[Mood stabilizers]

Mood stabilizers available in Japan include lithium, valproate, carbamazepine, and lamotrigine. These are prescribed for manic or hypomanic episodes of bipolar disorder, organic mania, and drug-induced mania. Careful dose titration is needed in consideration for serum drug level and clinical symptoms. Lithium frequently develops neurological toxicity because of its narrow therapeutic serum level. Valproate has the most favorable adverse effect profile among mood stabilizers, but gastrointestinal symptoms and weight gain can appear with a dose dependent fashion. Hyperammonemia is occasionally induced early after initiation of valproate and tends to be overlooked. Carbamazepine sometimes develops liver dysfunction and skin disorders associated with allergic mechanisms. Lamotrigine should be slowly titrated to avoid severe skin disorders such as Stevens-Johnson syndrome.

Ubiquitin C-terminal hydrolase L1 is required for pancreatic beta cell survival and function in lipotoxic conditions

AIMS/HYPOTHESIS

Ubiquitin C-terminal hydrolase L1 (UCHL1) is associated with neurodegenerative diseases and has been suggested to have roles in pancreatic beta cells. Our proteomic analysis revealed that UCHL1 was the most increased protein in MIN6 cells exposed to palmitate. The present study used a genetic loss-of-function model to test the hypothesis that UCHL1 is required for normal beta cell function and fate under lipotoxic conditions.

METHODS

Human islets, mouse islets and MIN6 cells were used to analyse UCHL1 protein levels and regulation of UCHL1 by palmitate. The levels of free mono-ubiquitin and poly-ubiquitinated proteins were assessed. Gracile axonal dystrophy (GAD) mutant mice lacking UCHL1 were fed a normal or lipotoxic high-fat diet. Glucose tolerance, insulin tolerance and insulin secretion were assessed in vivo. Beta cell death and proliferation were assessed by TUNEL and proliferating cell nuclear antigen (PCNA) staining. Insulin secretion, calcium signalling, endoplasmic reticulum (ER) stress, apoptosis and SNARE protein levels were assessed in vitro.

RESULTS

UCHL1 protein, which was highly specific to beta cells, was increased by palmitate at basal glucose, but not in the context of hyperglycaemia associated with frank diabetes. Although islet development and function were initially normal in Uchl1 (-/-) mice, a 4-week high-fat diet caused glucose intolerance and impaired insulin secretion. Uchl1 (-/-) mice had increased ER stress and beta cell apoptosis. The levels of SNARE proteins were dysregulated in Uchl1 (-/-) islets. Palmitate-stimulated vesicle-associated membrane protein 2 (VAMP2) ubiquitination was modulated by a chemical UCHL1 inhibitor.

CONCLUSIONS/INTERPRETATION

Together, these data suggest that UCHL1 has essential functional and anti-apoptotic roles in beta cells under stress conditions associated with lipotoxicity.

[Clinical issues on prescribing psychotropics for elderly patients]

Psychopharmaologic intervention for elderly patients requires careful considerations for physical characteristics, comorbid medical illness, and interaction between drugs for psychotropic and somatic diseases drugs. Elderly patients often suffer from depression, delirium, and dementia, which occasionally coexist with each other. Antidepressants, antipsychotics, anxiolytics and hypnotics are prescribed according to the targeted psychiatric symptoms. Drug effect tens to be strengthened and prolonged pharmacodynamically in elderly patients because of decline of drug clearance in liver and kidney, prolongation of elimination half life of lipophilic drug resulted from reduced muscle tissue, and elevated free serum drug level induced by low albuminemia. Elderly patients pharmacokinetically develop adverse effects in relatively lower serum drug level. Lower initial dose and slow titration should be strongly recommended. Cerebrovascular disease and neurodegerative disease are frequently observed among elderly patients. Significant number of patients with cerebrovascular disease are complicated with depression, delirium, and in lower prevalence, dementia. Although drugs used in acute phase stroke have no pharmacodynamic interaction with psychotropics, many patients be carefully titrated with continuous monitoring of PT-INR during concurrent use of tricyclic antidepressants and selective serotonin reuptake inhibitors. Alzheimer's disease and Parkinson's disease are highly prevalent and clinically important neurodegerative disease in elderly population. Patients with Alzheimer's disease frequently exhibit delirium soon after hospitalization, which necessitates appropriate pharmacotherapy with psychotropics. After Food and Drug Foundation warned against antipsychotic use for patients with dementia, this off-label use are considered to be avoided but disease frequently coincide with depression and receive antidepressant treatment. If selegiline id prescribed, antidepressants cannot be initiated without discontinuation of selegiline. When delirium develops in patients with Parkinson's disease, second generation antipsychotics such as quetiapine are firstly administered with caution for deterioration of motor symptoms.

