The gonio scratch study: methodology of a multicenter clinical trial establishing a new minimally invasive glaucoma surgery

There are numerous surgical procedures for glaucoma. Minimally invasive glaucoma surgery is becoming popular; however, the disadvantage is the high incidence of anterior chamber hemorrhage. Heavy bleeding can also lead to increased intraocular pressure (IOP) postoperatively. Gonio scratch is a surgical procedure that improves aqueous humor outflow by rubbing off deposits on the trabecular meshwork with a Diamond Dusted Sweeper. As the conjunctiva and trabecular meshwork are not incised, no postoperative bleeding is expected, and the IOP spike will be minimal. We designed this study to determine the efficacy and safety of gonio scratch. This is an on-going multicenter, prospective, clinical trial. Patients who are scheduled for glaucoma surgery with or without cataract surgery are being enrolled. A total of 80 eyes will be recruited in the Hiroshima University Hospital, Miyoshi Eye Clinic, Yokoyama Retina Clinic, and Kusatsu Eye Clinic. All patients will undergo gonio scratch. When combined with cataract surgery, gonio scratch is performed after the intraocular lens is inserted. The primary study endpoint is the change in IOP from baseline to 1 year after surgery. The secondary endpoints are complications, number of glaucoma medications, surgical time, and changes in visual acuity and the visual field. This study protocol was approved by the institutional review board of Hiroshima University. The trial results will be shared with the scientific community at international conferences and by publication in a peer-reviewed journal. Trial registration number is jRCTs062200003.

Surgical Outcomes of Ab Interno Trabeculotomy Without Phacoemulsification

Purpose

The aim of this study was to evaluate ab interno trabeculotomy outcomes without phacoemulsification.

Methods

This retrospective study evaluated 118 eyes of patients aged 18 and above who underwent ab interno trabeculotomy between December 2017 and August 2022. When surgeries were performed in both eyes, only the eye undergoing the initial surgery was evaluated. Prior to and after surgery, the intraocular pressure (IOP) and mean number of IOP-lowering medications were compared. An IOP of ≤21 mmHg (A) and ≤18 mmHg (B) along with a ≥20% reduction in the preoperative IOP was defined as survival. Cases that required reoperation for glaucoma were defined as surgical failure. The Kaplan-Meier method was used to evaluate the survival rates. A Cox proportional hazards model was used to analyze the preoperative factors that influenced survival rates.

Results

At 36 months postoperatively, the 13.4 ± 2.8 mmHg average IOP was significantly decreased from the preoperative 23.5 ± 9.8 mmHg value (P < 0.0001). Moreover, a significant decrease in the mean number of the IOP-lowering medications to 2.3 ± 1.4 at 36 months was found versus the initial 3.9 ± 1.1 preoperative value (P < 0.0001). The survival rates for criteria A and B at 36 months postoperatively were 28% and 25%, respectively. Only the preoperative IOP was identified by multivariate analysis as a factor influencing survival rates (P < 0.0001). Hyphema in 36 eyes (30.5%) and an IOP spike in 20 eyes (16.9%) were the only observed complications. Additional glaucoma surgery was required in 27 eyes (22.9%) during the follow-up period.

Conclusion

Utilization of ab interno trabeculotomy effectively lowered the IOP and reduced the number of IOP-lowering medications. Patients with higher preoperative IOP exhibited better postoperative outcomes.

Safety and Efficacy of the Rho-Kinase Inhibitor (Ripasudil) in Bleb Needling after Trabeculectomy: A Prospective Multicenter Study

Ripasudil, a rho-associated protein kinase inhibitor ophthalmic solution, shows a protective effect in preventing excessive scarring in vitro. This study aims to evaluate the safety and efficacy of ripasudil for glaucoma patients submitted to the needling procedure. In this prospective, multicenter, single-arm study, we included 20 eyes of 20 patients with glaucoma who underwent the needling procedure without antimetabolites. All patients administered ripasudil after needling for three months. The primary endpoint of this study was the safety of ripasudil in patients, and the secondary endpoint was the change in IOP at 12 weeks after the needling procedure. No serious complications were found in the patients. One eye experienced pruritus and conjunctival follicle, while another eye had conjunctival follicle. These complications were transient and resolved quickly after discontinuation of ripasudil. The mean preoperative IOP was 14.6 ± 4.6 mmHg, which decreased to 11.0 ± 4.7 mmHg (p = 0.0062) at 1 week postoperatively. The IOP reduction effect continued to 12 weeks (11.8 ± 3.1 mmHg; p = 0.0448). The administration of the ROCK inhibitor, ripasudil, after the needling procedure is safe and effective in maintaining IOP for 12 weeks.

A Retrospective Study of Risk Factors Affecting Long-Term Outcomes Following Ab Interno Trabeculotomy and Goniotomy Concomitant with Phacoemulsification

Purpose

To examine the potential risk factors affecting the long-term outcomes following a combination of phacoemulsification with ab interno trabeculotomy with the microhook (μLOT-Phaco) and goniotomy with the Kahook Dual Blade (KDB-Phaco).

Methods

For 12 months, we retrospectively examined a total of 100 eyes of 100 patients with primary open-angle glaucoma (POAG) and exfoliation glaucoma (EG) who had previously undergone surgery between December 2016 and December 2020. Patients with a preoperative intraocular pressure (IOP) ˂12 mmHg were excluded. Probability of success was calculated using the Kaplan-Meier method, with surgical failure defined as an IOP >18 mmHg, <20% IOP reduction or additional glaucoma surgery. The Cox proportional hazards model was used to examine the potential risk factors for failure, which included age, gender, type of glaucoma, surgical techniques, preoperative IOP, number and type of preoperative IOP-lowering medications, preoperative visual field mean deviation (MD) value, and axial length.

Results

For the 51 males and 49 females, mean preoperative age was 74.4 ± 9.0 years, with μLOT-Phaco performed in 44 and KDB-Phaco in 56 subjects. The type of glaucoma was POAG in 68 and EG in 32 eyes. Preoperative IOP was 20.5 ± 6.7 mmHg, while postoperative IOPs were 14.4 ± 4.2 mmHg, 13.7 ± 2.8 mmHg, and 14.6 ± 3.9 mmHg, respectively (P < 0.001). Significant decreases from the preoperative number of IOP-lowering medications (3.1 ± 1.2) were observed at 12, 24, and 36 months, respectively (1.2 ± 1.3, 1.6 ± 1.3, and 2.1 ± 1.4 (P < 0.001)). Probability of success at 12, 24, and 36 months postoperatively was 52.0%, 49.6%, and 47.7%, respectively. Lower preoperative IOP was shown to be a potential risk factor for surgical failure.

Conclusion

Long-term follow-ups showed IOP decreased in μLOT-Phaco and KDB-Phaco patients. Results suggest that patients with higher preoperative IOP may have better postoperative outcomes.

Effect of Ocular Dominance on Ocular Blood Flow Parameters

PURPOSE

In binocular vision, there is a dominant eye and a nondominant eye, a phenomenon termed ocular dominance. This study determined the differences and associations of the ocular blood flow parameters between dominant and nondominant eyes in healthy Japanese subjects.

METHODS

This cross-sectional study included 128 eyes of 64 subjects (13 male and 51 female) aged ≥ 20 years. The ocular blood flow parameters were assessed using laser speckle flowgraphy (LSFG), and software was used to calculate the mean blur rate (MBR), which reflects the blood flow velocity.

RESULTS

There were no significant differences in axial length (AL), spherical equivalent (SE), intraocular pressure (IOP), uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), or ocular blood flow parameters between the dominant and nondominant eyes. The ocular blood flow parameters of the dominant eye were significantly and positively correlated with those of the nondominant eye (all P < 0.001).

CONCLUSIONS

No significant differences in ocular blood flow parameters exist between the dominant and nondominant eyes in healthy subjects. The ocular blood flow parameters in the dominant eye are associated with those in the nondominant eye.

Comparison of surgical outcomes between iStent inject W implantation and microhook ab interno trabeculotomy in combination with phacoemulsification in primary open-angle glaucoma patients

Purpose

To examine primary open-angle glaucoma patients after undergoing combined cataract surgery with microhook ab interno trabeculotomy (μLOT-Phaco) or iStent inject W implantation (iStent-Phaco), and then evaluate the surgical outcomes after a minimum of 6 months of follow-up.

