Drug safety related to agents used for opioid maintenance therapy

Introduction

There is only little data regarding drug safety related to agents used for opioid maintenance therapy (OMT).

Objectives/aims

To study drug safety and the reporting behaviour of adverse drug reactions (ADR) related to OMT.

Methods

A cross-sectional questionnaire-based telephone survey among physicians providing outpatient OMT in a federal state of Germany (n = 176; response rate = 55.7%) was conducted.

Results

Most of the respondents (n = 97/55.1%) reported that they observe ADR related to buprenorphine, [dihydro]codein and [levo]methdone rarely (n = 38/21.6%), very rarely (n = 39/22.2%) or never (n = 20/11.4%). Methadone was reported to be most frequently associated with the occurrence of ADR (n = 82/46.6%), followed by levomethadone (n = 33/18.8%), buprenorphine (n = 6/3.4%), and dihydrocodeine (n = 3/1.7%). Frequently observed ADR related to these agents were gastrointestinal, nervous system and psychiatric disorders, and hyperhidrosis. Methadone and levomethadone (not buprenorphine) were reported to be frequently associated with fatigue, weight gain, and sexual dysfunction. Only buprenorphine was reported to be frequently associated with withdrawal and rebound effects, and drug intolerance. Hundred twenty-nine participants (73.3%) stated that they never report ADR related to OMT, whereas n = 19 (10.8%) did so when referring to ADR related to their complete medical practice (Chi2 = 141.070; df = 1; P < 0.001).

Conclusions

Our data revealed similar patterns of ADR related to outpatient OMT as those reported in the product information or in pain therapy. Motivation to report ADR related to agents used for OMT may be reduced compared to ADR related to the general medical practice.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Post-transplant diabetes mellitus - risk factors and effects on the function and morphology of the allograft

The incidence of post-transplant diabetes mellitus and its effects on the kidney allograft function and morphology were assessed. Patients were divided into three groups according to their glucose metabolism. Risk factors for diabetes were first assessed, and then changes in renal function were checked. Morphological changes in the allografts were examined by protocol biopsies. The overall incidence of diabetes was 16%. The development of diabetes was influenced significantly by the body mass index, the body weight and the age of the recipient. The incidence of diabetes was 8.6% in patients on cyclosporine A therapy and 28.8% in those on tacrolimus (p < 0.05). As to the morphology of the kidney, a significantly higher proportion of the biopsies showed severe interstitial fibrosis/tubular atrophy (p = 0.0004) and subclinical acute rejection ( p = 0.001) in the diabetic group compared to the normal one. This clinical study has revealed that the adverse effect of diabetes on the allograft can be detected with protocol biopsy before the manifestation of a functional deterioration.

Benefits of Periodontal Therapy When Preterm Birth Threatens

There is growing evidence that chronic periodontitis may be a risk factor for pre-term birth. The goal of this intervention study was to determine the effect of periodontal treatment on the pregnancy outcome in women with threatening pre-term birth and initial localized chronic periodontitis. Forty-one women with a singleton pregnancy were enrolled in the study. For this treatment group, oral hygiene instruction and periodontal therapy were provided in the third trimester, while those in the control group (42 persons) did not receive any periodontal treatment. In the treatment group, the mean weight of newborns was 3079.0 g, compared with the control group mean of 2602.4 g. The incidence of pre-term birth and low birthweight in the treatment group was significantly less than in the control group ( p = 0.015). Periodontal treatment completed before the 35th week appeared to have a beneficial effect on birth weight and time of delivery.

Prognostic significance of microvascularization in cases of operated lung cancer

OBJECTIVE

Measurement of microvascularization and determination of its prognostic significance in cases of lung cancer.

METHODS

Section prepared from histological material from 432 radically operated non-small cell lung cancer patients were stained with antibodies against factor VIII-associated antigen. During computer imaging, the absolute and relative parameters of the vascularization were determined, as was the density of tumour cells situated in the vicinity of the vessels. The results were compared with the TNM status, the cell type and the survival.

