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Wu Wai Ping. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2004. / Includes bibliographical references (leaves 163-177). / Abstracts in English and Chinese. / Abstract --- p.i / 摘要 --- p.iv / Acknowledgement --- p.vi / Table of Contents --- p.vii / Abbreviations --- p.x / Chapter Chapter 1 --- General introduction --- p.11 / Chapter 1.1 --- Introduction --- p.11 / Chapter 1.1.1 --- "Origin, processing and delivery form of TCM" --- p.11 / Chapter 1.1.2 --- Problems about the uses of TCM --- p.13 / Chapter 1.1.2.1 --- Quality control --- p.13 / Chapter 1.1.2.2 --- Efficacy --- p.14 / Chapter 1.1.2.3 --- Herb-drug interactions --- p.14 / Chapter 1.1.2.4 --- Authentication --- p.15 / Chapter 1.1.3 --- Commonly used Traditional Chinese Medicine --- p.15 / Chapter 1.2 --- Interactions between TCM and warfarin --- p.17 / Chapter 1.2.1 --- Danshen-warfarin interactions --- p.19 / Chapter 1.3 --- Danshen --- p.20 / Chapter 1.3.1 --- Chemical constituents --- p.20 / Chapter 1.3.2 --- Pharmacological effects of danshen --- p.24 / Chapter 1.3.2.1 --- Anti-oxidant effects --- p.24 / Chapter 1.3.2.2 --- Effects on liver fibrosis --- p.25 / Chapter 1.3.2.3 --- Effects on tumours --- p.26 / Chapter 1.3.2.4 --- Effects on cardiovascular system --- p.26 / Chapter 1.3.2.5 --- Effect on platelet aggregation --- p.27 / Chapter 1.4 --- Warfarin --- p.27 / Chapter 1.4.1 --- Pharmacology --- p.28 / Chapter 1.4.2 --- Pharmacokinetics --- p.30 / Chapter 1.4.3 --- Metabolism --- p.30 / Chapter 1.4.4 --- Warfarin-drug interactions --- p.32 / Chapter 1.4.4.1 --- Pharmacokinetic Interactions --- p.32 / Chapter 1.4.4.2 --- Pharmacodynamic interactions --- p.34 / Chapter 1.5 --- Aim of study --- p.35 / Chapter Chapter 2 --- Effects of danshen extract and some of its active ingredients on warfarin metabolism in rat liver microsomes --- p.36 / Chapter 2.1 --- Introduction --- p.36 / Chapter 2.2 --- Materials and methods --- p.39 / Chapter 2.2.1 --- Chemicals and reagents --- p.39 / Chapter 2.2.2 --- Animals --- p.39 / Chapter 2.2.3 --- Preparation of rat hepatic microsomes --- p.40 / Chapter 2.2.4 --- Protein assay --- p.40 / Chapter 2.2.5 --- Preparation of aqueous fraction and ethanolic fractions of danshen from danshen roots --- p.41 / Chapter 2.2.5.1 --- Aqueous extract of danshen --- p.41 / Chapter 2.2.5.2 --- Ethanolic extract of danshen --- p.42 / Chapter 2.2.6 --- Incubation condition for warfarin metabolism --- p.42 / Chapter 2.2.7 --- Effects of danshen extract and some of its active ingredients on warfarin metabolism in vitro --- p.43 / Chapter 2.2.8 --- Effects of danshen extract and some of its sctive ingredients on enzyme kinetics of warfarin metabolism in vitro --- p.44 / Chapter 2.2.9 --- High Pressure Liquid Chromatography (HPLC) analysis --- p.45 / Chapter 2.2.10 --- Calibration curves and validation of the HPLC systems --- p.48 / Chapter 2.2.11 --- Data analysis --- p.52 / Chapter 2.3 --- Results --- p.53 / Chapter 2.3.1 --- Effects of danshen extract on warfarin metabolism --- p.53 / Chapter 2.3.2 --- Effects of aqueous extract of danshen on warfarin metabolism --- p.60 / Chapter 2.3.3 --- Effects of ethanolic extract of danshen on warfarin metabolism --- p.62 / Chapter 2.3.4 --- Effects of tanshinone I on warfarin metabolism --- p.64 / Chapter 2.3.5 --- Effects of tanshinone IIA on warfarin metabolism --- p.70 / Chapter 2.3.6 --- Effects of cryptotanshinone on warfarin metabolism --- p.76 / Chapter 2.3.7 --- IC20 of danshen extract and its components on warfarin metabolism --- p.82 / Chapter 2.4 --- Discussion --- p.84 / Chapter Chapter 3 --- Effects of danshen extract and some of its active ingredients on warfarin metabolism in human pooled liver microsomes and the human CYP2C9 isoform --- p.89 / Chapter 3.1 --- Introduction --- p.89 / Chapter 3.2 --- Materials and methods --- p.92 / Chapter 3.2.1 --- Chemicals and reagents --- p.92 / Chapter 