Long-Term Trends and Sociodemographic Inequalities of Emotional/Behavioral Problems and Poor Help-Seeking in Adolescents During the COVID-19 Pandemic

PURPOSE

During the first 3 years of the coronavirus disease (COVID-19) pandemic, we investigated the long-term trends of emotional/behavioral problems and poor help-seeking behavior in adolescents and examined the sociodemographic inequalities in these trends.

METHODS

A multiwave cross-sectional survey was conducted in Japan from October-November 2020, June-July 2021, and June-July 2022 using an anonymous questionnaire. Trends of emotional/behavioral problems (e.g., emotional symptoms, hyperactivity/inattention, and total difficulties) and poor help-seeking were tested using a chi-squared test with Bonferroni correction. The effects of sociodemographic factors (grade, gender, country of origin, and number of parents) on emotional/behavioral problems and poor help-seeking were examined by two mixed-effect logistic regression models: (1) with fixed effects for years and sociodemographic factors and (2) stratified by years if the interaction terms between years and each sociodemographic factor were significant.

RESULTS

The prevalence of total difficulties and emotional symptoms was the highest in 2021. The number of adolescents reporting hyperactivity/inattention and poor help-seeking increased between 2020 and 2021 and remained high in 2022. Inequalities in emotional/behavioral problems and poor help-seeking behavior were found with respect to all sociodemographic factors.

DISCUSSION

Despite the persistent emotional/behavioral problems, the results suggested that the number of adolescents who were unable to seek help increased during the COVID-19 pandemic. Additionally, heterogeneities in the trends with respect to grade, gender, country of origin, and number of parents were detected. Prioritized supports targeting those with sociodemographic disadvantages may be needed to mitigate these inequalities in response to the pandemic.

Correlation with sympathetic skin response, 123I-MIBG scintigraphy, and 123I-FP-CIT SPECT in Parkinson's disease

BACKGROUND

Parkinson's disease (PD), and other parkinsonian syndromes are known to cause striatonigral dopaminergic system dysfunction and autonomic disturbances, including the vasomotor and sudomotor nervous systems. The detection of 123I-FP-CIT SPECT (DaT scan) imaging and autonomic dysfunction helps differentiate PD from multiple system atrophy (MSA) and progressive supranuclear palsy (PSP). The sympathetic skin response (SSR) is a simple, non-invasive electrophysiological test that assesses the sympathetic sudomotor nervous system. It is reported that the SSR is impaired in patients with PD, MSA, and PSP.

OBJECTIVE

To study the relationship between SSR, 123I-metaiodobenzylguanidine (MIBG) cardiac scintigraphy and DaT scan imaging parameters in patients with PD, MSA, and PSP.

METHODS

The study included 62, 25, and 19 patients with PD, MSA, and PSP, respectively. The SSR, MIBG cardiac scintigraphy, and DaT scan imaging were examined. The amplitude and latency of the SSR were measured in all limbs and were compared with the results of MIBG cardiac scintigraphy and DAT scan imaging.

RESULTS

The SSR amplitudes were lower than reported normal subjects' reference values in PD, MSA, and PSP. The SSR amplitude only correlated with MIBG cardiac scintigraphy and DaT scan imaging parameters in PD. Multiple regression analyses also showed a significant relationship between the amplitudes of SSR and DaT scan imaging in PD.

CONCLUSION

Unlike MSA, and PSP, the sudomotor nervous system is parallelly involved with cardiac sympathetic and central dopaminergic dysfunction from the early stage of PD.

High doses of opioids usage for amyotrophic lateral sclerosis patients with non-invasive ventilation

INTRODUCTION

While opioids have been found to be useful in relieving suffering in amyotrophic lateral sclerosis (ALS), there is a lack of evidence concerning how and how much to use them in practice. This study was conducted to clarify how opioids were used for patients with ALS.

METHODS

We performed a retrospective case-based analysis at a single tertiary neurology center in Tokyo from 2010 to 2018. We enrolled patients with ALS who had died before the end of 2018. We examined the opioid dosage equivalent of morphine hydrochloride and patients' clinical backgrounds, focusing on ventilatory support.

