[Pharmaceutical Research and Education].

The true central aim of pharmaceutical research and education is to strive for the patient's satisfaction, i.e., "for the sake of the patient". Our research focuses to bridge the gap between the ideal and current situation in pharmaceutical science. We also investigated/questioned the united roles of pharmacists and pharmacies, with the ambition of changing the work culture of pharmacists. This paper reviews the history of our research and discusses the future of pharmaceutical research and education.

Comparison of Community Pharmacy Practice in Japan and US State of Illinois.

In 2006, a new 6-year educational system of pharmaceutical sciences was initiated to turn out strong clinical pharmacists in Japan. However, this new attempt is estimated not to fully satisfy the demand of clinical sites and the needs of the society in Japan. The objective of this study is to assess the performance of pharmaceutical services of community pharmacists in Illinois, United States, and Japan with the aim of comparing these services and barriers to pharmacy service delivery. The study designed as a cross-sectional, web-based study among US and Japan pharmacists. The survey asks several questions about demographic data, technical-related information and pharmaceutical services offered to patients, and pharmacy service performance. Almost 50 (92.6%) community pharmacists in United States reported that they dispensed more than 100 prescriptions in 1 day during the study period. In contrast, in Japan, community pharmacists (55.2%) dispensed 10 to 50 prescriptions during the same period. Half of the pharmacists in Japan either strongly agreed or agreed that they lack sufficient interpersonal and management skills. And many pharmacists agreed that lack of appropriate knowledge and insufficient training before graduation are major barriers to optimized pharmacy services in Japan. These findings can be used to promote discussion between Japanese pharmacists and stakeholders about pharmacy education programs in Japan and the future role of the community pharmacists in patient care in Japan.

Impact of Diabetes Perceptions on Medication Adherence in Japan.

Background: Patients' perception of diabetes mellitus is one of the psychosocial factors influencing diabetic behavior. This patients' perception of the disease is a mental image formed from the experience of patients with type 2 diabetes mellitus and reportedly reflects the aspect of recuperation. We investigated the relationship between changes in the patients' perception of the disease and medication adherence, as influenced by the active involvement of community pharmacists. Methods: A prospective cohort study that used patient registry based in community pharmacies was conducted in patients with type 2 diabetes using oral antidiabetic agents at a pharmacy in Ishikawa Prefecture in Japan. Patients responded to the questionnaire at the time of enrollment and at the end of the one-year intervention period. The pharmacist confirmed the patient's medication status and treatment problems via telephone calls at least once every two weeks for one year. Main outcome measures: Type 2 diabetes patients' perception of the disease related to medication adherence. Results: The study enrolled 113 patients. Among the seven diabetes image factors, "Living an orderly life" and "Feeling of fear" were significantly associated with medication adherence. "Feeling of neglect of health" was significantly associated at the subscale level. Conclusion: All the three factors related to medication adherence indicated self-care ability. To enhance the self-care ability of the patient, pharmacists should assist in self-care interventions for the patients.

The relationship between patients' perception of type 2 diabetes and medication adherence: a cross-sectional study in Japan.

BACKGROUND: The self-management of type 2 diabetes mellitus (T2DM), which involves adherence to medical instructions on diet and nutritional advice, physical activity, medication regimen, and weight and stress management, is necessary for the treatment of T2DM.In this study, we investigated the relationship between patients' perceptions of their disease and their adherence to their medications. And we attempted to determine whether distinct subphenotypes of behavioral change of medication adherence can be discerned based on a patients' perceptions. METHOD: A cross-sectional study using a questionnaire was conducted among 157 patients with T2DM from October 2015 to September 2017. Questionnaires were administered to assess the participants' demographic and clinical characteristics, medication adherence, diabetes knowledge, and perception of being diabetic. Principal component analysis (PCA) and cluster analyses were performed to classify medication adherence patterns in the total cohort. Multiple regression analyses were performed to identify the determinant factors of medication adherence. RESULTS: PCA showed the interpretable medication adherence of patients with diabetes by using component 1 ("accessibility to medical treatment") and component 2 ("status of taking medicines"). We identified four groups that show significantly different medication adherence by using cluster analysis on the basis of the two components. Multiple regression analysis showed that body mass index (BMI), family history of diabetes, one factor of patient's perception (living an orderly life), and diabetes knowledge were found to be significant predictors of medication adherence in patients with T2DM. CONCLUSIONS: In patients with T2DM, the patient's diabetes perception of "living an orderly life" is associated with medication adherence. A poor adherence group may be able to change their adherence to diabetes treatment by developing the perception of "living an orderly life."

