Preventive effect of free radical scavenger edaravone lotion on cyclophosphamide chemotherapy-induced alopecia

PURPOSE

We investigated the inhibitory effect of edaravone (EDR) lotion on chemotherapy-induced alopecia (CIA) to improve the quality of life for patients with cancer.

METHODS

Wistar rats were intraperitoneally injected with cyclophosphamide (CPA, 75 mg/kg) to induce CIA and divided into six groups: (1) Control; (2) EDR 0%; (3) EDR 0.3%; (4) EDR 3%. The TUNEL-positive area was examined histologically, and mRNA expression levels of the apoptosis-related factors, such as B-cell/CLL lymphoma 2 (Bcl-2), and Bcl-2-associated X protein (Bax), were determined.

RESULTS

In the three CPA-treated groups, a decrease in the coverage score (percentage of hairs covered) was observed from days 16 to 18. In addition, coverage scores on day 21, the last day of observation, showed a tendency for the suppression of hair loss to increase, though hair loss was observed in all groups. The coverage scores of the EDR 0.3% and 3% groups after day 17 were significantly higher than those of the EDR 0% group. The TUNEL-positive area of skin tissue on day 16 was extensive in the EDR 0% group and decreased in the EDR 0.3% and 3% groups. The mRNA expression ratio of Bcl-2/Bax on day 21 was maintained at the same level as that of the control group only in the EDR 3% group.

CONCLUSION

This study confirmed the use of EDR lotion to inhibit hair loss, indicating that the clinical application of EDR lotion may improve the quality of life for patients with cancer and their willingness to undergo treatment.

The impact of rare cancer and early-line treatments on the benefit of comprehensive genome profiling-based precision oncology

BACKGROUND

Comprehensive genome profiling (CGP) serves as a guide for suitable genomically matched therapies for patients with cancer. However, little is known about the impact of the timing and types of cancer on the therapeutic benefit of CGP.

MATERIALS AND METHODS

A single hospital-based pan-cancer prospective study (TOP-GEAR; UMIN000011141) was conducted to examine the benefit of CGP with respect to the timing and types of cancer. Patients with advanced solid tumors (>30 types) who either progressed with or without standard treatments were genotyped using a single CGP test. The subjects were followed up for a median duration of 590 days to examine therapeutic response, using progression-free survival (PFS), PFS ratio, and factors associated with therapeutic response.

RESULTS

Among the 507 patients, 62 (12.2%) received matched therapies with an overall response rate (ORR) of 32.3%. The PFS ratios (≥1.3) were observed in 46.3% (19/41) of the evaluated patients. The proportion of subjects receiving such therapies in the rare cancer cohort was lower than that in the non-rare cancer cohort (9.6% and 17.4%, respectively; P = 0.010). However, ORR of the rare cancer patients was higher than that in the non-rare cancer cohort (43.8% and 20.0%, respectively; P = 0.046). Moreover, ORR of matched therapies in the first or second line after receiving the CGP test was higher than that in the third or later lines (62.5% and 21.7%, respectively; P = 0.003). Rare cancer and early-line treatment were significantly and independently associated with ORR of matched therapies in multivariable analysis (P = 0.017 and 0.004, respectively).

CONCLUSION

Patients with rare cancer preferentially benefited from tumor mutation profiling by increasing the chances of therapeutic response to matched therapies. Early-line treatments after profiling increase the therapeutic benefit, irrespective of tumor types.

Prevalence and implications of exercise pulmonary hypertension in chronic thromboembolic pulmonary disease

Introduction

Recent international statement on chronic thromboembolic pulmonary hypertension proposed the definition of chronic thromboembolic pulmonary disease (CTEPD) and advocated further research regarding its clinical characteristic, natural history, and therapeutic strategy. Exercise pulmonary hypertension (Ex-PH) has been considered a mild degree of pulmonary hypertension (PH) among patients with normal pulmonary hemodynamics at rest. However, the clinical significance of Ex-PH in CTEPD remains unknown.

Purpose

In the patients with CTEPD, we aimed to verify 1) the prevalence and clinical profiles of Ex-PH, 2) effect of BPA on pulmonary vascular response after exercise in Ex-PH, 3) long-term clinical outcomes of conservative management in non-Ex-PH.

Methods

We retrospectively reviewed 26 patients with CTEPD (median age 65 years, 38% male), who underwent cardiopulmonary exercise test with right heart catheterization (CPET-RHC). The definitions of CTEPD are the following 1) pulmonary artery occlusion due to organic thrombus confirmed by imaging studies after ≥3 months of anticoagulation, 2) mPAP<25 mmHg and PAWP≤15 mmHg at rest. PQslope was plotted using multipoint plots. Ex-PH was defined by PQ slope>3.0, and the patients were divided into Ex-PH and non-Ex PH groups. Clinical profiles and long-term outcomes were compared between two groups. The patients in Ex-PH groupunderwent CPET-RHC 6–12 months after balloon pulmonary angioplasty (BPA). In Non-Ex-PH group, serial measurements of echocardiography were performed.

Results

Overall, 5 and 21 patients were categorized as CTEPD with PH (mPAP 21–24mmHg) and without PH (mPAP≤20mmHg), and 14 and 12 were categorized Ex-PH and non-Ex-PH groups, respectively. Although all 5 patients with CTEPD with PH were classified as Ex-PH group (Figure 1), there was no significant difference in baseline hemodynamics at rest between Ex-PH and non-Ex-PH groups (mPAP: 19.5 [18.4–20.6] vs. 17.7 [16.6–18.9] mmHg, PVR: 2.2 [1.7–2.7] vs. 2.3 [1.9–2.8] wood units, P>0.05, respectively). PQ slope was significantly higher in Ex-PH group (4.6 [3.2–6.0] vs. 1.31 [0.2–2.8], p=0.002). There were no differences in respiratory function test, blood gas analysis, and 6-minute walk distance between two groups. There were no major adverse events such as all-cause mortality and hospitalization for PH in overall cohort. Among Ex-PH group, BPA decreased PQslope (4.8 [3.6–6.4] to 2.3 [1.9–3.0], p<0.05). Among no-Ex-PH group, there was no significant change in tricuspid regurgitation pressure gradient (28 [17–33] to 27 [21–36] mmHg, p>0.05) over the 997 [651–1451] days.