Methods

Between October 2020 and July 2022, 39 μLOT-Phaco eyes and 55 iStent-Phaco eyes that underwent surgery were evaluated in this retrospective, multicenter comparative case series. Data that included preoperative and postoperative intraocular pressure (IOP), number of glaucoma medications, and occurrence of complications were collected from medical records and then examined. Surgical failure was defined as patients exhibiting a < 20% reduction in the preoperative IOP or an IOP > 18 mmHg on two consecutive follow-up visits, or when patients were required to undergo reoperation. Success rates were determined based on a Kaplan-Meier survival analysis.

Results

At 3, 6 and 12 months postoperatively, there was a significant postoperative reduction in the IOP (p < 0.001) and in the medications scores (p < 0.001) for both of the groups. In the μLOT-Phaco and iStent-Phaco groups, the probabilities of success at 6 and 12 months were 55.3 and 45.5%, and 48.4 and 45.5% (p = 0.38; log-rank test), respectively. In the iStent-Phaco group, there was a significant decrease in the hyphema.

Conclusion

Comparable surgical outcomes occurred for both the μLOT and iStent inject W procedures.

Ex-PRESS Implantation versus Trabeculectomy for Long-Term Maintenance in Patients with Open-Angle Glaucoma

Purpose

To compare the efficacy of Ex-PRESS implantation (EXP) with that of trabeculectomy (TLE) with mitomycin C for maintaining low target intraocular pressure (IOP) in patients with open-angle glaucoma.

Patients and Methods

Patients were randomly assigned to receive EXP or TLE. Surgical success was defined according to three target mean IOP ranges (5 mmHg ≤ IOP ≤ 18 mmHg [criterion A], 5 mmHg ≤ IOP ≤ 15 mmHg [criterion B], and 5 mmHg ≤ IOP ≤ 12 mmHg [criterion C]) representing reductions of at least 20% below the baseline on two consecutive follow-up visits 3 months post-surgery, with or without antiglaucoma medication and without further glaucoma surgery. Participants were divided into three subgroups based on baseline mean deviation (MD) values: early (MD ≥ -6 dB), moderate (-6 dB > MD ≥ -12 dB), and advanced (-12 dB > MD). Survival rates were calculated by subgroup.

Results

A total of 73 patients, including 30 in the EXP group and 43 in the TLE group, were included in the study. No significant differences in baseline ocular or demographic characteristics were found between the two groups. No significant difference in IOP was noted every 6 months. After the 3-year follow-up, success rates were A) 60.0% and 60.2%, B) 45.7% and 58.1%, and C) 31.5% and 40.5% for the EXP and TLE groups, respectively. Moreover, there was no difference in success rate based on glaucoma level. Many glaucoma medications administered before surgery were associated with a higher failure rate in the TLE group but not in the EXP group.

Conclusion

Both procedures resulted in similar IOP reductions and success rates for a low target IOP. The number of preoperative glaucoma medications was a risk factor for TLE failure.

Comparison of Corvis ST Parameters between Primary Open-Angle Glaucoma and Primary Angle-Closure Glaucoma

BACKGROUND

We compared corneal visualization Scheimpflug technology (CST) parameters between eyes with primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG).

METHODS

A retrospective analysis was performed on data from 89 eyes with POAG and 83 eyes with PACG that had CST examinations. CST parameters were compared between eyes with POAG and those with PACG using a linear mixed model (LMM).

RESULTS

No differences were observed in age, central corneal thickness, intraocular pressure, or use of antiglaucoma eye drops between the two groups. Patients with PACG had a significantly shorter axial length (AL), a higher proportion of females, CST parameters, longer applanation 2 (A2) time, deeper A2 deformation amplitude, shorter peak distance, longer whole eye movement, and longer whole eye movement time than patients with POAG. The highest concavity (HC) length and PD showed a significant positive correlation with AL. However, A1 length, A1 deformation amplitude, A2 time, A2 velocity, A2 length, A2 deformation amplitude, HC time, whole eye movement, and whole eye movement time were negatively correlated with AL.

CONCLUSIONS

The biomechanical properties of the cornea differed between POAG and PACG. In some parts, AL differences between the POAG and PACG groups might contribute to the variation in CST parameters.

Posterior sclerectomy for persistent serous retinal detachment with secondary glaucoma in Sturge-Weber syndrome: A case report

INTRODUCTION

A serous retinal detachment is one of the most likely ocular manifestation of Sturge-Weber syndrome (SWS). This finding can frequently occur as a complication after filtering surgery to maintain the intraocular pressure (IOP). Proper treatment has been approached with choroidal hemangioma as an organ target. To the best of our knowledge, various treatments for SRD are associated with diffuse choroidal hemangioma has been approached. However, a second retinal detachment following radiation therapy has worsened the situation. Here, we report an unexpected serous retina and choroidal detachment after non penetrating trabeculectomy. Although radiation therapy has been proposed for previous detachment to the ipsilateral eye in this case, repetition radiation therapy was not suggested concerning the health and quality of life especially in for young subjects. However, the kissing choroidal detachment in this case necessitated immediate intervention. Thus, posterior sclerectomy was performed for the recurrent retinal detachment. We believe that an intervention for a SWS case related complication will remain a significant and important to share as a public health contribution.

CASE PRESENTATION

A 20 year-old male confirmed with SWS with no known family history was diagnosed with SWS. He was gain from another hospital for glaucoma therapy. On the left brain MRI showed severe hemiatrophy in the frontal and parietal lobes and leptomeningeal angioma. Although his right (RE) eye had 3 gonio surgeries, 2 Baerveldt tube shunts and Micropulse trans-scleral cyclophotocoagulation, his IOP remained uncontrollable when he was 20 years old. RE IOP was in controlled after non-penetrating filtering surgery hence, his RE developed a recurrent serous retinal detachment. A posterior sclerectomy was performed in 1 quadrant of the globe to drain subretinal fluid.

CONCLUSION

Sclerectomies to the inferotemporal quadrant of the globe for serous retinal detachment associated with SWS are considered efficient for optimal drain subretinal fluid, resulting in complete regression of detachment.

A multicenter phase II study on the safety of rho-kinase inhibitor (ripasudil) with needling for the patients after trabeculectomy

Background

There is no established method of maintaining or reducing intra ocular pressure after the needling procedure for failing blebs post trabeculectomy. Regarding newer antihypertensive medications, ripasudil, which is a rho-associated protein kinase inhibitor ophthalmic solution, was able to prevent excessive scarring in vitro. This study aims to evaluate the safety of glaucoma patients submitted to the needling procedure and administered ripasudil for preventing scarring after the procedure. We also investigate the efficacy of ripasudil after needling for bleb failure through suppression of fibrosis to the bleb.

Methods

This study is a multicenter, open-label, single-arm, phase II trial to evaluate the safety and efficacy of ripasudil in glaucoma patients after the needling procedure. Forty patients who will undergo needling at least 3 months after trabeculectomy will be recruited in Hiroshima university hospital and Hiroshima eye clinic. All the patients will instill ripasudil two times per day for three months after the needling procedure. The primary endpoint is the safety of ripasudil.

Conclusions

We plan to establish the safety of ripasudil and to collect information involving the efficacy of ripasudil widely in this study.

Usefulness of critical flicker fusion frequency measurement and its laterality for evaluating compressive optic neuropathy due to pituitary neuroendocrine tumors

Critical flicker fusion frequency (CFF) is a short but sensitive method for evaluating optic nerve function. We measured CFF in patients with pituitary neuroendocrine tumors (Pit-NETs) to assess its usefulness. Data from 184 patients with nonfunctioning Pit-NETs, who had been treated with transsphenoidal surgery and had no medical history of eye diseases, was used in this retrospective study. Visual acuity decline (VAD) was defined as > 0.10 reduction in logMAR visual acuity and CFF decline (CFD) was defined as CFF value < 35 Hz. Visual field defect (VFD) was evaluated by automated perimetry on a Humphrey visual field analyzer. Potential associations between abnormal test results and tumor height from the suprasellar were analyzed. Contact between the optic nerve or chiasma and the tumor was present and absent in 161 and 23 patients, respectively. In patients showing contact, the difference in CFF between the left and right eyes was larger (p = 0.0008), and the optimal cutoff value using the receiver operating characteristic curve was 3 Hz. Therefore, ≥ 3 Hz was considered positive for CFF laterality (CFL), the most prevalent condition. Tumor height was lower in patients with CFL positivity compared to those with VAD or VFD (p < 0.01). The prevalence of test abnormalities was the highest for small tumors compared to those of other tests. Changes in CFL permit early detection of Pit-NETs. Our results indicate that CFF laterality can be seen in the early stages of compressive optic neuropathy due to Pit-NET.

