Relationship between the diagnosis of food protein-induced enterocolitis syndrome and postemetic procalcitonin levels

Background

There are no reports on the relationship between food protein-induced enterocolitis syndrome (FPIES) diagnosis and procalcitonin levels.

Objective

Our study sought to demonstrate a correlation between the presence or absence and severity of FPIES symptoms and postemetic procalcitonin levels.

Methods

The subjects were 53 patients with FPIES (44 with hen's egg allergy, 4 with milk allergy, 4 with wheat allergy, and 3 with soy allergy), who collectively underwent a total of 75 oral food challenges (OFCs). Procalcitonin levels at 5 hours after antigen ingestion were compared between patients with a positive OFC result and those with a negative OFC result and between patients who experienced mild or moderate events and those who experienced severe events.

Results

At 5 hours after ingestion of the causative food, the median procalcitonin levels in patients with a negative OFC result, patients who experienced a mild or moderate event, and patients who experienced a severe event were 0.02, 0.03, and 0.16 ng/mL, respectively. The procalcitonin level was significantly higher in the groups with a positive OFC result than in the groups with a negative OFC result (P < .001), and it was significantly higher in those who experienced severe events than in those who experienced mild or moderate events (P = .012).

Conclusion

Measurement of procalcitonin levels has the potential to provide a quantitative and objective assessment of FPIES diagnosis and severity.

[INVESTIGATION OF THE IMPACT OF ALLERGIC DISEASE ON CHILDREN'S SARS-CoV-2 VACCINATION DECISIONS]

Background, Objectives: The factors associated with parents' decisions to vaccinate their children with SARS-CoV-2 vaccine and the impact of the coexistence of allergic diseases in their children are unclear.

METHODS

A cross-sectional survey was conducted among parents of patients aged 15 years or younger who visited our pediatric allergy outpatient clinic and three partner pediatric clinics between April and May 2021. Survey items included presence or absence of other allergic diseases, and SARS-CoV-2 vaccination preferences and reasons.

RESULTS

646 responses were received, with 568 valid responses (88%). Thirty-eight respondents (6.7%) did not want their children to receive SARS-CoV-2 vaccine. Factors that led parents to reject the SARS-CoV-2 vaccine for their children were the coexistence of food allergies and a low evaluation of the expectations of the safety and preventive effect of the SARS-CoV-2 vaccine. The top reasons for not wanting to vaccinate were related to concerns about side effects to the vaccine.

CONCLUSION

In order for parents to make correct decisions regarding SARS-CoV-2 vaccination of their children, it is necessary to create an environment in which up-to-date and correct information is available to avoid excessive anxiety. More care is needed, especially if the child has food allergies.

[BULLYING IN JAPANESE CHILDREN AND ADOLESCENTS WITH FOOD ALLERGIES]

OBJECTIVE

To elucidate the prevailing circumstances of victimization, including bullying, faced by children afflicted with food allergies in Japan.

METHODS

From July to August 2021, we executed a web-based questionnaire survey targeting children with food allergies enrolled in the fourth grade or higher, who sought medical attention at the Department of Pediatrics in Showa University Hospital or were affiliated with three allergy-focused patient associations. The survey aimed to ascertain whether these children had encountered instances of bullying, the nature of the bullying incidents, and whether such acts of bullying triggered allergic symptoms.

RESULTS

A total of sixty-six children with food allergies participated in the survey. Among them, forty-five (68%) were male, thirty-three (50%) were attending elementary school, and thirty-five (53%) reported experiencing some form of victimization throughout their lives. Specifically, fourteen (21%) had been subjected to bullying due to their food allergy, with two children being coerced into consuming allergens and one child experiencing symptoms induced by allergen-based bullying.

CONCLUSION

It is evident that a significant number of children with food allergies face bullying. Therefore, it is imperative for healthcare providers and parents to acknowledge the inherent risk of bullying as an integral aspect of caring for children with food allergies. Prompt measures should be taken, such as educating both teachers and non-allergic children about this risk.

Larger Posterior Revascularization Associated with Reduction of Choroidal Anastomosis in Moyamoya Disease: A Quantitative Angiographic Analysis

BACKGROUND AND PURPOSE

Choroidal anastomosis, a hemorrhage-prone periventricular collateral manifestation in Moyamoya disease, outflows to the cortex posterior to the central sulcus. The objective of the present study was to test whether the angiographic extent of revascularization posterior to the central sulcus contributes to the postoperative reduction of choroidal anastomosis.

MATERIALS AND METHODS

This retrospective cohort study included choroidal anastomosis-positive hemispheres before direct bypass surgery. The postoperative reduction of choroidal anastomosis was determined by a consensus of 2 raters according to the previous research. An imaging software automatically traced the angiographic revascularization area, which was subsequently divided into anterior and posterior parts by an anatomic line corresponding to the central sulcus. Each area was quantitatively measured as a percentage relative to the whole supratentorial area.

RESULTS

Postoperative reduction of choroidal anastomosis was achieved in 68 (85.0%) of the 80 included hemispheres. The revascularization area posterior to the central sulcus was significantly larger in the hemispheres with reduction than in those with no reduction (mean, 15.2% [SD, 7.1%] versus 4.2% [SD, 3.4%], P < .001), whereas no significant difference was observed in the revascularization area anterior to the central sulcus. Multivariate analysis revealed that the revascularization area posterior to the central sulcus was the only significant factor associated with reduction (OR, 1.57; 95% CI, 1.21-2.03, for every 1% increase).

