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.

Assessment of anthracycline-induced cardiotoxicity in patients with childhood cancer survivor for long-term follow-up

Funding Acknowledgements

Type of funding sources: None.

Background

 Anthracycline cardiotoxicity is an important prognostic determinant in childhood cancer survivors (CCSs). That has been reported to improve with early therapeutic intervention, and because it is dose-dependent and progressive, early diagnosis and long-term follow-up are important. In adult survivors of cancer, the longitudinal strain (LS) is useful as a sensitive index of cardiac function. In childhood cancer survivors, strain abnormalities are also observed at both short-term and long-term follow-up. Global longitudinal strain (GLS) abnormalities are common during or early after chemotherapy, whereas changes in global circumferential strain (GCS) are more significant and consistent on long-term follow-up.

Purpose

 In this study, we aimed to conduct a cross-sectional study using strain analysis in childhood cancer survivors of a wide age range to clarify the mode of progression of anthracycline-induced cardiotoxicity and to identify useful indicators for long-term follow-up.

Methods

 In total, 116 patients (median age: 15.5 [range: 4.7-40.2] years) with childhood cancer who had passed at least 1 year after chemotherapy with anthracycline, and 116 control patients of similar age. Strain measurements were assessed for longitudinal strain (LS) and circumferential strain at the apical, papillary and basal levels using speckle tracking imaging. Estimated value at 5, 15, 25 and 35 years old were mathematically calculated.

Results

 Results were shown in tables and figures. Most of conventional echocardiographic parameters were not significantly different between CCCs and controls. LS, papillary CS and basal CS in CCCs decreased compared to normal controls at all age. The difference of estimated value between CCCs and normal controls in LS at all age were relatively constant. However, those in basal CS tended to increase with aging. Furthermore, basal CS in CCCs decreased with aging (r = 0.212, p &lt; 0.001) and the duration after completion of anthracycline treatment (r = -0.244, p &lt; 0.008).

Conclusions

 In childhood cancer survivors, strain analysis is a more sensitive indicators of cardiac function than conventional parameters. In addition, basal CS may decrease most markedly over time and could be useful indicator in long-term follow-up. Longitudinal studies should be conducted in the future to improve the accuracy of predicting anthracycline cardiotoxicity. These are new findings regarding the decline in cardiac function in childhood cancer survivors. Abstract Figure. Relationship between age and strains  Abstract Figure. Estimated values for each age group

P–192 Efficacy of postponement of intracytoplasmic sperm injection timing after spindle visualization for Metaphase I oocytes

Study question

Does postponement of intracytoplasmic sperm injection (ICSI) timing after spindle visualization for Metaphase I (MI) oocytes improve developmental outcomes of embryos?

Summary answer

Postponement of ICSI timing after spindle visualization for MI oocytes improves blastocyst utility rates.

What is known already

Immature oocytes are generally considered poor developmental outcomes. Meanwhile, the timing of ICSI adjusted by using spindle visualization can improve clinically utilized embryos and live birth rates, but these outcomes remain inferior to those of mature oocytes. In in vitro maturation culture, nuclear maturation is thought to occur before the completion of cytoplasmic maturation, and in immature oocytes, synchronization of nuclear and cytoplasmic maturation may be insufficient for ICSI immediately after spindle visualization.

Study design, size, duration

Data for this retrospective cohort study were obtained 672 oocytes retrieved under mild stimulation cycles using letrozole, in patients aged younger than 39 years between April 2017 and October 2020.Written informed consent was obtained from all patients. This study was approved by the institutional review board.

Participants/materials, setting, methods

As a control group, 464 MetaphaseIIoocytes that underwent ICSI immediately after visualization of the spindle were used. In group A, 103 MI oocytes underwent ICSI immediately after the first polar body release and spindle visualization, and in group B, 105 oocytes underwent ICSI 2–3 hours after spindle visualization. The primary outcomes were fertilization rates, degeneration, cleavage, embryo blastocyst formation, and utility rates. Outcomes were compared among the three groups.

Main results and the role of chance

The baseline fertilization rates of each group (control, A, B) were 82.3% (382/464), 73.8% (76/103), and 83.8% (88/105), respectively. The rate was significantly lower in group A than in the control group (P &lt; 0.05), and also tended to be lower in group A than in group B, although the difference was not significant. There was no significant difference in abnormal fertilization rates, oocyte degeneration rates, cleavage rates, and blastocyst formation rates among the three groups. [control, A, B: abnormal fertilization rate: 4.3% (20/464), 8.7% (9/103), 4.8% (5/105); oocyte degeneration rates: 3.0% (14/464), 1.9% (2/103), 3.8% (4/105); cleavage rates: 95.6% (307/321), 93.8% (61/65), 98.7% (74/75); blastocyst formation rates: 58.6% (177/302), 51.7% (31/60), 55.4% (41/74), respectively]. The blastocyst utility rates of control group and group B were significantly higher than in group A [41.7% (126/302), 45.9% (34/74), 26.7% (16/60), respectively] (P &lt; 0.05). There were no significantly different outcomes between the control group and group B.

Limitations, reasons for caution

The optimal timing of ICSI for MI oocyte cannot be determined by the presence or absence of spindles. In addition, the postponement duration we set was based on reports which reported on final oocyte maturation, and further investigation is needed to establish the optimal ICSI timing for MI oocytes.

Wider implications of the findings: In MI oocytes, postponement of ICSI timing after spindle visualization is essential for synchronization of the nucleus and cytoplasmic maturation.

Trial registration number

none

P–609 The chances of one live birth rates after first ART cycle in minimal stimulation cycle IVF with letrozole only and natural cycle IVF

Study question

Are one live birth rates (LBRs) similar in minimal stimulation cycle IVF with letrozole only and natural cycle IVF for the first ART cycle?

Summary answer

LBRs after first ART cycle in minimal stimulation cycle IVF with letrozole only are superior to natural cycle IVF.

