Allogeneic Hematopoietic Cell Transplantation for Juvenile Myelomonocytic Leukemia with a Busulfan, Fludarabine, and Melphalan Regimen: JPLSG JMML-11.

Juvenile myelomonocytic leukemia (JMML), which is classified as a myelodysplastic/myeloproliferative neoplasm, is a rare hematologic malignancy of childhood. Most patients with JMML require allogeneic hematopoietic cell transplantation (HCT) as a curative therapy. A Japanese retrospective analysis demonstrated favorable outcomes for a busulfan (BU) + fludarabine (FLU) + melphalan (MEL) regimen, with an overall survival (OS) of 72% and an event-free survival (EFS) of 53%. To further validate the efficacy and safety of this regimen, the Japan Pediatric Leukemia/Lymphoma Study Group (JPLSG) conducted a nationwide prospective study, JMML-11. Between July 2011 and June 2017, 28 patients with newly diagnosed JMML were enrolled in JMML11. Low-dose chemotherapy for tumor control before HCT was recommended, and patients treated with AML-type chemotherapy and azacitidine were excluded. The conditioning regimen comprised i.v. BU, 16 doses administered every 6 h, with dose adjustment based on pharmacokinetic (PK) studies on days -11 to -8; FLU, 30 mg/m2/day or 1 mg/kg/day for patients <10 kg or age <1 year on days -7 to -4; and MEL, 90 mg/m2/day or 3 mg/kg/day for patients <10 kg or <1 year on days -3 to -2. The donor was selected by the physician in charge. A family donor was available for 7 patients (3 HLA-matched siblings, 3 HLA-1-antigen mismatched parents, and 1 haploidentical father). Overall, 21 patients received grafts from unrelated donors, including 8 HLA-matched donors and 13 HLA-mismatched donors. The graft source was related bone marrow (BM) for 7 patients, unrelated BM for 14 patients, and unrelated cord blood for 7 patients. Neutrophil engraftment was achieved in 21 of 28 patients (75%), with a median of 20.5 days (range, 11 to 39 days) after transplantation. The 3-year OS, 3-year EFS, 3-year relapse rate, and 3-year transplantation-related mortality were 63% (95% confidence interval [CI], 42% to 78%), 52% (95% CI, 32% to 69%), 18% (95% CI, 6% to 34%), and 21% (95% CI, 9% to 38%), respectively. WBC count before the conditioning regimen (≥7.0 × 109/L) was significantly associated with inferior EFS and OS. Body surface area ≥.5 m2, spleen size <4 cm before conditioning, and HLA-matched unrelated BM donors were significantly associated with better OS. Adverse effects related to the conditioning regimen included febrile neutropenia (86%), diarrhea (39%), hypoxemia (21%), and mucositis (18%). BU-associated toxicity, including sinusoidal obstruction syndrome (SOS) and thrombotic microangiopathy (TMA), occurred in 7 patients (25%; SOS, n = 6; TMA, n = 2). Retrospective analysis of PK data after the first BU dose in 23 patients, including 6 with SOS and 17 without SOS, did not show significant differences between groups. The JMML-11 study confirms the positive results of previous retrospective analyses. BU+FLU+MEL might become a standard conditioning regimen for patients with JMML.

Hematopoietic stem cell transplantation for infants with high-risk KMT2A gene-rearranged acute lymphoblastic leukemia.

