Risk of brainstem necrosis in pediatric patients with central nervous system malignancies after pencil beam scanning proton therapy.

Background: Radiation therapy (RT) plays an important role in management of pediatric central nervous system (CNS) malignancies. Centers are increasingly utilizing pencil beam scanning proton therapy (PBS-PT). However, the risk of brainstem necrosis has not yet been reported. In this study, we evaluate the rate of brainstem necrosis in pediatric patients with CNS malignancies treated with PBS-PT.Material and methods: Pediatric patients with non-hematologic CNS malignancies treated with PBS-PT who received dose to the brainstem were included. All procedures were approved by the institutional review board. Brainstem necrosis was defined as symptomatic toxicity. The actuarial rate was analyzed by the Kaplan Meier method.Results: One hundred and sixty-six consecutive patients were reviewed. Median age was 10 years (range 0.5-21 years). Four patients (2.4%) had prior radiation. Median maximum brainstem dose in the treated course was 55.4 Gy[RBE] (range 0.15-61.4 Gy[RBE]). In patients with prior RT, cumulative median maximum brainstem dose was 98.0 Gy [RBE] (range 17.0-111.0 Gy [RBE]). Median follow up was 19.6 months (range, 2.0-63.0). One patient who had previously been treated with twice-daily radiation therapy and intrathecal (IT) methotrexate experienced brainstem necrosis. The actuarial incidence of brainstem necrosis was 0.7% at 24 months (95% CI 0.1-5.1%).Conclusion: The rate of symptomatic brainstem necrosis was extremely low after treatment with PBS-PT in this study. Further work to clarify clinical and dosimetric parameters associated with risk of brainstem necrosis after PBS-PT is needed.

Global pharmacogenomics: Impact of population diversity on the distribution of polymorphisms in the CYP2C cluster among Brazilians.

The impact of biogeographical ancestry, self-reported 'race/color' and geographical origin on the frequency distribution of 10 CYP2C functional polymorphisms (CYP2C8*2, *3, *4, CYP2C9*2, *3, *5, *11, CYP2C19*2, *3 and *17) and their haplotypes was assessed in a representative cohort of the Brazilian population (n=1034). TaqMan assays were used for allele discrimination at each CYP2C locus investigated. Individual proportions of European, African and Amerindian biogeographical ancestry were estimated using a panel of insertion-deletion polymorphisms. Multinomial log-linear models were applied to infer the statistical association between the CYP2C alleles and haplotypes (response variables), and biogeographical ancestry, self-reported Color and geographical origin (explanatory variables). The results showed that CYP2C19*3, CYP2C9*5 and CYP2C9*11 were rare alleles (<1%), the frequency of other variants ranged from 3.4% (CYP2C8*4) to 17.3% (CYP2C19*17). Two distinct haplotype blocks were identified: block 1 consists of three single nucleotide polymorphisms (SNPs) (CYP2C19*17, CYP2C19*2 and CYP2C9*2) and block 2 of six SNPs (CYP2C9*11, CYP2C9*3, CYP2C9*5, CYP2C8*2, CYP2C8*4 and CYP2C8*3). Diplotype analysis generated 41 haplotypes, of which eight had frequencies greater than 1% and together accounted for 96.4% of the overall genetic diversity. The distribution of CYP2C8 and CYP2C9 (but not CYP2C19) alleles, and of CYP2C haplotypes was significantly associated with self-reported Color and with the individual proportions of European and African genetic ancestry, irrespective of Color self-identification. The individual odds of having alleles CYP2C8*2, CYP2C8*3, CYP2C9*2 and CYP2C9*3, and haplotypes including these alleles, varied continuously as the proportion of European ancestry increased. Collectively, these data strongly suggest that the intrinsic heterogeneity of the Brazilian population must be acknowledged in the design and interpretation of pharmacogenomic studies of the CYP2C cluster in order to avoid spurious conclusions based on improper matching of study cohorts. This conclusion extends to other polymorphic pharmacogenes among Brazilians, and most likely to other admixed populations of the Americas.