Conclusion

Ex-PH was common in patients with CTEPD, and there were no clinical profiles differentiating Ex-PH from non-Ex-PH, except parameters of CPET-RHC. BPA improved an abnormal pulmonary vascular response to exercise in Ex-PH. The conservative management in non-Ex-PH was feasible. Randomized clinical trials will be needed to further investigate this treatment strategy.

Funding Acknowledgement

Type of funding sources: None.

Therapeutic strategy for rheumatoid arthritis by induction of myeloid-derived suppressor cells with high suppressive potential

Combination treatment using fingolimod (FTY720), an immunomodulator, and a pathogenic antigen prevents the progression of glucose-6-phosphate isomerase (GPI)_325-339-induced arthritis. In this study, we focused on myeloid-derived suppressor cells (MDSCs; CD11b⁺Gr-1⁺ cells) and investigated the effects of the combination treatment on these cells. DBA/1J mice with GPI_325-339-induced arthritis were treated using FTY720 and/or GPI_325-339 for five days. The expanded CD11b⁺Gr-1⁺ cell population and its inhibitory potential were examined. The percentage of CD369⁺CD11b⁺Gr-1⁺ cells effectively increased in the combination-treated mice. The inhibitory potential of CD369⁺CD11b⁺Gr-1⁺ cells was higher than that of cells not expressing CD369. Among bone marrow cells, the expression of CD369 in CD11b⁺Gr-1⁺ cells increased following stimulation with granulocyte-macrophage colony-stimulating factor, and the expression of CD11c increased accordingly. The increased CD11c expression indicated a decrease in the potential to suppress T cell proliferation based on the results of the suppression assay. The percentage of CD11c^-CD369⁺ cells in CD11b⁺Gr-1⁺ cells that were induced by the combination treatment also increased, and these cells tended to have a higher capacity to inhibit T cell proliferation. In conclusion, the combination treatment using FTY720 and the pathogenic antigen effectively induces MDSC, which demonstrates a high potential for suppressing T cell proliferation in the lymph nodes, thereby establishing an immune-tolerant state.

Renin-angiotensin system inhibitors combined with cisplatin exacerbate cisplatin-induced nephrotoxicity in mice

INTRODUCTION

We previously reported that the concomitant use of enalapril and telmisartan exacerbates the risk of cisplatin (CDDP)-induced acute renal dysfunction compared to other antihypertensive drugs in mice. Thus, in the current study, we investigated the risk of developing chronic kidney disease following repeated concomitant use of CDDP and antihypertensive drugs.

MATERIALS AND METHODS

Male BALB/c mice were divided into 12 groups: (1) Control group (untreated), (2) CDDP group (7 mg/kg, CDDP), (3) AML group (5 mg/kg, amlodipine), (4) ENA group (2.5 mg/kg, enalapril), (5) TEL group (10 mg/kg, telmisartan), (6) LOS group (10 mg/kg, losartan), (7) CDDP+AML group (5 mg/mL, AML), (8) CDDP+ENA group (2.5 mg/kg, ENA), (9) CDDP+LowENA group (1.25 mg/kg, ENA), (10) CDDP+TEL group (10 mg/kg, TEL), (11) CDDP+LowTEL group (5 mg/kg, TEL), and (12) CDDP+LOS group (10 mg/kg, LOS). CDDP was administered intraperitoneally four times every 7 days, and each antihypertensive drug was administered orally from day 3 before CDDP administration until day 24 (six times a week). The degree of renal damage was assessed. The nephrotoxicity of each individual was evaluated by measuring serum creatinine and blood urea nitrogen levels. The degrees of renal fibrosis and epithelial-mesenchymal transition were also examined in kidney tissue sections.

RESULTS AND DISCUSSION

The results suggest that combinatorial treatment of CDDP and renin-angiotensin system inhibitors, particularly ENA and TEL, may exacerbate CDDP-induced nephrotoxicity. This study clearly demonstrates the need for large-scale clinical studies to construct treatment regimens that do not interfere with the therapeutic intensity of CDDP.

Sivelestat's effect on Candida albicans water-soluble fraction-induced vasculitis

BACKGROUND

We investigated the efficacy of sivelestat sodium hydrate (SSH) as a treatment for Kawasaki disease, and its pharmacological action sites, in mice with Candida albicans water-soluble fraction-induced vasculitis.

METHODS

Sivelestat sodium hydrate was administered intraperitoneally to Candida albicans water-soluble fraction-induced vasculitis model mice to assess its efficacy in preventing the development of coronary artery lesions based on the degree of inflammatory cell infiltration in the aortic root and coronary arteries (vasculitis score). The pharmacological sites of action were investigated based on changes in neutrophil elastase (NE) and intercellular adhesion molecule 1 (ICAM-1) positive areas, ICAM-1 and tumor necrosis factor-α mRNA expression levels in the upper heart, and the proportion of monocytes in the peripheral blood.

RESULTS

The vasculitis score decreased below the lower limit of the 95% confidence interval of untreated mice in 69% of the SSH-treated mice. The NE- and ICAM-1-positive regions, and the mRNA expression of ICAM-1 and tumor necrosis factor-α were lower in the SSH-treated mice than in the untreated mice. The proportion of monocytes in the peripheral blood was higher in the SSH-treated mice than in the untreated mice, whereas monocyte migration to inflammation areas was suppressed in the SSH-treated mice.