The role of allogeneic hematopoietic stem cell transplantation (HSCT) for infants with acute lymphoblastic leukemia (ALL) and KMT2A gene rearrangement (KMT2A-r) is controversial in terms of both its efficacy and potential for acute and late toxicities. In Japanese Pediatric Leukemia/Lymphoma Study Group trial MLL-10, by introducing intensive chemotherapy, indication of HSCT was restricted to patients with high-risk (HR) features only (KMT2A-r and either age <180 days or presence of central nervous system leukemia). Of the 56 HR patients, 49 achieved complete remission. Forty-three patients received HSCT in first remission including 38 patients receiving protocol-specified HSCT with conditioning consisting of individualized targeted doses of busulfan, etoposide, and cyclophosphamide. Three-year event-free survival (EFS) of 56.8% (95% confidence interval [CI], 42.4% to 68.8%) and overall survival of 80.2% (95% CI, 67.1% to 88.5%) were accomplished. Univariable analysis showed that Interfant-HR criteria and flow cytometric minimal residual disease (MRD; ≥0.01%), both at the end of induction and at the end of consolidation (EOC), were significantly associated with poorer EFS. In the multivariable analysis, positive MRD at EOC was solely associated with poor EFS (P < .001). Rapid pretransplant MRD clearance and tailored HSCT strategy in the MLL-10 trial resulted in a favorable outcome for infants with HR KMT2A-r ALL. However, considering the high rate of potentially life-threatening toxicities and the risk of late effects, its indication should be further restricted or even eliminated in the future by introducing more effective therapeutic modalities with minimal toxicities. This trial was registered at the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) as #UMIN000004801.

A risk-stratified therapy for infants with acute lymphoblastic leukemia: a report from the JPLSG MLL-10 trial.

The prognosis for infants with acute lymphoblastic leukemia (ALL), particularly those with KMT2A gene rearrangement (KMT2A-r), is dismal. Continuous efforts have been made in Japan to investigate the role of hematopoietic stem cell transplantation (HSCT) for infants with KMT2A-r ALL, but improvement in outcome was modest. In the Japanese Pediatric Leukemia/Lymphoma Study Group MLL-10 trial, infants with ALL were stratified into 3 risk groups (low risk [LR], intermediate risk [IR], and high risk [HR]) according to KMT2A status, age, and presence of central nervous system leukemia. Children's Oncology Group AALL0631 modified chemotherapy with the addition of high-dose cytarabine in early intensification was introduced to KMT2A-r patients, and the option of HSCT was restricted to HR patients only. The role of minimal residual disease (MRD) was also evaluated. Ninety eligible infants were stratified into LR (n = 15), IR (n = 19), or HR (n = 56) risk groups. The 3-year event-free survival (EFS) rate for patients with KMT2A-r ALL (IR + HR) was 66.2% (standard error [SE], 5.6%), and for those with germline KMT2A (KMT2A-g) ALL (LR), the 3-year EFS rate was 93.3% (SE, 6.4%). The 3-year EFS rate was 94.4% (SE, 5.4%) for IR patients and 56.6% (SE, 6.8%) for HR patients. In multivariable analysis, female sex and MRD ≥0.01% at the end of early consolidation were significant factors for poor prognosis. Risk stratification and introduction of intensive chemotherapy in this study were effective and were able to eliminate HSCT for a subset of infants with KMT2A-r ALL. Early clearance of MRD seems to have translated into favorable outcomes and should be incorporated into risk stratifications in future trials. This trial was registered at the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) as #UMIN000004801.

Expression profile of cytochrome P450s and effects of polycyclic aromatic hydrocarbons and antiepileptic drugs on CYP1 expression in MOG-G-CCM cells.

AIMS: This study was performed to investigate the expression profile of cytochrome P450 (CYP) isoforms and effects of polycyclic aromatic hydrocarbons (PAHs) and antiepileptic drugs on CYP1 expression in human astrocytoma MOG-G-CCM cells. MAIN METHODS: CYP1A1 and CYP1B1 expression were determined by quantitative real-time polymerase chain reaction, Western blotting, and immunocytochemistry. KEY FINDINGS: MOG-G-CCM cells expressed various CYP isoforms. Among the CYP isoforms analyzed, CYP1B1 showed the highest expression level, followed by CYP1A1. Furthermore, CYP1B1 was localized in both the endoplasmic reticulum and mitochondria. 3-Methylcholanthrene (3-MC), benz[a]anthracene (B[a]A), benzo[a]pyrene (B[a]P), and valproic acid (VPA) increased the expression of CYP1B1 and CYP1A1. The potent aryl hydrocarbon receptor antagonist GNF351 significantly suppressed the 3-MC- and VPA-mediated upregulation of CYP1B1 and CYP1A1. In addition, VPA potentiated the induction of CYP1B1 and CYP1A1 by 3-MC, B[a]A, and B[a]P, although the augmentation of CYP1A1 was more remarkable than that of CYP1B1. In contrast, other antiepileptic drugs (carbamazepine, lamotrigine, levetiracetam, phenytoin) did not affect the 3-MC-mediated upregulation of CYP1B1 and CYP1A1. VPA is known to act as a histone deacetylase (HDAC) inhibitor. Therefore, the effects of trichostatin A, a representative HDAC inhibitor, on CYP1 induction by 3-MC were examined. Trichostatin A enhanced the 3-MC-mediated upregulation of CYP1A1 but not CYP1B1. SIGNIFICANCE: These results partially indicated that VPA may augment the PAH-mediated induction of CYP1B1 and CYP1A1 through the activation of transcription by HDAC inhibition.

