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Oral bioavailability of sulphadiazine and trimethoprim in fed and fasted pigs.

The disposition of sulphadiazine (SDZ) and trimethoprim (TMP) was measured after intravenous and oral administration. Six healthy pigs weighing 17 to 34 kg received 20 mg kg-1 SDZ plus 4 mg kg-1 TMP intravenously, and 40 mg kg-1 SDZ plus 8 mg kg-1 TMP orally in both a fed and a fasted condition in a three-way cross-over design. After intravenous administration SDZ and TMP were present in plasma for 30 and 12 hours, respectively. The volume of distribution was 0.5 litre kg-1 bodyweight for SDZ and 1.8 litre kg-1 bodyweight for TMP. The oral bioavailabilities for SDZ and TMP in the fed pigs were 85 per cent and 92 per cent, and in the fasted pigs 89 per cent and 90 per cent, respectively. Although the presence of food did not affect the almost complete absorption of both drugs, it did prolong the absorption phase. Mean absorption time was nearly twice as long in the fed as in the fasted pig. Based on bioavailability and the resulting plasma concentrations it is concluded that the oral administration of SDZ and TMP was efficient in both the fed and fasted pigs.

Administration, Oral↗

Morphogenesis of O,O,S-trimethyl phosphorothioate-induced pulmonary injury in mice.

The purpose of this study was to establish and characterize an experimental model in mice that examined the pulmonary effects of O,O,S-trimethyl phosphorothioate (OOS-TMP), a contaminant present in commercially important organophosphorus insecticides. Characterization of the model will allow the delineation of comparative effects between species and its possible extrapolation to man, and provide an additional experimental animal species satisfactory for mechanistic-oriented studies on OOS-TMP and related compounds. The morphogenesis of pulmonary injury induced by OOS-TMP was studied in mice by light and transmission electron microscopy. Weanling female C57BL/Ka mice received OOS-TMP dissolved in corn oil by intraperitoneal injection and were studied at intervals from 6 to 168 hr after treatment. Morphologic changes were observed in Clara cells only at the initial time period examined. Injury of pulmonary parenchymal cell populations, including the endothelium and type I alveolar epithelium, occurred after morphologic changes indicative of severe cell injury and necrosis in Clara cells. Endothelial cell injury was accompanied by significant increases in wet lung weight and percentage lung water content. Type I alveolar epithelial cell injury and loss resulted in a bare basal lamina, followed by attenuation, hypertrophy, and hyperplasia of type II alveolar epithelial cells. The results of this study document the successful establishment of a mouse experimental model of OOS-TMP-induced pulmonary toxicity. It is concluded that the Clara cell was the initial and most severely affected pulmonary cell population in mice receiving OOS-TMP. The administration of OOS-TMP in mice also results in marked morphologic alterations in the pulmonary parenchyma that were accompanied by significant changes in lung weight and composition.

Animals↗

Long-term morphologic and biochemical changes induced by O,O,S-trimethyl phosphorothioate in the rat lung.

The long-term pulmonary morphologic and biochemical changes induced by a single, sublethal dose of O,O,S-trimethyl phosphorothioate (OOS-TMP), an impurity present in organophosphorus insecticides, was examined in female WAG/Rij rats. Animals received either corn oil or a corn oil solution of OOS-TMP at a dose of 40 mg/kg body weight by gavage and were studied at the following time intervals after treatment: 10 days, 30 days, 90 days, 6 months, and 1 year. No control or OOS-TMP-treated animal died spontaneously. Significant increases in wet and dry lung weights occurred at all times examined in OOS-TMP-treated rats compared to those in age-matched controls. No difference was observed in percentage lung water content between treated and control rats. OOS-TMP treatment resulted in hypertrophy and hyperplasia of type II alveolar epithelial cells having morphologic alterations in the size and number of osmiophilic lamellar bodies. Interstitial changes were characterized as increased numbers of fibroblasts accompanied by increased amounts of collagen fibrils and basement membrane alterations. There was also a significant increase in pulmonary hydroxyproline content in OOS-TMP-treated animals compared to that in controls at all time periods. Collagen deposition was predominantly associated with the interalveolar septa rather than being oriented around airways. The results of this study indicate that a single, sublethal dose of OOS-TMP induces long-term structural and biochemical changes in the rat lung.

