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

Study objectives

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

Methods

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

Results

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

Discussion

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

Conclusion

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

0757 Increasing Number of Cases Who Had Both Hypersomnolence Disorders and Developmental Disorders With Orexin Measurements

Introduction

Recently, attention has been paid to the relationship between developmental disorders such as attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), and sleep disorders. We meet many developmental disorder patients who complaint hypersomnolence. Among these patients, cases with coexistence of central hypersomnia and developmental disorders, or developmental disorder alone were increased. Therefore, we first investigated patients with the complaint of hypersomnolence, who were also suspected developmental disorders. Furthermore, we have been measuring CSF orexin in 17 cases suspected of both disorders to investigate orexin levels of these patients.

Methods

86patients who complained of EDS with suspicion of developmental disorders had been examined. In order to diagnose hypersomnolence disorders, PSG and MSLT were performed. Psychological examinations were performed for diagnosing developmental disorders.We have been measuring for CSF orexin in 17 cases suspected both hypersomnolence and developmental disorders. We examined the onset of hypersomnolence and the clinical history of these ADHD or ASD cases for more details.

Results

In 86 examined cases, developmental disorders coexisted in 30 cases. Among 30 cases, ADHD were 18, ASD were 6 and both diagnosed were 6 cases. Among them, 20 cases diagnosed as having coexistence of hypersomnia (8: narcolepsy, 12: IHS) and developmental disorders (ADHD:12, ASD:4, ADHD/ASD:4). In 17 cases with orexin measurements, 10 cases coexisted ADHD and 4 cases coexisted ASD. Two cases diagnosed as both ADHD and ASD. In 10 ADHD cases, 3 cases had low orexin levels, and 7 cases had normal orexin levels. Other 7 ASD cases had normal orexin levels.

Conclusion

ADHD has a higher rate of central hypersomnia (12/18) compared with ASD and the rate of narcolepsy was also high (5/12). While patients in ASD was diagnosed as IHS (3/6), narcolepsy cases were not observed. It became clear that the majority of patients had developmental disorder or had a tendency for developmental disorder before the onset of hypersomnolence.Although it is possible that ADHD/ASD symptoms may be exacerbated by orexin dysfunctions, ADHD/ASD may not newly occur. There were cases with low orexin levels, but it seems that narcolepsy happened to coexist with developmental disorders.

Support

a

0518 Sleep Facilitation by Artificial Carbonated Bathing in Healthy Elderly; EEG, Core, Proximal, and Distal Temperature Evaluations

Introduction

Bathing, especially with hot spring with various mineral compositions, is known to facilitate / improve sleep by warming the body. Artificial carbonated bathing (ACB) is known to keep the body warm too. Previous our study examined that ACB before sleep more specifically affected body temperature and sleep on healthy young subjects. In this study, we evaluated the effects of usual (plain hot water; PH) and artificial carbonated bathing, on sleep using clinical thermometers and EEG in healthy elderly subjects.

Methods

Nine healthy elderly women (average age 71.3 years old) were divided into 2 groups ACB (858 ppm, Awacomachi, Danrei Co.) and PH with a week interval. Subjects soaked in the bath (38 C degree) deep enough their chests touched the water for 10 min. From the time they finished bathing to the next morning, we measured their distal skin temperature (top side of the foot), proximal skin temperature (lower part of the clavicle) and EEG using a single channel portable device (Brain wave sensor, Proassist Co.). Subjects were told to sleep from 23:00-6:00. As the same time, subjects were examined with visual analog scale (VAS) and clinical flicker fusion test (CFF).

Results

There was no significant difference in body temperature (proximal, distal, distal-proximal temperature gradient: DPG) before and during sleep between ACB and PH. The condition of the ACB tended to have less light sleep compared to PH (150min vs 201min, p=0.08), but there was no significant difference in the SWS (44.1min vs 39.1min, ns), EEG delta power analysis, VAS and CFF.

In the previous study, bathing was performed for 15 min at a water temperature of 40 C degree, but this condition was considered to be a high risk for the elderly. The reason why there was no significant difference in body temperature. The effects of ACB were not fully demonstrated due to changes in hot water temperature and bathing time.

Conclusion

The effect of ACB on the body temperature of healthy elderly people could not be confirmed. However, a tendency to reduce light sleep was observed.

