Presynaptic Dopaminergic Imaging Characterizes Patients with REM Sleep Behavior Disorder Due to Synucleinopathy

OBJECTIVE

To apply a machine learning analysis to clinical and presynaptic dopaminergic imaging data of patients with rapid eye movement (REM) sleep behavior disorder (RBD) to predict the development of Parkinson disease (PD) and dementia with Lewy bodies (DLB).

METHODS

In this multicenter study of the International RBD study group, 173 patients (mean age 70.5 ± 6.3 years, 70.5% males) with polysomnography-confirmed RBD who eventually phenoconverted to overt alpha-synucleinopathy (RBD due to synucleinopathy) were enrolled, and underwent baseline presynaptic dopaminergic imaging and clinical assessment, including motor, cognitive, olfaction, and constipation evaluation. For comparison, 232 RBD non-phenoconvertor patients (67.6 ± 7.1 years, 78.4% males) and 160 controls (68.2 ± 7.2 years, 53.1% males) were enrolled. Imaging and clinical features were analyzed by machine learning to determine predictors of phenoconversion.

RESULTS

Machine learning analysis showed that clinical data alone poorly predicted phenoconversion. Presynaptic dopaminergic imaging significantly improved the prediction, especially in combination with clinical data, with 77% sensitivity and 85% specificity in differentiating RBD due to synucleinopathy from non phenoconverted RBD patients, and 85% sensitivity and 86% specificity in discriminating PD-converters from DLB-converters. Quantification of presynaptic dopaminergic imaging showed that an empirical z-score cutoff of -1.0 at the most affected hemisphere putamen characterized RBD due to synucleinopathy patients, while a cutoff of -1.0 at the most affected hemisphere putamen/caudate ratio characterized PD-converters.

INTERPRETATION

Clinical data alone poorly predicted phenoconversion in RBD due to synucleinopathy patients. Conversely, presynaptic dopaminergic imaging allows a good prediction of forthcoming phenoconversion diagnosis. This finding may be used in designing future disease-modifying trials. ANN NEUROL 2024.

Production of Noble-Metal Nanohelices Based on Nonlinear Dynamics in Electrodeposition of Binary Copper Alloys

Spatiotemporal pattern formation is dynamic self-organization widely observed in nature and drives various functions. Among these functions, chirality plays a central role. The relationship between dynamic self-organization and chirality has been an open question; therefore, the production of chiral nanomaterials by dynamic self-organization has not been achieved. Here, we show that the confinement of a two-dimensional spatiotemporal micropattern via the electrodeposition of a binary Cu alloy into a nanopore induces mirror symmetry breaking to produce a helical nanostructure of the noble-metal component although it is still not yet possible to control the handedness at this stage. This result suggests that spatiotemporal symmetry breaking functions as a mirror symmetry breaking if cylindrical pores are given as the boundary condition. This study can be a model system of how spatiotemporal symmetry breaking plays a role in mirror symmetry breaking, and it proposes a new approach to producing helical nanomaterials through dynamic self-organization.

Montreal Cognitive Assessment Predicts the Short-Term Risk of Lewy Body Disease in Isolated REM Sleep Behavior Disorder with Reduced MIBG Scintigraphy

Background

Long-term follow-up of isolated rapid eye movement (REM) sleep behavior disorder (IRBD) patients reveals a high risk of α-synucleinopathies.

Objective

We explored the early clinical predictive factors of phenoconversion from IRBD to Parkinson's disease (PD) or dementia with Lewy bodies (DLB).

Methods

We assessed baseline office-based cognitive test scores (Montreal Cognitive Assessment [MoCA-J], Mini-Mental State Examination [MMSE], and Frontal Assessment Battery [FAB]), motor function, and olfactory function in 36 consecutive polysomnography (PSG)-confirmed IRBD patients with reduced metaiodobenzylguanidine (MIBG) accumulation. PD or DLB was confirmed by medical chart review retrospectively.

Results

Of 36 IRBD patients, 19 (n = 19, 52.8%) with abnormal MoCA-J score (< 26) had significantly lower scores in trail making B, phonetic verbal fluency sub-items in the executive domain, and in delayed recall in the memory domain. In total, 12 (33.3%) patients developed PD or DLB; seven of 12 patients (58.3%) developed DLB at a mean follow-up period of 6.8 years. In the normal MoCA-J group (n = 17, 47.2%), two patients developed PD, but none developed dementia. Furthermore, in the abnormal MoCA-J group, seven patients developed DLB and three developed PD without dementia. The phenoconverter group had significantly lower scores in delayed recall in the memory domain compared to the disease-free group. Cox hazard analysis showed that MoCA-J was superior to MMSE.

