Phthalate and DINCH exposure and ovarian reserve markers among women seeking infertility care

Phthalate exposure can adversely impact ovarian reserve, yet investigation on the influence of its alternative substance, the non-phthalate plasticizer diisononyl-cyclohexane-1,2-dicarboxylate (DINCH), on ovarian reserve is very sparce. We aimed to investigate the associations of phthalate and DINCH exposure as well as their combined mixture with ovarian reserve. This present study included 657 women seeking infertility care in Jiangsu, China (2015-2018). Urine samples during enrollment prior to infertility treatment were analyzed using high-performance liquid chromatography-isotope dilution tandem mass spectrometry (UPLC-MS/MS) to quantify 17 phthalate metabolites and 3 DINCH metabolites. Multivariate linear regression models, Poisson regression models and weighted quantile sum (WQS) regression were performed to access the associations of 17 urinary phthalate metabolites and 3 DINCH metabolites with ovarian reserve markers, including antral follicle count (AFC), anti-Mullerian hormone (AMH), and follicle-stimulating hormone (FSH). We found that the most conventional phthalates metabolites (DMP, DnBP, DiBP, DBP and DEHP) were inversely associated with AFC, and the DINCH metabolites were positively associated with serum FSH levels. The WQS index of phthalate and DINCH mixtures was inversely associated with AFC (% change = -8.56, 95 % CI: -12.63, -4.31) and positively associated with FSH levels (% change =7.71, 95 % CI: 0.21, 15.78). Our findings suggest that exposure to environmental levels of phthalate and DINCH mixtures is inversely associated with ovarian reserve.

The shikimate pathway: gateway to metabolic diversity

Covering: 1997 to 2023The shikimate pathway is the metabolic process responsible for the biosynthesis of the aromatic amino acids phenylalanine, tyrosine, and tryptophan. Seven metabolic steps convert phosphoenolpyruvate (PEP) and erythrose 4-phosphate (E4P) into shikimate and ultimately chorismate, which serves as the branch point for dedicated aromatic amino acid biosynthesis. Bacteria, fungi, algae, and plants (yet not animals) biosynthesize chorismate and exploit its intermediates in their specialized metabolism. This review highlights the metabolic diversity derived from intermediates of the shikimate pathway along the seven steps from PEP and E4P to chorismate, as well as additional sections on compounds derived from prephenate, anthranilate and the synonymous aminoshikimate pathway. We discuss the genomic basis and biochemical support leading to shikimate-derived antibiotics, lipids, pigments, cofactors, and other metabolites across the tree of life.

An organic O donor for biological hydroxylation reactions

All biological hydroxylation reactions are thought to derive the oxygen atom from one of three inorganic oxygen donors, O2, H2O2, or H2O. Here, we have identified the organic compound prephenate as the oxygen donor for the three hydroxylation steps of the O2-independent biosynthetic pathway of ubiquinone, a widely distributed lipid coenzyme. Prephenate is an intermediate in the aromatic amino acid pathway and genetic experiments showed that it is essential for ubiquinone biosynthesis in Escherichia coli under anaerobic conditions. Metabolic labeling experiments with 18O-shikimate, a precursor of prephenate, demonstrated the incorporation of 18O atoms into ubiquinone. The role of specific iron-sulfur enzymes belonging to the widespread U32 protein family is discussed. Prephenate-dependent hydroxylation reactions represent a unique biochemical strategy for adaptation to anaerobic environments.

Metabotropic Glutamate Receptor 4 (mGlu4) Positive Allosteric Modulators Lack Efficacy in Rat and Marmoset Models of L-DOPA-Induced Dyskinesia

Background

Increased activity across corticostriatal glutamatergic synapses may contribute to L-DOPA-induced dyskinesia in Parkinson's disease. Given the weak efficacy and side-effect profile of amantadine, alternative strategies to reduce glutamate transmission are being investigated. Metabotropic glutamate receptor 4 (mGlu4) is a promising target since its activation would reduce glutamate release.

Objective

We hypothesized that two mGlu4 positive allosteric modulators, Lu AF21934 ((1 S,2 R)-N1-(3,4-dichlorophenyl)cyclohexane-1,2-dicarboxamide) and ADX88178 (5-Methyl-N-(4-methylpyrimidin-2-yl)-4-(1H-pyrazol-4-yl)thiazol-2-amine), would provide relief in rat and primate models of L-DOPA-induced dyskinesia.

Methods

The ability of Lu AF21934 or ADX88178 to reverse pre-established dyskinesia was examined in L-DOPA-primed 6-hydroxydopamine-lesioned rats expressing abnormal involuntary movements (AIMs) or in 1-methyl-4-phenyl,1,2,3,6-tetrahydropyridine (MPTP)-treated common marmosets expressing L-DOPA-induced dyskinesia. Additionally, the ability of Lu AF21934 to prevent the development of de novo L-DOPA-induced AIMs was explored in the 6-hydroxydopamine-lesioned rats.

Results

Neither Lu AF21934 (10 or 30 mg/kg p.o.) nor ADX88178 (10 or 30 mg/kg p.o.) reduced pre-established AIMs in 6-hydroxydopamine-lesioned rats. Similarly, in L-DOPA-primed common marmosets, no reduction in established dyskinesia was observed with Lu AF21934 (3 or 10 mg/kg p.o.). Conversely, amantadine significantly reduced (>40%) the expression of dyskinesia in both models. Lu AF21934 also failed to suppress the development of AIMs in 6-hydroxydopamine-lesioned rats.

Conclusions

This study found no benefit of mGlu4 positive allosteric modulators in tackling L-DOPA-induced dyskinesia. These findings are concordant with the recent failure of foliglurax in phase II clinical trials supporting the predictive validity of these pre-clinical dyskinesia models, while raising further doubt on the anti-dyskinetic potential of mGlu4 positive allosteric modulators.

Natural Oil Lure Outperforms Trimedlure in Capturing Males of the Mediterranean Fruit Fly, Ceratitis capitata (Diptera: Tephritidae)

Females of certain tephritid fruit fly species (Diptera: Tephritidae) pose an enormous agricultural threat, as they oviposit in commercially important fruits and vegetables. Trapping networks are often operated in fruit fly-free areas to detect incipient infestations. Trapping relies largely on male attractants, so-called male lures, with trimedlure (TML) being used to detect invasive Ceratitis spp. Operating large-scale surveillance programs incurs substantial costs for both supplies and labor, and the problem is exacerbated by the fact that trimedlure (as well as other male lures) is effective for relatively short intervals in the field (6-8 weeks). Because frequent servicing increases costs, there is considerable interest in modifying existing lures or developing new formulations to extend their effective field longevity. Here, we present results of a field study in Hawaii on a wild population of the Mediterranean fruit fly, Ceratitis capitata (Wiedemann), that compared male captures in traps baited with (i) fresh liquid TML, (ii) TML plugs, (iii) a novel controlled-release TML sachet, and (iv) a novel natural oil blend dispensed from a sachet. Catch was recorded weekly for 12 weeks and then at 16 and 20 weeks, with 12 traps deployed per treatment. The natural oil formulation, which contains the natural plant product α-copaene, was as effective as the fresh liquid TML even after weathering for 20 weeks. Future work will focus on developing a dispenser for this formulation that is compatible with standard trap design and deployment.

