The Japan-Multimodal Intervention Trial for Prevention of Dementia (J-MINT): The Study Protocol for an 18-Month, Multicenter, Randomized, Controlled Trial.

BACKGROUND/OBJECTIVES: The Japan-multimodal intervention trial for prevention of dementia (J-MINT) is intended to verify the effectiveness of multi-domain interventions and to clarify the mechanism of cognitive improvement and deterioration by carrying out assessment of dementia-related biomarkers, omics analysis and brain imaging analysis among older adults at high risk of dementia. Moreover, the J-MINT trial collaborates with partnering private enterprises in the implementation of relevant interventional measures. This manuscript describes the study protocol. DESIGN/SETTING: Eighteen-month, multi-centered, randomized controlled trial. PARTICIPANTS: We plan to recruit 500 older adults aged 65-85 years with mild cognitive impairment. Subjects will be centrally randomized into intervention and control groups at a 1:1 allocation ratio using the dynamic allocation method with all subjects stratified by age, sex, and cognition. INTERVENTION: The multi-domain intervention program includes: (1) management of vascular risk factors; (2) group-based physical exercise and self-monitoring of physical activity; (3) nutritional counseling; and (4) cognitive training. Health-related information will be provided to the control group every two months. MEASUREMENTS: The primary and secondary outcomes will be assessed at baseline, 6-, 12-, and 18-month follow-up. The primary outcome is the change from baseline to 18 months in a global composite score combining several neuropsychological domains. Secondary outcomes include: cognitive change in each neuropsychological test, incident dementia, changes in blood and dementia-related biomarkers, changes in geriatric assessment including activities of daily living, frailty status and neuroimaging, and number of medications taken. CONCLUSIONS: This trial that enlist the support of private enterprises will lead to the creation of new services for dementia prevention as well as to verify the effectiveness of multi-domain interventions for dementia prevention.

Hydroxylated and non-hydroxylated sulfatide are distinctly distributed in the human cerebral cortex.

Sulfatide (ST) is a sphingolipid with an important role in the central nervous system as a major component of the myelin sheath. ST contains a structurally variable ceramide moiety, with a fatty acid substituent of varying carbon-chain length and double-bond number. Hydroxylation at the α-2 carbon position of the fatty acid is found in half the population of ST molecules. Recent genetic studies of fatty acid 2-hydroxylase (FA2H) indicate that these hydroxylated sphingolipids influence myelin sheath stability. However, their distribution is unknown. Matrix-assisted laser desorption/ionization imaging mass spectrometry (MALDI-IMS) enables the analysis of distinct distributions of individual ST molecular species in tissue section. We examined human cerebral cortex tissue sections with MALDI-IMS, identifying and characterizing the distributions of 14 ST species. The distribution analysis reveals that the composition ratios of non-hydroxylated/hydroxylated STs are clearly reversed at the border between white and gray matter; the hydroxylated group is the dominant ST species in the gray matter. These results suggest that hydroxylated STs are highly expressed in oligodendrocytes in gray matter and might form stable myelin sheaths. As a clinical application, we analyzed a brain with Alzheimer's disease (AD) as a representative neurodegenerative disease. Although previous studies of AD pathology have reported that the amount of total ST is decreased in the cerebral cortex, as far as the compositional distributions of STs are concerned, AD brains were similar to those in control brains. In conclusion, we suggest that MALDI-IMS is a useful tool for analysis of the distributions of various STs and this application might provide novel insight in the clinical study of demyelinating diseases.

Brain site-specific gene expression analysis in Alzheimer's disease patients.

