Pharmakovigilanz bei Patienten mit Phenprocoumon-Therapie : Untersuchungen zu potentiellen Interaktionen und Betreuungsqualität

Zur Verbesserung der Sicherheit und Effektivität der Phenprocoumon-Therapie wurden drei unterschiedliche Untersuchungen durchgeführt.rnZunächst wurde auf Grundlage bekannter Datenbanken und Informationsquellen zu Arznei-mittelinteraktionen (Drugdex, Abda Datenbank, Marcumar® Fachinformation, Coumarin-Interaktionsliste der Federatie van Nederlandse Trombosediensten, Review zu Warfarin-Interaktionen) eine handlungsorientierte Interaktionsdatenbank für Phenprocoumon erstellt. Dazu wurden in einer Übersichtstabelle relevante Informationen zu potentiellen Interaktionen für insgesamt 375 Arzneimittel zusammengestellt. Diese Tabelle wurde durch ein dreiköpfiges Expertenteam begutachtet und die potentiellen Interaktionspartner fünf verschiedenen Schweregraden und Stufen klinischer Relevanz zugeordnet. Für fast 50% der potentiellen Interaktionspartner wurden Handlungen als nicht erforderlich erachtet. Für die restlichen potentiellen Interaktionspartner wurden Handlungen zum klinischen Management der Interaktion in Abhängigkeit vom zeitlichen Zusammenhang mit der Phenprocoumon-Einnahme festgelegt. rnAnschließend wurde in einer Anwendungsbeobachtung der Zusammenhang zwischen der zusätzlichen Einnahme potentiell interagierender Arzneimittel (in der entwickelten Datenbank eingestuft mit dem Schweregrad „hoch“ und „sehr hoch“) und der Häufigkeit von Änderungen der Phenprocoumon-Wochendosis an 116 Patienten untersucht. Das relative Risiko für eine Dosisanpassung war bei Patienten in der Interaktions-Gruppe (n=23) signifikant erhöht (RR=1,9; p<0,001). Als weitere potentielle Einflussfaktoren stellten sich zunehmendes Alter (Alter 80-85 Jahre: RR=2; p<0,05), vielfache Komorbiditäten (4 Komorbiditäten: RR=2,1; p<0,05) und eingeschränkte Nieren- (RR=1,47; p>0,05) und Leberfunktion (RR=1,3; p>0,05) heraus.rnZur Untersuchung der Betreuungsqualität von VKA-Patienten im Thrombosedienst Mainz wurden retrospektiv die Daten von 118 Patienten ausgewertet. Als Qualitätsparameter wurden die prozentuale Häufigkeit von INR-Werten im Zielbereich, die TTR (Time in Therapeutic Range), die Dauer der NMH-Therapie, die Zeit bis zum Erreichen des Zielbereichs und der durchschnittliche Abstand zwischen zwei Kontrollterminen ermittelt. Im Median lag jeder Patient mit 73% der gemessenen INR-Werte und im individuellen Zielbereich. Die TTR betrug im Median 80%. Die Patienten benötigten 7 Tage zum Erreichen des Zielbereiches. Die NMH-Therapie wurde über 8 Tage durchgeführt. Die Patienten kamen im Median alle 11 Tage zu einem Kontrolltermin. Im Benchmark zu international publizierten Qualitätskenn-zahlen zur VKA-Therapie ist die Betreuungsqualität im Thrombosedienst Mainz als sehr gut einzustufen.rn

Salomé et Jean Baptiste. Réinvestissements symboliques et récritures d'un mythe dans la littérature et dans l'art (1870-1914)

