The Nordic prescription databases as a resource for pharmacoepidemiological research--a literature review

PURPOSE

All five Nordic countries have nationwide prescription databases covering all dispensed drugs, with potential for linkage to outcomes. The aim of this review is to present an overview of therapeutic areas studied and methods applied in pharmacoepidemiologic studies using data from these databases.

METHODS

The study consists of a Medline-based structured literature review of scientific papers published during 2005-2010 using data from the prescription databases in Denmark, Finland, Iceland, Norway, and Sweden, covering 25 million inhabitants. Relevant studies were analyzed in terms of pharmacological group, study population, outcomes examined, type of study (drug utilization vs. effect of drug therapy), country of origin, and extent of cross-national collaboration.

RESULTS

A total of 515 studies were identified. Of these, 262 were conducted in Denmark, 97 in Finland, 4 in Iceland, 87 in Norway, and 61 in Sweden. Four studies used data from more than one Nordic country. The most commonly studied drugs were those acting on the nervous system, followed by cardiovascular drugs and gastrointestinal/endocrine drugs. A total of 228 studies examined drug utilization and 263 focused on the effects and safety of drug therapy. Pregnant women were the most commonly studied population in safety studies, whereas prescribers' adherence to guidelines was the most frequent topic of drug utilization studies.

CONCLUSIONS

The Nordic prescription databases, with their possibility of record-linkage, represent an outstanding resource for assessing the beneficial and adverse effects of drug use in large populations, under routine care conditions, and with the potential for long-term follow-up.

Optimal length of continuation therapy in depression: a prospective assessment during long-term fluoxetine treatment

OBJECTIVE

The purpose of this study was to determine prospectively the optimal length of therapy in a long-term, placebo-controlled continuation study of patients who responded to acute fluoxetine treatment for major depression (defined by DSM-III-R).

METHOD

The study was conducted at five outpatient psychiatric clinics in the United States. Patients who met criteria for remission after 12 or 14 weeks of open-label acute fluoxetine therapy, 20 mg/day (N=395 of 839 patients), were randomly assigned to one of four arms of a double-blind treatment study (50 weeks of placebo, 14 weeks of fluoxetine and then 36 weeks of placebo, 38 weeks of fluoxetine and then 12 weeks of placebo, or 50 weeks of fluoxetine). Relapse rate was the primary outcome measure. Both Kaplan-Meier estimates and observed relapse rates were assessed in three fixed 12-week intervals after double-blind transfers from fluoxetine to placebo at the start of the double-blind period and after 14 and 38 weeks of continued fluoxetine treatment.

RESULTS

Relapse rates (Kaplan-Meier estimates) were lower among the patients who continued to take fluoxetine compared with those transferred to placebo in both the first interval, after 24 total weeks of treatment (fluoxetine, 26.4%; placebo, 48.6%), and the second interval, after 38 total weeks of treatment (fluoxetine, 9.0%; placebo, 23.2%). In the third interval, after 62 total weeks of treatment, rates were not significantly different between the groups (fluoxetine, 10.7%; placebo, 16.2%).

CONCLUSIONS

Patients treated with fluoxetine for 12 weeks whose depressive symptoms remit should continue treatment with fluoxetine for at least an additional 26 weeks to minimize the risk of relapse.

Interexaminer reliability in physical examination of patients with low back pain

STUDY DESIGN

Seventy-one patients with low back pain were examined by two physiotherapists (50 patients) and two physicians (21 patients). The two physiotherapists had worked together for many years, but the two physicians had not. The interexaminer reliability of the clinical tests included in the physical examination was evaluated.

OBJECTIVES

To evaluate the interexaminer reliability of clinical tests used in the physical examination of patients with low back pain under ideal circumstances, which was the case for the physiotherapists.

SUMMARY OF BACKGROUND DATA

Numerous clinical tests are used in the evaluation of patients with low back pain. To reach the correct diagnosis, only tests with an acceptable validity and reliability should be used. Previous studies have mainly shown low reliability. It is important that clinical tests not be rejected because of low reliability caused by differences between examiners in performance of the examination and in their definition of normal results.

METHODS

Two examiners, either two physiotherapists or two physicians, independently examined patients with low back pain.

RESULTS

In approximately half of the clinical tests studied, an acceptable reliability was demonstrated.

CONCLUSION

On the basis of the physiotherapists series, the reliability was acceptable for a number of clinical tests that are used in the evaluation of patients with low back pain. The results suggest that clinical tests should be standardized to a much higher degree than they are today.

