AB0186 IMPROVEMENT OF RADIOGRAPHIC JOINT DESTRUCTION IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS IN THE LAST DECADE

Background

The paradigm shift has caused in the treatment for rheumatoid arthritis (RA) before the last decade [1]. The advent of high-dose MTX and biologics has maked it possible to treat RA with early and aggressive therapy, and prevent the joint destruction [2].

Objectives

To aim of this study, we investigated the joint destruction and clinical outcomes in patients with early RA every 5 years in the last decade.

Methods

81 patients with early RA (within 1 year from their onset of RA) enrolled retrospectively in this study. The number of patients with early RA were 21 in 2009, 23 in 2014, and 37 in 2019, respectively. They had 17 males and 64 females. Mean age was 59 years (19-92) at the first visit to our department. The following items were investigated: age, disease duration from onset to consultation, anti-cyclic citrullinated peptide antibody (ACPA) positivity (positivity was defined as >4.5 U/ml), CRP, DAS28CRP4, medications, and modified total sharp score (mTSS) at the time of initial consultation and 1 year later. Kruskal-Wallis test was used for statistics (PASW 25 software, SPSS Institute Inc., Chicago, IL, USA, p<0.05).

Results

The ACPA positivity rates were 71.4% (15/21) in 2009, 78.3% (18/21) in 2014, and 78.4% (29/37) in 2019, respectively. The mean value of DAS28CRP4 was 4.7 (2.4-6.8) in 2009, 4.2 (1.2-6.2) in 2014, and 4.2 (2.1-6.7) in 2019 at the time of the first visit to our department respectively. DAS28CRP4 under 2.6 was 29% (6/21) in 2009, 61% (14/23) in 2014, and 54% (20/37) in 2019 1 year after the first visit. The mean improvement of DAS28CRP4 (ΔDAS28CRP4) was -1.2 (-3.9 - 2.1) in 2009, -1.5 (-4.0 - 1.7) in 2014, and -1.7 (-4.1 - 0.4) in 2019, respectively. It had tended to improve gradually, however, it was not significantly different (p= 0.20, Figure 1).

Figure 1.

Mean value of improvement of mTSS and DAS28CRP4 (ΔmTSS and ΔDAS28CRP4) from initial visit to 1 year later at 2009, 2014 and 2019.

The changing of mTSS for a year (ΔmTSS) was 4.2 (0-17) in 2009, 0.9 (0-10) in 2014, and 0.6 (0-4) in 2019, respectivly. ΔmTSS in 2014 and 2019 was significantly lower compared to that in 2009 (p<0.05, Figure 1).

One year after the first visit to our department, the mean dose of MTX increased to 9.2 mg/week (2-14) in 2014 and 8.7 mg/week (4-16) in 2019 compared to 6.6 mg/week (2-8) in 2009 (p=0.19). The mean dose of PSL decreased 4.2 mg/day (1-8) in 2014, and 3.8 mg/day (1-10) in 2019 compared to 4.9 mg/day (2-10) in 2009, respectively (p=0.11). On the other hand, biological DMARDs were introduced in 24% (5/21) in 2009, 13% (3/23) in 2014, and 13% (1/37) in 2019, respectively.

Conclusion

Jonit destruction has been already reported to begin in patients with early-stage of RA [1, 2]. Based on the results of this study, joint desctruction in early RA was decreased in the last decade, because of more early and aggressive therapy for early RA with increasing mean dose of MTX gradually, not biologic DMARDs in real world. In addition, the mean dose of PSL in 2014 and 2019 decreased compared to that in 2009. The intensive therapy for early RA at our hospital has shown the improvement of joint destruction in the last decade.

References

[1]Emery P, Breedveld FC, Dougados M, et al. Early referral recommendation for newly diagnosed rheumatoid arthritis: evidence based development of a clinical guide. Ann Rheum Dis 2002;61:290–297.

[2]Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020;79:685-699.

Disclosure of Interests

None declared

Families' opinions about caring for patients with psychiatric disorders after involuntary hospitalization in Japan

OBJECTIVE

It is imperative to know families' opinions about where patients should live after discharge from involuntary hospitalization in the era of community mental health.

METHODS

Questionnaires were sent (March-May 2011) to 808 guardians of patients who were involuntarily hospitalized in Japan (response rate = 54.2%). The final sample size was 365 family members. Whether families wanted to live with the patient after discharge from the hospital was the primary outcome variable. The associations of the demographic characteristics of the patients and families with the outcome variable were tested using logistic regression analysis.

RESULTS

Approximately, 19% of the family guardians wanted to live with the patient after discharge from the hospital. Their wish to cohabit was positively associated with being a female (vs male) patient, having three or more cohabitants in the home and having lived together before hospitalization, after adjusting for the other covariates. Long-term hospitalization (10 years or longer) and siblings were significantly associated with the families not wanting to cohabit, after adjusting for the other covariates.

CONCLUSION

It is important to know families' opinions about patients' living situations after discharge from involuntary hospitalization to provide them with an effective support system.

Development of screening inventories for bipolar disorder at workplace: a diagnostic accuracy study

BACKGROUND

This study aimed to develop a new instrument for bipolar disorder screening, the Workplace Bipolar Inventory (WBI), and examine its efficiency as compared with Mood Disorder Questionnaire (MDQ) and Bipolar Spectrum Diagnostic Scale (BSDS) among workers on leave of the absence due to their mental health problems.

METHODS

Participants were recruited at a psychiatric outpatient clinic for return-to-work in Tokyo, Japan, during September to November 2009. 81 outpatients were recruited, 55 of whom (68%) agreed to participate in this study. Participants answered questionnaires including WBI, MDQ, BSDS, and demographic factors. Their diagnostic information according to the international statistical classification of diseases and related health problems 10th revision (ICD-10) was obtained from their attending psychiatrists. The WBI is a new self-rating 39-item questionnaire which developed with input from occupational mental health specialists and an analysis of WHO Composite International Diagnostic Interview (CIDI) items. The WBI contains 3 subtype scales: WBI-A (5 items), WBI-AB4 (9 items), and WBI-AB (39 items).

