Diagnostic performance of the classic symptom "abdominal pain before vomiting" for pediatric acute appendicitis

BACKGROUND

Acute appendicitis is the most common type of acute abdomen that requires surgical intervention in children. According to general pediatric textbooks, the presence of vomiting before abdominal pain is considered a classic patient history item for excluding acute appendicitis. However, its diagnostic performance in the pediatric population has yet to be investigated.

METHODS

This was a single-center retrospective observational study involving 134 children who were admitted to the hospital with both abdominal pain and vomiting. The reference standard for appendicitis was defined by computed tomography scanning. The diagnostic performance of "abdominal pain before vomiting" was calculated and compared to those of the Alvarado score and pediatric appendicitis score.

RESULTS

The diagnostic performance of "abdominal pain before vomiting" was as follows: sensitivity of 75.3% (95% confidence interval [CI], 64.7-83.6), specificity of 25.0% (95% CI, 15.5-36.7), positive likelihood ratio of 1.00 (95% CI, 0.82-1.22), negative likelihood ratio of 0.99 (95% CI, 0.54-1.79), and diagnostic odds ratio of 1.02 (95% CI, 0.46-2.25). In contrast, the Alvarado score and pediatric appendicitis score (with a threshold of 4 points) demonstrated favorable sensitivity (98.3% [95% CI, 92.4-99.6]), negative predictive value (94.6% [95% CI, 78.4-98.8]), negative likelihood ratio (0.04 [95% CI, 0.01-0.23]), and diagnostic odds ratio (49.9 [95% CI, 6.88-243.2]).

CONCLUSION

In this study, "abdominal pain before vomiting" was associated with poor diagnostic performance for ruling out acute pediatric appendicitis. Thus, the diagnosis of acute appendicitis in the pediatric population should be made based on existing validated scoring systems such as the Alvarado score and pediatric appendicitis score.

Risk factors for anemia of prematurity among 30-35-week preterm infants

BACKGROUND

The risk factors for anemia of prematurity (AOP) among late preterm infants are unelucidated. We identified risk factors for declining hemoglobin (Hb) concentration and triggering factors for AOP treatment in infants born at 30-35 gestational weeks.

METHODS

From 2012 to 2020, we conducted a single-center retrospective study of infants born at 30-35 weeks of gestation without congenital anomalies or severe hemorrhage. The primary outcome was AOP development, defined by initiation of treatments including red blood cell transfusion, subcutaneous injections of erythropoietin, and iron supplementation. A multivariable logistic regression model was used to investigate potential risk factors for AOP.

RESULTS

A total of 358 infants were included. Lower gestational age (odds ratio, 0.19; 95% confidence interval 0.11-0.32), small for gestational age (SGA; 7.17, 2.15-23.9), low maternal Hb level before birth (0.66, 0.49-0.87), low Hb at birth (0.71, 0.57-0.89), and multiple large blood samplings (1.79; 1.40-2.29) showed significantly higher odds for AOP development.

CONCLUSIONS

Gestational age, SGA, low maternal Hb before birth, Hb at birth, and high number of large blood samplings were positively associated with AOP development in infants born at 30-35 gestational weeks.

Acute Focal Bacterial Nephritis Caused by Staphylococcus simulans

A toddler girl presented to our hospital with a fever that lasted for five days. She had no prior history of urinary tract infections or contact with farm animals. Investigations revealed a diagnosis of acute focal bacterial nephritis (AFBN), and we initiated antimicrobial therapy with ampicillin and cefmetazole. On day five, methicillin-resistant coagulase-negative staphylococci were detected in her urine culture, and we changed the antibiotics to vancomycin. Antibiotic therapy was continued for 21 days, with no recurrence of fever. Finally, the bacteria were identified as Staphylococcus (S.) simulans, which is a common farm animal pathogen. Clinicians should be aware of the possibility of AFBN caused by S. simulans, even if the patient has no prior history of close contact with farm animals. If a rare organism is detected in urine culture during AFBN treatment, the patient should be treated with appropriate antibiotics for the pathogen.

Simultaneous assay of urine sepiapterin and creatinine in patients with sepiapterin reductase deficiency

OBJECTIVES

Sepiapterin reductase deficiency (SRD) causes central nervous system symptoms due to dopamine and serotonin depletion because sepiapterin reductase plays an important role in tetrahydrobiopterin biosynthesis. SRD cannot be detected by newborn screening because of the absent hyperphenylalaninemia. To diagnose SRD biochemically, confirmation of reduced monoamine metabolites and elevated sepiapterin in the cerebrospinal fluid (CSF) has been considered necessary, because a past study showed no elevation of urine sepiapterin. Recently, however, the elevation of urine sepiapterin in SRD was reported.

METHODS

We developed a fast method to measure sepiapterin and creatinine simultaneously using high-performance liquid chromatography with fluorescence and ultraviolet detection. Urine sepiapterin and creatinine were measured in three SRD patients, two SRD carriers, four SRD siblings, and 103 non-SRD patients.

