Application of regulation of reactive oxygen species and lipid peroxidation to disease treatment

Although many diseases in which reactive oxygen species (ROS) and free radicals are involved in their pathogenesis are known, and antioxidants that effectively capture ROS have been identified and developed, there are only a few diseases for which antioxidants have been used for treatment. Here, we discuss on the following four concepts regarding the development of applications for disease treatment by regulating ROS, free radicals, and lipid oxidation with the findings of our research and previous reports. Concept 1) Utilization of antioxidants for disease treatment. In particular, the importance of the timing of starting antioxidant will be discussed. Concept 2) Therapeutic strategies using ROS and free radicals. Methods of inducing ferroptosis, which has been advocated as an iron-dependent cell death, are mentioned. Concept 3) Treatment with drugs that inhibit the synthesis of lipid mediators. In addition to the reduction of inflammatory lipid mediators by inhibiting cyclooxygenase and leukotriene synthesis, we will introduce the possibility of disease treatment with lipoxygenase inhibitors. Concept 4) Disease treatment by inducing the production of useful lipid mediators for disease control. We describe the treatment of inflammatory diseases utilizing pro-resolving mediators and propose potential compounds that activate lipoxygenase to produce these beneficial mediators.

OP0062 EFFICACY AND SAFETY OF ADALIMUMAB WITH LOW AND HIGH DOSE-METHOTREXATE IN PATIENTS WITH RHEUMATOID ARTHRITIS WITH INADEQUATE RESPONSE TO METHOTREXATE: THE RANDOMISED CONTROLLED MIRACLE STUDY

Background

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that causes not only joint pain but also bone destruction resulting in impairment of quality of life. Tumor necrosis factor inhibitors have improved prognosis of patients with rheumatoid arthritis dramatically, especially in combination with methotrexate, however, the optimal dose of the concomitant methotrexate is unclear.

Objectives

To evaluate the efficacy and safety of adalimumab in combination with reduced dose of methotrexate in patients with early RA with inadequate response to methotrexate.

Methods

The MIRACLE study was a multinational, randomized, open-label study in patients with RA with inadequate response to methotrexate conducted in Asia. It compared low dose and high dose methotrexate upon starting adalimumab. Methotrexate-naive patients with RA with a disease duration of less than two years started methotrexate at 6 to 8 mg/week and increased it to the maximum tolerable dose by week 12. Patients who have not achieved remission according to simplified disease activity index (SDAI) despite methotrexate ≥ 10 mg/week at week 24 were randomised to the maximum tolerable dose of methotrexate group (10 to 25 mg/week) or the reduced dose group (6 to 8 mg/week) and started to receive subcutaneous adalimumab 40 mg every other week. The primary endpoint was non-inferiority in the achievement of SDAI remission at week 48 in the reduced dose group compared with the maximum tolerable dose group with a non-inferiority margin of -15% based on two-sided 90% confidence interval. (NCT03505008)

Results

A total of 300 patients were enrolled in the study. Among them, 291 started methotrexate and were included in the analysis. The mean age was 57.7±15.2 years, female was 74.6%, and the mean disease duration from the diagnosis of RA was 21.1±56.2 days. Anti-CCP antibody was positive in 211 (73.0%) and the mean SDAI at study enrollment was 26.5±12.4. At week 24, with the mean dose of methotrexate of 12.6±2.9 mg/week, 108 patients (37.1%) achieved remission according to SDAI and continued MTX monotherapy. 134 patients (46.0%) were randomised and started adalimumab with 68 patients in the maximum tolerable dose group and 66 patients in the reduced dose group. At week 48, the remission achievement rates were 38.4 % and 44.8 %, respectively, with the adjusted risk difference of the reduced dose group to the maximum tolerable dose group of 6.4% (-7.0% to 19.8%, 90% CI), which met the criterion for noninferiority. No significant difference was found in health assessment questionnaire disability index ≤0.5 (59.1% vs 62.0%, respectively, p=0.72) and in radiological remission rates (Δmodified total Sharp score ≤0.5, 66.3% vs 62.0 %, respectively, p=0.59). Adverse drug reactions tended to be more frequent in the maximum tolerable dose group than in the reduced dose group (22.1% vs 9.1%, respectively, p=0.06).

Conclusion

The MIRACLE randomised study demonstrated that, in patients with inadequate response to methotrexate, the efficacy of adalimumab with reduced dose of concomitant methotrexate was not inferior to that with maximum tolerable dose of methotrexate with better safety profile.

Disclosure of Interests

Hiroya Tamai Speakers bureau: Eisai, Grant/research support from: Eisai, Kei Ikeda Speakers bureau: AbbVie, Eisai, Eli Lilly, Novartis, Gilead, Asahi-Kasei, Grant/research support from: Mitsubishi-Tanabe, Toshiaki Miyamoto: None declared, Hiroaki Taguchi: None declared, Chang-Fu Kuo: None declared, Kichul Shin: None declared, Shintaro Hirata Speakers bureau: AbbVie, Asahi-Kasei, Astellas, Ayumi, Bristol Myers Squibb, Celgene, Chugai, Eisai, Eli Lilly, Gilead, Glaxo SmithKline, Janssen, Kyorin, Novartis, Pfizer, Sanofi, Tanabe-Mitsubishi, UCB, Paid instructor for: AbbVie, Mitsubishi-Tanabe, Consultant of: AbbVie, Astellas, Bristol Myers Squibb, Eisai, Gilead, Ily Lilly, Grant/research support from: AbbVie, Asahi-Kasei, Eisai, Otsuka, Sanofi, Shionogi, Chugai, Pfizer, Tanabe-Mitsubishi, Eli Lilly, UCB, yutaka okano: None declared, Shinji Sato Speakers bureau: AbbVie, Eisai, Grant/research support from: AbbVie, Eisai, Hidekata Yasuoka Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Daiichi-Sankyo, Eisai, Kissei, Takeda, Mitsubishi-Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Janssen, Sanofi, Teijin, Boehringer-Ingelheim, Bayer, Glaxo Smith Kline, Paid instructor for: AbbVie, Consultant of: AbbVie, Asahi Kasei, Grant/research support from: Mitsubishi-Tanabe, Takeda, Daiichi-Sankyo, Chugai, Bristol-Myers, MSD, Astellas, In Ah Choi Speakers bureau: Abbvie, Eisai, Sung-Hwan Park: None declared, Meng-Yu Weng Paid instructor for: Novartis, Eli Lilly, ChuGai, Abbvie, Consultant of: Abbvie, Masataka Kuwana Speakers bureau: Astellas, Asahi Kasei Pharma, Boehringer-Ingelheim, Chugai, Eisai, Janssen, Mochida, Nippon Shinyaku, Ono Pharmaceuticals, Pfizer, Mitsubishi-Tanabe, Consultant of: Boehringer-Ingelheim, Kissei, Mochida, Grant/research support from: AbbVie, Asahi Kasei Pharma, Boehringer-Ingelheim, Chugai, Eisai, MBL, Nippon Shinyaku, Ono Pharmaceuticals, Mitsubishi-Tanabe, Yun Jong Lee Grant/research support from: Yuhan, Tomonori Ishii Speakers bureau: Chugai, Mitsubishi-Tanabe, Glaxo Smith Kline, Pfizer, Eli Lilly, Janssen, AbbVie, Eisai, Astellas, Jinhyun Kim: None declared, Hideto Kameda Speakers bureau: AbbVie, Pfizer, Consultant of: AbbVie, Grant/research support from: AbbVie, Eisai, Toshihisa Kojima Speakers bureau: AbbVie, Pfizer, Eisai, Grant/research support from: AbbVie, Han Joo Baek: None declared, Ping-Ning Hsu: None declared, Chun-Ming Huang Paid instructor for: Abbvie, Pfizer, Tien-Tsai Cheng Paid instructor for: Abbvie, Grant/research support from: Abbvie, Wan-Yu Sung: None declared, Takehiro Taninaga Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Masahiko Mori Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Hideaki Miyagishi Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Yasunori Sato Speakers bureau: Eisai Co., Ltd. Kowa Company, Ltd., Consultant of: MOCHIDA PHARMACEUTICAL CO., LTD, Tsutomu Takeuchi Speakers bureau: Astellas, AbbVie, Ayumi, Bristol Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Glaxo Smith Kline, Janssen, Mitsubishi-Tanabe, Nippon-kayaku, Novartis, Pfizer, Sanofi, UCB, Grant/research support from: Asahi Kasei, AbbVie, Ayumi, Boehringer-Ingelheim, Chugai, Eisai, Eli Lilly, Mitsubishi-Tanabe, Sanofi, UCB, Yuko Kaneko Speakers bureau: Asahi Kasei, Astellas, Ayumi, Bristol Myers Squibb, Chugai, Eisai, Elli Lilly, Mitsubishi-Tanabe, Novartis, UCB, Grant/research support from: AbbVie, Chugai, Eisai, Mitsubishi-Tanabe, UCB.

Treatment outcomes for infantile spasms in Japanese children with Down syndrome

BACKGROUND

The aim of this study was to assess the treatment response to conventional antiepileptic drugs and low-dose adrenocorticotropic hormone therapy for infantile spasms in children with Down syndrome.

METHODS

We retrospectively investigated the response and relapse rates, electroencephalography findings, patient characteristics during drug withdrawal, and developmental outcome in 10 children with Down syndrome treated for infantile spasms in our hospital.