Conclusions

Among IRBD patients with reduced cardiac MIBG accumulation, MoCA-J score of <26 (Mild Cognitive Impairment-Lewy body) and a low sub-item score for delayed recall predicted short-term progression to probable DLB.

Odor identification predicts the transition of patients with isolated RBD: A retrospective study

Introduction

To determine if the severity of olfactory dysfunction in isolated REM sleep behavior disorder (IRBD) predicts conversion to Parkinson's disease (PD) or dementia with Lewy bodies (DLB).

Methods

Olfaction was tested using the Japanese version of the University of Pennsylvania Smell Identification Test (UPSIT‐J) in 155 consecutive patients with polysomnography‐confirmed IRBD and 34 healthy controls. IRBD patients were followed up for 5.8 ± 3.2 (range 0.2–11) years. Thirty‐eight patients underwent repeat UPSIT‐J evaluation at 2.7 ± 1.3 years after the baseline test.

Results

UPSIT‐J score was lower in IRBD patients than in age‐ and sex‐matched controls. The receiver operating characteristic curve analysis showed that the optimal cutoff score of 22.5 in UPSIT‐J discriminated between IRBD patients and controls with a sensitivity of 94.3% and specificity of 81.8%. Anosmia (UPSIT‐J score < 19) was present in 54.2% of IRBD patients. In total, 42 patients developed a neurodegenerative disease, of whom 17 had PD, 22 DLB, and 3 MSA. Kaplan–Meier analysis showed that the short‐term risk of Lewy body disease (LBD) was higher in patients with anosmia than in those without anosmia. At baseline, the UPSIT‐J score was similar between patients who developed PD and DLB (p = 0.136). All three IRBD patients (100%) who developed MSA did not have anosmia.

Conclusions

In IRBD patients, anosmia predicts a higher short‐term risk of transition to LBD but cannot distinguish between PD and DLB. At baseline, preserved odor identification may occur in latent MSA. Future IRBD neuroprotective trials should evaluate anosmia as a marker of prodromal LBD.

Brain Perfusion Single-Photon Emission Computed Tomography Using an Easy Z-Score Imaging System Predicts Progression to Neurodegenerative Dementia in Rapid Eye Movement Sleep Behavior Disorder

INTRODUCTION

Longitudinal studies have reported that patients with idiopathic rapid eye movement sleep behavior disorder (IRBD) have an increased risk of developing synucleinopathies, such as Parkinson's disease and dementia with Lewy bodies (DLB). Clinical trials of disease-modifying therapies for IRBD patients require suitable biomarkers that can predict the short-term onset of neurodegenerative dementia.

METHODS

We retrospectively examined if easy Z-score imaging system-specific volume-of-interest analysis (SVA) using brain perfusion single-photon emission computed tomography (SPECT) imaging or the cingulate island sign score can predict the short-term development of neurodegenerative dementia in 30 patients with IRBD.

RESULTS

Ten patients (33.3%) who exceeded the thresholds for three indicators (severity, extent, and ratio) were included in an SVA-positive group, while 20 (66.7%) were included in an SVA-negative group. Nine (30.0%) IRBD patients had phenoconversion, of which eight had DLB and one had Parkinson's disease with dementia. In Kaplan-Meier analysis, patients in the SVA-positive group converted to neurodegenerative dementia in a significantly shorter period of time compared to patients in the SVA-negative group.

CONCLUSIONS

These data suggest that SVA-positive IRBD patients have an increased short-term risk of developing neurodegenerative dementia.

Genome-wide association study of idiopathic hypersomnia in a Japanese population

Idiopathic hypersomnia (IH) is a rare sleep disorder characterized by excessive daytime sleepiness, great difficulty upon awakening, and prolonged sleep time. In contrast to narcolepsy type 1, which is a well-recognized hypersomnia, the etiology of IH remains poorly understood. No susceptibility loci for IH have been identified, although familial aggregations have been observed among patients with IH. Narcolepsy type 1 is strongly associated with human leukocyte antigen (HLA)-DQB1*06:02; however, no significant associations between IH and HLA alleles have been reported. To identify genetic variants that affect susceptibility to IH, we performed a genome-wide association study (GWAS) and two replication studies involving a total of 414 Japanese patients with IH and 6587 healthy Japanese individuals. A meta-analysis of the three studies found no single-nucleotide polymorphisms (SNPs) that reached the genome-wide significance level. However, we identified several candidate SNPs for IH. For instance, a common genetic variant (rs2250870) within an intron of PDE9A was suggestively associated with IH. rs2250870 was significantly associated with expression levels of PDE9A in not only whole blood but also brain tissues. The leading SNP in the PDE9A region was the same in associations with both IH and PDE9A expression. PDE9A is a potential target in the treatment of several brain diseases, such as depression, schizophrenia, and Alzheimer's disease. It will be necessary to examine whether PDE9A inhibitors that have demonstrated effects on neurophysiologic and cognitive function can contribute to the development of new treatments for IH, as higher expression levels of PDE9A were observed with regard to the risk allele of rs2250870. The present study constitutes the first GWAS of genetic variants associated with IH. A larger replication study will be required to confirm these associations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41105-021-00349-2.

