Rare Case of Paraneoplastic Pemphigus Associated With Prostatic Cancer

ABSTRACT

The combination of paraneoplastic pemphigus and prostate cancer is extremely unusual and has not been reported yet. Paraneoplastic pemphigus is caused by tumor-induced autoantibodies, which cause damage to the skin and mucosa. The essential treatment is active tumor control. Our patient received a robot-assisted radical prostatectomy and glucocorticoid therapy to improve his condition and relieve his skin lesions.

[Analysis of experience in diagnosis and treatment of fetal goiter in patients with Graves' disease complicated with pregnancy]

This article reported the clinical diagnosis and treatment experience of two cases of fetal goiter in Graves' disease (GD) complicated with pregnancy. Two GD patients took antithyroid drugs regularly during pregnancy and their thyroid functions were well controlled, but the levels of thyrotropin receptor antibody (TRAb) of the two cases were still above the upper limit in the second and third trimester. Two fetuses had fetal goiter in the middle and late stages of pregnancy. After continuously controlling maternal thyroid function and closely monitoring fetal ultrasound, there was no aggravation of the fetal goiter, and the delivery went smoothly. One case had neonatal hyperthyroidism. It is suggested that although the thyroid function was well controlled during pregnancy in patients with GD, the high level of serum TRAb still needs to be alert to the occurrence of fetal goiter, and fetal ultrasound is the most direct non-invasive monitoring method.

[The efficacy and safety of daratumumab in relapsed and refractory multiple myeloma]

Objective: To investigate the efficacy and safety of daratumumab in relapsed and refractory multiple myeloma (RRMM). Methods: The efficacy and adverse events (AEs) of daratumumab based regimens were retrospectively analyzed in 37 patients with RRMM from Peking University People's Hospital, Beijing Hospital and Fu Xing Hospital affiliated to Capital Medical University in China. The deadline for inclusion was December, 2019. Results: Among the 37 patients, 35 patients were available for response evaluation. The overall response rate (ORR) was 68.6%, which was better in patients receiving 16 mg/kg daratumumab than in those with fixed doses of 800 mg daratumumab [ORR: 78.3%(18/23) vs. 40.0%(4/10)]. The percentage of infusion related reactions of daratumumab was 27.0%(10/37). The most common hematological AEs were lymphocytopenia and thrombocytopenia, with the incidences of grade 3 or more severe 59.5%(22/37) and 43.2%(16/37) respectively. Pulmonary infections(37.8%, 14/37) were the most common non-hematological AEs. One patient with positive hepatitis B surface antigen (HBsAg) and two patients dependent on dialysis were safely treated with daratumumab. Conclusion: Daratumumab is highly effective in relapsed and refractory multiple myeloma. Adverse reactions are mild and well tolerable.

[A clinical analysis of micafungin treatment of pulmonary invasive fungal infection in pediatric patients with acute leukemia or post hematopoietic stem cells transplantation]

Objective: To investigate the efficacy and safety of micafungin (MCF) for pulmonary invasive fungal disease (PIFD) in pediatric patients with acute leukemia or post hematopoietic stem cells transplantation. Method: Twenty-five neutropenic PIFD children with acute leukemia or post hematopoietic stem cells transplantation in Sun Yat-sen Memorial Hospital of Sun Yat-sen University were selected from January 2012 to June 2015, including 12 males and 13 females, age range 2-15 (average 6.2±2.0) years. There were 12 cases of acute leukemia (AL) after chemotherapy, 4 cases of acute leukemia (AL) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) and 9 cases of β-thalassemia major after allo-HSCT. All children received MCM for the treatment of PIFD, the dosage of MCM was 3-4 mg/ (kg·d) , once a day. The children received 2 to 6 courses of treatment, individually with a course of 7 days. 1, 3-β-D glucan assay (G test), galactomannan antigen test (GM test), high-resolution CT and the biochemical indexes for organ functions were closely monitored. Result: Twenty-five cases were diagnosed as PIFD, including 2 patients diagnosed as proven, 6 as probable and 17 as possible. Of the 25 cases, 1 was confirmed aspergillus by biopsy pathology and 1 was candida albicans by blood culture. The G and GM test with positive results was 5 and 2 respectively. Chest CT scans of the 25 cases had obvious lesions: air crescent sign and cavitation in 4 cases, diffuse ground glass change in 9 cases, double lung scattered patchy, small nodules and cord like high density shadow in 7 cases, unilateral or bilateral chest wall wedge-shaped consolidation edge in 5 cases and pleural effusion in 5 patients. The effective rate of MCF in treatment of PIFD was 68% (17/25), including 13 cases cured, 4 cases improved, 4 cases were improved clinically and in 4 cases the treatment was ineffective. Eight cases were effective in MCF monotherapy group (12 cases) and nine were effective in MCF combined therapy group(13 cases), respectively. Side-effects including allergies, gastrointestinal side effects, electrolyte disturbances, impairment of liver and kidney function, and myelosuppression were not found in those children treated with MCF. Conclusion: Micafungin is effective and safe in the treatment of pulmonary invasive fungal disease in pediatric patients with acute leukemia or post hematopoietic stem cell transplantation.

