Rapid airway stenosis due to ruptured occipital artery in a patient with neurofibromatosis type I.

Background: Neurofibromatosis type I is rarely associated with vascular abnormalities. Here, we report a case of rapid airway stenosis caused by a ruptured occipital artery that was treated with surgical airway management. Case Presentation: A 40-year-old woman, with no medical history, presented with a chief complaint of a sudden neck pain on the left side. She had a prominent mass in the outer left side of the neck. After arrival at the emergency room, the patient complained of severe dyspnea and experienced a rapid drop in oxygen saturation. Supplemental ventilation was ineffective, and tracheal intubation was attempted; however, laryngeal expansion could not be observed because of the enlarged cervical mass. Therefore, to manage the surgical airway, a cricothyrotomy was first carried out, which resulted in an immediate increase in oxygen saturation. Two percutaneous embolizations and one surgical procedure were carried out, and the patient was discharged without any complications. Conclusion: For a sudden onset cervical mass, airway management should be undertaken, keeping in mind the possibility of worsening rapid airway narrowing due to bleeding.

Novel approach to evaluating granulation and segregation level considering the contribution of hydroxypropyl cellulose to the surface property change of granules.

The granulation process is critical to the uniformity of not only the active ingredient (API) but also other excipients in granules. Insufficient granulation results in unexpected product quality, e.g. delayed dissolution and lack of uniformity of API. Therefore, evaluating the granulation and segregation level of granules helps secure the uniformity of drug product quality. Here, we found that the polar surface free energy (SFE) of studied granules increased as granulation by a high shear granulator proceeded. Among the excipients formulated in the studied granules, only hydroxypropyl cellulose (HPC) showed a higher specific free energy of adsorption (ΔGsp) of chloroform, which is a parameter used to calculate polar SFE. This indicates that the ΔGsp of chloroform in granules helps detect the level of contribution of HPC to the granulation progress by inverse gas chromatography (IGC). We concluded that the ΔGsp of chloroform in a granulated sample is a novel critical material attribute (CMA) in relation to granulation level. In addition, we propose a novel approach to evaluating the quantitative granulation and segregation level based on the ΔGsp of chloroform in a granulated sample by focusing on the distribution of HPC in the granulated sample.

New approach to optimizing risk management of the sticking problem using scale-independent critical material attributes and the quantitative process parameter.

In pharmaceutical manufacturing of solid formulations, blending with a lubricant is a key process in preventing sticking during compression. Sticking not only results in tablets with a disfigured appearance but also brings about the interruption of continuous operations. The aim of our study was to identify blending scale-independent critical material attributes (CMAs) in relation to the sticking problem to appropriately define the end-point of the blending process with magnesium stearate as lubricant. Results showed that the dispersive surface free energy (SFE) and the specific free energy absorptions (ΔGsp) of ethanol decreased during blending with magnesium stearate. As the two parameters decreased, the sticking problem was improved. In conclusion, we propose that the dispersive SFE and ΔGsp of ethanol are scale-independent CMAs, and that the minimum blending time (BTmin), which can be calculated from the two CMAs, of the quantitative process parameter show the minimum blending time required to achieve higher risk assessment of the sticking problem.

Determinants of Intestinal Availability for P-glycoprotein Substrate Drugs Estimated by Extensive Simulation With Mathematical Absorption Models.

In this study, intestinal drug-drug interactions (DDIs) for substrate drugs of P-glycoprotein were simulated extensively using the extended QGut model and translocation model to explore the determinants of DDI. The results of analyses using both models suggested that permeability and active efflux clearance were the major factors that influenced the fraction absorbed (FA). The results of simulation for 100 virtual drugs in which parameters were generated considering the actual values of commercially available drugs suggested that the ratio of the pH-corrected passive permeability to the intrinsic efflux clearance (Pu/CLeff) relative to that of digoxin would be a useful and quantitative index of P-glycoprotein (P-gp)-mediated DDI risk at lower doses. At higher doses, such as 100 mg, the risk of P-gp-mediated DDI would be significantly reduced because of saturation of P-gp efflux. The simulation suggested that although drugs with lower permeability were more susceptible, even drugs with higher permeability than metoprolol, a representative highly permeable drug, such as BCS class 1 and 2, may experience DDIs owing to P-gp inhibition. Overall, this study demonstrated the usefulness of mathematical intestinal models when only limited observational data are available.

