Radiological imaging protection: a study on imaging dose used while planning computed tomography for external radiotherapy in Japan

Previous studies have primarily focused on quality of imaging in radiotherapy planning computed tomography (RTCT), with few investigations on imaging doses. To our knowledge, this is the first study aimed to investigate the imaging dose in RTCT to determine baseline data for establishing national diagnostic reference levels (DRLs) in Japanese institutions. A survey questionnaire was sent to domestic RT institutions between 10 October and 16 December 2021. The questionnaire items were volume computed tomography dose index (CTDIvol), dose-length product (DLP), and acquisition parameters, including use of auto exposure image control (AEC) or image-improving reconstruction option (IIRO) for brain stereotactic irradiation (brain STI), head and neck (HN) intensity-modulated radiotherapy (IMRT), lung stereotactic body radiotherapy (lung SBRT), breast-conserving radiotherapy (breast RT), and prostate IMRT protocols. Details on the use of motion-management techniques for lung SBRT were collected. Consequently, we collected 328 responses. The 75th percentiles of CTDIvol were 92, 33, 86, 23, and 32 mGy and those of DLP were 2805, 1301, 2416, 930, and 1158 mGy·cm for brain STI, HN IMRT, lung SBRT, breast RT, and prostate IMRT, respectively. CTDIvol and DLP values in institutions that used AEC or IIRO were lower than those without use for almost all sites. The 75th percentiles of DLP in each treatment technique for lung SBRT were 2541, 2034, 2336, and 2730 mGy·cm for free breathing, breath holding, gating technique, and real-time tumor tracking technique, respectively. Our data will help in establishing DRLs for RTCT protocols, thus reducing imaging doses in Japan.

Polarimetric calibration of a spectropolarimeter instrument with high precision: Sunrise chromospheric infrared spectropolarimeter (SCIP) for the sunrise iii balloon telescope

The Sunrise chromospheric infrared spectropolarimeter (SCIP) installed in the international balloon experiment sunrise iii will perform spectropolarimetric observations in the near-infrared band to measure solar photospheric and chromospheric magnetic fields simultaneously. The main components of SCIP for polarization measurements are a rotating wave plate, polarization beam splitters, and CMOS imaging sensors. In each of the sensors, SCIP records the orthogonal linearly polarized components of light. The polarization is later demodulated on-board. Each sensor covers one of the two distinct wavelength regions centered at 770 and 850 nm. To retrieve the proper circular polarization, the new parameter R, defined as the 45° phase shifted component of Stokes V in the modulation curve, is introduced. SCIP is aimed at achieving high polarization precision (1σ<3×10^-4 of continuum intensity) to capture weak polarization signals in the chromosphere. The objectives of the polarization calibration test presented in this paper are to determine a response matrix of SCIP and to measure its repeatability and temperature dependence to achieve the required polarization precision. Tolerances of the response matrix elements were set after considering typical photospheric and chromospheric polarization signal levels. We constructed a feed optical system such that a telecentric beam can enter SCIP with the same f-number as the light distribution instrument of the sunrise iii telescope. A wire-grid linear polarizer and achromatic wave plate were placed before SCIP to produce the known polarization. The obtained response matrix was close to the values expected from the design. The wavelength and spatial variations, repeatability, and temperature dependence of the response matrix were confirmed to be smaller than tolerances.

Stereotactic Body Radiotherapy for Stage I Lung Cancer With a New Real-time Tumor Tracking System

BACKGROUND/AIM

Suppression of respiratory movement is crucial for safe and effective stereotactic body radiotherapy (SBRT). SyncTraX FX4 is a novel device for synchronous respiratory irradiation. The purpose of this study was to evaluate the efficacy and toxicity of SBRT using SyncTraX FX4 for patients with lung cancer.

PATIENTS AND METHODS

Patients treated with SBRT using SyncTraX FX4 between November 2017 and August 2020 were included. In all cases, fiducial markers were inserted into the lung, and the total dose administered was 55 or 60 Gy, depending on the distance from the central region of the lung. Acute and late toxicities were reported, and local control, progression-free survival, cancer-specific survival, and overall survival were analyzed.

RESULTS

We evaluated 16 patients and 17 sites. The median follow-up period was 14.4 months. In both the acute and late phases, one patient experienced grade 3 radiation pneumonitis; however, grade 4 or higher toxicities were not observed. There was no local recurrence during the observation period, and the overall survival, cancer-specific survival, and progression-free survival at 2 years were 54.6%, 85.1%, and 33.7%, respectively.

CONCLUSION

SBRT with SyncTraX FX4 can provide safe and effective treatment for lung cancer patients in poor condition.

POS0675 IMPACT OF PAST USE OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS ON JAK INHIBITOR TREATMENT FOR RHEUMATOID ARTHRITIS - DATA FROM THE FUKUI ISHIKAWA TOYAMA DATABASE OF RHEUMATOID ARTHRITIS

Background

Currently, five types of Janus kinase inhibitors (JAKis) are used for rheumatoid arthritis (RA) treatment. The number of cases in which multiple JAKis have been prescribed is increasing. However, the real-world efficacy and safety of JAKis and related factors require further evaluation.

