Binary and ternary inclusion complexes of dapsone in cyclodextrins and polymers: preparation, characterization and evaluation

Dapsone (DAP) is a synthetic sulfone drug with bacteriostatic activity, mainly against Mycobacterium leprae. In this study we have investigated the interactions of DAP with cyclodextrins, 2-hydroxypropyl-beta-cyclodextrin (HP beta CD) and beta-cyclodextrin (beta CD), in the presence and absence of water-soluble polymers, in order to improve its solubility and bioavailability. Solid systems DAP/HP beta CD and DAP/beta CD, in the presence or absence of polyvinylpyrrolidone (PVP K30) or hydroxypropyl methylcellulose (HPMC), were prepared. The binary and ternary systems were evaluated and characterized by SEM, DSC, XRD and NMR analysis as well as phase solubility assays, in order to investigate the interactions between DAP and the excipients in aqueous solution. This study revealed that inclusion complexes of DAP and cyclodextrins (HP beta CD and beta CD) can be produced in order to improve DAP solubility and bioavailability in the presence or absence of polymers (PVP K30 and HPMC). The more stable inclusion complex was obtained with HP beta CD, and consequently HP beta CD was more efficient in improving DAP solubility than beta CD, and the addition of polymers had no influence on DAP solubility or on the stability of the DAP/CDs complexes.

A tellurium-based cathepsin B inhibitor: Molecular structure, modelling, molecular docking and biological evaluation

The crystallographically determined structure of biologically active 4,4-dichloro-1,3-diphenyl-4-telluraoct-2-en-1-one, 3, shows the coordination geometry for Te to be distorted psi-pentagonal bipyramidal based on a C2OCl3(lone pair) donor set. Notable is the presence of an intramolecular axial Te center dot center dot center dot O (carbonyl) interaction, a design element included to reduce hydrolysis. Raman and molecular modelling studies indicate the persistence of the Te center dot center dot center dot O(carbonyl) interaction in the solution (CHCl3) and gasphases, respectively. Docking studies of 3' (i.e. original 3 less one chloride) with Cathepsin B reveals a change in the configuration about the vinyl C = C bond. i.e. to E from Z (crystal structure). This isomerism allows the optimisation of interactions in the complex which features a covalent Te-SGCys29 bond. Crucially, the E configuration observed for 3' allows for the formation of a hypervalent Te center dot center dot center dot O interaction as well as an O center dot center dot center dot H-O hydrogen bond with the Gly27 and Glu122 residues, respectively. Additional stabilisation is afforded by a combination of interactions spanning the S1, S2, S1' and S2' sub-sites of Cathepsin B. The greater experimental inhibitory activity of 3 compared with analogues is rationalised by the additional interactions formed between 3' and the His110 and His111 residues in the occluding loop, which serve to hinder the entrance to the active site. (C) 2012 Elsevier B.V. All rights reserved.

An economic evaluation of antihypertensive therapies based on clinical trials

OBJECTIVE: Hypertension is a major issue in public health, and the financial costs associated with hypertension continue to increase. Cost-effectiveness studies focusing on antihypertensive drug combinations, however, have been scarce. The cost-effectiveness ratios of the traditional treatment (hydrochlorothiazide and atenolol) and the current treatment (losartan and amlodipine) were evaluated in patients with grade 1 or 2 hypertension (HT1-2). For patients with grade 3 hypertension (HT3), a third drug was added to the treatment combinations: enalapril was added to the traditional treatment, and hydrochlorothiazide was added to the current treatment. METHODS: Hypertension treatment costs were estimated on the basis of the purchase prices of the antihypertensive medications, and effectiveness was measured as the reduction in systolic blood pressure and diastolic blood pressure (in mm Hg) at the end of a 12-month study period. RESULTS: When the purchase price of the brand-name medication was used to calculate the cost, the traditional treatment presented a lower cost-effectiveness ratio [US$/mm Hg] than the current treatment in the HT1-2 group. In the HT3 group, however, there was no difference in cost-effectiveness ratio between the traditional treatment and the current treatment. The cost-effectiveness ratio differences between the treatment regimens maintained the same pattern when the purchase price of the lower-cost medication was used. CONCLUSIONS: We conclude that the traditional treatment is more cost-effective (US$/mm Hg) than the current treatment in the HT1-2 group. There was no difference in cost-effectiveness between the traditional treatment and the current treatment for the HT3 group.