RESULTS

Morphine was administered in 110 patients with ALS, and 84 were followed up until their death. Of these 84 patients, 57 (69.9%) did not use mechanical ventilation until death (no-MV group), and 21 (22.9%) utilized only non-invasive ventilation (NIV group). Final morphine dosage in the NIV group was significantly higher (mean 65.7 mg [SD 54.6], range 10-200 mg) than in the no-MV group (mean 31.7 mg [SD 26.9], range 0-120 mg; p = 0.015, Welch's t-test). The NIV group needed psychotropic drugs more frequently than the no-MV group (62% [n = 13] vs. 35% [n = 20]).

CONCLUSION

Patients in the NIV group used opioids for a statistically significantly longer time and at a higher dose than those in the no-MV group. Symptom control with opioids alone may be difficult, and the development of multifaceted evaluation and care is desirable.

[MR neurography reveals fascicular constriction of the median nerve in a patient with neuralgic amyotrophy]

Diagnosing neuralgic amyotrophy can be challenging in clinical practice. Here, we report the case of a 37-years old Japanese woman who suddenly developed neuropathic pain in the right upper limb after influenza vaccination. The pain, especially at night, was severe and unrelenting, which disturbed her sleep. However, X-ray and MRI did not reveal any fractures or muscle injuries, and brain MRI did not reveal any abnormalities. During neurological consultation, she was in a posture of flexion at the elbow and adduction at the shoulder. Manual muscle testing suggested weakness of the flexor pollicis longus, pronator quadratus, flexor carpi radialis (FCR), and pronator teres (PT), while the flexor digitorum profundus was intact. Medical history and neurological examination suggested neuralgic amyotrophy, particularly anterior interosseous nerve syndrome (AINS) with PT/FCR involvement. Innervation patterns on muscle MRI were compatible with the clinical findings. Conservative treatment with pain medication and oral corticosteroids relieved the pain to minimum discomfort, whereas weakness remained for approximately 3 months. For surgical exploration, lesions above the elbow and fascicles of the median nerve before branching to the PT/FCR were indicated on neurological examinations; thus, we performed high-resolution imaging to detect possible pathognomonic fascicular constrictions. While fascicular constrictions were not evident on ultrasonography, MR neurography indicated fascicular constriction proximal to the elbow joint line, of which the medial topographical regions of the median nerve were abnormally enlarged and showed marked hyperintensity on short-tau inversion recovery. In patients with AINS, when spontaneous regeneration cannot be expected, timely surgical exploration should be considered for a good outcome. In our case, MR neurography was a useful modality for assessing fascicular constrictions when the imaging protocols were appropriately optimized based on clinical assessment.

Educational challenges for 22q11.2 deletion syndrome in Japan: Findings from a mixed methods survey

BACKGROUND

The 22q11.2 deletion syndrome (22q11DS) is characterised by a changing pattern of overlapping intellectual, physical, and mental disabilities along the course of one's life. However, the impact of overlapping disorders (multimorbidity) on educational challenges remains unclear.

METHOD

A survey was conducted with 88 caregivers of individuals with 22q11DS. A quantitative analysis of educational challenges and support needs divided into age groups (7-12, 13-15, 16-18, and 19 years and over) and a qualitative analysis of the free-text items in the questionnaire was conducted.

RESULTS

Caregivers were more interested in comprehensive developmental support when their children were younger, and the emphasis shifted to concerns regarding environments that matched individual characteristics at older ages. Furthermore, when there are multiple disabilities or disorders, support is concentrated on the more obvious disabilities, and the lack of support for the less superficially obvious disabilities associated with multiple difficulties, including mental health problems, can be a challenge for people with 22q11DS and their families.

CONCLUSIONS

This study suggests a need for increased focus on multimorbidity and associated disabilities in school education that are difficult to observe because of their mildness or borderline levels if present alone.

Sex-based differences in the longitudinal association between autistic traits and positive psychotic experiences in adolescents: A population-based cohort study

Previous reports have suggested a cross-sectional association between autistic traits and psychotic experiences (PEs) in adolescents. However, while both autistic traits and PEs show sex-related differences, no studies have directly assessed whether such differences exist in the longitudinal association between autistic traits and PEs. Using a population-based adolescent cohort sample (n = 3007), we tested whether the longitudinal association between autistic traits and positive PEs was affected by sex-based differences using regression analyses. Autistic traits were assessed at 12 years old (timepoint 1 [T1]), and PEs were assessed at 12 and 14 years old (T1 and T2). Subsequently, we tested whether subdomains of autistic traits (difficulties in social interaction, communication, imagination, attention to detail, and attention switching) were associated with subtypes of PEs (auditory hallucinations, visual hallucinations, and delusions) using structural equation modeling, after controlling for PEs at T1, socio-economic status, school performance and parents' psychiatric disorders. After controlling for PEs at T1, we did not find any associations between autistic traits at T1 and PEs at T2 in both sexes. There was no significant positive or negative association between all subdomains of autistic traits and subtypes of PEs in both sexes. Autistic traits do not seem to predict future PEs in general adolescents regardless of sex.

