NMDA-receptor antagonist and morphine decrease CRPS-pain and cerebral pain representation.

A combination therapy of morphine with an NMDA-receptor antagonist might be more effective than morphine without a NMDA-receptor antagonist for the relief of neuropathic pain in patients with complex regional pain syndrome (CRPS). In order to test the efficacy of this combination therapy we performed a double-blind randomized placebo-controlled study on patients suffering from CRPS of the upper extremity. We used functional magnetic resonance imaging during movement of the affected and unaffected upper hand before and after a treatment regimen of 49 days that contrasted morphine and an NMDA-receptor antagonist with morphine and placebo. We postulated superior pain relief for the combination therapy and concomitant changes in brain areas associated with nociceptive processing. Only the combination therapy reduced pain at rest and during movement, and disability. After treatment, activation in the contralateral primary somatosensory (cS1) and anterior cingulate cortex was significantly reduced when the affected hand was moved. Pain relief during therapy was related to decreased activation in cS1 and secondary somatosensory cortex (S2). Our data suggest that the combination of morphine with an NMDA-receptor antagonist significantly affects the cerebral processing of nociceptive information in CRPS. The correlation of pain relief and decrease in cortical activity in cS1 and S2 is in accordance with the expected impact of the NMDA-receptor antagonist on cerebral pain processing with emphasis on sensory-discriminative aspects of pain.

Comparison of the effects of nebivolol and valsartan on BP reduction and sleep apnoea activity in patients with essential hypertension and OSA.

OBJECTIVES: To investigate the effect of nebivolol, a third generation beta-blocker, on blood pressure (BP) reduction and polysomnographic parameters in hypertensive patients with mild-to-moderate obstructive sleep apnoea (OSA). METHODS: In this double-blind, parallel group study, patients were randomized to nebivolol 5 mg or valsartan 80 mg once daily following a 14-day, placebo run-in period during which any antihypertensive medication were discontinued. BP and heart rate measurements and overnight polysomnography were performed at baseline and after 6 weeks of treatment. Safety and tolerability were assessed. RESULTS: Thirty-one patients were randomized to nebivolol (n = 16) or valsartan (n = 15). After six weeks both systolic and diastolic BP were effectively reduced by both treatments. Reductions in BP were not statistically significant different between agents, but mean heart rate was significantly decreased with nebivolol (compared with valsartan (p < 0.001). There was no statistically significant difference between both treatments for the change from baseline to treatment end for mean (+/-SD) Apnoea Hypopnoea Index (AHI) (nebivolol: 23.0 +/- 9.2 to 27.9 +/- 21.2 events/h; valsartan: 23.8 +/- 6.6 to 22.5 +/- 18.0 events/h; p = 0.48) or for any other sleep-related parameters. Both agents were well tolerated. CONCLUSION: Nebivolol has a significant BP reduction effect in patients with OSA that is similar to valsartan and reduces heart rate to a greater extent which may prove beneficial in selected patients.

Does the use of recombinant AAV5 in pulmonary gene therapy lead to lung damage?

This study investigated whether repeated administration of recombinant adeno-associated virus type 5 (rAAV5) to the airways induces inflammatory processes in the lungs of BALB/c-mice, with mechanical and histologic changes. Saline was instilled intratracheally in the control group, and rAAV5-green fluorescence protein (GFP) (4x10(11)particles) in the virus group (VR). These groups were subdivided into four subgroups: one dose analyzed 3 weeks later (VR1d3w) and two doses analyzed 1 (VR2d1w), 2 (VR2d2w) and 3 weeks (VR2d3w) after the second dose. Lung morphometry, mechanical parameters, airway responsiveness, rAAV5-GFP transduction and the expression of inflammatory cytokines were investigated. No significant differences in lung mechanics, airway responsiveness, and morphometry were observed. Re-administration of rAAV5 vector resulted in a decrease in GFP mRNA expression in the VR2d3w group. There was no evidence of inflammatory response or apoptosis in any group. rAAV5 did not induce an inflammatory process, mechanical or morphometric changes in the lungs. AAV5 may be an appropriate vector for lung gene therapy.

[Recent examples for drug (developments) in primary, secondary and tertiary prevention]. / Aktuelle Beispiele für Arzneimittel (-entwicklungen) in der primären, sekundären und tertiären Prävention.

