Anti-pruritic effect of isothiocyanates: Potential involvement of toll-like receptor 3 signaling.

The innate immune system has an emerging role as a mediator of neuro-immune communication and a therapeutic target for itch. Toll-like receptor 3 (TLR3) plays an important role in itch, as shown in TLR3 knock-out mice. In this study, to evaluate effects of TLR3 inhibitors on histamine-independent itch, we used two kinds of isothiocyanate (ITC). Both phenethyl isothiocyanate (PEITC) and sulforaphane (SFN) inhibited Poly I:C (PIC)-induced signaling in the RAW264.7 cell line. We then investigated the anti-pruritic effect of these compounds on PIC- and chloroquine (CQ)-induced scratching behavior. PEITC and SFN both suppressed PIC-evoked scratching behavior in mice, and PEITC also inhibited CQ-induced acute itch. Finally, we examined the oxazolone-induced chronic itch model in mice. Surprisingly, oral dosing of both compounds suppressed scratching behaviors that were observed in mice. Our findings demonstrate that TLR3 is a critical mediator in acute and chronic itch transduction in mice and may be a promising therapeutic target for pruritus in human skin disorders. It is noteworthy that SFN has potential for use as an antipruritic as it is a phytochemical that is used as a supplement.

New mechanism underlying IL-31-induced atopic dermatitis.

BACKGROUND: TH2 cell-released IL-31 is a critical mediator in patients with atopic dermatitis (AD), a prevalent and debilitating chronic skin disorder. Brain-derived natriuretic peptide (BNP) has been described as a central itch mediator. The importance of BNP in peripheral (skin-derived) itch and its functional link to IL-31 within the neuroimmune axis of the skin is unknown. OBJECTIVE: We sought to investigate the function of BNP in the peripheral sensory system and skin in IL-31-induced itch and neuroepidermal communication in patients with AD. METHODS: Ca2+ imaging, immunohistochemistry, quantitative real-time PCR, RNA sequencing, knockdown, cytokine/phosphokinase arrays, enzyme immune assay, and pharmacologic inhibition were performed to examine the cellular basis of the IL-31-stimulated, BNP-related itch signaling in dorsal root ganglionic neurons (DRGs) and skin cells, transgenic AD-like mouse models, and human skin of patients with AD and healthy subjects. RESULTS: In human DRGs we confirmed expression and co-occurrence of oncostatin M receptor ß subunit and IL-31 receptor A in a small subset of the neuronal population. Furthermore, IL-31 activated approximately 50% of endothelin-1-responsive neurons, and half of the latter also responded to histamine. In murine DRGs IL-31 upregulated Nppb and induced soluble N-ethylmaleimide-sensitive factor activating protein receptor-dependent BNP release. In Grhl3PAR2/+ mice house dust mite-induced severe AD-like dermatitis was associated with Nppb upregulation. Lesional IL-31 transgenic mice also exhibited increased Nppb transcripts in DRGs and the skin; accordingly, skin BNP receptor levels were increased. Importantly, expression of BNP and its receptor were increased in the skin of patients with AD. In human skin cells BNP stimulated a proinflammatory and itch-promoting phenotype. CONCLUSION: For the first time, our findings show that BNP is implicated in AD and that IL-31 regulates BNP in both DRGs and the skin. IL-31 enhances BNP release and synthesis and orchestrates cytokine and chemokine release from skin cells, thereby coordinating the signaling pathways involved in itch. Inhibiting peripheral BNP function might be a novel therapeutic strategy for AD and pruritic conditions.

Induction of humoural and cellular immunity by immunisation with HCV particle vaccine in a non-human primate model.