Line-field confocal optical coherence tomography for actinic keratosis and squamous cell carcinoma: a descriptive study

BACKGROUND

Early and accurate diagnosis of cutaneous squamous cell carcinomas (SCCs) and actinic keratoses (AK) is fundamental to reduce their associated morbidity and to select the correct treatment. Line-field confocal optical coherence tomography (LC-OCT) is a new imaging device that can characterize healthy skin and basal cell carcinoma, but no large studies on keratinocyte cell tumours have yet been published.

AIM

To identify and describe LC-OCT criteria associated with SCC and AK, and to compare LC-OCT findings in these tumours.

METHODS

A retrospective observational multicentre study was conducted. Lesions were imaged with the LC-OCT device before surgery and examined histologically. LC-OCT criteria for AK/SCC were identified and their presence was evaluated in all study lesions. Univariate and multivariate analyses were performed to compare AK and SCCs, and to investigate differences between in situ and invasive tumours.

RESULTS

In total, 158 patients with 50 AK and 108 SCCs (62 in situ and 46 invasive) were included. Cytological and architectural alterations were found in most lesions, and differences were found between AK and SCCs. Although the visualization of the dermoepidermal junction (DEJ) was often hampered by hyperkeratosis and acanthosis, an outlined DEJ without broad strands was observed in almost all AK and almost all in situ SCCs, but in only three invasive SCCs (P < 0.001) when the DEJ was detectable.

CONCLUSION

Our results suggest that LC-OCT can help clinicians in the identification of AK and SCC and their differentiation, providing a real-time and noninvasive examination. Further studies are needed to confirm our data.

Dopaminergic imaging and clinical predictors for phenoconversion of REM sleep behaviour disorder

This is an international multicentre study aimed at evaluating the combined value of dopaminergic neuroimaging and clinical features in predicting future phenoconversion of idiopathic REM sleep behaviour (iRBD) subjects to overt synucleinopathy. Nine centres sent 123I-FP-CIT-SPECT data of 344 iRBD patients and 256 controls for centralized analysis. 123I-FP-CIT-SPECT images were semiquantified using DaTQUANTTM, obtaining putamen and caudate specific to non-displaceable binding ratios (SBRs). The following clinical variables were also analysed: (i) Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale, motor section score; (ii) Mini-Mental State Examination score; (iii) constipation; and (iv) hyposmia. Kaplan-Meier survival analysis was performed to estimate conversion risk. Hazard ratios for each variable were calculated with Cox regression. A generalized logistic regression model was applied to identify the best combination of risk factors. Bayesian classifier was used to identify the baseline features predicting phenoconversion to parkinsonism or dementia. After quality check of the data, 263 iRBD patients (67.6 ± 7.3 years, 229 males) and 243 control subjects (67.2 ± 10.1 years, 110 males) were analysed. Fifty-two (20%) patients developed a synucleinopathy after average follow-up of 2 years. The best combination of risk factors was putamen dopaminergic dysfunction of the most affected hemisphere on imaging, defined as the lower value between either putamina (P < 0.000001), constipation, (P < 0.000001) and age over 70 years (P = 0.0002). Combined features obtained from the generalized logistic regression achieved a hazard ratio of 5.71 (95% confidence interval 2.85-11.43). Bayesian classifier suggested that patients with higher Mini-Mental State Examination score and lower caudate SBR asymmetry were more likely to develop parkinsonism, while patients with the opposite pattern were more likely to develop dementia. This study shows that iRBD patients older than 70 with constipation and reduced nigro-putaminal dopaminergic function are at high risk of short-term phenoconversion to an overt synucleinopathy, providing an effective stratification approach for future neuroprotective trials. Moreover, we provide cut-off values for the significant predictors of phenoconversion to be used in single subjects.

Line-field confocal optical coherence tomography of basal cell carcinoma: a descriptive study

BACKGROUND

Early diagnosis and subtype classification of basal cell carcinoma (BCC) are crucial to reduce morbidity and optimize treatment. Good accuracy in differentiating BCC from clinical imitators has been achieved with existing diagnostic strategies but lower performance in discriminating BCC subtypes. Line-field confocal optical coherence tomography (LC-OCT) is a new technology able to combine the technical advantages of reflectance confocal microscopy and OCT.