Effect of the rho-kinase inhibitor ripasudil in needling with mitomycin C for the failure of filtering bleb after trabeculectomy: a cross-sectional study

Background

Rho-kinase inhibitors can inhibit fibrosis after glaucoma surgery. This study aimed to evaluate the effect of rho-kinase inhibitor after needling procedure with mitomycin C for the failure of filtering bleb with trabeculectomy.

Methods

This retrospective single-center study examined the effects of rho-kinase inhibitor after the needling procedure. We included 27 eyes of 27 patients with glaucoma who underwent needling procedure using mitomycin C and were subsequently treated with ripasudil—a rho-associated protein kinase inhibitor (ripasudil group)—or without ripasudil (control group). The ripasudil and control groups were compared in terms of intraocular pressure (IOP) and the number of antiglaucoma medications. Success at 12 months after the needling procedure was defined as a > 20% decrease in IOP from the preoperative period without surgical reintervention.

Results

At 12 months after the needling procedure, the mean IOP decreased from 16.9 ± 4.5 to 12.6 ± 1.1 mmHg in the control group and from 16.0 ± 5.3 to 12.2 ± 1.2 mmHg in the ripasudil group (p = 0.77). The 12-month success rates were 60.00% and 56.25% in the control and ripasudil groups (p = 0.98), respectively. In the preoperative period, the numbers of antiglaucoma drugs were 0.27 ± 0.46 and 0.92 ± 0.91 in the control and ripasudil groups (p = 0.022), respectively, and at 12 months after the needling procedure, they were 1.07 ± 1.44 and 0.73 ± 1.10 (p = 0.52), respectively.

Conclusions

Treatment with ripasudil (a rho-associated protein kinase inhibitor) after the needling procedure with mitomycin C did not show better results than treatment with the mitomycin C needling procedure alone at 12 months after the procedure.

Association of the CYP39A1 G204E genetic variant with increased risk of glaucoma and blindness in patients with exfoliation syndrome

PURPOSE

Carriers of functionally deficient mutations in the CYP39A1 gene have been recently reported to have a 2-fold increased risk of exfoliation syndrome (XFS). The aim of this study was to evaluate the risk of blindness and related clinical phenotypes of XFS patients carrying the loss-of-function CYP39A1 G204E mutation in comparison to XFS patients without any CYP39A1 mutation.

DESIGN

Retrospective case study PARTICIPANTS: 35 patients diagnosed with XFS carrying the CYP39A1 G204E mutation and 150 XFS patients without any CYP39A1 mutation, who were randomly selected from the Japanese XFS cohort.

METHODS

Two-sided Fisher's Exact Test with an α-level <0.05 was used to estimate the significance of the calculated Odds Ratio (OR) for all categorical measures. Comparisons between groups of subjects were performed using linear mixed effect models with group as random effect and taking possible dependence between eyes within a subject into account.

MAIN OUTCOME MEASURES

Primary analysis compared the incidence of blindness (defined as visual acuity [VA]<0.05 decimal), prevalence of exfoliation glaucoma (XFG), history of glaucoma surgery, and indices of glaucoma severity such as visual field mean deviation (MD), intraocular pressure (IOP) and vertical cup-disc ratio (CDR), between CYP39A1 G204E carriers and those without any CYP39A1 mutation.

RESULTS

The overall risk for blindness was significantly higher in XFS patients carrying the CYP39A1 G204E variant (10/35 [28.6%]) compared to XFS patients without any CYP39A1 mutations (8/150 [5.3%]; OR7.1 [95%CI:2.7-20.2]; p<0.001). A higher proportion of XFS patients with the CYP39A1 G204E mutation (23/35 [65.7%]) had evidence of XFG in at least one eye compared to the comparison group (41/150 [27.3%]; OR5.1 [95%CI:2.4-11.4]; p<0.0001). Significantly higher peak IOP, larger vertical CDR and worse visual field MD were also found in CYP39A1 G204E variant carriers (p<0.001). Additionally, patients with the CYP39A1 G204E mutation (18/35 [51.4%]) required more laser or glaucoma surgical interventions compared to those without any CYP39A1 mutation (32/150 [21.3%], p<0.001).

CONCLUSIONS

Patients with XFS carrying the CYP39A1 G204E mutation had significantly increased risk of blindness, higher occurrence of XFG and more severe glaucoma compared to patients with XFS without any CYP39A1 mutation.

Treatment outcomes in the neovascular glaucoma tube versus trabeculectomy study

PURPOSE

To compare surgical outcomes between patients who underwent Baerveldt glaucoma implantation versus trabeculectomy (TLE) for the treatment of neovascular glaucoma.

METHODS

We performed a prospective, randomized, controlled clinical trial at Hiroshima University and Tsukazaki Hospital, Japan. Patients were randomized to Baerveldt glaucoma implantation (23 patients) or TLE (27 patients). The primary outcome measure was the rate of intraocular-pressure control. Secondary outcome measures included complications and interventions. We defined "failure" as intraocular pressure ≥ 22 mmHg or < 20% reduction from baseline pressure, on two consecutive follow-up visits; need for additional glaucoma surgery; vision-threatening complications; or loss of light perception. Kaplan-Meier analysis was used to determine surgical success rates. Postoperative complications and interventions were compared between the two groups with Pearson Chi-square tests.

RESULTS

There were no significant differences in demographic or ocular characteristics between the treatment groups at baseline. The postoperative follow-up was 26.6 ± 19.4 months in the Baerveldt group and 27.3 ± 20.1 months in the TLE group. There were no statistical differences (Mann-Whitney nonparametric tests with Bonferroni correction) in postoperative intraocular pressure measured at 6-month intervals. Success rates were 59.1 and 61.6% at 1-year after Baerveldt glaucoma implantation and TLE, respectively. Kaplan-Meier analysis showed no significant difference in success between groups (P = 0.71, log-rank test). Medication use, visual acuity, and interventions were similar between groups. Thirteen late postoperative complications developed in the Baerveldt glaucoma implantation group and four complications developed in the TLE group. Tube exposure was the most common late complication.

CONCLUSION

These two procedures produced similar surgical success, intraocular-pressure reductions, visual acuity, and number of medications at the last visit. The TLE group showed smaller numbers of late complications and patients who lost more than two lines of visual acuity. Therefore, TLE might be a safer and better way to treat patients with neovascular glaucoma.

Comparison of the Humphrey Field Analyzer and Photopic Negative Response of Focal Macular Electroretinograms in the Evaluation of the Relationship Between Macula Structure and Function

Purpose: To investigate the association between macular inner retinal layer thickness and macula visual field (VF) mean deviation as measured by the Humphrey Field Analyzer (HFA) or macular function as measured by focal macular electroretinograms (ERGs) in patients with glaucoma.

Methods: The participants in this cross-sectional study were 71 patients with glaucoma and 10 healthy controls. Macular inner retinal layer thickness and function were measured in all participants using optical coherence tomography (OCT) and HFA or focal macular ERGs, respectively. Macular OCT images were segmented into the macular retinal nerve fiber layer (mRNFL), macular ganglion cell layer/inner plexiform layer (GCL/IPL), and ganglion cell complex (GCC). Spearman correlation analysis was used to assess the relationship between macular inner retinal layer thickness and function.

Results: Focal macular ERGs were composed of a negative wave (N1), a positive wave (P1), and a slow negative wave (N2). The N2 response density was significantly reduced in eyes with glaucoma, and was significantly associated with the thickness of the mRNFL (R = 0.317), GCL/IPL (R = 0.372), or GCC (R = 0.367). The observed structure–function relationship was also significantly correlated with the HFA VF mean deviation for each thickness [mRNFL (R = 0.728), GCL/IPL (R = 0.603), or GCC (R = 0.754)].

