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.

Economic costs for outpatient treatment of eating disorders in Japan

BACKGROUND

Few studies have examined the economic costs of outpatient care for eating disorders in Japan. This study aimed to clarify the reimbursement for outpatient treatment of eating disorders and compare the costs between the departments of Psychosomatic Medicine and Psychiatry in Japan.

METHOD

A multicenter, prospective, observational study of patients with an eating disorder was conducted in the Psychosomatic Medicine departments of three centers and the Psychiatry departments of another three centers in Japan. We analyzed medical reimbursement for an outpatient revisit, time of clinical interviews, and the treatment outcome measured by the Eating Disorder Examination Questionnaire (EDE-Q) global scores and body mass index (BMI) at 3 months. Multivariate linear regression models were performed to adjust for covariates.

RESULTS

This study included 188 patients in the Psychosomatic Medicine departments and 68 in the Psychiatry departments. The average reimbursement cost for an outpatient revisit was 4670 yen. Even after controlling for covariates, the Psychosomatic Medicine departments had lower reimbursement points per minute of interviews than the Psychiatry departments (coefficient = - 23.86; 95% confidence interval = - 32.09 to - 15.63; P < 0.001). In contrast, EDE-Q global scores and BMI at 3 months were not significantly different between these departments.

CONCLUSIONS

This study clarifies the economic costs of treating outpatients with eating disorders in Japan. The medical reimbursement points per interview minute were lower in Psychosomatic Medicine departments than in Psychiatry departments, while there were no apparent differences in the treatment outcomes. Addressing this issue is necessary to provide an adequate healthcare system for patients with eating disorders in Japan.

A multi-center, randomized, parallel-group study to compare the efficacy of enhanced cognitive behavior therapy (CBT-E) with treatment as usual (TAU) for anorexia nervosa: study protocol

BACKGROUND

The superiority of Enhanced Cognitive Behavior Therapy (CBT-E) with regard to weight gain and improvement of psychopathology of eating disorders for patients with anorexia nervosa (AN) over other psychotherapies and treatment as usual (TAU) has not been demonstrated in randomized controlled trials (RCTs). However, a previous RCT showed that patients with AN whose baseline body mass index (BMI) was less than 17.5 kg/m² gained more weight when treated with CBT-E than with other psychotherapies. The aim of the study is to compare the efficacy of CBT-E and TAU for patients with AN. It was hypothesized that CBT-E would be superior to TAU, at least in terms of weight gain, as most patients with AN are likely to have a BMI lower than 17.5 kg/m².

METHODS/DESIGN

A randomized parallel-group multicenter trial will be conducted in three teaching hospitals in Japan between January 2023 and March 2026. Patients with DSM-5 AN, aged 16 years and older, with a BMI equal to or above 14.0 and below 18.5 will be eligible to participate. 56 patients will be randomly and evenly assigned to two intervention groups (CBT-E and TAU). Those assigned to CBT-E will be offered 25-40 sessions in accordance with their initial BMI. Patients assigned to TAU will have at least one session every 2 weeks, with the number of sessions and treatment period not fixed in advance. The primary outcome is BMI at 40 weeks after treatment initiation. The secondary outcomes are the results from the Japanese version of the Eating Disorder Examination Questionnaire and Clinical Impairment Assessment questionnaire to measure eating disorder psychopathology and psychological impairment. The follow-up assessment will be performed 6 months after the 40-week assessment.

DISCUSSION

This multi-center randomized controlled study will probably evaluate the efficacy of CBT-E compared with TAU for patients with more severe AN than in previous studies since Japanese patients are likely to have a lower BMI than those in Western countries. While it may be difficult to generalize the results of a study conducted in Japan, it would be valuable to clarify the efficacy of CBT-E as a treatment package.

TRIAL REGISTRATION

UMIN, UMIN000048847. Registered 12 Sep 2022.