RESULTS

In the three SRD cases, concentrations of urine sepiapterin were 1086, 914, and 575 µmol/mol creatinine (upper limit: 101.7 µmol/mol creatinine), and were markedly higher than those in other groups. CSF sepiapterin concentration was also measured in one SRD case and it was 4.1 nmol/L (upper limit: 0.5 nmol/L).

CONCLUSIONS

The simultaneous determination of urine sepiapterin and creatinine appears helpful for the diagnosis of SRD. This assay system can also be used to measure sepiapterin in the CSF.

POS0794 PREGNANCY AND CHILDBIRTH IN TAKAYASU ARTERITIS IN JAPAN – A NATIONWIDE RETROSPECTIVE STUDY

Background

Takayasu arteritis (TAK), a granulomatous large vessel vasculitis, mainly involves the aorta and its proximal branches and commonly occurs in young females. However, studies of pregnancy in women with TAK are sparse and limited, probably due to the rarity of the disease.

Objectives

The purpose of this study was to understand the status quo of medical treatments of the primary disease and outcomes of pregnancy in patients with TAK, and birth outcomes of the children in Japan.

Methods

Patients with TAK who conceived after the onset of the disease and were managed at medical facilities participating in the Japan Research Committee of the Ministry of Health, Labour, and Welfare for Intractable Vasculitis (JPVAS) were retrospectively enrolled in this study. The following information was collected from patients who had a live-born baby: age at diagnosis of TAK, disease classification, age at delivery, treatments before and during pregnancy, complications during pregnancy, birth outcomes of the children, and changes in disease activity during pregnancy and after delivery.

Results

Fifty-one cases and 69 pregnancies from 19 ethics committee-approved centers were enrolled during the study period 2019–2021. Of these, 49 cases and 66 pregnancies (95.7%) resulted in delivery and live-born babies. The Numano classification of the 49 cases was as follows: type I, 11; type IIa, 15; type IIb,12; type III, 1; type IV, 1; type V, 9; with type IIa being the most common. The age of diagnosis was 22 years (13–37 years, year of diagnosis 1965–2017), the median age of the delivery of 66 pregnancies was 31 years (year of delivery 1969-2021), and the median duration of illness at delivery was nine years. There were 34 planned pregnancies (51.5%, including four pregnancies by artificial insemination/ovulation induction). Preconception therapy included prednisolone (PSL) in 51 pregnancies (77.3%, median dose 7.5 mg (range 4–30 mg)/day), immunosuppressive drugs in 18 pregnancies (27.3%, azathioprine 8, tacrolimus 7, methotrexate 4, cyclosporin A 1, and colchicine 1), biologics in 12 pregnancies (18.1%, infliximab 6, tocilizumab 5, and adalimumab 1), antihypertensive drugs in 5 pregnancies (7.6%). Surgical treatment had been performed before pregnancy in 6 cases (aortic root replacement 2, subclavian artery dilatation 1, subclavian artery bypass 1, subclavian artery stenting 1, and ascending aorta semicircular artery replacement 1). Medications used during the course of pregnancy included PSL in 48 pregnancies (72.7%, median dose 8 mg (range 4–30 mg)/day, increased in 13 pregnancies, decreased in 1 pregnancy), immunosuppressants in 13 pregnancies (19.7%, azathioprine 6, tacrolimus 6, and cyclosporin A 1), biologics 9 pregnancies (13.6%, infliximab 4, tocilizumab 4, and adalimumab 1). Immunosuppressants and biologics were discontinued in five and four pregnancies after conception. Complications during pregnancy were observed in 20 pregnancies (30.3%), with hypertension being the most common. Complications related to TAK or its treatment were severe infections in two pregnancies and aneurysm enlargement due to increased circulating plasma volume in one pregnancy. Aortic arch replacement was performed after delivery for the latter case. Relapse of TAK was observed in 4 pregnancies (6.1%) during pregnancy and in 8 pregnancies (12.1%) after delivery. One pregnancy resulted in restenosis of subclavian artery for which dilatation procedure was performed prior to the pregnancy. There were 13/66 (19.7%) preterm infants and 17/59 (28.8%) low birth weight infants; all but one had a birth weight of more than 2,000 g and no had serious postnatal abnormalities. Forty-three (82.7%) of the 52 confirmed infants were breastfeed fully or mixed.

Conclusion

Most of the pregnancies in patients with TAK were successfully delivered while they had low disease activity at a dose of less than 10 mg/day of PSL. Relapse occurred during pregnancy and after delivery in some cases. The babies tended to have low birth weight, but 82.7% of them were breastfed without serious complications.

