Pharmacists must be able to select and collect important information for patient care, to accurately assess and monitor the status of patients, to develop care plans, propose optimal formulations, and provide advice to patients about pharmacotherapy. The core curriculum of Japan's pharmacy education model was revised in 2013 based on the “Basic competencies required of a pharmacist” that should be developed by the time of a student's graduation. Specific behavioral objectives to be acquired include competency in “The ability to implement pharmacotherapeutic management”, which involves gaining the ability to understand patient information, to design and propose prescriptions, and to conduct pharmacotherapeutic assessments. We thus introduced an integrated program for fifth-year students at Hokkaido Pharmaceutical University using problem-based learning and role-playing with simulated patients to teach clinical communication skills and the ability to design pharmaceutical care plans for patients. A survey of students who completed the program after pharmacy practical training revealed that most of them realized the value of the program: they were able to develop precise care plans for medical problems and learned good communication skills to collect information about patients.
The Learning Sciences constitute a rapidly expanding discipline that focuses on the learning potential of humans. In this paper, I will discuss the particular learning mechanism involved in the concomitant advancement of domain knowledge and 21st century skills, as well as the Constructive Jigsaw Method of knowledge construction through collaboration—that is, collaborative problem solving. An especially important focus on knowledge construction separates routine experts from adaptive experts. While routine experts develop a core set of skills that they apply throughout their lives with increasing efficiency, adaptive experts are much more likely to change their core skills and continually expand the depth of their expertise. This restructuring of core ideas and skills may reduce their efficiency in the short run but make them more flexible in the long run. The Constructive Jigsaw Method employs a learning mechanism that encourages the development of adaptive experts. Under this method, students first study a piece of material in an expert group. One member from each of several expert groups then joins a new study group, a jigsaw group. The members of this new group then combine what they have learned, creating new knowledge and a deeper understanding of the concept through collaboration, communication, and innovation.
In the School of Pharmacy, collaborative learning that includes both problem-based learning (PBL) and team-based learning (TBL) methods, has been introduced as an active learning method into the education of first-year pharmacy students. These methods are an educational approach to teaching and learning that involve groups of students working collaboratively to resolve a problem, complete a task, or develop a product. However, these methods might not aid students who focus more on the results than on the problem-solving process. In addition, the self-efficacy and learning motivation of students who dislike these learning methods might decrease. The Jigsaw Method respects the individuality of students and is a collaborative learning approach that decreases conflict among students with varied learning styles. Upon applying this method in the first-year course at Kobe Pharmaceutical University, it was observed that most students who attended the life science class increased their self-efficacy, and their passive learning attitudes transformed into active ones. The introduction of the Jigsaw Method to the education of first-year students can help them acquire an effective technique for learning integrated subjects.
To promote problem-solving ability within a pharmacotherapy course, we developed new problem-based learning (PBL) and information and communication technologies (ICT) support systems, and introduced the “Jigsaw Method,” an active learning method in which, similar to parts of a jigsaw puzzle, students are dependent on each other to create the full picture, to succeed. We conducted 10 PBL modules (one case per module), each lasting one week. To encourage constructive group work, information sharing, and student understanding in the individual modules, we implemented a Jigsaw Method-based wiki worksheet system in which students were to identify patient problems and check each other's work on an e-portfolio system. After completing this new curriculum, students were able to create comprehensive therapeutic care plans. A significant correlation was observed between the students' care plan evaluation scores and their module test results, suggesting that constructive group work can enhance problem-solving ability in therapeutics. These results clearly indicate the benefit of combining our new PBL-ICT support system with the Jigsaw Method.
In the Faculty of Pharmaceutical Sciences at Toho University, Kampo education commenced 40 years ago through a course titeled “Kampo”, which has since been renamed as “Kampo Pharmacology”. The current university curriculum offers courses in subjects such as Pharmacognosy and Practical Pharmacognosy for sophomores, Kampo Pharmacology for juniors, and Clinical Kampo Medicine for seniors. Kampo Pharmacology is a subject that bridges “Pharmacognosy” to “Clinical Kampo Medicine”. The functions of the crude drugs included in Kampo prescriptions are explained both in terms of efficacy from the perspective of Kampo and by contemporary evidence. Furthermore, the “Clinical Kampo Therapeutics” course offered for seniors involves lectures on the fundamentals of Kampo, determination of evidence and prescriptions, case analysis, and prescription analysis by physicians affiliated with our university's medical center. Acquiring an understanding of the effectiveness of crude drugs in herbal medicine and gaining practical clinical knowledge are considered beneficial for future pharmacists.