Implementation of online classes during national school closure due to COVID‐19 and mental health symptoms of adolescents: A cross‐sectional survey of 5000 students

Aim

Online classes were implemented in numerous schools during the school closure due to COVID‐19. The present study examined the relationship between online classes during national school closure and mental health symptoms after the reopening of schools.

Methods

We conducted a cross‐sectional survey from October 1 to November 7, 2020 using an anonymous self‐reported questionnaire to evaluate 21 junior and senior high schools in the Saitama prefecture of Japan. Out of the 5538 students who were recruited, 5000 agreed to participate. The relationship between the implementation of online classes and mental health symptoms (emotional symptoms, psychotic experience [PE], and smartphone addiction) was evaluated using mixed‐effect logistic regression models, while controlling for individual and class‐level covariates (e.g., gender, grades).

Results

Implementation of online classes was reported by 78.2% of classroom teachers, and it was associated with lower rates of emotional symptoms (OR = 0.79, 95% CI = 0.63–0.99, p = 0.040) and smartphone addiction (OR = 0.79, 95% CI = 0.65–0.96, p = 0.020), but not related to PE (OR = 0.91, 95% CI = 0.61–1.36, p = 0.637).

Conclusions

Implementing online classes during the national school closure might have had a potential protective effect for adolescents' mental health symptoms (especially emotional symptoms and smartphone addiction) after the reopening of schools during the ongoing COVID‐19 pandemic.

Trajectory and course of problematic alcohol use after the Great East Japan Earthquake: Eight-year follow-up of the Higashi-Matsushima cohort study

BACKGROUND

Problematic alcohol use (PAU) after natural disasters is an unignorable public health issue. However, the long-term trajectory and course of PAU after an earthquake disaster remain unknown.

METHODS

The Higashi-Matsushima cohort study was conducted between 2012 (time 1) and 2019 (time 8) in areas affected by the Great East Japan Earthquake in 2011. In the annual health checks, participants responded to self-report questionnaires on PAU, traumatic experiences (e.g., house damage), resources (e.g., social support), and other covariates (e.g., gender, psychological distress). The trajectory and course of PAU were estimated by latent growth model and latent class analyses. Risk factors for the long-term course of PAU were calculated by multinomial logistic regression analysis with multiple imputation. The analytical sample comprised 8929 residents who participated in at least one survey across the eight time points.

RESULTS

The trajectory of PAU showed a sustained trend (slope <0.001). Three potential courses of PAU (No PAU course: 84.3%, Subthreshold PAU course: 12.4%, and Persistent PAU course: 3.4%) were estimated. The long-term course of PAU, especially the persistent PAU course, was predicted by house damage (OR = 1.43, 95% CI 1.06 to 1.92), less social support (OR = 0.71, 95% CI 0.53 to 0.96), gender (male) (OR = 16.86, 95% CI 9.42 to 30.20), and psychological distress (OR = 1.15, 95% CI 1.09 to 1.20).

CONCLUSIONS

Long-term support is needed after an earthquake disaster, especially for residents who in early phases of the disaster suffer from PAU, males, and those in vulnerable situations resulting from conditions such as severe house damage, low social support, or high psychological distress.

Validation of the General Medicine in-Training Examination Using the Professional and Linguistic Assessments Board Examination Among Postgraduate Residents in Japan

Purpose

In Japan, the General Medicine In-training Examination (GM-ITE) was developed by a non-profit organization in 2012. The GM-ITE aimed to assess the general clinical knowledge among residents and to improve the training programs; however, it has not been sufficiently validated and is not used for high-stake decision-making. This study examined the association between GM-ITE and another test measure, the Professional and Linguistic Assessments Board (PLAB) 1 examination.

