MisuMedPT - Morbi-mortality consequences of misuse of psychoactive prescription drugs in Portugal

Background

In Portugal, there are no published data on the health-related consequences of prescription drug misuse, which is therefore a public health issue of unknown dimension in our country. Poison control centres and other pharmacoepidemiological sources can be part of a surveillance system for monitoring medicine's use and misuse.

Methods

Retrospective observational study of intentional exposures to opioid analgesics, antiepileptics, antidepressants, anxiolytics, hypnotics and sedatives reported to the Portuguese Poison Information Centre (CIAV) between 2014 and 2018. Variables studied were demographic characteristics of individuals, geographic distribution of calls, co-exposure to alcohol or illicit drugs, call origin, case evaluation and guidance.

Results

CIAV received 24624 calls reporting 34203 intentional exposures to any medicine, 31169 (91.1%) of which involving one of the studied psychoactive medicines and 20906 exposures having emergency room advice or effective hospitalisation. The most frequently involved medicines were benzodiazepines (62.0%) - alprazolam (15.4%) and diazepam (12.0%) - with trazodone ranking fifth (6.0%). Combination with non-medicinal products was seen in 2169 calls (9.4%), 2052 (94.6%) of which with alcohol.

Conclusions

There is female predominance in the poisonings reported involving any of the medicines studied. Benzodiazepines and antidepressants are the top classes reported. The rate of intentional exposures to psychoactive medicines is higher in Coimbra district, whose significant university student population requires further analysis of data. To adjust for the variability in the level of medicines' use in the population, work is undergoing to include rates of intentional poisonings in patients prescribed the studied medicines. To better characterise the potential consequences of misuse of psychoactive prescription drugs in Portugal, additional data on deaths involving these medicines will also be included in the project.

Key messages

First published Portuguese data on prescription drug poisoning reported to CIAV. First Portuguese project to analyse prescription drug poisoning, forensic and hospitalisation data.

Intensive monitoring of adverse drug events associated with the use of new glucose-lowering drugs: results from an inception cohort study in Portugal

AIMS

To determine the frequency and the time-course profile of adverse drug events associated with new glucose-lowering drugs in daily practice and to explore factors potentially associated to these events.

METHODS

An inception cohort study was implemented. Adults with type 2 diabetes mellitus initiating a dipeptidyl peptidase-4 inhibitor, a glucagon-like peptide-1 receptor agonist or a sodium-glucose co-transporter-2 inhibitor were eligible for inclusion. Data were collected through baseline and follow-up telephone questionnaires, administered at 2 weeks, 3 months and 6 months. Kaplan-Meier curves and log-rank were computed to compare the time to adverse drug event onset. Cox models were used to explore potential factors associated with adverse drug events.

RESULTS

A total of 1328 participants were recruited to the study. In all, 1118 adverse drug events were reported (of which 36% were not listed in the summary of product characteristics) by 41% of participants. The median latency time of adverse drug events reported in ≥1% of participants ranged from 0 to 2 days. Glucagon-like peptide-1 receptor agonist and sodium-glucose co-transporter-2 inhibitor subgroups were associated with an increased likelihood of adverse drug event reporting when compared with the dipeptidyl peptidase-4 inhibitor subgroup. A total of 328 glucose-lowering drugs were withdrawn, more than half as a result of an adverse drug event.

CONCLUSIONS

More than two-fifths of participants reported an adverse drug event; dipeptidyl peptidase-4 inhibitors led to the highest proportion of unlabelled adverse drug events. Adverse drug event latency time data show that counselling and adverse drug event management should be proactively addressed from treatment initiation. There should be greater focus on prevalent new users of glucose-lowering drugs, who were more complex participants in this study in terms of type 2 diabetes disease, as they were more likely to report an adverse drug event than the incident new users.