A new model for the population pharmacokinetics of didanosine in healthy subjects.

Didanosine (ddI) is a component of highly active antiretroviral therapy drug combinations, used especially in resource-limited settings and in zidovudine-resistant patients. The population pharmacokinetics of ddI was evaluated in 48 healthy volunteers enrolled in two bioequivalence studies. These data, along with a set of co-variates, were the subject of a nonlinear mixed-effect modeling analysis using the NONMEM program. A two-compartment model with first order absorption (ADVAN3 TRANS3) was fitted to the serum ddI concentration data. Final pharmacokinetic parameters, expressed as functions of the co-variates gender and creatinine clearance (CL CR), were: oral clearance (CL = 55.1 + 240 x CL CR + 16.6 L/h for males and CL = 55.1 + 240 x CL CR for females), central volume (V2 = 9.8 L), intercompartmental clearance (Q = 40.9 L/h), peripheral volume (V3 = 62.7 + 22.9 L for males and V3 = 62.7 L for females), absorption rate constant (Ka = 1.51/h), and dissolution time of the tablet (D = 0.43 h). The intraindividual (residual) variability expressed as coefficient of variation was 13.0%, whereas the interindividual variability of CL, Q, V3, Ka, and D was 20.1, 75.8, 20.6, 18.9, and 38.2%, respectively. The relatively high (>30%) interindividual variability for some of these parameters, observed under the controlled experimental settings of bioequivalence trials in healthy volunteers, may result from genetic variability of the processes involved in ddI absorption and disposition.

Inhibition by hypertonic solutions of Ca-dependent electrogenesis in single crab muscle fibers.

This study describes the effect of hypertonic solutions on isolated muscle fibers of Callinectes danae. Solutions of twice normal tonicity (2.0 T) inhibit both the normal graded membrane responses and the spikes induced by procaine, tetraethylammonium, or barium. The inhibition is maintained throughout exposure to hypertonic solutions prepared by addition of impermeant solutes such as NaCl, sucrose, or Tris-propionate, but is reversible on their withdrawal. In the presence of permeant solutes such as glycerol or acetamide, the inhibition is transient. In both cases the onset of inhibition of the depolarizing Ca electrogenesis is correlated with shrinkage of the fiber. In the case of permeant solutes, the time course of recovery of the graded responses or the spikes follows the recovery of the fiber volume. Changes in the passive electrical characteristics of the fibers due to hypertonic solutions were unrelated to the blockade of membrane Ca activation. The current-voltage relationship in hypertonic sollution revealed no increase in depolarizing K activation. Inhibition of the graded membrane responses and spikes appears to be associated with depression of Ca conductance. Hypertonic solutions might affect the activation of Ca conductance through reduction of the electric field generated by fixed negative surface charges and/or morphological changes in the T tubules. Membrane depolarization elicited little or no tension in 2.0 T solutions while caffeine contracture (10 mM) with an ampliture of 76% of the maximal contractile ability could still be elicited. This indicates that direct effects of hypertonic solutions on the contractile apparatus were not responsible for loss of tension. The latter is attributed to the inhibition of the transmembrane Ca currents.

Membrane calcium activation in excitation-contraction coupling.

Depolarization thresholds for eliciting tension and Ca electrogenesis have been compared in isolated crayfish muscle fibers. Just-detectable tensions and Ca spikes induced after treatment with procaine were elicited with intracellularly applied depolarizing currents of fixed duration. Both thresholds were found to increase in a similar manner in fibers exposed to increased concentrations of Ca in the bathing solution or addition of other divalent cations (Mg, Mn, Ni). However, antagonistic effects between divalent cations were also demonstrated. Substitution of increasing amounts of NaSCN for NaCl in the standard saline produced a progressive decrease in both thresholds. The correlation in the change in thresholds for the two processes supports the hypothesis that a change in membrane Ca conductance is an integral step in excitation-contraction coupling.

