[Identification of knowledge deficits of pharmacy students at the beginning of the fifth year of pharmacy practice experience: Proposals to change the content of academic programs]

INTRODUCTION

In France, community pharmacy students performed a hospital pharmacy practice experience during the 5th year of the university curriculum. The purpose of a part of the content of the academic teaching program delivered before this practice experience is to prepare the students for their future hospital activities. It should enable them for the practical use of knowledge in order to improve pharmacotherapy, laboratory diagnosis and monitoring of patients' care. The aim of this study was to show if there are gaps in this program.

METHODS

Fourteen students performing their clerkship in a teaching hospital were invited to highlight these gaps when they were gradually immersed in the pharmaceutical care. They did so under the careful observation of hospital pharmacist preceptors. These practitioners referred to professional guidelines, documentary tools used in daily clinical practice and publications supporting their pharmaceutical care practices.

RESULTS

Shortcomings and gaps identified were: how to communicate with other healthcare professionals and the content of verbal exchanges, how to conduct a patient-centered consultation, documentation tools required for relevant pharmacist' interventions, codification of pharmacist's interventions, risks related to drug packaging and benefit risk assessment of health information technologies.

DISCUSSION

These gaps represent a handicap by delaying the process that led to move from student to healthcare professional. Hospital pharmacist preceptors have to fill in these gaps before engaging students in pharmaceutical care.

CONCLUSION

These results invite to revise partly the content of the academic teaching program delivered before the 5th year hospital pharmacy practice experience.

Evaluation of the estimation of midazolam concentrations and pharmacokinetic parameters in intensive care patients using a bayesian pharmacokinetic software (PKS) according to sparse sampling approach

The aim of the study was to assess the performance of a bayesian program (PKS System, Abbott) for predicting midazolam concentrations and pharmacokinetic parameters in intensive care patients by comparing the pharmacokinetic parameters estimated by PKS to those calculated according to rich data. The study involved 42 patients receiving midazolam infusion for two hours or for several days. The program was used to predict plasma midazolam concentrations after feedback of 1, 2 or 3 concentrations. High correlation between observed and estimated concentrations was shown (r(2) > 0.992). Mean prediction error, mean absolute prediction error and root mean squared error were low for the patients of the reference and validation groups. From two or three feedback concentrations, midazolam pharmacokinetic parameters estimated by PKS were statistically comparable with those obtained using a rich pharmacokinetic analysis (P > 0.05 paired Wilcoxon test). Thus, PKS is useful for predicting midazolam concentrations and pharmacokinetic parameters when at least two feedback concentrations are known. This software seems to be appropriate for providing significant help to the clinician for midazolam dosage adjustment, according to midazolam concentrations and clinical sedation.

Pharmacokinetics and haemodynamics of ketamine in intensive care patients with brain or spinal cord injury

BACKGROUND

Ketamine is used as an anaesthetic agent for short surgical procedures, and as a sedative and analgesic in intensive care patients. Intensive care patients with brain or spinal cord injury may have physiological changes that could alter the pharmacokinetics of ketamine. The pharmacokinetics of ketamine have been studied in healthy volunteers and in patients undergoing different types of surgery, but no data are available in intensive care patients.

METHODS

We determined the pharmacokinetics of ketamine and its active metabolites, norketamine and dehydronorketamine, in 12 intensive care patients with brain or spinal cord injury. The effect of ketamine on haemodynamic variables was also investigated.

RESULTS

The total clearance of ketamine, mean (SD), was 36.0 (13.3) ml min(-1) kg(-1), the volume of distribution (Vbeta) was 16.0 (8.6) litre kg(-1), and the elimination half-life was 4.9 (1.6) h. Ketamine did not alter any haemodynamic variables in the patients studied.

CONCLUSIONS

Pharmacokinetic variables of ketamine in intensive care patients are greater than in healthy volunteers and in surgical patients. The increase in the volume of distribution is greater than the increase in clearance, resulting in a longer estimated half-life of ketamine in this patient group.