What is known already

The addition of letrozole to gonadotropins in ovarian stimulation (OS) may reduce the risk of OHSS, but there is no significant difference were reported in ongoing pregnancy rate or number of oocytes retrieved in the letrozole + FSH group compared to the FSH only. No differences were also reported in clinical pregnancy rates or number of mature oocytes in the additional of letrozole in an GnRH antagonist protocol group compared to the GnRH antagonist group. There are no previous study comparing LBRs after first ART cycle in minimal stimulation cycle IVF with letrozole and natural cycle IVF.

Study design, size, duration

Data for this retrospective cohort study were obtained 643 women, 30–39 years of age started their first ART cycle at one private fertility clinic between January 2016- December 2019.

Participants/materials, setting, methods

A total of 643 women were scheduled their first oocyte retrieval cycle. 118 women started with letrozole (LE) and 525 women started natural cycle (NC). The main strategy for OS in our center is minimal stimulation and natural cycle IVF. Patients consulted with gynecologists to determine their treatment plan based on patients’ preference or their menstrual cycle. All pregnancies generated from oocyte retrieval during the first IVF cycle including fresh and frozen-thaw cycles were registered.

Main results and the role of chance

The number of retrieved oocytes and the normal fertilization rates were significantly higher in the LE than NC (4.4 vs 3.4, 77.6% vs 71.1%), p &lt; 0.05 respectively). There was no significant difference in the clinical pregnancy rates (CPRs) per embryo transfer (ET) (fresh cleavage stage ET: 32.9% vs 28.0%, frozen-thaw blastocyst ET: 39.4% vs 44.9% ns). However, the CPRs and LBRs per oocyte retrieval (OR) were significantly higher in the LE group (39.0% vs 28.6, 33.9% vs 21.9%, p &lt; 0.05 respectively). In a subsequent regression analyses, LBRs per OR of LE was significantly higher than NC as well. (adjusted OR = 1.63 (95% CI: 1.02–2.58, p = 0.041).

Limitations, reasons for caution

The strength of the present study was the use of a large cohort of women who underwent minimal stimulation IVF with letrozole only. Although our results are promising, limited by retrospective cohort study. These interpretations prompted the need for a perspective cohort study to evaluate the efficacy of letrozole.

Wider implications of the findings: When comparing minimal stimulation IVF with letrozole only and natural cycle IVF, we found significantly higher LBRs per OR in minimal stimulation IVF with letrozole only, despite similar CPRs per ET.

Trial registration number

none

P1357 Left atrial function decreases with age in patients with repaired tetralogy of Fallot decrease

BACKGROUND

Left ventricular function has been shown to be an important prognostic indicator in patients with repaired tetralogy of Fallot (rTOF) and tends to decrease with age. In recent years, left atrial (LA) function was reported to be a useful prognostic indicator more than or equal to left ventricular function in acquired heart diseases. However, atrial function in rTOF has not yet been sufficiently examined.

PURPOSE

The aim of this study was to investigate the relationship between LA dysfunction and age in rTOF using strain analysis.

METHODS

In order to assess the relationship between LA function and age, we recruited 59 patients with rTOF ranging in age from 5-40 years. We stratified the patients into 3 groups (T1: 5-10 years, T2: 11-20 years, T3: 21-40 years) and divided 54 controls of similar age into 3 corresponding groups (N1, N2, and N3). Two-dimensional speckle tracking images (2D-STI) obtained from four- and two-chamber views were used to assess LA functions by measuring reservoir, conduit, and pump strain. Additionally, we measured the strain rate (SR) in the systole, early diastole, and late diastole.

RESULTS

LA reservoir strain (37.4 ± 2.2% vs. 47.9 ± 1.7%, P= 0.004), LA pump strain (8.3 ± 1.4% vs. 14.1 ± 2.7%, p &lt;.001), atrial systolic LA-SR (1.5 ± 0.4% vs. 2.4 ± 0.6%, p &lt;.001), and systolic LA-SR (1.5 ± 0.3% vs. 2.1 ± 0.4%, p = 0.003) were significantly decreased in T3 compared with N3. Although only LA conduit strain decreased with aging (r = -0.3204, p = 0011) in controls, all of the LA reservoir (r = -0.325, p = 0.020), conduit (r = -0.314, p = 0.025), and pump strain (r = -0.481, p &lt; 0.001) in rTOF decreased with aging.

Early diastole SR was significantly decreased in the T1 and T3 groups compared with the N1 and N3 groups (T1 vs N1, 3.00 ± 0.63% vs. 4.03 ± 0.0.80%, p &lt;.0.001, T3 vs N3, 2.31 ± 0.57% vs.3.31 ± 0.47%, p &lt; 0.001). Both systolic SR and late diastole SR decreased in T3 group compared with the N3 (1.54 ± 0.32% vs. 2.08 ± 0.42%, p = 0.003, 1.42 ± 0.32% vs.2.42 ± 0.61%, p &lt; 0.001), respectively. Although only early diastole SR decreased with aging (r = -0.415, p &lt; 0.001) in controls, all of the systole (r = -0.287, p = 0.041), early diastole (r = -0.337, p = 0.019), and late diastole SR (r = -0.407, p = 0.003) in rTOF decreased with aging.

CONCLUSIONS

In rTOF, most of the LA functions assessed by strain analysis decreased compared to normal controls in over 20 years old age. Furthermore, all measured functions decreased with age in rTOF while only two parameters decreased with age in normal controls. These results suggest that LA function may be an important indicator in long-term rTOF follow-up. These are new insights into LA function in patients with rTOF.

P1358 New insights into cardiac dysfunction assessed by left atrial function in patients with type 1 diabetes mellitus

BACKGROUND

There have been many reports of heart failure due to diabetic cardiomyopathy and decreased left ventricular (LV) function with increasing age in patients with type 1 diabetes mellitus (T1DM). Recently, although left atrial (LA) function has been occasionally reported to be a more useful prognostic indicator than LV function in acquired heart diseases, LA function in patients with T1DM has not yet been studied.

PURPOSE

To investigate LA dysfunction in patients with T1DM.

