A case of atrial septal defect with right-to-left shunting without pulmonary hypertension

We report a case of a 54-year-old man with atrial septal defect who presented with oxygen desaturation on pulse oximetry. Cardiac magnetic resonance imaging and transesophageal echocardiography showed right-to-left shunting through an atrial septal defect, which was confirmed by superior vena cavography and suggested Eisenmenger syndrome. However, cardiac catheterization revealed a normal pulmonary arterial pressure. Simultaneous measurement of interatrial pressure identified two transient interatrial pressure gradient points, where the right atrial pressure was higher than the left atrial pressure. The patient was finally diagnosed with atrial septal defect without pulmonary hypertension. Right-to-left shunting was primarily caused by a transient interatrial pressure gradient due to a time delay in both initial atrial contraction and completion of passive ventricular filling between the right and left sides of the heart. Surgical closure of the atrial septal defect was performed, and hypoxemia improved. This is the first report of right-to-left shunting without pulmonary hypertension caused by a transient interatrial pressure gradient due to a time delay between the right and left cardiac cycles. Precise assessment of the simultaneous interatrial pressure in addition to diagnostic imaging played a pivotal role in clarifying the etiology of this rare condition.

Learning objective

Atrial septal defect with right-to-left shunting without Eisenmenger syndrome is a rare condition. We identified transient interatrial pressure gradients associated with a time delay in both initial atrial contraction and completion of the passive ventricular filling phase, which we considered as the primary mechanism underpinning right-to-left shunting. Simultaneous measurement of interatrial pressure played a pivotal role in elucidating the hemodynamics and abnormal shunt flow mechanism.

Prognosis of low-flow low-gradient aortic valve stenosis with atrial fibrillation

Background

Patients with Low-flow low-gradient (LFLG) aortic valve stenosis (AS) have possibly poor prognosis. Recently, it was reported that the LFLG AS patients have similar outcomes compared to high-gradient (HG) patients but worse outcomes compared to the normal-flow low-gradient [NFLG: SVi≥35 ml/m2, mPG <40mmHg] subgroup. The main determinant of LF state in severe AS patients with preserved LVEF are male gender, heart rate, LV volume and atrial fibrillation (AF). However, the relationship between the comorbidity with AF in LFLG AS and the risk of heart failure (HF) remains unclear.

Purpose

We elucidated about the prognosis of LFLG AS with AF.

Methods

We included 225 consecutive patients with severe AS (SAS, iAVA<0.6 cm2/m2) from 2013 to 2020. Among these patients, high-gradient SAS [HG-SAS; mean pressure gradient (mPG) ≥40 mmHg, n=88] and LFLG AS [stroke volume index (SVi) ≤35 ml/m2, mPG <40 mmHg, n=82] patients was extracted and the baseline characteristics including the presence or absence of AF were evaluated. The primary endpoint was worsening HF that required unplanned hospitalization or readjustment of HF drug therapy.

Results

Among patients with HG SAS and LFLG AS, worsening HF was observed in 65 patients. LFLG AS patients exhibited a higher oral rate of renin-angiotensin-system inhibitors (p=0.02). In addition, SVi and E/e' was lower in LFLG AS patients compared with HG SAS [SVi; 29.4 (24.4–34.0) versus 37.7 (28.2–45.3), p<0.0001, E/E'; 16.0 (13.1–21.5) vs 20.9 (16.0–27.4), p=0.002]. There is no differences between 2 groups in AF prevalence. Furthermore, 2 groups were subdivided as follow; HG SAS with AF (n=25), HG SAS without AF (n=63), LFLG AS with AF (n=24), LFLG AS without AF (n=58). The Kaplan Meier curves demonstrated LFLG SAS with AF experienced higher rate of worsening HF compared with HG SAS without AF and equivalent rate of worsening HF compared with HG SAS with AF (log rank, p<0.001). In the Cox hazard analysis among the LFLG AS patients, LFLG AS with paroxysmal AF (pAF, n=12) instead of chronic AF (cAF, n=12) showed a higher risk for worsening HF compared with those without AF (HR 5.0; 95% CI, 1.8–14; p=0.0028, HR 1.9; 95% CI, 0.62–5.8; p=0.26, respectively).

Conclusion

LFLG AS with AF exhibited a poor prognosis for HF compared with HG SAS without AF and equivalent rate of worsening HF compared with HG SAS with AF. Furthermore, the presence of pAf was associated with an increased risk of HF in patients with LFLF AS. Thus, intervention including drugs and catheter ablation for pAF in LFLG AS patients could lead to prevent worsening clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

Relationship between age and the impact of revascularization on mortality in patients with non-ST-elevation myocardial infarction

Background

It is known that the early coronary revascularization in patients with non-ST-elevation myocardial infarction (NSTEMI) was associated with favorable clinical outcomes. However, it is still unclear whether this efficacy is equivalent over all the ages of the patients.

Methods

Patients with NSTEMI were screened from the database of the Tokyo CCU network registry. Of those, the patients treated without revascularization (medical treatment) were matched with the patients receiving revascularization by propensity score matching. The probabilities of in-hospital death were calculated in the logistic regression model. In two subgroups stratified according to median of the age (elderly and non-elderly subgroups), the odds ratios of revascularization for in-hospital death were calculated.

Results

In the patients registered between 2013 and 2017, 4,851 patients with NSTEMI were identified. After the screening, 370 patients with medical treatment were matched with 370 patients treated with revascularization. The incidence of in-hospital death was significantly higher in the patients with medical treatment (20.3% vs 13.0%, P=0.01). The two probability curves of in-hospital death in patients with and without revascularization converged as age increased. In the elderly subgroup, the revascularization was not significantly associated with favorable outcome of mortality, whereas it had a significant impact on mortality in the non-elderly subgroup (odds ratio: 0.47 [95% CI 0.23–0.95]).

Conclusion

The impact of revascularization on short-term mortality in patients with NSTEMI tended to be reduced as age increased.

Funding Acknowledgement

Type of funding source: None

The impact of low diastolic blood pressure on 30-day mortality of patients with acute myocardial infarction

Background

It is known that low diastolic blood pressure (DBP) is associated with long-term cardiovascular events after acute myocardial infarction (AMI). However, the impact of low diastolic blood pressure on short-term outcome has not yet been well investigated.

Methods and results

We included 15,208 patients who were hospitalized for AMI and registered in the Tokyo CCU network registry between 2013 and 2016. Thirty-day in-hospital mortality rate was 4.8% (728/15,208). To assess the relationship between DBP at the time of admission and 30-day mortality non-linearly, spline regression model was applied with the stratification of the cohort according to tercile of systolic blood pressure (SBP, low:≤122 mmHg, intermediate:123–148 mmHg, high:≥149 mmHg) and J-curve phenomenon was observed in the low and high SBP groups. In multivariate logistic regression analysis, adjusted odds ratio of the lowest quintile of DBP (≤64 mmHg) was 1.65 (95% CI:1.02–2.66) in low SBP group and 4.55 (95% CI:1.72–12.00) in high SBP group.

