Results of randomized controlled trials of low-versus high-osmolality contrast media

The authors reviewed 100 randomized controlled trials (RCTs) conducted in humans to compare safety or efficacy of new low-osmolality contrast media (LOM) with that of high-osmolality contrast media (HOM). Findings of the 43 RCTs judged to be of the highest quality suggest that the efficacy of LOM in imaging is equal or superior to that of HOM for all routes of administration. Heat sensation occurred less often with LOM for all routes and pain occurred less often with LOM for intraarterial routes. No differences were seen in nephrotoxicity or in frequency of nausea, vomiting, urticaria, bronchospasm, laboratory test abnormalities, or neurologic events. Greater cardiovascular changes were seen with HOM, including increased or decreased heart rate, increased left ventricular end-diastolic pressure, decreased systolic pressure, and QT prolongation, depending on route of administration. To demonstrate whether a reduction in clinically significant adverse outcomes truly occurs with LOM, trials will need to enlist larger numbers of patients and employ appropriate outcome measures. Future trials should stratify patients according to their risk of adverse reactions to provide better information about benefits of LOM in low- versus high-risk patients.     

Functional and ligand binding studies suggest heterogeneity of platelet prostacyclin receptors.

1. This study describes attempts to compare prostacyclin (IP-) receptors in human, pig, horse, rabbit and rat platelets and in circular muscle of human, rabbit and dog mesenteric and pig gastroepiploic arteries. Three stable prostacyclin analogues, iloprost, cicaprost and 6a-carba-prostacyclin (6a-carba-PGI2) and a prostaglandin endoperoxide analogue EP 157 (previously shown to mimic prostacyclin on human platelets) were used. 2. Our main conclusion is that prostacyclin receptors on human, pig and horse platelets are similar in nature, but distinct from those on rabbit and rat platelets. Functional studies (inhibition of aggregation) showed that iloprost and cicaprost always had similar potencies whereas 6a-carba PGI2 was much more potent than EP 157 on rabbit and rat platelets (300 and 1000 fold on a molar basis) compared with human, pig and horse platelets (2, 7 and 7 fold respectively). Measurement of initial rates of cyclic AMP production confirmed these orders of potency. 3. Although pig platelets were quite sensitive to inhibition by EP 157 (threshold = 10 nM in some experiments), maximal inhibition of aggregation was not always achieved (20 microM). EP 157 also produced only small elevations of cyclic AMP and inhibited rises in cyclic AMP induced by iloprost. It is possible that EP 157 has a lower efficacy than iloprost at the IP-receptor and on pig platelets it can sometimes act as a partial agonist. 4. Human, pig and horse platelet membranes bound [3H]-iloprost at 30 degrees C and this binding was inhibited by the four prostanoids. On human and pig membranes the order of potency was cicaprost = iloprost greater than 6a-carba PGI2 greater than EP 157. The order of potency may be similar on horse platelet membranes, but the analysis is complicated by the presence of a second component of [3H]-iloprost binding that is inhibited by iloprost and 6a-carba PGI2 but not by cicaprost. This binding may be due to the presence of an EP1-receptor, since iloprost and 6a-carba PGI2 but not cicaprost are known to have potent EP1-receptor agonist actions on smooth muscle preparations. IC50 values for cicaprost inhibition on human, pig and horse membranes were 110, 90 and 165 nM respectively. The need for IP-receptor radioligands of greater specificity is apparent from these studies. 5. Minimal binding of [3H]-iloprost to rabbit and rat platelet membranes was obtained at 30 degrees C.(ABSTRACT TRUNCATED AT 400 WORDS)     

The lesions of an ovine lysosomal storage disease. Initial characterization.

An inherited disease associated with deficiencies of beta-galactosidase and alpha-neuraminidase has been identified recently in sheep. The clinical signs, the deficiency of lysosomal enzymes, and the familial nature of the disorder suggested that the condition was a lysosomal storage disease. Four affected sheep were necropsied and their tissues were examined by histopathologic and histochemical methods to determine if the lesions were consistent with a lysosomal storage disease. Central nervous system neurons were enlarged with finely to coarsely granular cytoplasmic material, or less often, neurons were distended with multiple, variably-sized vacuoles. Loss of neurons without gliosis was evident and the Nissl substance was either dispersed and fragmented or condensed around the nuclei of remaining neurons. Neurons of intestinal and other peripheral ganglia, retinal ganglion cells, and heart Purkinje fibers were enlarged similarly. White matter of the cerebrum and spinal cord had numerous spheroid to ellipsoid axonal enlargements. Periportal hepatocytes and renal epithelial cells were enlarged with marked vacuolation. The neuronal storage material stained intensely with periodic acid-Schiff/alcian blue, with Luxol fast blue, for acid phosphatase, and moderately with oil red O stains. Renal and hepatocyte storage material stained intensely with oil red O and moderately with periodic acid-Schiff/alcian blue and Sudan black B stains. The lesions in these sheep were consistent with those of a lysosomal storage disease. Both neuronal and visceral storage occurred, but the neuronal storage was more severe.     

Endometriosis of the recto-vaginal septum treated by anterior resection

Two young nulliparous females with severe symptomatic recto-vaginal endometriosis that had not responded to medical treatment were considered for surgery. Pre-operatively they were investigated by laparoscopy and Magnetic Resonance Imaging (M.R.I.) which demonstrated that the lesions were confined to the recto-vaginal septum with no intraperitoneal involvement. Both patients underwent resection of the middle third of the rectum and part of the posterior wall of the vagina with preservation of the ovaries, uterus and fallopian tubes. In one patient a J-colonic pouch with colo-anal anastomosis was fashioned and in the other patient a stapled colo-rectal anastomosis. Both patients are now asymptomatic with normal bowel function six months post-operatively. Radical surgery is indicated very rarely. We believe it should be considered in young nulliparous women who wish to conceive, in whom the diagnosis has been confirmed histologically and who have severe symptoms. M.R.I. is a useful pre-operative investigation to delineate the extent of the disease.     