Activity of inflammatory bowel disease influences the expression of cytokines in gingival tissue

This study assessed the cytokine expression in gingival and intestinal tissues from periodontitis patients with inflammatory bowel disease (IBD) and evaluated if IBD activity is a covariate to the amount of gingival cytokines. Paired gingival and intestinal tissues were collected from 21 patients and homogenised using a cell disruptor. Cytokine expression (IL-1β, IL-4, IL-6, IL-10, IL-21, IL-22, IL-23, IL-25, IL-31, IL-33, IL-17A, IL-17F, IFN-γ, sCD40L, and TNF-α) was evaluated using bead-based multiplex technology. An inflammation score was developed using the intestinal cytokines that showed good accuracy to discriminate IBD active patients from those in remission and then a similar score was applied to gingival tissue. IL-4, IL-10 and IL-21 expressions were significantly increased in gingival tissue from patients with an active disease as compared to those with a disease in remission. The inflammation score (mean value of IL-1β, IL-6, IL-21, and sCD40L) was significantly higher in gingival tissue from patients with IBD activity. There was a significant correlation between gingival and intestinal inflammation scores (rho=0.548; P=0.01). Significantly higher IL-23 and IFN-γ levels and lower IL-31 and TNF-α levels were observed in gingival tissues than in intestinal ones. Activity of inflammatory bowel disease influenced the cytokine expression in gingival tissue.

Patients' access to biologics in rheumatoid arthritis: a comparison between Portugal and other European countries

BACKGROUND

Despite the widespread availability of biologics across Europe, rheumatoid arthritis (RA) patients' access to these drugs differs significantly among countries.

OBJECTIVES

To compare the proportion of RA patients treated with biologics across Europe and investigate the factors that most influence it, with focus on the Portuguese case, reportedly with low access rates to biologics.

METHODS

The biologics' market was characterized for 15 selected European countries. Variables potentially influencing patients' access to biologics (PAB) in RA were also collected, including demographic, disease, economic, funding and biologics' market-related data. A multivariable regression model identified the factors that best explain PAB. Based on these determinants, a cluster analysis was performed to group the countries with most similar behaviour regarding PAB allowing the evaluation of Portugal's relative position among these countries.

RESULTS

The regression model (R(2) = 0.953) indicated that PAB in selected countries is explained mostly by its gross domestic product (GDP) per capita, the usage of methotrexate (MTX) and the biologics' distribution channel. Current MTX usage in Portugal shows similarity with practice from UK, France, Germany or Spain 5 years before, explaining why PAB in Portugal stood at 7% in 2010, 12 percentage points below the average of selected countries.

CONCLUSIONS

Variations in RA PAB were found across selected countries with Portugal showing the lowest proportion. GDP per capita, biologics distribution channel and consumption of MTX appear to be the best explanatory factors for these fluctuations in European countries.

[Conservative surgery in pancreatic solid pseudo papillary tumor]

We report the case of a 18-year-old girl having a solid pseudopapillary pancreatic tumor. The patient underwent local enucleation of the tumor located on pancreatic head and remained free of recurrence on the 5th year of follow up. Surgical management is discussed.

The effect of massive weight loss on pulmonary function of morbid obese patients

STUDY OBJECTIVES

To test if morbid obesity causes pulmonary function changes and if massive weight loss have effect on pulmonary function (especially in subjects with BMI>or=60 kg/m(2)).

PARTICIPANTS

Thirty-nine morbid obese subjects before and after massive weight loss.

MEASUREMENTS AND RESULTS

Patients had baseline BMI>or=40 kg/m(2), pulmonary function test (PFT) before and after surgery for gastric volume reduction and massive weight loss, and presented no complaints unrelated to obesity. Based on initial BMI, the patients were divided in groups A (BMI 40-59.9 kg/m(2)) and B (BMI>or=60 kg/m(2)). Initially, group A (n=28) had normal PFT, however group B (n=11) presented FVC and FEV(1) measurements in the lowest limit of normality (with normal FEV(1)/FVC), significantly different from group A. After massive weight loss, the group B compared to A had a significant improvement in FVC (23.7% vs. 9.7%, P=0.012) and FEV(1) (25.6% vs. 9.1%, P=0.006); thus the initial difference in FVC and FEV(1) between groups no longer existed after weight loss.

CONCLUSIONS

These results point out that the severe morbid obesity (BMI>or=60 kg/m(2)) may lead to pulmonary function impairment and presents more prominent pulmonary function gain after massive weight reduction. The possible clinical implications of these results are that PFT abnormalities in subjects with BMI<60 kg/m(2) should probably be interpreted as consequence of intrinsic respiratory disease and that severe morbid obese patients may be encouraged to lose weight to improve their pulmonary function, especially those with concomitant pulmonary disorders.

