Patients' knowledge about paracetamol (acetaminophen): a study in a French hospital emergency department.

UNLABELLED: Paracetamol is the most widely used analgesic and antipyretic drug. In France, little is known concerning patients' knowledge and beliefs about paracetamol. OBJECTIVE: To determine how much outpatients attending an emergency department know about paracetamol. METHOD: A semi-structured questionnaire was applied to patients consulting for non-severe medical or traumatic conditions. RESULTS: Thirty-three (45%) of 73 participating patients knew that paracetamol was the active ingredient of the medication they used to reduce pain and/or fever. Three patients thought 2g was the maximum recommended single dose; 25% thought that a delay between two doses ≤ 3 hours was recommended and 15% thought the maximum daily dose was > 4 g. While 8% cited liver toxicity as a side effect, 38% did not believe an excessive dose could be fatal. Two patients correctly answered all questions and five gave no correct answer. DISCUSSION: Outpatients attending an emergency department (ED) have poor knowledge about paracetamol. This situation is disturbing and our results may serve as an eye opener to healthcare professionals. They emphasize the need for research programs with the following objectives: a) to determine the actual content of the message delivered by healthcare professionals; b) to study conditions under which this message is issued; c) to analyze how patients understand key messages and what their behavioral response is. CONCLUSION: In ED patients, the level of knowledge about paracetamol is insufficient to ensure its safe use in ambulatory care. Further studies are needed to determine the causes and to permit better patient education.

Liposomal tobramycin against pulmonary infections of Pseudomonas aeruginosa: a pharmacokinetic and efficacy study following single and multiple intratracheal administrations in rats.

OBJECTIVE: To determine the pharmacokinetics and efficacy of tobramycin against pulmonary infections of Pseudomonas aeruginosa in rats after intratracheal administration of conventional and liposomal formulations. METHODS: Male Sprague-Dawley rats were inoculated with 10(6) cfu of a mucoid variant of P. aeruginosa (MIC of tobramycin for PA 508 = 1 mg/l) and tobramycin (conventional or liposomal formulations) was administered in single (490 microg) and multiple dose (490 microg during 4 days) experiments. Rats were killed at multiple time points to determine the residual cfu of P. aeruginosa and tobramycin amounts in lungs. Pharmacokinetic parameters were calculated using a two-compartment model with NONMEM. RESULTS: Mean (+/-S.D.) elimination half-life (t(1/2beta)) and pulmonary exposure (AUC) of the conventional formulation were 14.0 +/-4.0 h and 663 +/-89 microg x h/lungs, respectively. The pharmacokinetic profile of liposomal tobramycin was markedly different, with a longer t(1/2beta) (34.4 +/-5 h, P < 0.05), resulting in an increased AUC (3890 +/-560 microg x h/lungs, P < 0.05). chi(2) analyses were carried out on cfu data distributed in the following categories: below 10(3), 10(3)-10(5), and above 10(5) cfu. In the single dose experiments, approximately 90% of the observations were above 10(5) cfu for both formulations. Significant differences in cfu distribution were observed after multiple treatments, with approximately 10% of the observations falling below 10(3) cfu of P. aeruginosa for the conventional formulation versus 30% for the liposomal formulation. CONCLUSION: The liposomal formulation of tobramycin promoted drug retention in lungs and improved its efficacy after multiple treatments.

[13C]aminopyrine and [13C]caffeine breath test: influence of gender, cigarette smoking and oral contraceptives intake.

The [13C]aminopyrine breath test ([13C]ABT) measures the global activity of cytochrome P450 in vivo and is a sensitive indicator of liver metabolic dysfunction. The present study aims to determine whether gender and cigarette smoking influence the results of [13C]ABT as well as to confirm the effect of oral contraceptive steroids (OCS) intake on this metabolic test. Hundred and ten healthy subjects, including men and women, smoker and non-smoker, women taking OCS or not, were phenotyped for CYP1A2 using the [13C]caffeine breath test and underwent a [13C]ABT. Both tests showed large inter-individual variations in accordance with that of CYP450 liver content. [13C]ABT was sensitive enough to point out a significant induction or inhibition related to cigarette smoking habits or OCS. The combined effect of smoking and OCS resulted in an overall unchanged metabolic activity. Consequently, the impact of the studied conditions on the [13C]ABT parameters must be considered by clinicians or clinical investigators.

13C basal abundance of expired CO2 -definition of pre-requisites for kinetic breath tests.

