Specific COVID-19 risk behaviors and the preventive effect of personal protective equipment among healthcare workers in Japan

As coronavirus disease 2019 (COVID-19) outbreaks in healthcare facilities are a serious public health concern, we performed a case-control study to investigate the risk of COVID-19 infection in healthcare workers. We collected data on participants' sociodemographic characteristics, contact behaviors, installation status of personal protective equipment, and polymerase chain reaction testing results. We also collected whole blood and assessed seropositivity using the electrochemiluminescence immunoassay and microneutralization assay. In total, 161 (8.5%) of 1,899 participants were seropositive between August 3 and November 13, 2020. Physical contact (adjusted odds ratio 2.4, 95% confidence interval 1.1-5.6) and aerosol-generating procedures (1.9, 1.1-3.2) were associated with seropositivity. Using goggles (0.2, 0.1-0.5) and N95 masks (0.3, 0.1-0.8) had a preventive effect. Seroprevalence was higher in the outbreak ward (18.6%) than in the COVID-19 dedicated ward (1.4%). Results showed certain specific risk behaviors of COVID-19; proper infection prevention practices reduced these risks.

National seroepidemiological study of COVID-19 after the initial rollout of vaccines: Before and at the peak of the Omicron-dominant period in Japan

Background

Based on routine surveillance data, Japan has been affected much less by COVID-19 compared with other countries. To validate this, we aimed to estimate SARS-CoV-2 seroprevalence and examine sociodemographic factors associated with cumulative infection in Japan.

Methods

A population-based serial cross-sectional seroepidemiological investigation was conducted in five prefectures in December 2021 (pre-Omicron) and February-March 2022 (Omicron [BA.1/BA.2]-peak). Anti-nucleocapsid and anti-spike antibodies were measured to detect infection-induced and vaccine/infection-induced antibodies, respectively. Logistic regression was used to identify associations between various factors and past infection.

Results

Among 16 296 participants (median age: 53 [43-64] years), overall prevalence of infection-induced antibodies was 2.2% (95% CI: 1.9-2.5%) in December 2021 and 3.5% (95% CI: 3.1-3.9%) in February-March 2022. Factors associated with past infection included those residing in urban prefectures (Tokyo: aOR 3.37 [95% CI: 2.31-4.91], Osaka: aOR 3.23 [95% CI: 2.17-4.80]), older age groups (60s: aOR 0.47 [95% CI 0.29-0.74], 70s: aOR 0.41 [95% CI 0.24-0.70]), being vaccinated (twice: aOR 0.41 [95% CI: 0.28-0.61], three times: aOR 0.21 [95% CI: 0.12-0.36]), individuals engaged in occupations such as long-term care workers (aOR: 3.13 [95% CI: 1.47-6.66]), childcare workers (aOR: 3.63 [95% CI: 1.60-8.24]), food service workers (aOR: 3.09 [95% CI: 1.50-6.35]), and history of household contact (aOR: 26.4 [95% CI: 20.0-34.8]) or non-household contact (aOR: 5.21 [95% CI:3.80-7.14]) in February-March 2022. Almost all vaccinated individuals (15 670/15 681) acquired binding antibodies with higher titers among booster dose recipients.

Conclusions

Before Omicron, the cumulative burden was >10 times lower in Japan (2.2%) compared with the US (33%), the UK (25%), or global estimates (45%), but most developed antibodies owing to vaccination.

Safety and immunogenicity of sequential administration of PCV13 followed by PPSV23 in pneumococcal vaccine-naïve adults aged ≥ 65 years: Comparison of booster effects based on intervals of 0.5 and 1.0 year

OBJECTIVE

An open-label study was conducted to compare the safety and immunogenicity of a sequential administration of 13-valent pneumococcal conjugate vaccine (PCV13) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23) between an interval of 0.5 (0.5-y) and 1 year (1.0-y) in adults aged ≥ 65 years.

METHODS

Pneumococcal vaccine-naïve adults aged ≥ 65 years (n = 129) received a sequential administration with an interval of 0.5-y or 1.0-y or received a single administration of PPSV23 (single PPSV23). We evaluated the immunogenicity before and 1 month after each vaccination and at 0.5-y intervals for 2 years. The primary endpoint was the increase in geometric mean fold rises (GMFRs) of immunoglobulin G (IgG) or opsonophagocytic activity (OPA) for eight common serotypes one month after one dose of PPSV23. The secondary endpoint was the safety profile for one dose of PPSV23.

RESULTS

One month after administration of PPSV23, the GMFRs of IgG considerably increased for five of eight serotypes in the 1.0-y interval group, whereas the GMFRs of IgG considerably increased for two serotypes in the 0.5-y interval group. Furthermore, GMFRs of OPA markedly increased for all eight serotypes in the 1.0-y interval group, while GMFRs of OPA markedly increased for four serotypes in the 0.5-y interval group. At 2 years after initial vaccination, GMFRs of IgG or OPA were higher for all serotypes, except for serotype 3, than those in the single PPSV23 group irrespective of intervals. No significant difference was found in the frequencies of local reactions of all grades between the two intervals.