CONCLUSIONS

The results suggest that a larger revascularization posterior to the central sulcus is associated with postoperative reduction of choroidal anastomosis regardless of the extent of anterior revascularization. It might facilitate optimal selection of the revascularization site for preventing hemorrhage.

Successful weaning of a patient with severe COVID-19 pneumonia under prolonged midazolam sedation using morphine

The coronavirus disease 2019 (COVID-19) pandemic continues to spread around the world. In April 2021, Japan experienced a fourth wave of COVID-19 infections, which led to the breakdown of the medical system. Osaka, Japan, was particularly affected, with many severe cases and the highest number of COVID-19-associated deaths in Japan. Herein, we present a patient with severe COVID-19 infection who received prolonged midazolam (MDZ) treatment since propofol was not available due to shortage of medical resources. Moreover, the duration of mechanical ventilation was extended due to the development of a pneumothorax. When MDZ tapering was initiated, tachypnea was observed, which resulted failure in ventilator weaning. However, the use of continuous morphine infusion led a successful weaning off the ventilator. We suggest that the administration of morphine may allow for a smoother weaning process for some patients with severe COVID-19 infection.

Cortical Distribution of Fragile Periventricular Anastomotic Collateral Vessels in Moyamoya Disease: An Exploratory Cross-Sectional Study of Japanese Patients with Moyamoya Disease

BACKGROUND AND PURPOSE

Collateral vessels in Moyamoya disease represent potential sources of bleeding. To test whether these cortical distributions vary among subtypes, we investigated cortical terminations using both standardized MR imaging and MRA.

MATERIALS AND METHODS

Patients with Moyamoya disease who underwent MR imaging with MRA in our institution were enrolled in this study. MRA was spatially normalized to the Montreal Neurological Institute space; then, collateral vessels were measured on MRA and classified into 3 types of anastomosis according to the parent artery: lenticulostriate, thalamic, and choroidal. We also obtained the coordinates of collateral vessel outflow to the cortex. Differences in cortical terminations were compared among the 3 types of anastomosis.

RESULTS

We investigated 219 patients with Moyamoya disease, and a total of 190 collateral vessels (lenticulostriate anastomosis, n = 72; thalamic anastomosis, n = 21; choroidal anastomosis, n = 97) in 46 patients met the inclusion criteria. We classified the distribution patterns of collateral anastomosis as follows: lenticulostriate collaterals outflowing anteriorly (P < .001; 95% CI, 67.0-87.0) and medially (P < .001; 95% CI, 11.0-24.0) more frequently than choroidal collaterals; lenticulostriate collaterals outflowing anteriorly more frequently than thalamic collaterals (P < .001; 95% CI, 34.0-68.0); and choroidal collaterals outflowing posteriorly more frequently than thalamic collaterals (P < .001; 95% CI, 14.0-34.0). Lenticulostriate anastomoses outflowed to the superior or inferior frontal sulcus and interhemispheric fissure. Thalamic anastomoses outflowed to the insular cortex and cortex around the central sulcus. Choroidal anastomoses outflowed to the cortex posterior to the central sulcus and the insular cortex.

CONCLUSIONS

Cortical distribution patterns appear to differ markedly among the 3 types of collaterals.

Prevalence of disease-causing genes in Japanese patients with BRCA1/2-wildtype hereditary breast and ovarian cancer syndrome

Panel sequencing of susceptibility genes for hereditary breast and ovarian cancer (HBOC) syndrome has uncovered numerous germline variants; however, their pathogenic relevance and ethnic diversity remain unclear. Here, we examined the prevalence of germline variants among 568 Japanese patients with BRCA1/2-wildtype HBOC syndrome and a strong family history. Pathogenic or likely pathogenic variants were identified on 12 causal genes for 37 cases (6.5%), with recurrence for 4 SNVs/indels and 1 CNV. Comparisons with non-cancer east-Asian populations and European familial breast cancer cohorts revealed significant enrichment of PALB2, BARD1, and BLM mutations. Younger onset was associated with but not predictive of these mutations. Significant somatic loss-of-function alterations were confirmed on the wildtype alleles of genes with germline mutations, including PALB2 additional somatic truncations. This study highlights Japanese-associated germline mutations among patients with BRCA1/2 wildtype HBOC syndrome and a strong family history, and provides evidence for the medical care of this high-risk population.

Abstract PD1-09: High incidence rate of occult cancer in risk reducing mastectomy specimens despite thorough assessment with breast MRI and ultrasound-findings from the hereditary breast and ovarian cancer registration 2016 in Japan

Introduction:One of the preemptive strategies for Hereditary Breast and Ovarian Cancer (HBOC) is prophylactic surgery. Data for risk reducing mastectomy (RRM) clearly showed a risk reduction of more than 90% for breast cancer.

Method: We report here the statistical results of the HBOC registration up to 2016. The subjects of this study were those who underwent BRCA1/2 genetic testing during the study period, at 7 medical institutions.

Results: A total of 1527 probands underwent BRCA testing; 1125 cases (73.7%) were negative for BRCA1/2 mutation, and 297 cases (19.5%) were positive, while 105 cases (6.9%) had uncertain results. Among the 297 cases with positive results, 157 cases (10.3%) were positive for BRCA1, 139 cases (9.1%) for BRCA2, and 1 case (0.1%) was positive for both.The mean age at breast cancer diagnosis was 41.7 years in BRCA1/2 mutation positive and 45.8 years in negative cases. In comparison to the National Registration for Breast Cancer Incidence 2011 in Japan (n=72,472), breast cancer with BRCA mutations occurred at a younger age. Among 359 cases of triple negative breast cancer, 101 cases (28.3%) were BRCA1 mutation positive while 18 cases (5.0%) were BRCA2 mutation positive.

