These results provide an insight into the degradation mode of the

These results provide an insight into the degradation mode of the enzyme, which may preferentially cleave at the α-1,4-linkage adjacent to nonreducing ends, showing the β-amylase

activity. The β-amylase showed a activity over a wide temperature range (30–90 °C), pH range (4.0–12.0), and NaCl concentrations (0–20%), with an optimum at 70 °C, pH 10.0% and 10% NaCl (Fig. 4). The thermal stability profile indicated that the enzyme was highly stable at temperatures below 70 °C after 24-h incubation, but was inactivated at 90 °C (Fig. 4a). Also, the β-amylase showed good pH stability retaining more than 80% activity in the pH range 6.0–11.0 (Fig. 4b). Furthermore, it was highly stable at NaCl concentrations between 2.5% and 20%, and more than 70% activity retained GSK1120212 ic50 after dialysis in the absence of NaCl (Fig. 4c). As shown in Table 1, the metal ions tested did not affect or slightly inhibit the amylase activity. The effect of enzyme inhibitors indicated that DEPC, PAO and EDTA completely inactivated

the enzyme, but PMSF and β-mercaptoethanol had no significant effect on its activity. Moreover, more than 78% activity of the amylase retained after incubation with surfactants, such as SDS, Triton X-100, and Tween-80. Optimal activity of the protease was found to be at 80 °C, pH 10.0% and 12.5% NaCl (Fig. 4). It was highly stable at temperatures below 70 °C after 24-h incubation, but was inactivated at higher temperatures (Fig. 4a). Meanwhile, the protease showed good

stability in a broad pH range (6.0–11.0), which retained more than 70% Roxadustat cell line activity (Fig. 4b). As shown in Fig. 4c, about 82% activity lost in the absence of NaCl, but 70% activity retained under high salinity conditions (20%). Moreover, the protease was highly stable at NaCl concentrations between 2.5% and 20%. None of the metal ions was found to enhance the protease activity, and about 80% activity lost in the presence of Hg2+. EDTA and β-mercaptoethanol had no significant effect on the enzyme activity. However, complete inhibition of the protease was shown by PMSF, DEPC, and PAO. In addition, more than 85% activity retained after incubation with surfactants tested (Table 1). As shown in Table 2, no complete inactivation of both enzymes was observed in the presence of organic solvents tested. Baricitinib More than 90% of the enzyme activity retained after incubation with DMSO, acetonitrile, ethanol, and acetone. Interestingly, ethanol and acetone even increased the amylase activity to 117.4% and 118.9%, respectively, and DMSO and ethanol also stimulated the protease activity (110.8% and 110.2%). The half-lives of both enzymes were drastically decreased in the presence of organic solvents with log Pow ≥ −0.24, but in the presence of organic solvents with lower log Pow, their half-lives were longer than in the absence of the solvents.

Participants also covered a range of pharmacy roles including med

Participants also covered a range of pharmacy roles including medicines counter assistants (MCAs) (n = 9), dispensing assistants (n = 6) and pharmacy technicians (n = 6). National multiple (n = 8), small chain (n = 2) and independently owned (n = 2) pharmacies were represented. Participants were recruited by contacting pharmacists in HLPs who nominated support staff for potential participation. Informed consent was obtained prior to conducting interviews. A topic guide was developed and underwent

face validity testing and piloting with one participant. Interviews were audio recorded, transcribed verbatim and analysed using Framework approach. The study was approved PD0332991 molecular weight by Robert Gordon University ethics committee. NHS ethics approval was not required. One of the themes identified from the data was integration

of public health activity into traditional pharmacy roles. Participants discussing integration Lumacaftor research buy of public health activities with other pharmacy duties included examples of advice when conducting product sales and responding to symptoms. An example participants often referred to was sales of nicotine replacement therapy: “…say if it’s somebody [who came in to buy] nicotine replacement therapy, we would say that there are services available, had they thought about giving up. And it’s just basically like a couple of lines like that.” HLP Champion, MCA you don’t realise that you are doing it. Because it’s all part and parcel of the job.” HLP Champion, MCA Whilst participants in this study described integration of public health advice for some pharmacy roles seamlessly, participants were less able to describe integration into dispensing activity despite opportunity in areas such as diabetes and cardiovascular health. Contextualisation of public health activity within community pharmacies for support staff could Thalidomide enable further integration of public health into the role of community pharmacy. Facilitators from achieving this

