A Common Marmoset Model of Mother-Infant Intervention for Breastfeeding Disorders in the Presence of Paternal Inhibition and Maternal Neglect

Parents' psychological stress during the perinatal and neonatal periods continues to increase in an environment of declining birthrates, aging populations, and shrinking family sizes. The increase in child abuse and neglect cases, most likely by inexperienced and insufficiently knowledgeable parents, necessitates education on childcare and intervention techniques in nursing and midwifery training. In particular, attachment formation early in life between mother and infant is crucial. To accurately teach sensitive and comprehensive information on intervention techniques for mother-child attachment formation, realistic videos, and educational materials are necessary. Although pseudoeducational materials are available, they might be limited in explaining complex realism, particularly to support breastfeeding that involves both parents and child and that encourages interaction between the two. In a previous study in a common marmoset (Callithrix jacchus) model, we experimentally controlled infant feeding and nurturing through 24 h of constant sensing and collected 1 month of quantitative data on psychological indices that possibly translated to psychological development. Age-dependent dynamic visualization of these data by multivariate analyses inferred causal relationships between early parental feeding and psychobiological rhythm formation. In the same primate model, we identified a spontaneous case of breastfeeding failure in which the father inhibited his neonatal infant's feeding and the mother appeared to abandon nurturing, leading to clinically significant weight loss in the infant. Thus, we explored intervention techniques to promote mother-infant interaction. The mother was trained to allow the infant to spontaneously explore her breast. Initially, the mother refused to display the feeding pose potentially due to pain associated with breast engorgement. Massage was used to soften the breast and feeding was reintroduced. We hypothesize that activation of instinctive attachment formation mechanisms by encouraging spontaneity in each parent and child is the key to successful feeding intervention.

Efficacy of cEEG and hepatic function to diagnose early acute encephalopathy

BACKGROUND

Early treatment may improve prognosis of acute encephalopathy. However, methods for the early diagnosis have not yet been established. In this paper, we examined methods for the early diagnosis.

METHODS

We extracted patients with febrile status epilepticus from the electronic medical records in our department between March 2016 and April 2021. Among these, 79 patients who underwent continuous electroencephalography (cEEG) were included in this study. Patients who exhibited psychomotor retardation or abnormal brain magnetic resonance imaging (MRI) findings were assigned to the acute encephalopathy group (Group E: n = 20), and the remaining patients were the control group (Group C: n = 59). The following tests on admission were compared retrospectively between these two groups: cEEG, serum hepatic function tests, and blood coagulation tests.

RESULTS

The percentage of patients who exhibited high-amplitude slow waves or flat waves on cEEG at the time of admission was statistically significantly higher in Group E than in Group C (p < 0.01). Moreover, the percentage of patients whose high-amplitude slow waves or flat brain waves on admission disappeared within six hours after an initial episode of convulsion was statistically significantly lower in Group E than in Group C (p < 0.01). Furthermore, all the items in the coagulation and in the hepatic function test were statistically significantly different in Group E than those in Group C (p < 0.05).

CONCLUSION

These results showed that cEEG adding to hepatic function and coagulation tests may be useful for the differential diagnosis of acute encephalopathy.

Arterial and Venous Thrombosis Complicated in COVID-19: A Retrospective Single Center Analysis in Japan

Background: Thrombosis is a characteristic complication in coronavirus disease 2019 (COVID-19). Since coagulopathy has been observed over the entire clinical course, thrombosis might be a clue to understanding the specific pathology in COVID-19. Currently, there is limited epidemiological data of COVID-19-associated thrombosis in the Japanese population and none regarding variant strains of SARS-CoV-2. Here, we elucidate the risk factors and the pattern of thrombosis in COVID-19 patients. Methods: The patients consecutively admitted to Tokyo Medical and Dental University Hospital with COVID-19 were retrospectively analyzed. SARS-CoV-2 variants of concern/interest (VOC/VOI) carrying the spike protein mutants E484K, N501Y, or L452R were identified by PCR-based analysis. All thrombotic events were diagnosed by clinical symptoms, ultrasonography, and/or radiological tests. Results: Among the 516 patients, 32 patients experienced 42 thromboembolic events. Advanced age, severe respiratory conditions, and several abnormal laboratory markers were associated with the development of thrombosis. While thrombotic events occurred in 13% of the patients with a severe respiratory condition, those events still occurred in 2.5% of the patients who did not require oxygen therapy. Elevated D-dimer and ferritin levels on admission were independent risk factors of thrombosis (adjusted odds ratio 9.39 and 3.11, 95% confidence interval 2.08-42.3, and 1.06-9.17, respectively). Of the thrombotic events, 22 were venous, whereas 20 were arterial. While patients with thrombosis received anticoagulation and antiinflammatory therapies with a higher proportion, the mortality rate, organ dysfunctions, and bleeding complications in these patients were higher than those without thrombosis. The incidence of thrombosis in COVID-19 became less frequent over time, such as during the replacement of the earlier strains of SARS-CoV-2 by VOC/VOI and during increased use of anticoagulatory therapeutics. Conclusion: This study elucidated that elevated D-dimer and ferritin levels are useful biomarkers of thrombosis in COVID-19 patients. The comparable incidence of arterial thrombosis with venous thrombosis and the development of thrombosis in less severe patients required further considerations for the management of Japanese patients with COVID-19. Further studies would be required to identify high-risk populations and establish appropriate interventions for thrombotic complications in COVID-19.

