Contributions to an improved phenytoin monitoring and dosing in hospitalized patients

Phenytoin (PHT) is one of the mostly used and well established anticonvulsants for the treatment of epilepsy and a standard in the antiepileptic prophylaxis in adults with severe traumatic brain injuries before and after neurosurgical intervention. Its therapeutic use is challenging as PHT has a narrow therapeutic range and shows non-linear kinetics. It is extensively metabolized by a variety of CYP enzymes. PHT shows 85-95% binding to plasma proteins mostly albumin. This renders PHT also an important drug interaction candidate. Therefore, therapeutic drug monitoring is often required. A rational timing for good interpretation of the lab data translated in optimal individual dosing are necessary. Therapeutic guidance especially in teaching hospitals are needed and have to be implemented. Bayesian Forecasting (BF) versus conventional dosing (CD): a retrospective, long-term, single centre analysis In the hospital, medication management for effective antiepileptic therapy with PHT often needs rapid IV loading and subsequent dose adjustment according to TDM. To investigate PHT performance in reaching therapeutic target serum concentration, a BF regimen was compared to CD, according to the official summary of product characteristics. In a Swiss acute care teaching hospital (Kantonsspital Aarau), a retrospective, single centre, and long-term analysis was assessed by using all PHT serum tests from the central lab from 1997 to 2007. The BF regimen consisted of a guided, body weight-adapted rapid IV PHT loading over five days with pre-defined TDM time points. The CD was applied without written guidance. Assuming non-normally distributed data, non-parametric statistical methods were used. A total of 6’120 PHT serum levels (2’819 BF and 3’301 CD) from 2’589 patients (869 BF and 1’720 CD) were evaluated and compared. 63.6% of the PHT serum levels from the BF group were within the therapeutic range versus only 34.0% in the CD group (p<0.0001). The mean BF serum level was 52.0 ± 22.1 µmol/L (within target range), whereas the mean serum level of the CD was 39.8 ± 28.2 µmol/L (sub-target range). In the BF group, men had small but significantly lower PHT serum levels compared to women (p<0.0001). The CD group showed no significant gender difference (p=0.187). A comparative sub-analysis of age-related groups (children, adolescents, adults, seniors, and elderly) showed significant lower target levels (p<0.0001) for each group in the CD group, compared to BF. Comparing the two groups, BF showed significantly better performance in reaching therapeutic PHT serum levels. Free PHT assessment However, total serum drug levels of difficult-to-dose drugs like PHT are sometimes insufficient. The knowledge of the free fraction is necessary for correct dosing. In a subgroup analysis of the above BF vs. CD study we evaluated the suitability of the Sheiner-Tozer algorithm to calculate the free PHT fraction in hypoalbuminemic patients. Free PHT serum concentrations were calculated from total PHT concentration in hypoalbuminemic patients and compared with the measured free PHT. The patients were separated into two groups (a low albumin group; 35 ≤ albumin ≥ 25 g/L and a very low albumin group; albumin < 25 g/L). These two groups were compared and statistically analysed for the calculated and the measured free PHT concentration. The calculated (1.2 mg/L, SD=0.7) and the measured (1.1 mg/L, SD=0.5) free PHT concentration correlated. The mean difference in the low and the very low albumin group was 0.10 mg/L (SD=1.4, n=11) and 0.13 mg/L (SD=0.24, n=12), respectively. Although the variability of the data could be a bias, no statistically significant difference between the groups was found: t-test (p=0.78), the Passing-Bablok regression, the Spearman’s rank correlation coefficient of r=0.907 and p=0.00, and the Bland-Altman plot including the regression analysis between the calculated and the measured value (M=0.11, SD=0.28). We concluded that in absence of a free PHT serum concentration measurement also in hypoalbuminemic patients, the Sheiner-Tozer algorithm represents a useful tool to assist TDM to calculate or control free PHT by using total PHT and the albumin concentration. GC-MS Analysis of biological PHT samples To correlate PHT blood serum levels, with “brain PHT levels” (the site of action of PHT), extracellular fluid from microdialysates in neurosurgical patients could be analyzed for PHT by an appropriate quantifying analytical method. In this investigation we describe the development and validation of a sensitive gas chromatography–mass spectrometry (GC–MS) method to identify and quantitate PHT in brain microdialysate, saliva and blood from human samples. For sample clean-up a SPE was performed with a nonpolar C8-SCX column. The eluate was evaporated with nitrogen (50°C) and derivatized with trimethylsulfonium hydroxide before GC-MS analysis. 5-(p-methylphenyl)-5-phenylhydantoin was used as internal standard. The MS was run in scan mode and the identification was made with three ion fragment masses. All peaks were identified with MassLib. Spiked PHT samples showed recovery after SPE of ≥ 94%. The calibration curve (PHT 50 to 1’200 ng/ml, n=6 at six concentration levels) showed good linearity and correlation (r2 > 0.998). The limit of detection was 15 ng/mL, the limit of quantification was 50 ng/mL. Dried extracted samples were stable within a 15% deviation range for ≥ 4 weeks at room temperature. The method met International Organization for Standardization standards and was able to detect and quantify PHT in different biological matrices and patient samples. The GC-MS method with SPE is specific, sensitive, robust and well reproducible and therefore, an appropriate candidate for pharmacokinetic assessment of PHT concentrations in different biological samples of treated patients