integration for medicines counter activities should be explored to inform better integration of public health into dispensary based activities. 1. Department of Health 2010 White Paper Healthy Lives Healthy People. Available at: https://www.gov.uk/government/publications/healthy-lives-healthy-people-our-strategy-for-public-health-in-england (Accessed 13/04/14) C. Easthalla,b, N. Taylorc, D. Bhattacharyab aUniversity of Leeds, Leeds, West Yorkshire, UK, bUniversity of East Anglia, Norwich, Norfolk, UK, cUniversity of New South Wales, Sydney, New South Wales, Australia Recent guidelines have called for adherence interventions to be grounded in theory; the Theoretical Domains Framework (TDF) is proposed as a ‘user-friendly’ collation of psychological theories related to the determinants of health behaviours.

For mixed glucose/fructose fermentation, both sugars were metabol

For mixed glucose/fructose fermentation, both sugars were metabolized simultaneously in the pgi− mutant and pgi+ strain, presumably as a result of mutational effect by the PTS of the parent Etoposide mw strain, which is responsible for glucose repression on the uptake of other sugars (Postma et al., 1993; Tchieu et al., 2001). Unlike the single-sugar glucose fermentation, the pgi− mutant in the mixed fermentation condition grew well and displayed a higher rate of glucose consumption, albeit slightly lower than the rate observed for the pgi+ strain. These results clearly indicated that the addition of fructose into the single-sugar glucose fermentation could recover

the reduced cell growth by pgi knockout. In silico constraints-based flux analysis was employed to characterize the experimentally observed cell

growth and SA production for glucose- and fructose-consuming pgi− mutants and their corresponding metabolic states. Based on the prediction results, we comparatively investigated the overall phenotypic effects of pgi gene knockout and carbon source utilization on cell growth and SA yield. Not surprisingly, increasing biomass synthesis led to decreased SA yield, reflecting the expected trade-off between cell growth and biochemical production (data not shown). In all cases, the maximum theoretical yields were calculated to be around 0.8 mol SA mol−1 sugar, indicating that changing carbon source condition and removing pgi gene has negligible effect on the theoretical SA production. However, the resultant flux distribution revealed a significant difference in the utilization of metabolic pathway for achieving maximum shikimate biosynthesis in the pgi− mutant grown on Selleckchem 5-FU the various carbon sources (Supporting Information, Fig. S1). It has been reported that NADPH plays a key role in the metabolic network of the pgi− mutant (Canonaco et al., 2001), which motivated us to investigate the effect of different carbon sources on NADPH metabolism in the pgi− mutant and pgi+ strain. As such, the utilization of different metabolic pathways is amenable to further

exploration nearly from the perspective of NADPH regeneration required for cell growth and SA production. We quantified NADPH regeneration represented by the overall turnover rate, that is, flux-sum value (see ‘Materials and methods’) (Kim et al., 2007; Chung & Lee, 2009) under various genetic/environmental conditions. Interestingly, NADPH flux-sum yield (molNADPH molsugar−1) for the pgi− mutant on glucose was approximately twice that of the pgi+ strain at all levels of biomass yield (Fig. 3b). However, under cultivation with fructose or glucose/fructose mixture as the carbon source, NADPH flux-sum yields were similar for both the pgi+ and pgi− strains (Fig. 3a). It is conceivable that the much higher NADPH requirement in the pgi− mutant on glucose may attenuate cell growth through cofactor balancing. NADPH regeneration largely depends on the PP pathway and tricarboxylic acid cycle.

2), with most isolates sampled from the same host grouping togeth

2), with most isolates sampled from the same host grouping together. In support, the host is known to have a significant impact on the genetic structure of pathogen populations, especially in pathosystems characterized by the rapid breakdown of race-specific resistance (McDonald et al., 1989). Finally, while Newton et al. (2001) and Bouajila et al. (2007) indicated no clear relationship between genetic and pathogenic variation using RAPD and AFLP markers, the calculated degree of coincidence between pathotype and SSR haplotypes (Table 4) allowed the determination of pathogenicity in 52% of the isolates by fingerprinting with seven microsatellite loci. A similar

discrepancy in the SSR haplotype and pathogenicity has also been reported Z VAD FMK by Takeuchi & Fukuyama (2009). In addition, many SSR alleles were shown to be linked to virulence (Table 3). These may serve as rapid

