Randomised controlled trials and 'unexpected' adverse events associated with newly released drugs : improvements in pharmacovigilance systems are necessary for real-time identification of patient safety risks

Adverse drug events are one of the major causes of morbidity in developed countries, yet the drugs involved in these events have been trialled and approved on the basis of randomised controlled trials (RCTs), regarded as the study design that will produce the best evidence.

Though the focus on adverse drug events has been primarily on processes and outcomes associated with the use of these approved drugs, attention needs to be directed to the way in which the RCT study design is structured. The implementation of controls to achieve internal validity in RCTs may be the very controls that reduce external validity, and contribute to the levels of adverse drug events associated with the release of a new drug to the wider patient population.

An examination of these controls, and the effects they can have on patient safety, underscore the importance of knowing about how the clinical trials of a drug are undertaken, rather than relying only on the recorded outcomes.

As the majority of new drugs are likely to be prescribed to older patients who have one or more comorbidities in addition to that targeted by a new drug, and as the RCTs of those drugs typically under-represent the elderly and exclude patients with multiple comorbidities, timely assessment of drug safety signals is essential.

It is unlikely that regulatory jurisdictions will undertake a reassessment of safety issues for drugs that are already approved. Instead, reliance has been placed on adverse drug event reporting systems. Such systems have a very low reporting rate, and most adverse drug events remain unreported, to the eventual cost to patients and healthcare systems.

This makes it essential for near real-time systems that can pick up safety signals as they occur, so that modifications to the product information (or removal of the drug) can be implemented.

Inhibitory effect of antidepressant drugs on contact hypersensitivity reaction

Background: Contact hypersensitivity (CS) reaction in the skin is T-cell mediated immune reaction which plays a major role in the pathogenesis and chronicity of various inflammatory skin disorders and, like other delayed-type hypersensitivity (DTH) reactions, affords immunity against tumor cells and microbes. CS response is a self-limiting reaction, and interleukin (IL)-10 is considered to be a natural suppressant of cutaneous inflammatory response. Recently, it has been demonstrated that major depression is related to activation of the inflammatory response and elevation of some parameters of cell-mediated immunity. It has been suggested that such activation of the immune system may play a role in etiology of depression. If this immunoactivation is involved in etiology of depression, one would expect that antidepressant agents may have negative immunoregulatory effects. To the best of our knowledge, the effect of antidepressants on contact hypersensitivity has not been studied.

Methods: The aim of the present study was to establish the effect of prolonged desipramine or fluoxetine treatment on CS reaction to picryl chloride.

Results: Antidepressants significantly suppressed CS reaction, fluoxetine by 53% whereas desipramine by 47% compared to positive control. Moreover, desipramine and fluoxetine decreased relative weight of auxillary lymph nodes. Desipramine decreased also relative weight of inguinal lymph nodes and spleens whereas desipramine and fluoxetine increased production of IL-10 in comparison to positive control.

Conclusion: The observed effect of antidepressant drugs on CS reaction is consistent with the hypothesis that T-cell mediated immunity is targeted by antidepressants.

Drugs, ships and containers : how anti-terrorism benefits shipping security

Using ships to transport illicit drugs is not new; nor is the practice of concealing them
in shipping containers decreasing – or is it? This article questions whether recent container security initiatives created to stop terrorism have also achieved a decrease in the use of containers for smuggling illicit drugs. Or, are these maritime security regimes creating a false sense of achievement, being too limited in scope to be truly useful in this secondary role? Logically, improved detection of illicit drugs in containers shipped by sea is more likely when port personnel are better trained, x-ray scanners installed, port fencing improved and official collaboration encouraged. However, since the number of containers being electronically screened and physically searched has only marginally improved, the question is, is it enough?

Disorder and the body of drugs : addiction, consumption, control, and city space

Different cultures and the specific culture manifested within them are intrinsically linked to addiction in a complex fashion which has a long history. For important thinkers, such as Nietzsche, addiction actually embodies human culture, rendering addiction and culture inseparable. This is clearly seen within the Western world’s addiction to the consumption of material goods and the damage that results.

Utopia has often become dystopia. Not only is an understanding of addiction key to understanding culture but to an understanding of the very act thinking itself and the way of being in the world. Addiction raises key philosophical questions, such as: do people really have a choice in their behavior, and what governs them; is it free will or predetermination? Is it biology or environment is it the external world or the internal that drives addiction, or a complex combination of both?