[Desensitization Therapy for Osimertinib in Patients Who Developed Toxic Erythema - Two Case Reports].

We encountered 2 cases of T790M-positive non-small cell lung cancer in patients who developed toxic erythema within a week after initiation of osimertinib(80mg/day)therapy. Since osimertinib was regarded as the suspected drug, we adminis- tered desensitization therapy for osimertinib at an initial dose of 10mg/day. During the process of dose escalation, slight eruption and flare were observed, but we were able to provide appropriate treatment. Osimertinib therapy was continued and conferred tumor reduction in both cases. We report the clinical course and suggest that desensitization therapy is an alternative therapy for patients who present with drug-induced allergic reaction.

Influence of azole antifungal drugs on blood tacrolimus levels after switching from intravenous tacrolimus to once-daily modified release tacrolimus in patients receiving allogeneic hematopoietic stem cell transplantation.

WHAT IS KNOWN AND OBJECTIVE: Azole antifungal drugs are often co-administered with tacrolimus after allogeneic hematopoietic stem cell transplantation (HSCT). However, the influence of azole antifungal drugs on variation in tacrolimus pharmacokinetics when switching from intravenous tacrolimus (Tac-iv) to once-daily modified release tacrolimus (Tac-MR) remains to be elucidated. This study was performed to evaluate the effects of oral azole antifungal drugs on variation in tacrolimus pharmacokinetics after conversion to Tac-MR in HSCT patients. METHODS: Patients concomitantly receiving fluconazole (FLCZ) or voriconazole (VRCZ) along with tacrolimus were evaluated retrospectively. Blood tacrolimus concentrations before and after changing to oral administration were compared between FLCZ and VRCZ groups. RESULTS AND DISCUSSION: A total of 52 patients (34 FLCZ and 18 VRCZ) were included in the analysis. There were no significant differences in the most recent daily dose (Div ) and blood level (Civ ) of Tac-iv, Civ /Div , and ratio of daily dose of tacrolimus on the first to second day after changing to Tac-MR (Dpo1-2 ) to Div between FLCZ and VRCZ groups (P > 0.2). The trough levels of tacrolimus on the first to second day after switching to Tac-MR (Cpo1-2 ) and on the third to fifth day after the switch (Cpo3-5 ) were significantly higher in the VRCZ group than the FLCZ group (P < 0.05). The values of (Civ /Div )/(Cpo1-2 /Dpo1-2 ) and (Civ /Div )/(Cpo3-5 /Dpo3-5 ) in the VRCZ group were significantly lower compared with those in the FLCZ group (P < 0.05). Furthermore, individual values of (Civ /Div )/(Cpo3-5 /Dpo3-5 ) in the FLCZ group varied widely. WHAT IS NEW AND CONCLUSION: Voriconazole increased blood tacrolimus level more markedly than FLCZ after switching to Tac-MR, whereas FLCZ caused a large variation in tacrolimus blood level. These results suggest that therapeutic monitoring of tacrolimus after the switch may need to be performed carefully considering that orally co-administered VRCZ and FLCZ exhibit different change in blood tacrolimus level just after the switch.

Hepatocyte nuclear factor 6 activates the transcription of CYP3A4 in hepatocyte-like cells differentiated from human induced pluripotent stem cells.