METHODS

Fifty patients with T1DM were recruited (age, 5–41 years). We excluded patients who had a history of heart disease, hypertension, and those taking cardioprotective agents. The patients and 50 age-matched controls were classified into 3 age groups (D1, C1, 5–14 years; D2, C2, 15–29 years; D3, C3, 30–41 years). The LA phasic function serving as the reservoir, conduit, and pump strains; the LA strain rate (SR) in the systole, early diastole, and late diastole; and the LV global longitudinal strain (LV-LS) as determined via 2-dimensional speckle tracking imaging were measured from the apical four- and two-chamber views. We also calculated the LA stiffness index as the ratio of E/e’ to the LA reservoir strain.

RESULTS

There was no significant difference in left ventricular ejection fraction in each age group. The LA reservoir strains in D2 and D3 were significantly lower than those in C2 (40.8 ± 5.7% vs. 47.2 ± 5.5%, p = 0.005) and C3 (39.2 ± 5.5% vs. 47.3 ± 5.7%, p = 0.004), respectively. The LA conduit strain in D2 was significantly lower than that in C2 (28.9 ± 5.8% vs. 35.0 ± 5.0%, p = 0.006). The LA pump strain and the three phases of LA SR were not significantly different among the age groups. The LA stiffness index in D3 increased significantly compared to that in N3 (0.18 ± 0.05 vs. 0.13 ± 0.01, p &lt;0.001). The LV-LS in D2 and D3 was significantly lower than that in C2 (-15.7 ± 1.7% vs. -18.7 ± 2.1%, p &lt;0.001) and C3 (-15.3 ± 1.8% vs. -19.3 ± 2.0%, p &lt;0.001), respectively. The LA reservoir strain significantly correlated with LV-LS (r = -0.468, p &lt; 0.001). Both the LA reservoir strain and LV-LS in patients with T1DM decreased significantly (p = 0.028, p &lt; 0.042, respectively) and correlated with increasing age (r = -0.323, r = 0.286, respectively). The LV stiffness index did not correlate with age or LV-LS.

CONCLUSIONS

The LA reservoir strain might be as useful as LV-LS as an early marker of cardiac dysfunction in patients with T1DM. The correlation coefficient between the LA reservoir strain and LV-LS was not strong. Therefore, although LV-LS might affect the LA reservoir strain, it might represent other aspects of cardiac dysfunction. The increase of LA stiffness might represent the changes in LA wall properties and could be another useful indicator of cardiac dysfunction during long-term follow-ups, which is independent of LV-LS. Overall, these findings provide new insights into cardiac dysfunction in patients with T1DM.

Relationship between ethanol consumption and TBL2 rs17145738 on LDL-C concentration in Japanese adults: a four season 3-day weighed diet record study

Background

LDL cholesterol (LDL-C) concentration is modified by dietary and genetic factors; however, little is known about the details of this relationship. Our aim was to investigate the associations taking into account dietary assessment methods, seasonal effects and missing values.

Methods

Study subjects completed food frequency questionnaires (FFQ) and supplied 3-day weighed dietary records (WDRs) and blood samples in four seasons. Approximately 660,000 single nucleotide polymorphisms (SNPs) were measured. Candidate SNPs related to LDL-C concentration were systematically selected. Multiple imputation was applied for missing values. A total of 312 repeated measures data were used for analyses. After adjusting for season and subjects as fixed and random effects, effects of nutrient intake and SNPs on LDL-C concentration were assessed according to three dietary assessment methods: the FFQ and first and four season 3-day WDRs (4 s-3d WDRs).

Results

For LDL-C concentration, ethanol consumption derived from all three dietary assessment methods was consistently associated (P < 0.09 for all). Positive and negative relationships were consistently shown with rs651007 and rs1160985 in the first and four seasons; but the latter remained after adjusting for total dietary fiber intake derived from the FFQ and 4 s-3d WDRs (P < 0.05, excepting the first 3-day WDRs). rs599839 was negatively associated after cholesterol intakes derived from the first and 4 s-3d WDRs were considered (P < 0.05 and 0.07, respectively). Each rs17145738 and ethanol consumption based on the 4 s-3d WDRs was related to LDL-C concentration (P < 0.05). Seasonal variations of LDL-C concentration were observed only in summer.

Conclusions

In contrast to nutrient intake, ethanol consumption was shown to be comprehensively related to LDL-C concentration, regardless of dietary assessment methods. Taking into account seasonal effects, critical relationships with LDL-C concentration for some SNPs, after adjustment for specific nutrients, were revealed. Our findings can be used to help to interpret the relationships between dietary and genetic factors on LDL-C concentration in large-scale epidemiological studies.

(10/10 keywords)

Distribution of gene segments of the pandemic A(H1N1) 2009 virus lineage in pig populations

Swine influenza viruses (SIVs) are important not only for pig farming, but also for public health. In fact, pandemic A(H1N1) 2009 viruses [A(H1N1)pdm09] were derived from SIVs. Therefore, timely characterization of locally circulating SIVs is necessary for understanding the global status of SIVs. To genetically characterize SIVs circulating in Japanese pig populations, we isolated 24 SIVs of three subtypes (17 H1N1, four H1N2 and three H3N2 strains) from 14 pig farms in Japan from 2013 to 2016. Genetic analyses revealed that the haemagglutinin (HA) and neuraminidase (NA) genes of the 17 H1N1 and the HA gene of one H1N2, A/swine/Aichi/02/2016 (H1N2), SIVs belonged to the A(H1N1)pdm09 lineage. More importantly, all of the remaining six gene segments (i.e., PB1, PB1, PA, NP, M and NS) of the 24 SIVs, regardless of the HA and NA subtype, were also classified as belonging to the A(H1N1)pdm09 lineage. These results indicate that gene segments of A(H1N1)pdm09 lineage are widely distributed in SIVs circulating in Japanese pig populations In addition, the NA gene of A/swine/Aichi/02/2016 (H1N2) shared less than 88.5% nucleotide identity with that of the closest relative A/swine/Miyagi/5/2003 (H1N2), which was isolated in Japan in 2003. These results indicate the sustained circulation of classical H1N2-derived SIVs with remarkable diversity in the NA genes in Japanese pig populations. These findings highlight the necessity of both intensive biosecurity systems and active SIV surveillance in pig populations worldwide for both animal and public health.