Surface expression of anti-CD3scfv stimulates locoregional immunotherapy against hepatocellular carcinoma depending on the E1A-engineered human umbilical cord mesenchymal stem cells

Tumor antigens is at the core of cancer immunotherapy, however, the ideal antigen selection is difficult especially in poorly immunogenic tumors. In this study, we designed a strategy to modify hepatocellular carcinoma (HCC) cells by surface expressing anti-CD3scfv within the tumor site strictly, which depended on the E1A-engineered human umbilical cord mesenchymal stem cells (HUMSC.E1A) delivery system. Subsequently, membrane-bound anti-CD3scfv actived the lymphocytes which lysed HCC cells bypassing the expression of antigens or MHC restriction. First, we constructed the anti-CD3scfv gene driven by human α-fetoprotein (AFP) promoter into an adenoviral vector and the E1A gene into the lentiviral vector. Our results showed that anti-CD3scfv could specifically express on the surface of HCC cells and activate the lymphocytes to kill target cells effectively in vitro. HUMSC infected by AdCD3scfv followed by LentiR.E1A could support the adenoviral replication and packaging in vitro 36 h after LentiR.E1A infection. Using a subcutaneous HepG2 xenograft model, we confirmed that AdCD3scfv and LentiR.E1A co-transfected HUMSC could migrate selectively to the tumor site and produce considerable adenoviruses. The new generated AdCD3scfv infected and modified tumor cells successfully. Mice injected with the MSC.E1A.AdCD3scfv and lymphocytes significantly inhibited the tumor growth compared with control groups. Furthermore, 5-fluorouracil (5-FU) could sensitize adenovirus infection at low MOI resulting in improved lymphocytes cytotoxicity in vitro and in vivo. In summary, this study provides a promising strategy for solid tumor immunotherapy.

[Study of mumps immunity after administrating measles-mumps-rubella vaccine among children aged 2-7 years old in Jiangsu Province in 2015]

Objective: To investigate the immunity to mumps after administrating measles-mumps-rubella vaccine (MMR) among children aged 2-7 years old in Jiangsu province in 2015. Methods: A total of 4 190 healthy children aged 2-7 years old, living in local places for at least 3 months, and having been vaccinated at least 1 dose MMR were recruited to the study from Wujin district of Changzhou city, Gaogang district of Taizhou city and Ganyu district of Lianyungang city by using stratified cluster random sampling method between September and November, 2015. Those who did not accept MMR vaccination, who refused venous blood collection, who had affected mumps according to the memory of parents or teachers and who were diagnosed serious disease by clinical doctors were excluded from study. The self-designed questionnaire was used to collect the general information of the subjects and their MMR immunization history; and 0.5-2.0 ml of venous blood was collected from each subject. ELISA was used to detect the mumps antibody level in the serum of patients. Positive was defined as the antibody level ≥108 mU/ml, and negative as <108 mU/ml. χ(2) test was used to compare the difference in positive rates among subjects; and analysis of variance was used to compare the GMC changes in different time points after MMR vaccination. Results: Among 4 190 children, 2 280 were males (54.42%) and 1 910 were females(45.58%), and the positive rate of IgG antibody was 81.38% (3 344). There were 3 156 (95.18%) children vaccinated with one dose MMR, 187 (4.80%) children with two dose MMR, and 1 (0.02%) child with three dose MMR. The difference in positive rate of IgG antibody among different aged subjects showed statistical significance (χ(2)=58.61, P<0.001), the highest positive rate was in group of subjects aged 4-5 years old, at 89.43% (406/454), while the lowest positive rate was found among subjects aged 6-7 years old, at 75.63% (1 648/2 179). The positive rate after one dose of MMR vaccination was 79.14% (3 156/3 988), significantly less than it after two doses (93.03%, 187/201) (χ(2)=22.93, P<0.001). The GMC level at years<1, 1-<2, 2-<3, 3-<4, ≥4 following one dose MMR in the 3 988 children was 152.47, 227.78, 167.08, 126.91, 79.43 mU/ml, whose difference was statistically significant (F=51.29, P<0.001). Conclusion: The sero-prevalence of IgG antibody in the children aged 2-7 years old in Jiangsu province was high. The positive rate among who received two doses MMR was significantly higher than it among who received just one dose, and the GMC level waned with times.