A novel function of neuroglobin for neuroregeneration in mice after optic nerve injury.

Neuroglobin (Ngb) is a recently discovered heme protein in the vertebrate brain that can bind to oxygen molecules. Mammalian Ngb plays a crucial role in neuroprotection under conditions of oxidative stress. To investigate other potential functions of Ngb, we investigated the mouse retinal Ngb system following optic nerve injury. In the retina of control mice, Ngb immunoreactivity was limited to the retinal ganglion cell (RGC) layer, and this immunoreactivity rapidly decreased to less than 50% of the control level 5 days after optic nerve injury. On the basis of this decrease, we designed in vivo experiments with enhanced expression of Ngb using adult mouse retina. The enhanced expression of Ngb was achieved by injecting chimeric human Ngb protein, which included the cell membrane-penetrating module of fish Ngb. One-day pretreatment with chimeric Ngb increased immunoreactivity levels of Ngb two-fold in mouse RGCs and increased the number of surviving RGCs three-fold by 14 days after optic nerve injury compared with vehicle controls. Furthermore, in the mouse retinas showing enhanced Ngb expression, several regenerating central optic axons exhibited outgrowth and were found to pass through the nerve crush site 14 days after nerve injury. No such regenerating optic axons were observed in the control mouse optic nerve during the same time frame. The data obtained from in vivo experiments strongly indicate that mammalian Ngb has neuroprotective and neuroregenerative properties.

Pharmacokinetics of Morphine in Rats with Adjuvant-induced Arthritis.

We investigated the in vivo dynamics and analgesic effect of morphine using an adjuvant-induced arthritis (AA) rat as a model of chronic inflammation. Morphine generally binds to µ-opioid receptors in the brain to exert its effects. After several minutes, it is metabolized by glucuronidation via a UDP-glucuronosyltransferase (UGT). Here, we showed that in AA rats, UGT activity in liver microsomes was reduced. Morphine-free serum fractions in AA rats were also decreased (control, 84.9%; AA, 63.9%) and the expression of ATP-binding cassette, sub-family B (MDR/TAP), member 1 (ABCB1), which plays a crucial role in morphine bile excretion, decreased to 23.0% that of the control group. However, we observed no significant difference between the AA and control groups regarding blood concentrations of morphine and morphine-3-glucuronide. In contrast, the analgesic effect of morphine increased 4-fold in AA rats. Our results showed that the pharmacokinetics of morphine is not changed, but the pharmacodynamics of morphine is enhanced in chronic inflammation.

Prescription rate of medications potentially contributing to lower urinary tract symptoms and detection of adverse reactions by prescription sequence symmetry analysis.

BACKGROUND: The lower urinary tract symptoms (LUTS) increases with age and can have a significant effect on the quality of life of the patients. Elderly patients, who are often characterized by a decline in physiological functional and polypharmacy, are susceptible to adverse drug reactions to pharmacotherapy. LUTS can also be a side effect of medication. The purpose of this study was to investigate the possible association between the initiation of LUTS-causing drug therapy and the onset of LUTS. METHODS: Drug dispensing data at the individual level were retrieved from the CISA (Platform for Clinical Information Statistical Analysis: http://www.cisa.jp) database. A retrospective study was conducted by reviewing patients with LUTS who were dispensed drugs that increased the risk of LUTS between April 2011 and March 2012. Prescription sequence symmetry analysis (PSSA) was employed to investigate the associations between the dispensing of medicines of LUTS and that of LUTS-causing drugs. RESULTS: LUTS-causing drugs were frequently dispensed to patients with LUTS. The use of medications potentially contributing to LUTS was associated with polypharmacy [number of prescription drugs:12.13 ± 6.78 (user) vs. 5.67 ± 5.24 (nonuser)] but not patient age [ age: (71.38 ± 13.28 (user) vs. 70.45 ± 14.80 (nonuser)]. Significant adverse drug events were observed the use of donepezil, cyclophosphamide, antiparkinson drugs, antidepressant, diazepam, antipsychotic drugs for peptic ulcer, tiotropium bromide, and opioids. CONCLUSIONS: The use of prescription LUTS-causing drugs was correlated with polypharmacy. The adverse drug events associated with LUTS-causing drugs were highly prevalent in elderly patients. To prevent of adverse drug events in patients with LUTS, pharmacists and physicians should regularly review medication lists and reduce the prescribed medicines.

