Risk Factors for Non-Adherence to Pharmacist or Non-Pharmacist Explanations on Preoperative Medication Discontinuation: A Retrospective Japanese Study

Purpose

The risk factors for non-adherence to pharmacist or non-pharmacist explanations of preoperative medication discontinuation are unknown. The primary outcome of this study was to determine whether the final explainer's occupation was a risk factor for non-adherence. The secondary outcomes were to determine the risk factors for non-adherence after limiting the departments or adjusting for age.

Patients and Methods

We retrospectively examined the data (including patient age, sex, prescription medications, comorbidities, presence of roommate, and number of days between receiving explanation and surgery) of 1132 patients on medications that could affect surgery at a Japanese university hospital between April 1, 2017, and March 31, 2020. The primary endpoint was whether the occupation of the last person explaining medication discontinuation to the patient was an independent risk factor for non-adherence (age ≥65 years vs <65 years). Secondary endpoints included subgroup analyses in urological, gastrointestinal, and otolaryngological areas, as well as a sensitivity analysis (age as a continuous variable) to confirm the validity of the primary endpoint results. A multivariate binary logistic regression identified independent non-adherence risk factors.

Results

The main analysis showed that discontinuing two or more medications was a risk factor for non-adherence (adjusted odds ratio (AOR): 1.67; 95% confidence interval (CI): 1.13-2.47; p = 0.01). However, in analyses coordinated by department (urological, gastrointestinal, and otolaryngological), ≥65 (versus <65) years of age was determined as a risk factor for increased nonadherence (AOR: 2.27, 95% CI: 1.11-4.63; p=0.024). Age-adjusted analysis (continuous variables) showed similar results to the primary endpoint (AOR: 1.68, 95% CI: 1.14-2.49, p = 0.009).

Conclusion

Two or more medications, and not the final explainer's occupation, were associated with pre-surgery medication non-adherence. To prevent non-adherence, pharmacists and non-pharmacists should educate patients about preoperative medication discontinuation. These findings could help identify high-risk non-adherence patients.

Risk Factors for Non-Adherence to Medications That Affect Surgery: A Retrospective Study in Japan

PURPOSE

Data on risk factors for non-adherence to doctors' and pharmacists' instructions to discontinue medications prior to surgery are lacking. This study aimed to identify characteristics and risk factors for such non-adherent patients.

PATIENTS AND METHODS

Data (including patient age, sex, prescription medications, comorbidities, presence of roommate at home, and number of days between receiving instruction and surgery) of 887 patients who used medications affecting surgery at a university hospital from April 2017 to March 2020 were retrospectively evaluated. The primary endpoint was to investigate the rate of non-adherence and to explore independent risk factors for non-adherence (with age categorized as ≥65 [versus <65] years). Secondary endpoints included analysis of limited number of departments subgroup and a sensitivity analysis (with age categorized as ≥75 [versus <75] years) to confirm the robustness of the primary endpoint results. Independent risk factors for non-adherence were identified using logistic regression analysis.

RESULTS

The non-adherence rate was 11.4% (n=101/887), median age (interquartile range) at admission was 73 (70-79) years, and proportion of male patients was 81.2% (n=82). The main analysis adjusted for age ≥65 (versus <65) years showed age as a risk factor for increased non-adherence (adjusted odds ratio: 2.1, 95% confidence interval: 1.09-4.05; p=0.027). However, analyses adjusted for departments (other than urology, gynecology, and breast surgery, with a large sex bias in hospitalized patients) and for age ≥75 (versus <75) years showed no such risk.

CONCLUSION

Age ≥65 years was associated with a higher risk of non-adherence to medications that should be discontinued before surgery. It is important for doctors and pharmacists to ensure that patients at high risk for non-adherence are aware of the importance of adherence. Our findings may help identify patients at high risk for non-adherence to such medications.

A fatal case of severe methemoglobinemia presumably due to chlorate ingestion

A fatal case due to severe methemoglobinemia is presented. A male in his forties was found unconscious in his house and, despite intensive care, death was confirmed approximately 11 hours later. Toxicological analysis using ion chromatography revealed the presence of chlorate in the stomach contents. However, chlorate was not detected in the blood, and no other drugs or ethanol were detected in the blood either. We concluded that the cause of death was presumably due to chlorate poisoning, based on the results of the autopsy and the toxicological examination.