La publication de nombreuses œuvres, à la fois littéraires et picturales, entre 1870 et 1914, inspirées par l’épisode biblique du meurtre de Jean Baptiste par Salomé, s’inscrit dans une crise qui touche à cette époque, en Europe, aussi bien le sujet que la notion de représentation. Le mythe de Salomé permet de poursuivre une réflexion de nature littéraire, historique et esthétique concernant le processus d’autonomisation de l’art. À partir des sources bibliques et antiques, dans lesquelles Salomé et Jean Baptiste incarnent respectivement le monde païen en conflit avec le monde chrétien, ces deux personnages font graduellement leur entrée dans l’univers de la fiction. Ils sont au cœur de la transition d’une lecture transcendante — reliée particulièrement à la tradition catholique — de l’épisode tragique qui les unit, à une lecture immanente qui en fait deux instances purement esthétiques. La danseuse et le dernier des prophètes émergent dans la littérature et dans l’art occidentaux comme deux pôles symboliques, liés l’un à l’autre par différents types de relation, susceptibles d’être librement réinvestis par de nouvelles significations et à l’écart des conventions. Si, dans la première partie du XIXe siècle, Salomé et Jean Baptiste sont encore liés à leur sens orthodoxe, au tournant du siècle ils finissent par s’autonomiser de l’Écriture et donnent lieu à de multiples récritures et à des adaptations inattendues. Celles-ci ressortissent alors moins du blasphème à proprement parler que d’un témoignage emblématique d’une transformation du rapport que l’artiste entretient avec son œuvre. Celui-ci, en s’identifiant avec le prophète décollé, se mesure à l’œuvre d’art, qui est incarnée par Salomé. La relation entre Salomé et Jean Baptiste, dans ces diverses représentations, exprime et reflète le moment où art et littérature se reconnaissent comme fictions.

In vivo and in vitro investigation of the tissue-specific activity of the human CYP3A4 and CYP3A5 promoters

The human cytochrome P450 3A4 (CYP3A4), the predominant but variably expressed cytochrome P450 in adult liver and small intestine is involved in the metabolism of over 50% of currently used drugs. Its paralog CYP3A5 plays a crucial role in the disposition of several drugs with low therapeutic index, including tacrolimus. Limited information is available for the CYP3A5 transcriptional regulation and its induction by xenobiotics remains controversial. In the first part of this study, we analysed the CYP3A5 transcriptional regulation and its induction by xenobiotics in vivo using transgenic mice. To this end, two transgenic strains were established by pronuclear injection of a plasmid, expressing firefly luciferase driven by a 6.2 kb of the human CYP3A5 promoter. A detailed analysis of both strains shows a tissue distribution largely reflecting that of CYP3A5 transcripts in humans. Thus, the highest luciferase activity was detected in the small intestine, followed by oesophagus, testis, lung, adrenal gland, ovary, prostate and kidney. However, no activity was observed in the liver. CYP3A5-luc transgenic mice were similarly induced in both sexes with either PCN or TCPOBOP in small intestine in a dose-dependent manner. Thus, the 6.2 kb upstream promoter of CYP3A5 mediates the broad tissue activity in transgenic mice. CYP3A5 promoter is inducible in the small intestine in vivo, which may contribute to the variable expression of CYP3A in this organ. rnThe hepato-intestinal level of the detoxifying oxidases CYP3A4 and CYP3A5 is adjusted to the xenobiotic exposure mainly via the xenosensor and transcriptional factor PXR. CYP3A5 is additionally expressed in several other organs lacking PXR, including kidney. In the second part of this study, we investigated the mechanism of the differential expression of CYP3A5 and CYP3A4 and its evolutionary origin using renal and intestinal cells, and comparative genomics. For this examination, we established a two-cell line models reflecting the expression relationships of CYP3A4 and CYP3A5 in the kidney and small intestine in vivo. Our data demonstrate that the CYP3A5 expression in renal cells was enabled by the loss of a suppressing Yin Yang 1 (YY1)-binding site from the CYP3A5 promoter. This allowed for a renal CYP3A5 expression in a PXR-independent manner. The YY1 element is retained in the CYP3A4 gene, leading to its suppression, perhaps via interference with the NF1 activity in renal cells. In intestinal cells, the inhibition of CYP3A4 expression by YY1 is abrogated by a combined activating effect of PXR and NF1 acting on their respective response elements located adjacent to the YY1-binding site on CYP3A4 proximal promoter. CYP3A4 expression is further facilitated by a point mutation attenuating the suppressing effect of YY1 binding site. The differential expression of CYP3A4 and CYP3A5 in these organs results from the loss of the YY1 binding element from the CYP3A5 promoter, acting in concert with the differential organ expression of PXR, and with the higher accumulation of PXR response elements in CYP3A4. rn

