Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe

Transmitted human immunodeficiency virus drug resistance in Europe is stable at around 8%. The impact of baseline mutation patterns on susceptibility to antiretroviral drugs should be addressed using clinical guidelines. The impact on baseline susceptibility is largest for nonnucleoside reverse transcriptase inhibitors.

Background. Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001.

Methods. Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)–infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0.

Results. The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%–9.5%) in 2008–2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones.

Conclusions. Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

Contribution of drug related problems to hospital admission in the elderly

PURPOSE

To investigate the frequency and type of drug related problems (DRPs) in geriatric patients (> 65 years), and to assess their contribution to hospital admission; to explore the appropriateness of drug therapy according to the Beers' criteria.

METHODS

Cross-sectional observational survey of 110 elderly patients admitted during three non-consecutive months to the geriatric ward of a university hospital. Explorative assessment of appropriateness of drug therapy prior to hospital admission based on the Beers' criteria.

RESULTS

A DRP was the dominant reason for hospital admission in 14 out of the 110 patients (12.7%); for another 9 patients (8.2%), a DRP was partly contributing to hospital admission. For these 23 patients, adverse drug reactions and noncompliance were the most important types of DRPs. We found no relationship between drug related hospital admission and intake of a drug listed in the Beers criteria for inappropriate drug use in the elderly. Patients admitted for a DRP took more drugs before admission than patients admitted because of other reasons.

CONCLUSIONS

DRPs are an important cause for admission on the geriatric ward of our hospital. The drugs causing DRPs in this study were not those listed in the Beers list of inappropriate drugs in the elderly.

Buflomedil for intermittent claudication

BACKGROUND

Intermittent claudication (IC) is pain caused by chronic occlusive arterial disease, that develops in a limb during exercise and is relieved with rest. Buflomedil is a vasoactive agent used to treat peripheral vascular disease. However, its clinical efficacy for IC has not yet been critically examined.

OBJECTIVES

To evaluate the available evidence on the efficacy of buflomedil for IC.

SEARCH STRATEGY

We searched the specialized trials register of the Cochrane Peripheral Vascular Diseases Review Group (last searched November 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 4, 2007), MEDLINE (1966 to November 2007), International Pharmaceutical Abstracts (IPA) (from inception to November 2007), Science Citation Index (from inception to November 2007). We contacted Abbott Laboratories (buflomedil distributor) for controlled clinical trial data and approached authors for additional trial information.

SELECTION CRITERIA

Double-blinded, randomized controlled trials (RCTs) in patients with IC (Fontaine stage II) receiving oral buflomedil compared to placebo. Pain-free walking distance (PFWD) and maximum walking distance (MWD) were analysed by standardized exercise test.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We included two RCTS with 127 participants. Both RCTs showed moderate improvements in PFWD for patients on buflomedil. This improvement was statistically significant for both trials (WMD 75.1 m, 95% confidence interval (CI) 20.6 to 129.6; WMD 80.6 m, 95% CI 3.0 to 158.2), the latter being a wholly diabetic population. For both RCTs, MWD gains were statistically significant with wide confidence intervals (WMD 80.7 m, 95% CI 9.4 to 152; WMD 171.4 m, 95% CI 51.3 to 291.5), respectively.

AUTHORS' CONCLUSIONS

There is little evidence available to evaluate the efficacy of buflomedil for IC. Most trials were excluded due to poor quality. The two included trials showed moderately positive results; these are undermined by publication bias since we know of at least another four unpublished, irretrievable, and inconclusive studies.Buflomedil's benefit is small in relation to safety issues and its narrow therapeutic range.

Buflomedil for intermittent claudication

BACKGROUND

Intermittent claudication (IC) is pain caused by chronic occlusive arterial disease, that develops in a limb during exercise and is relieved with rest. Buflomedil is a vasoactive agent used to treat peripheral vascular disease. However, its clinical efficacy for IC has not yet been critically examined.

OBJECTIVES

To evaluate the available evidence on the efficacy of buflomedil for IC.

SEARCH STRATEGY

We searched the specialized trials register of the Cochrane Peripheral Vascular Diseases Review Group (last searched August 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 3, 2007), MEDLINE (1966 to August 2007), International Pharmaceutical Abstracts (IPA) (from inception to August 2007), Science Citation Index (from inception to August 2007). We contacted Abbott Laboratories (buflomedil distributor) for controlled clinical trial data and approached authors for additional trial information.