Increased prevalence of eating disorders in Japan since the start of the COVID-19 pandemic

PURPOSE

The study aimed to investigate the effect of the COVID-19 pandemic on the prevalence of eating disorders in Japan.

METHODS

We retrospectively reviewed the medical records of new patients with eating disorders who visited an outpatient eating disorders clinic of a single university hospital in Tokyo, Japan, from April 2020 to March 2021 (FY2020) and April 2019 to March 2020 (FY2019). We determined whether the onset or course in each patient in FY2020 was associated with the COVID-19 pandemic and classified COVID-19-associated medical histories into the following categories: (1) fatness phobia, (2) acceleration of dieting, (3) family relationships, (4) social factors, and (5) mood change. We performed the Kolmogorov-Smirnov test to compare the cumulative distribution of disease onset by month in FY2020 and FY2019.

RESULTS

We reviewed the records of 112 and 77 patients with eating disorders in FY2020 and FY2019, respectively. The onset or course of 35 patients (31.3%) in FY2020 was associated with the COVID-19 pandemic. We classified 14 patients to fatness phobia category, 11 to acceleration of dieting, 4 to family relationships, 2 to social factors, and 4 to mood change. No COVID-19-associated cases were associated with fear of contracting the disease. The cumulative distribution of disease onset differed significantly in FY2020 and FY2019 (D = 0.248; P = 0.007).

CONCLUSION

This chart review suggests that the COVID-19 pandemic may increase the prevalence of eating disorders.

LEVEL OF EVIDENCE

III, cohort study.

Eating Disorder Neuroimaging Initiative (EDNI): a multicentre prospective cohort study protocol for elucidating the neural effects of cognitive-behavioural therapy for eating disorders

INTRODUCTION

Anorexia nervosa is a refractory psychiatric disorder with a mortality rate of 5.9% and standardised mortality ratio of 5.35, which is much higher than other psychiatric disorders. The standardised mortality ratio of bulimia nervosa is 1.49; however, it is characterised by suicidality resulting in a shorter time to death. While there is no current validated drug treatment for eating disorders in Japan, cognitive-behavioural therapy (CBT) is a well-established and commonly used treatment. CBT is also recommended in the Japanese Guidelines for the Treatment of Eating Disorders (2012) and has been covered by insurance since 2018. However, the neural mechanisms responsible for the effect of CBT have not been elucidated, and the use of biomarkers such as neuroimaging data would be beneficial.

METHODS AND ANALYSIS

The Eating Disorder Neuroimaging Initiative is a multisite prospective cohort study. We will longitudinally collect data from 72 patients with eating disorders (anorexia nervosa and bulimia nervosa) and 70 controls. Data will be collected at baseline, after 21-41 sessions of CBT and 12 months later. We will assess longitudinal changes in neural circuit function, clinical data, gene expression and psychological measures by therapeutic intervention and analyse the relationship among them using machine learning methods.

ETHICS AND DISSEMINATION

The study was approved by The Ethical Committee of the National Center of Neurology and Psychiatry (A2019-072). We will obtain written informed consent from all patients who participate in the study after they had been fully informed about the study protocol. All imaging, demographic and clinical data are shared between the participating sites and will be made publicly available in 2024.

TRIAL REGISTRATION NUMBER

UMIN000039841.

Effectiveness of enhanced cognitive behavior therapy for bulimia nervosa in Japan: a randomized controlled trial protocol

Background

The effectiveness of psychotherapeutic interventions for eating disorders (EDs) is widely studied in Europe, North America, and Australia/New Zealand. However, few controlled studies and no randomized controlled trials (RCTs) have been conducted in Japan despite the relatively high prevalence of EDs in the Japanese population. The aim of this study is to evaluate the effect of enhanced cognitive behavior therapy (CBT-E), an evidence-supported ED-focused form of cognitive behavior therapy (CBT), for the treatment of bulimia nervosa (BN) in Japan.

