HLA Gene in 5 Cases of Liver Injury Related to Baikal Skullcap.

HLA association with drug-induced liver injury has recently been pointed out about multiple medicines. The aim of this study was to evaluate relationship between HLA gene and liver injury related to Baikal skullcap-containing Kampo medicines (BSCK). We previously examined HLA genes in 3 cases of BSCK-induced liver injury. Recently we could encounter 2 cases diagnosed as "definitely-related case" of BSCK-induced liver injury. HLA genes of the 2 cases were analyzed by Sequencing Based Typing method with Next Generation Sequencer at HLA Laboratory in Kyoto. HLA-DPA1*02:02:02 and DPB1*05:01:01 were observed in the 2 cases: concordance was not observed in HLA-A, B, C, DRB1, DRB4, DQA1, or DQB1. The previous 3 cases of BSCK-induced liver injury had the same allele type to the 2 cases only in HLA-DPA1. Putting all these together, HLA-DPA1*02:02:02 was observed in common among 5 cases of BSCK-induced liver injury. HLA-DPA1*02:02:02 is possibly associated with BSCK-induced liver injury.

Clinical factors associated with the symptoms of constipation in patients with diabetes mellitus: A multicenter study.

BACKGROUND AND AIM: Changes in treatment protocols for patients with diabetes mellitus (DM) may influence the functions of the digestive tract. This study examined possible clinical factors associated with the symptoms of constipation in patients with DM. METHODS: This was a multicenter study. Participants were consecutive Japanese patients undergoing treatment for type 1 or type 2 DM. Constipation was evaluated using the gastrointestinal symptom rating scale. Diabetic neuropathy was evaluated by the presence or absence of peripheral neuropathy of the lower limbs. RESULTS: Of 419 participants, 258 were men and 161 women (ratio: 1.6:1), with a mean age of 63.6 ± 12.5 years. In multivariate analysis, symptoms of constipation were significantly associated with age (odds ratio [OR] = 1.02, 95% confidence interval [CI]: 1.01-1.04, P = 0.032), lower mental component summary (OR = 3.31, 95% CI: 1.69-6.48, P < 0.001), diabetic retinopathy (OR = 1.99, 95% CI: 1.14-3.45, P = 0.015), and diabetic neuropathy (OR = 1.86, 95% CI: 1.10-3.16, P = 0.021). In patients with peripheral neuropathy of the lower limbs, regardless of the presence of other complications (diabetic nephropathy and diabetic retinopathy), the prevalence of symptoms of constipation was twice that of patients without peripheral neuropathy (40.0-49.1% vs 22.0%). Diabetic drugs were not associated with symptoms of constipation. CONCLUSIONS: Diabetic neuropathy, defined as peripheral neuropathy of the lower limbs, was significantly associated with symptoms of constipation. Peripheral neuropathy of the lower limbs is not a direct risk factor for constipation but may be a useful criterion when assessing whether constipation is associated with DM.

A Study of Factors Associated with the Development of Pseudoaldosteronism in Outpatients.

Objective: The development of pseudoaldosteronism is shown to be mainly associated with four factors: daily dose of glycyrrhiza (licorice), duration of glycyrrhiza use, body size, and age. Recently, direct bilirubinemia and hypoalbuminemia are newly reported as possible factors that trigger pseudoaldosteronism due to glycyrrhiza ingestion. Pseudoaldosteronism occurs in the presence of combinations of these factors; therefore, the importance of each factor on the tolerance to glycyrrhiza loading is still unclear. Methods: In seven patients (63-78 years old, six women) who developed pseudoaldosteronism due to ingestion of glycyrrhiza-containing Kampo extract in their clinic, serum albumin and direct bilirubin (D-bil) levels were investigated. In six women, the authors evaluated the correlations between daily dose of glycyrrhiza ingested and each factor: age, height, weight, body mass index, body surface area (BSA), and duration of ingestion (Pearson's correlation coefficient). Results: No patients had abnormal levels of serum albumin or D-bil around the time of the onset. In six women, the highest correlation coefficient was observed between BSA and the glycyrrhiza dose in Kampo extract at the onset of pseudoaldosteronism. Conclusions: The findings suggested that in elderly women, BSA should be considered first as a factor for predicting the development of pseudoaldosteronism.

