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.

P1618A polymethoxy flavonoid, Nobiletin, Has a therapeutic potency against the development of heart failure through NBP1 activation

Introduction

Maladaptive hypertrophy is being recognized as a critical event during the development of heart failure. The control of cardiac hypertrophy may be one of the therapeutic strategy for heart failure therapy. In our previous study, we screened natural compound library and found that a natural compound, Nobiletin, could inhibit cardiomyocyte hypertrophy in culture. Nobiletin has various useful effects such as anti-cancer, anti-inflammation, and anti-oxidant and may be applicable to pharmacological therapy for heart failure.

Hypothesis

We thought that nobiletin might prevent the development of heart failure in vivo and investigated the target molecule of Nobiletin in the heart.

Methods and results

In primary cardiomyocytes, Nobiletin significantly inhibited phenylephrine (PE)-induced hypertrophic responses such as increases in cell size and hypertrophic gene transcription, such as ANF and BNP. C57BL6 mice were subjected to sham or transarotic constriction (TAC). Oral administrations of Nobiletin (20 mg/kg/day) or vehicle were repeated for 8 weeks. Nobiletin treatment significantly prevented TAC-induced increases in PWT and systolic dysfunction. Nobiletin also suppressed TAC-induced myocardial cell hypertrophy, perivascular fibrosis, and hypertrophic gene transcriptions. To investigate the target molecule of Nobiletin, Nobiletin-binding proteins were purified from rat heart using biotin-conjugated Nobiletin. We identified 162 novel binding protein of Nobiletin by LC/MS-MS. One of them, Nobiletin-binding protein 1 (NBP1) related to cellular metabolic pathway. Pulldown assay demonstrated that biotin-conjugated Nobiletin, but not biotin, directly interacted with recombinant NBP1. In vitro enzyme assay showed that Nobiletin enhanced NBP1 activity. Although NBP1 knockdown could not affect PE-induced hypertrophic response gene transcriptions and cardiomyocyte hypertrophy, NBP1 knockdown failed to exhibit Nobiletin-mediated anti-hypertrophic effects. NBP1-KO mice and WT mice were subjected to sham or TAC and randomly divided into two groups: Nobiletin (20 mg/kg/day) and vehicle. After 8 weeks, Nobiletin significantly improved TAC-induced cardiac hypertrophy and systolic dysfunction in WT mice but not in NBP1-KO mice. Nobiletin also prevented TAC-induced increases in HW/BW rate, myocardial cell hypertrophy, and mRNA levels of ANF and β-MHC in WT mice but not in NBP1-KO mice.

Conclusions

In this study, we demonstrate that Nobiletin inhibits cardiomyocyte hypertrophy and the development of heart failure in vivo. NBP1 activity is required to exhibit therapeutic potency of Nobiletin for heart failure. These finding suggest that a natural compound, nobiletin, might be a candidate for heart failure agent in human.

Acknowledgement/Funding

This work was supported by JSPS KAKENHI Grant.

Factors influencing seasonal influenza vaccination behaviour among elderly people: a systematic review

OBJECTIVES

To explore the behaviour-related factors influencing influenza vaccination among elderly people using a framework derived from the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA).

STUDY DESIGN

Systematic review.

METHODS

Five databases were searched using predetermined strategies in March 2016, and 1927 citations were identified. Articles were selected according to inclusion and exclusion criteria. Key information was extracted from selected studies using a predesigned sheet. Both authors assessed study quality using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) or Critical Appraisal Skills Programme (CASP) checklist.

RESULTS

Thirty-six articles were selected. A new framework was proposed that contributes to shared understanding of factors influencing health behaviour. Possible determinants of influenza vaccination among elderly people were knowledge, health promotion factors, all constructs of the HBM, and some concepts of the TRA. Key factors were threat perception, behavioural beliefs, subjective norms, recommendations, past behaviour and perceived barriers.

CONCLUSIONS

This is the first systematic review to analyse the factors influencing influenza vaccination behaviour of elderly people using a framework integrating the HBM and the TRA. The framework identified key factors of influenza vaccination and presented the inter-relation of behaviour-related variables. However, further well-designed studies are required to explore the inter-relationships accurately and comprehensively.

Costal cartilage graft with perichondrium, a possible anti-adhesive material

BACKGROUND

Adhesion occurs as a part of the wound healing process, but it sometimes compromises patients' daily activities. The authors were looking for materials and methods that could prevent adhesion, and noticed that the costal cartilage has possibility. The anti-adhesive property of the costal cartilage was examined histologically.