Swallow-induced esophageal shortening in patients without hiatal hernia is associated with gastroesophageal reflux

Longitudinal esophageal body shortening with swallow-induced peristalsis has been reported in healthy individuals. Esophageal shortening is immediately followed by esophageal re-elongation, and the lower esophageal sphincter (LES) returns to the baseline position. High-resolution manometry (HRM) allows for objective assessment of extent of shortening and duration of shortening. In patients without hiatal hernia at rest, swallow-induced esophageal shortening can lead to transient hiatal hernia (tHH) which at times may persist after the completion of swallow. This manometric finding has not been investigated in the literature, but a question arises whether this swallow-induced transient herniation can effect on the likelihood of gastroesophageal reflux. This study aims to assess the relationship between gastroesophageal reflux and the subtypes of swallow-induced esophageal shortening, i.e. tHH and non-tHH, in patients without hiatal hernia at rest. After Institutional Review Board (IRB) approval, we queried a prospectively maintained database to identify patients who underwent HRM evaluation and 24-hour pH study between January to December 2015. Patients with type-I esophagogastric junction (EGJ) morphology (i.e. no hiatal hernia) according to the Chicago classification v3.0 were included. The patterns of the esophageal shortening with swallows were divided into two subtypes, i.e. tHH and non-tHH. tHH was defined as an EGJ double high-pressure zones (≥1 cm) at the second inspiration after the termination of swallow-induced esophageal body contraction. The number of episodes of tHH was counted per 10 swallows and tHH size was measured for each patient. In total, 41 patients with EGJ morphology Type-I met the inclusion criteria. The mean age was 47.2 years, 35 patients (85.4%) were women, and the mean body mass index was 33.9 kg/m2. The mean number of tHH episodes was 3 out of 10 swallows; mean maximal tHH size was 1.3 cm. Patients who had tHH in ≥3 out of 10 swallows (n = 16; 39.0%) were more likely to have abnormal DeMeester scores than patients with <3 swallows (56% vs. 28%; P = 0.070). Patients with maximal tHH ≥2 cm in at least 1 swallow (n = 17; 41.5%) were more likely to experience pathological reflux than patients with maximal tHH <2 cm (59% vs. 25%; P = 0.029). In conclusion, we showed that, in a subset of patients with Type-I EGJ morphology, swallowing induced transient EGJ double high-pressure zones (≥1 cm) after peristalsis. We have named this new manometric finding the swallow-induced tHH. A high prevalence of pathological reflux disease was observed in patients with maximal tHH ≥2 cm. The degree of swallow-induced tHH could be an early indicator of lower esophageal sphincter dysfunction in patients without manometric hiatal hernia.

Classification for esophagogastric junction (EGJ) complex based on physiology

We propose a new classification for esophagogastric junction (EGJ) incorporating both physiologic and morphologic characteristics. Additionally, we contrast it with the Chicago v 3.0 EGJ classification. With Institutional Review Board (IRB) approval, prospectively maintained database was queried to identify patients who underwent high-resolution manometry (HRM) and pH-study between October 2011 and October 2015. Patients with prior foregut intervention, pH study on acid suppression, esophageal dysmotility, or lower esophageal sphincter-crural diaphragm separation of >5 cm were excluded. We classified patients into three groups-Type-A: Complete overlap of lower esophageal sphincter-crural diaphragm (single high-pressure zone); Type-B: Double high-pressure zone with pressure inversion point (PIP) at or above lower esophageal sphincter; Type-C: Double high-pressure zone with PIP below lower esophageal sphincter. A total of 214 included patients were divided into Type-A (n = 101), Type-B (n = 32), and Type-C (n = 81). Abdominal lower esophageal sphincter length (AL), lower esophageal sphincter pressure (LESP), and lower esophageal sphincter pressure integral (LESPI) were significantly lower in Type-C than both Type-A and Type-B [AL(cm): 0.2 vs. 2(P < 0.001) vs. 1.6(P <0.001); LESP(mmHg): 20.1 vs. 32.1(P < 0.001) vs. 29.2(P < 0.001); LESPI(mmHg.cm.s): 187 vs. 412(P < 0.001) vs. 343(P < 0.05)] while overall lower esophageal sphincter length(OL) and Integrated Relaxation Pressure (IRP) were significantly lower in Type-C than Type-A [OL(cm): 2.9 vs. 3.6(P < 0.001); IRP(mmHg): 8.2 vs. 9.6(P < 0.05)]. Type-C patients had significantly higher positive pH score (>14.7) than Type-A and Type-B [72% vs. 47% (P < 0.05) vs. 41% (P < 0.001)]. In Type-C morphology, there is both anatomical and physiological deterioration, weakest lower esophageal sphincter function (abdominal length, lower esophageal sphincter pressure, and lower esophageal sphincter pressure integral) and is most likely to be associated with pathological reflux. This proposed classification incorporates both physiological and morphological derangements in a graded fashion.

Frequency-dependent selection acting on the widely fluctuating sex ratio of the aphid Prociphilus oriens

Frequency-dependent selection is a fundamental principle of adaptive sex ratio evolution in all sex ratio theories but has rarely been detected in the wild. Through long-term censuses, we confirmed large fluctuations in the population sex ratio of the aphid Prociphilus oriens and detected frequency-dependent selection acting on these fluctuations. Fluctuations in the population sex ratio were partly attributable to climatic factors during the growing season. Climatic factors likely affected the growth conditions of host plants, which in turn led to yearly fluctuations in maternal conditions and sex ratios. In the process of frequency-dependent selection, female proportion higher or lower than ca. 60% was associated with a reduction or increase in female proportion, respectively, the next year. The rearing of aphid clones in the laboratory indicated that mothers of each clone produced an increasing number of females as maternal size increased. However, the mean male number was not related to maternal size, but varied largely among clones. Given genetic variance in the ability to produce males among clones, selection should favour clones that can produce more numerous males in years with a high female proportion. Population-level sex allocation to females was on average 71%-73% for three localities and more female-biased when maternal conditions were better. This tendency was accounted for by the hypothesis of competition among foundresses rather than the hypothesis of local mate competition. We conclude that despite consistent operation of frequency-dependent selection, the sex ratio continues to fluctuate because environmental conditions always push it away from equilibrium.