Brain dysfunction during motor activation and corpus callosum alterations in schizophrenia measured by cerebral blood flow and magnetic resonance imaging.

Sixteen unmedicated (14 never-medicated, 2 with washout periods of 1-2 weeks) schizophrenic patients displaying positive symptoms (e.g., formal thought disorder, hallucinations, delusions) without negative symptoms (e.g., flattening of affect, loss of energy, anhedonia--type I patients), 15 unmedicated (with washout periods from 1 week to 2 years) patients with marked negative symptomatology [type II patients; criterion score below 15/above 35 on the Munich version of the Scale of Assessment of Negative Symptoms (SANS), respectively], and 31 matched normal controls were investigated using regional cerebral blood flow [rCBF; dynamic single-photon emission computerized tomography (SPECT) with Xenon-133 as tracer] and magnetic resonance imaging (MRI; spin-echo technique, T1 weighted, midsagittal cuts). rCBF measurements were performed during both resting conditions and simple motor activation. Separately, on the same day, we performed a planimetric evaluation of the callosal-brain ratio in all subjects using MRI. In accordance with previous results on a smaller sample, we found signs of diffuse bilateral rCBF hyperactivation in type I patients, as compared with signs of nonreactivity in type II schizophrenics. Both activation patterns were different from a strictly contralateral sensorimotor rCBF activation seen in normal persons (only 8 studied with SPECT). The planimetry of relative callosal area did not reveal differences compared to normal persons, when type I/II patients were taken together. However, the threefold increased variance as compared with that found in normal persons suggested biological heterogeneity in patients. We found an increase of relative callosal size in type I as compared with type II patients. In the light of some recent findings linking lack of laterality of several brain functions to increased callosal size, we propose lack of laterality/diffuse hyperactivation and increased callosal size to be connected with positive symptomatology/good prognosis schizophrenia, and vice versa.

Correolide, a nor-triterpenoid blocker of Shaker-type Kv1 channels elicits twitches in guinea-pig ileum by stimulating the enteric nervous system and enhancing neurotransmitter release.

Correolide (1 - 10 microM), a nortriterpene purified from Spachea correae and a selective blocker of Kv1 potassium channels, elicits repetitive twitching in guinea-pig ileum. This effect is not seen in guinea-pig duodenum, portal vein, urinary bladder or uterine strips, nor in rat or mouse ileum. The time course and amplitude of the correolide-induced twitches in guinea-pig ileum are similar to those elicited by electrical stimulation of the enteric nervous system. The correolide-induced twitching is not affected by pre-treatment with capsaicin (1 microM), but is facilitated by the NO synthase inhibitor, N(G)-nitro-L-arginine methyl esther (L-NAME, 200 microM). The correolide-induced twitching is abolished by tetrodotoxin (1 microM) or hexamethonium (100 microM), and is markedly inhibited by nifedipine (0.3 microM) or atropine (0.2 microM). The atropine-resistant component is inhibited by selective antagonists of NK1 and NK2 tachykinin receptors, namely GR 82334 and GR 94800 (1 microM each). The former compound is more effective in inhibiting the correolide-induced, atropine-resistant activity. Correolide intensified the twitching of ileum segments exposed to saturating concentrations of margatoxin (MgTX), which suggests that Kv1 sub-types other than Kv1.1 (Kv1.4 or Kv1.5) are involved in the relatively greater degree of stimulation of the enteric nervous system by correolide, as compared to MgTX. We propose that blockade of Kv1 channels by correolide increases the excitability of intramural nerve plexuses promoting release of acetylcholine and tachykinins from excitatory motor neurons. This, in turn, leads to Ca(2+)-dependent action potentials and twitching of the muscle fibres.

Elevated response of growth hormone to graded doses of apomorphine in schizophrenic patients.

