Pharmacokinetics and clinical toxicity of prilocaine and ropivacaine following combined drug administration in brachial plexus anesthesia.

OBJECTIVE: Local anesthetics (LA) are often administered in combination for regional anesthesia in order to obtain the specific advantages (onset and duration of effect) of each drug. However, few data on the safety of such combinations are available and consequently plasma concentrations possibly associated with toxicity and interactions between the specific anesthetics are not sufficiently established. We measured pharmacokinetics and toxicity parameters of prilocaine and ropivacaine after combined use as single doses in brachial plexus blockade. METHODS: In an open clinical study using a combined dose regime (300 mg prilocaine followed immediately by 75 mg ropivacaine) total plasma concentrations of prilocaine and ropivacaine were measured serially in 60 patients using a gas-chromatographic method. The data were analyzed regarding a relationship with central nervous and cardiovascular toxicity. RESULTS: Following the administration in combination prilocaine and ropivacaine were rapidly absorbed. Mean prilocaine peak plasma concentrations (mean Cmax = 1.51 microg/ml) were measured between 15 and 30 min after injection. Highest ropivacaine plasma concentrations (mean Cmax = 1.12 microg/ml) were seen between 30 min and 1 hour after injection (calculated mean tmax = 44 min). One of 59 patients showed signs of myoclonus which were suspected of being due to intravascular injection. There was no relevant cardiovascular toxicity observed in terms of changes in the QRS complex, PQ interval prolongation, AV dissociation, occurrence of extrasystoles or sinus arrest. The pharmacokinetics of combined administration did not differ from those of prilocaine and ropivacaine given alone. CONCLUSION: The use of a combined prilocaine/ ropivacaine (300 mg/75 mg) dose regimen in patients given single dose for brachial plexus blockade can generally be regarded as safe with regard to peak plasma concentrations and cardiovascular toxicity and this holds true for patients with a higher perioperative risk profile (ASA III grading, American Society of Anesthesiologists). The considerable inter-individual variation in LA peak plasma concentrations observed in our patients and the one case of suspected accidental intravascular injection, highlight the necessity of adequate monitoring of the patients undergoing LA injections.

Atomoxetine effects on attentional bias to drug-related cues in cocaine dependent individuals.

RATIONALE: Biased attention towards drug-related cues and reduced inhibitory control over the regulation of drug-intake characterize drug addiction. The noradrenaline system has been critically implicated in both attentional and response inhibitory processes and is directly affected by drugs such as cocaine. OBJECTIVES: We examined the potentially beneficial effects of the noradrenaline reuptake inhibitor atomoxetine in improving cognitive control during two tasks that used cocaine- and non-cocaine-related stimuli. METHODS: A double-blind, placebo-controlled, and cross-over psycho-pharmacological design was employed. A single oral dose of atomoxetine (40 mg) was administered to 28 cocaine-dependent individuals (CDIs) and 28 healthy controls. All participants performed a pictorial attentional bias task involving both cocaine- and non-cocaine-related pictures as well as a verbal go/no-go task composed of cocaine- and food-related words. RESULTS: As expected, CDIs showed attentional bias to cocaine-related cues whilst controls did not. More importantly, however, atomoxetine, relative to placebo, significantly attenuated attentional bias in CDIs (F 26 = 6.73, P = 0.01). During the go/no-go task, there was a treatment × trial × group interaction, although this finding only showed a trend towards statistical significance (F 26 = 3.38, P = 0.07). CONCLUSIONS: Our findings suggest that atomoxetine reduces attentional bias to drug-related cues in CDIs. This may result from atomoxetine's modulation of the balance between tonic/phasic activity in the locus coeruleus and the possibly parallel enhancement of noradrenergic neurotransmission within the prefrontal cortex. Studying how cognitive enhancers such as atomoxetine influence key neurocognitive indices in cocaine addiction may help to develop reliable biomarkers for patient stratification in future clinical trials.

Serotonin transporter gene promoter methylation status correlates with in vivo prefrontal 5-HTT availability and reward function in human obesity.

