Urine concentrations of ketamine and norketamine following illegal consumption.

Ketamine, an anesthetic agent primarily used in veterinary medicine and pediatrics, continues to gain in popularity in the drug abuse scene or 'Rave Wave' of all-night dance clubs. The Division of Forensic Toxicology Laboratory (Office of the Armed Forces Medical Examiner) at the Armed Forces Institute of Pathology, as the primary analytical laboratory for criminal investigative agencies in the Department of Defense (DOD), has seen requests for ketamine analysis rise from 1 in 1997 to 116 in 2000. This increasing abuse has led the DOD Urine Drug Testing Laboratories to consider adding ketamine screening to their random urinalysis program. However, before ketamine testing can be implemented as standard policy, concentrations of ketamine and metabolites in urine need to be evaluated after actual drug use. There is very little information regarding the pharmacokinetics of ketamine, especially concentrations of the drug or its two major metabolites, norketamine and dehydronorketamine, that can be expected in urine. In fact, dehydronorketamine has been believed to be an analytical artifact caused by the high temperatures of gas chromatography. In this paper, we attempt to resolve this issue with the development of a liquid chromatography-mass spectrometry (LC-MS) method. The urine concentrations of ketamine, norketamine and dehydronorketamine (presumptive) detected in 33 "positive" cases received in our laboratory since 1998 are reported. Quantitations were accomplished with LC-MS. Ketamine concentrations ranged from 6 to 7744 ng/mL. Norketamine concentrations ranged from 7 to 7986 ng/mL and dehydronorketamine (presumptive) concentrations ranged from 37 to 23,239 ng/mL.

Recovery of neurofilament expression selectively in regenerating reticulospinal neurons.

During regeneration of lamprey spinal axons, growth cones lack filopodia and lamellipodia, contain little actin, and elongate much more slowly than do typical growth cones of embryonic neurons. Moreover, these regenerating growth cones are densely packed with neurofilaments (NFs). Therefore, after spinal hemisection the time course of changes in NF mRNA expression was correlated with the probability of regeneration for each of 18 identified pairs of reticulospinal neurons and 12 cytoarchitectonic groups of spinal projecting neurons. During the first 4 weeks after operation, NF message levels were reduced dramatically in all axotomized reticulospinal neurons, on the basis of semiquantitative in situ hybridization for the single lamprey NF subunit (NF-180). Thereafter, NF expression returned toward normal in neurons whose axons normally regenerate beyond the transection but remained depressed in poorly regenerating neurons. The recovery of NF expression in good regenerators was independent of axon growth across the lesion, because excision of a segment of spinal cord caudal to the transection site blocked regeneration but did not prevent the return of NF-180 mRNA. The early decrease in NF mRNA expression was not accompanied by a reduction in NF protein content. Thus the axotomy-induced loss of most of the axonal volume resulted in a reduced demand for NF rather than a reduction in volume-specific NF synthesis. We conclude that the secondary upregulation of NF message during axonal regeneration in the lamprey CNS may be part of an intrinsic growth program executed only in neurons with a strong propensity for regeneration.

A continuous quality improvement process to increase organ and tissue donation.

The Omnibus Budget Reconciliation Act of 1987 mandated that hospitals must identify potential organ and tissue donors, notify an organ procurement organization of the potential donor, and inform family members regarding the opportunity to donate organs and tissues. Although the Joint Commission on Accreditation of Healthcare Organizations requires that hospitals comply with this statute, no standard for documenting compliance exists. A continuous quality improvement process was developed at one institution to define a policy, educate staff, and document and monitor compliance. The number of referrals to the organ procurement organization and the number of organ and tissue donors were found to increase. These observations suggest that implementation of a continuous quality improvement process that ensures compliance with organ procurement regulations might increase the number of organ and tissue donors.

Pelvic tuberculosis presenting as an asymptomatic pelvic mass with rising serum CA-125 levels. A case report.

INTRODUCTION: The incidence of tuberculosis is rapidly rising. This disease may present in an atypical manner, and physicians must reacquaint themselves with its protean manifestations. CASE REPORT: A 41-year-old woman presented with an asymptomatic pelvic mass and rising levels of serum CA-125. At operation she had bilateral adnexal masses and generalized military peritoneal lesions, initially mistaken for ovarian carcinoma. The final diagnosis demonstrated tuberculosis. CONCLUSION: Tuberculosis must enter into the diagnosis of a pelvic mass.

Intraabdominal bleeding following laparoscopic adnexal surgery. A report of three cases.

