874
`
`THE LANCET,APRIL 13, 1985
`
`
`
`
`+
`+
`+
`+
`
`+
`+
`+
`+
`
`FLUORESCENT ANTIBODY RESPONSE IN LASSA, MOBALA, AND IPPY
`STRAINS USING SPECIFIC ANTIBODIES
`
`Anubody
`Lassa
`Mobala
`Ippy
`Humananti-Lassa serum*
`+
`+
`+
`+
`++
`Immune ascitic antr-Ippyt
`Monoclonal antibodies$
`atpope
`54-
`2074-0007
`2129-0018
`
`+
`+
`+
`+
`
`*Convalescent serum from Lassa fever patient (provided by CDC), at working dilution
`1/32.
`.
`Mouse immuneascitic fluid against Ippy virus prepared in Bangui (no 272), at working
`dilution = 1/40.
`
`+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.
`. Se
`
`Dr Swanepoel (March 16, p 639) has reported that the prototype
`strain ofIppy virus, isolated in 1970, is a member ofthe Lassa fever
`lex.
`The “Ippy” strains studied by us and by Swanepoeletal
`complex. af €
`. PPy
`:
`y :
`y
`P
`.
`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 Ippyviruses byclassical
`tests but the use of monoclonal antibodies may nowbe revealing
`some differences in epitopes.
`Institut Pasteur de Bangu,
`BP923, Bangui, Central African Republic
`Centers for Disease Control,
`tanta, Georgia
`Institut
`P
`deB
`nsuitur Sasteur
`de
`Orstrom, Bangui
`
`D. Y. MEUNIER
`BM
`J.
`B. McCorMIck
`A, J. GEORGES
`M. C. GEORGES
`J. P. GONZALEZ
`
`Sangur
`
`1. Digoutte JP Annual report of Insutur Pasteur, Bangui, Central African Republic,
`1970: 59
`2. Kiley MP, TomonO, 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 arenavirusisolatedfrom wild
`caught rodents (Praomys sp) 1n the Central African Republic. Intervirology 1983; 19:
`105-12.
`4. Wulff H, Lange JV. Indirect 1mmunofluorescence for the diagnosis of T.assa fever
`infections. Bull WHO 1975; 82: 429~36.
`5. Johnson KM, Elliott LH, Heymann KL. Preparation of polyvalent viral
`tmmunofluorescent intercellular antigens and use in human serosurveys. 7 Cit
`Microbiol 1981; 5: 527-29.
`
`GLYCOSYLATED HAEMOGLOBIN IN
`IRON-DEFICITENCY ANAEMIA
`
`Sir,—A 1984 Lancer editorial! discusses interference with the
`measurement of glycosylated haemoglobin used to evaluate long-
`term control ofblood glucose,” and cites as an example Brooks and
`colleagues’ report of the increased glycosylation ofhaemoglobin, as
`measured by a cation-exchange microcolumn method, in association
`with iron-deficiency anaemia.? However,
`the ion exchange
`chromatography method yields peaks that are likely to be
`contaminated
`by
`non-glycosylated
`haemoglobin.t Affinity
`chromatographyis 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-deficienc anaemia. Four
`v
`P
`y
`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+1+7%). Only one iron-deficient patient had a value (8-8%)
`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°541°7%).
`reported with cation-exchange
`The high levels of HbA,
`chromatography may be dueto post-translational modifications of
`haemoglobin other than glycosylation in iron deficiency,
`the
`
`modificd haemoglobin co-eluting with HbA). Support for this
`suggestion is provided by a study’ in which raised HbAj,+4 levels
`but normal or reduced HbA), levels were reported in association
`with iron deficiency. Such a modification would not influence
`affinity gel procedures which depend on binding betweenthegel
`and glucose residues on globin chains only.
`We conclude that when affinity gel separation is used iron-
`deficiency
`anaemia
`does
`not
`produce
`high
`glycosylated
`aemoglobin values.