SAFE Newsletter : 2013, Q3

Research: Joachim Weber, Benjamin Loos, Steffen Meyer, Andreas Hackethal "Individual Investors' Trading Motives and Security Selling Behavior" Ignazio Angeloni, Ester Faia "Monetary Policy and Prudential Regulations with Bank Runs" Helmut Siekmann "Legal Limits to Quantitative Easing" Policy Margit Vanberg "SAFE Summer Academy 2013 on 'International Financial Stability'" Guest Commentary Peter Praet "Cooperation between the ECB and Academia

Resonances: The sound of performance

It is a hot summer night in August 2013, as the audience gathers near the entrance of the large Gray Hall at the south side of the former coal mine Göttelborn (Germany). The sun has set, and there is only the gray light of dusk in the performance space inside, streaming through the large glass façade, falling onto a small array of stones laid out on the floor. Additional light from a video projector streams over the stones, and a tiny figure of a dancer is seen crawling over rocks, moving in the strange, a-syncopated rhythm of jump cuts. Slowly the sound of rocks scratching against a stone surface begins to be heard, it will remain the only sound for a while, then Japanese instrumentalist Emi Watanabe steps into the empty space with her flute

Murine models of renal disease: Possibilities and problems in studies using mutant mice

The elucidation of the pathogenesis of human renal disease at the molecular level has been facilitated by the growing field of gene targeting and the development of mouse strains with single-gene deletions - the `knock-out' mice. Experimental nephrology, therefore, requires well-characterized and reliable models of human renal disease that can be induced reproducibly in mice. Today surgical procedures for the induction of renal ischemia, chronic renal failure, and ureter obstruction are feasible in mice. Models of mesangioproliferative or crescentic glomerulonephritis, glomerulosclerosis, and tubulointerstitial disease are readily available; however, these depend heavily on the mouse genetic background. Attention to the genetic background and appropriate backcrossing are, therefore, of great importance in the design and interpretation of experimental studies, especially in transgenic mice. Simple murine models displaying the clinical features of other human renal diseases such as IgA nephropathy, membranous glomerulonephritis, and renal vasculitis are still lacking. Mouse strains that spontaneously develop distinct renal pathologies similar to lupus nephritis and focal-segmental glomerulosclerosis can be intercrossed with transgenic mice to study the impact of single-gene deletions on the renal phenotype. The present review provides a survey about currently available spontaneous and inducible murine models of renal disease with special attention to problems and future perspectives for their use in transgenic animals. Copyright (C) 2000 S. Karger AG, Basel

Identification of H2_2CCC as a diffuse interstellar band carrier

We present strong evidence that the broad, diffuse interstellar bands (DIBs) at 4881 and 5450\,\AA are caused by the B\,^1B$_1$\,$\leftarrow$\,X\,^1A$_1$ transition of H$_2$CCC (l-C$_3$H$_2$). The large widths of the bands are due to the short lifetime of the B\,^1B$_1$ electronic state. The bands are predicted from absorption measurements in a neon matrix and observed by cavity ring-down in the gas phase and show exact matches to the profiles and wavelengths of the two broad DIBs. The strength of the 5450\,\AA DIB leads to a l-C$_3$H$_2$ column density of $\sim5\times10^{14}$ cm$^{-2}$ towards HD\,183143 and $\sim2\times10^{14}$\,cm$^{-2}$ to HD\,206267. Despite similar values of $E$($B-V$), the 4881 and 5450\,\AA DIBs in HD\,204827 are less than one third their strength in HD\,183143, while the column density of interstellar C$_3$ is unusually high for HD\,204827 but undetectable for HD\,183143. This can be understood if C$_3$ has been depleted by hydrogenation to species such as l-C$_3$H$_2$ towards HD\,183143. There are also three rotationally resolved sets of triplets of l-C$_3$H$_2$ in the 6150$-$6330\,\AA region. Simulations, based on the derived spectroscopic constants and convolved with the expected instrumental and interstellar line broadening, show credible coincidences with sharp, weak DIBs for the two observable sets of triplets. The region of the third set is too obscured by the $\alpha$-band of telluric O$_2$.Comment: 22 pages, 9 figure