Characterizing Adversity of Lysosomal Accumulation in Nonclinical Toxicity Studies: Results from the 5th ESTP International Expert Workshop.

Lysosomes have a central role in cellular catabolism, trafficking, and processing of foreign particles. Accumulation of endogenous and exogenous materials in lysosomes represents a common finding in nonclinical toxicity studies. Histologically, these accumulations often lack distinctive features indicative of lysosomal or cellular dysfunction, making it difficult to consistently interpret and assign adverse dose levels. To help address this issue, the European Society of Toxicologic Pathology organized a workshop where representative types of lysosomal accumulation induced by pharmaceuticals and environmental chemicals were presented and discussed. The expert working group agreed that the diversity of lysosomal accumulations requires a case-by-case weight-of-evidence approach and outlined several factors to consider in the adversity assessment, including location and type of cell affected, lysosomal contents, severity of the accumulation, and related pathological effects as evidence of cellular or organ dysfunction. Lysosomal accumulations associated with cytotoxicity, inflammation, or fibrosis were generally considered to be adverse, while those found in isolation (without morphologic or functional consequences) were not. Workshop examples highlighted the importance of thoroughly characterizing the biological context of lysosomal effects, including mechanistic data and functional in vitro readouts if available. The information provided here should facilitate greater consistency and transparency in the interpretation of lysosomal effects.

An open-label, multicenter, phase 2 study of a food enriched with docosahexaenoic acid in adults with sickle cell disease.

Sickle cell disease (SCD) induces red blood cell sickling, which causes debilitating symptoms including vaso-occlusion and inflammation. We investigated a food enriched with omega-3 fatty acids to determine its effect on certain factors: blood cell membrane fatty acid composition (including anti-inflammatory elements-docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)-and the pro-inflammatory, arachidonic acid (AA)); the inflammation biomarker, C-reactive protein (CRP); and vaso-occlusive crisis (VOC) pain. Ten adults with SCD ingested the food, daily, for 28 days. Evaluated measures included blood cell membrane fatty acid ratios (AA vs omega-3 (DHA+EPA)), CRP (mg/L) levels, and Visual Analogue Scale (VAS) scores (a VOC assessment). The food was well tolerated and led to a statistically significant CRP reduction (39%). However, changes in omega-3 fatty acid ratios and VAS scores were not significant. Overall, while the omega-3-enriched food reduced inflammation, larger, blinded studies are needed to assess its effectiveness on other measures.

Dietary composition in restoring reproductive and metabolic physiology in overweight women with polycystic ovary syndrome.

Overweight women with polycystic ovary syndrome (PCOS) were randomized to a high protein (HP; 40% carbohydrate and 30% protein; n = 14) or a low protein (LP; 55% carbohydrate and 15% protein) diet (n = 14). The intervention consisted of 12 wk of energy restriction (approximately 6000 kJ/d), followed by 4 wk of weight maintenance. Pregnancies (two HP and one LP); improvements in menstrual cyclicity, lipid profile, and insulin resistance (as measured by the homeostasis model); and decreases in weight (7.5%) and abdominal fat (12.5%) occurred independently of diet composition. Improvements in menstrual cyclicity were associated with greater decreases in insulin resistance and fasting insulin (P = 0.011). On the LP diet, high density lipoprotein cholesterol decreased 10% during energy restriction (P = 0.008), and the free androgen index increased 44% in weight maintenance stages (P = 0.027). Weight loss leads to improvements in cardiovascular and reproductive parameters potentially mediated by improvements in surrogate measures of insulin resistance. An HP weight loss diet may result in minor differential endocrine and metabolic improvements.

Ghrelin and measures of satiety are altered in polycystic ovary syndrome but not differentially affected by diet composition.