An approach to educating our pharmaceutical students about Kampo medicine in the six-year system of undergraduate pharmacy education at Kyoto Pharmaceutical University is introduced, including the author's opinions. Curriculum revisions have been made in our university for students entering after 2012. In teaching Kampo medicine at present, a medical doctor and an on-site pharmacist share information difficult to give in a lecture with the teaching staff in my laboratory. For example, before the curriculum revision, we conferred with a pharmacist and a doctor in the course “Kampo Medicine A, B” for 4th year students, in which students were presented a basic knowledge of Kampo medicine, the application of important Kampo medicines, combinations of crude drugs, etc. Further, in our “Introduction to Kampo Medicine” for 6th year students, presented after they have practiced in hospitals and community pharmacies, we again lecture on the pharmacological characteristics of Kampo medicines, on “pattern (Sho)”, and on evidence-based medicine (EBM) and research studies of important Kampo medicines. After our curriculum revision, “Kampo Medicine A, B” was rearranged into the courses “Kampo and Pharmacognosy” and “Clinical Kampo Medicine”. “Kampo and Pharmacognosy” is now provided in the second semester of the 3rd year, and in this course we lecture on the basic knowledge of Kampo medicine. An advanced lecture will be given on “Clinical Kampo Medicine” in the 6th year. We are searching for the best way to interest students in Kampo medicine, and to counteract any misunderstandings about Kampo medicine.
Given the universal prevalence of complementary and alternative medicines, as well as integrative medicine, the usage of traditional medicine has been gaining in popularity worldwide. Japanese Kampo medicine and traditional Chinese medicine (TCM) are both derived from ancient medicines used in East Asia in the 5th-7th centuries, and have developed independently since the 14th century. Now Kampo medicine and TCM have different theories for the diagnosis and use of crude drugs. Unfortunately, Kampo medicine is not well known in Europe and the Americas; as a matter of practice, TCM is the international standard for traditional medicines derived from ancient East Asia. In the teaching of Kampo medicines to undergraduate students in a school of pharmacy, the author considers that a minimum requirement is to explain the differences between TCM and Kampo medicine. For graduate students of pharmaceutical science, the students must know the distinct medical theories of both TCM and Kampo medicine, and furthermore, must be able to read and write articles in English about traditional medicines, in order to help put Kampo medicine on the world map.
Kampo-medicine has become popular in Japanese medical practice combined with western medicine. For example, Daikenchu-To for intestinal obstruction after surgical operation, Shakuyakukanzo-To and Goshajinki-Gan for anti-cancer agents-induced neuropathy, and Yokkan-San for behavioral psychological symptoms of dementia are alternatively used in addition to conventional treatments in Japan. However, combined use of Kampo-medicine and western medicine may cause unexpected adverse events including undesirable drug-drug interactions because Kampo-medicine was not originally developed to be used with western medicine. Although adverse effects of Kampo-medicine are rare compared with those of western medicine, severe events such as liver dysfunction and interstitial pneumonia have been reported in increasing trends. Medical staff including pharmacists, therefore, should be aware of the onset of adverse events before the patients' symptoms become severe. Several adverse effects are caused by chemical constituents such as glycyrrhizin in licorice for pseudoaldosteronism and geniposide in Gardeniae fructus for mesenteric phlebosclerosis. To understand the adverse effects of Kampo-medicine, pharmacists should learn trends in current medication as well as pharmacology and toxicology of the chemical constituents in pharmacognosy. These issues should also be addressed in educational materials for students of clinical pharmacy and pharmacy practice.
What should we educate for Kampo medicine in the model core curriculum of pharmaceutical education? The curricular core should be discussed considering the points mentioned below. (1) Positioning of Kampo medicine in the Japanese medical care system. Kampo medicine is an authorized medical care category in the National Health Insurance (NHI) program in Japan. The NHI drug price list carries 148 Kampo formulations. According to the report of the Japan Kampo Medicines Manufacturers Association in 2011, approximately 90% of Japanese physicians prescribe Kampo medicines. (2) Differences between Kampo medicine and western medicine: In Kampo medicine, the most suitable formula among various Kampo formulas to normalize the psychophysical state of individual patients is selected. In other words, if there is a complaint, there are always some treatments. (3) A strong point of Kampo medicine: Kampo medicine enables physicians to deal with difficult-to-treat conditions by western medicine alone. Also, by using the scale of Kampo medicine, each patient can grasp his or her own systemic state and improve their lifestyle. To extend healthy life expectancy, a basic knowledge of Kampo medicine may play a significant role in integrated health care. “The guide book of the approval standards for OTC Kampo products”, “the pharmaceutical advanced educational guideline”, and “the manual of the exam questions preparation for registered sales clerks” should also be consulted before selecting the area and contents that should be covered.
