Usefulness of the Palliative Prognostic Index in Predicting Prognosis when Considering the Transition from Hospital to Home Care in Patients with Terminal Stage Cancer

BACKGROUND

No accurate prognostic tool is available for patients with cancer who spend their final days at home. In this study, we examined whether performance status (PS) and the palliative prognostic index (PPI), a well-known prognostic tool in palliative care units, could be used to predict prognosis in the home care setting at the time of intervention by home physicians.

SUBJECTS AND METHODS

Using medical records, we conducted a retrospective analysis of 132 patients who were referred to the Home Clinic Naginoki for home care for terminal stages of carcinoma in situ. Based on the status at the time of the first visit, the PPI-Low group was defined as those scoring six or below and the PPI-High group as those scoring greater than six.

RESULTS

The PPI-high group had a significantly poorer prognosis within 21 days than the PPI-low group (21-day-OS; Low 71.4% vs. High 13.2%; p<0.001). The Eastern Cooperative Oncology Group (ECOG) PS alone predicted better prognosis in the group with PS of one or two (21-day survival 90.1%), and the PPI score further significantly stratified the prognosis for patients with PS three or four, with a trend toward poor prognosis (p ≤ 0.005).

CONCLUSION

ECOG PS 1 or 2 has a favorable prognosis and that using PPI in ECOG PS 3 or 4 leads to a more accurate prognosis prediction. PPI evaluated during the hospital-based treatment of patients with terminal cancer can also be used to predict prognosis if the patient is transitioned to a home care environment.

Epstein-Barr Virus-Related Hemophagocytic Lymphohistiocytosis with Central Nervous System Symptoms

Hemophagocytic lymphohistiocytosis (HLH) involves pathological histiocytes and phagocytosis of normal blood cells through activation of inflammatory cytokines. We report a case of Epstein-Barr virus-HLH in a 75-year-old woman who presented with fever, thrombocytopenia, and loss of consciousness. Epstein-Barr virus-HLH was diagnosed after we identified massive hemophagocytosis in bone marrow and Epstein-Barr virus DNA in cerebrospinal fluid. The HLH-2004 protocol was applied, and lactate dehydrogenase levels-which reflect HLH disease status-decreased. However, persistent loss of consciousness and multiple organ failure led to the patient's death on day 18. Most cases of primary and secondary HLH involve pediatric patients; adult cases are rare. Few cases of central nervous system involvement in older adults have been reported. Therefore, accumulation of more data will help in developing better treatment strategies.

Safety and efficacy of high-dose cytarabine MEAM therapy and other treatments for auto-peripheral blood stem cell transplantation: A retrospective comparative study

AIM

The MEAM regimen consisting of ranimustine (MCNU), etoposide (ETP), cytarabine (Ara-C), and melphalan (MEL) is widely used before auto-peripheral blood stem cell transplantation (auto-PBSCT) for malignant lymphoma in Japan. The MEAM regimen generally consists of 200-400 mg/m² for 4 days, but we decided to increase the dosage of Ara-C from the standard to 2 g/m² for 2 days with the aim of increasing drug transferability to the central nervous system. We evaluate the safety and therapeutic efficacy of high-dose Ara-C MEAM therapy.

METHODS

The high-dose Ara-C MEAM protocol consisted of MCNU 300 mg/m² on day -7, ETP 200 mg/m² on days -6, -5, -4, -3 and Ara-C 2 g/m² on day -4 -3, and MEL 140 mg/m² on day -2. We retrospectively analyzed 37 cases of malignant lymphoma at our institution between May 2014 and July 2020.

RESULTS

All patients got engraftment and there were no cases of treatment-related mortality. In all cases, the 3-year overall survival (OS) and progression-free survival (PFS) after transplantation were 80.6% and 65.7%, respectively. Twenty-one cases of diffuse large B-cell lymphoma recurrence, for which there is proven usefulness of auto-PBSCT, showed good results after transplantation, with the 3-year OS and PFS after transplantation being 100% and 74.3%, respectively.

CONCLUSION

The safety and efficacy of high-dose Ara-C MEAM therapy were demonstrated, but the expected therapeutic effect on central nervous system lesions could not be fully evaluated owing to the small number of cases.

Loss of social role awareness, a subdomain of social frailty, is an independent predictor of future adverse events in hospitalized older patients with heart failure

Background

Frailty is a complex syndrome characterized by a decline in functional reserve, and associated with aging and chronic diseases including heart failure (HF). The impact of physical frailty on prognosis and the effect of cardiac rehabilitation in HF patients have been well established. However, the data on the prognostic impact of social frailty (SF) in HF patients is limited.

Aims

We aimed to get new insight into mechanisms of the association of SF with clinical outcomes in older hospitalized HF patients.

Methods

A single-center, retrospective cohort study was conducted using data from 308 HF patients aged ≥65 years (mean age of 78±8 years; 49% females) who were admitted to our institute for the management of HF. SF was assessed using the validated Makizako's five questions. The following responses were considered positive for SF: (1) going out less frequently compared with last year; (2) not visiting friends; (3) not talking with someone every day; (4) not feeling helpful toward friends or family; and (5) living alone. SF was defined as two or more positive responses. The primary outcome was composite events defined by all-cause death and cardiovascular events. The missing data were imputed using multiple imputation by chained -equations algorithm.

Results

Of 308 older HF patients, 189 patients (61%) were SF. Patients with SF were significantly older, had lower body mass index, and a higher percentage of patients with physical frailty and cognitive frailty than those without SF. Seventy-five patients (24%) experienced composite events during a median follow-up period of 1.55-years (interquartile range, 0.88–2.20 years). Kaplan-Meier curves showed a significantly higher composite event rate in patients with SF than those without SF. In multivariate Cox regression analyses, SF was independently associated with a higher composite event rate after adjusting for pre-existing risk factors [adjusted hazard ratio (HR), 1.91; 95% confidence interval (CI), 1.09–3.35; p=0.03] (Figure 1A). In addition, further analyses showed that only the positive response on the question corresponding to the social role – not feeling helpful toward friends or family – among the questionnaire was an independent predictor for the incidence of the composite event (adjusted HR, 2.10; 95% CI, 1.29–3.41; p&lt;0.01, Figure 1B). Inclusion of the response to the question regarding the social role into the baseline prognostic model improved the accuracy of prediction of the composite event (continuous net reclassification improvement, 0.46; 95% CI, 0.21–0.71; p&lt;0.01; integrated discrimination improvement, 0.025; 95% CI 0.004–0.047; p=0.02; Figure 2).

Conclusion

Loss of social role awareness was associated with increased composite event risk and provided additive prognostic information in older HF patients, suggesting the importance of healthcare professionals' decision-making on the prevention and management of SF.

Funding Acknowledgement

Type of funding sources: None.

Coexistence of sarcopenia and osteoporosis in patients with heart failure: prevalence and association with functional status

Background

Sarcopenia, the loss of muscle mass and function, and osteoporosis, a condition of low bone mass and micro-architectural deterioration of bone, frequently coexist and are associated with low functional status in heart failure (HF) patients.

Aims

We aimed to investigate the impact of coexistence of sarcopenia and osteoporosis on functional status in HF patients.

Methods

This cross-sectional study was conducted using data from patients who admitted to our institute for the diagnosis and management of HF from 1 November 2015 to 30 April 2021. All patients received the dual-energy X-ray absorptiometry (DEXA) method before discharge. The diagnosis of sarcopenia was made according to the criteria of Asia Working Group for Sarcopenia 2019 recommendation as follows: reduced skeletal muscle mass [appendicular skeletal muscle mass index (ASMI) by DEXA, &lt;7.00 kg/m2 in males and &lt;5.40 kg/m2 in females] plus lower muscle strength (handgrip strength, &lt;28 kg in males and &lt;18 kg in females) and/or poor physical performance (gait speed, &lt;1.0 m/s; chair stand test time. ≥12 s; short physical performance battery ≤9 points). In addition, bone mineral densities (BMDs) at the lumbar spine, femoral neck, and total femur were measured by DEXA, and osteoporosis was diagnosed when BMDs at any of the three sites were less than 70% of Young Adult Mean (YAM). Functional status was assessed by the Barthel Index (BI) within three days before discharge, and patients with a BI score of &lt;85 points was defined as having functional dependence (FD). The missing data were imputed using multiple imputation by chained -equations algorithm.

