Reconstructing the concept of empathy: an analysis of Japanese doctors' narratives of their experiences with illness

The ability of doctors to empathise with patients is a crucial concern in establishing humanistic medicine. Therefore, the cultivation of this ability has been discussed extensively in medical education. One theory suggests that the experience of patienthood can increase empathy among doctors. This theory is supported by previous research that published doctors' illness narratives. However, the concept of empathy has been ambiguously defined in academic fields, including medicine; therefore, analysing how doctors experience 'empathy' in their interactions with patients is difficult. Our research question is how doctors who became patients describe the relationship between their illness experiences and the interactions with patients after their illness. To this end, this paper initially tracks the debates on 'empathy' in medicine and other disciplines, to develop a lens for analysing doctors' illness narratives. Next, we conduct a narrative analysis of illness stories from 18 Japanese medical doctors who became patients. Our analysis supports the traditional idea that an illness can enable a doctor to become more empathetic. However, this is overly simplistic; how doctors experience and subsequently process their illness is more complex. Moreover, this notion can disregard doctors' suffering in these circumstances, and fail to represent the often-lengthy process of mastering 'empathy' based on their experiences. Therefore, our analysis deconstructed the concept of 'empathy', showing that it can appear in various ways. Further research is required to elucidate how empathy is cultivated during the process of transformation of doctors' illnesses, focusing on their communities and practices.

Patient experience (PX) among individuals with disabilities in Japan: a mixed-methods study

Background

People with disabilities (PWDs) tend to be disadvantaged in terms of receiving preventive medicine and medical checkups. About 7.6% of the Japanese population is estimated to have a disability. Although patient experience (PX) is an effective measure of patient-centeredness, little is known about the PX of PWDs. The present study aimed to compare the PX of PWDs with those of the non-disabled both quantitatively and qualitatively.

Methods

The present study involved a questionnaire survey and a free-response question on the survey form. The quantitative part of the study involved a comparison of JPCAT scores between PWDs and non-disabled participants. JPCAT is composed of five primary care principles: First contact, Longitudinality, Coordination, Comprehensiveness (service provided and service available), and Community orientation. Descriptive statistics were used to assess age, sex, years of education, self-rated health status, and type of disability (for PWDs). Multivariable analysis was performed using a linear regression model to detect differences between PWDs and non-disabled participants in total and domain-specific JPCAT scores. The model included the following confounding variables: age, sex, years of education, and self-rated health status. The qualitative part of the study involved a thematic analysis of answers to the free-response question.

Results

Data from 338 participants (169 PWDs and 169 non-disabled participants) were analyzed (response rate of 36% for PWDs). After adjusting for age, sex, years of education, and self-rated health status, PWD scores were significantly lower than those of non-disabled participants for the Longitudinality, Community Orientation, and Comprehensiveness (services available) domains of the JPCAT. Qualitative analysis yielded six themes, each of which was further divided to have Disability-Specific and General themes.

Conclusions

JPCAT scores in PWDs were significantly lower than those of non-disabled participants for the Longitudinality, Community Orientation, and Comprehensiveness (services available) domains. Qualitative analysis revealed that PWDs shared several themes with non-disabled participants, but also to face unique challenges due to disabilities, such as the lack of a health care provider familiar with disabilities and the insurance transition at age 65, a unique feature of the Japanese health care system.

Trial registration

The study was a non-interventional, observational research trial, and thus registration was not required.

Catalytic activity of Co-nanocrystal-doped tungsten carbide arising from an internal magnetic field

Pt is an excellent and widely used hydrogen evolution reaction (HER) catalyst. However, it is a rare and expensive metal, and alternative catalysts are being sought to facilitate the hydrogen economy. As tungsten carbide (WC) has a Pt-like occupied density of states, it is expected to exhibit catalytic activity. However, unlike Pt, excellent catalytic activity has not yet been observed for mono WC. One of the intrinsic differences between WC and Pt is in their magnetic properties; WC is non-magnetic, whereas Pt exhibits high magnetic susceptibility. In this study, the WC lattice was doped with ferromagnetic Co nanocrystals to introduce an ordered-spin atomic configuration. The catalytic activity of the Co-doped WC was ∼30% higher than that of Pt nanoparticles for the HER during the hydrolysis of ammonia borane (NH₃BH₃), which is currently attracting attention as a hydrogen fuel source. Measurements of the magnetisation, enthalpy of adsorption, and activation energy indicated that the synergistic effect of the WC matrix promoting hydrolytic cleavage of NH₃BH₃ and the ferromagnetic Co crystals interacting with the nucleus spin of the protons was responsible for the enhanced catalytic activity. This study presents a new catalyst design strategy based on the concept of an internal magnetic field. The WC–Co material presented here is expected to have a wide range of applications as an HER catalyst.

The catalytic activity of the Co-doped WC is 30% higher than that of Pt nanoparticles for the hydrogen evolution reaction arising from an internal magnetic field.

AB0387 TREATMENT STATUS FOR OSTEOPOROSIS IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: CROSS-SECTIONAL ANALYSIS FROM A LUPUS REGISTRY OF NATIONWIDE INSTITUTIONS (LUNA)

Background:

Osteoporosis is one of the most important adverse effects of glucocorticoids in patients with systemic lupus erythematosus (SLE). Because osteoporosis is accelerated by chronic kidney disease (CKD), more attention should be paid to the treatment for osteoporosis in SLE patients with CKD. Many treatment options for osteoporosis have emerged recently, but treatment status in patients with SLE is not elucidated.

Objectives:

The purpose of this study is to elucidate the treatment status for osteoporosis in patients with SLE among the CKD stages.

