The new 222-nm far ultraviolet-C lowers bacterial contamination to endoscopists during esophagogastroduodenoscopy

Objectives

This study aimed to clarify the disinfectant efficacy of the 222-nm far ultraviolet-C (UV-C) during esophagogastroduodenoscopy using bacterial cultures.

Methods

The endoscopists performed esophagogastroduodenoscopy wearing a gown with a tryptic soy agar medium plate on their epigastric region and were divided into two groups: 222-nm far UV-C irradiation (UV group) and non-UV irradiation (non-UV group). As a control group, tryptic soy agar medium plates were placed about 110 cm above the floor. The incidence of bacterial contamination was determined by positive bacterial culture. The cultured bacteria were identified by 16S rRNA sequencing. Additionally, the actual UV exposure dose was measured using the UV-indicator card which changed colors upon exposure to 222 nm far UV-C.

Results

The bacterial culture positivity in the UV group (5.03%) was significantly lower than that in the non-UV group (25.76%), p < 0.0001. Most of the bacteria identified in the UV and non-UV groups were normal constituents of the oral flora, including Streptococcus salivarius and Staphylococci. Conversely, pathogenic microbes were found in the control group. The actual exposure doses of 222-nm far UV-C at the endoscopists' face, neck, and epigastric region were 2.09 ± 0.29, 5.89 ± 0.49, and 7.36 ± 0.58 mJ/cm2, respectively.

Conclusions

The 222-nm far UV-C irradiation reduced bacterial contamination for endoscopists. It can be used with conventional physical coverings to provide more effective infection control.

Assessment of the Physical Invasiveness of Peroral Endoscopic Myotomy during the Perioperative Period Based on Changes in Energy Metabolism

A novel treatment method for achalasia of the esophagus and related disorders is known as peroral endoscopic myotomy (POEM). This study aimed to calculate the resting energy expenditure (REE) and evaluated the degree of physical invasiveness based on metabolic changes during the perioperative period of POEM. Fifty-eight patients who underwent POEM were prospectively enrolled; REE, body weight (BW), and basal energy expenditure were measured on the day of POEM, postoperative day 1 (POD 1), and three days after POEM (POD 3). The median REE/BW increased from 19.6 kcal/kg on the day of POEM to 24.5 kcal/kg on POD 1. On POD 3, it remained elevated at 20.9 kcal/kg. The stress factor on POD 1 was 1.20. Among the factors, including the Eckardt score, operation time, and the length of myotomy, the length of myotomy was associated with changes in REE/BW. During the perioperative period of POEM, the level of variation in energy expenditure was lower than that of esophageal cancer surgeries performed under general anesthesia. However, because the length of myotomy is a factor affecting changes in energy expenditure, careful perioperative management is desirable for patients with longer myotomy lengths.

Evaluation of Crohn's Disease Small-Bowel Mucosal Healing Using Capsule Endoscopy and Usefulness of Leucine-Rich α2-Glycoprotein

Recently, the importance of achieving clinical and deep remissions with mucosal healing (MH) has been demonstrated as a therapeutic goal to avoid Crohn's disease (CD) surgical operations. Although ileocolonoscopy (CS) is considered the gold standard, there are increasing reports on the benefits of capsule endoscopy (CE) and serum leucine-rich α2-glycoprotein (LRG) for evaluating small-bowel lesions in CD. We evaluated the data of 20 patients with CD who underwent CE in our department between July 2020 and June 2021 and whose serum LRG level was measured within 2 months. Concerning the mean LRG value, there was no significant difference between the CS-MH and CS-non-MH groups. Conversely, the mean LRG level was 10.0 μg/mL in seven patients in the CE-MH group and 15.2 μg/mL in 11 patients in the CE-non-MH group with a significant difference between the two groups (p = 0.0025). This study's findings show that CE can sufficiently determine total MH in most cases, and LRG is useful for evaluating CD small-bowel MH because of its correlation with CE-MH. Furthermore, satisfying CS-MH criteria and a cut-off value of 13.4 μg/mL for LRG suggests its usefulness as a CD small-bowel MH marker, which could be incorporated into the treat-to-target strategy.

Bacterial exposure risk to the endoscopist's face while performing endoscopy

Objectives

Gastrointestinal endoscopy increases the risk of bacterial exposure to endoscopists. However, before 2019, most endoscopists did not pay attention to microorganism transmission from patients. This study aimed to investigate the incidence of bacterial exposure to endoscopists' faces during gastrointestinal endoscopic procedures using the bacterial culture method.

