Évaluation et contrôle de l'irrégularité de la prise médicamenteuse : proposition et développement de stratégies rationnelles fondées sur une démarche de modélisations pharmacocinétiques et pharmacodynamiques

L'hétérogénéité de réponses dans un groupe de patients soumis à un même régime thérapeutique doit être réduite au cours d'un traitement ou d'un essai clinique. Deux approches sont habituellement utilisées pour atteindre cet objectif. L'une vise essentiellement à construire une observance active. Cette approche se veut interactive et fondée sur l'échange ``médecin-patient '', ``pharmacien-patient'' ou ``vétérinaire-éleveurs''. L'autre plutôt passive et basée sur les caractéristiques du médicament, vise à contrôler en amont cette irrégularité. L'objectif principal de cette thèse était de développer de nouvelles stratégies d'évaluation et de contrôle de l'impact de l'irrégularité de la prise du médicament sur l'issue thérapeutique. Plus spécifiquement, le premier volet de cette recherche consistait à proposer des algorithmes mathématiques permettant d'estimer efficacement l'effet des médicaments dans un contexte de variabilité interindividuelle de profils pharmacocinétiques (PK). Cette nouvelle méthode est fondée sur l'utilisation concommitante de données \textit{in vitro} et \textit{in vivo}. Il s'agit de quantifier l'efficience ( c-à-dire efficacité plus fluctuation de concentrations \textit{in vivo}) de chaque profil PK en incorporant dans les modèles actuels d'estimation de l'efficacité \textit{in vivo}, la fonction qui relie la concentration du médicament de façon \textit{in vitro} à l'effet pharmacodynamique. Comparativement aux approches traditionnelles, cette combinaison de fonction capte de manière explicite la fluctuation des concentrations plasmatiques \textit{in vivo} due à la fonction dynamique de prise médicamenteuse. De plus, elle soulève, à travers quelques exemples, des questions sur la pertinence de l'utilisation des indices statiques traditionnels ($C_{max}$, $AUC$, etc.) d'efficacité comme outil de contrôle de l'antibiorésistance. Le deuxième volet de ce travail de doctorat était d'estimer les meilleurs temps d'échantillonnage sanguin dans une thérapie collective initiée chez les porcs. Pour ce faire, nous avons développé un modèle du comportement alimentaire collectif qui a été par la suite couplé à un modèle classique PK. À l'aide de ce modèle combiné, il a été possible de générer un profil PK typique à chaque stratégie alimentaire particulière. Les données ainsi générées, ont été utilisées pour estimer les temps d'échantillonnage appropriés afin de réduire les incertitudes dues à l'irrégularité de la prise médicamenteuse dans l'estimation des paramètres PK et PD . Parmi les algorithmes proposés à cet effet, la méthode des médianes semble donner des temps d'échantillonnage convenables à la fois pour l'employé et pour les animaux. Enfin, le dernier volet du projet de recherche a consisté à proposer une approche rationnelle de caractérisation et de classification des médicaments selon leur capacité à tolérer des oublis sporadiques. Méthodologiquement, nous avons, à travers une analyse globale de sensibilité, quantifié la corrélation entre les paramètres PK/PD d'un médicament et l'effet d'irrégularité de la prise médicamenteuse. Cette approche a consisté à évaluer de façon concomitante l'influence de tous les paramètres PK/PD et à prendre en compte, par la même occasion, les relations complexes pouvant exister entre ces différents paramètres. Cette étude a été réalisée pour les inhibiteurs calciques qui sont des antihypertenseurs agissant selon un modèle indirect d'effet. En prenant en compte les valeurs des corrélations ainsi calculées, nous avons estimé et proposé un indice comparatif propre à chaque médicament. Cet indice est apte à caractériser et à classer les médicaments agissant par un même mécanisme pharmacodynamique en terme d'indulgence à des oublis de prises médicamenteuses. Il a été appliqué à quatre inhibiteurs calciques. Les résultats obtenus étaient en accord avec les données expérimentales, traduisant ainsi la pertinence et la robustesse de cette nouvelle approche. Les stratégies développées dans ce projet de doctorat sont essentiellement fondées sur l'analyse des relations complexes entre l'histoire de la prise médicamenteuse, la pharmacocinétique et la pharmacodynamique. De cette analyse, elles sont capables d'évaluer et de contrôler l'impact de l'irrégularité de la prise médicamenteuse avec une précision acceptable. De façon générale, les algorithmes qui sous-tendent ces démarches constitueront sans aucun doute, des outils efficients dans le suivi et le traitement des patients. En outre, ils contribueront à contrôler les effets néfastes de la non-observance au traitement par la mise au point de médicaments indulgents aux oublis

Structural basis for selective inhibition of trypanosomatid glyceraldehyde-3-phosphate dehydrogenase: Molecular docking and 3D QSAR studies

The glycolytic enzyme glyceraldehyde-3 -phosphate dehydrogenase (GAPDH) is as an attractive target for the development of novel antitrypanosomatid agents. In the present work, comparative molecular field analysis and comparative molecular similarity index analysis were conducted on a large series of selective inhibitors of trypanosomatid GAPDH. Four statistically significant models were obtained (r(2) > 0.90 and q(2) > 0.70), indicating their predictive ability for untested compounds. The models were then used to predict the potency of an external test set, and the predicted values were in good agreement with the experimental results. Molecular modeling studies provided further insight into the structural basis for selective inhibition of trypanosomatid GAPDH.