Macrophage-mediated inhibitory effect of Zingiber officinale Rosc, a traditional oriental herbal medicine, on the growth of influenza A/Aichi/2/68 virus.

The inhibitory effect of Zingiber officinale Rosc (ZOR), an Oriental traditional herbal medicine, on the growth of influenza A/Aichi/2/68 (Aichi) virus was investigated in Madin-Darby canine kidney (MDCK) cells. Direct addition of ZOR (0.1 approximately 100 microg/ml) to the infected cells did not have any inhibitory effect. However, the ZOR-induced conditioned medium (ZOR-CM) of RAW cells, a murine macrophage (Mphi) cell line, exhibited an apparent inhibitory effect on MDCK cells without cytotoxicity. In accordance with the time-dependent inhibitory effect of ZOR-CM, it has been demonstrated that tumor necrosis factor (TNF)-alpha was gradually accumulated in ZOR-CM by the induction of TNF-alpha mRNA expression in ZOR-stimulated RAW cells. Conversely, the inhibitory effect of ZOR-CM was reduced significantly by the removal of TNF-alpha after the formation of an immune complex with anti-TNF-alpha monoclonal antibody. These data suggested that ZOR itself has no inhibitory effect on the growth of influenza virus, but could exert its effect via macrophage activation leading to production of TNF-alpha.

Modified diagnostic criteria of drug-induced liver injury proposed by the international consensus meeting.

BACKGROUND/AIMS: The usefulness of the diagnostic criteria of the International Consensus Meeting (criteria A) has been previously reported. However, these criteria are not clinically adaptable in Japan where allergic reaction is one of the major etiologies of drug-induced liver injury and thus it was revised and reported in the Digestive Disease Week-Japan of 2002 as DDW-J criteria (criteria B). It remains controversial whether the revised criteria can exclude drugs not causing liver injury. METHODOLOGY: Two new diagnostic criteria (criteria C and D) were designed to supplement the DDW-J criteria. Usefulness and limitations of the four criteria were retrospectively examined using cases of drug-induced liver injury experienced in 8 hospitals. RESULTS: It was confirmed that the sensitivity of criteria B is excellent for diagnosis of drug-induced liver injury. However, diagnostic criteria B were found to be disadvantageous in relation to specificity, while diagnostic criteria D were disadvantageous in relation to sensitivity. Sensitivity of diagnostic criteria C was a little superior to that of diagnostic criteria A. CONCLUSIONS: On the basis, the significant sensitivity of criteria B was confirmed again, however, modification should be done for increasing specificity. Criteria C appear to be the best for their sensitivity and specificity.

Reexamination of the relation between menstrual cycle and kampo diagnosis, yin-yang.

Several Chinese herbal medicine textbooks describe that a short menstrual cycle indicates "yang" status and a long cycle indicates "yin" status. However, we sometimes encounter yang patients with a long cycle or yin patients with a short cycle in daily practice. Therefore, we reviewed the relationship between yin-yang and length of menstrual cycle. A questionnaire addressing both menstrual cycle and several parameters for determining yin-yang was completed at the time of the patients' visit to the hospital. Patients were divided into yang or yin groups, and menstrual cycle was compared between the two groups. A short menstrual cycle was mostly observed in yin patients (27.42 +/- 1.73, 95% CI: 26.32-28.52, n = 12) and a long cycle was mostly observed in yang patients (31.63 +/- 3.96, 95% C.I: 29.51-33.74, n = 16). The difference in menstrual cycle between the two groups was significant (p = 0.002), and this result was entirely opposite to the traditional theory. This study identified a discrepancy between the traditional theory and the actual menstrual cycle findings in this small population. Current reexamination of the relationship between yin-yang and menstruation in a larger population is warranted.

Challenge tests and kampo medicines: case report and review of the literature.

