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Analysis of selected constituents in methanolic extracts of Hypericum perforatum collected in different localities by capillary ITP-CZE.

The on-line combination of CZE with capillary ITP (ITP-CZE) was used for the separation and quantification of selected flavonoids and phenolic acids in Hypericum perforatum leaves and flowers collected in six different localities in Slovakia. The leading electrolyte in the ITP preseparation step was 10 mM HCl with Tris as counterion (pH* 7.2). The terminating electrolyte was 50 mM boric acid of pH* 8.2 (adjusted with barium hydroxide). The BGE in the electrophoretic step contained 25 mM beta-hydroxy-4-morpholinopropanesulfonic acid (MOPSO), 50 mM Tris, 65 mM boric acid, pH* 8.3. The content of methanol in all electrolytes was 20% v/v. The total time of the analysis (including the preseparation step) was approximately 35 min. The rectilinear calibration ranges were between 0.125 and 5.0 microg/mL with kaempferol as internal standard. The correlation coefficients ranged between 0.9912 (for quercitrin and chlorogenic acid) and 0.9988 (for isoquercitrin). The RSD values are between 0.86 and 7.78% (n = 6) when determining rutin and quercetin (4 microg/mL). The optimized method was employed for the assay of flavonoids in medicinal plant extract of different collections of Hypericum perforatum haulm. The variability of the content of the active components depending on the place of collection was confirmed.

Boric Acids↗

The new herpesviruses: emerging pathogens of dermatological interest.

OBJECTIVES: To discuss the current knowledge of 3 recently discovered human herpesviruses (HHV-6, HHV-7, and HHV-8), and to provide a dermatological point of view. DATA SOURCES: References identified from bibliographies of pertinent articles in the English language. STUDY SELECTION AND DATA EXTRACTION: Articles were selected according to their impact factor and the interest for dermatologists. DATA SYNTHESIS: As the other members of the family Herpesviridae, HHV-6, HHV-7, and HHV-8 may cause a primary infection, establish latent infection in a specific set of cells of their host, and then reactivate if conditions of altered immunity develop. The main pathological conditions associated with them are discussed. CONCLUSIONS: Human herpesvirus 6, HHV-7, and HHV-8 have provided new insights in some dermatological diseases. Although new studies are needed, they may have a profound impact on dermatology in the years to come.

Exanthema Subitum↗

Green tea and skin.

OBJECTIVE: To discuss the current knowledge of polyphenolic compounds present in green tea as anti-inflammatory, antioxidant, and anticarcinogenic in skin. DATA SOURCES: References identified from bibliographies of pertinent articles, including our work in related fields. STUDY SELECTION AND DATA EXTRACTION: Articles were selected based on the use of green tea or its polyphenolic constituents for prevention against inflammation and cancer in the skin. Also discussed is the possible use of green tea to treat various inflammatory dermatoses. DATA SYNTHESIS: The polyphenolic compounds from green tea were tested against chemical carcinogenesis and photocarcinogenesis in murine skin. These green tea polyphenols were found to afford protection against chemical carcinogenesis as well as photocarcinogenesis in mouse skin. A few experimental studies were conducted in human skin in our laboratory. Analysis of published studies demonstrates that green tea polyphenols have anti-inflammatory and anticarcinogenic properties. These effects appear to correlate with antioxidant properties of green tea polyphenols. CONCLUSIONS: The outcome of the several experimental studies suggests that green tea possess anti-inflammatory and anticarcinogenic potential, which can be exploited against a variety of skin disorders. Although more clinical studies are needed, supplementation of skin care products with green tea may have a profound impact on various skin disorders in the years to come. Arch Dermatol. 2000;136:989-994

Administration, Oral↗

Gastroesophageal reflux, barrett esophagus, and esophageal cancer: scientific review.