Several diseases are characterized by alterations in the molecular distribution of vascular structures, presenting the opportunity to use monoclonal antibodies for clinical therapies. This pharmaceutical strategy, often referred to as “vascular targeting”, has promise in promoting the discovery and development of selective biological drugs to regulate angiogenesis-related diseases such as cancer. Various experimental approaches have been utilized to discover accessible vascular markers of health and disease at the protein level. Our group has developed a new chemical proteomics technology to identify and quantify accessible vascular proteins in normal organs and at disease sites. Our developed methodology relies on the perfusion of animal models with suitable ester derivatives of biotin, which react with the primary amine groups of proteins as soon as the molecules are attached. This presentation reports biomedical applications based on vascular targeting strategies, as well as methodologies that have been used to discover new vascular targets. The identification of antigens located in the stromal tissue of pathological blood vessels may provide attractive targets for the development of antibody drugs. This method will also provide an efficient discovery target that could lead to the development of novel antibody drugs.
Biopharmaceuticals, including antibody drugs, are now popular because of their high specificity with low adverse effects, especially in the treatment of cancer and autoimmune diseases. However, because the active pharmaceutical ingredients of biopharmaceuticals are proteins, biophysical characterization of these therapeutic proteins should be required. In this manuscript, methods of chemical and physical characterization of therapeutic proteins are described. In terms of chemical characterization, analysis of chemical modifications of the constituent amino acids is explained. Physical characterization includes higher order structural analysis and assessment of protein aggregates. Quantification methods of aggregates with different sizes, recently encouraged by the U.S. Food and Drug Administration (FDA), are introduced. As for the stability of therapeutic proteins, the importance of chemical and physical stability is explained. Finally, the contribution of colloidal and structural stability to the production of an antibody drug less prone to aggregation is introduced.
The Platform for Drug Discovery, Informatics, and Structural Life Science (PDIS), which has been launched since FY2012, is a national project in the field of structural biology. The PDIS consists of three cores - structural analysis, control, and informatics - and aims to support life science researchers who are not familiar with structural biology. The PDIS project is able to provide full-scale support for structural biology research. The support provided by the PDIS project includes protein purification with various expression systems, large scale protein crystallization, crystal structure determination, small angle scattering (SAXS), NMR, electron microscopy, bioinformatics, etc. In order to utilize these methods of support, PDIS users need to submit an application form to the one-stop service office. Submitted applications will be reviewed by three referees. It is strongly encouraged that PDIS users have sufficient discussion with researchers in the PDIS project before submitting the application. This discussion is very useful in the process of project design, particularly for beginners in structural biology. In addition to this user support, the PDIS project has conducted R&D, which includes the development of synchrotron beamlines. In the PDIS project, PF and SPring-8 have developed beamlines for micro-crystallography, high-throughput data collection, supramolecular assembly, and native single anomalous dispersion (SAD) phasing. The newly developed beamlines have been open to all users, and have accelerated structural biology research. Beamlines for SAXS have also been developed, which has dramatically increased bio-SAXS users.
