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.

Caste-specific microRNA expression in termites: insights into soldier differentiation

Eusocial insects have polyphenic caste systems in which each caste exhibits characteristic morphology and behaviour. In insects, caste systems arose independently in different lineages, such as Isoptera and Hymenoptera. Although partial molecular mechanisms for the development of eusociality in termites have been clarified by the functional analysis of genes and hormones, the contribution of microRNAs (miRNAs) to caste differentiation is unknown. To understand the role of miRNAs in termite caste polyphenism, we performed small RNA sequencing in a subterranean termite (Reticulitermes speratus) and identified the miRNAs that were specifically expressed in the soldier and worker castes. Of the 550 miRNAs annotated in the R. speratus genome, 74 were conserved in insects and 174 were conserved in other termite species. We found that eight miRNAs (mir-1, mir-125, mir-133, mir-2765, mir-87a and three termite-specific miRNAs) are differentially expressed (DE) in soldiers and workers of R. speratus. This differential expression was experimentally verified for five miRNAs by real-time quantitative PCR. Further, four of the eight DE miRNAs in soldier and worker termite castes were also differentially expressed in hymenopteran castes. The finding that Isoptera and Hymenoptera shared several DE miRNAs amongst castes suggests that these miRNAs evolved independently in these phylogenetically distinct lineages.

Subcutaneous Xenotransplantation of Hybrid Artificial Pancreas Encapsulating Pancreatic B Cell Line (MIN6): Functional and Histological Study

The biohybrid artificial pancreas is designed to enclose pancreatic endocrine tissues with a selectively permeable membrane that immunoisolates the graft from the host immune system, allowing those endocrine tissues to survive and control glucose metabolism for an extended period of time. The pancreatic B cell line MIN6 is established from a pancreas B cell tumor occurring in transgenic mice harboring the human insulin promoter gene connected to the SV40 T-antigen hybrid gene. It has been proven that glucose-stimulated insulin secretion in MIN6 cells retains a concentration-dependent response similar to that of normal islets. In this study, we performed the histological and functional examination of three-layer microbeads employing MIN6 cells after subcutaneous xenotransplantation to evaluate this device as bioartificial pancreas. MIN6 cells were microencapsulated in three-layer microbeads formulated with agarose, polystyrene sulfonic acid, polybrene, and carboxymethyl cellulose. Microbeads were xenogenically implanted in the subcutaneous tissue of the back of Lewis rats with streptozotocin-induced diabetes. One week after implantation, microbeads were retrieved and cultured for 24 h before the static incubation. There was no evidence of adhesion to the graft and the fibrosis in the transplantation site as determined by gross visual inspection. Microscopic examination demonstrated that retrieved microbeads maintained normal shape, containing intact MIN6 cells. Histological study showed that these MIN6 cells in the microbeads appeared to be viable without cellular infiltration within or around the microbeads. Immunohistochemical analysis of the microbeads clearly revealed the intense staining of insulin in the cytoplasm of encapsulated MIN6 cells. Insulin productivity of MIN6 cells in the microbeads is strongly suggested to be preserved. In response to 16.7 mM glucose stimulation, static incubation of microbeads 1 wk after implantation caused the 2.3 times increase in insulin secretion seen after 3.3 mM glucose stimulation (84.3 ± 10.0 vs. 37.4 ± 10.7 μU/3 × 106 cells/hr, n = 5 each, p < 0.01). This study demonstrates that three-layer microbeads encapsulating MIN6 cells retain excellent biocompatibility and maintain good insulin secretion even after subcutaneous xenotransplantation, suggesting the possible future clinical application of this unique bioartificial pancreas to subcutaneous xenotransplantation.

Midterm outcome of total hip arthroplasty for rapidly destructive coxarthrosis

PURPOSE

To compare the midterm outcome in 12 women who underwent total hip arthroplasty (THA) for rapidly destructive coxarthrosis (RDC) and in 12 controls who underwent THA for osteoarthritis.

METHODS

Records of 12 women aged 50 to 80 (mean, 72.3) years who underwent THA for RDC after a mean of 9 (range, 4-11) months since symptom onset were reviewed. They were compared with 12 age-and sex-matched controls who underwent THA for primary or secondary osteoarthritis. Acetabular bone deficiency of the 12 RDC patients was classified as type I (n=7), type II (n=4), or type III (n=1). Type I was treated with cementless THA, and types II and III were treated with THA with a cemented acetabular component. The femoral component was cementless. Pre- and post-operative Harris Hip Score was assessed. Radiographs of the hip were evaluated for implant migration, osteolysis, and periprosthetic radiolucency in the acetabulum and proximal femur.

RESULTS

The 12 women who underwent THA for RDC and the 12 controls who underwent THA for osteoarthritis were comparable in terms of pre-, intra-, and post-operative parameters. After a mean follow-up of 9.3 years, the mean Harris Hip Score improved from 38.3 to 81.1 in RDC patients and from 43.6 to 84.2 in controls (p=0.13). One RDC patient had dislocation but did not require revision surgery. One RDC patient developed a radiolucent line <2 mm in zones 1 and 7 of the femoral component, but no migration occurred. No patient had progression of bony destruction, loosening, osteolysis, migration, or radiolucency of the acetabular component.

