Quantitative Analyses of Hepatic OATP-Mediated Interactions Between Statins and Inhibitors Using PBPK Modeling With a Parameter Optimization Method

This study aimed to construct a widely applicable method for quantitative analyses of drug-drug interactions (DDIs) caused by the inhibition of hepatic organic anion transporting polypeptides (OATPs) using physiologically based pharmacokinetic (PBPK) modeling. Models were constructed for pitavastatin, fluvastatin, and pravastatin as substrates and cyclosporin A (CsA) and rifampicin (RIF) as inhibitors, where enterohepatic circulations (EHC) of statins were incorporated. By fitting to clinical data, parameters that described absorption, hepatic elimination, and EHC processes were optimized, and the extent of these DDIs was explained satisfactorily. Similar in vivo inhibition constant (K_i ) values of each inhibitor against OATPs were obtained, regardless of the substrates. Estimated K_i values of CsA were comparable to reported in vitro values with the preincubation of CsA, while those of RIF were smaller than reported in vitro values (coincubation). In conclusion, this study proposes a method to optimize in vivo PBPK parameters in hepatic uptake transporter-mediated DDIs.

Endovascular Stenting for Pseudoaneurysms of the Cervical Carotid Artery

The authors report two cases of pseudoaneurysm of the cervical carotid artery treated with endovascular stenting. One patient presented with cerebral ischemia due to traumatic carotid dissection and underwent stent placement 3 weeks after injury when the wide-necked pseudoaneurysm was seen to enlarge at the dissecting portion.

The aneurysm thrombosed while the carotid artery remained patent without ischemic complications for 2 years. The other patient developed repeated massive bleeding from an exposed pseudoaneurysm at the right carotid-subclavian junction resulting from radiotherapy for thyroid cancer with subsequent skin infection.

Since skin grafting failed and two attempts at coil embolization resulted in compaction with recurrent enlargement of the aneurysm, endovascular stenting was performed with endosaccular coil packing between the stent struts. Hemostasis was achieved for 2 months. Both cases illustrate successes of the stent in highly difficult situations.

Cost-effectiveness of a community-based screening programme for chronic atrial fibrillation in Japan

Objectives: To examine the cost-effectiveness of a community-based screening programme for chronic atrial fibrillation (AF) in Japan.

Methods: Using a computer model of a Markov process, the cost-effectiveness of an annual ECG screening programme and an annual pulse palpation screening programme for arrhythmia were compared with no screening. A hypothetical Japanese population of 65 year old individuals was followed until 85 years of age. We assumed that individuals with irregular beats on palpation were worked up by ECG and that ECG was perfect in detecting AF, whereas palpation was not. It was also assumed that patients diagnosed with AF received anticoagulant therapy, that some AF patients developed ischaemic stroke, and that some on anticoagulant therapy developed intracranial or gastrointestinal haemorrhage. Costs, efficacy of anticoagulation, utility of health status, and clinical variables were estimated from the literature. Outcomes were expressed as US dollars per quality-adjusted life-year (QALY).

Results: Both annual ECG screening programme and annual palpation screening programme were more costly and at the same time more effective compared with no screening, with their incremental cost-effectiveness ratios approximately US$8000 per QALY in males and US$10,000 per QALY in females. Sensitivity analyses showed high sensitivity of cost-effectiveness ratios to the incidence of ischaemic stroke and anticoagulants prescription rate. Two annual screening programmes were similar in effectiveness and costs.

Conclusion: To prevent ischaemic stroke associated with AF, both annual ECG screening and annual palpation screening were favourable in the context of conventional criteria for cost-effectiveness.

A randomized phase III trial comparing S-1 versus UFT as adjuvant chemotherapy for stage II/III rectal cancer (JFMC35-C1: ACTS-RC)

This phase III study is the first study to demonstrate the superiority of new oral fluoropyrimidine S-1 over tegafur–uracil as adjuvant chemotherapy for stage II/III rectal cancer patients with no preoperative treatment in terms of relapse-free survival. S-1 can be considered an important option, especially for patients who have not received preoperative treatment.