OBJECTIVE: Although HCV is a major cause of chronic liver disease worldwide, there is currently no prophylactic vaccine for this virus. Thus, the development of an HCV vaccine that can induce both humoural and cellular immunity is urgently needed. To create an effective HCV vaccine, we evaluated neutralising antibody induction and cellular immune responses following the immunisation of a non-human primate model with cell culture-generated HCV (HCVcc). DESIGN: To accomplish this, 10 common marmosets were immunised with purified, inactivated HCVcc in combination with two different adjuvants: the classically used aluminum hydroxide (Alum) and the recently established adjuvant: CpG oligodeoxynucleotide (ODN) wrapped by schizophyllan (K3-SPG). RESULTS: The coadministration of HCVcc with K3-SPG efficiently induced immune responses against HCV, as demonstrated by the production of antibodies with specific neutralising activity against chimaeric HCVcc with structural proteins from multiple HCV genotypes (1a, 1b, 2a and 3a). The induction of cellular immunity was also demonstrated by the production of interferon-γ mRNA in spleen cells following stimulation with the HCV core protein. These changes were not observed following immunisation with HCVcc/Alum preparation. No vaccination-related abnormalities were detected in any of the immunised animals. CONCLUSIONS: The current preclinical study demonstrated that a vaccine included both HCVcc and K3-SPG induced humoural and cellular immunity in marmosets. Vaccination with this combination resulted in the production of antibodies exhibiting cross-neutralising activity against multiple HCV genotypes. Based on these findings, the vaccine created in this study represents a promising, potent and safe prophylactic option against HCV.

Amino Acid Mutations in the NS4A Region of Hepatitis C Virus Contribute to Viral Replication and Infectious Virus Production.

Hepatitis C virus (HCV) strain JFH-1, which belongs to genotype 2a, replicates autonomously in cultured cells, whereas another genotype 2a strain, J6CF, does not. Previously, we found that replacement of the NS3 helicase and NS5B-to-3'X regions of J6CF with those of JFH-1 confers J6CF replication competence. In this study, we aimed to identify the minimum modifications within these genomic regions needed to establish replication-competent J6CF. We previously identified 4 mutations in the NS5B-to-3'X region that could be used instead of replacement of this region to confer J6CF replication competence. Here, we induced cell culture-adaptive mutations in J6CF by the long-term culture of J6CF/JFH-1 chimeras composed of JFH-1 NS5B-to-3'X or individual parts of this but not the NS3 helicase region. After 2 months of culture, efficient HCV replication and infectious virus production in chimeric RNA-transfected cells were observed, and several amino acid mutations in NS4A were identified in replicating HCV genomes. The introduction of NS4A mutations into the J6CF/JFH-1 chimeras enhanced viral replication and infectious virus production. Immunofluorescence microscopy demonstrated that some of these mutations altered the subcellular localization of the coexpressed NS3 protein and affected the interaction between NS3 and NS4A. Finally, introduction of the most effective NS4A mutation, A1680E, into J6CF contributed to its replication competence in cultured cells when introduced in conjunction with four previously identified adaptive mutations in the NS5B-to-3'X region. In conclusion, we identified an adaptive mutation in NS4A that confers J6CF replication competence when introduced in conjunction with 4 mutations in NS5B-to-3'X and established a replication-competent J6CF strain with minimum essential modifications in cultured cells. IMPORTANCE: The HCV cell culture system using the JFH-1 strain and HuH-7 cells can be used to assess the complete HCV life cycle in cultured cells. This cell culture system has been used to develop direct-acting antivirals against HCV, and the ability to use various HCV strains within this system is important for future studies. In this study, we aimed to establish a novel HCV cell culture system using another HCV genotype 2a strain, J6CF, which replicates in chimpanzees but not in cultured cells. We identified an effective cell culture-adaptive mutation in NS4A and established a replication-competent J6CF strain in cultured cells with minimum essential modifications. The described strategy can be used in establishing a novel HCV cell culture system, and the replication-competent J6CF clone composed of the minimum essential modifications needed for cell culture adaptation will be valuable as another representative of genotype 2a strains.

NMR spectra and electrochemical behavior of catechol-bearing block copolymer micelles.

Here, we provide the NMR spectra and AFM data for antioxidant micelles prepared from amphiphilic PAM-PDA block copolymers composed of a poly(N-acryloyl morpholine) and a redox-active catechol-bearing block with different catechol content. We also provide details of the electrochemical analysis that showed micelles higher catechol content had a similar redox potential with the small catechol compound dopamine, but slowed down the redox reaction (Hasegawa et al., Polymer (in press)).

Identification of alpha-substituted acylamines as novel, potent, and orally active mGluR5 negative allosteric modulators.

This Letter describes the identification of a series of novel non-acetylenic mGluR5 negative allosteric modulators based on the alpha-substituted acylamine structure. An initial structure-activity relationship study suggested that (R)-19b and (R)-19j might have good in vitro activity. When administered orally, these compounds were found to have an anxiolytic-like effect in a mouse model of stress-induced hyperthermia.

