The value and benefits of the International Conference on Harmonisation to drug regulatory authorities: advancing harmonization for better public health.

The International Conference on Harmonisation (ICH) is an unparalleled undertaking, which has brought together drug regulatory authorities and pharmaceutical trade associations from Europe, Japan, and the United States, to discuss the scientific and technical aspects of medical product registration. Launched in 1990, the value and benefits of ICH to regulators are being realized. ICH has harmonized submission requirements and created a harmonized submission format that is relieving both companies and regulatory authorities of the burdens of assembling and reviewing separate submissions for each region. As more countries embrace ICH guidelines, we anticipate additional benefits, including the promotion of good review practices and, ultimately, a common regulatory language that will facilitate further interactions among global drug regulatory authorities.

Recurrent aphthous stomatitis.

Etiology and Epidemiology: The Greek term aphthai was initially used in relation to disorders of the mouth and is credited to Hippocrates (460-370 BC). Today, recurrent aphthous ulceration, or recurrent aphthous stomatitis (RAS), is recognized as the most common oral mucosal disease known to human beings. Considerable research attention has been devoted to elucidating the causes of RAS; local and systemic conditions, and genetic, immunologic, and infectious microbial factors all have been identified as potential etiopathogenic agents (Table 1). However, to date, no principal etiology has been discovered. Epidemiologic studies indicate that the prevalence of RAS is between 2% and 50% in the general population; most estimates fall between 5% and 25%. In selected groups, such as medical and dental students, it has been observed with a frequency as high as 50% to 60%. The peak age of onset for RAS is between 10 and 19 years. After childhood and adolescence, it may continue throughout the entire human lifespan without geographic or age-, sex-, or race-related preference.

Factors associated with dental anxiety.

This study assessed dental anxiety in adults living in the Detroit tricounty area and identified factors associated with it. The prevalence of dental anxiety was 10.0 percent. Regression analysis revealed six factors associated with dental anxiety: unfavorable attitudes toward dentists, infrequent checkups, dissatisfaction with one's month, small numbers of filled surfaces, being female and lower income. Dentists should be aware of these factors when assessing dental anxiety in their patient populations.

The effects of in vitro cocaine exposure on human sperm motility, intracellular calcium, and oocyte penetration.

OBJECTIVE: To determine if cocaine exposure affects human sperm motility, intracellular calcium level, and fertilizing capability. DESIGN AND METHODS: Human semen samples were treated with 1 to 1,000 microM cocaine hydrochloride for up to 2 hours in vitro. Sperm motion kinematics were measured by computer-assisted semen analysis (CASA). Spermatozoan intracellular calcium was determined by laser cytometry. The sperm fertilizing capability was assessed using the zona-free hamster oocyte penetration test. RESULTS: After a short exposure (15 minutes) to cocaine, the sperm motion kinematic parameters, straight line velocity and linearity, were decreased in the high concentration groups. However, after a longer exposure (2 hours) to cocaine, the differences were no longer significant. Cocaine treatment did not alter spermatozoa intracellular calcium levels. Most importantly, human sperm treated with cocaine at a high concentration were fully capable of penetrating zona-free hamster oocytes. CONCLUSION: Human spermatozoa acutely exposed to high concentrations of cocaine initially demonstrate a decrease in two motion kinematics, straight line velocity and linearity. However, overall, cocaine exposure had no significant effects on sperm motility and fertilizing capability.

Isolation of Mycoplasma gallopavonis from free-ranging wild turkeys in coastal North Carolina seropositive and culture-negative for Mycoplasma gallisepticum.

Serum samples and choanal cleft swabs were collected from livetrapped and hunter killed wild turkeys (Meleagris gallopavo) from Martin and Bertie counties, North Carolina (USA). Sera were tested for antibodies to Mycoplasma gallisepticum, Mycoplasma synoviae and Mycoplasma meleagridis by hemagglutination inhibition (HI). Sera from 33% (five of 15) of livetrapped turkeys were positive for antibodies to M. gallisepticum by HI, and all were negative for antibodies to M. synoviae and M. meleagridis. Choanal cleft swabs from 22 livertrapped and five hunter killed wild turkeys cultured in Frey's broth medium resulted in 23 mycoplasma isolations. Using direct immunofluorescence, 74% (17/23) were M. gallopavonis, and 26% (six of 23) were unidentified; no isolate was identified as M. gallisepticum, M. synoviae or M. meleagridis.

