Disparity of physician specialties in the management of chronic heart failure: trend analysis in Taiwan, 2000 - 2010.

OBJECTIVE: Chronic heart failure (CHF) is a condition that is daily confronted by clinicians in a variety of medical specialties, where physicians routinely seek optimum pharmacotherapy for their outpatients with CHF. We conducted a population- based study on pharmacotherapy for outpatients with CHF in Taiwan from 2000 to 2010, which focused on drug prescription patterns of different physician specialties. MATERIALS AND METHODS: We retrieved records from the National Health Insurance Research Database of patient ambulatory visits with diagnosed chronic heart failure, when cardiovascular drugs were prescribed. For purposes of this study, anti-chronic heart failure drugs were separated into categories: mortality reducing agents (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, ß-blockers, spironolactone, hydralazine plus nitrates) and symptom-relieving agents (digoxin, diuretics). Thereafter, the trends of prescription patterns related to different physician specialties were analyzed. RESULTS: From 2000 to 2010, the prescription rate of any mortality-reducing agent for CHF outpatients rose from 61.5% to 76.3% while the concomitant rate for digoxin decreased from 47.3% to 45.4%. Compared to internists and family physicians, cardiologists not only prescribed far more mortality-reducing agents from 2000 to 2010 (53.9 - 72.7%, 54.1 - 64.3%, 74.7 - 84.4%, respectively), but also prescribed two or three mortality-reducing drugs. CONCLUSION: There was a significant improvement of optimal pharmacotherapy for chronic heart failure in Taiwan. We observed that cardiologists were more aggressive than non-cardiologists when deciding whether to prescribe mortality-reducing drugs for heart failure management. However, those factors which influence the prescription patterns of internists and family physicians for their patients with CHF still require additional research.

A retrospective cohort study on the cardiotoxicity incidence rates of immune checkpoint inhibitors for oncology patients.

BACKGROUND: This present study investigated the incidence rates of cardiotoxicity among cancer patients treated with immune checkpoint inhibitors (ICIs) plus other anticancer drugs. METHODS: This was a retrospective hospital-based cohort study using the medical records and the Cancer Registry records from the Taipei Veterans General Hospital. We enrolled patients diagnosed with cancer between 2011 and 2017, who were over 20 years old and had received ICI therapy, including pembrolizumab, nivolumab, atezolizumab, and ipilimumab. Cardiotoxicity was defined by the diagnosis of myocarditis, pericarditis, arrhythmia, heart failure, and Takotsubo syndrome. RESULTS: We identified 407 patients who were eligible to participate in this study. We defined the three treatment groups as follows: ICI therapy, ICI combined with chemotherapy, and ICI combined with targeted therapy. Using ICI therapy as a reference group, the cardiotoxicity risk was not significantly higher compared to the ICI combined with chemotherapy group (adjusted hazard ratio 2.1, 95% confidence interval 0.2-21.1, p = 0.528] or to the ICI combined with targeted therapy group (adjusted hazard ratio 1.2, 95% confidence interval 0.1-9.2, p = 0.883). The total incidence rate of cardiotoxicity was 3.6 of 100 person-years, indicating an average incidence time of 1.0 ± 1.3 years (median: 0.5 years; range: 0.1-4.7 years) for 18 cardiotoxicity patients. CONCLUSION: The incidence rate of ICI-related cardiotoxicity is low. Combination of ICI with either chemotherapy or targeted therapy might not significantly increase the risk of cardiotoxicities among cancer patients. Nevertheless, it is recommend being careful in patients treated high-risk cardiotoxicity medications to avoid drug-related cardiotoxicity with a combination of ICI therapy.

Synemin down-regulation in human hepatocellular carcinoma does not destabilize cytoskeletons in vivo.