High-resolution manometry findings in symptomatic post-Nissen fundoplication patients with normal endoscopic configuration

The aim of this study was to investigate high-resolution manometry (HRM) findings in symptomatic post-fundoplication patients with normal endoscopic configuration. A retrospective review of a prospectively maintained database was conducted to identify patients who underwent evaluation with HRM and endoscopy for symptom evaluation after previous fundoplication. Study period extends from September 2008 to December 2012. Only patients with complete 360° fundoplication (Nissen) were included, and patients with partial fundoplication were excluded. Patients with endoscopic abnormality or patients who underwent Collis procedure were also excluded. Additionally, contrast study and 24-hour pH study if done were reviewed. Symptoms were graded using a standard questionnaire with symptoms graded on a scale of 0-3. Symptom grade 2 or 3 was considered a significant symptom. One hundred seventy-nine symptomatic patients with previous Nissen fundoplication underwent HRM and endoscopy during the study period. Of these, 136 patients were excluded (51 had recurrent hiatal hernia, 2 had disrupted fundoplication, 68 had slipped fundoplication, 10 had twisted fundoplication, 2 had esophageal stricture, and 3 had Collis procedure). Remaining forty-three patients met inclusion criteria (mean age of 56.0 ± 14.8, 32 females).The most common symptom was dysphagia (67%). Patients with dysphagia had a significantly longer length of distal esophageal high pressure zone (HPZ) and a higher integrated relaxation pressure (IRP) than patients without dysphagia (P = 0.020, 0.049). Especially, patients who had shorter HPZ (≤2 cm) were less likely to have significant dysphagia. Twenty-three patients (53%) had heartburn. There was no significant difference in HRM findings between patients with and without heartburn. Only 4 of 28 patients with concomitant pH study showed abnormal DeMeester score (>14.7), and there was no correlation between results of pH study and lower esophageal sphincter pressure/length and IRP. Longer HPZ complex length and higher IRP as measured with HRM is associated with post-Nissen fundoplication dysphagia in patients with normal endoscopic configuration. No HRM parameters are associated with reported heartburn or a positive pH score.

Spatiotemporal fluctuations in natural selection acting on the gall-parasitic aphid Tetraneura sorini

The measurement of the selection gradient is crucial for understanding the magnitude of selection acting directly on a trait and predicting the evolutionary trajectory of that trait. This study evaluated the selection gradient acting on the morphology of the gall-parasitic aphid Tetraneura sorini during the galling process and compared the strength among populations. Gall formers (first instars) frequently fight with conspecifics or heterospecifics for usurping incipient galls using their well-developed hind legs. First instars that successfully acquired galls were found within galls, whereas those that failed were found dead on leaf surfaces. Selection gradients were estimated using logistic stepwise regression and partial least square (PLS) regression. Calculated selection differentials indicated that first instars that secured galls were larger in body size than failed individuals through all populations. However, selection gradients on weapon traits varied largely among populations or among years in the same population. We confirmed microevolutionary changes in the relationship between traits, which accorded with the expectation from changes in the selection gradients. When gall formers were transferred onto developing buds individually, individuals that successfully induced galls had smaller body size than failed individuals. Available evidence suggests that the selection gradient on body size becomes higher with an increasing proportion of T. sorini in the Tetraneura species community. Thus, we concluded that more intense fighting with conspecifics leads to stronger selective pressure on body size, but that selective pressure for each trait is variable depending on differences in the tactics and species composition among populations.

Comparison of Brain Activation via Tooth Stimulation

The aim of this study was to evaluate the sensation of each tooth type at the cortical level. The tactical sensation from teeth plays an important role in controlling the masticatory system. However, the role of each tooth type has not been determined. Functional near-infrared spectroscopy (fNIRS) was used to detect changes in cerebral blood flow in the somatosensory cortex of 12 healthy volunteers. Painless vibrotactile stimuli were applied to 8 teeth (left maxillary and mandibular incisors, canines, 1st premolars, or 1st molars). The somatosensory cortex was activated during stimulation of all teeth. A comparison of cortical activation revealed significantly greater activation during stimulation of the maxillary and mandibular first molars. However, no significant differences were seen between any other teeth. These results indicate that the first molar is the most sensitive tooth type at the cortical level, and provide basic data on the relationship between input from individual tooth type and brain activation. These data could be useful for understanding the neural mechanisms of individual tooth types.

Distribution and species composition of juvenile and adult scombropids (Teleostei, Scombropidae) in Japanese coastal waters

Two scombropid fishes, Scombrops boops and Scombrops gilberti, are closely related and commercially important species in Japan. These species are often confused in commercial markets because of their morphological similarity. In this study, scombropid specimens collected from various Japanese coastal waters were subjected to polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis and phylogenetic analysis of the 16S rRNA gene in mitochondrial DNA. These analyses showed that all the scombropid specimens collected from localities in the Sea of Japan were identified as S. boops, whereas those from the Pacific Ocean included two species, S. boops and S. gilberti. Almost all juvenile (<200 mm standard body length, S(L)) S. gilberti originated from the Pacific coastal waters of the northern Japan, whereas adults (>400 mm S(L)) were found only in deep water off the Izu Peninsula to the Izu Islands. This suggests that S. gilberti might migrate extensively during its life cycle. In addition, differences in the number of specimens and the distribution between the two species suggest that S. gilberti is less abundant than S. boops in Japanese waters.

