Real-world Safety and Effectiveness of Edoxaban in Patients with Venous Thromboembolism with or without Preceding Parenteral Anticoagulants: A Single-center Retrospective Study

Objective Edoxaban is an anticoagulant used for venous thromboembolism (VTE) treatment and requires pretreatment with parenteral anticoagulants. However, pretreatment is not always performed in the clinical setting. In this study, we investigated the safety and effectiveness of edoxaban treatment in patients with VTE with or without pretreatment. Methods We retrospectively enrolled 364 patients who received edoxaban for VTE treatment between September 2014 and March 2020 and investigated patient demographics, VTE recurrence, and major bleeding as clinical outcomes in patients with or without pretreatment. Furthermore, the factors contributing to pretreatment decisions were assessed. Results Patients without pretreatment (n=208) had more active cancer cases and fewer pulmonary embolism complications than those with pretreatment (n=156). Lower levels of hemoglobin and higher levels of white blood cell counts, C-reactive protein, and D-dimer at the diagnosis were found in patients who received pretreatment than in those without pretreatment. No symptomatic VTE recurrence was observed. After propensity score matching, the cumulative incidence of major bleeding was not significantly higher in patients with pretreatment than in those without it (log-rank test, p=0.136). The incidence of deteriorated VTE on imaging did not significantly differ between patients with and without pretreatment, even after propensity matching (log-rank test, p=0.414). Conclusion In a real-world clinical setting, where physicians determined the use of parenteral anticoagulant lead-in according to their experience, patient demographics, and VTE characteristics, no significant differences were found regarding safety and effectiveness in edoxaban-treated VTE patients with or without pretreatment with parenteral anticoagulants.

Refractory cardiac arrest caused by type I Kounis syndrome treated with adrenaline and nicorandil: A case report

RATIONALE

Kounis syndrome is a rare but life-threatening anaphylactic reaction that can lead to acute coronary syndrome and cardiac arrest, and requires prompt diagnosis. Adrenaline, which is used to treat anaphylaxis, may cause coronary vasoconstriction and worsen ischemia, whereas coronary vasodilators may dilate systemic vessels and exacerbate hypotension. Delayed diagnosis of Kounis syndrome and inadequate therapeutic intervention may thus lead to a poor outcome.

PATIENT CONCERNS

A 59-year-old man was treated for sepsis due to a liver abscess. Following administration of daptomycin, the patient developed severe anaphylactic shock leading to refractory cardiac arrest. Because conventional cardiopulmonary resuscitation was ineffective, extracorporeal cardiopulmonary resuscitation was considered as an alternative approach.

DIAGNOSES

On bedside monitoring during cardiopulmonary resuscitation, unexpected ST-segment elevation was found on lead II electrocardiogram. Accordingly, the patient was clinically diagnosed with Kounis syndrome.

INTERVENTIONS

Nicorandil (6 mg/h), a coronary vasodilator with minimal blood pressure effects, was administered along with high doses of vasopressors, including adrenaline 0.2 µg/kg/min.

OUTCOMES

After the initiation of nicorandil administration, the patient achieved return of spontaneous circulation and did not require extracorporeal cardiopulmonary resuscitation. Based on the elevated serum tryptase level, normal creatine kinase-MB range, and lack of stenosis on coronary angiography, the patient was definitively diagnosed with type I (coronary vasospasm) Kounis syndrome. He was subsequently transferred to the referring hospital without neurological sequelae.

LESSONS

If anaphylaxis leads to refractory shock and cardiac arrest, ischemic changes on the electrocardiogram should be investigated to identify underlying Kounis syndrome. In addition to adrenaline, coronary dilators are the definitive treatment. Nicorandil may be a useful treatment option because of its minimal effect on blood pressure.

Fulminant Myocarditis and Acute Appendicitis after COVID-19 Vaccination

A 19-year-old Japanese man was hospitalized for cardiogenic shock 28 days after receiving a second dose of the coronavirus disease 2019 (COVID-19) mRNA-1273 vaccine. He had had a high fever for three days with vomiting and abdominal pain before arriving at our hospital. The patient visited a local hospital and was diagnosed with heart failure and acute appendicitis. An endomyocardial biopsy specimen showed myocarditis. Thereafter, Impella CP left ventricular assist device implantation and venoarterial peripheral extracorporeal membranous oxygenation were initiated immediately along with inotropic support and steroid pulse therapy. Given these findings, he was finally diagnosed with multiple inflammatory syndrome and fulminant myocarditis.

Comparison of Effectiveness and Safety Among 3 Direct Oral Anticoagulants in Patients With Venous Thromboembolism - A Single-Center Retrospective Study

Background: Direct oral anticoagulants (DOACs), including edoxaban, rivaroxaban, and apixaban, are administered for the treatment of venous thromboembolism (VTE) in Japan. However, only a few reports have compared the effectiveness and safety of these DOACs. Methods and Results: We retrospectively enrolled 702 patients who received DOACs for VTE treatment between September 2014 and March 2020. We investigated patient demographics, VTE recurrence, major bleeding, and mortality until March 2021, and compared them among the 3 DOACs. Most patients (~70%; n=496) were prescribed edoxaban, followed by apixaban (n=107) and rivaroxaban (n=99). Age, body mass index, renal function, and the proportion of cancer patients did not differ significantly among the DOACs. Edoxaban was administered relatively more in women with low body weight and anemia. The rate of pulmonary embolism was significantly lower among patients receiving edoxaban than apixaban or rivaroxaban (24.4% vs. 41.1% and 53.5%, respectively). VTE reoccurred in 2 patients administered apixaban and 1 patient administered edoxaban. The cumulative incidence of major bleeding at 1 year was 11.7%, 18.5%, and 9.0% in the edoxaban, apixaban, and rivaroxaban groups, respectively. There were no significant differences in the cumulative incidence of major bleeding and all-cause death, estimated by Kaplan-Meier analysis, among the DOACs (log-rank P=0.316 and 0.722, respectively). Conclusions: The safety of the 3 DOACs did not differ significantly in clinical settings, despite differences in patient demographics.

