Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

A Novel Imaging Technique for Analyzing Condylar Movement During Mastication in Patients With Jaw Deformities: Four-Dimensional Computed Tomography

OBJECTIVE

This study aimed to reveal characteristic condylar movements in patients with jaw deformities.

STUDY DESIGN

Thirty patients with jaw deformities before surgery were enrolled and instructed to chew a cookie during 4-dimensional computed tomography (4DCT). The distance between the most anterior and posterior positions of the bilateral condyles on 4DCT images was measured and compared among patients with different skeletal classes. Correlations between the condylar protrusion and cephalometric values were also determined.

RESULTS

The distances of condylar protrusion during mastication were significantly greater in the skeletal class II group than in the skeletal class III group ( P =0.0002). Significant correlations were found between the distances of condylar protrusion during mastication and the sella-nasion-B point angle ( r =-0.442, P =0.015), A point-nasion-B point angle ( r =0.516, P =0.004), sella-nasion plane to ramus plane angle ( r =0.464, P =0.01), sella-nasion plane to occlusal plane angle ( r =0.367, P =0.047), and condylion-gonion length ( r =-0.366, P =0.048).

CONCLUSION

Motion analysis with 4DCT images revealed that condylar movement in patients with retrognathism was larger than in patients with mandibular prognathism. Skeletal structure was therefore correlated with condylar movement during mastication.

Association Between Immune-Related Adverse Events and Efficacy and Changes in the Relative Eosinophil Count Among Patients with Advanced Urothelial Carcinoma Treated by Pembrolizumab

Background

To evaluate the association between immune-related adverse events (irAEs) and the clinical outcomes and also between irAEs and the post-treatment changes in the relative eosinophil count (REC) in advanced urothelial carcinoma (UC) patients treated with pembrolizumab.

Materials and Methods

This retrospective study analyzed 105 advanced UC patients treated with pembrolizumab after disease progression on platinum-based chemotherapy between January 2018 and June 2021. The association between the occurrence of irAEs and the efficacy of pembrolizumab was investigated. The change in the REC from before the initiation of pembrolizumab therapy, to three weeks after treatment and the incidence of irAEs were determined.

Results

Overall irAEs were associated with a significantly higher objective response rate (ORR) (58.8% vs 25.4%, P<0.001), a longer progression-free survival (PFS) (25.1 months vs 3.1 months, P< 0.001) and overall survival (OS) (31.2 months vs 11.5 months, P< 0.001) compared to patients without irAEs; however, grade ≥3 irAEs were not associated with the ORR (36.4% vs 36.2%, P=0.989), PFS (9.5 vs 5.5 months, P=0.249), or OS (not reached vs 13.7 months, P=0.335). Compared to a decreased REC at 3 weeks after pembrolizumab, an increased relative REC at 3 weeks was not associated with the incidence of any-grade irAEs (32.3% vs 32.5%, P=0.984) or of grade ≥3 irAEs (10.8% vs 10.0%, P=0.900). Multivariate analyses revealed a female sex (P=0.005), Eastern Cooperative Oncology Group Performance Status ≥1 (P=0.024), albumin <3.7 g/dl (P<0.001), decreased REC (3 weeks later) (P<0.001), and the absence of irAEs of any grade (P=0.002) to be independently associated with a worse OS.

Conclusion

Patients with irAEs showed a significantly better survival compared to patients without irAEs in advanced UC treated with pembrolizumab. An increased posttreatment REC may be a marker predicting improved clinical outcomes and it had no significant relationship with the incidence of irAEs.

Impact of nerve sparing in robot-assisted radical prostatectomy on the risk of positive surgical margin and biochemical recurrence

OBJECTIVES

Nerve sparing may increase positive surgical margin rate during radical prostatectomy. Our objective was to analyze the positive surgical margin rate and location as well as its impact on biochemical recurrence according to nerve sparing procedure in robot-assisted radical prostatectomy.

METHODS

We included 814 patients treated with robot-assisted radical prostatectomy between 2009 and 2021, and evaluated the impact of nerve sparing on positive surgical margin and biochemical recurrence using logistic regression and Cox models.

RESULTS

Unilateral nerve sparing and bilateral nerve sparing were performed in 152 (18.6%) cases and 118 (14.5%) cases, respectively. On multivariable analysis, in addition to nerve sparing, bilateral nerve sparing, but not unilateral nerve sparing was associated with an increased risk of positive surgical margin compared with non-nerve sparing. Positive surgical margin at any location increased the risk of biochemical recurrence. During unilateral nerve sparing, positive surgical margin in nerve sparing side, but not in non-nerve sparing side was associated with increased risk of biochemical recurrence on multivariate analysis.

CONCLUSIONS

Taken together, surgeons need to notice an increased risk of biochemical recurrence associated with positive surgical margin when performing nerve sparing in robot-assisted radical prostatectomy, and then need to choose the patients suitable for nerve sparing.

Comprehensive approach to simultaneous molar intrusion and canine retraction in the treatment of Class II anterior open bite using miniscrew anchorage

Introduction:

Anterior open bite is one of the most difficult malocclusions to correct in orthodontic treatment. Molar intrusion using miniscrew anchorage has been developed as a new strategy for open bite correction; however, this procedure still has an important concern about prolonged treatment duration in the patient with anteroposterior discrepancy due to the separate step-by-step movement of anterior and posterior teeth.

