Search

Introduction: Individuals with dementia are underrepresented in interventional studies for acute ischemic stroke (AIS). This research gap creates a bias against their treatment in clinical practice. Our goal was to compare the safety and efficacy of intravenous-thrombolysis (t-PA) and endovascular treatment (EVT) in individuals with or without pre-AIS dementia., Method: A retrospective study of AIS patients receiving t-PA or EVT between 2019 and 2022. Patients were classified as dementia on a case-by-case review of baseline assessment. Additional variables included demographic, vascular risk factors, AIS severity and treatment. Outcomes of interest were intracerebral hemorrhage, mortality in 90-days, and the difference in modified rankin scale (mRS) before AIS and in 90-days follow-up. Outcomes were compared across non-matched groups and following propensity-score matching., Results: Altogether, 628 patients were included, of which 68 had pre-AIS dementia. Compared to non-dementia group, dementia group were older, had a higher rate of vascular risk factors, higher pre-stroke mRS and higher baseline NIHSS. Individuals with dementia had higher rates of mortality (25% vs.11%,p < 0.01) on non-matched comparison. All cohort and restricted t-PA EVT matched analysis showed no difference in any outcome. Regression analysis confirmed that AIS severity at presentation and its treatment, not dementia, were the chief contributors to patients' outcomes., Discussion: Our results indicate that pre-AIS dementia does not impact the efficacy or safety of EVT or t-PA for AIS. We thus call for more inclusive research on stroke therapy with regards to baseline cognitive status. Such studies are urgently required to inform stroke guidelines and enhance care., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: To examine whether high ambient temperature and diurnal temperature range during the summer are associated with risk of stroke/transient ischemic attack (TIA)., Methods: A time-stratified case-crossover study design was conducted. The study sample comprised all individuals aged ≥50 years who had a stroke/TIA reported to the Israeli National Stroke Registry between 2014 and 2016 during the summer season. Daily temperature data were retrieved from the Israel Meteorological Service. Conditional logistic regression models were used with relative humidity and air pollution as covariates., Results: The sample included 15,123 individuals who had a stroke/TIA during the summer season (mean age 73 ± 12 years; 54% males). High ambient temperature was associated with stroke/TIA risk starting from the day before the stroke event, and increasing in strength over a six-day lag (OR = 1.10 95%CI 1.09-1.12). Moreover, a larger diurnal temperature range prior to stroke/TIA occurrence was associated with decreased stroke/TIA risk (OR = 0.96 95%CI 0.95-0.97 for a six-day lag)., Conclusions: High ambient temperature may be linked to increased risk of cerebrovascular events in subsequent days. However, relief from the heat during the night may attenuate this risk., Competing Interests: Declaration of competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: Management of early superficial lesions in the head and neck remains complex. We performed a phase 1 trial for high-grade premalignant and early superficial lesions of the head and neck using photodynamic therapy (PDT) with Levulan (ALA)., Materials and Methods: Thirty-five subjects with high grade dysplasia, carcinoma in situ, or microinvasive (⩽1.5mm depth) squamous cell carcinoma were enrolled. Cohorts of 3-6 patients were given escalating intraoperative light doses of 50-200J/cm(2) 4-6h after oral administration of 60mg/kg ALA. Light at 629-635nm was delivered in a continuous (unfractionated) or fractionated (two-part) schema., Results: PDT was delivered to 30/35 subjects, with 29 evaluable. There was one death possibly due to the treatment. The regimen was otherwise tolerable, with a 52% rate of grade 3 mucositis which healed within several weeks. Other toxicities were generally grade 1 or 2, including odynophagia (one grade 4), voice alteration (one grade 3), and photosensitivity reactions. One patient developed grade 5 sepsis. With a median follow-up of 42months, 10 patients (34%) developed local recurrence; 4 of these received 50J/cm(2) and two each received 100, 150, and 200J/cm(2). Ten (34%) patients developed recurrence adjacent to the treated field. There was a 69% complete response rate at 3months., Conclusions: ALA-PDT is well tolerated. Maximum Tolerated Dose appears to be higher than the highest dose used in this study. Longer followup is required to analyze effect of light dose on local recurrence. High marginal recurrence rates suggest use of larger treatment fields., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Whether novel risk variants of Alzheimer's disease (AD) identified through genome-wide association studies also influence magnetic resonance imaging-based intermediate phenotypes of AD in the general population is unclear. We studied association of 24 AD risk loci with intracranial volume, total brain volume, hippocampal volume (HV), white matter hyperintensity burden, and brain infarcts in a meta-analysis of genetic association studies from large population-based samples (N = 8175-11,550). In single-SNP based tests, AD risk allele of APOE (rs2075650) was associated with smaller HV (p = 0.0054) and CD33 (rs3865444) with smaller intracranial volume (p = 0.0058). In gene-based tests, there was associations of HLA-DRB1 with total brain volume (p = 0.0006) and BIN1 with HV (p = 0.00089). A weighted AD genetic risk score was associated with smaller HV (beta ± SE = -0.047 ± 0.013, p = 0.00041), even after excluding the APOE locus (p = 0.029). However, only association of AD genetic risk score with HV, including APOE, was significant after multiple testing correction (including number of independent phenotypes tested). These results suggest that novel AD genetic risk variants may contribute to structural brain aging in nondemented older community persons., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Photodynamic therapy (PDT) has been used for head and neck carcinomas with little experience in the oropharynx due to technical challenges in achieving adequate exposure. We present the case of a patient with a second right tonsil carcinoma following previous treatment with transoral robotic surgery (TORS) and postoperative chemoradiation for a left tonsil carcinoma. Repeat TORS for the right tonsil carcinoma reviewed multiple positive surgical margins. The power output from the robotic camera was modified to facilitate safe intraoperative three dimensional visualization of the tumor bed. The robotic arms facilitated clear exposure of the tonsil and tongue base with stable administration of the fluence. Real-time measurements confirmed stable photobleaching with augmentation of the prescribed light fluence secondary to light scatter in the oropharynx. We report a potential new role using TORS for exposure and accurate PDT in the oropharynx., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Photodynamic therapy (PDT) has been used for pre-malignant mucosal lesions. In an attempt to treat a patient with recurrent high-grade dysplasia of the glottic larynx, we were faced with technical challenges leading us to abandon the classic microlens fiber for a 2-cm long translucent diffusing balloon catheter to deliver photoactivating light to the targeted lesion. Real-time measurements confirmed stable photobleaching with augmentation of the prescribed light fluence secondary to light scatter in regions not in contact with the balloon diffuser. We report a potential new application of the balloon catheter that may be more suitable for anterior glottic lesions associated with minimal acute toxicity., ((c) 2010 Elsevier B.V. All rights reserved.)