Development and validation of the Epilepsy Self-Stigma Scale

Objective

Self‐stigma is the internalization of negative public attitudes and is often experienced by patients with epilepsy (PWE). Greater self‐stigma is associated with lower self‐esteem and hinders therapeutic behavior. The study aims were to develop the Epilepsy Self‐Stigma Scale (ESSS) to assess self‐stigma in PWE and to examine the scale's reliability and validity.

Methods

We created a test scale based on items from an existing stigma scale and the results of a previous qualitative analysis we conducted. We recruited 200 outpatients from departments specializing in epilepsy (psychiatry, neurology, and pediatric neurology) at four facilities in Tokyo and Saitama prefecture, Japan, between September and December 2020. Participants also completed the Rosenberg Self‐Esteem Scale (RSES) and Beck Depression Inventory (BDI‐II).

Results

Questionnaires were returned from 102 participants (response rate: 51%). After excluding two participants with incomplete questionnaires, data for 100 participants were analyzed (53 women, 47 men; mean age [standard deviation]: 39.86 [17.45] years). Exploratory factor analysis extracted eight items loading on three factors: internalization of stigma, societal incomprehension, and confidentiality. Cronbach's α for all items and each factor demonstrated acceptable internal consistency (α = 0.76‐0.87). Test‐retest reliability was confirmed using data from 21 participants who completed the scale twice (r = 0.72 to 0.90). ESSS total scores and subscale scores correlated with RSES and BDI‐II scores (r = −0.30 to 0.55). The ESSS demonstrated substantial constructive validity. However, total scores did not significantly correlate with objective physician assessment of self‐stigma.

Significance

The results showed that the eight‐item ESSS has high reliability and validity. This scale could facilitate the examination of factors associated with self‐stigma in PWE, which could inform the development of effective interventions for reducing stigma.

Guidelines for the diagnosis and treatment of acute encephalopathy in childhood

The cardinal symptom of acute encephalopathy is impairment of consciousness of acute onset during the course of an infectious disease, with duration and severity meeting defined criteria. Acute encephalopathy consists of multiple syndromes such as acute necrotizing encephalopathy, acute encephalopathy with biphasic seizures and late reduced diffusion and clinically mild encephalitis/encephalopathy with reversible splenial lesion. Among these syndromes, there are both similarities and differences. In 2016, the Japanese Society of Child Neurology published 'Guidelines for the Diagnosis and Treatment of Acute Encephalopathy in Childhood', which made recommendations and comments on the general aspects of acute encephalopathy in the first half, and on individual syndromes in the latter half. Since the guidelines were written in Japanese, this review article describes extracts from the recommendations and comments in English, in order to introduce the essence of the guidelines to international clinicians and researchers.

Inexpensive Home Infrared Living/Environment Sensor with Regional Thermal Information for Infant Physical and Psychological Development

The use of home-based image sensors for biological and environmental monitoring provides novel insight into health and development but it is difficult to evaluate people during their normal activities in their home. Therefore, we developed a low-cost infrared (IR) technology-based motion, location, temperature and thermal environment detection system that can be used non-invasively for long-term studies in the home environment. We tested this technology along with the associated analysis algorithm to visualize the effects of parental care and thermal environment on developmental state change in a non-human primate model, the common marmoset (Callithrix jacchus). To validate this system, we first compared it to a manual analysis technique and we then assessed the development of circadian rhythms in common marmosets from postnatal day 15–45. The semi-automatically tracked biological indices of locomotion velocity (BV) and body surface temperature (BT) and the potential psychological index of place preference toward the door (BD), showed age-dependent shifts in circadian phase patterns. Although environmental variables appeared to affect circadian rhythm development, principal component analysis and signal superimposing imaging methods revealed a novel phasic pattern of BD-BT correlation day/night switching in animals older than postnatal day 38 (approximately equivalent to one year of age in humans). The origin of this switch was related to earlier development of body temperature (BT) rhythms and alteration of psychological behavior rhythms (BD) around earlier feeding times. We propose that this cost-effective, inclusive sensing and analytic technique has value for understanding developmental care conditions for which continual home non-invasive monitoring would be beneficial and further suggest the potential to adapt this technique for use in humans.

Epidemiological changes of acute encephalopathy in Japan based on national surveillance for 2014-2017

BACKGROUND

We previously reported the nationwide, epidemiological data of acute encephalopathy in Japan during 2007-2010. Here we conducted the second national survey of acute encephalopathy during 2014-2017, and compared the results between the two studies to elucidate the trends in the seven years' interval as well as the influence of changes in pediatric viral infections and guidelines for acute encephalopathy in Japan.

METHODS

The Research Committee on Acute Encephalopathy supported by the Japanese Government sent a questionnaire to 507 hospitals throughout Japan, and collected the responses by mail.

RESULTS

A total of 1115 cases from 267 hospitals reportedly had acute encephalopathy during April 2014-June 2017. In this study, the age at onset was younger, the ratios of recently established syndromes, such as acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) and clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS), were higher, and the ratio of influenza-associated encephalopathy was lower, than in the previous study. The age at onset of influenza-associated encephalopathy was lower, and that of HHV-6/7-associated encephalopathy higher, compared to the first survey. The outcomes of entire acute encephalopathy remained unchanged.

