Cyclo(Val-Pro) and Cyclo(Leu-Hydroxy-Pro) from Pseudomonas sp. (ABS-36) alleviates acute and chronic renal injury under in vitro and in vivo models (Ischemic reperfusion and unilateral ureter obstruction)

The study aimed to identify small molecules having potentiality in alleviating renal injury. Two natural compounds cyclo(Val-Pro) (1) and cyclo(Leu-Hydroxy-Pro) (2) were first evaluated under acute renal injury model of ischemic reperfusion at different doses of 25, 50 and 75 mg/kg body weight. Further, the compounds were subjected to antimycin A-induced ischemic in vitro study (NRK-52E cell lines). Both the compounds significantly decreased plasma IL-1β levels (P < 0.05). Also, the mRNA expression levels of inflammatory markers (TNF-α, IL-6 and IL-1β) and renal injury markers (KIM-1, NGAL, α-GST and π-GST) in the renal tissues were significantly alleviated (P < 0.01) along with the improvement in histological damage and control over neutrophil infiltration as a result of ischemic reperfusion. The in vitro study revealed the protective effect against antimycin A-induced cytotoxicity (P < 0.05) and antiapoptotic effect acting through the regulation of Bax, caspase 3 (pro and cleaved) and BCL2 with reduction in Annexin⁺PI⁺ cells. Further, the compound cyclo(Val-Pro) (1) was evaluated (50 mg/kg body weight dose) in chronic unilateral ureter obstruction model of renal injury in mice and TGF-β-induced in vitro fibrotic model (NRK-49F cell lines). Cyclo(Val-Pro) (1) significantly reduced the expression levels of fibrotic markers (collagen-1, α-SMA and TGF-β) and showed marked alleviation of renal fibrosis (sirius red staining). Also, the proliferation of TGF-β-induced NRK-49F cells was significantly reduced along with decreased levels of collagen-1 and α-SMA in immunohistochemistry studies. In conclusion, the compounds significantly abrogated ischemic injury by inhibiting renal inflammation and tubular epithelial apoptosis. Further, cyclo (Val-Pro) (1) exhibited significant anti-fibrotic activity through the inhibition of fibroblast activation and proliferation. Thus, these proline-based cyclic dipeptides are recommended as drug leads for treating renal injury.

Halodule pinifolia (Seagrass) attenuated lipopolysaccharide-, carrageenan-, and crystal-induced secretion of pro-inflammatory cytokines: mechanism and chemistry

OBJECTIVES

The study aimed to explore the anti-inflammatory effect, underlying mechanism, and chemistry of Halodule pinifolia extract.

METHODS

The ethyl acetate (EHP) and methanol (MHP) extracts of Halodule pinifolia were screened for pro-inflammatory cytokine inhibition effect under various in vitro (LPSand crystal-induced inflammation) and in vivo models (LPS-induced endotoxaemia model, carrageenan-induced paw oedema model, and oxalate-induced renal nephropathy model of inflammation). The effect of EHP on the expression of inflammatory markers using western blot analysis (in vitro) was investigated. Chemical constituents of bioactive EHP were isolated through chromatography and characterised using NMR spectroscopy. Furthermore, EHP was standardised for rosmarinic acid, vanillic acid, and ethyl protocatechuate using HPLC. Also, total phytosterols, phenolic, and flavonoid content of EHP were determined by UV spectroscopy.

KEY FINDINGS

EHP was comparatively more effective than MHP in inhibiting cytokines secretions under LPS-induced in vitro models. Furthermore, EHP was screened under endotoxaemia in vivo model, EHP (250 mg/kg) reduced plasma IL-6, TNF-α, and IL-1β levels by 88.3%, 78.2%, and 74.5%, respectively. In the carrageenan-induced oedema model, EHP (200 mg/kg) reduced paw volume and release of TNF-α (69.3%) and IL-1β (43.1%). EHP (200 mg/kg) further controlled renal nephropathy by inhibiting plasma IL-1β and BUN levels. Also, a significant reduction of mRNA expressions of TNF-α and IL-1β and KIM-1 in renal tissues was observed. Through western blot, EHP was identified to regulate the expression of pro-form as well as mature-form of IL-1β and caspase-1. EHP constituted rosmarinic acid (RA), vanillic acid (VA), ethyl protocatechuate (EP), sitosterol, stigmasterol, campesterol, and dihydrobrassicasterol. It was determined that 4.6 mg/g of RA, 2.92 mg/g of VA, 0.76 mg/g of EP, 21.7 mg/g of total phenolics, 29.8 mg/g of total flavonoids, and 48.2 mg/g of total phytosterols were present in dry EHP. The presence of anti-inflammatory constituents such as RA, VA, and PE in EHP corroborated the in vitro and in vivo anti-inflammatory activity of EHP.