Implementation of a new neurochip using stochastic logic

Even though many neurochips have been developed and investigated, the best suitable way for implementation has not been known clearly. Our approach is to exploit stochastic logic for various operations required for neural functions. The advantage of stochastic logic is that complex operations can be implemented with a few ordinary logic gates. On the other hand, the operation speed is not so fast since stochastic logic requires certain accumulation time for averaging. However, a huge integration can be achieved and its reliability is high because all of operations are done on digital circuits. Furthermore, we propose a nonmonotonic neuron realized by stochastic logic, since the nonmonotonic property is efficient for the performance enhancement in association and learning. In this paper, we show the circuit design and measurement results of a neurochip comprising 50 neurons are shown. The advantages of nonmonotonic and stochastic properties are shown clearly.

Proteomic analysis of stage I primary lung adenocarcinoma aimed at individualisation of postoperative therapy

Although postoperative adjuvant chemotherapy (PAC) with uracil–tegafur significantly improves the prognosis of patients with stage I lung adenocarcinoma, subset analysis has revealed that only 11.5% of patients with stage IB derive actual benefit from such therapy. Therefore, it is extremely important to identify patients for whom adjuvant chemotherapy will be beneficial. We performed comprehensive protein analysis of 24 surgically resected specimens of stage I adenocarcinoma using liquid chromatography-tandem mass spectrometry (LC-MS/MS), followed by bioinformatical investigations to identify protein molecules. Furthermore, we carried out immunohistochemical studies of 90 adenocarcinoma specimens to validate the results of LC-MS/MS. We detected two kinds of protein molecules (myosin IIA and vimentin) by LC-MS/MS. We confirmed their immunohistochemical expression and distribution, and evaluated the relationship between the expression of these proteins and prognosis after adjuvant chemotherapy. Patients with no expression of either myosin IIA or vimentin showed a significantly better outcome regardless of PAC using uracil–tegafur. However, we were unable to select responders to uracil–tegafur using these proteins. Cases of adenocarcinoma lacking expression of either myosin IIA or vimentin show a good outcome without PAC, and therefore do not require such treatment.

Water chemistry gradient in a degraded bog area

Surface and ground water was sampled in a degraded bog area 36 times during 1993 - 2003 at Five representative points: point E (natural area with Sphagnum as the main vegetal cover), point W (boundary between the natural and degraded areas), point W' (area installed with vinyl sheeting), point WW (area where Sasa thrives), and point NC (area with naturally formed ditches). Analysis of variance (ANOVA) was conducted for parameters measured in surface water and ground water at 0.5, 1.0, 1.5, and 2.0 m depths. "Sampling point" (i.e. locations along the degradation gradient) accounted for most of the variation in surface and ground water chemistry. It accounted for 30-80% of the total variation in pH, electrical conductivity, ammonia, dissolved nitrogen, major cations (Na+, K+, Ca2+, Mg2+), alkalinity and dissolved organic carbon. "Year" accounted for more variation in nitrate, nitrite, chloride, and sulfate than the sampling point did, but the variation in dissolved reactive phosphorus and dissolved phosphorus concentrations was not based on any of the calculated variables.

Chromosome polymorphism and C-banding variation of the brachypterous grasshopper Podisma sapporensis Shir. (Orthoptera, Acrididae) in Hokkaido, northern Japan

The grasshopper Podisma sapporensis consists of two main chromosome races in Hokkaido. The western group of populations of P. sapporensis, belonging to the XO race, has a diploid number of chromosomes 2n = 23 in the male and 2n = 24 in the female (sex determination XO male/XX female). The eastern group of populations of this species, belonging to the XY race, differs from the western one as a result of Robertsonian translocation between the originally acrocentric X chromosome and M5 autosome in homozygous state, having resulted in the forming of chromosome sex determination neo-XY male/neo-XX female (2n = 22). These races are geographically isolated by the mountainous system consisting of the Mts Daisetsu and Hidaka range, occupying the central part of the island. The hybrid zones between the races have not so far been discovered. Various levels of polymorphism for the pericentric inversions and C-banding variation exist in different chromosomes throughout populations in both chromosome races. In some solitary populations (the population at the summit of Mt Yotei, populations in the vicinity of Naganuma, Oketo, and Tanno) pericentric inversions are fixed in some pairs of chromosomes, which enables marking of the discrete karyomorphes. In the Mt Daisengen population all chromosomes are two-armed as a result of fixing the pericentric inversions. These facts contradict karyotypical conservatism of the tribe Podismini. The level of diversity of P. sapporensis karyotypes could provide a new perspective on the evolutionary process of different karyotype in Orthoptera. The considerable occurrence of polymorphism in chromosomes suggests that karyotypic diversification is undergoing in P. sapporensis. The authors also proposed that P. sapporensis would be divided into four chromosome subraces in the XO chromosome race and two chromosome subraces in the XY race, on the basis of karyotypic features. These races may have been established by fundamental climatic changes during the glacial epoch.

Preliminary thermographic evaluation of new nitroglycerine tape on the peripheral circulatory disturbance in systemic sclerosis

OBJECTIVE

To evaluate the effects of newly developed nitroglycerine (NTG) tape on the peripheral circulatory disturbance in systemic sclerosis (SSc).

METHODS

The finger temperature (FT) of 25 patients with SSc was monitored by thermography before the application of NTG tape to the wrist and one hour afterwards. To check the placebo effect, the change of FT with placebo tape in six patients who had shown a distinct rise in FT (>2 degrees C) with NTG tape was monitored.

RESULTS

Twenty one patients with SSc had a low FT before the application of NTG tape (colder than mean-2SD of normal controls). FT was significantly raised in patients with SSc after the application of NTG tape (p<0.01). Patients with low FT showed a distinct rise in FT more often than patients with a normal FT (71% v 0%, p<0.01). FT was raised with NTG tape more than with placebo tape (4.2 (SD 1.9) degrees C v 2.2 (2.8) degrees C, p<0.05).

CONCLUSION

The application of NTG tape increases peripheral circulation in patients with SSc who have distinct circulatory disturbance. The application of NTG tape may improve peripheral circulatory disturbance in SSc.