CONCLUSION

Despite the rapid destruction of the acetabulum and femoral head in RDC patients, cemented or cementless THA achieved a good midterm outcome comparable to that for patients with primary or secondary osteoarthritis.

Development and evaluation of 'disaster preparedness' educational programme for pregnant women

PURPOSE

The objective of this study is the development and evaluation of the usability of an educational programme that teaches disaster preparedness to pregnant women.

METHODS

This intervention study examined an intervention group that attended an educational programme and a control group that did not. The subjects were pregnant women in their second trimester. The programme was developed with prior studies and evaluated by self-administered questionnaires that asked about disaster preparedness. The questionnaire was administered twice to the participants in both groups: to the intervention group just before the childbirth class and 1 month after the class, and to the control group at the time of their maternity examination and 1 month afterwards. Two hundred twenty-six members of the intervention group and 262 members of the control group responded to both questionnaires. Of these, 99 of the intervention group and 104 of the control group were primiparous without disaster experience, and the programme was evaluated by comparing these two groups. Effects due to the disaster experience were also analysed within the intervention group.

RESULTS

Among primiparous without disaster experience, an intervention effect was found in items concerning awareness modification (five of six items) and behaviour modification (three of seven items). The intervention effect was particularly pronounced in a comparison of primiparous without disaster experience.

CONCLUSIONS

An intervention effect was found among the pregnant women who took the programme. In particular, it was statistically significant among primiparous without disaster experience, which suggests that the programme should be shaped to reflect this subject demographic.

Activity of retreatment with sorafenib for metastatic renal cell carcinoma

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Background: Treatment options for metastatic renal cell carcinoma (mRCC) have increased. Complete remission is, however, rarely seen and patients are treated with multiple sequential therapies. We assessed clinical activity of sorafenib rechallenge after progressing on other therapies.

Methods: Patients with mRCC who received a second course of sorafenib therapy after failure of prior sorafenib and other agents were retrospectively identified. RECIST-defined objective response rate and progression-free survival (PFS) and toxicity were analyzed.

Results: Fourteen patients with mRCC who were retreated with sorafenib were identified and twelve patients were assessable for this study. 92% were male. Median age at first systemic therapy was 63 years. Prior nephrectomy was performed in 92% of patients. 42% of patients had favorable or intermediate risk, 17% poor, and the rest not available per MSKCC criteria. Eighty-three percent of patients were treated with other agents before initial sorafenib therapy, including 75% interferon-alpha (IFN-alpha), 50% interleukin-2 (IL-2), and 17% sunitinib. First sorafenib therapy began a median of 9.0 months after the diagnosis of mRCC and produced a clinical benefit (PR + SD) rate of 75% and a median PFS of 5.0 months. 67% of patients discontinued initial sorafenib for disease progression and 33% for adverse events. Interval between discontinuation of initial sorafenib and rechallenge was a median of 7.6 months. During the intervening period, 50% of patients were treated with sunitinib, 33% with everolimus, 25% with VEGFR1 vaccine, and others. Clinical benefit rate of 67% and a median PFS of 4.3 months were obtained on sorafenib rechallenge. There was no significant difference in outcome to sorafenib rechallenge based on duration between sorafenib treatments or number or type of intervening treatments. No new severe toxicity was observed during rechallenge.

Conclusions: Sorafenib rechallenge has potential to achieve clinical benefits, is well-tolerated, and may be considered after multiple sequential therapies in select mRCC patients.

No significant financial relationships to disclose.

Serum selenium and risk of prostate cancer in Japanese men

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Background: Epidemiologic studies suggest that low selenium levels are associated with an increased incidence of prostate cancer, although results are conflicting. We examined the association between serum selenium levels and risk of prostate cancer in men who received a prostate biopsy in our hospital. Methods: Our prospective study included 82 patients who received a prostate biopsy based on elevated PSA levels over 4.0ng/ml. Serum from each patient was sampled to determine the selenium level at the time of biopsy. Of these, 47 patients were diagnosed with prostate cancer (case group) and no malignant lesions in the biopsy specimen were detected in the remains, 35 patients (control group). Results: The mean serum selenium levels in the case and control group were 120.4 (SD, 14.4) ng/mL and 118.5 (SD, 16.1) ng/mL, respectively (p = 0.588). Serum selenium levels at biopsy were not associated with risk of prostate cancer diagnosis. In the case group, the mean serum selenium levels in patients diagnosed with 6 or less in Gleason score and 7 or more were 121.0 (SD, 9.9) ng/mL (n = 14) and 120.1 (SD, 16.1) ng/mL (n = 33), respectively (p = 0.851). Serum selenium levels at biopsy were not associated with Gleason score in the case group. An inverse association between serum selenium and PSA levels at biopsy was observed (p = 0.030). No correlation was observed between serum selenium level and age at biopsy. Conclusions: From this study, serum selenium level cannot predict the result of prostate biopsy. The inverse association between serum selenium and PSA levels may suggest that low selenium levels are associated with an increased incidence of prostate cancer.

No significant financial relationships to disclose.