Methods

This was a single-centered, retrospective study including endoscopists who performed various gastrointestinal endoscopy procedures at the Division of Endoscopy, Hirosaki University Hospital between August 31 and October 6, 2020. Endoscopists wore surgical masks and affixed pre-sterilized films over them. Following the gastrointestinal endoscopic procedures, attached microbes were collected from the endoscopists' surface films using sterilized swabs. Collected microorganisms were cultured on tryptic soy agar and 5% sheep blood agar, and the incidence of bacterial exposure was determined by bacterial culture positivity. Cultured bacteria were identified by gram staining and 16S rRNA gene sequencing.

Results

Bacterial culture positivity was 12.6%, and it was significantly higher in therapeutic than in diagnostic endoscopy. Notably, therapeutic endoscopy increased bacterial culture positivity in colonoscopy, but not in esophagogastroduodenoscopy. Staphylococci, including Staphylococcus epidermidis and Staphylococcus capitis, were the most commonly found bacteria in samples identified through 16S rRNA gene sequencing.

Conclusions

The risk of bacterial exposure to the endoscopist's face was increased in colonoscopy treatment procedures. Therefore, endoscopists should be aware of the significant risk of microbial infection from scattering fluid that comes from the endoscopy's working channel.

Development of independent dose verification plugin using Eclipse scripting API for brachytherapy

In this study, an independent dose verification plugin (DVP) using the Eclipse Scripting Application Programming Interface (ESAPI) for brachytherapy was developed. The DVP was based on the general 2D formalism reported in AAPM-TG43U1. The coordinate and orientation of each source position were extracted from the translation matrix acquired from the treatment planning system (TPS), and the distance between the source and verification point (r) was calculated. Moreover, the angles subtended by the center-tip and tip-tip of the hypothetical line source with respect to the verification point (θ and β) were calculated. With r, θ, β and the active length of the source acquired from the TPS, the geometry function was calculated. As the TPS calculated the radial dose function, g(r), and 2D anisotropy function, F(r,θ), by interpolating and extrapolating the corresponding table stored in the TPS, the DVP calculated g(r) and F(r,θ) independently from equations fitted with the Monte Carlo data. The relative deviation of the fitted g(r) and F(r,θ) for the GammaMed Plus HDR 192Ir source was 0.5% and 0.9%, respectively. The acceptance range of the relative dose difference was set to ±1.03% based on the relative deviation between the fitted functions and Monte Carlo data, and the linear error propagation law. For 64 verification points from sixteen plans, the mean of absolute values of the relative dose difference was 0.19%. The standard deviation (SD) of the relative dose difference was 0.17%. The DVP maximizes efficiency and minimizes human error for the brachytherapy plan check.

Nonreciprocal Directional Dichroism in Magnetoelectric Spin Glass

Optical absorption spectra in the visible and near-infrared light were measured for magnetoelectric spin glass Ni_{0.4}Mn_{0.6}TiO_{3} under various field-cooled conditions. Despite the absence of long-range magnetic-dipole order, this spin-glass system exhibits nonreciprocal directional dichroism (NDD) at zero external field after a magnetoelectric field-cooled procedure. This result is distinct from previous studies on NDD in systems with magnetic toroidal moments induced either by long-range magnetic-dipole order or by applying crossed electric and magnetic fields. The present Letter conclusively demonstrates that the observed NDD originates from magnetoelectrically induced ferroic order of magnetic toroidal moments without conventional magnetic-dipole order.

Do fathers have sufficient knowledge to administer medicine to children correctly?

Background

Recently, the father's involvement in childcare is increasing in Japan. Inappropriate use of medication for children at home has been reported worldwide, however, the most responsible person was likely to be the mother. We aimed to compare the knowledge related to administering medication to children between fathers and mothers among Japanese parents.

Methods

An online survey regarding medication administration to children was conducted in March 2022. Parents living with preschool children were recruited and categorized by four factors: sex (fathers and mothers), age of children, regular medication, and the difficulty level in giving medicine to their own children. The cross-sectional data were collected for each category. The knowledge related to administering medication to children was measured using ten statements such as “Children can be given a reduced dose of adult medicine” using a 5-point Likert scale. The answer “disagree” was defined as correct understanding and was compared between fathers and mothers (Chi-square test).

Results

The participants were 145 fathers and 128 mothers. The percentage of fathers who answered all questions correctly or all questions incorrectly was 9.0% (mothers = 13.3%) and 25.5% (mothers = 13.3%) respectively. Each statement was answered correctly by fathers 20.0-57.9% and by mothers 25.8-71.9% and fathers were less likely to have the correct knowledge than mothers (6 items, p &lt; 0.05). The biggest difference between those two groups was the statement of “Children should be given more than the proper dose for rapid effect”. Furthermore, the fathers having some difficulties in giving medicine had lower awareness about appropriate medication use than fathers having no difficulties.