[Use of midazolam in postoperative sedation of patients with multiple organ failure treated with hemodiafiltration. Clinical study and pharmacokinetics]

OBJECTIVES

Evaluate the risk of accumulation of midazolam and conjugated 1-hydroxy-midazolam in high-risk ICU patients treated by continuous veno-venous haemofiltration.

STUDY DESIGN

A prospective pharmocokinetic and clinical evaluation in 11 patients, with hepatic and renal failure.

METHODS

Midazolam and metabolites were dosed in plasma and ultratiltration liquid by chromatography. Sedation was assessed by a simplified Ramsay score (EDS) with 4 levels.

RESULTS

The mean duration of continuous infusion was 11 +/- 6 days. Peak plasma levels were over 150 ng ml-1 during the first 3 days, but normalized after that, only by drug adjustment based on scoring and clinical observation. There was no progressive accumulation of OH-midazolam, in spite of high levels (> 1000 ng ml-1). The Sieving coefficient (S) was 0.11 +/- 0.10 and 0.44 +/- 0.15 for midazolam and conjugated OH-midazolam respectively. A significant clearance (9.6 +/- 1.9 ml min-1) was observed for the conjugated products. T 1/2 beta was 11 h and was correlated with the mean time of recovery. A significant correlation was found between sedation score and both midazolam (r = 0.47) and OH-midazolam (r = 0.32).

CONCLUSION

OH-midazolam risk of accumulation and significant clearance by haemodiafiltration should be taken into account in the drug adjustment in patients treated by continuous veno-venous haemofiltration.

[Sedation induced by midazolam in intensive care: pharmacologic and pharmacokinetic aspects]

OBJECTIVE

Review on midazolam in order to optimize drug utilisation and therapeutic monitoring.

DATA SOURCES

Research of English or French articles published until August 2001, using Medline database. The key words were: midazolam, pharmacokinetics, pharmacodynamic, sedation, drug interaction.

STUDY SELECTION

Original articles, clinical cases and letters to the Editor were selected. Animal studies were excluded.

DATA EXTRACTION

The articles were analysed according to their interest in midazolam clinical practice.

DATA SYNTHESIS

Midazolam is a benzodiazepine widely used in intensive care unit, as a sedative, anxiety-relieving, and amnesic drug. Midazolam could be used in patients with cardiac, or respiratory failure, and in neurosurgery. A great interindividual variability on pharmacokinetic and pharmacodynamic response was observed. In intensive care patients, elimination half-life is known to be widely increased. Midazolam is metabolised by hepatic microsomes. The major metabolite is the 1-hydroxymidazolam, which is pharmacologically active. A prolonged sedation due to an accumulation of conjugated metabolite was observed in renal failure patients. Enzymatic inductors or inhibitors could influence pharmacokinetics and pharmacodynamic effects of midazolam.

CONCLUSION

According to midazolam pharmacokinetic and pharmacodynamic variability, an individual dosage adjustment is essential for long-term sedation. Target controlled sedation could be a mean to limit the variability and to reach quickly the pharmacodynamic effect.

Propofol metabolites in man following propofol induction and maintenance

BACKGROUND

The pharmacokinetics of propofol in man is characterized by a rapid metabolic clearance linked to glucuronidation of the parent drug to form the propofol-glucuronide (PG) and sulfo- and glucuro-conjugation of hydroxylated metabolite via cytochrome P450 to produce three other conjugates. The purpose of this study was to assess the urine metabolite profile of propofol following i.v. propofol anaesthesia in a Caucasian population.

METHODS

The extent of phase I and phase II metabolism of propofol was studied in 18 female and 17 male patients after an anaesthesia induced and maintained for at least 4 h with propofol. The infusion rates (mg kg(-1) h(-1)) of propofol were (mean (SD)) 4.1 (1.0) and 4.5 (1.3) for males and females, respectively. Urine was collected from each patient for the periods 0-4, 4-8, 8-12, and 12-24 h after the start of propofol administration. In a preliminary study, the three main glucuro-conjugated metabolites were isolated from urine and characterized by magnetic resonance spectroscopy. The quantification of these metabolites for the different collection periods was then performed by a HPLC-UV assay.