Objectives

The primary objective of this study was to elucidate the impact of past use of disease-modifying anti-rheumatic drugs on RA treatment using JAKis. The secondary objective was to investigate the safety profiles of these agents in a real-world setting.

Methods

Of the 303 JAKi-treated patients in the Fukui Ishikawa Toyama Database of RA included in this study, 30 had switched from one JAKi to another (JJ group), 214 switched from a biologic agent to a JAKi (BJ group), and 47 were naïve to either biologics or JAKis (NJ group). We compared baseline factors, treatment response, and JAKi continuation rates among the three groups. Factors related to JAKi discontinuation were assessed using Cox regression analysis. Furthermore, we investigated adverse events and reported them using exposure-adjusted incidence rates (EAIR; incidence rates per 100 patient-years).

Results

Data from the 303 cases were analyzed (mean age = 63.6 years; female, 82%; mean RA duration, 176 months). Of the 303 patients, 118, 106, 50, and 29 were treated with tofacitinib, baricitinib, peficitinib, and upadacitinib, respectively, on initial observation. Rate of concomitant use with methotrexate and prednisolone was 52% and 49%, respectively.

Regarding efficacy, no significant differences were observed among the three groups in terms of treatment response and JAKi continuation rates, except for the 6-month treatment response between the JJ and NJ groups. Cox regression analysis of the 303 cases revealed that only past use of JAKis during the disease history was significantly associated with JAKi discontinuation. The Kaplan–Meier method showed that patients who previously used JAKis had significantly shorter median JAKi treatment duration than those without such a history (20.9 vs. 54.7 months; p = 0.012). Treatment response was significantly poor in patients who had previously used JAKis, especially 6 months after treatment initiation.

In terms of safety, the total exposure period for the 303 cases was 495 person-years, and the total number of adverse events was 161 (EAIR, 32.5). There were 12 cases (EAIR, 2.5) of serious infections, 23 cases (EAIR, 5.1) of herpes zoster, 7 cases (EAIR, 1.4) of malignant tumors, and 4 cases (EAIR, 0.8) of MACE. Adverse events led to JAKi discontinuation in 34 patients (EAIR, 6.9); the main causes of adverse events leading to treatment discontinuation were infectious diseases in 10 cases (EAIR, 2) and neoplasms in 4 cases (EAIR, 0.8). Within 1 year of initiating JAKi therapy, 21 patients discontinued treatment owing to adverse events, which accounted for 27% of the reasons for treatment discontinuation.

We also investigated cases of JAKi dose reduction, observed in 42 of the 303 cases. Among them, 10 patients required a re-increase in the JAKi dose, and 13 patients (56.5%) were able to maintain the reduced dose for more than 1 year. The remaining 19 patients were excluded from the analysis because the treatment duration at the lower dose had not exceeded 1 year at the time of data extraction. No difference in disease activity at the time of dose reduction was observed between those who maintained the new dose and those who did not (mean DAS28-CRP: 1.48 ± 0.26 vs. 1.89 ± 0.62).

Conclusion

Past use of JAKis may contribute to decreased response and continuation rates for JAKi treatment. In this study, conducted in Japan, development of herpes zoster was found to the most frequent adverse event among the priority survey items.

Acknowledgements

I have no acknowledgements to declare.

Disclosure of Interests

None declared

A novel method for skin marking in radiotherapy: first clinical use of temporary organic tattoo seal

An oil-based pen is widely used as a skin marker for identification of the isocenter and computed tomography (CT)-coordinate origin during radiotherapy. However, use of this pen has some disadvantages, including color loss and color migration. To address these problems, we have developed use of a temporary fashion tattoo (Inkbox) for skin marking. The utility and feasibility of Inkbox as an alternative to an oil-based pen were evaluated in this study. The study included patients from two centers who required skin marking for radiotherapy performed between December 2020 and March 2021. Skin markings were made with an oil-based pen or with Inkbox. The durability was recorded during daily irradiation. Skin markings with Inkbox were made in 32 patients. The total number of skin markings was 94: 64 with Inkbox and 30 with an oil-based pen. A questionnaire survey to evaluate each method was conducted among patients after radiotherapy. The median durations of marking were 16 and 4 days with Inkbox and an oil-based pen, respectively (p-value < 0.001). The survey showed that Inkbox had less impact on the daily lives of patients, including reduced color migration to clothes and less concern about disappearance of the marking. There were no adverse cutaneous side effects with Inkbox. The duration of marking with Inkbox is about 16 days, with little impact on daily life. These findings suggest that Inkbox is a potentially useful method of skin marking in radiotherapy.