Objective:

This article illustrates a comprehensive orthodontic approach for dentoalveolar open bite correction of an adult patient, by using miniscrew.

Case report:

A woman 19 years and 5 months of age had chief complaints of difficulty chewing with the anterior teeth and maxillary incisor protrusion. An open bite of -2.0 mm caused by slight elongation of the maxillary molars was found. The patient was diagnosed with Angle Class II malocclusion with anterior open bite due to the vertical elongation of maxillary molars. After extraction of the maxillary first premolars, concurrent movements of molar intrusion and canine retraction were initiated with the combined use of sectional archwires, elastic chains and miniscrews.

Results:

At 4 months after the procedure, positive overbite was achieved subsequent to the intrusion of maxillary molars by 1.5 mm and without undesirable side effects. Class I canine relation was also achieved at the same time. The total active treatment period was 21 months. The resultant occlusion and satisfactory facial profile were maintained after 54 months of retention.

Conclusion:

The presented treatment shows the potential to shorten the treatment duration and to contribute to the long-term stability for open bite correction.

The different effects of intraoral vertical ramus osteotomy (IVRO) and sagittal split ramus osteotomy (SSRO) on mandibular border movement

OBJECTIVES

This study investigated the different effects of intraoral vertical ramus osteotomy (IVRO) and sagittal split ramus osteotomy (SSRO) on mandibular border movement.

METHODS

The participants included 22 patients receiving IVRO and 22 patients receiving SSRO who were treated at Okayama University Hospital. Their mandibular border movement was evaluated in three dimensions with 6° of freedom using an optical recording system.

RESULTS

A strong correlation between condylar and lower incisor movement was observed during maximum jaw protrusion and laterotrusion. Significant improvements in condylar and lower incisor movement were detected after orthognathic surgery during maximum jaw protrusion and laterotrusion in the IVRO group and during maximum jaw protrusion in the SSRO group.

DISCUSSION

IVRO likely achieves greater improvement in jaw movement than SSRO. Therefore, the application of IVRO could be considered in the treatment of patients with jaw deformities featuring temporomandibular joint problems.

A Single-center, Open-label, Randomized Controlled Clinical Trial to Evaluate the Efficacy and Safety of the Indirect Bonding Technique

Although accurate bracket placement is essential for orthodontic treatment, many practitioners apply brackets indiscriminately with direct or indirect bonding techniques. Nonetheless, there have been few prospective clinical comparisons of the 2 techniques. We will therefore conduct a single-center, randomized control trial in 100 patients aged 12 years and diagnosed with malocclusion. All patients will receive orthodontic treatment using brackets with direct or indirect bonding techniques. The primary endpoints will be the total treatment time, occlusal index, discomfort at bonding, and oral hygiene after bonding. This study will clarify whether indirect bonding can improve the efficiency of orthodontic treatment.

Orthodontic Treatment of a Patient with Bilateral Congenitally Missing Maxillary Canines: The Effects of First Premolar Substitution on the Functional Outcome

Permanent canines are thought to play a pivotal role in obtaining an ideal occlusion. Dentists occasionally encounter patients who lack canines and are therefore missing a key to harmonious guidance during functional mandibular excursions. This case report describes the substitution of maxillary first premolars for congenitally missing canines in the context of an orthodontic treatment plan. A boy, age 10 years and 11 months, with a chief complaint of crooked teeth was diagnosed with Class II division 2 malocclusion associated with a high mandibular plane angle and deep overbite. A stable occlusion with a satisfactory facial profile and functional excursions without interference were achieved after a comprehensive two-stage orthodontic treatment process. The resulting occlusion and satisfactory facial profile were maintained for 12 months. These results indicate that substituting the first premolars for the canines is an effective option in treating patients with missing canines while maintaining functional goals.

Comprehensive data on ionising radiation from Fukushima Daiichi nuclear power plant in the town of Miharu, Fukushima Prefecture: The Misho Project

Data related to radioactivity released from the Fukushima Daiichi Nuclear Power Plant (FDNPP) accident on 15 March 2011 gathered by residents of Miharu, Fukushima Prefecture, and by Tohoku University are presented. These data sets consist of (1) the earliest radiation monitoring by a Geiger counter in the town, (2) ratios of radioactivity between (132)Te and (137)Cs for a wide area between Fukushima and Tokyo, (3) radiation measurement of soil samples collected from 18 school grounds, and (4) external radiation exposure of 1400 students using OSL badges. By combining and analysing these various data sets, a curve for the cumulative total external exposure as a function of time, with 16 : 00 h on 15 March 2011 being time zero, is obtained. The average cumulative external dosage is estimated to be 10 mSv (σ = 4.2 mSv) over 10 years. In addition, the initiative that the residents of Miharu took in response to the FDNPP accident, which became known as The Misho Project (MP), is documented; in particular, the time at which the municipality instructed the immediate ingestion of iodine tablets by those under the age of 40, 13 : 00 h on 15 March 2011, is assessed.

Dose-ranging study with the glucokinase activator AZD1656 as monotherapy in Japanese patients with type 2 diabetes mellitus

AIM

To assess the glucose-lowering effects of monotherapy with the glucokinase activator AZD1656 in Japanese patients with type 2 diabetes mellitus.

