Evaluation of community pharmacist follow-up supported by the use of healthcare technology for type 2 diabetes patients

Background

Prevalence of type 2 diabetes is high in Belgium (estimated at over 10%, 1 patient out of 3 being unaware of their diagnosis). Management based on a change of lifestyle and the adoption of health-promoting behaviors, supplemented when needed with drug treatment, prevents complications, improves the patient's quality of life and reduces mortality. Multidisciplinary patient support is essential. In this, pharmacists have a key role, e.g. through therapeutic patient education activities, in which they are increasingly involved. Moreover, research suggests that the use of mobile technologies can be a useful tool for helping patients with their daily life and disease management.

Objectives

This study aims at exploring the benefits of community pharmacist follow-up supported by the use of mobile technologies in the monitoring of individuals with type 2 diabetes. The presented intervention aimed to reinforce the patients' willingness to actively participate in the management of their disease and to adopt favorable health behaviors, in order to increase their level of medication adherence.

Methods

A quantitative quasi-experimental study was conducted in community pharmacies throughout Belgium over a 6-month period with 3 data collection periods (before, during and after the intervention). Primary outcomes, related to the level of medication adherence, and secondary outcomes, considered as markers of the patient's overall health, were analyzed. In addition, qualitative data concerning participants' opinions on their experience were collected.

Results

66 patients participated in the study, with 50 remaining after 3 months and 46 completing the entire study. Statistical analyses did not show an improvement in the level of medication adherence. This parameter was high from the beginning, reflecting patients with controlled diabetes. However, statistically significant results were observed for systolic blood pressure and waist circumference (both improved), while other outcomes showed a positive trend or remained stable. Patient follow-up by the pharmacist was a positive experience for both parties which noted their interest and satisfaction for the project.

Conclusions

Although clinical results are not conclusive, patients were motivated and the attrition rate was low. Participants showed their interest in participating in this kind of project, opening up opportunities for further studies in the community pharmacy setting. As front-line health professionals, community pharmacists certainly have a key-role to play in therapeutic patient education and mobile technologies could be additional tools in this process.

Toxins of toxin/antitoxin systems are inactivated primarily through promoter mutations

AIMS

Given the extreme toxicity of some of the toxins of toxin-antitoxin (TA) systems, we were curious how the cell silences toxins, if the antitoxin is inactivated or independent toxins are obtained via horizontal gene transfer.

METHODS AND RESULTS

Growth curves of Escherichia coli K12 BW25113 harbouring plasmid pCA24N to produce RalR, MqsR, GhoT or Hha toxins, showed toxin inactivation after 3 h. Sequencing plasmids from these cultures revealed toxin inactivation occurred primarily due to consistent deletions in the promoter. The lack of mutation in the structural genes was corroborated by a bioinformatics analysis of 1000 E. coli genomes which showed both conservation and little variability in the four toxin genes. For those strains that lacked a mutation in the plasmid, single nucleotide polymorphism analysis was performed to identify that chromosomal mutations iraM and mhpR inactivate the toxins GhoT and MqsR/GhoT respectively.

CONCLUSION

We find that the RalR (type I), MqsR (type II), GhoT (type V) and Hha (type VII) toxins are inactivated primarily by a mutation that inactivates the toxin promoter or via the chromosomal mutations iraM and mhpR.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study demonstrates toxins of TA systems may be inactivated by mutations that primarily affect the toxin gene promoter instead of the toxin structural gene.

The use of European Randomized study of Screening for Prostate Cancer calculator as a diagnostic tool for prostate biopsy indication

BACKGROUND

It is a well-known fact, that too many men are having prostate biopsy performed with negative biopsy results. The decision to undertake prostate biopsy is usually based on prostate specific antigen (PSA) level and digital rectal examination (DRE). A risk-based strategy may reduce the numbers of unnecessary prostate biopsies.

METHODS

Retrospective statistical analysis of data from 195 men undergoing their initial prostate biopsy from 1.1.2015 to 31.12.2015 based on elevated PSA ≥ 4.0 ng/ml and/or abnormal DRE were included. Subsequent risk stratification using the European Randomized study of Screening for Prostate Cancer calculator (ERSPC) was used with the intent to calculate the accuracy of ERSPC with the aim to avoid unnecessary (negative) prostate biopsies.

