[Infant botulism]. / Botulismo del lactante.

We report a case of botulism in a 40 day old infant. The patient presented a descending flaccid paralysis requiring mechanical ventilation for 12 days. She is the first European patient treated with Human Botulism Immune Globulin. A few weeks later a second case of infant botulism was detected in our geographical region in Southern Spain. We emphasise the importance of an early diagnosis and treatment with Human Botulism Immune Globulin to decrease morbidity.

[Pharmaceutical care for patients with enteral nutrition]. / Original breve Atención farmacéutica en pacientes con nutrición enteral.

OBJECTIVE: To detect potential complications and interactions between drugs and enteral nutrition (EN) as to describe the interventions carried out by the pharmacist in those circumstances and to propose strategies of improvement. METHOD: Prospective assessment of patients admitted to hospital candidates to receive EN. The pharmacist worked as part of the team of Endocrinology and Nutrition for one month. A data collection form was designed for the study in which the following information had to be recorded: NE indications, nutrition characteristics (type, route of administration, infusion rate), pharmacological therapy, drug/EN interaction and complications. RESULTS: The study included 14 patients (mean age of 50 +/- 13 years) in which digestive (35.7%) and neurological (28.6%) complications were the most frequent indications for EN. Eleven patients (78.57%) reported complications associated to EN, mostly digestive (57.14%). The main cause for consultation was related to the administration of drugs via NGT (nasogastric tube). A total of 77 drugs were prescribed, 23 of which were administered in this way, so a guidelines for the administration of drugs via nasogastric tube was prepared. CONCLUSIONS: The hospital pharmacist can actively cooperate with nutritional support units, given the need to assess the nutritional support administered and to manage potential complications and interactions between nutritional status, drugs and artificial nutrition. The pharmacist also plays a significant role in the prevention and identification of problems related to the administration of drugs via NGT.

Atención farmacéutica en pacientes con nutrición enteral / Pharmaceutical care for patients with enteral nutrition

Objetivo: Detectar las posibles complicaciones e interaccionesentre medicamentos-nutrición enteral (NE) y describir lasintervenciones realizadas por el farmacéutico en este entorno,proponiendo estrategias de mejora.Método: Evaluación prospectiva en pacientes ingresados en elhospital candidatos a recibir NE. El farmacéutico se integra en elequipo de Endocrinología y Nutrición durante 1 mes. Para el estudiodiseña un impreso de recogida de datos donde se especifica:indicación de NE, características de la nutrición (tipo, vía de administración,velocidad de infusión), tratamiento farmacológico, interaccionesmedicamento/NE y complicaciones.Resultados: Se incluyeron 14 pacientes (edad media 50 ± 13años) en los que las alteraciones digestivas (35,7%) y las neurológicas(28,6%) fueron las indicaciones más frecuentes de NE. Seprodujeron complicaciones asociadas a NE en 11 pacientes(78,57%) siendo las digestivas (57,14%) las más frecuentes. Elprincipal motivo de consulta estuvo relacionado con la administraciónde medicamentos por sonda nasogástrica (SNG), se pautaronun total de 77 medicamentos de los que 23 se administraron porésta vía, por lo que se elaboró una guía de administración de fármacospor sonda.Conclusiones: El farmacéutico de hospital puede colaboraractivamente en las unidades de soporte nutricional ya que es necesarioevaluar el aporte nutricional administrado y manejar las posiblescomplicaciones e interacciones entre el estado nutricional,medicamentos y nutrición artificial. Del mismo modo juega unpapel importante en la prevención y detección de los problemasrelacionados con la administración de medicamentos por SNG

Objective: To detect potential complications and interactionsbetween drugs and enteral nutrition (EN) as to describe the interventionscarried out by the pharmacist in those circumstances andto propose strategies of improvement.Method: Prospective assessment of patients admitted to hospitalcandidates to receive EN. The pharmacist worked as part ofthe team of Endocrinology and Nutrition for one month. A datacollection form was designed for the study in which the followinginformation had to be recorded: NE indications, nutrition characteristics(type, route of administration, infusion rate), pharmacologicaltherapy, drug/EN interaction and complications.Results: The study included 14 patients (mean age of 50 ±13 years) in which digestive (35.7%) and neurological (28.6%)complications were the most frequent indications for EN. Elevenpatients (78.57%) reported complications associated to EN, mostlydigestive (57.14%). The main cause for consultation was relatedto the administration of drugs via NGT (nasogastric tube). Atotal of 77 drugs were prescribed, 23 of which were administeredin this way, so a guidelines for the administration of drugs vianasogastric tube was prepared.Conclusions: The hospital pharmacist can actively cooperatewith nutritional support units, given the need to assess the nutritionalsupport administered and to manage potential complicationsand interactions between nutritional status, drugs and artificialnutrition. The pharmacist also plays a significant role in theprevention and identification of problems related to the administrationof drugs via NGT

[Stability and in vitro activity of voriconazole eyedrops at a concentration of 3 microg/mL]. / La estabilidad y actividad in vitro de voriconazol en colirio a una concentración de 3 microg/mL.