CONCLUSION

The anti-inflammatory property of EHP and its action through attenuation of pan-cytokines suggest that it can be developed into an oral pharmaceutical drug.

P0684HDAC5/KLF2 AXIS REGULATES NLRP3 MEDIATED RENAL INFLAMMATION AND FIBROSIS ASSOCIATED WITH NEPHROCALCINOSIS-RELATED CHRONIC KIDNEY DISEASE

Background and Aims

Role of epigenetic factors like histone deacetylases (HDACs) is largely unexplored in the pathogenesis of Nephrocalcinosis-related chronic kidney disease. The present study was performed to evaluate the functional role of HDAC5 in fibroblast activation in in-vitro and in a mouse model of Nephrocalcinosis-related chronic kidney disease.

Method

C57BL/6 male mice (6-7weeks old) were procured from registered CPCSEA breeder (Hyderabad, India), NRK49F cell line were generously provided by NCCS (Pune, India). All experimental procedures were approved by the animal ethics committee of the institute. Nephrolithiasis (oxalate nephropathy) was induced by feeding oxalate rich diet (Ssniff, Soest, Germany) to C57/BL6 mice for 10 days. NRK49F cells were stimulated with LPS (1µg/ml) for 2hrs followed by TGF-β (25ng/ml) for 24hrs. To achieve HDAC5 knockdown, the cells were pre-incubated with HDAC5 specific siRNA for 24hrs before stimulating with LPS. In another set of experiment, cells were incubated with 4-sodium phenyl butyrate(PBA) a non-selective HDAC5 and HDAC4 inhibitor at a dose of 1mM. 24 hrs after LPS stimulation cell lysates were analysed for protein expression of α-SMA, Collagen1a, KLF2, NLRP3, HDAC5 and β-actin. Mice fed with high oxalate diet were treated with PBA (500mg/kg) twice a day and on day 10 mice were sacrificed to analyse renal function and fibrosis parameters. Mice kidney tissues were analysed for crystal deposition (pizaalato staining), renal fibrosis (Picrosirius staining), and renal histology (H&E staining). The fibrosis markers were analysed by RT-PCR and immunoblotting. Renal function was determined by plasma BUN and creatinine analysis. Diet containing high oxalate with calcium was provided to mice in the control diet group (negative diet control).

Results

Renal fibroblasts (NRK 49F) stimulated with LPS and TGF-β showed upregulation of HDAC5, NLRP3, α-SMA, and Collagen-1a. Depletion of HDAC5 expression with HDAC5 siRNA significantly reduced expression of NLRP-3, α-SMA, and Collagen-1 in stimulated NRK49F cells. The expression of KLF2 in HDAC5 depleted cells was found to be upregulated. PBA treatment also reduced the expression of HDAC5 in NRK49F cells and had significant reduction in the expression of NLRP3 along with fibroblast activation markers, while KLF-2 expression was found to be up-regulated. Similar to our observation in stimulated renal fibroblasts, the expression of HDAC5 was found to be upregulated in mouse model of oxalate nephropathy. Treatment with PBA showed significant downregulation of HDAC5 in kidneys of the mice fed with high oxalate diet. Mice treated with PBA showed down regulated renal expression of NLRP3, Collagen1a, α-SMA, TGF-β in comparison to vehicle treated mice. Treatment with PBA showed significant upregulation of KLF2 expression in kidney. PBA treated mice showed significant renal protection during nephrolithiasis as indicated by reduced plasma BUN and creatinine levels. Oxalate crystal deposition index was similar in all high oxalate diet groups. PBA treatment showed overall better renal histological protection observed through H&E (reduced tubular injury score) and picrosirius staining (reduced collagen deposition).

Conclusion

HDAC5 knockdown or HDAC5 inhibition with PBA attenuates fibroblasts activation by inhibiting NLRP3 expression. Treatment with PBA in mice with Nephrocalcinosis-related chronic kidney disease showed significant protection against renal fibrosis with downregulation of NLRP3 expression. We propose HDAC5 as a novel regulator of fibroblast activation in Nephrocalcinosis-related chronic kidney disease.

New synthetic coumarinolignans as attenuators of pro-inflammatory cytokines in LPS-induced sepsis and carrageenan-induced paw oedema models

OBJECTIVES

The aim of the study was to explore the inhibition efficacy of new synthetic coumarinolignans (SCLs) against the secretion of pro-inflammatory cytokines in two in vivo models of inflammation.