Background: Perioperative stroke (POS) is a devastating complication of coronary artery bypass grafting (CABG). Many studies have been published concerning risk factors and possible causes of POS but none have studied which side of the brain is more frequently involved. The finding of a strong preponderance of left-sided strokes calls into question some widely held theories as to the cause of POS and implicates end-hole aortic perfusion catheters as a major factor., Methods: During a 3-year period (1996 to 1998), prospective data were collected on all 2,217 consecutive CABG patients at one hospital (with surgery by different surgeons in different groups). Strokes were classified as perioperative (within 3 days of surgery) or late (beyond 3 days but during hospitalization)., Results: There were a total of 51 strokes (2.3%): 21 left, 10 right, 7 bilateral, 7 lacunar, 1 brainstem, and 5 indeterminate. There were 18 major territorial perioperative strokes on the left side and 6 on the right side. Thus, 75% (18 of 24) of POS were left-sided. Stroke patients were significantly younger than nonstroke patients (66.3 +/- 10.52 versus 71.4 +/- 8.47 years, p = 0.009). Other demographic data did not differ significantly., Conclusions: If aortic clamping, cannulation, or manipulation were responsible for most strokes, then right-sided strokes should predominate, as the innominate artery is closest to the source of such emboli. In contrast, end-hole aortic cannulas direct a high-velocity jet at the left carotid orifice and may be responsible for a large proportion of POS. Side-hole aortic cannulas may reduce the incidence of this complication.

Myo-inositol hexaphosphate (phytic acid), a highly charged antioxidant, has been found to chelate metal ions such as iron and calcium and to scavenge hydroxyl radicals, .OH. This study examined the efficacy of this antioxidant and redox agent in attenuating myocardial reperfusion injury. Sprague-Dawley rats were injected intravenously with three different doses of phytic acid (group 1, saline solution only, control; group 2, 1.5 mg/100 g; group 3, 7.5 mg/100 g; group 4, 15 mg/100 g) 30 minutes before excision of hearts. Isolated hearts were prepared by the Langendorff technique. Global ischemia was induced for 30 minutes, followed by 30 minutes of reperfusion. As expected, in group 1, reperfusion was associated with enhanced creatine kinase release, reduced coronary flow, poor recovery of ventricular function as evidenced by reduced left ventricular developed pressure and the first derivative of left ventricular pressure, and increased lipid peroxidation. Groups 3 and 4, but not group 2, demonstrated myocardial protection as evidenced by reduced creatine kinase release, improved left ventricular function and coronary flow, and decreased lipid peroxidation compared with the control group. These results suggest that potential use of this antioxidant in salvaging the heart from ischemic and reperfusion injury.

