Comparison of clinical and paraclinical characteristics of patients with urge, mixed, and passive fecal incontinence: a systematic literature review.

PURPOSE: Two subgroups of fecal incontinence (FI) are described in literature and used in clinical practice. However, the pertinence of this classification of FI is still unknown as there are no clear established guidelines. To a better understanding, we performed a systematic review to characterize the different types of FI (active, passive, or mixed) on the basis of clinical presentation and complementary explorations. METHODS: This systematic literature review was performed in reference to recommendations for systematic review using PRISMA guidelines without date restriction, until May 2020. This systematic review was performed without temporal limitation using MEDLINE-PubMed, Cochrane Library, and Google Scholar databases. RESULTS: Six hundred nine unique citations were identified from all the databases combined. Of those, 21 studies met the inclusion criteria, with 8 retrospective observational studies and 13 prospective observational studies. There was a lack of homogeneity in definitions of passive and urge (active) FI among studies. Prevalence of passive and urge FI was respectively of 4.0-5.0 and 15.0-35.0%. Clinical characteristics, physical examination, and endoanal imaging were not evaluated in most studies. In anorectal manometry, maximal squeeze pressure was higher in passive FI subgroup in most studies and results regarding maximal resting pressure remain discordant. There seemed to be no difference regarding first sensation volume and maximal tolerable volume among subgroups. A few studies evaluated pudendal terminal nerve motor latency with no difference among subgroups. CONCLUSION: There is a lack of well-conducted prospective studies comparing the different subtypes of FI with validated definitions in both clinical and paraclinical examinations.

Expanded statistical analysis of squats on the Great Britain (GB) mainline network.

Squat defects are one of the most common rail surface defects. Significant research effort has gone into understand squat defects over the last 10 years which has brought about important developments in the understanding of their initiation mechanism; however, further work is still required to fully understand squat and the best methods to control them. This study considers records of squat defects over a period 9 years, considering 2600 km of track across 8 different routes on the GB mainline network. The analysis separately reviews squats on: plainline, crossings, joints and welds. Results include an overview of the main factors influencing the development of each type of squats, practical methods to immediately reduce and manage squat defects and recommends focus areas for further research to understand squat defects. Results suggest that squats on plainline, crossings, joints and welds, all correlate with different influencing factors; headcheck defects appear to significantly influence the probability of squats and how other factors influence squat development. There is a strong connection between total head wear rate (combined material removal due to traffic and grinding) and squats; 90 % of all squats appear on rail with a headwear rate of <0.2 mm/year. Overall larger section rail (60 kg/m vs 56 kg/m) and harder material (260 Brinell vs 220 Brinell) is significantly less susceptible to squat damage. Track curvature has an influence of squat development, especially in rail with no headcheck cracking, where the tightest curves are significantly more likely to sustain squat damage. The probability of squat at vertical discontinuities, i.e. joints and crossings are significantly more likely as train speed increases. Whilst squats on joints are 1000 time more likely than squats on welds.

Rare lysosomal disease registries: lessons learned over three decades of real-world evidence.

Lysosomal storage disorders (LSD) are rare diseases, caused by inherited deficiencies of lysosomal enzymes/transporters, that affect 1 in 7000 to 1 in 8000 newborns. Individuals with LSDs face long diagnostic journeys during which debilitating and life-threatening events can occur. Clinical trials and classical descriptions of LSDs typically focus on common manifestations, which are not representative of the vast phenotypic heterogeneity encountered in real-world experience. Additionally, recognizing that there was a limited understanding of the natural history, disease progression, and real-world clinical outcomes of rare LSDs, a collaborative partnership was pioneered 30 years ago to address these gaps. The Rare Disease Registries (RDR) (for Gaucher, Fabry, Mucopolysaccharidosis type I, and Pompe), represent the largest observational database for these LSDs. Over the past thirty years, data from the RDRs have helped to inform scientific understanding and the development of comprehensive monitoring and treatment guidelines by creating a framework for data collection and establishing a standard of care, with an overarching goal to improve the quality of life of affected patients. Here, we highlight the history, process, and impact of the RDRs, and discuss the lessons learned and future directions.

Laboratory parameters associated with prolonged hospital length of stay in COVID-19 patients in Johannesburg, South Africa.

