Dry powder inhalers: study of the parameters influencing adhesion and dispersion of fluticasone propionate.

Interactions between particles are dependent on the physicochemical characteristics of the interacting particles but it is also important to consider the manufacturing process. Blending active pharmaceutical ingredient (API) with carrier is a critical stage that determines the blend homogeneity and is the first step towards obtaining the final quality of the powder blend. The aim of this work was to study parameters that influence the interactions between API and carrier in adhesive mixtures used in DPI and their effect on API dispersion. The study was done with fluticasone propionate blended with lactose 'Lactohale 200'. The study was based on the influence of the operating conditions (speed, mixing time, resting steps during mixing), the size of the carrier and the storage conditions on the blend properties and on the API dispersion. The quality of the blends was examined by analysing the API content uniformity. Adhesion characteristics were evaluated by submitting mixtures to a sieving action by air depression with the Alpine air-jet sieve. Aerodynamic evaluation of fine particle fraction (FPF) was obtained using a Twin Stage Impinger; the FPF being defined as the mass percentage of API below 6.4 µm. For good dispersion and therefore good homogeneity of the API in the carrier particles, speed and powder blending time have to be sufficient, but not too long to prevent the appearance of static electricity, which is not favourable to homogeneity and stability. The FPF increases with the decrease in the carrier size. The storage conditions have also to be taken into consideration. Higher humidity favours the adhesion of API on the carrier and decreases the FPF.

Imaging the Proangiogenic Effects of Cardiovascular Drugs in a Diabetic Model of Limb Ischemia.

Purpose: Peripheral artery disease (PAD) causes narrowing of arteries in the limbs, leading to tissue ischemia, gangrene, and eventually limb amputation. The presence of diabetes greatly exacerbates the course of PAD, accounting for the majority of lower limb amputations. Therapeutic strategies focussing on macrovascular repair are less effective in diabetic patients where smaller vessels are affected, and proangiogenic therapies offer a viable adjunct to improve vascularisation in these at risk individuals. The purpose of the current study was to assess the proangiogenic effects of drugs routinely used to treat cardiovascular disease in a diabetic murine model of hind limb ischemia longitudinally using multimodal imaging. Procedures: Diabetic mice underwent surgical intervention to induce hind limb ischemia and were treated with simvastatin, metformin, or a combination orally for 28 days and compared to diabetic and nondiabetic mice. Neovascularisation was assessed using [18F]FtRGD PET imaging, and macrovascular volume was assessed by quantitative time of flight MRI. At each imaging time point, VEGF expression and capillary vessel density were quantified using immunohistochemical analysis, and functional recovery and disease progression were assessed. Results: Combined use of simvastatin and metformin significantly increased neovascularisation above levels measured with either treatment alone. Early angiogenic events were accurately assessed using PET [18F]FtRGD, showing maximal retention in the ischemic hind limb by day 8, which translated to a sustained increase in vascular volume at later time points. Immunohistochemical analysis shows that combined therapy significantly increased VEGF expression and capillary density (CD31+) in a similar time course and also slowed disease progression while simultaneously improving functional foot use. Conclusions: Combined treatment with simvastatin and metformin led to a significant improvement in limb angiogenesis, vascular volume, and sustained functional recovery in a diabetic murine model of HLI. PET imaging with [18F]FtRGD provides a robust method for early detection of these proangiogenic effects preclinically and may be useful for the assessment of proangiogenic therapies used clinically to treat diabetic PAD patients.

Imaging Fibrogenesis in a Diet-Induced Model of Nonalcoholic Steatohepatitis (NASH).