RESULTS

Total recovery of propofol in the metabolites studied amounts to 38%, of which 62% was via the PG metabolite and 38% via cytochrome P-450. This percentage is significantly higher than that previously reported from patients after a bolus dose of propofol. Extreme values for PG (0-24 h period) were included from 73 to 49%. There was no significant difference between female and male patients in the metabolite ratio.

CONCLUSIONS

We conclude that the extent of hydroxylation in propofol metabolism was higher than in previous findings after administration of anaesthetic doses of propofol. Moreover, the ratio between hydroxylation and glucuronidation of propofol is subject to an inter-patient variability but this does not correlate with the dose of propofol. However, the variation of the metabolite profile observed in the present report does not seem to indicate an extended role of metabolism in pharmacokinetic variability.

Stability of sufentanil in human plasma samples

The stability of sufentanil in human plasma kept under various storage conditions was investigated. Extraction was performed using solid phase extraction with new mixed-mode cation exchange Oasis MCX columns; quantification was carried out using gas chromatography equipped with a mass spectrometry detector. When plasma was left at 4 degrees C in nonsilanized tubes, concentrations of sufentanil decreased significantly during the first hour. In plasma samples kept at -25 degrees C for 8 hours in nonsilanized glass tubes, a significant decrease of sufentanil concentrations was found, with an average loss of 10.1% of the initial concentration. A significant decrease occurred when plasma was kept in silanized glass tubes for 12 hours at -25 degrees C. The current study emphasizes the importance of sampling and storage conditions for an accurate determination of sufentanil concentration in plasma.

Midazolam disposition in patients undergoing continuous venovenous hemodialysis

The aim of the study was to investigate the pharmacokinetics and removal of midazolam and unconjugated and glucuronidated 1-hydroxy-midazolam in 4 intensive care patients on continuous venovenous hemodialysis. Plasma midazolam and its metabolites were assessed by HPLC from blood samples collected during continuous infusion and after the end of infusion. Additional samples from the arterial and venous bloodlines and ultrafiltrate were drawn to calculate sieving coefficient and clearance of ultrafiltration. The elimination half-life of midazolam ranged from 7.6 to 22.8 hours. The clearance of ultrafiltration was between 0.13 and 4.7 ml/min and reached approximately 11% of the total clearance. The range of sieving coefficient was from 0.006 to 0.26, with an average fraction removal of 0.2%. 1-Hydroxy-midazolam glucuronide was removed by continuous hemodialysis (sieving 0.36 to 0.63), with a clearance of ultrafiltration ranging from 7.8 to 12.0 ml/min. These preliminary results showed that midazolam is not removed efficiently, and approximately half of the 1-hydroxy-midazolam glucuronide was removed by dialysis.

High-performance liquid chromatographic assay to detect hydroxylate and conjugate metabolites of propofol in human urine

This paper describes a HPLC method for the simultaneous detection of phase I (2,6-diisopropyl-1-4-quinol and 2,6-diisopropyl-1-4-quinone) and phase II (4-(2,6-diisopropyl-1-4-quinol)-sulphate, 1-(2,6-diisopropyl-1-4-quinol)-glucuronide, 4-(2,6-diisopropyl-1-4-quinol)-glucuronide, and propofol-glucuronide) metabolites of propofol in human urine samples. Separation was based on a simple mobile phase and a reversed-phase chromatographic column. Metabolite identification was performed by UV spectrum on a diode-array detector and by LC-APCI-MS. The identification was also carried out using in vitro incubation mixtures (cytosol and microsomes prepared from liver) from several species: human, rat and rabbit. This assay was performed using UV, fluorescence and electrochemical detection modes. Each of these was analyzed and discussed.