Methods:

Using data from lupus registry of nationwide institutions (LUNA), a cross-sectional analysis was performed. We firstly described treatment status for osteoporosis in all enrolled patients. Secondary, treatment status for osteoporosis was compared among CKD stages. Finally, bone damage in Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) was compared among CKD stages.

Results:

The median age (interquartile range [IQR]) of enrolled 917 patients was 44 (34- 57) years and 809 patients (88%) were female. CKD stages were follows: CKD stage 1, 234 (26%); CKD stage 2, 465 (51%); CKD stage 3, 189 (21%); CKD stage 4, 9 (1%); CKD stage 5, 16 (2%). Median (IQR) age, female sex, and median (IQR) previous maximum dose of prednisolone in patients with and without CKD (≥CKD stage 3) were 56 (46.5-66) and 41 (32-50), 191 (89%) and 615 (88%), and 40 (30-60) and 40 (30-55) mg/day, respectively. Bisphosphonate was administered in 388 (42%) patients, vitamin D supplements in 448 (49%), Ca supplements in 36 (4%), denosumab in 20 (2%) and teriparatide in 14 (2%), respectively. Of enrolled patients, any treatment for osteoporosis was not administered in 226 (25%) patients. In spite of more frequent bone damage in patients with CKD compared to those without CKD (15% vs 10%, p=0.036), treatment status did not differ between patients with and without CKD (bisphosphonate: 41% vs 46%, p=0.29; vitamin D supplements: 50% vs 44%, p=0.14).

Conclusion:

About a quarter of patients with SLE did not take any treatment for osteoporosis. Treatment for osteoporosis might be strengthened to prevent bone damage in SLE patients with CKD.

Disclosure of Interests:

KEN-EI SADA Speakers bureau: I received speaker’s fee from GSK and Astra Zeneca K.K., Keigo Hayashi: None declared, Yosuke ASANO: None declared, Yu Katayama: None declared, Sumie Hiramatsu Asano: None declared, Keiji Ohashi: None declared, Michiko Morishita: None declared, Haruki Watanabe: None declared, Mariko Narazaki: None declared, Yoshinori Matsumoto: None declared, Nobuyuki Yajima: None declared, Ryusuke Yoshimi: None declared, Yasuhiro Shimojima: None declared, Shigeru Ono: None declared, Hiroshi Kajiyama: None declared, Kunihiro Ichinose: None declared, Shuzo Sato: None declared, Michio Fujiwara: None declared, Jun Wada: None declared

Damage accrual related to pregnancies before and after diagnosis of systemic lupus erythematosus: a cross-sectional and nested case-control analysis from a lupus registry

OBJECTIVE

The objective of this study was to evaluate the chronic damage associated with pregnancies before and after the diagnosis of systemic lupus erythematosus (SLE).

METHODS

Using childbearing-aged female SLE patient data registered at the Okayama and Showa University Hospitals, a nested case-control analysis was performed to investigate the relationship between pregnancy and chronic damage using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI).

RESULTS

Pregnancy occurred in 22 patients before and 13 patients after the diagnosis of SLE in 104 eligible patients. Live births occurred in 82% (33/40) and 50% (9/18) of the pregnancies before and after the diagnosis of SLE, respectively. After matching age and disease duration, 33 case patients with chronic damage (SDI ≥ 1) and 33 control patients without chronic damage (SDI = 0) were selected. Hypertension was more frequent in cases than in controls (48% vs. 24%, p = 0.041). Pregnancies before and after the diagnosis of SLE were comparable between cases and controls (before the diagnosis: nine case patients and eight control patients; after the diagnosis: three case patients and five control patients; p = 1.00). Even after adjusting for hypertension using multivariate analysis, the pregnancies before and after the diagnosis were not significant predictors for chronic damage (odds ratio = 1.48 (95% confidence interval 0.33-6.65)), p = 0.60 of the pregnancy before the diagnosis; odds ratio = 0.78 (95% confidence interval 0.13-4.74), p = 0.78 of the pregnancy after the diagnosis).

CONCLUSION

Pregnancies, either before or after the diagnosis of SLE, did not show any differences in chronic damage. Our results help alleviate fears regarding childbearing in female patients with SLE and their families.

Progressive reduction of serum complement levels: a risk factor for relapse in patients with hypocomplementemia in systemic lupus erythematosus

Objective

Serologically active clinically quiescent (SACQ)-SLE is a subtype of systemic lupus erythematosus (SLE); most SACQ-SLE patients relapse. Although complement and/or anti-dsDNA level fluctuations during SACQ status are reportedly not useful for predicting relapse, they might be useful in specific clinical settings. We aimed to assess the correlation between future relapse and progressive reductions in serum complement levels following remission in patients with hypocomplementemia .

Methods

We retrospectively reviewed patients aged ≥15 years who were treated with ≥20 mg/day of prednisolone for remission induction. After achieving remission, the patients treated with prednisolone tapered to ≤15 mg/day without relapse and followed by hypocomplementemia (first hypocomplementemia point) were analyzed. The primary outcome was the relapse during the first 24 months.

Results

Seventy-six patients were enrolled; 31 (40.8%) relapsed. A ≥10% reduction after the first hypocomplementemia point in serum C3, C4, and CH50 levels was found in 10, 21, and 16 patients, respectively. Hazard ratios (95% confidence intervals) for relapse were 2.32 (0.92–5.12) for serum C3 levels and 2.46 (1.18–5.01) for serum C4 levels. Progressive reductions in serum C3 and C4 levels had relatively high specificity (93.3% and 82.2%) but limited sensitivity (22.6% and 41.9%) for predicting relapse. However, simultaneous progressive reduction in C3 levels and increase in anti-dsDNA antibody levels had the highest specificity (97.8%), and simultaneous progressive reduction in C4 levels or increase in anti-dsDNA antibody levels had the highest sensitivity (71.0%).

