Determination of Dabigatran Concentration in Human Plasma and Breast Milk.

Venous thromboembolism (VTE) is an important cause of death following childbirth. Dabigatran etexilate can be a useful prophylaxis in susceptible women during the postpartum period. However, it is not clear whether dabigatran is excreted into breast milk in amounts which can be harmful to the suckling baby. We have developed an accurate, sensitive, and specific assay for the quantitation of dabigatran in both human plasma and breast milk. This is particularly useful for the determination of the extent by which dabigatran is secreted into breast milk in relation to its systemic availability. Dabigatran was enriched from both matrices using solid-phase extraction prior to separation on a C8-RPLC column and detection using SRM on a QqTrap mass spectrometer. The assay was validated for specificity, sensitivity, linearity, precision, accuracy, and stability of the analyte in human plasma and breast milk. The lower limit of detection for dabigatran was 20 pg/ml in plasma and 75 pg/ml in breast milk. This assay will aid future studies for the measurement of dabigatran concentrations in human breast milk to help determine if dabigatran etexilate can safely be administered to breast-feeding women.

Correlation between Trunk-Pelvis Inter-Segmental Coordination Parameters during Walking and Disability Level in Chronic Low Back Pain Patients.

BACKGROUND: Chronic low back pain (CLBP) disability has been particularly frustrating because its treatment has been a great therapeutic challenge. Disability has been suggested to depend on different factors that should be found and considered in the medical management. The inter-segmental coordination is often impaired in CLBP subjects; however, to the best of our knowledge, there is no evidence about the relationship between the existence of coordination problems and disability in CLBP patients. OBJECTIVE: To evaluate the correlation between sagittal plane trunk-pelvis inter-segmental coordination parameters during walking and disability level in CLBP patients. METHODS: Kinematic data were collected from 16 non-specific CLBP (18-40 years) volunteers during walking. Sagittal plane time-normalized segmental angles and velocities were used to calculate continuous relative phase for each data point. Coordination parameters, mean absolute relative phase (MARP) and deviation phase (DP) were derived to quantify the trunk-pelvis coordination pattern and variability during gait cycles, respectively. The disability level was quantified through Oswestry Disability Index (ODI) questionnaire. Pearson correlation coefficient was used to find the probable correlation between coordination parameters and disability level. RESULTS: The analysis demonstrated a significant correlation between sagittal plane MARP or DP and disability level (%ODI) in CLBP subjects during walking (r= -0.806 P<0.001 and r= -0.856, P<0.001, respectively). CONCLUSION: This study demonstrated that the lower the MARP (more in-phase pattern) and DP (less variable pattern) in the CLBP subjects, the more disability existing in such patients. The results suggest that clinicians should look beyond pain management when prescribing rehabilitation for CLBP and consider interventions that target segmental coordination improvement to manage CLBP induced disability.

Interleukin-6 secreted by oral cancer- associated fibroblast accelerated VEGF expression in tumor and stroma cells.

Oral cancer represents the sixth most common cancer type worldwide. Patients with oral cancer express high levels of IL-6 which is associated with very poor prognosis. Previous studies illustrated that IL-6 cytokine induces angiogenesis. It has also been reported that the presence of Cancer- Associated Fibroblasts (CAFs) is essential for angiogenesis. In this study, we examined the correlation between IL-6 and CAF and the role of this correlation on VEGF production. In this study, quantitative expression level of IL-6 and VEGF in CAF and Oral Cancer Cells (OCCs) examined through Real Time PCR and ELISA and western blot analysis. In addition, maintenance and retention of IL-6 and VEGF checked out in co-culture experiment of CAF and OCC cells. These experiments demonstrated that in oral cancer, CAF cell line secretes significantly more IL-6 than OCC. Also IL-6 is a factor that causes VEGF secretion in CAF cell line. CAF is the basic and the most essential source for producing IL-6 in patients with oral cancer. Secreted IL-6 is able to induce VEGF production in both CAF and OCCs. Correlation between CAF, IL-6 and VEGF could be considered as an approach for cancer therapy.

Molecular epidemiology of Escherichia coli sequence type 131 and its H30/H30-Rx subclones recovered from extra-intestinal infections: first report of OXA-48 producing ST131 clone from Iran.