METHODS

Four SCLs 1-4 were screened for their pro-inflammatory cytokine inhibitory potential through oral administration at a dose of 50 mg/kg body weight in lipopolysaccharide-induced mouse endotoxaemia and carrageenan-induced mouse paw oedema models. Levels of pro-inflammatory cytokines (IL-1β, TNFα and IL-6) in blood and paw tissue samples were estimated using ELISA. Paw oedema was measured using a plethysmometer. Results were compared with a natural coumarinolignan, cleomiscosin A (5), and the structure-activity relationship (SAR) was interpreted.

RESULTS AND DISCUSSION

Compound 2 had the greatest potential in the endotoxaemia model, exhibiting 66.41%, 62.56% and 43.15% inhibition of plasma IL-1β, TNFα and IL-6 secretions, respectively. Further dose-dependent study revealed its anti-inflammatory potential even at dose of 10 mg/kg body weight with 24.42% decline in the level of IL-1β. Nevertheless, SCLs 1, 3 and 4 showed marked inhibitory activity with 57.54%, 51.48% and 62.46% reduction in the levels of IL-1β, respectively. Moreover, compound 2 decreased the plasma TNFα and IL-1β levels to 50.03% and 36.58% along with the reduction of paw oedema volume in the local inflammation induced by carrageenan. All compounds including cleomiscosin A (5) were more effective against IL-1β. By studying SAR, the presence of dihydroxyl groups in the phenyl ring of lignans was identified to be essential for the activity. Also, esterification of lignans and presence of a 4-methyl substituent in the coumarin nucleus were found to play some role in enhancing the activity.

CONCLUSION

All four SCLs, especially compound 2, have shown vast potential to emerge out as promising anti-inflammatory drugs.

Structure-based design and synthesis of new 4-methylcoumarin-based lignans as pro-inflammatory cytokines (TNF-α, IL-6 and IL-1β) inhibitors

Suppression of pro-inflammatory cytokines (TNF-α, IL-1β and IL-6) along with nitric oxide reduction in RAW 264.7 cells by 7,8-dihydroxy-4-methylcoumarin, ethyl p-coumarate, ethyl caffeate and ethyl ferulate drove us to search structural-analogues of the aforementioned compounds through structure-based drug design. Docking studies revealed that substituted cinnamic acids and their ethyl esters (2-7c) showed higher GoldScore-fitness (GSF) and non-bonding interactions with target proteins than 7,8-dihydroxy-4-methylcoumarin (1a) and 7,8-dihydroxy-5-methylcoumarin (1b). With this background, the methylcoumarins (1a and 1b) and the cinnamic acid derivatives (2-7c) were fused in different permutations and combinations to generate sixty novel fused-cyclic coumarinolignans (FCLs) (8-13k). Docking studies on 8-13k indicated that several FCLs possess higher GSF, interesting active site interactions and distinctive π-π interactions compared to the standards (cleomiscosin A, diclofenac Na and prednisolone). Based on these findings, four novel FCLs (9d, 10d, 11d and 11e) were synthesized and tested for inhibition effect on TNF-α, IL-1β and IL-6 expressions in LPS and oxalate crystal-induced in-vitro models. Compound 10d exhibited significant effect (P < 0.0001 at 100 μM) with an IC₅₀ value of 8.5 μM against TNF-α. Compound 11e possessed IC₅₀ values of 13.29 μM and 17.94 μM against IL-6 and IL-1β, respectively. Study on SAR corroborated the requirement of C-4-methyl substituent in the coumarin moiety, dihydroxyl groups in the phenyl ring, and esterification of lignans for potent activity. Additionally, the reported excellent anti-inflammatory activity of cleomiscosin-A-glucoside was corroborated by from the higher GSF and better hydrophobic interactions than cleomsicosin A in the docking study. As an outcome, some novel and potentially active FCLs acting through NFκB and caspase 1 signaling pathways have been discovered as multiple cytokine inhibitors.

Possible mechanisms of gender bias in SLE: a new hypothesis involving a comparison of SLE with atopy

The prevalence of systemic lupus erythematosus (SLE) is far higher in females than in males, and numerous investigations of this gender bias have been performed from several perspectives. Sex hormones, particularly estrogens, may be significant in causing the gender discrepancy. This article discusses the possible importance of estrogens in regulating the expression of and responsivity to autoantigens in SLE and in atopic disorders, which are associated with hyperreactivity to exogenous antigens. Estrogens seem to play an important role in the overexpression of endogenous autoantigens, such as human endogenous retroviruses (HERV), and this may be related to the existence of a gender bias in the incidence of SLE but not atopy.

Association between patient education and health-related quality of life in patients with Parkinson's disease

BACKGROUND

Providing patients with disease- and treatment-related information is an important role of medical staff and is now reimbursed in Japan by the national health insurance system under the rubric 'patient education'. Evaluation of the effectiveness of patient education programs is necessary to ensure that limited health care resources are used efficiently.