Conclusion

Simultaneous progressive reductions in complement levels and increases in anti-dsDNA antibody levels may indicate future relapse SACQ-SLE patients.

Refractory neuromyelitis optica spectrum disorder in systemic lupus erythematosus successfully treated with rituximab

We present a case of a woman with systemic lupus erythematosus (SLE) who had refractory episodes of neuromyelitis optica spectrum disorder (NMOSD) and was successfully treated with rituximab. She was positive for anti-aquaporin-4 (AQP4) antibody and had typical cranial and longitudinally extended spinal lesions but no optic nerve involvement. There is no established treatment for NMOSD/SLE overlap cases. Our experience suggests that rituximab may be effective for patients with combined SLE and anti-AQP4 antibody-positive NMOSD.

Refractory neuromyelitis optica spectrum disorder in systemic lupus erythematosus successfully treated with rituximab

We present a case of a woman with systemic lupus erythematosus (SLE) who had refractory episodes of neuromyelitis optica spectrum disorder (NMOSD) and was successfully treated with rituximab. She was positive for anti-aquaporin-4 (AQP4) antibody and had typical cranial and longitudinally extended spinal lesions but no optic nerve involvement. There is no established treatment for NMOSD/SLE overlap cases. Our experience suggests that rituximab may be effective for patients with combined SLE and anti-AQP4 antibody-positive NMOSD.

Bronchus sign on thin-section computed tomography is a powerful predictive factor for successful transbronchial biopsy using endobronchial ultrasound with a guide sheath for small peripheral lung lesions: a retrospective observational study

Background

Recent advances in bronchoscopy, such as transbronchial biopsy (TBB) using endobronchial ultrasonography with a guide sheath (EBUS-GS), have improved the diagnostic yield of small-sized peripheral lung lesions. In some cases, however, it is difficult to obtain adequate biopsy samples for pathological diagnosis. Adequate prediction of the diagnostic accuracy of TBB with EBUS-GS is important before deciding whether bronchoscopy should be performed.

Methods

We retrospectively reviewed 149 consecutive patients who underwent TBB with EBUS-GS for small-sized peripheral lung lesions (≤30 mm in diameter) from April 2012 to March 2013. We conducted an exploratory analysis to identify clinical factors that can predict an accurate diagnosis by TBB with EBUS-GS. All patients underwent thin-section chest computed tomography (CT) scans (0.5-mm slices), and the CT bronchus sign was evaluated before bronchoscopy in a group discussion. The final diagnoses were pathologically or clinically confirmed in all studied patients (malignant lesions, 110 patients; benign lesions, 39 patients).

Results

The total diagnostic yield in this study was 72.5 % (95 % confidence interval: 64.8–79.0 %). Lesion size, lesion visibility on chest X-ray, and classification of the CT bronchus sign were factors significantly associated with the definitive biopsy result in the univariate analysis. In the multivariate analysis, only the CT bronchus sign remained as a significant predictive factor for successful bronchoscopic diagnosis. The CT bronchus sign was also significantly associated with the EBUS findings of the lesions.

Conclusion

Our results suggest that the CT bronchus sign is a powerful predictive factor for successful TBB with EBUS-GS.

[Efficacy and safety of cisplatin plus pemetrexed as a first-line treatment for Japanese patients with advanced non-squamous non-small-cell lung cancer -- a retrospective analysis]

BACKGROUND

Cisplatin plus pemetrexed is considered the standard of care for the first-line treatment of patients with advanced non-squamous non-small-cell lung cancer (NSCLC). However, little is known about the efficacy and safety of this regimen in Japanese patients in a daily clinical setting.

METHODS

We retrospectively analyzed 40 patients who received cisplatin (75 mg/m/(2)) and pemetrexed (500 mg/m(2)) as a first-line treatment for advanced non-squamous NSCLC.

RESULTS

Recorded Grade 3 or 4 hematological toxicities included neutropenia in 7 cases (17.5%), leukopenia in 5 cases (12.5%), anemia in 1 case (2.5%), thrombocytopenia in 1 case (2.5%), and febrile neutropenia in 1 case (2.5%). Grade 3 or 4 nonhematological toxicities included anorexia in 3 cases (7.5%), infection in 1 case (2.5%), rash in 1 case (2.5%), and increased transaminase expression in 1 case (2.5%). Therefore, the adverse events were mostly mild. There were no treatment related deaths. The overall response rate was 37.5%, median progression free survival was 5.6 months, and median overall survival (OS) was 18.8 months. In an epidermal growth factor receptor (EGFR) mutation status subgroup analysis, the median OS of patients with wild-type EGFR or unknown status (n=28)was 16.8 months.

CONCLUSION

Cisplatin plus pemetrexed was well tolerated as a first-line treatment and effective in Japanese patients with advanced non-squamous NSCLC.

Upregulation of CD11b on eosinophils in aspirin induced asthma

BACKGROUND

Although a challenge test using non-steroidal anti-inflammatory drugs (NSAIDs) is crucial for diagnosis of aspirin-induced asthma (AIA), it also has drawbacks in terms of possible side effects. Therefore, alternative in-vitro diagnostic methods for AIA are awaited.

METHODS

Nineteen stable non-AIA patients (9 males and 10 females; mean age, 49.4 ± 4.8 years), and 20 AIA patients (9 males and 11 females; mean age, 51.1 ± 4.8 years) were enrolled in this study. CD11b and CD16 expressions on the peripheral-blood granulocytes after administration of aspirin and different concentrations of PGE2 in vitro were examined using flowcytometry.

RESULTS

Aspirin induced a significant increase in CD11b expression on eosinophils (CD16 negative granulocytes) in 19 AIA patients and one non-AIA patient. Increase in CD11b expression on eosinophils by aspirin administration was suppressed by PGE2 in a dose-dependent manner.

