Cytoprotective effects of nicotinamide derivatives in endothelial cells

Following discovery of NAD(+)-dependent reactions that control gene expression, cytoprotection, and longevity, there has been a renewed therapeutic interest in precursors, such as nicotinamide and its derivatives. We tested 20 analogues of nicotinamide for their ability to protect endothelial cells from peroxynitrite stress and their effect on poly (ADP-ribose) polymerase (PARP) activity. Several nicotinamide derivatives protected endothelial cells from peroxynitrite-induced depletion of cellular NAD(+) and ATP concentrations, but only some of these compounds inhibited PARP. We conclude that some nicotinamide derivatives provide protection of endothelial cells against peroxynitrite-induced injury independent of inhibition of PARP activity. Preservation of the NAD(+) pool was a common effect of these compounds.

Metabolism of 4-pyridone-3-carboxamide-1-beta-D-ribonucleoside triphosphate and its nucleoside precursor in the erythrocytes

We recently discovered new nucleotides (4-pyridone-3-carboxamide-1-beta -D-ribonucleoside phosphates) in human erythrocytes. To establish the precursor compound and pathways of nucleotide derivative formation and breakdown, human erythrocytes were incubated for 3 hours with 0.3 mM 4-pyridone-3-carboxamide-1-beta-D-ribonucleoside (4PYR) and erythrocyte concentrations of 4PYR and adenine nucleotides were followed. 4PYR triphosphate increased from 16.1 +/- 0.6 micro M to 74.9 +/- 9.17 and 4PYR monophosphate increased from 5 micro M to 254.7 +/- 13.9 micro M. Conversely, incubation with 0.3 mM 4-pyridone-3-carboxamide (4PY) did not lead to additional 4PYR nucleotide formation. 4PYR nucleotides were catabolized to 4PYR. We conclude that 4PYR nucleotides are formed in erythrocytes by nucleoside kinase-mediated 4PYR phosphorylation and catabolized by 5'nucleotidase-mediated dephosphorylation.

Acute mastoiditis in children: presentation and long term consequences

Acute mastoiditis, a destructive bacterial infection of the mastoid bone and air cell system, is relatively uncommon today but remains a potentially serious condition. There is a lack of information in the literature regarding the long term otological problems that children may face following an episode of this condition.

OBJECTIVES

Our aim was to examine the presentation, complications and hospital course in this patient population, and to ascertain whether these patients had long term otological problems.

METHODS

We retrospectively reviewed the medical records of all patients presenting with acute mastoiditis between January 1990 and December 2005. Patients' parents were contacted by telephone and questioned about further otological problems.

RESULTS

Twenty-nine patients were included in the study, and 27 of these patients' parents were contactable to complete the telephone questionnaire. Sixty-nine per cent of children had no previous history of acute otitis media prior to presentation. Forty-five per cent of patients had received oral antibiotics prior to presentation. Sixty-two per cent of patients developed complications, i.e. a subperiosteal abscess or failure to respond to medical therapy, resulting in the need for surgical intervention (in the form of incision and drainage of periosteal abscess, cortical mastoidectomy, or grommet insertion). Mean follow up of patients was eight years and one month; five (17 per cent) patients had been followed up for less than one year. Two (7 per cent) patients developed a further episode of mastoiditis within six weeks of initial presentation, both of whom required cortical mastoidectomy. Three (10 per cent) patients had further problems with recurrent acute otitis media, requiring tympanostomy tube insertion. One patient required a modified radical mastoidectomy for cholesteatoma (15 years later). Twenty-two patients (91 per cent) had been followed up for longer than one year; these patients had subjectively normal hearing and were asymptomatic at the time of study.

CONCLUSION

The majority of patients who had suffered an episode of acute mastoiditis had no adverse long term otological sequelae.

Stimulatory effects of atorvastatin on extracellular nucleotide degradation in human endothelial cells

Endothelial degradation of extracellular nucleotides is known to be an important mechanism in regulation of thrombosis, inflammation and immune response. It is possible that this pathway is a target for pleiotropic drugs such as atorvastatin. We studied therefore the effect of atorvastatin on extracellular nucleotide degradation in human endothelial cells. Atorvastatin treatment of human umbilical vein endothelial cells (HUVEC) and human microvascular endothelial cells (HMEC-1) resulted in significant increase in ATP breakdown and adenosine formation both if analysed in intact cell studies and as enzyme activity in cell lysates. We conclude that one of the beneficial effects of atorvastatin may include acceleration of extracellular nucleotide breakdown. This will attenuate nucleotide mediated pro-inflammatory effect and stimulate protective mechanisms of adenosine.

