Supplemental patient education for patients taking oral anticoagulants: systematic review and meta-analysis.

OBJECTIVE: Lack of patient knowledge has been associated with poor anticoagulation control, but the effect of patient education on clinical outcomes is unclear. We systematically reviewed the effect of supplemental patient education vs. usual care on hemorrhage, thromboembolic events (TEEs), time in therapeutic range (TTR) and knowledge test scores for all oral anticoagulants. DATA SOURCES: The data sources were electronic databases, including MEDLINE, EMBASE, CENTRAL, CINAHL and IPA, to February 2012 examining any oral anticoagulant. We reviewed references for additional potentially relevant studies. METHODS: Only randomized controlled trials (RCTs) were considered. Data extraction and quality assessment were conducted with GRADE. Pooled relative risks (RRs) were calculated, and heterogeneity was determined by use of χ(2) and I(2) statistics. RESULTS: Seven RCTs (n = 1209) were included in the systematic review, and five RCTs (n = 847) in the meta-analysis. All included studies examined vitamin K antagonists. No significant difference was found for hemorrhage (RR 0.92, 95% confidence interval [CI] 0.04-20.56), TEE (RR 0.66, 95% CI 0.10-4.39), a composite outcome of hemorrhage or TEE (RR 0.48, 95% CI 0.23-1.01), or TTR (mean absolute difference of 2.02%, 95% CI - 2.81 to 6.84). Evidence was conflicting on the impact of supplemental education on test scores. All trials had at least one substantial methodologic limitation. CONCLUSION: Current evidence does not support supplemental patient education as a means to improve patient outcomes, but the quality of this evidence is poor. Larger randomized trials are needed with longer follow-up, recruitment of patients initiating anticoagulation in primary care settings, and clearly defined education interventions.

Hyperdynamic microtubules, cognitive deficits, and pathology are improved in tau transgenic mice with low doses of the microtubule-stabilizing agent BMS-241027.

Tau is a microtubule (MT)-stabilizing protein that is altered in Alzheimer's disease (AD) and other tauopathies. It is hypothesized that the hyperphosphorylated, conformationally altered, and multimeric forms of tau lead to a disruption of MT stability; however, direct evidence is lacking in vivo. In this study, an in vivo stable isotope-mass spectrometric technique was used to measure the turnover, or dynamicity, of MTs in brains of living animals. We demonstrated an age-dependent increase in MT dynamics in two different tau transgenic mouse models, 3xTg and rTg4510. MT hyperdynamicity was dependent on tau expression, since a reduction of transgene expression with doxycycline reversed the MT changes. Treatment of rTg4510 mice with the epothilone, BMS-241027, also restored MT dynamics to baseline levels. In addition, MT stabilization with BMS-241027 had beneficial effects on Morris water maze deficits, tau pathology, and neurodegeneration. Interestingly, pathological and functional benefits of BMS-241027 were observed at doses that only partially reversed MT hyperdynamicity. Together, these data suggest that tau-mediated loss of MT stability may contribute to disease progression and that very low doses of BMS-241027 may be useful in the treatment of AD and other tauopathies.

Out-patient chronic pain service in Hong Kong: prospective study.

OBJECTIVE: To examine the profile and referral pattern of patients attending an out-patient pain management service in Hong Kong. DESIGN: Prospective cross-sectional survey. SETTING: Regional public hospitals, Hong Kong. PATIENTS: All patients attending out-patient pain management clinics in the New Territories East public hospitals between 1 September and 31 December 2002. MAIN OUTCOME MEASURES: Demographic profiles, referring specialty, pain diagnosis, pain sites, duration and severity of pain, treatment modality, litigation, compensation, and social welfare status. Data were collected using a standardised questionnaire. RESULTS: Two hundred and forty-eight patients were interviewed. Most patients (70%) were middle-aged, with 21% over 60 years. Seventy-nine percent of patients were referred to the clinics either from orthopaedic surgeons (64.1%), general and other surgeons (14.9%), or general practitioners (3.6%). The median (range) duration of pain was 2.3 (0.08-26.7) years. The most common pain diagnoses were musculoskeletal back pain (46.4%) and neuropathic pain (27.8%). A total of 11.3% of the patients had two pain diagnoses, while 40.7% complained of pain in more than one location. Pain in the limbs was the most frequent complaint followed by the head, neck, and back. Approximately 38% of patients had tried four or more treatment modalities. Oral medication was the most common method (86.7%) of pain-relief treatment. More than half of the patients had also tried physiotherapy and traditional Chinese medicine. Approximately 37% of the patients were unemployed, while 31% were receiving social security subsidy. Eighty-six patients had pain associated with a work-related injury, and of these patients, 80% were involved in compensation claims. CONCLUSIONS: The profile of patients referred to the pain management clinics was complex. Patients were mainly referred from specialists. The economic implication in this group of patients is likely to be significant as many patients utilised multiple treatment modalities, were unemployed and on social welfare benefits, and were involved in compensation and litigation proceedings.

