Prognosis of pediatric ulcerative colitis after infliximab failure: A multicenter registry-based cohort study

BACKGROUND AND AIM

Even with increasing numbers of biologic agents available for management of ulcerative colitis (UC), infliximab (IFX) retains an important place in treatment of pediatric patients with this disease. As few reports have addressed outcomes in pediatric UC patients who had to discontinue IFX, we examined clinical course and prognosis after IFX failure in pediatric UC.

METHODS

A prospective cohort study of pertinent cases enrolled in the Japanese Pediatric Inflammatory Bowel Disease Registry between 2012 and 2020 was conducted to determine outcomes for pediatric UC patients who received IFX but required its discontinuation during follow-up (IFX failure).

RESULTS

Of the 301 pediatric UC patients in the registry, 75 were treated with IFX; in 36 of these, IFX was discontinued during follow-up. Severity of UC at onset and absence of concomitant immunomodulator therapy were significant risk factors for IFX failure (P = 0.005 and P = 0.02, respectively). The cumulative colectomy rate after IFX failure was 41.3% at 1 year and 47.5% at 2 years. Colectomy was significantly more frequent when IFX was discontinued before June 1, 2018, than when IFX was discontinued later (P = 0.013). This difference likely involves availability of additional biologic agents for treatment of UC beginning in mid-2018 (P = 0.005).

CONCLUSION

In pediatric UC patients, approximately 50% underwent colectomy during a 2-year interval following IFX failure. Prognosis after IFX failure appeared to improve with availability of new biologic agents and small-molecule drugs in mid-2018.

1122 Sleep Architecture and Leg Movement Activity During Sleep in Patients with Multiple Sclerosis

Introduction

Although sleep in patients with Multiple Sclerosis (MS) has been investigated in several studies using subjective measures, objective sleep data collected using polysomnography (PSG) are still scanty and often divergent. We herein present the largest study to date evaluating sleep architecture and total leg movement activity during sleep (LMS) in patients with MS.

Methods

We collected PSG recordings from 80 patients affected by multiple sclerosis (MS, 48.1±10.61yo 67.5% females), and 60 age and gender matched healthy control subjects (HC, 48.5±17.20 yo, 56% females). Group differences were computed using non-parametric statistics for all traditional sleep architecture parameters, LMS, short-interval (SILMS), periodic (PLMS), isolated LMS (ISOLMS) indices and duration, inter-movement interval (IMI) graphs and time-of-night distribution of LMS.

Results

Patients with MS showed a significantly decreased total sleep period, an increased number of awakenings and stages shifts per hour of sleep, and an increased representation of stage 1 (min and %) compared to the HC group; 26 (32.5%) MS patients had PLMS ≥15/hour versus 8 (13.3%) HC subjects. On average, the comparison between MS and HC groups yielded significant results in terms of an increase in LMS, PLMS, SILMS and ISOLMS indices but not durations. Moreover, MS patients displayed a higher periodicity index, an increased PLMS activity at all inter-movement intervals considered and their PLMS time-of-night distribution revealed that the PLMS increase was stable over the course of the night.

Conclusion

Sleep continuity is significantly impaired in patients with MS. Moreover, MS patients also an increased total LMS activity, including PLMS, which may contribute to disrupt sleep continuity. A disinhibition of lower spinal network due to cervical or supraspinal MS lesions might be implicated in the mechanisms underlying this latter finding.

Support

The Employer Department of Neurology, Regional Hospital Lugano (EOC), Lugano, Switzerland receives financial support from Teva, Merck Serono, Biogen Idec, Bayer Schering, Genzyme, Roche and Novartis. The submitted work is not related to these agreements.

Efficacy and safety of a capsule endoscope delivery device in children

OBJECTIVES

This multicenter, cross-sectional study aimed to elucidate the efficacy and safety of the AdvanCE capsule endoscope delivery device for children in Japan.

METHODS

The present study analyzed 183 cases of small bowel capsule endoscope (SBCE) insertion performed using the AdvanCE in 154 patients aged less than 18 years at participating institutions between 2013 and 2017. Statistical analyses were conducted to identify factors contributing to the completion rate for the entire small intestine examination, small intestine transit time, adverse events and technical issues.