Synemin is a large intermediate filament protein that has been identified in all types of muscle cells. It plays a role in human muscle diseases; however, the role of synemin in tumor cell transformation has rarely been investigated. Because hepatocellular carcinoma cells are morphologically different from normal human hepatocytes, we hypothesized that altered synemin expression and cytoskeletal disorganization might underlie this pleomorphic transformation. To test this hypothesis, we studied synemin expression in hepatocellular carcinoma and liver tissues by immunohistochemistry and immunoblotting. In addition, we analyzed the expression level and organization of all cytoskeletal elements after synemin knock-down in human Chang liver cells. Previously we found that plectin knock-down in human Chang liver cells causes a reduction in cytokeratin 18 expression with effects on intermediate filament disorganization and altered cellular morphology. In this study we also compared the effects of synemin knock-down and plectin knock-down on the cytoskeleton expression and organization. The results revealed that synemin expression was down-regulated in human hepatocellular carcinoma compared with normal liver, which is similar to the plectin expression. Surprisingly, the expression of cytoskeletal elements (cytokeratin 18, actin and tubulin) was not influenced by synemin knock-down in human Chang liver cells. The organization of cytoskeletal networks was also unaltered after synemin knock-down. In conclusion, both plectin and synemin are down-regulated in human hepatocellular carcinoma in vivo and transformed human liver cell in vitro. However, the mechanism of cell transformation caused by synemin knock-down is different from that of plectin knock-down. Plectin, but not synemin, knock-down provoked liver cell transformation via suppressing cytokeratin 18 expression and disrupting intermediate filament networks. Synemin knock-down did not influence the cytoskeleton expression and organization of human Chang liver cells.

Cytokeratin 18-mediated disorganization of intermediate filaments is induced by degradation of plectin in human liver cells.

Plectin is a cross-linking protein that organizes the cytoskeleton into a stable meshwork that helps maintain the uniform size and shape of cells. As cells of hepatocellular carcinoma are morphologically different from healthy human hepatocytes, we hypothesized that plectin deficiency and cytoskeletal disorganization underlies this pleomorphic transformation. To test this hypothesis we induced apoptosis as the most accessible pathway for creating plectin deficiency status in vivo. We analyzed expression levels and organization of plectin and other cytoskeletal elements, including intermediate filaments, microfilaments, and microtubules, after staurosporine-induced apoptosis in human Chang liver cells. The results revealed the expression of plectin and cytokeratin 18 were downregulated in hepatocellular carcinoma tissues in vivo. The expression of actin and tubulin, however, were not altered. In vitro analysis indicated that plectin and cytokeratin 18 were cleaved following staurosporine-treatment of human Chang liver cells. Time course experiments revealed that plectin was cleaved 2h earlier than cytokeratin 18. The organization of plectin and cytokeratin 18 networks collapsed after staurosporine-treatment. Conclusively, degradation of plectin induced by staurosporine-treatment in liver cells resulted in cytoskeleton disruption and induced morphological changes in these cells by affecting the expression and organization of cytokeratin 18.

Plectin deficiency on cytoskeletal disorganization and transformation of human liver cells in vitro.

Plectin is a versatile cytoplasmic cross-linking protein that connects intermediate filaments to microfilaments, microtubules, and membrane adhesion sites. The cross-linking functions of plectin help organize the cytoskeleton into a stable meshwork important for maintaining uniformity in cell size and shape. As cells of hepatocellular carcinoma are morphologically different from normal human hepatocytes, we hypothesized that altered plectin expression and cytoskeletal organization underlies this pleomorphic transformation. To test this hypothesis, we analyzed expression levels and organization of all cytoskeletal elements, including intermediate filaments, microfilaments, and microtubules, after plectin knockdown in human Chang liver cells. We found that expression of cytokeratin 18, but not actin or tubulin, was downregulated by suppression of plectin protein. Furthermore, cytokeratin networks were partially collapsed and actin-rich stress fibers were increased. The organization of microtubule networks, by contrast, was unaltered. These findings support our hypothesis that, via effects on cytoskeletal organization, plectin deficiency might play an important role in the transformation of human liver cells.

Pre-existing chronic kidney disease and hypertension increased the risk of cardiotoxicity among colorectal cancer patients treated with anticancer drugs.