Three different dosages of apomorphine (0.003 mg/kg, 0.006 mg/kg, 0.012 mg/kg) were administered to stimulate the release of growth hormone (GH) in 16 male schizophrenic patients (age: 30.6, SD: 8.1 years) and 12 healthy male controls (age: 29, SD: 3.2 years). Results showed a significantly higher GH response (P < 0.01) after stimulation with 0.006 mg/kg apomorphine (APO). In contrast, stimulation with 0.012 apomorphine was unable to distinguish patients from normal controls. The results support the hypothesis of an increased dopaminergic receptor sensitivity in the hypothalamic-pituitary system of acute schizophrenic patients. This disturbance of dopaminergic neurotransmission could be observed only after a stimulation with low doses of apomorphine.

Modulation of the Ca(2+) release channel of sarcoplasmic reticulum by amiloride analogs.

Dichlorobenzamil, phenamil and other amiloride analogs (1-100 microM) elicit transient tension in rabbit skinned muscle fibers. Tension requires preloading of Ca(2+) into the sarcoplasmic reticulum, is facilitated by low-[Mg(2+)] solutions, abolished by ruthenium red or by functional disruption of the sarcoplasmic reticulum, and is followed by inhibition of the caffeine-evoked tension. Bilayer recording of Cs(+) currents through the sarcoplasmic reticulum Ca(2+) release channel reveals that phenamil (10-100 microM) increases the open channel probability, whereas dichlorobenzamil affects the channel activity in a complex concentration- and time-dependent manner: stimulation occurs throughout exposure to 10 microM, but is followed by channel blockade when 100 microM dichlorobenzamil is used. It is concluded that stimulation of the sarcoplasmic reticulum Ca(2+) release channel accounts for the dichlorobenzamil- or phenamil-induced tension in skinned fibers, whereas depletion of sarcoplasmic reticulum Ca(2+) stores and channel block (with dichlorobenzamil) explains the inhibition of the caffeine-evoked tension by amiloride analogs.

Uridine triphosphate-sensitive pathway of Ca2+ release from the sarcoplasmic reticulum of rat skeletal muscle fibers.

The pyrimidine nucleotide, uridine triphosphate (UTP), was tested with skinned skeletal muscle fibers in order to investigate the UTP-sensitive pathway of Ca2+ release from the sarcoplasmic reticulum. The presence of ryanodine (200 microM), ruthenium red (10 microM) or heparin (2.5 mg/ml) did not affect the tension elicited in the presence of UTP, demonstrating that the UTP-induced Ca2+ release involved neither ryanodine nor inositol triphosphate-sensitive channels. Drugs such as compound 48/80 or cyclopiazonic acid used to inhibit Ca2+-ATPase in its reverse function appeared to be, respectively, non-specific or without any inhibitory effect on the tension induced by UTP. Finally, the UTP-induced tension as well as the trifluoperazine-induced tension were abolished in the presence of spermidine (50 mM), supporting the hypothesis that the UTP-sensitive pathway of the SR Ca2+ release might occur through the uncoupled calcium ATPase.

WIN 17317-3 blocks Ca2+-activated K+ channels and enhances motility of guinea-pig detrusor muscle.

Patch-clamp experiments in both clonal GH3 cells and guinea-pig bladder myocytes reveal that 1-benzyl-7-chloro-4-(n-pentylimino)-1,4-dihydroquinoline hydrochloride (WIN 17317-3), a potent blocker of Kv1.3 channels and potential immunomodulator, reduces, in a reversible manner and at low micromolar concentrations, K+ currents through Ca2+-activated high conductance K+ channels (BK channels). Blockade of BK channels is thought to account for the stimulatory effect of WIN 17317-3 on the contractility of guinea-pig bladder. This effect is not modified by tetrodotoxin (1 microM), but is abolished by nifedipine (0.1 microM). In conclusion. WIN 17317-3 lacks selectivity for the Kv1.3 channels, its postulated target for immunosuppression.

Effects of the K+ channel blockers paspalitrem-C and paxilline on mammalian smooth muscle.

