Biomarker Periodic Repolarization Dynamics Indicates Enhanced Risk for Arrhythmias and Sudden Cardiac Death in Myocardial Infarction in Pigs

BACKGROUND

Periodic repolarization dynamics (PRD) is an electrocardiographic biomarker that captures repolarization instability in the low frequency spectrum and is believed to estimate the sympathetic effect on the ventricular myocardium. High PRD indicates an increased risk for postischemic sudden cardiac death (SCD). However, a direct link between PRD and proarrhythmogenic autonomic remodeling has not yet been shown.

METHODS AND RESULTS

We investigated autonomic remodeling in pigs with myocardial infarction (MI)-related ischemic heart failure induced by balloon occlusion of the left anterior descending artery (n=17) compared with pigs without MI (n=11). Thirty days after MI, pigs demonstrated enhanced sympathetic innervation in the infarct area, border zone, and remote left ventricle paralleled by altered expression of autonomic marker genes/proteins. PRD was enhanced 30 days after MI compared with baseline (pre-MI versus post-MI: 1.75±0.30 deg2 versus 3.29±0.79 deg2, P<0.05) reflecting pronounced autonomic alterations on the level of the ventricular myocardium. Pigs with MI-related ventricular fibrillation and SCD had significantly higher pre-MI PRD than pigs without tachyarrhythmias, suggesting a potential role for PRD as a predictive biomarker for ischemia-related arrhythmias (no ventricular fibrillation versus ventricular fibrillation: 1.50±0.39 deg2 versus 3.18±0.53 deg2 [P<0.05]; no SCD versus SCD: 1.67±0.32 deg2 versus 3.91±0.63 deg2 [P<0.01]).

CONCLUSIONS

We demonstrate that ischemic heart failure leads to significant proarrhythmogenic autonomic remodeling. The concomitant elevation of PRD levels in pigs with ischemic heart failure and pigs with MI-related ventricular fibrillation/SCD suggests PRD as a biomarker for autonomic remodeling and as a potential predictive biomarker for ventricular arrhythmias/survival in the context of MI.

Atrial fibrosis heterogeneity is a risk for atrial fibrillation in pigs with ischaemic heart failure

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia and is associated with considerable morbidity and mortality. Ischaemic heart failure (IHF) remains one of the most common causes of AF in clinical practice. However, ischaemia-mediated mechanisms leading to AF are still incompletely understood, and thus, current treatment approaches are limited. To improve our understanding of the pathophysiology, we studied a porcine IHF model.

METHODS

In pigs, IHF was induced by balloon occlusion of the left anterior descending artery for 90 min. After 30 days of reperfusion, invasive haemodynamic measurements and electrophysiological studies were performed. Masson trichrome and immunofluorescence staining were conducted to assess interstitial fibrosis and myofibroblast activation in different heart regions.

RESULTS

After 30 days of reperfusion, heart failure with significantly reduced ejection fraction (left anterior obique 30°, 34.78 ± 3.29% [IHF] vs. 62.03 ± 2.36% [control], p < .001; anterior-posterior 0°, 29.16 ± 3.61% vs. 59.54 ± 1.09%, p < .01) was observed. These pigs showed a significantly higher susceptibility to AF (33.90% [IHF] vs. 12.98% [control], p < .05). Histological assessment revealed aggravated fibrosis in atrial appendages but not in atrial free walls in IHF pigs (11.13 ± 1.44% vs. 5.99 ± .86%, p < .01 [LAA], 8.28 ± .56% vs. 6.01 ± .35%, p < .01 [RAA]), which was paralleled by enhanced myofibroblast activation (12.09 ± .65% vs. 9.00 ± .94%, p < .05 [LAA], 14.37 ± .60% vs. 10.30 ± 1.41%, p < .05 [RAA]). Correlation analysis indicated that not fibrosis per se but its cross-regional heterogeneous distribution across the left atrium was associated with AF susceptibility (r = .6344, p < .01).

CONCLUSION

Our results suggest that left atrial cross-regional fibrosis difference rather than overall fibrosis level is associated with IHF-related AF susceptibility, presumably by establishing local conduction disturbances and heterogeneity.

Effects of Sex on the Susceptibility for Atrial Fibrillation in Pigs with Ischemic Heart Failure

Atrial fibrillation (AF) is the most prevalent arrhythmia, often caused by myocardial ischemia/infarction (MI). Men have a 1.5× higher prevalence of AF, whereas women show a higher risk for new onset AF after MI. However, the underlying mechanisms of how sex affects AF pathophysiology are largely unknown. In 72 pigs with/without ischemic heart failure (IHF) we investigated the impact of sex on ischemia-induced proarrhythmic atrial remodeling and the susceptibility for AF. Electrocardiogram (ECG) and electrophysiological studies were conducted to assess electrical remodeling; histological analyses were performed to assess atrial fibrosis in male and female pigs. IHF pigs of both sexes showed a significantly increased vulnerability for AF, but in male pigs more and longer episodes were observed. Unchanged conduction properties but enhanced left atrial fibrosis indicated structural rather than electrical remodeling underlying AF susceptibility. Sex differences were only observed in controls with female pigs showing an increased intrinsic heart rate, a prolonged QRS interval and a prolonged sinus node recovery time. In sum, susceptibility for AF is significantly increased both in male and female pigs with ischemic heart failure. Differences between males and females are moderate, including more and longer AF episodes in male pigs and sinus node dysfunction in female pigs.

A practical guide to setting up pig models for cardiovascular catheterization, electrophysiological assessment and heart disease research

Over the past years, the use of large animals has become increasingly interesting in translational research, to bridge the gap between basic research in rodents and targeted therapies in humans. Pigs are highly valued in cardiovascular research because of their anatomical, hemodynamic and electrophysiological features, which closely resemble those of humans. For studying these aspects in swine, cardiac catheterization techniques are essential procedures. Although cardiac catheterization seems to be comparatively easy in pigs as human equipment can be used to perform the procedure, there are some pitfalls. Here we provide a detailed protocol to guide the reader through different aspects of cardiac catheterization in pigs. We suggest an approach for safe intubation and extubation, provide tips for perioperative and postoperative management of the animals and guide the reader through different experimental steps, including sheath insertion. We also describe the procedures for basic electrophysiological assessment of conduction properties and atrial fibrillation induction, hemodynamic assessment via pressure-volume loops, right heart and left heart catheterization and the development of a myocardial infarction model by balloon occlusion. This protocol was developed in Landrace pigs and can be adapted to other pig breeds or other large animal species. This protocol requires approximately six and a half working hours in total and should be performed by researchers with previous experience in large animal experimentation and in the presence of a veterinarian.