Support

This work was supported by JSPS KAKENHI Grant Number JP19K11294

Cerebrospinal fluid orexin-A levels in systemic lupus erythematosus patients presenting with excessive daytime sleepiness

Objective Involvement of the hypothalamus is rare in patients with systemic lupus erythematosus (SLE). In this study, we measured cerebrospinal fluid (CSF) orexin-A levels in SLE patients with hypothalamic lesions to investigate whether the orexin system plays a role in SLE patients with hypothalamic lesions who present with excessive daytime sleepiness (EDS). Methods Orexin-A levels were measured in CSF from four patients with SLE who presented with hypothalamic lesions detected by MRI. Three patients underwent repeated CSF testing. All patients met the updated American College of Rheumatology revised criteria for SLE. Results Tests for serum anti-aquaporin-4 antibodies, CSF myelin basic protein and CSF oligoclonal bands were negative in all patients. All patients presented with EDS. Low to intermediate CSF orexin-A levels (92-180 pg/ml) were observed in three patients in the acute stage, two of whom (patients 1 and 2) underwent repeated testing and showed increased CSF orexin-A levels, reduced abnormal hypothalamic lesion intensities detected by MRI and EDS dissipation at follow-up. In contrast, CSF orexin-A levels were normal in one patient (patient 4) while in the acute stage and at follow-up, despite improvements in EDS and MRI findings. Patient 4 showed markedly increased CSF interleukin-6 levels (1130 pg/ml) and a slightly involved hypothalamus than the other patients. Conclusions Our findings suggest that the orexinergic system has a role in EDS in SLE patients with hypothalamic lesions. Furthermore, cytokine-mediated tissue damage might cause EDS without orexinergic involvement.

Aripiprazole is effective for the improvement of psychotic symptoms in patients with dementia with lewy bodies

Objective

Dementia with lewy bodies (DLB) is commonly considered the second most common form of dementia. The purpose of this study is to investigate the treatment effects of aripiprazole in patients with DLB.

Methods

Eleven patients who had meet the criteria for DLB participated in this study. The presence of psychotic symptoms was confirmed by scores of either the delusions or hallucinations items of the Neuropsychiatric Inventory (NPI) score. Patients who had 25 or more on the Mini-mental State Examination Scale (MMSE) at the entry or having brain damage were excluded. Aripiprazole was initiated at a low dose (3 or 6 mg/day) and titrated to higher doses at 2-weeks intervals or more rapidly based on investigator's judgment. Previous medications prior to aripiprazole administration were not changed through this trial. Patient's clinical status was assessed at baseline, then 2 weeks during the study by using NPI, Clinical Global Impression (CGI) and Brief Psychiatric Rating Scale (BPRS) to measure psychotic behavioral symptoms, and Simpson-Angus Scale (SAS) to measure parkinsonism symptoms. Clinical Dementia Rating (CDR) and MMSE were carried out at screening and end point to evaluate cognitive function.

Results

The mean scores of the SAS and CDR were significantly decreased at the study endpoint compared to baseline. The mean scores of the NPI and BPRS improved up until 4 weeks after having started aripiprazole. After 4 weeks, improvements slowed. The mean score of the CGI-S was decreased up until 8 weeks.

Conclusion

This study shows that aripiprazole may be effective for the treatment of psychotic symptoms in patients with DLB.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Hypocretin/orexin and narcolepsy: new basic and clinical insights

Narcolepsy is a chronic sleep disorder, characterized by excessive daytime sleepiness (EDS), cataplexy, sleep paralysis and hypnagogic hallucinations. Both sporadic (95%) and familial (5%) forms of narcolepsy exist in humans. The major pathophysiology of human narcolepsy has been recently discovered based on the discovery of narcolepsy genes in animals; the genes involved in the pathology of the hypocretin/orexin ligand and its receptor. Mutations in hypocretin-related genes are rare in humans, but hypocretin ligand deficiency is found in a large majority of narcolepsy with cataplexy. Hypocretin ligand deficiency in human narcolepsy is probably due to the post-natal cell death of hypocretin neurones. Although a close association between human leucocyte antigen (HLA) and human narcolepsy with cataplexy suggests an involvement of autoimmune mechanisms, this has not yet been proved. Hypocretin deficiency is also found in symptomatic cases of narcolepsy and EDS with various neurological conditions, including immune-mediated neurological disorders, such as Guillain-Barre syndrome, MA2-positive paraneoplastic syndrome and neuromyelitis optica (NMO)-related disorder. The findings in symptomatic narcoleptic cases may have significant clinical relevance to the understanding of the mechanisms of hypocretin cell death and choice of treatment option. The discoveries in human cases lead to the establishment of the new diagnostic test of narcolepsy (i.e. low cerebrospinal fluid hypocretin-1 levels for 'narcolepsy with cataplexy' and 'narcolepsy due to medical condition'). As a large majority of human narcolepsy patients are ligand deficient, hypocretin replacement therapy may be a promising new therapeutic option, and animal experiments using gene therapy and cell transplantations are in progress.