RESULTS

All patients showed cessation of infantile spasms and achieved electroencephalographic normalization. Spasm relapse occurred in one of 10 patients (10%). Antiepileptic drugs have been withdrawn for seven of 10 patients (70%), none of whom have experienced seizure relapse since drug withdrawal. The median developmental quotient (n = 8) was 20.5, which shows that the developmental outcome was unfavorable. Low-dose adrenocorticotropic hormone therapy achieved a low seizure remission rate of 28.6%.

CONCLUSIONS

Elucidation of the optimal treatment for infantile spasms in children with Down syndrome is needed to reduce the duration of infantile spasms and improve the developmental outcome.

N-Acetylcysteine prevents amyloid-β secretion in neurons derived from human pluripotent stem cells with trisomy 21

Down syndrome (DS) is caused by the trisomy of chromosome 21. Among the many disabilities found in individuals with DS is an increased risk of early-onset Alzheimer's disease (AD). Although higher oxidative stress and an upregulation of amyloid β (Aβ) peptides from an extra copy of the APP gene are attributed to the AD susceptibility, the relationship between the two factors is unclear. To address this issue, we established an in vitro cellular model using neurons differentiated from DS patient-derived induced pluripotent stem cells (iPSCs) and isogenic euploid iPSCs. Neurons differentiated from DS patient-derived iPSCs secreted more Aβ compared to those differentiated from the euploid iPSCs. Treatment of the neurons with an antioxidant, N-acetylcysteine, significantly suppressed the Aβ secretion. These findings suggest that oxidative stress has an important role in controlling the Aβ level in neurons differentiated from DS patient-derived iPSCs and that N-acetylcysteine can be a potential therapeutic option to ameliorate the Aβ secretion.

A nation-wide survey of Japanese pediatric MOG antibody-associated diseases

OBJECTIVE

To elucidate the clinical characteristics of Japanese pediatric patients with acquired demyelinating diseases (ADS), positive for myelin oligodendrocyte glycoprotein antibody (MOG-IgG), we conducted a nation-wide survey.

METHODS

Information about pediatric patients under 18 years old with ADS was solicited with surveys sent to 323 facilities. In an initial survey, we asked whether the center had any patients with ADS, and the MOG-IgG serostatus of the patients. In a follow-up survey, we requested more precise information on patients with ADS.

RESULTS

Initial survey: 263 replies providing information on 175 patients were received. MOG-IgG were examined in 78 patients and 54 of those (69%) were positive for MOG-IgG. Follow-up survey: The characteristic involvement was optic neuritis, with visual disturbance and optic pain as characteristic symptoms. The relapse rate was 44% in patients positive for MOG-IgG, which was higher than that in seronegative patients (38%). For acute phase treatments, corticosteroid (CS), plasma exchange, and intravenous immunoglobulin (IVIG) were useful. To prevent relapse, CS, intermittent IVIG, immunosuppressants, and monoclonal antibodies were useful, but the efficacies of disease modifying drugs were uncertain. Sequelae such as visual disturbance, cognitive impairment, motor dysfunction, and epilepsy were observed in 11% of patients with MOG-IgG.

CONCLUSIONS

MOG antibody-associated diseases were found to be common among pediatric ADS patients. Since a variety of sequelae were observed in these patients, it is important to identify the appropriate treatment to ensure the best outcome. The presence of the MOG autoantibody should be taken into consideration as part of the diagnostic criteria for pediatric ADS.

AB0253 COMPARISON OF PHARMACODYNAMICS OF METHOTREXATE AS METHOTREXATE-POLYGLUTAMATES CONCENTRATIONS IN RHEUMATOID ARTHRITIS; INTERIM DATA EVALUATION OF MIRACLE STUDY CONDUCTED IN JAPAN, KOREA AND TAIWAN

Background:

Methotrexate (MTX) is the first-line therapy for rheumatoid arthritis (RA). The concentrations of MTX-polyglutamates (PG) in erythrocytes, an active form of MTX, are useful markers for the optimal usage of MTX in patients with RA. The concentrations of MTX-PG have been reported to be different between Japanese and Caucasians. However, the difference among Asian ethnicity remains unclear.

Objectives:

To examine MTX-PG concentrations in association with MTX dose during the first 24 weeks after the initiation of MTX for newly diagnosed RA patients in Japan, Korea and Taiwan.

Methods:

MIRACLE study is a multicenter, open-label, randomized, 48 weeks interventional study conducted in Japan, Korea and Taiwan to evaluate non-inferiority of low dose to high dose of MTX as an add-on therapy to adalimumab in 300 patients with RA who do not achieve remission after 24 weeks MTX monotherapy in stipulated dosage. In the first 24 weeks, MTX was started at 6 to 8 mg/week for newly diagnosed RA patients, and promptly escalated to the maximum tolerable dose in 12 weeks in principle. This interim data evaluation was intended to investigate the differences among countries in the relationship between MTX dose, safety and MTX-PG concentrations in erythrocytes during the first 24 weeks. The efficacy of the treatment is not included at this point.

Results:

A total of 166 patients (106 in Japan, 35 in Korea, 25 in Taiwan) were included in this interim data. The age at treatment initiation was 57.2 years old on average and female was 79.5%. The time course changes in total and individual MTX-PG levels differed in the three countries. At 24 weeks, whereas the mean total MTX-PG concentrations were comparable (112.9 nmol/L in Japan, 104.4 nmol/L in Korea, and 115.7 nmol/L in Taiwan) with a dose of MTX of 12.3 mg/week, 14.1 mg/week, and 12.2 mg/week, respectively, the individual MTX-PG concentrations were different. The MTX-PG1 and MTX-PG2 concentrations were lower in Korea than Japan and Taiwan whereas MTX-PG3, MTX-PG4 and MTX-PG5 concentrations were the highest in Korea.

Conclusion:

The distribution of short-chain and long-chain MTX-PG concentrations were various among Asian countries despite similar dose of MTX administration: NCT03505008.

Disclosure of Interests:

Hiroya Tamai: None declared, Yuko Kaneko Speakers bureau: AbbVie, Astellas, Ayumi, Bristol–Myers Squibb, Chugai, Eisai, Eli Lilly, Hisamitsu, Jansen, Kissei, Kirin, Pfizer, Sanofi, Takeda, Tanabe-Mitsubishi, and UCB., Grant/research support from: Sanofi, Hideto Kameda Speakers bureau: AbbVie, Pfizer, Consultant of: AbbVie, Grant/research support from: AbbVie, Eisai, Masataka Kuwana Speakers bureau: Astellas, Asahi Kasei Pharma, Boehringer- Ingelheim, Chugai, Eisai, Janssen, Mochida, Nippon Shinyaku, Ono Pharmaceuticals, Pfizer, Mitsubishi-Tanabe, Consultant of: Corbus, Grant/research support from: AbbVie, Asahi Kasei Pharma, Boehringer- Ingelheim, Chugai, Eisai, MBL, Nippon Shinyaku, Ono Pharmaceuticals, Mitsubishi-Tanabe, Yutaka Okano: None declared, Tomonori Ishii Speakers bureau: Chugai, Mitsubishi- Tanabe, Glaxo Smith Kline, Pfizer, Eli Lilly, Janssen, AbbVie, Eisai, Astellas, Kei Ikeda Speakers bureau: AbbVie, Eli Lilly, Novartis, Mitsubishi-Tanabe, Eisai, BMS, Grant/research support from: Mitsubishi-Tanabe, Hiroaki Taguchi: None declared, Shinji Sato: None declared, Toshiaki Miyamoto: None declared, Shintaro Hirata Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Ayumi, Bristol Myers Squibb, Chugai, Eisai, Eli Lilly, Janssen, Glaxo Smith Kline, Kissei, Pfizer, Sanofi, Mitsubishi- Tanabe, UCB, Paid instructor for: AbbVie, Mitsubishi- Tanabe, Consultant of: AbbVie, Eisai, Gilead, Grant/research support from: AbbVie, Chugai, Mitsubishi-Tanabe, UCB, Hidekata Yasuoka Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Daiichi- Sankyo, Eisai, Kissei, Takeda, Mitsubishi- Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Janssen, Sanofi, Teijin, Boehringer- Ingelheim, Bayer, Glaxo Smith Kline, Paid instructor for: AbbVie, Consultant of: AbbVie, Asahi Kasei, Grant/research support from: Mitsubishi-Tanabe, Takeda, Daiichi-Sankyo, Chugai, Bristol-Myers, MSD, Astellas, Toshihisa Kojima Speakers bureau: AbbVie, Pfizer, Eisai, Grant/research support from: AbbVie, Sung-Hwan Park: None declared, Kichul Shin: None declared, Han Joo Baek: None declared, Yun Jong Lee Grant/research support from: research fund, In Ah Choi Speakers bureau: Abbvie, Eizai, Grant/research support from: Abbvie, Eizai, Jinhyun Kim: None declared, Ping-Ning Hsu: None declared, Chang-Fu Kuo: None declared, Chun-Ming Huang Paid instructor for: AbbVie, Pfizer, Meng-Yu Weng Consultant of: AbbVie, Wan-Yu Sung: None declared, Wen-Chan Tsai: None declared, Tien-Tsai Cheng Paid instructor for: AbbVie, Grant/research support from: AbbVie, Takehiro Taninaga Shareholder of: Eisai Co., Ltd., Employee of: Eisai Co., Ltd., Masahiko Mori Shareholder of: Eisai Co., Ltd., Employee of: Eisai Co., Ltd., Hideaki Miyagishi Employee of: Eisai Co., Ltd., Yasunori Sato: None declared, Tsutomu Takeuchi Speakers bureau: Astellas, Abbvie, Daiichi Sankyo, Ayumi, Eisai, GlaxoSmithKline, Mitsubishi Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Bristol Myers Squibb, Janssen, UCB, TaishoToyama, Sanofi–Aventis, Nipponkayaku, Taiho, Gilead, Boehringer Ingelheim, Grant/research support from: Asahikasei, Astellas, Abbvie, Daiichi Sankyo, Ayumi, Eisai, Takeda, Mitsubishi Tanabe, Chugai, Eli Lilly, UCB, Sanofi–Aventis, Nipponkayaku, Boehringer Ingelheim