Molecular recognition of niacin and lipid-lowering drugs by the human hydroxycarboxylic acid receptor 2

Niacin, an age-old lipid-lowering drug, acts through the hydroxycarboxylic acid receptor 2 (HCAR2), a G-protein-coupled receptor (GPCR). Yet, its use is hindered by side effects like skin flushing. To address this, specific HCAR2 agonists, like MK-6892 and GSK256073, with fewer adverse effects have been created. However, the activation mechanism of HCAR2 by niacin and these new agonists is not well understood. Here, we present three cryoelectron microscopy structures of Gi-coupled HCAR2 bound to niacin, MK-6892, and GSK256073. Our findings show that different ligands induce varying binding pockets in HCAR2, influenced by aromatic amino acid clusters (W91ECL1, H1614.59, W1885.38, H1895.39, and F1935.43) from receptors ECL1, TM4, and TM5. Additionally, conserved residues R1113.36 and Y2847.43, unique to the HCA receptor family, likely initiate activation signal propagation in HCAR2. This study provides insights into ligand recognition, receptor activation, and G protein coupling mediated by HCAR2, laying the groundwork for developing HCAR2-targeted drugs.

β-Peptides incorporating polyhydroxylated cyclohexane β-amino acid: synthesis and conformational study

We describe the synthesis of trihydroxylated cyclohexane β-amino acids from (-)-shikimic acid, in their cis and trans configuration, and the incorporation of the trans isomer into a trans-2-aminocyclohexanecarboxylic acid peptide chain. Subsequently, the hydroxyl groups were partially or totally deprotected. The structural study of the new peptides by FTIR, CD, solution NMR and DFT calculations revealed that they all fold into a 14-helix secondary structure, similarly to the homooligomer of trans-2-aminocyclohexanecarboxylic acid. This means that the high degree of substitution of the cyclohexane ring of the new residue is compatible with the adoption of a stable helical secondary structure and opens opportunities for the design of more elaborate peptidic foldamers with oriented polar substituents at selected positions of the cycloalkane residues.

Comparative Descriptive Analysis of Physician Versus Patient-Directed Gabapentin Usage In Chronic Pain - A Preliminary Report

BACKGROUND

Gabapentin is one of the most common medications employed in Pain Medicine, specifically targeting the management of neuropathic pain. We are most familiar with the incremental dosing strategy where a ceiling dose is eventually attained guided by efficacy and patient tolerance, after which a fixed dosing regimen is prescribed. We propose that autonomous short-term dose variations per patient could have rapid clinically significant effects in the management of chronic pain.

OBJECTIVES

This study examines the frequency at which patients take gabapentin on a fixed vs variable schedule and how the pattern of gabapentin use correlates with efficacy, side effects, and patient satisfaction.

STUDY DESIGN

Single institution, cross-sectional observational survey study with data collection performed over 2 phases as a pilot for proof of concept.

SETTING

Remote contact via telephone with researchers calling from a quiet, private location within the hospital complex conducive for confidential conversation.

METHODS

Patients recently prescribed gabapentin were queried on the patterns of use and self-perceived efficacy, satisfaction, and side effects in accordance to a standardized oral script. Patients selected met the criteria of being new patients freshly prescribed gabapentin who have been consistently on the medication for at least a month, while having chronic pain symptoms for over 3 months. Responses were collected in the form of a 5-point Likert scale. Statistical analyses were performed using GraphPad Prism.

RESULTS

Of the 222 patients, 92 patients agreed to participate in the survey for a response rate of 41.4. Of these, 51% had terminated the medication for various reasons. Of the patients still taking gabapentin, 73% were on a fixed schedule, while 27% were on a variable dosing schedule. Variable dosing cohort reported better efficacy (P = 0.027) and satisfaction (P = 0.036), while the side-effect profile between the 2 groups was similar.

LIMITATIONS

The study is limited by its nature of being a pilot, single-institution study performed on a relatively small sample size. None of the patients we surveyed had been given the autonomy to adjust gabapentin doses by their providers and this could significantly reduce the proportion of patients who would be encouraged to run a variable dosing regimen.

CONCLUSIONS

This pilot study suggests that a significant portion of patients choose to administer variable doses of gabapentin and associate this with better efficacy and satisfaction. A larger study is needed to confirm this supposition. Based upon this pilot study, the variable dosing option may be an option for improved therapeutic efficacy or as an alternative to those whose lifestyles do not allow for fixed dosing regimens. Discussion of the risks of gabapentin, including respiratory depression, and clear dosage parameters of use, would need to be outlined when considering a variable dose regimen.

Orthosteric ligand selectivity and allosteric probe dependence at Hydroxycarboxylic acid receptor HCAR2

Hydroxycarboxylic acid receptor 2 (HCAR2), a member of Class A G-protein-coupled receptor (GPCR) family, plays a pivotal role in anti-lipolytic and anti-inflammatory effects, establishing it as a significant therapeutic target for treating dyslipidemia and inflammatory diseases. However, the mechanism underlying the signaling of HCAR2 induced by various types of ligands remains elusive. In this study, we elucidate the cryo-electron microscopy (cryo-EM) structure of Gi-coupled HCAR2 in complex with a selective agonist, MK-6892, resolved to a resolution of 2.60 Å. Our structural analysis reveals that MK-6892 occupies not only the orthosteric binding pocket (OBP) but also an extended binding pocket (EBP) within HCAR2. Pharmacological assays conducted in this study demonstrate that the OBP is a critical determinant for ligand selectivity among the HCARs subfamily. Moreover, we investigate the pharmacological properties of the allosteric modulator compound 9n, revealing its probe-dependent behavior on HCAR2 in response to varying orthosteric agonists. Collectively, our findings provide invaluable structural insights that contribute to a deeper understanding of the regulatory mechanisms governing HCAR2 signaling transduction mediated by both orthosteric and allosteric ligands.

Elsholblanosides A-D, Four New Oleuropeic Acid Derivatives Isolated from Elsholtzia blanda and Their Inhibition of NO Production in LPS-activated RAW264.7 Cells

Phytochemical investigation on the aerial parts of Elsholtzia blanda Benth. afforded four new oleuropeic acid derivatives (1-4), named as elsholblanosides A-D, respectively, together with 11 known compounds (5-15). Their structures were determined based on extensive analyses of HR-ESI-MS, 1D and 2D NMR, and ECD spectra. Compounds 1-4 and 14 showed moderate NO production inhibition in LPS-activated RAW264.7 cells with their IC50 values ranging from 23.2 to 86.33 μM, compared to that of the positive control compound, dexamethasone, IC50 value of 16.9 μM.

