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.

Effect of human adipose-derived mesenchymal stem cell conditioned medium on musculoskeletal pain

OBJECTIVE

Several studies in animal models have shown the safety and effectiveness of mesenchymal stem cell conditioned medium (MSC-CM) in inflammatory lesions involving muscles and joints.

PATIENTS AND METHODS

In this report, we retrospectively evaluated 16 patients who received local administration of the human adipose-derived mesenchymal stem cells conditioned medium (hAMSC-CM) for musculoskeletal chronic pain. Overall, 27 body locations expressing pain have been treated. The local administrated dose was 5 ml in the joint cavity and/or 2 ml in the other locations. The patients were asked to conduct self-evaluation of the degree of pain using a numeric rating scale (NRS) questionnaire and record the severity of pain before administration and at 15 min, 1 day, 1 week, and 4 weeks after administration. A second administration has been performed in 7 locations. The analysis was done considering two conditions: the "current pain status" and the "worst pain status in a week."

RESULTS

The results showed statistically significant differences between before and after administration at each time point for "current pain status" and at 1-week and 4-week time points for "worst pain status in a week" after first administration (Tukey-Kramer test). After second administration, significant differences were found at 1-week and 4-week time points for "current pain status". No serious adverse effect was found.

CONCLUSIONS

It was concluded that local administration of hAMSC-CM appears to be safe and could be expected to have effective therapeutic value against musculoskeletal chronic pain. Further studies are needed to clarify analgesic effects of hAMSC-CM and its underlying mechanism(s).

Perioperative fluid dynamics evaluated by bioelectrical impedance analysis predict infectious surgical complications after esophagectomy

BACKGROUND

Transthoracic esophagectomy, among the most invasive surgeries, is highly associated with postoperative infectious complications which adversely affect postoperative management including fluid dynamics. The aim of the study is to evaluate the utility of perioperative bioelectrical impedance analysis (BIA) measurements for the patients after transthoracic esophagectomy.

METHOD

Multi-frequency BIA measurements were conducted in 24 patients undergoing transthoracic esophagectomy preoperatively, at 1 h after surgery, and twice daily for the following 7 days. The amounts of extracellular water (ECW), internal cellular water (ICW), total body water (TBW), and fat-free mass (FFM) were calculated. Changing trends in variables were analyzed, and the patients were subdivided according to the presence of infectious surgical adverse events to identify differences in fluid dynamics.

RESULTS

ECW was the major body fluid compartment showing an increase after surgery, and peaked on postoperative day (POD) 2. Twelve patients experienced infectious complications. The peaks of changes in ECW and ECW/TBW appeared earlier and their values at the highest peak were significantly lower in the group without infectious complications on POD 2. The ICW/FFM value showed a mild decrease as compared to POD1 and then gradually recovered. It was significantly lower even before surgery and showed the most significant stratification on POD2. ECW/TBW of 48% and ICW/FFM of 37% on POD2 were predictive cut-off values for infectious adverse events with high area-under receiver operating characteristic (ROC) curves: 0.80 or higher.

CONCLUSION

BIA measurements are useful for monitoring fluid retention and may predict infectious complications in the early phase after transthoracic esophagectomy.

TRIAL REGISTRATION

Registry name: UMIN-CTR, ID: UMIN000030734, Registered on January 9, 2018, retrospectively registered.

Non-linear association between long-term outcome and preoperative neutrophil-to-lymphocyte ratio in patients undergoing curative resection for gastric cancer: a retrospective analysis of 1335 cases in a tetrachotomous manner

Objective

Although the prognostic utility of the pretreatment neutrophil-to-lymphocyte ratio (NLR) has been widely reported for gastric cancer and several other malignancies, the optimal patient stratification methodologies for such analyses have yet to be established. We aimed to examine the predictive value of preoperative NLR in patients with operable gastric cancer, and to elucidate whether or not the relationship between long-term outcome and pretreatment NLR is monotonically linear.

Methods

Preoperative data from 1335 patients who underwent curative surgery for gastric cancer were retrospectively evaluated. Patients were divided into four groups (Q1-Q4) according to preoperative NLR (1.59, 2.11 and 2.96). Survival time was calculated applying the Cox proportional hazard model to both univariate and multivariate estimates.