Quantitative analysis of the intra-beam respiratory motion with baseline drift for respiratory-gating lung stereotactic body radiation therapy

This study aimed to quantitatively clarify the baseline drift for each respiratory cycle in two respiratory-gating methods using the intra-beam respiratory motion data of lung cancer patients. The residual motion and dose distribution were calculated based on intra-beam respiratory motion data with the baseline drift. To quantify the baseline drift $\Delta$ during irradiation, it was defined as the inclination between the detected expiration point and the expiration point in the next cycle in the anterior-posterior (AP), cranial-caudal (CC) and left-right (LR) directions obtained using an in-house programme. The baseline drift value reached up to 0.74 mm/s in the CC direction as per the respiratory motion data of 10 patients. The homogeneity index (HI) of the phase-gating method tended to increase because the target was irradiated even when the amplitude position of the target differed from period to period. In contrast, the amplitude-gating method enabled irradiation considering the amplitude position of the target because the gating window was set considering the amplitude position of the respiratory motion. The respiratory-gating methods and respiratory phase in respiratory-gating lung stereotactic body radiation therapy (SBRT) must be determined based on the respiratory motion of the patients.

Investigation of fiducial marker recognition possibility by water equivalent length in real-time tracking radiotherapy

Real-time tumor tracking radiotherapy (RTRT) systems typically use fiducial markers implanted near the tumor to track the target using X-ray fluoroscopy. Template pattern matching, used in tracking, is often used to automatically localize the fiducial markers. In radiotherapy of the liver, the thickness of the body that can recognize the fiducial markers must be clinically assessed. The purpose of this study was to quantify the recognition of fiducial markers according to body thickness in stereotactic body radiotherapy of the liver using clinical images obtained using SyncTraX FX4. The recognition scores of fiducial markers were examined in relation to water equivalent length (WEL), tube current, and each flat panel detector. The relationship between the contrast ratio of the fiducial marker and the background and the WEL was also investigated. The average recognition score was found to be less than 20 when the WEL was greater than 25 cm. The probability of successful tracking of image recognition was mostly smaller than 0.8 when the WEL was over 30 cm. The relationship between WEL and tube current did not significantly differ between 100 and 140 mA, but there was a significant difference (p < 0.05) for all other combinations. To ensure tracking of fiducial markers during SBRT, if the WEL representing body thickness is longer than 25 cm, the X-ray fluoroscopy arrangement should be determined based on the WEL.

Evaluation of differences and dosimetric influences of beam models using golden and multi-institutional measured beam datasets in radiation treatment planning systems

PURPOSE

The beam model in radiation treatment planning systems (RTPSs) plays a crucial role in determining the accuracy of calculated dose distributions. The purpose of this study was to ascertain differences in beam models and their dosimetric influences when a golden beam dataset (GBD) and multi-institution measured beam datasets (MBDs) are used for beam modeling in RTPSs.

METHODS

The MBDs collected from 15 institutions, and the MBDs' beam models, were compared with a GBD, and the GBD's beam model, for Varian TrueBeam linear accelerator. The calculated dose distributions of the MBDs' beam models were compared with those of the GBD's beam model for simple geometries in a water phantom. Calculated dose distributions were similarly evaluated in volumetric modulated arc therapy (VMAT) plans for TG-119 C-shape and TG-244 head and neck, at several dose constraints of the planning target volumes (PTVs), and organs at risk.

RESULTS

The agreements of the MBDs with the GBD were almost all within ±1%. The calculated dose distributions for simple geometries in a water phantom also closely corresponded between the beam models of GBD and MBDs. Nevertheless, there were considerable differences between the beam models. The maximum differences between the mean energy of the energy spectra of GBD and MBDs were -0.12 MeV (-10.5%) in AcurosXB (AXB, Eclipse) and 0.11 MeV (7.7%) in collapsed cone convolution (CCC, RayStation). The differences in the VMAT calculated dose distributions varied for each dose region, plan, X-ray energy, and dose calculation algorithm. The ranges of the differences in the dose constraints were -5.6% to 3.0% for AXB and -24.1% to 2.8% for CCC. In several VMAT plans, the calculated dose distributions of GBD's beam model tended to be lower in high-dose regions and higher in low-dose regions than those of the MBDs' beam models.

CONCLUSIONS

We found that small differences in beam data have large impacts on the beam models, and on calculated dose distributions in clinical VMAT plan, even if beam data correspond within ±1%. GBD's beam model was not a representative beam model. The beam models of GBD and MBDs and their calculated dose distributions under clinical conditions were significantly different. These differences are most likely due to the extensive variation in the beam models, reflecting the characteristics of beam data. The energy spectrum and radial energy in the beam model varied in a wide range, even if the differences in the beam data were <±1%. To minimize the uncertainty of the calculated dose distributions in clinical plans, it was best to use the institutional MBD for beam modeling, or the beam model that ensures the accuracy of calculated dose distributions.

[Multi-institutional Analysis of MLC Parameters for Commissioning of IMRT]

Multi-leaf collimator (MLC) parameters, which are registered with radiation treatment planning systems, are very important for intensity modulated radiation therapy (IMRT). In this study, we investigated MLC parameters of respective institutions for efficient commissioning of IMRT. Data of linac models, MLC types, nominal energy, irradiation technique, calculation algorithm, dosimetric leaf gap (DLG) values, and MLC transmission values were collected from each institution in which Varian linac and Eclipse were owned, and analyzed. The numbers of responses from institutions to questionnaire were 15, and the total number of linac was 22. In most institutions, volumetric modulated arc therapy (VMAT) technique was used, and the most used nominal energy was 10 MV. The higher nominal energy was, the higher values of MLC parameters (DLG and MLC transmission) were. In addition, values of MLC parameters of flattening filter free (FFF) beams were smaller than those of flattening filter (FF) beams, even when nominal energy was same. Values of DLG of VMAT tended to be greater than those of multi-field IMRT. These results are expected to be useful for institutions, in which IMRT is implemented.

