Are anaesthetists prone to suicide? A review of rates and risk factors.

Suicide represents a major source of mortality in Western countries. There is an emerging literature about suicide and the medical profession. The suicide of an anaesthetist represents a catastrophic event, with painful consequences for family, colleagues and the community at large. This review will examine the literature regarding suicide amongst anaesthetists and trainees in the field. It is presented in three sections. First, it provides an overview of existing epidemiological data, comparing rates in the general population, the medical profession, in general, and in anaesthesia, in particular. Second, risk factors that may account for differences in rates will be discussed. Finally, a series of recommendations has been formulated.

Determination of olanzapine in human breast milk by high-performance liquid chromatography with electrochemical detection.

A reversed-phase high-performance liquid chromatographic-electrochemical assay was developed and validated for the quantification of olanzapine in human breast milk. The assay involved a solid-phase extraction (SPE) of olanzapine and its internal standard on a Bond Elut Certify LRC mixed-mode cartridge. After conditioning of the SPE cartridge, human milk (1 ml) was passed through the cartridge. The cartridge was washed with five separate washing steps to remove endogenous compounds, and the analytes were eluted with ethyl acetate-ammonium hydroxide (98:2, v/v) solution. The eluate was evaporated to dryness (gentle stream of nitrogen at 40 degrees C), and the residue was dissolved in mobile phase. The extract was injected onto a YMC basic column (150 mmx4.6 mm I.D., 5 microm particle size) at a flow-rate of 1 ml/min. A mixture of 75 mM phosphate buffer, pH 7.0-acetonitrile-methanol (48:26:26, v/v/v) was used as the mobile phase. Standard curves with a lower limit of quantitation of 0.25 ng/ml of olanzapine were linear (r2> or =0.9992) over a range of 0.25-100 ng/ml. Based on the analysis of quality control (QC) samples, the average inter-day accuracy (RE) was 99.0% with an average precision (CV) of 6.64% over the entire range. The stability of olanzapine in human milk was established after three freeze-thaw-heat cycles and storage at -70 degrees C for 10 months. The validated method was used to measure olanzapine concentrations in human milk during a clinical trial.

Identification of the human cytochromes P450 responsible for the in vitro formation of the major oxidative metabolites of the antipsychotic agent olanzapine.

The formation kinetics of 2-hydroxymethyl olanzapine (2-OH olanzapine), 4'-N-oxide olanzapine (N-O olanzapine) and 4'-N-desmethyl olanzapine (NdM olanzapine) were analyzed in vitro. Biphasic kinetics were observed for formation of 2-OH and NdM olanzapine. The high-affinity enzyme responsible for 2-OH olanzapine formation by two human liver samples exhibited an intrinsic clearance (CLint) of 0.2 microliter/min/mg. NdM olanzapine formation by two human liver samples exhibited a CLint of 1.0 microliter/min/mg for the high affinity enzyme. The formation of N-O olanzapine was linear up to 300 microM olanzapine, yielding a CLint of 0.32 to 1.70 microliters/min/mg. The formation of 7-hydroxy olanzapine (7-OH olanzapine) exhibited an apparent Km of 24.2 microM. The rates of 2-OH olanzapine formation correlated with CYP2D6 levels and activity, and it was formed to the greatest extent by cDNA-expressed CYP2D6. N-O olanzapine formation correlated with human liver flavin-containing monooxygenase (FMO3) levels and activity. NdM olanzapine and 7-OH olanzapine formation correlated with CYP1A2 catalytic activities and they were formed to the greatest extent by expressed CYP1A2. These results suggest that CYP1A2 catalyzes NdM olanzapine and 7-OH olanzapine formation, CYP2D6 catalyzes 2-OH olanzapine formation and FMO3 catalyzes N-O olanzapine formation.

Disposition of the opioid antagonist, LY255582, in rats and dogs.