METHODS

This was a randomized, double-blind, placebo-controlled study performed in Japan (NCT01152385). Patients (n = 224) were randomized to AZD1656 (40-200, 20-140 or 10-80 mg titrated doses) or placebo. The primary variable was the placebo-corrected change from baseline to 4 months in glycated haemoglobin (HbA1c). Effects on fasting plasma glucose (FPG) and safety were also assessed.

RESULTS

HbA1c was reduced numerically from baseline by 0.3-0.8% with AZD1656 and by 0.1% with placebo over the first 2 months of treatment, after which effects of AZD1656 started to decline. The changes from baseline to 4 months in HbA1c were not significant for the AZD1656 40-200 mg group versus placebo [mean (95% CI) placebo-corrected change: -0.22 (-0.65, 0.20)%; p = 0.30]. Formal significance testing was not carried out for the other two AZD1656 dose groups. A higher percentage of patients on AZD1656 achieved HbA1c ≤ 7% after 4 months versus placebo, but responder rates were low. Results for FPG reflected those for HbA1c. Cases of hypoglycaemia were rare with AZD1656 (one patient) and no safety concerns were raised.

CONCLUSIONS

Although initially favourable plasma glucose reductions were observed, there was a loss of effect over time with sustained AZD1656 treatment. The study design did not allow an evaluation of the reasons for this lack of long-term efficacy.

H3K4 methylation profiling reveals distinct epigenetic signatures in CD4 T cell activation and memory formation. (P1146)

The roles of histone modifications in T cell activation and memory formation are poorly understood. Thus, we used RNAseq and ChIPseq in tandem to assess the impact of promoter H3K4 di- and trimethylation in naive vs memory human CD4 T cells at rest and 5 days after activation. Changes in H3K4me2 and me3 correlated strongly with changes in RNA expression when comparing naive and memory cells; e.g. increased H3K4 methylation with increased gene expression. These changes define unique signatures comprised of &gt;200 genes at rest and &gt;400 post-activation. Dramatically, activation of naïve CD4 resulted in differential H3K4 methylation of &gt;4000 genes while only ~800 changed with activation of memory. In contrast, activation-induced changes in gene expression and methylation correlated nearly perfectly in memory but poorly for naïve CD4 T cells. These data suggest a higher level of H3K4 methylation-based commitment in the memory subset 5 days after activation. We are presently doing the same studies for days 1 and 14 after activation to understand how quickly activation-induced H3K4 methylation changes occur and how well H3K4 methylation signatures are reflected 14 days after activation of naive cells. In sum, naïve and memory CD4 T cells demonstrate specific H3K4 methylation signatures, T cell activation is clearly an epigenetically dynamic process, and profiling of H3K4 methylation provides important insight into the epigenetic mechanisms driving the commitment to memory.

MULTI-SITE AEROSOL MONITORING USING MINI STEP SAMPLER

We developed mini step samplers with low manufacturing and running costs for application in multi-site air-pollution monitoring. The miniaturization of the sampler was achieved by reducing the suction nozzle size. We tested the samplers with suction nozzle diameters of 2 and 4 mm through simultaneous exposure in the same site. Elemental concentrations of aerosol collected by these samplers were consistent within ±20% during comparison and the sample uniformity did not differ significantly. Sampling with small suction nozzle did not adversely affect aerosol collection. Aerosol samples were collected simultaneously at two sites in our laboratory and in the hall outside for 3 days and analyzed subsequently by PIXE. The time variation of elemental concentrations was high during daytime and low at night time and also during the weekend. Elemental concentrations in the hall were always higher than those in the laboratory. In our laboratory, we change shoes at the entrance and therefore, elemental concentrations inside the lab are lower than in the hall. In a second field experiment, we carried out simultaneous multi-site aerosol sampling during two periods in correlation with meteorological data (wind direction and velocity). It was observed that elemental concentrations of some soil origin elements changed periodically. On the other hand, the concentration of Cu and Zn showed irregular concentration spikes whose pattern showed a variation with the sites. Analysis using the data of wind directions showed that Cu had been transported to the sites from northeasterly direction and that the concentration of Zn was influenced by two big factories nearby. In conclusion, it has been demonstrated that the multi-site sampling system combined with meteorological data is well suited to identify sources of pollution.

Multiple receptor-ligand interactions direct activation of epidermal γδ T cells in response to keratinocyte damage (63.7)

γδ T cells represent a major T cell population in epithelial tissues where they function in maintenance of the epithelium and provide a crucial first line defence against epithelial insults. Despite their importance, little is known about the molecular mechanisms involved in their activation and function. γδ T cells resident in the epidermis are a prototypic epithelial γδ T cell population and are an essential component of the wound healing process in the skin. We have exploited this population to identify molecules involved in the complex cell-cell interactions between epithelial resident γδ T cells and the neighboring cells they support. In the skin, keratinocyte damage is a primary trigger of γδ T cell activation, however the molecular interactions regulating this activation are unknown. Here we confirm a vital role for TCR-ligand interactions in the initiation of the γδ T cell response to keratinocyte damage. In addition, we identify two receptor-ligand pairs crucial for an effective γδ T cell response both in vitro and in vivo. Interactions between JAML and CAR provide costimulatory signals for γδ T cell activation and signals through CD100 and plexin B2 are responsible for γδ T cell morphology changes in response to wounding. Disruption of these interactions delays the γδ T cell-mediated wound healing response. Our results provide insight into the molecular mechanisms of γδ T cell activation and describe two novel receptor-ligand pairs vital to this process.

