Quality assurance of ethical issues and regulatory aspects relating to good clinical practices in the HELENA Cross-Sectional Study.

RATIONALE: Research involving humans is regulated by regulatory authorities through their specific requirements and controls. The Healthy Life Style in Europe by Nutrition in Adolescence Cross-Sectional Study (HELENA-CSS) is a multicenter biomedical research study of adolescents in several representative European cities, which requires satisfying medico-regulatory requirements including Independent Ethics Committee (IEC) approval and agreement by the national or local regulatory authorities. To achieve a high level of quality assurance relating to ethical issues, we followed the good clinical practices (GCP) described at the International Conference on Harmonisation (ICH), which we adapted to the national and local situations of each of the 11 participating cities in 10 European countries. OBJECTIVE: The main objective of the HELENA-CSS is to evaluate reliable and comparable data of nutritional habits and lifestyle in a representative sample of European adolescents. The aim of this paper is to present the methods relating to the ethical and regulatory issues of this study and to describe the current state of the medico-regulatory requirements involved in conducting this kind of study in each country. MATERIALS AND METHODS: Following the GCP-ICH guidelines, a protocol describing the HELENA-CSS was written and approved by all partners. In the pilot study, a case report form adapted to the study objectives and its manual of operation was constructed and used by all partners. All information letters to adolescents and their parents and consent forms were first written in English, then translated into the local language, and adapted to each local situation. All documents were then checked centrally for any deviation and corrected if required. An operation manual relating to ethical issues and other medico-regulatory requirements was also developed. This paper presents the current status of the medico-regulatory requirements from each HELENA-CSS participant country. RESULTS: Before the beginning of the study, most centers had satisfied the medico-regulatory requirements of IEC approval and agreement with other national or local regulatory authorities/organizations. For a few centers, some problems were detected and corrective actions were taken to improve missing information to reach a high level of quality assurance of ethical issues. CONCLUSION: The GCP-ICH guidelines about nontherapeutic biomedical research are interpreted and applied differently across Europe. This study shows that high-quality nontherapeutic biomedical research can address the ethical issues included in the GCP-ICH regulations and can be harmonized among the HELENA European partners.

Socioeconomic questionnaire and clinical assessment in the HELENA Cross-Sectional Study: methodology.

RATIONALE: Environmental factors such as dietary habits, breastfeeding, socioeconomic conditions and educational factors are strong influences on nutritional and puberty status, physical activity, food choices and their interactions. Several diseases of adulthood seem to be linked to, or to originate from, lifestyle in childhood and adolescence. OBJECTIVE: The aims of this study are to describe birth parameters and socioeconomic factors and to assess clinical status in adolescents aged 13-16 years from 10 European countries participating in the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) Cross-Sectional Study (CSS). METHODOLOGY: A self-report questionnaire on the socioeconomic status, a parental questionnaire concerning neonatal period and also a case report form (CRF), in which clinical items during clinical examination (such as medical history, treatments, anthropometry, Tanner staging, blood pressure, heart rate) were assessed. To develop these documents, first a list of items was established, a search of existing documents was performed and the advice of local and international experts was taken. All documents (questionnaires and an operations manual) were discussed in plenary HELENA meetings; a final version of these documents was fixed, and the process of translation and back translation was performed. RESULTS: The questionnaires and CRF were tested for validation in all 10 participant cities; 208 adolescents were enrolled during the pilot study. All items that caused problems or questions in one or more participating centers or were completed by < 85% of the adolescents were reviewed before the beginning of the HELENA-CSS. CONCLUSION: These final questionnaires and CRF will contribute to better understanding of the inequalities in nutrition, behavior and health in the European adolescent population. The experience and process should be useful for other multicenter studies.

Sampling and processing of fresh blood samples within a European multicenter nutritional study: evaluation of biomarker stability during transport and storage.