In a contemporary context the media frenzy around celebrity addiction continually fuels public debate in this area, and this book deepens the understanding of addiction within this contentious context. This book addresses a key concern over how addiction became the norm, and it seeks to understand its dominance comprehensively. How did it come to pass that not being an addict was a transgressive act and way of being?

While there has been a great deal of debate about addiction utilizing the discourse of individual and often competing disciplines such as biology and psychology, little attention has been paid to the cultural aspects of addiction. The innovative approach taken by this book is to offer insights into this complex area through a contemporary methodology that covers diverse interrelated areas. Drawing on different disciplines, offering deeper insights, from the analysis of music lyrics to empirical social science and anthropological work in AA groups in Mexico and the portrayal of the “addiction’ to therapy in film and television, amongst other areas, this book addresses the need for a more comprehensive approach.

Academic analysis is also given to the discourse on celebrity culture and addiction. A contemporary fusion of the humanities and the social sciences is the best way forward to tackle this subject and move the debate on. The focus of this study is an innovative interdisciplinary and intercultural approach to addiction, from the social sciences to the humanities, including cultural studies, film and media studies, and literary studies. Areas that have been overlooked, such as lost women’s writings, are examined, in addition to comics, popular film and television, and the work of AA groups.

This edited collection is the first study to provide such a comprehensive analysis of the cultures of addiction. Traversing cultures across the globe, including Asia, Central America, as well as Europe and America, this book opens up the debate in addiction studies and cultural studies. The important insights the book delivers helps to answer questions such as: In what way can Deleuze further the understanding of addiction through the analysis of rock lyrics? How does anthropology improve the understanding of AA groups? How can cultural studies deepen knowledge on the “addiction” to therapy? These are just some of the vast array of areas this book covers. Other areas include the condemnation of “addiction” to comic reading through an historical examination, violence in popular culture, and lost women’s writing on addiction. No other book has such depth and contemporary breadth.

Cultures of Addiction is an important book for those taking cultural studies courses across a range of interrelated disciplines, including English and literary studies, history, American studies, and film and media studies. This will be invaluable to library collections in these fields and beyond in the social sciences, and specifically in addiction studies and psychology.

(Jason Lee, Editor)

Studies on the anticancer potential of high molecular weight bovine lactoferrin in targeting ovarian carcinoma

High molecular weight bovine lactoferrin (HMW-bLf) has been successfully purified from bovine colostrum.The novel bioassay based findings from this study clearly proved the potential of HMW-bLf as a strong and promising therapeutic agent for targeting different kinds of cancers such as ovarian, breast and colon cancers.

Chemiluminescence detection of piperazine designer drugs and related compounds using tris(2,2?-bipyridine)ruthenium(III)

 An exploration of the chemiluminescence from reactions of a large number of benzyl and phenylpiperazine analytes with tris(2,2’-bipyridyl)ruthenium(III) was carried out providing information towards the emission intensity of this chemiluminescent reagent and the structure of analytes it interacts with.

Polystyrene-b-poly(oligo(ethylene oxide) monomethyl ether methacrylate)-bpolystyrene triblock copolymers as potential carriers for hydrophobic drugs

A simple and effective method is introduced to synthesize a series of polystyrene-b-poly(oligo(ethylene oxide) monomethyl ether methacrylate)-b- polystyrene (PSt-b-POEOMA-b-PSt) triblock copolymers. The structures of PSt-b-POEOMA-b-PSt copolymers were characterized by Fourier-transform infrared spectroscopy (FTIR) and nuclear magnetic resonance (1H NMR) spectroscopy. The molecular weight and molecular weight distribution of the copolymer were measured by gel permeation chromatography (GPC). Furthermore£ the self-assembling and drug-loaded behaviours of three different ratios of PSt-b-POEOMA-b-PSt were studied. These copolymers could readily self-assemble into micelles in aqueous solution. The vitamin E-loaded copolymer micelles were produced by the dialysis method. The micelle size and core-shell structure of the block copolymer micelles and the drug-loaded micelles were confirmed by dynamic light scattering (DLS) and transmission electron microscopy (TEM). The thermal properties of the copolymer micelles before and after drug-loaded were investigated by different scanning calorimetry (DSC). The results show that the micelle size is slightly increased with increasing the content of hydrophobic segments and the micelles are still core-shell spherical structures after drug-loaded. Moreover, the glass transition temperature (Tg) of polystyrene is reduced after the drug loaded. The drug loading content (DLC) of the copolymer micelles is 70%-80% by ultraviolet (UV) photolithography analysis. These properties indicate the micelles self-assembled from PSt-b- POEOMA-b- PSt copolymers would have potential as carriers for the encapsulation of hydrophobic drugs.

