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Aim: The objective of this study was to evaluate the clinical and epidemiological aspects of Candida infections. Methods: The study relied on the analysis of electronic medical records. Results: Among 183 patients with positive fungal infections, 57 were from the community and 126 from hospitals. Females predominated in both groups (82.4% in the community, 54.7% in hospitals). Non-albicans Candida spp. accounted for 62.8% of cases. Antifungal therapy was prescribed for 67 patients, with a 55.6% mortality rate. Conclusion: The increasing prevalence of non-albicans Candida species highlights the need for better candidiasis monitoring and control, especially concerning antifungal use amidst rising antimicrobial resistance, particularly in empirical therapy scenarios.

The emergence of fungal pathogens and changes in the epidemiological landscape are prevalent issues in clinical mycology. Reports of resistance to antifungals have been reported. This review aims to evaluate molecular and nonmolecular mechanisms related to antifungal resistance. Mutations in the ERG genes and overexpression of the efflux pump ( MDR1, CDR1 and CDR2 genes) were the most reported molecular mechanisms of resistance in clinical isolates, mainly related to Azoles. For echinocandins, a molecular mechanism described was mutation in the FSK genes. Furthermore, nonmolecular virulence factors contributed to therapeutic failure, such as biofilm formation and selective pressure due to previous exposure to antifungals. Thus, there are many public health challenges in treating fungal infections.

Objective. The aim of this study was to verify the association between anxiety, depression, and obesity in metabolic syndrome (MetS) patients. Methods. It is a retrospective study with 142 volunteers with MetS of both genders and age ≥20 years. Every subject responded to the hospital anxiety and depression scale (HADS). Data are shown as absolute and relative frequencies for categorical variables and a Pearson's chi-square test was performed to verify the association between anxiety or depression and body mass index (BMI). The value of p≤0.05 was considered to be statistically significant. Results. The frequency of anxiety and depression was 18.3% (n=26) and 12% (n=17), respectively. There was no significant association between anxiety or depression and BMI (p=0.481 and 0.079, respectively) in individuals with MetS. Conclusions. Although no association among anxiety, depression and obesity was found, the psychological factors should be added to the MetS treatment contributing to a more effective health care in order to find answers to manage and adhere to the conducts carried out from a more humanized and transdisciplinary perspective. The data also indicate that large sample and case-control methodology are required to obtain a more specific evaluation of this association., (© 2023 Jamile das Virgens Silva et al., published by Sciendo.)

Multidrug-resistant (MDR) mesophilic facultatively anaerobic Gram-negative rods are a public health issue and their spread from animal-source foods to humans is of concern worldwide. Hence, the aim of this study was to examine the antibiotic susceptibility patterns and physiological aspects of such rods, including their tolerance to toxic metals and the screening of efflux pumps expressing isolates among enterobacteria isolated from meat (chicken, beef and pork) and fish samples acquired from retail establishments in a Brazilian urban Centre of over 2,300,000 inhabitants. The study revealed that 62.9% of isolated bacteria were resistant to at least one antimicrobial, of which 32.3% and 8.1% were resistant to one and two of the tested drugs, respectively. A resistance of up to six antimicrobials was also observed (0.9%). Out of the total amount, 22.7% were classified as MDR. Chicken was the meat that harbored most MDR isolates, and fish harbored the least. It was not possible to distinguish the different types of meat or fish considering the resistance patterns. The MDR isolates showed a higher tolerance to mercury and cadmium salts and the increased activity of the efflux mechanisms compared to other susceptible or resistant strains. In One Health. the perspective occurrence of putative MDR bacteria in fresh meat and fish draws attention to the antimicrobial resistance phenomenon in an open environment.

The use of xenobiotics in food production and how food intake is carried out in different cultures, along with different eating habits (omnivorism (ON), ovolactovegetarianism (VT), and strict vegetarianism (VG)) seem to have implications for antimicrobial resistance, especially in the human gut microbiota. Thus, the aim of this study was to evaluate aspects of the clinical resistome of the human gut microbiota among healthy individuals with different eating habits. Volunteers were divided into 3 groups: n = 19 omnivores (ON), n = 20 ovolactovegetarians (VT), and n = 19 strict vegetarians (VG), and nutritional and anthropometric parameters were measured. Metagenomic DNA from fecal samples was used as a template for PCR screening of 37 antimicrobial resistance genes (ARG) representative of commonly used agents in human medicine. The correlation between eating habits and ARG was evaluated. There were no significant differences in mean caloric intake. Mean protein intake was significantly higher in ON, and fiber and carbohydrate consumption was higher in VG. From the screened ARG, 22 were detected. No clear relationship between diets and the occurrence of ARG was observed. Resistance genes against tetracyclines, β-lactams, and the MLS group (macrolides, lincosamides, and streptogramins) were the most frequent, followed by resistance genes against sulfonamides and aminoglycosides. Vegetables and minimally processed foods seem to be the main source of ARG for the human gut microbiota. Although eating habits vary among individuals, the open environment and the widespread ARG from different human activities draw attention to the complexity of the antimicrobial resistance phenomenon which should be addressed by a One Health approach.

Candidemia is the main invasive fungal disease among hospitalized patients. Several breakthrough candidemia (BrC) cases have been reported, but few studies evaluate the epidemiology, risk factors, molecular characterization, antifungal susceptibility profile and outcome of those patients, especially in developing countries and including patients using broad spectrum antifungals. We conducted a retrospective study from 2011 to 2016, including patients aged 12 years or older with candidemia. Epidemiological characteristics and risk factors for candidemia were evaluated and compared with patients with BrC using univariate and multivariate analysis. Sequential Candida isolates from BrC were identified by internal transcribed spacer sequencing, genotyped with amplified fragment length polymorphism fingerprinting (AFLP), and tested for antifungal susceptibility. From 148 candidemia episodes, 27 breakthrough episodes (18%) were identified, with neutropenia and mucositis being independent risk factors for BrC. Candida non-albicans was more frequent in the BrC group (P < .001). AFLP showed high correlation with conventional methods of identification among breakthrough isolates and a high genetic similarity among isolates from the same patient was observed. C. albicans was the most susceptible species with low MIC values for all antifungal agents tested. In contrast, we found isolates of C. glabrata, C. parapsilosis and C. tropicalis resistant to triazoles and echinocandins. In conclusion, BrC occurred mainly in severely immunosuppressed patients, with neutropenia and mucositis. Mortality did not differ between the groups. Candida non-albicans species were more recovered from BrC, with C. albicans being the most susceptible to antifungals.

Nonfermenting Gram-negative bacteria such as Pseudomonas aeruginosa and Acinetobacter baumannii are widespread in the environment and are increasingly associated with nosocomial infections, often associated with multidrug-resistance phenotypes. This study aimed to evaluate epidemiological, physiological, and molecular characteristics of carbapenem resistance in P. aeruginosa and A. baumannii. In total, 63 nonreplicated strains (44 A. baumannii and 19 P. aeruginosa) were isolated from hospitalized patients. Antimicrobial resistance patterns, biocide tolerance, oxidative stress, hemolytic activity, and biofilm formation were assessed. Genetic markers related to β-lactamase synthesis, efflux systems, and porin loss were screened by PCR. Epidemiological data of patients were analyzed. Advanced age, intensive care unit admission, invasive medical devices, treatment with fluoroquinolones or β-lactams/β-lactamase inhibitor combinations, and prolonged hospital stay were predisposing factors for infection. Colistin showed to be active in vitro against these bacteria. Carbapenem-resistant P. aeruginosa strains did not show hemolytic activity and were less tolerant to oxidative stress and biocides. However, increased ability of biofilm formation was observed, comparing to the carbapenem-susceptible isolates. Genetic markers related to oxacillinases synthesis (OXA-23 and OXA-143), oprD absence, and efflux pump (adeB) were detected in carbapenem-resistant A. baumannii. Screening for OXA-51-like gene was performed as confirmatory test for A. baumannii identification. In P. aeruginosa genes encoding efflux pumps (MexAB-OprM, MexCD-OprJ, MexEF-OprN, and MexXY-OprM) and SPM-1 were found; besides, oprD absence was also observed. Our results suggest that these organisms are well adapted to different environments and confirm the difficulty of therapeutic management of patients with infections associated with multidrug-resistant microorganisms, with direct impact on mortality and epidemiological control of these strains in health centers.

