Diplopia associated with the cosmetic use of botulinum toxin a for facial rejuvenation

We report three cases in which cosmetic injections of botulinum toxin A around the eye caused diplopia. Diplopia was due to inferior oblique paresis, which was bilateral in two cases. We suggest that consent for periocular botulinum toxin procedures should include a warning about diplopia.     

Drug-protein adducts: an industry perspective on minimizing the potential for drug bioactivation in drug discovery and development

It is generally accepted that there is neither a well-defined nor a consistent link between the formation of drug-protein adducts and organ toxicity. Because the potential does exist, however, for these processes to be causally related, the general strategy at Merck Research Laboratories has been to minimize reactive metabolite formation to the extent possible by appropriate structural modification during the lead optimization stage. This requires a flexible approach to defining bioactivation issues in a variety of metabolism vectors and typically involves the initial use of small molecule trapping agents to define the potential for bioactivation. At some point, however, there is a requirement to synthesize a radiolabeled tracer and to undertake covalent binding studies in vitro, usually in liver microsomal (and sometimes hepatocyte) preparations from preclinical species and human, and also in vivo, typically in the rat. This paper serves to provide one pragmatic approach to addressing the issue of bioactivation from an industry viewpoint based on protocols adopted by Merck Research Laboratories. The availability of a dedicated Labeled Compound Synthesis group, coupled to a close working relationship between Drug Metabolism and Medicinal Chemistry, represents a framework within which this perspective becomes viable; the overall aim is to bring safer drugs to patients.     

DNA-binding properties of cosmomycin D, an anthracycline with two trisaccharide chains

Cosmomycin D (CosD) is the major constituent fraction isolated from a culture of Streptomyces olindensis ICB20. The ability of this compound to intercalate with double-stranded DNA was studied by gel mobility shift assays and electrospray ionization mass spectrometry (ESI-MS). ESI-MS experiments showed that the complex of CosD with 16-mer double-stranded DNA was at least as stable as a complex of daunorubicin with the same DNA sequence. This is the first study showing DNA binding properties of an anthracycline containing a beta-rhodomycinone aglycone chromophore O-linked to two trisaccharide chains.     

Sequence variation in the I-like domain of the beta1 integrin subunit in human oral squamous cell carcinomas

We recently identified a heterozygous mutation in the beta1 integrin subunit of a squamous cell carcinoma (SCC) that maps to the I-like domain and activates ligand binding. To investigate the frequency of such mutations we screened 124 human oral SCCs. We identified six single nucleotide changes, all of which were also present in normal tissue, suggestive of polymorphisms. Two were in non-coding intronic sequences. Three were silent changes in exons. One caused a change in amino acid (A239V) that is unlikely to disturb integrin structure. We conclude that mutations in the beta1 I-like domain are uncommon in SCCs. However, population based studies of the polymorphisms we found may reveal an association with SCC development or prognosis.     

Randomized controlled trial of hip protectors among women living in the community

Objective: To asess whether hip protectors used among women living in the community in the United Kingdom and at high risk of hip fracture, lead to a reduction in hip fracture. Design: Pragmatic randomized controlled trial (RCT). Setting: Primary care with participants being recruited largely from general practitioners patient lists. Participants: Women aged 70 years and over with one or more risk factors for hip fracture (i.e., low body weight, current smoker, a prior fracture, family history of hip fracture). Intervention: Three pairs of hip protectors of the shell type mailed to participants with instructions on how to use them. Main outcome measure: Reduction in hip fractures. Results: 1,388 and 2,781 women aged 70 years or over were randomized to be given three pairs of hip protectors or act as controls, respectively. We followed up both groups of women for a minimum of 24 months (maximum 42 months, median 28). Compliance was poor with only 31% of participants reporting that they wore the hip protectors on a daily basis at 12 months. Intention-to-treat analysis showed that there was no statistically significant difference in the unadjusted odds ratios (ORs) of sustaining a hip fracture between the groups (OR=1.19; 95% confidence interval, 0.80 to 1.78, p=0.40). Adjustment for important covariates did not materially change these findings (OR=1.17; 95% CI, 0.78 to 1.75). Comparing the rate of hip fracture between those women who regularly wore the devices and the control group yielded an OR of 1.12 (95% CI, 0.58 to 2.03; p=0.83). Conclusion: This study is the largest RCT of hip protectors to date and provides no evidence of an effect of hip protectors among women living independently and at high risk of fracture.Members of the Primary Care Hip Protector Trial Group are listed in the Appendix.     

