Pure isolated medial talonavicular joint dislocation following low-energy trauma: a case report

Midtarsal dislocations are relatively rare injuries secondary to high-energy trauma and are typically accompanied by disruption of ligamentous structures and fractures of the midfoot. We herein present a case of a pure isolated medial swivel dislocation of the talonavicular joint (TNJ) that was sustained following low-energy trauma without an associated fracture. A 78-year-old woman visited our emergency department with severe pain in the midfoot area of the right foot without neurovascular deficits. She had sustained this injury after severe ankle inversion while going downstairs. Plain radiographs of the right foot showed that the navicular was dislocated medially on the talus; no other malalignments were present. Three-dimensional computed tomography revealed dislocation of the TNJ, but no other tarsal or midtarsal bone fractures or dislocations. A medial dorsal incision was made to expose the TNJ. The dorsal talonavicular ligament was ruptured and interposed between the navicular and talus. The ligament was removed and the TNJ was reduced. The clinical outcome at the 1-year follow-up was satisfactory with no limitations in daily activities. In summary, we have reported an extremely rare case of a pure isolated medial TNJ dislocation in which the interposed dorsal talonavicular ligament served as an obstacle to reduction.

Aryl Hydrocarbon Receptor and Autophagy-Related Protein Microtubule-Associated Protein Light Chain 3 Expression in Psoriasis

Background

The aryl hydrocarbon receptor (AHR) and autophagy are both important to maintain skin homeostasis. However, they are also involved in skin disorders. So far, their roles in psoriasis pathogenesis are unknown.

Objective

We studied the immunohistochemical and gene expression of AHR, CYP1A1, and microtubule-associated protein light chain 3 (LC3) in lesional skin of psoriasis patients to determine correlations among them.

Methods

We included 24 psoriasis patients and ten healthy volunteers. Skin biopsies were collected. AHR, CYP1A1, and LC3 protein expression was examined by immunohistochemistry, immunofluorescence, and western blotting. AHR, CYP1A1, LC3, ATG5, BECN1 and Nrf2 mRNA levels were measured by quantitative polymerase chain reaction.

Results

AHR and CYP1A1 protein expression were higher in psoriasis lesional skin than in normal skin. LC3 protein expression was lower in psoriasis lesions than in normal controls. AHR and CYP1A1 protein expression in psoriasis lesions showed significant positive correlations with mean epidermal thickness and inflammatory cell density. Significant negative correlations were noted between LC3 protein expression in psoriasis lesions and the mean epidermal thickness or inflammatory cell density. A significant negative correlation was found between AHR and LC3 expression in psoriatic skin. AHR, CYP1A1 and Nrf2 mRNA expression were upregulated while LC3, ATG5, and BECN1 mRNA were down-regulated, in psoriatic lesional skin compared with normal controls.

Conclusion

AHR and autophagy could play a role in psoriasis pathogenesis by modifying epidermal hyperproliferation and inflammation. AHR and autophagy regulation are potential therapeutic targets in chronic inflammatory skin diseases.

Tarsal tunnel syndrome caused by posterior facet talocalcaneal coalition: A case report

RATIONALE

Tarsal tunnel syndrome (TTS) is a compressive neuropathy of the posterior tibial nerve and its branches. Tarsal coalition is defined as a fibrous, cartilaginous, or osseous bridging of 2 or more tarsal bones. TTS with tarsal coalition is uncommon. Here, we present a rare example of successful surgical management of TTS with posterior facet talocalcaneal coalition.

PATIENT CONCERNS

A 74-year-old woman presented with hypoesthesia, numbness, and an intermittent tingling sensation on the plantar area over the right forefoot to the middle foot area. The hypoesthesia and paresthesia of the right foot began 6 years previously and were severe along the lateral plantar aspect. The symptoms were mild at rest and increased during daily activities. Tinel sign was positive along the posteroinferior aspect of the medial malleolus.

DIAGNOSIS

Lateral ankle radiography showed joint-space narrowing and sclerotic bony changes with a deformed C-sign and humpback sign. Oblique coronal and sagittal computed tomography revealed an irregular medial posterior facet, partial coalition, narrowing, and subcortical cyst formation of the posterior subtalar joint. Magnetic resonance imaging showed an abnormal posterior talocalcaneal coalition compressing the posterior tibia nerve. Electromyography and nerve conduction velocity studies were performed, and the findings indicated that there was an incomplete lesion of the right plantar nerve, especially of the lateral plantar nerve, around the ankle level.

INTERVENTIONS

Surgical decompression was performed. Intraoperatively, the lateral plantar nerve exhibited fibrotic changes and tightening below the posterior facet talocalcaneal coalition. The coalition was excised, and the lateral plantar nerve was released with soft-tissue dissection.

OUTCOMES

The patient's symptoms of tingling sensation and hypoesthesia were almost relieved at 4 months postoperatively, but she complained of paresthesia with an itching sensation when the skin of the plantar area was touched. The paresthesia had disappeared almost completely at 8 months after surgery. She had no recurrence of symptoms at the 1-year follow-up.

LESSONS

The TTS with tarsal coalition is rare. Supportive history and physical examination are essential for diagnosis. Plain radiographs and computed tomography or magnetic resonance imaging are helpful to determine the cause of TTS and verify the tarsal coalition. After diagnosis, surgical excision of the coalition may be appropriate for management with a good outcome.

Laparoscopic drainage as a minimally invasive treatment for a psoas abscess: A single-center case series and literature review

A psoas abscess is a rare but potentially devastating condition that is associated with risks of neurological deficits, septic shock, and even death. The current first-line treatment is percutaneous catheter drainage (PCD) under imaging guidance, combined with broad-spectrum antibiotics. Surgical drainage should be considered if PCD fails or is impossible.Although many studies on PCD and open surgical drainage have appeared, the outcomes of laparoscopic drainage have rarely been reported. Thus, we laparoscopically drained the psoas abscesses of 6 patients; drainage was complete and we encountered no recurrence or complication. All patients were evaluated by plain radiography, contrast-enhanced computed tomography, and laboratory tests; all were followed-up for 1 year. Laparoscopic drainage is a good treatment option when PCD fails, affording all the advantages of open surgery (complete drainage, resection of infected tissue, and contermporaneous treatment of concomitant lesions). Also, laparoscopic drainage is minimally invasive, requires a smaller incision, and allows rapid recovery.

Mucin gene polymorphisms are associated with endometriosis in Korean women

OBJECTIVE

Mucin family members mucin 1 (MUC1) and mucin 4 (MUC4) play an important role in transformation and adhesion, and are known markers for the detection of cancer. However, the pathophysiology of endometriosis associated with the mucin gene is unclear. In this study, we analyzed the relationship between MUC1 and MUC4 single-nucleotide polymorphisms (SNPs) and the risk for endometriosis.

METHODS

We performed a case-controlled study of 29 endometriosis clinical samples and 27 functional cysts as control. Sixteen SNPs (rs145224844, rs139620330, rs144273480, rs1611770, rs146141676, rs201798179, rs201815857, rs199840128, rs200788986, rs141460657, rs183700327, rs199768496, rs191544901, rs200639498, rs148332231, and rs11465209) of MUC1 gene and eight SNPs (rs1104760, rs1106502, rs882605, rs2291651, rs2291652, rs2291653, rs2291654, and rs375068067) of the MUC4 gene were identified. We amplified SNP sites by polymerase chain reaction (PCR) using specific primer sets followed by DNA sequencing.