OBJECTIVE: To assess the stability and activity of voriconazole 3 microg/mL eyedrops as prepared for use against amphotericin B- and fluconazole-resistant fungal endophthalmitis. METHOD: Stability (concentration using UV-spectrophotometry; pH, osmolarity, and particle formation) and sterility were analyzed under various preservation conditions--room temperature (22-24 degrees C) or refrigerated (2-8 degrees C). The preparation's in vitro efficacy was analyzed using the standard National Committee for Clinical Laboratory Standards method for 30 days. RESULTS: Voriconazole concentrations were found to be within limits allowed by the United Stated Pharmacopeia (90-115%). pH (room temperature: 6.96-7.60; refrigerated: 6.84-7.21) and osmolarity (room temperature: 265-284 mOsm/l; refrigerated: 270-285 mOsm/l) remained within eye physiological ranges throughout the study under the analyzed conditions. The preparation s antifungal activity remained stable during the first three weeks. CONCLUSIONS: The voriconazole 3 microg/mL eyewash preparation remained stable, sterile and with full antifungal activity for 21 days when stored both at room temperature and under refrigeration conditions.

Estabilidad y actividad in vitro de voriconazol en colirio a una concentración de 3 µg/mL / Stability and in vitro activity of voriconazole eyedrops at a concentrations of 3 mg/mL

Objetivo: Evaluar la estabilidad y actividad de un colirio devoriconazol 3 µg/mL, preparado para su uso en endoftalmitis fúngicasresistentes a anfotericina B y fluconazol.Método: Se analizaron la estabilidad (concentración medianteespectrofotometría-UV; pH, osmolaridad y aparición de partículas)y la esterilidad bajo condiciones de conservación diferentes:temperatura ambiente (22-24 °C) o refrigerado (2-8 °C) y la eficaciain vitro del preparado, mediante el método estándar delNacional Committee for Clinical Laboratory Standards duranteun periodo de 30 días.Resultados: Las concentraciones de voriconazol se encontrarondentro de los márgenes permitidos por la United StatesPharmacopeia (90-115%). El pH (ambiente 6,96-7,60; refrigerado:6,84-7,21) y la osmolaridad (ambiente: 265-284 mOsm/l;refrigerado: 270-285 mOsm/l) se mantuvieron en los intervalosfisiológicos para el ojo, a lo largo de todo el estudio en las doscondiciones analizadas. La actividad antifúngica del colirio permanecióestable durante las tres primeras semanas.Conclusiones: El colirio preparado de voriconazol 3 µg/mLpermanece estable, estéril y con plena actividad antifúngica durante21 días cuando se almacena tanto a temperatura ambientecomo en refrigeración

Objective: To assess the stability and activity of voriconazole3 µg/mL eyedrops as prepared for use against amphotericin Bandfluconazole-resistant fungal endophthalmitis.Method: Stability (concentration using UV-spectrophotometry;pH, osmolarity, and particle formation) and sterility were analyzedunder various preservation conditions – room temperature(22-24 °C) or refrigerated (2-8 °C ). The preparation's in vitroefficacy was analyzed using the standard National Committee forClinical Laboratory Standards method for 30 days.Results: Voriconazole concentrations were found to be withinlimits allowed by the United Stated Pharmacopeia (90-115%). pH(room temperature: 6.96-7.60; refrigerated: 6.84-7.21) andosmolarity (room temperature: 265-284 mOsm/l; refrigerated:270-285 mOsm/l) remained within eye physiological rangesthroughout the study under the analyzed conditions. The preparation'santifungal activity remained stable during the first threeweeks.Conclusions: The voriconazole 3 µg/mL eyewash preparationremained stable, sterile and with full antifungal activity for 21days when stored both at room temperature and under refrigerationconditions

[Tacrolimus blood levels and incidence of graft rejection in heart transplantation]. / Relación entre los niveles de tacrolimus en sangre y la incidencia de rechazo en enfermos trasplantados de corazón.