Inhibition of angiogenesis by antioxidant micelles.

Antioxidant micelles capable of scavenging reactive oxygen species (ROS) are prepared from poly(ethylene glycol)-b-poly(dopamine) block copolymers. The micelles inhibit tube formation of human umbilical vein endothelial cells (HUVECs) by scavenging endogenous ROS. Furthermore, the micelles inhibit angiogenesis in the chicken ex ovo chorioallantoic membrane assay. The results show that antioxidant micelles containing catechol moieties may be useful in anti-angiogenic therapy to treat various diseases such as cancer.

Neutralizing antibodies induced by cell culture-derived hepatitis C virus protect against infection in mice.

BACKGROUND & AIMS: Hepatitis C virus (HCV) infection is a major cause of liver cancer, so strategies to prevent infection are needed. A system for cell culture of infectious HCV particles (HCVcc) has recently been established; the inactivated HCVcc particles might be used as antigens in vaccine development. We aimed to confirm the potential of HCVcc as an HCV particle vaccine. METHODS: HCVcc derived from the J6/JFH-1 chimeric genome was purified from cultured cells by ultrafiltration and ultracentrifugation purification steps. Purified HCV particles were inactivated and injected into female BALB/c mice with adjuvant. Sera from immunized mice were collected and their ability to neutralize HCV was examined in naive Huh7.5.1 cells and urokinase-type plasminogen activator-severe combined immunodeficiency mice (uPA(+/+)-SCID mice) given transplants of human hepatocytes (humanized livers). RESULTS: Antibodies against HCV envelope proteins were detected in the sera of immunized mice; these sera inhibited infection of cultured cells with HCV genotypes 1a, 1b, and 2a. Immunoglobulin G purified from the sera of HCV-particle-immunized mice (iHCV-IgG) inhibited HCV infection of cultured cells. Injection of IgG from the immunized mice into uPA(+/+)-SCID mice with humanized livers prevented infection with the minimum infectious dose of HCV. CONCLUSIONS: Inactivated HCV particles derived from cultured cells protect chimeric liver uPA(+/+)-SCID mice against HCV infection, and might be used in the development of a prophylactic vaccine.

A New Program for Healthy Eating Study Using a Card Game.

OBJECTIVE: A new program using a card game for study of children's food risk communication was developed to meet the needs of learning healthy eating. To examine the effects of the new program, an experiment was carried out in an elementary school with 132 students. MATERIALS AND METHODS: The game rules resemble those of common card games. Keeping seven cards in their hands, players exchange one of their cards for another card from the card stack to make a set of food they usually eat. Through the process, they can learn other players' dietary lives. The effects of the card game program and the control program were evaluated by a questionnaire study. RESULTS: Scores for three characteristics-enjoyment, satisfaction, and communication with the other players-for the new program showed higher average values compared with the conventional program without the game. CONCLUSIONS: The findings indicate that the newly developed program is beneficial for children's learning healthy eating.

Evaluation of prosthetic venous valves, fabricated by electrospinning, for percutaneous treatment of chronic venous insufficiency.

Chronic venous insufficiency (CVI) remains a major health problem worldwide. Direct venous valve surgical repair and venous segment transplantation are clinical options; however, they are highly invasive procedures. The objectives of this study were to fabricate prosthetic venous valves (PVVs) by electrospinning, for percutaneous treatment of CVI, and evaluate their hydrodynamic characteristics in vitro at the same locations and under the same flow conditions. The PVVs consisted of polyurethane fiber scaffolds attached to a cobalt-chromium stent. PVVs with two different valve-leaflet configurations were compared: biomimetic PVV (bPVV) and open PVV (oPVV). A balloon catheter was used to implant the devices in a poly(vinyl chloride) tube and the column outlet was set at a height of 100 cm above the test valve to simulate the elevation of the heart above a distal vein valve while standing; 50 wt% glycerin solution was used as the test fluid. The devices were evaluated for antegrade flow, effect of ankle flexion, and stagnation zones around the valve leaflets. During sudden hydrostatic backpressure, little leakage and constant peripheral pressure were observed for the devices; under forward pulsatile pressure of 0-4 mmHg, to simulate the effect of breathing, the oPVV had a higher flow rate than the bPVV. With regard to the effect of ankle flexion, the oPVV was functionless. Moreover, the stagnation zone around the oPVV valve leaflets was larger than that around the bPVV valve leaflets. These results suggest that the bPVV would be clinically suitable for percutaneous treatment of CVI.