Disclosure of Interests

Takako Miyamae: None declared, Yusuke Manabe: None declared, takahiko sugihara Speakers bureau: TS has received honoraria from Abbvie Japan Co., Ltd., AsahiKASEI Co., Ltd., Astellas Pharma Inc., Ayumi Pharmaceutical, Bristol Myers Squibb K.K., Chugai Pharmaceutical Co., Ltd., Eli Lilly Japan K.K., Mitsubishi-Tanabe Pharma Co., Ono Pharmaceutical, Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., and UCB Japan Co., Grant/research support from: TS has received research grants from AsahiKASEI Co., Ltd., Daiichi Sankyo., Chugai Pharmaceutical Co., Ltd., and Ono Pharmaceutical., Natsuka Umezawa: None declared, Hajime Yoshifuji Speakers bureau: HY has received lecture fees from Janssen and Chugai., Naoto Tamura: None declared, Yoshiyuki Abe: None declared, Shunsuke Furuta Speakers bureau: Chugai Pharmaceutical Co.,Ltd.

DaiichiSankyo Co.,Ltd.

Asahi-Kasei Pharma Corporation, Manami Kato: None declared, Takashi Kumagai: None declared, Kaito Nakamura: None declared, Hiroko Nagafuchi: None declared, Jun Ishizaki: None declared, Naoko Nakano: None declared, Tatsuya Atsumi Speakers bureau: Mitsubishi Tanabe Pharma Co., Chugai Pharmaceutical Co., Ltd., Astellas Pharma Inc., Takeda Pharmaceutical Co., Ltd., Pfizer Inc., AbbVie Inc., Eisai Co. Ltd., Daiichi Sankyo Co., Ltd., Bristol-Myers Squibb Co., UCB Japan Co. Ltd., Eli Lilly Japan K.K., Novartis Pharma K.K., Eli Lilly Japan K.K., Kyowa Kirin Co., Ltd.,TAIHO PHARMACEUTICAL CO., LTD., Consultant of: AstraZeneca plc., MEDICAL & BIOLOGICAL LABORATORIES CO., LTD., Pfizer Inc., AbbVie Inc., ONO PHARMACEUTICAL CO. LTD.,

Novartis Pharma K.K., Nippon Boehringer Ingelheim Co., Ltd., Grant/research support from: Astellas Pharma Inc., TAIHO PHARMACEUTICAL CO., LTD.AbbVie Inc., Nippon Boehringer Ingelheim Co., Ltd.,Takeda Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Chugai Pharmaceutical Co., Ltd., Daiichi Sankyo Co. Ltd., Otsuka Pharmaceutical Co., Ltd. and Pfizer Inc. Alexion Inc., TEIJIN PHARMA LIMITED., Kohei Karino: None declared, Koichi Amano Speakers bureau: AbbVie GK, Asahi-Kasei Pharma, Astellas, Chugai Pharmaceutical Co.Ltd., Eisai, Eli Lilly, GlaxoSmithKlein, Janssen Pharma, Pfizer Japan, Grant/research support from: Asahi-Kasei Pharma,Chugai Pharmaceutical Co.Ltd., Takahiko Kurasawa: None declared, Shuichi Ito: None declared, Ryusuke Yoshimi: None declared, Noriyoshi Ogawa: None declared, Shogo Banno: None declared, Taio Naniwa Speakers bureau: Chugai, Tanabe, Abbbvie, Eisai, Grant/research support from: Chugai, Tanabe, Abbbvie, Eisai, Satoshi Ito Speakers bureau: SI has received speaker’s fees from pharmaceutical companies., Akinori Hara: None declared, Shinya Hirahara: None declared, Haruhito A. Uchida: None declared, Yasuhiro Onishi: None declared, Yohko Murakawa Speakers bureau: Astellas, UCB, Chugai, AbbVie, Grant/research support from: Chugai, AbbVie, Yoshinori Komagata: None declared, Yoshikazu Nakaoka: None declared, Masayoshi Harigai Speakers bureau: MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Janssen Pharmaceutical K.K., Kissei Pharmaceutical Co., Ltd., Novartis Japan, Pfizer Japan Inc., Mitsubishi Tanabe Pharma Co., Teijin Pharma Ltd and UCB Japan., Consultant of: MH is a consultant for AbbVie, Boehringer-Ingelheim, Kissei Pharmaceutical Co., Ltd., and Teijin Pharma.

Pathological assessment of osimertinib-associated cardiotoxicity in EGFR-mutated non-small cell lung cancer patients

Background

Osimertinib, a third-generation epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI), inhibits both EGFR-TKI sensitizing mutations and resistant T790M mutations detected in non-small cell lung cancer (NSCLC) patients. Cardiac adverse events (AEs) induced by osimertinib are infrequent; however, cases of severe associated cardiac dysfunction have been reported and remain poorly understood.

Purpose

To assess pathogenesis of osimertinib-associated cardiac AEs, we analyzed myocardial specimens of three NSCLC cases with osimertinib-associated cardiac dysfunction.