3.2.2 --- Incubation conditions for warfarin metabolism --- p.92 / Chapter 3.2.3 --- Effects of danshen extract and its components on warfarin metabolism in vitro --- p.93 / Chapter 3.2.4 --- High Pressure Liquid Chromatography (HPLC) analysis --- p.94 / Chapter 3.2.5 --- Calibration curves --- p.95 / Chapter 3.2.6 --- Data analysis --- p.95 / Chapter 3.3 --- Results --- p.96 / Chapter 3.3.1 --- Effects of danshen extract and its components on warfarin metabolism by using human pooled liver microsomes --- p.96 / Chapter 3.3.2 --- Effects of danshen extract and its components on S-warfarin metabolism by using human lymphoblast CYP2C9 isoform --- p.103 / Chapter 3.4 --- Discussion --- p.111 / Chapter Chapter 4 --- Effects of acute and subchonic pretreatment of danshen extract on the pharmacokinetics of warfarin in the rats in vivo --- p.115 / Chapter 4.1 --- Introduction --- p.115 / Chapter 4.2 --- Materials and methods --- p.118 / Chapter 4.2.1 --- Chemicals and reagents --- p.118 / Chapter 4.2.2 --- Animals Table of Contents --- p.118 / Chapter 4.2.3 --- Effects of acute danshen extract pretreatment on the pharmacokinetics of warfarin --- p.119 / Chapter 4.2.4 --- Effects of subchronic danshen extract pretreatment on the pharmacokinetics of warfarin --- p.119 / Chapter 4.2.5 --- Steady state warfarin study --- p.120 / Chapter 4.2.6 --- Sample extraction --- p.120 / Chapter 4.2.7 --- High Pressure Liquid Chromatography (HPLC) analysis --- p.121 / Chapter 4.2.8 --- Calibration curve --- p.121 / Chapter 4.4 --- Results --- p.123 / Chapter 4.3.1 --- Effects of acute danshen extract pretreatment on the pharmacokinetics of warfarin --- p.123 / Chapter 4.3.2 --- Effects of subchronic danshen extract pretreatment on the pharmacokinetics of warfarin --- p.128 / Chapter 4.3.3 --- Steady state warfarin study --- p.136 / Chapter 4.5 --- Discussion --- p.138 / Chapter Chapter 5 --- Effects of danshen extract on the absorption of warfarin by using Caco-2 cells model --- p.142 / Chapter 5.1 --- Introduction --- p.142 / Chapter 5.2 --- Materials and methods --- p.144 / Chapter 5.2.1 --- Materials for Caco-2 cells culture experiment --- p.144 / Chapter 5.2.2 --- Preparation of Caco-2 monolayer --- p.144 / Chapter 5.2.3 --- High Pressure Liquid Chromatography (HPLC) analysis for warfarin --- p.145 / Chapter 5.2.4 --- Calibration curve --- p.145 / Chapter 5.2.5 --- Stability test for warfarin and danshen extract --- p.145 / Chapter 5.2.6 --- Toxicity test of danshen extract on Caco-2 cells --- p.146 / Chapter 5.2.7 --- Transport study --- p.146 / Chapter 5.2.8 --- Data Analysis --- p.147 / Chapter 5.3 --- Results --- p.149 / Chapter 5.3.1 --- Stability of warfarin and danshen extract --- p.149 / Chapter 5.3.2 --- Toxicity test of danshen extract on Caco-2 cells --- p.149 / Chapter 5.3.3 --- Integrity of Caco-2 cells monolayer --- p.152 / Chapter 5.3.4 --- Transport study --- p.152 / Chapter 5.4 --- Discussion --- p.154 / Chapter Chapter 6 --- General discussion --- p.156 / References --- p.163

Chan Wai Hung Fredric. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2006. / Includes bibliographical references (leaves 67-72). / Abstracts in English and Chinese. / Acknowledgement --- p.i / Abstract --- p.ii / 摘要 --- p.iv / Table of contents --- p.vi / Publications --- p.ix / List of figures --- p.x / List of tables --- p.xi / Abbreviations --- p.xii / Chapter Chapter 1 --- Introduction / Chapter 1.1 --- Anticoagulation effect of warfarin --- p.2 / Chapter 1.2 --- Indications of warfarin therapy --- p.3 / Chapter 1.3 --- Monitoring systems for anticoagulation therapy --- p.4 / Chapter 1.4 --- Optimum target intensities for anticoagulation therapy --- p.5 / Chapter 1.5 --- Factors affecting anticoagulation effect of warfarin --- p.6 / Chapter 1.5.1 --- Drugs --- p.7 / Chapter 1.5.2 --- Diet --- p.8 / Chapter 1.5.3 --- Health supplements --- p.8 / Chapter 1.5.4 --- Comorbidities --- p.9 / Chapter 1.5.5 --- Genetic factors --- p.10 / Chapter 1.6 --- Management of anticoagulation therapy in Chinese patients --- p.11 / Chapter 1.7 --- Barriers to optimal INR control --- p.13 / Chapter 1.8 --- Two models of care for anticoagulation therapy - routine medical care and co-ordinated anticoagulation service --- p.14 / Chapter 1.9 --- Outcomes of two models of anticoagulation management --- p.14 / Chapter 1.9.1 --- Clinical outcomes --- p.14 / Chapter 1.9.2 --- Economic outcomes --- p.16 / Chapter 1.10 --- Clinical pharmacist involvement in the management of anticoagulation therapy --- p.17 / Chapter 1.11 --- Anticoagulation management in Hong Kong --- p.18 / Chapter 1.12 --- Hypothesis and objectives --- p.19 / Chapter Chapter 2 --- Materials and Methods / Chapter 2.1 --- Setting and subjects --- p.22 / Chapter 2.2 --- Interventions --- p.23 / Chapter 2.2.1 --- Newly proposed model --- p.23 / Chapter 2.2.1.1 --- Training of clinical pharmacist --- p.23 / Chapter 2.2.1.2 --- Development of management protocol --- p.24 / Chapter 2.2.1.3 --- Treatment algorithm of pharmacist-managed anticoagulation service --- p.25 / Chapter 2.2.1.4 --- Validation of the Coagucheck Pro DM --- p.28 / Chapter 2.2.2 --- Usual practice model --- p.29 / Chapter 2.3 --- Outcome measures --- p.29 / Chapter 2.3.1 --- Primary clinical outcomes --- p.29 / Chapter 2.3.1.1 --- Therapeutic and expanded therapeutic INR ranges --- p.29 / Chapter 2.3.1.2 --- A method to determine the amount of patient-time spent in each INR category --- p.30 / Chapter 2.3.2 --- Secondary clinical outcomes --- p.31 / Chapter 2.3.3 --- Economic outcomes --- p.32 / Chapter 2.3.4 --- Humanistic outcomes --- p.34 / Chapter 2.4 --- Sample size estimation --- p.34 / Chapter 2.5 --- Statistical analysis --- p.35 / Chapter Chapter 3 --- Results / Chapter 3.1. --- Patient demographics and indications --- p.37 / Chapter 3.2. --- Control of INR --- p.42 / Chapter 3.3. --- Incidence of major bleeding and thromboembolism --- p.44 / Chapter 3.4. --- Direct medical cost analysis --- p.46 / Chapter 3.5. --- Patient satisfaction --- p.48 / Chapter Chapter 4 --- Discussion and Conclusion / Chapter 4.1 --- Discussion --- p.51 / Chapter 4.1.1 --- Clinical outcomes of anticoagulation clinic --- p.52 / Chapter 4.1.2 --- Direct medical cost analysis --- p.56 / Chapter 4.1.3 --- Patient satisfaction --- p.59 / Chapter 4.1.4 --- Limitations --- p.62 / Chapter 4.1.5 --- Future studies --- p.63 / Chapter 4.2 --- Conclusion --- p.66 / References --- p.67 / Appendices / Appendix A. Management protocol --- p.73 / Appendix B. Data collection form --- p.96 / Appendix C. PSQ-18 --- p.104

Estudo prospectivo e randomizado de 30 pacientes, submetidos a derivação cavopulmonar total com tubo extracardíaco. Os dados refletem o período de 2008 a 2011, com seguimento de dois anos, por meio de avaliação clínica, laboratorial, ecocardiográfica, angiotomográfica e cintilográfica. Neste estudo, procuramos comparar a eficácia do ácido acetil salicílico (AAS) e da Varfarina na profilaxia da trombose na população estudada. Para tanto, analisamos alterações nos fatores de coagulação (VII, VIII e Proteína C ); ou nos dados clínicos que predispusessem a ocorrência de trombo no pós-operatório. Além disso, no pós-operatório, após a randomização (15 pacientes randomizados para receber Varfarina, Grupo I, e 15 pacientes randomizados para receber AAS, Grupo II), estudamos a interferência da fenestração na ocorrência de trombo; alterações hemodinâmicas que pudessem contribuir com a ocorrência de trombo (fluxo lento pelo tubo extracardíaco), por meio de ecocardiograma transesofágico realizado com até 10 dias de pós operatório, 3, 6, 12 e 24 meses de pós operatório. A presença do fenômeno tromboembólico era pesquisada, além dos ecocardiogramas acima citados, por meio de consultas clínicas realizadas com a mesma periodicidade e que avaliavam, ainda, efeitos colaterais ou complicações no uso de cada uma das