OBJECTIVE: To determine the relationship between pharmacokinetic parameters and clinical outcomes after heart transplantation and to determine the range of tacrolimus blood levels which provides the most effective protection against graft rejection. To study other factors that predict graft rejection. METHOD: We retrospectively analyzed the clinical outcomes of all adult patients who received a heart transplant between January 2000 and October 2003 and had routine monitoring of tacrolimus trough levels at the time of scheduled endomyocardial biopsy. Rejection was defined as Grade = 3, based on the International Society for Heart and Lung Transplantation (ISHLT) criteria. The follow-up period was 1 year. All patients were on a triple therapy regimen of Tacrolimus (TAC), Corticosteroids and Azatioprine/Micophenolate Mofetil. Data were analyzed by Student s t-test, univariate logistic regression and ROC curve. RESULTS: Tacrolimus blood levels measured at day +5 postransplant were the strongest predictor of acute graft rejection over a 1-year follow-up period (rejection 5.76 +/- 3.4 ng/ml vs no rejection 9.66 +/- 2.73 ng/ml, p = 0.016). A decrease of one unit in TAC trough level values at day +5 postransplant implied a 1.58 greater risk of rejection (p = 0.05). Overall incidence of treated acute rejection was lower for patients with trough levels higher than 8 ng/ml on day +5 postransplant (33 vs 80%, p = 0.055, Fisher s exact test). CONCLUSIONS: Data suggest that in heart transplant patients it may be crucial to achieve tacrolimus levels of at least 8 ng/ml during the first days postsurgery to avoid rejection.

Relación entre los niveles de tacrolimus en sangre y la incidencia de rechazo en enfermos trasplantados de corazón / Tacrolimus blood levels and incidence of graft rejection in heart transplantation

Objetivo: Evaluar la relación entre los niveles en sangre de tacrolimus, la incidencia de rechazo agudo en enfermos trasplantados de corazón y determinar el rango de concentración más adecuado para prevenir el rechazo. Estudiar otros factores predictores del rechazo. Método: Se realizó un estudio retrospectivo de todos los enfermos adultos trasplantados de corazón entre enero de 2000 y octubre de 2003 en tratamiento con tacrolimus, corticoides y azatioprina/ micofenolato mofetil. La eficacia del tratamiento se evaluó por confirmación histopatológica del rechazo agudo como grado ≥ 3A según criterios del Sociedad Internacional de Trasplante de Pulmón y Corazón (ISHLT). Se registraron los resultados de las biopsias endomiocárdicas y de los niveles mínimos de tacrolimus en sangre durante el primer año postrasplante. El análisis de los datos se realizó mediante la t de Student, regresión logística univariante y curva ROC. Resultados: Se encontraron diferencias significativas en la concentración mínima de tacrolimus en sangre alcanzada el día +5 postrasplante entre los enfermos que presentaron algún episodio de rechazo agudo el primer año y los que no (5,76 ± 3,4 vs 9,66 ± 2,73 ng/ml, p = 0,016). El nivel el día +5 fue el mejor predictor del rechazo (p = 0,05) de modo que el riesgo de un paciente respecto a otro con una unidad menos en el nivel de tacrolimus es 1,58 veces mayor. 8 ng/ml es el nivel con mayor poder de discriminación (sensibilidad = 75% y especificidad = 72,7%), de modo que alcanzar una concentración mínima en sangre de 8 ng/ml el día +5 reduce la incidencia de rechazo agudo de 33 a 80% (p = 0,055, p. exacta de Fisher). Conclusiones: Alcanzar niveles mínimos adecuados de tacrolimus en los primeros días postrasplante (al menos de 8 ng/ml el día +5) puede ser crucial para evitar el rechazo agudo en pacientes trasplantados de corazón

Objective: To determine the relationship between pharmacokinetic parameters and clinical outcomes after heart transplantation and to determine the range of tacrolimus blood levels which provides the most effective protection against graft rejection. To study other factors that predict graft rejection. Method: We retrospectively analyzed the clinical outcomes of all adult patients who received a heart transplant between January 2000 and October 2003 and had routine monitoring of tacrolimus trough levels at the time of scheduled endomyocardial biopsy. Rejection was defined as Grade ≥ 3, based on the International Society for Heart and Lung Transplantation (ISHLT) criteria. The follow-up period was 1 year. All patients were on a triple therapy regimen of Tacrolimus (TAC), Corticosteroids and Azatioprine/Micophenolate Mofetil. Data were analyzed by Student’s t-test, univariate logistic regression and ROC curve. Results: Tacrolimus blood levels measured at day +5 postransplant were the strongest predictor of acute graft rejection over a 1- year follow-up period (rejection 5.76 ± 3.4 ng/ml vs no rejection 9.66 ± 2.73 ng/ml, p = 0.016). A decrease of one unit in TAC trough level values at day +5 postransplant implied a 1.58 greater risk of rejection (p = 0.05). Overall incidence of treated acute rejection was lower for patients with trough levels higher than 8 ng/ml on day +5 postransplant (33 vs 80%, p = 0.055, Fisher’s exact test). Conclusions: Data suggest that in heart transplant patients it may be crucial to achieve tacrolimus levels of at least 8 ng/ml during the first days postsurgery to avoid rejection