molecular tools for pathogen detection, without the inoculation that requires long incubation periods before ultimate disease assessment. This investigation was cosponsored by ICARDA-ETH Zurich. The authors acknowledge the support and the use of facilities of ETH – Institute of Integrative Biology ‘Phytopathology Group’, where this work was carried out. We are grateful to Dr Bruce for providing SSR primers. “
“The plant hormone ethylene has been reported to inhibit the Agrobacterium tumefaciens-mediated transformation efficiency of many plants. In this study, an acdS gene that encodes 1-aminocyclopropane-1-carboxylic acid (ACC) deaminase, an enzyme that www.selleckchem.com/products/Lapatinib-Ditosylate.html breaks down ACC, the direct precursor of ethylene biosynthesis in all higher plants, was introduced into A. tumefaciens GV3101∷pMP90. It was found that the presence of active ACC deaminase in A. tumefaciens reduced ethylene levels produced by plant tissues during the process of infection SB-3CT and cocultivation, and significantly increased the transformation efficiency of three commercial canola cultivars: Brassica napus cv. Westar, B. napus cv. Hyola 401 and B. napus cv. 4414RR. Agrobacterium tumefaciens is an important tool for plant genetic engineering. However, the low

transformation efficiency of many commercially important crops is the main factor limiting its use. Among various factors, ethylene produced by plants is one that inhibits A. tumefaciens-mediated transformation efficiency. For example, it has been reported that reducing the ethylene level increased the expression of the vir genes of A. tumefaciens, thereby increasing gene delivery efficiency (Nonaka et al., 2008a). Moreover, application of ethylene inhibitors such as aminoethoxyvinylglycine or silver ions in the tissue culture medium has been reported to improve the transformation efficiency of many plant species, such as bottle gourd, cauliflower, apricot and apple trees (Chakrabarty et al., 2002; Burgos & Alburquerque, 2003; Han et al., 2005; Petri et al., 2005; Seong et al., 2005).

5) and pre-incubated at room temperature for 30 min before 1 mM G

5) and pre-incubated at room temperature for 30 min before 1 mM GTP or ATP was added to initiate the polymerization. The polymerization reaction was carried out at room temperature for 30 min. FtsZ or MreB polymers were precipitated by centrifugation at 100 000 g for 20 min, and the pellets were suspended in 50 μL of buffer P. Both the supernatant and pellet fractions were separated by a 17.5% SDS-PAGE, followed by Coomassie blue staining. Cell morphology was observed using an Olympus BX40 microscope. YgfX contains a long hydrophobic segment at the N-terminal region from W16 to V54 (Fig. 1a). There are two

Pro residues (P33 and P35) in the middle of the hydrophobic region, and thus, this protein CHIR-99021 datasheet likely forms

a hydrophobic hair-pin structure with two transmembrane (TM) domains: TM1 from W16 to M32 and TM2 from L36 to V54. The presence of positively charged residues on either side of the putative TM segments suggests that N-terminal and C-terminal soluble domains of YgfX reside in cytosol (Fig. 1b). In order to experimentally determine the localization of YgfX, the full-size YgfX was expressed from arabinose inducible vector, pBAD24 (pBAD24-ygfX). After YgfX expression was induced by the addition of 0.2% arabinose for 2 h, the total membrane proteins were collected from the cellular lysate by ultracentrifugation. YgfX was found exclusively localized in the membrane fraction (lane 4, Fig. 2). Total membrane proteins were further separated into the inner and outer membrane fractions based on the solubility in 1% N-lauroylsarcosine Cyclopamine (Hobb et al., 2009). As predicted, YgfX was shown to be localized in the inner membrane (lane 6, Fig. 2). Intriguingly, the overexpression of YgfX caused growth arrest starting at 5 h postinduction (Fig. 3a). The growth arrest was accompanied by morphological change (Fig. 3b). After 1-h induction of YgfX expression from pBAD24-ygfX, some cells started to elongate. clonidine After 5 h, elongated cells were divided into smaller cells and simultaneously, cells became inflated in the middle or at the

poles of cells. After overnight induction, cells became lemon shaped. We then examined whether YgfY can neutralize the toxicity caused by YgfX. First, the coding sequences of both ygfY and ygfX were cloned together in pBAD24. This construct did not show any growth inhibition at least for 48 h. The morphological change was also not observed. This result was confirmed by the expression of YgfX and YgfY separately from two independent plasmids. For this purpose, YgfY was cloned in a derivative of pCold vector (pCold-Km) and shown to be highly expressed (data not shown). Consistent with above experiments, cells expressing both YgfY and YgfX did not show any growth defect and alteration in morphology at least for 18 h, confirming that YgfY functions as an antitoxin for YgfX.