LY255582 is a phenylpiperidine opioid antagonist under development as an appetite suppressant and for the treatment of obesity. Female beagles were administered [14C]LY255582 at dosages of 0.72 mg/kg intravenously or 7.2 mg/kg orally. The majority (54-58%) of the radioactivity was eliminated in the urine over 8 days after both oral and intravenous drug administration, primarily as polar metabolites. Peak plasma levels of parent drug in the dog were 11.5 and 311 ng/ml after oral and intravenous administration, respectively, and declined with a half-life of 3.2 hr. Peak plasma levels of LY255582 in the rat were 7.9 and 160 ng/ml after administration of [14C]LY255582 at dosages of 35 mg/kg orally and 1 mg/kg intravenously, respectively. The half-life of parent drug in rats was 1.5 hr; however, the terminal half-lives of radioactivity equivalents were 7.9 and 31.7 hr after intravenous and oral administration, respectively. The bioavailability of parent LY255582 was < 1% in both the rat and the dog, primarily because of extensive first-pass metabolism. Whole-body autoradiographic studies in rats after administration of a single oral 35 mg/kg dose of [14C]LY255582 indicated that radioactivity was rapidly absorbed and distributed throughout the body. Radioactivity concentrated in the liver and was eliminated slowly. Little or no parent drug was eliminated in the urine of either species. As in the urine, the major residues present in the liver and bile of rats orally administered [14C]LY255582 were uncharacterized polar metabolites with little parent drug present.

Determination of a novel alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate receptor antagonist (LY300164) and its N-acetyl metabolite in mouse, rat, dog, and monkey plasma using high-performance liquid chromatography with ultraviolet detection.

A method for the analysis of the AMPA (alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate) receptor antagonist LY300164 (compound I) and its N-acetyl metabolite (compound II) in plasma was developed. The assay utilized solid-phase extraction on a C18 Bond Elut cartridge followed by reversed-phase HPLC with UV detection at 310 nm. The method exhibited a large linear range from 0.05 microgram/ml to 50 micrograms/ml with an intra-assay accuracy for compound I and compound II ranging from 89.0% to 114.5% and intra-assay precision ranging from 0.5 to 15.3% in mouse, rat, dog, and monkey plasma. The inter-assay accuracy of compound I and compound II was 93.3% to 101.8% and the inter-assay precision was 1.6% to 11.2% in dog plasma. The lower limit of quantitation was 0.05 microgram/ml for compound I in plasma from all species tested. The lower limit of quantitation for compound II was 0.05 microgram/ml in dog and monkey plasma and 0.1 microgram/ml in mouse and rat plasma. Extracts of compound I and II from dog plasma were shown to be stable for 24 h at room temperature, and both compounds were stable when spiked into rat and monkey plasma frozen at -70 degrees C for 27 days. The method has shown to be useful in the investigation of the pharmacokinetics of the parent compound (I) and metabolite (II) in preclinical studies.

Analysis of olanzapine in human plasma utilizing reversed-phase high-performance liquid chromatography with electrochemical detection.

A sensitive reversed-phase HPLC method for the analysis of olanzapine in human plasma is described. Isolation of olanzapine from plasma was accomplished by solid-phase extraction utilizing an ion-exchange/reversed-phase cartridge designed for basic drug extraction. The drug was subsequently separated by reversed-phase HPLC and monitored by electrochemical detection (ED). Electrochemical analysis was used to detect olanzapine due to its uniquely low oxidative potential. Ascorbic acid was added to prevent oxidation during extraction. The limit of quantitation for the assay was established at 0.25 ng/ml utilizing a 1-ml human plasma sample. The average inter-day accuracy was 96.6% with a average precision (% C.V.) of 3.22% over the concentration range of 0.25 to 100 ng/ml. This method was applied to human plasma samples from human clinical trials with olanzapine. The HPLC-ED method compared favorably with a negative chemical ionization GC-MS method previously utilized for analysis of olanzapine in human plasma.

Preclinical studies on LY228729: a potent and selective serotonin1A agonist.