Endovascular Treatment of Urgent Carotid Occlusion. Case selection & Technique

SUMMARY

Emergency revascularization of acute carotid artery occlusion is still controversial.We treated 15 patients (13 men and two women, mean age of 67.3 years) with acute atherosclerotic carotid occlusion by endovascular procedures and evaluated the usefulness of this treatment. All of the patients were evaluated with emergency MRI and MRA before treatment. Intracranial tandem arterial occlusion due to distal embolism was observed in nine patients, and contralateral carotid stenosis (> 70%) was observed in seven. The mean NIHSS score of the patients was 15.4 +/- 7.4 (mean +/- SD) before treatment. Treatment modality included local intraarterial fibrinolysis (LIF), percutaneous transluminal angioplasty (PTA), and carotid artery stenting (CAS). A protective balloon was successfully placed in the distal carotid artery through the plaque before recanalization in seven patients. Three patients were treated with LIF+PTA, five with PTA+CAS, six with LIF+PTA+CAS, and one with PTA only. Successful recanalization of the carotid artery was obtained in 14 of the 15 patients, and distal tandem middle cerebral artery occlusion was also successfully recanalized in eight of the nine patients. GOS was four or five in eight patients (good outcome group) and 1-3 in seven patients (poor outcome group). Mean NIHSS score of the 15 patients was (6.9 +/- 7.4) after treatment. Preoperative NIHSS score (10.3 +/- 7.4) in the good outcome group was significantly lower than that (21.3 +/- 5.4) in the poor outcome group. The protective balloon technique, PTA with stenting, seems to be useful for acute revascularization of urgent carotid occlusion. Simultaneous treatment of the intracranial tandem occlusive lesion is essential to achieve good clini-cal results. Patients with acute carotid occlusion with NIHSS scores of less than 16 could be good candidates for this advanced treatment.

CSF hypocretin measures in patients with obstructive sleep apnea

The majority of patients with narcolepsy-cataplexy were reported to have very low cerebrospinal fluid (CSF) hypocretin-1 (orexin-A) levels. The hypocretin-1 levels of secondary excessive daytime sleepiness (EDS) disorders are not known. In this study, we found that CSF hypocretin levels in the patients with obstructive sleep apnea syndrome were within the control range. The low hypocretin levels seem to reflect only the presence of cataplexy and DR2 positive in narcoleptics but not EDS itself.

CSF hypocretin levels in Guillain-Barre syndrome and other inflammatory neuropathies

CSF hypocretin-1 was measured in 28 Guillain-Barré syndrome (GBS), 12 Miller-Fisher syndrome, 12 chronic inflammatory demyelinating polyneuropathy (CIDP), and 48 control subjects. Seven GBS subjects had undetectably low hypocretin-1 levels (<100 pg/mL). Hypocretin-1 levels were moderately reduced in an additional 11 GBS, 5 Miller-Fisher syndrome, and 1 CIDP subject. Low levels in GBS occurred early in the disease and were associated with upper CNS level abnormalities.

Narcolepsy in a hypocretin/orexin-deficient chihuahua

A two-year-old male chihuahua suffered attacks of muscle weakness and immobility, although it had no family history of paroxysmal attacks. No neurological or blood biochemical abnormalities were recorded when it was first examined. The attacks were typically elicited by stimulation, such as feeding, and a case of sporadic narcolepsy-cataplexy was therefore suspected. Treatment orally three times a day with 1 mg/kg imipramine, was effective in reducing the attacks. The concentration of hypocretin-1/orexin A in the dog's cerebrospinal fluid was less than 80 pg/ml (22.5 pmol/litre), compared with normal canine levels of 250 to 350 pg/ml (70.0 to 98.3 pmol/litre), supporting a diagnosis of hypocretin-deficient narcolepsy.

Undetectable levels of CSF hypocretin-1 (orexin-A) in two prepubertal boys with narcolepsy

We report on two prepubertal narcoleptic boys with undetectable levels of hypocretin-1 (orexin-A) in their cerebrospinal fluid (CSF). The disease onset times were 6 and 8 years, and CSF was collected 8 and 20 months after the onset, respectively. The initial symptoms were excessive daytime sleepiness, cataplexy and disrupted nocturnal sleep. Both subjects are DRB1*1501 and DQB1*0602 positive. The measurement of CSF hypocretin-1 is valuable for the decisive diagnosis of narcolepsy and for selecting the type of treatment in prepubertal children. Our results suggest that a significant degree of hypocretin deficiency is already present at the disease onset.