Anticoagulant rodenticides

Anticoagulant pesticides are used widely in agricultural and urban rodent control. The emergence of warfarin-resistant strains of rats led to the introduction of a new group of anticoagulant rodenticides variously referred to as 'superwarfarins', 'single dose' or 'long-acting'. This group includes the second generation 4-hydroxycoumarins brodifacoum, bromadiolone, difenacoum, flocoumafen and the indanedione derivatives chlorophacinone and diphacinone. Most cases of anticoagulant rodenticide exposure involve young children and, as a consequence, the amounts ingested are almost invariably small. In contrast, intentional ingestion of large quantities of long-acting anticoagulant rodenticides may cause anticoagulation for several weeks or months. Occupational exposure has also been reported. Anticoagulant rodenticides inhibit vitamin K(1)-2,3 epoxide reductase and thus the synthesis of vitamin K and subsequently clotting factors II, VII, IX and X. The greater potency and duration of action of long-acting anticoagulant rodenticides is attributed to their: (i) greater affinity for vitamin K(1)-2,3-epoxide reductase; (ii) ability to disrupt the vitamin K(1)-epoxide cycle at more than one point; (iii) hepatic accumulation; and (iv) unusually long biological half-lives due to high lipid solubility and enterohepatic circulation. Substantial ingestion produces epistaxis, gingival bleeding, widespread bruising, haematomas, haematuria with flank pain, menorrhagia, gastrointestinal bleeding, rectal bleeding and haemorrhage into any internal organ; anaemia may result. Spontaneous haemoperitoneum has been described. Severe blood loss may result in hypovolaemic shock, coma and death. The first clinical signs of bleeding may be delayed and patients may remain anticoagulated for several days (warfarin) or days, weeks or months (long-acting anticoagulants) after ingestion of large amounts. There are now sufficient data in young children exposed to anticoagulant rodenticides to conclude that routine measurement of the international normalised ratio (INR) is unnecessary. In all other cases, the INR should be measured 36-48 hours post exposure. If the INR is normal at this time, even in the case of long-acting formulations, no further action is required. If active bleeding occurs, prothrombin complex concentrate (which contains factors II, VII, IX and X) 50 units/kg, or recombinant activated factor VII 1.2-4.8 mg or fresh frozen plasma 15 mL/kg (if no concentrate is available) and phytomenadione 10mg intravenously (100 microg/kg bodyweight for a child) should be given. If there is no active bleeding and the INR is < or =4.0, no treatment is required; if the INR is > or =4.0 phytomenadione 10mg should be administered intravenously.     

Stress induces rapid changes in central catecholaminergic activity in Anolis carolinensis: restraint and forced physical activity

Immobilization stress and physical activity separately influence monoaminergic function. In addition, it appears that stress and locomotion reciprocally modulate neuroendocrine responses, with forced exercise ameliorating stress-induced serotonergic activity in lizards. To investigate the interaction of forced physical activity and restraint stress on central dopamine (DA), norepinephrine (NE), and epinephrine (Epi), we measured these catecholamines and their metabolites in select brain regions of stressed and exercised male Anolis carolinensis lizards. Animals were handled briefly to elicit restraint stress, with some lizards additionally forced to run on a track until exhaustion, or half that time (50% of average time to exhaustion), compared to a control group that experienced no restraint or exercise. Norepinephrine concentrations in the hippocampus and locus ceruleus decreased with restraint stress, but returned to control levels following forced exhaustion. Levels of NE in the raphé nuclei and area postrema, and epinephrine in raphé became elevated following restraint stress, and returned to control levels following forced physical activity to 50% or 100% exhaustion. Striatal DA increased as animals were exercised to 50% of exhaustion, and returned to baseline with exhaustion. At exhaustion, striatal Epi levels were diminished, compared with controls. In the area postrema, exhaustion reversed a decline in epinephrine levels that followed forced physical activity. These results suggest that stress stimulates a rapid influence on central catecholamines. In addition, forced exercise, and even exhaustion, may alleviate the effects of restraint stress on central monoamines.