POS0455 EFFECT OF ANTI-Ro/SSA ANTIBODIES FOR TREATMENT RESPONSE TO METHOTREXATE IN RHEUMATOID ARTHRITIS: A RETROSPECTIVE MULTICENTER OBSERVATIONAL STUDY

Background:

Several previous observational studies have suggested that patients with anti-Ro/SSA antibody-positive rheumatoid arthritis (RA) may respond poorly to treatment, including tumor necrosis factor inhibitors1. However, its influence on methotrexate (MTX) treatment, which is the anchor drug of treat-to-target strategy in RA treatment, remains unclear.

Objectives:

We compared the clinical response to MTX in both anti-Ro/SSA antibody-positive and -negative patients with MTX-naiive RA and investigated the reasons for the difference in response.

Methods:

We recruited 210 consecutive patients with RA who were newly started on MTX in this retrospective cohort study. The effect of the presence of anti-Ro/SSA antibodies on achieving low disease activity (LDA) of DAS28-CRP at six months after initiating MTX was investigated by using logistic regression analysis. CDAI, SDAI, concomitant using DMARDs and painkillers, patient’s and evaluator’s VAS, tender joint counts, and swollen joint counts at six months were also compared between the anti-Ro/SSA-positive patients and -negative patients. Missing data were imputed by using multiple imputations before multivariate analysis.

Results:

32 anti-Ro/SSA antibody-positive patients and 178 anti-Ro/SSA antibody-negative patients were included. The rate of achieving DAS28-LDA at six months was significantly lower in the anti-Ro/SSA antibody-positive patients than those in the anti-Ro/SSA antibody-negative patients (56.2% versus 75.8%, P=0.03). in the logistic regression analysis, the presence of anti-Ro/SSA antibodies was an independent negative predictor for achieving DAS-28-LDA at six months (OR:0.431, 95%CI: 0.190-0.978, P=0.044) (Table1). Anti-Ro/SSA antibody-positive patients had significantly higher patient’s VAS at six months (median [IQR]: 22 [15-41] vs 19 [5-30], P=0.038), and prescribed NSAIDs (37.5% vs 18.0%, P=0.018). CDAI and SDAI after six months were not significantly different between the group.

Conclusion:

The presence of anti-Ro/SSA antibodies might be one of the predictive factors for the insufficient response to treat to target strategy in RA treatment. Residual pain was suspected as one of the mechanisms contributing to the lesser clinical response of MTX in anti-Ro antibody-positive RA.

References:

[1]Ran Matsudaira wt al. J Rheumatol 2011;38(11):2346-54

Table 1.

Logistic regression analysis for the rate of achieving DAS28 low disease activity at six months.

Risk factor Odds ratio95%CIP valueAge at onset0.9930.968-1.0180.586Sex (woman)0.6430.300-1.3840.258RF-positive1.9620.853-4.5110.112ACPA-positive0.5520.225-1.3510.192Anti-Ro/SSA antibody-positive0.4310.190-0.9780.044

Disclosure of Interests:

None declared

AB0660 COVID-19 SHARES CLINICAL FEATURES WITH ANTI-MELANOMA DIFFERENTIATION ASSOCIATED PROTEIN 5 POSITIVE DERMATOMYOSITIS AND ADULT STILL’S DISEASE

Background:

The coronavirus disease 2019 (COVID-19), caused by a novel corona virus named SARS-CoV-2, has emerged as a global pandemic. Severe inflammatory process is one of main pathogenesis of COVID-19 and this involves cytokine storm along with overactivation of macrophage. On another front, cytokine storm with macrophage activation is frequently observed in various connective tissue diseases including dermatomyositis with positive antimelanoma differentiation-associated protein 5 (anti-MDA5) autoantibodies and adult Still’s disease. Macrophage activation during inflammatory states is partially characterized by an increased serum ferritin levels and hyperferritinaemia and characteristics shared by the three diseases are a topic of interest to rheumatologists, however, no study has evaluated anti-MDA5-positive dermatomyositis and adult Still’s disease in comparison to COVID-19.

Objectives:

The aim of this study was to highlight the homology and heterogeneity of COVID-19, anti-MDA5 dermatomyositis, and adult Still’s disease by comparing clinical pictures of each disease in order to discuss their respective pathogeneses.

Methods:

We reviewed consecutive, newly diagnosed, untreated patients with COVID-19, anti-MDA5 dermatomyositis, or adult Still’s disease. We compared their clinical, laboratory, and radiological characteristics, including the prevalence of macrophage activation syndrome and lung involvement in each disease.

Results:

The numbers of patients with COVID-19, anti-MDA5 dermatomyositis, and adult-onset Still’s disease with hyperferritinaemia (serum ferritin ≥ 500ng/dL) who were included for main analysis were 22, 14, and 59, respectively. COVID-19 and adult Still’s disease both featured hyperinflammatory status, such as high fever and elevated serum C-reactive protein, whereas COVID-19 and anti-MDA5 dermatomyositis both presented with severe interstitial lung disease and hypoxaemia. While two-thirds of the patients in each group met the criteria for macrophage-activated syndrome that is used in systemic juvenile idiopathic arthritis, the HScore, an indicator of haemophagocytic lymphohistiocytosis, was low in anti-MDA5 dermatomyositis and COVID-19 even in severe or critical cases. The findings of chest computed tomography were similar between COVID-19 and anti-MDA5 dermatomyositis (Figure 1).

Conclusion:

COVID-19 shared clinical features with rheumatic diseases characterised by hyperferritinaemia, including anti-MDA5 dermatomyositis and adult Still’s disease. These findings should be investigated further in order to shed light on the pathogenesis of not only COVID-19 but also the aforementioned rheumatic diseases.

References:

[1]Mehta P, McAuley DF, Brown M, et al. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. (2020) 395: 1033-4.

[2]Gono T, Sato S, Kawaguchi Y, et al. Anti-MDA5 antibody, ferritin and IL-18 are useful for the evaluation of response to treatment in interstitial lung disease with anti-MDA5 antibody-positive dermatomyositis. Rheumatology (Oxford). 2012; 51(9):1563-70.

Figure 1.

Imaging characteristics of chest CT scans in patients with COVID-19, anti-MDA5 dermatomyositis, and adult Still’s disease A)Bilateral ground-glass and consolidative opacities with peripheral distribution in COVID-19. B)Bilateral ground-glass opacities with peripheral consolidations in anti-MDA5 dermatomyositis. C)Pleural effusion with pleural thickening on the left side in adult Still’s disease.

Disclosure of Interests:

Yasushi Kondo: None declared., Yuko Kaneko: None declared., Hisoshi Takei: None declared., Hiroya Tamai: None declared., Tsutomu Takeuchi Grant/research support from: received research grants outside the submitted work from Abbvie, Astra Zeneca, Bristol Myers Squibb, Chugai Pharmaceutical, Eisai Pharmaceutical, Janssen Pharmaceutical, Mitsubishi Tanabe Pharma Corporation, Novartis, Takeda Pharmaceutical, Abbott Japan Co., Ltd., Astellas Pharma, Ltd., Daiichi Sankyo, Pfizer, Sanofi–Aventis, Santen Pharmaceutical, Teijin Pharma Ltd., Asahikasei Pharma Corp., SymBio Pharmaceuticals Ltd., Celtrion, Nipponkayaku Co. Ltd., Eli Lilly Japan, and Taisho Toyama Pharmaceutical.

Secular trends in longevity among people with Down syndrome in Japan, 1995-2016

BACKGROUND

Life expectancy in Japan has increased dramatically and is one of the longest in the world. However, the changes in lifespan in Japanese individuals with congenital diseases remain unknown. We investigated secular changes in the lifespan of people with Down syndrome over the last 20 years.

METHODS

We observed secular trends in the number of stillbirths, deaths and the mortality rates at ages 20, 40, and 60 among all deaths registered with Down syndrome as the cause of death (ICD10 code: Q90) in the Japan national death registry database between 1995 and 2016. Changes in the median age at death between 1995-2005 and 2006-2016 were investigated based on sex and history of surgery.

RESULTS

We identified 240 stillbirths and 1,099 deaths in this period. The annual number of stillbirths and deaths above the age of 1 year increased, whereas the number of deaths below 1 year did not change. The proportional mortality indicator at ages 20, 40, and 60 increased from 21.7%, 11.7%, and 1.7% in 1995 to 69.9%, 66.7%, and 36.6% in 2016, respectively. The median age at death was higher in females, individuals without a surgical history, and deaths occurring in 2006-2016. The median age at death increased over the period in those without a surgical history.