Three hundred seventy cases underwent genetic testing prior to surgery, as a deciding factor for the surgical procedure. Among BRCA mutation positive cases, 58 cases (87.9%) chose to undergo total mastectomy, and 8 cases (12.1%) chose breast conserving surgery (BCS); on the other hand, 141 cases (46.4%) of BRCA mutation negative cases chose total mastectomy and 158 cases (52.0%) chose BCS.

Four cases of new onset breast cancers were observed among the 55 cases of previvors (mean observation period: 2.5 years; incidence rate: 2.9%/Y). Among the 73 BRCA1/2 mutation positive women who underwent BCS, 3 ipsilateral breast cancer cases were observed (mean observation period: 3.5 years; incidence rate: 1.2%/Y), while 2 cases were noted among 477 cases of BRCA1/2 mutation negative cases (mean observation period: 2.2 years; incidence rate: 0.2%/Y). Of 189 BRCA1/2 mutation positive cases with unilateral breast cancer, 8 contralateral breast cancer cases were noted (mean observation period: 3.0 years; incidence rate: 1.4%/Y), while 4 cases of contralateral breast cancer were observed among 892 cases of BRCA1/2 mutation negative cases (mean observation period: 2.2 years; incidence rate: 0.2%/Y).

Fifty-one patients had undergone RRM.Six cases (11.8%) of occult breast cancer were noted in the RRM specimens, among which 2 were BRCA1 positive cases and 4 were BRCA2 positive cases. All of these six cases had undergone extensive imaging work-up prior to surgery by using mammography, ultrasound and breast MRI.

Conclusions: The incidence rate of occult cancer after risk-reducing mastectomy was reported to be about 5% in the high-risk population. Our report showed a relatively higher incidence rate of occult cancer at 11.8% among BRCA mutation positive cases, despite thorough pre-operative radiological evaluations, which included a breast MRI. These results suggest the limitations in the use of MRI for the surveillance of patients with BRCA mutations.

Citation Format: Yamauchi H, Okawa M, Yokoyama S, Nakamura S, Arai M. High incidence rate of occult cancer in risk reducing mastectomy specimens despite thorough assessment with breast MRI and ultrasound-findings from the hereditary breast and ovarian cancer registration 2016 in Japan [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD1-09.

Effects of 1 alpha, 25-dihydroxyvitamin D3-26,23-lactone and its intermediate metabolites on bone metabolism in vivo and in vitro

Which intermediate metabolite of 23(S)25(R)-1 alpha,25-(OH)2D3-26,23-lactone causes the unique biological functions of 1 alpha,25-(OH)2D3-26,23-lactone different from that of 1 alpha,25-(OH)2D3 was examined comparatively. The three intermediate metabolites, 1 alpha,25(R)26-(OH)3D3, 1 alpha,23(S)25(R)26-(OH)4D3, and 23(S)25(R)-1 alpha,25-(OH)2D3-26,23-lactol stimulated bone resorption, as 1 alpha,25-(OH)2D3 did, in vitamin D-deficient rats. On the other hand, 1 alpha,25-(OH)2D3-26,23-lactone only inhibited bone resorption. 1 alpha,25-(OH)2D3, 1 alpha,25-(OH)2D3-26,23-lactone and the other three metabolites stimulated MNC formation from hematopoietic blast cells in a manner correlated with their binding affinities for the 1 alpha,25-(OH)2D3 receptor. However, CM obtained from 1 alpha,25-(OH)2D3-26,23-lactone-treated MC3T3-E1 cells inhibited MNC formation, probably by the action of some inhibitory factors elaborated by the cells treated with 1 alpha,25-(OH)2D3-26,23-lactone, whereas CM obtained from 1 alpha,25-(OH)2D3 or other metabolite-treated MC3T3-E1 cells stimulated MNC formation. These facts indicate that only 1 alpha,25-(OH)2D3-26,23-lactone has an inhibitory action of bone resorption and that the lactone ring plays a major part in its expression.

Immunochemical fecal occult blood tests predict dual antiplatelet therapy discontinuation after coronary stenting

OBJECTIVE

The discontinuation of dual antiplatelet therapy (DAPT) increases the risk of stent thrombosis after coronary stenting. Some patients must discontinue DAPT due to gastrointestinal (GI) tract disease; however, the type of examination that is most useful for detecting GI tract diseases has not been fully evaluated. The purpose of this study was to clarify whether the immunochemical fecal occult blood test (iFOBT) can be used to predict GI tract disease-related DAPT discontinuation following stent implantation in patients with coronary artery disease.

METHODS

A total of 181 consecutive DAPT-naïve patients who underwent coronary stenting were divided into two groups according to the results of iFOBTs: a positive iFOBT group (n=32) and a negative iFOBT group (n=149). During the 12-month follow-up period, the DAPT discontinuation rate was lower in the negative iFOBT group than in the positive iFOBT group (3.4 vs. 18.8%, p=0.005). Kaplan-Meier event-free curves showed that the DAPT discontinuation rate in the negative iFOBT group was lower than that observed in the positive iFOBT group (log-rank test: p=0.001). Logistic and Cox regression analyses showed that a positive iFOBT result was the strongest predictor of the risk of DAPT discontinuation after coronary stenting.

CONCLUSION

A positive iFOBT result is associated with DAPT discontinuation following coronary stenting.

