Kinetic-pharmacodynamic model of warfarin for prothrombin time-international normalized ratio in Japanese patients

AIMS

Genotype-guided dosing algorithms can explain about half of the interindividual variability in prothrombin time-international normalized ratio (PT-INR) under warfarin treatment. This study aimed to refine a published kinetic-pharmacodynamic model and guide warfarin dosage for an optimal PT-INR based on renal function.

METHODS

Using a retrospective cohort of adult patients (>20 years) who were administered warfarin and underwent PT-INR measurements, we refined the kinetic-pharmacodynamic model with age and the genotypes of cytochrome P450 2C9 and vitamin K epoxide reductase complex subunit 1 using the PRIOR subroutine in the nonlinear-mixed-effect modelling programme. We searched the significant covariates for parameters, such as the dose rate for 50% inhibition of coagulation (EDR50 ), using a stepwise forward and backward method. Monte Carlo simulation determined a required daily dose of warfarin with a target range of PT-INR (2.0-3.0 or 1.6-2.6) based on the significant covariates.

RESULTS

A total of 350 patients with 2762 PT-INR measurements were enrolled (estimated glomerular filtration rate [eGFR]: 47.5 [range: 2.6-199.0] mL/min/1.73 m2 ). The final kinetic-pharmacodynamic model showed that the EDR50 changed power functionally with body surface area, serum albumin level and eGFR. Monte Carlo simulation revealed that a lower daily dose of warfarin was required to attain the target PT-INR range as eGFR decreased.

CONCLUSIONS

Model-informed precision dosing of warfarin is a valuable approach for estimating its dosage in patients with renal impairment.

Classification of Patients with Painful Tumors to Predict the Response to Palliative Radiotherapy

PURPOSE/OBJECTIVE(S)

Palliative radiotherapy is an effective and commonly used treatment for pain relief in metastatic cancer patients. This study aimed to classify the patients to predict their response to palliative radiotherapy.

MATERIALS/METHODS

This study used the data from our single-center, prospective observational study (UMIN000044984), which included all patients undergoing palliative radiotherapy for the painful tumor, except for postoperative setting or brain metastases. The eligibility criteria were as follows: (1) numerical rating scale (NRS) was two or more before treatment, and (2) underwent palliative radiotherapy between August 2021 and September 2022. Questionnaires for pain site, NRS, and presence/dose of opioids were obtained before, on the last day of treatment, two weeks later, one month later, three months later, and every three months after that. Patients with severe performance status (PS) were contacted by telephone. Pain response was defined to reduce NRS 2 or more at the treated site without an analgesic increase. The primary outcome was the response rate within three months of the treatment. We used multivariable logistic regression to find the independent prognostic factors for the response based on the following covariates: age, sex, PS, body mass index, NRS, history of radiotherapy, treated site, radiographic features (lytic/sclerotic/mixed), metastatic complication, presence/dose of opioids, bone-modifying agents, radiation dose, type of primary tumor, radiosensitivity, number of metastases, and days from diagnosis to treatment. A classification model was created using significant factors, and response rates were calculated for each class. Statistical significance was defined as P<0.05.

RESULTS

Among 488 targets of 300 patients registered, 366 targets of 261 patients met the criteria. The median age was 65 years, 44% were female, and PS (0/1/2/3/4) was 6/63/18/9/4%. The major type of tumor was gastrointestinal (32%), lung (19%), and breast (12%). Bone metastases were 75% at treated sites. Opioids were used by 72%, BMA was 27%, and chemotherapy was 50%. Re-irradiation rate was 22%. With a median follow-up of 5.8 months, 113 patients were alive, 129 had died, and 20 were lost follow-up. The average NRS was reduced from 6.1 to 3.1 from pretreatment to 3 months later per evaluable 232 targets, resulting in a pain relief rate of 60%. Opioids use (P<0.001) and re-irradiation (P<0.001) were significant factors of poor response in multivariate analysis. In our classification model, 89 targets were classified as class 1 (no opioids & no irradiation history), 211 were class 2 (other than class 1 and 3), and 66 were class 3 (opioids & re-irradiation), were 75/61/36% (P<0.001) of response rate. The 6-month cumulative pain progression rate was 12/22/32% (P<0.001), respectively.