Conclusion

Low DBP was associated with increased 30-day in-hospital mortality rate after AMI even in patients with high SBP.

Funding Acknowledgement

Type of funding source: None

Relationship between pneumatization of lateral recess in the sphenoid sinus and removal of cavernous sinus invasion in pituitary adenomas by endoscopic endonasal surgery

Background:

Endoscopic endonasal transsphenoidal surgery (EES) is the gold standard for pituitary adenoma (PA) resection. The sphenoid sinus (SS), a highly variable anatomic structure, is located in the center of the cranial base. It has previously been reported that poor pneumatization of the lateral recess of the SS (LRSS) increases the difficulty level of the surgery and the risk of neural and vascular injury. However, to date no studies have evaluated the association between LRSS volume and PAs removal rate by EES.

Methods:

The present study analyzed 23 consecutive patients with new-onset PAs categorized as Knosp Grades 3 and 4 who underwent EES. A retrospective radiographic analysis was conducted on patients undergoing magnetic resonance imaging and high-resolution computed tomography scans.

Results:

Among PA cases categorized as Knosp 3 and 4, no significant association was found between the whole tumor’s resection rate and LRSS volume (R = 0.08, P = 0.70). However, a significant association was found between cavernous sinus (CS) tumors’ removal rate and LRSS volume (R = 0.52, P = 0.011). The same results were achieved in PAs with a Knosp Grade 4, with a stronger correlation (R = 0.60, P = 0.014).

Conclusion:

The development of LRSS pneumatization affects the removal rate of CS tumors in PAs. Preoperative analysis of LRSS development should be considered when planning EES against PA with CS invasion.

P850Clinical difference of recent myocardial infarction compared with acute myocardial infarction - Insights from Tokyo CCU network multicenter registry

Background

Although the patient's characteristics and outcome of acute myocardial infarction (AMI) have been sufficiently investigated and primary percutaneous coronary intervention (PCI) has been recognized as established treatment strategy, those of recent myocardial infarction (RMI) have not been fully evaluated.

Purpose

The purpose of the present study was to clarify clinical characteristics and in-hospital outcomes of RMI patients from the database of the Tokyo CCU network multicenter registry.

Methods

In Tokyo CCU network multicenter registry database from 2013 to 2016, 15788 consecutive patients were registered as AMI (within 24 hours from onset) and RMI (within 2–30 days from onset). However 1246 patients were excluded because of inadequate data. And we excluded 66 cases because of out of onset period and 129 cases that strongly suspected of involvement of vasospastic events. Therefore, remaining 14347 patients were categorized to RMI group (n=1853) and AMI group (n=12494), and analyzed.

Results

Compared with AMI group, average age was older (70.4±12.9 vs 68.0±13.4 years, p<0.001), male was less (72.4 vs 76.4%, p<0.001), chest pain as chief complaint was less (75.2 vs 83.6%, p<0.001), prevalence of diabetes mellitus was higher (35.9 vs 31.0%, p<0.001), multi-vessel coronary disease was more (54.7 vs 44.6%, p<0.001), patients undergoing PCI was less (79.0 vs 91.2%, p<0.001), and the incidence of mechanical complication was more in RMI group (3.0 vs 1.5%, p<0.001). Although 30-day mortality was equivalent between 2 groups (5.3 vs 5.8%, p=0.360), the major cause of death in AMI group was cardiogenic shock, while in the RMI group it was a mechanical complication. On Kaplan-Meier analysis, the 2 groups had significantly different cumulative incidence of death due to cardiogenic shock (p=0.006, Log-rank test) and mechanical complication (p=0.021, Log-rank test). Furthermore death due to mechanical complication in AMI group was plateau after about 1 week from hospitalization, whereas in RMI group it continued to increase.

Kaplan-Meier analysis

Conclusions

RMI patients had distinctive clinical features in backgrounds and treatment strategies compared with AMI patients, and the major cause of death of RMI patients was different from that of AMI patients. Furthermore, even though treatment during hospitalization of RMI patients was well done, death due to mechanical complications continued to increase.

Abstract P4-11-02: Subjective and objective assessment of efficacy of frozen gloves and socks to prevent nab-paclitaxel-induced peripheral neuropathy in patients with breast cancer

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a frequent side-effect of taxanes which play a central role in the treatment of breast cancer. CIPN can negatively influence long-term quality of life, warranting the development of effective prevention strategies. This study investigates the efficacy of frozen gloves and socks (FGS) in reducing the incidence and severity of nab-paclitaxel-induced peripheral neuropathy. Endpoints were evaluated using both clinician and patient reports.

Methods: This is a multicenter phase II single arm trial study of the effects of FGS for advanced or metastatic breast cancer patients receiving nab-paclitaxel (260 mg/m2) every 3 weeks. Patients wore FGS on their diseased side hand and foot for 60 min during infusion. The other side acted as the untreated control. CIPN was assessed using Patient Neurotoxicity Questionnaire (PNQ), PRO-CTCAE and CTCAE at baseline and every cycle of nab-paclitaxel. The primary endpoint was the incidence of CIPN assessed by PNQ (grade C or higher) after receipt of up to 4 cycles of nab-paclitaxel.

Results: Between September 2012 and January 2015, 50 patients from 16 sites were enrolled in this study. Of 50 patients, 27 (54%) received at least 4 cycles of nab-paclitaxel. There was a trend for the incidence of CIPN assessed by PNQ and PRO-CTCAE to be lower in the intervention side than in the control side, although this difference was not statistically significant. The incidence of CIPN assessed by CTCAE was significantly lower in the treated hand (Table).

Conclusions: Among breast cancer patients who received nab-paclitaxel, FGS produced favorable effects as detected by reduced clinician-reported CTCAE grades for CIPN, although the study did not detect differences in self-reported symptoms of CIPN using PRO-CTCAE or PNQ. Clinical trial information: UMIN000007907.

Difference according to the evaluation method of CIPN   Hands (%)  Feet (%)   InterventionControlp*InterventionControlp*Patient-Reporting CIPNPNQ (grade C or higher)12190.3416160.63Patient-Reporting CIPNPRO-CTCAE       Severity ≥ Moderate13180.0815160.56 Interference ≥ Somewhat7100.328100.32Clinician-Grading CIPNCTCAE (≥ Grade II)15190.0314131.0

*McNemar's test

Citation Format: Yamashita T, Hattori M, Nakada T, Hayashi T, Kamei K, Tatsuya T, Nagao Y, Mase T, Wada M, Mizuno T, Shimozuma K, Iwata H, Yamaguchi T. Subjective and objective assessment of efficacy of frozen gloves and socks to prevent nab-paclitaxel-induced peripheral neuropathy in patients with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-11-02.