CONCLUSIONS

Our results showed that SSH might prevent the development of coronary artery lesions and ameliorate disease activity. In addition to its NE-inhibitory effect, SSH sites of action may also include monocytes.

“Target Heart Rate” calculated aiming at zero overlap of mitral E and A waves is useful for prediction of long-term outcome for patients with heart failure and reduced ejection fraction

Background

Lower heart rate (HR) is associated with more favourable long-term outcome in patients with heart failure with reduced ejection fraction (HFrEF). However, an optimal threshold of HR remains unclear. Targeted HR (THR), defined by echocardiographic deceleration time (DCT) to eliminated overlap of E and A waves, may aid in risk stratification of HFrEF patients.

Purpose

In this study, we aimed to clarify the impact of on long-term clinical outcome in patients with HFrEF.

Methods

In the multicenter WET-HF registry, 4000 consecutive patients hospitalized for acute decompensated HF (ADHF) were registered between 2006 and 2017. Among them, the patients with EF ≥40% or a history of atrial fibrillation were excluded. THR was calculated based on their DCT value measured in compensated HF phase during the index admission. The following formula was applied; THR (bpm)=93 - 0.13 × deceleration time (DCT, msec). A total of 876 patients with HFrEF were included in the present analysis (age: 72 [60–81], male: 69%) and the patients were divided into the 2 groups of HR at discharge ≤ THR (L group) and > THR (H group). The primary endpoint (PE) was defined as the composite of all-cause death and ADHF re-admission.

Results

Compared to the H group, the L group showed higher prevalence of males (74% vs. 66%, P=0.025) with higher body mass index (BMI, 23.2 vs. 22.2, P=0.016), hemoglobin (Hb, 12.9 vs. 12.4, P=0.031), albumin (Alb, 3.7 vs. 3.6, P=0.039) and larger left atrial diameter (LAD, 44 mm vs. 41 mm, P=0.002) and tricuspid regurgitation pressure gradient (TRPG, 29 mmHg vs. 27 mmHg, P=0.012). Age, estimated glomerular filtration rate (eGFR), LVEF (29% vs. 30%, P=NS) and E/e' (17.7 vs. 16.8, P=NS) were similar for both groups. At discharge, HR was lower in L group (66 [60–71] bpm vs. 80 [74–86] bpm, P<0.001), albeit there were no significant differences in b-blocker prescription (90% vs. 85%, P=0.069) or its dose (3.75 [1.25–7.25] mg vs. 2.5 [1.25–5] mg, P=0.11).

In the survival analysis, the L group showed a significantly lower rate of PE (P=0.03), whereas there was no significant difference in the incidence of PE between the patients with HR at discharge ≥70 bpm and <70 bpm (P=NS).

Multivariate Cox hazard analysis showed that HR at discharge ≤ THR was an independent predictor of PE (hazard ratio 0.67 [0.46–0.97], P=0.037), even after adjusting for confounding factors including age, sex, BMI, Hb, Alb, and b-blocker prescription, whereas HR at discharge <70 bpm was not (hazard ratio 0.94 [0.65–1.33], P=0.71).

Conclusion

THR was associated with long-term outcomes in patients with HFrEF after acute decompensation, suggesting that it may aid in tailored treatment for HR reduction in these patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Telmisartan Exacerbates Cisplatin-Induced Nephrotoxicity in a Mouse Model

Cisplatin (CDDP; cis-diamine dichloroplatinum)-induced nephrotoxicity is the main reason for dose limitations, which can reduce the efficacy of cancer treatment. Lower blood pressure and administration of renin angiotensin system (RAS) inhibitors have been reported as factors that exacerbate CDDP-induced nephrotoxicity; however, the detailed mechanisms remain unknown and the results of previous studies are conflicting. In this study, we examined the influence of various hypotensive drugs, including RAS inhibitors and calcium channel blockers, on CDDP-induced nephrotoxicity in BALB/c mice. The mice were divided into nine groups: (1) CDDP group (15 mg/kg CDDP), (2) AML group (5 mg/kg amlodipine), (3) ENA group (2.5 mg/kg enalapril), (4) telmisartan (TEL) group (10 mg/kg telmisartan), (5) LOS group (10 mg/kg losartan), (6) CDDP + AML group, (7) CDDP + ENA group, (8) CDDP + TEL group, and (9) CDDP + LOS group. Nephrotoxicity was evaluated by measuring serum creatinine (CRE) and blood urea nitrogen (BUN) levels. In addition, the kidney sections were stained with Masson's trichrome and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling (TUNEL) to assess the renal fibrosis area and apoptotic area. Serum CRE and BUN levels were increased in the CDDP + ENA, CDDP + LOS, and CDDP + TEL groups compared to those in the CDDP alone group, and the CDDP + AML group showed an increasing trend. However, there was no correlation between ∆CRE or ∆BUN levels and ∆ systolic blood pressure. The CDDP + TEL group showed a significant increase in the renal fibrosis area. These results suggest that exacerbation of CDDP-induced nephrotoxicity is not correlated with systolic blood pressure but is associated with administration of RAS inhibitors, particularly TEL.

Preventive effect of edaravone ointment on cyclophosphamide-chemotherapy induced alopecia

PURPOSE

We evaluated the preventive effect of the antioxidant edaravone (EDR) on chemotherapy-induced alopecia (CIA) to improve quality of life in cancer patients.