RESULTS

Each parameter demonstrated an enhanced vascularization in classifications T2 and T4, but only the surface fraction, the mean vascular circumference and the mean vascular area displayed a significant change. The microvascularization parameters did not differ significantly between with different N status, however, the cell density progressively increased in the areas close to the vessels in advanced pN classifications. Elevation of the tumour cell density within 20 microm distance of the vessels was accompanied by a significantly poorer survival rate. The density of tumour cells within 20 microm region was the second strongest prognostic factor after the N status.

CONCLUSIONS

More advanced tumour classifications grow with enhanced vascularization. A clear-cut connection cannot be demonstrated between the vascularization and appearance of lymph node metastases. The density of tumour cells measured in the direct vicinity of vessels is an important prognostic factor.

Levofloxacin versus clarithromycin in COPD exacerbation: focus on exacerbation-free interval

Antibiotic treatment of bacterial exacerbation of chronic obstructive pulmonary disease (COPD) shows some immediate clinical benefits and may also minimise the frequency of further recurrences. Patients (n=511) were enrolled into a randomised double-blind multicentric study comparing the exacerbation-free interval (EFI), efficacy and safety of 7-day levofloxacin versus 10-day clarithromycin in patients with COPD exacerbation. Patients were monitored over a 1-yr period. A total of 434 patients (per protocol population) received the medication for > or =5 days. The median EFI in the per protocol population was 300 days for levofloxacin and 350 days for clarithromycin. For patients with a new documented exacerbation during follow-up (n=223), the median EFI was 100.5 days in the levofloxacin group and 95 days for clarithromycin. No significant differences in EFI between groups could be observed when stratifying the study population according to microbial aetiology and severity of bronchial obstruction. Levofloxacin and clarithromycin showed similar clinical success rates. The bacteriological success rate was significantly higher in the levofloxacin group. Both antibiotics were well tolerated. In summary, levofloxacin was associated with a significantly higher bacteriological eradication rate but similar exacerbation-free interval in patients with chronic obstructive pulmonary disease exacerbation compared to clarithromycin.

Ki-67, cyclin D1, p53 and bcl-2 expression in advanced head and neck cancer

In order to analyse the radiosensitivity of tumours and to evaluate the possibility of improving the treatment results with regard to genetic alterations, we examined 33 patients with advanced head and neck tumours after 66-70 Gy irradiation. Between 1998 and 2001, 33 patients with advanced head and neck squamous cell carcinoma (HN-SCC) were observed. They received 66-70 Gy to the primary tumour site and pathological lymph nodes. One month later, physical examination and CT were performed to verify the effect of radiotherapy, and the patients were followed until their death. The histological grading and Ki-67, cyclin D1, p53 and bcl-2 status were examined from the aspect of their potential prognostic value in all patients. The average survival was 13 months; 25% of the patients survived for at least 20 months. Seventy-two percent of the patients demonstrated Ki-67 positivity, 69% p53 positivity and 40% cyclin D1 positivity; there were only 12% bcl-2-positive cases. A significant correlation was not found between the tumour response or the duration of survival and the Ki-67, p53 or cyclin D1 positivity. Only bcl-2-positive cases exhibited significantly better outcome. These parameters indicate the proliferating (Ki-67 and cyclin D1) and apoptotic (p53 and bcl-2) activities of advanced HN-SCC cells. Our results proved that they proliferate rapidly and have impaired repair or apoptotic functions. The heterogeneity of our results did not allow us to conclude that the above parameters are of clinically reliable prognostic value, but the obviously high kinetic activity of HN-SCC underlines the potential efficacy and need for accelerated irradiation in these cases.

