The white blood cell count is an independent predictor of no-reflow and mortality following acute myocardial infarction in the coronary interventional era

BACKGROUND: In the era before the use of coronary reperfusion therapy, an elevated white blood cell (WBC) count was associated with a higher risk of adverse events following acute myocardial infarction (AMI). However, the relationship between WBC count and prognosis after AMI has not been investigated since coronary intervention was introduced. AIM: To evaluate whether a high WBC count within 48 hours of the onset of AMI predicts future adverse events in patients undergoing percutaneous coronary intervention (PCI). METHOD: We evaluated 1,016 patients who underwent PCI in the acute phase of MI using the Japanese Acute Coronary Syndrome Study (JACSS) database. RESULTS. WBC count was significantly associated with smoking, sudden onset AMI, and the no-reflow phenomenon during PCI, as were age, peak creatine kinase level, and Killip class. An elevated WBC count was significantly associated with higher risk of in-hospital mortality. Patients in the highest quartile of WBC count were about three times more likely to have a poor prognosis after AMI compared to those in the lowest quartile. CONCLUSIONS: The WBC count is of great significance for stratifying patient risk and can be used as a universal marker for predicting future adverse events following any treatment for AMI.     

Delivery of peptide drugs to the brain by adenovirus-mediated heterologous expression of human oligopeptide transporter at the blood-brain barrier

The feasibility of using adenovirus-mediated human oligopeptide transporter (hPEPT1) gene transfer to achieve peptide drug delivery to the brain across the blood-brain barrier was tested by examining the accumulation of model peptides in a rat brain endothelial cell line (RBEC1) and rat brain after transduction with a recombinant adenovirus encoding hPEPT1-enhanced yellow fluorescent protein fusion gene (AdhPEPT1-EYFP). In vitro uptake of [(3)H]GlySar was determined in RBEC1 transduced with AdhPEPT1-EYFP. In vivo, the accumulation of cefadroxil in rat brain was evaluated after transduction of AdhPEPT1-EYFP. At pH 6.0, the uptake of [(3)H]GlySar by RBEC1 transduced with AdhPEPT1-EYFP was increased 4-fold compared with that of nontransduced cells. At pH 7.4, uptake of [(3)H]GlySar in AdhPEPT1-EYFP transduced RBEC1 was 1.5 times higher than that of nontransduced cells. Unlabeled glycylsarcosine (10 mM) reduced the uptake of [(3)H]GlySar to a level comparable with that of nontransduced cells. At 30 min after intravenous administration of cefadroxil to rats transduced with AdhPEPT1-EYFP at 3.2 x 10(9) plaque-forming units/rat by an in situ brain perfusion method, the brain-to-plasma concentration ratio (Kp) of cefadroxil was increased about 2 times compared with that of nontransduced or AdGFP (control vector)-transduced rats, although this was not statistically significant. In contrast, Kp of [(14)C]inulin, a marker for extracellular fluid space, remained unchanged after adenoviral transduction. In conclusion, our results suggest that adenovirus-mediated heterologous expression of hPEPT1 in vivo could be a useful approach to deliver oligopeptides to the brain.     

Rapidly progressive fatal pneumococcal sepsis in adults: a report of two cases

We report two cases of a rapidly progressive fatal overwhelming pneumococcal infection. Patient 1 was a 67-year-old man with a 24-h history of fever and malaise and was transferred to our department. He was severely ill, tachypneic, and felt a chill. A purpuric discoloration with ecchymosis of the skin was noted over the body. The chest X-ray findings demonstrated thickening of the bronchovascular bundle in the right lower lung field, which later revealed the presence of bronchopneumonia. Laboratory studies revealed the presence of metabolic acidosis and disseminated intravascular coagulation. After presentation, rapid deterioration occurred followed by cardiopulmonary arrest. Despite cardiopulmonary resuscitation, the patient died only 3 h after presentation. The isolates from the patient's blood revealed penicillin-susceptible Streptococcus pneumoniae, serotype 4. Patient 2 was a 30-year-old woman with a prior history of uneventful pregnancies was transferred to our department with a 2-day history of fever, nausea, headache, and malaise. Although she was in the 19th week of pregnancy at the time, she suffered a miscarriage just prior to admission. Upon presentation to our department, she demonstrated unstable vital signs, diminished consciousness, anuria, and icterus. Purpuric discoloration with ecchymosis of the skin was noted in over most of her body, including the distal extremities. The chest X-ray findings were close to normal. Initial laboratory studies revealed the presence of severe metabolic acidosis and disseminated intravascular coagulation with multiple organ failure. Despite aggressive cardiopulmonary support, normal neurological responses disappeared on the 2nd day following admission and the patient died on the 16th day after admission. The patient's isolates from blood and vaginal swabs both later revealed penicillin-susceptible Streptococcus pneumoniae, serotype 12F. The presentation of rapidly progressive septic shock should raise the treating physician's suspicion of overwhelming pneumococcal infection, which has limited management options.     