METHODS

Hair loss was induced by intraperitoneally administering cyclophosphamide (CPA, 75 mg/kg) to rats, and topically applying EDR ointment (100 mg/day) once daily for 16 days (when hair loss starts) or 21 days (just before hair growth). The rats were divided into four groups: control group (without CPA or EDR), EDR 0% group (CPA + EDR 0%), EDR 3% group (CPA + EDR 3%), and EDR 30% group (CPA + EDR 30%). The prevention of CIA was evaluated by the hair coverage score (five levels from 0 to 4). Furthermore, we measured the size of the hair follicle area and the expression levels of insulin-like growth factor (IGF)-1 mRNA in dermal papilla cells.

RESULTS

The EDR 3% and EDR 30% groups exhibited higher hair coverage scores than the EDR 0% group on day 16 and day 21. On day 16, the hair follicle area in the EDR 3% and EDR 30% groups was significantly larger than that in the EDR 0% group. Furthermore, IGF-1 expression levels in the EDR 3% group were significantly higher than those in the EDR 0% group. On day 21, no significant difference was observed in hair follicle area or IGF-1 mRNA levels among the groups.

CONCLUSION

Our results show that EDR administration lessened hair loss due to CPA in a dose-independent manner above doses of 3%, suggesting potential applications beside chemotherapy.

Characterization of an Expanded IL-10-Producing-Suppressive T Cell Population Associated with Immune Tolerance

An increase in the number of glucocorticoid-induced tumor necrosis factor receptor-family related gene/protein (GITR)⁺CD25^- (or fork-head box protein 3: Foxp3^-) CD4⁺ T cells, after treating a mouse model of arthritis with fingolimod (FTY720), and a pathogenic antigen may play a key role in the establishment of immune tolerance. In this study, we characterized a specific expanded T cell subset in this population. Mice with glucose-6-phosphate isomerase peptide (GPI_325-339)-induced arthritis were treated with FTY720 (1 mg/kg, per os) and GPI_325-339 (10 µg/mouse, intravenously) for five days, starting from the onset of symptoms. The expanded GITR⁺CD25^- (or Foxp3^-) CD4⁺ T cell population and its cytokine production were examined using flow cytometry. Furthermore, time-dependent changes in T-bet and/or early growth response gene 2 (Egr-2) expression in this T cell subset were examined. The density of T cell immunoreceptors with immunoglobulin (Ig) and immunoreceptor tyrosine-based inhibition motif domains (TIGIT)⁺CD39⁺ cell subset in the GITR⁺Foxp3^-CD4⁺ T cell population was significantly increased only in the combined treatment group, compared to that in the untreated and single-treatment groups. In the TIGIT⁺CD39⁺GITR⁺Foxp3^-CD4⁺ T cell population, T-bet⁺Egr-2⁺/T-bet⁺Egr-2^- cell ratio increased in the latter stage of the treatment. Furthermore, this T cell subset, which corresponded to a T helper 1 (Th1) response, produced high levels of both interleukin (IL)-10 and interferon (IFN)-γ. In conclusion, expanded TIGIT⁺CD39⁺GITR⁺Foxp3^-CD4⁺ T cells shifted from an effector Th1 to IL-10-producing-suppressor T cell phenotype, which may promote an immune-tolerant state.

Efficacy and outcomes of balloon pulmonary angioplasty in elderly vs non-elderly chronic thromboembolic pulmonary hypertension patients

Introduction

Balloon pulmonary angioplasty (BPA) has been reported as an effective and safe treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, its safety and efficacy in elderly patients remains unknown.

Purpose

We investigated the effect of BPA on hemodynamics and respiratory parameters, functional capacity, and short- and long-term outcome in elderly patients.

Methods

From November 2012 to May 2018, 141 consecutive CTEPH patients who underwent BPA in a single university hospital were enrolled (age: 65 [54.5–74] years old, WHO functional class [WHO-FC] II/III/IV; 35/96/10). Patients were divided into two groups according to the age; elderly (≥75 years, N=32) and young groups (<75 years, N=109). Hemodynamics (right-sided heart catheterization), biomarkers (brain natriuretic peptide), respiratory function (spirometry and diffusion capacity measurement), and functional capacity (6-minute walk distance [6MWD] and WHO-FC) were evaluated at baseline and 1-year post BPA. Procedure-related complications (in hospital death, use of percutaneous cardiopulmonary support [PCPS], and pulmonary injury) and all cause death during the follow up period were also assessed.

Results

At baseline, although elderly group had less severe hemodynamics (mPAP: 33.1±6.7 vs 39.0±11.8 mmHg, p<0.05), they had poor exercise capacity and reduced pulmonary diffusion capacity, compared with young group (6MWD: 264.6±101.3 vs 369.7±105.2 m, %DLco: 42.0±12.0 vs 50.2±12.7%, all p<0.05). BPA improved hemodynamics, biomarkers, exercise capacity, and pulmonary diffusion capacity in both elderly and young groups (all p<0.05). There was no in-hospital death or use of PCPS in both groups, although the incidence of pulmonary injury was higher in elderly group (14.3% vs 5.3%, p<0.01). Under the normalized hemodynamics 1-year after BPA in both groups, exercise capacity and pulmonary diffusion capacity were worse in the elderly group than young groups (p<0.01). The incidence of all-cause death in the follow up period was higher in elderly group, all of which were due to non-pulmonary hypertension (PH)-related death (p<0.01).

Conclusion

BPA was effective in improving hemodynamics and respiratory parameters and functional capacity, in associated with no critical complication, regardless of the age. Elderly patients who were treated with BPA were associated with higher incidence of non-PH-related death.

Changes of mean PAP in the two groups

Funding Acknowledgement

Type of funding source: None

De-escalation/discontinuation of oxygen-therapy and medication is feasible and safe in chronic thromboembolic pulmonary hypertension patients treated with balloon pulmonary angioplasty

Introduction

There has been increasing evidence of the efficacy of balloon pulmonary angioplasty (BPA) in improving the hemodynamics, exercise capacity, and biomarkers of patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, there is no consensus on the adjustment of home oxygen therapy (HOT) and pulmonary hypertension (PH)-specific medications after BPA in patients with CTEPH.