A microfluidic system for testing the responses of head and neck squamous cell carcinoma tissue biopsies to treatment with chemotherapy drugs

Tumors are heterogeneous masses of cells characterized pathologically by their size and spread. Their chaotic biology makes treatment of malignancies hard to generalize. We present a robust and reproducible glass microfluidic system, for the maintenance and “interrogation” of head and neck squamous cell carcinoma (HNSCC) tumor biopsies, which enables continuous media perfusion and waste removal, recreating in vivo laminar flow and diffusion-driven conditions. Primary HNSCC or metastatic lymph samples were subsequently treated with 5-fluorouracil and cisplatin, alone and in combination, and were monitored for viability and apoptotic biomarker release ‘off-chip’ over 7 days. The concentration of lactate dehydrogenase was initially high but rapidly dropped to minimally detectable levels in all tumor samples; conversely, effluent concentration of WST-1 (cell proliferation) increased over 7 days: both factors demonstrating cell viability. Addition of cell lysis reagent resulted in increased cell death and reduction in cell proliferation. An apoptotic biomarker, cytochrome c, was analyzed and all the treated samples showed higher levels than the control, with the combination therapy showing the greatest effect. Hematoxylin- and Eosin-stained sections from the biopsy, before and after maintenance, demonstrated the preservation of tissue architecture. This device offers a novel method of studying the tumor environment, and offers a pre-clinical model for creating personalized treatment regimens.

Identification of unprecedented anticancer properties of high molecular weight biomacromolecular complex containing bovine lactoferrin (HMW-bLf)

With the successful clinical trials, multifunctional glycoprotein bovine lactoferrin is gaining attention as a safe nutraceutical and biologic drug targeting cancer, chronic-inflammatory, viral and microbial diseases. Interestingly, recent findings that human lactoferrin oligomerizes under simulated physiological conditions signify the possible role of oligomerization in the multifunctional activities of lactoferrin molecule during infections and in disease targeting signaling pathways. Here we report the purification and physicochemical characterization of high molecular weight biomacromolecular complex containing bovine lactoferrin (≥250 kDa), from bovine colostrum, a naturally enriched source of lactoferrin. It showed structural similarities to native monomeric iron free (Apo) lactoferrin (∼78-80 kDa), retained anti-bovine lactoferrin antibody specific binding and displayed potential receptor binding properties when tested for cellular internalization. It further displayed higher thermal stability and better resistance to gut enzyme digestion than native bLf monomer. High molecular weight bovine lactoferrin was functionally bioactive and inhibited significantly the cell proliferation (p<0.01) of human breast and colon carcinoma derived cells. It induced significantly higher cancer cell death (apoptosis) and cytotoxicity in a dose-dependent manner in cancer cells than the normal intestinal cells. Upon cellular internalization, it led to the up-regulation of caspase-3 expression and degradation of actin. In order to identify the cutting edge future potential of this bio-macromolecule in medicine over the monomer, its in-depth structural and functional properties need to be investigated further.

Vascular contribution to metastasis

It has been 40 years since Folkman's seminal paper [Cancer Res 1974. 34:2109-13], proposing the presence of a tumour associated angiogenic factor, which could be targeted as an anticancer therapy. There are currently a handful of drugs in trial or use that have been marketed as targeting angiogenesis. Unfortunately, the most widely used of these, bevacizumab (Avastin™, Roche), has met with limited success clinically. For this reason and based on a calculation of cost benefit, bevacizumab is now only publically subsidised for use in a limited range of solid tumours. That the contribution of vasculature to malignancy remains poorly understood is increasingly clear. At the same time, the traditional view that vascularisation is a passive participant in the process of malignancy, and that endothelium merely provides a conduit by which tumour cells spread, is being replaced with an understanding that vasculature is a key player in the process of metastasis. Furthermore, the identification of non-traditional sources of vasculature has complicated our understanding of the tumour endothelium as a unique population that can be simply targeted as an anticancer therapy. The following review seeks to provide an up-to-date view of vascular contribution to metastasis and implications for new vasculature-targeted anticancer treatments.