Introduction: Non-fermenting Gram-negative bacteria such as Pseudomonas aeruginosa and Acinetobacter baumannii are widespread in the environment and are increasingly associated with nosocomial infections. Extensive and indiscriminate use of antibiotics in hospitals has contributed to an increased number of infections caused by these microorganisms, that are resistant to a wide variety of antimicrobials, including β-lactams. This study aimed to isolate and identify carbapenem-resistant Acinetobacter spp. and P. aeruginosa from hospitalized patients, to determine their antimicrobial susceptibility patterns and to screen for blaOXA-23, blaOXA-24, blaOXA-51, blaOXA-58, and blaOXA-143 genes among the isolated bacteria., Methodology: Antimicrobial resistance patterns were performed using the disk-diffusion method. Genetic markers related to carbapenem resistance were screened by polymerase chain reaction., Results: Carbapenem-resistant Acinetobacter spp. (n = 44) and P. aeruginosa (n = 28) samples were isolated from patients admitted to a tertiary hospital. Polymyxin B was the only effective drug for all isolates. Considering the oxacillinase gene screening, genetic markers were observed only in Acinetobacter isolates. The most frequent genotype observed was blaOXA-23+/blaOXA-51+ (45.5%), followed by blaOXA-51+/blaOXA-143+ (41%). The oxacillinase genes blaOXA-24 and blaOXA-58 were not detected. High mortality rates (> 70%) were observed., Conclusions: The data suggest the need for rational use of antimicrobials associated with early diagnosis of multidrug-resistant bacteria, especially considering non-fermenting Gram-negative rods, which are widespread in hospitals. The findings of blaoxa-51(-) strains suggest the occurrence and spread of non-A. baumannii species throughout our hospitals. Effective implementation of surveillance programs in hospitals is needed to reduce infectious and resistant intra- and inter-species bacteria.

Introduction: Bacterial resistance is a growing concern in the nosocomial environment in which Klebsiella pneumoniae and Enterobacter aerogenes play an important role due to their opportunism and carbapenemase-production. This work aimed to evaluate physiological and molecular characteristics of carbapenem-resistant K. pneumoniae and E. aerogenes isolated in a Brazilian tertiary hospital., Methodology: In total, 42 carbapenem-resistant bacteria isolated from clinical specimens were included (21 K. pneumoniae and 21 E. aerogenes). Drug-sensitive K. pneumoniae (n = 27) were also included. Antimicrobial susceptibility and biocide tolerance patterns, hemolytic activity, tolerance to oxidative stress, and aggregative ability were assessed. Genetic markers related to carbapenem resistance, or ESBL-production were screened by PCR., Results: Compared to drug-sensitive strains, carbapenem-resistant K. pneumoniae were more tolerant to biocides and to oxidative stress, and they displayed an increase in biofilm formation. The genetic markers blaKPC (95.2%) and blaTEM (90.5%) were the most frequent. Among the carbapenem-resistant E. aerogenes strains, blaKPC, and blaTEM were detected in all bacteria. Drug-sensitive E. aerogenes were not isolated in the same period. blaSHV, blaVIM, and blaCTX markers were also observed among carbapenem-resistant bacteria., Conclusions: Results suggest that carbapenemase-producing enterobacteria might show peculiar characteristics regarding their physiology associated with their environmental persistency, virulence, and multidrug resistance. The observed phenomenon may have implications not only for antimicrobial chemotherapy, but also for the prognosis of infectious diseases and infection control.

An ultrasound-assisted extraction procedure was evaluated for the multi-element determination of Cu, Mn, Ca, and Mg in alternative oilseed crops using flame atomic absorption spectrometry. The best results were obtained when 0.3g of samples were used to extract the mineral content using 10 mL of a 1.40 mol L(-1) HNO3 solution for 10 min at 25 °C. The accuracy and precision of the analysis were evaluated using two oilseed reference materials, and the results were in agreement with reference values at 95% confidence level (paired t-test). The method was used to analyze five oilseed samples and the results were in agreement with those obtained using a closed-vessel microwave-assisted acid digestion system for sample preparation. The relative standard deviations were 0.52-6.13% for all of the standard and sample measurements, and the limits of detection were 666.7, 416.7, 333.4 μg g(-1), and 3.5 mg g(-1) for Cu, Mn, Ca, and Mg, respectively., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: A published clinical prediction score indicated that a unilateral adrenal adenoma and either hypokalemia or an estimated glomerular filtration rate of 100 ml/min/1.73 m2 was 100% specific for unilateral primary aldosteronism. This study aimed to validate this score in a separate cohort of patients with primary aldosteronism., Methods: A review of patients with primary aldosteronism from June 2005 to July 2013 at a single center's hypertension clinic. One hundred twelve patients with primary aldosteronism underwent successful adrenal vein sampling and the 110 patients with full data available were included in the final analysis. Adrenal vein sampling was performed all patients desiring surgery by the simultaneous collection of sample prior to and 15 minutes after a cosyntropin infusion with a 3:1 aldosterone/cortisol ratio diagnosing unilateral primary aldosteronism. The derived score was applied to the cohort. Sensitivity and specificity were calculated for clinical prediction score of ≥5 points., Results: There were 64 patients found to have unilateral primary aldosteronism and 48 had bilateral disease. A score ≥5 points had 64% sensitivity (95% confidence interval, 51-76) and 85% specificity (95% confidence interval, 71-94) for unilateral disease. Four patients had lateralization of primary aldosteronism to the side contralateral to the adenoma., Conclusions: The 100% specificity of the score for the unilateral origin of primary aldosteronism was not validated in this cohort with a score of ≥5 points. At best, a high score in this prediction rule may be an additional tool for helping to confirm a decision to offer patients adrenal vein sampling.

Beta-lactamases enzymes such as extended-spectrum beta-lactamases (ESBL) and carbapenemase type beta-lactamases (KPC) confer resistance to beta-lactam drugs among Gram-negative rods, mainly Enterobacteriaceae, as those frequently related to urinary tract infections (UTI). The aim of this study was to evaluate ESBL and KPC among enterobacteria isolated from monomicrobial UTI and to establish correlations between the presence of genetic markers and the phenotypic resistance to beta-lactam antibiotics. Out of 12 304 urine samples collected during 2009, 93 enterobacteria showing an ESBL phenotype were recovered. Imipenem was used for KPC screening and modified disk approximation assay was used for detection of ESBL phenotype. Polymerase chain reaction was used for screening of bla(SHV), bla(TEM), bla(CTX-M), and bla(KPC). Considering the isolated bacteria showing ESBL phenotype 56% of the isolates were positive for two genes. The bla(TEM) was the most frequent (87·1%). Neither KPC phenotype nor bla(KPC)-harboring bacteria were observed. Monitoring the antimicrobial resistance is extremely important to sustain empirical therapy of community-acquired urinary tract infections (Co-UTI).

Background: Computed tomography (CT) of the adrenals is a common first step for investigation of primary aldosteronism (PA). However, prior studies report poor specificity, necessitating adrenal vein sampling (AVS) prior to surgical consideration., Methods: We examined our AVS database to determine whether CT adrenal findings could help select patients with a high likelihood of lateralization by AVS or high-value blood pressure (BP) outcomes. Subjects (N = 113) with validated outcomes were divided into groups of CT 'positive' or CT 'negative' according to the presence or absence of an adrenal mass and compared for the outcomes of lateralization by AVS or proportions achieving normotension off medications following surgery., Results: For patients with CT adrenal masses, there was a significantly higher odds ratio (OR) for both outcomes (6.3 and 9.7, p < 0.01). In subgroup analysis, age <40 years carried particularly high odds for lateralization and cure when a CT mass was present (ORs 45 and 26, p < 0.01). Young individuals with normal CT adrenals rarely lateralized (10 %) and, in such patients, even factors like hypokalemia, body mass index (BMI), and plasma aldosterone level did not change the result on regression analysis., Conclusions: CT-imaged adrenal masses strongly predicted lateralization by AVS and normotension with surgical treatment of lateralized PA. In PA, CT-positive patients should indeed be offered AVS and/or surgery given the high chance of good outcomes; younger CT-negative patients should be advised of a low chance of finding surgical disease by AVS.

