Critical Need for Clinical Trials: An Example of a Pilot Human Intervention Trial of a Mixture of Natural Agents Protecting Lymphocytes Against TNF-α Induced Activation of NF-κB

Humans typically consume “natural agents” that are believed to be chemoprotective and are known to decrease inflammation biomarker NF-κB in vitro; however, no intervention studies in humans have been done to date. This commentary documents the in vivo results as a powerful example for supporting the superiority of a complex mixture of natural agents. Human volunteers consumed two 500 mg capsules (BID) containing a mixture of natural agents for a period of 2 weeks, and blood samples were collected pre- and post-intervention. The purified lymphocytes were subjected to ex-vivo exposure to TNF-α or kept as untreated control. The mean NF-κB DNA binding activity was increased upon TNF-α treatment in pre-intervention samples; however, TNF-α was unable to induce NF-κB in post-intervention samples, suggesting that the mixture of four important natural agents could be useful to protect humans against oxidative stress.     

Electronic reminders to improve medication adherence—are they acceptable to the patient?

Objective Low levels of adherence to medication are commonly reported in chronic medical conditions. Empirical evidence suggests that patients are willing to accept pharmacist interventions to improve adherence. This study aimed to assess the levels of self-reported adherence to antidepressant medication in the community and to investigate the acceptability of text message reminders to self-reported unintentional non-adherers. Setting Community pharmacy in Wexford; Republic of Ireland. Method A structured questionnaire was administered to patients who were collecting antidepressant medication, which had been prescribed for at least 6 months. Results Of the 59 patients who completed the study, 54% reported that they were unintentionally non-adherent. This group tended to be younger in age (t = −2.50, P = 0.02). Fifty-nine percent of the unintentional non-adherers were willing to receive a prompt such as a text message from the pharmacy to remind them to take their medication. There was no association between gender or age and acceptability of text message reminders. Conclusion Unintentional non-adherence to antidepressant medication exceeded 50% in this population. Electronic reminders, in this case text messages, were acceptable to approximately 60% of patients who reported being unintentionally non-adherent. Reasons for refusal of electronic reminders should be investigated as this will affect the applicability of this intervention.     

Mangrove trees affect the community structure and distribution of anammox bacteria at an anthropogenic-polluted mangrove in the Pearl River Delta reflected by 16S rRNA and hydrazine oxidoreductase (HZO) encoding gene analyses

Anaerobic ammonium oxidizing (anammox) bacterial community structures were investigated in surface (1–2 cm) and lower (20–21 cm) layers of mangrove sediments at sites located immediately to the mangrove trees (S0), 10 m (S1) and 1000 m (S2) away from mangrove trees in a polluted area of the Pearl River Delta. At S0, both 16S rRNA and hydrazine oxidoreductase (HZO) encoding genes of anammox bacteria showed high diversity in lower layer sediments, but they were not detectable in lower layer sediments in mangrove forest. S1 and S2 shared similar anammox bacteria communities in both surface and lower layers, which were quite different from that of S0. At all three locations, higher richness of anammox bacteria was detected in the surface layer than the lower layer; 16S rRNA genes revealed anammox bacteria were composed by four phylogenetic clusters affiliated with the “Scalindua” genus, and one group related to the potential anammox bacteria; while the hzo genes showed that in addition to sequences related to the “Scalindua”, sequences affiliated with genera of “Kuenenia”, “Brocadia”, and “Jettenia” were also detected in mangrove sediments. Furthermore, hzo gene abundances decreased from 36.5 × 10⁴ to 11.0 × 10⁴ copies/gram dry sediment in lower layer sediments while increased from below detection limit to 31.5 × 10⁴ copies/gram dry sediment in lower layer sediments from S0 to S2. The results indicated that anammox bacteria communities might be strongly influenced by mangrove trees. In addition, the correlation analysis showed the redox potential and the molar ratio of ammonium to nitrite in sediments might be important factors affecting the diversity and distribution of anammox bacteria in mangrove sediments.     