BACKGROUND: This population-based study was to investigate the potential risk factors of cardiotoxicity among colorectal cancer (CRC) patients treated with anticancer drugs. METHODS: This was a retrospective cohort study using the National Health Insurance Research Database to identify the CRC patients receiving chemotherapy (CT) alone or CT combined with targeted therapies between 2000 and 2013. The patients enrolled were those who had the first diagnosis of CRC established ≥20 years and had no cancer history three years before the incident diagnosis of CRC. The outcomes of cardiotoxicity were defined by the diagnosis of acute myocarditis, cardiomyopathy, heart failure, hypertensive heart disease, and so on. RESULTS: A total of 11 819 CRC patients were identified and 3781 were eligible; 556 (14.7%) patients developed cardiotoxicity after receiving anticancer treatment. Patients showed a similar risk of having primary outcome (hazard ratio [HR], 0.7; p = 0.3662) between CT and CT combined with targeted therapy groups, whereas the risk of developing secondary outcome was significantly different between the two groups (HR, 0.7; p = 0.0339). The hazard was found to be increased with age (60-69, HR 2.1, p = 0.0236; 70-79, HR 3.3, p = 0.0003; and ≥80, HR 3.7, p < 0.0001). CRC patients who had a prior history of hypertension exhibited a higher risk than those without hypertension (HR 1.6, p < 0.0001). The hazard of having cardiotoxicity among patients with a prior history of severe chronic kidney disease was 2.4 times than that in those without renal dysfunction, regardless of the stage of cancer (HR 2.4, p < 0.0001). CONCLUSION: CRC patients over 60 years of age run a higher risk of developing cardiotoxicity when treated with anticancer drugs. For CRC patients who have a previous history of hypertension or chronic kidney disease, physicians must be careful in evaluating the risk of anticancer drugs-related cardiotoxicity. Prescribe drugs may prevent cardiotoxicity if necessary.

Hematologic adverse drug reactions leading to hospitalization among cancer patients: A retrospective case-control study.

BACKGROUND: Cancer is one of the leading causes of death worldwide. Despite the rapid evolution of cancer treatment, chemotherapy remains the mainstay in the management of cancer. Chemotherapy can result in various adverse drug reactions (ADRs), which may lead to hospitalization and even life-threatening side-effects. Hematologic ADRs are among the most severe forms of ADR following chemotherapy, as they generally lead to hospitalization. It is important to realize the predictors and outcome of hematologic ADRs in cancer patients. METHODS: We conducted a hospital-based case-control study to include all the cancer patients who were hospitalized to receive chemotherapy in Taipei Veterans General Hospital during 2013. Among them the patients rehospitalized after chemotherapy due to neutropenia, leucopenia, or pancytopenia were identified as the study group. Control subjects consisted of hospitalized cancer patients who did not display the aforementioned ADRs. The study and control groups were numbered in the ratio of 1:4 and were age- and gender-matched. Their demographic and clinical characteristics were collected through chart review. Determinants of hematologic ADRs were then analyzed. RESULTS: During the study period, we collected a total of 64 patients into the study group and 256 as control subjects. The mean length of hospitalization was 11 days in the study group of patients, which was 5 days longer than that in the control group (p < 0.001). Predictors of hematologic ADR-related hospitalization included history of hematologic ADRs, hypertension, cisplatin treatment, and a Charlson comorbidity score of 2 to 3. CONCLUSION: Severe outcomes of hematologic ADRs may increase healthcare costs and decrease patient productivity. Therefore, the determinants of ADR-related hospitalization identified in this study may help improve the quality of healthcare for cancer patients.

Emodin induces apoptosis of human tongue squamous cancer SCC-4 cells through reactive oxygen species and mitochondria-dependent pathways.

Emodin was isolated from Rheum palmatum L. and exhibits an anticancer effect on human cancer cell lines, however, the molecular mechanisms of emodin-mediated apoptosis in human tongue cancer cells have not been fully investigated. In this study, treatment of human tongue cancer SCC-4 cells with various concentrations of emodin led to G2/M arrest through promoted p21 and Chk2 expression but inhibited cyclin B1 and cdc2; it also induced apoptosis through the pronounced release of cytochrome c from mitochondria and activations of caspase-9 and caspase-3. These events were accompanied by the generation of reactive oxygen species (ROS), disruption of mitochondrial membrane potential (delta psi(m)) and a decrease in the ratio of mitochondrial Bcl-2 and Bax content; emodin also promoted the levels of GADD153 and GRP78. The free radical scavenger N-acetylcysteine and caspase inhibitors markedly blocked emodin-induced apoptosis. Taken together, these findings suggest that emodin mediated oxidative injury (DNA damage) based on ROS production and ER stress based on the levels of GADD153 and GRP78 that acts as an early and upstream change in the cell death cascade to caspase- and mitochondria-dependent signaling pathways, triggers mitochondrial dysfunction from Bcl-2 and Bax modulation, mitochondrial cytochrome c release and caspase activation, consequently leading to apoptosis in SCC-4 cells.