Alcohol and aldehyde dehydrogenase polymorphisms and risk for suicide: a preliminary observation in the Japanese male population

Epidemiological studies have shown that excessive alcohol consumption is a potent risk factor to develop suicidal behavior. Genetic factors for suicidal behavior have been observed in family, twin, and adoption studies. Because alcohol dehydrogenase (ADH1B) His47Arg and mitochondrial aldehyde dehydrogenase (ALDH2) Glu487Lys single nucleotide polymorphisms (SNPs), which affect alcohol metabolism, have been reported to exert significant impacts on alcohol consumption and on the risk for alcoholism in East Asia populations, we explored associations of the two functional SNPs with suicide using a case-control study of 283 completed suicides and 319 control subjects in the Japanese population. We found that the inactive ALDH2 allele (487Lys) was significantly less frequent in the completed suicides (19.3%) than in the controls (29.3%), especially in males, whereas this was not the case in females. The males bearing alcoholism-susceptible homozygotes at both loci (inactive ADH1B Arg/Arg and active ALDH2 Glu/Glu genotypes) have a 10 times greater risk for suicide compared with the males bearing alcoholism-protective homozygotes at both loci. Our data show the genetic impact of the two polymorphisms on suicidal behavior in the Japanese population, especially in males. Because we did not verify the daily alcohol consumption, the association of these SNPs with suicide might be due to alcoholism itself. Further studies using case-control subjects, which verifies the details of current and past alcohol consumption and diagnosis for alcoholism, are required to confirm these findings.

Dosage adjustment of quinolone antibiotics and angiotensin-converting enzyme inhibitors in patients with renal dysfunction

The aim of this study was to verify an approach for calculating pharmacokinetic parameters suitable for adjusting dosage regimens in patients with renal dysfunction. We carried out a retrospective analysis of the pharmacokinetic profiles of 12 new quinolone antibiotics and 11 angiotensin-converting enzyme inhibitors (ACEIs) in patients with normal and impaired renal function to obtain the renal excretion ratio (R(renal)) of each drug. We demonstrated that the pharmacokinetics of each drug in a patient with renal dysfunction can be adequately estimated using the R(renaI) value of each drug together with the creatinine clearance as an index of the individual's renal function. Using the R(renaI) value obtained, we could successfully simulate pharmacokinetic profiles of the drugs in publications other than that used to obtain the R(renal) values. On the other hand, age-related changes in the pharmacokinetics of new quinolone antibiotics are not always adequately predicted using the R(renal) value compared to using creatinine clearance alone as an index, and the reasons for this are not fully understood. These results demonstrate that dosage regimens of quinolone antibiotics and ACEIs in patients with renal dysfunction can be adequately optimized using the R(renal) value for each drug using the present approach.

Development of a novel systemic gene delivery system for cancer therapy with a tumor-specific cleavable PEG-lipid

For successful cancer gene therapy via intravenous (i.v.) administration, it is essential to optimize the stability of carriers in the systemic circulation and the cellular association after the accumulation of the carrier in tumor tissue. However, a dilemma exists regarding the use of poly(ethylene glycol) (PEG), which is useful for conferring stability in the systemic circulation, but is undesirable for the cellular uptake and the following processes. We report the development of a PEG-peptide-lipid ternary conjugate (PEG-Peptide-DOPE conjugate (PPD)). In this strategy, the PEG is removed from the carriers via cleavage by a matrix metalloproteinase (MMP), which is specifically expressed in tumor tissues. An in vitro study revealed that the PPD-modified gene carrier (Multifunctional Envelope-type Nano Device: MEND) exhibited pDNA expression activity that was dependent on the MMP expression level in the host cells. In vivo studies further revealed that the PPD was potent in stabilizing MEND in the systemic circulation and facilitating tumor accumulation. Moreover, the i.v. administration of PPD or PEG/PPD dually-modified MEND resulted in the stimulation of pDNA expression in tumor tissue, as compared with a conventional PEG-modified MEND. Thus, MEND modified with PPD is a promising device, which has the potential to make in vivo cancer gene therapy achievable.

Primary care in the treatment of functional gastrointestinal symptoms in Japan: prescription preferences and impression of results

BACKGROUND

Functional gastrointestinal (GI) disorders are common in primary care. However, proper pharmacological approaches have not yet been established. The reason for a lack of proper approaches may be attributable to the lack in clarity of their pathogenesis and pathophysiology. Meta-analysis of pharmacological approaches to functional GI disorders failed to identify the solid cluster of patients' symptoms.

AIM

The aim of this study is to assess the perspective of primary care doctors concerning prescriptions for functional GI symptoms, evaluate the efficacy of the drugs prescribed, and the need for medication for these symptoms.

METHOD

Questionnaires were sent to primary care doctors, and a total of 149 responses were obtained. Efficacy of each medication was evaluated by the number of doctors favouring the category, and the respective impressions of prescriptions given.

RESULTS

Symptoms of heartburn were well controlled by anti-secretory drugs (H2RAs and PPIs), while appetite loss and abdominal gurgling were not controlled by any medications.

CONCLUSIONS

This survey reveals differences in need for various prescription drugs in functional GI symptoms.

