Improvement of patient localization repeatability using a light-section based optical surface guidance system in a pre-positioning procedure.

PURPOSE: Surface-guided radiotherapy is useful for the pre-positioning and monitoring of radiotherapy. The purpose of this study was to investigate the impact of surface guidance on the repeatability of patient localization and to estimate the specific point at which high positional errors occur. MATERIALS AND METHODS: Ten patients without the VOXELAN system (non-VXLN group) and 10 patients with the VOXELAN as the pre-positioning procedure (VXLN group) were included in this analysis. Twelve regions of interest (ROI) were defined in all the patients to verify any misalignment during radiotherapy. Thirteen ROIs were defined on the isocenter. RESULTS: Compared with the non-VXLN group, the translational positional errors of the VXLN group were the same for all the ROIs. The mean translational positional errors of the VXLN group in the longitudinal direction were approximately 0.1mm, and the standard deviation was the largest among the three directions in all the ROIs. The magnitude of the standard deviation in the non-VXLN group varied independently of the ROI and direction. The standard deviations of the VXLN group in the longitudinal direction were large in all the ROIs, while the standard deviations in the vertical and lateral directions were small. CONCLUSION: Pre-positioning with a surface guidance system reduced the body twist and rotation, which could not be corrected by image-guided radiotherapy alone. Since the VOXELAN can detect positioning errors quickly and without additional radiation exposure to the patient, it can be used as a tool for pre-positioning in radiotherapy.

Association between health risks and frailty in relation to the degree of housing damage among elderly survivors of the great East Japan earthquake.

BACKGROUND: Many survivors of the Great East Japan Earthquake that occurred in 2011 were at risk of deteriorating health, especially elderly people living in disaster-stricken areas. The objectives of this prospective study were: a) to clarify the different lifestyle and psychosocial factors associated with frailty by sex among the non-disabled elderly survivors, and b) to describe the differences in characteristics stratified by the degree of disaster-related housing damage. METHODS: We followed 2261 Japanese survivors aged ≥65 years (45.3% male; mean age, 71.7 years) without disability or frailty who completed a self-administered questionnaire at baseline. All participants completed a baseline questionnaire in 2011 and at least one identical follow-up questionnaire between 2012 and 2015 regarding lifestyle (smoking status, alcohol intake, physical activity, sedentary lifestyle, and dietary intake) and psychosocial factors (self-rated health, standard of living, psychological distress, and social networks). Frailty was defined as a score of ≥5 on the Kihon Checklist, which is used by the Japanese government to certify the need for long-term care insurance. Adjusted odds ratios and 95% confidence intervals with frailty as the dichotomous dependent variable and health factors as the independent variables were calculated using a multilevel model for repeated measures by sex, followed by stratification analyses by the degree of housing damage. RESULTS: Over the 4-year study period, 510 participants (22.6%) developed frailty. In the post-disaster setting, many of the psychosocial factors remained more prevalent 4 years later among survivors with extensive housing damage. The presence of risk factors regarding the development of frailty differed by the degree of housing damage. Among men, psychological distress, in parallel with a poor social network, was related to frailty among only the participants with extensive housing damage and those living in temporary housing, whereas among women, worsening psychological distress was associated only with no damage and no displaced survivors. Among women with extensive damage and displacement, health outcomes such as overweight and diabetes and poor social networks were strongly related to frailty. CONCLUSIONS: Lifestyle and psychosocial factors associated with the risk of frailty differ by sex and the degree of housing damage.

Subjective Well-Being Is Associated with Food Behavior and Demographic Factors in Chronically Ill Older Japanese People Living Alone.