[Molecular epidemiologic study on Mycobacterium tuberculosis from drug resistance monitoring sites of Guangdong Province, 2015]

Objective: To understand the characteristics of Mycobacterium tuberculosis (MTB) in epidemiology and distribution from Guangdong Province, and to explore the risk factors associated with drug resistance. Methods: A total of 225 clinical strains of MTB collected from 5 drug resistance monitoring sites of Guangdong Province in 2015 were tested by Regions of Difference 105 (RD105) deletion test and 15 loci mycobacterial interspersed repetitive units (MIRU) were used for genotyping. Gene clustering was analyzed using BioNumerics7.6. Drug susceptibility test was tested by proportion method. The statistical analysis used chi-square test and multivariate logistic regression. Results: There were 158 (70.2%) Beijing family strains from the 225 cases. Hunter-gaston index of MIRU loci varied from each other. The MTBs from Guangdong Province were categorized into 2 gene clusters by clustering analysis in which the rate of cluster of complexⅠwas significantly higher than complexⅡ(χ(2) values were 9.331, P values were 0.020). It was found by multivariate logistic regression that Qub11b was associated with resistance to rifampicin and isoniazid (P values were 0.013, 0.012 respectively.), ETR F with resistance to isoniazid, streptomycin, ethambutol and ofloxacin (P values were 0.039, 0.040, 0.023 and 0.003 respectively), Mtub21 with resistance to capreomycin (P values were 0.040), and QUB26 with resistance to ethionamide (P values were 0.047). Conclusions: The genes of MTB from Guangdong Province were of polymorphisms and the distribution of strains were stable. QUB11b, ETR F, Mtub21 and QUB26 could be related to biomarkers for predicting drug resistance.

Dural sinus thrombosis owing to polycythaemia vera in a 12-year-old girl

Because of the rarity of dural sinus thrombosis in children with polycythaemia vera (PV), the options for diagnosis and treatment remain elusive. A 12-year-old girl was admitted with dural sinus thrombosis associated with PV, diagnosed by magnetic resonance venography. She was managed with interventional endovascular thrombolectomy and venoplasty, phlebotomy, hydroxyurea, low molecular weight heparin, and aspirin followed by warfarin. She made a good recovery without residual neurological deficit. This case highlights the importance of diagnosis and appropriate intervention with multi-modality treatments in patients with PV and thrombosis.

Developments of scanning probe microscopy with stress/strain fields

An innovative stress/strain fields scanning probe microscopy in ultra high vacuum (UHV) environments is developed for the first time. This system includes scanning tunneling microscope (STM) and noncontact atomic force microscope (NC-AFM). Two piezo-resistive AFM cantilever probes and STM probes used in this system can move freely in XYZ directions. The nonoptical frequency shift detection of the AFM probe makes the system compact enough to be set in the UHV chambers. The samples can be bent by an anvil driven by a step motor to induce stress and strain on their surface. With a direct current (dc) power source, the sample can be observed at room and high temperatures. A long focus microscope and a monitor are used to observe the samples and the operation of STM and AFM. Silicon(111) surface in room temperature and silicon(001) surface in high temperature with stress were investigated to check the performance of the scanning probe microscope.

