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MORPHOLOGY OF RED BLOOD CELLS IN ALCOHOLICS
913
Serum cholesterol (mmol/1) concentrations in to duration of aminoglutethimide therapy.
patients, according
values and for those whose treatment duration was more than 5 weeks (p<0-001 for 5-7 weeks, p<0-01 1 after 7 weeks). However, the Mann Whitney U test showed that there was no further increase in cholesterol levels after 10 weeks. The mean percentage increase was 14% between 5 and 7 weeks and then remained constant at 25-30% when treatment duration was more than 8 weeks. Although the results were highly significant, variations between patients were great: after 8 weeks the percentage cholesterol level increase was 28-t22% but in one patient a 76% increase was observed. The increase was of the same order of magnitude for patients receiving 500 mg as for those on 1 g
daily. In all seven patients whose post-treatment cholesterol was measured the serum cholesterol returned to normal a few weeks after aminoglutethimide therapy was stopped. An increase in cholesterol levels in a majority of patients on aminoglutethimide (and hydrocortisone) would not be a major problem in disseminated disease. However, in the setting of
adjuvant therapy hypercholesterolaemia might predispose to atherosclerosis in women whose life expectancy is good. Lipid metabolism in patients on aminoglutethimide should be studied further before this treatment is proposed for adjuvant hormone therapy. J. BONNETERRE Centre Oscar Lambret, Centre Anticancéreux de la 59020 Lille, France
M. NGUYEN Région Nord,
B. HECQUET P. CAPPELAERE
—
MORPHOLOGY OF RED BLOOD CELLS IN ALCOHOLICS
give objective pointers to the level of people suspected of abusing alcohol-namely,
SIR,-Indices intended alcohol intake in
Scanning EM of RBCs from alcoholic patient. K knizocyte; T triangulocyte; S stomatocyte. Lower part shows normal cell, from control (N).
to
serum y-glutamyl-transpeptidase and aspartate transaminase activities and red cell mean corpuscular volume (MCV)-have proved to be insensitive and unreliable. Although the rise in MCV, which is not related to folate deficiency and has been attributed to a direct effect of alcohol on bone marrow erythroblasts,2is not very useful in discriminating non-drinkers from those who abuse alcohol it has never been properly explained. We have been concentrating on the morphology of the red blood cell (RBC) to try and find out what causes the macrocytosis. Scanning electron microscopy (EM) has produced interesting results. We have studied 31 individuals: 16 alcoholics, 3 patients with non-alcoholic liver disease, and 12 controls. Scanning EM was done in the department of physiology, University of Birmingham
=
=
Medical School, with a Jeol 100 CX microscope at 20 kV. Freshly drawn blood was collected in tubes containing KrEDT A. RBCs were separated by centrifugation and were washed three times in sodium chloride solution (155 mmol/1). Washed cells (100 1) were fixed in 2 5% v/v glutaraldehyde solution in Millonig’s buffer3at pH 7 -3for 30 min and then washed twice with distilled water. The cells were diluted 1 in 500 with distilled water and a small volume (5-10 1) was applied to copper grids. The specimens were allowed to dry overnight and were then coated with 15-18 nm platinum in a ’Polaron 5400’ sputtering system coater. The scanned fields were chosen at random. From the alcoholics blood was taken on the morning after admission to the drug addiction unit, All Saints Hospital, Birmingham, where they had been admitted because of their excessive consumptionofalcohol. The 3 patients with non-alcoholic liver disease were not consuming alcohol and were under the care of Dr Elwyn Elias at the Queen Elizabeth Medical Centre. The 12 controls were members of
1 Morgan MY.
Markers for detecting alcoholism and monitoring for continued abuse. Pharmacol Biochem Behav 1980; 13 (suppl 1): 1-8. 2. Wu A, Chanarin I, Levi AJ. Macrocytosis of chronic alcoholism. Lancet 1974; i 829-30.