CONCLUSIONS

The age at death among people with Down syndrome has increased over the last 20 years, with currently 1 in 3 persons living over 60 years, necessitating adequate social welfare services in this aging population.

Myovascular Preserving Open-Door Laminoplasty for Cervical Spondylotic Myelopathy With Miniplate Fixation

OBJECTIVE

Laminoplasty is an effective procedure for treating cervical spondylotic myelopathy. We conduct myovascular preserving open-door laminoplasty (MPLP) in combination with a laminoplasty plate to improve the stability of the enlarged lamina. We compare the details of the MPLP technique with conventional open-door laminoplasty.

METHODS

We compared 25 cases of MPLP (mean age = 70.5, mean follow-up period = 19 months) with 15 controls who received conventional open-door laminoplasty using hydroxyapatite spacers (mean age = 74, mean follow-up period = 53 months). Regarding surgical outcomes, blood loss, operative time, Japanese Orthopaedic Association score, and postoperative visual analog score for neck pain were measured. Regarding image analysis, preoperative and postoperative range of motion (ROM), C2-7 angle, implant back out, hinge bone fusion time, presence or absence of hinge bone union failure, and posterior neck fat infiltration rate were evaluated.

RESULTS

Operative time was significantly shorter for MPLP, and postoperative neck pain was significantly decreased. In image evaluation, %ROM was significantly increased in MPLP, but no difference in C2-7 angle existed between the 2 groups. Implant back out was not recognized in either group. In MPLP, the hinge union period was significantly shortened, and the postoperative fat infiltration rate was significantly decreased.

CONCLUSIONS

We were able to reduce neck pain after surgery by an approach entailing longitudinal splitting of the spinous processes. We were able to ensure shorter operation times due to cervical plates and better hinge bone fusion times due to initial stability.

LEVEL OF EVIDENCE

4.

Relationship between Skeletal Muscle Mass, Bone Mineral Density, and Trabecular Bone Score in Osteoporotic Vertebral Compression Fractures

STUDY DESIGN

A retrospective observational study was performed.

PURPOSE

We investigated the relationships between skeletal muscle mass, bone mineral density (BMD), and trabecular bone score (TBS) in patients with osteoporotic vertebral compression fractures (VCFs).

OVERVIEW OF LITERATURE

The TBS has attracted attention as a measurement of trabecular bone microarchitecture. It is derived from data obtained using dual-energy X-ray absorptiometry (DXA) and is a reported indicator of VCFs, and its addition to the Fracture Risk Assessment Tool increases the accuracy of fracture prediction.

METHODS

BMD, skeletal muscle mass, and TBS were measured in 142 patients who visited Shimoshizu National Hospital from April to August 2019. Patients were divided into a VCF group and a non-VCF group. Whole-body DXA scans were performed to analyze body composition, including appendicular skeletal muscle mass index (SMI; lean mass [kg]/height [m2]) and BMD. The diagnostic criteria for sarcopenia was an appendicular SMI <5.46 kg/m2. A logistic regression analysis was conducted to identify the risk factors for VCFs.

RESULTS

The significant (p<0.05) findings (VCF group vs. non-VCF group, respectively) included age (79 vs. 70 years), femoral BMD (0.50 vs. 0.58 g/cm2), TBS (1.25 vs. 1.29), and lower limb muscle mass (8.6 vs. 9.9 kg). The VCF group was significantly older and had a lower femur BMD and decreased leg muscle mass than the non-VCF group. Based on the multiple logistic regression analysis, lower femoral BMD and decreased leg muscle mass were identified as risk factors for vertebral fracture independent of age, but the TBS was not.

CONCLUSIONS

Patients with VCFs had low BMD, a low TBS, and low skeletal muscle mass. Lower femoral BMD and decreased leg muscle mass were identified as risk factors for VCFs independent of age, whereas the TBS was not identified as a risk factor for VCFs.

Helicobacter pylori test-and-treat strategy for second-year junior high school students aimed at the prevention of gastric cancer in Takatsuki City

BACKGROUND

More than 90% of gastric cancer cases are caused by Helicobacter pylori infections. To prevent gastric cancer, an H pylori test-and-treat strategy targeting young people has been implemented in various places in Japan. In this study, we evaluated the effectiveness of an H pylori test-and-treat strategy for second-year junior high school students in Takatsuki City.

MATERIALS AND METHODS

In 2014-2017, a urine-based H pylori test was used for initial screening. The final infection status was determined by a ¹³ C-urea breath test (¹³ C-UBT). Successful H pylori eradication was confirmed by ¹³ C-UBT 3 months after treatment. First-line eradication therapy was changed from 10 mg of rabeprazole, 750 mg of amoxicillin, and 200 mg of clarithromycin twice daily for 7 days in 2014 to 20 mg of vonoprazan, 750 mg of amoxicillin, and 200 mg of clarithromycin twice daily for 7 days in 2015-2017. Second-line eradication therapy included 10 mg of rabeprazole, 750 mg of amoxicillin, and 250 mg of metronidazole twice daily for 7 days.

RESULTS

In total, 8067 of 13 055 students participated this project and 206 students were diagnosed with H pylori infection. The success rate of first-line therapy was 45.9% in 2014 and 83.8% after the revised first-line therapy was administered. The final eradication rate was 98.5%. There were no severe side effects.

CONCLUSION

Our results support the use of the H pylori test-and-treat strategy for junior high school students as a safe approach for the prevention of gastric cancer. H pylori eradication therapy with vonoprazan could be a standard therapy in children.

FRI0505 TOCILIZUMAB DISCONTINUATION AFTER REMISSION ACHIEVEMENT IN PATIENTS WITH ADULT STILL’S DISEASE

Background:

The efficacy of tocilizumab, an interleukin (IL)-6 receptor inhibitor, has been proved in patients with adult Still’s disease on suppressing systemic inflammation and decreasing glucocorticoid dose. However, whether tocilizumab can be discontinued after remission achievement is unclear.

Objectives:

To clarify the possibility of tocilizumab discontinuation in patients with adult Still’s disease who achieved remission with tocilizumab.

Methods:

Consecutive patients with adult Still’s disease diagnosed according to the Yamaguchi’s criteria in our hospital from April 2012 until September 2019 were retrospectively reviewed. Patients who were in good control with tocilizumab were included in the analysis, and their clinical courses were collected from their medical charts. Patients were divided according to the presence of recurrence after tocilizumab discontinuation and compared.

Results:

Among 42 patients with adult Still’s disease who had a history of intravenous tocilizumab of 8mg/kg use, 13 patients discontinued tocilizumab following a good disease control. During the mean observation period of 26.4 months, six patients (46%) remained in remission while seven patients (54%) developed recurrence after tocilizumab discontinuation. The sex and the mean observation period were not different between the patients with recurrence and those without (71% vs 50%, p=0.43; 27.3 months vs 25.4 months, p=0.93, respectively), but the age at tocilizumab discontinuation tended to be higher in the recurrence group than the non-recurrence group (64.0 years vs 46.5 years, p=0.08). The disease activity including swollen joint counts and laboratory data at tocilizumab discontinuation were comparable between the two groups (serum ferritin levels, 88 ng/mL vs 122 ng/mL, p=0.67). While the duration of tocilizumab use was not different between the two groups (29.4 months vs 39.5 months, p=0.40), the mean interval of tocilizumab infusion at tocilizumab discontinuation in the recurrence group was 3.6 weeks, shorter than the 6.7 weeks in the non-recurrence group (p=0.03). The median dose of prednisolone at tocilizumab discontinuation was 5.0 mg/day in the recurrence group and 0.0 mg/day in the non-recurrence group (p=0.06). In the recurrence group, the duration from the last tocilizumab administration to recurrence was 7.8 months, and the median dose of prednisolone at recurrence was 5.0 mg/day.

Conclusion:

Patients with adult Still’s disease remaining in remission with a longer interval of tocilizumab administration and a lower dose of prednisolone was likely to succeed in withdrawal of tocilizumab.

Disclosure of Interests:

Hiroya Tamai: None declared, Yuko Kaneko Speakers bureau: Dr. Kaneko reports personal fees from AbbVie, personal fees from Astellas, personal fees from Ayumi, personal fees from Bristol-Myers Squibb, personal fees from Chugai, personal fees from Eisai, personal fees from Eli Lilly, personal fees from Hisamitsu, personal fees from Jansen, personal fees from Kissei, personal fees from Pfizer, personal fees from Sanofi, personal fees from Takeda, personal fees from Tanabe-Mitsubishi, personal fees from UCB, Tsutomu Takeuchi Grant/research support from: Eisai Co., Ltd, Astellas Pharma Inc., AbbVie GK, Asahi Kasei Pharma Corporation, Nippon Kayaku Co., Ltd, Takeda Pharmaceutical Company Ltd, UCB Pharma, Shionogi & Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Daiichi Sankyo Co., Ltd., Chugai Pharmaceutical Co. Ltd., Consultant of: Chugai Pharmaceutical Co Ltd, Astellas Pharma Inc., Eli Lilly Japan KK, Speakers bureau: AbbVie GK, Eisai Co., Ltd, Mitsubishi-Tanabe Pharma Corporation, Chugai Pharmaceutical Co Ltd, Bristol-Myers Squibb Company, AYUMI Pharmaceutical Corp., Eisai Co., Ltd, Daiichi Sankyo Co., Ltd., Gilead Sciences, Inc., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd.