Results

On univariate Cox regression analysis, preoperative NLR was significantly associated with overall survival (OS) and relapse-free survival (RFS). On subsequent multivariate analysis, preoperative NLR, as a tetrachotomous variable, was independently associated with OS and RFS (P = 0.028, 0.023, respectively). When comparing Q1 with Q3 or Q4 in multivariate analysis, there were no significant prognostic differences in OS (P = 0.23, 0.37, respectively) and RFS (P = 0.26, 0.46, respectively). The Q2 group showed significantly longer RFS than the Q1 group (hazard ratio 0.69, 95% confidence interval 0.48-0.99, P = 0.048).

Conclusions

Although preoperative NLR was significantly associated with long-term outcome in gastric cancer patients, the association was not linear.

A surgical case of radiotherapy induced esophageal perforation accompanying pyogenic spondylodiscitis: a case report

Background

Stereotactic body radiotherapy has been a treatment choice for lung cancer, especially in medically inoperable patients. However, the acute and late toxicity to adjacent organs have been reported as an uncommon but severe adverse effect.

Case presentation

A 65-year-old male was presented with his back pain and pyrexia. He had been followed up for non-small-cell lung cancer, which was treated by the stereotactic body radiotherapy 4 years prior to the current visit. The endoscopy revealed an esophageal perforation on its left side in the upper thoracic locus. Because of his poor lung function, he was managed by the conservative treatment. After 3 months, his back pain recurred with developing paraplegia in the lower extremities. The MRI revealed an abscess formation at the posterior side of the upper thoracic esophagus which destroyed the vertebral body and compressed the spinal cord. Laminectomy and two-stage operation—the first stage, nontransthoracic esophagectomy, cervical and transhiatal approach using mediastinoscope and laparoscope, and the second stage, esophageal reconstruction—were performed.

Conclusion

This complex disease status was successfully managed by the orthopedic surgery followed by a two-stage esophagectomy without transthoracic approach.

Radical esophagectomy for a 92-year-old woman with granulocyte colony-stimulating factor-producing esophageal squamous cell carcinoma: a case report

Background

Granulocyte colony-stimulating factor (G-CSF)-producing esophageal squamous cell carcinoma (ESCC) has been considered to have a poor prognosis. We successfully treated a case of G-CSF-producing ESCC in a 92-year-old woman.

Case presentation

A 92-year-old woman was admitted to our hospital with the complaints of choking while swallowing and dysphagia. Esophagogastroduodenoscopy and contrast-enhanced computed tomography revealed a type 2 esophageal cancer located 26–35 cm from the dental arch, with no distant metastasis. The patient was diagnosed with G-CSF-producing ESCC based on remarkable leukocytosis and high G-CSF levels. The patient underwent radical subtotal esophagectomy. Subsequently, the level of neutrophils (from 23,500/μL to 5000/μL) and the level of G-CSF (from 131 to <19.5 pg/mL) decreased significantly. Immunohistochemistry analysis of the resected tissue specimen showed positive staining for G-CSF in the cytoplasm of the tumor cells. Although the patient developed aspiration pneumonitis, after antibiotic treatment, she promptly recovered and was discharged.

Conclusions

Herein, we describe a case of successfully treated G-CSF-producing ESCC in a 92-year-old woman. Precise detection and safely performed immediate radical operation are considered essential to achieve a good clinical course.

Discovery of a patient with strongly suspected bullous pemphigoid in a ward by oral health care providers

OBJECTIVES

Oral health care providers may discover systemic diseases incidentally from signs observed in the oral cavity. Here, we report a case in which oral health care providers in a hospital discovered a patient with strongly suspected bullous pemphigoid (BP), which is a relatively rare but important disease, in a ward.

METHODS

The patient was a 78-year-old Japanese woman admitted to our hospital because of severe Alzheimer's disease. We discovered recurrent ulcers in the oral mucosa and skin when performing oral care in her ward. Biopsy could not be performed safely because of involuntary biting. We performed blood tests for anti-BP180-NC16a antibody, which is autoantibody specific for BP.

RESULTS

The patient had a very high anti-BP180-NC16a antibody titre. We consulted a dermatologist regarding her clinical course and the clinical features of the oral mucosa and skin along with blood test results. BP was very strongly suspected.

DISCUSSION

In cases in which oral health care providers suspect their patients may have BP, appropriate examination and provision of information to the doctor are important. Oral health care providers should have knowledge about systemic diseases, the signs of which appear in oral cavity to avoid missing important systemic diseases.