INTRODUCTION: Analysis of several biological markers improves the quality and physiologic comprehension of data obtained in epidemiological nutritional studies. AIM: To develop a methodology that guarantees the centralized analysis and quality assurance of the most relevant blood parameters from fresh blood samples in adolescents in a European multicenter study. MATERIALS AND METHODS: Stability of selected nutrients and biomarkers (vitamins, fatty acids, iron metabolism and immunological parameters) chosen with respect to time and temperature of sample transport and storage was evaluated as part of the pilot study of the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) project. RESULTS: Routine biochemistry and iron status parameters included in the HELENA Cross-Sectional Study (CSS) protocol could be analyzed within 24 h from fresh blood samples without any stability problems (coefficient of variation (CV)<5%, P<0.05). However, stability tests for lymphocyte subpopulations, vitamin C and fatty acids showed that they are very unstable at room temperature without any treatment. Therefore, a special handling for these samples was developed. Vitamin C was stabilized with metaphosphoric acid and transported under cooled conditions (CV 4.4%, recovery rate >93%, P>0.05). According to the results, a specific methodology and transport system were developed to collect blood samples at schools in 10 European cities and to send them to the centralized laboratory (IEL, Bonn, Germany). To guarantee good clinical practice, the field workers were instructed in a training workshop and a manual of operation was developed. CONCLUSION: The handling and transport system for fresh blood samples developed for the European multicenter study HELENA is adequate for the final part of the HELENA-CSS and will provide, for the first time, reference values for several biological markers in European adolescents.

Effects of two marine dietary supplements with high calcium content on calcium metabolism and biochemical marker of bone resorption.

BACKGROUND/OBJECTIVE: Calcium is essential for the bone metabolism but daily calcium requirements are not met in a significant proportion of the population. Fortunately, oral calcium supplementation can help to meet these needs; however, the calcium bioavailability depends on the calcium sources. The calcium absorption and bioavailability of dietary supplements from marine sources are not known. The objectives of this study were to evaluate the effects of two marine dietary supplements with a high calcium content: a fishbone powder (Phoscalim) and a ray cartilage hydrolysate (Glycollagene), in comparison with milk, and a placebo (maltodextrin), on calcium metabolism and a biochemical marker of bone resorption, using the oral calcium tolerance test. SUBJECTS: Twenty male volunteers were randomized to eat 836 mg of calcium from different sources compared to maltodextrin during a Latin square study. Serum calcium concentrations and other parameters of the calcium metabolism, such as serum intact parathyroid hormone (iPTH) and serum C telopeptides (s-CTX), were measured after an acute oral calcium load based on the Pak protocol. RESULTS: An increase in serum-corrected calcium areas under the curve (AUC) occurred with Phoscalim and Glycollagene when compared to milk. Significantly lower iPTH concentrations were observed with Glycollagene than with milk at T0+1 h, T0+3 h, T0+6 h and with Phoscalim than with milk at T0+6 h. A significantly lower s-CTX concentration was observed with Glycollagene than with milk and Phoscalim at T0+6 h. Furthermore, the urinary calcium/creatinine ratio increased significantly more with Glycollagen than with milk in T0 h+3 h and T3 h+6 h. CONCLUSION: These two dietary supplements from marine sources constitute oral calcium sources when compared to milk on calcium absorption and bone resorption markers on short time.

Effect of training and detraining on heart rate variability in healthy young men.

The purpose of this study was to investigate the effect of twelve weeks of aerobic training and eight weeks of training cessation on Heart Rate Variability (HRV). Ten healthy young men (Age: 21.7 +/- 2.2 years; Height: 179.2 +/- 6.9 cm; Mass 72.7 +/- 11.1 kg) completed an incremental test and a 60 degrees tilt test during which R-R intervals were recorded before (T0) and after (T12) 12 weeks of intensive training, and after 2, 4 and 8 weeks of training cessation (D2, D4 and D8, respectively). HRV was computed in time and frequency domains. Training resulted in a significant increase in estimated VO2max after T12 (p < 0.01), followed by a significant decrease during D2 and D8 (p < 0.05). Total power (LF + HF) and low frequency power (LF) increased significantly in the supine position after the training period (p < 0.05) and decreased moderately after D2 (p > 0.05) to stabilize afterwards. LF + HF and LF were not different from T0 at D8 (p > 0.05). It was concluded that eight weeks of training cessation allow to reverse the cardiovascular autonomic adaptations induced by 12 weeks of intensive training in healthy young men.