Deautonomization by singularity confinement: an algebro-geometric justification

The ‘deautonomization’ of an integrable mapping of the plane consists in treating the free parameters in the mapping as functions of the independent variable, the precise expressions of which are to be determined with the help of a suitable criterion for integrability. Standard practice is to use the singularity confinement criterion and to require that singularities be confined at the very first opportunity. An algebro-geometrical analysis will show that confinement at a later stage leads to a non-integrable deautonomized system, thus justifying the standard singularity confinement approach. In particular, it will be shown on some selected examples of discrete Painlevé equations, how their regularization through blow-up yields exactly the same conditions on the parameters in the mapping as the singularity confinement criterion. Moreover, for all these examples, it will be shown that the conditions on the parameters are in fact equivalent to a linear transformation on part of the Picard group, obtained from the blow-up.

Secretion of Mono- and Diacylglycerol Lipase fromPenicillium camembertiiU-150 bySaccharomyces cerevisiaeand Site-directed Mutagenesis of the Putative Catalytic Sites of the Lipase

Yeast cells carrying intronless mono- and diacylglycerol lipase (MDGL) genes, constructed by recombination of the genomic gene and cDNA, secreted MDGL into the culture supernatant. Most of the yeast MDGL were extensively glycosylated while they had a similar glyceride specificity to that of native MDGL. Site-directed mutagenesis was used to directly confirm the involvements in enzyme activity of the presumptive amino acid residues to form the catalytic center of MDGL. These residues were conserved in the primary structure alignment of a lipase family from filamentous fungi. Mutant lipase proteins in which Ser83, Ser145, or His259 was replaced with glycine were secreted by yeast transformants as inactive proteins. Mutant proteins replacing Asp199 with glycine or asparagine were not detected in the culture supernatant. Replacing other two highly conserved aspartic acids (at positions 232 and 243) with glycine did not render the enzyme inactive. These results indicate that Ser83, Ser145, and His259 in MDGL, are essential to enzyme activity. Asp199 is also likely to be involved.

Phase II Clinical Study of Protection of Nail Change and Skin Toxicity by Using a Frozen Glove in Japanese Patients with Early Breast Cancer Treated by Docetaxel and Cyclophosphamide (TC) [TBCRG-03 Study]

Background: The combination docetaxel with cyclophosphamide (TC) regimen is one of standard treatment for early breast cancer patients. TC regimen has been widely used in Japan. However, a management for adverse event such as especially edema and nail/skin toxicity by docetaxel is very important due to give a completely full dosage. This multicenter phase II study was designed to evaluate the protection of nail and skin toxicity by using a frozen glove for early breast cancer patients treated by TC.Methods: Four cycles of docetaxel (75mg/m2) and cyclophosphamide (600mg/m2) administered intravenously (i.v.) every 21 days after surgery for primary breast cancer. All patients were attached frozen glove at right or left hand (protected hand) from 15 minutes before to 30 minutes after administration of docetaxel. The other hand (control hand) of same patient is not attached frozen glove between a administration of TC. Safety was assessed every cycle after the start of treatment. Primary endpoint is comparison the rates of nail and skin toxicity between protected and control hand. Secondary endpoints are feasibility of adjuvant TC regimen and adverse events by frozen glove in Japanese women.Results: Fifty two patients were enrolled from September 2007 to June 2008. The nail changes (grade 1 and 2) was occurred in 10 events (19.2%) and 19 events (36.5%) at protected and control hand, respectively. The skin toxicity was occurred in 14 events (26.9%, G1:8, G2:6) and 21 events (40.4%, G1:14, G2:7) at protected and control hand, respectively. The appearance of nail and skin toxicity was significantly decreased at protected hand than control hand (p=0.01). Overall, 41 patients (78%) completed the planned four cycles of TC without dose reductions or study discontinuation. One patient discontinued because of hematological toxicity defined as discontinuation by protocol. The dose reductions were necessary in 10(19%) patients because of hematological (febrile neutropenia) and non hematological toxicity by TC. Grade 3 and 4 adverse events (AEs) were neutropenia (G3:3.9%, G4:21.6%), febrile neutropenia (21.2%), fatigue (1.9%) and dermatitis (3.8%). Grade 1 or 2 AEs frequently observed (more than 20%) were dermatitis such as rash (45%, G1:29.4%, G2:15.7%), pigmentation, nausea, anorexia, disturbance of taste, tear dropping, fatigue, edema and peripheral sensory disturbance. However, there are no adverse events by frozen glove.Conclusion: TC is feasible regimen for early Japanese breast cancer patients after surgery. Frozen glove may be useful procedure which protected the nail and skin toxicity. Furthermore, it is necessary to protect the severe dermatitis due to completely performed planned TC treatment after surgery in Japan.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 808.

Practical asymmetric synthesis of a selective endothelin A receptor (ETA) antagonist

[structure: see text]. A practical, chromotography-free asymmetric synthesis was developed for the large scale preparation of an endothelin receptor antagonist 2. This synthesis includes a new efficient process for the preparation of 6-bromo-2,3-dihydrobenzofuran, a stereoselective conjugate addition of an aryllithium followed by stereospecific addition of the Grignard reagent of the top aryl bromide, and an aminophosphate-mediated sterospecific intramolecular enolate alkylation, which led to the formation of the five-membered ring bearing three contiguous asymmetric centers.

Synthesis of a muscarinic receptor antagonist via a diastereoselective Michael reaction, selective deoxyfluorination and aromatic metal-halogen exchange reaction

An efficient synthesis of a structurally unique, novel M(3) antagonist 1 is described. Compound 1 is conveniently disconnected retrosynthetically at the amide bond to reveal the acid portion 2 and the amine fragment 3. The synthesis of key intermediate 2 is highlighted by a ZnCl(2)-MAEP complex 19 catalyzed diastereoselective Michael reaction of dioxolane 7 with 2-cyclopenten-1-one (5) to establish the contiguous quaternary-tertiary chiral centers and a subsequent geminal difluorination of ketone 17 using Deoxofluor in the presence of catalytic BF(3).OEt(2). The synthesis of the amine moiety 3 is highlighted by the discovery of a novel n-Bu(3)MgLi magnesium-halogen exchange reaction for selective functionalization of 2,6-dibromopyridine. This new and practical metalation protocol obviated cryogenic conditions and upon quenching with DMF gave 6-bromo-2-formylpyridine (26) in excellent yield. Further transformations afforded the amine fragment 3 via reductive amination with 35, Pd-catalyzed aromatic amination, and deprotection. Finally, the highly convergent synthesis of 1 was accomplished by coupling of the two fragments. This synthesis has been used to prepare multi-kilogram quantities of the bulk drug.

Isolation and characterization of a trypsin-like protease from Trichoderma viride

A serine endopeptidase with a molecular mass of 25 kDa has been purified from the culture filtrate of Trichoderma viride to electrophoretic homogeneity. The isoelectric point was determined at 7.3. Two carboxyl sites at Arg22 and Lys29 of the oxidized insulin B-chain were cleaved, and peptidyl-p-nitroanilide substrates with Lys or Arg at the P1 position were also hydrolyzed by the enzyme. These results suggest that the specificity of T. viride protease is similar to that of trypsin. However, the hydrolytic activity toward casein of T. viride protease was less than that of porcine trypsin. The amino-terminal sequence of the enzyme protein is similar to that of bovine trypsin. It seems that the trypsin of T. viride is a protease which is promising for the substitution of animal trypsin in the food industry and in medicine at this stage.