Genomic drift and copy number variation of chemosensory receptor genes in humans and mice

Recent studies about the structural variation of genomic sequences have shown that there is a large amount of copy number variations (CNVs) of genes within species. Analyzing Redon et al.'s (2006) crude data on copy number variable regions (CNVRs), we previously showed that CNVs are particularly high for chemosensory receptor genes in human populations. In this paper, we reanalyzed the CNVs of these genes using more refined data by Perry et al. (2008). The results showed that the extent of CNVs is somewhat lower in this dataset than in the previous one, but that the extent is still substantial for olfactory receptor (OR), vomeronasal receptor (VR), and taste receptor (TR) genes. We also studied the CNVs for chemosensory receptor genes in mice, using CNVR data obtained from inbred strains. It was found that the extent of CNVs is quite substantial but is lower than that for human populations. However, because the mouse data came from inbred strains and might be biased, this conclusion should be regarded as tentative. Despite this reservation, the distribution of gene copy number for the OR gene family was approximately normal in both humans and mice, suggesting that genomic drift caused by random duplication and deletion of genes plays important roles in determining the evolutionary change of chemosensation.

Inhibition of donor-derived T cells trafficking into target organs by FTY720 during acute graft-versus-host disease in small bowel transplantation

In small bowel transplantation (SBTx), graft-versus-host disease (GVHD) is mediated by donor-derived T cells recognizing host major histocompatibility complex (MHC) alloantigens, and represents an important immunological event influencing life in experimental and clinical situations. We evaluated the possibility that a new sphingosine 1-phosphate receptor agonist, FTY720, could diminish GVHD in a rat SBTx model through traffic alteration of donor-derived T cells in target organs. Heterotopic SBTx was performed using a parent (WF)-into-F(1) (WF x ACI) rat combination. Recipient survival, body weight, histopathology, donor-derived T cell subpopulation and cytokine production were compared with untreated controls. FTY720 inhibited lethality and histopathological changes in target organs when administered at 0.5 mg/kg, possibly due to sequestration of donor-derived T cells in the intestinal graft. FTY720 caused a significant reduction in donor T cell numbers in target organs by promoting these cells to home into donor, but not recipient, secondary lymphoid tissues. FTY720 significantly decreased production of interferon (IFN)-gamma in target organs. These findings indicate that FTY720 effectively reduced recirculation of activated donor-derived T cells and recruitment to target organs in GVHD, and was also associated with down-regulated IFN-gamma production. These properties may offer the potential to treat ongoing GVHD in SBTx.

Regulation of Donor T Cells in the Tolerant Rats to Graft-Versus-Host Disease by FTY720 Following Small Bowel Transplantation

AIMS

The potency of immunosuppression is a critical factor in small bowel transplantation (SBTx). FTY720 altered lymphocyte trafficking and prevented the donor T cells from migrating into target organs, resulting in the prolongation of recipient survival in acute graft-versus-host disease (GVHD) of SBTx. However, the effect of FTY720 on donor T cells in the chronic phase of GVHD following SBTx remains unclear.

METHODS

Heterotopic SBTx was performed in a WF-to-F1 (WF x ACI) rat combination. Recipients were given FTY720 for 14 days after SBTx. The subpopulations of donor-derived T cells and the cytokine production in the target tissues were evaluated on postoperative day 150.

RESULTS

FTY720 treatment significantly prolonged recipient survival over 150 days without any clinical signs of GVHD. The numbers of donor-derived CD4+ and CD8+ T cells in the peripheral blood, mesenteric lymph nodes, and Peyer's patches of recipients were maintained at low levels on postoperative 150, which were almost similar to the levels on postoperative day 14. In the host lamina propria, however, a significant higher number of donor T cells (CD4+, 18.4 +/- 4.3 x 10(4); CD8+, 13.9 +/- 3.6 x 10(4)) were still observed on postoperative day 150. Production of interferon-gamma was significantly reduced in target tissues by FTY720 treatment both in the acute and chronic phase. However, interleukin-4 and interleukin-10 production, which was significantly higher on day 14, returned to the level of naive rats in the chronic phase.

CONCLUSIONS

A 14-day treatment of FTY720 induced tolerance in our SBTx model. Down-regulation of both Th1 and Th2 immune response was observed in the chronic phase.

Endoanal ultrasonography in the diagnosis and operative management of perianal endometriosis: report of two cases

We report two cases of perianal endometriosis in which we were greatly assisted by endoanal ultrasonography. Patient 1 was a 43-year-old woman with perianal pain. Endosonography showed a hypoechoic mass in the anterior perianal region without involvement of the anal sphincter. Local excision was performed under spinal anesthesia without damage to the anal sphincter. Patient 2 was a 30-year-old woman with perianal pain coinciding with her menstrual period. Endosonography showed a heterogeneous mass containing cystic anechoic areas in the right anterior perianal region and involving the external anal sphincter. Wide excision, including the episiotomy scar and part of the external anal sphincter, and primary sphincteroplasty were performed under spinal anesthesia. According to our experience, preoperative endosonography is a reliable technique for visualizing perianal endometriosis and for diagnosing anal sphincter involvement. Operative management should be determined on the basis of preoperative and intraoperative ultrasonographic assessment.

Beneficial effects of pancreas transplantation: regeneration of pancreatic islets in the spontaneously diabetic Torii rat

AIMS

Type 2 diabetes is characterized by a combination of insulin resistance and pancreatic beta-cell dysfunction. Although pancreas transplantation (PTx) is mainly performed in patients with type 1 disease, both clinical and experimental data have demonstrated that PTx improves insulin sensitivity in type 2 diabetic recipients. However, it remains unclear whether PTx has the potential to induce islet neogenesis in a recipient's native pancreas.

