Controlled E. coli Aggregation Mediated by DNA and XNA Hybridization

Chemical cell surface modification is a fast-growing field of research, due to its enormous potential in tissue engineering, cell-based immunotherapy, and regenerative medicine. However, engineering of bacterial tissues by chemical cell surface modification has been vastly underexplored and the identification of suitable molecular handles is in dire need. We present here, an orthogonal nucleic acid-protein conjugation strategy to promote artificial bacterial aggregation. This system gathers the high selectivity and stability of linkage to a protein Tag expressed at the cell surface and the modularity and reversibility of aggregation due to oligonucleotide hybridization. For the first time, XNA (xeno nucleic acids in the form of 1,5-anhydrohexitol nucleic acids) were immobilized via covalent, SNAP-tag-mediated interactions on cell surfaces to induce bacterial aggregation.

Pharmacogenetic CYP2D6 variability, phenoconversion and treatment outcomes: A Danish population-based cohort study in 6,798 individuals initiating atomoxetine treatment

Introduction

Atomoxetine, a first-line treatment option for ADHD, is affected by pharmacogenetic (PGx) variation of the drug-metabolizing enzyme CYP2D6. Despite the recommendation of CYP2D6 testing, the use of PGx-guided dosing remains low in Denmark.

Objectives

We investigated wide-ranging clinical outcomes in atomoxetine users in association with PGx variability.

Methods

We analyzed 6,798 individuals (55% children) with a first prescription for atomoxetine identified from the Danish population-based iPSYCH case-cohort study linking biobank information with Danish registers. Individuals were categorized based on their single-nucleotide-polymorphism-based CYP2D6 genotype into normal (NM), intermediate (IM), and poor metabolizer (PM). Clinical outcomes included treatment switching, discontinuation, psychiatric inpatient-, outpatient-, and emergency contact, suicide attempt/self-harm, sleep problem, and depression. Individuals’ CYP2D6-status could change due to drug-drug-interactions of weak, intermediate, or strong-CYP2D6 inhibitors (phenoconversion), which we accounted for by time-varying phenotype assessment. Incidence rate ratios (IRR) were estimated using Poisson regression analyses and adjusted for a wide range of potential confounders and covariates.

Results

Over two-thirds of the individuals had a hospital diagnosis of ADHD at the first atomoxetine prescription. The distribution of CYP2D6 phenotypes was similar in children and adults. IM/PM children had a significantly higher risk of a sleeping problem compared with NM children (IRR 1.25, 95% CI 1.01-1.54). Compared with NM adults, those with IM/PM had a higher risk of switching (1.15, 95% CI 0.98-1.35).

Conclusions

This is the first study showing the potential impact of PGx variability on clinical outcomes of atomoxetine users in a population-based setting, highlighting the utility of PGx testing.

Disclosure

No significant relationships.

Pharmacogenetics and antidepressant treatment outcomes in pregnancy: a Danish-population based study

Introduction

Depression in pregnancy is common and often requires treatment with antidepressant drugs. Most antidepressants are metabolized by the cytochrome P450 system (CYP), in particular CYP2C19 and -2D6, both of which are genetically polymorphic. Additionally, the activity of these enzymes is altered during pregnancy.

Objectives

To investigate pharmacogenetic variability regarding CYP2C19 and -2D6 in pregnant users of antidepressants and treatment outcomes.

Methods

The study population comprises all women born between 1981-1999, who gave birth to at least one child before December 2015 identified from the large Danish population-based iPSYCH2012 case-cohort study sample linked to information on genetic variants, prescription drug use and outcome data. Pharmacogenetic genotypes and phenotypes of CYP2C19 and CYP2D6 will be categorized into poor, (PM), intermediate, (IM), extensive, (EM), rapid (RM) and ultra-rapid metabolizers (RM) using array-based SNP information. Antidepressant drug use and comedication during pregnancy will be assessed based on prescription data. Outcomes include treatment discontinuation, switching and psychiatric hospitalizations. Cox regression analysis will be performed to estimate the hazard ratios comparing the rates of the different outcomes in people with different phenotypes, compared with EM adjusted for a number of confounding factors.

Results

Based on previous research we will be able to identify approximately 6531 pregnant women with a psychiatric history. Among those, we estimate to find 14 PM, 161 IM, 285 EM, 168 RM and 25 UM of CYP2C19, and 27 PM, 218 IM and 408 EM of CYP2D6. Exposure to antidepressants is estimated at 10%.