Coordination exercise and postural stability in elderly people: Effect of Tai Chi Chuan.

OBJECTIVE: To evaluate the effects of coordination exercise on postural stability in older individuals by Chinese shadow boxing, Tai Chi Chuan (TCC). DESIGN: Cross-sectional study. SETTING: Research project in a hospital-based biomechanical laboratory. PARTICIPANTS: The TCC group (n = 25) had been practicing TCC regularly for 2 to 35 years. The control group (n = 14) included healthy and active older subjects. INTERVENTION: Static postural stability test: progressively harder sequential tests with 6 combinations of vision (eyes open, eyes closed, sway-referenced) and support (fixed, sway-referenced); and dynamic balance test: 3 tests of weight shifting (left to right, forward-backward, multidirectional) at 3 speeds. MAIN OUTCOME MEASURES: Static and dynamic balance of Sensory Organization Testing (SOT) of the Smart Balance Master System. RESULTS: In static postural control, the results showed no differences between the TCC or control group in the more simple conditions, but in the more complicated SOT (eyes closed with sway surface, sway vision with sway surface), the TCC group had significantly better results than the control group. The TCC group also had significantly better results in the rhythmic forward-backward weight-shifting test. Duration of practice did not seem to affect the stability of elder people. CONCLUSION: The elderly people who regularly practiced TCC showed better postural stability in the more challenged conditions than those who do not (eg, the condition with simultaneous disturbance of vision and proprioception). TCC as a coordination exercise may reduce the risk of a fall through maintaining the ability of posture control.

The effects of Tai Chi Chuan on postural stability in the elderly: preliminary report.

BACKGROUND: Tai chi chuan (TCC) is a traditional Chinese conditioning exercise, consisting of a series of graceful movements linked together in a continuous sequence so that the body is constantly shifting from one foot to the other. We propose that subjects practicing TCC will have better postural control and stability than will active non-practitioners. METHODS: We compare static and dynamic postural controls in 14 TCC practitioners and 14 healthy active older adults using the Smart Balance Master System. The TCC group, containing 7 male and 7 female subjects (mean age, 70.9 +/- 3.3 years), had been practicing TCC regularly for 2 to 35 years. The control group included 4 male and 10 female healthy and active older subjects (mean age, 69.1 +/- 3.1 years), with age and body size matched to the TCC group. RESULTS: The results of static postural control tests showed no differences between the TCC and control groups under simple conditions (eyes open, eyes closed, swaying vision, and eyes open with swaying surface), but in the more complicated conditions (eyes closed with sway-referenced support and sway-referenced vision and support), the TCC group had significantly better results than the control group. In the dynamic balance test, the TCC group had significantly better results only in the rhythmic forward-backward weight-shifting test. CONCLUSION: Our data demonstrate that regular TCC practitioners have better postural stability, especially in the more complicated conditions with disturbed visual and somatosensory conditions.

Recurrence of hyperparathyroidism after total parathyroidectomy and autotransplantation in peritoneal dialysis patients.