CONTEXT: Gastroesophageal reflux disease (GERD) is a risk factor for adenocarcinoma of the esophagus, a rare cancer whose incidence is increasing. Adenocarcinoma may develop from Barrett esophagus, a metaplastic change of the esophageal epithelium from squamous to intestinalized columnar mucosa, which is associated with chronic reflux. Some have recommended that patients with chronic reflux symptoms undergo upper endoscopy to assess for Barrett esophagus and to screen for cancer. OBJECTIVES: To review the evidence linking GERD and Barrett esophagus to esophageal adenocarcinoma and to examine the utility of upper endoscopy as a screening tool in adenocarcinoma of the esophagus among individuals with GERD. DATA SOURCES: A MEDLINE search was performed to identify all pertinent English-language reports about GERD, adenocarcinoma, and Barrett esophagus from 1968 through 2001. Reports were of randomized controlled clinical trials if available, case-control data if trials were unavailable, and cohort studies if case-control data were unavailable. Pertinent bibliographies were also reviewed to find reports not otherwise identified. STUDY SELECTION AND DATA EXTRACTION: Studies were selected by using the search terms gastroesophageal reflux, adenocarcinoma, and Barrett's esophagus, with subheadings for classification, complications, drug therapy, economics, epidemiology, mortality, surgery, and prevention and control. Clinical guidelines for the care of subjects with GERD and Barrett esophagus were retrieved and abstracted. DATA SYNTHESIS: Cohort studies demonstrate that symptoms of GERD occur monthly in almost 50% of US adults and weekly in almost 20%. Three large case-control studies demonstrate a positive association between reflux symptoms and risk of adenocarcinoma of the esophagus, with more prolonged and severe symptoms accentuating this risk. However, because of the low incidence of adenocarcinoma of the esophagus and the ubiquity of reflux symptoms, the risk of cancer in any given individual with reflux symptoms is low. No randomized trial data are available to demonstrate either decreased cancer incidence or increased life expectancy in subjects with GERD who undergo screening endoscopy. CONCLUSIONS: Strong evidence supports the association of GERD and adenocarcinoma of the esophagus; however, the risk of cancer in any given individual with GERD is low. Barrett esophagus appears to be a common precursor lesion to this cancer. Given the low absolute risk of cancer in those with GERD and the lack of demonstrated efficacy of endoscopic screening, insufficient evidence exists to endorse routine endoscopic screening of patients with chronic GERD symptoms.

Adenocarcinoma↗

Intravenous immunoglobulin in autoimmune neuromuscular diseases.

CONTEXT: Intravenous immunoglobulin (IVIG) enhances immune homeostasis by modulating expression and function of Fc receptors, interfering with activation of complement and production of cytokines, providing anti-idiotypic antibodies, and affecting the activation and effector functions of T and B cells. These mechanisms may explain the effectiveness of IVIG in autoimmune neuromuscular disorders. OBJECTIVE: To systematically review the current status of the treatment of autoimmune neuromuscular diseases with IVIG, with emphasis on controlled trials. DATA SOURCES: Peer-reviewed publications identified through MEDLINE (1966-2003), EMBASE (1974-2003), and references from bibliographies of pertinent articles. Each autoimmune neuromuscular disease term was searched in combination with the term intravenous immunoglobulin. STUDY SELECTION AND DATA EXTRACTION: Criteria for selection of studies included controlled study design, English language, and clinical pertinence. Data quality was based on venue of publication and relevance to clinical care. DATA SYNTHESIS: Outcomes of controlled trials indicate that IVIG at a total dose of 2 g/kg is effective as first-line therapy in Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy and as second-line therapy in stiff-person syndrome, dermatomyositis, myasthenia gravis, and Lambert-Eaton myasthenic syndrome. In other controlled studies, IVIG produced a modest, variable, and transient but not statistically significant benefit in patients with inclusion body myositis and paraproteinemic anti-myelin-associated glycoprotein antibody demyelinating polyneuropathy. Intravenous immunoglobulin is not effective in patients with multiple sclerosis who have established weakness or optic neuritis. In myasthenia gravis, it should be reserved for difficult cases or before thymectomy in lieu of plasma exchange. CONCLUSION: Intravenous immunoglobulin is effective in many autoimmune neurologic diseases, but its spectrum of efficacy, especially as first-line therapy, and the appropriate dose for long-term maintenance therapy are not fully established. Further controlled studies of IVIG, combined with a dose-finding effect, pharmacoeconomics, and quality-of-life assessments, are warranted to improve the evidence base for clinical practice.

