Assessment of the in vitro developmental toxicity of diethylstilbestrol and estradiol in the zebrafish embryotoxicity test.

The present study investigated the developmental toxicity of diethylstilbestrol (DES) in the zebrafish embryotoxicity test (ZET). This was done to investigate whether the ZET would better capture the developmental toxicity of DES than the embryonic stem cells test (EST) that was previously shown to underpredict the DES-induced developmental toxicity as compared to in vivo data, potentially because the EST does not capture late events in the developmental process. The ZET results showed DES-induced growth retardation, cumulative mortality and dysmorphisms (i.e. induction of pericardial edema) in zebrafish embryos while the endogenous ERα agonist 17ß-estradiol (E2) showed only growth retardation and cumulative mortality with lower potency compared to DES. Furthermore, the DES-induced pericardial edema formation in zebrafish embryos could be counteracted by co-exposure with ERα antagonist fulvestrant, indicating that the ZET captures the role of ERα in the mode of action underlying the developmental toxicity of DES. Altogether, it is concluded that the ZET differentiates DES from E2 with respect to their developmental toxicity effects, while confirming the role of ERα in mediating the developmental toxicity of DES. Furthermore, comparison to in vivo data revealed that, like the EST, in a quantitative way also the ZET did not capture the relatively high in vivo potency of DES as a developmental toxicant.

SIDE EFFECTS OF DIETHYLSTILBESTROL (DES) FROM THE PERSPECTIVE OF TORT LAW.

OBJECTIVE: The aim of the article is to analyze the reasoning of the Supreme Court of California in Sindell v. Abbott Laboratories. PATIENTS AND METHODS: Materials and methods: Materials of the study encompass US case law as well as case law of other countries concerning compensation of damage caused by defective drugs and other cases of uncertain causation. The survey is conducted within the framework of comparative law studies. In addition, elements of law and economics approach are also employed in the paper. CONCLUSION: Conclusions: Case of Sindell v. Abbott Laboratories has launched a new direction in discourse on causation in tort law and product liability. The mathematical elegance of the Court's theory is that net burden of liability borne by a particular drug manufacturer is equal to the amount of damage actually caused by its drug.

In vivo assessment of gonad status, secondary sex characteristics and spawning in transparent Casper zebrafish.

Important aspects of vertebrate reproduction, such as gametogenesis, involve changes in organs found deep internally and thus not easily studied directly in most living vertebrates due to obscuring pigment and overlying tissues. Transparent lines of zebrafish, especially the Casper double mutant, allow direct observation and analysis of reproductive events in the gonads in vivo. The natural production of fertilized eggs in zebrafish is a complex process involving oogenesis, spermatogenesis, mating behavior, endocrine and neurological processes with inputs from the environment including light, temperature and nutrition. While these factors play important roles, the hypothalamic-pituitary-gonadal axis (HPGA) is central in the regulation of embryo output. Endocrine disrupting compounds (EDCs) include a variety of pollutants often present in the environment. EDCs may have direct effects on the HPGA or indirect effects through toxic action on supporting organs such as the liver or kidney. Estrogenic compounds such as diethylstilbestrol (DES) have been reported to affect reproduction in a variety of species including man. In this study, the effects of DES on reproduction were determined in a novel way by using transparent Casper zebrafish that allow direct visualization of gonad status over time. Changes in gonad status with DES treatment were correlated with effects on secondary sex characteristics (i.e., genital vent size and breeding tubercles) spawning and embryo production. The results suggest that the Casper zebrafish is a useful model for studying dynamics of reproductive events in vertebrate gonads in vivo and for determining effects of EDCs on zebrafish reproduction.

Assessment of estrogenic potential of di-n-butyl phthalate and butyl benzyl phthalate in vivo.