The prevention of disease and the prevention of subsequent disease is one of the main themes in public health as well as in clinical medicine. Besides targeted interventions aiming at the total population (public health) individual steps like life style intervention and use of pharmacotherapy are important components. Taking acute myocardial infarction as an example it is illustrated, how risk factors can be targeted and which new drugs in development have been either just registered or are in late phase III of clinical testing shortly before registration and final approval. In this context it was shown that there are many exciting new options to reduce risk factors. On the other hand there are indications in which new drug development is likely not to contribute to an improvement of the situation (e. g. arterial hypertension) and in which further targeted intervention aiming at physicians (therapeutic pathways, guidelines, point of care research) and patients (life style intervention, compliance) has to be undertaken to improve the efficacy of currently available pharmacotherapy.

Socio-economic status and the therapeutic effectiveness of antihypertensive treatment--the design of the LEO study.

OBJECTIVE: The risk of arterial hypertension and subsequent cardiovascular disease morbidity and mortality increases with low socio-economic status (SES). Even small differences in blood pressure, whether untreated or despite treatment, account for this substantial difference. Most of the increased risk in the low socio-economic group is due to traditional cardiovascular risk factors such as overweight and obesity, alcohol consumption and a sedentary life style. Intense treatment of arterial hypertension has been shown to overcome these prognostic inequalities. Therefore, drugs with high efficacy, optimal treatment adherence and a low potential for drug-related side effects are needed in order to reduce the cardiovascular risk burden of patients with a low SES. The angiotensin receptor blocker (ARB) olmesartan will be used to investigate the effectiveness of this drug in different socio-economic classes. RESEARCH DESIGN AND METHODS: The LEO (Long-term Effectiveness of Olmesartan in different Socioeconomic groups) study is a large observational long-term study which has been set up to test the effectiveness of olmesartan within this context. The study has a matched-pairs design (1403 patients in both the low and the high socio-economic classes). MAIN OUTCOME MEASURES: The LEO study will test whether this regimen can reduce the SES-related difference in long-term blood pressure control and compliance in the low SES population. CONCLUSIONS: The study may generate valuable information about the antihypertensive effectiveness of olmesartan alone or in combination with hydrochlorothiazide in different socio-economic classes. It will further test whether the drug helps to reduce the inherent inequalities in cardiovascular prognosis between different socio-economic groups. CURRENT STATUS: The study commenced in July 2007. Results are anticipated in December 2008.

Intranasal delivery of whole influenza vaccine prevents subsequent allergen-induced sensitization and airway hyper-reactivity in mice.

BACKGROUND: Infection with influenza virus has been associated with seemingly opposing effects on the development of asthma. However, there are no data about the effects of mucosal vaccination with inactivated influenza on the inception of allergic asthma. OBJECTIVE: To assess the immunological effects of inhaled inactivated influenza vaccine, using two different types of flu vaccines, on the inception of allergic sensitization and allergen-mediated airway disease in a mouse model. METHODS: BALB/c mice were intranasally or intratracheally vaccinated with whole or split influenza virus vaccine (days -1 or -1, 27) before systemic sensitization with ovalbumin (OVA) (days 1, 14) and repeated airway allergen challenges (days 28-30). Allergen sensitization (IgE serum levels), airway inflammation (differential cells in bronchoalveolar lavage fluid) and airway hyper-reactivity (AHR) (in vivo lung function) were analysed. RESULTS: The intranasal instillation of whole influenza vaccine before allergen sensitization significantly reduced the serum levels of total and OVA-specific IgE as well as allergen-induced AHR. Prevention was due to an allergen-specific shift from a predominant T helper (Th)2- towards a Th1-immune response. Application of split influenza vaccine did not show the same preventive effect. CONCLUSION: Intranasal administration of inactivated whole influenza vaccine reduced subsequent allergen sensitization and prevented allergen-induced AHR. Our results show that the composition of the influenza vaccine has a major influence on subsequent development of allergen-induced sensitization and AHR, and suggest that mucosal inactivated whole influenza vaccination may represent a step towards the development of a preventive strategy for atopic asthma.

Non-cardiac complications during pregnancy in women with isolated congenital pulmonary valvar stenosis.