OBJECTIVE: To evaluate the effectiveness of total parathyroidectomy (PTX) with autotransplantation in the treatment of secondary hyperparathyroidism (HPT), and to assess recurrence rate of HPT in this peritoneal dialysis (PD) population. DESIGN: A retrospective study in a single home PD unit. PATIENTS: Between 1994 and 1998, 19 of 574 patients on PD underwent PTX for treatment of secondary HPT. MAIN OUTCOME MEASURES: Clinical and biochemical improvement, recurrence of HPT, improvement in anemia post-PTX. RESULTS: Nineteen (3.3%) patients required PTX between 1994 and 1998. These 5 men and 14 women ranged in age from 22 to 66 years; they had been on maintenance PD pre-PTX for 47.5 +/- 38.1 months, and were followed for 26.1 +/- 15.5 months post-PTX. Sixteen patients had temporary hypocalcemia that was managed by oral (n = 10) or intravenous (n = 6) calcium supplements and calcitriol, while 3 patients had severe "hungry bone" syndrome postoperatively. One patient had recurrent laryngeal nerve palsy post-PTX. Bone pain disappeared in all 12 patients. Pruritus improved in 12/13 patients; fatigue improved in 15/16 patients. Comparison showed significant differences between hemoglobin and hematocrit values 1 month pre-PTX and 12 months post-PTX (p < 0.05). Parathyroid hormone (PTH) level in 15 (79%) patients returned to normal (< or = 7.6 pmol/L) during the first month post-PTX. In 5/12 (42%) patients, PTH level was < or = 7.6 pmol/L 2 years post-PTX, while in 2/12 (17%), PTH was > 22.8 pmol/L (three times normal) 2 years post-PTX, and 3/5 (60%) patients had a PTH > 22.8 pmol/L 3 years post-PTX. CONCLUSIONS: Total PTX with autotransplantation is associated with a tendency for recurrence of HPT. Our findings suggest that total PTX with autotransplantation may be an ineffective procedure in controlling HPT over the long term.

Influence of Sanguisorba officinalis, a mineral-rich plant drug, on the pharmacokinetics of ciprofloxacin in the rat.

The significance of an interaction between ciprofloxacin and Sanguisorba officinalis L. (SO), a mineral-rich herbal medicine, was evaluated in this study. Male Sprague-Dawley rats (220-250 g) receiving ciprofloxacin dosages of 20 mg/kg po were concomitantly dosed with an aqueous extract of SO (equivalent to 2 g/kg crude drug). Blood and urine samples were collected over 6 and 24 h, respectively, for the quantitation of ciprofloxacin by HPLC. The presence of SO reduced significantly (P < 0.05) the maximum plasma concentration, the area under the concentration-time curve and the urinary recovery of ciprofloxacin, by 94%, 78% and 79%, respectively, compared with rats receiving only ciprofloxacin. The presence of SO also caused an eight-fold and two-fold increase in drug distribution (Vd, lambda(z)/F) and terminal elimination half-life (t1/2, lambda(z)) from 30.8 L/kg and 1.96 h, respectively. Therefore, should the use of both agents be required, sufficient time should be allowed to ensure the efficacy of ciprofloxacin.

Effects of taraxacum mongolicum on the bioavailability and disposition of ciprofloxacin in rats.

Taraxacum mongolicum (TM), also known as dandelion, is a herb widely used in the East for its antibacterial activity. The high mineral content of TM presents a potential problem for the absorption of quinolone antibiotics. This study was undertaken to discern the significance of a drug-drug interaction between TM and ciprofloxacin. Two groups of Sprague Dawley rats (220-250 g) were employed; one received a single oral dose of ciprofloxacin (20 mg/kg) with concomitant oral administration of an aqueous TM extract (2 g crude drug/kg) while the control group received oral ciprofloxacin (20 mg/kg) only. Ciprofloxacin in plasma and urine, collected over 6 and 24 h, respectively, was determined by HPLC. Noncompartment analysis was employed for pharmacokinetic parameter estimation. Results indicated that, as compared to control, maximum plasma concentration (Cmax) of ciprofloxacin was significantly lowered by 73% in rats receiving concurrent TM dosing. Oral TM also caused a 3-fold increase in both apparent drug distribution volume (Vd,lambdaz/F: 92. 0 vs 30.8 L/kg) and terminal elimination half-life (t1/2,lambdaz; 5. 71 vs 1.96 h). Partly due to the changes in drug distribution and elimination, relative bioavailability of ciprofloxacin, as assessed by AUC0-->infinity, remained similar for both dosing groups. These findings suggest the possibility of a multifactorial drug-drug interaction between TM and ciprofloxacin. Thus, the implications of concomitant dosing of the two agents should not be overlooked.

Effect of oral administration of fennel (Foeniculum vulgare) on ciprofloxacin absorption and disposition in the rat.