Diurnal variation of mood and the cortisol rhythm in depression and normal states of mind.

A large scale chronobiological investigation was undertaken in 20 drug-free psychiatric inpatients displaying RDC major depression (endogenous subtype) in comparison to 10 healthy control subjects and 10 of the patients after clinical recovery. A series of measurements was taken 6 times a day and, in 8 of a total of 14 variables, also once a night over a period of 10 to 14 days. The following variables were assessed: mood (three different scales), performance (two tests), motor activity (three measures), salivary flow, urinary excretion of water, sodium, potassium, and free cortisol (UFC), and rectal temperature. A phase chart of the acrophases of the 8 variables with measurements taken during day and night revealed two clusters in the depressives and three in the non-depressed subjects. In the depressives, the acrophases of the mood scales clustered around the time of awakening in the morning, together with the acrophase of UFC, whereas all other acrophases clustered in the afternoon. In the non-depressed subjects, however, the mood scales reached their circadian maxima in the middle of the night around the time when sleep was interrupted to take measurements. All other acrophases corresponded roughly with those found in the depressives. The coincidence of the time course of depressed mood and cortisol excretion in the patients was interpreted as reflecting a temporal relationship between diurnal mood swings in depression and the cortisol rhythm. This interpretation was supported by the significant correlation between the acrophases of the two respective rhythms in patients showing a significant diurnal variation in mood. The mood curves of non-depressed subjects seemed unrelated to the cortisol rhythm. Probably, they mirror diurnal fluctuations of vigilance rather than fluctuations of mood. According to the literature, this rhythm is temporally related to the rhythm of melatonin secretion.

Neuroendocrinological studies on depression with special reference to research at the Max-Planck-Institute of Psychiatry.

Hypercortisolism due to Cushing's syndrome or glucocorticoid therapy induces disturbances in several other endocrine systems and may also cause mental changes, predominantly depression of various degrees. On the other hand, it has repeatedly been shown that endogenous depression is often accompanied by hypercortisolemia, usually of a modest degree, and/or by changes in other hormonal systems similar to those observed in Cushing's syndrome and during treatment with glucocorticoids. Research performed at the MPIP on 327 psychiatric patients and 103 healthy subjects has demonstrated that, in contrast to Cushing's syndrome, the circadian rhythm in depression is usually well preserved, and that diurnal variation in mood is correlated with that rhythm. Furthermore, it was found that a modest hyperactivity of the HPA system, as indicated by enhanced UFC excretion and nonsuppression in the DST, is not specific for depression in general or its endogenous subtype. It can also be observed in many other psychiatric disorders and seems to mirror stress and the influence of other factors, such as weight loss due to anorexia, rather than a particular nosology. TSH blunting in the TRH test appears as a consequence of hypercortisolemia in psychiatric disorders as is the case in Cushing's syndrome and in the course of glucocorticoid therapy. Differences in the patterns of neuroendocrine abnormalities in depressives and other psychiatric patients probably reflect differences in the individual responsiveness of the various hormonal axes to stress rather than nosological subtypes of the disorder. A comparison of these results with the past and current literature reveals remarkable changes in the concepts of neuroendocrine dysfunctions in depression and leads to suggestions of new strategies for research on this subject.

The nature of neuroendocrine abnormalities in depression: a controversial issue in contemporary psychiatry.