In order to diagnose Kampo medicine-induced liver injury, a challenge test using the suspected medicine is the most reliable method of assessing the relationship between Kampo medication and liver injury. However, such a challenge test may cause severe liver injury. We examined the clinical features and safety of challenge tests conducted by a physician in a case of Kampo medicine-induced liver injury that we encountered as well as in the previous literature (six cases) in Japan. In all cases except two, one-third of the daily dose was given a few times for the challenge test (challenge dose was not described in two cases). The reaction induced by the challenge peaked 1-3 days after challenge. Mild eosinophilia (6%) was observed in two cases. All liver injuries induced by challenge cleared within 2 weeks, and neither severe nor fatal liver injury was observed. In conclusion, a challenge with a small dose of Kampo medicine conducted in our case and in the previous literature induced mild and reversible liver injury. The safety and availability of challenge with a small dose of Kampo medicine should be further examined in a larger population with Kampo medicine-induced liver injury.

Inducible activity of ginger rhizome (Zingiber offifinale Rosc.) on the mRNA expression of macrophage-inducible nitric oxide (NO) synthase and NO production in a macrophage cell line, RAW264.7 cells.

We have investigated the effect of Zingiber offifinale Rosc. (ZOR) on macrophage-inducible nitric oxide (NO) synthase (macNOS) mRNA expression and NO production in RAW264.7 cells, a murine macrophage cell line; 100 microg/ml ZOR can induce macNOS mRNA expression, but induction effects at a dose below 10 microg/ml were weak or negligible. Kinetic studies showed that macNOS mRNA can be detected from 4 hours to 24 hours after dosing, with a peak at 8 hours. In accordance with the induction of macNOS mRNA expression, NO concentrations increased from 3.4 microM at 2 hours to almost 150 microM at 24 hours, reflecting a longer period of macNOS mRNA expression. The activity of ZOR can be considered to contribute, at least in part, to the beneficial effects of ZOR through the macNOS-mediated activation of the biodefense mechanism.

The efficacy of herbal medicine (kampo) in reducing the adverse effects of IFN-beta in chronic hepatitis C.

The purpose of this study was to determine if the adverse effects of interferon (IFN) in hepatitis C patients could be reduced by treatment with Japanese Oriental (Kampo) medicine. Twelve patients with chronic hepatitis C were treated with a combination of IFN-beta and either Mao-to or Dai-seiryu-to (groups A and B), and 16 patients were treated with IFN-beta alone (group C). Mao-to was administered to eight patients and Dai-seiryu-to was administered to four in groups A and B, respectively. Adverse effects were evaluated by clinical and laboratory examinations. The severity of symptoms was daily self-classified into four categories (1: none, 2: very slight, 3: moderate, and 4: serious), using a questionnaire consisting of 29 items. Scores of symptom such as discomfort and fever in group A, and discomfort, general malaise, paresthesia and arthralgia in group B were significantly lower than those in group C (p < 0.05). In all patients, HCV-RNA was negative at the end of the treatment, and serum alanine aminotransferase (ALT) levels had normalized transiently in all group A and B patients with genotype 1b by 2 weeks after cessation of IFN treatment. This study indicates that Kampo medicines are useful for reducing the adverse effects accompanying IFN treatment in patients with chronic hepatitis C without reducing the antiviral effects.

Herbal medicine and false-positive results on lymphocyte transformation test.

