Revised Cut-Off Value of Human Epididymis Protein 4 Enhances Its Use as an Ovarian Tumor Marker.

OBJECTIVES: Human epididymis protein 4 (HE4), a protein secreted by ovarian tumors, has been used as an ovarian tumor marker. This study aimed to improve the usefulness of HE4 to detect malignant ovarian tumors by reviewing the cut-off values. DESIGN: A retrospective study without intervention was conducted. PARTICIPANTS: One hundred forty-nine healthy women (premenopausal, 126; postmenopausal, 23) and 24 patients with ovarian tumors (malignant, 12; benign, 12) participated in the study. SETTING: The study used the Department of Obstetrics and Gynecology of a university hospital in Japan and the university hospital as a workplace from 2016 to 2018. METHODS: The basic performance of the HE4 assay was evaluated, and the serum HE4 levels of participants were measured. Receiver operating characteristic analysis was performed using the HE4 data of the patients. RESULTS: There were no significant differences in HE4 levels between the pre- and postmenopausal groups of healthy women. When the global cut-off values (premenopausal, 70 pmol/L; postmenopausal, 140 pmol/L) were adopted, the clinical sensitivity, specificity, positive predictive value, and negative predictive value were 41.7%, 91.7%, 83.3%, and 61.1%, respectively. Based on the results of the receiver operating characteristic analysis, we set the HE4 cut-off level at 60 pmol/L, regardless of the menopausal status. With the newly set cut-off value, the clinical sensitivity, specificity, positive predictive value, and negative predictive value were 66.7%, 91.7%, 88.9%, and 73.3%, respectively. That is, the clinical sensitivity of HE4 was improved without lowering specificity. LIMITATIONS: The small number of subjects and the fact that the health status of the healthy women was evaluated based on questionnaires were limitations to the study. CONCLUSION: A clinically useful cut-off value for HE4 as an ovarian tumor marker was established regardless of the menopausal status of the women, with improved clinical sensitivity, positive predictive value, and negative predictive value without lowering specificity. Currently, different cut-off values for HE4 in pre- and postmenopausal women are used globally. The cut-off value for CA125 was the same between pre- and postmenopausal women. Therefore, with the newly established cut-off value, HE4 can be used more conveniently in a non-specialized setting, especially when it is used in combination with CA125.

[A Simulation Surgery of Valve-sparing Aortic Root Replacement Using a Three-dimensional Printed Model].

Aortic valve-sparing surgery is a delicate procedure that requires specialized skills to control aortic valve regurgitation. Therefore, simulating the surgery before performing it on a patient is good practice for inexperienced surgeons. Herein, we present our experience of a simulation surgery using a three-dimensionally printed aortic root model of a 60-year-old man with severe aortic regurgitation and aortic root enlargement. We fabricated the model using multi-slice computed tomography data. The model revealed the two pitfalls:unbalanced commissure position and lower coaptation height of the right coronary cusp. We completed the simulation surgery from the proximal suture and valve reimplantation to coronary ostial reconstructions during approximately three hours with medical staffs. In the actual operation, the aortic valve regurgitation completely disappeared by accurately reconstructing the commissure in the Valsalva graft and adjusting the height of the right coronary cusp using central plication procedure. We believe that carrying out simulations before the actual surgery improves the surgeon's confidence and the patient's outcomes.

[Application of dementia care mapping (DCM) for one year in a geriatric health services facility: Effects of developmental evaluation based on collaboration by medical and welfare staff aimed at person-centred care].

PURPOSE: This study aimed to clarify the effects of dementia care mapping (DCM) for one year in a healthcare center for older adults. DCM was conducted between September 2016 and August 2017. The care staff include nurses and caregivers in a narrow sense, medical staff, such as a physician, physical therapists, and occupational therapists worked on DCM as care staff in this study. RESULTS: There were 24 participants, with an average work experience of 7.21 (±4.74) years. In comparison to the baseline evaluation, the final assessment of self-efficacy through person-centred care showed significant improvement in 'Forecasting and Problem Solving on the Job' within 'Perceived Job Competence of Care Workers'. Six main categories of content were extracted from focus group interviews: 'Awareness,' 'Change of Elderly People under the Care of Staff throughout the Development of Mapping', 'Affirmative Feelings of Care Staff for Mapping', 'Negative Feelings for Mapping', 'Need for the Efficacy and Efficiency of the Mapping', and 'Mapping Based on the Age of the Participant and Future Prospects for Mapping'. The results of person-centred care showed that both the older patients and the staff noticed changes through the development of mapping. CONCLUSION: The developmental evaluation, based on collaboration by medical and welfare staff can improve self-efficacy through the practice of person-centred care and improves the ability to solve problems during the provision of care.