A sufficiently stable rate of 13CO2 exhalation is necessary when the diagnostic 13CO2 breath tests are performed in healthy subjects and patients. The aim of the research was to define prerequisite conditions for kinetic breath tests in order to ensure a stable 13CO2 background. A 3-part protocol was developed. Part I: a study of the one-day variation of 13CO2 abundance in expired CO2 confirmed that shifts of the basal 13C abundance in breath are inherent in nature. Part II: a study of the variations of 13C enrichment after the ingestion of different meals and beverages showed that ingestion of food items containing C4 plant sugars, such as maize, induces a significant increase in isotopic abundance. Part III: a new test breakfast containing rice grain cereal, milk and orange juice was tested. This test meal induces no significant change on the basal 13CO2 abundance in healthy subjects. This new finding allows to avoid the fasting period normally required prior to a breath test which is sometimes difficult for children and pregnant women.

Accuracy of the [13C]-urea breath test in diagnosing Helicobacter pylori gastritis in pediatric patients.

BACKGROUND: The causal association between Helicobacter pylori (H. pylori) colonization of the gastric mucosa and gastritis is now well established. Histologic examination of endoscopic biopsy specimens has long been regarded as the gold standard for diagnosis. However, the changes can be focal in nature and presence of the organism may be missed in nonsampled areas. The urea breath test, which uses a stable isotope, offers distinct advantages, in that it is noninvasive and measures the activity of the micro-organism. It thus represents a potentially invaluable tool in the initial diagnosis of the infection and in verifying its eradication. METHODS: The study design was that of a prospective, blinded comparison of the [13C]-urea breath test with histologic assessment of antral biopsy specimens using the Warthin-Starry stain, to diagnose H. pylori infection in a group of 79 consecutive pediatric patients. RESULTS: Patients classified as negative by histology (n=67) had breath 13C enrichment of 0.97+/-0.07 delta per thousand (mean+/-SEM), with a range of -0.20 and 2.83 delta per thousand. In contrast, those with a positive histologic results (n=12) had an enrichment of 25.41+/-5.01 delta per thousand (range, 3.43-58.80; p < 0.001). At the chosen cutoff point of 3 delta per thousand, the sensitivity and specificity as well as the positive and negative predictive values of the breath test were uniformly 100%. CONCLUSION: The [13C]-urea breath test is a highly reliable, noninvasive method for the diagnosis of H. pylori gastritis in children and adolescents.

Possible involvement of multiple human cytochrome P450 isoforms in the liver metabolism of propofol.

Previous studies of propofol (2,6-diisopropylphenol) pharmacology have shown that this widely used anaesthetic drug is extensively cleared from the body by conjugation of the parent molecule or its quinol metabolite. On the basis of potential influence of propofol on the metabolism of co-administered agents, many investigators have evaluated the effects of propofol on cytochrome P450 (CYP) activities. CYP isoforms involved in propofol metabolism are not defined. In this study, our objective was to elucidate further the CYP isoforms responsible for the hydroxylation of propofol. Using microsomes from 12 different human livers, we investigated CYP isoforms involved in propofol hydroxylase activity, using selective chemical inhibitors of CYP isoforms, correlation with immunoquantified specific CYP isoform content, immunoinhibition, and 11 functionally active human CYP isoforms expressed in a heterologous system (yeast and human B-lymphoblastoid cells). We found a low variability in the production of the hydroxylated metabolite of propofol, 2,6-diisopropyl-1,4-quinol. This activity was mediated by CYP and followed Michaelis-Menten kinetics with apparent K(M) and Vmax values of 18 microM (95% Cl 15.1-20.1) and 2.6 nmol min-1 mg-1 (95% Cl 2.45-2.68) respectively. Part of the propofol hydroxylase activity was mediated by CYP2C9 in human liver, especially at low substrate concentration. Moreover, propofol was likely to be metabolized by additional isoforms such as CYP2A6, 2C8, 2C18, 2C19 and 1A2, especially when substrate concentrations are high. This low specificity among CYP isoforms may contribute to the low interindividual variability (two-fold) and may contribute to the low level of metabolic drug interactions observed with propofol.

Oxidative decarboxylation of benzoic acid by peroxyl radicals.