CONCLUSION

Palliative radiotherapy is highly effective for patients with painful tumors especially for those without previous irradiation history or use of opioids.

Hyperkalemia by eplerenone or esaxerenone in the presence or absence of clarithromycin in hypertensive patients: a retrospective observational cohort study

OBJECTIVE

Mineralocorticoid receptor antagonists (MRAs), eplerenone and esaxerenone, cause hyperkalemia dose-dependently. We investigated the cytochrome P450 3A4-mediated drug-drug interaction between the MRAs and clarithromycin.

METHODS

This retrospective observational study included adult hypertensive patients with MRA plus clarithromycin or MRA alone with a propensity score matching (1:1). The difference in serum potassium level (ΔK, maximum level - baseline level) between groups was compared using the Mann-Whitney U -test. Linear regression analysis was used to detect variables that correlated with ΔK in patients with MRA plus clarithromycin.

RESULTS

After propensity score matching (each nine patients), serum potassium level was elevated after treatment with MRA plus clarithromycin [4.3 (3.5 to 5.1) meq/l to 4.9 (4.0 to 5.5) meq/l, P  = 0.0234] and MRA alone [4.3 (4.0 to 4.7) meq/l to 4.6 (4.4 to 5.2) meq/l, P  = 0.0469]. Although there was no significant difference in ΔK between groups [MRA plus clarithromycin: 0.5 (0.1 to 1.1) meq/l vs. MRA alone: 0.3 (0.1 to 1.2) meq/l, P  = 0.7231], ΔK was significantly higher in esaxerenone plus clarithromycin than in esaxerenone alone [0.6 (0.5 to 1.1) meq/l vs. 0.1 (0.1 to 0.2) meq/l, P  = 0.0495]. Conversely, clarithromycin did not show a significant effect on ΔK in patients with eplerenone [0.4 (-0.2 to 1.2) meq/l vs. 0.8 (0.1 to 1.3) meq/l, P  = 0.5745]. A positive correlation was found between ΔK and age in patients with MRA plus clarithromycin ( y  = 0.03 ×  x - 1.38, r  = 0.71, P  = 0.0336).

CONCLUSION

The drug-drug interaction between MRAs and clarithromycin was evident, particularly in esaxerenone. Serum potassium levels should be closely monitored in older patients.

Correlation between magnesium pre-loading and cisplatin-induced nephrotoxicity in 5-fluorouracil/cisplatin combination therapy for esophageal cancer

The use of cisplatin may cause nephrotoxicity in patients. Hydration solutions supplemented with magnesium could reduce cisplatin-induced nephrotoxicity. In this study, we evaluated the preventive effect of magnesium pre-loading on cisplatin-induced nephrotoxicity in patients with esophageal cancer. We retrospectively evaluated the prevalence of, and risk factors for, nephrotoxicity in 160 patients with esophageal cancer treated with the 5-fluorouracil/cisplatin regimen from 2014 to 2016 with and without magnesium supplementation. Significant differences were observed between the magnesium and non-magnesium groups in terms of frequency of estimated creatinine clearance of grade 2 or higher that was at 4% (n = 3) and 13% (n = 10) (p = 0.027), respectively. The logistic regression analysis revealed that eCcr of grade 2 or higher was significantly associated with the non-magnesium regimen (odds ratio (OR), 4.175; 95% confidence interval (CI) = 1.061-16.430; p = 0.041) and age ≥ 65 years (OR, 13.951; 95% CI = 1.723-112.974; p = 0.014). This study suggests that 20 mEq magnesium pre-loading significantly reduces the prevalence of cisplatin-induced nephrotoxicity. Furthermore, when cisplatin is administered to individuals older than 64 years, a close observation for the onset of cisplatin-induced nephrotoxicity is crucial.