Results

Analysis of LVEF prior to and after osimertinb administration in 36 NSCLC patients showed significant decrease of LVEF from 69% to 63%. Within this cohort, right ventricular (RV) biopsy was performed in 2 cases to further understand the pathophysiology of cardiac dysfunction. Case 1 was 78-year-old female with advanced NSCLC harboring an EGFR L858R mutation was treated with osimertinib as second line therapy. After 3 moths of osimetinib treatment, she presented with dyspnea, high NT-proBNP and troponin I, and significantly decreased left ventricular ejection fraction (LVEF) at 28%. RV biopsy showed moderate cardiomyocyte hypertrophy without inflammatory cell infiltration. Case 2 was 52-year-old female with advanced NSCLC harboring L858R mutation. She was treated with osimertinib as first line therapy. After 2 weeks of osimertinib, screening echocardiography revealed a reduction of LVEF from 63% to 41% without cardiac symptom. RV biopsy showed mild cardiomyocyte hypertrophy with infiltration of a few inflammatory cells in interstinum. We further analyzed death case of NSCLC. Case 3 was 63-year-old female with advanced NSCLC harboring EGFR ex. 19 del. and T790M mutations. After 6 months of osimertinib, she suffered from severe respiratory failure and severely reduced LVEF at 27%. She died on the 44th day after admission. Pathological autopsy revealed mild to moderate cardiomyocyte hypertrophy without inflammatory cell infiltration in both ventricles. These pathological findings may indicate neither myocyte injury nor myocarditis was induced by osimertinib in myocardium.

Conclusion

Although additional data collection of advanced NSCLC patients will be important in understanding the pathophysiology of cardiac AEs with osimertinib, osimertinib-associated cardiotoxicity may result from functional inhibition of myocyte contractility by osimertinib without induction of cell death or inflammation.

Funding Acknowledgement

Type of funding source: None

Renal abscess with bacteremia caused by extended-spectrum β-lactamase-producing Escherichia coli: a case report

Background

Renal abscess in children is a rare and severe form of infectious kidney disease that is responsible for several serious complications. In this report, we describe a previously healthy 5-year-old girl with a renal abscess caused by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (E. coli), which led to bacteremia and renal scarring.

Case presentation

The patient presented to our department with high fever, headache, vomiting for 2 days and high inflammatory response. We diagnosed her with a urinary tract infection and initiated treatment with ampicillin and cefotaxime. Gram-negative bacilli bacteremia was noted on day 3. On day 4, her fever persisted, and a computed tomography (CT) scan revealed a renal abscess in the left kidney. After identifying the bacteria as ESBL-producing E. coli from the blood culture, we switched to the antibiotic meropenem and continued treatment for 3 weeks. The renal abscess was not drained. Although the renal abscess was successfully treated and it disappeared, a low-density area remained in same lesion on subsequent CT scans and a dimercaptosuccinic acid renal scan performed 4 months after onset revealed renal scarring.

Conclusion

Given the increasing prevalence of ESBL-producing microorganisms, clinicians should be aware of the possibility of renal abscesses caused by community-acquired ESBL-producing organisms even in previously healthy children. Once a renal abscess is suspected, early diagnosis and management are important for reducing the risk of life-threating complications and renal scarring.

Early detection of Niemann-pick disease type C with cataplexy and orexin levels: continuous observation with and without Miglustat

Study objectives

Niemann-Pick type C (NPC) is an autosomal recessive and congenital neurological disorder characterized by the accumulation of cholesterol and glycosphingolipids. Symptoms include hepatosplenomegaly, vertical supranuclear saccadic palsy, ataxia, dystonia, and dementia. Some cases frequently display narcolepsy-like symptoms, including cataplexy which was reported in 26% of all NPC patients and was more often recorded among late-infantile onset (50%) and juvenile onset (38%) patients. In this current study, we examined CSF orexin levels in the 10 patients of NPC with and without cataplexy, which supports previous findings.

Methods

Ten patients with NPC were included in the study (5 males and 5 females). NPC diagnosis was biochemically confirmed in all 10 patients, from which 8 patients with NPC1 gene were identified. We compared CSF orexin levels among NPC, narcoleptic and idiopathic hypersomnia patients.

Results

Six NPC patients with cataplexy had low or intermediate orexin levels. In 4 cases without cataplexy, their orexin levels were normal. In 5 cases with Miglustat treatment, their symptoms stabilized or improved. For cases without Miglustat treatment, their conditions worsened generally. The CSF orexin levels of NPC patients were significantly higher than those of patients with narcolepsy-cataplexy and lower than those of patients with idiopathic hypersomnia, which was considered as the control group with normal CSF orexin levels.

Discussion

Our study indicates that orexin level measurements can be an early alert of potential NPC. Low or intermediate orexin levels could further decrease due to reduction in the neuronal function in the orexin system, accelerating the patients’ NPC pathophysiology. However with Miglustat treatment, the orexin levels stabilized or improved, along with other general symptoms. Although the circuitry is unclear, this supports that orexin system is indeed involved in narcolepsy-cataplexy in NPC patients.