A polymorphism in the promoter region of the human serotonin transporter (5-HTT)-coding SLC6A4 gene (5-HTTLPR) has been implicated in moderating susceptibility to stress-related psychopathology and to possess regulatory functions on human in vivo 5-HTT availability. However, data on a direct relation between 5-HTTLPR and in vivo 5-HTT availability have been inconsistent. Additional factors such as epigenetic modifications of 5-HTTLPR might contribute to this association. This is of particular interest in the context of obesity, as an association with 5-HTTLPR hypermethylation has previously been reported. Here, we tested the hypothesis that methylation rates of 14 cytosine-phosphate-guanine (CpG) 5-HTTLPR loci, in vivo central 5-HTT availability as measured with [11C]DASB positron emission tomography (PET) and body mass index (BMI) are related in a group of 30 obese (age: 36±10 years, BMI>35 kg/m2) and 14 normal-weight controls (age 36±7 years, BMI<25 kg/m2). No significant association between 5-HTTLPR methylation and BMI overall was found. However, site-specific elevations in 5-HTTLPR methylation rates were significantly associated with lower 5-HTT availability in regions of the prefrontal cortex (PFC) specifically within the obese group when analyzed in isolation. This association was independent of functional 5-HTTLPR allelic variation. In addition, negative correlative data showed that CpG10-associated 5-HTT availability determines levels of reward sensitivity in obesity. Together, our findings suggest that epigenetic mechanisms rather than 5-HTTLPR alone influence in vivo 5-HTT availability, predominantly in regions having a critical role in reward processing, and this might have an impact on the progression of the obese phenotype.

Essential competencies in prescribing: A first european cross-sectional study among 895 final-year medical students.

European medical students should have acquired adequate prescribing competencies before graduation, but it is not known whether this is the case. In this international multicenter study, we evaluated the essential knowledge, skills, and attitudes in clinical pharmacology and therapeutics (CPT) of final-year medical students across Europe. In a cross-sectional design, 26 medical schools from 17 European countries were asked to administer a standardized assessment and questionnaire to 50 final-year students. Although there were differences between schools, our results show an overall lack of essential prescribing competencies among final-year students in Europe. Students had a poor knowledge of drug interactions and contraindications, and chose inappropriate therapies for common diseases or made prescribing errors. Our results suggest that undergraduate teaching in CPT is inadequate in many European schools, leading to incompetent prescribers and potentially unsafe patient care. A European core curriculum with clear learning outcomes and assessments should be urgently developed.

Congenital oesophageal atresia discordant for tracheo-oesophageal fistula occurring in a set of dizygotic twins.

The authors present a set of female diamnionic and dichorionic twins with different blood types and congenital oesophageal atresia (EA) in both. Surgical management was successful. It can be assumed that EA with tracheo-oesophageal fistula in twin B occurred during an early embryological stage whereas the isolated EA in twin A was the result of a later event. To our knowledge, this is the first published set of dizygotic twins with different types of EA.

D2 dopamine receptor occupancy, risperidone plasma level and extrapyramidal motor symptoms in previously drug-free schizophrenic patients.

RATIONALE: A relationship between high D2 occupancy (above 80%) and extrapyramidal-motor symptoms under neuroleptic treatment has been observed in several neuroimaging studies. OBJECTIVES: We investigated the striatal dopamine D2 receptor occupancy, risperidone plasma level and extrapyramidal-motor symptoms in drug-free schizophrenic patients. METHODS: Ten schizophrenic patients were treated with 3 - 6 mg risperidone daily. After four weeks administration, a [(123)I]iodobenzamide ([(123)I]IBZM)-single photon emission tomography (SPET) scan for determination of D2 receptor occupancy was carried out (in eight responders) and compared to a control group. Plasma concentrations of risperidone and its active metabolite 9-hydroxyrisperidone (active moiety) were determined by high performance liquid chromatography and electrochemical detection. Extrapyramidal-motor symptoms were assessed by means of the Simpson-Angus-Scale and a handwriting test before treatment and coincident with the scan. RESULTS: The D2 receptor occupancy (Mean 62%, SD 13%) positively correlated with the plasma level of the risperidone active moiety as well as with the reduction in handwriting area. Multiple linear regression revealed an inherent relationship with a coefficient of determination of r = 0.956 (p = 0.02). No clinical relevant extrapyramidal-motor symptoms were observed. CONCLUSIONS: In drug-free schizophrenic responders, the simultaneous assessment of both plasma level and reduction in handwriting area may be a useful clinical tool for a surrogate estimate of D2 receptor occupancy under risperidone treatment. This may help to minimize or even prevent extrapyramidal-motor symptoms.