External Evaluation of a Bayesian Warfarin Dose Optimization Based on a Kinetic-Pharmacodynamic Model

Warfarin is a representative anticoagulant with large interindividual variability. The published kinetic-pharmacodynamic (K-PD) model allows the prediction of warfarin dose requirement in Swedish patients; however, its applicability in Japanese patients is not known. We evaluated the model's predictive performance in Japanese patients with various backgrounds and relationships using Bayesian parameter estimation and sampling times. A single-center retrospective observational study was conducted at Tokyo Women's Medical University, Medical Center East. The study population consisted of adult patients aged >20 years who commenced warfarin with a prothrombin time-international normalized ratio (PT-INR) from June 2015 to June 2019. The published K-PD model modified by Wright and Duffull was assessed using prediction-corrected visual predictive checks, focusing on clinical characteristics, including age, renal function, and individual prediction error. The external dataset included 232 patients who received an initial warfarin daily dose of 3.2 ± 1.28 mg with 2278 PT-INR points (median [range] follow-up period of 23 d [7-28]). Prediction-corrected visual predictive checks carried a propensity for underprediction. Additionally, age >60 years, body mass index ≤25 kg/m², and estimated glomerular filtration rate ≤60 mL/min/1.73 m² had a pronounced tendency to underpredict PT-INR. However, Bayesian prediction using four prior observations reduced underprediction. To improve the prediction performance of these special populations, further studies are required to construct a model to predict warfarin dose requirements in Japanese patients.

Development of a simple method for measuring tedizolid concentration in human serum using HPLC with a fluorescent detector

The objective of the present study was to develop a method to measure tedizolid (TZD) concentration for studying target concentration intervention, pharmacokinetics, and pharmacodynamics of TZD. We established a high-performance liquid chromatography-fluorescence detector assay to measure the TZD concentration in serum for clinical application. Chromatographic separation was carried out on a 5 μm octadecyl silane hypersil column 150 mm × 4.6 mm. The mobile phase consisted of 0.1 M phosphoric acid and methanol (60:40, pH 7.0). Detection was performed at 300 nm and 340 nm for the excitation and emission wavelengths, respectively. The average retention times of TZD and the internal standard were 12.9 and 8.8 min, respectively. High linearity was exhibited over a concentration range of 0.025 to 10.0 μg/mL for TZD (R2 > 0.999). The intra- and inter-assay accuracies of TZD were 99.2% to 107.0% and 99.2% to 107.7%, respectively. The lower limit of quantitation and the lower limit of detection for TZD measurement were 0.025 and 0.01 μg/mL, respectively. The extraction recoveries of TZD were 100.4% to 114.1%.The high-performance liquid chromatography method developed in this study could separate the analytes with a single eluent (isocratic system), within a total run time of 15 min. Both TZD and IS were well separated, without interference from the peaks. Sharp peaks were observed in the chromatograms; problems such as double peaks, shoulder peaks, and broadened peaks were not observed. The proposed method showed acceptable analytical performance and could be used to evaluate serum TZD concentrations in patients.

Habitual exercise provides better prognosis for cardiac arrest with coronary artery disease

Background

Although regular physical activity has beneficial cardiovascular effects, exercise can trigger sudden cardiac arrest (SCA). Coronary artery disease (CAD) was identified as the most common cause of an exercise-related out-of-hospital cardiac arrest (OHCA). Regular exercise has been reported to reduce the risk of plaque rupture in animal studies and basic research. Therefore, we compared the coronary artery findings in CAD-OHCA patients with and without habitual exercise.

There have been few reports on whether regular exercise changes the prognosis in OHCA due to CAD (CAD-OHCA). We investigated the association between the better clinical outcome and the regular exercise in patients with CAD-OHCA.

Methods

This is a single-center retrospective analysis from 2006 to 2019. The consecutive 397 patients with OHCA due to myocardial ischemia underwent coronary angiography (CAG). After excluding 73 patients with vasospastic angina, the remaining 324 patients with CAD were enrolled in this study. We divided these patients into two groups according to whether they were habitually exercising (Exercise group: N=37) or not/unknown (Non-Exercise group: N=287).

Clinical outcome was a 30-day survival with minimal neurologic impairment represented by a Glasgow-Pittsburgh Cerebral Performance Categories Scale value 1 or 2.

