Beta-adrenergic receptor polymorphisms and cardiac graft function in potential organ donors.

Prior studies have demonstrated associations between beta-adrenergic receptor (ßAR) polymorphisms and left ventricular dysfunction-an important cause of allograft nonutilization for transplantation. We hypothesized that ßAR polymorphisms predispose donor hearts to LV dysfunction after brain death. A total of 1043 organ donors managed from 2001-2006 were initially studied. The following ßAR single nucleotide polymorphisms were genotyped: ß1AR 1165C/G (Arg389Gly), ß1AR 145A/G (Ser49Gly), ß2AR 46G/A (Gly16Arg) and ß2AR 79C/G (Gln27Glu). In multivariable regression analyses, the ß2AR46 SNP was significantly associated with LV systolic dysfunction, with each minor allele additively decreasing the odds for LV ejection fraction <50%. The ß1AR1165 and ß2AR46 SNPs were associated with higher dopamine requirement during the donor management period: donors with the GG and AA genotypes had ORs of 2.64 (95% CI 1.52-4.57) and 2.70 (1.07-2.74) respectively for requiring >10 µg/kg/min of dopamine compared to those with the CC and GG genotypes. However, no significant associations were found between ßAR SNPs and cardiac dysfunction in 364 donors managed from 2007-2008, perhaps due to changes in donor management, lack of power in this validation cohort, or the absence of a true association. ßAR polymorphisms may be associated with cardiac dysfunction after brain death, but these relationships require further study in independent donor cohorts.

The 4G/4G genotype of the PAI-1 (serpine-1) 4G/5G polymorphism is associated with decreased lung allograft utilization.

Widespread thrombi are found among donor lungs rejected for transplantation. The 4G/5G polymorphism in the plasminogen activator inhibitor (PAI-1) gene impacts transcription and the 4G allele is associated with increased PAI-1 levels. We hypothesized that the 4G/4G genotype would be associated with decreased lung graft utilization, potentially because of worse oxygenation in the donor. We genotyped donors managed by the California Transplant Donor Network from 2001 to 2008 for the 4G/5G polymorphism in the PAI-1 gene. Non-Hispanic donors from 2001 to 2005 defined the discovery cohort (n = 519), whereas donors from 2006 to 2008 defined the validation cohort (n = 369). We found, that the odds of successful lung utilization among Non-Hispanic white donors were lower among donors with the 4G/4G genotype compared to those without this genotype in both the discovery (OR = 0.55, 95% CI = 0.3-0.9, p = 0.02) and validation (OR = 0.5, 95% CI = 0.3-0.9, p = 0.03) cohorts. This relationship was independent of age, gender, cause of death, drug use and history of smoking. Donors with the 4G/4G genotype also had a lower PaO2/FiO2 ratio (p = 0.03) and fewer donors with the 4G/4G genotype achieved the threshold PaO2/FiO2 ratio ≥ 300 (p = 0.05). These findings suggest a role for impaired fibrinolysis resulting in worse gas exchange and decreased donor utilization.

The use of 1-aminobenzotriazole in differentiating the role of CYP-mediated first pass metabolism and absorption in limiting drug oral bioavailability: a case study.

Preliminary studies in our laboratory demonstrated low oral bioavailability of Drug X in male Sprague Dawley rats. However, the factors responsible for the observed poor bioavailability were not well understood. The objective of this study was to investigate the contribution of cytochrome P450(s) metabolism to the observed poor oral bioavailability of Drug X in male Sprague-Dawley rats in the presence of 1-aminobenzotriazole, a non-specific irreversible inhibitor of cytochrome P450s. Male Sprague-Dawley rats were pre-treated with or without oral 1-aminobenzotriazole (50 mg/kg) two hours prior to receiving a single intravenous or oral dose of Drug X (3 mg/kg). Blood samples were collected from animals at different time points over six hours following Drug X dosing. Plasma concentrations of Drug X were determined using LC/MS/MS. Pharmacokinetic data obtained from an intravenous dose study in rats suggested that Drug X exhibited a high clearance (55 mL/min/kg) and moderate volume of distribution (1.3 L/kg) with short half-life in rats (0.7 hr). Oral dosing of Drug X to rats resulted in low oral bioavailability (19%). 1-aminobenzotriazole pre-treatment of male Sprague Dawley rats followed by an intravenous dose of Drug X resulted in a decrease in plasma clearance by 71% and an increase in half-life by 100%, without affecting the volume of distribution. Furthermore, the oral bioavailability of Drug X increased markedly with 1-aminobenzotriazole pre-treatment. However, the fraction absorbed of Drug X did not significantly change with 1-aminobenzotriazole pre-treatment. The results of this study indicated that CYP-mediated metabolism played a major role in limiting the oral bioavailability of Drug X in rats. The data suggests that 1-aminobenzotriazole can be used as an effective tool in assessing the factors contributing to the poor oral bioavailability of drugs.

Oral mucositis and the clinical and economic outcomes of hematopoietic stem-cell transplantation.

PURPOSE: To explore the relationship between oral mucositis and selected clinical and economic outcomes in blood and marrow transplant patients. PATIENTS AND METHODS: Subjects consisted of 92 transplant patients from eight centers who participated in a multinational pilot study of a new oral mucositis scoring system (Oral Mucositis Assessment Scale [OMAS]). In the pilot study, patients were evaluated for erythema and ulceration/pseudomembrane formation beginning on the first day of conditioning and continuing for 28 days. We examined the relationship between patients' peak OMAS scores and days with fever (body temperature > 38.0 degrees C), the occurrence of significant infection, days of total parenteral nutrition (TPN), and days of injectable narcotic therapy (all over 28 days), days in hospital (over 60 days), total hospital charges for the index admission, and vital status at 100 days. RESULTS: Patients' peak OMAS scores spanned the full range of possible values (0 to 5) and were significantly (P <.05) correlated with all of the outcomes of interest except days with fever (P =.21). In analyses controlling for type of graft (autologous v allogeneic) and study center, a 1-point increase in peak OMAS score was associated with (1) 1.0 additional day with fever (P <.01), (2) a 2.1-fold increase in risk of significant infection (P <.01), (3) 2.7 additional days of TPN (P <.0001), (4) 2.6 additional days of injectable narcotic therapy (P <.0001), (5) 2.6 additional days in hospital (P <.01), (6) $25,405 in additional hospital charges (P <.0001), and (7) a 3.9-fold increase in 100-day mortality risk (P <.01). Mean hospital charges were $42,749 higher among patients with evidence of ulceration compared with those without (P =.06). CONCLUSION: Oral mucositis is associated with significantly worse clinical and economic outcomes in blood and marrow transplantation.

Customer service and its role in health care.

"Customer service is an important constituent of marketing but it is not a substitute for marketing". Virginia Hayden explains what it is and why it is worth the money and effort.

An appropriate use of market research for service design or improvement.

The Griffiths Report said in 1983 that it was essential for authorities to ascertain how well the service was being delivered at local level by obtaining the experience and perceptions of patients and the community, and that the methods of doing this could include market research. Since then many authorities have tried market research, but if they interpret that as the use of questionnaires they may not get the information they really need.