3 Tanaka Y, Goodman JR Methods In Tanaka Y, Goodman JR, eds Electron scopy of human blood cells New York. Harper and Row, 1972 1-16
micro-
914 AGE, HISTORY OF DRINKING, AND BIOCHEMICAL AND HAEMATOLOGICAL TESTS IN ALCOHOLIC PATIENTS, PATIENTS WITH LIVER DISEASES, AND HEALTHY CONTROLS
Percent increase in *In 1 control only. tlncludes stomatocytes
and
knizocytes. AspT=aspartate transaminase; yGT= =
y-glutamy-transpeptidase.
laboratory staff, all of whom were social drinkers consuming less than 40 g of alcohol per day. All the alcoholic patients had distinctly abnormal RBC morphology (see figure). A high proportion of RBCs from alcoholics showed morphological abnormalities while those from the controls were virtually all normal in shape. The most consistent abnormal finding was the presence of stomatocytes and cells with two (knizocytes)4 or three (triangulocytes)5 large indentations. The findings are summarised in the table. The presence of stomatocytes in the RBCs of patients with nonalcoholic liver disease is well known. Triangulocytes have also been described by Wisloff and Boman,6 who associated such cells with terminal alcoholic liver disease, but none of our alcoholics were in this category. We have evidence from in-vitro work with alcohol and normal RBCs that the changes in morphology are directly due to alcohol. These abnormal cells seem to have the usual RBC lifespan. Scanning EM of RBCs is unlikely to become a routine test for alcohol abuse, but our finding could help in research. We thank Dr M. P. Osborne and Mrs Lesley Tomkins, department of physiology, University of Birmingham, for the scanning EM work; Dr A. Kahn for kindly allowing us to study his patients; Dr M. Pearson for clinical assistance; and Prof J. Stuart for advice. F. H. is supported by the World Health Organisation.
Department of Clinical Chemistry, Wolfson Research Laboratories,
University of Birmingham, Birmingham B15 2TH
FADIA R. HOMAIDAN LARRY J. KRICKA THOMAS P. WHITEHEAD
POOR BRONCHODILATOR EFFECT OF ORAL ETAMIPHYLUNE IN ASTHMATIC CHILDREN
SIR,-Etamiphylline camsylate (’Solufilina’ in Spain, ’Millophylline’ in UK) is a N-7 theophylline derivative. "Martindale"notes that it is used similarly to aminophylline and that the suggested oral dose for children is 2 -5mg/kg up to 200 mg. Preparations for intravenous, rectal, and oral use are available in the UK, and the drug is also marketed in Spain, where it has gained wide acceptance for the treatment of bronchial asthma, and in France. Etamiphylline does not dissociate to theophylline; serum theophylline levels are consistently zero after intravenous administration. Despite its use for many years no adequate information is available about the pharmacokinetics of etamiphylline in man and its real bronchodilator power. .:1 Bessis AA P",uTh"’^I"UT.....e>ø",;e>oc> T.... 11""......;... JB)( 4. M. Erythrocytic series. In: Bessis
n1......-I......_smears M, o,7le.."....f.,aat...n_va.-_w ed(translated by Brecher G). Blood reinterpreted. Berlin: Springer International, 1977: 25-104. 5. Gaines KC, Salhany JM, Tuma DJ, Sorrell MF. Reaction of acetaldehyde with human erythrocyte proteins. FEBS Lett 1977; 75: 115-19. 6. Wislöff F, Boman D. Acquired stomatocytosis in alcoholic liver disease. Scand J Haematol 1979; 23: 43-50. 1. Reynolds JEF, ed. Martindale: The extra pharmacopoeia, 28th ed. London: The
Pharmaceutical Press, 1982. 347.
FEVI after drug administration.
Left: after oral etamiphylline, theophylline, nebulised salbutamol. Bars represent ±SEM.
