Patient- and caregiver-reported bleeding symptoms and reasons for starting and stopping treatment with recombinant factor VIIa: analysis of the Dosing Observational Study in Haemophilia (DOSE).

Acute haemorrhage treatment in patients with congenital haemophilia with inhibitors (CHwI) has transitioned to home. Patient/caregiver perceptions of bleeding symptoms and reasons for starting/stopping treatment were investigated. Frequently bleeding CHwI patients (≥ 4 episodes in 3 months) prescribed recombinant factor VIIa (rFVIIa) as first-line therapy, or their caregivers, completed daily diaries for 3-6 months capturing bleeding symptoms and treatment decisions. Thirty-eight patients reported 131 joint, 19 muscle and 44 other bleeding events. Symptoms (all/joint/muscle haemorrhages) included pain (78.9%/90.1%/89.5%), joint swelling (44.8%/65.6%/5.3%), decreased mobility (41.2%/48.9%/68.4%), local warmth (21.1%/26.0%/15.8%), other swelling (16.0%/6.9%/47.4%), irritability (14.9%/16.8%/10.5%), visible bleeding (12.4%/7.6%/5.3%) and redness (10.3%/6.1%/10.5%). Most patients/caregivers recognized when bleeds started (58.4%/58.0%), but were less clear when bleeds stopped (43.5%/33.3%). Medication was commonly started by patients/caregivers when bleeds were identified (73.7%/47.4%) or when concerned bleeds might start (32.9%/27.6%). Common reasons for delays in starting medication by patients included 'I thought it might not be a bleed' (48.9%), 'I wanted to see if the bleed progressed' (46.8%) and 'I thought it was just joint pain' (44.7%). Common reasons for caregivers were: 'I wanted to see if it progressed' (37.9%), 'I didn't have medication' (20.7%) and 'I thought it might not be a bleed' (17.2%). Reasons for stopping medication for patients/caregivers were pain cessation/stabilization (93.9%/54.7%), arrest of swelling progression (60.6%/46.9%) and improved mobility (50.0%/35.9%). Patients/caregivers have difficulty in determining bleed onset and particularly resolution, both quite necessary for treatment decisions and clinical trials. Caregivers' inability to assess resolution in children may lead to longer treatment duration seen in the Dosing Observational Study in Haemophilia (DOSE).

Clinical perspectives in lymphoma.

The classification of both Hodgkin's and non-Hodgkin's lymphomas continues to evolve. The current World Health Organization classification incorporates data derived from advances in our understanding of the pathogenesis of these disorders together with their distinguishing immunophenotypic, genotypic, clinical and histopathological characteristics. As outcomes have improved, the main emphasis of treatment has been to incorporate a risk-adapted approach to reduce long-term toxicity without sacrificing efficacy through the use of varying combinations of chemotherapy, radiotherapy and immunotherapy.

Prevalence and risk factors of diabetic retinopathy in non-Hispanic whites and Hispanics with NIDDM. San Luis Valley Diabetes Study.

Diabetic retinopathy (DR) is the leading cause of blindness in adults in the United States. Because photocoagulation can reduce the incidence of blindness from severe DR by approximately 50%, it is important to identify people at increased risk for DR so that appropriate treatment can be accomplished. Use of populations at increased risk for diabetes may identify groups at increased risk for complications. A recent report from the San Antonio Heart Study showed that Mexican Americans were at greater risk for servere DR than non-Hispanic Whites. To compare the prevalence of DR between non-Hispanics and Hispanics in southern Colorado, 279 people with non-insulin-dependent diabetes mellitus (NIDDM) were identified, and retinal photographs identified the presence and severity of retinopathy. The worse eye was used to classify the severity of DR for each patient. Ninety percent of the subjects (166 Hispanics and 85 non-Hispanic Whites) were classified by retinopathy level. The duration-adjusted prevalence of any DR was 41.8% in Hispanics and 54.1% in non-Hispanic Whites. Severe DR (preproliferative and proliferative) occurred in 18.5% of the Hispanics and in 21.3% of the non-Hispanic Whites. The odds ratio for any DR, comparing Hispanics with non-Hispanic Whites adjusted for other risk factors, was 0.40 (95% confidence interval = 0.21, 0.76). Other risk factors for the presence of any retinopathy included use of exogenous insulin, increased duration of diabetes, younger age at diagnosis, increased glycosylated hemoglobin level, and increased systolic blood pressure. These data suggest that, compared with non-Hispanic Whites, Hispanics in Colorado may be at decreased risk for diabetic retinopathy.