B chromosomes, translocation between B and autosomes, and C-heterochromatin polymorphism of the grasshopper Podisma sapporensis Shir. (Orthoptera, Acrididae) in Hokkaido, northern Japan

Seven categories of B chromosomes found in the brachypterus grasshopper Podisma sapporensis from Hokkaido populations differ in structure, size, and C-band content. The interchange between B and one autosome from M3 and sporadically M7 was observed in most of the populations examined. Such an interaction between standard and non-standard chromosomal set provides an insight into the integration of supernumerary chromosome. In addition, C-heterochromatin polymorphism was also identified in male karyotypes in some populations. These facts indicate P. sapporensis is a highly polymorphic species from the cytogenetic point of view.

Genetic variation in 16S-23S rDNA internal transcribed spacer regions and the possible use of this genetic variation for molecular diagnosis of Bacteroides species

The structural variation in 16S-23S rDNA internal transcribed spacer regions (ITS) among Bacteroides species was assessed by PCR amplification and sequencing analysis, and its possible use for molecular diagnosis of these species was evaluated. Ninety strains of the genus Bacteroides, including the species B. distasonis, B. eggerthii, B. fragilis, B. ovatus, B. thetaiotaomicron, B. uniformis and B. vulgatus, produced one to three ITS amplification products with sizes ranging from 615 to 810 bp. Some Bacteroides strains could be differentiated at species level on the basis of ITS amplification patterns and restriction fragment length polymorphism (RFLP) analysis using a four-nucleotide-recognizing enzyme, Msp I. The results of sequence analysis of ITS amplification products revealed genes for Ile-tRNA and Ala-tRNA in all strains tested. The nucleotide sequence, except for that in tRNA-coding regions, was highly variable and characteristic for each species, but a common sequence among B. fragilis, B. thetaiotaomicron and B. ovatus was observed. A digoxigenin-labeled oligonucleotide probe (named FOT1), which was designed from this conserved sequence, specifically hybridized to the ITS amplification products from B. fragilis, B. thetaiotaomicron and B. ovatus. These results suggest that the ITS region is a useful target for the development of rapid and accurate techniques for identification of Bacteroides species.

Modified windmill porphyrin arrays: coupled light-harvesting and charge separattion, conformational relaxation in the S1 state, and S2-S2 energy transfer

The architecture of windmill hexameric zinc(II) -porphyrin array 1 is attractive as a light-harvesting functional unit in view of its three-dimensionally extended geometry that is favorable for a large cross-section of incident light as well as for a suitable energy gradient from the peripheral porphyrins to the meso-meso-linked diporphyrin core. Three core-modified windmill porphyrin arrays 2-4 were prepared for the purpose of enhancing the intramolecular energy-transfer rate and coupling these arrays with a charge-separation functional unit. Bisphenylethynylation at the meso and meso' positions of the diporphyrin core indeed resulted in a remarkable enhancement in the intramolecular S1-S1 energy transfer in 2 with tau=2 approximately 3 ps, as revealed by femtosecond time-resolved transient absorption spectroscopy. The fluorescence lifetime of the S2 state of the peripheral porphyrin energy donor determined by the fluorescence up-conversion method was 68 fs, and thus considerably shorter than that of the reference monomer (150 fs), suggesting the presence of the intramolecular energy-transfer channel in the S2 state manifold. Such a rapid energy transfer can be understood in terms of large Coulombic interactions associated with the strong Soret transitions of the donor and acceptor. Picosecond time-resolved fluorescence spectra and transient absorption spectra revealed conformational relaxation of the S1 state of the diporphyrin core with tau = 25 ps. Upon photoexcitation of models 3 and 4, which bear a naphthalenetetracarboxylic diimide or a meso-nitrated free-base porphyrin attached to the modified diporphyrin core as an electron acceptor, a series of photochemical processes proceeded, such as the collection of the excitation energy at the diporphyrin core, the electron transfer from the S1 state of the diporphyrin to the electron acceptor, and the electron transfer from the peripheral porphyrins to the diporphyrin cation radical, which are coupled to provide a fully charge-separated state such as that in the natural photosynthetic reaction center. The overall quantum yield for the full charge separation is better in 4 than in 3 owing to the slower charge recombination associated with smaller reorganization energy of the porphyrin acceptor.

Determination of serum prostate-specific antigen-alpha1-antichymotrypsin complex for diagnosis of prostate cancer in Japanese cases

OBJECTIVE

The clinical utility of the determination of serum prostate-specific antigen-alpha1-antichymotrypsin complex (PSA-ACT) for the diagnosis of prostate cancer, especially in cases in the diagnostic gray zone, is still unclear.

MATERIAL AND METHODS

With the use of a newly approved enzyme immunoassay for the detection of PSA-ACT, 907 sera, including those from non-urological benign and malignant diseases, were analysed.

RESULTS

Serum values of PSA-ACT in non-prostate cancer males increased according to age from the 40s to 70s. The serum values were high only in the patients with prostatic diseases and, in prostate cancer patients, the values became high as the clinical stage progressed. By receiver-operating characteristic analysis significantly better results in PSA-ACT than total PSA were observed. In the group with a total PSA of 2-20 ng/ml, the detection of PSA-ACT showed better results, although not significantly so, than the free-to-total PSA ratio.

CONCLUSIONS

The detection of PSA-ACT showed a high clinical utility in the diagnosis of prostate cancer. Therefore, it may replace total PSA determination.

Cytoplasmic beta-catenin accumulation as a predictor of hematogenous metastasis in human colorectal cancer

The membranous, cytoplasmic and nuclear levels of beta-catenin were evaluated immunohistochemically in archival tissue specimens from 96 Japanese patients with primary colorectal carcinoma who had undergone surgery. The relationships between beta-catenin and clinicopathological variables were analyzed statistically. Reduced beta-catenin immunoreactivity in the cell membranes of cancer cells was found in 70% of the tumors, and cytoplasmic and nuclear accumulation of beta-catenin were found in 68 and 66% of tumors, respectively. Significant correlations between cytoplasmic beta-catenin accumulation and the depth of invasion, venous invasion and focal dedifferentiation were observed. Cytoplasmic beta-catenin accumulation was also found to be a useful predictor of hematogenous metastasis (hazard ratio = 8.94, p = 0.054), though neither a reduced cell membrane level nor nuclear accumulation of beta-catenin correlated with metastasis.

