Seguimiento farmacoterapéutico y sistemas personalizados de dosificación como herramientas para optimizar farmacoterapia y adherencia: caso clínico en prácticas tuteladas / Pharmacotherapeutic monitoring and personalised dosing systems as tools to optimise pharmacotherapy and adherence: a clinical case in supervised internships

PRESENTACIÓN DEL CASO: varón, 88 años, refiere episodios de tos crónica e irritación de garganta que le preocupan e incapacitan. Últimamente se encuentra asténico. Se le ofrece SFT y acepta. Problemas de salud actuales: HTA, hiperlipidemia, ERGE, tos, anemia, disuria, astenia.T ratamiento actual: enalapril 10 mg + nitrendipino 20 mg (1/0/0), simvastatina 20 mg (0/0/1), omeprazol 20 mg (1-0-0, incumple), carbocisteina 50 mg/ml (10/10/10), paracetamol 1 g (si dolor), sulfato ferroso 325 mg (1-0-0, incumple). Otros datos de interés PA: 119/52. Resto de parámetros bioquímicos dentro de la normalidad.EVALUACIÓN: se detectan los siguientes PRMs y RNMs: 1.- Enalapril/nitrendipino. Sospecha de PRM: reacción adversa, posible causa de tos. RNM: inseguridad no cuantitativa 2.- Omeprazol. PRM: incumplimiento terapéutico, posible causa de tos por ERGE no controlado. RNM: inefectividad cuantitativa3.- Carbocisteína. PRM: medicamento no necesario, no existe indicación. RNM: efecto de medicamento innecesario4.- Hierro. PRM: incumplimiento terapéutico, posible causa de anemia. RNM: inefectividad cuantitativa 5.- Disuria. PRM: problema de salud no tratado, el paciente refiere dificultad al miccionar. RNM: problema de salud no tratado.INTERVENCIONES: a.- Emitimos informe al MAP proponiendo valorar tratamiento antihipertensivo (enalapril) como causa de tos, poniéndole también en antecedentes del incumplimiento terapéutico de hierro y omeprazol e informándole de la astenia y la disuria. b.- Se retira carbocisteina, medicamento no sujeto a prescripción médica y, por tanto, susceptible de indicación farmacéutica. Se plantea sustitución por comprimidos para chupar como tratamiento sintomático alternativo. c.- Para mejorar la adherencia terapéutica del paciente a su farmacoterapia se le oferta el servicio de SPD, que acepta. Resultados1. (AU)

Thrombin in the Activation of the Fluid Contact Phase in Patients with Hereditary Angioedema Carrying the F12 P.Thr309Lys Variant.

Hereditary angioedema due to pathogenic FXII variants (HAE-FXII) is a rare dominant disease caused by increased activation of the plasma contact system. The most prevalent HAE-FXII variant, c.1032C > A p.Thr309Lys (FXII309Lys), results in a smaller FXII protein with increased sensitivity to fluid-phase activation by poorly understood mechanisms. We aimed to investigate the functionality of the FXII309Lys variant in 33 HAE-FXII patients, 25 healthy controls and 46 patients with congenital disorders of glycosylation (CDG). Activation of the plasma contact system was assessed by western blot and amidolytic assay in basal conditions or after treatment with either artificial or physiological activators. Recombinant wild-type and FXII309Lys variants were expressed in S2 insect (Drosophila) cells. Amidolytic and fibrin generation assays were performed in fresh plasma samples. FXII309Lys samples exhibited an increased electrophoretic mobility comparable with N-glycan-deficient FXII from CDG patients and asialo-FXII generated by neuraminidase treatment. They presented increased sensitivity to activation by dextran sulphate and silica which resulted in the generation of an aberrant 37-kDa heavy chain. We did not observe increased susceptibility of FXII309Lys to proteolysis by exogenous or tPA-generated plasmin. However, both exogenous and endogenous thrombin cleaved the FXII309Lys variant, releasing a 37-kDa fragment and resulting in enhanced proteolytic activation on the fluid phase. This model supports a sequential proteolytic activation process involving thrombin priming of FXII309Lys, followed by kallikrein cleavage and generation of active ßFXIIa. The present results and the observation that angioedema episodes in HAE-FXII patients occur predominantly during hypercoagulable situations suggest a key role for thrombin.