Cyclohexanecarboxylic acid degradation with simultaneous nitrate removal by Marinobacter sp. SJ18

Naphthenic acid (NA) is a toxic pollutant with potential threat to human health. However, NA transformations in marine environments are still unclear. In this study, the characteristics and pathways of cyclohexanecarboxylic acid (CHCA) biodegradation were explored in the presence of nitrate. The results showed that CHCA was completely degraded with pseudo-first-order kinetic reaction under aerobic and anaerobic conditions, accompanied by nitrate removal rates exceeding 70%, which was positively correlated with CHCA degradation (P < 0.05). In the proposed CHCA degradation pathways, cyclohexane is dehydrogenated to form cyclohexene, followed by ring-opening by dioxygenase to generate fatty acid under aerobic conditions or cleavage of cyclohexene through β-oxidation under anaerobic conditions. Whole genome analysis indicated that nitrate was removed via assimilation and dissimilation pathways under aerobic conditions and via denitrification pathway under anaerobic conditions. These results provide a basis for alleviating combined pollution of NA and nitrate in marine environments with frequent anthropogenic activities.

Apoptosis is responsible for the cytotoxic effects of anti-GD2 ganglioside antibodies and aurora A kinase inhibitors on human neuroblastoma cells

In recent years, immunotherapy has been identified as an effective treatment method for high-risk neuroblastoma. A previous study demonstrated that an anti-GD2 ganglioside (GD2) mouse 14G2a monoclonal antibody (mAb) combined with a small molecule, i.e., an aurora A kinase inhibitor (MK-5108), significantly increased cytotoxicity against human neuroblastoma cells, as compared to monotherapy. This study aimed to demonstrate the mechanism of neuroblastoma cell death in vitro following the addition of an anti-GD2 human-mouse chimeric ch14.18/CHO mAb (presently used in clinics) and two aurora A inhibitors (MK-5108 and MK-8745). The effects of the aforementioned agents on neuroblastoma cells were determined by measuring the level of ATP, the level of apoptotic and necroptotic markers, and the activity of caspase 3/7. The results revealed that the ch14.18/CHO mAb decreased cellular ATP levels in the IMR-32 and CHP-134 neuroblastoma cell lines, similarly to the 14G2a mAb. Regarding ch14.18/CHO mAb treated IMR-32 cells, the observed cytotoxic effect was concomitant with induced caspase 3 cleavage, which indicated the induction of apoptosis in IMR-32 cells, but not in CHP-134 cells. Furthermore, the MK-5108 inhibitor induced apoptosis, as indicated by the increased cleavage of caspase 3 and increased activity of caspase 3/7. However, the presence of necroptosis was ruled out in MK-5108-treated IMR-32 and CHP-134 cells. In summary, the effects of the combination of ch14.18/CHO mAb and aurora A kinase inhibitors (MK-5108 and MK-8745) were shown to enhance apoptosis in IMR-32 cells compared to when used individually.

The novel piperazino-enaminone JOAB-40 reduced colitis severity in mice via inhibition tumor necrosis factor-α and interleukin-1β

BRIEF INTRODUCTION

The synthetic compound enaminone E121 has an established role as a potent anti-tussive, bronchodilator and anti-inflammatory agent in asthma, cough, and colitis induced animal models. The addition of an N-alkylated piperazine motif to the terminal end of E121 lead to the generation of various analogues such as JOAB-40. JOAB-40 was shown to be more potent than the lead compound E121 in inhibiting the expression of the chemokine receptor CCR2, ERK1/2 phosphorylation, and the release of pro-inflammatory cytokines in vitro.

MAIN OBJECTIVE OF THE STUDY

We hypothesize that JOAB-40 is more potent than the lead compound E121 in reducing colitis severity in mice in part through inhibiting the release of TNFα and IL-1β.

METHODS

Colitis was induced by dextran sulfate sodium (DSS) administration using prophylactic and treatment approaches. The severity of the inflammation was determined by the gross (macroscopic) and histological (microscopic) assessments. The levels of TNFα, IL-1β, and IL-10 release in response to lipopolysaccharide (LPS) stimulation from the adherent murine macrophage cell line J774.2 in vitro, and the circulating levels of TNFα in vivo was measured by ELISA-based technique.

SIGNIFICANT FINDINGS FROM THE STUDY

E121 administration (1-60 mg/kg) in mice with established colitis (treatment approach) did not reduce colitis severity. On the other hand, JOAB-40 administration significantly reduced colitis severity in mice when administered using two approaches; a) prophylactic (given along colitis induction), and b) treatment (given after colitis was established) with doses as low as 10 mg/kg. The degree of inhibition of TNFα and IL-1β (but not IL-10) release from J774.2 cell line in response to LPS stimulation was more potent with JOAB-40 than E121. This was also observed in vivo in regards to the circulating levels of TNFα.

RELEVANT CONTRIBUTION TO KNOWLEDGE

Our results indicate that JOAB-40 is more potent than E121 in reducing colitis severity in mice and may be a promising future therapeutic target for the management of inflammatory bowel disease (IBD).

Improving the Lifetime Efficiency of Trimedlure-Dispensing System in Trapping the Fruit Fly Ceratitis capitata Using Polyethylene Matrix

Detection of the Mediterranean fruit fly, Ceratitis capitata (Wiedemann), is highly reliant on traps loaded with trimedlure (TML), a male-specific attractant. The successful application of attractants requires that constituents are placed in a suitable dispensing system to reduce volatilization and increase the effective field longevity of the attractant. A series of trials were conducted in different fruit orchards to test 1) the efficiency of a polyethylene-matrix plug in regulating the emission rate of TML 2) and the lifetime attractiveness of the plug compared to the cotton wick dispenser. Cotton dispensers containing the recommended dose of TML (0.75 cm3) and with a double dose (1.5 cm3) remained active for 6 and 8 wk, respectively. The increase in TML dose from 0.75 cm3 to 1.5 cm3 led to an increase in the longevity of the cotton dispenser, but there was no significant difference between the doses in biological activity. In all trials, TML-polyethylene matrix dispensers were more efficient under field conditions as they attracted more males for up to 12 wk and prolonged the release of TML more than the cotton wick dispensers. The TML-loaded polyethylene matrix dispensers might be useful in 1) minimizing the losses of the liquid TML from cotton wicks, 2) avoiding the damage that occurs when using other dispensers, 3) prolonging the TML lifetime in the field through regulating its release rates, 4) potentially minimizing the adverse effect of high temperatures on release rate, and, finally, 5) minimizing the costs of using large amounts of expensive TML solutions.

