Low dose exposure to Bisphenol A alters development of gonadotropin-releasing hormone 3 neurons and larval locomotor behavior in Japanese Medaka

Accumulating evidence indicates that chronic low dose exposure to Bisphenol A (BPA), an endocrine disruptor, may disrupt normal brain development and behavior mediated by the gonadotropin-releasing hormone (GnRH) pathways. While it is known that GnRH neurons in the hypothalamus regulate reproductive physiology and behavior, functional roles of extra-hypothalamic GnRH neurons remain unclear. Furthermore, little is known whether BPA interacts with extra-hypothalamic GnRH3 neural systems in vulnerable developing brains. Here we examined the impact of low dose BPA exposure on the developing GnRH3 neural system, eye and brain growth, and locomotor activity in transgenic medaka embryos and larvae with GnRH3 neurons tagged with GFP. Fertilized eggs were collected daily and embryos/larvae were chronically exposed to 200ng/ml of BPA, starting at 1 day post fertilization (dpf). BPA significantly increased fluorescence intensity of the GnRH3-GFP neural population in the terminal nerve (TN) of the forebrain at 3dpf, but decreased the intensity at 5dpf, compared with controls. BPA advanced eye pigmentation without affecting eye and brain size development, and accelerated times to hatch. Following chronic BPA exposure, 20dpf larvae showed suppression of locomotion, both in distance covered and speed of movement (47% and 43% reduction, respectively). BPA-induced hypoactivity was accompanied by decreased cell body sizes of individual TN-GnRH3 neurons (14% smaller than those of controls), but not of non-GnRH3 neurons. These novel data demonstrate complex neurobehavioral effects of BPA on the development of extra-hypothalamic GnRH3 neurons in teleost fish.

Downregulation of microRNA-362-3p and microRNA-329 promotes tumor progression in human breast cancer

p130Cas regulates cancer progression by driving tyrosine receptor kinase signaling. Tight regulation of p130Cas expression is necessary for survival, apoptosis, and maintenance of cell motility in various cell types. Several studies revealed that transcriptional and post-translational control of p130Cas are important for maintenance of its expression and activity. To explore novel regulatory mechanisms of p130Cas expression, we studied the effect of microRNAs (miRs) on p130Cas expression in human breast cancer MCF7 cells. Here, we provide experimental evidence that miR-362-3p and miR-329 perform a tumor-suppressive function and their expression is downregulated in human breast cancer. miR-362-3p and miR-329 inhibited cellular proliferation, migration, and invasion, thereby suppressing tumor growth, by downregulating p130Cas. Ectopic expression of p130Cas attenuated the inhibitory effects of the two miRs on tumor progression. Relative expression levels of miR-362-3p/329 and p130Cas between normal and breast cancer correlated inversely; miR-362-3p/329 expression was decreased, whereas that of p130Cas increased in breast cancers. Furthermore, we showed that downregulation of miR-362-3p and miR-329 was caused by differential DNA methylation of miR genes. Enhanced DNA methylation (according to methylation-specific PCR) was responsible for downregulation of miR-362-3p and miR-329 in breast cancer. Taken together, these findings point to a novel role for miR-362-3p and miR-329 as tumor suppressors; the miR-362-3p/miR-329-p130Cas axis seemingly has a crucial role in breast cancer progression. Thus, modulation of miR-362-3p/miR-329 may be a novel therapeutic strategy against breast cancer.

The effect of the introduction of a nationwide DUR system where local DUR systems are operating--The Korean experience

OBJECTIVE

Outpatient clinics in Korea usually have local DUR (drug utilisation review) systems, which are integrated with EMRs or health insurance claims submission systems. Whenever, the government announces a list of drug contraindications, each local DUR system loads the list and applies it in practice. In December 2010, a nationwide DUR system was introduced. This study is to investigate the impact of the nationwide DUR system on prescribing practices where local DUR systems are already operating.

METHODS

Between January 2009 and December 2012 the monthly number of drugs per prescription was retrieved from the health insurance claims data warehouse at the Health Insurance Review and Assessment (HIRA). The monthly proportions of 3 DDI (drug-drug interaction) pairs, 6 drug-age contraindications, and 3 drug-pregnancy contraindications from January 2007 to December 2012, at the outpatient clinic level, were also retrieved. An interrupted time series analysis was used for controlling government announcements of drug contraindications.