Conclusion

The NPC patients with cataplexy had low or intermediate orexin levels. In the cases without cataplexy, their orexin levels were normal. Our study suggests that orexin measurements can serve as an early alert for potential NPC; furthermore, they could be a marker of therapy monitoring during a treatment.

Prenatal clinical manifestations in individuals with COL4A1/2 variants

BACKGROUND

Variants in the type IV collagen gene (COL4A1/2) cause early-onset cerebrovascular diseases. Most individuals are diagnosed postnatally, and the prenatal features of individuals with COL4A1/2 variants remain unclear.

METHODS

We examined COL4A1/2 in 218 individuals with suspected COL4A1/2-related brain defects. Among those arising from COL4A1/2 variants, we focused on individuals showing prenatal abnormal ultrasound findings and validated their prenatal and postnatal clinical features in detail.

RESULTS

Pathogenic COL4A1/2 variants were detected in 56 individuals (n=56/218, 25.7%) showing porencephaly (n=29), schizencephaly (n=12) and others (n=15). Thirty-four variants occurred de novo (n=34/56, 60.7%). Foetal information was available in 47 of 56 individuals, 32 of whom (n=32/47, 68.1%) had one or more foetal abnormalities. The median gestational age at the detection of initial prenatal abnormal features was 31 weeks of gestation. Only 14 individuals had specific prenatal findings that were strongly suggestive of features associated with COL4A1/2 variants. Foetal ventriculomegaly was the most common initial feature (n=20/32, 62.5%). Posterior fossa abnormalities, including Dandy-Walker malformation, were observed prenatally in four individuals. Regarding extrabrain features, foetal growth restriction was present in 16 individuals, including eight individuals with comorbid ventriculomegaly.

CONCLUSIONS

Prenatal observation of ventriculomegaly with comorbid foetal growth restriction should prompt a thorough ultrasound examination and COL4A1/2 gene testing should be considered when pathogenic variants are strongly suspected.

Integrated genetic and epigenetic analysis revealed heterogeneity of acute lymphoblastic leukemia in Down syndrome

Children with Down syndrome (DS) are at a 20‐fold increased risk for acute lymphoblastic leukemia (ALL). Compared to children with ALL and no DS (non‐DS‐ALL), those with DS and ALL (DS‐ALL) harbor uncommon genetic alterations, suggesting DS‐ALL could have distinct biological features. Recent studies have implicated several genes on chromosome 21 in DS‐ALL, but the precise mechanisms predisposing children with DS to ALL remain unknown. Our integrated genetic/epigenetic analysis revealed that DS‐ALL was highly heterogeneous with many subtypes. Although each subtype had genetic/epigenetic profiles similar to those found in non‐DS‐ALL, the subtype distribution differed significantly between groups. The Philadelphia chromosome‐like subtype, a high‐risk B‐cell lineage variant relatively rare among the entire pediatric ALL population, was the most common form in DS‐ALL. Hypermethylation of RUNX1 on chromosome 21 was also found in DS‐ALL, but not non‐DS‐ALL. RUNX1 is essential for differentiation of blood cells, especially B cells; thus, hypermethylation of the RUNX1 promoter in B‐cell precursors might be associated with increased incidence of B‐cell precursor ALL in DS patients.

Factors associated with possession of accurate knowledge regarding occupational health management among operations leaders of radiation decontamination workers in Fukushima, Japan: a cross-sectional study

OBJECTIVES

An operations leader (OL) takes an important role in occupational health management for radiation decontamination workers in Japan, and candidates for the position must participate in a training session to acquire the necessary knowledge as required by law. However, it has not been clarified whether the candidates for the OL position actually possess accurate knowledge regarding occupational health management for such work after the training session. We, therefore, aimed at examining the current occupational health management knowledge among the candidates and investigating factors related to the knowledge, with hypothesis that possession of accurate knowledge is associated with prior experience of having worked in radiation decontamination.

DESIGN

A cross-sectional study.

SETTING

The training sessions held by Fukushima Prefecture Labor Standard Associations in Fukushima, Japan, in 2017.

PARTICIPANTS

Eighty male candidates participated in the training sessions.

OUTCOME

The number/proportion of correct answers to the questions regarding occupational health management, such as those on working environment management, control of operations and health management.

RESULTS

The proportion of those who possessed accurate knowledge regarding working environment management, control of operations and health management was 68.8%, 55.0% and 51.2%, respectively. Experience of radiation decontamination work was associated with the possession of inaccurate knowledge regarding working environment management (OR 0.140 (95% CI 0.042 to 0.464)), and the uncertainty of future radiation decontamination work schedules in difficult-to-return zones was associated with the possession of accurate knowledge regarding health management (OR 4.344 (95% CI 1.509 to 12.50)).

CONCLUSIONS

Previous experience in radiation decontamination work may hinder the ability to acquire accurate information regarding working environment management among candidates for an OL position. To promote adequate occupational health management for radiation decontamination workers, it is required to establish an effective instructional method for the OL candidate training sessions with consideration of previous relevant experience.