RESULTS

Reliability of these scales was moderate. In the AUC of these scales, BSDS was the best of them (0.83). In the optimal cut-off point of these scales, WBI-AB4 showed good efficiency of screening (sensitivity=0.78, specificity=0.75). Both MDQ and BSDS had high specificity, while low in sensitivity.

LIMITATIONS

The well validated diagnostic method (i.e., the structured clinical interview for DSM-IV [SCID] or CIDI) was not applied in this study.

CONCLUSIONS

The WBI, especially WBI-AB4 would be a useful workplace screening tool for workers with bipolar disorder.

[Discharge Dynamics and Related Factors of Long-stay Patients in Psychiatric Hospitals]

A longstanding challenge in Japan is prolonged psychiatric hospitalization and the associated difficulty of discharge, lost opportunities for patients' social participation, and stagnant reallocation of medical resources. Although the length of stay has been shortened recently on average, its distribution tends to be polarized into high-turnover and long-stay groups. To resolve these problems, we must understand the discharge dynamics of long-stay patients. Three questionnaires were sent to 733 randomly selected psychiatric hospitals (response rate: 24.3%; 178 hospitals, 2,480 patients). One questionnaire was on hospitalized patient numbers for one-year or longer stays as at the end of June 2007, recording each combination of Group (A or B), diagnosis, and hospitalization type. Group A referred to patients continuously hospitalized as at the end of June 2008; Group B referred to those discharged between July 2007 and June 2008. The second questionnaire was on hospital characteristics (founder, bed number, medical function, etc.), and the third questionnaire was on detailed patient characteristics (residential setting post-discharge, etc., for each Group B patient; a maximum of 20 patients per hospital consecutively in order of discharge). Valid data were obtained from 171 hospitals and 2,419 patients, with the latter increasing to 3,543 after weighting. The annual discharge rate (ADR; B/[A+B]) for the entire sample was 16.3%. Regarding the diagnosis, dementia showed the highest ADR (27.8%) and schizophrenia the lowest (13.5%). The ADRs for depression, bipolar disorder, and alcoholism were 23.9, 20.6, and 23.7% respectively. Regarding the hospitalization type, voluntary hospitalization (16.0%) and hospitalization for medical care and protection (16.8%) showed similar ADRs. Regarding the district, ADRs were high in Kinki (19.9%) and Kyushu (18.8%), and low in Kanto (14.1%) and Chugoku/Shikoku (14.2%). Multivariate analyses revealed that discharge within one year was significantly correlated with the diagnosis, district, hospital founder, and presence of psychiatric emergency or acute-phase treatment (acute-phase-type) wards in hospitals, but not with the hospitalization type, presence of psychiatric long-term care wards, or presence of senile dementia wards. The probability of discharge (odds ratio [95% confidence interval]) regarding the diagnosis was higher in dementia (2.47 [2.23-2.74]), alcoholism (2.09 [1.71-2.55]), depression (2.07 [1.65-2.59]), and bipolar disorder (1.70 [1.35-2.16]) than in schizophrenia (reference). Regarding the district, the probability was higher in Kinki (1.32 [1.12-1.54]) and Kyushu (1.27 [1.14-1.42]) than Kanto (reference). The probability was also lower in private hospitals (0.58 [0.51-0.66]) than in public/university hospitals (reference), and higher in hospitals with acute-phase-type wards (1.24 [1.14-1.35]) than in those without them (reference). The most common residential setting post-discharge for the total sample of weighted Group B patients was temporary hospitalization in another department prearranging psychiatric readmission (THAD, 35.8%), followed by death (18.2%), living with families/relatives (LF/R, 11.3%), a residential care facility for the aged (RCF-A, 9.5%), residential care facility for the disabled (RCF-D, 8.6%), hospitalization in another psychiatric hospital (7.4%), living alone (LA, 4.3%), permanent hospitalization in another department (PHAD, 4.3%), and others (0.7%). In dementia, death was common (31.0%) ; LF/R (1.8%) and LA (0.0%) were rare. As the age increased, the proportions of LF/R, LA, RCF-D, RCF-A, PHAD, and death changed; particularly, LA decreased and death increased markedly with age. Additionally, THAD amounted to approximately 40% in every age class of 40 years or older, contrasting with 11.4% in those under 40 years. The study's limitations include a low response rate, the elapsed time after the survey, and lack of attention paid to symptom severity. Nevertheless, it provides valuable insights into long-stay patients, including that discharge is least likely in schizophrenia and most likely via transfer or death for dementia. These results may encourage the efficient promotion of discharge and prevention of prolonged hospitalization according to patients' demographic, clinical, and social conditions.

Impact of mental disorders on work performance in a community sample of workers in Japan: the World Mental Health Japan Survey 2002-2005

Most studies that investigate the impact of mental disorders on work performance have been conducted in Western countries, but this study examines the impact of common mental disorders on sick leave and on-the-job work performance in a community sample of Japanese workers. Data from the World Mental Health Japan survey were analyzed. A subsample of 530 workers aged 20-60years were interviewed using the WHO Composite International Diagnostic Interview 3.0. The WHO Health and Work Performance Questionnaire, was used to assess sick days and on-the-job work performance for the previous 30days. Linear regression was used to estimate the impact of mental disorders on these indicators of work performance over 12months. Mood disorders, including major depressive disorder, and alcohol abuse/dependence were significantly associated with decreased on-the-job performance. There were no significant associations between mental disorders and sick/absent days. Consistent with previous studies, major depression has a great impact on on-the-job work performance in Japan. The lost productivity was estimated at approximately 28-30 lost days per year. A similar decrease in on-the-job work performance was found for alcohol abuse/dependence, which is stronger than that in other countries, probably attributable to greater tolerance of problematic drinking at Japanese worksites.