Response of prostate-specific antigen after androgen withdrawal and prognosis in men with metastatic prostate cancer

OBJECTIVE

Patients with prostate cancer generally respond to androgen withdrawal therapy, but progression to androgen independence is frequently observed. To evaluate prognostic factors in metastatic prostate cancer, patients who had been treated with endocrine therapy were investigated.

METHODS

One hundred and thirty-nine patients with untreated metastatic prostate cancer (TxNxM1) who received endocrine therapy between 1986 and 1993 were included in the present study. Blood chemistry, histological grade, extent of bony metastases, clinical response to hormone therapy, and the prognosis of the patients were evaluated.

RESULTS

With univariate analysis, performance status, hemoglobin concentration, serum alkaline phosphatase, lactate dehydrogenase, histological grade, extent of bony disease, and response of prostate-specific antigen (PSA) at 3 months were shown to be significant prognostic factors. With multivariate analyses, response of PSA and histological grade were significant factors predicting prognosis.

CONCLUSIONS

Patients whose PSA had not normalized 3 months after the start of endocrine therapy were in the high-risk group, and should be given more aggressive treatment.

Incidence and characteristics of antiandrogen withdrawal syndrome in prostate cancer after treatment with chlormadinone acetate

OBJECTIVES

In patients with progressive prostate cancer who have been treated with surgical or medical castration plus an antiandrogen, antiandrogen withdrawal can result in a significant decline in serum prostate-specific antigen (PSA). Although the incidence of antiandrogen withdrawal syndrome after combination treatment with the nonsteroidal antiandrogen flutamide has been thoroughly documented, the phenomenon clearly occurs in many other combination therapies and is presently being widely investigated. This paper would like to contribute to this effort by describing the endocrine withdrawal phenomenon in patients treated with combinations of castration plus chlormadinone acetate, ethynylestradiol or estramustine phosphate.

MATERIALS AND METHODS

Clinical records of 68 prostate cancer patients who had been treated with surgical castration plus the administration of chlormadinone acetate, ethynylestradiol or estramustine phosphate, and who had shown clinical progression associated with a steady increase in serum PSA, were investigated. Forty-one cases were evaluable for changes in PSA after discontinuation of the hormonal agents.

RESULTS

Of 28 patients who had been treated with chlormadinone acetate, 12 (42.9%) revealed 50% or more decline in PSA level following withdrawal of the agent. Among these, 5 cases (17.9%) showed subjective and/or objective improvements. There was no significant difference in histological grade of the tumor at diagnosis, mode of progression, time interval from the start of endocrine therapy to discontinuation of the hormonal agents, or PSA level at withdrawal of the agents between patients who did develop antiandrogen withdrawal syndrome and those who did not.

CONCLUSION

When a steady increase in serum PSA is noted in a prostate cancer patient who has been treated with castration plus a steroidal antiandrogen, discontinuation of the antiandrogen may benefit the patient.

Tumor growth and metastasis of human colorectal cancer cell lines in SCID mice resemble clinical metastatic behaviors

Ten human colorectal cancer (CRC) cell lines were implanted orthotopically into the ceca and also into the livers, muscles and peritoneal cavities of SCID mice in order to analyze the characteristics regulating metastatic behaviors of CRCs. All the CRC cell lines formed tumors in the muscle and cecum, but they could be classified into two groups: (1) six cell lines with high tumorigenicity in the liver (HTLs) forming differentiated tumors, and (2) four with no tumorigenicity in the liver (NTLs) forming poorly differentiated tumors in SCID mice. After orthotopic implantation, NTLs never metastasized to the liver, whereas HTLs did. Therefore, intrahepatic tumorigenicity and differential status were closely associated with liver metastasis whereas differentiation was not associated with lung metastasis. The 6 HTLs demonstrated an inverse correlation between liver metastases and peritoneal dissemination, and immunohistochemistry indicated expression of sLeX, CA19-9 and carcinoembryonic antigen in tumors which correlated well with the liver metastatic rate. We found a strong correlation between liver metastasis and intrahepatic tumorigenicity and could reproduce the clinical correlations between the pattern of the metastatic spread and the differentiation phenotype of CRC in vivo. We consider further examination using this model will be useful for analyzing the complex mechanisms involved in clinically metastasizing CRCs.

Outbreak of human parvovirus B19 in hospital workers

We report an outbreak of human parvovirus B19 (HPV B19) infection affecting five nursing staff, four hospital office workers and one physiotherapist and its possible transmission between hospital staff. We investigated the presence of the virus in serum specimens using a nested PCR assay to confirm HPV B19 infection. The viral genome was detected in serum specimens from a nurse with a rash and arthralgia and from three hospital office workers with a febrile illness. The DNA sequence of the PCR products from three staff members was identical. Our findings suggest that transmission of HPV B19 between hospital staff members occurred.

Disaccharide analysis of skin glycosaminoglycans in atrophoderma of Pasini and Pierini

There are divergent opinions as to whether atrophoderma of Pasini and Pierini (APP) is a nosologic entity or a primary atrophic morphoea. In this study, we used high performance liquid chromatography to analyse the skin disaccharide contents of glycosaminoglycan (GAG) in two patients with APP and compared the results with those from a typical atrophic morphoea patient. Perilesional uninvolved skin was used as a control in each patient. In the atrophic phase morphoea, both the total amount of disaccharide per skin punch-biopsy and the amount of DeltaDi-4S(DS) - the main disaccharide unit of dermatan sulphate - per mg dry weight were increased. These changes were consistent with sclerotic phase morphoea. In contrast, the total amount of disaccharide per skin punch-biopsy was decreased and the amount of DeltaDi-4S(DS) per mg dry weight was decreased or unchanged in APP. Our results suggest that GAG metabolism in APP may be unique and quite different from that in morphoea.