Objective: To present a case of symptomatic autoimmune adrenal insufficiency with initially normal serum cortisol and to caution about limitations of the current diagnostic algorithm for adrenal insufficiency, which does not reflect the pathophysiology of early disease., Methods: We describe the clinical presentation and relevant investigations of a patient ultimately found to have Addison's disease, which is followed by a focused review of the literature., Results: A 41-year-old Caucasian woman with autoimmune hypothyroidism, premature ovarian failure, and microscopic colitis presented with nausea, salt craving, increased skin pigmentation, and postural hypotension. Initial bloodwork revealed a normal morning cortisol of level of 19.2 μg/dL (normal, 7.2 to 25 μg/dL) but an adrenocorticotropic hormone (ACTH) level 10 times normal, at 513.6 pg/mL (normal, <52.5 pg/mL). Her potassium was normal, but her aldosterone level was 4.12 ng/dL (normal, 12.3 to 62.5 ng/dL) and her renin activity was increased (23.0 mg/dL/hour; normal, <6.0 mg/dL/hour). Six weeks after initial presentation, she was found to have anti-adrenal antibodies. It was not until 10 weeks after her initial symptomatic presentation that her morning cortisol level was found to be subnormal and a formal diagnosis of adrenal insufficiency was made., Conclusion: The present case and literature review reveal that common diagnostic approaches will miss patients with (possibly symptomatic) early adrenal insufficiency. We suggest that serum ACTH level testing or tests of mineralocorticoid function be included in the initial step of investigation for suspected primary adrenal insufficiency.

This retrospective review examined all primary aldosteronism (PA) adrenal vein sampling (AVS), diagnoses, and outcomes from an endocrine hypertension unit where confirmatory testing was abandoned in 2005 to determine the potential rate of false-positive diagnoses. Patients with outcome-verified PA (surgical patients) were compared with patients with high-probability PA (nonsurgical but high aldosterone-renin ratio, imaging abnormalities, and/or hypokalemia) or possible PA (nonsurgical, no features besides mild elevation of aldosterone-renin ratio, a potential false diagnosis of PA). Of 83 patients, 58% had unilateral PA and 42% had bilateral aldosteronism. Less than 3% of the cohort showed bilateral aldosteronism without hypokalemia or computed tomographic findings, potentially representing the false-positive PA diagnosis rate with omission of confirmatory tests in this population. In a hypertension referral unit enriched in high-probability PA cases and where high AVS success is achieved, omission of a PA confirmatory test yields a high rate of surgical diagnosis with few potential false-positive diagnoses., (©2014 Wiley Periodicals, Inc.)

We hypothesized aldosteronoma responsiveness to cosyntropin may be a characterizing feature that could be determined in addition to standard adrenal vein sampling (AVS) data. We reviewed an AVS database from June 2005 to October 2011 including 65 patients with confirmed primary aldosteronism (PA) who underwent AVS and, if applicable, unilateral adrenalectomy. Patients were divided into confirmed lateralized and non-lateralized groups and subgrouped by histology. Plasma aldosterone in inferior vena cava (IVC) pre- and post-cosyntropin infusion during AVS was measured. Peak aldosterone and proportional change was compared between groups. Baseline and peak IVC aldosterone was higher in lateralized patients but incremental aldosterone rise was much greater in subjects with bilateral hyperplasia. From receiver operator characteristics (ROC) analysis, the optimized diagnostic cut point of peak IVC aldosterone of >649 pmol l(-1) would have a sensitivity of 94% for surgical disease although specificity of just 59%. A 250% increase in IVC aldosterone following cosyntropin would be specific enough to exclude 87% of surgical/lateralized disease. These diagnostic capabilities are similar to other results with non-AVS tests performed for diagnosis of lateralization. Although not specific enough to replace standard AVS interpretation, a marked IVC aldosterone increase after cosyntropin during AVS is a useful additional test to diagnose non-lateralizing forms of PA. Such a calculation requires no additional expense or tests.

Background: Malignancy risk may be increased in chronic inflammatory conditions that are mediated by tumor necrosis factor (TNF), such as juvenile idiopathic arthritis (JIA), but the role of TNF in human cancer biology is unclear. In response to a 2011 United States Food & Drug Administration requirement of TNF blocker manufacturers, we evaluated reporting rates of all malignancies in patients =30 years old who received the TNF blocker etanercept., Methods: All malignancies in etanercept-exposed patients aged =30 years from the Amgen clinical trial database (CTD) and postmarketing global safety database (PMD) were reviewed. PMD reporting rates were generated using exposure information based on commercial sources. Age-specific incidence rates of malignancy for the general US population were generated from the Surveillance Epidemiology and End Results (SEER) database v7.0.9., Results: There were 2 malignancies in the CTD: 1 each in etanercept and placebo/comparator arms (both in patients 18-30 years old). Postmarketing etanercept exposure was 231,404 patient-years (62,379 patient-years in patients 0-17 years; 168,485 patient-years in patients 18-30 years). Reporting rates of malignancy per 100,000 patient-years in the PMD and incidence rates in SEER were 32.0 and 15.9, respectively, for patients 0-17 years and 46.9 and 42.1 for patients 18-30 years old. Reporting rates were higher than SEER incidence rates for Hodgkin lymphoma in the 0-17 years age group. PMD reporting rates per 100,000 patient-years and SEER incidence rates per 100,000 person-years for Hodgkin lymphoma were 9.54 and 0.9, respectively, for patients 0-17 years and 1.8 and 4.2 for patients 18-30 years old. There were =5 cases of leukemia, lymphoma, melanoma, thyroid, and cervical cancers. Leukemia, non-Hodgkin lymphoma, melanoma, thyroid cancer, and cervical cancer rates were similar in the PMD and SEER., Conclusions: Overall PMD malignancy reporting rates in etanercept-treated patients 0-17 years appeared higher than incidence rates in SEER, attributable to rates of Hodgkin lymphoma. Comparison to patients with similar burden of disease cannot be made; JIA, particularly very active disease, may be a risk factor for lymphoma. No increased malignancy reporting rate in the PMD relative to SEER was observed in the young-adult age group.

Background: Insulin-induced hypoglycemia (IHT) is considered the gold standard test for evaluating the HPA axis. Serum free cortisol or its surrogate, salivary cortisol as opposed to total cortisol concentrations, offers a better reflection of the activation of HPA axis. Our study aimed to derive reference ranges for the normal salivary cortisol levels in healthy patients and patients with adrenal insufficiency., Design and Methods: Serum cortisol concentrations, using the gold standard of IHT, and salivary cortisol were obtained. 36 patients referred to our outpatient endocrine testing unit for evaluation of adrenal function were included in the study. Most subjects had a history of suspected hypothalamic/pituitary disease causing adrenal insufficiency., Results: We found a strong linear correlation between the serum and salivary cortisol concentrations in simultaneously collected samples (r=0.81, 95% CI 0.74-0.86, p<0.0001). The corresponding salivary cortisol equivalent to a serum cortisol of 500 nmol/L, using a linear-regression equation, was 16.7 nmol/L (95% CI 13.3-20.1 nmol/L, p=0.0001). A salivary cortisol of 13.3 nmol/L has a specificity of 89.3% to detect abnormal HPA function. Using the upper 95% CI result of salivary cortisol 20.1 yields a sensitivity of 87.5%., Conclusion: With the present assay, adrenal insufficiency may be diagnosed with reasonable confidence if a random salivary cortisol is lower than 13.3 nmol/L and excluded if a random salivary cortisol is higher than 20.1 nmol/L. Future studies should correlate these thresholds with clinical outcomes., (Copyright © 2013 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.)