A chemical model based on the thermal decomposition of AAPH (2,2'-azobis(2-amidinopropane) dihydrochloride is used for the production of peroxyl radicals. Peroxyl radicals induces the decarboxylation of [7-13C]benzoic acid and the production of 13CO2, which is measured by gas chromatography-isotope ratio mass spectrometry (GC-IRMS). The decarboxylation depends on temperature, AAPH, and benzoic acid concentrations. The decarboxylation also depends on the presence of oxygen. Electron spin resonance studies are performed to confirm the presence of peroxyl radicals under oxygen and of carbon-centered radicals in the absence of oxygen. Decarboxylation rates are measured in the presence of various antioxidants: ascorbate, dimethylsulfoxide, mannitol, and uric acid. It turns out that the decarboxylation is inhibited by each of these antioxidants. The ratio of decarboxylation rates, with and without the antioxidant, varies linearly with the antioxidant concentration. HPLC and GC-MS analyses of reaction products between benzoic acid and AAPH-derived radicals do not detect the presence of radical substitution products on the aromatic ring or the products derived from benzoic acid. There is no doubt that GC-IRMS is a powerful technique to investigate the effects of peroxyl radicals on benzoic acid. In addition, it is possible to follow the degradation of 13C-labeled chemical targets exposed to peroxyl radicals through the production of 13CO2.

Possible involvement of multiple cytochrome P450S in fentanyl and sufentanil metabolism as opposed to alfentanil.

Fentanyl, sufentanil, and alfentanil are commonly used as opioid analgesics. Alfentanil clearance has previously been shown to exhibit an important interindividual variability, which was not observed for fentanyl or sufentanil. Differences in pharmacokinetic parameters of alfentanil have previously been associated with the wide distribution of CYP3A4, the only known hepatic cytochrome P450 monooxygenase (CYP) involved in the conversion of alfentanil to noralfentanil. Little is known about the involvement of CYP enzymes in the oxidative metabolism of fentanyl and sufentanil. Microsomes prepared from different human liver samples were compared for their abilities to metabolize fentanyl, sufentanil and alfentanil, and it was found that disappearance of the three substrates was well correlated with immunoreactive CYP3A4 contents but not with other CYPs, including CYP1A2, CYP2A6, CYP2C8, CYP2C9, CYP2D6 and CYP2E1. Specific known inhibitors of CYP enzymes gave similar results, whereas the use of recombinant human CYP enzymes expressed in yeast provided information about the possible involvement of other CYPs than CYP3A4 in the biotransformation of fentanyl and sufentanil. The possible in vivo interaction of fentanyl and sufentanil with other drugs catalyzed by CYP3A4 is also discussed.

Gas chromatographic-mass spectrometry and gas chromatographic-Fourier transform infrared spectroscopy assay for the simultaneous identification of fentanyl metabolites.

Fentanyl, a synthetic opioid, undergoes important biotransformation to several metabolites. A gas chromatographic-mass spectrometric assay was applied for the simultaneous analysis of fentanyl and its major metabolites in biological samples. The identification of different metabolites was performed by gas chromatography-mass spectrometry (electronic impact and chemical ionisation modes) and gas chromatography-Fourier transform infrared spectroscopy. In the present study, rat and human microsomes incubation mixtures and human urines were analysed. In vitro formation of already known fentanyl metabolites was confirmed. The presence of metabolites not previously detected in human urine is described.

Deuterium isotope effects on caffeine metabolism.

The aim of this work was to study the influence of labelling on caffeine metabolism according to the incubation mode. It has been observed that labelling induces an isotopic effect on metabolisation speed: apparent half-lives are systematically increased. Moreover, isotopic effects are in agreement with those previously observed for retention times. Qualitatively, caffeine labelling systematically induces metabolic variations to the detriment of the metabolic pathway that induces the loss of the trideuteromethyl group. Caffeine accumulation and the release of the main metabolites have been studied with respect to isotopic effects on crossing the cell membrane. It has been demonstrated that, in most of the cases, accumulation decreased and that either metabolite release was increased or no isotopic effect was observed.

Gas chromatography-atomic emission detection for the measurement of isotopes. Application to bioequivalence studies.

This study was designed to demonstrate the ability of gas chromatography-atomic emission detection (GC-AED) to quantitatively measure amounts of labeled and unlabeled molecules when they are mixed together with both variable overall concentrations (labeled+unlabeled) and variable isotope ratios. To perform this study, simulations of bioequivalence trials were carried out using 13C stable isotopically labeled molecules (SIL) coadministered with the unlabeled drug to act as biological internal standards. Various methodological approaches are shown and different methods of calculation developed for the quantitative determination of both SIL and unlabeled molecules. The pharmacokinetic parameters experimentally obtained are quite in accordance with the target values and GC-AED appears to be a valuable alternative to mass spectrometry for this kind of trial with concomitant use of labeled and unlabeled molecules.