Whole-Mount Immunofluorescence Staining, Confocal Imaging and 3D Reconstruction of the Sinoatrial and Atrioventricular Node in the Mouse

The electrical signal physiologically generated by pacemaker cells in the sinoatrial node (SAN) is conducted through the conduction system, which includes the atrioventricular node (AVN), to allow excitation and contraction of the whole heart. Any dysfunction of either SAN or AVN results in arrhythmias, indicating their fundamental role in electrophysiology and arrhythmogenesis. Mouse models are widely used in arrhythmia research, but the specific investigation of SAN and AVN remains challenging. The SAN is located at the junction of the crista terminalis with the superior vena cava and AVN is located at the apex of the triangle of Koch, formed by the orifice of the coronary sinus, the tricuspid annulus, and the tendon of Todaro. However, due to the small size, visualization by conventional histology remains challenging and it does not allow the study of SAN and AVN within their 3D environment. Here we describe a whole-mount immunofluorescence approach that allows the local visualization of labelled mouse SAN and AVN. Whole-mount immunofluorescence staining is intended for smaller sections of tissue without the need for manual sectioning. To this purpose, the mouse heart is dissected, with unwanted tissue removed, followed by fixation, permeabilization and blocking. Cells of the conduction system within SAN and AVN are then stained with an anti-HCN4 antibody. Confocal laser scanning microscopy and image processing allow differentiation between nodal cells and working cardiomyocytes, and to clearly localize SAN and AVN. Furthermore, additional antibodies can be combined to label other cell types as well, such as nerve fibers. Compared to conventional immunohistology, whole-mount immunofluorescence staining preserves the anatomical integrity of the cardiac conduction system, thus allowing the investigation of AVN; especially so into their anatomy and interactions with the surrounding working myocardium and non-myocyte cells.

Characterization of a porcine model of atrial arrhythmogenicity in the context of ischaemic heart failure

Atrial fibrillation (AF) is a major healthcare challenge contributing to high morbidity and mortality. Treatment options are still limited, mainly due to insufficient understanding of the underlying pathophysiology. Further research and the development of reliable animal models resembling the human disease phenotype is therefore necessary to develop novel, innovative and ideally causal therapies. Since ischaemic heart failure (IHF) is a major cause for AF in patients we investigated AF in the context of IHF in a close-to-human porcine ischaemia-reperfusion model. Myocardial infarction (AMI) was induced in propofol/fentanyl/midazolam-anaesthetized pigs by occluding the left anterior descending artery for 90 minutes to model ischaemia with reperfusion. After 30 days ejection fraction (EF) was significantly reduced and haemodynamic parameters (pulmonary capillary wedge pressure (PCWP), right atrial pressure (RAP), left ventricular enddiastolic pressure (LVEDP)) were significantly elevated compared to age/weight matched control pigs without AMI, demonstrating an IHF phenotype. Electrophysiological properties (sinus node recovery time (SNRT), atrial/AV nodal refractory periods (AERP, AVERP)) did not differ between groups. Atrial burst pacing at 1200 bpm, however, revealed a significantly higher inducibility of atrial arrhythmia episodes including AF in IHF pigs (3/15 vs. 10/16, p = 0.029). Histological analysis showed pronounced left atrial and left ventricular fibrosis demonstrating a structural substrate underlying the increased arrhythmogenicity. Consequently, selective ventricular infarction via LAD occlusion causes haemodynamic alterations inducing structural atrial remodeling which results in increased atrial fibrosis as the arrhythmogenic atrial substrate in pigs with IHF.

Study connective capabilities of solid residues from the waste incineration

Currently there is increasingly closer interaction between the importance of environmental protection and efficient promoting of scientific and technological progress in the field of waste incineration. Waste is not only undesirable source of pollution, but if it is effectively used it also has great economic importance. In the Czech Republic 34.5 million tonnes of all wastes was produced in 2017, of which 5.7 million tonnes of municipal waste. 50% of the produced municipal waste was used, 38% of which was used for the material and 12% for energy utilization. 45% of municipal waste was deposited in the landfills. The method of waste incineration is among the major tools to reduce the landfill waste. The use or processing of the product which the process of incineration of municipal and hazardous waste generated can be considered as an obstacle to the favorable reception of this process. Apart from flammable components, waste also contains certain amount of dangerous particles. This is especially the sulfur chlorides, fluorine, PCBs and other heavy decomposable organic substances and heavy metals. This fact puts high demands on the gas cleaning processes followed by neutralization of other products that the incinerator leaves, in which these substances can be contained in higher concentrations than in the original waste. For this reason subsequent stabilization of these toxic substances is necessary to ensure new environmental burdens are avoided when not used properly. The major part of the waste combustion process is made up of ash and slag. One of the most common ways of dealing with these solid residues is disposing them to avoid creating new hazardous waste landfills. Other filtering waste also passes hazardous waste stabilization process before landfilling. Currently there is intensive search for new possibilities for utilization of solid residues from incineration. Nowadays there is emphasis on process control of their pretreatment for the production of draft procedure with its management. Appropriate procedures may minimize the instances of improper use.

Patients' intention to consume prescribed and non-prescribed medicines: A study based on the theory of planned behaviour in selected European countries

WHAT IS KNOWN AND OBJECTIVE

Polypharmacy has a significant impact on patients' health with overall expenditure on over-the-counter (OTC) medicines representing a substantial burden in terms of cost of treatment. The aim of this study, which was conducted within the framework of a European Project funded by the European Union under the Seventh Framework Programme and was entitled OTC-SOCIOMED, was to report on possible determinants of patient behaviour regarding the consumption of medicines, and particularly OTCs, in the context of primary care.

METHODS

A multicentre, cross-sectional study was designed and implemented in well-defined primary healthcare settings in Cyprus, the Czech Republic, France, Greece, Malta and Turkey. Patients completed a questionnaire constructed on the basis of the theory of planned behaviour (TPB), which was administered via face-to-face interviews.