Polycystic ovary syndrome (PCOS) is a common endocrine condition in women of reproductive age associated with obesity. It may involve dysregulation of ghrelin, a hormone implicated in appetite regulation. The effect of diet composition on ghrelin is unclear. Overweight women with and without PCOS were randomized to a high-protein (40% carbohydrate, 30% protein; 10 PCOS, six non-PCOS) or standard protein diet (55% carbohydrate, 15% protein; 10 PCOS, six non-PCOS) for 12 wk of energy restriction and 4 wk of weight maintenance. Diet composition had no effect on fasting or postprandial ghrelin or measures of satiety. Non-PCOS subjects had a 70% higher fasting baseline ghrelin (P = 0.011), greater increase in fasting ghrelin (57.5 vs. 34.0%, P = 0.033), and greater maximal decrease in postprandial ghrelin after weight loss (-144.1 +/- 58.4 vs. -28.9 +/- 14.2 pg/ml, P = 0.02) than subjects with PCOS. Subjects with PCOS were less satiated (P = 0.001) and more hungry (P = 0.007) after a test meal at wk 0 and 16 than subjects without PCOS. Appetite regulation, as measured by subjective short-term hunger and satiety and ghrelin homeostasis, may be impaired in PCOS.

Recognition memory in treated epileptic patients.

In this study there was no qualitative difference in the performance of a heterogeneous group of epileptic patients and normal subjects on a recognition task for visually presented verbal material. There was, however, a significant overall difference in the number of words recognised. After a statistical correction for V.I.Q. was made this difference disappeared. The small sample size and statistical corrections made on the data make it difficult to draw firm conclusions. The data is part of a pilot study investigating the parameters of the test procedure itself. This test will be used in a carefully controlled, prospective study of the cognitive effects of anticonvulsant drugs.

Standardisation of a self-report questionnaire for use in evaluating cognitive, affective and behavioural side-effects of anti-epileptic drug treatments.

The development and standardisation of an inventory for measuring anti-epileptic drug effects on cognition and affect is described. The Side Effect and Life Satisfaction inventory (SEALS) was derived from symptoms and side-effects reported by a patient population. It was administered to 45 patients on two occasions and test-retest reliability was demonstrated. It was administered to 923 patients with epilepsy. An underlying factor structure was produced by principal components analysis, consisting of five sub-scales which were stable when data from males and females were analysed separately or together. Validity was evaluated by comparing inventory scores of patients undergoing a number of treatment trials to show that the inventory was sensitive to treatment differences when other variables were controlled. Patients taking two or more anti-epileptic drugs had poorer SEALS scores than those taking a single drug. Patients taking vigabatrin and one other AED had poorer scores than those taking lamotrigine (LTG) and one other AED. A comparison of changes from baseline to week 4 of a double blind comparison of carbamazepine (CBZ) and LTG showed significantly greater improvement in SEALS scores for patients taking LTG, and significantly poorer scores in those patients taking CBZ who dropped out of the study, than in those who continued. It is concluded that SEALS is a valid and reliable tool for use in anti-epileptic drug trials.

Retrobulbar block using pentothal as a sedative for ambulatory cataract surgery.

Cataract surgery comprises 80% to 85% of the surgical procedures performed at our ambulatory surgical center. We have developed a safe and effective method of sedation and amnesia for performing a retrobulbar block. We use sodium thiopental, administered intravenously, just prior to the block. We encourage the anesthesia departments of other facilities to consider this relatively simple blocking procedure for the comfort and safety of the patient.

Improved pregnancy rates for obese, infertile women following a group treatment program. An open pilot study.

Thirty-seven women with a mean initial weight of 98.5 +/- 18.7 kg completed a group treatment program for obese, infertile women. The program lasted for 24 weeks and included regular exercise and group discussion of topics such as coping with the psychological impact of infertility, developing healthy eating patterns, and the effects of obesity on reproductive physiology. There was significant weight loss (mean weight loss 6.2 +/- 4.5 kg, p < 0.001) and improvement on measures of self-esteem, anxiety, depression, and general health. Twenty-nine women became pregnant during the follow-up period (21-36 months). Two women were avoiding pregnancy, so only six who had completed the group program and wished to become pregnant had not conceived by the end of the follow-up period. A further five women did not complete the program as they became pregnant while attending the group. Our results suggest that active measures to improve mood and self-esteem, along with better nutrition and weight reduction through diet and exercise, can produce considerable improvement in the outcome of treatment for infertility in obese women.

A group program for obese, infertile women: weight loss and improved psychological health.