Purpose: Liver fibrosis is the hallmark of chronic nonalcoholic steatohepatitis (NASH) and is characterised by the excessive deposition of extracellular matrix proteins. Early detection and accurate staging of liver fibrosis is critically important for patient management. One of the earliest pathological markers in NASH is the activation of hepatic stellate cells (HSCs) which may be exploited as a marker of fibrogenesis. Activated HSCs secreting factors such as integrin α v ß 3 propagate fibrosis. The purpose of the current study was to assess the utility of the integrin α v ß 3 imaging agent [18F]FtRGD for the early detection of fibrosis in a diet-induced model of NASH longitudinally using PET imaging. Procedures: Mice were fed with either standard chow diet (SD), high-fat diet (HFD), or a choline-deficient, L-amino acid-defined high-fat fibrogenic diet (CDAHFD) to mimic the clinical pathology of liver disease and followed longitudinally for 10 weeks to assess the development of liver fibrosis using [18F]FtRGD positron emission tomography (PET) imaging. Standard blood biochemistry, histological measures, and qPCR were used to quantify integrin α v ß 3, smooth muscle actin, and collagen types 1 and 6 to assess the extent of NASH pathology and accurately stage liver fibrosis. Results: The CDAHFD fibrogenic diet predictably developed hepatic inflammation and steatosis over the 10 weeks studied with little NASH pathology detected in high fat diet-treated animals. Stage 1 fibrosis was detected early by histology at day 21 and progressed to stage 2 by day 35 and stage 3 by day 56 in mice fed with CDAHFD diet only. Noninvasive imaging with [18F]FtRGD correlated well with integrin α v ß 3 and was able to distinguish early mild stage 2 fibrosis in CDAHFD animals compared with standard chow diet-fed animals at day 35. When compared with high fat diet-fed animals, [18F]FtRGD was only able to distinguish later moderate stage 2 fibrosis in CDAHFD animals at day 49. Conclusions: The diet-induced progression of liver fibrosis was confirmed using histology and correlated well with the mRNA of integrin α v ß 3 and extracellular matrix protein expression. [18F]FtRGD showed very good correlation between liver uptake and integrin α v ß 3 expression and similar detection sensitivity to the current clinical gold standard modalities for staging of liver fibrosis.

Imaging adipose tissue browning using the TSPO-18kDa tracer [18F]FEPPA.

OBJECTIVES: The browning of white adipose tissue (WAT) into beige has been proposed as a strategy to enhance energy expenditure to combat the growing epidemic of obesity. Research into browning strategies are hampered by the lack of sensitive, translatable, imaging tools capable of detecting beige fat mass non-invasively. [18F]FDG is able to detect activated beige fat but provides little information on unstimulated beige fat mass. We have assessed the use of [18F]FEPPA, a tracer for the TSPO-18KDa found on the outer mitochondrial membrane, as an alternative imaging agent capable of detecting unstimulated brown fat (BAT) and beige fat. METHODS: Female Balb/c mice (n = 5) were treated for 7 days with the ß3 adrenergic agonist CL-316,243 to induce the browning of inguinal WAT (beige fat). Animals were imaged longitudinally with [18F]FDG and [18F]FEPPA and uptake in interscapular BAT and inguinal WAT assessed. The browning of inguinal WAT was confirmed using H&E and immunohistochemical detection of UCP-1 and TSPO. RESULTS: Repeated dosing with ß3-adrenergic agonist CL-316,243 caused a significant increase in [18F]FDG uptake in both interscapular BAT and inguinal WAT associated with the increased metabolic activity of brown and beige adipocytes respectively. [18F]FEPPA uptake was likewise increased in inguinal WAT but showed no increase in BAT uptake due to stimulation over the same time course. Furthermore, inguinal WAT uptake was unaffected by pharmacological blockade, indicating that [18F]FEPPA uptake is associated with the expression of mitochondria in BAT and beige adipocytes and independent of activation. CONCLUSION: These data show that [18F]FEPPA can detect BAT and newly formed beige fat under non-stimulated, thermoneutral conditions and that uptake after stimulation is linked to mitochondrial expression as opposed to activation.

Research diagnostic criteria: rationale and reliability.

A crucial problem in psychiatry, affecting clinical work as well as research, is the generally low reliability of current psychiatric diagnostic procedures. This article describes the development and initial reliability studies of a set of specific diagnostic criteria for a selected group of functional psychiatric disorders, the Research Diagnostic Criteria (RDC). The RDC are being widely used to study a variety of research issues, particularly those related to genetics, psychobiology of selected mental disorders, and treatment outcome. The data presented here indicate high reliability for diagnostic judgments made using these criteria.

Multiple risk factors predict suicide in alcoholism.

From a study of the lives of 50 alcoholics who committed suicide, seven nonacute clinical/historical features were identified post hoc that appear to be intimately linked to suicide. They included continued drinking, major depressive episode, suicidal communication, poor social support, serious medical illness, unemployment, and living alone. This study examined whether these features are common to alcoholics generally and/or to nonalcoholics who commit suicide or if they may be specifically predictive of suicide in alcoholics. The frequencies of these factors were compared with those in an earlier sample of 32 alcoholics who committed suicide, then with data from two St Louis studies of living alcoholics and a cohort of individuals with major depressive disorder who committed suicide. The frequency of the identified items was replicated among the 32 alcoholics in a larger community sample of individuals who committed suicide. The white men from those two samples of alcoholics who committed suicide were then combined for the advantage of sample size. Six of the seven factors could be compared with a population survey sample of 106 living alcoholics and five with a clinically identified sample of 142 living alcoholics. All compared factors were significantly more frequent among those who committed suicide than among controls. Any four of the six factors identified 46 (69%) of the 67 individuals who committed suicide with few false-positive results among the controls. Regarding all seven of the identified factors, 54 (81%) of the 67 men and 64 (83%) of the entire sample of 82 individuals who committed suicide had four or more risk factors. Alcoholic women and blacks showed the same pattern as white men.(ABSTRACT TRUNCATED AT 250 WORDS)

A contrast of the three more common illnesses with the ten less common in a study and 18-month follow-up of 314 psychiatric emergency room patients.