SELECTION CRITERIA

Double-blinded, randomized controlled trials (RCTs) in patients with IC (Fontaine stage II) receiving oral buflomedil compared to placebo. Pain-free walking distance (PFWD) and maximum walking distance (MWD) were analysed by standardized exercise test.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We included two RCTS with 127 participants. Both RCTs showed moderate improvements in PFWD for patients on buflomedil. This improvement was statistically significant for both trials (WMD 75.1 m, 95% confidence interval (CI) 20.6 to 129.6; WMD 80.6 m, 95% CI 3.0 to 158.2), the latter being a wholly diabetic population. For both RCTs, MWD gains were statistically significant with wide confidence intervals (WMD 80.7 m, 95% CI 9.4 to 152; WMD 171.4 m, 95% CI 51.3 to 291.5), respectively.

AUTHORS' CONCLUSIONS

There is little evidence available to evaluate the efficacy of buflomedil for IC. Most trials were excluded due to poor quality. The two included trials showed moderately positive results; these are undermined by publication bias since we know of at least another four unpublished, irretrievable, and inconclusive studies.Buflomedil's benefit is small in relation to safety issues and its narrow therapeutic range.

[Information about drugs from physicians and pharmacists]

Good quality information is essential for those who prescribe, deliver or use medications. This information should meet quality criteria: it should be evidence based, practice oriented, easy to find and topical. Pharmacists and physicians receive information from different sources and of valable quality. Initiatives should be taken to improve the quality. The authorities should stimulate these initiatives, and make sure that the information is evidence based. Medical schools and pharmacy schools should educate the students in these matters, and play a role in the continuing medical education thereabout. Opinion leaders should be aware of their responsibility. Existing initiatives should be expanded, and should be coordinated. Finally, there is the ethical obligation for health professionals to remain informed. One wonders in how far incentives (or even coercive measures) are necessary. There is a task there for the "Orders" of physicians and pharmacists, and the scientific and professional bodies.

Evaluation of human albumin use in a university hospital in Belgium

In 1996-1997, a drug use evaluation (DUE) of human albumin was conducted in the Ghent University Hospital (Belgium) to determine the pattern and appropriateness of the albumin use. The DUE was followed by permanent review of the albumin consumption. This paper describes how the DUE was carried out and how the albumin use in our hospital changed over time.

METHOD

The study was based on criteria for indications and end of treatment, accepted by consensus of the physicians prescribing albumin. Albumin treatment episodes were classified as appropriate or inappropriate according to these criteria.

RESULTS

For 115 treatment episodes in 90 patients, the researchers found 21 (18.3%) deviations from the developed criteria. After analysis, half out of them were considered as minor. Most deviations involved starting treatment too early (n = 17). Follow-up results indicated that the overall consumption of albumin dropped by 50.1% from 1994 to 1999, while the consumption of colloid solutions during the same period remained stable.

CONCLUSION

A good compliance with internally developed criteria for indications and end of treatment with human albumin was observed. Discussion with the clinicians involved led to the development of stricter criteria and a continuous decrease in albumin consumption.

Use of laxatives in institutions for the mentally retarded

OBJECTIVE

To study, in institutionalized mentally retarded patients, the prevalence of regular laxative use, and to identify its correlates.

METHODS

Twenty-one of the 22 institutions for the mentally retarded in Flanders (Belgium) provided the setting for the study, which included a population of 3712 residents with an IQ of < 50. This was a descriptive cross-sectional study of a random sample of 20 patients per institution, consisting of a structured interview of the personnel responsible for daily care of the selected patients. The study population consisted of 420 mentally retarded patients. Their median age was 29 years (range 2-72 years). Twenty-six percent of patients had an IQ of 35-49, 40% an IQ of 20-34 and 34% an IQ of <20. Sixteen percent of the patients were non-ambulant.