RESULTS AND DISCUSSION

The percentage of patients who had consumed prescribed medicines over a 6-month period was consistently high, ranging from 79% in the Czech Republic and 82% in Turkey to 97% in Malta and 100% in Cyprus. Reported non-prescribed medicine consumption ranged from 33% in Turkey to 92% in the Czech Republic and 97% in Cyprus. TPB behavioural antecedents explained 43% of the variability of patients' intention to consume medicines in Malta and 24% in Greece, but only 3% in Turkey. Subjective norm was a significant predictor of the intention to consume medicines in all three countries (Greece, Malta and Turkey), whereas attitude towards consumption was a significant predictor of the expectation to consume medicines, if needed.

WHAT IS NEW AND CONCLUSION

This study shows that parameters such as patients' beliefs and influence from family and friends could be determining factors in explaining the high rates of medicine consumption. Factors that affect patients' behavioural intention towards medicine consumption may assist in the formulation of evidence-based policy proposals and inform initiatives and interventions aimed at increasing the appropriate use of medicines.

Important drug interactions in patients with rheumatic disorders: interactions of glucocorticoids, immunosuppressants and antimalarial drugs

Despite the fact that biological treatments are very promising, classical immunosuppressants, antimalarial drugs and glucocorticosteroids are still very important and widely used in practice. Although drug interactions can have fatal consequences, few studies have reviewed drug interactions of these classical drugs used in rheumatology, and very few guidelines are available on this subject. Therefore, this report summarizes important interactions of immunosuppressants, antimalarial drugs and glucocorticosteroids with drugs commonly used in internal medicine. In the present study, more than 300 interactions were retrieved from the Micromedex ® database. The selection was reduced to the interactions rated as moderate, major or contraindicated. The selected interactions were further checked against PubMed ®, MEDLINE ®, InfoPharm Compendium of Drug Interactions and Summaries of Product Characteristics. For each interaction, its nature, mechanism, onset and clinical severity were indicated, documentation quality was rated and recommendations for clinical practice were formulated. Twenty significant interactions that we rated as moderate, severe and very severe were identified. Interacting drugs were warfarin, fluoroquinolones, azole antifungals, co-trimoxazole, proton pump inhibitors, amiodarone, cholestyramine, activated carbon, allopurinol, angiotensin-converting enzyme inhibitors, statins, digoxin, iron, aluminium and magnesium salts, and hepatotoxic and nephrotoxic agents.

[Pharmaceutical care of patients with diabetes mellitus and its relationship to clinical pharmacy]

INTRODUCTION

Pharmaceutical care develops both at universities in the Czech Republic and in daily practice, and is focused on drug-related issues as a pharmacist has the broadest knowledge of the drug and offers such knowledge to other persons involved in patient care. Pharmaceutical care is part of health care and although the pharmacist is considered to be a health service officer by legislation, health insurance companies--probably due to the fact the pharmacist is paid based on the margin obtained in business activities from the purchase and sale of prescribed drugs--do not see the pharmacist as such and they need to be convinced that such activity is necessary for the patient and is positive within the medical team. The aim of the article is to define what pharmaceutical care is, where it can be provided, why it is necessary within medical and nursing care, and to point out drug-related issues occurring in diabetic patients as well as the method for identifying and resolving them.

METHOD

The method is the answer to the following questions: Where to class pharmaceutical care and how to define the knowledge preconditions for such activity? Where is pharmaceutical care provided and what is its objective? How and where is pharmaceutical care taught? How can pharmaceutical care be applied in diabetology? The answers to the questions raised are based on literature and the authors' own teaching experience and activities performed in the position of clinical pharmacist at the 2nd Department of Internal Medicine of the University Hospital in Hradec Králové. Another method was the analysis of the incidence of drug issues related to the prescription of antidiabetics identified by 66 pharmacists over 2 months of active recording of drug-related issues and detected in hospitalized patients of the 2nd Department of Internal Medicine, both in outpatient and inpatient care. Another method was the monitoring of physicians' opinions about the doctor-pharmacist cooperation in the form of an interactive lecture at the spring congress of physicians in Prague in 2008.

RESULTS

The basic method of pharmaceutical care is the maximization of benefits (instructions, how to use the drug correctly, how to support the patient's compliance, change in lifestyle) and the minimization of risks (to look for risk signals and to help resolve them; to resolve them directly with the OTC drug). Pharmacists can do this, in particular, if they are educated in clinical pharmacy and have sufficient training in pharmaceutical care--which nowadays is not an inaccessible activity. Pharmacists have identified, within the analysis of drug-related mistakes, 38 drug issues related to antidiabetics--which represent approximately 3 percent of all detected drug-related issues. The following problems were identified in diabetic patients at the 2nd Department of Internal Medicine: high doses of hydrochlorothiazide administered to diabetic patients, the administration of beta-blockers to diabetic patients with hypoglycemic attacks, the administration of metformin to a patient with malfunctioning kidneys, the reduction of corticoids without sufficient diabetes control. Most of the interviewed physicians (approx. 200) supported active cooperation with pharmacists not only in economic but also in professional issues.

CONCLUSION

A pharmacist is able, within pharmaceutical care, to identify the first signs of the disease and to recommend the patient for a medical examination. He can detect drug-related issues thus minimising risks. He can maximise the effect by supporting drug compliance, repeating instructions for use of the drug and recommending a change in lifestyle; he can also help detect and minimise the impact of various risk factors. All these activities (in the strategic alliance of doctor-patient-pharmacist) can reduce the incidence of complications, which are expensive for the payers and reduce the quality of the patient's life.

Can intranasal corticosteroids cause migraine-like headache?

Intranasal corticosteroids (INCs) act predominantly locally and are considered to exert minimal systemic effects. On reviewing the international data collected in the World Health Organization's global pharmacovigilance programme an unexpected cluster was found of 38 case reports of migraine in suspected connection with INCs. These reports came from five countries (May 2007) and concerned six different drugs. In all reports the INC was the sole suspect drug. In nine cases re-exposure to the drug had taken place, leading to the recurrence of the event in eight of these patients. However, INCs are mainly used for rhinitis, and there is a known connection between rhinitis and migraine. Although representing only 0.6% of the total of case reports, international pharmacovigilance data suggest that the use of INCs may cause or trigger migraine or migraine-like headache. Further study is needed to determine if the reported association is true or not and, if so, what the possible mechanism is.