RESULTS

The single mutation analysis of MUC4 showed that MUC4 mutations had no effect on the risk for endometriosis, but the frequencies of haplotypes [T/T + T/T + C/C] (rs2291653, 2291654 and rs375068067) were associated with endometriosis.

CONCLUSION

The MUC1 genotype may not be correlated with endometriosis susceptibility. However, MUC4 polymorphisms are associated with the risk for endometriosis in Korean women.

Peroneal tendon irritation after arthroscopic modified Broström procedure: A case report

RATIONALE

With the development of ankle arthroscope techniques and procedures, the number of arthroscopic modified Broström procedures (MBPs) is increasing. All-inside arthroscopic MBP was developed recently, with good to excellent results. However, several complications have been reported in patients after arthroscopic MBP. This case report describes a rare complication of arthroscopic MBP.

PATIENT CONCERNS

A 34-year-old woman presented with severe pain in her right ankle and underwent arthroscopic MBP for lateral ankle instability. About 6 months postoperatively, she presented with severe pain on the lateral aspect of the right ankle, especially while walking.

DIAGNOSIS

In physical examinations, there was marked swelling around the ankle and focal tenderness in the posterolateral malleolar area. Ankle ultrasonography showed a diffuse low-echoic mass-like lesion at the distal fibula between the fibular tip and peroneus tendon. T1-weighted sagittal magnetic resonance imaging images showed an irregularly shaped mass-like lesion with a heterogeneous signal near the distal fibula posteriorly where the anchor protruded.

INTERVENTIONS

The suture anchor in the posterior distal fibula area, which had irritated the peroneus tendon, was removed with debridement of the granulomatous lesion.

OUTCOMES

At the 3-month follow-up, the patient was almost asymptomatic and had a nearly full range of motion. No complications or recurrent symptoms were noted at the 1-year follow-up.

LESSONS

Three-dimensional computed tomography studies of the appropriate fibular depth and position of suture anchors are needed to standardize the procedure and reduce complications.

Closed atraumatic complete rupture of the flexor halluces longus tendon during forward lunge exercise: A case report

RATIONALE

Acute rupture of the flexor halluces longus (FHL) tendon due to trauma or laceration is a well-known phenomenon. Partial rupture of the FHL tendon caused by tendinitis or stenosing tenosynovitis is common in ballet dancers and athletes. However, atraumatic complete rupture of the FHL is rare: as of 2018, only 7 cases of closed atraumatic complete rupture of the FHL tendon have been reported in the literature. Here, we report on a patient who presented with a closed atraumatic complete rupture of the FHL tendon during a forward lunge exercise.

PATIENT CONCERNS

A 35-year-old female visited the clinic with pain in the plantar medial aspect of the left foot, along with weakness and loss of great toe flexion. The patient had a normal foot structure and no history of trauma or systemic disease. She performed a forward lunge exercise more than 50 times on 1 leg per day, more than once a week to strengthen her leg muscles. She reported that she felt a slight pain in her left, great toe while exercising for 3 weeks prior to her visit. One week prior to presentation, severe pain occurred suddenly when her left hallux dorsiflexed strongly during an anterior lunge exercise motion.

DIAGNOSIS

Magnetic resonance imaging revealed complete rupture of the FHL tendon near the level of the metatarsal head and neck junction. The lesion was prolonged, with the proximal end displaced to the metatarsal shaft region.

INTERVENTIONS

Complete rupture of the FHL tendon was treated with a primary suture.

OUTCOMES

At the 1-year follow-up, active plantar flexion of the interphalangeal joint was possible but joint function had a range of 0° to 25°. Flexion strength was reduced slightly, measuring about 70% when compared to the contralateral side, but flexion strength of the metatarsophalangeal joint was normal.

LESSONS

We describe an extremely rare case of complete rupture of the FHL tendon at the level of metatarsal head and neck junction. It should be understood that this injury can occur not only in professional athletes but also in the general public, and we recommend educating personal trainers on how to prevent it.

Intertrochanteric fracture with low-energy trauma in a young woman with anorexia nervosa: A case report

RATIONALE

Anorexia nervosa is a chronic psychiatric disease defined by severe weight loss, due to fear of obesity, and self-imposed semi-starvation. Of the many complications following anorexia nervosa, low bone mineral density (BMD) is a significant risk factor for fractures. Anorexia nervosa is associated with higher risk of incident fracture in females across all age groups, and in males >40 years old. Sites at highest risk of fracture include the hip/femur and pelvis in females, and vertebrae in males with anorexia nervosa.

PATIENT CONCERNS

A 29-year-old woman known to have suffered from anorexia nervosa 15 years ago visited the emergency department due to right hip pain after falling while getting out of a taxi. During the period of anorexia nervosa, she had a body mass index (BMI) of 14.06 kg/m (weight, 36 kg; height, 1.60 m) and suffered from amenorrhea. At the time of presentation, she had a BMI of 19.53 kg/m (weight, 50 kg; height, 1.60 m) and had regular menstrual periods, indicating clinical recovery from anorexia nervosa.

DIAGNOSES

Plain radiography, computed tomography, and bone scintigraphy revealed AO 31-A2.2 type right hip proximal femur intertrochanteric fracture. The BMD showed a T score of -3.9 in the hip and -3.6 at the lumbar level, indicating severe osteoporosis.

INTERVENTIONS

Osteosynthesis was performed with proximal femoral nail antirotation (PFNA) and wiring.

OUTCOMES

There were no specific symptoms, such as trauma or infection, during postoperative rehabilitation and postoperative management, and she was discharged after 2 weeks. After 1 year of follow-up at our outpatient clinic, she had no complications.

LESSONS

Here, we describe an unusual case of unilateral femoral intertrochanteric fracture that occurred after clinical recovery from anorexia nervosa. This case indicated that the risk of fracture remains even after recovery of BMI. We propose that women who have clinically recovered from anorexia nervosa should be advised to undergo annual osteodensitometric analyses after consulting with specialists in other areas (psychiatry, endocrinology, eating disorders).

MiR-9 Controls Chemotactic Activity of Cord Blood CD34⁺ Cells by Repressing CXCR4 Expression

Improved approaches for promoting umbilical cord blood (CB) hematopoietic stem cell (HSC) homing are clinically important to enhance engraftment of CB-HSCs. Clinical transplantation of CB-HSCs is used to treat a wide range of disorders. However, an improved understanding of HSC chemotaxis is needed for facilitation of the engraftment process. We found that ectopic overexpression of miR-9 and antisense-miR-9 respectively down- and up-regulated C-X-C chemokine receptor type 4 (CXCR4) expression in CB-CD34⁺ cells as well as in 293T and TF-1 cell lines. Since CXCR4 is a specific receptor for the stromal cell derived factor-1 (SDF-1) chemotactic factor, we investigated whether sense miR-9 and antisense miR-9 influenced CXCR4-mediated chemotactic mobility of primary CB CD34⁺ cells and TF-1 cells. Ectopic overexpression of sense miR-9 and antisense miR-9 respectively down- and up-regulated SDF-1-mediated chemotactic cell mobility. To our knowledge, this study is the first to report that miR-9 may play a role in regulating CXCR4 expression and SDF-1-mediated chemotactic activity of CB CD34⁺ cells.