Detection of new propofol metabolites in human urine using gas chromatography/mass spectrometry and liquid chromatography/mass spectrometry techniques

Using hyphenated analytical techniques, gas chromatography/mass spectrometry (GC/MS) and liquid chromatography/mass spectrometry (LC/MS), a study on minor propofol metabolites in human urine was conducted. These techniques allowed identification of two new phase I metabolites (2-(omega-propanol)-6-isopropylphenol and 2-(omega-propanol)-6-isopropyl-1,4-quinol). In addition, their four corresponding conjugates (three glucuronides and one sulphate) were detected. Thus in human urine at least eight conjugate metabolites are produced, derived from four different aglycones (propofol; 2, 6-diisopropyl-1,4-quinol; 2-(omega-propanol)-6-isopropylphenol and 2-(omega-propanol)-6-isopropyl-1,4-quinol).

Pyrolysis-gas-liquid chromatography with atomic emission detection for the identification of Corynebacterium species

We report here the application of pyrolysis-gas chromatography followed by atomic emission detection (AED) for the characterisation of microorganisms. AED measured the quantity of carbon, sulfur and nitrogen in the molecules separated chromatographically. Twenty-three strains, representing eight Corynebacterium species, were tested in this preliminary study. Co-ordinate principal analysis grouped 11 strains in their respective species group. Most of the other strains appear randomly distributed, perhaps because these strains require additional nutrients. These preliminary results show that the method could be used as a tool for the taxonomic and perhaps the epidemiologic characterisation of bacteria.

Implementation of a quality system in a therapeutic drug monitoring laboratory

The concept of quality assurance is emerging in public and private clinical laboratories in France following the introduction of decrees on Hospital Accreditation procedure. We report here the methodology used for the implementation of a quality system in a Therapeutic Drug Monitoring laboratory. The quality manual, which represents the basis of the quality system, was drafted according to the following methodology: Step 1--study of the requirements of ISO 9001 Standard; Step 2--analysis and synthesis of the European EN 45001 Standard and French regulation GBEA system respectively, compared with the 20 headings of the ISO 9001 Standard; Step 3--elaboration of the quality manual on the basis of steps 1 and 2 and relating to: laboratory and staff organization, quality document management, quality planning relating to specific activities relevant to projects or contracts on drug monitoring and pharmacokinetic studies, and operating procedures. The implementation of a quality system in a public hospital laboratory may be considered as a means of improving the laboratory organization and management.

Identification of 6-methylmercaptopurine derivative formed during acid hydrolysis of thiopurine nucleotides in erythrocytes, using liquid chromatography-mass spectrometry, infrared spectroscopy, and nuclear magnetic resonance assay

6-Thioguanine and 6-methylmercaptopurine (Me6-MP) nucleotides are the two major thiopurine metabolites of azathioprine found in erythrocytes. During the acid hydrolysis required for the conversion of thiopurine nucleotides into their free bases, Me6-MP was converted into a compound that could be analyzed on a Purospher RP18-e column with dihydrogen phosphate-methanol buffer as eluent. The pH of the acid extract strongly influenced the conversion of Me6-MP into its derivative. The Me6-MP derivative was identified using liquid chromatography-mass spectrometry and infrared and nuclear magnetic resonance spectrometric methods. During the acid hydrolysis of thiopurine nucleotides in erythrocytes, Me6-MP undergoes degradation, leading to 4-amino-5-(methylthio)carbonyl imidazole.

Pharmacokinetics of midazolam and its main metabolite 1-hydroxymidazolam in intensive care patients

The pharmacokinetics of midazolam and of its main metabolite, 1-hydroxymidazolam, were investigated in intensive care patients after intravenous bolus of 0.2 mg/kg followed by a 0.1 mg/kg/h intravenous infusion of midazolam over 2 hours. A wide interpatient variability of the main pharmacokinetic parameters of midazolam was found. The mean values of elimination half life and volume of distribution, 4.5 +/- 5.4 h and 1.7 +/- 0.7 l/kg respectively, were higher than those reported in healthy subjects. Total plasma clearance was significantly increased in patients taking drugs that induce hepatic metabolism. Significant concentrations of the unconjugated form of 1-hydroxymidazolam were recovered in plasma. The volume of distribution and the elimination half life of the metabolite were higher than those of the parent drug. These results show that 1-hydroxymidazolam might contribute to the pharmacodynamic effect of midazolam and consequently must be taken into account during pharmacokinetic and pharmacodynamic studies.

