No description available.

Thesis (doctoral)--Rijksuniversiteit te Groningen.

Class of 2008 Abstract / Objectives: This investigation was to assess the patient, hospital, or payer characteristics of inpatient cases of agranulocytosis from 1997 and 2005 with descriptive statistics. Methods: The retrospective database investigation used the U. S. Department of Health & Human Services, Agency for Healthcare Research and Quality, Healthcare Cost & Utilization Project public use database Nationwide Inpatient Sample (H-CUP NIS) for a principal diagnosis of agranulocytosis. Significance of difference between variables, including standard error (SE), was assessed with a z-test and an alpha level of 0.05. Results: alpha level of 0.05. RESULTS: The mean charges increased from 1997 at $19,670(SE $366) per patient vs. 2005 at $26,866 (SE $813) per patient (p<0.001) while inpatient mortality was not different in 1997 at 718(SE 72) vs. 2005 at 759(SE 69) (p=0.63) and the percentage of patients discharged to home declined from 84.32% [0.85%] in 1997 to 80.12% [1.29%] in 2005 (p=0.007). In 2005, inpatient mortality was lower in teaching hospitals at 1.13%( standard error 0.15%) vs. non teaching hospitals at 2.38%(SE 0.25%) (p<0.001) and for metropolitan areas hospitals at 1.42%(SE 0.14%) vs. non-metropolitan area hospitals at 3.60%(SE 0.68%) (p=0.002). Conclusions: Data from H-CUP NIS indicates higher costs per patient for the primary diagnosis of agranulocytosis in 2005 vs. 1997 while overall inpatient survival is not different and the percentage of patients discharged to home decreased. In 2005 rates of inpatient survival were higher in teaching hospitals than in non-teaching hospitals and hospitals in metropolitan areas than in non-metropolitan areas. These differences were not found in 1997.

Idiosyncratic drug reactions (IDRs) are unpredictable adverse drug reactions. Their exact mechanisms are unknown but most appear to be immune-mediated. Mechanistic studies require valid animal models, but there are very few available and none for the study of drug-induced agranulocytosis. Thus, the first part of my thesis has focused on the development of an animal model of agranulocytosis. We pursued many attempts to develop one in rabbits, guinea pigs, and rats by treatment with aminopyrine, amodiaquine, and clozapine and manipulating the factors hypothesized to be involved in the mechanism of IDRs such as reactive metabolite formation/detoxication and immune stimulation. Clozapine-induced agranulocytosis is not associated with immune memory, which suggests that it may not be immune-mediated. Therefore, other factors, specifically selenium and vitamin C deficiencies, were assessed as possible risk factors for clozapine-induced agranulocytosis. Despite many attempts, we were not able to develop an animal model of idiosyncratic drug-induced agranulocytosis. The second part of this thesis was focused on investigating the effects of clozapine on neutrophils. It is known that the reactive metabolite of clozapine increases neutrophil apoptosis in vitro; however, it was not clear that the conditions of these experiments reflect in vivo conditions. Therefore, the effect of clozapine on neutrophil kinetics in vivo was examined. We found that clozapine treatment decreased the half-life of circulating neutrophils and increased the rate of release of neutrophils in rabbits. Thus, even though these animals did not develop agranulocytosis clozapine did appear to cause neutrophil damage that was compensated for by an increased production of neutrophils. Failure of the bone marrow to keep up with the increased rate of neutrophil destruction in certain individuals could result in agranulocytosis. Alternatively, damage to neutrophils could lead to an immune response in some patients that results in agranulocytosis. The failure to develop an animal model of drug-induced agranulocytosis despite many attempts using interventions based on the current mechanistic hypotheses suggests that these hypotheses are wrong. However, it is also possible that we are just unable to overcome the default response of immune tolerance; future studies will examine this possibility and the mechanism of clozapine-induced neutrophil damage.