Improvements in antibiotic prescribing by community paediatricians in the Czech Republic

Repeated surveys among primary care paediatricians were performed annually from 1998 to 2002 in the Czech Republic. The task was to assess the prescription of antibiotics in treatment of respiratory infections in children. The results were evaluated in the light of existing guidelines and conclusions were used in a number of interventions aimed at reducing the inadequate use of antibiotics and hence preventing the potential increase of the antibiotic resistant bacteria. In addition, data on overall consumption of antibiotics in outpatient care and trends in the prevalence of resistant strains of Streptococcus pneumoniae and Streptococcus pyogenes are discussed.

Mannose-binding lectin gene polymorphic variants predispose to the development of bronchopulmonary complications but have no influence on other clinical and laboratory symptoms or signs of common variable immunodeficiency

Mannose-binding lectin (MBL), activating protein of the lectin pathway of the complement system, is an important component of the non-specific immune response. MBL2 gene polymorphisms, both in the coding and promoter regions, lead to low or deficient serum MBL levels. Low serum MBL levels were shown to be associated with serious infectious complications, mainly in patients in whom other non-specific immune system barriers were disturbed (granulocytopenia, cystic fibrosis). We have analysed two promoter (-550 and -221) and three exon (codons 52, 54 and 57) MBL2 polymorphisms in a total of 94 patients with common variable immunodeficiency (CVID) from two immunodeficiency centres. Low-producing genotypes were associated with the presence of bronchiectasis (P = 0.009), lung fibrosis (P = 0.037) and also with respiratory insufficiency (P = 0.029). We could not demonstrate any association of MBL deficiency with age at onset of clinical symptoms, age at diagnosis, the number of pneumonias before diagnosis or serum immunoglobulin (Ig)G, IgA and IgM levels before initiation of Ig treatment. No association with emphysema development was observed, such as with lung function test abnormalities. No effect of MBL2 genotypes on the presence of diarrhoea, granuloma formation, lymphadenopathy, splenomegaly, frequency of respiratory tract infection or the number of antibiotic courses of the patients was observed. Our study suggests that low MBL-producing genotypes predispose to bronchiectasis formation, and also fibrosis and respiratory insufficiency development, but have no effect on other complications in CVID patients.

[Risk of drug interactions and their possible solutions in the population of patients with inflammatory bowel disease]

Concurrent use of several medicinal preparations is connected with an increased risk of the occurrence of drug interactions. This study analyzes the complete pharmacotherapy of 573 patients diagnosed with inflammatory bowell disease. An analysis of the medication of the cohort of patients tested identified potential drug interactions of all degrees of gravity. All drug interactions in the study were considered to be only potential, and therefore they are not known to cause any complications for the patient. An important factor in the process of revealing drug interaction may be the pharmacist during dispensation in a pharmacy. Pharmacist's expertise of the problems of drug interactions is a component of his/her professional competence and should be continuously intensively increased in postgraduate education. This study is not limited to simply stating the occurrence of potential drug interactions. It is also focused on the management of drug interactions from the party of the physician and the pharmacist and attempts to outline the way of encountering this problem.

[Consumption of old and new antiepileptic drugs in the Czech Republic in 1999-2004]

Trends in antiepileptic drug (AEDs) consumption in the period from 1999 to 2004 in the Czech Republic were assessed in this study. The data from extramurally prescribed, reimbursed AEDs were obtained from the Czech Health Insurance Company Skoda Mladá Boleslav. The AEDs utilization was assessed according to ATC/DDD methodology on the fourth and fifth level of the ATC classification and expressed as the number of defined daily doses per 1000 insured per day (DDD/TID). During the study period, the AEDs consumption increased by 130%; 76% of which consisted of new AEDs. The most frequently prescribed drugs were carbamazepine and valproate. It correlates well with recent guidelines, where carbamazepine and valproate are licensed as the first line therapy in the treatment of epilepsy. The utilization of barbiturates and hydantoines is decreasing. Gabapentin, lamotrigine and topiramate were the most frequently prescribed new AEDs. The total cost of AEDs increased three times, 84.5% of this increase accounted for new AEDs. The outcomes are in agreement with current recommendations. The AEDs consumption follows trends similar to those in other countries with a fast shift to new antiepileptic drugs.

The spectrum and types of adverse side effects to biological immune modulators: a proposal for new classification

In recent years, a growing number of biological agents such as cytokines, monoclonal antibodies and fusion proteins have become available for the treatment of various autoimmune, neoplastic, cardiovascular, infectious, allergic, and other conditions. Their introduction has resulted in marked clinical improvements for many patients. Nevertheless, a variety of adverse side effects have been observed with these agents. Based on the special features of biological agents a new classification of these side effects of biological agents is proposed--related but clearly distinct from the classification of side effects observed with chemicals and drugs. This classification differentiates five distinct types, namely clinical reactions due to high cytokine levels (type alpha), hypersensitivity due to an immune reaction against the biological agents (type beta), immune or cytokine imbalance syndromes (type gamma), symptoms due to cross-reactivity (type delta), and symptoms not directly affecting the immune system (type epsilon). This classification could help to better deal with the clinical features of these side effects, to identify possible individual and general risk factors and to direct research in this novel area of medicine.

Deep vein thromboembolism in malignant diseases

Tumourous diseases are associated with haemorrhagic as well as thrombotic complications. Trousseau described in 1865 a mutual association between tumourous diseases and venous thromboembolism. As many as 15-20% patients with venous thromboembolism have an undetected malignity, which equals a prevalence of 2-3% in the population. From this ensues the relative risk of a newly diagnosed malignity which is higher during the first year after venous thromboembolism. Migrating thrombophlebitis is a relatively specific sign in tumours, in particular in pancreatic tumours. In the pathogenesis of venous thromboembolisms in tumourous diseases, the following factors play a significant part: elevated coagulation parameters, reduced fibrinolysis, frequent immobilization, surgical operations in the case history, chemotherapy, hormonal therapy and central venous catheters. Conventional long term management of VTE involves the use of vitamin K antagonists, such as warfarin, to reduce the risk of recurrence. Recent evidence-based approach in long term management of VTE in patients with tumorous disease shows that the use of LMWH offers an effective alternative to VKAs with higher efficacy, without a significantly increased risk of bleeding, and without the need for regular laboratory monitoring.