Evaluation of a bayesian pharmacokinetic program for phenytoin concentration predictions in outpatient population

The present work evaluates the performances of a Bayesian program (PKS) for phenytoin concentration predictions in an outpatient population. The retrospective study involved 19 epileptic adults receiving oral phenytoin. The program was used to predict estimated serum concentrations from 0, 1, 2 or 3 feedback concentrations. Measurements of prediction bias (ME) decreased as soon as one steady-state concentration (Css) was used for estimations. Precision (MAE) was significantly improved with 1 Css and was even better and stable with 2 and 3 Css. Likewise, RMSE (composite of bias and precision) regularly decreased when the number of Css used increased. On a clinical way, 12% of the estimations were unacceptable (prediction error > 5 mg/l) with 1 Css and less than 3% with 2 or 3 Css. This number of rejected estimations increased to 45% when no feedback concentration was used. Besides, the program was able to predict important rises of serum levels in spite of relative low increase of the dose when 1 Css at least was known. Thus, the phenytoin dosing program has acceptable performances when at least 1 Css is known, and represents a potential tool to assist the clinician in the particular condition of outpatient population.

HPLC determination of ketamine, norketamine, and dehydronorketamine in plasma with a high-purity reversed-phase sorbent

We developed an isocratic, selective, and very sensitive HPLC method for the determination of ketamine and its two main metabolites in plasma. The compounds were extracted from plasma by a liquid-liquid extraction with a dichloromethane:ethyl acetate mixture followed by an acidic back-extraction. Separation was achieved on a new stationary phase, Purospher RP-18 endcapped, with a mobile phase containing acetonitrile:0.03 mol/L phosphate buffer (23:77 by vol) adjusted to pH 7.2. Because of the high column efficiency and the significant improvement of peak symmetry, the quantification limit could be down to 5 micrograms/L for ketamine and norketamine (NK). The intraday and interday CVs ranged from 1.7% to 5.8% and 3.1% to 10.2% for all compounds respectively. The method is sensitive enough for monitoring ketamine, NK, and dehydroketamine in plasma during pharmacokinetic studies after an intravenous bolus of a low dose of ketamine.

Simultaneous determination of 6-thioguanine and methyl 6-mercaptopurine nucleotides of azathioprine in red blood cells by HPLC

6-thioguanine (6-TGN) and methyl 6-mercaptopurine nucleotides (Me6-MPNs) are the two major metabolites found in erythrocytes after administration of azathioprine. In an attempt to understand the role of these metabolites in the pharmacologic and toxic activity of thiopurines, we have developed a HPLC method for the simultaneous determination of 6-TGNs and Me6-MPNs in erythrocytes. A simple and rapid treatment procedure based on deproteinization by perchloric acid with dithiothreitol is described. The nucleotides were hydrolyzed to their own bases by heating the sample for 45 min at 100 degrees C. During acid hydrolysis Me6-MP was converted into a compound analyzed on a Purospher RP18-e column with 0.02 mol/L dihydrogenophosphate buffer-methanol as eluents. With this procedure, mean recoveries of 73.1% and 84.0% for 6-TGN and Me6-MPN derivatives, respectively, were found.