RESULTS

There was no difference in the number of drugs per prescription before and after the introduction of the nationwide DUR system. Most proportions of the 3 DDI pairs, 6 drug-age contraindications, and 3 drug-pregnancy contraindications, were significantly reduced following the government announcement of drug contraindications in the short term and/or long term.

CONCLUSION

The number of drugs per prescription was not related to the nationwide DUR introduction in places where local DUR systems are operating. The introduction of duplicate guidelines, in locations where the guidelines were already well followed, is considered to be the main reason for this. Furthermore, the Doctor's ignorance of alerts, and their continued substitution of regulated drugs, for non-regulated drugs, likely played a role in nullifying the effectiveness of the nationwide DUR system.

Cost-effectiveness of Tofacitinib in the Treatment of Moderate to Severe Rheumatoid Arthritis in South Korea

PURPOSE

This study evaluated the cost-effectiveness of introducing tofacitinib, an oral Janus kinase inhibitor, to the treatment of Korean patients with rheumatoid arthritis (RA) and an inadequate response to conventional disease-modifying antirheumatic drugs.

METHODS

In this cost-utility analysis model, patients transitioned through treatment sequences based on Korean guidelines for RA patients with inadequate response to conventional disease-modifying antirheumatic drugs. Lifetime health-related quality of life and costs were evaluated. Characteristics of the model cohort were based on those reported by the Oral Rheumatoid Arthritis phase 3 triaL (ORAL) Standard randomized Controlled trial of tofacitinib or adalimumab versus placebo. Efficacy was assessed using American College of Rheumatology response rates, converted to the changes in Health Assessment Questionnaire-Disability Index (HAQ-DI) scores, based on tofacitinib clinical trials data. Published clinical trial data on discontinuation rates of the indicated drugs were incorporated in the model. The HAQ-DI scores were mapped onto utility values to calculate outcomes in terms of quality-adjusted life-years (QALYs); HAQ-DI-to-utility (EuroQoL 5D) mapping was based on data from 5 tofacitinib clinical trials. Costs were analyzed from a societal perspective, with values expressed in 2013 Korean won (KRW). Cost-effectiveness is presented in terms of incremental cost-effectiveness ratios (ICERs). One-way sensitivity analyses were performed to assess the robustness of the model.

FINDINGS

First-line tofacitinib used before the standard of care (base-case analysis) increased both treatment costs and QALYs gained versus the standard-of-care treatment sequence, resulting in an ICER of KRW 13,228,910 per QALY. Tofacitinib also increased costs and QALYs gained when incorporated as a second-, third-, or fourth-line therapy. The inclusion of first-line tofacitinib increased the duration of active immunomodulatory therapy from 9.4 to 13.2 years. Tofacitinib-associated increases in costs were attributable to the increased lifetime drug costs. In sensitivity analyses, variations in input parameters and assumptions yielded ICERs in the range of KRW 6,995,719 per QALY to KRW 37,450,109 per QALY.

IMPLICATIONS

From a societal perspective, the inclusion of tofacitinib as a treatment strategy for moderate to severe RA is cost-effective; this conclusion was considered robust based on multiple sensitivity analyses. The study was limited by the lack of clinical data on follow-up therapy after tofacitinib administration and a lack of long-term data on discontinuation of drug use.

Cost-benefit Analysis of Posaconazole Versus Fluconazole or Itraconazole as a Primary Antifungal Prophylaxis in High-risk Hematologic Patients: A Propensity Score-matched Analysis

PURPOSE

Posaconazole is effective for the prophylaxis of invasive fungal infections (IFIs) in patients with acute myeloid leukemia or myelodysplastic syndrome during remission induction chemotherapy. However, a cost-benefit analysis of posaconazole versus fluconazole or itraconazole has not been conducted in Korea.

METHODS

We retrospectively reviewed data for all consecutive patients who received primary antifungal prophylaxis during remission induction chemotherapy in our acute myeloid leukemia/myelodysplastic syndrome cohort from December 2010 to November 2013. Patient characteristics and factors known as a risk of IFI were matched with propensity score analysis. We evaluated the medical cost according to the prophylactic antifungal agents (posaconazole vs fluconazole/itraconazole), the development of breakthrough IFIs, and survival status after propensity score matching in a 1:1 ratio.