The impact of premenstrual symptomatology on functioning and treatment-seeking behavior: experience from the United States, United Kingdom, and France

Up to 80% of women experience mood and physical symptoms associated with the menstrual cycle. This study assessed the impact of premenstrual symptomatology on functioning and treatment-seeking behavior for a community-based sample of women in the United States, United Kingdom, and France. A sample of 1045 menstruating women (aged 18-49) completed a telephone questionnaire that measured, at a point in time, premenstrual symptoms, impact on functioning, and treatment-seeking behavior. Results were generally consistent across the three countries. Irritability/anger, fatigue, and physical swelling/bloating, or weight gain were among the most commonly reported symptoms (approximately 80%). Functional impairment tended to be highest at home, followed by social, school, and occupational situations. Among working women, over 50% reported at least somewhat affected occupational functioning. Of women who ever missed work because of symptoms, 1-7 days were missed in the past year. Almost three fourths of the women had never sought treatment, and symptom severity was an important factor in treatment-seeking behavior. Treatment with selective serotonin reuptake inhibitors (SSRIs), which have demonstrated efficacy in this population, occurred with surprisingly low frequency. The functional impairment of premenstrual symptomatology (home, social, and occupational) and treatment-seeking behavior is consistent across countries. Women who experience more impairment are more likely to have severe symptoms and are more likely to believe, relative to women with less severe symptoms, that no treatment is available. This suggests significant unmet medical need in this more severely affected population. Improved clinical identification of these women and increasing awareness of the efficacy of SSRIs in treating premenstrual symptomatology may be of benefit.

Disturbance of the intestinal mucosal immune system of farmed Atlantic salmon (Salmo salar), in response to long-term hypoxic conditions

The gastrointestinal (GI) tract has many important biological functions. One is to serve as a barrier between the fish and the external environment. A decreased physical barrier function of the intestine may lead to increased inflow of luminal content and subsequent activation of the intestinal mucosal immune system. This activation is governed by the ability of various compounds to induce cytokine release and immune cell activity, leading to an immune response. In mammals, the impact of stress on the intestinal barrier is well documented and results in increased intestinal permeability and thus increased stimulation of the mucosal immune system. Fish reared in sea cages may at times be exposed to unfavourable environmental conditions leading to chronic stress and disturbed intestinal integrity. This change in permeability may increase the exposure of the mucosal immune system to activating compounds. In the present study, the effect of a prolonged stress on the intestinal mucosal immune system of fish is therefore addressed. Atlantic salmon were exposed to low levels (50%) of dissolved oxygen (DO) for 6-7 weeks in consecutive experiments performed at 8 and 16 °C. Immune parameters were assessed in terms of mRNA expression of the key cytokines, interleukin-1β (IL-1β), IL-8, IL-10, interferon-γ (IFNγ) and transforming growth factor-β (TGFβ) as well as the immune regulatory inhibitor of nuclear factor κB (IκB). In the experiment at 8 °C also mucosal neutrophil infiltration was monitored. Subjecting the fish to low DO levels at 8 °C resulted in an increased mucosal neutrophil infiltration together with a down-regulation of IκB. At the higher temperature, 16 °C, low DO levels created decreased expression of the pro-inflammatory cytokine IL-1β in both intestinal regions as well as an increased expression of IL-10 in the proximal intestine. These results suggest that husbandry conditions in sea cages with DO levels as low as 50% clearly affects the intestinal mucosal immune system and results in a chronic inflammation. Moreover, the effects of low DO levels on the immune factors examined were more pronounced in the 16 °C experiment suggesting additive effects of high temperatures.

Cortisol mediates the increase in intestinal fluid absorption in Atlantic salmon during parr-smolt transformation

We have previously shown in Atlantic salmon that the rate of fluid absorption by the posterior intestine (Jv) is elevated during the smolt stage in spring as a preadaptive development for osmoregulation in seawater. In the present study, we examined developmental differences in the responsiveness of Jv to cortisol and the corticosteroid antagonist, RU 486, through the parr-smolt transformation. Freshwater, juvenile salmon were administered slow-release implants of cortisol (50 micrograms/g body wt), RU 486 (1 mg/g body wt), or the implant without steroid (controls) at seven times from November 1992 through June 1993. Seven and 8 days after implantation, plasma cortisol concentrations and in vitro Jv were measured. In control salmon, both plasma cortisol and Jv peaked in April and were positively correlated over time. Cortisol implants stimulated Jv of salmon only during the parr and postsmolt stages, when Jv of controls was low. The exogenous cortisol was sufficient to stimulate Jv to a rate comparable to that measured for control salmon in the smolt stage. Conversely, RU 486 implants inhibited Jv only during the peak smolt period, when Jv of controls was elevated. Taken together, these results demonstrate that cortisol is a necessary and sufficient endocrine signal mediating this developmental change in intestinal function during parr-smolt transformation. This is the first report of plasma cortisol levels measured in fish treated with RU 486. Plasma cortisol was elevated by RU 486, suggesting that this corticosteroid antagonist blocked feedback inhibition on the pituitary-interrenal axis.