Autoimmune Diseases of the Nervous System↗

A simplified approach to the management of non-ST-segment elevation acute coronary syndromes.

CONTEXT: While current practice guidelines provide an evidence-based approach to management of acute coronary syndromes (ACS), application of the evidence by individual physicians has been suboptimal. OBJECTIVE: To assess and synthesize the evidence regarding optimal management of non-ST-segment elevation ACS (NSTE-ACS). DATA SOURCES: Systematic searches of peer-reviewed publications were performed in MEDLINE and the Cochrane Database from January 1990 through November 2004, with consultation by content experts. Search terms included antiplatelet therapy, antithrombotic therapy, angiotensin-converting enzyme inhibition, angiotensin receptor blockade, beta-blockade, hypertension, hyperlipidemia, cigarette smoking, diet, diabetes mellitus, exercise, myocardial ischemia, and coronary artery disease. STUDY SELECTION AND DATA EXTRACTION: Criteria for selection of studies included controlled study design, English language, and clinical pertinence. Data quality was based on the publishing journal and relevance to clinical management of NSTE-ACS. DATA SYNTHESIS: While outcomes of controlled studies support a comprehensive approach in the management of patients with NSTE-ACS, many physicians perceive existing guidelines as lengthy and complex. After risk stratification to identify those patients most likely to benefit from an early invasive vs early conservative strategy, a comprehensive management plan can be assembled through an "ABCDE" approach. The elements of this include "A" for antiplatelet therapy, anticoagulation, angiotensin-converting enzyme inhibition, and angiotensin receptor blockade; "B" for beta-blockade and blood pressure control; "C" for cholesterol treatment and cigarette smoking cessation; "D" for diabetes management and diet; and "E" for exercise. CONCLUSION: An "ABCDE" approach for the management of NSTE-ACS provides a practical and systematic means to implement evidence-based medicine into clinical practice.

Adrenergic beta-Antagonists↗

Strategy for selection of methods for separation of bioparticles from particle mixtures.

The desired product of bioprocesses is often produced in particulate form, either as an inclusion body (IB) or as a crystal. Particle harvesting is then a crucial and attractive form of product recovery. Because the liquid phase often contains other bioparticles, such as cell debris, whole cells, particulate biocatalysts or particulate by-products, the recovery of product particles is a complex process. In most cases, the particulate product is purified using selective solubilization or extraction. However, if selective particle recovery is possible, the already high purity of the particles makes this downstream process more favorable. This work gives an overview of typical bioparticle mixtures that are encountered in industrial biotechnology and the various driving forces that may be used for particle-particle separation, such as the centrifugal force, the magnetic force, the electric force, and forces related to interfaces. By coupling these driving forces to the resisting forces, the limitations of using these driving forces with respect to particle size are calculated. It shows that centrifugation is not a general solution for particle-particle separation in biotechnology because the particle sizes of product and contaminating particles are often very small, thus, causing their settling velocities to be too low for efficient separation by centrifugation. Examples of such separation problems are the recovery of IBs or virus-like particles (VLPs) from (microbial) cell debris. In these cases, separation processes that use electrical forces or fluid-fluid interfaces show to have a large potential for particle-particle separation. These methods are not yet commonly applied for large-scale particle-particle separation in biotechnology and more research is required on the separation techniques and on particle characterization to facilitate successful application of these methods in industry.

Biological Products↗

Characterization via liquid chromatography coupled to diode array detector and tandem mass spectrometry of supercritical fluid antioxidant extracts of Spirulina platensis microalga.

Spirulina platensis microalga has been extracted on a pilot scale plant using supercritical fluid extraction (SFE) under various extraction conditions. The extraction yield and the antioxidant activity of the extracts were evaluated in order to select those extracts with both the highest antioxidant capacity and a good extraction yield. These extracts were characterized using LC coupled to diode array detection (DAD) and LC coupled to mass spectrometry (MS) with two different interfaces, atmospheric pressure chemical ionization (APCI) and electrospray (ESI) which allowed us to perform tandem MS by using an ion trap analyzer. The best extraction conditions were as follows: CO2 with 10% of modifier (ethanol) as extraction solvent, 55 degrees C (extraction temperature) and 220 bar (extraction pressure). Fractionation was achieved by cascade depressurization providing two extracts with different activity and chemical composition. Several compounds have been identified in the extracts, corresponding to different carotenoids previously identified in Spirulina platensis microalga along with chlorophyll a and some degradation products. Also, the structure of some phenolic compounds could be tentatively identified. The antioxidant activity of the extracts could be attributed to some of the above mentioned compounds.