Medication-related factors affecting discharge to home.

To assess the reasons for barriers to home discharge by determining whether they were predicted by medication, clinical variables, and patient characteristics, the retrospective cohort study of 282 patients discharged from Kanazawa Red Cross Hospital in Kanazawa, Japan from January 2011 to December 2012 was performed. The percentage of patients discharged was 67.4%. By multivariate logistic analysis, significant differences in home discharge destination were determined by six factors: the duration of hospitalization before discharge (odds ratio (OR) 0.993; 95% 95% confidence interval (CI) 0.988-0.999), the presence of excretion assistance (OR 0.115; 95% CI 0.043-0.308), individual payment of medical expense (OR 0.344; 95% CI 0.146-0.811), the degree of independent living for the demented elderly (OR4.570; 95% CI 1.969-10.604), presence of the primary caregiver (OR 8.638; 95% CI 3.121-23.906), and admission to a hospital from home (OR 5.483; 95% CI 2.589-11.613). This study suggests that necessity of excretion assistance, long duration of hospitalization, and high individual payment of medical expense were barriers to home discharge. In contrast, three factors i.e., admission to a hospital form home, low degree of independent living for the demented elderly, and presence of the primary caregiver, favored home discharge. The relation between a patient's status (cognitive status and incontinence) and a caregiver has an important effect on the home discharge. However, medication characteristics appeared to have little effect on recuperation destination.

Nipradilol promotes axon regeneration through S-nitrosylation of PTEN in retinal ganglion cells.

Nipradilol (Nip) is registered as an anti-glaucoma agent. More recently, a protective effect of Nip has been demonstrated in retinal ganglion cells (RGCs) mediated by S-nitrosylation of antioxidative-related Keap1 protein due to its nitric oxide (NO)-donating effect. It also has been reported that Nip promoted axon outgrowth in cat RGCs. However, the detailed mechanism remains unclear. NO physiologically regulates numerous cellular responses through S-nitrosylation of protein at cysteine residues. It has been reported that phosphatase and tensin homologue deleted on chromosome 10 (PTEN) deletion strongly showed axon regeneration after optic nerve injury. PTEN inactivation by S-nitrosylation results in the accumulation of phosphatidylinositol (3, 4, 5) triphosphate (PIP3) and the activation of Akt/mammalian target of rapamycin (mTOR) signaling. The ribosomal S6 kinase 1 (S6K) which can monitor as phospho-S6 (pS6) is one of major target of mTOR. In this study, we investigated the possibility that Nip can promote axon outgrowth in RGCs by Akt/mTOR signaling thorough S-nitrosylation of PTEN.

Requirement of retinoic acid receptor ß for genipin derivative-induced optic nerve regeneration in adult rat retina.

Like other CNS neurons, mature retinal ganglion cells (RGCs) are unable to regenerate their axons after nerve injury due to a diminished intrinsic regenerative capacity. One of the reasons why they lose the capacity for axon regeneration seems to be associated with a dramatic shift in RGCs' program of gene expression by epigenetic modulation. We recently reported that (1R)-isoPropyloxygenipin (IPRG001), a genipin derivative, has both neuroprotective and neurite outgrowth activities in murine RGC-5 retinal precursor cells. These effects were both mediated by nitric oxide (NO)/S-nitrosylation signaling. Neuritogenic activity was mediated by S-nitrosylation of histone deacetylase-2 (HDAC2), which subsequently induced retinoic acid receptor ß (RARß) expression via chromatin remodeling in vitro. RARß plays important roles of neural growth and differentiation in development. However, the role of RARß expression during adult rat optic nerve regeneration is not clear. In the present study, we extended this hypothesis to examine optic nerve regeneration by IPRG001 in adult rat RGCs in vivo. We found a correlation between RARß expression and neurite outgrowth with age in the developing rat retina. Moreover, we found that IPRG001 significantly induced RARß expression in adult rat RGCs through the S-nitrosylation of HDAC2 processing mechanism. Concomitant with RARß expression, adult rat RGCs displayed a regenerative capacity for optic axons in vivo by IPRG001 treatment. These neuritogenic effects of IPRG001 were specifically suppressed by siRNA for RARß. Thus, the dual neuroprotective and neuritogenic actions of genipin via S-nitrosylation might offer a powerful therapeutic tool for the treatment of RGC degenerative disorders.