METHODS

Nondiabetic 10-week-old and diabetic (defined as blood glucose level >250 mg/dL) 25-week-old (average onset age of diabetes) male spontaneously diabetic Torii (SDT; RT1(a)) rats served as donors and recipients, respectively.

RESULTS

In nontreated control SDT rats, beta-cell mass gradually decreased and blood glucose levels progressively increased (>600 mg/dL after 40 weeks of age). In PTx rats, however, the onset of diabetes was significantly delayed (>47.5 +/- 18.2 [graft age] versus 25.2 +/- 3.9 weeks in control rats). On immunohistochemical staining, insulin-secreting islets were observed in the naive pancreata of 40-week-old recipients with PTx (PTx40w), whereas no islets were found in 40-week-old control SDT rats. Moreover, the islets in the native pancreata of PTx40w recipients were located close to ductal structures, and PDX-1 (pancreatic duodenal homeobox-1)-positive cells were more clearly visible. These results indicate the possibility of beta-cell regeneration in the recipient native pancreas by avoiding glucose toxicity under normoglycemic condition achieved by PTx.

CONCLUSIONS

Pancreas transplantation has beneficial effects on impaired islet, inducing regeneration in the spontaneously diabetic Torii rat.

New immunosuppression with monoclonal antibody to intracellular adhesion molecule 1 (ICAM-1) in rat organ transplantation

Inbred, male Lewis rats underwent heterotopic heart allografting from F344 donor rats, or streptozocin (STZ)-induced diabetic Lewis rats underwent pancreas allografting with bladder drainage from F344 or ACI donor rats. A monoclonal antibody (MoAb) to intracellular adhesion molecule 1 (ICAM-1) was given i. p. (1.0 mg/kg) for 10 days, and its immunosuppressive potency was evaluated. The mean survival time (MST) of the heart allografts was significantly prolonged in the MoAb-treated group. Both exocrine and endocrine MST of pancreas allografts were also prolonged by MoAb administration across the minor and major histocompatibility barriers. However, complete graft tolerance was not induced. Our study demonstrated that the MoAb to ICAM-1 alone can delay the allograft rejection in rat organ transplantation.

Pharmacokinetic and pharmacodynamic analysis of TS-943, a selective non-peptide platelet glycoprotein-IIb/IIIa (GPIIb/IIIa) receptor antagonist, using a nonlinear mixed effect model in dogs

A simultaneous analysis of the pharmacokinetics and pharmacodynamics of TS-943, a selective nonpeptide platelet glycoprotein-IIb/IIIa (GPIIb/IIIa) receptor antagonist, was made in dogs using a nonlinear mixed effect model. Plasma concentrations of TS-943 were determined after bolus intravenous injection, constant infusion and bolus plus constant infusion. Pharmacokinetic/pharmacodynamic data were fitted using NONMEM software. The pharmacokinetics of TS-943 fitted a two-compartment open model with first-order elimination. The pharmacodynamic model that best fitted platelet aggregation was an inhibitory sigmoid Emax model. The final estimates for E0 (baseline effect), Emax (maximum effect), IC50 (50% inhibitory concentration) and gamma (Hill coefficient) were 66.3%, 64.3%, 104 ng mL(-1) and 1.37, respectively. Correlations between TS-943 plasma concentration and extension of template bleeding time were examined by fitting with an exponential model. The TS-943 plasma concentration necessary to double bleeding time (C2-BTE) was approximately 209 ng mL(-1). The model estimated that the C2-BTE/IC50 (inhibition of platelet aggregation) ratio was approximately 2.0-fold in dogs. Our results suggest that the ratio values for dogs and man are comparable. A nonlinear mixed effect model was a useful tool for exploring the concentration-effect relationship for both efficacy and safety of TS-943 in dogs and man. In this study, the dog was found to be a useful model for screening of efficacy and safety of TS-943 in man.

Isolation, culture, and characterization of endocrine cells from 6-month-old porcine pancreas

Porcine endocrine cells were isolated from pancreas of 6-month-old pigs by two-step enzymatic digestion procedures. They were separated by the density gradient (isopycnic) centrifugation method using Histopaque-1077. Isolated cells were cultured and divided into two groups: suspension cells and adhesion cells. Suspension cells maintained their cell numbers on and after 7 days in culture. Approximately 1 x 10(7) cells were obtained from single pancreas of a 6-month-old pig. The cultured suspension cells took up dithizone (DTZ) staining 14 days after isolation in culture and indicated the presence of beta-cells. In in vitro study, the suspension cells were capable of secreting insulin into the culture medium. The suspension cells were tested for insulin and glucagon staining by Western blot analysis. These results indicated the maintenance of endocrine cell function after isolation. However, cultured adhesion cells failed to maintain their function during culture. In in vivo study, the suspension cells were transplanted into diabetes-induced nude mice. Reduction in blood glucose level was obtained after transplantation. Intraperitoneal glucose tolerance test (IPGTT) results showed a normal pattern of blood glucose clearance. After 1 week, the transplanted endocrine cells were detected with anti-insulin antibody by immunostaining and it showed the presence of viable beta-cells under the renal capsule of nude mice. Collectively, our results suggest that isolated and cultured suspension porcine endocrine cells maintained their endocrine function. These endocrine cells can be used as isolated islets for further study, including transplantation experiments.

