874
`
`FLUORESCENT ANTIBODY RESPONSE IN LASSA, MOBALA, AND IPPY
`STRAINS USING SPECIFIC ANTIBODIES
`
`*Convalescent serum from Lassa fever patient (provided by CDC), at working dilution
`1/32.
`t Mouse immune ascitic fluid against Ippy virus prepared in Bangui (no 272), at working
`dilution= 1/40.
`4:Lassa/Mozambique nucleocapsid specificity, 2093-0004 at working dilution 1/20;
`Lassa/Mozambique nucleocapsid specificity, 2054-0006 at working dilution 1/40; Lassa
`glycoprotein specificity, 2074-0007 at working dilution 1/20; Lassa/Mozambique
`nucleocapsid specificity, 2129-0018 at working dilution 1/20.
`
`Dr Swanepoel (March 16, p 639) has reported that the prototype
`strain of Ippy virus, isolated in 1970, is a member of the Lassa fever
`complex. The "Ippy" strains studied by us and by Swanepoel et al
`seem to differ in that our strain reacted with monoclonal antibody
`2093-0004 while Swaneopoel’s did not (2093-0004 is the same as
`5293-4). These two strains are identified as Ippy viruses by classical
`tests but the use of monoclonal antibodies may now be revealing
`some differences in epitopes.
`Institut Pasteur de Bangui,
`BP923, Bangui, Central African Republic
`Centers for Disease Control,
`Atlanta, Georgia
`
`D. Y. MEUNIER
`
`J. B. MCCORMICK
`
`Institut Pasteur de Bangui
`
`Orstrom; Bangui
`
`M. C. GEORGES
`
`J. P. GONZALEZ
`
`1. Digoutte JP Annual report of Institut Pasteur, Bangui, Central African Republic,
`1970: 59
`2. Kiley MP, Tomori O, Regnery AL, Johnson KM. Characterisation ofthe Arenaviruses
`Lassa and Mozambique. In: Bishop DHL, Compans RW, eds. The replication of
`negative strand viruses. Amsterdam: Elsevier North Holland, 1981: 1-9.
`3. Gonzalez JP, McCormick JB, Saluzzo JF, Georges AJ. An arenavirus isolated from wild
`caught rodents (Praomys sp) in the Central African Republic. Intervirology 1983; 19:
`105-12.
`4. Wulff H, Lange JV. Indirect immunofluorescence for the diagnosis of Lassa fever
`infections. Bull WHO 1975; 52: 429-36.
`5. Johnson KM, Elliott LH, Heymann KL. Preparation of polyvalent viral
`immunofluorescent intercellular antigens and use in human serosurveys. J Clin
`Microbiol 1981; 5: 527-29.
`
`GLYCOSYLATED HAEMOGLOBIN IN
`IRON-DEFICIENCY ANAEMIA
`SIR,-A 1984 Lancet editorial discusses interference with the
`measurement of glycosylated haemoglobin used to evaluate long-
`term control of blood glucose, and cites as an example Brooks and
`colleagues’ report of the increased glycosylation of haemoglobin, as
`measured by a cation-exchange microcolumn method, in association
`with iron-deficiency anaemia.3 However, the ion exchange
`chromatography method yields peaks that are likely to be
`contaminated by non-glycosylated haemoglobin.4 4
`Affinity
`chromatography is thought to be more specific, and this is the
`method we have used in our attempt to confirm Brooks’ findings.
`We selected fourteen patients with iron-deficiency anaemia. Four
`patients were male and ten female, ages ranged from 27 to 89 years
`(mean 54 y), and all were non-diabetic. The mean glycosylated Hb
`(6-9±0-9% SD) was not significantly different from normal
`(7 0--:t I - ° 7070). Only one iron-deficient patient had a value (8 - ° 8°70)
`just above the normal range of 5 - 3-8 - 6%. All patients responded to
`oral iron with significant increases in haematological indices but
`their mean glycosylated haemoglobin values did not change
`(6 - 5-t I - 7%).
`The high levels of HbAI reported with cation-exchange
`chromatography may be due to post-translational modifications of
`haemoglobin other than glycosylation in iron deficiency, the
`
`modified haemoglobin co-eluting with HbAI. Support for this
`suggestion is provided by a study in which raised HbAla+b levels
`but normal or reduced HbA1c levels were reported in association
`with iron deficiency. Such a modification would not influence
`affinity gel procedures which depend on binding between the gel
`and glucose residues on globin chains only.
`We conclude that when affinity gel separation is used iron-
`deficiency anaemia does not produce high glycosylated
`haemoglobin values.
`Department of Pathology,
`Kingston Hospital,
`Galsworthy Road,
`Kingston Upon Thames,
`Surrey KT2 7QB
`
`C. VAN HEYNINGEN
`R. G. DALTON
`
`1. Editorial. Glycosylation and disease. Lancet 1984; ii: 19-20.