Idiosyncratic drug reactions (IDRs) are unpredictable adverse drug reactions. Their exact mechanisms are unknown but most appear to be immune-mediated. Mechanistic studies require valid animal models, but there are very few available and none for the study of drug-induced agranulocytosis. Thus, the first part of my thesis has focused on the development of an animal model of agranulocytosis. We pursued many attempts to develop one in rabbits, guinea pigs, and rats by treatment with aminopyrine, amodiaquine, and clozapine and manipulating the factors hypothesized to be involved in the mechanism of IDRs such as reactive metabolite formation/detoxication and immune stimulation. Clozapine-induced agranulocytosis is not associated with immune memory, which suggests that it may not be immune-mediated. Therefore, other factors, specifically selenium and vitamin C deficiencies, were assessed as possible risk factors for clozapine-induced agranulocytosis. Despite many attempts, we were not able to develop an animal model of idiosyncratic drug-induced agranulocytosis. The second part of this thesis was focused on investigating the effects of clozapine on neutrophils. It is known that the reactive metabolite of clozapine increases neutrophil apoptosis in vitro; however, it was not clear that the conditions of these experiments reflect in vivo conditions. Therefore, the effect of clozapine on neutrophil kinetics in vivo was examined. We found that clozapine treatment decreased the half-life of circulating neutrophils and increased the rate of release of neutrophils in rabbits. Thus, even though these animals did not develop agranulocytosis clozapine did appear to cause neutrophil damage that was compensated for by an increased production of neutrophils. Failure of the bone marrow to keep up with the increased rate of neutrophil destruction in certain individuals could result in agranulocytosis. Alternatively, damage to neutrophils could lead to an immune response in some patients that results in agranulocytosis. The failure to develop an animal model of drug-induced agranulocytosis despite many attempts using interventions based on the current mechanistic hypotheses suggests that these hypotheses are wrong. However, it is also possible that we are just unable to overcome the default response of immune tolerance; future studies will examine this possibility and the mechanism of clozapine-induced neutrophil damage.

No description available.

Die Habilitationsschrift beinhaltet eine zusammenfassende Darstellung unterschiedlicher Marker der biologischen Psychiatrie. Hierzu wurden mittels neuroendokriner und molekulargenetischer Verfahren depressive Patienten, alkoholabhängige Patienten und schizophrene Patienten mit einer seltenen Arzneimittelnebenwirkung untersucht und die jeweiligen Befunde als State- Trait- und Residualmarker charakterisiert. Im Bereich Neuroendokrinologie wurden der Dex/CRH-Test und Liquoruntersuchungen bei depressiven Patienten und die Apomorphin-induzierte HGH-Sekretion bei alkoholabhängigen Patienten durchgeführt. Im Bereich Pharmakogenetik erfolgten molekularbiologische HLA-und Enzymsystemuntersuchungen bei Patienten mit einer Clozapin-induzierten Agranulocytose. Es zeigten sich folgende Charakterisierungen einzelner Substrate: * HHN-Systemveränderungen (messbar über Cortisol- und ACTH-Serumkonzentrationen) sind State-bzw. Residualmarker der Depression. CRH-, AVP-und Somatostatin-Liquorkonzentrationen sind keine biologischen Marker der Depression * Das HGH-"Blunting" alkoholabhängiger Patienten ist ein spezifischer Marker für Alkoholabhängigkeit mit ungünstigem klinischen Verlauf * Spezifische HLA-Haplotypen sind als Traitmarker der Clozapin-induzierten Agranulocytose zu werten. Enzymsystem-Polymorphismen haben keine Bedeutung bei der Entwicklung dieser Arzneimittelnebenwirkung Der spezifischen Charakterisierung einzelner Befunde schließt sich eine Diskussion über deren Bedeutung für die biologische Psychiatrie an. / Neuroendocrine and pharmacogenetic studies were performed in depressive and alcohol-dependent patients as well as schizophrenic patients with clozapine-induced agranulocytosis to characterize different serological or molecular substrates as state-, trait or residualmarker. Depressive patients were assessed using the dexamethasone/corticotropin releasing hormone test and measuring neuropeptide hormone concentrations in cerebrospinal fluid (CSF), whereas dopaminergic responsiveness of alcohol-dependant patients was assessed by the apomorphine-induced human growth hormone (HGH) secretion. HLA-subtyping and screening of relevant polymorphisms of clozapine metabolizing enzyme systems was performed in patients with clozapine-induced agranulocytosis (CA). * HPA-alterations as a function of cortisol-and ACTH serum concentration appear as state- and residual marker of depression. CSF-CRH, -AVP and -SOM do not fulfill marker criteria * HGH blunting may serve as a residual marker of alcoholism with poor clinical outcome * HLA alleles but not polymorphisms of clozapine metabolizing enzyme systems are associated with CA and thus, underline the importance of imunogenetic mechanisms in the pathophysiology of this idiosyncratic drug reaction. In conclusion, the importance of biological markers for psychiatric research and future directions are discussed