Spinal cord involvement by atrophy and associations with disability are different between multiple sclerosis and neuromyelitis optica spectrum disorder

BACKGROUND AND PURPOSE

The cervical and thoracic cross-sectional spinal cord area (CS-SCA) in multiple sclerosis (MS) correlates with disability, whilst such a correlation remains to be established in neuromyelitis optica spectrum disorder (NMOSD). Our aim was to clarify differences between MS and NMOSD in spinal cord segments where CS-SCA is associated with disability.

METHODS

The CS-SCA at C2/C3, C3/C4, T8/T9 and T9/T10 vertebral disc levels was measured in 140 MS patients (111 with relapsing-remitting MS and 29 with progressive MS) and 42 NMOSD patients with anti-aquaporin-4 immunoglobulin G. Disability was evaluated by Expanded Disability Status Scale (EDSS) scores. Multivariate associations between CS-SCA and disability were assessed by stepwise forward multiple linear regression.

RESULTS

Thoracic CS-SCA was significantly smaller in NMOSD patients than in MS patients even after adjusting for age, sex and disease duration (P = 0.002 at T8/T9), whilst there was no difference in cervical CS-SCA between the two diseases. Cervical and thoracic CS-SCA had a negative correlation with EDSS scores in MS patients (P < 0.0001 at C3/C4 and P = 0.0002 at T8/T9) whereas only thoracic CS-SCA correlated with EDSS scores in NMOSD patients (P = 0.0006 at T8/T9). By multiple regression analyses, predictive factors for disability in MS were smaller cervical CS-SCA, progressive course, older age and a higher number of relapses, whilst those in NMOSD were smaller thoracic CS-SCA and older age.

CONCLUSIONS

Thoracic CS-SCA is a useful predictive marker for disability in patients with NMOSD whilst cervical CS-SCA is associated with disability in patients with MS.

Effect of biological factors on successful measurements with skeletal-muscle (1)H-MRS

Background

Our purpose in this study was to clarify whether differences in subject group attributes could affect data acquisition in proton magnetic resonance spectroscopy (¹H-MRS).

Methods

Subjects without diabetes mellitus (DM) were divided into two groups (group A, in their 20s; group B, 30–60 years old). Subjects with DM formed group C (30–60 years old). The numbers of subjects were 19, 27, and 22 for group A, B, and C respectively. For all subjects, ¹H-MRS measurements were taken of the soleus muscle (SOL) and the anterior tibial muscle (AT). We defined the success of the measurements by the detection of intramyocellular lipids. Moreover, we also measured the full width at half maximum of the water peaks for all subjects.

Results

The success rate was significantly higher for the AT (100%) than for the SOL (81.6%) (P<0.01). For the SOL, the success rate was 100% in group A, 85.2% in group B, and 77.3% in group C. There was a significant difference (P<0.05) between groups A and B, as well as between groups A and C. In all subjects, there was a significant difference (P<0.01) in the full width at half maximum (Hz) of the water peak between the AT and SOL measurements.

Conclusion

We conclude that differences in the age and DM history of subjects could affect the probability of successful ¹H-MRS data acquisition.

Note: Utilization of polymer gel as a bolus compensator and a dosimeter in the near-surface buildup region for breast-conserving therapy

Tangential beam radiotherapy is routinely used for radiation therapy after breast conserving surgery. A tissue-equivalent bolus placed on the irradiated area shifts the depth of the dose distribution; this bolus provides uniform dose distribution to the breast. The gel bolus made by the BANG-Pro(®) polymer gel and in an oxygen non-transmission pack was applicable as a dosimeter to measure dose distribution in near-surface buildup region. We validated the use of the gel bolus to improve in the whole-breast/chest wall, including the near-surface buildup region.

Structural and magnetic properties of mixed Co–Ln (Ln = Nd, Sm, Eu, Gd and Ho) diethyleneglycolate complexes

Co–Ln diethyleneglycolates consisting of 1D-chains of [(Ln₂Co₂)(Cl)₂(deg)₄] tetramers were produced in degH₂. In the tetramers 5 and 7 Co²⁺ and Ln³⁺ coordinated cations are antiferromagnetically weakly interacting.