Preparation of new 5-fluorouracil-loaded zein nanoparticles for liver targeting

This study proposes a new zein nanoparticle (ZP) encapsulated 5-fluorouracil (5-FU) that target liver through intravenous delivery. The ZPs were prepared by phase separation process and optimized using uniform experimental design. The physical properties, in vitro drug release and stability of optimal drug-loaded ZPs were studied. The biodistribution and the target efficiency of the particles were investigated in a mouse model. The highest drug loading was obtained using zein: 5-FU, 3:1 (v/v); zein concentration, 12.5mg/ml, pH 9.18, mixing time, 3h and ethanol concentration, 40%. The encapsulation efficiency and the drug loading were 60.7 ± 1.74 and 9.17 ± 0.11 respectively. The size of ZPs and zeta potential were 114.9 ± 59.4 nm and -45 ± 0.3 mV respectively. Differential scanning calorimetry (DSC) demonstrated that the drug was encapsulated within the ZPs. A sustained release profile of 5-FU was observed from ZPs. The more stable storage condition of ZPs was at a temperature of 4 °C. In vivo, ZPs was mostly accumulated in liver following intravenous injection, and the targeting efficiency increased 31.33%. The relative uptake rate of liver was 2.79. Also, nano-sized ZPs were beneficial for prolonged blood residence (7.2-fold increase). These demonstrated that the drug-loaded ZPs could be efficiently targeted at the liver by intravenous delivery.

A role of cell apoptosis in lipopolysaccharide (LPS)-induced nonlethal liver injury in D-galactosamine (D-GalN)-sensitized rats

Lipopolysaccharide (LPS) is implicated in the pathology of acute liver injury and can induce lethal liver failure when simultaneously administered with D-galactosamine (D-GalN). At the present time, nonlethal liver failure, the liver injury of clinical implication, is incompletely understood following challenge by low-dose LPS/D-GalN. We report here our investigation of the effects of liver injury following a nonlethal dose LPS/D-GalN and the role of apoptosis in this disorder. Blood biochemistry indexes, including those of alanine aminotransferase (ALT), aspartate aminotransferase (AST) and total bilirubin (TBIL), had risen by 6 h post-LPS/D-GalN injection, reached a peak at 24 h and sustained high levels at 48 h. An abnormal liver appearance was found at 24 and 48 h post-injection. Histopathological changes of hepatic injuries accompanied by hepatocellular death, inflammatory infiltration and hemorrhage began to appear at 6 h and were markedly aggravated at 24 and 48 h. Cell apoptosis was significantly induced by the nonlethal dose LPS/D-GalN challenge, and the apoptotic indexes (AIs) in 24 h- and 48 h-treated rats were approximately 70%, as estimated by the terminal transferase dUTP nick end labeling (TUNEL) assay. The mRNA levels of the inflammatory cytokine IL-1beta rose markedly at 6 h and maintained high levels at 24 and 48 h; however, TNF-alpha levels were normal in the liver tissues of 6-, 24- and 48-h-treated rats. mRNA expression of the damage gene nitric oxide synthase (NOS) was also induced early by the LPS/D-GalN challenge, reaching a peak at 6 h, then gradually decreasing in a stepwise manner; conversely, high expression levels of the apoptosis-inducing gene p53 mRNA were not found in the early post-injection period (6 h) but emerged in the crest-time of liver apoptosis (24 h) and were maintained at this level until the late stage (48 h). We also observed that in 24 h-treated rats, caspase-3, -8, -9 and -12 were markedly activated by LPS/D-GalN challenge. These results suggest that a challenge with low-dose LPS in conjunction with D-GalN can induce nonlethal but marked liver failure, the main morphological feature of which is hepatic apoptosis, which may be associated with a high expression of inducible (i)NOS (early post-injection period) and p53 genes (in the mid and late stages) and at least three apoptosis pathways participate in the pathogenesis.

[Construction of a recombinant Pim3-expressing plasmid and expression and activity thereof: experiment with rats]

OBJECTIVE

To construct a plasmid expressing green fluorescent protein (GFP) and gene of Pim-3, a member of the serine/threonine kinase family, and to investigate the in vivo expression of the construct and its effect on cell apoptosis.