In vitro mitogenic activity of 16 herbs and 3 Kampo (herbal medicine) formulae have been reported in experimental studies. It is not known how many herbs and Kampo formulae in total have mitogenic activity. Lymphocyte transformation test (LTT) is generally utilized to diagnose drug-induced liver injury. In LTT, mitogenic activity is assessed by measuring 3H-thymidine incorporation. The objective of the present study was to determine which herbs and which Kampo formulae caused false-positivity on LTT. We examined 2496 summaries of all admission records from 1979 to 1999 in our department. We selected patients in whom liver injuries were diagnosed as definitely unrelated to Kampo medication. In these patients, LTT was performed for some herbs contained in the suspect Kampo medicines, resulting in positive LTT for 17 herbs: Evodiae Fructus (Goshuyu), Zizyphi Fructus (Taiso), Ginseng Radix (Ninjin), Zingiberis Rhizoma (Shokyo), Hoelen (Bukuryo), Aconiti Tuber (Bushi), Angelicae Radix (Toki), Cnidii Rhizoma (Senkyu), Rehmanniae Radix (Jio), Ephedrae Herba (Mao), Anemarrhenae Rhizoma (Chimo), Cinnamomi Cortex (Keihi), Bupleuri Radix (Saiko), Artemisiae Capillari Spica (Inchinko), Persicae Semen (Tonin), Moutan Cortex (Botanpi) and Paeoniae Radix (Shakuyaku). These results were considered false-positive, because the results were observed in the "definitely unrelated" patients. Mitogenic activity inherent to some herbs and Kampo formulae may sometimes cause false-positivity on LTT in clinical situations. These examples suggest that LTT for Kampo formulae may be unreliable as a diagnostic method for drug-induced liver injury.

Rhubarb use in patients treated with Kampo medicines--a risk for gastric cancer?

In vitro mutagenic effects have been reported for ingredients contained in rhubarb. Therefore, rhubarb (Rhei Rhizoma) as an anthranoid laxative could be associated with a risk of developing gastric cancer as well as colorectal cancer. We are not aware of any reports that have examined the relationship between the use of rhubarb and the development of gastric cancer. During the period between 1979 and 1999, we treated 14,616 patients using various Kampo medicines, which sometimes contained rhubarb. In the present study, we determined whether patients, diagnosed with gastric cancer during the period between 1979 and 1999, had been administered rhubarb before the development of gastric cancer. Among the 10 enrolled patients, only 2 patients had been administered rhubarb before the development of gastric carcinoma. The other 8 patients had never received rhubarb before the development of gastric carcinoma. Rhubarb use may have little connection with the development of gastric cancer in practice, even if some ingredients in rhubarb have shown carcinogenic activity in experimental studies.

[Relationships among urine pH, serum uric acid and pyuria in hospitalized elderly patients].

To identify risk factors of urinary tract infection (UTI) in geriatric patients, the levels of serum uric acid, serum creatinine, and urine pH were compared between pyuria-positive and -negative patients in a geriatric ward. The level of serum uric acid was higher with lower urine pH level in the pyuria-negative patients than in positive patients. The level of serum creatinine was relatively higher in the pyuria-negative patients than in the positive patients. Even after matching for serum creatinine, serum uric acid was significantly higher in the pyuria-negative male patients. The results in the present study proposed an interesting hypothesis about backgrounds for UTI in geriatric patients. The relationships among serum uric acid, serum creatinine, urine pH, and pyuria should be examined further in a larger population and in experimental studies.

[Opinions of doctors and nurses about appropriate medical treatment for terminally ill geriatric patients].

We investigated the opinions of medical doctors and nursing staff about desirable medical treatment for terminally ill geriatric patients. The purpose of the present study is: 1) to examine the recent opinion of doctors and nurses, 2) to examine discrepancies of opinions between doctors and nurses on treatment for terminal geriatric patients. Doctors and nurses working in long-term care wards in four hospitals were enrolled. They were asked to fill in a questionnaire which asked about desirable medical treatments for a typical bedridden terminally ill geriatric patient. The difference of answers between doctors and nurses were analyzed. The most common opinion of the 18 doctors and 84 nurses were as follows: 1) for the treatment of relapsing pneumonia, they would perform oxygenation, antibiotic injections, and continuous intravenous infusion during the period of discontinuation of enteral nutrition, 2) for the treatment of relapsing urinary tract infection, they would catheterize patients for a brief period and would irrigate the bladder, and would perform antibiotics injection, 3) for chronic anemia, they would perform iron replacement, 4) for decubitus ulcer, they would treat conventionally, and 5) at the final stage just before death, they would avoid special therapy for shock after obtaining informed consent from patient's family. To most questions, the proportion of each answer was almost identical between doctors and nurses; however, there were discrepancies concerning "way of nutrition in patients with relapsing pneumonia" and "irrigation of the urinary bladder" (p = 0.0544 and 0.0531, respectively). We expect that the present study will activate a discussion of what constitutes appropriate medical treatment for terminally ill geriatric patients.