Determination of the cell types proliferating in the dermis of patients with psoriasis should identify those cells experiencing activation or responding to growth factors in the psoriatic dermal milieu. Toward that end, sections of formalin-fixed biopsies obtained from 3H-deoxyuridine (3H-dU)-injected skin of eight psoriatic patients were immunostained, followed by autoradiography. Proliferating dermal cells exhibit silver grains from tritium emissions. The identity of the proliferating cells could then be determined by simultaneous visualization with antibodies specific for various cell types. UCHL1+ (CD45RO+) T cells (recall antigen-reactive helper T-cell subset) constituted 36.6 +/- 3.1% (mean +/- SEM, n = 6) of the proliferating dermal cells in involved skin, whereas Leu 18+ (CD45RA+) T cells (recall antigen naive T-cell subsets) comprised only 8.7 +/- 1.5% (n = 6). The Factor XIIIa+ dermal perivascular dendritic cell subset (24.9 +/- 1.5% of proliferating dermal cells, n = 6) and Factor VIII+ endothelial cells (23.0 +/- 2.3%, n = 6) represented the two other major proliferating populations in lesional psoriatic dermis. Differentiated tissue macrophages, identified by phase microscopy as melanophages or by immunostaining with antibodies to Leu M1 (CD15) or myeloid histiocyte antigen, comprised less than 5% of the proliferating population in either skin type. In addition to calculating the relative proportions of these cells to each other as percent, we also determined the density of cells, in cells/mm2 of tissue. The density of proliferating cells within these populations was increased in involved versus uninvolved skin: UCHL1+, 9.0 +/- 1.7 cells/mm2 versus 1.8 +/- 0.6 cells/mm2, p less than 0.01; Factor XIIIa+, 6.0 +/- 0.7 cells/mm2 versus 1.5 +/- 0.5 cells/mm2, p less than 0.01; Factor VIII+, 5.5 +/- 1.4 cells/mm2 versus 0.0 cells/mm2, p less than 0.05. The presence of preferential active proliferation of a T-cell subset in lesional dermis suggests that activating signals specific for this subset are contained within the psoriatic dermis in vivo. The activation of recall antigen-reactive T cells may be a driving force behind the dendritic cell and endothelial cell proliferation. Alternatively, the selective proliferation and expansion of these two constitutive cell types (Factor XIIIa+ and Factor VIII+) may result in signals that promote activation of UCHL1+ (CD45RO+) T cells.

A simple, isocratic, sensitive (1 ng), and specific high-performance liquid chromatographic (HPLC) method based on photodiode-array detection (PAD) is described for simultaneous quantitation of the bioactive peptides, lysine vasopressin (LVP), arginine vasopressin (AVP) and oxytocin (OXY). Acidified pig plasma and left ventricular (LV) tissue samples were first extracted with Sep-Pak C18 columns, and the bioactive peptides were eluted with methanol, then dried at 37 degrees C and reconstituted with HPLC mobile phase. The bioactive peptides were separated by HPLC on a Dynamax 3009-A C8 column with a mobile phase of 0.1% trichloroacetic acid-50 mM heptanesulfonic acid-30mM triethylamine-20% acetonitrile in water, pH 2.5 and identified with a Waters 990-PAD system (spectrum index plots in the range 200-400 nm). Standards of LVP, AVP and OXY and their mixtures showed a linear increase in the range 5 to 100 ng and were eluted at 6.1, 6.9 and 4.6 min, respectively. Spectrum analysis showed a distinct absorption peak at 280 nm, corresponding to peptide bonds. The reproducibility of the method coefficient of variation for standards is 6.9, 5.8 and 4.7% for LVP, AVP and OXY, respectively. In plasma and tissue it is much higher: 12.9% (LV tissue) and 18.6% (plasma) for LVP. Pig plasma contains negligible amounts of AVP and OXY; LVP is much higher (0.28 +/- 0.19 ng/ml). In pig tissue, LVP predominates (6.95 ng/g wet weight) compared to AVP (1.45) and OXY (1.50). Spectral analysis is necessary to identify the bioactive peptide peaks among interfering substances and to increase the sensitivity four-fold. The method described here is useful for the simultaneous determination of LVP, AVP and OXY in the nanogram range and can be extended to picogram levels by employing PAD spectral analysis techniques.

Based on recent experience that Cyclosporin A, an immunosuppressive drug, produces marked improvement in psoriasis, possible immunomodulatory activities of methotrexate (MTX) have been reviewed to look for alternate mechanisms of MTX action in psoriasis. It is generally considered that the therapeutic results of MTX in psoriasis are related to a direct effect on epidermal cell hyperplasia through inhibition of DNA synthesis. Several studies in the literature now suggest possible effects of MTX on the immune system of psoriatics as well as in animal models that may have some pathogenic similarities to psoriasis. In psoriatics receiving MTX, neutrophil chemotaxis is suppressed, resulting in a possible alteration in the potential pathologic activity of neutrophils commonly found in lesional skin. MTX does improve both psoriatic and rheumatoid arthritis. Animal studies of the latter using adjuvant arthritis and graft vs host disease (GVHD) have indicated several possible mechanisms for MTX that affect these processes. In GVHD, MTX selectively destroys cycling CD8+ cells, and in adjuvant arthritis the activation of macrophages is prevented by inhibition of T-cell function. While MTX generally has not been clinically utilized as an immunomodulatory drug for immunologically related diseases, it may, nonetheless, have selective actions that could be specific for some diseases. MTX and Cyclosporin A could work mechanistically in similar ways but at different steps in the activation of T cells and macrophages. It may be that the major direct effect of MTX on epidermal cell proliferation is complemented or even mediated by subtle immunoregulatory effects on the melange of cells in the affected skin and the systemic immune response.