Early stage ovarian carcinoma with symptoms mimicking tuberculous peritonitis in a postmenopausal woman: A case report

RATIONALE

Ovarian cancer has the poorest prognosis of the gynecological cancers. Early diagnosis and treatment are important, but early-stage ovarian carcinoma has nonspecific symptoms. Ultrasonography, computed tomography, magnetic resonance imaging, and serum CA-125 levels can be helpful but may not elucidate cases of diffuse peritoneal diseases mimicking carcinomatosis.

PATIENT CONCERNS

The patient had intermittent abdominal discomfort and dysuria. Abdominal-pelvic computed tomography findings were suspicious for peritoneal tuberculosis (TB) and a small cystic mass in the left ovary. The CA-125 values were normal.

DIAGNOSES

She underwent laparoscopy for pathologic confirmation of tuberculous peritonitis and management of the ovary mass. Bilateral adnexectomy was performed. Histopathological examination of the surgical specimen revealed a serous ovarian carcinoma in her left ovary and salpinx.

INTERVENTIONS

Laparoscopic hysterectomy, pelvic lymphadenectomy, para-aortic nodal dissection, and omentectomy were carried out for staging evaluation.

OUTCOMES

We encountered a rare case of ovary cancer stage IA serous ovarian carcinoma incidentally discovered by laparoscopy in a postmenopausal woman. She received adjuvant chemotherapy without relapse.

LESSONS

Peritoneal TB may mimic peritoneal or ovarian carcinoma, but the reverse case is rare. Hence, gynecologists should be careful in assessment of patients before treatment.

Maternal anaphylactic shock in pregnancy: A case report

RATIONALE

Anaphylaxis is a very rare event in pregnancy, triggering maternal hypotension leading to intrapartum hypoxic-ischemic encephalopathy in infant. Furthermore, cesarean sections are performed at a high rate in anaphylactic pregnant women.

PATIENT CONCERNS

A 34-year-old pregnant woman presented with maternal anaphylaxis following prophylactic antibiotic injection for cesarean section. Within a few minutes after initiation of intradermal skin test with cefotetan, the pregnant woman developed generalized itchy rash, chest tightness, and dyspnea.

DIAGNOSES

Several minutes after the injection of antibiotics, a diffuse urticarial rash was detected over her face and trunk followed by complaints of chest tightness and dyspnea. She was diagnosed with hypotension and hypoxia. Further, fetal heart tones showed bradycardia. A presumptive diagnosis of anaphylactic reaction induced by cefotetan was made for surgical prophylaxis.

INTERVENTIONS

The patient was managed for anaphylaxis, via administration of epinephrine, glucocorticoid, and antihistamine. Emergency cesarean section performed under general anesthesia resulted in a favorable perinatal outcome for the fetus.

OUTCOMES

Maternal and fetal outcomes were good after prompt treatment for anaphylaxis and emergency cesarean section.

LESSONS

This is the first reported case of anaphylaxis following cefotetan administration in pregnancy. Cefotetan, a second-generation cephalosporin, is a commonly prescribed antibiotic used to treat a wide range of bacterial infections. The case demonstrated life-threatening anaphylactic reaction during pregnancy. Even a skin test using antibiotics alone triggered anaphylaxis.

Loss of RUNX3 is significantly associated with advanced tumor grade and stage in endometrial cancers

Loss of runt-related transcription factor 3 (RUNX3) has been reported in various cancers, and one of the mechanisms mediating loss of RUNX3 expression is DNA methylation. However, the role of RUNX3 expression and its DNA methylation status as prognostic factors in endometrial cancer remain unclear. In the present study, the expression and promoter methylation of RUNX3 was examined in endometrial cancer tissues and cell lines, as well as their association with endometrial cancer prognosis. Fifty-five endometrial cancer tissues and two endometrial cancer cell lines (HEC1-α and Ishikawa) were studied. RUNX3 expression and promoter methylation were examined using reverse transcription-polymerase chain reaction (RT-PCR), methylation specific PCR (MS-PCR), and immunohistochemical staining. The demethylating agent 5-aza-2′-deoxycytidine (ADC) was used to reverse the methylation of the RUNX3 promoter. Loss of RUNX3 expression was observed in 50.9% (27/53) of endometrial cancer tissues and in the HEC1-α cell line by immunohistochemistry and RT-PCR, respectively. Methylation of the RUNX3 promoter was observed in 62.2% (33/53) of endometrial cancer tissues, 12.5% (1/8) of normal endometrial tissues, and the HEC1-α cell line by MS-PCR. Tumor grade and stage were significantly correlated with loss of RUNX3 expression. The expression of RUNX3 was restored by treatment with ADC and resulted in growth inhibition in HEC1-α cells. The present results suggested that methylation may serve a critical role in the silencing of RUNX3 and loss of RUNX3 expression may serve as a prognostic marker in endometrial cancer.

Ovarian torsion of mixed epithelial tumor misdiagnosed as a malignancy in postmenopausal woman: A case report

RATIONALE

Adnexal torsion is 1 of the most common emergency gynecological disease. It is more often diagnosed in reproductive age, but rarely in postmenopausal women. The clinical symptoms of adnexal torsion are nonspecific in postmenopausal women. Epithelial ovarian tumors are common in adults, and the risk of malignancy increases with age, especially after menopause. So, it is difficult to diagnose adnexal torsion precisely compared with reproductive women, and most cases of adnexal torsion with postmenopausal women are diagnosed as a malignancy preoperatively. We report a case of ovarian torsion with mixed epithelial tumor misdiagnosed as a malignancy in postmenopausal woman.

PATIENT CONCERNS

A 65-year-old woman presented lower left abdominal pain, and there was slight abdominal distension, but no tenderness or rebound tenderness on abdominal palpation.

DIAGNOSES

Radiologic assessments showed a huge multiseptated cystic mass with solid portion in the left ovary, and malignancy was suspected. The test for serum tumor markers revealed normal levels of cancer antigen 125 (CA-125).

INTERVENTIONS

The patient underwent a laparotomy and there was torsion of the left ovary. We conducted frozen biopsy of left ovary for confirming malignancy before performing staging surgery.

OUTCOMES

The result of a frozen section biopsy confirmed a borderline Brenner tumor associated with a benign mucinous tumor. Subsequently, total hysterectomy and right salpingo-oophorectomy were performed. The operation was completed without addition procedures LESSONS:: Ovarian torsion is benign in most cases and malignancy is rare. Although very rare, ovarian torsion can occur in postmenopausal women, and it should be taken into consideration that the possibility of malignancy is low in postmenopausal women with normal CA-125 levels. Instead of performing staging surgery, it appears to be appropriate to carry out surgery based on the result of intraoperative frozen section biopsy so that we were able to avoid unnecessary surgical procedures.