Results

Four hundred-thirty eight patients [median age of 74 years (interquartile range, 65–82 years), 37% females] were included in the analyses. Of these, percentage of HF patients with sarcopenia, osteoporosis, and sarcopenia and osteoporosis was 45%, 34%, and 20%, respectively (Figure 1A). The analysis of covariance showed a lower %YAM at any sites in patients with sarcopenia than those without sarcopenia (Figure 1B). When patients were divided into subgroups according to the presence or absence of sarcopenia and osteoporosis, the prevalence of FD was 32%, 34%, and 48% in patients with osteoporosis alone, sarcopenia alone, and sarcopenia and osteoporosis, respectively. Multivariate logistic regression analysis indicated that an increase in adjusted odds ratio (OR) for predicting FD was observed across subgroups in the following order: patients with osteoporosis alone [OR, 1.64; 95% confidence interval (CI), 0.63–4.24; p=0.31], those with sarcopenia alone (OR, 2.44; 95% CI, 1.13–5.25; p=0.02) and those with both conditions (OR, 3.34; 95% CI, 1.52–7.38; p&lt;0.01) (Figure 2).

Conclusion

There was considerable overlap between sarcopenia and osteoporosis in HF patients, which appeared to be a risk factor for FD.

Funding Acknowledgement

Type of funding sources: None.

P-205 Blastocyst derived from oocytes with smooth endoplasmic reticulum aggregates (SERa) has similar clinical and perinatal outcomes with those of oocytes without SER

Study question

This study was to investigate effect of SERa on the fertilization rate, embryonic development after ICSI, and clinical and perinatal outcomes after single blastocyst transfer.

Summary answer

SERa (+) derived embryo can be selected as embryos for transfer when no available SERa (-) derived embryos.

What is known already

Based on findings that the risk of congenital abnormalities in the newborn is higher in ovum with SERa in the cytoplasm, the Istanbul consensus workshop at the 2011 meeting of the ESHRE recommended against fertilizing ovum with SERa due to these risks. However, there have been several reports of healthy infants born from embryos derived from SERa, suggesting that, while more long-term follow-up is necessary, healthy births are possible from such embryos. In 2017, the 2011 recommendations were reviewed in the Alpha/ESHRE consensus (Vienna), which said the approach should be determined on a case-by-case basis.

Study design, size, duration

We retrospectively investigated 23,007 oocytes which was retrieved between January 2016 and March 2020. Of these, 1,038 oocytes (4.5%) with visible SERa comprised SERa (+), while 21,969 oocytes (95.5%) without SERa comprised SERa (-).

Participants/materials, setting, methods

SERa were observed under the microscopy after denudation. The rate of fertilization, good-quality day-3 embryos, good-quality day-5 blastocysts, and day-5, 6 or 7 blastocysts were evaluated for both groups. We also compared the rate of clinical pregnancy, live birth, miscarriage, and birth defects in single blastocyst transfer between SERa (+) derived 114 blastocysts and SERa (-) derived 6,290 blastocysts from January 2016 and December 2018.

Main results and the role of chance

The results are shown. 2PN fertilization rate outcomes after ICSI (SERa(-) eggs vs. SERa(+)eggs),81.4%(17,873/21,969) vs.79.4% (823/1,038),and good-quality day3 rate was 61.1%(10,927/17,873)vs.60.9% (501/823) which was not significantly different. Good-quality day5 blastocyst rate was 46.5% (7,876/16,955) vs. 39.8%(304/763), and day 5 blastocyst success rate was 60.8% (10,317/16,955) vs.54.3% (414/763), which were both significantly lower with SERa(+). (P &lt; 0.001) The day 6 blastocyst success rate was 69.9% (11,849/16,955) vs. 65.5% (500/763) (P = 0.01), and the day 7 blastocyst success rate was 70.9% (12,024/16,955) vs. 67.5% (515/763) (P = 0.04), which were all significantly lower with SERa(+).The clinical pregnancy rate was 39.4% (2,481/6,290) vs. 35.1% (40/114), the live birth rate was 27.7% (1,745/6,290) vs. 26.3% (30/114), and the miscarriage rate was 27.5% (683/2,481) vs. 20.0% (8/40) and the congenital abnormality rate was 1.6% (29/1,757) vs. 0% (0/30) for SERa(-) embryos and SERa(+) embryos, respectively, which were not significantly different. Blastocyst derived from oocytes with SERa has similar clinical and perinatal outcomes with those of oocytes without SERa. Significant differences were examined using the chi-squared test, with p &lt; 0.05, indicating a significant difference.

Limitations, reasons for caution

Embryos derived SERa (+) were transferred when the patient did not want any more oocytes retrievals, no embryos derived SERa (-) were available, and only if the couple desired embryo transfer after the problems associated with SERa (+) embryos were fully explained.

Wider implications of the findings

To the best of our knowledge, this study is the largest number of live births investigating the outcome of SERa (+) derived embryos. SERa (+) derived embryo can be selected as embryos for transfer when no available SERa (-) derived embryos.

Trial registration number

Not Applicable

Does serum 25-hydroxyvitamin D levels have impacts on sarcopenia in patients with chronic heart failure?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Sarcopenia is associated with poor functional status and clinical outcomes in heart failure (HF) patients. Although recent observational studies showed the relationship between lower serum vitamin D levels and the development of poor physical function in community-dwelling older adults, involvement of vitamin D status in the development of sarcopenia in HF patients remain unclear. This study aimed to investigate the impact of serum vitamin D concentrations on sarcopenia in patients with HF.

Methods

We retrospectively enrolled 269 consecutive patients [median age of 73 years (interquartile range 63-82 years); 35% female] admitted to our institute for diagnosis and management of HF, and received the dual-energy X-ray absorptiometry (DEXA) method during the period from 1 September 2018 to 30 September 2021. The 25-hydroxyvitamin D [25(OH)D] was detected by a chemiluminescence immunoassay (CLIA) technology. The diagnosis of sarcopenia was made according to the criteria of Asia Working Group for Sarcopenia incorporating reduced skeletal muscle mass (appendicular skeletal muscle index [ASMI], &lt;7.00 kg/m2 in males and &lt;5.40 kg/m2 in females), and lower muscle strength (handgrip strength, &lt;28 kg in males and &lt;18 kg in females) and/or poor physical performance (gait speed, &lt;1.0 m/s; chair stand test time, ≥12 s; short physical performance battery, ≤9 points).

Results

Of 269 patients, 116 (43%) patients had sarcopenia. An adjusted logistic regression model with a restricted cubic spline function showed that the odds ratio (OR) for sarcopenia increased as the serum 25(OH)D levels decreased. When the value that corresponded to an upper limit of 95% confidence interval (CI) for an OR of 1.0 was defined as the cut-off value of 25(OH)D levels for predicting sarcopenia, it was 18 ng/mL (Figure 1A). A multivariate logistic regression model was fit to calculate the propensity score (PS) for the 25(OH)D levels being &lt;18 ng/mL based on covariates such as age, sex, and N-terminal pro B-type natriuretic peptide. (C-statistics 0.761). The inverse probability of treatment weighting (IPTW) was computed using PS to minimize differences in potential confounding factors between patients with a low serum 25(OH)D levels (&lt;18 ng/mL) and those with a high serum 25(OH)D levels (≥18 ng/mL, Figure 1B). Results of the multivariate logistic regression analysis in the IPTW-weighted patients showed that a low serum 25(OH)D was independently associated with presence of sarcopenia (adjusted OR 2.03, 95% CI 1.31-3.16, p&lt;0.01). In addition, patients with a low serum 25(OH)D had a significantly lower muscle strength and poor physical performance, but not ASMI, than those with a high serum 25(OH)D (Figure 2).

Conclusion

Decreased serum 25(OH)D levels are associated with decline in muscle strength and physical performance in HF patients. Serum 25(OH)D levels of &lt;18 ng/mL may be a novel risk factor of sarcopenia in HF patients.