Purpose

We aimed to examine the current status of the de-escalation/discontinuation of HOT and PH-specific medications post-BPA, and clarify its effect on subsequent hemodynamics, biomarkers, and long-term clinical outcomes.

Methods and results

From November 2012 to July 2019, 134 consecutive CTEPH patients who underwent BPA at a single university hospital were enrolled (age; 63.6±13.4 years, female; n=87 [64.9%], WHO functional class [WHO-FC] II/III/IV; 33/92/9). Hemodynamic data, functional capacity (6-minute walk distance and WHO-FC), biomarkers (brain natriuretic peptide [BNP] and high-sensitivity troponin T [hs-TropT]), and respiratory function were evaluated at baseline, immediately and 1 year post-BPA. Clinical outcomes (all-cause death and heart failure [HF] admission) were also assessed during the follow up period. The total number of sessions was 6.3±2.0, and the number of target vessels was 14.3±2.0. Mean pulmonary arterial pressure decreased from 37.8±11.2 to 20.4±5.1 mmHg 1-year after BPA (p<0.01). The proportion of patients who required HOT (at rest or on exertion) and combination medical therapy (≥2 PH-specific medications) decreased 1 year post-BPA (from 59.0% to 7.5%, and from 41.8% to 10.4%, respectively; Figure). Among 79 patients who required HOT during daytime, 64 patients (81.0%) discontinued HOT just after BPA completion. Among 56 patients who required combination medical therapy, 29 (51.8%) discontinued combination therapy. Baseline factors influencing the continuation of HOT and combination medical therapy post-BPA were almost identical (i.e. lower exercise capacity and pulmonary diffusion capacity, and worse hemodynamics). Results showed that discontinuation of HOT and combination medical therapy did not affect the maintenance of improved hemodynamics and levels of BNP and hs-TropT, and no adverse clinical outcomes (all-cause death and HF hospitalization) were observed during 1 year post-BPA.

Conclusions

Most CTEPH patients discontinued HOT and PH-specific combination medical therapy after BPA, which was not associated with the deterioration of hemodynamics, functional capacity, or biomarkers. No adverse long-term outcomes were observed. De-escalation/discontinuation of HOT and PH-specific combination medical therapy after BPA is feasible and safe for patients with CTEPH.

De-escalation of HOT and medical therapy

Funding Acknowledgement

Type of funding source: None

[Learning Strategy for Pharmacy Students to Develop Empathy for Hepatitis B Patients through a Lecture Presented by Patients Describing Their Daily Lives]

In April 2018, as part of their fifth-year pre-clinical education curriculum, pharmacy students at Setsunan University attended a lecture presented by hepatitis B patients and their lawyer entitled "Lecture by Hepatitis B Patients". This lecture was intended to help the students to understand the circumstances and difficulties encountered by hepatitis B patients on a daily basis. For this study, we conducted questionnaire surveys of the pharmacy students before and after the lecture. The survey items pertained to students' knowledge about hepatitis B (e.g., its spread and infection possibility in daily life). Students' responses before and after the lecture varied depending on the survey topic. Hepatitis B knowledge acquired by the students in their junior year increased after the lecture; moreover, attitudes to hepatitis B patients and understanding of the difficulties and prejudice that they experienced showed a significant change. For example, responses to the items, "Feel sympathy for patients suffering from discrimination and prejudice" and "Hard to work…" were much more sympathetic after the lecture; additionally, students were less likely to "Fear infection when near patients" and more likely "… to associate with patients". Thus, the "Lecture by Hepatitis B Patients" had a significant impact on the pharmacy students' perceptions of these patients, allowing them to cultivate greater empathy. From an educational standpoint, it is of the utmost importance for pharmacy/medical students to develop their humanity as members of healthcare teams. Educational real-world experiences, such as the "Lecture by Hepatitis B Patients", provide opportunities for this development.

2206Prevalence and determinants of complicated grief in bereaved caregivers of patients admitted for cardiovascular diseases

Introduction

Few studies have examined complicated grief in bereaved caregivers of patients with cardiovascular diseases (CVD), in contrast with studies in caregivers of patients with cancers. We examined the prevalence and determinants of complicated grief among bereaved caregivers of patients with CVD.

Methods

We conducted a cross-sectional survey using a self-administered questionnaire for bereaved family members of CVD patients who had died in the cardiology departments of 9 tertiary care centers in Japan. We assessed bereaved caregiver grief status using the Brief Grief Questionnaire (BGQ), and its association with their depression (Patient Health Questionnaire-9 [PHQ-9]). Questionnaire also covered following associated factors: bereaved family member and patient characteristics, end-of-life care (Care Evaluation Scale [CES], a scale for assessment of the structure and process of care); and the quality of the deceased patients' death (Good Death Inventory [GDI]).

Results

A total of 269 bereaved caregivers (mean age, 64±12 years; 35% male) of patients with CVD (heart failure n=155 myocardial infarction n=32, cardiopulmonary arrest n=15, arrhythmia n=8, and others n=59) were enrolled in the study. Overall, 14.1% of the bereaved caregivers had complicated grief (BGQ≥8), 32.3% had subthreshold complicated grief (BGQ=5–7), and 13.3% had depression (PHQ-9≥10). Bereaved caregivers with complicated grief frequently developed depression (58% vs. 6%, p<0.001). Among the bereaved caregivers with complicated grief, the assessment of end-of-life care was worse (CES score: 28 [21–40] vs. 23 [19–39], p=0.04), and the assessment of the deceased patients' quality of death tended to be worse (GDI score: 4.0 [3.0–4.8] vs. 4.3 [3.7–4.9], p=0.05). The cause of admission as well as preferences of the patient and family (e.g., treatment [focusing on extending life vs. relieving discomfort], desire for information, place of end-of-life) were not associated with the prevalence of complicated grief. The prevalence of complicated grief was associated with loss of a spouse, poor psychological health during the deceased patients' admission, and poor preparation for the patient's imminent death (all p<0.05). Bereaved caregivers with complicated grief had experienced more decisional burdens regarding the deceased patients' treatment (55% vs. 25%, p=0.001). Notably, 64% of bereaved caregivers with complicated grief were not treated (i.e., neither routine follow-up by psychiatrists/psychotherapist nor prescription for anti-depressants/tranquilizers).