Seaweed prevents breast cancer?

To investigate the chemopreventive effects of seaweed on breast cancer, we have been studying the relationship between iodine and breast cancer. We found earlier that the seaweed, wakame, showed a suppressive effect on the proliferation of DMBA (dimethylbenz(a)anthracene)‐induced rat mammary tumors, possibly via apoptosis induction. In the present study, powdered mekabu was placed in distilled water, and left to stand for 24 h at 4°C. The filtered supernatant was used as mekabu solution. It showed an extremely strong suppressive effect on rat mammary carcinogenesis when used in daily drinking water, without toxicity. In vitro, mekabu solution strongly induced apoptosis in 3 kinds of human breast cancer cells. These effects were stronger than those of a chemothera‐peutic agent widely used to treat human breast cancer. Furthermore, no apoptosis induction was observed in normal human mammary cells. In Japan, mekabu is widely consumed as a safe, inexpensive food. Our results suggest that mekabu has potential for chemoprevention of human breast

Pharmacological properties of (2R)-N-[1-(6-aminopyridin-2-ylmethyl)piperidin-4-yl]-2-[(1R)-3,3-difluorocyclopentyl]-2-hydroxy-2-phenylacetamide: a novel mucarinic antagonist with M(2)-sparing antagonistic activity

We evaluated the pharmacological profiles of (2R)-N-[1-(6- aminopyridin-2-ylmethyl)piperidin-4-yl]-2-[(1R)-3,3-difluorocyclopentyl]-2-hydroxy-2-phenylacetamide(compound A), which is a novel muscarinic receptor antagonist with M(2)-sparing antagonistic activity. Compound A inhibited [(3)H]NMS binding to cloned human muscarinic m1, m2, m3, m4, and m5 receptors expressed in Chinese hamster ovary cells with K(i) values (nM) of 1.5, 540, 2.8, 15, and 7.7, respectively. In isolated rat tissues, compound A inhibited carbachol-induced responses with 540-fold selectivity for trachea (K(B) = 1.2 nM) over atria (K(B) = 650 nM). In in vivo rat assays, compound A inhibited acetylcholine-induced bronchoconstriction and bradycardia with intravenous ED(50) values of 0.022 mg/kg and >/=10 mg/kg, respectively. Furthermore, in dogs, compound A (0.1-1 mg/kg p.o.) dose dependently shifted the methacholine concentration-respiratory resistance curves. In mice, compound A (10 mg/kg i.v.) did not inhibit oxotremorine-induced tremor. The brain/plasma ratio (K(p)) of compound A (3 mg/kg i.v.) was 0.13 in rats; this K(p) was less than that of scopolamine (1.7) and darifenacin (0.24). The inhibition of compound A (3 mg/kg i.v.) on ex vivo binding in rat cerebral cortex was almost similar to that of NMS. These findings demonstrate that compound A has high selectivity for M(3) receptors over M(2) receptors, displays a potent, oral M(3) antagonistic activity without inhibition of central muscarinic receptors because of low brain penetration. It is well known that central muscarinic antagonists may have diverse CNS effects, and M(2) receptors regulate cardiac pacing and act as autoreceptors in the lung and bladder. Thus, compound A may have fewer cardiac or CNS side effects than nonselective compounds.

A potent, long-acting, orally active (2R)-2-[(1R)-3, 3-difluorocyclopentyl]-2-hydroxy-2-phenylacetamide: novel muscarinic M(3) receptor antagonist with high selectivity for M(3) over M(2) receptors

A novel series of (2R)-2-[(1R)-3, 3-difluorocyclopentyl]-2-hydroxy-2-phenylacetamides was designed and synthesized based on the structure and biological profiles of an active metabolite 2 of our prototype muscarinic M(3) receptor selective antagonist 1, to develop a potent, long-acting, orally active M(3) antagonist for the treatment of urinary tract disorders, irritable bowel syndrome, and respiratory disorders. Investigation of (2R)-2-[(1R)-3, 3-difluorocyclopentyl]-2-hydroxy-2-phenylacetamides containing a phenyl or heterocyclic ring as the piperidinyl side chain in place of the 4-methyl-3-pentenyl moiety of 15a revealed that this acid moiety was a versatile template for improving the selectivity for M(3) over M(2) receptors in comparison with the corresponding cyclopentylphenylacetic acid group. However, since the in vitro metabolic stability of these analogues was insufficient compared with that of 2, further derivatization was performed by introducing an appropriate hydrophilic group into the phenyl or 2-pyridyl ring. Thus, the 1-(6-aminopyridin-2-ylmethyl)piperidine analogue 15y exhibiting 190-fold selectivity for M(3) receptors (K(i) = 2.8 nM) over M(2) receptors (K(i) = 530 nM) in a human binding assay and good in vitro metabolic stability in dog and human hepatic microsomes was identified. This compound has excellent oral activity at 4 h after oral dosing (1 mg/kg), inhibiting methacholine-induced bronchoconstriction in dogs, and may be useful in clinical situations in which M(3) over M(2) selectivity is desirable.

A novel class of inhibitors for human and rat steroid 5alpha-reductases: synthesis and biological evaluation of indoline and aniline derivatives. III

While searching for novel nonsteroidal inhibitors of human and rat prostatic 5alpha-reductases, we found a new series of indoline and aniline derivatives that showed potent inhibitory activities for both enzymes. Among them, 3-chloro-4-¿[1-(4-phenoxybenzyl)indolin-5-yl]oxylbenzoic acid (2e, YM-36117) showed a more potent inhibitory activity for the human enzyme than ONO-3805 with an IC50 value of 5.3 nM and a reduced rat prostatic dihydrotestosterone (DHT) concentration by oral administration. The synthesis and the structure-activity relationships of these indoline and aniline derivatives are presented.

[Surgical treatment for infective endocarditis with multiple embolic complications]

A 59-year-old man was transferred to our hospital because of severe right leg pain, dyspnea and anuria. Due to severe cyanosis of the legs below the knees and severe hyperkalemia, he had undergone embolectomy of the right femoral artery and hemodialysis. Medical treatment for infective endocarditis was started after the first operation, because transesophageal echo cardiography revealed severe aortic regurgitation and massive vegetation of the aortic valve. Amputation of the right leg below the knee and of the left leg below the Lisfranc joint was performed after 19 days and aortic valve replacement with patch closure of a perivalvular abscess was performed one month after the first operation. The post-operative course was uneventful. He was weaned from hemodialysis and the follow-up echocardiographic study revealed no vegetation.