Oxycodone versus fentanyl for intravenous patient-controlled analgesia after laparoscopic supracervical hysterectomy: A prospective, randomized, double-blind study

BACKGROUND

Oxycodone, a semisynthetic thebaine derivative opioid, is widely used for the relief of moderate to severe pain. The aim of this study was to compare the efficacy and side effects of oxycodone and fentanyl in the management of postoperative pain by intravenous patient-controlled analgesia (IV-PCA) in patients who underwent laparoscopic supracervical hysterectomy (LSH).

METHODS

The 127 patients were randomized to postoperative pain treatment with either oxycodone (n = 64, group O) or fentanyl group (n = 63, group F). Patients received 7.5 mg oxycodone or 100 μg fentanyl with 30-mg ketorolac at the end of anesthesia followed by IV-PCA (potency ratio 75:1) for 48 hours postoperatively. A blinded observer assessed postoperative pain based on the numerical rating scale (NRS), infused PCA dose, patient satisfaction, sedation level, and side effects.

RESULTS

Accumulated IV-PCA consumption in group O was less (63.5 ± 23.9 mL) than in group F (85.3 ± 2.41 mL) during the first 48 hours postoperatively (P = 0.012). The NRS score of group O was significantly lower than that of group F at 4 and 8 hours postoperatively (P < .001); however, the incidence of postoperative nausea and vomiting (PONV), dizziness, and drowsiness was significantly higher in group O than in group F. Patient satisfaction was lower in group O than in group F during the 48 hours after surgery (P < 0.001).

CONCLUSIONS

Oxycodone IV-PCA (potency ratio 1:75) provided superior analgesia to fentanyl IV-PCA after LSH; however, the higher incidence of side effects, including PONV, dizziness, and drowsiness, suggests that the doses used in this study were not equipotent.

Measurement of Interleukin 8 in Cervicovaginal Fluid in Women With Preterm Premature Rupture of Membranes: A Comparison of Amniotic Fluid Samples

Cervicovaginal fluid (CVF) samples may be a feasible alternative to amniotic fluid (AF) sampling in women with preterm premature rupture of the membranes (PPROMs), because PPROM causes AF to spill into the CVF. We aimed to assess the correlation and limits of agreement of interleukin 8 (IL-8) levels between CVF and AF in women with PPROM and to compare the clinical value of CVF IL-8 to AF IL-8 for the prediction of microbial invasion of amniotic cavity (MIAC). A retrospective cohort observational study was conducted on 85 women with singleton pregnancies (24-34 weeks) presenting with PPROM. The CVF samples were obtained simultaneously with AF samples retrieved by transabdominal amniocentesis. The levels of IL-8 in paired CVF and AF samples were measured with enzyme-linked immunosorbent assay in the same plate in duplicate using the same dilutions. The prevalence of a positive AF culture was 40% (34 of 85). The CVF IL-8 levels were significantly and positively correlated with AF IL-8 levels ( r = 0.778). However, the level of agreement between CVF and AF IL-8 levels yielded a Cohen κ statistic of 0.276. Paired Student t test revealed that the difference between CVF and AF IL-8 levels was statistically significant. The area under the curve for AF IL-8 was significantly higher than that for CVF IL-8 ( P = .013). In women with PPROM, IL-8 levels in CVF were significantly correlated with, but were significantly different from, those in AF samples. The CVF IL-8 has moderate predictive capability for the risk of MIAC, but this is inferior to AF IL-8.

Prediction of spontaneous preterm birth in women with cervical insufficiency: Comprehensive analysis of multiple proteins in amniotic fluid

AIM

The purpose of this study is to determine whether proinflammatory cytokines and matrix metalloproteinases (MMPs) in amniotic fluid (AF), alone or in combination with clinical risk factors, can predict spontaneous preterm delivery (SPTD) at < 34 weeks in women with cervical insufficiency.

METHODS

This retrospective cohort study included 57 consecutive singleton pregnant women (17-28 gestational weeks) with cervical insufficiency who underwent amniocentesis. AF was assayed for five cytokines (interleukin [IL]-6, IL-8, monocyte chemotactic protein-1, macrophage inflammatory protein [MIP]-1α, and MIP-1β) and five MMPs (MMP-1, MMP-2, MMP-3, MMP-8, and MMP-9) using multiplex immunoassay kits. The primary outcome measure was SPTD at < 34 weeks.

RESULTS

The AF concentrations of MMP-1, MMP-3, MMP-8, MMP-9, IL-6, IL-8, MIP-1α and MIP-1β were significantly higher in women with SPTD at < 34 weeks. Women who had SPTD at < 34 weeks were younger, had significantly more advanced cervical dilatation at presentation and a higher rate of positive AF cultures. Using stepwise regression analysis, a combined prediction model was developed that included maternal age, cervical dilatation at presentation, AF MMP-1 and AF MMP-8 (area under the curve [AUC] 0.951). The AUC for this model was significantly greater than for any single protein alone in AF or for each of the clinical risk factors alone.

CONCLUSION

A model combining proteins in AF and clinical factors can improve the accuracy of risk prediction for preterm birth and this combination is more accurate than each of the biomarkers alone in women with cervical insufficiency.

Prediction of impending preterm delivery based on sonographic cervical length and different cytokine levels in cervicovaginal fluid in preterm labor

AIMS

The aim of this study was to determine whether cervicovaginal interleukin (IL)-1β, IL-6 and IL-8 levels, and cervical length, alone or in combination, could predict impending preterm delivery in women with preterm labor and intact membranes.

MATERIAL AND METHODS

Cervicovaginal swab samples for IL-1β, IL-6, and IL-8 assays were taken from 136 consecutive women with preterm labor (23-34 weeks) before the transvaginal ultrasonography examination to measure cervical length. The primary outcome measurement was spontaneous preterm delivery within 7 days of sampling.

RESULTS

Spontaneous preterm delivery within 7 days occurred in 28.6% (39/136) of patients. Receiver-operator characteristic (ROC) curves indicated that cervical length (P < 0.001), cervicovaginal IL-6 (P < 0.001) and IL-8 (P = 0.014), but not IL-1β, could predict delivery within 7 days. According to the logistic regression analysis, high cervicovaginal IL-8 (P = 0.008) and IL-6 (P = 0.038) levels and short cervical length (P < 0.001) were significantly associated with delivery within 7 days, even after controlling for baseline variables. A combination of cervix length and cervicovaginal IL-8 increased the specificity of detecting delivery within 7 days to 92.8%, which was superior to either test alone (P < 0.001), but the sensitivity was only 56.4%.

CONCLUSION

In women with preterm labor, among the parameters assessed, cervicovaginal IL-6 and IL-8 and cervical length are the most important parameters in predicting impending preterm delivery. A combination of cervix length and cervicovaginal IL-8 appeared to be the best for predicting impending preterm delivery, but the relatively low sensitivity of this test may limit its clinical usefulness.

Predicting outcomes of emergency cerclage in women with cervical insufficiency using inflammatory markers in maternal blood and amniotic fluid

OBJECTIVE

To identify inflammatory markers in maternal blood and amniotic fluid that can predict outcomes of emergency cerclage in women with cervical insufficiency.