Cytotoxicity of amorphous silica particles against macrophage-like THP-1 cells depends on particle-size and surface properties

Recent studies have indicated that amorphous silica particles (SPs) show cytotoxicity against various types of cells, including macrophages. However, the mechanism of cell death has not been determined, and systematic investigations of the relationship between particle characteristics and cytotoxicity are still quite limited. Here, we compared the cytotoxicity of SPs of various sizes (30-1000 nm) and surface properties against differentiated THP-1 human macrophage-like cells. We found that 300 and 1000 nm SPs showed cytotoxicity against THP-1 cells, whereas 30, 50, and 70 nm SPs did not induce cell death. We demonstrated that 1000 nm SP showed strong cytotoxicity that depended on reactive oxygen species but was independent of caspases. Furthermore, we showed that surface modification of 1000 nm SPs dramatically suppressed their cytotoxicity. Our results suggest that systematic evaluation of the association between particle characteristics and biological effects is necessary for the creation of safe SPs.

Exponentially growing solutions in homogeneous Rayleigh-Bénard convection

It is shown that homogeneous Rayleigh-Bénard flow, i.e., Rayleigh-Bénard turbulence with periodic boundary conditions in all directions and a volume forcing of the temperature field by a mean gradient, has a family of exact, exponentially growing, separable solutions of the full nonlinear system of equations. These solutions are clearly manifest in numerical simulations above a computable critical value of the Rayleigh number. In our numerical simulations they are subject to secondary numerical noise and resolution dependent instabilities that limit their growth to produce statistically steady turbulent transport.

Long-term normalization in the central nervous system, ocular manifestations, and skeletal deformities by a single systemic adenovirus injection into neonatal mice with mucopolysaccharidosis VII

Systemic injection of an adenovirus vector into adult mice resulted in pathological improvements in multiple visceral organs of mice with mucopolysaccharidosis VII; however, no therapeutic efficacy was observed for mental retardation, skeletal deformities, corneal clouding, and retinal degeneration. In this study, an adenovirus vector expressing human beta-glucuronidase was injected into mice with mucopolysaccharidosis VII within 24 h of birth, and therapeutic efficacy was evaluated. In the brains of the mice, more than 20% of GUSB activity was maintained for at least 20 weeks after birth, and histopathological analysis showed no obvious lysosomal storage. Furthermore, no vacuolated cells were detected in corneal stroma and retinal pigment epithelium in the eyes of the mice treated in the neonatal period, while pathological improvement was not observed in adult MPSVII mice that received similar treatments. The treated mice also lacked characteristic facial skeletal deformities, and radiographic analysis demonstrated that their facial and cranial bones were morphologically normal. These results indicate that a single systemic adenovirus injection in the neonatal period could prevent the progression of mental retardation, corneal clouding, retinal degeneration, and skeletal deformities, all of which are frequently observed clinical manifestations and difficult to treat in adulthood.

The boundary between mixed and manic episodes in the ICD-10 classification

OBJECTIVE

To investigate the boundary between ICD-10 mixed and manic episodes, which has apparently remained understudied.

METHOD

In-patients with ICD-10 mixed (n=36) and manic episodes (n=145) were compared in terms of demographic, clinical, therapeutical and outcome variables.

RESULTS

Of in-patients with manic episode, 26 (18%) had several depressive symptoms at admission. These patients (dysphoric manic patients) were very similar to patients with ICD-10 mixed episode in terms of current symptomatic presentations and several clinical and therapeutic variables, which were significantly different from those in patients with pure mania.

CONCLUSION

The ICD-10 boundary between mixed and manic episodes is unlikely to be effective although experienced clinicians made the diagnoses. The system may have a high probability of diagnosing dysphoric manic patients as having manic episode, despite their great similarities to patients with mixed episode in terms of current psychopathological presentations as well as clinically important variables.

Widespread distribution of adenovirus-transduced monkey amniotic epithelial cells after local intracerebral injection: implication for cell-mediated therapy for lysosome storage disorders