OBJECTIVE

The objective is to determine whether educating patients with Parkinson's disease (PD) is related to better health-related quality of life (HRQOL).

DESIGN

A cross-sectional study was conducted.

SETTING

Members of the Japan Association of Patients with Parkinson's disease were randomly selected.

PARTICIPANTS

A total of 1200 patients with PD were asked to fill in written questionnaires and replies from 762 (63.5%) were analyzed.

MEASUREMENTS

The questionnaire inquired about clinical characteristics, comorbidity, symptoms of PD, complications of therapy, HRQOL, and patient education. SF-36 was used to assess HRQOL. The section on patient education comprised one question each on patient-perceived satisfaction with information provided on (1) disease condition and pathophysiology, (2) effectiveness of drug therapy, (3) adverse drug reactions, (4) publicly available financial and social resources, and (5) rehabilitation and daily activities. Patient education score was defined as the sum of the individual scores for these five questions. The relationships between scores on the SF-36 subscales and the patient education score were examined.

RESULTS

More satisfaction with patient education was associated with higher scores in all SF-36 subscales except physical functioning and bodily pain. The difference in score between the most satisfied and the least satisfied patients ranged from 8.4 points on the subscales of general health and 16.7 points on the subscale of role limitation due to emotional problems.

CONCLUSION

The conclusion that patient education is associated with better HRQOL in patients with PD is drawn.

Cost analysis of paediatric tuberculosis treatment in Japan

OBJECTIVE

To estimate the cost of treating a tuberculosis (TB) case and to analyse TB-related medical service utilisation, a cost-of-illness study was conducted for all patients with a primary diagnosis of TB admitted to a public hospital in Japan.

METHODS

Retrospective analysis by abstracting in- and out-patient medical records of 57 paediatric patients diagnosed with TB during 1993-1998 at a public hospital in Osaka prefecture. Costs were estimated based on third party's payer perspectives according to the service utilisation pattern. In addition to cost data, sociodemographic information and service utilisation pattern were also extracted from the medical records. Cost of preventing a case of TB was abstracted from the published literature.

RESULTS

The average cost of treatment was 8384 US dollars (95%CI 5667-11,099), while the average length of hospitalisation was 63 days (95%CI 43-84). Based on 20-80% vaccine efficacy, the cost of preventing a case of TB was 35,950-175,862 US dollars. In univariate analysis, site of TB (P = 0.04) was significantly associated with TB treatment cost, while case-finding method (contact tracing, symptoms, etc.) was associated with length of hospitalisation (P = 0.03). Multivariate regression analysis, however, showed none of the factors to be significant predictors of TB treatment cost and length of hospital stay.

CONCLUSION

The cost of treating a case of paediatric TB is much lower than that of preventing one. Japan's universal BCG vaccination policy should be re-examined in the light of economic, social and political issues.

Successful treatment of chromomycosis using carbon dioxide laser associated with topical heat applications

A 59-year-old Japanese man presented with a slightly elevated, pruritic, erythematous plaque on his left buttock measuring 5 x 5 cm in diameter. The man had a history of chromomycosis, dating 6 years prior to the current consultation, for which he had been treated with oral terbinafine. Diagnosis of a recurrence of chromomycosis of the skin due to infection by Foncecaea pedrosoi was made after careful analysis of the clinical features, skin biopsy, KOH mounts, and fungal culture results. We administered topical heat therapy followed by treatment with CO2 laser to eradicate the unresponsive remnants of the lesion. The operative site re-epithelized within 10 weeks, and 1 year after the treatment there was no evidence of recurrence. For a recalcitrant case of chromomycosis, as in this case, the use of CO2 laser combined with topical heat therapy may be a new therapeutic modality.

Establishment and characterization of a murine mast cell line derived from NC/Nga mice

A cell line, termed NCJ, was established from the bone marrow-derived mast cells (BMMCs) of NC/Nga mice that are mouse models for atopic dermatitis. NCJ cells expressed FcepsilonRI and c-kit and showed a metachromasia of the granules with a toluidine blue-positive and safranin-negative staining pattern that is characteristic for immature-type mast cells. Interestingly, NCJ cells showed proliferation independent of IL-3, which was associated with constitutive phosphorylation of Raf-1 and Erk kinases. Although NCJ cells had several characteristics of mast cells, we failed to detect FcepsilonRI-mediated beta-hexosaminidase release and its histamine content. These findings indicated that NCJ cells represented a mast cell line with an immature phenotype and the ability to proliferate in the absence of mast cell growth factors. NCJ cells might thus be useful to study the molecular basis of mast cell proliferation.

Economic evaluation of universal BCG vaccination of Japanese infants

BACKGROUND

The international controversy surrounding the use and effectiveness of the Bacillus Calmette-Guérin (BCG) vaccine and the low incidence of tuberculosis (TB) among Japanese children prompted this study.