Taking the sting out of darting : Risks, restraint drugs and procedures for the chemical restraint of Southern Hemisphere otariids

The need to manage otariid populations has necessitated the development of a wide range of capture methods. Chemical restraint by remote drug delivery (i.e., darting) is a highly selective method that can be used to facilitate otariid capture in a range of scenarios, when other methods may be impracticable. However, the risks associated with darting otariids are not widely known and guidelines necessary to promote and refine best practice do not exist. We review the risks associated with darting and in light of our findings, develop darting guidelines to help practitioners assess and minimize risks during capture, anesthesia and recovery. Published studies reveal that mortalities associated with darting predominantly result from complications during anesthetic maintenance (e.g., prolonged respiratory depression, apnea, or hyperthermia), rather than from complications during capture or recovery. In addition to monitoring vital signs and proper intervention, the risk of irreversible complications during anesthesia can be reduced by administering drug doses that are sufficient to enable the capture and masking of animals, after which anesthetic depth can be regulated using gas anesthesia.

Using clinical trial data and linked administrative health data to reduce the risk of adverse events associated with the uptake of newly released drugs by older Australians: a model process

BACKGROUND: The study was undertaken to evaluate the contribution of a process which uses clinical trial data plus linked de-identified administrative health data to forecast potential risk of adverse events associated with the use of newly released drugs by older Australian patients. METHODS: The study uses publicly available data from the clinical trials of a newly released drug to ascertain which patient age groups, gender, comorbidities and co-medications were excluded in the trials. It then uses linked de-identified hospital morbidity and medications dispensing data to investigate the comorbidities and co-medications of patients who suffer from the target morbidity of the new drug and who are the likely target population for the drug. The clinical trial information and the linked morbidity and medication data are compared to assess which patient groups could potentially be at risk of an adverse event associated with use of the new drug. RESULTS: Applying the model in a retrospective real-world scenario identified that the majority of the sample group of Australian patients aged 65 years and over with the target morbidity of the newly released COX-2-selective NSAID rofecoxib also suffered from a major morbidity excluded in the trials of that drug, indicating a substantial potential risk of adverse events amongst those patients. This risk was borne out in post-release morbidity and mortality associated with use of that drug. CONCLUSIONS: Clinical trial data and linked administrative health data can together support a prospective assessment of patient groups who could be at risk of an adverse event if they are prescribed a newly released drug in the context of their age, gender, comorbidities and/or co-medications. Communication of this independent risk information to prescribers has the potential to reduce adverse events in the period after the release of the new drug, which is when the risk is greatest.Note: The terms 'adverse drug reaction' and 'adverse drug event' have come to be used interchangeably in the current literature. For consistency, the authors have chosen to use the wider term 'adverse drug event' (ADE).

The control of epidermal growth factor grafted on mesoporous silica nanoparticles for targeted delivery

The performance of biomaterials in a biological environment is largely influenced by the surface properties of the biomaterials. In particular, grafted targeting ligands significantly impact the subsequent cellular interactions. The utilisation of a grafted epidermal growth factor (EGF) is effective for targeted delivery of drugs to tumours, but the amount of these biological attachments cannot be easily quantified as most characterization methods could not detect the extremely low amount of EGF ligands grafted on the surface of nanoparticles. In this study, hollow mesoporous silica nanoparticles (HMSNs) were functionalized with amine groups to conjugate with EGFs via carbodiimide chemistry. Time of flight secondary ion mass spectrometry (ToF-SIMS), a very surface specific technique (penetration depth <1.5 nm), was employed to study the binding efficiency of the EGF to the nanoparticles. Principal component analysis (PCA) was implemented to track the relative surface concentrations of EGFs on HMSNs. It was found that ToF-SIMS combined with the PCA technique is an effective method to evaluate the immobilization efficiency of EGFs. Based on this useful technique, the quantity and density of the EGF attachments that grafted on nanoparticles can be effectively controlled by varying the EGF concentration at grafting stages. Cell experiments demonstrated that the targeting performance of EGFR positive cells was affected by the number of EGFs attached on HMSNs.