Modified Gant-Miwa-Thiersch procedure (mucosal plication with anal encircling) for rectal prolapse.

AIM: Rectal prolapse (RP) is usually associated with elderly women and is well recognized as having a detrimental effect on quality of life. A number of surgical procedures for RP are available, but morbidity and mortality are substantial. The Gant-Miwa-Thiersch procedure (GMT) has been frequently used for RP in Japan. However, as GMT has a high recurrence rate it is not widely used elsewhere. The aim of this study was to evaluate a modified version of GMT (mGMT) in comparison with other procedures. METHOD: mGMT was performed under spinal or local anaesthesia in 187 patients with RP. No normal mucosa was left between the tags and lateral wounds were created in the Thiersch procedure. Morbidity, mortality and recurrence rates were recorded. RESULTS: No serious postoperative complications and no operative deaths occurred after mGMT. Eight per cent of patients suffered from infection of the strings. The overall recurrence rate after mGMT was 7.5% with a median follow-up period of 13.8 years. CONCLUSION: On the basis of these results, we consider that mGMT has a number of advantages: it is minimally invasive, does not require general anaesthesia, is technically simple to perform and is associated with satisfactory outcomes and low morbidity. mGMT should be considered an option for the treatment of RP in elderly patients.

Risk of serious adverse events and fatal adverse events with sorafenib in patients with solid cancer: a meta-analysis of phase 3 randomized controlled trials†.

Background: Sorafenib is a multikinase-tyrosine kinase inhibitor commonly used in a variety of cancers. There are concerns about the increased risk of serious adverse events (SAEs) and fatal adverse events (FAEs) with sorafenib. We performed an up-to-date meta-analysis of all phase 3 randomized controlled trials (RCTs) of sorafenib to quantify the increased risk of SAEs and FAEs. Patients and methods: We carried out a systematic search of electronic databases for studies published from inception to February 2016 without any restrictions. Eligibility criteria included phase 3 RCTs of solid tumors comparing sorafenib, alone or in combination with nontargeted chemotherapy (Sorafenib arm) versus placebo or nontargeted chemotherapy (control arm). Data on SAEs and FAEs for both the arms were extracted from each study and pooled to determine the overall incidence, relative risks (RRs) and 95% Confidence Intervals (CIs). Results: Of 471 studies identified, a total of 12 phase 3 RCTs involving 6797 solid cancer patients comparing sorafenib with control met the eligibility criteria and were included. The overall incidence of SAEs and FAEs with sorafenib were 26.4% (95% CI, 18.0-36.9%) and 1.3% (95% CI: 0.8-2.2%), respectively. Compared with control, sorafenib use significantly increased the risk of both SAEs (RR: 1.49, 95% CI: 1.18-1.89, P = 0.001) and FAEs (RR: 1.82, 95% CI: 1.05-3.14, P = 0.033). This association varied significantly with cancer types (P < 0.001) and approval status (P = 0.012) for SAEs but no evidence of heterogeneity was found for FAEs. Conclusions: This meta-analysis of phase 3 RCTs demonstrates an increased risk of both SAEs and FAEs with sorafenib use in adult patients with solid cancers. This quantification of increased risks of SAEs and FAEs will be important in considering the trade-off of sorafenib treatment during shared decision-making.

Pituitary adenylate cyclase-activating polypeptide promotes eccrine gland sweat secretion.

BACKGROUND: Sweat secretion is the major function of eccrine sweat glands; when this process is disturbed (paridrosis), serious skin problems can arise. To elucidate the causes of paridrosis, an improved understanding of the regulation, mechanisms and factors underlying sweat production is required. Pituitary adenylate cyclase-activating polypeptide (PACAP) exhibits pleiotropic functions that are mediated via its receptors [PACAP-specific receptor (PAC1R), vasoactive intestinal peptide (VIP) receptor type 1 (VPAC1R) and VPAC2R]. Although some studies have suggested a role for PACAP in the skin and several exocrine glands, the effects of PACAP on the process of eccrine sweat secretion have not been examined. OBJECTIVES: To investigate the effect of PACAP on eccrine sweat secretion. METHODS: Reverse transcriptase-polymerase chain reaction and immunostaining were used to determine the expression and localization of PACAP and its receptors in mouse and human eccrine sweat glands. We injected PACAP subcutaneously into the footpads of mice and used the starch-iodine test to visualize sweat-secreting glands. RESULTS: Immunostaining showed PACAP and PAC1R expression by secretory cells from mouse and human sweat glands. PACAP immunoreactivity was also localized in nerve fibres around eccrine sweat glands. PACAP significantly promoted sweat secretion at the injection site, and this could be blocked by the PAC1R-antagonist PACAP6-38. VIP, an agonist of VPAC1R and VPAC2R, failed to induce sweat secretion. CONCLUSIONS: This is the first report demonstrating that PACAP may play a crucial role in sweat secretion via its action on PAC1R located in eccrine sweat glands. The mechanisms underlying the role of PACAP in sweat secretion may provide new therapeutic options to combat sweating disorders.

