Relationship between office blood pressure and actual antihypertensive drug use in patients with hypertension following the promulgation of the guidelines for hypertension (JSH2019).

To achieve appropriate blood pressure control in the treatment of hypertension in Japan, this study examined the relationship between office blood pressure and actual antihypertensive drug use in general hospitals following the promulgation of the guidelines for hypertension (JSH2019). This study focused on blood pressure levels and drug use in outpatients on antihypertensive treatment from June to July 2020. The subjects were 2,537 patients classified into four groups based on their medical history, patients with: hypertension only; hypertension and cardiovascular disease; hypertension and dyslipidaemia; and hypertension and diabetes mellitus. The results showed a significant difference in systolic blood pressure (SBP) between patients with hypertension only and those with hypertension and cardiovascular disease (138.3±17.9 mmHg vs 135.6±19.9 mmHg, p<0.05). Regarding actual drug use, it was found that diuretics were prescribed more frequently in patients with hypertension and cardiovascular disease than in those with hypertension alone (15.5% vs 37.9%, p<0.05), even though the number of drugs for hypertension did not differ significantly. In addition, the dose of diuretics was greater only in patients with cardiovascular disease. These results show the actual drug use and blood pressure for each comorbidity. Furthermore, they suggest that the results of antihypertensive treatment may differ by changing the combination and dosage of antihypertensive drugs without changing the number of antihypertensive drugs used. The study also shows the problem of using less diuretics depending on the risk the patient has, and solving the problem may lead to achieving further antihypertensive goals.

Evaluating the impact of de-escalating antimicrobial therapy in burn patients: a retrospective cohort study.

Antimicrobials should be used appropriately to minimise the risk of resistant strains arising in association with overuse. De-escalation of antimicrobial therapy is one strategy used to ensure appropriate use, but its safety and efficacy in burn patients are unclear. The aim of this study was to evaluate the safety and efficacy of de-escalation therapy for treating infections in burn patients. This retrospective cohort study investigated patients admitted to our intensive care unit with burns and treated for infection between October 1, 2013, and September 30, 2020. Patients were classified into a de-escalation group (Group D) comprising patients treated with empiric antimicrobial therapy followed by de-escalation and a non-de-escalation group (Group ND) comprising patients who did not undergo de-escalation. Characteristics and outcomes were compared between groups. Forty-three patients met the inclusion criteria, including 15 patients in Group D and 28 patients in Group ND. Bacterial species commonly detected in these patients were Corynebacterium spp. (17.3%), Pseudomonas aeruginosa (16.1%), and Staphylococcus aureus (9.6%) . No inter-group difference was seen in 28-day mortality (6.7% vs 21.4%, p =0.391). Multidrug-resistant strains were detected significantly less frequently in Group D (13.0%) than in Group ND (26.1%, p =0.003). De-escalation was associated with use of two or more antimicrobials as empiric antimicrobial therapy. As the use of de-escalation in infection treatment did not impact 28-day mortality, de-escalation might be safe for treating infections in burn patients.

Preparation and evaluation of orally disintegrating tablets containing taste masked microparticles of acetaminophen.

In the present work, taste masked particles of acetaminophen (AAP), a highly soluble bitter tasting drug, were developed and ODT containing the taste masked particles were prepared. Taste masked particles of AAP were prepared using different amounts of tetraglycerol polyricinoleate (TGPR) and Eudragit ®E100. Although the drug content ratio and drug recovery decreased with increasing TGPR, drug release from AAP-CR100 particles containing a large amount of TGPR was mostly suppressed for 2 min. Hence, AAP-CR100 was incorporated into ODT as taste masked particles for AAP. Three major disintegrants were used for ODT, and it was confirmed that the tensile strength of all formulations showed applicable hardness for handling. The AAP-CR100-CP(40) formulation containing crospovidone showed the shortest disintegration time and the drug release from AAP-CR100-CP(40) into pH 6.8 test solution was suppressed compared with commercial AAP tablets. Because the drug release from AAP-CR100-CP(40) into the pH 1.2 test solution was rapid, it was suggested that drug release from AAP-CR100-CP(40) is suppressed in the oral cavity, and the drug is released promptly in the stomach. Thus AAP-CR100-CP(40) may be useful as an ODT in which the dissolution of AAP in the oral cavity is suppressed.