Human induced pluripotent stem cells (iPSCs) are a valuable source of hepatocytes for applications in drug metabolism studies. However, the current protocols for generating iPSC-derived hepatocyte-like cells (iPSHCs) are still very inefficient, and iPSHCs do not have sufficient hepatocyte-specific features, which include expression of a series of hepatocyte-specific genes, such as those encoding cytochrome P450 (CYP). In this study, we investigated whether introduction of human hepatocyte nuclear factor 6 (HNF6) could modulate the expression of CYP3A4 and other CYP genes in iPSHCs as well as in HepG2 cells, a fetal liver cell line (HFL cells), and in hepatocytes. CYP3A4 mRNA could be detected in iPSHCs, but the expression level was very low compared with those in HepG2 cells and hepatocytes. However, the CYP3A4 mRNA levels markedly increased on introduction of HNF6 and reached one-tenth of those in hepatocytes. We also found that HNF6 introduction increased CYP3A4 gene transcription in HFL cells and HepG2 cells, which have features similar to those of fetal hepatocyte-like cells; however, it did not affect CYP3A4 mRNA expression in hepatocytes. These results suggest that HNF6 plays an important role in the gene regulation of CYP3A4 during development from the fetal period to the postnatal period.

Clinical evidence of pharmacokinetic changes in thalidomide therapy.

The teratogenic effects of thalidomide have been studied for more than 50 years. However, there have been few studies of the pharmacokinetic changes occurring during thalidomide therapy. Thalidomide was originally developed as a sedative. However, thalidomide induces multiple birth defects when used in pregnant women. Thalidomide is now used in the treatment of multiple myeloma (MM) and erythema nodosum leprosum (ENL) in Japan. Rational use of thalidomide is problematic due to a lack of basic research regarding its mechanism of action and serum concentration/effect relationships. There are a number of hypotheses for pharmacokinetic changes in thalidomide therapy. Genetic factors including single nucleotide polymorphisms (SNPs) that change cytochrome P450 (CYP) activity and epigenetic regulation that modifies CYP expression levels may contribute to the changes in pharmacokinetics and adverse drug reactions (ADRs) of thalidomide. Environmental factors include the pharmacological context of drug-drug interactions and the physiological context of liver diseases. Liver and kidney diseases do not play important roles in pharmacokinetic changes or ADRs in thalidomide therapy. To date, most research has focused on teratogenic activity, while the impact of polymorphisms in genes encoding drug metabolic enzymes and drug-drug interactions could mediate ADRs. Here, we discuss clinical evidence of pharmacokinetic changes in thalidomide therapy.

Safety and effectiveness of low-dose propofol sedation during and after esophagogastroduodenoscopy in child A and B cirrhotic patients.

BACKGROUND: Effective and safe sedation for patients with liver cirrhosis is problematic. AIM: To examine the safety and effectiveness of low-dose propofol sedation during and after esophagogastroduodenoscopy (EGD) in cirrhotic patients. METHODS: Study 1 was a prospective study in cirrhotic patients who underwent diagnostic EGD under propofol sedation. Propofol was given by bolus injection with an age-adjusted standard protocol consisting of 40 mg for patients <70 years, 30 mg for patients aged 70-89 years; additional injections of 20 mg propofol were given up to a maximum of 120 mg. The principal parameter was the occurrence of adverse events within 24 h after EGD. Secondary parameters included successful procedures, complications, and full recovery within 60 min. In Study 2, the residual effects of propofol were evaluated using a driving simulator and blood propofol concentrations in a subset of cirrhotic patients undergoing EGD and compared with healthy individuals. The principal parameter was driving ability. RESULTS: Study 1: Consecutive cirrhotic patients were entered and all 163 successfully completed EGD. The mean dose of propofol was 46 mg (range 30-120 mg). No complications occurred. Full recovery had occurred in 100 % 60 min after the procedure. No adverse events occurred within 24 h after EGD. Study 2: There were no significant differences in blood propofol levels between cirrhotic patients (n = 21) and healthy individuals (n = 20) after sedation. In cirrhotic patients, there was no deterioration in driving ability as compared with healthy individuals. CONCLUSION: Low-dose propofol sedation provided safe and effective sedation for EGD in cirrhotic patients with rapid recovery.