Differential expression of the eukaryotic release factor 3 (eRF3/GSPT1) according to gastric cancer histological types

BACKGROUND

There are now several lines of evidence to suggest that protein synthesis and translation factors are involved in the regulation of cell proliferation and cancer development.

AIMS

To investigate gene expression patterns of eukaryotic releasing factor 3 (eRF3) in gastric cancer.

METHODS

RNA was prepared from 25 gastric tumour biopsies and adjacent non-neoplastic mucosa. Real time TaqMan reverse transcription polymerase chain reaction (RT-PCR) was performed to measure the relative gene expression levels. DNA was isolated from tumour and normal tissues and gene dosage was determined by a quantitative real time PCR using SYBR Green dye.

RESULTS

Different histological types of gastric tumours were analysed and nine of the 25 tumours revealed eRF3/GSPT1 overexpression; moreover, eight of the 12 intestinal type carcinomas analysed overexpressed the gene, whereas eRF3/GSPT1 was overexpressed in only one of the 10 diffuse type carcinomas (Kruskal-Wallis Test; p < 0.05). No correlation was found between ploidy and transcript expression levels of eRF3/GSPT1. Overexpression of eRF3/GSPT1 was not associated with increased translation rates because the upregulation of eRF3/GSPT1 did not correlate with increased eRF1 levels.

CONCLUSIONS

Overexpression of eRF3/GSPT1 in intestinal type gastric tumours may lead to an increase in the translation efficiency of specific oncogenic transcripts. Alternatively, eRF3/GSPT1 may be involved in tumorigenesis as a result of its non-translational roles, namely (dis)regulating the cell cycle, apoptosis, or transcription.

Polyglycine expansions in eRF3/GSPT1 are associated with gastric cancer susceptibility

Gastric cancer remains a major cause of death in the developed countries, and a large percentage is still genetically unexplained. Because of their major role in cell survival, mutations in translation factors and altered expression of these genes have been associated with cancer development. Apart from its role in translation termination, the eukaryotic translation release factor 3 (eRF3) is involved in several critical cellular processes, such as cell cycle regulation, cytoskeleton organization and apoptosis. The aim of this study was to evaluate eRF3/GSPT1 gene as a potential genetic susceptibility associated locus for gastric cancer, analysing a stable GGC expansion in exon 1 encoding a polyglycine tract in the N-terminal domain of the protein. DNA was obtained from 139 patients with gastric cancer and from 100 individuals of a healthy control population. The GGC expansion was amplified by PCR and the number of repeats determined by genotyping in an automatic sequencer. There are five known alleles encoding from 8 to 12 glycines. The most common allele encodes 10 glycines. The 12-Gly allele was detected exclusively in the cancer patients (allelic frequency = 5%). Regardless of the genotype, patients with the 12-Gly allele had a 20-fold increased risk for gastric cancer. We also detected a single-base alteration in the gene (G274T) although no correlation with cancer development has been found. Thus, our results show that the GGC expansion may have a potential role in regulating eRF3/GSPT1 expression and/or changing the protein function that can lead to gastric cancer development.

Essential oil composition and antimicrobial activity of Santiria trimera bark

The composition and the antimicrobial activity of the bark oil of Santiria trimera (Oliv.) Aubrév., a plant widely used by the traditional healers in S. Tomé and Príncipe, especially for wound healing, are reported for the first time. The analysis of the essential oil was carried out by GC and GC-MS. The oil contains a high content of monoterpenes, alpha-pinene (66.6 %) being the major constituent, followed by beta-pinene (20.0 %). The essential oil was active against both bacteria and fungi strains, except Staphylococcus epidermidis and Aspergillus niger. It exhibited significant antimicrobial activity against Proteus vulgaris and Cryptococcus neoformans with MICs values of 1.11 microl/ml and lower than 0.71 microl/ml, respectively.