Gallic acid inhibits murine leukemia WEHI-3 cells in vivo and promotes macrophage phagocytosis.

Gallic acid is a polyhydroxyphenolic compound which can be found in various natural products. It is recognized to be an excellent free radical scavenger and has been shown to induce apoptosis in lung cancer and leukemia cells. No report has addressed whether gallic acid affects mouse leukemia cells in vivo. In this study, we examined the in vivo effects of gallic acid on leukemia WEHI-3 cells and on macrophage phagocytosis. Gallic acid caused a significant decrease in the weights of the spleens and livers from BALB/c mice. One of the major characteristic of WEHI-3 leukemia is the enlarged spleen in mice after i.p. injection of WEHI-3 cells. Gallic acid did not affect the percentages of CD3, CD11 and CD19 markers but decreased the percentage of Mac-3 in a high-dose (80 mg/kg) treatment while promoting Mac-3 levels in a low-dose (40 mg/kg) treatment. Gallic acid promoted the activity of macrophage phagocytosis in the white blood cells from peripheral blood mononuclear cells (PBMCs) at 40 and 80 mg/kg treatment doses, but decreased the macrophage phagocytosis in isolated peritoneal cells at the 80 mg/kg dose.

The influence of plectin deficiency on stability of cytokeratin18 in hepatocellular carcinoma.

Intermediate filaments are important in building the cellular architecture. Previously we found cytokeratin18 was modulated in human hepatocellular carcinoma. Plectin is a cross-linking protein that organizes the cytoskeleton into a stable meshwork, which can maintain the uniform size and shape of hepatocytes. Because the cells of hepatocellular carcinoma were morphologically different from the hepatocytes, we speculated that expression of plectin and organization of intermediate filament might play roles in the pleomorphism of hepatocellular carcinoma cells. In this paper, we studied the plectin expression of hepatocellular carcinoma and liver tissues by immunohistochemistry and immunoblot. The results revealed that plectin was deficient and cytokeratin18 was modulated in hepatocellular carcinoma. Furthermore, we knockdown the plectin mRNA in Chang cells, the result revealed the plectin was deficient and the organization of cytokeratin18 was altered. Conclusively, this study offers a hypothesis that plectin deficient might play an important role in the tumorigenesis of hepatocellular carcinoma.

Diallyl disulfide (DADS) induces apoptosis in human cervical cancer Ca Ski cells via reactive oxygen species and Ca2+-dependent mitochondria-dependent pathway.

The mechanisms of apoptosis induced by diallyl disulfide (DADS) were explored in human cervical cancer Ca Ski cells. Flow cytometric analysis, DNA gel electrophoresis and DAPI staining demonstrated that DADS induced apoptosis in Ca Ski cells. DADS induced apoptosis through the production of reactive oxygen species and Ca2+, and induced abrogation of mitochondrial membrane potential (Deltapsim) and cleavage of Bid protein (t-Bid). DADS increased the levels of p53, p21 and Bax, but caused a decrease in the level of Bcl-2. DADS also promoted the activities of caspase-3 leading to DNA fragmentation, thus indicating that DADS-induced apoptosis is caspase-3 dependent. In addition, DADS induced an increase in the level of cytochrome c in the cytoplasm, which was released from mitochondria. BAPTA attenuated the Deltapsim abrogation and significantly diminished the occurrence of DADS-induced apoptosis in Ca Ski cells. In conclusion, DADS-induced apoptosis occurs via production of ROS and caspase-3 and a mitochondria-dependent pathway in Ca Ski cells.

Degradation of plectin with modulation of cytokeratin 18 in human liver cells during staurosporine-induced apoptosis.