FINDINGS

Of the 419 baseline patients, 100 patients in each group were analyzed after matching. A significant decrease was found in the development of breakthrough proven or probable IFIs (3.0% vs 14.0%; P = 0.009) and the rate of empirical antifungal therapy (EAFT) (12.0% vs 46.0%; P < 0.001) in the posaconazole group. Total in-hospital medical costs per patient were not statistically different between posaconazole and fluconazole/itraconazole prophylaxis. However, the daily medical cost was lower for posaconazole prophylaxis, resulting in a total daily cost savings of $72 (₩79,458) per patient (P = 0.002). In the cases of breakthrough proven/probable IFIs, EAFT, and in-hospital deaths, the total medical costs per patient were significantly higher than in nonproven/probable IFIs, non-EAFT, and in-hospital survivors, as much as $7,916 (₩8,700,758), $4605 (₩5,062,529), and $11,134 (₩12,238,422), respectively. Costs for the antifungal agent used in targeted or empirical therapy were lower in the posaconazole group, resulting in a savings of $697 (₩766,347) per patient (P < 0.001).

IMPLICATIONS

Posaconazole appears to be cost beneficial for primary antifungal prophylaxis in high-risk patients with hematologic malignancy, at a single center, in Korea. Cost-benefit is closely related with clinical outcomes, including breakthrough IFI development, EAFT, and survival status.

Protective Effects of Quercetin Against HgCl₂-Induced Nephrotoxicity in Sprague-Dawley Rats

Mercury is a well-known environmental pollutant that can cause nephropathic diseases, including acute kidney injury (AKI). Although quercetin (QC), a natural flavonoid, has been reported to have medicinal properties, its potential protective effects against mercury-induced AKI have not been evaluated. In this study, the protective effect of QC against mercury-induced AKI was investigated using biochemical parameters, new protein-based urinary biomarkers, and a histopathological approach. A 250 mg/kg dose of QC was administered orally to Sprague-Dawley male rats for 3 days before administration of mercury chloride (HgCl2). All animals were sacrificed at 24 h after HgCl2 treatment, and biomarkers associated with nephrotoxicity were measured. Our data showed that QC absolutely prevented HgCl2-induced AKI, as indicated by biochemical parameters such as blood urea nitrogen (BUN) and serum creatinine (sCr). In particular, QC markedly decreased the accumulation of Hg in the kidney. Urinary excretion of protein-based biomarkers, including clusterin, kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), monocyte chemoattractant protein-1 (MCP-1), tissue inhibitor of metalloproteinases 1 (TIMP-1), and vascular endothelial growth factor (VEGF) in response to HgCl2 administration were significantly decreased by QC pretreatment relative to that in the HgCl2-treated group. Furthermore, urinary excretion of metallothionein and Hg were significantly elevated by QC pretreatment. Histopathological examination indicated that QC protected against HgCl2-induced proximal tubular damage in the kidney. A TUNEL assay indicated that QC pretreatment significantly reduced apoptotic cell death in the kidney. The administration of QC provided significant protective effects against mercury-induced AKI.

Living arrangements, chronic diseases, and prescription drug expenditures among Korean elderly: vulnerability to potential medication underuse

Background

Insufficient social security combined with family structure changes has resulted in a poverty of the elderly. The objective of this study was to examine an association of living arrangements of the elderly with chronic disease prevalence and prescription drug use.

Methods

2008 Korea Health Panel Survey (KHPS) data were used in this study. Information on living arrangements, socio-demographics, health behaviors, chronic disease prevalence and healthcare expenditures including out-of-pocket (OOP) prescription drug expenditures for elderly aged 65 or older were collected from self-reported diaries and receipts. OOP prescription drug expenditure as a total cost that subject paid to a pharmacy for prescription drugs was examined. Logistic regression was used to identify differences in major chronic disease prevalence by living arrangements. The association of living arrangements with prescription drug use was analyzed using generalized linear model with a log link and a gamma variance distribution.

Results

Proportions of elderly living alone, elderly living with a spouse only, and elderly living with adults aged 20–64 were 14.5%, 48.3%, and 37.2%, respectively. Elderly living alone showed 2.43 odds ratio (OR) (95% confidence interval (CI) = 1.66-3.56) for having major chronic diseases prevalence compared to elderly living with adults. Despite a higher major chronic disease prevalence, elderly living alone showed lower OOP prescription drug expenditures (Cost Ratio = 0.80, 95% CI = 0.67-0.97) after adjusting for the number of major chronic diseases. Total OOP prescription drug expenditures were significantly lower in patients with a low income level versus high income level.