Methods

Ninety-seven residents who completed the GM-ITE in fiscal year 2019 were recruited and took the PLAB 1 examination in Japanese. The association between two tests was assessed using the Pearson product-moment statistics. The discrimination indexes were also assessed for each question.

Results

A total of 91 residents at 17 teaching hospitals were finally included in the analysis, of whom 69 (75.8%) were women and 59 (64.8%) were postgraduate second year residents. All the participants were affiliated with community hospitals. Positive correlations were demonstrated between the GM-ITE and the PLAB scores (r = 0.58, p < 0.001). The correlations between the PLAB score and the scores in GM-ITE categories were as follows: symptomatology/clinical reasoning (r = 0.54, p < 0.001), physical examination/procedure (r = 0.38, p < 0.001), medical interview/professionalism (r = 0.25, p < 0.001), and disease knowledge (r = 0.36, p < 0.001). The mean discrimination index of each question of the GM-ITE (mean ± SD; 0.23 ± 0.15) was higher than that of the PLAB (0.16 ± 0.16; p = 0.004).

Conclusion

This study demonstrates incremental validity evidence of the GM-ITE to assess the clinical knowledge acquisition. The results indicate that GM-ITE can be widely used to improve resident education in Japan.

Medical, welfare, and educational challenges and psychological distress in parents caring for an individual with 22q11.2 deletion syndrome: A cross-sectional survey in Japan

Parents of children with 22q11.2 deletion syndrome (22q11DS) experience distress not only due to multimorbidity in the patients, but also due to professionals' lack of understanding about 22q11DS and insufficient support systems. This study investigated relationships between medical, welfare, and educational challenges and parental psychological distress. A cross‐sectional survey was conducted on primary caregivers of children with 22q11DS. Participants included 125 parents (114 mothers, 91.2%; average age = 44.3 years) who reported their challenges, psychological distress, and child's comorbidities of 22q11DS. Results showed that the difficulty in going to multiple medical institutions (β = 0.181, p < 0.05) and lack of understanding by welfare staff and insufficient welfare support systems for 22q11DS (β = 0.220–0.316, all p < 0.05) were associated with parental psychological distress, even after adjusting for child's comorbidities. In the subsample of parents whose child attended an educational institution, inadequate management in classroom and mismatch between service and users in educational settings were associated with psychological distress (β = 0.222–0.296, all p < 0.05). This study reveals the importance of assessing not only severity of comorbidities in 22q11DS, but also the medical, welfare, and educational challenges for parental mental health.

Trigeminal Neuralgia Caused by Dural Arteriovenous Fistula of the Transverse-Sigmoid Sinus without Vessel Compression at Root Entry Zone

Objective

The vessel compression at the root entry zone (REZ) of trigeminal nerve is a common cause of trigeminal neuralgia (TN). We report a rare case of TN caused by dural arteriovenous fistula (DAVF) of the transverse-sigmoid sinus without vessel compression at REZ.

Case Presentation

A 45-year-old woman presented with right side tinnitus and was diagnosed as a DAVF of the right transverse-sigmoid sinus (Borden Type I). After that, the facial pain in the right maxillary nerve area appeared and was getting worse. DSA revealed an enlargement of the artery of foramen rotundum (AFR) as one of the feeding arteries. MRI revealed no evidence of vascular compression at REZ. The patient was treated with transarterial embolization (TAE) with Onyx via the branches of the middle meningeal artery (MMA) and occipital artery (OA). The AFR decreased in size and the facial pain was improved. However, the DAVF and the facial pain were recurred. Finally, the DAVF was completely embolized with transvenous embolization (TVE). During 1-year follow-up period, the patient remained free of pain without recurrence.

Conclusion

The compression of the maxillary nerve by the AFR might result in TN, because the pain diminished after shrinkage of the AFR by the endovascular treatment.

Enlarged high frequency oscillations of the median nerve somatosensory evoked potential and survival in amyotrophic lateral sclerosis

OBJECTIVE

A large N20 and P25 of the median nerve somatosensory evoked potential (SEP) predicts short survival in amyotrophic lateral sclerosis (ALS). We investigated whether high frequency oscillations (HFOs) over N20 are enlarged and associated with survival in ALS.