In vitro tolerance to inhibition by ethanol of N-methyl-D-aspartate-induced depolarization in locus coeruleus neurons of behaviorally ethanol-tolerant rats.

Intracellular recordings were made in pontine slice preparations of the rat brain containing the locus coeruleus (LC). Ethanol at 100 mM, but not at 10 or 30 mM inhibited depolarizing responses to pressure-applied N-methyl-D-aspartate (NMDA) in LC neurons of ethanol-naive rats. Ethanol (100 mM) had a similar effect in LC neurons of ethanol-naive rats, of rats treated with ethanol for 14 days (3 g/kg daily, i.p.) and of rats treated with equicaloric amounts of saccharose (5 g/kg daily, i.p.). The blood concentration of ethanol was markedly decreased at 4 h, and was below the detection limit at 24 h after the last injection. Behavioral measurements in the open-field system demonstrated the development of tolerance in rats receiving ethanol for 14 days. Moreover, an anxiety-related reaction was shown to develop when the acute effect of the last ethanol injection vanished. Therefore, in subsequent in vitro experiments, ethanol (10 mM) was continuously present in the superfusion medium in order to mimic a steady blood concentration and to prevent a withdrawal-like situation. Under these conditions, ethanol (100 mM) still continued to inhibit the NMDA-induced depolarization in slices of untreated rats, but became ineffective in slices of ethanol-treated rats at 4 h after the last injection. By contrast, a supersensitivity to ethanol developed in brain slices at 24 h after the last ethanol injection. In conclusion, in vitro tolerance between systemically and locally applied ethanol at LC neurons could only be demonstrated when a low concentration of ethanol was added to the superfusion medium to simulate the blood concentration of this compound.

Anticonvulsant and sodium channel blocking activity of higher doses of clenbuterol.

Clenbuterol, a lipophilic beta2-adrenoceptor agonist, was investigated in various seizure models of experimental epilepsy. In the maximal electroshock seizure threshold test, clenbuterol (> or =4 mg/kg i.p.) increased the electroconvulsive threshold for tonic seizures in mice. In the traditional maximal electroshock seizure (MES) test in mice, ED50 values of 11 mg/kg i.p. or s.c. were determined. In both models, the beta2-receptor antagonist ICI 118.551 did not antagonize the anticonvulsant activity of clenbuterol. Combinations of clenbuterol with standard antiepileptics revealed additive anticonvulsant effects. Repeated administration of clenbuterol (5 mg/kg s.c., twice daily for 14 days) to mice did not significantly influence its anticonvulsant potency or the effectiveness of phenobarbital in the MES test. In various chemically-induced seizure tests with tonic convulsions, clenbuterol inhibited or tended to suppress the tonic phase. However, this drug was not effective in preventing clonic seizures in the pentylenetetrazol (85 mg/kg s.c.) seizure threshold test. In the rotarod ataxia test (mice), a minimal "neurotoxic" dose (TD50) of 41 mg/kg i.p. was determined. In unrestrained rats with chronically implanted electrodes in the dorsal hippocampus, clenbuterol (2 mg/kg and 4 mg/kg i.p.) significantly reduced the duration of electrically evoked hippocampal afterdischarges. In amygdala-kindled rats, clenbuterol (5 mg/kg and 10 mg/kg i.p.) reduced the seizure severity to stage 3. Additional studies indicated that clenbuterol (6 mg/kg i.p.) increased the heart rate and decreased the blood pressure, but this drug did not alter the plasma level of the two tested antiepileptics phenobarbital and carbamazepine. Furthermore, in whole-cell voltage-clamp experiments on cultured neonatal rat cardiomyocytes, clenbuterol (1-100 microM) depressed the fast sodium current in a concentration- and frequency-dependent manner. In conclusion, the anticonvulsant effects of higher doses of clenbuterol against generalized tonic-clonic and complex partial seizures seem to be related to the inhibition of voltage-dependent sodium channels and not to the modulation of beta-adrenoceptors.