METHODS

We compared 'universal BCG vaccination' with 'no vaccination at all' using a cost-effectiveness analysis. The study population was a hypothetical cohort comprising a total of 1.2 million infants born in 1996 at locations all over Japan. A model was developed to calculate the number of TB cases prevented by the vaccination programme. Assuming 40-80% overall vaccine efficacy (64-86% for TB-meningitis) and 10 years of protection, we calculated the cost and number of immunizations required to prevent one child from developing TB, the total number of TB cases averted by vaccination and total costs required for the programme.

RESULTS

Based on an assumption of flexible vaccine efficacy (40-80%), we estimated that 111-542 TB cases including 10-27 of TB-meningitis would be prevented during the 10 years after BCG vaccination among the cohort of infants born in 1996. About US$35 950-175 862 or 2125-10 399 immunizations would be required to prevent one child from developing TB. Sensitivity analyses covering a wide duration of protection, incidence of TB, vaccine coverage and discount rate, revealed that other than vaccine efficacy, the cost of preventing a single case of TB is highly sensitive to the duration of BCG protection and TB incidence.

CONCLUSION

The cost per case of TB prevented is heavily dependent on vaccine efficacy and the duration of protection, and is high compared with the cost of treating one child who has developed TB.

Estimating the effect of bystander-initiated cardiopulmonary resuscitation in Japan

Low incidence of bystander-initiated cardiopulmonary resuscitation (CPR) is allegedly responsible for poor survival from out-of-hospital cardiac arrest (OHCA) in Japan. This study was conducted to determine significant predictors for survival after collapse-witnessed OHCA of presumed cardiac etiology to investigate the impact of bystander-initiated CPR. Logistic regression analysis of OHCA of presumed cardiac etiology was performed on retrospective data sets from three Japanese suburban communities. All arrest incidents were witnessed and occurred prior to the arrival of EMS personnel. Outcome measure was survival to discharge. Initial electrocardiogram (ECG) rhythm (ventricular fibrillation (VF) or not), interval from collapse to CPR (within 5 min or not), and initial ECG rhythm/collapse-to-CPR interval interaction were significantly associated with survival. Patient age (70 years or less/over 70 years), interval from collapse to EMS response, and bystander-initiated CPR were significantly associated with VF in an initial ECG. The effectiveness of bystander-initiated CPR for OHCA can be successfully predicted based on the interval from collapse to CPR and initial ECG rhythm. The increase in the proportion of bystander-initiated CPR from the present level of 20-50% would be expected to rescue another 1800 victims of OHCA per year in Japan.

Pseudohyperkalaemia caused by recentrifugation of blood samples after storage in gel separator tubes

Because hyperkalaemia above a certain level is life-threatening, erroneous interpretation of serum potassium concentration may misguide and complicate diagnostic procedures. We investigated a number of cases with pseudohyperkalaemia, which was assumed to have been caused by the recentrifugation of blood samples after storage in gel separator tubes. The time trend of serum potassium concentration was explored before (January-March 1997) and after (May-July 1997) ceasing the practice of recentrifuging blood samples after overnight storage. Next, we conducted an experiment on a volunteer's serum. The sample was divided into two groups and centrifuged once (control group) or twice (recentrifugation group). For both groups, serum potassium concentrations were measured immediately, and at 24, 48 and 72 h. For the recentrifugation group, the second centrifugation was done just before the measurement. The time series study showed that the mean serum potassium concentrations measured after overnight storage were 4.68 (95% CI: 4.60-4.76) mmol/L before and 4.14 (4.07-4.20) mmol/L after ceasing the practice of recentrifugation. The experiment showed that the mean serum potassium concentrations in the control group versus the recentrifugation group were 3.95 (95% CI: 3.89-4.01) mmol/L versus 4.05 (3.92-4.17) immediately (P=0.0979), 3.95 (3.89-4.01) versus 5.95 (5.61-6.29) at 24 h (P=0.0001), 4.13 (4.05-4.22) versus 6.90 (6.46-7.34) at 48 h (P=0.0001), and 4.22 (3.85-4.58) versus 7.61 (6.94-8.30) at 72 h (P<0.0001). Recentrifugation of blood samples after storage causes a spurious rise in serum potassium concentration to the degree of clinical significance. Clinicians and biochemists should take appropriate measures to stop this practice.

Differences in management and outcomes of acute myocardial infarction among four general hospitals in Japan

OBJECTIVE

To ascertain the differences among hospitals in Japan in the management patterns and outcomes of patients with acute myocardial infarction (AMI).

DESIGN

Retrospective cohort study by means of patient chart review.

SETTING

Four tertiary-care teaching hospitals in Japan observed over a 1-year period.