Conclusions

The prevalence of complicated grief of bereavement was 14.0%. When subthreshold complicated grief was included, the prevalence of complicated grief increased to include half of the caregivers; therefore, routine screening of the bereaved could be recommended. Clinicians should pay particular attention to bereaved families with high risk factors to identify those at risk for future development of complicated grief.

P5411Prognostic communication with hospitalized heart failure patients; the patients' perspective

Background

Informing heart failure (HF) patients about their prognosis is an important part of clinical management, particularly at the time of hospitalization. Current European Society of Cardiology guidelines recommend communicating this information to HF patients at the time of hospitalization and with any change in clinical status. However, little is known about actual patient preferences, understanding, and attitudes towards prognostic communication with their treating physicians.

Methods

We surveyed 113 consecutive hospitalized HF patients in a single university hospital. We assessed patient understanding of prognosis (likelihood of survival beyond 2 years), and compared patient expectations to model predictions. Model-predicted 2-year survival rate was calculated by the Seattle Heart Failure Model (SHFM). We also assessed patient preferences for information disclosure using the Prognosis and Treatment Perception Questionnaire (PTPQ). The PTPQ assesses patient beliefs regarding 1) the importance of knowing about prognosis, 2) the importance of knowing about treatment option, and 3) frequency of having a conversation about prognosis during the hospital stay.

Results

Enrolled patients were predominantly male (65.5%), with a mean age of 73.6±9.6 years and mean left ventricular ejection fraction was 46.2±15.4%. Median SHFM-estimated 2-year survival rate was 89.2% (interquartile range: 83.8–92.9%). Overall, patient understanding about prognosis was suboptimal. Among patients with a guarded 2-year survival (SHFM <90%: N=60), 44% reported that their likelihood of 2-year survival was >90% (Figure; red box). However, among patients with favorable 2-year survival (>90%: N=53), 38% reported a likelihood of <90% (Figure; blue box). Regarding treatment options, most patients (98%) desired to learn as many details as possible. Responses varied with regard to information on individual prognosis; whereas 51% wanted to know more about prognosis than their present status alone, a significant number (28%) of subjects answered “never” or “less often” to a query on the frequency of discussion about prognosis. Patient preference for more information about prognosis was associated with female sex (odds ratio [OR]: 2.52; 95% confidence interval [CI]: 1.12–5.69), fewer symptoms of depression (1-point increase on Patient Health Questionnaire-2, OR: 0.66; 95% CI: 0.49–0.87), and previous stroke (OR: 2.92; 95% CI: 1.04–8.19), but not other social/demographic or clinical factors (e.g., age, education, caregiver support, HF phenotype and severity, and other comorbid conditions).

Figure 1

Conclusions

There were substantial discrepancies in patient understanding of prognosis and in desire for more information from physicians. Interventions to improve prognostic understanding are warranted for HF patients, and hospitalization for HF could represent an opportunity for optimization.

Intravenous lipid emulsion therapy for acute clomipramine intoxication in rats

Aim

In this study, to assess the utility of lipid emulsion (ILE) therapy as a treatment option for overdoses of lipophilic drugs, we examined the detoxification effect of ILE therapy in rats that were administered overdoses of the tricyclic antidepressant clomipramine hydrochloride (CMI).

Methods

Female Wistar rats were orally administered 50 mg/kg CMI five times in 2‐h intervals to examine whether intralipos accelerated the elimination of CMI in the peripheral blood. Rats were divided into the intralipos (i.v. 2 g/kg intralipos) and placebo (i.v. saline) groups. The concentrations of CMI and desmethylclomipramine (DMCMI), a metabolite of CMI, in blood were measured over time by high‐performance liquid chromatography. We then gave the animals 100 mg/kg CMI orally to examine whether intralipos could inhibit the distribution of CMI. The CMI and DMCMI concentrations in peripheral blood, liver, and brain were measured 60 min after intralipos administration.

Results

The blood concentration of CMI was significantly higher in the intralipos group than in the placebo group at 60 and 120 min. After a single administration of 100 mg/kg CMI, the ratio of the concentration of CMI in liver/serum was significantly lower in the intralipos group than in the placebo group. We also found a significantly faster elimination rate for CMI in peripheral blood in the intralipos group than in the placebo group.

Conclusion

The distribution of CMI from blood to tissue was suppressed by intralipos. Therefore, ILE therapy is a promising candidate for the treatment of overdoses of lipophilic drugs.

Intrachoroidal Dye Leakage in Indocyanine Green Fundus Angiography after Experimental Commotio Retinae

Dye leakage in sodium fluorescein (FLUO) fundus angiography indicates damage to the blood-retinal barrier. However, dye leakage in indocyanine green (ICG) fundus angiography does not mean the same, because of the larger molecular size of the dye and impermeability of the choroidal vessels to it. The possibility of dye leakage in ICG angiography has not yet been revealed in an experimental study in which the blood-retinal barrier is undamaged. We report here that intrachoroidal dye leakage may occur in ICG angiography in an experimental model of the traumatic retinal opacity of the rabbit eye, even when the blood-retinal barrier is undamaged. This mechanism of dye leakage in ICG angiography is quite different from the leakage of FLUO angiography. Pathological choroidal vessels with increased permeability, such as choroidal neovascularization under the retinal pigment epithelium, can be observed using ICG angiography.