CONCLUSIONS

The 1.0-y interval provided better booster effects induced by PPSV23 than those of the 0.5-y interval in a sequential administration in pneumococcal vaccine-naïve adults aged ≥ 65 years. No difference was found in the safety profile between both intervals.

A seroepidemiological study across age groups before and after the 2010-2011 mumps epidemic in Japan

In Japan, large-scale mumps epidemics recur every 4-6 years because of low vaccination coverage. This study aimed to describe the seroprevalence of mumps in the Japanese population and identify the age groups most affected. The prevalence of anti-mumps antibodies was evaluated based on 1000 serum samples obtained from the Japanese National Serum Reference Bank. These samples consisted of 50 sera for each of 10 different age groups, collected during 2007-2008 (pre-epidemic period) and 2012-2013 (post-epidemic period). Seropositivity was lowest in the 6-11 months subgroup (3% and 0% in pre- and post-epidemic periods, respectively) and highest in the 10-14 years group (66% and 72% in pre- and post-epidemic periods, respectively). A comparison of anti-mumps antibody prevalence throughout the two periods considered revealed a large rise in seropositivity among the 2004-2008 birth cohort, using that of the 1-4 years group as representative in the pre-epidemic period (from 22% in pre- to 58% in post-epidemic periods; p = 0.0002). These results indicate that most people likely gain antibodies to the mumps virus during their childhood, especially during the first epidemic that they experience after their second year of life. Therefore, children should be vaccinated against mumps soon after their first birthday for effective prevention.

Vasovagal reactions after COVID-19 vaccination in Japan

Coronavirus disease 2019 (COVID-19) vaccine administration started in February 2021 in Japan. As of December 2021, approximately 75% of the population aged ≥12 years had received two doses of vaccine. We conducted a study to investigate vasovagal reactions (VVR) after COVID-19 vaccination using data on adverse events following immunization. The crude reporting rate of VVR (cases/1,000,000 doses) after vaccination was 9.6 in all age groups combined, and was more frequent in the younger age groups: 28.6 and 37.2 in individuals aged 10–19 years and 20–29 years, respectively. In individuals aged 10–29 years, the rate was similar in males and females (33.0 and 34.2, respectively, p = 0.53); but was higher after dose 1 than after dose 2 (57.4 and 8.8, respectively, p < 0.001). Based on these results, caution needs to be exercised when vaccinating adolescents and young adults, especially with dose 1 of COVID-19 vaccines.

Seroepidemiological analysis of anti-pneumococcal surface protein A (PspA) immunoglobulin G by clades in Japanese population

BACKGROUND

Pneumococcal surface protein A (PspA) is one of the candidates of the novel pneumococcal protein vaccines. The seroepidemiology of naturally acquired anti-PspA immunoglobulin G (IgG) by clades, across a wide range of ages has not been investigated.

METHODS

We examined the concentrations of anti-PspA IgG by clades (1, 2, 3, 4, and 5) in 397 sera from persons aged 0-≥70 years by enzyme-linked immunosorbent assay, and determined the geometric mean concentrations (GMCs) by age group. The relationships between concentrations of anti-PspA IgG antibody for each clade for each person were also assessed.

RESULTS

GMC of anti-PspA IgG was lowest, highest, and plateaued in those aged 6-11 months, 5-9-years, and 20-49 years, respectively. It gradually declined in those aged > 70 years. GMCs patterns in different age groups were similar for all clades. Correlations were found especially within the same PspA family (between clades 1 and 2 or clades 4 and 5).

CONCLUSIONS

Our data suggested that most people acquired anti-PspA IgG across clades 1, 2, 3, 4, and 5 during childhood. These results would be a fundamental data of clade-specific anti-PspA IgG antibodies.

Rubella outbreak among workers in three small- and medium-size business establishments associated with imported genotype 1E rubella virus-Shizuoka, Japan, 2015

On 12 February 2015, a local health department (LHD) in Shizuoka prefecture identified two reported rubella cases in its jurisdiction as employees of the same company. As other employees at the company resided both inside and outside of the health department's jurisdiction, it began collaborating with two additional LHDs and the National Institute of Infectious Diseases to investigate and respond to the outbreak, which subsequently identified cases in two additional companies. We obtained epidemiological, clinical, and outbreak response information from the national epidemiological surveillance of infectious disease system's database, the local health departments, and the associated companies. One specimen for genetic sequencing was collected from each of the three companies. The outbreak included a total of twenty-five cases, with seventeen confirmed and eight probable cases from three companies. Among them, 24 (96%) were male, 22 (88%) were employees of one company (Company X), and none had rubella vaccination history. The median age was 45 years (interquartile range: 40-51). Epidemiological information did not reveal the source of infection nor transmission route. All rubella viruses sequenced from the three specimens were classified into genotype 1E. The nucleotide sequences in the 739 bp-window region were completely identical in two specimens, with only one nucleotide difference in the third specimen. According to phylogenetic analysis, these strains were closely related to the Southeast and East Asian lineage. This rubella outbreak at three companies, ranging in size from small- to medium-size, in Japan occurred among unvaccinated employees aged at least 30 years, most of whom were male. Virologic analyses suggest all cases were infected with the same viral strain imported from Southeast Asia. Similar to these companies, most employees at small- and medium-size businesses in Japan are males with no vaccination history for rubella, which poses a serious risk for associated cases of congenital rubella syndrome (CRS).