When genetic and surname analyses meet historical sources: The C56R mutation associated with factor XI deficiency as a marker of human migration during the Spanish Reconquista.

The C56R mutation associated with factor XI deficiency has been first evidenced in individuals from the French Basque Country. Genetic investigations revealed that this mutation occurred about 5400 years ago as a founder effect in this zone. Other cases were subsequently described in Southwestern Europe. Noticeably a cluster of cases was evidenced in Yecla, a small city from the province of Murcia, in Southeastern Spain. In correlation with historical sources our genetic data and surname analysis argue for associating this mutation with the migration of people from Western Pyrenees (and more probably from the Navarra province) toward Southeastern Spain during the Reconquista period.

High incidence of FXI deficiency in a Spanish town caused by 11 different mutations and the first duplication of F11: Results from the Yecla study.

INTRODUCTION: Factor XI (FXI) deficiency is a rare disorder with molecular heterogeneity in Caucasians but relatively frequent and molecularly homogeneous in certain populations. AIM: To characterize FXI deficiency in a Spanish town of 60 000 inhabitants. METHODS: A total of 324 764 APTT tests were screened during 20 years. FXI was evaluated by FXI:C and by Western blot. Genetic analysis of F11 was performed by sequencing, multiplex ligation-dependent probe amplification and genotyping. RESULTS: Our study identified 46 unrelated cases and 170 relatives with FXI deficiency carrying 12 different genetic defects. p.Cys56Arg, described as founder mutation in the French-Basque population, was identified in 109 subjects from 24 unrelated families. This mutation was also identified in 2% of the general population. p.Cys416Tyr, c.1693G>A and p.Pro538Leu were identified in 7, 6 and 2 unrelated families, respectively. NGS analysis of the whole F11 gene revealed a common haplotype for each of the four recurrent mutations, suggesting a founder effect. The analysis of plasma FXI of four p.Pro538Leu homozygous carriers revealed that this variant was not activated by FXIIa. We identified four mutations previously described in other Caucasian subjects with FXI deficiency (p.Lys536Asn; p.Thr322Ile, p.Arg268Cys and c.325G>A) and four new gene defects: p.(Cys599Tyr) potentially causing a functional deficiency, p.(Ile426Thr), p.(Ile592Thr) and the first worldwide duplication of 1653 bp involving exons 8 and 9. Bleeding was rare and mild. CONCLUSIONS: Our population-cohort study supplies new evidences that FXI deficiency in Caucasians is more common than previously thought and confirmed the wide underlying genetic heterogeneity, caused by both recurrent and sporadic mutations.

A new method to quantify ß-antithrombin glycoform in plasma reveals increased levels during the acute stroke event.

INTRODUCTION: ß-antithrombin, the minor antithrombin glycoform in plasma, is probably the major thrombin inhibitor in vivo because of its high heparin affinity. The levels and variability of this glycoform in general population and its relevance in thromboembolic diseases is unknown since there is no specific method to measure this glycoform in clinical samples. METHODS: Plasma and recombinant α- and ß-antithrombins were purified by heparin affinity chromatography. An anti-FXa chromogenic method in presence of pentassacharide was used with two NaCl concentrations (15mM and 1.1M). This method was applied to plasma samples from 97 healthy subjects and 117 consecutive patients with ischemic cerebrovascular disease during the acute event and one year later. SERPINC1 sequencing was done in cases with antithrombin deficiency. RESULTS: High salt concentrations specifically restricted the pentassacharide-induced activation of antithrombin to the ß glycoform. ß-antithrombin displayed a normal distribution in the general population (89.5%-103.5%), with no significant variations according to age or sex. In patients, whole antithrombin values remained within the normal range. Only five cases had antithrombin deficiency during the thrombotic event, one carrying the L99F mutation in SERPINC1. Interestingly, both ß-antithrombin and the ß/whole antithrombin ratio were significantly higher in patients during the acute event but normalized after one year. CONCLUSIONS: We have developed a rapid, simple, sensitive and specific method to quantify ß-antithrombin activity using 1µL of plasma. ß-antithrombin significantly increases in patients with ischemic cerebrovascular disease during the acute event, probably by its release from the vasculature.