Health science students' attitudes towards healthcare teams: A comparison between two universities.

There have been few studies comparing the attitudes towards healthcare teams between different universities. This study analysed the differences in attitudes towards healthcare teams between health science students at Gunma University, Japan, which implements a comprehensive interprofessional education (IPE) programme, and Kanazawa University, a similar national university. Study populations were first- and third-year students at the Gunma University School of Health Sciences and the Kanazawa University School of Health Sciences. The present study was performed just after the IPE and multi-professional education subjects at Gunma University in the first term of the 2012 academic year. The first-year students were different cohort from the third-year students. The modified Attitudes Toward Health Care Teams Scale (ATHCTS) was used to measure attitudes towards healthcare teams. The overall mean score on the modified ATHCTS of students at Gunma University was significantly higher than that of those at Kanazawa University. In both first- and third-year students, the regression factor score of "patient-centred care" was significantly higher at Gunma University than at Kanazawa University. Based on the present study, it can be stated that IPE may foster the value of collaborative practice (CP) among health science students.

Apixaban versus Warfarin for the Prevention of Periprocedural Cerebral Thromboembolism in Atrial Fibrillation Ablation: Multicenter Prospective Randomized Study.

INTRODUCTION: Stroke can be a life-threatening complication of atrial fibrillation (AF) catheter ablation. Uninterrupted warfarin treatment contributes to minimizing the risk of stroke complications. METHODS AND RESULTS: This was a prospective, open-label, randomized, multicenter study assessing the safety and efficacy of apixaban for the prevention of cerebral thromboembolism complicating AF catheter ablation. Two hundred patients with drug-resistant AF were equally assigned to take either apixaban (5 mg or 2.5 mg twice daily) or warfarin (target international normalized ratio, 2-3) for at least 1 month before AF ablation. Neither drug regimen was interrupted throughout the operative period. Diffusion-weighted magnetic resonance imaging was performed for all patients to detect silent cerebral infarction (SCI) after the ablation. Primary outcomes were defined as the occurrence of stroke, transient ischemic attack, SCI, or major bleeding that required intervention. The secondary outcome was minor bleeding. The groups did not statistically differ in patients' backgrounds or procedural parameters. During AF ablation, the apixaban group required administration of more heparin to maintain an activated clotting time > 300 seconds than the warfarin group (apixaban, 14,000 ± 4,000 units; warfarin, 9,000 ± 3,000 units). Three primary outcome events occurred in each group (apixaban, 2 SCI and 1 major bleed; warfarin, 3 SCI, P = 1.00), and 3 and 4 secondary outcome events occurred in the apixaban and warfarin groups (P = 0.70), respectively. CONCLUSION: Apixaban has similar safety and effectiveness to warfarin for the prevention of cerebral thromboembolism during the periprocedural period of AF ablation.

Professional identity acquisition process model in interprofessional education using structural equation modelling: 10-year initiative survey.

The mandatory interprofessional education (IPE) programme at Gunma University, Japan, was initiated in 1999. A questionnaire of 10 items to assess the students' understanding of the IPE training programme has been distributed since then, and the factor analysis of the responses revealed that it was categorised into four subscales, i.e. "professional identity", "structure and function of training facilities", "teamwork and collaboration", and "role and responsibilities", and suggested that these may take into account the development of IPE programme with clinical training. The purpose of this study was to examine the professional identity acquisition process (PIAP) model in IPE using structural equation modelling (SEM). Overall, 1,581 respondents of a possible 1,809 students from the departments of nursing, laboratory sciences, physical therapy, and occupational therapy completed the questionnaire. The SEM technique was utilised to construct a PIAP model on the relationships among four factors. The original PIAP model showed that "professional identity" was predicted by two factors, namely "role and responsibilities" and "teamwork and collaboration". These two factors were predicted by the factor "structure and function of training facilities". The same structure was observed in nursing and physical therapy students' PIAP models, but it was not completely the same in laboratory sciences and occupational therapy students' PIAP models. A parallel but not isolated curriculum on expertise unique to the profession, which may help to understand their professional identity in combination with learning the collaboration, may be necessary.

