Rates of serum level determinations of antiepileptic drugs in accord with guidelines: A clinical study at a tertiary center.

OBJECTIVE: To compare our rates of appropriate therapeutic drug monitoring (TDM) with those defined in the French guidelines for measuring drug levels of antiepileptic drugs (AEDs) during the pre- and post-medical/pharmaceutical interventional periods. METHODS: This study was prospectively carried out at a tertiary center (epilepsy unit of the Pitié-Salpêtrière Hospital in Paris) between 2013 and 2016 over three time periods. Criteria for appropriateness were those stated in the current French guidelines. The main outcome measure was the percentage of drug level measurements with an appropriate indication, while a second outcome measure was the impact of education on clinical practice. RESULTS: Of the 698 AED level measurements requested, 84% overall were found to have appropriate indications ranging from 75% to 90%, according to French guideline criteria. Rates of appropriate indications for the three most commonly used individual AEDs-valproate, carbamazepine and lamotrigine-were 79.6%, 77.3% and 90.7%, respectively, whereas the requests considered to not have an appropriate indication involved the majority (63.5%) of cases of routine drug monitoring. In addition, dedicated education seems to substantially increase rates of appropriateness. CONCLUSION: At our center, 84% of AED level determinations had an appropriate indication according to a priori defined and reliable criteria. Moreover, it was noted that a specific educational intervention substantially increased rates of appropriateness. Thus, it appears to be crucial to ensure that medical and paramedical staff are aware of the official recommendations to avoid taking unnecessary drug level measurements.

Long-term, high-level hepatic secretion of acid α-glucosidase for Pompe disease achieved in non-human primates using helper-dependent adenovirus.

Pompe disease (glycogen storage disease type II (GSD-II)) is a myopathy caused by a genetic deficiency of acid α-glucosidase (GAA) leading to lysosomal glycogen accumulation causing muscle weakness, respiratory insufficiency and death. We previously demonstrated in GSD-II mice that a single injection of a helper-dependent adenovirus (HD-Ad) expressing GAA resulted in at least 300 days of liver secretion of GAA, correction of the glycogen storage in cardiac and skeletal muscles and improved muscle strength. Recent reports suggest that gene therapy modeling for lysososomal storage diseases in mice fails to predict outcomes in larger animal models. We therefore evaluated an HD-Ad expressing GAA in non-human primates. The baboons not only tolerated the procedure well, but the results also confirmed that a single dose of the HD-Ad allowed the livers of the treated animals to express and secrete large amounts of GAA for at least 6 months, at levels similar to those achieved in mice. Moreover, we detected liver-derived GAA in the heart, diaphragm and skeletal muscles of the treated animals for the duration of the study at levels that corrected glycogen accumulation in mice. This work validates our proof-of-concept studies in mice, and justifies future efforts using Ad-based vectors in Pompe disease patients.

[Nutritional status in patients with recurrent glioblastoma]. / Évaluation du statut nutritionnel chez les patients présentant un glioblastome en récidive.

INTRODUCTION: Nutritional status is a major clinical parameter in multiple cancers. Indeed, nutritional status is a prognostic factor and a predictor of response and toxicity to treatments in breast and lung cancers for instance. To our knowledge, in patients suffering from malignant primary brain tumors, nutritional status has been poorly investigated. METHODS: Nutritional status of 26 glioblastoma patients relapsing after a first line of treatment was studied. The body mass index (BMI), the prognostic inflammatory and nutritional index (PINI) and the instant nutritional score (INS) were assessed. RESULTS: The BMI was abnormal in 12 patients, two were malnourished while 10 were overweight. The BMI was not correlated to age of patients. Overweight status did not impact patient survival but it was associated with reduced performance status. The PINI was abnormal in three patients. Finally, the INS was abnormal in 24 patients, noted 2 (n=22) or 4 (n=4). CONCLUSIONS/DISCUSSION: Our results were not in favor of systematic nutritional support in patients with recurrent glioblastoma after a first line of treatment. Being overweight does not influence prognosis but may influence performance status. Steroid therapy and chemotherapy (inducing sodium and water retention and lymphopenia) weaken the relevance of BMI and INS for nutritional assessment in patients with recurrent glioblastoma. Further studies using additional nutritional tests in larger, independent and prospective cohorts of patients are warranted to obtain more details.