OBJECTIVES

To identify and describe LC-OCT criteria associated with BCC and explore their association with BCC subtypes.

METHODS

Basal cell carcinoma were imaged with a handheld LC-OCT device before surgical excision. LC-OCT images were retrospectively evaluated by three observers for presence/absence of criteria for BCC. Multivariate logistic regression models were used to find independent predictors of BCC subtypes.

RESULTS

Eighty-nine histopathologically proven BCCs were included, of which 66 (74.2%) were pure subtypes [superficial BCC (sBCC): 19/66 (28.8%); nodular BCC (nBCC): 31/66 (47.0%); infiltrative BCC (iBCC): 16/66 (24.2%)]. Lobules, blood vessels and small bright cells within epidermis/lobules were the most frequent criteria for BCC. LC-OCT criteria independently associated with sBCC were presence of hemispheric lobules, absence of lobule separation from the epidermis, absence of stretching of the stroma; with nBCC were presence of macrolobules, absence of lobule connection to the epidermis; and with iBCC were presence of branched lobules.

CONCLUSIONS

This was the first study describing the characteristics of BCC under LC-OCT examination. We proposed morphologic criteria, which could be potentially useful for diagnosis and subtype classification of BCC, as well as for its therapeutic management. Future studies are needed to assess these hypotheses.

Current state of hypnotic use disorders: Results of a survey using the Japanese version of Benzodiazepine Dependence Self-Report Questionnaire

Aims

Benzodiazepine receptor agonists (BZ‐RAs) are frequently prescribed to treat insomnia; however, their long‐term use is not recommended. To introduce an appropriate pharmaco‐therapy, the current state and background factors of BZ‐RAs' dependence must be elucidated. In this study, we developed a Japanese version of the Benzodiazepine Dependence Self‐Report Questionnaire (Bendep‐SRQ‐J) and conducted a study of BZ‐RAs' use disorder.

Methods

The Bendep‐SRQ‐J was created with permission from the original developer. Subjects were inpatients and outpatients receiving BZ‐RAs between 2012 and 2013. Clinical data collected were Bendep‐SRQ‐J scores, sleep disorders for which BZ‐RAs were prescribed, physical comorbidities, psychotropic drugs, and lifestyle factors. Logistic analysis was performed to extract factors associated with severe symptoms.

Results

Of the 707 patients prescribed BZ‐RAs, 324 had voluntarily tapered or discontinued their drugs. Logistic analysis showed that the total number of drugs administered in the last 6 months correlated with both worsening of symptoms or conditions. This was more notable among younger patients, and the proportion of patients with severe symptoms or conditions increased with the increasing number of drugs.

Conclusion

Using the Bendep‐SRQ‐J, we elucidated the current state of BZ‐RA dependence. Nearly half of the patients were non‐compliant. The proportion of patients with severe symptoms or disease conditions increased with the increase in the number of drugs administered. These findings highlight the need for clinicians to be aware of the likelihood of benzodiazepine dependence, especially in young patients and patients prescribed multiple hypnotics.

Using the Bendep‐SRQ‐J, we elucidated the current state of BZ‐RA dependence. Nearly half of the patients were non‐compliant.

Determination of Lycopene Concentration in Fresh Tomatoes by Spectrophotometry: A Collaborative Study

BACKGROUND

Lycopene has been the object of considerable research attention recently, and the effects of the intake of lycopene, or of tomato products, have been studied in various ways. In Japan, interest in the health-promoting function of food components has increased.

OBJECTIVE

Developing a method to determine lycopene contents in tomato that meets the Japanese Agricultural Standard (JAS).

METHOD

In the proposed JAS method, the test sample consists of fresh tomatoes; a hexane-acetone mixture is utilized as the extraction solvent. A collaborative study was conducted to evaluate the interlaboratory performance of the method.

RESULTS

Ten laboratories participated and analyzed six test materials characterized by a lycopene content between 39 and 170 mg/kg as blind duplicates. After removing statistical outliers, RSDr ranged from 1.2 to 3.0% and RSDR ranged from 2.4 to 4.2%. The HorRat values were calculated and found to be in the 0.26-0.49 range.

CONCLUSIONS

The method for determining the lycopene content in tomato was evaluated by means of a collaborative study, and the reproducibility of this method was found to be acceptable.

HIGHLIGHTS

Intended for standardization in Japan, a method to determine lycopene content in tomato has been developed and shown to have acceptable precision in a collaborative study.