Repeated cross-sectional study of the longitudinal changes in attitudes toward interprofessional health care teams amongst undergraduate students.

The interprofessional education (IPE) program at Gunma University, Maebashi, Japan, uses a lecture style for first-year students and a training style for third-year students. To investigate the comprehensive implications of IPE, the change pattern of attitudes toward health care teams was examined longitudinally in pre-qualified students. The modified Attitudes Toward Health Care Teams Scale (mATHCTS) was used. The overall mean score of the mATHCTS improved significantly after the training-style IPE in their third year. Two individual items in the factor "quality of care delivery" decreased significantly during the first year. In contrast, two individual items in the factor "patient-centered care" increased significantly during the third year. These changes over time were confirmed by analyses using regression factor scores. There are at least two independent attitudes toward collaborative practice (CP) or IPE in response to IPE interventions: the attitude toward "value of IPE for health care providers" may response negatively to IPE in the early stages, and the attitude toward "value of IPE for health care receivers" positively in the later stages. These findings suggest that the continuation of mandatory IPE, which must be designed on the basis of students' high expectations for IPE and CP on entry, may result in profound changes in attitudes amongst participating students.

Attitudes toward interprofessional healthcare teams: a comparison between undergraduate students and alumni.

The goal of effective interprofessional education (IPE) is high-quality patient-care delivery and attaining a high level of patient satisfaction in clinical settings. We aimed to examine if alumni who have studied in an IPE program at a pre-licensure stage maintain a positive attitude toward collaborative practice (CP) in the postgraduate clinical experience. This paper presents a cross-sectional descriptive study which employed the modified attitudes toward health care teams scale (ATHCTS) to examine the relationship between exposure to clinical practice and the attitudes toward interprofessional healthcare teams. Results indicated that the overall mean score of alumni was significantly lower than that of undergraduate students on the modified ATHCTS. Only "team efficacy" had a significantly lower regression factor score in alumni than undergraduate students. Our findings suggest that changes in professional identity in a team may be due to contact with patients after graduation in the postgraduate clinical healthcare experience. The reduction of attitudes toward healthcare teams in the postgraduate clinical experience may be related to "team efficacy". We emphasize the need for in-service IPE for sustaining attitudes and providing a useful CP, which results in good clinical outcome.

Changes in attitudes toward interprofessional health care teams and education in the first- and third-year undergraduate students.

The interprofessional education (IPE) program at Gunma University, Maebashi, Japan, implements a lecture style for the first-year students and a training style for the third-year students. Changes in the scores of modified Attitudes Toward Health Care Teams Scale (ATHCTS) and those of modified Readiness of health care students for Interprofessional Learning Scale (RIPLS) at the beginning and the end of the term were evaluated in the 2008 academic year. Two hundred and eighty-five respondents of a possible 364 completed the survey. In both the scales, the overall mean scores declined significantly after the lecture-style learning in the first-year students, while the scores improved significantly after the training-style learning in the third-year students. Exploratory factor analysis revealed that the modified ATHCTS was composed of three subscales, and the modified RIPLS two subscales. Analyses using regression factor scores revealed that the scores of "quality of care delivery" subscale in the modified ATHCTS and those of "expertise" subscale in the modified RIPLS declined significantly in the first-year students. Consequently, IPE programs may be introduced early in the undergraduate curriculum to prevent stereotyped perceptions for IPE, and comprehensive IPE curricula may result in profound changes in attitudes among participating students.

Elasticity and physico-chemical properties during drinking water biofilm formation.