METHODS

A total of 145 patients with ALS and 57 healthy subjects were studied. We recorded the median nerve SEP and measured the onset-to-peak amplitude of N20 (N20o-p), and peak-to-peak amplitude between N20 and P25 (N20p-P25p). We obtained early and late HFO potentials by filtering SEP between 500 and 1 kHz, and measured the peak-to-peak amplitude. We followed up patients until endpoints (death or tracheostomy) and analyzed the relationship between SEP or HFO amplitudes and survival using a Cox analysis.

RESULTS

Patients showed larger N20o-p, N20p-P25p, and early and late HFO amplitudes than the control values. N20p-P25p was associated with survival periods (p = 0.0004), while early and late HFO amplitudes showed no significant association with survival (p = 0.4307, and p = 0.6858, respectively).

CONCLUSIONS

The HFO amplitude in ALS is increased, but does not predict survival.

SIGNIFICANCE

The enlarged HFOs in ALS might be a compensatory phenomenon to the hyperexcitability of the sensory cortex pyramidal neurons.

[A proposal of a novel palliative care scale and analysis of suffering in amyotrophic lateral sclerosis]

OBJECTIVE

We proposed a novel palliative care scale (Amyotrophic Lateral Sclerosis Palliative Care Scale: ALSPCS) for patients with ALS, and analyzed the suffering reported by patients.

METHODS

Thirty-one patients participated in the study. The ALSPCS has 15 items to evaluate physical and psychological suffering; patients scored their subjective suffering on a scale of 0-5 for each item. This study analyzed 13 of 15 items.

RESULTS

The mean scores obtained from the patients were as follows: 'dyspnea', 2.5; 'pain', 2.4; 'restlessness', 2.4; 'thirst', 3.0; 'burning sensation', 2.0; 'choking', 2.0; 'nausea', 0.4; 'constipation', 1.5; 'insomnia', 2.5; 'anxiety', 3.5; 'loneliness', 2.4; 'irritation', 2.1; and 'communication difficulty', 2.3. Multiple correlation analysis using Spearman's rank correlation coefficient showed significant correlations of dyspnea with restlessness, thirst, burning sensation and anxiety; of restlessness with dyspnea, thirst, loneliness and irritation; and of anxiety with dyspnea, thirst and loneliness (P < 0.0038 after Bonferroni's correction). In the principal component analysis, every item showed a positive loading value in the first principal component. Dyspnea, restlessness, thirst, anxiety, loneliness and irritation had loading values >0.7; thus, these symptoms might be the main features in ALS patients. The total scores or each ALSPCS score showed no significant association with post-assessment survival period.

CONCLUSION

This study, using ALSPCS, showed that the subjective suffering of ALS patients was variable and strongly correlated with each other. Appropriate and comprehensive assessment of physical and psychological affliction with ALSPCS could be potentially useful in verifying the effectiveness of palliative care for end-of-life stage ALS patients in the future.

Long and short sleep duration and psychotic symptoms in adolescents: Findings from a cross-sectional survey of 15 786 Japanese students

Sleep problems during adolescence affect current and subsequent mental health and are associated with experiences of psychotic symptoms. Recent studies have suggested that short sleep duration increases the risk of experiencing psychotic symptoms in the general adolescent population; however, whether long sleep duration is associated with an increased risk of psychotic symptoms in adolescence remains unclear. The present study aimed to examine the relationships between long sleep duration, short sleep duration, and the risk of experiencing psychotic symptoms in adolescence. Cross-sectional survey data from 15,786 junior and senior high school students (12- to 15-year-olds and 15- to 18-year-olds, respectively) in Japan were collected and analyzed using logistic regression analysis after controlling for covariates, including depressive symptoms. Long sleep duration was associated with a 1.6- to 2.8-fold increased risk of psychotic symptoms in male but not in female adolescents. Short sleep duration was also related with a 1.6- to 2.9-fold increased risk of experiencing psychotic symptoms, except for 15- to 18-year-old female adolescents. The present study suggested that adolescents with long and short sleep duration should be assessed for their risk of experiencing psychotic symptoms regardless of concurrent depressive symptoms.