Prior TIA, lipid-lowering drug use, and physical activity decrease ischemic stroke severity.

OBJECTIVE: To determine clinical and pharmacologic factors that could influence the initial severity and short-term outcome of cerebral ischemia. METHODS: In a cross-sectional hospital-based study of patients with acute supratentorial ischemic stroke, we systematically collected medical history, previous leisure-time physical activity, current and previous treatments, blood pressure, temperature, blood glucose, fibrinogen, NIH Stroke Scale (NIHSS) score at admission, and outcome at day 8. Factors potentially associated with initial stroke severity and outcome were selected by univariate analyses and then validated in logistic regression analyses with lower severity of stroke at admission (NIHSS 0 to 5) or good outcome at day 8 (modified Rankin Scale 0 to 1, Barthel Index 95 to 100) as dependent variables. RESULTS: In 362 consecutive patients (median age 70 years, range 16 to 97 years; 195 women), independent factors associated with a lower severity at admission were previous leisure-time physical activity (adjusted odds ratio [OR] 1.67, 95% CI 1.07 to 2.66), TIA (adjusted OR 2.28, 95% CI 1.06 to 4.87) and treatment with lipid-lowering drug (adjusted OR 1.76, 95% CI 1.02 to 3.03). Previous treatment with lipid-lowering drug and leisure-time physical activity were also independent factors associated with a good short-term outcome. CONCLUSION: Both regular physical activity and lipid-lowering drugs should be prospectively evaluated to determine whether they reduce the severity of ischemic stroke.

Lipid lowering agents are associated with a slower cognitive decline in Alzheimer's disease.

BACKGROUND: Data from epidemiological studies and animal models imply that disturbances in cholesterol metabolism are linked to Alzheimer's disease susceptibility. Lipid lowering agents (LLAs) may have implications for the prevention of Alzheimer's disease. OBJECTIVE: To investigate whether LLAs are associated with a slower cognitive decline in Alzheimer's disease. METHODS: An observational study in 342 Alzheimer patients followed in a memory clinic for 34.8 months (mean age 73.5 years, mini-mental state examination score (MMSE) 21.3 at entry); 129 were dyslipaemic treated with LLAs (47% with statins), 105 were untreated dyslipaemic, and 108 were normolipaemic. The rate of cognitive decline was calculated as the difference between the first and last MMSE score, divided by the time between the measurements, expressed by year. Patients were divided into slow and fast decliners according to their annual rate of decline (lower or higher than the median annual rate of decline in the total population). RESULTS: Patients treated with LLAs had a slower decline on the MMSE (1.5 point/year, p = 0.0102) than patients with untreated dyslipaemia (2.4 points/year), or normolipaemic patients (2.6 points/year). Patients with a slower decline were more likely to be treated with LLAs. Logistic regression analysis, with low annual cognitive decline as the dependent variable, showed that the independent variable LLA (treated with or not) was positively associated with the probability of lower cognitive decline (odds ratio = 0.45, p = 0.002). CONCLUSIONS: LLAs may slow cognitive decline in Alzheimer's disease and have a neuroprotective effect. This should be confirmed by placebo controlled randomised trials in patients with Alzheimer's disease and no dyslipaemia.

Grapefruit juice-nifedipine interaction: possible involvement of several mechanisms.