CONCLUSIONS

The measurement of CD11b expression on peripheral-blood eosinophils showed very high sensitivity and specificity of (-95%) in diagnosing AIA. Although this method requires laboratory facilities for flowcytometry, it may be very useful in diagnosis of AIA without side effects. In addition, PGE2 may be involved in regulation of CD11b expression on eosinophils by aspirin administration.

Mechanisms of pharmacokinetic enhancement between ritonavir and saquinavir; micro/small dosing tests using midazolam (CYP3A4), fexofenadine (p-glycoprotein), and pravastatin (OATP1B1) as probe drugs

We investigated the mechanisms of ritonavir-mediated enhancement effect on the pharmacokinetics of saquinavir using in vivo probes for CYP3A4 (midazolam), p-glycoprotein (fexofenadine), and OATP1B1 (pravastatin) following oral micro/small dosing. A cocktail of the drugs (2 mg of saquinavir, 100 µg of each probe) was administered to eight healthy volunteers (phase 1), and then coadministered with 20 mg (phase 2) and 100 mg (phase 3) of ritonavir. Plasma concentrations of the drugs were measured by validated LC-MS/MS methods. The mean plasma AUC0-24 (pg hour/mL) of saquinavir at phases 1, 2, and 3 was 101, 2 540, and 23 900 (P < .01), respectively. The relative area under the plasma concentration-time curve (AUC)0-24 ratios of midazolam and fexofenadine at phases 1, 2, and 3 were 1:5.9:14.7 (P < .01), and 1:1.4:2.2 (P < .01-.05), respectively. In contrast, there was no difference in the pharmacokinetics of pravastatin. Inhibition of intestinal and hepatic CYP3A-mediated metabolism, and intestinal p-glycoprotein-mediated efflux of saquinavir, but not OATP1B1, is involved in the enhancement mechanism. Micro/small dosing is useful for examining the mechanism of drug interactions without safety concern.

A. actinomycetemcomitans LPS Enhances Foam Cell Formation Induced by LDL

The objective of this study was to examine whether native low-density lipoprotein (LDL) induces foam cell formation by macrophages and to examine the effect of lipopolysaccharide (LPS) on native LDL-induced foam cell formation by macrophages in vitro. RAW 264.7 cells were cultured with LDL or high-density lipoprotein (HDL) in the presence of LPS derived from Aggregatibacter actinomycetemcomitans. Foam cell formation was determined by staining with Oil-red-O to visualize cytoplasmic lipid droplet accumulation. The expression of LDL-receptor and the degree of internalization of FITC-conjugated LDL in RAW 264.7 cells were examined by immunofluorescence microscopy. The images were digitally recorded and analyzed with Image J software. Statistical analysis was performed by JMP software. Foam cell formation was induced by the addition of native LDL in dose- and time-dependent manners, whereas HDL showed no effect. LPS enhanced the foam cell formation induced by native LDL. In addition, LPS stimulated the expression of LDL-receptor protein on RAW 264.7 cells and enhanced the internalization of LDL. The enhancement of foam cell formation induced by LPS and LDL was inhibited by the depolymerizing agent nocodazole and amiloride analog 5-(N-ethyl-N-isoprophyl) amiloride (EIPA). Our findings indicate that LPS plays an important role in foam cell formation by LDL-stimulated macrophages.

Pharmacokinetic interaction study of sulphasalazine in healthy subjects and the impact of curcumin as an in vivo inhibitor of BCRP

BACKGROUND AND PURPOSE An ATP-binding cassette (ABC) transporter, breast cancer resistance protein (BCRP)/ABCG2, limits oral bioavailability of sulphasalazine. Here we examined the effect of curcumin, the principal curcuminoid of turmeric, on oral bioavailability of microdoses and therapeutic doses of sulphasalazine in humans. EXPERIMENTAL APPROACH Effects of curcumin were measured on the ATP-dependent sulphasalazine uptake by hBCRP-expressing membrane vesicles and on oral bioavailability of sulphasalazine in wild-type and Bcrp(-/-) mice. Eight healthy Japanese subjects received an oral dose of sulphasalazine suspension (100 µg) or tablets (2 g) alone or after curcumin tablets (2 g). Uptake of sulphasalazine was studied in HEK293 cells transfected with the influx transporter (OATP)2B1. KEY RESULTS Curcumin was a potent hBCRP inhibitor in vitro (K(i) 0.70 ± 0.41 µM). Curcumin increased the area under the curve (AUC)(0-8) of plasma sulphasalazine eightfold in wild-type mice at 300 and 400 mg·kg(-1), but not in Bcrp(-/-) mice. Curcumin increased AUC(0-24) of plasma sulphasalazine 2.0-fold at microdoses and 3.2-fold at therapeutic doses in humans. Non-linearity of the dose-exposure relationship was observed between microdoses and therapeutic doses of sulphasalazine. Sulphasalazine was a substrate for OATP2B1 (K(m) 1.7 ± 0.3 µM). Its linear index (dose/K(m)) at the therapeutic dose was high and may saturate OATP2B1. CONCLUSIONS AND IMPLICATIONS Curcumin can be used to investigate effects of BCRP on oral bioavailability of drugs in humans. Besides the limited dissolution, OATP2B1 saturation is a possible mechanism underlying non-linearity in the dose-exposure relationship of sulphasalazine.