BACKGROUND: Coronavirus disease (COVID-19) has imposed unprecedented stressors on South Africa (SA)'s healthcare system. Superimposed on the country's quadruple burden of disease, pandemic-related care further exposes existing inequities. Some of these inequities are specific to hospital-based inpatient services, such as the geographical maldistribution of hospital beds, lack of oxygen supplies and assisted ventilation, and scarcity of trained healthcare workers. Certain high-risk groups, such as individuals with cardiometabolic comorbidity, are likely to develop severe COVID-19 disease requiring hospitalisation with potential for a prolonged length of stay (LoS). It may be helpful for health authorities to identify those at risk for prolonged LoS to facilitate appropriate health systems planning. OBJECTIVES: To identify hospital admission laboratory parameters associated with a hospital stay >14 days in patients with COVID-19 pneumonia. METHODS: A retrospective observational study design was used. Laboratory data were obtained from an SA private laboratory for 642 inpatients with suspected or confirmed COVID-19 pneumonia, comprising 7 months of admission laboratory data from six private hospitals in Johannesburg, Gauteng Province. RESULTS: Of 642 hospital admissions for pneumonia, 497 were confirmed to have COVID-19 infection (reverse transcription-polymerase chain reaction test positive). In the COVID-19-positive group, hospital LoS was prolonged in 35.4% of admissions. Univariate analysis demonstrated an association with the following risk factors for prolonged LoS: older age; male sex; high serum creatinine, sodium (Na), chloride, potassium and urea levels and low estimated glomerular filtration rate; raised white blood cell count, lymphopenia, neutrophilia and an elevated neutrophil-to-lymphocyte ratio (NLR); and elevated levels of D-dimers, interleukin-6 (IL-6), and procalcitonin (PCT). The strongest univariate associations (relative risk (RR) ≥2.0) with a hospital stay >14 days were high Na levels, NRL >18, high PCT levels and IL-6 >40 pg/mL. On multivariable analysis, the following factors remained significantly associated with prolonged LoS: older age (RR 1.015 per year of age; 95% confidence interval (CI) 1.005 - 1.024); hypernatraemia (RR 1.80; 95% CI 1.25 - 2.60); hyperkalaemia (RR 1.61; 95% CI 1.18 - 2.20); and neutrophilia (RR 1.47; 95% CI 1.15 - 1.88). CONCLUSIONS: COVID-19 pandemic preparedness requires hospital-based inpatient care to be prioritised in resource-limited settings, and availability of beds and prompt admissions are essential to ensure good clinical outcomes. In this study of COVID-19 patients admitted with pneumonia, multivariable analysis showed older age, hypernatraemia, hyperkalaemia and neutrophilia to be associated with LoS >14 days. This may assist with healthcare systems planning.

Long-term outcomes of liver transplantation in type 1 Gaucher disease.

Gaucher disease (GD) is the most prevalent lysosomal storage disorder. Enzyme replacement therapy (ERT) has demonstrable efficacy in reversing clinical and pathological manifestations of GD. We report four patients with GD and severe hepatic impairment who were successfully treated by orthotopic liver transplantation. Liver failure resulted from GD in two patients and due to a comorbidity in two others (HCV and autoimmune chronic active hepatitis). Following successful liver transplantation, patients received long-term ERT. Liver transplantation is a life-saving treatment for end-stage liver disease in patients with Gaucher disease. All four patients have had excellent outcomes from liver transplantation for up to 10 years postprocedure with no evidence of Gaucher-related pathology in the graft.

HIV-occlusive vascular disease.

OBJECTIVES: To evaluate peripheral arterial occlusive disease in HIV-infected patients regarding clinical presentation and outcome of surgical intervention. DESIGN: Prospective clinical survey. PATIENTS AND METHODS: Routine voluntary testing for HIV/AIDS was performed in all patients presenting to our vascular unit. HIV+ patients were enrolled in a registry and followed up prospectively. RESULTS: We identified 154 HIV+ patients, of whom 91 (59%) presented with occlusive disease. There were 71 males and 20 females with a mean age of 44.2 years. The usual risk factors for atherosclerosis were present, but the incidence was less than reported in the classic atherosclerosis population. More than 90% of the patients presented with advanced stage vascular disease (Fontaine III/IV), which explains the high rate (31.9%) of primary amputation. Eighty-seven patients presented with lower-limb ischaemia, 2 patients with upper-limb ischaemia and 2 patients with symptomatic carotid artery stenosis. Seventy-eight procedures were performed on 72 patients, with a perioperative mortality of 6.95%. The limb salvage rate for femoro-popliteal bypass procedures was poor (36.1%), resulting in a high incidence of secondary amputations and prolonged hospital stay. Long-term mortality for the operated patients was 20% over a mean follow-up period of 15.4 months. Hypo-albuminaemia was found to be an important predictor of outcome. CONCLUSION: Patients presenting with HIV-associated peripheral arterial disease should be carefully selected for intervention, taking into consideration nutritional and immune status, stage of the vascular disease and selecting the appropriate procedure.