CONCLUSION

Some of these changes reflected the recent trends of viral infectious diseases including 2009 influenza pandemic, and others the standardization of the diagnosis of acute encephalopathy in Japan.

Nationwide epidemiological survey of holoprosencephaly in Japan

BACKGROUND

Holoprosencephaly (HPE) is a congenital malformation with an estimated prevalence of 0.10-6.06 per 10 000 births but with no nationwide data specific to Japan.

METHODS

This nationwide retrospective questionnaire survey was conducted from 2011 to 2013. All 467 training hospitals for perinatal and neonatal care certified by the Japan Society of Perinatal and Neonatal Medicine were contacted. The birth prevalence rate (BPR) was assessed from the primary survey and clinical characteristics from the secondary survey.

RESULTS

We received valid responses from 253 hospitals in the primary survey (54.6%). Of 390 342 live births, 60 were diagnosed with HPE (23 males and 37 females), resulting in an actual BPR of 1.54 per 10 000 live births. The point estimate for HPE cases was 100 (95% confidence interval [CI]: 80.7-120), and the estimated BPR of HPE was calculated to be 0.32 per 10 000 live births (95% CI: 0.26-0.38) based on 3 117 853 live births according to Japanese national statistics during the study period. In the secondary survey, we obtained data for 49 cases (19 males and 30 females). Of these, 20 were alobar (40.8%), 20 were semilobar (40.8%), five were lobar (10.4%), and four were of unknown type. Genetic examination was performed in 37 of the 49 HPE patients and revealed that chromosomes 13, 18, and 7 were affected in eight, six, and four patients, respectively.

CONCLUSIONS

This is the most extensive survey on holoprosencephaly to date in Japan. The estimated BPR was consistent with that reported in previous research.

Pattern Visually Evoked Potentials in Japanese Girl With Optic Neuritis and Seropositive to Anti-myelin Oligodendrocyte Glycoprotein (MOG) Antibody

Purpose: To describe a Japanese girl with unilateral optic neuritis who was seropositive for the anti-myelin-oligodendrocyte glycoprotein (MOG). Serial recordings of the pattern visual evoked potentials (pVEPs) were made to follow the dynamic changes of the disease activity.

Observations: A 5-year-old girl developed a sudden reduction of vision and deep ocular pain in her right eye. On examination at our university hospital, the best-corrected visual acuity (BCVA) was light perception, and a swelling of the optic disc and tortuous vessels at the posterior pole of the right eye were observed. MRI demonstrated that her right optic nerve was hyperintense on short TI inversion recovery (STIR) sequence. A diagnosis of right papillitis was made, and she was treated with steroid pulse therapy followed by a gradual tapering of oral prednisolone. The visual acuity decreased to no light perception and plasmapheresis combined with high-dose intravenous immunoglobulin therapy was performed. The decimal visual acuity rapidly improved and recovered to 1.2, and no recurrence was observed for at least 1 year. On day 19, she was found to be anti-MOG antibody positive and anti-Aquaporin 4 antibody negative. pVEPs were recorded during the course of the disease process which showed the dynamic changes of the physiology of the visual pathways. The implicit times of the N75 and P100 components were prolonged in the right eye in the acute phase. The right visual acuity remained at 1.2 for at least 1 year, but the implicit times of the N75 and P100 components of the pVEPs of the right eye were still prolonged compared to left eye.

Conclusion: Our findings indicate a positive relationship between the anti-MOG antibodies-positivity and the prolonged pVEPs. Further analyses of the pVEPs and other clinical findings of the optic neuritis are needed to establish the clinical significance of the anti-MOG antibodies positivity and optic neuritis for the diagnosis, treatment, and prognosis for this disease.

Comparison of the ventilation characteristics in two adult oscillators: a lung model study

BACKGROUND

Two recent large randomized controlled trials did not show the superiority of high-frequency oscillatory ventilation (HFOV) in adults with ARDS. These two trials had differing results, and possible causes could be the different oscillators used and their different settings, including inspiratory time % (IT%). The aims of this study were to obtain basic data about the ventilation characteristics in two adult oscillators and to elucidate the effect of the oscillator and IT% on ventilation efficiency.

METHODS

The Metran R100 or SensorMedics 3100B was connected to an original lung model internally equipped with a simulated bronchial tree. The actual stroke volume (aSV) was measured with a flow sensor placed at the Y-piece. Carbon dioxide (CO₂) was continuously insufflated into the lung model ([Formula: see text]CO₂), and the partial pressure of CO₂ (PCO₂) in the lung model was monitored. Alveolar ventilation ([Formula: see text]A; L/min) was estimated as [Formula: see text]CO₂ divided by the stabilized value of PCO₂. [Formula: see text]A was evaluated with several stroke volume settings in the R100 (IT = 50%) or several airway pressure amplitude settings in the 3100B (IT = 33%, 50%) at a frequency of 6 and 8 Hz, a mean airway pressure of 25 cmH₂O, and a bias flow of 30 L/min. Assuming that [Formula: see text]A = frequency^a × aSV^b, values of a and b were determined. Ventilation efficiency was calculated as [Formula: see text]A divided by actual minute ventilation.