Novel equation for skeletal muscle mass estimation is useful for predicting mortality in patients with heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

Skeletal muscle mass in heart failure (HF) patients is closely related to exercise tolerance and prognosis. Although the dual-energy X-ray absorptiometry (DEXA) method is a standard method for measuring skeletal muscle mass, it is not suitable in a daily clinical setting since it is a costly and hospital-based modality. We recently reported that an equation for appendicular skeletal muscle mass index (ASMI) estimation using anthropometric parameters predicted DEXA-measured ASMI in HF patients with reasonable accuracy. Here, we examined the prognostic impacts of ASMI predicted by the equation (predicted ASMI) in HF patients.

Methods

Data for 539 patients with HF ( 73 ± 14 years old, 43% female) who received the DEXA method and measurements of calf circumference (CC) and mid-arm circumference (MAC) between August 1, 2015, to August 31, 2020, were used for analyses. DEXA measured-appendicular skeletal muscle (ASM) was calculated as the sum of bone-free lean masses in the arms and legs, and ASMI was defined as ASM/height². Predicted ASMI was calculated as we previously reported: predicted ASMI (kg/m²) = [0.214 × weight (kg) + 0.217 × CC (cm) - 0.189 × MAC (cm) + 1.098 (male = 1, female = -1) + 0.576]/height² (m²). Low ASMI was defined as &lt;7.0 kg/m² in males and &lt;5.4 kg/m² in females, respectively. The primary endpoint was all-cause death. Multiple imputation using chained equations was used for the substitution of missing values.

Results

The median follow-up period was 1.75 years (interquartile range, 0.96 to 2.37 years), and 73 patients (15%) has died. Kaplan-Meier survival curves showed that patients with low DEXA measured-ASMI and patients with low predicted ASMI had significantly lower survival rates than those with high ASMI (Figure 1). In a multivariate Cox proportional hazard analyses adjusted for age, sex, logarithmic B-type natriuretic peptide, cystatin C based-estimated glomerular filtration rate, and gait speed, DEXA-measured ASMI [hazard ratio (HR), 0.982; 95% confidence interval (CI), 0.967 to 0.988; p&lt;0.001] and predicted ASMI (HR, 0.979; 95% CI, 0.962 to 0.996; p=0.018) were independent predictors of all-cause mortality, respectively. Inclusion of predicted ASMI into the adjustment model improved the accuracy of prediction of the mortality after discharge [continuous net reclassification improvement, 0.338, p&lt;0.01; integrated discrimination improvement, 0.020, p &lt; 0.05] (Figure 2).

Conclusions

ASMI estimated by an equation using CC and MAC predicted the prognosis of HF patients at a similar level of accuracy to DEXA-measured ASMI, and it can be applied to the assessment of skeletal muscle mass in a daily clinical setting and in large population-based studies.

Barthel Index score predicts mortality in elderly heart failure: a goal of comprehensive cardiac rehabilitation

Background

Accurate prediction of mortality in heart failure (HF) patients is crucial for decision-making regarding HF therapies, but a strategy for the prediction of mortality in elderly HF patients has not been established. In addition, although favorable effects of comprehensive cardiac rehabilitation (CR) on clinical outcomes and functional status in HF patients have been demonstrated, a goal of comprehensive CR during hospitalization for reducing mortality remains unclear.

Aims

We examined whether assessment of basic activities of daily living (ADL) by the Barthel Index (BI), the most widely used tool for assessment of basic ADL, is useful for predicting all-cause mortality in elderly HF patients who received comprehensive CR.

Methods

This study was a single-center, retrospective and observational study. We retrospectively examined 413 HF patients aged ≥65 years (mean age, 78±7 years; 50% female) who were admitted to our institute for management of HF and received comprehensive CR during hospitalization. Functional status for performing basic ADL ability was assessed by the BI within 3 days before discharge. The clinical endpoint was all-cause death during the follow-up period.

Results

Of 413 HF patients, 116 patients (28%) died during a follow-up period of median 1.90-years (interquartile range, 1.20–3.23 years). Results of an adjusted dose-dependent association analysis showed that the hazard ratio (HR) of mortality increases in an almost linear fashion as the BI score decreases and that the BI score corresponding the hazard ratio of 1.0 is 85 (Figure A). To minimize the differences in potential confounding factors between patient with low BI (&lt;85) and patients with high BI (≥85), inverse probability treatment weighting (IPTW) was calculated using propensity score. Kaplan-Meier survival curves, in which selection bias was minimized by use of IPTW for confounders, showed that patients with low BI (&lt;85) had a higher mortality rate than did patients with high BI (≥85) (Figure B). In multivariate Cox regression analyses, low BI was independently associated with higher mortality after adjustment for predictors including brain natriuretic peptide and prior HF hospitalization (IPTW-adjusted HR, 1.75 [95% confidence interval, 1.03–2.98], p&lt;0.001). Inclusion of the BI into the adjustment model improved the accuracy of prediction of mortality (continuous net reclassification improvement, 0.292, p=0.008; integrated discrimination improvement, 0.017, p=0.022).

Conclusion

A BI score of &lt;85 at the time of discharge is associated with increased mortality independently of known prognostic markers, and achievement of functional status of a BI score ≥85 by comprehensive CR during hospitalization may contribute to a favorable outcome in elderly HF patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): the Japan Society for the Promotion of Science

Neural dynamics of semantic categorization in semantic variant of primary progressive aphasia

Semantic representations are processed along a posterior-to-anterior gradient reflecting a shift from perceptual (e.g., it has eight legs) to conceptual (e.g., venomous spiders are rare) information. One critical region is the anterior temporal lobe (ATL): patients with semantic variant primary progressive aphasia (svPPA), a clinical syndrome associated with ATL neurodegeneration, manifest a deep loss of semantic knowledge. We test the hypothesis that svPPA patients perform semantic tasks by over-recruiting areas implicated in perceptual processing. We compared MEG recordings of svPPA patients and healthy controls during a categorization task. While behavioral performance did not differ, svPPA patients showed indications of greater activation over bilateral occipital cortices and superior temporal gyrus, and inconsistent engagement of frontal regions. These findings suggest a pervasive reorganization of brain networks in response to ATL neurodegeneration: the loss of this critical hub leads to a dysregulated (semantic) control system, and defective semantic representations are seemingly compensated via enhanced perceptual processing.

Clinical determinants and prognostic impact of osteoporosis in patients with chronic heart failure

Background

Despite accumulating evidence of a close association between orthopedic fractures and chronic heart failure (CHF), the clinical risk factors of osteoporosis, defined as reduction in bone mineral densities (BMDs), in CHF patients have not been systematically analyzed. In addition, the impact of osteoporosis on prognosis of CHF remains unclear.

Aims

We aimed to clarify the prevalence, clinical risk factors, and prognostic impact of osteoporosis in CHF patients.

Methods

We retrospectively examined 303 CHF patients (75 years, [interquartile range (IQR), 66–82 years]; 41% female). BMDs at the lumber spine, femoral neck, and total femur were measured by dual-energy X-ray absorptiometry (DEXA), and osteoporosis was diagnosed when BMD at any of the three sites was less than 70% of Young Adult Mean.

Results

The prevalence of osteoporosis in the CHF patients was 40%. Patients with osteoporosis were older (79 [IQR, 74–86] vs. 72 [IQR, 62–80] years), included a large percentage of females, had slower gait speed and had lower body mass index (BMI). Loop diuretics and warfarin were used more frequently and direct oral anticoagulants (DOACs) were used less frequently in patients with osteoporosis than in patients without osteoporosis. Multivariate logistic regression analysis indicated that sex (odds ratio [OR] 5.07, 95% Confidence Interval [CI] 2.68–9.61, p&lt;0.01), BMI (OR, 0.83; 95% CI, 0.75–0.91; p&lt;0.01), gait speed (OR, 0.80; 95% CI, 0.70–0.92; p&lt;0.01), loop diuretics use (OR, 2.52; 95% CI, 1.20–5.27; p=0.01) and no DOACs use (OR, 0.43; 95% CI, 0.19–0.96; p=0.04) were independently associated with osteoporosis. During the mean follow-up period of 290±254 days, 92 patients (30.4%) had adverse events. When patients with osteoporosis were divided into subgroups according to the number of sites with BMD of an osteoporosis level, Kaplan-Meier survival curves showed that the rate of adverse events (death and cardiovascular events) was higher in patients with osteoporotic BMD at two or more sites than in patients without osteoporosis (51% vs. 23%, p=0.03) (Figure). In multivariate Cox regression analyses, osteoporotic BMD at two or more sites was an independent predictor of adverse events after adjustment for age, sex, and NT-proBNP level (Hazard ratio, 1.74; 95% CI, 1.01–2.99; p=0.04).