Computer Assisted Image Analysis Using the Subtraction Method in Indocyanine Green Angiography

The choroidal vessels are three dimensionally distributed and very complex in their patterns. They often appear to be overlaid in indocyanine green (ICG) angiograms so it is harder to analyze ICG angiography than fluorescein angiography. When an earlier frame is subtracted from a later frame in a sequence of angiograms, the fluorescence which has increased during the time between the two frames can theoretically be demonstrated.

We applied computer-assisted image subtraction methods in selected clinical cases of directly acquired digital ICG angiography to demonstrate how this method works. We used software already installed in an IMAGEnet computer system (Topcon) for image subtraction. We applied the subtraction technique in 18 cases with various diseases. When two images with a time difference of several seconds were subtracted, filling of the choriocapillaris, the neovascularization or the pathological vessels could be observed. When the images had a time difference of several minutes, intrachoroidal dye leakage could be seen more clearly. This method is very helpful for analyzing pathological changes in ICG angiography in clinical cases, when two images are selected appropriately.

Consideration of Preventing Local Venous Pain by Dacarbazine

Local venous pain caused by dacarbazine (DTIC) injection is due to its photodegradation product 5-diazoimidazole-4-carboxamide (Diazo-IC). The production of Diazo-IC can be decreased by protecting the drug from light. Furthermore, the production of Diazo-IC reportedly increases with time; however, there are no studies reporting the association between the injection preparation time and local venous pain caused by the DTIC injection. We evaluated the efficacy of the following: (1) method used to shorten the injection preparation time and (2) method used to change the diluting solution for DTIC. We found that shortening the injection preparation time tended to decrease the local venous pain expression due to DTIC, and Veen F decreased the production of Diazo-IC compared with the normal saline and 5% glucose solution. These results indicate that shortening the injection preparation time may be effective in preventing the local venous pain caused by the DTIC injection; moreover, using Veen F for DTIC may also reduce the pain.

Digital hardware implementation of a stochastic two-dimensional neuron model

This study explores the feasibility of stochastic neuron simulation in digital systems (FPGA), which realizes an implementation of a two-dimensional neuron model. The stochasticity is added by a source of current noise in the silicon neuron using an Ornstein-Uhlenbeck process. This approach uses digital computation to emulate individual neuron behavior using fixed point arithmetic operation. The neuron model's computations are performed in arithmetic pipelines. It was designed in VHDL language and simulated prior to mapping in the FPGA. The experimental results confirmed the validity of the developed stochastic FPGA implementation, which makes the implementation of the silicon neuron more biologically plausible for future hybrid experiments.

Combination treatment with fingolimod and a pathogenic antigen prevents relapse of glucose-6-phosphate isomerase peptide-induced arthritis

INTRODUCTION

Combination treatment with fingolimod (FTY720) plus pathogenic antigen is thought to prevent glucose-6-phosphate isomerase (GPI)325-339-induced arthritis progression by effective induction of immune tolerance. Here, we examined the efficacy of this combination treatment on remission maintenance.

METHODS

GPI325-339-induced arthritis mice were treated for 5 days with FTY720 (1.0 mg/kg, p.o.) alone, GPI325-339 (10 μg/mouse, i.v.) alone, or with the FTY720 plus GPI325-339 combination. In some experiments, mice were resensitized with GPI325-339.

RESULTS

Following resensitization with GPI325-339, combination-treated mice exhibited neither severe relapse nor elevated lymphocyte infiltration in joints. Neither anti-human nor mouse GPI325-339 antibody levels were correlated with clinical symptoms. This suggests that combination treatment prevents relapse following resensitization via regulation of pathogenic antigen-specific T cells. The proportion of regulatory T (Treg) cells in inguinal lymph nodes was increased post treatment in the FTY720 alone and FTY720 plus GPI325-339 groups. In contrast, the proportion of glucocorticoid-induced tumor necrosis factor receptor-family-related gene/protein (GITR)(+) non-Treg cells was increased only in combination-treated mice. Furthermore, GITR(+) non-Treg cells, which were induced by the combination treatment in vivo, possess suppressive activity and high ability to produce interleukin (IL)-10.

CONCLUSION

GITR(+) non-Treg cells might play a key role in relapse prevention following resensitization. Thus, this combination treatment might establish immune tolerance by induction of GITR(+) non-Treg cells.

Gene amplification-associated overexpression of the RNA editing enzyme ADAR1 enhances human lung tumorigenesis

The introduction of new therapies against particular genetic mutations in non-small-cell lung cancer is a promising avenue for improving patient survival, but the target population is small. There is a need to discover new potential actionable genetic lesions, to which end, non-conventional cancer pathways, such as RNA editing, are worth exploring. Herein we show that the adenosine-to-inosine editing enzyme ADAR1 undergoes gene amplification in non-small cancer cell lines and primary tumors in association with higher levels of the corresponding mRNA and protein. From a growth and invasion standpoint, the depletion of ADAR1 expression in amplified cells reduces their tumorigenic potential in cell culture and mouse models, whereas its overexpression has the opposite effects. From a functional perspective, ADAR1 overexpression enhances the editing frequencies of target transcripts such as NEIL1 and miR-381. In the clinical setting, patients with early-stage lung cancer, but harboring ADAR1 gene amplification, have poor outcomes. Overall, our results indicate a role for ADAR1 as a lung cancer oncogene undergoing gene amplification-associated activation that affects downstream RNA editing patterns and patient prognosis.