RESULTS

The commonest reason for using the AdvanCE was the patient's inability to swallow the SBCE, which was attributed to young age. SBCE was successfully delivered into the stomach or duodenum in 180 cases and was placed in the duodenum in 90% patients. In 89% patients, the entire small intestine was completely examined, and in 63% patients, findings leading to a new diagnosis or involving changing or maintaining the treatment strategy were obtained. No severe adverse events were observed; however, mild adverse events were observed in 35% patients. No factors considerably contributed to the completion rate for the entire small intestine examination or small intestine transit time and onset of technical issues. The factors that contributed to mild adverse events included intravenous anesthesia, technical issue, and absence of prior insertion of a patency capsule using the AdvanCE.

CONCLUSION

The AdvanCE is well tolerated and effective for children.

A silkworm infection model to investigate Vibrio vulnificus virulence genes

The halophilic marine bacterium, Vibrio vulnificus, occasionally causes fatal septicemia in immunocompromised patients. Mice are commonly used as experimental animals to investigate the virulence of V. vulnificus, however, a large number of mice are generally required for bioassays. The present study examined whether the invertebrate species, silkworms, can be used instead of mice to investigate V. vulnificus virulence. When the silkworms were inoculated with 1.2x107 colony forming units of V. vulnificus OPU1‑Rf, a virulent strain of V. vulnificus, all injected silkworms died within 48 h, however, those injected with culture filtrate or diluent did not. This silkworm infection model was then used to isolate attenuated V. vulnificus mutants from 1,016 transposon‑inserted mutants. Consequently, a harmless mutant, SW998, was isolated. In this strain, the transposon was inserted into the rtxA gene, which is a known V. vulnificus virulence gene. In conclusion, the present study demonstrated that silkworms are useful animals for investigating the virulence of V. vulnificus.

Transnodal lymphangiography and post-CT for protein-losing enteropathy in Noonan syndrome

Noonan syndrome, which is a multiple congenital disorder, may be associated with lymphatic abnormalities. Protein-losing enteropathy (PLE) developing in Noonan syndrome is rare. We performed transnodal lymphangiography by directly accessing bilateral inguinal nodes under ultrasound guidance in a 17-year-old female with PLE developing in Noonan syndrome to assess detailed anatomical findings regarding lymphatic vessels. There have been no reports on transnodal lymphangiography for Noonan syndrome. Post-lymphangiographic CT images revealed multiple lymphatic abnormalities and lipiodol extravasation into the duodenum and the proximal jejunum. Transnodal lymphangiography was easy and safe for PLE developing in Noonan syndrome, and post-lymphangiographic CT provided invaluable information.

Phenotypic spectrum of patients with PLA2G6 mutation and PARK14-linked parkinsonism

BACKGROUND

PLA2G6 is the causative gene for infantile neuroaxonal dystrophy, neurodegeneration associated with brain iron accumulation, and Karak syndrome. Based on previous reports, patients with PLA2G6 mutations could show axonal dystrophy, dystonia, dementia, and cerebellar signs. Recently, PLA2G6 was also reported as the causative gene for early-onset PARK14-linked dystonia-parkinsonism.

METHODS

To clarify the role of PLA2G6 mutation in parkinsonism, we conducted mutation analysis in 29 selected patients with very early-onset (≤ 30, mean 21.2 ± 8.4 years, ± SD) parkinsonism. These patients had other clinical features (e.g., mental retardation/dementia [14/29], psychosis [15/29], dystonia [11/29], and hyperreflexia [11/29]).

RESULTS

Two novel compound heterozygous PLA2G6 mutations were detected (patient A: p.F72L/p.R635Q; patients B1 and B2: p.Q452X/p.R635Q). All 3 patients had early-onset l-dopa-responsive parkinsonism with dementia and frontotemporal lobar atrophy. Disease progression was relatively rapid. SPECT in patient B1 showed frontotemporal lobar hypoperfusion. MRI in patient A showed iron accumulation in the substantia nigra and striatum.

CONCLUSIONS

Although the clinical presentation of PLA2G6-associated neurodegeneration was reported to be homogeneous, our findings suggest patients with PLA2G6 mutation could show heterogeneous phenotype such as dystonia-parkinsonism, dementia, frontotemporal atrophy/hypoperfusion, with or without brain iron accumulation. Based on the clinical heterogeneity, the functional roles of PLA2G6 and the roles of PLA2G6 variants including single heterozygous mutations should be further elucidated in patients with atypical parkinsonism, dementia, or Parkinson disease. PLA2G6 mutations should be considered in patients with early-onset l-dopa-responsive parkinsonism and dementia with frontotemporal lobar atrophy.