Identification of novel E2F1 target genes regulated in cell cycle-dependent and independent manners

The transcription factor E2F mediates cell cycle-dependent expression of genes important for cell proliferation in response to growth stimulation. To further understand the role of E2F, we utilized a sensitive subtraction method to explore new E2F1 targets, which are expressed at low levels and might have been unrecognized in previous studies. We identified 33 new E2F1-inducible genes, including checkpoint genes Claspin and Rad51ap1, and four genes with unknown function required for cell cycle progression. Moreover, we found three groups of E2F1-inducible genes that were not induced by growth stimulation. At least, two groups of genes were directly induced by E2F1, indicating that E2F1 can regulate expression of genes not induced during the cell cycle. One included Neogenin, WASF1 and SGEF genes, which may have a role in differentiation or development. The other was the cyclin-dependent kinase inhibitor p27(Kip1), which was involved in suppression of inappropriate cell cycle progression induced by deregulated E2F. E2F1-responsive regions of these genes were located more upstream than those of typical E2F targets and did not have typical E2F sites. These results indicate that there are groups of E2F1 targets, which are regulated in a distinct manner from that of typical E2F targets.

An epistatic effect of the female specific loci on the development of autoimmune vasculitis and antinuclear autoantibody in murine lupus

OBJECTIVE

To identify the genetic loci regulating the incidence and severity of renal autoimmune vasculitis developed in murine lupus.

METHODS

Vasculitis of renal arteries was histopathologically evaluated in MRL/Mp-Fas(lpr) (MRL/lpr), C57BL/6-Fas(lpr) (B6/lpr), (MRL/lpr x B6/lpr) F1, and MRL/lpr x (MRL/lpr x B6/lpr) F1 backcross mice. Using genomic DNA samples of the backcross mice, genome-wide scans, association studies, and linkage analyses were carried out based on genotypes of polymorphic microsatellite markers. Correlations of vasculitis grade and levels of various autoantibodies were also evaluated.

RESULTS

Two recessive susceptibility loci of the MRL allele were identified on chromosomes 4 and 1, which had previously been defined as the autoimmune related loci termed Arvm1 and Sle-1/Nba2, respectively. The former was epistatic to the latter in a female specific manner. The titre of antinuclear autoantibody (ANA) in IgG class, but not ANA in IgM class or anti-dsDNA in either IgG or IgM class, correlated significantly with vasculitis grade.

CONCLUSIONS

The present loci have been reported in previous studies using a different set of murine strains, suggesting that they are of importance in the development of autoimmune vasculitis in murine models. The concomitance of autoimmune vasculitis and IgG ANA suggests a shared genetic factor regulating these traits.

Crystal structure of thermostable DNA photolyase: pyrimidine-dimer recognition mechanism

DNA photolyase is a pyrimidine-dimer repair enzyme that uses visible light. Photolyase generally contains two chromophore cofactors. One is a catalytic cofactor directly contributing to the repair of a pyrimidine-dimer. The other is a light-harvesting cofactor, which absorbs visible light and transfers energy to the catalytic cofactor. Photolyases are classified according to their second cofactor into either a folate- or deazaflavin-type. The native structures of both types of photolyases have already been determined, but the mechanism of substrate recognition remains largely unclear because of the lack of structural information regarding the photolyase-substrate complex. Photolyase from Thermus thermophilus, the first thermostable class I photolyase found, is favorable for function analysis, but even the type of the second cofactor has not been identified. Here, we report the crystal structures of T. thermophilus photolyase in both forms of the native enzyme and the complex along with a part of its substrate, thymine. A structural comparison with other photolyases suggests that T. thermophilus photolyase has structural features allowing for thermostability and that its light-harvesting cofactor binding site bears a close resemblance to a deazaflavin-type photolyase. One thymine base is found at the hole, a putative substrate-binding site near the catalytic cofactor in the complex form. This structural data for the photolyase-thymine complex allow us to propose a detailed model for the pyrimidine-dimer recognition mechanism.

[Role of new devices for angioplasty in the unprotected left main coronary artery]

OBJECTIVES

Angioplasty for the unprotected left main trunk remains controversial, but new procedures and devices such as directional coronary atherectomy and stenting have improved the results. We compared the results of angioplasty with the inflexible balloon and new devices.

METHODS

The procedures were performed in 239 consecutive lesions in 160 patients between April 1986 and March 2000. This study excluded emergency cases and repeat angioplasty cases, and included 120 initial and elective cases. Initial and long-term results were compared between the balloon group (n = 29) and the new device group (n = 91).

RESULTS

Lesion success rate was lower in the balloon group (90% vs 100%, p < 0.05), but there were no significant differences in in-hospital results including cardiac death (0% vs 0%), noncardiac death (0% vs 3.3%), Q-wave myocardial infarction (0% vs 2.2%), non-Q wave myocardial infarction (3.4% vs 6.6%), bypass surgery (0% vs 0%) and repeat angioplasty (6.9% vs 1.1%). Quantitative angiography showed significant improvements in minimal lumen diameter (mean 2.17 vs 3.16 mm, p < 0.001) and percentage diameter stenosis (mean 31% vs 13%, p < 0.001) in the new device group after the procedures. The minimum lumen diameter remained larger at 3 (p < 0.001) and 6 months (p < 0.05) in the new device group. Therefore, angiographic restenosis rate was higher in the balloon group (55% vs 21%, p < 0.005). Five-year survival rate showed no significant difference between the groups (75.0% vs 83.8%).