drogas. Avaliamos também a viabilidade e aderência ao uso de cada uma delas. O seguimento contou igualmente com a realização de angiotomografia aos 6, 12 e 24 meses de pós-operatório para avaliação de alterações na parede interna do tubo, bem como trombos e cintilografia pulmonar, ventilação-perfusão para avaliar possível tromboembolismo pulmonar. Durante o seguimento, ocorreram dois óbitos, ambos no grupo em uso de Varfarina. Ao todo, durante os dois anos de seguimento, 33,3% dos pacientes apresentaram fenômeno tromboembólico. Sendo que, entre os paciente em uso de AAS, 46,7% apresentaram tal complicação e 20% entre os pacientes em uso de Varfarina (p=0,121). Com relação a avaliação pré-operatória, a ocorrência prévia de trombo e baixos níveis de proteína C da coagulação foram os únicos fatores que influenciaram no tempo de sobrevida livre de trombo, com valores de p de 0,035 e 0,047 respectivamente. Ao final de dois anos de seguimento, na avaliação angiotomográfica, 35,7% dos pacientes em uso de AAS tinham material hiper-refringente depositado em tubo extracardíaco com espessura superior a 2mm ( p= 0,082). Já na avaliação por cintilografia de ventilação-perfusão, dois pacientes apresentaram sinais de tromboembolismo pulmonar, ambos em uso de AAS (p=0,483), e um deles com evolução desfavorável do circuito tipo Fontan. Com relação a segurança e aderência ao tratamento, cinco pacientes tiveram dificuldade de aderência (só viabilizada por tratar-se de protocolo de estudo), entre eles, quatro em uso de Varfarina e apresentando INR variando de 1 a 6,4. Para comprovação numérica, com força estatística dos dados encontrados, uma força tarefa deve ocorrer para que se consiga um grupo maior de pacientes incluídos neste estudo. No entanto, a diferença entre os dois grupos na evolução livre de trombo nos dois primeiros anos de pós-operatório não pode, e nem deve, ser ignorada / Prospective randomized trial of 30 patients who had undergone total cavopulmonary anastomosis via an extracardiac conduit. The data reflect the period between 2008 and 2011, with two-year follow-up, through clinical, laboratorial, echocardiographic, angiotomographic, and scintigraphic assessment. In this study, we aimed to compare the efficiency of ASA (Aspirin) and Warfarin in the preventive treatment of thrombosis in the tried population. For such, we\'ve analyzed changes in coagulation factors (VII, VIII and Protein C) or in the clinical data which would predispose the occurrence of postoperative thrombus. Moreover, during postoperative care, after randomization (15 patients randomly selected to be trated with Warfarin, referred to as Group I, and 15 patients randomly selected to be treated with ASA, referred to as Group II), we also studied the influence of fenestration in the occurrence of thrombus; hemodynamic variations which could contribute to the occurrence of thrombus (slow blood flow in the extracardiac conduit), with postoperative transesophageal echocardiogram being performed within 10 days, and thereafter 3, 6, 12 and 24 months. Besides the echocardiograms aforementioned, the presence of thromboembolic events was sought after by clinical appointments taking place with the same frequency, which evaluated, apart from thromboembolism, side effects or complications from the usage of each of the drugs. We\'ve also evaluated the compliance to and feasibility of each of them. Postoperative angiotomography was also performed during the follow-up, within 6, 12 and 24 months, for the evaluation of changes on the inside wall of the extracardiac conduit, as well as thrombi, and pulmonary ventilation/perfusion scintigraphy for assessment of pulmonary thromboembolism possibility. During the follow-up, two deaths were registered, both in the group being treated with Warfarin. Overall, in the two-year follow-up, 33,3% of the patients presented thromboembolic events. Among the group being treated with ASA, 46,7% presented