Serum amyloid A predicts early mortality in acute coronary syndromes: A TIMI 11A substudy.

OBJECTIVES: We evaluated the ability of serum amyloid A (SAA), alone and in combination with a rapid qualitative assay for cardiac-specific troponin T (cTnT), to predict 14-day mortality in patients with unstable angina or non-Q wave myocardial infarction (NQMI). BACKGROUND: Elevated C-reactive protein (CRP) has been associated with adverse outcomes in unstable coronary syndromes but data regarding its acute phase counterpart, SAA, are conflicting. METHODS: Serum amyloid A measurement and a rapid cTnT assay were performed on blood obtained at enrollment into Thrombolysis in Myocardial Infarction 11A, a dose-ranging trial of enoxaparin for unstable angina and NQMI. RESULTS: Serum amyloid A was higher in patients who died compared with survivors (6.28 vs. 0.75 mg/dL, p = 0.002). Among patients with a negative rapid cTnT, mortality was higher for those in the top quintile of SAA (6.1 vs. 0.7%, p = 0.003). Patients with both an early positive rapid cTnT (< or =10 min until assay positive) and SAA in the fifth quintile had the highest mortality followed by those with either markedly elevated SAA or an early positive rapid cTnT, while patients with both a negative rapid cTnT and SAA in quintiles 1-4 were at very low risk, (9.1 vs. 3.6 vs. 0.7%, p <0.002). CONCLUSIONS: Similar to CRP, baseline elevation of SAA identifies patients hospitalized with unstable angina and NQMI at higher risk for early mortality, even among those with a negative rapid assay for cTnT. These data support further investigation of inflammatory markers used alone and in combination with cardiac troponins for risk assessment in unstable coronary syndromes.

C-reactive protein is a potent predictor of mortality independently of and in combination with troponin T in acute coronary syndromes: a TIMI 11A substudy. Thrombolysis in Myocardial Infarction.

OBJECTIVES: We evaluated C-reactive protein (CRP) alone and in conjunction with a rapid qualitative assay for cardiac-specific troponin T (cTnT) for predicting 14-day mortality in patients with unstable angina or non-Q wave myocardial infarction (NQMI). BACKGROUND: Elevated CRP has been found to correlate with higher risk for cardiac events in patients with coronary disease. METHODS: At enrollment into the Thrombolysis in Myocardial Infarction (TIMI) 11A trial, a dose-ranging trial of enoxaparin for unstable angina and NQMI, serum was obtained for CRP measurement and rapid cTnT assay. RESULTS: Quantitative CRP and rapid cTnT assays were performed in all patients. CRP was higher among patients who died than in survivors (7.2 vs. 13 mg/dl, p = 0.0038). The probability of a positive rapid cTnT assay rose with increasing CRP concentration (p < 0.0001). Among patients with a negative rapid cTnT assay, the mortality rate was higher among patients with CRP > or = 1.55 mg/dl (5.80% vs. 0.36%, p = 0.006). Patients with both an early positive rapid cTnT assay (< or = 10 min until assay positive) and CRP > or = 1.55 mg/dl had the highest mortality, followed by those with either CRP > or = 1.55 mg/dl or an early positive rapid cTnT assay, whereas patients with both a negative rapid cTnT assay and CRP < 1.55 mg/dl were at very low risk (9.10% vs. 4.65% vs. 0.36%, p = 0.0003). CONCLUSIONS: Elevated CRP at presentation in patients with unstable angina or NQMI is correlated with increased 14-day mortality, even in patients with a negative rapid cTnT assay. Quantitative CRP and a rapid cTnT assay provide complementary information for stratifying patients with regard to mortality risk.

Characterization of tumor-infiltrating lymphocytes from murine mammary adenocarcinomas.

The aim of this investigation was to assess the in vitro functional and phenotypic characteristics of lymphocytes isolated from C3H mouse mammary adenocarcinomas. A protocol was developed for the expansion of TILs in long-term culture. The homing pattern of TILs prepared and grown in this manner was studied. Cells that had been in culture for up to 96 days accumulated at higher levels in mammary tumors than in corresponding normal mammary tissue 24 hr after adoptive transfer. The ability of cultured TILs to lyse YAC-1 cells was determined. Peak activity was demonstrated by lymphocytes that had been in culture for three days. By two weeks in culture the level of cytotoxicity returned to that of fresh TILs, and after 45 days it was negligible. T cells were the major constituents in all preparations. The relative frequency of CD8+ cells remained fairly constant over time in culture, but that of CD4+ cells declined. At all time points the CD4:CD8 ratio for TILs was less than 1. The percentage of ASGM1+ bright cells among fresh TILs was low. It increased dramatically within 3 days, remained high for about 7 weeks, and then declined rapidly to pre-culture levels. An unusual large cell characterized by the presence of an intensely PAS positive peripheral region was observed.