Multidrug-resistant (MDR) O25b-ST131 clone of Escherichia coli is well established as a significant cause of extra-intestinal infections worldwide. However, there have been no studies about the prevalence of ST131 and its H30/H30Rx subclones from Iran. The prevalence of ST131 was 29.8% among phylogroups B2, D, and F of E.coli isolates recovered from extra-intestinal infections. Fifty-seven (90.4%) and six (9.6%) of isolates belonged to serogroups O25b and O16 respectively, and exhibited high rates of MDR (98.4% and 83.3%) and extended spectrum ß-lactamase (ESBL) production (96.8% and 83.3%). The majority (56/57, 98.2%) of O25b isolates belonged to H30 lineage; of those, 24 isolates (42.8%) belonged to H30-Rx subclone. O16-ST131 isolates were H30-negative. The resistance rate values of O16-ST131subgroup were lower for fluoroquinolones/aminoglycosides and higher for carbapenems, cephalosporins, ß-lactam/ß-lactamase inhibitors and trimethoprim/sulfamethoxazole, as compared to O25b-ST131 isolates. Among H30 sub lineage and in comparison with non-Rx isolates, H30-Rx subclone showed higher resistance score and virulence genes (papA and papC), and was also associated with CTX-M group 1. bla OXA-48 carbapenemase was detected in seven O25b and one O16 isolates; of those, one O25b-ST131 isolate was carbapenem-susceptible. The ST131 isolates comprised 15 'enterobacterial repetitive intergenic consensus' (ERIC) clusters, and O16 isolates remained distributed in five groups in cluster with O25b-ST131 isolates. In conclusion, this is the first report of the presence of MDR, bla OXA-48/CTX-M-positive O25b/O16-ST131 isolates in Iran. Contrary to lower prevalence of O16-ST131 subgroup, higher resistance rates to ß-lactam antibiotics may indicate the importance of this subgroup in the spread of MDR E.coli isolates.

Cost-effectiveness of pharmacogenetic-guided dosing of warfarin in the United Kingdom and Sweden.

We aimed to assess the cost-effectiveness of pharmacogenetic-guided dosing of warfarin in patients with atrial fibrillation (AF) in the United Kingdom and Sweden. Data from EU-PACT, a randomized controlled trial in newly diagnosed AF patients, were used to model the incremental costs per quality-adjusted life-year (QALY) gained by pharmacogenetic-guided warfarin dosing versus standard treatment over a lifetime horizon. Incremental lifetime costs were £26 and 382 Swedish kronor (SEK) and incremental QALYs were 0.0039 and 0.0015 in the United Kingdom and Sweden, respectively. The corresponding incremental cost-effectiveness ratios (ICERs) were £6 702 and 253 848 SEK per QALY gained. The ICER was below the willingness-to-pay threshold of £20 000 per QALY gained in 93% of the simulations in the United Kingdom and below 500 000 SEK in 67% of the simulations in Sweden. Our data suggest that pharmacogenetic-guided dosing of warfarin is a cost-effective strategy to improve outcomes of patients with AF treated with warfarin in the United Kingdom and in Sweden.

Influence of CYP2C9 polymorphism on the fall in International Normalized Ratio in patients interrupting warfarin therapy before elective surgery.

BACKGROUND: Patients on warfarin are normally required to stop treatment for a fixed number of days prior to an invasive procedure. However, the anticoagulant activity of warfarin subsides at different rates among different patients. OBJECTIVES: The aim of this study was to investigate the potential influence of CYP2C9 polymorphism on the variable rate of fall in the International Normalized Ratio (INR) in patients withdrawing from warfarin treatment prior to elective surgery. PATIENTS/METHODS: One hundred and fifty-two patients aged 43-93 years were recruited. Demographic data on age, height, weight, gender, daily warfarin dose, indication for anticoagulation therapy, medical diagnosis, surgical operation planned and concomitant medication were recorded. A blood sample was taken for later CYP2C9 genotyping. RESULTS: For patients with two CYP2C9 variant alleles (CYP2C9*2*2 or CYP2C9*2*3), the odds of having an INR of ≥ 1.5 before the planned day of surgery were 8.64 times greater (95% confidence interval [CI] 2.25-33.25) than for other patients. Multiple regression analysis revealed that the rate of fall in the INR was reduced in the presence of two CYP2C9 variant alleles, as well as increasing patient age, weight and number of comorbidities, and increased with increasing initial INR (F5,132  = 242.9, P < 0.0001), all of which accounted for ~ 90% of the interindividual variability in the fall in INR. CONCLUSION: A genotype-guided protocol to tailor warfarin withdrawal according to an individual patient's CYP2C9 genotype could reduce cancellation or delays of planned procedures, and could also be beneficial when transitioning patients from warfarin to one of the new oral anticoagulants.