Developing ICF Core Sets for persons with sleep disorders based on the International Classification of Functioning, Disability and Health

BACKGROUND

With the International Classification of Functioning, Disability and Health (ICF), we can now rely on a globally agreed-upon framework and system for classifying the typical spectrum of problems in the functioning of persons given the environmental context in which they live. ICF Core Sets are subgroups of ICF items selected to capture those aspects of functioning that are most likely to be affected by sleep disorders.

OBJECTIVE

The objective of this paper is to outline the developmental process for the ICF Core Sets for Sleep.

METHODS

The ICF Core Sets for Sleep will be defined at an ICF Core Sets Consensus Conference, which will integrate evidence from preliminary studies, namely (a) a systematic literature review regarding the outcomes used in clinical trials and observational studies, (b) focus groups with people in different regions of the world who have sleep disorders, (c) an expert survey with the involvement of international clinical experts, and (d) a cross-sectional study of people with sleep disorders in different regions of the world.

CONCLUSION

The ICF Core Sets for Sleep are being designed with the goal of providing useful standards for research, clinical practice and teaching. It is hypothesized that the ICF Core Sets for Sleep will stimulate research that leads to an improved understanding of functioning, disability, and health in sleep medicine. It is of further hope that such research will lead to interventions and accommodations that improve the restoration and maintenance of functioning and minimize disability among people with sleep disorders throughout the world.

Restless legs syndrome in hemodialysis patients: health-related quality of life and laboratory data analysis

AIMS

To compare clinical data, sleep quality and health-related quality of life (HRQOL) with and without RLS in HD patients.

MATERIALS AND METHODS

The international RLS study group diagnosis questionnaire was completed by 228 HD patients. The Pittsburg Sleep Quality Index (PSQI) for the evaluation of sleep quality and the Kidney Disease Quality of Life (KDQOL-SF) for the analysis of HRQOL were also used.

RESULTS

53 (23%) patients were diagnosed as RLS. Age and age at the initiation of HD were significantly younger in the RLS group. Serum calcium concentration (Ca) was significantly higher in the RLS group. Sleep quality evaluated by PSQI was significantly lower in the RLS group. In SF-36 domains of KDQOL-SF, bodily pain, general health perceptions, vitality, role functioning emotional, mental health and mental component score were significantly lower in the RLS group. In kidney targeted scales of KDQOL-SF, symptoms/problems, burden of kidney disease, cognitive function, quality of social interaction, sleep and patient satisfaction were significantly lower in the RLS group.

CONCLUSION

High Ca was possibly connected to the pathophysiology of RLS which impaired sleep quality as well as HRQOL including mental health and many kidney disease related scales.

Flow cytometric determination of intracytoplasmic Wiskott-Aldrich syndrome protein in peripheral blood lymphocyte subpopulations

We have produced a novel monoclonal antibody (mAb) directed against Wiskott-Aldrich syndrome protein (WASP) by immunizing mice with the recombinant protein. The mAb designated 5A5 is highly specific to WASP and suitable for Western blot analysis and immunoprecipitation. A flow cytometric assay using the 5A5 mAb identifies expression of intracytoplasmic WASP in lymphocytes from normal individuals. Double staining analysis with cell surface CD3, CD19, and CD56, and intracytoplasmic molecules revealed WASP expression in each subpopulation. With regard to WASP expression in patients with Wiskott-Aldrich syndrome (WAS) and X-linked thrombocytopenia (XLT), peripheral blood mononuclear cells (PBMCs) from nine patients and Epstein-Barr virus-transformed B-lymphoblastoid cell lines from seven patients examined did not show WASP expression by flow cytometric analysis. These results were confirmed by Western blot analysis. We conclude that WASP expression in lymphocyte subpopulations from patients with WAS and XLT can be more precisely evaluated by flow cytometry as compared with Western blot analysis. This flow cytometry method is important as a supplement to Western blots, but even more important as an alternative and powerful assay that can contribute to research on WASP as well as diagnosis in a clinical setting.