Cell-mediated therapy for mucopolysaccharidosis type VII (MPSVII) was studied using monkey amniotic epithelial cells (mAEC). The cells were transduced with a recombinant adenovirus expressing human beta-glucuronidase (GUSB), and cells overexpressing GUSB were generated. The cells expressed 2000-fold higher activities than the endogenous GUSB activities of nontransduced mAEC, demonstrating that mAEC were successfully transduced with adenoviral vectors. These cells also secreted high levels of GUSB. To clarify the cross-correction of GUSB secreted from mAEC, the conditioned medium containing high levels of GUSB was added into the medium for culturing human or murine fibroblasts established from an MPSVII patient or a mouse model of the disease. Dramatic increases in GUSB activities were observed in both fibroblasts. We then transplanted the cells transduced with an adenovirus expressing LacZ into the caudate-putamen of monkey brain. Survival and distribution of the transplanted cells 1 month after the treatment were evaluated. Histochemical analysis showed that LacZ-positive cells were widely distributed in the brain, suggesting that the transplanted cells had migrated and were distributed even at regions far from the implantation site. These findings suggest that local intracerebral engraftment of genetically engineered amniotic epithelial cells is favorable for the treatment of lysosome storage disorders, whose pathological abnormalities are not restricted to specific regions of the brain.

Retinal ischemia and angle neovascularization in proliferative diabetic retinopathy

PURPOSE

To analyze the relationship between the extent of retinal ischemia in proliferative diabetic retinopathy and angle neovascularization.

METHODS

Panoramic fundus fluorescein angiography and 360-degree fluorescein gonioangiography to detect the angle neovascularization were performed on 70 eyes of 46 patients with proliferative diabetic retinopathy. Statistical significance was evaluated by chi-squared test. Statistical significance was evaluated if the value (T) was greater than the level of significance, chi(0.05)(2)(2) = 5.99.

RESULTS

Retinal ischemia in fluorescein angiography was evaluated in four areas: capillary occlusion in (1) temporal raphe; (2) radial peripapillary capillaries; (3) the midperiphery (grade I, less than 25% of the area; grade II, 25% to 50%; grade III, 50% to 75%; grade IV, more than 75%); and (4) optic disk with neovascularization. The angle neovascularization was divided into two types: type I (14 eyes) and type II (12 eyes). Capillary occlusion in the temporal raphe and radial peripapillary capillaries, and papillary leakage significantly increased the risk of angle neovascularization (T = 8.28, 10.04, 6.44 respectively). Grade III and IV capillary occlusion in the midperiphery had a significant risk of angle neovascularization when compared with grade I (between grade III: T = 9.03, grade IV: T = 19.36) and II (between grade III: T = 6.31, grade IV: T = 16.09).

CONCLUSION

Risk factors for angle neovascularization were retinal nonperfusion in the midperiphery wider than grade III, capillary occlusion in the radial peripapillary capillaries and temporal raphe, and optic disk. Fluorescein gonio angiography was found to be a powerful tool for the early detection of angle neovascularization, especially in dark irides.

Terminal deoxynucleotidyltransferase is negatively regulated by direct interaction with proliferating cell nuclear antigen

BACKGROUND

The repertoires of Ig and TcR are generated by a combinatorial rearrangement of variable (V), diversity (D), and joining (J) segments (V(D)J recombination) in B- and T-cells. Terminal deoxynucleotidyltransferase (TdT) adds extra nucleotides (N nucleotides) at the junctions of the gene segments to enhance the Ig and TcR genes diversity. Using an anti-TdT antibody column, TdT has been purified as a member of a megadalton protein complex from rat thymus. The N region would be synthesized with the large protein complex.

RESULTS

The cDNAs for proliferating cell nuclear antigen (PCNA) were isolated by yeast two-hybrid screening as the gene products which directly interacted with TdT. The interaction between PCNA and TdT was confirmed by co-immunoprecipitation, both in vitro and in vivo. TdT binds directly to a PCNA trimer, as shown by gel filtration. TdT interacts with PCNA in its DNA polymerization domain (DPD), but not in its BRCA-1 C-terminal (BRCT) domain. TdT activity was reduced to 17% of the maximum value by TdT/PCNA complex formation.

CONCLUSION

TdT interacts directly with PCNA through its DPD. A functional consequence of this interaction is the negative regulation of TdT activity. These findings suggest that TdT catalyses the addition of N nucleotides under the negative control of PCNA during V(D)J recombination.

Seasonal and spatial studies on pesticide residues in surface waters of the Shinano river in Japan

Water samples collected once a week from early April 1996 to the end of August 1996 from four sites on the Shinano River in Japan were analyzed for pesticides and their metabolites using a gas chromatograph-mass spectrometer. Among the total of 53 chemicals found, 22 were herbicides, 15 were insecticides, 11 were fungicides, and 5 were metabolites. The concentrations of chemicals found ranged from 3 ng/L (bromobutide) to 8200 ng/L (isoprothiolane). Herbicides were found primarily during May and June at all four sites. Insecticides and fungicides were found primarily during July and August at all four sites. The presence of pesticides in the river water correlated with the time of pesticide application to the rice fields near the river.