The tremorgenic alkaloids, paxilline and paspalitrem-C (0.1-10 microM), increased the spontaneous contractility of guinea-pig and rat urinary bladder, and rat duodenum, and induced tension in guinea-pig trachea. These effects are ascribed to blockade of high-conductance, Ca(2+)-activated K+ (BKCa) channels. Paxilline potentiated the charybdotoxin-induced stimulation of guinea-pig detrusor muscle; this is consistent with the alkaloid's ability to allosterically enhance the binding of charybdotoxin to smooth muscle membranes (Knaus et al., 1994). Paspalitrem-C and paxilline did not affect the myogenic activity of isolated portal vein from guinea-pig, which is insensitive to charybdotoxin, or of that from rat which is stimulated by charybdotoxin. Paxilline and paspalitrem-C also differed from charybdotoxin in that the alkaloids did not consistently elicit tension in guinea-pig aortic rings. These discrepancies are attributed to differences in relative potency, sites and/or mechanisms of action of the indole alkaloids vs. peptidyl blockers of the BKCa channel.

Ca2+-entry blockade by CAF603, a carotane sesquiterpene isolated from Trichoderma virens.

Isometric tension recordings and patch-clamp methods were combined to explore the functional effects and mechanisms of action of 8-daucene-3,4-diol (CAF603), a carotane sesquiterpene isolated from the fungus Trichoderma virens. CAF603 (1-100 microM) inhibited the spontaneous motility of guinea-pig portal vein, duodenum and ileum, and the Ca2+-induced tension of depolarized ileum strips. These effects were not antagonized by either iberiotoxin or glyburide. CAF603 increased the spontaneous motility of guinea-pig detrusor muscle, but inhibited the contraction induced by high-KCl, depolarizing salines. CAF603 blocked L-type Ca2+ channel currents of rabbit cardiac myocytes. It is proposed that Ca2+-entry blockade accounts for the inhibitory effects of CAF603 on smooth muscle contractility, whereas the stimulation of spontaneous motility of detrusor muscle is ascribed to blockade of Ca2+-activated K+ (BKCa) channel currents. The latter interpretation is consistent with the allosteric modulation of charybdotoxin binding to BKCa in smooth muscle membranes [Lee et al., 1995. J. Nat. Prod. 58, 1822-1828].

Release of sarcoplasmic enzymes from skeletal muscle by Bothrops jararacussu venom: antagonism by heparin and by the serum of South American marsupials.

The venom of B. jararacussu induced a time- and dose-dependent (2-100 micrograms/ml) increase in the rate of release of sarcoplasmic enzymes (CK and LDH) from isolated rat and frog muscles. This effect, which we attribute to sarcolemmal damage by the venom, persisted in a Ca2+-free media, suggesting that phospholipase A activity was not required. The venom-induced enzyme release from the isolated muscles was reversibly inhibited by the sera (1-10 microliters/ml) of the marsupials Didelphis marsupialis aurita and Philander opossum, by an acidic glycoprotein fraction isolated from the opossum serum (50 micrograms/ml), and by heparin (50 micrograms/ml). Incubation of the B. jararacussu venom with opossum sera or heparin prevented the increase in plasma CK level observed in mice in which the snake venom (2.5-5.0 micrograms/g) was injected i.m. It is suggested that formation of acid-base complexes between basic myotoxins of B. jararacussu venom and either acidic components in the marsupial sera or the polyanionic heparin could account for the inhibition of the in vitro and in vivo effects of the venom on the release of sarcoplasmic enzymes from skeletal muscles.

Inhibition of the myotoxic and hemorrhagic activities of crotalid venoms by Eclipta prostrata (Asteraceae) extracts and constituents.