METHODS

Thirty-five patients with microtia who provided consent for participating in this study were enrolled between April 2008 and March 2015. In the first stage of microtia reconstruction surgery, the excess cartilage was used to create these three types of specimens: (A) a piece of cartilage retaining the perichondrium on one side, (B) a piece of only cartilage parenchyma sliced with a plane parallel to the long axis of costal cartilage, and (C) the costal cartilage in a plane perpendicular to the long axis sliced pieces. These specimens were implanted into the subcutaneous fat of the chest. After at least 6 months in the second stage of surgery (i.e. auricular elevation), these specimens, wearing a little around the adipose tissue, we removed and examined histologically.

RESULT

A fibrosis formation of the perichondrium side of Specimen A was thicker significantly than that of the cartilage side. A fibrosis formation of Specimen B was thicker significantly than that of the cartilage side of Specimen A.

CONCLUSION

It was suggested that, if there is perichondrium, the costal cartilage parenchyma surface makes less adhesion with surrounding tissues. Costal cartilage with unilateral perichondrium is likely to be an effective surgical material for adhesion prevention.

Ecteinascidins. A review of the chemistry, biology and clinical utility of potent tetrahydroisoquinoline antitumor antibiotics

The ecteinascidin family comprises a number of biologically active compounds, containing two to three tetrahydroisoquinoline subunits. Although isolated from marine tunicates, these compounds share a common pentacyclic core with several antimicrobial compounds found in terrestrial bacteria. Among the tetrahydroisoquinoline natural products, ecteinascidin 743 (Et-743) stands out as the most potent antitumor antibiotics that it is recently approved for treatment of a number of soft tissue sarcomas. In this article, we will review the backgrounds, the mechanism of action, the biosynthesis, and the synthetic studies of Et-743. Also, the development of Et-743 as an antitumor drug is discussed.

Feasibility of thoracoscopic esophagectomy after neoadjuvant chemotherapy

INTRODUCTION

Minimally invasive esophagectomy has been increasingly accepted to treat esophageal cancer. In Japan, neoadjuvant chemotherapy followed by surgery has become the standard procedure for advanced esophageal cancer. A randomized control study has shown neoadjuvant chemotherapy's survival benefits, but it is unknown whether minimally invasive esophagectomy after chemotherapy is viable. This study investigated the feasibility of thoracoscopic esophagectomy after neoadjuvant chemotherapy.

METHODS

From a database of patients with esophageal cancer, 105 patients who had undergone thoracoscopic esophagectomy with radical lymphadenectomy were analyzed retrospectively. Among them, 51 patients had received neoadjuvant chemotherapy with 5-fluorouracil and cisplatin (NAC group). Their operative outcomes, including operative duration, blood loss, the number of dissected lymph nodes, and postoperative morbidity and mortality, were compared with those of 54 patients who underwent surgery without neoadjuvant chemotherapy (control group). The efficacy of neoadjuvant chemotherapy was also assessed.

RESULTS

The operating time in the NAC group was significantly longer than in the control group (543 vs 472 min, P < 0.001), but the blood loss was less (323 vs 528 mL, P < 0.001). Recurrent laryngeal nerve palsy was the most frequently observed complication in both groups (27% vs 32%, P = 0.65). No significant differences were observed in the frequency of postoperative complications. There was no mortality in either group. In the NAC group, 43 patients (84.3%) underwent curative resection, and response of more than two-thirds of the pathological tumor was achieved in 11 patients (21.6%), including complete response in one patient (2.0%).

CONCLUSION

Thoracoscopic esophagectomy following neoadjuvant chemotherapy could be safely adopted for patients with advanced esophageal cancer.

MicroRNA-192 and -215 are upregulated in human gastric cancer in vivo and suppress ALCAM expression in vitro