BACKGROUND: Information on the outcome of pregnancy in patients with pulmonary valvar stenosis is scarce, mostly limited to cardiac complications observed during pregnancy. OBJECTIVES: To investigate the magnitude and determinants of non-cardiac and fetal risks during pregnancy of women with isolated pulmonary valvar stenosis. METHODS: Using the nationwide registry (CONgenital CORvitia), 106 women with (un-)corrected pulmonary valvar stenosis receiving care in six tertiary medical centres in The Netherlands were included. A total of 51 women had 108 pregnancies, including 21 (19%) miscarriages and 6 elective abortions. RESULTS: In the 81 completed (>20 weeks of gestation) pregnancies, we observed a high number of hypertension-related disorders (n = 12, 15%, including pre-eclampsia (n = 4) and eclampsia (n = 2)), premature deliveries (n = 14, 17%, including one twin) and thromboembolic events (n = 3, 3.7%). Furthermore, recurrence of congenital heart defects in the offspring was detected in three children (3.7%, pulmonary valvar stenosis (n = 2) and complete transposition of the great arteries in combination with anencephaly). In addition to the intrauterine fetal demise of the transposition child, three other children died shortly after birth owing to immaturity, hydrocephalus combined with prematurity and meningitis (overall offspring mortality, 4.8%). CONCLUSION: In this largest report on pregnancy in women with (un-) corrected isolated pulmonary valvar stenosis, an excessive number of (serious) non-cardiac complications and mortality were observed in the offspring.

Solid-state characterization of non-stoichiometric hydrates of ester-type local anaesthetics. Part XI. Crystal polymorphism of local anaesthetic drugs.

Three structurally closely related local anaesthetic drugs, hydroxyprocaine hydrochloride (4-butylamino-2-hydroxybenzoic acid 2-dimethylaminoethyl ester hydrochloride, HPCHC), tetracaine hydrochloride (4-butylamino-2-hydroxybenzoic acid 2-dimethylaminoethyl ester hydrochloride, TCHC) and hydroxytetracaine hydrochloride (4-butylamino-2-hydroxybenzoic acid 2-dimethylaminoethyl ester hydrochloride, SLCHC) are found to form hydrated crystals. Those were characterized by thermal analysis (hot stage microscopy, differential scanning calorimetry, thermogravimetry), vibrational spectroscopic methods (FTIR-, FT-Raman-spectroscopy), powder X-ray diffractometry, solid-state NMR and water sorption/desorption analysis. The formation and the stability of the hydrated solid phases are evaluated by sorption isotherms derived from different sorption/desorption analytic methods. The three substances investigated show conformational polymorphism with the anhydrated phases including a high temperature form mod. I, which is highly hygroscopic and isostructural with the hydrate. The hydrated form is present in commercial products at various contents. These hemihydrates crystallize from water, whereas the anhydrates crystallize from all other tested organic solvents. Different methods of water sorption/desorption analysis indicate the formation of non-stoichiometric hydrates. Different methods of drying lead to the same results. Solid-state NMR spectra were used to obtain both structural and molecular level mobility information.

Polymorphism and pseudopolymorphism of salicaine and salicaine hydrochloride crystal polymorphism of local anaesthetic drugs, part V.

The local anaesthetic drug salicaine hydrochloride (hydroxytetracaine hydrochloride, 4-butylamino-2-hydroxybenzoic acid 2-dimethylaminoethyl ester hydrochloride, SLCHC) and the free-base salicaine (SLC) were characterized by thermal analysis, vibrational and solid-state NMR-spectroscopy, X-ray powder diffraction, X-ray single crystal structure analysis, and water vapor sorption analysis. Additionally, the crystal structures of the anhydrate mod. II degrees (monoclinic, space group P2(1)/n), the hydrated mod. I (triclinic, space group P(bar)1), and of the free base (SLC) in the form of the hemihydrate (triclinic, space group P(bar)1 are discussed. Mod. II degrees of the polymorphic SLCHC is the thermodynamically stable form at room temperature and is present in commercial products mostly contaminated with a hydrated form that is isomorphic with mod. I. Mod. II degrees crystallizes from most organic solvents and from the melt below 110 degrees C. Mod. I crystallizes from the melt at temperatures above 110 degrees C, and additionally appears on dehydration of the hydrated mod. I. A third polymorph monotropically related to mod. II degrees was found by freeze-drying. The free-base SLC was found to crystallize from ethanol/water as a triclinic hemihydrate.

Structural characteristics and crystal polymorphism of three local anaesthetic bases crystal polymorphism of local anaesthetic drugs: part VII.

Benzocaine (BZC), butambene (BTN) and isobutambene (BTI) are basic local anaesthetic agents of the ester type, preferentially used for surgery and dental procedures. The compounds, official in the USP (BZC and BTN) and Ph. Eur. (BZC), were each found to exist in two polymorphic crystal forms and their solid state characteristics have been determined by thermomicroscopy, differential scanning calorimetry (DSC), FTIR-, FT-Raman-spectroscopy as well as X-ray powder diffractometry. This work further emphasizes the comparison of solid state characteristics of three compounds with closely related structural features on molecular level, leading to opportunities for the investigation of structure-property relationships. Mod. I0 is the particular thermodynamically stable form at room temperature in all of the three systems. This form is present in commercial products and can be crystallized from solvents at room conditions. Mod. II can be obtained by annealing the supercooled melt or fast cooling of a saturated solution, respectively. The endothermic transformation of mod. II to mod. I0 upon heating confirms that mod. I0 is thermodynamically stable at ambient conditions (heat of transition rule) whereas mod. II is enantiotropically related to mod. I0, i.e. is metastable at temperatures above the transition temperature. The metastable forms show different kinetic stabilities at room temperature.