New strategies of cyclosporine monitoring in heart transplantation: initial results.

The aim of this study was to evaluate cyclosporine (CyA) absorption profiles in heart transplantation to establish the most adequate monitoring strategy and determine the optimal therapeutic range for AUC(0-4) or C2 levels. A total of 22 full pharmacokinetic studies were performed at steady-state in 22 adult heart transplant recipients (18 men, 4 women). Twelve studies were performed during the first month posttransplant (group I), and 10 studies were done after 1 month (group II). In 9 outpatients we performed an abbreviated AUC(0-4). The mean age of the patients was 49+/-15 years (range, 15-72 years), and the mean weight was 70.4+/-10.8 kg (mean, 54-98 kg). The CyA dosage had been adjusted to maintain trough levels (C0) in the putative target ranges of 200 to 400 ng/mL in group I and between 100 to 300 ng/mL in group II. Blood samples were drawn prior to and at 0.5, 1, 2, 4, 6, 8, and 12 hours after the morning dose. The CyA blood levels were measured by the AxSYM cyclosporine assay. The AUC was calculated by the trapezoidal rule. Multiple linear regression was done to evaluate the predictive ability of various limited sampling strategies. The C0 correlated poorly, either with the full AUC (r2=0.64) or the AUC(0-4) (r2=0.43), while C2 seemed to be the most accurate single predictor of drug exposure (r2=0.92 for AUC(0-12); r2=0.74 for AUC(0-4)). For both AUC(0-4) and AUC(0-12), all 2- or 3-point strategies had r2 values approaching that of the C2 value. In conclusion, C2 is a simple, fast, and accurate value to predict AUC(0-4) in routine clinical practice. Its implementation must focus on ensuring the commitment of all unit staff, thus ensuring that patients are sampled on time and minimizing the impact on workload.

Clinical pharmacokinetics of tacrolimus in heart transplantation: new strategies of monitoring.

The aim of this study was to investigate the absorption profile of tacrolimus (TAC) in heart transplant patients in order to find the best sampling time to predict the total exposure and to explore the target range for optimal clinical immunosuppression. Twenty-five full pharmacokinetic studies were performed in 22 heart transplant patients (11 men and 7 women) at less than 1 year posttransplant. The immunosuppressive treatment was steroids plus azathioprine or mycophenolate mofetil and TAC. The mean age was 55 years (36-64 years) and the mean weight 70.49 kg (50-111 kg). After three days of receiving the same dose, eight blood samples were collected at 0.5, 1, 2, 4, 6, 8, and 12 hours postmorning dose. TAC concentrations were measured by microparticle enzyme immunoassay (IMx). Area under the concentration-time curve(AUC(0-12)) was calculated by the trapezoidal rule. Using 0-4 hours TAC blood concentrations, a projected 12 hours AUC (extrapolated AUC(0-4)) was calculated assuming C0 and C12 were comparable. A high interpatient TAC pharmacokinetics variability that was greater during the absorption phase was observed. A Cmax (30.5+/-13.8 ng/mL) was reached at 2.3+/-1.5 h. When target trough levels were achieved (10-20 ng/mL), the mean tacrolimus exposure was 230.6+/-59.2 ng h/mL (120.14-327.7) (n=19). Correlation between AUC(0-12) and C0 was relatively good (r2=0.74). Between individual time points, C4 showed the best correlation (r2=0.88). In any case the best strategy to monitor is to obtain the extrapolated AUC(0-4) (r2=0.98), as a good approach to patients with a poor response to treatment.

Microsatellite variability in peach [ Prunus persica (L.) Batsch]: cultivar identification, marker mutation, pedigree inferences and population structure.