BACKGROUND: The incidence of major complications from laparoscopy is reported to be 0.6-2.5%. The literature reviewing laparoscopic adnexal surgery reports few cases of intraoperative or postoperative complications. CASES: We describe three cases of intraabdominal bleeding following laparoscopic oophorectomy and salpingo-oophorectomy and salpingo-oophorectomy. In two of the three cases, postoperative exploratory laparotomy failed to identify the source of bleeding. CONCLUSION: Possible causes of postoperative bleeding are loosening of clips from an automated stapling device and delayed bleeding from vessels tamponaded by the pneumoperitoneum. Many complications of operative laparoscopy probably are underreported and, when present, may occur outside a health care facility since many of these cases are performed on an ambulatory basis. Some patients will acquire medical and/or surgical intervention.

Developmental increases in expression of neurofilament mRNA selectively in projection neurons of the lamprey CNS.

Neurofilaments of the sea lamprey are unique in being homopolymers of a single subunit (NF-180). Digoxigenin-labeled RNA probes complementary to NF-180 were used to determine the distribution and timing of expression of neurofilament message in the brain and spinal cord of the lamprey. In the brainstem, detection of NF-180 mRNA was restricted to neurons with axons projecting to the spinal cord or the periphery. The majority of brainstem neurons, whose axons project locally, did not express NF-180 within the detection limits of this technique. NF-180-positive neurons included cells with a wide range of axon diameters, suggesting neurofilament mRNA expression was linked to axon length rather than caliber. To further evaluate this hypothesis, expression was studied in animals of different developmental stages between larvae and adults. In younger (shorter) larvae, the large Mauthner and rhombencephalic Müller cells did not express NF-180 mRNA, even though their axons are among the largest caliber in the animal and extend the entire length of the spinal cord. In contrast, many other reticulospinal neurons, whose axons are smaller in diameter than those of the Müller and Mauthner cells, expressed NF-180 message throughout larval development. Furthermore, neurons of the cranial motor nuclei did not express NF-180 until later developmental stages and the extraocular motor neurons did not label until metamorphosis. Therefore, while detectable neurofilament mRNA expression in the lamprey is restricted to neurons with long axons, its expression in this population of neurons appears to be developmentally regulated by factors still not determined. It is postulated that need for NF message is determined by a balance between the volume of axon to be filled and the rate of turnover of NF in that axon.

Epidemiology of injuries by needles and other sharp instruments. Minimizing sharp injuries in gynecologic and obstetric operations.

Surgical and obstetric HCWs and epidemiologists will benefit from working together to describe the frequency and circumstances of percutaneous injuries in operating and delivery rooms. Rates of percutaneous injury vary among institutions, and attending and resident surgeons are among those at greatest risk for injury. Gynecologic surgery appears to have one of the highest rates of injury of the surgical specialties, and rates of injury vary by procedure within a given specialty. Suture needles cause the majority of injuries. Certain actions such as holding tissue while suturing or cutting are associated with a higher risk of injury. Many percutaneous injuries appear to be preventable. Epidemiologic data can be used to develop strategies based on the industrial hygiene model to reduce the incidence of percutaneous injury and to collect and disseminate data on the efficacy of new preventive measures. Potentially safer instruments and suture needles, technique modification strategies, and personal protective equipment such as cut-resistant gloves and finger protective strips are now available. Scientific assessment is needed of these and other new measures to determine whether they will decrease the risk of percutaneous injury, be acceptable to users, be cost effective, and avoid adverse consequences to patients or HCWs.

Cervical smears prepared by an automated device versus the conventional method. A comparative analysis.

An automated, fluid-based method for the preparation of cervical Papanicolaou smears/slides was compared to the conventional Papanicolaou smear (CPS) method used for the screening of neoplasia. We determined diagnostic agreement and sources of error for diagnostic disagreement. For 665 patients, one cervical sample was collected to make one CPS. The collection devices, a wooden Ayre spatula and endocervical brush, were rinsed into a vial with fluid medium to be processed in the automated device. All slides were distributed among five cytotechnologists in a blind fashion. Exact diagnostic agreement was 94.6%. The results were not statistically significant (P > or = .70, McNemar's test) but were clinically important, as evidenced by the detection of low grade lesions (LGL), during initial screening, on three slides prepared by the automated device but not on their matched-pair CPSs (0.5% of all specimens). After reevaluation, the three matched CPSs demonstrated LGL. Sources of diagnostic error on the CPSs were: air-drying artifact, obscuring blood/inflammation, crowding/overlapping of cells and/or absence of diagnostic cells. The only source of error in the automated-method smears was absence of diagnostic cells.

Chemotherapy rapidly alternating with accelerated radiotherapy for advanced carcinoma of the uterine cervix.