OBJECTIVE: To develop a model based on mean residence time for better understanding the effect of grapefruit juice on the metabolism of nifedipine (NIF). MATERIAL AND METHODS: Sixteen healthy volunteers from an urban population were included. For each trial, the subjects drank water, fresh grapefruit juice or bottled grapefruit juice. Thirty minutes later, the subjects took a 10 mg capsule of NIF, orally. Plasma concentration of NIF was measured and the kinetic parameters were calculated with a non-compartmental model. RESULTS: Grapefruit juice increased the bioavailability of NIF, but did not significantly reduce the drug's metabolism as shown by the approximately constant metabolite to parent drug AUC ratio (P = 0.948). There was no significant increase in the amount of non-metabolized drug absorbed during first-pass: 0.12 and 0.16 (P = 0.470) without and with grapefruit juices respectively. There was an increase in the relative bioavailability (P = 0.039) and the apparent volume of distribution (Vdm) (P = 0.025) of dehydronifedipine with grapefruit co-administration. A second peak was also observed in the NIF plasma-concentration profile when the drug is co-administered with grapefruit juice. Therefore, the most likely explanation for the double peak phenomenon is a delay in gastric emptying (+32 min with grapefruit juice) caused by the pH of grapefruit juice. CONCLUSION: This study shows that grapefruit juice interferes with the metabolism of NIF by inhibiting NIF metabolism and slowing down the rate of gastric emptying. This study also confirms that the metabolic inhibition is not a first pass effect, but is a secondary oxidative step.

Molecular characterization of the idiopathic hypereosinophilic syndrome (HES) in 35 French patients with normal conventional cytogenetics.

Idiopathic hypereosinophilic syndrome (HES) characterized by unexplained and persistent hypereosinophilia is heterogeneous and comprises several entities: a myeloproliferative form where myeloid lineages are involved with the interstitial chromosome 4q12 deletion leading to fusion between FIP1L1 and PDGFRA genes, the latter acquiring increased tyrosine kinase activity. And a lymphocytic variant, where hypereosinophilia is secondary to a primitive T lymphoid disorder demonstrated by the presence of a circulating T-cell clone. We performed molecular characterization of HES in 35 patients with normal karyotype by conventional cytogenetic analysis. TCRgamma gene rearrangements suggesting T clonality were seen in 11 (31%) patients, and FIP1L1-PDGFRA by RT-PCR in six (17%) of 35 patients, who showed no evidence of T-cell clonality. An elevated serum tryptase level was observed in FIP1L1-PDGFRA-positive patients responding to imatinib, whereas serum IL-5 levels were not elevated in T-cell associated hypereosinophilia. Sequencing FIP1L1-PDGFRA revealed scattered breakpoints in FIP1L1-exons (10-13), whereas breakpoints were restricted to exon 12 of PDGFRA. In the 29 patients without FIP1L1-PDGFRA, no activating mutation of PDGFRA/PDGFRB was detected; however; one patient responded to imatinib. FISH analysis of the 4q12 deletion was concordant with FIP1L1-PDGFRA RT-PCR data. Further investigation of the nature of FIP1L1-PDGFRA affected cells will improve the classification of HES.

Heart rate variability and Parkinson's disease severity.

Heart rate variability (HRV) decrease in Parkinson's disease (PD) could only be a consequence of reduce motor activity besides of being a marker of cardiovascular dysautonomia. Under continuously recorded and standardised motor activity, we studied thirty patients compared to controls in 3 PD stages: group I: less than 2 year-evolution, slight impaired without L-dopa; group II: mildly impaired with L-dopa; group III: advanced PD with motor complications. No difference was observed between group I and controls. The diurnal low frequency power (LF) and the ratio of LF/high frequency (HF) power decreased in groups II and III. The nocturnal vagal indicators: HF power and pNN50 were decreased in group III. Those parameters were correlated with Off-drug-motor handicap, suggesting an evolutive HRV decrease with disease severity but not with On-drug-motor activity. The low LF despite the higher motor activity in group III, due to dyskinesias, suggested a defective cardiovascular up-regulation.

Study of circadian melatonin secretion pattern at different stages of Parkinson's disease.