The present study combines four factors: an initial research interview, a blind follow-up of the patients seen initially, the use of specified diagnostic criteria, and the application of these techniques to a psychiatric emergency room population of 314 patients. Follow-up studies were done in 299 patients (95%) a mean of 18.2 months after the initial interview. The patients were described diagnostically and demographically. There were three more common diagnoses: affective disorder, alcoholism, and antisocial personality. There were ten additional less common diagnoses, as well as an undiagnosed group and a group without diagnosis. There were single diagnoses in 190 patients and multiple diagnoses in the remaining 124 patients. Three diagnoses or less per patient were not uncommon; more than three diagnoses per patient were uncommon. Diagnoses of affective disorder, alcoholism, and antisocial personality occurred in 64% of the total number of diagnoses. The remainder of the diagnoses occurred in 36%. Prompt hospitalization occurred in 14% of the total sample.

A contrast of the three more common illnesses with the ten less common in a study and 18-month follow-up of 314 psychiatric emergency room patients. II. Characteristics of patients with the three more common illnesses.

The three more common illnesses diagnosed in the sample of 314 emergency room patients were (in order of frequency) affective disorder (N = 135), alcoholism (N = 112), and antisocial personality (N = 57). This study describes the occurrence and frequency of affective disorders and evaluates the relative usefulness of three separate sets of diagnostic criteria for the depressive phase of the illness, which are considered in three self-evident, mutually exclusive groups, the definition of which depends on chronology of onset in relation to other diagnoses. Findings show a 3:2 ratio of primary affective disorder to secondary affective disorder. The 112 diagnoses of alcoholism were based on defined criteria that separated "definite" (N = 102) from probable (N = 10) alcoholism. A high incidence of secondary affective disorder (38%) in patients with a first diagnosis of alcoholism is noted. The third most common diagnosis, antisocial personality, was based on defined criteria requiring a specified number of manifestations both before and after age 15 years. Only 11% of the antisocial personality patients received a single diagnosis of antisocial personality. An additional diagnosis of alcoholism occurred in 61%. Besides antisocial symptoms, the 57 patients reported 74 different nonantisocial symptoms, supporting the conclusion that antisocial personality patients may be as susceptible to neurotic and psychotic symptoms as other patients.

A contrast of the three more common illnesses with the ten less common in a study and 18-month follow-up of 314 psychiatric emergency room patients.

An 18-month follow-up of 314 randomly selected psychiatric emergency room patients showed that, although there were 15 possible diagnostic groups the diagnoses made at initial interviews proved to be largely accurate. Follow-up results showed the prediction based on those initial diagnoses was 84% correct in the 299 patients (95%) that could be followed up. Follow-up results also showed that 88% of the individual diagnoses (as opposed to diagnosed patients) were correct. The kappa coefficients were high, all of them being above 0.60, some between 0.80 and 0.90. In addition to the relatively high diagnostic validity, the results also demonstrated a high item reliability for the more than 400 separate items for which kappa coefficients were calculated. Less than 15% of these items had a kappa coefficient of less than 0.60. This study thus demonstrated a high diagnostic reliability and a high diagnostic validity The basis of these diagnoses in a heterogeneous psychiatric population was the application of precisely defined and applied diagnostic criteria. The diagnostic process was blind in that the follow-up diagnosis was made in the absence of knowledge of the initial diagnosis. The use of precisely defined and systematically applied criteria may prove to be superior to multivariate analysis, cluster analysis, or other statistical techniques.

Lithium carbonate treatment of mania. Cerebrospinal fluid and urinary monoamine metabolites and treatment outcome.