BACKGROUND: Hepatoma cells are morphologically different from those of the normal liver. Intermediate filaments (IFs) are important in building the cellular architecture and maintaining the outline of cells. Plectin is a cross-linking protein that organizes the cytoskeleton into a stable meshwork, which can maintain the uniform size and shape of hepatocytes. Apoptosis might be the most possible pathway for creating plectin deficiency in the in vivo state. MATERIALS AND METHODS: Apoptosis was induced by staurosporine (STS) treatment in liver cells. The protein expression of cytokeratin 18 (CK18) and plectin as well as the morphology of the liver cells and the distribution of CK18 and plectin in the cells was studied after STS treatment. RESULTS: Plectin was cleaved in the liver cells during apoptosis and CK18 was modulated. Morphological changes were observed in the liver cells. CONCLUSION: By affecting the organization of IFs, plectin might play an important role in the pleomorphism of hepatoma cells and even the tumorigenesis of hepatoma.

Possible relation between histone 3 and cytokeratin 18 in human hepatocellular carcinoma.

BACKGROUND: Previously we found some low molecular weight proteins identified as histone in hepatocelluar carcinoma. Our objective was to clarify whether the coimmunoprecipitation of histone and cytokeratin 18 was an artifact or not. MATERIALS AND METHODS: Histone 3 and cytokeratin 18 were investigated in three cases of human hepatocellular carcinoma and one case of normal liver tissue. Nuclei of the tissues were isolated; the proteins inside the nuclei were analyzed by Western blot. RESULTS: The results revealed histone was co-immunoprecipitated with cytokeratin 18 in hepatocellular carcinoma. It was speculated that modulation of the cytoskeleton in human hepatocellular carcinoma might disturb the organization of the nucleoskeleton. The unstable nucleoskeleton might further cause instability and fragility of nuclei, thus possibly exposing the histone and co-immunoprecipitating it with cytokeratin 18. CONCLUSION: The evidence might indicate that expression of histone 3 was highly related to modulation of cytokeratin 18 and might play an important role in tumorigenesis of hepatocellular carcinoma.

Effects of curcumin on N-bis(2-hydroxypropyl) nitrosamine (DHPN)-induced lung and liver tumorigenesis in BALB/c mice in vivo.

Curcumin (diferuloylmethane), a phenolic compound from the plant Curcuma longa (Linn.) has been shown to exhibit antitumor activity and apoptosis in many human cancer cell lines including that of lung and liver cancer. In this study, curcumin was evaluated in BALB/c mice for its ability to inhibit pulmonary and liver adenoma formation and growth after they were orally treated with N-bis(2-hydroxypropyl)nitrosamine (DHPN). Animals were treated with DHPN in water for approximately 14 days before multiple doses of curcumin were given intraperitoneally. It was found that 200 microM curcumin reduced lung and liver tumor multiplicity by 37% (p<0.05) and 30% (p<0.05) respectively. The results indicated that curcumin significantly inhibited pulmonary and liver adenoma formation and growth in BALB/c mice. The precise mechanism by which curcumin inhibits lung and liver tumorigenesis remains to be elucidated. Thus, curcumin appears to be a promising new chemotherapeutic and preventive agent for lung and liver cancer induced by DHPN.

Effects of oral administration of berberine on distribution and metabolism of 2-aminofluorene in Sprague-Dawley rats.