Ligand-installed PEGylated bionanosphere

The synthesis of poly(ethylene glycol)-b-poly(2-N,N-dimethylaminoethylmethacrylate) processing an acetal group at the PEG chain end (acetal-PEGPAMA) is reported. The obtained acetal-PEGPAMA block copolymer was found to reduce tetrachloroauric acid at room temperature to produce gold nanoparticles. The size of these nanoparticles was controllable in the range of 6 to 13 nm by changing the initial Au3+: polymer ratio. In addition to the reduction of tetrachloroauric acid, acetal-PEGPAMA bonds on the surface of the obtained gold nanoparticles to improve their dispersion stability in an aqueous medium even at a salt concentration as high as two. Biotinyl-PEGPAMA-anchored gold nanoparticles undergo specific aggregation in the presence of streptavidin thereby revealing their promising utility as colloidal sensing systems for use in biological systems. Biotin-PEGPAMA can also be utilised for the preparation of a functionally PEGylated quantum dot (QD). When CdCl2 and Na2S were mixed in aqueous media in the presence of the biotin-PEGPAMA, a CdS QD with an approximately 5 nm size was prepared. The polyamine segment was anchored onto the surface of the formed CdS nanoparticle, whereas the PEG segment was tethered onto the surface to form a hydrophilic palisade, thus improving the dispersion stability in aqueous media even under a high salt concentration condition. An effective fluorescent resonance energy transfer (FRET) was observed by the specific interaction of the biotin-PEGPAMA stabilised CdS QD with TexasRed-labelled streptavidin with the physiological ionic strength of 0.15 M. The extent of the energy transfer was in proportion to the concentration of the TexasRed-streptavidin. This FRET system using the PEGylated CdS QD coupled with fluorescent-labelled protein can be utilised as a highly sensitive bioanalytical system.

Sugar-installed block copolymer micelles: their preparation and specific interaction with lectin molecules

Several types of sugar-installed poly(ethylene glycol)/poly(DL-lactide) (sugar-PEG/PLA) block copolymers were synthesized. The synthesized block copolymer forms a core-shell type polymeric micelle in aqueous media possessing sugar molecules on its surface. Specific recognition of lectin proteins with the sugar molecules on the micelle surface was observed. Both the galactose- and lactose-installed micelles specifically interacted with RCA-1; on the other hand the mannose-installed micelle interacted specifically with Con A. With a lectin-immobilized affinity column, the cluster effect of the sugar molecule on the micelle surface was clearly observed.

Surface characterization of functionalized polylactide through the coating with heterobifunctional poly(ethylene glycol)/polylactide block copolymers

An AB-type block copolymer composed of alpha-acetalpoly(ethylene glycol) (PEG) as the hydrophilic segment and polylactide (PLA) as the hydrophobic segment was synthesized and utilized to construct a functionalized PEG layer possessing a reactive aldehyde group at the free end of the tethered PEG chain by simple coating on polylactide substrates. Detailed characterization of the functionalized PEGylated surfaces was done from the physicochemical (contact angle and zeta potential) as well as the biological (protein adsorption) point of view to highlight their potential utility as biofunctional interfaces. The amount of protein adsorption was inversely correlated with the degree of water structuring around the PEG molecules, which facilitates the formation of a strongly bound water film to increase the surface hydration. For these surfaces investigated, the extent of surface hydration was more important in determining the materials biocompatibility rather than the actual PEG molecular weight, as evidenced by an extremely low receding contact angle directly related to the adhesive energy of a water molecule. Furthermore, the contact angle relaxation less than a few minutes proved to be determinant for the receding contact angle and resultant hysteresis, caused by rearrangement of the hydrophilic PEG component. Aldehyde groups were confirmed to be present at the tethered PEG chain end using an electron spin resonance probe and can be derivatized with bioactive molecules with amino or hydrazide functionality. The functionalized PEG layer thus prepared on a biodegradable polylactide surface has both nonfouling and ligand-binding properties and may have promising utility as engineered biomaterials including tissue engineering scaffolds.

Long-circulating poly(ethylene glycol)-poly(D,L-lactide) block copolymer micelles with modulated surface charge

Reactive polymeric micelles consisting of an alpha-acetal-poly(ethylene glycol)-poly(D,L-lactide) block copolymer (acetal-PEG-PDLLA) with a narrow size distribution were prepared in this study to conjugate small peptidyl ligands, tyrosine (Tyr) and tyrosyl-glutamic acid (Tyr-Glu), through reductive amination after converting the alpha-acetal group to an aldehyde group, allowing modulation of the surface charge of the micelles from neutral (Tyr-) to anionic (Tyr-Glu-). Both of these micelles showed a significantly long circulating time in the blood compartment with 25% of injected dose still circulating even at 24 h. Further, an appreciably lowered uptake into the liver and spleen was demonstrated for the anionic Tyr-Glu-conjugated PEG-PDLLA micelle compared with a neutral Tyr-conjugated micelle, suggesting a substantial role of the slight anionic charge on the micelle surface in avoiding non-specific organ uptake. Stability of the micelle form in the blood compartment was directly observed for the Tyr-PEG-PDLLA micelle by a gel filtration assay of a plasma sample collected from the micelle-injected mice at 24 h. These results demonstrated that a surface-modulated PEG-PDLLA micelle with a suitable size and a narrowly distributed nature has promising potential as a long-circulating carrier system with desirable biocompatibility and biofunctionality.