Protective action of nipradilol mediated through S-nitrosylation of Keap1 and HO-1 induction in retinal ganglion cells.

Nipradilol (Nip), which has α1- and ß-adrenoceptor antagonist and nitric oxide (NO)-donating properties, has clinically been used as an anti-glaucomatous agent in Japan. NO mediates cellular signaling pathways that regulate physiological functions. The major signaling mechanisms mediated by NO are cGMP-dependent signaling and protein S-nitrosylation-dependent signalings. Nip has been described as having neuroprotective effects through cGMP-dependent pathway in retinal ganglion cells (RGCs). However, the effect seems to be partial. On the other hand, whether Nip can prevent cell death through S-nitrosylation is not yet clarified. In this study, we therefore focused on the neuroprotective mechanism of Nip through S-nitrosylation. Nip showed a dramatic neuroprotective effect against oxidative stress-induced death of RGC-5 cells. However, denitro-nipradilol, which does not have NO-donating properties, was not protective against oxidative stress. Furthermore, an NO scavenger significantly reversed the protective action of Nip against oxidative stress. In addition, we demonstrated that α1- or ß-adrenoceptor antagonists (prazosin or timolol) did not show any neuroprotective effect against oxidative stress in RGC-5 cells. We also demonstrated that Nip induced the expression of the NO-dependent antioxidant enzyme, heme oxygenase-1 (HO-1). S-nitrosylation of Kelch-like ECH-associated protein by Nip was shown to contribute to the translocation of NF-E2-related factor 2 to the nucleus, and triggered transcriptional activation of HO-1. Furthermore, RGC death and levels of 4-hydroxy-2-nonenal (4HNE) were increased after optic nerve injury in vivo. Pretreatment with Nip significantly suppressed RGC death and accumulation of 4HNE after injury through an HO-1 activity-dependent mechanism. These data demonstrate a novel neuroprotective action of Nip against oxidative stress-induced RGC death in vitro and in vivo.

Change in pharmacokinetics of mycophenolic acid as a function of age in rats and effect of coadministered amoxicillin/clavulanate.

Changes of mycophenolic acid (MPA) pharmacokinetics with aging were investigated in rats. We also compared the effect of concomitant amoxicillin/clavulanate combination (CVA/AMPC) on the pharmacokinetics of MPA in 4-week-old and 12-week-old rats (the package insert of CVA/AMPC warns of possible interaction with MPA). Four-week-old rats showed a 1.4-fold higher total body clearance of MPA and a lower volume of distribution of MPA (65%), compared to the values in 12-week-old rats. However, the difference in MPA pharmacokinetics disappeared when enterohepatic circulation was eliminated by bile duct cannulation (BDC). Concomitant CVA/AMPC significantly reduced plasma MPA concentration in intact rats of both age groups, and the age-dependent difference of MPA pharmacokinetics was no longer apparent. The effect of CVA/AMPC was not seen in rats that had undergone BDC, suggesting that the drug-drug interaction can be attributed to inhibition of enterohepatic circulation by CVA/AMPC. These results indicate that the aging-related alteration of MPA pharmacokinetics is a consequence of immature enterohepatic circulation in 4-week-old rats. Higher doses of MPA may be necessary in juveniles.

[Development of evaluation methods for student performance in National Universities: formative assessment and portfolio].