Terminal deoxynucleotidyltransferase directly interacts with a novel nuclear protein that is homologous to p65

BACKGROUND

Terminal deoxynucleotidyltransferase (TdT) is a DNA polymerase that enhances Ig and TcR gene diversity in the N region in B- and T-cells. TdT is found as a member of a large protein complex in the lysate of the thymocytes. To elucidate the molecular mechanism of the synthesis of the N region, we first attempted to isolate the genes with products that are interacting directly with TdT.

RESULTS

Using a yeast two-hybrid system, we isolated a cDNA clone encoding a novel nuclear protein that interacts with TdT. This protein was designated as TdT interacting factor 1 (TdIF1). TdIF1 has a high degree of homology to the transcription factor p65, which belongs to the nuclear receptor superfamily. TdIF1 contains HMG-I and HMG-Y DNA binding domains (AT-hooks) and can bind to single- and double-stranded DNA. TdT and TdIF1 were co-eluted at position 232 kDa by gel filtration of MOLT4 lysate. TdIF1 can enhance TdT activity fourfold in vitro assay system using oligo(dT)16 as primers.

CONCLUSIONS

TdIF1 binds directly to TdT, both in vitro and in vivo. TdIF1 and TdT exist as the members of a 232 kDa protein complex. TdIF1 can enhance TdT activity maximum fourfold in vitro assay system, suggesting that it positively regulates the synthesis of the N region during V(D)J recombination in the Ig and TcR genes.

Dynamic computer tomography is useful in the differential diagnosis of juxtaglomerular cell tumor and renal cell carcinoma

We compared dynamic computer tomographic CT images of 3 cases of juxtaglomerular (JG) cell tumor with those of 8 cases of renal cell carcinoma (RCC). The JG cell tumor was visualized as a low- to high-density area in case 1, a low-density area in case 2, and a low- to iso-density area in case 3 before contrast enhancement. None of the JG cell tumors were stained during the early phase (1 min), but all were stained moderately during the late phase (5 min) after contrast enhancement. Although all cases of RCC were visualized as a low- to iso-density area before contrast enhancement, they were intensely stained during the early phase with significant washout during the late phase. The present results suggest that the dynamic CT scan is useful in the differential diagnosis of the JG cell tumor and RCC.

Autonomy of cortisol secretion in clinically silent adrenal incidentaloma

Recent progress in non-invasive imaging techniques have resulted in an increasing frequency of adrenal incidentaloma discovery. In addition, even clinically silent adrenal tumor has been suggested to possess a subtle production of adrenal hormones. The aim of the study was to ascertain the autonomy of cortisol production in clinically silent adrenocortical incidentaloma. We investigated the hypothalamic-pituitary-adrenal axis in 38 patients with adrenal incidentaloma. Basal plasma cortisol level was reproducibly within normal range in all the patients with adrenal incidentaloma, but was also normal in half of the Cushing's syndrome cases studied. Eighteen of 38 patients showed plasma cortisol above 3 microg/dl after 1 mg dexamethasone (Dex) and above 1 microg/dl after 8 mg Dex, respectively, and were defined as preclinical Cushing's syndrome. These patients were subjected to further evaluation of the autonomy of cortisol production. The incidence of positive findings indicating autonomy of cortisol secretion was as follows: suppressed basal plasma ACTH level in 44%, loss of normal diurnal rhythm in 79%, lack of ACTH response to CRF in 35%, decreased plasma DHEA-S level in 28%, significant laterality of 131I-adosterol uptake in 75%, atrophy of the contralateral side of the adrenal on CT scan in 6%, and histological atrophy of the adjacent adrenal cortex in 56%, respectively. The endocrine feature relevant to the hypothalamic-pituitary-adrenal axis varied from patient to patient, ranging from the non-functioning adrenal adenoma to Cushing's syndrome. In addition, the results of each test did not coincide with others in each patient. These results clearly demonstrated that the incidence of autonomy of cortisol production in the clinically silent adrenal incidentaloma is not infrequent, showing significant diversity. Systemic evaluation of the hypothalamic-pituitary-adrenal axis before adrenal surgery is warranted for an appropriate glucocorticoid replacement after adrenal surgery.