METHODS

This retrospective cohort study included patients at 18-24 weeks of pregnancy who underwent amniocentesis before receiving emergency cerclage for cervical insufficiency between August 2004 and August 2013 at a university teaching hospital in South Korea. Total and differential white blood cell counts were measured during amniocentesis. Amniotic fluid was cultured and analyzed for the presence of interleukin (IL)-6 and IL-8. The primary outcome measure was spontaneous preterm delivery (SPTD) at less than 32weeks of pregnancy following cerclage placement.

RESULTS

Of 37 patients, 18 (49%) experienced SPTD at less than 32weeks of pregnancy. These patients were found to have significantly more advanced cervical dilatation at presentation, as well as higher mean neutrophil-lymphocyte ratios (NLRs) and higher IL-6 and IL-8 levels in amniotic fluid in comparison with those who did not experience SPTD at less than 32weeks of pregnancy. In a multivariable analysis, a high NLR and high amniotic fluid IL-8 levels showed a significant correlation with the occurrence of SPTD at less than 32weeks of pregnancy (P=0.032).

CONCLUSION

Pre-operative NLR and amniotic fluid IL-8 levels may be important markers for predicting emergency cerclage outcomes in women with cervical insufficiency.

Clinical and sonographic parameters at mid-trimester and the risk of cesarean delivery in low-risk nulliparas

BACKGROUND

To examine the potential clinical and sonographic parameters at mid-trimester that predict the risk of intrapartum cesarean delivery at term among low-risk nulliparas.

METHODS

This prospective study recruited nulliparas with singleton low-risk pregnancies at 20.0-24.0 weeks. Sonographic measurement of the cervical length and fetal biometry was performed. The data collected at enrollment included maternal age, measured weight at first prenatal visit to the hospital, current weight, height, fetal biometric parameters, and cervical length. A multivariate analysis was conducted, with control for known intra- and postpartum confounding factors associated with cesarean delivery, including sex of the fetus.

RESULTS

Based on multivariate analyses of 652 women, of all variables at mid-trimester, only maternal height was significantly associated with increased risk of cesarean delivery (61, 9.4%), whereas for intra- or postpartum variables, induction of labor, epidural analgesia, male gender, and nightshift delivery showed statistically significant association with the risk of cesarean delivery.

CONCLUSIONS

Maternal height and fetal gender, as measured at mid-trimester, are potential independent predictors for the risk of intrapartum cesarean delivery at term in low-risk nulliparas; however, sonographic measurements of the cervical length, fetal biometric ratio, maternal age, and current weight at mid-trimester were not predictive of cesarean delivery at term. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43:235-242, 2015.

Is complementary and alternative therapy effective for women in the climacteric period?

Vasomotor symptoms start about 2 years prior to menopause in women who are approaching menopause, and early menopause symptoms appear including emotional disturbance and anxiety, followed by physical changes such as vaginal dryness, urinary incontinence and skin wrinkles. As time progresses, osteoporosis, cardiovascular diseases, and dementia occur consecutively. Hormone therapy is primarily considered for the relief of menopause symptoms in postmenopausal women. However, as hormone replacement has emerged as a therapy that increases the potential risk of thrombosis, cerebral infarction and breast cancer, complementary and alternative medicine has drawn much attention. This study aimed to examine the types and effects of evidence-based complementary and alternative therapies that are currently used.

Intra-amniotic infection/inflammation as a risk factor for subsequent ruptured membranes after clinically indicated amniocentesis in preterm labor

The aim of this study was to determine whether intra-amniotic infection/inflammation (IAI) was associated with subsequent ruptured membranes in women with preterm labor and intact membranes who had a clinically indicated amniocentesis. This retrospective cohort study included 237 consecutive women with preterm labor (20-34.6 weeks) who underwent amniocentesis. The clinical and laboratory parameters evaluated included demographic variables, gestational age, C-reactive protein (CRP) and amniotic fluid (AF) white blood cell, interleukin-6 (IL-6) and culture results. IAI was defined as a positive AF culture and/or an elevated AF IL-6 level (>2.6 ng/mL). The primary outcome was ruptured membranes in the absence of active labor occurring within 48 hours of amniocentesis. Preterm premature rupture of membranes subsequently developed in 10 (4.2%) women within 48 hr of amniocentesis. Multivariate analysis demonstrated that only IAI was independently associated with the ruptured membranes occurring within 48 hr of amniocentesis. In the predictive model based on variables assessed before amniocentesis, only CRP level was retained. IAI is an independent risk factor for subsequent ruptured membranes after clinically indicated amniocentesis in preterm labor. Prior to amniocentesis, measurement of serum CRP level can provide a risk assessment for the subsequent development of ruptured membranes after the procedure.

The relationship between cord blood cytokine levels and perinatal factors and retinopathy of prematurity: a gestational age-matched case-control study

PURPOSE

To investigate the relationship between cytokine levels in cord blood and perinatal factors and retinopathy of prematurity (ROP) in gestational age-matched, preterm, newborn infants.

METHODS

Each of 20 premature singleton infants with ROP (gestational age < 32 weeks) was matched for gestational age, birth weight, and sex with two control infants without ROP. The concentration of 10 cytokines in cord blood extracted at birth was measured using a multiplex bead array assay. Data on maternal factors, labor and delivery characteristics, and neonatal parameters were also collected from both groups. The variables obtained were compared using the conditional logistic regression model.

RESULTS

No differences in the levels of inflammatory cytokines (IL-1β, IL-4, IL-6, IL-8, IL-10, IL-12, interferon-γ, and TNF-α) and growth factors (insulin-like growth factor-1 and VEGF) were detected between the two groups. Multivariate conditional logistic regression analysis indicated that elevated maternal leukocyte count on admission and low Apgar scores at 5 minutes were significantly associated with an increased risk of ROP.

CONCLUSIONS

Cytokine levels in cord blood are not associated with the risk of ROP, whereas elevated maternal blood leukocyte count and low Apgar score are associated with ROP. These data suggest that the determination of cytokine levels in cord blood samples in premature infants may be of little value for predicting ROP.

Predictive value of combined cervicovaginal cytokines and gestational age at sampling for intra-amniotic infection in preterm premature rupture of membranes

OBJECTIVE

To determine whether interleukin (IL)-1β, IL-6, and IL-8 in cervicovaginal fluid, alone or in combination with clinical risk factors, could predict intra-amniotic infection in women with preterm premature rupture of membranes (PPROM).

DESIGN

A prospective cohort study.

SETTING

University teaching hospital.

POPULATION

Women with singleton pregnancies presenting PPROM between 20 and 35 weeks of gestation (n = 76).

METHODS

Cervicovaginal fluid samples were collected for IL-1β, IL-6, and IL-8 measurements immediately before amniocentesis. Amniotic fluid obtained by amniocentesis was cultured and the white blood cell count was determined. Clinical risk factors analyzed included demographics and gestational age. Cervicovaginal concentrations of cytokines were measured using a multiplex bead array assay.

MAIN OUTCOME MEASURE

A positive amniotic fluid culture.