Common origin of the circular-dichroism pattern in angle-resolved photoemission spectroscopy of SrTiO3 and Cu(x)Bi2Se3

Circular dichroism in the angular distribution of photoelectrons from SrTiO(3):Nb and Cu(x)Bi(2)Se(3) is investigated by 7-eV laser angle-resolved photoemission spectroscopy. In addition to the well-known node that occurs in the circular dichroism pattern when the incidence plane matches the mirror plane of the crystal, we show that another type of node occurs when the mirror plane of the crystal is vertical to the incidence plane and the electronic state is two-dimensional. The flower-shaped circular dichroism patterns in the angular distribution occurring around the Fermi level of SrTiO(3):Nb and around the Dirac point of Cu(x)Bi(2)Se(3) are explained on equal footings. We point out that the penetration depth of the topological states of Cu(x)Bi(2)Se(3) depends on momentum.

Two-Fermi-surface superconducting state and a nodal d-wave energy gap of the electron-doped Sm1.85Ce0.15CuO(4-δ) cuprate superconductor

We report on laser-excited angle-resolved photoemission spectroscopy in the electron-doped cuprate Sm1.85Ce0.15CuO(4-δ). The data show the existence of a nodal hole-pocket Fermi surface both in the normal and superconducting states. We prove that its origin is long-range antiferromagnetism by an analysis of the coherence factors in the main and folded bands. This coexistence of long-range antiferrmagnetism and superconductivity implies that electron-doped cuprates are two-Fermi-surface superconductors. The measured superconducting gap in the nodal hole pocket is compatible with a d-wave symmetry.

Low mean corpuscular hemoglobin level is a predictor of discontinuation of antiplatelet therapy in patients with acute coronary syndrome

OBJECTIVE

Premature discontinuation of antiplatelet therapy (APT) increases the risk of thrombosis in patients who have undergone placement of a drug-eluting stent for acute coronary syndrome (ACS). The goal of the present study was to identify predictors of patients who would prematurely discontinue APT following stent implantation.

METHODS

One-hundred and sixty-one ACS patients who underwent percutaneous coronary intervention in our institution between November 2004 and September 2008 were enrolled in this study.

RESULTS

Over the 12-month follow-up period, 18 patients (11.2%) discontinued APT. Among baseline demographic and laboratory variables, multivariate analysis revealed that mean corpuscular hemoglobin (MCH) level was an independent risk factor for APT discontinuation (OR: 0.738, p=0.017). Kaplan-Meier survival analysis showed that the incidence of APT discontinuation was significantly higher in patients with low MCH (<30.0 pg) than in patients with high MCH (≥30.0 pg) (p=0.0006).

CONCLUSION

Low baseline MCH level was a predictor of APT discontinuation in ACS patients. Thus, careful consideration should be made before employing a drug-eluting stent in patients with low MCH levels.

Strong valence fluctuation in the quantum critical heavy fermion superconductor β-YbAlB4: a hard x-ray photoemission study

Electronic structures of the quantum critical superconductor β-YbAlB4 and its polymorph α-YbAlB4 are investigated by using bulk-sensitive hard x-ray photoemission spectroscopy. From the Yb 3d core level spectra, the values of the Yb valence are estimated to be ∼2.73 and ∼2.75 for α- and β-YbAlB4, respectively, thus providing clear evidence for valence fluctuations. The valence band spectra of these compounds also show Yb2+ peaks at the Fermi level. These observations establish an unambiguous case of a strong mixed valence at quantum criticality for the first time among heavy fermion systems, calling for a novel scheme for a quantum critical model beyond the conventional Doniach picture in β-YbAlB4.

Orbital-dependent modifications of electronic structure across the magnetostructural transition in BaFe2As2

Laser angle-resolved photoemission spectroscopy (ARPES) is employed to investigate the temperature (T) dependence of the electronic structure in BaFe2As2 across the magnetostructural transition at T{N} approximately 140 K. A drastic transformation in Fermi surface (FS) shape across T{N} is observed, as expected by first-principles band calculations. Polarization-dependent ARPES and band calculations consistently indicate that the observed FSs at k{z} approximately pi in the low-T antiferromagnetic state are dominated by the Fe3d{zx} orbital, leading to the twofold electronic structure. These results indicate that magnetostructural transition in BaFe2As2 accompanies orbital-dependent modifications in the electronic structure.

An evaluation of polyvinylidene film dressing for treatment of pressure ulcers in older people

OBJECTIVE

To compare the effectiveness of polyvinylidene (PVL) food wrap as a dressing material versus conventional ointments and gauze dressings for pressure ulcers in patients aged 60 years or over.

METHODS

A prospective open controlled trial was conducted. The severity of pressure ulcers in both groups was evaluated using the DESIGN system. Scores were compared at baseline, four, eight and 12 weeks.

RESULTS

Twenty-five patients were treated with the PVL film (test) dressings and 24 with the conventional treatment (control). The test group showed greater improvement in DESIGN scores than the control group throughout the observation period, and the difference reached statistical significance at 12 weeks (p < 0.05). The incidences of local wound infection in the two groups were not statistically different (p > 0.999).

CONCLUSION

The PVL film dressing was more effective than conventional treatment in the management of severe pressure ulcers.

Serine racemase binds to PICK1: potential relevance to schizophrenia

Accumulating evidence from both genetic and clinico-pharmacological studies suggests that D-serine, an endogenous coagonist to the NMDA subtype glutamate receptor, may be implicated in schizophrenia (SZ). Although an association of genes for D-serine degradation, such as D-amino acid oxidase and G72, has been reported, a role for D-serine in SZ has been unclear. In this study, we identify and characterize protein interacting with C-kinase (PICK1) as a protein interactor of the D-serine synthesizing enzyme, serine racemase (SR). The binding of endogenous PICK1 and SR requires the PDZ domain of PICK1. The gene coding for PICK1 is located at chromosome 22q13, a region frequently linked to SZ. In a case-control association study using well-characterized Japanese subjects, we observe an association of the PICK1 gene with SZ, which is more prominent in disorganized SZ. Our findings implicating PICK1 as a susceptibility gene for SZ are consistent with a role for D-serine in the disease.