[An evaluation of fatigue in patients with glioblastoma relapse treated with the combination of irinotecan-bevacizumab]. / Évaluation de la fatigue dans les glioblastomes en récidive traités par l'association irinotécan-bévacizumab.

OBJECTIVE: The combination of irinotecan-bevacizumab is effective in patients with glioblastoma relapse but fatigue is a commonly reported side effect. The objective of this study was to evaluate the level and evolution of fatigue in a series of patients treated with therapeutic combination. PATIENTS AND METHODS: We used two self-evaluation tools to quantify the physical and emotional aspects of this fatigue. The Norris Visual Analog Scale (VAS Norris) and the Multidimensional Fatigue Inventory-20 (MFI) tools were undertaken by 39 patients with glioblastoma relapse treated with irinotecan-bevacizumab, initially before the first cycle and thereafter with each cycle up until tumor progression. RESULTS: Analysis of the results of the VAS Norris scale did not demonstrate an increase in emotional fatigue but did show an increase in physical fatigue that did not reach statistical significance. With regards to the MFI 20 tool, analysis of the results demonstrated a significant increase in general (P=0.0260) as well as physical (P=0.0141) fatigue but there was no difference in the other indices. CONCLUSION: This study demonstrated a progressive increase in physical fatigue in patients with glioblastoma relapse treated with irinotecan-bevacizumab. We suspect that this is as a direct consequence of the treatment. There are however other confounding factors: insidious tumour progression not detected on follow-up imaging or delayed side effects of the initial radiotherapy-chemotherapy.

Amphiregulin and nerve growth factor expression are regulated by barrier status in murine epidermis.

Disruption of the murine permeability barrier by solvents or tape stripping stimulates a homeostatic repair response that includes increased epidermal DNA synthesis. To identify potential mediators of the increase in DNA synthesis, we have measured epidermal levels of mRNAs encoding various growth factors after acute barrier disruption. In this study, mRNAs for amphiregulin and nerve growth factor were each shown to increase over controls at 30 min, reach peak levels of 12- to 30-fold at 1-2 h, and return to control levels by 6 h after tape stripping. A similar time course for the increase of amphiregulin and nerve growth factor mRNAs was observed after an unrelated form of barrier disruption, i.e., acetone treatment. Furthermore, artificial restoration of the barrier by Latex occlusion, immediately following barrier disruption by acetone treatment, inhibited the increase in epidermal amphiregulin and nerve growth factor mRNA levels, indicating that barrier status regulates the production of these growth factors. In contrast, mRNA levels of transforming growth factor-beta1, an inhibitory growth factor, were unchanged at early times and decreased by 53% (p < 0.02) 6 h after tape stripping, whereas mRNA levels of transforming growth factor-alpha remained unchanged at all times after acute barrier disruption. These results suggest that barrier disruption stimulates the expression of amphiregulin and nerve growth factor. Together, these regulators of keratinocyte growth and differentiation may be responsible for the increased proliferative response that is associated with barrier disruption.

[Endovascular treatment of aorto-iliac aneurysms. Made-to-measure endoprotheses increase the feasibility]. / Traitement endovasculaire des anévrismes aorto-iliaques. La confection astisanale sur mesure des endoprothèses augmente le taux de faisabilité.

The authors describe their experience of tailoring endoprostheses for endovascular treatment of aorto-iliac aneurysms with components available on the market. Between January 1996 and December 1999, 188 aorto-iliac aneurysms were treated by tailor-made endoprostheses using self-expanding Z stents made of stainless steel compiled with polyester ligatures and covered with standard commercially available polyester prostheses. These endoprostheses were implanted with an 18 to 24 Fr (usually 20 Fr) introducer and positioned by a surgical approach. This method allows construction of tubular, bifurcated, digressive or occlusive endoprostheses associated with an extra-anatomical bypass graft. It increased the number of endovascular procedures for aorto-iliac aneurysms in the authors' department. This number has been further increased by using endoprostheses with an uncovered proximal or distal stent for cases with particularly short or angled necks and by using hybrid endoprostheses with one or more extremities without a stent, allowing surgical suture of the anastomosis. The authors' results show that tailoring endoprostheses considerably increased the feasibility of endovascular treatment of aorto-iliac aneurysms, even in unselected patients whilst providing an effectiveness and safety to justify the continuation of this experience.