RESULTS

The prevalence of a positive amniotic fluid culture was 46.1% (35/76). Stepwise multivariate regression analysis yielded a model using cervicovaginal IL-6 and gestational age at sampling with the area under the curve (AUC) of 0.807 for predicting intra-amniotic infection. The AUC for this model was significantly higher than either parameter retained in this model but no differences were observed between the AUC of this model based on non-invasive variables, and amniotic fluid white blood cell count using invasive amniocentesis for the prediction of intra-amniotic infection.

CONCLUSIONS

Among measured cytokines, the combination of cervicovaginal IL-6 and gestational age appears to be best in predicting intra-amniotic infection and allows for a considerably better accuracy than the use of either factor alone. Overall, this combination performed as well as amniotic fluid WBC count for predicting intra-amniotic infection.

Early human papillomavirus testing predicts residual/recurrent disease after LEEP

Objective

The purpose of this study was to determine the predictive factors for residual/recurrent disease and to analyze the timing for Pap smears and human papillomavirus (HPV) testing during follow-up after loop electrosurgical excision procedure (LEEP) for cervical intraepithelial neoplasia (CIN) 2 or worse.

Methods

We retrospectively analyzed 183 patients (mean age, 39.3 years) with CIN 2/3 who were treated with LEEP. Post-LEEP follow-up was performed by Pap smear and HPV hybrid capture2 (HC2) testing. The definition of persistent/recurrent disease was biopsy-proven CIN 2 or worse.

Results

Among 183 patients, punch biopsies were CIN 2 in 31 (16.9%) and CIN 3 in 152 (83.1%). HPV HC2 tests before LEEP were positive in 170 (95.5%) of 178 patients. During follow-up, 12 patients (6.6%) had residual/recurrent CIN 2+. LEEP margin status was a significant predictive factor for persistent/recurrent disease. Other factors such as age, HPV HC2 viral load (≥100 relative light units), and HPV typing (type 16/18 vs. other types) did not predict recurrence. Early HPV HC2 testing at 3 months after LEEP detected all cases of residual/recurrent disease. The sensitivity and negative predictive value of the HPV HC2 test for residual/recurrent disease were both 100% at 3 and 6 months.

Conclusion

Margin involvement in conization specimens was a significant factor predicting residual/recurrent disease after LEEP. HPV test results at 3 and 6 months after treatment were comparable. Early 3-month follow-up testing after LEEP can offer timely information about residual/recurrent disease and alleviate patient anxiety early about treatment failure.

Relationship between maternal serum C-reactive protein, funisitis and early-onset neonatal sepsis

The aim of this study was to determine whether maternal serum C-reactive protein (CRP) is of value in predicting funisitis and early-onset neonatal sepsis (EONS) in women with preterm labor or preterm premature rupture of membranes (PROM). This retrospective cohort study included 306 consecutive women with preterm labor or preterm PROM who delivered preterm singleton neonates (23-35 weeks gestation) within 72 hr of CRP measurement. The CRP level was measured with a highly sensitive immunoassay. The sensitivity, specificity, positive predictive value, and negative predictive value of an elevated serum CRP level (≥ 8 mg/L) were 74.1%, 67.5%, 32.8%, and 92.4% for funisitis, and 67.7%, 63.3%, 17.2%, and 94.6% for EONS, respectively. Logistic regression analysis demonstrated that elevated levels of serum CRP were significantly associated with funisitis and EONS, even after adjusting gestational age. The maternal serum CRP level obtained up to 72 hr before delivery is an independent predictor of funisitis and EONS in women with preterm labor or preterm PROM. A low serum CRP level (< 8 mg/L) has good negative predictive value in excluding funisitis and EONS, and may therefore be used as a non-invasive adjunct to clinical judgment to identify low-risk patients.

Noninvasive prediction of intra-amniotic infection and/or inflammation in preterm premature rupture of membranes

OBJECTIVE

To develop a model based on noninvasive parameters to predict the probability of intra-amniotic infection and/or inflammation (IAI) in women with preterm premature rupture of membranes (PPROMs).

METHODS

Maternal blood was collected for determination of the C-reactive protein (CRP) level and white blood cell (WBC) count immediately after amniocentesis in 171 consecutive women with PPROMs. Intra-amniotic infection and/or inflammation was defined as a positive amniotic fluid (AF) culture and/or an elevated AF interleukin 6 level (≥2.6 ng/mL).

RESULTS

A risk score based on a model including maternal blood CRP, WBC, parity, and gestational age was calculated for each patient. The model was shown to have an adequate goodness of fit (P = .516), and the area under the receiver-operating characteristic curve was 0.848, indicating very good discrimination.

CONCLUSION

The noninvasive model based on maternal blood CRP, WBC, parity, and gestational age is highly predictive of IAI in women with PPROMs.

Bishop score and cervical length at 33-35 weeks of gestation and the risk of intrapartum cesarean delivery of twins

AIM

The aim of this study is to determine the association between Bishop score and cervical length measured at 33-35 weeks of gestation and the intrapartum risk of cesarean delivery of twins.

METHODS

This prospective observational study recruited women with vertex/vertex twin gestations at 33-35 weeks of gestation. Determination of the Bishop score and ultrasound measurement of the cervical length were performed. A regression model was constructed with control for known intrapartum and postpartum confounders.

RESULTS

One hundred and forty-six women were analyzed; 18 women (12.3%) had cesarean deliveries during labor. Based on univariate analysis, the Bishop score at 33-35 weeks was significantly associated with the risk of intrapartum cesarean delivery of twins, whereas cervical length, maternal age, height, and weight at 33-35 weeks were not associated. Multivariate logistic regression analysis identified induction of labor and birth weight of the first-born twin, but not Bishop score, as independent predictors of intrapartum cesarean delivery of twins.

CONCLUSIONS

A low Bishop score at 33-35 weeks of gestation was associated with an increased risk of intrapartum cesarean delivery of twin gestations. However, this relationship disappeared after adjusting for relevant intrapartum or postpartum confounders. Only labor induction and high birth weight of the first-born twin were independently associated with an increased risk of cesarean delivery in labor.

Prediction of imminent preterm delivery in women with preterm premature rupture of membranes

AIMS

To develop a model based on non-invasive clinical parameters to predict the probability of imminent preterm delivery (delivery within 48 h) in women with preterm premature rupture of membranes (PPROM), and to determine if additional invasive test results improve the prediction of imminent delivery based on the non-invasive model.

METHODS

Transvaginal ultrasonographic assessment of cervical length was performed and maternal serum C-reactive protein (CRP) and white blood cell (WBC) count were determined immediately after amniocentesis in 102 consecutive women with PPROM at 23-33+6 weeks. Amniotic fluid (AF) obtained by amniocentesis was cultured and interleukin-6 (IL-6) levels and WBC counts were determined.

RESULTS

Serum CRP, cervical length, and gestational age were chosen for the non-invasive model (model 1), which has an area under the curve (AUC) of 0.804. When adding AF IL-6 as an invasive marker to the non-invasive model, serum CRP was excluded from the final model (model 2) as not significant, whereas AF IL-6, cervical length, and gestational age remained in model 2. No significant difference in AUC was found between models 1 and 2.

