Therapeutic drug monitoring (TDM) during maintenance phase treatment at a community mental health centre.

OBJECTIVE: To assess the extent to which therapeutic drug monitoring during maintenance phase treatment with lithium and clozapine was performed according to an agreed protocol and to identify strategies that may support monitoring. METHODS: Data concerning the prescribing and monitoring patterns of lithium for 31 patients and clozapine for 53 patients were collected retrospectively over a period of 2 years. RESULTS: Adherence to clozapine monitoring throughout the study period was 90.5%, while the monitoring of lithium was less likely at 58.1% (P < 0.001). While those prescribed lithium were less likely to adhere to prescribed dosing than those prescribed clozapine (P < 0.007), they were also more likely to have a change of medication (P < 0.005) and require admission to inpatient care (P < 0.002). CONCLUSIONS: Despite the initiatives established to improve adherence to monitoring, there was a significantly lower level of lithium monitoring compared to that of clozapine. Strategies that are likely to support monitoring include the use of labels to clarify tests required, the use of a database to keep track of those requiring pathology tests and allocation of time each week for a nurse to work with medical staff and case managers to support monitoring.

Protocol for Cancloz: multicentre randomised, placebo-controlled, double-blind, parallel-group adaptive trial of cannabidiol for clozapine-resistant schizophrenia.

BACKGROUND: Although clozapine is the most effective antipsychotic for people with treatment-resistant schizophrenia (TRS), only 40% of people with TRS respond, and there is limited evidence for augmentation agents. Cannabidiol (CBD) reduces positive symptoms in individuals with schizophrenia, but no trials have specifically examined its efficacy in those with clozapine-resistant schizophrenia. AIMS: To examine the clinical efficacy of CBD augmentation in people with clozapine-resistant schizophrenia. METHOD: This is a 12-week randomised, placebo-controlled, double-blind, parallel-group trial (registration number: ACTRN12622001112752). We will recruit 88 individuals with clozapine-resistant schizophrenia, randomised (1:1) to 1000 mg daily CBD versus placebo. Eligible individuals will be aged between 18 and 64 years, fulfil DSM-IV criteria for schizophrenia or schizoaffective disorder, have a total PANSS (Positive and Negative Syndrome Scale) score ≥60, have received oral clozapine for at least 18 weeks and have a clozapine level of >350 ng/mL. Interim analyses will be conducted at 25, 50 and 75% recruitment; these will also provide an opportunity to reallocate participants dependent on conditional power. The primary endpoint will be the difference in PANSS positive scores at the end of week 12. Secondary endpoints include depression, anxiety, sleep, quality of life, alcohol consumption, change in weight and metabolic syndrome components, and neurocognitive measures, as well as safety and tolerability. DISCUSSION: Novel treatments for clozapine-resistant schizophrenia are urgently needed. If found to be effective, CBD may have a role as a novel and safe adjunct to clozapine.

Challenging presentations of germ cell tumours in routine clinical practice.

Testicular cancer is the most common malignancy in young men. We discuss four cases of germ cell tumours (GCTs) presenting to general practitioners and physicians where there were notable preventable delays in the diagnosis and management. This diagnostic delay is associated with a more advanced stage of disease, and subsequent increased treatment-related morbidity and decreased survival. Our series highlights the variety of ways in which GCTs may present and we discuss the importance of prompt diagnosis through a thorough history and examination, early measurement of serum tumour markers and appropriate multidisciplinary team discussion. GCTs are highly curable cancers in the majority of patients and delays in management can, therefore, have devastating consequences.

Antimicrobial lexitropsins containing amide, amidine, and alkene linking groups.

The synthesis and properties of 80 short minor groove binders related to distamycin and the thiazotropsins are described. The design of the compounds was principally predicated upon increased affinity arising from hydrophobic interactions between minor groove binders and DNA. The introduction of hydrophobic aromatic head groups, including quinolyl and benzoyl derivatives, and of alkenes as linkers led to several strongly active antibacterial compounds with MIC for Staphylococcus aureus, both methicillin-sensitive and -resistant strains, in the range of 0.1-5 microg mL-1, which is comparable to many established antibacterial agents. Antifungal activity was also found in the range of 20-50 microg mL-1 MIC against Aspergillus niger and Candida albicans, again comparable with established antifungal drugs. A quinoline derivative was found to protect mice against S. aureus infection for a period of up to six days after a single intraperitoneal dose of 40 mg kg-1.

Distamycin analogues with enhanced lipophilicity: synthesis and antimicrobial activity.

Forty-eight heterocyclic amino acid trimers, analogues of distamycin, with a number of features that enhance lipophilicity are described. They contain alkyl or cycloalkyl groups larger than methyl; some are N-terminated by acetamide or methoxybenzamide and are C-terminated by dimethylaminopropyl or aliphatic heterocylic aminopropyl substituents. The ability of these compounds to bind principally to AT tracts of DNA has been evaluated using capillary zone electrophoresis. Significant antimicrobial activity against key organisms such as MRSA and Candida albicans is shown by several compounds, especially those containing a thiazole. Moreover, these compounds have low toxicity with respect to several mammalian cell lines.

Screening methods used to determine the anti-microbial properties of Aloe vera inner gel.

The emergence of antibiotic resistant bacterial strains is a growing problem and is an important concern for patients, physicians, healthcare managers, and policymakers as it results in poorer health and economic outcomes. This has led to an urgent global call for new antimicrobial drugs, particularly from natural resources. We have been studying the antimicrobial properties of the inner leaf gel component of Aloe barbadensis Miller and have used a number of different, simple in vitro assays to establish a scientific basis for the potential use of Aloe vera on a range of clinically relevant bacteria. The bacteria used include Shigella flexneri, Methicillin-Resistant Staphylococcus aureus (MRSA), Enterobacter cloacae and Enterococcus bovis. In this paper, we compare standard methods recommended by the Clinical and Laboratory Standards Institute (CLSI) with a microtitre assay using a metabolic colour indicator Alamar blue. All the techniques described have shown that Aloe vera has an antimicrobial effect, however, the microtitre assay enables high throughput screening, under similar conditions and is less wasteful of plant material.

Synthesis and antimicrobial activity of some netropsin analogues.

Nine novel lexitropsins were synthesized by linking two netropsin-like moieties through three different dicarboxylic acids; 9,10-dihydro-2,7-phenanthrenedicarboxylic acid; [(3-[[(carboxymethyl)amino]carbonyl]benzoyl)amino]acetic acid and indole-2,5-dicarboxylic acid. The netropsin residues were modified by the use of N-isopentylpyrrole, 5-methylthiophene or 5-isopropylthiazole heterocyclic building blocks in place of the usual N-methylpyrrole. The compounds were tested against five gram-positive bacteria: Staphylococcus aureus, Streptomyces faecalis, methicillin resistant Staphylococcus aureus, Enterobacter cloacae, Mycobacterium fortuitum, three gram-negative bacteria: Klebsiella aerogenes, Proteus vulgaris, Escherichia coli and three fungi: Aspergillus niger, Candida albicans and Aspergillus nidulans. Some of the compounds showed significant inhibitory effects on the growth of the microorganisms.