Remarkable Improvement of Cardiac Function After Pre-emptive Kidney Transplant in a Patient With Severe Mitral Regurgitation Accompanied by Low Cardiac Function: A Case Report.

Patients with end-stage renal disease are at a high risk for cardiovascular diseases. It is controversial whether end-stage renal disease patients with low cardiac function can safely accept kidney transplant. Here, we present a 42-year-old kidney transplant recipient with severe mitral regurgitation accompanied by low cardiac function. He wanted to undergo a pre-emptive kidney transplant from his uncle. We decided to perform living kidney transplant prior to cardiac surgery. Despite adequate ultrafiltration and hemodiafiltration before operation, the patient's ejection fraction still remained 35% 1 day before transplant. He showed complete recovery of cardiac function in only 2 days after pre-emptive kidney transplant, although his body weight did not change before and after the operation. Early removal of the uremic toxin or inflammatory cytokines may play a role in rapid improvement of the cardiac function. Increase of vasoactive substances by improvement of kidney function may lead to reduction of afterload and amelioration of cardiac microcirculation. This report also suggests that optimal timing for operation might be important.

Systemic administration of α-lipoic acid suppresses excitability of nociceptive wide-dynamic range neurons in rat spinal trigeminal nucleus caudalis.

Although a modulatory role has been reported for α-lipoic acid (LA) on T-type Ca2+ channels in the nervous system, the acute effects of LA in vivo, particularly on nociceptive transmission in the trigeminal system, remain to be determined. The aim of the present study was to investigate whether acute intravenous LA administration to rats attenuates the excitability of wide dynamic range (WDR) spinal trigeminal nucleus caudalis (SpVc) neurons in response to nociceptive and non-nociceptive mechanical stimulation in vivo. Extracellular single unit recordings were made from seventeen SpVc neurons in response to orofacial mechanical stimulation of pentobarbital-anesthetized rats. Responses to both non-noxious and noxious mechanical stimuli were analyzed in the present study. The mean firing frequency of SpVc WDR neurons in response to both non-noxious and noxious mechanical stimuli was significantly and dose-dependently inhibited by LA (1-100 mM, i.v.) and maximum inhibition of the discharge frequency of both non-noxious and noxious mechanical stimuli was seen within 5 min. These inhibitory effects lasted for approximately 10 min. These results suggest that acute intravenous LA administration suppresses trigeminal sensory transmission, including nociception, via possibly blocking T-type Ca2+ channels. LA may be used as a therapeutic agent for the treatment of trigeminal nociceptive pain.

Anticholinergic load negatively correlates with recovery of cognitive activities of daily living for geriatric patients after stroke in the convalescent stage.

WHAT IS KNOWN AND OBJECTIVE: Anticholinergic drugs are associated with risks of falls, confusion and cognitive dysfunction. However, the effect of anticholinergic drug use on rehabilitation outcomes after a stroke is poorly documented. We therefore aimed to establish whether the anticholinergic load was associated with functional recovery among geriatric patients convalescing after stroke. METHOD: Consecutive geriatric stroke patients admitted and discharged from a convalescence rehabilitation ward between 2010 and 2016 were included in this retrospective cohort study. Anticholinergic load was assessed by the Anticholinergic Risk Scale (ARS), and functional recovery was assessed by the Functional Independence Measure (FIM). The primary outcome was cognitive FIM (FIM-C) gain, but we also assessed the interaction of other putative factors identified from univariate analysis. Multivariate analyses were performed, adjusting for confounding factors. RESULTS AND DISCUSSION: We included 418 participants (171 males, 247 females) with a median age of 78 years (interquartile range, 72-84 years). Multiple regression analysis revealed that ARS change, length of stay, and epilepsy were independently and negatively correlated with cognitive FIM gain. Multiple logistic regression analysis indicated that the "Comprehension" and "Memory" items of the cognitive FIM gain were independently and negatively associated with anticholinergic load. WHAT IS NEW AND CONCLUSION: A causal relationship cannot be established, but increased ARS scores during hospitalization may predict limited cognitive functional improvement in geriatric patients after stroke. Alternatively, cognitive impairment may lead to increased use of anticholinergic drugs.