The dismal outcome of gastric cancer patients highlights the need for diagnostic biomarkers and effective therapeutic targets, such as microRNAs. We sought to discover microRNAs involved in gastric cancer, and to elucidate their downstream target mechanisms. Both cultured gastric epithelial cells (HFE145 and NCI-N87) and primary human gastric tissues (31 non-neoplastic stomach (NS) and 25 gastric carcinomas (GC)) were studied. MicroRNA microarrays and quantitative RT-PCR were applied to discover and verify differentially expressed microRNAs. in vitro cell migration and invasion, cell proliferation, cell cycle and apoptosis assays were executed to elucidate biological effects of microRNA-192 and -215. Western blotting and luciferase assays were performed to confirm direct messenger RNA targeting by microRNA-192 and -215. MicroRNA microarray analyses revealed that 25 and 20 microRNAs were upregulated and downregulated in GC vs NS, respectively. Expression levels of both microRNA-192 and -215 were significantly higher in GC than in NS (P<0.05). Luciferase assays suggested that microRNA-215 inhibits activated leukocyte cell adhesion molecule (ALCAM) expression at the posttranscriptional level. In addition, expression levels of ALCAM were significantly lower in GC than in NS. Mimics and inhibitors, respectively, of microRNA-192 or -215 exerted no effect on cell cycle or apoptosis in the immortalized normal gastric cell line HFE145 or the gastric cancer cell line NCI-N87. However, mimics of microRNA-192 or -215 significantly increased growth rates in HFE145 cells, whereas inhibitors of microRNA-192 or -215 caused significant decreases in growth rates in NCI-N87 cells. ALCAM knockdown by an ALCAM-specific siRNA significantly increased cell growth in HFE145 cells. Both transfection of mimics of microRNA-192 or -215 and ALCAM knockdown by an ALCAM-specific siRNA significantly increased the migration of HFE145 cells. In conclusion, in gastric cancer, both microRNA-192 and -215 are overexpressed in vivo and exert cell growth and migration-promoting effects in vitro, thus representing potential microRNAs with a role in cancer in the human stomach.

Hypermethylation of the nel-like 1 gene is a common and early event and is associated with poor prognosis in early-stage esophageal adenocarcinoma

The nel-like1 (NELL1) gene maps to chromosome 11p15, which frequently undergoes loss of heterozygosity in esophageal adenocarcinoma (EAC). NELL1 promoter hypermethylation was examined by real-time methylation-specific polymerase chain reaction in 259 human esophageal tissues. Hypermethylation of this promoter showed highly discriminative receiver-operator characteristic curve profiles, clearly distinguishing esophageal squamous cell carcinoma (ESCC) and EAC from normal esophagus (NE) (P<0.001). NELL1 normalized methylation values were significantly higher in Barrett's metaplasia (BE), dysplastic Barrett's (D) and EAC than in NE (P<0.0000001). NELL1 hypermethylation frequency was zero in NE but increased early during neoplastic progression, to 41.7% in BE from patients with Barrett's alone, 52.5% in D and 47.8% in EAC. There was a significant correlation between NELL1 hypermethylation and BE segment length. Three (11.5%) of 26 ESCCs exhibited NELL1 hypermethylation. Survival correlated inversely with NELL1 hypermethylation in patients with stages I-II (P=0.0264) but not in stages III-IV (P=0.68) EAC. Treatment of KYSE220 ESCC and BIC EAC cells with 5-aza-2'-deoxycytidine reduced NELL1 methylation and increased NELL1 mRNA expression. NELL1 mRNA levels in EACs with an unmethylated NELL1 promoter were significantly higher than those in EACs with a methylated promoter (P=0.02). Promoter hypermethylation of NELL1 is a common, tissue-specific event in human EAC, occurs early during Barrett's-associated esophageal neoplastic progression, and is a potential biomarker of poor prognosis in early-stage EAC.

Transcriptional profiling suggests that Barrett's metaplasia is an early intermediate stage in esophageal adenocarcinogenesis

To investigate the relationship between Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC), we determined gene expression profiles of discrete pathological stages of esophageal neoplasia using a sequence-verified human cDNA microarray. Fifty one RNAs, comprising 24 normal esophagi (NE), 18 BEs, and nine EACs were hybridized to cDNA microarrays. Five statistical analyses were used for the data analysis. Genes showing significantly different expression levels among the three sample groups were identified. Genes were grouped into functional categories based on the Gene Ontology Consortium. Surprisingly, the expression pattern of BE was significantly more similar to EAC than to NE, notwithstanding the known histopathologic differences between BE and EAC. The pattern of NE was clearly distinct from that of EAC. Thirty-six genes were the most differentially modulated, according to these microarray data, in BE-associated neoplastic progression. Twelve genes were significantly differentially expressed in cancer-associated BE's plus EAC (as a single combined tissue group) vs noncancer-associated BE's. These genes represent potential biomarkers to diagnose EAC at its early stages. Our results demonstrate that molecular events at the transcriptional level in BE are remarkably similar to BE's-associated adenocarcinoma of the esophagus. This finding alarmingly implies that BE is biologically closer to cancer than to normal esophagus, and that the cancer risk of BE is perhaps higher than we had imagined. These findings suggest that changes modulated at the molecular biologic level supervene earlier than histologic changes, and that BE is an early intermediate stage in the process of EAC.