Chapter III: Management of cardiovascular risk factors and medical therapy

Critical limb ischaemia (CLI) is a particularly severe manifestation of lower limb atherosclerosis posing a major threat to both limb and life of affected patients. Besides arterial revascularisation, risk-factor modification and administration of antiplatelet therapy is a major goal in the treatment of CLI patients. Key elements of cardiovascular risk management are smoking cessation and treatment of hyperlipidaemia with dietary modification or statins. Moreover, arterial hypertension and diabetes mellitus should be adequately treated. In CLI patients not suitable for arterial revascularisation or subsequent to unsuccessful revascularisation, parenteral prostanoids may be considered. CLI patients undergoing surgical revascularisation should be treated with beta blockers. At present, neither gene nor stem-cell therapy can be recommended outside clinical trials. Of note, walking exercise is contraindicated in CLI patients due to the risk of worsening pre-existing or causing new ischaemic wounds. CLI patients are oftentimes medically frail and exhibit significant comorbidities. Co-existing coronary heart and carotid as well as renal artery disease should be managed according to current guidelines. Considering the above-mentioned treatment goals, interdisciplinary treatment approaches for CLI patients are warranted. Aim of the present manuscript is to discuss currently existing evidence for both the management of cardiovascular risk factors and treatment of co-existing disease and to deduct specific treatment recommendations.

Reshaping Rural Extension: Learning for Sustainability (LforS): An Integrative and Learning-Based Advisory Approach for Rural Extension with Small-Scale Farmers

This publication offers concrete suggestions for implementing an integrative and learning-oriented approach to agricultural extension with the goal of fostering sustainable development. It targets governmental and non-governmental organisations, development agencies, and extension staff working in the field of rural development. The book looks into the conditions and trends that influence extension today, and outlines new challenges and necessary adaptations. It offers a basic reflection on the goals, the criteria for success and the form of a state-of-the-art approach to extension. The core of the book consists of a presentation of Learning for Sustainability (LforS), an example of an integrative, learning-oriented approach that is based on three crucial elements: stakeholder dialogue, knowledge management, and organizational development. Awareness raising and capacity building, social mobilization, and monitoring & evaluation are additional building blocks. The structure and organisation of the LforS approach as well as a selection of appropriate methods and tools are presented. The authors also address key aspects of developing and managing a learning-oriented extension approach. The book illustrates how LforS can be implemented by presenting two case studies, one from Madagascar and one from Mongolia. It addresses conceptual questions and at the same time it is practice-oriented. In contrast to other extension approaches, LforS does not limit its focus to production-related aspects and the development of value chains: it also addresses livelihood issues in a broad sense. With its focus on learning processes LforS seeks to create a better understanding of the links between different spheres and different levels of decision-making; it also seeks to foster integration of the different actors’ perspectives.

Report from a consensus conference on antibody-mediated rejection in heart transplantation

The problem of AMR remains unsolved because standardized schemes for diagnosis and treatment remains contentious. Therefore, a consensus conference was organized to discuss the current status of antibody-mediated rejection (AMR) in heart transplantation.