Incident hepatitis C virus infection in a community-based population in Japan

Hepatitis C virus (HCV) is an important cause of liver disease throughout the world. However, the natural history and pathogenesis of this infection is still not completely understood. The aim of this study was to characterize the evolution of incident, asymptomatic HCV infection in a community-based population in Japan. The Miyazaki Cohort Study is a prospective study of adult residents in two villages, one of which has a very high prevalence of HCV. Nine hundred and seventy-three people from this village were enrolled in the cohort between 1984 and 1995, with antibodies to HCV (anti-HCV) found in 23%. During subsequent visits to annual health screens, new HCV seroconverters were identified among susceptible individuals, and their sequential samples were tested for anti-HCV, HCV-RNA, and HCV core antigen. Fourteen participants (six males, eight females) acquired anti-HCV during the first 11 years of study follow-up, at an incidence rate of 362 per 100 000 person-years. Detectable HCV-RNA and high anti-HCV titres (> 1:2048) were observed for more than 5 years following seroconversion in 80% (8/10) of seroconverters with sufficient information, indicating the development of persistent infection in these subjects. Three (37.5%) of the eight sero converters with persistent infection had fairly consistent, albeit mild, alanine aminotransferase elevations (30-130 IU/L) during the study. Anti-HCV seroconversions occurred at a very high rate in this community-based population in Japan, in which this infection is endemic. Persistence also developed at a high frequency among the cases of newly acquired infection, although the associated liver enzyme abnormalities were mild.

Tonic and phasic inhibition indices are constant among nights: new indices for evaluating the degree of the two types of motor inhibition during REM sleep

BACKGROUND

Tonic inhibition index (TII) and phasic inhibition index (PII) were proposed as indices for evaluating the degree of two types of motor inhibition activity during rapid eye movement (REM) sleep.

METHODS

In the present study, therefore, six healthy men underwent two consecutive all-night polysomnography, and reproducibility of TII and PII was evaluated.

RESULTS

TII was 0.85+/-0.07 (mean+/-SD) on the first night and 0.88+/-0.08 on the second; and PII was 3.4+/-2.1 on the first night and 4.9+/-1.8 on the second. Neither TII nor PII was significantly different between the two nights.

CONCLUSION

One night sleep study is considered sufficient for using TII and PII as a tool for evaluating motor inhibition activity during REM sleep in adults.

Increased prevalence of vascular dementia in Japan: a community-based epidemiological study

BACKGROUND AND OBJECTIVE

It has been suggested that there is a major difference in the ratio of AD to vascular dementia (VaD) between Japan and Western countries. To determine the type-specific prevalence of dementia in community-dwelling elderly from the Japanese community of Nakayama, all patients with dementing illness underwent a CT scan.

METHODS

A door-to-door three-phase population survey was carried out on all persons aged 65 years and older residing at home on the prevalence day (January 1, 1997). The ascertainment of cases was made between January 1997 and March 1998. The study included a psychiatric interview; physical, neurologic, and neuropsychologic examinations; comprehensive laboratory tests; and cranial CT. A public health nurse also interviewed a person close to each subject. Dementia was defined according to the Diagnostic and Statistical Manual of Mental Disorders, third edition-revised, criteria, AD according to the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association, and VaD according to Diagnostic and Statistical Manual of Mental Disorders, fourth edition, combined with information from the patient's neurologic history and CT scanning.

RESULTS

Of 1438 inhabitants, 1162 (81.0%) completed the protocol. The prevalence of dementia was 4.8%. Of the 60 subjects with dementia, 35% had AD, 47% had VaD, and 17% had dementia resulting from other causes.

CONCLUSIONS

The prevalence of dementia was similar to previous reports, but, contrary to results of virtually all studies conducted in developed countries and those recently conducted in Japan, almost half of the cases in the present study appeared to have VaD with neuroradiologic confirmation.

Sequential change of virus markers in seroconverters with community-acquired infection of human T lymphotropic virus type I

Twenty-three human T lymphotropic virus type I (HTLV-I) seroconverters were identified among 1120 HTLV-I-seronegative adults followed up for 11 years in an area of Japan endemic for HTLV-I. The geometric mean titer of anti-HTLV-I was 1:453 in the first year after seroconversion; the titer of each subject did not change significantly during 2-10 years of follow-up. HTLV-I proviral DNA load was quantified in 15 seroconverters, and a broad range of levels was observed-from <10 to >1000 copies/10(5) peripheral blood mononuclear cells. However, there was no obvious change in HTLV-I proviral DNA load over several years within individual subjects. Therefore, both proviral DNA load and humoral response in adult HTLV-I seroconverters were shown to stabilize within a few years after initial infection. In addition, 1 subject tested positive for HTLV-I proviral DNA before antibody seroconversion, which suggests the existence of a window period in community-acquired infection.

[Nasal continuous positive airway pressure and noninvasive positive ventilation in the treatment of sleep apnea/hypopnea syndrome]

The main medical treatment of moderate to severe obstructive sleep apnea/hypopnea syndrome is nasal continuous positive airway pressure(nCPAP). When compliance of the patient is low due to nasal or oral dryness, heated humidifier is added to nCPAP. In Japan frequent complaints such as nasal cold and dryness were observed in winter because of infrequent air conditioning in the sleeping room. In the case of dyspnea using nCPAP, bilevel PAP or auto CPAP is recommended. We treated 384 patients with nCPAP and 24% of the patients were added heated humidifier. Auto CPAP and bilevel PAP was administered in 10% and 6% of the patients indicated for PAP treatment, respectively.