Digestive physiology of the pig symposium: G protein-coupled receptors in nutrient chemosensation and gastrointestinal hormone secretion.

The gastrointestinal tract is a highly effective and efficient organ system that digests and absorbs nutrients, contributes to the regulation of glucose homeostasis, and signals postprandial satiety. A network of enteroendocrine cells orchestrates these events through the release of neuropeptide hormones secreted in response to the specific nutrient components within the intraluminal milieu. Nutrient chemosensing by these cells is mediated by cell membrane proteins that have been localized to hormone-producing cells. However, functional studies of the nutrient detection abilities of the endocrine cell population have been limited due to its rare and singly distributed cell type. Recent technological advances have enabled investigations with primary endocrine cells that promise to enhance our current understanding of enteroendocrine cell biology. This review focuses on a particular subset of chemosensing receptors, the G protein-coupled receptors (GPCR), that have been identified as putative nutrient sensors of the major macronutrients, lipids, proteins, and carbohydrates by enteroendocrine cells. The contributions of these receptors in directly activating and stimulating hormone secretion in several subsets of enteroendocrine cells will be discussed, based on evidence gathered by functional studies in animal models, in vitro studies in endocrine cell lines, and newly described findings in primary endocrine cells. Key insights in chemosensory detection and hormone secretion from enteroendocrine cells may help further the studies in larger animal models and guide the formulation of feed or supplements to influence the gastrointestinal signals regulating optimal food intake, absorptive capacity, and growth.

Activation of vagal afferents in the rat duodenum by protein digests requires PepT1.

Intestinal infusion of protein digests activates a vago-vagal reflex inhibition of gastric motility. Protein digests release cholecystokinin (CCK) from enteroendocrine cells; however, the precise cellular mechanisms leading to vagal afferent activation is unclear. The hypothesis that the oligopeptide transporter PepT1 plays a major role in the initiation of this vago-vagal reflex was tested by recording activation of duodenal vagal afferent activity and inhibition of gastric motility in response to protein hydrolysates in the presence of 4-aminomethylbenzoic acid (4-AMBA), a competitive inhibitor of PepT1, or 4-aminophenylacetic acid (4-APAA), an inactive 4-AMBA analog. Duodenal infusion of the protein hydrolysate increased vagal afferent discharge and inhibited gastric motility; these responses were abolished by concomitant infusion of 4-AMBA, but not 4-APAA. Duodenal infusion with Cefaclor, a substrate of PepT1, increased duodenal vagal afferent activity; Cefaclor and protein hydrolysates selectively activated CCK-responsive vagal afferents. This study demonstrates that products of protein digestion increase spontaneous activity of CCK-sensitive duodenal vagal afferents via a mechanism involving the oligopeptide transporter PepT1.

Compensatory caspase activation in MPP+-induced cell death in dopaminergic neurons.

Many have hypothesized that cell death in Parkinson's disease is via apoptosis and, specifically, by the mitochondrial-mediated apoptotic pathway. We tested this hypothesis using a mouse dopaminergic cell line of mesencephalic origin, MN9D, challenged with the Parkinsonism-causing neurotoxin MPP+ (1-methyl-4-phenylpyridinium ion). Apoptosis was the main mode of cell death when the cells were subjected to MPP+ treatment under serum-free conditions for 24 h. Caspase-3 and caspase-9, however, were not activated, thus indicating the existence of alternate or compensatory cell death pathway(s) in dopaminergic neuronal cells. Using caspase inhibitors, we demonstrated that these pathways involve caspase-2, -8, -6 and -7. A time-course study indicated that activation of caspase-2 and -8 occurred upstream of caspase-6 and caspase-7. Upon MPP+ challenge, the apoptosis-inducing factor was translocated from the mitochondria into the MN9D cytosol and nucleus. These results suggest the existence of alternative apoptotic pathways in dopaminergic neurons.