Conclusions

Fathers were more likely to have lower knowledge related to administering medication to children than mothers. Medical professionals like pharmacists will need to support fathers.

Key messages

Endoscopic and histopathologic features of Anti‐PD‐1‐related collagenous colitis

Objectives

Cancer patients treated with immune checkpoint inhibitors occasionally show persistent diarrhea accompanied by endoscopic features of ulcerative colitis. The endoscopic mucosal inflammation may appear mild in some patients compared to the clinical severity, which can make choosing a treatment challenging. In this study, we evaluated the factors that support the continuation of chemotherapy by assessing the endoscopic and histopathological characteristics of patients who experienced diarrhea after immune checkpoint inhibitor administration.

Methods

This study included eight patients who were diagnosed with collagenous colitis based on pathological assessments. We retrospectively investigated these patients’ backgrounds, laboratory data, and computed tomography images that were extracted from their medical records. We also summarized their endoscopic and pathologic findings.

Results

All eight patients were being treated with anti‐programmed cell death‐1/programmed cell death‐ligand 1 therapeutic agents and had a recent history of oral proton pump inhibitor therapy. The anti‐programmed cell death‐1‐related collagenous colitis in these cases was characterized by endoscopically mild mucosal inflammation, high fecal calprotectin levels, and a lower frequency of intestinal wall thickening on computed tomography. Histological assessments showed CD8⁺ lymphocytes predominantly infiltrating the lamina propria and crypts of the colonic mucosa. Suspending the proton pump inhibitor therapy relieved the patients’ symptoms and allowed the continuation of the anti‐programmed cell death‐1/programmed cell death‐ligand 1 therapy.

Conclusions

Anti‐programmed cell death‐1‐related collagenous colitis is reversible; appropriate diagnosis of adverse events is crucial for the continuation of immune checkpoint inhibitor therapy.

Awareness of knowledge related to administering medication for children by mothers among pharmacists

Background

Inappropriate medication use for children by caregivers such as mothers and nursery staff has been reported in Japan. The pharmacists have the responsibility to support adequate medication administration and should consult effectively. However, it is not clear how much pharmacists are aware of the knowledge of medication use by caregivers. This study aimed to examine the knowledge related to administering medication for children among mothers and nursery staff and to evaluate the awareness of that understanding among pharmacists.

Methods

Three online surveys involving 600 mothers living with nursery school children, 558 nursery staff at nursery schools, and 584 pharmacists in Japan were conducted separately (Cross-sectional data, in 2019/2021). Ten statements about the knowledge related to administering medication for children such as “You could give the medicine that has been prescribed before if similar symptoms are shown”, “You should give children the medicine using favorite beverages such as milk and juice, regardless of the kind of medicine” were shown and measured using a 5-point Likert scale. The answer: “disagree”, was considered as correct understanding. The pharmacists were asked how much they think mothers/nursery staff answered correctly using a 5-point Likert scale.

Results

The proportion of correct answers for ten statements by mothers and nursery staff were 35.8%-76.0% and 43.0%-69.9%, respectively. Most answers from pharmacists were in the category range of 40%-59%. Only 11.5%-33.0% of pharmacists chose the correct category in each of ten items with mothers' answers and 24.0%-83.4% of them had lower awareness.

Conclusions

Overall, the pharmacists were less likely to be aware of the mothers'/nursery staff members' knowledge related to administering medication. The pharmacists need to instruct mothers to administer medication after confirming their understanding at the pharmacy.

Key messages

The awareness of knowledge related to administering medication for children by mothers and nursery staff among pharmacists was lower than the answers. The pharmacists need to instruct mothers to administer medication at the pharmacy after confirming their understanding of medication use.

Association between maternal factors and appropriate medication for nursery school children in Japan

Background

Inappropriate medication use for children by caregivers has been reported in Japan. We focused on the factors which could be associated with health literacy (HL) and knowledge of medication (KM). We aimed to examine the association between appropriate use for nursery school children and maternal socioeconomic status (SES) or behavior related to medication adherence among mothers in Japan.