RESULTS

The specific values of sensitivity and specificity in this cohort were 94.34 % and 24.72 %. In direct comparison of PSA and ERSPC calculator, the differences between sensitivity, specificity, negative predictive value and false omission rate as negative were statistically insignificant, but the positive predictive value was on the edge of statistical significance (p = 0.054), slightly in favor for ERSPC calculator.

CONCLUSION

PSA still remains the single most predictive factor for identifying men with an increased risk of prostate cancer to be detected on prostate biopsy, but using other risk factors included in ERSPC can considerably reduce the numbers of unnecessary biopsies on initial screening (Tab. 4, Fig. 2, Ref. 23).

Morbidity, mortality and long term survival in patients with vascular resection in pancreatic cancer - single center experience

Although venous resection in pancreatic cancer is widely used method, recently published data about its safety and survival benefit showed conflicting results. A retrospective case matched study was performed to compare the results of patients who underwent venous resection to those with no venous resection during radical surgery in pancreatic cancer.From January 2010 to December 2015, 297 pancreatic resections due to pancreatic tumor were performed in the National Cancer Institute (NCI). Fifty-three patients with venous resection were identified and enrolled into the study and matched with 66 patients without vascular resection during radical resection of pancreatic head/body cancer. Both groups matched for age, ASA score, need for preoperative biliary drainage and clinical staging of the tumor. Morbidity was determined according Clavien and Dindo classification [1] and was similar in both groups of patients (p = 0.48). Thirty day postoperative mortality was also equal in both groups 5.6 vs 4.5% (p > 0.99) and long term survival was with no significant difference. Median overall survival was 18.8 vs 20.7 months (p = 0.33) for patients with/without venous resection.Therefore we consider venous resection in pancreatic cancer safe procedure with equal morbidity and perioperative mortality as in patients with no need for vascular resection and with the same long term survival if R0 resection is achieved.

Emergence of Resistance to Colistin During the Treatment of Bloodstream Infection Caused by Klebsiella pneumoniae Carbapenemase-Producing Klebsiella pneumoniae

We report the emergence of colistin resistance in Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae after 8 days of colistin-based therapy, resulting in relapse of bloodstream infection and death. Disruption of the mgrB gene by insertion of a mobile genetic element was found to be the mechanism, which was replicated in vitro after exposure to subinhibitory concentrations of colistin and meropenem.

Oxidative stress and the amyloid beta peptide in Alzheimer's disease

Oxidative stress is known to play an important role in the pathogenesis of a number of diseases. In particular, it is linked to the etiology of Alzheimer’s disease (AD), an age-related neurodegenerative disease and the most common cause of dementia in the elderly. Histopathological hallmarks of AD are intracellular neurofibrillary tangles and extracellular formation of senile plaques composed of the amyloid-beta peptide (Aβ) in aggregated form along with metal-ions such as copper, iron or zinc. Redox active metal ions, as for example copper, can catalyze the production of Reactive Oxygen Species (ROS) when bound to the amyloid-β (Aβ). The ROS thus produced, in particular the hydroxyl radical which is the most reactive one, may contribute to oxidative damage on both the Aβ peptide itself and on surrounding molecule (proteins, lipids, …). This review highlights the existing link between oxidative stress and AD, and the consequences towards the Aβ peptide and surrounding molecules in terms of oxidative damage. In addition, the implication of metal ions in AD, their interaction with the Aβ peptide and redox properties leading to ROS production are discussed, along with both in vitro and in vivo oxidation of the Aβ peptide, at the molecular level.

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Oxidative stress plays a role in Alzheimer’s disease (AD), a multifactorial disease leading to loss of cognitive functions.

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Metal ions can bind the amyloid beta peptide (Aβ) and are involved in the production of reactive oxygen species (ROS).

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Oxidation targets neuronal membrane biomolecules and leads to disruption of membrane integrity.

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Aβ is damaged during ROS production, with consequences regarding aggregation, ROS production and cell toxicity.

Tigecycline exhibits inhibitory activity against Clostridium difficile in the intestinal tract of hospitalised patients

No new acquisition of Clostridium difficile occurred among 12 hospitalised patients receiving tigecycline, and pre-existing colonisation was reduced to undetectable levels in 2 patients. Moreover, 91% of stool suspensions obtained during tigecycline therapy exhibited inhibitory activity against C. difficile. These results suggest that tigecycline achieves sufficient concentrations to inhibit intestinal colonisation by C. difficile.