Fourteen well-described caffeine withdrawal symptoms factor into three clusters

Rationale  Abrupt cessation of caffeine often results in several withdrawal symptoms among habitual caffeine consumers. Objective  The objective of the study was to determine whether caffeine withdrawal symptoms co-exist as clusters in some individuals. Materials and methods  Withdrawal symptoms and caffeine intake were assessed for men (n = 126) and women (n = 369), aged 20–29, using a caffeine habits questionnaire and a semi-quantitative food frequency questionnaire, respectively. Principal components factor analysis was used to identify common underlying factors among 14 well-described caffeine withdrawal symptoms. Odds ratios (OR) and 95% confidence intervals (CI) were calculated to determine if the likelihood of reporting a withdrawal factor was associated with habitual caffeine consumption. Results  The 14 withdrawal symptoms were grouped into three factors termed “fatigue and headache”, “dysphoric mood”, and “flu-like somatic”. The likelihood of reporting the fatigue and headache and dysphoric mood factors increased with higher levels of habitual caffeine consumption. Compared to <100 mg/day of caffeine, the ORs (95% CI) of reporting the fatigue and headache factor with a habitual intake of 100–200 mg/day and >200 mg/day were 1.97 (1.21, 3.21) and 4.44 (2.50, 7.86), respectively. The corresponding ORs (95% CI) for the dysphoric mood factor were 1.55 (0.96, 2.52) and 3.34 (1.99, 5.60). Conclusions  The 14 well-described caffeine withdrawal symptoms factor into three clusters, suggesting the existence of three distinct underlying mechanisms of caffeine withdrawal. Increasing habitual caffeine consumption is associated with an increased likelihood of reporting the fatigue and headache and dysphoric mood symptoms, but not the flu-like somatic symptoms.     

Differences in adherence and motivation to HIV therapy—two independent assessments in 1998 and 2002

Objective The aim of this study was to compare the level of adherence and motivation in two independent cross-sectional samples of HIV-infected patients conducted in 1998 and 2002, and to investigate the relationship between adherence and motivation.Method Consecutive HIV-infected patients on treatment at a Swedish clinic were asked to complete an anonymous questionnaire. In 1998, 60 patients participated and in 2002, 53 participated. In 2002, the 9-item Morisky Medication Adherence Scale (MMAS) was added to the questionnaire set.Main outcome measure Self-reported adherence and motivation.Results In 1998, 28.1% of the respondents were considered adherent, while the corresponding proportion was 57.4% in 2002 (P = 0.002). The mean summary score for MMAS was 10.7 in 2002 (13 = perfect adherence). The proportion considered motivated were 22.4% in the 1998 survey and 41.3% in 2002 (P = 0.038). Of the respondents considered motivated in the 2002 survey, 46.7% scored the maximum summary score on the MMAS, while 8.7% of the non-motivated respondents did so (P = 0.016).Conclusion The respondents in 2002 were more adherent and motivated than the respondents in 1998 and a relationship between motivation and adherence was found. The difference in adherence and motivation might be due to a new treatment model at the clinic.     

Heroin-using drivers: importance of morphine and morphine-6-glucuronide on late clinical impairment

Objective To evaluate the relationship between major heroin metabolites (morphine, morphine-6-glucoronide), pattern of drug use, and late impairment of psychomotor functions.Methods From the database of the Norwegian Institute of Public Health, Oslo, blood morphine concentration in samples from heroin users (n=70) containing only morphine were correlated with results of the clinical test for impairment (CTI). For comparison, test results were explored in individuals without any positive analytical finding in blood samples (n=79) selected from the same database.Results In the “no drug” cases, 86% were judged as not impaired and 14% as impaired. In the morphine only cases, 20% were judged as not impaired, and 80% as impaired. Both daily users and non-daily users had the same proportion of impaired cases. Median blood morphine concentration (M) was 0.09 μmol/l in the “not impaired” group and 0.15 μmol/l in the “impaired” group (P=0.067). For morphine-6-glucuronide (M6G), the median blood concentration was 0.09 μmol/l in the “not impaired” group and 0.14 μmol/l in the “impaired” group (P=0.030). A significant correlation between concentration quartiles and number of cases determined as “impaired” was found for M6G (P=0.018) and for the sum M+M6G (P=0.013).Conclusion In our population of heroin-drugged drivers, blood concentrations of M6G and the sum M+M6G appeared to have concentration-dependent effects on the CNS that may lead to impairment as judged from a CTI. Variations in pattern of use did not seem to have any bearing on the judgement of impairment.     