We report on a group program for obese infertile women. Sixty-four women completed the 24-week program, which included exercise, information about healthy eating and group discussion sessions. Their mean initial weight was 101.9 +/- 18.14 kg. The mean weight loss on completion of the program was 5.2 +/- 5.11 kg (p < 0.0001). There was significant improvement on ratings of self-esteem and depression. Changes to life-style and health which are known to improve fertility may be a useful precursor to invasive, high technology infertility treatment procedures.

Naturally occurring lesions of the uterine tube in sheep and serologic evidence of exposure to Chlamydophila abortus.

The uterine tubes from 405 ewes, collected at an abattoir, were assessed grossly and microscopically for abnormalities that correlated with serological evidence of exposure to Chlamydophila abortus. Gross lesions were found in 41 ewes and 86 had microscopic lesions. Enzyme immunoassay (EIA) of serum was used as an indication of exposure of individual ewes to C. abortus; 52 were found to be positive. Chi-squared analysis indicated no association between EIA-positive animals and lesions of the uterine tube.

Case study to illustrate a multidisciplinary approach to a case of critical limb ischaemia and the role of chemical lumbar sympathectomy.

This case study illustrates the role of the Podiatrist in the primary health care team and how a multidisciplinary approach to treatment promotes successful diagnosis and treatment regimes. It also outlines the role for chemical lumbar sympathectomies in treating critical lower limb ischaemia, a procedure regarded as having been superseded by more effective treatments but which proved to be the treatment of choice in this case. The subject of this case study presented at a community podiatry clinic exhibiting the signs of acute ischaemia, together with two recently developed ulcers on her right foot. After further vascular investigations, including angiograms and doppler studies, a blockage in the popliteal artery was revealed. Due to anatomically slender arteries, angioplasty and by-pass surgery were contra indicated. A chemical lumbar sympathectomy was performed in an attempt to increase blood flow to the tissues and to reduce the extreme pain being experienced by the patient. This proved successful, allowing the lesions to heal and also the collateral circulation to develop, resulting in a re-vascularized, viable foot.

Evaluation of dexfenfluramine in a weight loss program for obese infertile women.

OBJECTIVE: To evaluate the usefulness of dexfenfluramine as an adjunct to a group treatment program for obese infertile women. METHOD: Twenty-one obese infertile women were referred by the Reproductive Medicine Unit. They attended a 24-week group program which included exercise and educational sessions. Dexfenfluramine and placebo were given, each for 12 weeks, in a double-blind crossover design. RESULTS: Dexfenfluramine treatment was not associated with greater loss of weight. The mean weight loss during dexfenfluramine treatment was 3.21 kg (SD 3.09) and during placebo was 3.31 kg (SD 3.15). Self-esteem, anxiety, and depression ratings all improved significantly over the 24 weeks. DISCUSSION: The group treatment program appeared to be equally effective with or without dexfenfluramine. Previous studies have found dexfenfluramine to be effective in combination with individual treatment, but it has not previously been evaluated as an adjunct to group treatment. It is unclear whether dexfenfluramine may be less effective in combination with group treatment programs, or whether its usefulness is restricted in this particular population of obese patients. No differences were found associated with the order in which active and placebo treatments were given. Patients showed improvement in self-esteem and reduction in depression and anxiety, but dexfenfluramine treatment was not associated with any difference in these measures, compared to placebo.

A comparative study of the cognitive effects of phenytoin and carbamazepine in new referrals with epilepsy.

This study compares cognitive function in new referrals with epilepsy well-controlled on single drug therapy with either phenytoin or carbamazepine with that in an untreated control group. Patients receiving phenytoin performed consistently less well on memory tasks than did those untreated or receiving carbamazepine. Although patients on phenytoin overall showed a trend towards poorer performance on a tracking task, higher blood levels of this drug were correlated with better tracking performance. The correlation between blood levels of carbamazepine and tracking performance was the opposite from that of phenytoin. Blood levels of carbamazepine were negatively correlated with measures of anxiety, depression, and fatigue. These findings have implications for the choice of drug in the management of epilepsy and also for the reported claims of a psychotropic effect of carbamazepine.

Long term outcome of treatment of end stage renal failure.