Animals↗

Characteristics of chemical binding to alpha 2u-globulin in vitro--evaluating structure-activity relationships.

alpha 2u-Globulin (alpha 2u) has been shown to accumulate in the kidneys of male rats treated with 2,2,4-trimethylpentane (TMP). 2,4,4-Trimethyl-2-pentanol (TMP-2-OH), a metabolite of TMP, is found reversibly bound to alpha 2u isolated from the kidneys of these treated rats. The objectives of the following study were to characterize the ability of [3H]TMP-2-OH to bind to alpha 2u in vitro and to determine whether other compounds that cause this protein to accumulate have the same binding characteristics. Although compounds that have been shown to cause the accumulation of alpha 2u in male rat kidneys compete in vitro with [3H]TMP-2-OH for binding to alpha 2u, they do so to varying degrees. The binding affinity (Kd) of the [3H]TMP-2-OH-alpha 2u complex was calculated to be on the order of 10(-7) M. The inhibition constant values (Ki) determined for d-limonene, 1,4-dichlorobenzene, and 2,5-dichlorophenol were all in the range 10(-4) M, whereas the Ki values for isophorone, 2,4,4- or 2,2,4-trimethyl-1-pentanol, and d-limonene oxide were determined to be in the range 10(-6) and 10(-7) M, respectively. TMP and 2,4,4- and 2,2,4-trimethylpentanoic acid did not compete for binding. This suggests that other factors, besides binding, are involved in the accumulation of alpha 2u. In this study the ability of a chemical to bind to alpha 2u was used as a measure of biological activity to assess structure-activity relationships among the chemicals tested and known to cause the accumulation of alpha 2u. The results so far suggest that binding is dependent on both hydrophobic interactions and hydrogen bonding.

Alpha-Globulins↗

Epidural blood flow during prostaglandin E1 or trimethaphan induced hypotension.

To evaluate the effect of prostaglandin E1 (PGE1) or trimethaphan (TMP) induced hypotension on epidural blood flow (EBF) during spinal surgery, EBF was measured using the heat clearance method in 30 patients who underwent postero-lateral interbody fusion under isoflurane anaesthesia. An initial dose of 0.1 microgram.kg-1.min-1 of PGE1 (15 patients), or 10 micrograms.kg-1.min-1 of TMP (15 patients) was administered intravenously after the dural opening and the dose was adjusted to maintain the mean arterial blood pressure (MAP) at about 60 mmHg. The hypotensive drug was discontinued at the completion of the operative procedure. After starting PGE1 or TMP, MAP and rate pressure product (RPP) decreased significantly compared with preinfusion values (P < 0.01), and the degree of hypotension due to PGE1 remained constant until 60 min after its discontinuation. Heart rate (HR) did not change in either group. EBFF did not change during PGE1 infusion whereas in the TMP group, EBF decreased significantly at 30 and 60 min after the start of TMP (preinfusion: 45.9 +/- 13.9 ml/100g/min. 30 min: 32.3 +/- 9.9 ml/100 g/min (P < 0.05). 60 min: 30 +/- 7.5 ml/100 g/min (P < 0.05)). These results suggest that PGE1 may be preferable to TMP for hypotensive anaesthesia in spinal surgery because TMP decreased EBF.

Adult↗

Epidural blood flow during prostaglandin E1 or trimethaphan induced hypotension.

To evaluate the effect of prostaglandin E1 (PGE1) or trimethaphan (TMP) induced hypotension on epidural blood flow (EBF) during spinal surgery, EBF was measured using the heat clearance method in 30 patients who underwent postero-lateral interbody fusion under isoflurane anaesthesia. An initial dose of 0.1 microgram.kg-1.min-1 of PGE1 (15 patients), or 10 micrograms.kg-1.min-1 of TMP (15 patients) was administered intravenously after the dural opening and the dose was adjusted to maintain the mean arterial blood pressure (MAP) at about 60 mmHg. The hypotensive drug was discontinued at the completion of the operative procedure. After starting PGE1 or TMP, MAP and rate pressure product (RPP) decreased significantly compared with preinfusion values (P < 0.01), and the degree of hypotension due to PGE1 remained constant until 60 min after its discontinuation. Heart rate (HR) did not change in either group. EBF did not change during PGE1 infusion whereas in the TMP group, EBF decreased significantly at 30 min and 60 min after the start of TMP (preinfusion: 45.9 +/- 13.9 ml/100 g/min. 30 min: 32.3 +/- 9.9 ml/100 g/min (P < 0.05). 60 min: 30 +/- 7.5 ml/100 g/min (P < 0.05). These results suggest that PGE1 may be preferable to TMP for hypotensive anaesthesia in spinal surgery because TMP decreased EBF.