Results

The patients in the Exercise Group were significantly younger (exercise vs. non-exercise, 57±12 vs. 64±12 years; P&lt;0.01) than those in the non-exercise group. The Exercise group had a lower incidence of diabetes mellitus (22% vs. 42%; P=0.02) and a higher incidence of dyslipidemia (81% vs. 62%; P=0.02) than the non-exercise group. The time from collapse to cardiopulmonary resuscitation (1.4±4.0 vs. 3.0±4.8min) and from collapse to return of spontaneous circulation (11.9±10.0 vs. 28.0±25.3min) were shorter in Exercise group (all p&lt;0.05). The ST-segment elevation was recorded on electrocardiography in fewer of the Exercise group (22% vs. 63%; P&lt;0.01). The finding of culprit lesion in the coronary arteries on arrival resulted significant differences between the 2groups (good collateral and/or TIMI3 flow: 62% vs. 25%, the plaque rupture and/or thrombus: 22% vs. 73%) (all p&lt;0.01) (Figure 1). Kaplan-Meier curve showed Exercise group has better neurological outcome at 30days compared than Non-Exercise (95% vs 51%; P&lt;0.001, log-rank test) (Figure 2). Multivariable Cox proportional hazards models revealed that a habitual exercise was one of the predictors of a good neurological outcome (HR 0.21, 95% CI 0.05–0.92; P=0.039).

Conclusions

The patients with habitual exercise had less plaque rupture, less coronary thrombosis than non-exercise. The patients with regular exercise had better clinical outcomes than non-exercise after CAD-OHCA.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Tokyo Metropolitan Goverment Figure 1. Findings of the culprit lesion in coronar arteriesFigure 2. Kaplan-Meier analysis

Double inferior vena cava filter implantation in a patient with duplication of the inferior vena cava

An 84-year-old-woman was admitted because of syncope and dyspnea. She also required surgery for lumbar disc herniation. Computed tomography revealed bilateral massive pulmonary thromboembolism, deep vein thrombosis, and duplication of the inferior vena cava (IVC) in which the left IVC had merged with the left renal vein. Two retrievable IVC filters were deployed in both IVCs, and direct oral anticoagulant therapy was started. After orthopedic surgery for the lumbar disc herniation, the IVC filters were retrieved. No complications occurred. Different treatment strategies could be required for IVC filter implantation in a patient with duplication of the IVC.

Application of a hemodialysis clearance prediction model using quantitative structure-pharmacokinetic relationship analysis

Hemodialysis (HD) is a method used to remove biogenic substances or blood components that cause disease and some drugs used by patients to treat their diseases. Therefore, dosing schedule must be planned according to HD clearance (CL_HD ) when medical treatment is provided to patients receiving HD. We aimed to clarify the physical properties (eg, octanol-water partition coefficient and molecular electronegativity) or pharmacokinetic parameters (eg, volume of distribution) of compounds affecting CL_HD and to construct a mathematical model to predict CL_HD . The analysis covered individual CL_HD data for nine compounds from the literature. The molecular descriptors which are physical properties or pharmacokinetic parameters were calculated using the structural formula of each compound, and searched for factors related to CL_HD among the calculated 148 molecular descriptors. Nonlinear mixed-effects model analysis with CL_HD as objective variable and molecular descriptors as explanatory variable was conducted to examine the factor affecting CL_HD and develop a model for predicting CL_HD . The logarithm of the brain/blood partition coefficient was detected as a factor affecting CL_HD . The predictive accuracy of CL_HD using the constructed mathematical model with the logarithm of the brain/blood partition coefficient as explanatory variable was adequate.

Venous Thromboembolism in Patents With Lung Cancer

Lung cancer is the leading cause of death from cancer in Japan. Studies in other countries have reported a venous thromboembolism (VTE) rate of 4%-20% in cancer patients. In this study, we aimed to determine the incidence of VTE in lung cancer patients in Japan and compared the characteristics of patients with and without VTE. In this retrospective cohort study, the clinicopathological characteristics of study patients with and without concomitant VTE were compared. Patients with lung cancer treated at Fukui Prefectural Hospital, Japan from 2008 to 2017. Of the 1471 patients with lung cancer studied, 28 developed VTE. Five patients developed pulmonary thromboembolism (PTE) alone, 9 PTE with concomitant deep vein thrombosis, and 14 deep vein thrombosis alone. Compared with patients in the non-VTE group, the VTE group was significantly younger (mean value ± SD 66.3 ± 10.1 vs. 73.0 ± 10.6 years, p = 0.001), contained significantly more patients with stage IIIb-IV disease (p = 0.002), and had a significantly higher rate of chemotherapy (p < 0.001) and radiation therapy (p = 0.007). There was no significant difference in median survival time from lung cancer diagnosis between the VTE and non-VTE groups. The 1-year mortality rate after VTE diagnosis was 60.7%. Lung cancer was the most frequent cause of death, followed by infection and VTE. Several baseline characteristics differed between patients with and without VTE. The prognosis may worsen after development of VTE, suggesting that lung cancer patients should be carefully monitored for it.