Phthalate compounds are widely used industrial chemicals; when incorporated into polyvinyl chloride, they are not covalently bound and released into the surrounding media. Some of them have estrogenic potential in vitro but data on in vivo studies are scanty. For the 3-day uterotrophic assay, di-n-butyl phthalate (DBP;10 and 100 mg/kg), butyl benzyl phthalate (BBP; 20 and 200 mg/kg), and diethylstilbestrol (DES, 40 µg/kg, positive control) were administered orally to immature female rats for three consecutive days from postnatal day (PND) 21. For the 20-day pubertal onset assay, DBP (10 and 20 mg/kg), BBP (20 and 200 mg/kg), and DES (6 µg/kg) were administered orally from PND 21 daily for 20 days. In the uterotrophic assay, in groups treated with higher dose of DBP and BBP, the uterine wet weight significantly decreased in the higher dose, and there were minor variations in the ovary wet weight, while the wet weight of these organs increased significantly in DES-treated group. In the 20-day pubertal assay, the weight of uterus and ovary declined significantly and changes in vaginal weight were nonsignificant in DBP- and BBP-treated groups. However, in DES-treated group nonsignificant elevation in vagina weight was observed. All the DES-treated animals showed the vaginal opening (VO) on day 26.17 ± 0.16. However, VO was not observed in any of the animals in control, vehicle control, BBP-, and DBP-treated groups up to PND 42, except in one animal each in vehicle control and DBP (100 mg/kg)-treated groups. The data indicated that both DBP and BBP were unable to induce elevation in the uterine and ovarian weight. While DES treatment can accelerate the growth of uterus and ovary and alter the onset of puberty and estrous cyclicity in prepubertal rats. These suggest that these compounds may not have estrogenic potential in vivo.

Risk assessment of xenoestrogens in a typical domestic sewage-holding lake in China.

Release of domestic sewage leads to accumulation of xenoestrogens in holding waters, especially in closed or semi-enclosed waters such as lakes. In the study, the occurrence, distribution, estrogenic activity and risk of eight xenoestreogens were evaluated in Lake Donghu, China. Nonylphenol (NP), octylphenol (OP), and bisphenol A (BPA) were identified as the main xenoestrogens ranging from tens of ngL(-1) (in the surface water) or ng g(-1)dw (in the suspended particles and sediment) to tens of µgL(-1) or µg g(-1)dw. The sum of 17ß-estradiol equivalents (∑EEQs) ranged from 0.32 to 45.02 ngL(-1) in the surface water, 0.53 to 71.86 ng g(-1)dw in the suspended particles, and 0.09 to 24.73 ng g(-1)dw in the sediment. Diethylstilbestrol (DES) was determined as the main contributor to ∑EEQs followed by NP. The risk assessment showed a higher risk in the surface water than in the suspended particles and sediment in such domestic sewage-holding lake.

Clinicians choose distinctive approaches to OC management.

PIP: A survey of comparing management styles regarding oral contraceptives of 294 nurse practitioners, 152 physicians, 24 nurse midwives and 25 physician's assistants is reported. The 1st choice of pill was ON7/7/7 among 64% of nurse practitioners, 60% of physician's assistants, 57% of physicians, and 47% of nurse midwives. Triphasic pills were preferred by 70% of nurse practitioners, 70% of physicians, 62% of nurse midwives and 60% of physician's assistants. Next choices were ON 1/35 or Norinyl 135 (Syntex). In answer to the question whether to prescribe pills to daughters of mothers who took diethylstilbestrol, all physician's assistants and 95% of physicians would, but only 80 and 53% of nurse practitioners and nurse midwives would do so, preferring to refer the patient to a physician, who would prescribe pills. The results followed a similar trend in answer to the question of giving pills to a very young sexually active teen: 83% of physicians, 72% of physician's assistants, 65% of nurse practitioners and 64% of nurse midwives would give out pills. The most common age ceiling for oral contraceptive prescription was 40 years; physicians more often would make exceptions and prescribe to women over 50, while the other clinicians spread their answers broadly over ages 35, 40, 45 and 50.^ieng

Theories of recovery for DES damage. Is tort liability the answer?

PIP: An estimated 1000 individual or class action products liability lawsuits have been filed against the pharmaceutical manufacturers of diethylstilbestrol (DES). The field of potential plaintiffs is estimated at 500,000-6,000,000 and there are 150-300 potential defendant manufacturers. This article addresses the question of whether the current system of tort liability dispenses fair, timely, and uniform justice both to DES claimants and manufacturers and presents a historical perspective on the basis for liability. Traditional theories of tort recovery are based on negligence, breach of warranty, and strict liability. They place the burden of proof on the claimant to specifically identify the product manufacturer and establish proximate causation. Novel theories of recovery have had to be applied in DES lawsuits, including concert of action and alternative liability. Most of these theories have been unaccepted by trial and appellate courts because of the inability to identify the manufacturer. Even if DES manufacturers were to be held liable under a theory of industry-wide or market share liability, defendants would be called upon to allocate liability among themselves. Many believe that any departure from traditional tort principles should be accomplished by the legislature, not the judiciary. There is not currently a bill before the US Congress dealing specifically with compensation for damages to DES victims. Any model toxic tort legislation should aim to eliminate the benefit inequities as between claimants and the cost inequities in delivering benefits to qualified recipients by the responsible parties. The claimant's burden of establishing fault should be eliminated in exchange for a claimant's surrender of a right to sue a third party, and a standardization of compensatory damages. The requirements of specific product identification, duration of exposure, and degree of fault would be eliminated. Jurisdictional requirements and statues of limitation must be drafted to permit recovery for previously unknown injuries. Finally, there should be an overall goal of promptness in recovery. The most equitable solution to problems with the tort system is legislation which deals with the toxic tort problem as a whole and not just on a case-by-case basis.^ieng

Inhibition of progestational activity for fertility regulation.