CONCLUSIONS

New devices significantly improved the minimal lumen diameter after angioplasty for unprotected left main trunk disease, and lead to significant improvement of restenosis rate at follow-up.

[A case of polyarteritis nodosa limited to both calves with a low titer of MPO-ANCA]

A-57-year-old woman had suffered from high fever, general malaise, and loss of weight (6 kg) since January, 2000. She was admitted to our hospital in May, 2000, because of gait disturbance following to swelling of bilateral calves with severe pain beside the above symptoms. Laboratory data showed leukocytosis (WBC 10,000/microliter), high ESR (98 mm/hr), positive CRP (3.43 mg/dl), positive ANA (x160), high titer of RA (266 IU/l), and a low titer of MPO-ANCA (18 EU). T 2-weighted magnetic resonance image (MRI) showed intensity area of the M. gastrocnemius. Skin biopsy specimens of the right leg demonstrated necrotizing arteritis of small-sized arteries. These findings supported the diagnosis of limited type of polyarteritis nodosa (PN). In this report, we demonstrate a rare case of PN limited to both calves with characteristic MRI findings and a low titer of MPO-ANCA.

[A case of giant dumbbell shaped schwannoma with massive pleural effusion]

A 58-year-old female was admitted to the hospital complaining of dyspnea. The chest roentgenogram and CT scan revealed a large mediastinum tumor and massive pleural effusion in the right hemithorax. The diagnosis of lung cancer with carcinomatous pleulitis was performed through thoracocentesis an treatment of chemotherapy was chosen. After 6 years, she was admitted again to the hospital complaining of dull pain in the right leg. Chest CT scan and MRI showed a giant dumbbell shaped mass connected to the spinal canal. The tumor was larger than that of six years ago and diagnosed as schwannoma by CT-guided pericutaneous needle biopsy. At operation, hemilaminectomy of Th 1-3 was done first, and total tumor resection was performed through posterolateral thoracotomy. Intrathoracic adhesion was severe and it was difficult to control air leakage from the lung, thoracoplasty was performed.

Functional recovery and regeneration of descending tracts in rats after spinal cord transection in infancy

STUDY DESIGN

The functional recovery of rats that underwent spinal cord transection in infancy was evaluated by multimodal examination (functional tests, electrophysiologic evaluation, tract-tracing) to determine the basis for the recovery.

OBJECTIVES

To determine whether the hind limb function in rats that underwent spinal cord transection in infancy is regained completely, which descending tracts regenerate after the transection, and whether the functional recovery is correlated with axonal reconnection.

SUMMARY OF BACKGROUND DATA

It is widely accepted that a newborn rat recovers its hind limb function after spinal cord transection even without any specific treatments. This functional recovery might be attributed to possible regeneration of some descending pathways, although there is a counterargument that well-trained spinal cord reflexes may bring about functional compensation.

METHODS

The thoracic spinal cord of infant rats was completely transected at Th10 when they were 2 weeks of age. Multimodal functional tests and electrophysiologic studies were performed 5 weeks later. Some recovered rats (i.e., those able to walk after the transection) underwent spinal cord retransection, with subsequent reevaluation of locomotion and muscle-evoked potentials. At 6 weeks after the initial transection, tract-tracing studies were performed in some animals.

RESULTS

A motor performance score detected the functional differences between the control and the recovered rats. Muscle-evoked potentials of hind limbs after electrical stimulation to the brain were recorded in some of the recovered rats, but never in the unrecovered rats. Moreover, the muscle-evoked potentials of the recovered rats disappeared after spinal cord retransection that resulted in loss of voluntary movement. Morphologic studies in two rats provided evidence that reconnection of rubrospinal, vestibulospinal, and reticulospinal tracts had occurred, whereas corticospinal regeneration was not detected.

CONCLUSIONS

It can be concluded that the hind limb function of rats that underwent spinal cord transection in infancy was partially regained; that axonal regeneration of the rubrospinal, vestibulospinal, or reticulospinal tracts was demonstrated, whereas the reconnection of the corticospinal tract was not observed; and that the axonal regeneration of these tracts is involved in the functional recovery.

A case of localized primary sclerosing cholangitis mimicking intrahepatic bile duct cancer

A 75-year-old woman with chronic hepatitis was regularly followed-up in our hospital. A computed tomography (CT) scan revealed an obviously enlarged intrahepatic bile duct in the posterior branch of the left lateral segment. Percutaneous cholangiography revealed an enlarged posterior branch of the left lateral segment and a narrow stenotic region at the root of this branch. We diagnosed her as having intrahepatic bile duct cancer, and a left lateral segmentectomy of the liver was performed. However, microscopic examination of the resected specimens revealed peribiliary fibrosis in the stenotic bile duct and other areas of the intrahepatic bile duct with no malignant cells. Thus, the final diagnosis was made to be primary sclerosing cholangitis. We must consider primary sclerosing cholangitis in the differential diagnosis of localized stenosis of the intrahepatic bile duct.