Biological evaluation of hydroxynaphthoquinones as anti-malarials

Abstract Background The hydroxynaphthoquinones have been extensively investigated over the past 50 years for their anti-malarial activity. One member of this class, atovaquone, is combined with proguanil in Malarone®, an important drug for the treatment and prevention of malaria. Methods Anti-malarial activity was assessed in vitro for a series of 3-alkyl-2-hydroxy-1,4-naphthoquinones (N1-N5) evaluating the parasitaemia after 48 hours of incubation. Potential cytotoxicity in HEK293T cells was assessed using the MTT assay. Changes in mitochondrial membrane potential of Plasmodium were measured using the fluorescent dye Mitrotracker Red CMXROS. Results Four compounds demonstrated IC50s in the mid-micromolar range, and the most active compound, N3, had an IC50 of 443 nM. N3 disrupted mitochondrial membrane potential, and after 1 hour presented an IC50ΔΨmit of 16 μM. In an in vitro cytotoxicity assay using HEK 293T cells N3 demonstrated no cytotoxicity at concentrations up to 16 μM. Conclusions N3 was a potent inhibitor of mitochondrial electron transport, had nanomolar activity against cultured Plasmodium falciparum and showed minimal cytotoxicity. N3 may serve as a starting point for the design of new hydroxynaphthoquinone anti-malarials.

Interchangeability among therapeutic equivalents of lamotrigine: evaluation of quality of life

Epilepsy is the most common serious neurological disorder worldwide. Approximately 70% of patients with epilepsy have their seizures controlled by clinical and pharmacological treatment. This research evaluated the possible influence of interchangeability among therapeutic equivalents of LTG on the clinical condition and quality of life of refractory epileptic patients. The study was divided into three periods of 42 days, and an equivalent therapeutic LTG randomly dispensed for each period (two similars - formulations A and B, and the reference product - formulation C). The mean dose of LTG was 5.5 mg/kg/day. The presence of side effects tends to have a greater deleterious effect on quality of life of refractory epileptics compared to variations in number of seizures or changes in plasma concentrations. The results showed that independently of the drug prescribed, interchangeability among therapeutic equivalents can negatively impact epilepsy control.

Use of VEGFR-2 targeted microbubbles (BR55, Bracco imaging) for the early ultrasound evaluation of response to antiangiogenic treatment in a xenograft model of hepatocarcinoma

Aim: To evaluate the early response to treatment to an antiangiogenetic drug (sorafenib) in a heterotopic murine model of hepatocellular carcinoma (HCC) using ultrasonographic molecular imaging. Material and Methods: the xenographt model was established injecting a suspension of HuH7 cells subcutaneously in 19 nude mice. When tumors reached a mean diameter of 5-10 mm, they were divided in two groups (treatment and vehicle). The treatment group received sorafenib (62 mg/kg) by daily oral gavage for 14 days. Molecular imaging was performed using contrast enhanced ultrasound (CEUS), by injecting into the mouse venous circulation a suspension of VEGFR-2 targeted microbubbles (BR55, kind gift of Bracco Swiss, Geneve, Switzerland). Video clips were acquired for 6 minutes, then microbubbles (MBs) were destroyed by a high mechanical index (MI) impulse, and another minute was recorded to evaluate residual circulating MBs. The US protocol was repeated at day 0,+2,+4,+7, and +14 from the beginning of treatment administration. Video clips were analyzed using a dedicated software (Sonotumor, Bracco Swiss) to quantify the signal of the contrast agent. Time/intensity curves were obtained and the difference of the mean MBs signal before and after high MI impulse (Differential Targeted Enhancement-dTE) was calculated. dTE represents a numeric value in arbitrary units proportional to the amount of bound MBs. At day +14 mice were euthanized and the tumors analyzed for VEGFR-2, pERK, and CD31 tissue levels using western blot analysis. Results: dTE values decreased from day 0 to day +14 both in treatment and vehicle groups, and they were statistically higher in vehicle group than in treatment group at day +2, at day +7, and at day +14. With respect to the degree of tumor volume increase, measured as growth percentage delta (GPD), treatment group was divided in two sub-groups, non-responders (GPD>350%), and responders (GPD<200%). In the same way vehicle group was divided in slow growth group (GPD<400%), and fast growth group (GPD>900%). dTE values at day 0 (immediately before treatment start) were higher in non-responders than in responders group, with statistical difference at day 2. While dTE values were higher in the fast growth group than in the slow growth group only at day 0. A significant positive correlation was found between VEGFR-2 tissue levels and dTE values, confirming that level of BR55 tissue enhancement reflects the amount of tissue VEGF receptor. Conclusions: the present findings show that, at least in murine experimental models, CEUS with BR55 is feasable and appears to be a useful tool in the prediction of tumor growth and response to sorafenib treatment in xenograft HCC.