[Multiple sleep latency test]

Daytime sleepiness is such a familiar thing for most Japanese, dozing off in a commuting train is regarded as completely normal. Sleepiness, however, can yield a lot of problems. Not only deteriorating efficiency of the work, it sometimes leads to traffic accidents, and also serves as a cause for disastrous accidents. Although excessive daytime sleepiness has been gradually known to Japanese health workers as one of the symptoms of sleep apnea syndrome, some patients cannot recognize sleepiness, and even neglect it, feeling others are sleepy as well. In this respect multiple sleep latency test is a valuable tool as an objective measures of daytime sleepiness, and commonly used procedures of this testing was described in details.

Reassessment of K-ras mutations at codon 12 by direct PCR and sequencing from tissue microdissection in human pancreatic adenocarcinomas

K-ras mutations at codon 12 have been detected in almost all pancreatic adenocarcinomas by highly sensitive assays. We reassessed the K-ras mutation status by direct polymerase chain reaction (PCR) and sequencing from tissue microdissection without DNA extraction in 10 pancreatic adenocarcinomas, and also assessed the K-ras and DPC4 genes in nine pancreatic cancer cell lines. Eight pancreatic adenocarcinomas were found to harbor K-ras mutations at codon 12 of either GTT or GAT, five of which were inferred to harbor amplified mutant alleles. Mutations at the sites other than codon 12 were found in seven of 70 clones (seven of 9,380 bases) by the TA cloning analysis, suggesting that artifactual mutations at the first or second base of codon 12 before and during PCR could occur at a frequency of approximately 10(-3), enough for highly sensitive assays to detect. Two cell lines without K-ras mutations at codon 12 were found to have homozygous deletions at the DPC4 gene. Thus the K-ras mutation status was demonstrated to be correctly determined by just direct sequencing from tissue microdissection. All possible mutations or multiple mutations at K-ras codon 12 that have been reported in pancreatic adenocarcinomas might include artifacts or mutations without a selective advantage. In addition, we must be very cautious about contamination.

Muscle CT scan findings in McLeod syndrome and chorea-acanthocytosis

Computed tomography (CT) scans of lower leg muscles reveal a selective pattern of fat infiltration in the posterior compartment with spared gracilis, semitendinosus, and the lateral head of the gastrocnemius in both McLeod syndrome and chorea-acanthocytosis, which are disorders characterized by the presence of circulating acanthocytes. The selectivity of affected muscles indicates that late onset and slowly progressive muscular atrophy in both diseases could be a consequence of primary myopathy. Asymmetrical muscle involvement may be seen during the process of degeneration only in McLeod syndrome, however, and may be helpful in distinguishing this disease from chorea-acanthocytosis.

Nodular lung disease with five year survival and unilateral pleural effusion in AL amyloidosis

A 67-year-old female patient with biopsy proven AL systemic amyloidosis developed rapidly progressive dyspnea. Chest roentgenogram and CT scan revealed a large right pleural effusion in addition to nodular lesions with bilateral hilar lymphadenopathy. The patient's serum showed IgG lambda type monoclonal gammopathy and she also had Bence Jones proteinuria. The pleural effusion was an exudate that contained many mononuclear cells and a high concentration of protein. Cardiac function was not seriously disturbed. Except for amyloidosis, no other causes for the severe pleural effusion were found. This patient was treated with chemical pleurodesis using Picibanil and a low dose of prednisolone. Eighteen months after this treatment, her right pleural effusion did not recur. Bronchopulmonary tissues are known to be frequently involved by AL systemic amyloidosis, but a nodular pattern of pulmonary amyloid deposition and a unilateral large pleural effusion are rare clinical manifestations in this disease.