The effect of verapamil administered before aortic cross-clamping was assessed in 40 patients undergoing elective coronary artery bypass grafting. Myocardial protection consisted of cold blood potassium cardioplegia, topical ice slush, and moderate (28 degrees C) systemic hypothermia. Patients were randomly divided into two groups: group 1 (18 patients) received verapamil (0.1 mg/kg up to 10 mg) intravenously three to five minutes before aortic cross-clamping; group 2 (22 patients) did not (control). Myocardial injury was assessed by cumulative release of the cardiac-specific isoenzyme of creatine kinase (CK-MB) after release of the aortic cross-clamp. Release of CK-MB was significantly lower in the verapamil group (44.9 +/- 6.2 versus 72.2 +/- 9.0 IU at 24.5 hours, p = 0.005). Calculated total infarct size was also lower in the verapamil group (6.0 +/- 0.9 versus 8.9 +/- 1.0 g-Eq, p = 0.035). Individual CK-MB release curves showed either one or two peaks. The two-peak pattern was more frequent in control patients (18 of 21 control patients versus 6 of 18 verapamil patients, p = 0.001) and was associated with a larger infarct size. Atrioventricular pacing was not required in any verapamil patient, but was needed in 1 control patient. We conclude that verapamil administered before aortic cross-clamping protects against myocardial injury during coronary artery bypass grafting with no increase in the incidence of atrioventricular block.

Twenty-four children (ages 1 to 18 years, mean 12.2 years) underwent 27 operations for aortic, mitral, or combined aortic and mitral valve replacement. There was 1 operative death. Of the 23 operative survivors (12 aortic, 8 mitral, 3 combined valve replacement), only 5 were given warfarin for long-term anticoagulation. The remaining 18 (10 aortic, 8 mitral valve replacement) were given aspirin (plus dipyridamole in 5). Twelve of the 18 had at least one mechanical valve (11 Björk-Shiley and Beall valves; 1 Björk-Shiley valve was replaced with a Beall disc valve as the child grew). These 18 patients were followed for 1 to 59 months (mean, 20.4 months). There was no thrombotic, embolic, or bleeding complications. There were 2 late deaths (one cardiac). Review of the available literature indicates that in children with prosthetic cardiac valves, aspirin (with or without dipyridamole) provides adequate protection against thromboemboli and avoids the hemorrhagic complications associated with warfarin.

Direct autoradiographic identification of the epidermal growth fraction (GF) requires the delivery of tritiated thymidine ([3H]dThd) to the skin during the time interval of an entire cell cycle. The GF in normal human epidermis has not been directly measured using this technique because the systemic infusion of radioactive [3H]dThd in benign skin conditions is precluded by ethical considerations. Studies were undertaken to assess the feasibility of measuring the epidermal GF in vivo by the topical delivery of [3H]dThd. The percutaneous penetration of [3H]dThd in various vehicles was evaluated to select an effective topical delivery system. A vehicle consisting of Azone, isopropanol, and water (2:49:49) was the best of 4 different vehicles tested. The optimal penetration of [3H]dThd, with respect to the concentration of Azone over a range of 0-4%, was achieved at 2%. During the initial 24 h following a single topical application of [3H]dThd to hairless mice the labeling increased linearly with time. In vivo studies in hairless mice produced a GF of 95% by both continuous systemic [3H]dThd infusion, and by twice daily topical [3H]dThd. Azone vehicles induced epidermal hyperplasia which was minimized by lowering the Azone concentration and by decreasing the frequency of applications from 24 to 48 h. These studies establish the rationale for using topical delivery of [3H]dThd for the in vivo measurement of epidermal GF.

Cell proliferation of the uninvolved psoriatic skin was compared with normal skin of volunteers following stimulation by the intradermal injections of saline or propranolol, or stripping of the stratum corneum with pressure-sensitive tape. Initially, no significant in vivo difference in tritiated thymidine labeling indices were observed between normal and uninvolved epidermal cells. However, 48 hr after each stimulus more DNA synthesizing cells were found in the uninvolved psoriatic than in normal epidermis. Of these 3 stimuli, propranolol was the most effective in distinguishing between uninvolved psoriatic skin and skin from normal control subjects. Thus, uninvolved psoriatic skin appears to possess an abnormal regulation of epidermopoiesis that may be amplified by propranolol injection.