Effect of single-dose extended-release oral azithromycin on anticoagulation status in warfarinized patients.

OBJECTIVE: The aim of this study was to investigate the possible influence of single-dose 2.0-g azithromycin (AZ-ER) on anticoagulation in patients taking warfarin. STUDY DESIGN: Eighteen consecutive patients receiving long-term stable warfarin therapy were enrolled in this study. AZ-ER was administered 1 hour prior to tooth extraction. The international normalized ratio (INR) value was measured prior to AZ-ER administration as well as during, 1 day after, and 7 days after the tooth extraction. Additionally, the azithromycin concentration in the extraction wound as well as in the peripheral venous blood was assessed. RESULTS: The changes in INR throughout the study period were not statistically significant (2-factor analysis of variance, NS). The azithromycin concentration in extraction wounds was higher than that in peripheral veins. CONCLUSIONS: The results of this study suggest that prophylactic administration of AZ-ER to patients receiving daily warfarin therapy with a stable coagulation status has no relevant effect on the anticoagulant effect of warfarin.

Treatment of a GIST patient with modified dose of sunitinib by measurement of plasma drug concentrations.

In this study we report the pharmacokinetics and severe adverse effects of sunitinib in a woman with a gastrointestinal stromal tumor (GIST). A 60-year-old woman with small intestinal GIST developed severe thrombocytopenia (1.7×10(4)/µl) following 1 week of treatment with sunitinib at 50 mg/day. Although the dose of sunitinib was reduced to 25 mg/day, platelet levels remained low. On day 7, the trough concentration of sunitinib plus SU12662 was 46.1 ng/ml and the area under the curve (AUC) was 1,393.0 ng·h/l. The dose was again reduced to 12.5 mg/day. However, the day after resumption of treatment, the patient developed symptoms of left heart failure due to myocardosis caused by sunitinib. Sunitinib has been reported to inhibit platelet-derived growth factor receptor (PDGFR) phosphorylation at concentrations over the range of 50-100 ng/ml (sunitinib plus SU12662) in vivo. In this case, the plasma concentration was sufficient to inhibit PDGFR at 25 or 50 mg/day. However, thrombocytopenia appeared at both dosages. Although the results in this case did not suggest a correlation between thrombocytopenia and plasma concentration, the degree of thrombocytopenia was decreased by reduction of the dose. In conclusion, the findings reported here indicate that the plasma concentration of sunitinib plus SU12662 is an important indicator to reduce adverse effects.

Influence of cytochrome P450 2C19 gene variations on pharmacokinetic parameters of thalidomide in Japanese patients.

PURPOSE: Cytochrome P450 (CYP)2C19 polymorphisms may partly explain the variability of thalidomide concentration and adverse drug effects by altering its metabolism. To compare the genetic and clinical factors responsible for the adverse effects and efficacy of thalidomide treatment, we investigated CYP2C19 genetic polymorphisms in Japanese subjects. MATERIALS AND METHODS: Variations in the CYP2C19 gene in 6 patients treated with thalidomide were analyzed. The dosage of thalidomide, concentrations of (R)- and (S)-thalidomide in whole blood, and clinical laboratory test results were used as pharmacokinetic and pharmacodynamic indices. Using genomic DNA, CYP2C19*2 and *3 allele frequencies were determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assays. RESULTS: The frequencies of CYP2C19 PM and hetero EM (hetEM) genotypes in Japanese patients taking thalidomide were 2 (33.3%) and 4 (66.7%), respectively. The areas under the curve (AUC) of (R)-thalidomide were 3.42 and 5.33 µg·h/L, and those of (S)-thalidomide were 1.64 and 2.46 µg·h/L for hetEM and PM, respectively. CONCLUSIONS: This study provided new insights regarding the contribution of CYP2C19 gene variations to adverse responses to thalidomide. Genotyping of CYP2C19*2 and *3 can be considerably simplified by using KOD FX as a polymerase for prediction of adverse effects to thalidomide by the PCR-RFLP method. CYP2C19 PM patients tend to have high serum thalidomide concentrations.