Treatment of manic patients with lithium carbonate was associated with significant decreases in cerebrospinal fluid (CSF) 3-methoxy-4-hydroxyphenylglycol (MHPG) and urinary norepinephrine excretion. These measures, before treatment, were higher in manic patients than in either depressed or normal subjects and correlated significantly with severity of mania. Levels in CSF of homovanillic acid and 5-hydroxyindoleacetic acid did not correlate with severity or with change during lithium carbonate treatment. Responders (about 70% of the patients) did not differ from nonresponders in pretreatment mania ratings or neurotransmitter measures. The CSF MHPG and urinary norepinephrine excretion were reduced during lithium carbonate treatment in both responders and nonresponders. Unlike the case before treatment, urinary MHPG excretion was higher during treatment in nonresponders than in responders and correlated with several indexes of symptom severity. These results support a relationship between mania and increased noradrenergic function. Treatment outcome, however, was not related exclusively to the reduction of noradrenergic indexes by lithium carbonate since reductions were similar in both responders and nonresponders. Reduced noradrenergic activity may therefore be necessary but not sufficient for successful outcome during lithium carbonate treatment.

Pretreatment DST and hypothalamic-pituitary-adrenocortical function in depressed patients and comparison groups. A multicenter study.

Pretreatment measures of hypothalamic-pituitary-adrenocortical (HYPAC) function in depressed, manic, and healthy normal subjects showed that nonsuppression on the dexamethasone suppression test (DST) had less positive predictive value for major diagnostic category and was more frequent in normals (8/77) than recently reported, although it was yet more frequent in depressed patients (35/111). Nonsuppression was common in manics (8/16), was similar in unipolar and bipolar depressed patients (35% and 27%, respectively), and did not segregate with melancholic, endogenous, or psychotic depression subtypes. Patterns of post-DST plasma cortisol concentration other than simple escape or nonescape from suppression were common. Nonsuppression of 9 AM plasma cortisol levels on the DST had as good or better diagnostic specificity as nonsuppression of any of three post-DST samples. Nonsuppression was not completely synonymous with HYPAC hypersecretion. Means of pre-DST HYPAC measures (morning plasma cortisol, urine free cortisol, and CSF cortisol levels) were elevated in depressed patients compared with normals. There were significant differences in HYPAC measures of depressed patients studied at different centers. Age correlated positively and body weight negatively with plasma cortisol level.

Neuroanatomical correlates of a lactate-induced anxiety attack.

Positron emission tomographic measurements of regional blood flow were used to assess local neuronal activity in patients with panic disorder and in normal control subjects before and during the infusion of sodium lactate. A new technique for the analysis of positron emission tomographic data was employed to identify significant changes in regional blood flow associated with lactate infusion in the panicking patients, nonpanicking patients, and controls. Lactate-induced panic was associated with significant blood flow increases bilaterally in the temporal poles; bilaterally in insular cortex, claustrum, or lateral putamen; bilaterally in or near the superior colliculus; and in or near the left anterior cerebellar vermis. Lactate infusion was not associated with significant changes in regional blood flow in the nonpanicking patients or control subjects. Thus, the identified regions seemed to be involved in an anxiety attack.

Effect of L-carnitine on cultured murine melanoma cells exposed to azelaic acid.

The cytotoxic effect of azelaic acid on murine melanoma cells in culture is due, at least in part, to an antimitochondrial action. We investigated the possibility that the addition of carnitine to the medium may increase the transport of azelaic acid into the mitochondria and thereby increase its cytotoxic effect. Using mitochondrial cross-sectional area measured from electron micrographs as a criterion for mitochondrial damage, we found that the addition of L-carnitine to the culture medium had no effect either alone or with a low (10(-3) M) concentration of azelaic acid. At a high concentration (5 X 10(-2) M) azelaic acid caused swelling and disruption of the mitochondria to such an extent that this was not increased by carnitine. At 10(-2) M azelaic acid, however, some swelling of the mitochondria occurred which was significantly increased by the addition of carnitine. This indicates that carnitine-mediated transport of the diacid into the mitochondria had occurred. We conclude that carnitine may reduce the time or concentration needed for azelaic acid to have a toxic effect on the malignant melanocyte.

Effect of dicarboxylic acids on Harding-Passey and Cloudman S91 melanoma cells in tissue culture.

Clinically, dicarboxylic acids have a cytotoxic effect on the abnormally hyperactive and malignant epidermal melanocyte, and diacids from C8 to C13 have been shown to inhibit mitochondrial oxidoreductases. Here, their effect on the growth kinetics and ultrastructure of murine melanoma cells in culture is examined. Cultures of Harding-Passey and Cloudman S91 melanoma cells were exposed to single doses of the disodium salts of C12, C9, and C6 (which does not significantly inhibit mitochondrial enzymes) dicarboxylic acids at concentrations of 10(-3) M to 10(-1) M. With C12 and C9, viability and cell proliferation over 3 days were significantly affected by concentrations greater than 10(-2) M. With exposure to C6 at 10(-1) M and to medium to which NaCl was added to produce equal osmolarity, the effect was much less. Electron microscopy of cells exposed to C9 at 10(-1) M for 1 h and 6 h revealed massive swelling of mitochondria with destruction of cristae, but plasma and nuclear membranes and membranes of endoplasmic reticulum were intact. Similar damage was not seen with C6 at 10(-1) M nor with equiosomolar NaCl. The results confirm (1) the cytotoxicity of dicarboxylic acids for malignant melanocytes, and (2) that the mitochondrion is a prime target for their action.