Invasive fungal disease (IFD) shows distinct regional incidence patterns and epidemiological features depending on the geographic region. We conducted a prospective survey in eight centres in Brazil from May 2007 to July 2009. All haematopoietic cell transplant (HCT) recipients and patients with acute myeloid leukaemia (AML) or myelodysplasia (MDS) were followed from admission until 1 year (HCT) or end of consolidation therapy (AML/MDS). The 12-month cumulative incidence (CI) of proven or probable IFD was calculated, and curves were compared using the Grey test. Among 237 AML/MDS patients and 700 HCT recipients (378 allogeneic, 322 autologous), the 1-year CI of IFD in AML/MDS, allogeneic HCT and autologous HCT was 18.7%, 11.3% and 1.9% (p <0.001), respectively. Fusariosis (23 episodes), aspergillosis (20 episodes) and candidiasis (11 episodes) were the most frequent IFD. The 1-year CI of aspergillosis and fusariosis in AML/MDS, allogeneic HCT and autologous HCT were 13.4%, 2.3% and 0% (p <0.001), and 5.2%, 3.8% and 0.6% (p 0.01), respectively. The 6-week probability of survival was 53%, and was lower in cases of fusariosis (41%). We observed a high burden of IFD and a high incidence and mortality for fusariosis in this first multicentre epidemiological study of IFD in haematological patients in Brazil., (© 2012 The Authors. Clinical Microbiology and Infection © 2012 European Society of Clinical Microbiology and Infectious Diseases.)

Background: In primary aldosteronism (PA), lateralized aldosterone excess can be treated with aldosterone antagonists or surgery, which raises the question as to whether surgery or medications should be the preferred management. A difference in required patient follow-up/clinic resource utilization might provide a surrogate estimate of the comparative outcome efficacy of medical versus surgical therapy., Methods: From a retrospective review of our adrenal vein sampling (AVS) database June 2005 to August 2011, we chose all patients with PA who were surgical candidates and investigated with AVS. There were 77 subjects; 38 (with aldosteronoma) had unilateral adrenalectomy, and 39 (7 aldosteronoma and 32 hyperplasia) were treated with primary medical therapy. After AVS, patients with nonsurgical disease immediately started mineralocorticoid antagonists and follow-up measured from the AVS date. Surgical patients were seen in the clinic immediately after hospital discharge and follow-up measured from the operative date. Target BP was <140/90 before discharge to the community., Results: Total follow-up ranged from 1 to 55 months, and 4 subjects were lost to follow-up. Mean follow-up in the medical and surgical groups was 13.4 versus 6.5 months (p < 0.004). There was a trend toward more clinic visits for the medical group (7.0 vs 5.2, p = 0.17)., Conclusions: Most PA patients can be managed by medical or surgical approaches. Medically treated patients require much longer-term follow-up to manage their condition, whereas most surgical patients can be successfully discharged shortly after surgery. When possible, surgical management may represent a more expeditious means of treating PA.

"Successful" adrenal vein catheterization in primary aldosteronism (PA) is often defined by a ratio of >3:1 of cortisol in the adrenal vein vs the inferior vena cava. Non-use of corticotropin (ACTH) during sampling may increase the apparent failure rate of adrenal vein catheterization due to lower cortisol levels. A retrospective study was performed on all patients with confirmed unilateral PA between June 2005 and August 2011. Adrenal vein sampling (AVS) included simultaneous bilateral baseline samples with repeat sampling 15 minutes after intravenous infusion of 250 μg of Cortrosyn (ACTH-S). Successful catheter placement was judged as adrenal cortisol:IVC cortisol of >3:1, applied to both baseline and ACTH-S samples and lateralization of aldosteronism was judged as normalized aldosterone/cortisol (A/C) ratio >3 times the contralateral A/C ratio. In ACTH-S samples, 94% of right-sided catheterizations were biochemically successful with 100% success on the left. Among baseline samples, only 47% of right- and 44% of left-sided samples met the 3:1 cortisol criteria. However, 95% of apparent "failed" baseline cortisol sets still showed lateralization of A/C ratios that matched the ultimate pathology. Non-ACTH-stimulated samples may be incorrectly judged as failed catheter placement when a 3:1 ratio is used. ACTH-stimulated sampling is the preferred means to confirm catheterization during AVS., (© 2013 Wiley Periodicals, Inc.)

We present a case of early coma, metabolic acidosis and methemoglobinemia after substantial acetaminophen toxicity in the absence of hepatic failure. A 77-year-old female presented to the emergency department with a decreased level of consciousness. She was found unresponsive by a family member in her bed, and was reported to be acting normally when she was last seen eight hours earlier. Laboratory results on arrival were: pH 7.19, sodium 139 mmol/L, chloride 106 mmol/L, potassium 3.3 mmol/L, CO2 8 mmol/L, and an anion gap of 25. Both venous lactate (10.2 mmol/L) and methemoglobin (9.4 %) were elevated. The patient's acetaminophen concentration was markedly elevated at 7138 µmol/L (1078 µg/ml). Hepatic enzymes and coagulation tests were normal [alanine transaminase (ALT) 8 U/L, international normalized ratio (INR) 1.0]. Intravenous N-acetylcysteine (NAC) was initiated at a dose of 150 mg/kg over 15 minutes, followed by 50 mg/kg over the next four hours, followed by 100 mg/kg over the next 16 hours. Twenty-four hours after admission, the anion gap metabolic acidosis had resolved, and the methemoglobin was 2.1%. Aminotransferases peaked at 44 U/L and INR peaked at 1.9. A urine 5-oxoproline assay performed five days after admission was negative, suggesting no evidence of a 5-oxoprolinase deficiency. We describe the pathophysiology and discuss the literature on acetaminophen-induced coma and metabolic acidosis in the absence of hepatic injury; and propose mechanisms for associated methemoglobinemia.

Candida glabrata is an infrequent cause of candidemia in Brazilian public hospitals. We investigated putative differences in the epidemiology of candidemia in institutions with different sources of funding. Prospective laboratory-based surveillance of candidemia was conducted in seven private and two public Brazilian tertiary care hospitals. Among 4,363 episodes of bloodstream infection, 300 were caused by Candida spp. (6.9%). Incidence rates were significantly higher in public hospitals, i.e., 2.42 vs. 0.91 episodes per 1,000 admissions (P< 0.01). Patients in private hospitals were older, more likely to be in an intensive care unit and to have been exposed to fluconazole before candidemia. Candida parapsilosis was more frequently recovered as the etiologic agent in public (33% vs. 16%, P< 0.001) hospitals, whereas C. glabrata was more frequently isolated in private hospitals (13% vs. 3%, P < 0.001). Fluconazole resistance among C. glabrata isolates was more frequent in private hospitals (76.5% vs. 20%, P = 0.02). The 30-day mortality was slightly higher among patients in public hospitals (53% vs. 43%, P = 0.10). Candida glabrata is an emerging pathogen in private institutions and in this setting, fluconazole should not be considered as a safe option for primary therapy of candidemia.

Use of vascular devices represents one of the most common procedures used as a complementary measure in the treatment of patients. An indication algorithm was established to serve as a guideline for nurses in choosing the best intravenous device, considering the main variables of drug therapy. A protocol approved by the Institute of Orthopedics and Traumatology of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (IOT-HCFMUSP), where the authors work, was subsequently established and the nurse carried out the evaluation for the indication of both the peripheral device and the central device, whether a peripherally inserted central catheter (PICC) or other device inserted by the physician. As a result, there was a decrease in the incidence of phlebitis from 0.77% in 2010 to 0.17% in 2011, with an annual curve of negative tendency. The nursing team also appeared more satisfied, diminishing stress related to puncture failure.