Synthesis, maturation, and trafficking of human Na+-dicarboxylate cotransporter NaDC1 requires the chaperone activity of cyclophilin B

Renal excretion of citrate, an inhibitor of calcium stone formation, is controlled mainly by reabsorption via the apical Na(+)-dicarboxylate cotransporter NaDC1 (SLC13A2) in the proximal tubule. Recently, it has been shown that the protein phosphatase calcineurin inhibitors cyclosporin A (CsA) and FK-506 induce hypocitraturia, a risk factor for nephrolithiasis in kidney transplant patients, but apparently through urine acidification. This suggests that these agents up-regulate NaDC1 activity. Using the Xenopus lævis oocyte and HEK293 cell expression systems, we examined first the effect of both anti-calcineurins on NaDC1 activity and expression. While FK-506 had no effect, CsA reduced NaDC1-mediated citrate transport by lowering heterologous carrier expression (as well as endogenous carrier expression in HEK293 cells), indicating that calcineurin is not involved. Given that CsA also binds specifically to cyclophilins, we determined next whether such proteins could account for the observed changes by examining the effect of selected cyclophilin wild types and mutants on NaDC1 activity and cyclophilin-specific siRNA. Interestingly, our data show that the cyclophilin isoform B is likely responsible for down-regulation of carrier expression by CsA and that it does so via its chaperone activity on NaDC1 (by direct interaction) rather than its rotamase activity. We have thus identified for the first time a regulatory partner for NaDC1, and have gained novel mechanistic insight into the effect of CsA on renal citrate transport and kidney stone disease, as well as into the regulation of membrane transporters in general.

Nursing the fatherland? Hohenzollern statebuilding and the hidden transcript of political resistance in Hanoverian female charity during the Second German Empire

In summer 1866 the Austro-Prussian struggle for supremacy in Germany erupted into open conflict. King Georg V of Hanover sided with other governments loyal to the German Confederation against Prussia, but after initially defeating Prussian forces at Langensalza, he was forced to capitulate. Two days after the battle, on June 29, 1866, the widow of the Hanoverian general Sir Georg Julius von Hartmann told her daughter in no uncertain terms how she felt about the Prussian government and its allies. In her opinion they were nothing more than “robber states” that cloaked their disregard for the Ten Commandments in sanctimonious public displays of piety. “These Protestant Jesuits,” she continued, “offend me more than the Catholic ones. You know that I am German with all my heart and love my Germany, but I cannot consider them genuine Germans anymore because they only want to make Germany Prussian.”

Relationship of porcine IGF2 imprinting status to DNA methylation at the H19 DMD and the IGF2 DMRs 1 and 2

BACKGROUND: Porcine IGF2 and the H19 genes are imprinted. The IGF2 is paternally expressed, while the H19 gene is maternally expressed. Extensive studies in mice established a boundary model indicating that the H19 differentially methylated domain (DMD) controls, upon binding with the CTCF protein, reciprocal imprinting of the IGF2 and the H19 genes. IGF2 transcription is tissue and development specific involving the use of 4 promoters. In the liver of adult Large White boars IGF2 is expressed from both parental alleles, whereas in skeletal muscle and kidney tissues we observed variable relaxation of IGF2 imprinting. We hypothesized that IGF2 expression from both paternal alleles and relaxation of IGF2 imprinting is reflected in differences in DNA methylation patterns at the H19 DMD and IGF2 differentially methylated regions 1 and 2 (DMR1 and DMR2). RESULTS: Bisulfite sequencing analysis did not show any differences in DNA methylation at the three porcine CTCF binding sites in the H19 DMD between liver, muscle and kidney tissues of adult pigs. A DNA methylation analysis using methyl-sensitive restriction endonuclease SacII and 'hot-stop' PCR gave consistent results with those from the bisulfite sequencing analysis. We found that porcine H19 DMD is distinctly differentially methylated, at least for the region formally confirmed by two SNPs, in liver, skeletal muscle and kidney of foetal, newborn and adult pigs, independent of the combined imprinting status of all IGF2 expressed transcripts. DNA methylation at CpG sites in DMR1 of foetal liver was significantly lower than in the adult liver due to the presence of hypomethylated molecules. An allele specific analysis was performed for IGF2 DMR2 using a SNP in the IGF2 3'-UTR. The maternal IGF2 DMR2 of foetal and newborn liver revealed a higher DNA methylation content compared to the respective paternal allele. CONCLUSIONS: Our results indicate that the IGF2 imprinting status is transcript-specific. Biallelic IGF2 expression in adult porcine liver and relaxation of IGF2 imprinting in porcine muscle were a common feature. These results were consistent with the IGF2 promoter P1 usage in adult liver and IGF2 promoter P2, P3 and P4 usages in muscle. The results showed further that bialellic IGF2 expression in liver and relaxation of imprinting in muscle and kidney were not associated with DNA methylation variation at and around at least one CTCF binding site in H19 DMD. The imprinting status in adult liver, muscle and kidney tissues were also not reflected in the methylation patterns of IGF2 DMRs 1 and 2.