Backgrounds

Preventing distant recurrence and achieving local control are important challenges in rectal cancer treatment, and use of adjuvant chemotherapy has been studied. However, no phase III study comparing adjuvant chemotherapy regimens for rectal cancer has demonstrated superiority of a specific regimen. We therefore conducted a phase III study to evaluate the superiority of S-1 to tegafur–uracil (UFT), a standard adjuvant chemotherapy regimen for curatively resected stage II/III rectal cancer in Japan, in the adjuvant setting for rectal cancer.

Patients and methods

The ACTS-RC trial was an open-label, randomized, phase III superiority trial conducted at 222 sites in Japan. Patients aged 20–80 with stage II/III rectal cancer undergoing curative surgery without preoperative therapy were randomly assigned to receive UFT (500–600 mg/day on days 1–5, followed by 2 days rest) or S-1 (80–120 mg/day on days 1–28, followed by 14 days rest) for 1 year. The primary end point was relapse-free survival (RFS), and the secondary end points were overall survival and adverse events.

Results

In total, 961 patients were enrolled from April 2006 to March 2009. The primary analysis was conducted in 480 assigned to receive UFT and 479 assigned to receive S-1. Five-year RFS was 61.7% [95% confidence interval (CI) 57.1% to 65.9%] for UFT and 66.4% (95% CI 61.9% to 70.5%) for S-1 [P = 0.0165, hazard ratio (HR): 0.77, 95% CI 0.63–0.96]. Five-year survival was 80.2% (95% CI 76.3% to 83.5%) for UFT and 82.0% (95% CI 78.3% to 85.2%) for S-1. The main grade 3 or higher adverse events were increased alanine aminotransferase and diarrhea (each 2.3%) in the UFT arm and anorexia, diarrhea (each 2.6%), and fatigue (2.1%) in the S-1 arm.

Conclusion

One-year S-1 treatment is superior to UFT with respect to RFS and has therefore become a standard adjuvant chemotherapy regimen for stage II/III rectal cancer following curative resection.

Risk Factors for the Discontinuation of Home Medical Care among Low-functioning Older Patients

OBJECTIVES

Older patients receiving home medical care often have declining functional status and multiple disease conditions. It is important to identify the risk factors for care transition events in this population in order to avoid preventable transitions. In the present study, therefore, we investigated the factors associated with discontinuation of home medical care as a potentially preventable care transition event in older patients.

METHODS

Baseline data for participants in the Observational study of Nagoya Elderly with HOme MEdical (ONEHOME) study and data on the mortality, institutionalization, or hospitalisation of the study participants during a 2-year follow-up period were used. Discontinuation of home care was defined as admission to a hospital for any reason, institutionalization, or death. Univariate and multivariate Cox hazard models were used to assess the association of each of the factors with the discontinuation of home care during the observational period. The covariates included in the multivariate analysis were those significantly associated with the discontinuation of home care at the level of P<0.05 in the univariate analysis.

RESULTS

The univariate Cox hazard model revealed that a low hemoglobin level (< 11g/dL), low serum albumin level (< 3g/dL), higher Charlson Comorbidity Index score, and low Mini Nutritional Assessment Short Form score (< 7) were significantly associated with the discontinuation of home care. A multivariate Cox hazard model including these four factors demonstrated that all four were independently associated with home-care discontinuation.

CONCLUSIONS

The present results demonstrated that anemia, hypoalbuminemia, malnourishment, and the presence of serious comorbidities were associated with the discontinuation of home medical care among low-functioning older patients.