Evaluation of insulin secretion of isolated rat islets cultured in extracellular matrix

Islet isolation involves enzymatic digestion of the interstitial matrix and mechanical disruption of the tissue. It is possible that a fundamental change of islet biology resulting from the loss of critical factors required for islet function or survival will occur. Extracellular matrix (ECM) is one of the most important components of the islet microenvironment. Reconstruction of the cell-matrix relationship seems to be effective for improving the loss of differentiated islet structure and function. The purpose of this study was to characterize and compare the effects of collagen gel mixture or Matrigel on beta-cell function and islet cell survival. After isolation by the collagenase digestion technique, rat islets were divided and cultured with various types of collagen gel mixture. They were assessed for their glucose-stimulated insulin secretion and cell viability. Glucose-induced insulin secretion of islets cultured with collagen type I gel or a mixture of collagen type I and IV was improved after 11 days in culture. In conclusion, a type of gel composed of collagen type I and/or type IV as an islet microenvironment is sufficient to maintain glucose responsiveness and may be useful for islet transplantation.

Development of a new method to induce angiogenesis at subcutaneous site of streptozotocin-induced diabetic rats for islet transplantation

The subcutaneous space is a potential site for clinical islet transplantation. Even though there are several advantages, poor blood supply at this site mainly causes failure of islet survival. In this study, angiogenesis was induced in advance at the diabetic rats subcutis for islet transplantation by implanting a polyethylene terephthalate (PET) mesh bag containing gelatin microspheres incorporating basic fibroblast growth factor (bFGF) (MS/bFGF) and a collagen sponge. The bFGF was incorporated into gelatin microspheres for controlled release of bFGF. As controls, a PET mesh bag with or without either collagen sponges or MS/bFGF was implanted at the subcutaneous site of diabetic rats. Macroscopic and microscopic examinations revealed the formation of capillary network in and around the PET mesh bag containing MS/bFGF and collagen sponges 7 days after implantation when compare with other control groups. When tissue hemoglobin level was also measured, a significantly high level of hemoglobin amount was observed compared with that of control groups. When allogeneic islets mixed with 5% agarose were transplanted into the prevascularized rat subcutis, normoglycemia was maintained for more than 40 days, while other control groups were ineffective. This study demonstrated that combination of gelatin microspheres incorporating bFGF and collagen sponges enabled the mesh to induce neovascularization even at the subcutaneous site of streptozotocin-induced diabetic rats, resulting in improved function of islet transplantation.

Wear of resin-modified glass ionomers: an in vitro study

The purpose of this study was to evaluate the wear resistance and clinical applicability of resin-modified glass ionomer cements as restorative or fissure-sealing materials. The in vitro wear of resin-modified glass ionomers was compared to conventional glass ionomers, a resin-based sealant, and a composite resin. A three-body wear test (enamel block--polymethylmethacrylate powder--experimental dental material) was performed by 20,000 cycles with a load of 4 kgf/cm2. The depth of wear of the experimental materials was measured and calculated using a computerized laser surface scanner. The glass ionomers generally showed more wear than the resin-based sealant and the composite resin, but there was no difference in wear between resin-modified and conventional glass ionomers. Type III ionomers (used for sealant) showed lower wear resistance than type II ionomers (used for restoration).

Rotational acetabular osteotomy for acetabular dysplasia

Between 1986 and 1990, we carried out 55 rotational acetabular osteotomies in 54 patients with acetabular dysplasia. Five hips were lost to follow-up. Of the 50 remaining, the degenerative changes were classified according to the criteria of Tönnis as grade 0 in 23, grade 1 in 16 and grade 2 in 11. The mean age of the three men and 46 women at the time of operation was 31.8 years (13 to 53). The mean follow-up was 137 months (120 to 174).

At the most recent follow-up, 48 patients had satisfactory relief from pain. There was a slight decrease in the range of movement, particularly of flexion, in 18 hips. Radiologically, all osteotomies had united satisfactorily. There was radiological evidence of improvement in degenerative changes in 13 hips (5 grade 1 and 8 grade 2). Ten deteriorated (5 grade 0, 3 grade 1, and 2 grade 2) and one required total hip arthroplasty ten years after osteotomy. The osteoarthritis in the two hips with an associated valgus osteotomy progressed. The changes in radiological indices such as the centre-edge angle, acetabular femoral head index, acetabular root obliquity and horizontal or vertical displacement of the femoral head showed no statistical difference (unpaired Student’s t-test) between the patients with radiological progression and those with and without improvement.

Visualization of signal propagation from sciatic nerve to spinal cord in canine

The neuroelectric activity that ascends the sciatic nerve and moves to the spinal cord was visualized by measuring the magnetic compound action fields (CAFs) with a superconducting quantum interference device gradiometer. The sciatic nerve of a dog was stimulated electrically, and propagating evoked CAFs were measured non-invasively. Isomagnetic field maps were made on the basis of this data, and the signal propagation was visualized. The evoked magnetic fields presented a quadrupole consisting of two elements: depolarization and repolarization. Measuring the magnetic CAFs of the sciatic nerve on the body surface enabled us to visualize the non-invasively the signal movement continuously from the sciatic nerve to the spinal cord.