Chum salmon (Oncorhynchus keta) stanniocalcin inhibits in vitro intestinal calcium uptake in Atlantic cod (Gadus morhua)

Chum salmon (oncorhynchus keta) stanniocalcin was purified, partially identified and tested for bioactivity in an assay on the intestinal calcium uptake in a marine teleost (Gadus morhua). Basic ethanol extraction, ion exchange chromatography, gel filtration and reverse-phase high-performance liquid chromatography resulted in the isolation of a homogeneous glycoprotein that appears as a 46-kDa product under nonreducing conditions and as a 23-kDa product under reducing conditions after sodium dodecylsulphate-polyacrylamide gel electrophoresis. The glycoprotein is likely to be a homodimer composed of two subunits of 23 kDa each. Further characterization indicates homology to Australian eel, sockeye salmon, coho salmon and rainbow trout stanniocalcin, and the glycoprotein is thus concluded to be stanniocalcin. Stanniocalcin-like immunoreactivity was demonstrated in the corpuscles of Stannius of the Atlantic cod, with a specific antiserum raised against purified chum salmon stanniocalcin. The physiological importance and the biological activity of chum salmon stanniocalcin was tested by evaluating its effect on intestinal calcium uptake by the Atlantic cod in vitro. The intestine was perfused, both vascularly and through the intestinal lumen, and the calcium mucosa-to-serosa flux was measured using 45Ca2+ as a tracer. Stanniocalcin decreased the intestinal calcium uptake in a dose-related manner by 13.5% and 22.4% at doses of 2.2 and 10.9 nM stanniocalcin, respectively. The results establish the intestine as a target organ for stanniocalcin in marine teleosts.

Growth hormone endocrinology of Atlantic salmon (Salmo salar): pituitary gene expression, hormone storage, secretion and plasma levels during parr-smolt transformation

A number of studies on the Atlantic salmon (Salmo salar), have reported changes in plasma GH during parr-smolt transformation, but there is a lack of information about the endocrinology of the GH system during this process. In order to elucidate the mechanisms underlying these changes in plasma GH levels during the parr-smolt transformation of Atlantic salmon, GH mRNA expression in the pituitary was studied together with total pituitary GH content, in vitro GH secretion rate and plasma GH and IGF-I levels. Atlantic salmon were kept in outside tanks, under natural condition from early February until late June. Approximately three times a month fish were killed and pituitaries and blood were sampled for investigation. Further, pituitaries were moved to the laboratory for in vitro GH secretion studies. The results show that the GH system is first activated by an increase in GH secretion rate, which leads to an increase in plasma GH levels and causes a drop in the total GH content of the pituitary. This drop in pituitary GH content is later reversed by an increased GH synthesis seen as an increase in GH mRNA expression. Maximal activation of the GH system is seen to occur in early May, when plasma IGF-I levels reach highest levels, after which a certain deactivation of the GH system takes place. The data show that plasma levels of GH are to a large extent regulated by the secretion rate from the pituitary, although changes in the GH clearance rate are also likely to take place and influence the plasma GH levels. The study further underlines the significant role that the GH-IGF-I axis plays in the parr-smolt transformation of the Atlantic salmon.

1,25(OH)2 vitamin D3 increases ionized plasma calcium concentrations in the immature Atlantic cod Gadus morhua

Intraperitoneal injections of 1,25(OH)2 vitamin D3 (1,25(OH)2D3) produced hypercalcemia in the marine teleost the Atlantic cod (Gadus morhua) with increased plasma concentrations of ionized calcium (CaI) while the total plasma calcium concentrations (CaT) were unaffected. A single injection of 10 micrograms kg bw-1 of 1,25(OH)2D3 increased CaI concentrations from 1.74 +/- 0.03 mM to 1.8 +/- 0.01 mM after 24 hr in Experiment 1 and from 1.67 +/- 0.03 mM to 1.82 +/- 0.06 mM after 72 hr in Experiment 2. This hypercalcemic effect was sustained by daily injections for 5 but not 7 days. Daily injections of a lower dose of 1,25(OH)2D3, 1 microgram kg bw-1, caused hypercalcemia after 5 days (CaI increased from 1.68 +/- 0.01 mM to 1.76 +/- 0.02 mM). Plasma calcium concentrations were not affected by any of the other seco-steroids (vitamin D3, (25(OH)), vitamin D3 (25(OH)D3), or 24,25(OH)2 vitamin D3 (24,25(OH)2D3), except for a decrease in CaT concentrations after 7 daily in injections of 25(OH)D3 (2 micrograms kg bw-1). Plasma phosphate concentrations were not changed by any of the seco-steroids. It is concluded that 1,25(OH)2D3 is hypercalcemic in the marine Atlantic cod.

Beliefs about medicines are strongly associated with medicine-use patterns among the general population

AIMS

To investigate self-reported beliefs and perceived sensitivity to medicines and their effects in relation to self-reported use of medicines and herbal remedies.