BACKGROUND: Alzheimer's disease (AD) is an age-related neurodegenerative disorder that is characterized by a progressive loss of higher cognitive functions. The brain of an individual with AD exhibits extracellular senile plaques (SPs) of aggregated amyloid-beta peptide (Abeta) and intracellular neurofibrillary tangles (NFTs). Given the critical role of neuronal transport of both proteins and organelles, it is not surprising that perturbation of microtubule-based transport may play a major role in the pathogenesis of AD. MATERIALS AND METHODS: We used the cDNA subtraction methodology and in vitro neural cell culture analyses to study the meaning of the brain site-specific gene expression pattern in cerebral tissue obtained from AD patients and also from control subjects at autopsy. RESULTS: We observed that cytoskeleton-associated proteins were down-regulated in AD subjects. We also noted an altered expression of the microtubule-associated protein 1B (MAP1B), the heat-shock protein (HSP)-90 (a key chaperone molecule), the tripartite motif-containing proteins (TRIM)-32/37 (an anti apoptotic enzyme with ubiquitin-protein ligase activity) and the Reticulon-3 (a modulator of the amyloid-precursor-protein (APP) cleavage) in AD brains. Additional molecular- and cell-biological studies revealed that small interfering RNA (siRNA)-mediated down-regulation of MAP1B expression leads to neuronal cell death in vitro. CONCLUSION: Altered expression of MAP1B, HSP90, TRIM32/37 and Reticulon-3 provides new clues by which the ubiquitin-proteasome-, the protein-chaperon- and the APP-processing systems are disturbed in AD, thus, leading to neuritic amyloid plaques and neurofibrillary tangles.

Characterizing the new transcription regulator protein p60TRP.

Active cell death ('apoptosis' or 'programmed cell death') is essential in the development and homeostasis of multicellular organisms and abnormal inhibition of apoptosis is an indicator of cancer and autoimmune diseases, whereas excessive cell death might be implicated in neurodegenerative disorders such as Alzheimer's disease (AD). Using bioinformatics-, Western-blotting-, yeast-two-hybrid-system-, polymerase chain reaction (PCR)-, and fluorescence microscopy-analyses, we demonstrate here that the neuroprotective protein p60TRP (p60-transcription-regulator-protein) is a basic helix-loop-helix (bHLH) domain-containing member of a new protein family that interacts with the Ran-binding-protein-5 (RanBP5) and the protein-phosphatase-2A (PP2A). The additional findings of its influence on NNT1 and p48ZnF (new-neurotrophin-1, p48-zinc-finger-protein)-signaling and its down-regulation in the brain of AD subjects point to a possible pivotal role of p60TRP in the control of cellular aging and survival.

Increased hepatocyte growth factor level in cerebrospinal fluid in Alzheimer's disease.

BACKGROUND & OBJECTIVE: Hepatocyte growth factor (HGF), also known as the scatter factor, is a potent mitogen for mature hepatocytes, and also has multifunctional effects on some cells in various organs. Recently, we have found expression and localization of HGF in white matter astrocytes in human brain tissues. Furthermore, immunohistochemistry using anti-HGF antibody revealed more intense immunolabeling in Alzheimer's disease (AD) than control brains. The aim of the study is to investigate the level of HGF in cerebrospinal fluid (CSF) from patients with AD. MATERIAL AND METHODS: We examined the level of HGF in CSF from 34 AD and 15 age-matched disease control patients by highly sensitive enzyme-linked immunoabsorbent assay (ELISA) system. RESULTS: Consistent with the immunohistochemical data, a significantly higher concentration of HGF in AD CSF was found as compared with controls. A significant correlation was also seen between CSF HGF levels and white matter high-signal foci determined on brain magnetic resonance imaging (MRI) in AD patients. CONCLUSION: These results indicate that CSF HGF levels correspond with the white matter damage in AD brain.

Hepatocyte growth factor in cerebrospinal fluid in neurologic disease.

OBJECTIVE: To investigate hepatocyte growth factor (HGF) concentration in cerebrospinal fluid (CSF) in neurologic disease. MATERIALS AND METHODS: We determined CSF concentration of HGF with human-HGF-specific enzyme-linked immunosorbent assays (ELISA) in 121 patients: Alzheimer's disease (AD) (33), amyotrophic lateral sclerosis (ALS) (10), Parkinson's disease (PD) (5), progressive supranuclear palsy (PSP) (3), spinocerebellar degeneration (7), acute disseminating encephalomyelitis (ADEM) (6), human T-lymphotropic virus-1 (HTLV-1)-associated myelopathy (HAM) (6), multiple sclerosis (MS) (7), aseptic meningitis (AM) (12), and peripheral neuropathy and myopathy as control diseases (32). RESULTS: HGF concentrations in CSF were significantly higher with diseases of the central nervous system (CNS) than control diseases and were slightly higher with AD than other neurodegenerative diseases. Values were highest with ADEM but decreased during corticosteroid treatment. We found no relationship between HGF in CSF and CSF cells or protein, immunoglobulin index, or Q albumin. CONCLUSION: It is suggested that high concentrations of HGF in CSF may be partially related to CNS pathology, especially to demyelinating disease.

