Health guidance for prevention of lifestyle-related diseases using health-related mobile applications

Issue

Lifestyle modifications are essential for the prevention of lifestyle-related diseases such as hypertension, hyperlipidaemia, and type 2 diabetes. Healthcare providers in Japan are required to use information and communications technologies (ICT), such as health-related mobile applications (mHealth apps), in health guidance.

Description of the Problem

To understand the results of and issues in health guidance, two searches were conducted to identify the domains of health guidance provided using ICT. We searched the PubMed and Japan Medical Abstracts Society databases to identify articles published from 2000-2018. The first search identified frameworks of health guidance provided using ICT. The second search identified primary studies about using mHealth apps published between 2000 and 2018. The sample comprised 22 unique programs from 38 primary studies. The following research questions were explored: 1) What is the purpose of using the mHealth app?

2) Is there a significant difference in the effect of using the mHealth app instead of face-to-face communication?

Results

The mHealth app was used to enhance convenience and to improve or modify lifestyle. The latter included self-monitoring, typing health information, providing knowledge, sharing information, providing encouragement and praise, and correction of action plans. Some positive effects were observed, including compensating for insufficient information, enhancing self-management, and improving degrees of satisfaction of users. Only two programs did not report a significant difference in the effect of using the mHealth app as compared to face-to-face communication.

Lessons

This review showed that the frequency of typing information about diet and exercise appeared to be related to the prevention of primary lifestyle-related diseases and the improvement of self-management behaviour.

Key messages

Use of the mHealth app for providing health guidance might enhance continuous support for self-monitoring and self-management behaviour. Use the mHealth app for providing encouragement and praise might promote a smooth conversation, which in turn would facilitate appropriate self-management behaviour.

47 Inhibition of endoplasmic reticulum stress during invitro maturation improves the developmental competence of bovine cumulus-oocyte complexes

Endoplasmic reticulum (ER) stress, a dysfunction in protein-folding capacity of ER, is involved in many physiological responses including embryonic development. Evidence shows that the ER stress-induced unfolded protein response signaling pathway is associated with impairment of oocyte maturation and pre-implantation embryonic development; supplementation of culture medium with tauroursodeoxycholic acid (TUDCA), an ER stress inhibitor, improved the developmental process of oocytes and embryos by attenuating ER stress. However, no reports are available on the role of TUDCA in reducing ER stress during IVM of bovine oocytes. Therefore, the aim of this study was to examine the mechanism of TUDCA on reducing ER stress in maturation of bovine cumulus-oocyte complexes (COCs) and whether inhibition of ER stress during maturation can promote subsequent embryonic development. Bovine ovaries were collected from a local slaughterhouse, and after aspiration COCs were matured with/without TUDCA (50, 100, and 200 µM) for 22h at 38.5°C in a humidified atmosphere of 5% CO2. After IVM, we examined the maturation rate, reactive oxygen species, apoptosis, protein/mRNA expression levels, and subsequent embryonic development after IVF. The data were analysed using analysis of variance followed by the Tukey-Kramer multiple comparison test. As a result, the dose-dependent experiment shows that a 100μM concentration of TUDCA significantly increased the maturation rate and decreased the percentage of apoptotic cells in COCs and reactive oxygen species levels in denuded oocytes. Subsequently, the expression of ER stress inducible protein GRP78/BIP significantly decreased in COCs treated with 100 µM TUDCA compared with the control COCs. In addition, the mRNA expression of ER stress and pro-apoptotic markers (GRP78/BIP, PERK, IER1, ATF4, XBP1, CHOP, and BAX) in COCs were significantly decreased by TUDCA (100 µM) treatment, whereas it increased anti-apoptotic BCL2 expression. Moreover, we show that TUDCA (100 µM) supplementation enhances embryonic development by significantly increasing the blastocyst formation rate (43.6±1.8% vs. 49.7±1.3%) and decreasing the number of apoptotic cells (7.7±1.1% vs. 5.03±0.6%) in blastocysts. These findings suggest that existence of ER stress during maturation alters the developmental competence of bovine COCs. Therefore, for the first time, we demonstrate that application of TUDCA during IVM plays a crucial role in reducing ER stress and improves the meiotic maturation, oocyte quality, and subsequent embryonic development invitro.

Refractory Hypotension during Combined General and Epidural Anaesthesia in a Patient on Tricyclic Antidepressants

We report a case of refractory hypotension that occurred after epidural injection of local anaesthetic, in a patient who was receiving tricyclic antidepressant therapy and was under general anaesthesia. The patient failed to respond to repeated injections of appropriate doses of sympathomimetics, but did respond to high-dose catecholamine infusions. We suggest that epidural anaesthesia should be used with care when combined with general anaesthesia for patients on long-standing tricyclic antidepressant therapy. If refractory hypotension should occur in such patients, the use of direct-acting vasoconstrictors such as noradrenaline should be considered.