Conclusions

We expect to be able to present the results at the conference.

Disclosure

No significant relationships.

Clinical impact of functional CYP2C19 and CYP2D6 gene variants on treatment outcomes in patients with depression: a Danish cohort study

Introduction

Pharmacogenetic (PGx) targets to optimize drug therapy, but its implementation is rare.

Objectives

We evaluate the clinical utility of PGx testing in psychiatry by investigating the one-year risks of clinical outcomes in patients with depression taking sertraline, (es)citalopram or fluoxetine by their Cytochrome P450 (CYP) 2C19/2D6 phenotypes.

Methods

We investigated 17,297 individuals born between 1981-2005 with a depression diagnosis between 1996-2012 from the iPsych2012 case-cohort. Based on array-based single-nucleotide-polymorphism genotype data, individuals were phenotyped as CYP2C19/CYP2D6 normal (NM, reference group), ultra-rapid- (UM), rapid- (RM), intermediate- (IM), or poor-metabolizer (PM). Outcomes were treatment switching or discontinuation, psychiatric in-, out-, and emergency room contacts (ER), and suicide attempt/self-harm. Incidence rate ratios (IRR) by age groups were estimated using Poisson regression analysis with 95% confidence intervals, adjusted for potential confounders.

Results

Risks of switching (IRR=1.89[1.22-2.93]), ERs (1.69 [1.01-2.81]) and suicide attempt/self-harm (2.73 [1.49-5.01]) were higher in CYP2C19 PMs <19 years taking (es)citalopram. Fluoxetine users <19 years had a decreased risk of discontinuation in CYP2D6 PMs (0.5 [0.27-0.95]) and decreased risk of out-patient contacts in CYP2D6 PMs and IMs (IRR_IM=0.83 [0.68-1.00] and IRR_PM=0.59 [ 0.37-0.96]). We observed an increased risk for ERs in CYP2D6 PMs aged 19-25 years taking fluoxetine (4.53 [1.54-13.35]). In CYP2C19 UMs >25 years taking (es)citalopram the risk of suicide attempt/self-harm was more than three-fold increased (3.64 [ 1.01-13.19]). We found no significant results in users of sertraline.

Conclusions

PGx variability was associated with treatment outcomes in depression in patients with CYP2C19 PM or UM status taking (es)citalopram, or CYP2D6 PM or IM status taking fluoxetine.

Disclosure

No significant relationships.

Adherence to Direct Oral Anticoagulants in Patients With Non-Valvular Atrial Fibrillation: A Cross-National Comparison in Six European Countries (2008-2015)

Aims: To describe and compare the adherence to different direct oral anticoagulants (DOACs) in eight European databases representing six countries. Methods: Longitudinal drug utilization study of new users (≥18 years) of DOACs (dabigatran, rivaroxaban, apixaban) with a diagnosis of non-valvular atrial fibrillation (2008-2015). Adherence was examined by estimating persistence, switching, and discontinuation rates at 12 months. Primary non-adherence was estimated in BIFAP and SIDIAP databases. Results: The highest persistence rate was seen for apixaban in the CPRD database (81%) and the lowest for dabigatran in the Mondriaan database (22%). The switching rate for all DOACs ranged from 2.4 to 13.1% (Mondriaan and EGB databases, respectively). Dabigatran had the highest switching rate from 5.0 to 20.0% (Mondriaan and EGB databases, respectively). The discontinuation rate for all DOACs ranged from 16.0 to 63.9% (CPRD and Bavarian CD databases, respectively). Dabigatran had the highest rate of discontinuers, except in the Bavarian CD and AOK NORDWEST databases, ranging from 23.2 to 64.6% (CPRD and Mondriaan databases, respectively). Combined primary non-adherence for examined DOACs was 11.1% in BIFAP and 14.0% in SIDIAP. There were differences in population coverage and in the type of drug data source among the databases. Conclusion: Despite the differences in the characteristics of the databases and in demographic and baseline characteristics of the included population that could explain some of the observed discrepancies, we can observe a similar pattern throughout the databases. Apixaban was the DOAC with the highest persistence. Dabigatran had the highest proportion of discontinuers and switchers at 12 months in most databases (EMA/2015/27/PH).