`2 Nathan DM, Singer DE, Hurxthal K, et al. The clinical information value of the
`glycosylated hemoglobin assay. N Engl J Med 1984; 310: 341-46.
`3 Brooks AP, Metcalfe J, Day JL, Edwards M. Iron deficiency and glycosylated
`haemoglobin A, Lancet 1980; ii: 141.
`4. Garlick RL, Mazer JS, Higgins PJ, Bunn HF Characterization of glycosylated
`haemoglobins. J Clin Invest 1983; 71: 1062-72
`5. Fairbanks VF, Zimmerman BR. Measurement of glycosylated haemoglobin by affinity
`chromatography Mayo Clin Proc 1983; 58: 770-73.
`6. Hall PM, Cook JGH, Gould BJ. An inexpensive, rapid and precise affinity
`chromatography method for the measurement of glycosylated haemoglobins. Ann
`Clin Biochem 1983; 20: 129-35.
`7. Horton BF, Huisman THJ. Studies on the heterogeneity of haemoglobin. Br J Haemat
`1965; 11: 296-304.
`
`REGRESSION OF METASTATIC VIPOMA WITH
`SOMATOSTATIN ANALOGUE SMS 201-995
`
`SIR,-Vasoactive intestinal polypeptide (VIP) has been implicated
`as the cause of the severe watery diarrhoea of Verner-Morrison
`syndrome and raised blood levels are found in patients with
`bronchogenic carcinoma, phaeochromocytoma, ganglioneuro-
`blastoma, and pancreatic tumours. Early diagnosis and resection of
`a vipoma may be curative, but inoperable or metastatic vipomas are
`difficult to treat. Intravenous somatostatin suppresses VIP
`secretion but its plasma half-life is only 1-1-3-0 0 min.2 SMS
`201-995 is a synthetic octapeptide with a longer half-life which can
`be given by subcutaneous injection; it also suppresses VIP levels.
`We report a case of a metastatic vipoma treated with SMS 201-995
`50 g once daily.
`A 75-year-old woman with a 9 year history of watery diarrhoea
`associated with hypokalaemia and mild hyperglycaemia was found
`to have raised plasma VIP levels. The primary tumour was removed
`
`,""un’n;) o
`
`Fig 1-Neurotensin, VIP and PP levels before and during treatment
`with SMS 201-995.
`Normal ranges: VIP <30 pmol/l; PP <300
`
`pmol/l; neurotensin <200 pmol I
`
`Par Pharm., Inc.
`Exhibit 1062
`Page 001
`
`

`
`by partial pancreatectomy in October, 1977, but liver secondaries
`could not be resected. In 1981 she was started on tolbutamide for
`diabetes, this treatment being replaced by insulin in March, 1983.
`By June, 1984, she was having watery diarrhoea up to fifteen
`times a day passing 1 - 5-2 litres, had lost weight, and was
`hypokalaemic despite potassium supplementation. Her plasma
`VIP, pancreatic polypeptide (PP), and neurotensin concentration
`were raised; gastrin and glucagon levels were normal.
`SMS 201-995 50 g once daily produced a progressive
`improvement in hormone levels (fig 1) accompanied by a weight
`gain of 5 kg, reduced stool frequency and volume, and correction of
`hypokalaemia. There have been no side-effects, apart from a
`reduced insulin requirement. Computerised axial tomography (CT)
`after 5 months of treatment revealed a reduction in the number, size,
`and contrast enhancement of the liver secondaries (fig 2).
`
`Fig 2-CT scan appearances before (upper) and after (lower) SMS
`201-995 treatment.
`
`Vipomas are often accompanied by increases in neurotensin-like
`immunoreactivity and pancreatic polypeptide levels, as in our
`patient. Her main problem was profound secretory diarrhoea, and,
`though the specific peptide responsible for this diarrhoea is not
`known, VIP remains the most likely candidate.
`There has been considerable interest in the use ofSMS 201-995
`in the treatment of tumours and- diarrhoea, and some success has
`been reported in the treatment ofvipomas, 5-10 including one case of
`regression of liver secondaries and a response without tumour
`regression.9 Our patient has improved considerably on once-daily
`treatment (given at the same time as the insulin by the district nurse)
`with 50 g of SMS 201-995, with improvement of symptoms, CT
`scan appearances, and VIP, PP, and neurotensin levels. The CT
`evidence supports a direct effect of SMS 201-995 on the tumour as
`a mechanism for the clinical and biochemical improvement. This
`patient’s tumour has been successfully controlled with once-daily
`
`875
`
`treatment for 9 months so far. However, the exact place of SMS
`201-995 remains to be defined in the lighl of long-term follow-up of
`its effects and possible complications.
