Updates to and quality of clinical practice guidelines for high-priority diseases in Japan.

PURPOSE: To examine the update status of clinical practice guidelines (CPGs) for 24 main diseases in Japan, and to clarify the quality of and issues pertaining to the most recent versions of CPGs for each disease. DATA SOURCES: CPGs were searched in two Japanese guideline databases. STUDY SELECTION: All relevant Japanese CPGs published between January 1999 and July 2016 were selected. DATA EXTRACTION: The developer and issue date were extracted for all target CPGs. The most recent CPGs were assessed using the Appraisal of Guidelines for Research and Evaluation-II (AGREE II) instrument. RESULTS OF DATA SYNTHESIS: Among 106 target CPGs, 24 most recent CPGs were subjected to assessment using the AGREE II instrument. CPGs for 11 diseases (46%) had a mean time interval for update of ≥5 years. Among the 24 CPGs subjected to AGREE II assessment, median domain scores were 74% for "Domain 1: Scope and Purpose," 43% for "Domain 2: Stakeholder Involvement," 46% for "Domain 3: Rigor of Development," 69% for "Domain 4: Clarity of Presentation," 24% for "Domain 5: Applicability" and 27% for "Domain 6: Editorial Independence." CONCLUSIONS: The systematic assessment of CPGs for 24 major diseases in Japan revealed a trend for a delay in timing of update for many CPGs. Moreover, the 24 most recent CPGs had low domain scores for domains 2, 3, 5 and 6. In the future, concrete measures will need to be considered in order to improve the quality of CPGs.

Trends in descriptions of palliative care in the cancer clinical practice guidelines before and after enactment of the Cancer Control Act (2007): content analysis.

BACKGROUND: Palliative care was a priority issue in the Cancer Control Act enacted in 2007 in Japan, and this has resulted in efforts being made toward educational goals in clinical settings. An investigation of how descriptions of palliative care for the treatment of cancer have changed in clinical practice guidelines (CPGs) could be expected to provide a better understanding of palliative care-related decision-making. This study aimed to identify trends in descriptions of palliative care in cancer CPGs in Japan before and after enactment of the Cancer Control Act. METHODS: Content analysis was used to count the lines in all relevant CPGs. We then compared the number of lines and the proportion of descriptions mentioning palliative care at two time points: the first survey (selection period: February to June 2007) and the second survey (selection period: February to December 2015). Descriptions from the CPGs were independently selected from the Toho University Medical Media Center and Medical Information Network Distribution Service databases, and subsequently reviewed, by two investigators. RESULTS: Descriptions were analyzed for 10 types of cancer. The proportion of descriptions in the first survey (4.4%; 933/21,344 lines) was similar to that in the second survey (4.5%; 1325/29,269 lines). CONCLUSIONS: After the enactment of the Cancer Control Act, an increase was observed in the number, but not in the proportion, of palliative care descriptions in Japanese cancer CPGs. In the future, CPGs can be expected to play a major role in helping cancer patients to incorporate palliative care more smoothly.

Activation of double-stranded RNA-activated protein kinase (PKR) by interferon-stimulated gene 15 (ISG15) modification down-regulates protein translation.

The ubiquitin-like molecule ISG15 (UCRP) and protein modification by ISG15 (ISGylation) are strongly induced by interferon, genotoxic stress, and pathogen infection, suggesting that ISG15 plays an important role in innate immune responses. However, how ISGylation contributes to innate immune responses is not clear. The dsRNA-dependent protein kinase (PKR) inhibits translation by phosphorylating eIF2α to exert its anti-viral effect. ISG15 and PKR are induced by interferon, suggesting that a relationship exists between ISGylation and translational regulation. Here, we report that PKR is ISGylated at lysines 69 and 159. ISG15-modified PKR is active in the absence of virus infection and phosphorylates eIF2α to down-regulate protein translation. The present study describes a novel pathway for the activation of PKR and the regulation of protein translation.

PRMT1 interacts with AML1-ETO to promote its transcriptional activation and progenitor cell proliferative potential.