FOXO3 is essential for CD44 expression in pancreatic cancer cells.

Pancreatic ductal adenocarcinoma (PDAC) is one of the most fatal types of cancer and the 5-year survival rate is only 5%. Several studies have suggested that cancer stem cells (CSCs) are thought to be involved in recurrence and metastasis and so it is essential to establish an approach targeting CSCs. Here we have demonstrated that cyclic guanosine monophosphate (cGMP) suppressed CD44 expression and the properties of CSCs in PDAC. Microarray analysis suggested that cGMP inhibited Forkhead box O3 (FOXO3), which is known as a tumor suppressor. Surprisingly, our data demonstrated that FOXO3 is essential for CD44 expression and the properties of CSCs. Our data also indicated that patients with high FOXO3 activation signatures had poor prognoses. This evidence suggested that cGMP induction and FOXO3 inhibition could be ideal candidates for pancreatic CSC.

Usefulness of intraoperative diagnosis of hepatic tumors located at the liver surface and hepatic segmental visualization using indocyanine green-photodynamic eye imaging.

BACKGROUND: To improve the diagnostic accuracy for hepatic tumors on the liver surface, we investigated the usefulness of an indocyanine green-photodynamic eye (ICG-PDE) system by comparison with Sonazoid intraoperative ultrasonography (IOUS) in 117 patients. Hepatic segmentation by ICG-PDE was also evaluated. METHODS: ICG was administered preoperatively for functional testing and images of the tumor were observed during hepatectomy using a PDE camera. ICG was injected into portal veins to determine hepatic segmentation. RESULTS: Accurate diagnosis of liver tumors was achieved with ICG-PDE in 75% of patients, lower than with IOUS (94%). False-positive and false-negative diagnosis rates for ICG-PDE were 24% and 9%, respectively. New small HCCs were detected in 3 patients. The ICG fluorescent pattern in tumors was strong staining in 41%, weak staining in 13%, rim staining in 20% and no staining in 26%. Hepatocellular carcinoma predominantly showed strong staining (61%), while rim staining predominated in cholangiocellular carcinoma (60%) and liver metastasis (55%). Hepatic segmental staining was performed in 28 patients, proving successful in 89%. CONCLUSION: ICG-PDE is a useful tool for detecting the precise tumor location at the liver surface, identifying new small tumors, and determining liver segmentation for liver resection.

Prognostic influence of the liver hanging maneuver for patients with hepatobiliary malignancies who underwent hepatic resections.

BACKGROUND: Prognostic influences of hepatic transection by an anterior approach using the liver hanging maneuver (LHM) has not been fully clarified. METHODS: We examined 233 patients who underwent major hepatectomy with the LHM (n = 75; hepatocellular carcinoma (HCC) in 35, colorectal liver metastasis (CLM) in 10, intrahepatic cholangiocarcinoma (ICC) in 14 and perihilar bile duct carcinoma (BDC) in 16) or without it (n = 158; HCC in 78, CLM in 21, ICC in 31 and BDC in 28). RESULTS: In HCC patients, cancer-positive margin rate, blood loss, transection time and prevalence of posthepatectomy ascites in the LHM group were significantly lower than those in the non-LHM group (p < 0.05). In CLM, transection time in the LHM group was significantly lower than that in the non-LHM group (p < 0.05). In BDC patients, amount of blood loss, transection time and prevalence of ascites in the LHM group were significantly lower than those in the non-LHM group (p < 0.05). In CLM patients, tumor recurrence rate in the non-LHM group was significantly higher than that in the LHM group and disease-free survival in the LHM group was significantly better than that in the non-LHM group in CLM patients and, however, this difference was not observed in a large CLM exceeding 5 cm. However, significant differences of posthepatectomy disease-free and overall survivals were not observed in HCC, ICC and BDC patients. CONCLUSIONS: Although advantages of LHM improving surgical records in major anatomical liver resections were clarified, oncological advantages in the long-term survival of LHM was still uncertain in the hepatobiliary malignancies.