RESULTS

Regular laxative use was found in 26.4% (111/420) of the residents. In addition, occasional laxative use was found in 2% (10/420) of the residents. Oral laxatives were used daily by 13% (56/420) and oral laxatives daily in combination with enemas were used by 9% (39/420). Enemas but no oral laxatives were used by 3% (11/420); manual evacuation in combination with oral laxatives and enemas was used by 1% (5/420). Seventy-eight percent (78/100) of the oral laxative users used them for more than 1 year. Seventy-one percent (71/100) used one laxative, 23% two and 6% three. Thirty different brands of oral laxatives were used. Sixty-seven percent (67/100) used osmotic laxatives alone or in combination, 30% used stimulant laxatives, 19% used bulk forming laxatives and 19% mineral oil. Oral laxatives were always prescribed by attending physicians, while enemas were also initiated by nurses in 35% (18/52). Laxative use was positively and independently correlated with female gender, with being non-ambulant, with oral motor dysfunction and with the use of medication other than laxatives. It did not correlate with age. Within the institutions, laxative use varied from one to 15 users out of the 20 randomly selected patients (median 4/20).

CONCLUSION

Laxative use is frequent in institutions for the mentally retarded, with a large inter-institution variation, indicating that constipation is an important problem and underlining the need for research into cost-effective treatment.

[Drug policy 1996]

The task of the authorities with regard to medications starts with formulating the appropriate rules concerning clinical studies, mainly for drugs that are not yet registered, and also includes registration and reimbursement. There is, however, an important task for the authorities with regard to post-marketing activities, e.g. pharmacovigilance and drug use studies, in order to define better the value of a product, with implications for the future fate and reimbursement of a product. The authorities have also an important role in providing information to those who prescribe, deliver or use medications. Also in order to improve prescribing, the prescriber should be aware of his/her prescribing pattern. Ever more emphasis is put upon the "rational use of drugs" (use only drugs for which validated studies exist, use them in an appropriate manner and with consideration for the financial aspects) and upon "Evidence-Based Medicine" and "Evidence-Based Pharmacotherapy". For rational prescribing and use of medications based on evidence, a long term policy is needed and Belgium has in this regard still much to do.

Effect of penicillin on the clinical course of streptococcal pharyngitis in general practice

The aim of the study was to explore whether penicillin was superior to placebo in altering the clinical course of proven streptococcal pharyngitis. A randomised, parallel, double blind placebo controlled trial of 10 days duration was undertaken in 42 general practices in the Gent region (Flemish part of Belgium). Phenoxymethylpenicillin (adults 250 mg t.i.d. and children 125 mg t.i.d.) or placebo were administrated to 173 patients, aged 5 to 50 y, with acute sore throat and a positive culture for Group A beta-haemolytic streptococci. Penicillin and placebo tablets were identical. Patient compliance was monitored by assay of penicillin in urine (Sarcina lutea method). The primary outcome variable was sore throat as recorded by the physician on Day 3. The experiences of the patients themselves over the 10 day period were also assessed. Secondary outcome variables were other local and general symptoms and signs of streptococcal throat infection. In the penicillin group on Day 3, 23.2% of the patients still complained of sore throat versus 65.9% in the placebo group: difference 42.7% (C.I. 29.4%, 56.1%). This finding was confirmed by survival analysis of the symptom 'sore throat', as recorded by the patients. The physicians recorded on Day 3 a significant positive effect on another symptom (malaise: P < 0.04) and certain clinical signs (abnormal throat: P < 0.07; and redness of throat: P < 0.003). Penicillin had more adverse effects than placebo (P < 0.007). It also inhibited the rise in ASLO (P < 0.001). In this study in general practice, penicillin had a slight but definitive positive effect on the clinical evolution of streptococcal pharyngitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Concentrations of 5-ASA and Ac-5-ASA in human ileocolonic biopsy homogenates after oral 5-ASA preparations