Method of Determining Pyrrole-Imidazole Polyamide in Rat Plasma Using Ultra-Fast Liquid Chromatography-Ultraviolet Spectrometry

To improve the efficiency of drug-discovery research on pyrrole-imidazole polyamides (PIs), a more rapid method for quantitative and qualitative measurement of PI in rat plasma samples was developed here using ultra-fast liquid chromatography-ultraviolet spectrometry (UFLC-UV) in order to shorten the measurement time. A measurement method of PIs by HPLC developed until now takes 45 min for one sample measurement. This method was inefficient to investigate extraction conditions from biological samples and measurement of animal experimental samples. In the developed method of this study, PI and phenacetin (internal standard, IS) were separated with an ACQUITY UPLC HSS T3 (1.8 µm, 2.1 × 50 mm; Nihon Waters K.K., Japan) column using a mobile phase of 0.1% acetic acid (mobile phase A) and acetonitrile (mobile phase B) at a flow rate of 0.3 mL/min with a linear gradient. The detection wavelength was 310 nm. The calibration curve was linear in the range of 0.225-4.5 µg/mL (correlation coefficients ≥0.9995, n = 5). The intra- and inter-day accuracies were in the range of -6.04 to 12.2%, and the precision was less than 2.99%. The measurement time of this method (7 min per injection) was markedly shortened to about one-sixth of the previous measurement time (45 min per injection). This is the first report describing the quantitative and qualitative measurement of PI in plasma using UFLC-UV. The present method will be very useful for the drug-discovery research of PIs.

P3708Prognostic significance of electrocardiographic changes after subarachnoid hemorrhage

Background and purpose

Many reports have examined electrocardiographic (ECG) changes after subarachnoid hemorrhage from long ago; however, there are few reports on the prognosis of patients who have an ECG abnormality. Therefore, in this study, the prognoses of patients with subarachnoid hemorrhage showing abnormal ECG findings were retrospectively analyzed.

Methods

Over 30 months from January 2014 to June 2016, 199 patients (mean age, 61.1±17.0 years; 46.7% male) admitted with a subarachnoid hemorrhage (SAH) were enrolled. To assess the mechanism underlying abnormal ECG in the SAH, predictor variables, such as demographics (age, sex, and body surface area), hemodynamics (heart rate and systolic blood pressure), blood biochemical results, neurological assessments (Glasgow Coma Scale), and computed tomography (CT) severity classification (World Federation of Neurosurgical Societies classification) were recorded. The subarachnoid hemorrhage was classified into either the cerebral aneurysm rupture group (N=132) or traumatic subarachnoid hemorrhage group (N=67) and analyzed.

Results

In the cerebral aneurysm rupture group, the QT prolongation was significantly increased compared with the traumatic subarachnoid hemorrhage group (424.8±87.7 ms vs. 400.5±95.8 ms, P<0.05). There was a correlation between consciousness level (Glasgow Coma Scale) on admission and QT prolongation, and significant QT prolongation was observed in critical patients (Pearson's correlation coefficient test P=0.04). ST changes correlated with CT classification severity (WFNS classification), and the most severe group (WFNS Grade 5) showed significant ST changes. On admission, the cerebral aneurysm rupture group and 97.0% in the traumatic subarachnoid hemorrhage group.

Conclusions

Significantly prolonged QT and ST changes are noted in patients with severe aneurysmal subarachnoid hemorrhage. The cause of the ECG abnormality in subarachnoid hemorrhage patients is not yet understood. A small number of experimental animal models have shown that electrocardiogram abnormalities associated with subarachnoid hemorrhage develop in the brain stem, and an autonomic nerve abnormality may also be involved.

A D-dimer is positively correlated with both aneurysm trauma and traumatic subarachnoid hemorrhage and may be used for auxiliary diagnosis of a subarachnoid hemorrhage.

