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Inoue M, Yoshida J, Oka S, Honda Y, Chikaishi Y, Yasuda D. P1.04-53 A High PD-L1 Expression in Non-Small Cell Lung Cancer Correlates with Expression of SPOP and CD8 Tumor-Infiltrating Lymphocytes. J Thorac Oncol 2019. [DOI: 10.1016/j.jtho.2019.08.956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Shimada J, Okada S, Tsunezuka H, Shimomura M, Ishihara S, Inoue M, Naito Y. EP1.16-36 A Good Intestinal Bacterial Environment Can Reduce the Side Effects of Tyrosine Kinase Inhibitors and Enhance Their Anti-Cancer Effects. J Thorac Oncol 2019. [DOI: 10.1016/j.jtho.2019.08.2401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Okubo M, Iida A, Inoue M, Saito Y, Ogasawara M, Hayashi S, Noguchi S, Nishino I. EP.102Genetic diagnosis in large Japanese cohort using targeted re-sequencing system. Neuromuscul Disord 2019. [DOI: 10.1016/j.nmd.2019.06.508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Indrawati L, Noguchi S, Tanboon J, Ogasawara M, Saito Y, Kumutpongpanich T, Inoue M, Okubo M, Fukuda T, Sugie H, Goto Y, Iida A, Hayashi S, Nishino I. P.89Infantile-onset lipid storage myopathy. Neuromuscul Disord 2019. [DOI: 10.1016/j.nmd.2019.06.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Yamashita T, Kamada H, Kanasaki S, Nagano K, Inoue M, Higashisaka K, Yoshioka Y, Tsutsumi Y, Tsunoda S. Ephrin type-A receptor 2 on tumor-derived exosomes enhances angiogenesis through the activation of MAPK signaling. DIE PHARMAZIE 2019; 74:614-619. [PMID: 31685088 DOI: 10.1691/ph.2019.9474] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
Exosomes are potent players in the development of metastases and they play an important role in cancer angiogenesis and exacerbation. However, it is unclear how proteins on exosomes affect development of blood vessel networks. In this study, we focused on relationships between membrane proteins on exosomes and angiogenesis using human umbilical vein endothelial cells (HUVEC). Lung tumor cell-derived exosomes induced tube formation and growth of endothelial cells in vitro in a dose-dependent manner involving MAPK activation, but this was not seen in normal lung epithelial cells. Ephrin type-A receptor 2 (EphA2) was identified by proteomic analysis and an inhibition assays showed it is a major MAPK activator on exosomes. Thus EphA2 on exosomes participates in angiogenesis as a ligand of the ephrin signaling pathway. These results support the development of novel therapeutic strategies such as blockade of remote cancer communications through exosomes.
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Inoue M, Uchino S, Iida A, Noguchi S, Hayashi S, Takahashi T, Fujii K, Komaki H, Takeshita E, Nonaka I, Yoshizawa T, Van Lommel L, Schuit F, Goto Y, Mimaki M, Nishino I. METABOLIC DISTURBANCES IN NEUROMUSCULAR DISEASES. Neuromuscul Disord 2019. [DOI: 10.1016/j.nmd.2019.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Sakakida T, Ishikawa T, Chihara Y, Harita S, Uchino J, Tabuchi Y, Komori S, Asai J, Narukawa T, Arai A, Tsunezuka H, Kosuga T, Konishi H, Moriguchi M, Yasuda H, Hongo F, Inoue M, Hirano S, Ukimura O, Itoh Y, Taguchi T, Takayama K. Safety and efficacy of PD-1/PD-L1 blockade in patients with preexisting antinuclear antibodies. Clin Transl Oncol 2019; 22:919-927. [PMID: 31576495 DOI: 10.1007/s12094-019-02214-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 09/13/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE Immune checkpoint inhibitors (ICIs) show promising clinical activity in advanced cancers. However, the safety and efficacy of PD-1/PD-L1 blockade in patients with preexisting antinuclear antibodies (ANA) are unclear. METHODS 191 patients treated with nivolumab, pembrolizumab, atezolizumab, or durvalumab for unresectable advanced cancers between September 2014 and December 2018 were identified retrospectively. Patients were divided into positive (ANA titers ≥ 1:160) and negative ANA groups (ANA titers < 1:160). Development of immune-related adverse events (irAEs), the overall response rate (ORR), and disease control rate (DCR) were monitored. RESULTS Positive ANA titers were seen in 9 out of 191 patients. Four patients in the positive ANA group and 69 patients in the negative group developed irAEs of any grade