Syngeneic consecutive rat spleen transplantation bearing infantile testis

Seventy-seven Lewis adult rats received autologous testicular implants in the spleen. These spleens were retransplanted in a consecutive transplant fashion as we described earlier. Some were observed as long as 26 to 27 months. Although earlier splenic-testicular transplants showed benign granulosa cell tumors, some of the long-term follow-ups showed a seminoma-like transformation.

Preventive management of hypoglycemia in very low-birthweight infants following indomethacin therapy for patent ductus arteriosus

BACKGROUND

To evaluate the effects of an increase in glucose infusion rate of 2 mg/kg per min from the basal infusion rate on the prevention of hypoglycemia in very low-birthweight (VLBW) infants, following indomethacin therapy for patent ductus arteriosus (PDA).

METHODS

Forty VLBW infants with PDA were given indomethacin 0.2 mg/kg intravenously up to three doses. In 15 of the 40 infants (supplemented group: between April 1995 and March 1996) the glucose infusion rate was increased in 2 mg/kg per min increments from the basal rate just before the initial indomethacin administration, compared with 25 historical control infants who received a fixed glucose infusion rate during the first 12 h after the initial dose. We evaluated the changes in blood glucose levels and glucose infusion rates in both groups.

RESULTS

In the control group 11 of 25 (44%) infants had a blood glucose value below 40 mg/dL between 12 and 60 h (mean 32.7 h). In contrast only two out of 15 infants in the supplemented group reached the glucose level below 40 mg/dL between 72 and 96 h but both two were light-for-dates infants (defined as birthweight below the 10th percentile for gestational age on the standard intrauterine growth curve). Blood glucose values in the supplemented group were significantly higher than those in the control group between 12 and 96 h. However, glucose infusion rates were similar before and between 72 and 96 h.

CONCLUSIONS

This retrospective study shows that an increase in glucose infusion rate of 2 mg/kg per min, in addition to the pre-existing stable maintenance glucose intake, might prevent against the occurrence of unexpected hypoglycemia in VLBW infants following indomethacin therapy.

In vitro and in vivo antibacterial activity and pharmacokinetics of SC-002 and its derivative, SC-004: new oral cephalosporins

SC-002 is a novel oral cephalosporin possessing a unique thiadiazolylethenyl moiety at the 3 position. In the present study, it was the most active against gram-positive bacteria among oral cephalosporins such as cefdinir (CFDN), cefpodoxime, cefditoren and cefaclor (CCL). It was equal to or 16 times more active than CFDN against standard and clinical strains. In particular, against clinical isolates of Morganella morganii and Haemophilus influenzae, SC-002 was 8-64 times more active than CFDN. The antibacterial activity of SC-002 against some beta-lactam-resistant strains was superior to that of CFDN. The in vivo antibacterial activity of SC-004, a pivaloyloxymethyl ester of SC-002, was 1.2-8 times more protective against systemic infections due to Streptococcus pneumoniae, Escherichia coli and Klebsiella pneumoniae than that of CFDN. The therapeutic effects of SC-004 on experimental respiratory tract infections caused by S. pneumoniae or H. influenzae were superior to those of CFDN and CCL. SC-004 showed higher and longer-lasting blood levels and higher urinary excretion in pharmacokinetics in mice.

Oral combination of cyclophosphamide, uracil plus tegafur and estramustine for hormone-refractory prostate cancer

OBJECTIVE

To evaluate the clinical usefulness of an oral combination of cyclophosphamide, uracil plus tegafur (UFT) and estramustine in the treatment of patients with hormone-refractory prostate cancer (HRPC).

METHODS

Twenty-one patients were treated with oral administration of cyclophosphamide (100 mg/day), UFT (400 mg/day) and estramustine phosphate (560 mg/day). The median age of the patients was 70 years. Twelve patients had symptomatic bone metastasis, 6 had asymptomatic bone metastasis, 5 had lymph node metastasis, while 2 had only biochemical progression evaluated by prostate-specific antigen (PSA).

RESULTS

Twelve (57%) out of 21 patients showed a PSA decline of 50% or greater. The median response duration was 7 months (range 2-15 months). Among the 20 patients assessable for bone pain, 2 (10%) improved, 12 (60%) remained stable and 6 (30%) progressed. Among the 10 patients assessable for bone metastasis, 1 (10%) improved, 5 (50%) were stable and 4 (40%) progressed on bone scan. Among 3 patients assessable for measurable disease (lymph node metastasis), 2 (67%) showed partial response and 1 (33%) progression. Most toxicities were mild.

CONCLUSIONS

The combination of cyclophosphamide, UFT and estramustine is an active and well-tolerated regimen for HRPC. To evaluate the survival benefit, further randomized studies are required.

[Hypersensitivity pneumonitis caused by a factory humidifier. A case report]

A 64-year-old man was hospitalized for productive cough and dyspnea. Both chest radiographs and CT scans showed areas of ground-glass opacity in the middle and lower lung fields on both sides. The BAL and TBLB findings were compatible with hypersensitivity pneumonitis. The serum was negative for antibodies against Trichosporon species, and the result of a lymphocyte stimulating test for administered drugs including a Chinese medicine was also negative. A humidifier was suspected as the cause because it had been used for more than 10 years in the factory where the patient had been working. An inhalation test using the humidifier fluid successfully provoked dyspnea, fever and fine crackle, and laboratory tests demonstrated hypoxemia, reduction in vital capacity and the elevation of CRP. Agar gel diffusion using the patient's serum showed a precipitating line against Cephalosporium acremonium, but this line did not fuse with any precipitating line formed between the humidifier fluid and the serum, indicating that no Cephalosporium was Present in the humidifier fluid. Since a high level of beta-D glucan was detected in the humidifier fluid, an unidentified fungus was suspected to be the antigen.