0%) The Framingham equation predicted a higher cardiovascular ri

0%). The Framingham equation predicted a higher cardiovascular risk compared with the Rama-EGAT and D:A:D equations, which

seemed to agree relatively well. Only d4T use was marginally associated with a high Rama-EGAT score; longer ART duration and current viral suppression were significantly associated with a high Framingham score. The low predicted cardiovascular risk in our cohort can probably be explained by the similarly low prevalence of cardiovascular risk factors. A low prevalence of cardiovascular risk factors in a Thai population was previously described in the EGAT study [7], although the data were collected over 20 years ago. The prevalences of hypertension, hypercholesterolaemia, diabetes and smoking in a similarly aged (mean Enzalutamide in vitro 43 years) group of HIV-uninfected Thais in 1985 were 18, 32, 6 and 42%, respectively, compared with 13, 24, 7 and 13% in the present study. The lower prevalence of risk factors in our study may reflect Erismodegib ic50 under-diagnosis (hypertension), undocumented treatment (hypercholesterolaemia), the effect of smoking cessation campaigns, and the lower proportion of male subjects. CHD was an important cause of death in the EGAT cohort (28 of 165 deaths over 12 years of follow-up); the overall prevalence

was not reported. To our knowledge, this is the first study to evaluate the Rama-EGAT and D:A:D equations in an HIV-infected Asian population. The Rama-EGAT Heart Score comes from the EGAT study, which followed 3499 HIV-uninfected Thais aged 35 to 54 years employed at the EGAT from 1985 to 1997 [7,10]. The risk equation published by the D:A:D Study Group was derived from a data set of 22 625

HIV-infected subjects in 20 countries across Europe and Australia [11]. That the cardiovascular risks predicted by these equations agreed relatively well suggests that HIV-infected Thai individuals may not be at increased risk for CVD compared with those without HIV infection. Furthermore, the lack of statistically significant associations between HIV-related factors and high Rama-EGAT scores suggests that traditional cardiovascular risk factors may be interpreted similarly in HIV-infected and uninfected populations, a conclusion also drawn from the D:A:D study [11]. Rama-EGAT risks were, in fact, slightly higher than D:A:D risks; this may be explained by the broader cardiovascular outcome definition used in the Rama-EGAT heptaminol equation (MI or invasive coronary procedure in Rama-EGAT vs. only MI in D:A:D). This study has several limitations. First, cardiovascular risk data were obtained by physicians using a form with open-ended questions, allowing misinterpretations. ART histories were complex because of treatment changes and interruptions. Lipodystrophy was not defined by standardized criteria; however, it was assessed by experienced physicians at HIV-NAT with most subjects having at least one obvious sign (i.e. facial or buttock fat loss, increased abdominal girth, or prominent veins).

, 2006) Bacteria have developed different mechanisms to confer r

, 2006). Bacteria have developed different mechanisms to confer resistance to copper, which vary significantly among the species. In Pseudomonas species, the well characterized copper resistance system is the plasmid-encoded cop system in Pseudomonas

syringae pv. tomato (Cha & Cooksey, 1991; Cooksey, 1993). In this organism, a 35-kb plasmid pPT23D carries the cop operon, which consists of four structural genes (copABCD) and two regulatory genes (copRS). Recent proteomic analysis of Pseudomonas putida KT2440 in response to copper and cadmium identified that the bacterial isolate is able to survive under copper stress by up-regulation of the expression of copper-binding proteins (CopA and CopR), oxidative stress protective Proteasome inhibitor proteins and several enzymes involved in the Krebs cycle (Miller et al., 2009). Besides genetic and proteomic studies, the metabolomic approach provides additional information on how the bacteria adapt to various environments (Frimmersdorf et al., 2010). Changes in tricarboxylic acid cycle (TCA) cycle, glycolysis, pyruvate and nicotinate selleck products metabolism of Pseudomonas fluorescens planktonic culture in response to copper stress were found using a combined gas chromatography-mass spectrometry (GC-MS) and nuclear