without a significant difference between the groups. The development of endocrine, pulmonary, and cutaneous irAEs was not significant, whereas positive ANA was significantly higher in patients who developed colitis (2/9) than in patients who did not (3/182, P = 0.0002). DCR in the positive and negative ANA group was 37.5% and 67.5%, respectively, and was not statistically significant, but had better efficacy in patients without ANA (P = 0.08). ANA-related autoimmune diseases such as SLE, Sjögren's syndrome, MCTD, scleroderma, dermatomyositis, and polymyositis was not induced in either group. However, one patient with preexisting dermatomyositis had a flare up after initiation of atezolizumab. CONCLUSION Further studies to identify predictive factors for the development of irAEs are required to provide relevant patient care and maximize the therapeutic benefits of ICIs.
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Kabeya Y, Iwamori T, Yonezawa S, Takeuchi Y, Nakano H, Nagisa Y, Okubo M, Inoue M, Tokumasu R, Ozawa I, Takano A, Nishino I. O.37AI-based muscle histopathologist can differentiate major muscular dystrophies better than human. Neuromuscul Disord 2019. [DOI: 10.1016/j.nmd.2019.06.320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ophinni Y, Inoue M, Kotaki T, Kameoka M, Hayashi Y. CRISPR/Cas9 targeting HIV-1 regulatory genes inactivates latent proviral DNA and prevents new infection in T cell culture with inhibition of viral escape. J Virus Erad 2019. [DOI: 10.1016/s2055-6640(20)31056-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Tanioka H, Nagasaka T, Uno F, Inoue M, Okita H, Katata Y, Kanzaki H, Kuramochi H, Satake H, Shindo Y, Doi A, Nasu J, Yamashita H, Yamaguchi Y. Relationship between peripheral neuropathy and effectiveness in second-line chemotherapy for unresectable advanced gastric cancer: a prospective, observational, multicenter study protocol. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz155.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Inoue M, Tanboon J, Okubo M, Theerawat K, Saito Y, Ogasawara M, Indrawati LA, Uruha A, Okiyama N, Fujimoto M, Suzuki S, Nishino I. Absence of sarcoplasmic myxovirus resistance protein A (MxA) expression in antisynthetase syndrome in a cohort of 194 cases. Neuropathol Appl Neurobiol 2019; 45:523-524. [DOI: 10.1111/nan.12551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sugawara Y, Tsuji I, Mizoue T, Inoue M, Sawada N, Matsuo K, Ito H, Naito M, Nagata C, Kitamura Y, Sadakane A, Tanaka K, Tamakoshi A, Tsugane S, Shimazu T. Cigarette smoking and cervical cancer risk: an evaluation based on a systematic review and meta-analysis among Japanese women. Jpn J Clin Oncol 2019; 49:77-86. [PMID: 30407555 DOI: 10.1093/jjco/hyy158] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/30/2018] [Indexed: 11/13/2022] Open
Abstract
Background There is a body of evidence to suggest that cigarette smoking increases the risk of cervical cancer in women, but no study has examined the magnitude of the association in Japanese women. Here, we evaluated the association between cigarette smoking and the risk of cervical cancer in Japanese women based on a systematic review of epidemiological evidence. Methods Original data were obtained from a MEDLINE search using PubMed or from a search of the 'Ichushi' database, as well as by a manual search. Evaluation of associations was based on the strength of evidence and the magnitude of association, together with biological plausibility as evaluated previously by the International Agency for Research on Cancer. Meta-analysis of associations was also conducted to obtain a summarized overview of the data. Results We identified two cohort studies and three case-control studies. All five studies had indicated strong positive associations between cigarette smoking and the risk of cervical cancer. Our summary estimate indicated that the relative risk (RR) for individuals who had ever-smoked relative to never-smokers was 2.03 (95% confidence interval: 1.49-2.57). Four studies had also demonstrated dose-response relationships between cigarette smoking and the risk of cervical cancer. Conclusion We conclude that there is convincing evidence that cigarette smoking increases the risk of cervical cancer among Japanese women.