Combined chemotherapy and radiation therapy for central nervous system germ cell tumors: preliminary results of a Phase II study of the Japanese Pediatric Brain Tumor Study Group

The authors conducted a multiinstitutional phase II study to establish a postsurgical combined chemotherapy and radiation therapy regimen for patients with primary germ cell tumors of the brain. After surgical debulking of the tumor and histological verification, patients were divided into three therapeutic groups: good prognosis, intermediate prognosis, and poor prognosis. Patients received two kinds of chemotherapy (three courses) prior to receiving radiation therapy: carboplatin-etoposide combination ([CARB-VP]: carboplatin 450 mg/m(2) on Day 1, etoposide 150 mg/m(2) on Days 1-3) or ifosphamide-cisplatin-etoposide combination ([ICE]: ifosphamide 900 mg/m(2), cisplatin 20 mg/m(2), and etoposide 60 mg/m(2) on Days 1-5). Patients in the good prognosis group (those with germinomas) were treated with CARB-VP followed by local radiation therapy (24 Gy). Patients in the intermediate prognosis group received CARB-VP followed by local radiation therapy (50 Gy); they received five additional chemotherapy treatments. Patients in the poor prognosis group received ICE followed by whole craniospinal radiation therapy; they also received five additional chemotherapy treatments. Eighty-two patients were evaluated. For the 56 patients with germinomas, a 93% rate of complete remission after treatment was achieved. The remission rate was 76% for 21 patients in the intermediate prognosis group, and no recurrence was detected during a median follow-up period of 2.6 years. In the group of five patients with poor prognosis, the disease in three patients progressed during chemotherapy or radiation therapy and they died within 6 months. There were no serious complications in the surviving patients. The authors found their treatment protocols to be currently effective for patients with germinomas and those with an intermediate prognosis.

43 EFFECT OF VITRIFICATION AT GERMINAL VESICLE STAGE ON THE MITOCHONDRIAL AND CYTOSKELETAL INTEGRITY IN BOVINE OOCYTES

In the previous report, we demonstrated that bovine germinal vesicle (GV) stage oocytes vitrified using a nylon mesh holder showed an in vitro maturation rate to the metaphase II (MII) stage similar to that of fresh ones. However, cleavage and developmental rates of vitrified oocytes were low. Because mitochondria and the cytoskeleton are thought to have a central role in energy supply and cellular division in mammalian embryogenesis, it seems possible that alternation in their function in vitrified GV oocytes may contribute to subsequent lower cleavage and developmental rates. The oxygen consumption rate reflects the mitochondrial activity and its measurement may be an effective way for non-invasive evaluation of oocyte quality. In this study, to ascertain that altered mitochondrial functions and cytoskeleton may contribute to reduce the quality of oocytes after vitrification, we evaluated the distribution of active mitochondria and the cytoskeleton in vitrified oocytes. We also examined the relationship between oxygen consumption rate and the distribution of active mitochondria in vitrified oocytes. Bovine GV oocytes connected with cumulus cells were exposed to the cryoprotectant (EFS40) in a stepwise way and transferred onto a nylon mesh holder, followed by plunging them directly into liquid nitrogen. After warming, vitrified oocytes were allowed in vitro maturation. After denuding, matured oocytes were stained with a mitochondria-specific probe, rhodamine-123 and then oxygen consumption rate using an embryo respirometer (HV-403; Research Institute for Functional Peptides, Yamagata, Japan) was measured in each oocyte. According to morphological distribution of mitochondria, oocytes were classified as follows: type 1, uniform distribution; type 2, spotted distribution; and type 3, a weak fluorescence. The oxygen consumption rate of the fresh oocytes at the MII stage was significantly (P < 0.05) higher than that of vitrified oocytes (5.24 and 4 × 1015 mol–1 s–1, respectively), although there was no difference between the fresh and vitrified groups at the GV stage (5.02 and 5.06 × 1015 mol–1 s–1, respectively). The oxygen consumption rates of type 1 oocytes in fresh and vitrified groups at the MII stage tended to be higher than those of type 2 and 3 oocytes (type 1, 5.29 and 5.27; type 2, 4.99 and 4.52; type 3, 4.77 and 4.48 × 1015 mol–1 s–1, respectively). In addition, the percentage of type 1 oocytes in the fresh group was significantly (P < 0.05) higher than that in the vitrified group (59.4 and 34.3%, respectively). The matured oocytes also were stained with α-tubulin monoclonal antibody or F-phalloidin independently to examine the morphological status of microtubules or microfilament. The rates of oocytes with abnormal microtubules and microfilament in the vitrified group were 29.7 and 43.5%, respectively, showing higher rates compared with corresponding fresh oocytes (9.8%; P < 0.05 and 25.0%; P = 0.21, respectively). These results suggested that the reduction of quality and subsequent developmental competence in vitrified oocytes might be related to damages of mitochondria and cytoskeleton.

Chondrosarcoma of the skull base: report of six cases

Five patients with chondrosarcoma, grade I or II, and one with mesenchymal chondrosarcoma of the skull base were treated at our clinic between 1967 and 1991. The patients were three men and three women who ranged in age from 21 to 39 years. The presenting symptoms were diplopia, decreased visual acuity, or symptoms of involvement of VIIIth and lower cranial nerves. The duration of the symptoms ranged from 18 months to 14 years. A plain skull x-ray and tomography of the skull, computed tomographic (CT) scans, and magnetic resonance images (MRI) revealed a calcified mass. Angiograms showed an occlusion of the arteries or venous sinuses, or both, in four patients, and a distinct tumor stain in one. The tumors were subtotally removed in all six cases. Two patients received postoperative irradiation for the residual tumor. In one patient, extraocular movement was compromised postoperatively, although in the other five patients there was no aggravation of the neurologic signs. Follow-up CT scans and MRI demonstrated no recurrent tumors nor any enlargement of residual tumors. Based on these findings, we advocate aggressive surgical removal of these tumors, which should be augmented by radiation therapy if the postoperative CT scans or MRI reveal residual tumors.