Living in temporary housing and later psychological distress after the Great East Japan Earthquake of 2011: A cross-lagged panel model

Living in temporary housing is a risk factor for psychological distress after a natural disaster. As temporary housing is an essential resource for those affected by disasters, investigation of factors which potentially mediate living in temporary housing and psychological distress is needed. This is a cohort study in general population of areas affected by the Great East Japan Earthquake in 2011. Data were obtained from self-report questionnaires in annual health checks between 2014 and 2016 regarding residential situation (e.g., prefabricated or privately-rented temporary housing), psychological distress, sleep disturbances, social support, and covariates. Mediation effects of sleep disturbances and social support on the relationship between temporary housing and psychological distress were evaluated using a cross-lagged panel model during three time points. Among 3,116 participants in 2014, approximately 12% lived in prefabricated or privately-rented temporary housing. Living in prefabricated (β = 0.046, p = 0.031) and privately-rented temporary housing (β = 0.043, p = 0.042) predicted later psychological distress. There was no mediation effect by sleep disturbances (prefabricated temporary housing: β = 0.001, p = 0.620; privately-rented temporary housing: β = −0.001, p = 0.467) or social support (prefabricated temporary housing: β < 0.001, p = 0.748; privately-rented temporary housing: β < 0.001, p = 0.435). CLPM also showed no relationship between living in temporary housing and increased sleep problems or decreased social support. Mental health support may be required for residents who lived in prefabricated or privately-rented temporary housing three years after a natural disaster, whereas support focusing only on sleep disturbances or social support in residents who lived in temporary housing may not be enough to contribute to reducing psychological distress.

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This study investigated mediators on link temporary housing and distress following natural disaster.

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Living in prefabricated and privately-rented temporary housing was associated with distress.

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However, this link was not mediated by sleep disturbances or social support.

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Mental health support may be required for individuals who lived in temporary housing.

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Support focusing only on sleep disturbances or social support may not be enough to contribute to reducing distress.

Effects of oral care on prolonged viral shedding in coronavirus disease 2019 (COVID-19)

Aim

To assess the effects of oral care on prolonged viral shedding in coronavirus disease 2019 (COVID‐19) patients.

Methods and results

We evaluated the clinical course of eight COVID‐19 patients, including their duration of viral shedding, by PCR testing of nasopharyngeal swabs. The average time from the onset of symptoms until the virus was no longer detectable was 31.6 ± 11.8 days (mean ± SD; range 17‐53). Thus, it took 15.1 ± 14.7 (1‐40) days from the time of clinical recovery for the virus to become undetectable. In two patients who had mental retardation and psychiatric disorders, the viral shedding period continued for 44 days or 53 days. These two patients did not voluntarily brush their teeth. When they were instructed on the importance of oral care, including tooth brushing and gargling, their tests for the coronavirus became negative.

Conclusion

Most of the patients with COVID‐19 had a viral shedding period of 30 days or less. In cases of prolonged viral shedding (≥44 days), noninfectious viral nucleic acid may have accumulated in uncleaned oral cavities and continued to be detected. We propose that tooth brushing and gargling remove such viral nucleic acid and improve the accuracy of PCR testing.

Social withdrawal and testosterone levels in early adolescent boys

Social withdrawal may lead to mental health problems and can have a large impact on a life course, particularly among boys. To support adolescents with social withdrawal, an integrative understanding of the biological bases would be helpful. Social dominance, a possible opposite of social withdrawal, is known to have positive associations with testosterone levels. A previous study suggested that social withdrawal has a negative relationship with sexual maturity among adolescent boys. However, the relationship between social withdrawal and testosterone in adolescence is unknown. This study aimed to examine whether social withdrawal was negatively associated with testosterone levels in early adolescent boys. Salivary samples were collected from 159 healthy early adolescent boys (mean age [standard deviation]: 11.5 [0.73]) selected from participants of the "population-neuroscience study of the Tokyo Teen Cohort" (pn-TTC). Social withdrawal and confounding factors, such as the secondary sexual characteristics and their age in months, were evaluated by self-administered questionnaires completed by the primary parents. The degree of social withdrawal was assessed with the Child Behaviour Checklist (CBCL). Levels of salivary testosterone, and cortisol as a control, were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Logistic regression was conducted to examine the association between social withdrawal and testosterone levels. A higher risk of social withdrawal was associated with a lower salivary testosterone level after adjustment for age in months (odds ratio 0.55, 95 % confidence interval 0.33-0.94), and the association remained significant after adjusting for body mass index, the degree of anxiety/depression and pubertal stage. Thus, we found a negative relationship between social withdrawal and testosterone levels in early adolescent boys. These findings may help to clarify the biological foundations of and to develop support for social withdrawal.