Elucidation of the subunit orientation in CCT (chaperonin containing TCP1) from the subunit composition of CCT micro-complexes.

A collection of chaperonin containing TCP1 (CCT) micro-complexes that are comprised of subsets of the constitutively expressed CCT subunits have been identified. These CCT micro-complexes have mol. wts ranging from 120 to 250 kDa and are present in cells at lower abundance (<5%) as compared with intact CCT. Biochemical characterization of these microcomplexes has shown that several are comprised of two different types of CCT subunit. Furthermore, it was observed that each subunit associates with only one or two other different types of subunit, suggesting that each subunit has fixed partners. This observation, together with CCT gene counting being concordant with the 8-fold structural symmetry, is consistent with predictions derived from analysis of the primary structures of these subunits concerning inter-subunit interactions, and implies a unique topology of the subunits constituting the torodial ring in CCT. The series of subunit-subunit association patterns determined from CCT micro-complexes has provided information to infer, from the 5040 (7!factorial) combinatorial possibilities, one probable subunit orientation within the torodial ring.

The chaperonin containing TCP-1 (CCT) displays a single-ring mediated disassembly and reassembly cycle.

The chaperonin-containing TCP-1 (CCT) assists in the folding of actins and tubulins in eukaryotic cells. CCT is composed of 8 subunit species encoded by separate genes. CCT purifies as a single hetero-oligomeric protein complex of 950 kDa through multiple chromatographic and antibody affinity procedures. The CCT 16-mer contains 7 polypeptide species in equimolar amounts (CCTalpha, beta, gamma, delta, epsilon, zeta, eta), together with another subunit (CCTtheta) which is around half-molar. Here we show, by in vitro translation of CCT subunit mRNAs in rabbit reticulocyte lysate, that none of the CCT subunit proteins are themselves folded by CCT. However, the newly translated CCT subunits can incorporate into the endogenous CCT complex present in the lysate via a mechanism involving a nucleotide-dependent disassembly reaction to produce single-rings and then a reassembly reaction whereby free CCT subunits assemble onto these single-rings. This cycling behaviour is an inherent property of the CCT chaperonin complex and provides a powerful method for introducing single amino acid residue changes into this 8578 residue protein complex.

Identification of the major chromaffin granule-binding protein, chromobindin A, as the cytosolic chaperonin CCT (chaperonin containing TCP-1).

Chromobindin A is a multisubunit complex ATPase that binds to chromaffin granule membranes in a calcium-dependent manner and requires ATP for release from the membrane (Martin, W. H., and Creutz, C. E. (1987) J. Biol. Chem. 262, 2803-2810). Here we report that the seven previously characterized subunits of chromobindin A cross react with antisera specific to subunits of CCT, the chaperonin containing TCP-1 (Kubota, H., Hynes, G., Carne, A., Ashworth, A., and Willison, K. (1994) Curr. Biol. 4, 89-99). The chromobindin A subunits previously called chromobindins 12, 13, 14, 15, 16, 18, and 19 cross-react specifically with subunits beta, delta, theta, alpha, zeta, xi, and gamma, respectively, of CCT. Additional similarities in subunit molecular weights, isoelectric points, and the morphologies of the two protein complexes as determined by electron microscopy support identification of chromobindin A as an adrenal medullary form of CCT. The chromobindin A/CCT complex was found to bind at least 7-fold more efficiently to affinity columns of chromaffin granule membranes than of adrenal medullary cytosol proteins, suggesting a specific interaction occurs between the complex and membrane components. The results indicate that the previously described characteristics of chromobindin A are likely to be relevant to the functions of CCT and suggest that the adrenal medullary form of CCT may play a role in the activities of secretory vesicle membranes.

Accuracy of replacing three tapered transfer impression copings in two elastomeric impression materials.

