Cocaine reduction in unmotivated crack users using carbamazepine versus placebo in a short-term, double-blind crossover design.

On the basis of cocaine-caused kindling in animals and the usefulness of carbamazepine in treating kindling-type seizures, carbamazepine has been tried in clinical settings with cocaine-dependent individuals. This report presents findings of a 20-day, double-blind, placebo-controlled crossover study in 32 nontreatment-motivated, paid, chronic crack cocaine users. Carbamazepine significantly lowered the mean number of positive urine specimens compared with placebo. Of clinical importance, serum carbamazepine levels of 4 micrograms/ml (17 mumol/L) or more were associated with greater improvement. A consistent, clinically important trend linked therapeutic levels with improvement for all subjective and objective outcome variables. Comparison of daily acknowledged cocaine use or professed cocaine abstinence, with cocaine use indicated by daily urinalysis in these chronic cocaine users, has suggested the possibility of cocaine saturation as an important methodologic limitation inherent in outpatient studies of cocaine use in humans.

Value of random urinary homovanillic acid and vanillylmandelic acid levels in the diagnosis and management of patients with neuroblastoma: comparison with 24-hour urine collections.

Urinary homovanillic acid (HVA) and vanillylmandelic acid (VMA) levels were determined in random samples and in 24-hour collections from 13 patients with neuroblastoma and 22 patients without neuroblastoma. Random sample levels were compared with levels in 24-hour collections and showed a positive correlation of 95% for HVA (N = 59) and 93% for VMA (N = 52). No false positives or false negatives occurred using random samples for diagnosis. Nonneuroblastoma (normal) HVA (N = 126) and VMA (N = 119) levels are reported for different age groups. Sequential random HVA and VMA determinations in patients with neuroblastoma during and after therapy are shown. Random urinary HVA and VMA levels are shown to be adequate for utilization in the diagnosis of neuroblastoma and sequential determinations of random HVA and VMA are shown to be helpful in the follow-up of those patients.

Facile synthesis of [16,16,17-2H3]-testosterone, -epitestosterone and their glucuronides and sulfates.

The analysis of trace components in complex biological matrices requires the use of reliable internal standards. For the gas chromatography/mass spectrometry (GC/MS) and high performance liquid chromatography/mass spectrometry (HPLC/MS) analyses, the stable isotope-labelled analogues of the analyte molecules are the most appropriate internal standards. In this work high-yield synthetic procedures for stably labelled and isotopically pure [16,16,17-2H3]-testosterone and- epitestosterone are reported. Synthetic methodologies for the glucuronidation and sulfation were established with the commercially available epitestosterone. Structure characterization of 4-androsten-17 alpha-ol-3-one methyl-2',3',4'-tri-O-acetyl-beta-D-glucuronate was made by two-dimensional nuclear magnetic resonance (COSY). Subsequently glucuronidation of [16,16,17-2H3]-testosterone and sulfation of [16,16,17-2H3]-epitestosterone were carried out at greater than 60% yield. However, the yield from the glucuronidation of epitestosterone was not as high. Electrospray mass spectrometry of four conjugates: testosterone sulfate, epitestosterone sulfate, testosterone glucuronide and epitestosterone glucuronide was carried out in the positive ion mode at a number of orifice voltages (50-95 V). Studies of the collisionally induced dissociation at both the interface and in the collision cell (MSMS) confirmed that the glycosidic bond of epitestosterone glucuronide was more labile than that of testosterone glucuronide. Use of the deuterated internal standards is reported to demonstrate the direct analysis of the steroid conjugates by HPLC/MS.

Fetal supraventricular tachycardia treated with high-dose quinidine: toxicity associated with marked elevation of the metabolite, 3(S)-3-hydroxyquinidine.

We observed a patient at 33 weeks' gestation who was administered exceptionally large doses of quinidine to treat a fetal supraventricular tachycardia. The patient had clinical evidence of quinidine toxicity at low to mid-therapeutic levels of quinidine, but markedly elevated levels of the metabolite 3(S)-3-hydroxyquinidine (3-hydroxyquinidine). This pattern is consistent with a "fast metabolism" of quinidine. There is substantial evidence that 3-hydroxyquinidine has pharmacologic activity. We conclude that elevated levels of 3-hydroxyquinidine can be associated with a clinically significant quinidine toxicity. This can occur in the presence of a nontoxic serum quinidine level. We also measured the levels of quinidine and 3-hydroxyquinidine in the amniotic fluid and cord blood. The levels in the cord blood were 31 and 27%, respectively, of those in a simultaneously drawn maternal blood sample.