OBJECTIVES: This study aimed to examine the relationships among subjective well-being, food and health behaviors, socioeconomic factors, and geography in chronically ill older Japanese adults living alone. DESIGN: The design was a cross-sectional, multilevel survey. A questionnaire was distributed by post and self-completed by participants. SETTING: The sample was drawn from seven towns and cities across Japan. PARTICIPANTS: A geographic information system was used to select a representative sample of older people living alone based on their proximity to a supermarket. Study recruitment was conducted with municipal assistance. MEASUREMENTS: To assess subjective well-being and food and health behaviors of respondents with disease, a logistic regression analysis was performed using stepwise variable analyses, adjusted for respondent age, socioeconomic status, and proximity to a supermarket. The dependent variable was good or poor subjective well-being. RESULTS: In total, 2,165 older people (744 men, 1,421 women) completed the questionnaire (63.5% response rate). Data from 737 men and 1,414 women were used in this study. Among people with a chronic disease, individuals with good subjective well-being had significantly higher rates than those with poor subjective well-being for satisfaction with meal quality and chewing ability, food diversity, food intake frequency, perception of shopping ease, having someone to help with food shopping, eating home-produced vegetables, preparing breakfast themselves, eating with other people, and high alcohol consumption. A stepwise logistic analysis showed that the factors strongly related to poor subjective well-being were shopping difficulty (men: odds ratio [OR] = 3.19, 95% confidence interval [CI], 1.94-5.23; P < 0.0001; women: OR = 2.20, 95% CI, 1.54-3.14; P < 0.0001), not having someone to help with food shopping (women: OR = 1.41, 95% CI, 1.01-1.97; P = 0.043), not preparing breakfast (women: OR = 2.36, 95% CI, 1.40-3.98; P = 0.001), and eating together less often (women: OR = 1.99, 95% CI, 1.32-3.00; P = 0.002). CONCLUSION: Subjective well-being of people with chronic diseases is associated with food intake and food behavior. The factors that affect poor subjective well-being in chronically ill older Japanese people living alone include food accessibility and social communication.

Association between Satisfaction with State of Health and Meals, Physical Condition and Food Diversity, Health Behavior, and Perceptions of Shopping Difficulty among Older People Living Alone in Japan.

OBJECTIVE: This study aimed to examine perceptions of shopping difficulty, and the relationships with satisfaction with state of health and meals, physical condition, food diversity and health behavior in older people living alone in Japan. DESIGN: A cross-sectional, multilevel survey was designed. The questionnaire was distributed by mail and self-completed by participants. SETTING: The sample was drawn from seven towns and cities across Japan. PARTICIPANTS: A geographic information system was used to select the sample of older people living alone, by proximity to a supermarket. In total, 2,346 older people (827 men and 1,519 women) completed the questionnaire. MEASUREMENTS: The dependent variable was whether shopping was easy or difficult. A logistic regression analysis was performed, adjusting for age, socioeconomic status and proximity of residence to a supermarket using stepwise variable analyses. RESULTS: The response rate was 67.8%. Overall, 14.5% of men and 21.7% of women considered shopping difficult. The stepwise logistic analysis showed that the factors most strongly related to shopping difficulty were a subjective feeling of poor health (men: OR = 3.01, women: OR = 2.16) and lack of satisfaction with meals (men: OR = 2.82, women: OR = 3.69). Other related physical condition and dietary factors were requiring nursing care (men: OR = 3.69, women: OR = 1.54), a high level of frailty, measured using the frailty index score (women: OR = 0.36) and low food diversity score (men: OR = 1.84, women: OR = 1.36). CONCLUSION: The study found that older people's assessment of their shopping difficulty was related to satisfaction aspects, including a subjective feeling of poor health, and lack of satisfaction with meals, as well as physical condition. These have a greater influence on shopping difficulty than income in both sexes, and proximity to a supermarket in women.

SU-E-T-196: Commissioning for Volumetric Modulated Radiation Therapy on Varian Clinac 21EX.