METHODS

Pim-3 gene was cloned from myocardium tissues of Wistar rat by RT-PCR and subcloned into GFP-expressing plasmid vector pEGFP-N2 by restriction enzyme. The recombinant plasmid pEGFP-N2/Pim-3 was constructed by T4-ligase and then identified through enzyme digestion and gene sequencing. Thirty-two Wistar rats were randomly divided into 4 equal groups: Group A, as control group; Group B, injected intravenously with Ringer's solution; Group C, injected with blank vector, and Group D, injected with the recombinant plasmid pEGFP-N2/Pim-3. One day later, endotoxin/D-galactoamine (D-GalN) was intraperitoneally injected. 24 hours later the rats were killed. Fluorescence microscopy was used to observe the expression of the reporter gene GFP in the liver tissues. RT-PCR was used to detect the Pim-3 mRNA expression. The hepatic apoptosis was detected by TUNEL assay. The activity of caspase-3 was detected.

RESULTS

A 998 bp target cDNA fragment with restriction enzyme sites was amplified and inserted into the multiple clone site of pEGFP-N2 successfully. High expression levels of the target gene Pim-3 and reporter gene GFP were achieved in the rat liver after transfer of the recombinant plasmid. The relative Pim-3 expression level of Group D was 0.49 +/- 0.15, significantly higher than those of Groups A, B, and C (0.06 +/- 0.02, 0, and 0 respectively, all P < 0.01). The apoptotic index of Group D was (4.9 +/- 1.2)%, significantly lower than those of Groups B and C [(72.5 +/- 6.1)% and (69.8 +/- 5.7)% respectively, both P < 0.01]; however, not significantly different from that of Group A [(3.1 +/- 0.7)%]. The activity of caspase-3 of Group D was (76 +/- 27) pmol.min(-1).mg(-1), significantly lower than those of Groups B and C [(147 +/- 55) and (142 +/- 50) pmol.min(-1).mg(-1), respectively, both P < 0.01]; however, not significantly different from that of Group A (60 +/- 15).

CONCLUSION

The recombinant plasmid pEGFP-N2/Pim-3 can achieve high expression in living cells and have an inhibitory effect on hepatic apoptosis.

[Cloning and expression of the extracellular domain of 4-1BBL]

RT-PCR was used to clone DNA fragment of the extracellular domain of 4-1BBL from human THP-1 cells (human monocyte), and the expression vector pAYZ4-1BBL was constructed by cloning the extracellular domain of 4-1BBL into the expression vector pAYZ. The extracellular domain of 4-1BBL was expressed in E. coli 16C9 and purified by affinity chromatography. SDS-PAGE and Western blot analysis showed that the relativae molecular weight of soluble 4-1BBL is 22kD which was consistent with the theoretically predicted value. So far as we know, it is the first time that the soluble expression of 4-1BBL in E. coli was achieved 4-1BBL induced a significant release of IL-2 in stimulated Jurkat cells after 48h incubation, especially in the presence of tumor cell. At the same time the apoptosis level of Jurkat cell reduce more than 50%. In conclusion, 4-1BBL may be useful in cancer immunotherapy.

Diffusion of a freely water-soluble drug in aqueous enteric-coated pellets

The effects of filler used in the pellet cores (ie, waxy cornstarch or lactose) and the enteric film coat thickness on the diffusion and dissolution of a freely soluble drug were studied. Two kinds of pellet cores containing riboflavin sodium phosphate as a model drug, microcrystalline cellulose (MCC) as a basic filler, and waxy cornstarch or lactose as a cofiller were film coated (theoretically weight increase 20% or 30%) with an aqueous dispersion of cellulose acetate phthalate (CAP). The diffusion of riboflavin sodium phosphate in aqueous enteric-coated pellets was investigated using noninvasive confocal laser scanning microscopy (CLSM). The in vitro release tests were performed using a USP apparatus I (basket method). Diffusion of drug from the core to the film coat was found to be greater with lactose-containing pellets than with waxy cornstarch-containing pellets. The dissolution test showed that 30% enteric-coated waxy cornstarch pellets had a good acidic resistance in 0.1 N HCl solution for at least 1 hour, while the other enteric pellet formulations failed the test. The waxy cornstarch-containing enteric pellets dissolved at SIF in less than 10 minutes. Confocal images of film-coated pellets showed that waxy cornstarch-containing pellets had less drug dissolved than respective lactose-containing pellets. The observations were further confirmed by measurement of fluorescence intensity of riboflavin sodium phosphate in the film coat. The dissolution test was consistent with the confocal microscopy results. In conclusion, waxy cornstarch as a cofiller in the pellet cores minimizes premature drug diffusion from the core into the film coat layer.