Neuroendocrine abnormalities in depression have been regarded, by many authors, as relatively specific markers of nosological subtypes of the disorder, e.g. primary vs. secondary, endogenous vs. non-endogenous or unipolar vs. bipolar depression. They should reflect the same changes in central neurotransmitters (e.g. noradrenergic insufficiency and/or cholinergic hyperactivity) that were hypothesized as the cause of clinical symptoms. This view is challenged on the basis of our own neuroendocrine investigations in 317 psychiatric patients and 103 normal controls. According to these studies the abnormalities are nosologically rather unspecific. They are induced by a large variety of factors, e.g. emotional stress associated with the clinical symptomatology, weight loss due to malnutrition as a consequence of reduced appetite, medication and drug withdrawal. Stress-induced hypercortisolism appears to be the most common abnormality that may trigger other neuroendocrine dysfunctions, such as a blunted TSH response to TRH. Differences in neuroendocrine abnormalities of depressives are probably due to variations in the manifold factors influencing the hormonal axes involved, to temporal changes in hormonal patterns (e.g. one abnormality triggering another) and to individual differences in the basic activity and the responsiveness of the various axes.

Circadian rhythms in endogenous depression.

A comprehensive study of circadian rhythms was carried out in 16 drug-free patients with endogenous depression, 10 of whom were reinvestigated after clinical remission, and 10 healthy controls. No free-running periods were observed in body temperature, urinary excretion of potassium and free cortisol, or any other variable. Moreover, there was little, if any, indication of phase-advance. The circadian variation of several variables was reduced during depression, e.g., motor activity, body temperature, and (less markedly) urinary potassium, but not cortisol. The circadian worsening of mood tended to occur around the time of awakening during depression, i.e., several hours later than after remission or in normal controls. In patients with circadian variation of self-rated mood, the acrophase of this variable correlated significantly with that of urinary free cortisol. This indicates an entrainment of the disease process to the circadian rhythm of cortisol secretion, probably via circadian variations of neurotransmitters in the hypothalamus. The other circadian phenomena observed in depression can adequately be explained by masking effects (negative or positive) of psychopathological symptoms (e.g., early morning awakening) on overt circadian rhythms.

Are biological rhythms disturbed in depression?

In a large-scale investigation of circadian rhythms in endogenous depression, no free-running rhythms or indications of phase-advance were found in the patients compared with themselves after clinical recovery and with healthy controls. They exhibited a reduction of the amplitude of depression scales, partially due to a "ceiling effect" of highly elevated scores. A reduction of the amplitude of body temperature was probably related to a negative masking of the temperature rhythm by e.g. the patients' sleep disturbances. An increase in the amplitude of the cortisol rhythm, due to an elevation of the circadian maximum, was particularly pronounced in patients with significant diurnal variation in the severity of depression. It was thus probably related to a stress-induced positive masking of that rhythm. The acrophases of depression scores and the cortisol rhythm coincided roughly during but not outside depression. This may indicate a circadian modulation of the disease process and the activity of the hypothalamo-pituitary-adrenocortical system by the same clock-like mechanism within the hypothalamus.

The limited utility of the dexamethasone suppression test for the diagnostic process in psychiatry.

In 231 psychiatric in-patients, the 1 mg or 1.5 mg DST with blood samples at 0900 h, 1600 h and 2300 h and a post-dexamethasone plasma cortisol threshold of greater than or equal to 5 micrograms/dl were tested for their differential diagnostic utility in clinical psychiatry. Neither test significantly separated endogenous depressed patients from patients with other depressive or non-depressive psychiatric disorders. Studies of the 1 mg or 1.5 mg DST in 75 healthy subjects revealed about 12% of cortisol non-suppressors, when a post-dexamethasone cortisol threshold of greater than or equal to 5 micrograms/dl was used. This seemed to be an unacceptably low specificity of the test in normal subjects. A threshold criterion of greater than or equal to 8 micrograms/dl, however, yielded only 2.7% of non-suppressed normal subjects. Analyses of the DST data of the psychiatric patients, using a cortisol threshold of greater than or equal to 8 micrograms/dl, also failed to reveal a significantly higher specificity of the DST for endogenous depression. However, it was demonstrated that intervening variables such as stress due to hospital admission, drug withdrawal, suicidal turmoil, weight loss, as well as a low dexamethasone plasma level, enhance the rate of abnormal DST results in psychiatric in-patients, regardless of their diagnostic classification.