Background: Paraproteins, immunoglobulins (Igs), which are elevated in various autoimmune disorders, are known to interfere with various laboratory immunoassays, including vancomycin (VANC). Rheumatoid factor (RF), a known immunoassay interferant, may cause falsely elevated results., Objectives: The aims of this study were to (1) evaluate the effect of 3 paraproteins (IgA, IgG, and IgM) on 4 commercial VANC immunoassays [fluorescence polarization immunoassay; enzyme multiplied immunoassay; 2 particle-enhanced turbidimetric inhibition immunoassays]; (2) determine the concentration at which the effect is obtained, and (3) examine the influence of RF on the VANC methods., Method: Serum and plasma pools from patients prescribed VANC and a spiked VANC pool (20 mg/L) were each mixed 1:1 with individual patient specimens containing IgA (6-63 g/L), IgG (6-54 g/L), IgM (3-30 g/L) (n = 4 for each Ig), and a patient RF pool (196 IU/L). The mixtures (n = 39) were split and distributed for VANC analysis., Results: IgA and IgG in serum and plasma did not affect any of the VANC immunoassays. RF added to plasma specimens did not interfere, but in serum, elevated VAN results were observed. IgM did not affect the fluorescence polarization immunoassay and enzyme multiplied immunoassay methods but did attenuate VANC concentrations by both particle-enhanced turbidimetric inhibition immunoassays (Siemens, Beckman Coulter), with a more pronounced effect on the latter, producing concentrations >20% lower than expected in the patient serum and spiked plasma pools. The effect was progressively negative at effective IgM concentrations of 10 and 15 mg/L., Conclusions: This phenomenon is a major analytical and clinical issue that must be communicated to health care professionals caring for patients receiving VANC, so optimal therapy is achieved.

We present a case of refractory cardiogenic shock secondary to sustained release diltiazem poisoning.  Intravenous lipid emulsion therapy was initiated approximately 13 hours after ingestion. Vasopressors were weaned off hours after initiation of intravenous lipid emulsion therapy and the patient went on to make a full recovery.  This report adds to the paucity of data on intravenous lipid emulsion rescue therapy in sustained release diltiazem poisoning. We hypothesize that the intravenous lipid emulsion may have mediated its favorable hemodynamic effects via increases in myocardial calcium concentration with resultant increased inotropy.

Chemical evaluation of the semi-purified fraction from the seeds of guaraná, Paullinia cupana H.B.K. var. sorbilis (Mart.) Ducke, yielded the following compounds: caffeine, catechin, epicatechin, ent-epicatechin, and procyanidins B1, B2, B3, B4, A2, and C1. Measurement of the antioxidant activity by reduction of the DPPH radical confirmed the anti-radical properties of the aqueous (AqE) and crude (EBPC) extracts and semi-purified (EPA and EPB) fractions. The EPA fraction showed radical-scavenging activity (RSA) and protected DPPH from discoloration at 5.23 +/- 0.08 (RSD% = 1.49) microg/mL, and for the phosphomolybdenum complex showed a higher Relative Antioxidant Capacity (RAC) at 0.75 +/- 0.01 (1.75). The EPA fraction had a total polyphenolics content of 65.80% +/- 0.62 (RSD% = 0.93). The plant drug showed 5.47% +/- 0.19 (RSD% = 3.51) and 6.19% +/- 0.08 (RSD% = 1.29) for total polyphenolics and methylxanthines, respectively. In vitro assessment of the antibacterial potential of the Paullinia cupana extracts against Streptococcus mutans showed that these could be used in the prevention of bacterial dental plaque.

Background: Circulating mediators, including thromboxane A2, the vasoconstrictor, platelet aggregant, and smooth muscle mitogen, may contribute to the progression of vascular narrowing in primary pulmonary hypertension (PPH)., Methods: To further understand the contribution of thromboxane and to provide novel therapy for PPH, we administered the potent orally active thromboxane synthetase inhibitor and thromboxane receptor antagonist terbogrel for 12 weeks to patients with New York Heart Association functional classification II and III PPH. The study had a multicenter randomized placebo-controlled design. The primary endpoint was a change in the distance walked during 6 minutes. The pharmacologic effects of terbogrel on thromboxane and prostacyclin metabolism also were studied., Results: Although the planned enrollment was 135 patients, the study was halted after only 71 patients had been randomized because of the unforeseen side effect of leg pain, which occurred almost exclusively in patients with terbogrel treatment. Only 52 patients completed the 12-week study, and only 22 patients (31%) were fully compliant with the study medication. The leg pain confounded the primary endpoint of walking distance. On an intention-to-treat analysis, no improvements in 6-minute walk distance or in hemodynamics in patients with terbogrel treatment were seen. However, terbogrel was effective from a pharmacologic standpoint, reducing thromboxane metabolites by as much as 98% (P <.0001), with a modest but statistically insignificant (39%) rise in prostacyclin metabolites., Conclusion: Inhibition of thromboxane with an orally active agent is feasible in PPH, but the incidence of severe leg pain with terbogrel precludes its use in this disorder. Similar therapeutic efforts, with other thromboxane inhibitors, should be considered.

Objective: Homocysteine is a sulfur-containing amino acid formed during the demethylation of methionine. Vitamin B12 and folate deficiency and therapy with antifolate drugs may predispose patients with inflammatory bowel disease (IBD) to hyperhomocysteinemia. The known associations between hyperhomocysteinemia and smoking, osteoporosis, and thrombosis make it an interesting candidate as a pathogenetic link in IBD. The aim of this study was to identify the prevalence and risk factors of hyperhomocysteinemia in patients with IBD., Methods: Sixty-five consecutive IBD patients were recruited from a tertiary outpatient gastroenterology practice. Fasting plasma homocysteine levels were measured, along with vitamin B12 and folate. Data regarding medication use, multivitamin use, disease location and severity, and extraintestinal manifestations of IBD were gathered. Homocysteine levels in 138 healthy control subjects were compared with the IBD cohort, and adjustments for age and sex were made using logistic regression. Multivariate analysis was performed to seek predictors of homocysteine levels., Results: The mean age in the IBD cohort was 42+/-13.4 yr (+/-SD), and 43% were male. The mean disease duration was 13.8+/-9.4 yr, and 32% had used steroids within the last 3 months. Immunomodulator therapy had been used in 32%, and 75% had had an intestinal resection. Osteoporosis was present in 33% of patients. Five patients had experienced venous thrombosis or stroke, but only one of these had hyperhomocysteinemia. Of the 10 IBD patients (15.4%) with hyperhomocysteinemia, only two had vitamin B12 deficiency. The homocysteine levels in the IBD cohort cases and controls were 8.7 and 6.6 micromol/L, respectively (p < 0.05). IBD significantly increased the risk of hyperhomocysteinemia (adjusted odds ratio = 5.9 [95% CI: 1.5-24]). Advanced age, male sex, vitamin B12 deficiency or lower vitamin B12 serum levels, and multivitamin therapy were independently associated with higher homocysteine levels in the multivariate analysis (R2 = 0.55; p = 0.001)., Conclusions: Hyperhomocysteinemia is significantly more common in patients with IBD compared with healthy controls, and is associated with lower (but not necessarily deficient) vitamin B12 levels.

This open-label, crossover study had two objectives: to compare the steady-state pharmacokinetics of high-dose telmisartan with and without coadministered high-dose hydrochlorothiazide and to compare the steady-state pharmacokinetics of hydrochlorothiazide with and without coadministered telmisartan. A total of 13 healthy males and females of nonchildbearing potential received the following oral, once-daily medications, each for 7 days: telmisartan 160 mg, hydrochlorothiazide 25 mg, and telmisartan 160 mg plus hydrochlorothiazide 25 mg. Between medication periods, there was a 14-day washout. Blood was collected at intervals over 48 and 84 hours, respectively, at the end of the 7-day dosing period for the determination of plasma telmisartan and hydrochlorothiazide concentrations by high-performance liquid chromatography. Predose blood samples were also collected on days 1, 6, and 7. Tolerability of single-agent and combination medication was monitored. For hydrochlorothiazide and telmisartan, given alone or in combination, there were no appreciable differences in trough plasma concentrations between days 6, 7, and 8; thus, at day 7, both agents had achieved steady state. Mean values of the primary end points (Cmax and AUC0-24) and secondary end points (Cmin and t1/2) for both telmisartan and hyrochlorothiazide were unaffected when administered simultaneously. Moreover, concurrent telmisartan had no effect on urinary excretion of hydrochlorothiazide. Transient lightheadedness, associated with postural hypotension, was the most common adverse event. The absence of any significant effects on the pharmacokinetics of either hydrochlorothiazide or telmisartan shows that no dose adjustment is required if the two agents are given concurrently for the management of hypertension.