Delayed Acute Perimyocarditis and Bilateral Facial Nerve Palsy in a Patient with COVID-19

A 41-year-old Japanese man was admitted to our hospital with acute perimyocarditis 4 weeks after coronavirus disease 2019 (COVID-19) infection. Ten days after admission, the patient showed bilateral facial nerve palsy in the course of improvement of perimyocarditis under treatment with aspirin and colchicine. After prednisolone therapy, perimyocarditis completely improved, and the facial nerve palsy gradually improved. Acute perimyocarditis and facial nerve palsy can occur even 4 weeks after contracting COVID-19.

Vasospastic Angina: An Immune-related Adverse Event

A 54-year-old Japanese woman was admitted to our ward because of recurrent chest pain at rest for 2 months. She had been treated with nivolumab, an immune checkpoint inhibitor for inoperable advanced hypopharyngeal cancer for 21 months. She had no chest pain after cessation of nivolumab treatment. Cardiac catheterization confirmed the presence of vasospastic angina. Benidipine 8 mg was started, and she had no chest pain even after resuming therapy with nivolumab. Vasospastic angina is an adverse effect of nivolumab.

Impact of Morning Onset on the Incidence of Recurrent Acute Coronary Syndrome and Progression of Coronary Atherosclerosis in Acute Myocardial Infarction

BACKGROUND

The relationship between time of onset of acute myocardial infarction (MI) and long-term clinical outcome has not been completely understood. We hypothesized that morning onset acute MI may be associated with adverse cardiac events.Methods and Results:This study involved 663 patients who underwent primary percutaneous coronary intervention (PCI). The main outcome measures were cardiac death, recurrent acute coronary syndrome (ACS), and re-hospitalization for heart failure. Major adverse cardiac events (MACE) were defined as a composite of individual adverse outcomes. Morning onset acute MI occurred in 212 patients (32.0%); they had higher rates of recurrent ACS (13% vs. 8%, P=0.03) and MACE (21% vs. 14%, P=0.012) than the patients with other times of onset. The PCI rate for progressive lesions was also higher than for patients with other times of onset (23% vs. 14%, P=0.013). On multivariate Cox regression analysis, morning onset was an independent predictor of recurrent ACS, MACE, and PCI for progressive lesions, with adjusted hazard ratios of 1.34 (95% CI: 1.06-2.92, P=0.030), 1.51 (95% CI: 1.02-2.23, P=0.038), and 1.58 (95% CI: 1.03-2.42, P=0.037), respectively.

CONCLUSIONS

Morning onset may be associated with increased risk of recurrent ACS and coronary atherosclerosis progression.

Effects of moderate-to-severe obstructive sleep apnea on the clinical manifestations of plaque vulnerability and the progression of coronary atherosclerosis in patients with acute coronary syndrome

AIMS

It is unclear whether obstructive sleep apnea (OSA) increases the recurrence of acute coronary syndrome (ACS) in patients with acute myocardial infarction (MI). We hypothesized that moderate-to-severe OSA increased the number of adverse cardiovascular events in patients who underwent primary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

This study included 272 patients with acute MI. Polysomnography at first admission determined that 124 patients suffered from moderate-to-severe OSA. The main study outcome measures were cardiac death, recurrence of ACS, and re-admission for heart failure. Major adverse cardiac events (MACEs) were defined as composite end points of individual clinical outcomes. Follow-up coronary angiograms were obtained in 222 patients. PCI-related measures were target vessel revascularization and newly necessitated PCI for progressive lesions. The moderate-to-severe OSA patients had increased ACS recurrence and MACEs compared with patients with mild OSA or without sleep apnea (16% vs. 7%, p = 0.014; 22% vs. 11%, p = 0.014, respectively). PCI for progressive lesions was also higher in the moderate-to-severe OSA patients (28% vs. 15%, p = 0.015). Cox regression analysis showed that moderate-to-severe OSA was an independent predictor of ACS recurrence (hazard ratio = 2.30, p = 0.040). In addition, moderate-to-severe OSA was an independent predictor of PCI for progressive lesions, with a hazard ratio of 2.38 (p = 0.015).

CONCLUSIONS

Moderate-to-severe OSA increased the risk of ACS and the incidence of PCI for progressive lesions. Increased plaque vulnerability might be related to these clinical manifestations.

Hyperplastic polyposis associated with two asynchronous colon cancers

We report a patient with hyperplastic polyposis who had two asynchronous colon cancers, a combined adenoma-hyperplastic polyp, a serrated adenoma, and tubular adenomas. Hyperplastic polyposis is thought to be a precancerous lesion; and adenocarcinoma arises from hyperplastic polyposis through the hyperplastic polyp-adenoma-carcinoma sequence. Most polyps in patients with hyperplastic polyposis present as bland-looking hyperplastic polyps, which are regarded as non-neoplastic lesions; however, the risk of malignancy should not be underestimated. In patients with multiple hyperplastic polyps, hyperplastic polyposis should be identified and followed up carefully in order to detect malignant transformation in the early stage.