Dihydrofolate reductase (DHFR) inhibitors, which differ from the classical folate antagonists in physicochemical and pharmacologic parameters such as lipid solubility and mechanisms of cellular transport, were screened for DHFR inhibitory activity and biologic activity in newborn rat skin. The most effective drugs from this screen were tested for their effects on de novo DNA synthesis in psoriatic epidermis in vitro. Of the 24 compounds studied, methotrexate (MTX) was the most potent inhibitor of rat skin DHFR (I50=8.6 X 10(-9) M). Methotrexate-dimethylester, methasquin-diethylester, DDEP (2,4-diamino-5-(3',4'-dichlorophenyl)-6-ethylprimidine), and Baker's triazine antifolate (NSC 139105), while less effective than MTX as DHFR inhibitors, were more effective than MTX as inhibitors of de novo DNA synthesis in rat skin in vitro. Baker's antifolate was the only compound tested which was considerably more effective than MTX as an inhibitor of de novo DNA synthesis in psoriatic epidermis in vitro.

The kinetics of cell proliferation in the matrix cells of human scalp hair were determined in vivo. Autoradiographic analysis was employed on biopsy specimens taken at specific time intervals after intradermal injection of tritiated thymidine (3H-TdR) into the scalps of volunteer subjects. The durations of the S and G2 phases (Ts and Tg2) were 11.1 and 3.6 hr respectively, obtained from the composite percent labeled mitosis curve. The labeling index of the hari matrix cells was 28.6% +/- 2.2%. The durations of mitosis and of the total cell cycle (Tm and Tgc) were calculated to be 0.8 hr and 38.8 hr respectively. The growth fraction of hair root germinative cells was estimated as 75-100% on the basis of "continuous" 3H-TdR exposure over the duration of the cell cycle. It is noted that the kinetics of human hair root cells are quite similar to the kinetics of psoriatic epidermal cells, suggesting that both tissues are approaching the maximum proliferative rate of keratinogenic epithelial cells.

The case history of a 60-year-old man with symptomatic recurrent stenosis of the left carotid artery 20 years after carotid endarterectomy is presented. At reoperation (repeat endarterectomy and venous patch angioplasty) the lumen was found to be reduced by 60% and histopathologic study revealed atheromatosis with organizing mural thrombus. The case is discussed in the context of the recent literature concerning restenosis, the reported frequency of which varies depending on the size of the population studied and the method of follow-up, with noninvasive studies revealing that restenosis is more commonly asymptomatic than symptomatic. Early simple fibrous restenosis differs histologically from the more complex, frankly atherosclerotic late restenosis and appears to reproduce the original pathologic condition of the carotid bifurcation; as in the original lesions hemodynamic conditions probably play a major etiologic role in the formation of the restenoses. The most important clinical factor in restenosis is continued cigarette smoking. In the majority of the studies reviewed, more than half of the patients with recurrent disease presented with symptoms referable to the site of the original operation. An argument in favor of routine vein patching during the primary procedure to attempt to prevent restenosis is presented.

One of the presumed reasons for the lack of clinical activity of topical methotrexate in psoriasis is insufficient percutaneous penetration necessary to inhibit epidermal DNA synthesis. The present study was undertaken to select a vehicle to optimize penetration of methotrexate in vitro and to determine the effects of this topical formulation on epidermal DNA synthesis in vivo in hairless mouse skin. Increased penetration of methotrexate was obtained in human skin in vitro with Vehicle N compared to water and n-decylmethylsulfoxide vehicles. Repeated topical application of this methotrexate/Vehicle N preparation produced marked epidermal atrophy in treated sites in both normal and hyperproliferative essential fatty acid deficient hairless mouse skin without similar effects at a distant skin site. Local inhibition of epidermal DNA synthesis was also obtained without systemic effects at a distant site. These studies demonstrate that methotrexate in Vehicle N may produce a direct effect on epidermis which may be useful for the topical therapy of psoriasis.

A detailed examination of cell proliferation kinetics in normal human epidermis is presented. Using tritiated thymidine with autoradiographic techniques, proliferative and differentiated cell kinetics are defined and interrelated. The proliferative compartment of normal epidermis has a cell cycle duration (Tc) of 311 h derived from 3 components: the germinative labeling index (LI), the duration of DNA synthesis (ts), and the growth fraction (GF). The germinative LI is 2.7% +/- 1.2 and ts is 14 h, the latter obtained from a composite fraction of labeled mitoses curve obtained from 11 normal subjects. The GF obtained from the literature and from human skin xenografts to nude mice is estimated to be 60%. Normal-appearing epidermis from patients with psoriasis appears to have a higher proliferation rate. The mean LI is 4.2% +/- 0.9, approximately 50% greater than in normal epidermis. Absolute cell kinetic values for this tissue, however, cannot yet be calculated for lack of other information on ts and GF. A kinetic model for epidermal cell renewal in normal epidermis is described that interrelates the rate of birth/entry, transit, and/or loss of keratinocytes in the 3 epidermal compartments: proliferative, viable differentiated (stratum malpighii ), and stratum corneum. Expected kinetic homeostasis in the epidermis is confirmed by the very similar "turnover" rates in each of the compartments that are, respectively, 1246, 1417, and 1490 cells/day/mm2 surface area. The mean epidermal turnover time of the entire tissue is 39 days. The Tc of 311 h in normal cells in 8-fold longer than the psoriatic Tc of 36 h and is necessary for understanding the hyperproliferative pathophysiologic process in psoriasis.