METHODS

A survey sent to 13,931 randomly selected Swedish adults included the Beliefs about Medicines Questionnaire-General (BMQ-General) Questionnaire and the Perceived Sensitivity to Medicines Scale (PSM). The survey also asked about individuals' use of prescribed and over-the-counter (OTC) medicines and herbal remedies in the past month. We examined all associations between scores on the BMQ-General subscales and PSM in relation to the use of medicines and herbal remedies, using analysis of covariance adjusted for potential confounders.

RESULTS

Among 7099 respondents, those using herbal remedies exclusively believed strongly that prescription and OTC medicines are harmful and overprescribed. Respondents using prescription and OTC medicines reported more positive beliefs [coefficient 0.67 (95% CI 0.47-0.87) and 0.70 (95% CI 0.51-0.90)] on the benefits of medicines compared with those using herbal remedies [-0.18 (95% CI -0.57-0.20)]. Perceived sensitivity to medicines was higher among those using herbal remedies only [1.25 (95% CI 0.46-2.03)] compared with those using no medicines (reference 0) or prescription [-0.44 (95% CI -0.84 to -0.05)] or OTC [-0.27 (95% CI -0.66-0.12)] medicines alone.

CONCLUSION

Respondents using prescription and/or OTC medicines reported stronger positive beliefs about the benefits of medicines in general, supporting the hypothesis that beliefs influence medicine use. Therefore, addressing beliefs and concerns about medicines during patient counselling may influence medicine use, particularly regarding unintentional non-adherence.

Slow release cortisol implants result in impaired innate immune responses and higher infection prevalence following experimental challenge with infectious pancreatic necrosis virus in Atlantic salmon (Salmo salar) parr

Stress can affect the immune system and increase susceptibility to various diseases but knowledge of the underlying mechanisms is scarce. There is a complex interaction between the immune system and the endocrine system of vertebrates. In fish, cortisol is a key hormone regulating stress response and recent studies have also suggested that this hormone can affect the immune system, where cortisol is mainly regarded as an immunosuppressive factor. The aim of the present study was to examine the impact of chronically elevated levels of cortisol on the immune response and susceptibility to experimental infection with infectious pancreatic necrosis virus (IPNV). Further, the effect of IPNV challenge on circulating levels of cortisol was investigated. Atlantic salmon parr were implanted intraperitoneally with sustained-release implants of bovine of cortisol (50 μg cortisol g(-1) body weight in an implant based on vegetable lipids). Vehicle implants were used as control (sham-injected). At 45 days after implantation (DAI), fish were challenged with a low virulent isolate of IPNV (by immersion). Samples of plasma, liver and head kidney was taken from fish before and 24 h, 48 h, 7 days week and 21 days post infection (DPI). Cortisol level in plasma was measured using radioimmunoassay and gene expression in liver and head kidney was analyzed with real-time PCR (RT-PCR). Infection prevalence in infected fish was assessed by virus culture and RT-PCR of head kidney samples. Cortisol implantation compared with sham-implanted fish had increased levels of plasma cortisol at 45 DAI. The relative expression of Interferon alpha-1 (IFNα-1), Myxo virus-1 Mx, Heat-shock protein 70 (HSP70), Serum amyloid A (SAA), Glucocorticoid receptor (GR) and Heat-shock protein 90 (HSP90) tends to be down-regulated by cortisol implantation. There was a higher prevalence of fish with detectable levels of IPNV, as measured by cell culture and RT-PCR, in the cortisol-implanted group challenged with IPNV (0 = 0.0305) relative to the group that received a sham implantation. Further, cortisol seems to delay the induction of the antiviral IFNα-1 pathway and Mx mRNA expression. This study shows that elevated plasma cortisol level leads to an impaired innate immune response, and higher virus (IPNV) prevalence in Atlantic salmon parr.

Effects of vitamin D3, 25(OH) vitamin D3, 24,25(OH)2 vitamin D3, and 1,25(OH)2 vitamin D3 on the in vitro intestinal calcium absorption in the marine teleost, Atlantic cod (Gadus morhua)

The role of vitamin D3, 25(OH) vitamin D3, 24,25(OH)2 vitamin D3, and 1,25(OH)2 vitamin D3, in the regulation of calcium absorption across the intestine in the marine teleost, Gadus morhua, was investigated. The intestine was perfused, in vitro, both vascularly and through the intestinal lumen, and the calcium influx was measured using 45Ca. Vitamin D3 and its metabolites were tested in perfusate concentrations of 10 ng.ml-1.25(OH)D3 increased the intestinal calcium uptake by 65%, while 24,25(OH)2D3 decreased it by 36%. Vitamin D3 and 1,25(OH)2D3, on the other hand, did not affect the calcium influx across the intestinal mucosa. This indicates that 25(OH)D3 and 24,25(OH)2D3 may be active regulators of calcium transport across the intestine of Atlantic cod.