Hypersomnia due to acute disseminated encephalomyelitis in a 5-year-old girl

A 5-year-old girl suffering from hypersomnia due to acute disseminated encephalomyelitis (ADEM) is reported. Brain CT revealed a large low-density lesion involving the lentiform nucleus, posterior limb of the internal capsule, thalamus, posterior hypothalamus and midbrain in the left side. She was treated with intravenous dexamethazone. After the initial dose of dexamethazone, hypersomnia was dramatically and rapidly improved. A later brain CT study disclosed that the lesion in the brain disappeared. The brain lesion in this case involved the waking center in the brain, which was described by Von Economo. We concluded that hypersomnia in this case was due to ADEM involving the neural mechanism for maintaing wakefulness, probably in the thalamus and posterior hypothalamus. Repeat all night polysomnograpy in this case disclosed prolonged total sleep time and increased amount of stage 3-4 sleep in the hypersomniac state.

The effects of oral melatonin on the autonomic function in healthy subjects

We investigated the influence of melatonin on the human autonomic functions by measuring muscle sympathetic nerve activity (MSNA). Five healthy male volunteers took 3 mg of melatonin, and their plasma melatonin concentration, blood pressure, heart rate, and burst rate of MSNA were then recorded. The peak level of melatonin concentration showed a marked interindividual variation. Blood pressure was reduced significantly, while heart rate and burst rate of MSNA did not change significantly. These results indicate that melatonin has a hypotensive effect on blood pressure, and the central cardiovascular regulatory mechanism such as lowering of the baroreflex setpoint would be involved in the effect.

Implication of dopaminergic mechanisms in the wake-promoting effects of amphetamine: a study of D- and L-derivatives in canine narcolepsy

Using a canine model of narcolepsy and selective DA and NE uptake inhibitors, we have recently shown that DA uptake inhibition promotes wakefulness, while NE uptake inhibition inhibits rapid eye movement sleep and cataplexy. In order to further delineate the respective roles of the dopaminergic and noradrenergic systems in the pharmacological control of symptoms of narcolepsy, we compared the potency of amphetamine isomers (D- and L-amphetamines) and a derivative (L-methamphetamine) on wakefulness and cataplexy. Their respective effects on these narcolepsy symptoms were then compared with their in vivo effects on extracellular DA levels in the caudate and NE levels in the frontal cortex during local drug perfusion in narcoleptic dogs. Polygraphic recordings demonstrated that D-amphetamine was about twice as potent as L-amphetamine, and was six times more potent than L-methamphetamine in increasing wakefulness and reducing slow-wave sleep. D-Amphetamine and L-amphetamine were equipotent in reducing rapid eye movement sleep and cataplexy, and L-methamphetamine was about half as potent as L- and D-amphetamines. D-Amphetamine was found to be more potent in increasing DA efflux than L-amphetamine, and L-methamphetamine was found to have little effect on DA efflux; there was no significant difference in the potencies of the three derivatives on NE efflux. The potencies of these amphetamines on wakefulness correlated well with DA, but not NE, efflux in the brain of narcoleptic dogs during local drug perfusion. Our current results further exemplify the importance of the DA system for the pharmacological control of electroencephalogram arousal and suggest that increased DA transmission mediates the wake-promoting effects of amphetamine-like stimulants.

Thalidomide increases both REM and stage 3-4 sleep in human adults: a preliminary study

Polysomnography was used to assess the effect of thalidomide on human sleep. This compound significantly increased the time spent in REM and stage 3-4 sleep as compared with placebo. On the other hand, thalidomide significantly decreased the time spent in stage 1, while the time spent in stage 2 was unchanged. The effect of thalidomide on REM and stage 3-4 sleep is unique as compared with other hypnotics. Although the mode of action of this compound is unknown, further studies on thalidomide should help in our understanding of the mechanisms of sleep regulation.

Sleep-disordered breathing in a patient with congenital myopathy

A case of adult onset myopathy who showed a peculiar sleep-related respiratory disorder (SRRD) is reported. She recovered from respiratory failure after tracheostomy and/or with the aid of the respirator used only during the night. Sleep study without the use of respirator revealed that her sleep was highly fragmented by frequent arousal responses due to inspiratory effort but not by apnea or hypopnea. To our knowledge this type of SRRD has not been described.