Diagnóstico de las relaciones bilaterales entre Colombia y República Dominicana en torno al tema del narcotráfico desde 1998 hasta el 2010

El tema del narcotráfico ha sido ampliamente tratado, así como el caso de las drogas en Colombia, pero la afectación de dicho problema no ha sido analizada desde la República Dominicana y mucho menos desde la relación bilateral entre esta y Colombia. Aunque el tema es de gran relevancia en la agenda internacional, así como en la agenda interna de cada uno de estos Estados, no es el tema principal en la relación bilateral, donde los asuntos comerciales tienen mayor importancia, aún cuando hay ciertos mecanismos que buscan eliminar el tráfico ilegal de estupefacientes. En esta investigación, se busca dar un diagnóstico de las relaciones bilaterales y de aquellos instrumentos existentes, específicamente aquellos implementados desde la acogida internacional del término responsabilidad compartida en el año 1998 hasta el año 2010, para determinar la efectividad de los mismos y de aquellos factores que no son precisamente resultantes de las relaciones bilaterales pero que sí afectan de una u otra manera el tráfico de drogas ilegales entre estos dos países. Así, se buscará encontrar las debilidades, en los instrumentos bilaterales entre Colombia y República Dominicana y hacer recomendaciones para hacerlos más efectivos.

Export competitiveness in an oil and gas economy: the case of Trinidad and Tobago, 1985-2010

The oil and gas sector has led the economy of Trinidad and Tobago since the late 1970s and, more pronouncedly, since 2000, accounting for a large share of gdp, total exports and tax revenue. Its prospects in the medium term could be negatively affected, however, if oil and gas extraction expands in other countries, and if the United States attains energy self-sufficiency. This paper offers an analysis of the evolution and competitiveness of its oil and non-oil exports to both the United States and global markets, based on the revealed comparative advantage (rca) index used by eclac. Other foreign trade indicators are also included to determine the structure of the country’s trading relations. The period from 1985 to 2010 is analysed and the results presented are intended to advocate the diversification of Trinidad and Tobago’s exports into more dynamic and diversified markets.

Toward the prediction of class I and II mouse major histocompatibility complex-peptide-binding affinity:in silico bioinformatic step-by-step guide using quantitative structure-activity relationships

Quantitative structure-activity relationship (QSAR) analysis is a cornerstone of modern informatics. Predictive computational models of peptide-major histocompatibility complex (MHC)-binding affinity based on QSAR technology have now become important components of modern computational immunovaccinology. Historically, such approaches have been built around semiqualitative, classification methods, but these are now giving way to quantitative regression methods. We review three methods--a 2D-QSAR additive-partial least squares (PLS) and a 3D-QSAR comparative molecular similarity index analysis (CoMSIA) method--which can identify the sequence dependence of peptide-binding specificity for various class I MHC alleles from the reported binding affinities (IC50) of peptide sets. The third method is an iterative self-consistent (ISC) PLS-based additive method, which is a recently developed extension to the additive method for the affinity prediction of class II peptides. The QSAR methods presented here have established themselves as immunoinformatic techniques complementary to existing methodology, useful in the quantitative prediction of binding affinity: current methods for the in silico identification of T-cell epitopes (which form the basis of many vaccines, diagnostics, and reagents) rely on the accurate computational prediction of peptide-MHC affinity. We have reviewed various human and mouse class I and class II allele models. Studied alleles comprise HLA-A*0101, HLA-A*0201, HLA-A*0202, HLA-A*0203, HLA-A*0206, HLA-A*0301, HLA-A*1101, HLA-A*3101, HLA-A*6801, HLA-A*6802, HLA-B*3501, H2-K(k), H2-K(b), H2-D(b) HLA-DRB1*0101, HLA-DRB1*0401, HLA-DRB1*0701, I-A(b), I-A(d), I-A(k), I-A(S), I-E(d), and I-E(k). In this chapter we show a step-by-step guide into predicting the reliability and the resulting models to represent an advance on existing methods. The peptides used in this study are available from the AntiJen database (http://www.jenner.ac.uk/AntiJen). The PLS method is available commercially in the SYBYL molecular modeling software package. The resulting models, which can be used for accurate T-cell epitope prediction, will be made are freely available online at the URL http://www.jenner.ac.uk/MHCPred.