`h
`:
`8
`Department ofPathology,
`Kingston Hospital,
`Galsworthy Road,
`Kingston Upon Thames,
`Surrey KT27QB
`
`C. VAN HEYNINGEN
`R. G. DALTon
`
`-
`E
`1. Panonal:Glycosylation and disease. Lancer 198451i: 19-20.
`DM,Singer DE, Hurxthal K,ct al. The clinical information value ofthe
`2
`Narhan
`glycosylated hemoglobin assay. N Engl 7 Med 1984; 310: 341~46,
`3 Brooks AP, Metcalfe J, Day JL, Edwards M.
`Iron deficiency and glycosylated
`haemoglobin A, Lancet 1980; 11: 141.
`4. Garlick RL, Mazer JS, Higgins PJ, Bunn HF Characterization of glycosylated
`hacmoglobins. ¥ Cln Invest 1983; 71: 1062-72
`5. Fairbanks VF, Zimmerman BR. Measurementofglycosylated haemoglobinbyaffinity
`chromatography Mayo Cli Proc 1983; 58: 770-73.
`.
`6. Hall PM, Cook JGH, Gould BJ. An imexpensive,
`rapid and precise affinity
`chromatography method for the measurement of glycosylated haemoglobins. Ann
`Chin Biochem 1983; 20: 129-35.
`7. eeeeeapemanTHI- Studies on theheterogeneityofhaemoglobin. BrJHaemat
`_
`.
`
`REGRESSION OF METASTATIC VIPOMA WITH
`SOMATOSTATIN ANALOGUESMS201-995
`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 maybe curative, but inoperable or metastatic vipomasare
`difficult f° treat.
`Intravenous
`somatostatin SUPPTesses VIP
`secretion’ but its plasma half-life is only 1-1-3-0 min.“ SMS
`201-995 is a synthetic octapeptide with a longer half-life which can
`be given by subcutaneous injection; it also suppresses VIP levels
`’
`: 2
`:
`+
`+
`:
`We report a case of a metastatic vipoma treated with SMS 201-995
`50 pg once daily.
`year history of watery diarrhoea
`A 75-year-old woman with a 9
`a ‘ld h
`: an ith bi
`kal
`.
`y 1
`: y
`found
`associated wit
`ypokalaemia and mi
`yperglycaemia was foun
`to have raised plasma VIPlevels. The primary tumour was removed
`
`pmol / 1
`
`Oo
`
`pmold 1
`
`wdla
`
`100
`
`NEUROTENSIN
`
`oa
`
`i000
`
`*x
`:/
`*
`a
`Ff —,
`if
`aa* 4
`yoo YY
`4
`*
`
`
`aan
`1
`2
`3
`i
`5
`MONTHS
`Fig i—Neurotensin, VIP and PP levels before and during treatment
`with SMS 201-995.
`Normal ranges: VIP <30 pmol/l; PP <300 pmol/|; neurotensin <200 pmol !
`
`West-Ward Pharm.
`Exhibit 1062
`Page 001
`
`West-Ward Pharm.
`Exhibit 1062
`Page 001
`
`

`

`THE LANCET, APRIL 13, 1985
`
`875
`
`treatment for 9 months so far. However, the exact place of SMS
`201-995 remains to be definedin the lighi oflong-term follow-up of
`its effects and possible complications.
`We thank Dr R. Shentall of Sandoz for the supply of SMS 201-995. The
`peptide assays were done at the Royal Postgraduate Medical School, London,
`in Prof S. R. Bloom’s department.
`Department of Medicine,
`Queen Elizabeth Hospital,
`Birmingham Bi5 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 ofexogenous somatostatin
`in man. ¥ Clin Endocrinol Metab 1979; 48: 50-33.