To explore changes in melatonin secretion patterns and biologic rhythms in Parkinson's disease patients with or without levodopa-related motor complications (LDRMCs), the authors investigated, in an observational study, circadian rhythms of central temperature, motor activity, plasma cortisol, and melatonin in three groups: de novo untreated patients (group I), patients treated with levodopa + dopamine agonist and without LDRMCs (group II), and patients treated with levodopa + dopamine agonist and with LDRMCs (group III). There were no differences among the three groups for the rhythm of temperature, motor activity, or plasma cortisol. There was a significant (p < 0.05) phase advance in plasma melatonin secretion in patients receiving a dopaminergic treatment compared with untreated patients. The daytime area under the curve (AUC) was increased significantly in group III, and the nighttime AUC-to-daytime AUC ratio of melatonin secretion decreased significantly in group III, suggesting that the nychthemeral pattern of melatonin secretion was changed in patients with LDRMCs. Comparison of the three groups suggests a slight but insignificant phase advance and amplitude decrease of circadian melatonin secretion related to both evolution and treatment of Parkinson's disease. Despite the lack of a global desynchronization in other circadian biologic rhythms, the circadian secretion pattern of melatonin is modified in patients with LDRMCs.

Identification of genetic variants in the human thromboxane synthase gene (CYP5A1).

Thromboxane synthase (CYP5A1) catalyzes the conversion of prostaglandin H2 to thromboxane A2, a potent mediator of platelet aggregation, vasoconstriction and bronchoconstriction. It has been implicated in the patho-physiological process of a variety of diseases, such as atherosclerosis, myocardial infarction, stroke and asthma. On the basis of the hypothesis that variations of the CYP5A1 gene may play an important role in human diseases, we performed a screening for variations in the human CYP5A1 gene sequence. We examined genomic DNA from 200 individuals, for mutations in the promoter region, the protein encoding sequences and the 3'-untranslated region of the CYP5A1. Eleven polymorphisms have been identified in the CYP5A1 gene including eight missense mutations R61H, D161E, N246S, L357V, Q417E, E450K, T451N and R466Q. This is the first report of genetic variants in the human CYP5A1 altering the protein sequence. The effect of these variants on the metabolic activity of CYP5A1 remains to be further evaluated.

The effect of alcohol consumption on the circadian control of human core body temperature is time dependent.

The few controlled studies dealing with the action of alcohol on core body temperature in humans have focused on the effect of a single dose of ethanol and reported that it has a hypothermic effect. No studies report the effects of repeated ethanol intake over a 24-h period, a pattern of consumption much closer to the clinical condition of chronic alcoholism. We therefore designed a trial in which alcohol was repeatedly and regularly administered, with a total dose of 256 g. Nine healthy male volunteers (mean age 23.3 +/- 2.9 yr; range 21-30) each served as his own control. The circadian temperature rhythm was studied by a single-blind, randomized, crossover study that compared a 26-h alcohol session to a 26-h placebo session. The trial controlled for so-called masking effects known to affect temperature. The volunteers were in bed; the ambient temperature was maintained between 20 and 22 degrees C. Meals were standardized. And light was controlled during the night. All sessions took place between November and April. The two sessions were separated by 2 to 5 wk. Rectal temperature was monitored every 20 min throughout the trial. We found the standard hypothermic effect of alcohol in the early hours of the trial, during the daytime, but our principal result is that alcohol consumption induced a very significant hyperthermic effect (+0.36 degrees C) during the night and thereby reduced the circadian amplitude of core body temperature by 43%. The dramatic decrease of the amplitude of circadian temperature rhythm that we observed may explain, at least in part, some clinical signs observed in alcoholic patients, including sleep and mood disorders. We suggest that jet lag, shift work, and aging, which are known to alter body temperature, are aggravated by alcohol consumption.

Characterization of new mutations in the coding sequence and 5'-untranslated region of the human prostacylcin synthase gene (CYP8A1).

Inheritable interindividual differences in prostacyclin production may be implicated in the pathogenesis of several human vascular diseases. Using a polymerase chain reaction/single-strand conformation polymorphism strategy, we screened for mutations in the gene encoding cytochrome P450 prostacyclin synthase (CYP8A1). DNA samples from healthy French volunteers (n = 130) of Caucasian origin were examined. Five mutations, comprising two previously reported silent mutations and three novel rare missense mutations (P38L, S118R, and R379S), were identified in the coding sequence of the gene. In the 5'-proximal region, we also found a variable number of tandem repeats (VNTR) polymorphism that consisted of four different alleles with 4-6 tandem repeats of a 9-bp unit containing a putative Spl transcriptional factor binding site. One of these (R6), a frequent allele (23.6% of alleles tested) harboring six repeats, is novel, whereas the other three are known. In vitro analysis of the effect of each VNTR allele on promoter activity of a reporter gene was performed by a transient transfection assay. Data confirmed the modulator effect of the VNTR polymorphism on reporter gene transcription. Furthermore, the data demonstrate that allele R6 has the most potent inducing effects in the A549 cell line and, after IL-6 stimulation, in human pulmonary artery endothelial cells. Overall, the data demonstrate that CYP8A1 is polymorphic in Caucasians, and that a polymorphism affecting the 5'-proximal region may result in interindividual differences in CYP8A1 transcriptional regulation in vivo. Additional factors, such as the presence of inflammatory mediators, may be required to modulate transcription of the CYP8A1 gene.