ACTN4 copy number increase as a predictive biomarker for chemoradiotherapy of locally advanced pancreatic cancer.

BACKGROUND: Several clinical trials have compared chemotherapy alone and chemoradiotherapy (CRT) for locally advanced pancreatic cancer (LAPC) treatment. However, predictive biomarkers for optimal therapy of LAPC remain to be identified.We retrospectively estimated amplification of the ACTN4 gene to determine its usefulness as a predictive biomarker for LAPC. METHODS: The copy number of ACTN4 in 91 biopsy specimens of LAPC before treatment was evaluated using fluorescence in situ hybridisation (FISH). RESULTS: There were no statistically significant differences in overall survival (OS) or progression-free survival (PFS) of LAPC between patients treated with chemotherapy alone or with CRT. In a subgroup analysis of patients treated with CRT, patients with a copy number increase (CNI) of ACTN4 had a worse prognosis of OS than those with a normal copy number (NCN) of ACTN4 (P=0.0005, log-rank test). However, OS in the subgroup treated with chemotherapy alone was not significantly different between patients with a CNI and a NCN of ACTN4. In the patients with a NCN of ACTN4, the median survival time of PFS in CRT-treated patients was longer than that of patients treated with chemotherapy alone (P=0.049). CONCLUSIONS: The copy number of ACTN4 is a predictive biomarker for CRT of LAPC.

Effect of SGLT2 inhibitors in a murine model of urinary tract infection with Candida albicans.

AIMS: Urinary tract infection (UTI) is a common clinical problem in diabetic patients; however, the relationship between UTI and glucosuria remains uncertain. To investigate the relationship, we examined the effect of glucosuria induced by sodium glucose cotransporter 2 (SGLT2) inhibitors on the progression of UTI in mice. METHODS: From 1 day before transurethral inoculation with Candida albicans, female mice were treated orally once a day with an SGLT2 inhibitor in different treatment regimens: (i) dapagliflozin at 10 mg/kg for 2, 3 or 7 days, (ii) dapagliflozin at 0.1, 1 or 10 mg/kg for 3 days and (iii) dapagliflozin, canagliflozin or tofogliflozin at 10 mg/kg for 3 days. To evaluate the ascending UTI, the kidneys were removed 6 days after the inoculation, and the number of viable C. albicans cells in kidney was measured as colony-forming units (CFU). RESULTS: In mice treated with dapagliflozin, the number of C. albicans CFU in kidney increased in accordance with both treatment duration and dose. The number of CFU significantly increased when mice were treated with 10 mg/kg dapagliflozin or canagliflozin but not tofogliflozin. With dapagliflozin and canagliflozin, urine glucose concentration (UGC) significantly increased up to 24 h after drug administration; with tofogliflozin, UGC significantly increased only up to 12 h after drug administration. CONCLUSIONS: Our data indicate that increased susceptibility to UTI is associated with a persistent increase in UGC.

Diagnostic and prognostic significance of the alternatively spliced ACTN4 variant in high-grade neuroendocrine pulmonary tumours.