Conclusions: Although a significant correlation was found between the N2 response density and the thickness of the macular inner layer, the observed structure–function relationship with the mean deviation of the HFA VF was higher than that of the N2 response density.

Association of Rare CYP39A1 Variants With Exfoliation Syndrome Involving the Anterior Chamber of the Eye

IMPORTANCE

Exfoliation syndrome is a systemic disorder characterized by progressive accumulation of abnormal fibrillar protein aggregates manifesting clinically in the anterior chamber of the eye. This disorder is the most commonly known cause of glaucoma and a major cause of irreversible blindness.

OBJECTIVE

To determine if exfoliation syndrome is associated with rare, protein-changing variants predicted to impair protein function.

DESIGN, SETTING, AND PARTICIPANTS

A 2-stage, case-control, whole-exome sequencing association study with a discovery cohort and 2 independently ascertained validation cohorts. Study participants from 14 countries were enrolled between February 1999 and December 2019. The date of last clinical follow-up was December 2019. Affected individuals had exfoliation material on anterior segment structures of at least 1 eye as visualized by slit lamp examination. Unaffected individuals had no signs of exfoliation syndrome.

EXPOSURES

Rare, coding-sequence genetic variants predicted to be damaging by bioinformatic algorithms trained to recognize alterations that impair protein function.

MAIN OUTCOMES AND MEASURES

The primary outcome was the presence of exfoliation syndrome. Exome-wide significance for detected variants was defined as P < 2.5 × 10-6. The secondary outcomes included biochemical enzymatic assays and gene expression analyses.

RESULTS

The discovery cohort included 4028 participants with exfoliation syndrome (median age, 78 years [interquartile range, 73-83 years]; 2377 [59.0%] women) and 5638 participants without exfoliation syndrome (median age, 72 years [interquartile range, 65-78 years]; 3159 [56.0%] women). In the discovery cohort, persons with exfoliation syndrome, compared with those without exfoliation syndrome, were significantly more likely to carry damaging CYP39A1 variants (1.3% vs 0.30%, respectively; odds ratio, 3.55 [95% CI, 2.07-6.10]; P = 6.1 × 10-7). This outcome was validated in 2 independent cohorts. The first validation cohort included 2337 individuals with exfoliation syndrome (median age, 74 years; 1132 women; n = 1934 with demographic data) and 2813 individuals without exfoliation syndrome (median age, 72 years; 1287 women; n = 2421 with demographic data). The second validation cohort included 1663 individuals with exfoliation syndrome (median age, 75 years; 587 women; n = 1064 with demographic data) and 3962 individuals without exfoliation syndrome (median age, 74 years; 951 women; n = 1555 with demographic data). Of the individuals from both validation cohorts, 5.2% with exfoliation syndrome carried CYP39A1 damaging alleles vs 3.1% without exfoliation syndrome (odds ratio, 1.82 [95% CI, 1.47-2.26]; P < .001). Biochemical assays classified 34 of 42 damaging CYP39A1 alleles as functionally deficient (median reduction in enzymatic activity compared with wild-type CYP39A1, 94.4% [interquartile range, 78.7%-98.2%] for the 34 deficient variants). CYP39A1 transcript expression was 47% lower (95% CI, 30%-64% lower; P < .001) in ciliary body tissues from individuals with exfoliation syndrome compared with individuals without exfoliation syndrome.

CONCLUSIONS AND RELEVANCE

In this whole-exome sequencing case-control study, presence of exfoliation syndrome was significantly associated with carriage of functionally deficient CYP39A1 sequence variants. Further research is needed to understand the clinical implications of these findings.

Determinants of corneal endothelial cell loss after sulcus placement of Ahmed and Baerveldt drainage device surgery

AIM

In patients who underwent multiple intraocular surgeries, we evaluated determinants of decreased corneal endothelial cell density (CECD) after sulcus placement following Ahmed and Baerveldt drainage device surgery.

METHODS

We retrospectively reviewed consecutive patients with glaucoma who underwent sulcus placement with an Ahmed glaucoma valve or a Baerveldt glaucoma implant. We compared presurgical and postsurgical CECD and risk factors for decreased CECD.

RESULTS

We examined 41 eyes of 41 patients. Postsurgical CECD measurements were assessed 2.0±1.0 times during a median follow-up period of 28 months. The mean intraocular pressure (IOP) decreased from 28.4±11.6 mmHg to 12.2±5.3 mmHg 24 months after the operation. At 24 months, CECD decreased 14.6±5.4% after considering the variability in the number and time points of CECD determinations. History of prior surgery and higher preoperative IOP were significantly associated with a trend for a time-dependent decrease in CECD.

CONCLUSIONS

Risk factors for decreased CECD after sulcus placement during Ahmed and Baerveldt drainage device surgery included the number of previous intraocular surgeries and higher presurgical IOP.

Effects of Study Population, Labeling and Training on Glaucoma Detection Using Deep Learning Algorithms

Purpose

To compare performance of independently developed deep learning algorithms for detecting glaucoma from fundus photographs and to evaluate strategies for incorporating new data into models.

Methods

Two fundus photograph datasets from the Diagnostic Innovations in Glaucoma Study/African Descent and Glaucoma Evaluation Study and Matsue Red Cross Hospital were used to independently develop deep learning algorithms for detection of glaucoma at the University of California, San Diego, and the University of Tokyo. We compared three versions of the University of California, San Diego, and University of Tokyo models: original (no retraining), sequential (retraining only on new data), and combined (training on combined data). Independent datasets were used to test the algorithms.

Results

The original University of California, San Diego and University of Tokyo models performed similarly (area under the receiver operating characteristic curve = 0.96 and 0.97, respectively) for detection of glaucoma in the Matsue Red Cross Hospital dataset, but not the Diagnostic Innovations in Glaucoma Study/African Descent and Glaucoma Evaluation Study data (0.79 and 0.92; P < .001), respectively. Model performance was higher when classifying moderate-to-severe compared with mild disease (area under the receiver operating characteristic curve = 0.98 and 0.91; P < .001), respectively. Models trained with the combined strategy generally had better performance across all datasets than the original strategy.

Conclusions

Deep learning glaucoma detection can achieve high accuracy across diverse datasets with appropriate training strategies. Because model performance was influenced by the severity of disease, labeling, training strategies, and population characteristics, reporting accuracy stratified by relevant covariates is important for cross study comparisons.

Translational Relevance

High sensitivity and specificity of deep learning algorithms for moderate-to-severe glaucoma across diverse populations suggest a role for artificial intelligence in the detection of glaucoma in primary care.

Relationship between novel intraocular pressure measurement from Corvis ST and central corneal thickness and corneal hysteresis

Aims

Corvis ST (CST) yields biomechanical corrected IOP (bIOP) which is purported to be less dependent on biomechanical properties. In our accompanied paper, it was suggested that the repeatability of bIOP is high. The purpose of the current study was to assess the relationship between intraocular pressure (IOP) measured with CST and central corneal thickness (CCT) and corneal hysteresis (CH), in comparison with IOP measured with Goldmann applanation tonometry (GAT) and the ocular response analyzer (ORA).

Methods

A total of 141 eyes from 141 subjects (35 healthy eyes and 106 glaucomatous eyes) underwent IOP measurements with GAT, CST and ORA. The relationships between IOP measurements (ORA-IOPg, ORA-IOPcc, CST-bIOP and GAT IOP) and biomechanical properties (CCT, CH and corneal resistance factor (CRF)) were analysed using the linear regression analysis.

Results

IOPg, IOPcc and GAT IOP were significantly associated with CCT (p<0.001), whereas bIOP was not significantly associated with CCT (p=0.19). IOPg, bIOP and GAT IOP were significantly associated with CH (IOPg: p<0.001; bIOP: p<0.001; GAT IOP: p=0.0054), whereas IOPcc was not significantly associated with CH (p=0.18). All of IOP records were associated with CRF (p<0.001).

Conclusion

The bIOP measurement from CST is independent from CCT, but dependent on CH and CRF.