Methods/design

This multicenter RCT will compare CBT-E with treatment as usual (TAU), which is widely used in Japan. A group of 140 adult outpatients with a Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) diagnosis of BN, ≥18 years of age, a body mass index (BMI) > 17.5 and < 40 kg/m² will be randomly assigned to CBT-E or TAU. Participants will be stratified by intervention site and BN severity. CBT-E participants will receive 20 sessions of focused form CBT-E for 20 weeks. Those in the TAU group will receive routine treatment provided by specialists. Assessment will be performed in a blinded manner prior to the start of treatment, after 6 weeks of treatment, at the end of treatment (20 weeks), and at follow-up at 40 and 80 weeks after the start of treatment. The primary outcome is the remission of BN, defined by the absence, in the previous 4 weeks, of symptoms required to meet the DSM-5 criteria for a diagnosis of BN. Secondary outcomes include the levels of ED psychopathology and impairment due to the ED, anxiety, depression, family function, and satisfaction with treatment.

Discussion

This will be the first RCT conducted in Japan to compare CBT-E and TAU for the treatment of BN. If CBT-E is found to be more effective than TAU, then the evidence would support its wider use for patients with BN in Japan. Because it is possible to train therapists who do not possess extensive specialist experience, wider use is also likely to be practically feasible. In addition, demonstrating the effectiveness of CBT-E in Japan would demonstrate that it could be successfully extended to additional world cultures and regions.

Trial registration

UMIN, UMIN000031625. Registered 7 Mar 2018.

Cryopreservation of in vitro Shoot Tips of Ulluco (Ullucus tuberosus Cal.) Using D Cryo-Plate Method

　　BACKGROUND: Maintenance of in vitro collections of ulluco (Ullucus tuberosus Cal.) is cumbersome and costly in an ex-situ genebank. An alternative method for long term preservation which is safe and cost-effective is required.

OBJECTIVE

To apply a novel cryopreservation procedure using the cryo-plate system to improve the long-term conservation of ulluco.

MATERIALS AND METHODS

Initially V and D cryo-plate methods were tested, subsequently the D cryo-plate method was selected for ulluco cryopreservation. The D cryo-plate procedures were optimized for post-LN regrowth procedures including cold-hardening, sucrose addition in alginate gel, and duration of LS treatment. Optimized procedures were tested with 11 ulluco lines.

RESULTS

Shoot tips were isolated from cold-hardened shoots for 3-4 weeks at 5 degree C were excised to 1.0-1.5 mm long and 0.5 mm wide and precultured for 16h at 25 degree C on MS with 0.3 M sucrose. The shoot tips were attached on the cryo-plates by alginate gel with 0.4M sucrose. The cryo-plates with attached shoot tips were treated with 2.0 M glycerol and 1.0 M sucrose solution for 90 min at 25 degree C and dehydrated on filter paper in a Petri dish by air current flow at 25 degree C for 45 min before direct immersion in LN. This optimized procedure was applied to shoot tips of 11 ulluco lines, resulting regrowth ranging from 73 % to 97 %, with an average of 90 % post-LN regrowth.

CONCLUSION

D cryo-plate is a practical and simple procedure for cryo-storage of in vitro grown ulluco shoot tips in an ex situ genebank.

Marked increase in the rate of ocular lens regeneration in the newt,Cynops pyrrhogaster, following partial body exposure to low dose X-rays

In recent years, concern over the stimulating effects of low-dose X-rays has been growing. Therefore, the effects of low-dose X-irradiation on lens regeneration in the newt were examined. Newts were subjected to sham or whole-body X-ray exposure at a dose of 0.2 Gy or 0.4 Gy, delivered at a rate of 0.43 Gy min(-1). The eyeballs were fixed in formalin solution, embedded in paraffin and assessed histologically. On day 14 after lens removal, unexposed animals showed the formation of a hollow epithelial vesicle of depigmented cells continuous with the laminae of the iris corresponding to the expected regeneration stage (Reyer's regeneration stage II). In contrast, lenses from newts exposed to a 0.2 Gy dose of X-rays showed some formation of the primary lens fibre nucleus corresponding to the fibre differentiation stage (Reyer's regeneration stage III-early). Thus, low-dose X-irradiation induced regeneration compared with the unexposed groups. An acceleration from Reyer's stage II to III-early was also found on day 14 following irradiation of only the upper belly, including the spleen. The effects of low-dose X-irradiation on lens regeneration may be mediated by changes in immune activity.