Fragment filtration: a method for the accurate determination of flow cytometric kinetic data from bone marrow aspirates.

The extent to which bone marrow obtained by conventional aspiration is contaminated by peripheral blood has been confirmed and quantitated. In marrow aspirates from normal subjects the median percentage of nucleated cells that had originated from the peripheral blood was 32% (range 2.5%-64%), in patients with acute leukemia 23% (range 0.5%-96.5%), in patients with chronic leukemia 59% (range 17%-76%), and in patients with lymphoma 31% (range 0.5%-74%). Flow cytometric (FCM) DNA analysis of conventional marrow aspirates from a range of subjects significantly underestimated the proportions of S-phase cells present, when compared with results from trephines obtained at the same time. Having shown, using 51Cr-labeled red cells in mice, that circulating red cells do not reenter the marrow parenchyma, a mathematical correction for contaminating blood similar to that described by Holdrinet et al. was devised. This correction improved the S-phase cell estimate from aspirated marrows, and the corrected values were not significantly different from values from paired trephine samples. A previously described technique for collecting fragments by filtration of aspirated marrow has been adapted for FCM analysis as a more direct way of overcoming problems due to blood contamination. This method was shown to yield estimates of S-phase cells not significantly different from those in paired marrow trephines and offers an alternative to routine trephine biopsies for FCM analysis of marrow cell kinetics.

Fine needle aspiration sampling of bone marrow for DNA flow cytometric analysis.

Fine needle aspiration (FNA) was used to obtain bone marrow samples from 57 patients with a variety of hematologic disorders, and from three normal subjects. We confirm that the technique is well tolerated and show that reliable cytokinetic and cell differential data can be obtained provided marrow fragments are isolated for analysis. This requires aspiration of a larger volume of marrow than originally described but this can still be achieved with minimal discomfort to the patient. The technique thus provides a means by which marrow samples could be obtained at frequent intervals in the monitoring of chemotherapy.

Effects of cytosine arabinoside on human leukemia cells.

Cytosine arabinoside (Ara-C) is used to treat leukemias, with complete remission induced by combination chemotherapy in approximately 70% of cases of acute myelogenous leukemia (AML). Ara-CTP acts as a competitive inhibitor of DNA polymerase and may also be incorporated into DNA. Accumulation of deoxyribonucleoside triphosphates (dNTPs) induced by Ara-C may indicate disruption of DNA synthesis in susceptible leukemia cells. A procedure has been developed for the quantification of Ara-CTP and dNTPs from small samples of leukaemia cells from patients (4 x 10(7) cells) activated with concanavalin A (10 micrograms/ml, 48 hr) and grown in the presence of [32P]orthophosphate (1.1 microM, 9 x 10(6) Ci/mol, 16 hr). The susceptibilities to Ara-C of the human leukemia cell lines CCRF-CEM (IC50 = 6.30 nM), CCRF-HSB-2 (IC50 = 10.4 nM) and MOLT-4 (IC50 = 10.0 nM) may be correlated with their abilities to accumulate high concentrations of Ara-CTP (> 1000 amol/cell) with increases of between 1.3- and 3.4-fold in dATP, dGTP and dTTP for the four cell lines, while dCTP decreased between 0.23- and 0.78-fold. By contrast, an Ara-C-resistant derivative of HL-60 cells (IC50 = 400 nM) accumulated only low concentrations of Ara-CTP (71 amol/cell) without significant changes in dNTPs. High concentrations of Ara-CTP in leukemia cells induce accumulations of dATP, dGTP and dTTP due to inhibition of DNA synthesis, and depletion of dCTP. This imbalance in the pools of the four dNTPs could lead to genetic miscoding and cell death.