Stealth Fluorescence Labeling for Live Microscopy Imaging of mRNA Delivery

Methods for tracking RNA inside living cells without perturbing their natural interactions and functions are critical within biology and, in particular, to facilitate studies of therapeutic RNA delivery. We present a stealth labeling approach that can efficiently, and with high fidelity, generate RNA transcripts, through enzymatic incorporation of the triphosphate of tC^O, a fluorescent tricyclic cytosine analogue. We demonstrate this by incorporation of tC^O in up to 100% of the natural cytosine positions of a 1.2 kb mRNA encoding for the histone H2B fused to GFP (H2B:GFP). Spectroscopic characterization of this mRNA shows that the incorporation rate of tC^O is similar to cytosine, which allows for efficient labeling and controlled tuning of labeling ratios for different applications. Using live cell confocal microscopy and flow cytometry, we show that the tC^O-labeled mRNA is efficiently translated into H2B:GFP inside human cells. Hence, we not only develop the use of fluorescent base analogue labeling of nucleic acids in live-cell microscopy but also, importantly, show that the resulting transcript is translated into the correct protein. Moreover, the spectral properties of our transcripts and their translation product allow for their straightforward, simultaneous visualization in live cells. Finally, we find that chemically transfected tC^O-labeled RNA, unlike a state-of-the-art fluorescently labeled RNA, gives rise to expression of a similar amount of protein as its natural counterpart, hence representing a methodology for studying natural, unperturbed processing of mRNA used in RNA therapeutics and in vaccines, like the ones developed against SARS-CoV-2.

Pharmacogenetic drug use in young danish individuals with severe mental disorders

Introduction

Pharmacogenetics (PGx) studies genetic variance and related differences in drug outcomes. PGx guidelines for psychotropic drugs are available (PGx drugs), but PGx testing is used only limitedly in psychiatric clinical practice.

Objectives

The aim of this study is to pinpoint different aspects of PGx drug use in the population, to support clinical uptake of PGx.

Methods

This drug utilization study investigated prescription PGx drug use in 56,065 young individuals with different severe mental disorders (SMD) in the Danish iPSYCH sample (born 1981-2005). We investigated the number of PGx drug users (incidence, prevalence), age (at first PGx drug use), sex, multiple PGx drugs per user (in light of panel-based PGx testing) and concomitant use of PGx drugs (in light of combinatorial PGx testing).

Results

We identified substantial PGx drug use in terms of incidence rates (e.g. 333 per 10,000 person years for the anticonvulsant lamotrigine) and prevalence (e.g. 15,260 users for the antidepressant citalopram) in patients with SMD. The age of first time PGx drug use ranged from 11.6-20 years, depending on SMD and sex. On average, more than one PGx drug was used by a single person (range 1.6-5.6 drugs, depending on SMD) or even used concomitantly (41-69%) affecting mostly two different PGx genes (84-92% of concomitant PGx drug users).

Conclusions

PGx drugs were frequently used in young individuals with SMD, often subsequently and concomitantly, arguing for panel-based/combinatorial PGx testing over single-gene testing. PGx testing could be applied already at a very young age.

Disclosure

We thank the iPSYCH consortium, in specific the iPSYCH PI’s (Merete Nordentoft, Anders Børglum, Preben B. Mortensen, Ole Mors, Thomas Werge and David M. Hougaard). The iPSYCH project is funded by the Lundbeck Foundation Denmark and the universities and un

Pharmacogenetic profiles of young danish individuals with and without severe mental disorders

Introduction

Pharmacogenetics (PGx) studies genetic variance and related differences in drug outcomes. PGx guidelines for psychotropic drugs are available (PGx drugs). By executing PGx testing in a prospective or pre-emptive setting, dose adjustments or even change of treatment type can be applied prior to start of therapy to patients who carry a specific geno- or phenotype (i.e. actionable geno- or phenotypes). By doing so, increased efficacy of therapy or reduced risk of adverse events of treatment can be accomplished. In Denmark, broad implementation of PGx is currently still low.

Objectives

The aim of this study is to classify the PGx profiles of Danish individuals with and without severe mental disorders (SMD), to be used in follow-up studies investigating PGx and drug outcomes.

Methods

This study made use of imputed genotyping data of the Danish iPSYCH sample, which includes 77,639 young individuals born between 1981-2005, with or without a diagnosis of one or more of five selected SMD (i.e. depression, attention-deficit/hyperactivity disorder, autism, bipolar disorder and schizophrenia). We investigated a panel of 48 genetic variants with known PGx applications (part of the U-PGx consortium, a Horizon2020 funded project on clinical relevant PGx in the EU).

Results

Imputed data contains over 11 million SNPs of 77,639 individuals.