B(0)-B(0) mixing in unquenched lattice QCD

We present an unquenched lattice calculation for the B(0)-B(0) transition amplitude. The calculation, carried out at an inverse lattice spacing 1/a=2.22(4) GeV, incorporates two flavors of dynamical quarks described by the O(a)-improved Wilson fermion action and heavy quarks described by nonrelativistic QCD. Particular attention is paid to the uncertainty that arises from the chiral extrapolation, especially the effect of pion loops, for light quarks, which we find could be sizable for the leptonic decay constant, whereas it is small for the B parameters. We obtain f(B(d))=191(10)(+12-22) MeV, f(B(s))/f(B(d))=1.13(3)(+13-2), B(B(d))(m(b))=0.836(27)(+56-62), B(B(s))/B(B(d))=1.017(16)(+56-17), and xi=1.14(3)(+13-2), where the first error is statistical, and the second is systematic, including uncertainties due to chiral extrapolation, finite lattice spacing, heavy quark expansion, and perturbative operator matching.

[Anesthetic management of an infant with Freeman-Sheldon syndrome]

We report the anesthetic management of Freeman-Sheldon (whistling face) syndrome in a two-month-old boy scheduled for lateral canthoplasty. He had features of the syndrome including blepharophimosis, hypertelorism, a flat nose, microstomia with a limited opening, micrognathia, a very short webbed neck, scoliosis and multiple arthrogryposis. He was fed with a naso-gastric tube and suffered from several episodes of aspiration and oxygen desaturation. Difficult airway and intubation were anticipated. Anesthesia was induced via a mask with sevoflurane, although mask ventilation was difficult. Direct laryngoscopy and the insertion of a laryngeal mask airway were impossible due to microstomia with the limited opening as anticipated. A naso-tracheal intubation was achieved using a fiberoptic bronchoscope via a fiberoptic mask while ventilating the lungs. The operation and anesthesia afterwards were uneventful. In the ward, he was given supplemental oxygen but with occasional desaturation episodes. Thirteen days after the operation he was found cyanotic and resuscitation was attempted but failed. Autopsy demonstrated the hypoplasia of the lungs and thorax, atelectasis and bronchitis.

[Intraoperative massive pulmonary hemorrhage due to pulmonary aspergillosis]

A 16-year-old girl had suffered from chronic graft versus host disease (GVHD) caused by peripheral blood stem cell transplantation (PBSCT) after chemotherapy for neuroblastoma and pulmonary aspergillosis of the right upper lobe. She presented with hematemesis and underwent upper gastrointestinal endoscopy under general anesthesia. At the end of the examination, massive pulmonary hemorrhage occurred suddenly. A double lumen endobronchial tube was inserted for unilateral ventilation in order to control hemorrhage, and right pulmonary hemorrhage was found. Pulmonary scintigram and angiography could not demonstrate the bleeding site, and we suspected that pulmonary hemorrhage had been caused by pulmonary aspergillosis because aspergillus is known to have pathologically invasive character to the adjacent tissue and blood vessels. Despite right pneumonectomy was performed to control pulmonary hemorrhage, she died five days later from multiple organ failure. This case suggests that immediate unilateral ventilation is useful for the isolation of the bleeding lung when pulmonary hemorrhage is massive and we should know the risk of pulmonary hemorrhage in patients with pulmonary aspergillosis.

The effect of CYP2C19 and CYP2D6 genotypes on the metabolism of clomipramine in Japanese psychiatric patients

In this study, the authors investigated the relationship between the metabolism of clomipramine (C) and the genotypes of cytochrome P450 (CYP) CYP2C19 and CYP2D6. Fifty-one Japanese patients (18 men and 33 women) were administered 10 to 250 mg/day of C by mouth and maintained on the same daily dose of C for at least 2 weeks to obtain steady-state concentrations. Plasma levels of C and its metabolites N-desmethylclomipramine (DC), 8-hydroxyclomipramine, and 8-hydroxy-N-desmethylclomipramine (HDC) were determined by high-performance liquid chromatography. The allele frequencies of CYP2C19*2, CYP2C19*3, CYP2D6*5, and CYP2D6*10 were 27.5%, 12.8%, 2.9%, and 43.1%, respectively. Subjects who were homozygous for mutated alleles of CYP2C19 showed approximately 75% higher concentrations of C corrected by dose and body weight compared with those who were homozygous for wild-type alleles. Also, subjects who were homozygous for mutated alleles of CYP2C19 showed an approximately 68% higher value of C/DC compared with those who were homozygous for wild-type alleles. No significant difference in the ratio of DC/HDC was observed between subjects who were homozygous for mutated alleles of CYP2D6 and those who were homozygous for wild-type alleles. These results suggest that genotyping CYP2C19 is useful for grossly predicting the risk of getting high plasma concentrations of C and the low individual capacity to demethylate C because there is marked interindividual variability within each genotype. However, the genotyping of CYP2D6 is not useful for predicting the individual capacity to hydroxylate DC.