Stability evaluation of a prostaglandin E1 saline solution packed in insulin syringes.

This article describes the preparation and stability of a sterile prostaglandin E1 solution. The solution is packed in insulin syringes as single dose injections for the treatment of erectile disfunction. The stability of this preparation is 24 weeks when stored at 5 degrees C.

Recombinant bovine/human parainfluenza virus type 3 (B/HPIV3) expressing the respiratory syncytial virus (RSV) G and F proteins can be used to achieve simultaneous mucosal immunization against RSV and HPIV3.

Recombinant bovine/human parainfluenza virus type 3 (rB/HPIV3), a recombinant bovine PIV3 (rBPIV3) in which the F and HN genes were replaced with their HPIV3 counterparts, was used to express the major protective antigens of respiratory syncytial virus (RSV) in order to create a bivalent mucosal vaccine against RSV and HPIV3. The attenuation of rB/HPIV3 is provided by the host range restriction of the BPIV3 backbone in primates. RSV G and F open reading frames (ORFs) were placed under the control of PIV3 transcription signals and inserted individually into the rB/HPIV3 genome in the promoter-proximal position preceding the nucleocapsid protein gene. The recombinant PIV3 expressing the RSV G ORF (rB/HPIV3-G1) was not restricted in its replication in vitro, whereas the virus expressing the RSV F ORF (rB/HPIV3-F1) was eightfold restricted compared to its rB/HPIV3 parent. Both viruses replicated efficiently in the respiratory tract of hamsters, and each induced RSV serum antibody titers similar to those induced by RSV infection and anti-HPIV3 titers similar to those induced by HPIV3 infection. Immunization of hamsters with rB/HPIV3-G1, rB/HPIV3-F1, or a combination of both viruses resulted in a high level of resistance to challenge with RSV or HPIV3 28 days later. These results describe a vaccine strategy that obviates the technical challenges associated with a live attenuated RSV vaccine, providing, against the two leading viral agents of pediatric respiratory tract disease, a bivalent vaccine whose attenuation phenotype is based on the extensive host range sequence differences of BPIV3.

Bovine parainfluenza virus type 3 (BPIV3) fusion and hemagglutinin-neuraminidase glycoproteins make an important contribution to the restricted replication of BPIV3 in primates.

This study examines the contribution of the fusion (F) and hemagglutinin-neuraminidase (HN) glycoprotein genes of bovine parainfluenza virus type 3 (BPIV3) to its restricted replication in the respiratory tract of nonhuman primates. A chimeric recombinant human parainfluenza type 3 virus (HPIV3) containing BPIV3 F and HN glycoprotein genes in place of its own and the reciprocal recombinant consisting of BPIV3 bearing the HPIV3 F and HN genes (rBPIV3-F(H)HN(H)) were generated to assess the effect of glycoprotein substitution on replication of HPIV3 and BPIV3 in the upper and lower respiratory tract of rhesus monkeys. The chimeric viruses were readily recovered and replicated in simian LLC-MK2 cells to a level comparable to that of their parental viruses, suggesting that the heterologous glycoproteins were compatible with the PIV3 internal proteins. HPIV3 bearing the BPIV3 F and HN genes was restricted in replication in rhesus monkeys to a level similar to that of its BPIV3 parent virus, indicating that the glycoprotein genes of BPIV3 are major determinants of its host range restriction of replication in rhesus monkeys. rBPIV3-F(H)HN(H) replicated in rhesus monkeys to a level intermediate between that of HPIV3 and BPIV3. This observation indicates that the F and HN genes make a significant contribution to the overall attenuation of BPIV3 for rhesus monkeys. Furthermore, it shows that BPIV3 sequences outside the F and HN region also contribute to the attenuation phenotype in primates, a finding consistent with the previous demonstration that the nucleoprotein coding sequence of BPIV3 is a determinant of its attenuation for primates. Despite its restricted replication in the respiratory tract of rhesus monkeys, rBPIV3-F(H)HN(H) conferred a level of protection against challenge with HPIV3 that was indistinguishable from that induced by previous infection with wild-type HPIV3. The usefulness of rBPIV3-F(H)HN(H) as a vaccine candidate against HPIV3 and as a vector for other viral antigens is discussed.