Assessing facial recognition after orthognathic surgery at automated border controls in airports.

The aim of this paper was to find out whether orthognathic surgery affects facial recognition at automated border controls in airports, and whether we should recommend that patients update their photographic identification postoperatively. We collected data on all 82 patients who had orthognathic surgery between August 2013 and June 2017. They were contacted by telephone and asked about any difficulties they had encountered when passing through automated or human-operated border controls or when using other forms of photographic identification such as driving licences. All questions were asked with reference to experiences before the operation. A total of 50 patients responded, of which 35 had travelled by aeroplane since their operations. Six of them had had problems passing through passport control (two human-operated and four automated) but after additional security checks had successfully continued their journeys. Four had had bimaxillary surgery, one had had maxillary advancement, and one mandibular advancement. Orthognathic surgery does affect identification at border controls, and most of our patients had had difficulties at automated checks because of the differences between the biometric data within the e-passport chip and the live biometric that was scanned. These findings will enable us to improve the information we give to our patients before operation, but further studies are required to increase the sample size and improve reliability.

Management of non-neuronopathic Gaucher disease with special reference to pregnancy, splenectomy, bisphosphonate therapy, use of biomarkers and bone disease monitoring.

Enzyme replacement was introduced as treatment for non-neuronopathic Gaucher disease more than 15 years ago. To ensure the best use of this costly ultra-orphan agent, a systematic disease management approach has been proposed by an international panel; this includes the development, by consensus, of achievable treatment goals. Here we critically review these goals and monitoring guidelines and incorporate emerging experience of the disease in the therapeutic era, as well as contemporary clinical research. This review makes recommendations related specifically to the management of pregnancy; the appropriate use of splenectomy and bisphosphonate treatment; the relevance of biochemical markers to disease monitoring; and the use of semi-quantitative methods for assessing bone marrow infiltration. In addition, we identify key areas for development, including the requirement for a validated index of disease severity; the need to correlate widely used biomarkers with long-term disease outcomes, and the desirability of establishing agreed standards for monitoring of bone disease particularly in infants and children with Gaucher disease.

Changes in glycaemic control, blood pressure and lipids 5 years following laparoscopic adjustable gastric banding combined with medical care in patients with type 2 diabetes: a longitudinal analysis.

The long-term outcomes of weight loss maintenance induced by laparoscopic adjustable gastric band (LAGB) followed by multidisciplinary medical care in patients with type 2 diabetes mellitus (T2DM) (beyond 3 years) are scarcely reported. Study aims were to determine the longer term metabolic outcomes following LAGB combined with medical care in patients with T2DM. This is a longitudinal analysis of 200 adults with T2DM who had LAGB between 2003 and 2008 and were followed up till 2013 at a single bariatric unit in a tertiary UK centre. A total of 200 patients (age 47 ± 9.7 years; body mass index [BMI] 52.8 ± 9.2 kg m-2 ; glycosylated haemoglobin (HbA1c) 7.9 ± 1.9% [62.8 mmol mol-1 ]; women, n = 123 [61.5%]; insulin treatment, n = 71 [35.5%]) were included. The mean follow-up was 62.0 ± 13.0 months (range 18-84 months). There were significant reductions in body weight (-24.4 ± 12.3% [38 ± 22.7 kg]), HbA1c (-1.4 ± 2.0%), systolic blood pressure [BP] (-11.7 ± 23.5 mmHg), total cholesterol and triglyceride levels. The proportion of patients requiring insulin reduced from 36.2% to 12.3%. The overall band complication rate was 21% (21 patients). LAGB when combined with multidisciplinary medical care significantly improved metabolic outcomes in patients with T2DM independent of diabetes duration, and baseline BMI over 5 years. Diabetes duration and baseline BMI did not predict changes in glycaemic control, BP or lipids following LAGB.

Individual variation in the effects of dietary cholesterol on plasma lipoproteins and cellular cholesterol homeostasis in man. Studies of low density lipoprotein receptor activity and 3-hydroxy-3-methylglutaryl coenzyme A reductase activity in blood mononuclear cells.