Relationship between the occurrence of anti-SSA, anti-SSB autoantibodies and HLA class II alleles from the aspect of in vitro inhibitory effect of glucocorticosteroid on the antibody-dependent cellular cytotoxicity in patients with primary Sjögren's syndrome

Though at present there is no evidence-based algorithm for the treatment of primary Sjögren's syndrome, it is generally accepted that glucocorticosteroid (GS) therapy must be introduced in cases with severe systemic manifestations. As the side-effects of the GSs are well known, it would be useful to know in advance how the patients will respond to this type of treatment. For this reason we measured the in vitro steroid sensitivity of 29 SS patients using inhibition of antibody dependent cellular cytotoxicity (ADCC) test by methylprednisolone compared to that of 28 controls. SS patients proved to be significantly less sensitive to GSs than controls (inhibition of ADCC reaction: 42.4 vs 53.1%; p < 0.01). This was especially true in SS patients with anti-SSA and/or SSB autoantibody positivity and with HLA-DR2 and/or -DR3 alleles. Comparing the results of the in vitro GS sensitivity and the clinical effectiveness of the previously applied corticosteroid therapy it seems that steroid inhibition of ADCC reaction has a predictive value in determination of in vivo sensitivity to GSs. However, in patients with decreased in vitro GS sensitivity a more expressed in vivo steroid sensitivity cannot be excluded.

Absolute levels of MDR-1, MRP, and BCL-2 MRNA and tumor remission in acute leukemia

Mononuclear cells prepared from peripheral blood or bone marrow of 119 AML and 28 ALL patients prior and following therapy were analyzed for absolute transcript levels of the chemoresistance genes mdr-1 and MRP, and the proto-oncogene bcl-2, by validated contamination-protected quantitative RT-PCR. In newly diagnosed AML mainly tumors of the granulocytic lineage (FAB M1-M2) expressed increased mdr-1 mRNA amounts. The MRP gene was expressed in all investigated samples without relation to a particular FAB class. High initial expression of both genes did not confer a poor prognosis even at high number of CD34+ cells. Data compared prior to and after therapy start (paired samples) revealed that AML patients who did not respond to therapy (NR) expressed increased levels of mdr-1 mRNA, as well as MRP and bcl-2 cDNA normalized to GAPDH reference transcripts, when compared to patients achieving complete remission (CR; p = 0.003, 0.008 and 0.0005, respectively). In ALL-NR the mdr-1 and bcl-2 genes were entirely more active after induction chemotherapy. Arbitrary cut-off values were established in order to delimit pathological from non-pathological gene expression. 59% of studied AML and 33% of ALL-NR exceeded the arbitrary values (mdr-1: > 2 amol/microgram RNA, MRP: > 10 zmol/amol GAPDH, bcl-2: > 5 zmol/amol GAPDH) for one and 11% of AML-NR for two parameters. Only 17% of the AML-CR and none of the ALL-CR group were above these limits. The results indicate that high individual activity of usually one, rarely two of the investigated genes might be associated with poor clinical outcome in treated acute leukemia.

[Inpatient treatment costs of exacerbated chronic obstructive lung disease]

Economic aspects are of increasing importance in health care. However, treatment expenditures for most diseases are unknown. We performed a detailed cost analysis for the treatment of the exacerbated chronic obstructive pulmonary disease (ECOPD) in our department. For one year, all patients admitted because of exacerbated chronic obstructive pulmonary disease were included in this study. The workload was assessed for each patient by time keeping. Diagnostic and therapeutic procedures were considered according to the price list of the German hospital association. From 101 patients included into the study, 100 were evaluable. The median duration of inpatient hospitalisation amounted to 18 days (range: 4 to 210 days). Median total cost was DM 7680.- and mean cost DM 11900.-. This consisted of non-medical cost items (36%), personnel expenditures (29%), laboratory tests (14%), respiratory and cardiovascular laboratory (7%), radiology (5%) and pharmacy cost (7%). Endoscopy, external diagnostics and medical reports amounted to 2.8% of the expenditure. Treatment cost correlated with the duration of stay, but hardly with lung function and blood gases, these being independent of age and sex, but significantly higher in case of bronchiectasis, enterobacteriae, cor pulmonale or intensive care. The proportion of the pharmacy expenditures was rather small, and hence this is not a primary target for the realisation of major savings.