Health promotion through rediscovery of one's sensibilities of health: the Lifemap and WIFY Methods.

Japanese people place a high priority on maintaining social harmony and conforming with what we perceive to be mainstream thought and opinion. These social norms present challenges for developing health promotion policies and programs that value individual uniqueness and individual sensibilities about health. To address this challenge, over the past 20 years the author has developed two 'write-and-share' methods - Life-map and WIFY (What Is Important For you) to allow participants to reflect and rediscover their own and one another's feelings about daily life and health. This article summarizes his experiences using these methods and discusses their possible usefulness in other Asian societies.

Isolation of ON bipolar cell genes via hrGFP-coupled cell enrichment using the mGluR6 promoter.

mGluR6 expression is a characteristic property of retinal ON bipolar cells. mGluR6 is also the causal gene for a form of congenital night blindness. To elucidate physiological and pathological functions of ON bipolar cells and mGluR6, we thought it important to identify genes specifically expressed in them. We thus made transgenic mouse lines expressing humanized Renilla reniformis green fluorescent protein (hrGFP), under the control of the mGluR6 promoter. From their retina, we isolated hrGFP-positive cells by cell sorting, and analysed the gene-expression profile of these cells by using DNA microarray. Further analysis revealed that about half of the initially selected ON bipolar cell genes were expressed in the expected retinal layer. We confirmed previously ambiguous retinal localization of regulator of G-protein signalling 11 (RGS11) and transient receptor potential cation channel, subfamily M, member 1 (TRPM1). In addition, we showed the expression of calcium channel, voltage-dependent, alpha2/delta subunit 3 (Cacna2d3) in ON bipolar cells for the first time. Although we could not completely exclude the possibility that a small population of hrGFP-positive cells might not be ON bipolar cells, these mice as well as our strategy would be highly valuable for the further analysis of ON bipolar cells.

Essential role of Rap signal in pre-TCR-mediated beta-selection checkpoint in alphabeta T-cell development.

We demonstrate that lck promoter-driven conditional expression of transgenic SPA-1, a Rap GTPase-activation protein, causes a profound defect of alphabeta T-cell development at the CD4/CD8 double-negative (DN) stage due to enhanced cell death without affecting gammadelta T-cell development. The effect was specific to the DN stage, because CD4 promoter-driven SPA-1 expression hardly affected T-cell development. Rap1A17, a dominant-negative Rap mutant, interfered with the generation of double-positive (DP) cells from Rag2(-/-) fetal thymocytes in vitro in the presence of anti-CD3epsilon antibody and Notch ligand. Rap GTPases were activated in a DN cell line by the expression of self-oligomerizing CD3 (CD8:CD3epsilon chimera), which substituted autonomous pre-T-cell receptor (TCR) signal, inducing CD69 expression and CD25 down-regulation. Reciprocally, expression of C3G, a Rap guanine nucleotide exchange factor, in both normal and Rag2(-/-) DN cells markedly enhanced Notch-dependent generation and expansion of DP cells without additional anti-CD3epsilon antibody, thus bypassing pre-TCR. Defective alphabeta T-cell development in the conditional SPA-1-transgenic mice was restored completely by introducing a p53(-/-) mutation. These results suggest that endogenous Rap GTPases downstream of pre-TCR play an essential role in rescuing pre-T cells from the p53-mediated checkpoint response, thus allowing Notch-mediated expansion and differentiation.

Quality of life from the viewpoint of patients with dementia in Japan: nurturing through an acceptance of dementia by patients, their families and care professionals.