The aim of this study was to investigate the possibility of a drug-drug interaction between ciprofloxacin and fennel (Foeniculum vulgare) in a rat model. Pharmacokinetic assessment of ciprofloxacin was performed in two groups of male Sprague-Dawley rats. One group (n = 5) received 20 mg kg(-1) antibiotic orally with concomitant oral dosing of the aqueous fennel extract (2 g herb kg(-1)) whereas the controls (n = 5) received 20 mg kg(-1) oral ciprofloxacin. Blood and urine samples were collected over 6 and 24 h, respectively, for quantitation of ciprofloxacin by HPLC. A non-compartmental model was employed for pharmacokinetic analysis. Major ingredients and metal cations in the fennel extract were determined. Compared with the control, maximum plasma concentration, area under the curve and urinary recovery of ciprofloxacin were significantly (P < 0.05) lower, by 83, 48 and 43%, respectively, in rats receiving concomitant dosing of the two agents. The relative bioavailability of ciprofloxacin, under the influence of fennel, was estimated to be 0.52. In addition, its apparent volume of distribution and terminal elimination half-life were significantly (P < 0.05) increased, from 30.8 +/- 11.1 (L kg(-1)) and 2.0 +/- 0.4 (h) to 143.8 +/- 31.6 (L kg(-1)) and 5.2 +/- 2.0 (h), respectively. Although none of the organic components of fennel seemed to cause this interaction, the total amount of ten metal cations measured was found to be 13 mg g(-1). Significant interaction between ciprofloxacin and fennel was observed in this study. Absorption, distribution and elimination of ciprofloxacin were all affected. These changes might be because of the formation of a more lipophilic ciprofloxacin chelate in the presence of relatively large amounts of metal cations. If, therefore, the two therapeutic agents are used concurrently, an adequate dosing interval is needed to ensure the efficacy of ciprofloxacin.

Ursodeoxycholic acid may inhibit deoxycholic acid-induced apoptosis by modulating mitochondrial transmembrane potential and reactive oxygen species production.

BACKGROUND: The hydrophilic bile salt ursodeoxycholate (UDCA) inhibits injury by hydrophobic bile acids and is used to treat cholestatic liver diseases. Interestingly, hepatocyte cell death from bile acid-induced toxicity occurs more frequently from apoptosis than from necrosis. However, both processes appear to involve the mitochondrial membrane permeability transition (MPT). In this study, we determined the inhibitory effect of UDCA on deoxycholic acid (DCA)-induced MPT in isolated mitochondria by measuring changes in transmembrane potential (delta psi m) and production of reactive oxygen species (ROS). In addition, we examined the expression of apoptosis-associated proteins in mitochondria isolated from livers of bile acid-fed animals. MATERIALS AND METHODS: Adult male rats were maintained on standard diet supplemented with DCA and/or UDCA for 10 days. Mitochondria were isolated from livers by sucrose/percoll gradient centrifugation and MPT was measured using spectrophotometric and fluorimetric assays. delta psi m and ROS generation were determined by FACScan analysis. Cytoplasmic and mitochondrial protein abundance were determined by Western blot analysis. RESULTS: DCA increased mitochondrial swelling 25-fold over controls (p < 0.001); UDCA reduced the swelling by > 40% (p < 0.001). Similarly, UDCA inhibited DCA-mediated release of calcein-loaded mitochondria by 50% (p < 0.001). delta psi m was significantly decreased in mitochondria incubated with DCA but not with UDCA. delta psi m disruption was followed closely by increased superoxide anion and peroxides production (p < 0.01). Coincubation of mitochondria with UDCA significantly inhibited the changes associated with DCA (p < 0.05). In vivo, DCA feeding was associated with a 4.5-fold increase in mitochondria-associated Bax protein levels (p < 0.001); combination feeding with UDCA almost totally inhibited this increase (p < 0.001). CONCLUSION: UDCA significantly reduces DCA-induced disruption of delta psi m, ROS production, and Bax protein abundance in mitochondria, suggesting both short- and long-term mechanisms in preventing MPT. The results suggest a possible role for UDCA as a therapeutic agent in the treatment of both hepatic and nonhepatic diseases associated with high levels of apoptosis.

Antiaggregatory activity of 8-epi-prostaglandin F2 alpha and other F-series prostanoids and their binding to thromboxane A2/prostaglandin H2 receptors in human platelets.

