[Tapering of psychotropic drugs: current practice and needs of patients and their relatives]. / Deprescriptie van psychofarmaca; praktijk en behoeften van patiënten en naasten.

BACKGROUND: The prevalence of mental illness has remained stable in recent decades, yet the use of psychotropic drugs has increased. This trend suggests that psychotropic drugs are being prescribed with an unnecessary frequency. Internationally, there is growing attention for deprescribing. AIM: To investigate what experiences and needs patients and their loved ones/relatives have with regard to deprescribing of psychotropics. METHOD: An online questionnaire was distributed among members of the MIND mental health care panel, which consists of (former) patients with a psychiatric disorder and their loved ones. RESULTS: A total of 564 respondents took part in this survey. Most patients have phased out/stopped their psychotropic drugs (83.8%). This was usually done at the initiative of the patient (66.7%), in consultation with the practitioner (72.9%). The practitioner only took the initiative to deprescribe in 15.1% of the cases. In 68.6% tapering was not discussed at the start of psychotropic drug use. Patients did not experience willingness from practitioners in deprescribing, and would like to discuss deprescribing more often (79.5%). CONCLUSION: There is an undeniable demand among patients and near ones for more emphasis on deprescribing of psychotropic drugs. We advise to include this topic in the shared decision making process.

Renal expression of heat shock proteins after brain death induction in rats.

The majority of transplanted kidneys are derived from brain-dead patients. This nonphysiological state influences the hemodynamic and hormonal status of the donor. As a result, kidneys derived from brain-dead donors have inferior graft survival and increased graft function loss. Heat shock proteins (HSPs) are a family of stress-inducible proteins involved in maintaining cell homeostasis and regulating the immune system. We studied renal expression of the genes HO-1, HSP27, HSP40, and HSP70 after experimental brain death in rats. Brain death was induced in male F344 rats by slowly inflating a balloon catheter in the epidural space. Untreated rats were used as controls. Animals were humanely killed after 4 hours of brain death. Kidneys were analysed using RT-PCR, Western blotting, and immunohistochemistry. RT-PCR showed an increase in expression of genes coding for HO-1 (3.6-fold; P < .05) and HSP70 (2.7-fold; P < .05) after brain death. Western blotting also revealed an increase in HO-1 protein levels (4.6-fold; P < .001) but changes in HSP70 protein expression were not detected. Immunohistochemistry showed increments of HO-1 protein expression in the renal cortical tubules of brain-dead rats. HSP70 was predominantly increased in renal distal tubules of brain-dead rats treated for hypotension. No changes were observed in renal HSP27 and HSP40 expression after brain death. Renal stress caused by brain death induces expression of the cytoprotective genes HO-1 and HSP70, but not of HSP27 and HSP40. The up-regulation of these cytoprotective genes could be part of a recuperative mechanism induced by stress associated with brain death.

Prorenin accumulation and activation in human endothelial cells: importance of mannose 6-phosphate receptors.

ACE inhibitors improve endothelial dysfunction, possibly by blocking endothelial angiotensin production. Prorenin, through its binding and activation by endothelial mannose 6-phosphate (M6P) receptors, may contribute to this production. Here, we investigated this possibility as well as prorenin activation kinetics, the nature of the prorenin-activating enzyme, and M6P receptor-independent prorenin binding. Human umbilical vein endothelial cells (HUVECs) were incubated with wild-type prorenin, K/A-2 prorenin (in which Lys42 is mutated to Ala, thereby preventing cleavage by known proteases), M6P-free prorenin, and nonglycosylated prorenin, with or without M6P, protease inhibitors, or angiotensinogen. HUVECs bound only M6P-containing prorenin (K(d) 0.9+/-0.1 nmol/L, maximum number of binding sites [B(max)] 1010+/-50 receptors/cell). At 37 degrees C, because of M6P receptor recycling, the amount of prorenin internalized via M6P receptors was >25 times B(max). Inside the cells, wild-type and K/A-2 prorenin were proteolytically activated to renin. Renin was subsequently degraded. Protease inhibitors interfered with the latter but not with prorenin activation, thereby indicating that the activating enzyme is different from any of the known prorenin-activating enzymes. Incubation with angiotensinogen did not lead to endothelial angiotensin generation, inasmuch as HUVECs were unable to internalize angiotensinogen. Most likely, therefore, in the absence of angiotensinogen synthesis or endocytosis, M6P receptor-mediated prorenin internalization by endothelial cells represents prorenin clearance.

Cholesterol or triglyceride loading of human monocyte-derived macrophages by incubation with modified lipoproteins does not induce tissue factor expression.

