Deprescribing Using the Guidelines for Medical Treatment and Its Safety in the Elderly and Changes in Patient QOL and Activities of Daily Living

Pharmacists applied deprescribing, which is a process for the rational use of drugs, for 13 at-home patients. The standard used for the rational use of drugs was the "Guidelines for Medical Treatment and Its Safety in the Elderly" (the Guidelines). The results of the deprescribing were discussed with physicians to determine prescriptions. After the prescription change, activities of daily living (ADL) and QOL were assessed using the Barthel Index and SF-36v2, respectively. Potentially inappropriate medications (PIMs) were detected in 10 of the 13 patients (76.9%). This detection rate is higher than previous PIM detection rates of 48.4% and 40.4% reported in prescriptions for home-care patients in Japan under the Beers and STOPP/START criteria. The Guidelines appeared useful as a decision support tool for deprescribing. The patients continuing the changed prescriptions showed no decrease in ADL or QOL after deprescribing, suggesting its rationality. The 10 measurement items of the Barthel Index were all suitable for evaluating the physical conditions of the patients. Meanwhile, SF-36v2 includes many items, but few indexes were directly applicable.

Late Onset of Acute Urticaria after Bee Stings

Here we report the cases of five patients with a late onset of acute urticaria after a bee sting. The ages of the five Japanese patients ranged from 33 to 86 years (median: 61). All patients had no history of an allergic reaction to bee stings. The onset of urticaria was 6–14 days (median: 10) after a bee sting. Although four of the patients did not describe experiencing a bee sting at their presentation, the subsequent examination detected anti-bee-specific IgE antibodies. So, we think a history of a bee sting should thus be part of the medical interview sheet for patients with acute urticaria, and an examination of IgE for bees may help prevent a severe bee-related anaphylactic reaction in the future.

EFFECTS OF PHOSPHORUS ADDITIONS ON LEAD AND MERCURIUM BIOAVAILABILITIES IN A CONTAMINATED SOIL

The soils enriched with elements potentially toxic (EPT) have limited use for agricultural purposes. In this case, the corresponding site should be isolated and then procedures for decontamination or stabilization of EPT in the soils must be applied. The objective of this study was to evaluate the influence of adding different rates of phosphate on the bioavailability of mercury (Hg) and lead (Pb) in a contaminated soil, using lettuce grown on this soil. For this, different phosphorus rates were used to control bioavailability of Hg and Pb, in lettuce plants. The element concentrations were analyzed by instrumental neutron activation analysis (INAA), and the results were compared to control treatment to verify the reduction of absorption of Hg and Pb. The Hg concentration in shoots decreased with the application of 250 mg kg-1 of P and Pb with the application of 250 to 1000 mg kg-1 of P. The accumulation of Hg and Pb in shoots of lettuce increased as a function of P demonstrating the inefficiency of application of P in the absorption of these elements.

Ablation of demineralized dentin using a mid-infrared tunable nanosecond pulsed laser at 6 μm wavelength range for selective excavation of carious dentin

In dental clinic, some lasers have already realized the optical drilling of dental hard tissue. However, conventional lasers lack the ability to discriminate and excavate carious tissue only, and still depend on the dentist's ability. The objective of this study is to develop a selective excavation of carious dentin by using the laser ablation with 6 μm wavelength range. Bovine dentin demineralized with lactic acid solution was used as a carious dentin model. A mid-infrared tunable pulsed laser was obtained by difference-frequency generation technique. The wavelength was tuned around the absorption bands called amide 1 and amide 2. In the wavelength range from 5.75 to 6.60 μm, the difference of ablation depth between demineralized and normal dentin was observed. The wavelength at 6.02 μm and the average power density of 15 W/cm(2), demineralized dentin was removed selectively with less-invasive effect on normal dentin. The wavelength at 6.42 μm required the increase of average power density, but also showed the possibility of selective ablation. In the near future, development of compact laser device will open the minimal invasive laser treatment to the dental clinic.