Gene expression of cell surface antigens in the early phase of murine influenza pneumonia determined by a cDNA expression array technique.

BACKGROUND: Influenza virus is a worldwide health problem with significant economic consequences. To study the gene expression pattern induced by influenza virus infection, it is useful to reveal the pathogenesis of influenza virus infection; but this has not been well examined, especially in vivo study. AIMS: To assess the influence of influenza virus infection on gene expression in mice, mRNA levels in the lung and tracheal tissue 48 h after infection were investigated by cDNA array analysis. METHODS: Four-week-old outbred, specific pathogen free strain, ICR female mice were infected by intra-nasal inoculation of a virus solution under ether anesthesia. The mice were sacrificed 48 h after infection and the tracheas and lungs were removed. To determine gene expression, the membrane-based microtechnique with an Atlas cDNA expression array (mouse 1.2 array II) was performed in accordance with the manual provided. RESULTS AND CONCLUSIONS: We focused on the expression of 46 mRNAs for cell surface antigens. Of these 46 mRNAs that we examined, four (CD1d2 antigen, CD39 antigen-like 1, CD39 antigen-like 3, CD68 antigen) were up-regulated and one (CD36 antigen) was down-regulated. Although further studies are required, these data suggest that these molecules play an important role in influenza virus infection, especially the phase before specific immunity.

Natural killer cytolytic activity is associated with the expression of killer cell immunoglobulin-like receptors on peripheral lymphocytes in human.

Although it has been shown that killer cell immunoglobulin-like receptors (KIRs) on peripheral lymphocytes are upregulated by interleukin-2 (IL-2), which activates natural killer (NK) activity, it has not been demonstrated whether the expression of KIRs is related to NK activity. Therefore, we investigated the association between the KIR expression on lymphocytes and NK activity. CD158a/b expression on lymphocytes obtained from 37 subjects was analyzed using flow cytometry. Simultaneously, NK activity was measured each sample using a 51Cr-release assay. Additionally, lymphocytes were cultured in RPMI 1640 medium with or without IL-2 for 48 h, and then their CD158a/b expression and NK activity was analyzed. CD158a/b expression was significantly correlated with NK activity. Especially, the percentage of CD16+CD158a+ and CD8+CD158a/b+ cells in lymphocytes showed a highly significant correlation with NK activity. However, analysis of CD8+ and CD16+ cells revealed that there was only a significant correlation between the percentage of CD8+CD158a+ cells among only CD8+ cells and NK activity. The upregulation of CD16+CD158a+/b+ cells in response to IL-2 tended to be related to the increase of NK activity, but the relationship was not significant. In conclusion, the level of KIR expression was correlated with NK activity, and IL-2 treatment resulted in an increase of NK activity as well as KIR expression, suggesting that upregulation of KIRs enhances the ability to sort target cells, such as virus-infected cells from uninfected cells, according to major histocompatibility complex class I expression.

A case-control study of purple urine bag syndrome in geriatric wards.

The clinical background of purple urine bag syndrome (PUBS) has not yet been well characterized. In previous reports, clinical, biochemical, or bacteriological analyses were carried out using urine or bacteria from a limited number of patients. Other than one report, we are not aware of any case-control studies that compared the clinical, biochemical, or bacteriological background between patients with and without PUBS. To examine the risk of PUBS, we carried out a case-control study. Twenty-six patients, in three long-term care wards, who had been catheterized for more than 3 months with the same types of balloon catheters and who had the same type of disposable plastic urine bags were enrolled as the PUBS-positive case group (14 patients; 2 men and 12 women), and as the PUBS-negative control group (12 patients; 4 men and 8 women) were enrolled. The data for urine tests (pH, sugar, protein, leukocyte counts, and bacterial yields and species) were compared for the two groups. A relatively higher prevalence of PUBS was observed in female and alkaline-urine-producing patients. Bacteriological studies, using fresh urine collected through the catheter, showed that the bacterial counts were significantly higher, by 1 to 2 logs, in most samples from the case group than those from the control group (P = 0.012). Although a total of 66 bacterial strains, belonging to 12 separate species, were isolated from the urine accumulated in bags, no causative relationship between bacterial species and PUBS was observed. These data suggest that a higher bacterial yield in urine acts as the most important factor in PUBS, in combination with other facilitating factors, such as female-specific ones and the alkaline condition of urine.