Lower expression of HNF4α and PGC1α might impair rifampicin-mediated CYP3A4 induction under conditions where PXR is overexpressed in human fetal liver cells.

Pregnane X receptor (PXR) mRNA was detected in HepG2 cells by RT-PCR, but not in human fetal liver (HFL) cells. CYP3A4 was induced by rifampicin (RIF), mifepristone (RU486), clotrimazole (CTZ), and dexamethasone (DEX) in HepG2 cells, while these PXR ligands with the exception of DEX did not induce CYP3A4 mRNA expression in HFL cells. Ad-PXR infection increased mRNA levels of PXR and CYP3A4 in both cells despite the absence of PXR ligands. Similar results were observed in reporter gene assays. However, in HFL cells, RIF-mediated CYP3A4 induction was insufficient compared with HepG2 cells, despite PXR overexpression. The expression levels of five coactivators (HNF4α, PGC1α, SRC1, CBP, and P300) related to CYP3A4 expression in HepG2, HFL cells, and human adult liver were analyzed by RT-PCR. Expression levels of HNF4α and PGC1α in HFL cells were downregulated to 20% of those in the human adult liver. On the other hand, the expression level of HNF4α in HepG2 cells was higher than that in HFL cells, although PGC1α expression level was almost the same as that in HFL cells. HNF4α mRNA expression level in HepG2 cells was 57% of that in human adult liver, and the level in HFL cells was 30% of that in HepG2 cells. These results suggested that lower expression of HNF4α and PGC1α may impair RIF-mediated CYP3A4 induction under conditions of PXR overexpression in HFL cells.

Effects of hypoxia-inducible factor-1α chemical stabilizer, CoCl(2) and hypoxia on gene expression of CYP3As in human fetal liver cells.

Distinctive response patterns of CYP3A4 and CYP3A7 to cobalt chloride (CoCl(2)) in human fetal liver (HFL) cells were observed and compared with those under hypoxic conditions. The expression levels of CYP3A4 and CYP3A7 mRNAs were decreased by CoCl(2) and hypoxia, although significance could not be determined in HFL cells cultured under 3% O(2). The hypoxia-inducible factor-1α (HIF-1α) protein content in HFL cells was significantly increased by CoCl(2) and 3% O(2). Transcriptional activities of CYP3A4 and CYP3A7 were not altered by 3% O(2) when reporter plasmids containing the promoter region ranging up to about 10 kb and 12 kb upstream, respectively, were transfected into HFL cells, although the activity was significantly suppressed by CoCl(2). These results suggested that the mechanisms controlling CYP3A gene expression of HIF-1α chemical stabilizer in fetal hepatocytes might be different from those in adult hepatocytes, and that HIF-1α is not directly involved in regulation of CYP3A4 or CYP3A7 expression.

Psychomotor recovery and blood propofol level in colonoscopy when using propofol sedation.

BACKGROUND: It is commonly recommended that patients refrain from driving for 24 hours after endoscopy for which sedation is given. OBJECTIVE: The aim of this study was to evaluate psychomotor recovery and blood propofol concentrations after colonoscopy with propofol sedation to determine whether driving might be safe. DESIGN: A prospective, consecutive study. SETTING: Municipal hospital outpatients. PATIENTS: This study involved 48 consecutive patients scheduled for colonoscopy with propofol sedation. INTERVENTION: Patient clinical features, psychomotor recovery, and blood concentrations of propofol were assessed. Psychomotor recovery was assessed before colonoscopy and 1 and 2 hours after colonoscopy by using the number connection test and a driving simulator test. MAIN OUTCOME MEASUREMENTS: Clinical features, psychomotor recovery, and blood concentration of propofol. RESULTS: All patients successfully completed the post-sedation assessments. Although there was a significant difference in results of the number connection test between before colonoscopy and 1 hour after colonoscopy, all number connection test results were within normal limits (<40 seconds). Scores were as follows: mean time (standard deviation) before colonoscopy, 32.2 (2.0) seconds (range 29-36 seconds) versus after colonoscopy, 32.7 (2.0) seconds (range 27-38 seconds); P = .0019. Driving skills had recovered to the baseline levels 1 hour after colonoscopy. Scores were as follows: tracking error (%) before colonoscopy, 45.0 (5.6) versus after colonoscopy, 46.0 (5.5); P = .61; accelerating reaction time in seconds before colonoscopy, 0.65 (0.15) versus after colonoscopy, 0.62 (0.14); P = .40; braking reaction time in seconds before colonoscopy, 0.58 (0.13) versus after colonoscopy, 0.61 (0.13); P = .50. LIMITATIONS: Small sample size, single-center study. CONCLUSION: Although consistent findings on the number connection test and driving simulation (psychomotor recovery) test are present as early as 1 hour after propofol sedation, a study of additional numbers of patients as well as different patient populations are needed before these results can be universally recommended.