Heparin affinity of factor VIIa: implications on the physiological inhibition by antithrombin and clearance of recombinant factor VIIa.

Factor VIIa (FVIIa), a trypsin-like serine protease, plays an essential role in haemostasis by initiating the coagulation in complex with its cofactor, tissue factor (TF). The TF pathway inhibitor is the main physiological inhibitor of FVIIa-TF complex, but FVIIa can also be inhibited by antithrombin, although little is known about this process. Functional analyses by second order kinetic determination and identification of FVIIa-antithrombin complex by electrophoresis, evaluating the effect of different cofactors: pentasaccharide, low molecular weight heparin (LMWH) and unfractionated heparin (UFH), confirmed that any activation of antithrombin significantly enhanced the inhibition of FVIIa. The analysis of the binding of FVIIa to heparin by surface plasmon resonance identified a high affinity interaction under physiologic conditions (K(D)=3.38 µM, with 0.15M of ionic strength) strongly dependent on Ca(2+) and ionic strength. This interaction was verified in cell models, indicating that FVIIa also binds to the surface of endothelial cells with similar requirements. Structural modeling suggests the presence of a potential exosite II in FVIIa. However, the binding of heparin did not display significant changes on both the intrinsic fluorescence and the associated functional consequences of FVIIa. These results indicate that FVIIa binds to exposed glycosaminglycans of the endothelium through an exosite II, structurally similar to that reported for thrombin and suggested for FIXa. This binding may favor its inhibition by antithrombin in the absence of TF, contributing to the physiological control of this protease. This process may also play an important role in the clearance of recombinant FVIIa administered to patients.

Effect of citrullination on the function and conformation of antithrombin.

Antithrombin is an anticoagulant serpin with conformational sensitivity. Mutations and environmental factors may induce its polymerization by a mechanism involving domain swapping, which still requires verification. We have evaluated the functional and conformational effects on antithrombin of citrullination, a post-translational modification catalyzed by peptidylarginine deiminase (PAD), which changes arginine to citrulline. Purified antithrombin (native and latent forms) and plasma were incubated with PAD in the presence and absence of heparin. Citrullines were identified by proteomic analysis. Anti-activated factor X activity determination, IEF, SDS/PAGE and native PAGE were performed. The cleavage pattern with the metalloprotease AspN was studied, and its target residues were identified by Edman sequencing. We confirmed that citrullination of antithrombin abolished its activity; this abolition of activity was accelerated by heparin, which facilitated the early citrullination of Arg393 (P1 residue). Proteomic analyses revealed nine additional citrullines that caused a significant decrease in its electrostatic potential (from 5.95 to 5.06). It was demonstrated that citrullination of antithrombin caused its polymerization. The observation that these polymers, like heat-generated polymers, are cleaved by AspN in helix I is compatible with their linkage by domain swapping from strand 5 to strand 4 of beta-sheet A.

Effects of acrolein, a natural occurring aldehyde, on the anticoagulant serpin antithrombin.

We studied the effect of acrolein, an alpha,beta-unsaturated aldehyde that causes adduct-modification of lysine, cysteine, and histidine residues, on antithrombin, a key anticoagulant serpin. Intrinsic fluorescence, functionality (anti-FXa and anti-IIa activity), heparin affinity and conformational features of plasma and purified antithrombin were evaluated. In vivo experiments were carried out in mice. Intrinsic fluorescence showed a two-step conformational change. Acrolein, even at low dose, impaired the anticoagulant function of purified antithrombin by affecting its heparin affinity. However, higher concentrations of acrolein and long incubations are required to cause mild functional effects on plasma antithrombin and mice.