Synthesis and evaluation of 18-F-radiopharmaceuticals within the serotonergic receptor system for molecular imaging

Molecular imaging technologies as Positron Emission Tomography (PET) are playing a key role in drug discovery, development and delivery due to the possibility to quantify e.g. the binding potential in vivo, non-invasively and repetitively. In this context, it provides a significant advance in the understanding of many CNS disorders and conditions. The serotonergic receptor system is involved in a number of important physiological processes and diseases such as depression, schizophrenia, Alzheimer’s disease, sleep or sexual behaviour. Especially, the 5-HT2A and the 5-HT1A receptor subtypes are in the focus of fundamental and clinical research due to the fact that many psychotic drugs interact with these neuronal transmembrane receptors. This work describes the successful development, as well as in vitro and in vivo evaluation of 5-HT2A and 5-HT1A selective antagonistic PET-radiotracers. The major achievements obtained in this thesis are: 1. the development and in vitro evaluation of several 5-HT2A antagonistic compounds, namely MH.MZ (Ki = 9.0 nM), (R)-MH.MZ (Ki = 0.72 nM) and MA-1 (Ki = 3.0 nM). 2. the 18F-labeling procedure of these compounds and their optimization, whereby radiochemical yields > 35 % in high specific activities (> 15 GBq/µmol) could be observed. Synthesis time inclusive secondary synthon synthesis, the radioactive labeling procedure, separation and final formulation took no longer than 120 min and provided the tracer in high radiochemical purity. 3. the in vivo µPET evaluation of [18F]MH.MZ and (R)-[18F]MH.MZ resulting in promising imaging agents of the 5-HT2A receptor status; from which (R)-[18F]MH.MZ seems to be the most promising ligand. 4. the determination of the influence of P-gp on the brain biodistribution of [18F]MH.MZ showing a strong P-gp dependency but no regional alteration. 5. the four-step radiosynthesis and evaluation of [18F]MDL 100907 resulting in another high affine tracer, which is, however, limited due to its low radiochemical yield. 6. the development and evaluation of 3 novel possible 5-HT2A imaging agents combining structural elements of altanserin, MDL 100907 and SR 46349B demonstrating different binding modes of these compounds. 7. the development, the labeling and in vitro evaluation of the novel 5-HT1A antagonistic tracer [18F]AH1.MZ (Ki = 4.2 nM).

Evaluation der Langzeitcompliance lebertransplantierter Patienten mit der immunsuppressiven Therapie und eines Betreuungsmodells zur intersektoralen kooperativen pharmazeutischen Betreuung durch eine Krankenhausapotheke und öffentliche Apotheken