Evaluation of protein-energy malnutrition in surgical patients from plasma valine and other amino acids, proteins, and anthropometric measurements.

Eight plasma proteins, four anthropometric measurements, and 21 amino acids were measured in 24 fasting patients before surgery. A matrix of partial correlation coefficients, correcting for age and height, showed many correlations including several between biochemical and anthropometric data such as between valine or prealbumin and arm muscle circumference. Valine was the most highly correlated variable and was used to rank and group the patients. Ten patients with low valine had the greatest weight loss and also had low values for 18 variables which could be subdivided. 1) Thirteen of the low variables were interrelated and correlated with valine, i.e., arm muscle circumference, prealbumin, retinol-binding protein, transferrin, haemoglobin, isoleucine, leucine, methionine, phenylalanine, tyrosine, serine, alanine, and proline. 2) Fat, threonine, glycine, and beta-lipoprotein were interrelated with one another but not with the larger group. Only beta-lipoprotein were interrelated with one another but not with the larger group. Only beta-lipoprotein correlated with valine. It is suggested that variables in both groups reflect protein-energy malnutrition but that those in the second group are affected predominantly by energy intake.

Assessment of protein-calorie malnutrition in surgical patients from plasma proteins and anthropometric measurements.

Six plasma proteins, two anthropometric measurements, hemoglobin and total lymphocytes were determined in 54 surgical patients and 19 normal individuals. Preoperative patients had a low mean values for prealbumin, retinol binding protein, and arm muscle circumference. In postoperative patients, plasma transferrin, albumin, hemoglobin, total lymphocytes and body weight were also low and complement C3 was higher than normal. A correlation matrix for 10 variables showed interrelationships between the biochemical and anthropometric data. Prealbumin and transferrin were highly correlated with most of the variables. The effects of protein-calorie malnutrition were analyzed from the data ranked and grouped according to the plasma prealbumin or transferrin concentration. Those groups with low mean values for these proteins also had low values for most of the other variables. Protein calorie malnutrition in surgical patients may be conveniently assessed from plasma prealbumin, transferrin, arm muscle circumference, percentage weight loss, and hemoglobin.

Plasma proteins in patients receiving intravenous amino acids or intravenous hyperalimentation after major surgery.

Eleven plasma proteins were compared for each of three groups of 10 closely matched patients before and 15 days after rectal excision who were receiving an addition to oral diets the following parenteral solutions by central venous catheter: 1) no hyperalimentation, 2) hypertonic glucose plus amino acids, or 3) amino acids alone. Plasma transferrin, prealbumin, and retinol-binding protein were normal before surgery in all but seven patients. Postoperatively, concentrations were decreased, but were restored to normal after full hyperalimentation whereas they were significantly less and lower than normal in controls and patients receiving amino acids. Acute phase proteins were higher than normal before surgery and also 15 days later. Lower values in patients receiving hyperalimentation were mainly due to hydration compared with higher values in the other groups caused by the higher incidence of sepsis. It is concluded that full hyperalimentation after major surgery restores "visceral" proteins more rapidly than by infusion of amino acids alone and is associated with fewer clinical complications.

The effect of vitamin C supplements on body weight, serum proteins, and general health of an elderly population.

A double-blind placebo trial of vitamin C has been undertaken in 94 elderly "long-term" inpatients known to have initially low levels of plasma and leukocyte vitamin C (mean values 0.17 mg/100 ml plasma; 10.1 microgram/10(8) leukocytes). At the end of 2 months treatment, plasma and leukocyte vitamin C had increased considerably in those receiving C supplements, and in this group there were slight but significant increases in the mean values for body weight (0.41 kg), plasma albumin (0.46 g/l), and prealbumin (25.4 mg/l) compared with those receiving placebo therapy where there were decreases of 0.60 kg, 0.53 g/l, and 7.0 mg/l, respectively. There was also some clinical improvement as indicated by reductions in purpura and petechial hemorrhages in those receiving vitamin C, but no changes in mood or mobility were observed.