Doppler flow wire evaluation of renal blood flow reserve in hypertensive patients with normal renal arteries.

PURPOSE: To study the vasomotor responses of the renal microcirculation in patients with essential hypertension. METHODS: We studied the reactivity of the renal microcirculation to papaverine, with intraarterial Doppler and quantitative arteriography, in 34 renal arteries of 19 hypertensive patients without significant renal artery stenosis. Isosorbide dinitrate was given to maximally dilate proximal renal arteries. APV (average peak blood flow velocity) was used as an index of renal blood flow. RESULTS: Kidneys could be divided into two distinct subgroups based on their response to papaverine. An increase in APV of up to 55% occurred in 21 kidneys, an increase > 55% in 13 kidneys. Within each group the values were normally distributed. Both baseline APV and the effect of papaverine on mean velocity differed significantly between groups. CONCLUSION: There seems to be a subgroup of patients with essential hypertension that has an impaired reactivity to papaverine, consistent with a functional impairment of the renal microcirculation. Further studies are required to determine whether this abnormality contributes to or results from elevated blood pressure.

[Long-term results of anatomic repair of transposition of great vessels]. / Résultats à long-terme de la réparation anatomique d'une transposition des gros vaisseaux.

The long-term complications after anatomical repair of transposition of the great arteries (TGA) were analysed in a prospective study of 30 successive patients, from August 1996 to October 1999, who were presumed asymptomatic and investigated 10 years after surgery. All underwent clinical examination, ECG, stress Thallium 201 myocardial scintigraphy, Doppler echocardiography, Holter ECG, pulmonary perfusion scintigraphy, right and left cardiac catheterization with selective coronary angiography. Five patients had coronary lesions (4 thromboses and 1 coronary-pulmonary artery fistula). The other abnormalities observed were mild bilateral stenosis of the two pulmonary arteries (1 case), grade 1 aortic regurgitation (6 cases), including 1 case of aortic root dilatation. Type B to E coronary circulations (Yacoub classification) were not significantly correlated with coronary artery disease in this series (p = 0.06). For the diagnosis of these lesions, myocardial scintigraphy and Doppler echocardiographic detection of wall motion abnormalities had a sensitivity of 50% and respective specificities of 88% and 35%. Long-term results after anatomical repair of TGA are satisfactory. However, the high incidence of coronary lesions makes regular follow-up and systematic coronary angiography necessary in all children.

Genotypic analysis of thiopurine S-methyltransferase in patients with Crohn's disease and severe myelosuppression during azathioprine therapy.

BACKGROUND & AIMS: Myelosuppression in patients with Crohn's disease (CD) treated with azathioprine has been attributed to low activity of thiopurine S-methyltransferase (TPMT). Allelic variants of the TPMT gene responsible for changes in the enzyme activity have been characterized. We investigated the distribution of mutant alleles associated with TPMT deficiency in patients with CD and myelosuppression during azathioprine/6-mercaptopurine therapy. METHODS: Forty-one patients with CD were included. They developed leukopenia or thrombocytopenia during azathioprine or 6-mercaptopurine treatment. Polymerase chain reaction-based methods were used to search for mutations associated with TPMT deficiency. RESULTS: Four patients (10%) had 2 mutant alleles associated with TPMT deficiency, 7 (17%) had 1 mutant allele, and 30 (73%) had no known TPMT mutation. The delay between administration of the drug and occurrence of bone marrow toxicity was less than 1.5 months in the 4 patients with 2 mutant alleles, and ranged from 1 to 18 months in patients with 1 mutant allele and from 0.5 to 87 months in patients with normal genotype. CONCLUSIONS: Twenty-seven percent of patients with CD and myelosuppression during azathioprine therapy had mutant alleles of the TPMT gene associated with enzyme deficiency. Myelosuppression is more often caused by other factors. Continued monitoring of blood cell counts remains mandatory in patients treated with azathioprine.