Twelve cases of jugular foramen neurinoma

Twelve patients with jugular foramen neurinoma were operated on at our clinic between 1974 and 1990. The initial signs and symptoms were variable; dysfunctions of the 7th, 8th, 9th, 10th, and 11th nerves were frequently observed. Among these, involvement of the eighth nerve was most frequent, and three patients were given a misdiagnosis of acoustic neurinoma. Computed tomography scan and magnetic resonance imaging were useful not only for the correct diagnosis, but also for planning the surgical treatment and postoperative followup. Surgical resection was accomplished with four different approaches: (1) suboccipital approach without opening the jugular foramen, (2) suboccipital approach with opening the jugular foramen, (3) suboccipital approach with opening the jugular foramen combined with infralabyrinthine approach, (4) infralabyrinthine approach. The surgical approach depended on the presence of intracranial tumor and on the extent of extracranial involvement. There was no operative mortality. Dysfunction of the 8th, 9th, 10th, or 11th nerve did not improve in any patient after tumor removal. In contrast, 12th nerve palsy improved in two of three patients after tumor removal. The nerve of origin was identified in five cases; those were from the ninth nerve in three and from the 11th nerve in two.

Risk factors for regrowth of intracranial meningiomas after gamma knife radiosurgery: importance of the histopathological grade and MIB-1 index

INTRODUCTION

The influence of histopathological grade and MIB-1 index of intracranial meningioma on the results of its radiosurgical management is not clear. The objective of the present retrospective study was to make an evaluation of these factors along with an analysis of other variables associated with progression-free survival after gamma knife radiosurgery (GKR).

PATIENTS AND METHODS

Thirty-four intracranial meningiomas with known detailed histopathological diagnosis were analyzed. Tumors of WHO histopathological grades I, II, and III were diagnosed in 24, 3, and 7 cases, respectively. The median MIB-1 index was 1.3% (range: 0-31.9%). In 14 cases the MIB-1 index was 3.0% and more. In 26 cases the treatment was done at the time of tumor recurrence. Median volume of the neoplasm at the time of GKR was 4.1 mL (range: 0.4-43.1 mL). Median marginal dose was 12 Gy (range: 8-19 Gy). Median length of follow-up constituted 63 months (range: 19-132 months).

RESULTS

Actuarial progression-free survival at 1, 3, 5, and 10 years constituted 100, 94, 83, and 58%, respectively. Histopathological grade II or III (p<0.0001), MIB-1 index 3% and more (p=0.0004), and non-skull base location (p=0.0026) of the tumor showed negative associations with progression-free survival in multivariate analyses. Actuarial progression-free survival at 5 years after GKR for benign and non-benign meningiomas constituted 100 and 45%, respectively (p<0.0001).

CONCLUSION

Radiosurgery is a highly effective management option for benign intracranial meningiomas, but growth control of non-benign ones is significantly worse. It requires close neuroradiological follow-up and necessitates the search for modified treatment strategies.

Simple biodosimetry method for use in cases of high-dose radiation exposure that scores the chromosome number of Giemsa-stained drug-induced prematurely condensed chromosomes (PCC)

There is a need for quick dose estimation by a simple method in radiation accidents. This study develops a simple and rapid dose estimation protocol for victims of such accidents, in particular those involving high radiation doses. Human peripheral blood lymphocytes (PBL) were gamma-irradiated in vitro at several dose points up to 60 Gy, and were stimulated with phytohaemagglutinin-P (PHA-P) for 2 days to obtain dividing cells. PBL were then forced to condense prematurely, using 50 nM calyculin A, and the obtained chromosome spreads were Giemsa stained. The G2-PCC (prematurely condensed chromosomes) index and chromosome number for each radiation dose point were scored. G2-PCC were stably induced using calyculin A within 24 h delays in stimulation of PBL with PHA-P. The chromosome number of G2-PCC increased steeply with radiation doses up to 30 Gy at a rate of 0.31 Gy(-1) and then decreased at 0.30 Gy(-1) up to 40 Gy. More than 10% of G2-PCC index remained up to a 15 Gy dose. Even after 40 Gy irradiation, about 2% PCC index was obtained, and this value was enough to score a sufficient number of chromosome spreads for analysis. Therefore, the combined use of chromosome number and G2-PCC index allows biodosimetry to be done easily and rapidly. If PCC are not induced using calyculin A, it is strongly suggested that the radiation dose is over 50 Gy. A rapid and easy dose estimation for large dose exposure whole-body was realized by combined analysis of Giemsa-stained chromosome number of G2-PCC and PCC index using calyculin A. This simple method will be of use for rapid decision making of therapy for radiation accident victims. This method also has potential for use as a biodosimeter for partial-body exposure accidents.

Dynamics of metabolic changes in intracranial metastases and distant normal-appearing brain tissue after stereotactic radiosurgery: a serial proton magnetic resonance spectroscopy study

The present study evaluated the dynamics of metabolic changes in intracranial metastases and distant normal-appearing brain after stereotactic radiosurgery (SRS). Forty neoplasms were evaluated with single-voxel proton magnetic resonance spectroscopy ((1)H-MRS) both before and after treatment. From one to six examinations (median, 3) were done in each individual case during follow-up. At the time of each investigation additional (1)H-MRS was obtained from the normal-appearing brain distant from the radiosurgical target. Investigated metabolites included N-acetylaspartate (NAA), choline-containing compounds (Cho), creatine (Cr), and mobile lipids (Lip). Within the first month after SRS responded tumors showed a statistically significant increase in NAA/Cho ratio, and decrease of Cho content and Lip-to-normal brain Cr (nCr) ratio. By contrast, statistically significant metabolic alterations were not detected in stabilized tumors. Statistically significant volumetric and metabolic changes were not marked between three and 12 months after treatment in non-progressing lesions. Alternatively, decrease of NAA/Cho ratio, NAA content and Cr content, and increase in Lip/nCr ratio and Cho content were evident in progressive neoplasms, and subtle metabolic alterations could be revealed even before the increase in the lesion volume. Metabolic characteristics of normal-appearing brain distant from the radiosurgical target did not show statistically significant changes within the first year after treatment. In conclusion, additional use of serial (1)H-MRS during follow-up after SRS for intracranial metastases permits detailed evaluation of the metabolic tumor response and may be potentially helpful for early prediction of recurrence.