Dietary intake of vitamin B12 and folic acid is associated with lower blood pressure in Japanese preschool children

BACKGROUND

An elevated plasma homocysteine level is an independent risk factor for high blood pressure and cardiovascular disease, and its level is regulated by three vitamins; vitamin B6, B12, and folic acid. Until now, the association between the intake of these vitamins and blood pressure has been examined only in adult populations. We purposed to examine the association between dietary intake of these three vitamins and blood pressure of young children.

METHODS

We conducted a cross-sectional study at Japanese preschools in 2006. Blood pressure was measured among 418 children aged 3-6 years. Diets including vitamins were assessed by a 3-day dietary record. We compared the blood pressure levels among the four groups defined according to quartile of energy-adjusted vitamin intake by using analysis of covariance after controlling for age, sex, and body mass index.

RESULTS

The mean systolic blood pressure was 6.6 mm Hg lower and the mean diastolic blood pressure was 5.7 mm Hg lower in the highest quartile than in the lowest quartile of vitamin B12 intake (P for trend was <0.001 and 0.006, respectively). The mean systolic blood pressure was 4.1 mm Hg lower in the highest quartile than in the lowest quartile of folic acid intake (P for trend = 0.004). Vitamin B6 intake was not significantly associated with blood pressure.

CONCLUSIONS

The data suggest that high intakes of folic acid and vitamin B12 are associated with lower levels of blood pressure among preschool children.

Glycated albumin but not HbA1c reflects glycaemic control in patients with neonatal diabetes mellitus

AIMS/HYPOTHESIS

It is difficult to use HbA(1c) as an indicator of glycaemic control in patients with neonatal diabetes mellitus (NDM) because of high levels of fetal haemoglobin (HbF) remaining in the blood. In this study, glycated albumin (GA), which is not affected by HbF, and HbA(1c) were compared to evaluate whether they reflect glycaemic control in patients with NDM.

METHODS

This study included five patients with NDM. Age at diagnosis was 38 ± 20 days. Insulin therapy was started in all patients, and levels of GA, HbA(1c) and HbF were measured monthly for 6 months. One-month average preprandial plasma glucose (aPPG) was calculated using self-monitoring of blood glucose.

RESULTS

Plasma glucose and GA were elevated (29.7 ± 13.1 mmol/l [n = 5] and 33.3 ± 6.9% [n = 3], respectively) but HbA(1c) was within normal limits (5.4 ± 2.6% [35.5 ± 4.9 mmol/mol]; n = 4) at diagnosis. With diabetes treatment, aPPG (r = -0.565, p = 0.002), GA (r = -0.552, p = 0.003) and HbF (r = -0.855, p < 0.0001) decreased with age, whereas HbA(1c) increased (r = 0.449, p = 0.004). GA was strongly positively correlated with aPPG (r = 0.784, p < 0.0001), while HbA(1c) showed no correlation with aPPG (r = 0.221, p = 0.257) and was significantly inversely correlated with HbF (r = -0.539, p = 0.004).

CONCLUSIONS/INTERPRETATION

GA is a useful indicator of glycaemic control in patients with NDM, whereas HbA(1c) is influenced by age-related changes in HbF and does not accurately reflect glycaemic control.

Gait balance disorder by thalamic infarction with the disorder of interstitial nucleus of cajal

The interstitial nucleus of Cajal (INC) is thought to play an important role in torsional/vertical eye position and head posture, and disorders of the INC induce abnormal ocular movements and head tilt. Our patients with ocular tilt reactions simultaneously also had disturbances in ambulatory balance, yet no reports address the loss of balance control induced by disorders of the INC. We examined the ambulatory disturbances induced by INC lesion. We experienced three patients with ocular movement disorders and abnormal head tilt due to thalamic infarction. We performed ophthalmic examinations on and checked the balance of them. With funduscopy, abnormal cycloduction was seen in the unaffected side and normal cycloduction was observed in the affected side. Nevertheless, Hess charts showed distortions in the visual image of both eyes. They all had disorders of balance control. We tried to treat them using the Bobath approach for improving their ambulatory balance. With subsequent improvements in balance control it was possible for them to take short walks, but it was difficult to make any improvements in their ocular movement. The INC is related to balance control of ambulation and disorders of the INC induce ambulatory disturbances. Cycloduction was only observed in the unaffected side, but Hess charts showed distortions of the visual image in both eyes. Ambulation was briefly improved, but diplopia persisted in these patients.