STUDY PARTICIPANTS

Consecutive patients (N=482) admitted for AMI.

MAIN OUTCOME MEASURES

Clinical characteristics, rates of diagnostic and therapeutic procedures performed, cardiac complications, and length of stay.

RESULTS

Patients' clinical characteristics differed significantly among the four hospitals in terms of age, gender, and prior cardiac history, but not in terms of comorbidity or infarct location. The frequency and type of diagnostic and therapeutic procedures were different, and in-hospital mortality varied (4-14%, P=0.022). Average length of hospital stay ranged from 15.8+/-12.6 days to 41.0+/-19.4 days (P=0.0001). After adjustment for the clinical characteristics, these differences remained significant among hospitals.

CONCLUSION

Considerable differences in the management and outcomes of patients with AMI exist in Japan.

The defibrillation system of basic emergency medical technicians in Japan: a comparison with other systems from a 14-year review of out-of-hospital cardiac arrest reports

Although seven years have passed after basic emergency medical technician (EMT) defibrillation system was introduced in Japan, the overall survival for out-of-hospital cardiac arrest (OHCA) remains poor. We investigated factors leading to such an unanticipated result in Japan by comparing the data of OHCA in Japan with those in other countries. We obtained population-based OHCA data from three communities in Japan. We also performed a comprehensive literature and manual search to identify reports that included rates for incidence and survival or provided sufficient data for the calculation of these rates of OHCA. Statistical analysis was performed to compare survival and incidence rates between the communities. We identified 36 articles from 16 countries by a comprehensive literature search. There was no significant difference in incidence and survival rates among communities in Japan. Although the incidence rate of collapse-witnessed OHCA with ventricular fibrillation (VF) was much lower in Japan than western countries, the proportions of survival from it were comparable to those. Basic-EMT defibrillation system in Japan has yielded excellent result in terms of the survival of VF cases. However, much lower proportion of VF to all cases is responsible for lower overall rates of survival from OHCA in Japan.

Cost-effectiveness analysis of dopamine agonists in the treatment of Parkinson's disease in Japan

BACKGROUND

Dopamine agonists such as bromocriptine or pergolide are often used in Japan to treat Parkinson's disease. Dopamine agonists are relatively expensive drugs; economic evaluations are required.

OBJECTIVE

To evaluate the cost effectiveness of dopamine agonists for the treatment of Parkinson's disease in Japan.

DESIGN AND SETTING

We used a Markov model to simulate the course of Parkinson's disease and to compare the cost effectiveness of dopamine agonists added to levodopa with that of levodopa alone in Japan. The model assumed that 60-year-old men with Parkinson's disease in Hoehn-Yahr (HY) stages 2 to 5 using levodopa were administered dopamine agonists or continued on levodopa alone. The incremental cost effectiveness of dopamine agonists used for 10 years was then estimated.

STUDY PERSPECTIVE

Societal.

MAIN OUTCOME MEASURES AND RESULTS

In the patients in HY stage 2, the incremental cost effectiveness of dopamine agonists was 18,610,000 to 19,320,000 yen per quality-adjusted life-year (QALY) [$US 172,300 to $US 178,900/QALY; 1998 values] . In patients in HY stage 3 or higher, the use of dopamine agonists was dominant over levodopa alone mainly due to reduced cost for care. In sensitivity analyses, costs and effectiveness of dopamine agonists significantly influenced the results. The use of a generic formulation of bromocriptine was dominant over levodopa alone even in the patients with HY stage 2 disease.

CONCLUSIONS

Dopamine agonists appear to be cost effective in advanced Parkinson's disease, although their use is sensitive to the costs and effectiveness of dopamine agonists. If factors discouraging the prescription of generic drugs in Japan were removed, the treatment of Parkinson's disease would become more cost effective.

[The effect of suplatast tosilate on immunological parameters for the patients with atopic dermatitis]