Conclusion

The risk of osteoporosis may be increased in users of loop diuretics and may be decreased in users of DOACs in CHF patients. Extent of osteoporosis is a novel predictor of adverse events in CHF patients.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Japan Society for the Promotion of Science KAKENHI

P4537Impact of body composition analysis on prediction of short-term readmission events in heart failure: muscle wasting vs. obesity

Background

Obesity, defined as higher body mass index (BMI), is associated with better prognosis in patients with chronic heart failure (CHF), though the presence of obesity is a risk factor of development of CHF (Obesity paradox). On the other hand, muscle wasting, i.e. reduction in skeletal muscle mass, is frequently observed in CHF, leading to lower exercise capacity and poor cardiovascular outcome.

Purpose

The aim of this study was to examine whether analysis of body composition improves prediction of short-term readmission rates in patients with CHF.

Methods

We retrospectively analyzed data for 167 consecutive HF patients who were admitted to our institute for management of HF and received a Dual-energy X-ray absorptiometry (DEXA) scan. Muscle wasting was defined as DEXA-measured appendicular skeletal muscle mass index <7.0 kg/m2 in male and <5.4 kg/m2 in female according to the Asian Working Group for Sarcopenia criteria. Obesity was defined according to the criteria by the use of DEXA-measured percent body fat mass: >25% in male, >30% in female. The primary endpoint was readmission due to cardiac events including worsening heart failure, arrhythmia, and cardiopulmonary arrest during a 180-days follow-up period after discharge.

Results

The mean age of the patients was 74±13 years and 46% of them were male. The mean BMI was 21.8±3.8 kg/m2. Forty-seven percent of the patients were classified as NYHA functional class III. The most frequent etiology of HF was cardiomyopathy (30%), followed by ischemic heart disease (27%) and valvular heart disease (27%). The prevalence of muscle wasting and that of obesity were 69% and 59%, respectively. Patients with muscle wasting had lower BMI level, higher prevalence of NYHA functional class III and diabetes mellitus compared with those without muscle wasting. On the other hand, patients with obesity had higher prevalence of hypertension and dyslipidemia, higher level of BMI, fasting plasma insulin and triglyceride, and lower level of HDL-cholesterol compared with those without obesity. During the follow-up period, 34 patients (19%) were re-hospitalized due to cardiac events. Kaplan-Meier survival curves showed that patients with obesity had a significantly lower readmission rate during a 180-days follow-up period than did the patients without obesity (14.3% vs. 29.0%, Log-Rank test, p<0.01). There was no difference in readmission rates between patients with and without muscle wasting (20.0% vs. 21.2%, p=0.88). In multivariate Cox regression analyses adjusted for age, sex, diabetes, and renal function, obesity was independently associated with lower readmission rates (hazard ratio 0.45, 95% confidence interval 0.22–0.93). However, the association between obesity and readmission rate was lost after the adjustment for NT-proBNP levels.

Conclusion

Body composition analysis by DEXA enables to find CHF patients with increased fat mass who have lower risk of short-term readmission.

P1538Low energy intake predicts readmission of elderly heart failure patients independently of nutritional status

Background

Malnutrition is frequently present and closely associated with poor clinical outcomes in elderly heart failure (HF) patients. Our previous study showed that low energy intake (EI) is associated with worse functional status in elderly HF inpatients after cardiac rehabilitation, but significance of EI in prediction of hospital readmission has not been elucidated fully.

Purpose

We examined whether low EI is a predictor of readmission for cardiac events in elderly HF patients.

Methods

We retrospectively retrieved data for 298 HF patients aged ≥65 years (median age of 77 years, interquartile range [IQR]: 71 - 82, female: 53%) who admitted to our institute for diagnosis and treatment of HF. Medical records were reviewed with regard to demography, medical history, comorbidities, medications, laboratory data, echocardiograms, functional status, nutritional status and total energy intake. Nutritional status was assessed using the Mini Nutritional Assessment Short Form (MNA-SF) and total EI per day were calculated at discharge by a registered dietitian and a trained physical therapist. The primary endpoint was readmission due to cardiovascular events including worsening HF, arrhythmia, angina pectoris and myocardial infarction during a 1-year follow-up period.

Results

The median period of follow-up was 235 days (IQR: 78–365 days). The 1-year readmission rate for cardiovascular events was 54.4%. The cutoff values of MNA-SF score and EI, calculated by ROC curve analysis to predict the primary endpoint, were 7 points (area under the curve [AUC]: 0.59, sensitivity: 0.65, specificity: 0.50) and 31.8 kcal/kg/day (AUC: 0.59, sensitivity: 0.83, specificity: 0.35), respectively. Patients with low MNF-SF score (≤7) or low EI (≤31.8 kcal/kg/day) had significantly higher readmission rate during a 1-year follow-up period than did the patients with high MNF-SF score or EI (MNA-SF: 60.7% vs. 45.6%, p<0.01, EI: 60.4% vs. 36.8%, p<0.01), respectively. When patients were classified into four groups using cutoff values of MNA-SF score and EI, 1-year readmission rate was significantly higher in patients with low EI than in those with high EI regardless of MNF-SF scores. In multivariate Cox proportional hazard analyses adjusted for known prognostic factors in addition to age and gender, hazard ratios (HR) were significantly higher in patients with high MNA-SF score and low EI (adjusted HR: 2.81, 95% confidential interval [CI]: 1.15 - 9.32, p=0.02) and low MNA-SF score (≤7) and low EI (adjusted HR: 4.16, 95% CI: 1.72 - 13.72, p<0.01) than those with high MNA-SF score and high EI.

Kaplan-Meier curves of readmission rates

Conclusions

Low energy intake is a nutritional status-independent predictor of 1-year readmission rate in elderly HF patients.

Effect of brefelamide on proliferation of 1321N1 human astrocytoma cells induced by glial cell line-derived neurotrophic factor

Malignant gliomas are highly resistant to chemotherapy and radiation and more effective options for treatment are urgently needed. We reported previously that the aromatic amide brefelamide, which is isolated from methanolic extracts of the cellular slime molds Dictyostelium giganteum and D. brefeldianum, hinders cellular proliferation in a glioma model utilizing 1321N1 human astrocytoma cells. Herein, we examined the mechanisms underlying the inhibition of 1321N1 cell proliferation by brefelamide. Glial cell line-derived neurotrophic factor (GDNF) was found to enhance the rate of proliferation of serum-free cultured 1321N1 cells, but did not affect proliferation in PC12 cells. Brefelamide pretreatment inhibited GDNF-induced cell proliferation and expression of rearranged during transfection (RET). GDNF enhanced the phosphorylation of extracellular signal-regulated kinase (ERK), AKT, and c-jun-N-terminal kinase (JNK); however, brefelamide pretreatment inhibited these effects. Brefelamide also reduced the expression of GDNF mRNA and GDNF secretion. Together, the findings from this study indicate that brefelamide inhibits the proliferation of 1321N1 cell via several mechanisms including reduced GDNF receptor expression and GDNF secretion, and reduced phosphorylation of ERK, AKT, and JNK.