[Extrapleural pneumonectomy for malignant pleural mesothelioma]

Standard treatment for malignant pleural mesothelioma (MPM) has not been proved yet. However, it has been recognized that extrapleural pneumonectomy (EPP) is a treatment of choice for epithelial MPM when combined with adjuvant therapies though EPP may frequently cause fetal complications. We report 5 cases of MPM with EPP, including 1 with good prognosis. Sixteen patients with MPM were admitted to our hospital between 1988 and 2003. Five patients underwent EPP, among which 4 were male and 1 female with ages from 46 to 61 years old. Histologically, 3 of them were epithelial and 2 were biphasic. Those with biphasic experienced acute respiratory failure and empyema, and died 81 days and 8 months after the surgery respectively. Among those with epithelial MPM, 2 are alive with no recurrence at 129 and 29 months after the surgery, and the other, followed by postoperative radiotherapy, died at 12 months. More cases with EPP or randomized controlled trials regarding EPP are necessary to evaluate efficacy of EPP for MPM.

Validity of intraoperative pathological diagnosis of paratracheal lymph node as a strategy for selection of patients for cervical lymph node dissection during esophagectomy

The aim of this paper is to examine whether intraoperative examination of paratracheal nodes can indicate cervical node dissection and whether this approach is valid. From 1988 to 1997, 76 patients with thoracic esophageal squamous cell carcinoma received esophagectomies with and without cervical lymph node (LN) dissection based on the results of intraoperative pathological diagnosis from selective checking of paratracheal LN. We retrospectively examined the outcomes for the patients and the micro metastasis in the dissected lymph node using cytokeratin staining. Three of the seven patients with cervical LN dissection were detected as having cervical LN metastasis by postoperative hematoxylin-eosin or cytokeratin staining. Five (7%) of the 69 patients without cervical LN dissection had cervical LN recurrence after the operation. Four of the seven patients who were diagnosed as having metastasis or micro metastasis in paratracheal LN by postoperative examination had cervical LN recurrence after the operation. In conclusion, the esophagectomy with and without cervical LN dissection for thoracic esophageal squamous cell carcinoma based on the results of intraoperative pathological diagnosis from selective checking of paratracheal LN was not fully acceptable. The reliability of intraoperative pathological diagnosis of selective checking may improve by increasing the number of checked LN and the detection of micro metastasis.

[Is the bronchoscopic criteria of early lung cancer valid?]

We studied the validity of the bronchoscopic criteria of the early lung cancer using the surgical specimen excised between 1980 and 1999. Twenty-four cases with squamous cell carcinoma of the lung of clinical stage I were located subsegmental or more proximal bronchi and trachea, and the size less than 20 mm in greatest dimension. We histopathologically investigated the endoscopic features in relation to the width of superficial extent, the depth of cancer invasion, and lymph node metastasis. Tumors of the thickened type lesions less than 20 mm in greatest dimension showed no invasion into the cartilaginous layer and no lymph node metastasis. On the other hand, in the nodular and polypoid types, invasion beyond the cartilaginous layer was observed more or less, and lymph node metastasis was observed in 1 case. These cases would not be suitable for bronchoscopic (photodynamic) therapy. In conclusion, the bronchoscopic criteria of early lung cancer is valid in the thickened type, but not in the nodular type or polypoid type.

Gene expression profiling in human esophageal cancers using cDNA microarray

Human esophageal cancer cell lines and human esophageal cancer tissues were profiled on cDNA microarrays. In esophageal cancer cell lines, KYAE and OE-33 (adenocarcinomas) were distinguished from KYSE series (squamous cell carcinomas). Although SK-GT-4 and TE7 were derived from adenocarcinomas, they had a comparatively similar expression profile to the KYSE series. A set of genes whose expression commonly either increased or decreased in cancer cell lines was identified. Genes that were characteristically expressed in KYAE and OE-33 were also identified. The gene expression profiles of cancer tissues (CTs) were remarkably different from those of the cancer cell lines (CCLs). Notable differences between CCLs and CTs were observed in matrix metalloproteinases, plasminogen activator, collagens, paxillin, and thrombospondin 2, etc., whose expression was not increased in CCLs but increased in CTs. Twenty-three genes were extracted to categorize patients according to their prognoses, and clustering analyses, using these genes, were performed successfully.

Determination of sucrose esters of fatty acids in food additive premixes by gas chromatography and confirmation of identity by gas chromatography/mass spectrometry

A gas chromatographic (GC) method was developed for the determination of sucrose monoesters of fatty acids (mono-SuE) and sucrose acetate isobutyrate (SAIB) in food additive premixes. Mono-SuE and SAIB fractions were prepared by column chromatography with either a C8 or a silica gel solid-phase extraction column. The mono-SuE fraction was acetylated and applied to a wide-bore GC column (0.53 mm x 15 m) by splitless injection for determination. The SAIB fraction was applied to the GC column without derivatization. Gas chromatography/mass spectrometry was used to confirm the identity of GC peaks. The detection limits for mono-SuE and SAIB were 0.005 and 0.01%, respectively. Mono-SuE (C12, C14, C16, C18, and C18:1) and SAIB were found in commercial food additive premixes and some foods.