A case of Niemann-Pick disease type C with neonatal liver failure initially diagnosed as neonatal hemochromatosis

BACKGROUND

Niemann-Pick type C (NPC) is a lysosomal lipid storage disease with mutation of NPC1/NPC2 genes, which transport lipids in the endosome and lysosome, and various neurological symptoms. NPC patients also develop hepatosplenomegaly or liver disorder in the neonatal period, and 10% suffer severe liver failure. Neonatal hemochromatosis (NH) is a liver disorder characterized by hepatic and extrahepatic siderosis. Although the etiology of NH is unclear, recent reports suggest that the gestational alloimmune mechanism is the cause of NH. Herein, we report a Japanese NPC patient initially diagnosed as NH.

CASE REPORT

A 5-day-old boy was transferred to our hospital with severe cholestatic liver failure. Congenital infections and metabolic screening were negative, and NH was suspected. However intra and extrahepatic siderosis were not found. As his liver deteriorated rapidly, liver transplantation was performed at 19 days old. The explanted liver showed cirrhosis, and strong C5b-9 complex staining of hepatocytes, so NH was diagnosed. From the age of one and a half years, he developed regression, vertical supranuclear gaze palsy and cataplexy. Fibroblast filipin staining was strong, blood oxysterol was high, and there were compound heterozygous mutations in NPC1,p.[(F288L)];[(K1206N)]. The patient was then diagnosed as NPC and started on miglustat.

CONCLUSION

Neonatal liver failure was initially diagnosed as NH. Later, the patient developed various neurological symptoms characteristic of NPC. Neurological follow-up of children who develop NH is required.

Anharmonicity in a double hydrogen transfer reaction studied in a single porphycene molecule on a Cu(110) surface

Anharmonicity plays a crucial role in hydrogen transfer reactions in hydrogen-bonding systems, which leads to a peculiar spectral line shape of the hydrogen stretching mode as well as highly complex intra/intermolecular vibrational energy relaxation. Single-molecule study with a well-defined model is necessary to elucidate a fundamental mechanism. Recent low-temperature scanning tunnelling microscopy (STM) experiments revealed that the cis↔cis tautomerization in a single porphycene molecule on Cu(110) at 5 K can be induced by vibrational excitation via an inelastic electron tunnelling process and the N-H(D) stretching mode couples with the tautomerization coordinate [Kumagai et al. Phys. Rev. Lett. 2013, 111, 246101]. Here we discuss a pronounced anharmonicity of the N-H stretching mode observed in the STM action spectra and the conductance spectra. Density functional theory calculations find a strong intermode coupling of the N-H stretching with an in-plane bending mode within porphycene on Cu(110).

Spectroscopic and microscopic investigations of tautomerization in porphycenes: condensed phases, supersonic jets, and single molecule studies

Tautomerization of porphycene, coherent in supersonic jets and a rate process in solutions, can be controlled for single molecules on surfaces.

Local electronic structure, work function, and line defect dynamics of ultrathin epitaxial ZnO layers on a Ag(1 1 1) surface

Using combined low-temperature scanning tunneling microscopy and Kelvin probe force microscopy we studied the local electronic structure and work function change of the (0 0 0 1)-oriented epitaxial ZnO layers on a Ag(1 1 1) substrate. Scanning tunneling spectroscopy (STS) revealed that the conduction band minimum monotonically downshifts as the number of the ZnO layers increases up to 4 monolayers (ML). However, it was found by field emission resonance (FER) spectroscopy that the local work function of Ag(1 1 1) slightly decreases for 2 ML thick ZnO but it dramatically changes and drops by about 1.2 eV between 2 and 3 ML, suggesting a structural transformation of the ZnO layer. The spatial variation of the conduction band minimum and the local work function change were visualized at the nanometer scale by mapping the STS and FER intensities. Furthermore, we found that the ZnO layers contained line defects with a few tens of nm long, which can be removed by the injection of a tunneling electron into the conduction band.

Novel double step approach for optical sensing via microsphere WGM resonance

The use of resonant whispering gallery modes (WGMs) for sensing exhibits various drawbacks and critical points related to the microsphere and tapered optical fiber fabrication tolerance. The uncertainty on the fiber taper and microsphere geometry or the gap between the microsphere and the fiber taper can complicate or limit the actual use of these devices for sensing, requiring peculiar calibration of the WGM based sensing set-up. An alternative double-step approach is proposed in this paper. In particular, the geometrical parameters of the set-up are recovered preliminarily and then the rare earth parameters are recovered via simple transmittance/gain measurements. The method is based on a refined electromagnetic model of the device suitably integrated with a particle swarm optimization (PSO) approach. The percent errors made on the up-conversion coefficients C_up and C₃ are extremely low, being 0.75%, 0.05%, respectively. The procedure is very robust. It can be applied more in general, allowing the sensing of other physical parameters via simple transmittance measurements instead of wavelength shift ones, in both microsphere and microbubble based set-up.