Aged↗

Toxicity and efficacy of daily dapsone as Pneumocystis jiroveci prophylaxis after hematopoietic stem cell transplantation: a case-control study.

The toxicity and efficacy of dapsone given daily as Pneumocystis jiroveci (PCP) prophylaxis in hematopoietic stem cell transplant (HSCT) recipients who cannot take trimethoprim-sulfamethoxazole (TMP-SMX) have not been fully evaluated. We compared 155 HSCT recipients who received daily dapsone as second-line PCP prophylaxis with 310 matched control patients who received TMP-SMX throughout the posttransplantation course. Among patients who started dapsone before transplantation because of TMP-SMX allergy, there was no difference in the transfusion requirement after HSCT when compared with controls. Among patients who started dapsone after transplantation, increased red blood cell ( P<.0001) and platelet transfusion ( P=.003) requirements were noted compared with controls. This effect was, however, limited to patients who were receiving dapsone for reasons (mostly neutropenia) other than TMP-SMX allergy. Two of 155 patients developed PCP, compared with 0 of 310 controls ( P=.11); both patients survived. In conclusion, the efficacy of daily dapsone in preventing PCP was similar to that observed in patients able to remain on TMP-SMX prophylaxis. Dapsone did not seem to cause hematologic toxicity among TMP-SMX--allergic patients. The observed higher transfusion need in patients who received dapsone for reasons other than TMP-SMX allergy seems mostly due to an underlying condition of poor marrow reserve. Further studies are required to establish whether the drug has an etiologic role in these situations.

Adolescent↗

Effect of tetramethylpyrazine on acute nociception mediated by signaling of P2X receptor activation in rat.

Tetramethylpyrazine (TMP) has been used in traditional Chinese medicine as an analgesic for dysmenorrhea. In the present study, we try to investigate the effects of TMP on acute nociception mediated by P2X receptor activation of rat hindpaw and the membrane depolarization of rat dorsal root ganglion (DRG) neurons induced by P2X receptor agonists. The subcutaneous administration of TMP (0.1-10 mmol) into rat hindpaw in a dose-dependent manner decreased acute paw flinching responses mediated by adenosine 5'-triphosphate (ATP, 1000 nmol) or alpha,beta-methylene ATP (alpha,beta-meATP, 600 nmol). The subcutaneous administration of TMP (5 or 10 mmol) into rat hindpaw inhibited significantly the first phase of nociceptive behaviors induced by 5% formalin and attenuated slightly the second phase of nociceptive behaviors induced by 5% formalin. The subcutaneous administration of TMP (10 mmol) into rat hindpaw reduced the nociceptive responses induced by alpha,beta-meATP (200 nmol) co-injected with Prostaglandin E2 (PGE2), 5 micromol). The membrane depolarization induced by ATP (200 micromol) or alpha,beta-meATP (50 micromol) in DRG neurons was inhibited by TMP (300 micromol). The data suggest that the antinociceptive effect of TMP is involved in blocking the signaling of P2X3 receptor activation in rat.

Adenosine Triphosphate↗

Role of cGMP signals in tetramethylpyrazine induced relaxation of the isolated rat aortic strip.

In the present study, role of guanosine-3',5'-cyclic monophosphate (cGMP) in the vasodilatation of tetramethylpyrazine (TMP), one of the active ingredients of the Chinese herb Chuang-xion, was investigated. We found that the TMP could decrease the vascular tone of isolated rat aorta precontracted with phenylephrine (10(-8) M) in a concentration-dependent manner from 10(-5) M to 10(-3) M. Also, the TMP-induced relaxation was reduced by 1H-(1,2,4)-oxadiazol-(4,3-a)-quinoxalin-1-one (ODQ) or methylene blue, the inhibitor of soluble guanylyl cyclase. Moreover, the vasodilative response to TMP was enhanced significantly in the presence of sildenafil, a well-known inhibitor of phosphodiestrase type 5 that is sensitive to cGMP. In addition, TMP could increase the cGMP level in the isolated aortic rings and TMP-induced vasodilatation was deleted by cGMP-dependent protein kinases (PKG) blockade. These results suggest that relaxation of rat aortic strip by TMP is induced in the cGMP-dependent manner.