8-Epi-prostaglandin F2 alpha (8-epi-PGF 2 alpha) is a nonenzymatic, free radical-catalyzed peroxidation product of arachidonic acid that has potent biological activity, including contraction of vasculature and inhibition of aggregation induced by thromboxane (TX) A2 mimetics. In the present study, we demonstrate that 8-epi-PGF2 alpha could inhibit platelet aggregation induced by the TX mimetics U46619 and I-BOP as well as low-dose collagen but not thrombin or the primary wave of aggregation caused by high-dose ADP. The secondary (TX-dependent) wave of aggregation induced by high-dose ADP, however, was not affected. This suppression was dose dependent where 3.6 and 3.3 microM of 8-epi-PGF2 alpha caused 50% inhibition of platelet aggregation induced by U46619 and I-BOP, respectively, whereas 10 microM caused approximately 72% inhibition of collagen-induced aggregation. In contrast, 8-epi-PGF2 alpha significantly potentiated reversible platelet aggregation in response to low-dose ADP. These results indicate that 8-epi-PGF2 alpha has partial agonist activity. 9 alpha,11 beta-PGF2, a structural isomer of 8-epi-PGF2 alpha, inhibited platelet aggregation induced by collagen, high- and low-dose ADP and thrombin, demonstrating marked differences between structural isomers where 9 alpha,11 beta-PGF2 inhibited platelet aggregation induced by TX-dependent as well as TX-independent stimuli. In addition to platelet aggregation, we performed competition-binding assays on washed human platelets using [125I]BOP to further investigate the interaction of 8-epi-PGF2 alpha and 9 alpha,11 beta-PGF2 with TXA2/PGH2 receptors.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of 14,15-epoxyeicosatrienoic acid infusion on blood pressure in normal and hypertensive rats.

Intravenous (IV) and intraarterial (IA) infusion of 14,15-epoxyeicosatrienoic acid (14,15-EET) produced a dose-dependent decrease in mean arterial blood pressure (MAP) in normal and spontaneously hypertensive rats (SHR). The hypotensive effect of 14,15-EET was observed from 1 microgram/kg to 10 micrograms/kg with a maximum reduction in MAP as much as 45 +/- 6 mmHg in both normal and SHR. In normal rats the hypotensive effect was found to be more pronounced when 14,15-EET was infused IA than IV. This suggests that 14,15-EET may be metabolized as it passes through the lungs. However, in SHR there was no difference in MAP when 14,15-EET was infused either IA or IV. This indicates that there is a differential removal of the epoxide across the pulmonary circulation. Administration of indomethacin failed to inhibit the hypotensive action of 14,15-EET, suggesting that it may not be a cyclo-oxygenase dependent mechanism. However, the PAF antagonist of BN-52021 inhibited the hypotensive action of 14,15-EET. This therefore, suggests that the release of PAF may be involved in the hypotensive action of this epoxide of arachidonic acid.

Transformation of 15-hydroperoxide of eicosapentaenoic acid to lipoxins and trihydroxyeicosatetraenoic acids by 5-lipoxygenase partially purified from potato tubers.

Incubation of 15-hydroperoxide of 5,8,11,14,17-eicosapentaenoic acid (15-HPEPE) with 5-lipoxygenase enzyme, partially purified from potato tubers, resulted in the generation of 6 isomers of lipoxin A5. These compounds were identified by GC/MS analysis of their methyl ester and trimethylsilyl ether derivatives with C-values: 23.3, 24.5, 24.6, 24.9, 25 and 25.2 respectively. The major products of the enzymatic reaction on 15-HPEPE are 5,15-DiHEPE and 13,14,15-trihydroxy eicosatetraenoic acid as identified by RP-HPLC and GC/MS analysis. There are also two new trihydroxyl compounds of eicosapentaenoic acid identified as 11,12,15-trihydroxy and 11,14,15-trihydroxy eicosatetraenoic acid respectively. The transformation of these two trihydroxyl compounds may be due to non-enzymatic rearrangement of 15-HPEPE.

Participation of Hageman factor dependent pathways in human disease states.

Abnormalities of Hageman factor dependent pathways have been described in a wide variety of human disease states. Congenital deficiencies of factor XII (Hageman trait) prekallikrein (Fletcher trait) and high molecular weight kininogen (Williams, Fitzgerald and Flaujeac traits) although resulting in profound in vitro changes, do not cause in vivo difficulties. In contrast, deficiency of C1 esterase inhibitor (hereditary angioedema) results in significant morbidity and mortality. Acquired diseases may exhibit decreased synthesis of these three proteins in cirrhosis and dengue fever. In vivo activation of factor XII initiated pathways occur in septic shock, disseminated or localized intravascular coagulation, typhoid fever, polycythemia vera, hyperbetalipoproteinemia, coronary artery disease, nephrotic syndrome, transfusion reactions, hemodialysis and extracorporeal bypass. Activation of both the intrinsic system and tissue mediators contribute to the vasomotor phenomena in carcinoid syndrome and postgastrectomy dumping. Roles for factor XII, prekallikrein and kininogen have been suggested in gouty arthritis, allergic disorders and cystic fibrosis but the evidence is not yet convincing in these disorders.