Mass spectrometric characterization of the beta-subunit of human chorionic gonadotropin.

A high-performance liquid chromatographic/electrospray mass spectrometric (HPLC/MS) technique is described for the characterization of the beta-subunit of the glycopeptide human chorionic gonadotropin (hCG). The beta-subunit of hCG was dissociated from the alpha-subunit using 0.1% trifluoroacetic acid (TFA) and separated by reversed-phase HPLC using a 0.1% TFA-acetonitrile gradient. Although reductive alkylation with 4-vinylpyridine allowed direct observation of the intact beta-subunit of hCG by HPLC/MS due to the increase in charge, the heterogeneity of the carbohydrate fractions resulted in poor detection limits and extremely complex spectra. After reductive alkylation with either iodoacetate or 4-vinylpyridine, tryptic fragments of either the alpha- or beta-subunit can be observed using reversed-phase HPLC/MS. HPLC/MS data were consistent with the reported primary sequence, although oligosaccharide attachment sites at both 127Ser and 132Ser could not be documented. Microheterogeneity of the carbohydrate moiety on both N-glycosylation sites on the beta-subunit could be readily observed. A larger degree of heterogeneity was observed on 13Asn. Differences were also observed in the oligosaccharide distribution in three commercial preparations of hCG. Detection of the C-terminal portion of the beta-subunit required enzymatic deglycosylation prior to HPLC/MS analysis.

Direct measurement of urinary testosterone and epitestosterone conjugates using high-performance liquid chromatography/tandem mass spectrometry.

Measurement of the ratio of testosterone (T) and epitestosterone (E) in urine has been used as an indication of 'natural' steroid supplementation for a decade. The direct measurement of the glucuronide and sulfate conjugates of testosterone and epitestosterone by high-performance liquid chromatography/tandem mass spectrometry (HPLC/MS/MS) should resolve a number of issues regarding unusual metabolism due to either genetic disposition or attempts to avoid detection of abuse. Determination of nanomoles per liter (0.1 ppb) concentrations of analytes in a complex biological matrix by HPLC/MS/MS is complicated by sample matrix-specific ion suppression during ESI. Deuterated internal standards of all compounds were used to overcome the effects of suppression. Comparison of the HPLC/MS/MS method with a two-part gas chromatographic/mass spectrometric method showed statistical equivalence in urine samples. Analysis of urine samples with elevated T-glucuronide to E-glucuronide ratios did not show that a significant number could be explained by an elevated excretion of epitestosterone sulfate. The HPLC/MS/MS method was also used further to characterize genetic and metabolic factors that give rise to unusual T/E ratios.

Therapeutic monitoring for cyclosporine: difficulties in establishing a therapeutic window.

Despite the fact that cyclosporine (CsA) has been used clinically for a number of years, there is still uncertainty about the efficacy of monitoring its blood levels. Few if any studies have documented clear differentiation of rejection, immunosuppression, and toxicity on the basis of CsA concentrations alone. The issues in CsA monitoring include selection of sample matrix, analytical method, dosing interval and the timing of trough measurements, the temporal relationship between measurements and physiological events such as toxicity, the concurrent presence of multiple other immunosuppressive agents, and the lack of "gold standards" for determining rejection, adequate immunosuppression, and toxicity. In contrast to using CsA levels for the differential diagnosis of rejection and toxicity, there is evidence that maintenance of CsA concentrations within a therapeutic window results in a lower prevalence of toxicity and rejection.

The clinical significance of cyclosporine metabolites.

Cyclosporine (CsA) is extensively metabolized, with over 14 metabolites having been characterized to date. The confirmation of structure and purity is a prerequisite for studies involving CsA metabolites. Analytical techniques such as fast atom bombardment/mass spectroscopy (FAB/MS), tandem mass spectrometry (MS), 1H- and 13C-nuclear magnetic resonance (NMR) can be used for such purposes. In vitro experiments indicate that metabolites are considerably less immunosuppressive and toxic than CsA. In vivo studies have been hampered by sufficient quantities of metabolites and a suitable animal model. Preliminary results in the rat suggest that CsA metabolites are less immunosuppressive and toxic than CsA, although these results must be confirmed using a more suitable animal model. Present data indicate that the routine monitoring of metabolites is not warranted in transplant patients, although additional information is required to confirm these findings.