Clinical course of drug-induced hypersensitivity syndrome treated without systemic corticosteroids

BACKGROUND/AIM

Drug-induced hypersensitivity syndrome (DIHS) is a severe reaction to drugs which characteristically occurs after a long latency period. In addition, human herpes virus 6 (HHV-6) reactivation is a characteristic finding in DIHS, which has been known to be related to disease severity. Because DIHS has generally been treated by systemic corticosteroids, the natural clinical course is not clear.

METHODS

Data for patients with both DIHS and HHV-6 reactivation were retrospectively collected from four hospitals.

RESULTS

Data were collected on 12 patients ranging in age from 21 to 76 years (median, 65.5). All cases had been suspected of DIHS at their initial visit, and the elevation of serum anti-HHV-6 antibody had been confirmed (4-256 times: median; 32). The culprit drugs were carbamazepine (6), salazosulfapyridine (4), mexiletine (1) and zonisamide (1). The period of latency from the first administration of the drug ranged from 15 to 50 days (median, 30). All patients were treated conservatively for DIHS without systemic corticosteroids. The peaks of the patients' symptoms and laboratory findings were as follows (days from the onset of skin lesions): fever, 4-16 (median, 10.5); liver abnormality, 3-22 (median, 7.5); leukocytosis, 7-20 (median, 9). All patients recovered without pneumonia, myocarditis, nephritis or other systemic disease, from 7 to 37 days (median, 18) after withdrawal of the drug and from 11 to 44 days (median, 21) after the onset of skin lesions.

CONCLUSION

It might be unnecessary to give systemic corticosteroids immediately to all patients suspected of having DIHS.

[Vacuum-assisted closure therapy for the treatment of sternal wound infection after cardiac surgery]

Sternal wound infection is still one of the critical and challenging complications after cardiac surgery. Vacuum-assisted closure (VAC) therapy is a unique and simple system that helps promote wound healing. We report 3 cases with the sternal wound infection after cardiac surgery, in which VAC therapy was applied between January, 2005 and April, 2007. Two of them had good response to VAC therapy and had their wound healed after 3 and 5 weeks, respectively. However, the remaining case, in which bilateral internal thoracic artery had been taken down for coronary artery bypass grafting (CABG) and osteomyelitis of the sternum was not well controlled, did not respond to VAC therapy. Our results suggested that VAC might facilitate wound healing of the patients with sternal wound infection only after abscess was drained and opened, while it might not be useful for the patents with osteomyelitis.

Long‐term accumulation and microdistribution of uranium in the bone and marrow of beagle dog

The accumulation and microdistribution of uranium in the bone and marrow of Beagle dogs were determined by both neutron activation and neutron-fission analysis. The experiment started immediately after the weaning period, lasting till maturity. Two animal groups were fed daily with uranyl nitrate at concentrations of 20 and 100 microg g(-1) food. Of the two measuring techniques, uranium accumulated along the marrow as much as in the bone, contrary to the results obtained with single, acute doses. The role played by this finding for the evaluation of radiobiological long-term risks is discussed. It was demonstrated, by means of a biokinetical approach, that the long-term accumulation of uranium in bone and marrow could be described by a piling up of single dose daily incorporation.

Assessment of atmospheric metallic pollution in the metropolitan region of São Paulo, Brazil, employing Tillandsia usneoides L. as biomonitor

Tillandsia usneoides L. is an epiphytic bromeliad plant able to absorb water and nutrients directly from the air. For this reason this species was selected to carry out a monitoring study of air pollution in the metropolitan region of São Paulo, Brazil. Five consecutive transplantation experiments (8 weeks each) were performed in 10 sites of the city, submitted to different sources of air pollution (industrial, vehicular), using plants collected from an unpolluted area. After exposure, trace metals were analyzed in the plant by instrumental neutron activation analysis. Traffic-related elements such as Zn and Ba presented high concentrations in exposure sites near to heavy traffic avenues (cars, buses and trucks) and may be associated to vehicular sources. For Zn and Co the highest contents were related to industrial zones and can be associated to the presence of anthropogenic emission sources. The rare earth elements, Fe and Rb, probably have soil particles as main source.