[A case of lung cancer underwent carinal resection with right upper lobectomy and carinal reconstruction with double-barreled anastomosis]

A 70-year-old male complaining cough was admitted to our hospital. Bronchoscopic examination revealed a tumor mass which occluded the orifice of the right upper lobe. Chest computed tomographic (CT) scans gave the image of tumor invasion at the carina. The pathological diagnosis of the tumor was squamous cell carcinoma. Operation was accomplished by right posterolateral thoracotomy approach through the fifth rib bed. The carinal resection with right upper lobectomy was followed by a double-barreled anastomosis of the right intermediate trunk and left main-stem bronchus into the carina. The operation was successfully performed and was considered curative. The length of resected airway measured 4.0 cm from tracheal line of resection to the divided the right intermediate trunk. Reinforcement of the anastomosis was not performed in this case. No postoperative complication occurred but mild ischemia of the anastomosis. The patient died of recurrent tumor in a year and 2 months after operation.

Dogger Bank Itch revisited: isolation of (2-hydroxyethyl) dimethylsulfoxonium chloride as a cytotoxic constituent from the marine sponge Theonella aff. mirabilis

(2-Hydroxyethyl) dimethylsulfoxonium chloride (1), the well-known causative agent of Dogger Bank Itch, has been isolated as a cytotoxic constituent from the marine sponge Theonella aff. mirabilis. The structure of 1 was determined by spectral and X-ray crystallographic analyses.

Total synthesis of polyamine toxin HO-416b and Agel-489 using a 2-nitrobenzenesulfonamide strategy

Total synthesis of spider toxins HO-416b (1) and Agel-489 (2) was accomplished using the 2-nitrobenzenesulfonamide (Ns) group as both a protecting and activating group. In this strategy, the C-N bonds were constructed by alkylation of sulfonamides with alkyl halides or Mitsunobu reaction with the corresponding alcohol. Beginning with monoprotection of the symmetrical diamine, the construction of the backbone from diamine 3 was efficiently accomplished in 7 steps for 14 and 9 steps for 29. Removal of the Ns group while the substrate was attached to a novel solid support enabled the efficient isolation of this highly polar compound.

[Validity and controversies in the new postoperative pathologic TNM classification based on the results of surgical treatment of non-small cell lung cancer]

In 1997, the latest revision of the International System for Staging Lung Cancer was published. To validate the new pathologic TNM classification for non-small cell lung cancer (NSCLC), we analyzed the survival data of 455 patients who underwent pulmonary resection and pathologic staging at our institution from January 1980 through December 1999. The overall 5-year survival rate was 51.0%. Using the revised new stage classification, the survival rate for each stage was as follows; IA: 74.2%, IB: 66.4%, IIA: 56.0%, IIB: 51.8%, IIIA: 21.0%, IIIB: 16.0%, and IV: 0%. The current TNM classification well reflected the long-term prognostic hierarchy. There were significant differences in survival rates between patients with stage IA and IB, and between patients with stage IIB and IIIA. However, there was no significant difference between patients with stage IIA and IIB. No significant difference in survival was observed among patients with stage IIIA, stage IIIB, and stage IV. Five-year survival rate of 48.3% in the T3N0M0 category was significantly better than that of 21.0% found in the new stage IIIA. The survival of patients with intrapulmonary metastases in the same lobe (pm1) was not significantly better than that found in the stage IV. The TNM staging system accurately reflects the prognosis in NSCLC, but some stage definitions can be discussed.

Hydroxy-Directed, SmI(2)-Induced Conversion of Carbohydrates into Carbocycles

Polyoxygenated six-membered carbocycles were derived from carbohydrates with complete stereocontrol through hydroxy-directed coupling cyclization induced by SmI(2). For example, the cis-1,3-cyclohexanediol 3 is obtained from the D-glucopyranoside derivative 1 in excellent yield. The coupling cyclization is initiated by single-electron transfer from SmI(2) to the formyl group of the delta-hydroxy aldehyde 2 generated in an equilibrium process.

hobo Induced rearrangements in the yellow locus influence the insulation effect of the gypsy su(Hw)-binding region in Drosophila melanogaster

The su(Hw) protein is responsible for the insulation mediated by the su(Hw)-binding region present in the gypsy retrotransposon. In the y2 mutant, su(Hw) protein partially inhibits yellow transcription by repressing the function of transcriptional enhancers located distally from the yellow promoter with respect to gypsy. y2 mutation derivatives have been induced by the insertion of two hobo copies on the both sides of gypsy: into the yellow intron and into the 5' regulatory region upstream of the wing and body enhancers. The hobo elements have the same structure and orientation, opposite to the direction of yellow transcription. In the sequence context, where two copies of hobo are separated by the su(Hw)-binding region, hobo-dependent rearrangements are frequently associated with duplications of the region between the hobo elements. Duplication of the su(Hw)-binding region strongly inhibits the insulation of the yellow promoter separated from the body and wing enhancers by gypsy. These results provide a better insight into mechanisms by which the su(Hw)-binding region affects the enhancer function.