Ca2+ uptake through voltage-gated L-type Ca2+ channels by polarized enterocytes from Atlantic cod Gadus morhua

The presence and localization of voltage-gated Ca2+ channels of L-type were investigated in intestinal cells of the Atlantic cod. Enterocytes were loaded with the fluorescent Ca2+ probe, fure-2/AM and changes in intracellular Ca2+ concentrations ([Ca2+]i) were measured, in cell suspensions, in the presence of high potassium levels (100 mm), BAY K-8644 (5 microM), nifedipine (5 microM) or omega-conotoxin (1 microM). L-type Ca2+ channels were visualized on intestinal sections using the fluorescent dihydropyridine (-)-STBodipy. Depolarization of the plasma membrane produced a rapid (within 5 sec) and transient (at basal levels after 21 sec) increase in [Ca2+]i. BAY K-8644 increased the [Ca2+]i by 7.2%. Cells in a Ca2+-free buffer increased [Ca2+]i after addition of 10 mm Ca2+, and this increase was abolished by nifedipine in both depolarizing and normal medium but not by omega-conotoxin. Single cell experiments using video microscopy revealed that enterocytes remained polarized several hours after preparation and that the Ca2+ entry and extrusion occurred at specific and different regions of the enterocyte outer membrane. Fluorescent staining of L-type Ca2+ channels in the intestinal mucosa showed the most intense staining at the brushborder membrane. These results demonstrate the presence of voltage gated L-type Ca2+ channels in enterocytes from the Atlantic cod. The channels are mainly located at the apical side of the cells, and there is a polarized uptake of Ca2+ into the enterocytes. This suggests that the L-type Ca2+ channels are involved in the transcellular Ca2+ entry into the enterocytes.

Role of parenting styles in adolescent substance use: results from a Swedish longitudinal cohort study

OBJECTIVE

Adolescent substance use is an area of concern because early substance use is associated with a higher risk of adverse outcomes. Parenting style, defined as the general style of parenting, as well as substance-specific parenting practices may influence children's substance use behaviour. The present study aims to probe the impact of parenting style on adolescent substance use.

METHOD

A cohort of 1268 adolescents (48% girls), aged 12-13 years at baseline, from 21 junior high schools was assessed in the first semester of junior high school, and then again in the last semester of the 9th grade, 32 months later. Parenting style, operationalised as a fourfold classification of parenting styles, including established risk factors for adolescent substance use, were measured at baseline.

RESULTS

Neglectful parenting style was associated with worse substance use outcomes across all substances. After adjusting for other proximal risk factors in multivariate analyses, parenting style was found to be unrelated to substance use outcomes with one exception: authoritative parenting style was associated with less frequent drinking. Association with deviant peers, delinquent behaviour, provision of alcohol by parents, and previous use of other substances were associated with substance use outcomes at follow-up.

CONCLUSIONS

The results of the present study indicate that parenting style may be less important for adolescent substance use outcomes than what has previously been assumed, and that association with deviant peers and delinquent behaviour may be more important for adolescent substance use outcomes than general parenting style.

Physiological concentrations of 24,25-dihydroxyvitamin D3 rapidly decrease the in vitro intestinal calcium uptake in the Atlantic cod, Gadus morhua

The effects of physiological concentrations of 1,25(OH)2D3 and 24,25(OH)2D3 on the intestinal Ca2+ uptake in the Atlantic cod (Gadus morhua) were investigated. The intestine was perfused, in vitro, both vascularly and through the intestinal lumen, and the Ca2+ influx was measured using 45Ca. At 2.02, 4.04, 10.1, and 20.2 nM 24,25(OH)2D3 decreased the Ca2+ influx across the intestinal mucosa by 21, 31, 34, and 28%, respectively, whereas perfusion with 1,25(OH)2D3 (concentrations: 85.3, 128, 256, and 640 pM) had no effect. The actions of 24,25(OH)2D3 were dose-related, observed within 10 to 25 min, and are concluded to affect intestinal Ca2+ influx via a rapid nongenomic mechanisms; 1,25(OH)2D3 seems to be without transcaltachic effect. Thus, for the rapid, short-term regulation of intestinal calcium uptake in the Atlantic cod, 24,25(OH)2D3 is a more important vitamin D3 metabolite, in contrast to other vertebrates in which 1,25(OH)2D3 is of major importance.