Efficacy of early intravenous landiolol, an ultrashort-acting beta-blocker on infarct size and its safety in patients with myocardial infarction undergoing primary PCI: a randomized, controlled study

Background

Previous clinical studies showed that early intravenous metoprolol before reperfusion in patients with ST-elevation myocardial infarction (STEMI) undergoing primary PCI reduced infarct size. However, intravenous beta-blockers in acute phase of STEMI can be associated with adverse effects such as cardiogenic shock and atrioventricular block. Landiolol is an ultrashort-acting beta-blocker with a half-life of 3 min that is eight times more cardioselective than esmolol.

Purpose

We evaluate the efficacy of intravenous infusion of landiolol on infarct size and its safety in STEMI patients undergoing primary PCI.

Methods

This study is a multicenter randomized control trial. A total of 47 patients with Killip class II or less STEMI undergoing PCI within 12 hours of symptoms onset were randomized to receive intravenous landiolol (n=23) or not (control, n=24). Patients allocated to landiolol group delivered an intravenous continuous dose of 3μg/min/kg before reperfusion and then continued until a total dose of 50mg. All patients started oral metoprolol or carvedilol within 12 hours. The primary end point was myocardial salvage index (MSI) on magnetic resonance imaging performed 5 to 7 days after PCI. MSI was defined as the difference between the area at risk and the area of necrosis analyzed using a commercial software.

Results

Magnetic resonance imaging was performed in 35 patients (17 patients in landiolol group and 18 patients in the control group), and ischemia duration time was 229 minutes in the landiolol group and the 242 minutes in control. In adjusting for confounding variables, the areas of myocardium at risk were not difference in both groups (54.4g in the landiolol group, and 46.8g in the control group; p=0.31). However, MSI in the landiolol group was significantly reduced than that in the control group (36.8% and 57.0%; p&lt;0.001).

In both group blood pressure was not difference in recruitment (142mmHg in landiolol group, and 144 in control) and starting PCI (163mmHg in landiolol group, and 165 in control). Regarding safety, the composite of death, malignant ventricular arrhythmia, cardiogenic shock, and atrioventricular block at 24 hours did not differ between the landiolol and the control groups (8.7% and 8.3%, respectively, p=0.93).

Conclusion

Early intravenous landiolol before starting primary PCI reduced infarct size in STEMI patients without significant hemodynamic adverse effects.

Funding Acknowledgement

Type of funding source: None

Clinical Usefulness of New R-R Interval Analysis Using the Wearable Heart Rate Sensor WHS-1 to Identify Obstructive Sleep Apnea: OSA and RRI Analysis Using a Wearable Heartbeat Sensor

Obstructive sleep apnea (OSA) is highly associated with cardiovascular diseases, but most patients remain undiagnosed. Cyclic variation of heart rate (CVHR) occurs during the night, and R-R interval (RRI) analysis using a Holter electrocardiogram has been reported to be useful in screening for OSA. We investigated the usefulness of RRI analysis to identify OSA using the wearable heart rate sensor WHS-1 and newly developed algorithm. WHS-1 and polysomnography simultaneously applied to 30 cases of OSA. By using the RRI averages calculated for each time series, tachycardia with CVHR was identified. The ratio of integrated RRIs determined by integrated RRIs during CVHR and over all sleep time were calculated by our newly developed method. The patient was diagnosed as OSA according to the predetermined criteria. It correlated with the apnea hypopnea index and 3% oxygen desaturation index. In the multivariate analysis, it was extracted as a factor defining the apnea hypopnea index (r = 0.663, p = 0.003) and 3% oxygen saturation index (r = 0.637, p = 0.008). Twenty-five patients could be identified as OSA. We developed the RRI analysis using the wearable heart rate sensor WHS-1 and a new algorithm, which may become an expeditious and cost-effective screening tool for identifying OSA.

Longitudinal study of striatal aromatic l-amino acid decarboxylase activity in patients with idiopathic rapid eye movement sleep behavior disorder

STUDY OBJECTIVES

To determine if nigrostriatal dopaminergic system function, evaluated by aromatic l-amino acid decarboxylase (AADC) activity using 6-[¹⁸F]fluoro-meta-tyrosine brain positron emission tomography (FMT-PET) can accurately and efficiently identify idiopathic rapid-eye-movement behavior disorder (IRBD) individuals at risk for conversion to a clinical diagnosis of Parkinson's disease (PD) or dementia with Lewy bodies (DLB).

METHODS

We assessed prospectively striatal aromatic l-amino acid decarboxylase activity using FMT brain PET imaging in IRBD patients who were followed systematically every 1-3 months for 1-10 years. IRBD patients (n = 27) were enrolled in this prospective cohort study starting in 2009. Those who underwent follow-up scans between January 2011 and September 2014 (n = 24) were analyzed in the present study.

