[Assessment of possible drug-drug interactions in psychopharmacotherapy after hospital discharge using an interactive database]

INTRODUCTION

Psychiatry is confronted with increasing requirements in quality management, guidelines and an increasing proportion of elderly, chronic multimorbid patients with psychiatric disorders. The latter give rise to polypharmacy which may lead to drug-drug interactions. Assessment of drug interactions is more and more difficult as the total number of drugs taken increases. In the present study hospital discharge medication was analysed semiautomatically for possible drug-drug interactions.

METHODS

In-hospital cases were randomly selected. Discharge medication was analysed using PsiacOnline, a large web-based database for drug interactions.

RESULTS

The selection yielded 342 cases from 213 patients (mean age 46.3 years, 53 % females). 86 patients had one psychiatric diagnosis; the other patients had at least two or more diagnoses. The discharge prescription was analysed for 55 different psychotropic drugs from 4 large drug groups (18 antidepressants; 17 antipsychotic drugs; 5 mood stabilisers/epileptic drugs and 13 different hypnotic/anxiolytic drugs). Antipsychotic drugs were the most frequent drugs (n = 334); followed by antidepressants (n = 312) and mood stabilizers (n = 112). 47 patients (13.7 %) were discharged with monotherapy. Mean drug number was 2.7. PsiacOnline revealed 535 hits: 126 (23.6 %) combinations were non-critical, 86 (16.1 %) combinations were critical based on pharmacological properties of the drugs; 232 (43.4 %) combinations were critical according to in vitro studies or animal experiments; critical drug combinations in high-risk patients: 67 × (12.5 %); combinations with reported risks for side effects due to interaction: 17 × (3.2 %) and combinations with documented risks for severe drug interactions: 7 × (1.3 %).

CONCLUSION

Although the majority of drug combinations was considered not critical, approximately 3 % of cases had an increased risk for adverse drug actions and a further 1.3 % cases with a severe risk gave evidence that integration of an IT-based pharmacological expert system in a computerised physician order entry (CPOE) should be considered. Suggested beneficial effects need to be shown by an appropriately-designed clinical study.

[Improvement of CME questions from Der Nervenarzt]

BACKGROUND

Multiple choice questions play an important role in training and continuing education. Der Nervenarzt has been publishing articles for continuing medical education (CME) since 2002 which usually have ten multiple choice questions. Studies from other fields have shown that CME questions are often formulated awkwardly from a didactic standpoint. In this study we analyzed the CME questions contained in Der Nervenarzt to assess their instructional quality.

MATERIALS AND METHODS

The standardized evaluation was performed by semiskilled nonprofessionals. The setup permitted differentiation of 15 known quality criteria for multiple choice questions from the educational medical literature.

RESULTS

Of the 796 questions studied that had been posed in 2002-2008 (370 neurology, 346 psychiatry, and 80 interdisciplinary), 518 questions had an awkward construction for didactic purposes. A negative wording of the stem, followed by unintentional cues and obsolete combination formats were most frequently observed. The proportion of precisely phrased questions has increased significantly since 2006.

CONCLUSION

The CME questions in the German medical journal Der Nervenarzt have improved regarding their instructional quality since the beginning of the program.

[Differential diagnosis of neurodegenerative disorders in young adults]

Neurodegenerative diseases are relatively common and usually occur in older patients. In young adulthood, neurodegeneration is less common and more frequent due to underlying inborn errors of metabolism (IEMs) that typically have a wide range of clinical presentations. In the following overview, we present a case of SSPE and NBIA. The main differential diagnoses, cardinal symptoms, diagnosis and treatment options of neurodegenerative-like disesase in young adults are presented.