Differential activities of 1alpha,25-dihydroxy-16-ene-vitamin D(3) analogs and their 3-epimers on human promyelocytic leukemia (HL-60) cell differentiation and apoptosis

To clarify physiological role of the carbon 3 (C-3) epimerization of 1alpha,25(OH)(2)D(3) and biologic significance of a 3-epi metabolite of 1alpha,25(OH)(2)D(3), we examined biologic activities of the 3-epimers of 1alpha,25(OH)(2)D(3) and 1alpha,25(OH)(2)-16-ene-D(3) analogs in terms of modulation of cell cycle phase distribution and cell-surface CD11b antigen expression of HL-60 cells, transactivation of vitamin D target genes in transfected cells, stimulation of VDR/RXRalpha heterodimer formation in a rabbit reticulocyte lysates transcription/translation system, stimulation of VDR/RXRalpha/VDRE complex formation, and induction of HL-60 cell apoptosis. The analogs tested here were 1) 1alpha,25(OH)(2)D(3), 2) 1alpha,25(OH)(2)-3-epi-D(3), 3) 1alpha,25(OH)(2)-16-ene-D(3), 4) 1alpha,25(OH)(2)-16-ene-3-epi-D(3), 5) 1alpha,25(OH)(2)-16-ene-23-yne-hexafluoro(F(6))-D(3), 6) 1alpha,25(OH)(2)-16-ene-23-yne-hexafluoro(F(6))-3-epi-D(3), 7) 1alpha,25-(OH)(2)-16-ene-20-epi-23-yne-D(3), and 8) 1alpha,25(OH)(2)-16-ene-20-epi-23-yne-3-epi-D(3). When compared to the 3-natural (beta) analogs, the 3-epi (alpha) analogs were biologically significantly less active. The findings support the hypothesis that the C-3 epimerization is an inactivation pathway of 1alpha,25(OH)(2)D(3) and its analogs in vitamin D target tissues. We also found that the 3-epi analogs, but not the 3-natural (beta) analogs, were the potent inducers of apoptosis of HL-60 cells. These results suggest that the analogs could be divided into two groups, in which the 3-epi analogs were the potent inducers of apoptosis of HL-60 cells, and the 3-natural analogs were the potent modulators of HL-60 cell growth and differentiation. This is the first report demonstrating that the 3-epimerization of the hydroxyl group at C-3 of the A-ring of 1alpha,25(OH)(2)D(3) plays an important role to modulate HL-60 cell differentiation and apoptosis.

Systematic studies on synthesis, structural elucidation, and biological evaluation of A-ring diastereomers of 2-methyl-1alpha,25-dihydroxyvitamin D(3) and 20-epi-2-methyl-1alpha,25-dihydroxyvitamin D(3)

All possible A-ring diastereomers of 2-methyl-1alpha,25-dihydroxyvitamin D(3) (2) and 20-epi-2-methyl-1alpha,25-dihydroxyvitamin D(3) (3) were synthesized by palladium-catalyzed coupling reaction of A-ring 'enyne' synthons with CD-ring portions. The A-ring synthons were rationally synthesized via a novel and practical route, starting with methyl (R)-(+)- and (S)-(-)-3-hydroxy-2-methyl-propionate, in good yields. X-ray crystallographic analysis of 2alpha-methyl-1alpha,25-dihydroxyvitamin D(3) (2b) and conformational analysis of the A-ring of 2alpha-methyl-(2b) and 2beta-methyl-1alpha,25-dihydroxyvitamin D(3) (2f) were carried out, and the results are described. All A-ring diastereomers (2 and 3), thus synthesized, were biologically evaluated both in vitro and in vivo. The biologic potency was highly dependent on the stereochemistry of the A-ring substituents. In particular, 2b showed 4-fold higher vitamin D receptor [VDR] binding activity than the natural hormone, and its 20-epimer (3b) exhibited exceptionally high activity, 12-fold more potent in VDR binding, 7-fold in calcium mobilization, and 590-fold in induction of human promyelocytic leukemia (HL-60) cell differentiation as compared with the natural hormone. Further, the 20-epi-2beta-Me-1beta, 3alpha(OH)(2) isomer (3g) had significant biologic potencies compared to the natural hormone despite having 1beta-OH configuration. The transcriptional activities on human osteocalcin gene promoter, including VDRE in transfected mammalian cells, were also evaluated. Finally, there was a clear contrast between the effects of the 2-methyl group on the HL-60 cell differentiation- and apoptosis-inducing activities of 2 and 3.

Structure-specific control of differentiation and apoptosis of human promyelocytic leukemia (HL-60) cells by A-ring diastereomers of 2-methyl-1alpha,25-dihydroxyvitamin D(3) and its 20-epimer

1alpha,25-dihydroxyvitamin D(3) (1alpha,25(OH)(2)D(3)) has been shown to modulate not only proliferation and differentiation but also apoptosis of malignant cells, indicating that it would be useful for the treatment of hyperproliferative diseases such as cancer and psoriasis. Little information is available concerning structural motifs of the 1alpha,25(OH)(2)D(3) molecule responsible for modulation of differentiation and apoptosis. We synthesized all possible A-ring diastereomers of the 2-methyl-1alpha,25(OH)(2)D(3) and its 20-epimer and evaluated their biological activities in human promyelocytic leukemia (HL-60) cells. Surprisingly, the potent analogues could be clearly divided into two groups: (i) those bearing the 1alpha- and 3beta-hydroxyl groups on the A-ring were potent inducers of differentiation and growth inhibitors of HL-60 cells and (ii) those bearing the 1beta-hydroxyl group together with either 3alpha- or 3beta-hydroxyl groups on the A-ring were potent stimulators of apoptosis in these cells. We have clearly identified for the first time the structural motifs on the basis of the stereochemistry of both hydroxyl groups at positions 1 and 3 of the A-ring of the 1alpha,25(OH)(2)D(3) molecule responsible for the induction of differentiation and apoptosis of HL-60 cells. These findings provide useful information not only for structure-function studies of 1alpha,25(OH)(2)D(3) analogues but also for the development of therapeutic agents for the treatment of leukemia and other cancers.