PURPOSE: Recently the volumetric arc therapy (VMAT) technology such as RapidArc is widely distributed in Japan. These technologies are normally provided by the high spec linear accelerator such as Trilogy, Novalis Tx, Synergy, et al. The specific DICOM-file is generally used for commissioning of these technologies. On the other hand, we had to apply RapidArc into historic linear accelerator. This title expresses an experience how we performed the commissioning of RapidArc with the old linear accelerator. METHODS: Two Varian's linear accelerators "Clinac 21EX" equipped with Millenium multi-leaf collimator and a Varian's treatment planning system "Eclipse ver.8.9" were used for this study. The commissioning for RapidArc was performed in energy 4,6,10,15 MV (Max-DR: 250, 600, 400, 600 MU/min). Commissioning procedure composed two categories: the general machine QA for DMLC-IMRT procedure and the specific RapidArc QA procedure. In RapidArc QA procedure, we modified DICOM-file to apply into the potential spec of Clinac 21EX optimally. The specific MLC-motion sequence and the gantry rotation speed were created by the dedicated programs (Shaper and DicomEdit, Varian) for RapidArc QA procedure. Each tolerance value was defied by the data from daily/monthly QA and the paper by Ling et al. RESULTS: As the results of the general machine QA procedure, the variance of radiation output during static/dynamic gantry rotation was less than 1%. The deference of fence tests during static/dynamic gantry rotation and RapidArc were less than 1 mm in each. However, the results of the RapidArc QA were worse than the latest machine (especially variable gantry speed) and it was careful to define tolerance level. CONCLUSION: The procedure of commissioning for RapidArc on historic linear accelerator was proposed. Several minor revisions for DICOM-file should be required for suitable commissioning and it may ensure the tolerance limit for gantry/MLC-leaf motion speeds.

Transition and improvement in surgical treatment for rectal cancer during the last 21 years in our department.

The subject of this study was to examine the net effect of numerous changes in basic strategies, personnel and devices, upon the clinical courses and outcomes of rectal cancer patients. A total of 151 rectal cancer patients who underwent low anterior resection were divided into 4 groups (period 1 to 4) based upon the time period of the operation. They were compared among groups based upon the following parameters: blood loss, operation time, incidence of leakage and urinary dysfunction, incidence of ileus, duration of naso-gastric tube insertion, timing of initial oral feeding and survival. The blood loss during the operations, urinary dysfunction and duration of naso-gastric tube insertion tended to decrease in every period. Timing of initial oral feeding became faster. The operation times, incidence of leakage and ileus were nearly the same in each period. The 5-year survival rates on Dukes' C cases were 100% in period 4, 82.4% in period 3 and 50% in period 2. Survival rates became better. Our net outcome for rectal cancer treatment was satisfactory, because the survival rates became better under function preserving strategies.

Over-expression of vascular endothelial growth factor after preoperative radiation therapy for rectal cancer.

Vascular endothelial growth factor expression before and after preoperative radiation therapy was examined in 16 stage III rectal carcinoma patients. The biopsied tissues before preoperative radiation therapy and the tissues at operation were immunohistochemically stained. Four cases were negative for VEGF expression before radiation, but the other 12 cases were positive, with 4 cases showing strong immunoreactivity. After radiation, all except 1 case showed VEGF positive patterns, in which 14 cases demonstrated strong staining. In 12 cases, VEGF expression became higher after radiation therapy than before, as compared to the only 1 case that showed lower expression than before.

Incarcerated paraesophageal hernia associated with perforation of the fundus of the stomach: report of a case.

We report herein a case of incarcerated paraesophageal hernia associated with perforation of the fundus of the stomach. A 71-year-old woman was transferred to our hospital after a diagnosis of gastrointestinal tract perforation had been made at a local hospital. Her history included an esophageal hiatal hernia. A laparotomy was performed which revealed that the antrum of stomach and the duodenal bulb had prolapsed into the esophageal hiatus and become incarcerated. This prolapse had caused stenosis in the corpus of the stomach, resulting in distension of the oral side of the stomach and thinning of the wall. A perforation, 15 mm long, was recognized in the major curvature of the fundus. The patient suffered respiratory failure postoperatively, necessitating respiratory support for 1 week. She was discharged on postoperative day 40. This case report serves to demonstrate that because of the very serious complications that may result from an untreated paraesophageal hernia, elective repair should be performed wherever possible even in asymptomatic patients.

Hepatic resection for metastatic tumors from noncolorectal carcinoma.