Isotopic effects on retention times of caffeine and its metabolites 1,3,7-trimethyluric acid, theophylline, theobromine and paraxanthine.

Physicochemical parameters that influence gas chromatographic separation are numerous. Consequently, isotope labelling, because it modifies physicochemical properties, can induce isotopic effects on retention time. Caffeine has been chosen to study this influence because as itself and its metabolites, it allows the preparation of different methylxanthine isotopomers and thus is one of the best models to study isotopic effects induced by stable isotope labelling. Using a caffeine molecule labelled with deuterium at different positions and rat hepatocytes to obtain metabolites, it was possible to study the influence of labelling on retention time [(14% cyanopropylphenyl)methylpolysiloxane] and to point out the role of each labelled site. It appears that isotopic effects induced by the labelling depend not only on the number of labelling atoms but also on whether this labelling is at position 1, 3 or 7 and, consequently, on the role of the labelled site on the function of the molecule.

Comparison between gas chromatography-atomic emission detection and gas chromatography-mass spectrometry for the assay of propofol.

Quantitation by gas chromatography-atomic emission detection (GC-AED) is based on the intensity of the signal measured at a wavelength characteristic of an element, after atomisation by the plasma. This response depends only on the number of atoms of this element present in the molecule under investigation, and is independent of the structure of the molecule. This technique was used for the assay of propofol, and the estimation of its two metabolites, after calibration with standard solutions of pure propofol. The results were compared with those obtained by gas chromatography-mass spectrometry (GC-MS). Propofol was quantified with higher precision and accuracy by GC-AED than by GC-MS which exhibited larger residual values. Concentration assessment for two metabolites showed a better agreement with the theoretical value by GC-AED since the response depends only on the number of carbon atoms in each molecule.

[Value of the use of the oral route versus the injectable route for fluoroquinolones. Pharmacoeconomic incidence and bibliographical study]. / Intérêt de l'utilisation de la voie orale par rapport à la voie injectable pour les fluoroquinolones. Incidence pharmacoéconomique et étude bibliographique.

The aim of this study was to research the optimal conditions to shift to oral from injectable administration route for the fluoroquinolone antibiotics and the pharmacoeconomic and therapeutic impact of such a shift. Two indicators were used: proportion of the two administration routes, and mean cost per administration. The published results of pharmacokinetic studies in healthy and diseased subjects, and the clinical and/or pharmacokinetic studies including the notion of a therapeutic shift from the parenteral route to the oral route have been selected. The bioequivalence pharmacokinetic parameters of oral and injectable forms and the major clinical data of the therapeutic shift have been listed. Literature analysis reveals that there are few studies covering the specific assessment of the switch. The financial consequences of oral administration early use show the importance of such studies.

Gas chromatographic-mass spectrometric method to characterise the transfer of dietary odorous compounds into plasma and milk.

The flavours contained in a mammalian mother's milk can exert a marked influence on her offspring's proximate suckling behaviour and later preferences. The aim of this study was to establish a reliable analytical procedure to characterise the mammary transfer of selected volatile constituents of maternal food from non-pregnant and recently parturient ewes. Six known volatile compounds, most representative of cumin aroma (alpha-pinene, gamma-terpinene, cuminaldehyde, p-cymene, limonene and cineole), were traced in the blood and milk of ewes fed with cumin seeds, using liquid-liquid extraction combined with gas chromatography-specific ion monitoring mass spectrometry. Among the six cumin odour markers, only one, p-cymene, was transferred in quantifiable amounts into the venous plasma. The other cumin markers could only be detected as traces corresponding to amounts lower that the limit of quantification. In milk, four of the cumin markers could be detected, and two of these were quantified.

Aminopyrine breath test: development of a 13C-breath test for quantitative assessment of liver function in humans.