Fusion protein AML1-ETO, resulting from t(8;21) translocation, is highly related to leukemia development. It has been reported that full-length AML1-ETO blocks AML1 function and requires additional mutagenic events to promote leukemia. We have previously shown that the expression of AE9a, a splice isoform of AML1-ETO, can rapidly cause leukemia in mice. To understand how AML1-ETO is involved in leukemia development, we took advantage of our AE9a leukemia model and sought to identify its interacting proteins from primary leukemic cells. Here, we report the discovery of a novel AE9a binding partner PRMT1 (protein arginine methyltransferase 1). PRMT1 not only interacts with but also weakly methylates arginine 142 of AE9a. Knockdown of PRMT1 affects expression of a specific group of AE9a-activated genes. We also show that AE9a recruits PRMT1 to promoters of AE9a-activated genes, resulting in enrichment of H4 arginine 3 methylation, H3 Lys9/14 acetylation, and transcription activation. More importantly, knockdown of PRMT1 suppresses the self-renewal capability of AE9a, suggesting a potential role of PRMT1 in regulating leukemia development.

Mutational analysis of TSC1 and TSC2 in Japanese patients with tuberous sclerosis complex revealed higher incidence of TSC1 patients than previously reported.

Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by multiple hamartias and hamartomas involving throughout the body. To date, many TSC1 and TSC2 mutations have been reported all over the world, however, few TSC mutation studies have been performed in the Japanese population, and genetic characteristics of Japanese TSC patients are not yet clear. In this study, we analyzed TSC1 and TSC2 in 57 Japanese patients with TSC (8 familial and 49 sporadic; 46 definite and 11 suspect TSC) and identified 31 mutations including 11 TSC1 mutations (two familial and nine sporadic; all definite TSC) and 20 TSC2 mutations (2 familial and 18 sporadic; 19 definite and 1 suspect TSC). We also reviewed all Japanese TSC mutations previously reported. Our study demonstrates significantly higher incidence (P=0.007) of TSC1 mutations among sporadic TSC patients in the Japanese population compared with US and European studies. No differences emerged in mutation distributions and types in precedent studies, excepting low frequency of the TSC2 nonsense mutation. Comparing clinical manifestations, developmental delay and/or mental retardation were milder in TSC1 patients than TSC2 patients for its frequency (P=0.032) and severity (P=0.015); however, no other symptoms were clearly different.

Determinants of Awareness of Clinical Practice Guidelines among Healthcare Users in Japan.

Clinical practice guidelines (CPGs) are used by both healthcare users and providers, so their recognition is important. The present study's purpose was to clarify the features of healthcare users who are aware of the CPGs. A cross-sectional survey was conducted targeting Internet survey panels (n = 6000). The study participants (age range, 20s to 60s) had no medical qualifications and had received medical care in the last 3 months. Multivariate logistic regression analysis was performed to clarify the factors related to the awareness of CPGs. When "I have seen the CPGs" was used as the objective variable, the odds ratios (ORs) were high for "e-health literacy/score 31-40" (OR = 8.72, 95% confidence interval [CI]: 6.51-11.68), "Sources of health information/healthcare workers and professionals" (OR = 2.61, 95% CI: 2.17-3.14), "Age/20s" (OR = 2.38, 95% CI: 1.74-3.23), and "I have been diagnosed and treated for a major illness" (OR = 2.01, 95% CI: 1.52-2.65). These results could be applied to aid the dissemination and utilization of CPGs among healthcare users.

TRIM8 regulates Nanog via Hsp90ß-mediated nuclear translocation of STAT3 in embryonic stem cells.

TRIM8 is a member of a protein family defined by the presence of a common domain structure composed of a tripartite motif including a RING-finger, one or two B-box domains and a coiled-coil motif. Here, we show that TRIM8 interacts with Hsp90ß, which interacts with STAT3 and selectively downregulates transcription of Nanog in embryonic stem cells. Knock-down of TRIM8 increased phosphorylated STAT3 in the nucleus and also enhanced transcription of Nanog. These findings suggest that TRIM8 modulates translocation of phosphorylated STAT3 into the nucleus through interaction with Hsp90ß and consequently regulates transcription of Nanog in embryonic stem cells.

Applying and testing the conveniently optimized enzyme mismatch cleavage method to clinical DNA diagnosis.