The most common causes of end stage renal failure in 46 children (mean age 11 years, range 4-14) treated between January 1972 and June 1977 were: reflux nephropathy (n = 12), cystinosis (n = 7), focal and segmental glomerulosclerosis (n = 6), and Schönlein-Henoch disease (n = 5). The quality of life, degree of renal function, and height attainment of the 31 survivors were assessed in June 1985, when their mean age was 22 years (range 14-27), using hospital records and a questionnaire designed to highlight social and psychological problems. Twenty six patients had a functioning transplanted kidney. Average growth during treatment for all survivors was normal, but most were disappointed with their 'final height'. Though five patients had some form of disabling bone disease, all 31 could walk and 27 could run. Sixteen (67%) were in full or part time employment and nine were living independently. A group of 32 patients with juvenile onset diabetes treated at this hospital for at least five years were also asked to complete the questionnaire and of these, 17 responded. On average, their data could usefully be compared with those of cases of end stage renal failure. More of the diabetics had jobs, but most sexually mature patients with renal disease were concerned about their physical appearance and had not achieved any stable long term sexual relationships. We suggest that a poor body image resulting in low self esteem may be responsible for the deficiency and believe that further study in this group is warranted.

Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment.

Obesity affects ovulation, response to fertility treatment, pregnancy rates and outcome. In this prospective study, a weight loss programme was assessed to determine whether it could help obese infertile women, irrespective of their infertility diagnosis, to achieve a viable pregnancy, ideally without further medical intervention. The subjects underwent a weekly programme aimed at lifestyle changes in relation to exercise and diet for 6 months; those that did not complete the 6 months were treated as a comparison group. Women in the study lost an average of 10.2 kg/m2, with 60 of the 67 anovulatory subjects resuming spontaneous ovulation, 52 achieving a pregnancy (18 spontaneously) and 45 a live birth. The miscarriage rate was 18%, compared to 75% for the same women prior to the programme. Psychometric measurements also improved. None of these changes occurred in the comparison group. The cost savings of the programme were considerable. Prior to the programme, the 67 women had had treatment costing a total of A$550,000 for two live births, a cost of A$275,000 per baby. After the programme, the same women had treatment costing a total of A$210,000 for 45 babies, a cost of A$4600 per baby. Thus weight loss should be considered as a first option for women who are infertile and overweight.

The specificity of the antibody response to internal antigens of Ascaris: heterogeneity in infected humans, and MHC (H-2) control of the repertoire in mice.

Children from an area of Africa endemic for the large roundworm of humans, Ascaris lumbricoides, were found to vary considerably in the specificity of their serum IgG response to the internal antigens of the parasite. This was particularly noticeable for responses to a 14-kD protein (ABA-1) of the parasite that has previously been shown to be the subject of a strong IgE antibody response in infected animals. The possibility that this heterogeneity in immune repertoire has a genetic basis was explored in inbred mice infected with Ascaris suum. This showed that no strain responded to all the potential antigens, that the recognition profiles of strains bearing independent haplotypes were unique, and only H-2-identical strains had responses of similar specificities. Major histocompatability complex (MHC) restriction was confirmed using H-2-congenic animals on BALB and B10 backgrounds, which responded according to their H-2 haplotype. It is likely, therefore, that it is the MHC which controls the repertoire to Ascaris antigens in infected people. If this is so, then there will be implications for immunopathology associated with ascariasis, and possibly also for resistance and susceptibility to infection.

Weight loss results in significant improvement in pregnancy and ovulation rates in anovulatory obese women.

Obesity can affect ovulation and the chances of pregnancy. In this prospective study, a weight loss programme was assessed to determine whether it could help infertile overweight anovulatory women to establish ovulation and assist in achieving pregnancy, ideally without further medical intervention. The subjects acted as their own historical controls. They underwent a weekly programme of behavioural change in relation to exercise and diet over 6 months; those who did not complete the 6 months were treated as the comparison group. Women in the study group lost an average of 6.3 kg, with 12 of the 13 subjects resuming ovulation and 11 becoming pregnant, five of these spontaneously. Fitness, diet and psychometric measurements all improved. Fasting insulin and testosterone concentrations dropped significantly, while sex hormone binding globulin concentrations rose. None of these changes occurred in the comparison group. Thus, weight loss with a resultant improvement in ovulation, pregnancy outcome, self-esteem and endocrine parameters is the first therapeutic option for women who are infertile and overweight.