Animals↗

Tetramethylpyrazine reduces ischemic brain injury in rats.

Tetramethylpyrazine (TMP), which is widely used in the treatment of ischemic stroke by Chinese herbalists, is one of the most important active ingredients of the traditional Chinese herbal medicine, Ligusticum wallichii Franchat (Chung Xiong). However, the mechanism by which TMP protects the brain is still not clear. We examined neuroprotective effects of TMP after transient focal cerebral ischemia using common carotid artery and middle cerebral artery occlusion model in rats and evaluated the involvement of anti-inflammation. TMP administrated intraperitoneally significantly protected the brain against ischemic insult as evidenced by the reduction in infarction volume, preservation of neurons, and decrease in brain edema. TMP markedly reduced cerebral ischemia/reperfusion-induced inflammatory cell activation and proinflammatory mediator production. Moreover, TMP suppressed lipopolysaccharide/interferon-gamma-induced inflammation and prostaglandin E(2) production in cultured glial cells. Our findings suggest that one of neuroprotective effects of TMP against ischemic brain injury might involve its anti-inflammatory potential.

Animals↗

Tetramethylpyrazine elicits disparate responses in cardiac contraction and intracellular Ca(2+) transients in isolated adult rat ventricular myocytes.

Tetramethylpyrazine (TMP) is the biologically active ingredient isolated from a popular Chinese medicinal plant, Ligusticum wallichil franchat, which has been used effectively since the 1970s to treat ischemic heart disease, cerebrovascular and thrombotic vascular diseases. The direct action of TMP on cardiac contractile function, however, is largely unclear. This study was designed to examine the effect of TMP on ventricular contractile function at the single cardiac myocyte level. Adult rat ventricular myocytes were isolated and stimulated to contract at 0.5 Hz, and mechanical and intracellular Ca(2+) properties were evaluated using an IonOptix Myocam system. Contractile properties analyzed included peak shortening (PS), time-to-peak shortening (TPS), time-to-90% relengthening (TR(90)), maximal velocity of shortening/relengthening (+/-dl/dt), resting intracellular Ca(2+) level, Ca(2+)-induced Ca(2+) release (CICR) and decay. TMP (10(-10)-10(-5) M) exhibited an increase in PS with a maximal increase of 30.9%. TMP had no effect on +/-dl/dt, TPS/TR(90) or CICR but lowered resting intracellular Ca(2+) level and slowed intracellular Ca(2+) decay. Pretreatment with either the nonspecific nitric oxide synthase (NOS) inhibitor Nomega-nitro-L-arginine methyl ester (L-NAME, 100 microM) or inducible NOS inhibitor W1400 effectively abolished the positive effect of TMP on myocyte shortening. Our data demonstrate a direct positive inotropic effect of TMP in cardiac myocytes, which may be related, at least in part, to NO production.

Amidines↗

Addressing antibiotic resistance.

Management of uncomplicated urinary tract infections (UTIs) has traditionally been based on 2 important principles: the spectrum of organisms causing acute UTI is highly predictable (Escherichia coli accounts for 75% to 90% and Staphylococcus saprophyticus accounts for 5% to 15% of isolates), and the susceptibility patterns of these organisms have also been relatively predictable. As a result, empiric therapy with short-course trimethoprim-sulfamethoxazole (TMP-SMX) has been a standard management approach for uncomplicated cystitis.However, antibiotic resistance is now becoming a major factor not only in nosocomial complicated UTIs, but also in uncomplicated community-acquired UTIs. Resistance to TMP-SMX now approaches 18% to 22% in some regions of the United States, and nearly 1 in 3 bacterial strains causing cystitis or pyelonephritis demonstrate resistance to amoxicillin. Fortunately, resistance to other agents, such as nitrofurantoin and the fluoroquinolones, has remained low, at approximately 2%. Preliminary data suggest that the increase in TMP-SMX resistance is associated with poorer bacteriologic and clinical outcomes when TMP-SMX is used for therapy. As a result, these trends have necessitated a change in the management approach to community-acquired UTI. The use of TMP-SMX as a first-line agent for empiric therapy of uncomplicated cystitis is only appropriate in areas where TMP-SMX resistance prevalence is <10% to 20%. In areas where resistance to TMP-SMX exceeds this rate, alternative agents need to be considered.