Laparoscopic features of primary biliary cirrhosis in AMA-positive and AMA-negative patients

BACKGROUND AND STUDY AIMS: Antimitochondrial antibody (AMA)-negative primary biliary cirrhosis (PBC) has been difficult to diagnose. Laparoscopic features of AMA-negative PBC were evaluated in comparison with those of AMA-positive PBC and autoimmune hepatitis. PATIENTS AND METHODS: 71 patients who fulfilled the diagnostic criteria for PBC were enrolled in the study; 48 were AMA-positive and 23 were AMA-negative. As a disease control, 46 autoimmune hepatitis patients were included. Both the frequency and specificity of each laparoscopic finding were evaluated. A laparoscopic scoring system was introduced, which used, common and uncommon laparoscopic findings, and was evaluated for the diagnosis of AMA-negative PBC. RESULTS: The characteristic laparoscopic findings for AMA-positive PBC were yellowish-white marking (92 %), dark-brown discoloration (73 %), gentle undulation (67 %), reddish patch (38 %), and yellowish-white nodules (32 %). On the other hand, laparoscopic findings such as trench-like depression, reddish markings, and wide and small depressions were uncommon in PBC compared with autoimmune hepatitis. The frequencies of characteristic and uncommon laparoscopic findings did not differ statistically between AMA-positive and AMA-negative PBC, but were different between AMA-positive or AMA-negative PBC and autoimmune hepatitis. Scores based on common and uncommon laparoscopic findings were 5.5 +/- 1.5 (mean +/- SD) in AMA-positive PBC, 5.6 +/- 2.0 in AMA-negative PBC, and - 0.30 +/- 0.5 in autoimmune hepatitis. CONCLUSION: The laparoscopic findings in AMA-negative PBC did not differ from those of AMA-positive PBC. A laparoscopic scoring system may be helpful in the diagnosis of AMA-negative PBC.     

Role of SLC xenobiotic transporters and their regulatory mechanisms PDZ proteins in drug delivery and disposition.

Various types of xenobiotic (or drug) transporters have been recently identified to play important roles as barriers against toxic compounds and influx pumps to take up nutrients into the body. Since those xenobiotic transporters generally have wide range of recognition specificity and accept various types of compounds as substrates, localization and functional expression of such transporters could be one of the critical factors that affect the disposition and subsequent biological activity of therapeutic agents. Identification and characterization of drug transporters have given us a scientific basis for understanding drug delivery and disposition, as well as the molecular mechanisms of drug interaction and inter-individual/inter-species differences. To precisely understand pharmacological roles of the transporters in the body, it is also important to clarify molecular mechanisms involved in regulation of the transporters. As a first step to clarify the regulatory mechanisms that govern cell-surface expression and/or function of these transporters, recent researches have focused on PDZ (PSD-95/Discs-large/ZO-1) binding motif localized on carboxylic terminus of several types of xenobiotic transporters. Most of the transporters showing direct interaction potential with the PDZ domain-containing proteins are expressed on apical membranes in epithelial cells of kidney and/or small intestine, implying that such protein-protein interaction may play a role in apical localization of the transporters. In this mini-review article, we summarize importance of transporters and their regulatory mechanisms in drug delivery and disposition, focusing on several aspects of transporter-mediated drug targeting.     

Clinicopathological analysis of biopsy-proven diabetic nephropathy based on the Japanese classification of diabetic nephropathy

Background

The Japanese classification of diabetic nephropathy reflects the risks of mortality, cardiovascular events and kidney prognosis and is clinically useful. Furthermore, pathological findings of diabetic nephropathy are useful for predicting prognoses. In this study, we evaluated the characteristics of pathological findings in relation to the Japanese classification of diabetic nephropathy and their ability to predict prognosis.

Methods

The clinical data of 600 biopsy-confirmed diabetic nephropathy patients were collected retrospectively from 13 centers across Japan. Composite kidney events, kidney death, cardiovascular events, all-cause mortality, and decreasing rate of estimated GFR (eGFR) were evaluated based on the Japanese classification of diabetic nephropathy.

Results

The median observation period was 70.4 (IQR 20.9–101.0) months. Each stage had specific characteristic pathological findings. Diffuse lesions, interstitial fibrosis and/or tubular atrophy (IFTA), interstitial cell infiltration, arteriolar hyalinosis, and intimal thickening were detected in more than half the cases, even in Stage 1. An analysis of the impacts on outcomes in all data showed that hazard ratios of diffuse lesions, widening of the subendothelial space, exudative lesions, mesangiolysis, IFTA, and interstitial cell infiltration were 2.7, 2.8, 2.7, 2.6, 3.5, and 3.7, respectively. Median declining speed of eGFR in all cases was 5.61 mL/min/1.73 m²/year, and the median rate of declining kidney function within 2 years after kidney biopsy was 24.0%.

Conclusions

This study indicated that pathological findings could categorize the high-risk group as well as the Japanese classification of diabetic nephropathy. Further study using biopsy specimens is required to clarify the pathogenesis of diabetic kidney disease.