Methods

The data regarding the conditions of medication for children (aged from six months to six years old) at home and in nursery school by the online survey from April to May 2019 was used. Maternal SES, such as education, occupational status, and economic conditions, were asked via a self-administered questionnaire. Maternal behaviors were measured using a 5-point Likert scale and classified into two groups. HL and KM were scored and divided into two categories. Appropriate medication use was evaluated using a 5-point Likert scale for the statement “I give my child medicine as per instructions,” and the answers were classified into two groups. Poisson regression was employed to investigate the association. Age, maternal SES, chronic disease of children, birth order, HL, and KM were used as covariates.

Results

A total of 233 (38.8%) of 600 mothers aged 24-48 years, reported appropriate medication use for children. None of the maternal SES was statistically significant. After adjustment, the individuals, who consent to prescribed medications for children, were 2.16 times (95% confidence interval [CI]:1.64-2.86) more likely to use medicine appropriately compared with their counterparts. ’To be able to consult with pharmacists’ were also statistically significant (Prevalence Ratio=2.14, 95% CI:1.63-2.81).

Conclusions

The mothers, who consent to prescribed medications for children, who consult with pharmacists were more likely to use medicine appropriately. Community pharmacists could support those to improve their skills.

Key messages

The maternal behaviors related to adherence were associated with appropriate medication for children among Japanese mothers, although none of the maternal SES was statistically significant. Community pharmacists could support mothers and contribute appropriate medical treatment for children.

Toward High-Resolution Soil Moisture Monitoring by Combining Active-Passive Microwave and Optical Vegetation Remote Sensing Products with Land Surface Model

The assimilation of radiometer and synthetic aperture radar (SAR) data is a promising recent technique to downscale soil moisture products, yet it requires land surface parameters and meteorological forcing data at a high spatial resolution. In this study, we propose a new downscaling approach, named integrated passive and active downscaling (I-PAD), to achieve high spatial and temporal resolution soil moisture datasets over regions without detailed soil data. The Advanced Microwave Scanning Radiometer (AMSR-E) and Phased Array-type L-band SAR (PALSAR) data are combined through a dual-pass land data assimilation system to obtain soil moisture at 1 km resolution. In the first step, fine resolution model parameters are optimized based on fine resolution PALSAR soil moisture and moderate-resolution imaging spectroradiometer (MODIS) leaf area index data, and coarse resolution AMSR-E brightness temperature data. Then, the 25 km AMSR-E observations are assimilated into a land surface model at 1 km resolution with a simple but computationally low-cost algorithm that considers the spatial resolution difference. Precipitation data are used as the only inputs from ground measurements. The evaluations at the two lightly vegetated sites in Mongolia and the Little Washita basin show that the time series of soil moisture are improved at most of the observation by the assimilation scheme. The analyses reveal that I-PAD can capture overall spatial trends of soil moisture within the coarse resolution radiometer footprints, demonstrating the potential of the algorithm to be applied over data-sparse regions. The capability and limitation are discussed based on the simple optimization and assimilation schemes used in the algorithm.

Mechanical regulation of bone homeostasis through p130Cas-mediated alleviation of NF-κB activity

Mechanical loading plays an important role in bone homeostasis. However, molecular mechanisms behind the mechanical regulation of bone homeostasis are poorly understood. We previously reported p130Cas (Cas) as a key molecule in cellular mechanosensing at focal adhesions. Here, we demonstrate that Cas is distributed in the nucleus and supports mechanical loading-mediated bone homeostasis by alleviating NF-κB activity, which would otherwise prompt inflammatory processes. Mechanical unloading modulates Cas distribution and NF-κB activity in osteocytes, the mechanosensory cells in bones. Cas deficiency in osteocytes increases osteoclastic bone resorption associated with NF-κB-mediated RANKL expression, leading to osteopenia. Upon shear stress application on cultured osteocytes, Cas translocates into the nucleus and down-regulates NF-κB activity. Collectively, fluid shear stress-dependent Cas-mediated alleviation of NF-κB activity supports bone homeostasis. Given the ubiquitous expression of Cas and NF-κB together with systemic distribution of interstitial fluid, the Cas-NF-κB interplay may also underpin regulatory mechanisms in other tissues and organs.

Visualization of von Willebrand Factor Multimers by Immunoenzymatic Stain Using Avidin-Biotin Peroxidase Complex

A technique for the detection of von Willebrand factor multimers separated by discontinuous SDS agarose electrophoresis has been developed using non-radioactive com-v pounds. The multimeric patterns were visualized by monospecific anti-human vWF:Ag followed by incubation with biotinylated antibody. After addition of avidin-biotin-peroxidase complex, the peroxidase activitiy was detected by 4-chloro-l-naphthol, giving sharp bands with a clear background.