Effects of low-intensity pulsed ultrasound on healing of mandibular bone defects: an experimental study in rabbits.

Research evidence suggests that low-intensity pulsed ultrasound (LIPU) produces significant osteoinductive effects, accelerating the healing of bone defects. The authors investigated the effects of LIPU on mandibular bone defects in a rabbit model. Fifty-six adult Dutch rabbits were divided randomly into control, LIPU-1 (1MHz), and LIPU-3 (3MHz) groups. A mandibular defect was created in all rabbits. The effect of LIPU on mandibular defects was assessed by frequency (1 or 3MHz) and timing (2 and 4 weeks). Bone mineral density (BMD) was measured and stereology and histology performed; results were compared at the end of 2 and 4 weeks. LIPU-3 resulted in significantly higher bone formation compared to the control group at the end of week 4 on histological assessment (P=0.008). BMD was significantly higher at 4 weeks than at 2 weeks (P=0.03). LIPU-3 increased the numerical density of osteoblasts and osteocytes at the end of week 4 (P=0.05 and P=0.001, respectively). The results of this study are in favour of using LIPU 3MHz to accelerate mandibular bone healing. However, this study suggests that a frequency of 3MHz and the longer application of LIPU 3MHz for 4 weeks can only promote 8% mandibular bone healing in rabbits. Therefore, the use of LIPU has no really convincing, consistent clinical effects on maxillofacial bone healing.

Patients benefit from genetics-guided coumarin anticoagulant therapy.

Observational studies have overwhelmingly shown that variants in the genes CYP2C9 and VKORC1 are significant determinants of individual dose of coumarin anticoagulants needed to maintain a therapeutic international normalized ratio (INR).(1) Until recently, however, few randomized clinical trials had been performed relating to the use of genetic data to predict dosing. Three sucsh clinical trials have now reported their findings.

Quality of bevacizumab compounded for intravitreal administration.

AIM: To compare the quality and stability of unlicensed, repackaged bevacizumab intended for intravitreal injection, as provided by five licensed compounding pharmacies in the United Kingdom, with bevacizumab in its original glass vial. METHODS: Repackaged bevacizumab was obtained from five UK suppliers. Samples were analyzed at two time points (day 1 and day 14). Microflow imaging was performed to evaluate subvisible particle size, particle density, and particle size distribution. Protein concentration, immunoglobulin G (IgG) content, and molecular weight were also determined. RESULTS: A significant difference in subvisible particle density was observed between bevacizumab batches from the five suppliers on day 1 (P<0.001). An increase in subvisible particle density was observed between day 1 and 14 for repackaged bevacizumab from all suppliers (all P<0.05), but not the reference compound. Protein concentration, IgG content, and molecular weight were comparable between batches from each supplier and the reference bevacizumab. DISCUSSION: The study results indicate that the quality of bevacizumab repackaged into prefilled plastic syringes is variable among the different compounding pharmacies in the United Kingdom. Furthermore, particle density may increase with storage in repackaged syringes. It is noteworthy that particle size distribution in both the repackaged and reference bevacizumab fell outside of the range specified by the United States Pharmacopeia for injectable ophthalmic solutions. These data highlight the need for further research into the use of unlicensed, repackaged bevacizumab intended for intravitreal injection.

Effect of lidocaine phonophoresis on sensory blockade: pulsed or continuous mode of therapeutic ultrasound?