Validation of a Deep Learning Model to Screen for Glaucoma Using Images from Different Fundus Cameras and Data Augmentation

PURPOSE

To validate a deep residual learning algorithm to diagnose glaucoma from fundus photography using different fundus cameras at different institutes.

DESIGN

Cross-sectional study.

PARTICIPANTS

A training dataset consisted of 1364 color fundus photographs with glaucomatous indications and 1768 color fundus photographs without glaucomatous features. Two testing datasets consisted of (1) 95 images of 95 glaucomatous eyes and 110 images of 110 normative eyes, and (2) 93 images of 93 glaucomatous eyes and 78 images of 78 normative eyes.

METHODS

A deep learning algorithm known as Residual Network (ResNet) was used to diagnose glaucoma using a training dataset. The 2 testing datasets were obtained using different fundus cameras (different manufacturers) across multiple institutes. The size of the training data was artificially increased by adding minor alterations to the original data, known as "image augmentation." Diagnostic accuracy was assessed using the area under the receiver operating characteristic curve (AROC).

MAIN OUTCOME MEASURES

Area under the receiver operating characteristic curve.

RESULTS

When image augmentation was not used, the AROC was 94.8% (90.3-96.8) in the first testing dataset and 99.7% (99.4-100.0) in the second dataset. These AROC values were significantly (P < 0.05) smaller without augmentation (87.7% [82.8-92.6] in the first testing dataset and 94.5% [91.3-97.6] in the second testing dataset).

CONCLUSIONS

The previously developed deep residual learning algorithm achieved high diagnostic performance with different fundus cameras across multiple institutes, in particular when image augmentation was used.

Effects of perinatal stress on the anxiety‐related behavior of the adolescence mouse

We evaluated the effects of sound noise or forced swim stress applied to pregnant mice or to neonatal mice on the anxiety-related behavior using the elevated plus-maze test performed during the age of 5 weeks. The forced swim stress applied at the late gestation period, days 10-18 of pregnancy, caused a significant reduction of the body weight gain of the dams. However, the anxiety-related behavior of the male and female offspring were not affected by the antenatal stress treatment. When the forced swim stress was applied to the neonatal mice during the late lactation period, 14-18 days after birth, the male mice showed an elevated level of anxiolytic behavior accompanying the reduction of the emotion-related motor activity. The anxiety-related behavior of the female mice was not affected by the stress treatment. Furthermore, we applied the sound noise or forced swim stress to the neonatal mice immediately after the weaning, 21-25 days after birth. The stress applied after the weaning period had no effect on the anxiety-related behavior. These results suggested that the stress applied during the lactation period, but not that during the antenatal period, nor after the weaning period, might have gender-dependently reduced the anxiety level of the male mouse. It was shown that the effects of perinatal stress on the anxiety-related behavior of the adolescent mouse varied according to the period of application and gender. The hypothesis that gender-dependent abnormalities in neurodevelopment might be caused by the excess stress applied to the breast-fed infant is of importance in elucidating the relationship between the psychoneurotic disorder in childhood and the environment stress of the breast-fed infant.

Effects of (Z)-3-hexenol, a major component of green odor, on anxiety-related behavior of the mouse in an elevated plus-maze test and biogenic amines and their metabolites in the brain

In the present study, the effect of (Z)-3-hexenol, one of the main constituent of green odor, on the anxiety-related behavior of mouse and the content of 5-hydroxytryptamine (5-HT), dopamine and their metabolites in the brain were investigated. Evaluation of anxiety-related animal behavior was performed by measuring the percent of time spent on the open arms and the percent of open-arm entries as conventional anxiety indices. The number of times displaying risk-assessment from a closed arm was also measured as an ethological anxiety index. Diazepam, an anxiolytic agent, enhanced the percent of time spent on the open arms and the percent of open-arm entries. The number of times displaying risk-assessment was not affected by diazepam in the present study. The percent of time on the open arms were depressed, and the number of times displaying risk-assessment were stimulated by 1-(3-trifluoromethylphenyl)piperazine (TFMPP), indicating that TFMPP acts as an anxiogenic agent. (Z)-3-Hexenol revealed anxiolytic activity and increased the percent of time spent on the open arms and decreased the number of times displaying risk-assessment. In the neurochemical study, diazepam had no effect on the content of 5-HT and its metabolite in the brain cortex or hippocampus. On the other hand, TFMPP inhibited the 5-HT turnover rate accompanied by the elevation of the 5-HT content and reduction of the 5-HIAA content in the brain cortex and hippocampus. (Z)-3-Hexenol significantly increased the 5-HT content without affecting the 5-HIAA content or the 5-HT turnover rate in the brain cortex or hippocampus. Changes in serotonergic activity in the cortex and hippocampus were suggested to be involved in the anxiolytic effect of (Z)-3-hexenol observed in the elevated plus-maze test.

Platelet-derived endothelial cell growth factor is not implicated in progression of cervical cancer

We examined the expression of platelet-derived endothelial cell growth factor (PD-ECGF) mRNAs in 47 invasive cervical cancer tissues by semi-quantitative RT-PCR and addressed its association with clinicopathological features including microvessel density. Squamous cell carcinomas expressed higher levels of PD-ECGF mRNA than non-squamous cell carcinomas (P=0.014). We found no association between FIGO stage and levels of PD-ECGF mRNA. A subset of 31 patients with stage Ib-II cervical cancer underwent radical hysterectomy and pelvic lymphadenectomy. There were no significant differences in PD-ECGF mRNA levels with respect to tumor size, degree of stromal invasion, lymphvascular space involvement, parametrial involvement, vaginal involvement or lymph node metastasis among these patients. There was no correlation between microvessel density and the levels of PD-ECGF mRNA. These findings suggest that PD-ECGF expression is not associated with progression and metastasis of cervical cancer.

Vascular endothelial growth factor is implicated in early invasion in cervical cancer

The association between the expression of vascular endothelial growth factor (VEGF) and clinicopathological factors has scarcely been examined in cervical cancer. This study examines the level of VEGF messenger RNA (mRNA) expression in invasive cervical cancer and its association with clinicopathological features including microvessel density. The level of VEGF mRNA was assessed by semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR) using beta-actin as an internal control in 66 patients with stages Ia-IVb invasive cervical cancer. In 42 patients who underwent surgery, the microvessel count was also assessed by immunostaining for factor VIII-related antigen in the most neovascularised area of the specimen. The highest level of VEGF mRNA expression was observed in early invasive cervical cancers. Except for stage IVb, the stage of the disease inversely correlated with the level of VEGF mRNA (P < 0.05). There was no significant difference in the level of VEGF mRNA with respect to histological cell types. 38 patients with stages Ib-IIb cervical cancer underwent radical hysterectomy and pelvic lymphadenectomy. There was no significant difference in the level of VEGF mRNA with respect to lymph node metastasis, depth of stromal invasion, tumour size, parametrial involvement or vaginal involvement among these patients. A significant relationship was found between the microvessel density and the level of VEGF mRNA (P < 0.01). These findings provide evidence that the expression of VEGF is involved in the promotion of angiogenesis in cervical cancer and plays an important role in early invasion.

Serum C-reactive protein as a prognostic factor in patients with epithelial ovarian cancer

OBJECTIVE

It is well known that the serum level of Interleukin-6 (IL-6) correlates with the level of C-reactive protein (CRP). The purpose of this study is to determine the significance of CRP as a prognostic factor in epithelial ovarian cancer.

STUDY DESIGN

The present study is comprised of 120 patients with epithelial ovarian cancer from 1985 to 1992. In this study, CRP levels above 50 mg/l were considered high CRP. Univariate and multivariate analyses were performed to identify clinicopathological variables associated with poor survival.

RESULTS

The serum CRP value was significantly associated with the volume of ascites (P = 0.000004). Univariate analysis showed that the FIGO stage, primary tumour diameter, size of residual tumour, histologic grade, volume of ascites and high serum level of CRP were significant prognostic factors. Cox's multivariate proportional hazard model showed that histologic grade was the most important prognostic factor (P = 0.0026). FIGO stage and volume of ascites were also independent factors for 5-year survival (P = 0.0310 and P = 0.0216, respectively). However, the serum CRP value was not an independent prognostic factor.