Gabapentin: Change is in the Wind

In the midst of a national opioid crisis, Americans have a heightened awareness of the potential for prescription drugs that can be abused. One drug-gabapentin-is frequently prescribed in long-term care facilities for seizures and postherpetic neuralgia, and its use is a growing concern globally. Approved for two uses, but used off-label for many others, gabapentin can induce euphoria at high doses. In older adults, clinicians prescribe it for seizures, pain, migraine, and aggression associated with dementia, among other things. Gabapentin's rapid onset of action, side effect profile, limited drug-drug interactions, and extensive pharmacokinetic data in renal impairment have made prescribers comfortable using it in older adults. This gabapentinoid-a cousin to the Schedule V drug pregabalin-has seen widespread recreational abuse and has led to its reclassification in the United Kingdom and in several U.S. states. Consultant pharmacists need to be aware that the evidence behind off-label use is scant; withdrawal is likely after as few as three weeks of treatment; and drug diversion is possible, even likely. In addition, it is the tenth-most prescribed medication in the United States.

A Meta-Analysis of Therapeutic Efficacy and Safety of Gabapentin in the Treatment of Postherpetic Neuralgia from Randomized Controlled Trials

OBJECTIVE

The study aims to systematically evaluate the clinical effect of gabapentin in the treatment of postherpetic neuralgia (PHN).

METHOD

Data were retrieved electronically from PubMed, Embase, CNKI, the China Biomedical Database, and the Library of Clinical Database, beginning from the time of inception to April 2017, in order to collect data on randomized controlled trials (RCTs) of gabapentin and placebo in PHN treatment.

RESULTS

A total of 11 RCTs (2376 people) were retrieved. The gabapentin group reported significantly reduced pain intensity [MD=-0.91, 95% CI -1.32 to -0.51, P<0.00001] compared with the placebo group. Those treated with gabapentin also experienced significantly improved sleep quality [SMD=-0.44, 95% CI -0.66 to -0.23, P<0.0001], but were more likely to experience incidence of adverse events, such as somnolence, dizziness, and peripheral edema. Results of the subgroup analysis showed that the source of heterogeneity may be related to the formulations of the drug.

CONCLUSION

Gabapentin can be used to effectively and safely treat PHN.

Suppression of Mediterranean Fruit Fly (Diptera: Tephritidae) With Trimedlure and Biolure Dispensers in Coffea arabica (Gentianales: Rubiaceae) in Hawaii

To assess the potential to suppress Mediterranean fruit fly, Ceratitis capitata (Wiedemann; Diptera: Tephritidae), via mass trapping with Trimedlure (TML), we compared fly catch (as catch per trap per time period) provided by either a novel, solid, triple-lure dispenser with TML, methyl eugenol (ME), and raspberry ketone (RK) (TMR) or solid TML plugs, both without insecticides, in addition to Biolure bait stations. Work was done in a coffee plantation that had a dense C. capitata population. Three treatments were compared: 1) TMR or TML (50 traps per ha), 2) Biolure (50 traps per ha), 3) TML (25 per ha) or TMR (25 per ha) + Biolure (25 per ha), and 4) an untreated control. During coffee season, based on C. capitata captures (mean flies per trap per wk) inside plastic McPhail traps, all treatments were significantly different than the control: Biolure (9.57) = TMR (11.28) = Biolure +TMR (13.50) < Control (36.06 flies/trap/wk). During non-coffee season, all treatments were significantly different than the control and TML was significantly lower than Biolure (wax matrix bait stations): TML (0.95) < Biolure (1.43) = Biolure +TML (1.77) < Control (2.81 flies/trap/wk). Surprisingly, captures were not lower in plots treated with combinations of Biolure + TMR or TML, compared to individual plots with Biolure or TML or TMR alone. Mass trapping with either TML or TMR dispensers deserves further study as a component of Integrated Pest Management programs for C. capitata in Hawaii and may have global potential for management of C. capitata.

Phantom motor execution facilitated by machine learning and augmented reality as treatment for phantom limb pain: a single group, clinical trial in patients with chronic intractable phantom limb pain

BACKGROUND

Phantom limb pain is a debilitating condition for which no effective treatment has been found. We hypothesised that re-engagement of central and peripheral circuitry involved in motor execution could reduce phantom limb pain via competitive plasticity and reversal of cortical reorganisation.

METHODS

Patients with upper limb amputation and known chronic intractable phantom limb pain were recruited at three clinics in Sweden and one in Slovenia. Patients received 12 sessions of phantom motor execution using machine learning, augmented and virtual reality, and serious gaming. Changes in intensity, frequency, duration, quality, and intrusion of phantom limb pain were assessed by the use of the numeric rating scale, the pain rating index, the weighted pain distribution scale, and a study-specific frequency scale before each session and at follow-up interviews 1, 3, and 6 months after the last session. Changes in medication and prostheses were also monitored. Results are reported using descriptive statistics and analysed by non-parametric tests. The trial is registered at ClinicalTrials.gov, number NCT02281539.

FINDINGS

Between Sept 15, 2014, and April 10, 2015, 14 patients with intractable chronic phantom limb pain, for whom conventional treatments failed, were enrolled. After 12 sessions, patients showed statistically and clinically significant improvements in all metrics of phantom limb pain. Phantom limb pain decreased from pre-treatment to the last treatment session by 47% (SD 39; absolute mean change 1·0 [0·8]; p=0·001) for weighted pain distribution, 32% (38; absolute mean change 1·6 [1·8]; p=0·007) for the numeric rating scale, and 51% (33; absolute mean change 9·6 [8·1]; p=0·0001) for the pain rating index. The numeric rating scale score for intrusion of phantom limb pain in activities of daily living and sleep was reduced by 43% (SD 37; absolute mean change 2·4 [2·3]; p=0·004) and 61% (39; absolute mean change 2·3 [1·8]; p=0·001), respectively. Two of four patients who were on medication reduced their intake by 81% (absolute reduction 1300 mg, gabapentin) and 33% (absolute reduction 75 mg, pregabalin). Improvements remained 6 months after the last treatment.

INTERPRETATION

Our findings suggest potential value in motor execution of the phantom limb as a treatment for phantom limb pain. Promotion of phantom motor execution aided by machine learning, augmented and virtual reality, and gaming is a non-invasive, non-pharmacological, and engaging treatment with no identified side-effects at present.

FUNDING

Promobilia Foundation, VINNOVA, Jimmy Dahlstens Fond, PicoSolve, and Innovationskontor Väst.

[Treatment of pediatric epilepsy]

Recently, the treatment strategy for pediatric epilepsy has been dramatically changed in Japan, because of the approval of new-generation antiepileptic drugs. Since 2006, a total of 6 new antiepileptic drugs, including gabapentin (GBP; adults/pediatric patients: 2006/2011 [year of approval]), topiramate (TPM; 2007/2013), lamotrigine (LTG; 2008/2008), levetiracetam (LEV; 2010/2013), stiripentol (STP; 2012/2012), and rufinamide (RUF; 2013/2013), have been introduced. Thus far, valproate (VPA) and carbamazepine (CBZ) have been first indicated for "generalized" epilepsy and "focal" epilepsy syndromes/types, respectively, in Japan. However, the approval of these new drugs could allow us to choose more effective and less toxic ones at an early stage of treatment. In this chapter, we describe the latest domestic and foreign guidelines for the treatment of pediatric epilepsy.