Atomic force microscope techniques and multi-staining fluorescence microscopy were employed to study the steps in drinking water biofilm formation. During the formation of a conditioning layer, surface hydrophobic forces increased and the range of characteristic hydrophobic forces diversified with time, becoming progressively complex in macromolecular composition, which in return triggered irreversible cellular adhesion. AFM visualization of 1 to 8 week drinking water biofilms showed a spatially discontinuous and heterogeneous distribution comprising an extensive network of filamentous fungi in which biofilm aggregates were embedded. The elastic modulus of 40-day-old biofilms ranged from 200 to 9000 kPa, and the biofilm deposits with a height >0.5 µm had an elastic modulus <600 kPa, suggesting that the drinking water biofilms were composed of a soft top layer and a basal layer with significantly higher elastic modulus values falling in the range of fungal elasticity.

[Practical side of teamwork-based training--practice and evaluation in Gunma University].

In Gunma University, the School of Health Sciences was integrated with the Junior College Department into the Faculty of Medicine in 1996. For faculty integration, one of the most fundamental aspects of education was set as interprofessional education (IPE) in this school. To enhance collaboration between health professionals and overcome the fragmented nature of specialized medicine, the school has developed a curriculum, fundamentally based on holistic medicine and interprofessional work (IPW). The original and distinctive IPE was first introduced to 3rd grade students in 1999. The mandatory IPE practice training curriculum, designated as IPE, with multi-disciplinary students following a simulation training approach, has been implemented continuously for over 10 years. The major advantage of the curriculum lies in the training program, "a simulated interprofessional training", where students work in groups and perform a series of activities, including group discussions, clinical training at facilities, general meetings, and reporting. To assess the efficacy of IPE, a questionnaire survey was conducted for 11 years from 1999/2009. Students were asked to complete a short questionnaire with 10 questions and 2 or 3 open ended questions at the end of each IPE module. This systemic assessment of achievement has been developed independent of those described elsewhere, revealing the efficacy of the curriculum from a team building point of view. In this article, we introduce the results of the questionnaire survey in 2009. We hope that this article help in the teamwork-based training of students aiming to be medical technologists.

[A case of non-small cell lung cancer with hemodialysis which responded to docetaxel monotherapy].

A 56-year-old man receiving hemodialysis treatment was hospitalized for examination of a mass in the right middle lobe. Chest computed tomography showed a right hilar mass shadow accompanied by pleural effusion. Non-small cell lung cancer (NSCLC) was diagnosed by cytological examination of the pleural effusion. No epidermal growth factor receptor (EGFR) mutation was found. He was treated with 6 courses of docetaxel as first-line chemotherapy. Docetaxel was administered on the same day as hemodialysis. Adverse events, including hematotoxicity, were managed safely and no delay in administration occurred. This chemotherapy resulted in a partial response. Because docetaxel is metabolized in the liver and does not affect renal function, it can be administered as a standard regimen. This suggests that docetaxel monotherapy is an efficient therapy for non-small cell lung cancer patients receiving hemodialysis.

Systematic inclusion of mandatory interprofessional education in health professions curricula at Gunma University: a report of student self-assessment in a nine-year implementation.

BACKGROUND: The mandatory interprofessional education programme at Gunma University was initiated in 1999. This paper is a statistical evaluation of the programme from 1999 to 2007. METHODS: A questionnaire of 10 items to assess the achievement levels of the programme, which was developed independently of other assessment systems published previously, was distributed, as well as two or three open-ended questions to be answered at the end of each annual module. A multivariate analysis of variance model was used, and the factor analysis of the responses was performed with varimax rotation. RESULTS: Over all, 1418 respondents of a possible 1629 students completed the survey, for a total response rate of 87.1%. Cronbach's alpha of 10 items was 0.793, revealing high internal consistency. Our original questionnaire was categorized into four subscales as follows: "Role and responsibilities", "Teamwork and collaboration", "Structure and function of training facilities", and "Professional identity". Students in the Department of Occupational Therapy reached a relatively lower level of achievement. In the replies to the open-ended questions, requests for the participation of the medical students were repeated throughout the evaluation period. CONCLUSION: The present four subscales measure "understanding", and may take into account the development of interprofessional education programmes with clinical training in various facilities. The content and quality of clinical training subjects may be remarkably dependent on training facilities, suggesting the importance of full consultation mechanisms in the local network with the relevant educational institutes for medicine, health care and welfare.

Adjacent segment disease following expansive lumbar laminoplasty.