[Study on evaluation method of patient dose in diagnostic radiology required for introducing the guidance level: investigation of entrance surface dose of patient using direct measurement by TLD]

Using direct measurement, we investigated entrance surface doses of patients for routine radiographs in attempt to develop evaluation methods of patient dose in order to establish the guidance level in Japan. To date, patient doses have been evaluated by calculations based on radiographic conditions, or model experiments using phantoms. Their patient doses are then evaluated based on several assumptions. Direct measurement of patient dose is difficult to perform in many patients due to its time requirement, level of expertise required and difficulty in providing an explanation of the procedure to the patient. However, such direct measurement is essential since it incorporates all aspects of radiography from the radiographic equipment used, to the actual conditions of each patient without assumption. In this study, we examined the (1) need for introducing the guidance level, (2) controversial points in the calculation method for patient dose evaluation, (3) evaluation accuracy required for introducing the guidance level, and (4) necessity for a standardized method.

The local noise property in positron volume imaging and optimal conditions for the signal-to-noise ratio of the 3D reconstructed image

The local noise property of a 3D PET reconstructed image is investigated for a uniform-activity sphere distributed in a constantly attenuating spherical object. The positional dependence of the statistical noise is approximately derived and calculated for some special cases. It is suggested that a larger diameter of the activity sphere causes noise amplification, and the noise property for the large attenuating sphere is close to that for a non-attenuating object with the same total number of measuring counts. By considering noise propagation of two spherical activity distributions, we suggest that the signal-to-noise ratio of the image depends on a set of projection directions and the sizes and intensities of the activity distributions. In a simple case, we derive an optimal value of the maximum acceptance angle for the projection directions to improve the signal-to-noise ratio of the image.

[Response analysis for an approximate 3-D image reconstruction in cone-beam SPECT]

Cone-beam Single Photon Emission Computed Tomography (SPECT) offers the potential for a large increase in sensitivity as compared with parallel hole or fan-beam collimation. Three-dimensional image reconstruction was approximately accomplished by backprojecting filtered projections using a two-dimensional fan-beam algorithm. The cone-beam projection data were formed from mathematical phantoms as analytically derived line integrals of the density. In order to reduce the processing time, the filtered projections were backprojected into each planes parallel to the circle on which the focal point moved. Discrepancy of source position and degradation of resolution were investigated by computer simulation in three-dimensional image space. The obtained results suggest that, the nearer to the central plane or the axis of rotation, the less image degradation is performed. By introducing a parameter of angular difference between the focal point and fixed point in the image space during rotation, degradation of the reconstructed image can be estimated for any cone-beam SPECT system.

Cutaneous mucinosis associated with SLE--a case provoked by PUVA

A patient with SLE which was complicated by a characteristic cutaneous mucinosis is reported. The skin lesions were composed of intradermal soft nodules, purple-red plaques, and alopecia of the scalp. Acid mucopolysaccharides accumulated in each lesion. PUVA provoked an infiltrated skin lesion in which acid mucopolysaccharides were deposited in the dermis. Deposition of immunoglobulins and complements were also observed at the dermo-epidermal junction and on the vascular walls. Some immunological processes which may stimulate the synthesis of acid mucopolysaccharides in the dermis were suggested.