CONCLUSIONS

The non-invasive model based on cervical length, gestational age, and serum CRP is highly predictive of imminent delivery in women with PPROM. However, invasive test results did not add predictive information to the non-invasive model in this setting.

Absence of dysplasia in the excised cervix by a loop electrosurgical excision procedure in the treatment of cervical intraepithelial neoplasia

OBJECTIVE

Absence of dysplasia in the excised specimen following loop electrosurgical excision procedure (LEEP) for treatment of cervical intraepithelial neoplasia (CIN) 2/3 is an occasional finding of uncertain clinical significance. We evaluated several factors including age, liquid-based Pap (LBP) test, human papillomavirus (HPV) load before treatment, and HPV typing as predictors for absence of dysplasia. Absence of dysplasia in LEEP specimens was analyzed in terms of factors for recurrent disease after LEEP conization

METHODS

In total, 192 women (mean age, 39.3+/-8.4 years; range, 24 to 70 years) with biopsy-proven CIN 2/3 were treated by LEEP conization. Age, LBP test, histological grade, HPV load, and HPV DNA typing were evaluated as possible predictors of the absence of residual dysplasia or recurrent disease.

RESULTS

Of the LEEP specimens, 34 (17.7%) showed no dysplasia in preoperative biopsies from patients with proven CIN 2/3. Low HPV load (<100 relative light units [RLU]) was significantly related to the absence of dysplasia in LEEP specimens, using logistic regression. Margin involvement and high HPV load (>/=400 RLU) were significant factors for recurrence.

CONCLUSION

Absence of dysplasia in LEEP specimens occurred in 17.7% of our specimens. Prediction of the absence of dysplasia in LEEP specimens was associated with low HPV load. Residual/recurrent disease after LEEP was associated with a positive resection margin and high viral load, and was not associated with absence of dysplasia in LEEP specimens. Even if there is no dysplasia in conization specimens, close follow-up for residual/recurrent disease is needed.

In Vitro Alternatives and Phototoxicity Testing. II. Effects of Reactive Oxygen Species in In Vitro Phototoxicity Assays

The effects of reactive oxygen species (including singlet oxygen) in two in vitro phototoxicity assays -- the 3T3 cell neutral red uptake phototoxicity (3T3 NRU PT) assay and the photohaemolysis assay -- were assessed by using scavengers. Fifteen test substances, which had previously been shown to be phototoxic in vitro, were assessed. Eleven of these produced singlet oxygen. The major factor in the photodynamic reaction of bithionol was thought to be a Type I reaction, because bithionol did not produce singlet oxygen and did not react to histidine. Acridine was regarded as a Type II substance, because of the evident effect of histidine as a scavenger. 8-Methoxypsoralen and 5-methoxypsoralen produced singlet oxygen, but their actions were not affected by the scavengers. In this study, we confirmed that reactive oxygen species have great effects in in vitro phototoxicity, and that the 3T3 NRU PT assay can be used to detect effects which are thought to be the direct reaction of an excited photosensitiser to biological substrates (Type III reaction), for example, 8-methoxypsoralen. Therefore, we suggest that photohaemolysis and phototoxicity could be used to evaluate the photodynamic mechanisms of photosensitising chemicals.

Simultaneous optimization of wet granulation process involving factor of drug content dependency on granule size

Computer optimization technique was applied to the simultaneous optimization of wet granulation process by a high-speed mixer granulator. Four pharmaceutical properties, including yield, drug content uniformity, geometrical mean diameter of granules, and uniformity of granule size, were selected to evaluate the quality of the granules. In particular, dependence of drug content uniformity on granule size was investigated using two model drugs, ascorbic acid and ethenzamide. An appreciable dependence of ascorbic acid content on granule size was not observed in model formulations. On the other hand, ethenzamide was contained more in small-size granules, and its content was decreased with an increase in amounts of hydroxypropyl cellulose (HPC-L; used as a binder) and binder solution. These observations suggested that drug content uniformity is influenced not only by drug solubility in the binder solution, but also by the use of HPC-L. A simultaneous optimal point incorporating four pharmaceutical properties was obtained using the generalized distance function. The experimental values of the four response variables obtained in newly prepared granules were found to correspond well with the predicted values of both granules containing ascorbic acid and ethenzamide. These results suggested that computer optimization would benefit the wet granulation process even if drug content segregation was involved in the process. Further, data obtained from computer optimization, in particular the contour diagram, will be valuable in the process validation.

In vitro degradation of tropoelastin by reactive oxygen species

The effects of reactive oxygen species (ROS) on elastin molecules (tropoelastin) were studied in vitro. ROS generated by ultraviolet A and hematoporphyrin rapidly degraded tropoelastin within 5 min. Their degradative activity was inhibited by the addition of NaN3. Treatment of tropoelastin with copper sulfate/ascorbic acid resulted in degradation of tropoelastin producing fragments of molecular weight 45, 30 and 10 kDa within 30 min. The degradation of tropoelastin was partially blocked by the addition of mannitol. ROS induced by the xanthine/xanthine oxidase system also degraded tropoelastin within 6 h. The degradation was blocked by catalase but not by superoxide dismutase (SOD). ROS generated by copper-ascorbate seems to be unique in that it cleaves relatively specific sites of the tropoelastin molecule. Thus ROS may play a degradative role in elastin metabolism which may cause the elastolytic changes or the deposition of fragmented elastic fibers in photoaged skin or age-related elastolytic disorders.

Optimization of the granulation process for designing tablets

A computer optimization technique based on surface response methodology was applied to optimize the wet granulation process for designing tablets. Physical properties (mean granule size, granule size distribution, compressibility, granule strength) of a model granule formulation containing ethenzamide were accurately described by a second polynomial equation based on two independent variables (amounts of binder and binder solution). This regression equation also gave a good correlation for three physical properties of tablets (distintegration time, compactibility, compression force variance), but the correlation for tablet hardness and weight variation was poor. These results imply that not only the above physical properties of granules but also the rheological behavior and porous structure of granules are closely related to tablet properties. Using an optimization of five tablet properties using the generalized distance function, the predicted values of the physical properties of both granules and tablets agreed well with experimental values. This agreement indicates that the computer optimization technique is useful for optimizing the granulation process for designing tablets.

Linoleic acid and alpha-linolenic acid lightens ultraviolet-induced hyperpigmentation of the skin

This study was conducted to evaluate the effects of unsaturated fatty acids on ultraviolet-induced hyperpigmentation of the skin. An efficient lightening effect was observed following topical application of linoleic acid or alpha-linolenic acid to UV-stimulated hyperpigmented dorsal skin of brownish guinea pigs. The number of melanocytes in the treated skin was similar to the number in the skin of the pigmented control, indicating that the pigment-lightening effect was not due to depletion of melanocytes. In vitro experiments using cultured murine melanoma cells showed that melanin production was inhibited most effectively by alpha-linolenic acid, followed by linoleic acid and then by oleic acid. Furthermore, the turnover of the stratum corneum, which plays an important role in the removal of melanin pigment from the epidermis, was accelerated by linoleic acid and by alpha-linolenic acid. Taken together, the results suggest that the pigment-lightening effects of linoleic acid and alpha-linolenic acid are, at least in part, due to suppression of melanin production by active melanocytes, and to enhanced desquamation of melanin pigment from the epidermis.