By this method, the differences of vWF : Ag multimers could be easily observed between normal plasma and the plasmas from variant type vWD (IIA, IIB, platelet-type). Large and intermediate multimers were absent in the plasma with vWD type IIA, while only large multimers were absent in the plasma with vWD IIB and platelet-type. The absence of large multimers was also observed in two commercial F VIII preparations having the ratio of vWF/vWF : Ag 0.18 and 0.63. The preparation with the ratio of 0.63 showed the presence of larger intermediate multimers.

Electrophoresis in SDS 1.5% agarose gel revealed triplet structure of each small multimer, and a relative increase of the smallest subband was observed in vWD IIA plasma, platelet-type vWD plasma and commercial F VIII preparations.

The procedures described are easy and safe to perform and are useful for screening or classifying cases with vWD in general laboratories.

Vimentin-positive gastric adenocarcinoma arising in a hyperplastic polyp

We report a case of vimentin-positive early gastric adenocarcinoma arising in a hyperplastic polyp (HP). A 72-year-old Japanese man was admitted for the detailed examination of a gastric polyp. He had a subtotal gastrectomy due to acute abdomen 12 years ago. Upper endoscopy revealed a pedunculated polyp measuring approximately 2 cm on the greater curvature of upper body of the remnant stomach. Magnifying endoscopy revealed that the microsurface pattern was irregular and partially absent accompanied with irregular microvessels at the upper end of the polyp. We speculated that the lesion was an adenocarcinoma arising in the HP. Endoscopic submucosal dissection (ESD) was performed. Histological examination of the ESD specimen revealed that the lesion consisted of well- to poorly differentiated adenocarcinoma at the protruding lesion and foveolar hyperplastic epithelia at the base of the polyp. Immunohistochemically, most of tumor cells that comprised poorly-differentiated adenocarcinoma were positive for both cytokeratin and vimentin. Although carcinomas have occasionally been found in HPs, the histological features of the present case are considered extremely unusual. To the best of our knowledge, this is the first case of vimentin-positive early gastric carcinoma arising in a HP.

Increased ghrelin signaling prolongs survival in mouse models of human aging through activation of sirtuin1

Caloric restriction (CR) is known to retard aging and delay functional decline as well as the onset of diseases in most organisms. Ghrelin is secreted from the stomach in response to CR and regulates energy metabolism. We hypothesized that in CR ghrelin has a role in protecting aging-related diseases. We examined the physiological mechanisms underlying the ghrelin system during the aging process in three mouse strains with different genetic and biochemical backgrounds as animal models of accelerated or normal human aging. The elevated plasma ghrelin concentration was observed in both klotho-deficient and senescence-accelerated mouse prone/8 (SAMP8) mice. Ghrelin treatment failed to stimulate appetite and prolong survival in klotho-deficient mice, suggesting the existence of ghrelin resistance in the process of aging. However, ghrelin antagonist hastened death and ghrelin signaling potentiators rikkunshito and atractylodin ameliorated several age-related diseases with decreased microglial activation in the brain and prolonged survival in klotho-deficient, SAMP8 and aged ICR mice. In vitro experiments, the elevated sirtuin1 (SIRT1) activity and protein expression through the cAMP-CREB pathway was observed after ghrelin and ghrelin potentiator treatment in ghrelin receptor 1a-expressing cells and human umbilical vein endothelial cells. Furthermore, rikkunshito increased hypothalamic SIRT1 activity and SIRT1 protein expression of the heart in the all three mouse models of aging. Pericarditis, myocardial calcification and atrophy of myocardial and muscle fiber were improved by treatment with rikkunshito. Ghrelin signaling may represent one of the mechanisms activated by CR, and potentiating ghrelin signaling may be useful to extend health and lifespan.

Ferroelectricity by Bose-Einstein condensation in a quantum magnet

The Bose–Einstein condensation is a fascinating phenomenon, which results from quantum statistics for identical particles with an integer spin. Surprising properties, such as superfluidity, vortex quantization or Josephson effect, appear owing to the macroscopic quantum coherence, which spontaneously develops in Bose–Einstein condensates. Realization of Bose–Einstein condensation is not restricted in fluids like liquid helium, a superconducting phase of paired electrons in a metal and laser-cooled dilute alkali atoms. Bosonic quasi-particles like exciton-polariton and magnon in solids-state systems can also undergo Bose–Einstein condensation in certain conditions. Here, we report that the quantum coherence in Bose–Einstein condensate of the magnon quasi particles yields spontaneous electric polarization in the quantum magnet TlCuCl₃, leading to remarkable magnetoelectric effect. Very soft ferroelectricity is realized as a consequence of the O(2) symmetry breaking by magnon Bose–Einstein condensation. The finding of this ferroelectricity will open a new window to explore multi-functionality of quantum magnets.