Cardiac tissue-restricted deletion of plakoglobin results in progressive cardiomyopathy and activation of {beta}-catenin signaling

Mutations in the plakoglobin (JUP) gene have been identified in arrhythmogenic right ventricular cardiomyopathy (ARVC) patients. However, the mechanisms underlying plakoglobin dysfunction involved in the pathogenesis of ARVC remain poorly understood. Plakoglobin is a component of both desmosomes and adherens junctions located at the intercalated disc (ICD) of cardiomyocytes, where it functions to link cadherins to the cytoskeleton. In addition, plakoglobin functions as a signaling protein via its ability to modulate the Wnt/beta-catenin signaling pathway. To investigate the role of plakoglobin in ARVC, we generated an inducible cardiorestricted knockout (CKO) of the plakoglobin gene in mice. Plakoglobin CKO mice exhibited progressive loss of cardiac myocytes, extensive inflammatory infiltration, fibrous tissue replacement, and cardiac dysfunction similar to those of ARVC patients. Desmosomal proteins from the ICD were decreased, consistent with altered desmosome ultrastructure in plakoglobin CKO hearts. Despite gap junction remodeling, plakoglobin CKO hearts were refractory to induced arrhythmias. Ablation of plakoglobin caused increase beta-catenin stabilization associated with activated AKT and inhibition of glycogen synthase kinase 3beta. Finally, beta-catenin/TCF transcriptional activity may contribute to the cardiac hypertrophy response in plakoglobin CKO mice. This novel model of ARVC demonstrates for the first time how plakoglobin affects beta-catenin activity in the heart and its implications for disease pathogenesis.

Myocardial blood volume and coronary resistance during and after coronary angioplasty

Animal experiments have shown that the coronary circulation is pressure distensible, i.e., myocardial blood volume (MBV) increases with perfusion pressure. In humans, however, corresponding measurements are lacking so far. We sought to quantify parameters reflecting coronary distensibility such as MBV and coronary resistance (CR) during and after coronary angioplasty. Thirty patients with stable coronary artery disease underwent simultaneous coronary perfusion pressure assessment and myocardial contrast echocardiography (MCE) of 37 coronary arteries and their territories during and after angioplasty. MCE yielded MBV and myocardial blood flow (MBF; in ml · min(-1) · g(-1)). Complete data sets were obtained in 32 coronary arteries and their territories from 26 patients. During angioplasty, perfusion pressure, i.e., coronary occlusive pressure, and MBV varied between 9 and 57 mmHg (26.9 ± 11.9 mmHg) and between 1.2 and 14.5 ml/100 g (6.7 ± 3.7 ml/100 g), respectively. After successful angioplasty, perfusion pressure and MBV increased significantly (P < 0.001 for both) and varied between 64 and 118 mmHg (93.5 ± 12.8 mmHg) and between 3.7 and 17.3 ml/100 g (9.8 ± 3.4 ml/100 g), respectively. Mean MBF increased from 31 ± 20 ml · min(-1) · g(-1) during coronary occlusion, reflecting collateral flow, to 121 ± 33 ml · min(-1) · g(-1) (P < 0.01), whereas mean CR, i.e., the ratio of perfusion pressure and MBF, decreased by 20% (P < 0.001). In conclusion, the human coronary circulation is pressure distensible. MCE allows for the quantification of CR and MBV in humans.