Usefulness of MALDI/TOF mass spectrometry of immunoprecipitated serum variant transthyretin in the diagnosis of familial amyloid polyneuropathy

A matrix-assisted laser desorption ionization/time-of-flight (MALDI/TOF) mass spectrometry (MS) system was used to detect variant transthyretin (TTR) in immunoprecipitated serum TTR molecules obtained from 6 patients with familial amyloid polyneuropathy (FAP) who were already proven not to have ATTR Val30Met. This simple and quick method showed six different patterns of mass spectra of TTR-related immunoprecipitates from these patients, and in each patient the clearly identified characteristic doublet-shaped ion peaks consisted of normal and variant TTR apart from each other peak with a mass difference between them. DNA sequencing confirmed that the patterns of variant TTR corresponded respectively to ATTR Val30Leu, ATTR Phe33Val, ATTR Asp38Ala, ATTR Ser50Arg, ATTR Ala97Gly and ATTR Ala97Ser. ATTR Asp38Ala and ATTR Ala97Ser are previously unknown variants of TTR leading to the development of FAP. ATTR Phe33Val was found in a Chinese FAP patient and ATTR Ala97Ser in a Taiwanese. Serum analysis using immunoprecipitation and MALDI/TOF MS system can provide useful information when investigating FAP patients with diverse types of variant TTR.

Modulation of T-cell responses to a recall antigen in human T-cell leukemia virus type 1-infected individuals

To determine the mechanism of the purified protein derivative (PPD)-specific hyporesponsiveness in Mycobacterium bovis BCG-vaccinated human T-cell leukemia virus type 1 (HTLV-1)-infected individuals, we examined cytokine production in response to PPD in the following four groups of individuals: (i) HTLV-negative, PPD nonresponders (n = 11; NN); (ii) HTLV-negative, PPD responders (n = 18; NP); (iii) HTLV-positive, PPD nonresponders (n = 15; PN); and (iv) HTLV-positive, PPD responders (n = 15; PP). In vitro stimulation with PPD resulted in both proliferative responses and gamma interferon (IFN-gamma) production in NP and PP (P < 0.02), with minimal proliferation and IFN-gamma production in the NN and PN groups. Further, PPD-specific interleukin 10 (IL-10) production was significantly reduced in the PN group (P < 0.01), while the other groups had comparable levels. Cytokine reconstitution experiments demonstrated that while addition of recombinant IL-12 (rIL-12) plus anti-IL-4 restored PPD-specific responses in the NN group, it had no effect in the PN group. However, addition of rIL-12 resulted in the increased production of IFN-gamma in both nonresponder groups (NN and PN), suggesting that the lack of IFN-gamma production was not responsible for the PPD anergy. We conclude that PPD-specific anergy in HTLV-1-infected individuals appears to be due in part to their inability to respond to rIL-12.

Development of REM sleep atonia

OBJECTIVES

To study the functional development of neuronal systems that suppress muscle activity, we quantified the chronological change of atonia in rapid-eye-movement sleep (REMS).

METHODS

REMS atonia was quantified by the tonic and phasic inhibition indices (TII and PII). TII indicates the shortness of chin muscle activity, whereas PII standardizes the simultaneous occurrence of chin muscle activity and bursts of rapid eye movements. TII and PII were calculated in REMS of 135 polysomnographical recordings obtained in healthy humans from premature babies to a 77-year-old man.

RESULTS

TII increased significantly with age, while PII decreased significantly. TII reached an adult level at preadolescence, while PII at early infancy.

CONCLUSION

Human nervous systems involved in both tonic and phasic inhibition in REMS raise their activities with age. Since TII and PII reach adult levels at different ages, suppression of muscle activity is hypothesized to be mediated through at least 2 independent systems in humans.

What prevents Japan from establishing a clinical service of sleep medicine: experience gained at a local hospital

We opened a mini-sleep disorders clinic in a local general hospital in rural Japan, and have been operating it for more than 3 years. We encountered many difficulties during this period when we tried to provide proper clinical service. Problems ranged from lack of sleep specialists and polysomnography technicians, shortage of funding, non-existence of an educational system to obtain comprehensive knowledge about sleep medicine, and also lack of cooperation among different departments necessary for maintaining clinical service. Through our experience, we analyzed various factors that prevent Japan from establishing a clinical service of sleep medicine.

Sleep-disordered breathing at an early stage of amyotrophic lateral sclerosis

Eighteen amyotrophic lateral sclerosis (ALS) patients having neither respiratory complaints nor subjective symptoms of sleep disturbance were studied by using an ambulatory multi-parameter monitoring system during sleep. They were divided into two groups: 11 patients with predominantly bulbar form and seven with non-bulbar form. After performing daytime pulmonary function tests, the presence of sleep-disordered breathing (SDB) was evaluated by using a portable device. ALS patients did not show significant SDB as a whole, and the respiratory disturbance index (RDI) was not significantly different between the bulbar group and the non-bulbar group. However, three patients of the bulbar group showed significant SDB, and the patterns of apnea/hypopnea suggested that both bulbar weakness and minimal diaphragmatic weakness might cause SDB in ALS patients at an early clinical stage. Multi-parameter respiratory monitoring during sleep should be included in the routine evaluation of ALS patients at an early clinical stage, especially those with predominantly bulbar involvement, in order to predict early respiratory failure.