Conclusions

Even though elderly living alone had a higher risk of chronic disease, they spent less on OOP prescription drug expenditures. Optimal drug use is important for elderly with chronic diseases to achieve good health outcomes and quality of life. Public health policies should be supplemented to optimize medical treatment for vulnerable elderly living alone.

Use of injectable drugs with oral-formulation alternatives for outpatients in South Korea

This study analyzed the use of injectable drugs with oral-formulation alternatives in the outpatient setting in South Korea. We conducted a retrospective cross-sectional data analysis using 2008 National Health Insurance claims data. All active ingredients were categorized into dual-formulation ingredients (DFIs) and single formulation ingredients (SFIs), and were identified by the type of healthcare service provider (HSP) and anatomical therapeutic chemical (ATC) group. 14.6 % (102/701) of total drugs were extracted as DFIs at about the same rate as that for drugs in the World Health Organization database (14.45 %), showing similar patterns by ATC group. The rate of injectable drug use varied more substantially for DFIs (range 0.94-4.54 %) than for SFIs (range 0.27-1.12 %) by the type of HSP. For DFIs, the highest proportion of injectable drug use was observed in group H (all hormonal preparations, 22.74 %) and group M (anti-inflammatory and anti-rheumatic preparations, 10.23 %) among ATC groups. The proportion of injectable drug use was higher in clinics and small hospitals than in tertiary hospitals and general hospitals where patients with more severe cases tend to visit. The results imply the potentially inappropriate or excessive use of injectable drugs and suggest the need to develop standard guidelines for injectable drug use and strategies to promote high-quality healthcare including education on rational prescribing.

Long-term metformin use reduces gastric cancer risk in type 2 diabetics without insulin treatment: a nationwide cohort study

BACKGROUND

Metformin use has been associated with a decreased incidence and mortality of various cancers.

AIM

To evaluate the association between metformin use and gastric cancer.

METHODS

We randomly selected 100 000 type 2 diabetic patients from the 2004 Korean National Health Insurance claim database, and assessed gastric cancer incidence among 39 989 patients (aged 30-97 years) who were regularly treated with anti-diabetic drugs and followed-up from 2004 to 2010. In total, 26 690 patients had used metformin out of 32 978 diabetics who had not regularly used insulin (insulin non-users), and 5855 patients had used metformin out of 7011 regular insulin users.

RESULTS

Patients who used metformin showed a lower incidence of gastric cancer than those who did not use metformin, in insulin non-users (P = 0.047, log-rank test). However, in patients on regular insulin, there was no difference of gastric cancer incidence according to metformin use. In insulin non-users, the adjusted hazard ratio (AHR) for metformin use was 0.73 (95% confidential interval [CI], 0.53-1.01) with borderline statistical significance (P = 0.059). Duration of metformin use was associated with the reduction in gastric cancer risk (AHR, 0.88; 95% CI 0.81-0.96, P = 0.003), especially in patients who used metformin for more than 3 years (AHR, 0.57; 95% CI, 0.37-0.87; P = 0.009).

CONCLUSION

Metformin use >3 years in type 2 diabetics who do not use insulin is associated with a significantly reduced gastric cancer risk.

Effects of computerized physician order entry on medication turnaround time and orders requiring pharmacist intervention

BACKGROUND

Previous studies have demonstrated that computerized physician order entry (CPOE) of prescriptions reduces both turnaround time (TAT) and medication errors. However, these studies have been performed primarily in large academic centers with a relatively small number of medication orders. As such, many studies investigating the impact of CPOE on the level of pharmacist intervention have yielded conflicting results.

OBJECTIVE

The objective of this study was to examine the effects of CPOE on medication order TAT and the frequency of medication orders requiring pharmacist intervention in a community-based medical center.

METHODS

A prospective cohort study was conducted at a community-based medical center. A total of 24,767 prescriptions written for 940 patients over a six-month period were stratified into CPOE or non-CPOE (handwritten) cohorts. TAT between cohorts were tested using analysis of variance and Tukey's Honestly Significant Difference test. The number of orders requiring pharmacist intervention was compared between cohorts and tested using chi-square test or Fisher's exact test. Medication orders requiring pharmacist intervention were stratified by patient characteristics, therapeutic class, and types of medication error.