A model of bacterial translocation in neuroblastoma-bearing mice

PURPOSE

The aim of this study was to establish a model of bacterial translocation (BT) in neuroblastoma-bearing mice.

METHODS

A suspension of 1 x 10(6) cells of the murine neuroblastoma cell line C1300 was injected subcutaneously into the thighs of 8-week-old female A/J mice, which were then killed after 7, 14, and 21 days. Some of the mice were given 1-microm or 2-microm fluorescein-labeled latex beads in their drinking water for 7 days before being killed. Mesenteric lymph nodes (MLNs) were aseptically removed and cultured for 72 hours at 37 degrees C. Segments of distal ileum were obtained for histologic examination. Samples of venous blood were obtained for laboratory tests.

RESULTS

Tumors were found at the injection sites on days 14 and 21 after C1300 injection. Although tumors were not found in 7 days, significantly high number of 1-microm latex beads were detected in MLNs compared with the control, and the number increased with tumor growth. The number of 2-microm latex beads was significantly higher on days 14 and 21. The percentage of mice with MLN cultures positive were significantly higher on day 14, and the percentage increased along with tumor growth. On day 21 after C1300 injection, body weight loss and anemia were observed, and histologic findings of the terminal ileum showed mucosal edema and villous thinning. Serum levels of interleukin (IL)-6 were significantly higher in mice killed 14 and 21 days after injection.

CONCLUSIONS

The results suggest that BT from the gut to MLNs may occur in neuroblastoma C1300-bearing mice, and it increases along with tumor growth. Even in the early stage of malignancy, particles as small as 1 microm may translocate from the gut to MLNs.

Inhibitory effect of TNP-470 on hepatic metastasis of mouse neuroblastoma

PURPOSE

TNP-470 is a strong inhibitor of angiogenesis. The present study was designed to determine whether the angiogenesis inhibitor TNP-470 inhibits metastasis of mouse neuroblastoma cells to the liver and thus increases survival.

METHODS

A murine neuroblastoma cell line, C1300, and A/J mice were used in this study. First, to demonstrate the inhibitory effects of TNP-470 on angiogenesis, we quantified the area of angiogenesis on images made with SP-500 image analyzer (Olympus) 7 days after implanting a millipore chamber and compared the areas for the TNP-470-treated mice and control mice. Next, to determine the inhibitory effect of TNP-470 on metastasis of neuroblastoma cells to the liver, we made a murine hepatic metastasis model by implanting C1300 cells (1 x 10(6)) in the spleen of the mice and compared histologic findings, sizes, and weights of the livers of treated mice and control mice 14 days after the beginning of a 7-day infusion of TNP-470 (60 mg/kg). We also compared survival rates using the Kaplan-Meier method.

RESULTS

When the angiogenesis inhibitor TNP-470 was infused into mice that received tumor cells, the area of angiogenesis in the TNP-470-treated mice was smaller than that in the control mice (52.5 +/- 6.3 SD vs 94.1 +/- 27.6 mm(2), P < 0.001). After the same treatment in other mice, no histologic evidence of metastasis was found, whereas control mice had countless tumor cell masses. Similarly, the weight of the liver was less in TNP-470-treated mice (0.8 +/- 0.1 g vs 4.5 +/- 0.3 g, P < 0.001). Survival was longer in the TNP-470-treated mice than in controls (80% of treated mice were alive more than 60 days after treatment, whereas all control mice died by Day 20).

CONCLUSION

TNP-470 inhibits metastasis of mouse C1300 neuroblastoma cells to the liver, and thus increases survival. TNP-470 inhibits metastasis by inhibiting angiogenesis.

Novel ring A stereoisomers of 2-methyl-1alpha,25-dihydroxyvitamin D(3) and 2-methyl-20-epi-1alpha,25-dihydroxyvitamin D(3): transactivation of target genes and modulation of differentiation in human promyelocytic leukemia (HL-60) cells