Mechanism of the development of gastric ulcer after percutaneous endoscopic gastrostomy.

BACKGROUND AND STUDY AIMS: The present study was carried out in order to elucidate the mechanism of the development of gastric ulcer, one of the serious complications of PEG tube placement. PATIENTS AND METHODS: This retrospective study included 92 patients who underwent gastric endoscopy after PEG tube placement. Gastric ulcers detected at gastroscopy were examined in relation to the length of the protrusion from the PEG tubes intragastric bumper and the use of histamine H 2 -receptor antagonists. RESULTS: Gastric ulcers were found in nine of the 92 patients, and in all nine the ulcer was found on the posterior wall of the gastric body, where the tip of the PEG tube was attached. Seven of the 21 patients (33.3 %) who had a PEG tube with a long protrusion from the intragastric bumper developed gastric ulcer. By contrast, only two of the 71 patients (2.8 %) who had a PEG tube with a short protrusion developed gastric ulcer. The use of H 2 -blockers had no significant impact on the development of gastric ulcer. CONCLUSIONS: The occurrence of gastric ulcer after PEG placement was attributable to the shape of the PEG tube within the intragastric space, and not to the use of H 2 -blockers, suggesting that appropriate placement of the PEG tube is an important factor in preventing gastric ulcer.

Contribution of anaphylatoxin C5a to late airway responses after repeated exposure of antigen to allergic rats.

We attempted to elucidate the contribution of complement to allergic asthma. Rat sensitized to OVA received repeated intratracheal exposures to OVA for up to 3 consecutive days, and pulmonary resistance was then estimated for up to 6 h after the last exposure. Whereas the immediate airway response (IAR) in terms of R(L) tended to decrease in proportion to the number of OVA exposures, late airway response (LAR) became prominent only after three. Although premedication with two kinds of complement inhibitors, soluble complement receptor type 1 (sCR1) or nafamostat mesylate, resulted in inhibition of the IAR after either a single or a double exposure, the LAR was inhibited after the triple. Premedication with a C5a receptor antagonist (C5aRA) before every exposure to OVA also inhibited the LAR after three. Repeated OVA exposure resulted in eosinophil and neutrophil infiltration into the bronchial submucosa which was suppressed by premedication with sCR1 or C5aRA. Up-regulation of C5aR mRNA was shown in lungs after triple OVA exposure, but almost no up-regulation of C3aR. Pretreatment with sCR1 or C5aRA suppressed the up-regulation of C5aR expression as well as cytokine messages in the lungs. The suppression of LAR by pretreatment with sCR1 was reversed by intratracheal instillation of rat C5a desArg the action of which was inhibited by C5aRA. In contrast, rat C3a desArg or cytokine-induced neutrophil chemoattractant-1 induced cellular infiltration into the bronchial submucosa by costimulation with OVA, but these had no influence on the LAR. These differences might be explained by the fact that costimulation with OVA and C5a synergistically potentiated IAR, whereas that with OVA and either C3a or cytokine-induced neutrophil chemoattractant-1 did not. C5a generated by Ag-Ab complexes helps in the production of cytokines and contributes to the LAR after repeated exposure to Ag.

Up-regulation of calcineurin Abeta mRNA in the Alzheimer's disease brain: assessment by cDNA microarray.

Recent advances in cDNA microarray technology have made it possible to analyze expression of more than 8000 genes. Using this technology, gene expression in the hippocampus containing neurofibrillary tangle-associated lesions from an Alzheimer's disease (AD) patient was compared with expression in the parietal cortex from the same patient that lacked these lesions. We also compared gene expression using a control brain. The top 20 named genes significantly up-regulated or down-regulated only in the AD brain were determined. The most up-regulated gene proved to be calcineurin Abeta mRNA (CAbeta). In situ hybridization histochemistry revealed that CAbeta was significantly up-regulated in pyramidal neurons of the hippocampus in the AD brain. RT-PCR analysis revealed that CAbeta was up-regulated in the hippocampus from two out of three AD brains while there were no changes in three control brains. Our study suggests that CAbeta may play a crucial role in the pathophysiological mechanisms in AD.