[New antiepileptic drugs: characteristics and clinical applications]

New antiepileptic drugs (AEDs) that have been used in many other countries for more than 10 years have only recently became available for use in Japan. Gabapentin, topiramate, lamotrigine and levetiracetam were licensed for use in Japan between 2006 and 2010. Stiripentol for Dravet syndrome and rufinamide for Lennox-Gastaut syndrome were also approved in 2012 and 2013 as orphan drugs. Clinical trials of other new AEDs such as oxcarbazepine, vigabatrin, lacosamide, and perampanel are in progress. In this review, the general characteristics of the new AEDs are discussed with regards to their effectiveness, tolerability, drug interaction, safety and mechanisms of action. The effectiveness, of the new AEDs compared with established AEDs is also discussed. Clinical applications of the new AEDs, focusing on gabapentin, topiramate, lamotrigine and levetiracetam are also discussed based on our domestic experience as well as overseas reports.

[Lacosamide as an alternative in the treatment of post-surgery neuropathic pain in an allergic patient]

INTRODUCTION

Neuropathic pain is a condition that is still not well understood, although it affects a significantly high percentage of the population. The main problem lies in the fact that it can become a fairly disabling pathology. The most frequent treatment is based essentially on two drugs: gabapentin and pregabalin. Other pharmaceuticals, such as antidepressants, opioids or N-methyl-D-aspartate receptor antagonists can also be employed in combination with the primary drugs. All the same, treatment remains unsatisfactory. Furthermore, it must be borne in mind that there may be patients who are allergic to the two main drugs.

CASE REPORT

We report the case of a 36-year-old female with neuropathic pain secondary to surgery to correct a neurinoma in the brachial plexus, who could not be treated with gabapentin or pregabalin because of a personal history of allergy to these substances. Treatment with another drug (lacosamide), however, was very effective and displayed a very good response.

CONCLUSIONS

Lacosamide is a third-generation antiepileptic drug that has been proven to be effective, safe and with few side effects. It has been considered a good therapeutic option for the treatment of neuropathic pain in patients who are allergic to pregabalin.

Lack of Pharmacokinetic Interactions Between Cilomilast and Theophylline or Smoking in Healthy Volunteers

The pharmacokinetic profile of cilomilast (Ariflo), a selective phosphodiesterase 4 (PDE4) inhibitor, was investigated in three separate studies. Two of these studies explored the drug interaction potential of cilomilast with the nonselective PDE inhibitor, theophylline, and a third study compared the pharmacokinetic profile of cilomilast in smokers and nonsmokers. Repeated administration of cilomilast had no effect on the steady-state pharmacokinetics of theophylline in either a pilot dose-ranging or definitive therapeutic study. At therapeutic doses, the point estimate and 90% confidence interval for theophylline AUC(0-12) and C(max) were completely contained within the range (0.8, 1.25). Similarly, repeated administration of theophylline had little clinically relevant effect on the steady-state pharmacokinetics of cilomilast when compared to placebo, as only slight average increases in cilomilast AUC(0-12) and C(max) (6% and 3%, respectively) were observed. In addition, mean cilomilast exposure (AUC(0- infinity )) was found to be similar in both smokers and nonsmokers (8.47 +/- 2.20 microg*h/mL and 7.70 +/- 2.25 microg*h/mL, respectively). Throughout all three studies, cilomilast was well tolerated, and concomitant use of these selective and nonselective inhibitors, although unlikely in the clinic, is hypothetically feasible. Taken together, these studies clearly differentiate cilomilast from theophylline for drug-drug liability issues in a smoker and nonsmoker population, as well as highlight the potential to switch from one drug to another without undue clinical concern.

[Efficacy of new antiepileptic drugs and the next generation drugs]

Recent development and success in the field of new antiepileptic drug treatment, has resulted in the commercialization of many new drugs. The efficacy of these drugs has been assessed in many countries. Despite the progress in USA and European countries, a time lag of approximately 10 years concerning these new drugs exists in Japan. Since 2000, the above mentioned new drugs have been commercially available and are used to treat many patients with refractory epileptic seizures and verify their efficacy as well in Japan. Induced pluripotent stem (iPS) cells, which were invented in Japan are expected to accelerate the invention of more effective antiepileptic drugs in the near future.

Pharmacological studies of bronchial constriction inhibited by parasympatholytics and cilomilast using equine precision-cut lung slices

Equine precision cut lung slices (PCLS) were used to evaluate the ability of several pharmacologic compounds, parasympatholytics atropine, ipratropium, tiotropium and phosphodiesterase (PDE) 4-inhibitor cilomilast, to inhibit methacholine (MCh) induced bronchial constriction. The study war performed using vital lung samples from 20 horses, harvested immediately after euthanasia and lung examination.Tissue samples from the cranial, caudal and accessory lobe were taken for histological examination. Viability in PCLS of 250 +/- 20 microm was confirmed by observation of cilia movement and bronchial contraction in response to the addition of increasing concentrations of MCh (10(-8) to 10(-4) mol/l). Washing in pure RPMI-medium resulted in bronchial reopening. After incubation (20 minutes in an RPMI-solution containing cilomilast (10(-5) mol/l), atropine, ipratropium or tiotropium (10(-7) mol/l) each group (randomized, placebo controlled) was treated with MCh again. After reopening the unaffected viability of the PCLS was confirmed by the addition of MCh. EC50 values were calculated from bronchial cross-sections for each contraction. EC50 values significantly increased after atropine, ipratropium and tiotropium addition. No difference was found for cilomilast and in control slices. Statistical analysis showed a large interindividual, but a small intraindivual variability. No correlation was found between the clinical examination, histological findings and PCLS' responsiveness. We were able to confirm Vietmeier's (2007) values for the responsiveness of equine PCLS to MCh and to proof the effect of several new bronchodilatators using a new technique that allows the assessment of several substances in the same horse.

[Selective phosphodiesterase-4 (PDE-4) inhibitors in COPD]

Chronic obstructive pulmonary disease (COPD) is a worldwide health problem resulting in significant morbidity and mortality; however, it could not be understood totally so far. Treatment options for the disease are quite limited and there is an urgent need for new treatment strategies. Among new therapeutic agents that are under development, a group of significant importance is phosphodiesterase-4 (PDE-4) inhibitors shown to have antiinflammatory actions. Phosphodiesterases are the enzymes responsible from the breakdown and inactivation of cyclic adenosine monophosphate (cAMP) which is an intracellular second messenger molecule. They are present in several structural and inflammatory cells, in these cells the inactivation of cAMP results in a proinflammatory cascade. So, in COPD which goes together with chronic inflammation, prevention of cAMP inactivation via phosphodiesterase enzyme inhibition made phosphodiesterase enzymes potential targets. Main phosphodiesterase playing a part in COPD is PDE-4 which is predominantly present in inflammatory cells and airway smooth muscle cells. The studies therefore focused on inhibitors selective to PDE-4 subtype. The two selective PDE-4 inhibitors that are at Phase III clinical trial stage are cilomilast and roflumilast. The studies have demonstrated that antiinflammatory effects of cilomilast and roflumilast positively contribute to the respiratory function, frequency of exacerbations and quality of life of COPD patients. Despite we need new studies to evaluate the influence of these agents on the natural course of COPD as well as their long-term safety; we can certainly comment that cilomilast and roflumilast are promising hope in COPD treatment by their clinical and antiinflammatory effects.