BACKGROUND CONTEXT: We developed the technique of expansive lumbar laminoplasty in 1981. In the procedure of laminoplasty, the spinal canal is decompressed by rotatory elevation of the laminae, and bone grafts from the spinous process and posterior iliac bone are placed on the surface of the operated laminae. Therefore, adjacent segment disease due to mechanical stress could be anticipated in the long-term follow-up. PURPOSE: To investigate the incidence of symptomatic adjacent segment disease after expansive lumbar laminoplasty, to identify the factors which are related to the development of this disease, and to discuss the treatment of this postoperative problem. STUDY DESIGN/SETTING: This is a retrospective cohort study. PATIENT SAMPLE: Seventy-one patients (53 men and 18 women with a mean age of 55.7 years) underwent expansive lumbar laminoplasty for the treatment of spinal stenosis. The average length of follow-up was 5.4 years with a range of 2 to 13 years. OUTCOME MEASURES: Follow-up evaluation was primarily by means of clinical visits. METHODS: The incidence of adjacent segment disease which resulted in the deterioration of Japanese Orthopaedic Association score was analyzed. The diagnosis of symptomatic adjacent segment disease was based on both newly developed clinical symptoms and radiological lesions at the disc levels adjacent to the lumbar laminoplasty. We evaluated the correlation between the incidence of symptomatic adjacent segment disease and the clinical parameters and radiological parameters. RESULTS: Eight patients (11%) showed deterioration in the lesions at the segment adjacent to laminoplasty. The disease-free survival rates by Kaplan-Meier survival analysis were 95.7% at 5 years, 63.1% at 10 years, and 42.1% at 13 years. The incidence of spondylolisthesis in the disease group was higher than that in the disease-free group. The preoperative range of motion of L1-L5 in the disease group was significantly higher than that in the disease-free group. In five patients in whom conservative treatment failed for adjacent segment disease, reoperations were performed and they were effective. CONCLUSIONS: It should be taken into account that adjacent segment disease occurs after expansive lumbar laminoplasty. Spondylolisthesis might be a risk factor for the disease. Although reoperation was effective, it is necessary to consider the patient's age and physical condition before choosing further surgical therapy.

Identification of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD)-inducible genes in human amniotic epithelial cells.

BACKGROUND: Exposure to dioxins results in a broad range of pathophysiological disorders in human fetuses. In order to evaluate the effects of dioxins on the feto-placental tissues, we analyzed the gene expression in 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) treated primary cultures of human amniotic epithelial cells. METHODS: Human amniotic epithelial cells were dispersed by trypsin from amniotic membranes and cultured in DME/Ham's F12 medium supplemented with 10% FBS. Two weeks after plating, cells were treated with 50 nM TCDD or DMSO (control), further incubated for 48 hrs, and the gene expression was analyzed by DNA microarray technology and quantitative real-time PCR. RESULTS: Thirty eight TCDD-inducible genes, including cytochromeP4501A1 and cytochromeP4501B1, were identified. One of the remarkable profiles of the gene expression was the prominent up-regulation of interferon-inducible genes. The genes involved in the interferon gene expression and interferon signaling pathways were also up-regulated. Furthermore, the expression of genes related to collagen synthesis or degradation was enhanced by TCDD. CONCLUSION: Using DNA microarray and quantitative real-time PCR analyses, we identified TCDD-inducible genes, including interferon-inducible genes and genes related to collagen synthesis or degradation, in human amniotic epithelial cells.

Postoperative delirium in spine surgery.

BACKGROUND CONTEXT: Postoperative delirium is a great concern in the treatment of hip fracture. However, there have been no reports regarding the postoperative delirium in spine surgery. PURPOSE: To determine the incidence and risk factors for postoperative delirium in the patients who have had spine surgery. STUDY DESIGN/SETTING: The incidence and intraoperative risk factors of postoperative delirium were retrospectively examined in patients who had spine surgery during a 3-year period. PATIENT SAMPLE: Three hundred forty-one patients who underwent spine surgery from 2000 to 2002 were included. METHODS: The presence of delirium was determened by the Confusion Assessment Method. Laboratory data were checked preoperatively, at 1 day and 1 week postoperatively. The prognosis of postoperative delirium was evaluated. RESULTS: Postoperative delirium was found in 13 patients; all of them were in their 70's or 80's. The incidence of delirium was 12.5% in the patients over 70 years old. Hemoglobin and hematocrit levels at 1 day after surgery in the delirium group were significantly lower than those in the control group. One patient had persistent cognitive dysfunction after surgery. Two patients who developed postoperative delirium died during the follow-up period. CONCLUSION: Low concentrations of hemoglobin and hematocrit 1 day after surgery were risk factors for postoperative delirium. As delirium is thought to represent not only brain dysfunction, but also impaired general physical condition, careful observation is necessary for the management of patients with postoperative delirium.