Increasing in situ nick end labeling of oligodendrocytes in white matter of patients with Binswanger's disease.

Increasing evidence suggests the presence of apoptotic cell death in many neurodegenerative diseases. However, in Binswanger's disease (BD), no information is available concerning the apoptosis-related pathologic changes that may occur in the white matter. To investigate whether apoptotic cell death is included in the pathophysiology of the white matter changes in BD, autopsied brains from patients with BD (n = 5) were compared with those of non-neurologic controls (n = 5). Terminal deoxynucleotidyl transferase-mediated dUTP in situ nick end labeling (TUNEL) was used as a marker for cell damage with DNA fragmentation. A proteolipid protein (PLP) messenger RNA (mRNA) hybridization signal was also used as a sensitive and specific marker of oligodendrocytes as well as glial fibrillary acidic protein (GFAP) immunoreactivity as a marker of astrocytes. There were frequent TUNEL-positive cells in the rarefied white matter of patients with BD. TUNEL-positive cells were found 15-fold more numerously in BD than in controls (P < .01). TUNEL-positive cells were presumably oligodendrocytes because of their coexpression with PLP mRNA. The numbers of GFAP-positive astrocytes were significantly decreased in BD compared with those in control subjects. The reduction in numbers of PLP mRNA-positive oligodendrocytes were also seen in BD, but these changes did not reach the level of significance. The pathologic alterations in BD brains include increased TUNEL-positive oligodendrocytes, associated with degradation of myelin. Although TUNEL-positive glial cells did not show typical apoptotic morphologic features, these findings suggest that increase in in situ nick end labeling of oligodendrocytes in white matter may play an important role in the pathophysiology of BD.

Molecular cloning and partial characterization of rat procarboxypeptidase R and carboxypeptidase N.

Carboxypeptidase R (EC 3.4.17.20) (CPR) and carboxypeptidase N (EC 3.4.17.3) (CPN) cleave carboxy-terminal arginine or lysine residues from biologically active peptides such as kinins or anaphylatoxins in the circulation thereby regulating their activities. Although CPN is present in a stable active form in plasma, CPR is generated from proCPR, a plasma zymogen, by proteolytic enzymes such as thrombin, thrombin-thrombomodulin complex and plasmin. We have isolated rat proCPR and CPN cDNA clones which can induce enzymatic activities in culture supernatants of the transfected cells. mRNA of proCPR was detected only in rat liver by Northern hybridization and showed hepatocyte-specific expression. Expression of proCPR mRNA was enhanced following LPS injection, indicating that proCPR production is increased under inflammatory conditions.

Localization of a novel type trypsin-like serine protease, neurosin, in brain tissues of Alzheimer's disease and Parkinson's disease.

Neurosin, a novel type of trypsin-like serine protease, has been shown to be preferentially expressed in human brain by northern blotting. We examined neurosin immunolabeling in the brains of neurologically normal persons and patients with Alzheimer's disease (AD) and with Parkinson's disease. We also identified the expression of the mRNA for neurosin by in situ hybridization histochemistry and reverse transcription-polymerase chain reaction (RT-PCR). The neurosin antibody stained all of the nuclei of various cell types. In neurons, there was also staining of neuronal cytoplasm, nucleoli and their processes. In AD, staining of neurons with processes was rare in the damaged areas. Some senile plaques, extracellular tangles and Lewy bodies were also positive for neurosin. Expression of the mRNA for neurosin was seen in neurons in the gray matter, and in microglial cells in the white matter. In AD, the intensity of the signal for neurosin mRNA in the gray matter was decreased compared with normal control brains. The relative levels of neurosin mRNA in AD brains, measured by RT-PCR, were lower than those in controls. These results suggest that in human brain neurosin plays various physiological roles, and that in AD this molecule, like other serine proteases, may have a role in the degradation of such substances as beta-amyloid protein.