Psychosis and suicide.

The prevalence and characteristics of psychosis were observed in a population of 134 subjects who committed suicide in St. Louis in a 1-year period. Psychosis was diagnosed if a subject had, in the period just prior (1 month or less) to his suicide, experienced any of the following: delusions; hallucinations; bizarre behavior; disorientation, confusion, or memory loss; or formal thought disorder. Using these criteria, 25 (19%) of the 134 subjects were found to be psychotic at the time of suicide.

Regional serotonin levels in brain: a comparison of depressive suicides and alcoholic suicides with controls.

The levels of 5-hydroxytryptamine have been measured in 33 areas of the human brain and these levels compared in depressed suicides, in alcoholic suicides, and in controls. The values obtained for control brains ranged from 5.3 mumole 5-HT/kg wet weight in substantia nigra to 0.4 mumole 5-HT/kg wet weight in frontal gray. No significant differences were found among diagnostic groups in any of the areas studied.

The natural history of acute organic mental syndrome after bilateral electroconvulsive therapy.

Thirty-one patients undergoing electroconvulsive therapy (ECT) were followed prospectively for the development of acute organic mental syndrome (AOMS); 15 patients (48.4%) developed AOMS during ECT. For these 15 patients, the average number of ECTs before development of AOMS was 5.5 with average duration of AOMS being 20.1 days. Comparison of these 15 patients to the 16 patients who did not develop AOMS for diagnoses, demographic data, pre-ECT laboratory data, and medications, differed only in exposure to psychoactive medications and prior presence of major medical illness.

Effects of amitriptyline and imipramine on brain amine neurotransmitter metabolites in cerebrospinal fluid.

The effects of amitriptyline (AMI) or imipramine (IMI) on levels of 3-methoxy-4-hydroxyphenylethyleneglycol (MHPG), 5-hydroxyindoleacetic acid (5-HIAA), and homovanillic acid (HVA) (the major brain metabolites of the neurotransmitters norepinephrine [NE], serotonin [5-HT], and dopamine [DA]) in cerebrospinal fluid were determined in 66 subjects with unipolar and bipolar depression. There were significant reductions in MHPG and 5-HIAA levels for the depressed group taken as a whole, but levels of HVA did not change significantly. The changes were similar when subjects were grouped as treated with AMI and IMI and with unipolar and bipolar depression. Reductions in MHPG and 5-HIAA levels were greater in women than in men. In all subjects with depression and in those treated with AMI and IMI, amine metabolite changes did not differ significantly between those who had a positive clinical response to drug therapy and those who did not. Responders with bipolar depression had smaller reductions in MHPG levels than did responders with unipolar depression. The similar effects of AMI and IMI on MHPG and 5-HIAA differ from the dissimilar effects of the two drugs on NE and 5-HT amine uptake systems reported in animal and in in vitro studies. Results provide conclusive evidence of the effects of AMI and IMI on noradrenergic and serotonergic (but not dopaminergic) systems in patients with depression.

Clinical criteria for psychiatric diagnosis and DSM-III.

The authors identify the differences in formal inclusion and exclusion criteria used to classify patient data into diagnoses as the largest source of diagnostic unreliability in psychiatry. They describe the efforts that have been made to reduce these differences, particularly the specified criteria approach to defining diagnostic categories, which was developed for research purposes. On the basis of studies showing that the use of specified criteria increases the reliability of diagnostic judgments, they suggest that including such criteria in the next edition of APA's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) would improve the reliability and validity of routine psychiatric diagnosis.

The application of positron emission tomography to the study of panic disorder.

Positron emission tomography was used to study eight patients with panic disorder who were vulnerable to lactate-induced panic, eight patients with panic disorder who were not vulnerable to lactate-induced panic, and 25 normal control subjects. Patients who were vulnerable to lactate-induced panic had several abnormalities in the resting, nonpanic state: an abnormal hemispheric asymmetry of parahippocampal blood flow, blood volume, and oxygen metabolism; abnormally high whole brain metabolism; and abnormal susceptibility to episodic hyperventilation. A hypothetical model for the neurobiology of panic disorder, involving the abnormal parahippocampal region and its afferent and efferent connections, is proposed.