Vascular calcification and secondary hyperparathyroidism of severe chronic kidney disease and its relation to serum phosphate and calcium levels

BACKGROUND AND PURPOSE

Various complications consequent on disordered calcium and phosphate homeostasis occur frequently in chronic kidney disease (CKD) patients. Particularly, vascular calcification has high morbidity and mortality rates. There is a clear need for a better CKD model to examine various aspects of this disordered homeostasis.

EXPERIMENTAL APPROACH

Oral dosing with adenine induced CKD in rats in only 10 days. Serum calcium, phosphate and parathyroid hormone were measured and calcification in aorta was assessed histologically. The effects of varying phosphorus content of diet or treatment with phosphate binders or active vitamin D(3) on these parameters were examined.

KEY RESULTS

After adenine dosing, significant hyperphosphatemia, hypocalcemia and secondary hyperparathyroidism (2HPT) were observed during the experimental period of 15 weeks. Aortic calcification was detected in only some of the animals even at 15 weeks (approximately 40%). Treatment with vitamin D(3) for 18 days, even at a low dose (100 ng x kg(-1), 3-4 times week(-1), p.o), caused aortic calcification in all animals and increases in serum calcium levels up to the normal range. The vitamin D(3)-induced calcification was significantly inhibited by phosphate binders which lowered serum phosphate levels and the calcium x phosphate product, although serum calcium levels were elevated.

CONCLUSIONS

These data suggest that rats dosed orally with adenine provide a more useful model for analysing calcium/phosphate homeostasis in severe CKD. Controlling serum calcium/phosphate levels with phosphate binders may be better than vitamin D(3) treatment in hyperphosphatemia and 2HPT, to avoid vascular calcification.

Differentiation of High-Grade and Low-Grade Gliomas Using Pattern Analysis of Long-Echo Single-Voxel Proton Magnetic Resonance Spectroscopy ((1)H-MRS)

The usefulness of proton magnetic resonance spectroscopy ((1)H-MRS) for glioma grading is not clear, particularly due to the absence of standard criteria for data analysis. Previously we had developed an original classification of the pathological (1)H-MRS spectra based on the identification of the predominant metabolite peak, N-acetylaspartate (NAA) for Type I, choline-containing compounds (Cho) for Type II, and mobile lipids (Lip) for Type III, and presence or absence of other metabolite peaks: lactate (Lac), Lip, or Cho. The present study evaluated the effectiveness of this classification in grading of previously non-treated gliomas. A total of 38 low-grade and 33 high-grade neoplasms were investigated. Four tumors had (1)H-MRS spectra Type I, and all of those were low-grade. Three tumors had (1)H-MRS spectra Type III, and all those were glioblastomas. Fifteen tumors with (1)H-MRS spectra Type II had a Lip/NAA ratio more than 1 (Type II C with moderate elevation of lipids), and 12 of those neoplasms were high-grade. The differences in distribution of high-grade and low-grade gliomas among another 49 gliomas with (1)H-MRS spectra Type II did not depend on the presence of Lac and/or Lip peaks, and in this subgroup NAA/Cho ratio was also evaluated. Inclusion of both characteristics (type of the (1)H-MRS spectrum and NAA/Cho ratio with defined cut-off level of 0.6) into the diagnostic algorithm yielded 72% diagnostic accuracy (95% confidence interval: 62%-82%) in discriminating high-grade and low-grade neoplasms. In conclusion, pattern analysis of the pathological (1)H-MRS spectra using the proposed classification along with evaluation of NAA/Cho ratio might be helpful for non-invasive glioma grading.

Metabolic characteristics of intracranial metastases, detected by single-voxel proton magnetic resonance spectroscopy, are seemingly not predictive for tumor response to gamma knife radiosurgery

Metabolic characteristics of intracranial metastases, detected with proton magnetic resonance spectroscopy (1H-MRS) have known associations with clinical predictors of tumor response to radiosurgery. Therefore, it can be suspected that the metabolic profile of the neoplasm by itself might have some prognostic significance for the outcome after irradiation. Twenty-six intracranial metastases, which underwent metabolic evaluation with single-voxel 1H-MRS before gamma knife radiosurgery (GKR) and were followed for at least 3 months after treatment, were selected for retrospective analysis. The tumors most frequently originated from the lungs (9 cases), breast (7 cases), colon and rectum (5 cases). The average volume of the investigated intracranial neoplasm was 5.4+/-2.0 mL. The average marginal irradiation dose was 18.6+/-2.3 Gy. The mean follow-up after GKR constituted 8.0+/-5.5 months. Tumor response to GKR was identified in 13 cases on average 2.2+/-1.8 months after treatment. Local recurrence was marked in 10 cases on average 8.7+/-4.1 months after treatment. None of the investigated 1H-MRS metabolic parameters of intracranial metastases showed a statistically significant association with the outcome after GKR. The negative results of the present study make doubtful the predictive value of metabolic characteristics of intracranial metastases, detected with single-voxel 1H-MRS, for the outcome after radiosurgery.