Ein wichtiger Baustein für den langfristigen Erfolg einer Lebertransplantation ist die Compliance mit der lebenslang einzunehmenden immunsuppressiven Therapie. Im Rahmen der vorliegenden Arbeit wurde erstmals mittels MEMS® die Compliance bei lebertransplantierten Patienten untersucht, deren Transplantation einige Jahre zurücklag. Rekrutiert wurden Patienten, die vor 2, 5, 7 oder 10 Jahren (Gruppe 2 y.p.t., 5 y.p.t., 7 y.p.t., 10 y.p.t.) in der Universitätsmedizin Mainz lebertransplantiert wurden. 39 Patienten nahmen an der prospektiven Anwendungsbeobachtung teil. Die Compliance wurde mittels MEMS® über eine Beobachtungszeit von 6 Monaten erfasst. Bei der MEMS®-Auswertung war zu vermuten, dass 10 Patienten diese nicht wie vorgesehen verwendet hatten. Folglich konnten die mittels MEMS® gemessenen Compliance-Parameter nur für 29 Patienten valide ermittelt werden. Die mittlere Dosing Compliance betrug 81 ± 21 %, wobei die Gruppe 2 y.p.t. mit 86 ± 14 % bessere Werte zu verzeichnen hatte als die Gruppe 5 y.p.t. (75 ± 27 %) und 7 y.p.t. (74 ± 28 %). Die Ergebnisse waren jedoch nicht signifikant unterschiedlich (p=0,335, Kruskal-Wallis-Test). Unter Einbeziehung aller mittels MEMS® gemessenen Compliance-Parameter wurden 19 von 29 Patienten (66 %) als compliant eingestuft. Bei der Analyse der Gesamtcompliance basierend auf den subjektiven Compliance-Messmethoden (Morisky-Fragebogen, MESI-Fragebogen, Selbsteinschätzung), der Arzneimittel-Blutspiegel und der Anzahl an Abstoßungsreaktionen, in der alle 39 Patienten einbezogen werden konnten, wurden 35 Patienten (90 %) als compliant eingestuft. rnIm zweiten Teil der Arbeit wurde die Etablierung und Bewertung eines intersektoralen Pharmazeutischen Betreuungskonzepts für lebertransplantierte Patienten untersucht. Erstmals wurden anhand eines entwickelten schnittstellenübergreifenden, integrierten Betreuungskonzepts niedergelassene Apotheker in die Pharmazeutische Betreuung lebertransplantierter Patienten eingebunden. 20 Patienten wurden rekrutiert und während ihres stationären Aufenthaltes nach Transplantation pharmazeutisch betreut. Die Betreuung umfasste eine intensive Patientenschulung mit drei bis vier Gesprächen durch einen Krankenhausapotheker. Während des stationären Aufenthaltes wurden arzneimittelbezogene Probleme erkannt, gelöst und dokumentiert. Bei Entlassung stellte der Krankenhausapotheker einen Medikationsplan für den Hausarzt sowie für den niedergelassenen Apotheker aus und führte mit den Patienten ein ausführliches Entlassungsgespräch. Darüber hinaus wurden den Patienten Arzneimitteleinnahmepläne und eine Patienteninformation über ihr immunsuppressives Arzneimittel übergeben. 15 Patienten konnten daraufhin ambulant von niedergelassenen Apothekern pharmazeutisch weiterbetreut werden. Das kooperierende pharmazeutische Personal wurde durch ein eigens für die Studie erstelltes Manual zur Pharmazeutischen Betreuung lebertransplantierter Patienten geschult und unterstützt. Die niedergelassenen Apotheker sollten die Patienten in ihrer Arzneimitteltherapie begleiten, indem Beratungsgespräche geführt und arzneimittelbezogene Probleme erkannt und gelöst wurden. Die Nutzeffekte der intensiven Pharmazeutischen Betreuung konnte anhand verschiedener Erhebungsinstrumente dargelegt werden. Im Ergebnis resultierte eine hohe Zufriedenheit der Patienten und Apotheker mit dem Betreuungskonzept, die mittels Selbstbeurteilungsfragebögen ermittelt wurde. Die Compliance der Patienten wurde anhand des Morisky- und MESI-Fragebogens, der Selbsteinschätzung der Patienten, Blutspiegelbestimmungen sowie der Einschätzung durch den niedergelassenen Apotheker bestimmt. 86 % der Patienten wurden als compliant eingeordnet. Die Kenntnisse der Patienten über ihre immunsuppressive Therapie, welche anhand von Interviews erfragt wurden, lagen auf einem sehr hohen Niveau. Abschließend kann festgestellt werden, dass die Pharmazeutische Betreuung lebertransplantierter Patienten in den niedergelassenen Apotheken durchführbar ist. Anhand der Dokumentationsprotokolle lässt sich allerdings nur sehr schwer beurteilen, in welchem Maße die Betreuung tatsächlich erfolgte. Das tatsächliche vorliegen einer mangelnden Betreuung oder aber eine lückenhafte Dokumentation der Betreuungsleistung war nicht zu differenzieren. Ein limitierender Faktor für die intensivierte Betreuung ist sicherlich der erhebliche Aufwand für nur einen Patienten mit einem seltenen Krankheitsbild. Das Erkennen und Lösen von 48 ABP durch den Krankenhausapotheker und 32 ABP durch die niedergelassenen Apotheker, d. h. insgesamt 4,5 ABP pro Patient zeigt, dass die Pharmazeutische Betreuung einen wichtigen Beitrag für eine qualitätsgesicherte Arzneimitteltherapie leistet. Die intersektorale Pharmazeutische Betreuung stellt eine wesentliche Hilfe und Unterstützung der Patienten im sicheren Umgang mit ihrer Arzneimitteltherapie dar.rn