Magnons, quantized spin excitations in magnetic materials, may undergo Bose-Einstein condensation into a macroscopic correlated quantum state at low temperature. Here, the authors demonstrate how magnon condensation in quantum magnet TlCuCl₃ generates an electrical polarization.

Expression dynamics of CXCL12 and CXCR4 during the progression of mycosis fungoides

BACKGROUND

Mycosis fungoides (MF) classically presents from patch stage to plaque stage over a number of years and finally progresses to tumour stage with nodal or visceral involvement. The mechanism of progression remains incompletely elucidated. Chemokines and their receptors are known to be involved in disease mechanisms, with CXCL12 and CXCR4 playing a critical role in carcinogenesis, invasion and cancer cell migration in various carcinomas.

OBJECTIVES

To investigate the expression of CXCL12 and CXCR4 in different cutaneous stages of MF.

METHODS

Formalin-fixed, paraffin-embedded skin samples from 40 patients with MF (21 patch stage, 10 plaque stage, nine tumour stage) and 30 non-neoplastic control skin samples were analysed. CXCL12 and CXCR4 were assessed by quantitative reverse-transcription polymerase chain reaction and immunohistochemical staining.

RESULTS

The expression level of mRNA for CXCL12 in plaque-stage MF was significantly higher than in control skin (P = 0.0035), or patch-stage (P = 0.0108) or tumour-stage disease (P = 0.0089). The CXCR4 mRNA expression level in plaque-stage disease was significantly higher than in control skin (P = 0.0090) or patch-stage disease (P = 0.0387). CXCL12- and CXCR4-positive cell rates in patch-stage and plaque-stage MF were significantly higher than those in control skin (P < 0.0001). CXCL12- and CXCR4-positive cell rates in tumour-stage MF were significantly lower than those in patch- and plaque-stage disease (P = 0.0274 and P = 0.0492, respectively).

CONCLUSIONS

Our data suggest that neoplastic T cells in MF are exposed to the microenvironment, given the abundance of CXCL12 during its progression, and also that neoplastic T cells express CXCR4, especially in the pretumour stage. We reveal that the CXCL12-CXCR4 axis plays a critical role in MF progression.

Assessment of interfractional prostate motion in patients immobilized in the prone position using a thermoplastic shell

The aim of this study was to evaluate the interfractional prostate motion of patients immobilized in the prone position using a thermoplastic shell. A total of 24 patients with prostate calcifications detectable using a kilo-voltage X-ray image-guidance system (ExacTrac X-ray system) were examined. Daily displacements of the calcification within the prostate relative to pelvic bony structures were calculated by the ExacTrac X-ray system. The average displacement and standard deviation (SD) in each of the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) directions were calculated for each patient. Based on the results of interfractional prostate motion, we also calculated planning target volume (PTV) margins using the van Herk formula and examined the validity of the PTV margin of our institute (a 9-mm margin everywhere except posteriorly, where a 6-mm margin was applied). In total, 899 data measurements from 24 patients were obtained. The average prostate displacements ± SD relative to bony structures were 2.8 ± 3.3, -2.0 ± 2.0 and 0.2 ± 0.4 mm, in the SI, AP and LR directions, respectively. The required PTV margins were 9.7, 6.1 and 1.4 mm in the SI, AP and LR directions, respectively. The clinical target volumes of 21 patients (87.5%) were located within the PTV for 90% or more of all treatment sessions. Interfractional prostate motion in the prone position with a thermoplastic shell was equivalent to that reported for the supine position. The PTV margin of our institute is considered appropriate for alignment, based on bony structures.

Prediction of time-dependent interaction of aspirin with ibuprofen using a pharmacokinetic/pharmacodynamic model

WHAT IS KNOWN AND OBJECTIVE

Low-dose aspirin is widely used for prevention of thrombosis, but combined use of aspirin with non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, reduces the antiplatelet effect of aspirin. However, there has been no report describing the effects of the timing of the ibuprofen dose on the degree of interaction between low-dose aspirin and ibuprofen. The purpose of this study was to predict the time-course of the antiplatelet effect of low-dose aspirin when ibuprofen is administered as a single dose or repeatedly in combination with aspirin at various time intervals.

METHODS

We simulated ex vivo platelet aggregation using a previously developed pharmacokinetic (PK)/pharmacodynamic (PD) model.