The effects of berberine on the in vivo N-acetylation and metabolism of 2-aminofluorene (2-AF) in bladder, blood, colon, kidney, liver, feces and urine samples and brain tissues (cerebrum, cerebellum and pineal gland) of male Sprague-Dawley rats were investigated. Major metabolites, such as 1-OH-2-AAF, 3-OH-2-AAF, 8-OH-2-AAF and 9-OH-2-AAF were found in bladder tissues, 1-OH-2-AAF, 5-OH-2-AAF and 8-OH-2-AAF were found in blood samples, 1-OH-2-AAF, 3-OH-2-AAF, 5-OH-2-AAF, 8-OH-2-AAF and 9-OH-2-AAF were found in colon tissues, 1-OH-2-AAF, 3-OH-2-AAF and 9-OH-2-AAF were found in kidney tissues, 1-OH-2-AAF, 3-OH-2-AAF and 8-OH-2-AAF were found in liver tissues, 1-OH-2-AAF, 3-OH-2-AAF, 5-OH-2-AAF, 7-OH-2-AAF, 8-OH-2-AA and 9-OH-2-AAF were found in feces samples and 1-OH-2-AAF, 3-OH-2-AAF, 5-OH-2-AAF, 7-OH-2-AAF, 8-OH-2-AA and 9-OH-2-AAF were also found in urine samples, 1-OH-2-AAF, 3-OH-2-AAF and 8-OH-2-AAF were found in cerebrum tissues, 1-OH-2-AAF, 3-OH-2-AAF and 7-OH-2-AAF were found in cerebellum tissues. In the control group, however, only 2-AF and 2-AAF were found in pineal gland after rats had been orally treated with 2-AF (50 mg/kg) for 24 h. Pre-treatment of male rats with berberine (40 mg/kg) 24 h prior to the administration of 2-AF (50 mg/kg), as well as the co-administration of berberine and 2-AF led to a decrease in the amounts of 3-OH-2-AAF and an increase in the amounts of 8-OH-2-AAF in bladder tissues. In blood samples, there were significant decreases of 2-AF, 2-AAF, 1-OH-2-AAF and 8-OH-2-AAF, after rats were pre-treated with berberine for 24 h before the addition of 2-AF. However, co-administration of berberine and 2-AF led to an increase in the amounts of 5-OH-2-AAF. In colon tissues, there were significant decreases of 2-AF, 2-AAF, 1-OH-2-AAF and 8-OH-2-AAF in colon samples after rats were treated with berberine for 24 h before the addition of 2-AF. 2-AF, 1-OH-2-AAF, 3-OH-2-AAF and 9-OH-2-AAF levels were significantly different between control and the group treated with berberine and 2-AF at the same time. In kidney tissues, significant decreases of 2-AF and 2-AAF and of 3-OH-2-AAF were observed after rats were treated with both compounds separately and simultaneously. However, 24 h berberine pre-treatment followed by addition of 2-AF led to significant increase of 9-IH-2-AAF. In liver tissues, there were significant decreases of 2-AAF and 1-OH-2-AAF, after co-administration of berberine and 2-AF. The amounts of 2-AAF, 1-OH-2-AAF and 3-OH-2-AAF were significantly different between the control and the group pretreated with berberine 24 h before the addition of 2-AF. In the feces samples, there were significant decreases of 2-AAF, 3-OH-2-AAF, 7-OH-2-AAF, 8-OH-2-AAF and 9-OH-2-AAF after co-administration of berberine and 2-AF. However, the berberine pre-treatment followed by addition of 2-AF led to a significant increase of 2-AF, 2-AAF and 1-OH-2-AAF levels. In urine samples, there were significant differences of 2-AF, 2-AAF, 1-OH-2-AAF, 3-OH-2-AAF, 5-OH-2-AAF, 8-OH-2-AAF and 9-OH-2-AAF after the co-treatment. However, berberine treatment followed by 2-AF led to significant differences in 1-OH-2-AAF and 5-OH-2-AAF levels. In the cerebrum samples, there were significant differences in 1-OH-2-AAF and 8-OH-2-AAF after both berberine co-treatment and pre-treatment. In cerebellum samples, there were also significant differences in the 1-OH-2-AAF and 3-OH-2-AAF levels after both co- and pretreatment. In pineal gland samples, there were significant differences in 2-AAF levels after co-treatment with berberine and 2-AF and 1-OH-2-AAF was also found in both groups. However, berberine pre-treatment followed by 2-AF led to different levels of 2-AF and 2-AAF, but not of 3-OH-2-AAF.

Effects of ellagic acid by oral administration on distribution and metabolism of 2-aminofluorene in Sprague-Dawley rats.