A double-blind comparison of fluconazole and nystatin in the prevention of candidiasis in patients with leukaemia. Antifungal Prophylaxis Study Group.

In this multicentre, randomised, double-blind study, the safety and efficacy of oral fluconazole (200 micrograms/day) and nystatin suspension (6,000,000 IU/day) for the prevention of fungal infections were compared in patients with leukaemia undergoing remission induction chemotherapy. Antifungal prophylaxis was initiated at the time chemotherapy was started and continued throughout the hospital stay or the period of neutropenia to a maximum of 42 days. Prophylaxis was successful (no evidence of fungal infection or fever of unknown origin unresponsive to antibiotics) in 38 of 56 (68%) fluconazole-treated and 25 of 53 (47%) nystatin-treated patients (P = 0.03). 2 patients (4%) in the fluconazole group and 6 (11%) patients in the nystatin group developed systemic fungal infections (P = 0.15). The overall frequency of adverse events was similar among fluconazole-treated (29%) and nystatin-treated (32%); most events in both treatment groups involved the gastrointestinal tract. These results indicated fluconazole was more effective than nystatin in preventing Candida infections in patients with leukaemia; fluconazole was well tolerated.

A simple and rapid immunological technique for visualising chromosome-mediated gene transfer (CMGT).

A method is described for visualising chromosome-mediated gene transfer (CMGT) by detecting chromosomes labelled with bromodeoxyuridine (BrdU) using a monoclonal antibody to BrdU. In this experiment, the CCRF-CEM T cell line was grown in the presence of BrdU and the labelled chromosomes were isolated and transfected into human embryonic fibroblasts. Uptake and retention of chromosomes were compared for transfection with either PEG or DMSO treatments. Following transfection the labelled chromosomes could be visualised in recipient cells using a monoclonal antibody to BrdU, followed by immunoperoxidase staining. Chromosome uptake into cells was similar for both DMSO and PEG treatments and was a relatively frequent event; about 1 in 5 recipient cells had labelled material present. This technique can be used to assess the technical aspects of the earliest stages of chromosome-mediated gene transfer.

Differential tolerance and cross-tolerance to repeated daily injections of mu and kappa opioid agonists in the rat.

This study was designed to compare the development of tolerance to the effects of morphine and ethylketocyclazocine ( EKC ) on EEG, EEG power spectra and behavior and to assess any cross-tolerance. Adult female Sprague-Dawley rats were implanted with chronic cortical EEG and temporalis muscle EMG recording electrodes and with permanent cannulae in the external jugular vein. In non-tolerant rats, 10 mg/kg (i.v.) injections of morphine and of ethylketocyclazocine produced biphasic EEG and behavioral profiles lasting for 3 and 2 hr , respectively. In both cases, a stuporous phase, associated with high-voltage cortical EEG bursts, was followed by a hyperactive phase, associated with low-voltage desynchronized EEG. However, power spectra derived from epochs of EEG bursting produced by morphine and ethylketocyclazocine were qualitatively different. One group of rats was then given a series of automatic, intravenous injections of morphine, while a second group received ethylketocyclazocine. Following chronic treatment, the duration of the biphasic EEG and behavioral profiles induced by morphine and ethylketocyclazocine were both significantly reduced. In both cases, the intensity of EEG bursting was also reduced as reflected by significant quantitative reductions in EEG power spectral densities. In assessments of cross-tolerance, ethylketocyclazocine tolerant rats were found to be cross-tolerant to the effects of morphine. However, no cross-tolerance to the effects of ethylketocyclazocine in morphine-tolerant rats was observed. These data contribute to a further understanding of the relative heterogeneity of mu and kappa receptor populations and to the differential pharmacodynamics of morphine and ethylketocyclazocine.

Differential neuropharmacological effects of mu, kappa and sigma opioid agonists on cortical EEG power spectra in the rat. Stereospecificity and naloxone antagonism.