Treatment of high-risk peripheral T-cell lymphomas other than anaplastic large-cell lymphoma with a dose-intensified CHOP regimen followed by high-dose chemotherapy. A single institution study

We investigated the efficacy of a dose-intensified double-CHOP regimen followed by high-dose chemotherapy with or without peripheral blood stem cell transplantation (PBSCT) in 11 patients with four types of peripheral T-cell lymphoma (PTCL). Three of the 4 patients with unspecified PTCL (PTCLu) achieved complete response (CR); 1 patient relapsed and 1 died of secondary leukemia after consolidation therapy. All angioimmunoblastic T-cell lymphoma (AILT) and subcutaneous panniculitis-like T-cell lymphoma (SPTCL) patients achieved CR; 5 of 6 have remained disease free for more than 3 years. The patient with hepatosplenic lymphoma did not achieve CR even after PBSCT and underwent allogenic bone marrow transplantation (allo-BMT). Thus, our regimen appears to be effective for high-risk AILT and SPTCL. However, allo-BMT should be considered for high-risk of PTCLu and hepatosplenic T-cell lymphoma.

Pioglitazone inhibits the growth of human leukemia cell lines and primary leukemia cells while sparing normal hematopoietic stem cells

Peroxisome proliferator-activated receptors (PPARs) compose a subfamily of nuclear hormone receptors functioning as transcriptional regulators. Originally, the PPARgamma ligand known as thiazolidinedione (TZD) was used for the treatment of diabetic patients. However, recent studies have shown that TZD also has an antitumor effect that inhibits cell growth in several types of human malignant neoplasms, including leukemia cell lines. Since pioglitazone is the only TZD currently available in clinics in Japan and the role of TZD in normal human hematopoietic cells or primary leukemia cells has not been previously reported, we investigated the effect of pioglitazone on human normal hematopoietic progenitor cells, primary leukemia cells, and leukemia cell lines (HL60, K562, U937, HEL, CEM, Jurkat, and NALM1). Pioglitazone inhibited the proliferation of leukemia cells in a dose-dependent manner. The viable cell numbers of HL60, K562, and Jurkat leukemia cell lines were profoundly reduced when the cells were cocultured with pioglitazone. Colony formation in the leukemia cell lines as well as the primary leukemia cells was significantly inhibited to 20-71% and 1-25% of that in control cultures by the addition of 100 and 300 microM of pioglitazone, respectively. However, the CFU-E and CFU-GM colonies of cells obtained from healthy volunteers were not altered in the presence of 100 microM of pioglitazone. Pioglitazone (300 microM) induced slight decrease of CFU-E and CFU-GM. BFU-E was more sensitive to pioglitazone than CFU-E and CFU-GM. Pioglitazone-induced growth inhibition in HL60 cells was associated with cell cycle arrest at the G1 phase, as has been reported for another TZD, troglitazone. Similar levels of PPARgamma protein were observed in both leukemia and normal bone marrow cells by Western blotting, suggesting that the expression of PPARgamma protein was not associated with the inhibitory potency of pioglitazone. In conclusion, our results suggest that pioglitazone may offer a new therapeutic approach to aid in the treatment of leukemia.

Varicose veins associated with CADASIL result from a novel mutation in the Notch3 gene

No genetically diagnosed cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) pedigrees with venous insufficiency have been described. In a CADASIL pedigree with varicose veins, the authors have identified a novel heterozygous mutation in the 3' splice acceptor site of intron 15 of the Notch3 gene. This, based on mRNA analysis, resulted in skipping of exon 16 including eight cysteine residues of EGF-like repeats.

WT1 expression level and clinical factors in multiple myeloma

Although Wilm's Tuomor gene (WT1) was first identified as a tumor suppressor gene for Wilm's tumor, WT1 overexpression has been detected in different malignant cell types including leukemia. Increased expression of WT1 in acute leukemia is potentially used as a marker of minimal residual disease. However, the significance of the gene for multiple myeloma is still not clear. To determine the clinical relevance of WT1 expression in multiple myeloma, we examined the association of clinical parameters and WT1 expression in bone marrow for 17 newly diagnosed multiple myeloma patients. WT1 was assessed by real-time quantitative polymerase chain reaction (RQ-PCR) and calculated standardized WT1 expression level per 100 plasma cells in the bone marrow specimen as "corrected WT1". The expression of standardized WT1 and corrected WT1 in myeloma was 59 to 1,600 copies/microg RNA and 0.05 to 406.3 copies/microg RNA/100 plasma cells, respectively, lower than in leukemia. WT1 transcripts increased when clinical factors worsen, including the stage, amount of M protein, Hb, platelet count, blood urea nitrogen (BUN), creatinine, serum alkaline phosphatase (ALP), calcium, beta2-microglobulin, thymidine kinase activity (TK), and C-reactive protein (CRP). In conclusion, the expression level of WT1 could be an additional marker to the standard parameters considered in risk assessment for multiple myeloma.