Evaluation of extraction procedures for the ion chromatographic determination of arsenic species in plant materials.

The determination of arsenic species in plants grown on contaminated sediments and soils is important in order to understand the uptake, transfer and accumulation processes of arsenic. For the separation and detection of arsenic species, hyphenated techniques can be applied successfully in many cases. A lack of investigations exists in the handling (e.g., sampling, pre-treatment and extraction) of redox- and chemically labile arsenic species prior to analysis. This paper presents an application of pressurized liquid extraction (PLE) using water as the solvent for the effective extraction of arsenic species from freshly harvested plants. The method was optimized with respect to extraction time, number of extraction steps and temperature. The thermal stability of the inorganic and organic arsenic species under PLE conditions (60-180 degrees C) was tested. The adaptation of the proposed extraction method to freeze-dried, fine-grained material was limited because of the insufficient reproducibility in some cases.

Determination of arsenic species in water, soils and plants.

Ion chromatographic separation coupled with ICP-MS was used to determine arsenic species in plant and soil extracts. A scheme for growth, harvesting, sample pre-treatment and analysis was developed for the arsenic species to enable determination. Preliminary results obtained with ten herb plants grown on arsenic-contaminated soil compared to non-contaminated soil show a heterogeneous pattern of accumulation rate, metabolization and detoxification mechanisms in monocots and dicots. Arsenite appears to be the major component in plants with good growth. Organic arsenic species were even detected at very low concentrations (< 150 microg kg(-1) (dry mass)).

The role of the polymorphic genes apolipoprotein E and methylene- tetrahydrofolate reductase in the development of dementia of the Alzheimer type.

The gene for apolipoprotein E (APOE) is polymorphic, and its variant APOE4 is a major risk factor for the development of Alzheimer-type dementia (AD). Another risk factor for AD appears to be negative cobalamin balance, which is very common in elderly people. Cobalamin and folate are interdependent and essential components of the one-carbon metabolism. Another important component is methylenetetrahydrofolate reductase (MTHFR), the gene for which is also polymorphic. Thermolabile MTHFR (tMTHFR), a gene variant that reduces the activity of its enzyme, is common in the general population. In the present study, 75% of 140 AD patients had at least one APOE4 allele. The numbers of APOE4 and tMTHFR alleles correlated significantly with the serum folate levels, however, in opposite directions. The significance of this was augmented by an inverse correlation between APOE4 and tMTHFR. Thus, not only MTHFR but also APOE appears to be related to the one-carbon metabolism, suggesting that APOE4 and insufficient one-carbon metabolism may be synergistic risk factors for AD.

Oklahoma Firearm-Related Injury Surveillance.

CONTEXT: The magnitude of firearm-related deaths is known, but few studies have evaluated the magnitude and epidemiology of nonfatal firearm-related injuries. The circumstances resulting in fatal versus nonfatal injury are likely very different. No single data source provides complete details on nonfatal shootings. OBJECTIVE: To establish a surveillance system to define the epidemiology of fatal and nonfatal firearm-related injuries. DESIGN: Data were collected on fatal and nonfatal firearm-related injuries that occurred in 1995. SETTING: State of Oklahoma. PARTICIPANTS: Medical Examiner, Vital Statistics, hospital emergency and medical records departments, police departments, newspaper clipping service. MAIN OUTCOME MEASURES: Incidence rate of firearm-related injuries; case-fatality rate; demographic, medical, and epidemiologic data; sensitivity of each reporting source; completeness of reporting. RESULTS: The incidence rate of firearm-related injuries was 45.5 per 100,000 population. The case fatality rate was 35%. Injury rates were highest among adolescents, young adults, males, and African Americans. The Medical Examiner and Vital Statistics reported 87% and 98% of fatal cases, respectively. Passive surveillance of hospital emergency departments identified 72% of patients seeking hospital treatment. Among inpatients, 81% were identified by medical records departments. Newspaper clippings were obtained for 31% of cases. Information on the victim-perpetrator relationship and the type of firearm was available for 79% and 80% of cases, respectively. CONCLUSIONS: Statewide surveillance of firearm-related injuries using multiple data sources is possible and provides a picture of the overall firearm-related injury problem. Strategies to enhance computer linkages of medical and police data should be pursued to maximize the sensitivity of reporting and minimize the costs of surveillance.