Development and evaluation of a 44 Ti, 44 Sc radionuclide generator and labeling of biomolecules with 44 Sc and 68 Ga for PET imaging

Non-invasive molecular-imaging technologies are playing a key role in drug discovery, development and delivery. Positron Emission Tomography (PET) is such a molecular imaging technology and a powerful tool for the observation of various deceases in vivo. However, it is limited by the availability of vectors with high selectivity to the target and radionuclides with a physical half-life which matches the biological half-life of the observed process. The 68Ge/68Ga radionuclide generator makes the PET-nuclide anywhere available without an on-site cyclotron. Besides the perfect availability 68Ga shows well suited nuclide properties for PET, but it has to be co-ordinated by a chelator to introduce it in a radiopharmaceuticals.rnHowever, the physical half-life of 68Ga (67.7 min) might limit the spectrum of clinical applications of 68Ga-labelled radiodiagnostics. Furthermore, 68Ga-labelled analogues of endoradiotherapeuticals of longer biological half-live such as 90Y- or 177Lu-labeled peptides and proteins cannot be used to determine individual radiation dosimetry directly. rnThus, radionuclide generator systems providing positron emitting daughters of extended physical half-life are of renewed interest. In this context, generator-derived positron emitters with longer physical half-life are needed, such as 72As (T½ = 26 h) from the 72Se/72As generator, or 44Sc (T½ = 3.97 h) from the 44Ti/44Sc generator.rnIn this thesis the implementation of radioactive gallium-68 and scandium-44 for molecular imaging and nuclear medical diagnosis, beginning with chemical separation and purification of 44Ti as a radionuclide mother, investigation of pilot generators with different elution mode, building a prototype generator, development and investigation of post-processing of the generator eluate, its concentration and further purification, the labeling chemistry under different conditions, in vitro and in vivo studies of labeled compounds and, finally, in vivo imaging experiments are described.

Radiolabeling of defined polymer architectures with fluorine-18 and iodine-131 for ex vivo and in vivo evaluation : visualization of structure-property relationships