Analytical evaluation of particle-enhanced immunonephelometric assays for C-reactive protein, serum amyloid A and mannose-binding protein in human serum.

Against a background of growing interest in more sensitive assays for quantifying various acute phase proteins, we evaluated the performance of recently developed tests for C-reactive protein (CRP), serum amyloid A (SAA) and mannose-binding protein (MBP) on the Behring nephelometer II (BNII). Sample results outside the calibration ranges of 3.5 to 220 mg/L for CRP, 3.3 to 215 mg/L for SAA and 0.09 to 5.6 mg/L for MBP were automatically re-measured at another dilution. The lower limits of detection were 0.01, 0.7 and 0.01 mg/L for CRP, SAA and MBP, respectively. The coefficients of variation (CV) for intra- (n > or = 20) and inter- (n > or = 15) assay precision were < 5.2% and < 8.5%, respectively, for the three proteins at concentrations representing low, normal and high. Linearity for each method was within 5% of the expected values throughout the calibration range. We observed no significant interference from bilirubin (up to 300 mg/L) or haemoglobin (up to 10 g/ L) for the three tests. Method comparison studies performed for CRP and SAA yielded the following results: y (CRP on BNII) = 0.75x (ELISA, Hemagen) -0.25 mg/L (r = 0.981, Sy/x = 2.1 mg/L; y (SAA on BNII) = 1.44x (ELISA, Hemagen) -9.9 mg/L (r = 0.972, Sy/x = 6.9 mg/L), where ELISA is enzyme-linked immunosorbent assay. Reference intervals established in 261 adult blood donors (aged 36.2 +/- 9.0 years) were found to be log-normal with 2.5th, 50th, and 97.5th centiles of < 0.17, 1.00 and 10.1 mg/L for CRP, < 0.84, 2.10 and 9.70 mg/L for SAA; and 0.30, 1.28 and 4.10 mg/L for MBP. We observed no relationship with CRP concentration and age; however, SAA levels increased with age while MBP levels decreased. The BNII provides a simple, rapid and sensitive system for measuring CRP, SAA and MBP in human serum.

NONLIN84/PCNONLIN: software for the statistical analysis of nonlinear models.

A new software package, NONLIN84, has been developed for the analysis of general nonlinear models including pharmacokinetic models. NONLIN84 is easier to use than the older NONLIN77, and can handle a wider class of estimation problems, such as maximum likelihood estimation involving iterative reweighting. Two large libraries of pharmacokinetic models are distributed with NONLIN84 and can be accessed by simply specifying a model number. A companion program, PCNONLIN, runs on DOS based microcomputers and retains most of the features of NONLIN84.

Bioavailability of medroxalol in man.

Ten healthy male volunteers received single oral doses of 100 mg of medroxalol administered as a solution, a preliminary tablet formulation and a single dose of 100 mg administered intravenously in a randomized three-way crossover study. Mean terminal half-lives of 12.4, 13.4, and 11.3 h were observed for the intravenous, solution and tablet formulation, respectively. Mean urinary recovery of parent drug at 48 h was 8.9 per cent, 3.9 per cent, and 3.2 per cent. Absolute bioavailability estimated from plasma AUC was 54 per cent for the solution and 38 per cent for the tablet, and the relative bioavailability from the tablet was 71 per cent.

A simulation study of parameter estimation in the one and two compartment models.

Few attempts have been made to examine the statistical problems that the user of compartmental models must face. Some properties of the estimators of parameters for one and two compartmental models based on nonlinear estimation were studied through simulation. Of particular interest were the effect of the experimental design and the effect of different error structures on the empirical sampling distribution for the estimators. For the one compartment model it was found that nonlinear estimation yielded essentially unbiased estimators that were normally distributed unless the random error for the model was large. In the two compartment model simulations, bias appeared in the estimators to the extent that bimodal sampling distributions of the estimators were observed as the random error for the model was increased.

A forecasting approach to accelerate drug development.