The effects of ellagic acid on the in vivo N-acetylation and metabolism of 2-aminofluorene (2-AF) were investigated in bladder, blood, colon, kidney, liver, feces and urine samples from male Sprague-Dawley rats. Major metabolites such as 1-OH-2-AAF, 8-OH-2-AAF and 9-OH-2-AAF were found in bladder tissues, 1-OH-2-AAF, 5-OH-2-AAF and 8-OH-2-AAF were found in blood samples, 1-OH-2-AAF, 3-OH-2-AAF, 5-OH-2-AAF, 8-OH-2-AAF and 9-OH-2-AAF were found in colon tissues, 1-OH-2-AAF, 3-OH-2-AAF and 9-OH-2-AAF were found in kidney tissues, 1-OH-2-AAF, 3-OH-2-AAF and 8-OH-2-AAF were found in liver tissues, 1-OH-2-AAF, 3-OH-2-AAF, 5-OH-2-AAF and 8-OH-2-AAF were found in feces samples and 1-OH-2-AAF, 3-OH-2-AAF, 5-OH-2-AAF and 8-OH-2-AAF were also found in urine samples after rats had been orally treated with 2-AF (50 mg/kg) for 24 h. Pretreatment of male rats with ellagic acid (10 mg/kg) 24 h prior to the administration of 2-AF (50 mg/kg) resulted in absence of 8-OH-2-AAF in bladder tissues, and there were significant decreases of 8-OH-2-AAF in blood and urine samples. In blood samples, amounts of 2-AAF and 8-OH-2-AAF were significantly decreased; in colon tissues, amounts of 2-AF, 1-OH-2-AAF and 3-OH-2-AAF, in liver tissues, amounts of 2-AAF, 1-OH-2-AAF and 3-OH-2-AAF, and in urine samples, amounts of 2-AF and 8-OH-2-AAF were significantly decreased in 24-h ellagic acid (EA)-treated rats before 2-AF was added to the diet. However, significantly increased 1-OH-2-AAF concentrations were found in urine samples in 24-h EA-treated rats before 2-AF was administered. In the EA and 2-AF rats, in the same time treated groups, bladder, colon and liver tissues, and feces and urine samples showed significant differences when compared to the ones without EA co-treatment. We saw significant decreases of the amounts of 2-AF and 1-OH-2-AAF in colon tissues. The feces samples showed increased amounts of 2-AAF in EA- and in 2-AF- treated rats in the same time groups, but urine samples showed a decreased amount of 8-OH-2-AAF in both EA-treated groups. The total amounts of 2-AF metabolites in bladder, blood, kidney and liver tissues showed significant difference between control and the group which was EA-treated 24 h before 2-AF was added. The total amounts of 2-AF metabolites in the liver, feces and urine showed significant decreases between control and EA-treated at the same time with 2-AF groups. This is the first report of EA affecting the N-acetylation and metabolism of 2-AF in rat tissues in vivo.

Ellagic acid inhibits growth and arylamine N-acetyltransferase activity and gene expression in Staphylococcus aureus.

It is well documented that N-acetyltransferase (NAT) plays a key role in the N-acetylation of arylamine compounds. Ellagic acid was demonstrated to elicit dose-dependent bacteriostatic activity and inhibition of N-acetylation of 2-aminofluorene (AF). N-acetylation of AF in S. aureus was determined by high preformance liquid chromatography. The apparent values of Km and Vmax of NAT were decreased after co-treatment with 0.5 mM ellagic acid in the cytosol of S. aureus. PCR also indicated that ellagic acid inhibited NAT gene expression (NAT mRNA) in S. aureus.

Physicians Failed to Write Flawless Prescriptions When Computerized Physician Order Entry System Crashed.

PURPOSE: Clinical care has become increasingly dependent on computerized physician order entry (CPOE) systems. No study has reported the adverse effect of CPOE on physicians' ability to handwrite prescriptions. This study took advantage of an extensive crash of the CPOE system at a large hospital to assess the completeness, legibility, and accuracy of physicians' handwritten prescriptions. METHODS: The CPOE system had operated at the outpatient department of an academic medical center in Taiwan since 1993. During an unintentional shutdown that lasted 3.5 hours in 2010, physicians were forced to write prescriptions manually. These handwritten prescriptions, together with clinical medical records, were later audited by clinical pharmacists with respect to 16 fields of the patient's, prescriber's, and drug data. FINDINGS: A total of 1418 prescriptions with 3805 drug items were handwritten by 114 to 1369 patients. Not a single prescription had all necessary fields filled in. Although the field of age was most frequently omitted (1282 [90.4%] of 1418 prescriptions) among the patient's data, the field of dosage form was most frequently omitted (3480 [91.5%] of 3805 items) among the drug data. In contrast, the scale of illegibility was rather small. The highest percentage reached only 1.5% (n = 57) in the field of drug frequency. Inaccuracies of strength, dose, and drug name were observed in 745 (19.6%), 517 (13.6%), and 435 (11.4%) prescribed drug items, respectively. IMPLICATIONS: The unintentional shutdown of a long-running CPOE system revealed that physicians fail to handwrite flawless prescriptions in the digital era. The contingency plans for computer disasters at health care facilities might include preparation of stand-alone e-prescribing software so that the service delay could be kept to the minimum. However, guidance on prescribing should remain an essential part of medical education.