BACKGROUND/AIMS: The role of liver resection for hepatic metastases from noncolorectal carcinomas has yet to be clarified. The present study examines a single institutional experience of hepatic resection for noncolorectal metastases. METHODOLOGY: From January 1987 to March 1999, 14 patients underwent curative resection for liver metastases from noncolorectal carcinomas. Records of these patients were reviewed. RESULTS: Resections were performed for liver metastases from gastric cancers (n = 8), pancreatic cancers (n = 2), and cancers of bile duct, the papilla of Vater, kidney, and breast (n = 1, each). Six patients (5 with gastric cancers and 1 with pancreas cancer) presented with synchronous disease and 8 with metachronous disease. In the gastric cancer patients, there are 2 disease-free survivors (26 and 53 months) in the metachronous group, though all of the 5 patients with synchronous disease died within 29 months. All of the 4 patients with pancreatobiliary carcinomas died within 2 years. One case of breast cancer and another of renal cell cancer are alive without disease at 49 and 9 months, respectively. CONCLUSIONS: For metastases from gastric cancers, better survival after hepatic resection is expected in metachronous cases than in synchronous cases. Hepatic resection may afford little benefit for patients with liver metastases from pancretobiliary cancers.

Primary structure and expression of a 24-kD vacuolar protein (VP24) precursor in anthocyanin-producing cells of sweet potato in suspension culture.

A 24-kD vacuolar protein (VP24) accumulates abundantly in intravacuolar pigmented globules in anthocyanin-containing sweet potato (Ipomoea batatas) cells in suspension culture. A cDNA clone encoding VP24 was isolated from a cDNA library constructed from light-irradiated suspension-cultured cells. Sequence analysis revealed that a 2.9-kbp VP24 cDNA encodes a protein of 893 amino acid residues with a molecular mass of 96.3 kD. According to the deduced amino acid sequence of VP24 cDNA, VP24 is probably synthesized as a large precursor protein with an N-terminal extension composed of a signal peptide and a propeptide, plus the polypeptide of the mature VP24 and its C-terminal propeptide, which contains the multiple transmembrane domains. A search in the ProDom database revealed the mature VP24 domain belongs to the zinc metalloprotease family. Northern analysis revealed that the single 2.9-kb VP24 mRNA increases rapidly after light irradiation, whereas VP24 mRNA was undetectable in the dark-cultured cells or in the presence of a high concentration of 2,4-dichlorophenoxyacetic acid. Light-induced VP24 gene expression closely correlated with the accumulation of anthocyanin in the vacuoles. These results suggested that proteins derived from the VP24 precursor protein may be involved in vacuolar transport and/or accumulation of anthocyanin synthesized in the cytosol.

A severe type of rectus sheath hematoma requiring surgery: report of a case.

This report illustrates the case of a 79-year-old woman in whom a severe type of rectus sheath hematoma was found during conservative therapy for myocardial infarction. Although establishing a correct diagnosis and initiating conservative therapy is usually considered the most appropriate management of this clinical entity, the rectus sheath hematoma in this patient required surgical treatment.

[Cost accounting for gastrectomy under critical path--the usefulness of direct accounting of personnel expenses and a guide to shortening hospital stay].

In this study, cost accounting was made for a surgical case of gastrectomy according to critical path (path) and the economic contribution of the path was determined. In addition, changes in the cost percentage with changes in number of hospital days were simulated. Basically, cost accounting was done by means of cost accounting by departments, which meets the concept of direct cost accounting of administered accounts. Personnel expenses were calculated by means of both direct and indirect calculations. In the direct method, the total hours personnel participated were recorded for calculation. In the indirect method, personnel expenses were calculated from the ratio of the income of the surgical department to that of other departments. Purchase prices for all materials and drugs used were recorded to check buying costs. According to the direct calculating method, the personnel expenses came to approximately 300,000 yen, total cost was approximately 700,000 yen, and the cost percentage was 59%. According to the indirect method, the personnel expenses were approximately 540,000 yen and the total cost was approximately 940,000 yen, the cost percentage being 80%. A simulation study of changes in the cost with changes in hospital days revealed that the cost percentages were assessed to be approximately 53% in 19 hospital days and approximately 45% in 12 hospital days.

Perianal mucinous carcinoma successfully treated with a combination of external beam radiotherapy and high dose rate interstitial brachytherapy.