BACKGROUND: High-grade neuroendocrine tumours (HGNTs) of the lung manifest a wide spectrum of clinical behaviour, but no method for predicting their outcome has been established. MATERIALS AND METHODS: We newly established a monoclonal antibody specifically recognizing the product of the alternatively spliced ACTN4 transcript (namely, variant actinin-4), and used it to examine the expression of variant actinin-4 immunohistochemically in a total of 609 surgical specimens of various histological subtypes of lung cancer. RESULTS: Variant actinin-4 was expressed in 55% (96/176) of HGNTs, but in only 0.8% (3/378) of non-neuroendocrine (NE) lung cancers. The expression of variant actinin-4 was significantly associated with poorer overall survival in HGNT patients (P=0.00021, log-rank test). Multivariate analysis using the Cox proportional hazards model showed that the expression of variant actinin-4 was the most significant independent negative predictor of survival in HGNT patients (hazard ratio (HR), 2.15; P=0.00113) after the presence of lymph node metastasis (HR, 2.25; P=0.00023). CONCLUSIONS: The expression of variant actinin-4 is an independent prognostic factor for patients with HGNTs. This protein has a high affinity for filamentous actin polymers and likely promotes aggressive behaviour of cancer cells. The present clinical findings clearly support this notion.

Distinct outcome of stage I lung adenocarcinoma with ACTN4 cell motility gene amplification.

BACKGROUND: Even if detected at an early stage, a substantial number of lung cancers relapse after curative surgery. However, no method for distinguishing such tumors has yet been established. PATIENTS AND METHODS: The copy number of the actinin-4 (ACTN4) gene was determined by fluorescence in situ hybridization on tissue microarrays comprising 543 surgically resected adenocarcinomas of the lung. RESULTS: Amplification (an increase in the copy number by ≥ 2.0 fold) of the ACTN4 gene was detected in two of seven lung adenocarcinoma cell lines and 79 (15%) of 543 cases of pathological stage I-IV lung adenocarcinoma. Multivariate analysis revealed that ACTN4 gene amplification was the most significant independent factor associated with an extremely high risk of death (hazard ratio, 6.78; P = 9.48 × 10(-5), Cox regression analysis) among 290 patients with stage I lung adenocarcinoma. The prognostic significance of ACTN gene amplification was further validated in three independent cohorts totaling 1033 patients. CONCLUSIONS: Amplification of the ACTN4 gene defines a small but substantial subset of patients with stage I lung adenocarcinoma showing a distinct outcome. Such patients require intensive medical attention and might benefit from postoperative adjuvant chemotherapy.

Reduction in radiation and contrast medium dose via optimization of low-kilovoltage CT protocols using a hybrid iterative reconstruction algorithm at 256-slice body CT: phantom study and clinical correlation.

AIM: To optimize low-kilovoltage (kV) computed tomography (CT) protocols using a hybrid iterative reconstruction (HIR) algorithm at 256-detector-row body CT. MATERIALS AND METHODS: Based on preliminary phantom studies, three different tube voltage protocols with an equal contrast-to-noise ratio (CNR) were developed. They were a conventional 120 kV protocol with filtered back-projection (FBP), an 80 kV protocol with HIR (a 160% increase in the tube current-time product and a 40% reduction in the contrast medium dose), and a 100 kV protocol with HIR (a 20% reduction in the tube current-time product and the contrast medium dose). The clinical study included 70 patients (34 women, 36 men; mean age 70.5 ± 9.1 years, range 44-92 years) who had undergone CT at 120 kV a mean of 148 ± 137 days before undergoing low kV contrast-enhanced body CT (80 kV with HIR, n = 35; 100 kV with HIR, n = 35). The estimated effective radiation dose (ED), image noise, and CNR were calculated and the visual image quality was scored on a four-point scale. RESULTS: Mean ED was 12.3, 8.4, and 15.4 mSv for the 80, 100, and 120 kV protocol, respectively, and significantly lower using the low kV protocols. There was no significant difference in the image noise and CNR between the low kV protocols with HIR and the 120 kV protocol with FBP, or in the visual scores among the three protocols. CONCLUSION: Without ensuing image-quality degradation, the radiation and contrast medium dose can be reduced with optimal contrast-enhanced CT protocols using a low kV technique and an HIR algorithm.

Effects of short-term intensive glycemic control on insulin, glucagon, and glucagon-like peptide-1 secretion in patients with Type 2 diabetes.