Predictors of level of circulating abnormal lymphocytes among human T-lymphotropic virus type I carriers in Japan

Human T-lymphotropic virus type I (HTLV-I) carriers often have abnormal lymphocytes (Ably) that resemble malignant cells of adult T-cell leukemia (ATL). To identify predictors of the level of Ably in a longitudinal study of asymptomatic HTLV-I carriers, we analyzed data from 215 subjects (67 men and 148 women) with multiple Ably measurements on blood smears. Ably+ (those having Ably > 0.6% of leukocytes counted on a blood smear at least once) was strongly associated with a high proviral load (OR 8.9; 95% CI 4.1, 19.5). The association among those defined as Ably++ (Ably > 0.6% at all screens or Ably > 1.6% at least once) was higher (19.7; 6.9, 56.1). Ably++ was also significantly associated with male gender (2.8; 1.0, 7.8). Multivariate analysis of Ably level indicates that men with a high proviral load, high anti-HTLV-I titer and low anti-Tax reactivity have the highest Ably level.

[Preliminary screening for antiviral AIDS drugs. VIII. Report for fiscal year 1995]

Preliminary screening of antiviral AIDS drugs has been carried out using three different in vitro assay systems. Among 96 samples of different origin tested, two were shown to inhibit the growth of HIV in vitro. One of the positive samples (plant origin) has hopeful signs, as the ranges of effective doses are wider than those of most of positive samples which had been found by us.

An outbreak of hepatitis A in a day-care center: immunoprophylaxis with human immunoglobulin

BACKGROUND

An outbreak of seven cases of hepatitis A (HA) occurred in a day-care center. Five of the cases were children attending the center, one was a nurse and one was the mother of a child. It is probable that the first case with HA was a male child infected by an unknown source.

METHODS AND RESULTS

Human immunoglobulin (HIG) was administered to both children and staff at the center following which there were no new cases of infection among in-center contacts. However, a new case of HA among household contacts developed 3 weeks following the treatment of in-center contacts.

CONCLUSIONS

The outbreak may have been prevented if the sibling (case 2) of the source case of infection (case 1) had been given HIG as soon as infection had been confirmed. Additionally, the data suggest that HIG for prevention of HA should be given not only to children but also to their parents.

Intrafamilial transmission of HTLV-I and its association with anti-Tax antibody in an endemic population in Japan

To assess the relationship of anti-Tax antibody to human T-cell lymphotropic virus type-I (HTLV-I) transmission, the sero-prevalence of HTLV-I was analyzed among married couples and among mother/child (both adults) pairs. HTLV-I seroprevalence was significantly higher among wives with anti-Tax+ than those with anti-Tax- HTLV-I carrier husbands (82.4% vs. 59.5%). However, in the group of wives aged 60 years or older, there was no statistical difference in HTLV-I seropositivity based on the husbands' anti-Tax sero-status. In the group whose wives were less than 60 years old, more anti-Tax sero-positive than sero-negative husbands had high DNA levels (57.1% and 20.0%), whereas in the group of husbands whose wives were aged 60 years or older, the number of anti-Tax sero-positive and sero-negative individuals with high DNA levels was similar. HTLV-I sero-prevalence was significantly higher among the adult men with anti-Tax+ carrier mothers than those with anti-Tax- carrier mothers (52.0% vs. 14.3%). For women, HTLV-I sero-prevalence did not differ significantly according to their mothers' anti-Tax sero-status. Our results suggest that the presence of anti-Tax antibody in HTLV-I carriers is an age-dependent risk factor for male-to-female HTLV-I transmission. Furthermore, the effect of the mother's anti-Tax antibody as a risk factor for vertical HTLV-I transmission could be observed in men even after becoming adults.