magnetic resonance (NMR) approach (Booth et al., 2011). Pseudomonas sp. TLC6-6.5-4 isolated from Torch Lake sediment contaminated Cetuximab clinical trial by copper mine tailings shows high resistance with the minimum inhibitory concentration of 5 mM in basic salt medium (BSM) and 6 mM in Luria broth (LB) medium (Li & Ramakrishna, 2011). The bacteria produce indole-3-acetic acid and siderophores and solubilize phosphate, which promotes plant growth. The objective of this study was to investigate how this bacterium adapts to the toxic

levels of copper. We created a transposon insertion library, screened for copper-sensitive mutants and found that the disruption of ATP-dependent clp protease (clpA) gene caused a significant reduction in copper resistance of Pseudomonas sp. TLC6-6.5-4. Further, we performed proteomic and metabolomic analyses to compare the copper-sensitive mutant with the wild type. Bacterial strain Pseudomonas sp. TLC6-6.5-4 was grown in Luria broth (LB) with 4 mM Cu2+ at 30 °C and shaken at 140 r.p.m. until the OD600 mm reached 0.4 (exponential phase). This concentration challenged the bacteria but did not inhibit growth. Bacteria grown in LB medium without copper were used as control. Bacterial cells were stained using a gram staining kit (BD) and observed under an Olympus BX51 microscope (Leeds Precision). In addition, the morphology of the bacterial isolate was examined using a scanning electron microscope (SEM) (JSM-6400, JEOL). Sample preparation was carried out as described by Shi & Xia (2003). The bacterial length was measured using image j software (http://rsb.info.nih.gov/ij).

The SD in LH-mcrA amplicon length for one clone in each of the di

The SD in LH-mcrA amplicon length for one clone in each of the different operational taxonomic units or phylotypes (Fig. 2) ranged from 0.1 to 0.2 bp (Table 1). All partial mcrA gene sequences aligning into the order Birinapant Methanomicrobiales had a 488-bp theoretical amplicon length (from sequencing) but had 483-, 485- or 487-bp phylotypes when experimentally screened by LH-mcrA (Table 1). The majority of the clones related to Methanoculleus had an amplicon length of 483 bp, except phylotypes 7A7 and 7C12 (both at 485-bp). The 7A7 phylotype represented 9% and 5% of the clones in the libraries from PF1 and PF8, respectively. Only one clone

was retrieved

in the libraries that corresponded to the 7C12 phylotype. The clones related to Methanogenium and Methanospirillaceae also had an amplicon length of 485 bp. One clone was related to Methanocorpusculum and had a length of 486.6 bp. Partial mcrA gene sequences aligning within the Methanosarcinaceae family and the Methanobrevibacter spp. had an experimental amplicon length of 481 and 464 bp, respectively. A cluster of unidentified clones (Fig. 2) had amplicon lengths ranging from 466 to 467 bp and were evenly distributed in both PF1 and PF8. Overall, relative abundances using LH-mcrA were in agreement with clone library analyses (Table 1): (1) the 483-bp amplicon accounted for 26% and 70% compared with

33% and 67% of the corresponding clones; (2) the 485-bp amplicon accounted for 40% and 15% compared Bak protein with 34% and 13% of the clones; and (3) the 467-bp amplicon was present at 20% and 13% compared with 19% and 18%; in PF1 and PF8, respectively. One concern with this method is that the variation in amplicon length that distinguishes the Methanomicrobiales and Methanosarcinaceae Phospholipase D1 is only 2 bp (481-, 483- and 485-bp amplicons). Capillary electrophoresis clearly resolved these methanogen groups in mixtures of clones (Supporting Information, Fig. S1 and technical details in Appendix S1). The SD of the amplicon lengths determined on five replicated PCRs ranged between 0.1–0.4 bp (Table S1 in Appendix S2). To test more directly the quantitative aspect of the novel LH-mcrA fingerprint method, PCR products from five different clones having amplicon lengths of 464, 467, 481, 483 or 485 bp were purified and mixed in equal proportion to be used as DNA template in LH-mcrA PCRs. A mean relative abundance and SD of 20.0 ± 3.7% with minimum (for the 483-bp amplicon) and maximum (for the 464-bp amplicon) relative abundances of 13% and 25%, respectively (Table S2 in Appendix S2), were obtained from five LH-mcrA replicated analyses (Table 2, Mixed clones).