A field study on characteristics and diversity of gene expression in the liver of dairy cows during the transition period

Metabolic and endocrine adaptations to support milk production during the transition period vary between individual cows. This variation between cows to adapt to lactation may have a genetic basis. The present field study was carried out to determine hepatic adaptations occurring from late pregnancy through early lactation by measuring mRNA abundance of candidate genes in dairy cows on-farm. Additionally, the objective was to observe the diversity in inter-individual variation for the candidate genes that may give indications where individual adaptations at a molecular level can be found. This study was carried out on-farm including 232 dairy cows (parity >3) from 64 farms in Switzerland. Blood and liver samples were collected on d 20+/-7 before parturition, on d 24+/-2, and on d 89+/-4 after parturition. Blood plasma was assayed for concentrations of glucose, nonesterified fatty acids, beta-hydroxybutyrate, cholesterol, triglycerides, urea, albumin, protein, insulin, insulin-like growth factor-1, leptin, 3,5,3'-triiodothyronine, and thyroxine. Liver samples were obtained at the same time points and were measured for mRNA abundance of 26 candidate genes encoding enzymes and nuclear receptors involved in gluconeogenesis, fatty acid beta-oxidation, fatty acid and triglyceride synthesis, ketogenesis, citric acid cycle, cholesterol synthesis, and the urea cycle. The cows in the present study experienced a marked metabolic load in early lactation, as presented by changes in plasma metabolites and hormones, and responded accordingly with upregulation and downregulation of almost all candidate genes involved in metabolic processes in the liver. The observed inter-individual variation for the candidate genes, which was highest for acetyl-CoA-carboxylase and glycerol-3-phosphate dehydrogenase 2, should be further investigated to unravel the regulation at molecular level for optimal adaptive performance in dairy cows.

Pulmonary artery pressure and cardiac function in children and adolescents after rapid ascent to 3,450 m

High-altitude destinations are visited by increasing numbers of children and adolescents. High-altitude hypoxia triggers pulmonary hypertension that in turn may have adverse effects on cardiac function and may induce life-threatening high-altitude pulmonary edema (HAPE), but there are limited data in this young population. We, therefore, assessed in 118 nonacclimatized healthy children and adolescents (mean ± SD; age: 11 ± 2 yr) the effects of rapid ascent to high altitude on pulmonary artery pressure and right and left ventricular function by echocardiography. Pulmonary artery pressure was estimated by measuring the systolic right ventricular to right atrial pressure gradient. The echocardiography was performed at low altitude and 40 h after rapid ascent to 3,450 m. Pulmonary artery pressure was more than twofold higher at high than at low altitude (35 ± 11 vs. 16 ± 3 mmHg; P < 0.0001), and there existed a wide variability of pulmonary artery pressure at high altitude with an estimated upper 95% limit of 52 mmHg. Moreover, pulmonary artery pressure and its altitude-induced increase were inversely related to age, resulting in an almost twofold larger increase in the 6- to 9- than in the 14- to 16-yr-old participants (24 ± 12 vs. 13 ± 8 mmHg; P = 0.004). Even in children with the most severe altitude-induced pulmonary hypertension, right ventricular systolic function did not decrease, but increased, and none of the children developed HAPE. HAPE appears to be a rare event in this young population after rapid ascent to this altitude at which major tourist destinations are located.

Improvement in renal function after everolimus introduction and calcineurin inhibitor reduction in maintenance thoracic transplant recipients: the significance of baseline glomerular filtration rate

The NOCTET (NOrdic Certican Trial in HEart and lung Transplantation) trial demonstrated that everolimus improves renal function in maintenance thoracic transplant (TTx) recipients. Nevertheless, introduction of everolimus is not recommended for patients with advanced renal failure. We evaluated NOCTET data to assess everolimus introduction amongst TTx recipients with advanced renal failure.