Professional ethics in pharmacy practice: developing a psychometric measure of moral reasoning

Objective To develop and validate a psychometric measure of cognitive moral development in professional ethics in pharmacy. Setting Pharmacy practice in Australia. Method A psychometric instrument, the Professional Ethics in Pharmacy (PEP) test, was developed and validated following a systematic procedure. The theoretical foundation of the instrument was based on a hypothesised theory of cognitive moral development in professional ethics, which was integrated into a selection of scenarios experienced in practice by pharmacists in NSW, Australia. The PEP, along with the well established DIT test, was mailed in the form of a questionnaire to a randomly selected sample of 1,500 practising pharmacists. Data collected from returned questionnaires were statistically analysed to establish validity and reliability of the instrument. Main outcome measures The P-score calculated for each participant from DIT and PEP data and defined as a measure of principled moral reasoning, represented the main outcome measure for statistical testing. Pearson’s correlation coefficient was used to determine the strength of the relationship of the PEP with the DIT (regarded as the “gold standard”) in order to establish criterion and concurrent validity. Factor analysis was used to investigate construct validity. Cronbach’s Alpha, a measure of reliability of the instrument, was used for indicating internal consistency. Linear regression models further investigated construct validity in relation to predictors of moral reasoning. Results Face and content validity were established by pilot and peer review. Pearson’s coefficient of 0.53 indicated an acceptable level of concurrent validity. Factor analysis yielded factors closely related to the theoretical stages of cognitive moral development hypothesised, which indicated construct validity. Cronbach’s alpha of 0.75 demonstrated the reliability of the instrument, and linear regression models provided further evidence of construct validity. The PEP was established as a robust instrument on several dimensions of validity and reliability. Conclusion The validated PEP test has the potential to provide the pharmacy profession with valuable information for use education and research. The validation process also provided evidence supporting the hypothesis that moral reasoning in professional ethics in pharmacy is a developmental process, which has profound implications for furthering the understanding of professional behaviour.     

Comparison of three nicotine treatments: initial reactions and preferences with guided use

Rationale Misuse or dislike of nicotine replacement treatments (NRTs) undermines their effectiveness. Brief testing among NRTs could allow tailoring by preference to improve outcome. Objective To test initial reactions/preferences to NRTs in a single session crossover design with guided use. Methods Smokers were offered two doses of three NRTs: gum (2 and 4 mg), inhaler, and nasal spray (NNS) in a 5-h test with proper use enforced. Subjects rated each NRT and ranked among NRTs on use variables and preferences. Results Gum was ranked over inhaler and NNS for “ease of use,” “safety” and “prefer in public.” Four-milligram gum was rated higher than 2 mg on several variables. With experience, “ease of use” and “liking” improved for gum. Both inhaler and NNS ranked low on considering “use >3 months” vs gum. Dislike of NRT was reflected in refusal of second doses. For those testing all doses (n=9), inhaler ranked last on “relief of withdrawal,” “choose under stress,” and “choice to help quit.” Craving and withdrawal were relieved over time with any NRT use. Conclusions Sampling of treatments can identify reactions key to initial compliance with these NRTs.     