The objective of this study was to assess the efficacy and tolerability of transdermal clonidine in inner-city African-American and Hispanic-American patients with essential hypertension. A multiclinic open-label, prospective trial for 12 weeks was used. Dose titration was based on office blood pressure (BP) measurements of > 140/90 mm Hg. Clinical sites were community-based primary care centers. Untreated and treated hypertensive patients whose diastolic BP exceeded 90 mm Hg were administered transdermal clonidine at 0.1 mg or 0.2 mg delivery daily. The drug was titrated after 1 month if diastolic BP was greater than 90 mm Hg. At 12 weeks of treatment, change in blood pressure from baseline as well as adverse effects and patient satisfaction were assessed. A total of 357 patients entered the treatment phase of the study, and 315 patients (244 African-Americans, 67 Hispanic-Americans) had evaluable data. Transdermal clonidine significantly (P <.001) lowered BP in all patients by 15.7/12.8 +/- 18.1/9.6 mm Hg, and heart rate was reduced by 3 +/- 9 beats/min (P <.001). There were no differences in BP reduction according to race and ethnicity, gender, or age. The most common adverse effects were pruritus or discomfort at the patch site, dizziness, dry mouth, and fatigue. Eleven percent of the patients discontinued treatment because of one of these adverse effects. A large proportion of patients (67%) reported that transdermal clonidine was more convenient to use than oral therapy. Transdermal clonidine, alone or in combination with other antihypertensive therapies, significantly lowered BP and heart rate in inner-city hypertensive patients. The drug was generally well tolerated, with 89% of the patients remaining in the trial. Patient acceptability was high with the once-weekly treatment, which is an important feature for this particular hypertensive population.

The immunosuppressive drugs rapamycin (Rap) and cyclosporine A (CsA) are used clinically to modify or abolish immune-mediated functions. This study examined the effect of orally administered regimens of Rap, CsA, and a combination of Rap/CsA on intestinal function in male New Zealand white rabbits. Animals received oral doses of CsA (15 mg/kg/body weight/day), low-dose (LD) and high-dose (HD) Rap (0.25 or 1 mg/kg/body wt/day, respectively), or Rap/CsA (0.25 and 5 mg/kg/body wt/day, or 0.5 and 5 mg/kg/body wt/day, respectively) for 20 days. We measured in vitro uptake of nutrients and permeability, and morphometric measurements in the jejunum and ileum were made. Animals receiving HD-Rap or HD-Rap/CsA had decreased food intake, body weight, and intestinal weight, when compared with LD-Rap, LD-Rap/CsA, CsA, or controls. The maximal transport rate (Vmax) for the active jejunal uptake of D-glucose was increased in HD-Rap and CsA, but not in the HD-Rap/CsA-treated animals. The jejunal Vmax of D-glucose in the LD-Rap- or -Rap/CsA-treated animals was no different from controls. In the HD-Rap- and HD-Rap/ CsA-treated animals, jejunal rates of uptake of stearic, linoleic, and linolenic acids were reduced when compared with controls. Jejunal and ileal permeability (as assessed by the passive uptake of L-glucose, tissue conductance, and mucosal-to-serosal flux of [3H]inulin) was increased in animals treated with HD-Rap or HD-Rap/CsA, when compared with CsA or controls. These parameters of permeability were no different at lower doses of Rap or Rap/CsA. The jejunal and ileal villous surface area was increased in CsA, but decreased in HD-Rap or HD-Rap/CsA animals. Thus, HD-Rap given alone or in combination with CsA reduced body weight gain, in part due to reduced food intake and malabsorption of lipids, which was due at least in part to reduced intestinal surface area. The relevance of these findings to patients undergoing chronic immunosuppressive drug therapy needs to be established.

Objective: The purpose of this work was to develop applications for the EMIT Cyclosporine (CsA) Assay on the Hitachi 911 and 917 analyzers., Methods and Results: Instrument settings were optimized to arrive at the following assay characteristics on the Hitachi 917. Limit of sensitivity was 50 micrograms/L. Intra-assay coefficients of variation (CV) were 8.1% (n = 20; mean = 62 micrograms/L) and 4.2% (n = 20; mean = 315 micrograms/L), while interassay CVs were 13.0% (n = mean = 73 micrograms/L) and 5.7% (n = 43; mean = 391 micrograms/L). Recoveries of 95-104% were obtained by spiking aliquots of 3 whole blood patient pools of known CsA concentrations with CsA. Serial dilutions of 3 patient specimens demonstrated linear relationships between expected and actual CsA concentrations (r = 0.99, 0.99, 0.98; regression lines: y = 1.19x -17.1; y = 0.75x + 18.0; y = 1.01x + 3.7). Specimen carryover was not evident. Calibration stability is at least 10 days. Comparable assay characteristics were found for the Hitachi 911. Sequentially-collected trough whole blood specimens from renal (n = 3), liver (n = 3) and heart (n = 4) transplant patients prescribed CsA were collected up to 78 days post-transplant and analyzed by EMIT on the Hitachi 917 and also by fluorescence polarization immunoassay (FPIA) and high performance liquid chromatography (HPLC). The following linear regression equations were produced for the renal [EMIT = 0.801 (TDx) + 4.98, r = 0.91, Sy/x = 32, n = 37; EMIT = 0.877 (HPLC) + 56, r = 0.87, Sy/x = 38, n = 37]; liver [EMIT = 0.808 (TDx) - 27, r = 0.94, Sy/x = 42, n = 37; EMIT = 0.953 (HPLC) + 44, r = 0.89, Sy/x = 57, n = 37] and heart [EMIT = 0.820 (TDx) - 24, r = 0.94, Sy/x = 31, n = 45, EMIT = 0.956 (HPLC) + 54, r = 0.91, Sy/x = 38, n = 45] patient samples. FPIA values average 32% more than EMIT-derived CsA concentrations on the Hitachi 917, which in turn averaged 15% more than HPLC values. In addition, these levels were compared intra-individually. CsA concentrations within all patients were significantly higher (p < 0.05, paired t-test) by FPIA compared to EMIT and by FPIA compared to HPLC. Although CsA concentrations within most patients were significantly higher (p < 0.05) by EMIT compared to HPLC, levels determined in 4 transplant patients (1 renal, 1 liver, 2 heart) were not different., Conclusion: Development of applications for the EMIT CsA Assay on two highly automated, random access instruments, the Hitachi 911 and Hitachi 917, enhances the versatility of the immunoassay for routine therapeutic drug monitoring of this immunosuppressant in the clinical setting.

We tested whether patients presenting with atrial fibrillation (AF) or flutter (AFl) with a rapid ventricular response could maintain control of heart rate while transferring from a bolus and continuous infusion of intravenous diltiazem to oral diltiazem. Forty patients with AF or AFI and sustained ventricular rate > or = 120 beats/min received intravenous diltiazem "bolus" (20 to 25 mg for 2 minutes) and "infusion" (5 to 15 mg/hour for 6 to 20 hours). Oral long-acting diltiazem (diltiazem CD 180, 300, or 360 mg/24 hours) was administered in patients in whom stable heart rate control was attained during constant infusion. Intravenous diltiazem infusion was discontinued 4 hours after the first oral dose, and patients were monitored during 48 subsequent hours of "transition" to oral therapy. Response to diltiazem was defined as heart rate <100 beats/min, > or = 20% decrease in heart rate from baseline, or conversion to sinus rhythm. Other rate control or antiarrhythmic medications were not allowed during the study period. Thirty-seven of 40 patients maintained heart rate control during the bolus, and 35 of the remaining 37 maintained control during the infusion of intravenous diltiazem. Of the 35 patients achieving heart rate control with intravenous diltiazem who entered the transition to oral therapy, 27 maintained heart rate control (response rate of 77%/, 95% confidence interval 63% to 91%). The median infusion rate of intravenous diltiazem was 10 mg/hour, and the median dose of oral diltiazem CD was 300 mg/day. Oral long-acting diltiazem was 77% effective in controlling ventricular response over 48 hours in patients with AF or AFl in whom ventricular response was initially controlled with intravenous diltiazem.