Cytokine-related and sodium channel polymorphism as candidate predisposing factors for childhood encephalopathy FIRES/AERRPS

Febrile infection-related epilepsy syndrome (FIRES), or acute encephalitis with refractory, repetitive partial seizures (AERRPS), is an epileptic encephalopathy beginning with fever-mediated seizures. The etiology remains unclear. To elucidate the genetic background of FIRES/AERRPS (hereafter FIRES), we recruited 19 Japanese patients, genotyped polymorphisms of the IL1B, IL6, IL10, TNFA, IL1RN, SCN1A and SCN2A genes, and compared their frequency between the patients and controls. For IL1RN, the frequency of a variable number of tandem repeat (VNTR) allele, RN2, was significantly higher in the patients than in controls (p=0.0067), and A allele at rs4251981 in 5' upstream of IL1RN with borderline significance (p=0.015). Haplotype containing RN2 was associated with an increased risk of FIRES (OR 3.88, 95%CI 1.40-10.8, p=0.0057). For SCN1A, no polymorphisms showed a significant association, whereas a missense mutation, R1575C, was found in two patients. For SCN2A, the minor allele frequency of G allele at rs1864885 was higher in patients with borderline significance (p=0.011). We demonstrated the association of IL1RN haplotype containing RN2 with FIRES, and showed a possible association of IL1RN rs4251981 G>A and SCN2A rs1864885 A>G, in Japanese patients. These preliminary findings suggest the involvement of multiple genetic factors in FIRES, which needs to be confirmed by future studies in a larger number of FIRES cases.

Molecular diagnosis of 65 families with mucopolysaccharidosis type II (Hunter syndrome) characterized by 16 novel mutations in the IDS gene: Genetic, pathological, and structural studies on iduronate-2-sulfatase

Mucopolysaccharidosis type II (MPS II: also called as Hunter syndrome) is an X-linked recessive lysosomal storage disorder characterized by the accumulation of extracellular glycosaminoglycans due to the deficiency of the enzyme iduronate-2-sulfatase (IDS). Previous observations suggested that MPS II can be classified into two distinct disease subtypes: (1) severe type of MPS II involves a decline in the cognitive ability of a patient and (2) attenuated type of MPS II exhibits no such intellectual phenotype. To determine whether such disease subtypes of MPS II could be explained by genetic diagnosis, we analyzed mutations in the IDS gene of 65 patients suffering from MPS II among the Japanese population who were diagnosed with both the accumulation of urinary glycosaminoglycans and a decrease in their IDS enzyme activity between 2004 and 2014. Among the specimens examined, we identified the following mutations: 33 missense, 8 nonsense, 7 frameshift, 4 intronic changes affecting splicing, 8 recombinations involving IDS-IDS2, and 7 other mutations including 4 large deletions. Consistent with the previous data, the results of our study showed that most of the attenuated phenotype was derived from the missense mutations of the IDS gene, whereas mutations associated with a large structural alteration including recombination, splicing, frameshift, and nonsense mutations were linked to the severe phenotype of MPS II. Furthermore, we conducted a homology modeling study of IDS P120R and N534I mutant as representatives of the causative mutation of the severe and attenuated type of MPS II, respectively. We found that the substitution of P120R of the IDS enzyme was predicted to deform the α-helix generated by I119-F123, leading to the major structural alteration of the wild-type IDS enzyme. In sharp contrast, the effect of the structural alteration of N534I was marginal; thus, this mutation was pathogenically predicted to be associated with the attenuated type of MPS II. These results suggest that a combination of the genomic diagnosis of the IDS gene and the structural prediction of the IDS enzyme could enable the prediction of a phenotype more effectively.

Efficacy of Diluted NBCA Mixture for Embolization of Arteriovenous Malformations

The purpose of this study is to evaluate the efficacy and problems of the embolization for cerebral arteriovenous malformations (AVMs) with diluted cyanoacrylate adhesives.

Twelve consecutive AVM cases were treated with N-butyl-2-cyanoacrylate (NBCA) glues between January 1997 and July 1998. The mean age of the patients was 37 years old. Intracerebral hemorrhage was the presenting symptom in seven cases, seizure in three, headache in one and mental deterioration in one. According to the classification of Spetzler and Martin, seven were Grade 11, five were Grade III. We used a mixture of NBCA (normally 25% Histoacryl, 75% Ethidol) for embolization. Microcatheter was navigated into the nidus and the tip of the catheter was set in a wedged position. Then the glue was injected using complete column technique.

Nineteen sessions of embolization were performed in 12 patients. The mean volume of each nidus was reduced from 22.5 ml to 3.4 ml (85%) after embolization. Four cases were cured by embolization alone. Surgical resection was performed after embolization without any residual nidus in three cases. Five were treated with stereotactic radiosurgery following embolization. One was completely cured in 18 months after and the other four have been decreasing their sizes of nidus. One case was suffered from delayed intracerebral hemorrhage three days after embolization, and resulted in mild hemiparesis and memory disturbance. The others had no complications and were clinically improved or unchanged after embolization.