Drug Delivery to the Skin From Sub-micron Polymeric Particle Formulations: Influence of Particle Size and Polymer Hydrophobicity

Purpose  To investigate the influence of particle size and polymer properties on the topical delivery of a lipophilic “active” species (Nile Red (NR)) from sub-micron polymeric particles. Methods  Three poly-(ε-caprolactone) (CAPA) formulations were examined to assess the impact of particle size. Three other formulations, based on cellulose acetate butyrate (CAB), CAPA and polystyrene were studied to address the role of polymer hydrophobicity. In vitro skin permeation, and confocal microscopy and stratum corneum (SC) tape-stripping were used to evaluate the cutaneous disposition of NR. Results  NR delivery into the SC was greater from the larger particles, the overall smaller surface area of which enhanced the “leaving tendency” of the lipophilic “active”. Skin uptake of NR (measured as “%payload released”) from polystyrene, CAPA and CAB particles increased with decreasing polymer hydrophobicity (polystyrene > CAPA > CAB) as expected. Confocal microscopy revealed that NR released from the particles accumulated in, and penetrated via, lipid domains between the SC corneocytes. The particles showed affinity for hairs, and concentrated on the skin surface at the follicular openings. Conclusions  Delivery of a model drug to the skin from sub-micron polymeric particle formulations is sensitive to the particle size and the relative hydrophobicity of the carrier.     

Validating the Children’s Medicines Use Questionnaire (CMUQ) in Australia

Objective: To pilot test the validity and reliability of the English version of the Children’s Medicines Questionnaire (CMUQ) and to explore the attitudes of Australian caregivers towards the use of medicines in children. Setting: Survey of Australian parents and primary care givers of children 0–15 years. Methods: The questionnaire was translated from Finnish to English then back-translated to ensure semantic equivalence. A total of 153 parents/main caregiver of a child aged 0–15 years were recruited via convenience sampling. Construct validity of the attitudinal section of the CMUQ was performed using exploratory factor analysis. Reliability was assessed using the Cronbach’s alpha coefficient as a marker of internal consistency. Three focus groups were conducted to explore participants’ attitudes towards medicating children and to triangulate quantitative data. Main outcome measure: Construct validity and internal reliability of the CMUQ. Results: Factor analysis generated a parsimonious four factor solution explaining 50% of variance in the data. The four subscales representing the four factor solution each returned a Cronbach’s Alpha coefficient >0.6, indicating good internal consistency. Participants in focus groups were satisfied with the structure and content of the questionnaire. There were 5 emergent themes through focus group discussions with parents and primary care givers of children, regarding the perception of medicines use in children. These included, ‘concerns about the negative effects of medicines’, ‘medicines are useful, necessary and safe in treating illnesses in children’, ‘the body’s natural processes are sufficient in fighting illness’, ‘over the counter medicines are effective and useful in treating illness’, ‘perception of alternative medicines use in children’. Conclusions: The CMUQ is a valid and reliable tool to measure parents’ medicine use for their children in an Australian sample. Although small modifications should be made, this instrument will be valuable in informing the development of medicines information for this cohort in the future.     

Prevalence of Self-medication in Rural Areas of Portugal

Objectives: To study the prevalence of self-medication among pharmacy customers in rural areas of Portugal, to assess possible predictors of self-medication and to find out whether there was a seasonal dependence in the purchase of drugs for self-medication. Method: A cross-sectional study during four different periods of a year was conducted. Community pharmacies of rural areas of Portugal were invited to participate and pharmacists were asked to recruit one person every hour during the opening hours and administer a questionnaire. Drugs dispensed were classified according to the Anatomical Therapeutic Chemical Classification system up to the second level. Main outcome measure: Prevalence of self-medication is defined as the percentage of patients acquiring a medicine that was not prescribed (written) or recommended (orally) by a physician. Results: The prevalence of self-medication was 21.5%. Main therapeutic groups acquired for self-medication were “other alimentary tract and metabolism products” (A16; proportion acquired for self-medication= 75.0%), “throat preparations” (R02; 74.7%), “antiemetics and antinauseants” (A04; 70.0%), “cough and cold preparations” (R05; 56.5%), and “nasal preparations” (R01; 50.0%). Variables found to be predictors of self-medication were age, type of health professional or person consulted when a mild health problem occurred, time elapsed since last visit to the physician and time waited between setting an appointment and the actual visit. Seasonality seemed to occur for only “cough and cold preparations”, for “dermatologicals” and for “anti-inflammatory and anti-rheumatic products”. Conclusion: In rural Portugal about one fifth of the pharmacy customers engaged in self-medication. However, further research should be made to address appropriateness of self-medication.     