Formative assessment which refers to frequent, interactive assessments of student progress and understanding is one of the most effective strategies for promoting high student performance and developing students' "learning to learn" skills. Portfolio (personal record of learning) is a useful tool for tracking individual student progress toward learning goals. We conducted the questionnaire survey in 14 National Universities on approach to the formative assessment methods and the use of portfolio in the long-term practice experience (pharmacy clerkship) at community pharmacy and hospital pharmacy which was undergone for the first time in 2010. The finding obtained from our questionnaires implicated that portfolio is useful for sharing information among student, tutorial pharmacist and faculty members. All universities have provided tools for visible assessment of student achievement. However, they are not used enough for feedback on student performance, and formative assessment is not practiced systematically. A reason seems to be differences in understanding of it. In addition to improvement of the tools to support formative assessment, promotion of effective assessment practice will need for systematic evaluation.

[Investigation for relation of gustatory and olfactory impairment in patients receiving cancer chemotherapy].

Because it is considered that there is a close connection between gustation and olfactation, and that a decline in the function of either sensation influences the other one, it would be useful to clarify the relation between gustatory and olfactory disorders in patients receiving cancer chemotherapy. Therefore, we investigated the frequency of gustatory and olfactory disorders in patients administered anticancer drugs at the Division of Outpatient Chemotherapy of Kanazawa University. Among 136 patients who consented to participate in the investigation, 75 patients (55%) complained of a gustatory disorder, and 26 patients (19%) complained of an olfactory disorder. The occurrences of olfactory disorder were significantly greater in patients who had gustatory disorder than in patients who did not. The expression frequency of gustatory disorders was significantly higher among those taking docetaxel (85%) when compared with patients on other regimens. Although not statistically significant, the incidence of olfactory disorder was higher in patients taking docetaxel (31%), irinotecan+l-leucovorin (l-LV)+5-fluorouracil (5-FU) (31%), l-oxaliplatin+l-LV+5-FU (28%), trastuzumab (23%), and weekly paclitaxel (22%). Medical staff should recognize that olfactory disorders are similar to gustatory disorders, as they both have adverse reactions induced by anticancer drugs.

Neuritogenic activity of a genipin derivative in retinal ganglion cells is mediated by retinoic acid receptor ß expression through nitric oxide/S-nitrosylation signaling.

Genipin, a herbal iridoid, is known to have both neuroprotective and neuritogenic activity in neuronal cell lines. As it is structurally similar to tetrahydrobiopterin, its activity is believed to be nitric oxide (NO)-dependent. We previously proposed a novel neuroprotective activity of a genipin derivative, (1R)-isoPropyloxygenipin (IPRG001), whereby it reduces oxidative stress in RGC-5, a neuronal precursor cell line of retinal origin through protein S-nitrosylation. In the present study, we investigated another neuritogenic property of IPRG001 in RGC-5 cells and retinal explant culture where in we focused on the NO-cGMP-dependent and protein S-nitrosylation pathways. IPRG001 stimulated neurite outgrowth in RGC-5 cells and retinal explant culture through NO-dependent signaling, but not NO-dependent cGMP signaling. Neurite outgrowth with IPRG001 requires retinoic acid receptor ß (RARß) expression, which is suppressed by an RAR blocking agent and siRNA inhibition. Thereby, we hypothesized that RARß expression is mediated by protein S-nitrosylation. S-nitrosylation of histone deacetylase 2 is a key mechanism in chromatin remodeling leading to transcriptional gene activation. We found a parallelism between S-nitrosylation of histone diacetylase 2 and the induction of RARß expression with IPRG001 treatment. The both neuroprotective and neuritogenic activities of genipin could be a new target for the regeneration of retinal ganglion cells after glaucomatous conditions.

Evaluation of selective competitive binding of basic drugs to alpha1-acid glycoprotein variants.

We examined the binding of various basic drugs to the F(1)S and A genetic variants of alpha(1)-acid glycoprotein (AGP), which were isolated from native human commercial AGP (total AGP) by chromatography on an immobilized copper(II) affinity adsorbent. The values of the dissociation constant (K(d)) of some basic drugs with the F(1)S variant in equilibrium dialysis differed characteristically from those with the A variant. The selective binding to these variants was evaluated by measuring the displacement ratio of dicumarol bound to the F(1)S variant or that of acridine orange bound to the A variant, using circular dichroism spectroscopy. There was reasonably good agreement between the K(d) values and displacement ratios. There was a characteristic difference between the values of inhibition constant (K(i)) of basic drugs towards dipyridamole binding to F(1)S and towards disopyramide binding to A in total AGP. We found that the K(i) values for dipyridamole binding were well correlated with the K(d) values for the F(1)S variant, whereas those for disopyramide binding were well correlated with the K(d) values for the A variant. In conclusion, the higher the affinity of basic drugs for AGP, the more they inhibit the binding of other basic drugs, and further, the inhibitory potency depends on the selectivity of binding to the AGP variants.