The case of an 84-year-old man with perianal mucinous carcinoma is presented. The tumour was 6 cm in diameter and extended into the surrounding tissues. Taking the patient's advanced age and disease into account, rectosigmoidectomy and colostomy were carried out without resection of most of the tumour. Radiotherapy consisted of pre-operative external beam radiotherapy (EBRT) of 40 Gy in 20 fractions, post-operative EBRT of 24 Gy in 12 fractions, and high dose rate interstitial brachytherapy of 12 Gy in a single fraction. The patient tolerated the entire course of radiotherapy well. The patient is doing well without regrowth or complications 7 years after radiotherapy. To our knowledge, there have been no reports on the successful outcome of radiotherapy for perianal mucinous carcinoma. This case suggests that a combination of EBRT plus interstitial brachytherapy boost may play a role in the definitive treatment of perianal mucinous carcinoma.

M-31 mutant (virA::Tn5) of Agrobacterium tumefaciens is capable of transferring its T-DNA into the nucleus of host cell, but incapable of integrating it into the chromosome.

An avirulent mutant (M-31 strain) was produced by the transposon (Tn5) mutagenesis of Agrobacterium tumefaciens (A-208 strain). A binary vector, pIG121-Hm, containing a kanamycin resistance gene (nptII) and beta-glucuronidase (GUS) gene with an intron, was introduced into M-31 and A-208 strains. The resultant Agrobacteria were inoculated onto leaves of Kalanchoe daigremontiana and to tobacco BY-2 cells to assay GUS activity to monitor the T-DNA transfer into the nuclei of host cells. The results indicated that T-DNA was transferred into the nuclei of cells of both host plants inoculated with the M-31 mutant. The M-31 mutant strain had an insertion of Tn5 in the virA gene on its Ti plasmid. The introduction of the virA gene in the M-31 mutant complemented its avirulent phenotype. No kanamycin-resistant cells were observed when the M-31 mutant harboring the pIG121-Hm was inoculated to tobacco BY-2 cells. The M-31 mutant (virA::Tn5) seems to transfer T-DNA into the nucleus of the host cell, but is unable to integrate it to the chromosome.

Spontaneous rupture of bladder diverticulum after postoperative radiotherapy for carcinoma of the uterine cervix: a case report.

We present a case of spontaneous rupture of bladder diverticulum three years after postoperative whole pelvic irradiation (50.4 Gy) for carcinoma of the uterine cervix. The patient had suffered from a neurogenic bladder after hysterectomy, but excretory urography revealed no abnormalities. Bladder diverticulum was found two years later. Spontaneous rupture of the urinary bladder is one of the late complications associated with radiotherapy, although it is very rare. Postoperative neurogenic bladder may also be associated with rupture. We should be aware of this rare complication in patients who receive pelvic irradiation.

Prognostic significance of perirectal lymph node micrometastases in Dukes' B rectal carcinoma: an immunohistochemical study by CAM5.2.

Lymph node metastasis is an important prognostic factor for rectal carcinoma, but only a few attempts at defining the relationship between lymph node micrometastases and prognosis have been made. The purpose of this study was to examine the correlation between the presence of micrometastases and prognosis in patients with rectal carcinoma. Six hundred forty-four lymph nodes were dissected from 42 patients with Dukes' B rectal carcinoma and stained immunohistochemically using a monoclonal antibody, CAM5.2, that binds cytokeratin. Clinicopathological factors, rate of recurrence, and prognosis were compared among patients with and without micrometastases. Micrometastases were detected in 19 lymph nodes (19 of 644 = 2.9%) from 9 patients (9 of 42 = 21.4%). The presence of micrometastases was not related to clinicopathological factors. There were significant differences in recurrence rates (5 of 9 versus 5 of 33, P = 0.02), relapse-free survival rates (P = 0.04), and 10-year survival rates (P = 0.03) between patients with and without micrometastases. Immunohistochemistry successfully identified micrometastatic foci in lymph nodes missed with conventional staining methods. The existence of micrometastases influenced the prognosis in patients with Dukes' B rectal carcinoma.

Neurovascular compression syndrome of the eighth cranial nerve. Can the site of compression explain the symptoms?