RESULTS

The relationship between aSV and [Formula: see text]A or ventilation efficiency were different depending on the oscillator and IT%. The values of a and b were 0 < a < 1 and 1 < b < 2 and were different for three conditions at both frequencies. [Formula: see text]A and ventilation efficiency were highest with R100 (IT = 50%) and lowest with 3100B (IT = 33%) for high aSV ranges at both frequencies.

CONCLUSIONS

In this lung model study, ventilation characteristics were different depending on the oscillator and IT%. Ventilation efficiency was highest with R100 (IT = 50%) and lowest with 3100B (IT = 33%) for high aSV ranges.

Bias flow rate and ventilation efficiency during adult high-frequency oscillatory ventilation: a lung model study

Background

Bias flow (BF) is essential to maintain mean airway pressure (MAP) and to washout carbon dioxide (CO₂) from the oscillator circuit during high-frequency oscillatory ventilation (HFOV). If the BF rate is inadequate, substantial CO₂ rebreathing could occur and ventilation efficiency could worsen. With lower ventilation efficiency, the required stroke volume (SV) would increase in order to obtain the same alveolar ventilation with constant frequency. The aim of this study was to assess the effect of BF rate on ventilation efficiency during adult HFOV.

Methods

The R100 oscillator (Metran, Japan) was connected to an original lung model internally equipped with a simulated bronchial tree. The actual SV was measured with a flow sensor placed at the Y-piece. Carbon dioxide (CO₂) was continuously insufflated into the lung model (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{\mathrm{V}} $$\end{document}V˙CO₂), and the partial pressure of CO₂ (PCO₂) in the lung model was monitored. Alveolar ventilation (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{\mathrm{V}} $$\end{document}V˙A) was estimated as \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{\mathrm{V}} $$\end{document}V˙CO₂ divided by the stabilized value of PCO₂. \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{\mathrm{V}} $$\end{document}V˙A was evaluated by setting SV from 80 to 180 mL (10 mL increments, n = 5) at a frequency of 8 Hz, a MAP of 25 cmH₂O, and a BF of 10, 20, 30, and 40 L/min (study 1). Ventilation efficiency was calculated as \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{\mathrm{V}} $$\end{document}V˙A divided by the actual minute volume. The experiment was also performed with an actual SV of 80, 100, and 120 mL and a BF from 10 to 60 L/min (10 L/min increments: study 2).

Results

Study 1: With the same setting SV, the \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{\mathrm{V}} $$\end{document}V˙A with a BF of 20 L/min or more was significantly higher than that with a BF of 10 L/min. Study 2: With the same actual SV, the \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{\mathrm{V}} $$\end{document}V˙A and the ventilation efficiency with a BF of 30 L/min or more were significantly higher than those with a BF of 10 or 20 L/min.

Conclusions

Increasing BF up to 30 L/min or more improved ventilation efficiency in the R100 oscillator.

Electronic supplementary material

The online version of this article (10.1186/s40635-018-0176-3) contains supplementary material, which is available to authorized users.

Psycho-Cognitive Intervention for ASD from Cross-Species Behavioral Analyses of Infants, Chicks and Common Marmosets

Educational treatment to support social development of children with autism spectrum disorder (ASD) is an important topic in developmental psychiatry. However, it remains difficult to objectively quantify the socio-emotional development of ASD children. To address this problem, we developed a novel analytical method that assesses subjects' complex behaviors using multivariate analysis, 'Behavior Output analysis for Quantitative Emotional State Translation' (BOUQUET). Here, we examine the potential for psycho-cognitive ASD therapy based on comparative evaluations of clinical (human) and experimental (animal) models. Our observations of ASD children (vs. their normally developing siblings) and the domestic chick in socio-sensory deprivation models show the importance of unimodal sensory stimulation, particularly important for tactile- and auditory-biased socialization. Identifying psycho-cognitive elements in early neural development, human newborn infants in neonatal intensive care unit as well as a New World monkey, the common marmoset, also prompted us to focus on the development of voluntary movement against gravity. In summary, striking behavioral similarities between children with ASD and domestic chicks' socio-sensory deprivation models support the role of multimodal sensory-motor integration as a prerequisite step for normal development of socio-emotional and psycho-cognitive functions. Data obtained in the common marmoset model also suggest that switching from primitive anti-gravity reflexes to complex voluntary movement may be a critical milestone for psycho-cognitive development. Combining clinical findings with these animal models, and using multivariate integrative analyses may facilitate the development of effective interventions to improve social functions in infants and in children with neurodevelopmental disorders.

Manifestations and characteristics of congenital adrenal hyperplasia-associated encephalopathy

BACKGROUND

This study aimed to clarify the characteristics of acute encephalopathic episodes in patients with congenital adrenal hyperplasia (CAH), which we termed "CAH-associated encephalopathy (CAHE)."

METHODS

This retrospective study was conducted using a questionnaire as a nationwide survey of patients with CAH with acute encephalopathy and related episodes.

RESULTS

Fifteen patients were recruited on the bases of clinical data that supported a diagnosis of CAHE. Fourteen patients displayed seizures at onset, and 12 patients exhibited refractory seizures. Deep coma lasting >24h was noted in 12 patients. Neuroimaging studies revealed some heterogeneous features. Diffuse or focal edematous lesions in the cerebrum, which produce high signal intensity on diffusion-weighted magnetic resonance imaging or low density on computer tomography, were found in the acute period in all 15 patients. In the chronic period, 14 patients survived, 11 of whom had some degree of neurological sequelae. Moreover, various degrees of cerebral shrinkage were observed in 11 of 14 surviving patients. Surprisingly, there were no abnormal neuroimaging findings in the basal ganglia, brainstem, and cerebellum in any patient.