CONCLUSION

CRP is an adverse prognostic factor in univariate analysis, but not in multivariate analysis.

CD44 exon v6 correlates with cellular differentiation but not with progression and metastasis of cervical cancer

The purpose of this study was to investigate whether CD44v6 expression correlates with progression or metastasis of cervical cancer. The presence of mRNA for CD44v6 was examined, the association with clinicopathological features was assessed in 80 patients with cervical cancer by reverse transcriptase-polymerase chain reaction (RT-PCR) and subsequent Southern blot hybridisation with an oligonucleotide probe specific for v6. The standard form of CD44 was expressed in all specimens and 53 of 80 cervical cancers expressed an isoform containing exon v6 in combination with other variant exons. In addition, longer size transcripts of more than 1350 bp (long form) were identified in 22 of the 53 CD44v6 positive patients. The expression of CD44v6 and CD44v6 long form in squamous cell carcinomas was significantly higher than that in non-squamous cell carcinomas (P < 0.001). The expression of CD44v6 long form in histological grade 1 and 2 was significantly higher than that in grade 3 (P < 0.05). 47 patients in stage Ib-IIb cervical cancers were treated by radical hysterectomy and pelvic lymphadenectomy. We did not find any association between the expression of the long form or the short form of CD44v6 and any pathological features, except for histological cell type. These findings suggest that the regulation of CD44v6 seems to be different between different histological cell types and different tumour grades, and the expression of CD44v6 might not be implicated in the progression and metastasis of cervical cancer.

CD44 exon v6 is not implicated in the progression and metastasis of endometrial cancer

We examined the presence of mRNA for CD44v6 and assessed the association with clinicopathological features in 42 patients with endometrial cancer by RT-PCR and subsequent Southern blot hybridization with oligonucleotide probe specific for v6. The standard form of CD44 was expressed in all specimens and 20 out of 42 endometrial cancers expressed an isoform containing exon v6 in combination with other variant exons. However, there was no correlation between the expression of CD44v6 and any clinicopathological factors. These findings suggested that the expression of CD44v6 is not implicated in the progression and metastasis of endometrial cancer.

Placenta growth factor is abundantly expressed in human cervical squamous cell carcinoma

Tumor angiogenesis is essential for solid tumor growth. The object of this study was to investigate the presence of newly identified angiogenic factor, placenta growth factor (P1GF) in human cervical cancers. The expression of P1GF mRNA was assessed by RT-PCR in 29 patients with cervical cancer. Fifteen out of 29 cervical cancers expressed a certain level of P1GF mRNA. In addition, the expression levels of P1GF mRNA in squamous cell carcinomas were significantly higher than those in adenocarcinomas. There was no correlation between the expression of P1GF mRNA and FIGO stage. These results indicate that the expression of P1GF may be implicated in the promotion of angiogenesis in human cervical squamous cell carcinomas, but not in human cervical adenocarcinomas.

Different angiogenic pathways in human cervical cancers

OBJECTIVE

The objective of this study is to clarify the association between the expression of two types angiogenic factors, vascular endothelial growth factor (VEGF) and platelet-derived endothelial cell growth factor (PD-ECGF)/thymidine phosphorylase(dThdPase) and clinicopathological features, including tumor angiogenesis, in cervical cancers.

METHODS

The expression of VEGF and PD-ECGF was evaluated by immunohistochemical staining of tumor specimens from 73 patients with stage Ib-IIb cervical cancer (51, squamous cell carcinoma; 19, adenocarcinoma; 3, adenosquamous carcinoma) who underwent radical hysterectomy. The microvessel density was assessed by immunostaining for factor VIII-related antigen in the most neovascularized area.

RESULTS

The microvessel density in adenocarcinomas was significantly higher than that in squamous cell carcinomas (P < 0.01). The intensity of VEGF expression in adenocarcinomas was significantly stronger than that in squamous cell carcinomas (P < 0.05). In contrast, the expression of PD-ECGF in squamous cell carcinomas was significantly higher than that in adenocarcinomas (P < 0.0001) and adenosquamous carcinomas (P < 0.01). There was an inverse relationship between VEGF expression and PD-ECGF expression among all patients studied (P < 0.001). The microvessel density was significantly correlated with the intensity of VEGF expression (P < 0.05). In contrast, there was no correlation between the microvessel density and the expression of PD-ECGF.

CONCLUSIONS

The expression of VEGF appears to be involved in the promotion of angiogenesis in cervical cancers. Furthermore, we propose that angiogenic pathways may be different in different types of cervical cancers.

The expression of vascular endothelial growth factor and transforming growth factor-beta associates with angiogenesis in epithelial ovarian cancer

The object of this study was to clarify the association between microvessel density and clinicopathologic factors, as well as the association of angiogenic factors (vascular endothelial growth factor [VEGF] and transforming growth factor-beta [TGF-beta]) with tumor angiogenesis and patient survival in epithelial ovarian cancer. The expression of VEGF and TGF-beta was evaluated by immunohistochemical staining in 60 patients with epithelial ovarian cancer. The microvessel density, assessed by immunostaining for factor VIII-related antigen in the most neovascularized areas, varied depending on histological types but not on International Federation of Gynecology and Obstetrics stage. Patients with stage III carcinomas and positive TGF-beta had more extensive peritoneal dissemination and a worse outcome. The microvessel density of VEGF-rich and TGF-beta positive tumors was significantly higher than that of VEGF-poor and TGF-beta negative tumors. Angiogenesis appears to be an early event in epithelial ovarian cancer and may be induced differently in tumors of different histological types. The expression of VEGF and TGF-beta associates with the promotion of angiogenesis, and the expression of TGF-beta is a prognostic indicator in epithelial ovarian cancers.

Dose response effects of 2-acetylaminofluorene on DNA damage, cytotoxicity, cell proliferation and neoplastic conversion in rat liver

This study measured the effect of precise doses of 2-acetylaminofluorene (AAF) in inducing DNA damage, functional changes and neoplastic conversion in rat liver. Groups of male F344 rats at 9 weeks of age were exposed to cumulative doses of 0.5 or 2.0 mmol AAF per kg body weight given by gavage daily 5 days per week over an 8-week period and maintained with no further exposure for up to 8 weeks. Administration of AAF resulted in the formation of N-deoxyguanosin-(8-yl)-2-aminofluorene in liver DNA in relationship to dose. In centrilobular hepatocytes the zone of glutamine synthetase-expressing cells was reduced by exposure. By 8 weeks, but not at 4 weeks, the higher of the two doses of AAF provoked an increase in cell proliferation measured by immunohistochemical incorporation of bromodeoxyuridine. Altered hepatocellular foci expressing the placental form of glutathione transferase were induced by the high dose of AAF at 4 weeks, but not at the low dose. At 8 weeks the incidence of foci at the high dose was 79 times that induced by the low dose. These foci were highly proliferative. In animals exposed to AAF for 8 weeks and maintained for 4 weeks with no exposure, DNA adducts decreased by 80% and cell proliferation subsided by 80%, although the glutamine synthetase zone remained diminished. After discontinuation of AAF, the number of foci diminished by 50% and their proliferation subsided by 80% at 4 weeks, indicating a phenotypic reversion of many foci. With this protocol of administration of precise doses of AAF, we have established non-linearity of effects and a lack of correlation between DNA adduct formation and induction of cellular lesions. We suggest that doses in the range of those reported can be used to study the contribution of epigenetic and genotoxic effects in carcinogenesis and to study threshold events.

