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.

85 The effects of heat exposure on the growth and developmental competence of oocytes derived from early antral follicles in dairy cows

Summer heat stress in dairy cows impairs the developmental competence of oocytes from antral follicles (2–8mm) which are used in conventional IVM and IVF systems. Moreover, summer heat stress is considered to impair the oocyte competence derived from smaller follicles; therefore, the impairment of oocyte competence possibly continues into the cooler autumn season. To investigate the thermosensitivity of early antral follicles (&lt;1mm), we evaluated the effects of heat exposure on the growth and developmental competence of oocytes using invitro culture of oocyte–cumulus-granulosa complexes (OCGCs) derived from early antral follicles. OCGCs (n=315) were collected from early antral follicles (0.5–1mm) and cultured for 12 days. OCGCs in the heat shock group were cultured using a temperature cycle of 38.5°C for 5h, 39.5°C for 5h, 40.5°C for 5h, and 39.5°C for 9h, whereas those in the control group were cultured at a constant temperature of 38.5°C for 24h. The diameters of oocytes were measured before culture. Half of the culture medium was replaced every 4 days. Oestradiol-17β (E2) and progesterone (P4) production during the first, second, and third 4-day periods were measured by enzyme immunoassay; the viability of OCGCs was evaluated based on their morphology. Oocytes that survived after 12 days of culture (n=191) were subjected to IVM (38.5°C, 22h); their diameter and nuclear status were evaluated. Some oocytes (n=71) were subjected to IVF (38.5°C, 18h) and embryo culture (39.0°C, 150h). Cleavage and blastocyst rates were evaluated at 48h and 168h after IVF. Effects of treatment groups and culture periods on E2 and P4 production and diameters of oocytes were evaluated by two-way ANOVA followed by Tukey-Kramer or Student’s t-test. The viability of OCGCs, nuclear maturation, cleavage and blastocyst rates between two groups were compared by the chi-squared or Fisher’s exact test. E2 and P4 production and the viability of OCGCs were not different between the 2 groups. Although mean oocyte diameters before culture did not differ between the 2 groups, the mean diameters after IVM were significantly smaller in the heat shock group (108.0µm, n=56) than in the control group (111.7µm, n=61; P&lt;0.05). The nuclear maturation rate in the heat shock group (36.4%, n=55) was significantly lower than in the control group (60.3%, n=58; P&lt;0.05). Cleavage rates were similar between the control (54.5%, n=33) and heat shock groups (45.7%, n=35). However, no oocytes developed to blastocysts in the heat shock group (0%, n=35), whereas 30.3% (n=33) oocytes developed to blastocysts (cell number±s.d.; 92.4±28.4) in the control group (P&lt;0.05). These findings suggest that summer heat stress in dairy cows impairs the growth, nuclear maturation, and developmental competence of oocytes derived from early antral follicles. This experimental model could be used to explore the mechanisms by which heat stress subsequently impairs oocyte competence during the cooler autumn season.

Insulin secretion and sensitivity before and after surgical treatment for aldosterone-producing adenoma

AIM

Primary aldosteronism, which is usually caused by an aldosterone-producing tumour, affects glucose metabolism. The effects of this condition on insulin secretion and insulin sensitivity have remained unclear, however. To gain insight into the influence of primary aldosteronism on glucose tolerance, various parameters related to insulin secretion or insulin sensitivity in patients with an aldosterone-producing tumour were comprehensively analyzed.

METHODS

To assess 14 patients with an aldosterone-producing tumour, hyperglycaemic and hyperinsulinaemic-euglycaemic clamp tests as well as oral glucose tolerance tests (OGTTs) were performed before and after tumour excision. Time between presurgical analysis and surgery was 27-559 (194±132) days, and 14-142 (51±38) days between surgery and postsurgical analysis. Various parameters related to insulin secretion or sensitivity as determined by OGTT as well as hyperglycaemic and hyperinsulinaemic-euglycaemic clamp analyses were evaluated.

RESULTS

Surgical treatment of tumours ameliorated hypokalaemia and reduced plasma aldosterone levels. First and second phases of insulin secretion during the hyperglycaemic clamp, as well as the insulinogenic index and total insulin secretion measured during OGTT, were also improved after surgery. In addition, the insulin sensitivity index determined during the hyperinsulinaemic-euglycaemic clamp was reduced after surgery.

CONCLUSION

Primary aldosteronism impairs insulin secretion.