Budd-Chiari syndrome and extrahepatic portal obstruction associated with congenital antithrombin III deficiency

We report a patient with Budd-Chiari syndrome (BCS) and extrahepatic portal obstruction (EHO) associated with congenital antithrombin (AT) III deficiency. A 35-year-old man was admitted to Nishi Kobe Medical Center for evaluation of abnormal intrahepatic veins. By various imaging modalities, BCS and EHO were diagnosed. Laboratory data revealed parallel decreases in activity and antigen concentration of AT III despite normal liver function. Taken together, the etiology of both BCS and EHO was considered to be thrombosis, associated with congenital AT III deficiency. Two years after beginning warfarin therapy, the patient has no symptoms and his liver function remains normal. Anticoagulant therapy is considered useful for preventing progression of the disease.

The association of degeneration of the intervertebral disc with 5a/6a polymorphism in the promoter of the human matrix metalloproteinase-3 gene

It has been suggested that matrix metalloproteinase-3 (MMP-3, stromelysin-1) has an important role in the degeneration of intervertebral discs (IVDs). A human MMP-3 promoter 5A/6A polymorphism was reported to be involved in the regulation of MMP-3 gene expression. We suggest that IVD degeneration is associated with 5A/6A polymorphism.

We studied 54 young and 49 elderly Japanese subjects. Degeneration of the lumbar discs was graded using MRI in the younger group and by radiography in the elderly. 5A/6A polymorphism was determined by polymerase-chain reaction-based assays. We found that the 5A5A and 5A6A genotype in the elderly was associated with a significantly larger number of degenerative IVDs than the 6A6A (p < 0.05), but there was no significant difference in the young. In the elderly, the IVD degenerative scores were also distributed more highly in the 5A5A and 5A6A genotypes (p = 0.0029).

Our findings indicate that the 5A allele is a possible risk factor for the acceleration of degenerative changes in the lumbar disc in the elderly.

The association of degeneration of the intervertebral disc with 5a/6a polymorphism in the promoter of the human matrix metalloproteinase-3 gene

It has been suggested that matrix metalloproteinase-3 (MMP-3, stromelysin-1) has an important role in the degeneration of intervertebral discs (IVDs). A human MMP-3 promoter 5A/6A polymorphism was reported to be involved in the regulation of MMP-3 gene expression. We suggest that IVD degeneration is associated with 5A/6A polymorphism. We studied 54 young and 49 elderly Japanese subjects. Degeneration of the lumbar discs was graded using MRI in the younger group and by radiography in the elderly. 5A/6A polymorphism was determined by polymerase-chain reaction-based assays. We found that the 5A5A and 5A6A genotype in the elderly was associated with a significantly larger number of degenerative IVDs than the 6A6A (p < 0.05), but there was no significant difference in the young. In the elderly, the IVD degenerative scores were also distributed more highly in the 5A5A and 5A6A genotypes (p = 0.0029). Our findings indicate that the 5A allele is a possible risk factor for the acceleration of degenerative changes in the lumbar disc in the elderly.

Initial and long-term results of directional coronary atherectomy in unprotected left main coronary artery

Angioplasty in the unprotected left main coronary artery (LMCA) has been controversial. Recently, several studies have suggested that new procedures and devices such as directional coronary atherectomy (DCA) and stents may change this situation. Although there are many reports of unprotected LMCA stenting, there are few reports of DCA of this lesion. Therefore, initial and long-term results were evaluated in 101 patients who underwent DCA for unprotected LMCA in our hospital. Emergency procedures were performed in 15 patients and electively in 86 patients. Scheduled angiographic follow-up was routinely performed, and all patients were clinically followed for >4 months after DCA. Technical success was achieved in 99%, and in-hospital outcomes were cardiac death (2%), noncardiac death (4%), Q-wave myocardial infarction (1%), non-Q-wave myocardial infarction (8.9%), coronary artery bypass grafting (0%), and repeat angioplasty (4%). In-hospital results varied considerably, depending on presentation. In-hospital mortality was significantly higher in the emergency, left ventricular ejection fraction < or =35%, and high-risk surgical subgroups. The angiographic restenosis rate was 20.4% at follow-up, and its predictor was postminimal lumen diameter by multivariate analysis. Mean clinical follow-up was 2.8 years; estimated 1- and 3-year survival rates were 87% and 80.7%, respectively. The cardiac survival rate of the low-risk surgical subgroup was significantly higher than that of the high-risk surgical subgroup (p <0.05). Thus, our data show that DCA can be performed safely and effectively in unprotected LMCA with an acceptable low restenosis rate and high survival rate.

Requirement of nitric oxide for murine oocyte maturation, embryo development, and trophoblast outgrowth in vitro