Clinical findings in patients with febrile seizure after 5 years of age: A retrospective study

OBJECTIVE

Febrile seizures (FSs) typically occur in infants and children between 6 and 60 months of age. Rarely, FS can occur in late childhood (late FS [LFS]; >5 years of age); however, the clinical features of LFS remain unclear. We aimed to clarify the clinical features of LFS.

METHODS

We retrospectively analyzed data from patients with LFS who visited Hirakata City Hospital between January 2004 and December 2014. We defined LFS as a seizure accompanied by fever (temperature ≥38 °C) occurring after 5 years of age, without a central nervous system infection.

RESULTS

A total of 505 patients (349 boys, 156 girls: 5-14 years old) were included. A history of FS before 60 months of age was observed in 319 of 460 patients (69.3%) with sufficient information about previous FS history among the 505 patients enrolled. LFS was more likely to occur in males (69.1%). Seizure duration was ≤15 min in 87.4% of cases. A family history of FS in first-degree relatives was observed in 103/327 cases (31.5%). Among LFS cases, 45% occurred at 5 years of age, and 92.1% experienced only one seizure after 5 years of age. The number of seizure episodes gradually lessened with age, decreasing drastically to 5.6% of cases older than 9 years.

CONCLUSIONS

Our findings suggest that sex differences, seizure duration, and family history were similar for LFS and FS. Over 90% patients with LFS experienced no recurrence after 5 years of age. Further study is needed to verify the recurrence rate of LFS.

Simultaneous MR neurography and apparent T2 mapping of cervical nerve roots before microendoscopic surgery to treat patient with radiculopathy due to cervical disc herniation: Preliminary results

There is no imaging modality to quantitatively evaluate compressed cervical nerve roots in cervical radiculopathy. Here we sought to evaluate the usefulness of simultaneous apparent T2 mapping and neurography with nerve-sheath signal increased with inked rest-tissue rapid acquisition of relaxation-enhancement imaging (SHINKEI-Quant) to evaluate compressed nerves quantitatively in patients with cervical radiculopathy due to cervical disc hernia before microendoscopic surgery. One patient with cervical radiculopathy due to cervical disc hernia before microendoscopic surgery and 5 healthy subjects underwent simultaneous apparent T2 mapping and neurography with SHINKEI-Quant. The patient was a 49-year-old man with severe right upper arm pain and numbness. Based on MRI images, we suspected right C7 radiculopathy due to C6-7 cervical disc hernia. The T2 relaxation times of the cervical dorsal root ganglia of the brachial plexus bilaterally at C5-C8 were measured. We observed no significant differences in T2 relaxation times between the nerve roots on the left and right at each spinal level with values in healthy subjects. In our patient, neurography revealed swelling of the right C7 nerve, and a prolonged T2 relaxation time compared with that of the contralateral, unaffected C7 nerve. We performed microendoscopic surgery and the symptoms improved. We were able to evaluate the injured nerve root quantitatively in a patient with cervical radiculopathy using the SHINKEI-Quant technique, being the first study to our knowledge to show the usefulness of this technique to evaluate cervical radiculopathy quantitatively before microendoscopic surgery.

Diffusion tensor tractography of the lumbar nerves before a direct lateral transpsoas approach to treat degenerative lumbar scoliosis

OBJECTIVEThe purpose of this study was to determine the relationship between vertebral bodies, psoas major morphology, and the course of lumbar nerve tracts using diffusion tensor imaging (DTI) before lateral interbody fusion (LIF) to treat spinal deformities.METHODSDTI findings in a group of 12 patients (all women, mean age 74.3 years) with degenerative lumbar scoliosis (DLS) were compared with those obtained in a matched control group of 10 patients (all women, mean age 69.8 years) with low-back pain but without scoliosis. A T2-weighted sagittal view was fused to tractography from L3 to L5 and separated into 6 zones (zone A, zones 1-4, and zone P) comprising equal quarters of the anteroposterior diameters, and anterior and posterior to the vertebral body, to determine the distribution of nerves at various intervertebral levels (L3-4, L4-5, and L5-S1). To determine psoas morphology, the authors examined images for a rising psoas sign at the level of L4-5, and the ratio of the anteroposterior diameter (AP) to the lateral diameter (lat), or AP/lat ratio, was calculated. They assessed the relationship between apical vertebrae, psoas major morphology, and the course of nerve tracts.RESULTSAlthough only 30% of patients in the control group showed a rising psoas sign, it was present in 100% of those in the DLS group. The psoas major was significantly extended on the concave side (AP/lat ratio: 2.1 concave side, 1.2 convex side). In 75% of patients in the DLS group, the apex of the curve was at L2 or higher (upper apex) and the psoas major was extended on the concave side. In the remaining 25%, the apex was at L3 or lower (lower apex) and the psoas major was extended on the convex side. Significant anterior shifts of lumbar nerves compared with controls were noted at each intervertebral level in patients with DLS. Nerves on the extended side of the psoas major were significantly shifted anteriorly. Nerve pathways on the convex side of the scoliotic curve were shifted posteriorly.CONCLUSIONSA significant anterior shift of lumbar nerves was noted at all intervertebral levels in patients with DLS in comparison with findings in controls. On the convex side, the nerves showed a posterior shift. In LIF, a convex approach is relatively safer than an approach from the concave side. Lumbar nerve course tracking with DTI is useful for assessing patients with DLS before LIF.

Post-Operative Spinal Epidural Hematoma after Thoracic and Lumbar Spinous Process-Splitting Laminectomy for Thoracic and Lumbar Spinal Stenosis

Introduction

To investigate the risk of epidural hematoma after spinous process-splitting laminectomy (SPSL).

Methods

A total of 137 cases (mean age, 72.4 years; 68 men) of SPSL were included. Of these, there were instances (3.7%; mean age, 70.5 years; all male) of postoperative development of new neurologic deficit due to epidural hematoma requiring reoperation. The 133 subjects (72.5 years; 64 men) with normal postoperative course were used as controls, and comparisons were made between both groups using chi-squared and Student's t-tests. Regarding our investigation of risk factors for epidural hematoma, logistic regression was conducted with presence or absence of hematoma as our primary outcome variable, and age, gender, disease duration, number of laminectomies, which levels were decompressed, blood loss, length of case, drain output, coagulopathy, and whether or not there was an intraoperative dural tear were our explanatory variables.

Results

All cases of hematoma were single-level laminectomies; there was one case of T9-10 and 3 cases of L2-3. In our direct comparison of both groups (hematoma versus control), the proportion of men was significantly higher in the hematoma group (100% versus 48%, p < 0.05); levels decompressed were also significantly higher (p < 0.05) in the hematoma group, and drain outputs were significantly lower (113 mL versus 234 mL, p < 0.05). From our logistic regression analysis, the levels were significantly higher (χ² = 15, p = 0.0001) and the drain outputs were smaller (χ² = 4.6, p = 0.03) in the hematoma group.

Conclusions

Single-level decompression higher than the L2-3 level and reduced drain output were risk factors for spinal epidural hematoma. With this method of spinous process suturing and reconstruction there is less decompression compared with more conventional methods; therefore, the effect of hematoma may be more pronounced at higher vertebral levels with reduced canal width, and drain failure may also occur with this limited space.

The findings of musculoskeletal ultrasonography on primary Sjögren's syndrome patients in childhood with articular manifestations and the impact of anti-cyclic citrullinated peptide antibody

Objective: We researched the findings of musculoskeletal ultrasound sonography (MSUS) on primary Sjogren's syndrome in childhood (pSS-C) with articular manifestations. The correlation of rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA) were investigated to evaluate the usefulness of MSUS on their articular prognosis. Method: The objective patients are pSS-C cases who visited our hospital complaining joint pain and/or joint swelling and for whom MSUS was performed. Result: Eight patients included 6 female and 2 male, 5 RF-positive patients and 3 ACPA- positive patients. The mean age of onset was 11.1 ± 3.0 years (352 physical joint findings and 284 MSUS findings. The number of joints found clinical articular manifestations was 58/352 joints, and arthritis detected by MSUS was 30/284 joints). In multivariate analysis, the odds ratio of clinical articular manifestations was significant high in RF-positivity (2.9, 95%CI 1.5-6.2). The odds ratio of arthritis detected by MSUS in ACPA-positivity was significant high (3.7, 95%CI 1.5-11.6), although odds ratio in RF-positivity had no statistical significance and a similar trend was seen in odds ratios of subclinical arthritis (4.9, 95%CI 1.6-18.0). Conclusion: It was indicated that MSUS is useful for pSS-C. ACPA-positive pSS-C patients have arthritis and subclinical arthritis more frequently than ACPA-negative patients.