[Two pediatric cases of malignant hyperthermia caused by sevoflurane]

We experienced two cases of malignant hyperthermia (MH) triggered by sevoflurane. Case 1 was a six-year-old girl, 15.8 kg, undergoing strabismus repair. She had flat back, elevated diaphragm and high arched palate. Anesthesia was induced and maintained with sevoflurane and nitrous oxide in oxygen. Her trachea was intubated without the use of muscle relaxant. Thirty minutes after the induction of anesthesia, ETco2 was over 60 mmHg despite hyperventilation. Muscle rigidity of legs and the rise in temperature were noted. MH was diagnosed and dantrolene i.v. was administered. Her maximum esophageal temperature was 40.2 degrees C. ETco2 and temperature returned to baseline values after dantrolene administration. Creatine phosphokinase (CK) level was 252 U.l-1 preoperatively, and 1690 U.l-1 next day. Case 2 was a year-and-9-month-old boy undergoing accessory ear resection. Anesthesia was induced with sevoflurane and nitrous oxide in oxygen. His trachea was intubated with an aid of vecuronium. Forty minutes after administration of sevoflurane his temperature rose to 38.6 degrees C with heart rate 191 bpm and Spo2 93%, and muscle rigidity of legs. MH was diagnosed and dantrolene was administered. His highest temperature was 39.3 degrees C and was reduced promptly after dantrolene. Postoperatively he was noted to have downslanting palpebral fissures, micrognathia, low set ears, and a single crease of the fifth finger and diagnosed as King syndrome which is reported to have association with MH. Both patients had no history of anesthesia nor abnormal family history. Both of them were rescued with dantrolene and recovered without sequelae.

DPPH (1,1-diphenyl-2-picrylhydrazyl) radical scavenging activity of flavonoids obtained from some medicinal plants

A reactive oxygen species has been implicated in a range of human pathological diseases such as atherosclerosis and certain cancers. Flavonoids are reported to exhibit various biological activities, including antioxidative and free radical scavenging activities. Several flavonoids obtained from barley leaves, soybean and some medicinal plants, Silybum marianum, Sophorae Flos, Cinnamon, Ephedrae Herba and Scutellariae Radix, were tested for their DPPH (1,1-diphenyl-2-picrylhydrazyl) radical scavenging activity. The structure-activity relationships suggested that not only the numbers of hydroxy group but also the position of hydroxy group might be important for mediating potent activity.

Behavioral and emotional problems in Chinese adolescents: parent and teacher reports

OBJECTIVE

This study examined behavioral and emotional problems in Chinese adolescents.

METHOD

A sample of 1,694 adolescents aged 12 to 16 years participated in this study in 1997. Parents completed the Child Behavior Checklist (CBCL), and teachers completed the Teacher's Report Form (TRF).

RESULTS

For both parent and teacher reports, internalizing syndromes were scored higher in girls and externalizing syndromes were scored higher in boys. Scores on most of the CBCL and TRF subscales were higher for the older adolescents. The overall prevalence rates of parent- and teacher-reported behavioral problems were 23.1% and 19.2%, respectively. The eight cross-informant syndromes were highly comorbid, with a significant association across syndromes (mean odds ratio = 16.1 for CBCL and 22.5 for TRF). Correlations between parent and teacher reports were 0.51 for eight subscales and 0.68 for Total Problems.

CONCLUSIONS

These findings demonstrate that behavioral and emotional problems tend to increase with age and cluster in the same individuals. The prevalence rates of behavioral problems in Chinese adolescents are comparable to those reported in Western countries. In contrast to findings for Western samples, parent reports of behavioral problems were highly correlated with teacher reports.

Subjective sleep quality and sleep problems in the general Japanese adult population

To dimensionally describe subjective sleep quality using the Pittsburgh Sleep Quality Index (PSQI) and estimate the prevalence rate of sleep problems (PSQI global score > 5) in the general Japanese adult population, 1871 subjects randomly selected from the 1995 Census were examined. The PSQI component scores (mean +/- SD) widely ranged (e.g. 0.04 +/- 0.31 in hypnotic medication use for males aged 20-29 years, 0.03 +/- 0.18 in hypnotic medication use for females aged 20-29 years, 1.10 +/- 0.94 in sleep latency for males aged 80 or older, 1.52 +/- 1.03 in sleep latency for females aged 80 or older). Statistical significance was found in each component score among age groups by gender. The PSQI global scores (mean +/- SD) by age groups ranged from 4.00 +/- 2.59 to 5.02 +/- 3.89 for males (P < 0.39) and 4.30 +/- 2.34 to 6.75 +/- 4.10 for females (P < 0.001). The respective prevalence rates of sleep problems were 26.4% (95% CI = 23.6, 29.3) for males and 31.1% (95% CI = 28.1, 33.9) for females.

Somatic and psychological complaints and their correlates with insomnia in the Japanese general population

OBJECTIVE

This cross-sectional study was conducted to estimate the prevalence of somatic and psychological complaints (SPCs) and to investigate the association of SPCs with insomnia in a sample of the general adult population of Japan.

METHODS

We randomly selected 4000 adult residents (-20 years old) from five areas of Japan using stratified sampling and conducted interviews using a structured questionnaire. The questionnaire solicited information about eight somatic symptoms, eight psychological symptoms, three sleep problems, and demographic and health-related information. A total of 3,030 subjects completed questionnaires, giving a response rate of 75.8%.