Role of dexamethasone and oncostatin M on the formation of vacuoles in human fetal liver cells.

Combined treatment with dexamethasone and oncostatin M (DEX/OSM) or interleukin-6 (DEX/IL-6) resulted in the appearance of numerous large vacuoles in human fetal liver (HFL) cells and showed synergistic effects on the formation of vacuoles. The number of vacuoles formed by DEX, DEX/OSM, or DEX/IL-6 was significantly suppressed by RU-486, a glucocorticoid receptor antagonist. On the other hand, the size of vacuoles formed by OSM, IL-6, DEX/OSM, or DEX/IL-6 was significantly decreased to about 65% by madindoline A (MDL-A), which is a non-peptide antagonist of gp130 and an inhibitor of cytokines, such as IL-6, mediated by gp130 homodimerization, while RU-486 did not affect the size of vacuoles. Expression of IL-6 mRNA in HFL cells was markedly induced by OSM. Expression of IL-6R mRNA was induced by DEX. These results indicate that DEX contributes to the formation of vacuoles through glucocorticoid receptors and that OSM and IL-6 contribute to enlargement of these vacuoles.

Safety and driving ability following low-dose propofol sedation.

BACKGROUND AND AIM: Automobile driving is prohibited after midazolam sedation because of the slow recovery of psychomotor function. This study prospectively assessed the safety of low-dose propofol sedation (study 1) and compared driving ability following propofol and midazolam sedation (study 2). METHODS: Study 1: We prospectively investigated bolus injection of a low-dose of propofol (40-80 mg for <70 years and 30 mg for >or=70 years) for diagnostic esophagogastroduodenoscopy (EGD). Respiratory depression, time to full recovery, and overall patient satisfaction were evaluated and blood concentrations of propofol were measured. Study 2: A subset of subjects undergoing diagnostic EGD were randomized to receive 40 mg of propofol (n = 30), 4 mg of midazolam (n = 30) or no sedation controls (n = 20), and the residual effects of each drug were tested using a driving simulator. The primary outcome measure was driving ability. The second outcome measures were overall patient satisfaction and complications. RESULTS: Study 1: Only 1.1% of 12,031 healthy subjects developed transient oxygen desaturation. Full recovery was present in 97.5% 30 min after the procedure; 99.8% were willing to repeat the same procedure. The blood levels of propofol (40-80 mg) at 60 min were <100 ng/ml. Study 2: Driving ability recovered to the basal level within 60 min of propofol administration but not with 120 min with midazolam. There were no complications; overall patient satisfaction was similar between propofol and midazolam (8.9 vs. 8.5, p = 0.34). CONCLUSION: Low-dose propofol sedation was safe and recovery including driving ability was with 60 min.

Propofol sedation for endoscopic procedures in patients 90 years of age and older.