[Discharge dynamics and related factors of newly-admitted patients in psychiatric hospitals]

The focus of psychiatric services in Japan is being shifted from hospitalization to community care, and the Ministry of Health, Labour and Welfare aims for the prompt discharge of newly-admitted patients. Correspondingly, it set a goal to lower the "mean residual rate (MRR)", which indicates the discharge dynamics of newly-admitted patients, to 24%. As a measure to achieve this goal, the present situation should be investigated in each homogeneous patient group. In this study, we conducted a survey of newly-admitted patients to investigate discharge dynamics and related factors by the diagnosis and type of hospitalization. Out of 1,459 psychiatric hospitals to which we sent questionnaires, 183 (12.5%) replied. Each hospital completed questionnaires regarding a maximum of 5 patients for each type of hospitalization (voluntary hospitalization [VH], hospitalization for medical care and protection [HMCP], and involuntary hospitalization ordered by the prefectural governor [IHOPG]) between October 2005 and January 2006. We weighted the obtained patient data in proportion to the estimated total number of patients, and analyzed valid data on 1,784 patients. The MRR for the whole sample was 29.4%. By diagnosis, dementia showed the highest MRR (45.6%), followed by schizophrenia (34.9%); depression, bipolar disorder, and alcoholism showed the lowest MRRs (20-21%). We calculated MRRs by the type of hospitalization for dementia and the other diagnoses separately, considering confounding effect between the diagnosis and type of hospitalization (markedly high proportion of HMCP observed in dementia). In dementia, HMCP showed a higher MRR (46.8%) than VH (43.7%). In the other diagnoses, IHOPG showed the highest MRR (43.7%), followed by HMCP (34.5%) and VH (25.6%). Dementia differed from the other diagnoses in the distribution of residential settings before admission, with a higher proportion of residential care facilities (25.5%) and hospitalization in other departments (19.3%). In dementia, the residential setting after discharge showed a similar distribution, and death was also frequent (6.6%). Multivariate analyses revealed that a long stay (one year or longer) was significantly associated with a residential setting before admission, the type of ward at admission, a founder (a private hospital or public/university hospital), and symptom severity at admission in schizophrenia; and with the type of ward at admission and hospital founder in dementia. In schizophrenia, the risk of a long stay was higher on hospitalization in other psychiatric hospitals (odds ratio [OR] : 28) and other departments (OR: 18), and living alone (OR: 2.1) than in living with the family by residential setting. The risk was also higher in psychiatric long-term care wards than in general psychiatric wards by the type of ward (OR: 3.0), and in private hospitals than in public/university hospitals by hospital founder (OR: 3.0). Additionally, the higher risk was associated with higher symptom severity assessed using a 6-point scale (OR: 1.3 per point). In dementia, the risk was higher in senile dementia wards than in general psychiatric wards by the type of ward (OR: 2.9), and in private hospitals than in public/university hospitals by hospital founder (OR: 6.8). The most frequently reported direct causes of a long stay were problems regarding a family's acceptance (51.5%), poor improvement of symptoms (48.8%), and poor recovery of daily living abilities (44.0%). In dementia, physical diseases (20.8%) and undecidedness of residence after discharge (29.2%) were also frequent. Considering the elapsed time after survey, the low response rate, and the data analyses with sampling bias adjustment, the results should be interpreted carefully. Nevertheless, the discharge dynamics and related factors in newly-admitted patients varied with the diagnosis and type of hospitalization. Particularly, schizophrenia and dementia, as well as IHOPG and HMCP, showed high MRRs and frequent long stays. Additionally, a long stay was related to patients' demographic and social characteristics. Adopting measures suiting patients' characteristics and arranging treatment and casework for patients at high risk of a long stay are important to facilitate community care.

Cost of depression among adults in Japan in 2005

AIM

Major depression is expected to become the leading contributor to disease burden worldwide by 2020. Previous studies have shown that the societal cost of depression is not less than that of other major illnesses, such as cardiovascular diseases or AIDS. Nevertheless, the cost of depression in Japan has never been examined. The goal of the present study was to estimate the total cost of depression in Japan and to clarify the characteristics of this burden.

METHODS

A prevalence-based approach was adopted to measure the total cost of depression. The total cost of depression was regarded as being comprised of the direct cost, morbidity cost and mortality cost. Diagnoses included in this study were depressive episodes and recurrent depressive disorder according to the ICD-10 or major depressive disorder according to the DSM-IV. Data were collected from publicly available statistics and the World Mental Health Japan Survey database.

RESULTS

The total cost of depression among adults in Japan in 2005 was estimated to be ¥2.0 trillion. The direct cost was ¥0.18 trillion. The morbidity cost was ¥0.92 trillion, while the mortality cost was ¥0.88 trillion.

CONCLUSION

The societal costs caused by depression in Japan are enormous, as in other developed countries. Low morbidity costs and extremely high mortality costs are characteristic in Japan. Effective interventions for preventing suicide could reduce the societal costs of depression.

Evaluation of the DSM-IV and ICD-10 criteria for depressive disorders in a community population in Japan using item response theory

The DSM-IV and ICD-10 are both operational diagnostic systems that classify known psychological disorders according to the number of criteria symptoms. Certain discrepancies between the criteria exist and may lead to some inconsistencies in psychiatric research. The purpose of this study was to investigate these differences in the assessment of depression with item response theory (IRT) analyses. The World Mental Health-Japan (WMHJ) Survey is an epidemiological survey of the general population in Japan. We analyzed data from the WMHJ completed by 353 respondents who had either depressive mood or diminished interest. A two-parameter logistic model was used to evaluate the characteristics of the symptoms of the DSM-IV and ICD-10. IRT analyses revealed that the symptoms about psychomotor activity, worthlessness and self-reproach were more informative and suggestive of greater severity, while the symptoms about dietary habits were less informative. IRT analyses also revealed that the ICD-10 seems more sensitive to the mild range of the depression spectrum compared to the DSM-IV. Although there were some variations in severity among respondents, most of the respondents diagnosed with a severe or moderate depressive episode according to the ICD-10 were also diagnosed with a major depressive episode according to the DSM-IV.

Lifetime comorbidities between phobic disorders and major depression in Japan: results from the World Mental Health Japan 2002-2004 Survey

BACKGROUND

Although often considered of minor significance in themselves, evidence exists that early-onset phobic disorders might be predictors of later more serious disorders, such as major depressive disorder (MDD). The purpose of this study is to investigate the association of phobic disorders with the onset of MDD in the community in Japan.