Oral biodrug delivery using cell-penetrating peptide

During the past few decades, the novel biotherapeutic agents such as peptides and proteins have been contributed to the treatment of several diseases. However, their oral absorption is significantly limited due to their poor delivery through the intestinal mucosa. Therefore, the feasible approaches are needed for improving the oral bioavailability of biodrugs. Recently, cell-penetrating peptides (CPPs) such as HIV-1 Tat, penetratin and oligoarginine are considered as a useful tool for the intracellular delivery of therapeutic macromolecules. Hence, it was expected that the ability of CPPs may be applicable to enhance the absorption of biodrugs through intestinal epithelial membrane. CPPs are likely to become powerful tools for overcoming the low permeability of therapeutic peptides and proteins through the intestinal membrane, the major barrier to their oral delivery. Further advantage of this promising strategy is that this successful intestinal absorption could be achieved by more convenient methodology, coadministration of CPP with drugs via intermolecular interaction among them. Hereafter, the further establishment of delivery system based on CPPs is required to realize the development of the oral forms of therapeutic peptides and proteins. The aim here is to introduce our vision focusing on oral biodrug delivery by the use of CPPs as potential peptide carrier in order to provide new information in the design and development of new oral delivery systems for novel biotherapeutics.

[Miliary tuberculosis and tuberculous peritonitis during infliximab treatment for rheumatoid arthritis]

A 55-year-old woman treated with infliximab for rheumatoid arthritis was admitted due to progressive ascites. A CT scan showed massive ascites, bilateral pleural effusion, disseminated granular shadows in the lung, and multiple swollen mediastinal lymph nodes. A FDG-PET/CT scan showed increases of FDG uptake in the mesentery and peritoneum, mimicking peritoneal carcinomatosis. Subsequent pleural and peritoneal fluid analysis showed elevated adenosine deaminase activity levels with no malignant cells. A right pleural biopsy specimen revealed Langhans giant cells and granulomas. Finally, a diagnosis of miliary tuberculosis was established because cultures of the sputum and gastric fluid were positive for Mycobacterium tuberculosis. Several weeks after a standard anti-tuberculosis regimen with 4 drugs was initiated, her clinical condition and radiological findings ameliorated. Since the initial manifestations of tuberculosis tend to be more severe during treatment of rheumatoid arthritis with tumor necrosis factor-alpha inhibitors such as infliximab due to immune suppression, we should pay closer attention to the possibility of tuberculosis infection in these patients.

Structural requirements of penetratin absorption enhancement efficiency for insulin delivery

Penetratin, a 16-residue peptide, is used widely as a highly efficient delivery carrier for a wide range of poorly permeable therapeutic cargoes. The crucial structural features of penetratin remain unclear, as demonstrated by the difficulties encountered in designing new molecules. The efficiency in enhancing nasal insulin absorption was compared between l-penetratin and 20 of its analogues in rats. We also measured lactate dehydrogenase (LDH) leakage as an indicator of cytotoxicity and scored the histopathological irritation. Substitution of a cationic residue (Arg or Lys) with Leu or addition of tetra-arginine to the C- or N-terminus of penetratin caused considerable reduction in the enhancing efficiency properties of the modified analogues. Mutual exchanging of Arg and Lys in corresponding analogues produced nearly inactive analogues, although changing Arg to Lys in the same analogue produced similar penetratin activity. In addition, activity was impaired markedly upon modification of penetratin within amphiphilic (Trp) or hydrophobic (Ile and Phe) residues. Chain size-modified analogues lacked the ability to induce nasal insulin absorption. In contrast, rearrangement of the modified analogues by C,N-half-exchange and reverse analogues produced activity similar to that of the original penetratin. The enhancing activity was inhibited almost completely upon sequence arrangement of the resulting analogues. Surprisingly, a shuffle (Arg, Lys fix) 2 analogue increased insulin absorption significantly, reaching a relative bioavailability value 1.85-times that of original penetratin. This analogue caused negligible release of LDH in nasal lavage fluid and maintained the integrity of the nasal respiratory epithelium. In conclusion, modulation of amino acid sequences by fixing the cationic residue positions can augment penetratin-enhanced nasal absorption and may lead to improvements in nasal insulin absorption.

The role of intermolecular interactions with penetratin and its analogue on the enhancement of absorption of nasal therapeutic peptides

We investigated the relationship between intermolecular binding and the ability of novel cell-penetrating peptides (CPPs) to enhance the nasal absorption of therapeutic peptides and proteins. The absorption-enhancing effect of a novel l-penetratin analogue, 'shuffle (R,K fix) 2' coadministered with different biotherapeutic peptides was evaluated after nasal administration in rats. Shuffle (R,K fix) 2 significantly increased the nasal absorption of insulin, glucagon-like-peptide-1 (GLP-1) and exendin-4, compared with the absorption seen with l-penetratin. Intermolecular binding was analyzed by surface plasmon resonance (SPR)-based binding assay. The binding characteristics implied that the higher the amount of CPP bound, the greater the nasal drug absorption. In addition, the calculated binding ratio between CPP and drug proved a critical aspect in enhancing the absorption of insulin and GLP-1. This difference in the enhancing effect of CPPs on nasal drug absorption is attributed to the degree of binding with the therapeutic macromolecule.