A collection of 212 peach and nectarine cultivars covering a wide variation of the species were studied with 16 polymorphic single-locus microsatellite, or simple-sequence repeat (SSR), markers. The average number of alleles per locus was 7.3, 35% of the cultivar x locus combinations analyzed were heterozygous and 87% of the cultivars studied could be individually identified. Most of the groups where two or more cultivars had the same SSR fingerprint included known peach mutants or possible synonymies. Pedigree information was tested with the SSR data. Five unexpected genotypes, due to a mutation at five SSR loci were found when comparing the SSR fingerprint of 14 known mutant cultivars and putative synonymous cultivars. The pedigree data were not consistent with the observed data in 11 out of 38 cases that could be analyzed. The group of non-melting fruit flesh cultivars, generally used by the canning industry, was more variable and genetically distant than the rest of the cultivars tested. Based on their level of homozygosity it was possible to separate those cultivars that were obtained by modern breeding technologies from those that were selected from traditional orchards after generations of seed propagation. The former had a distribution of genotypic frequencies close to a random mating model while the latter had a higher level of homozygosity. The implications of these data for the use of SSR fingerprints in breeder's rights protection and peach breeding are discussed.

A set of simple-sequence repeat (SSR) markers covering the Prunus genome.

A set of 109 microsatellite primer pairs recently developed for peach and cherry have been studied in the almond x peach F(2) progeny previously used to construct a saturated Prunus map containing mainly restriction fragment length polymorphism markers. All but one gave amplification products, and 87 (80%) segregated in the progeny and detected 96 loci. The resulting Prunus map contains a total of 342 markers covering a total distance of 522 cM. The approximate position of nine additional simple sequence repeats (SSRs) was established by comparison with other almond and peach maps. SSRs were placed in all the eight linkage groups of this map, and their distribution was relatively even, providing a genome-wide coverage with an average density of 5.4 cM/SSR. Twenty-four single-locus SSRs, highly polymorphic in peach, and each falling within 24 evenly spaced approximately 25-cM regions covering the whole Prunus genome, are proposed as a 'genotyping set' useful as a reference for fingerprinting, pedigree and genetic analysis of this species.

Long-term iloprost infusion therapy for severe pulmonary hypertension in patients with connective tissue diseases.

OBJECTIVE: To determine the effects of short-term, maximum-tolerated-dose and long-term, optimum-dose iloprost treatment of severe pulmonary hypertension associated with systemic sclerosis (SSc) and the primary antiphospholipid syndrome (APS). METHODS: Three patients with SSc and 2 with APS who had failed to respond to oral vasodilator therapy for pulmonary hypertension were enrolled in a 32-week, open, prospective trial. Short-term infusion of maximum-tolerated doses and continuous infusion of optimum doses of iloprost were carried out following baseline cardiac catheterization. Catheterization was repeated at 2 and 32 weeks. All 5 patients completed the study and continued therapy for an average of 82 weeks (range 58-103). RESULTS: Acute infusion of maximum tolerated doses significantly ameliorated the cardiac index (0.92 liters/minute/m2; P < 0.01), pulmonary artery O2 saturation (10.6%; P < 0.05), and pulmonary resistance (-6.7 units; P < 0.05). After 2 weeks of continuous infusion of optimum doses, there was improvement in pulmonary resistance (> or = 16%) and pulmonary artery O2 saturation (> 30%) in the 2 patients with primary APS. After 2 and 32 weeks, the 3 SSc patients showed variable hemodynamic responses. New York Heart Association functional class and exercise tolerance improved in all patients. There was 1 episode of bacteremia, and 1 patient died after 72 weeks of study. CONCLUSION: Continuous iloprost infusion may improve exercise tolerance and quality of life in patients with severe pulmonary hypertension associated with SSc and primary APS.

Different hemodynamic responses between acute and chronic infusion of iloprost (prostacyclin-stable analogue) in severe pulmonary hypertension.

We report the hemodynamic and clinical effects of acute and chronic administration of iloprost in two patients with severe pulmonary hypertension caused by toxic oil syndrome. We tested the acute effect of progressive increments of iloprost, followed by long-term infusion of the drug during 14 days. The acute response produced an increase in cardiac output and moderate reduction in pulmonary vascular resistance, with no change in pulmonary artery pressure. Nevertheless, a maintained reduction in pulmonary artery pressure and resistance, as well as clinical improvement, was observed after chronic infusion. We conclude that (1) the acute effect of iloprost does not necessarily predict long-term hemodynamic response, and (2) iloprost given in long-term infusion seems to have been an efficacious and safe drug in our two patients, and it opens a new line of treatment.