or
placebo. Right:
after
the bronchodilator effect of oral in a double-blind study in twenty-seven randomised, etamiphylline asthmatic children aged 9 - 7-t I - 8 (SD) years, who were free of acute symptoms but had forced expiratory flow (FEF2s-7s) values below 70% of predicted. The patients received a single oral dose of one of three solutions containing etamiphylline (6-96 mg/kg, range 180-322 mg), theophylline (6-96 mg/kg, range 160-380 mg), or placebo. Forced vital capacity and peak flow were measured basally and 30, 60, 120, and 240 min later. 4 h after the drug administration the patients received a 4 mg dose of nebulised salbutamol through a Monagham nebuliser and face mask, to rule out any difference in individual bronchodilator responsiveness that might account for any difference in drug effect. Data were analysed by NewmanKeules analysis of variance and Mann-Whitney U test. There were no differences in basal pulmonary function between the three groups of patients. The successive mean percent increases of FEV, were 9 -4%, 10 - 9%, 7 -2%, and 605% for etamiphylline; 20-7%, 28-6%, 3409%, and 29-4% for theophylline; and 3 . 2070, 5.9%, 5-4%, and 8-5% for placebo (figure). Values after etamiphylline and theophylline administration were significantly different at 60 min (p<0-05), 120 min (p<0.01), and 240 min No existed after differences between values (p<0.01). etamiphylline and after placebo administrations. Changes in PEFR and FEF25-75 were identical to those observed in FEV1.15 min after salbutamol the value of FEV increased more in the group of children who had received etamiphylline or placebo than in the group given theophylline (p<0.01), probably because in this last had the obstruction been group partly reversed before the airway use of salbutamol. Our data suggest that the bronchodilator effect of oral etamiphylline is weaker than that of theophylline. Since serum levels of etamiphylline were not measured it is possible that poor bioavailability of the drug can partly account for the findings. Poor bioavailability, short half-life, and weak power have been noted for other theophylline derivatives.2-4 In our opinion, theophylline remains the only xanthine clinically useful for the oral treatment of bronchial asthma. We
have
investigated
Department of Paediatrics, Division of Paediatric Neurology, Hospital Infantil dela Seguridad Social, Cruces, Bilboa, Spain
2. Zuidema
1978;
J, Merkus FWHM. Is acephylline
CARLOS VAZQUEZ TERESA LABAYRU JUAN RODRIGUEZ-SORIANO
a
theophylline
bronchodilator? Lancet
i: 1318-19.
3. Simmons
FER, Simons KS, Bierman CW. The pharmacokinetics of dihydroxypropyltheophylline: a basis for rational therapy. J Allergy Clin Immunol 1975; 56: 347-55.
4.
Weinberger M, Hendeles L. General management of allergic disease: pharmacologic management. In: Bierman CW, Pearlman DS, eds. Allergic diseases of infancy, childhood and adolescence. Philadelphia: Saunders, 1980: 322.
Serum cholesterol (mmol/1) concentrations in to duration of aminoglutethimide therapy.
patients, according
values and for those whose treatment duration was more than 5 weeks (p<0-001 for 5-7 weeks, p<0-01 1 after 7 weeks). However, the Mann Whitney U test showed that there was no further increase in cholesterol levels after 10 weeks. The mean percentage increase was 14% between 5 and 7 weeks and then remained constant at 25-30% when treatment duration was more than 8 weeks. Although the results were highly significant, variations between patients were great: after 8 weeks the percentage cholesterol level increase was 28-t22% but in one patient a 76% increase was observed. The increase was of the same order of magnitude for patients receiving 500 mg as for those on 1 g
daily. In all seven patients whose post-treatment cholesterol was measured the serum cholesterol returned to normal a few weeks after aminoglutethimide therapy was stopped. An increase in cholesterol levels in a majority of patients on aminoglutethimide (and hydrocortisone) would not be a major problem in disseminated disease. However, in the setting of
adjuvant therapy hypercholesterolaemia might predispose to atherosclerosis in women whose life expectancy is good. Lipid metabolism in patients on aminoglutethimide should be studied further before this treatment is proposed for adjuvant hormone therapy. J. BONNETERRE Centre Oscar Lambret, Centre Anticancéreux de la 59020 Lille, France
M. NGUYEN Région Nord,
B. HECQUET P. CAPPELAERE
—
MORPHOLOGY OF RED BLOOD CELLS IN ALCOHOLICS
give objective pointers to the level of people suspected of abusing alcohol-namely,
SIR,-Indices intended alcohol intake in
Scanning EM of RBCs from alcoholic patient. K knizocyte; T triangulocyte; S stomatocyte. Lower part shows normal cell, from control (N).