Establishing a simple and effective mutation screening method is one of the most compelling problems with applying genetic diagnosis to clinical use. Because there is no reliable and inexpensive screening system, amplifying by PCR and performing direct sequencing of every coding exon is the gold standard strategy even today. However, this approach is expensive and time consuming, especially when gene size or sample number is large. Previously, we developed CEL nuclease mediated heteroduplex incision with polyacrylamide gel electrophoresis and silver staining (CHIPS) as an ideal simple mutation screening system constructed with only conventional apparatuses and commercially available reagents. In this study, we evaluated the utility of CHIPS technology for genetic diagnosis in clinical practice by applying this system to screening for the COL2A1, WRN and RPS6KA3 mutations in newly diagnosed patients with Stickler syndrome (autosomal dominant inheritance), Werner syndrome (autosomal recessive inheritance) and Coffin-Lowry syndrome (X-linked inheritance), respectively. In all three genes, CHIPS detected all DNA variations including disease causative mutations within a day. Direct sequencing of all coding exons of these genes confirmed 100% sensitivity and specificity. We demonstrate high sensitivity, high cost performance and reliability of this simple system, with compatibility to all inheritance modes. Because of its low technology, CHIPS is ready to use and potentially disseminate to any laboratories in the world.

AML1/ETO oncoprotein is directed to AML1 binding regions and co-localizes with AML1 and HEB on its targets.

A reciprocal translocation involving chromosomes 8 and 21 generates the AML1/ETO oncogenic transcription factor that initiates acute myeloid leukemia by recruiting co-repressor complexes to DNA. AML1/ETO interferes with the function of its wild-type counterpart, AML1, by directly targeting AML1 binding sites. However, transcriptional regulation determined by AML1/ETO probably relies on a more complex network, since the fusion protein has been shown to interact with a number of other transcription factors, in particular E-proteins, and may therefore target other sites on DNA. Genome-wide chromatin immunoprecipitation and expression profiling were exploited to identify AML1/ETO-dependent transcriptional regulation. AML1/ETO was found to co-localize with AML1, demonstrating that the fusion protein follows the binding pattern of the wild-type protein but does not function primarily by displacing it. The DNA binding profile of the E-protein HEB was grossly rearranged upon expression of AML1/ETO, and the fusion protein was found to co-localize with both AML1 and HEB on many of its regulated targets. Furthermore, the level of HEB protein was increased in both primary cells and cell lines expressing AML1/ETO. Our results suggest a major role for the functional interaction of AML1/ETO with AML1 and HEB in transcriptional regulation determined by the fusion protein.

The reporting checklist for public versions of guidelines: RIGHT-PVG.

BACKGROUND: Public or patient versions of guidelines (PVGs) are derivative documents that "translate" recommendations and their rationale from clinical guidelines for health professionals into a more easily understandable and usable format for patients and the public. PVGs from different groups and organizations vary considerably in terms of quality of their reporting. In order to address this issue, we aimed to develop a reporting checklist for developers of PVGs and other potential users. METHODS: First, we collected a list of potential items through reviewing a sample of PVGs, existing guidance for developing and reporting PVGs or other similar evidence-based patient tools, as well as qualitative studies on original studies of patients' needs about the content and/or reporting of information in PVGs or similar evidence-based patient tools. Second, we conducted a two-round Delphi consultation to determine the level of consensus on the items to be included in the final reporting checklist. Third, we invited two external reviewers to provide comments on the checklist. RESULTS: We generated the initial list of 45 reporting items based on a review of a sample of 30 PVGs, four PVG guidance documents, and 46 relevant studies. After the two-round Delphi consultation, we formed a checklist of 17 items grouped under 12 topics for reporting PVGs. CONCLUSION: The RIGHT-PVG reporting checklist provides an international consensus on the important criteria for reporting PVGs.

t(8;21)(q22;q22) Fusion proteins preferentially bind to duplicated AML1/RUNX1 DNA-binding sequences to differentially regulate gene expression.