Immune thrombocytopenic purpura risk by live, inactivated and simultaneous vaccinations among Japanese adults, children and infants: a matched case-control study

This case–control study investigated immune thrombocytopenic purpura (ITP) risk following live, inactivated, and simultaneous vaccination, with a focus on infants aged < 2 years. We matched case patients with ITP to one or two control patients with other diseases by institution, hospital visit timing, sex, and age. We calculated McNemar’s pairwise odds ratios (ORs [95% confidence interval]) with 114 case–control pairs. The case group had 27 (44%) males and 22 (35%) infants, and the control group included 49 (43%) males and 42 (37%) infants. For all age groups, the McNemar’s OR for ITP occurrence was 1.80 (0.54–6.84, p = 0.64) for all vaccines. Among infants, these were 1.50 (0.17–18.0, p = 0.50) for all vaccines, 2.00 (0.29–22.1, p = 0.67) for live vaccines, and 1.00 (0.01–78.5, p = 0.50) for inactivated vaccines. Sex-adjusted common ORs for simultaneous vaccination were 1.52 (0.45–5.21, p = 0.71) for all vaccines, 1.83 (0.44–7.59, p = 0.40) for inactivated vaccines only, and 1.36 (0.29–6.30, p = 0.69) for mixed live and inactivated vaccines. In infants, these were 1.95 (0.44–8.72, p = 0.38), 1.41 (0.29–6.94, p = 0.67) and 2.85 (0.43–18.9, p = 0.28), respectively. These limited data suggest no significant ITP risk following vaccinations or simultaneous vaccination in any age group, including infants.

Trends in varicella and mumps vaccination rates in children under 3 years of age in a tertiary children's hospital in Japan

BACKGROUND

In Japan, the voluntary vaccination rate is not known accurately. Although two doses of the measles and rubella vaccines have been part of the universal vaccine program since 2006, the varicella vaccine was added in October 2014 while the mumps vaccine still remains voluntary. The aim of this study was to evaluate trends in the live measles, rubella, varicella and mumps vaccination rates in Japan.

METHODS

This retrospective cohort study was conducted at Tokyo Metropolitan Children's Medical Center between October 2012 and December 2016. Patients aged 1-2 years who were admitted to the Department of General Pediatrics were enrolled. The trend in the vaccination rate against measles, rubella, varicella, and mumps was examined.

RESULTS

The measles and rubella vaccination rate was 80-90%. The varicella vaccination rate in the second quarter of 2012, the third quarter of 2014, and the fourth quarter of 2016 was 34.6%, 67.1%, and 80.7%, respectively. The mumps vaccination rate in the second quarter of 2012, the third quarter of 2014, and the fourth quarter of 2016 was 27.6%, 59.5%, and 61.8%, respectively.

CONCLUSIONS

The varicella and mumps vaccination rate improved until 2014 despite the fact that they were voluntary vaccinations. After varicella vaccination was added to the universal vaccination program, the varicella vaccination rate continued to improve. The mumps vaccination, which was not included, failed to improve, suggesting that the universal vaccination program contributed to increasing the uptake of the vaccines it includes.

Comparison of Haemophilus influenzae Seroprevalence in Serum Samples Collected from 0- to 5-Year-Old Japanese Children in 1980, 1995, 2010, and 2012

Haemophilus influenzae type b (Hib) causes several invasive infections such as meningitis, septic arthritis, and pneumonia, especially in children below 5 years old. Despite the availability of Hib vaccines against Hib infection, seroepidemiological surveys of Hib infections have not yet been systematically conducted in Japan. We analyzed 1,338 serum samples, provided by the National Serum Reference Bank of the National Institute of Infectious Diseases (Tokyo, Japan), from 0- to 5-year-old children. Anti-polyribosylribitol phosphate (PRP) immunoglobulin G (IgG) antibody levels against Hib were determined using an anti-H. influenzae IgG enzyme immunoassay kit. In a total of 1,168 (87.3%) serum samples from children, anti-PRP IgG antibody levels were ≥ 0.15 μg/mL, providing natural immunity. Titers expected to provide long-term protection (≥ 1 μg/mL) were increased from 2.7% to 51.6% in children < 1 year old after the introduction of Hib vaccine (1980, 5.3%; 1995, 2.7%; 2010, 22%; 2012, 51.6%). Our data confirmed that the introduction of Hib vaccination in children below 5 years old increased the proportion of children having high anti-PRP IgG antibody levels, ensuring long-term protection against Hib.

Enterovirus D68 respiratory infection in a children's hospital in Japan in 2015

BACKGROUND

Outbreaks of enterovirus D68 (EV-D68) respiratory infections in children were reported globally in 2014. In Japan, there was an EV-D68 outbreak in the autumn of 2015 (September-October). The aim of this study was to compare EV-D68-specific polymerase chain reaction (PCR)-positive and EV-D68-specific PCR-negative patients.