The quality of life (QoL) of patients with dementia was investigated from the patient's viewpoint, and the role of an acceptance of dementia in maintaining important and distinctive elements of QoL was analysed by questionnaire and interview methods. The subjects of the present study were 18 patients, 21 family members and eight members of staff at a day-care facility in Japan. Patients with dementia hoped to maintain an 'ordinary' way of life. Living peacefully, living together, living healthily and helping each other were considered by patients with dementia to be the important elements of their QoL. Living happily in the present is important, but hopes and expectations for the maintenance of human values in their future lives are of greater importance in their estimation of QoL. Through recognizing these needs, a culture and understanding of 'living with dementia' can be nurtured. A dynamic process involving the mutual acceptance of dementia in the relationships between patients with dementia, their families and care professionals enabled elderly people to surmount their initial troubles, and to recoup and activate their former humane attitudes. Positive thinking reappeared and new forms of relationships emerged. The patients, their families and the care professionals came to understand each other better and gained the sense of 'living together'. The process began with 'confronting' the situation and progressed to the final stage of 'acceptance': the patient with dementia was confronted with the dementia itself, the family was confronted with the elderly person as a human being, and the care professional was confronted with her or himself. At first, the care professionals had felt a sense of social responsibility for delivering justice, but they had gradually noticed that they were themselves relieved of the strain resulting from these attitudes. Acceptance of dementia by the care professional was important in carrying forward this dynamic process, which helps to ensure the desired QoL for the patient with dementia.

Social factors associated with psychological distress among inhabitants in a methyl-mercury polluted area in rural Japan.

Little attention has been paid to the mental health of inhabitants of methylmercury-polluted areas in Japan. This study examined the relationship between one's experience with Minamata disease (MD) (such as compensation issues) and psychological distress. The subjects were 133 (44.2%) of the 301 inhabitants over the age of 40 years living in two fishing village districts along the coast of the Yatsushiro Sea which had been contaminated with methylmercury. Data on the inhabitants' experience with MD, social network factor, health condition and mental health were obtained using questionnaires including the General Health Questionnaire (GHQ)-30. The proportional odds model was used to estimate the adjusted odds ratios of factors associated with a higher GHQ score after adjustment for age, sex and village. MD status based on MD compensation, level of participation in MD patients' groups, and presence of certified MD patients in the family were significantly associated with psychological distress. Although these associations decreased after further adjustments were made taking health condition into consideration, MD status, participation in several sit-ins and the presence of certified MD patients in the family maintained marginally positive association with psychological distress. Further investigations with more precise and detailed measurements are needed to corroborate the relationship between inhabitants' experience with MD and mental health.

Retrospective study of preventive effect of maize on mortality from Parkinson's disease in Japan.

The findings of a negative association between past maize (Zea mays) production and current Parkinson's disease mortality by each prefecture in Japan tends to support the hypothesis that the nutritional condition that causes niacin deficiency might protect people from Parkinson's disease. Specifically, the negative association between both the area planted for dried corn in 1960, 1970 or 1977 and the area planted for sweet corn in 1960 and age-adjusted death rates for Parkinson's disease is ecological evidence supporting the hypothesis. Extending the analysis to other cultivated crops, even stronger negative associations of age-adjusted death rates for Parkinson's disease and cultivation of rice and soybeans were found, but associations were not significant for a large variety of vegetables. The findings for soybean and rice are attributed to the correspondence (co-linearity) of cultivation of these other two seed-crops with maize. Hence, further testing of the theory of niacin deprivation and prevention of Parkinson's disease finds some circumstantial support in the cultivation patterns of a grain of poor niacin and tryptophan availability.

Changes in the fatty acid composition and hydroxyproline content in rat lung in relation to collagen synthesis after paraquat administration.

OBJECTIVES: Effect of paraquat on the fatty acid composition (weight percentage) of rat lung was studied with particular reference to the change of hydroxyproline content in the course of paraquat-induced dysfunction and subsequent repair. METHODS: Eight-week-old male Wistar rats were administered paraquat at 20 mg/kg body weight subcutaneously, and the wet weight, hydroxyproline content and fatty acid composition of lungs of each group rats were analyzed at 2, 7, 14 or 28 days after treatment, respectively. RESULTS: The percentage of palmitic acid (C16:0), arachidonic acid (C20:4) and docosahexaenoic acid (C22:6) significantly increased, and the percentage of oleic acid (C18:1) and the ratio of monounsaturated fatty acids/saturated fatty acids (M/S) significantly decreased comparing to control on day 28 after paraquat administration. The time-course of each fatty acid was observed for 28 days after paraquat administration. M/S ratio decreased after paraquat administration up to the 28th day, but the polyunsaturated fatty acids/saturated fatty acids (P/S) ratio decreased during the first 7 days, followed by a increase, and then reached higher level than the 0 day control at the 28th day. Hydroxyproline also increased between the 14th and the 28th days. Eicosapentaenoic acid (C20:5) had once increased during the first 2 days and decreased gradually, while C20:4 maintained high level in this period. C22:6 increased after paraquat administration and maintained high level up to the 28th day. This result indicated that desaturation and elongation in n-3 series fatty acids were accelerated after paraquat treatment, and consequently C20:5 was rapidly converted into C22:6 and decreased. CONCLUSIONS: Paraquat might cause elevation of unsaturated fatty acids, espe- cially C20:4 but not C20:5 by the stimulation of the fatty acid desaturase system, and could consequently stimulate local collagen synthesis by C20:4 metabolites in the healing stage.