Anti-allergic effect of tea-leaf saponin (TLS) from tea leaves (Camellia sinensis var. sinensis)

We investigated the anti-allergic effect of tea-leaf saponin (TLS), which was a mixture of saponins separated from the leaves of Camellia sinensis var. sinensis, in guinea pigs and rats. TLS (20-100 mg/kg) dose-dependently inhibited experimentally-induced asthma, and ID50 was 61.7 mg/kg. TLS (20-100 mg/kg) dose-dependently inhibited a 48 h homologous PCA (passive cutaneous anaphylaxis) reaction, and the inhibitory effect was similar to that of tranilast. TLS (1-100 microg/ml) also inhibited the release of antigen-induced leukotriene (LT) C4 from sensitized guinea pig lung samples in a dose-dependent fashion, but did not prevent histamine release. TLS (0.01-0.5 microg/ml) inhibited histamine release from rat peritoneal mast cells induced by compound 48/80. At higher concentrations, TLS elicited histamine release. These findings suggest that TLS may be a useful protective agent against clinical allergy, and that the inhibitory effects of TLS on mediator release are in some way related to its inhibitory effect on experimentally-induced asthma and PCA reaction.

[A case of gastric cancer developed in the gastric tube 11 years after subtotal esophagectomy for esophageal cancer]

A case of adenocarcinoma developed in the reconstructed gastric tube after esophagectomy was reported. The patient was 66 years old man and he had received subtotal esophagectomy for the carcinoma of the esophagus 11 years previously. The follow-up examination of upper GI series revealed an ulcerative lesion in the lower part of the gastric tube and endoscopic biopsy showed adenocarcinoma. The partial resection of the lower gastric tube with mediansternotomy was performed because of limiting the invasion of the carcinoma. Pathological examination showed that poorly differentiated adenocarcinoma with signet ring cells had invaded muscularis propria. The postoperative course was uneventful and he is well without any recurrence 6 months after the operation. A double carcinoma, such as esophageal cancer concomitant gastric cancer is not rare, but a carcinoma of the gastric tube which was substituted for the esophagus is rare. Recently, the incidence of carcinoma of the gastric tube is increasing due to the increasingly long-term survival rate of patients who had esophageal carcinoma. In order to ensure the early detection of a second carcinoma which can minimalize damage from curative resections, follow up examinations should be conducted with the utmost diligence.

The influence of Helicobacter pylori infection on the progression of gastric mucosal atrophy and occurrence of gastric cancer

AIM

To study the effects of Helicobacter pylori infection on the progression of gastric mucosal atrophy and the development of gastric cancer.

PATIENTS AND METHODS

We investigated the extension of the atrophic area as assessed on the basis of the Kimura-Takemoto atrophic patterns and the development of gastric cancer in a selected sample of 64 patients who were endoscopically followed up for more than 3 years, and who showed H. pylori infection by culture at the start of the investigation and at some stages during the follow-up.

RESULTS

No progression of atrophy was observed in 14 patients who were H. pylori-negative at the beginning of the follow-up, whereas various degrees of expansion of the atrophic area were found in 22% of 50 positive cases. Well differentiated mucosal cancer was diagnosed in four patients during the follow-up. These patients displayed moderate to severe atrophy. At the beginning of the follow-up, 50% of patients were H. pylori culture-positive, but all patients had H. pylori antibodies in their blood.

CONCLUSIONS

The results support the view that H. pylori infection influences the development of atrophic gastritis and is related to the pathogenesis of gastric cancer.

Inhibitory effect of epinastine on superoxide generation by rat neutrophils

We studied the effects of antiallergic drugs, epinastine, ketotifen, oxatomide, mequitazine and cromolyn sodium on superoxide anion (O2-) generation from rat neutrophils. Epinastine, ketotifen, oxatomide and mequitazine dose-dependently prevented the N-formyl-Met-Leu-Phe- and phorbol 12-myristate 13-acetate-induced O2- generation, but cromolyn sodium did not prevent it. When membrane and cytosol fractions were incubated with each drug, epinastine, ketotifen and mequitazine prevented O2- generation. On the other hand, when only the membrane fraction was incubated with each drug, ketotifen and mequitazine prevented O2- generation, but epinastine did not. Epinastine may inhibit the NADPH oxidase system through the obstruction of NADPH oxidase-associated cytosol components.