RESULTS

Of the 24 IRBD patients with baseline and follow-up FMT-PET scans, 11 (45.8%) developed PD (n = 6) or DLB (n = 5). Compared to IRBD patients who were still disease-free, those who developed PD (n = 5) or DLB with parkinsonism (n = 1) had significantly reduced bilateral putaminal FMT uptake during the follow-up. Furthermore, the rate of FMT decline between baseline and follow-up scans was higher in all converted patients, even for those with DLB without parkinsonism, than in IRBD patients who remained disease-free.

CONCLUSIONS

FMT-PET, which represents a dynamic change in AADC activity over time, may also be a useful predictor for the risk of conversion to PD or DLB over short-term clinical follow-up periods, or when testing neuroprotective and restorative strategies in the prodromal phases of PD or DLB.

[REM Sleep Behavior Disorder and α-synucleinopathy]

REM sleep behavior disorder (RBD) can progress to Parkinson's disease, Lewy body dementia, or multiple system atrophy within 20 years of onset. Accurate diagnosis of RBD is therefore important for early intervention. The development of markers that can more sensitively evaluate the effects of high-risk groups or candidate therapies that develop α-synucleinopathy in the short term is the key to a successful clinical trial. Clinical protocols for early diagnosis of α-synucleinopathy are currently being developed. The next stage will be to conduct clinical trials for candidate therapies.

Relationship of substantia nigra hyperechogenicity to risk of Lewy body disease in idiopathic REM sleep behavior disorder patients: a longitudinal study

BACKGROUND

We examined the relationship between baseline substantia nigra (SN) echogenicity on transcranial sonography (TCS) images and medium-to long-term developments of Parkinson's disease (PD) and dementia with Lewy bodies (DLB) in idiopathic RBD (IRBD) patients.

METHODS

From 2007-2009, TCS and odor identification tests were performed in 34 consecutive IRBD patients (67.9 ± 6.1 years). A medical chart review was conducted in August 2019 to investigate the development of PD or DLB.

RESULTS

Of the 34 IRBD patients, 14 (41.2%) showed SN hyperechogenicity (SN+) on TCS at baseline. There were no significant differences in age, Unified Parkinson's Disease Rating Scale (UPDRS) score, Mini-Mental State Exam (MMSE) score, or odor identification (OSIT-J) score between the SN+ and SN normoechogenicity (SN-) groups at baseline. The phenoconversion rate was 57.4% (n = 8) in the SN+ group (mean 5.8 years from baseline TCS), and 25.0% (n = 5) in the SN- group (mean 8.6 years from baseline TCS). Of those with phenoconversions, there were five PD patients and three DLB patients in the SN+ group, and one PD patient and four DLB patients in the SN- group. The SN+ group had a higher estimated risk for disease development than the SN- group. The coexistence of SN+ with functional anosmia may predict a short-term Lewy body disease onset risk.

CONCLUSION

A single baseline TCS for IRBD patients may be a suitable test for screening and predicting groups at high-risk for developing PD or DLB. This may help to select appropriate IRBD patients in clinical trials for disease modifying therapy to prevent progression to PD or DLB.

Two cases of BRAF-mutated, bulbar conjunctival melanoma, and review of the published literature

We describe two patients with BRAF-mutated melanoma of the epithelioid cell type arising from primary acquired melanosis with severe atypia of the right bulbar conjunctiva. Patient 1 was a 71-year-old Japanese man. After adjuvant cryotherapy and enucleation of the right eyeball, therapy with vemurafenib was administered for a distant metastasis to a lumbar vertebra, accompanied by erythema multiforme and two keratinous tumours. The patient died due to metastases to the liver and multiple vertebrae, despite therapy with nivolumab and combination therapy with dabrafenib plus trametinib. Patient 2 was a 72-year-old Japanese man. After adjuvant cryotherapy, periodic mitomycin C eye drops, and excision of the superficial portion of the right parotid gland and the dissection of cervical lymph nodes, he was treated with adjuvant combination therapy with dabrafenib plus trametinib. Dermatologists should be familiar with BRAF-mutated conjunctival melanoma, which is usually located on the bulbar conjunctiva and associated with more frequent distant metastasis.

Sudden onset of sleep caused by hypothalamic infarction: a case report

Background

Hypothalamic lesions, such as tumors and demyelinating diseases, reportedly cause abnormal sleepiness. However, stroke involving the hypothalamus has rarely been described. Here, we report a patient with infarction restricted to the hypothalamus who presented with sudden onset of sleep.