A huge frontal meningioma associated with intraoperative massive bleeding and severe brain swelling--case report

A 58 year old female presented with progressive memory disturbance and personality change. Magnetic resonance (MR) imaging disclosed a huge mass lesion accompanied by prominent oedema in the right frontal lobe. Cerebral angiogram demonstrated a vascular-rich tumour and a major drainer through diploic vein. A right frontotemporal craniotomy was performed. We encountered massive bleeding from diploic vein and dura mater immediately at the craniotomy. We were also faced with severe brain swelling at the dural incision. The tumour was solid, highly vascularised, and fairly well demarcated. We performed total removal of the tumour as quickly as possible in order to reduce the intracranial hypertension and avoid the impending brain herniation. The patient had an uneventful recovery and was asymptomatic at 10 months follow-up.

Gas chromatographic-mass spectrometric determination of hydrophilic compounds in environmental water by solid-phase extraction with activated carbon fiber felt

Simple gas chromatographic-mass spectrometric determination of hydrophilic organic compounds in environmental water was developed. A cartridge containing activated carbon fiber felt was made by way of trial and was evaluated for solid-phase extraction of the compounds in water. The hydrophilic compounds investigated were acrylamide, N,N-dimethylacetamide, N,N-dimethylformamide, 1,4-dioxane, furfural, furfuryl alcohol, N-nitrosodiethylamine and N-nitrosodimethylamine. Overall recoveries were good (80-100%) from groundwater and river water. The relative standard deviations ranged from 4.5 to 16% for the target compounds. The minimum detectable concentrations were 0.02 to 0.03 microg/l. This method was successfully applied to several river water samples.

Treatment of Setleis syndrome. Case report

Setleis syndrome is characterised by a leonine appearance. We have treated an 8-year-old boy with the syndrome and describe the plastic surgical procedures done and the histological findings.

Identification of zinc finger proteins bound to a silencer region in the rat glutathione transferase P gene

The rat glutathione transferase P (GST-P) gene is strongly induced during chemical hepatocarcinogenesis, whereas mRNA of this gene is rarely expressed in normal rat liver. We previously identified a silencer region in the promoter of this gene. This silencer has several DNA binding sites and at least three proteins (Silencer factor A, -B, and -C (SF-A, SF-B, and SF-C)) bind to these sites. We previously cloned and characterized the Nuclear Factor 1 (NF1) family and the CCAAT/enhancer-binding protein (C/EBP) family as SF-A and SF-B, respectively. However, SF-C which binds to GST-P silencer 2 (GPS2) remains to be cloned. By screening using yeast one-hybrid system, several zinc finger proteins were identified as a candidate of SF-C. The gel-mobility shift analyses showed that BTEB2, EZF, LKLF, TFIIIA, TIEG1, and novel zinc finger protein MZFP bound to GPS2 with different affinities. Several proteins of these are known to be transcriptional activators or repressors, suggesting that zinc finger proteins bind to GPS2 and regulate GST-P expression in the rat liver.

Engraftment of genetically engineered amniotic epithelial cells corrects lysosomal storage in multiple areas of the brain in mucopolysaccharidosis type VII mice

Cell-mediated gene therapy for visceral lesions of lysosomal storage diseases is promising; however, the treatment of central nervous system (CNS) lesions remains a challenge. In this study, we generated rat amniotic epithelial cells (AEC) that overexpress and secrete human beta-glucuronidase (GUSB) following transduction with an adenoviral vector encoding human GUSB. The AEC were used as donor cells for cell-mediated gene therapy of CNS lesions in mice with mucopolysaccharidosis type VII (MPSVII), a lysosomal storage disorder caused by an inherited deficiency of GUSB activity. After confirmation that the secreted GUSB was taken up mainly via mannose 6-phosphate receptors in primary cultured neurons, the AEC were transplanted into the brains of adult MPSVII mice. Histochemical analysis showed extensive GUSB activity throughout the ipsilateral hemisphere of the recipient brains, and pathological improvement of the lysosomal storage was observed even in regions far from the site of injection. These results suggest that intracerebral transplantation of genetically engineered AEC has therapeutic potential for the treatment of CNS lesions in lysosomal storage disorders.