Infective exacerbations of chronic bronchitis: relation between bacteriologic etiology and lung function

STUDY OBJECTIVE

In patients with severe COPD, acute infective exacerbations are frequent. Streptococcus pneumoniae and Haemophilus influenzae are the most commonly isolated bacteria in sputum cultures from these patients. We hypothesized that in patients with advanced disease, Gram-negative bacteria other than H influenzae play at least an equally important role.

METHODS

We evaluated clinical data and sputum culture results from 211 unselected COPD patients admitted to our hospital with an acute infective exacerbation of COPD. One hundred twelve patients fulfilled our protocol criteria of reliable microbiologic results and reproducible lung function tests; the patients were categorized according to the recently published three stages of severity.

RESULTS

Lung function tests revealed an FEV1 of > or =50% of the predicted value in 30 patients (stage I), an FEV1 of 35% to <50% of the predicted value in 30 patients (stage II), and an FEV1 of < or =35% of the predicted value in 34 patients (stage III). Bacteria were classified into three groups: group 1 contained S pneumoniae and other Gram-positive cocci; group 2, H influenzae and Moraxella catarrhalis; and group 3, Enterobacteriaceae and Pseudomonas spp. For all patients together, the most frequently isolated bacteria were group 3 organisms (Enterobacteriaceae and Pseudomonas spp, 48.2%), followed by group 1 organisms (S pneumoniae and other Gram-positive cocci, 30.4%), and group 2 organisms (H influenzae and M catarrhalis, 21.4%). In stage I patients, 14 of 30 had bacteria from group 1, seven of 30 had group 2, and nine of 30 had group 3. In stage II patients, eight of 30 had group 1 bacteria, 10 of 30 had group 2, and 12 of 30 had group 3. In stage III patients, 12 of 52 had group 1 bacteria, seven of 52 had group 2, and 22 of 52 had group 3. The three groups of bacteria causing infective exacerbations were unevenly distributed among the three severity stages of lung function (p=0.016).

CONCLUSION

There is a correlation between deterioration of lung function and the bacteria isolated from patients with infective exacerbations of COPD. In acute infective exacerbations, Enterobacteriaceae and Pseudomonas spp are the predominant bacteria in patients with an FEV1 < or =35% of the predicted value.

[Pulmonary melioidosis in a German Southeast Asia tourist]

HISTORY AND CLINICAL FINDINGS

A patient who returned from a 3-year stay in Thailand and India one year ago, was admitted with fever of 38.5 degrees C and productive cough for the last four weeks. He remembered wounding his foot three years ago in India with contamination by soil. Subsequently, recurrent pustulae appeared on his feet. One such pustule was found on admittance. The clinical examination showed low body weight, without further abnormalities.

INVESTIGATIONS

The blood examinations revealed high inflammation parameters and ruled out any immunodeficiency. Smouldering infiltrates in the upper lobes were found on the chest radiography. Sputum was free of acid fast bacilli and no mycobacterial DNA was detected by polymerase chain reaction. Bronchoscopy showed a normal endobronchal situation, Burkholderia pseudomallei were found to grow from specimens of bronchial mucus.

TREATMENT AND COURSE

Under the empirical treatment with ampicillin/sulbactam, we could not find any response. After switching to Ceftazidime and trimethoprim/sulfamethoxazol (TMP/SMZ) we observed quick clinical improvement and normalisation of the inflammation parameters and notable radiological response over three weeks. We continued a five months TMP/SMZ therapy after discharge in order to prevent relapses.

CONCLUSION

For travellers and immigrants from Southeast Asia presenting smouldering infiltrations of the upper lobes, one should include Melioidosis in the differential diagnosis.