METHODS

Data from the World Mental Health Japan 2002-2004 Survey were analyzed. A total of 2,436 community residents aged 20 and older were interviewed using the WHO Composite International Diagnostic Interview 3.0 (response rate, 58.4%). A Cox proportional hazard model was used to predict the onset of MDD as a function of prior history of DSM-IV specific phobia, agoraphobia, or social phobia, adjusting for gender, birth-cohort, other anxiety disorders, education, and marital status at survey.

RESULTS

Social phobia was strongly associated with the subsequent onset of MDD (hazard ratio [HR]=4.1 [95% CI: 2.0-8.7]) after adjusting for sex, birth cohort, and the number of other anxiety disorders. The association between agoraphobia or specific phobia and MDD was not statistically significant after adjusting for these variables.

CONCLUSIONS

Social phobia is a powerful predictor of the subsequent first onset of MDD in Japan. Although this finding argues against a simple neurobiological model and in favor of a model in which the cultural meanings of phobia play a part in promoting MDD, an elucidation of causal pathways will require more fine-grained comparative research.

Prevalence of and risk factors for suicide-related outcomes in the World Health Organization World Mental Health Surveys Japan

AIM

Suicide is a major public health concern in Japan but little is known about the prevalence of and risk factors for suicidal ideation, plans, and attempts. The aim of the present study was to clarify the prevalence of and risk factors for important suicide-related outcomes.

METHODS

Important suicide-related outcomes and risk factors were assessed in face-to-face interviews with 2436 adult respondents in seven areas as part of the World Health Organization (WHO) World Mental Health Survey Initiative. Mental disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI).

RESULTS

The lifetime prevalence estimates of suicidal ideation, plans, and attempts were 10.9%, 2.1%, and 1.9%, respectively. Risk of suicide plans and attempts was highest when suicidal ideation occurred at an early age and within the first year of ideation. In middle-aged individuals, the period after first employment and the presence of mental disorders were risk factors.

CONCLUSIONS

Risk of suicide plans and attempts is highest when suicidal ideation occurred at an earlier age and within the first year of ideation. Mental disorders are as predictive of the suicide-related outcomes examined here, and comorbidity is an important predictor.

Heart disease, other circulatory diseases, and onset of major depression among community residents in Japan: results of the World Mental Health Survey Japan 2002-2004

We examined whether selected circulatory diseases (heart disease, stroke, diabetes and hypertension) were associated with an increased risk of major depression in the Japanese community population. Face-to-face household surveys were carried out in 7 areas, and a total of 2,436 persons participated (overall response rate: 58.4%) from 2002 to 2004. The WHO Composite International Diagnostic Interview 3.0 was used to diagnose major depression according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and additional interviews assessed the presence of circulatory diseases. Using data from a random subsample of the respondents (n=832), we conducted Cox proportional hazards models to calculate hazard ratios for the onset of major depression with comorbid circulatory diseases as a time-dependent covariate. Heart attack was significantly associated with the onset of major depression (hazard ratio [HR], 7.51 [95% Confidential Interval (CI), 1.36-41.45]) after adjusting for sex, birth cohort, smoking, alcohol intake, and education. Heart disease (HR, 2.12 [95% CI, 0.79-5.70]), diabetes (HR, 2.36 [95% CI, 0.42-13.34]) and hypertension (HR, 0.97 [95% CI, 0.37, 2.50]) were not significantly associated. There were no subjects who developed major depression after stroke. These results suggest that heart attack, and maybe also heart disease and diabetes, affect the onset of major depression.

The performance of the Japanese version of the K6 and K10 in the World Mental Health Survey Japan

Two new screening scales for psychological distress, the K6 and K10, have been developed using the item response theory and shown to outperform existing screeners in English. We developed their Japanese versions using the standard back-translaton method and included them in the World Mental Health Survey Japan (WMH-J), which is a psychiatric epidemiologic study conducted in seven communities across Japan with 2436 participants. The WMH-J used the WMH Survey Initiative version of the Composite International Diagnostic Interview (CIDI) to assess the 30-day Diagnostic and Statistical Manual of Mental Disorders--Fourth Edition (DSM-IV). Performance of the two screening scales in detecting DSM-IV mood and anxiety disorders, as assessed by the areas under receiver operating characteristic curves (AUCs), was excellent, with values as high as 0.94 (95% confidence interval = 0.88 to 0.99) for K6 and 0.94 (0.88 to 0.995) for K10. Stratum-specific likelihood ratios (SSLRs), which express screening test characteristics and can be used to produce individual-level predicted probabilities of being a case from screening scale scores and pretest probabilities in other samples, were strikingly similar between the Japanese and the original versions. The Japanese versions of the K6 and K10 thus demonstrated screening performances essentially equivalent to those of the original English versions.

Twelve-month use of mental health services in four areas in Japan: findings from the World Mental Health Japan Survey 2002-2003

The aim of the present study was to provide basic descriptive data regarding utilization of 12-month mental health services in the Japanese community population. Face-to-face household surveys were carried out in four areas (two urban cities and two rural municipalities), and a total of 1663 persons participated (overall response rate: 56.4%). For data collection, the structured psychiatric interview, World Mental Health version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI) was used, allowing DSM-IV diagnoses, severity, and service utilization. It was found that 7.3% of total respondents had received any service, either professional or non-professional, in the past 12 months, including 20.0% of those with 12-month DSM-IV disorders and 6.2% of those without. Thirty-three percent of those with any mood disorder used any service, and 26.8% of those used some type of health care. The probability of people with 13-15 years of education receiving mental health treatment was fourfold higher than those with >or=16 years of education. Gender, age, or income were not found to contribute to utilization of mental health services. The results confirm that the majority of people with a recent psychiatric disorder have not used mental health care or other support systems. The mental health care system in Japan has improved over the past decade, but not enough for people suffering from mental disturbances.