Characterization of trace elements in Casearia medicinal plant by neutron activation analysis

Leaves of Casearia sylvestris, Casearia decandra and Casearia obliqua plant species, collected at the Atlantic Forest in Brazil, were analyzed by using instrumental neutron activation analysis (INAA). Short and long irradiations using thermal neutron flux of the IEA-R1 nuclear reactor were carried out for these analyses. Concentrations of Ca, K and Mg were found in these samples at the percentage levels, Br, Cl, Fe, Mn, Na, Rb and Zn at the microg g(-1) levels and Co, Cr, Cs, La, and Sc at the microg kg(-1) levels. Comparisons were made among the element concentrations obtained in these three Casearia species and significant differences were found for the elements Cl, Co, Cs, Cr, La, Mn, Na and Sc. The precision and the accuracy of the results were evaluated by analyzing the certified reference materials NIST-1515 Apple Leaves and NIST-1573a Tomato Leaves.

Diesel emissions significantly influence composition and mutagenicity of ambient particles: a case study in São Paulo, Brazil

In 2003, a bus strike paralyzed the fleet of buses in Sao Paulo, Brazil during 3 days, from 6 to 8 of April, the complete interruption of services being achieved on the 7th. We evaluated the effect of the absence of this source of pollution on the composition, mutagenicity, and toxicity of the fine particulate material collected during this period. Particles were sampled in glass fiber filters on days 7 and 15 of April of 2003 (strike and nonstrike days, respectively), using a high-volume sampler. Trace element determinations (As, Br, Co, Cl, Fe, La, Mn, Sb, Sc, and Th) of particulate material samples were carried out by neutron activation analysis. Sulfur determination was done by X-ray fluorescence analysis. The ratio between nonstrike/strike concentrations of hydrocarbons associated with automotive emissions (benzene, toluene, ethyl-benzene, and xylenes; BTEX) was determined by gas chromatography/mass spectrometry. Mutagenesis of testing solutions was determined by means of the Tradescantia micronucleus assay in early tetrads of Tradescantia pallida. The inhibition of mitosis of the cells of the primary meristema of the root tips of Allium cepa was used as an index of the toxicity. Fine particle trace element contents were lower during the strike. The concentrations of sulfur and BTEX were 50% and 39.3% lower, respectively, on the strike day. A significant (P=0.038) reduction of micronuclei induced by fine particles sampled during the strike was observed. No effect of the strike on toxicity was detected. These results indicate that a program aiming to reduce emissions of the bus fleet in our town may impact positively the air quality by reducing the mutagenic potential of ambient particles.

Long-term accumulation of uranium in bones of Wistar rats as a function of intake dosages

Groups of Wistar rats were fed with ration doped with uranyl nitrate at concentration A ranging from 0.5 to 100 ppm, starting after the weaning period and lasting until the postpuberty period when the animals were sacrificed. Uranium in the ashes of bones was determined by neutron activation analysis. It was found that the uranium concentration in the bones, as a function of A, exhibits a change in its slope at approximately 20 ppm-a probable consequence of the malfunctioning of kidneys. The uranium transfer coefficient was obtained and an analytical expression was fitted into the data, thus allowing extrapolation down to low doses. Internal and localized doses were calculated. Absorbed doses exceeded the critical dose, even for the lowest uranium dosage.