Effects of 4-nonylphenol,fish predation and food availability on survival and life history traits of <Emphasis Type="Italic">Daphnia magna</Emphasis> straus

This study aimed to investigate the compound effect of environmentally relevant 4-nonylphenol (NP) concentrations and natural stressors—namely fish predation and food availability—on Daphnia magna, which were exposed to four NP concentrations (0, 1, 5 and 10 μg l⁻¹) under optimum or low food concentrations (1.00 and 0.075 mg C l⁻¹, respectively) in water (un)conditioned by a fish predator (Alburnus alburnus). A(n) “environmentally relevant” and “no observable effect” concentration (NOEC) of NP (10 μg l⁻¹) resulted in a significant reduction (P < 0.01**) in daphnids’ survival when it was encountered concurrently with conditions of low food availability and presence of fish predation. The significance of the results lies in the observation that not only environmentally relevant concentrations of NP but also NP concentrations reported to have no observable effect on daphnids may in reality have unexpected critical effects on D. magna survival under conditions more parallel to natural ecosystems. The deterioration of the life-history traits—namely, NP-induced delay in the age at first reproduction (P < 0.001***) and fish kairomone-induced reduction in the size at first reproduction (P < 0.001***)—of the D. magna individuals is also crucial, as such alterations could significantly influence future generations and result in ultimate adverse effects at the community level because large-bodied daphnids are key-stone species in freshwater ecosystems. The results of this study demonstrate the importance of taking into account environmentally realistic conditions while investigating the effects of NOEC levels of toxicants on non-target aquatic species.     

Blocking Effect of an Immuno-Suppressive Agent,Cynarin, on CD28 of T-Cell Receptor

Purpose  Cynarin, a potential immunosuppressant that blocks the interaction between the CD28 of T-cell receptor and CD80 of antigen presenting cells, was found in Echinacea purpurea by a new pharmaceutical screening method: After Flowing Through Immobilized Receptor (AFTIR; Dong et al., J Med Chem, 49: 1845-1854, 2006). This Echinacea component is the first small molecule that is able to specifically block “signal 2” of T-cell activation. Methods  In this study, we used the AFTIR method to further confirm that cynarin effectively blocked the binding between CD80 of B-cells and CD28 of T-cells, and provide details of its mechanism of action. Results  The experimental results showed that cynarin blocked about 87% of the CD28-dependent “signal 2” pathway of T-cell activation under the condition of one to one ratio of T-cell and B-cell in vitro. Theoretical structure modeling showed that cynarin binds to the “G-pocket” of CD28 (Evans et al., Nat Immunol, 6:271-279, 2005), and thus interrupts the site of interaction between CD28 and CD80. Conclusions  These results confirm both that AFTIR is a promising method for screening selective active compounds from herbal medicine and that cynarin has great potential as an immuno-suppressive agent.     

A therapeutic dose of zolpidem reduces thalamic GABA in healthy volunteers: a proton MRS study at 4 T

Background  Zolpidem is a nonbenzodiazepine sedative/hypnotic that acts at GABA_A receptors to influence inhibitory neurotransmission throughout the central nervous system. A great deal is known about the behavioral effects of this drug in humans and laboratory animals, but little is known about zolpidem’s specific effects on neurochemistry in vivo. Objectives  We evaluated how acute administration of zolpidem affected levels of GABA, glutamate, glutamine, and other brain metabolites. Materials and methods  Proton magnetic resonance spectroscopy (¹H MRS) at 4 T was employed to measure the effects of zolpidem on brain chemistry in 19 healthy volunteers. Participants underwent scanning following acute oral administration of a therapeutic dose of zolpidem (10 mg) in a within-subject, single-blind, placebo-controlled, single-visit study. In addition to neurochemical measurements from single voxels within the anterior cingulate (ACC) and thalamus, a series of questionnaires were administered periodically throughout the experimental session to assess subjective mood states. Results  Zolpidem reduced GABA levels in the thalamus, but not the ACC. There were no treatment effects with respect to other metabolite levels. Self-reported ratings of “dizzy,” “nauseous,” “confused,” and “bad effects” were increased relative to placebo, as were ratings on the sedation/intoxication (PCAG) and psychotomimetic/dysphoria (LSD) scales of the Addiction Research Center Inventory. Moreover, there was a significant correlation between the decrease in GABA and “dizzy.” Conclusions  Zolpidem engendered primarily dysphoric-like effects and the correlation between reduced thalamic GABA and “dizzy” may be a function of zolpidem’s interaction with α1GABA_A receptors in the cerebellum, projecting through the vestibular system to the thalamus.     