Pharmacokinetics of acyclovir in patients undergoing continuous venovenous hemodialysis

The pharmacokinetics of acyclovir in three patients undergoing continuous venovenous hemodialysis was investigated. Acyclovir was administered as an intravenous infusion over 1 hour at a dose of 5 mg/kg daily in one patient and 10 mg/kg every 48 hours in two patients. Samples from the arterial and venous blood lines and from ultrafiltrate were collected to calculate pharmacokinetic parameters, sieving coefficient and clearance of ultrafiltration. Plasma concentrations of acyclovir were assessed by high-performance liquid chromatography. Peak plasma concentrations were 9.3 mg/l for the patient receiving 5 mg/kg daily, 29.6 mg/l and 20.7 mg/l for the two patients with 10 mg/kg every 48 hours. The elimination half-life ranged from 8.8 to 11.2 hours and was approximately half those found in patients with renal impairment. The clearance by ultrafiltration was from 17.4 to 22.3 ml/minute and reached nearly 35% of the total clearance. The sieving coefficient ranged from 0.92 to 0.98 with an average rate of removal over the dosing interval ranging from 6.7 to 13.0 mg/hour. These data should be taken into account to optimize drug therapy in patients on continuous hemodialysis. Until formal guidelines are defined, acyclovir dosage should be adjusted according to monitoring of plasma drug concentrations.

Dynamics of MLAEP changes in midazolam-induced sedation

This study aimed at assessing the effects of midazolam (MDZ) sedation on auditory brainstem (BAEP) and middle latency (MLAEP) evoked potentials in intensive care conditions. Ten ventilated comatose patients were receiving an intravenous MDZ bolus dose (0.2 mg/kg) followed by a 2 h continuous infusion (0.1 mg/kg/h). MLAEPs and BAEPs elicited by clicks (90 dB HL + masking) were simultaneously and continuously monitored during the first 6 h and for 30 min the next morning. We found no effect of MDZ sedation on BAEPs. Only MLAEP components were modified. However, none of the patients presented any total abolition of the MLAEPs. Bolus injection led to very early alteration of cortical responses, beginning after 5 min and lasting almost 1 h (maximum Pa latency increase, 3.1 ms; maximum Pa-Nb amplitude decrease, 46%). During continuous infusion, MLAEPs remained slightly, although significantly, altered (Pa latency, +1.3 ms; Pa-Nb amplitude, 27%). The Nb wave seemed to be modified earlier and to return to normality later than the Pa wave. These findings incite a careful interpretation of MLAEP tracings acquired during the first hour following MDZ bolus injection. If possible, MDZ should be administered as continuous infusion for reliable interpretation of evoked potential changes in intensive care unit, or during surgery.

Predictions of carbamazepine concentrations using a Bayesian program (PKS System, Abbott): a retrospective evaluation in an outpatient population

This work evaluates the performance of a Bayesian program (PKS System, Abbott) for predicting carbamazepine concentrations in an outpatient population. The retrospective study involved 20 epileptic patients (12 adults and 8 children) receiving carbamazepine monotherapy orally. The program was used to predict measured serum levels after feedback of 0, 1 or 2 steady-state concentrations. A significant negative prediction bias was observed when no feedback concentration was used for estimation. However, the prediction bias (mean prediction error; m.e.) decreased as soon as one feedback concentration was used for estimation. Precision (mean absolute prediction error; m.a.e.) was significantly improved with one feedback concentration and was even better with two concentrations. Likewise, r.m.s.e. (root mean squared error; composite of bias and precision) regularly decreased when the number of feedback concentrations used was increased. Eleven percent of the estimates were unacceptable clinically (prediction error > 2 mg L-1) when 1 feedback concentration was used; less than 3% were unacceptable when two concentrations were used. Thus the performance of the Bayesian dosing program is acceptable when two feedback concentrations are known, and seems able to help the clinician adjust carbamazepine dosage in an outpatient population.

Determination of acyclovir in human plasma by high-performance liquid chromatography

A selective and sensitive isocratic high-performance liquid chromatographic method for the analysis of acyclovir in human plasma was described. Acid deproteinisation was used as sample treatment. Mean analytical recoveries were higher than 94% at low and high concentrations. The quantification limit was 0.1 mg/l for a plasma volume of 500 microl and precision study exhibits coefficients of variation lower than 5%. The method is suitable for therapeutic monitoring of acyclovir concentrations in organ-transplant recipients.