Species differences in androgen receptor expression in the medial preoptic and anterior hypothalamic areas of adult male and female rodents

The medial preoptic and anterior hypothalamic areas (MPO/AH) are important androgen targets regulating homeostasis, neuroendocrinology and circadian rhythm as well as instinctive and sociosexual behaviors. Although species differences between rats and mice have been pointed out in terms of morphology and physiology, detailed distributions of androgen receptor (AR) have never been compared between the two rodents. In the present study, AR distribution was examined immunohistochemically in serial sections of the MPO/AH and compared for adult rats and mice. Western blotting and immunohistochemistry clearly demonstrated that AR expression in the brain was stronger in mice than in rats and was stronger in males than in females. In addition, we found (1) an "obliquely elongated calbindin-ir cell island" in mice medial preoptic nucleus (MPN) expressed AR intensely, as well as the sexually dimorphic nucleus in the MPN (SDN-MPN) in rats, strongly supporting a "putative SDN-MPN" previously proposed in mice; (2) AR expression in the suprachiasmatic nucleus (SCN) was much more prominent in mice than in rats and differed in localization between the two species; (3) a mouse-specific AR-ir cell cluster was newly identified as the "tear drop nucleus (TDN)", with male-dominant sexual dimorphism; and (4) two rat-specific AR-ir cell clusters were also newly identified as the "rostral and caudal nebular islands", with male-dominant sexual dimorphism. The present results may provide basic morphological evidence underlying species differences in androgen-modified psychological, physiological and endocrinergic responses. Above all, the findings of the mouse-specific TDN and differing AR expression in the SCN might explain not only species difference in gonadal modification of circadian rhythm, but also distinct structural bases in the context of transduction of SCN oscillation. The current study could also serve as a caution that data on androgen-sensitive functions obtained from one species should not always be directly applied to others among rodents.

Depletion of foxp3(+) T cells abrogates tolerance of skin and heart allografts in murine mixed chimeras without the loss of mixed chimerism

The relative contribution of central and peripheral mechanisms to the generation and maintenance of allograft tolerance is of considerable interest. Here, we present new evidence that regulatory T cells (Foxp3(+) ) maintain skin and heart allograft tolerance in mixed hematopoietic chimeric mice. Transient depletion of both donor- and recipient-derived Foxp3(+) cells was necessary and sufficient to induce decisive rejection of long-accepted skin and heart allografts. In contrast, stable hematopoietic chimerism remained, and there was no detectable induction of donor-specific reactivity to hematopoietic cells. Foxp3(+) cell depletion did not result in the rejection of skin grafts of only MHC-disparate donors (B6.C-H2(d) /bByJ), indicating that MHC antigens were not the target in the graft. We conclude that two different mechanisms of tolerance are present in mixed chimeras. Hematopoietic chimerism, resistant to Foxp3(+) depletion, is probably due to deletional tolerance to MHC antigens, as supported by previous studies. In contrast, regulatory tolerance mechanisms involving Foxp3(+) cells are required to control reactivity against non-MHC antigens not present on hematopoietic lineages.

[Investigation of polymer gel dosimetry for small circular irradiated fields]

Polymer gels can be used as tissue equivalent dosimeters, and polymer gel dosimetry can be employed without perturbation of the radiation field. In this study, polymer gel dosimetry was used for small circular irradiation fields 10-30 mm in diameter using a radiation planning system. The irradiated gels were compared with planned data for a 50% dose width of 6 Gy dose maximum, and for the dose difference between gels and planned data over an 80% dose maximum area. The present study investigated magnetic resonance imaging (MRI) conditions based on an optimal dose-R2 calibration curve. The average difference between the full width half maximum of the 50% dose width between gels and planned data was 11%. The average dose difference over 80% of the dose was 5.6%. Optimal dose-R2 calibration curves were acquired using images with echo times of 30 and 60 ms. For cases of larger thicknesses and an increasing number of averages, the coefficients of variance of the curves were smaller than under other conditions. Compared to other traditional dosimetric tools, polymer gels have the advantage of providing three-dimensional dosimetric data. An arbitrary profile from the gel's data can be compared with the profile of the planned data. In the future, new gel dosimeters will be needed that demonstrate improved dose evaluation under 1 Gy and stability in high dose areas.

[Comparison of diffusion tensor imaging-derived fractional anisotropy in multiple centers for identical human subjects]

The fractional anisotropy (FA) is calculated by using diffusion tensor imaging (DTI) with multiple motion probing gradients (MPG). While FA has become a widely used tool to detect moderate changes in water diffusion in brain tissue, the measured value is sensitive to scan parameters (e.g. MPG-direction, signal to noise ratio, etc.). Therefore, it is paramount to address the reproducibility of DTI measurements among multiple centers. The purpose of this study was to assess the inter-center variability of FA. We studied five healthy volunteers who underwent DTI brain scanning three times at three different centers (I-III), each with a 1.5 T scanner having a different MPG-schema. Then, we compared the FA and eigenvalue from the three centers measured in seven brain regions: splenium of corpus callosum (CCs), genu of corpus callosum (CCg), putamen, posterior limb of internal capsule, cerebral peduncle, optic radiation, and middle cerebellar peduncle. At the CCs and CCg, there was a statistical difference (p<0.05) between center Iand center IIfor the same MPG-directions. Furthermore, at CCs and CCg, there was a statistical difference (p<0.05) between center II and center III for different MPG-directions. Conversely, no statistical differences were found between center I and center III for the different MPG-directions for all regions. These results indicate that the FA value was affected by the MPG-schema as well as by the MPG-directions.