A case of hemosuccus pancreaticus associated with hereditary pancreatitis

We report a 25-year-old male with hemosuccus pancreaticus associated with hereditary pancreatitis. He was originally diagnosed as having familial chronic pancreatitis at the age of 12, because his brother was also diagnosed as having pancreatitis. No history of pancreatitis was found in their parents. The patient was admitted because of a growing pancreatic pseudocyst. While he had undergone conservative treatment for the pseudocyst, computed tomography incidentally revealed a pancreatic pseudoaneurysm. Endoscopic examination revealed spontaneous bleeding from the major papilla. Interventional embolization was successfully performed. An R122H mutation in the cationic trypsinogen gene was identified in this patient, his brother, and his mother, indicating that they have hereditary pancreatitis. To our knowledge, this is the first report of hemosuccus pancreaticus associated with hereditary pancreatitis. Mutational screening is useful for the diagnosis of hereditary pancreatitis, especially in patients whose diagnosis is inconclusive based on the traditional clinical criteria.

Analysis of the human pancreatic secretory trypsin inhibitor (PSTI) gene mutations in Japanese patients with chronic pancreatitis

Chronic pancreatitis (CP) is a continuing or relapsing inflammatory disease of the pancreas. Several studies have demonstrated that mutations in the cationic trypsinogen (PRSS1) gene and the cystic fibrosis transmembrane conductance regulator (CFTR) gene are causative of the pathogenesis in a subset of hereditary and/or idiopathic CP cases. Recently, the N34S alteration of the pancreatic secretory trypsin inhibitor (PSTI) gene has been suggested to be closely associated with the pathogenesis of hereditary and/or idiopathic CP. Herein we analyzed genetic alterations of the PSTI gene in 32 unrelated Japanese CP patients who developed juvenile-onset CP or had a family history of CP; 5 patients were found to harbor alterations in this gene. In 3 of these 5 patients, heterozygous N34S alterations were found; this frequency is significantly lower than that in Caucasian patients reported previously. Moreover, a novel homozygous G-to-A transition in the promoter region of PSTI at 215bp upstream from the translation initiation site (-215G>A) was observed in 2 patients. We further surveyed the -215G>A alteration in 117 normal individuals; none of these individuals harbored this alteration. Our results suggested that the -215G>A alteration, as well as the N34S alteration, is a predisposing factor for CP.

Quantitative and reversible lectin-induced association of gold nanoparticles modified with alpha-lactosyl-omega-mercapto-poly(ethylene glycol)

Gold nanoparticles (1-10 nm size range) were prepared with an appreciably narrow size distribution by in situ reduction of HAuCl(4) in the presence of heterobifunctional poly(ethylene glycol) (PEG) derivatives containing both mercapto and acetal groups (alpha-acetal-omega-mercapto-PEG). The alpha-acetal-PEG layers formed on gold nanoparticles impart appreciable stability to the nanoparticles in aqueous solutions with elevated ionic strength and also in serum-containing medium. The PEG acetal terminal group was converted to aldehyde by gentle acid treatment, followed by the reaction with p-aminophenyl-beta-D- lactopyranoside (Lac) in the presence of (CH(3))(2)NHBH(3). Lac-conjugated gold nanoparticles exhibited selective aggregation when exposed to Recinus communis agglutinin (RCA(120)), a bivalent lectin specifically recognizing the beta-D-galactose residue, inducing significant changes in the absorption spectrum with concomitant visible color change from pinkish-red to purple. Aggregation of the Lac-functionalized gold nanoparticles by the RCA(120) lectin was reversible, recovering the original dispersed phase and color by addition of excess galactose. Further, the degree of aggregation was proportional to lectin concentration, allowing the system to be utilized to quantitate lectin concentration with nearly the same sensitivity as ELISA. This simple, yet highly effective, derivatization of gold nanoparticles with heterobifunctional PEG provides a convenient method to construct various colloidal sensor systems currently applied in bioassays and biorecognition.