Intracellular thiopurine nucleotides and azathioprine myelotoxicity in organ transplant patients

AIMS

Despite widespread use of azathioprine in organ transplant recipients, the mechanism of its myelotoxicity remains unclear. The aim of this study was to assess the importance of thiopurine metabolites on bone marrow toxicity.

METHODS

We investigated the relationship between intracellular concentrations of 6-thioguanine (6-TGN), 6-mercaptopurine (6-MPN) and 6-thioxanthine (6 TXN) nucleotides and the absolute count of white or red cells in forty-seven lung or heart/lung transplant patients after oral administration of azathioprine.

RESULTS

No significant correlation between red cell concentrations of 6-TGN or total thiopurine metabolites and white or red cell counts was found, with no difference between the sexes. Likewise, high 6-TGN levels were not related to bone marrow depletion.

CONCLUSIONS

These results suggest that red blood cell 6-TGN alone do not predict the haematopoietic toxicity of azathioprine.

Comparison of capillary electrophoretic and liquid chromatographic determination of hypoxanthine and xanthine for the diagnosis of xanthinuria

A capillary electrophoretic (CE) method for the determination of hypoxanthine and xanthine in urine was developed to diagnose xanthinuria. The linearity was excellent up to 200 mumol l-1 for the two compounds and the limit of quantitation was 2 mumol l-1. A comparison o the results obtained using CE was made with those obtained by the high-performance liquid chromatographic (HPLC) technique described previously. With regard to specificity, sensitivity and reproducibility, the results are similar but CE is more rapid than HPLC.

Sample preparation for the determination of purine nucleotide analogues in tissues

A sample treatment procedure for the determination of thiopurine and ganciclovir nucleotides in human tissues was developed. Owing to the lack of suitable standards for most of the active nucleotide analogues, the procedure was based on two steps: (1) perchloric acid homogenization and deproteinization of the tissue specimen and (2) conversion of purine nucleotides into parent drug or free bases by enzymatic or acid hydrolysis. The parent drug or purine bases formed were then analyzed on a Hypersil ODS column using isocratic elution with dihydrogenphosphate buffer for ganciclovir nucleotides or the gradient elution mode with dihydrogenphosphate buffermethanol for thiopurine nucleotides. The sample treatment procedure was evaluated using guanosine triphosphate (GTP), 6-thioinosinic acid (6TIMP) and 6-thioguanosine monophosphate (6TGMP) as standards. Mean analytical recoveries determined by adding known concentrations of standards to the tissue specimen before sampling processing were higher than 97%. The sample preparation described is simple and represents a suitable method for the investigation of active nucleotide pool in tissues.

Liquid-chromatographic study of purine metabolism abnormalities in purine nucleoside phosphorylase deficiency

Using HPLC methods, we measured the concentrations of nucleosides and nucleotides for a patient with no purine nucleoside phosphorylase (PNP; EC 2.4.2.1) enzymatic activity. Concentrations of inosine and guanosine were abnormally high in urine and plasma, whereas guanosine diphosphate (GDP) and guanosine triphosphate (GTP) concentrations in erythrocytes were depleted. The unusual presence of deoxyribonucleosides (deoxyinosine and deoxyguanosine) and deoxyribonucleotides (dGDP and dGTP) was also notable. Thus, HPLC represents an accurate and useful tool for the study of purine metabolic disorders.

Liquid-chromatographic study of purine metabolism abnormalities in purine nucleoside phosphorylase deficiency

Using HPLC methods, we measured the concentrations of nucleosides and nucleotides for a patient with no purine nucleoside phosphorylase (PNP; EC 2.4.2.1) enzymatic activity. Concentrations of inosine and guanosine were abnormally high in urine and plasma, whereas guanosine diphosphate (GDP) and guanosine triphosphate (GTP) concentrations in erythrocytes were depleted. The unusual presence of deoxyribonucleosides (deoxyinosine and deoxyguanosine) and deoxyribonucleotides (dGDP and dGTP) was also notable. Thus, HPLC represents an accurate and useful tool for the study of purine metabolic disorders.