Anti-Bacterial Agents↗

Acute cystitis: a prospective study of laboratory tests and duration of therapy.

The efficacy of single-dose therapy with trimethoprim-sulfamethoxazole (TMP-SMZ) and the cost-effectiveness of routine urinalyses and cultures were studied in a prospective randomized trial of 200 women who presented with symptoms of acute lower urinary tract infection. Without the physician's knowledge of the results of urinalysis or culture, the patients were randomly assigned to receive either a single dose or a 10-day multiple-dose course of TMP-SMZ and were followed up for 6 months. Of the 136 patients with positive urine cultures, 68 received single-dose therapy with TMP-SMZ--10 of whom had relapses--and 68 received multiple-dose therapy with TMP-SMZ--only 2 of whom had relapses (P less than 0.02). Fifteen patients in each treatment group experienced reinfection. Side effects of rash and vaginitis were more common in patients who received multiple-dose therapy, but they were mild and well tolerated. Of the 51 patients with urethral syndrome, 48 became asymptomatic after therapy. None of the following tests predicted treatment outcome: pretreatment urinalysis, urine culture or susceptibility testing, antibody-coated bacteria testing, or routine follow-up urinalyses or urine cultures. Empiric therapy with TMP-SMZ in selected women with symptoms of acute uncomplicated urinary tract infection seems practical, safe, and cost-efficient. Considerable savings can be achieved by reserving urinalyses and urine cultures for patients with persistent or recurrent symptoms. Higher cure rates can be expected in patients who receive a standard 10-day course of therapy with TMP-SMZ compared with those who receive single-dose therapy with TMP-SMZ.

Acute Disease↗

[Assay of plasma thrombomodulin in systemic diseases].

Membrane thrombomodulin (TM) is a very efficient natural anti-thrombin glycoprotein with anticoagulant properties expressed on endothelial cell surface. Circulating plasmatic thrombomodulin (TMp) detected by enzyme immunoassay in plasma is considered as a cell marker of endothelial injury. The TMp levels are increased in many conditions (diabetes mellitus, atheromatous disease...). In cases of collagen vascular diseases, where vascular endothelium damage is suspected, TMp is increased particularly in systemic lupus erythematosus (SLE) and systemic sclerosis (SSc). It is noteworthy that the TMp level is correlated with disease activity. Since TMp is a non specific marker of endothelial damage, it may be of interest as a useful marker for the supervision of these diseases. Further studies are needed on larger series. TMp level change during spontaneous evolution or under treatment will help determine wether TMp is a predictor and prognostic marker of these systemic diseases.

Acute Disease↗

Characterization of a tumor-associated gene, a member of a novel family of genes encoding membrane glycoproteins.

To isolate genes involved in tumor formation and in embryogenesis, a subtracted cDNA library was constructed from a c-myc-induced mouse brain tumor. A gene isolated in this screen, named TMP (tumor-associated membrane protein), codes for a putative glycoprotein with four transmembrane domains. The TMP gene was found to be highly expressed in brain tumor cells but not in normal brain. It is also expressed at high levels in undifferentiated embryonic stem cells, but markedly down-regulated in these cells after their differentiation into embryoid bodies. The TMP amino acid sequence bears high homology to the growth arrest specific protein PMP22/GAS-3, which is involved in several human peripheral neuropathies. The expression patterns of the TMP and PMP22 genes in NIH-3T3 fibroblasts were compared at different proliferation states. The results suggest an inverse pattern of expression for the two homologs, TMP expression being high during cell proliferation and PMP22 expression being high during growth arrest. To further characterize the TMP gene we have isolated its human homolog and examined its expression in embryonic and adult tissues. In our search for human sequences homologous to TMP and PMP22, we identified two new genes which we have named XMP and YMP. Thus, we present a novel family of membrane glycoproteins, one member of which is closely associated with proliferation and another with growth arrest.

3T3 Cells↗

Physicochemical characterization and percutaneous delivery of 2,3,5,6-tetramethylpyrazine.