AF-6 controls integrin-mediated cell adhesion by regulating Rap1 activation through the specific recruitment of Rap1GTP and SPA-1.

In the present study, we showed that SPA-1, a Rap1 GTPase-activating protein (GAP), was bound to a cytoskeleton-anchoring protein AF-6. SPA-1 and AF-6 were co-immunoprecipitated in the 293T cells transfected with both cDNAs as well as in normal thymocytes. In vitro binding studies using truncated fragments and their mutants suggested that SPA-1 was bound to the PDZ domain of AF-6 via probable internal PDZ ligand motif within the GAP-related domain. The motif was conserved among Rap1 GAPs, and it was shown that rapGAP I was bound to AF-6 comparably with SPA-1. RapV12 was also bound to AF-6 via the N-terminal domain, and SPA-1 and RapV12 were co-immunoprecipitated only in the presence of AF-6, indicating that they could be brought into close proximity via AF-6 in cells. Immunostaining analysis revealed that SPA-1 and RapV12 were co-localized with AF-6 at the cell attachment sites. In HeLa cells expressing SPA-1 in a tetracycline-regulatory manner, expression of AF-6 inhibited endogenous Rap1GTP and beta(1) integrin-mediated cell adhesion to fibronectin in SPA-1-induced conditions, whereas it affected neither of them in SPA-1-repressed conditions. These results suggested that AF-6 could control integrin-mediated cell adhesion by regulating Rap1 activation through the recruitment of both SPA-1 and Rap1GTP via distinct domains.

The starch branching enzyme I locus from Aegilops tauschii, the donor of the D genome to wheat.

Analysis of DNA from Aegilops tauschii revealed that sequences hybridisable to the starch branching enzyme I (SBE I) gene were contained within a 53-kb fragment. There were at least four genes or gene fragments but of these only one appeared to encode the SBE I observed in the endosperm. Two large-insert DNA clones that encode SBE I from A. tauschii were isolated. Hybridisation analysis confirmed the presence of multiple SBE I gene type sequences within this DNA fragment of approximately 100 kb. Fluorescent in situ hybridisation (FISH) on extended DNA fibres provided further evidence of the close proximity of three of these genes. Sequence analysis was undertaken and this demonstrated that wSBE I-D3, wSBE I-D2 and wSBE I-D4 genes were clustered within 27 kb of DNA; of these only wSBE I-D4 encodes the SBE I purified from the endosperm. Multiple but distinct cDNAs containing SBE I-related sequences have been reported and these could arise from the SBE I locus by different transcription/splicing regimes.

Change of the smoking behavior and related lifestyle variables among physicians in Fukuoka, Japan: a longitudinal study.

Two cross-sectional surveys of the entire membership of the Fukuoka Prefecture Medical Association were conducted in 1983 and 1990 using a self-administered questionnaire, and respondents were registered as the study cohort. In this investigation the trend of the actual prevalence of smoking among physicians and the relationship between their smoking cessation and living habits were studied. A decline in the actual prevalence of smoking was demonstrated among the 2,656 subjects who responded to both surveys (2,543 men and 113 women). To examine any relationship between lifestyle variables and smoking cessation after 1983, those who were smokers in 1983 (1,099 men and 7 women, total 1,106) were divided into two groups, according to whether or not they still smoked in 1990. Subjects who quit smoking accounted for a larger proportion of those physicians with any of the following life-style variables: earlier bedtimes, unawareness of mental stress, greater consumption of fresh vegetables and fruit, and less coffee consumption. Further observation of the relationship between smoking cessation and changes in lifestyle variables showed that there were more who quit smoking among those who became employed physicians, had an increase of the body mass index (BMI) and began to be aware of mental stress. These results suggested that, for physicians who smoked, it is a possibility that smoking was an important way of coping with stress, and thus pointed to the need to take mental-health measures to help physicians to stop smoking.