`3 Biackburn AM, Bryant MG, Arian TE, Bloom SR. Pancreatic tumours produce
`neurotensin. J Clim 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 ¥ 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. Lancer 1984; 1i: 282-83
`6. Kraenzlin ME, Ch’ng JC, Wood SM,Bloom SR.Caninhibition ofhormonesecretion
`be associated with endocrine tumour shrinkage? Lancet 1983; 1: 1501
`“I
`. Kraenzlin ME, Ch’ng JLLC, Wood SM, Bloom SR. Remission of symptoms and
`shrinkage of metastasis with long term treatment with somatostatin analogue Gut
`1984; 25: A576
`8. Willams NS, Cooper JC, Axon ATR, King RFGJ, Barker M. Use of a long acting
`somatostatin analogue in controlling life threatening ileostomy diarrhoea. Br MedJ
`1984, 289; 1027-28.
`9. Maton PN, O’Doristo TM, McArthur KE,et al. Effect of long-acting somatostatin
`analogue (SMS 201-995) 1n a patient with pancreatic cholera. N Engi 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; u- 782-84.
`
`RENAL FUNCTIONIN DIABETICS
`
`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 byinsulin in March, 1983.
`By June, 1984, she was having watery diarrhoea upto 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 ug once daily produced a progressive
`improvement in hormonelevels (fig 1) accompanied by a weight
`gain of 5 kg, reduced stool frequency and volume, and correction of
`hypokalaemia. here have been no side-effects, apart from a
`reduced insulin requirement. Computerised axial tomography (CT)
`after 5 months oftreatmentrevealed a reduction in the number,size,
`and contrast enhancement ofthe liver secondaries (fig 2).
`
`
`
`Fig 2—CT scan appearances before (upper) and after (lower) SMS
`201-995 treatment.
`
`Sir,—Lancet correspondence about renal function in diabetics
`(Jan.5, p53; 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/l) ratio
`(RA/C) measured. A micro-ELISA technique! was used to measure
`urinary albumin andthe Jaffe method for urinary creatinine. In our
`laboratory the upper limits of normal are 7-5 ug/min for AER and
`1-9 for RA/C (mean +2SDafter log transformation in 114 non-
`diabetic controls). Infected urine specimens are excluded.
`As expected, the prevalence ofproteinuria was greater in group R
`than in group G (see table). Microalbuminuria was also commoner.
`Vipomas are often accompanied by increases in neurotensin-like
`This is consistent with the similar microangiopathic basis of
`immunoreactivity? and pancreatic polypeptide levels,* as in our
`retinopathy and nephropathy.
`patient. Her main problem was profound secretory diarrhoea, and,
`Our findings confirm that macroalbuminuria and=micro-
`
`though the specific peptide responsible for this diarrhoea is not
`albuminuria
`are more
`common in diabetics with serious
`known, VIP remains the most likely candidate.
`.
`retinopathy. Since, according to our figures, 40% of patients with
`There has been considerable interest in the use of SMS 201-995
`a treatable blinding condition will be missed, there is little case
`in the treatment of tumours and-diarrhoea, and some success has
`for using microalbuminuria to identify these diabetics with
`been reporred in the treatment ofvipomas,*!° including one case of
`retinopathy. Also,
`its use to predict future retinopathy remains
`regression of liver secondaries’ and a response without tumour
`regression.” Our patient has improved considerably on once-daily
`ALBUMINURIA IN TWO DIABETIC POPULATIONS
`treatment (given at the same timeas the insulin by the district nurse)
`with 50 pg of SMS 201-995, with improvement of symptoms, CT
`
`Group R Group G
`scan appearances, and VIP, PP, and neurotensin levels. The CT
`Albustix posittve
`18/115 (15- 7%)
`50/843 ( 5-9%)
`evidence supports a direct effect of SMS 201-995 on the tumour as
`Raised AER
`33/55 (60%)
`125/447 (28+ 0%)
`a mechanism for the clinical and biochemical improvement. This
`Raised RA/C
`212/551 (38-5%)
`44/68 (65%)
`patient’s tumour has been successfully controlled with once-daily
`
`
`
`
`
`West-Ward Pharm.
`Exhibit 1062
`Page 002
`
`West-Ward Pharm.
`Exhibit 1062
`Page 002
`
`