Time-dependent disposition of cyclosporine after pancreas transplantation, and application of chronopharmacokinetics to improve immunosuppression.

We studied the circadian influences on cyclosporine pharmacokinetics in five recipients of pancreatic allografts. Results from these patients demonstrate a slightly increased area under the concentration-time curve (p = 0.156) resulting from decreased apparent clearance during the resting (PM) versus activity (AM) period (p = 0.199). A significant delay in mean residence time was observed after the PM dose (p = 0.039), and the PM area under the moment curve was larger than the AM value (p = 0.063). We propose three chronopharmacokinetic dosing methods that alter either the PM dose administration time or redistribute the daily dose to produce equal exposure to cyclosporine during the active and resting periods. These trends and differences suggest that more sophisticated time-dependent cyclosporine dosing methods are needed to balance AM and PM drug exposure and thereby improve immunosuppression.

The dose-dependent inhibition of rat renal translation elongation seen after in vivo cyclosporin A is not caused by cyclosporin metabolites.

Cyclosporin A (CsA) given to Sprague-Dawley rats in vivo produced a tissue-specific, dose-dependent inhibition of translation elongation in renal microsomes. CsA at an oral dose of 50 mg/kg/day for 6 days reduced renal microsomal translation by 70.5%. Renal cytoplasm from rats treated in vivo with CsA inhibited translation by 55% when added to renal microsomes isolated from tissues of control animals. In contrast, CsA added to renal microsomes in vitro did not inhibit translation. Renal cytoplasm from CsA-treated rats containing translation inhibitory factor was found by HPLC to contain CsA and CsA metabolites M1 and M17. CsA metabolites M1, M17, M18 and M21 were isolated from human bile and tested in vitro for translation elongation inhibitory activity in renal microsomes. CsA, M18 and M21 did not inhibit translation elongation at concentrations of up to 2500 ng/ml. M17 inhibited translation elongation, but only by 8.4% at the highest concentration tested (2500 ng/ml), a level 20-fold higher than that measured in renal cytoplasm (125 ng/ml). M1 produced a concentration-dependent inhibition of translation elongation, beginning at 500 ng/ml, or approximately 2-fold higher than that found in renal cytoplasm (260 ng/ml). M1 at 2500 ng/ml or approximately 10-fold higher than the concentration measured in renal cytoplasm, inhibited translation elongation by 23.8%, only 1/3 that observed upon addition of renal cytoplasm containing translation inhibitory factor. We conclude from these findings that the dose-dependent inhibition of renal translation elongation following in vivo CsA cannot be explained by the renal formation or uptake of known CsA metabolites.

Cyclosporine metabolite disposition after oral administration in pretransplant end-stage renal disease patients.

The results of this study have shown large interpatient variability in the disposition of M17 and M1 following a single oral dose of CsA in pretransplant end-stage renal disease patients. The differences in the distribution of M17 and M1 in WB and P at 37 degrees C has particular relevance in the interpretation of CsA therapeutic drug monitoring by nonspecific assays such as the RIA. Additional studies characterizing the disposition of M17 and M1 in WB and P separated at 37 degrees C following chronic CsA therapy will be needed to further understand the role of these metabolites in therapeutic drug monitoring of CsA. New analytical techniques or refinements in the present techniques will be required to identify and separate coeluting substances that are now being recognized with the present techniques.

Quantitative analysis of lidocaine hydrochloride delivery by diffusion across tissue expander membranes.