The antimyotoxic and antihemorrhagic effects of Eclipta prostrata (EP) and three of its constituents (wedelolactone, WE; stigmaterol, ST; and sitosterol, SI) were investigated. The myotoxicity of crotalid venoms (Bothrops jararaca, Bothrops jararacussu and Lachesis muta), purified myotoxins (bothropstoxin, BthTX; bothropasin; and crotoxin), and polylysine was quantified in vitro by the release rate of creatine kinase (CK) from rat or mouse extensor digitorum muscles, and in vivo by the plasma CK activity in mice. The in vitro myotoxicity of the crotalid venoms and myotoxins was neutralized by simultaneous exposure of the muscles to an aqueous extract of EP or to WE. ST and SI were less effective than WE, but interacted synergistically with it. Both the EP extract and WE failed to neutralize the in vitro myotoxic effects of polylysine. The in vivo myotoxicity of venoms and myotoxins was neutralized by their preincubation with the EP extract or WE. Intravenous administration of the plant extract or WE attenuated the increase in plasma CK activity induced by subsequent intramuscular injections of the crotalid venoms or the myotoxins. EP and WE inhibited the hemorrhagic effect of B. jararaca venom, as well as the phospholipase A2 activity of crotoxin and the proteolytic activity of B. jararaca venom. The data provide direct evidence for antimyotoxic and antihemorrhagic effects of EP and WE against the crotalid venoms responsible for most cases of envenomation by snakebites in Brazil. These effects are interpreted as consequences of antiproteolytic and antiphospholipase A2 activities of EP and its constituents.

Antagonism of the myotoxic effects of Bothrops jararacussu venom and bothropstoxin by polyanions.

The effects of heparin and other polyanions on the myotoxicity of Bothrops jararacussu venom and purified bothropstoxin (BthTX) were investigated. The release rate of creatine kinase (CK) from isolated extensor digitorum longus muscle and the plasma CK activity of mice were used to quantify the results. The myotoxic effects of B. jararacussu venom or BthTX were inhibited by preincubation of these agents with one of the following: a heterogeneous heparin preparation (designated 'heparin'), low mol. wt heparin (H-4500) or dextran sulfates (DS-8000 and DS-500,000). Non-sulfated dextran (D-40,000) and two chondroitin sulfates were ineffective. The antimyotoxic effects of the polyanions are ascribed to their forming inactive acid-base complexes with the basic myotoxins of Bothrops venoms. Gel-filtration experiments in Sephadex provided direct evidence for complex formation between heparin and BthTX. Intravenous (i.v.) administration of H-4500 or DS-8000 opposed the increase in plasma CK activity induced by a subsequent i.m. injection of venom or BthTX. In contrast, pretreatment with i.v. heparin or DS-500,000 enhanced the venom-induced increase in plasma CK activity. This effect was not observed (1) when the animals were treated with a polyvalent antivenom, which inhibits the coagulation and local stasis induced by Bothrops venoms, and (2) when BthTX, which has no thrombotic or hemorrhagic properties, was the myotoxic agent. The potentiation of the venom-induced increase in plasma CK activity by heparin and DS-500,000 is ascribed to improved washout of the CK released from damaged fibers, because of the anticoagulant properties of the drugs.

Neutralization of lethal and myotoxic activities of South American rattlesnake venom by extracts and constituents of the plant Eclipta prostrata (Asteraceae).

Ethanolic extracts of the aerial parts of Eclipta prostrata L. (Asteraceae) neutralized the lethal activity of the venom of South American rattlesnake (Crotalus durissus terrificus) when mixed in vitro before i.p. injection into adult Swiss mice. Samples of ethanolic extract corresponding to 1.8 mg of dry extract per animal neutralized up to four lethal doses of the venom (LD50 = 0.08 micrograms venom/g animal). Three substances isolated from the plant--wedelolactone (0.54 mg/animal), sitosterol (2.3 mg/animal) and stigmasterol (2.3 mg/animal)--were able to neutralize three lethal doses of the venom. Aqueous extracts of the plant inhibited the release of creatine kinase from isolated rat muscle exposed to the crude venom. The protection conferred against the myotoxic effects of the venom could be demonstrated also in vivo, when the venom was preincubated with the extract prior to injection into mice.