Chromosome abnormalities are frequently associated with cancer development. The 8;21(q22;q22) chromosomal translocation is one of the most common chromosome abnormalities identified in leukemia. It generates fusion proteins between AML1 and ETO. Since AML1 is a well-defined DNA-binding protein, AML1-ETO fusion proteins have been recognized as DNA-binding proteins interacting with the same consensus DNA-binding site as AML1. The alteration of AML1 target gene expression due to the presence of AML1-ETO is related to the development of leukemia. Here, using a 25-bp random double-stranded oligonucleotide library and a polymerase chain reaction (PCR)-based DNA-binding site screen, we show that compared with native AML1, AML1-ETO fusion proteins preferentially bind to DNA sequences with duplicated AML1 consensus sites. This finding is further confirmed by both in vitro and in vivo DNA-protein interaction assays. These results suggest that AML1-ETO fusion proteins have a selective preference for certain AML1 target genes that contain multimerized AML1 consensus sites in their regulatory elements. Such selected regulation provides an important molecular mechanism for the dysregulation of gene expression during cancer development.

Factors affecting the use of clinical practice guidelines by hospital physicians: the interplay of IT infrastructure and physician attitudes.

BACKGROUND: Compliance with clinical practice guidelines (CPGs) remains insufficient around the world, despite frequent updates and continuing efforts to disseminate and implement these guidelines through a variety of strategies. We describe the current status of young resident physician practices towards CPGs and investigate the multiple factors associated with the active use of CPGs, including the physician's knowledge, attitudes, behaviours, CPG-related education received, and the hospital's IT infrastructures. The aim is to identify a more effective point for intervention to promote CPG implementation. METHODS: We conducted a questionnaire survey among resident physicians working at 111 hospitals across Japan in 2015 and used results with hospital IT score data collected from a prior survey. Multivariable logistic regression analysis was performed to examine the determinants of frequent use of CPGs (defined at least once per week). The independent variables were selected based on physician demographics, clinical speciality and careers, daily knowledge and behaviour items, CPG-related education received, digital preference, and hospital IT score (high/medium/low), with and without interaction terms. RESULTS: Responses from 535 resident physicians, at 61 hospitals, were analysed. The median hospital IT score was 6 out of a possible 10 points. Physicians who had learned about CPGs tended to work at hospitals with medium to high IT scores, had easier access to paywalled medical databases, and had better knowledge of the guideline network 'Minds'. In addition, these physicians tended to use CPGs electronically. A physician's behaviour towards using CPGs for therapeutic decision-making was strongly associated with frequent use of CPGs (odds ratio [95% CI] 6.1 [3.6-10.4]), which indicated that a physician's habit strongly promotes CPG use. Moreover, CPG-related education was associated with active use of CPGs (OR1.7 [1.1-2.5]). The interaction effects between individual digital preferences and higher hospital IT score were also observed for frequent CPG use (OR2.9 [0.9-8.8]). CONCLUSIONS: A physician's habitual behaviours, CPG-related education, and a combination of individual digital preference and superior hospital IT infrastructure are key to bridging the gap between the use and implementation of CPGs.

[Anti-diabetic effect of ethanol extract of Cyclolepis genistoides D. Don (Palo azul), made in Paraguay].

Extract of Cyclolepis genistoides D. Don (vernacular name Palo azul; Palo) are traditionally consumed in the Republic of Paraguay in South America for the treatment of diabetes and kidney disease, and is sold in Japan as dietary supplement. This study aimed to elucidate the mechanism of anti-diabetes activity of Palo, especially focused on insulin resistance. Palo promoted adipocytes differentiation and regulated adipokine profiles in 3T3-L1 adipocytes by modulation of PPARγ, a major regulator of adipose differentiation. Human adipocyte showed almost similar profile with 3T3-L1 against Palo treatment. Furthermore, Palo treatment (250 or 1000 mg/kg) was performed with C57BL/6J mice for 14 weeks, being fed high-fat-diet (HFD60) simultaneously. Palo 250 mg/kg exhibited a tendency to decrease subcutaneous adipose volume along with increase of PPARγ and its target, adiponectin mRNA expression. In addition, as the other insulin targeted cell, effect on muscle differentiation was examined. Palo increased differentiation of C2C12 mouse muscle myoblasts by increase of IGF-1, myogenin, and myosine heavy chain (MHC) as well as 5'-AMP-activated protein kinase (AMPK) activation. Palo subsequently promoted myotube formation under differentiation condition. From the above, it was clarified that Palo acts variously on the differentiation and maturation of both adipocytes and muscle cells, and from the viewpoint of the regulatory mechanism for adipocytes, PPARγ-inducing action was shown to be a mechanism that acts across species.