Gene expression of CCAAT/enhancer-binding protein delta mediated by autoregulation is repressed by related gene family proteins

CCAAT/enhancer-binding protein delta (C/EBPdelta) transcription factor is rapidly induced at an early stage of acute phase response. We previously reported that this induction was mainly mediated by acute phase response factor/signal transducers and activators of transcription 3 (APRF/STAT3). Furthermore, the high expression level of C/EBPdelta is maintained by autoregulation mechanisms through the C/EBPdelta binding sites located downstream of C/EBPdelta gene. Thereafter, the expression of C/EBPdelta gene decreases rapidly to the basal level. However, these mechanisms are still unknown. According to both transfection and DNA binding analyses, liver-enriched inhibitory protein (LIP), the shorter form of C/EBPbeta and C/EBP-homologous protein 10 (CHOP10), were found to inhibit C/EBPdelta gene expression. DNA binding analysis has further indicated that both LIP and CHOP10 form heterodimers with C/EBPdelta, and inhibit the binding of C/EBPdelta homodimer to the C/EBPdelta binding sites located downstream of C/EBPdelta gene. Taken together, these findings indicated that the maintained expression of C/EBPdelta gene by autoregulation was inhibited and decreased to the basal level as a result of the competition of other C/EBP family proteins. Thus, C/EBPdelta gene expression is mediated by the gene regulation circuit through the downstream C/EBPdelta binding sites.

Two nuclear localization signals are required for nuclear translocation of nuclear factor 1-A

Nuclear factor 1 (NF1) proteins are encoded by at least four genes (NF1-A, B, C, X). Although DNA-binding and the transcription regulation domains of these proteins are well characterized, the nuclear localization signals (NLSs) are still unknown in all NF1s. We have identified two NLSs in NF1-A, and both are required for full translocation to the nucleus, although one of them itself has a partial translocation ability. These two NLSs are conserved in all four NF1s. Interestingly, three isoforms of NF1-A (NF1-A1, A2, A4) have two NLSs and translocate completely to the nucleus. In contrast, NF1-A3 lacks the second NLS and partially stays in the cytoplasm. Since NF1s construct homodimer and heterodimer, these findings indicate the differential regulations of the NF1 translocation.

Augmented expression of tissue endothelin-1 messenger RNA is a common feature in hypertensive rats

Recent studies revealed important roles for endothelin-1 (ET-1) in the pathogenesis of hypertension. Whether ET-1 could be a primary cause of hypertension or a secondary factor associated with hypertension, however, remains unknown. In this study, we determined plasma ET-1 levels and the expression of ET-1 mRNA in tissues of rats rendered hypertensive using distinct mechanisms: deoxycorticosterone acetate (DOCA)-salt hypertension: N(G)-nitro-L-arginine-methyl ester- (L-NAME) induced hypertension; and spontaneously hypertensive rats (SHR-SP). ET-1 mRNA expression level was determined by reverse transcriptase polymerase chain reaction (RT-PCR) followed by Southern blotting. There was no significant difference in plasma ET-1 levels between the hypertensive rats and normotensive rats. By contrast, ET-1 mRNA level was significantly increased in various tissues including the adrenal, lung, kidney and brain of these hypertensive rats compared with control rats. Thus, ET-1 gene expression was ubiquitously augmented in tissues of hypertensive rats irrespective of the cause of the hypertension. The results suggest that the increase in ET-1 expression is not the primary cause of hypertension but a secondary outcome which may further exacerbate the hypertension.

Hydralazine decreases blood pressure and endothelin-1 mRNA expression in tissues but not cardiac weight in SHR-SP/Izm rats

Although evidence has been accumulated to support a role of endothelin-1 (ET-1) in cardiac hypertrophy, details of the pathophysiological significance of ET-1 in cardiac hypertrophy remain to be elucidated. In the present study, we investigated the effects of the vasodilator hydralazine on the blood pressure, cardiac hypertrophy and ET-1 gene expression in various tissues of spontaneously hypertensive rats (SHR-SP/Izm). Hydralazine (20 mg/kg/day) was administered orally from the age of 4 weeks for 8 weeks. Tissues of the kidney, heart, aorta and brain were obtained at the age of 12 weeks. Tissue expression of ET-1 mRNA was determined by reverse transcriptase polymerase chain reaction (RT-PCR) followed by Southern blot analysis. Administration of hydralazine resulted in a significant decrease in the blood pressure (156 +/- 1 mmHg vs 212 +/- 4 mmHg in controls) and an increase in the heart rate (470 +/- 20 bpm vs 402 +/- 23 bpm in controls). ET-1 mRNA expression was significantly decreased in the heart (x 1/2), kidney (x 1/4) and brain (x 1/2). There was no significant change of the cardiac weight (309 +/- 4 mg/100 g body weight vs 307 +/- 5 mg/100 g body weight in controls). The dissociation between ET-1 mRNA expression and cardiac hypertrophy in hydralazine-treated rats may suggest that the increased tissue ET-1 is not an indispensable factor of cardiac hypertrophy in hypertension. Sympathetic activation, as shown by the reactive tachycardia, may overcome the effects on the blood pressure and ET-1 expression.