The clinical phase of drug development should be concluded sooner and at a lower cost if primarily only the pivotal and supportive studies were to be conducted. Such improved efficiency requires development of a decision support system that delivers five new capabilities: (i) it enables one to predict a result of a clinical study and to identify those studies that are expected to have an acceptable probability of success; (ii) it will allow one to optimally utilize available pharmacokinetic and pharmacodynamic (PK/PD) data and improve its predictive capability as more data become available; (iii) it will enable one to project useful population results, not just mean results; (iv) predictions will be accompanied by a measure of reliability; and (v) expected initial clinical results will be predictable from animal and related drug class data. With such a tool population targets could be specified very early in the drug development programme, challenged, and then rationally revised at each step during the development process. This report describes progress in developing and testing a clinical trials Forecaster, a prototype for such a system. The Forecaster generates estimates of the joint density for a population of combined PK/PD parameters. That population then serves as a surrogate for the population of individuals. When the resulting joint density is sampled, the obtained sets of parameters may be used to generate data that is statistically indistinguishable from the original experimental data. Such simulated data can be used to validate assumptions, and make inferences on specified population targets that are accompanied by a measure of prediction reliability. We demonstrate use of the forecaster by employing N = 22 PK/PD parameter sets for an orally administered analgesic.

Cardiac toxicity of intravenous terbutaline for the treatment of severe asthma in children: a prospective assessment.

OBJECTIVE: To examine the cardiac toxicity as measured by elevations in serum cardiac troponin T (cTnT) and to compare creatine kinase (CK) and creatine kinase MB (CK-MB) and findings on electrocardiography (ECG) as markers of cardiac toxicity with cTnT during the infusion of intravenous terbutaline for the treatment of severe asthma in children. STUDY DESIGN: Prospective cohort study of patients receiving intravenous terbutaline for severe asthma. RESULTS: Only 3 (10%) of the 29 patients had elevations in cTnT. Each underwent mechanical ventilation for >72 hours, which was the earliest point at which cTnT elevations were identified. Eighteen (62%) patients had an elevation in CK, and 3 had an elevation in CK-MB fraction without an elevated cTnT. Twenty (69%) patients had ECG findings consistent with ischemia, and 19 of these patients had the ischemic findings on their preterbutaline ECG. Elevations in CK and CK-MB and ischemic changes on ECG did not correlate with elevations in cTnT. Both mechanical ventilation (P =.02) and prolonged administration (>72 hours) of intravenous terbutaline (P =. 02) were significantly associated with elevations in cTnT. CONCLUSIONS: We found no clinically significant cardiac toxicity from the use of intravenous terbutaline for severe asthma as measured by serum cTnT elevations.

Method of analysis of the new cardiotonic agent, MDL 19,205, in plasma and urine and its application in a dog pharmacokinetic study.

A high-performance liquid chromatographic method has been developed for the analysis of plasma and urine concentrations of a new cardiotonic agent, MDL 19,205 (I). This procedure was utilized to study the pharmacokinetics of I in beagle dogs. The results of the dog study show that the compound is completely and rapidly absorbed. Plasma concentrations fell in a monoexponential manner with a half-life of about 1.3 h which was unaffected by dose in the range 3-30 mg/kg. Urinary excretion of unchanged I accounts for about one-half of the dose and is essentially complete in 24-48 h.

Cardiovascular properties of a new cardiotonic agent: MDL 17,043 (1.3-dihydro-4-methyl-5-[4-(methylthio)-benzoyl]-2H-imidazol-2-one).

The cardiovascular properties of a new noncatechol, nonglycoside cardiotonic agent, MDL 17,043, were investigated in anesthetized and conscious dogs and the dog heart-lung preparation. MDL 17,043 (0.1-1 mg/kg), administered to anesthetized dogs by intravenous injection, produced dose-related increases in cardiac contractile force lasting more than 1 h. It also produced relatively minor and shorter-lasting increases in heart rate, and brief decreases in blood pressure. These effects were not blocked by propranolol. Of these effects, the increase in cardiac contractile force was, by far, the most prominent. the cardiac effects were also observed in the dog heart-lung preparation. When administered to anesthetized dogs by constant intravenous infusion, MDL 17,043 (09.03 and 0.1 mg/kg/min) produced a marked and sustained increase in cardiac contractile force and a sustained decrease in blood pressure without altering heart rate, suggesting a wide separation between the inotropic instrumented dogs, MDL 17,043 (3-30 mg/kg) produced a sustained increase in dP/dt without altering heart rate or blood pressure. It reversed the depressant effect of pentobarbital on the ventricular function curve in the dog heart-lung. When the hemodynamic characteristics of compensated heart failure were produced by propranolol in anesthetized dogs, MDL 17,043 reversed these effects. These studies suggest that MDL 17,043 may have a beneficial effect in the treatment of heart failure.