[The role of anti-ulcerative drugs in treatment and prevention of gastropathies induced by nonsteroidal anti-inflammatory drugs]

Nonsteroidal anti-inflammatory drugs (NSAIDs) as effective agents for the relief of pain and inflammation are among the most widely prescribed drugs. Unfortunately, their benefits especially for patients with osteoarthritis and other chronic musculoskeletal conditions, are accompanied by well established toxicity. A significant percentage of NSAIDs users experience some type of gastrointestinal adverse events, ranging from manageable dyspepsia to clinically important complications (gastrointestinal bleeding, ulcer perforation, obstruction). In an attempt to reduce the incidence of NSAID-induced gastropathy, the following approaches have been proposed: avoidance of NSAIDs or minimising their dosage, selecting NSAID known to cause less damage and coprescription of various agents. Patients who require NSAIDs therapy should be assessed for factors that increase risk of gastrointestinal damage. In high risk patients, use of misoprostol, which reduces even serious gastrointestinal complications, or proton pump inhibitors, whose efficacy in preventing gastroduodenal ulcers due to NSAIDs exposure has been demonstrated in large clinical trials, is possible to use. The first step in the treatment of NSAID-associated ulcers lies in discontinuation of NSAIDs therapy. If NSAIDs cannot be withdrawn, an antisecretory therapy should be initiated. Proton pump inhibitors appear to be the most effective at healing NSAID-related ulcers among whose with continuous NSAIDs therapy. Another therapeutic option in the management of NSAID-gastropathy is to use specific cyclooxygenase-2 inhibitors. However, the clinical experience with these agents is still limited and further surveillance to resolve this issue as well as e.g. the role of Helicobacter pylori infection in NSAID-induced gastrointestinal injury are needed.

[Comparison of utilization of cardiovascular drugs in the Czech Republic and in Wales]

AIM

To compare and describe the trends in the consumption of selected groups of cardiovascular drugs in several districts of the Czech Republic and counties of Wales in the period of 1997-2000.

METHODS

A retrospective analysis of prescription data from General Medical Insurance Company (three districts in the Czech Republic) and data from the Health Solutions Wales (3 counties of Wales). The data were analyzed during seven half-year intervals from January 1997 till June 2000. The authors investigated the consumption of antihypertensives, diuretics, beta-blockers, calcium channel blockers, ACE inhibitors, hypolipidemic drugs, digoxin and acetylsalicylic acid classified according to ATC classification. The drug consumption was expressed at defined daily doses (DDD) and standardized per 1,000 insured individuals and day for the Czech districts and per 1,000 inhabitants and day for the Welsh counties (DID).

RESULTS

The total consumption of the cardiovascular drugs under study in the last half-year of the investigated period of time (1/00) proved to be highest in CZ2 (40.2 DID), the value being by 40% higher than in CZ1 (348.6 DID) and by 11% higher than in CZ3 (386.9% DID). The rates of consumption in the Welsh counties during this period of time were 338.8 DID (W1), 307.9 DID (W2) and 298.0 DID (W3), respectively. Diuretics proved to be used at the highest rate in both countries. The consumption of thiazides and loop diuretics in the Czech districts during 1/00 represented 67.6% and 16.7% of the all diuretic consumption on the average, whereas the corresponding values in Wales were 42.3% for thiazide preparations and 46.7% for the loop diuretics. An increase in the consumption of new drugs such as ACE inhibitors, calcium channel blockers of 2nd generation and statins was noted in both countries. The statins represented 33.5% of total prescription of hypolipidemic drugs in the Czech districts, whereas their consumption in the Welsh districts represented 88.1% consumption of these drugs.

CONCLUSION

The most significant differences were found in the consumption of diuretics and hypolipidemic drugs. The results of consumption studies could highlight the differences in drug utilization and thereby stimulate discussion on optimization of drug selection.

[Characteristics of patients with osteopenia treated with glucocorticoids at the Osteoporosis Clinic of the Medical Faculty Hospital in Hradec Kralove]

One-hundred-ninety-seven osteopenic or osteoporotic patients registered at the University hospital osteology outpatient clinic during 1995-1999 and exposed to glucocorticoids were included in the cohort. Prevalence of glucocorticoid treatment (of all patients) was 12.4%. The patients diagnosed with rheumatoid arthritis showed the greatest reduction in bone density (average T-score = -2.70), fractures were most frequently recorded in patients suffering from asthma or lupus erythematodes.

[Use of a health insurance company database for study of theoretical exposure to hypolipidemic agents]

OBJECTIVE

The objective of the investigation was to analyze theoretical exposures to hypolipidaemics in patients treated chronically with these drugs, using the database of the health insurance company.

INVESTIGATED GROUP

From the database (with information on age, sex of the insured person, the number of packages and the type of hypolipidemic and year of issue of the prescription) of subjects insured at the Employees Health Insurance Skoda Mladá Boleslav comprising some 100,000 insured subjects in 1994-2000. Patients with long-term (more than one year) hypolipidaemic treatment were selected in years from 1995 to 1999. The group increased every year. In 1995 it comprised 668 cases in 1999, 2396 subjects.

METHOD

The consumption of hypolipidaemics was expressed in defined daily doses (DDD). The authors investigated the ratio of chronically treated patients and the proportion of the following groups of patients according to their annual consumption in 1995-1999: group of of drug "vacation" (0 DDD) and the group with a low (< 121.7 DDD), medium (< 243.3 & > 121.7 DDD) and optimal (> 243.3 DDD) consumption of hypolipidaemics and their relationship to sex and age. For statistical ealuation software SPSS 10.1 was used.