Influence of losartan intake on the circadian rhythm of melatonin secretion in humans.

It has been reported that losartan, an angiotensin II receptor blocker, alters the circadian rhythm of melatonin secretion and significantly reduces melatonin production. However, this finding has been confirmed at the animal experiment level only, and there are no reports of studies in humans. Therefore, we performed this study to confirm the reproducibility of the aforementioned findings of animal experiments in humans. Ten male subjects who were in good general health and free from any medical condition were recruited for this study. After a preliminary observation period of 7 days, the subjects received oral losartan treatment, 50 mg daily for 7 days. Blood samplings for measurement of the plasma melatonin concentrations were performed on day 7 of the preliminary observation period and day 7 of the losartan treatment period. The circadian rhythm of melatonin secretion after the 7-day treatment with losartan showed no significant difference from that recorded before the losartan administration. The significant decrease of the home blood pressure was observed on the afternoons. The blood samples showed significant decrease of the serum sodium and uric acid levels, along with a significant increase of the serum potassium level. The pharmacological actions of losartan at the ordinarily used clinical dose level were confirmed in humans, however, no significant inhibitory effect of the drug on melatonin secretion could be confirmed. These results are expected to be useful for guiding the proper use of angiotensin II receptor blockers.

Examination of factors that delay the elution of acetaminophen from over-the-counter drugs.

The information on the stability of medications is important to secure their quality. There is, however, little information about the stability of medications which assume to be kept by patients and customers. We previously showed that a delay in drug release occurs in some over-the-counter (OTC) drugs following storage in a high temperature, high humidity environment. In this study we prepared model tablet formulations containing an active ingredient and excipients to investigate the cause of this delayed release. The results reveal that delayed release occurs in preparations compounded with acetaminophen (AA) as the active ingredient and erythritol (ET) and crospovidone (CP) as excipients. In addition, ET deliquesces in a high humidity environment, then incorporates other particles during room temperature storage to form an aggregate. SEM observations and micropore distribution measurements conducted on OTC tablets that exhibit delayed release revealed that the number of intraparticle pores decreased after storage under high temperature, high humidity conditions. Thus, the delayed release by these pharmaceutical product formulations may be due to a change in the micropore structure both on the surface and within the particles, thereby decreasing the solvent infiltration pathways leading to the interior of the preparation.

Role of major histocompatibility complex class II in the development of autoimmune type 1 diabetes and thyroiditis in rats.

Although the MHC class II 'u' haplotype is strongly associated with type 1 diabetes (T1D) in rats, the role of MHC class II in the development of tissue-specific autoimmune diseases including T1D and autoimmune thyroiditis remains unclear. To clarify this, we produced a congenic strain carrying MHC class II 'a' and 'u' haplotypes on the Komeda diabetes-prone (KDP) genetic background. The u/u homozygous animals developed T1D similar to the original KDP rat; a/u heterozygous animals did develop T1D but with delayed onset and low frequency. In contrast, none of the a/a homozygous animals developed T1D; about half of the animals with a/u heterozygous or a/a homozygous genotypes showed autoimmune thyroiditis. To investigate the role of genetic background in the development of thyroiditis, we also produced a congenic strain carrying Cblb mutation of the KDP rat on the PVG.R23 genetic background (MHC class II 'a' haplotype). The congenic rats with homozygous Cblb mutation showed autoimmune thyroiditis without T1D and slight to severe alopecia, a clinical symptom of hypothyroidism such as Hashimoto's thyroiditis. These data indicate that MHC class II is involved in the tissue-specific development of autoimmune diseases, including T1D and thyroiditis.

Metastatic cutaneous carcinosarcoma to the tongue.