The accuracy of replacing three manufacturers' (Dental Imaging Associates, Implant Innovations Inc, and Steri-Oss) tapered transfer impression copings into impressions made with two different materials (Impregum F and Extrude) was evaluated. Five operators replaced these copings into the elastomeric impression materials. The angular deviations (replacement error) of the copings between the control (original) position and the replaced position in the impressions were evaluated. It was found that no one coping could be replaced into the impressions accurately and consistently by all five operators. However, there were significant differences in replacement accuracy between the three copings. Lower angular deviations were found for the Steri-Oss and Dental Imaging Associates copings when compared to the Implant Innovations coping. There was no significant difference in replacement accuracy between the two impression materials.

Bioavailability of fluoride in postmenopausal women: comparative study between sodium fluoride and disodium monofluorophosphate-calcium carbonate.

Fluoride (F) increases trabecular bone mass and can be used in the treatment of osteoporosis with crush fractures. As the bioavailability of sodium fluoride (NaF) can be impaired by concomitant absorption of calcium, both drugs have to be ingested separately. However, disodium monofluorophosphate-calcium carbonate (MFP-Ca), another F compound, allows a single administration. In a cross-over randomized study, we compared the bioavailability of both drugs under regular conditions of prescription. Ten postmenopausal women (aged 48-77 years) with glomerular filtration rate (GFR) greater than 70 ml/minute and without bone disease entered the study. Each received 25 mg of NaF [i.e., 11.3 mg F ion (F-)] fasting and 100 mg of Na2FPO3-1250 mg CaCO3 (i.e., 13.2 mg F-) with breakfast in a single dose separated by an 8-day washout. After dosing, plasma F levels and fractionated and total urinary F collection were determined during a 24-hour period using a specific electrode. Results show a significant shorter lag time absorption (Tmax = 1.4 +/- 0.2 hour) and a higher maximal concentration (Cmax = 260 +/- 60 ng/ml) for MFP-Ca than for NaF (Tmax = 2.5 +/- 0.4 hour; Cmax = 200 +/- 85 ng/ml). However, areas under curve (AUC) for MFP-Ca (1711 +/- 195 micrograms/liter/hour) and for NaF (1202 +/- 147 micrograms/liter/hour) were not significantly different. The relative bioavailability of both F compounds related to their fluoride content (i.e., 1.22 for AUC ratio) was equivalent, according to the Westlake method. These data provide the first evidence of comparable bioavailability of two F compounds in a population of postmenopausal women.(ABSTRACT TRUNCATED AT 250 WORDS)

Complement activation and use of a cell saver in cardiopulmonary bypass.

Complement activation was evaluated in ten patients undergoing cardiopulmonary bypass (CPB) and intraoperative blood salvage with a cell saver (CS) to assess the inflammatory response related to the CS. The washed red blood cell concentrate was reinfused after protamine injection. Plasma C3a was measured by radioimmunoassay preoperatively, 5 min before CPB, at 5, 60, and 90 min during CPB, 5 min after protamine infusion, at the end of surgery, and after 24 hr. In addition, a clinical score based on renal, pulmonary, neurologic, and myocardial postoperative evolution was given (0-8) to every patient. Results were compared with the C3a changes and clinical scores obtained from 26 routine (no CS) cardiac surgical patients. Results showed maximal C3a generation after protamine and no further activation in cases of CS concentrate reinfusion, which ranged from 400 ml to 2,000 ml. No difference in clinical score was observed between the CS (1 +/- 1) and control (0.85 +/- 0.6) groups. The authors conclude that the CS does not enhance complement activation resulting from extracorporeal circulation and can be safely used as a blood saving strategy in cardiac surgery.

Factors affecting liver fibrosis in human immunodeficiency virus-and hepatitis C virus-coinfected patients: impact of protease inhibitor therapy.