Abnormal neutrophil scattergram obtained using Pentra MS CRP in the patients with myelodysplastic syndrome showing dysgranulopoiesis

INTRODUCTION

Pentra MS CRP is an automated hematology analyzer capable of cytochemistry using Chlorazol black E, a lipid-staining agent, for white blood cell (WBC) differentials. Pentra MS CRP displays a WBC scattergram according to the cell volume obtained using flow impedance and light absorbance reflecting the Chlorazol black E (CBE)-positive lipid content.

METHOD

Neutrophil scattergrams obtained using Pentra MS CRP were compared between 5 patients with myelodysplastic syndrome (MDS) and normal controls. Sudan black B (SBB)-staining patterns of peripheral blood neutrophils were subdivided into four types (types I, II, III, and VI) based on their staining intensity and scored by counting 200 cells. Such SBB scores were also compared between the two groups.

RESULTS

Neutrophil scattergrams deviated downward in the MDS group, suggesting the decreased CBE positivity that seemed reflect the reduction of the lipid content in dysplastic neutrophils. SBB scores determined in this study were also decreased in the MDS group when compared with those in normal controls.

CONCLUSION

Pentra MS CRP might rapidly generate useful information on dysplastic neutrophils in patients with MDS based on its cytochemistry for WBC differentials during routine laboratory hematology.

Functional Mechanism(s) of the Inhibition of Disease Progression by Combination Treatment with Fingolimod Plus Pathogenic Antigen in a Glucose-6-phosphate Isomerase Peptide-Induced Arthritis Mouse Model

We previously reported that combination treatment with fingolimod (FTY720) plus antigenic peptide of glucose-6-phosphate isomerase (residues 325-339) (GPI325-339) from the onset of symptoms significantly inhibited disease progression in a mouse model of GPI325-339-induced arthritis. In this study, we investigated the mechanism(s) involved. The model mice were treated from arthritis onset with FTY720 alone, GPI325-339 alone, or the combination of FTY720 plus GPI325-339. At the end of treatment, inguinal lymph nodes (LNs) were excised and examined histologically and in flow cytometry. Levels of apoptotic cells, programmed death-1-expressing CD4(+)forkhead box P3(-) nonregulatory T cells (non-Tregs), and cytotoxic T-lymphocyte antigen 4-expressing non-Tregs in inguinal LNs were markedly increased in the combination treatment group mice. Regulatory T cells (Tregs) were also increased. These results indicate that combination treatment with FTY720 plus GPI325-339 inhibits the progression of arthritis by inducing clonal deletion and anergy of pathogenic T cells and also by immune suppression via Tregs.

[Studies Using Text Mining on the Differences in Learning Effects between the KJ and World Café Method as Learning Strategies]

The KJ method (named for developer Jiro Kawakita; also known as affinity diagramming) is widely used in participatory learning as a means to collect and organize information. In addition, the World Café (WC) has recently become popular. However, differences in the information obtained using each method have not been studied comprehensively. To determine the appropriate information selection criteria, we analyzed differences in the information generated by the WC and KJ methods. Two groups engaged in sessions to collect and organize information using either the WC or KJ method and small group discussions were held to create "proposals to improve first-year education". Both groups answered two pre- and post- session questionnaires that asked for free descriptions. Key words were extracted from the results of the two questionnaires and categorized using text mining. In the responses to questionnaire 1, which was directly related to the session theme, a significant increase in the number of key words was observed in the WC group (p=0.0050, Fisher's exact test). However, there was no significant increase in the number of key words in the responses to questionnaire 2, which was not directly related to the session theme (p=0.8347, Fisher's exact test). In the KJ method, participants extracted the most notable issues and progressed to a detailed discussion, whereas in the WC method, various information and problems were spread among the participants. The choice between the WC and KJ method should be made to reflect the educational objective and desired direction of discussion.

[Concept extraction of graduate research by modified grounded theory approach and creating of rubric oriented to performance evaluation]

  A revised core curriculum model for pharmaceutical education, developed on the basis of the principles of outcome-based education, will be introduced in 2015. Inevitably, appropriate assessments of students' academic achievements will be required. Although evaluations of the cognitive domain can be carried out by paper tests, evaluation methods for the attitude domain and problem-solving abilities need to be established. From the viewpoint of quality assurance for graduates, pharmaceutical education reforms have become vital to evaluation as well as learning strategies. To evaluate student academic achievements on problem-solving abilities, authentic assessment is required. Authentic assessment is the evaluation that mimics the context tried in work and life. Specifically, direct evaluation of performances, demonstration or the learners' own work with integrated variety knowledge and skills, is required. To clarify the process of graduate research, we obtained qualitative data through focus group interviews with six teachers and analyzed the data using the modified grounded theory approach. Based on the results, we clarify the performance students should show in graduate research and create a rubric for evaluation of performance in graduate research.

[A self-improvement and participatory career development education program involving internships and volunteer training experience for pharmacy students: results verified in a follow-up survey three years after participation]

The Faculty of Pharmaceutical Sciences, Setsunan University, offers the Self-improvement and Participatory Career Development Education Program: Internship and Volunteer Training Experience for Pharmacy Students to third-year students. We previously reported that the training experience was effective in cultivating important attributes among students, such as a willingness to learn the aims of pharmacists, an awareness of their own role as healthcare workers, and a desire to reflect on their future careers and lives. A follow-up survey of the participants was carried out three years after the training experience. The questionnaire verified that the training experience affected attendance at subsequent lectures and course determination after graduation. We confirmed the relationship between the participants' degree of satisfaction with the training experience and increased motivation for attending subsequent lectures. Through the training experience, participants discovered future targets and subjects of study. In addition, they became more interested in subsequent classroom lessons and their future. The greater the participants' degree of satisfaction with their training experience, the more interest they took in practical training and future courses. The present study clarified that the training experience was effective in cultivating important attributes such as a willingness to learn and an interest in future courses. Moreover, the training positively affected the course determination after graduation.