METHODS

Pediatric patients admitted for any respiratory symptoms between September and October 2015 were enrolled. Nasopharyngeal swabs were tested for multiplex respiratory virus PCR and EV-D68-specific reverse transcription-PCR. EV-D68-specific PCR-positive and -negative patients were compared regarding demographic data and clinical information.

RESULTS

A nasopharyngeal swab was obtained from 76 of 165 patients admitted with respiratory symptoms during the study period. EV-D68 was detected in 40 samples (52.6%). Median age in the EV-D68-specific PCR-positive and -negative groups was 3.0 years (IQR, 5.5 years) and 3.0 years (IQR, 4.0 years), respectively. The rates of coinfection in the two groups were 32.5% and 47.2%, respectively. There was no significant difference in the history of asthma or recurrent wheezing, length of hospitalization, or pediatric intensive care unit admission rate between the groups. The median days between symptom onset and admission was significantly lower for the EV-D68-positive group (3.0 days vs 5.0 days, P = 0.001). EV-D68 was identified as clade B on phylogenetic analysis. No cases of acute flaccid myelitis were encountered.

CONCLUSIONS

More than half of the samples from the children admitted with respiratory symptoms were positive for EV-D68-specific PCR during the outbreak. Asthma history was not associated with the risk of developing severe respiratory infection.

Polio vaccination coverage and seroprevalence of poliovirus antibodies after the introduction of inactivated poliovirus vaccines for routine immunization in Japan

In Japan, the oral poliovirus vaccine (OPV) was changed to 2 types of inactivated poliovirus vaccine (IPV), the standalone conventional IPV (cIPV) and the Sabin-derived IPV combined with diphtheria-tetanus-acellular pertussis vaccine (DTaP-sIPV), for routine immunization in 2012. We evaluated polio vaccination coverage and the seroprevalence of poliovirus antibodies using data from the National Epidemiological Surveillance of Vaccine-Preventable Diseases (NESVPD) from 2011 to 2015. Several years before the introduction of IPV in 2012, OPV administration for children was refused by some parents because of concerns about the risk of vaccine-associated paralytic poliomyelitis. Consequently, in children aged <1 years who were surveyed in 2011-2012, polio vaccination coverage (45.0-48.8%) and seropositivity rates for poliovirus (type 1: 51.7-65.9%, type 2: 48.3-53.7%, and type 3: 15.0-29.3%) were decreased compared to those surveyed in 2009. However, after IPV introduction, the vaccination coverage (95.5-100%) and seropositivity rates (type 1: 93.2-96.6%, type 2: 93.1-100%, and type 3: 88.6-93.9%) increased among children aged <1 years in 2013-2015. In particular, seropositivity rates and geometric mean titers (GMTs) for poliovirus type 3 in <5-year-old children who received 4 doses of IPV (98.5% and 247.4, respectively) were significantly higher than in those who received 2 doses of OPV (72.5% and 22.9, respectively). Furthermore, in <5-year-old children who received 4 doses of either DTaP-sIPV or cIPV, the seropositivity rates and the GMTs for all 3 types of poliovirus were similarly high (96.5-100% and 170.3-368.8, respectively). Our findings from the NESVPD demonstrate that both the vaccination coverage and seropositivity rates for polio remained high in children after IPV introduction.

Descriptive epidemiology of varicella based on national surveillance data before and after the introduction of routine varicella vaccination with two doses in Japan, 2000-2017

Routine childhood immunization using two doses of the varicella vaccine was introduced in Japan in October 2014. In this study, we analyzed the data extracted from national varicella surveillance, including pediatric sentinel surveillance from 2000 to 2017 and hospitalized varicella surveillance from the 38th week of 2014 to the 37th week of 2017. Compared with the 2000-2011 baseline data, the number of varicella cases per sentinel decreased substantially by 76.6% overall and by 88.2% among children aged 1-4 years in 2017. Of 997 hospitalized patients, we found a decreasing trend in the number of cases among children aged <5 years. We also found a decreasing trend in the number of cases with complications among children aged 1-4 years. Data on the self-reported transmission sites in 35.5% (354/997) of the hospitalized varicella patients showed that transmission of varicella zoster virus (VZV) occurred frequently in household, at school for young children, in the workplace for adults, and at hospital for all age groups. Data from 29.0% (289/997) of the hospitalized patients with a self-reported source of infection showed that transmission of VZV occurred from a patient with herpes zoster (HZ) in 30.4% (88/289) of cases. Our data demonstrate a substantial decrease in the number of varicella cases in young children following introduction of routine childhood vaccination program with two-dose varicella vaccination in Japan. These data highlight the unique aspects of transmission sites across age groups and the important role of HZ cases in disease circulation.

Characteristics and Outcomes of Influenza-Associated Encephalopathy Cases Among Children and Adults in Japan, 2010-2015

Background

Influenza-associated encephalopathy (IAE) can result in severe neurologic disease with high mortality. Most IAE cases are reported among children worldwide. Understanding of IAE among adults is limited.