Successful removal of a giant skull base metastasis from hepatocellular carcinoma after direct ethanol injection: case report

Skull metastases from hepatocellular carcinoma (HCC) are extremely rich in vascularity, which sometimes makes surgery dangerous. For minimally invasive surgery, it is very important to diminish the intratumoral vascular flow preoperatively. We report the case of a 69-year-old man with a giant skull base metastasis from HCC that was successfully removed after two sessions of direct ethanol injection into the tumor as a preoperative treatment to diminish the intratumoral vascular flow. Direct ethanol injection is a modification of percutaneous ethanol injection therapy, which is widely used in the treatment of primary HCC. In this article, we describe in detail the practical procedures and the usefulness of this treatment for a giant skull base metastasis from HCC.

Relationship of intake of plant-based foods with 6-n-propylthiouracil sensitivity and food neophobia in Japanese preschool children

BACKGROUND/OBJECTIVES

Diets rich in plant-based foods such as vegetables, fruits and soy foods have been suggested to have beneficial effects on health. However, phytochemicals contained in plant-based foods are generally bitter and acrid. We investigated whether intake of vegetables, fruits and soy foods is associated with sensitivity to bitterness and reluctance to eat new foods (food neophobia) in Japanese preschool children.

SUBJECTS/METHODS

Subjects of this cross-sectional study were healthy Japanese, 167 boys and 156 girls, aged 4-6 years. Intake of vegetables, fruits and soy foods was estimated from 3-day dietary records. Subjects were classified as either tasters or non-tasters of 6-n-propylthiouracil (PROP) based on their ability to taste 0.56 mmol/l PROP. Information on each child's age, height, weight, food neophobia status and food variety, as well as maternal diet and parental control over the child's eating, was obtained by a parent-administered questionnaire. Food neophobia was assessed using the Child Food Neophobia Scale (CFNS).

RESULTS

A high intake of vegetables was significantly associated with a low CFNS score in boys after controlling for covariates (P=0.0008). Among the boys, soy food intake was significantly higher in PROP non-tasters than in tasters, except those with low CFNS scores (P=0.0019). High intake of soy foods was significantly associated with a low neophobia score in PROP tasters but not in non-tasters (P=0.0024).

CONCLUSIONS

These data suggest that sensitivity to bitter taste and food neophobia may influence the consumption of vegetables and soy foods among Japanese preschool boys.

Photodetachment of positronium negative ions

Photodetachment of the positronium negative ion, a bound state of one positron and two electrons, has been observed. Development of a method to produce the ions efficiently using a Na coated tungsten surface has enabled the first observation of the photodetachment. The obtained lower limit of the photodetachment cross section for the wavelength of 1064 nm is consistent with the theoretical calculations reported so far. The experimental field developed in the present work gives new opportunities to explore the quantum mechanical three-body problem and to develop energy-tunable positronium beams.

Characterization of aortic aneurysms in cardiovascular disease patients harboring Porphyromonas gingivalis

OBJECTIVE

Porphyromonas gingivalis was recently shown to cause intimal hyperplasia in a mouse model by a novel cholesterol-independent mechanism, suggesting to be a pathogen-specific feature of cardiovascular diseases. The aim of this study was to characterize the clinical and histopathological features of aortic aneurysms in cardiovascular disease patients harboring oral P. gingivalis.

SUBJECT AND METHODS

Aortic aneurysm specimens were collected from 76 Japanese patients who underwent surgery, of whom dental plaque specimens were also collected from 31 patients. Bacterial DNA was extracted from each specimen to detect P. gingivalis by polymerase chain reaction. Histopathological analyses of the aortic aneurysm specimens, including immunohistochemical staining for embryonic myosin heavy chain isoform (SMemb) and S100 calcium-binding protein A9 (S100A9), were also performed.

RESULTS

The number of aneurysms occurring in the distal aorta was significantly higher in subjects positive for P. gingivalis in dental plaque compared with those who were negative. The expressions of S100A9 and SMemb were also significantly greater in the subjects positive for P. gingivalis in dental plaque. On the other hand, there were no significant differences in adipocellular accumulation between the groups.