High serum dihydrotestosterone examined by ultrasensitive LC-MS/MS as a predictor of benign prostatic hyperplasia or Gleason score 6 cancer in men with prostate-specific antigen levels of 3-10 ng/mL

There has been no consensus on the role of serum androgen concentrations in prostate cancer detection in men with prostate-specific antigen levels of 3-10 ng/mL. In this study, testosterone and dihydrotestosterone concentrations in blood were examined by a newly developed method using ultrasensitive liquid chromatography with two serially linked mass spectrometers (LC-MS/MS). We investigated the correlation between serum androgen levels and Gleason scores at biopsy. We analyzed data of 157 men with a total prostate-specific antigen range of 3-10 ng/mL who underwent initial systematic prostate needle biopsy for suspected prostate cancer between April 2000 and July 2003. Peripheral blood testosterone and dihydrotestosterone concentrations were determined by LC-MS/MS. Blood levels of testosterone and dihydrotestosterone were compared with pathological findings by multivariate analyses. Median values of prostate-specific antigen and prostate volume measured by ultrasound were 5.7 ng/mL and 31.4 cm³ , respectively. Benign prostatic hyperplasia was diagnosed in 97 patients (61.8%), and prostate cancer was diagnosed in 60 (38.2%) patients, including 31 (19.7%) patients with a Gleason score of 6 and 29 (18.5%) patients with a Gleason score of 7-10. Median values of testosterone and dihydrotestosterone in blood were 3798.7 and 371.7 pg/mL, respectively. There was a strong correlation between serum testosterone and dihydrotestosterone. In multivariate analysis, age, prostate volume, and serum dihydrotestosterone were significant predictors of benign prostatic hyperplasia or prostate cancer with a Gleason score of 6. The area under the receiver operating characteristics curve for age, prostate volume, and serum dihydrotestosterone were 0.67, 0.67, and 0.67, respectively . We confirmed that high dihydrotestosterone blood levels can predict benign prostatic hyperplasia or prostate cancer with a Gleason score of 6 in men with prostate-specific antigen levels of 3-10 ng/mL.

Development of prostate cancer in a patient with primary hypogonadism: intratumoural steroidogenesis in prostate cancer tissues

Intratumoural steroidogenesis may play a significant role in the progression of prostate cancer (PC) in the context of long-term ablation of circulating testosterone (T). To clarify the mechanism accounting for the progression of PC in a 74-year-old man who had undergone bilateral orchiectomy when he was 5 years old, we performed immunohistochemical studies of androgen receptor (AR) and steroidogenic enzymes in the prostate. We also measured steroid hormone levels in the serum and prostate, as well as mRNA levels of genes mediating androgen metabolism in the prostate. Positive nuclear staining of AR was detected in malignant epithelial cells. The levels of androstenedione (Adione), T, and 5-alpha dihydrotestosterone (DHT) in the serum of the patient were similar to those in PC patients receiving neoadjuvant androgen deprivation therapy (ADT), but were higher in the patient's prostate than in PC patients not receiving ADT. The gene expression of CYP17A1 and HSD3B1 was not detected, whereas that of STS, HSD3B2, AKR1C3, SRD5A1, and SRD5A2 was detected. Moreover, cytoplasmic staining of HSD3B2, AKR1C3, SRD5A1, and SRD5A2 was detected in malignant epithelial cells. Hence, in the present case (a man with primary hypogonadism), steroidogenesis in PC tissues from adrenal androgens, especially dehydroepiandrosterone sulphate, was the mechanism accounting for progression of PC. This mechanism might help elucidate the development of castration-resistant PC.

[Usefulness of ultrasonically activated scalpel for pulmonary resection in video-assisted thoracoscopic surgery]

We evaluated the reliability and efficacy of the ultrasonically activated scalpel (Harmonic Scalpel) for pulmonary resection in video-assisted thoracoscopic surgery (VATS). Fifty-six cases of primary or metastatic lung cancer with history of lobectomy or segmentectomy from July 2003 to June 2006 were investigated. The ultrasonically activated scalpel was used to separate aborted lobulation and segment in the surgery. The outcome of the operation using the ultrasonically activated scalpel revealed the mean operation time of 224.5 minutes and mean blood loss volume of 116.7 ml. The chest drainage catheter was removed at the postoperative day 3.4 and hospitalization lasted 10.4 days on average. By means of statistical analysis, no significant differences were noted when compared with the cases using surgical stapler to separate the lobules or segments of the lungs. Histopathological results showed destruction of alveolar structures and denaturation of cells at the cut surface of the resected lung through the use of the ultrasonically activated scalpel. This method resulted in good lung expansion and preservation of the residual lung volume. Furthermore, it prevented postoperative air leakage by appropriate treatment to the cut surfaces of the residual lung. Indeed, the method appears to be useful in the separation of lung tissues in severe aborted lobulation and segmentectomy by VATS.

Immunological evaluation of personalized peptide vaccination with gemcitabine for advance pancreatic cancer patients

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Background: A phase I clinical study was performed to determine safety and immunogenicity of personalized peptide vaccination with gemcitabine (GEM) in advanced pancreatic cancer patients (APC). Methods: Thirteen human histocompatibility leukocyte antigen (HLA)-A24+ or A2+ patients with unresectable (n=10) or recurrent (n=3) pancreatic cancer were treated with GEM plus up to four peptides that were positive for pre-vaccination measurement of peptide-specific IgG antibodies and/or cytotoxic T lymphocyte (CTL) precursors in the circulation (personalized peptide vaccine). GEM was administered at 1000mg/m2 as a 30-min intravenous infusion once a week for three week, followed by 1 week of rest. All patients were treated on outpatient basis. The cycle was repeated every 8 weeks. Results: Peptide doses of vaccination per week were planned as follows: level 1, 1mg; level 2, 2mg; and level 3, 3mg. The main grade 3 toxicities observed during the first cycle in each level were neutropenia (15%), anemia (23%) and thrombocytopenia (15%). No significant differences in the toxicities were found between each level. There was no dose limiting toxicity (DLT) observed in each level. Augmentation of peptide-specific CTL responses in the post-vaccination peripheral blood mononuclear cells was observed in each level, while increased titer of peptide-specific IgG antibodies was observed in the post-vaccination plasma in level 2 and level 3. Applicable responses were no complete response, two partial responses (15%), and 7 stable diseases (55%). Nevertheless 7 patients of them (54%) were under the second-line chemotherapy, disease control rate was 70%, the median TTP (time to progression) was 18.5 weeks and the MST (median survival time) was 7.6 months in this study. Conclusions: The combination therapy of personalized peptide vaccination with GEM for APC patients is feasible and safe. Because of positive immune responses under a full dose of GEM, the peptide vaccination of 3 mg is recommended.

No significant financial relationships to disclose.

Clock gene expression in the submandibular glands

Clock genes, which mediate molecular circadian rhythms, are expressed in a circadian fashion in the suprachiasmatic nucleus and in various peripheral tissues. To establish a molecular basis for circadian regulation in the salivary glands, we examined expression profiles of clock-related genes and salivary gland-characteristic genes. Clock-related genes-including Per1, Per2, Cry1, Bmal1, Dec1, Dec2, Dbp, and Reverbalpha-showed robust circadian expression rhythms in the submandibular glands in 12:12-hour light-dark conditions. In addition, a robust circadian rhythm was observed in amylase 1 mRNA levels, whereas the expression of other salivary-gland-characteristic genes examined was not rhythmic. The Clock mutation resulted in increased or decreased mRNA levels of Per2, Bmal1, Dec1, Dec2, and Dbp, and in Cry1-/- background, Cry2 disruption also increased or decreased mRNA levels of these clock-related genes and the amylase 1 gene. These findings indicate that the Clock- and Cry-dependent molecular clock system is active in the salivary glands.

Furanodictine A and B: amino sugar analogues produced by cellular slime mold Dictyostelium discoideum showing neuronal differentiation activity

We investigated the constituents of Dictyostelium discoideum to clarify the diversity of secondary metabolites of Dictyostelium cellular slime molds and to explore biologically active substances that could be useful in the development of novel drugs. From a methanol extract of the multicellular fruit body of D. discoideum, we isolated two novel amino sugar analogues, furanodictine A (1) and B (2). They are the first 3,6-anhydrosugars to be isolated from natural sources. Their relative structures were elucidated by spectral means, and the absolute configurations were confirmed by asymmetric syntheses of 1 and 2. These furanodictines potently induce neuronal differentiation of rat pheochromocytoma (PC-12) cells.