Nuclear medicine imaging techniques such as PET are of increasing relevance in pharmaceutical research being valuable (pre)clinical tools to non-invasively assess drug performance in vivo. Therapeutic drugs, e.g. chemotherapeutics, often suffer from a poor balance between their efficacy and toxicity. Here, polymer based drug delivery systems can modulate the pharmacokinetics of low Mw therapeutics (prolonging blood circulation time, reducing toxic side effects, increasing target site accumulation) and therefore leading to a more efficient therapy. In this regard, poly-N-(2-hydroxypropyl)-methacrylamide (HPMA) constitutes a promising biocompatible polymer. Towards the further development of these structures, non-invasive PET imaging allows insight into structure-property relationships in vivo. This performant tool can guide design optimization towards more effective drug delivery. Hence, versatile radiolabeling strategies need to be developed and establishing 18F- as well as 131I-labeling of diverse HPMA architectures forms the basis for short- as well as long-term in vivo evaluations. By means of the prosthetic group [18F]FETos, 18F-labeling of distinct HPMA polymer architectures (homopolymers, amphiphilic copolymers as well as block copolymers) was successfully accomplished enabling their systematic evaluation in tumor bearing rats. These investigations revealed pronounced differences depending on individual polymer characteristics (molecular weight, amphiphilicity due to incorporated hydrophobic laurylmethacrylate (LMA) segments, architecture) as well as on the studied tumor model. Polymers showed higher uptake for up to 4 h p.i. into Walker 256 tumors vs. AT1 tumors (correlating to a higher cellular uptake in vitro). Highest tumor concentrations were found for amphiphilic HPMA-ran-LMA copolymers in comparison to homopolymers and block copolymers. Notably, the random LMA copolymer P4* (Mw=55 kDa, 25% LMA) exhibited most promising in vivo behavior such as highest blood retention as well as tumor uptake. Further studies concentrated on the influence of PEGylation (‘stealth effect’) in terms of improving drug delivery properties of defined polymeric micelles. Here, [18F]fluoroethylation of distinct PEGylated block copolymers (0%, 1%, 5%, 7%, 11% of incorporated PEG2kDa) enabled to systematically study the impact of PEG incorporation ratio and respective architecture on the in vivo performance. Most strikingly, higher PEG content caused prolonged blood circulation as well as a linear increase in tumor uptake (Walker 256 carcinoma). Due to the structural diversity of potential polymeric carrier systems, further versatile 18F-labeling strategies are needed. Therefore, a prosthetic 18F-labeling approach based on the Cu(I)-catalyzed click reaction was established for HPMA-based polymers, providing incorporation of fluorine-18 under mild conditions and in high yields. On this basis, a preliminary µPET study of a HPMA-based polymer – radiolabeled via the prosthetic group [18F]F-PEG3-N3 – was successfully accomplished. By revealing early pharmacokinetics, 18F-labeling enables to time-efficiently assess the potential of HPMA polymers for efficient drug delivery. Yet, investigating the long-term fate is essential, especially regarding prolonged circulation properties and passive tumor accumulation (EPR effect). Therefore, radiolabeling of diverse HPMA copolymers with the longer-lived isotope iodine-131 was accomplished enabling in vivo evaluation of copolymer P4* over several days. In this study, tumor retention of 131I-P4* could be demonstrated at least over 48h with concurrent blood clearance thereby confirming promising tumor targeting properties of amphiphilic HPMA copolymer systems based on the EPR effect.

Coronary optical frequency domain imaging (OFDI) for in vivo evaluation of stent healing: comparison with light and electron microscopy

Coronary late stent thrombosis, a rare but devastating complication, remains an important concern in particular with the increasing use of drug-eluting stents. Notably, pathological studies have indicated that the proportion of uncovered coronary stent struts represents the best morphometric predictor of late stent thrombosis. Intracoronary optical frequency domain imaging (OFDI), a novel second-generation optical coherence tomography (OCT)-derived imaging method, may allow rapid imaging for the detection of coronary stent strut coverage with a markedly higher precision when compared with intravascular ultrasound, due to a microscopic resolution (axial approximately 10-20 microm), and at a substantially increased speed of image acquisition when compared with first-generation time-domain OCT. However, a histological validation of coronary OFDI for the evaluation of stent strut coverage in vivo is urgently needed. Hence, the present study was designed to evaluate the capacity of coronary OFDI by electron (SEM) and light microscopy (LM) analysis to detect and evaluate stent strut coverage in a porcine model.