The effects of dietary cholesterol on plasma lipoproteins and cholesterol homeostasis in blood mononuclear cells have been examined in healthy adults. Addition of 1,500 mg of cholesterol to the daily diet of 37 subjects for 14 d was associated with a wide range of response of plasma total cholesterol concentration (from -6 to +75 mg/dl; mean change, +29 mg/dl; P < 0.001). Increases in plasma cholesterol reflected increased cholesterol concentrations in intermediate density lipoprotein (IDL; 1.006-1.019 g/ml), low density lipoprotein (LDL; 1.019-1.063 g/ml), and the HDL(2) subclass (1.063-1.125 g/ml) of high density lipoprotein, which on average accounted for 20, 58, and 22%, respectively, of the total increment. Similar responses occurred in 14 other subjects given 750 mg cholesterol per day for 28 d. Plasma apolipoprotein B concentrations in IDL and LDL also increased. THESE EFFECTS ON PLASMA LIPOPROTEINS WERE ACCOMPANIED BY THREE CHANGES IN FRESHLY ISOLATED BLOOD MONONUCLEAR CELLS: (a) an increase in cell cholesterol content (mean change, +17%; P < 0.01); (b) suppression of 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase activity (-32%; P < 0.001); and (c) reduction of LDL receptor activity (-74%; P < 0.01), quantified as the rate of degradation of (125)I-LDL to noniodide trichloroacetic acid-soluble material. These results provide the first direct evidence for the modulation of LDL receptor activity and HMG CoA reductase activity in a peripheral cell type in response to a dietary perturbation of human lipoprotein metabolism.The percentage increase in LDL cholesterol was negatively correlated with the percentage decrease in HMG CoA reductase activity (r = -0.49, P < 0.01). An additional negative correlation existed between the increment in plasma cholesterol concentration and the capacity of cells to degrade (125)I-LDL after derepression by preincubation for 72 h in lipoprotein-deficient medium (r = -0.74, P < 0.001). Thus, differences between individuals in the responses of the plasma lipoproteins to dietary cholesterol appear to be related in part to differences in the capacity of peripheral cells to catabolize LDL and to down-regulate cholesterol synthesis.

Strong selection for cells containing new ecotropic recombinant murine leukemia virus provirus after propagation of C57BL/6 radiation-induced thymoma cells in vitro or in vivo.

Using the Southern procedure, we have studied the presence of ecotropic-specific murine leukemia viral sequences in genomic DNA isolated from primary X-ray-induced thymomas, from lymphoid cell lines established from them, or from secondary tumors passaged in vivo. We found that primary radiation-induced thymomas and infiltrated spleens do not harbor newly acquired ecotropic provirus. However, additional ecotropic proviruses (which appear recombinant in the gagpol region) could be detected in most of the tumorigenic cell lines established in vitro from them and in tumors arising from subcutaneous transplantation of the primary thymomas. These results suggest that primary radiation-induced thymomas may not be clonal. They also indicate a strong correlation between the presence of ecotropic recombinant proviruses in the genome and the growth ability, both in vitro and in vivo, of specific cells within these thymomas, suggesting a possible mitogenic function for murine leukemia virus.

[Therapeutic objectives in Gaucher disease]. / Buts thérapeutiques dans la maladie de Gaucher.

Evidence-based therapeutic goals have been developed by European and North American experts in the field of Gaucher disease (GD, lysosomal acid beta glucosidase deficiency, OMIM 230 800) in an attempt to reverse the entire disease phenotype, improve quality of life and prevent life-threatening complications. Patients with GD usually have maximal clinical benefit when enzyme replacement treatment (ERT) efficiency is administered at the optimal time i.e. generally during the asymptomatic phase of the disease. Currently, imiglucerase is the standard of care for type 1 GD due to its high efficiency at improving bleeding tendencies, anemia, reversing heptosplenomegaly and part of skeletal damages and eliminating bone crises. ERT has also demonstrated a remarkable safety profile with tolerability at 3 years greater than 99%. Treatment of GD is a lifelong treatment that patients should not interrupt without a careful monitoring of the disease evolution.

A prospective comparison of secondary interventions and mortality in open and endovascular infrarenal abdominal aortic aneurysm repair.