Usefulness of intraoperative magnetic resonance imaging for glioma surgery

BACKGROUND

Radical resection of gliomas can increase patient's survival. There is known concern, however, that aggressive tumour removal can result in neurological morbidity. The objective of the present study was to evaluate the usefulness of low magnetic field strength (0.3 Tesla) open intraoperative magnetic resonance imaging (iMRI) for complete resection of glioma with emphasis on functional outcome.

METHODS

From 2000 to 2004, 96 patients with intracranial gliomas underwent tumour resection with the use of iMRI in Tokyo Women's Medical University. There were 50 men and 46 women; mean age was 39 years. Tumour volume varied from 1.2 ml to 198 ml (median: 36.5 mL). Resection rate and postoperative neurological status were compared between control group (46 cases, operated on during the initial period after installation of iMRI), and study group (50 most recent cases, in whom surgery was done using established treatment algorithm and improved image quality).

FINDINGS

Overall, mean resection rate was 93%, and medial residual tumour volume was 0.17 ml. Total tumour removal was achieved in 44 cases (46%). Compared to control group, resection rate in the study group was significantly higher (91%, vs. 95%; P < 0.05), whereas residual tumour volume was significantly smaller (1.7 mL vs. 0.025 mL; P < 0.001). Nine patients in the control group (20%) and 24 in the study group (48%) experienced temporary postoperative neurological deterioration (P < 0.01), however, the rate of permanent morbidity evaluated 3 months after surgery did not differ significantly between the groups investigated (13% vs. 14%).

CONCLUSIONS

Use of iMRI during surgery for intracranial gliomas permits to attain aggressive tumour resection with good functional outcome. Nevertheless, surgical experience with the iMRI system, establishment of treatment algorithm, and improvement of image quality are of paramount importance for optimal results.

Interaction of local anaesthetics with lipid membranes under inflammatory acidic conditions

The clinical fact that local anaesthetics do not successfully work in the patients with inflammation has been generally interpreted on the basis of inflamed tissue acidification. In order to verify this hypothesis, the interaction of local anaesthetics with lipid membranes was studied by determining the drug-induced changes of membrane physicochemical property (membrane fluidity) at different pH covering inflammatory acidic conditions. At clinically relevant concentrations, lidocaine, procaine, prilocaine and bupivacaine fluidized 1,2-dipalmitoylphosphatidylcholine membranes with the potency decreased with lowering the pH from 7.9 to 5.9. When treated as the aqueous acidic solution (pH 4.0) similar to marketed injection solutions, lidocaine showed more pronounced pH dependence, so the reduction of its membrane-fluidizing effects at acidic pH theoretically correlated to that of its non-ionized membrane-interactive concentrations. Unlike phosphatidylcholine membranes, however, nerve cell model membranes consisting of different phospholipids and cholesterol were fluidized by lidocaine at pH 6.4-6.9 corresponding to the acidity of inflamed tissues. Cationic lidocaine was effective in fluidizing anionic phosphatidylserine and cardiolipin membranes at pH 6.4, but not zwitterionic phospholipid membranes, whereas it was ineffective on any membranes at pH 2.0 where membrane acidic phospholipids were not ionized. Local anaesthetics are considered to form the ion-pairs specifically with counter-ionic phospholipids and act on the membranes of nerve cells even under inflammatory acidic conditions. The drug and membrane interaction causable in inflamed tissue acidification does not support the conventional theory on the local anaesthetic failure associated with inflammation.

Risk of developing ovarian cancer among women with ovarian endometrioma: a cohort study in Shizuoka, Japan

Although some studies have indicated that endometriosis may increase the risk of developing ovarian cancer, there are no data from epidemiologic studies in Japan. We prospectively analyzed all cases of ovarian endometrioma enrolled in the prefecture-wide Shizuoka Cohort Study on Endometriosis and Ovarian Cancer Programme, which was initiated in 1985. To evaluate the risk of ovarian cancer by time periods subsequent to ovarian endometrioma diagnosis, a cohort of 6,398 women with a clinically documented ovarian endometrioma in Shizuoka between 1985 and 1995 was identified from the Shizuoka Cancer Registry (SCR), with follow-up through 2002. Ovarian cancer incidence among cohort members was ascertained by linkage to the SCR using a unique person-identification number. Standardized incidence ratios (SIR) and their 95% confidence intervals (CI) were computed by a use of prefecture-wide rates of ovarian cancer, adjusted for age and calendar year. During follow-up of up to 17 years of the ovarian endometrioma cohort, 46 incident ovarian cancers were identified, yielding that the ovarian cancer risk was elevated significantly among patients with ovarian endometrioma (SIR = 8.95, 95% CI = 4.12-15.3). The SIR did not increase with increasing follow-up duration. The risk increased with increasing age at ovarian endometrioma diagnosis, with a SIR equal to 13.2 (95% CI = 6.90-20.9) in women above 50 years of age. Our findings for the first time support the hypothesis that ovarian endometrioma increases the subsequent risk of developing ovarian cancer in Shizuoka, Japan.