Hepatitis C virus (HCV)-related liver fibrosis progression is accelerated in human immunodeficiency virus (HIV)-infected patients. The effect of protease inhibitor (PI) therapy on liver fibrosis is unknown. The aim of this work was to analyze the impact of PI therapy on HCV-related liver fibrosis in HIV/HCV coinfected patients. We evaluated in a long-term follow-up retrospective cohort study the influence of antiretroviral therapy containing PI on liver fibrosis in 182 consecutive HIV/HCV coinfected patients. At liver biopsy, 63 patients had received PI and 119 patients had never been treated with PI. Relationships between liver histologic features, age, alcohol consumption, CD4 cell count, HIV-RNA load, and antiretroviral regimens were analyzed. Liver fibrosis stage was lower in patients receiving PIs by comparison with patients who had never received PIs (P =.03). The 5-, 15-, and 25-year cirrhosis rates were 2% versus 5%, 5% versus 18%, and 9% versus 27%, respectively, in patients who had received PIs compared with PI-untreated patients (P =.0006). Multivariate analysis identified 4 independent predictors of progression to cirrhosis: absence of protease inhibitor therapy (relative risk [RR] = 4.74, 95% confidence interval [CI], 1.34-16.67), heavy alcohol consumption (> or = 50 g daily) (RR = 4.71, 95% CI, 1.92-11.57), low CD4 cell count (<200/microL) (RR = 2.74, 95% CI, 1.17-6.41), and age at HCV contamination (> or = 20 years) (RR = 2.37, 95% CI, 1.04-5.38). In conclusion, protease inhibitor therapy might not accelerate progression to HCV-related cirrhosis. Furthermore, chronic use of antiretroviral therapy containing PI together with reduction of alcohol consumption and maintenance of high CD4 count could have a beneficial impact on liver fibrosis progression in HIV/HCV coinfected patients.

Barrier disruption increases gene expression of cytokines and the 55 kD TNF receptor in murine skin.

The signalling mechanisms that regulate epidermal permeability barrier homeostasis are not known. Previous Northern blot analysis showed that both acute and chronic barrier disruption increase mRNA levels of several cytokines in murine epidermis. To further characterize the epidermal response to barrier abrogation, we used more sensitive, multi-probe RNase protection assays to measure the mRNA levels of additional cytokines, as well as cytokine receptors in acute and chronic models of barrier disruption. Normal mouse epidermis expressed interleukin (IL)-1 alpha, interferon-gamma (IFN-gamma), tumor necrosis factor-alpha (TNF-alpha) and IL-6 mRNAs. Following tape-stripping, only the mRNA levels for TNF-alpha, IL-1 alpha, IL-1 beta and IL-6 increased at 2.5 and 7 h, and returned toward normal levels by 18 h. No mRNAs encoding TNF-beta, IL-2, IL-3, IL-4 or IL-5, were detected in the epidermis either under basal conditions or after tape-stripping. Similarly, in a chronic model, essential fatty acid deficiency, epidermal levels of TNF-alpha, IL-1 alpha, IL-1 beta and IL-6 mRNAs, but not IFN-gamma mRNA, were elevated over controls; and again, mRNAs for the remaining probed cytokines were not detected. In contrast, in the dermis, only IL-1 beta mRNA levels increased 2.5 h after tape-stripping, and remained elevated at 18 h. mRNAs encoding the IL-1 (p60), IFN-gamma and IL-6 receptors were present in epidermis, but their levels remained unchanged following either acute or chronic barrier disruption. In contrast, epidermal TNF (p55) receptor mRNA levels were increased by 87% (P < 0.01) at 2.5 h, returned to control levels at 7 h and were increased by 68% (P < 0.03) at 18 h after tape-stripping. The increase at 2 h was confirmed by Northern blot analysis and was not prevented by latex occlusion performed immediately after tape-stripping mRNAs for the IL-1 (p80) receptor and TNF (p75) receptor were not detected in epidermis. Low levels of TNF (p55) receptor mRNA were present in the dermis, and they remained unchanged after tape-stripping. The presence of specific receptor mRNAs in the epidermis and dermis suggests that these tissues are capable of responding in an autocrine and/or paracrine fashion to the cognate cytokines. These results suggest that epidermal cytokines produced after barrier disruption may initiate a cytokine cascade which could regulate cytokine and cytokine receptor production and/or inflammatory responses.