such complication, whereas in the group being treated with Warfarin, 20% had the same complication (p=0,121). Regarding the preoperative evaluation, prior occurrence of thrombus and low levels of coagulation factor Protein C were the only variables which influenced living time without thrombus, with p-values of 0,035 and 0,047. At the end of the two-year follow-up, in the angiotomographic evaluation, 35,7% of patients treated with ASA presented material accumulation inside the extracardiac conduit, with over 2mm of thickness (p=0,082). As for the ventilation/perfusion scintigraphy, two patients presented traces of pulmonary thromboembolism, both treated with ASA (p=0,483), one of whom with unfavorable development of the Fontan circuit. Concerning safety and compliance to the treatment, five patients had difficulty to comply with the treatment (only viable for its trial nature), among those, four under treatment with Warfarin and presenting INR values ranging from 1 to 6,4. For quantitative verification, providing statistic value to the data, an effort must be made for a larger number of patients to be gathered and tried with this treatment. However, the difference in results concerning thrombus-free recovery between the two groups during the two years following surgery cannot, and must not, be ignored

Estudo prospectivo e randomizado de 30 pacientes, submetidos a derivação cavopulmonar total com tubo extracardíaco. Os dados refletem o período de 2008 a 2011, com seguimento de dois anos, por meio de avaliação clínica, laboratorial, ecocardiográfica, angiotomográfica e cintilográfica. Neste estudo, procuramos comparar a eficácia do ácido acetil salicílico (AAS) e da Varfarina na profilaxia da trombose na população estudada. Para tanto, analisamos alterações nos fatores de coagulação (VII, VIII e Proteína C ); ou nos dados clínicos que predispusessem a ocorrência de trombo no pós-operatório. Além disso, no pós-operatório, após a randomização (15 pacientes randomizados para receber Varfarina, Grupo I, e 15 pacientes randomizados para receber AAS, Grupo II), estudamos a interferência da fenestração na ocorrência de trombo; alterações hemodinâmicas que pudessem contribuir com a ocorrência de trombo (fluxo lento pelo tubo extracardíaco), por meio de ecocardiograma transesofágico realizado com até 10 dias de pós operatório, 3, 6, 12 e 24 meses de pós operatório. A presença do fenômeno tromboembólico era pesquisada, além dos ecocardiogramas acima citados, por meio de consultas clínicas realizadas com a mesma periodicidade e que avaliavam, ainda, efeitos colaterais ou complicações no uso de cada uma das drogas. Avaliamos também a viabilidade e aderência ao uso de cada uma delas. O seguimento contou igualmente com a realização de angiotomografia aos 6, 12 e 24 meses de pós-operatório para avaliação de alterações na parede interna do tubo, bem como trombos e cintilografia pulmonar, ventilação-perfusão para avaliar possível tromboembolismo pulmonar. Durante o seguimento, ocorreram dois óbitos, ambos no grupo em uso de Varfarina. Ao todo, durante os dois anos de seguimento, 33,3% dos pacientes apresentaram fenômeno tromboembólico. Sendo que, entre os paciente em uso de AAS, 46,7% apresentaram tal complicação e 20% entre os pacientes em uso de Varfarina (p=0,121). Com relação a avaliação pré-operatória, a ocorrência prévia de trombo e baixos níveis de proteína C da coagulação foram os únicos fatores que influenciaram no tempo de sobrevida livre de trombo, com valores de p de 0,035 e 0,047 respectivamente. Ao final de dois anos de seguimento, na avaliação angiotomográfica, 35,7% dos pacientes em uso de AAS tinham material hiper-refringente depositado em tubo extracardíaco com espessura superior a 2mm ( p= 0,082). Já na avaliação por cintilografia de ventilação-perfusão, dois pacientes apresentaram sinais de tromboembolismo pulmonar, ambos em uso de AAS (p=0,483), e um deles com evolução desfavorável do