Block copolymer micelles for drug delivery: design, characterization and biological significance

Recently, colloidal carrier systems have been receiving much attention in the field of drug targeting because of their high loading capacity for drugs as well as their unique disposition characteristics in the body. This paper highlights the utility of polymeric micelles formed through the multimolecular assembly of block copolymers as novel core-shell typed colloidal carriers for drug and gene targeting. The process of micellization in aqueous milieu is described in detail based on differences in the driving force of core segregation, including hydrophobic interaction, electrostatic interaction, metal complexation, and hydrogen bonding of constituent block copolymers. The segregated core embedded in the hydrophilic palisade is shown to function as a reservoir for genes, enzymes, and a variety of drugs with diverse characteristics. Functionalization of the outer surface of the polymeric micelle to modify its physicochemical and biological properties is reviewed from the standpoint of designing micellar carrier systems for receptor-mediated drug delivery. Further, the distribution of polymeric micelles is described to demonstrate their long-circulating characteristics and significant tumor accumulation, emphasizing their promising utility in tumor-targeting therapy. As an important perspective on carrier systems based on polymeric micelles, their feasibility as non-viral gene vectors is also summarized in this review article.

[11C]methionine positron emission tomography for the evaluation of pancreatic exocrine function in chronic pancreatitis

Positron emission tomography (PET) can be used for the quantitative analysis of amino acid metabolism. The aim of this study was to investigate whether pancreatic exocrine function can be evaluated by [11C]methionine PET in chronic pancreatitis (CP) patients. Dynamic PET scan of the pancreas and liver was performed in eight healthy subjects and seven patients with CP after intravenous (i.v.) injection of [11C]methionine. Simultaneously, duodenal juice was collected with the background of continuous i.v. administration of secretin (125 ng/kg/h). The radioactivity ratio of the pancreas to that of the liver (PLR) was calculated by regions of interest (ROI) analysis. Amylase output and bicarbonate concentration were measured in the duodenal aspirates. The PLR of CP patients was significantly lower than that of healthy subjects at all time points after methionine injection. The PLRs at 4.5 minutes (PLR4.5) after methionine injection were positively correlated with the amylase output, mean bicarbonate concentration, and volume of duodenal aspirates (R = 0.74, 0.69, 0.46). It is concluded that [11C]methionine PET would be a noninvasive method for the evaluation of exocrine pancreatic function, which may represent total amino acids uptake of viable acinar cells in the pancreas.

Selective synthesis of heterobifunctional poly(ethylene glycol) derivatives containing both mercapto and acetal terminals

A novel synthetic route to heterobifunctional poly(ethylene glycol) (PEG) derivatives containing both mercapto and acetal terminal groups was established in this study using anionic ring opening polymerization of ethylene oxide (EO) using potassium 3, 3-diethoxypropanolate (PDP) as the initiator, followed by the successive conversion of the end-alkoxide group to a methanesulfonic group, and then to an ethyldithiocarbonate moiety. Molecular functionalities of the acetal and the mercapto terminal groups of the heterotelechelic PEG (acetal-PEG-SH) thus prepared were confirmed to 1.00 and 0.85, respectively, indicating that the reaction proceeds almost quantitatively. The obtained acetal-PEG-SH products, including 2-pyridyldithio derivatives, have a promising utility for bioconjugation in the fields of medicine and biology.

Adenovirus-mediated in utero gene transfer in mice and guinea pigs: tissue distribution of recombinant adenovirus determined by quantitative TaqMan-polymerase chain reaction assay

Fetal somatic cell gene therapy could become an attractive solution for some congenital genetic diseases or the disorders which manifest themselves during the fetal period. We performed adenovirus-mediated gene transfer to mice and guinea pig fetuses in utero and evaluated the efficiency of gene transfer by histochemical analysis and a quantitative TaqMan-polymerase chain reaction (TaqMan-PCR) assay. We first injected a replication-deficient recombinant adenovirus containing the Escherichia coli LacZ gene driven by a CAG promoter (AxCALacZ) into pregnant mice through the amniotic space, placenta, or intraperitoneal space of the fetus. Histochemical analysis showed limited transgene expression in fetal tissues. We then administered AxCALacZ to guinea pig fetuses in the late stage of pregnancy through the umbilical vein. The highest beta-galactosidase expression was observed in liver followed by moderate expression in heart, spleen, and adrenal gland. The transgene expression was also present in kidney, intestine, and placenta to a lesser degree. No positively stained cells were observed in lung, muscle, or pancreas except in the vascular endothelium of these organs. Quantitative measurement of recombinant adenoviral DNA by the TaqMan-PCR assay showed that the vast majority of the injected viruses was present in liver. The current study indicated that adenovirus-mediated gene transfer into guinea pig fetus through the umbilical vein is feasible and results in efficient transgene expression in fetal tissues. The experimental procedures using pregnant guinea pigs might serve as a good experimental model for in utero gene transfer. Since our TaqMan-PCR assay detects the LacZ gene, one of the most widely used reporter genes, it may be generally applicable to adenovirus quantification in various gene transfer experiments.