Effects of aging on nicotinic and muscarinic autoreceptor function in the rat brain: relationship to presynaptic cholinergic markers and binding sites

The main objective of the present work was to determine whether the regulation of ACh release by nicotinic and muscarinic autoreceptors is compromised in the aged rat brain. For this, the effects of the nicotinic agonist N-methylcarbamylcholine (MCC) and the muscarinic-M2 antagonist AF-DX 116 on ACh release from brain slices of young (3-month-old), adult (9-month-old), and aged (27-month-old) rats were tested. The ability of MCC to enhance spontaneous ACh release in hippocampal, cerebral cortical, and cerebellar slices was only modestly altered with age. In contrast, the sensitivity of muscarinic autoreceptors in the aged hippocampus and cerebral cortex, but not the striatum, to blockade by the muscarinic-M2 antagonist AF-DX 116 was severely attenuated. To assess whether the age-related changes in cholinergic autoreceptor function may be due to deficits in presynaptic cholinergic markers, we tested whether choline acetyltransferase (ChAT) activity, basal and evoked ACh release, and nicotinic and muscarinic binding sites are altered in the aged rats. ChAT activity in forebrain regions was decreased in the aged compared to the young and mature adult rats. Furthermore, the potassium-evoked, but not the spontaneous, release of ACh was markedly depressed in striatal, hippocampal, and cortical slices of aged rats. The densities of nicotinic and muscarinic-M2 binding sites, assessed using 3H-MCC and 3H-AF-DX 116 as selective ligands, respectively, were markedly reduced in homogenates of the striatum, hippocampus, cerebral cortex, and thalamus of aged rats. In contrast, muscarinic-M1 sites, selectively labeled with 3H-pirenzepine, were not affected. Therefore, it appears that age-related decrements in ChAT activity and in muscarinic-M2, but not nicotinic, binding sites in the rat brain are reflected in a decreased function of muscarinic-M2 autoreceptors. However, the positive correlation between loss of ChAT activity, decreased muscarinic-M2 binding sites, and impaired muscarinic autoreceptor function is clearly tissue dependent.     

Successful treatment with etoposide phosphate in patients with previous etoposide hypersensitivity.

OBJECTIVE: To review the experience of treatment with etoposide phosphate in patients with acute etoposide hypersensitivity treated in a large tertiary referral center hospital specializing in curable malignancies. CASE SUMMARIES: The cases of 6 patients with advanced malignancies who experienced acute etoposide hypersensitivity are documented. There were 3 male and 3 female patients and their ages ranged from 16 to 68. Four patients had curable malignancies with trophoblast tumors or germ cell tumors and two were receiving palliative chemotherapy for other malignancies. All of the 6 patients who experienced etoposide hypersensitivity developed their symptoms in the first few minutes of the initial infusion. The most common symptoms were chest pain, facial flushing, and bronchospasm. All of the patients had emergency treatment with discontinuation of the infusion and usually the administration of hydrocortisone and chlorpheniramine, which lead to the rapid resolution of their symptoms.For the next cycle of chemotherapy each patient was rechallenged with etoposide phosphate, with steroid cover given in only two of the cases. None of the 6 patients experienced any hypersensitivity symptoms on treatment with etoposide phosphate and in one the steroids were withdrawn for all the subsequent cycles. The 4 patients with curable malignancies all remain disease free, while the 2 palliative patients obtained significant control of their disease. DISCUSSION: Etoposide is one of the most important chemotherapy drugs in the treatment of many curable malignancies but an acute hypersensitivity reaction occurs in around 1% of patients. Retreatment with etoposide in these patients is difficult and generally alternative drugs/regimens have to be used. A small number of case reports have suggested that etoposide phosphate can be safely used in these patients and 6 cases have been found in the pharmacy records where this has been done. In all of the patients, treatment with etoposide phosphate proceeded without any symptoms or the use of repeated steroid cover in 5 of the 6 patients. CONCLUSION: Etoposide hypersensitivity is a rare clinical problem and responds promptly to drug discontinuation, steroids, and chlorpheniramine. Patients with previous etoposide hypersensitivity can safely be treated with etoposide phosphate and do not need any additional hypersensitivity prophylaxis.     

Isthmic spondylolysis of the lumbar spine: MR imaging at 1.5 T

The appearance on magnetic resonance (MR) images of the normal pars interarticularis in 13 patients was reviewed and contrasted with that of the pars in eight patients with spondylolysis. The pars defect usually had an intermediate signal intensity with all pulse sequences; however, this intensity was somewhat variable depending on the exact ratio of cartilage, fat, and fluid within each bone defect. The pars defect was best seen with spin-echo 600/20 (repetition time msec/echo time msec) images. In three cases, out-of-phase images showed the spondylolysis best, because of extension of fat to the borders of the defect. The sagittal view allowed one to separate spondylolysis from the joint space of posterior facets since the orientation of the defects is perpendicular to the facets; thus, a common pitfall encountered with cross-sectional axial imaging techniques is avoided. MR imaging poorly delineated bone fragments around the defect, which may produce nerve root impingement, but revealed other numerous complications that occur with spondylolysis, including spondylolisthesis and herniation of the disk above.