Correlation of the endoscopic findings for small and large bowels in pediatric patients with established Crohn's disease

Small bowel capsule endoscopy can detect subtle mucosal lesions in pediatric patients with Crohn’s disease, and our aim was to evaluate its application in established ileocolonic Crohn’s disease. Colonic inflammation was evaluated with the colonic Simple Endoscopic Score for Crohn’s Disease (SES-CD) (excluding the score of the terminal ileum). Small bowel inflammation was evaluated with the Lewis score and/or Capsule Endoscopy Crohn’s Disease Activity Index (CECDAI). A Lewis score <135 was defined as small bowel inactive. A colonic SES-CD of 0 (colonic inactive group) was observed in 22/42 procedures (52.4%), and active small bowel lesions were observed in 11/22 procedures (50.0%). The Lewis score was lower in the colonic inactive group compared to the colonic active group. Correlations between the colonic SES-CD, the Lewis score and CECDAI were weak. The Lewis score and CECDAI in the colonic inactive group had significant correlation with fecal calprotectin levels. We suggest that Crohn’s disease patients without both colonic active lesions and elevation of fecal calprotectin levels may not need to receive small bowel capsule endoscopy due to low incidence of lesions in small bowel.

Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode

OBJECTIVES

To confirm the safety of using acetaminophen for febrile seizures (FSs) and to assess its efficacy in preventing FS recurrence during the same fever episode.

METHODS

In this single-center, prospective, open, randomized controlled study, we included children and infants (age range: 6-60 months) with FSs who visited our hospital between May 1, 2015, and April 30, 2017. The effectiveness of acetaminophen was examined by comparing the recurrence rates of patients in whom rectal acetaminophen (10 mg/kg) was administered every 6 hours until 24 hours after the first convulsion (if the fever remained >38.0°C) to the rates of patients in whom no antipyretics were administered. No placebo was administered to controls. The primary outcome measure was FS recurrence during the same fever episode.

RESULTS

We evaluated 423 patients; of these, 219 were in the rectal acetaminophen group, and 204 were in the no antipyretics group. In the univariate analysis, the FS recurrence rate was significantly lower in the rectal acetaminophen group (9.1%) than in the no antipyretics group (23.5%; P < .001). Among the variables in the final multiple logistic regression analysis, rectal acetaminophen use was the largest contributor to the prevention of FS recurrence during the same fever episode (odds ratio: 5.6; 95% confidence interval: 2.3-13.3).

CONCLUSIONS

Acetaminophen is a safe antipyretic against FSs and has the potential to prevent FS recurrence during the same fever episode.

Altered Expression of Retinol Metabolism-Related Genes in an ANIT-Induced Cholestasis Rat Model

Cholestasis is defined as a reduction of bile secretion caused by a dysfunction of bile formation. Insufficient bile secretion into the intestine undermines the formation of micelles, which may result in the reduced absorption of lipids and fat-soluble vitamins. Here, we investigated the retinol homeostasis and the alterations of retinol metabolism-related genes, including β-carotene 15,15′ monooxygenase (BCMO), lecithin:retinol acyltransferase (LRAT), aldehyde dehydrogenase (ALDH), cytochrome P450 26A1 (CYP26A1), and retinoic acid receptors (RAR) β, in a α-naphthyl isothiocyanate (ANIT)-induced cholestasis rat model. Moreover, we examined the expression of the farnesoid X receptor (FXR) target genes. Our results showed that plasma retinol levels were decreased in ANIT rats compared to control rats. On the contrary, hepatic retinol levels were not different between the two groups. The expression of FXR target genes in the liver and intestine of cholestasis model rats was repressed. The BCMO expression was decreased in the liver and increased in the intestine of ANIT rats compared to control rats. Finally, the hepatic expression of LRAT, RARβ, and ALDH1A1 in cholestatic rats was decreased compared to the control rats, while the CYP26A1 expression of the liver was not altered. The increased expression of intestinal BCMO in cholestasis model rats might compensate for decreased circulatory retinol levels. The BCMO expression might be regulated in a tissue-specific manner to maintain the homeostasis of retinol.

Shwachman-Diamond syndrome: Nationwide survey and systematic review in Japan

BACKGROUND

Shwachman-Diamond syndrome (SDS) is a rare multisystem disorder associated with exocrine pancreatic insufficiency. The present study reports the results of a nationwide survey and a systematic review on SDS to develop consensus guidelines for intractable diarrhea including SDS.

METHODS

Questionnaires were sent to 616 departments of pediatrics or of pediatric surgery in Japan in a nationwide survey. A second questionnaire was sent to doctors who had treated SDS patients and included questions on clinical information. Additionally, a systematic review was performed using digital literature databases to assess the influence of medical (i.e. non-surgical) treatment on SDS prognosis.

RESULTS

Answers were received from 529 institutions (85.9%), which included information on 24 patients with SDS (median age, 10.4 years; male, n = 15) treated from January 2005 to December 2014. Although 75% of patients received pancreatic enzyme replacement therapy, there was no significant association between treatment and prognosis. Systematic review identified one clinical practice guideline, two case series, eight case reports and 26 reviews. Patient information from those studies was insufficient for meta-analysis.

CONCLUSIONS

The rarity of SDS makes it difficult to establish evidence-based treatment for SDS. According to the limited information from patients and published reports, medical treatment for malabsorption due to SDS should be performed to improve fat absorption and stool condition, but it is not clear whether this treatment improves the prognosis of malabsorption.

Therapeutic experience with hepatoblastoma associated with trisomy 18

Trisomy 18 is often fatal, but patients with this disease can now have longer survival due to proactive treatment intervention. However, hepatoblastomas may develop in these patients. In this study, we report four cases of hepatoblastoma associated with trisomy 18. All of the patients had congenital heart disease and three had undergone intracardiac surgical repair. Tumor growth was relatively slow in all cases, and there were no problems with chemotherapy tolerability and surgical resection. Three of the patients are currently disease-free and the fourth is alive with remaining of the tumor. These cases suggest that combined chemotherapy and surgical resection may be an option to treat hepatoblastoma associated with trisomy 18 when cardiac pulmonary function is relatively stable.

Japanese clinical practice guidelines for allied disorders of Hirschsprung's disease, 2017

BACKGROUND

Despite the presence of ganglion cells in the rectum, some patients have symptoms similar to those of Hirschsprung's disease. A consensus has yet to be established regarding the terminology for these diseases. We defined this group of diseases as "allied disorders of Hirschsprung's disease" and compiled these guidelines to facilitate accurate clinician diagnosis and provide appropriate treatment strategies for each disease.

METHODS

These guidelines were developed using the methodologies in the Medical Information Network Distribution System (MINDS). Of seven allied disorders, isolated hypoganglionosis; megacystis-microcolon-intestinal hypoperistalsis syndrome; and chronic idiopathic intestinal pseudo-obstruction were selected as targets of clinical questions (CQ). In a comprehensive search of the Japanese- and English-language articles in PubMed and Ichu-Shi Web, 836 pieces of evidence related to the CQ were extracted from 288 articles; these pieces of evidence were summarized in an evidence table.

RESULTS

We herein outline the newly established Japanese clinical practice guidelines for allied disorders of Hirschsprung's disease. Given that the target diseases are rare and intractable, most evidence was drawn from case reports and case series. In the CQ, the diagnosis, medication, nutritional support, surgical therapy, and prognosis for each disease are given. We emphasize the importance of full-thickness intestinal biopsy specimens for the histopathological evaluation of enteric ganglia. Considering the practicality of the guidelines, the recommendations for each CQ were created with protracted discussions among specialists.

CONCLUSIONS

Clinical practice recommendations for allied disorders of Hirschprung's disease are given for each CQ, along with an assessment of the current evidence. We hope that the information will be helpful in daily practice and future studies.

The efficacy of adrenocorticotropic hormone in a girl with anti-N-methyl-D-aspartate receptor encephalitis

BACKGROUND

Immunomodulatory therapy has shown some therapeutic benefits in patients with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis. In this report, we describe the use of adrenocorticotropic hormone (ACTH) immunotherapy with good outcome in a patient with anti-NMDAR encephalitis.

SUBJECT AND METHODS

A 4-year-old girl developed convulsions in her right arm and leg without impaired consciousness. These convulsions occurred frequently in clusters of 10-20 events of 10-20 s duration. She was admitted to our hospital on the 6th day following her initial series of convulsions. Flaccid paralysis of the right hand and leg was also found. Interictal electroencephalography showed high-amplitude slow waves. No abnormal findings were shown on MRI. ^99mTc-ECD brain SPECT on the 14th day showed hyperperfusion in the left hemisphere, including the left basal ganglia. The convulsions ceased following the oral administration of valproic acid on the 10th day; however, paralysis associated with choreic dyskinesia of the right arm and leg remained. ACTH immunotherapy was then performed on the 15th day. We identified the presence of N-methyl-D-aspartate receptor antibody in CSF samples taken on the 6th day. After ACTH therapy, the patient fully recovered from the paralysis associated with choreic dyskinesia of the right arm and leg. She has not had a relapse and has not required medication for over a year.

CONCLUSION

ACTH immunotherapy may be a useful treatment option for patients with anti-NMDAR encephalitis, although further evaluation is required.

Prognostic factors in the early phase of acute encephalopathy

BACKGROUND

Neurological sequelae occur in 40% of patients with acute encephalopathy (AE). The early prediction of poor outcomes is critical to the initiation of appropriate treatment. The aim of the present study was therefore to elucidate prognostic factors that can be quickly and feasibly evaluated on hospital admission in patients with AE.

METHODS

We analyzed data from 51 AE patients admitted to Hirakata City Hospital between January 2005 and December 2014. Age at onset, sex, underlying disease, status epilepticus (SE), presence of benzodiazepine-resistant SE (BZD-resistant SE), and basic blood serum parameters on admission were evaluated in relation to each patient's outcome.