Grade 3 Status Dominates Prognosis in Breast Cancer

Background: Histological grading (HG) is probably the most important clinico-pathological parameter that will provide information about tumour intrinsic characteristics and aggressiveness. HG is included in prognostic guidelines for treatment decision making such as St Gallen, Nottingham Prognostic Index and Adjuvant!Online. Grade 3 (G3) Breast cancer (BC) is associated with poor prognosis in terms of survival and recurrence. G3 BC reflects independent biological entities rather than being the end of the spectrum of cancer progression. Our aim is to establish the clinical relevance of HG as prognostic factor in a specific cohort of BC patients and define its relation with survival and recurrence endpoints.Method: This is a retrospective cohort analysis from 1489 operable Breast Cancer patients attending the Oncology Service at Singleton Hospital, Wales, UK between 1996 and 2002.HG was recorded for 1339 cases and outcome data were available on 1213 cases. Correlation of clinical variables with Overall Survival (OS), Distant Disease Free Survival (DDFS) and Disease Free Survival (DFS) was performed using Cox regression model.Results:The median follow-up for the cohort was 5.43 years (range 0.09 to 10.14 years) Patients were characterised according to age, HG, tumour size (TNM-T), nodal status, ER status and systemic treatment received (polychemotherapy/tamoxifen). Independent Cox regression models for each endpoint were developed based on univariate analyses. Multivariate analysis results are presented in Figure 1.Subgroup analysis of G3 cases showed a younger population: median age G3 59.4y vs G1/G2 62.9 y p:&lt; 0.001); 47.5% of G3 cases were ER positive against 94.5% of Grade 1/2 (p &lt; 0.001). Patients with G3 tumours died more rapidly from all causes (median time to death 2.22 vs 3.42 y, p &lt;0.001) and from BC (median time to death from BC 2.22 y vs 3.82 y in G1/G2, p &lt;0.001) than other HG. Similarly, G3 also relapsed quicker both distantly, (median time 1.64 vs 2.54 y G1/G2 (p&lt;0.04) and locally, median time to relapse 1.6 vs 2.35 y for G1/G2 (p&lt;0.036). There was also a significant association between grade and tumour size (median G1/G2 1.7cm vs G3 2.2cm(p&lt; 0.001); and nodal involvement and tumour size, median 1.5cm N-ve, 2.2 cm N+ve (p&lt; 0.001).Conclusion: Patients with G3 tumours tended to be younger, had a more advanced TNM staging at diagnosis and relapsed and died more rapidly than other histological grades. In our cohort, G3 tumours were adversely associated with OS, DDFS and DFS with a stronger association with these endpoints than node positivity. It is perhaps time to reconsider the HG as a prognostic factor as important as nodal status for the selection of adjuvant chemotherapy regimens.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6005.

Molecular Heterogeneity of Grade 3 Breast Cancer

Background: Histological grade (HG) is one the main prognostic factors used in clinical practice, along with nodal status and tumour size, for the classification of patients into different prognostic groups that support the clinical decision making process and to tailor adjuvant treatment according to specific risk of death or relapse. The aim of this study was to examine the effect of Grade in prognosis in an unselected series of breast cancers, and to examine copy number alteration (CNA) specifically in Grade 3 (G3) breast cancer and its relationship to nodal status (N-ve/N+ve) and clinical outcome, to seek genetically determined markers of prognosis for treatment tailoring in this poor prognosis group.Method: We established a clinical database of 1489 operable Breast Cancer patients attending the Oncology Service at Singleton Hospital, Wales, UK between 1996 and 2002. HG was known for 1339 of these cases, and outcome in 1213, with a median of 5.32 years (range 0.09 - 10.14 years) follow-up. From the 466 G3 cases of primary breast cancer, we analysed 81 cases using 1Mb BAC array CGH for genomic copy number alterations. Spatial normalisation, circular binary segmentation and the CGHcall algorithm was used to generate CGH profiles. Unsupervised hierarchical clustering, supervised, correlation and survival analyses were carried out using packages and tests within the R statistical platform.Results: Patients were characterised according to grade, ER and nodal status. Kaplan Meier analysis for overall survival (OS) and disease specific survival (DFS) confirmed the poor prognosis of G3 (Cox proportional hazards regression, Wald-test p-value &lt;&lt; 0.05). The majority of G1 (98%) and G2 (93%) cases were ER +ve, whereas 52.5% G3 cases were ER-ve. ER status was known for 316 of the 466 G3 cases, and ER negativity was significantly associated with a decreased OS (p-value 0.02), but not DFS (p-value: 0.13). Similarly N+vity also showed significant correlation with both OS and DFS (p-values &lt; 0.05). BAC aCGH analysis showed significant copy number gains on chromosomes 1,4,5,7,11 and 21 in N+ve and losses on chromosomes 1,6 and 10 in N-ve G3. One region of chromosome 1 (1p36 – 1p35) in particular was lost in N0 but gained in N+ve, and this was significantly associated with ER-ve/N+ve cases (FDR p-value &lt; 0.05). BAC aCGH profiles did not significantly associate with ER status in G3 disease. Two clusters, delineated on unsupervised hierarchical cluster analysis, correlated with OS. Neither correlated with nodal or ER status, indicating that further analysis may discover genes of prognostic potential within these profiles.Conclusion HG was significantly associated with clinical outcome and ER status. Genomic copy number analysis (CNA) in G3 breast cancer revealed significant associations between DNA alterations and nodal status and OS. The study is currently being extended to investigate the relationship between specific CNA and clinical outcome in G3 disease.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5167.

Efficiency of cell-penetrating peptides on the nasal and intestinal absorption of therapeutic peptides and proteins

The purpose of our study was to investigate the potential of cell-penetrating peptides; penetratin as novel delivery vector, on the systemic absorption of therapeutic peptides and proteins across different mucosal administration sites. The absorption-enhancing feasibility of l- and d-penetratin (0.5mM) was used for glucagon-like peptide-1 (GLP-1), and exendin-4 as novel antidiabetic therapy, in addition to interferon-beta (IFN-beta) as protein biotherapeutic model from nasal and intestinal route of administration was evaluated as first time in rats. Nasal route is the most feasible for the delivery of therapeutic peptides coadministered with penetratin whereas the intestinal route appears to be more restricted. The absolute bioavailability (BA (%)) values depend on the physichochemical characters of drugs, stereoisomer character of penetratin, and site of administration. Penetratin significantly increased the nasal more than intestinal absorption of GLP-1 and exendin-4, as the BA for nasal and intestinal administration of GLP-1 was 15.9% and 5%, and for exendin-4 were 7.7% and 1.8%, respectively. Moreover, the BA of IFN-beta coadministered with penetratin was 11.1% and 0.17% for nasal and intestinal administration, respectively. From these findings, penetratin is a promising carrier for transmucosal delivery of therapeutic peptides and macromolecules as an alternative to conventional parenteral routes.