The objective of this study was to determine the feasibility of treating patients with advanced cervical carcinoma using a regimen combining chemotherapy with intermittent hyperfractionated teletherapy. Eight patients with advanced cervical carcinoma were treated with bleomycin, ifosfamide and cisplatin, followed by a 5-day course of hyperfractionated external radiation. Three such courses were given at 21-day intervals. Treatment was completed using standard brachytherapy. Seven of the eight patients were evaluable for response; all obtained a complete response. Two patients developed recurrence (one in the pelvis and one distant) and died of disease. One patient died of treatment complications. The remaining four remain alive and free of disease 9-42 months after treatment. The simultaneous use of chemotherapy and intermittent hyperfractionated teletherapy is a promising strategy for the treatment of cervical carcinoma, resulting in a high rate of complete response.

The single lamprey neurofilament subunit (NF-180) lacks multiphosphorylation repeats and is expressed selectively in projection neurons.

The lamprey is considered the most primitive living vertebrate and its neurofilaments (NFs) are unique in being homopolymers of a single 180 kDa subunit (NF-180). Previous immunologic studies have suggested that the sidearm of NF-180 is highly phosphorylated selectively in the largest diameter axons. We report in this study the isolation and characterization of cDNA clones encoding the NF-180 lamprey protein. In situ hybridization with digoxigenin-labeled cRNA revealed NF-180 message exclusively in neurons with long axons, such as reticulospinal neurons and cranial motor neurons. The core of NF-180 was similar in structure to those of mammalian neurofilaments, but surprisingly, the carboxy sidearm lacked the multiphosphorylation repeats characteristic of higher vertebrate and invertebrate neurofilaments. Overall there was a paucity of potential phosphorylation sites in the NF-180 carboxy-terminus compared to NF-M and NF-H of mammals, fish and squid. This, along with the highly acidic nature of the NF-180 sidearm, makes it unlikely that phosphorylation of sidearm residues regulates interfilament spacing and axon diameter through global electrostatic repulsion of the carboxy-terminus away from the filament backbone. Furthermore, the expression of a single neurofilament subunit in the lamprey that is most similar to the NF-M of higher vertebrates suggests that all three mammalian neurofilament subunits evolved from a single NF-M-like precursor.

Analysis of the cocaine metabolite in the urine of patients and physicians during clinical use.

Cocaine is considered a superb anesthetic for many otolaryngologic procedures and has been shown to be positive in the urine of patients for up to 72 hours after surgery with a standard radioimmunoassay test. The standard cutoff for drug screening of benzoylecgonine, the main urine metabolite of cocaine, has been 300 ng/ml. However, the new threshold value in many laboratories is now 150 ng/ml. In review of the literature, no study has been performed that quantitates the actual level of the urine cocaine metabolite after a routine otolaryngologic procedure in both physicians and their patients with the gold standard for urine testing, gas chromatography. This study documents the quantitative level of the urine cocaine metabolite in patients and reveals that there are metabolite levels present in physicians during a single exposure, although they are below the current cutoff level that will be picked up on current screening assays. Evidence has also been presented demonstrating a cumulative effect on the benzoylecgonine levels in physicians who clinically use cocaine anesthesia more frequently; these levels can be above the cutoff level on current screening assays.

A method for in situ hybridization in wholemounted lamprey brain: neurofilament expression in larvae and adults.

Nonisotopic in situ hybridization (NISH) using both cDNA and cRNA probes is rapidly gaining favor over autoradiographic methods. Typically, either biotinylated or digoxigenin-labeled probes are used to detect mRNAs in sectioned tissue or in cultured cells. With a few exceptions, most applications of NISH in wholemount preparations have been limited to Drosophila embryos. A protocol developed for NISH in whole adult Drosophila CNS was extended to wholemounted larval and adult lamprey brain preparations. Digoxigenin-labeled RNA probes were transcribed from cloned fragments of a lamprey neurofilament (NF180) cDNA. Hybridization with these probes, and comparisons with Nissl-stained wholemounts and wholemounts retrogradely labeled by injections of tracer into the spinal cord, demonstrated that NF180 mRNA was expressed in only a subset of neurons in the lamprey CNS. These included primarily neurons with long axons that project out of the brainstem, e.g., reticulospinal neurons and cranial motor neurons. Metamorphosis from the larval to the adult form was accompanied by an increase in the number of neurons expressing NF180 and in the apparent level of NF expression as judged by the intensity of labeling. For example, in the oculomotor and trochlear nuclei, expression of NF180 was seen in postmetamorphic young adult lampreys but not in larvae. In the trigeminal motor nucleus, both the number of neurons expressing NF180 and the intensity of the hybridization labeling increased with metamorphosis. The ability to do NISH in lamprey brain wholemounts eliminates the need for serial reconstructions and thus facilitates the study of selected gene expression during metamorphosis and regeneration.

A phase I trial of a rhenium 186-labeled monoclonal antibody administered intraperitoneally in ovarian carcinoma: toxicity and clinical response.