CONCLUSION

Our results indicated that patients with CAH have a risk of developing CAHE, and thus, they should be followed closely because not only status epilepticus or deep coma but also minor symptoms, such as fever and nausea, may lead to CAHE. Because CAHE may feature some heterogeneous encephalopathic episodes, further validation is needed to clarify its etiology.

[Successful treatment with chloramphenicol in four pediatric cases of intractable bacterial meningitis]

Chloramphenicol (CP) is recently one of the rarely-used antibiotics. In this study, we present four patients with intractable bacterial meningitis, who were successfully treated with CP and discuss the therapeutic indications of CP in these pediatric cases. The patients were diagnosed as bacterial meningitis at the ages ranging from 2 months to 1 year and 4 months. The causative organisms found in three of the patients were H. influenzae and in the fourth patient, S. pneumoniae. According to the microbial sensitivity tests, these organisms were highly sensitive to antibiotics including ceftriaxone, meropenem and/or panipenem/betamipron. Treatment with these antibiotics was initially effective; however, recurrences of meningitis appeared in all patients. Administration of CP (100 mg/kg/day) started between the 11th and the 58th days, and was continued for 9 days up to 19 days. Their fever had disappeared within four days after the administration of CP, and it was confirmed that all patients completely recovered from meningitis. Two of the patients developed a mild degree of anemia, but soon recovered after the discontinuation of CP. None of them had neurological sequela. We recommend CP as one of the choices for the treatment of intractable bacterial meningitis.

Characteristic MRI features of chronic inflammatory demyelinating polyradiculoneuropathy

We present characteristic magnetic resonance imaging (MRI) features in a pediatric female patient with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Muscle weakness developed at 8 years old and fluctuated during the clinical course over 7 years. Electrophysiological studies showed a demyelination pattern with moderately delayed nerve conduction velocity, as well as dispersion phenomenon. MRI showed marked changes in thickening of the spinal nerve roots and their peripheral nerves in the lumber and brachial plexuses, as well as in the bilateral trigeminal nerves. It is suggested that these MRI features are characteristic and strongly supportive of the diagnosis of CIDP with a prolonged clinical course.

Early-infant diagnostic predictors of the neuro-behavioral development after neonatal care

Multidimensional diagnosis plays a central role in infant developmental care, which leads to the prediction of future disabilities. Information consolidated from objective and subjective, early and late, central and peripheral data may reveal neuro-pathological mechanisms and realize earlier and more precise preventive intervention. In the current study, we retrospectively searched correlating factors to the following neurological and behavioral development of 'Head Control' and 'Roll Over' using multivariate correlation analysis of differ-ent diagnostic domains over age, subject/object information of the patients who were previously admitted in our neonatal intensive care unit (NICU) and could be developmentally followed up in our outpatient clinic. Based on the hematologic and biochemical data, MRI brain anatomy during NICU hospitalization, we characterized all the acquired data distribution from 31 infants with either 'appeared neurologically normal (ANN, n = 21)’ or 'appeared neurologically abnormal (ANA, n = 10)’ pro tempore, with a physician's clinical judgment before discharge. Besides single factor comparisons between ANN and ANA, we examined their development difference by using the multidimensional information processing, principal component analysis (PCA). The diagnostic predictors of neuro-behavioral development were selected by regression analysis with variable selection. It resulted that hematological and brain anatomical factors seemed correlated to both ‘Head Control’ and ‘Roll Over’. This report suggested certain possibility of the cross-domain translational approach between subjective and objective developmental information through multivariate analyses, with candidate markers preliminarily to be evaluated in further studies.

Acute encephalopathy associated with hemolytic uremic syndrome caused by Escherichia coli O157: H7 and rotavirus infection

We reported a case of a 22-months child with hemolytic uremic syndrome associated with encephalopathy. As the cause of this case, the involvements of verotoxin 1 and 2 caused by O157: the H7 strain of the enterohemorrhagic Escherichia coli and rotavirus were presumed. We administered brain hypothermic therapy and steroid pulse therapy in the intensive care unit, but we were not able to save his life and the child died on the 6th day from the onset.

Susceptible period of socio-emotional development affected by constant exposure to daylight

As a diurnal experimental primate, the common marmoset (Callithrix jacchus) has recently contributed to numerous kinds of studies of neurobiological psychiatry as an essential pre-clinical model. The marmoset matures sexually within one or two years after birth. Thus, we can observe how the primate learns and develops psycho-cognitive functions through experiences in experimental environment for a much shorter period compared to that of humans. Longer daylight exposure may affect psychological development of children. In our research, we focus on raising marmosets under constant daylight from birth until various ages. In order to quantitatively evaluate the development of higher-ordered psychological functions, we designed a system of socio-behavioral tests and multivariate correlation analysis methods based on principal component analysis. With reference to the call and typical body movement expressed during a particular social context, we statistically inferred the emotional features of the subjects. In the current literature, we review our published results showing increased alert behaviors by constant light, and then, attempted to extend our additional analysis to seek age-dependent susceptibility to constant light. We then present the neurobiological mechanisms with reference to previous research reports. The current review suggests possible existence of a susceptible period earlier than three to five month-old in the environment-induced developmental disorder model, supposedly like attention deficit hyperactive disorders (ADHD) or oppositional defiant disorder (ODD).