Preparation and characterization of polymer micelles from poly(ethylene glycol)-poly(D,L-lactide) block copolymers as potential drug carrier

Poly(ethylene glycol)-poly(D,L-lactide) block copolymers (PEG-PLA) with varying composition were prepared through successive ring-opening polymerization of ethylene oxide and D,L-lactide using an anionic initiator, and their property of multimolecular micellization in aqueous milieu was examined in detail from the standpoint of designing carriers for hydrophobic drugs. The heterogeneity of PEG-PLA was found to crucially affect the size and distribution of micelles, and narrowly-distributed micelles with sizes of approximately 30 nm in diameter were formed only from PEG-PLA with a substantially narrow molecular weight distribution and an appropriate balance in the length ratio of the PEG and PLA segments in PEG-PLA, indicating the importance of establishing a reliable synthetic route for the block copolymers. PEG-PLA micelles have a considerably low critical association concentration (approximately 1.0 mg/l) which is apparently an advantage in utilizing these micelles as drug carriers in an extremely diluted condition.

Reversal of hypopigmentation in phenylketonuria mice by adenovirus-mediated gene transfer

Phenylketonuria (PKU) is caused by deficiency of phenylalanine hydroxylase (PAH) in the liver. Patients with PKU show increased L-phenylalanine in blood, which leads to mental retardation and hypopigmentation of skin and hair. As a step toward gene therapy for PKU, we constructed a replication-defective, E1/E3-deleted recombinant adenovirus harboring human PAH cDNA under the control of a potent CAG promoter. When a solution containing 1.2 x 10(9) plaque-forming units of the recombinant adenovirus was infused into tail veins of PKU model mice (Pah(enu2)), predominant expression of PAH activity was observed in the liver. The gene transfer normalized the serum phenylalanine level within 24 h. However, it also provoked a profound host immune response against the recombinant virus; as a consequence, the biochemical changes lasted for only 10 d and rechallenge with the virus failed to reduce the serum phenylalanine concentration. Administration of an immunosuppressant, FK506, to mice successfully blocked the host immune response, prolonged the duration of gene expression to more than 35 d, and allowed repeated gene delivery. We noted a change in coat pigmentation from grayish to black after gene delivery. The current study is the first to demonstrate the reversal of hypopigmentation, one of the major clinical phenotypes of PKU in mice as well as in humans, by adenovirus-mediated gene transfer, suggesting the feasibility of gene therapy for PKU.

Minimized platelet interaction with poly(2-hydroxyethyl methacrylate-block-4-bis(trimethylsilyl)methylstyrene) hydrogel showing anomalously high free water content

Novel hydrophilic-hydrophobic block copolymers - poly(2-hydroxyethyl methacrylate-block-4-bis(trimethylsilyl)methylstyrene) (poly(HEMA-block-BSMS) or BH polymer) - were prepared as materials potentially useful for blood-contacting devices. Among the BH(X) series including poly(HEMA) itself, platelet adhesion and activation are minimum on the surface of BH(10), the block copolymer composed of 10 mol% of the hydrophobic segment. The unique physicochemical characteristics of BH(10) such as the high free water content and the increased mobility of PHEMA segments seem to play an important role in the prevention of platelet adhesion and activation. The water content of BH(10) was twice that of poly(HEMA) itself, even in the presence of 10 mol% of the hydrophobic moiety [poly(BSMS)]. Further, an anomalous increase in free water content was observed for the BH(10) sample measured by DSC. The glass transition temperature of BH(10) in the dry state was determined to be c. 10 degrees C, which was much lower than that observed for each of the homopolymers (c.f.: Tg [poly(HEMA)] = 70 degrees C; Tg [poly(BSMS)] = 160 degrees C), suggesting an increased mobility of tethered PHEMA segments in the BH(10) film.

Synthesis of heterobifunctional poly(ethylene glycol) with a reducing monosaccharide residue at one end

A new synthetic method for a heterobifunctional poly(ethylene glycol) (PEG) having a monosaccharide moiety at one end was created. PEG with a reducing monosaccharide residue at the alpha-end, which is linked to a defined position of the sugar molecule, could be prepared via the anionic polymerization of ethylene oxide (EO) initiated with a potassium alkolate of a protected monosaccharide such as 1,2;5,6-di-O-isopropylidene-D-glucofuranose (DIGL), 1,2;3,4-di-O-isopropylidene-D-galactopyranose (DIGA), and 1,2-O-isopropylidene-3,5-O-benzylidene-D-glucofuranose (IBGL). The resulting PEGs possess the corresponding sugar molecule at the alpha-chain end and a hydroxyl group at the omega-chain end. The omega-chain end could be converted to several functional groups such as allyl, amino, and hydroxycarbonyl groups in high yield. Such heterobifunctional PEGs possessing a reducing monosaccharide residue at the alpha-end are one of the promising tools for bioconjugate chemistries.