Management of asthma in patients supervised by primary care physicians or by specialists

French asthma patients may be supervised by general practitioners (GPs) and/or specialists. Therefore, this study examined asthma management in patients exclusively supervised by specialists (SPE), GPs, (GP) and both (GP+SPE group), and compared the findings. Asthma patients were consecutively recruited in 348 pharmacies. Each patient completed a questionnaire providing data on personal characteristics, asthma management, perception of disease and asthma supervision. Asthma control was measured using the Asthma Control Test. Questionnaires were linked to computerised records of medications which had been dispensed before inclusion in the study. From the 1,256 patients (mean age = 36.1 yrs, 54.3% females), 11.4, 36.6, and 52.0% were placed in the SPE, GP, and GP+SPE groups, respectively. During the previous 4 weeks, most patients in the SPE group were properly controlled (52.2 versus 26.4 and 21.5% in GP and GP+SPE groups, respectively). The SPE group made more use of fixed combinations of long-acting beta agonist and inhaled corticosteroid, while receiving less short-acting beta agonists, antitussives and antibiotics. Striking differences in symptoms and asthma management were observed according to the type of asthma supervision. The current results strongly support the need to improve the management of asthma in primary care, and the coordination of care between general practitioners and specialists.

Symptom-based outcome measures for asthma: the use of discrete choice methods to assess patient preferences

This paper reports on an application of discrete choice modelling to the measurement of patient preferences over asthma symptoms. A sample of patients with moderate to severe asthma was asked to choose between a series of pairs of scenarios characterised by different combinations of asthma symptoms. Their responses were analysed using a random effects ordered probit model. The results implied that patients weighted some symptoms more highly than others. Discrete choice modelling proved to be a useful approach for developing preference based outcome measures, although the results show how, in contexts where preferences over health care outcomes based on symptoms or some measure of health status are involved, a conventional linear additive model may not always be suitable.

Asthma leaflets for patients: what do asthma nurses use?

This study investigated patient information leaflets used by trained asthma nurses, and nurses' satisfaction with these. Main outcome measures were frequency of use, sources of material, and rating of reliability and readability. A total of 775 practice nurses with a diploma in asthma working in the general practice setting were surveyed using a postal questionnaire. Forty two percent of questionnaires (326) were returned. The provision of asthma information is an integral part of patient care by the trained asthma nurse. Most nurses (260, 83%) gave out between one and ten leaflets per week. An abundance of diverse information is available from a variety of sources, main sources used were Glaxo-Wellcome (cited by 47% of respondents), National Asthma Campaign (NAC) (19% of respondents) and Astra (19%). Pharmaceutical company material was considered more easily available, free of charge and more attractively presented. NAC material was viewed as more accurate. Assessment of NAC, Glaxo-Wellcome and Astra booklets revealed that they conformed to British Thoracic Society Guidelines for acute asthma. Thus, nurses stated a preference for charity information but in practice used a predominance of pharmaceutical company information. This appears to be because pharmaceutical company information was more readily available and free of charge. Nurses felt unease with self-perceived over-reliance on pharmaceutical company information.

Guided self-management and patient education in asthma

Asthma is a disease characterized by fluctuation in symptom severity which often requires alterations in management in response to symptom changes. Patient awareness and skill in decision making is important for effective self-management of asthma. Patient education helps patients to develop these skills. However, patient education that is based solely on general asthma information is not effective in improving patient self-management. Individual management plans improve patient outcomes in asthma. These asthma management plans give clear guidelines about how and when the patient should vary medication. They provide a basis for discussion and improved communication between the patient and health-care professionals. Management plans use severity of symptoms or peak flow measurements to guide patient action. They also address the concerns of asthma patients, e.g. the need to know how to control their symptoms and to understand how to use their own medication.

Measuring quality of life for young children with asthma and their families

In assessing therapeutic interventions in asthma we have become increasingly aware of the importance of measuring outcomes which relate to patient experience of illness and its impact on their lives. These patient oriented assessments are usually defined as "quality of life" measures. There are good reasons for wanting to measure the impact of disease on people with asthma. Quality of life is likely to be related to health behaviour, such as adherence to therapy and use of health resources. Quality of life may be a stronger predictor of these behaviours than objective symptoms. Thus, in evaluating health-related interventions, quality of life is an important dimension of outcome measurement. Adult measures are now frequently used but there has been less development of measures suitable for children. Important issues in measuring quality of life for children include the development of age-appropriate scales, measurement of the impact of illness on the whole family, and the relationship between child's report and proxy report. Recently developed asthma specific scales for children include the Child Asthma Questionnaire (CAQ), and the Paediatric Asthma Quality of Life Questionnaire (PAQLQ). The PAQLQ comprises a form directly assessing child quality of life and a form assessing paediatric care-givers (usually a parent). The impact of child asthma on the family as a whole may be particularly important not only for comparing benefits of different interventions, but also for predicting outcomes, such as medical help-seeking.