Anxiolytic effect of a CRH receptor antagonist in the dorsal periaqueductal gray

Corticotropin-releasing hormone (CRH) is anxiogenic when microinjected into the dorsal periaqueductal gray (DPAG). Microinjection of alpha-helical-CRH9-41 (0.5 microgram), a CRH receptor antagonist, however, failed to change anxiety levels. The objective of this study was to verify if this compound has any effect in the anxiogenic behavior of rats submitted to 4 hr of restraint stress 24 hr before the test in an elevated plus maze. Results showed that stressed rats had a decreased exploration of open arms without changing the number of enclosed arm entries. The stress effect was reversed by intra-DPAG injection of alpha-helical-CRH9-41 (0.5 microgram). These results suggest that the anxiogenic behavior of rats previously stressed by forced immobilization might involve facilitation of CRH-mediated neurotransmission in the DPAG.

Essential oil composition and antimicrobial activity of three Zingiberaceae from S.Tomé e Príncipe

The essential oil composition of three Zingiberaceae widely used as medicinal aromatic plants from S. Tomé and Príncipe: Aframomum danielli (Hook. f.) K. Schum., Curcuma longa L. and Zingiber officinale Rosc. was studied. Two samples of the essential oils from fruit of A. danielli and from rhizomes of the other two species, were obtained by hydrodistillation and analyzed by GC, GC-MS, and (13)C-NMR. The essential oil from fruits of A. danielli has been studied for the first time and was characterised by its high content of monoterpenes, with 1,8-cineole (25.5 - 34.4 %) the major constituent, followed by beta-pinene (14.1 - 15.2 %) and alpha-terpineol (9.9 - 12.1 %). Essential oils from the rhizomes of C. longa contained a lower content of ar-turmerone (4.0 - 12.8 %) than those reported in the literature for C. longa from other origins (24.7 - 31.4 %), whereas the results for Z. officinale essential oils were in accordance with the literature data. The essential oils of A. danielli and Z. officinale showed antimicrobial activity against all Gram-positive and Gram-negative bacteria tested, as well as against yeasts and filamentous fungi, using the agar diffusion method.

Antimicrobial activity and chemical composition of the bark oil of Croton stellulifer, an endemic species from S. Tomé e Príncipe

The composition and the antimicrobial activity of the bark oil of Croton stellulifer, an endemic and rare species of these islands (S. Tomé and Príncipe) are reported. Analysis was carried out by GC, GC/MS and 13C-NMR. The major constituents were alpha-phellandrene (15.4-18.6%), p-cymene (14.4-17.7%), linalool (12.0-12.6%) and alpha-pinene (8.1-9.1%). Kessane, a sesquiterpenoid oxide, not yet reported in the genus Croton, was identified by NMR. The essential oil of C. stellulifer was active against both bacterial and fungal strains, except Aspergillus niger.

Immediate replantation of maxillary incisors in rats: effects of tooth immersion in sodium fluoride and subsequent removal of the periodontal ligament

The advantages and disadvantages of maintaining the periodontal ligament (PDL) in immediate replantation as well as chemical treatment of the root surface have been a matter of discussion because the vitality of such tissue in surgery is always questioned. This study evaluated the effects of conserving the tooth in sodium fluoride and the removal of the PDL before replantation of incisors in rats. There was more cementum-dentin resorption in the group with the PDL. The group without the PDL showed more discreet resorption, repair occurred through the newly formed bone tissue in the PDL space and ankylosis was more extensive than in the group with the PDL.

Composition of the essential oils of Ocimum canum, O. gratissimum and O. minimum

The essential oils of OCIMUM CANUM, O. GRATISSIMUM and O. MINIMUM grown in S. Tomé, where they are used in Traditional Medicine mainly as febrifuge and for the treatment of respiratory diseases, were investigated. The essential oils were obtained from the aerial parts by hydrodistillation and subsequently analysed by GC, GC-MS and (13)C-NMR. (13)C-NMR SPECTROSCOPY proved to be an important tool, which can be very useful in the identification of most of the constituents. Major compounds in the volatile oil of O. GROTISSIMUM were thymol (48.1%) and P-cymene (12.5%). The essential oil of O. CANUM was characterized by its high content of TRANS-METHYL cinnamate (79.7%), whereas the most important oil constituent of O. MINIMUM was linalool (52.7%).