Systemic hypertension following coronary artery bypass graft (CABG) procedures has been reported to occur in 15% to 80% of cases. Previous reports have implicated the renin-angiotensin system as being responsible, at least in part, for this phenomenon. In this prospective study, 18 previously normotensive subjects were studied before, during, and after CABG. In 4 patients (22%), paroxysmal postoperative hypertension developed (systolic blood pressure greater than 150 mm Hg). There were no differences between the normotensive and hypertensive groups in plasma renin activity, angiotensin II level, or aldosterone level. Despite the trend toward elevation of these variables during cardiopulmonary bypass (CPB), all had returned to control levels within two hours after CPB, whether or not hypertension developed. Serum norepinephrine levels were elevated (.10 greater than p greater than .05) in the hypertensive group at the time hypertension developed. No other relationship or pattern could be defined to distinguish the hypertensive from the normotensive group. The renin-angiotensin system does not appear to be responsible for paroxysmal hypertension following CABG.

Studies on the cell proliferation kinetics of psoriatic epidermal cells are presented and the results compared to similar studies for normal epidermis. The short 36-h duration of the psoriatic cell cycle (Tc) is confirmed with the first double-peaked fraction of labeled mitoses (FLM) curve in human subjects. The growth fraction of psoriasis using two experimental techniques approximates 100% within 36 h, confirming the rapid Tc found by the FLM method. The cell kinetic basis for the pathophysiology of psoriasis consists of at least 3 proliferative abnormalities in comparison to normal epidermis. By far the largest alteration is the shortening of the Tc from 311 to 36 h. There is also a doubling of the proliferative cell population in psoriasis from 27,000 to 52,000 cells/mm and an increase in the growth fraction from 60% to 100%. As a consequence of these abnormalities the psoriatic epidermis produces 35,000 cells/day from a proliferative compartment of 52,000 cells/mm2 surface area. This is a 28-fold greater production of cells than the 1,246 cells/day produced in normal epidermis. The biochemical or control factors leading to these kinetic differences continue to remain elusive.

The present studies have demonstrated that topical application of a low concentration of eicosa-5,8,11-trienoic acid (a 20:3,n9 fatty acid previously reported to inhibit competitively the activity of the sheep vesicular cyclooxygenase) to skin of normal fed hairless mice produced severe scaly dermatosis which is characterized by marked hyperplasia and acanthosis of the epidermal layer. The precise mechanism of this induction of scaly dermatosis is presently unclear. It is nonetheless interesting that the treatment of skin with similar concentrations of other unsaturated fatty acids produced no visible or histologic effects. Furthermore, endogenous levels of arachidonic acid in epidermal phospholipid and triglyceride fractions were shown to increase significantly (p < 0.01) in skin treated with the 20:3,n9 fatty acid while the endogenous level of PGE2 in the same tissue decreased markedly. This latter observation is consistent at least in part, with a previous report from this laboratory in which the 20:3,n9 fatty acid inhibited in vitro the activity of the sheep vesicular cyclooxygenase (the rate limiting enzyme in the transformation of arachidonic acid into the prostaglandin endoperoxides) although the increase in arachidonic acid may also reflect an increased incorporation of this fatty acid into the epidermal lipids by the hyperproliferative tissue. Evaluation of the proliferative status of 20:3,n9 fatty acid-treated skin showed a significant increase (p < 0.01) in labeling and mitotic indices. The use of this potentially endogenous fatty acid may be a useful tool for further investigations of hyperproliferative skin diseases where dietary deficiency of essential fatty acids does not exist.

Factors affecting the percutaneous penetration of methotrexate (MTX) and its analogues through excised human skin were studied. With application of 0.05% MTX solution to the epidermis, 0.07% of the applied dose was recovered in the epidermis and less than 0.005% penetrated completely through the skin. The percent of drug which penetrated remained constant from 0.05% to 2.0% MTX and was also unchanged by increasing incubation temperature from 28 degrees C to 37 degrees C. Cellophane tape stripping of stratum corneum following drug incubation removed essentially all the MTX that had been measured in whole epidermis. Binding of MTX was localized to the outermost layers of the stratum corneum. With removal of the stratum corneum prior to drug incubation, 25% of the applied MTX penetrated through the skin. Various vehicles were tested to determine their effect on MTX percutaneous absorption. Dimethylsulfoxide (80%), dimethylacetamide (25%), or retinoic acid (0.1%) had no effect on penetration. Maximum enhancement of penetration by 25-fold and 143-fold was obtained with retinoic acid (saturated solution in aqueous ethanol) and C-10-methylsulfoxide (2.5%), respectively. The penetration of lipid-soluble derivatives of MTX was also tested. The compound that penetrated best was the dimethyl ester of dichloro-MTX with a 3-fold increase in penetration over MTX.