Cytochrome P450 enzymes involved in the metabolic pathway of the histamine 2 (H2)-receptor antagonist roxatidine acetate by human liver microsomes

Roxatidine acetate hydrochloride (ROX, 2-acetoxy-N-[3-[m-(1-piperidinylmethyl)phenoxy]propyl]acetamide hydrochloride, CAS 78273-80-0), a histamine 2 (H2)-receptor antagonist, has been clinically applied for the treatment of gastritis, gastric and duodenal ulcers. There is no report on the identification of the metabolic enzyme of M-1 (2-hydroxy-N-[3-[m-(1-piperidinylmethyl)phenoxy]propyl]acetamide), the pharmacologically active metabolite, in humans. In this study, the Cytochrome P450 (CYP or P450) enzymes which participate in the metabolism of ROX were identified using human liver microsomes and S9 fractions. M-1 was converted to M-4 (3-[m-(1-piperidinyl-methyl)phenoxy]propylamine) by the enzyme reaction with the S9 but not with microsomes. M-4 was further metabolized to M-5 (3-[m-(1-piperidinylmethyl)phenoxy]propanol) by microsomes. The metabolism was inhibited by coumarin and anti-CYP2A1 serum. (3-[m-(1-piperidinylmethyl)-phenoxy]propionic acid) and M-3 (m-(1-piperidinylmethyl) phenol) formation from M-5 were inhibited by quinidine and anti-CYP2D6 serum. Moreover, M-5 was converted to M-2 and M-3 by cDNA-expressed CYP2D6. In conclusion, this study shows that microsomal enzymes do not participate in the clearance of the active metabolite M-1, CYP2A6 primarily catalyzes M-5 formation from M-4, and CYP2D6 primarily catalyzes M-2 and M-3 formation from M-5 in humans.

Sensitive detection and differentiation of Sapporo virus, a member of the family Caliciviridae, by standard and booster nested polymerase chain reaction

Norwalk virus and Sapporo virus (SV) were approved as type species of the genus Norwalk-like viruses and the genus Sapporo-like viruses, respectively, in the family Caliciviridae. Nested polymerase chain reaction (PCR), using newly designed primers in the RNA-dependent RNA polymerase region, was developed to detect and differentiate viruses in the three genetic groups of SV based on the relative size of the PCR products obtained. In addition, a booster nested PCR that performs nested PCR in a single tube was introduced to reduce the chance of contamination during the procedure of standard nested PCR. The specificity of the newly developed PCR was confirmed by testing 77 stool specimens and 16 tissue culture fluids derived from growth of unrelated viruses. The sensitivity of the nested PCR was compared with the conventional PCR using Sapp35/Sapp36 primer pair by testing the three cDNA clones obtained from viruses in the SV/SV82, the SV/London92, and the SV/Parkville virus, respectively. This assay can detect SV in a more sensitive way than the conventional PCR and Southern hybridization. Sensitive and suitable methods to detect and differentiate SV are required to obtain accurate epidemiological data on these viruses and the standard and booster nested PCR should be a very useful tool for this purpose.

Behavioural rhythm splitting in the CS mouse is related to clock gene expression outside the suprachiasmatic nucleus

CS mice exhibit a spontaneous splitting in the circadian rhythm of locomotor activity under constant darkness, suggesting that they contain two weakly coupled oscillators in the circadian clock system regulating locomotor activity rhythm. In order to clarify whether the two oscillators are located in the suprachiasmatic nucleus (SCN), a site of the master circadian pacemaker in mammals, circadian rhythms in mRNA of mouse Period genes (mPer1, mPer2 and mPer3) in the SCN and cerebral cortex were examined during rhythm splitting by in situ hybridization. In the SCN, mPer1 and mPer2 showed a circadian rhythm with a single peak in both split and unsplit mice. The rhythms of mPer1 and mPer2 were slightly phase delayed during rhythm splitting in reference to the activity onset, but the phase relationship between the two rhythms was not changed. In the cerebral cortex, the expression of mPer1 and mPer2 underwent the bimodal fluctuation with peaks temporally corresponding to split activity components. The unsplit mice showed the circadian rhythms with a single peak. There was no difference in the mPer3 rhythms in either the SCN or the cerebral cortex between the split and unsplit mice. These results indicate that the circadian oscillations of mPer1, mPer2 and mPer3 in the SCN are not related to the rhythm splitting of CS mice. The split rhythms of the CS mice are suggested to be caused by uncoupling of oscillators located outside the SCN from the SCN circadian pacemaker.

Circadian activity rhythm in methamphetamine-treated Clock mutant mice

It is well established that the Clock gene is essential for expressing circadian activity rhythms in mammals under constant darkness. The Clock gene product is a positive component of a molecular feedback loop which is assumed to generate the circadian rhythm. On the other hand, chronic treatment of methamphetamine (MAP) induces locomotor activity rhythm in a circadian domain, which is independent of the suprachiasmatic nucleus (SCN) and is driven by a pacemaker outside the SCN. However, it is not known whether the pacemaker outside the SCN possesses a similar molecular mechanism to that in the SCN. Here we show that MAP restores locomotor activity rhythm in arrhythmic homozygous Clock mutant (Clock/Clock) mice under constant darkness. This result indicates that the Clock mutation does not affect the MAP-induced locomotor rhythm.

Liquid meal attenuates meal anticipation in rat adrenocortical activity

Effects of dietary consistency were examined on the development and persistence of meal anticipation in adrenocortical activity in rats under restricted daily feeding (RF), in which food supply was restricted to a fixed time of day. Restricted daily solid meal produced the anticipatory hormone peak in 8 days, whereas restricted daily liquid meal produced the peak in 12 days. The developed hormone peak was less prominent by liquid meal than by solid. The anticipatory corticosterone peak developed by solid meal persisted throughout the period examined (3 weeks) after the termination of RF, whereas the peak developed by liquid meal disappeared after the first week. It is concluded that liquid meal attenuates the meal anticipation in the adrenocortical activity in rats under RF.

Clinical severity of Norwalk virus and Sapporo virus gastroenteritis in children in Hokkaido, Japan

OBJECTIVE

To clarify the clinical significance and etiologic impact of Norwalk virus (NV) and Sapporo virus (SV) in viral gastroenteritis in Japanese children.

STUDY DESIGN

Two outbreaks each of NV gastroenteritis and SV gastroenteritis occurring in an infant home in Sapporo, Japan, as well as 95 hospitalized children with acute gastroenteritis were retrospectively evaluated using a 0- to 20-point clinical severity scoring system.

RESULTS

The mean severity scores for NV and SV gastroenteritis outbreaks were 7.9 and 5.2, respectively, as compared with 8.4 for rotavirus A gastroenteritis that occurred in the same infant home. Among 95 hospitalized children with acute gastroenteritis, rotavirus A was detected in 47% followed by NV in 18%. SV was not found.

CONCLUSION

Our data indicate that NV can cause severe gastroenteritis and is an important etiologic agent in hospitalized cases, whereas SV causes mild gastroenteritis in Japanese children.

Quantitative analysis of synaptic contacts made between functionally identified oralis neurons and trigeminal motoneurons in cats

A previous study revealed that rostrodorsomedial oralis (Vo.r) neurons synapsing on trigeminal motoneurons use GABA and/or glycine as neurotransmitters. To determine the number and spatial distribution of contacts, injections of biotinamide and horseradish peroxidase were made into a Vo.r neuron and an alpha-motoneuron in the jaw-closing (JC) and jaw-opening (JO) motor nucleus, respectively, in 39 cats. All Vo.r neurons responded to low-threshold mechanical stimulation of the oral tissues. Single Vo.r neurons terminating in the JC nucleus (Vo.r-dl neurons; n = 5) issued, on average, 10 times more boutons than Vo.r neurons terminating in the JO nucleus (Vo.r-vm neurons; n = 5; 4437 vs 445). The Vo.r-dl neuron-JC alpha-motoneuron pairs (n = 4) made contacts on either the soma-dendritic compartment or dendrites, and the Vo.r-vm neuron-JO motoneuron pairs (n = 2) made contacts on dendrites, with a range of two to seven contacts. In five of the six pairs, individual or groups of two to three terminals contacted different dendritic branches of a postsynaptic cell. The Vo.r-dl neurons innervated a greater number of counter-stained motoneuronal somata than did the Vo.r-vm neurons (216 vs 26). Total number of contacts per Vo.r neuron was higher for the Vo.r-dl than Vo.r-vm neurons (786 vs 72). The present study demonstrates that axonal branches of Vo.r neurons are divided into two types with different innervation domains on the postsynaptic neuron and that they are highly divergent. The overall effect exerted by these neurons is predicted to be much greater within the JC than JO motoneuron pool.