Impact of a warning CPOE system on the inappropriate pill splitting of prescribed medications in outpatients.

BACKGROUND: Prescribing inappropriate pill splitting is not rare in clinical practice. To reduce inappropriate pill splitting, we developed an automatic warning system linked to a computerized physician order entry (CPOE) system for special oral formulation drugs in outpatient settings. We examined the impact of the warning system on inappropriate prescribing of pill splitting and assess prescribers' responses to the warnings. METHODS: Drugs with extended-release or enteric-coated formulations that were not originally intended to be split were recognized as "special oral formulations". A hard-stop system which could examine non-integer doses of drugs with special oral formulations, provide warnings to interrupt inappropriate prescriptions was integrated in CPOE in a medical center since June 2010. We designed an intervention study to compare the inappropriate splitting before and after the implementation of the warning system (baseline period 2010 January to May vs. intervention period 2010 June to 2011 August). During the intervention period, prescription changes in response to a warning were logged and analyzed. RESULTS: A total of 470,611 prescribed drug items with 34 different drugs with special oral formulations were prescribed in the study period. During the 15-month intervention period, 909 warnings for 26 different drugs were triggered among 354,523 prescribed drug items with special oral formulations. The warning rate of inappropriate splitting in the late intervention period was lower than those in baseline period (0.16% vs. 0.61%, incidence rate ratio 0.27, 95% CI 0.23-0.31, P<0.001). In respond to warnings, physicians had to make adjustments, of which the majority was changing to an unsplit pill (72.9%). CONCLUSIONS: The interruptive warning system could avoid the prescriptions with inappropriate pill splitting. Accordingly, physicians changed their behavior of prescribing special oral formulations regarding inappropriate pill splitting. We suggest the establishment of such system to target special oral formulations with warnings to prevent inappropriate pill splitting.

Association between physician specialty and risk of prescribing inappropriate pill splitting.

BACKGROUND: Prescription errors that occur due to the process of pill splitting are a common medication problem; however, available prescription information involving inappropriate pill splitting and its associated factors is lacking. METHODS: We retrospectively evaluated a cohort of ambulatory prescriptions involving extended-release or enteric-coated formulations in a Taiwan medical center during a 5-month period in 2010. For this study, those pill splitting prescriptions involving special oral formulations were defined as inappropriate prescriptions. Information obtained included patient demographics, prescriber specialty and prescription details, which were assessed to identify factors associated with inappropriate pill splitting. RESULTS: There were 1,252 inappropriate prescriptions identified in this cohort study, representing a prescription frequency for inappropriate pill splitting of 1.0% among 124,300 prescriptions with special oral formulations. Among 35 drugs with special oral formulations in our study, 20 different drugs (57.1%, 20/35) had ever been prescribed to split. Anti-diabetic agents, cardiovascular agents and central nervous system agents were the most common drug classes involved in inappropriate splitting. The rate of inappropriate pill splitting was higher in older (over 65 years of age) patients (1.1%, 832/75,387). Eighty-seven percent (1089/1252) of inappropriate prescriptions were prescribed by internists. The rate of inappropriate pill splitting was highest from endocrinologists (3.4%, 429/12,477), nephrologists (1.3%, 81/6,028) and cardiologists (1.3%, 297/23,531). Multivariate logistic regression analysis revealed that the strongest factor associated with individual specific drug of inappropriate splitting was particular physician specialties. CONCLUSION: This study provides important insights into the inappropriate prescription of special oral formulation related to pill splitting, and helps to aggregate information that can assist medical professionals in creating processes for reducing inappropriate pill splitting in the future.