The effect of pH and temperature on the dissociation constant for fura-2 and their effects on [Ca(2+)](i) in enterocytes from a poikilothermic animal, Atlantic cod (Gadus morhua)

In this study, we investigated the validity of the fluorescent probe fura-2 in determinations of intracellular Ca(2+) concentrations ([Ca(2+)](i)), at physiological temperatures, in poikilothermic animals living at low temperatures. The K(d) for fura-2 was found to decrease with increasing temperature (5-37 degrees C) and DeltaH, in the Van't Hoff isochore equation, was determined to be 11.03 kJ/mol, when pH was corrected to 7.2 for all temperatures tested. The absorption maxima (340 nm) and isobestic point (360 nm) for the UV spectra of fura-2 were not affected by temperature. Thus, if pH- and temperature-dependent changes in K(d) are corrected for, fura-2 is a suitable tool for measurements of [Ca(2+)](i) at temperatures of 5-37 degrees C. The present study demonstrates that Atlantic cod enterocytes, acclimated to 37 degrees C, show a lower basal [Ca(2+)](i) (65 +/- 8 nM) compared to enterocytes acclimated to 10 degrees C (161 +/- 6 nM). Furthermore, addition of 10 mM Ca(2+) increases the [Ca(2+)](i) by 526%, when compared to basal [Ca(2+)](i), in cells at 37 degrees C but only by 36%, in cells kept at 10 degrees C. Thus, performing experiments at unphysiological temperatures results in cellular responses that would not be observed under physiological conditions.

Development of intestinal ion-transporting mechanisms during smoltification and seawater acclimation in Atlantic salmon Salmo salar

This study investigated the expression of ion transporters involved in intestinal fluid absorption and presents evidence for developmental changes in abundance and tissue distribution of these transporters during smoltification and seawater (SW) acclimation of Atlantic salmon Salmo salar. Emphasis was placed on Na(+) , K(+) -ATPase (NKA) and Na(+) , K(+) , Cl(-) co-transporter (NKCC) isoforms, at both transcriptional and protein levels, together with transcription of chloride channel genes. The nka α1c was the dominant isoform at the transcript level in both proximal and distal intestines; also, it was the most abundant isoform expressed in the basolateral membrane of enterocytes in the proximal intestine. This isoform was also abundantly expressed in the distal intestine in the lower part of the mucosal folds. The protein expression of intestinal Nkaα1c increased during smoltification. Immunostaining was localized to the basal membrane of the enterocytes in freshwater (FW) fish, and re-distributed to a lateral position after SW entry. Two other Nka isoforms, α1a and α1b, were expressed in the intestine but were not regulated to the same extent during smoltification and subsequent SW transfer. Their localization in the intestinal wall indicates a house-keeping function in excitatory tissues. The absorptive form of the NKCC-like isoform (sub-apically located NKCC2 and/or Na(+) , Cl(-) co-transporter) increased during smoltification and further after SW transfer. The cellular distribution changed from a diffuse expression in the sub-apical regions during smoltification to clustering of the transporters closer to the apical membrane after entry to SW. Furthermore, transcript abundance indicates that the mechanisms necessary for exit of chloride ions across the basolateral membrane and into the lateral intercellular space are present in the form of one or more of three different chloride channels: cystic fibrosis transmembrane conductance regulator I and II and chloride channel 3.

Glucose-lowering treatment and clinical results in 163 121 patients with type 2 diabetes: an observational study from the Swedish national diabetes register

AIMS

To analyse clinical characteristics and treatment results in unselected type 2 diabetes mellitus (T2DM) patients, with non-pharmacological treatment as well as the most commonly used pharmacological glucose-lowering treatment regimens, in everyday clinical practice.

METHODS

In this population-based cross-sectional study, information was linked from the Swedish National Diabetes Register, Prescribed Drug Register and Patient Register. T2DM patients with non-pharmacological treatment and T2DM patients continuously using the 12 most common pharmacological treatment regimens were included in the study (n = 163121).

RESULTS

There were statistically significant differences in clinical characteristics between the groups. Patients with insulin-based treatment regimens had the longest duration of diabetes and more cardiovascular risk factors than the T2DM-population in general. The proportion of patients reaching HbA1c ≤ 7% varied between 70.1% (metformin) and 25.0% [premixed insulin (PMI) + SU) in patients with pharmacological treatment. 84.8% of the patients with non-pharmacological treatment reached target. Compared to patients on metformin, patients on other pharmacological treatments had a lower likelihood, with hazard ratios ranging from 0.58; 95% confidence interval (CI), 0.54-0.63 to 0.97;0.94-0.99, of having HbA1c ≤ 7% (adjusted for covariates). Patients on insulin-based treatments had the lowest likelihood, while non-pharmacological treatment was associated with an increased likelihood of having HbA1c ≤ 7%.

CONCLUSION

This nation-wide study shows insufficiently reached treatment goals for haemoglobin A1c (HbA1c) in all treatment groups. Patients on insulin-based treatment regimens had the longest duration of diabetes, more cardiovascular risk factors and the highest proportions of patients not reaching HbA1c target.