Dexamethasone induces a heat-stress response that ameliorates the conformational consequences on antithrombin of L-asparaginase treatment.

BACKGROUND: L-asparaginase (L-ASP) treatment of patients with acute lymphoblastic leukemia causes a severe antithrombin deficiency by intracellular retention of this serpin within the endoplasmic reticulum (ER) of hepatic cells, and a subsequent risk of thrombosis. Interestingly, co-administration of dexamethasone with L-ASP seems to reduce the risk of thrombosis. OBJECTIVES: We have investigated the effect of two corticoids, dexamethasone and prednisone, on the conformational consequences of L-ASP treatment on antithrombin. PATIENTS/METHODS: Levels, activity, conformation and immunohistological features of antithrombin were studied in patients, cell and mice models. Because of the importance of the steroid receptor-heat stress response (HSR) axis, and the role of unfolded protein response (UPR) in conformational diseases, we also evaluated Hsp27, Hsp70, Hsp90, HSF-1 and ER chaperons (Grp78 and Grp94). RESULTS: In all models, L-ASP alone or in combination with prednisone caused the intracellular retention of antithrombin associated with a severe deficiency. In contrast, the combination of L-ASP with dexamethasone ameliorated both the deficiency and intracellular retention of the serpin, which is associated with increased expression of heat shock proteins and ER-chaperons. CONCLUSIONS: These results suggest a protective effect of dexamethasone on the conformational consequences of L-ASP on antithrombin as a result of exacerbated HSR and UPR that help to explain the reduced risk of thrombosis reported in patients that follow this scheme of treatment.

Tratamiento endoluminal de pseudoaneurisma de aorta torácica tras cirugía abierta de coartación / Edoluminal repair ofthoracic aortic pseudoaneurysm after coarctation open surgery

La formación de un pseudoaneurisma es una de las complicaciones tardías posibles y no infrecuentes de la reparación abierta de las coartaciones de aorta y que comporta una alta morbimortalidad. Presentamos un caso de pseudoaneurisma de aorta torácica con clínica de hemoptisis masiva que fue tratado con éxito mediante la implantación de una endoprótesis aórtica tipo Zenith TX2 (Cook). En la discusión se comentan los diversos factores predictores de la aparición de estos pseudoaneurismas, el seguimiento preciso para diagnosticarlos a tiempo y las posibilidades terapéuticas actuales a la hora de abordar esta grave complicación tardía (AU)

The pseudoaneurysm develop is a late complication of coarctation open repair and bear high morbility and mortality. We show a thoracic aortic pseudoaneurysm case with massive hemoptysis treated with Zenith TX2 (Cook) stent-graft repair. We speak about predictors of this pseudoaneurysm formation, follow up and therapeutic possibilities for approach this problem (AU)

Distribución de lesiones traumáticas en los festejos taurinos: hacia una racionalización d ela asistencia / Bullfights injurys distribution: Towards assistance aproach

OBJETIVOS. Conocer la frecuencia y distribución de las lesiones traumáticas que acontecen durante la lidia de reses bravas así como ofrecer una clasificación de las mismas que comporte una actitud terapéutica en el lugar del accidente. PACIENTES Y MÉTODOS. Se revisan los partes facultativos emitidos en todos los festejos taurinos profesionales celebrados en España durante los años 2005 y 2006, y se analizan los datos referentes a su frecuencia, tipología, topografía y pronóstico. RESULTADOS. Se registran 412 lesiones en 365 lesionados. Las lesiones más frecuentes son: cornadas (39´56%), fracturas óseas (12´62%), heridas (11´89%), puntazos (8´74%), varetazos/ contusiones (7´52%), esguinces (6´06%), luxaciones (4´36%) y TCE (3’15%). Encontramos lesionados con parte facultativo emitido en el 8´05% de los festejos, si bien en las plazas de primera categoría esta frecuencia se eleva al 15´17%. Se presenta una clasificación de los lesionados en 4 grupos o categorías que comportan una orientación tipológica, pronóstica y una actitud terapéutica en el lugar del accidente. CONCLUSIÓN. El tratamiento definitivo de estos lesionados obliga a un abordaje multidisciplinar que en gran número de casos no es posible realizar en el lugar del accidente. Por ello creemos que un planteamiento “ABCD” como el que se ofrece, contribuye a una mejor comprensión de estos percances y a una racionalización de su asistencia (AU)