Inhibition by gonadectomy of effects of 2-acetylaminofluorene in livers of male, but not female rats

The influence of gonadectomy on the effects of 2-acetylaminofluorene (AAF) in the livers of rats was studied. Groups of male and female F344 rats at 9 weeks of age were given AAF by daily gavage 5 days per week for 4 or 8 weeks for total cumulative doses of 1.0 or 2.0 mmol/kg body wt. AAF was administered either with no pretreatment or beginning 4 weeks after gonadectomy, which was performed at 5 weeks of age. In male rats AAF induced a large number of placental glutathione S-transferase foci in livers by 8 weeks, while in female rats the number was about 10% of that in males. Orchidectomy decreased the AAF induction of foci in male rats by 60%, whereas ovariectomy had no effect in female rats. Similarly, orchidectomy decreased DNA adduct levels approximately 85% in male rats given AAF by gavage for 4 weeks. In ovariectomized female rats at 4 and 8 weeks hepatic DNA adduct levels were somewhat elevated (< 50%) as compared to intact controls. The zone of glutamine synthetase-positive hepatocytes around the central vein was reduced by AAF exposure of male, but not female, rats. Male rats displayed a larger zone than females and the zone in males was reduced to the level of females by orchidectomy. Orchidectomy also diminished the effect of AAF on glutamine synthetase-positive cells. Thus, the induction of neoplastic conversion by AAF in rat liver, the extent of DNA adduct formation and the reduction of the glutamine synthetase-positive zone of hepatocytes were greater in males than females and were dependent upon the hormonal status of males.

Cell proliferation induced in the kidneys and livers of rats and mice by short term exposure to the carcinogen p-dichlorobenzene

Cell proliferation in the kidneys and livers of rats and mice exposed short-term to p-dichlorobenzene (p-DCB) was evaluated by immunohistochemical measurement of bromodeoxyuridine (BrdU) incorporation into nuclei of DNA-synthesizing cells. p-DCB was given by gavage at two doses up to 600 mg/kg body weight for 4 days. The cumulative fraction of proliferating cells was increased in the proximal tubule epithelial cells of male rats at the high dose, but not at the low dose nor in females at either dose using gamma-glutamyl transferase reaction to identify tubular cells. Also, no increase in cell proliferation was found in mouse kidneys. The fractions of proliferating cells in the livers of rats and mice of both sexes were also increased. The increased cell proliferation in only male rat kidney and in the livers of mice of both sexes correlates with the reported carcinogenic effects of p-DCB in those tissues. However, the finding that p-DCB also induced cell proliferation in the livers of rats of both sexes, which were not a site of p-DCB-induced tumors in bioassays, and in female mice at the low dose, which was not affected by an increase in tumors, reveals a lack of concordance and indicates that acute induction of cell proliferation is not sufficient to lead to carcinogenesis.

Inhibition of colon carcinogenesis by prostaglandin synthesis inhibitors and related compounds

The inhibitory effect of 40 and 80% maximum tolerated dose (MTD) levels of piroxicam, ibuprofen, ketoprofen and glycyrrhetinic acid on colon carcinogenesis was investigated in male F344 rats. The MTD levels of piroxicam, ibuprofen, ketoprofen and glycyrrhetinic acid as determined in male F344 rats were 500, 500, 250 and 3000 p.p.m. respectively. At 5 weeks of age, groups of male F344 rats were fed the control (AIN-76A) diet and 40 and 80% MTD levels of each test agent in AIN-76A diet. At 7 weeks of age, all animals except the vehicle (saline)-treated controls received azoxymethane (AOM) at a dose rate of 15 mg/kg body wt, once weekly for 2 weeks. All animals were necropsied 50 weeks after the second AOM injection and colon tumor incidences were compared among the groups fed the control diet and chemopreventive agents. Animals fed 400 (80% MTD) and 200 p.p.m. (40% MTD) of piroxicam, 400 p.p.m. (80% MTD) of ibuprofen and 200 p.p.m. (80% MTD) of ketoprofen showed a significant inhibition of colon tumorigenesis as compared to those fed the control diet. Results analyzed by the linear regression method suggested a dose-dependent inhibition of colon carcinogenesis with increasing levels of piroxicam or ibuprofen. In contrast, glycyrrhetinic acid had no measurable chemopreventive effect on colon carcinogenesis.

Butylated hydroxytoluene lacks the activity of phenobarbital in enhancing diethylnitrosamine-induced mouse liver carcinogenesis

The effect of the food additive butylated hydroxytoluene (BHT) as an enhancer of liver carcinogenesis in mice was investigated. Liver carcinogenesis was initiated by intraperitoneal injection of diethylnitrosamine (DEN) in male B6C3F1 mice at 100 or 200 mumol/kg body weight once a week for 10 weeks (total exposure 1000 or 2000 mumol/kg body weight). After an exposure-free recovery interval of 4 weeks, groups of mice were fed either basal diet or diets containing either 5000 ppm BHT or 500 ppm phenobarbital (PB), as a positive control, for 24 weeks. Exposure to the initiating doses of DEN alone induced no liver foci at 10 weeks or at 14 weeks after the recovery period, but at termination at 38 weeks, foci and adenomas were present in a dose-related incidence. In the groups given BHT after DEN/recovery, the incidence and the multiplicity of liver foci and adenomas were not different from those in mice given only DEN/recovery, whereas, in the groups given PB after DEN, liver lesions were increased by 1.7-3.0-fold. In conclusion, BHT had no promoting or syncarcinogenic effect on DEN-induced mouse liver carcinogenesis, whereas under the same conditions, PB acted as an enhancer.

Chemoprevention of colon carcinogenesis by dietary administration of piroxicam, alpha-difluoromethylornithine, 16 alpha-fluoro-5-androsten-17-one, and ellagic acid individually and in combination

The chemopreventive action of 40 and 80% maximum tolerated dose (MTD) levels of piroxicam, D,L-alpha-difluoromethylornithine (DMFO), 16 alpha-fluoro-5-androsten-17-one (DHEA analogue 8354), and ellagic acid (EA) administered in diet individually and in combination before and during initiation and postinitiation phases of azoxymethane-induced neoplasia of the intestine was studied in male F344 rats. The MTD levels of piroxicam, DFMO, DHEA analogue, and EA were determined in male F344 rats and found to be 500, 5,000, 500, and 10,000 ppm, respectively, in modified AIN-76A diet. When these agents were fed in combination, the MTD levels were: piroxicam plus DFMO, 250 and 2500 ppm; piroxicam plus DHEA analogue, 250 and 250 ppm; piroxicam plus EA, 250 and 5000 ppm; piroxicam plus DFMO plus DHEA analogue, 250, 2500, and 250 ppm; and piroxicam plus DFMO plus EA, 250, 2500, and 5000 ppm. From these MTD values, 40 and 80% MTD levels were calculated and tested for their efficacy. At 5 weeks of age, animals were fed the modified AIN-76A (control) diet and experimental diets containing 40 and 80% MTD levels of piroxicam, DFMO, DHEA analogue, and EA individually and in combination. At 7 weeks of age, all animals except the vehicle-treated groups were administrated s.c. injections of azoxymethane (15 mg/kg body weight/week for 2 weeks). Animals intended for vehicle treatment received s.c. injections of an equal volume of normal saline. Fifty-two weeks after azoxymethane and saline treatment all the animals were necropsied, and colon and small intestinal tumor incidence (percentage of animals with tumors) and multiplicity (tumors/animal) were compared among various dietary groups. The results indicate that 40 and 80% MTD levels of dietary piroxicam and DFMO significantly (P less than 0.001) inhibited colon and small intestinal tumor incidence and multiplicity. DHEA analogue at 40% MTD level significantly decreased the small intestinal and colon tumor incidences (P less than 0.05), whereas 80% MTD of DHEA analogue inhibited only small intestinal tumor incidence. EA at 40 and 80% MTDs had no significant effect on colon tumor incidence (P greater than 0.05), but 80% MTD of EA showed a significant inhibitory effect on the incidence of small intestinal adenocarcinomas (P less than 0.01). In the combination study, 40 and 80% MTD levels of piroxicam plus DFMO significantly (P less than 0.001) inhibited colon adenocarcinoma incidence (8.3%) and multiplicity (0.08 +/- 0.04) (SE) when compared to colon adenocarcinoma incidence (72.2%) and multiplicity (1.14 +/- 0.18) in control diet-fed animals.(ABSTRACT TRUNCATED AT 400 WORDS)

Effect of different levels of calorie restriction on azoxymethane-induced colon carcinogenesis in male F344 rats