Evaluation of oral corticosteroids and phosphodiesterase-4 inhibitor on the acute inflammation induced by inhaled lipopolysaccharide in human

BACKGROUND

Endotoxins are pro-inflammatory substances present in the environment. In man, inhalation of its purified derivative lipopolysaccharide (LPS) induces inflammation related to macrophages and neutrophils. Corticosteroids and phosphodiesterase (PDE)-4 inhibitors have inhibiting effects on macrophages and neutrophils, respectively. This study investigated the effect of prednisolone and of the PDE-4 inhibitor cilomilast on the LPS-induced acute inflammation.

METHODS

The study was a placebo-controlled, double-blind crossover design. On three occasions, at 2 weeks interval, 16 healthy subjects inhaled 50 microg LPS after a 6-day treatment with cilomilast (15 mg bd), prednisolone (10 mg bd) or placebo. For the assessment of the inflammatory response, induced sputum was obtained before inclusion and 6h post-LPS while blood samples were collected before, 6 and 24 h post-LPS.

RESULTS

Inhaled LPS induced an increase in sputum neutrophils (p<0.0001), logMMP-9 (p<0.05), logMMP-9/TIMP-1 (p<0.01) and logTNF-alpha (p<0.02). At the blood level there were significant rise in neutrophilia (p<0.001), E-selectin (p<0.02), C-reactive protein (CRP) (p<0.001) and LPS-binding protein (p<0.001). There was both a slight, but not significant, increase in body temperature and decrease in forced expiratory volume in 1 s (FEV(1)). Neither prednisolone nor cilomilast had protective effect on the LPS-induced airways' inflammation. The LPS-induced CRP acute-phase protein of inflammation (0.58+/-0.13 and 3.52+/-0.41 mg/dL, before and after LPS, respectively) was significantly inhibited by a pre-treatment with prednisolone (1.39+/-0.32 mg/dL, p<0.01) and attenuated (2.65+/-0.30 mg/dL, p=0.09) with cilomilast.

CONCLUSION

In healthy subjects, while the LPS-induced airways' inflammation was not modified either by oral prednisolone or by PDE-4 inhibitor cilomilast (at actual dosage), the LPS-induced acute phase of blood inflammation was reduced by prednisolone.

Phosphodiesterase 4 inhibitors augment levels of glucocorticoid receptor in B cell chronic lymphocytic leukemia but not in normal circulating hematopoietic cells

Type 4 cyclic AMP (cAMP) phosphodiesterase (PDE4) inhibitors, a class of compounds in clinical development that activate cAMP-mediated signaling by inhibiting cAMP catabolism, offer a feasible means by which to potentiate glucocorticoid-mediated apoptosis in lymphoid malignancies such as B-cell chronic lymphocytic leukemia (B-CLL). In this study, we show that PDE4 inhibitors up-regulate glucocorticoid receptor (GRalpha) transcript levels in B-CLL cells but not T-CLL cells or Sezary cells or normal circulating T cells, B cells, monocytes, or neutrophils. Because GRalpha transcript half-life does not vary in CLL cells treated with the prototypic PDE4 inhibitor rolipram, the 4-fold increase in GRalpha mRNA levels observed within 4 h of rolipram treatment seems to result from an increase in GRalpha transcription. Rolipram treatment increases levels of transcripts derived from the 1A3 promoter to a greater extent than the 1B promoter. Treatment of B-CLL cells with two other PDE4 inhibitors currently in clinical development also augments GR transcript levels and glucocorticoid-mediated apoptosis. Washout studies show that simultaneous treatment with both drug classes irreversibly augments apoptosis over the same time frame that GR up-regulation occurs. Although treatment of B-CLL cells with glucocorticoids reduces basal GRalpha transcript levels in a dose-related manner, cotreatment with rolipram maintained GRalpha transcript levels above baseline. Our results suggest that as a result of their unusual sensitivity to PDE4 inhibitor-mediated up-regulation of GRalpha expression, treatment of B-CLL patients with combined PDE4 inhibitor/glucocorticoid therapy may be of therapeutic benefit in this disease.

Advances in pharmacologic agents in imaging: new A2A receptor agonists

Pharmacologic stress myocardial perfusion imaging is being performed with increasing frequency over exercise stress. Dipyridamole and adenosine have a high side-effect profile, provide higher than needed coronary artery flow rates, and use a relatively complicated method of administration. Based on preclinical animal work, three selective adenosine A2A receptor agonists, regadenoson (CVT3146), binodenoson (MRE0470 or WRC0470), and apadenoson (BMS068645 or ATL146e), may overcome these limitations and are now in Phase III studies as pharmacologic stress agents. For single-photon emission CT imaging, binodenoson and regadenoson were concordant with adenosine images for detection and quantitation of ischemia. Despite the high A2A selectivity of binodenoson and regadenoson in preclinical studies, subjective side effects attributable to other adenosine receptor subtypes were still observed in human studies and are similar to or slightly lower than adenosine. There have been no reports of atrioventricular block or bronchospasm with either regadenoson or binodenoson in published trials.