PIP: This review examines a number of areas of postconceptive fertility regulation, focusing on promising new antiprogestational agents. Pregnancy is dependent upon the availability of progesterone for the uterus and its withdrawal results in the breakdown of the secretory endometrium. Its availability can be interferred with at several levels and the new methods which allow for progesterone inhibition must be tested for possible defeminizing properties or for serious side effects. In the evaluation of contragestational agents, several areas must be taken into consideration--assessment of biological activities, dose requirements and mode of action, duration of effects, route of administration, and drug tolerance and side effects. The failure to maintain progesterone in the blood at levels required for pregnancy maintenance may be due to a decrease in progesterone secretion by the ovary or to an increased rate of metabolism and excretion of circulating progesterone. The various substances discussed do either 1 or the other; however even when a compound is known to result in a decrease in the rate of progesterone secretion, the process by which it does this may not be known. Prostaglandins seem to affect myometrial contraction, luteinizing hormone releasing hormones can inhibit steroid production or interfere with LH binding to its receptor, and immunization against hCG is a successful immunological approach to conception. Lithospermic acid is another substance which interferes with gonadotropin support of the ovary and has good potential. Other compounds that interfere with progesterone secretion act to inhibit steroidogenesis in the ovary and placenta; such substances include aminoglutethimide, oxymetholone, trilostane, azastene, and danazol. Another progesterone-suppression method would remove a sufficient amount of progesterone from the body to cause endometrium involution and promote contractility of the myometrium. Progesterone antagonists include ORF 9361, R3434, Anordrin, ORF 3858, and other estrogens, triazole compounds, ORF 5513, trichosanthin, and zoapatanol.^ieng

Payton v. Abbott Laboratories: an analysis of the Massachusetts DES class action suit.

In Payton v. Abbott Laboratories, U.S. District Court Judge Walter J. Skinner recently granted class certification to an action brought by twenty-seven Massachusetts women against major manufacturers of DES. This is the first case in which a judge has interpreted the requirements of Rule 23 of the Federal Rules of Civil Procedure to allow women exposed in utero to DES to sue as a class to determine liability for their injuries. This Note reviews the Payton certification in light of prior class action decisions involving DES and other types of claims, and of legal commentary on Rule 23. This Note contends that Judge Skinner's application of the Rule 23 requirements in Payton was procedurally correct, and recommends the class action device as an effective method for litigating such controversies. Finally, this Note analyzes the implication of this landmark ruling for plaintiffs seeking class certification in DES suits and in suits presenting analogous factual situations.

PIP: In Payton v. Abbott Laboratories, U. S. District Court Judge Walter J. Skinner recently granted class certification to an action brought by 27 Massachusetts women against major manufacturers of DES. This is the first case in which a judge had interpreted the requirements of Rule 23 of the Federal Rules of Civil Procedure to allow women exposed in utero to DES to sue as a class to determine liability for their injuries. This reviews the Reyton certificiation in eight of prior class action decisions involving DES and other types of claims, and of legal commentary on Rule 25. The Note for contends that Judge Skinner's application of the Rule 23 requirements in Payton was procedurally correct, and recommends the class action device as an effective method for litigating such controversies. Finally, this Note analyzes the implications of this landmark ruling for plaintiffs seeking class certification in DES suits and in suits presenting analogous factual situations. Rule 23 requires that the plaintiffs' proposed class action fulfill all the prerequisities for the class format enumerated in subdivision (a). These are as follows: 1) numerosity; 2) common questions of law or fact; 3) typicality of the claim; and, 4) adequacy of the representation. The granting of class status in Payton most directly affects the estimated 2 million daughters of women given the synthetic hormone diethylstilbestrol between 1940 and 1971.

Carriers to pay N.J. hospitals preset fees for services.