to
serum y-glutamyl-transpeptidase and aspartate transaminase activities and red cell mean corpuscular volume (MCV)-have proved to be insensitive and unreliable. Although the rise in MCV, which is not related to folate deficiency and has been attributed to a direct effect of alcohol on bone marrow erythroblasts,2is not very useful in discriminating non-drinkers from those who abuse alcohol it has never been properly explained. We have been concentrating on the morphology of the red blood cell (RBC) to try and find out what causes the macrocytosis. Scanning electron microscopy (EM) has produced interesting results. We have studied 31 individuals: 16 alcoholics, 3 patients with non-alcoholic liver disease, and 12 controls. Scanning EM was done in the department of physiology, University of Birmingham
=
=
Medical School, with a Jeol 100 CX microscope at 20 kV. Freshly drawn blood was collected in tubes containing KrEDT A. RBCs were separated by centrifugation and were washed three times in sodium chloride solution (155 mmol/1). Washed cells (100 1) were fixed in 2 5% v/v glutaraldehyde solution in Millonig’s buffer3at pH 7 -3for 30 min and then washed twice with distilled water. The cells were diluted 1 in 500 with distilled water and a small volume (5-10 1) was applied to copper grids. The specimens were allowed to dry overnight and were then coated with 15-18 nm platinum in a ’Polaron 5400’ sputtering system coater. The scanned fields were chosen at random. From the alcoholics blood was taken on the morning after admission to the drug addiction unit, All Saints Hospital, Birmingham, where they had been admitted because of their excessive consumptionofalcohol. The 3 patients with non-alcoholic liver disease were not consuming alcohol and were under the care of Dr Elwyn Elias at the Queen Elizabeth Medical Centre. The 12 controls were members of
1 Morgan MY.
Markers for detecting alcoholism and monitoring for continued abuse. Pharmacol Biochem Behav 1980; 13 (suppl 1): 1-8. 2. Wu A, Chanarin I, Levi AJ. Macrocytosis of chronic alcoholism. Lancet 1974; i 829-30.
3 Tanaka Y, Goodman JR Methods In Tanaka Y, Goodman JR, eds Electron scopy of human blood cells New York. Harper and Row, 1972 1-16
micro-
914 AGE, HISTORY OF DRINKING, AND BIOCHEMICAL AND HAEMATOLOGICAL TESTS IN ALCOHOLIC PATIENTS, PATIENTS WITH LIVER DISEASES, AND HEALTHY CONTROLS
Percent increase in *In 1 control only. tlncludes stomatocytes
and
knizocytes. AspT=aspartate transaminase; yGT= =
y-glutamy-transpeptidase.
laboratory staff, all of whom were social drinkers consuming less than 40 g of alcohol per day. All the alcoholic patients had distinctly abnormal RBC morphology (see figure). A high proportion of RBCs from alcoholics showed morphological abnormalities while those from the controls were virtually all normal in shape. The most consistent abnormal finding was the presence of stomatocytes and cells with two (knizocytes)4 or three (triangulocytes)5 large indentations. The findings are summarised in the table. The presence of stomatocytes in the RBCs of patients with nonalcoholic liver disease is well known. Triangulocytes have also been described by Wisloff and Boman,6 who associated such cells with terminal alcoholic liver disease, but none of our alcoholics were in this category. We have evidence from in-vitro work with alcohol and normal RBCs that the changes in morphology are directly due to alcohol. These abnormal cells seem to have the usual RBC lifespan. Scanning EM of RBCs is unlikely to become a routine test for alcohol abuse, but our finding could help in research. We thank Dr M. P. Osborne and Mrs Lesley Tomkins, department of physiology, University of Birmingham, for the scanning EM work; Dr A. Kahn for kindly allowing us to study his patients; Dr M. Pearson for clinical assistance; and Prof J. Stuart for advice. F. H. is supported by the World Health Organisation.