Regulation on introducing process of the highly difficult new medical technologies: A survey on the current status of practice guidelines in Japan and overseas.

Since serious problematic cases regarding the technical safety of technically demanding operations were reported in Japan, the Ministry of Health, Labor and Welfare issued new regulations on June 10, 2016 requiring each hospital to check the status of informed consent, skill of surgery team and governance system of the surgical unit, when the highly difficult new medical technologies were introduced to a hospital. In order to firmly establish this new system for highly difficult new medical technologies, it is very important and informative to survey the current situation for guidelines and consensus regarding introduction of medical technology with special skills in Japan and overseas. Based on the survey of questionnaires, document retrieval, and expert interviews, we found that documentation related to the introduction process of highly difficult medical technologies is very rare, and the regulations were mainly issued by academic societies. Moreover, even if such documentation existed, the quality of the regulations is poor and not sufficient enough to perform surgical practice safely. Therefore, for medical practitioners, comprehensive and concrete regulations should be issued by the government or ministry to legally follow in regard to technically demanding operations. A new practice guideline was proposed by our special research group to regulate the introduction process of highly difficult new medical technologies in hospitals in Japan. This guideline, gained understanding from relevant academic societies, provided a comprehensive view on the interpretation of "high difficulty new medical technology" prescribed by the law and show the basic idea at a preliminary examination from the viewpoints of "Surgeon's requirement", "Guidance system", "Medical safety" , and "Informed consent". These efforts will contribute to the improvement of the quality of guidelines regarding "highly difficult new medical technology".

Does hospital information technology infrastructure promote the implementation of clinical practice guidelines? A multicentre observational study of Japanese hospitals.

OBJECTIVES: It remains unclear whether insufficient information technology (IT) infrastructure in hospitals hinders implementation of clinical practice guidelines (CPGs) and affects healthcare quality. The objectives of this study were to describe the present state of IT infrastructure provided in acute care hospitals across Japan and to investigate its association with healthcare quality. METHODS: A questionnaire survey of hospital administrators was conducted in 2015 to gather information on hospital-level policies and elements of IT infrastructure. The number of positive responses by each respondent to the survey items was tallied. Next, a composite quality indicator (QI) score of hospital adherence to CPGs for perioperative antibiotic prophylaxis was calculated using administrative claims data. Based on this QI score, we performed a chi-squared automatic interaction detection (CHAID) analysis to identify correlates of hospital healthcare quality. The independent variables included hospital size and teaching status in addition to hospital policies and elements of IT infrastructure. RESULTS: Wide variations were observed in the availability of various IT infrastructure elements across hospitals, especially in local area network availability and access to paid evidence databases. The CHAID analysis showed that hospitals with a high level of access to paid databases (p<0.05) and internet (p<0.05) were strongly associated with increased care quality in larger or teaching hospitals. CONCLUSIONS: Hospitals with superior IT infrastructure may provide higher-quality care. This allows clinicians to easily access the latest information on evidence-based medicine and facilitate the dissemination of CPGs. The systematic improvement of hospital IT infrastructure may promote CPG use and narrow the evidence-practice gaps.

Interaction of alpha1-syntrophin with multiple isoforms of heterotrimeric G protein alpha subunits.

Syntrophins are components of the dystrophin-glycoprotein complex of the plasma membrane in muscular and neuronal cells, and recruit signaling proteins such as neuronal nitric oxide synthase via their multiple protein-protein interaction motifs. In this study, we found that alpha1-syntrophin binds to various subtypes of guanine nucleotide-binding protein alpha subunits (Galpha). A pull-down analysis using full-length recombinant alpha1-syntrophin and MS analysis showed that alpha1-syntrophin was coprecipitated with several isoforms of Galpha proteins in addition to known binding partners such as dystrobrevin and neuronal nitric oxide synthase. Further analysis using recombinant Galpha isoforms showed that alpha1-syntrophin associates with at least Galphai, Galphao, Galphas and Galphaq subtypes. The region of alpha1-syntrophin required for its interaction with Galphas was determined as the N-terminal half of the first pleckstrin homology domain. In addition, the syntrophin unique domain of alpha1-syntrophin was suggested to contribute to this interaction. In COS-7 cells, downregulation of alpha1-syntrophin by RNAi resulted in enhanced cAMP production and cAMP response element-binding protein phosphorylation induced by isoproterenol treatment. These results suggest that alpha1-syntrophin provides a scaffold for the Galpha family of heterotrimeric G proteins in the brain to regulate the efficiency of signal transduction evoked by G-protein-coupled receptors.