Prediction of permeability of FD-4 through porous poly (2-hydroxyethyl methacrylate) membrane by multiple linear regression and artificial neural network

The aim of this study was to predict the permeability through porous poly (2-hydroxyethyl methacrylate) (pHEMA) membranes of fluorescein isothiocyanate-labeled dextran molecular weight 4400 (FD-4) as a model of peptide and protein drug movement. Homogeneous standard membranes were prepared by redox polymerization. Permeability data were predicted by an artificial neural network (ANN) as a function of polymerization factors, and the accuracy was compared with that of conventional multiple linear regression (MLR). Good linearity was observed with each model, with the correlation coefficient of a leave-one-out cross-validation (Rcross) being 0.857 for the MLR model and 0.876 for the ANN model. The mean bias and mean accuracy for the ANN were somewhat smaller than those of the MLR. The ANN method provides an accurate quantitative approximation of the permeability coefficient of FD-4, as judged by conventional MLR, and could be applied to prediction of the non-linear relation between polymerization factors and the permeability of FD-4.

Importance of intermolecular interaction on the improvement of intestinal therapeutic peptide/protein absorption using cell-penetrating peptides

Our previous reports showed that the absorption of therapeutic peptides and proteins was significantly improved by coadministration of cell-penetrating peptides (CPPs) as the physical mixture. However, the mechanisms for this improvement are not clear. In the present study, we verified the hypothesis that the electrostatic interaction between drug and CPP is related to the enhancing effect of the CPP on the intestinal absorption of therapeutic peptides and proteins. In this study, the intermolecular binding was analyzed by surface plasmon resonance (SPR)-based binding assay, and the effect of CPPs on the intestinal absorption of peptide drugs was examined by in situ absorption study using a rat intestinal loop. Among the 16 peptide drugs possessing different isoelectric points, it was observed that only gastrin, insulin and glucagon-like peptide-1 (GLP-1) bound to D-R8 (D-form arginine octamer, a typical CPP), and subsequently their intestinal absorption increased by coadministration of D-R8. In contrast, the intestinal absorption of other peptide drugs that did not bind to D-R8 was not affected in the presence of D-R8. Thus, this study suggests that intermolecular binding between drug and CPP is an important factor governing the enhancing effect of the CPP on the intestinal absorption of therapeutic peptides and proteins.

Chemotherapy (CT) with radiotherapy versus CT alone for FIGO Stage IIIc endometrial cancer

To determine optimal treatment for women with Stage IIIc endometrial carcinoma, extended-field radiotherapy (RT) plus chemotherapy (CT) was compared versus CT alone as adjuvant therapy. Twenty-nine patients with FIGO Stage IIIc endometrial cancer who underwent adjuvant treatment with 4.4 courses of CT (CAP or TC/DC) or 4.5 courses of CT (CAP or TC/DC) plus external pelvic RT (50 Gy) with paraaortic boost after surgery between 1992 and 2004 were retrospectively assessed. Fifteen patients underwent CT alone and 14 received combined treatment with CT/RT. Following treatment, the recurrence rate was 46.6% and 28.5% in the two treatment arms, respectively. There was a significant (p < 0.05) difference in the pelvic recurrence rate (33.3% and 7.1%, respectively). Combined treatment with RT/CT was associated with a better survival rate than CT alone (78% versus 62%, respectively). In Stage IIIc endometrial cancer, combined treatment with RT and CT reduces pelvic recurrence and improves progression-free survival and overall survival compared with CT alone.

Complexation hydrogels for intestinal delivery of interferon beta and calcitonin

Recent studies have suggested that complexation hydrogels poly(methacrylic acid-g-ethylene glycol) (henceforth designated as P(MAA-g-EG)) exhibit high insulin incorporation efficiency, rapid insulin release in the intestine based on their pH-dependent complexation properties, enzyme-inhibiting effects and mucoadhesive characteristics. Therefore, they are promising carriers for insulin delivery via an oral route. As we designed these hydrogels as carriers suitable for oral administration of various peptide/protein drugs, in this study we aimed at investigating the applicability of P(MAA-g-EG) hydrogels to improving the intestinal absorption of various peptide/protein drugs. High loading efficiency into hydrogels was observed for insulin, calcitonin, and interferon beta. In addition, polymer microparticles loaded with calcitonin and interferon beta exhibited complexation/decomplexation and pH-sensitive release behavior. The molecular weight and chemical structure appeared to affect the efficiency of loading and release depending on the peptides and proteins. Furthermore, a drastic reduction of plasma calcium concentration accompanied by calcium absorption and a dose-dependent enhancement of plasma interferon beta concentration were observed after the administration of particles loaded with calcitonin or interferon beta into closed rat ileal segments. These findings indicate that P(MAA-g-EG) hydrogels are promising carriers for administration of various peptides and proteins via an oral route.