Conclusions

We expect results in the end of 2020.

Disclosure

We thank the iPSYCH consortium, in specific the iPSYCH PI’s (Merete Nordentoft, Anders Børglum, Preben B. Mortensen, Ole Mors, Thomas Werge and David M. Hougaard). The iPSYCH project is funded by the Lundbeck Foundation Denmark and the universities and un

Pharmacogenetics and adhd treatment outcomes in the danish population-based IPSYCH sample

Introduction

Pharmacogenetics (PGx) studies genetic variance and related differences in drug outcomes. The aim of PGx testing is to increase therapy efficacy and safety, by applying e.g. dose adjustments in patients with a specific geno- or phenotype. PGx guidelines for psychotropic drugs are available (PGx drugs), including atomoxetine used in the treatment of attention deficit hyperactivity disorder (ADHD). In Denmark, broad implementation of PGx is currently still low, possibly due to the lack of population-based studies investigating the real-world impact of PGx variability.

Objectives

The aim of this study is to investigate the association of PGx variability (patients’ genotype/phenotype) in users of atomoxetine and different treatment outcomes in a large population-based sample of individuals with ADHD.

Methods

This study will use data of the large Danish population-based iPSYCH case-cohort study sample including information on genetic variants, prescription drug use and outcome data, e.g. psychiatric and somatic hospitalizations and death. The study population comprises all individuals diagnosed with ADHD born 1981-2005 with at least one prescription for atomoxetine between 1995 and 2016. All individuals will be categorized according to their CYP2D6 phenotypes. We will perform Cox regression analysis to estimate the hazard ratios comparing the rates of the different outcomes in people with different phenotypes adjusted for a number of confounding factors.

Results

We have identified approximately 20,000 individuals with ADHD, of whom an estimated 10-20% have filled at least one prescription of atomoxetine.

Conclusions

We expect results in the beginning of 2021.

Disclosure

We thank the iPSYCH consortium, in specific the iPSYCH PI’s (Merete Nordentoft, Anders Børglum, Preben B. Mortensen, Ole Mors, Thomas Werge and David M. Hougaard). The iPSYCH project is funded by the Lundbeck Foundation Denmark and the universities and un

The effectiveness of involuntary electroconvulsive therapy (ECT): A population-based study

Introduction

Involuntary electroconvulsive therapy (ECT) can be a life-saving intervention for patients suffering from potentially lethal conditions who are unable to give informed consent. However, its use is not widespread, probably partly due to the scarce data on hard outcomes following involuntary ECT. In Denmark, involuntary ECT is only used when patients are at imminent/potential risk of dying if not receiving ECT.

Objectives

We aimed to assess the effectiveness of involuntary ECT by estimating the 1-year survival following its administration.

Methods

We conducted a register-based cohort study involving i) all patients receiving involuntary ECT in Denmark between 2008 and 2019, ii) age and sex-matched patients receiving voluntary ECT, and iii) age and sex-matched individuals from the general population. 1-year survival rates were compared via mortality rate ratios.

Results

We identified 618 patients receiving involuntary ECT, 547 patients receiving voluntary ECT, and 3,080 population-based controls. The survival rate in the year after involuntary ECT was 90%. For patients receiving involuntary ECT, the 1-year mortality rate ratios were 3.1 (95% confidence interval (CI)= 1.9-5.2) and 5.8 (95%CI = 4.0-8.2) compared to those receiving voluntarily ECT and to the population-based controls, respectively. Risk factors for early death among patients receiving involuntary ECT were male sex, being ≥70 years old and having organic mental disorder as the treatment indication.

Conclusions

Treatment with involuntary ECT is associated with a high survival rate, suggesting that the intervention is effective. However, patients receiving involuntary ECT constitute a high-risk population that should be monitored closely after this treatment.

Disclosure

No significant relationships.

Incidence of medically treated depression in Denmark among individuals 15-44 years old: a comprehensive overview based on population registers

OBJECTIVE

Examine the overall incidence of medically treated depression in Denmark among individuals 15-44 years old, and estimate the 5-year cumulative incidence of psychiatric hospital care among individuals treated first in non-hospital-based care.

METHODS

We followed all individuals born in Denmark between 1969 and 1998 from age 15 or 2006 (whichever came first) until first depression treatment; death; emigration; or December 31, 2013. Incidence rates were estimated using Poisson regression. Cumulative incidence of hospital care following treatment in non-hospital care was estimated using Kaplan-Meier curves.