LY228729 is a conformationally restricted tryptamine derivative with a carboxamide serving as a protophilic group to mimic the hydroxyl in serotonin (5-HT). LY228729 has high affinity for the 5-HT1A receptor, weak affinity for the 5-HT1D receptor and no significant affinity for other monoaminergic receptors studied. LY228729 was less effective than 5-carboxamidotrytamine in suppressing K(+)-evoked release of 3H-5-HT from parietal-occipital cortical slices from guinea pigs, which is in agreement with its weak 5-HT1D receptor affinity. LY228729 reduced hypothalamic 5-hydroxyindole-3-acetic acid levels and increased serum corticosterone levels in rats. LY228729 reduced hypothalamic 5-hydroxytryptophan accumulation after decarboxylase inhibition. LY228729 increased flat posture and lower lip retraction scores in rats at doses between 0.1 and 1 mg/kg s.c. (p.o. doses were 10 times higher) and these effects were blocked by (+/-) pindolol. LY228729 induced a hypothermic response in rats, which was blocked by (+/-) pindolol. These in vivo responses are characteristics of compounds with 5-HT1A agonist activity. In the preclinical efficacy models, LY228729 suppressed motion sickness responses in cats; decreased ejaculatory latency and the increased copulatory efficiency and rate in rats and increased punished responding at lower doses than it lowered unpunished responding in rats. Collectively, these results indicate that LY228729 is potent 5-HT1A agonist with bioavailability properties sufficient for clinical evaluation and with efficacy in preclinical models of anxiety, sexual disorders and motion sickness. Since the 5-HT1A agonists that have been studied previously have antidepressant activity, this indication will also be evaluated.

Disposition of the novel serotonin agonist, LY228729, in monkeys and rats.

The disposition of a novel 5HT-1a agonist, LY228729, was studied in rats after oral administration and in monkeys after both i.v. and oral administration of a radiolabeled drug. Plasma concentrations of LY228729 declined with a half-life of 2.3 and 1.5 hr in monkeys after oral dosing and i.v. administration, respectively, and 1.9 hr in rats dosed orally. Peak plasma concentrations of the N-despropyl metabolite were greater than the parent drug following oral administration in both rats and monkeys and declined with a half-life of 3.2-3.5 hr. Plasma levels of total radioactivity rapidly exceeded that of the parent drug in both species. Radioactivity was eliminated more slowly, with terminal half-lives of 39.4 hr in the monkey and 48.6 hr in the rat. The parent drug and its despropyl metabolite accounted for only a small percentage of the total radioactivity in the plasma. Following i.v. and oral administration, radioactivity was eliminated predominantly in the urine of monkeys, but was distributed evenly between the urine and feces of rats. Parent drug and the N-despropyl metabolite were the major products in rat urine. In the monkey, the major metabolite was an uncharacterized polar compound.

Enterohepatic circulation of T-2 toxin metabolites in the rat.

The enterohepatic circulation of T-2 toxin and its conjugated metabolites was examined in bile duct-cannulated male rats. Rats administered tritiated T-2 toxin intraduodenally (id) eliminated 44.65% and 57.25% of the administered dose in the bile within 4 and 8 hr post-dosing, respectively. TLC profiles of the T-2 metabolites were similar after intravascular and id administration. The major metabolites detected were 3'-OH-hydroxytryptamine-2 (HT-2), glucuronic acid conjugates, T-2 tetraol (TOL), 4-deacetylneosolaniol (4-DN), and HT-2. Tritium-labeled glucuronides obtained from the bile of rats administered [3H]T-2 toxin intravascularly were extracted and purified using C-18 and silica column chromatography. Enzymatic hydrolysis followed by TLC and GC/MS indicated that the aglycone portion of the glucuronides were composed of 3'-OH HT-2, HT-2, 4-DN, and TOL. After id administration of the glucuronides the rats eliminated 6.01% (4 hr) and 11.86% (8 hr) of the dose in the bile. No free metabolites of T-2 toxin were detected in the bile of any animals administered the purified glucuronides. Oral treatment of the rats with the beta-glucuronidase inhibitor, saccharolactone, did not produce a significant decline in the amount of radioactivity recovered in the bile following administration of the tritium-labeled glucuronides. These studies substantiate the enterohepatic circulation of T-2 toxin metabolites.

A model system for studying the bioavailability of intestinally administered microcystin-LR, a hepatotoxic peptide from the cyanobacterium Microcystis aeruginosa.