The study was designed to determine and compare the acute effects of the enantiomers of mu, kappa and sigma opioid agonists on the cortical EEG with the spectral analysis technique. The relative ability of naloxone to antagonize such effects was also assessed. Adult female Sprague-Dawley rats were implanted with chronic cortical EEG and temporalis muscle EMG recording electrodes, and with permanent indwelling external jugular cannulae. (-)-Methadone(mu agonist) produced increases in spectral power over the zero to 10Hz range, while (-)-ketocyclazocine (kappa agonist) produced increases in the 5-8 Hz band as a predominant peak. The(+) enantiomers of methadone and ketocyclazocine were inactive. The drug (+)-SK-10,047 (sigma agonist), produced a predominant spectral peak in the 7-9 HZ band that was associated with behavior that suggested psychotomimetic effects. The effects of morphine (mu agonist) on EEG and EEG power spectra were more sensitive to antagonism by naloxone than those produced by ketocyclazocine. The effects of (+/-)-SKF-10,047 and (+)-SKF-10,047 were not antagonized by 10 mg/kg of naloxone, while the effects of (-)-SKF-10,047 were partially antagonized by 10 mg/kg of naloxone. These findings further delineate the specificity of the differential effects of mu, kappa and sigma opioid agonists on the EEG and EEg power spectra in the rat.

Modulation of morphine-induced EEG and behavioral effects by dynorphin A-(1-13) in non-tolerant and morphine-tolerant rats.

The purpose of the present study was to assess effects of dynorphin A-(1-13) on morphine-induced changes in electroencephalographic (EEG) spectral power and morphine-induced suppression of slow-wave sleep in non-tolerant and morphine-tolerant rats. Adult female Sprague-Dawley rats were implanted with chronic cortical EEG electrodes, electromyographic electrodes in the temporalis muscle and with intracerebroventricular (i.c.v.) cannulae and, in some cases, additional intravenous (i.v.) cannulae. Injections of morphine (i.c.v., 20 micrograms/rat) produced a biphasic EEG and behavioral response, composed of 2-3 hr of slow-wave bursts and increased spectral power (0-4 Hz) in the EEG, associated with behavioral stupor, followed by 2-3 hr of EEG and behavioral arousal. Dynorphin (i.c.v., 20 micrograms/rat), administered 10 min before injections of morphine in non-tolerant rats, antagonized morphine-induced increases in spectral power of the EEG and morphine-induced suppression of slow-wave sleep. In addition, EEG power spectra obtained after intraventricular administration of morphine from rats, treated with dynorphin and morphine intraventricularly 24 hr earlier, were qualitatively similar to those previously found after acute administration of kappa opioid agonists. In morphine-tolerant rats, pretreatment with dynorphin given intraventricularly, 10 min prior to intraventricular administration of morphine, restored morphine-induced increases in EEG spectral power and suppression of slow-wave sleep. The results suggest that dynorphin may modulate the characteristics of opioid receptors.

Differential tolerance to repeated daily injections of N-allylnormetazocine and its enantiomers in the rat.

This study was designed to compare the development of tolerance to the effects of N-allylnormetazocine (SKF-10,047) and its enantiomers on the EEG and on behavior. Adult female Sprague-Dawley rats were implanted with chronic cortical electroencephalogram (EEG) and electromyogram (EMG) recording electrodes in the temporalis muscle and with permanent cannulae in the external jugular vein. In non-tolerant rats, 10 mg/kg (i.v.) injections of SKF-10,047 racemate produced primarily aroused wakefulness for about 120 min, that was associated with alternation between desynchronized EEG and theta waves in the EEG. After these rats received a series of automatic, intravenous injections of SKF-10,047 racemate, the aroused wakefulness state induced by SKF-10,047 racemate lasted for about 40 min. In non-tolerant rats, 2.5 mg/kg (i.v.) injections of (+)-SKF-10,047 induced a psychotomimetric EEG and behavioral state for about 30 min, which included continuous theta wave activity in the EEG. After chronic treatment with (+)-SKF-10,047, the psychotomimetic state induced by (+)-SKF-10,047 persisted for about 20 min. In non-tolerant rats, 2.5 mg/kg (i.v.) injections of (-)-SKF-10,047 produced an aroused EEG and behavioral wakefulness for about 30 min, which was then followed by slow-wave bursts in the EEG and associated behavioral stupor for about 90 min. After chronic treatment with (-)-SKF-10,047, injection of (-)-SKF-10,047 produced predominantly aroused wakefulness for about 45 min. The data suggest that (+)-SKF-10,047 exerts psychotogenic properties, but not opioid properties. On the other hand, the data suggest that (-)-SKF-10,047 possesses opioid properties.