Estradiol-17β-induced calcium uptake and resorption in juvenile rainbow trout, Oncorhynchus mykiss

Juvenile rainbow trout, Oncorhynchus mykiss, were injected with estradiol-17β (E2) in order to study the source of extra calcium needed during vitellogenesis. E2-treatment increased the calcium uptake from the external medium as well as calcium mobilization from muscle and scale. Judged by the increase in plasma protein-bound calcium levels, the E2-induced increase in calcium uptake is an apparent over-mobilization of calcium, i.e., the calcium uptake of the fish is in excess of what is found bound to plasma proteins. As the calcium excretion and calcium space (calculated from free plasma calcium levels) were unaffected, the excess calcium is suggested to be incorporated into internal calcium stores. This implies that the systems regulating vitellogenesis and calcium balance are integrated on the mechanistic or endocrine level, and that E2 causes calcium mobilization of a magnitude geared to the needs of the sexually maturing female.

1,25-Dihydroxyvitamin D3 in the Atlantic cod: plasma levels, a plasma binding component, and organ distribution of a high affinity receptor

Physiological studies of the Atlantic cod, Gadus morhua, have suggested a role for the vitamin D3 system in this marine teleost similar to that in other vertebrates. Accordingly, the present study was carried out to assess the plasma concentrations of vitamin D3, 25-hydroxyvitamin D3 (25OHD3), and 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3] in this fish. Additionally, the presence of binding proteins in plasma and target-specific tissue receptors for these vitamin D3 metabolites was studied in organs normally associated with calcium regulation. Plasma levels of 25-OHD3 (undetectable to 148 pg/ml; n = 5) were comparatively low (20-30 ng/ml), whereas the levels of vitamin D3 (approximately 30 ng/ml) and 1,25-(OH)2D3 (approximately 50 pg/ml) were comparable to levels reported in higher vertebrates. Cod plasma contained a protein that bound both 25OHD3 and 1,25-(OH)2D3. This plasma binding protein revealed low affinity for 25OHD3, did not bind G-actin, and had a sedimentation coefficient of 3.4S. High affinity 1,25-(OH)2D3 receptors [Kd, 1.02 +/- 0.36 (n = 6), 1.02 +/- 0.3 (n = 5), and 0.95 +/- 0.51 (n = 5) nM; mean +/- SEM] were found in high salt cytosols from intestine, liver, and gills, respectively, and had sedimentation coefficients (3.6-3.8S in 0.3 M KCl sucrose gradients) similar to those in higher vertebrates. No specific 1,25-(OH)2D3 binding was found in kidney, ultimobranchial glands, corpuscles of Stannius, or bone. The finding of significant quantities of 1,25-(OH)2D3 in the plasma, the presence of plasma binding proteins that bind this seco-steroid, and the localization of specific high affinity receptors for this metabolite in calcium regulatory tissues in teleosts are all consistent with a physiological role for the vitamin D3 system in the calcium regulation of the cod.

Effect of biofilm formation on antimicrobial tolerance of Flavobacterium psychrophilum

Treatment of bacterial fish diseases can be complicated by resistant bacterial biofilms harbouring pathogenic bacteria and causing recurrent exposure of fish to infections. In this study, the effect of biofilm formation on antimicrobial tolerance was examined using three bacterial isolates of the fish pathogen Flavobacterium psychrophilum and two antimicrobial agents, oxytetracycline and flumequine, commonly used in aquaculture. Planktonic and biofilm cells were exposed to a minimum inhibitory concentration (MIC), to a 3 × MIC concentration and to an environmental concentration level of each antimicrobial in 96-well microtitre plates after which growth on agar plates was measured. The type strain NCIMB1947 of F. psychrophilum was further used to study the development of antimicrobial resistance in biofilm cells. The results suggest that at high bacterial densities (>10(7) CFU mL(-1)), biofilm cells of F. psychrophilum are less susceptible to antimicrobial agents. Furthermore, the results imply that biofilm cells of F. psychrophilum may rapidly develop resistance to both oxytetracycline and flumequine if exposed to subinhibitory concentrations of these antimicrobials.

Translocation of viable Aeromonas salmonicida across the intestine of rainbow trout, Oncorhynchus mykiss (Walbaum)

The pathogenic bacterium Aeromonas salmonicida is the causative agent of the destructive disease furunculosis in salmonids. Horizontal transmission in salmonids has been suggested to occur via the skin, gills and/or intestine. Previous reports are contradictory regarding the role of the intestine as a route of infection. The present study therefore investigates the possibility of bacterial translocation across intestinal epithelia using Ussing chamber technology, in vitro. Intestinal segments were exposed for 90 min to fluorescein isothiocyanate-labelled pathogenic A. salmonicida. Sampling from the serosal side of the Ussing chambers showed that bacteria were able to translocate across the intestinal epithelium in both the proximal and distal regions. Plating and subsequent colony counting showed that the bacteria were viable after translocation. During the 90 min exposure to A. salmonicida, the intestinal segments maintained high viability as measured by electrical parameters. The distal region responded to bacterial exposure by increasing the electrical resistance, indicating an increased mucus secretion. This study thus demonstrates translocation of live A. salmonicida through the intestinal epithelium of rainbow trout, suggesting that the intestine is a possible route of infection in salmonids.