BACKGROUND: Short-term intensive insulin therapy (IIT) in patients with Type 2 diabetes mellitus (T2DM) has beneficial effects on insulin secretion. However, IIT effect on glucagon and glucagon-like peptide-1 (GLP-1) secretion is unknown. AIM: We evaluated short-term intensive glycemic control effects on insulin, glucagon, and GLP-1 secretory dynamics in T2DM. MATERIALS AND METHODS: Twenty-six patients with T2DM were hospitalized and treated with IIT for 10-14 days. A meal tolerance test was performed before and after IIT and the differences in serum immunoreactive insulin (IRI) and C-peptide immunoreactivity (CPR) as well as plasma glucagon and active GLP-1 levels were evaluated. RESULTS: Glycoalbumin levels decreased significantly from 23.0% before to 19.6% after IIT (p<0.001). However, pre- and post-IIT, IRI and CPR levels were not significantly different; post-IIT glucose levels were significantly decreased. The post-IIT glucagon levels at 0 and 60 min were lower than pre-IIT levels. Moreover, post- IIT area under the curve (AUC) of glucagon significantly reduced from 6755 ± 996 pg/dl · 60 min to 5796 ± 1074 pg/dl · 60 min (p<0.001). Furthermore, post-IIT GLP-1 levels and AUC were significantly higher than pre-IIT values. CONCLUSIONS: Our results suggest that patients with T2DM who received shortterm IIT demonstrated decreased postprandial glucagon levels and increased GLP-1 levels following a meal tolerance test.

Prevalence of delirium among outpatients with dementia.

BACKGROUND: Delirium and dementia are highly interrelated. However, few comprehensive epidemiological studies have examined this altered state of consciousness superimposed on dementia. We investigated the frequency of delirium in patients with dementia, its prevalence in patients with each dementia type, and its association with cerebrovascular disease (CVD) in patients with neurodegenerative dementias. METHODS: We studied 261 consecutive outpatients in the memory clinic of a psychiatric hospital between April 2010 and September 2011. All patients underwent routine laboratory tests and computed tomography (CT), and their Mini-Mental State Examination, Neuropsychiatric Inventory (NPI), Physical Self-Maintenance Scale (PSMS), and Delirium Rating Scale - Revised 98 scores were recorded. The diagnosis of delirium was based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision. CVD was detected by CT. RESULTS: Among the 206 patients with dementia, delirium was present in 40 (19.4%). The proportion of patients who experienced episodes of delirium was 14.7% in the Alzheimer's disease, 34.4% in the vascular dementia, 31.8% in the dementia with Lewy bodies, and none in frontotemporal lobar degeneration. Delirium was frequently observed in patients with dementia and CVD. The NPI total and agitation subscale scores were significantly higher in dementia patients with delirium than in those without delirium. PSMS scores were significantly lower for patients with delirium than for patients without delirium. CONCLUSIONS: The frequency of delirium varies with each dementia type. In addition, delirium decreases activities of daily living, exaggerates behavioral and psychological symptoms dementia, and is associated with CVD in patients with neurodegenerative dementias.

Effects of interocclusal distance on bite force and masseter EMG in healthy participants.

The aim of this study was to investigate effects of interocclusal distance (IOD) on bite force and masseter electromyographic (EMG) activity during different isometric contraction tasks. Thirty-one healthy participants (14 women and 17 men, 21·2 ± 1·8 years) were recruited. Maximal Voluntary Occlusal Bite Force (MVOBF) between the first molars and masseter EMG activity during all the isometric-biting tasks were measured. The participants were asked to bite at submaximal levels of 20%, 40%, 60% and 80% MVOBF with the use of visual feedback. The thickness of the force transducer was set at 8, 12, 16 and 20 mm (= IOD), and sides were tested in random sequence. MVOBF was significantly higher at 8 mm compared with all other IODs (P < 0·001). Only in women, IOD always had significant influence on the corresponding root-mean-square (RMS) value of EMG (P < 0·011). When biting was performed on the ipsilateral side to the dominant hand, the working side consistently showed higher masseter EMG activity compared with the balancing side (P < 0·020). On the contralateral side, there was no difference between the masseter EMG at any IODs. The results replicated the finding that higher occlusal forces can be generated between the first molars at shorter IODs. The new finding in this study was that an effect of hand dominance could be found on masseter muscle activity during isometric biting. This may suggest that there can be a general dominant side effect on human jaw muscles possibly reflecting differences in motor unit recruitment strategies.

Correlation of mandibular impacted tooth and bone morphology determined by cone beam computed topography on a premise of third molar operation.