A number of chemotherapeutic drugs have been subjected to intravaginal testing in mice to measure their local inhibitory activity on DNA, RNA, and protein synthesis in vaginal epithelium. The drugs have been tested at various concentrations and in different vehicles and evaluated by autoradiographic techniques. Systemic absorption of the drugs was monitored by simultaneous study of the gastrointestinal mucosa of the rectum. Methotrexate inhibited deoxyuridine incorporation into DNA in both vaginal and rectal epithelium. Several lipid-soluble analogues of methotrexate were found to have no effect on deoxyuridine incorporation. Nitrogen mustard and emetine have been shown to selectively inhibit DNA and protein synthesis, respectively, without systemic effects. This animal assay system may be useful for predicting the effectiveness of potential drugs for the topical treatment of psoriasis.

Topical methylglyoxal bis(guanylhydrazone) (MGBG) previously has been shown to produce partial clinical improvement in psoriasis. To enhance therapeutic activity, studies were undertaken to optimize MGBG percutaneous penetration in vitro and to study biochemical changes related to epidermal proliferation in vivo. MGBG penetration in saline, Vehicle N, decylmethylsulfoxide, and N-methylpyrrolidone was determined in normal human skin in vitro. Maximum penetration was obtained with 10% MGBG in Vehicle N (3 micrograms/h/cm2). Both topical and systemic MGBG resulted in increased levels of S-adenosyl-L-methionine decarboxylase, suggesting an extended half-life as a consequence of MGBG binding. Topical treatment with 10% MGBG in Vehicle N also resulted in decreased epidermal polyamine levels. The changes in polyamine metabolism were also associated with inhibition of epidermal DNA synthesis. These studies suggest that this topical MGBG formulation may be a candidate for use in the treatment of psoriasis and other hyperproliferative cutaneous diseases associated with increased polyamine synthesis.

The effect of prostaglandin E2 (PGE2) on DNA synthesis in human skin was evaluated. PGE2 (1 mug) was infected intradermally into normal buttock skin of 15 volunteers followed by tritiated thymidine for autoradiographic quantitation of DNA synthesizing cells. Controls of normal saline, histamine (50 mug), and lower doses of PGE2 were also injected into 8 of the volunteers. Forty-eight hours after injection of 1 mug and 0.1 mug PGE2 there was a 264% and 62% increase, respectively, in the number of DNA synthesizing epidermal cells/high-power field as compared to saline controls. These differences were statistically significant (p smaller than 0.01). Histamine (50 mug) produced a statistically significant 36% higher labeling index compared to its saline controls (p smaller than 0.05). Many types of skin injury, including ultraviolet light (UVL) irradiation, produce an increase in the number of DNA synthesizing cells about 48 hr after the stimulus. Our findings suggest that PGE, a putative mediator of UVL-induced inflammation, may be one of the chemical mediators for the UVL-induced increase in DNA synthesizing cells. Histamine may also contribute to the increase in DNA synthesizing cells following UVL-induced inflammation.

The successful treatment of psoriasis with folic acid antagonists during the past 25 years has led to extensive research in the areas of cytokinetics and chemotherapy. In this paper we shall review selected aspects of these topics relevant to the treatment of psoriasis. The effectiveness of methotrexate treatment of psoriasis can be related to both the hyperproliferative cytokinetics of psoriasis and an increased biochemical sensitivity of psoriatic epidermal cells to this drug. Future research goals in chemotherapy of psoriasis include (a) optimizing drug schedules for available drugs; (b) identifying other susceptible biochemical points of selective drug attack; (c) identifying secondary advantages in order to facilitate selective drug action in psoriasis, such as ultraviolet light therapy in combination with a systemic drug; and (d) developing topically effective chemotherapeutic agents. Approaches to research on topical therapy are reviewed with specific reference to animal testing models for psoriasis and percutaneous penetration of topically applied agents.

Alpha-terthienyl (alpha-T), a phototoxic thiophene compound isolated from marigolds (Tagetes species), affects cell membranes and does not appear to induce cytogenetic damage. This study was undertaken to investigate topical delivery of alpha-T and characterize its cutaneous phototoxicity in combination with long-wave UV radiation (UVA) in comparison with locally (intradermal) administered alpha-T. Percutaneous penetration (PC) of 0.1% and 1% alpha-T in a 3% Azone gel vehicle was studied in guinea pig skin in vitro and quantitated by UV fluorescence microscopy. Dose-dependent PC of epidermis, adnexae, and superficial dermis was demonstrated in vitro. Alpha-terthienyl (0.1% and 1%) in this vehicle was applied topically in vivo and irradiated with 30 J/cm2 UVA at intervals of 10 min-24 h. Maximum sensitization was achieved with irradiation 1 h following drug application. The clinical response was dose-dependent consisting of erythema, edema, crusting, erosion, and inhibition of hair growth and was observed 72 h to 7 days postirradiation. A comparable dose-dependent phototoxic response was observed when 5-500 micrograms alpha-T were injected intradermally and irradiated with UVA. These results indicated that low-dose topical alpha-T in a nonirritating vehicle can rapidly produce cutaneous photosensitization. Topical alpha-T/UVA may provide a selective and safer alternative approach for the photochemotherapy of psoriasis and other cutaneous diseases.