Molecular characteristics and physical state of human papillomavirus DNA change with progressing malignancy: studies in a patient with epidermodysplasia verruciformis

In order to establish the role of human papillomavirus (HPV) in carcinogenesis of epidermodysplasia verruciformis (EV), the presence, the molecular characteristics and the physical state of HPV DNA in a benign lesion, a primary carcinoma and a metastatic carcinoma developing in the same EV patient were studied and compared. Of the 2 HPV DNAs isolated from benign macular lesions, only one (a subtype of HPV 5) was detected in both primary and metastatic tumors. Only one normal species of viral DNA molecule was detected in the benign lesion, whereas most, if not all, viral DNA molecules present in the carcinoma (both primary and metastatic) were aberrant ones. The major viral DNA molecule in the primary carcinoma was a large HPV DNA with duplicated 40% subgenomic segments, and was present as free episomes. The major viral DNA molecule in the metastatic carcinoma was the 40% subgenomic segment itself, lacking the remaining 60% segment of the viral genome, and was integrated within cellular DNA. Thus, HPV DNA was present in tumors at any stage of malignancy, and its molecular characteristics and physical state changed not only with the development but also with the enhancement of malignancy, consistently conserving its defined 40% subgenomic segment as the predominant viral sequences. Our results suggest that HPV 5 may be actually involved in carcinogenesis in EV patients.

[Comparative clinical study of roxithromycin and josamycin for suppurative skin and soft tissue infections by a double-blind method]

The clinical efficacy and safety of Roxithromycin (RU 28965, RU), a new macrolide preparation, were compared with those of Josamycin (JM) in superficial suppurative skin infections. The study was designed as double-blind controlled trial with daily dosages of 300 mg in RU group and 1200 mg in JM group. A total of 209 cases (RU:105; JM:104) was analyzed and the final global improvement rating was 82.9% in the RU group and 80.8% in the JM group; there was no significant difference between the two groups. Slight adverse reactions were observed in 3.6% (4 cases) of the RU group and in 4.6% (5 cases) of the JM group. In conclusion, RU at daily doses of 300 mg is as effective as JM at daily doses of 1200 mg in superficial suppurative skin infections.

Two sisters with impetigo herpetiformis

Two sisters (non-twins) had impetigo herpetiformis triggered by their first pregnancy. One sister treated with etretinate had good resolution of skin disease. Impetigo herpetiformis is probably a variant of pustular psoriasis and may be provoked or precipitated by factors, such as pregnancy. Both patients shared common HLA antigens (All, AW24, BW44, BW54 and DR6Y).

Persistence of foam cells in rabbit xanthoma after normalization of serum cholesterol level

Xanthoma was produced in diet-induced hypercholesterolemic rabbits by intradermal dextran sulfate injections. The serum cholesterol level returned to the normal range at about 10 weeks after ending the cholesterol diet. Gross observations after cessation of the cholesterol diet revealed a decrease in xanthomatous infiltrations. However, the dense foam cell infiltrations and cholesterol accumulations showed no signs of regression at even 9 months after ending the cholesterol diet. Signs of foam cell migration into the blood stream were not observed. The persistence of the xanthoma may be due to a lack of acceptors, such as high-density lipoproteins, that remove the cholesterol from the foam cells. During our 9-month observation period, some foam cells were degenerated and a few were fused with each other to transform into Touton-type giant cells. Nonfoamy histiocytes were infiltrated around these degenerating foam cells. The histiocytes may have transformed into foam cells by incorporating the lipids of the degenerated foam cells.