Endovascular aneurysm repair (EVAR) has provided a safe and effective alternative to the standard open repair of abdominal aortic aneurysms (AAAs). It has, however, been associated with a high requirement for secondary interventions. This prompted us to compare the two procedures with regard to secondary interventions and mortalities. The sample size was 278 patients, of whom 156 had undergone the open operation and 122 had undergone EVAR. The perioperative morbidity and mortality, as well as the major and minor secondary intervention rates, were obtained for these patients. The results suggest that there is no significant difference in secondary interventions and mortality between the two groups, despite the EVAR group being at significantly higher risk.

Phenotype variations in Gaucher disease.

The Gaucher phenotype is very complex and it cannot be simply evaluated on the basis of blood counts or splenomegaly, but by the analysis of all disease compartments. To establish the diagnosis of Gaucher disease, biochemical assay of glucocerebrosidase activity is the most reliable method. However, it can be supplemented by molecular diagnosis, which may be helpful to predict the severity and the rate of progression of clinical manifestations. The genotype-phenotype correlations are very complex with a high inter-individual variability in the severity of clinical manifestations within a same genotype. Genetic modifiers may play an important role in determining the eventual Gaucher phenotype. Despite of some devastating complications, which can arise with advancing age, Gaucher disease worsen progressively in the majority of patients homozygous for the N370S mutation. The analysis of the data of the International Collaborative Gaucher Group registry should provide a better understanding of the natural history of the Gaucher disease.

Therapeutic goals in Gaucher disease.

Evidence-based therapeutic goals have been developed by several European and American experts in Gaucher disease in order to attempt to reverse the entire Type 1 Gaucher phenotype, prevent complications, improve quality of life and prevent life-threatening complications. Patients with Gaucher disease will benefit by maximum enzyme replacement treatment (ERT) efficiency if it is given at the optimal time i.e. generally during the asymptomatic phase of the disease. Currently, Cerezyme is the standard of care for all severities of type 1 Gaucher disease due to its high efficiency at ameliorating bleeding tendencies, reversing organomegaly and part of skeletal damages and eliminating bone crises. ERT has also demonstrated a remarkable safety profile with tolerability at 3 years greater than 99%. Treatment of Gaucher disease is a long-life treatment that the patient should not interrupt without a careful monitoring of the disease evolution.

Comparison of cellular accumulation and cytotoxicity of cisplatin with that of tetraplatin and amminedibutyratodichloro(cyclohexylamine)platinum(IV) (JM221) in human ovarian carcinoma cell lines.

We have compared the cellular accumulation and cytotoxicity of three platinum compounds in a panel of five human ovarian carcinoma cell lines. The cell lines, which were established from both untreated and pretreated patients, showed a wide range in sensitivity to cisplatin and other platinum drugs. The panel consisted of two sensitive (41M, CH1), one in vivo acquired resistant (PXN/94) with moderate sensitivity, and two intrinsically resistant (SKOV-3, HX/62) cell lines. The cisplatin 2-h concentration of drug required to inhibit cell growth by 50% compared with vehicle treated control cells (IC50 values) for these cell lines were in the following order: CH1 < 41M < PXN/94 < SKOV-3 < HX/62. None of the cell lines showed saturation of platinum accumulation (per mg protein) at 2 h after exposure to cisplatin concentrations of up to 500 microM. The highest cellular platinum accumulation was observed in the sensitive 41M cell line which was established from an untreated patient. The lowest accumulation was found in the intrinsically resistant HX/62 cell line. The rate of platinum accumulation at an equimolar concentration of cisplatin was 41M > SKOV-3 > CH1 > PXN/94 > HX/62. The relationship between drug accumulation and cytotoxicity was evaluated by comparing 2-h IC50 values with platinum accumulation following exposure to both equimolar and equitoxic doses of the agent. The results suggest that reduced drug accumulation may play a partial role in the mechanism of intrinsic resistance to cisplatin in one cell line (SKOV-3) and a major role in another (HX/62), where reduced accumulation is attributable to reduced uptake rather than enhanced efflux. Decreased drug accumulation may also contribute significantly to the lower sensitivity of the PXN/94 cell line to cisplatin. Interestingly, both the PXN/94 and the sensitive CH1 cell lines, which were established from patients pretreated with platinum drugs, showed reduced drug accumulation relative to the 41M cell line. Cellular accumulation of tetraplatin and JM221 [(ammine)dibutyratodichloro(cyclohexylamine)platinum(IV)], a novel platinum(IV) dicarboxylate complex exhibiting enhanced cytotoxicity compared to cisplatin, was also examined. Comparison with platinum accumulation from cisplatin suggests that the increased cytotoxicity of tetraplatin and JM221 may be related to their increased accumulation. Significantly both agents are more lipophilic than cisplatin, which may account partially for their improved uptake in cisplatin resistant cells.