Methods

Data were collected on IAE cases reported through the National Epidemiological Surveillance of Infectious Diseases database in Japan from 2010 through 2015. IAE cases were stratified by age category and analyzed using descriptive statistics to assess differences in characteristics and outcomes.

Results

Among 385 IAE cases, median age at diagnosis was 7 years (range, 0-90), and 283 (74%) were aged <18 years. Mean seasonal incidence of IAE cases among children and adults (aged ≥18 years) was 2.83 and 0.19 cases per 1000000 population, respectively. IAE incidence did not vary by predominant influenza A virus subtype. IAE frequency was highest in school-aged (5-12 years) children (38%), followed by children aged 2-4 years (21%) and adults aged 18-49 years (11%). The proportion of cases with seizures was more common in children. There were more cases with cerebrospinal fluid pleocytosis among adults than in children (P < .01), especially among those aged 18-49 (17%) and 50-64 (19%) years. Case fatality proportion was highest in those aged 40-64 (17%) and ≥65 (20%) years.

Conclusions

We found differences in the clinical features of IAE between adults and children in Japan. Although IAE incidence was higher in children, mortality was higher in adults. Efforts are needed to prevent and improve survival of patients with IAE, especially in adults.

Nebulized hypertonic saline in infants hospitalized with moderately severe bronchiolitis due to RSV infection: A multicenter randomized controlled trial

INTRODUCTION

The efficacy of nebulized hypertonic saline (HS) therapy for shortening hospital length of stay (LOS) or improving bronchiolitic symptoms remains controversial. Most studies enrolled small numbers of subjects and did not consider the role of respiratory syncytial virus (RSV), the most common cause of acute bronchiolitis. Our aim was to evaluate the efficacy and safety of nebulized HS therapy for acute bronchiolitis due to RSV in moderately ill hospitalized infants.

MATERIALS AND METHODS

This was an open-label, multicenter, randomized controlled trial comparing a nebulized HS treatment group with a normal saline (NS) group. The subjects, 128 infants with bronchiolitis due to RSV, were admitted to five hospitals in Tokyo, Japan. Three-percent HS or NS was administered via bronchodilator four times daily post-admission. The primary outcome was LOS, defined as the time until the patients fulfilled the discharge criteria, namely, absence of fever, no need for supplemental oxygen, and adequate feeding. Survival analysis was conducted in accordance with the intention-to-treat principle.

RESULTS

The baseline characteristics were similar between the two groups. There was no significant overall difference in LOS between the groups (4.81 ± 2.14 days in HS vs 4.61 ± 2.18 days in NS; P = 0.60). Survival analysis by log-rank test also showed no significance (P = 0.62). Multivariate adjustment did not significantly alter the results. The treatment was well-tolerated, with no adverse effects attributable to the use of HS.

CONCLUSIONS

Nebulized HS therapy did not significantly reduce LOS among infants with bronchiolitis due to RSV.

A heterozygous dominant-negative mutation in the coiled-coil domain of STAT1 is the cause of autosomal-dominant Mendelian susceptibility to mycobacterial diseases

Heterozygous dominant-negative mutations of STAT1 are responsible for autosomal-dominant Mendelian susceptibility to mycobacterial diseases (AD-MSMD). So far, only 7 mutations have been previously described and are localized to 3 domains: the DNA-binding domain, the SH₂ domain, and the tail segment. In this study, we demonstrated the first coiled-coil domain (CCD) mutation of c.749G>C, p.G250A (G250A) in STAT1 as a genetic cause of AD-MSMD in a patient with mycobacterial multiple osteomyelitis. This de novo heterozygous mutation was shown to have a dominant-negative effect on the gamma-activated sequence (GAS) transcriptional activity following IFN-γ stimulation, which could be attributable to the abolished phosphorylation of STAT1 from the wild-type (WT) allele. The three-dimensional structure of STAT1 revealed the G250 residue was located distant from a cluster of residues affected by gain-of-function mutations responsible for chronic mucocutaneous candidiasis.

Pediatric hypervirulent Klebsiella pneumoniae septic arthritis

Cases of infection with hypervirulent Klebsiella pneumoniae are gradually increasing in number, and cause life-threatening community-acquired infection even in immunocompetent patients. A 14-year-old boy developed septic hip arthritis due to hypervirulent K. pneumoniae (sequence type 23, serotype K1, magA positive). The patient initially seemed to have been successfully treated with antibiotics and surgical intervention, but septic arthritis developed into osteomyelitis of the femoral head and myositis, which required long-term antibiotic therapy and additional surgical intervention. This is the first pediatric case of hypervirulent K. pneumoniae septic hip arthritis. Treatment plans should mainly consist of antibiotic therapy and surgical intervention. Clinicians, even pediatricians, in developed countries should be aware of the increasing incidence of hypervirulent Klebsiella pneumoniae infection.