RESULTS

In this sample of 2 014 760 individuals, incidence rates of depression in non-hospital and hospital-based care in 2012-2013 were 6.6 (95% Confidence Interval: 6.5-6.7) per 1000 person-years and 1.5 (95% CI: 1.5-1.6) per 1000 person-years, respectively. Overall, 85-90% of first medical treatment for depression took place outside of psychiatric hospitals, but a quarter (26.3%) of individuals treated for depression received hospital care initially or within 5 years. Incidence of hospital care was higher in women and younger individuals.

CONCLUSIONS

Most medical treatment for depression in Denmark takes place in non-hospital settings. Women and younger individuals are more likely to receive hospital care both initially and within 5 years after first antidepressant treatment.

Modulation of BACE1 Activity by Chemically Modified Aptamers

A modified DNA aptamer that binds BACE1, a therapeutic target involved in Alzheimer's disease has been developed. This ssXNA not only tightly binds to BACE1 but also inhibits its protease activity in vitro in the same range as a previously described unmodified aptamer. We report the in vitro selection of functional oligonucleotides incorporating two nucleobase modifications: 5-chlorouracil and 7-deazaadenine. The nucleoside analogue 5-chloro-2'-deoxyuridine has already been explored as a replacement for thymidine in a chemically modified genome of a bacterium. Thus, 5-chlorouracil modification is a good candidate to support genetic transfer in vivo as well as functional activity.

Nucleic Acid Aptamers: Emerging Applications in Medical Imaging, Nanotechnology, Neurosciences, and Drug Delivery

Recent progresses in organic chemistry and molecular biology have allowed the emergence of numerous new applications of nucleic acids that markedly deviate from their natural functions. Particularly, DNA and RNA molecules-coined aptamers-can be brought to bind to specific targets with high affinity and selectivity. While aptamers are mainly applied as biosensors, diagnostic agents, tools in proteomics and biotechnology, and as targeted therapeutics, these chemical antibodies slowly begin to be used in other fields. Herein, we review recent progress on the use of aptamers in the construction of smart DNA origami objects and MRI and PET imaging agents. We also describe advances in the use of aptamers in the field of neurosciences (with a particular emphasis on the treatment of neurodegenerative diseases) and as drug delivery systems. Lastly, the use of chemical modifications, modified nucleoside triphosphate particularly, to enhance the binding and stability of aptamers is highlighted.

C-reactive protein and white blood cell levels in schizophrenia, bipolar disorders and depression - associations with mortality and psychiatric outcomes: a population-based study

BACKGROUND

Mental disorders have been associated with increased levels of inflammatory markers, which can affect disease trajectories. We aimed to assess levels of C-reactive protein (CRP) and white blood cells (WBC) across individuals with schizophrenia, bipolar disorder, and depression, and to investigate associations with subsequent psychiatric admission and mortality.

METHODS

We identified all adults in the Central Denmark Region during 2000-2012 with a first diagnosis of schizophrenia, bipolar disorder, or depression and a baseline measurement of CRP and/or WBC count. We followed these individuals until outcome of interest (psychiatric admission or death), emigration or December 31, 2012, using Cox regression analysis to estimate hazard ratios (HRs).

RESULTS

Baseline median CRP differed significantly between mental disorders (P=0.01) being highest in individuals with bipolar disorder (3.5mg/L) (particularly during manic states, 3.9mg/L), followed by schizophrenia (3.1mg/L), and depression (2.8mg/L), while baseline WBC count did not differ (median 7.1×10⁹/L). Elevated CRP levels were associated with increased all-cause mortality by adjusted HRs of 1.56 (95% CI: 1.02-2.38) for levels 3-10mg/L and 2.07 (95% CI: 1.30-3.29) for levels above 10mg/L compared to individuals with levels below 3mg/L. WBC counts were not associated with all-cause mortality. No association was observed between levels of the inflammatory markers and subsequent psychiatric admissions.

CONCLUSIONS

People with severe mental disorders had increased inflammatory markers at first diagnosis, and elevated CRP levels were associated with increased mortality. Thorough screening for physical diseases is of utmost importance among individuals who are diagnosed with severe mental disorder.

Psychopharmacological drug utilization patterns in pregnant women with bipolar disorder - A nationwide register-based study

BACKGROUND

Bipolar disorder is often associated with a lifetime indication for treatment with psychotropic drugs, thus pregnant women face the dilemma whether to continue treatment or not. This study describes the psychopharmacological drug utilization patterns among women with bipolar disorder from 12 months preconception to 12 months postpartum.