Antioxidants↗

Overview of protease inhibitors.

PURPOSE: To provide a basic review of the four currently available protease inhibitors: saquinavir, ritonavir, indinavir, and nelfinavir. Included are sections on surrogate markers of HIV disease and resistance to protease inhibitor therapy, as well as dosing information, pharmacokinetics, studies, adverse effects, and drug interaction potential. DATA SOURCES: Conducted a review of published literature (MEDLINE), abstracts from national meetings and conferences, and product labeling and information available at the time of preparation through July 1997. STUDY SELECTION AND DATA EXTRACTION: Material was selected for inclusion based on relevance to objectives, publication in English, and presence of useful information for practicing pharmacists. DATA SYNTHESIS: Limited published information is currently available on the protease inhibitors, especially with regard to randomized, controlled, comparative trials and establishment of guidelines for direct therapy. Much of the available information relies heavily on product information and trials that are published only in abstract form. The evaluation of the protease inhibitors (with regard to place in therapy as well as resistance and toxicities) is an ongoing process. CONCLUSION: Protease inhibitors have changed opinions about the futility of the treatment of HIV disease. Protease inhibitors dramatically improve patients' surrogate markers and even show mortality benefits, especially when combined with additional antiretroviral agents. The optimism surrounding these new drugs is tempered by the toxicity profile, development of resistance, drug interaction profiles, and added costs to current regimens. Designing tolerable, effective regimens will require careful monitoring for compliance, adverse effects, and potential drug interactions.

Biomarkers↗

Advantages of soxflo extractions for phytochemical analysis and bioassay screening. 1. Terpenoids.

The Soxflo technique was evaluated for the rapid extraction of plant materials (<90 min) at room temperature. Qualitatively similar chromatograms were obtained by gas chromatography and thin layer chromatography (TLC) with Soxflo (SoF) and Soxhlet (SoL) extracts. Sequential solvent extractions by SoF gave slightly higher yields (132%) of five major sesquiterpenoids. TLC revealed that SoF extractions at room temperature were more selective as extracts contained compounds with a narrower range of R(f)() values. This means that the SoF technique offers the potential for one-step extractions and partial fractionation. This study also showed that there were large differences in the volatile composition of dried and fresh Piper fruits: dried fruits had predominantly sesquiterpenoids while fresh fruits had considerable quantities of both mono- and sesquiterpenoids. This is the first report of alpha-guaiene and alpha- and beta-selinene in Piper guineense fruits. It is suggested that the SoF technique can be useful for the screening of large numbers of plants for phytochemicals or for the preparation of plant extracts for subsequent bioassay studies.

Chromatography, Thin Layer↗

Nail analysis for drugs of abuse: extraction and determination of cannabis in fingernails by RIA and GC-MS.

Fingernail clippings were evaluated as analytical specimens for the detection and quantitation of cannabinoids. Specimens were obtained from consenting adults attending a drug clinic, along with information concerning the drugs which they had used over the previous six months. Methods for the surface decontamination and extraction of the specimens were evaluated. Detergent, water, and methanol washes followed by alkaline hydrolysis and liquid-liquid extraction were selected for use in the study. Extracts were analyzed by radioimmunoassay (RIA) and gas chromatography-mass spectrometry (GC-MS) to detect and quantitate cannabinoids present in fingernail clippings. Positive RIA results were obtained from specimens from six known cannabis users. The mean cannabinoid concentration in fingernail clippings determined by RIA was 1.03 ng/mg. Using GC-MS, the mean delta9-tetrahydrocannabinol concentration in fingernail clippings from a further 14 known cannabis users was 1.44 ng/mg. Using GC-MS, the average 11-nor-delta9-tetrahydrocannabinol-9-carboxylic acid concentration in fingernail clippings from three known cannabis users extracted in acidic pH was 19.85 ng/mg. Based on these results, fingernails are potentially useful biological specimens for the detection of past cannabis use in cases of medicolegal interest.