The patient perspective. What should a new anti-asthma agent provide?

Patients want medication that they feel confident using and that will control symptoms and be well tolerated. Patients may dislike and use ineffectively some asthma delivery devices such as inhalers, and they may have anxieties about adverse effects of inhaled corticosteroid medication. Oral medication may offer the advantage of improved patient compliance and, in 2 studies, patients have stated a preference for oral medication. However, the introduction of any new medication is likely to arouse anxieties and expectations in patients, and it is important that they be given clear information on medication use and that time be spent discussing any concerns about change. In the general practice consultation, patients are not always able to raise all the issues that are important to them in their asthma management. Asthma clinics staffed by nurses have more time and the opportunity to deal with patient concerns and teach good medication practice. Pharmacists may also have a role to play in patient counselling and giving advice on changes in medication.

Set up and run an objective structured clinical exam

Objective structured clinical exams are increasingly used as a way of assessing a range of clinical skills at both undergraduate and postgraduate level. To those planning to introduce such assessments, this article provides basic guidance on their development and structure and the personnel required. For those already using the assessments, our article may provide new ideas or be the impetus for an exchange of ideas. For those who are facing such formal assessment as candidates, we hope this article shows the efforts that are made to achieve the necessary structure and objectivity in this type of examination.

Pharmacokinetics of aztreonam in patients with liver cirrhosis and ascites

The pharmacokinetics of aztreonam were studied in six healthy male subjects (group I) and 12 male patients with post-hepatitis liver cirrhosis and ascites. Patients were allocated into two groups according to serum creatinine; group II included nine patients with serum creatinine. < or = 15 mg/L while group III included three patients with serum creatinine > 15 mg/L. Aztreonam 1 g was given as iv bolus injection. Aztreonam reached a peak concentration in the ascitic fluid (AF) of 6.2 +/- 2.3 mg/L at 4 h, and of 8.7 +/- 4.4 mg/L at 6 h in groups II and III respectively. The level of the drug in AF 24 h post-dosing was still higher than MIC90 for Enterobacteriaceae in most patients. The half-life of elimination from serum increased significantly (P > 0.001) from 1.82 +/- 0.14 h in group I to 6.6 +/- 2.1 h and to 8.87 +/- 0.2 h in groups II and III, respectively. Both the central and the terminal volumes of distribution were higher in cirrhotic patients than in healthy volunteers. Liver cirrhosis and ascites resulted in a significant increase (P < 0.001) of the total body clearance (Cl) of aztreonam from 84 +/- 8 mL/h/kg in group I to 209 +/- 87 mL/h/kg in group II. However, the concomitant association of mild renal impairment in group III abolished this increase; Cl in group III was 122 +/- 50 mL/h/kg. The AUC0-infinity serum was 137.5 +/- 12.2, 78.5 +/- 24.9 and 151 +/- 42 mg.h/L in groups I, II and II, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetics of cefodizime in patients with liver cirrhosis and ascites

The pharmacokinetics of cefodizime were studied in 6 healthy male volunteers (group A) and 6 patients with liver cirrhosis and ascites (group B) receiving 1 g of the drug as an i.v. bolus. Cefodizime was assayed in serum and ascitic fluid (AF) samples by a microbiological assay. The serum concentration-time curve fitted a two-compartment open model in group A and a three-compartment open model in group B. Initially, the serum level of cefodizime in group A exceeded that in group B for about 10 h; thereafter the reverse occurred until 24 h post-dosing. Cefodizime penetrated rapidly into the AF, reaching a peak at 6 h, and its AF level was still above the MIC90 for Enterobacteriaceae in most patients at 24 h post-dosing. The half-life of distribution did not differ significantly between the two groups, while the elimination half-life was prolonged significantly (p < 0.001) from 2.7 +/- 0.2 h in group A to 5.4 +/- 0.8 h in group B. The central volume of distribution (Vc) did not differ significantly in the two groups, while the terminal volume of distribution (Vp) was significantly smaller (p < 0.01) in group A (0.172 +/- 0.30 l/kg) than in group B (0.55 +/- 0.20 l/kg). The area under the serum concentration-time curve (AUC0-infinity serum) was significantly larger (p < 0.001) in group A [322 +/- 34 (micrograms/ml).h than in group B (180 +/- 34 (micrograms/ml).h]. The area under the AF concentration-time curve (AUC0-infinity ascites) in group B was 141 +/- 37 (micrograms/ml).h.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetics of ceftazidime in patients with liver cirrhosis and ascites