Our objective is to know frecuency and distribution of injurys during bullfights, and present an injured person clasification according to treatment on accident place. ETHODS. We rewiew all phisician reports emited in spanish bullfights during the period 2005-2006, recording frecuency, tipology, topography and forecast injury dates. RESULTS. We record 412 injurys in 365 injured persons. The principal injurys are: “cornadas” (39´56%), bony fractures (12´62%), wounds (11´89%), “puntazos” (8´74%), contusions (7´52%), sprains (6´06%), dislocations (4´36%) and craneoencefalic injurys (3´15%). 8´05% of bullfights bear with injured persons and 15´17% at first category bullfights. We offer an injured persons classification in four groups in order to tipology, forecast and treatment on accident place. CONCLUSIONS. Definitive treatment of this injurys involve several medical specialists and treatment on accident place is not ever possible. In this way, an “ABCD” aproach can contribute to a better understanding and treatment of this injurys (AU)

In vivo effects of hyperthermia on the functional and conformational characteristics of antithrombin.

BACKGROUND: High temperatures produce in vitro transitions of antithrombin to its inactive latent and polymeric forms. Accordingly, high body temperatures might contribute in vivo to conformational changes in antithrombin associated with increased thrombotic risk. METHODS: We assessed the in vivo effects of different hyperthermic stimuli on antithrombin. We studied two mouse models of hyperthermia. (i) Febrile syndrome induced by turpentine. (ii) Heat stroke generated by exposure to 42 degrees C. Body temperatures were measured. Antigen, anti-factor Xa activity and conformational features of plasma antithrombin were studied. Furthermore, structural and ultrastructural features from livers were analyzed. Intracellular retention of serpins (antithrombin and alpha1-antitrypsin) was studied by western-blotting, immunohistochemistry, and immunogold-labeling-electron microscopy. RESULTS: Hyperthermic stimuli caused a moderate deficiency of circulating antithrombin and a slight increase in its latent form. Moreover, hyperthermia caused intracellular retention of antithrombin into aggregates within the lumen of the endoplasmic reticulum of hepatocytes. This effect was similar for alpha1-antitrypsin. CONCLUSION: Hyperthermia causes minor conformational changes on circulating antithrombin in vivo, although it has severe consequences for intracellular antithrombin and other hepatic serpins, inducing the intracellular retention of the nascent protein. These effects may contribute to the moderate plasma deficiency of antithrombin and the increased thrombotic risk detected in hyperthermic conditions.

Glucación no enzimática de la antitrombina. Implicaciones en el riesgo trombótico de pacientes con diabetes mellitus / Non-enzymatic antithrombin glycation. Association with atherothrombotic risk in diabetic patients