Natural products as leads for anticancer drug discovery: discovery of new chemotypes of microtubule stabilizers through reengineering of the epothilone scaffold

Epothilones are bacterial macrolides with potent microtubule-stabilizing and antiproliferative activity, which have served as successful lead structures for the discovery of several clinical candidates for cancer treatment. Overall, seven epothilone-type agents have been advanced to clinical evaluation in humans so far and one of these has been approved by the FDA in 2007 for clinical use in breast cancer patients. Notwithstanding these impressive numbers, however, the structural diversity represented by the collection of epothilone analogs that have been (or still are) investigated clinically is rather limited and their individual structures show little divergence from the original natural product leads. In contrast, we have elaborated a series of epothilone-derived macro-lactones, whose overall structural features significantly deviate from those of the natural epothilone scaffold and thus define new structural families of microtubule-stabilizing agents. Key elements of our hypermodification strategy are the change of the natural epoxide geometry from cis to trans, the incorporation of conformationally constrained side chains, the removal of the C(3)-hydroxyl group, and the replacement of C(12) with nitrogen. The latter modification leads to aza-macrolides that may be described as 'non-natural natural products'.

"Drug mules" as a radiological challenge: Sensitivity and specificity in identifying internal cocaine in body packers, body pushers and body stuffers by computed tomography, plain radiography and Lodox

PURPOSE: The purpose of our study was to retrospectively evaluate the specificity, sensitivity and accuracy of computed tomography (CT), digital radiography (DR) and low-dose linear slit digital radiography (LSDR, Lodox(®)) in the detection of internal cocaine containers. METHODS: Institutional review board approval was obtained. The study collectively consisted of 83 patients (76 males, 7 females, 16-45 years) suspected of having incorporated cocaine drug containers. All underwent radiological imaging; a total of 135 exams were performed: nCT=35, nDR=70, nLSDR=30. An overall calculation of all "drug mules" and a specific evaluation of body packers, pushers and stuffers were performed. The gold standard was stool examination in a dedicated holding cell equipped with a drug toilet. RESULTS: There were 54 drug mules identified in this study. CT of all drug carriers showed the highest diagnostic accuracy 97.1%, sensitivity 100% and specificity 94.1%. DR in all cases was 71.4% accurate, 58.3% sensitive and 85.3% specific. LSDR of all patients with internal cocaine was 60% accurate, 57.9% sensitive and 63.4% specific. CONCLUSIONS: CT was the most accurate test studied. Therefore, the detection of internal cocaine drug packs should be performed by CT, rather than by conventional X-ray, in order to apply the most sensitive exam in the medico-legal investigation of suspected drug carriers. Nevertheless, the higher radiation applied by CT than by DR or LSDR needs to be considered. Future studies should include evaluation of low dose CT protocols in order to address germane issues and to reduce dosage.

How valuable are multiple treatment comparison methods in evidence-based health-care evaluation?

Objectives To compare the use of pair-wise meta-analysis methods to multiple treatment comparison (MTC) methods for evidence-based health-care evaluation to estimate the effectiveness and cost-effectiveness of alternative health-care interventions based on the available evidence. Methods Pair-wise meta-analysis and more complex evidence syntheses, incorporating an MTC component, are applied to three examples: 1) clinical effectiveness of interventions for preventing strokes in people with atrial fibrillation; 2) clinical and cost-effectiveness of using drug-eluting stents in percutaneous coronary intervention in patients with coronary artery disease; and 3) clinical and cost-effectiveness of using neuraminidase inhibitors in the treatment of influenza. We compare the two synthesis approaches with respect to the assumptions made, empirical estimates produced, and conclusions drawn. Results The difference between point estimates of effectiveness produced by the pair-wise and MTC approaches was generally unpredictable—sometimes agreeing closely whereas in other instances differing considerably. In all three examples, the MTC approach allowed the inclusion of randomized controlled trial evidence ignored in the pair-wise meta-analysis approach. This generally increased the precision of the effectiveness estimates from the MTC model. Conclusions The MTC approach to synthesis allows the evidence base on clinical effectiveness to be treated as a coherent whole, include more data, and sometimes relax the assumptions made in the pair-wise approaches. However, MTC models are necessarily more complex than those developed for pair-wise meta-analysis and thus could be seen as less transparent. Therefore, it is important that model details and the assumptions made are carefully reported alongside the results.