Progressive deterioration of sensory cortex excitability in advanced amyotrophic lateral sclerosis with invasive ventilation

We describe a patient with sporadic amyotrophic lateral sclerosis (ALS) who showed progressive deterioration of sensory cortex excitability at the advanced stage, while using invasive ventilation. At the time of diagnosis, the patient showed enlarged N20 of the median nerve somatosensory evoked potential (SEP). Following ventilator use through tracheostomy, the patient gradually fell into a totally locked-in state for four years and the N20 showed progressive deterioration in the amplitude, which finally led to its loss. Magnetic resonance imaging (MRI) showed frontotemporal and mild parietal cortex atrophy, subcortical white matter hyperintensity and brainstem atrophy suggesting the involvement of the central sensory pathways. MRI and flash visual evoked potentials revealed that the occipital lobe was well-preserved throughout the course of the disease. This is the first case report of a physiological demonstration of multisystem neurodegeneration involving the central sensory pathway in a patient with advanced ALS and invasive ventilation use.

[Progressive supranuclear palsy-Richardson syndrome with visual attention disturbance (Holmes and Horrax) and ataxie optique (Garcin): a case report]

[Background] Supranuclear extraorbital muscle palsy is the core feature of progressive supranuclear palsy (PSP), and ordinarily presents as spontaneous vertical gaze constriction. However, higher visual function associated with visuospatial cognition in PSP patients was not previously considered. [Case presentation] We present a 72-year old right-handed man with PSP- Richardson syndrome (PSP-RS) and abnormal higher visual function. His symptoms began 2 years previously and included the use of small steps while walking, forgetfulness, and postural instability. Neurological examination revealed supranuclear vertical gaze limitation, akinesia, and lead-pipe rigidity without laterality. Neuro-ophthalmological examination showed abnormal ocular movement consistent with PSP, and no visual abnormality was observed. General cognitive functions, including attention and prominent visuospatial orientation and visual attention disturbances, were assessed using neuropsychological tests and concomitant spatial agraphia and impaired configuration using figure copying. Although he presented with mildly decreased and monotonous speech with palilalia, he showed no apparent aphasia, apraxia, visual object agnosia, or Bálint's 'optische Ataxie' i.e. visual ataxia under fixation. Brain MRI revealed atrophy of the mesencephalic tegmentum, bilateral frontal lobe, and bilateral hippocampus. N-isopropyl-p-(iodine-123)-iodoamphetamine single photon emission computed tomography revealed decreased cerebral blood flow in the bilateral frontal lobe, lateral temporal lobe, and basal ganglia. Dopamine transporter single photon emission CT revealed uptake attenuation in the bilateral striatum. ¹²³I-metaiodobenzyl-guanidine myocardium scintigraphy results were normal. [Discussion] The patient's symptoms indicated classical PSP-RS accompanied with a combination of disturbances in spatial orientation and visual attention as noted by Holmes and Horrax and 'ataxie optique' by Garcin. Thus, as observed in this patient, many clinically diagnosed PSP patients with undiagnosed higher visual dysfunction, masked by limited eye movement may exist. These symptoms may further our understanding about posterior cortical atrophy and tauopathy including not only PSP but also corticobasal syndrome and Alzheimer disease.

Relationship between EMG-detected and ultrasound-detected fasciculations in amyotrophic lateral sclerosis: A prospective cohort study

OBJECTIVES

Fasciculation potentials (FP) are an important consideration in the electrophysiological diagnosis of ALS. Muscle ultrasonography (MUS) has a higher sensitivity in detecting fasciculations than electromyography (EMG), while in some cases, it is unable to detect EMG-detected fasciculations. We aimed to investigate the differences of FP between the muscles with and without MUS-detected fasciculations (MUS-fas).

METHODS

Thirty-one consecutive patients with sporadic ALS were prospectively recruited and in those, both needle EMG and MUS were performed. Analyses of the amplitude, duration, and number of phases of EMG-detected FPs were performed for seven muscles per patient, and results were compared between the muscles with and without MUS-fas in the total cohort.