Haloperidol serum concentrations and D2 dopamine receptor occupancy during low-dose treatment with haloperidol decanoate.

The aim of this study was to examine the relationship between serum concentrations of haloperidol and central D2 receptor occupancy in eight schizophrenic patients treated with low doses of haloperidol decanoate. The accompanying psychopathology was assessed. During a 4-week interval after administration of haloperidol decanoate (dose range 30-70 mg), serum concentrations of haloperidol were determined once a week by using a sensitive high-performance liquid chromatography method. The patients' D2 receptor occupancy was determined with single-photon emission computed tomography on two separate occasions. One week after depot administration the mean haloperidol serum concentration was 7.3 nmol/l (range 3.9-22.7 nmol/l) and the mean D2 receptor occupancy was 75% (range 52-100%). After 4 weeks the mean haloperidol serum concentration had decreased to 1.8 nmol/l (range 0-5.7 nmol/l) and the mean D2 receptor occupancy to 53% (range 12-89%). Differences were seen in two subgroups, defined by their history of neuroleptic exposure before inclusion into the study. Patients treated with depots of haloperidol decanoate for months showed higher D2 receptor occupancy and corresponding higher serum haloperidol concentrations at week 4 than did patients who had a history of oral haloperidol treatment. Because the difference in the dynamics of D2 receptor occupancy could be reflected by corresponding serum concentrations of haloperidol, it seems useful to involve haloperidol drug monitoring as a possible surrogate marker for D2 receptor occupancy in optimizing low-dose treatment with haloperidol decanoate.

Poisoning with tilidine and naloxone: toxicokinetic and clinical observations.

The opioid analgesic tilidine and its metabolites were detected by high performance liquid chromatography (HPLC) with UV-detection in serum from a 28 year-old woman who ingested 100 ml Valoron (o)N containing 6.94 g of tilidine and about 0.56 g of naloxone with suicidal intention. Data on the toxicokinetics of tilidine in severe poisonings are missing. Therefore we followed serum concentrations of tilidine and metabolites for 48 or 96 h and for the first time calculated basic kinetic parameters in a massive life threatening poisoning. Serum concentration of tilidine 3 h after ingestion was 38.1 mg/l which is about 70 times of the upper therapeutic level in man and about ninefold above toxic concentrations known so far. The concentration of nortilidine, the primary active metabolite at this time was 18.8 mg/l. The terminal elimination half life's of tilidine and nortilidine were explicit, prolonged with 23.9 and 13.9 h respectively. The competitive opiate antagonist naloxone, which is added as a part of the industrially produced preparation Valoron N solution to minimise oral abuse is not able to prevent ventilatory depression in massive overdoses.

The pharmacologic stability of 35-year old theophylline.

The propensity to preserve and to hoard drugs over the years at home is a well-known phenomenon and offers the possibility for intentional and accidental drug poisoning in man. We report a case of acute theophylline poisoning in an 80-year old women after ingestion of 'Asthmo-Kranit', a 35-year old combined preparation containing theophylline and aminopyrine as the main ingredients. The patient developed the typical clinical picture of a symptomatic theophylline poisoning with flush, tremor, tachycardia, hyperventilation, hypotonia, and hyperglycaemia. The clinical course after treatment with beta-blockers was without complications. The determination of theophylline in tablets showed stability of 90% of the labelled amount of the drug 30 years beyond the expiration date. The case illustrates the prolonged shelf stability and pharmacological potency of some pharmaceuticals and points to the risk of long-outdated prescriptions. Physicians should primarily not underestimate drug toxicity in consequence of old-age pharmaceuticals.