Serum bactericidal activities and comparative pharmacokinetics of meropenem and imipenem-cilastatin

The pharmacokinetics and serum bactericidal activities (SBAs) of imipenem and meropenem were investigated in a randomized crossover study. Twelve healthy male volunteers received a constant 30-min infusion of either 1 g of imipenem plus 1 g of cilastatin or 1 g of meropenem. The concentrations of the drugs in serum and urine were determined by bioassay and high-pressure liquid chromatography. Pharmacokinetic parameters were based on an open two-compartment model and a noncompartmental technique. At the end of infusion, the mean concentrations of imipenem and meropenem measured in serum were 61.2 +/- 9.8 and 51.6 +/- 6.5 mg/liter, respectively; urinary recoveries were 48.6% +/- 8.2% and 60.0% +/- 6.5% of the dose in 12 h, respectively; and the areas under the concentration-time curve from time zero to infinity were 96.1 +/- 14.4 and 70.5 +/- 10.3 mg.h/liter, respectively (P < or = 0.02). Imipenem had a mean half-life of 66.7 +/- 10.4 min; that of meropenem was 64.4 +/- 6.9 min. The volumes of distribution at steady state of imipenem and meropenem were 15.3 +/- 3.3 and 18.6 +/- 3.0 liters/70 kg, respectively, and the mean renal clearances per 1.73 m2 were 85.6 +/- 17.6 and 144.6 +/- 26.0 ml/min, respectively. Both antibiotics were well tolerated in this single-dose administration study. The SBAs were measured by the microdilution method of Reller and Stratton (L. B. Reller and C. W. Stratton, J. Infect. Dis. 136:196-204, 1977) against 40 clinically isolated strains. Mean reciprocal bactericidal titers were measured 1 and 6 h after administration. After 1 and 6 h the median SBAs for imipenem and meropenem, were 409 and 34.9 and 97.9 and 5.8, respectively, against Staphylococcus aureus, 19.9 and 4.4 and 19.4 and 4.8, respectively, against Pseudomonas aeruginosa, 34.3 and 2.2 and 232 and 15.5, respectively, against Enterobacter cloacae, and 13.4 and 2.25 and 90.7 and 7.9, respectively, against Proteus mirabilis. Both drugs had rather short biological elimination half-lives and a predominantly renal route of elimination. Both carbapenems revealed high SBAs against clinically important pathogens at 1 h; meropenem had a higher SBA against E. cloacae and P. mirabilis, and the SBA of imipenem against S. aureus was greater than the SBA of meropenem.

Subpopulations of alveolar macrophages in smokers and nonsmokers: relation to the expression of CD11/CD18 molecules and superoxide anion production

We were previously able to show that the number of alveolar macrophages (AM) expressing CD11/CD18 molecules is increased in smokers compared with nonsmokers and related to the superoxide anion (O2-) production of these cells. Since it has been demonstrated that AM are a heterogeneous cell population that can be separated by density, we performed this study to investigate the expression of CD11/CD18 molecules and O2- production in relation to cell density of AM from smokers and nonsmokers. AM were obtained by bronchoalveolar lavage (BAL) from smokers (n = 32) and nonsmokers (n = 20). Subpopulations were isolated using discontinuous Percoll density-gradient centrifugation with four densities (fraction 1: 1.030; fraction 2: 1.040; fraction 3: 1.050; and fraction 4: 1.070 g/ml). Expression of CD11/CD18 on freshly isolated cells and on AM before and after density centrifugation was studied using peroxidase-antiperoxidase staining. The contribution of AM subpopulations to O2- production in smokers was determined by monitoring the reduction of ferricytochrome C to ferrocytochrome C. We obtained 0.92 +/- 0.1 x 10(5) AM/ml BAL in nonsmokers and 2.4 +/- 0.3 x 10(5) AM/ml in smokers. Recovery after density centrifugation was > or = 72%. The absolute number of AM in smokers was significantly increased in fractions 3 and 4 (median 4.37 x 10(6) and 2.05 x 10(6), respectively) compared with nonsmokers (median 1.26 x 10(6) and 0.7 x 10(6), respectively) (p < 0.05). In both smokers and nonsmokers, fractions 3 and 4 showed a comparable increase in the percentage of CD11/CD18-positive AM compared with fractions 1 and 2.(ABSTRACT TRUNCATED AT 250 WORDS)