Increased insulin demand promotes while pioglitazone prevents pancreatic beta cell apoptosis in Wfs1 knockout mice

AIMS/HYPOTHESIS

The WFS1 gene encodes an endoplasmic reticulum (ER) membrane-embedded protein called Wolfram syndrome 1 protein, homozygous mutations of which cause selective beta cell loss in humans. The function(s) of this protein and the mechanism by which the mutations of this gene cause beta cell death are still not fully understood. We hypothesised that increased insulin demand as a result of obesity/insulin resistance causes ER stress in pancreatic beta cells, thereby promoting beta cell death.

METHODS

We studied the effect of breeding Wfs1 ( -/- ) mice on a C57BL/6J background with mild obesity and insulin resistance, by introducing the agouti lethal yellow mutation (A ( y ) /a). We also treated the mice with pioglitazone.

RESULTS

Wfs1 ( -/- ) mice bred on a C57BL/6J background rarely develop overt diabetes by 24 weeks of age, showing only mild beta cell loss. However, Wfs1 ( -/- ) A ( y ) /a mice developed selective beta cell loss and severe insulin-deficient diabetes as early as 8 weeks. This beta cell loss was due to apoptosis. In Wfs1 ( +/+ ) A ( y ) /a islets, levels of ER chaperone immunoglobulin-binding protein (BiP)/78 kDa glucose-regulated protein (GRP78) and phosphorylation of eukaryotic translation initiation factor 2, subunit alpha (eIF2alpha) apparently increased. Levels of both were further increased in Wfs1 ( -/- ) A ( y ) /a murine islets. Electron micrography revealed markedly dilated ERs in Wfs1 (-/-) A ( y ) /a murine beta cells. Interestingly, pioglitazone treatment protected beta cells from apoptosis and almost completely prevented diabetes development.

CONCLUSIONS/INTERPRETATION

Wfs1-deficient beta cells are susceptible to ER stress. Increased insulin demand prompts apoptosis in such cells in vivo. Pioglitazone, remarkably, suppresses this process and prevents diabetes. As common WFS1 gene variants have recently been shown to confer a risk of type 2 diabetes, our findings may be relevant to the gradual but progressive loss of beta cells in type 2 diabetes.

Effect of therapeutic immunization using Ad5/35 and MVA vectors on SIV infection of rhesus monkeys undergoing antiretroviral therapy

Antiretroviral therapy (ART) effectively slows the progression of AIDS. However, drug resistance and/or toxicity can limit the utility of ART in many patients. In this study, we assessed whether a viral vector-based vaccine can be used as a therapeutic vaccine in simian immunodeficiency virus (SIV)-infected monkeys. The effect of vaccinating SIVmac239-infected rhesus monkeys with an SIV gag and gp120-expressing adenovirus (Ad) vector vaccine and a modified vaccinia Ankara (MVA) vaccine was explored while being treated with ART. Rhesus monkeys were intravenously infected with 10 and 1000 TCID(50) (50% tissue culture infectious dose) of SIVmac239. Two months after SIV infection, the monkeys received a 4-month treatment with ART. Some of the monkeys were immunized with adenovirus-based vaccine and MVA-based vaccine with 2 months interval during ART. Viral load, CD4 count and SIV-specific immune responses were observed for 7 months after interruption of ART. The vaccinated animals had higher (i) CD4 counts, (ii) SIV-specific cell-mediated immune responses and (iii) anti-SIV-neutralizing antibody (Ab) titers than monkeys treated with ART alone. More importantly, the vaccination significantly reduced the SIV RNA load from animals infected with a low dose of SIV (10 TCID(50)). The anti-SIV cell-mediated and humoral responses induced by the vaccination was inversely correlated with a reduction in SIV viral load and positively correlated with an increase in CD4(+) T cell counts. These results suggest that vaccination can improve antiviral cell-mediated and humoral immunity, which may contribute to controlling viral replication.

Implications of bevacizumab on vascular endothelial growth factor and endostatin in human choroidal neovascularisation

AIM

To evaluate the implications of intravitreal bevacizumab on proangiogenic vascular endothelial growth factor (VEGF) with regard to the endogenous angiogenesis inhibitor endostatin in human choroidal neovascularisation (CNV) secondary to age-related macular degeneration.

METHODS

Retrospective review of an interventional case series of 48 patients who underwent full macular translocation surgery with removal of CNV. Twenty-five patients were treated with intravitreal bevacizumab injection 1 to 154 days prior to surgery (bevacizumab CNV). Twenty-three CNV without any kind of previous treatment were used as controls (control CNV). CNV were stained for CD34, cytokeratin18, VEGF, endostatin and E-selectin. A "predominance score of VEGF over endostatin" (PS) was defined by the difference between VEGF and endostatin staining scores.

RESULTS

Bevacizumab CNV revealed a weaker VEGF expression in endothelial cells (p = 0.0245) but significantly more intense endostatin in retina pigment epithelium (RPE) (p = 0.0001) and stroma (p<0.0001). Consequently, PS was significantly lower in RPE (p = 0.02), vessels (p = 0.03) and stroma (p = 0.0004) in bevacizumab CNV. The intensity of E-selectin expression in bevacizumab CNV was comparable with that in control CNV.