Isolation and characterization of the human inter-alpha-trypsin inhibitor family heavy chain-related protein (IHRP) gene (ITIHL1)

Inter-alpha-trypsin inhibitor (ITI) family heavy chain-related protein (IHRP) is a novel human glycoprotein that shows significant homology in amino acid sequence to proteins of the ITI family heavy chains from human plasma. Three overlapping clones that encode the human inter-alpha-trypsin inhibitor family heavy chain-related protein (IHRP) gene (ITIHL1) were isolated and characterized. The IHRP gene spans 15 kb and is composed of 24 exons from 27 to 207 bp in size with consensus splice sites. The gene codes for the precursor of IHRP, which is similar to inter-alpha-trypsin inhibitor (ITI) family heavy chains. Two major transcription initiation sites were identified in the 5'-flanking region. They contain putative promoter elements, but no typical TATA box. Some exons of this gene showed significant similarities to those of the ITI-H1 gene in nucleotide length and in intron phasing. The tissue-specific transcription of this gene may be due to the presence of binding sites for the hepatocyte nuclear factors LF-A1, HNF-5, NF-IL6, and C/EBP. This gene was found to be localized very close to another unknown gene related to EST (GenBank accession #: R54643, R50663, R50563, H27139, and R54913).

The role of pituitary-adrenal counterregulation of inflammation in cerulein-induced pancreatitis: a comparison between Fischer and Lewis rats

The role of the hypothalamic-pituitary-adrenal axis (HPA axis) in acute pancreatitis has not yet been clarified. In the present study, the concentrations of serum corticosterone and amylase, the severity of pancreatic edema, and the histology of the pancreas during cerulein-induced pancreatitis were compared in two strains of rats whose HPA axes have been reported to be hyperresponsive (Fischer female) and hyporesponsive (Lewis female) to inflammatory mediators. First, we confirmed that the secretory response of corticosterone to lipopolysaccharide was remarkably blunted in Lewis rats compared with Fischer rats. With a single intraperitoneal injection of cerulein at a dose of 50 micrograms/kg, the serum corticosterone of Fischer rats increased promptly, and their serum levels were significantly higher than those of Lewis rats at all points after the induction of pancreatitis. The edema formation and infiltration of inflammatory cells into the pancreas were more severe in Lewis rats than in Fischer rats. The serum amylase concentration was not significantly different between the two strains, except at 2 h after the induction of pancreatitis. The in vitro study using dispersed pancreatic acini showed that there was no significant difference in cerulein-stimulated amylase secretion between the two strains. These findings suggest that the responsiveness of the HPA axis and the consequent secretion of glucocorticoids might modify the pathological features of acute pancreatitis.

Primary amino-terminal heterobifunctional poly(ethylene oxide). Facile synthesis of poly(ethylene oxide) with a primary amino group at one end and a hydroxyl group at the other end

Well-defined poly(ethylene oxide) (PEO) with a cyano group at one end and a hydroxyl group at the other terminus was synthesized by the anionic ring opening polymerization of ethylene oxide (EO) initiated with (cyanomethyl)potassium (CMP) which was prepared by the metalation reaction of acetonitrile with potassium naphthalene in THF. Primary amino-terminal heterotelechelic PEO was obtained by the reduction of the cyano group at the end of the polymer chain by lithium aluminum hydride.

Formyl-ended heterobifunctional poly(ethylene oxide): synthesis of poly(ethylene oxide) with a formyl group at one end and a hydroxyl group at the other end

Well-defined poly(ethylene oxide) (PEO) with a formyl group at one end and a hydroxyl group at the other terminus was synthesized by the anionic ring opening polymerization of ethylene oxide (EO) with a new organometallic initiator possessing an acetal moiety, potassium 3,3-diethoxypropyl alkoxide. Hydrolysis of the acetal moiety produced a formyl group-terminated heterobifunctional PEO with a hydroxyl group at the other end.

Heterobifunctional poly(ethylene oxide): synthesis of alpha-methoxy-omega-amino and alpha-hydroxy-omega-amino PEOs with the same molecular weights

Well-defined alpha-methoxy-omega-amino and a alpha-hydroxy-omega-amino poly(ethylene oxide)s (PEOs) were obtained after chemical modifications of alpha-hydroxy-omega-allyl PEO which was synthesized by anionic polymerization of ethylene oxide (EO) with allyl alcoholate as initiator; molecular weights of the prepolymer were controlled by the monomer/initiator ratio. Addition of methyl iodide on the hydroxy function of this prepolymer led to an alpha-methoxy-omega-allyl PEO; completion of the reaction and purity of the resulting polymer were demonstrated by 1H, 13C NMR and GPC studies. Addition reactions of 2-amino-ethanethiol hydrochloride on alpha-hydroxy-omega-allyl PEO and alpha-methoxy-omega-allyl PEO in the presence of azobisisobutyronitrile (AIBN) led to the expected homopolymers without any side reactions as shown by 1H and 13C NMR spectra.