Effect of cell-penetrating peptides on the nasal absorption of insulin

The goal of this study was to evaluate whether cell-penetrating peptides (CPPs) affect the nasal absorption of insulin. L- or D-forms of penetratin, or the L- or D-forms of octaarginine (L- or D-R8), was used as first time for nasal insulin delivery. Furthermore, the concentration of lactate dehydrogenase (LDH) in nasal lavage fluid was determined and a histopathological study of nasal respiratory epithelium was conducted. CPPs dramatically increased nasal insulin absorption, and it was more pronounced for L- and D-penetratin than L- or D-R8. L-penetratin was the most effective promoter of insulin absorption compared with others CPPs. A dose-dependent relationship of L-penetratin and insulin bioavailability was statically significant. The pharmacological availability and bioavailability of nasally administered insulin was up to 76.7% and 50.7% relative to the subcutaneous route, respectively. In contrast, increasing the D-penetratin concentration decreased the efficiency of nasal insulin absorption. There was no significant difference in the release of LDH in nasal lavage fluid and the integrity of nasal respiratory epithelium when L-penetratin was present. In conclusion, these data demonstrate that L-penetratin markedly increased the permeability of insulin across the nasal membrane without causing detectable damage to the integrity of cells in the nasal respiratory mucosa.

Usefulness of colon targeted DHA and EPA as novel diabetes medications that promote intrinsic GLP-1 secretion

Glucagon-like peptide-1 (GLP-1) is a gut-derived peptide secreted from intestinal L-cells and now considered as an ideal diabetic medicine. Recently, it was reported that the unsaturated fatty acid alpha-linoleic acid promotes the secretion of GLP-1 via a G protein-coupled receptor, GPR120. However, the effects of long-chain polyunsaturated fatty acids on the secretion of GLP-1 have not been examined in vivo. The aim of this study was to evaluate the effects of the long-chain polyunsaturated fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) on blood glucose levels, plasma insulin, and GLP-1 concentrations. In addition, site-specific differences in these effects were determined using several intestinal segments: stomach, jejunum, and colon. After an intraperitoneal glucose administration (1.5 mg/g weight), each mouse was administered vehicle or an alpha-linoleic acid, DHA, EPA or EPA ester (EPA-E) solution to each intestinal segment. After an intraperitoneal glucose challenge, marked endogenous GLP-1 secretion, substantial insulin release and subsequent glucose reductions were observed in the intracolonic DHA and EPA treatment groups. In contrast, DHA and EPA did not increase GLP-1 secretion when given in the other segments. These data suggested that the colon-specific delivery of DHA, EPA, and possibly EPA-E would be a novel antidiabetic treatment by the stimulation of intrinsic GLP-1 secretion.

Complexation Hydrogels for Oral Insulin Delivery: Effects of Polymer Dosing on in Vivo Efficacy

Hydrogels comprised of poly(methacrylic acid) grafted with poly(ethylene glycol) (P(MAA-g-EG)) were characterized and examined for their potential as oral insulin carriers. Insulin loaded polymer (ILP) samples were made using two different polymer formulations. The values for the effective molecular weight between crosslinks, M _e , and the network mesh size, xi, were characterized and increased with increasing pH levels for both formulations. Insulin uptake studies indicated a high insulin loading efficiency for all samples tested, however release was dependent on the amount of insulin loaded. The effect of total polymer dosing was investigated by in situ administration in isolated ileal segments in rats. All ILP samples induced a hypoglycemic effect and an increase in insulin levels, proving that insulin was still biologically active. Insulin dosing amounts were varied by (i) maintaining a constant insulin fraction within an ILP sample while changing the amount of ILP and (ii) by varying the insulin fraction while dosing with the same amount of ILP. The total insulin absorption was dependent on both the amount of the polymer present and the concentration of insulin within an ILP sample, with a maximum relative bioavailability of 8.0%.

Capecitabine and docetaxel combination for the treatment of breast cancer

The management of breast cancer depends on the tumor and patient's characteristics. Anthracycline-based regimens have been proven to decrease the risk of relapse and prolong survival time in breast cancer. Taxanes have been incorporated not only into metastatic breast cancer but also into adjuvant regimens. Capecitabine, an oral fluoropyrimidine carbamate, has good single-agent activity and, together with docetaxel, demonstrated preclinical synergy and a survival benefit in metastatic breast cancer. Recent analyses show that capecitabine/docetaxel dosing flexibility for managing side effects does not compromise efficacy, and define this combination regimen as an important treatment option for its efficacy, tolerability and cost-effectiveness.

Current challenges in non-invasive insulin delivery systems: a comparative review

The quest to eliminate the needle from insulin delivery and to replace it with non- or less-invasive alternative routes has driven rigorous pharmaceutical research to replace the injectable forms of insulin. Recently, various approaches have been studied involving many strategies using various technologies that have shown success in delivering insulin, which are designed to overcome the inherent barriers for insulin uptake across the gastrointestinal tract, mucosal membranes and skin. This review examines some of the many attempts made to develop alternative, more convenient routes for insulin delivery to avoid existing long-term dependence on multiple subcutaneous injections and to improve the pharmacodynamic properties of insulin. In addition, this article concentrates on the successes in this new millennium in developing potential non-invasive technologies and devices, and on major new milestones in modern insulin delivery for the effective treatment of diabetes.

Key functions in polymer carriers for intestinal absorption of insulin

This work aimed to clarify the relationship between polymer function and insulin absorption, and to evaluate the optimized preparative formulation predicted from this relationship. Insulin-loaded polymer (ILP) carrier systems were prepared following a two-factor composite second-order spherical experimental design. To investigate the polymer function, we evaluated its insulin release, bioadhesiveness, and protective effect. Each ILP was administered intestinally, and glucose reduction was monitored as the pharmacological effect. Based on these data, an optimized formulation was predicted and how the polymer function affects insulin absorption was clarified by multivariate spline (MVS) interpolation. A greater pharmacological effect was apparent in ILPs with a smaller particle size and loaded with more insulin. The pharmacological effect predicted by MVS after the administration of ILP made under optimized preparative conditions was almost identical to the observed effect. Moreover, MVS clarified the relationship between the polymer function and the pharmacological effect. These results supported that MVS can be an effective tool with which to approximate the relationship between the function of a dosage form and its absorption, and to explore the optimized preparative conditions.