Cleavage of platelet endothelial cell adhesion molecule-1 (PECAM-1) in platelets exposed to high shear stress

Platelet endothelial cell adhesion molecule-1 (PECAM-1, CD31) is a 130 kDa transmembrane glycoprotein that belongs to the immunoglobulin superfamily and is expressed on the surface of endothelial cells, platelets, and other blood cells. Although the importance of this adhesion molecule in various cell-cell interactions is established, its functional role in platelets remains to be elucidated. In this study, we examined whether PECAM-1 underwent changes in platelets exposed to high shear stress. Platelet PECAM-1 was cleaved under high shear stress and was released into the extracellular fluid as a fragment with an approximate molecular weight of 118 kDa. The cleavage was inhibited by an anti-VWF MoAb, but not by recombinant VWF A1 domains. These findings suggest that the GPIb-VWF interaction is involved in PECAM-1 cleavage under high shear stress, and that the cleavage is independent of GPIb clustering by VWF multimers. Furthermore, EGTA or calpeptin inhibited PECAM-1 cleavage. This finding provides evidence for the involvement of calpain in PECAM-1 cleavage. Flow-cytometric analysis revealed that PECAM-1 expression on the platelet surface was decreased under high shear stress. This reduction occurred exclusively in a specific population of platelets, which corresponded to platelet-derived microparticles (PMP). In conclusion, PECAM-1 cleavage under high shear stress is closely related to the activation of calpain and the process of PMP formation mediated by the GPIb-VWF interaction.

[A case of Sanfilippo syndrome type C: long-term clinical course and treatment]

We reported a Japanese girl with the Sanfilippo syndrome type C. She was born to healthy parents married consanguineously. She began to deteriorate and became disoriented at the age of 6 year and 8 month. She also developed sleep problems and dysphagia. Physical examination revealed short stature, slightly coarse facial features, contracture of the PIP joints and hypertrophy of the tonsils. There was neither hepatomegaly nor corneal clouding. Laboratory examination demonstrated an increase in urinary excretion of glycosaminoglycan. Electrophoresis of the urinary glycosaminoglycans indicated that heparan sulfate was the predominant component. Enzymatic assay using her skin fibroblasts demonstrated a complete deficiency of acetyl-CoA: a-glucosaminide N-acetyltransferase activity. Low dose erythromycin alleviated hypertrophy of her tonsils, thereby improving dysphagia.

[Study of appropriate expiratory velocity when measuring exhaled nitric oxide (NO) concentration]

We studied the appropriate expiratory velocity when measuring exhaled NO concentration by constant expiratory flow maneuver in relation to height and the required time for measurement, and obtained the following results. 1) There was a significant positive correlation between height and the required time. 2) There was a significant negative correlation between expiratory velocity and the required time. 3) Percent ratios of children who reached the plateau of exhaled NO concentration were significantly higher when expiratory velocity was over 2000 ml/minute. These findings suggest that expiratory velocity of over 2000 ml/minute may be appropriate when measuring exhaled NO concentration.

Role of N-acetylglutamate turnover in urea synthesis by rats treated with the thyroid hormone

We determined whether the synthesis and degradation of N-acetylglutamate would regulate urea synthesis when the thyroid status was manipulated. Experiments were done on three groups of rats, each being given 6-propyl-2-thiouracil (PTU, a thyroid inhibitor) without a triiodothyronine (T3) treatment, treated with PTU + T3, or receiving neither PTU nor T3 (control). The plasma concentration and urinary excretion of urea, the liver concentration of N-acetylglutamate, and the liver N-acetylglutamate synthesis in rats given PTU alone were each significantly higher than in the control rats. Compared with the control rats, the liver N-acetylglutamate degradation was significantly lower in those rats given PTU without the T3 treatment. Treatment of the PTU-treated rats with T3 reversed the effects of PTU to the values of the control rats. N-Acetylglutamate synthesis in the liver was closely correlated with the excretion of urea, and inverse correlation between the liver N-acetylglutamate degradation and urea excretion was found. These results suggest that the greater synthesis and lower degradation of N-acetylglutamate in the hypothyroid (PTU alone) rats would be likely to increase the hepatic concentration of this compound and stimulate urea synthesis.

Familial neuronal migration disorder: subcortical laminar heterotopia in a mother and pachygyria in the son

We describe clinical manifestations and magnetic resonance imaging (MRI) findings in a man and his mother who were diagnosed as having a neuronal migration disorder. The son had severe psychomotor retardation and the mother had intractable seizures and mild psychomotor retardation. MRI demonstrated moderate pachygyria in the son and subcortical heterotopia in the mother. In both patients, the frontal parts of the brain were characteristically more affected than any other areas. A dominant pattern of inheritance in the family suggests a genetic role in the underlying cause of the migration disorder. The difference in severity between the two patients also suggests an X-linked dominant inheritance. Our family fits the condition of X-linked lissencephaly.

Distribution of referred pain from the lumbar zygapophyseal joints and dorsal rami

OBJECTIVE

The purpose of this study was to determine the distribution of referred pain from the lumbar zygapophyseal joints (L1/2 to L5/S1) and the medial branches of the lumbar dorsal rami (Th12 to L5) in a large number of patients with chronic low back pain.

SETTING

This study was conducted at the pain clinics of Kanto Teishin Hospital and Hannan Central Hospital from March 1994 to May 1996.

PATIENTS AND DESIGN

Chronic low back pain patients who underwent zygapophyseal joint injection or radiofrequency facet denervation were studied. Under fluoroscopic control, the joints from L1/2 to L5/S1 were stimulated by injection of contrast medium, and the lumbar medial branches of the dorsal rami from Th12 to L5 underwent electrical stimulation during radiofrequency facet denervation.

OUTCOME MEASURES

If the injection or electrical stimulation reproduced the patient's usual pain, the distribution of induced pain was determined, and the sites of induced pain were divided into six areas.

RESULTS AND CONCLUSIONS

A total of 71 joints and 91 medial branches were studied in 48 patients. The distribution of referred pain from the L1/2 to L5/S1 zygapophyseal joints, and the medial branches of the dorsal rami from L1 to L5 were similar for each level stimulated, and the overlap of referred pain between each level was considerable.