Immediate screening method for predicting the necessity of massive transfusions in trauma patients: a retrospective single-center study

Background

Hemostatic resuscitation might improve the survival of severely injured trauma patients. Our objective was to establish a simplified screening system for determining the necessity of massive transfusions (MT) at an early stage in trauma cases.

Methods

We retrospectively analyzed the cases of trauma patients who had been transported to our institution between November 2011 and October 2013. Patients who were younger than 18 years of age or who were confirmed to have suffered a cardiac arrest at the scene or on arrival were excluded. MT were defined as transfusions involving the delivery of ≥10 units of red blood cell concentrate within the first 24 h after arrival.

Results

A total of 259 trauma patients were included in this study (males: 178, 69%). Their mean age was 49 ± 20, and their median injury severity score was 14.4. Thirty-three (13%) of the patients required MT. The presence of a shock index of ≥1, a base excess of ≤ −3 mmol/L, or a positive focused assessment of sonography for trauma (FAST) result was found to exhibit sensitivity and specificity values of 0.97 and 0.81, respectively, for predicting the necessity of MT. Furthermore, this method displayed an area under the receiver operating characteristic curve of 0.934 (95% confidence interval, 0.891–0.978), which indicated that it was highly accurate.

Conclusions

Our screening method based on the shock index, base excess, and FAST result is a simple and useful way of predicting the necessity of MT early after trauma.

Brain hypothermia therapy for status epilepticus in childhood

OBJECTIVE

At the Dokkyo Medical University Hospital, we introduced a brain hypothermia therapy protocol for treating childhood status epilepticus and acute encephalitis/encephalopathy in 2004.

PATIENTS AND METHODS

This protocol focuses on infants with a minimum age of six months or 7.5 kg in weight. Applicable diseases include acute encephalitis/encephalopathy occurring from status epilepticus or seizures lasting for 30 minutes or longer, in cases such as near drowning, hypoxic-ischemic encephalopathy, post-resuscitation encephalopathy, cardio-respiratory arrest, severe head injury, or other diagnoses in which the pediatric neurologist recognizes the possibility of neurological complications. Brain hypothermia therapy is managed within the intensive care unit (ICU).

RESULTS

The target body temperature is a bladder or rectum temperature of 34.0 to 35.0 degrees. This body temperature is reduced to the target temperature within six hours of the seizures. Hypothermia is maintained for 48 hours and concomitant steroid pulse therapy may be used at appropriate times. Sodium thiopental is used to sedate and rewarming is carried out at 0.5 degrees per 12 hours. Osmotic diuretics, muscle relaxants and circulatory antagonists may be concomitantly used at appropriate times.

CONCLUSIONS

This paper reviews the brain hypothermia therapy protocol.

A cross-species socio-emotional behaviour development revealed by a multivariate analysis

Recent progress in affective neuroscience and social neurobiology has been propelled by neuro-imaging technology and epigenetic approach in neurobiology of animal behaviour. However, quantitative measurements of socio-emotional development remains lacking, though sensory-motor development has been extensively studied in terms of digitised imaging analysis. Here, we developed a method for socio-emotional behaviour measurement that is based on the video recordings under well-defined social context using animal models with variously social sensory interaction during development. The behaviour features digitized from the video recordings were visualised in a multivariate statistic space using principal component analysis. The clustering of the behaviour parameters suggested the existence of species- and stage-specific as well as cross-species behaviour modules. These modules were used to characterise the behaviour of children with or without autism spectrum disorders (ASDs). We found that socio-emotional behaviour is highly dependent on social context and the cross-species behaviour modules may predict neurobiological basis of ASDs.

[Treatment of status epilepticus]

Status epilepticus is defined as epileptic seizure with the duration for over 30 min or clustered seizure without complete recovery of consciousness for 30 min or more. From the management point of view, therapeutic intervention is recommended for prolonged seizures for 5 min or more. Intranasal, buccal or intramuscular administration of midazolam is strongly evidence-based and highly recommended method for the treatment of prolonged seizures before the intravenous access. Diazepam or midazolam is the first choice as initial intravenous treatment. Intravenous bolus administration of fosphenytoin or phenobarbital is the second line treatment. General anesthesia using such as thiopental or propofol is indicated for refractory status epileptic, which should be managed in the intensive care unit.

Novel c.2216T > C (p.I739T) mutation in exon 13 and c.1481T > A (p.L494X) mutation in exon 8 of MUT gene in a female with methylmalonic acidemia

We report herein a 1.5-year-old girl with methylmalonic acidemia (MMA) in whom two missense mutations were found: a novel I739T mutation located in exon 13 and the L494X mutation in exon 8. The results of organic acid test showed a pronounced increase in methylmalonate excretion with increased methylcitrate and 3-OH-propionate excretion, leading to a diagnosis of MMA, and Vitamin B12 administration was started. Analysis of the mut gene confirmed a T-to-A substitution at nucleotide position 1481 in exon 8 and a T-to-C substitution at nucleotide position 2216 in exon 13, leading to the amino acid isoleucine at position 739 being changed to threonine, resulting in c.2216T > C (p.I739T). The patient has now been on high-dose oral administration of Vitamin B12 and carnitine therapy (900 mg of levocarnitine chloride) for 5 years without experiencing further attacks, and her cognitive and motor development is normal. Further tests on residual enzyme activity, as well as experience with more cases, may shed light on the relationship between gene mutations and phenotypes in MMA.