RESULTS AND DISCUSSION

The antiplatelet effect of low-dose aspirin (81 mg) was predicted to be markedly reduced when ibuprofen (200 mg; the usual prescribed dose in Japan) was administered 1 h or less after aspirin, but not when it was administered more than 2 h after the administration of aspirin. Moreover, the administration of ibuprofen up to 12 h before aspirin completely abrogated the antiplatelet effect of aspirin. When ibuprofen (200 mg) was administered three times daily for 3 days (day 1 to day 3) on a background of continuous low-dose aspirin (81 mg) once daily, 2 h after aspirin, no reduction in the antiplatelet effect of aspirin was predicted on day 1, but a reduction is predicted from day 2, with no return to the initial level until more than 3 days after discontinuation of ibuprofen. A marked reduction in the antiplatelet effect of aspirin was also seen on the same schedule when the dosage of ibuprofen was 150 mg, which is the dose used in over-the-counter (OTC) preparations.

WHAT IS NEW AND CONCLUSION

This study indicates that the antiplatelet effect of low-dose aspirin can be markedly reduced with combined use of ibuprofen, depending on the timing of co-administration. As even the lower OTC dose of ibuprofen (150 mg) was enough to affect the antiplatelet effect of aspirin, health professionals should take into account patients' use of OTC ibuprofen when prescribing low-dose aspirin.

Erythroderma as a paraneoplastic cutaneous disorder in systemic anaplastic large cell lymphoma

BACKGROUND

  Paraneoplastic cutaneous disorders (PCDs) or dermadromes are skin conditions that have an association with internal malignancies but are not themselves malignant. We report the first two cases of systemic anaplastic large cell lymphoma (s-ALCL) accompanied by erythroderma and multiple leg ulcers as PCDs. CASE 1:  A 52-year-old Japanese man presented with disseminated itchy papular erythemas which he had over his entire body for the preceding 5 years that later exacerbated to erythroderma. Multiple punched-out ulcers also developed on his lower legs. Superficial lymph nodes (LNs) were swollen, and a left axillary LN biopsy demonstrated dense CD30(+) atypical large cell (ALC) infiltration. By contrast, lymphocytes infiltrating into the erythroderma and leg ulcers were CD30(-) , and T-cell receptor β (TCRβ) chain gene rearrangement was negative in skin biopsy specimens. Thus, he was diagnosed with s-ALCL. Not only his s-ALCL but also his erythroderma and leg ulcers responded well to chemotherapy. CASE 2:  A 71-year-old Japanese woman presented with erythroderma that persisted for approximately 20 years after mastectomy. At her initial hospital visit, she was diagnosed with s-ALCL by biopsy of swollen left inguinal LNs. Similar to Case 1, CD30(+) ALCs were negative in skin samples with normal TCRβ chain gene rearrangement. As the erythrodermic skin lesion responded well to chemotherapy for s-ALCL, it was considered a PCD.

CONCLUSION

  s-ALCL development may be predicted by the precedence and concurrence of intractable paraneoplastic erythrodermic and ulcerative skin lesions, as reported in our two cases.

Increased circulating Th17 frequencies and serum IL-22 levels in patients with acute generalized exanthematous pustulosis

BACKGROUND/OBJECTIVE

Acute generalized exanthematous pustulosis (AGEP) is a diffuse pustular disorder that usually begins in intertriginous folds with widespread erythema. The causes in the majority of the cases are drugs. T cells and interleukin (IL)-8 play roles in the development of AGEP, but the mechanism remains to be elucidated. We investigated the involvement of Th17 cells and their cytokine IL-22 in the pathogenesis.

METHODS

Three patients with AGEP were enrolled in this study. The percentages of IL-17(+) Th17 cells, interferon γ(+) T cells and IL-4(+) T cells were measured in the patients' peripheral blood lymphocytes by intracellular cytokine staining and flow cytometry. The concentration of IL-22 in the sera was measured by enzyme-linked immunosorbent assay.

RESULTS

The percentages of Th17 cells were markedly higher in all three patients than healthy control individuals. The frequencies of interferon γ(+) T cells were slightly high in the patients compared with the control, and there was no definite tendency in IL-4(+) T-cell frequencies. The concentration of IL-22 was remarkably high in all patients when compared with normal subjects with levels under detection.

CONCLUSION

Th17 cells and their produced cytokine IL-22 were elevated in the peripheral blood of patients with AGEP. As IL-17 and IL-22 cooperatively stimulate keratinocytes to produce IL-8, IL-8 may contribute to the accumulation of neutrophils in the lesional epidermis of AGEP.