The association between anticholinergic medication burden and health related outcomes in the ‘oldest old’: A systematic review of the literature

Background: Increased exposure to anticholinergic medication is problematic, particularly in those aged 80 years and older.

Objective: The aim of this systematic review was to identify tools used to quantify anticholinergic medication burden and determine the most appropriate tool for use in longitudinal research, conducted in those aged 80 years and older.

Methods: A systematic literature search was conducted across six electronic databases to identify existing tools. Data extraction was conducted independently by two researchers; studies describing the development of each tool were also retrieved and relevant data extracted. An assessment of quality was completed for all studies. Tools were assessed in terms of their measurement of the association between anticholinergic medication burden and a defined set of clinical outcomes, their development and their suitability for use in longitudinal research; the latter was evaluated on the basis of criteria defined as the key attributes of an ideal anticholinergic risk tool.

Results: In total, 807 papers were retrieved, 13 studies were eligible for inclusion and eight tools were identified. Included studies were classed as ‘very good’ or ‘good’ following the quality assessment analysis; one study was unclassified. Anticholinergic medication burden as measured in studies was associated with impaired cognitive and physical function, as well as an increased frequency of falls. The Drug Burden Index (DBI) exhibited most of the key attributes of an ideal anticholinergic risk tool.

Conclusion: This review identified the DBI as the most appropriate tool for use in longitudinal research focused on older people and their exposure to anticholinergic medication burden.

A review and comparative analysis of international drug driving policies. Report to the New South Wales (NSW) Centre for Road Safety

The New South Wales (NSW) Centre for Road Safety (CRS) called for research services to conduct a review of international policy and practice to address drug-driving. The project sought to provide Transport for NSW (TfNSW) with a comprehensive review of current and emerging international practices in this area1. This report is submitted by the Centre for Accident Research and Road Safety – Queensland (CARRS-Q)...

Biochemical effects of the porphyrinogenic drug allylisopropylacetamide. A comparative study with phenobarbital

Successive administrations of allylisopropylacetamide, a potent porphyrinogenic drug, increase liver weight, microsomal protein and phospholipid contents. There is an increase in the rate of microsomal protein synthesis in vivo and in vitro. The drug decreases microsomal ribonuclease activity and increases NADPH–cytochrome c reductase activity. Phenobarbital, which has been reported to exhibit all these changes mentioned, is a weaker inducer of δ-aminolaevulinate synthetase and increases the rate of haem synthesis only after a considerable time-lag in fed female rats, when compared with the effects observed with allylisopropylacetamide. Again, phenobarbital does not share the property of allylisopropylacetamide in causing an initial decrease in cytochrome P-450 content. Haematin does not counteract most of the biochemical effects caused by allylisopropylacetamide, although it is quite effective in the case of phenobarbital. Haematin does not inhibit the uptake of [2-14C]allylisopropylacetamide by any of the liver subcellular fractions.

A cross-site, comparative effectiveness study of an integrated HIV and substance use treatment program.

Co-occurrence of HIV and substance abuse is associated with poor outcomes for HIV-related health and substance use. Integration of substance use and medical care holds promise for HIV patients, yet few integrated treatment models have been reported. Most of the reported models lack data on treatment outcomes in diverse settings. This study examined the substance use outcomes of an integrated treatment model for patients with both HIV and substance use at three different clinics. Sites differed by type and degree of integration, with one integrated academic medical center, one co-located academic medical center, and one co-located community health center. Participants (n=286) received integrated substance use and HIV treatment for 12 months and were interviewed at 6-month intervals. We used linear generalized estimating equation regression analysis to examine changes in Addiction Severity Index (ASI) alcohol and drug severity scores. To test whether our treatment was differentially effective across sites, we compared a full model including site by time point interaction terms to a reduced model including only site fixed effects. Alcohol severity scores decreased significantly at 6 and 12 months. Drug severity scores decreased significantly at 12 months. Once baseline severity variation was incorporated into the model, there was no evidence of variation in alcohol or drug score changes by site. Substance use outcomes did not differ by age, gender, income, or race. This integrated treatment model offers an option for treating diverse patients with HIV and substance use in a variety of clinic settings. Studies with control groups are needed to confirm these findings.