Macrophages/foam cells localized in cholesterol- and triglyceride-rich regions of atherosclerotic plaques express high levels of tissue factor (TF), the essential cofactor and receptor of factor VIIa. It is not clear whether modified lipoproteins, for which several agonistic effects on macrophages have been described, are independent stimuli of TF expression in these cells. Therefore, we studied the effect of short-term (1 day) and long-term (4 to 7 days) incubation of human monocyte-derived macrophages cultured in suspension with modified and native LDLs or VLDLs on the expression of TF mRNA, antigen, and activity. We used native LDL or VLDL, moderately oxidized LDL or VLDL, severely oxidized LDL or VLDL, acetylated LDL, and beta-VLDL at a protein concentration of 100 microg/mL. Cholesterol loading occurred within 9 hours after the addition of acetylated LDL and continued during long-term incubation. Incubation of severely oxidized LDL for 7 days resulted in a slight increase in cholesterol content. Triglyceride loading was observed during short-term and long-term incubation with native and modified VLDLs. Neither cholesterol nor triglyceride loading resulted in expression of TF. Bacterial LPS still could induce TF expression in lipid-laden macrophages. Our results show that incubation with modified lipoproteins or lipid loading does not lead to TF expression in monocyte-derived macrophages cultured in suspension. This suggests that induction of TF expression in foam cells in the atherosclerotic lesion is triggered by additional or other components.

Tissue factor expression during monocyte-macrophage differentiation.

Tissue factor (TF), the high affinity receptor and cofactor of factor VII, is considered as the main procoagulant in stimulated monocytes and macrophages. We studied the effect of longterm culture (differentiation) on "spontaneous" and induced (LPS) expression of TF (mRNA, antigen, cell surface associated VIIa-cofactor activity) in isolated human monocytes. TF was expressed transiently in monocytes cultured on Teflon membranes (suspension monocytes, Mo-S) and on plastic dishes (adherent monocytes, Mo-A), reaching maximal levels between days 3 and 5. Increased expression of TF was accompanied by increased stable expression of macrophage specific markers (CD71, the mannose receptor, the scavenger receptor). Bacterial lipopolysaccharide (LPS) induced (additional) TF mRNA, antigen, and activity in both Mo-S and Mo-A. In Mo-S and Mo-A of days 3 to 5, the period in which there was "spontaneous" expression of TF, TF response to LPS was considerably lower. It is concluded that during monocyte-macrophage transition, TF is "spontaneously" and transiently expressed and that with respect to TF induction the responsiveness of the cells to LPS is maintained.

Characterization of a negative retinoic acid response element in the murine Oct4 promoter.

Expression of Oct4 in embryonic stem cells is controlled by a distal upstream stem cell-specific enhancer that is deactivated during retinoic acid (RA)-induced differentiation by an indirect mechanism not involving binding of RA receptors (H. Okazawa, K. Okamoto, F. Ishino, T. Ishino-Kaneko, S. Takeda, Y. Toyoda, M. Muramatsu, and H. Hamada, EMBO J. 10:2997-3005, 1991). Here we report that in RA-treated P19 embryonal carcinoma cells the Oct4 promoter is also subject to negative regulation by RA. The minimal Oct4 promoter sequence mediating repression consists of a promoter-proximal sequence containing a GC-rich SP1 consensus-like sequence and several hormone response element half-sites that can be arranged into direct repeats with different spacing. The GC box binds a nuclear factor that is invariably present in undifferentiated and RA-treated differentiated P19 cells. By contrast, the hormone response element-containing sequence binds factors that are induced following RA treatment. Mutational analysis and competition experiments show that the functional entity binding the RA-induced factor is a direct repeat sequence with a spacing of one nucleotide, previously shown to be a binding site for COUP transcription factors (COUP-TFs). Cotransfected orphan receptors COUP-TF1, ARP-1, and EAR-2 were able to repress the activity of Oct4 promoter-driven reporters in P19 EC cells, albeit with different efficiencies. Furthermore, the negative transcriptional effect of COUP-TFs is dominant over the activating effect of the Oct4 embryonic stem cell-specific enhancer. These results show that negative regulation of Oct4 expression during RA-induced differentiation of embryonic stem cells is controlled by two different mechanisms, including deactivation of the embryonic stem cell-specific enhancer and promoter silencing by orphan nuclear hormone receptors.

Biosynthesis and secretion of insect lipoprotein.

Biosynthesis of high density lipophorin (HDLp) was studied in larvae and adults of the migratory locust, Locusta migratoria. In an in vitro system, fat bodies were incubated in a medium containing a mixture of tritiated amino acids. Using SDS-PAGE and immunoblotting, it was shown that larval and adult fat bodies secreted both HDLp apoproteins, apolipophorin I (apoLp-I) and apolipophorin II (apoLp-II). Radiolabel was recovered in both apoproteins, indicative of de novo synthesis. The density of the fractions containing the apoproteins synthesized and secreted by larval and adult fat bodies was determined by density gradient ultracentrifugation. A radiolabeled protein fraction was found at density 1.12 g/ml. Using an enzyme-linked immunosorbent assay for detecting apoLp-I and apoLp-II, it was demonstrated that both apoproteins were present in this fraction, which had a density identical to that of circulating HDLp in hemolymph. Lipid analysis revealed that it contained phospholipid, diacylglycerol, sterol, and hydrocarbons. From these results it is concluded that the fat body of the locust synthesizes both apoLp-I and apoLp-II, which are combined with lipids to a lipoprotein particle that is released into the medium as HDLp.