PIP: The report of a task force on DES was recently released by HEW Secretary Joseph Califano. The task force, chaired by Dr. Diane Fink of the National Cancer Institute, urged doctors to discontinue routine use of estrogens as postcoital contraceptives, oral contraceptives, and postmenopausal therapy. Estrogens should be used only after careful consideration and medical judgment. The risk of breast or gynecological cancer for girls exposed to DES during gestation is not established but seemingly serious. Risk of adenocarcinoma of the vagina or cervix may not be as high as previously feared. In any case, DES daughters should begin periodic gynecologic screening at 14 or the onset of menses, whichever occurs first. Their mothers should also have regular examinations. DES sons have a higher risk of genital and possibly urinary abnormalities. No effects of DES have been found in the 3rd generation. Doctors should notify all their patients with previous DES exposure and provide follow-up medical care.^ieng

Fertility regulation technology: status and prospects.

PIP: The current status of and prospects for contraceptive methods is reviewed. Regulations governing the development, safety, and effectiveness of contraceptive methods are discussed, as well as the nature of the female and male reproductive system. Methods reviewed include coitus interruptus, the condom, spermicidal contraceptive agents, postcoital douching, the vaginal diaphragm, male and female sterilization, the rhythm method, oral contraceptives, IUDs, induced abortion, progesterone-releasing IUDs, postcoital estrogens, abortifacient agents (prostaglandins), immunization against human chorionic gonadotropin (HCG), pharmacologic suppression of the corpus luteum, long-acting injections of Depo-Provera, implantation of capsules containing norgestrel, the intravaginal ring, intracervical devices, release of contraceptive steroids through an arm bracelet, and male contraceptive agents. New areas of contraceptive research include influencing the release of luteininzing hormone-releasing hormone, ''turning-off'' corpus luteum function in early pregnancy by competitors for HCG, affecting sperm or ovarian membranes to prevent fertilization, and interferring with sperm and egg development.^ieng

Litigation involving DES.

PIP: Focus is on the diethylstilbestrol (DES) litigation which has resulted from the 1971 discovery that this synthetic estrogen can cause cancer in the daughters of women who used the drug during pregnancy in an effort to prevent threatened abortion. Possibly 100 suits are pending at this time in which DES daughters claim injuries. In most of these vaginal or cervical cancer has appeared -- with or without a hysterectomy having been performed. Several women died from cancer. The fact that the use of DES occurred many years ago is the legal hurdle most troublesome to lawyers. The average women coming to a lawyer's office today has a mother who used some form of DES, perhaps in 1955. Few drugstores have records today of the prescriptions which they filled 20 years ago. It has been estimated that over the 1950-1970 period more than 200 different companies manufactured or "tabletized" under their own name DES plus a variety of similar synthetic estrogens promoted for the prevention of threatened abortion. A further hurdle caused by the passage of time is that even the records of the physicians are frequently lost. A final problem created by the age of the cases is statute of limitations. If the actual manufacturer of the DES cannot be identified, this is generally the end of the lawyer's interest in the case. The chance of the plaintiff winning may be increased if the action against all the manufacturers is a class action. Most of the pending DES suits are against the manufacturer and not against the doctor. Thus far no DES case has been tried to completion. Several have been settled by the manufacturers on the eve of the trial, generally for less than the full sum that a cancer victim would expect to receive.^ieng

Assuring the safety and efficacy of therapies.

PIP: The randomized, controlled clinical trial now makes it possible to test the hypothesis that 1 form of treatment is preferable to another and to express the results in the form of the probability of the differences found being because of chance or not. The means exist to evaluate much of medical and surgical therapy, and the problems of evaluating surgical procedures, increasing drug use and adverse reactions to therapy are discussed. The purpose is to raise key issues and critical questions. The example of a minor epidemic of drug induced cancer is described to illustrate the use of the epidemiologic method in detecting adverse effects and for its implications for the development of of a more resonsible public policy to prevent such occurrences. The example of the use of DES in pregnancy and the resulting minor "epidemic" of adenocarcinoma of the vagina among the adolescent daughters of these women was chosen because this example of an adverse drug reaction reveals 1) the complexities of detection; 2) the role of the epidemiologist; 3) the possible results of uncritical acceptance of therapeutic reports; and 4) the need for a new policy of drug regulation. Advances in the epidemiologic detection of adverse effects, along with the development and application of the controlled clinical trial have provided the needed evidence for the development of new governmental regulations which ensure safety and efficacy. Such evidence suggests that regulation should be expanded to require that manufacturers of new drugs introduced into the market demonstrate, in addition to safety and efficacy, the relative efficacy of their products over existing formulations. Surgical procedures also need to be subjected to scrutiny. More attention needs to be paid to the ecologic consequences of drugs and food additives.^ieng