ADORA2A polymorphism predisposes children to encephalopathy with febrile status epilepticus

OBJECTIVE

Acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) is a childhood encephalopathy following severe febrile seizures, leaving neurologic sequelae in many patients. However, its pathogenesis remains unclear. In this study, we clarified that genetic variation in the adenosine A2A receptor (ADORA2A), whose activation is involved in excitotoxicity, may be a predisposing factor of AESD.

METHODS

We analyzed 4 ADORA2A single nucleotide polymorphisms in 85 patients with AESD. The mRNA expression in brain samples, mRNA and protein expression in lymphoblasts, as well as the production of cyclic adenosine monophosphate (cAMP) by lymphoblasts in response to adenosine were compared among ADORA2A diplotypes.

RESULTS

Four single nucleotide polymorphisms were completely linked, which resulted in 2 haplotypes, A and B. Haplotype A (C at rs2298383, T at rs5751876, deletion at rs35320474, and C at rs4822492) frequency in patients was significantly higher than in controls (p = 0.005). Homozygous haplotype A (AA diplotype) had a higher risk of developing AESD (odds ratio 2.32, 95% confidence interval 1.32-4.08; p = 0.003) via a recessive model. mRNA expression was significantly higher in AA than AB and BB diplotypes, both in the brain (p = 0.003 and 0.002, respectively) and lymphoblasts (p = 0.035 and 0.003, respectively). In lymphoblasts, ADORA2A protein expression (p = 0.024), as well as cellular cAMP production (p = 0.0006), was significantly higher in AA than BB diplotype.

CONCLUSIONS

AA diplotype of ADORA2A is associated with AESD and may alter the intracellular adenosine/cAMP cascade, thereby promoting seizures and excitotoxic brain damage in patients.

Autopsy report of a 7-year old patient with the mosaic trisomy 13

We present here a long survival case of a patient with the mosaic form of trisomy 13 who died of aspiration pneumonia at the age of 7 years and 4 months. The autopsy revealed olfactory aplasia and fenestration of the septum pellucidum, and dilated lateral ventricles and atrophic hippocampus. Furthermore, there were numerous "torpedos" (i.e., swollen fusiform Purkinje cell axons), mostly in the granular layer underneath the Purkinje cell layer, and, occasionally, in the granular layer. Similar neuropathological findings have been reported in elderly cases of essential tremor, Parkinson's disease, or Alzheimer's disease. Precise mechanism for this axonal change is still unclear. These pathological changes have never previously been reported in the literature on trisomy 13, and the present patient is one of the oldest autopsied individuals with the mosaic trisomy 13.

Peer attachment formation by systemic redox regulation with social training after a sensitive period

Attachment formation is the most pivotal factor for humans and animals in the growth and development of social relationships. However, the developmental processes of attachment formation mediated by sensory-motor, emotional, and cognitive integration remain obscure. Here we developed an animal model to understand the types of social interactions that lead to peer-social attachment formation. We found that the social interaction in a sensitive period was essential to stabilise or overwrite the initially imprinted peer affiliation state and that synchronised behaviour with others based on common motivations could be a driver of peer social attachment formation. Furthermore, feeding experience with supplementation of ubiquinol conferred peer social attachment formation even after the sensitive period. Surprisingly, the experience of feeding beyond the cage window was also effective to reduce the required amount ubiquinol, suggesting that peri-personal space modulation may affect socio-emotional cognition and there by lead to attachment formation.

Partial epilepsy and developmental delay in infant with ring chromosome 14

Ring chromosome 14 (r14) is clinically characterized by early-onset epilepsy, mental retardation, delayed speech, microcephaly, extremely mild facial dysmorphisms and ophthalmologic abnormalities. We report a case presenting with partial seizures and delayed development in infancy in which r14 was diagnosed based on chromosomal analysis. The patient was a girl with a normal family and delivery history. Afebrile generalized convulsions developed at age 9 months, and phenobarbital was started, but was changed to zonisamide due to impaired liver function. Chromosome analysis led to a diagnosis of 46, XX, r(14) (p11.2q32.3). At age 5 years, while under treatment with zonisamide and clobazam, epilepsy was characterized by multiple daily episodes of complex partial seizures. Although there are no consistent brain MRI or electroencephalogram findings, experienced pediatric neurologists can make a diagnosis based on facial dysmorphisms. When refractory epilepsy is encountered in infancy with developmental delay of unknown cause, chromosome analysis should be performed.