Molecular and cellular properties of the rat AA4 antigen, a C-type lectin-like receptor with structural homology to thrombomodulin.

The murine fetal stem cell marker AA4 has recently been cloned and is known to be the homolog of the human phagocytic C1q receptor involved in host defense. We herein report the molecular cloning and the cellular expression pattern of the rat AA4 antigen. Modular architecture analysis indicated that the rat AA4 is a member of C-type lectin-like family and, interestingly, displays similar domain composition and organization to thrombomodulin. Northern blot and reverse transcriptase-polymerase chain reaction analyses indicated that rat AA4 was encoded by a single transcript of 7 kilobases expressed constitutively in all tissues. In situ hybridization showed that AA4 was expressed predominantly by pneumocytes and vascular endothelial cells. Using an affinity purified polyclonal antibody raised against a rat AA4-Fc fusion protein, AA4 was identified as a glycosylated protein of 100 kDa expressed by endothelial cells > platelets > NK cells and monocytes (ED1+ cells). The staining was associated to the cell surface and intracytoplasmic vesicles. Conversely, erythrocytes, T and B lymphocytes, neutrophils, and macrophages (ED2+ cells) were consistently negative for AA4. As expected, the macrophage cell line NR8383 expressed weak levels of AA4. Taken together, our results support the idea that AA4/C1qRp is involved in some cell-cell interactions.

Pro-carboxypeptidase R is an acute phase protein in the mouse, whereas carboxypeptidase N is not.

Carboxypeptidase R (EC 3.4.17.20; CPR) and carboxypeptidase N (EC 3. 4.17.3; CPN) cleave carboxyl-terminal arginine and lysine residues from biologically active peptides such as kinins and anaphylatoxins, resulting in regulation of their biological activity. Human proCPR, also known as thrombin-activatable fibrinolysis inhibitor, plasma pro-carboxypeptidase B, and pro-carboxypeptidase U, is a plasma zymogen activated during coagulation. CPN, however, previously termed kininase I and anaphylatoxin inactivator, is present in a stable active form in plasma. We report here the isolation of mouse proCPR and CPN cDNA clones that can induce their respective enzymatic activities in culture supernatants of transiently transfected cells. Potato carboxypeptidase inhibitor can inhibit carboxypeptidase activity in culture medium of mouse proCPR-transfected cells. The expression of proCPR mRNA in murine liver is greatly enhanced following LPS injection, whereas CPN mRNA expression remains unaffected. Furthermore, the CPR activity in plasma increased 2-fold at 24 h after LPS treatment. Therefore, proCPR can be considered a type of acute phase protein, whereas CPN is not. An increase in CPR activity may facilitate rapid inactivation of inflammatory mediators generated at the site of Gram-negative bacterial infection and may consequently prevent septic shock. In view of the ability of proCPR to also inhibit fibrinolysis, an excess of proCPR induced by LPS may contribute to hypofibrinolysis in patients suffering from disseminated intravascular coagulation caused by sepsis.

[Complications of percutaneous endoscopic gastrostomy in the elderly: local skin infection and respiratory infection].

We investigated post-operative management of acute complications of percutaneous endoscopic gastrostomy (PEG) which often caused respiratory infections and local skin infections. The subjects were a total of 341 patients (male 131, female 210, and the mean age was 80.3), they were classified into six groups by method of feeding and use of antibiotics. Patients were divided into three groups based on the time that feeding was started. In Group I, enteral feeding was not started within the first five days. In Group II, sterilized enteral feeding (lactated Ringer's solution for intravenous infusion) using sterilized intravenous infusion kit started within 24 hours after the procedure, and in Group III, feeding of the usual enteral formula started within 24 hours after the procedure. And as for the using of antibiotics, they were also divided into two groups, antibiotics administered[AB (+)] and no antibiotics administered[AB (-)]. Thus, the patients were divided into six groups according to the time of starting nutrition and the use of antibiotics. The rates of incidence of acute respiratory infections and local skin infections in the six groups were compared by the chi-square test and differences in the rates of incidence of complication were also compared between two PEG methods; the Pull/Push method and the Introducer method. The frequency of local skin infection in Group III was significantly higher than in Group I and Group II. As for the PEG methods, the frequency of local skin infection in the Pull/Push method was significantly higher than Introducer methods. Acute respiratory infections occurred significantly less in the AB (+) group than in the AB (-) group. Postoperative administration of antibiotics would seem to be appropriate for prophylaxis of respiratory infection in elderly patients after PEG. On the other hand, local skin infections are not related to administration of antibiotics, and are highly related to the method of feeding. We concluded that nutrition of sterilized enteral feeding immediately after operation using a sterilized intravenous infusion kit and administration of antibiotics are advisable to prevent major complications in elderly patients.