Sensitivity to novel platinum compounds of panels of human lung cancer cell lines with acquired and inherent resistance to cisplatin.

We have developed panels of human lung cancer cell lines with acquired and inherent resistance to cisplatin. Three parental cell lines, NCI-H69/P (small cell), COR-L23/P (large cell), and MOR/P (adenocarcinoma), were grown in increasing concentrations of cisplatin over a period of 6-9 months. This resulted in the development of sublines, H69/CPR, L23/CPR, and MOR/CPR which were 3- to 8-fold resistant to cisplatin as determined by a 6-day 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay. None of the resistant sublines showed a significant change in cellular glutathione content or sensitivity to cadmium chloride (an indicator of metallothionein content), although changes in glutathione-S-transferase activity were seen. The sublines each showed cross-resistance to melphalan. Cisplatin accumulation was unchanged in H69/CPR, 1.3-fold reduced in L23/CPR, and 2.0-fold reduced in MOR/CPR compared with their respective parent lines. In a panel of 10 small cell lung cancer cell lines, there was a 16-fold range of sensitivities to cisplatin. The panels have been used to examine cross-resistance between cisplatin, carboplatin, iproplatin, tetraplatin, and a series of 10 novel ammine/amine dicarboxylate platinum(IV) compounds. Whereas H69/CPR and MOR/CPR showed little or no cross-resistance to any of the other compounds, L23/CPR was generally cross-resistant to all of them. In the panel of small cell lines, whereas the ranking of sensitivity to carboplatin and cisplatin were similar, each of the other compounds provided individual patterns of sensitivity. There was always a wide range of sensitivities among the panel, ranging from 8- to 28-fold. Among the dicarboxylate compounds, there was a great range of potencies, with two compounds (JM273 and JM274) being approximately 100-fold more potent than cisplatin.

Ammine/amine platinum(IV) dicarboxylates: a novel class of platinum complex exhibiting selective cytotoxicity to intrinsically cisplatin-resistant human ovarian carcinoma cell lines.

Using a panel of six human ovarian carcinoma cell lines varying by two orders of magnitude in terms of cisplatin cytotoxicity, we have investigated the in vitro antitumor activity of a series of novel alkylamine ammine dicarboxylatodichloroplatinum(IV) complexes of the general formula c,t,c-[PtCl2(OCOR1)2NH3(RNH2)]. A clear relationship existed between increasing the number of carbons in the R1 substituent and increasing cytotoxicity up to R1 = C5H11. In terms of changing the R group, maximum cytotoxic effects were conferred by alicyclic substituents. Furthermore, increasing the alicyclic ring size from cyclobutane through to cycloheptane resulted in increasing cytotoxicity. The agents with longer axial chains (e.g., JM300, R = cyclohexyl, R1 = C6H13) were significantly more cytotoxic than cisplatin and, moreover, exhibited a selective cytotoxic effect against the most intrinsically cisplatin-resistant cell lines (e.g., for HX/62, cisplatin 50% inhibitory concentration, 12.6 microM; SKOV-3, cisplatin 50% inhibitory concentration, 4.4 microM and 41 M; cisplatin 50% inhibitory concentration, 0.23 microM; JM300 was 840-, 440-, and only 34-fold more active, respectively). The dicarboxylates JM221 (R = cyclohexyl, R1 = C3H7) and JM244 (R = n-propyl, R1 = C6H5) also retained activity against a 4-fold cisplatin-acquired resistant variant of the 41M cell line. At least part of the increased cytotoxicity of the dicarboxylate, JM221, over cisplatin appeared to be attributable to an increased intracellular accumulation. This novel class of platinum compound represents a valuable lead in the development of a "third-generation" agent capable of exhibiting activity against clinical disease currently resistant to cisplatin.

Establishment and characterization of an in vitro model of acquired resistance to cisplatin in a human testicular nonseminomatous germ cell line.