The relationship between the daily step counts and low back pain during pregnancy

PURPOSE

To investigate the relationship between the change of daily step counts and low back pain (LBP) during pregnancy. Materials and

METHODS

Pregnant women at less than eight weeks of gestation (WG) were recruited. Daily step counts were measured with a pedometer. To assess LBP, the Oswestry disability index (ODI) score was recorded. Thirty-six individuals were divided into the LBP and non-LBP groups. The effect of step counts on LBP between the two groups was analyzed.

RESULTS

At 16-19 WG, step counts were not considerably changed in the non-LBP group but were significantly increased in the LBP group. At 24-27 and 32-35 WG, step counts were increased in the non-LBP group but were significantly decreased in the LBP group.

CONCLUSIONS

Acute increase of daily step counts in early pregnancy is a risk for LBP, and gradual increases of step counts after mid-pregnancy is recommended for women.

[Acute encephalopathy with biphasic seizures and late reduced diffusion with visual disturbance and higher brain dysfunction]

Acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) is a recently described clinicoradiologic syndrome. Clinically, a prolonged febrile seizure is followed by subsequent seizures which occur several days after the initial seizure. On MRI, reduced diffusion appears predominantly in the frontoparietal subcortical white matter at the time of the subsequent seizures. The main symptom between the initial and subsequent seizures is disturbance of consciousness. We report a case with AESD who presented 1) reduced diffusion on MRI which was dominant in the occipital lobe, and 2) reversible visual disturbance followed by higher brain dysfunction such as a cognitive deficit and disturbed speech. A 2-year-old Japanese girl was admitted because of visual disturbance which appeared 4 days after a generalized tonic-clonic seizure associated with fever. Two days later, she had another seizure when MRI revealed reduced diffusion in the subcortical white matter. The MRI finding was not typical of AESD in that reduced diffusion appeared dominantly in the occipital lobe. Normal ophthalmologic findings and abnormal visual evoked potential results suggested that her visual disturbance was due to an impaired visual pathway in the subcortical white matter in the occipital lobe. The present case indicates that there is a subgroup of AESD in which the subcortical lesion seen on MRI is dominant in the occipital lobe.

[The efficacy of perioperative administration of steroid and erythromycin in the surgery for lung cancer complicated with interstitial pneumonia]

OBJECTIVES

We evaluated the efficacy of perioperative administration of steroid and erythromycin in surgery for lung cancer complicated with interstitial pneumonia (IP) to prevent postoperative acute exacerbation.

PATIENTS AND METHODS

We operated on 21 lung cancer patients with IP for 10 years. The patients were given 400 mg of erythromycin over 1 week before surgery and re-administered on the 1st operative day. The patients were also given 125 mg of methylprednisolone intravenously just before operation and continued until the 2nd operative day.

RESULTS

Lobectomy was performed in 16, segmentectomy or partial resection in 2 each, and completion pneumonectomy in 1. Three patients developed acute exacerbation of IP, but it occurred after the re-operation due to postoperative complications in 2. We experienced no operative death within 30 days, however, 2 died during the hospital stay due to multiple organ failure and sepsis. Seven of 21 patients had postoperative complications; air leakage over 1 week in 4, arrhythmia in 3, and atelectasis, postoperative bleeding, and pneumonia in 1 each, the morbidity rate was 33%.

CONCLUSIONS

We conclude that the administration of steroid and erythromycin in surgery for lung cancer with IP was suspected the usefulness to prevent a postoperative acute exacerbation of IP.

Spontaneous regression of hepatic inflammatory pseudotumor with primary biliary cirrhosis: Case report and literature review

Hepatic inflammatory pseudotumor (IPT) is a rare benign non-neoplastic lesion characterized by proliferating fibrous tissue infiltrated by inflammatory cells. The exact etiology of IPT remains unclear. Although the association of IPT with systemic inflammatory disorders has been well established, a specific relationship with cholangitis is distinctly rare. We report a case of spontaneous regression of hepatic IPT with primary biliary cirrhosis (PBC). To date, only two cases of IPT with PBC have been reported. In our case, however, IPT developed during the course of improvement of cholangitis of PBC induced by effective treatment, differing from two previously reported cases. Our case indicates that the development of IPT does not also relate to the activity of cholangitis and/or hyper gamma-globulinemia, since our case was confirmed radiologically to be free of IPT when biliary enzymes and immunoglobulins were much higher than the corresponding values on admission. Comparison of our case with the two previously reported cases suggests that IPT occurring with PBC does not represent the same disease entity or be a bystander for PBC.

[Surgical treatment for stage IV lung cancer]

OBJECTIVE

To find out the optimal surgical indication in stage IV lung cancer patients, we evaluated them retrospectively.

METHODS & RESULTS

From 1975 to 2005, 62 patients without multiple metastases were operated at our hospital. The most common histological type was adenocarcinoma (67.7%). The metastatic lesions were lung (33.9%), brain (24.2%), liver, bone, adrenal gland and so on. The overall survival rate of stage IV lung cancer was 10.4% at 5-year. Five-year survival for patients with lung or brain metastasis who had no lymph node metastasis were significantly more superior than those with lymph node metastasis (p=0.0389, 0.0021). Four of 62 patients had 5-year survival. Two were lung and the others were brain and adrenal gland metastasis without lymph node metastasis.