CONCLUSIONS

A shift within the angiogenic balance in terms of decreased VEGF predominance over endostatin is detected in human CNV treated with bevacizumab.

Comparison of pre- vs. postmeal administration of miglitol for 3 months in type 2 diabetic patients

AIM

alpha-Glucosidase inhibitors (alphaGIs) primarily modify postprandial plasma glucose levels and should be taken just before meals. We previously demonstrated that a single administration of miglitol within 30 min after the start of a meal was equally effective as when administered just before a meal. We here compared pre- vs. postmeal administration of miglitol for 3 months in type 2 diabetic patients.

METHODS

Thirty-one type 2 diabetic outpatients who had never been treated with insulin injections or alphaGIs were randomized to two groups: patients in group A were asked to take miglitol just before meals, while patients in group B were asked to take miglitol after meals. We measured 1,5-anhydroglucitol (1,5-AG) and HbA(1C) levels in these patients.

RESULTS

The administration of miglitol after meals for a 3-month period decreased HbA(1C) and increased 1,5-AG levels to the same extent as when administered just before meals. The incidence of adverse effects seemed to be unrelated to the timing of the miglitol administration.

CONCLUSIONS

Our results suggest that if patients have difficulty remembering to take miglitol just before meal, they should be instructed to take the medicine together with other medicine(s) after the meal; this instruction may improve the treatment compliance of diabetic patients.

Progression rate of ALSFRS-R at time of diagnosis predicts survival time in ALS

The authors calculated the progression rate (DeltaFS) using the total revised ALS Functional Rating Scale (ALSFRS-R) and symptom duration at diagnosis in 82 Japanese patients with ALS. Survival (death or tracheostomy) differed significantly with the DeltaFS and postdiagnostic period according to log-rank testing, but Cox proportional hazards modeling revealed no strong association between total ALSFRS-R and mortality, suggesting that the DeltaFS provides an additional predictive index beyond ALSFRS-R alone.

Complete nucleotide sequence of the new potexvirus "Alstroemeria virus X". Brief report

A flexuous virus was isolated in Japan from an alstroemeria plant showing mosaic symptoms. The virus had a broad host range but had systemically latent infectivity in alstroemeria. The virus was assigned to the genus Potexvirus based on morphology and physical properties and on an analysis of the complete nucleotide sequence. The genomic RNA of the virus was 7,009 nucleotides in length, excluding the 3'-terminal poly (A) tail. It contained five open reading frames (ORFs), which was consistent with other members of the genus Potexvirus. Although nucleotide sequences of the ORFs differ from previously reported potexviruses, a phylogenetic analysis placed it phylogenetically close to Narcissus mosaic virus and Scallion virus X. Therefore, we propose that this virus should be designated as Alstroemeria virus X (AlsVX).

Clinical manifestations of chronic inflammatory demyelinating polyneuropathy with anti-cardiolipin antibodies

OBJECTIVE

Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune syndrome where certain autoantibodies define clinicopathologic subgroups. In the present study, serum anti-cardiolipin antibodies (aCL) were evaluated.

MATERIALS AND METHODS

We investigated aCL in sera from 21 patients diagnosed with CIDP in our hospital between 1991 and 2001. The four CIDP patients with aCL (aCL+) were compared with 17 patients without aCL (aCL-).

RESULTS

All aCL+ patients displayed sensory-motor polyneuropathy, with severity and distribution of weakness resembling those in aCL- patients. Anti-nuclear antibody titer of aCL+ patients were significantly higher than those in aCL- patients. None of aCL+ patients presented clinical manifestations of primary anti-phospholipid syndrome (APS), such as thromboses or recurrent abortion. Although the aCL+ patients were older and had more complications and more severe pathologic features than aCL- patients, they responded well to steroid pulse or intravenous immunoglobulin.

CONCLUSION

The aCL in CIDP apparently differ from 'autoimmune' aCL in APS, instead being among the autoantibodies pathologically involved in CIDP subgroups.

Opposite morphological responses of partially denervated cortical serotonergic and noradrenergic axons to repeated stress in adult rats

We examined plastic changes in serotonin (5-HT) axons following repeated stress in the adult rat brain, and compared stress-induced changes between 5-HT and noradrenaline (NA) axons. We locally injected the specific neurotoxin to 5-HT axons or to NA axons into the frontal cortex to cause partial denervation. The animals were mildly restrained from 1 day after the neurotoxin injection and this stress was repeated daily for 20 min during the first 2 days and for 40 min during the next 11 days. On the fourteenth day after injection, the brains were removed to visualize 5-HT and NA axons by immunohistochemistry. Repeated stress did not significantly alter the denervation area of 5-HT or NA axons, but the density of 5-HT axons was increased whereas that of NA axons was decreased in cortical regions outside the denervation site. In addition, the expression of brain-derived neurotrophic factor (BDNF) was increased in cortical regions where the 5-HT axon density was increased in response to stress. These results suggest that repeated stress causes opposite changes in the morphology of partially denervated 5-HT and NA axons in the cerebral cortex. The stress-induced increase in BDNF expression may contribute to 5-HT axon sprouting following repeated stress.