Bone metabolic analysis in patients with primary hyperparathyroidism

Surgical treatment for primary hyperparathyroidism (PHPT) improves not only the calcium and phosphate metabolism but also the bone metabolism. This study was conducted to analyze the bone metabolism after PHPT operations. Bone mineral density (BMD) was measured by dual-photon absorptiometry in 50 patients before and after operation. Osteocalcin (OC) and alkaline-phosphatase activity (Alp) in serum were measured before and after surgery as markers of bone formation, and urinary deoxypiridinorine (DPD) as an index of osteoclast activity. The 50 patients under study were 40 women (80%) and ten men (20%). Increases in BMD at the lumbar spine were remarkable at three months following operation. Slow but steady progress was made until six months, reaching a plateau thereafter. The increase in BMD of lumbar spine was approximately 10%. Urinary DPD was the most sensitive among the three bone metabolic markers. Although serum Alp and OC remained high after operation, urinary DPD was normalized earlier. The discrepancy of bone formation and resorption was shown after operation and this contributed to the increases in BMD in the first six months.

[Catastrophic pulmonary vasoconstriction associated with protamine reversal of heparin]

Administration of protamine intravenously to neutralize the anticoagulant effects of heparin may be associated with hypotension. These adverse cardiovascular responses to protamine fall into three distinct types: transient hypotension related to rapid drug administration; anaphylactic responses: and catastrophic pulmonary vasoconstriction. We recently observed three patients who had catastrophic pulmonary vasoconstriction, which were treated with the assist circulation and intraaortic balloon pumping. The two patients were survived except one who was dead due to the cerebral ischemic damage which was introduced by delayed establishment of circulatory assist device. We conclude that meticulous longstanding observation of the hemodynamic condition is important after administration of protamine under the unremoved cannulations.

Tamponade after open-heart surgery with percutaneous cardiopulmonary support

A 56-year-old man presented with late cardiac tamponade appearing on 9 postoperative day after weaning from percutaneous cardiopulmonary support. He had been referred to our hospital for congestive heart failure. He underwent aortic valve replacement and fell into postcardiotomy low output syndrome. He could not be weaned from extracorporeal circulation, and we had to use an intraaortic balloon pump and percutaneous cardiopulmonary support. On postoperative day 9, percutaneous cardiopulmonary support was successfully withdrawn without problems, but he showed signs of superior vena cava syndrome after the cannulas were removed. An echocardiogram also showed cardiac tamponade. When the wound was reopened, a lot of old clots had compressed the right atrium and, after clot removal, the patient's hemodynamic state improved markedly. It is important to be aware that percutaneous cardiopulmonary support may conceal hemodynamic deterioration due to cardiac tamponade and to take care that a patient does not experience hemodynamic deterioration after percutaneous cardiopulmonary support withdrawal.

Discovery of a muscarinic M3 receptor antagonist with high selectivity for M3 over M2 receptors among 2-[(1S,3S)-3-sulfonylaminocyclopentyl]phenylacetamide derivatives

In the course of developing a metabolically stable M3 receptor antagonist from the prototype antagonist, J-104129 (1), introduction of certain substituents into the cyclopentane ring of 1 was found to be effective not only in improving metabolic stability but also in greatly enhancing the subtype selectivity. Among the cyclopentane analogues, sulfonamide derivatives (10f) and (10g) displayed 160- and 310-fold selectivity for M3 over M2 receptors, and both were significantly more selective than the prototype antagonist (120-fold). Subsequent derivatization of the sulfonamide series led to the highly selective M3 receptor antagonists (10h, 10i and 10j) with >490-fold selectivity for M3 over M2 receptors. Among them, p-nitrophenylsulfonamide (J-107320, 10h) exhibited 1100-fold selectivity for M3 receptors (Ki = 2.5 nM) over M2 receptors (Ki = 2800 nM) in the human muscarinic receptor binding assay using [3H]-NMS as a radio ligand.

A novel class of inhibitors for human steroid 5alpha-reductase: synthesis and biological evaluation of indole derivatives. II

In a search for novel nonsteroidal inhibitors of human prostatic 5alpha-reductase, we found a new series of indole derivatives that showed potent inhibitory activities for the human enzyme. Among them, 4-[(1-benzyl-1H-indol-5-yl)oxyl-3-chlorobenzoic acid (2d, YM-32906) showed more potent inhibitory activity than finasteride with an IC50 value of 0.44 nM. 3-Chloro-4-[[1-(4-phenoxybenzyl)-1H-indol-5-yl]oxy]benzoic acid (2m) showed inhibitory activities for both human and rat prostatic 5alpha-reductase with IC50 values of 2.1 and 73 nM, respectively. The synthesis and structure-activity relationships of these indole derivatives are presented.

The novel neuropeptide Y Y(1) receptor antagonist J-104870: a potent feeding suppressant with oral bioavailability

Neuropeptide Y (NPY) is known to induce robust feeding through the action of NPY receptors in the hypothalamus. Among the subtypes of NPY receptors, Y(1) receptors may play a key role in feeding regulation. In the present study, we demonstrated that a novel Y(1) antagonist, J-104870, shows high selectivity and potency for the Y(1) receptor with an anorexigenic effect on NPY-mediated feeding. J-104870 displaced [(125)I]peptide YY (PYY) binding to cloned human and rat Y(1) receptors with K(i) values of 0.29 and 0.54 nM, respectively, and inhibited the NPY (10 nM)-induced increase in intracellular calcium levels (IC(50) = 3.2 nM) in cells expressing human Y(1) receptors. In contrast, J-104870 showed low affinities for human Y(2) (K(i) > 10 microM), Y(4) (K(i) > 10 microM), and Y(5) receptors (K(i) = 6 microM). In rat hypothalamic membranes, J-104870 also completely displaced the binding of [(125)I]1229U91, which is known to bind to the typical Y(1) receptor, with a high affinity (K(i) = 2.0 nM). Intracerebroventricular (ICV) injection of J-104870 (200 microg) significantly suppressed NPY (5 microg)-induced feeding in satiated Sprague-Dawley rats by 74%. Furthermore, ICV and oral administration of J-104870 (200 microg and 100 mg/kg, respectively) significantly suppressed spontaneous food intake in Zucker fatty rats. These findings suggested that J-104870 is a selective and potent nonpeptide Y(1) antagonist with oral bioavailability and brain penetrability. In addition, the anorexigenic effect of J-104870 clearly revealed the participation of the Y(1) receptor in NPY-mediated feeding regulation. The potent and orally active Y(1) antagonist J-104970 is a useful tool for elucidating the physiological roles of NPY in obesity.

[Administration of docetaxel in cases of recurrent breast carcinoma with malignant pleural effusion controlled by intrapleural administration of OK-432]

Docetaxel is an anti-tumor agent which promotes the congregation and stabilization of microtubules, there by preventing cell division. It is reported to have anti-tumor activity against breast or non-small cell lung carcinomas which have been resistant to other anti-tumor agents. On the other hand, it causes peripheral edema and effusion in the pleural or peritoneal cavities. Thus, pleural or peritoneal effusions, which require drainage have been considered to be contraindications for the administration of docetaxel. OK-432 is an agent which causes adhesion by evoking a local inflammatory reaction. We experienced two cases of recurrent breast carcinoma with malignant pleural effusion. We successfully managed their pleural effusion with the intrapleural administration of OK-432. Thereafter, we safely administered docetaxel, and obtained good outcomes. The present paper also discussed the synergistic action between these agents.