CONCLUSIONS

These results suggest that aortic aneurysms in patients harboring oral P. gingivalis have greater expression of S100A9 and proliferative smooth muscle cells, which was different from the present patients without oral P. gingivalis.

Altered morphine-induced analgesia in neurotensin type 1 receptor null mice

Both neurotensin (NT) and opioid agonists have been shown to induce antinociception in rodents after central administration. Besides, previous studies have revealed the existence of functional interactions between NT and opioid systems in the regulation of pain processing. We recently demonstrated that NTS1 receptors play a key role in the mediation of the analgesic effects of NT in long-lasting pain. In the present study, we therefore investigated whether NTS1 gene deletion affected the antinociceptive action of mu opioid drugs. To this end, pain behavioral responses to formalin were determined following systemic administration of morphine in both male and female NTS1 knockout mice. Acute injection of morphine (2 or 5 mg/kg) produced strong antinociceptive effects in both male and female wild-type littermates, with no significant sex differences. On the other hand, morphine analgesia was considerably reduced in NTS1-deficient mice of both sexes compared to their respective controls, indicating that the NTS1 receptor actively participates in mu opioid alleviating pain. By examining specifically the flinching, licking and biting nociceptive behaviors, we also showed that the functional crosstalk between NTS1 and mu opioid receptors influences the supraspinally-mediated behaviors. Interestingly, sexual dimorphic action of morphine-induced pain inhibition was found in NTS1 null mice in the formalin test, suggesting that the endogenous NT system interacts differently with the opioid network in male and female mice. Altogether, these results demonstrated that NTS1 receptor activation operates downstream to the opioidergic transmission and that NTS1-selective agonists combined with morphine may act synergistically to reduce persistent pain.

Minimally invasive endoscopic bilateral decompression with a unilateral approach (endo-BiDUA) for elderly patients with lumbar spinal canal stenosis

OBJECTIVES

Endoscopic spinal surgery has become increasingly common year for year because it is a minimally invasive procedure. In our hospital, we introduced endoscopic bilateral decompression with a unilateral approach (endo-BiDUA) in 2006. In this paper, we review clinically and radiographically the elderly patients who underwent the endo-BiDUA.

METHODS

Fifteen patients aged over 65 years were included in this review. They had undergone endo-BiDUA between January 2006 and July 2008. Operation time, blood loss, complications, clinical outcome using the Japanese Orthopedic Association (JOA) score, and enlargement ratio of the dural tube on magnetic resonance imaging (MRI), were evaluated.

RESULTS

The mean operation time per level of endo-BiDUA was 144 min. Blood loss was about 60.2 mL. One patient had a post-surgical hematoma and required an additional laminectomy and removal of the hematoma 2 days after the surgery. No other complications such as dural tear, nerve root injury, or infection were encountered. All patients but one, who had a post-surgical hematoma, could start walking within 2 days following the surgery. Before surgery, the mean JOA score was 17.0 and it improved to about 23.3 after the surgery. The area of the dural tube increased to 408.0% after the surgery (range: 211-774%).

CONCLUSIONS

Endo-BiDUA facilitated the return of elderly patients with lumbar spinal canal stenosis to their original daily activities.

Clinical evaluation of tocilizumab for patients with active rheumatoid arthritis refractory to anti-TNF biologics: tocilizumab in combination with methotrexate

We retrospectively observed the clinical efficacy and safety of tocilizumab (TCZ) in 74 patients with rheumatoid arthritis (RA) at 13 hospitals, without any restrictions on disease duration or stage, treatment history, and other influencing factors. TCZ was infused by the approved method, and disease activity was evaluated every 4 weeks until week 24 using a joint disease activity score (DAS28). Remission and treatment response were categorised using European League Against Rheumatism (EULAR) definitions. We also analysed the impact of previous treatment with other biologics and of concomitant methotrexate (MTX) therapy on the efficacy of TCZ. At week 24, the DAS28 had improved from 5.5 to 2.7 and the EULAR remission rate was 55.2%. Good and moderate responses according to the EULAR criteria were obtained in 61 and 36% of the patients, respectively. The biologic-naïve group had a significantly better DAS28 (2.1 vs. 2.8) and a significantly higher "good" response rate (86% vs. 54%) than the biologic-exposed group. Although the TCZ + MTX treatment group and the TCZ monotherapy group had a good response rate of 71 and 48%, respectively, the difference was not significant. Based on these results, we conclude that TCZ is able to significantly alleviate disease symptoms in a wide range of patients with RA in a normal clinical context.