RESULTS

In the course of the investigation among the insured subjects the statin consumption increased 76 times and the consumption of fibrates 5 times. The ratio of consumption of resin derivatives and of nicotinic acid was negligible. The size of the group of subjects treated with hypolipidaemics for longer than one year increased from 0.8% in 1995 to 2.2% of the database. The average age increased from 55 to 59 years. The ratio of seniors (> or = 65 years) increased in the course of the investigation and reached 33% in 1999 of all members of the investigated group. The mean annual consumption of hypolipidaemics increased significantly as compared with 1995 and the interannual increase as compared with the previous year was statistically significant in 1997 and 1999. In 1999 it was 237 DDD/per consumer. A lower consumption was recorded in women and in seniors. Drug "vacations" were recorded in 6% of the insured subjects of the group and the frequency did not change significantly in the course of the investigation and no relationship with age and sex was found. A low exposure according to DDD was found in 20%, medium exposure in about 40% and optimal exposure in only one third of the subjects of the investigated group.

CONCLUSION

The authors developed a method which makes it possible, when individual data of the health insurance company are available, to investigate the theoretical exposure to hypolipidaemics in insured subjects treated on a long-term basis with these drugs. The authors provided evidence that analysis of the database of the health insurance company can provide certain signals for further pharmacoepidemiological research and for application in a defined medical discipline. Some of the insured subjects are exposed to smaller doses than theoretically assumed. It is necessary to extend the investigation so that the results will better reflect the population of patients and prescribing physicians. Complete evaluation of cases with a low exposure from the aspect of morbidity and drug compliance will be also essential.

[Monitoring utilization of hypolipemic agents using an insurance company database]

Databases of health insurance companies can provide information on the motion of a drug in the society. The present paper examines several databases of health insurance companies and analyzes the development of the consumption of hypolipidemic agents in 1994 through 1998. So-called evaluation databases making it impossible to identify a particular patient and the prescribing physician were prepared for the evaluation. They were obtained from the VZP central health insurance office, VZP district health insurance offices in Hradec Králové and Kladno, and the Zamĕstnanecká pojistovna Skoda (Employees Health Insurance Company Skoda). It was not necessary to blind the data in the first cohort, in the second one it was carried out by shortening the identification numbers, and in others by introducing artificial identification codes. The consumption was expressed in DDD and in the relative representation in the group. The consumption of the principal groups of hypolipidemic agents (fibrates, statins, sequestrants of bile acids, and derivatives of nicotinic acid) and the individual medicinal substances was evaluated. Relative values of consumption were obtained by calculation to the magnitude of the denominator--the number of the insured, or the number of patients to whom a hypolipidemic agent was prescribed. The consumption was on the increase in all three databases, in four years increasing from approx. 0.4-4DDD/1000 of the insured/day to 16-24DDD/1000 of the insured/day. At the beginning, the main share in the consumption of hypolipidemic agents was represented by fibrates, approx. 90%, but in four years this share decreased to only 60%, whereas in the period under study the share of statins increased up to 30%. Databases of health insurance companies do not significantly differ in the consumption of hypolipidemic agents, which may give evidence of their validity. In the course of the study, an increase in the consumption of hypolipidemic agents, primarily statins, was found. The shift in the consumption of statins corresponds with the available information about the evidence of their therapeutic effectiveness. The average consumption per one patient does not reach 1DDD, which is a signal that probably very few patients receive long-term treatment and that new patients emerge during the year.

[Cross-sectional study of choice of drug therapy in the acute phase of treatment in acute myocardial infarct--part 1]

INTRODUCTION

Treatment of acute myocardial infarction is undergoing changes. In the treatment of acute myocardial infarction in particular the following proved useful: thrombolysis, administration of anti-aggregating drugs, beta-blockers and inhibitors of angiotensin converting enzyme. An decisive part is played by the interval between the onset of symptoms and the beginning of hospital treatment.

OBJECTIVE

To describe treatment of patients hospitalized at intensive care units for acute myocardial infarctions. Investigate differences between faculty and other hospitals.

METHOD

The authors investigated by means of questionaires in a prospective study during the first three months in 1996 all patients who were hospitalized on account of acute myocardial infarction. The investigation was implemented in seven intensive care units of faculty hospitals and in nine intensive care units of hospitals and information on diagnosis, pharmacotherapy and results of therapy were assembled. During the first 24 hours of treatment more detailed information was procured.

RESULTS

Antiaggregants were used in 88%, nitrates in 77.8%, thrombolytics, beta-blockers and and ACE inhibitors in ca 30% patients. Percutaneous transluminal coronary angioplasty was used in ca 7% patients.

CONCLUSIONS

The authors describe treatment of the acute stage of myocardial infarction. In faculty hospitals in 1996 thrombolysis, percutaneous transluminal coronary angioplasty, beta-blockers and nitrates by the i.v. route were used more frequently.

[Prognosis for the development of Czech pharmaceutical services]

On the basis of a survey of opinions of Czech pharmaceutical experts a prognosis of some changes in the pharmaceutical service in the Czech Republic was made by means of Delphi method. It has been confirmed that the use of this method is suitable for this purpose. It has followed from the answers of the experts that implementation of most innovations in the pharmaceutical service will take place at the beginning of the new century. Most of them believe in rapid introduction of computer technology into pharmacies and limitation of the assortment sold in pharmacies. A decrease in extemporaneous preparation below 5% and an establishment of fixed prices of pharmaceuticals for the final consumer are considered possible. Preparation of infusion mixtures exclusively in pharmacies and introduction of the one-dose system is considered as a long-term task.

European drug information centres--survey of activities

A questionnaire survey of European drug information centres (DICs) was conducted. DICs mentioned in the ESCP directories and other sources were identified and contacted. Information on basic characteristics was obtained: affiliation, the scope of activities, employees, question-answer service characteristics, information sources and the economic aspects of the DICs' work. Information from 84 DICs was analysed (return rate = 71.3%). DICs are mainly affiliated to hospitals (68%), rather rarely with faculties of pharmacy (6%) or with faculties of medicine (8.3%). Activities of DICs mainly include: question-answer service (98%), issue of bulletins (68%), participation in P&T committees (63%), tuition (61%) and drug-use evaluation (52%). Pharmacists, 1-2 full- or part-time, are the most frequent employees working in the DICs. When the question-answer service was analysed, it was found that 56% of the DICs are open only to the health-care professionals and 43% provide a service to the lay public. Questions are mainly concerned with the side effects, indication/therapeutic use and the dosage of the drugs. The majority of DICs (91%) document their activities, very often on a computer database. Quality assurance is provided by almost 75% of DICs, usually by a review (58%) or a feed-back questionnaire (32%). Information sources listed as most frequently used include Martindale--The Extrapharmacopeia, journals such as Lancet, Medline and Micromedex databases. DICs are usually financially supported by the organizations to whom they are affiliated. Fees are charged, for special activities, by 9.5% of DICs.