Cannabis↗

Meningococcemia as a model for testing the hypothesis of antisepsis therapies.

OBJECTIVE: To critically review the advantages and disadvantages of pediatric meningococcemia as a model for testing antisepsis therapies. DATA SOURCES: Research and review articles on the pathogenesis and treatment of human meningococcemia, as well as editorial commentaries discussing the failure of clinical trials for adult sepsis or Systemic Inflammatory Response Syndrome. Data from these sources are presented in the context of the author's experience as principal investigator in a large, randomized trial on children with invasive meningococcal disease. STUDY SELECTION AND DATA EXTRACTION: Studies were selected to include aspects of epidemiology, pathophysiology, outcome prediction, and therapeutic trials. DATA SYNTHESIS: Compared with an adult sepsis population, meningococcemia is a single disease, diagnosed clinically with high reliability. Patients are previously healthy, without underlying medical or surgical conditions. In contrast to sepsis trials, nearly all patients with meningococcal disease receive effective antibiotics. Finally, meningococcemia most closely resembles animal models of endotoxin infusion, in which most antisepsis therapies have been highly effective. However, the meningococcal model carries major disadvantages, among them that meningococcemia is rare and rapidly progressive and patients are widely dispersed geographically. In addition, a wide range of experimental therapies is routinely provided in an attempt to preserve life or limbs. CONCLUSIONS: Meningococcemia is an ideal model of a rapidly progressive bacterial infection associated with marked endotoxemia. Problems with the model can be overcome by extensive pretrial logistic planning, as well as close coordination and cooperation with national regulatory agencies.

Adult↗

Postmenopausal hormone therapy and breast cancer: a systematic review and meta-analysis.

OBJECTIVE: There is a rapidly evolving debate on the indications and appropriate duration of therapy for postmenopausal hormone therapy. The objective of this meta-analysis was to examine the specific relationships of postmenopausal estrogen therapy (ET), postmenopausal combined (estrogen-progestogen) hormone therapy (CHT), and the incidence of breast cancer. DESIGN: We performed computerized searches of MEDLINE and CancerLit through September 2003 and reviewed reference lists of retrieved studies and meta-analyses. We included English-language studies that identified noncontraceptive postmenopausal hormone use; reported on the risks of "current use" of ET and/or CHT and breast cancer incidence; were case-control, cohort, or experimental; and reported either an odds ratio (OR), relative risk (RR), or HR with CIs. Two investigators were involved during all stages of study selection and independently extracted all data selected for inclusion in meta-analyses. RESULTS: Meta-analysis of 13 studies of ET and breast cancer (700,000 women) resulted in an OR of 1.16 (95% confidence limits [CL] 1.06, 1.28), with estimates for less than 5 years use 1.16 (1.02, 1.32) and more than 5 years use 1.20 (1.06, 1.37). Meta-analysis of eight studies of CHT and breast cancer (650,000 women) resulted in an OR of 1.39 (95% CL 1.12, 1.72), with estimates for less than 5 years use 1.35 (1.16, 1.57) and more than 5 years use 1.63 (1.22, 2.18). CONCLUSIONS: Data from observational studies support the association of increased but considerably different risks for breast cancer incidence among current users of ET and CHT. These represent the first pooled estimates for ET. CHT estimates correspond to those from randomized trials.

Breast Neoplasms↗

Understanding the biology of aging: the key to prevention and therapy.