Cilomilast

The central role of cyclic nucleotides as intracellular second messengers dates back almost 50 years. The importance of phosphodiesterase in regulating this system was recognized early, and the potential therapeutic role of phosphodiesterase inhibitors in modulating pathologic conditions was also suggested. At that time, the methylxanthines represented major pharmacologic agents capable of inhibiting cyclic nucleotides and were widely used in respiratory medicine. Initially, bronchodilator effects were considered their major mechanism of action, but subsequent studies suggested other potential roles including an anti-inflammatory one. A number of developments led to the decline in popularity of this class of agents, the foremost being their side-effect profile. The discovery of multiple phosphodiesterase isoforms paired with a better understanding of the physiologic and clinical properties of the phosphodiesterases has re-awakened interest in therapeutic agents in this area and in particular the potential for the development of selective phosphodiesterase inhibitors. Cilomilast is a systemically available, second- generation, selective phosphodiesterase-4 inhibitor. It retains the therapeutic activity of the first generation phosphodiesterase-4 inhibitors (such as rolipram) but is believed to have less of an emetic effect. Cilomilast causes a reduction of tissue cells considered central to the ongoing inflammatory process (macrophages and CD8+ lymphocytes) in patients with chronic obstructive pulmonary disease. Chronic obstructive pulmonary disease is now considered a chronic inflammatory disease of the lungs resulting from prolonged exposure to inflammatory agents in cigarette smoke and other environmental and occupational pollutants, and it is currently the principal target of cilomilast. It is characterized by progressive destruction of parenchymal tissue and punctuated by acute exacerbations. The inflammation is thought to begin in the peripheral airways and lung parenchyma. Chronic obstructive pulmonary disease is a progressive disease, leading to disability and eventual death despite conventional therapy. Cilomilast is completely absorbed following oral administration and has negligible first-pass metabolism. It exhibits low between-subject variability. Cilomilast is predominantly protein bound. Plasma clearance is almost entirely metabolic, through multiple parallel pathways. Its terminal elimination half-life is approximately 6.5 hours, and steady state is rapidly achieved. A dose of 15 mg twice daily has been found to be clinically effective. Smoking and age have no clinically relevant effects on cilomilast pharmacokinetics. Most drugs frequently used in patients with chronic obstructive pulmonary disease do not alter its side effect profile. Initial concerns of arteritis involving the gastrointestinal tract in rodent animal models have not been reported in clinical trials. Nausea, presumably of central origin, is the principal adverse reaction seen in healthy subjects taking cilomilast. It has not been associated with the serious cardiac or neurological adverse effects seen with theophylline. Preliminary clinical studies suggest a favorable clinical effect in chronic obstructive pulmonary disease. Cilomilast is generally well tolerated and has not generated safety concerns in reported clinical studies.

PDE4B5, a Novel, Super-Short, Brain-Specific cAMP Phosphodiesterase-4 Variant Whose Isoform-Specifying N-Terminal Region Is Identical to That of cAMP Phosphodiesterase-4D6 (PDE4D6)

The cAMP-specific phosphodiesterase-4 (PDE4) gene family is the target of several potential selective therapeutic inhibitors. The four PDE4 genes generate several distinct protein-coding isoforms through the use of alternative promoters and 5'-coding exons. Using mouse transcripts, we identified a novel, super-short isoform of human PDE4B encoding a novel 5' terminus, which we label PDE4B5. The protein-coding region of the novel 5' exon is conserved across vertebrates, chicken, zebrafish, and fugu. Reverse-transcription-polymerase chain reaction (PCR) and quantitative (PCR) measurements show that this isoform is brain-specific. The novel protein is 58 +/- 2 kDa; it has cAMP hydrolyzing enzymatic activity and is inhibited by PDE4-selective inhibitors rolipram and cilomilast (Ariflo). Confocal and subcellular fractionation analyses show that it is distributed predominantly and unevenly within the cytosol. The 16 novel N-terminal residues of PDE4B5 are identical to the 16 N-terminal residues of the super-short isoform of PDE4D (PDE4D6), which is also brain-specific. PDE4B5 is able to bind the scaffold protein DISC1, whose gene has been linked to schizophrenia. Microarray expression profiling of the PDE4 gene family shows that specific PDE4 genes are enriched in muscle and blood fractions; however, only by monitoring the individual isoforms is the brain specificity of the super-short PDE4D and PDE4B isoforms revealed. Understanding the distinct tissue specificity of PDE4 isoforms will be important for understanding phosphodiesterase biology and opportunities for therapeutic intervention.

Effects of cyclosporin A and cilomilast on activated canine, murine and human keratinocytes

The calcineurin inhibitor cyclosporin A and the phosphodiesterase 4 inhibitor cilomilast exhibit potent immunomodulatory properties which make them interesting therapeutics for the treatment of skin disorders like canine and human atopic dermatitis. Cyclosporin A and phosphodiesterase 4 inhibitors have already demonstrated clinical efficacy in the therapy of canine and human atopic dermatitis. Their direct impact on keratinocytes, especially canine keratinocytes, is less obvious. Thus, an investigation was carried out to ascertain whether cyclosporin A and cilomilast modulate keratinocyte proliferation and secretion of proinflammatory mediators. Cyclosporin A inhibited canine and murine keratinocyte proliferation, whereas cilomilast had no affect. Cyclosporin A and cilomilast reduced the lipopolysaccharide-induced prostaglandin E2 synthesis in canine and murine keratinocytes. Both immunomodulators also inhibited the production of the CXC chemokine KC and CCL2 in the murine keratinocyte cell line MSC-P5. The two immunomodulators also significantly reduced the interferon-gamma-induced production of interferon-gamma-inducible protein 10 in human keratinocytes (HaCaT cells). Thus, cyclosporin A and cilomilast directly modulate keratinocyte functions which might contribute to the anti-inflammatory and immunomodulatory action of these compounds in the treatment of allergic skin diseases.

L-454,560, a potent and selective PDE4 inhibitor with in vivo efficacy in animal models of asthma and cognition

Type 4 phosphodiesterases (PDE4) inhibitors are emerging therapeutics in the treatment of a number of chronic disorders including asthma, chronic obstructive pulmonary disease (COPD) and cognitive disorders. This study delineates the preclinical profile of L-454,560, which is a potent, competitive and preferential inhibitor of PDE4A, 4B, and 4D with IC50 values of 1.6, 0.5 and 1.2 nM, respectively. In contrast to the exclusive binding of cilomilast and the preferential binding of roflumilast to the PDE4 holoenzyme state (Mg2+-bound form), L-454,560 binds to both the apo-(Mg2+-free) and holoenzyme states of PDE4. The intrinsic enzyme potency for PDE4 inhibition by L-454,560 also results in an effective blockade of LPS-induced TNFalpha formation in whole blood (IC50 = 161 nM) and is comparable to the human whole blood potency of roflumilast. The cytokine profile of inhibition of L-454,560 is mainly a Th1 profile with significant inhibition of IFNgamma and no detectable inhibition of IL-13 formation up to 1 microM. L-454,560 was also found to be efficacious in two models of airway hyper-reactivity, the ovalbumin (OVA) sensitized and challenged guinea pig and the ascaris sensitized sheep model. Furthermore, L-454560 was also effective in improving performance in the delayed matching to position (DMTP) version of the Morris watermaze, at a dose removed from that associated with potential emesis. Therefore, L-454,560 is a novel PDE4 inhibitor with an overall in vivo efficacy profile at least comparable to roflumilast and clearly superior to cilomilast.

An update and appraisal of the cilomilast Phase III clinical development programme for chronic obstructive pulmonary disease

Cilomilast (Ariflo, SB 207499) is an orally active, second-generation phosphodiesterase (PDE) 4 inhibitor that is being developed by GlaxoSmithkline for the treatment of chronic obstructive pulmonary disease (COPD). The results of Phase I and Phase II studies have demonstrated that cilomilast significantly improves lung function and quality of life to a clinically meaningful extent, which has led to a comprehensive Phase III programme of research evaluating efficacy, safety and mechanism of action. However, the results of those Phase III studies are unremarkable and disappointing, raising doubt over the future of cilomilast as a novel therapy for COPD. This review summarizes data obtained from the Phase III clinical development programme, highlights some of the potential concerns both specific to cilomilast and to PDE4 inhibitors in general and assesses the likelihood that cilomilast will reach the market.