Lymphocyte transformation test for medicinal herbs yields false-positive results for first-visit patients.

We performed lymphocyte transformation tests (LTTs) for toki (angelicae radix) and ogon (scutellariae radix) on first-visit patients who had never taken Kampo medicines. LTTs for both herbs were positive in 12 of 14 patients, suggesting that LTTs for these herbs are unreliable for the diagnosis of Kampo medicine-induced liver injury.

The effect of interleukin-15 on the expression of killer-cell immunoglobulin-like receptors on peripheral natural killer cells in human.

Interleukin (IL)-15 has emerged as a key regulator of both natural killer (NK) cell differentiation and activation. The aim of the present study was to investigate the expansion of the population of cells expressing killer-cell immunoglobulin-like receptors (CD158a and CD158b) in human peripheral lymphocytes by treatment with IL-15. One million peripheral lymphocytes were cultured in RPMI1640 medium alone or in medium containing IL-2 at 100 U/ml or IL-15 at 0.1, 1.0, or 10.0 ng/ml for 48 h. After each incubation, we assessed the natural killing activity and the population of CD16(+)CD158a(+)/b(+) cells and CD8(+)CD158a(+)/b(+) cells. IL-15 increased the NK activity and expanded the populations of CD16(+)CD158a(+)/b(+) cells and CD8(+)CD158a(+)/b(+) cells. These actions were dose dependent, and the effects of IL-15 at 1.0 ng/ml were close to those of IL-2 at 100 U/ml. These findings suggest that IL-15 induces the effector functions of resting NK cells throughout the body, and thereby plays a critical role in the activation of tissue-associated immune responses.

Four cases of panic disorder successfully treated with Kampo (Japanese herbal) medicines: Kami-shoyo-san and Hange-koboku-to.

Kampo medicines have been used to treat patients with psychogenic disorders from ancient times. In the present report the cases are described of four patients with panic disorder successfully treated with Kampo medicines. These four patients fulfilled the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for panic disorder with agoraphobia. The Kampo medicine Kami-shoyo-san (TJ-24) relieved panic attacks, anticipatory anxiety and agoraphobia in two patients, and Hange-koboku-to (TJ-16) relieved these symptoms in the other two patients. The patients in whom Kami-shoyo-san was effective were older and complained of more symptoms than those in whom Hange-koboku-to was effective. These Kampo medicines may be useful as additional or alternative treatments for panic disorder.

Suppressive effects of Stephania tetrandra on the neutrophil function in patients with rheumatoid arthritis.

Crude preparations of Stephania tetrandra (ST), a traditional herbal medicine, have been used safely for arthritis and silicosis in China. The concentration of granulocyte elastase - alpha 1 protease inhibitor complex in plasma is enhanced in inflammatory processes, e.g. in septicaemia and rheumatoid arthritis (RA), being an expression of granulocyte activation during inflammatory response. It has previously been reported that ST showed beneficial and immunomodulatory effects in the treatment of relatively mild RA. After the administration of ST for 12 weeks, the proportion of granulocytes and the granulocyte count in peripheral blood decreased significantly. The lipid peroxide and human granulocyte elastase levels of stored plasma declined significantly. Furthermore, both the leukocyte/elastase ratio and granulocyte/elastase ratio increased significantly. The findings of this study suggest that the suppressive effect of ST administration on excessive granulocyte activation resulted in the improvement of inflammation with rheumatoid arthritis.