Genetic constitution of germ cells in intervarietal and interspecific chimeras of Brassica induced by in-vitro grafting

The characteristics of intervarietal and interspecific chimeras synthesized by the graft-culture method were determined by morphology, anthocyanin pigmentation pattern, and crossing. In an intervarietal chimera between 'YR-ranpou' (green cabbage) and 'Ruby ball' (red cabbage) in Brassica oleracea, a segregation phenomenon was noted in which seeds giving rise to purple and green plants were both produced in a single capsule in F1 progeny from crosses of chimeras with YR ranpou, the anthocyanin-free graft partner type. The degrees of segregation varied, reflecting the structure of the chimeras. YR ranpou-dominant chimeras produced capsules in which seeds gave rise to green plants at a high frequency, while Ruby ball-dominant chimeras produced capsules in which seeds in one capsule gave rise to purple plants at a high frequency. Mixed chimeras produced capsules with green plants or purple plants more regularly than did other chimeral types. Furthermore, a chimeral type in which seeds gave rise to green and purple plants was found in 3.2% of the total crosses. Segregation patterns in the progenies corresponded with the chimeral types. Chlorophyll-deficient variation (resulting in variegation or the production of albino plants) was found at a frequency of 2.6%. These results show that chimeric tissues are actually in a mixed state and that either the ovary develops from more than two cells or else that variation occurs in the germ-cell layer. In interspecific chimeras between Ruby ball and Komatsuna (B. campestris) various types of chimeras generally showed low pollen fertility, few capsules, and low seed-setting. Progenies from selves (geitonogamy), open crosses and crosses with the two parental species produce a predominantly homogeneous genotype showing either the Ruby ball or the Komatsuna type. Only two crosses produced four interspecific hybrids which expressed variations in their morphological and isozymic characters.

Superoxide anion-induced histamine release from rat peritoneal mast cells

We investigated the properties of superoxide anion (O2-)-induced histamine release from rat peritoneal mast cells using superoxide anion radicals obtained from potassium superoxide (KO2). KO2 elicited a rapid histamine release in a dose-dependent fashion, without lactate dehydrogenase (LDH) release. The KO2-induced release was temperature- and energy-dependent. KO2 rapidly increased the intracellular free Ca2+ concentration, accompanied by a marked increase of Ca(2+)-uptake. These findings indicate that the increase in intracellular Ca2+ concentration is involved in the initiation of KO2-induced histamine release, and KO2 could be used as an agent of O2(-)-induced biological reactions.

Effects of transgalactosylated disaccharides on the human intestinal microflora and their metabolism

The effects of transgalactosylated disaccharide (TD) intake on human fecal microflora and their metabolism were investigated in 12 Japanese males. TD is a mixture of sugars, galactosyl galactose, and galactosyl glucose, synthesized from lactose through the transgalactosylation reaction of Streptococcus thermophilus beta-galactosidase. Volunteers took 15 g of the test sugar daily for 6 days. The TD ingestion increased the number of bifidobacteria and lactobacilli, but decreased the number of Bacteroidaceae and Candida spp. in the feces. The ratio of bifidobacteria to total bacteria increased from 0.28 to 0.51. TD decreased the fecal concentrations of propionic acid, isobutyric acid, isovaleric acid, and valeric acid. This sugar also lowered the fecal pH, and the concentrations of fecal ammonia, p-cresol, and indole. Moreover, a positive correlation was found between the concentration of ammonia, and that of branched-chain fatty acids (isobutyric acid and isovaleric acid), p-cresol, and indole. All of these compounds are produced from amino acids through deamination by the intestinal bacteria. The depression of amino acid fermentation by intestinal bacteria may be involved in the reduction of fecal ammonia. These results suggest that a part of the transgalactosylated disaccharides passes into the colon, inducing changes in the colonic microflora composition, hastening carbohydrate fermentation, and depressing amino acid fermentation in the human gut.