Astaxanthin improves the developmental competence of in vitro-grown oocytes and modifies the steroidogenesis of granulosa cells derived from bovine early antral follicles

In this study we investigated the effect of astaxanthin (Ax), which exhibits strong antioxidant activity, during invitro growth (IVG) on the developmental competence of oocytes and steroidogenesis of granulosa cells derived from early antral follicles. Bovine oocyte–cumulus–granulosa complexes collected from early antral follicles were cultured for 12 days in the presence or absence (control) of 500µM Ax. The viability of oocytes and antrum formation in the granulosa cell layer during IVG culture were greater in the presence than absence of Ax (P&lt;0.05). Regardless of Ax treatment, 17β-oestradiol production increased during IVG culture; however, progesterone production was significantly lower in the presence than absence of Ax (P&lt;0.05). Reactive oxygen species levels were lower in Ax-treated oocytes than in controls after IVG (P&lt;0.05). Although nuclear maturation and cleavage rates did not differ between the Ax-treated and control groups, Ax treatment led to weaker cathepsin B activity in oocytes and better blastocyst rates than in controls (P&lt;0.05). Accordingly, Ax treatment during IVG increased the total number of cells in blastocysts (P&lt;0.05). These results indicate that Ax supplementation of IVG medium improves the quality of bovine oocytes due to its antioxidative effects on growing oocytes and its suppression of the luteinisation of granulosa cells.

120 Effects of antral follicle count in ovaries on follicular development and endocrine dynamics of follicle-stimulating hormone and steroid hormones in cattle

The antral follicle count (AFC) in mammalian ovaries positively correlates with female fertility. We have reported previously that cumulus-oocyte complexes derived from high-AFC ovaries produce more oestradiol-17β (E2) and have higher developmental competence than those from low-AFC ovaries in in vitro growth (Sakaguchi et al. WCRB2017, Okinawa, Japan; 1-15). We also indicated that follicular growth was different between high- and low-AFC cows, and that follicular deviation occurred earlier in high-AFC cows (Nagai et al. 2015 Anim. Reprod. Sci. 163, 172-178). To clarify the causes of the higher E2 production and earlier follicular deviation in high-AFC cows, we investigated circulating steroid hormones and FSH during the oestrous cycle, as well as steroidogenesis in follicles at different phases of the oestrous cycle. Four high-AFC cows (&gt;40 follicles) and 3 low-AFC cows (&lt;20 follicles) based on the peak AFC were used. We ablated their follicles 8 days after oestrus and administered prostaglandin F2α on Day 12. After 40h of prostaglandin F2α injection, follicular fluid of a dominant follicle (preovulatory phase) was collected and subordinate follicles were ablated. Gonadotropin-releasing hormone was then injected to induce LH surge. Seven days after gonadotropin-releasing hormone, follicular fluids were collected from dominant follicles (luteal phase) and all follicles were ablated. Four days later, follicular fluids were again collected from the largest follicles (selection phase). Steroid hormones in follicular fluids were measured by enzyme immunoassay. Throughout the study, we daily examined ovaries by ultrasonography and collected blood for hormone measurements. We analysed data using two-way ANOVA followed by Tukey-Kramer or Student’s t test. The number of small follicles (&lt;4mm) was greater in high-AFC than low-AFC groups (low v. high=7.6v. 46.9; P&lt;0.05), whereas that of large follicles (&gt;8mm) was similar between groups (0.8v. 0.8) at any time. Although the number of medium-sized follicles (4-8mm) was not affected in the low-AFC group (4.2-6.7) after follicle ablation, the number increased from 1 to 4 days (10.5 to 17.8) then decreased 6 days after follicle ablation (11.5) in the high-AFC group, which means that degradation of follicles occurs at selection phase in high-AFC cows. Peripheral FSH concentration was higher (low v. high: 4.7v. 2.1 ng/mL), but E2 concentration was lower in the low-AFC (2.4 pg/mL) than high-AFC group (3.3 pg/mL) during the selection phase (P&lt;0.05). Although follicular diameter was similar in both groups at any phase, E2 (low v. high=333.8v. 1127.4 ng/mL; P&lt;0.05) and testosterone (low v. high=16.7v. 35.0 ng/mL; P=0.07), but not progesterone, concentrations were higher in the high-AFC than low-AFC group in the preovulatory phase. These findings suggest that a lower response to FSH causes low E2 production in the low-AFC group, resulting in high FSH concentration and a consistent development of medium-sized follicles. Conversely, higher E2 concentration suppresses FSH secretion, resulting in obvious degradation of follicles in the high-AFC group at the selection phase.