METHODS

We conducted a register-based cohort study among all Danish women aged 15-55 with a diagnosis of bipolar disorder, who gave birth to their first and singleton child between January 1997 and December 2012. Psychotropic drug use was determined by prescriptions obtained from the Danish National Prescription Registry.

RESULTS

We identified 336 women. The proportion of women redeeming prescriptions for any psychotropic drug decreased during pregnancy, from 54.8% in the 3 months preconception to 36.6% in the third trimester (p<0.001). Lithium dosing increased significantly during pregnancy. A total of 35 (41.2%) of the women on psychotropic monotherapy and 37 (50.0%) of the women on psychotropic polypharmacy used an antidepressant without concomitant use of a mood-stabilizer at some time during pregnancy.

LIMITATIONS

Only redemption of prescriptions was assessable, thus we were not able to assess compliance and discontinuation of treatment before the end of the treatment duration. There was no information on drug use during hospitalizations.

CONCLUSIONS

We found a decrease in the proportion of women redeeming prescriptions during pregnancy. There was a high prevalence of antidepressant use without a mood-stabilizer, potentially putting women at risk for a switch to mania - although this is still debated. This calls for further investigation.

Infections and exposure to anti-infective agents and the risk of severe mental disorders: a nationwide study

OBJECTIVE

Severe infections are associated with increased risks of mental disorders; however, this is the first large-scale study investigating whether infections treated with anti-infective agents in the primary care setting increase the risks of schizophrenia and affective disorders.

METHOD

We identified all individuals born in Denmark 1985-2002 (N = 1 015 447) and studied the association between infections treated with anti-infective agents and the subsequent risk of schizophrenia and affective disorders during 1995-2013. Cox regression analyses were adjusted for important confounders.

RESULTS

Infections treated with anti-infective agents were associated with increased risks of schizophrenia by a hazard rate ratio (HRR) of 1.37 (95%-CI = 1.20-1.57) and affective disorders by a HRR of 1.64 (95%-CI = 1.48-1.82), fitting a dose-response and temporal relationship (P < 0.001). The excess risk was primarily driven by infections treated with antibiotics, whereas infections treated with antivirals, antimycotics, and antiparasitic agents were not significant after mutual adjustment. Individuals with infections requiring hospitalization had the highest risks for schizophrenia (HRR = 2.05; 95%-CI = 1.77-2.38) and affective disorders (HRR = 2.59; 95%-CI = 2.31-2.89).

CONCLUSION

Infections treated with anti-infective agents and particularly infections requiring hospitalizations were associated with increased risks of schizophrenia and affective disorders, which may be mediated by effects of infections/inflammation on the brain, alterations of the microbiome, genetics, or other environmental factors.

Cardiovascular drug use and mortality in patients with schizophrenia or bipolar disorder: a Danish population-based study

BACKGROUND

Cardiovascular (CV) co-morbidity is one of the major modifiable risk factors driving the excess mortality in individuals with schizophrenia or bipolar disorder. Population-based studies in this area are sparse.

METHOD

We used Danish population registers to calculate incidence rate ratios (IRRs) for CV drug use, and mortality rate ratios comparing subjects with schizophrenia or bipolar disorder with subjects with no prior psychiatric hospitalization.

RESULTS

IRRs for CV prescriptions were significantly decreased in patients with schizophrenia or bipolar disorder compared with the general population. Among persons without previous myocardial infarction (MI) or cerebrovascular disease, persons with schizophrenia or bipolar disorder had an up to 6- and 15-fold increased mortality from all causes or unnatural causes, respectively, compared with the general population, being most pronounced among those without CV treatment (16-fold increase). Among those with previous MI or cerebrovascular disease, excess all-cause and unnatural death was lower (up to 3-fold and 7-fold increased, respectively), but was similar in CV-treated and -untreated persons.

CONCLUSIONS

The present study shows an apparent under-prescription of most CV drugs among patients with schizophrenia or bipolar disorder compared with the general population in Denmark. The excess of mortality by unnatural deaths in the untreated group suggests that the association between CV treatment and mortality may be confounded by severity of illness. However, our results also suggest that treatment of CV risk factors is neglected in these patients.