The appropriate secretion of insulin from pancreatic β-cells is essential for regulating blood glucose levels. Glucose-stimulated insulin secretion (GSIS) involves the following steps: Glucose uptake by pancreatic β-cells is metabolized to produce ATP. Increased ATP levels result in the closure of ATP-sensitive K+ (KATP) channels, resulting in membrane depolarization that activates voltage-dependent Ca2+ channels to subsequently trigger insulin secretion. In addition to this primary mechanism through KATP channels, insulin secretion is regulated by cyclic AMP and diacylglycerol (DAG), which mediate the effects of receptor agonists such as GLP-1 and acetylcholine. Glucose by itself can also increase the levels of these second messengers. Recently, we have shown an obligatory role of diacylglycerol kinase (DGK), an enzyme catalyzing the conversion of DAG to phosphatidic acid, in GSIS. Of the 10 known DGK isoforms, we focused on type-I DGK isoforms (i.e., DGKα, DGKβ, and DGKγ), which are activated by Ca2+. The protein expression of DGKα and DGKγ was detected in mouse pancreatic islets and the pancreatic β-cell line MIN6. Depletion of these DGKs by a specific inhibitor or siRNA decreased both [Ca2+]i and insulin secretion in MIN6 cells. Similar [Ca2+]i responses were induced by DiC8, a membrane-permeable DAG analog. These results suggest that DGKα and DGKγ play crucial roles in insulin secretion, and that their depletion impairs insulin secretion through DAG accumulation. In this article, we review the current understanding of the roles of DAG- and DGK-signaling in pancreatic β-cells, and discuss their pathophysiological roles in the progression of type-2 diabetes.
Upon elevation of plasma glucose concentration, pancreatic β-cells generate bursts of action potentials to induce cyclic changes in [Ca2+]i regulating insulin release. Glucose-dependent insulin secretion is synergistically enhanced by glucagon-like peptide-1 (GLP-1), which increases [cAMP]i and activates protein kinase A (PKA) and exchange protein activated by cAMP (Epac). The insulinotropic effect of GLP-1 is mediated, at least in part, by modulating multiple ion channels/transporters at the plasma membrane and ER through PKA- and EPAC-dependent mechanisms, which increase membrane excitability and intracellular Ca2+ release. However, because of complex interactions between multiple cellular factors involved in the GLP-1 effects, quantitative aspects of the molecular/ionic mechanisms have not yet been determined. We thus performed simulation studies and mathematical analysis to investigate how GLP-1 signals control [cAMP]i and subsequently modify the bursting activities and Ca2+ dynamics. First, a GLP-1 receptor signal transduction model was developed and introduced to our β-cells model. Secondly, modulatory effects of PKA/Epac on ion channels/transporters were incorporated based on experimental studies. Increases in the frequency and duration of the bursting activity observed during GLP-1 stimulation were well reconstructed by our model, and lead potential analysis quantitatively determined the functional role of each ion channel/transporter in modifying the burst pattern. Finally, an IP3R model was developed to reproduce GLP-1-induced Ca2+ transients/oscillations. Instantaneous equilibrium analysis and bifurcation analysis also elucidated the quantitative mechanisms involved in generating IP3R-mediated Ca2+ mobilization. The results of this theoretical analysis of the effects of GLP-1 on membrane excitability/Ca2+ dynamics are discussed in this review.
Alterations in the cytosolic concentration of calcium ions (Ca2+) are important signals for various physiological events. The engagement of B cell receptors (BCR) results in the transient release of Ca2+ into cytosol from endoplasmic reticulum (ER) stores. In turn, this decrease in ER luminal Ca2+ concentration triggers the opening of Ca2+ channels in the plasma membrane, inducing a sustained influx of extracellular Ca2+ into cells. These processes are referred to as store-operated Ca2+ entry (SOCE), which is an essential pathway for continuous Ca2+ signaling. While the ER calcium sensor stromal interaction molecule (STIM) 1 and STIM2 are crucial components for SOCE activation, their physiological roles in B cells are unknown. Here we uncover the physiological function of SOCE in B cells by analyzing mice with B cell-specific deletions of STIM1 and STIM2. Our findings indicate that STIM1 and STIM2 are critical for BCR-induced SOCE, as well as the activation of nuclear factors of activated T cells (NFAT), and the subsequent production of interleukin-10 (IL-10). Although STIM proteins are not essential for B cell development and antibody responses, these molecules are required to suppress experimental autoimmune encephalomyelitis (EAE) via an IL-10-dependent mechanism. Accumulating evidence underscores the importance of IL-10-producing B cells in autoimmunity, although the identity of IL-10-producing B cells with a regulatory function in vivo remains unclear. We addressed this issue and identified plasmablasts as IL-10-producing B cells that can suppress EAE inflammation. Our data established STIM-dependent SOCE as a key signal for the regulatory plasmablasts required to limit autoimmunity.