Introducción/objetivos. La glucación no enzimática incorpora azúcares a los residuos lisina y arginina de proteínas, lo que puede alterar su función. La glucación de la antitrombina, un potente anticoagulante natural, podría asociarse con el riesgo trombótico observado en situaciones de hiperglucemia, como la diabetes mellitus. Nuestro objetivo fue estudiar el efecto de la glucación de la antitrombina y determinar si es relevante en las complicaciones trombóticas de la diabetes mellitus. Métodos. 1. Glucación no enzimática in vitro de antitrombina plasmática y purificada con metilglioxal y glucosa. 2. Se analizó el efecto de diferentes compuestos sobre la glucación no enzimática de la antitrombina in vitro. 3. Estudio de 101 pacientes diabéticos. En todas las muestras se analizaron los valores antigénicos, la actividad anti-FXa, las características conformacionales y la afinidad a la heparina de la antitrombina. Resultados. La glucación no enzimática in vitro de la antitrombina con metilglioxal o glucosa no ocasiona modificaciones conformacionales significativas en la molécula, pero induce su transformación a una forma con baja afinidad por la heparina, que explica la pérdida significativa de su actividad (valor < 40% del basal). Este efecto se previene con heparina, aminoguanidina y catequina. Los pacientes diabéticos muestran menores valores antigénicos y funcionales de antitrombina (80%) que los sujetos controles, pero esta disminución no se correlaciona con la glucemia ni con los valores de hemoglobina glucosilada. Conclusiones. La glucación de residuos lisina y arginina localizados en el sitio de unión a la heparina de la antitrombina reduce significativamente su actividad anticoagulante, aunque puede ser protegida por la heparina, la aminoguanidina y la catequina. Sin embargo, la relevancia de la glucación de la antitrombina en pacientes diabéticos es apenas perceptible debido a la lenta acción glucante de la glucosa, y a la reducida vida media de la antitrombina (AU)

Introduction/Aims. Non-enzymatic glycation of proteins can impair their function by incorporating sugars into their lysine and arginine residues. Glycation of antithrombin, a powerful anticoagulant, might be associated with the thrombotic risk observed in hyperglycemic conditions such as diabetes mellitus. Our aim was to study the effects of antithrombin glycation and determine its significance in the thrombotic complications observed in diabetes. Methods. 1) In vitro study of non-enzymatic glycation of purified and plasma antithrombin by their incubation with methylglyoxal and glucose. 2) The effect of different compounds on the in vitro glycation of antithrombin was analyzed. 3) We studied 101 diabetic patients. Antigen levels, anti-FXa activity, conformational features and antithrombin affinity to heparin were determined. Results. In vitro non-enzymatic glycation of antithrombin with methylglyoxal or glucose caused no significant conformational change in the molecule, but induced the transformation to a low heparin-affinity form, which explains the significant loss of activity observed (< 40% of basal). This effect was prevented by heparin, aminoguanidine and catechin. Diabetic patients presented lower antigenic and antithrombin functional levels (80%) than controls. However, no correlation between activity or antigen levels of antithrombin and glycemia or glycosylated hemoglobin was found in diabetic patients. Conclusions. In vitro glycation of lysine and arginine residues located in the heparin-binding site of antithrombin significantly reduces its anticoagulant activity. Interestingly, heparin, aminoguanidine and catechin prevented this effect. However, the non-enzymatic glycation of antithrombin in diabetic patients seems to be mild, since the action of glucose is very slow and the half life of antithrombin in plasma is short (AU)

Efficacy and safety of a phytoestrogen preparation derived from Glycine max (L.) Merr in climacteric symptomatology: a multicentric, open, prospective and non-randomized trial.

A multicentric, open, prospective, observational and no-randomized clinical trial was carried out in Spain with 190 postmenopausal women receiving a soy preparation rich in isoflavones (PHYTO SOYA, capsules containing 17.5 mg isoflavones). The main object of the present study was to investigate its efficacy in alleviating the symptomatology derived from the lack of estrogen, mainly hot flushes, but also other symptoms such as sleep disorder, anxiety, depression, vaginal dryness, loss of libido and bone pain. Each patient received 35 mg isoflavones per day in two doses. During the four months' treatment, a statistically significant decrease in the number of hot flushes with PHYTO SOYA was experienced by 80.82% women; only 5,48% patients did not improve with the treatment. The average reduction was 47.8%, which is equivalent to 4 hot flushes. All the other studied parameters also showed a statistically significant decrease. No severe side-effects were reported and tolerance was excellent. Treatment with PHYTO SOYA resulted in a significant improvement of the symptomatology that accompanies the lack of estrogen during menopause.