Carcinosarcoma is a rare malignant tumour composed of a mixture of carcinomatous and sarcomatous elements. Carcinosarcoma metastatic to the tongue is extremely rare. An 84-year-old woman presented with a rapidly growing mass on the tongue. She had a history of surgery for carcinosarcoma of the occipital skin 9 months before. An excisional biopsy of the tongue mass was performed, and the lesion was histopathologically diagnosed as carcinosarcoma. PET after diagnosis showed multiple hot uptakes in the whole body. The patient died of the disease 2 months after diagnosis. Therapies for patients with metastatic malignant tumours to the oral cavity are difficult, especially in aggressive case such as this. To the authors' knowledge, this is the first case of metastatic carcinosarcoma to the tongue.

Effects of kaempferol on the mechanisms of drug resistance in the human glioblastoma cell line T98G.

Food contains components that may either increase or decrease the bioavailability of a drug. In particular, it is known that grapefruit juice and St. John's Wort induce drug interactions via an effect on the drug-metabolizing enzyme cytochrome P450 (CYP). However, interactions with membrane transporters, such as P-glycoprotein and multidrug resistance-related protein (MRP), may also influence drug bioavailability. The objective of the present study was to investigate the effects of kaempferol, a flavonoid present in food, on the cytotoxicity of anticancer drugs and the mechanisms of drug resistance in the human glioblastoma cell line T98G. Acute exposure to kaempferol inhibited the efflux of calcein, a substrate of MRP; however, chronic exposure caused no apparent effect on calcein efflux. The cytotoxicity of doxorubicin was not influenced by chronic exposure of cells to kaempferol, although that of cisplatin was significantly reduced. Multidrug resistance is often associated with increased levels of MRP1, glutathione S-transferase (GST) and activity by chronic exposure to kaempferol, although MRP2 protein levels are decreased. Accordingly, we hypothesized that the cytotoxicity of anticancer drugs that conjugate with glutathione and the substrate of MRPs may be influenced by long-term intake of drugs such as kaempferol, which are substrates of MRPs and GST.

Relationship between period of survival and clinicopathological characteristics in patients with colorectal liver metastasis.

AIM: Cancer death in the early period after hepatectomy still occurs in patients with colorectal liver metastasis (CLM). We examined the relationship between clinicopathological parameters and survival periods in 130 CLM patients who underwent hepatectomy. PATIENTS/METHODS: Patients were divided into four groups: Group 1 (5-year survivors without tumor relapse), Group 2 (survivors at 2-5 years), Group 3 (cancer death at 2-5 years), and Group 4 (cancer death within 2 years). RESULTS: A short surgical margin was frequent in Group 4 compared to Group 1 (31 vs. 78%, P<0.05). Primary node-positive status, absence of fibrous pseudo-capsular formation, higher Clinical Risk Score, and tumor recurrence within 12 months were frequent in Group 4 (P<0.05). Multivariate analysis revealed a short surgical margin (HR; 3.5) and early tumor relapse (HR; 5.9) as independently significant related parameters (P<0.05). CONCLUSIONS: Sufficient surgical margins and careful follow-up for early tumor relapse may be important for improving postoperative outcomes for CLM patients.

Neutrophil elastase inhibitor (sivelestat) reduces the levels of inflammatory mediators by inhibiting NF-kB.

OBJECTIVE: Sivelestat sodium hydrate (sivelestat) is a specific synthetic inhibitor of neutrophil elastase (NE). Various studies suggest that sivelestat treatment reduces inflammation. In this study, we tested the hypothesis that sivelestat acts as an inhibitor of inflammatory mediators and prevents nuclear factor-kB (NF-kB) activation. METHODS: In the presence and absence of sivelestat, the mouse macrophage cell line RAW 264.7 was stimulated with lipopolysaccharide (LPS) and the levels of inflammatory mediators (TNF-alpha, IL-6 and high mobility group box 1 (HMGB1)) and nitrite in the cell supernatant were measured, along with inducible nitric oxide synthase (iNOS) expression. RESULTS: While LPS administration increased the secretion of inflammatory mediators and nitric oxide (NO), sivelestat decreased the secretion of these mediators. Cell signaling studies demonstrated that sivelestat decreased NF-kB activation by inhibiting IkB phosphorylation. CONCLUSION: Sivelestat may inhibit the various inflammatory mediators through NF-kB inhibition.