Calmodulin-dependent cyclic nucleotide phosphodiesterase (PDE1) is a pharmacological target of differentiation-inducing factor-1, an antitumor agent isolated from Dictyostelium.

The differentiation-inducing factor-1 (DIF-1) isolated from Dictyostelium discoideum is a potent antiproliferative agent that induces growth arrest and differentiation in mammalian cells in vitro. However, the specific target molecule(s) of DIF-1 has not been identified. In this study, we have tried to identify the target molecule(s) of DIF-1 in mammalian cells, examining the effects of DIF-1 and its analogs on the activity of some candidate enzymes. DIF-1 at 10-40 micro M dose-dependently suppressed cell growth and increased the intracellular cyclic AMP concentration in K562 leukemia cells. It was then found that DIF-1 at 0.5-20 micro M inhibited the calmodulin (CaM)-dependent cyclic nucleotide phosphodiesterase (PDE1) in vitro in a dose-dependent manner. Kinetic analysis revealed that DIF-1 acted as a competitive inhibitor of PDE1 versus the substrate cyclic AMP. Because DIF-1 did not significantly affect the activity of other PDEs or CaM-dependent enzymes and, in addition, an isomer of DIF-1 was a less potent inhibitor, we have concluded that PDE1 is a pharmacological and specific target of DIF-1.

A rare case: bioprosthetic tricuspid valvuloplasty dramatically improved hepatic encephalopathy.

A 51-year-old woman was diagnosed as severe stenosed tricuspid bioprosthetic valve. She had developed an encephalopathy due to elevated serum ammonia concentration caused by congestive hepatic failure. Re-tricuspid valve replacement was deemed too risky, and balloon bioprosthetic valvuloplasty was instead planned. This procedure was successfully performed using a standard mitral valvuloplasty protocol. The 30-mm INOUE-BALLOON was inflated five times. The mean pressure gradient across the bioprosthetic valve decreased from 7.8 to 3.5 mmHg, and the tricuspid valve orifice area increased from 1.09 to 3.13 cm(2), without worsening of the tricuspid valve regurgitation. Finally, her hepatic encephalopathy was dramatically improved.

Spinal stenosis due to ossified lumbar lesions.

OBJECT: Spinal stenosis due to lumbar ossified lesions is a rare pathological entity. The authors retrospectively evaluated the clinical features and surgical results associated with cases involving lumbar ossified lesion-induced stenosis. METHODS: Data obtained in 20 surgically treated patients with lumbar hyperostotic spinal stenosis were included. To evaluate the background of the disease, body mass index and general complications were assessed. Whole-spine radiological examination was conducted. The presence of ossification of the posterior longitudinal ligament or ossification of the ligamentum flavum was evaluated. Surgical results were classified according to the Japanese Orthopaedic Association (JOA) scale. In the patients in whom neurological deterioration was observed during follow up, the causes of deterioration were reviewed. Seven patients (35%) were obese and six patients (30%) suffered diabetes mellitus. Twelve patients harbored coexisting cervical and/or thoracic ossified lesions. The overall mean JOA score improved from 10.2 to a peak of 22.5; at last follow-up examination the mean JOA score was 20.9. In female and older patients with a long history of preoperative symptoms, a low preoperative JOA score, and other spinal lesions, recovery tended to be poorer. Recovery was poor in one patient, and neurological deterioration due to coexisting ossified spinal lesions occurred in another patient during the follow-up period. CONCLUSIONS: Because coexisting ossified lesions were frequently seen, whole-spine analysis is recommended. Early diagnosis and appropriate treatment are important to achieve a better surgical outcome.