Prevention of hypoglycaemia in a patient with type Ib glycogen storage disease by an amylase (alpha-glucosidase) inhibitor

Patients with type Ib glycogen storage disease (GSD Ib) are susceptible to hypoglycaemic episodes. To determine whether an amylase (alpha-glucosidase) inhibitor, voglibose, can be useful in the control of hypoglycaemia, we tried it in a 14-y-old male with GSD Ib. Oral administration of voglibose prolonged the duration of normoglycaemia and reduced the incidence of hypoglycaemia attacks. These findings indicate that voglibose may be useful for preventing hypoglycaemia in GSD Ib patients.

Cross-linking of collagen by singlet oxygen generated with UV-A

Singlet oxygen (1O2), a highly reactive and toxic intermediate, may play a role in photo-induced aging. We examined singlet oxygen generation from hematoporphyrin (HP) with UV-A, by monitoring the emission at 1,268 nm corresponding to 1O2 --> 3O2. Singlet oxygen was formed HP-dose-dependently in this system. We then investigated the reaction of singlet oxygen generated by UV-A irradiation with collagen, which is related to skin elasticity and softness. Collagen from skin was rapidly and dose-dependently cross-linked by singlet oxygen. The reaction was inhibited by NaN3, a selective quencher of singlet oxygen. In contrast, SOD (superoxide dismutase) and mannitol had no effect. These results suggested that cross-linking of collagen was caused by UV-A-generated singlet oxygen, not by any other reactive oxygen species. Compared with another multisubunit protein, alcohol dehydrogenase, collagen was cross-linked much more efficiently. Further, the finding that semicarbazide inhibited cross-linking of collagen showed that cross-links were formed between photooxidized histidyl residues and amino groups. Singlet oxygen generated by UV-A irradiation may contribute to cross-linking of collagen in the process of skin photoaging.

Study of the effective dose of a topical antifungal agent, omoconazole nitrate, on the basis of percutaneous pharmacokinetics in guinea-pigs and mice

The clinically useful optimum dose of omoconazole nitrate, a topical antifungal agent, has been examined by analysing the percutaneous pharmacokinetics of the drug to assess its pharmacological activity in an in-vivo study. Creams containing omoconazole nitrate were prepared on a pilot basis. The therapeutic effect of the omoconazole nitrate creams was examined in an in-vivo pharmacological dermatophytosis infection model in guinea-pigs. Creams containing 0.25% or higher concentrations of omoconazole nitrate resulted in significant inhibition compared with no treatment and with vehicle-treated controls. In the mycological examination no growth of dermatophytes was observed for creams containing 1% or higher concentrations. In an in-vitro hairless mouse skin-permeability test a non-linear least squares program based on a fast inverse Laplace transform algorithm was used to calculate the partition and diffusion parameters of omoconazole nitrate in the stratum corneum and viable epidermis. The time-course of drug concentrations in the skin of the guinea-pig, estimated on the basis of these parameters, led to predictions that percutaneous drug concentrations on the guinea-pig would require 10 or more days to reach equilibrium in the skin; that drug concentrations in the corneum-viable epidermis border, where dermatophytes are considered to grow, would exceed the minimum effective concentration when 0.1% higher concentration creams were used; and that for binding to keratin drug concentrations would reach the practical minimum effective concentration when creams containing 0.5% or more omoconazole nitrate were used. These results show that partition and diffusion parameters obtained from in-vitro skin permeation studies can be used to predict in-vivo percutaneous pharmacokinetics and to estimate therapeutically effective concentrations.

Participation of reactive oxygen species in phototoxicity induced by quinolone antibacterial agents

To elucidate the mechanism of phototoxicity induced as a side effect by some of the new quinolone antibiotics, we studied sparfloxacin (SPFX), lomefloxacin, enoxacin, ofloxacin, and ciprofloxacin. We first examined the photosensitized formation of reactive oxygen species such as singlet oxygen (1O2) and superoxide anion (O2-) mediated by the new quinolones. Although a large number of studies have been reported, there is no direct evidence that these drugs generate reactive oxygen species. We employed a near-infrared emission spectrometer to detect 1O2-specific emission (1268 nm), and the nitroblue tetrazolium reduction method to detect O2-. All the quinolones investigated in this study were found to produce 1O2. Four drugs, but not SPFX, produced O2-. We also examined photodynamic DNA strand-breaking activity as a possible mechanism to explain the participation of reactive oxygen species in the phototoxicity of the drugs. All the drugs exhibited photodynamic DNA strand-breaking activity. The inhibitory effect of scavengers of reactive oxygen species indicated that the main active species was 1O2. The DNA strand-breaking activity was correlated not with the 1O2-forming ability, but with the affinity of the drugs for DNA. This result may be due to the short lifetime of 1O2. These data suggested that the phototoxicity of the new quinolones was related to DNA damage caused by reactive oxygen species, especially 1O2.

Characterization of acetohexamide reductases purified from rabbit liver, kidney, and heart: structural requirements for substrates and inhibitors

The structural requirements of acetohexamide reductases purified from rabbit liver, kidney, and heart for substrates and inhibitors were examined. Acetohexamide, an oral antidiabetic drug with a ketone group, and analogs of it with various alkyl groups instead of the cyclohexyl group were used as substrates for these three enzymes. The results obtained as to substrate specificity suggested that the nature of the substrate-binding region of the heart enzyme is markedly different from those of the substrate-binding regions of the liver and kidney enzymes. Tolbutamide, which has no ketone group within its chemical structure, strongly inhibited the heart enzyme, whereas it had little ability to inhibit the liver or kidney enzyme. The inhibition of the heart enzyme by tolbutamide was competitive with respect to acetohexamide and uncompetitive with respect to NADPH. Furthermore, tolbutamide analogs with n-pentyl and n-hexyl groups instead of the n-butyl group exhibited very pronounced inhibition of only the heart enzyme. Therefore, it is reasonable to postulate that the heart enzyme, unlike the liver and kidney ones, has a cleft of a strongly hydrophobic nature near its substrate-binding region, and that this hydrophobic cleft plays a critical role in the interaction of the heart enzyme with the cyclohexyl group of acetohexamide.

Singlet oxygen (1 delta g) generation from coproporphyrin in Propionibacterium acnes on irradiation

Although singlet oxygen has been postulated to be a highly reactive and toxic intermediate, there has been no evidence of considerable generation of singlet oxygen in vivo level except for special cases. In this work, we firstly measured the near-infrared emission spectra corresponding to the O2(1 delta g) --> O2(3 epsilon g-) transition of singlet oxygen of cutaneous Propionibacterium acnes (P. acnes) porphyrin under laser excitation. A comparison of the singlet oxygen production of coproporphyrin, which is produced predominantly from P. acnes, with that of other photosensitizers revealed coproporphyrin to be a highly efficient singlet oxygen generator under ultraviolet light A irradiation on the skin. These results suggest that singlet oxygen can be generated on the skin surface from P. acnes porphyrin under ultraviolet irradiation and induce serious damage to the skin.