Department of Clinical Chemistry, Wolfson Research Laboratories,
University of Birmingham, Birmingham B15 2TH
FADIA R. HOMAIDAN LARRY J. KRICKA THOMAS P. WHITEHEAD
POOR BRONCHODILATOR EFFECT OF ORAL ETAMIPHYLUNE IN ASTHMATIC CHILDREN
SIR,-Etamiphylline camsylate (’Solufilina’ in Spain, ’Millophylline’ in UK) is a N-7 theophylline derivative. "Martindale"notes that it is used similarly to aminophylline and that the suggested oral dose for children is 2 -5mg/kg up to 200 mg. Preparations for intravenous, rectal, and oral use are available in the UK, and the drug is also marketed in Spain, where it has gained wide acceptance for the treatment of bronchial asthma, and in France. Etamiphylline does not dissociate to theophylline; serum theophylline levels are consistently zero after intravenous administration. Despite its use for many years no adequate information is available about the pharmacokinetics of etamiphylline in man and its real bronchodilator power. .:1 Bessis AA P",uTh"’^I"UT.....e>ø",;e>oc> T.... 11""......;... JB)( 4. M. Erythrocytic series. In: Bessis
n1......-I......_smears M, o,7le.."....f.,aat...n_va.-_w ed(translated by Brecher G). Blood reinterpreted. Berlin: Springer International, 1977: 25-104. 5. Gaines KC, Salhany JM, Tuma DJ, Sorrell MF. Reaction of acetaldehyde with human erythrocyte proteins. FEBS Lett 1977; 75: 115-19. 6. Wislöff F, Boman D. Acquired stomatocytosis in alcoholic liver disease. Scand J Haematol 1979; 23: 43-50. 1. Reynolds JEF, ed. Martindale: The extra pharmacopoeia, 28th ed. London: The
Pharmaceutical Press, 1982. 347.
FEVI after drug administration.
Left: after oral etamiphylline, theophylline, nebulised salbutamol. Bars represent ±SEM.
or
placebo. Right:
after
the bronchodilator effect of oral in a double-blind study in twenty-seven randomised, etamiphylline asthmatic children aged 9 - 7-t I - 8 (SD) years, who were free of acute symptoms but had forced expiratory flow (FEF2s-7s) values below 70% of predicted. The patients received a single oral dose of one of three solutions containing etamiphylline (6-96 mg/kg, range 180-322 mg), theophylline (6-96 mg/kg, range 160-380 mg), or placebo. Forced vital capacity and peak flow were measured basally and 30, 60, 120, and 240 min later. 4 h after the drug administration the patients received a 4 mg dose of nebulised salbutamol through a Monagham nebuliser and face mask, to rule out any difference in individual bronchodilator responsiveness that might account for any difference in drug effect. Data were analysed by NewmanKeules analysis of variance and Mann-Whitney U test. There were no differences in basal pulmonary function between the three groups of patients. The successive mean percent increases of FEV, were 9 -4%, 10 - 9%, 7 -2%, and 605% for etamiphylline; 20-7%, 28-6%, 3409%, and 29-4% for theophylline; and 3 . 2070, 5.9%, 5-4%, and 8-5% for placebo (figure). Values after etamiphylline and theophylline administration were significantly different at 60 min (p<0-05), 120 min (p<0.01), and 240 min No existed after differences between values (p<0.01). etamiphylline and after placebo administrations. Changes in PEFR and FEF25-75 were identical to those observed in FEV1.15 min after salbutamol the value of FEV increased more in the group of children who had received etamiphylline or placebo than in the group given theophylline (p<0.01), probably because in this last had the obstruction been group partly reversed before the airway use of salbutamol. Our data suggest that the bronchodilator effect of oral etamiphylline is weaker than that of theophylline. Since serum levels of etamiphylline were not measured it is possible that poor bioavailability of the drug can partly account for the findings. Poor bioavailability, short half-life, and weak power have been noted for other theophylline derivatives.2-4 In our opinion, theophylline remains the only xanthine clinically useful for the oral treatment of bronchial asthma. We
have
investigated
Department of Paediatrics, Division of Paediatric Neurology, Hospital Infantil dela Seguridad Social, Cruces, Bilboa, Spain
2. Zuidema
1978;
J, Merkus FWHM. Is acephylline
CARLOS VAZQUEZ TERESA LABAYRU JUAN RODRIGUEZ-SORIANO
a
theophylline
bronchodilator? Lancet
i: 1318-19.
3. Simmons
FER, Simons KS, Bierman CW. The pharmacokinetics of dihydroxypropyltheophylline: a basis for rational therapy. J Allergy Clin Immunol 1975; 56: 347-55.
4.
Weinberger M, Hendeles L. General management of allergic disease: pharmacologic management. In: Bierman CW, Pearlman DS, eds. Allergic diseases of infancy, childhood and adolescence. Philadelphia: Saunders, 1980: 322.