A comprehensive validation of very early rule-out strategies for non-ST-segment elevation myocardial infarction in emergency departments: protocol for a multicentre prospective cohort study

INTRODUCTION

Recent advances in troponin sensitivity enabled early and accurate judgement of ruling-out myocardial infarction, especially non-ST elevation myocardial infarction (NSTEMI) in emergency departments (EDs) with development of various prediction-rules and high-sensitive-troponin-based strategies (hs-troponin). Reliance on clinical impression, however, is still common, and it remains unknown which of these strategies is superior. Therefore, our objective in this prospective cohort study is to comprehensively validate the diagnostic accuracy of clinical impression-based strategies, prediction-rules and hs-troponin-based strategies for ruling-out NSTEMIs.

METHODS AND ANALYSIS

In total, 1500 consecutive adult patients with symptoms suggestive of acute coronary syndrome will be prospectively recruited from five EDs in two tertiary-level, two secondary-level community hospitals and one university hospital in Japan. The study has begun in July 2018, and recruitment period will be about 1 year. A board-certified emergency physician will complete standardised case report forms, and independently perform a clinical impression-based risk estimation of NSTEMI. Index strategies to be compared will include the clinical impression-based strategy; prediction rules and hs-troponin-based strategies for the following types of troponin (Roche Elecsys hs-troponin T; Abbott ARCHITECT hs-troponin I; Siemens ADVIA Centaur hs-troponin I; Siemens ADVIA Centaur sensitive-troponin I). The reference standard will be the composite of type 1 MI and cardiac death within 30 days after admission to the ED. Outcome measures will be negative predictive value, sensitivity and effectiveness, defined as the proportion of patients categorised as low risk for NSTEMI. We will also evaluate inter-rater reliability of the clinical impression-based risk estimation.

ETHICS AND DISSEMINATION

The study is approved by the Ethics Committees of the Kyoto University Graduate School and Faculty of Medicine and of the five hospitals where we will recruit patients. We will disseminate the study results through conference presentations and peer-reviewed journals.

Impact of renal function on mid-term outcomes in heart failure patients treated with tolvaptan

Background:

Although tolvaptan, an electrolyte-free water diuretic for congestive heart failure (HF), is reported to have no effect on long-term mortality or HF-related morbidity, there may exist some subgroups of patients who may receive beneficial effect of tolvaptan. The purpose of this study was to identify clinical factors associated with mid-term effect of tolvaptan on clinical outcomes of patients who discharged after acute HF.

Methods:

We retrospectively analyzed 140 patients (88 male; mean age, 77.1 ± 11.0 years) with acute HF who received tolvaptan (initial dose 8.6 ± 3.6 mg/day) during their hospitalization. They were divided into two groups according to how the tolvaptan was used at discharge; 77 in the tolvaptan-continued group and 63 in the discontinued group.

Results:

The Cox proportional hazards model revealed that eGFR was the only independent predictor for the occurrence of mid-term cardiac events (composite of re-hospitalization due to HF and all-cause death; aHR = 0.9870, p = 0.02597). The Kaplan–Meier survival curves of the two groups demonstrated no difference in cumulative event-free rates. In the subgroup with preserved renal function at admission (eGFR ⩾ 30 ml/min/1.73 m²), the continuous use of tolvaptan increased composite events (aHR = 2.130, p = 0.02549).

Conclusions:

The continuous use of tolvaptan after discharge did not affect mid-term cardiac events of HF overall but may be associated with increased cardiac events in the subgroup with preserved renal function. These findings suggest that the tolvaptan administration might need to be limited to treatment of in-hospital acute HF.

Trunk movement asymmetry associated with pain, disability, and quadriceps strength asymmetry in individuals with knee osteoarthritis: a cross-sectional study

OBJECTIVE

This study examined 1) the clinical relevance of trunk movement asymmetry, which was evaluated using a trunk-mounted inertial measurement unit (IMU), and 2) the relationship between trunk movement asymmetry and lower limb muscle strength asymmetry in individuals with knee osteoarthritis (OA).