[Rhabdomyolysis following water intoxication in two schizophrenic patients]

We report two cases of self-induced water intoxication with rhabdomyolysis. They had been diagnosed as chronic schizophrenia, and admitted to mental hospitals. The patients were transferred to our emergency room because of sudden loss of consciousness and generalized convulsions. Laboratory findings revealed marked hyponatremia (case 1; 109 mEq/L and case 2; 104 mEq/L). CT scans showed the effacement of interhemispheric and bilateral sylvian fissures and sulci of the cerebral hemisphere due to diffuse brain edema. 10% glycerol and saline were intravenously injected to the patients. They recovered from hyponatremia after excreting a large amount of urine. Their disturbed consciousness recovered to the normal level in parallel with the normalization of their serum sodium concentration. Soon after the normalization of their consciousness level, their serum creatine kinase (CK) was markedly elevated (case 1; 13086 IU/L and case 2; 41832 IU/L), and their serum myoglobin level was also significantly elevated (case 1; 2670 ng/ml and case 2; 1420 ng/ml). A sufficient amount of transfusion was performed for avoiding the acute renal failure. The two patients recovered from rhabdomyolysis without any severe complication. We conclude that brain CT is useful for the diagnosis of brain edema, and monitoring of CK is also important to anticipate renal damage secondary to rhabdomyolysis.

Effects of thyrotropin-releasing hormone and its analogs on daytime sleepiness and cataplexy in canine narcolepsy

The therapeutic potential of thyrotropin-releasing hormone (TRH) and TRH analogs in narcolepsy, a sleep disorder characterized by abnormal rapid eye movement (REM) sleep and daytime sleepiness, was examined using the canine model. The effects of TRH and the biologically stable TRH analogs CG3703, CG3509, and TA0910 on daytime sleep and cataplexy, a symptom of abnormal REM sleep, were assessed using polysomnographic recordings and the food elicited cataplexy test (FECT), respectively. CG3703 (100 and 400 microg/kg, i.v.) and TA0910 (100 and 400 microg/kg, i.v.) significantly increased wakefulness and decreased sleep in narcoleptic canines, whereas TRH (400 and 1600 microg/kg, i.v.) had no significant effect. TRH (25-1600 microg/kg, i.v.) and all three TRH analogs, CG3703 (6. 25-400 microg/kg, i.v., and 0.25-16 mg/kg, p.o.), CG3509 (25-1600 microg/kg, i.v.), and TA0910 (25-1600 microg/kg, i.v.), significantly reduced cataplexy in canine narcolepsy. These compounds did not produce any significant side effects during behavioral assays, nor did they alter free T3 and T4 levels in serum even when used at doses that completely suppressed cataplexy. Although more work is needed to establish the mode of action of TRH analogs on alertness and REM sleep-related symptoms, our results suggest a possible therapeutic application for TRH analogs in human sleep disorders.

Prognostic factors for renal cell carcinoma: a multivariate analysis of 320 cases

BACKGROUND

We performed a multivariate analysis of clinical variables in 320 patients with renal cell carcinoma to identify important prognostic factors for long-term survival.

METHODS

We retrospectively reviewed the medical records of 320 patients who presented with renal cell carcinoma. Survival curves were calculated by the Kaplan-Meier method and statistical differences were determined by the log-rank test. Significant prognostic factors were evaluated by Cox's multivariate proportional hazard model.

RESULTS

The median follow-up period was 29 months. The overall survival rates at 1, 5, and 10 years were 90.0%, 77.6%, and 69.9%, respectively. Seventeen of the 19 prognostic factors evaluated were shown to be significant by the log-rank test: patient age, sex, performance status, body temperature, erythrocyte sedimentation rate (ESR), levels of hemoglobin, alpha 2-globulin, C-reactive protein, fibrinogen, immunosuppressive acidic protein (IAP), size or involvement of tumor (T classification), regional lymph node involvement (N classification), extent of metastasis (M classification), pathologic grade, tumor cell type, mode of tumor infiltration, and the modality of treatment (curative surgery). Among them, the body temperature, ESR, alpha 2-globulin, fibrinogen, IAP, and mode of tumor infiltration were excluded from multivariate analysis because of missing data. Curative surgery was also excluded because it is a treatment modality and different from the other variables which are clinical or pathologic characteristics. From the remaining 10 variables, multivariate analysis showed that age (P = 0.0389), N classification (P = 0.0289), and M classification (P < 0.0001) were important and independent prognostic factors for long survival.