RESULTS

The mean amplitude and phase number of FP were significantly lower in patients with EMG-detected FP alone (0.39 ± 0.25 mV and 3.21 ± 0.88, respectively) than in those with both FP and MUS-fas (1.22 ± 0.92 mV and 3.74 ± 1.39, respectively; p < 0.0001 and p = 0.017, Welch's t-test).

CONCLUSION

Small FP may be undetectable with MUS. MUS cannot replace EMG in the diagnostic approach for ALS.

SIGNIFICANCE

Clinicians should use a combination of EMG and MUS for the detection and quantitative analysis of fasciculation in ALS.

The course of chronic and delayed onset of mental illness and the risk for suicidal ideation after the Great East Japan Earthquake of 2011: A community-based longitudinal study

This study investigated how the course of a mental illness is distributed and evaluated the risk factors and suicidality of chronic and delayed onset mental illness after the Great East Japan Earthquake. The first, second, and third waves of this study were conducted in 2012, 2013, and 2014, respectively. Psychological distress, suicidal ideation, and socio-demographics were assessed by a self-report questionnaire for affected residents (N = 1473; 768 females, 52.1%; average age = 66.3 years, ranged from 20 to 89 years). Prevalence of mental illness was 10.0%, 14.7%, and 11.8% in the first, second, and third waves, respectively. Prevalence of mental illness for three years was found to be 21.4% and of remission, chronic, and delayed-onset course was 5.0% (2.9-7.1%), 3.6% (1.6-5.8%), and 6.2% (4.2-8.4%), respectively. Psychological distress and serious damage to their homes in the first wave predicted chronic course. Psychological distress in the first wave, living at temporary housing, and unemployment in the third wave increased risk for delayed onset. Among the participants, 9.8% reported suicidal ideation. Chronic or delayed onset course showed a higher risk of suicidal ideation. Many residents, who showed high risk of suicidality, still suffer from mental illness requiring housing, occupation, and psychological support.

A diver with immersion pulmonary oedema and prolonged respiratory symptoms

Immersion pulmonary oedema (IPE) is particularly associated with an excessive reaction to exercise and/or cold stress. IPE usually resolves without recompression therapy within a day or two. Herein we report a diver diagnosed with IPE, in whom symptoms persisted for five days. A 58-year-old man presented with sudden onset of dyspnoea, cough and haemoptysis after surfacing. He was an experienced diving instructor with a history of moderate mitral valve regurgitation. While IPE was diagnosed and oxygen administered, respiratory symptoms deteriorated, and serum C-reactive protein elevated. No evidence of infection was seen. Three hyperbaric oxygen treatments were given on the basis of suspected decompression sickness, and symptoms subsequently resolved. The recently diagnosed mitral valve regurgitation and inflammatory response were considered to have contributed to the prolongation of symptoms.

Chronic Brachial Plexus Neuritis That Developed into Typical Neuralgic Amyotrophy and Positively Responded to Immunotherapy

Based on the hypothesis that autoimmunity plays a role in the pathogenesis of neuralgic amyotrophy (NA), immunotherapy is sometimes administered. Early intervention is recommended for a good prognosis. We herein report the case of a 55-year-old man who presented with neuralgia, weakness, and muscle atrophy in his right shoulder girdle and upper arm, which progressed for ten months following a marine sports accident. The patient was diagnosed with NA. His neurological deficits gradually improved after several courses of immunotherapy, suggesting that in addition to being effective for treating early-stage disease, immunotherapy may be effective for treating chronic cases.

Mutation analysis of the methyl-CpG-binding protein 2 gene (MECP2) in Rett patients with preserved speech

Genomic DNAs from 35 Japanese sporadic patients with Rett syndrome (RTT) were screened for DNA mutations in the entire coding region and exon-intron boundaries of methyl-CpG-binding protein 2 (MECP2). We detected mutations in 30 (85.7%) of 35 patients. Among these 35 RTT patients, five patients (14%) had the preserved speech variant of this disease. Four respective mutations (R133C, R306C, R294X, 2 base pair (bp) deletion) were found in these five patients. Two patients had the same missense mutation, R133C. The patients with the R133C mutation and one with frameshift mutation presented the relatively mild clinical presentation, and the R133C mutation was not found in any other patient without preserved speech. We confirmed that the preserved speech variant is one of the clinical phenotypes of RTT and is also caused by MECP2 mutation. We speculated that the clinical phenotype of patients with the R133C missense mutation might be mild.