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Inoue M. EAST MEETS WEST: THE CURRENT STATE AND RESEARCH FINDINGS OF ADVANCE CARE PLANNING. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Inoue M, Kestenbaum M, Muir C. SOCIODEMOGRAPHIC FACTORS ASSOCIATED WITH AT-HOME DEATH AMONG HOSPICE PATIENTS. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Sakai K, Inoue M, Nishimura H, Mikami S, Kuwabara Y, Kojima A, Toda M, Kobayashi Y, Kikuchi S, Hirata Y, Kyoyama H, Moriyama G, Gemma A, Uematsu K. P2.06-31 Inhibition of Heat Shock Protein 70 Function Suppresses Proliferation in Mesothelioma Cells. J Thorac Oncol 2018. [DOI: 10.1016/j.jtho.2018.08.1286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Magara J, Watanabe M, Tsujimura T, Hamdy S, Inoue M. Cold thermal oral stimulation produces immediate excitability in human pharyngeal motor cortex. Neurogastroenterol Motil 2018; 30:e13384. [PMID: 29856098 DOI: 10.1111/nmo.13384] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/24/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Current strategies of swallowing therapy include facilitation of swallowing initiation by sensory modulation. Although thermal tactile oral stimulation is a common method to treat dysphagic patients to improve swallowing movement, little is known about the possible mechanisms. This study is aimed to investigate whether thermal oral (tongue) stimulation can modulate the cortico-pharyngeal neural motor pathway in humans. METHODS Eighteen healthy volunteers participated and were intubated with an intraluminal catheter for recording pharyngeal electromyography. Each participant underwent baseline transcranial magnetic stimulation (TMS) cortico-pharyngeal motor evoked potential (MEP) measurements bilaterally. MEPs were then measured during thermal stimulation over the dorsal tongue, applied using the Peltier device at three different temperatures; 45°C, 37°C, and 15°C, in a pre-ordered manner. Each of the three temperatures was given twice with a 5-min resting time between each trial. Averaged MEP amplitude changes were analyzed using ANOVA and post-hoc t-tests. KEY RESULTS Two-way repeated measures ANOVA with factors of Temperature × Trial in amplitude of MEP demonstrated a significant effect of Temperature both in the stronger (F2,34 = 5.775, P = .007) and weaker (F2,34 = 4.771, P = .017) pharyngeal hemispheres. Subsequent post-hoc tests showed the significant increase in pharyngeal MEPs at 15° compared to 37° in both hemispheres (P < .05). CONCLUSIONS & INFERENCES Cold oral stimulation was able to induce significant changes in pharyngeal cortical excitability, demonstrating evidence for a sensorimotor interaction between oral and pharyngeal cortical areas.