Oxygen Transport Capacity and Hemodynamic Effect of Newly Developed Artificial Blood “Neo Red Cells (NRC)”

The purpose of this study was to evaluate liposome-encapsulated hemoglobin, named Neo Red Cells (NRC), on hemodynamics and oxygen-transport capacity in a blood exchange experiment. The experiment was carried out in nine mongrel dogs. Depending on the percentage of blood exchange with NRC, the animals were divided into two groups; Group I (4 animals with an exchange rate less than 88%), and Group II (5 animals with an exchange rate over 88%). After blood exchange, total peripheral vascular resistance index (TPRI) decreased and cardiac index (CI) increased. These changes were more marked in Group II than in Group I, thus showing that NRC relieved the burden on the heart, probably due to the fact that the viscosity of NRC is 2 cp which is less than 1/3 that of whole blood. The oxygen binding capacity per 1g hemoglobin in NRC was 2-4 times as much as red blood cells. Thus, NRC was superior to natural red blood cells in terms of oxygen transport capacity and its effects on the circulatory system.

Breast-feeding regulates immune system development via transforming growth factor-β in mice pups

BACKGROUND

Breast milk contains important nutrients and immunoregulatory factors that are essential for newborn infants. Recently, epidemiological studies suggested that breast-feeding prevents a wide range of infectious diseases and lowers the incidence of infant allergic diseases.

METHODS

To examine the effects of breast milk on immunological development in infancy, we established an artificial rearing system for hand-feeding mice and compared mouse pups fed with either breast milk or milk substitute. All mice were killed at 14 days of age and immune cells in the thymus, spleen, and small intestine were examined on flow cytometry.

RESULTS

The number of thymocytes was higher whereas that of total immune cells of peripheral lymphoid tissues was lower in mice fed breast milk compared with milk substitute-fed mice. In peripheral lymphoid tissues, the proportion of B cells was higher and that of CD8+ T cells, macrophages, dendritic cells, and granulocytes was significantly lower in breast milk-fed mice. The same alteration in immune cells of the thymus and peripheral lymphoid tissues in milk substitute-fed mice was also observed in pups reared by mother mice treated with anti-transforming growth factor-β (anti-TGF-β) monoclonal antibody.

CONCLUSIONS

Breast milk regulates the differentiation and expansion of innate and adaptive immune cells partly due to TGF-β. Hence, TGF-β in breast milk may be a new therapeutic target for innate immune system-mediated diseases of infancy.

Vascularized Tissue-Engineered Model for Studying Drug Resistance in Neuroblastoma

Neuroblastoma is a vascularized pediatric tumor derived from neural crest stem cells that displays vasculogenic mimicry and can express a number of stemness markers, such as SOX2 and NANOG. Tumor relapse is the major cause of succumbing to this disease, and properties attributed to cancer stem-like cells (CSLC), such as drug-resistance and cell plasticity, seem to be the key mechanisms. However, the lack of controllable models that recapitulate the features of human neuroblastoma limits our understanding of the process and impedes the development of new therapies. In response to these limitations, we engineered a perfusable, vascularized in vitro model of three-dimensional human neuroblastoma to study the effects of retinoid therapy on tumor vasculature and drug-resistance.

METHODS

The in vitro model of neuroblastoma was generated using cell-sheet engineering and cultured in a perfusion bioreactor. Firstly, we stacked three cell sheets containing SKNBE(2) neuroblastoma cells and HUVEC. Then, a vascular bed made of fibrin, collagen I and HUVEC cells was placed onto a collagen-gel base with 8 microchannels. After gelling, the stacked cell sheets were placed on the vascular bed and cultured in the perfusion bioreactor (perfusion rate: 0.5 mL/min) for 4 days. Neuroblastoma models were treated with 10μM isotretionin in single daily doses for 5 days.

RESULTS

The bioengineered model recapitulated vasculogenic mimicry (vessel-like structure formation and tumor-derived endothelial cells-TECs), and contained CSLC expressing SOX2 and NANOG. Treatment with Isotretinoin destabilized vascular networks but failed to target vasculogenic mimicry and augmented populations of CSLCs expressing high levels of SOX2. Our results suggest that CSLCs can transdifferentiate into drug resistant CD31⁺-TECs, and reveal the presence of an intermediate state STEC (stem tumor-derived endothelial cell) expressing both SOX2 and CD31.