[Multiple myeloma of the IgD-lambda type invading CNS]

A 52-year-old woman was admitted to the gynecological department of our hospital on July 29, 2002 because of a right lower abdominal mass. She has been suffering from pain in the right leg and inguinal area for a month before coming to the hospital. She was found to have pancytopenia and high serum levels of LDH and IgD. A bone marrow examination showed 63.8% of plasma cells and serum immunoelectrophoresis showed M-protein of the IgD-lambda type. She was diagnosed as having multiple myeloma and transferred to our department. VAD therapy was started from August 22. Although the plasma cells in the bone marrow almost disappeared, the right lower abdominal mass remained and a new mass appeared on the right frontal chest wall after two courses of the treatment. Combination chemotherapy with vincristine, ranimustine, melphalan, and dexamethasone (ROAD) was started on November 1. This was followed with thalidomide and radiation therapy of the right inguinal region was added. On December 16th, she suddenly experienced speech disturbance, nausea and the disturbance of consciousness. Examination of her cerebrospinal fluid showed 368/microl mononuclear cells with 93% plasma cells. The plasma cells disappeared after the 6th intrathecal injection with MTX and prednisolone and the chemotherapy was resumed. One month later, CNS relapse was apparent followed by generalized spread of the tumor mass, and she died on March 17, 2003.

Reversible hyperintensity lesion on diffusion-weighted MRI in hypoglycemic coma

In a woman aged 73 years who recovered from hypoglycemic coma without neurologic deficit after glucose infusion, admission diffusion-weighted MRI showed the presence of hyperintensive lesions. The lesions regressed after glucose infusion.

Acute pulmonary and hematological effects of two types of particle surrogates are influenced by their elemental composition

Several epidemiological studies have consistently demonstrated significant associations between ambient levels of particulate matter and lung injury and cardiovascular events with increased morbidity and mortality. Particle surrogates (PS), such as residual oil fly ash (ROFA), have been widely used in experimental studies aimed at characterizing the mechanisms of particle toxicity. Since PS composition varies depending on its source, studies with different types of PS may provide clues about the relative toxicity of the components generated by high-temperature combustion process. In this work, we have studied the effects of nasal instillation of increasing doses of different PS in mice: saline, carbon, and two types of particle surrogates. PS type A (PSA) was the ROFA collected from the waste incinerator of our university hospital; PS type B (PSB) was collected from the electrostatic precipitator of a large steel company and thus had an elevated metal content. After 24h, we analyzed hematological parameters, fibrinogen, bronchoalveolar lavage, bone marrow, and pulmonary histology. Nasal instillation of the two types of PS-induced leucopenia. PSB elicited a greater elevation of plasma fibrinogen levels. Bone marrow and pulmonary inflammatory changes were more intense for PSA. We concluded that the PS composition modulates acute inflammatory changes more significantly than the mass for these two types of PS.

A novel maxizyme vector targeting a bcr-abl fusion gene induced specific cell death in Philadelphia chromosome-positive acute lymphoblastic leukemia

Patients with Philadelphia chromosome-positive (Ph(+)) acute lymphoblastic leukemia (ALL) generally have a poor prognosis and would benefit from the development of new therapeutic approaches. We previously demonstrated that an allosterically controllable ribozyme, maxizyme (Mz), can induce apoptosis in chronic myelogenous leukemia (CML) cells. Ph(+) ALL cells harbor a bcrabl fusion gene (e1a2) encoding a 190-kDa fusion protein (p190) involved in disease pathogenesis. In this study, we have designed a Mz that specifically cleaves e1a2 mRNA and transduced this e1a2Mz into Ph(+) ALL cells using a third-generation lentiviral vector system. In 3 of 5 Ph(+) ALL cell lines, e1a2Mz transduction resulted in a significant decrease in viability and increased cell apoptosis. We observed a decrease in e1a2 mRNA in all Ph(+) ALL cells transduced with e1a2Mz, and the e1a2 mRNA level was higher in e1a2Mz-resistant cells than in e1a2Mz-sensitive cells. All samples of primary Ph(+) ALL cells tested showed e1a2Mz-induced growth inhibition and apoptosis. Importantly, e1a2Mz did not influence the colony formation of normal CD34(+) cord blood cells. These results indicate that e1a2Mz kills Ph(+) ALL cells specifically, suggesting that it may be used as a novel gene therapy strategy for Ph(+) ALL.