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Suzuki H, Tsunezuka H, Inoue M. P2.15-27 Lung Volume Change After Lobectomy Estimated by Three-Dimensional Image Analysis System. J Thorac Oncol 2018. [DOI: 10.1016/j.jtho.2018.08.1469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Ishiyama A, Kusabiraki S, Inoue M, Oya Y, Miyahara H, Takeshita E, Motohashi Y, Komaki H, Sasaki M, Nishino I. FSHD / OPMD / EDMD / DMI. Neuromuscul Disord 2018. [DOI: 10.1016/j.nmd.2018.06.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ishihara S, Okada S, Ogi H, Kodama Y, Itoh K, Marx A, Inoue M. P1.14-11 The Expression Pattern of Programmed Death-Ligand 1 According to the Pathological Type of Malignant Thymic Epithelial Tumors. J Thorac Oncol 2018. [DOI: 10.1016/j.jtho.2018.08.913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Kabeya Y, Takeuchi Y, Nakano H, Okubo M, Inoue M, Tokumasu R, Ozawa I, Takano A, Iwamori T, Yonezawa S, Nishino I. NEXT GENERATION SEQUENCING AND EXPERIMENTAL MYOLOGY. Neuromuscul Disord 2018. [DOI: 10.1016/j.nmd.2018.06.432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Sekine D, Fukata K, Amimoto K, Fujino Y, Inoue M, Inoue M, Takahashi Y, Takahashi H, Makita S. Analysis of the subjective postural vertical on diagonal plane in elderly subjects and left hemiparetic patients after stroke. Ann Phys Rehabil Med 2018. [DOI: 10.1016/j.rehab.2018.05.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Sasazuki S, Inoue M, Shimazu T, Wakai K, Naito M, Nagata C, Tanaka K, Tsuji I, Sugawara Y, Mizoue T, Matsuo K, Ito H, Tamakoshi A, Sawada N, Nakayama T, Kitamura Y, Sadakane A, Tsugane S. Evidence-based cancer prevention recommendations for Japanese. Jpn J Clin Oncol 2018; 48:576-586. [PMID: 29659926 DOI: 10.1093/jjco/hyy048] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 03/23/2018] [Indexed: 12/19/2022] Open
Abstract
A comprehensive evidence-based cancer prevention recommendation for Japanese was developed. We evaluated the magnitude of the associations of lifestyle factors and infection with cancer through a systematic review of the literature, meta-analysis of published data, and pooled analysis of cohort studies in Japan. Then, we judged the strength of evidence based on the consistency of the associations between exposure and cancer and biological plausibility. Important factors were extracted and summarized as an evidence-based, current cancer prevention recommendation: 'Cancer Prevention Recommendation for Japanese'. The recommendation addresses six important domains related to exposure and cancer, including smoking, alcohol drinking, diet, physical activity, body weight and infection. The next step should focus on the development of effective behavior modification programs and their implementation and dissemination.
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Inoue M, Baba T, Morohashi KI. Recent progress in understanding the mechanisms of Leydig cell differentiation. Mol Cell Endocrinol 2018; 468:39-46. [PMID: 29309805 DOI: 10.1016/j.mce.2017.12.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/25/2017] [Accepted: 12/26/2017] [Indexed: 01/26/2023]
Abstract
Leydig cells in fetal and adult testes play pivotal roles in eliciting male characteristics by producing androgen. Although numerous studies of Leydig cells have been performed, the mechanisms for differentiation of the two cell types (fetal Leydig and adult Leydig cells), their developmental and functional relationship, and their differential characteristics remain largely unclear. Based on recent technical progress in genome-wide analysis and in vitro investigation, novel and fascinating observations concerning the issues above have been obtained. Focusing on fetal and adult Leydig cells, this review summarizes the recent progress that has advanced our understanding of the cells.