[Usage of drugs with potential adverse effects on cognition in a memory-clinic]

Cognitive decline is a frequent clinical symptom in elderly patients. In particular, memory disturbances are an early sign and a risk factor for subsequent development of neurodegenerative dementia. At the same time, elderly patients often receive multiple medications due to an increasing number of acquired diseases. Certain drugs have adverse side effects on cognition due to interference with the cholinergic or GABA-ergic system. This could lead to underestimation of the actual cognitive status at initial clinical presentation. In the present study we included 221 patients (mean age 68,5 years) who presented for the first time in a specialized memory-clinic and who had or developed dementia during follow up. Most patients had mixed vascular-degenerative dementia (57 %). On average, patients took 2.1 drugs. 19.9 % of the patients had medications with potential adverse effects on cognition. Patients with medication affecting cognition had a worse cognitive performance than patients with a medication not influencing cognitive functioning (Mini-Mental vs. 18.8. 22.01, p = 0.01) in univariate analysis. Psychotropic drugs were used less frequently (38 %) than primary non-CNS medication. The results remained unchanged even after performing a case-control study with the mixed dementia population with age and gender matched patients. However, in multivariate analysis, only the absolute number of medication taken remained as an independent factor. Our data highlight the clinical importance of medication history in the diagnostic work-up of cognitive impairment. The absolute number of medication taken seems to be more important than medication with possible adverse side effects on cognition.

[Sensitivity of neurochemical dementia diagnostics in CSF compared to 99mTc-SPECT in Alzheimer's dementia]

The diagnosis of Alzheimer's dementia is currently changing from a late and exclusion diagnosis towards a pathophysiology-based early and positive diagnosis. Especially advances in neuro-chemical dementia diagnostics in the cerebrospinal fluid (NDD-CSF) and imaging techniques like PET, SPECT or MRI are of particular interest. Unfortunately, many studies investigated only either one or other technique. In the present study 56 patients (average 67.1 years; average mini-mental status test (MMST) 22.2) were examined with the clinical diagnosis of Alzheimer's dementia. All patients both underwent NDD-CSF as well as 99mTc-SPECT. Only the SPECT, but not the NDD-CSF correlated with disease severity. Sensitivity of NDD-CSF was 89 % and SPECT 48 % for all patients and 93 % resp. 61 % for patients with MMST < 24. Below MMST 20 both methods had equal sensitivity. Both diagnostic techniques showed no statistic coherence (p = 0.27), neither after correction for subgroups like disease severity or the APOE genotype. Our results are compatible with the hypothesis that the NDD-CSF reflects beta-amyloid-aggregation and Tau-Protein pathology as a pathophysiologic biomarker. Our results suggest that SPECT is rather a state parameter for the rCBF changes following cortical neurodegeneration.

[Neuropsychological complications after coronary bypass grafting]

BACKGROUND

Coronary bypass grafting is more and more performed in elderly, atherosclerotic patients with increased risk of developing postoperative neuropsychological complications. In the present study, we investigated the relative importance of clinical, genetic or metabolic factors with possible impact on any of the primary endpoint encephalopathy, stroke and death after coronary bypass grafting.

METHODS

98 prospective patients (mean age 67.9 years, 23 females, 75 males) underwent conventional elective bypass surgery. All had standardized cardiovascular risk factor assessment, prior stroke, EuroSCORE, a neuropsychologic battery and testing for Apolipoprotein E (APOE) Genotype and Homocysteine. Follow up was possible on 90 patients postoperatively and after 3, 6 and 12 months, monitoring cognitive decline, death or dependency and general health assessment.

RESULTS

Early mortality was 3.1 % (3 patients); 3 patients (3.0 %) developed postoperative ischemic stroke and 2 further strokes occurred within the next 3 months. Postoperative encephalopathy occurred in 14 patients (14.3 %). Homocysteine elevation or Apolipoprotein E 4 (APO E 4) did not correlate with immediate postoperative cognitive function. Patients with high EuroSCOREs had significantly lower postoperative Mini-Mental scores. Neither Homocysteine nor presence of an APO E 4 allele was associated with any postoperative endpoint at 3, 6 or 12 months after surgery. The EuroSCORE was modestly associated with postoperative encephalopathy (relative risk 1.3 - 1.5), but not with outcome after one year. Preoperative stroke was highly associated with postoperative ischemic stroke and cognitive decline on follow-up (relative risk 11), but not with postoperative encephalopathy.

CONCLUSIONS

Amongst clinical factors, the EuroSCORE may indicate moderate risk increase for acute postoperative encephalopathy. Most strokes occur early after surgery. Patients having suffered stroke prior to cardiac surgery may represent a high-risk group in the acute as well as chronic outcome after cardiac surgery.

Genetic polymorphism of N-acetyltransferase 2 in the susceptibility to laryngeal squamous cell carcinoma

BACKGROUND

The purpose of this study was to investigate whether polymorphism of N-acetyltransferase 2 (NAT2) genotypes are associated with the risk of laryngeal squamous cell carcinoma (SCC).