RESULTS

On univariate analysis age at onset, BZD-resistant SE, and serum aspartate aminotransferase (AST), alanine aminotransferase, lactate dehydrogenase, and platelet count varied significantly according to outcome. On multivariate analysis age at onset (≤21 months), presence of BZD-resistant SE, and AST (≥46 IU/L) were identified as independent variables associated with poor outcome.

CONCLUSION

Age at onset, presence of BZD-resistant SE, and AST are associated with a poor prognosis in AE.

Recent advances in magnetic resonance neuroimaging of lumbar nerve to clinical applications: A review of clinical studies utilizing Diffusion Tensor Imaging and Diffusion-weighted magnetic resonance neurography

Much progress has been made in neuroimaging with Magnetic Resonance neurography and Diffusion Tensor Imaging (DTI) owing to higher magnetic fields and improvements in pulse sequence technology. Reports on lumbar nerve DTI have also increased considerably. Many studies have shown that the use of DTI in lumbar nerve lesions, such as lumbar foraminal stenosis and lumbar disc herniation, makes it possible to capture images of interruptions of tractography at stenotic sties, enabling the diagnosis of stenosis. DTI can also reveal significant decreases in fractional anisotropy (FA) with significant increases in apparent diffusion coefficient (ADC) values in compression lesions. FA values have higher accuracy than ADC values. Furthermore, strong correlations exist between FA values and indications of neurological severity, including the Japanese Orthopedic Association (JOA) score, the Oswestry Disability Index (ODI), and the Roland-Morris Disability Questionnaire (RDQ) in patients with lumbar disc herniation-induced radiculopathy. Most lumbar DTI has become 3T; 3T MRI has made it possible to take high-resolution DTI measurements in a short period of time. However, increased motion artifacts in the magnetic susceptibility effect lead to signal irregularities and image distortion. In the future, high-resolution DTI with reduced field-of-view may become useful in clinical applications, since visualization of nerve lesions and quantification of DTI parameters could allow more accurate diagnoses of lumbar nerve dysfunctions. Future translational studies will be necessary to successfully bring MR neuroimaging of lumbar nerve into clinical use.

Microvascular endothelial function in Japanese early adolescents

Endothelial dysfunction is the early predictive factor for the development of atherosclerosis and future cardiovascular diseases in adulthood. The prevalence of endothelial dysfunction in children and early adolescents is increasing worldwide. Peripheral arterial tonometry is a noninvasive technique for assessing peripheral microvascular function and is used as a validated marker of endothelial function. We assessed anthropometric parameters, blood pressure, arterial stiffness, and peripheral endothelial function in 157 Japanese early adolescents (75 boys and 82 girls). We measured peripheral endothelial function by using peripheral arterial tonometry to determine the reactive hyperemia index, and assessed the association of reactive hyperemia index with parameters of anthropometry and arterial stiffness. The mean reactive hyperemia index of all subjects was 1.85 ± 0.6, and there was no difference of reactive hyperemia index according to sex. Reactive hyperemia index was significantly associated with systolic and diastolic blood pressures, and had no correlation with anthropometric parameters and arterial stiffness markers. The reactive hyperemia index values among Japanese early adolescents were similar to those reported in previous studies on children and early adolescents. This noninvasive technique may be useful for the assessment of microvascular endothelial function among children and early adolescents.

Autonomic nervous system function in adolescent migraineurs

BACKGROUND

Migraine is a common and disabling neurological disorder. Studies on the relationship between migraine and the autonomic nervous system (ANS) have been inconclusive. Moreover, pediatric studies are extremely limited. Therefore, the present study investigated interictal ANS function in adolescent migraineurs.

METHODS

We studied 21 patients with migraine and 26 healthy controls. Beat-to-beat blood pressure (BP) and heart rate (HR) were non-invasively and continuously measured in the supine and standing positions. ANS function was evaluated on power spectral analysis of HR variability and diastolic BP (DBP) variability.

RESULTS

Heart rate and systolic BP were not different between the two groups in either the supine or standing position. DBP did not differ between groups in the standing position, but was significantly higher in migraineurs in the supine position. The vasoconstrictor index was significantly higher in migraineurs. High-frequency (HF) RR interval variability (RR-HF) and the ratio of the low-frequency (LF) to HF component of RR interval variability (RR-LF/HF) were not different between the two groups in both positions. The LF component of DBP variability (DBP-LF) in the supine position was significantly lower in migraineurs, while DBP-LF during standing in migraineurs was significantly higher than in controls.

CONCLUSION

Migraineurs have significantly lower sympathetic vasomotor activity in the supine position, while sympathetic vasomotor activity was hyperresponsive during standing.

Evaluation of uric acid levels, thyroid function, and anthropometric parameters in Japanese children with Down syndrome

Down syndrome, caused by trisomy 21, is characterized by congenital abnormalities as well as mental retardation. From the neonatal stage through adolescence, patients with Down syndrome often have several complications. Thus, it is important to attain knowledge of the prevalence of these comorbidities in children with Down syndrome. We, therefore, evaluated the biochemical data, thyroid function, and anthropometric parameters, and analyzed the association among them in Japanese children and early adolescents with Down syndrome. There was no difference in the prevalence of obesity and overweight between boys and girls. The level of uric acid was higher in boys than in girls. Moreover, the prevalence of hyperuricemia was also higher in boys than in girls (approximately 32% and 10%, respectively). The prevalence of subclinical hypothyroidism in children with Down syndrome was approximately 20%, with no significant sex differences. The levels of uric acid and dehydroepiandrosterone-sulfate were positively associated with age, while the levels of thyroid-stimulating hormone and free thyroxine had a negative association with age. Overall, children with Down syndrome, exhibit a higher incidence of hyperuricemia. Therefore, uric acid levels, as well as thyroid function, from childhood to early adulthood should be monitored in this patient cohort.

Dehydroepiandrosterone Alters Retinol Status and Expression of the β-Carotene 15,15'-Monooxygenase and Lecithin:Retinol Acyltransferase Genes

Dehydroepiandrosterone (DHEA) and its sulfate ester DHEA-sulfate (DHEA-S) are the most abundant adrenal steroids in humans. DHEA has a critical role as a steroidal precursor of androgens and/or estrogens, and in human studies and animal experiments, both DHEA and DHEA-S have multiple beneficial effects. However, there are few reports regarding the relationship between DHEA and nutrient status, especially for vitamins. Therefore, we elucidated the effect of DHEA administration on retinol status. Wistar rats were fed with a standard diet containing 0.4% (wt/wt) DHEA for 2 wk. We assessed retinol status and the expression of retinol-related proteins, including metabolic enzymes, binding proteins, cytochrome P450 (CYP) enzymes, and antioxidant enzymes. Retinol levels in the plasma and the liver of DHEA-fed rats were lower than those of controls. Expression of β-carotene 15,15'-monooxygenase (BCMO) in the liver and intestine of DHEA-fed rats was lower, whereas BCMO expression in the testes of DHEA-fed rats was higher than that of controls. Expression of the retinol-metabolizing aldehyde dehydrogenase (ALDH) enzyme ALDH1A2 was repressed in the liver of DHEA rats, whereas ALDH1A1 expression was unaltered. Hepatic expression of lecithin:retinol acyltransferase (LRAT) and CYP26A1 was lower in DHEA-fed rats than in controls. Retinol status in DHEA-fed rats might be affected by altered BCMO expression in the liver and intestine and hepatic LRAT expression, whereas BCMO expression in peripheral tissues may be regulated in a tissue-specific manner. We have shown that DHEA administration may influence retinol status and the expression of retinol-related proteins.

Assessment of Clinical Symptoms in Lumbar Foraminal Stenosis Using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire

Objective

It is important to develop an easy means of diagnosing lumbar foraminal stenosis (LFS) in a general practice setting. We investigated the use of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) to diagnose LFS in symptomatic patients.

Methods

Subjects included 13 cases (mean age, 72 years) with LFS, and 30 cases (mean age, 73 years) with lumbar spinal canal stenosis (LSCS) involving one intervertebral disc. The visual analogue scale score for low back pain and leg pain, the JOABPEQ were evaluated.

Results

Those with LFS had a significantly lower JOA score (p<0.001), while JOABPEQ scores (p<0.05) for lumbar dysfunction and social functioning impairment (p<0.01) were both significantly lower than the scores in LSCS. The following JOABPEQ questionnaire items (LFS vs. LSCS, p-value) for difficulties in: sleeping (53.8% vs. 16.6%, p<0.05), getting up from a chair (53.8% vs. 6.6%, p<0.001), turning over (76.9% vs. 40%, p<0.05), and putting on socks (76.9% vs. 26.6%, p<0.01) such as pain during rest, and signs of intermittent claudication more than 15 minutes (61.5% vs. 26.6%, p<0.05) were all significantly more common with LFS than LSCS.

Conclusion

Results suggest that of the items in the JOABPEQ, if pain during rest or intermittent claudication is noted, LFS should be kept in mind as a cause during subsequent diagnosis and treatment. LFS may be easily diagnosed from LSCS using this established patient-based assessment method.

Associations between sarcopenia and degenerative lumbar scoliosis in older women

Background

Age-related sarcopenia can cause various forms of physical disabilities. We investigated how sarcopenia affects degenerative lumbar scoliosis (DLS) and lumbar spinal canal stenosis (LSCS).