Sprague-Dawley rats were used to evaluate a model system for studying the hepatotoxicity caused by microcystin-LR (MCYST-LR), a toxin produced by the cyanobacterium (blue-green alga) Microcystis aeruginosa, and for evaluating the in vivo therapeutic potential of cholestyramine resin (CTR) which was found to bind the toxin in vitro. Female rats were treated with either toxin or an equivalent volume of the saline vehicle by direct administration into the lumen of an in situ isolated ileal loop. Male rats were dosed with toxin as described above, and then animals were dosed in the ileal loop with either cholestyramine resin (CTR, 50 mg/rat) or an equivalent vehicle. The survivors in both studies were killed six hours after dosing and hepatotoxicity was assessed by change in relative liver weights. In all groups given toxin alone, there was a significant increase in liver weight and males and females were equally susceptible. Liver weights of the toxin plus CTR treated rats were similar to those in vehicle-treated rats. When the toxin was administered into a similarly isolated jejunal loop, liver weight was significantly less than that found when an equivalent dose was administered into the ileal loop suggesting an intestinal site specificity for toxin absorption.

Tissue residues of diacetoxyscirpenol in pigs and calves after intravenous dosing.

Pigs (n = 19) were given 0, 0.1, 0.5, or 1 mg of diacetoxyscirpenol (DAS)/kg of body weight, and heifers (n = 7) were given 0 or 0.5 mg of DAS/kg. Animals were anesthetized and exsanguinated 8 hours after administration of DAS, and liver, kidney, skeletal muscle, mesenteric lymph node, and spleen were analyzed for DAS. Diacetoxyscirpenol was not detected in tissues from animals not given DAS. All tissues from pigs and calves given DAS contained at least traces (less than or equal to 10 ng/g of tissue) of DAS.

The role of intestinal microflora in the metabolism of trichothecene mycotoxins.

The role of faecal and intestinal microflora on the metabolism of trichothecene mycotoxins was examined in this study. Suspensions of microflora obtained from the faeces of horses, cattle, dogs, rats, swine and chickens were incubated anaerobically with the trichothecene mycotoxin, diacetoxyscirpenol (DAS). Micro-organisms from rats, cattle and swine completely biotransformed DAS, primarily to the deacylated deepoxidation products, deepoxy monoacetoxyscirpenol (DE MAS) and deepoxy scirpentriol (DE SCP). By contrast, faecal microflora from chickens, horses and dogs failed to reduce the epoxide group in DAS and yielded only the deacylation products, monoacetoxyscirpenol (MAS) and scirpentriol (SCP), in addition to unmetabolized parent compound. Intestinal microflora obtained from rats completely biotransformed DAS to DE MAS, DE SCP and SCP; and T-2 toxin to the deepoxy products, deepoxy HT-2 (DE HT-2) and deepoxy T-2 triol (DE TRIOL). Rat intestinal microflora also biotransformed the polar trichothecenes, T-2 tetraol and scirpentriol, to their corresponding deepoxy analogues. Deepoxy T-2 toxin (DE T-2) was synthesized from T-2 toxin and demonstrated to be 400 times less toxic than T-2 toxin in the rat skin irritation bioassay and non-toxic to mice given 60 mg/kg ip, demonstrating that epoxide reduction is a significant single step detoxification reaction for trichothecene mycotoxins.

Gas chromatographic screening method for T-2 toxin, diacetoxyscirpenol, deoxynivalenol, and related trichothecenes in feeds.

A gas chromatographic method for screening trichothecene mycotoxins in feeds is described. Feed is extracted with acetonitrile-water, and the toxins are purified with charcoal-alumina-Celite, Florisil, and silica mini-columns. Deoxynivalenol (DON), nivalenol (NIV), diacetoxyscirpenol (DAS), T-2 toxin, and their fungal metabolites are hydrolyzed to their corresponding parent alcohols (DON, NIV, scirpentriol, or T-2 tetraol) by alkaline hydrolysis. After derivatization to their pentafluoropropionyl analogs, they are quantitated by capillary gas chromatography with electron capture detection. Identity can be confirmed and sensitivity can be increased by using negative chemical ionization mass spectrometry with no additional sample workup. Recoveries of DAS, DON, and T-2 toxin averaged, respectively, 80, 65, and 85% in corn; 84, 65, and 88% in soybeans; and 70, 57, and 96% in mixed feeds at concentrations ranging from 0.1 to 2.0 ppm. Recoveries of 15-monoacetoxyscirpenol (MAS), HT-2, NIV, and T-2 tetraol were 97, 97, 86, and 56%, respectively, in corn at a concentration of 0.25 ppm: A detection limit of 0.02 ppm in corn, soybeans, and mixed feeds, and 0.05 ppm in silages is estimated.