A dose of 300 mg/day of suplatast tosilate was administered to one hundred one cases of atopic dermatitis for eight weeks, and the severity scores, peripheral blood eosinophil count, total serum IgE levels, plasma eosinophil cationic protein (ECP) levels, and other immunological parameters before and after the trial were observed and comparatively examined. The results are as follows: 1) Temporary improvements were found in the scores of severity and itchiness on all evaluated skin regions (face, limbs, and trunk). These scores decreased significantly for all observation periods at two, four, six and eight weeks after administration of suplatast tosilate compared with those before the administration (p < 0.01). 2) There was no sign of adverse effects on the drug. In the blood tests, one patient displayed elevated levels of GPT and another showed elevated total bilirubin. In the urine test (qualitative test), one case with positive urinary protein was observed. 3) Clinical examinations including assessment of the immunologic parameters were conducted at an average of 8.68 +/- 0.36th week. The peripheral blood eosinophil count, the percentage of eosinophil, and plasma ECP levels significantly diminished compared with those before administration, but no significant difference was found in total serum IgE levels and LDH levels. 4) The subjects were divided into two groups, one in which the clinical scores were improved by more than five and another with scores of less than five (including worsening), and the fluctuation of the immunological parameters (values before and after administration of the drug) of the two groups were compared. As a result, a significant difference was observed in the plasma ECP levels (p = 0.02) and peripheral blood eosinophil count (p = 0.091), but no difference was observed in total serum IgE levels and LDH levels. From the above mentioned results, the high efficacy and safety of suplatast tosilate in the treatment of severe atopic dermatitis were confirmed. At the same time, a decrease in the peripheral blood eosinophil count and the serum ECP levels were observed, suggesting the possibility that these values could be used as indices of the severity of atopic dermatitis.

Melatonin scavenges hydroxyl radical and protects isolated rat hearts from ischemic reperfusion injury

During postischemic reperfusion, free radicals are produced and have deleterious effects in isolated rat hearts. We investigated whether melatonin (MEL) reduces the production of hydroxyl radical (*OH) in the effluent and aids in recovery of left ventricular (LV) function. Hearts were subjected to 30 min of ischemia followed by 30 min of reperfusion. Salicylic acid (SAL) was used as the probe for *OH, and its derivatives 2,5- and 2,3-dihydroxybenzoic acid (DHBA) were quantified using HPLC. In addition, thiobarbituric acid reactive substances (TBARS) in the myocardium was measured. Plateaus in the measurement of 2,5- and 2,3-DHBA were seen from 3 to 8 min after reperfusion in each group. The group that received 100 microM MEL+ SAL had significantly reduced amounts of 2,5- and 2,3-DHBA by multiple folds, compared to the SAL group. TBARS was significantly decreased in the 100 microM MEL group (1.20+/-0.36 vs 1.85+/-0.10 micromol/g of drug-free group, p<0.001). More importantly, the 100 microM MEL group significantly recovered in LV function (LV developed pressure, +dp/dt, and -dp/dt; 63.0%, 60.3%, and 59.4% in the 100 microM MEL group; 30.2%, 29.7%, and 31.5% in the drug-free group, respectively; p<0.05). Duration of ventricular tachycardia or ventricular fibrillation significantly decreased in the 100 microM MEL group (100 microM MEL, 159+/-67 sec; drug-free, 1244+/-233 sec; p<0.05). As a result of scavenging *OH and reducing the extent of lipid peroxidation, MEL is an effective agent for protection against postischemic reperfusion injury.

Association of thromboangiitis obliterans with cigarette and bidi smoking in Bangladesh: a case-control study

BACKGROUND

In addition to cigarettes, bidi, made of unprocessed and low-grade tobacco, is being smoked widely in Bangladesh and in other south Asian countries. The cause-and-effect relationship is established between thromboangiitis obliterans (TAO) and smoking. However, type of smoking material(s) most strongly related to TAO is not yet determined.

METHODS

We conducted a hospital-based case-control study in Rajshahi, Bangladesh, to examine the relationship of type of smoking materials (cigarette versus bidi) with TAO on 103 pairs of cases and controls matched by age and sex during the period 1995 to 1996. The inclusion criteria for cases were newly diagnosed TAO and current smoker, while those for controls were current smokers admitted to the hospital due to non-cardiovascular diseases.

RESULTS

Among the cases 35.0% and 65.0% were cigarette and bidi smokers, while among the controls 69.9% and 30.1%, respectively. Using logistic regression approach, considering cigarette smoking approximately 10 per day as reference, bidi smoking >20 per day (odds ratio [OR] = 34.76, 95% CI: 6.11-197.67) and 11-20 per day (OR = 7.12, 95% CI: 2.35-21.63) had greater risk of TAO after adjusting confounding factors. Respective OR for bidi smoking approximately 10 per day, cigarette smoking 11-20 per day and cigarette smoking >20 per day, were 2.18 (95% CI: 0.64-7.51), 3.81 (95% CI: 1.37-10.57) and 6.88 (95% CI: 1.87-25.30).

CONCLUSION

Within the limits inherent to case-control study, our findings suggest that bidi smoking may well play a more important role in causing TAO than cigarettes. It leads to the speculation that unprocessed and low-grade tobacco used for producing bidi might play a more potent role to initiate TAO than cigarettes.