Lung diffusion estimated by oxygen and carbon monoxide

The study was objected to the comparison of the results of lung diffusion estimated by oxygen to those of routinely used single breath carbon monoxide method. The method described is based on the analysis of the speed of response of arterial partial oxygen pressure (paO2) to increasing inspiratory fraction of oxygen (Fi). The transcutaneous oximetry was used to follow paO2 by means of transcutaneous oxygen pressure (ptCO2). The study was performed on 35 patients of both sexes with interstitial lung involvement with normal or only slightly decreased FVC and FEV1. The close correlation between the results of both methods was proved (r = 0.848, p < 0.0001).

[Analysis of the activities of the Information Service of the National Institute for Drug Control]

An analysis was carried out concerning the questions regarding drug information solved by the information service section of the State Institute for Drug Control (SUKL) in 1992-1995. A rapid decrease in the number of questions was observed during the period under study. This trend was mainly caused by a decline in questions regarding the availability of drugs in the market. Questions were posed in a similar ratio by physicians and pharmacists predominantly from Prague and surrounding areas. Questions from other categories of health-care professionals and the lay public are in minority. Most questions focus on the characteristic of the drug and its availability. AISLP, Martindale and Rote Liste serve as the principal information sources.

Distribution of fenofibric acid in lipoprotein fractions of patients

The antidyslipidemic agent fenofibrate (procetofen) is hydrolysed in vivo to its main active metabolite--fenofibric (procetofenic) acid. This metabolite is usually determined in pharmacokinetic studies, because plasma concentrations of fenofibrate are practically undetectable. Presented study is focussed on the distribution of fenofibric acid into lipoprotein (VLDL, LDL, IDL and HDL) fractions of human and (for comparison) minipig blood plasma, which has not been studied yet. In order to obtain more accurate results, a new HPLC method based on the use of newly synthetized internal standards was developed. Four homologues of fenofibric acid prepared have identical chromophoric part of their molecules and hence the same UV spectra as fenofibric acid. From this point of view, these standards are more suitable for determination of fenofibric acid than the formerly used ones--naproxen or bezafibrate. Fenofibric acid levels in the high density lipoprotein fraction has been shown to be significantly higher (in both human and minipig plasma) than in the other lipoprotein fractions. This fact may be explained by higher affinity of the fenofibric acid to proteins constituting major part of the high density lipoprotein fraction.

Monitoring of TPN consumption at the University Teaching Hospital in Hradec Králové

To standardize studies on the utilization and consumption of drugs, the World Health Organization recommends the use of the Anatomical Therapeutic Chemical (ATC) classification system, using the defined daily dose (DDD value) as a technical unit of measurement of drug consumption. DDD values of total parenteral nutrition have not been established yet. In our descriptive study the methodology by E. Frankfort et al. (1993) is used. This methodology allows the calculation of both the total number of DDD values for TPN and the number of DDD values for the individual substances. Suggested DDD values and consumption of total parenteral nutrition by E. Frankfort et al. (1994) were compared with the values at the Teaching Hospital in Hradec Králové. During 3 months 142 patients administered only TPN were included in the study. The following data from every patient were collected: sex, age, the main diagnosis, composition of TPN each day and duration of this administration. The mean PDD value for carbohydrates was 200 +/- 41 g, for fat emulsion 77 +/- 27 g and for amino acids 93 +/- 16 g. The difference between our and Frankfort's results were found.

[Development of resistance and utilization of fluoroquinolones in a university hospital]

The results of a retrospective study in the Faculty Hospital, Hradec Králové (FHHK) show a steep increase in the consumption of fluoroquinolones in the course of six years. Since 1989, when 360 defined daily doses (DDD) were administered, the consumption increased to 2,825 DDDs in 1992 and 52,162 DDDs in 1995. At the same time, resistance to ofloxacine and ciprofloxacine was increased many times in some bacterial species isolated from patients admitted to FHHK. In the strains Pseudomonas aeruginosa, resistance to ofloxacine increased from 3% to 38% in 1995, in Serratia marcescens from 13% in 1992 to 30% in 1995. A marked increase was observed also in Acinetobacter calcoaceticus. In the naturally highly sensitive species E. coli and Klebsiella pneumoniae no increase in resistance has been observed yet, in Enterobacter cloaceae resistance slightly increased (from 0% in 1992 to 7% in 1995). Due to the fact that in FHHK fluoroquinolones take the first place in the consumption of antibiotics at present, an increase in resistance can be expected also in these bacteria in the future. Investigation of changes in resistance due to the consumption of fluoro-quinolones is a suitable model of a pharmacoepidemiological study (DUE-Drug Utilisation Evaluation) as the relationship of the consumption of a drug and its effect can be observed practically since the introduction of fluoroquinolones into the market.

Drug information centre--analysis of activities of a regional centre

Description and evaluation of a drug information centre's (DIC) professional activities one year after establishment are summarized. The aims of the centre are: to evaluate which problem areas are frequently requested, how frequently and by whom; which information sources are the most appropriate for the service and the approximate cost of such a service. We received 80 questions during the first 8 months. The questions were mainly asked by hospital physicians (32.5%) and pharmacists (32.5%), other health-care professionals were a minority; the scopes of most frequently asked questions include general properties of active substances (12.2%), contents of particular preparations (21%), dosage (11%), side effects (21%) and indications/contraindications (15%). Cost of the service included variable (mainly phone and mail charges, copy and print of the documents) and fixed costs (cost of software and salary of the staff).