A Clostridium difficile Infection (CDI) Stewardship Initiative Improves Adherence to Practice Guidelines for Management of CDI

A Clostridium difficile infection (CDI) stewardship initiative reduced inappropriate prescription of empirical CDI therapy and improved timeliness of treatment and adherence to clinical practice guidelines for management of CDI. The initiative required minimal resources and could easily be incorporated into traditional antimicrobial stewardship programs.

Metabolomics analysis identifies intestinal microbiota-derived biomarkers of colonization resistance in clindamycin-treated mice

BACKGROUND

The intestinal microbiota protect the host against enteric pathogens through a defense mechanism termed colonization resistance. Antibiotics excreted into the intestinal tract may disrupt colonization resistance and alter normal metabolic functions of the microbiota. We used a mouse model to test the hypothesis that alterations in levels of bacterial metabolites in fecal specimens could provide useful biomarkers indicating disrupted or intact colonization resistance after antibiotic treatment.

METHODS

To assess in vivo colonization resistance, mice were challenged with oral vancomycin-resistant Enterococcus or Clostridium difficile spores at varying time points after treatment with the lincosamide antibiotic clindamycin. For concurrent groups of antibiotic-treated mice, stool samples were analyzed using quantitative real-time polymerase chain reaction to assess changes in the microbiota and using non-targeted metabolic profiling. To assess whether the findings were applicable to another antibiotic class that suppresses intestinal anaerobes, similar experiments were conducted with piperacillin/tazobactam.

RESULTS

Colonization resistance began to recover within 5 days and was intact by 12 days after clindamycin treatment, coinciding with the recovery bacteria from the families Lachnospiraceae and Ruminococcaceae, both part of the phylum Firmicutes. Clindamycin treatment caused marked changes in metabolites present in fecal specimens. Of 484 compounds analyzed, 146 (30%) exhibited a significant increase or decrease in concentration during clindamycin treatment followed by recovery to baseline that coincided with restoration of in vivo colonization resistance. Identified as potential biomarkers of colonization resistance, these compounds included intermediates in carbohydrate or protein metabolism that increased (pentitols, gamma-glutamyl amino acids and inositol metabolites) or decreased (pentoses, dipeptides) with clindamycin treatment. Piperacillin/tazobactam treatment caused similar alterations in the intestinal microbiota and fecal metabolites.

CONCLUSIONS

Recovery of colonization resistance after antibiotic treatment coincided with restoration of several fecal bacterial metabolites. These metabolites could provide useful biomarkers indicating intact or disrupted colonization resistance during and after antibiotic treatment.

The response of the different soybean metallothionein isoforms to cadmium intoxication

Cadmium is a highly toxic heavy metal for both plants and animals. The presence of Cd in agricultural soils is of major concern regarding its entry into the food chain, since Cd compounds are readily taken up by plants, and accumulated in edible parts due to their high solubility. In this study, we first demonstrate the high capacity for Cd concentration of soybean grains. Consequently, we considered the study and characterization of the molecular determinants of Cd accumulation -such as metallothioneins (MT)- to be of major practical importance. We report here the first characterization of the soybean MT system, with the identification of nine genes (one of which is a truncated pseudogene), belonging to the four plant MT types. The most highly expressed of each type was chosen for further function analysis. All of them are expressed at high levels in soybean tissues: GmMT1, GmMT2 and GmMT3 in roots, shoots and seeds, and GmMT4 only in seeds. The corresponding recombinant soybean MTs, synthesized in Escherichia coli cells cultured in metal supplemented media, exhibit greater cadmium than zinc binding capacity. These results suggest a definite role of GmMTs in Cd(II) accumulation as one of the main responses of soybean to an overload of this metal.