Effect of a thyroid hormone treatment on brain protein synthesis in rats

The effect of the thyroid hormone on the rate of brain protein synthesis in rats was studied. Experiments were conducted on three groups of rats given 6-propyl-2-thiouracil (PTU, a thyroid inhibitor) without a triiodothyronine (T3) treatment, those treated with PTU + T3, and those treated with neither PTU nor T3 (control). The fractional rates of protein synthesis in the brain, liver, and kidney of rats given PTU + T3 were significantly greater than those in rats given PTU alone. In the brain and kidney, the RNA activity [g of protein synthesized/(g of RNA.d)] were significantly correlated with the fractional rates of protein synthesis. In the liver and kidney, the RNA concentration (mg of RNA/g of protein) was related to the fractional rate of protein synthesis. These results suggest that the thyroid hormone treatment would be likely to increase the rate of protein synthesis in the brain of rats, and that the RNA activity is, at least partly, related to the fractional rate of brain protein synthesis.

Role of ornithine transport into mitochondria in urea synthesis of rats treated in thyroid hormone

The purpose of this study was to find whether or not the ornithine transport into mitochondria regulated urea synthesis when the thyroid status is manipulated. Experiments were done on three groups of rats: given 6-propyl-2-thiouracil (PTU, a thyroid inhibitor) without triiodothyronine (T3) treatment, treated with PTU+T3 or receiving neither PTU nor T3 (control). The urinary excretion of urea, liver concentration of ornithine and ornithine transport into isolated hepatic mitochondria in rats given PTU+T3 were significantly lower than in rats given PTU alone. Ornithine transport was significantly inhibited by the addition of lysine specifically. This response was achieved well within the physiological concentration of lysine. Compared with rats given PTU without T3 treatment, the liver concentration of lysine was significantly higher in rats treated with PTU+T3 and control rats. Ornithine transport into hepatic mitochondria was closely correlated with the excretion of urea. The results suggest that the greater ornithine transport in the hypothyroid (PTU alone) rats is likely to stimulate urea synthesis. A thyroid hormone-induced increase in lysine concentration may be at least partly responsible for the changes in ornithine transport into mitochondria.

Epileptic seizures and event-related potentials (P300) in childhood partial epilepsies

To clarify the relationship between cognitive function and clinical seizures, auditory event-related potentials (P300) were examined in 72 patients (185 trials) with partial epilepsy. Twenty-six patients (67 trials) had idiopathic partial epilepsies (IPE), and 46 (118 trials) symptomatic or cryptogenic partial epilepsies (SPE). In this study, to rule out the effects of epileptogenesis and other factors, we only examined patients with partial epilepsies undergoing carbamazepine (CBZ) monotherapy at doses of less than 16 mg/kg/day. The results were: 1) the mean age-corrected P300 latency in the patients with SPE (394 +/- 38 msec) was significantly prolonged compared with that in the patients with IPE (378 +/- 28). 2) The prolongation of the P300 latency had no relationship to the seizure frequency, seizure type or seizure duration. 3) In both epileptic groups, there was no significant correlation between the seizure-free period and the age-corrected P300 latency. Our results suggest that the effect of clinical seizures on the cognitive function may be relatively little, and that the cognitive dysfunction in partial epilepsies may mainly originate from epileptogenesis or other factors.

[Trigeminal neuralgia caused by tortuous vertebrobasilar system--the clinical and imaging features]

Ten (6.8%) out of 146 patients with trigeminal neuralgia (TN) who underwent SPGR-MRI and 3D-TOF-MRA from August 1993 to October 1996, were found to have vascular compression caused by a tortuous vertebrobasilar system (TVBS). They were mostly males, demonstrated left-sided predominance, and had ipsilateral hemifacial spasm, compared with other 52 patients whose offending arteries were either superior cerebellar artery (SCA), anterior inferior cerebellar artery (AICA)or posterior inferior cerebellar artery (PICA). The patients who showed vascular compression by TVBS, presented an artery which compresses and dislocates the rootentry zone (REZ) of the trigeminal nerve, presses the brain stem at REZ and simultaneously compresses the REZ of the facial nerve. In addition, the diameters of the two branches of vertebrobasilar artery were not equal. These features indicate that the atherosclerotic change of the offending artery in TN caused by TVBS is more severe than that caused by SCA, AICA or PICA. This change causes an irregular running of artery which leads a strong compression of the trigeminal nerve REZ and of the brain stem. Consequently, the facial nerve REZ is severely affected leading to the presence of tic convulsif in TN caused by TVBS.

Event-related potentials (P300) and EEG activity in childhood partial epilepsy

To clarify the relationship between the cognitive function and EEG activity, auditory event-related potentials (P300) were examined in 72 patients with partial epilepsy. Twenty-six patients (67 trials) had idiopathic partial epilepsies (IPE), and 46 (118 trials) symptomatic or cryptogenic partial epilepsies (SPE). For this study, patients undergoing carbamazepine monotherapy with a dose of less than 16 mg/kg/day were selected to rule out the effects of anti-epileptic drugs. The results were as follows: (1) The P300 latency tended to be prolonged in association with the EEG slowing in both epileptic groups. (2) There was no clear relationship between the frequency of paroxysmal discharges and the P300 latency. (3) The P300 latency was slightly prolonged in the patients with temporal foci compared with that in ones with extra-temporal foci. (4) There was no significant relationship between the generalization of focal paroxysmal discharges and the P300 latency. These results suggested that the influence of EEG abnormalities (particularly paroxysmal discharges) on the P300 latency is relatively little, and the cognitive dysfunction in partial epilepsies mainly originates from other factors such as the epileptogenic lesion itself.