Objectives: To evaluate the performance of a new, benchtop, fully automated urine analyzer the CLINITEK ATLAS and compare it with the URICHEM 1000 CHEMSTRIP UA analyzer. Macroscopic analysis included measurement of 8 urine analyte chemistries and specific gravity by the refractive index method (SgRl)., Methods: The analytical performance studies conducted were calibration stability, precision (within-run and day-to-day), comparison of results of 437 fresh patient urine specimens, analysis of time performance, and problem logging over a 16-day evaluation period., Results: Satisfactory calibration reproducibility, within-run (n = 10), and day-to-day (n = 16) precision was found because results fell within the +/- one color-block by the proposed National Committee for Clinical Laboratory Standards (NCCLS) criteria. Patient results (n = 437) from the 2 analyzers giving the same color-block agreement was found to be for pH, 52%; glucose, 92%; ketones, 86%; protein, 79%; bilirubin, 97%; leukocytes, 72%; blood, 80%; and nitrite, 98%. The concordance defined by the NCCLS criteria as the agreement of results +/- one color-block between the 2 analyzers was found to be for pH, 96%; glucose, 99%; ketones, 100%; protein, 95%; bilirubin, 100%; leukocytes, 97%; and blood 86%. The SgRl determined on ATLAS was correlated with the RD-10 Rapid Density analyzer with the following results: slope = 0.97, intercept = 0.033, r = 0.94, Syx = 0.003, for a range of values from 1.002 to 1.070., Conclusion: Our preliminary data indicate that the analytical performance, and automatable features for complete walk-away function of this analyzer can significantly increase the overall testing efficiency in the urinalysis laboratory.

Objective: To evaluate an in vitro method for predicting oral availability of novel immunosuppressive drugs, cyclosporine A (CsA) and rapamycin (RAPA)., Methods: In this study, we report the development and characterization of an in vitro method to study the influence of vehicle composition on cyclosporine A (CsA) and rapamycin (RAPA) drug efflux across 12 days postconfluent, absorptive human Caco-2 intestinal epithelial cell monolayers. The apical-to-basal (Jab) and the basal-to-apical (Jba) fluxes of 0.5 muCi 3H-CsA or 0.05 muCi 14C-RAPA solubilized in a 10 mg/L final drug concentration in vehicle were measured., Results: The Jab CsA flux was found to be dose dependent, temperature sensitive, and highly polarized (Jab > Jba). For CsA the vehicles were Neoral, Sandimmune, 95% (v/v) ethanol/fetal bovine serum (ethanol/FBS); and for RAPA these were polyethylene glycol/dimethylacetamide (PEG/DMA), polysorbate/Phosal PEG, ethanol/FBS. When Neoral-CsA was tested, the Jab flux of 3H-CsA was the highest and increased almost linearly even after an incubate time of 240 min. The Jab flux of 3H-CsA when Sandimmune-CsA or ethanol/FBS-CsA were used as vehicle was lower and reached a maximal rate by 120 min. In contrast the Jab flux of 14C-RAPA using either PEG/DMA-RAPA or ethanol/FBS-RAPA as vehicle was highest and reached a maximal rate by 120 min, in contrast to the polysorbate/Phosal PEG-RAPA vehicle, which was significantly lower., Conclusion: These data are consistent with the pharmacokinetics of these ISD reported in vivo in human patients or in rabbits, using the same vehicles in the oral formulation. As an integral part of drug development, the data presented that an in vitro system as described may be useful in predicting the effect of drug vehicle on absorption in vivo.

Leflunomide (HWA 486, LEF) is a novel isoxazole derivative with potent immunosuppressive properties. LEF is converted to its active metabolite (A77 1726) after absorption. Presently, the blood distribution and pharmacokinetics of LEF have not been reported. Such information would prove invaluable in determining the appropriate medium for analysis and optimal immunosuppressive dosing regimes. In this study, A77 1726 was found to be primarily associated (> 95%) with the lipoprotein free fraction of plasma at all tested concentrations ranging from 0.4 to 100 mg/L. Detectable levels of A77 1726 (0.34 +/- 0.18 mg/L), analyzed by HPLC, were found in the plasma free fraction only at the highest tested concentration (100 mg/L). Single-dose pharmacokinetics of A77 1726 (i.v.) and HWA 486 (p.o.) were investigated in five healthy New Zealand white rabbits. The half-lives (t1/2) of A77 1726 i.v. and HWA 486 p.o. administration were 3.88 +/- 2.3 and 3.18 +/- 1.6 h, respectively. The volume of distribution by both routes of administration indicates minimal distribution into tissues (Vdss p.o. = 0.14 +/- 0.03 L/kg and Vdssi.v. = 0.09 +/- 0.02 L/kg). The mean residence time of A77 1726 was greater after oral administration of LEF (MRTp.o. = 10.54 +/- 2.6 h and MRTi.v. = 6.76 +/- 1.0 h). Identical areas under the curve suggest bioavailability was 100% (AUCp.o. = 421.16 +/- 204.5 mg.h/L and AUCi.v. = 399.75 +/- 126.9 mg.h/L).

This study examines the therapeutic outcome of a low plant sterol diet and adjunctive drug therapy (cholestyramine) in the long term treatment of beta-sitosterolemia. A diet restricted in plant sterols, cholesterol and fat was implemented in a 48-year-old male beta-sitosterolemic patient. The plant sterols beta-sitosterol, campesterol and stigmasterol, and cholesterol content of the diet were quantitated by a gas chromatography method (GLC) during metabolic ward studies. Food table analysis of dietary sterols, while quantitatively similar to GLC, significantly underestimated the level of plant sterols and therefore overestimated dietary cholesterol intake. The duration of the study was 18 months. The effect of the diet over a period of 6 months on the sterol levels of plasma and individual lipoprotein fractions (VLDL, LDL, HDL) was evaluated. Apolipoproteins A-1 and B-100 levels were measured. The same parameters were assessed over the next 12 months with the adjunctive use of cholestyramine and dietary restrictions. The diet was effective in lowering total, VLDL, and LDL plant sterols by 37%, 59%, and 32% respectively. The low plant sterol diet did not change total plasma, VLDL or LDL cholesterol. With the addition of cholestyramine, total plasma and LDL cholesterol declined by 64 and 76%, respectively, while HDL-cholesterol remained unchanged. LDL plant sterols declined by 77%, while VLDL plant sterol showed no further change. The decline showed no discrimination among the individual plant sterols. One week after cholestyramine therapy, apolipoprotein B fell from 1.03 to 0.11 g/L, while apolipoprotein A rose from 1.29 to 1.79 g/L. These levels subsequently stabilized at 70% below (0.29 g/L) and 42% above (1.81 g/L) that of diet therapy alone. Xanthomas, angina pectoris, and intermittent claudication resolved during the diet and cholestyramine therapy period. Dietary restriction of plant sterols combined with cholestyramine therapy is an effective means of treating beta-sitosterolemia.