Differential effects of phosphodiesterase PDE-3/PDE-4-specific inhibitors on vasoconstriction and cAMP-dependent vasorelaxation following balloon angioplasty

It is known that cAMP and cGMP are important for vasorelaxation, and cyclic nucleotide phosphodiesterases (PDEs) regulate their levels. Balloon angioplasty (BAL) is associated with reduced cAMP and cGMP levels, and inhibition of PDE-3 reduces restenosis. In this study, we found that BAL increased PDE-3 activity, which affected vasoreactivity of rat aortic rings 24-h post-BAL; these were compared with intact (INT) and ex vivo endothelium-denuded rings (RUB) from sham rats. In BAL and RUB rings, vasorelaxant responses to ACh were abolished. The EC(50) for phenylephrine (PE) was 1.8-fold less in RUB than in INT or BAL, whereas the maximal contractile effect of PE was greater in BAL than in INT or RUB. PDE-3 inhibitors reduced the maximal response to PE by >65% in BAL compared with 10-30% in INT and RUB; the reduction of the maximal response to U-46619 was 37% in BAL compared with 8% in INT with no reduction in RUB. PDE-4 inhibitors reduced PE-induced tone by <30% in an endothelium-dependent manner. Vasorelaxant responses to agonists that utilize cAMP were greatly impaired in BAL and RUB rings, and inhibition of PDE-3 enhanced the vasorelaxant responses in BAL or RUB. Inhibition of PDE-4 increased vasorelaxant responses to isoproterenol (ISO) to a much lesser degree. Thus PDE-3 and PDE-4 inhibitors exhibited differential effects on PE-induced tone and vasorelaxant responses to ISO. Inhibition of PDE-3 also produced a greater increase in cAMP in BAL than INT or RUB rings. These results suggest that increased PDE-3 activity after BAL may promote a vasospastic state and that the reduction in cAMP may, possibly, influence vessel remodeling.

Making Sense of the Evidence Regarding Nonhormonal Treatments for Hot Flashes

The demand for nonhormonal interventions for hot flashes is increasing because of the number of patients diagnosed with hormone-sensitive cancers and the results of the Women's Health Initiative indicating that hormone replacement therapy is not as beneficial as originally believed. Since 2002, numerous studies testing nonhormonal treatments for hot flashes have been conducted. Clinicians need to be able to use these research findings to help patients make treatment decisions. Because hot flashes can interfere with activities of daily living such as sleep and work, clinicians first should assess the extent to which hot flashes are disruptive to a woman's life. The evidence for nonhormonal interventions is summarized, and a decision treatment algorithm is offered for use in clinical practice. This algorithm includes nonhormonal options of the antidepressants available in addition to gabapentin, an antiseizure medication. A short review of the evidence for possible complementary therapies also is included.

[Newer antiepileptic drugs]

Ten newer antiepileptic drugs have been developed since 1990s. These drugs have wider therapeutic spectra, fewer side-effects, and lesser drug-to-drug interactions compared with the older typical antiepileptic drugs. Among them, zonisamide was developed in Japan and has been used from 1989. Gabapentin was at length approved in 2006. The other newer antiepileptic drugs are not approved yet in Japan. Felbamate can not be used in Europe because it may induce lethal hepatic toxicity and aplastic anemia. Vigabatrin is not approved in USA because it may induce permanent visual field deficit. The USA guideline for epilepsy treatment recommends that patients with newly diagnosed epilepsy can be treated with gabapentin, lamotrigine, topiramate, and oxcarbazepine. In contrast, based on epilepsy treatment guideline in England, newer antiepileptic drugs are considered only when patients with newly diagnosed epilepsy are unable to use the older antiepileptic drugs for some reasons. All newer antiepileptic drugs are used for intractable partial epilepsies, and lamotrigine and topiramate can also be used for idiopathic generalized epilepsies. The response rate (seizure reduction rate with 50% or more) and drop-out rate are overlapping among all newer antiepileptic drugs. Gabapentin, levetiracetam, and pregabalin are eliminated from kidney, and they had no drug-to-drug interactions and can be titrated rapidly. The serum concentration of lamotrigine is decreased with co-administration of hepatic enzyme inducing drugs and is increased with co-administration of valproic acid. Hypersensitivity reactions are rare with gavapentin, levetiracetam, topiramate, and tiagabin. Psychoses are reported to be induced with zonisamide, however, they can be induced with the other newer drugs (topiramate, levetiracetam, etc.). Drug-induced psychiatric symptoms, especially depression, may be often underdiagnosed. Many of these newer drugs (gabapentine, lamotrigine, levetiracetam, oxycarbazepine, etc.) have effects on chronic neuropathic pain. Some newer drugs show mood stabilizing effects (lamotrigine, oxycarbazepine, etc.), or antianxiety effect (gabapentin, topiramate, levetiracetam, pregavalin, etc.). Wide range of action to central nervous system of these newer antiepileptic drugs may serve not only for clinical seizure suppression, but also for neuroprotection.

Phosphodiesterase-4 inhibitors as a novel approach for the treatment of respiratory disease: cilomilast

Phosphodiesterase-4 (PDE4) is an important cAMP-metabolising enzyme in immune and inflammatory cells, airway smooth muscle and pulmonary nerves. The phosphodiesterase 4 (PDE4) enzyme plays a significant role in modulating the activity of cAMP, an important second messenger that mediates the relaxation of airway smooth muscle and suppresses inflammatory cell function, thereby attenuating the inflammatory response. Selective inhibitors of this enzyme show a broad spectrum of activity in animal models of COPD and asthma. These drugs block the hydrolysis of cAMP via inhibition of PDE4 and are attractive candidates for novel anti-inflammatory drugs. At present, two second-generation PDE4 inhibitors for the treatment of COPD and asthma patients are being tested in clinical Phase III trials. The most advanced compound is the orally active, selective PDE4 inhibitor cilomilast (Ariflo, SB-207499, cis-4-cyano-4-[3-cyclopentyloxy-4-methoxyphenyl]-cyclohexanecarboxylic acid; GlaxoSmithKline). Cilomilast shows high selectivity for cAMP-specific PDE4, an isoenzyme that predominates in pro-inflammatory and immune cells and that is 10-fold more selective for PDE4D than for PDE4A, -B or -C. In vitro, cilomilast suppresses the activity of several pro-inflammatory and immune cells that have been implicated in the pathogenesis of asthma and COPD. Moreover, it is highly active in animal models of these diseases. Cilomilast has been shown to exert potent anti-inflammatory effects both in vitro and in vivo. It is orally active and may be effective in the treatment of asthma and COPD; however, complete assessment of the therapeutic value of this novel compound class must await the outcome of longer-term clinical trials. This review presents a summary of the preclinical and clinical profile of cilomilast in patients with COPD.