RESULTS

Stiff neck/shoulder (45.3%), backache (35.1%), and fatigue (31.4%) were the most common complaints in this population. In general, SPCs were more prevalent in younger persons and in women. Logistic regression analyses, controlling for other factors, showed that insomnia was significantly associated with a number of SPCs: backache (odds ratio [OR] = 1.4, 95% confidence interval [CI] = 1.1-1.6), epigastric discomfort (OR = 1.7, 95% CI = 1.3-2.2), weight loss (OR = 2.0, 95% CI = 1.2-3.3), headache (OR = 1.7, 95% CI = 1.3-2.2), fatigue (OR = 1.7, 95% CI = 1.4-2.1), worrying (OR = 1.6, 95% CI = 1.1-2.3), irritability (OR = 1.4, 95% CI = 1.1-1.7), and loss of interest (OR = 1.8, 95% CI = 1.2-2.7).

CONCLUSIONS

SPCs were common and were largely associated with insomnia in the general adult population of Japan. Further study is needed to examine the causal links between SPCs and insomnia.

Association of structural polymorphisms in the human period3 gene with delayed sleep phase syndrome

Recent progress in biological clock research has facilitated genetic analysis of circadian rhythm sleep disorders, such as delayed sleep phase syndrome (DSPS) and non-24-h sleep-wake syndrome (N-24). We analyzed the human period3 (hPer3) gene, one of the human homologs of the Drosophila clock-gene period (Per), as a possible candidate for rhythm disorder susceptibility. All of the coding exons in the hPer3 gene were screened for polymorphisms by a PCR-based strategy using genomic DNA samples from sleep disorder patients and control subjects. We identified six sequence variations with amino acid changes, of which five were common and predicted four haplotypes of the hPer3 gene. One of the haplotypes was significantly associated with DSPS (Bonferroni's corrected P = 0.037; odds ratio = 7.79; 95% CI 1.59-38.3) in our study population. Our results suggest that structural polymorphisms in the hPer3 gene may be implicated in the pathogenesis of DSPS.

Interaction of phytoestrogens with estrogen receptors alpha and beta

The human estrogen receptor (hER) exists as two subtypes, hER alpha and hER beta, that differ in the C-terminal ligand-binding domain and in the N-terminal transactivation domain. In this study, we investigated the estrogenic activities of soy isoflavones after digestion with enteric bacteria in competition binding assays with hER alpha or hER beta protein, and in a gene expression assay using a yeast system. The estrogenic activities of these isoflavones were also investigated by the growth of MCF-7 breast cancer cells. Isoflavone glycoside binds weakly to both receptors and estrogen receptor-dependent transcriptional expression is poor. The aglycones bind more strongly to hER beta than to hER alpha. The binding affinities of genistein, dihydrogenistein and equol are comparable to the binding affinity of 17 beta-estradiol. Equol induces transcription most strongly with hER alpha and hER beta. The concentration required for maximal gene expression is much higher than expected from the binding affinities of the compounds, and the maximal activity induced by these compounds is about half the activity of 17 beta-estradiol. Although genistin binds more weakly to the receptors and induces transcription less than does genistein, it stimulates the growth of MCF-7 cells more strongly than does genistein.

Low birth weight, developmental milestones, and behavioral problems in Chinese children and adolescents

This study examined the association of low birth weight (LBW) and developmental milestones with behavioral and emotional problems in a general population sample of 3344 Chinese children and adolescents aged 6-16 years in 1997. Parents completed a self-administrated questionnaire including information about birth weight and developmental milestones (i.e. lifting the head up, tooth eruption, speech, walking and bedwetting cessation), and the Child Behavioral Checklist (CBCL). Teachers completed the Teacher's Report Form (TRF) to assess classroom behavior problems. Results indicated that LBW and delayed developmental milestones were significantly associated with an increased risk for almost all parent- and teacher-reported behavioral problems after controlling for the potential effects of child's gender, age and birth order, parental ages at birth, education, occupation, complications at birth and number of children in the family. LBW was significantly associated with delay in achieving all developmental milestones including lifting of the head, tooth eruption, sitting without support, walking without help, speech as saying words with meaning, and bedwetting cessation. It is concluded that LBW and delayed early childhood development may predict the occurrence of a wide range of behavioral and emotional problems in later childhood and adolescence.

Open study of effects of alprazolam on seasonal affective disorder

Seasonal affective disorder (SAD) differs from depression with melancholic features in atypical symptoms, such as hyperphagia, hypersomnia and weight gain. Moreover, SAD is confined to a certain season of the year. We examined the pharmacological efficacy of alprazolam for treatment of patients with SAD. Six patients with SAD were treated with alprazolam at doses of 1.2 mg/day or 1.2 mg/day first and then 2.4 mg/day for 2 weeks. The improvement was evaluated by the change of total score of the SIGH-SAD (with both 21 items HAMD and eight items atypical symptoms) and the clinical global impression (CGI). Although only two patients showed a remarkable improvement by SIGH-SAD, all patients showed a higher than moderate improvement with CGI. Our findings suggest that alprazolam might be efficacious for certain SAD patients.

Diminished melatonin secretion in the elderly caused by insufficient environmental illumination

The pineal hormone melatonin has some circadian regulatory effects and is assumed to have a close relation with sleep initiation and maintenance. Many previous reports have described age-related decreases in melatonin levels, especially in elderly insomniacs (EIs), which may act as causal or exacerbating factors in sleep disturbances in the elderly. Ten elderly residents with psychophysiological insomnia (mean age, 74.2 yr), 10 healthy residents of the same home [elderly control (EC) group; mean age, 72.7 yr], and 10 healthy young control subjects (mean age, 20.9 yr) living at home participated in this study. The elderly persons, especially the EIs, were exposed to significantly less environmental light and simultaneously suffered from significantly diminished nocturnal melatonin secretion. Supplementary exposure to 4 h (1000 to 1200 h, 1400 to 1600 h) of midday bright light in the EI group significantly increased melatonin secretion to levels similar to those in the young control group without circadian phase-shifting. There was a tendency for the magnitude of the increase in nocturnal melatonin secretion stimulated by bright light to parallel amelioration of sleep disturbances in these subjects. The present findings suggest that we need to pay attention to elderly individuals who suffer under conditions of poor environmental light resulting in disorganized circadian rhythms, including the sleep-wake cycle.