Relationships between blood ethanol levels and ethanol-induced changes in cortical EEG power spectra in the rat.

Adult female Sprague-Dawley rats were implanted with chronic cortical and temporalis muscle electrodes and/or intravenous cannulas. After acute ethanol administration, dose-dependent linear declines in blood ethanol concentration were found. Ethanol-induced increases in EEG spectral power in the 0 - 4 Hz band persisted long after blood ethanol levels and declined to zero; therefore, we found no correlation. Acute ethanol administration also produced an initial drop in 8 - 13 Hz spectral power. Then, as blood ethanol levels declined, 8 - 13 Hz spectral power increased toward normal; a significant negative linear correlation was found.

Effects of acute delta 9-THC administration on EEG and EEG power spectra in the rat.

This study was designed to determine the acute effects of delta 9-THC on the cortical EEG with the spectral analysis technique. Adult female Sprague-Dawley rats were implanted with chronic cortical and temporalis muscle electrodes. Intraperitoneally administered delta 9-THC (5 and 10 mg/kg) produced a reduction in peak-to-peak voltage of the desynchronized cortical EEG during wakefulness. Associated spectral power was reduced to about 50% of control during the first hour after injection of delta 9-THC and gradually returned toward the control value over an 8-hr period. Occurrences of delta 9-THC-induced high-voltage EEG bursts, overriding the reduced EEG tracing, were associated with an EEG spectral peak at 6 Hz. The first few slow-wave sleep (SWS) episodes appearing after delta 9-THC administration were associated with more slow-frequency waveforms and more slow-frequency spectral power than with control slow-wave sleep episodes. During control rapid eye movement (REM) sleep episodes, an EEG theta wave pattern, with an associated spectral peak at about 8 Hz, was characteristic. Conversely, the first few REM sleep episodes emerging after delta 9-THC administration contained overriding high-voltage bursts, the related power spectra of which had two peaks at about 7 and 11 Hz.

Haloperidol pretreatment unmasks the kappa opioid effects of U-50, 488H on cortical EEG and EEG power spectra in rats.

Adult female Sprague-Dawley rats were implanted with chronic cortical EEG electrodes and intravenous cannulae. U-50, 488H injection (5.0 mg/kg) produced initial EEG desynchrony and EEG spectral power that was mainly distributed over the zero to 10 Hz range, including a relatively small spectral peak in the 4-6 Hz band. In contrast, following haloperidol pretreatment (0.1 mg/kg), U-50, 488H injection produced high-voltage EEG bursts and a predominant EEG spectral peak in the 4-6 Hz band. These effects of U-50, 488H after haloperidol pretreatment were identical to those previously demonstrated with the benzomorphan kappa agonist ethylketocyclazocine. Thus, haloperidol pretreatment unmasked the kappa opioid effects of U-50, 488H.

Sigma receptors mediated the psychotomimetic effects of N-allylnormetazocine (SKF-10,047), but not its opioid agonistic-antagonistic properties.

Our present findings suggest that SKF-10,047, the prototype sigma agonist, has its opioid entity residing with its (-) isomer, while both its (+) and (-) isomers possess psychotogenic properties similar to those produced by PCP. We found that (-)-SKF-10,047 blocks EEG and behavioral effects of morphine in the naive rat, precipitates withdrawal in morphine-dependent rats, produces physical dependence as evidenced by naloxone-induced withdrawal, and displaces [3H]dihydromorphine from brain homogenates. (+)-SKF-10,047 did not produce dependence upon chronic treatment, and it did not displace [3H]dihydromorphine from brain homogenates. Such pharmacodynamic dissociation with SKF-10,047 suggests an association of sigma receptors with psychogenic, but not opioid effects. The latter are most likely mediated by mu or kappa receptors.