Endoscopic ultrasonography using a 15/20 MHz probe in a direct contact technique: evaluation and application in esophageal and gastric varices

Endoscopic ultrasonography (EUS) has been recently developed as a new diagnostic technique for portal hypertension. However, its conventional water-filled balloon technique is not suitable for the evaluation of esophageal varices, because the vessel lumen is compressed by the inflated balloon. Particularly for small varices, the vessel tends to collapse and is difficult to display. A miniature ultrasonic probe for use via the forceps channel in EUS has been developed and is expected to overcome this difficulty. Here we report the efficacy of this new probe in patients with esophago-gastric varices. Instead of using a water-filled balloon for an acoustic window, we displayed the EUS findings from the new probe in direct contact with gastrointestinal wall by removing air from the lumen under vacuum. Both conventional endoscopy and the new EUS were performed on 3 patients with esophageal varices. The transforceps-channel ultrasonic probe visualized grade 1 varices in addition to the larger varices, confirming this technique to be a useful method for assessing of esophageal varices. Moreover, this method does not require a specially designed endoscope for EUS, rather it can be employed in combination with conventional endoscopy. We conclude that this new technique is a preferred diagnostic technique, and it should become more widely accepted for routine clinical applications.

[Laryngeal fractures due presumably to tracheal intubation in resuscitation]

In three autopsy cases performed in our department, we observed the throat-skeleton fractures occurring presumably during the tracheal intubation in resuscitation. Case 1. 63-year-old man died of acute hemorrhagic pancreatitis shortly after the quarrel with a suspected person. The autopsy examination showed the fractured hyoid bone with haemorrhage at the fracture site. The question whether direct pressure on his neck by the suspected person results the fracture of the hyoid bone was investigated. Case 2. 75-year-old man treated for senile dementia was clubbed with a walking stick by the other patient treated for same disease and he died of traumatic shock. The fracture of the hyoid bone was also noted like case 1. The strike in the throat and/or the neck compression by the assailant were suspected of being the cause of this fracture. Case 3. 47-year-old man got the severe head injury during the quarrel. He died about two weeks after operation and the cause of death was multiple organ failure. The autopsy findings revealed the fracture of the superior thyroid horn. The neck compression by the suspected person was the questionable cause of this fracture. In all these cases, the asphyxia findings and the signs of the direct pressure on the neck by the assailants were not recognized other than the above-mentioned laryngeal fractures. From the autopsy findings, together with the criminal investigation, we consider collectively that the tracheal intubation in resuscitation induced presumably these laryngeal injuries. In general, throat-skeleton fractures seem to be the signs of homicidal violence against the neck.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of fibrinolytic therapy by measuring cross-linked fibrin derivatives and plasmin-alpha 2-plasmin inhibitor complex in plasma

Plasma levels of alpha 2-plasmin inhibitor (alpha 2PI), plasmin-alpha 2PI complex and cross-linked fibrin derivatives (XDP) were measured in 8 patients (12 episodes) with thromboembolic disorders on the initial administration of urokinase. In conjunction with a decrease in plasma alpha 2PI activity and antigen, plasmin-alpha 2PI complex increased following urokinase infusion in all cases except one who received a low dose (60,000 units) of urokinase. However, changes in XDP were variable among the patients. Plasma XDP level increased markedly in one, moderately in 4, slightly in one, and remained unchanged in 6 cases (episodes). The increment of plasma XDP correlated (r = 0.804, p = 0.003) with the dose of urokinase administered, but was independent of changes in plasmin-alpha 2PI complex. The plasma XDP elevation was associated with clinical improvement. These results suggest that simultaneous measurements of XDP and plasmin-alpha 2PI complex in plasma would be valuable for the pharmacological or hemostatic assessment of thrombolytic therapy.

[A case of remission of metastatic gastric cancer lesions in the chest and abdominal wall by 5'-DFUR administration]

52-year-old female was weakened and bed-ridden by metastasis of gastric cancer to the chest and abdominal wall, and peritonitis carcinomatosa 2 years after gastrectomy. One week after administration of 5'-DFUR, 1200 mg/d, p.o., a clinical effect was seen. In 3 weeks metastatic lesions had diminished in size, ascites had decreased and the patient had regained her appetite and put on weight. She recovered sufficiently to be able to do some daily work. Pathological degeneration and necrosis of cancer cells were observed. Although she died 8 months after remission, 5'-DFUR was effective in improving her condition and prolonging her life.