Increased cyclooxygenase-2 expression is correlated with suppressed antitumor immunity in cervical adenocarcinomas

Cyclooxygenase-2 (COX-2) inhibition suppressed the growth of various tumors. The augmentation of antitumor immunity by increasing cytotoxic lymphocytes may be an important mechanism for COX-2 inhibition. Among cervical cancers, adenocarcinomas present more aggressive behavior and overexpressed COX-2. The expression of COX-2 and the CD8+ lymphocyte infiltrations were evaluated in this study by immunohistochemistry. We studied COX-2 expression and CD8+ lymphocyte infiltration in 55 women with cervical adenocarcinomas. COX-2 expression and tumor stromal CD8+ lymphocytes were evaluated by semiquantified methods. Tumor intraepithelial lymphocytes were counted under microscopic field of x200. Correlations between these data and other clinicopathologic features were investigated. Thirty-seven out of 55 (67.3%) cervical adenocarcinomas significantly expressed COX-2. Patients who died within 5 years showed higher percentage of COX-2 expression than survivors (100% vs 58.1%, P < 0.05). Victims also showed lesser intraepithelial CD8+ lymphocyte counts than survived patients (3.4 vs 26.4, P < 0.05). COX-2 expression and tumor intraepithelial lymphocyte count were reversely correlated with each other (correlation index: -0.38, P < 0.01). Up-regulated COX-2 expression and lesser tumor intraepithelial CD8+ lymphocyte count are poor prognostic indicators for cervical adenocarcinoma patients. COX-2 may play an important role in the suppression of host antitumor immunity in cervical adenocarcinomas.

Mitotic arrest caused by an X-ray microbeam in a single cell expressing EGFP-aurora kinase B

Although the highest radiosensitivity of cells in the M phase among the other cell phases, such as the G(1), S and G(2) phases, has been known, the exact mechanism of radiosensitivity in mitotic cells remains unclear. Recently, mitotic arrest caused by DNA-damaging reagents has been shown, and the molecular mechanism in the arrest has been discussed in detail. In this study, abnormal cell-cycle progression in the M phase was investigated when a single mitotic cell in each mitotic stage was irradiated with a 5.35 keV X-ray microbeam focused on the cell nucleus. An X-ray microbeam irradiation system installed at BL-27 in Photon Factory, High Energy Accelerator Research Organization (HEARO, Tsukuba) was used. HeLa cells, genetically modified and expressing enhanced green fluorescent protein-tagged aurora kinase B, were used as irradiated samples in order to recognise the stage of each cell in the M phase. Thus, 10 Gy irradiation concentrated at the nucleus of a single cell elongated the cell-cycle progression in the M phase by delaying the metaphase/anaphase transition. The dose dependence of the elongation of the M phase was also examined. An irregular distribution of DNA in anaphase cells was observed after irradiation.

Malignant Progression of Benign Brain Tumors after Gamma Knife Radiosurgery: Is it Really Caused by Irradiation?

Malignant transformation of benign neoplasm after radiosurgery is usually diagnosed based on the initial presence of benign tumor, its exposure to ionizing radiation, elapsed time from radiation exposure to malignant progression, and different histological characteristics or growth rate of the regrowing tumor comparing with those originally treated. Three presented cases fulfilled these diagnostic criteria; however, it seems that progression of the tumors (schwannoma, meningioma, chordoma) resulted from the natural course of the disease, rather than represented side effects of gamma knife radiosurgery. Evaluation of the proliferative potential of the benign neoplasm before radiosurgical treatment either directly, if tumor sampling is available, or indirectly, by calculation of the tumor growth rate and/or analysis of the data of the metabolic imaging (PET, MRS) is important for identification of "aggressive" subtypes, precise prediction of prognosis, and confirmation of the radiation-induced malignant transformation in cases of tumor regrowth.

Differentiation of the Radiation-Induced Necrosis and Tumor Recurrence after Gamma Knife Radiosurgery for Brain Metastases: Importance of Multi-Voxel Proton MRS

Comparative analysis of the diagnostic accuracy of FDG PET, single-voxel, and multi-voxel proton MRS for differentiation between radiation-induced necrosis and tumor recurrence was done in 9 patients with brain metastases treated by gamma knife radiosurgery. In all cases enlargement of the lesion and increase of the perilesional edema were demonstrated by MRI on average 10.6+/-2.6 months after initial treatment. Radiation-induced necrosis was identified in 5 patients (histologically in 2, clinically in 3). In one of these a false positive result of FDG PET was observed, whereas data of proton MRS were always correct. The diagnosis of tumor recurrence was established in 4 patients (histologically in 3, clinically in 1). Among these both FDG PET and single-voxel proton MRS showed false negative results (each method twice), whereas multi-voxel proton MRS always permitted us to establish the correct diagnosis. The present study demonstrates the higher diagnostic accuracy of multi-voxel proton MRS, in comparison with single-voxel proton MRS and FDG PET, for the differentiation of the radiation-induced necrosis and tumor recurrence. Its use is especially important in mixed lesions with co-existence of both post-irradiation changes and viable neoplasm. Monitoring of the treatment response by serial multi-voxel proton MRS seems to be reasonable during follow-up of patients with brain metastases after radiosurgery.

Chromosomal aberrations in normal human cells induced by the auger effect via Ca atoms

PURPOSE

To quantify the Auger effect on chromosomal aberrations via Ca atoms in human cells.

MATERIAL AND METHODS

Exponentially growing human normal fibroblasts (GM05389) were irradiated with 4.047 (CaK-P), 4.026 (CaK-L) and 4.067 (CaK-H) keV X-rays (corresponding to the resonance absorption edge of the Ca K-shell and slightly below and slightly above the edge, respectively) using synchrotron radiation at the photon factory (PF) of the High Energy Accelerator Organization located in Tsukuba. Chromosomal aberrations induced by the irradiation were analyzed by the premature chromosome condensation (PCC) method using calyculin A. The dependency of the chromosomal aberrations on the incubation time post 2 Gy irradiation was observed for each energy. Irradiation using 200 kVp conventional X-rays was also examined as a reference to CaK irradiation.