CONCLUSION

Our results reveal some roles of SOX2 in drug resistance and tumor relapse, and suggest that SOX2 could be a therapeutic target in neuroblastoma.

Autophagy is required for cell survival under L-asparaginase-induced metabolic stress in acute lymphoblastic leukemia cells

L-asparaginase has been used for more than three decades in acute lymphoblastic leukemia (ALL) patients and remains an essential drug in the treatment of ALL. Poor response to L-asparaginase is associated with increased risk of therapeutic failure in ALL. However, both the metabolic perturbation and molecular context of L-asparaginase-treated ALL cells has not been fully elucidated. Here we identify that treatment with L-asparaginase results in metabolic shutdown via the reduction of both glycolysis and oxidative phosphorylation, accompanied by mitochondrial damage and activation of autophagy. The autophagy is involved in reducing reactive oxygen species (ROS) level by eliminating injured mitochondria. Inhibition of autophagy enhances L-asparaginase-induced cytotoxicity and overcomes the acquired resistance to L-asparaginase in ALL cells. The ROS-p53-positive feedback loop is an essential mechanism of this synergistic cytotoxicity. Thus, our findings provide the rationale for the future development of combined treatment of L-asparaginase and anti-autophagy drug in ALL patients.

Salmonella Enterica Serovar Pomona Infection in Farmed Juvenile American Alligators (Alligator Mississippiensis)

A fatal epizootic of salmonellosis occurred in farmed juvenile American alligators in Louisiana. Six animals were examined. Gross lesions included severe fibrinonecrotizing enterocolitis, necrotizing splenitis, coelomic effusion, and perivisceral and pulmonary edema. Microscopic examination revealed severe necrotizing enterocolitis and splenitis with intralesional bacteria and pneumocyte necrosis with fibrin thrombi. Salmonella enterica serovar Pomona was isolated from intestine and lung. Clinical salmonellosis is a rare finding in reptiles and salmonellosis caused by S. Pomona is not previously reported in American alligators. Since S. Pomona is a commonly isolated Salmonella serotype from patients with reptile-associated salmonellosis in the United States, and since alligator meat is consumed and the skin is exported to numerous countries, risk of human and animal infection should be considered.

Polymeric immunoglobulin receptor expression and local immunoglobulin A production in bovine sublingual, submandibular and parotid salivary glands

The submandibular and parotid glands are the main sources of immunoglobulins A (IgAs) in human and rat saliva. These glands express the polymeric immunoglobulin receptor (pIgR), which transports IgAs into saliva. The main source of IgAs in saliva and pIgR expression in salivary glands has not been well documented in cattle. Expressions of pIgR were determined in the major bovine salivary glands (sublingual, submandibular, and parotid) by RT-PCR for mRNA and by Western blot analysis and immunohistochemistry (IHC) using an anti-human pIgR antibody for protein. The protein detected with the antibody was identified by nano-liquid chromatography-quadrupole time of flight mass spectrometry. Additionally, the distribution of Ig-producing plasma cells was analyzed by IHC. RT-PCR showed that pIgR was expressed in the sublingual and submandibular glands, but not in the parotid gland. Higher protein levels were observed in sublingual glands than in submandibular glands by Western blot. By IHC, pIgR was mainly located on the apical side of the cytoplasmic membrane in the sublingual gland, whereas it was observed only on the basal side in the submandibular gland. The highest density of plasma cells expressing IgAs was observed in the sublingual gland. These results suggest that the sublingual gland plays an important role in first-line defence of the oral cavity in cattle in contrast to humans and rats.