`We thank Dr R. Shentall of Sandoz for the supply of SMS 201-995. The
`pepttde assays were done at the Royal Postgraduate Medical School, London,
`in Prof S. R. Bloom’s department.
`Department of Medicine,
`Queen Elizabeth Hospital,
`Birmingham B15 2TH
`
`D. CLEMENTS
`E. ELIAS
`
`1 Ruskone A, Rene E, Chayvialle JA, et al. Effect of somatostatin on diarrhoea and on
`small intestinal water and electrolyte transport in a patient with pancreatic cholera.
`Dig Dis Sci 1982, 27: 459-66
`2. Sheppard M, Shapiro B, Pimstone B, Kronheim S, Berelowitz M, Gregory M.
`Metabolic clearance and plasma half-disappearance time of exogenous somatostatin
`in man. J Clin Endocrinol Metab 1979; 48: 50-33.
`3 Blackburn AM, Bryant MG, Arian TE, Bloom SR. Pancreatic tumours produce
`neurotensin. J Clin Endocrinol Metab 1981; 51: 820-22.
`4 Long RG, Bryant MG, Mitchell SJ, et al. Clinicopathological study of pancreatic and
`ganglioneuroblastoma tumours secreting vasoactive intestinal polypeptide
`(vipomas). Br Med J 1982; 282: 1767-71.
`5. Von Werder K, Losa M, Muller OA, et al. Treatment of metastasing GRF-producing
`tumour with long-acting somatostatin analogue. Lancet 1984; ii: 282-83
`6. Kraenzlin ME, Ch’ng JC, Wood SM, Bloom SR. Can inhibition of hormone secretion
`be associated with endocrine tumour shrinkage? Lancet 1983; ii: 1501
`7. Kraenzlin ME, Ch’ng JLC, Wood SM, Bloom SR. Remission of symptoms and
`shrinkage of metastasis with long term treatment with somatostatin analogue Gut
`1984; 25: A576
`8. Williams NS, Cooper JC, Axon ATR, King RFGJ, Barker M. Use of a long acting
`somatostatin analogue in controlling life threatening ileostomy diarrhoea. Br Med J
`1984, 289: 1027-28.
`9. Maton PN, O’Dorisio TM, McArthur KE, et al. Effect of long-acting somatostatin
`analogue (SMS 201-995) in a patient with pancreatic cholera. N Engl J Med 1984;
`312: 17-21
`10. Plewe G, Beyer J, Krause U, Neufield M, Del Pozo E. Long-acting and selective
`suppression of growth hormone by somatostatin analogue SMS 201-995 in
`acromegaly. Lancet 1984; ii: 782-84.
`
`RENAL FUNCTION IN DIABETICS
`
`SIR,-Lancet correspondence about renal function in diabetics
`(Jan,5, p 53; Feb 23, p 466) prompted us to review our research. We
`have investigated the prevalence of diabetic nephropathy in a
`general diabetic population (G; n=843) and amongst diabetics
`attending a special eye clinic (R; n = 115). Group G was drawn from
`a well-defined epidemiological population and group R consists of
`patients with serious diabetic retinopathy (maculopathy or
`preproliferative or proliferative changes, confirmed by an
`ophthalmologist). Both groups contained non-insulin-dependent
`and insulin-dependent diabetics.
`Urine samples were tested for proteinuria (’Albustix’) and
`patients were asked to submit a timed overnight urine collection to
`measure albumin excretion rate (AER). However, as the response
`rate for these samples was poor, a sample from a midstream urine
`specimen passed at the clinic was taken and the random urinary
`albumin/creatinine (albumin in mg/l, creatinine in mmol/1) ratio
`(RA/C) measured. A micro-ELISA technique I was used to measure
`urinary albumin and the Jaffe method for urinary creatinine. In our
`laboratory the upper limits of normal are 7’ 5 pg/min for AER and
`1-9 9 for RA/C (mean + 2SD after log transformation in 114 non-
`diabetic controls). Infected urine specimens are excluded.
`As expected, the prevalence of proteinuria was greater in group R
`than in group G (see table). Microalbuminuria was also commoner.
`This is consistent with the similar microangiopathic basis of
`retinopathy and nephropathy.
`Our findings confirm that macroalbuminuria and micro-
`albuminuria are more common in diabetics with serious
`retinopathy. Since, according to our figures, 40% of patients with
`a treatable blinding condition will be missed, there is little case
`for using microalbuminuria to identify these diabetics with
`retinopathy. Also, its use to predict future retinopathy remains
`
`ALBUMINURIA IN TWO DIABETIC POPULATIONS
`
`Par Pharm., Inc.
`Exhibit 1062
`Page 002