Potassium ion (K+) channels play an important role in the modulation of calcium ion (Ca2+) signaling via control of the membrane potential. In T-lymphocytes, the voltage-gated K+ channel, KV1.3, and the intermediate-conductance Ca2+-activated K+ channel, KCa3.1, predominantly contribute to K+ conductance, and are responsible for cell proliferation, differentiation, apoptosis and infiltration. Inflammatory bowel disease (IBD), including ulcerative colitis and Crohn's disease, afflicts more than 0.1% of the population worldwide. In the chemically-induced IBD model mouse, an increase in KCa3.1 activity was observed in mesenteric lymph node CD4+ T-lymphocytes, concomitant with an upregulation of KCa3.1 and a positive KCa3.1 regulator, NDPK-B. Pharmacological blockade of the KCa3.1 K+ channel by TRAM-34 and/or ICA17043 elicited 1) a significant decrease in IBD severity, as assessed by diarrhea, visible fecal blood, inflammation and crypt damage of the colon; and 2) restoration of the expression levels of KCa3.1 and Th1 cytokines in CD4+ T-lymphocytes in the IBD model. Recent studies have indicated the impact of K2P5.1 upregulation in T lymphocytes on the pathogenesis of autoimmune diseases such as rheumatoid arthritis and multiple sclerosis. The K2P5.1 K+ channel is therefore highlighted as a potent therapeutic target in managing the pathogenesis of autoimmune diseases. Alternatively, pre-mRNA splicing of ion channels is associated with the development and progression of various diseases, including autoimmune diseases. Therefore, mRNA-splicing mechanisms underlying the transcriptional regulation of K2P5.1 K+ channels may be a new strategic therapeutic target for autoimmune and inflammatory diseases.
Cl−-permeable channels and transporters expressed on the cell membranes of various mammalian cell types play pivotal roles in the transport of electrolytes and water, pH regulation, cell volume and membrane excitability, and are therefore expected to be useful molecular targets for drug discovery. Both TMEM16A (a possible candidate for Ca2+-regulated Cl− channels recently identified) and cystic fibrosis transmembrane conductance regulator (CFTR) (or cAMP-regulated Cl− channels) have been known to be involved in Cl− secretion and reabsorption in the rat salivary gland. Crosstalk between two types of regulatory pathways through these two types of channels has also been described. Previously, we demonstrated that CLCA, a Ca2+-activated Cl− channel modulator, was involved in Cl− absorption in rat salivary ducts. In addition to Ca2+, basal NF-κB activity in a mouse keratinocyte line was shown to be involved in the transcriptional regulation of CLCA. Conversely, a truncated isoform of CLCA was found in undifferentiated epithelial cells present in the rat epidermal basal layers. Under regulation by Ca2+ and PKC, the surface expression of β1-integrin and cell adhesion were decreased in the CLCA-overexpressing cells. Knockdown of this isoform elevated the expression of β1-integrin in rat epidermis in vivo. These results indicate that the specific differentiation-dependent localization of CLCA, and transcriptional regulation through Ca2+, are likely to affect ion permeability and the adhesive potential of epithelial cells. In summary, these types of Cl− channels and their modulators may function in a coordinated manner in regulating the functions of epithelial cells under different physiological conditions.
Photoacoustic imaging (PA imaging or PAI) has been focused on as a new technique to provide images of high spatial resolution, at depths of up to 5 cm, and the development of novel PAI probes for tumor imaging is of marked interest. Although nanomaterials such as gold nanorods have been reported as PAI probes, dyes are required to aid their ease of preparation, cost-effectiveness, and safety. However, because PAI has relatively low intrinsic sensitivity compared to optical imaging, and requires high-energy laser pulse exposure, an appropriate probe design, high tumor accumulation, and photostability are required for PAI probes. We developed some dyes and evaluated their usefulness as PAI probes. We first developed a high tumor-accumulation dye probe, IC7-1-Bu, which utilizes serum albumin as a tumor-targeting carrier to deliver an adequate PA signal at the tumor. Although IC7-1-Bu showed strong tumor targeting ability and a sufficient PA signal at the tumor in in vivo studies, IC7-1-Bu lacks photostability against multiple laser irradiations of PAI. In order to improve dye photostablity, we focused on the effect of singlet oxygen (1O2) generated by excited PAI probes on probe degeneration, and developed a triplet-state quencher conjugated dye probe, IC-5-T. IC-5-T reduced 1O2 generation and improved photostability against multiple irradiations compared to IC7-1-Bu. IC-5-T also showed a sufficient PA signal at the tumor, and 1.5-fold higher photostabillity compared to IC7-1-Bu in sequential in vivo PAI studies. These results suggest that IC-5-T is a potential PAI probe for tumor imaging.