RhoA and lysophosphatidic acid are involved in the actin cytoskeleton reorganization of astrocytes exposed to ethanol

Astroglial cells play an important role in maintaining neuronal function in the adult and in the developing nervous system. Ethanol exposure induces profound alterations in the astrogliogenesis process, affecting important cell functions, including intracellular protein trafficking. Because the actin cytoskeleton plays a crucial role in intracellular protein transport, the aim of the present study was to analyze the effects of ethanol on actin cytoskeleton organization and the involvement of the RhoA signaling pathway in these effects. We show that RhoA and lysophosphatidic acid (LPA), an upstream activator of RhoA, stimulate the formation of stress fibers and focal adhesion in cortical astrocytes in primary culture. Exposure of cultured astrocytes to different concentrations of ethanol profoundly disorganizes the actin cytoskeleton, leading to the formation of actin rings at the cell periphery and decreasing the content of focal adhesion proteins. Furthermore, LPA treatment or RhoA transfection revert the ethanol-induced actin alterations in astrocytes, whereas transfection with an inactive mutant of RhoA is unable to revert the actin ring organization. In addition, inhibition of endogenous RhoA by C3 exoenzyme effectively blocks ethanol-induced actin ring formation. These results suggest that the effects of alcohol on actin cytoskeleton organization are mediated by the RhoA signaling pathway. Disruptions in actin organization may impair important astrocyte functions, participating in ethanol-induced astroglial and brain damage during development.

Neural cell adhesion molecule is endocytosed via a clathrin-dependent pathway

Neural cell adhesion molecule (NCAM) constitutes a group of cell surface glycoproteins that regulate cell-cell interactions in the developing and adult brain. Endocytosis is a mechanism which dynamically controls the amount of cell surface NCAM expression and may involve the rapid changes occurring in NCAM expression under certain physiological or pathological conditions. However, the endocytic pathway of NCAM is presently unknown. Using astrocytes in culture and immunofluorescence we show that NCAM is internalized and that the immunolabelling presents a high degree of colocalization with clathrin, alpha-adaptin and transferrin, suggesting that NCAM is endocytosed by a clathrin-dependent pathway. Potassium depletion which disrupts clathrin-mediated endocytosis, inhibited internalization of NCAM. Electron microscopy and immunogold studies also demonstrate that the surface of clathrin-coated vesicles are also immunolabelled for both alpha-adaptin and PSA-NCAM, the highly sialylated isoform of NCAM. Furthermore, immunoprecipation studies demonstrate that NCAM is associated with both clathrin and alpha-adaptin, a component of adaptor complex AP-2, in brain, neurons and astrocytes. These findings indicate that NCAM is mainly endocytosed via clathrin-coated vesicles, suggesting a possible mechanism that may contribute to the rapid changes in NCAM expression at the cell surface.

Posttranslational modification of the glycosylation inhibiting factor (GIF) gene product generates bioactive GIF

Glycosylation inhibiting factor (GIF) and macrophage migration inhibitory factor (MIF) share an identical structure gene. Here we unravel two steps of posttranslational modifications in GIF/MIF molecules in human suppressor T (Ts) cell hybridomas. Peptide mapping and MS analysis of the affinity-purified GIF from the Ts cells revealed that one modification is cysteinylation at Cys-60, and the other is phosphorylation at Ser-91. Cysteinylated GIF, but not the wild-type GIF/MIF, possessed immunosuppressive effects on the in vitro IgE antibody response and had high affinity for GIF receptors on the T helper hybridoma cells. In vitro treatment of wild-type recombinant human GIF/MIF with cystine resulted in preferential cysteinylation of Cys-60 in the molecules. The cysteinylated recombinant human GIF and the Ts hybridoma-derived cysteinylated GIF were comparable both in the affinity for the receptors and in the immunosuppressive activity. Polyclonal antibodies specific for a stretch of the amino acid sequence in alpha2-helix of GIF bound bioactive cysteinylated GIF but failed to bind wild-type GIF/MIF. These results strongly suggest that cysteinylation of Cys-60 and consequent conformational changes in the GIF/MIF molecules are responsible for the generation of GIF bioactivity.

Long-term effects of clinical outcome with low and high dose in the Captopril in Heart Insufficient Patients Study (CHIPS)

BACKGROUND

Although angiotensin-converting enzyme inhibitors are recommended as first line therapy in patients with chronic heart failure, the target doses proven to be effective in major morbidity and mortality trials (e.g. captopril 50 mg b.i.d), are generally not used in daily practice in Belgium.

AIM

The objective of this study (CHIPS, Captopril in Heart Insufficient Patients Study) was to compare the long-term effects of a low dose (25 mg b.i.d.) and a high dose (50 mg b.i.d.) of captopril in mild to moderate heart failure. After a titration period of at least 10 days, patients who tolerated 50 mg b.i.d., were randomly assigned to receive either the low dose or the high dose of captopril and followed up to 2 years.