CONCLUSION

This analysis showed that age, N classification, and M classification were the most important factors predicting long-term survival of patients with renal cell carcinoma.

Serum prostate-specific antigen values for the prediction of clinical stage and prognosis in patients with prostate cancer: an analysis of 749 cases

BACKGROUND

The clinical significance of pretreatment serum prostate-specific antigen (PSA) values was studied to determine the ability to predict clinical stage and prognosis using a relatively large number of patients with prostate cancer.

METHODS

Serum PSA values at diagnosis were analyzed from 749 patients with newly-diagnosed prostate cancer and registered in the Tokai Urological Cancer Registry. Correlations between the PSA value, the clinical stage and prognosis of the patients were evaluated.

RESULTS

Serum PSA values at each stage of diagnosis showed positivity (> or = 3.6 ng/mL) in 23% (stage A1) to 91.2% (stage D2) of patients, and it was possible to obtain statistical differences between the stages, even between A1 and A2. Based on a cumulative study of PSA distribution, stages greater than A2 could be diagnosed using a cut-off of 7.2 ng/mL, with a 99.2% positive predictive value (PPV), and a 16.2% negative predictive value (NPV). At a PSA level of 10.8 ng/mL, stages greater than B2 could be predicted with a PPV of 95.3% but an NPV of 40.3%. Pretreatment PSA values were a significant prognostic indicator in stage D2 patients using 100 to 150 ng/mL as the cut-off values. These differences were primarily found in the poorly differentiated group, which showed a statistical difference using cut-off PSA values from 75 to 150 ng/mL.

CONCLUSIONS

Serum PSA levels from a large number of patients can be used to predict the stage and prognosis of prostate cancer patients.

Thalidomide, a hypnotic with immune modulating properties, increases cataplexy in canine narcolepsy

Thalidomide is a sedative hypnotic that was widely used in the 1950s but was withdrawn due to its teratogenic properties. The compound has recently been reintroduced as an immune modulating agent. Thalidomide significantly aggravates canine cataplexy, a pathological manifestation of rapid eye movement (RFM) sleep atonia seen in narcolepsy. This compound also increases REM sleep and slow wave sleep in these animals. In vitro receptor binding and enzyme assays demonstrate that thalidomide does not bind to or enzymatically modulate the neurotransmitter systems reported to be involved in the regulation of cataplexy. Thalidomide may therefore affect cataplexy through its immune modulation properties. Further studies on the mechanisms of action of thalidomide should increase our understanding of the pathophysiology of this disabling disorder.

Systemic lupus erythematosus with pulmonary hypertension

A 50-year-old Japanese female with a long history of Raynaud's phenomenon presented with progressive dyspnea due to pulmonary hypertension. The diagnosis of systemic lupus erythematosus was confirmed by proteinuria, lymphocytopenia, bilateral pleurisy, and a seizure of convulsion which was consistent with neurological manifestations of systemic lupus erythematosus, whereas the antinuclear antibody showed a low titer. Despite improvement in the activity of systemic lupus erythematosus, steroid treatment did not alter the progression of pulmonary hypertension, which increased in severity, eventually resulting in her death. We believe pulmonary hypertension to be an unusual but critical complication of systemic lupus erythematosus.

Muscle sympathetic nerve activity during apneic episodes in patients with obstructive sleep apnea syndrome

Muscle sympathetic nerve activity (MSNA) was recorded from peroneal nerve in 4 OSAS patients during sleep. During apneic episode, MSNA was enhanced, but it did not increase progressively toward the end of the apneic episode. MSNA remained at a stable level in the later part of an apneic episode. A surge of MSNA took place just preceding or just at the end of an apneic episode and it was followed by a transient marked blood pressure elevation.