Determination of midazolam and its unconjugated 1-hydroxy metabolite in human plasma by high-performance liquid chromatography

A selective and sensitive high-performance liquid chromatographic method for the analysis of midazolam and its unconjugated 1-hydroxy metabolite in plasma samples was developed. The compounds were extracted from plasma by a liquid-liquid extraction procedure with diethyl ether. Mean analytical recoveries were 87% and 86% at a concentration of 300 ng/ml for midazolam and 1-hydroxymidazolam, respectively, and the quantification limit was 2 ng/ml for a plasma volume of 1 ml. The separation of midazolam, 1-hydroxymidazolam and flurazepam (internal standard) was achieved on a Spherisorb 5 CN column using methanol-2(r)propanol (75:25, v/v) containing 0.015% perchloric acid at a flow-rate of 1.5 ml/min. The method is sensitive enough for monitoring midazolam and also the unconjugated form of the active metabolite in plasma during pharmacokinetic studies.

Determination of thiopurine nucleotides in human lung tissue by high-performance liquid chromatography

A method for the analysis of thiopurine nucleotides in human transbronchial lung biopsy was developed. The sample treatment procedure is based on perchloric acid homogenisation and deproteinisation with dithiothreitol and hydrolysis of thiopurine nucleotides into their free bases by heating of the acid extract. Then, the free bases were analyzed in the gradient elution mode on a Hypersil ODS, 3-microns column using dihydrogenphosphate buffer-methanol as eluent. Mean analytical recoveries for 6-thioguanosine monophosphate and 6-thioinosinic acid from lung tissue were 97.0 +/- 2.0 and 98.0 +/- 1.8% at a concentration of 3.0 nmol/ml and the minimum detectable amounts were 3.5 and 2 pmol, respectively. The procedure described is simple and represents a suitable method for the investigation of thiopurine nucleotides in tissues.

High-performance liquid chromatographic determination of ganciclovir nucleotides in human myocardial tissue

A method for the analysis of ganciclovir nucleotides in myocardial tissues was developed. The antiviral effect of ganciclovir is attributed to intracellular ganciclovir nucleotides. The procedure is based on perchloric acid deproteinization and enzymatic hydrolysis of the ganciclovir nucleotides to ganciclovir. Then, the parent drug was analyzed on a Hypersil ODS column using potassium dihydrogenphosphate buffer as mobile phase. The mean analytical recovery of ganciclovir from myocardial tissue was 101 +/- 2% and the detection limit was 2 pmol. The sample treatment procedure described is simple and presents a suitable analytical tool for the investigation of the ganciclovir nucleotides pool in tissues.

Effect of cardiopulmonary bypass on plasma concentrations of diltiazem and its two active metabolites

Diltiazem is often used to prevent myocardial ischaemia during the perioperative period of coronary artery bypass surgery. The purpose of this study was to investigate the effect of cardiopulmonary bypass (CPB) on plasma concentrations of diltiazem and of its two main and active metabolites (N-monodemethyldiltiazem (N-desmethyldiltiazem) and desacetyldiltiazem). The patients were administered their usual treatment during the preoperative days. The last dose was administered immediately before anaesthesia. At the onset of CPB, a significant decrease in the plasma concentrations of diltiazem and its metabolites was observed, whereas the variation was slight and not significant when the plasma concentrations were corrected for haemodilution. These results confirm that the decrease observed at the initiation of the bypass procedure can be ascribed to the haemodilution induced by the CPB. During CPB, the concentrations of diltiazem and its metabolites remained constant suggesting that the rate of metabolism and excretion of the drug was altered during the bypass procedure. At the end of CPB, there was no increase of drug plasma concentrations suggesting that no redistribution of diltiazem from tissues to plasma occurred. Furthermore, this study shows that only 33% of subjects have therapeutic levels of diltiazem before anaesthesia, and that all subjects have subtherapeutic levels during and after the CPB. These results suggest that a higher chronic oral dose of the drug should be given in patients undergoing cardiac surgery with CPB.