Trisectionectomy for large hepatocellular carcinoma using the liver hanging maneuver.

BACKGROUND/PURPOSE: Large liver tumors often expand and severely compress intrahepatic vessels. In cases of the trisectionectomy for such tumors, however, it is difficult to adequately expose the transection planes. The liver hanging maneuver (LHM) is a useful technique for hemihepatectomy and an adequate transection plane might be also required in trisectionectomy. METHODS: LHM procedure is basically followed by the Belghiti's method. A nasogastric tube was used for hanging. At the hepatic hilum, the tube was placed between the liver and Glisson's pedicle. RESULTS: We report here the application of LHM for right and left trisectionectomy in patients with a large hepatoma in two cases. In case of a right trisectionectomy for a large tumor compressing the umbilical Glisson's pedicle, an adequate transection plane was obtained using the LHM because the resected and remnant livers rotated to the other side upon lifting the tube during transection. In case of a left trisectionectomy for a large hepatic tumor compressing the right hepatic vein, an adequate transection plane along the right hepatic vein was obtained using LHM as well. CONCLUSIONS: LHM is a useful surgical application for right and left trisectionectomy in patients with large liver tumors compressing the cut plane.

Comparison of survival between anatomic and non-anatomic liver resection in patients with hepatocellular carcinoma: significance of surgical margin in non-anatomic resection.

AIMS: Anatomic resection, i.e., systematic removal of a liver segment confined by portal branches, is theoretically effective in eradicating intrahepatic metastasis of hepatocellular carcinoma (HCC). The procedure may reduce tumour recurrence and enhance survival of HCC patients. To determine the significance of anatomic resection for HCC patients, we retrospectively conducted a comparative analysis between anatomic (AR) and non-anatomic liver resection (NAR) in 113 Japanese HCC patients with a solitary tumour, a tumour located within one segment, absence or invasion of distal to second order branches of the portal vein, and absence or invasion of peripheral branches of the hepatic vein. METHODS: Patients were divided into two groups, AR group (n = 49) and NAR group (n = 64). RESULTS: The prevalence of liver damage Grade B in the NAR group was significantly greater than in the AR group (p < 0.05). Tumour-free and overall survival following liver resection was not significantly different between AR and NAR groups. In the NAR group, tumour-free and overall survival in patients with tumour exposure at the surgical margin was significantly lower than with a surgical margin greater than 0 mm (not exposed) (p < 0.05). Survival between the AR and NAR groups without tumour exposure at the surgical margin was similar. CONCLUSIONS: Anatomic resection is the theoretical aim. In HCC patients with impaired liver functions, limited liver resection without tumour exposure may provide longer tumour-free and overall survival.

Inhibition of the formation of oral calcium phosphate precipitates: the possible effects of certain honeybee products.

BACKGROUND AND OBJECTIVE: We studied the effects of honeybee products on the in vitro formation of calcium phosphate precipitates. MATERIAL AND METHODS: Screening tests of the in vitro formation of calcium phosphate precipitates using 20 types of honey and four types of propolis were carried out using the pH drop method. RESULTS: The inhibitory effect on the rate of amorphous calcium phosphate transformation to hydroxyapatite and on the induction time varied greatly among the 20 types of honey and four types of propolis. We classified them according to their effects on decreasing the rate of amorphous calcium phosphate transformation to hydroxyapatite and/or increasing the induction time. Two of the 20 honeys showed little or no inhibition, either on the rate of amorphous calcium phosphate transformation to hydroxyapatite or on the induction time. Six of the honeys reduced the rate of amorphous calcium phosphate transformation to hydroxyapatite by 12-35% and with a 2.5- to 4.4-fold increase in the induction time. The remaining 12 honeys showed even greater activity. Because four of these 12 honeys had an inhibitory effect on the rate of amorphous calcium phosphate formation, they were excluded as candidates for anticalculus agents. Furthermore, three of the four types of propolis showed an inhibitory effect that was the same as or greater than 1-hydroxyethylidene- 1,1-bisphosphonate. CONCLUSION: These results suggest that eight honeys and three types of propolis may have potential as anticalculus agents in toothpastes and mouthwashes.