DESIGN

One-hundred-thirty-one participants (mean age, 74.2 years; 71.8% female; Kellgren and Lawrence [K&L] grade ≥1) underwent gait analysis at their preferred pace for IMU-based measurement of trunk movement asymmetry (harmonic ratio [HR] and improved HR). The isometric strength of quadriceps and hip abductors was evaluated using a hand-held dynamometer. Pain and disability level were evaluated using a validated self-reported questionnaire. Multiple regression analyses with covariate adjustment were performed to examine the relationship between trunk movement asymmetry (independent variable) and pain, disability level, or muscle strength asymmetry (dependent variables).

RESULTS

Individuals with severe knee OA (K&L grade ≥3) had increased trunk movement asymmetry in the medio-lateral axis compared to those with a K&L grade of 1. Increased trunk movement asymmetry was associated with a greater knee pain and disability. The increased trunk movement asymmetry was significantly associated with an increase in the asymmetry of quadriceps strength, but not with asymmetry in the strength of hip abductor.

CONCLUSION

Our findings indicate that increased medio-lateral trunk movement asymmetry may be an indicator of impairment, rather than adaptation, in individuals with knee OA. This preliminary finding warrants validation by future study. Paying close attention to medio-lateral trunk movement asymmetry may be key to our understanding of OA-related pain and disability.

Early results of a randomized two-by-two factorial phase II trial comparing neoadjuvant chemotherapy with two and four courses of cisplatin/S-1 and docetaxel/cisplatin/S-1 as neoadjuvant chemotherapy for locally advanced gastric cancer

Background

Neoadjuvant chemotherapy (NAC) is a promising method of improving the survival of resectable gastric cancer. Cisplatin/S-1 (CS) and docetaxel/cisplatin/S-1 (DCS) are both effective against metastatic gastric cancer. This report clarified the impact of these regimens on early endpoints, including the pathological responses, chemotherapy-related toxicities, and surgical results.

Methods

Patients with M0 and either T4 or T3 in case of junctional cancer or scirrhous type received two or four courses of cisplatin (60 mg/m2 at day 8)/S-1 (80 mg/m2 for 21 days with 1 week rest) or docetaxel (40 mg/m2 at day 1)/cisplatin (60 mg/m2 at day 1)/S-1 (80 mg/m2 for 14 days with 2 weeks rest) as NAC. Patients then underwent D2 gastrectomy and adjuvant S-1 chemotherapy for 1 year. The primary endpoint was the 3-year overall survival.

Results

Between October 2011 and September 2014, 132 patients were assigned to receive CS (n = 66; 33 in 2 courses and 33 in 4 courses) or DCS (n = 66; 33 in 2 courses and 33 in 4 courses). The respective major grade 3 or 4 hematological toxicities (CS/DCS) were leukocytopenia (14.1%/26.2%), neutropenia (29.7%/47.7%), anemia (14.1%/12.3%), and platelet reduction (3.1%/1.5%). The rate of pathological response, defined as a complete response or < 10% residual cancer remaining, was 19.4% in the CS group and 15.4% in the DCS group, and 15.6% in the two-course group and 19.0% in the 4-course group. The R0 resection rate was 72.7% in the CS group and 81.8% in the DCS group and 80.3% in the two-course group and the 74.2% in the four-course group. No treatment-related deaths were observed.

Conclusions

Our results do not support three-drug therapy with a taxane over two-drug therapy, or any further treatment beyond two cycles as an attractive candidate for the test arm of NAC.

Pharmacokinetics and Pharmacodynamics of Meloxicam in East Asian Populations: The Role of Ethnicity on Drug Response

We aimed to reanalyze the differences in the pharmacokinetics (PKs) of meloxicam in East Asian populations based on a population approach using previously published data and to investigate the factors found in population PK analysis that affect the pharmacodynamics (PDs) of meloxicam. Population PK analysis was performed in 119 healthy male subjects (30 Japanese, 30 Chinese, 29 Korean, and 30 white) under strictly controlled trial conditions with regulated meals and a single lot of the drug. We found that CYP2C9 genotype and lean body mass were statistically significant predictors of clearance and volume of distribution, respectively. A statistical significant difference in the PK parameters between ethnic groups could not be identified. Simulations using PK/PD models showed that CYP2C9 genotype is the factor that affects the PDs of meloxicam. The genetic polymorphisms highlighted in this study would be beneficial for conducting clinical trials in East Asians with similar genetic backgrounds.