On the arterial supply in the human biceps brachii muscle

The distribution of the arterial supply and innervation of skeletal muscle in the whole human body has been being researched in our laboratory. The results obtained on the biceps brachii from 25 bodies (50 sides) are reported here. Generally, in this muscle, A. coracobrachialis (Cb, SATO, 1980), a branch of A. axillaris (Ax), is distributed at the upper muscle bundles of the short head after running parallel to N. musculocutaneus (Nmc) and supplying M. coracobrachialis. The main artery (Ma), which is a branch of A. brachialis (Br), is distributed at the upper and middle parts of both heads, and the point where Ma enters the muscle bundles almost coincides with the point where R. brachialis (Rb) branches from Nmc. R. biceps brachii (Rbi), which is distributed only at this muscle and Om, the common trunk to other muscles, is distributed at the lower part of the muscle bundles. The arterial supply of this muscle was classified as follows according to the conditions of origin and its distribution. Type I: Ax(Cb) was distributed to the upper part of the muscle bundle. Type II: The absence of Ax(Cb) in the upper part of the muscle bundle. Type A, a and 1: Ma.Br(Om) supplying the long, short and both heads of the biceps brachii. Type B, b and 2: Ma.Br(Rbi) supplying the long, short and both heads of the biceps brachii. In the long head, Type II-A accounted for 62.0%, Type II-B for 30.0%. In the short head, Type I-a was 62.0%, Type I-b 28.0%. In both heads, Type I-1 was 62.0%, Type I-2 28.0%. There were significant differences in the distribution of the nutrient arteries between the long and short heads. A. brachialis superficialis (Bs) was recognized in 3 of these cases (2 cases of Type III and 1 case of Type VII by Adachi's classifications), which were rare cases. In these cases, arterial branches other than Cb branching from A. brachialis profunda are branches of Bs. This means, judging from ontogeny, that Bs, the blood vessels in the superficial layer, supplies this muscle, which belongs to the superficial layer of the brachium.

Ganglioneuroblastoma with disseminated bone marrow infiltration in an adult

Ganglioneuroblastoma is an extremely rare neoplasm of adults. We present a case of adrenal ganglioneuroblastoma in a 47-year-old female with disseminated bone marrow involvement. Bone marrow involvement was the major manifestation which determined the mortality of this patient. This case suggests that the diagnosis of bone marrow involvement should be carefully considered even in adult-onset ganglioneuroblastoma.

[The muscular arch of the axilla and its nerve supply in Japanese adults]

We examined 94 axillary regions of 47 Japanese adults and found the muscular arch of the axilla (Maa) in five sides of three cadavers as well as the tendinous arch of the axilla (Taa) in two sides of two cadavers. The results are summarized as follows: 1) The frequency of Maa was 6.4% of the total bodies and 5.3% of the sides in this series. 2) In the left side of a 57-year-old male (No. 427), Maa was attached to the surface of the coracobrachialis muscle after fusing with the dorsal surface of the inserting tendon of the pectoralis quartus muscle. Both muscles were supplied by the caudal pectoral nerve (Npc) from the medial pectoral nerve. Moreover, in this same specimen, the sternalis muscle was recognized on the ventral surface of the pectoralis major muscle. In the left side of a 93-year-old female (No. 386), the cranial part of the muscular arch of the axilla (Cpa) was extended to the coracoid process by a tendon and attached to the abdominal part of the pectoralis major by two muscle bundles supplied by independent branches from Npc. One muscle bundle was attached to the lower margin of the abdominal part of the pectoralis major on the same plane, and the other bundle was located on the dorsal surface of the abdominal part. In a 74-year-old female (No. 411), the well-developed lateral part of the muscular arch of the axilla (Lpa) was attached to the inferior side of the tendinous arch. According to Ruge (1914) and Kasai et al. (1977), this arch was in the transition of the muscle bundle of Cpa to the arch. In the right side of the same specimen, only the thoracodorsal nerve (Ntd) was distributed into Lpa, whereas in the left side, only Npc supplied branches to Lpa. 3) The axillary arch was classified into 8 types based on the form and the supplying nerve of Cpa and Lpa. Cpa consisting of the muscle bundle is Type I, and Cpa consisting of the tendinous arch is Type II. We proposed that only Type II-A, with Cpa as tendinous arch and no Lpa, be designated as Taa (found in two cases), and the others as Maa. The following types were found in this study: Type I-A, consisting of only Cpa supplied by Npc (two cases); Type I-D, consisting of Cpa supplied by Npc and Lpa supplied by Ntd (one case); Type II-B, consisting of the tendinous arch and Lpa supplied by Npc (one case); Type II-D, consisting of the tendinous arch and Lpa supplied by Ntd (one case). 4) From the above findings, it can be suggested that Maa of varying shapes have been formed by a portion of the latissimus dorsi muscle supplied by Ntd, together with the pectoralis subcutaneous muscle, consisting of the pectoralis abdominalis, humeroabdominalis, humerodorsalis and ventrolateralis muscles supplied by Npc. The latter three muscles were proposed by Ura (1937) as the panniculus carnosus muscle, which was well developed in some lower mammalian orders. However, early investigators suggested that Maa was derived from the panniculus. Maa might have occurred as a rudimentary phylogenetic remainder in an early human embryonic stage.