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Goto A, Noda M, Goto M, Yasuda K, Mizoue T, Yamaji T, Sawada N, Iwasaki M, Inoue M, Tsugane S. Predictive performance of a genetic risk score using 11 susceptibility alleles for the incidence of Type 2 diabetes in a general Japanese population: a nested case-control study. Diabet Med 2018; 35:602-611. [PMID: 29444352 DOI: 10.1111/dme.13602] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2018] [Indexed: 01/05/2023]
Abstract
AIMS To assess the predictive ability of a genetic risk score for the incidence of Type 2 diabetes in a general Japanese population. METHODS This prospective case-control study, nested within a Japan Public Health Centre-based prospective study, included 466 participants with incident Type 2 diabetes over a 5-year period (cases) and 1361 control participants, as well as 1463 participants with existing diabetes and 1463 control participants. Eleven susceptibility single nucleotide polymorphisms, identified through genome-wide association studies and replicated in Japanese populations, were analysed. RESULTS Most single nucleotide polymorphism loci showed directionally consistent associations with diabetes. From the combined samples, one single nucleotide polymorphism (rs2206734 at CDKAL1) reached a genome-wide significance level (odds ratio 1.28, 95% CI 1.18-1.40; P = 1.8 × 10-8 ). Three single nucleotide polymorphisms (rs2206734 in CDKAL1, rs2383208 in CDKN2A/B, and rs2237892 in KCNQ1) were nominally significantly associated with incident diabetes. Compared with the lowest quintile of the total number of risk alleles, the highest quintile had a higher odds of incident diabetes (odds ratio 2.34, 95% CI 1.59-3.46) after adjusting for conventional risk factors such as age, sex and BMI. The addition to the conventional risk factor-based model of a genetic risk score using the 11 single nucleotide polymorphisms significantly improved predictive performance; the c-statistic increased by 0.021, net reclassification improved by 6.2%, and integrated discrimination improved by 0.003. CONCLUSIONS Our prospective findings suggest that the addition of a genetic risk score may provide modest but significant incremental predictive performance beyond that of the conventional risk factor-based model without biochemical markers.
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Aoyama H, Ebata T, Hattori M, Takano M, Yamamoto H, Inoue M, Asaba Y, Ando M, Nagino M, Aoba T, Kaneoka Y, Arai T, Shimizu Y, Kiriyama M, Sakamoto E, Miyake H, Takara D, Shirai K, Ohira S, Kobayashi S, Kato Y, Yamaguchi R, Hayashi E, Miyake T, Mizuno S, Sato T, Suzuki K, Hashimoto M, Kawai S, Matsubara H, Kato K, Yokoyama S, Suzumura K. Reappraisal of classification of distal cholangiocarcinoma based on tumour depth. Br J Surg 2018; 105:867-875. [DOI: 10.1002/bjs.10869] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/22/2018] [Accepted: 03/02/2018] [Indexed: 02/02/2023]
Abstract
Abstract
Background
In the eighth edition of the AJCC cancer staging classification, the T system for distal cholangiocarcinoma (DCC) has been revised from a layer-based to a depth-based approach. The aim of this study was to propose an optimal T classification using a measured depth in resectable DCC.
Methods
Patients who underwent pancreatoduodenectomy for DCC at 32 hospitals between 2001 and 2010 were included. The distance between the level of the naive bile duct and the deepest cancer cells was measured as depth of invasion (DOI). Invasive cancer foci were measured as invasive tumour thickness (ITT). Log rank χ2 scores were used to determine the cut-off points, and concordance index (C-index) to assess the survival discrimination of each T system.
Results
Among 404 patients, DOI was measurable in 182 (45·0 per cent) and ITT was measurable in all patients, with median values of 2·3 and 5·6 mm respectively. ITT showed a positive correlation with DOI (rs = 0·854, P < 0·001), and the cut-off points for prognosis were 1, 5 and 10 mm. Median survival time was shorter with increased ITT: 12·4 years for ITT below 1 mm, 5·2 years for ITT at least 1 mm but less than 5 mm, 3·0 years for ITT at least 5 mm but less than 10 mm, and 1·5 years for ITT 10 mm or more (P < 0·001). This classification exhibited more favourable prognostic discrimination than the T systems of the seventh and eighth editions of the AJCC (C-index 0·646, 0·622 and 0·624 respectively).
Conclusion
ITT is an accurate approach for depth assessment in DCC. The four-tier ITT classification with cut-off points of 1, 5 and 10 mm seems to be a better T system than those in the seventh and eighth editions of the AJCC classification.
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