Quantitative ultrastructure of slowly adapting lingual afferent terminals in the principal and oral nuclei in the cat

Previous studies provide evidence that a structure/function correlation exists in the cytoarchitectonically different zones of the trigeminal sensory nuclei. To extend this relationship, we examined the ultrastructural features of trigeminal primary afferent neurons in the cat dorsal principal nucleus (Vpd) and the rostrodorsomedial oral nucleus (Vo.r) using intra-axonal labeling with horseradish peroxidase and morphometric analyses. All labeled boutons contained round synaptic vesicles. Eighty-two percent of the boutons in the Vo.r and 99% of the boutons in the Vpd were presynaptic to nonprimary dendrites. The remaining boutons in the Vo.r were presynaptic to somata (8%) or primary dendrites (10%). The average number of postsynaptic profiles per labeled bouton did not differ in the Vpd and Vo.r. Most labeled boutons in the two nuclei were postsynaptic to unlabeled axon terminals with pleomorphic vesicles (p-ending). The number of p-endings per labeled bouton was higher in the Vpd than Vo.r A morphometric analysis indicated that labeled bouton volume and apposed surface area were larger in the Vpd than Vo.r while active zone area and vesicle number did not differ. All these parameters were larger than those of p-endings in each nucleus. In both labeled boutons and p-endings, the parameters were positively correlated with bouton size. These results suggest that sensory information conveyed through trigeminal afferents is more strongly controlled at the level of the first synapse by presynaptic mechanisms in the Vpd than in the Vo.r, while the efficacy of transmission at primary afferent synapses does not differ.

Regional pacemakers composed of multiple oscillator neurons in the rat suprachiasmatic nucleus

Regional specificities of the dorsal and ventral regions of the suprachiasmatic nucleus (SCN) were examined to elucidate the structure of multioscillator circadian organization. The circadian rhythms of arginine vasopressin (AVP) and vasoactive intestinal polypeptide (VIP) release, and of electrical activity of individual neurons were measured in an organotypic, static slice culture of the SCN obtained from neonatal rats. Five days after the start of culture, robust circadian rhythms were detected in AVP release with a peak located consistently at the middle of the original light phase, while the 24 h profiles of VIP release were either arrhythmic or rhythmic. In the latter case, a phase delay of 5-7 h was observed in the circadian peak from the AVP rhythm. Multi-channel, extracellular recording revealed that 51 (76.1%) out of 67 firing neurons, examined in the SCN, showed circadian rhythms in their firing rate. The percentage of rhythmic neurons was significantly larger in the dorsal (86.8%) than in the ventral (62.1%) region of the SCN, where the AVP and VIP containing neurons predominate, respectively. Twenty-seven percent of the firing rhythms were almost antiphasic from the majority of rhythms. There was no regional specificity in the distribution of the antiphasic rhythm. These findings, that the dorsal and ventral regions of the SCN both contain circadian pacemakers with different properties that regulate the AVP and VIP release separately, is probably due to differences in the number and, hence, the coupling strength of oscillating neurons.

Phase-advance shifts of human circadian pacemaker are accelerated by daytime physical exercise

Effects of forced sleep-wake schedules with and without physical exercise were examined on the human circadian pacemaker under dim light conditions. Subjects spent 15 days in an isolation facility separately without knowing the time of day and followed a forced sleep-wake schedule of a 23 h 40-min period for 12 cycles, and physical exercise was imposed twice per waking period for 2 h each with bicycle- or rowing-type ergometers. As a result, plasma melatonin rhythm was significantly phase advanced with physical exercise, whereas it was not changed without exercise. The difference in phase was already significant 6 days after the start of exercise. The amplitude of melatonin rhythm was not affected. A single pulse of physical exercise in the afternoon or at midnight significantly phase delayed the melatonin rhythms when compared with the prepulse phase, but the amount of phase shift was not different from that observed in the sedentary controls. These findings indicate that physical exercise accelerates phase-advance shifts of the human circadian pacemaker associated with the forced sleep-wake schedule.

Effects of light and sleep stages on heart rate variability in humans

Effects of light intensity and sleep stages on heart rate variability (HRV) were investigated in young healthy subjects. The low-frequency (LF)/high-frequency (HF) ratio was significantly increased by exposing either to bright lights of 10 000 lx or to extreme darkness (< 0.01 lx), while HF and LF components of HRV were not changed, when compared with those under dim light (100 lx). However, LF was significantly increased at REM sleep, when compared with that at the pre-sleep wake. In contrast, HF was increased at all stages of sleep, and the LF/HF ratio was decreased at slow wave sleep during the baseline night.

Multiple oscillators in the suprachiasmatic nucleus

The suprachiasmatic nucleus (SCN) of the hypothalamus is the site of the pacemaker that controls circadian rhythms of a variety of physiological functions. Data strongly indicate the majority of the SCN neurons express self-sustaining oscillations that can be detected as rhythms in the spontaneous firing of individual neurons. The period of single SCN neurons in a dissociated cell culture is dispersed in a wide range (from 20h to 28h in rats), but that of the locomotor rhythm is close to 24h, suggesting individual oscillators are coupled to generate an averaged circadian period in the nucleus. Electrical coupling via gap junctions, glial regulation, calcium spikes, ephaptic interactions. extracellular ion flux, and diffusible substances have been discussed as possible mechanisms that mediate the interneuronal rhythm synchrony. Recently, GABA (gamma-aminobutyric acid), a major neurotransmitter in the SCN, was reported to regulate cellular communication and to synchronize rhythms through GABA(A) receptors. At present, subsequent intracellular processes that are able to reset the genetic loop of oscillations are unknown. There may be diverse mechanisms for integrating the multiple circadian oscillators in the SCN. This article reviews the knowledge about the various circadian oscillations intrinsic to the SCN, with particular focus on the intercellular signaling of coupled oscillators.

Pneumocystis carinii pneumonia with an atypical granulomatous response in a patient with chronic lymphocytic leukemia

We have recently seen a patient who developed Pneumocystis carinii pneumonia (PCP) in the course of treatment for chronic lymphocytic leukemia (CLL). This case showed uncommon pathological findings with extensive formation of granulomatous lesions. Despite advanced CLL associated with poor B-cell function, she responded well to anti-PCP treatment. In contrast to B-cell function, the T-cell functions were well preserved in vitro, and the numbers of peripheral CD4- and CD8-positive cells were normal, and T-cell functions were normal. These findings suggest that the production of granulomatous lesions to PCP may have been associated with the patients' immune status, and that it may constitute a good indicator in PCP infection in patients with underlying hematological malignancy.

Quantitative trait locus analysis of abnormal circadian period in CS mice

CS mice show a free-running period (tau) longer than 24 h and rhythm splitting in constant darkness (DD). These features in behavioral circadian rhythms are distinctive as compared with other inbred strains of mice, which exhibit robust free-running rhythms with T shorter than 24 h. To identify the genes affecting tau, quantitative trait locus (QTL) analysis was initially conducted by using 289 F2 mice derived from a cross between CS and C57BL/6J strain. A suggestive QTL (LOD = 3.71) with CS allele increasing tau was detected on the distal region of Chromosome (Chr) 19. Next, using 192 F2 mice from a cross between CS and MSM strain, the presence of the QTL on Chr 19 was examined, and we confirmed the QTL at the genome-wide significant level (LOD = 4.61 with 10.4% of the total variance explained). This QTL was named long free-running period (Lfp). Three other suggestive QTLs (LOD = 3.24-4.28) were mapped to the midportion of Chr 12 in (CSxC57BL/6J)F2 mice, and to the proximal and middle region of Chr 19 in (CSxMSM)F2 mice, respectively, of which, CS alleles for two QTLs on Chr 19 have the effect of lengthening tau. None of these QTLs were mapped to the chromosomal regions of previously described QTLs for tau and known clock genes (Clock, mPer1, Bmal1, mCrv1, mCry2, mTim, and Csnk1e).