The objective of this work is to investigate the percutaneous permeability of 2,3,5,6-tetramethylpyrazine (TMP), an active ingredient originally isolated from Ligusticum wallichii Franch. Certain physicochemical properties of TMP, including its partition coefficient and pH-solubility profile, were studied. The influence of pH on the percutaneous permeation of TMP was studied in vitro using hairless mouse skin. Comparative in vitro permeability of TMP through hairless mouse, rat, rabbit, and human cadaver skin was also investigated. The results indicate that hairless mouse skin and rat skin were about three to four times more permeable to TMP than human cadaver skin. The permeability of TMP through rabbit skin was not significantly different from that of human cadaver skin. The observed lag times for all skin membranes were about 1-2h. Although pharmacokinetic data are not currently available to permit precise calculation of a clinically effective patch size, the data from this study indicate that the transdermal delivery of TMP should nevertheless be possible.

Administration, Cutaneous↗

Trimethoprim-sulphamethoxazole as primary Pneumocystis carinii prophylaxis does not increase serum homocysteine levels in HIV-positive subjects.

Background: We recently observed that a short course of trimethoprim 300 mg b.i.d. in healthy volunteers can cause a substantial increase in fasting plasma homocysteine levels, up to concentrations reportedly associated with atherothrombotic complications. The purpose of this study was to determine whether primary Pneumocystis carinii prophylaxis (PCP) with trimethoprim-sulphamethoxazole (TMP-SMX) adversely affects serum homocysteine levels in HIV-positive patients. Methods: We studied 34 subjects [29 male, 5 female, mean age 36.8+/-7.9 (S.D.) years] with no prior AIDS-defining disease who required primary PCP prophylaxis (CD4+ T-cell count <200/mm(3)). The common dose of TMP-SMX was 80/400 mg (80 mg trimethoprim and 400 mg sulphamethoxazole) once daily. Serum total homocysteine levels were determined in four samples: two collected prior to the start of TMP-SMX and two collected on average 2.6+/-2.2 and 5.3+/-3.5 months into the first year of prophylactic therapy. Results: Mean serum homocysteine was 13.9+/-3.7 &mgr;mol/l pre-treatment and 14.4+/-5.0 &mgr;mol/l during treatment with TMP-SMX, a non-significant increase of 0.5 &mgr;mol/l (95% CI: -0.5 to +1.4, P=0.34). Folate levels were equally unaffected by TMP-SMX (13.1+/-6.5 nmol/l versus 13.3+/-5.3 nmol/l, before and during therapy, respectively). Baseline folate levels did not predict the response of homocysteine to TMP-SMX, and neither did age, gender, or serum creatinine. Conclusion: Long-term therapy with 80/400 mg TMP-SMX does not adversely affect homocysteine levels.

Journal Article↗

Concentration-dependent phototoxicity in trimethylpsoralen bath psoralen ultraviolet A.

BACKGROUND: Long-term use of topical trimethylpsoralen (TMP) psoralen bath plus ultraviolet A (bath PUVA) is considered safe with regard to the risk of skin cancer. However, the potential for severe phototoxicity limits its use. OBJECTIVES: To study the effect of dilution of the TMP bath on the minimal phototoxic dose (MPD). METHODS: Fifteen volunteers participated in the study. The MPD tests were performed for three TMP concentrations: 0.33 mg L-1, 0.1 mg L-1 and 0.033 mg L-1 at 2-week intervals. Geometric UVA dose series increasing by a factor of radical2 were used for the testing on the previously unexposed buttock skin. The MPD72 h was assessed at 72 h from the bath. RESULTS: For the highest TMP concentration of 0.33 mg L-1, the median MPD72 h was 0.14 J cm-2 (95% confidence interval (CI), 0.10-0.14 J cm-2). For the diluted TMP bath concentration of 0.1 mg L-1, the median MPD72 h increased to 0.29 J cm-2 (95% CI, 0.2-0.41 J cm-2) and for 0.033 mg L-1 to 0.81 J cm-2 (95% CI, 0.57-1.15 J cm-2), respectively. Thus, diluting the labelled concentration of 0.33 mg L-1 1 : 10 increased the median MPD72 h 5.6-fold. CONCLUSIONS: With regard to the safety and practicality of the TMP bath PUVA, the lower concentrations of TMP may be of clinical importance, and this needs to be validated in future controlled clinical trials.

Adult↗