Clinically, human testicular nonseminomatous germ cell tumors exhibit remarkable sensitivity to platinum-based chemotherapy. To define better the mechanistic basis for this unusual sensitivity, the biochemical determinants of platinum-induced cytotoxicity have been investigated in a human testicular tumor cell line (GCT27) established from a previously untreated patient and in an in vitro derived 5.6-fold cisplatin-resistant stable variant (GCT27cisR). Compared to 12 ovarian and 5 cervical human tumor cell lines, the parent GCT27 line was among the most sensitive to the cytotoxic effects of both cisplatin (dosage producing 50% inhibition, 0.2 microM) and carboplatin (dosage producing 50% inhibition, 2.9 microM), thus reflecting clinical data. A 4-day exposure sulforhodamine B-staining assay was used to determine that GCT27cisR was cross-resistant to carboplatin and iproplatin and the classical bifunctional alkylating agents melphalan and chlorambucil. Partial cross-resistance was observed to tetraplatin, methotrexate, and mitomycin C. No cross-resistance was observed to Adriamycin, etoposide, vinblastine, bleomycin, 1-beta-D-arabinofuranosylcytosine, and 5-fluorouracil. Intracellular cisplatin accumulation across the dose range 2.5-100 microM (for 2 h) was 1.6 +/- 0.39-fold (mean +/- SD) greater for the parent line. There was no significant difference in glutathione levels between the two lines. The acquired resistance line was 1.9-fold more resistant than the parent line to the cytotoxic effects of cadmium chloride. There was no significant difference between the two lines, however, in the total amounts of platinum bound to DNA after cisplatin exposure (25, 50, or 100 microM for 2 h). The removal of total platinum adducts from DNA was significantly faster for GCT27cisR compared to the parent line (half-times of removal, 32 and 67 h, respectively). These data suggest that the abnormal sensitivity of the parent testicular tumor cell line to platinum-containing anticancer drugs may be due predominantly to an inherent defect in the ability of these cells to remove platinum from their DNA. This defect is apparently lost in the acquired resistance counterpart. Reduced intracellular accumulation and increased cytoplasmic concentrations of metallothionein may also contribute, in part, to the acquisition of cisplatin resistance in this model.

Mechanism-related circumvention of acquired cis-diamminedichloroplatinum(II) resistance using two pairs of human ovarian carcinoma cell lines by ammine/amine platinum(IV) dicarboxylates.

Acquired resistance to cisplatin has been generated in vitro in two human ovarian carcinoma cell lines: 41M, established from a previously untreated patient; and CH1, from a patient previously treated with cisplatin and cis-diammine-1,1-cyclobutane dicarboxylatoplatinum(II) (carboplatin). In neither cell line with acquired resistance did intracellular detoxification (via increased glutathione or metallothioneins) appear to be a major determinant of resistance. Resistance in 41McisR (resistance factor of 4.7) appeared to be due predominantly to a reduced platinum accumulation (levels were only 23.8% in 41McisR versus 41M). This was also reflected at the DNA level by a similar level of reduced DNA interstrand cross-links and total platinum-DNA adducts measured immediately after a 2-h exposure to cisplatin in 41McisR versus 41M. Conversely, for CH1cisR (resistance factor of 6.5), platinum accumulation, and initial numbers of DNA-interstrand cross-links and total DNA-platinum adducts were not significantly different from the parent CH1 line. This is suggestive of a resistance mechanism involving increased DNA repair or tolerance to platinum-DNA adducts operating in the CH1cisR/CH1 pair of lines. Cross-resistance to carboplatin and partial cross-resistance to the 1,2-diaminocyclohexane-containing agent, (trans-d,l)-1,2-diaminocyclohexane tetrachloroplatinum(IV) (tetraplatin), was observed in both pairs. However, two novel platinum(IV) ammine/amine dicarboxylates, ammine dibutyratodichloro(cyclohexylamine)platinum(IV) (JM221) and ammine dibenzoatodichloro(propylamine)platinum(IV) (JM244), completely circumvented resistance in 41McisR to produce some collateral sensitivity (resistance factors of 0.67 and 0.54, respectively) but showed cross-resistance in CH1cisR (resistance factors of 3.7 and 4.6). In contrast to the data for cisplatin, intracellular platinum levels were not significantly different between the 41M and 41McisR pair of cell lines after exposure to JM244. These results suggest that the ammine/amine platinum(IV) dicarboxylates, which show considerably greater in vitro cytotoxicity than cisplatin, are capable of circumventing acquired cisplatin resistance which is due to decreased intracellular accumulation but are not able to overcome resistance at the level of DNA platination and removal.