Amylopectin as a subcoating material improves the acidic resistance of enteric-coated pellets containing a freely soluble drug

The effect of an aqueous amylopectin subcoating on the acidic resistance and dissolution behaviour of enteric-coated pellets was studied. Freely water-soluble riboflavin sodium phosphate (RSP) was used as a model drug, and microcrystalline cellulose (MCC) and lactose as fillers in the pellet cores. The pellets were subcoated with 5% aqueous amylopectin solution or with 5% hydroxypropyl methylcellulose (HPMC) solution, and subsequently film-coated with aqueous dispersion of cellulose acetate phthalate (CAP). Drug release of enteric-coated pellets was investigated by confocal laser scanning microscopy (CLSM). Dissolution tests showed that amylopectin subcoating improved the acidic resistance of the enteric-coated pellets in 0.1 N hydrochloric acid (HCl) compared with HPMC subcoating. As the amylopectin subcoating load was increased to 4% and the aqueous CAP coating load to 35%, the coated pellets resisted in 0.1 N HCl solution for approximately 1 h (the amount of drug released was below 10%), and they dissolved in the SIF without enzymes in less than 10 min. Confocal microscopy images and profiles of mean fluorescence intensities of RSP (obtained in the range of the interface of the pellet core and the film and the film coating surface) showed consistent results with dissolution tests. It seems that amylopectin subcoating can prevent the influx of the dissolution medium into the pellet core, and thus decrease the premature dissolution and release of the drug from the enteric-coated pellets in 0.1 N HCl solution. The drug release mechanism appeared to be osmotically driven release, and followed by diffusion through the polymer film.

Molecular dynamics study of the behavior of a single long chain polyethylene on a solid surface

A molecular dynamics simulation has been used in exploring the behavior of a single long chain polyethylene (PE) on a solid surface. We have established how varying the intermolecular (polymer-surface) van der Waals (vdW) interaction force effects the structural and dynamic properties of the polymer chain. For a high intermolecular vdW force, the starting PE chain absorbs on to solid surface, and develops into a stretched monolayerlike structure. However, for a low intermolecular vdW force, segments in the PE chain avoid the surface and fold into a compact lamellalike structure. However, for a moderate intermolecular vdW force, the PE chain forms into a polylayerlike structure where stems align parallel to the surface. Unlike the short chain molecules, the overall conformations developed by the long chain PE possess a degree of intramolecular (intrachain) order. In addition to these, we have systematically analyzed the changes in components of the square of the radius of gyration parallel and orthogonal to the surface, as well as the intermolecular and intramolecular vdW energy of the PE chain when it transforms to monolayerlike, lamellalike, and polylayerlike configurations. Results show that the structural change is in phase with the variation of parallel and orthogonal components of the square of the radius of gyration, and has a corresponding relation with the intermolecular and intramolecular vdW energy. The intermolecular vdW force drags the PE chain lying on the surface and stretching into a loose monolayer. The intramolecular vdW force, rather than any of the other intramolecular interactions, drives the PE chain folding into a compact, ordered lamella.

Characterization of particle deformation during compression measured by confocal laser scanning microscopy

Direct compression of riboflavin sodium phosphate tablets was studied by confocal laser scanning microscopy (CLSM). The technique is non-invasive and generates three-dimensional (3D) images. Tablets of 1% riboflavin sodium phosphate with two grades of microcrystalline cellulose (MCC) were individually compressed at compression forces of 1.0 and 26.8 kN. The behaviour and deformation of drug particles on the upper and lower surfaces of the tablets were studied under compression forces. Even at the lower compression force, distinct recrystallized areas in the riboflavin sodium phosphate particles were observed in both Avicel PH-101 and Avicel PH-102 tablets. At the higher compression force, the recrystallization of riboflavin sodium phosphate was more extensive on the upper surface of the Avicel PH-102 tablet than the Avicel PH-101 tablet. The plastic deformation properties of both MCC grades reduced the fragmentation of riboflavin sodium phosphate particles. When compressed with MCC, riboflavin sodium phosphate behaved as a plastic material. The riboflavin sodium phosphate particles were more tightly bound on the upper surface of the tablet than on the lower surface, and this could also be clearly distinguished by CLSM. Drug deformation could not be visualized by other techniques. Confocal laser scanning microscopy provides valuable information on the internal mechanisms of direct compression of tablets.