RESULTS

298 patients were included and were followed up for a mean of 12 months. Progression in heart failure seems to be favourably influenced by therapy with high dose in comparison to low dose; a relative difference of 29% in the rates of heart failure worsening was observed between the two doses, 31.5% and 22.4% for low and high dose (p = 0.088), respectively. Treatment with high dose showed also a trend to benefit as compared to low dose in reducing the number of hospitalizations for all causes from 22.4 to 14.5% (p = 0.1) and for congestive heart failure from 14.7 to 7.2% (p = 0.06); moreover, the incidence of fatal and nonfatal cardiac events showed a trend in favour of the high dose of 22% (p = 0.142). The total number of adverse events was comparable for both doses, but dizziness and hypotension were a little more frequently reported in the high-dose group. Serum creatinine values showed no significant changes either in the low-dose or in the high-dose group.

CONCLUSION

In the CHIPS-study, in comparison to a low dose, therapy with a high dose of captopril tends to improve the long-term clinical outcome of patients with mild to moderate heart failure without significantly more toxicity.

[Cardiological fitness examination of the athlete and prevention of sudden death]

Sudden death happening to an athlete is a frightening tragedy. Epidemiological data are quite controversial but sudden death occurring during sporting activity is probably not a rare occurrence. Beside drug abuse and accidental causes, cardiovascular abnormalities represent the principal origin of sudden death. Cardiomyopathy in young athletes and coronary artery disease in older athletes are the underlying pathologic substrates for most incidences. A certain proportion of sudden death in apparently healthy athletes was preceded by symptoms of exercise intolerance; pre participation evaluation directed to detect the cardiovascular abnormalities is probably of more value to reduce sudden cardiac death in athletes than detailed and routine sophisticated investigations.

Belgian multicenter clinical study of alfuzosin, a selective alpha 1-blocker, in the treatment of benign prostatic hyperplasia. The Alfuzosin Belgian Group

The effects of alfuzosin, a potent alpha 1-blocker, were assessed in patients with benign prostatic hyperplasia, in a double-blind, multicenter, placebo-controlled, cross-over study. Treatment duration was 4 weeks for both alfuzosin and placebo. A significant beneficial effect of alfuzosin (7.5 to 10 mg a day) on clinical subjective and objective criteria was observed as compared to placebo: total Boyarsky score decreased by 1.63 points, peak urinary flow improved by 2.03 ml/sec. Alfuzosin was well tolerated, the observed adverse events corresponded to the pharmacological properties of this compound, and resolved rapidly.

Phase II trial of cisplatin and tegafur (Ftorafur) as initial therapy in squamous-cell carcinoma of the head and neck

Cisplatin and 5-fluorouracil infusion combination produces a high response rate in squamous-cell carcinoma of the head and neck. Tegafur (Ftorafur) is an analog of 5-fluorouracil, and its oral form is well absorbed. This agent has a moderate toxicity. We report a study to determine the efficacy of the cisplatin (100 mg/m2, day 1) and tegafur (1,000 mg/m2 daily for 21 days) combination. Thirty-nine patients entered the study; 36 were evaluable for response. Overall response was 94%, with a 22% complete response. Toxicity was moderate. We conclude that the cisplatin and tegafur combination is active in untreated patients with head and neck cancer.

Phase II trial of carboplatin and tegafur (Ftorafur) as induction therapy in squamous-cell carcinoma of the head and neck

Cisplatin and 5-fluorouracil by continuous infusion combination produces a high response rate in squamous-cell carcinoma of the head and neck (SCCHN). Carboplatin (CBDCA) is a cisplatin analogue with lower emetic potential and nephrotoxicity, although the myelosuppression potential is higher. Tegafur (ftorafur, FT) is an analogue of 5-fluorouracil. It is absorbed well in its oral form and has moderate gastrointestinal and hematologic toxicity. This clinical trial tested the association of CBDCA i.v. plus FT p.o. in patients with SCCHN who had not been previously treated. Twenty-one patients were evaluable for response; the overall response was 62% (33% complete response, 29% partial response). Toxicity was moderate in most of the patients, although there was a treatment-related death.