Circadian pattern, light responsiveness and localization of rPer1 and rPer2 gene expression in the rat retina

Circadian expression, light-responsiveness and localization of clock genes, rPer1 and rPer2, were examined in the rat retina under constant darkness. A significant circadian variation was detected in rPer2 transcript levels with a peak at ZT14, but not in the rPer1. A light pulse given after constant darkness of 3 days increased both rPer1 and rPer2 expression phase-dependently, while rPer1 was induced at more times than rPer2. A major site of these gene expression within the retina was the inner nuclear layer. These findings indicate that rPer1 and rPer2 genes play different roles in the generation and regulation of circadian rhythms in the retina from those in the suprachiasmatic nucleus.

Effect of rotavirus vaccine on Sapporo virus gastroenteritis in Finnish infants

BACKGROUND

Sapporo-like viruses (SLVs) occur worldwide, but there is limited information about the SLV-associated gastroenteritis outside Japan.

METHODS

Stool specimens from 1,432 episodes of gastroenteritis that occurred in children between 2 months and 2 years of age during a rotavirus vaccine trial (776 episodes in placebo-vaccinated and 656 in rotavirus-vaccinated infants) were examined for SLVs using a reverse transcription-PCR assay. The reverse transcription-PCR took advantage of new primers specific for Sapporo virus genetic clusters I, II and III; SV/SV82 (SV/Sapporo virus 82); SV/Lond92 (SV/ London 92); and SV/PV (Parkville virus).

RESULTS

SLVs were detected in association with 132 (9.2%) of all episodes; in 80 (5.6%) episodes SLV was the only gastroenteritis virus detected. The epidemic season of SLVs peaked from March to May concurrently with rotaviruses and astroviruses and overlapping withNorwalk-like viruses. Clinically SLV gastroenteritis was characterized by a mild diarrheal disease, being sharply different from the Norwalk-like virus-associated "winter vomiting disease." Rotavirus vaccination did not have any effect on the number of SLV episodes, but the intensity and duration of SLV-associated diarrhea were reduced in rotavirus-vaccinated children compared with placebo-vaccinated children (P = 0.0008).

CONCLUSIONS

SLVs are common causative agents of acute gastroenteritis in young Finnish children. SLV disease is characterized by diarrhea, which is usually mild but can be severe. By an unknown mechanism rotavirus vaccine seems to reduce the severity of SLV-associated diarrhea.

Quantitative ultrastructure of synapses on functionally identified primary afferent neurons in the cat trigeminal mesencephalic nucleus

Though a number of studies have reported the presence of synapses on neurons in the trigeminal mesencephalic nucleus (Vmes), there have been no quantitative studies of either the density of innervation, or the ultrastructure, of the synapses on single, physiologically identified neurons in this nucleus. In this study we recorded from single neurons in the Vmes, identified them as being either muscle spindle afferents (MS) or periodontal ligament mechanoreceptor afferents (PL), and then labeled the neurons by intra-axonal injection of horseradish peroxidase (HRP). The material was first processed to reveal the HRP activity, following which ultrathin sections through the labeled somata were cut and examined under the electron microscope. Complete serial reconstructions were made through the soma of one MS neuron and one PL neuron, and the contacts on the neurons reconstructed. Boutons were found on the soma, spines, appendages and the axon hillock and the initial segment of the axon. The numbers of boutons terminating on the two neurons were 198 (PL) and 424 (MS), giving a packing density of 4.4 and 10.7 boutons respectively (i.e., number of boutons/100 micron 2 of the postsynaptic membrane). Boutons could be separated into two types on the basis of their vesicles: those containing clear, round vesicles (i.e., S-type) and those containing a mixture of round, oval and flattened vesicles (P-type). Ninety-five (PL neuron) and 99% (MS neuron) of terminals on the two neurons were P-type. All the S-type boutons and 80% of the P-type boutons formed asymmetric synaptic contacts while 10% of the P-type boutons made symmetric contacts. Quantitative measurements of the P-type boutons on the labeled neurons, in which the data of MS and PL neurons were pooled, revealed that bouton volume was highly correlated with bouton surface area, active zone number, total active zone area, vesicle number, and mitochondrial volume. However, comparing the quantitative measurements of the P-type boutons with those of previously reported vibrissa afferent terminals and their associated axon terminals revealed that all the parameters were smaller for the P-type boutons (on Vmes neurons) than those of the vibrissa afferent terminals but similar to those of axon terminals presynaptic to the vibrissa afferents. Taken together, our results emphasize the wide scope for synaptic interactions in the Vmes and suggest that it may be more fruitful to view the Vmes as an integrating center.

Evaluation of nine sets of PCR primers in the RNA dependent RNA polymerase region for detection and differentiation of members of the family Caliciviridae, Norwalk virus and Sapporo virus

Norwalk virus and Sapporo virus were approved as type species of the genus "Norwalk-like viruses" and the genus "Sapporo-like viruses," respectively, in the family Caliciviridae. A total of 116 stool specimens containing Norwalk virus (NV) or Sapporo virus (SV) were tested by RT-PCR and Southern hybridization to evaluate nine sets of PCR primers and seven internal oligonucleotide probes in the RNA dependent RNA polymerase region of NV and SV for detection and differentiation of viruses in the NV and SV. Fifty-five stool samples were collected from 11 outbreaks of NV and/or SV gastroenteritis in an infant home, where residents were infants under 2 years of age, in Sapporo, Japan. Sixty specimens were obtained in Sapporo from sporadic cases in children, mainly under 6 years of age, of acute gastroenteritis due to small round structured viruses detected by EM. There is no single primer pair to detect all NV and SV, and at least three primer pairs, G1 set, G2 set and Sapp35/Sapp36, are required to detect viruses in the NV and SV clades. Many NV and SV strains were successfully classified into one of the NV/genogroup I, NV/genogroup II and SV by single-round RT-PCR and Southern hybridization. The new detection method for SV reported in this study combined with those for NV previously reported may elucidate the importance of Norwalk virus and Sapporo virus as a cause of viral gastroenteritis in all age groups in the world.

Clock gene expressions in the suprachiasmatic nucleus and other areas of the brain during rhythm splitting in CS mice

The CS mouse is a mutant strain which displays spontaneous splitting in the circadian locomotor rhythm under continuous darkness. To clarify whether the rhythm splitting occurs in the suprachiasmatic nucleus (SCN) where the mammalian circadian clock is located, the circadian rhythmicities of mammalian clock genes, mPer1, mBMAL1 and mClock, were examined in the SCN and cerebral cortex during rhythm splitting. The circadian profiles of the clock genes during rhythm splitting were essentially the same as those observed under unsplit conditions. However, the mPer1 gene expression throughout the day was bimodal in the piriform and cingulate cortices, peaking in correspondence with two split components of behavioral rhythm. These results indicate that the circadian profiles of three clock gene expressions in the SCN are not consistent with the overt circadian locomotor rhythm, suggesting that the site of rhythm splitting is somewhere outside the SCN, or alternatively different subregions or other clock genes in the SCN are involved in rhythm splitting.

Continuous measurement of targeted promoter activity by a secreted bioluminescence reporter, Vargula hilgendorfii luciferase

The promoter activity of growth hormone (GH) was continuously monitored in rat pituitary adenoma cells (GH3) by a secreted bioluminescence reporter, Vargula hilgendorfii (Vh) luciferase. The sensitivity of the reporter was approximately 60-times higher than that of the firefly luciferase. GH3 cells were transfected with a plasmid containing a DNA sequence of the GH promoter (1.8 kb) and a full length of the Vh luciferase cDNA. Using the stable transformants, the Vh luciferase activity was monitored in the plate culture through the bioluminescence of Vh luciferase secreted into the culture medium. The reporter activity was well correlated with GH mRNA as well as GH when the GH promoter activity was activated by thyroid hormone. To develop a continuous monitoring system of the promoter, the reporter activity was sequentially measured in the perfusion system. When the promoter activity of the stable transformants was suppressed by a transcription inhibitor, the reporter activity and GH in the perfusate were simultaneously decreased. The Vh luciferase reporter is a sensitive and convenient tool for continuous and prolonged measurement of promoter activity in living cell culture systems.