We investigated the extent to which NO participates in the developmental competence (oocyte maturation, fertilization and embryo development to blastocyst) using an in vitro culture system adding sodium nitroprusside (SNP), NO donor, and NOS inhibitor (N-omega-nitro-L-arginine methyl ester, L-NAME). We also assessed the effects of NO/NOS system on blastocyst implantation using an in vitro trophoblast outgrowth assay. The treatment of low concentrations of SNP (10(-7) M) significantly stimulated meiotic maturation to metaphase II stages in cumulus enclosed oocytes. In contrast, 10(-3) and 10(-5) M L-NAME demonstrated a significant suppression in resumption of meiosis. This inhibition was reversed by the addition of SNP. No development beyond the four-cell stage was observed by the addition of high concentration of SNP (10(-3) M). Inhibition of embryo development, especially the conversion of morulae to blastocysts, was also observed in the treatment of lower doses of SNP (10(-5) and 10(-7) M). Similarly, inhibition of NO by NOS inhibitor resulted in the dose-dependent inhibition of embryo development and hatching rates, but the concomitant addition of SNP with L-NAME reversed the inhibitory effect by each SNP or L-NAME treatment. Furthermore, low concentration of SNP (10(-7) M) but not high concentration of SNP (10(-3) M) significantly stimulated trophoblast outgrowth, whereas the addition of L-NAME suppressed the spreading of blastocysts in a dose-dependent manner. These results suggest that NO may have crucial roles in oocyte maturation and embryogenesis including the process of implantation. The observed differences in required amount of NO and the sensitivity to cytotoxicity of NO in each developmental stage embryos may also suggest that NO/NOS system is tightly regulated in developmental stage specific manner.

Vascularity of advanced gastric carcinoma: evaluation by using power Doppler imaging

BACKGROUND

We investigated the vascularity of advanced gastric adenocarcinomas by using percutaneous power Doppler imaging.

METHODS

Seventeen patients with gastric cancer and 10 without a gastric tumor, but with a slightly thick gastric wall in the B-mode ultrasound, were investigated with the use of power Doppler imaging. The color signals of the gastric lesion were graded as follows: 1, no color signals or the same as the surroundings; 2, color signals were slightly increasing; and 3, color signals were obviously increasing.

RESULTS

The color signals of three patients were graded 1, those of eight patients were graded 2 and those of six patients were graded 3 in the gastric cancer group. The color signals of all 10 patients without a gastric tumor were grade 1. This difference was statistically significant (P = 0.0002).

CONCLUSIONS

Power Doppler imaging showed vascularity of gastric cancer increasing in the majority of patients (14 of 17: 82%). Thus, power Doppler imaging might be a good screening examination method for gastric cancer.

[Predictors of prognosis after angioplasty in the unprotected left main coronary artery]

OBJECTIVES

The short-term and long-term predictors of outcome after coronary angioplasty in the unprotected left main coronary artery were investigated.

METHODS

The procedure was performed in 122 consecutive patients for de novo lesions without myocardial infarction in our hospital between April 1986 and October 1998, including 16 emergency cases. Procedures were directional coronary atherectomy (73 patients), balloon angioplasty (31 patients), and stent implantation (18 patients). There were 101 males and mean age was 68 +/- 10 years. Follow-up angiography was performed in 98% of discharged patients, and all patients were clinically followed up for more than 1 year. Clinical and angiographic predictors of in-hospital and long-term outcome were evaluated.

RESULTS

The in-hospital mortality was 5.7% (7 of 122 patients). Multivariate analysis revealed that more patients were admitted as emergency cases (57% vs 10%, p = 0.0088), with left ventricular ejection fraction < or = 35% (57% vs 22%, p = 0.029) and renal failure (43% vs 3%, p = 0.0004) finally died. Mean follow-up period was 3.5 years. Estimated survival rate was 77.1%, and cardiac-death free survival rate was 81.0% at 5 years by the Kaplan-Meier method. Univariate analysis showed that the predictors of cardiac death were emergency angioplasty, renal failure, decreased left ventricular ejection fraction, multivessel disease and unstable angina and/or congestive heart failure. Cox's regression model showed that renal failure (p = 0.0004) and multivessel disease (p = 0.0075) were significant predictors of long-term prognosis.

CONCLUSIONS

Renal failure was the strongest predictor of outcome after unprotected left main coronary artery angioplasty.

Bilateral oophorectomy in asymptomatic women over 50 years old selected by ovarian cancer screening

The purpose of this study was to evaluate bilateral oophorectomy in women over 50 years old found to have an adnexal mass using transvaginal ultrasonography (TVS) as a mass screening. With TVS a total of 23,451 women without symptoms were examined for ovarian cancer at annual screening for uterine cervical cancer. Two hundred fifty-eight women over 50 years old persistently had abnormal TVS results and 95 women gave informed consent for surgical tumor removal. In the 95 women operated, 7 malignant ovarian cancers were found. Especially adnexal masses which were thought to be benign were treated by laparoscopic surgery.

Initial and 6-month results of biodegradable poly-l-lactic acid coronary stents in humans

BACKGROUND

Although metallic stents are effective in preventing acute occlusion and reducing late restenosis after coronary angioplasty, many concerns still remain. Compared with metallic stents, poly-l-lactic acid (PLLA) stents are biodegradable and can deliver drugs locally. The aim of this study was to evaluate the feasibility, safety, and efficacy of the PLLA stent.

METHODS AND RESULTS

Fifteen patients electively underwent PLLA Igaki-Tamai stent implantation for coronary artery stenoses. The Igaki-Tamai stent is made of a PLLA monopolymer, has a thickness of 0.17 mm, and has a zigzag helical coil pattern. A balloon-expandable covered sheath system was used, and the stent expanded by itself to its original size with an adequate temperature. A total of 25 stents were successfully implanted in 19 lesions in 15 patients, and angiographic success was achieved in all procedures. No stent thrombosis and no major cardiac event occurred within 30 days. Coronary angiography and intravascular ultrasound were serially performed 1 day, 3 months, and 6 months after the procedure. Angiographically, both the restenosis rate and target lesion revascularization rate per lesion were 10.5%; the rates per patient were 6.7% at 6 months. Intravascular ultrasound findings revealed no significant stent recoil at 1 day, and they revealed stent expansion at follow-up. No major cardiac event, except for repeat angioplasty, developed within 6 months.