CONCLUSION

Stage IV lung cancer with lung or brain or adrenal gland metastasis without lymph node metastasis should be resected.

Comparative study of survival of patients with hepatocellular carcinoma predicted by different staging systems using multivariate analysis

AIMS

In a previous pilot study, we reported the usefulness of the modified the Cancer of the Liver Italian Program (CLIP) score for patients with hepatocellular carcinoma (HCC). To determine the best staging system for predicting the survival of HCC patients, we conducted a comparative analysis of prognosis using multivariate analysis in 210 Japanese HCC patients who underwent hepatic resection.

METHODS

We compared the survival as predicted by various staging systems, including tumour node metastasis (TNM) stage of the American Joint Commission on Cancer (AJCC) and the Liver Cancer Study Group of Japan, the Japan Integrated Staging (JIS) score (Japanese TNM and Child-Pugh classification), CLIP score and our modified CLIP score using protein induced by vitamin K absence or antagonist II (PIVKA-II).

RESULTS

Univariate analysis showed that discrimination of disease-free survival in the early and advanced stages by the JIS score and modified CLIP score was clearer than by the Japanese or AJCC TNM or the original CLIP score. Discrimination between stages of overall survival by all staging systems was significant. Multivariate analysis showed that the JIS, CLIP and modified CLIP scores were better staging systems for predicting survival than the Japanese and AJCC TNM. The modified CLIP score showed the lowest Akaike information criteria statistical value for disease-free and overall survival, which means the best discrimination ability for patient survival compared with the JIS score and CLIP score.

CONCLUSIONS

A staging system that combines tumour factors, sensitive tumour marker(s) and hepatic function is the best predictor of prognosis of HCC patients.

Cerebral atrophy in myotonic dystrophy: a voxel based morphometric study

Brain involvement in myotonic dystrophy type 1 (DM1) is characterised by cortical atrophy and white matter lesions. We compared the magnetic resonance imaging derived grey matter maps of 22 DM1 patients with those of matched, healthy controls using voxel based morphometry to evaluate the extension of global and regional cortical atrophy in DM1, as well as its relationships with clinical and genetic features. Patients had significantly reduced brain tissue volumes. Grey matter volume was inversely correlated with age; this inverse correlation was significantly stronger in DM1 than in controls. Neither the clinical and genetic characteristics nor white matter lesions were correlated with cortical atrophy. Grey matter atrophy was located mainly in the bilateral frontal and parietal lobes, in the bilateral middle temporal gyrus, and in the left superior temporal and occipital gyrus.

The Japanese integrated staging score using liver damage grade for hepatocellular carcinoma in patients after hepatectomy

AIMS

The new Japanese staging system for hepatocellular carcinoma (HCC), the Japan integrated staging (JIS) score, accounts for both Child-Pugh classification and Japan tumour node metastasis (TNM) staging. However, in HCC patients who undergo hepatectomy, liver function is relatively good and a better prognostic classification of hepatic function is necessary.

METHODS

The present study was designed to analyse the modified JIS score using liver damage grade by the Liver Cancer Study Group of Japan instead of the Child-Pugh classification (using the category indocyanine green retention rate at 15 min [ICG(R15)] instead of encephalopathy), and to compare the Japan TNM stage in 101 patients who underwent resection of HCC.

RESULTS

The liver damage grade showed significantly better discrimination of disease-free and overall survival than did the Child-Pugh classification. The modified JIS score system showed significant differences of disease-free and overall survivals in each score and this system was superior for discriminating survivals compared with the TNM staging.

CONCLUSIONS

The combined staging system of hepatic function, particularly ICG(R15), and tumour stage provides a better prediction of prognosis. The JIS score using the liver damage grade was a useful predictor of prognosis of HCC patients who underwent hepatic resection.

Vertebral artery dissection in an infant: ultrastructural aberrations in connective tissue components

We report on a 14-month-old boy who had acute multiple infarcts in the posterior circulation due to an extremely early onset of spontaneous vertebral artery dissection. Despite the absence of clinical signs of connective tissue disorders, an ultrastructural change of collagen fibrils and elastic fibers indicated connective tissue abnormalities. Arterial dissection should be considered as a cause of stroke during infancy.

Modified CLIP using PIVKA-II for evaluating prognosis after hepatectomy for hepatocellular carcinoma

AIMS

The new staging system proposed by the Cancer of the Liver Italian Program (CLIP) for hepatocellular carcinoma (HCC) accounts for both liver dysfunction and tumour characteristics. The present study was designed to analyze UICC TNM stage, CLIP and modified CLIP in 91 patients who underwent hepatic resection for HCC.

METHODS

In the modified CLIP, scoring of AFP was replaced by that of protein induced by vitamin K absence or antagonist II (PIVKA-II; predictive value, > or = 400 mAU/ml).