METHODS

The study group consisted of 45 white patients with laryngeal SCC (42 men, with a mean age of 54 years [range, 37-70 years] and three women, with a mean age of 47 years [range, 32-55 years]) and 104 control subjects (68 men and 36 women; mean age, 50 years; range, 28-73 years). All of the patients were primarily treated with surgical intervention. Blood samples (5 mL) were obtained before surgery or from the patients under follow-up to 5 years after surgery (mean follow-up, 27 months; range, 6-48 months). DNA was extracted from the lymphocytes by high pure template preparation kit. NAT2*5A, NAT2*6A, NAT2*7A/B, and NAT2*14A were detected by use of LightCycler-NAT2 mutation detection kit by real-time polymerase chain reaction with Light Cycler instruments. The association between NAT2 polymorphisms and laryngeal SCC was prospectively modeled through multivariate logistic regression analysis.

RESULTS

We found that the risk of laryngeal SCC was 7.3-fold higher in individuals with NAT2*5 mutant allele, 3.8-fold higher in subjects with NAT2*6 heterozygote allele, and 38.3-fold higher in NAT2*6 mutant allele. We also found that individuals with NAT2*7 heterozygote allele had a 0.2-fold less risk for the development of laryngeal SCC (p = .018).

CONCLUSION

In this population, patients with NAT2*5 mutant and *6 heterozygous and mutant genotypes had a significantly higher risk for development of laryngeal SCC.

Nitric oxide reverses endotoxin-induced inflammatory hyperalgesia via inhibition of prostacyclin production in mice

We examined whether nitric oxide (NO), derived from constitutive NO synthase (NOS) and/or inducible NOS (iNOS), could contribute to endotoxin-induced inflammatory hyperalgesia via interacting with nuclear factor-kappaB (NF-kappaB), inducible cyclooxygenase (COX-2) and/or polyADP-ribose synthase (PARS). Injection of endotoxin (10 mg kg(-1), i.p.) to mice elicited hyperalgesia, determined by hot plate test, which is prevented by NO precursor (L-arginine), cNOS/iNOS inhibitor (N(G)-nitro-L-arginine methyl ester; L-NAME), NF-kappaB inhibitor (N-acetylserotonin), COX inhibitor (indomethacin), COX-2 inhibitor (DFU) and PARS inhibitor (3-aminobenzamide). Endotoxin caused a decrease in serum nitrite levels prevented by N-acetylserotonin, L-arginine, indomethacin, DFU or 3-aminobenzamide. Endotoxin increased serum 6-keto-PGF(1alpha) levels diminished by L-arginine or aminoguanidine (iNOS inhibitor). L-Arginine, L-NAME, aminoguanidine, DFU or 3-aminobenzamide prevented endotoxin-induced decrease in heart, lungs, kidneys and brain nitrite and malonedialdehyde levels and myeloperoxidase activity. In conclusion, NO reverses endotoxin-induced inflammatory hyperalgesia via inhibition of prostacyclin production, and also contributes to the analgesic effect of NF-kappaB, COX or PARS inhibitors.

Serum levels of antioxidant vitamins, copper, zinc and magnesium in children with chronic rhinosinusitis

Reactive oxygen species including hydroxyl radicals, superoxide anions and hydrogen peroxide which are produced by activated granulocytes play an essential role in many biochemical processes and diseases. Oxidant-mediated tissue damage may be important in the development of chronic sinusitis. The aim of this study was to investigate the serum levels of antioxidant vitamins and elements in 24 children (14 boys and 10 girls, age range: 7-12 years, mean age: 9.2 years) with chronic rhinosinusitis, compared to 20 age and sex matched healthy children. Blood samples were collected in the morning before breakfast and prior to any medication. Vitamin A, E and C levels were determined using reagent kits for high performance liquid chromatography. Cu, Zn and Mg levels were analyzed by atomic absorption spectrometry. Vitamin E, vitamin C, Cu and Zn levels were significantly lower in the patients group than in the control group. However, vitamin A and Mg levels did not differ. In conclusion, serum levels of antioxidant vitamins and elements may be important in the pathogenesis and treatment of chronic rhinosinusitis in children.