Psychometric assessment of subjective sleep quality using the Japanese version of the Pittsburgh Sleep Quality Index (PSQI-J) in psychiatric disordered and control subjects

Subjective sleep quality has been identified as an important clinical construct in psychiatric disordered patients. The Pittsburgh Sleep Quality Index (PSQI), one of the most widely used standardized measures to assess subjective sleep quality, generates a global score and scores seven components. The present study psychometrically assessed clinical profiles of subjective sleep quality in 82 control and 92 psychiatric disordered subjects (primary insomnia, n=14; major depression, n=30; generalized anxiety disorder, n=24; and schizophrenia, n=24), using the Japanese version of the Pittsburgh Sleep Quality Index (PSQI-J). The overall reliability coefficient of the PSQI-J was high (Cronbach's alpha=0.77). Correlation coefficients between the PSQI-J global and component scores were statistically significant. The PSQI-J global and component mean scores were significantly higher in psychiatric disordered subjects than control subjects, except for the component of sleep duration. Using a cut-off point of 5.5 in the PSQI-J global score, estimations of sensitivity and specificity provided 85.7 and 86.6% for primary insomnia, 80.0 and 86.6% for major depression, 83.3 and 86.6% for generalized anxiety disorder, and 83.3 and 86.6% for schizophrenia, respectively. The present study supports the utility of the PSQI-J as a reliable and valid measure for subjective sleep quality in clinical practice and research.

Prevalence and correlates of sleep problems in Chinese schoolchildren

STUDY OBJECTIVES

This study examined the prevalence and correlates of sleep problems in Chinese schoolchildren.

DESIGN AND SETTING

A cross-sectional questionnaire survey was undertaken in Shandong Province, People's Republic of China.

PARTICIPANTS

A total of 2004 elementary school children (998 boys and 1006 girls) participated in the survey.

MEASUREMENTS AND INTERVENTIONS

The parents completed a questionnaire that asked about sleep problems, and characteristics of the family and child. Teachers completed a questionnaire that included the Modified Conners Hyperkinesis Index (MCHI), whether the child slept in class, and school achievement.

RESULTS

Parent-reported sleep problems that occurred "sometimes" or "often" were sleep walking/talking, 14.2%; too little sleep, 14.0%; too much sleep, 12.5%; nightmares, 12.0%; trouble sleeping, 6.1%; and nocturnal enuresis, 4.5%. Teachers reported that 9.4% of children slept in class "sometimes" or "often". Approximately 11% of children were reported to have any sleep problem "often". Children with sleep problems were more frequently reported to be hyperactive, and to have poorer child-parent relations, poorer peer relations, and poorer social competency and school achievement. Multivariate logistic regression analysis indicated that sleep problems were significantly correlated with following factors: poor parental relations, crowded homes, bedwetting cessation after age 4, chronic physical diseases, reported hyperactivity and poor peer relations.

CONCLUSIONS

Parent-reported sleep problems in Chinese children were less prevalent than those reported in Western countries, and associated with multiple family, prenatal, and child developmental factors. Children with sleep problems were reported to be more hyperactive, and to have social and academic problems more frequently. <=

Life events, locus of control, and behavioral problems among Chinese adolescents

This study examined associations of life events and locus of control with behavioral problems among 1,365 Chinese adolescents by using the Youth Self-Report (YSR), Adolescent Self-Rating Life Events Checklist (ASLEC), and the Nowicki-Strickland Locus of Control Scale for Children. Results indicated that the overall prevalence of behavioral and emotional problems was 10.7% (95% CI = 9.9-11.5%). Logistic-regression analyses showed that a total of 13 negative life events mainly coming from academic domain and interpersonal relationships, high life-stress score, and high external locus score significantly increased the risk for behavioral problems. Life stress and locus of control significantly interacted with behavioral problems. These findings support the linkage between stressful life events and psychopathology in a general population of adolescents from mainland China, and demonstrate the stress-moderating effects of locus of control on psychopathology as well.

Diurnal fluctuation of sleep propensity and hormonal secretion across the menstrual cycle

BACKGROUND

The fact that most women experience sleep changes across the menstrual cycle is thought to be associated with changes in circadian rhythms; however, few studies have investigated this relationship.

METHODS

We applied an ultrashort sleep-wake schedule to eight healthy women and studied diurnal fluctuations in sleep propensity, sleepiness, rectal temperature, and serum concentrations of melatonin, thyroid-stimulating hormone, and cortisol in the follicular and luteal phases.

RESULTS

In the luteal phase, amplitude of core body temperature, total melatonin secretions, and amplitudes of TSH and cortisol rhythms were significantly decreased, whereas sleepiness and occurrence of slow-wave sleep during the daytime were significantly increased. Differences in the amount of daytime slow-wave sleep across the menstrual cycle were positively correlated with differences in the daily mean rectal temperature.

CONCLUSIONS

The findings suggest that the amplitude of circadian oscillation may be dampened in the luteal phase. Increased daytime sleepiness in the luteal phase may be associated with increased daytime slow-wave sleep, due possibly to changes in thermoregulation in the luteal phase.