RESULTS

(1) Soon after irradiation with 2Gy, the enhancement ratios of CaK-H X-rays to CaK-L X-rays were 1.21, 1.51 and 2.70 for breaks/gaps, isochromatid breaks and exchanges, respectively. The enhancement ratios of CaK-P X-rays to CaK-L X-rays were 1.82, 0.98 and 6.30, for breaks/gaps, isochromatid breaks and exchanges, respectively. (2) After a 6-hr incubation treatment post 2 Gy irradiation, the enhancement ratios of CaK-H X-rays to CaK-L X-rays were 1.59, 2.03 and 2.14 for breaks/gaps, isochromatid breaks and exchanges, respectively. The enhancement ratios of CaK-P X-rays to CaK-L X-rays were 1.69, 1.66 and 2.00 for breaks/gaps, isochromatid breaks and exchanges, respectively. (3) Soon after irradiation, the ratios of the efficiencies of CaK-P X-rays to those of 200 kVp X-rays were 1.74, 1.29 and 2.51 for breaks/gaps, isochromatid breaks and exchanges, respectively. And after a 6-hr incubation treatment, the ratios were 5.50, 1.93 and 1.81 for breaks/gaps, isochromatid breaks and exchanges, respectively.

CONCLUSIONS

An effective enhancement of chromosomal aberrations, such as breaks/gaps, isochromatid breaks and exchanges, was caused by Ca K-shell ionization or excitation. Auger electrons emitted by Ca atoms in irradiated cells appear to have an important role in causing this enhancement. Comparing these efficiencies of chromosomal aberrations with those produced by 200 kVp conventional X-rays suggests un-repaired and complicated damage is induced by the X-rays around the Ca K-shell resonance absorption edge.

C-erbB-2 or mutant Ha-ras induced malignant transformation of immortalized human ovarian surface epithelial cells in vitro

Ovarian cancer is believed to develop from the ovarian surface epithelium through the accumulation of aberrations of oncogenes and/or tumor suppressor genes. However, it is unclear how the gene abnormalities are involved in ovarian carcinogenesis. To elucidate the process, we transfected genes reported to show their abnormalities in human ovarian cancers into human ovarian surface epithelial cells. Immortalization of the cells was achieved by the transfection of SV40 large T antigen (LT) and human telomerase reverse transcriptase (hTERT); however, the resultant cells showed no tumorigenesis. Additional transfection of either c-erbB-2 or mutant Ha-ras into the immortalized cells showed the anchorage-independent growth and tumorigenesis in mice with the incidence of 50% and 40%, respectively. Histologically, all the tumours were undifferentiated. In association with the tumorigenesis, the cells expressing c-erbB-2 or mutant Ha-ras demonstrated increased vascular endothelial growth factor secretion under hypoxia and enhanced resistance to apoptosis compared with the immortalized cells. Collectively, the introduction of either c-erbB-2 or mutant Ha-ras in the cells, which were efficiently immortalized by the transfection of LT and hTERT, showed tumorigenicity, suggesting that c-erbB-2 or mutant Ha-ras genes might be involved in ovarian carcinogenesis.

New possibilities for stereotaxis. Information-guided stereotaxis

Information-guided stereotaxis, assisted by visualization of medical information, will become the next generation of neurosurgical systems. We performed 76 open MRI surgeries at Tokyo Women's Medical University between March 3, 2000 and April 12, 2001. Of them, comparisons of pre- and post-operative MR images for malignant gliomas in 21 cases revealed an average resection rate of 90.3% (the maximum 100%, the minimum 55%). In this article we describe real time updated navigation, augmented reality navigation, three-dimensional navigation, chemical navigation, information-guided navigation system (High definition visual Computer Aided Surgery System: HivisCAS), and open MRI-guided surgery that we are developing.

Quantitative analysis of the energetics of DNA damage

Application of Monte Carlo track structure has been very successful in the modelling and quantification of DNA damage, clustered-damage and spectrum of DNA damage for energetic electrons and ions. However, there are paradoxical axioms in quantitative assessment of the energetics of DNA damage at very low electron energy and in the vacuum UV region. This paper, after a brief review of the parameters used in modelling of DNA damage, presents an analysis of experimental data of strand breaks in aqueous solution in the vacuum UV, the region to which little attention has been paid in spite of its fundamental importance in providing reaction parameters for radiation actions.

Enhancement of X-ray-induced breaks in DNA bound to molecules containing platinum: a possible application to hadrontherapy

Complexes made of DNA and chloroterpyridine platinum (PtTC) bound to plasmid DNA were placed in aqueous solution and irradiated with monochromatic X rays tuned to the resonant photoabsorption energy of the L(III) shell of the platinum atom. The number of single- and double-strand breaks (SSBs and DSBs) induced by irradiation on a supercoiled DNA plasmid was measured by the production of the circular-nicked and linear forms. To distinguish the contribution of the direct effects of ionization from the indirect effects due to a free radical attack, experiments were also performed in the presence of a hydroxyl free radical scavenger, dimethyl sulfoxide (DMSO). An enhancement of the number of SSBs and DSBs was observed when the plasmids contained the platinum intercalating molecules. A quantitative analysis was made to evaluate the respective contributions of the direct effects (Auger effect) and the indirect effects (free radical attack) to the number of DNA strand breaks. Even when off-resonant X rays were used, the strand break efficiency remained higher than expected based upon the absorption cross section, suggesting that the platinum bound to DNA might be increasing the yield of strand breaks. A mechanism is suggested that involves photoelectrons generated from the ionization of water which efficiently ionize platinum atoms. If this mechanism is correct, then heavy atoms, with a large cross section for ionization by electrons that are bound to the DNA, should behave as a radiosensitizer. This observation may provide insight into understanding the effects of new radiotherapy protocols, related chemotherapeutic agents such as cisplatin, and conventional radiotherapy for the treatment of tumors. A possible way to deliver the dose selectively in a well-defined volume, which uses the properties of the linear energy transfer of atomic ions interacting with matter, is suggested.