OBJECTIVE: The optimisation of drug absorption through skin is of great value in modern therapy. Phonophoresis is the use of therapeutic ultrasound to increase percutaneous drug absorption. However, few studies have compared pulsed and continuous modes of therapeutic ultrasound. This study compared these two modes by investigating the effect of lidocaine phonophoresis on sensory blockade. Lidocaine is a common local anaesthetic drug that is used topically to relieve pain and also for minor surgery. DESIGN: Pre-post intervention study. PARTICIPANTS: Ninety-three healthy volunteers, assigned at random to one of three ultrasound groups: pulsed (ultrasound+lidocaine), continuous (ultrasound+lidocaine) and control (sham ultrasound+lidocaine). INTERVENTION: Lidocaine (approximately 2 cm3) was administered transdermally using a transducer. OUTCOME MEASURES: Two-point discrimination, touch and maximum pain thresholds were assessed before and after the intervention in each group. RESULTS: There were significant increases in two-point discrimination, touch and maximum pain thresholds after the intervention in all groups (P<0.05). The mean differences in the threshold changes between the pulsed and continuous groups were significant [two-point discrimination: mean difference 0.66 (standard deviation, SD 0.41) mm, 95% confidence interval (CI) 0.18 to 1.21, P<0.001; touch: mean difference 1.31 (SD 0.23) mA, 95% CI 0.98 to 1.96, P<0.001; maximum pain: mean difference 5.59 (SD 4.01) mA, 95% CI 1.01 to 10.11, P<0.001]. Statistical analysis also revealed significant differences for all senses between the pulsed and control groups [two-point discrimination: mean difference 0.61 (SD 0.29) mm, 95% CI 0.26 to 1.3, P<0.001; touch: mean difference 1.45 (SD 0.38) mA, 95% CI 0.96 to 2.1, P<0.001; maximum pain difference 9.17 (SD 4.13) mA, 95% CI 4.32 to 14.1, P<0.001]. The mean difference in the change in maximum pain threshold between the continuous and control groups was significant [mean difference 3.58 (SD 3.44) mA, 95% CI 0.09 to 8.3, P=0.001], but two-point discrimination and touch threshold changes revealed no significant difference between the continuous and control groups [two-point discrimination: mean difference 0.05 (SD 0.28) mm, 95% CI -0.31 to 0.48, P=0.968; touch: mean difference 0.14 (SD 0.19) mA, 95% CI -0.21 to 0.43, P=0.339]. CONCLUSION: Pulsed ultrasound with topical lidocaine gel induced greater anaesthetic effect compared with continuous ultrasound with topical lidocaine gel and lidocaine application alone. The mechanical properties of pulsed ultrasound appear to be responsible for greater drug penetration.

A proposal for an individualized pharmacogenetics-based warfarin initiation dose regimen for patients commencing anticoagulation therapy.

A significant proportion of the interindividual variability in warfarin dose requirements can be explained on the basis of CYP2C9 and VKORC1 genotypes. We report the development of a novel pharmacogenetics-based 3-day warfarin initiation dose (ID) algorithm based on the International Warfarin Pharmacogenetics Consortium (IWPC) maintenance dose algorithm and the CYP2C9 genotype-based variance in warfarin half-life. The predictive value of the pharmacogenetics-based ID was assessed in a large cohort of 671 newly diagnosed patients with thromboembolic disorders who were about to commence anticoagulation therapy in accordance with standard induction regimens. In patients with mean international normalized ratio (INR)days 4-7>4.0 (n=63) after warfarin initiation, the pharmacogenetics-based ID algorithm predicted a markedly lower dose requirement (median reduction=4.2 mg), whereas in those with mean INRdays 4-7<2.0 (n=145), the predicted dose requirement was very similar to that in the standard regimen. The use of a pharmacogenetics-based ID may avoid overshooting of INR in warfarin-sensitive patients without unduly affecting the time taken to reach target range in the majority of patients.

[Adenosine deaminase in the blood cells and serum of patients with tuberculous pleurisy].

The common complication of pulmonary tuberculosis is pleurisy that requires not only special treatments, but also gives rise to difficulties in the differential diagnosis of tuberculosis. The investigation has studied the possibility of determining the activity of adenosine deaminase (ADA) as a marker of pleural effusion of tuberculous etiology. The patients with tuberculous pleurisy have been found to have higher lymphocytic and red blood ADA, and ADA, activities and a significantly increased serum ADA2 activity. Thus, the changes in the activity of ADA and its isozymes have been shown to be specific to pleurisy of tuberculous etiology and to be of diagnostic value.