OBJECTIVES: To determine the maximum tolerated dose, spectrum of toxicity, and response of persistent and recurrent ovarian carcinoma to intraperitoneal injection of a conjugate of rhenium 186 (186Re) and a monoclonal antibody; to measure the radiation distribution to normal structures; and to establish the fate of the infused isotope. METHODS: Rhenium 186 was conjugated to murine monoclonal antibody NR-LU-10, which binds to a cell surface antigen present on ovarian carcinoma. In a dose-escalating phase I trial, a single dose of 25 mg/m2 of antibody complexed with 25-150 mCi/m2 of 186Re was administered intraperitoneally to 17 women with ovarian carcinoma that was recurrent or persistent after platinum-based chemotherapy. RESULTS: Severe myelosuppression was observed at 150 mCi/m2 of 186Re in two evaluable patients. Other clinically significant toxicities included low-grade fever and transient skin rash. Hepatic enzyme elevation was seen in 12 of 17 patients, but was not clinically significant. No chronic enteric toxicity was observed. Decreased tumor size was demonstrated by repeat operation in four of seven patients with disease measuring less than 1 cm at the time of treatment (four of 17 total). All four responders had serum CA 125 levels of 35 U/mL or less at the time of treatment and had received only one regimen of chemotherapy. CONCLUSION: This immunoconjugate can be administered intraperitoneally with acceptable toxicity and produces objective responses after a single dose in patients with minimal objective disease.

A phase II trial of Didemnin B (NSC #335319) in patients with previously treated epithelial ovarian cancer. A Gynecologic Oncology Group Study.

Sixteen evaluable patients with advanced or recurrent epithelial ovarian carcinoma following progression on combination chemotherapy were treated with 4.2 mg/m2 of Didemnin B (NSC #325319) intravenously every 28 days until progression of disease. All patients had prior cisplatin-containing chemotherapy. There were no responders. Seven patients had stable disease (43.7%) and nine (53.3%) had increasing disease. The toxicities were significant, consisting of nausea and vomiting in seven patients (44%), one grade 3 hepatic toxicity, and three instances of grade 4 toxicities (1 leukopenia, 1 GI, and 1 GU). When used with this schedule Didemnin B is ineffective in patients with previously treated epithelial ovarian cancer.

A phase II trial of didemnin B (NSC No. 325319) in advanced and recurrent cervical carcinoma: a Gynecologic Oncology Group study.

Didemnin B was administered to 24 women with recurrent squamous cell cervical carcinoma. The initial dose was 4.2 mg/m2, intravenously, repeated every 28 days. Twenty-three patients were evaluable for toxicity and twenty-one for response. Toxicity was mild, consisting mainly of nausea and vomiting. There were no objective responses; 43% had stable disease for at least 3 months. Didemnin B, when given in this dosage schedule, appears to have minimal effect against this tumor.

Incisional recurrence of squamous cell cervical carcinoma following operative staging.

A patient with FIGO Stage IIB cervical carcinoma underwent an extraperitoneal lymphadenectomy with exploratory laparotomy and washings for surgical staging. Intraperitoneal tumor was found. Seven months later, the tumor recurred as a subcutaneous nodule in the surgical incision. The implications of this recurrence are discussed.

Effect of oral contraceptives on adrenocorticotropin and growth hormone secretion following CRH and GHRH administration.

Previous investigations have demonstrated that basal ACTH plasma levels are reduced and that GH levels are either increased or unchanged in women taking oral contraceptives. The purpose of the present investigation was to determine the secretion of ACTH and GH following an intravenous infusion of human corticotropin releasing hormone (CRH) and human growth hormone releasing hormone (GHRH) in control women (N = 8) and in women taking a triphasic oral contraceptive (N = 9). The studies were initiated between 7:00 and 9:00 a.m. and all women were fasting. An intravenous catheter attached to a 3-way stopcock was used for blood sampling and to inject a bolus of CRH and GHRH (1 microgram/kg). Plasma samples were frozen immediately and stored at -70 degrees C until assayed for content of ACTH and GH by radioimmunoassay. The plasma levels of ACTH and GH increased following infusion of CRH and GHRH in all women. The mean plasma levels of growth hormone were not statistically different in oral contraceptive users compared to normal women. In contrast, ACTH plasma levels in oral contraceptive users were reduced approximately 25% overall, and significantly lower (p less than 0.04) at 120 minutes following the CRH infusion compared to controls. In conclusion, the GHRH-stimulated GH release was similar in normal women and oral contraceptive users. CRH-stimulated ACTH release was modestly reduced in oral contraceptive users compared to normal women suggesting that estrogens and progestogens may have a suppressive effect on the release of ACTH by the pituitary.