Prevalence of antidepressant use and contacts with psychiatrists and psychologists in pregnant and postpartum women

OBJECTIVE

We aimed to study prevalence of antidepressant drug use from 12 months prior childbirth to 12 months postpartum and to compare the prevalences with those in a group of women of similar age who did not give birth. We additionally studied prevalences of contacts with private practicing psychiatrists and psychologists during a similar time period.

METHOD

Our study population comprised of pregnant women, and their controls were drawn from a 25% sample of the entire Danish population. Information on redeemed prescriptions for antidepressants and referrals to psychiatrists and psychologists was extracted. The outcome measure was period prevalence calculated in 3-month intervals from 12 months before childbirth to 12 months postpartum.

RESULTS

In the 2-year observation period around childbirth, 2733 (3.17%) women had one or more prescriptions for an antidepressant and 935 (1.18%) and 1399 (1.76%) were referred to consultations with a psychiatrist or psychologist, respectively. Women giving birth had a markedly lower use of antidepressants compared to controls, with the largest observed difference during third trimester of pregnancy (0.6% vs. 2.20%).

CONCLUSION

We found that the prevalence of redeemed prescriptions for antidepressants decreased during pregnancy and increased postpartum. Similar patterns were observed for contacts with private practicing psychiatrists and psychologists.

The frequency of inappropriate tablet splitting in primary care

INTRODUCTION

We assessed the frequency and determinants of tablet splitting in primary care in Germany and evaluated the quality of information on divisibility in the Summary of Product Characteristics (SPCs) and in the Package Leaflet (PL) as legal sources of information for health care providers and patients.

METHODS

We performed a cross-sectional questionnaire survey among patients of 59 general practitioners in the German Federal State Saxony-Anhalt in 2005 in order to collect detailed information on all drugs of patients maintained on more than three drugs.

RESULTS

The response rate was 82.1% (n=905) and 3,158 drugs (tablets and dragées) were included in the analyses. Of all drugs, 24.1% were split (762 of 3,158): 8.7% of all split tablets were unscored (66 of 762) and 3.8% of all split tablets were not allowed to be split (29 of 762). Tablets of the higher price categories and higher strengths were twice as likely to be split. Only 22.5% of the SPCs (9 of 40) of the split unscored tablet brands contained explicit information on divisibility and only 36.4% of the PLs (8 of 22) of the split brands that were not allowed to be split stated that splitting was not appropriate.

CONCLUSION

The splitting of tablets in primary care is a frequent habit likely driven by medical and economic considerations. Almost 1% of all tablets are split that must not be fragmented. However, the SPC and PL provide only limited information on divisibility stressing the need to improve this information promptly to avoid medication errors.

Substrate specificity of vaccinia virus thymidylate kinase

Anti-poxvirus therapies are currently limited to cidofovir [(S)-1-(3-hydroxy-2-phosphonylmethoxypropyl)cytosine], but drug-resistant strains have already been characterized. In the aim of finding a new target, the thymidylate (TMP) kinase from vaccinia virus, the prototype of Orthopoxvirus, has been overexpressed in Escherichia coli after cloning the gene (A48R). Specific inhibitors and alternative substrates of pox TMP kinase should contribute to virus replication inhibition. Biochemical characterization of the enzyme revealed distinct catalytic features when compared to its human counterpart. Sharing 42% identity with human TMP kinase, the vaccinia virus enzyme was assumed to adopt the common fold of nucleoside monophosphate kinases. The enzyme was purified to homogeneity and behaves as a homodimer, like all known TMP kinases. Initial velocity studies showed that the Km for ATP-Mg2+ and dTMP were 0.15 mm and 20 microM, respectively. Vaccinia virus TMP kinase was found to phosphorylate dTMP, dUMP and also dGMP from any purine and pyrimidine nucleoside triphosphate. 5-Halogenated dUMP such as 5-iodo-2'-deoxyuridine 5'-monophosphate (5I-dUMP) and 5-bromo-2'-deoxyuridine 5'-monophosphate (5Br-dUMP) were also efficient alternative substrates. Using thymidine-5'-(4-N'-methylanthraniloyl-aminobutyl)phosphoramidate as a fluorescent probe of the dTMP binding site, we detected an ADP-induced conformational change enhancing the binding affinity of dTMP and analogues. Several thymidine and dTMP derivatives were found to bind the enzyme with micromolar affinities. The present study provides the basis for the design of specific inhibitors or substrates for poxvirus TMP kinase.