Cross-reactivity of antibodies against T-2 with deepoxide T-2 toxin.

Two types of antibodies raised against T-2 toxin, namely anti-T-2-HS-BSA and anti-3 -Ac -NEOS-HS -BSA, showed good cross-reactivity with deepoxy T-2 toxin. Our results indicate that the epoxide is not an important epitope for the production of antibody against T-2 toxin.

Preparation and characterization of the deepoxy trichothecenes: deepoxy HT-2, deepoxy T-2 triol, deepoxy T-2 tetraol, deepoxy 15-monoacetoxyscirpenol, and deepoxy scirpentriol.

The production of deepoxy metabolites of the trichothecene mycotoxins T-2 toxin and diacetoxyscirpenol, including deepoxy HT-2 (DE HT-2), deepoxy T-2 triol, deepoxy T-2 tetraol, deepoxy 15-monoacetoxyscirpenol, and deepoxy scirpentriol is described. The metabolites were prepared by in vitro fermentation with bovine rumen microorganisms under anaerobic conditions and purified by normal and reverse-phase high-pressure liquid chromatography. Capillary gas chromatographic retention times and mass spectra of the derivatized metabolites were obtained. The deepoxy metabolites were significantly less toxic to brine shrimp than were the corresponding epoxy analogs. Polyclonal and monoclonal T-2 antibodies were examined for cross-reactivity to several T-2 metabolites. Both HT-2 and DE HT-2 cross-reacted with mouse immunoglobulin monoclonal antibody 15H6 to a greater extent than did T-2 toxin. Rabbit polyclonal T-2 antibodies displayed greater specificity to T-2 toxin compared with the monoclonal antibody, with relative cross-reactivities of only 17.4, 14.6, and 9.2% for HT-2, DE HT-2, and deepoxy T-2 triol, respectively. Cross-reactivity of both antibodies was weak for T-2 triol, T-2 tetraol, 3'OH T-2, and 3'OH HT-2.

Isolation and characterization of 4'-hydroxy T-2 toxin, a new metabolite of the trichothecene mycotoxin T-2.

Biotransformation of the trichothecene mycotoxin T-2 by the hepatic S-9 fraction prepared from phenobarbital-treated rats yielded a new metabolic product designated RLM-3. The metabolite was purified from the hepatic preparation using preparative HPLC. The structural analysis of RLM-3 was carried out using gas chromatography/mass spectrometry and 1H and 13C NMR. RLM-3 was identified as 4'-hydroxy T-2. The toxicity of RLM-3 in comparison to T-2 toxin and 3'-hydroxy T-2 was assessed using a rat skin bioassay technique. The metabolite 4'-hydroxy T-2 was shown to be deacylated at the C-4 position to yield 4'-hydroxy HT-2 when incubated with rat hepatic S-9 preparations.

Comparative in vitro metabolism of T-2 toxin by hepatic microsomes prepared from phenobarbital-induced or control rats, mice, rabbits and chickens.

Hepatic microsomes were prepared from phenobarbital (PB)-treated and control rats, mice, rabbits and chickens and were incubated with T-2 toxin (100 micrograms/mg microsomal protein). Additional microsomes from PB-induced animals were incubated with T-2 toxin and the esterase inhibitor paraoxon (PA) at 2.5 nmol/mg microsomal protein. The major metabolite in microsomal preparations from both control and PB-induced rats, rabbits and mice was HT-2. In microsomes isolated from PB-treated chickens, 3'-hydroxy T-2 was the major metabolite, but 30 and 79% of the added T-2 toxin remained unmetabolized at 60 min in incubations from PB-induced and control birds, respectively. The percentage of hydroxylated metabolites formed in the microsomal preparations of the four species studied was significantly increased following PB treatment compared with the non-treated controls. The addition of PA to the incubation system effectively inhibited the hydrolysis of the ester groups in T-2 toxin, resulting in 1.4- and 1.25-fold increases in the percentage of 3'-hydroxy T-2 in the mouse and rat microsomal samples, respectively. In the rabbit microsomal preparations, 3'-hydroxy T-2, which was not detected in the absence of PA, represented 11% of the added substrate in the PB/PA incubation samples. Addition of PA did not cause a significant change in the amount of 3'-hydroxy T-2 formed in chicken microsomal samples, since competition between hydrolysis and hydroxylation pathways for the T-2 toxin substrate was not an important factor in this species. Two new metabolites, designated RLM-2 and RLM-3 were detected in chicken, rat and mouse microsomal preparations. On the basis of gas chromatography/mass spectrometry data, the compounds were tentatively identified as isomers of 3'-hydroxy T-2.