RESULTS

Medication orders not using CPOE were approximately 8 times more likely to require pharmacist intervention (2.26% versus 0.29%; P < 0.001), with the majority of pharmacist interventions performed to prevent medication errors. The overall mean TAT for medication orders was significantly shorter in the CPOE group in comparison with the non-CPOE group (22.2 ± 86.5 min versus 81 ± 256.7 min; P < 0.001). CPOE orders nearly eliminated medication errors with wrong dosage forms and formulary issues.

CONCLUSIONS

Medication orders entered via CPOE are associated with a significant reduction in medication TAT and less likely to require pharmacist intervention. Use of CPOE may improve quality of patient care and efficiency of health care delivery.

Inhibition of adipogenesis in 3T3-L1 cells and suppression of abdominal fat accumulation in high-fat diet-feeding C57BL/6J mice after downregulation of hyaluronic acid

OBJECTIVE

Adipogenesis can be spatially and temporally regulated by extracellular matrix (ECM). We hypothesized that the regulation of hyaluronic acid (HA), a component of the ECM, can affect adipogenesis in fat cells. The effects of HA on adipogenesis were investigated in vitro in 3T3-L1 cells and in vivo in high-fat diet-feeding C57BL/6J mice.

METHODS

We investigated the effects of HA by degradation of pre-existing or synthesized HA and artificial inhibition of HA synthesis in adipogenesis.

RESULTS

In vitro adipogenesis in 3T3-L1 cells was inhibited by treating them with exogenous hyaluronidase (HYAL) and with 4-methylumbelliferone, which inhibited the synthesis of HA in a concentration-dependent manner. In vivo, abdominal fat accumulation in high-fat diet-feeding C57BL/6J mice was suppressed by exogenous HYAL 10(4) IU injections, which was associated with reduction of lipid accumulation in liver and increase of insulin sensitivity.

CONCLUSION

Changes in the ECM such as accumulation of high molecular weight of HA by HAS and degradation of HA by endogenous HYAL were essential for adipogenesis both in vitro and in vivo.

Activation of de novo GSH synthesis pathway in mouse spleen after long term low-dose γ-ray irradiation

Glutathione (GSH) is an important cellular antioxidant and has a critical role in maintaining the balance of cellular redox. In this study, we investigated the GSH biosynthesis genes involved in the elevation of endogenous GSH levels using an irradiation system with an irradiation dose rate of 1.78 mGy/h, which was about 40,000 times less than the dose rates used in other studies. The results showed that GSH levels were significantly increased in the low-dose (0.02 and 0.2 Gy) irradiated group compared to those in the non-irradiated group, but enzymatic antioxidants such as superoxide dismutase and catalase were not induced at any doses tested. The elevation in GSH was accompanied by elevated expression of glutamate-cysteine ligase modifier subunit, but no changes were observed in the expression of glutamate-cysteine ligase catalytic subunit and thioredoxin in de novo GSH synthesis. In the case of genes involved in the GSH regeneration cycle, the expression of glutathione reductase was not changed after irradiation, whereas glutathione peroxidase was only increased in the 0.2 Gy irradiated group. Collectively, our results suggest that the de novo pathway, rather than the regeneration cycle, may be mainly switched on in response to stimulation with long-term low-dose radiation in the spleen.

Blebbishields, the emergency program for cancer stem cells: sphere formation and tumorigenesis after apoptosis

Caspases mediate apoptosis and have also been implicated in stem-cell biology. How caspases are linked to stem-cell biology is not known. Here, we show that the apoptotic blebs of cancer cells fuse together to form novel structures called 'blebbishields'. Blebbishields form spheres by fusion. Both blebbishield formation and sphere formation involve active caspases and N-linked glycosylation. Sphere formation is enhanced by acidic pH and is counteracted by inhibitors of proton pump, caspases, and cholesterol. The blebbishields from VEGFR2(High) cells are capable of enhanced sphere formation. Blebbishields express transiently downregulated stem-cell markers and the sphere-forming blebbishield-derived cells are tumorigenic. Our study demonstrates that the cancer stem cells can survive after apoptosis by blebbishield formation and subsequent sphere formation.