Permeability of Silastic tissue expander shells to lidocaine was studied to investigate the feasibility of intraluminal lidocaine injection for pain relief during soft-tissue expansion. Both intact expanders and an apparatus using isolated Silastic membrane segments were used to partition solutions of various lidocaine concentrations, and the rate of diffusion was quantitatively measured using a fluorescence polarization immunoassay. Lidocaine flux was found to follow Fick's law of passive diffusion with respect to time, surface area, and concentration gradient for the first 9 hours, with a permeability coefficient of 10.3 +/- 2.6 micrograms (h.cm2.percent)-1 (mean +/- SD) and diffusion coefficient of 7.5 x 10(-7) cm2/min for an average membrane thickness of 473 +/- 23 microns. After 9 hours, the lidocaine flux decreased exponentially, although the concentration gradient across the membrane remained essentially the same order of magnitude. Plasma proteins in the outer bathing solution and methylparaben used as a preservative in the standard lidocaine formulation had no influence on the change in transport flux with time. At the end of the linear portion of the diffusion curve, less than 2 percent of the total intraluminal lidocaine had crossed the membrane. Potential toxicity in the event of implant rupture limits the maximum total lidocaine dose to approximately 500 mg within an expander at any one time. Within these limits, the capacity for lidocaine delivery of 500 mg lidocaine by a 640-cc tissue expander would be only 6 mg during the first 9 hours after administration.(ABSTRACT TRUNCATED AT 250 WORDS)

Electrical muscle stimulation for pressure variation at the seating interface.

A new method is proposed for pressure sore prevention using electrical muscle stimulation (EMS). Potential mechanisms through which EMS may act for this purpose are discussed, including both short-term/dynamic and chronic effects. Measurements of maximum pressure variation in three able-bodied subjects using low levels of stimulation were performed. Pressure distribution changes were also measured. Fatigue effects on pressure redistribution were studied for four able-bodied subjects as well as for one C4, complete spinal cord injured individual. The results indicate that EMS produces sizeable pressure reduction under the ischial tuberosity, with redistribution occurring over other parts of the seating surface in able-bodied subjects. Fatigue effects were not observed in the four able-bodied subjects even after prolonged stimulation. Fatigue was observed with the spinal cord injured subject, but only after extensive stimulation. These studies demonstrate the feasibility of using EMS at relatively low intensity to vary seating interface pressure. The results warrant continued investigation of EMS to assist in pressure sore prevention.

Capillary gas chromatographic separation of urinary organic acids. Retention indices of 101 urinary acids on a 5% phenylmethyl silicone capillary column.

Gas chromatographic retention indices (methylene units) are reported for 101 urinary organic acids as their trimethylsilyl and oximated trimethylsilyl derivatives on a 5% phenylmethyl silicone fused silica capillary column. Using anion exchange chromatography, organic acids were extracted from urines of five healthy individuals, seven patients with neuroblastoma, and nine patients with inherited organic acidurias. Separation of the various acids was achieved by capillary gas chromatography and identification was done by mass spectrometry using a computerized library search program. All identifications were confirmed by visual comparison with reference mass spectra. Standard deviations of the retention indices for all acids were less than 0.035 methylene units and for 46 acids less than 0.01 methylene units. Three chromatograms of urine from individuals with neuroblastoma, phenylketonuria, and propionic acidemia and one from a healthy individual are shown.

Determination of urinary succinylacetone by capillary gas chromatography.

The average analytical recovery of succinylacetone added to urine and separated by capillary gas chromatography was 69% for solvent extraction and 72% for anion exchange separation. Treating succinylacetone with hydroxylamine hydrochloride at a pH of less than 5 caused formation of a derivative separated by capillary gas chromatography into two isomers: 3-methyl-5- isoxazole propionate and 5-methyl-3- isoxazole propionate as their trimethylsilyl derivatives (molecular weight 227). In a pH greater than or equal to 5, succinylacetone dioxime was formed and separated into 3 isomers as their trimethylsilyl derivatives (molecular weight 404). Succinylacetone dioxime was converted to 3(5)-methyl-(3)5- isoxazole propionate whenever the pH of the solution was dropped to less than 5. Mass spectra of both derivatives are shown. This study demonstrates that capillary gas chromatography is suitable for use in urinary succinylacetone determination.

Athletic drug testing.

A drug-control program requires testing to ensure compliance and to deter use. In the athletic drug testing area, measurement of performance-enhancing substances is complex partly because of the large number of prohibited substances. A number of sophisticated analytical techniques, such as high-resolution mass spectrometry, are increasingly used to provide the maximum detection time window. Endogenous steroids pose an increasing challenge because of their availability in "nutritional supplements". Continued vigilance is required to prevent the pharmacologic enhancement of performance.