BACKGROUND/AIM: 14C-aminopyrine breath test (ABT) has been shown to be well correlated to the severity of liver diseases, but its use is limited in countries where radioactive isotopes are severely controlled. The goal of this study was to develop a 13C-ABT based on a highly sensitive method to measure 13CO2 in breath samples. MATERIALS AND METHODS: The relevant parameters were studied in 26 controls and 27 patients: the 13CO2 enrichment of expired breath between t-10 and t+60 minutes was determined as the most simple and clinically useful parameter. The 13C-ABT was then prospectively compared to clinico-biological data and the galactose elimination capacity (GEC) in 82 patients. RESULTS: The 13C-ABT was well correlated to: i) the Child-Pugh classification; ii) GEC results; iii) the hepatic volume. The presence of ascites or alcoholic consumption did not alter significantly the results of the test. 13C-ABT appeared more sensitive than GEC to evaluate minor liver dysfunctions. CONCLUSIONS: The 13C-ABT is a simple and sensitive test to measure liver function. The use of the stable isotope 13C ensures the harmlessness of the test and the possibility to repeat it in a given patient.

Quantitation of propofol in whole blood by gas chromatography-mass spectrometry.

A gas chromatographic-mass spectrometric assay, using selected-ion monitoring (GC-MS-SIM) with thymol as internal standard, was developed for quantitating propofol, an intravenous anaesthetic. The method described is rapid and sensitive for the determination of propofol in whole blood. The sensitivity of the present method is 10 ng/ml. The recovery of propofol added to human whole blood in the concentration range 10-10,000 ng/ml ranged between 95 and 100%. A single extraction procedure was used with chloroform-ethyl acetate. The assay allowed the detection of two metabolites formed during propofol metabolism: 2,6-diisopropyl-1,4-quinone and 2,6-diisopropyl-1,4-quinol.

Theophylline pharmacokinetics and metabolism in rabbits following single and repeated administration of Capsicum fruit.

Pharmacokinetics and metabolism of theophylline were studied in three groups of male rabbits, after intravenous administration (12 mg/kg), with and without oral ground Capsicum fruit suspension. Compared with control values, plasma theophylline half-life of distribution and of elimination, areas under plasma curves, clearance and volume of distribution did not show any significant difference. On the contrary, the elimination rate constant (k1,0) is significantly different (0.01 < P < 0.05) after a single dose of capsicum and remained unchanged after a repeated dose. Concerning the metabolism of theophylline in rabbits, the results showed that the oral administration of a single dose of Capsicum fruit suspension does not significantly affect the urinary excretion of theophylline and its metabolites--1,3-dimethyluric acid (1,3-DMU) and 1-methyluric acid (1-MU). On the other hand, after a repeated dose of Capsicum fruit for 7 days, the quantity of 1-MU was significantly reduced (0.01 < P < 0.05). In conclusion, it was found that a single dose of Capsicum fruit could affect pharmacokinetic parameters of theophylline (k1,0), while a repeated dose affected the metabolic pathway of xanthine oxidase.

Effects of capsaicinoids on oxidative metabolism of caffeine in isolated rat hepatocytes.

The metabolism of caffeine was studied in isolated rat hepatocytes, in the absence and presence of capsaicinoids. Caffeine and four primary metabolite fractions were identified by high performance liquid chromatography: 1,7-dimethylxanthine, 3,7-dimethylxanthine, 1,3-dimethylxanthine and 1,3,7-trimethyluric acid. The incubation with the lowest concentrations (0.1 and 1 microM) of capsaicinoids (natural extract, capsaicin, dihydrocapsaicin) showed a stimulatory effect on caffeine metabolism, which was further enhanced with capsaicin. At 10 microM, capsaicin stimulated the two pathways of metabolism of caffeine (N-demethylation and C-8 oxidation). In contrast, dihydrocapsaicin and the natural extract seem to inhibit the N-demethylation pathways without affecting the C-8 oxidation route. The inhibitory activity on the N-demethylation pathways and especially the N-7 demethylation pathway was pronounced at the first 30 min of incubation. These results suggest that the two pathways (N-demethylation and C-8 oxidation) are mediated by different isozymes of cytochromes P-450. This is in agreement with recent findings.

Human hepatic macrovesicular steatosis: a noninvasive study of mitochondrial ketoisocaproic acid decarboxylation.

Differentiating between alcoholic and nonalcoholic hepatic steatosis is often a difficult clinical task. However, decreased fatty acid mitochondrial oxidation appears as the main factor for alcoholic steatosis, whereas nonalcoholic steatosis may be due to other causes. We studied mitochondrial function, based on a 13C-ketoisocaproic acid (13C-KIC) breath test, in nine alcoholic and 12 nonalcoholic steatosis patients and 10 healthy volunteers. Our results showed a 42% 13C-KIC decarboxylation decrease in alcoholic steatosis patients, but not in nonalcoholic steatosis patients. This noninvasive breath test appears helpful for the diagnostic work-up of hepatic steatosis.