OpenLabs: the application of advanced informatics and telematics for optimization of clinical laboratory services

OpenLabs has four major objectives: to improve the efficiency and effectiveness of clinical laboratory services by the integration of Knowledge Based Systems (KBSs) with Laboratory Information Systems (LISs) and equipment; to provide and implement standard solutions for Electronic Data Interchange (EDI) between laboratories and other medical systems; to specify a fully Open architecture for an integrated Clinical LIS and demonstrate the integration of various KBS modules on the open architecture platform; and to demonstrate the integration of OpenLabs modules with existing LISs.

Prophylactic external irradiation in differentiated thyroid cancer: a retrospective study over a 30-year observation period

Following surgery which left no microscopic residue, 114 patients with differentiated thyroid cancer (58 papillary, 56 follicular) were subgrouped on the basis of the dose of externally applied prophylactic postoperative radiation: group 1 received an adequate dose of radiation (> or = 4,500 cGy of telecobalt, > or = 4,000 R of orthovoltage therapy), while group 2 received an inadequate dose of radiation (this group included non-irradiated patients). Local/regional-relapse-free survival (LRRFS), distant-metastatic-relapse-free survival (DMRFS) and total-cause-specific survival (TCSS) were calculated by means of life-table analysis for each histologic type. TCSS and LRRFS were significantly (p < 0.001) better for group 1 in papillary cancer. No difference was found in DMRFS. LRRFS was significantly (p < 0.001) better for group 1 in follicular cancer. No differences were found in TCSS and DMRFS. We conclude that (1) prophylactic postoperative external irradiation is an effective method for survival prolongation in papillary cancer, reducing local/regional recurrences, and (2) external irradiation should be considered in the postoperative management of follicular cancer, to diminish local/regional relapse.

[External irradiation of differentiated thyroid cancer: 30 follow up]

Following surgery which left no macroscopic residue 114 patients with differentiated thyroid cancer (58 papillary, 56 follicular) were subgrouped on the basis of the dose of prophylactic postoperative external radiation applied: group I--an adequate dose of radiation (greater than or equal to 4500 cGy of telecobalt, greater than or equal to 4000 R of orthovolt therapy); group II--an inadequate dose of radiation (including non-irradiated patients). Local/regional relapse-free survival (LRRFS), distant metastatic relapse-free survival (DMRFS) and total cause-specific survival (TCSS) were calculated by means of life-table analysis for both histologic types separately. Results. 1. TCSS and LRRFS were significantly (p less than 0.001) better for group I in papillary cancer. No difference was found in DMRFS. 2. LRRFS was significantly (p less than 0.001) better for group I in follicular cancer. No differences were found in TCSS and DMRFS.

CONCLUSIONS

1. The prophylactic postoperative external irradiation is an effective method for survival prolongation in papillary cancer, the local/regional recurrences thereby being reduced. 2. External irradiation, in conjunction with radioiodine treatment, should be considered in the postoperative management of follicular cancer to diminish local/regional relapse.

[The normal right-side electrocardiogram]

QRS complex, ST segment and T wave were investigated in V1R--V8R right chest wall leads in 122 healthy individuals (76 women, 46 men, mean age: 36.8 years). There was no Q wave in V1-3R. Going towards V8R, occurrence of QR and QS complexes increased. R/S ratio was the highest in V8R, while second r wave (r') was found to be most frequent (in 20.5%) in V6R. ST elevation at 80 msec after J point was found in all right chest wall leads, most frequently (in 91%) in V2R. All three forms of T wave morphology (positive, negative, isoelectric) were observed in these leads.

Hypopituitarism in diabetes mellitus

A woman with stable diabetes presented with hypoglycemia and decreased insulin requirement. Further history suggested decreasing pituitary function. Laboratory tests confirmed pituitary deficiencies, associated with her increased insulin sensitivity. It may be helpful to be aware of this syndrome when dealing with diabetic patients who show decreasing insulin requirements.