Detection of polyanion-restricted anti-histone antibodies in patients with systemic lupus erythematosus

The nature of the antibodies responsible for lupus erythematosus (LE) cells in systemic lupus erythematosus (SLE) remains obscure. We examined whether polyanion-restricted anti-histone antibodies were present in serum of patients with SLE using Western blotting analysis. Dextran sulfate or alginate was used as a polyanion compound in place of DNA. Antibodies which recognized dextran sulfate-histone complexes were present in serum of patients with SLE (17/34, 50%). These antibodies were detected in most SLE patients positive for LE cells (17/18, 94%) but not in those negative for LE cells or in patients with other collagen diseases. Similar results were obtained using alginate-histone complexes as antigens for Western blotting analysis. The antibodies to dextran sulfate-histone or alginate-histone complexes in serum of SLE patients were completely absorbed by treatment of serum with DNA-histone complexes, while they were unaffected by treatment with DNA only. The presence of antibodies to free histones and dextran sulfate-histone complexes did not seem to be related to the titer of anti-single stranded DNA antibody and anti-double stranded DNA antibody. We demonstrated the presence of polyanion-restricted antibodies in SLE, which may be responsible for the LE factor.

REM sleep motor dysfunction in multiple system atrophy: with special emphasis on sleep talk as its early clinical manifestation

Various neurodegenerative diseases involving brainstem structures as one of the main pathological lesions are reported to be associated with REM sleep behaviour disorder. Full blown REM sleep behaviour disorder can be diagnosed clinically, but REM sleep motor dysfunction, a pathophysiological basis of REM sleep behaviour disorder, is difficult to detect without all night polysomnography. Twenty one consecutive patients with multiple system atrophy with no complaints of nocturnal abnormal behaviours were clinically evaluated to determine the presence of sleep related symptoms. All night polysomnography with video monitoring was performed to investigate REM sleep characteristics and patients' behaviours. In 85.7% (18 of 21) of the patients' sleep talk started or increased around or after the clinical onset of the primary diseases. REM sleep without atonia occupied more than 15% (16.2%-100%) of the REM sleep time in all but one patient. In 90.5% (19 of 21) of patients, motor events such as sleep talk and various combinations of craniofacial, orofacial, or limb movements occurred at various frequencies mostly during REM sleep without atonia. In patients with multiple system atrophy, REM sleep motor dysfunction is a common polysomnographic finding which is otherwise overlooked, and sleep talk may be its early clinical manifestation.

Subclinical REM sleep behavior disorder in a patient with corticobasal degeneration

Various neurodegenerative diseases have been reported to be associated with rapid eye movement (REM) sleep behavior disorder (RBD). This is the first report of a patient with corticobasal degeneration (CBD) associated with subclinical RBD. A 72-year-old woman was admitted complaining of fine tremor of the right hand and weakness of the right lower extremity. She was diagnosed as having CBD on the basis of clinical features and neuroimaging studies. Her family noticed snoring and increase in sleep talk, but they did not regard them as pathological. All-night polysomnography (PSG) revealed REM sleep without atonia (RWA) during which 14 episodes of talking and singing were observed. They ranged from the utterance of one word to that of comprehensible words of a song for about 3 minutes accompanied by various nonpurposeful movements of the mouth, hands, and limbs. These episodes were not associated with any sleep-disturbed breathing. Future PSG studies on CBD patients together with postmortem analysis of brain stem structures that are crucial for generating REM sleep-related atonia are warranted for further understanding of the pathophysiological mechanism of RBD.

Heterosexual transmission of hepatitis C virus among married couples in southwestern Japan

The heterosexual transmission of hepatitis C virus (HCV) remains controversial, and data from general populations are scanty. In this cross-sectional study, we assessed the seroprevalence of antibodies to hepatitis C virus (anti-HCV) and the presence and genotype of HCV-RNA among 109 married couples within an endemic, community-based Japanese population. Overall, 25% of the husbands and 32% of the wives had anti-HCV. Spouses with anti-HCV-positive partners were around 2 times more likely to have anti-HCV than spouses with anti-HCV-negative partners (p = 0.01). Of 6 couples in which both spouses had HCV-RNA, however, 3 presented discordant HCV genotypes (type 1b vs. 2b). The couples' anti-HCV concordance status was not significantly influenced by the presence or absence of HCV-RNA among anti-HCV-positive partners (odds ratio [OR]: 0.8 for wives, 0.6 for husbands), nor by the length of marriage, the number of pregnancies or the use of contraceptives. No significant associations with anti-HCV were observed for serum markers of sexually transmitted agents, including human T-lymphotropic virus (OR = 1.1, 95% confidence interval [CI] 0.5-2.3), Treponema pallidum (OR = 0.7; CI 0.1-6.1) and hepatitis B virus (OR = 1.6; CI 0.9-3.0). Our results suggest that the clustering of HCV infection among specific couples within this endemic population may not be attributable to heterosexual transmission. Follow-up studies are necessary to determine the risk of heterosexual transmission of HCV in endemic areas.