Scanning laser Doppler flowmeter study of retinal blood flow in macular area of healthy volunteers

AIM

To compare the interocular and intraocular differences of capillary perfusion, and the intraocular regional differences of retinal blood flow in the macular area of healthy volunteers.

METHODS

Tissue blood flow in the macula was examined in both eyes of 20 healthy volunteers with the Heidelberg retinal flowmeter. Blood flow measurements were made in a 10 degrees x 2.5 degrees area superior and inferior to the macula. The mean blood flow (MBF) was calculated by an automatic full field perfusion image analyser program. The MBF in the right and left eyes and in the superior and inferior macular areas of the same eye were compared.

RESULTS

The ratios of the MBF in the right eye to the left eye in the macular areas were 1.00, and 1.03, respectively. The ratio of the MBF in the superior macular area to the inferior area was 1.01 for the right eyes and 1.04 for the left eyes.

CONCLUSIONS

Because no significant differences were found in the MBF between the two eyes and between the superior and inferior macular areas in the same eye, interocular (for example, affected eye versus fellow eye) and intraocular (superior versus inferior macular areas) comparisons of MBF can be made to determine if changes in retinal perfusion have occurred.

Cooperative induction of 15-lipoxygenase in rheumatoid synovial cells by IL-4 and proinflammatory cytokines

OBJECTIVE

To clarify the role of interleukin-4 (IL-4) in the expression of 15-lipoxygenase (15-LOX), whose metabolities are known to suppress the inflammatory reaction, in freshly prepared rheumatoid synovial cells.

METHODS

Adherent synovial cells were prepared by enzymatic digestion of synovia obtained from patients with rheumatoid arthritis (RA). Protein expression of 15-LOX was determined by Western blot analysis. The messenger RNAs of 15-LOX were determined by reverse transcription and the polymerase chain reaction (RT-PCR).

RESULTS

Freshly prepared rheumatoid synovial cells did not express 15-LOX at either the mRNA or protein levels. IL-4 induced the protein expression of 15-LOX after 24 hours of culture. Although interleukin-1 alpha (IL-1 alpha) and tumor necrosis factor alpha (TNF alpha), major inflammatory cytokines in rheumatoid synovia, did not induce the expression of 15-LOX, IL-4 and these inflammatory cytokines synergistically enhanced the protein expression of 15-LOX. The synergistic effect was also observed at the level of mRNA.

CONCLUSIONS

We demonstrate that IL-4 cooperated with the inflammatory cytokines IL-1 alpha and TNF alpha to enhance the expression of 15-LOX in rheumatoid synovial cells. Since 15-LOX metabolites have potent anti-inflammatory actions, our data suggest that IL-4 might downregulate rheumatoid inflammation via the induction of 15-LOX and its metabolites.

Resting T cells negatively regulate osteoclast generation from peripheral blood monocytes

There is accumulating evidence that T cells may be involved in osteoclastogenesis in a variety of murine systems. However, the precise role of human T cells in the regulation of osteoclast generation is still unclear. To address this issue, we investigated the effect of resting peripheral T cells on receptor activator of NF-kappaB ligand (RANKL)-induced osteoclast generation from human peripheral monocytes. Although osteoclasts were not generated in the culture of human peripheral blood mononuclear cells (PBMC) in the presence of RANKL and macrophage colony-stimulating factor (M-CSF), the addition of cyclosporine A (CsA), a potent inhibitor of T-cell function, resulted in the formation of an increasing number of lacunae resorption on dentine, suggesting T cells may inhibit osteoclast formation. In a coculture of T cells and monocytes, which were isolated from PBMC, T cells inhibited the osteoclast generation from monocytes, as determined by tartrate-resistant acid phosphatase (TRAP) staining and a pit assay using dentine. This inhibition of osteoclast generation by T cells was also observed in a culture of the parathyroid hormone-stimulated SaOS4/3 osteoblast cell line and monocytes. The culture in Transwell plates revealed that the cell-to-cell interaction was not required for the inhibition, suggesting that T-cell cytokines may be responsible for the inhibition. Among inhibitory T-cell cytokines on osteoclastogenesis, granulocyte-macrophage colony-stimulating factor (GM-CSF) and interferon-gamma (IFN-gamma) were actively produced by CD4 T cells but not CD8 T cells in the coculture of T cells with monocytes, and the neutralizing antibodies to these cytokines partially rescued the T-cell-induced inhibition of osteoclast formation. Although CsA did not affect RANKL-induced osteoclast generation in the culture of monocytes alone, it completely rescued the T-cell-induced inhibition of osteoclast formation and strongly inhibited the production of GM-CSF and IFN-gamma. Thus, we demonstrate that resting T cells negatively regulate the osteoclast generation via production of GM-CSF and IFN-gamma by CD4 T cells and that CsA stimulates the osteoclast generation through the inhibition of the production of these cytokines. These findings provide new insight into therapeutic strategies for immunosuppression-induced bone loss in transplant and other diseases.