Methods

Subjects comprised 40 elderly women (mean age 74 years) with spinal disease whose chief complaints were low back pain and lower limb pain. They included 15 cases of DLS (mean 74.8 years) and 25 cases of LSCS (mean age 72.9 years).

We performed whole-body dual-energy X-ray absorptiometry (DXA) to analyze body composition, including appendicular and trunk skeletal muscle mass index (SMI; lean mass (kg)/height (m)²) and bone mineral density (BMD). A diagnostic criterion for sarcopenia was an appendicular SMI <5.46. To check spinal alignment, lumbar scoliosis (LS), sagittal vertical axis (SVA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), and vertebral rotational angle (VRA) were measured. Clinical symptoms were determined from the Japanese Orthopedic Association scores, low back pain visual analog scale, and Roland-Morris Disability Questionnaire (RDQ). Criteria for DLS were lumbar scoliosis >10° and a sagittal vertical axis (SVA) >50 mm. Sarcopenia prevalence, correlations between spinal alignment, BMD, and clinical symptoms with appendicular and trunk SMIs, and correlation between spinal alignment and clinical symptoms were investigated.

Results

DLS cases had significantly lower body weight, BMI, lean mass arm, and total lean mass than LSCS cases. Sarcopenia prevalence rates were 4/25 cases (16%) in LSCS and 7/15 cases (46.6%) in DLS, revealing a high prevalence in DLS. Appendicular SMIs were DLS 5.61 and LSCS 6.13 (p < 0.05), and trunk SMIs were DLS 6.91 and LSCS 7.61 (p < 0.01) showing DLS to have significantly lower values than LSCS. Spinal alignment correlations revealed the appendicular SMI was negatively correlated with PT (p < 0.05) and the trunk SMI was found to have a significant negative correlation with SVA, PT, LS, and VRA (p < 0.05). The trunk SMI was found to have a significant positive correlation with BMD (p < 0.05). As for clinical symptoms, RDQ was negatively correlated with appendicular SMI and positively correlated with PT (P < 0.05).

Conclusions

Sarcopenia complications were noted in 16% of LSCS patients and a much higher percentage, or 46.6%, of DLS patients. Appendicular and trunk SMIs were both lower in DLS, suggesting that sarcopenia may be involved in scoliosis. The appendicular skeletal muscle was related to posterior pelvic tilt, while the trunk muscle affected stooped posture, posterior pelvic tilt, lumbar scoliosis, and vertebral rotation. Decreases in trunk muscle mass were also associated with osteoporosis. Moreover, RDQ had a negative correlation with appendicular skeletal muscle mass and a positive correlation with PT, suggesting that sarcopenia may be associated with low back pain as a result of posterior pelvic tilt. Our research reveals for the first time how sarcopenia is involved in spinal deformations, suggesting decreases in pelvic/lumbar support structures such as trunk and appendicular muscle mass may be involved in the progression of spinal deformities and increased low back pain.

Supplementation with carnitine reduces the severity of constipation: a retrospective study of patients with severe motor and intellectual disabilities

Carnitine is an essential nutrient for the mitochondrial transport of fatty acids. Carnitine deficiency causes a variety of symptoms in multiple organs. Patients with severe motor and intellectual disabilities often have carnitine deficiency. This study aimed to determine the correlation between constipation and carnitine deficiency in them. Patients with severe motor and intellectual disabilities at our hospital were retrospectively reviewed. The correlation between level of free carnitine and severity of constipation was examined. Constipation and non-constipation groups were compared for age; sex; body mass index; bed rest period; use of anti-epileptic drugs, valproate sodium, or enteral nutrition; and serum levels of albumin, pre-albumin, totalcholesterol, free carnitine, folic acid, and trace elements. Moreover, severity of constipation before and after carnitine supplementation was assessed. Twenty-seven patients were enrolled. Of these, 14 were assigned to the constipation group and 13 to the non-constipation group. The free carnitine level was significantly correlated with severity of constipation (R = 0.7604, p<0.01). Free carnitine was significantly lower in the constipation compared with the non-constipation group (p<0.01). No other significant differences between the groups were found. The severity of constipation was significantly relieved after carnitine supplementation (p<0.001). In conclusion, carnitine supplementation could reduce the severity of constipation.

A nationwide survey of pediatric acquired demyelinating syndromes in Japan

OBJECTIVE

To investigate the clinical and epidemiologic features of pediatric acquired demyelinating syndromes (ADS) of the CNS in Japan.

METHODS

We conducted a nationwide survey and collected clinical data on children with ADS aged 15 years or younger, who visited hospitals between 2005 and 2007.

RESULTS

Among 977 hospitals enrolled, 723 (74.0%) responded to our inquiries and reported a total of 439 patients as follows: 244 with acute disseminated encephalomyelitis (ADEM), 117 with multiple sclerosis (MS), 14 with neuromyelitis optica (NMO), and 64 with other ADS. We collected and analyzed detailed data from 204 cases, including those with ADEM (66), MS (58), and NMO (10). We observed the following: (1) the estimated annual incidence rate of pediatric ADEM in Japan was 0.40 per 100,000 children (95% confidence interval [CI], 0.34-0.46), with the lowest prevalence in the north; (2) the estimated prevalence rate of MS was 0.69 per 100,000 children (95% CI, 0.58-0.80), with the lowest prevalence in the south; (3) NMO in Japan was rare, with an estimated prevalence of 0.06 per 100,000 children (95% CI, 0.04-0.08); and (4) the sex ratio and mean age at onset varied by ADS type, and (5) male/female ratios correlated with ages at onset in each ADS group.

CONCLUSIONS

Our results clarify the characteristic clinical features of pediatric ADS in the Japanese population.

Hippocampal signal abnormality on the first day of illness in acute encephalopathy with biphasic seizures and late reduced diffusion caused by HHV-6 infection

We report a 13-month-old girl who developed acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) with transient reduced diffusion in the hippocampus and anterior commissure on diffusion-weighted imaging (DWI), which was performed on the first day after febrile status epilepticus (FSE) as the initial neurological symptom of AESD. DWI just after late seizures showed high signal intensity lesions in both left hippocampus and anterior commissure, and left extratemporal and occipital subcortical white matter. HHV-6 DNA was positive in both blood and cerebrospinal fluid samples. DWI at two months after onset showed atrophy in the left mesial temporal lobe and extratemporal and occipital lobe without the signal abnormalities. Although it has been reported that magnetic resonance images tend to show no acute abnormality during the first two days in typical AESD, transient reduced diffusion could be found on the DWI performed on the first day of AESD.

Fatal cardiac anomaly of unguarded mitral orifice with asplenia syndrome

We report the case of a newborn baby with an unguarded mitral orifice associated with asplenia syndrome, double-outlet right ventricle, dysplastic tricuspid valve, and pulmonary stenosis. This case was accompanied by severe tricuspid regurgitation and severe right ventricular hypertrophy. The patient had a fatal clinical course due to severe hypoxia and congestive heart failure. Unguarded mitral orifice is a rare disease in which there has been no previous report of lethal clinical course during the neonatal period. Prior reports stated that unguarded mitral orifice was a new constellation of defects and that its etiology and embryology could be classified in the same category because of similar associated malformations of double-outlet right ventricle and pulmonary stenosis or atresia. However, the present case was diagnosed on autopsy as also having asplenia syndrome. Therefore, it is possible that the genetic etiology of unguarded mitral orifice in this case was different from cases of non-heterotaxy. <Learning objective: Unguarded mitral orifice is a rare disease that might be associated with asplenia syndrome and dysplastic tricuspid valve. If unguarded mitral orifice is associated with such defects, the clinical course can be fatal. Therefore, when this diagnosis is recognized, the physician should explain the possibility of neonatal death and plan the treatment of such a case to include grief therapy for the family.>.

Post-vaccination MDEM associated with MOG antibody in a subclinical Chlamydia infected boy

The mechanism of post-vaccination acute disseminated encephalomyelitis (ADEM) has been hypothesized as resulting from vaccination-injected antigens cross-reacting with myelin components, however, a precise etiology has been uncertain. In this report, we describe the case of a 6-year-old Japanese boy who had multiphasic disseminated encephalomyelitis (MDEM), and was positive for both anti-myelin oligodendrocyte glycoprotein (MOG) antibodies and Chlamydophila pneumoniae antibodies. After vaccinations that were the second one for measles and rubella, and the booster immunization for Japanese encephalitis, the patient presented with fever, headache, vomiting, and a change in personality. He was treated with a high-dose of intravenous methylprednisolone in the diagnosis of ADEM. However, these symptoms recurred with different magnetic resonance imaging lesion, and he was diagnosed as MDEM. Retrospective testing for pathogens revealed C. pneumoniae IgM and IgG antibodies, and it was considered that he was infected with C. pneumoniae subclinically. The patient's serum indicated a positive response for the anti-MOG antibody from the onset of the ADEM diagnosis and in all recurrent episodes. Chlamydia species infection has been known to play a role in demyelinating diseases. It is also known that the anti-MOG antibody may be present but not exhibit its pathogenesis in the absence of a cell-mediated inflammatory response; however, the precise mechanism of action of the anti-MOG antibodies is not yet determined. We propose the possibility that post-vaccination demyelinating disease may result from the synergistic effects of a preceding anti-MOG antibody, possibly produced in response to a subclinical Chlamydia species infection.