Localization of phospho-tyrosine489-beta-adducin immunoreactivity in the hypothalamic tanycytes and its involvement in energy homeostasis.

beta-Adducin is a cytoskeletal protein that interacts with the actin filaments to suppress actin polymerization and facilitate actin-spectrin binding. We have previously shown that beta-adducin is phosphorylated by Fyn at tyrosine489 in the rat brain and bound to its Src-homology 2 domain. In the present study, we examined the immunohistochemical localization of the tyrosine489-phosphorylated form of beta-adducin (pY489-beta-adducin) in the rat brain. Among brain regions, highest immunoreactivity was located in the hypothalamic tanycytes that are of glial origin lining around the third cerebral ventricle. Their immunoreactive processes extended into the arcuate nucleus, ventromedial hypothalamus and the median eminence. In addition, the pY489-beta-adducin immunoreactivity in the tanycytes was enhanced after fasting for 36-48 h, being associated with a morphological change of the DARPP-32-immunoreactivity. Intraperitoneal injection of 2-deoxy-d-glucose also enhances pY489-beta-adducin immunoreactivity in the tanycytes, along with increased food intake. These results suggest that tyrosine phosphorylation of beta-adducin in the tanycytes is involved in hypothalamic regulation of food intake and energy homeostasis.

Colocalization of a carnosine-splitting enzyme, tissue carnosinase (CN2)/cytosolic non-specific dipeptidase 2 (CNDP2), with histidine decarboxylase in the tuberomammillary nucleus of the hypothalamus.

Carnosine is a naturally occurring dipeptide (beta-alanyl-l-histidine) present in mammalian tissues such as the brain and skeletal muscles. Carnosine is not only a radical scavenger but also a possible neurotransmitter-like molecule that regulates neuronal functions such as hypothalamic control of the autonomic nervous system. CN2 (CNDP2) is a cytosolic enzyme that can hydrolyze carnosine to yield l-histidine and beta-alanine. In order to understand the functions of carnosine and CN2 in the brain, we have investigated the immunohistochemical localization of CN2 in the hypothalamus. CN2-immunoreactivity was highly concentrated in neuronal cells in the dorsal part of the tuberomammillary nucleus of the posterior hypothalamus. Since the tuberomammillary nucleus is the exclusive origin of histaminergic neurons, we further investigated whether CN2 is present in the histaminergic neurons. We found that CN2-immunoreactivity was colocalized with that of histidine decarboxylase, which is the key enzyme for histamine biosynthesis specifically expressed in the histaminergic neurons of the tuberomammillary nucleus. These results suggest that CN2 is highly expressed in the histaminergic neurons in the tuberomammillary nucleus, implying that it may supply histidine to histaminergic neurons for histamine synthesis.

Expression of AML/Runx and ETO/MTG family members during hematopoietic differentiation of embryonic stem cells.

Runx1/AML1 plays important roles in hematopoiesis, including the commitment of cells to hematopoiesis during embryonic development, and in the maintenance of hematopoietic cell populations. It is also one of the most common genes involved in chromosomal translocations related to leukemia. One such translocation is t(8;21), which fuses the Runx1 gene to the MTG8/ETO gene and generates the Runx1-MTG8 (AML1-ETO) fusion gene. Both Runx1 and MTG8 have two additional family members that are much less studied in hematopoiesis. Here we report the expression of every member of the Runx and MTG families as well as the Runx heterodimerization partner CBFbeta during hematopoietic differentiation of murine embryonic stem cells. We observed substantially increased expression of Runx1, Runx2, and MTG16 during hematopoietic differentiation. Furthermore, the increase in Runx2 expression is delayed relative to Runx1 expression, suggesting their possible sequential contribution to hematopoiesis.