Hepatic lymphocyte transplantation in hyperbilirubinemic gunn rats

Hepatic lymphomyeloid cells (HLCs) are thought to contain liver stem cells. We investigated whether HLCs generated enzyme-producing cells in vivo. HLCs from normal Wistar/Shi rats and rats in which liver ischemia was induced using a portal clamp 4 days previously were studied histopathologically and characterized using flow cytometry. Splenic lymphocytes obtained from these animals were compared as a control. The proliferative activity of HLCs and splenic cells from both groups was also tested by stimulation with concanavalin A. HLCs contained a significantly higher number of NK-T cells and OV6+ cells compared with the splenic cells. The HLCs from rats in which liver ischemia was induced tended to have greater proliferative activity than those from normal rats, while the proliferative activity of splenic lymphocytes was impaired by liver ischemia. The HLCs obtained from Wistar/Shi rats with liver ischemia were then injected into hereditary hyperbilirubinemic Gunn rats to determine whether the HLCs generated enzyme-producing cells. After injection of these stimulated HLCs, the titer of serum bilirubin in the recipient rats was markedly reduced over a long time course (6.80+/-0.93 to 4.87+/-0.22 mg/dl after 1 month and 3.52+/-1.33 mg/dl after 6 months). The results of the present study indicate that HLCs have different populations than splenic cells, and ischemia-reperfusion of the liver increased their proliferative activity. HLC transplantation successfully reduced high bilirubin levels over a long time course.

Rotational acetabular osteotomy for severely dysplastic acetabulum

The operative procedures chosen for arthrosis with severe acetabular dysplasia vary among orthopaedic surgeons. We operated on 250 hips using the rotational acetabular osteotomy (RAO) method of Ninomiya and Tagawa [8]. In this report, we describe the technique of RAO and the results of this procedure in patients with severely dysplastic hips. Among the 250 hips, there were 6 which were classified as Severin group V. In those hips, the CE angle was less than 0 degrees, and the femoral head showed superolateral subluxation. After acetabular osteotomy with straight and curved osteotomes, smooth inferolateral rotation could be done in all cases. At the latest follow-up symptoms were improved remarkably, especially pain. Radiographically, adequate coverage of the femoral head was achieved and joint congruence improved in all 6 hips.

Effects of albumin infusion therapy on total and unbound bilirubin values in term infants with intensive phototherapy

BACKGROUND

The purpose of the present study was to evaluate the effect of intravenous albumin administration on the serum total and unbound bilirubin values in term non-hemolytic hyperbilirubinemic neonates during intensive phototherapy.

METHODS

Fifty-eight infants (gestational age 39.4 +/- 1.4 weeks; birth weight 3,245 +/- 435 g) were given phototherapy with similar light energy. Twenty infants (control group) received only phototherapy, while 38 others (albumin-treated group) were also given human albumin at 1 g/kg bodyweight, i.v., during the first 2 h of phototherapy.

RESULTS

When comparing changes in total and unbound bilirubin values 0, 2, 6 and 24 h after entering the study between the albumin-treated group and the control group, there was a significant reduction in the serum unbound bilirubin values at the end of albumin treatment and at 6 and 24 h. However, there was no significant reduction in total serum bilirubin values during the study period. In the albumin-treated group, the mean serum unbound bilirubin reduction from the baseline level at the end of albumin treatment and at 6 and 24 h was 0.40 +/- 0.19, 0.41 +/- 0.20 and 0.43 +/- 0.20 microg/dL, respectively.

CONCLUSIONS

The results suggest that albumin priming may be effective for an immediate reduction in serum unbound bilirubin values, the fraction that is potentially neurotoxic.

Removal and decomposition of malodorants by using titanium dioxide photocatalyst supported on fiber activated carbon

Effective and compact deodorization systems have been required for the measure of small-scale emission sources of offensive odors usually found in urban areas. We have developed a sheet material with titanium dioxide (TiO2) photocatalyst supported on fiber activated carbon (FAC) for a compact deodorization system. In the deodorization system using the TiO2/FAC sheet and a ultraviolet lamp, malodorants can be collected on the TiO2/FAC sheet by adsorption and then decomposed by photocatalysis with UV-irradiation. In this study, we obtained basic information about the removal and the decomposition of malodorants in the photocatalytic deodorization system using the TiO2/FAC sheet. The malodorants used in this study were methyl mercaptan, ammonia, and hydrogen sulfide. In addition, two kinds of light sources, a black light bulb (BLB; dominant wavelength: 365 nm) and an ultraviolet germicidal lamp (UV2; dominant wavelength: 254 nm) were used to analyze the effect on removal and decomposition characteristics by different dominant wavelengths. The removal rates of malodorants from the gas phase were determined in the deodorization system in the presence or absence of the TiO2/FAC sheet and UV-irradiation in order to study each removal effect due to adsorption onto the TiO2/FAC sheet, direct photolysis by UV-irradiation, and photocatalytic decomposition. The effect of adsorption onto the TiO2 /FAC sheet was pronounced in this batch-type experiment. The effect of photocatalysis was observed from the removal rates of methyl mercaptan. The percent oxidation of ammonia to nitrate and that of methyl mercaptan to sulfate were examined by determining products, i.e. nitrate and sulfate ions, with purified water after the reaction. The formation of nitrate or sulfate was not observed without UV-irradiation using the BLB, while the reactions progressed in the presence of the TiO2/FAC sheet. When the UV2 lamp was used, the oxidation of methyl mercaptan to sulfate occurred without the TiO2/FAC sheet. This suggests that the decomposition characteristics of malodorants were dependent on the wavelength of the light source.