[Primary plasma cell leukemia associated with hypercalcemia]

A 34-year-old male was admitted to our hospital because of anorexia and nausea in September, 1987. On admission, anemia, thrombocytopenia and hypercalcemia were observed, and the peripheral blood showed leukocytosis with atypical plasma cells (50%). Bone marrow aspiration showed hypercellularity, with a presence of atypical plasma cells (82%). The M-type protein in the serum and urine was identified as lambda Bence Jones protein by immunoelectrophoresis. On systemic skeletal X-rays, osteolytic lesions were not detected. Thus, a diagnosis of plasma cell leukemia associated with hypercalcemia was made. Hypercalcemia was treated successfully with overhydration. However the disease was refractory to combination chemotherapy, and at 10 months after diagnosis, he died of septic candidiasis. Hypercalcemia associated with plasma cell leukemia in its initial stage is rare.

Measurement of 5'-methylthioadenosine in patients with neoplasms

The amount of polyamines in urine from patients with various neoplasms is larger than in normal subjects. We have determined the concentration of 5'-methylthioadenosine (MTA), a by-product of the polyamine biosynthesis, in patients with malignancies as well as normal subjects. Our studies indicate that the amount of MTA in urine from patients with leukemias and malignant lymphomas was higher than in normal subjects (p less than 0.005). Urine samples from patients with other malignancies contained normal amounts of MTA. The levels of blood MTA in patients with leukemias before treatment or in relapse was higher than in control subjects (p less than 0.005), while in patients with other malignancies and leukemia in remission, the levels were not different from control subjects. Peripheral blood MTA levels clearly decreased after effective chemotherapy. The measurement of MTA levels in urine and blood may not be as useful as polyamine assays for the detection of malignancies, but blood levels of MTA may be useful as an indicator of the efficacy of chemotherapy in leukemic patients.

[Treatment of 255 patients with bladder tumors]

During about 10 years from November, 1977 to March, 1987, two hundreds and fifty-five patients with bladder tumors were treated at the Department of Urology, Hamamatsu University School of Medicine and the affiliated hospitals. There were 198 males and 57 females with the highest age incidence in the seventies. Histologically, 242, 11 and 2 tumors were of transitional cell, squamous cell and adenocarcinoma, respectively. Of the 242 transitional cell carcinomas, 7 were Tis; 43 Ta, 111 T1, 33 T2, 19 T3, 5 T4, 14 M+ (with metastatic lesion), and 10 TX. As to grading, 6 was G0; 66 G1, 100 G2, 64 G3, and 6 GX. Staging was correlated with grading. The 5-year survival rates (Kaplan-Meier's method) were 64% in patients with transitional cell carcinoma; 58% in those with squamous cell carcinoma. In patients with transitional cell carcinoma, the 5-year survival rates were 100% for G0, 73% for G1, 73% for G2 and 40% for G3. As to staging, the 5-year survival rates were 67%, 81%, 81%, 35%, 41%, 40% and 12% in patients with stage of Tis, Ta, T1, T2, T3, T4 and M+, respectively. As to the initial treatment, the 5-year survival rates after TUR (137 cases), partial cystectomy (4 cases) and total cystectomy (56 cases) were 81%, 36% and 61%, respectively. The rate of intravesical recurrence after TUR was evaluated with the cumulative non-recurrence rate calculated by Kaplan-Meier's method.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of 46 cases of renal pelvic and ureteral tumors]

During about 10 years from November, 1977 to March, 1987, 46 patients with renal pelvic and ureteral tumors were treated at the Department of Urology, Hamamatsu University School of Medicine and the affiliated hospitals. There were 34 males and 12 females with the highest age incidence in the seventies. Histologically, 44 transitional cell carcinomas and 2 squamous cell carcinomas were found. Of the 44 transitional cell carcinomas, 1 was Tis; 13 T1, 2 T2, 8 T3, 15 M+ (with metastatic lesion), and 5 TX. As to grading, 1 was G1; 24 G2, 15 G3, and 4 GX. Staging was correlated with grading. The 5-year survival rates (Kaplan-Meier's method) were 37% in patients with transitional cell carcinoma. Among patients with transitional cell carcinoma, the 5-year survival rate was 43% for G2 and 42% for G3. As to staging, the 5-year survival rates were 71% and 46% in patients with stage of T1 and T3, respectively. No patient with M+ survived longer than 4 years. The 5-year survival rates were 38% and 34% in renal pelvic tumors (24 cases) and ureteral tumors (20 cases), respectively. As to the treatments, the 5-year survival rates after curable treatment (24 cases) and non-curable treatment (20 cases) were 63% and 7%, respectively.