CONCLUSIONS

Our preliminary experience suggests that coronary PLLA biodegradable stents are feasible, safe, and effective in humans. Long-term follow-up with more patients will be required to validate the long-term efficacy of PLLA stents.

Regulation of UDP-glucose:ceramide glucosyltransferase-1 by ceramide

We report that the expression of mRNA and the activity of UDP-glucose:ceramide (Cer) glucosyltransferase-1 (GlcT-1) of human hepatoma Huh7 and mouse melanoma B16 cells increases after treatment with bacterial sphingomyelinase or upon addition of short-chain Cer. Interestingly, however, GlcT-1 gene transcription was not increased by Cer when GlcT-1 cDNA was introduced with the CMV promoter in GlcT-1-deficient GM95 cells, suggesting that the normal promoter region of GlcT-1 gene is essential for the response. The conversion of C6-Cer to C6-GlcCer occurred much more rapidly in GlcT-1-overexpressing Huh7 cells than in mock transfectants. As a result, GlcT-1-overexpressing cells acquired a greater resistance to C6-Cer-mediated cell death.

The iteron regions necessary for the RepE-iteron interaction in vivo in mini-F plasmids of Escherichia coli

We have determined the nucleotide positions of an incC iteron essential for RepE binding by analyzing mutated incC iterons defective in exerting incompatibility towards mini-F plasmids. The mutations affecting this incompatibility occurred mostly at two positions within the incC iteron, i.e. an iteron conserved position and a mini-F specific position. Most of the iterons with a base-change at either of these two positions had lost the binding affinity for RepE. This agrees with the crystallographic structure of the RepE-iteron complex which showed that the N and C terminal domains of RepE interact with the two major grooves on one face of the iteron DNA. These grooves contain the iteron conserved and mini-F specific positions necessary for RepE binding. Thus the binding mode may be common to in the case of mini-F like plasmids.

Spinal cord herniation into an extensive extradural meningeal cyst: postoperative analysis of intracystic flow by phase-contrast cine MRI

We report a patient with idiopathic spinal cord herniation who underwent postoperative myelography and phase-contrast cine magnetic resonance imaging (MRI) to clarify the condition of the ventral cystic lesion into which the spinal cord had been herniated. This 58-year-old man showed symptoms and signs compatible with Brown-Séquard syndrome. A myelogram and MRI showed that the spinal cord was incarcerated in a small space, and this finding led to the diagnosis of spinal cord herniation. In the operation, the herniated spinal cord was returned to the initial intradural space, and the dural defect was enlarged to prevent recurrence of the herniation. After the operation, leg muscle strength improved and bladder and bowel dysfunction resolved, but analgesia was unchanged. Postoperative myelography revealed a very large extradural cystic lesion, which extended from C2 to L1 vertebral level. A cerebrospinal fluid (CSF) flow study of the intradural space disclosed a near-normal pattern, but the intracystic CSF dynamics were abnormal. In the intracystic space at just the upper level of the lesion, cranial flow (reverse directional flow in comparison with the intradural flow) was seen in the systolic cycle after momentary fast caudal flow, and these CSF dynamics may have been related to the spinal cord herniation.

Characterization of a zebra mutant of rice with increased susceptibility to light stress

The rice zebra mutant TCM248 is a single recessive mutant. This mutant develops transverse-striped leaves with green and white sectors under alternate light/dark growth conditions. Mutants that were grown under a higher light intensity during the light period showed a more intense striped phenotype. The white tissues contained abnormal chloroplasts with few internal membrane structures, while the green tissues in the mutants contained normal chloroplasts. The white tissue contained only trace amounts of Chls and carotenoids, and mRNA accumulation of nuclear genes encoding chloroplast proteins (rbcS, cab) was strongly suppressed compared to that in the wild type plants. A series of growth condition shift experiments demonstrated that the mutant displayed the striped phenotype only if it was exposed to the alternate light/dark growth conditions during a limited stage of early leaf development. These data suggest that the zebra gene is involved in the acquisition of photoprotective capacity of the plants and that this gene functions at an early stage of chloroplast differentiation.

Endoscopic resection of small inflammatory fibroid polyp of the colon

Inflammatory fibroid polyp (IFP) is a solitary intestinal lesion of unknown etiology. Although IFP is benign, laparotomy for the resection of colonic IFP is performed in most cases because the polyp is usually large. We report a successful endoscopic resection of cecal IFP. It is considered that colonic IFP should be resected endoscopically if the polyp is small and is located submucosally.

Effect of age on cerebrospinal fluid levels of metabolites of biopterin and biogenic amines

We identified an age effect on biopterin and biogenic amine metabolites in the cerebrospinal fluid from 56 neurologically normal patients, aged 1 mo to 80 y. The levels of total and reduced forms of biopterin, homovanillic acid, and 5-hydroxyindoleacetic acid were found to peak during the first year of life. The levels of these metabolites then gradually decreased, plateauing at the age of 20 y. We found significant correlations between biopterin, homovanillic acid, and 5-hydroxy-indoleacetic acid.