We evaluated the biological activity of two sets of ring A stereoisomers of 2-methyl-1alpha,25-dihydroxyvitamin D(3) (2-methyl-1alpha,25(OH)(2)D(3)) and 2-methyl-20-epi-1alpha, 25-dihydroxyvitamin D(3) (2-methyl-20-epi-1alpha,25(OH)(2)D(3)) in terms of the following: transactivation of a rat 25-hydroxyvitamin D(3)-24-hydroxylase gene promoter including two vitamin D response elements (VDREs) and a human osteocalcin gene promoter including a VDRE in transfected human osteosarcoma (MG-63) cells; a vitamin D receptor (VDR)-mediated response using a VDR-GAL4 one-hybrid luciferase reporter system and a retinoid X receptor alpha (RXRalpha)-mediated response using an expressed VDR/RXRalpha-GAL4 modified two-hybrid luciferase reporter system in transfected human epitheloid carcinoma, cervix (HeLa) cells; and modulation of cell surface CD11b antigen expression in human leukemia (HL-60) cells. All the diastereomers of both analogues exhibited unique biological activity profiles depending upon the configurations of the C-1 and C-3 hydroxyl groups, the C-2 methyl group in ring A, and the C-20 methyl group in the side chain. Of the eight possible diastereomers of the 2-methyl analogues, 2alpha-methyl-1alpha,25(OH)(2)D(3) was the most potent and exhibited comparable or even greater biological potency than 1alpha,25(OH)(2)D(3). Of the eight possible diastereomers of the 2-methyl-20-epi analogues, 2alpha-methyl-20-epi-1alpha,25(OH)(2)D(3) was the most potent and exhibited 100- to 200-fold higher transcriptional potencies than 1alpha,25(OH)(2)D(3) and exceptionally high cell regulatory activities. 2beta-methyl-20-epi-1alpha,25(OH)(2)D(3) was nearly as potent as its 2-epimer, 2alpha-methyl-20-epi-1alpha,25(OH)(2)D(3), whereas its 20-epimer, 2beta-methyl-1alpha,25(OH)(2)D(3), was almost completely biologically inactive. In these respects, it can be postulated that the double modification of 2-methyl substitution and 20-epimerization to 1alpha,25(OH)(2)D(3) induces remarkable changes in a VDR/RXRalpha/VDRE-mediated signaling response and greatly enhances biological activity. The other striking finding was that 2beta-methyl-20-epi-3-epi-1beta,25(OH)(2)D(3) is transcriptionally more active than 1alpha,25(OH)(2)D(3) despite lacking the 1alpha-hydroxyl group, which was believed to be essential for expressing VDR-mediated gene transcription. Since the C-20 natural counterpart, 2beta-methyl-3-epi-1beta,25(OH)(2)D(3), was almost completely biologically inactive, 20-epimerization is probably responsible for activation of gene expression. Although earlier extensive structure-activity studies of vitamin D analogues showed stereochemistry at the C-1, C-3, and C-20 of 1alpha,25(OH)(2)D(3) to be the key structural motif for vitamin D action, our results clearly demonstrated that stereochemistry at the C-2 is also an important structural motif for vitamin D action and imply that 2-methyl substitution possibly induces conformational changes in ring A depending upon the combinations of configurations of the C-1 and C-3 hydroxyl groups with C-20 stereochemistry. Consequently, several of these analogues exhibit exceptionally high or unexpected biological activities at the molecular and cellular levels. These results suggest that 2-methyl substitution together with alterations of stereochemistry in both ring A and the side chain of 1alpha, 25(OH)(2)D(3) will provide useful analogues for structure-activity studies and development of therapeutic agents with unique biological activity profiles.

Efficient synthesis and biological evaluation of all A-ring diastereomers of 1alpha,25-dihydroxyvitamin D3 and its 20-epimer

An improved synthesis of the diastereomers of 1alpha,25-dihydroxyvitamin D3 (1) was accomplished utilizing our practical route to the A-ring synthon. We applied this procedure to synthesize for the first time all possible A-ring diastereomers of 20-epi-1alpha,25-dihydroxyvitamin D3 (2). Ten-step conversion of 1-(4-methoxyphenoxy)but-3-ene (6), including enantiomeric introduction of the C-3 hydroxyl group to the olefin by the Sharpless asymmetric dihydroxylation, provided all four possible stereoisomers of A-ring enynes (3). i.e., (3R,5R)-, (3R,5S)-, (3S,5R)- and (3S,5S)-bis[(tert-butyldimethylsilyl)oxy]oct-1-en-7-yne, in good overall yield. Palladium-catalyzed cross-coupling of the A-ring synthon with the 20-epi CD-ring portion (5), (E)-(20S)-de-A,B-8-(bromomethylene)cholestan-25-ol, followed by deprotection, afforded the requisite diastereomers of 20-epi-1alpha,25-dihydroxyvitamin D3 (2). The biological profiles of the synthesized stereoisomers were assessed in terms of affinities for vitamin D receptor (VDR) and vitamin D binding protein (DBP). HL-60 cell differentiation-inducing activity and in vivo calcium-regulating potency in comparison with the natural hormone.

In vitro biological activities of a series of 2 beta-substituted analogues of 1 alpha,25-dihydroxyvitamin D3

Biological activities of a series of 2beta-substituted analogues of 1alpha,25-dihydroxyvitamin D3 [1alpha,25(OH)2D3] were evaluated in vitro in terms of their binding affinity with regard to calf thymus cytosolic vitamin D receptor (VDR) and rat plasma vitamin D-binding protein (DBP). Additionally, reporter gene luciferase activities using either a rat 25-hydroxyvitamin D3-24-hydroxylase gene promoter, including two vitamin D-responsive elements (VDREs), in transfected rat osteoblast-like ROS17/2.8 cells, or a human VDR-GAL4 modified two-hybrid system in transfected human epitheloid carcinoma, cervix HeLa cells were examined. Binding affinity for VDR, transactivation potency on the target gene and VDR-mediated gene regulation of the hydroxyalkyl and hydroxyalkoxy 2beta-substituted analogues were almost comparable to those of 1alpha,25(OH)2D3, while the alkyl and alkenyl analogues were much less active than 1alpha,25(OH)2D3. This study investigated the biological evaluation of a series of 2beta-substituted analogues at the molecular level, with regard to the structural differences of alkyl, alkenyl, hydroxyalkyl, hydroxyalkoxy, alkoxy, hydroxy and chloro substituents at the 2beta-position of 1alpha,25(OH)2D3.

Spontaneous rupture of splenic hamartoma: a case report

Splenic hamartomas are rare. The authors report a case of spontaneously ruptured splenic hamartoma in a 5-month-old boy. This rupture led to the death of the child. If abdominal pain is present and a mass is palpated, the splenic hamartoma should be managed surgically in an expeditious manner. There have been only two known previous reports of spontaneous rupture of splenic hamartoma in adults, but none in children.

Pyriform sinus fistula appearing as a neck tumor in the neonatal period: a case report

Pyriform sinus cyst and fistula is a relatively rare tumor of the neck, even less is the neonatal period. We experienced a case of this one, and preoperative diagnosis was made by using endoscopy and cine-esophagography. A dyeing method that confirmed the fistula tract of cyst lead us to successful resection.