Hemodynamic and biochemical effects of endothelin-A- and -B-receptor antagonist TAK-044 in stroke-prone spontaneously hypertensive rats

We have demonstrated previously that endothelin-1 (ET-1) mRNA expression is increased in hypertensive rats. The aim of the study reported here was to elucidate the effects of the endothelin (ET) receptor antagonist on the hemodynamic and biochemical parameters in stroke-prone spontaneously hypertensive rats (SHRSPs/Izm). The endothelin-A- and -B- (ETA/ETB) receptor antagonist (TAK-044, Takeda Chemical Industries, Osaka, Japan) was administered subcutaneously at a dose of 10 mg/kg/day from the age of 8 weeks for 4 weeks. Blood samples and tissues of the kidney, heart and brain were obtained at the age of 12 weeks. Tissue expression of ET-1 mRNA was determined by reverse transcriptase-polymerase chain reaction (RT-PCR) followed by Southern blot analysis. Treatment with TAK-044 resulted in a significant decrease in systolic blood pressure (SBP), blood urea nitrogen (BUN), serum creatinine concentration, plasma aldosterone level, heart weight, and kidney weight. In addition, ET-1 contents and mRNA expression level in the kidney, heart and brain were significantly decreased by the treatment with TAK-044. These results suggest that the ET receptor antagonist TAK-044 is able to attenuate ET-1 gene expression in addition to its specific antagonism of the biological actions of ET via the receptors.

Effects of acute and chronic cigarette smoking on the expression of endothelin-1 mRNA of the cardiovascular tissues in rats

Although smoking has been suggested to be involved in the development of cardiovascular diseases, details of the mechanism still need to be revealed. We investigated the effects of cigarette smoking on the tissue mRNA expression of endothelin-1 (ET-1). Male Wistar rats of 4 weeks of age were exposed to smoke from six cigarettes for 30 min (acute exposure) and six cigarettes for 30 min/day, 5 days a week for 6 months (chronic exposure). Half of the rats exposed to 6 months smoking were kept in clean-air conditions for a further 3 months to clear the effects. Tissue expression of ET-1 mRNA in the kidney, aorta, heart and lung was determined by reverse transcriptase polymerase chain reaction (RT-PCR) followed by Southern blot analysis. There was no significant difference in body and organ weight of the heart and kidney between the control and smoking group in either the acute or chronic experiment. In the acute-exposure experiment, expression of ET-1 mRNA was increased in the heart and lung, while that in the kidney and aorta was unchanged. In the chronic-exposure experiment, however, there was no significant difference in the expression of ET-1 mRNA in all the tissues between the smoking and control groups. These results suggest that cigarette smoking could cause cardiovascular and pulmonary diseases by modulating ET-1 mRNA expression in the tissues.

Analysis of the candidate genes responsible for non-syndromic cleft lip and palate in Japanese people

In order to assess the association of alleles for candidate genes with non-syndromic cleft lip and palate, DNA samples from 43 Japanese patients were compared with those from 73 control subjects with respect to the genes encoding transforming growth factor alpha (TGFalpha), TGFbeta and gamma-aminobutyric acid type A receptor beta3 (GABRB3). The restriction fragment length polymorphisms of the 3'-non-coding region of the TGFalpha gene K-primer region were observed after digestion with NcoI and HinfI. Allele 4 was the most common among cases of cleft lip with or without cleft palate, whereas allele 2 was the most common among controls. A significant difference was found in this region between groups with cleft lip (with or without cleft palate) and controls (chi2=10.190; P=0.017). Three alleles of the TGFbeta2 gene were tested, and allele 2 was the most common in both cases and controls. The proportion of allele 2 in the case group was greater than that in the control group, showing a significant difference between cases of cleft lip (with or without cleft palate) and controls (chi(2)=19.208; P<0.0001). No significant differences in variants of TGFbeta3 or GABRB3 between case and control populations were observed. Thus it is concluded that TGF genes play a role in craniofacial development, and that alleles of TGFalpha or/and TGFbeta2 are associated with cleft lip and cleft palate in Japanese populations.