circuito tipo Fontan. Com relação a segurança e aderência ao tratamento, cinco pacientes tiveram dificuldade de aderência (só viabilizada por tratar-se de protocolo de estudo), entre eles, quatro em uso de Varfarina e apresentando INR variando de 1 a 6,4. Para comprovação numérica, com força estatística dos dados encontrados, uma força tarefa deve ocorrer para que se consiga um grupo maior de pacientes incluídos neste estudo. No entanto, a diferença entre os dois grupos na evolução livre de trombo nos dois primeiros anos de pós-operatório não pode, e nem deve, ser ignorada / Prospective randomized trial of 30 patients who had undergone total cavopulmonary anastomosis via an extracardiac conduit. The data reflect the period between 2008 and 2011, with two-year follow-up, through clinical, laboratorial, echocardiographic, angiotomographic, and scintigraphic assessment. In this study, we aimed to compare the efficiency of ASA (Aspirin) and Warfarin in the preventive treatment of thrombosis in the tried population. For such, we\'ve analyzed changes in coagulation factors (VII, VIII and Protein C) or in the clinical data which would predispose the occurrence of postoperative thrombus. Moreover, during postoperative care, after randomization (15 patients randomly selected to be trated with Warfarin, referred to as Group I, and 15 patients randomly selected to be treated with ASA, referred to as Group II), we also studied the influence of fenestration in the occurrence of thrombus; hemodynamic variations which could contribute to the occurrence of thrombus (slow blood flow in the extracardiac conduit), with postoperative transesophageal echocardiogram being performed within 10 days, and thereafter 3, 6, 12 and 24 months. Besides the echocardiograms aforementioned, the presence of thromboembolic events was sought after by clinical appointments taking place with the same frequency, which evaluated, apart from thromboembolism, side effects or complications from the usage of each of the drugs. We\'ve also evaluated the compliance to and feasibility of each of them. Postoperative angiotomography was also performed during the follow-up, within 6, 12 and 24 months, for the evaluation of changes on the inside wall of the extracardiac conduit, as well as thrombi, and pulmonary ventilation/perfusion scintigraphy for assessment of pulmonary thromboembolism possibility. During the follow-up, two deaths were registered, both in the group being treated with Warfarin. Overall, in the two-year follow-up, 33,3% of the patients presented thromboembolic events. Among the group being treated with ASA, 46,7% presented such complication, whereas in the group being treated with Warfarin, 20% had the same complication (p=0,121). Regarding the preoperative evaluation, prior occurrence of thrombus and low levels of coagulation factor Protein C were the only variables which influenced living time without thrombus, with p-values of 0,035 and 0,047. At the end of the two-year follow-up, in the angiotomographic evaluation, 35,7% of patients treated with ASA presented material accumulation inside the extracardiac conduit, with over 2mm of thickness (p=0,082). As for the ventilation/perfusion scintigraphy, two patients presented traces of pulmonary thromboembolism, both treated with ASA (p=0,483), one of whom with unfavorable development of the Fontan circuit. Concerning safety and compliance to the treatment, five patients had difficulty to comply with the treatment (only viable for its trial nature), among those, four under treatment with Warfarin and presenting INR values ranging from 1 to 6,4. For quantitative verification, providing statistic value to the data, an effort must be made for a larger number of patients to be gathered and tried with this treatment. However, the difference in results concerning thrombus-free recovery between the two groups during the two years following surgery cannot, and must not, be ignored