Epidemiology of acute encephalopathy in Japan, with emphasis on the association of viruses and syndromes

A research committee supported by the Japanese government conducted a nationwide survey on the epidemiology of acute encephalopathy in Japan using a questionnaire. A total of 983 cases reportedly had acute encephalopathy during the past 3 years, 2007-2010. Among the pathogens of the preceding infection, influenza virus was the most common, followed by human herpesvirus-6 (HHV-6) and rotavirus. Among syndromes of acute encephalopathy, acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) was the most frequent, followed by clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS), acute necrotizing encephalopathy (ANE) and hemorrhagic shock and encephalopathy syndrome (HSES). Influenza virus was strongly associated with ANE and MERS, HHV-6 with AESD, and rotavirus with MERS. Mortality was high in ANE and HSES, but was low in AESD, MERS and HHV-6-associated encephalopathy. Neurologic sequelae were common in AESD and ANE, but were absent in MERS.

Determinants of outcomes following acute child encephalopathy and encephalitis: pivotal effect of early and delayed cooling

BACKGROUND

Acute encephalopathy/encephalitis is one of the most important causatives of mortality and neurological deficit during childhood. The aim of this retrospective observational study was to investigate clinical variables and therapeutic options associated with the outcome of children with acute encephalopathy/encephalitis.

METHODS

Relationships between the clinical information at admission and the neurological outcome evaluated using Pediatric Cerebral Performance Category Scale (PCPC) at 12 months after admission were assessed in 43 patients who were treated at 10 Japanese paediatric intensive care units.

RESULTS

Sixteen patients were cared for at normothermia, whereas mild hypothermia was applied to 27 children. In univariate analysis, ages ≤ 18 months, marked elevation in serum lactate dehydrogenase (LD) and aspartate transaminase, diagnosis of either acute necrotising encephalopathy or haemorrhagic shock and encephalopathy syndrome and longer hypothermic periods were associated with increased risks of death or severe neurological deficit, whereas hypothermia showed pivotal effects: the outcome of children cooled after 12 h of diagnosis was statistically invariant with normothermic children, but was significantly worse compared with children cooled ≤ 12 h. In multivariate analysis, younger ages and elevated serum LD were associated with adverse outcomes, whereas early initiation of cooling was related to favourable outcomes. For normothermic children, PCPC scores were dependent on the computed tomographic findings suggestive of cerebral oedema, serum LD levels and Glasgow Coma Scale at admission. For hypothermic children, PCPC scores depended on longer delays in cooling initiation.

CONCLUSION

Without therapeutic hypothermia, the outcome of children was determined by variables suggestive of the severity of encephalopathy/encephalitis at admission. Hypothermia may have pivotal impacts on the outcome of children according to the timing of cooling initiation following acute encephalopathy/encephalitis.

[A case of neurocutaneous melanosis associated with focal cortical dysplasia]

A newborn baby boy presented with giant melanocytic nevi on the face, trunk and extremities, and focal cortical dysplasia on MRI. At 3 months of age, he developed intractable epilepsy, and MRI at 2 years of age revealed a high-intensity area in the bilateral cerebellum on T1-weighted images, indicative of melanosis. Based on the findings of the skin and MRI, we diagnosed the boy with neurocutaneous melanosis. Cytodiagnosis of cerebrospinal fluid showed no malignancies. EEG, magnetoencephalogram and ECD-SPECT indicated that the clonic seizures originated from a focus in the right focal cortical dysplasia. Complications also included sebaceous nevus of the head and face, which was characteristic of sebaceous nevus syndrome, lipoma of the face and cauda equina, and limbal dermoid. Sebaceous nevus syndrome may have been due to certain allelic defects that were independent of those for neurocutaneous melanosis.

[Acute encephalopathy with febrile convulsive status epilepticus (AEFCSE)]

Acute encephalopathy in childhood is a wide and heterogenous neurological category, composed of several syndromes or diseases yet to be fully established. Recent progresses in diagnostic radiology and laboratory tests has allowed us to elucidate the nature of this huge entity. Acute encephalopathy with febrile convulsive status epilepticus (AEFCSE) is the most common type of acute encephalopathy in childhood in Japan, which develops with prolonged febrile convulsion, followed by mild unconsciousness, then subsequently provoking a cluster of convulsions (late seizures) with comatous state. Diffusion-weighted MR images shows high signal in the subcortical white matter as with cerebral lobar distribution pattern. "Acute infantile encephalopathy predominantly affecting the frontal lobes (AIEF)" is the most common subtype of AEFCSE, which is unique in that frontal lobes are the primary focus for the neurological manifestations and radiological features.

Acute encephalitis with refractory, repetitive partial seizures (AERRPS): a peculiar form of childhood encephalitis

OBJECTIVE

We conducted a nationwide multicenter study in Japan to elucidate the clinical and laboratory characteristics of acute encephalitis with refractory, repetitive partial seizures (AERRPS).

MATERIALS AND METHODS

Clinical and laboratory features, treatment, and outcome were assessed using a structured questionnaire.

RESULTS

Twenty-nine children were enrolled in the study. Refractory and repetitive partial seizures accompanied by fever were the cardinal clinical features. Partial seizures consisted principally of eye deviation or facial twitching, being periodically repeated during the acute phase. These seizures were refractory to conventional anticonvulsants and were only suppressed by high-dose intravenous barbiturate administration. Rhythmic activities on electroencephalography and non-specific cerebral atrophy on neuroimaging were common. Serum or cerebrospinal antibodies against GluRepsilon2 were positive in six patients. General prognosis was unfavorable due to intractable epilepsy and cognitive deficits.

CONCLUSION

Based on the peculiar and homogenous features, AERRPS can be regarded as a distinct clinical entity.