Reassessment of the two-site enzyme immunoassay for human epidermal growth factor (hEGF) and measurement of immunoreactive hEGF in human sera and urine

We reassessed the enzyme immunoassay (EIA) system for hEGF previously developed by our laboratory (Clin Chim Acta 156:51-60, 1985), since it appeared that the reported EIA system detected not only hEGF but also pS2 protein owing to minor contamination by pS2 protein in the hEGF sample used for immunization. In this study, we purified the hEGF sample using Benzamidine-Sepharose 6B column chromatography as a critical step for purification and newly developed an EIA system with specificity for hEGF. We also measured the hEGF level in serum, plasma, and urine from normal subjects by our new EIA system and found that the values measured by the previous system were 1.2-5.8-fold higher than the new system values. These results suggest that the previous system detected "hEGF" in excess owing to the nonspecificity of the antibody used. We investigated the molecular nature of immunoreactive hEGF detected in serum using our new system and confirmed that considerable amounts of immunoreactive hEGF exist as a high molecular weight form through S-S linkage with some macromolecule(s) in human blood as reported previously (Biochem Int 12:677-683, 1986).

Peroxidase-linked anti-basic fibroblast growth factor monoclonal antibody Fab' conjugates: application for two-site enzyme immunoassay and immunohistochemical detection

After conjugating thiol groups in the hinge region of monoclonal antibody (mAb) Fab' fragments specific for basic fibroblast growth factor (bFGF) with maleimido-horseradish peroxidase HRP) complexes synthesized by incubation of HRP with the heterobifunctional reagent N-succinimidyl-4-(maleimidomethyl)cyclohexane-1-carboxylate, we developed a fluorometric enzyme immunoassay method based on the sandwiching of the factor between anti-bFGF IgG-coated polystyrene beads and the conjugates, and also an immunohistochemical method for detection of the location of the factor. The discriminatory detection limit by the developed enzyme immunoassay (EIA) was as low as 30 pg/mL. The reproducibility of within- and between-assay series was 6.07-9.18% and 6.28-6.82%, respectively, and the recovery of exogenous bFGF from serum was approximately 98%. The curves generated by the concentrated fraction that eluted at the same position as standard bFGF by size-exclusion chromatography on a TSK 2000SW column were parallel to the curve for standard bFGF. From these results, we consider the developed EIA method to be acceptable in regard to sensitivity, precision, and specificity. Also, without the introduction of any additional signal amplification system, positive immunohistochemical reactions were successfully detected by the HRP-linked anti-bFGF mAb Fab' in fibroblastic and endothelial cells, which have already been shown to synthesize and secrete bFGF, indicating that these conjugates provide a useful means for direct immunohistochemical detection of the factor.

Fluorometric enzyme immunoassay of basic fibroblast growth factor with monoclonal antibodies

We compared three different strategies for measuring basic fibroblast growth factor (bFGF) by fluorometric enzyme immunoassay (EIA). After optimizing conditions, we found that a primary anti-bFGF MAb directly conjugated with peroxidase gave the best detection limit for recombinant bFGF (approximately 30 ng/L, 3 pg/assay tube) in a two-site sandwich assay. The detection limit of methods based on biotinylated primary MAbs or on secondary antibodies followed by streptavidin-conjugated peroxidase was slightly lower than that of the above method. Using the most sensitive EIA examined in this study, we made a preliminary measurement of immunoreactive bFGF in sera of apparently healthy people and found it to be 190 (SD 32) ng/L (n = 48), in agreement with an earlier reported value (30-206 ng/L). Also, the concentration of immunoreactive bFGF in sera was above normal in 19 of 31 patients with stomach cancer.

Fluorometric Enzyme Immunoassay of Basic Fibroblast Growth Factor with Monoclonal Antibodies

We compared three different strategies for measuring basic fibroblast growth factor (bFGF) by fluorometric enzyme immunoassay (EIA). After optimizing conditions, we found that a primary anti-bFGF MAb directly conjugated with peroxidase gave the best detection limit for recombinant bFGF (approximately 30 ng/L, 3 pg/assay tube) in a two-site sandwich assay. The detection limit of methods based on biotinylated primary MAbs or on secondary antibodies followed by streptavidin-conjugated peroxidase was slightly lower than that of the above method. Using the most sensitive EIA examined in this study, we made a preliminary measurement of immunoreactive bFGF in sera of apparently healthy people and found it to be 190 (SD 32) ng/L (n = 48), in agreement with an earlier reported value (30-206 ng/L). Also, the concentration of immunoreactive bFGF in sera was above normal in 19 of 31 patients with stomach cancer.

Production and some properties of monoclonal antibodies against human pancreatic secretory trypsin inhibitor

Hybridomas that secrete monoclonal antibodies against human pancreatic secretory trypsin inhibitor (PSTI) were established by fusion of spleen cells obtained from mice immunized with PSTI with mouse NS-I-Ag 4/1 myeloma cells. One of three resulting monoclonal antibodies (KN-1) was found to recognize the N-terminal moiety of the inhibitor, while the others (KN-2 and KN-3) reacted with other as yet undefined parts of the molecule. Trypsin inhibitory activity of PSTI treated with KN-1 monoclonal antibody was the same as that of PSTI itself, thus indicating no relationship between the N-terminal moiety of the PSTI molecule and its inhibitory activity. We further examined the applicability of one of the monoclonal antibodies (KN-1) for immunohistochemical study of human pancreatic cancer tissue including the normal as a model, and found granular staining of the cytoplasm of the normal acinar and duct cells and also of that of adenocarcinoma cells in formalin-fixed, paraffin-embedded tissue sections.