Atrium contributes to osmoregulation in eels acclimated to sea water

Since highly concentrated NaCl is suspected to enter into the heart of the seawater eels, effects of high NaCl concentration on the atrial beating was examined, and plasma ion concentrations and osmolality were measured simultaneously in the blood collected from the bulbus arteriosus and from the caudal vessels. When 100 mmole l(-1) NaCl was added to the incubation medium, atrial contraction was enhanced significantly. Similar enhancement in the atrial contractility was also observed after addition of NaCH3SO4 (100 mmole l(-1)) or Tris HCl (100 mmole l(-1)), indicating that Na(+) and Cl(-) are not indispensable for the positive inotropic effect. Furthermore, an addition of sucrose (200 mmole l(-1)) also enhanced the contraction. Inversely, hypoosmotic solution reduced the atrial contraction. These results indicate that the eel atrium is sensitive to environmental osmolarity. The eel atrium responses even at 20 mmole l(-1) sucrose. Such an inotropic effect of sucrose was not depressed after blocking adrenoceptor with betaxolol, a beta1-adrenoceptor antagonist, indicating that the effect is not due to adrenaline release from nerve endings. Plasma osmolality and Na(+) concentration were higher in bulbus arteriosus than in caudal vessels, indicating that the eel heart is really exposed to hyperosmotic blood in sea water. The osmotically enhanced atrial contraction may increase the cardiac outflow into the gill. Such property of the atrium would have clear advantages for seawater teleosts, since the concentrated NaCl from the esophagus can be excreted immediately through the gill, without circulating their body, and blood homeostasis can be maintained efficiently.

Comparison between chest digital tomosynthesis and CT as a screening method to detect artificial pulmonary nodules: a phantom study

OBJECTIVES

The objective of this study was to evaluate the imaging capabilities of chest digital tomosynthesis (DT) as a screening method for the detection of artificial pulmonary nodules, and to compare its efficiency with that of CT.

METHODS

DT and CT were used to detect artificial pulmonary nodules (5 mm and 8 mm in diameter, ground-glass opacities) placed in a chest phantom. Using a three-dimensional filtered back-projection algorithm at acquisition angles of 8°, 20°, 30° and 40°, DT images of the desired layer thicknesses were reconstructed from the image data acquired during a single tomographic scan. Both standard and sharp CT reconstruction kernels were used, and the detectability index (DI) valves computed for both the DT scan acquisition angles and CT reconstruction kernel types were considered. For the observer study, we examined 50 samples of artificial pulmonary nodules using both DT and CT imaging. On the basis of evaluations made by five thoracic radiologists, a jackknife free-response receiver operating characteristic (JAFROC) study was performed to compare and assess the differences in detection accuracy between CT and DT imaging.

RESULTS

For each increased acquisition angle, DI obtained by DT imaging was similar to that obtained by CT imaging. The difference in the observer-averaged JAFROC figure of merit for the five readings was 0.0363 (95% confidence interval: -0.18, 0.26; F=0.101; p=0.75).

CONCLUSION

With the advantages of a decreased radiation dose and the practical accessibility of examination, DT may be a useful alternative to CT for the detection of artificial pulmonary nodules.

Effect of CT fluoroscopy-guided transpulmonary radiofrequency ablation of liver tumours on the lung

OBJECTIVE

We retrospectively evaluated the effect of transpulmonary radiofrequency ablation (RFA) of liver tumours on the lung.

METHODS

16 patients (10 males and 6 females; mean age, 65.2 years) with 16 liver tumours (mean diameter 1.5 cm) underwent transpulmonary RFA under CT fluoroscopic guidance. The tumours were either hepatocellular carcinoma (n=14) or liver metastasis (n=12). All 16 liver tumours were undetectable with ultrasonography. The pulmonary function values at 3 months after transpulmonary RFA were compared with baseline (i.e. values before RFA).

RESULTS

In 8 of 16 sessions, minor pulmonary complications occurred, including small pneumothorax (n=8) and small pleural effusion (n=1). In two sessions, major pulmonary complications occurred, including pneumothorax requiring a chest tube (n=2). These chest tubes were removed at 4 and 6 days, and these patients were discharged 7 and 10 days after RFA, respectively, without any sequelae. The pulmonary function values we evaluated were forced expiratory volume in 1 s (FEV1.0) and vital capacity (VC). The mean values of FEV1.0 before and 3 months after RFA were 2.55 l and 2.59 l, respectively; the mean values of VC before and 3 months after RFA were 3.20 l and 3.27 l, respectively. These pulmonary values did not show any significant worsening (p=0.393 and 0.255 for FEV1.0 and VC, respectively).

CONCLUSION

There was no significant lung injury causing a fatal or intractable complication after transpulmonary RFA of liver tumours.