PURPOSE: To determine the width and morphology of the mandible in the impacted third molar region, and to identify the location of the mandibular canal prior to planning impacted third molar operations. METHODS: Cone beam computed tomography (CBCT) data of 87 mandibular third molars from 62 Japanese patients were analyzed in this study. The width of the lingual cortical bone and apex-canal distance were measured from cross-sectional images in which the cortical bone was thinnest at the lingual side in the third molar region. Images were used for measuring the space (distance between the inner border of the lingual cortical bone and outer surface of the third molar root), apex-canal distance (distance from the root of the third molar tooth to the superior border of the inferior alveolar canal) and the cortical bone (width between the inner and outer borders of the lingual cortical bone). RESULTS: The means of the space, apex-canal distance and lingual cortical width were 0.31, 1.99, and 0.68 mm, respectively. Impacted third molar teeth (types A-C) were observed at the following frequencies: type A (angular) 37 %; type B (horizontal), 42 %; type C (vertical), 21 %. The morphology of the mandible at the third molar region (types D-F) was observed as: type D (round), 49 %; type E (lingual extended), 18 %; and type F (lingual concave), 32 %. CONCLUSIONS: The width and morphology of the mandible with impacted teeth and the location of the mandibular canal at the third molar region could be clearly determined using cross-sectional CBCT images.

An extremely energetic cosmic ray observed by a surface detector array.

Cosmic rays are energetic charged particles from extraterrestrial sources, with the highest-energy events thought to come from extragalactic sources. Their arrival is infrequent, so detection requires instruments with large collecting areas. In this work, we report the detection of an extremely energetic particle recorded by the surface detector array of the Telescope Array experiment. We calculate the particle's energy as [Formula: see text] (~40 joules). Its arrival direction points back to a void in the large-scale structure of the Universe. Possible explanations include a large deflection by the foreground magnetic field, an unidentified source in the local extragalactic neighborhood, or an incomplete knowledge of particle physics.

Migratory patterns of exotic brown trout Salmo trutta in south-western Hokkaido, Japan, on the basis of otolith Sr:Ca ratios and acoustic telemetry.

Acoustic telemetry and microchemical analysis of otolith strontium-calcium ratios were used to evaluate how exotic brown trout Salmo trutta have responded to Japanese riverine environments of south-western Hokkaido by observing their migratory patterns. The existence of anadromous S. trutta was also verified. Most S. trutta caught in rivers for otolith analysis were freshwater residents (95·6%), whereas those caught in the sea were mainly smolts (91·3%), which had just migrated from rivers during spring. Anadromous S. trutta (n = 6) were captured in rivers and in the sea, confirming the existence of mature pre- and post-spawning fish. According to telemetry results, both mature and immature S. trutta used the river in winter, and their estimated sea-run timings showed individual differences. Through the combination of these two methods, migratory patterns on various spatio-temporal scales were observed. This first documentation of the presence of both male and female anadromous S. trutta in the same region within Japan indicated the risk of further colonization of exotic S. trutta via oceanic migration.

Modified open posterior internal sphincterotomy with sliding skin graft for chronic anal fissure and anal stenosis: Low recurrence rate and no serious faecal incontinence postoperative complication.

AIM: Lateral internal sphincterotomy (LIS) remains a standard for chronic anal fissure even though other surgical techniques have shown high efficacy. Faecal incontinence is a well-documented complication of LIS. We devised modified open posterior internal sphincterotomy (m-OPIS) with sliding skin graft (SSG), which is a combined procedure of OPIS and anal advancement flap. The aim of this study is to evaluate m-OPIS+SSG. METHODS: This was a retrospective, observational, single-arm study. m-OPIS+SSG was performed for chronic anal fissure and anal stenosis. m-OPIS involved incision of the internal sphincter muscle at the posterior midline until four fingers could be passed. The incision wound was closed by anastomosis of the anoderm and skin. Then, an arcuate skin incision was created and the skin graft was advanced into the anal canal. Follow-up was conducted by clinical consultation and telephone interview. Faecal continence was assessed by Cleveland Clinic Faecal Incontinence (CCFI) score. RESULTS: m-OPIS+SSG was performed in 143 patients. The mean patient age was 50±16 years. The success and overall recurrence rates after m-OPIS+SSG were 99% and 0.7%, respectively, with a median follow-up period of 16.3 years. One patient developed incontinence with liquid stools once during the 6-month period. None of the other patients suffered permanent faecal incontinence postoperatively. The postoperative CCFI score was 0.5±0.9. CONCLUSIONS: We consider m-OPIS+SSG as one of the efficacious options of procedure for chronic anal fissure and anal stenosis, owing to its high success rate, low recurrence rate and no postoperative complication of serious faecal incontinence.