[Count rate characteristics and count loss correction of Positologica II: a whole body positron emission tomograph]

This paper describes evaluation and correction of count rate characteristics of POSITOLOGICA II, a multi-slice whole body positron emission tomography system. The present study was performed using three phantoms; a 5 cm inner diameter, water-filled lucite cylinder, a 20 cm inner diameter, water-filled lucite cylinder and a chest phantom. After injection of high activity (about 1.85 GBq (50 mCi] of 13N ammonia into each phantom, rates of true coincidence, random coincidence and single photon detections were measured during decay of the isotope through more than two orders of magnitude of activity. At very high levels of activity, count rate characteristics of the system were saturated and limited to 660 kcps of total coincidence rate, which was the sum of rates in on-time and off-time windows, by the FIFO (first-in first-out) output frequency. Below those levels of activity the relationship between count loss and true coincidence rate was not unique but depended on the phantom configurations, suggesting that count loss correction using the above relationship was inadequate for quantitative study. However, the relationship between count loss and single rate was almost independent of the phantom configurations. Thus in conclusion count loss could be corrected using single rate for POSITOLOGICA II. A practical method of count loss correction was also proposed.

Stationary positron emission tomography and its image reconstruction

Feasibility of stationary positron emission tomography (PET) using discrete detectors has been investigated by simulation studies. To enable full utilization of detector resolution, a "bank array" of detectors is proposed and an EM algorithm is adopted for image reconstruction. The bank array consists of an odd number of detector banks arranged on a circular ring with a gap equal to one half the detector width. The EM algorithm [11] is used with some modifications for reducing the quantity of computation, improving the convergence speed, and suppressing statistical noise, so as to meet the present purpose. Simulation studies involving several phantoms show that the stationary PET with the new detector array provides image quality which is good enough for clinical applications. For fast dynamic studies with low spatial resolution, the convolution-backprojection method is efficient, but for high-resolution static imaging, resolution enhancement by an iterative method is required. Problems arising in the corrections for attenuation of photons and detector sensitivity, etc., are also discussed. A totally stationary PET avoids the mechanical problems associated with accurate movement of heavy assemblies and is particularly advantageous in gated cardiac imaging or in fast dynamic studies. Elimination of a scan along the detector plane allows a quick scan in the axial direction to achieve three-dimensional imaging with a small number of detector rings.

[Double-blind comparison of cefadroxil and cephalexin granules in the treatment of impetigo]

A double-blind clinical comparison of cefadroxil granules (CDX) and a long-acting preparation of cephalexin granules (L-CEX) was conducted in the treatment of impetigo in children. The long-acting cephalexin preparation was composed of 3 parts of granules soluble in the stomach and 7 parts of those soluble in the intestine. Drugs were administered at 3 different doses depending on the body weight of patients (Group I: less than 10 kg, Group II: between 10 kg and 20 kg, Group III: over 20 kg). Overall clinical evaluation by attending doctors: CDX group scored slightly better but not statistically significant results. Evaluation of usefulness: CDX group scored slightly better but not statistically significant results. Partially standardized evaluation: CDX scored statistically significantly higher points in the evaluation of total cases and Group II on Day 5, and Group II on Day 7. Cumulative points through Day 5 and Day 7 were not statistically significant. Follow-up evaluation by attending doctors: CDX group got a better result in total cases and Group II on day 3, and in total cases on days 5 and 7. Otherwise there was no statistically significant difference. Incidence of side effects was not significantly different between the 2 drug groups. As shown in Fig. 1, CDX was administered on rising in the morning, after lunch, and at bed time whereas L-CEX was given on rising and at bed time when the patients were relatively in fasting condition. This may have reduced the expected merit of L-CEX and some reserve is required in the interpretations of the results shown herein.

[Experimental studies of cefmetazole in the field of dermatology]

Cefmetazole was studied experimentally in the field of dermatology. The following results were obtained. 1. The in vitro antibacterial activities of cefmetazole against S. aureus and S. epidermidis were studied. Most strains of both staphylococci were inhibited by 1.56 micrograms/ml or less of cefmetazole. 2. Serum and skin concentrations of cefmetazole in rats were studied after intramuscular administration of 20 mg/kg of cefmetazole. Mean serum concentrations were 40.3, 21.5, 7.1, 0.56 micrograms/ml respectively at 0.25, 0.5, 1 and 2 hours, and the corresponding skin concentrations were 12.5, 6.1, 0.62, 0.61 micrograms/g (n = 4).