Case presentation

A 42-year-old woman with a history of migraine without aura presented with irresistible sleepiness and developed several episodes of sudden onset of sleep. Neurological examinations were unremarkable except for partial left Horner syndrome. Brain magnetic resonance imaging (MRI) revealed a high-intensity lesion restricted to the left hypothalamus on diffusion-weighted and fluid-attenuated inversion recovery MRI images. Cerebrospinal fluid (CSF) orexin-A levels obtained on hospital day 3 after her sleepiness had resolved were normal (337 pg/mL; normal > 200 pg/mL). Serum anti-nuclear and anti-aquaporin 4 (AQP4) antibodies and CSF myelin basic protein and oligoclonal band were negative. A small hypothalamic infarction was suspected, and the patient was treated with intravenous edaravone and argatroban, as well as oral clopidogrel. Three months later, there had been no clinical relapse, and the hypothalamic lesion had almost disappeared on follow-up MRI. No new lesion suggestive of demyelinating disease or tumor was observed.

Conclusion

Hypothalamic stroke should be considered a cause of sudden onset of sleep.

[Increased frequency and spread of restlessness as the early manifestation of Parkinson's disease in a woman with restless legs syndrome]

A 57-year-old woman had been suffered from insomnia due to restlessness and abnormal sensation of the left side of the body for 33 years. Since the preceding year of the first visit frequency of the symptoms increased, and the abnormal sensation was spread to the right leg. Her daughter had restless legs syndrome (RLS) since age 20. Neurological examination showed no abnormality. Laboratory test results showed normal ferritin levels. There was no renal dysfunction or anemia. A diagnosis of RLS was made, and her symptoms responded well to pramipexole treatment. However, the patient developed right shoulder pain and right-hand tremor one year and one and a half year after the first visit, respectively. Based on clinical findings and the findings of dopamine transporter scan and cardiac ¹²³I-MIBG scintigraphy, the patient was diagnosed with Parkinson's disease (PD). Careful observation of changes in RLS symptoms is required as an increased frequency and spread of symptoms of RLS could be the early manifestation of PD.

Phenoconversion from Idiopathic Rapid Eye Movement Sleep Behavior Disorder to Lewy Body Disease

Background

The conversion rate and estimated risk of neurodegenerative diseases vary with idiopathic rapid eye movement sleep behavior disorder (IRBD).

Methods

This retrospective cohort study examined 273 patients (213 men, 60 women) with polysomnographic-confirmed IRBD (192 and 81 patients in the Sleep Center [SC] cohort and Neurological Center [NC] cohort, respectively) who were followed longitudinally. The date of diagnosis was determined as the onset of an overt neurological syndrome. The conversion rate was calculated; the risk of developing an overt neurological syndrome was estimated using the Kaplan-Meier method.

Results

The estimated onset risk for a neurodegenerative syndrome from the time of IRBD diagnosis when the SC and NC cohorts were combined was 11.9%, 20.3%, 33.2%, and 51.4% at three, five, seven, and ten years, respectively. The phenoconversion rate (21.7% with a mean follow-up period from the time of IRBD diagnosis of 3.9 ± 3.0 years) was lower than in prior studies, but the conversion risk increased progressively as the follow-up period increased. The majority of patients developed Lewy body disease, while multiple system atrophy was rare. The risk of developing Lewy body disease differed significantly between the SC and NC cohorts (P = 0.02).

Conclusions

In this first study of a large Asian IRBD population, the estimated conversion risk leading to diagnosis differed between the two cohorts, which could be attributed to different evaluation results depending on the observed population due to a referral bias and follow-up duration. Researchers should be aware of potential selection bias in their clinical studies.

A variant at 9q34.11 is associated with HLA-DQB1*06:02 negative essential hypersomnia

Essential hypersomnia (EHS) is a lifelong disorder characterized by excessive daytime sleepiness without cataplexy. EHS is associated with human leukocyte antigen (HLA)-DQB1*06:02, similar to narcolepsy with cataplexy (narcolepsy). Previous studies suggest that DQB1*06:02-positive and -negative EHS are different in terms of their clinical features and follow different pathological pathways. DQB1*06:02-positive EHS and narcolepsy share the same susceptibility genes. In the present study, we report a genome-wide association study with replication for DQB1*06:02-negative EHS (408 patients and 2247 healthy controls, all Japanese). One single-nucleotide polymorphism, rs10988217, which is located 15-kb upstream of carnitine O-acetyltransferase (CRAT), was significantly associated with DQB1*06:02-negative EHS (P = 7.5 × 10^-9, odds ratio = 2.63). The risk allele of the disease-associated SNP was correlated with higher expression levels of CRAT in various tissues and cell types, including brain tissue. In addition, the risk allele was associated with levels of succinylcarnitine (P = 1.4 × 10^-18) in human blood. The leading SNP in this region was the same in associations with both DQB1*06:02-negative EHS and succinylcarnitine levels. The results suggest that DQB1*06:02-negative EHS may be associated with an underlying dysfunction in energy metabolic pathways.