A new physiologically based pharmacokinetic model for the prediction of gastrointestinal drug absorption: translocation model.

This study aimed to construct a new local pharmacokinetic model of gastrointestinal absorption, the translocation model (TLM), using an anatomically relevant, minimally segmented structure to explain linear and nonlinear intestinal absorption, metabolism, and transport. The TLM was based on the concept of a single absorption site that flexibly moves, expands, and shrinks along with the length of the gastrointestinal tract after the intake of an oral dose. The structure of the small intestine is continuous, and various time- and location-dependent issues are freely incorporated in the analysis. Since the model has only one absorption site, understanding and modification of factors affecting absorption are simple. The absorption site is composed of four compartments: solid drug in the lumen, solution drug in the lumen, concentration in the enterocytes, and concentration in the lamina propria. The lamina propria includes the blood capillaries. Blood flow in the absorption site of the lamina propria appropriately accounts for the absorption. In the TLM, the permeability of the apical membrane and that of the basolateral membrane are distinct. By considering plicate, villi, and microvilli expansions of the surface area, the apparent permeability measured in Caco-2 experiments was converted to the effective permeability in vivo. The intestinal availability, bioavailability, and dose product of intestinal availability and absorption rate relationship of the model drugs were well explained using the TLM. The TLM would be a useful tool for the consideration of local pharmacokinetics in the gastrointestinal tract in various situations.

Preliminary report of a Web-based instrument to assess and teach knowledge and clinical thinking to medical student.

OBJECTIVE: We report the preliminary development of a unique Web-based instrument for assessing and teaching knowledge and developing clinical thinking called the "Sequential Questions and Answers" (SQA) test. Included in this feasibility report are physicians' answers to the Sequential Questions and Answers pre- and posttests and their brief questionnaire replies. METHODS: The authors refined the SQA test case scenario for content, ease of modifications of case scenarios, test uploading and answer retrieval. Eleven geographically distant physicians evaluated the SQA test, taking the pretest and posttest within two weeks. These physicians completed a brief questionnaire about the SQA test. RESULTS: Eleven physicians completed the SQA pre- and posttest; all answers were downloaded for analysis. They reported the ease of website login and navigating within the test module together with many helpful suggestions. Their average posttest score gain was 53% (p=0.012). CONCLUSIONS: We report the successful launch of a unique Web-based instrument referred to as the Sequential Questions and Answers test. This distinctive test combines teaching organization of the clinical narrative into an assessment tool that promotes acquiring medical knowledge and clinical thinking. We successfully demonstrated the feasibility of geographically distant physicians to access the SQA instrument. The physicians' helpful suggestions will be added to future SQA test versions. Medical schools might explore the integration of this multi-language-capable SQA assessment and teaching instrument into their undergraduate medical curriculum.

Relationship between the urinary excretion mechanisms of drugs and their physicochemical properties.

The purpose of this study was to clarify the relationship between the physicochemical properties of drugs and their urinary excretion mechanisms. Three hundred twenty-five drugs were classified into the reabsorption, intermediate, and secretion types based on their ratio of renal clearance to protein-unbound fraction glomerular filtration rate. Fifty percent of ionized and neutral drugs were the secretion and reabsorption types, respectively. The mean molecular weight of the neutral drugs was slightly smaller than those of the ionized drugs (296 vs. 330-368 g/mol). The reabsorption-type anionic drugs were characterized by their low molecular weights (mean value 269 g/mol) and the logarithmic measure of the acid dissociation constants (pKa s) greater than 4.5, whereas the secretion-type anionic drugs all had pKa s below 4.5. Cationic drugs with pKa s lower than 8.0 tended to be the reabsorption type. Some cationic drugs were classified as the secretion type, despite their high molecular weights (734-811 g/mol) and high log P values (3.1-5.3). The organic anion transporter (OAT)1 and OAT3 substrates were all secretion-type drugs. The same trend was observed for the substrates of organic cation transporter 2, multidrug and toxin extrusion, multidrug resistance-associated protein 4, and multidrug resistance 1/breast cancer resistance protein, but substantial fractions of the substrates were categorized as the intermediate or reabsorption types (9%-38%). This work provides a clue to the renal elimination mechanism of new chemical entities during drug development.