[Experimental and clinical studies of fortimicin in the field of dermatology]

1. Fortimicin (KW-1070) was found to be similar to amikacin in vitro activity against S. aureus of 27 strains and S. epidermidis of 17 strains isolated in dermatological field. 2. Serum and skin levels of the drug were determined in rats. Mean serum levels (n = 4) were 4.91 mcg/ml at 1/4 hour, 2.40 mcg/ml at 1/2 hour, 2.40 mcg/ml at 1 hour and 0.51 mcg/ml at 2 hours. The corresponding skin levels were 2.15 mcg/g, 2.27 mcg/g, 0.83 mcg/g and 0.19 mcg/g. 3. Seven cases with dermatological infections were treated with fortimicin. No side effects were observed both in subjective and in laboratory findings.

Analytical study of the performance of a multilayer positron computed tomography scanner

The image-forming performance of multilayer positron tomographs for extended sources is evaluated analytically. The analysis is simplified by "rotation transform," by which three-dimensional photon detection problems are solved by two-dimensional treatment. Event rates of singles, unscattered true coincidence, and a single- and double-scattered coincidence are formulated for a uniform cylinder phantom as functions of various design parameters. Angle factors for Compton scattering and other parameters used in the evaluation are presented. Scatter components in projections and their effect on the reconstructed images are also evaluated. The scatter component in the reconstructed image depends critically on the detector ring radius, phantom radius, method of attenuation correction, etc. When the director radius is relatively small (40 or approximately 45 cm in diameter), the scatter/true ratio at the image center of a 20 cm diameter phantom may be larger than the scatter/true ratio in the event rates. Comparison with experimental data obtained with a head positron tomograph, POSITOLOGICA, showed reasonable agreement both in the total coincidence rates and in the scatter components in the images for a cylindrical phantom of 20 cm in diameter.

[Clinical use of amoxicillin preparation with prolonged activity in dermatology (author's transl)]

C-AMOX was administered to adult patients of acute bacterial skin infection at the dosage of 500 mg 2 times a day after meals in the morning and in the evening. Evaluation was done in 4 grades, i.e. excellent, good, fair and poor. Of 42 cases treated, excellent was marked in 11 cases and good was in 14 cases. Percentage of excellent and good results was 59.5%. Fair results being included, the percentage rises to 83.3%. As subjective side effects, stomach trouble (including stomachache) were observed in 2 cases and diarrhea, perleche, rash, nausea and loss of appetite were each 1 case.

[Use of cefroxadine dry syrup in the management of acute skin infections in children (author's transl)]

1. Cefroxadine dry syrup was in principle administered at the dosage of 10 mg per kilogram of body weight 3 times a day. 2. Evaluation was done in 4 grades, i.e. excellent, good, fair and poor. 3. According to subjective judgement by attending doctors, 'excellent' or 'good' was recorded in 90.7%. 4. If the evaluation was partially standardized, 'excellent' or 'good' was obtained in 74.8% of total 163 cases and in 78.7% of 108 impetigo cases. 5. Side effects were observed in 3 cases (diarrhea 1, fever 2). No direct correlation of these complaints with the administration of the present drug was confirmed.