J-104129, a novel muscarinic M3 receptor antagonist with high selectivity for M3 over M2 receptors

A new class of 4-acetamidopiperidine derivatives has been synthesized and investigated for human muscarinic receptor subtype selectivity. Introduction of a hydrocarbon chain of appropriate length into the piperidine nitrogen of the racemic N-(piperidin-4-yl)-2-cyclobutyl-2-hydroxy-2-phenylacetamide platform conferred up to 70-fold selectivity for human muscarinic M3 receptors over M2 receptors. Subsequent synthetic derivatizations resulted in highly potent M3 receptor antagonists with selectivity greater than two orders of magnitude for M3 over M2 receptors, from which the analogue 4r was selected. Preparation of both enantiomers of 4r led to the identification of (2R)-N-[1-(4-methyl-3-pentenyl)piperidin-4-yl]-2-cyclopentyl-2-hyd roxy-2-phenylacetamide (J-104129, (R)-4r), which exhibited 120-fold selectivity for M3 receptors (Ki = 4.2 nM) over M2 receptors (Ki = 490 nM). In isolated rat trachea, (R)-4r potently and specifically antagonized acetylcholine (ACh)-induced responses with a K(B) value of 3.3 nM. The highly subtype-selective profile was also seen in isolated rat tissue assays (50-fold) and in anesthetized rats (> 250-fold). Oral administration of J-104129 ((R)-4r) antagonized ACh-induced bronchoconstriction with an ED50 value of 0.58 mg/kg in rats. Thus, J-104129 ((R)-4r) may effectively facilitate bronchodilation in the treatment of obstructive airway disease.

Hyperphosphatemia accelerates parathyroid cell proliferation and parathyroid hormone secretion in severe secondary parathyroid hyperplasia

We studied the role of phosphorus retention in parathyroid cell proliferation and parathyroid hormone (PTH) oversecretion in severe secondary parathyroid hyperplasia. Mice transplanted with human parathyroid tissue from a patient who had undergone parathyroidectomy for severe secondary hyperparathyroidism were divided into four groups; each group was given a diet with a different phosphorus content (0.4, 0.7, 1.0, and 1.2%) to alter serum phosphorus concentrations. Histologic examinations of grafts by hematoxylin-eosin or by bromodeoxyuridine (BrdU) immunohistochemical staining were performed to assess parathyroid cell proliferation. Changes in serum phosphorus concentrations unidirectionally affected PTH secretion from the graft, because human PTH did not cross-react with mouse PTH. Serum phosphorus concentrations of 1.0P and 1.2P groups were significantly higher than those of 0.4P and 0.7P groups (p<0.05). Serum phosphorus concentrations were significantly correlated with the gradient of human PTH elevation with a coefficient of 0.48 and a p<0.05. Furthermore, serum phosphorus concentrations and the gradient of human PTH elevation were significantly higher in mice with BrdU-immunoreactive cells in the parathyroid graft than in mice without immunoreactive cells in the graft. These results indicate that uncontrolled hyperphosphatemia may accelerate the proliferation of parathyroid cells, exacerbating PTH oversecretion.

Wakame seaweed suppresses the proliferation of 7,12-dimethylbenz(a)-anthracene-induced mammary tumors in rats

We examined the anti-tumor proliferation effects of wakame seaweed on 7,12-dimethylbenz(a)-anthracene (DMBA)-induced rat mammary tumor. DMBA was administered to 8-week-old female Sprague-Dawley rats, and rats which developed mammary tumors were assigned randomly to three groups. Commercial rat feed was used in a control group (group I-A), and two feed mixtures were prepared, which contained commercial rat feed blended with wakame at 1.0% (group I-B) and 5.0% (group I-C) by weight. The respective feeds were given to each group for 8 weeks, and changes in mammary tumor size were compared. At the end of the experiment, mammary tumors and thyroid glands were resected to compare their weights. Serum total iodine and thyroxin (T4) levels were measured. Immunohistochemical studies for bromodeoxyuridine (BrdU) labeling, transforming growth factor (TGF)-beta, and apoptosis were carried out in the resected tumor. Significant suppression of tumor growth was observed in groups I-B and I-C compared with I-A. In groups I-B and I-C, the weights of resected mammary tumors were significantly lower and serum total iodine concentration was significantly higher than in I-A. BrdU indices were significantly lower in groups I-B and I-C, compared with I-A. TGF-beta and apoptotic index were inversely related to BrdU. These results suggest that iodine is transported from the serum into mammary tissues and induces apoptosis through the expression of TGF-beta. In conclusion, wakame suppressed the proliferation of DMBA-induced mammary tumors.

Effects of glucose on lipase activity

To establish the utility of lipase as a biocatalyst, the effects of glucose on the hydrolysis activities of lipase were investigated. Among 13 kinds of lipase from microorganisms, 6 lipases were inhibited in hydrolysis up to 50% of the original activities by 10 mM glucose. The activities of other microbial lipases and 2 kind of porcine pancreatic lipases were not affected by the addition of glucose. Six lipases that were sensitive to glucose were modified by a synthetic detergent. After they were converted to modified lipases, they were not inhibited by glucose. Even at 20 mM glucose, each modified lipase retained more than 95% activity compared with that in the absence of glucose. In the modified lipase, the detergent attached to the lipase molecule would disturb the access of glucose to the enzyme. To detect the interaction between lipase and glucose, the fluorescence of tryptophan was traced. The fluorescence intensities of lipases that were inhibited by glucose depended on the concentration of glucose, suggesting that glucose induced some structural change in the lipase molecule.

A novel class of inhibitors for human steroid 5 alpha-reductase: phenoxybenzoic acid derivatives. I

In a search for novel nonsteroidal inhibitors of human prostatic 5 alpha-reductase, we found a new series of phenoxybenzoic acid derivatives to be potent human prostatic 5 alpha-reductase inhibitors. Among them, 4-(biphenyl-4-yloxy)benzoic acid derivatives (2n, YM-31758), 2o and 2s showed more potent inhibitory activities than finasteride with IC50 values of 0.87, 0.67 and 0.56 nM, respectively. The optimized structures for the phenoxybenzoic acid derivatives 2d-2i were calculated by molecular modeling analysis, and the favorable distance between the carbon of the carboxyl group and the centroid of the phenyl group (benzene ring C) was found to be in the 9-11 A range.

Stereoselective synthesis of a new muscarinic M3 receptor antagonist, J-104129

A diastereoselective synthesis of J-104129 (1) was developed. A key step of this synthesis was Michael addition of enolate generated from cis-chiral dioxolane 2 to cyclopentenone, followed by hydrogenolysis of the resultant enol triflate 4. A mixture of cyclopentyldioxolane (5, 6) was hydrolyzed with sodium hydroxide to yield carboxylic acid 7 in 86% ee.