Warfarin and miconazole oral gel interactions: analysis and therapy recommendations based on clinical data and a pharmacokinetic model

WHAT IS KNOWN AND OBJECTIVE

Miconazole is a strong inhibitor of CYP2C9, one of the main enzymes involved in the metabolism of warfarin. Concurrent use of the two drugs leads to potentially serious adverse effects. Although it is often assumed that use of the oral miconazole gel is acceptable with concomitant warfarin, because of the low bioavailability following buccal administration, drug-drug interactions have been reported following such use. We aimed to investigate case reports of such interactions and develop a pharmacokinetic model to model such interactions.

METHODS

The Medline database from 1966 to October 2010 was used for literature search. Case reports of the potentiation of the anticoagulant effects of warfarin, such as the elevation of prothrombin time (INR), by concomitant administration of warfarin and miconazole oral gel were collected. We quantitatively estimated the extent of inhibition of warfarin metabolism by orally administered miconazole gel and compared our findings with case reports.

RESULTS AND DISCUSSION

Metabolism of (S)-warfarin is inhibited potently following administration of a standard dose (200-400 mg/day in Japan) of miconazole gel. This may lead to in an increase in the blood concentration of warfarin and lead to serious adverse effects. The literature reports of clinical interactions with concomitant use of those drugs show that other factors may amplify the effects of any increase in blood concentration.

WHAT IS NEW AND CONCLUSION

We summarize all reported, clinically significant, cases of drug interaction between miconazole oral gel and warfarin. Pharmacokinetic modelling shows that concomitant administration of warfarin and miconazole oral gel can lead to substantial increase in warfarin concentration. However, our PK/PD model fails to capture the dramatic increases seen in INR values, and hence bleeding complications, reported in the literature. Taken together, the evidence suggests that concomitant use of miconazole gel and warfarin should be avoided. Even over-the-counter products containing miconazole should be used with caution by patients receiving warfarin.

Development of visual cells in the Pacific bluefin tuna Thunnus orientalis

The development of rod and cone photoreceptor cells was investigated in the retinas of Pacific bluefin tuna larvae and juveniles, using RET-P1 monoclonal antibody labeling to identify photoreceptors. At 60 h after hatching, which was about when feeding began, opsin (presumably green opsin (Rh2)) was expressed in the outer segments of cone cells. At 15 days after hatching (dah), although many labeled cone cells were observed in the dorsal retina, the same type of cone cells had partially appeared in the ventral retina. The presence of rod cell bodies was confirmed by the expression of Rh1 opsin at 15 dah. At 21 dah, the presence of outer segments of rod cells was confirmed by the expression of Rh1 opsin and by morphology. The observations suggest that the cone cells were substantially operable upon the development of their outer segment at around the beginning of the post-larval stage, and the rod cells began to function at around 15 to 21 dah, before and during metamorphosis.

Ontogenetic changes in schooling behaviour during larval and early juvenile stages of Pacific bluefin tuna Thunnus orientalis

Schooling was first observed at 25-27 days after hatching (26. 2-33. 8 mm, total length) in the Pacific bluefin tuna Thunnus orientalis. At this time, the mode of swimming changed from intermittent sprinting to continuous cruising, and this allowed the fish to adjust to an inertial hydrodynamic environment.

In-vivo kinetics of the interaction between midazolam and erythromycin in rats, taking account of metabolic intermediate complex formation

To predict, quantitatively, the extent of drug interaction during repeated administration of a metabolic inhibitor, we analysed the effects of erythromycin treatment under several regimens on the area under the concentration curve (AUC) of midazolam in rats. Midazolam was administered into the portal vein 12 h after erythromycin treatment for 1, 2 or 3 days, or 12, 24, 36, 48, 72 and 96 h after erythromycin treatment for 4 days, and the plasma-concentration profiles of midazolam were analysed to assess the AUC. Moreover, the contents of total cytochrome P450 and inactive metabolic intermediate (MI) complex were simultaneously quantitated. While the AUC value of midazolam was not affected by the administration of erythromycin for 1 day, repeated administration of erythromycin evoked an increase in AUC ratio (AUC in erythromycin-treated rats/AUC in vehicle-treated rats), which reached a maximum value of 1.99 at 12 h after 4 days' treatment with erythromycin. The total content of cytochrome P450 in liver microsomes was unaffected by erythromycin treatment. Although the MI complex was undetectable after 1 day's treatment with erythromycin, its content increased with duration of erythromycin treatment, and the complex disappeared after the end of erythromycin treatment with a half-life of 12.3 h. In conclusion, the interaction between erythromycin and midazolam could be well predicted when the formation of MI complex in the liver was taken into account.