Medicine and the Internet.

Practicing physicians are frequently overwhelmed by the amount of new medical information. The internet is increasingly becoming an important vehicle for accessing that information with a variety of online resources for medical professionals. In its current state, however, the internet abounds with misleading information, making it difficult to sort out what is both meaningful and accurate from among the thousands of electronic documents. In this article, we list medical web sites that we have found to be useful, accurate, and easy to navigate. We also give an overview of the internet and World Wide Web to provide a starting point for novice users, and we briefly discuss how internet policy relates to medical practice.

[Usefulness and problems of percutaneous endoscopic gastrostomy in a geriatric hospital].

Usefulness and problems of percutaneous endoscopic gastrostomy (PEG) placement in a geriatric hospital where most patients were severely demented or bed-ridden were evaluated. The variables examined were acute complications, chronic complications, restraint of patients before and after PEG placement, change in physical activity, and ability of oral intake. Results showed that both acute and chronic complications were not rare, but these problems are not peculiar to geriatric hospitals. Quality of life (QOL) was clearly improved. Restraint could be reduced or stopped in 65.2% of restrained patients after PEG tube placement, activity was improved in 55.5% of patients, and oral intake became possible in 14.0% of patients. There were also some improvements in the management of PEG, as the incidence of self-extubation decreased, and tube exchange became easier. In conclusion, it is possible to insert and manage the PEG tubes even in geriatric hospitals, and PEG tubes are quite useful in managing patients with chronic disease and in improving QOL.

Cerebral venous thrombosis in nephrotic syndrome.

This report describes cerebral venous sinus thrombosis, a rare and perhaps under-diagnosed complication of nephrotic syndrome. We review the pathophysiology of the coagulopathy associated with nephrotic syndrome including abrupt renal loss of antithrombin III. We propose a rationale approach to treating this condition with low-molecular-weight heparin and antithrombin III replacement.

[Gastro-esophageal reflux successfully treated with transgastrostomal jejunal tube feeding].

An 82-year-old man suffered from recurrent melena due to reflux esophagitis and aspiration pneumonia, which were caused by severe gastroesophageal reflux. We constructed a gastric stoma by percutaneous endoscopic gastrostomy (PEG) and fixed a transgastrostomal jejunal tube (TGJ tube) in the jejunum through the stoma. Direct administration of fluid into the jejunum was followed by a significant reduction in gastro-esophageal reflux. The reflux esophagitis and aspiration pneumonia did not recur. There was no vomiting, self-extubation, or restlessness that might have been caused by dementia, and the patient was could discharged cared for at into home.

Unique expression of HRF20 (CD59) in human nervous tissue.

Damage to autologous tissue by complement is limited by several widely distributed membrane-associated glycoproteins which restrict the action of the complement in homologous species. These include decay accelerating factor (DAF), membrane cofactor protein (MCP) and 20 kDa homologous restriction factor (HRF20,CD59). Using immunohistochemical techniques, we examined the localization of these proteins in the central nervous system (CNS) and peripheral nervous system (PNS) using non-neurological human nervous tissue since some complement components have been demonstrated to be synthesized in the CNS. There was no evidence of parenchymal staining by anti-DAF or anti-MCP antibodies in either type of tissue except for the staining of the endothelium in capillaries. On the other hand, anti-HRF20 antibody clearly stained myelinated axons in the CNS as well as Schwann cells in the PNS. In addition, we detected positive staining by anti-DAF antibody in the PNS of a Paroxysmal nocturnal hemoglobinuria (PNH) patient who is genetically deficient in HRF20.