We report the influence of media lipids, growth in lipid-poor medium, and cell differentiation on delta 9, delta 6, and delta 5 desaturase activity in the human CaCo-2 enterocyte cell line. We also describe the level of incorporation of palmitic (16:0), linoleic (18:2n-6), and eicosapentaenoic (EPA) acids (20:5n-3) and their higher homologues into cytosolic and membrane lipids during long-term (10 days) medium supplementation in fully differentiated 16- to 18-day-old cultures. CaCo-2 monolayers reached confluency by day 6 with subsequent development of microvilli and maximal expression of microvillus membrane sucrose, alkaline phosphatase, and gamma-glutamyltransaminase occurring between days 16 and 23 after plating. There was evidence of the presence and modulation of delta 9, delta 6, and delta 5 desaturase activity (delta 9 > delta 6 > delta 5). delta 6 Desaturase activity decreased approximately 2-fold between days 6 and 24 of culture and when the fetal bovine serum concentration was increased from 0.5% to 25%; in contrast, when cells were starved for 72 h, activity increased 5.4-fold. When the media was supplemented with either linoleic acid and/or EPA, both delta 6 and delta 5 desaturase activities were inhibited, the greatest reduction of delta 5 desaturase activity occurring with EPA. Incorporation of media fatty acids plus their desaturase and elongase products was highly dependent on medium composition with the homologues of delta 9 > delta 6 > delta 5. Supplementation of cellular media with 100 microM EPA for 10 days decreased membrane phosphatidylethanolamine arachidonic acid level from 13.2 to 8.9%. From these results we conclude that enterocyte membrane fatty acid composition and desaturase enzyme activity are regulated by both dietary fat intake and cell maturation. The clinical relevance of these observations on lipid dietary modification for the management of chronic inflammatory bowel disease is still uncertain but these observations suggest that the beneficial effects of EPA supplements on human ulcerative colitis may be due to a reduction in enterocyte arachidonic acid content by down-regulation of delta 6 and delta 5 desaturase activity.

The immunosuppressive activity of leflunomide is expressed after conversion to its pharmacologically active metabolite A77 1726. Leflunomide is a potent immunosuppressant that inhibits both T-cell and B-cell activity. To date, no pharmacokinetic data have been reported on leflunomide or A77 1726, primarily because of lack of a suitable method for its analysis. We describe here the development and evaluation of a reverse-phase high-performance liquid chromatographic (HPLC) method for the analysis of A77 1726 in whole blood or plasma from humans or rabbits. In human blood, the method exhibited good analytic recoveries from 78 +/- 13.5% to 108 +/- 4.8% (mean +/- SD) for drug concentrations ranging from 400 to 100,000 micrograms/L. When using a sample volume of 0.25 ml the sensitivity of the method was found to be 400 micrograms/L, with a working standard range of up to 200,000 micrograms/L. The sensitivity of the method can be increased to 40 micrograms/L when 1.0 ml of sample is used. Between-run coefficients of variation of 12.2 and 14.7% at A77 1726 mean concentrations of 1,006 and 8,146 micrograms/L were found for this method. No significant differences in recovery of drug were noted when either human or rabbit plasma or whole blood was used as the medium of analysis. In whole-blood specimens, A77 1726 was found to be stable for up to 10 days at -20 or -70 degrees C.

This study examines the efficacy of various doses of intravenous diltiazem to control the ventricular response during atrial fibrillation or atrial flutter. Control of the ventricular response of patients with atrial fibrillation and a rapid ventricular response can provide patients with relief of symptoms and improve hemodynamics. Eighty-four consecutive patients with atrial fibrillation or atrial flutter, or both, received an intravenous bolus dose of diltiazem followed by a continuous infusion of diltiazem at 5, 10, and 15 mg/hour. The mean ventricular response and blood pressure were monitored. Overall, 94% of patients (79 of 84) responded to the bolus dose with a > 20% reduction in heart rate from baseline, a conversion to sinus rhythm, or a heart rate < 100 beats/min. Seventy-eight patients received the continuous infusion. After 10 hours of infusion, 47% of patients (confidence interval [CI]: 36%, 59%) had maintained response with the 5 mg/hour infusion, 68% (CI: 57%, 79%) maintained response after the infusion was titrated to 10 mg/hour, and 76% (CI: 66%, 85%) after titration from the 5 and 10 mg/hour infusion to the 15 mg/hour dose. For the 3 diltiazem infusions studied, mean (+/- SD) heart rate was reduced from a baseline value of 144 +/- 14 beats/min to 98 +/- 19, 107 +/- 25, 107 +/- 22, 101 +/- 22, 91 +/- 17, and 88 +/- 18 beats/min at infusion times 0, 1, 2, 4, 8, and 10 hours, respectively. By the end of the infusion, 18% of patients (14 of 78) had conversion to sinus rhythm.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect on intestinal nutrient transport of the immunosuppressive drugs cyclosporin A (CsA), cyclosporin G (CsG), and rapamycin (RAP) was determined in New Zealand white rabbits. Rabbits received oral doses of CsA (20 mg/kg/day), CsG (10 mg/kg/day), or RAP (1 mg/kg/day) for 10 days. Animals receiving RAP had decreased food intake and weight gain compared with controls. This correlated with a decrease in both total ileal weight and corresponding mucosal weight. CsA and CsG administration had no effect on food intake, total weight gain, or intestinal weight. Villus surface area was significantly decreased in all groups as compared with controls. Jejunal uptake of D-glucose as well as 1 medium and 4 long chain fatty acids was not affected by drug administration, while both mucosal-to-serosal and net 3-0-methylglucose fluxes were increased (P < 0.05) in the jejunum by all 3 drugs. In the ileum, the rates of uptake of D-glucose as well as stearic and linoleic acids were increased in animals treated with RAP compared with controls. There was an increase in the ileal values of the maximal transport rate (Vmax) and apparent Michaelis constant (Km*) in RAP, and a fall in the Vmax and Km* in CsG. CsG administration resulted in a decreased cholesterol uptake in both jejunum and ileum, and a decreased D-glucose uptake in the ileum compared with controls. These differences in glucose uptake among groups could not be attributed to variations in body, intestinal, or mucosal weights. It is unlikely that the changes observed in CsA- and CsG-treated animals would have nutritional importance, as these animals gained weight normally. In addition, in these animals the changes mainly occurred in the ileum, not in the jejunum, where most glucose is absorbed, and the associated alterations in the values of the Vmax and Km* would lead to reciprocal changes in the rates of uptake of varying luminal concentrations of glucose. In contrast, these changes are likely to be of more importance in RAP-treated animals, since they failed to gain weight normally. The significance of these findings needs to be established in chronically treated animals.

The objective of this multicenter, randomized, double-blind, placebo-controlled study was to determine the safety and efficacy of intravenous diltiazem in the treatment of 37 patients with rapid (ventricular rate, mean +/- SD 142 +/- 17 beats/min) atrial fibrillation or flutter and moderate to severe congestive heart failure (ejection fraction, mean +/- SD 36 +/- 14%; New York Heart Association class III [23 patients], class IV [14 patients]). During the double-blind portion of the study, patients received either intravenous diltiazem, 0.25 mg/kg over 2 minutes, or placebo followed 15 minutes later by diltiazem or placebo, 0.35 mg/kg over 2 minutes, if the first dose was tolerated but ineffective. Placebo nonresponders were given open-label intravenous diltiazem in a similar fashion as in the double-blind portion of the study. In the double-blind part of the study, 21 (18 with 0.25 mg/kg, 3 with an additional 0.35 mg/kg) of the 22 patients (95%) responded to diltiazem, and 0 of 15 patients (0%) responded to placebo (p < 0.001). All 15 patients (13 with 0.25 mg/kg and 2 with an additional 0.35 mg/kg) who received placebo during the double-blind period had a therapeutic response to diltiazem during open-label therapy. Overall, 36 of 37 patients (97%) had a therapeutic response to intravenous diltiazem. Heart rate response to diltiazem after the 2-minute bolus infusions consisted of a > or = 20% decrease in heart rate from baseline in 36 patients; in addition, 17 patients also had heart rates decreased to < 100 beats/min, whereas no patient had conversion to sinus rhythm.(ABSTRACT TRUNCATED AT 250 WORDS)