A case-controlled study of laparoscopic compared with open lateral adrenalectomy

BACKGROUND

Few studies have been done regarding laparoscopic transperitoneal lateral adrenalectomy compared with open transretroperitoneal lateral adrenalectomy in a case-controlled fashion.

METHODS

A case-controlled study of 40 laparoscopic and 40 open adrenalectomies was done in patients who were matched for age, gender, endocrine disorder, side and size of tumor, and area of body surface. Follow-up was complete in 92.5% of the patients, with a mean follow-up period of 30 months.

RESULTS

Statistically significant differences (P <0.05) were present (laparoscopic versus open) when the following results were compared: estimated blood loss (40 g versus 172 g), operating time (147 versus 79 minutes), analgesic equivalents (2.9 versus 5.2 times), hospital stay (12 versus 18 days), and late morbidity (0% versus 47.5%). There were no statistically significant differences between the laparoscopic and open groups with regard to time to oral intake, time to walking, intraoperative and early complications, and total cost.

CONCLUSIONS

Laparoscopic adrenalectomy is a safe technique that results in greater patient comfort, decrease in estimated blood loss, and earlier discharge than open adrenalectomy, with no increase in cost. It should be adopted as the technique of choice for the removal of functioning adenomas and for adrenal masses less than 6 cm in diameter.

Parathyroid autotransplantation with total thyroidectomy for thyroid carcinoma: long-term follow-up of grafted parathyroid function

BACKGROUND

Permanent hypoparathyroidism is a major complication of thyroidectomy. Autotransplantation of parathyroid glands has been attempted to prevent this complication. However, no direct data have been available to assess grafted parathyroid function after long-term follow-up in terms of the serum intact parathyroid hormone (PTH) concentration.

METHODS

Eighty-four consecutive patients with differentiated thyroid carcinoma who underwent total thyroidectomy and bilateral modified neck dissection from 1992 to 1996 were enrolled. They concomitantly underwent total parathyroidectomy and autotransplantation of all parathyroid glands to the pectoralis major muscle. The serum intact PTH concentration was periodically measured as an index of grafted parathyroid function.

RESULTS

The mean follow-up was 34 months. In all autotransplanted patients serum intact PTH concentrations fell below detectable limits immediately after surgery. They were restored to the normal range within 1 month postoperatively and were maintained during observation in 80 (95%) of 84 patients. Seventy-eight of 80 patients with normal intact PTH values were normocalcemic without any treatment and the remainder were normocalcemic with 1 microgram of 1 alpha-vitamin D3. Four hypoparathyroid patients were normocalcemic with 2 micrograms of 1 alpha-vitamin D3. The postoperative average serum intact PTH concentration of patients having more than 2 autotransplanted parathyroid glands was almost equal to that of patients with preservation of the parathyroid glands in situ. The incidence of permanent hypoparathyroidism was inversely correlated with the number of autotransplanted parathyroid glands.

CONCLUSIONS

The recovery patterns of the intact PTH concentration indicate that the glands were grafted successfully and functioned for a long period. This feasible method of parathyroid autotransplantation bears comparison with the previous reports in terms of the incidence of permanent postoperative hypoparathyroidism, and it can be performed simply and is reproducible.

Laparoscopic partial adrenalectomy

BACKGROUND

Most laparoscopic adrenalectomies involve total removal of the whole adrenal gland, and reports of laparoscopic partial adrenalectomies have been very few. The criteria for performing a laparoscopic partial adrenalectomy have not been described.

METHODS

(a) Patients with functioning adrenal tumors smaller than 3 cm in diameter were selected. (b) The solitary adrenal tumors were evaluated by preoperative thin-slice computed tomography (CT) scan. (c) Solitary lesions were reconfirmed with intraoperative ultrasonography. (d) Partial adrenalectomy was performed with at least a 5-mm margin using a vascular stapler.

RESULTS

Laparoscopic partial adrenalectomy was performed in five patients using the vascular stapler. Hemostasis was perfect in all five patients. The tumor was located in the inferior part of the right adrenal gland in three cases and in the upper pole of the left adrenal gland in two cases. The postoperation pathologic diagnosis was adrenocortical adenoma in all five patients, and excessive hormonal levels or symptoms all disappeared.

CONCLUSIONS

Laparoscopic partial adrenalectomy can be performed safely using a vascular stapler.

2-(3-Pyridyl)thiazolidine-4-carboxamide derivatives. III.) Synthesis of metabolites and metabolism of 2-(3-pyridyl)thiazolidine-4-carboxamides YM461 and YM264 as platelet-activating factor (PAF) receptor antagonists

The metabolism of 2-(3-pyridyl)thiazolidine-4-carboxamides YM461 and YM264 was investigated, and their metabolites were compared with separately synthesized materials by measuring 1H-NMR spectra, mass spectra, and HPLC retention times, and evaluated for platelet activating factor (PAF) antagonistic activity. YM461 was metabolized by two different metabolic pathways (cleavage of the thiazolidine ring and oxidation of the benzyl position), whereas YM264 was metabolized by three metabolic pathways. The minor metabolite M7 from YM264 possessed potent PAF antagonistic activity, as strong as YM264 and this existed as an active metabolite. From pharmacokinetics studies, YM264 was almost completely absorbed from the gastrointestinal tract, but readily metabolized in rats. In dogs, pharmacokinetic parameters of YM264 were significantly improved compared to those in rats, and YM264 tended to show better pharmacokinetics than YM461 due to an extension of the half-life period.

Synthesis of the selective 5-hydroxytryptamine 4 (5-HT4) receptor agonist (+)-(S)-2-chloro-5-methoxy-4-[5-(2-piperidylmethyl)-1,2,4-oxadiazol-3-y l]aniline

In a search for novel 5-hydroxytryptamine 4 (5-HT4) agonists focusing on the linker group of benzamide derivatives, 2-chloro-5-methoxy-4-[5-(2-piperidylmethyl)-1,2,4-oxadiazol-3-yl]a niline (2) was prepared and its optical isomers were separated. The S isomer 2(S) showed high affinity for the human 5-HT4 receptor without affinity for the human 5-HT3 receptor, and potent 5-HT4 agonistic activity in longitudinal muscle myenteric plexus (LMMP) preparations of guinea pig ileum. The R isomer 2(R) showed opposite selectivity. As a result of other receptor binding studies, 2(S) (YM-53389) was shown to be a highly selective 5-HT4 agonist.