Biological and immunological properties of human hepatocyte growth factor from plasma of patients with fulminant hepatic failure

We have recently purified human hepatocyte growth factor (hHGF), a heterodimer with molecular weight of about 83,000, from plasma of patients with fulminant hepatic failure (Gohda, E. et al., J. Clin. Invest. 81, 414-419, 1988). Biological and immunological properties of hHGF were examined. Out of the well-known growth factors tested, only epidermal growth factor (EGF) and transforming growth factor-alpha (TGF-alpha) stimulated DNA synthesis of adult rat hepatocytes in primary culture. hHGF enhanced the DNA synthesis at less than one-tenth of the molar concentrations of EGF and TGF-alpha. Half-maximal stimulations by hHGF, EGF and TGF-alpha were observed at 30, 400 and 900 pM, respectively. Maximal stimulation by TGF-alpha, however, was greater than those caused by hHGF and EGF. The effect of hHGF was additive with the maximal effects of EGF and TGF-alpha. Anti-hHGF antiserum was prepared in a rabbit by injecting with purified hHGF. This antiserum recognized nonreduced hHGF, but not reduced hHGF. The antiserum for hHGF did not inhibit growth-promoting activity of EGF, that was neutralized by incubation with anti-EGF antiserum. The activity of hHGF was completely inhibited by anti-hHGF antiserum, but not by anti-EGF antiserum. hHGF did not show any cross-reactivity to anti-EGF antiserum as measured by enzyme immunoassay for EGF. Thus, biological and immunological properties of hHGF are different from those of EGF and TGF-alpha.

Anti-skeletal muscle antibodies in the sera from myasthenic patients with thymoma: identification of anti-myosin, actomyosin, actin, and alpha-actinin antibodies by a solid-phase radioimmunoassay and a western blotting analysis

We recently reported a strong association between the occurrence of anti-skeletal muscle (SM) antibodies and the presence of thymoma in patients with myasthenia gravis (MG). To further examine the immunoreactivity of MG sera against human muscle antigens, we developed a solid-phase radioimmunoassay (RIA) using purified muscle antigens and a Western blotting analysis in MG sera with high titers of anti-SM antibodies. Our results showed that MG patients with thymoma (thymoma group) had markedly high titers of anti-myosin and anti-actomyosin antibodies than those without thymoma (non-thymoma group). Furthermore, a close correlation was found between titers of anti-SM, anti-myosin and anti-actomyosin antibodies. The antibody titers against actin, alpha-actinin and tropomyosin were all low and did not correlate with titers of anti-SM antibodies. But, significant levels of these three antibodies were found in the thymoma group. By a Western blotting analysis, immunoreactivity of sera from the thymoma group appeared to be predominantly directed against myosin, actin and alpha-actinin.

Monoclonal antibodies specific for high molecular weight form of human epidermal growth factor

Hybridomas that secrete monoclonal antibodies specific for the high molecular weight (HMW) form of human epidermal growth factor (hEGF) were established by fusing spleen cells obtained from mice immunized with purified urinary HMW-hEGF with myeloma P3 x 63Ag8.653. The resulting monoclonal antibodies were characterized basically into two groups. One group recognized both EGF and HMW-hEGF, while the other recognized HMW-hEGF specifically on radio immunoprecipitation. Surprisingly, the majority of the isolates was positive by western blotting. Utilizing these monoclonal antibodies for affinity chromatography, we purified HMW-hEGF successfully from urine. These antibodies may be an extraordinarily powerful tool for histological study related to both forms of EGF.

A sensitive two-site enzyme immunoassay for human pancreatic secretory trypsin inhibitor (PSTI) using monoclonal antibodies

By using monoclonal antibody against human pancreatic secretory trypsin inhibitor (PSTI), we developed a highly sensitive, simple, and reliable two-site enzyme immunoassay system. The minimum amount of PSTI detected by this EIA is approximately 10 pg/ml when a 100 microliter aliquot of the sample is used. Good reproducibilities of within- and between-assay series and excellent recovery of exogenous PSTI from serum were observed. The correlation between the values obtained by the EIA and RIA methods was given by the linear regression equation, y = 1.09x + 4.6, for which the correlation coefficient (r) was 0.980 (n = 20). Antigenicity of the trypsin-PSTI complexes was found to be approximately 10% of that of PSTI. From these results, it seems that our recently developed EIA system for PSTI is useful in clinical testing for quantitation of PSTI in body fluids, for biochemical studies on synthesis and secretion of PSTI, and also for study of pathophysiological mechanisms involved in the development of acute pancreatitis and certain malignant neoplasms.

Demonstration of a considerable amount of mouse epidermal growth factor in aqueous humor

In a previous study we reported the presence of a considerable amount of mouse epidermal growth factor (mEGF) in abdominal effusion. Using our EIA system for mEGF, we identified a high level of EGF-like immunoreactive material(s) in mouse aqueous humor. This material(s) and mEGF from mouse submaxillary gland were virtually equivalent with respect to molecular weight and antigenicity. Also, on chromatofocusing analysis, the mEGF-like material(s) gave a major peak at pH 4.7 with a minor one at pH 4.2. These results demonstrate that the mEGF-like immunoreactive material(s) found in aqueous humor is a molecule identical to submaxillary gland EGF. Also, no clear difference was observed in the mEGF levels in aqueous humor between male and female. Further, sialoadenectomy did not change dramatically the EGF level in aqueous humor. From these results, it seems that mEGF found in aqueous humor may be synthesized by cells in the eyeball itself or be transported there from some site other than the submaxillary gland.