BACKGROUND AND AIM: There are only a few studies on propofol sedation for very elderly patients. The present study was undertaken to evaluate the safety of propofol sedation in patients 90 years of age and older undergoing endoscopic procedures. METHODS: We prospectively assessed endoscopic procedures for patients 90 years of age and older using propofol sedation. Endoscopic procedures, dosage used, respiratory depression, complications and 30-day mortality were evaluated. In a subset of the enrolled patients, the blood concentrations of propofol were measured. RESULTS: All 241 patients completed endoscopic procedures. For esophagogastroduodenoscopy, percutaneous endoscopic gastrostomy, colonoscopy, and endoscopic retrograde cholangiopancreatography, the mean propofol doses used were 22, 24, 46 and 42 mg, respectively. Four patients required oxygen and 1 patient was treated by short periods of mask ventilation. There was no perforation, bleeding, pancreatitis or 30-day mortality. In diagnostic esophagogastroduodenoscopy, the level of sedation and propofol blood concentrations after administration of propofol (24 +/- 6.8 mg) in patients 90 years of age and older corresponded to those of propofol (61 +/- 13 mg) in middle-aged patients (control). CONCLUSION: Low-dose propofol sedation is safe and may be enough for patients 90 years of age and older undergoing endoscopic procedures.

Comparison of basal gene expression and induction of CYP3As in HepG2 and human fetal liver cells.

Human fetal liver (HFL) cell culture was initiated from a pool of six normal human liver tissues. The proliferation and viability of HFL cells were evaluated using 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide assay, and the cells increased by more than 100-fold by culture for 15 d. The levels of expression of albumin (ALB), hepatocyte nuclear factor 4alpha, hepatocyte growth factor, CYP3A4, CYP3A5, and CYP3A7 mRNAs in HFL cells increased with culture period, while that of alpha-fetoprotein (AFP) mRNA decreased gradually. In HepG2 cells, however, the expression levels of ALB and AFP mRNAs were not changed, and the levels of expression of CYP3A4, CYP3A5, and CYP3A7 mRNAs decreased gradually. The mRNA expression of major CYP isoforms including CYP3As, i.e., CYP1A2, CYP2A6, CYP2B6, CYP2C (2C9 and 2C19), CYP2D6, and CYP2E1, could be detected in HepG2 cells. With the exception of CYP1A2, all of the CYP mRNAs expressed in HepG2 cells were detected in HFL cells. In HFL cells, CYP3A4 and CYP3A7 mRNA expression levels were markedly up-regulated by dexamethasone (DEX), but not by rifampicin (RIF). CYP3A5 mRNA expression was increased to a level 3-fold greater than control by DEX. On the other hand, CYP3A4, CYP3A5, and CYP3A7 mRNA expression levels in HepG2 cells were increased from 2- to 3-fold by treatment with DEX and RIF. Pregnane X receptor mRNA was expressed in HepG2 cells, but not HFL cells. These results indicate that the character of HFL cells with regard to CYP expression was different from that of HepG2 cells.

CD40 expression in HCV-associated chronic liver diseases.

CD40 is expressed primarily on B cells and plays an important role in antigen presentation, B cell proliferation, and T cell activation. It has been reported that the CD40 signal modulates apoptosis and has an anti-viral effect in certain cells. Therefore, we investigated the expression and the function of CD40 in HCV-associated chronic liver disease. The expression of CD40 on liver tissues was determined through immunohistochemistry on 50 liver specimens obtained from HCV-positive patients. The effect of CD40 signaling on apoptosis of HepG2 cells was assessed using the MTT assay. The effect of CD40 stimulation on NF-kappaB activation was determined in NF-kappaB reporter gene-transfected HepG2 cells with the Luciferase assay. CD40 positive hepatocytes were observed in both periportal and lobular areas, accompanied by inflammation. In both areas, CD40 staining intensity became significantly stronger, correlating with the histological grading. Similarly, it became stronger with the progression of the histological staging in F1, F2 and F3 cases; however, the expression level decreased in F4 cases. CD40 ligation induced apoptosis in HepG2 cells in the presence of 500 ng/ml of actinomycin D, while CD40 ligation alone could not. Anti-CD40 monoclonal antibody caused NF-kappaB activation in HepG2 cells in a dose-dependent manner. These results suggest that hepatocyte over-expression of CD40 might play an important role in regulating hepatocyte survival and death in HCV-associated chronic liver diseases.