Bacillus Calmette-Guérin perfusion therapy for the treatment of transitional cell carcinoma in situ of the upper urinary tract

OBJECTIVES

The aim of this study is to evaluate the efficacy and safety of intrarenal bacillus Calmette-Guérin (BCG) instillation as a treatment for transitional cell carcinoma in situ (CIS) of the upper urinary tract.

METHODS

Diagnostic criteria of upper urinary tract CIS were (1) positive urinary cytology, (2) negative multiple random biopsy of the bladder and prostatic urethra, (3) negative radiographic findings in the upper urinary tract and (4) two serial positive cytologies in selective ipsilateral urine sampling from the pyeloureteral system. Eleven patients diagnosed as having upper urinary tract CIS were enrolled in this study. Thus, 11 renal units were treated with BCG instillation. After placing a 6-french Double-J stent, BCG (80 mg) in 40 ml saline was instilled into the bladder weekly, 6 times in total as one course.

RESULTS

At the end of one course, 9 cases showed negative urinary cytology. Among these 9 cases, 2 showed recurrence in the upper urinary tract after 4 months and 8 months of disease-free interval, respectively. These 2 cases have received an additional course of BCG instillation, but the urinary cytology did not normalize. Mean recurrence-free time was 19.6 months. Of the other 7 cases who responded to the first course of instillation, 6 cases were alive with no evidence of the disease. The remaining patient died of rectal cancer with no evidence of transitional cell carcinoma (TCC). Of the 2 cases who showed positive urinary cytology even after the first course, 1 underwent nephroureterectomy. The other case was diagnosed as having malignant lymphoma 3 months after the end of this instillation therapy, and he died of malignant lymphoma. As side effects, 8 cases (72.7%) showed bladder irritability, and 4 presented fever higher than 38 degrees C. However, no patient needed antitubercular treatment.

CONCLUSION

As for the short-term response, BCG instillation for the treatment of upper urinary tract CIS is considered to be effective and safe. Longer follow-up and further experience with this treatment are required.

[A case of ectopic prostatic tissue in urinary bladder and uretero-seminal vesicle fistula with ipsilateral aplastic kidney]

A case of ectopic prostatic tissue in urinary bladder and uretero-seminal vesicle fistula with ipsilateral aplastic kidney is reported. A 29-year-old man was admitted to our hospital for residual sensation and perineal pain. Ultrasound examination revealed a cystic change in the right side of urinary bladder. C.T. and M.R.I. revealed a defect of a right kidney and ipsilateral ureteral dilation and seminal vesicle swelling. A cystscopy under lumbar anesthesia revealed a edematous cystic change of the right side of trigone and defect of the right ureteral orifice. Trans urethral resection of the wall of urinary bladder was simultaneously performed. And the contents of the cyst were sperum and old red blood cells. A retrograde ureterograph showed blind-ending ureter at L5 level and seminal vesicle swelling. A resected bladder tissue contained prostatic tissue. After operation he was free from complaints. Uretero-seminal vesicle fistula with ipsilater aplastic kidney is rare disease. In addition a case complicated ectopic prostatic tissue in urinary bladder was not reported in Japanese medical literature.

Prolonged function of hepatocytes transplanted into the spleens of Nagase analbuminemic rats

Hepatocytes isolated from F344 rats were transplanted into the spleens of congenic Nagase analbuminemic rats (NARs). The morphology and function of the transplanted hepatocytes were investigated after 18 months. The hepatocytes had formed nodules that occupied approximately 35% of the area of the splenic parenchyma on microscopic examination. Ultrastructural examination demonstrated that the organelles of the transplanted cells were indistinguishable from those of normal hepatocytes. The serum albumin level in NARs at 18 months after intrasplenic transplantation (HCTx) was about 3.6% of that in normal rats. We confirmed that the hepatocytes in the spleen produced albumin and increased the serum albumin level in NARs with HCTx. The NAR model demonstrates the effect of HCTx and prolonged changes in the morphology of the hepatized spleen.

Synthesis of decalin type chiral synthons based on enzymatic function

Enzymatic monobenzoylation of (+/-)-2-hydroxy-decahydro-5,5,8a-trimethyl-1-naphthalenemethano l derivatives (1-4) using vinyl benzoate in organic solvent gave the optically active diols (1-4) and monobenzoates (16-19). The enantiomeric excess (ee) of the enzymatic reaction products were found to be in the range of 11% to 49%. On the other hand, enzymatic hydrolysis of the acetoxybenzylidene acetal (+/-)-25d, e was found to give more than 90% ee of (10aS)-25d, e in moderate yield. Finally, the 90% ee of (10aS)-25e was converted to the 90% ee of the desired (8aS)-1.