the non-Beijing East Asia lineage. In addition, genetic characterization of clinical M. tuberculosis isolates required improved SNP definitions rather than spoligotyping alone. Accordingly, a simple and robust real-time TaqMan SNP assay was established for differentiating East Asia lineage M. tuberculosis isolates with 100% sensitivity and specificity in this study.