Epidemiological and animal model studies indicate that increased calorie intake increases the risk for colon cancer development. Previous studies in animal models restricted the calorie intake severely, and none of these studies have investigated a dose-response effect of different levels of calorie restriction on colon carcinogenesis. The present study was designed to investigate the effect of various levels of calorie restriction on colon carcinogenesis in male F344 rats fed the low and high fat diets and the effect of these diets on the activities of colonic mucosal and tumor ornithine decarboxylase (ODC) and protein tyrosine kinase. Starting at 5 weeks of age, groups of male F344 rats were fed the low fat or high fat diets ad libitum. At 7 weeks of age, all animals except the vehicle-treated groups were given s.c. injections of azoxymethane (AOM) (15 mg/kg body weight, once weekly for 2 weeks). Four days after the second injection, groups of animals were restricted to 90, 80, or 70% of total calories consumed by the high fat ad libitum group (i.e., 10, 20, and 30% calorie restriction, respectively). In the low fat groups, animals were restricted to 80% of total calories consumed by the low fat ad libitum group (i.e., 20% restriction). Thirty-six weeks after AOM injections, all animals were necropsied and colon tumors were used for histopathology and ODC and protein tyrosine kinase analysis. In the second experiment, the protocol was the same as above except that the animals were sacrificed 5 days after the second AOM injection and colonic mucosal ODC and protein tyrosine kinase activities were assayed. The incidence and multiplicity of colon tumors were significantly inhibited in animals fed the high fat 20% calorie-restricted and high fat 30% calorie-restricted diets, as compared to those fed the high fat ad libitum diet. The regression coefficient representing the dose-response effect of different levels of calorie restriction in both high fat groups is significant. Results also indicate that AOM treatment significantly increased the colonic mucosal ODC and protein tyrosine kinase activities. This stimulation was inhibited by feeding the calorie-restricted diets. ODC and protein tyrosine kinase activities were lower in the colon tumors of animals fed the calorie-restricted diets.

Chemoprevention of colon carcinogenesis by concurrent administration of piroxicam, a nonsteroidal antiinflammatory drug with D,L-alpha-difluoromethylornithine, an ornithine decarboxylase inhibitor, in diet

The effect of three levels of piroxicam and three levels of D,L-alpha-difluoromethylornithine (DFMO) fed individually and in combination during the postinitiation phase of carcinogenesis was studied in male F344 rats to generate a data base on the efficacy and synergistic and additive effects of these compounds as inhibitors of colon carcinogenesis. The maximum tolerated dose of DFMO was determined in male F344 rats and found to be 5000 ppm in the AIN-76A diet. Piroxicam at levels of 25, 75, and 150 ppm and DFMO at concentrations of 400, 1000, and 4000 ppm (20, 50, and 80% maximum tolerated dose) in AIN-76 diet were tested individually and in combinations. At 7 weeks of age, while the rats were consuming the control diet (AIN-76A), all animals except the vehicle (saline)-treated controls were given a single s.c. injection of azoxymethane (CAS: 25843-45-2) at a dose level of 29.6 mg/kg body weight to induce intestinal tumors. One week after azoxymethane injection, animals were transferred to their respective experimental diets containing piroxicam and DFMO. Fifty-six weeks after azoxymethane injection, all animals were necropsied and colon and small intestinal tumor incidences and multiplicity were compared among the various dietary groups. Feeding of diets containing 75 and 150 ppm piroxicam or 1000 and 4000 ppm DFMO significantly inhibited the incidence (percentage of animals with tumors) of colon adenocarcinomas compared to that of control diet. The multiplicity (number of tumors/rat) of adenocarcinomas was significantly inhibited in animals fed the 25, 75, and 150 ppm piroxicam or 400, 1000, and 4000 ppm DFMO diets. Results analyzed by the linear regression method suggested a dose-dependent inhibition in colon adenocarcinoma incidence with increasing levels of piroxicam or DFMO. The incidence and multiplicity of colon adenocarcinomas were significantly inhibited in animals fed the diets containing combinations of 25, 75, and 150 ppm piroxicam and 400, 1000, and 4000 ppm DFMO. Piroxicam and DFMO administered together had a stronger inhibitory effect than did those given individually. Piroxicam and DFMO when administered individually had no significant inhibitory effect on colon adenoma incidence and multiplicity; in contrast, combinations of these compounds significantly inhibited colon adenomas. No consistent differences were found in the incidence and multiplicity of small intestinal tumors among the dietary groups.(ABSTRACT TRUNCATED AT 400 WORDS)

[A study of ornithine decarboxylase activity in tumor tissue and rectal mucosa in patients with colorectal cancer or adenoma]

Rectal mucosa from normal controls (n = 25) and tumor tissue and rectal mucosa from patients with colorectal cancer (n = 38) and adenoma (n = 35) were biopsied via colonoscopy. Ornithine decarboxylase (ODC) activity was determined in order to study the role of promoters in the process of colorectal carcinogenesis. ODC activity of cancer tissue was significantly higher than that of adenoma tissue. Normal mucosal ODC activity in rectum and sigmoid colon was 2 to 4 times higher than that in the proximal colon. Moreover, rectal mucosal ODC activity was significantly higher in patients with cancer or adenoma than that in normal controls. When ODC activity is regarded as an index of promoter, the possibility is suggested that cancer and adenoma developed in similar mucosa of the large bowel. Furthermore, ODC activity in colon cancer was significantly higher than that in rectal cancer. This suggests the possibility that TPA type promoter assumes a greater role in the process of carcinogenesis of colon cancer than that of rectal cancer.

[Gastric mucosa in patients with fundic hyperplastic polyps]

To assess the functional and morphological characteristics of the gastric mucosa of patients with fundic hyperplastic polyps (FP), the determination of gastric acid secretion, serum gastrin levels, serum pepsinogen 1 (PG1) levels and histological examination were undertaken in 24 patients with FP, 34 with foveolar hyperplastic polyps (HP) and 62 controls, who had no gastric lesions. The following were the results of our investigation. 1) There were no differences between the patients with FP and the controls as to gastric acid secretion, serum gastrin levels, and serum PG1 levels. On the other hand, hypochlorhydria, hypergastrinemia and hypopepsinogenemia were common in those with HP. 2) Histological examination using gastric biopsy specimens showed almost normal gastric mucosa in patients with FP. However, severe atrophic gastritis of the fundus was common in patients with HP. 3) It was shown that there were definite differences between the patients with FP and those with HP with regard to the gastric function and morphology, although both types of gastric polyp were histologically classified as hyperplastic.

[Observations on the growth rate of polypoid type gastric cancers with doubling times based on a retrospective roentgenological study]

For the purpose of estimating the growth rate, 11 cases of polypoid type gastric cancer have been studied. The mean doubling time was found to be 16.6 months in early cases, and 7.6 months in advanced cases. There were two groups with different growth rates in polypoid type gastric cancer. However, from a study of a case growing faster according to the extension of tumor, it is suggested that the difference of the growth rate between the two groups may have resulted from a discrepancy of when the observation began.

[A case of type IIa early gastric cancer complicated with multiple endocrine cell micronests in pernicious anemia]

The patient, a 5-year-old male, was diagnosed as having pernicious anemia at our hospital in 1969. By means of an upper G-I series, he was found to have a gastric protruded lesion on the greater curvature of the upper corpus in 1983. After an endoscopic polypectomy, a type II a early gastric cancer was diagnosed which, histologically, showed a well-differentiated adenocarcinoma and a total gastrectomy was performed. From the histologic findings of the resected stomach, the were multiple endocrine cell micronests, that coincided with the distribution of intestinal metaplasia localized in the fundic gland area.

[Advanced gastric cancer with DIC and multiple bone metastasis treated with surgical resection and chemotherapy]

Endoscopic examination of a 35-year-old patient complaining of tarry stool, palpitation and lumbago led to a diagnosis of gastric cancer of Borrmann type 4. Laboratory data and bone scintigraphy revealed findings of DIC and multiple bone metastasis. He was treated with continuous intravenous infusion of FOY, but laboratory data with DIC went from bad to worse. It was considered that resection of the tumor was effective for DIC, then total gastrectomy and partial transverse colonectomy were performed, and the patient recovered from DIC. For the multiple bone metastasis, he received chemotherapy using cisplatinum and mitomycin C, and subsequent bone scintigraphy showed a dramatic improvement. Doxorubicin and 5-fluorouracil controlled peritoneal dissemination of the cancer.