Tritiated thymidine incorporation, a measure of DNA synthesis, was studied in circulating leukocytes from patients with widespread psoriasis who were being treated with photochemotherapy using oral 8-methoxypsoralen (8-MOP) and high-intensity, long-wave ultraviolet light (UVA). Seven of 13 psoriasis patients treated with photochemotherapy demonstrated a significant (p less than 0.05) reduction in leukocyte incorporation of tritiated thymidine immediately after UVA in comparison to incorporation before UVA. None of 10 control subjects treated with UVA alone demonstrated such reduction in leukocyte tritiated thymidine incorporation. Photochemotherapy thus affects circulating blood cells in some patients with psoriasis in addition to its therapeutic effect on epidermal cells. Further investigations are needed to determine the reasons for the differences in susceptibility to inhibition of leukocyte DNA synthesis among patients and the possible long-term consequences of such inhibition.

Two double-blind studies comparing the effectiveness of the cyclic nucleotide-altering agent (4-[3-butoxy-4-methoxybenzyl]-2-imidazolidinone) (Ro 20-1724) vs vehicle have demonstrated that this compound can improve psoriatic lesions. Although Ro 20-1724 was not as effective as intensive occlusive treatment of psoriatic lesions with 0.025% triamcinolone acetonide, Ro 20-1724 had no adverse systemic or cutaneous effects. Ro 20-1724 and other cyclic nucleotide-altering agents may have therapeutic potential in the future treatment of psoriasis.

Photochemotherapy offers a unique approach for the selective therapy of skin diseases. Hematoporphyrin derivative (HPD) in combination with visible light exhibits cytocidal activity in vitro and systemically has demonstrated applicability to the treatment of experimental and human tumors. This study was undertaken to investigate the phototoxic effects in guinea pig skin of systemic HPD in comparison with locally (intradermal) and topically administered HPD. Maximum erythema was obtained by irradiation with red light or UVA 6 h postsystemic HPD (10 mg/kg). Erythema response was dependent upon the dose of irradiation. Systemic HPD produced complete inhibition of epidermal DNA, RNA, and protein synthesis 6-12 h postirradiation with red light, with a lesser degree of inhibition in the deeper hair roots. Local (intradermal) HPD (5-500 micrograms) in combination with red light or UVA produced a dose-dependent erythema and inhibition of epidermal DNA synthesis. Effective in vitro percutaneous penetration of HPD was demonstrated in vehicles containing Azone and N-methylpyrrolidone. Topical application of these HPD formulations in vivo in combination with red light or UVA produced significant erythema and inhibition of epidermal DNA synthesis. These results suggest that HPD can cause photosensitization of the skin. It may therefore be reasonable to explore topical applications as an alternative approach for the photochemotherapy of psoriasis and other cutaneous diseases.

The results of current investigation into cellular kinetics of both normal and abnormal human genital tissue have stimulated interest in programming chemotherapeutic drug regimens for the treatment of genital cancer. This report outlines the results of cell kinetic studies of normal and abnormal squamous epithelium of the female genital tract and presents preliminary results of a regimen utilizing methotrexate, hydroxyurea, and vincristine in patients with far-advanced squamous-cell cancer of the vulva, vagina, and cervix. A total of 92 patients have received 444 courses of programmed chemotherapy by either pelvic intra-arterial infusion or systemic administration of the drugs. Our results are presented and the theoretical basis of the research is discussed.

Topical methylglyoxal bis(guanylhydrazone) (MGBG) and alpha-difluoromethylornithine (DFMO) individually have been shown to produce partial clinical improvement in psoriasis. In an effort to further enhance therapeutic activity, studies were designed to optimize percutaneous penetraton of DFMO in vitro and to determine the effects of the combination of DFMO and MGBG on DNA synthesis and polyamine levels in hairless mouse skin. MGBG was shown to be more effective than DFMO in inhibiting DNA synthesis in vitro and in vivo. Maximum in vitro percutaneous penetration of DFMO (5%) was obtained in Vehicle N containing 10% Azone (297 micrograms/h/cm2). Topical administration of the combination of 5% DFMO and 0.1% MGBG in this vehicle produced a greater inhibition of DNA synthesis and depletion of polyamine levels than either drug individually. The simultaneous topical administration of DFMO and MGBG, allowing the use of lower concentrations of the more toxic MGBG, may be useful for therapy of psoriasis and other cutaneous disorders associated with abnormalities in polyamine metabolism.