Comparative biochemical analysis of three members of the Schistosoma mansoni TAL family: Differences in ion and drug binding properties

The tegumental allergen-like (TAL) proteins from Schistosoma mansoni are part of a family of calcium binding proteins found only in parasitic flatworms. These proteins have attracted interest as potential drug or vaccine targets, yet comparatively little is known about their biochemistry. Here, we compared the biochemical properties of three members of this family: SmTAL1 (Sm22.6), SmTAL2 (Sm21.7) and SmTAL3 (Sm20.8). Molecular modelling suggested that, despite similarities in domain organisation, there are differences in the three proteins’ structures. SmTAL1 was predicted to have two functional calcium binding sites and SmTAL2 was predicted to have one. Despite the presence of two EF-hand-like structures in SmTAL3, neither was predicted to be functional. These predictions were confirmed by native gel electrophoresis, intrinsic fluorescence and differential scanning fluorimetry: both SmTAL1 and SmTAL2 are able to bind calcium ions reversibly, but SmTAL3 is not. SmTAL1 is also able to interact with manganese, strontium, iron(II) and nickel ions. SmTAL2 has a different ion binding profile interacting with cadmium, manganese, magnesium, strontium and barium ions in addition to calcium. All three proteins form dimers and, in contrast to some Fasciola hepatica proteins from the same family; dimerization is not affected by calcium ions. SmTAL1 interacts with the anti-schistosomal drug praziquantel and the calmodulin antagonists trifluoperazine, chlorpromazine and W7. SmTAL2 interacts only with W7. SmTAL3 interacts with the aforementioned calmodulin antagonists and thiamylal, but not praziquantel. Overall, these data suggest that the proteins have different biochemical properties and thus, most likely, different in vivo functions.

Comparative Study of Different Methods for the Prediction of Drug− Polymer Solubility

In this study, a comparison of different methods to predict drug−polymer solubility was carried out on binary systems consisting of five model drugs (paracetamol, chloramphenicol, celecoxib, indomethacin, and felodipine) and polyvinylpyrrolidone/vinyl acetate copolymers (PVP/VA) of different monomer weight ratios. The drug−polymer solubility at 25 °C was predicted using the Flory−Huggins model, from data obtained at elevated temperature using thermal analysis methods based on the recrystallization of a supersaturated amorphous solid dispersion and two variations of the melting point depression method. These predictions were compared with the solubility in the low molecular weight liquid analogues of the PVP/VA copolymer (N-vinylpyrrolidone and vinyl acetate). The predicted solubilities at 25 °C varied considerably depending on the method used. However, the three thermal analysis methods ranked the predicted solubilities in the same order, except for the felodipine−PVP system. Furthermore, the magnitude of the predicted solubilities from the recrystallization method and melting point depression method correlated well with the estimates based on the solubility in the liquid analogues, which suggests that this method can be used as an initial screening tool if a liquid analogue is available. The learnings of this important comparative study provided general guidance for the selection of the most suitable method(s) for the screening of drug−polymer solubility.

Substance use and depression. Comparative course in adolescents.

OBJECTIVE: To examine the relation between depression and substance use in adolescents and the concomitant courses of both disorders. METHODS: Four individual interviews were administered to 85 adolescent substance users aged 14-19 years (mean 17.1 years, SD 1.4) over a 3.5 year period using the Adolescent Drug Abuse Interview (ADAD) and the Beck Depression Inventory (BDI-13). RESULTS: No predictive effect was observed on one dimension over the other, but each dimension was predictive of its own course. A decrease in substance-use severity paralleled a decrease in depressive state. Similarly, stable substance-use rates, either at a low or a high level, tended to be associated with low or high levels of depression, respectively. However, an increase in substance use was not accompanied by an increase in depressive states. Moreover, depression varied greatly between adolescents, and according to gender and age. CONCLUSIONS: Depressive states and substance use in adolescents can vary considerably overtime, and are closely but rather synchronically related. Since most of the adolescents do not seek help for substance-related problems, substance use should be systematically assessed in adolescents presenting with a depressive state.

A comparative evaluation of open loop and closed loop drug administration strategies in the treatment of AIDS.

In recent years, many researchers in the field of biomedical sciences have made successful use of mathematical models to study, in a quantitative way, a multitude of phenomena such as those found in disease dynamics, control of physiological systems, optimization of drug therapy, economics of the preventive medicine and many other applications. The availability of good dynamic models have been providing means for simulation and design of novel control strategies in the context of biological events. This work concerns a particular model related to HIV infection dynamics which is used to allow a comparative evaluation of schemes for treatment of AIDS patients. The mathematical model adopted in this work was proposed by Nowak & Bangham, 1996 and describes the dynamics of viral concentration in terms of interaction with CD4 cells and the cytotoxic T lymphocytes, which are responsible for the defense of the organism. Two conceptually distinct techniques for drug therapy are analyzed: Open Loop Treatment, where a priori fixed dosage is prescribed and Closed Loop Treatment, where the doses are adjusted according to results obtained by laboratory analysis. Simulation results show that the Closed Loop Scheme can achieve improved quality of the treatment in terms of reduction in the viral load and quantity of administered drugs, but with the inconvenience related to the necessity of frequent and periodic laboratory analysis.