Determination of nicotine and cotinine in human serum by means of LC/MS.

As part of a joint clinical research project to study the effects of nicotine on the brain, a HPLC electrospray ionisation mass spectrometry method with a solid-phase extraction sample preparation was developed for the quantitative determination of nicotine and cotinine in human serum in volunteers. The measured concentrations of nicotine and cotinine were used as control for smoking behaviour. A X-Bridge-column from Waters, and a SSQ 7000 single quadropole mass spectrometer with a TSP liquid chromatographic system were used. The method includes a simple and robust sample preparation and this assay has been shown to be of a sufficient sensitivity for this application. The limits of quantification were 5 and 2ng/ml for cotinine and nicotine, respectively. A simultaneous study was conducted to measure nicotine receptor availability and the vigilance in the same group of volunteers.

[Cardiac arrest caused by an ecstasy intoxication]. / Hyperdynamer Kreislaufstillstand nach Ingestion von Ecstasy.

We report about a 19 years old man, suffering from an cardiac arrest (ventricular fibrillation) caused by an ecstasy intoxication. A supraventricular tachycardia was recorded on day three after resuscitation. No pathological findings were demonstrated by coronary angiography. An slow- fast- av -nodal- reentry- tachycardia (AVNRT) was detected and successfully treated by electrical ablation of the slow pathway during electrophysiological mapping. No severe neurological deficits were found in discharge from hospital.

[The clinical significance of serotonin antagonists]. / Zur klinischen Bedeutung von Serotonin-Antagonisten.

Issuing from the physiological role of the serotonine, the possible significance of this biogenic amine for the pathogenesis of cardiovascular diseases is discussed. From this are derived indications for the use of serotonine antagonists. At present, of these ketanserine is regarded as the best investigated substance. The results of the hitherto performed clinical studies justify the application in hypertension. In contrast to this the assessment of the clinical and therapeutic value in chronic arteriosclerotic occlusive disease at stage II according to Fontaine and in Raynaud's syndrome is rendered difficult.

[Calcium antagonists--determination of current status and therapeutic significance]. / Calciumantagonisten--Bestandsaufnahme und therapeutische Bedeutung.

The important group of drugs known as calcium antagonists is surveyed from a clinico-pharmacological viewpoint. The recently introduced substances are presented in a detailed manner. Common features and differences in pharmacodynamics and pharmacokinetics of the individual calcium antagonists are explained and their differential therapeutic use in the treatment of chronic cardiovascular diseases is discussed. The article also reports on drug interferences, contraindications and possible extensions of indications. An assessment is made of results achieved so far when applying calcium antagonists in the treatment of chronic cardiovascular diseases and in the prevention of arteriosclerosis.

[Beta receptor blockers. Their role and therapeutic importance]. / Beta-Rezeptorenblocker. Bestandsaufnahme und therapeutische Bedeutung.

From clinico-pharmacological view the present paper gives a survey of the important drug group of the beta-receptor blockers. While non-selective blockers effect a global depression of the sympathico-adrenergic activity of the organism, the beta 1-selective blockers are characterized by a dose-dependent preferred affinity to the cardiac and renal beta 1-receptors. Thus in low and moderate dosages undesired pulmonary, vascular and metabolic effects can be avoided. Main indications for beta-receptor blockers are the arterial hypertension, the coronary heart disease and the tachycardiac disturbances of the cardiac rhythm. Apart from the increase of the life-quality of the patient the prognosis improving effect in clinical long-term studies confirmed for several beta-receptor blockers should be used therapeutically.

[Possibilities and limits of pharmacotherapy of chronic venous insufficiency]. / Möglichkeiten und Grenzen der Pharmakotherapie der chronisch-venösen Insuffizienz.

The conservative therapy of the chronic venous insufficiency is always carried out with etiopathogenetic orientation and according to the stages of disease. Of the medicamentous therapy oedema-protective and vein-tonicising drugs, oral anticoagulants and non-steroidal antiphlogistics are discussed. Furthermore, the alternative and supplementary prescription of physiotherapy and movement cure depending on findings is dealt with.