Dramatic inhibition of amiodarone metabolism induced by grapefruit juice.

AIMS: Grapefruit juice increases blood concentrations of many drugs metabolized by CYP3A. Amiodarone is metabolized by CYP3A to N-desethylamiodarone (N-DEA). The aim of this study was to determine amiodarone kinetics when administrated with and without grapefruit juice. METHODS: Eleven healthy adult volunteers took part in a single sequence, repeated-measures design study. Each subject, who had been evaluated 6 months previously for amiodarone pharmacokinetics, was given a single oral dose of amiodarone (17 mg kg-1) with three glasses of 300 ml of grapefruit juice on the same day. RESULTS: Grapefruit juice completely inhibited the production of N-DEA, the major metabolite of amiodarone, in all subjects and increased the area-under-the-curve (AUC) and maximum concentration of amiodarone (Cmax) by 50% and 84%, respectively, as compared with the control period during which water had been administrated instead of grapefruit juice (AUC: 35.9 +/- 14.3 vs 23.9 +/- 11.2 microg ml-1 h, P < 0.005 and Cmax: 3.45 +/- 1.7 vs 1.87 +/- 0.6 microg ml-1, P < 0. 02, respectively) (means +/- s.d.). This inhibition of N-DEA production led to a decrease in the alterations caused by amiodarone on PR and QTc intervals. CONCLUSIONS: Grapefruit juice dramatically alters the metabolism of amiodarone with complete inhibition of N-DEA production. These results are in agreement with in vitro data pointing to the involvement of CYP3 A in the metabolism of amiodarone and suggests that this interaction should be taken into account when prescribing this antiarrhythmic drug.

Electrophysiological effects of dofetilide in an in vitro model of "border zone" between normal and ischemic/reperfused myocardium.

BACKGROUND: To evaluate both class III activity and antiarrhythmic action of dofetilide at the level of the "border zone," we investigated its electrophysiological effects on guinea pig ventricular strips submitted partly to normoxia (normal zone, NZ) and partly to simulated severe ischemia, then reperfusion (altered zone, AZ). METHODS AND RESULTS: Because of the differential class III effects of dofetilide in normal and ischemic regions, the dispersion of the action potential duration at 90% repolarization (APD(90)) between NZ and AZ was reduced by 5 nmol/L of drug during early ischemia (at 10 minutes, APD(90) NZ/APD(90) AZ was 1.68+/-0.22 versus 2.82+/-0.17 in control, P<0.05), whereas 50 nmol/L dofetilide worsened it during late ischemia (at 30 minutes, APD(90) NZ/APD(90) AZ was 4.62+/-0.76 versus 2.57+/-0.21 in control, P<0.05). Concomitantly, dofetilide at 5, 10, and 50 nmol/L abolished the early extrastimulus (ES)-induced arrhythmias, and at 10 and 50 nmol/L, it significantly enhanced the incidence of late spontaneous repetitive responses (in 86% and 75% of preparations treated with 10 and 50 nmol/L, respectively, versus 25% in control, P<0.05). During reperfusion, dofetilide at 5, 10, and 50 nmol/L exhibited concentration-dependent class III effects, as it did in the NZ, and did not modify the incidence of spontaneous arrhythmias. CONCLUSIONS: Dofetilide 5 nmol/L decreased APD(90) dispersion between NZ and AZ and reduced the early ES-induced arrhythmias. However, dofetilide 50 nmol/L increased APD(90) dispersion, and at 10 and 50 nmol/L, it increased the late spontaneous arrhythmias.