OBJECTIVE: To review recent progress and consider future approaches for basic research on aging with clinical applicability. DATA SOURCES: Peer-reviewed publications on experimental gerontology and geriatrics. STUDY SELECTION AND DATA EXTRACTION: Studies were selected that described experimental approaches in gerontology and geriatrics, starting with the evolutionary basis of aging, through theories trying to explain its major causes, to novel experimental approaches, e.g., computer informatics, protein chemistry and genetics. DATA SYNTHESIS: Our increased understanding of the evolutionary basis of aging has made it possible to consider a number of experimental strategies more rationally. Most theories on the causes of aging involve some kind of somatic damage that accumulates with age, the rate of which is determined by environmental, genetic, and behavioral factors. The recent emergence of more powerful methodology offers new possibilities for identifying basic mechanisms of aging, which would increase our understanding of biologically based susceptibility to age-related health problems. CONCLUSIONS: There is a growing awareness that age-related deterioration will affect an ever growing number of people, in both absolute and relative terms. It can be expected that this will further increase the resources that will be made available for research on aging. Although ultimately unavoidable, aging is a process that appears to be experimentally accessible. Therefore, the mechanisms of senescence and death may eventually be more completely understood, with the promise of preventing and/or delaying many of the adverse effects associated with aging, including most of the common diseases, and possibly also of extending lifespan.

Aged↗

Therapy of Candida infections: susceptibility testing, resistance, and therapeutic options.

OBJECTIVE: Review the epidemiology of fungal infections, approved susceptibility testing methods, the scope of antifungal resistance, and advances in the treatment of fungal infections. DATA SOURCES: MEDLINE databases (from 1966 to March 1998) were searched for literature pertaining to the epidemiology and management of fungal infections. STUDY SELECTION AND DATA EXTRACTION: Articles were selected to assist in providing the reader an understanding of the epidemiology and management of fungal infections. DATA SYNTHESIS: Fungi have emerged as an important class of pathogens. Even though fungi rank as the fourth most commonly encountered nosocomial bloodstream pathogen, and are associated with the highest mortality of commonly encountered pathogens, only within the past year have methods for conducting and guidelines for interpreting in vitro susceptibility tests been approved. Under the guidance of these standards, we have begun to understand important issues regarding fungi such as the scope and mechanisms of antifungal resistance. Although there has not been a significant addition to our antifungal armamentarium since 1992, advances in antifungal therapy have been realized with the reformulation of available agents and the delineation of the pharmacodynamic characteristics of several antifungals. Additionally, several new agents, including a new class of antifungals, probably will enter into clinical use within the next 5 years. CONCLUSIONS: We have entered an era in which our understanding of fungi is increasing tremendously. Clinicians need to familiarize themselves with the current concepts surrounding the management of fungal infections in order to provide optimal care for their patients.

Antifungal Agents↗

Ziprasidone: the fifth atypical antipsychotic.

OBJECTIVE: To review the pharmacology, pharmacokinetics, clinical efficacy, and adverse effects of ziprasidone as a treatment for schizophrenia. DATA SOURCES: Information was selected from a MEDLINE search (July 2000-October 2001) of English-language medical literature using ziprasidone as the search term. Manual searches of pertinent journal article references, request for medical information from Pfizer, and access of the Web site of the Food and Drug Administration were also performed. STUDY SELECTION: All available published information regarding the pertinent characteristics of ziprasidone were considered for selection. DATA EXTRACTION: Pharmacology and pharmacokinetic studies were selected to provide a comprehensive description of these characteristics. Clinical investigations were evaluated for design, sample size, diagnosis, duration, and outcome. Data from all investigations were selected by 1 author and reviewed by both authors. DATA SYNTHESIS: Ziprasidone is a benzisothiazolyl piperazine-type atypical antipsychotic that shares the serotonin(2A)/dopamine(2) (5-HT(2A)/D(2)) profile of the available atypical antipsychotics. Ziprasidone has demonstrated in vitro activity as a 5-HT(1A) receptor agonist and as a very weak inhibitor of serotonin and norepinephrine reuptake. These data do not support ziprasidone as being a clinically meaningful inhibitor of serotonin/norepinephrine reuptake. Oral bioavailability of ziprasidone taken with food is approximately 60%, half-life is approximately 6-7 hours, and protein binding is extensive at >99%. Twelve metabolites have been identified, yet only 4 of these are considered to be primary metabolites. Metabolism of ziprasidone by aldehyde oxidase produces its only metabolite with potential pharmacologic activity; CYP3A4 also contributes to the metabolism of ziprasidone. Clinical studies support ziprasidone as efficacious for the treatment of patients with acute exacerbations of schizophrenia or schizoaffective disorder. Daily doses permitted in these clinical trials ranged from 40 to 160 mg, but only doses between 120 and 160 mg/d have been superior to placebo. Future research efforts should be directed toward refractory schizophrenia, cognitive impairment in schizophrenia, affective and anxiety symptoms associated with schizoaffective disorder, and bipolar disorder. Adverse effect characteristics of ziprasidone commonly include headache, nausea, and somnolence; infrequent effects include extrapyramidal symptoms and weight gain. Ziprasidone has been reported to cause an average QTc prolongation of approximately 20 msec; there have only been 2 patients (0.06%) reported by the manufacturer to have a measured QTc interval >500 msec. CONCLUSIONS: Ziprasidone is a safe and efficacious atypical antipsychotic for the acute management of schizophrenia. Efficacy data and most safety data for ziprasidone support its use as a first-line treatment for schizophrenia; however, its potential effects on ventricular repolarization relegate it to second-line status in patients with comorbid cardiovascular risks.