[Search for new anti-angiogenic agents with structural analogy with thalidomide]

Despite its teratogenic effects, thalidomide has been reintroduced in human anticancer treatment for its anti-angiogenic activity, especially observed in patients with multiple myeloma. Here, we report the synthesis of new analogues designed to increase the thalidomide anti-tumour properties. The anti-angiogenic activity of the compounds was tested on EA.hy 926 endothelial cell lines. In this model, that is easier to manipulate than HUVEC cells, thalidomide is active in a similar dose range as reported on HUVEC cells and one of our compounds is more efficient.

Assessing hypertension management in the community: trends of prevalence, detection, treatment, and control of hypertension in the MONICA Project, Augsburg 1984-1995

OBJECTIVE

To assess trends in prevalence and detection, treatment and control of hypertension in a German population between 1984 and 1995.

SETTING AND PARTICIPANTS

Independent random samples of the population were examined in cross-sectional surveys with identical methods in 1984/85 (age range 25 to 64 years, n = 4022 participants), 1989/90 (age range 25 to 74 years, n = 4940) and 1994/95 (age range 25 to 74 years, n = 4856).

MAIN OUTCOME MEASURES

Prevalence of hypertension and proportions of hypertensives detected, treated and controlled. Hypertension was defined as blood pressure above 140/90 mm Hg or taking antihypertensive medication.

RESULTS

The prevalence of hypertension did not change significantly over the 10 years (25--64 years, age-standardised 1984/85: 37.8% in men and 24.6% in women; 1994/95: 39.3% and 24.8%, respectively). Rates of detection, treatment and control of hypertension did not change much either. Of all hypertensives in 1994/95, 54% were detected in men and 64% in women, the treatment rates were 23% and 32%, and the proportions of those with controlled hypertension (below 140/90 mm Hg with treatment) were as low as 7% and 13%, respectively. Rates were higher in the older age groups, however, control rates never exceeded 20% at any age.

CONCLUSIONS

Despite considerable changes in the pharmacological treatment of hypertension there was a disappointing stagnation with regard to the management of this important risk factor in the community. The reasons for this unfavourable trend need clarification and appropriate public health action. Journal of Human Hypertension (2001) 15, 27-36

Incidence of first-time idiopathic seizures in users of tramadol

STUDY OBJECTIVE

To assess the risk of idiopathic incident seizures among patients who ever took tramadol.

DESIGN

Nested case-control design.

SETTING

General Practice Research Database from November 1996-August 1998.

PATIENTS

Eleven thousand three hundred eighty-three patients.

INTERVENTION

Comparison of risks of idiopathic incident seizures during exposed and unexposed times among patients who had ever taken tramadol and other analgesics with 90-day follow-up.

MEASUREMENTS AND MAIN RESULTS

Among the 11,383 subjects we identified 21 cases of idiopathic seizures, 10 of which were categorized as definite cases and 11 categorized as possible cases. Three patients were exposed to tramadol alone in the previous 90 days, 10 to opiates, three to both tramadol and opiates, one to other analgesics, and four to no analgesics.

CONCLUSION

The risk of idiopathic seizures was similarly elevated in each analgesic exposure category compared with nonusers, suggesting that the risk for patients taking tramadol was not increased compared with other analgesics.

Population trends in antihypertensive drug use: results from the MONICA Augsburg Project 1984 to 1995

Trends in antihypertensive drug use were assessed among 25- to 64-year-old participants of three independent surveys of the MONICA Augsburg region in 1984/85, 1989/90, and in 1994/95. Despite constant prevalences of hypertension, the percentage of hypertensives taking medication increased over the study period. The latter was mainly due to significant rises in antihypertensive monotherapy. By contrast, the use of combination treatments with two or more agents remained constant; however, although combinations composed of only two drugs were taken more often in 1995, those with three or more agents and fixed-dose preparations decreased substantially. Beta-blockers were most frequently, and with a rising tendency, taken as antihypertensive monotherapy. Newer drug classes like calcium channel blockers and ACE-inhibitors were introduced as monotherapy more hesitantly. Diuretics persisted as the basis of antihypertensive combination therapy. The use of combination therapies containing obsolete drugs, like reserpine, declined significantly with corresponding increases in drug combinations of, in particular, calcium channel blockers or ACE-inhibitors. We conclude that monotherapies account for most of the rising antihypertensive treatment rates and probably reflect intensified therapy of borderline hypertensives. The trends in antihypertensive drug classes and treatment regimens reflect a less rapid adoption of novel therapeutic concepts but a fairly close adherence to national and international guidelines.