Hamartoma of the mitral valve with blood cysts: a rare tumor detected by echocardiography

A 16-year-old boy was submitted to a cardiac examination after an episode of faintness. A transthoracic echocardiogram was performed, which revealed a very mobile multicystic tumor attached to the mitral valve. A small solid mass adherent to the cysts was better defined by transesophageal echocardiography. The patient was submitted to cardiac surgery consisting of tumor resection and a mitral prosthesis implant. The surgery was successful. The tumor consisted of three bright red tense cysts with hematic content, each 1 to 2 cm in diameter. The cysts were coalescent and adherent to a solid mass attached to the posterior papillary muscle head. Histopathologic examination revealed a hamartoma with a cystic part composed of the proliferation of myofibroblast cells in a stroma with vessels, collagen, and elastin fibers. Valvular hamartoma with blood cysts is a very rare cardiac tumor both for its histopathology and its localization.

Anxiogenic effect of corticotropin-releasing hormone in the dorsal periaqueductal grey

To investigate whether the dorsal periaqueductal grey (DPAG) might be involved in the anxiogenic effect of intracerebroventricular (i.c.v.) administered corticotropin-releasing hormone (CRH), rats (n = 6-13) received microinjections into the DPAG of CRH (1 or 2 microg) or saline and were tested on the elevated plus maze. The drug caused a dose-dependent decrease in plus maze exploration (percentage of entries into open arms: saline 31.9 +/- 8.6, CRH 1 microg 19.2 +/- 4.0, CRH 2 microg 6.9 +/- 3.7; p < 0.01, ANOVA). In a second experiment the anxiogenic effect of intra-DPAG CRH (2 microg) was prevented by previous microinjection of alpha-helical-CRH(9-41) (0.5 microg), a CRH antagonist (percentage of entries into open arms: saline + CRH 20.3 +/- 3.7, alpha-helical-CRH(9-41) + CRH 45.7 +/- 1.6). These results suggest that the DPAG may be a site of the anxiogenic effect of i.c.v. injected CRH.

[Hemangioma of the right ventricle]

A 36-year-old male with unspecific symptoms and normal physical examination had right cardiac enlargement on chest X-ray. Two-dimensional echocardiographic and thoracic computed tomography demonstrated an intracardiac mass. The tumor was surgically resected and the pathological diagnosis was mixed-type epicardial hemangioma. We discuss this case and review the literature.

Mechanisms underlying degeneration of cryopreserved vascular homografts

OBJECTIVE

To analyze the mechanism(s) underlying homograft degeneration, we designed an experimental model in which the behavior of cryopreserved autografts and homografts, as well as fresh autografts, implanted in the same animal was compared.

METHODS

A cryopreserved homograft was implanted in the aorta of 14 sheep. The excised aortic autologous segment was then subjected to cryopreservation, and 1 to 8 weeks later it was implanted 1 to 2 cm below the cryopreserved homograft. The intermediate segment of the native aorta, the fresh autograft, was dissected at this point. Animals were put to death at different times and the implanted segments were harvested together with a portion of native aorta. Histologic and immunohistochemical analyses, as well as cell viability assessments, were then performed on the explanted segments. Similar studies were also conducted on fragments of cryopreserved autografts and homografts before implantation.

RESULTS

With the exception of a partial loss of the endothelium, cryopreserved specimens retained cell viability and morphologic integrity before implantation. Explanted cryopreserved homografts showed profound changes affecting all strata, as well as a decline in cell viability. Lymphocyte infiltrates were found up to 12 months after implantation. Endothelium was always absent in cryopreserved homografts. However, a reendothelialization of the cryopreserved autografts was observed. After an initial period of neuronal degeneration, reenervation of the cryopreserved autograft segment occurred 6 to 12 months after the operation. Findings regarding the fresh autografts were similar to those of the cryopreserved autografts.

CONCLUSION

Our results suggest that the immunologic reaction rather than the cryopreservation process is responsible for the degenerative process occurring in cryopreserved homografts.