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

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

[A 70-year-old woman presenting with restless shoulder following posterior internal capsule infarction]

A 70-year-old woman noticed difficulty in speech and weakness of the left upper and lower limb upon awakening. Neurological examination showed dysarthria and left hemiparesis. No sensory disturbance was observed. Brain MRI revealed acute infarction in the right posterior limb of the internal capsule. On the hospital day 1, she developed the abnormal sensations restricted to the bilateral shoulders, resulting in difficulty initiating sleep. On laboratory data, renal function and serum hemoglobin and ferritin levels were normal. When four essential features of restless legs syndrome (RLS) were applied to her shoulders, the patient met RLS criteria. Following low dose pramipexole treatment, the abnormal sensation of the shoulders and insomnia significantly improved. We should be aware of the possibility of RLS or its variant, including "restless shoulder" of our patient, for the cause of insomnia following acute ischemic infarction.

A Card-type Odor Identification Test for Japanese Patients with Parkinson's Disease and Related Disorders

Objective The characteristics of olfactory impairment in Parkinson's disease (PD), multiple system atrophy (MSA) and progressive supranuclear palsy (PSP) have not been determined in detail. We assessed the olfactory function among PD, MSA and PSP patients. Methods A card-type odor identification test, Open Essence (OE, Wako, Japan), which consists of 12 different odorants familiar to Japanese subjects, was administered to 98 PD patients, 32 MSA patients, 17 PSP patients and 96 control subjects ≥50 years of age. Results The PD patients had significantly lower OE scores than the other groups. The OE scores of the MSA and PSP patients fell between those of the PD patients and the control subjects. A cut-off OE score of 6 was beneficial for differentiating PD patients from controls with 84.7% sensitivity and 85.4% specificity. A cut-off OE score of 4 had 60.2% sensitivity and 77.6% specificity for differentiating PD patients from MSA and PSP patients. The correct answer rates for the curry, Japanese orange and perfume odorants in the PD patients were lower than those in the MSA and PSP patients and controls. The PD patients also had the highest ratio of "not detected" choices across the 12 odors. Conclusion Marked olfactory impairment was a feature of the patients with PD, while mild olfactory impairment was observed in those with MSA or PSP. The answer patterns and the specific odorants may also be useful in differentiating PD from related disorders.

Impact of sleep-related symptoms on clinical motor subtypes and disability in Parkinson's disease: a multicentre cross-sectional study

OBJECTIVES

To investigate the impact of sleep disturbances on Parkinson's disease (PD) clinical motor subtypes and disease-related disability in a multicentre setting.

METHODS

We report a cross-sectional relationship between sleep-related symptoms and clinical motor subtypes (tremor dominant (TD); intermediate; postural instability and gait disturbances (PIGDs)) identified in a multicentre study, including 436 patients with PD and 401 age-matched controls. PD-related sleep problems (PD-SP), excessive daytime sleepiness (EDS) and probable REM sleep behaviour disorder (pRBD) were evaluated using the PD sleep scale (PDSS)-2, Epworth Sleepiness Scale (ESS) and RBD screening questionnaire-Japanese version (RBDSQ-J), respectively.

RESULTS

PD-SP (PDSS-2 ≥18; 35.1% vs 7.0%), EDS (ESS ≥10; 37.8% vs 15.5%) and pRBD (RBDSQ-J ≥5; 35.1% vs 7.7%) were more common in patients with PD than in controls. The prevalence of restless legs syndrome did not differ between patients with PD and controls (3.4% vs 2.7%). After adjusting for age, sex, disease duration and Movement Disorder Society-Unified PD Rating Scale (MDS-UPDRS) part III score, the PIGD group had higher PDSS-2 and ESS scores than the TD group. The RBDSQ-J scores did not differ among the TD, intermediate and PIGD groups. A stepwise regression model predicting the MDS-UPDRS part II score identified the Hoehn and Yahr stage, followed by the number of sleep-related symptoms (PD-SP, EDS and pRBD), disease duration, MDS-UPDRS part III score, PIGD subtype, depression and MDS-UPDRS part IV score as significant predictors.

CONCLUSION

Our study found a significant relationship between sleep disturbances and clinical motor subtypes. An increased number of sleep-related symptoms had an impact on disease-related disability.