Efficacy and side effects of haloperidol in psychotic patients: oral versus intravenous administration.

It is a commonly held view among clinicians that intravenously administered haloperidol has a greater antipsychotic effect than oral haloperidol. To test this hypothesis, the authors carried out a double-blind study on patients with acute schizophrenia and patients with schizophreniform or schizoaffective (with manic features) psychoses. Using biologically equivalent doses, they found that intravenously administered haloperidol was slightly more effective during the first 3 hours; thereafter the route of administration did not make a difference in effectiveness.

Behavior, attitude, nutrition and endocrinology in anorexia nervosa.

Twenty-four anorexia nervosa patients participated in an inpatient broad spectrum behavior therapy program. The changes in body weight, anorectic behaviors and attitudes and endocrine variables (24-h plasma cortisol, dexamethasone suppression test, 24-h plasma luteinizing hormone) were measured. Data indicate that specific anorectic behaviors and attitudes showed significant improvement during inpatient treatment, while attitudes of a more general neurotic scope such as the feeling of insufficiency, general distress, (sexual) anxieties and anancasm did not. On admission 24-h plasma cortisol levels were elevated, episodic secretory spikes occurred at unusual times and the number was increased, cortisol plasma half-life was increased and non-suppression of cortisol secretion following the application of dexamethasone was observed. All these parameters normalized already after 10% weight gain. 24-h plasma LH pattern showed a close relationship with body weight. Our data suggest that the dysfunctions in anorexia nervosa patients in the hypothalamo-pituitary-adrenal and -gonadal axis have little specificity for this disease and are mainly a consequence of nutritional factors and starvation. The relationship between cortisol and HL-secretion, behavioral and attitudinal variables and weight gain was more complex than previously suggested by others and a positive relationship between the LH secretory pattern and anorectic symptomatology could be established.

Neuroendocrinological and neurophysiological studies in major depressive disorders: are there biological markers for the endogenous subtype?

The possibility of characterizing subgroups of depressive disorders by biological markers was studied by means of the dexamethasone suppression test (DST), the 24-hr urinary free cortisol (UFC), the growth hormone response to the insulin tolerance test (ITT), and polygraphic sleep recordings. Forty-five hospitalized patients suffering from a moderate to severe nonpsychotic major depressive disorder were clinically subdivided into three groups: endogenous (n = 20), neurotic (n = 19), and "ambiguous" (n = 6). These clinical diagnoses were supplemented by operational diagnostic tools, namely, the Research Diagnostic Criteria (RDC) and the Newcastle Scale. The different diagnostic procedures exhibited a high degree of correspondence. Whereas the results of the ITT were normal in almost all patients, 20% of all patients were dexamethasone nonsuppressors and more than half of the patients showed a shortened REM latency. Both markers did not reveal any specificity for the endogenous subtype. A significant influence of weight loss on the DST and the excretion of UFC was evident.

Temporal coordination of rest-activity cycle, body temperature, urinary free cortisol, and mood in a patient with 48-hour unipolar-depressive cycles in clinical and time-cue-free environments.

During medication-free observation a 66-year-old male patient showed an almost strict alternation of days with depressed mood and days with normal mood. The experiment consisted of two parts; the first was 4 weeks' observation in the psychiatric ward, while the second was 2 weeks' observation in an experimental unit where the patient was deprived of all known information on local time. In the psychiatric ward the observed circadian rhythms, i.e., the rest-activity cycle, the body temperature, the urinary free cortisol, and the mood rhythm, were all synchronized with the geophysical day. Under isolation from time cues the average rest-activity cycle duration was reduced to about 19.5 hr, whereas the body temperature and the urinary free cortisol continued to show rhythms with near-24-hr periods. The main finding of the study is the persistence of a near-48-hr periodicity in the mood fluctuation under isolation from time cues. Besides this, in the time course of body temperature and urinary free cortisol evoked components correlating with the mood cycles were found.