Antagonistic effects of 24R,25-dihydroxyvitamin D3 and 25-hydroxyvitamin D3 on L-type Ca2+ channels and Na+/Ca2+ exchange in enterocytes from Atlantic cod (Gadus morhua)

There is mounting evidence that vitamin D and its metabolites play important roles in regulating plasma calcium concentrations in teleost fish as in other vertebrates. The aims of the present study were to elucidate the possible cellular target mechanisms for the rapid actions of 24R,25(OH)(2)D(3), 25(OH)D(3) and 1,25(OH)(2)D(3) in Atlantic cod enterocytes at physiological doses, and to establish the concentration and thus the physiological range of circulating 24R,25(OH)(2)D(3), 25(OH)D(3) and 1,25(OH)(2)D(3) in the Atlantic cod. The plasma concentrations of 25(OH)D(3), 1,25(OH)(2)D(3) and 24R,25(OH)(2)D(3) were 15.3 +/- 2.7nM, 125.1 +/- 12.3pM and 10.1 +/- 23.5nM respectively. Exposure of enterocytes to 10mM calcium (Ca(2+)) evoked an increase in intracellular Ca(2+) concentrations ([Ca(2+)](i)). This increase was suppressed by 24R,25(OH)(2)D(3) dose-dependently, with an EC(50) of 4.9nM and a maximal inhibition of 60%. 24R,25(OH)(2)D(3) (20nM) abolished an increase in [Ca(2+)](i) (approximately 252%) in the control enterocytes exposed to 10microM S(-)-BAYK-8644, suggesting that the hormone acts by inhibiting Ca(2+) entry through L-type voltage-gated Ca(2+) channels. Administration of 20nM 24R,25(OH)(2)D(3) to enterocytes in the absence of extracellular Ca(2+) increased [Ca(2+)](i) by approximately 20%, indicating a release of Ca(2+) from intracellular stores. Administration of 25(OH)D(3) (20nM) resulted in a biphasic change in the enterocyte [Ca(2+)](i): within 1--5s, it decreased to 87 +/- 12nM below its mean basal [Ca(2+)](i) (334 +/- 13nM), followed by a rapid recovery of [Ca(2+)](i) to a new level, 10% lower than the initial [Ca(2+)](i). The rapid decrease, the recovery rate and the final [Ca(2+)](i) were all affected dose-dependently by 25(OH)D(3), with EC(50) values of 8.5, 17.0 and 18.9nM respectively. Furthermore, the effects of 25(OH)D(3) were sensitive to sodium (Na(+)), bepridil (10microM) and nifedipine (5 microM), suggesting that 25(OH)D(3) regulates the activity of both basolateral membrane-associated Na(+)/Ca(2+) exchangers and brush border membrane-associated L-type Ca(2+) channels. Administration of 25(OH)D(3) (10nM) to enterocytes in the absence of extracellular Ca(2+) increased [Ca(2+)](i) by approximately 18%, indicating a release of Ca(2+) from intracellular stores. 1,25(OH)(2)D(3) also affected enterocyte [Ca(2+)](i) in a biphasic manner: the rapid decrease, the recovery rate, and the mean final [Ca(2+)](i) were all affected dose-dependently, with EC(50) values of 8.3, 24.5 and 7.7nM respectively. The high EC(50) values for 1,25(OH)(2)D(3) compared with circulating concentrations of 1,25(OH)(2)D(3) (130pM) suggest that this effect is pharmacological, rather than of physiological relevance in enterocyte Ca(2+) homeostasis of the Atlantic cod. It is concluded that 24R,25(OH)(2)D(3) has a physiological role in decreasing intestinal Ca(2+) uptake via inactivation of L-type Ca(2+) channels, whereas the physiological role of 25(OH)D(3) is to increase enterocyte Ca(2+) transport via activation of Na(+)/Ca(2+) exchangers, concurrent with activation of L-type Ca(2+) channels.

The role of protein kinase C-alpha (PKC-alpha) in malignancies of the gastrointestinal tract

Drugs specifically designed to block cellular signalling proteins are currently evaluated as a new way to treat gastrointestinal tumours. One such "new targeted agent" is aprinocarsen, an antisense oligonucleotide that specifically blocks the mRNA of protein kinase C-alpha (PKC-alpha). Blocking PKC-alpha, an important cellular signalling molecule associated with tumour growth, is anticipated to result in tumour cell arrest and achieve clinical benefits. However, it is not known which patients may benefit most from a specific inhibition of PKC-alpha. Past experience with other novel targeted agents suggests that expression of the target molecule is an important factor for the success of such a specific therapy. Therefore, reviewing the specific role of PKC-alpha in various gastrointestinal tumours may contribute to focus the clinical development of selective or specific PKC-alpha inhibitors, such as aprinocarsen, on those patients with a distinctive PKC-alpha expression pattern.