Over-expression of the LTC4 synthase gene in mice reproduces human aspirin-induced asthma.

BACKGROUND: The pathogenesis of aspirin-induced asthma (AIA) is presumed to involve the aspirin/non-steroidal anti-inflammatory drug (NSAID)-induced abnormal metabolism of arachidonic acid, resulting in an increase in 5-lipoxygenase (5-LO) metabolites, particularly leukotriene C(4) (LTC(4) ). However, the role of LTC(4) in the development of AIA has yet to be conclusively demonstrated. OBJECTIVE: The aim of this study was to evaluate the contribution of the lipid product LTC(4) secreted by the 5-LO pathway to the pathogenesis of AIA. METHODS: To evaluate antigen-induced airway inflammation, the concentrations of T-helper type 2 cytokine in bronchoalveolar lavage fluid (BALF) obtained from LTC(4) synthase-transgenic (Tg) and wild-type (WT) mice after challenge with ovalbumin were measured. Subsequently, the ex vivo and in vivo effects of the NSAID sulpyrine were investigated in these Tg and WT mice by measuring the secretion of LTC(4) from sulpyrine-treated BAL cells and the levels of LTC(4) in BALF following challenge with sulpyrine. Finally, the sulpyrine-induced airway response by the administration of pranlukast, an antagonist of the cysteinyl (cs)-LT1 receptor, was analysed. RESULTS: The concentrations of IL-4, -5, and -13 in BALF from Tg mice were significantly higher than those in WT mice. In addition, sulpyrine augmented the secretion of LTC(4) in BALF and by BAL cells in Tg mice, but not in WT mice. Additionally, the increased airway resistance induced by sulpyrine could be reduced by treatment with pranlukast. Furthermore, the secretion of LTC(4) from mast cells, eosinophils, and macrophages was increased in the allergen-stimulated LTC(4) synthase gene Tg mice, even in the absence of sulpyrine, as well as in BAL cells after sulpyrine. CONCLUSION AND CLINICAL RELEVANCE: The over-expression of the LTC(4) synthase in a mouse asthma model also replicates the key features of AIA. And our study supports that cys-LTs play a major role in the pathogenesis of AIA in patients with chronic asthma.

In vivo morphometric analysis of inflammatory condylar changes in rat temporomandibular joint.

OBJECTIVE: Injection of complete Freund's adjuvant (CFA) into the temporomandibular joint (TMJ) causes acute swelling around the joint and subsequent morphological alterations in the condyle. We aimed to evaluate changes in the three-dimensional architecture of the condyle induced with CFA. MATERIALS AND METHODS: The CFA was injected into the unilateral TMJ of rats and morphological changes in the condyle were assessed repeatedly for 14 days by in vivo micro-CT. RESULTS: Osseous abnormalities of condyle were first observed at 3-5 days after CFA injection on the tomographic images, and the condylar deformation became more obvious thereafter. Among 12 condyles examined at 14 days postinjection, osteophytosis was observed in all of the specimens and bone erosion coexisted in five condyles. None of the saline-treated condyles showed architectural changes. Significant changes were detected in the mesiolateral and rostrocaudal widths of the CFA-treated condyles at 10-14 days postinjection (P < 0.01). The extent of both condylar bone formation and resorption was greater in the CFA-injected TMJs than in saline-injected TMJs (P < 0.05). CONCLUSION: These results indicate that CFA causes dynamic morphological changes in the condyle and that our experimental approach will provide new insights into the subacute inflammatory processes in the TMJ.

Development of an application tool to support returnees in Fukushima.

To promote radiation protection and health promotion among returning residents (returnees) in coastal areas of Fukushima, eHealth principles were used to develop a new application tool (app) that can record radiation exposure and health status while providing comprehensive support to returnees. Intended users are returnees and health and welfare workers. After assessing their needs, a flowchart and prototype for operational logic were created using commercially available software tools. Professional developers will focus on improving the user interface and ensuring data security. The finished app will be compatible with mobile telephones and tablets. Utility and ease of use are paramount to serve returnees of all ages effectively.