[Improvement of epirubicin-induced phlebitis to switch from liquid preparation to lyophilized formulation].

Adjuvant chemotherapy containing epirubicin is commonly used to treat patients with pre- or post-operative breast cancer. It is known that the epirubicin(FarmorubicinRTU)preparation often caused phlebitis, whereas dexamethasone has been used to prevent that reaction. We examined whether the lyophilized formulation of epirubicin(Farmorubicin)can reduces the incidence of phlebitis compared with the preparation. All infusions were administered through a peripheral vein. Adverse drug reaction including phlebitis was evaluated after each infusion and at the subsequent visit to four or six cycles. Sixty-two patients were given the preparation and 35 the lyophilized formulation. Epirubicininduced phlebitis was observed in 45.7% of patients given the preparation and in 48.4% of those given the lyophilized formulation. There was no statistically significant difference between the two groups(p=0.41). However, the incidence of severe phlebitis requiring treatment with steroid ointment was significantly increased among patients treated with the preparation(27.4% vs 9.7%, p<0.05, respectively). There was no significant difference in the incidence of adverse drug reactions other than severe phlebitis between the two groups. In this study, lyophilized formulations of epirubicin significantly reduced the incidence of severe phlebitis compared with that among patients receiving the preparation. Using lyophilized formulations of epirubicin should be considered to prevent a reduction in QOL with epirubicin-induced phlebitis in patients with breast cancer.

Essential role of the apoptotic cell engulfment genes draper and ced-6 in programmed axon pruning during Drosophila metamorphosis.

Axon pruning is a common phenomenon in neural circuit development. Previous studies demonstrate that the engulfing action of glial cells is essential in this process. The underlying molecular mechanisms, however, remain unknown. We show that draper (drpr) and ced-6, which are essential for the clearance of apoptotic cells in C. elegans, function in the glial engulfment of larval axons during Drosophila metamorphosis. The drpr mutation and glia-specific knockdown of drpr and ced-6 by RNA interference suppress glial engulfment, resulting in the inhibition of axon pruning. drpr and ced-6 interact genetically in the glial action. Disruption of the microtubule cytoskeleton in the axons to be pruned occurs via ecdysone signaling, independent of glial engulfment. These findings suggest that glial cells engulf degenerating axons through drpr and ced-6. We propose that apoptotic cells and degenerating axons of living neurons are removed by a similar molecular mechanism.

Axonal regeneration of fish optic nerve after injury.

Since Sperry's work in the 1950s, it has been known that the central nervous system (CNS) neurons of lower vertebrates such as fish and amphibians can regenerate after axotomy, whereas the CNS neurons of mammals become apoptotic after axotomy. The goldfish optic nerve (ON) is one of the most studied animal models of CNS regeneration. Morphological changes in the goldfish retina and tectum after ON transection were first researched in the 1970s-1980s. Many biochemical studies of neurite outgrowth-promoting substances were then carried out in the 1980s-1990s. Many factors have been reported to be active substances that show increased levels during fish ON regeneration, as shown by using various protein chemistry techniques. However, there are very few molecular cloning techniques for studying ON regeneration after injury. In this review article, we summarize the neurite outgrowth-promoting factors reported by other researchers and describe our strategies for searching for ON regenerating molecules using a differential hybridization technique in the goldfish visual system. The process of goldfish ON regeneration after injury is very long. It takes about half a year from the start of axonal regrowth to complete restoration of vision. The process has been classified into three stages: early, middle and late. We screened for genes with increased expression during regeneration using axotomized goldfish retinal and tectal cDNA libraries and obtained stage-specific cDNA clones that were upregulated in the retina and tectum. We further discuss functional roles of these molecules in the regeneration processes of goldfish ON.