Water irradiation by high-frequency ultrasonic wave: effects on properties of passive film formed on stainless steel

In this paper an aqueous solution was irradiated with a 1.63MHz ultrasonic wave. It is shown that if stainless steel can passivate under dynamic polarization in this medium, under static polarization, the latter does not show any repassivation behaviour with time. This is attributed to a diminution of the diffusion layer thickness that is developed at the electrode/electrolyte interface, which is associated with a production of H(2) species by sonolysis and which maintains reductive conditions at the interface. The oxide film formed under ultrasonic irradiation for 1h at a passive potential of+0.2V(SCE) shows an early stage of passivation and an increased disordered state, which implies a considerable decrease in the corrosion resistance behaviour of the sample. The polarization resistance of the stainless steel R(p) is divided by a value of 4.5 under ultrasonic conditions.

Hepatitis C virus NS4 protein impairs the Th1 polarization of immature dendritic cells

Dendritic cells (DCs) in chronic hepatitis C patients display impaired function, although the details remain unclear. To investigate the hepatitis C virus (HCV) protein that has the most impact on DC function, we compared five recombinant proteins and seven HCV protein genes in modulating DC phenotype and function. Immature DCs (iDCs) were established from healthy donor peripheral blood monocytes with granulocyte-macrophage colony stimulating factor (GM-CSF) and IL-4. Lipopolysaccharide was used to establish mature DCs (mDCs). Cells were then pulsed with HCV recombinant proteins or transfected with HCV plasmids and subsequently assayed for cell surface marker expression by flow cytometry. For cytokine and proliferative T-cell response analysis, DCs were cultured with autologous CD4 T cells and tuberculin purified protein derivative (PPD). Mean fluorescent intensity of CD86 was reduced in HCV protein-pulsed iDCs. Proliferative T-cell responses and Th1 cytokine concentrations were reduced with HCV nonstructural proteins (NS), particularly with HCV NS4. HCV nonstructural proteins, particularly NS4, change the iDC phenotype and reduce antigen-specific T-cell stimulatory function with Th1 cytokine reductions.

Video-assisted skin-sparing breast-conserving surgery for breast cancer and immediate reconstruction with autologous tissue: Clinical outcomes

e11580

Background: This study analyzed clinical results of video-assisted breast-conserving surgery for breast cancer. Methods: Video-assisted breast-conserving surgery is indicated for breast cancer that has not invaded the skin. A skin incision is made at an inconspicuous site. Skin-sparing partial mastectomy was performed endoscopically on 244 patients (stage I, n=94; stage II, n=150). Morbidity, curability and patient satisfaction were analyzed. Results: Skin necrosis was seen in 9 patients. Local recurrence was seen in 13 patients (mean postoperative interval, 65.3 months). Distant metastasis-free survival at 60 months was 93.6% for stage I and 90.5% for stage II. Overall survival was 95.7% for stage I and 96.9% for stage II. Satisfaction with surgery as investigated by questionnaire was “good” for 72.3% of patients. Conclusions: Video-assisted breast-conserving surgery showed no increases in local or distant recurrence and patient satisfaction was high. Video-assisted breast-conserving surgery appears useful for local treatment of breast cancer.

No significant financial relationships to disclose.

[Bleeding by staple in video-assisted thoracoscopic interlobar plasty of the lung]

A 58-year-old man underwent video-assisted thoracoscopic right upper lobectomy. He was discharged without event on postoperative day 8. On postoperative day 12, he visited emergently in a pre-shock state. Chest radiography showed massive right pleural effusion and intrathoracic bleeding was suspected. Thoracotomy was immediately performed and the bleeding point was identified as an internal thoracic artery. Hemostasis was performed but no cause of arterial injury was apparent. In another case, we had seen incidental snag the pleura on the internal thoracic artery by a staple from interlobar plasty of the lung. We therefore suspected that the cause in this case was injury of the internal thoracic artery by staple during video-assisted thoracoscopic interlobar plasty of the lung.

Rapid and effective method for separation of Staphylococcus aureus from somatic cells in mastitis milk

Quantitative PCR can be an effective method for identifying the bacteria causing mastitis. However, PCR detection is hampered by the presence of inflammatory somatic cells. To eliminate this problem, we attempted to establish methods that allow the effective separation of bacterial cells from somatic cells in mastitis milk with amino-silica. Somatic cells and Staphylococcus aureus cells have different sizes, surface structures, and overall electrical charges; therefore, their adsorption and desorption behavior on amino-silica was also different. We found that although amino-silica could efficiently adsorb both somatic cells and Staph. aureus, somatic cells were adsorbed much more strongly than bacterial cells. We identified conditions under which most of the somatic cells adsorbed and only Staph. aureus desorbed from amino-silica upon addition of a desorption solution. We demonstrated that this procedure effectively eliminated somatic cells in heavily contaminated milk samples, which resulted in improved clarity of the PCR band. These results indicate that pretreatment of the samples with amino-silica made the PCR-based strategy for identifying and quantifying disease-causing bacteria applicable for all milk samples.