It is possible to embolize the nidus of AVMs more accurately and safely with diluted mixture of NBCA, compared with the method using relatively higher concentration of NBCA glues. This technique is useful and effective method for the treatment of AVMs.

Living-Donor Liver Transplantation From a Heterozygous Parent for Infantile Refsum Disease

Infantile Refsum disease (IRD) is a rare autosomal recessive disorder of peroxisome biogenesis characterized by generalized peroxisomal metabolic dysfunction, including accumulation of very long-chain fatty acids (VLCFAs) and phytanic acid (PA), as well as decreased plasmalogen contents (PL). An effective therapy for this intractable disease has not been established, and only supportive management with docosahexaenoic acid supplementation and low PA diet has been reported so far. A boy of 3 years and 8 months presented with facial dysmorphism, transaminitis, and psychomotor retardation. Biochemical analysis showed elevated PA and VLCFAs, with reduced PL in the serum. Immunofluorescence study of fibroblasts from the patient indicated a mosaic pattern of catalase-positive and -negative particles, and molecular analysis revealed compound heterozygous mutations of PEX6 The failure of medical management to prevent the progression of clinical symptoms and abnormal biochemistry prompted us to consider liver transplantation (LT). With the chances of receiving a deceased donor liver being poor, we performed a living-donor LT from the patient's heterozygous mother. At 6-month follow-up, the patient's serum PA levels had normalized. VLCFAs and PL levels had declined and increased, respectively. To the best of our knowledge, this is the second reported case in which IRD was treated by living-donor LT by using a heterozygous donor. Only long-term follow-up will reveal if there is any clinical improvement in the present case. With the liver being a major site for peroxisomal pathways, its replacement by LT may work as a form of partial enzyme therapy for patients with IRD.

A selective detection of lysophosphatidylcholine in dried blood spots for diagnosis of adrenoleukodystrophy by LC-MS/MS

X-linked adrenoleukodystrophy (X-ALD) is a rare inherited metabolic disorder characterized by an impaired beta-oxidation of very long chain fatty acids in the peroxisomes. Recent studies have suggested that 1-hexacosanoyl-2-hydroxy-sn-glycero-3-phosphocholine (Lyso-PC 26:0) can be a sensitive biomarker for X-ALD. Although approximately 10-fold increase in the concentration of Lyso-PC 26:0 in DBSs from X-ALD-affected individuals were reported, whether the carriers might be distinguished from the healthy controls remained unclear. To address this question, we have validated previously developed LC-MS/MS-based analytical procedures using QC DBS. We found that the recovery of Lyso-PC 26:0 from the QC DBSs was 73.6 ± 0.3% when 2 μM of Lyso-PC 26:0 was spiked into the blood. Based on this result, the amounts of Lyso-PC 26:0 in the controls and ALD-affected individuals were 0.090 ± 0.004 (n = 11) and 1.078 ± 0.217 (n = 4) pmol/DBS, respectively. Interestingly, the concentration of Lyso-PC 26:0 in the carriers were 0.548 ± 0.095 pmol/DBS (n = 3), indicating that the carriers and the healthy controls can be distinguished. These results suggest that LC-MS/MS-based technique can be used for the detection of asymptomatic carriers and X-ALD-affected subjects in the newborn screening.

Direct Observation of Photoinduced Tautomerization in Single Molecules at a Metal Surface

Molecular switches are of fundamental importance in nature, and light is an important stimulus to selectively drive the switching process. However, the local dynamics of a conformational change in these molecules remain far from being completely understood at the single-molecule level. Here, we report the direct observation of photoinduced tautomerization in single porphycene molecules on a Cu(111) surface by using a combination of low-temperature scanning tunneling microscopy and laser excitation in the near-infrared to ultraviolet regime. It is found that the thermodynamically stable trans configuration of porphycene can be converted to the metastable cis configuration in a unidirectional fashion by photoirradiation. The wavelength dependence of the tautomerization cross section exhibits a steep increase around 2 eV and demonstrates that excitation of the Cu d-band electrons and the resulting hot carriers play a dominant role in the photochemical process. Additionally, a pronounced isotope effect in the cross section (∼100) is observed when the transferred hydrogen atoms are substituted with deuterium, indicating a significant contribution of zero-point energy in the reaction. Combined with the study of inelastic tunneling electron-induced tautomerization with the STM, we propose that tautomerization occurs via excitation of molecular vibrations after photoexcitation. Interestingly, the observed cross section of ∼10(-19) cm(2) in the visible-ultraviolet region is much higher than that of previously studied molecular switches on a metal surface, for example, azobenzene derivatives (10(-23)-10(-22) cm(2)). Furthermore, we examined a local environmental impact on the photoinduced tautomerization by varying molecular density on the surface and find substantial changes in the cross section and quenching of the process due to the intermolecular interaction at high density.