Effects of DL-alpha-difluoromethylornithine, 4-deoxypyridoxine and methylglyoxal bis(guanylhydrazone) on allograft prolongation.

DL-alpha-difluoromethylornithine (DFMO), 4-deoxypyridoxine (4-DOP), and methylglyoxal bis (guanylhydrazone) (MGBG) were tested as inhibitors of acute skin graft rejection. Proximal full thickness tail skins were exchanged between C57BL/6 and Balb/C mice. Distal autografts were placed to monitor healing. Inhibitors were given singly or in combination, either orally or by injection, in various schedules to 10 groups of mice. Compared to controls, singly treated mice had significant mean prolongation of allografts ranging from 126% to 141%. Likewise, DFMO plus MGBG extended mean time of complete rejection ranging from 172% to 206%. Autografts remained intact. Some grafts persisted after discontinued immunosuppression. Complete rejection was preceded by a decline in vascularity of the graft bed and/or gradual replacement by host tissue. Graft protection in such stringent circumstances i.e., the use of skin in strains with complete histoincompatibility at the H-2 MHC loci, clearly indicate the anti-rejection effects of polyamine synthesis inhibitors. Moreover, primary and secondary effects of DFMO establish the critical role of polyamine pathway activation in acute rejection. In doses and schedules used, toxicity was encountered when DFMO and 4-DOP were used in combination and when increased amounts of MGBG were administered.

Effects of phenytoin on the ventricular tachyarrhythmias of chronic Chagas' disease.

The effects of phenytoin on the ventricular tachyarrhythmias of 11 patients with chronic chagasic myocarditis were investigated, and correlated with the serum phenytoin levels. Physical examination, laboratory tests and 24- to 48-h ambulatory electrocardiographic recordings were performed before, during (7-14 days) and after treatment with phenytoin (4-6 mg/kg/day, orally, in three divided doses). Significant (greater than 90%) reduction of couplets, bigeminy and runs of ventricular tachycardia were observed in 50-67% of the patients, whereas the frequency of isolated premature ventricular contractions was significantly (greater than 70%) reduced in only 2 patients (18%). Proarrhythmic activity was not observed and adverse side effects were of mild intensity and usually transient, except in one patient, who developed pruritus and skin rash in the presence of toxic phenytoin serum levels (27 micrograms/ml). It is suggested that phenytoin may be useful for the control of repetitive forms of ventricular tachyarrhythmias in selected patients with chronic chagasic myocarditis.

Carbamazepine: a bioequivalence study and limited sampling modeling.

OBJECTIVES: To assess the bioequivalence of 2 formulations of carbamazepine and to develop and validate limited sampling strategy (LSS) models for estimating the area under the plasma concentration-time curve (AUC0-infinity) and the peak plasma concentration (Cmax) of carbamazepine. METHODS: Twenty-four (12 men, 12 women) healthy volunteers received single oral doses (400 mg) of carbamazepine, as reference and test conventional-release formulations, in a standard 2-sequence, 2-period crossover design. Bioequivalence assessment was based on the individual ratios of log-transformed values of AUC0-infinity and Cmax LSS modeling was developed in a training set of 12 randomly assigned volunteers and was validated on the other 12 subjects (validation set). RESULTS: Carbamazepine AUC0-infinity and Cmax can be accurately predicted (R2 = 0.89 - 0.95, precision = 2.6 - 7.2%) by single-point (72 h) and 2-point LSS models (6, 32 h), respectively. Bioequivalence assessments based on LSS-derived AUC0-infinity and Cmax provided results similar to those obtained using all the concentration-in-plasma data points, and indicated that the 2 formulations are bioequivalent. CONCLUSION: One-and 2-point LSS models provided accurate estimates of carbamazepine's AUC0-infinity and Cmax, and allowed correct assessment of bioequivalence between the formulations studied.