Acute Disease↗

Calcimimetics and the treatment of primary and secondary hyperparathyroidism.

OBJECTIVE: To review the mechanism of action, development, and clinical application of the calcimimetic compounds being investigated for the treatment of primary and secondary hyperparathyroidism (HPT). DATA SOURCES: A MEDLINE search (1990-April 2004) was performed to identify all published articles related to calcimimetics. Published abstracts over the previous 5 years from various scientific meetings (American Society of Nephrology, American Society for Clinical Pharmacology and Therapeutics, American Society of Bone and Mineral Research) were also searched for reports regarding investigational calcimimetic agents. Data on cinacalcet HCl were provided by Amgen, Inc. STUDY SELECTION AND DATA EXTRACTION: Studies were selected based on number of patients included, relevance to the approved indications, and inclusion of pharmacokinetic and drug interaction information. DATA SYNTHESIS: The investigational calcimimetic compounds directly modulate the calcium-sensing receptor and can produce at least a 30% reduction in parathyroid hormone (PTH) secretion in secondary HPT. Cinacalcet appears to have more predictable pharmacokinetics and a lower risk of symptomatic hypocalcemia than the older agent, R-568. The safety profile and effective reduction in PTH and simultaneous reductions in calcium and phosphorus (and the calcium-phosphorus product) induced by cinacalcet make this agent advantageous over previously used therapies, such as vitamin D and phosphate-binding agents. More studies are required to determine additional uses of cinacalcet. CONCLUSIONS: Cinacalcet has a unique mechanism for reducing PTH concentration and appears to be a safe and effective oral therapy for both primary and secondary HPT.

Aniline Compounds↗

Lipid management with statins in type 2 diabetes mellitus.

OBJECTIVE: To provide an update on lipid management and recent modifications in cholesterol guidelines for use of hydroxymethylglutaryl coenzyme A reductase inhibitors (statins), specifically in patients with diabetes. DATA SOURCES: Studies and guidelines were identified through a MEDLINE search (1996-April 2005). STUDY SELECTION AND DATA EXTRACTION: Studies were selected for review if the primary treatment intervention was a statin, at least 4% of the study population held a diagnosis of diabetes, and diabetes subgroup analysis was available. DATA SYNTHESIS: The Heart Protection Study demonstrated an approximately 25% relative risk reduction of a first coronary event in patients with diabetes, a reduction similar to those without diabetes. In subjects with diabetes, a significant reduction in coronary events was noted regardless of the baseline cholesterol level. The Collaborative Atorvastatin Diabetes Study demonstrated a 37% relative risk reduction in the primary prevention of cardiovascular morbidity in patients with diabetes. CONCLUSIONS: Based on the current literature, a low-density lipoprotein cholesterol (LDL-C) level <100 mg/dL remains an appropriate goal for patients with diabetes in the absence of established cardiovascular disease. For higher-risk patients, such as those with diabetes and a history of cardiovascular disease, a more stringent LDL-C goal of <70 mg/dL is an option according to current clinical trial evidence. At least a 30-40% reduction in the LDL-C level is advisable when initiating statin therapy.

Cardiovascular Diseases↗