Aetiology and therapy of community-acquired pneumonia: a hospital study in northern Italy

Objectives: The primary aim of this study was to determine whether the use of a therapeutic protocol in the treatment of community-acquired pneumonia (CAP) proved equally effective as the initial empirical anti-infective therapy usually employed. A secondary aim was to compare the cost of therapy and the incidence of the pathogens responsible for so-called “atypical” pneumonia in the study area. Methods: A comparison was made between 11 hospital departments agreeing to abide by the study protocol and 12 hospital departments, well matched for size and type, implementing their usual therapy. The protocol provided different anti-infective therapy options for the patients regarded as being at risk and not at risk, and, secondarily, for infections likely to be of the “typical bacterial” or so-called “atypical” type. The main outcome measures were need to change the initial anti-infective therapy owing to inefficacy, final clinical and radiological outcome, mean cost of pharmacological therapy per patient and result of the serological investigations of the pathogens responsible for “atypical” pneumonia. Results: A total of 345 patients with CAP were assessed. The initial therapy was changed in 8.6% of patients treated according to the protocol, and in 24.5% of patients treated with the usual anti-infective therapies. The cost of therapy for the protocol was almost half of that in the control group. Clinical and radiological outcome was similar in the two groups, with a very low mortality rate. The overall proportion of cases of “atypical” pneumonia amounted to 13%. Conclusions: The use of the therapeutic protocol gave an efficacy comparable to that achieved with routine therapy, but at a distinctly lower cost of antibiotic therapy. The use of microbiological investigations is very limited in day-to-day clinical practice, and the incidence of so-called “atypical” pneumonia was low in the study area, apart from specific outbreaks. Received: 28 May 1996 / Accepted in revised form: 21 August 1996     

Testicular toxicity of methyl thiophanate in the Italian wall lizard (Podarcis sicula): morphological and molecular evaluation

The effects of the fungicide methyl thiophanate (MT) on testis were determined in the Italian wall lizard (Podarcis sicula) using morphological and molecular analyzes. Three experimental trials were performed: an acute test using six doses, a two-week chronic test, and “ecotoxicological” exposure (3 weeks). The minimal lethal dose (LD₅₀) of pure MT, reached by the acute test, was 100 mg/kg body weight. Testicular histopathology of surviving animals showed a reduced lumen and several multinucleated giant cells 24 h after injection followed by large decreases in spermatogonia (72%) and secondary spermatocytes (58%) and a loss of spermatids and sperms 7 days after. In the chronic test, a dose equivalent to 1/100 of LD₅₀ was injected on alternate days. Complete shutting of the lumen and a great decrease in spermatogonia (82%) were observed. In “ecotoxicological” exposure, achieved with a commercial MT compound, testis showed a decrease in primary spermatocytes (20%) and several vacuoles. An increase in germ cell apoptosis was observed in all experimental groups using TUNEL assay. A decrease in expression of androgen and estrogen receptor (AR and ER) mRNAs was seen in all experimental groups. The reduction in AR and ER mRNAs was correlated to exposure time. Indeed, in the “ecotoxicological” treatment (30 days), the decrease reached 82 and 90% for AR and ER mRNAs, respectively. These data strongly indicate that treatment with MT, damaging the seminiferous epithelium and decreasing steroid receptor expression, might render exposed lizards infertile.