2-(3-Pyridyl)thiazolidine-4-carboxamide derivatives. II. Structure-activity relationships and active configuration of 2-(3-pyridyl)thiazolidine-4-carboxamides as platelet-activating factor receptor antagonists

Conversion of the 2-(3-pyridyl)thiazolidine part of 1-(3-phenylpropyl)-4-[2-(3-pyridyl)thiazolidine-4-carbonyl]piperazine (YM461), which is a potent platelet-activating factor (PAF) antagonist, to other rings was performed, and PAF antagonistic activities evaluated. The 2-(3-pyridyl)thiazolidine skeleton, which exists as a mixture of cis and trans diastereomers, played an important role in the potency of PAF antagonism. In this study, new effective skeletons were not uncovered, however, 2-(4-pyridyl)thiazolidine-4-carboxamides (1n and 1z) showed potent PAF antagonistic activities equal to the 3-pyridyl derivatives. From the results obtained for 1a, 1a(S), 1g and 1i, a cis-(2R,4R)-2-(3-pyridyl)thiazolidine-4-carboxamide was assumed to be the active configuration for PAF antagonism.

Synthesis and pharmacological characterization of novel 6-fluorochroman derivatives as potential 5-HT1A receptor antagonists

A series of novel 6-fluorochroman derivatives was prepared and evaluated as antagonists for the 5-HT1A receptor. N-2-[[(6-Fluorochroman-8-yl)oxy]ethyl]-4-(4-methoxyphenyl)butylami ne (3; J. Med. Chem. 1997, 40, 1252-1257) was chosen as a lead, and structural modifications were done on the aliphatic portion of the chroman ring, the tether linking the middle amine and the terminal aromatic ring, the aromatic ring, and lastly the amine. Radioligand binding assays proved that the majority of the novel compounds behaved as good to excellent ligands at the 5-HT1A receptor, some of which were selective with respect to alpha1-adrenergic and D2-dopaminergic receptors. The antagonist activity of the compounds was assessed in the forskolin-stimulated adenylate cyclase assays in CHO cells expressing the human 5-HT1A receptors. Among the modifications attempted, introduction of an oxo or an optically active hydroxy moiety at the chroman C-4 position was effective in ameliorating the receptor selectivity. Six analogues were selected through the in vitro screens and further evaluated for their in vivo activities. A 4-oxochroman derivative (31n), having a terminal 1, 3-benzodioxole ring, demonstrated antagonist activities toward 8-OH-DPAT-induced behavioral and electrophysiological responses in rats.

Novel 5-hydroxytryptamine 4 (5-HT4) receptor agonists. Synthesis and gastroprokinetic activity of 4-amino-N-[2-(1-aminocycloalkan-1-yl)ethyl]-5-chloro-2-methoxybenzamide s

A novel series of 4-amino-N-[2-(1-aminocycloalkan-1-yl)ethyl]-5-chloro-2-methoxyb enzamides. derivatives (1), which had amines conformationally restricted due to the effect of repulsion by neighboring substituents, were prepared and evaluated for 5-hydroxytryptamine 4 (5-HT4) agonistic activities by using the contraction of longitudinal muscle myenteric plexus (LMMP) of guinea pig ileum. One of the most potent compounds in this series was 4-amino-5-chloro-N-[2-(1-dimethylamino-1-cyclohexyl)ethyl]-2-methoxybenz amide (1c, YM-47813) with an EC50 value of 1.0 microM on LMMP. This compound effectively enhanced gastric motility and gastric emptying in conscious dogs by oral administration (1-3 mg/kg).

[The effects of YM26818: 1-(2-dimethylaminoethyl)-1-(3,4,5-trimethoxyphenyl)urea and derivatives on pulmonary surfactant secretion and lung compliance]

To discover a novel compound which has an effect on pulmonary surfactant (PS) secretion, we studied the effects of various compounds on PS secretion by measuring the contents of PS in the bronchoalveolar lavage (BAL) fluid in guinea pigs. In the chemical modification study of ambroxol, which is known as a PS secretagogue, and a compound we discovered from our compounds library, 1-(2-dimethylaminoethyl)-1-(3,4,5-trimethoxyphenyl)urea: YM-26818 (the increasing effect on PS in BALF, 34.7% at 50 mg/kg, i.p.). In the surfactant deficient model induced by BAL in guinea pigs, YM-26818 (5 and 10 mg/kg, p.o.) significantly increased the contents of PS in the BAL fluid compared with that of control animals (5 mg/kg: 60.3 +/- 8.0, 10 mg/kg: 59.4 +/- 4.3% increase). Concomitantly by these effects, the recovery of lung compliance was observed in this model (AUC of lung volume, control: 560 +/- 15, YM-26818 5 mg/kg: 898 +/- 51, YM-2681 10 mg/kg: 956 +/- 11 ml.min). These results may indicate that YM-26818 is useful for the therapy of adult respiratory distress syndrome (ARDS) and obstructive pulmonary diseases.

[Two cases of coronary artery aneurysm including one case of the left main coronary artery aneurysm]

We report two cases of coronary artery aneurysm including one case of the left main coronary artery aneurysm. The coronary angiogram of one patient, a 68-year-old male, having anterior chest pain on exertion, revealed left anterior descending coronary artery (segment 6) aneurysm of 7 mm in diameter with 90% stenosis distal to the aneurysm and 75% stenosis in the right coronary artery (segment 2). The coronary angiogram of another patient, a 69-year-old female, having chest pain unrelated to exertion, revealed left main coronary artery aneurysm of 25 mm in diameter and delayed filling of contrast medium into the left anterior descending coronary artery. We decided to operate by the reason of not only significant coronary artery stenosis but risks of myocardial infarction due to embolization into distal coronary arteries and rupture of the aneurysm. We performed coronary artery bypass graftings using the great saphenous veins and closure of the coronary arteries running into and out the aneurysm under cardiopulmonary bypass. It is recommended that ligation of the coronary arteries connecting to the aneurysm or resection of the aneurysm followed by coronary artery bypass grafting is performed before developing myocardial infarction or rupture of aneurysm.

Solution structure of calmodulin-W-7 complex: the basis of diversity in molecular recognition

The solution structure of calcium-bound calmodulin (CaM) complexed with an antagonist, N-(6-aminohexyl)-5-chloro-1-naphthalenesulfonamide (W-7), has been determined by multidimensional NMR spectroscopy. The structure consists of one molecule of W-7 binding to each of the two domains of CaM. In each domain, the W-7 chloronaphthalene ring interacts with four methionine methyl groups and other aliphatic or aromatic side-chains in a deep hydrophobic pocket, the site responsible for CaM binding to CaM-dependent enzymes such as myosin light chain kinases (MLCKs) and CaM kinase II. This competitive binding at the same site between W-7 and CaM-dependent enzymes suggests the mechanism by which W-7 inhibits CaM to activate the enzymes. The orientation of the W-7 naphthalene ring in the N-terminal pocket is rotated approximately 40 degrees with respect to that in the C-terminal pocket. The W-7 ring orientation differs significantly from the Trp800 indole ring of smooth muscle MLCK bound to the C-terminal pocket and the phenothiazine ring of trifluoperazine bound to the N or C-terminal pocket. These comparative structural analyses demonstrate that the two hydrophobic pockets of CaM can accommodate a variety of bulky aromatic rings, which provides a plausible structural basis for the diversity in CaM-mediated molecular recognition.