NC/Nga mice: a mouse model for atopic dermatitis

Atopic dermatitis (AD) is a common pruritic disease that occurs primarily in infancy and childhood. AD is characterized by itching and the patient having an individual or family history of atopic diseases. Although AD is also frequently associated with elevated serum IgE levels and with common environmental factors contributing to its pathogenesis, the etiology of AD is still unknown. We examined NC/Nga mice (NC mice) that showed AD-like skin lesions with aging as a possible mouse model for AD. NC mice were maintained under conventional (Conv) or specific pathogen-free (SPF) conditions. Clinical symptoms, serum IgE levels and histopathology of the skin were compared between these 2 groups, and we explored their application as a model of human AD. It was found that the skin lesions of inbred NC mice were clinically and histologically very similar to human AD when the mice were raised under Conv conditions, but not under SPF conditions, and we assumed that some kinds of environmental factors might trigger AD-like signs and symptoms in NC mice. To further investigate the pathophysiology and treatment of AD, a suitable animal model is absolutely required, and NC mice are very useful for this purpose.

Influence of superstition on the date of hospital discharge and medical cost in Japan: retrospective and descriptive study

OBJECTIVES

To determine the influence of superstition about Taian (a lucky day)-Butsumetsu (an unlucky day) on decision to leave hospital. To estimate the costs of the effect of this superstition.

DESIGN

Retrospective and descriptive study.

SETTING

University hospital in Kyoto, Japan.

SUBJECTS

Patients who were discharged alive from Kyoto University Hospital from 1 April 1992 to 31 March 1995.

MAIN OUTCOME MEASURES

Mean number, age, and hospital stay of patients discharged on each day of six day cycle.

RESULTS

The mean number, age, and hospital stay of discharged patients were highest on Taian and lowest on Butsumetsu (25.8 v 19.3 patients/day, P=0.0001; 43.9 v 41.4 years, P=0.0001; and 43.1 v 33.3 days, P=0.0001 respectively). The effect of this difference on the hospital's costs was estimated to be 7.4 million yen (¿31 000).

CONCLUSION

The superstition influenced the decision to leave hospital, contributing to higher medical care costs in Japan. Although hospital stays need to be kept as short as possible to minimise costs, doctors should not ignore the possible psychological effects on patients' health caused by dismissing the superstition.

Protection of chickens with or without maternal antibodies against both Marek's and Newcastle diseases by one-time vaccination with recombinant vaccine of Marek's disease virus type 1

We constructed a stable recombinant Marek's disease virus type 1 (rMDV1) expressing the fusion protein (F) of Newcastle disease virus (NDV) by inserting the coding sequence within the US10 gene of MDV1 by homologous recombination and designated this as rMDV1-US10L(F). The NDV-F protein was significantly expressed under control of the SV40 late promoter in cultured cells infected with the rMDV1. To examine the protective efficacy of the rMDV1, specific pathogen-free (SPF) chickens were vaccinated with rMDV1 at one-day-old. Almost all birds (> 95%) were protected from NDV challenge via intramuscular, ocular, intranasal and intratrachial routes at 4 weeks after vaccination. The rMDV1 showed 100% protection against virulent MDV1 challenge in SPF chickens. Antibody responses against NDV-F and MDV1 antigens were observed at least up to 11 weeks after immunization. When the sera from chickens vaccinated with the rMDV1 were examined for the presence of anti-NDV-F antibody on the day of NDV challenge, the vaccinated bird group which did not survive from NDV challenge were found to show lower antibody titers than the surviving group. The rMDV1 also provided sufficient protection against NDV and MDV1 challenges in commercial chickens with maternal antibodies against NDV-F and MDV1 antigens.

[Congenital Minamata disease accompanied by arachnoid cyst (author's transl)]

A male, born on December 8, 1956, during the period when many Minamata diseases broke out in a district. His parents who ate much fish and shell fish taken in Minamata Bay suffered from the light, incomplete Minamata disease showing sensory disturbance, the constriction of the visual field, muscular weakness, etc. He weighed 3,225 gr. upon the normal birth given 10 months after pregnancy. His abnormalities were noted since his head was not stabilized on the neck even six months after the birth. Because of the delay in the development of the motor function, he became barely able to sit, stand up and begin walking at the ages of 3, 5 and 6 respectively. In 1962 (at the age of 6), his congenital Minamata disease was diagnosed in view of his clinical symptoms and epidemiological conditions. The mercury value in the hair and blood upon the birth is not known because a considerable time had elapsed after the birth when his mercury poisoning was discovered. However, the clinical symptoms included intelligence disturbance, character change, dysarthria, primitive reflexes, strabismus, hypersalivation, ataxia and hyperkinesia, indicating a typical congenital Minamata disease. Until he became 13 years old (1969) or so, his mental and motor function developed, both gradually. In the same year, he was admitted to a special class for the handicapped. EEG examination revealed that there was a slow alpha activity in the basic pattern and that 6 Hz positive spike was found in the sleep EEG. The constriction of the visual field was classified through examination.2+