Germinal Center B-Cell-Associated Nuclear Protein (GANP) Involved in RNA Metabolism for B Cell Maturation

Germinal center B-cell-associated nuclear protein (GANP) is upregulated in germinal center B cells against T-cell-dependent antigens in mice and humans. In mice, GANP depletion in B cells impairs antibody affinity maturation. Conversely, its transgenic overexpression augments the generation of high-affinity antigen-specific B cells. GANP associates with AID in the cytoplasm, shepherds AID into the nucleus, and augments its access to the rearranged immunoglobulin (Ig) variable (V) region of the genome in B cells, thereby precipitating the somatic hypermutation of V region genes. GANP is also upregulated in human CD4(+) T cells and is associated with APOBEC3G (A3G). GANP interacts with A3G and escorts it to the virion cores to potentiate its antiretroviral activity by inactivating HIV-1 genomic cDNA. Thus, GANP is characterized as a cofactor associated with AID/APOBEC cytidine deaminase family molecules in generating diversity of the IgV region of the genome and genetic alterations of exogenously introduced viral targets. GANP, encoded by human chromosome 21, as well as its mouse equivalent on chromosome 10, contains a region homologous to Saccharomyces Sac3 that was characterized as a component of the transcription/export 2 (TREX-2) complex and was predicted to be involved in RNA export and metabolism in mammalian cells. The metabolism of RNA during its maturation, from the transcription site at the chromosome within the nucleus to the cytoplasmic translation apparatus, needs to be elaborated with regard to acquired and innate immunity. In this review, we summarize the current knowledge on GANP as a component of TREX-2 in mammalian cells.

Levobupivacaine-dextran mixture for transversus abdominis plane block and rectus sheath block in patients undergoing laparoscopic colectomy: a randomised controlled trial

We performed a randomised controlled double-blinded study of patients having laparoscopic colectomy with bilateral transversus abdominis plane block plus rectus sheath block, comparing a control group receiving 80 ml levobupivacaine 0.2% in saline with a dextran group receiving 80 ml levobupivacaine 0.2% in 8% low-molecular weight dextran. Twenty-seven patients were studied in each group. The mean (SD) maximum plasma concentration of levobupivacaine in the control group (1410 (322) ng.ml(-1) ) was higher than the dextran group (1141 (287) ng.ml(-1) ; p = 0.004), and was reached more quickly (50.6 (30.2) min vs 73.2 (24.6) min; p = 0.006). The area under the plasma concentration-time curve from 0 min to 240 min in the control group (229,124 (87,254) ng.min.ml(-1) ) was larger than in the dextran group (172,484 (50,502) ng.min.ml(-1) ; p = 0.007). The median (IQR [range]) of the summated numerical pain rating score at rest during the first postoperative 24 h in the control group (16 (9-20 [3-31]) was higher than in the dextran group (8 (2-11 [0-18]); p = 0.0001). In this study, adding dextran to levobupivacaine decreased the risk of levobupivacaine toxicity while providing better analgesia.

The long-term outcome of transvaginal anterior levatorplasty for intractable rectovaginal fistula

AIM

Several procedures have been described for rectovaginal fistula with a wide range of success, but there is little information on the long-term outcome. The aim of the present study was to investigate the long-term outcome after transvaginal anterior levatorplasty (ALP) for intractable rectovaginal fistula.

METHOD

Data of 16 consecutive patients undergoing transvaginal ALP with fistulectomy and closure of the rectum and vagina between 1998 and 2011 were prospectively recorded and retrospectively investigated to study the long-term outcome.

RESULTS

Birth injury (n = 7), low anterior resection for rectal cancer (n = 3), pouch surgery for ulcerative colitis (n = 2) and a procedure for prolapse and haemorrhoids (n = 2) were the main causes of the fistula. Nine patients had a covering stoma before surgery. All patients underwent ALP, with a covering stoma in two patients. Infection occurred in one patient and wound rupture after surgery in another patient. These patients underwent reoperation by ALP. All fistulae had healed at a median follow-up of 84 (8-193) months after initial surgery or stoma closure.

CONCLUSION

Transvaginal ALP is effective for the treatment of mid or low rectovaginal fistula. The results show that a graft is not necessary regardless of whether or not previous surgery has been performed.