Cholesterol synthesis and esterification in experimental xanthoma tissues

We studied cholesterol metabolism in experimental xanthoma tissues which were induced by injection of high molecular weight sodium dextran sulfate into the dermis of hypercholesterolemic rabbits. Control studies were performed on dermal specimens of the dextran sulfate-injected site of normolipemic rabbits. Cholesterol accumulation was much greater in the hypercholesterolemic rabbit tissues than in the normolipemic rabbit tissues. Histiocytes and foam cells in such lesions had an ability to synthesize cholesterol. However, cholesterol synthesis was suppressed in the cholesterol-rich tissues of hypercholesterolemic rabbits. This suppression was obviously caused by the accumulation of cholesterol in the tissues which take up lipoprotein in hypercholesterolemic rabbits. On the other hand, esterification of cholesterol was greater in the hypercholesterolemic rabbit tissues than in the normolipemic rabbit tissues. Cholesterol was esterified more selectively with oleic acid than with palmitic acid. Therefore, cholesteryl oleate increased in the tissues concomitantly with the accumulation of cholesteryl esters. Fatty acids of serum origin rather than those synthesized in situ were more important in the esterification process. It was suggested that cholesterol esterification was mediated by acyl-coenzyme A:cholesterol acyltransferase and that lecithin:cholesterol acyltransferase contributed little to the process.

New Anger scintillation cameras with improved count rate capability

This paper proposes scintillation cameras which can handle input pulse rates beyond 1 Mcps with negligible as spatial resolution and energy resolution at low pulse rates. The cameras are based on the "variable sampling-time technique", in which phototube current pulses are first shortened in width and then selectively integrated by gated integrators followed by sample-and-hold circuits. The period of integration before sampling is not fixed but shortened by the arrival of the following pulse to keep a high pulse-pair time resolution. An approximate expression for the count rate characteristics has been derived, and its validity was confirmed by Monte Carlo simulation. The results indicates that the maximum observed count rate will reach 420-520 kcps with an energy window fraction of 0.5 for typical design parameters.

Demonstration of immunoglobulin G in normal human epidermis by peroxidase-labeled antibody

Cytoplasmic immunoglobulin G (IgG) in normal human epidermis was defined by a peroxidase-labeled antibody method. A correlation between cytoplasmic staining and the serum level of IgG was found. Epidermal cells containing IgG were not present when the serum level of IgG was less than 1000 microgram/ml.

A semiquantitative measurement of anti-nuclear antibody using immuno-microfluorimetry

1. Using microfluorimetry, the strength of fluorescence was measured on fluoresceinated anti-nuclear antibody of SLE sera. The indirect "Sandwich" method was applied using human peripheral lymphocytes as substrates tissue. 2. The results of using three FITC-labelled anti-human IgG conjugates of different types were compared with each other. 3. More specific and more consistent results were obtained with conjugates with a lower F/P ratio and lower antibody and protein concentration that those in the case of conjugates with a higher F/P molar ratio and higher antibody and protein concentration. 4. The immuno-microfluorimetric technique is very useful for the objective determination of the results of fluorescence microscopy and for the comparison of conjugates of different qualities.

Prolidase deficiency: its dermatological manifestations and some additional biochemical studies

Prolidase deficiency occurred in a 13-year-old girl. Determinations were made of prolidase and prolinase activities in cultured fibroblasts, and thin layer chromatographic studies of skin prolidase were performed. The patient had chronic, recurrent ulcers on the legs and feet, diffuse telangiectasia, shallow scar-like atrophic lesions on the face and arms, soft and thin abdominal skin, and premature gray hairs. Prolidase in the patient's skin fibroblasts was absent. Greatly reduced prolidase activity was demonstrated in the patient's skin. A review of hitherto reported cases of this disease showed such skin manifestations as (1) skin ulceration or skin fragility with scar formation, (2) purpuric lesions, (3) telangiectasia and/or photosensitivity, and (4) thickening of the skin with lymphedema.

Epidermodysplasia verruciformis: viral particles in early malignant lesions

Two cases of epidermodysplasia verruciformis were studied histologically and electron microscopically. Four lesions examined were histologically benign, and had viral particles morphologically similar to that of common human warts. Two lesions on the forehead and the face were histologically in the stages of malignant transformation, the intraepidermal epithelioma and the early invasive squamous cell carcinoma. Similar viral particles were also observed in the upper layers of these 2 lesions. These results suggest that at least some of the virus-induced lesions of epidermodysplasia verruciformis actually become malignant.