[Identification of offending vessels in trigeminal neuralgia and hemifacial spasm using SPGR-MRI and 3D-TOF-MRA]

We investigated 100 consecutive patients with trigeminal neuralgia (TN) and 53 patients with hemifacial spasm (HFS) concerning the anatomical relationship between the root entry (exit) zone (REZ) of cranial nerve and the offending artery, using spoiled GRASS MRI (SPGR-MRI) and three dimensional-time of fly-MRA (MRA). In 67 of 100 (67%) patiets with TN, this new radiological method, SPGR-MRI and MRA demonstrated the relationship between the fifth cranial nerve root and offending artery causing neurovascular compression (NVC), and in 46 of 53 (87%) with HFS, demonstrated the similar relationship between seventh and eighth nerve complex and offending artery. Microvascular decompression (MVD) was performed in 10 with HFS, and NVC of the REZ of the facial nerve caused by the offending artery was exactly predicted by SPGR-MRI and MRA in 9 (90%). The combination of SPGR-MRI and MRA is very useful for demonstrating NVC as the cause of TN and HFS. On the other hand, we investigated asymptomatic 206 trigeminal and 253 facial nerves about the relationship between their REZ and the surrounding structures using the similar method. The contact of REZ of cranial nerve with surrounding artery is demonstrated in 31.6% of trigeminal nerves and in 22.5% of facial nerves. These results indicate that the contact of REZ of cranial nerve with surrounding artery is not rare in healthy subjects, though causing TN and HFS in particular patients. In this context, we discussed the difference between the contact which is asymptomatic and the compression which is symptomatic.

Withdrawal of antiepileptic drug treatment in childhood epilepsy: factors related to age

The clinical and electroencephalographic changes with age were evaluated in 304 patients with childhood epilepsies, whose antiepileptic treatment had been discontinued after a seizure free period of more than three years. The withdrawal rate differed significantly between epileptic syndromes, being higher in idiopathic epilepsy and lower in symptomatic epilepsy. The age at withdrawal was characteristic for each epileptic syndrome, and generally showed two peaks: at preadolescence and early school age. Forty one (13.5%) of the 304 patients experienced relapses. The relapse rate differed between epileptic syndromes. Relapses occurred at a unique age in each epileptic syndrome, and were frequent in preadolescence and early adulthood. Electroencephalography that still showed paroxysmal discharges at withdrawal did not necessarily predict the occurrence of a relapse, but the changes in background activity with age, which may indicate maturation of the CNS, were significantly different between the patients with and those without relapses. The results suggest that age related to each epileptic syndrome should be considered when deciding on withdrawal of antiepileptic drugs.

Effects of antiepileptic drugs on EEG background activity in children with epilepsy: initial phase of therapy

The effects of antiepileptic drugs (AED) on EEG background activity were evaluated in 37 newly treated children with epilepsy, compared with 46 age-matched healthy controls. Before AED therapy, the children with epilepsy, both partial (treated with carbamazepine, CBZ group) and generalized seizures (treated with valproic acid, VPA group), already exhibited significant slowing of EEG with increased delta and decreased alpha power. Following 3 to 6 months of AED therapy, this EEG slowing was enhanced in the CBZ group and reduced in the VPA group. Following 1 year of AED therapy, an increase in frequency was recognized in the CBZ group. These results suggest that 1) most children with epilepsy already exhibit slowing of the EEG at the onset of seizures, which may reflect CNS developmental deficit, 2) the short-term effects on EEG are different between CBZ and VPA, and 3) EEG development with age continues under continuous AED administration. The EEG background activity in children with epilepsy is affected by many factors, which include the underlying CNS dysfunction of the epilepsy itself and also AED therapy (type of AEDs, duration of therapy, etc).

Changes of P300 latency with age in childhood epilepsy

Auditory event-related potentials (P300 latency; odd-ball paradigm) were examined in 129 patients with childhood epilepsies and 53 controls. The P300 latency in the patients with epilepsies (373 +/- 39.4 ms) was significantly longer than in controls (356 +/- 38.4), and the prolongation was greatest in the patients with symptomatic partial epilepsies (390 +/- 40.5), mild in those with idiopathic generalized epilepsies (370 +/- 24.3), and minimum in those with idiopathic partial epilepsies (363 +/- 28.9). Abnormal P300 latency occurred at all ages during childhood in patients with symptomatic partial epilepsies, and at older ages in patients with idiopathic generalized epilepsies. The shortening of latency with age was relatively small in patients with epilepsies compared with controls. These results suggest that the prolongation of P300 latency (i.e., existence of cognitive disturbance) displays characteristic changes with age in each epileptic syndrome.

Flunitrazepam for sleep disturbance in children with intractable epilepsy

Add-on therapy with flunitrazepam (FNZ) was performed in 5 children with marked sleep disturbance and intractable seizures. Correction of the sleep disturbance was attained immediately after the start of FNZ administration in all patients. Furthermore, a significant decrease in the seizure frequency (3 patients) and improved quality of life (4 patients) were concomitantly observed. There was no adverse effect or interaction with conventional AEDs on long-term use.

Distribution and origins of cerebrovascular NADPH-diaphorase-containing nerve fibers in the rat

Neuronal NADPH-diaphorase has been proved to be nitric oxide synthase itself. In this study, we investigated distribution and origins of NADPH-diaphorase-containing nerve fibers in the cerebral vessels in the rat. Adult male Sprague-Dawley rats were divided into 4 groups. Nasociliary nerves were transected bilaterally in group 1. In group 2, intracranial branches of the sphenopalatine ganglion were transected bilaterally. In group 3, both of these structures were transected. The remaining animals were served as control (group 4). Two weeks after the above procedures, they were perfused with paraformaldehyde and glutaraldehyde. The pial arteries and superior cervical, trigeminal, internal carotid, otic and sphenopalatine ganglia were dissected. All specimens were processed for NADPH-diaphorase histochemistry. Numerous NADPH-diaphorase-containing nerve fibers with varicosities forming plexuses were observed in the circle of Willis and its branches. Relatively thick nerve bundles were noted in the anterior half of the circle of Willis. They are most abundant in the internal ethmoidal artery. Approximately 5% of such fibers in anterior half of the circle of Willis disappeared in group 1, 90% in group 2, and no fibers were seen to remain in group 3. NADPH-diaphorase reaction was positive in the neurons of sphenopalatine, otic trigeminal and internal carotid ganglia. Among these ganglia, the reaction was prominent in sphenopalatine, otic and internal carotid ganglia. In summary: (1) NADPH-diaphorase-containing nerve fibers distribute to the circle of Willis and its branches.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in EEG foci with age in childhood partial epilepsies

The age changes of epileptic foci on EEG were evaluated in 208 patients with childhood partial epilepsies, who were followed for more than 3 years. 1) The incidence of EEG foci in each region apparently differed with age. Frontal and central foci were frequent before school age and after adolescence. Temporal foci showed a peak around adolescence, and occipital foci a peak from 3 to 7 years, respectively. Parietal foci were rare at all ages. 2) The migration of EEG foci was recognized 171 times in 81 of the 208 patients (38.9%) during the clinical course. The migration was frequently seen at early school age and preadolescence, and the direction of migration was predominantly anterior to posterior at early school age, and posterior to anterior at preadolescence. These results suggest that EEG foci show characteristic changes with age during the clinical course, which may be related to maturation of the central nervous system.