Identification of epidermal growth factor in mouse abdominal effusion

Epidermal growth factor (mEGF)-like immunoreactive material(s) was identified in mouse abdominal effusion (approximately 2.1 ng/mg protein) by our enzyme immunoassay (EIA) for mEGF. This material(s) and mEGF from the submaxillary glands of male mice were virtually equivalent with respect to the molecular weight and the antigenicity. Also, on isoelectric focusing analysis, the mEGF-like material(s) identified in abdominal effusion gave a major peak at pH 4.2 and a minor one at pH 4.5. These results demonstrate that the mEGF-like material(s) found in abdominal effusion is a molecule identical to mouse submaxillary gland EGF. Further we found that sialoadenectomy did not cause a marked decrease in the level of mEGF in abdominal effusion, suggesting that the source of mEGF found in abdominal effusion is other than the submaxillary glands.

Production of an hEGF-like immunoreactive factor by human gastric cancer cells depends on differentiational state of the cells

We have extended our recent observation that human gastric cancer cells (MKN-45) synthesize and secrete an hEGF-like immunoreactive factor (designated as EGF-LI) by characterization of EGF-LI produced by five human gastric cancer cell lines in culture. Two cell lines (MKN-45 and KATO-III) derived from poorly differentiated adenocarcinoma synthesized and secreted a much larger amount of EGF-LI than three cell lines (MKN-1, MKN-28, and MKN-74) derived from well-differentiated adenocarcinoma. Treatment of MKN-45 cells by retinoic acid reduced significantly synthesis and secretion of EGF-LI, suggesting that production of EGF-LI is dependent on differentiational state of gastric cancer cells.

Synthesis and secretion of an hEGF-like immunoreactive factor by human gastric cancer cells (MKN-45)

A large amount of an immunoreactive factor was detected in the medium conditioned by human gastric cancer cells, strain MKN-45, by our enzyme immunoassay system for human epidermal growth factor (hEGF) based on hEGF isolated from urine. However, the dose-response curve of the immunoreactive factor (designated as MKN-45 EGF) was not parallel with the standard curve of hEGF. The molecular weight of MKN-45 EGF was slightly larger than that of hEGF and was estimated to be 7,000-8,000 by gel filtration on Sephadex G-50. On isoelectric focusing analysis, MKN-45 EGF gave a major peak at pH 5.0 and a minor one at pH 4.3. These results demonstrate that MKN-45 cells synthesize and secrete into the culture medium a polypeptide immunologically related to hEGF.

Some properties of human epidermal growth factor (hEGF)-like immunoreactive material originating from platelets during blood coagulation

During blood coagulation, a considerable amount of human epidermal growth factor (hEGF)-like immunoreactive material (designated as platelet hEGF-LI) was liberated from platelets. The molecular nature of the platelet hEGF-LI was examined. The molecular weight of platelet hEGF-LI estimated by gel filtration was approximately 60,000-70,000. On chromatofocusing chromatography, platelet hEGF-LI was eluted mainly at pH 4.75 as a sharp peak with a minor peak at 4.30, like urine EGF. By treatment with 2-mercaptoethanol, the factor was converted into a material with molecular weight of 35,000-40,000. These results suggest that the majority of hEGF-LI in platelets may exist either in a covalently bound-form with some protein(s) in platelets or as a dimer intermolecularly cross-linked by an S-S linkage. Details of the biological properties and the physiological significance of the platelet hEGF-LI remain to be clarified.

Molecular nature of human epidermal growth factor (hEGF)-like immunoreactivity in human plasma

To investigate the molecular features of hEGF in the circulatory system, we analyzed hEGF-like immunoreactivity (hEGF-LI) in human serum and plasma by our two-site enzyme immunoassay (EIA), using an aliquot of each fraction obtained by gel filtration of human serum or plasma on Sephadex G-100. The results demonstrated that the majority of the hEGF-LI in the plasma (HMW X hEGF-LI) emerged in the void volume, while a small amount of hEGF-LI (LMW X hEGF-LI) eluted at a position similar with that of standard hEGF. After reduction of HMW X hEGF-LI with 2-mercaptoethanol, hEGF-LI emerged at the same elution position as that of standard hEGF, suggesting that the predominant form of hEGF may circulate as a complex with some macromolecule(s) in human blood. The biochemical properties of the plasma component(s) with high molecular weight which form the complex with hEGF and the physiological significance of this circulating complex still remain to be clarified.

Development of a sensitive enzyme immunoassay for human epidermal growth factor (urogastrone)

A sensitive two-site enzyme immunoassay (EIA) for human epidermal growth factor (hEGF) was developed, based on the sandwiching of an antigen between anti-hEGF IgG-coated polystyrene beads and anti-hEGF Fab'-linked peroxidase complex (horseradish peroxidase, EC. 1.11.1.7). This method has four advantages: the anti-hEGF Fab'-linked peroxidase complex is more stable than 125I-labelled antibody; the procedure is simple and rapid compared to bioassay; its discriminatory sensitivity is as low as 0.1 pg/assay tube; and serial dilution curves of unextracted human serum and urine samples all paralleled that of standard hEGF. The validity of the measurement of hEGF-like immunoreactivity in human serum and plasma is discussed.

Human breast cancer cells synthesize and secrete an EGF-like immunoreactive factor in culture

A human breast cancer cell line, strain MCF-7, in culture synthesized and secreted a large amount of a polypeptide (designated as MCF-7 EGF) immunologically related to human epidermal growth factor (hEGF). The molecular weight of MCF-7 EGF estimated by gel filtration on Sephadex G-75 was similar to that of hEGF from human urine. On isoelectric focusing analysis, MCF-7 EGF gave a major peak at pH 4.6 and a minor peak at pH 5.0. In our enzyme immunoassay system, however, the dose-response curve of MCF-7 EGF did not show good parallelism with that of standard hEGF. From these results, it is suggested that MCF-7 cells synthesize and secrete a polypeptide immunologically related to hEGF into the culture medium.