Considerable skepticism still exists concerning the concept of neurovascular compression (NVC) syndromes of the eighth cranial nerve (8th N). If such syndromes exist, the sites of compression of the nerve must explain the symptoms encountered. We recorded compound action potentials of the cochlear nerve (CCAPs) during neurovascular decompression (NVD) to examine the topography of the three components of the 8th N. The sites of compression of the 8th N in cases of NVC syndrome confirmed at surgery were superimposed on the topography of the CN and vestibular nerve (VN) in order to determine the relationship between the sites of compression and the symptoms. CCAPs were clearly and consistently recorded on the caudal surface of the 8th N along the midline. In patients with vertigo and tinnitus there was vascular compression of the rostroventral (VN) and caudal surface (CN) of the nerve, respectively. In patients with both vertigo and tinnitus, there was compression of both VN and CN. Our findings clearly demonstrate that the symptoms of NVC of the 8th N depend on the part of the nerve that is compressed by blood vessels, and they support the concept of NVC syndrome of the 8th N.

[CT analysis of mucosal surface dose in intraluminal irradiation for esophageal cancer].

PURPOSE: Balloon applicators are generally used in intraluminal irradiation for esophageal cancer. CT exhibits a distortion of the applicator during treatment. Because little attention has been paid to dose non-uniformity in the esophageal mucosa, we analyzed mucosal surface dose using CT. MATERIALS AND METHODS: Eleven patients with esophageal cancer treated with a double-lumen balloon applicator (balloon length: 15 cm, diameter: 20 mm) were evaluated. Reference dose was prescribed at 5 mm under the mucosal surface. Mucosal surface points were determined from CT images, and relative surface dose to reference dose was calculated. Hot and cold spots were defined respectively, as dose points receiving at least 200% and less than 100% of the reference dose. RESULTS: The mean mucosal dose ranged from 138% to 174%. Mucosal dose was distributed widely from 100% to 199% in 94% of all patients. Hot and cold spots accounted for 5.3% and 0.7% of mucosal dose points, respectively. CONCLUSION: 1) CT analysis exhibited the inhomogeneity of esophageal mucosal dose in intraluminal irradiation. 2) At present, it is acceptable to prescribe the reference dose at 5 mm under the esophageal surface. 3) Balloon applicators should be improved to achieve dose uniformity in the esophageal mucosa.

[A case of stage IV esophageal cancer successfully treated by chemoradiation].

A 63-year-old man was admitted to our institution with a hard tumor on the left side of the neck. He was diagnosed as having advanced esophageal cancer (Stage IV) with a massive supraclavicular lymph node metastasis, and the lesion was thought to be unresectable. He was treated with chemotherapy (CDDP-VDS-5-FU) and radiation therapy, and all the tumors completely disappeared on endoscopic and CT examination. A stricture with scarring was detected in the esophagus at 6 months after treatment. No neoplastic tissue was detected in the lesion, and his dysphagia was relieved by dilation of the stricture. Recurrence on the left side of the neck was detected by CT at 2.5 years after chemoradiation therapy. However, the tumor has not grown over the 2-year interval since then, so it seems to be dormant. He has now survived with a good QOL for 5 years since the first hospital admission. We conclude that advanced esophageal cancer can be treated with chemoradiation therapy if the patient is in sufficiently good overall condition.

Microsatellite instability and frameshift mutations in the Bax gene in hereditary nonpolyposis colorectal carcinoma.

We studied microsatellite instability (MI) and bax gene abnormalities in colorectal carcinomas from 36 patients diagnosed as having hereditary nonpolyposis colorectal cancers (HNPCC) according to the clinical criteria (12 with confirmed HNPCC in group A and 24 at high risk of HNPCC in group B) and from 20 randomly selected patients with other colorectal cancers. MI was examined at 4 dinucleotide microsatellite loci and one mononucleotide locus. Frameshift mutations in the bax gene were detected by polymerase chain reaction-single strand conformation polymorphism analysis. MI was detected in 7 of the 12 patients in group A and 12 of the 24 in group B. Three MI patterns were identified: type 1, MI in both mono- and dinucleotide repeats; type 2, MI only in mononucleotide repeats and type 3, MI only in dinucleotide repeats. Most MI-positive patients in group A showed type 1 MI, whereas in group B, 5 showed type 1, 3 showed type 2 and 4 showed type 3. Frameshift mutations in the bax gene correlated strongly with type 1 and type 2 MI. These results indicate that mutations of different DNA mismatch repair genes may cause several types of MI and result in several different clinical phenotypes of HNPCC. The bax gene may be one of the target genes which play a role in the tumorigenesis of HNPCC.