After undertaking the e-module there were statistically significa

After undertaking the e-module there were statistically significant increases in the self-ranked confidence and knowledge levels of

junior doctors regarding diabetes management. This included improvements in identifying different types AZD2281 price of insulin, making insulin dose adjustments for hypoglycaemia/hyperglycaemia and a reduction in reported prescription errors. The results from the NaDIA also suggest an improvement in ‘good diabetes days’ for insulin-treated patients with diabetes and a pattern of reduction in prescription and management errors. This study demonstrates that an inpatient diabetes management e-module increases junior doctors’ knowledge and confidence in managing diabetes. A multi-centre study would be needed to confirm whether this translates into better management of inpatients with diabetes. E-modules may be used to cover further topics in diabetes, and to support nursing and patient education. Copyright © 2013 John Wiley & Sons. Practical Diabetes 2013; 30(3): 122–127 “
“Insulin related drug errors are a significant source of adverse incidents in the inpatient learn more hospital setting. The answer to this issue is not more training or ‘trying harder’: it is to recognise that errors will occur and to work around this, by identifying the common sources of error and making changes

to systems, introducing checklists and increasing awareness of the difficulty of getting insulin dosing right. Such changes require clinical leadership and both junior and senior diabetologists should be at the forefront of getting involved and addressing the problem as a commitment to patient care. Copyright © 2012 John Wiley & Sons. “
“Coping with diabetes and managing daily challenges remain a major factor in adolescents. After initial diagnosis, the daily management of diabetes happens at home. Dealing with diabetes on a daily basis affects dietary habits and physical acetylcholine activities. Daily multiple testing of finger

blood glucose levels increases the emotional burden of the disease. Clarifying the responsibility for diabetes self-management should be a continuous dialogue between adolescents and parents. These are two cases of adolescents with type 1 diabetes mellitus that did not have direct parental supervision at home. The two adolescents concerned have altered the results of their self-glucose monitoring to obtain secondary gain and avoid diabetes self-management, showing how manipulative teenagers can be when it comes to dealing with diabetes. Copyright © 2013 John Wiley & Sons. “
“Diabetes UK has supported the concept of integrated diabetes care to ensure that the person with diabetes is seen by the right professional at the right time in the right place.

Until more sensitive and specific methods for assessment of treat

Until more sensitive and specific methods for assessment of treatment results are available, repeated treatment should be considered in patients with continuous symptoms or other indications of treatment failure even when viable ova are not detectable. Alternatively, given AZD2281 order the low toxicity of praziquantel, repeated treatment of all nonimmune patients after 1 to 3 months might be reasonable. Clinical studies comparing the efficacy of different regiments of praziquantel in treatment of imported schistosomiasis are needed. Both authors

state they have no conflicts of interest to declare. “
“The psychological problems of non-Japanese people are becoming more outstanding, in accordance with the increase of foreign nationals in Japan. Five illustrative cases of English-speaking Nintedanib mw patients were analyzed, from the viewpoint of psychosomatic medicine. The most common psychiatric disorders were adjustment disorders, because of the cultural differences and language barriers. The number of non-Japanese people living in Japan is increasing, and consequently the psychological problems of foreign nationals are becoming more outstanding in Japanese medicine.[1]

Psychosomatic medicine (PSM) was established in Japan in 1996 as a specific medical field for “psychosomatic disorders,” which consists of stress-related physical symptoms and psychological distress. To examine expatriate reactions to living in Japan, we examined the cases of five non-Japanese, English-speaking patients who visited

the Department of Psychosomatic Medicine, Sakai Hospital and Nihonbashi Clinic, Kinki University Faculty of Medicine for the first time between June 2004 and July 2011. This study was conducted according to the ethics rules of our hospital. The purpose of this study was explained to the patients and informed consent was obtained for publication of the study. In terms of Japanese proficiency, one patient (case 2) was unable to communicate in Japanese at all, three patients these (cases 1, 3, and 5) were able to exchange greetings, but not express themselves sufficiently, and the remaining patient (case 4) was able to participate in daily conversation, but could not fully explain his symptoms. All of them were considered as having limited Japanese proficiency, therefore history taking, physical examination, and explanation of results were conducted by a doctor in English. The self-rating depression scale (SDS) and the state-trait anxiety inventory (STAI) were used to evaluate emotional distress in terms of depression and anxiety.[2, 3] In SDS, a cut-off score of 50 was adopted in this study to determine that patients were considered to be in a depressive state. In STAI, cut-off scores of 42/45 (STAI-S/T for female) and 41/44 (STAI-S/T for male) were adopted to determine that patients possessed a tendency toward anxiety.