L-NOARG, an inhibitor of nitric oxide synthase, induces catalepsy in mice

The objective of this study was to investigate possible motor effects of NG-nitro-L-arginine (L-NOARG), an inhibitor of nitric oxide synthase. Acute administration of L-NOARG (5-80 mg kg-1, i.p.) induced catalepsy in a dose-dependent manner in male albino-Swiss mice. The drug had an additive effect with haloperidol (0.125-0.5 mg kg-1, i.p.). The acute effect of L-NOARG (40 mg kg-1, i.p.) was attenuated by previous treatment with L-arginine (300 mg kg-1, i.p.). Sub-chronic treatment with L-NOARG (40 mg kg-1, i.p., twice a day for 4 days) was also able to attenuate the cataleptic effect of acute drug administration (40 mg kg-1, i.p.). These results show that acute systemic injections of L-NOARG induce significant motor effects.

The large septal arteries in normal hearts, in aortic valve disease, and in tetralogy of Fallot

BACKGROUND

Several surgical techniques such as the Ross operation or total correction of tetralogy of Fallot require incisions of the upper ventricular septum. Very few reports on the anatomy of the septal arteries of the pathologic heart can be found in the literature. To get a more precise knowledge of the large septal arteries in pathologic hearts, we have compared the anatomy of normal hearts with that of hearts with aortic valve disease and of tetralogy of Fallot.

METHODS

Twenty-six normal heart specimens (group A), 11 with aortic valve disease (group B), and 4 with tetralogy of Fallot (group C) were dissected.

RESULTS

In groups B and C a single large septal artery was always found. The large septal artery had the orientation previously described for normal hearts. Still, its course in the lower border of the anterior extension of the septomarginal trabecula was deeper. The anterior extension of the septomarginal trabecula was 4 +/- 3 mm deep in group A, 6 +/- 2 mm in group B, and 3 mm in group C. The interventricular septum was much thicker in groups B and C than in group A.

CONCLUSIONS

The position of the large septal artery can be predicted from coronary angiography and from the morphology of the anterior extension of the septomarginal trabecula. Knowledge of its position can improve the safety of operations performed on the outflow of the interventricular septum.

Can the location of the large septal artery be predicted?

The aim of this study is to establish anatomical landmarks for the trajectory of the large septal artery. Thirty hearts were dissected, 20 of which had no cardiac pathology and the remaining with different cardiac conditions. One large septal artery was located in 27 of these hearts, two large septal arteries in 2 and three large septal arteries in 1. For all cases there existed one large septal artery in the lower border of the anterior limb of the septomarginal trabecula. When more than one large septal artery was encountered, the first was located within the subendocardial outflow tract of the left ventricle, the second was in the lower border of the anterior limb of the septomarginal trabecula and the third 1.5 cm below the second.

[Acute appendicitis in children]

From January 1st, 1987 to December 31st, 1989, 267 patients were operated upon for acute appendicitis representing 97% of emergency laparotomies at the Pediatric Surgery Department of Santa Maria Hospital (HSM); of these, 207 records were analysed using a retrospective protocol and the results were as follows: most frequent symptoms were abdominal pain (99% of cases) and anorexia (86%). Referral for surgical evaluation was made in 35.8% of cases 48 hours after the onset of symptoms; surgery was performed in 129 patients (62.4%) in advanced stages of disease, with histopathological examinations of necrotic, perforated and gangrenous appendices. 15 patients (7.2%) had no appendicitis-11 were found to have follicular hyperplasia and 4 normal histology; of these, luminal distention by parasitic eggs was found in 4. Antibiotic therapy was used in 89 patients preoperatively and in 200 patients postoperatively; cefoxitin was the most commonly used in 89.9% and 83.0% respectively. There were 19 complications (9.2%): 8 parietal, 5 pelvic and 1 subphrenic abscesses, 4 total or partial obstructions and 1 lost drain; 4 patients (1.9%) were reoperated and there was no mortality.

[Cyclosporin A--a therapeutic alternative in giant-cell arteritis?]

Cyclosporine A (CyA) is an immune modulator that may treat immune diseases. The authors present two cases of temporal arteritis treated with CyA; the two patients improved very quickly and after the first six or eight weeks of treatment there were no clinical or laboratory signs of inflammation. As to adverse effects there was a moderate increase in serum creatinine and arterial pressure levels which were controlled when the CyA dosage was reduced. In view of the good results achieved in these two patients, the authors concluded that CyA may be an alternative therapy for giant-cell arteritis and that this hypothesis should be further investigated in a larger group of patients.