[The effect of prostaglandin E1 and prostaglandin F2 alpha in the ischemic small intestine of dogs]

The effect of PGE1 and PGF2 alpha in the ischemic intestinal tract were examined. In 40 mongrel dogs, we studied ischemic models of small intestine. PGE1 or PGF2 alpha was injected into the anterior mesenteric artery after reperfusion according to each occlusion time, and the tissue blood flow was measured on both mucosal and serous sides of small intestinal loop by laser flowmeter to examine the relation to the extent of tissue damage. Tissue blood flow of the ischemic intestine after the injection of PGE1 increased by 148-208% in the 3-5 hr occlusion group and by 86-110% in the 7-10 hr occlusion group. Tissue blood flow after the injection of PGF2 alpha decreased by 39-59% in the 3-5 hr occlusion group and by 1-15% in the 7-10 hr occlusion group. These results indicate that the effect of PGE1 and PGF2 alpha in the ischemic intestine would be available up to 3-5 hr of ischemia. Histological examination revealed that viability of the remaining crypt was high in the PGE1 injection group but low in the PGF2 alpha injection group. These findings suggest that PGE1, if try at the early stage, would be effective for the treatment of ischemic lesion.

[An experimental pathologic study of acute small intestinal ischaemic in mongrel dogs--occluded proximal site of anterior mesenteric artery by balloon catheter]

We prepared experimental of small intestinal ischemia by occluding the inlet of the anterior mesenteric artery of adult mongrel dogs with balloon catheters. With these experimental models, the degree of tissue damage of the small intestinal mucosa, which became ischemic, was studied according to the different occlusion times of the anterior mesenteric artery (3, 5, 7, 10, 15 and 30 hours). As a result, ischemic mucosal lesions in the small intestine at an initial stage occurred on the antimesenteric side. In the gross findings of the mucosa when the occlusion time was within 5 hours, linear and spotted lesions appeared in a zone on the antimesenteric side. When the occlusion time was 7 hours or more, these lesions fused and the entire intestinal mucosa became a hemorrhagic lesion. By occluding the anterior mesenteric artery for 22-30 hours, all 6 experimental ischemic animals died.

Antibacterial effect of bovine milk antibody against Escherichia coli in a mouse indigenous infection model

A skim-milk fraction and a whey-protein concentrate (WPC) fraction were prepared from the cows that had been immunized with E. coli isolated from the mouse intestine. The antibacterial effect of these fractions against E. coli was examined. They contained antibody with a high affinity for E. coli strain 48, a representative strain in the mouse intestine, which is composed of a large amount of IgG and smaller amounts of IgA and IgM. Although these fractions showed no bactericidal or bacteriostatic activity against E. coli 48 directly in vitro, they exhibited strong agglutination and opsonization activities against the bacteria in vitro. The bacteria opsonized with the WPC fraction were taken up more effectively by liver macrophages in vivo, compared with unopsonized E. coli, after an intravenous injection into mice. Oral administration of the skim-milk fraction to mice significantly reduced the susceptibility to the lethal toxicity of 5-fluorouracil (5 FU). The increase in the population levels of E. coli in the intestinal tract after administration of 5 FU was inhibited by oral administration of the skim-milk fraction. These results strongly suggest that specific antibody may be effective in the prophylaxis against the indigenous infection with gram-negative bacteria such as E. coli after a period of chemotherapy in cancer patients.

A noninvasive method of measuring Max(dP/dt) of the left ventricle by Doppler echocardiography

Although slightly affected by alterations in preload, the maximum first derivative of left ventricular pressure with respect to time, Max(dP/dt), is widely regarded as a simple and convenient index of cardiac contractility for clinical use. The feasibility of noninvasive, hence repeatable, measurement of Max(dP/dt) will certainly lead to re-evaluation of its usefulness. Max(dP/dt) is given by the following equation: Max(dP/dt) = rho c Max(du/dt), where rho is the blood density, c the pulse wave velocity, and mu the flow velocity in the aorta. This equation has been previously validated in animal experiments and has now been applied to the clinical setting for the first time. In 20 patients without aortic stenosis, left ventricular pressure was measured with a catheter-tip micromanometer, aortic ejection flow velocity was measured by Doppler echocardiography, and pulse wave velocity by mechanocardiography or Doppler echocardiography. Then, delta c Max (du/dt was calculated from the measured data and compared with measured Max (dP/dt). A significant positive correlation was found between them (rho c Max (du/dt) = 0.96 x Max (dP/dt) + 6.52, r = 0.83, p < 0.001). In 11 patients with hypertension, rho c Max (du/dt) was obtained before and after long-term (average 13.1 months) treatment with antihypertensive drugs. In spite of the expected reduction in blood pressure and the regression of left ventricular mass, rho c Max (du/dt) remaioned unchanged. In 9 patients with dilated cardiomyopathy, the effects of beta 1-agonist were tested at the beginning of therapy (30 mg/day denopamine) and 6 months later. The increase in rho c Max (du/dt) observed 1 hour after oral administration of he drug had not changed significantly 6 months later. We conclude that the index rho c Max (du/dt), is useful in assessing the contractile state of the left ventricle noninvasively.