Messenger ribonucleic acid for the mouse decidual prolactin is present and induced during in vitro decidualization of endometrial stromal cells

Although decidualization of endometrial stromal cells is crucial for blastocyst implantation and maintenance of pregnancy, its complex mechanism still remains largely unknown. To explore the mechanisms of decidualization, we have established an in vitro decidualization model in mice. Through extraction of mRNA from endometrial stromal cells for subsequent reverse transcriptase polymerase chain reaction analysis, we found that two ovarian hormones, 17 beta-estradiol and progesterone, induced morphological changes and expression of mRNA for prolactin (PRL) and the decidual/trophoblastic PRL-related protein (d/tPRP) in cultured mouse endometrial stromal cells. The expression of mRNA for the decidual PRL was also detected in the mouse decidua in vitro. In conclusion, mouse mRNA for decidual PRL is present and induced by estradiol and progesterone through in vitro decidualization of endometrial stromal cells.

Active Crohn disease with maternal vitamin K deficiency and fetal subdural hematoma

BACKGROUND

Fetal subdural hematoma is a rare condition not considered a complication of Crohn disease in pregnancy.

CASE

A young woman with a diagnosis of Crohn disease presented at 22 weeks' gestation with diarrhea and melena for 3 weeks. Dietary and medicinal therapies were begun. At 28 weeks' gestation, fetal ultrasonography showed an intracranial mass, which was seen to expand on serial ultrasound and magnetic resonance imaging studies. A hematoma was suspected, and, although the mother had no overt hemorrhagic manifestations, maternal vitamin K deficiency was diagnosed by enzyme immunoassay and corrected. After cesarean delivery at 36 weeks' gestation, the newborn was normal, but magnetic resonance imaging showed a chronic subdural hematoma.

CONCLUSION

Maternal vitamin K deficiency in active Crohn disease might cause fetal hemorrhage. Monitoring of vitamin K status during pregnancy with Crohn disease seems warranted.

Clinical implications of flow cytometry crossmatch with T or B cells in living donor liver transplantation

BACKGROUND

Acute allograft rejection (AR) in solid organ transplantation is generally regarded to develop through cell-mediated immune response following activation of helper T cells. Since production of antibodies is also mediated by helper T cells, humoral immunity may play some roles in AR. Although flow cytometry crossmatch (FCXM) is reported as a useful method for the detection of antibodies against donor antigen, specific role of T- or B-cell FCXM and its sensitivity for AR is controversial.

METHODS

T- and B-cell FCXM using fresh donor peripheral lymphocytes were performed before and after blood-type compatible living donor liver transplantation in 47 patients. IgM and IgG anti-donor antibodies were analyzed in relation to clinical AR.

RESULTS

Positive pre-transplant T-cell FCXM was associated with a high incidence of positive post-transplant T-cell FCXM (p=0.017). Four of five cases (80%) with positive pre-transplant T-cell FCXM experienced earlier AR (day 8.0+/-4.4, mean+/-SD) than 16 of 42 cases (31%) with negative pre-transplant T-cell FCXM (17.3+/-6.8; p=0.016). In addition, higher dose of steroids was given to treat AR episodes in cases with positive pre-transplant T-cell FCXM (79.9+/-10.3 mg/kg/month) than in those with negative pre-transplant T-cell FCXM (47.1+/-26.6; p=0.039). In the first month after transplantation, 13 episodes of positive post-transplant T-cell FCXM were all concomitant with or preceded clinical AR compared with seven ARs in T-cell FCXM-negative cases (p<0.0001). T-cell FCXM between positive sera and third parties revealed some crossreactions. In contrast, detection of antibodies by B-cell FCXM in pre- and post-transplant phases was scarcely associated with AR, and no correlation was found between T- and B-cell FCXM before and after transplantation.

CONCLUSIONS

Positive T-cell FCXM is closely related with AR and that before transplantation is a predictor of early and refractory AR as well as post-transplant FCXM. In contrast, not a few detections of antibodies irrelevant to AR are observed in B-cell FCXM, suggesting its low specificity.

Surgical treatment of falcotentorial meningioma

Meningiomas arising from the falcotentorial junction are rare. Among our surgical experience of 375 meningiomas, only 4 cases of so-called falcotentorial meningiomas were encountered. We present these four surgical cases. An occipital transtentorial approach was used in three cases, and a combined midline occipital and suboccipital approach in one case. Total tumour excision was impossible in two cases because of engulfing deep venous structures including the great vein of Galen. Postoperative Gamma knife radiosurgery was performed in these two cases. On the other hand, a posteriorly located tumour was relatively easy to remove, and macroscopic total removal was accomplished. In conclusion, precise microvascular anatomical knowledge is indispensable to satisfactorily excise meningiomas in the falcotentorial area without significant morbidity.