Analysis of pharmacotherapy of hypertension in out-patients

In the present pilot study an attempt was made to evaluate the usefulness of results obtained about the treatment of patients suffering from high blood pressure for a pharmacoepidemiological study of the therapeutic value of antihypertensive agents. Data from 90 hypertensive patients were used in the present retrospective-prospective study. These patients all attended an out-patient clinic located in one of the East-Bohemian districts that are participating in the MONICA programme. Instead of the analysis of the population data, regular blood pressure measurements, plasma glucose levels, and total cholesterol concentrations were measured and analysed. The consumption of various antihypertensive drugs in this study was similar to that found in larger studies performed in other health districts of the Czech Republic. Diuretics were the drugs most frequently prescribed for hypertensive patients. General practitioners rarely prescribed calcium channel blockers and angiotensin-converting enzyme inhibitors in 1990 and 1991. The metabolic effects of antihypertensive drugs, mostly diuretics, were not significantly evident. The most frequent occurrence of non-compensated blood pressure was recorded for the treatments with Trimecryton and methyldopa. However, the validity of these findings should be tested in a larger group of hypertensic patients.

Pharmacokinetic parameters of verapamil and its active metabolite norverapamil in patients with hepatopathy

Verapamil (CAS 52-53-9) is a calcium channel blocker with a vasodilatatory effect. Because of its significant first-pass effect, verapamil might be advantageous in the treatment of portal hypertension. It does not produce any excessive systemic effects, provided the doses are suitably adjusted. A decision was made to examine the pharmacokinetic parameters, independent of compartmental analysis of verapamil and its active metabolite norverapamil, in patients with portal hypertension. Their biological half-lives of the terminal phase were significantly prolonged as compared with the control group. However, no statistically significant differences were found in the values of tmax and Cmax. The calculated pharmacokinetic parameters of norverapamil were not significantly different from those of verapamil, except for the tmax of norverapamil, which was significantly longer in patients suffering from portal hypertension as compared with verapamil. The ratio of areas under the plasma concentration-time curve (AUC) of verapamil and norverapamil was comparable in both groups of patients. No relationship between the changes in the pharmacokinetic parameters and the extent of hepatic insufficiency was observed.

Hyperparathyroidism after kidney transplantation: a retrospective case controlled study

We studied retrospectively patients with hyperparathyroidism after successful renal allotransplantation. Since 1972, 1119 transplantations have been performed in our department, and 534 patients survive with functioning grafts. Hyperparathyroidism requiring parathyroidectomy developed in 32 (5.9%). The frequency of interventions increased markedly after introduction of cyclosporine A treatment in our unit. The time between transplantation and parathyroidectomy was 22.5 months (SD 16.5, range 1-82 months). The age of the patients was 49.0 years (SD 10.5, range 17-63 years); the group consisted of 16 female and 16 male patients. All patients but two (no measurement performed) repeatedly exhibited high serum parathormone and calcium levels and therefore underwent surgery. In comparison to a control group, matched for time of transplantation, age, sex, and cause of renal failure, the patients with hyperparathyroidism had longer dialysis treatment (54.2 months, range 9-132 vs 26.9 months, range 1-72) and exhibited lower phosphate concentrations in the early posttransplantation period. Before surgery, serum chemistry was different for hyperparathyroid and control subjects: serum calcium 2.80 +/- 0.23 mmol/l vs 2.48 +/- 0.13 mmol/l and alkaline phosphatase 157.4 +/- 92.0 U/l vs 85.2 +/- 51.5, respectively. We did not see any influence of oral phosphate binders, calcium supplementation, or vitamin D treatment on the development of parathyroid gland hyperactivity during dialysis treatment. Serum creatinine concentration did not change after parathyroidectomy. In four patients, long-term calcium supplementation after surgery was necessary.

Netilmicin in the neonate: population pharmacokinetic analysis and dosing recommendations

Netilmicin pharmacokinetics were studied in neonates of 27 to 42 weeks' gestational age and 0.8 to 5.0 kg body weight in their first 2 weeks of life by the population pharmacokinetic approach. The data were best described by a two-compartment model. Clearance depends on body weight, gestational age, and postnatal age. Volume of distribution of the central and peripheral compartments was also related to body weight. Including these patient characteristics in the population pharmacokinetic regression model resulted in a marked reduction of the unexplained interindividual variability. This enabled us to derive dosage recommendations that result in peak and average concentrations within the desired range for 95% of the neonates with gestational age above 31 weeks, thus avoiding the need for individual drug-level monitoring in a well-defined large group of patients. Only for infants with gestational age less than 31 weeks who are less than 6 days old is individual dose adjustment based on serum concentration measurements required.

[Serum levels and urinary excretion of amino acids during high intensity physical exertion in healthy men]

The authors investigated the effect of a physical load on a bicycle ergometer on serum concentrations and urinary excretion of 19 amino acids. The initial load of 1 W/kg was increased after 5-minute intervals by 10-20 W to achieve the maximum after 50 minutes exercise. During the last 2-3 minutes of the maximal load a spiroergometric examination was made. The serum alanine concentration increased under these conditions significantly from 474 +/- 133 to 739 +/- 171 mumol/l (p less than 0.001), while the serum threonine concentration declined significantly from 155 +/- 39 to 143 +/- 37 mumol/l (p less than 0.05). Urinary excretion and renal clearance of amino acids declined significantly (p less than 0.05-0.001). The authors found a significant correlation between the drop of the urinary excretion and the rise of serum concentration of alanine (p less than 0.05). The drop of the urinary alanine excretion can contribute to its elevated serum concentration. The fractional amino acid excretions did not decline and the decline of amino acid and creatinine clearances was more or less proportional. The authors conclude that the decline of amino acid excretion is directly associated with a drop of glomerular filtration. The revealed, correlations between the drop of gin, lys, pala, thr and Na excretion suggest that the sodium transport through the nephron can influence the transport of these amino acids.

Nonlinear kinetics of propafenone metabolites in healthy man

The pharmacokinetics of oral and i.v. propafenone and its major metabolites have been investigated in 8 healthy subjects. The total body clearance of propafenone was 963 ml/min, the terminal half-life 198 min and its absolute bioavailability was 15.5%. The two active metabolites (5-hydroxypropafenone and N-depropylpropafenone) showed non-linear kinetics in that both the dose-corrected area under the serum concentration-time curve and the amount excreted in the urine were larger after oral dosing. This resulted in considerably higher serum concentrations of the metabolites despite comparable serum concentrations of the parent compound. Thus, the concentration-effect relationship in the same patient may differ after oral and intravenous doses if concentrations of the active metabolite(s) are not taken into consideration. Although the mechanism of the nonlinearity is not clear, the data indicate that it may be due to saturable biliary excretion of the metabolites.