Intramucosal 5-aminosalicylic acid (5-ASA) and acetylated 5-ASA (Ac-5-ASA) concentrations were determined in ileocolonic biopsy specimens from 61 patients with irritable bowel syndrome treated for one week with near equimolar doses of different slow release preparations of 5-ASA (Claversal, Asacol, or Pentasa) or azo-bound drugs (Salazopyrin, Dipentum). The transit time in these patients was accelerated by a laxative, metoclopramide, and colonic lavage. The presence of 5-ASA in the mucosa was confirmed by autofluorescence. The highest concentrations of 5-ASA were obtained after Asacol (mean (SEM), 298.5 (37.3) ng/mg wet wt), followed by Claversal 500 mg (108.8 (11.7) ng/mg wet wt) and Pentasa (25.7 (2.2) ng/mg wet wt). Very low concentrations only were observed after Claversal 250 mg (0.3 (0.03) ng/mg wet wt), Salazopyrine (1.2 (0.1) ng/mg wet wt), and Dipentum (11.0 (3.2) ng/mg wet wt). The results for Ac-5-ASA were similar but the concentrations were generally lower. Serum concentration-time curves over eight hours were obtained from 34 healthy volunteers after a single oral dose of 400 to 500 mg of the different drugs. For the slow release forms, an apparently inverse relationship was found between the area under the curve of the serum concentrations and the intramucosal concentrations, supporting the importance of the local availability of the drug. This inverse relationship was absent for the azo-bound drugs. Colonic washout induced mechanical removal of intraluminal 5-ASA with a secondary disturbance in absorption resulting in a rapid decline in the serum concentrations. However, only for Dipentum did this result in significantly lower 5-ASA mucosal concentrations. This is the first reported attempt to evaluate the mucosal availability of 5-ASA after different oral preparations. It shows that where transit time is accelerated higher mucosal concentrations occur after slow release preparations (except for Claversal 250 mg) than after azo-bound drugs. Additional studies are necessary to correlate these concentrations with clinical effects.

PCNA expression in cutaneous keratinous neoplasms and verruca vulgaris

Using an antibody to PCNA and a standard immunohistochemical system, the authors examined normal epidermis and cutaneous neoplasias for expression of PCNA, a protein associated with DNA polymerase delta and DNA replication. In squamous cell carcinoma in situ (SCCI), a unique expression of PCNA, which frequently involved the nuclei of all keratinocytes within the lesion, was found. Heaviest staining was in the uppermost layers of the epidermis. PCNA expression ended abruptly at the histologic margin of the lesion. Because SCCI can be associated with the presence of human papillomavirus (HPV) DNA, the authors evaluated PCNA expression in verruca vulgaris and found a pattern similar to that in SCCI. Assuming that PCNA expression in these two lesions is related to cell division, the authors hypothesize that the mechanisms that control proliferation in SCCI may be similar to those operative in verruca vulgaris.

Use of pharmaceuticals in industrial workers--possible implications for epidemiological studies

A total of 129 workers exposed to carbon disulphide (CS2) and 81 non-exposed controls were asked about their current use of pharmaceuticals, using a self-administered questionnaire. In all, 31% of the exposed and 19.8% of the non-exposed used some medicine (P = 0.08). The average number of pharmaceuticals per subject amounted to 0.71 in the exposed vs. 0.36 in the non-exposed (P = 0.049). Predominant types of medicines used were analgesics (12.4% in the exposed vs. 8.6% in the non-exposed, P = 0.50) and sedatives/hypnotics (10.1% in the exposed vs. 4.9% in the non-exposed, P = 0.21). The pharmaceuticals consumed can cause numerous (side) effects that are similar to the toxic effects of CS2. To take into account these possibly confounding agents, a classification system for possible (side) effects of pharmaceuticals was developed, taking the dose into account. According to this method, many (side) effects of pharmaceuticals that could occur were recorded with higher frequency and intensity in the exposed subjects. Potential (side) effects that occurred significantly more frequently in the exposed than in the non-exposed were: tiredness, sedation, dizziness (20.9% vs. 4.9%, P = 0.001), excitation, anxiety (10.9% vs. 2.5%, P = 0.03), vision disturbances (7.0% vs. 0%, P = 0.01), and erection decrease (5.4% vs. 0%, P = 0.045). The implications of these findings for epidemiological studies are discussed.

[Tolerance to nitrate derivatives: clinical implications]

With chronic use of organic nitrates, attenuation of their clinical efficacy in angina pectoris and in congestive heart failure can occur. This attenuation is more pronounced if controlled release preparations for oral or transdermal use, leading to continuous high plasma concentrations of the nitrates, are used. Twenty-four hour protection, e.g. in a patient with angina pectoris, is not possible with nitrates, and other substances such as beta-adrenergic blockers and calcium antagonists will often have to be associated. The introduction of "nitrate-free periods" to overcome tolerance is discussed. The use of SH-providing substances such as N-acetylcystein to counteract the development of nitrate tolerance is, at this moment, only experimental.