Utility of a single adjusting compartment: a novel methodology for whole body physiologically-based pharmacokinetic modelling.

BACKGROUND: There are various methods for predicting human pharmacokinetics. Among these, a whole body physiologically-based pharmacokinetic (WBPBPK) model is useful because it gives a mechanistic description. However, WBPBPK models cannot predict human pharmacokinetics with enough precision. This study was conducted to elucidate the primary reason for poor predictions by WBPBPK models, and to enable better predictions to be made without reliance on complex concepts. METHODS: The primary reasons for poor predictions of human pharmacokinetics were investigated using a generic WBPBPK model that incorporated a single adjusting compartment (SAC), a virtual organ compartment with physiological parameters that can be adjusted arbitrarily. The blood flow rate, organ volume, and the steady state tissue-plasma partition coefficient of a SAC were calculated to fit simulated to observed pharmacokinetics in the rat. The adjusted SAC parameters were fixed and scaled up to the human using a newly developed equation. Using the scaled-up SAC parameters, human pharmacokinetics were simulated and each pharmacokinetic parameter was calculated. These simulated parameters were compared to the observed data. Simulations were performed to confirm the relationship between the precision of prediction and the number of tissue compartments, including a SAC. RESULTS: Increasing the number of tissue compartments led to an improvement of the average-fold error (AFE) of total body clearances (CL tot) and half-lives (T 1/2) calculated from the simulated human blood concentrations of 14 drugs. The presence of a SAC also improved the AFE values of a ten-organ model from 6.74 to 1.56 in CL tot, and from 4.74 to 1.48 in T 1/2. Moreover, the within-2-fold errors were improved in all models; incorporating a SAC gave results from 0 to 79% in CL tot, and from 14 to 93% in T 1/2 of the ten-organ model. CONCLUSION: By using a SAC in this study, we were able to show that poor prediction resulted mainly from such physiological factors as organ blood flow rate and organ volume, which were not satisfactorily accounted for in previous WBPBPK models. The SAC also improved precision in the prediction of human pharmacokinetics. This finding showed that the methodology of our study may be useful for functionally reinforcing a WBPBPK model.

Ancestry of American polyploid Hordeum species with the I genome inferred from 5S and 18S-25S rDNA.

BACKGROUND AND AIMS: The genus Hordeum exists at three ploidy levels (2x, 4x and 6x) and presents excellent material for investigating the patterns of polyploid evolution in plants. Here the aim was to clarify the ancestry of American polyploid species with the I genome. * METHODS: Chromosomal locations of 5S and 18S-25S ribosomal RNA genes were determined by fluorescence in situ hybridization (FISH). In both polyploid and diploid species, variation in 18S-25S rDNA repeated sequences was analysed by the RFLP technique. * KEY RESULTS: Six American tetraploid species were divided into two types that differed in the number of rDNA sites and RFLP profiles. Four hexaploid species were similar in number and location of both types of rDNA sites, but the RFLP profiles of 18S-25S rDNA revealed one species, H. arizonicum, with a different ancestry. * CONCLUSIONS: Five American perennial tetraploid species appear to be alloploids having the genomes of an Asian diploid H. roshevitzii and an American diploid species. The North American annual tetraploid H. depressum is probably a segmental alloploid combining the two closely related genomes of American diploid species. A hexaploid species, H. arizonicum, involves a diploid species, H. pusillum, in its ancestry; both species share the annual growth habit and are distributed in North America. Polymorphisms of rDNA sites detected by FISH and RFLP analyses provide useful information to infer the phylogenetic relationships of I-genome Hordeum species because of their highly conserved nature during polyploid evolution.