Safety information regarding drug use during pregnancy is insufficient. The present study aimed to establish an optimal signal detection method to identify adverse drug reactions in pregnant women and to evaluate information in the Japanese Adverse Drug Event Report (JADER) database between April 2004 and November 2014. We identified reports on pregnant women using the Standardised MedDRA Queries. We calculated the proportional reporting ratio (PRR) and reporting odds ratio (ROR) of the risk factors for the two known risks of antithyroid drugs and methimazole (MMI) embryopathy, and ritodrine and fetal/infant cardiovascular events. The PRR and ROR values differed between all reports in the JADER database and those on pregnant women, affecting whether signal detection criteria were met. Therefore we considered that reports on pregnant women should be used when risks associated with pregnancy were determined using signal detection. Analyses of MMI embryopathy revealed MMI signals [PRR, 159.7; ROR, 669.9; 95% confidence interval (CI), 282.4-1588.7] but no propylthiouracil signals (PRR, 1.98; ROR, 2.0; 95%CI, 0.3-15.4). These findings were consistent with those of reported risks. Analyses of fetal/infant cardiovascular events revealed ritodrine signals (PRR, 2.1; ROR, 2.1; 95%CI, 1.4-3.3). These findings were also consistent with reported risks. Mining the JADER database was helpful for analyzing adverse drug reactions in pregnant women.
The Japanese Ministry of Health, Labor, and Welfare lists hand-foot syndrome as a serious adverse drug event. Therefore, we evaluated its association with anticancer drug therapy using case reports in the Japanese Adverse Drug Event Report (JADER) and the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS). In addition, we calculated the reporting odds ratio (ROR) of anticancer drugs potentially associated with hand-foot syndrome, and applied the Weibull shape parameter to time-to-event data from JADER. We found that JADER contained 338224 reports from April 2004 to November 2014, while FAERS contained 5821354 reports from January 2004 to June 2014. In JADER, the RORs [95% confidence interval (CI)] of hand-foot syndrome for capecitabine, tegafur-gimeracil-oteracil, fluorouracil, sorafenib, and regorafenib were 63.60 (95%CI, 56.19-71.99), 1.30 (95%CI, 0.89-1.89), 0.48 (95%CI, 0.30-0.77), 26.10 (95%CI, 22.86-29.80), and 133.27 (95%CI, 112.85-157.39), respectively. Adverse event symptoms of hand-foot syndrome were observed with most anticancer drugs, which carry warnings of the propensity to cause these effects in their drug information literature. The time-to-event analysis using the Weibull shape parameter revealed differences in the time-dependency of the adverse events of each drug. Therefore, anticancer drugs should be used carefully in clinical practice, and patients may require careful monitoring for symptoms of hand-foot syndrome.
To avoid fluctuation of the serum lithium concentration (CLi), sodium chloride (NaCl) intake was regulated in oral alimentation. A 62-year-old woman was hospitalized and orally administered 400 mg of lithium carbonate a day to treat her mania. Her CLi was found to be 0.75-0.81 mEq/L. Vomiting made it difficult for the patient to ingest meals orally, and therefore parenteral nutrition with additional oral intake of protein-fortified food was initiated. On day 22, parenteral nutrition was switched to oral alimentation to enable oral intake of food. The total NaCl equivalent amount was decreased to 1.2 g/d, and the CLi increased to 1.15 mEq/L on day 26. Oral alimentation with semi-solid food blended in a mixer was immediately initiated. Although the total NaCl equivalent amount was increased to 4.5-5.0 g/d, her CLi remained high at 1.14-1.17 mEq/L on days 33 and 49, respectively. We investigated oral administration of NaCl (1.8 g/d) on day 52. The total NaCl equivalent amount was increased to 6.3-6.8 g/d, and the CLi decreased to 1.08-0.97 mEq/L on days 63 and 104, respectively. After the start of the orally administered NaCl, her diet was changed to a completely blended diet on day 125. The total NaCl equivalent amount was increased to 9.0-14.5 g/d, and the CLi decreased to 0.53 mEq/L on day 152; therefore, the oral administration of NaCl was discontinued on day 166. The CLi was found to be 0.70-0.85 mEq/L on days 176 and 220.