The toxicity of T-2 toxin in swine following topical application. I. Clinical signs, pathology, and residue concentrations.

T-2 toxin at 0 or 15 mg/kg in 0.75 ml dimethyl sulfoxide was topically applied to 11- to 12-week-old specific-pathogen-free derived crossbred female pigs. Animals were killed on Days 1, 3, 7, or 14 after treatment. Clinical signs and morphologic changes in the skin and internal organs, as well as the residual concentrations of T-2 toxin and its metabolites in plasma, bile, urine, skin, and subcutaneous tissue, were examined. The T-2-treated pigs had signs of lethargy, anorexia, posterior weakness or paresis, and persistent fever. The skin at the site of application was red and swollen initially and progressively became dark red and then purple. By Day 7, at the margin of the exposed area, clefts had formed and were covered by serosanguinous exudate. By Day 14, the affected skin was focally separated from the underlying tissue and covered by a thick scab. The initial skin lesions were characterized as a spongiotic dermatitis and were located mainly in the dermal papillae and stratum germinativum of the epidermis. These lesions progressed to a locally extensive necrotizing dermatitis between Days 3 and 7 that was still evident at Day 14. Healing began on Day 7 and was more prominent on Day 14. Morphologic changes in the internal organs were minimal. They consisted of necrosis of single cells in the follicles of lymphoid tissues and in the exocrine pancreas.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of some metabolites of T-2 toxin, diacetoxyscirpenol and deoxynivalenol by thermospray high-performance liquid chromatography-mass spectrometry.

Detection and identification of mycotoxin metabolites is a very challenging task. In order to achieve adequate sensitivity and specificity an analytical technique must overcome serious matrix interferences. Gas chromatography-mass spectrometry (GC-MS) which has the sensitivity and specificity to detect and identify mycotoxin metabolites requires hydrolysis of conjugated metabolites as well as derivatization. Thermospray high-performance liquid chromatography-mass spectrometry (HPLC-MS) offers the sensitivity, specificity, and structural information to detect and identify some mycotoxin metabolites in fecal and urine samples without derivatization. The mycotoxins evaluated in this study include deoxynivalenol (DON), T-2 toxin, and diacetoxyscirpenol. The de-epoxy and hydroxy metabolites of each toxin and the glucuronide conjugate of DON were isolated, extracted, and analyzed to detect their occurrence in animals. The thermospray mass spectra of the toxins showed an [M + H]+ ion and numerous structurally significant fragment ions in the positive ion detection mode. Negative ion detection exhibited primarily [M + acetate]- cluster ions with less fragmentation than observed by positive ion detection. The operation of the interface in the filament-on mode greatly increased the sensitivity in both positive and negative ion detection mode. Detection limits of 50-500 pg injected on column are obtained for these toxins and their metabolites using multiple ion detection. The urine and fecal extracts from rats, hens, and cows did not interfere with the HPLC-MS analysis for the specific metabolites or the glucuronide conjugate.

Pharmacokinetics of diacetoxyscirpenol in cattle and swine: effects of halothane.

In swine and cattle given 0, 0.1, or 0.5 and 0, 0.5 mg of diacetoxyscirpenol (DAS)/kg of body weight, IV, respectively; DAS had a large volume of distribution and total body clearance. The shortness of the interval between halothane and DAS exposures significantly (P greater than 0.05) decreased DAS biotransformation. Urinary excretion of DAS as a parent compound was not an important route of elimination. In swine and cattle, DAS was transformed by sequential deacetylation to monoacetoxyscirpenol and scirpentriol.