The pharmacokinetics of ceftazidime were studied in 18 male individuals, including six healthy volunteers and 12 patients with liver cirrhosis and ascites. Each participant received 1 g of ceftazidime as a single intravenous bolus injection. The elimination half-life was longer in cirrhotic than in control patients (5.40 +/- 1.02 h) vs. (1.98 +/- 0.24 h), P less than 0.01; probably due to slow return from the ascitic compartment. Nevertheless, total body clearance did not differ significantly between the two groups (81.4 +/- 30.3 ml/h/kg vs. 83.6 +/- 24.9 ml/h/kg). Dose reduction is not necessary when treating systemic infection in cirrhotics. Ceftazidime attained a concentration of 1 microgram/ml in the ascitic fluid in most patients 15 to 30 min after the injection, and maintained this level, which is higher than the MIC90 of Enterobacteriaceae, for 24 h. An intravenous bolus injection of 1 g ceftazidime every 24 h is sufficient to treat patients with spontaneous bacterial peritonitis caused by a susceptible organism other than Pseudomonas aeruginosa.

Re-evaluation of the value of ascitic fluid pH lactate dehydrogenase and total proteins in the diagnosis of spontaneous bacterial peritonitis (SBP)

In view of high mortality, variable clinical presentation, and late results of bacterial culture, early diagnosis of SBP and treatment are based on indirect parameters of infection. Forty-two patients with ascites and liver cirrhosis were studied. Ascitic fluid (AF) was examined for total protein content, pH, lactate dehydrogenase, amylase, absolute polymorphonuclear cell count (PMN) and for presence of bacteria by examining a fresh smear of the deposit and culture of the fluid under aerobic and anaerobic conditions. AF/serum gradient of total proteins and LDH was calculated. One patient proved to have a malignant ascites and was excluded. The remaining 41 patients fell into two groups: Group I PMN less than 250 cell mm-3, culture negative, sterile ascites, 36 patients. Group II PMN greater than 250 cell mm-3. (a) Culture positive neutrophilic ascites (SBP), three patients. (b) Culture negative neutrophilic ascites (CNNA), two patients. In both CNNA and SBP:AF/serum total LDH gradient greater than 0.75 In the sterile group: AF/serum total LDH gradient less than 0.58 There was no correlation between presence of infection and ascitic fluid pH, protein content and AF/serum total protein gradient. Therefore AF PMN greater than 250 mm and AF/serum total LDH gradient greater than 0.6 should be considered reliable, indirect parameters of infection, and CNNA a variant of SBP with a small bacterial inoculum size.

Interferon in chronic active hepatitis B. Preliminary results

Twenty patients with documented chronic active hepatitis B were randomized in equal numbers to either an alpha-2b interferon treatment group or a control group with no treatment. Patients in the first group received 5 IU interferon three times weekly by subcutaneous injection for 16 weeks. All 20 patients were HBeAg positive at the beginning. All 10 patients in the interferon-treated group lost their initial e antigen while only 2 patients in the control group turned HBeAg negative. Six patients in the treated group acquired HBe antibodies in comparison with two patients only in the untreated group. Other markers of suppression of viral replication as well as a 24-month follow-up are ongoing at the moment for final assessment of the value of interferon therapy in chronic active hepatitis B.

Ofloxacin therapy of difficult-to-treat infections due to multiresistant organisms

Sixty-four patients with complicated UTI (58) and P. aeruginosa ear infections (6) were treated with oral ofloxacin. All patients were infected with multiply-resistant problem organisms, which had very low minimum inhibitory concentrations (MICs) when tested in vitro with ofloxacin. The immediate cure rate was 86% and the maintained cure rate was 75%, an excellent result considering the complicated nature of the infections. This result has been attributed to the great efficacy of ofloxacin and its excellent pharmacokinetics. There was a very low incidence of mild side effects. Because resistance to quinolones is not mediated by R-factors, it is recommended to select them as first choice in the treatment of patients with complicated UTI with indwelling catheters or nephrostomy tubes, and in patients with discharging ears in order to limit the spread of resistant strains in the hospital environment and in the community.