Auditory event-related potentials in benign childhood epilepsy with centrotemporal spike: the effects of carbamazepine

To clarify the relationship between cognitive function and CBZ therapy, auditory event-related potentials (P300) were examined in 23 patients with Benign Childhood Epilepsy with Centrotemporal Spike (BCECT) compared with 54 normal controls. The results were 1) the mean P300 latency in BCECT (368 +/- 29 msec) was significantly prolonged compared with that in normal controls (349 +/- 30 msec), but most individual patients showed normal values. 2) The prolongation of P300 latency was greatest during the course of therapy. 3) On repeated examination of P300, P300 latency was found to gradually become shorter with age in spite of continuous CBZ therapy. At initiation of CBZ therapy, the P300 latency became shorter; on the other hand, P300 latency became shorter with the discontinuation of CBZ. 4) The age-corrected P300 latency showed a significant positive correlation with the serum concentration of CBZ. Our results suggest that CBZ therapy has both an undesirable effect (chronic impairment) and a desirable effect (improvement of underlying dysfunction caused by epileptogenesis) on cognitive function.

[The relationship between P300 latencies, and WISC-R and Wechsler memory scale results in epileptic children]

Auditory event-related potentials (ERPs) were recorded in 35 epileptic children of 9 to 13 years of age, and compared with conventional test batteries of cognitive functions. ERPs were elicited with the auditory oddball paradigm. Corrected P300 latencies showed an inverse correlation with the total score (IQ) of WISC-R and that of the Wechsler memory scale (WMS). A strong inverse correlation was also observed with specific items of these test batteries, as follows; "comprehension", "picture completion" and "coding" in WISC-R, and "associated learning", "digit span", "visual reproduction", "mental control", "orientation" and "information" in WMS. These findings suggested that the prolongation of P300 latencies in epileptic children are related with the impairment of cognitive functions. The P300 latency is correlated with a characteristic kind of cognitive function; "simple recognition", "short term memory" and "easy judgement".

[Treatment of cancer pain with the percutaneous electrocoagulation of spinal nerves]

To our knowledge, this is the first report of high-frequency thermocoagulation applied to the spinal root. We treated 34 patients suffering from cancer pain with this technique. Among these patients, cancer pain occurred due to intrapelvic metastasis in 11 patients, and 13 complained of chest pain due to cancer. Every patient was considered to have good or excellent response when his or her pain score was reduced to 6 points or less from the score before thermocoagulation; 10 points. Based on this criterion, 54.5% and 30.8% of the above-mentioned patients showed good and excellent responses respectively one month after treatment. This technique, therefore, was considered to be effective with less side effects compared with other nerve blocking techniques.

Carbamazepine-induced skin rash in children with epilepsy

The clinical and epidemiological findings in children with epilepsy who experienced skin rashes induced by carbamazepine (CBZ) were prospectively evaluated. Thirty-three (9.9%) of 335 patients who received CBZ therapy experienced a skin rash. Seven had diffuse erythema, 13 miliary exanthema, 11 maculopapular or speckled reddish rash, 3 petechiae, and 2 mucocutaneous syndrome. A skin rash was more frequent in older children (over 6 years old). The skin rashes appeared soon after initiation of the therapy, i.e., from the 8th to 60th day (mean: 14.3 +/- 9.6 days) after the start of CBZ therapy and disappeared within a few days after discontinuation of the therapy. Haematological abnormalities (30.3%), such as leucocytopenia and thrombocytopenia, and hepatic dysfunction (27.3%) sometimes appeared concomitantly with the skin rash. CBZ is an effective and safe antiepileptic drug, but careful management is necessary on initiation of the therapy.

[The EEG background activity in children with epilepsy--effects of the removal of anticonvulsants on the EEG]

The development of the EEG background activity is generally impaired in children with epilepsy. Antiepileptic drugs (AEDs) are one of the important factor which influence the EEG background activity. We studied the effect of AEDs on the EEG. Subjects were 46 normal children and 48 children with epilepsy aged 5 to 15, who had not any organic brain damage and showed normal psychomotor development. Forty children with epilepsy (CBZ; 30 cases, VPA; 10 cases) had been on monopharmacy and 8 cases on polypharmacy. All of them have outgrown their epilepsy. The serial EEGs were recorded during withdrawal and after discontinuation of AED in each patient. These records were evaluated using computerized power spectral analysis. CBZ reduction associated with a decrease in delta and theta powers and an increase in alpha-2 power, which were also observed at VPA reduction in concomitant AEDs (VPA+CBZ). No parameter changed by VPA reduction in monopharmacy. The slowing of the EEG background activity was noticed even after discontinuation of CBZ. It required more time after discontinuation of CBZ in younger children than older before the EEG background activity became normal controls. These findings suggested that CBZ had a adverse effect, which was more remarkable in younger children than older children, on the development of EEG background activity and that the effect of CBZ on EEG was different from that of VPA.

[Six cases of epidural abscess probably caused by epidural block and examination by gadolinium-MRI imaging]

We treated six cases of epidural abscess caused probably by epidural block. Three patients were given only chemotherapy and the other three underwent surgical treatment. Four patients were cured completely, but bilateral paresis in the lower limbs persisted in two patients. The symptoms at onset, laboratory findings, imaging findings including MRI and CT, treatment methods and prognosis were reported. Accelerated blood sedimentation rate, positive CRP results and abnormal findings at the site of the catheter insertion appeared to be important initial signs for the early discovery of epidural abscesses. The route of infection, selection of treatment methods, methods of prevention and examination by Gadolinium-MRI imaging were also discussed.