[Lobectomy for local recurrence of lung cancer after 3-dimensional-conformal radiotherapy]

An 85-year-old man was diagnosed as having primary cancer located in the middle lobe (squamous cell carcinoma cT1N0M0 stage IA). Because of his general conditions and status as an octogenarian, 3-dimensional-conformal radiotherapy (3D-CRT, 75Gy in 25 fractions) was selected. The therapeutic response was partial remission, and the adverse reaction was radiation pneumonitis (grade 2). Seventeen months after 3D-CRT, local recurrence was detected. Surgery was performed. Thoracoscopic findings demonstrated scarring fibrosis in the middle lobe and there was no adhesion in the pulmonary hilum. Therefore, video-assisted thoracoscopic lobectomy was performed safely. The patient was discharged on the 10th days post operatively without complication. After 12 months follow-up, there has been no recurrence.

Recurrence and morbidity in patients undergoing sentinel lymph node biopsy in Japanese breast cancer patients

11062

Background: Aim of this study was to determine the axillary lymph nodes recurrence rate in breast cancer patients with tumor less than 5 cm (T2), who did not have axillary node dissection with negative sentinel lymph node (SLN). Methods: SLN biopsies were performed in 403 consecutive patients with breast cancer up to 5 cm and clinically negative axillary node from May, 2000, to December, 2005. SLN were identified using the combined method with sulfan blue dye and technetium 99m-labelled stannous phytate. SLN were examined with H&E staining. In patinets with negative SLN, additional axillary nodes dissection were avoided. Results: The SLN identification rate was 99.8% (402 out of 403). Three-hundred forty-one (341) patients (84.8%) who were found to have no metastatic disease, were observed and followed without further axillary dissection. At a mean follow-up of 35.7 months (range, 12–79 months), five of these patients (1.5%) developed an axillary recurrence. SLN biopsy was not associated with morbidity such as arm lymph edema. Conclusion: With intermediate-term follow-up, the axillary recurrence rate was low and there was none of morbidity. We conclude that SLN biopsy is a promising alternative to axillary lymph node dissection in patients with breast cancer up to 5 cm in Japanese women.

No significant financial relationships to disclose.

A novel therapeutic strategy for ER-negative human breast cancers, targeting AP-1 activity

14129

Background: While agents targeting estrogen receptors are the most effective in adjuvant therapy for human breast cancers expressing estrogen receptor(ER), breast cancers lacking ER are clinically serious, because they are highly malignant and exhibit resistance to the usual anti-cancer drugs, including estrogen receptor-antagonists and DNA breaking agents. Although a transcription factor, AP-1, is known to be related to tumor malignancy including metastasis, invasion and drug-resistance, it remains to be elucidated how AP-1 plays in development and expression of malignant characters of human breast cancers. Methods and Results: Here, we used MX-1, a human breast cancer cell line lacking ER and several ER positive cell lines, to clarify the roles of AP-1 and the therapeutic efficacy of ascochlorin, a newly developed prenylphenol antibiotic on ER-negative breast cancer. We found that MX-1 exhibited higher AP-1 activity and expressed higher levels of c-Jun, c-Fos and Fra-1 when compared with conventional ER-positive human breast cancer cell lines. Consistent with this study in vitro, histological study on human breast cancer tissues suggests that ER-negative cancers express high Fra-1 protein, and that paclitaxel- sensitive cancers express low Fra-1 protein. The ascochlorin, which inhibits AP-1 through the Erk signaling pathway, suppressed the AP-1 activity of MX-1 cells, and selectively killed MX-1 cells, partly due to induction of apoptosis. Moreover, administration of ascochlorin elongated life span of mice intraperitoneally implanted with murine mammary carcinoma cells. Conclusions: Our results suggest that AP-1 is an effective clinical target molecule for the treatment of ER-negative human breast cancer, and that ascochlorin is promising therapeutic agent for these refractory breast cancers.

No significant financial relationships to disclose.