RESULTS

After hepatic resection, 54 patients developed recurrent tumours. High PIVKA-II was a significant determinant of recurrence (p<0.05). However, a high score of the modified CLIP as well as those other staging systems did not correlate with tumour-recurrence rate. Univariate analysis showed that high TNM score, CLIP score and our modified CLIP score were significant predictors of poor prognosis. Multivariate Cox's analysis revealed that high PIVKA-II and high modified CLIP score were associated with higher risk for disease-free and overall survival as well as high TNM stage.

CONCLUSIONS

Compared with the original CLIP, our modified CLIP was a better predictor of prognosis of HCC patients who underwent hepatic resection.

Autoantibodies to glutamic acid decarboxylase in downbeat nystagmus

The cause of downbeat nystagmus (DBN) remains undiagnosed in about 40% of patients. This paper reports the presence of antiglutamic acid decarboxylase antibodies (GAD-Ab) in a patient with DBN. Antibodies against GABAergic neurons located in the vestibular complex may induce chemical denervation of the floccular neurons, which normally suppress the peripheral imbalance between vertical semicircular canal systems, thereby causing DBN. Testing for GAD-Ab may be indicated in DBN patients without an identifiable anatomical brain lesion.

[Strategy for preventing recurrence after video-assisted thoracoscopic surgery for spontaneous pneumothorax; efficacy of talc pleurodesis and absorbable mesh covering]

Video-assisted thoracoscopic surgery (VATS) has been widely used in the treatment of spontaneous pneumothorax. The unexpectedly high increase of the recurrence rate is the most important problem. We examined the interaction between recurrence, clinical features and patient's backgrounds. The main causes of recurrence were oversight of bullae and the emphysematous changes at the periphery of the site where an autosuture device was used. 90% of the recurrence occurred in the patients with type III small diffuse bullae. Introduction of the regional talc pleurodesis and covering stapled line with absorbable mesh were extremely useful to lower the recurrence rate after VATS for spontaneous pneumothorax.

Satellite potentials on EMG: neurophysiologic evidence of axonal transection in MS?

To detect signs of axonal damage in MS, the authors investigated the occurrence in EMG of motor unit action potentials with satellite potentials (SP-MUAP) in the upper limb muscles in 10 consecutive patients with MS with cervical spinal cord demyelinating lesions and 10 control subjects. Subjects' SP-MUAP rate was 0 to 2.5% (median 0%) in the control group, and 0 to 17.5% (median 7.5%) in the MS group (p < 0.01). Motor unit remodeling secondary to axonal transection of spinal motor neurons traversing cervical demyelinating lesions may be hypothesized.

Scanning electron-microscopic view of the oral and basal epithelial surfaces of the rat soft palate

We studied corresponding structures on the oral and basal surfaces of the oral epithelial layer, focusing on the microanatomy of gustatory papillae. Specimens for scanning electron microscopy were obtained from the rat soft palates and fixed with a mixture of 2% paraformaldehyde and 1% glutaraldehyde. They were first prepared without postfixation and conductive-staining to study the oral surface. After examination, the epithelium was reinforced by additional sputter coating and treated with 6 N NaOH at 60 degrees C to exfoliate the basal epithelial surfaces without any significant artifacts. The papillae, showing circular, elliptical or fusiform protuberances on the oral surface, were classified into two types: types I and II. The type I and type II papillae contained one and two taste pores, respectively. On the basal epithelial surface, the basal portions of the taste buds were associated with concentrically arranged nerve fibers and Schwann cells. Another characteristic finding on the basal epithelial surface was the presence of excretory ducts of minor salivary glands in a close spatial relationship to taste buds. It is suggested that saliva coming out through the duct is mixed with food, thus enabling intimate contact with the taste pores of the papillae.

Natural history of cardiac involvement in myotonic dystrophy: correlation with CTG repeats

The authors prospectively studied the natural course of cardiac involvement and its relationship to cytosine-thymine-guanine (CTG) expansion in 50 patients with myotonic dystrophy who were submitted to periodic cardiovascular EKG and EKG-Holter monitoring during a median follow-up of 56 months. Nineteen patients (38%) developed major EKG changes. CTG length was not correlated with the frequency of EKG abnormalities, but was inversely correlated with the age at onset of EKG abnormalities (p < 0.0001). CTG length influences the timing of cardiac complications in myotonic dystrophy.

Sensory involvement in spinal-bulbar muscular atrophy (Kennedy's disease)

Spinal-bulbar muscular atrophy (SBMA) is a rare X-linked neuronopathy associated with an abnormal representation of androgen receptors in the nervous system. Standard nerve conduction and histopathological studies have disclosed the involvement of large myelinated sensory fibers in the spinal nerves of SBMA patients. Little is known about the involvement of small sensory neurons and trigeminal nerves. Laser evoked potentials (LEPs) were studied in 6 unrelated patients with SBMA; 5 of these patients also underwent trigeminal reflex recordings, and 3 a sural nerve biopsy. LEPs were markedly abnormal, indicating a dysfunction in pain pathways. Given the sparing of small fibers in the sural nerve specimens, we hypothesize a dysfunction in spinothalamic cells, possibly due to an abnormal representation of the androgen receptors. Except for the jaw-jerk, all the trigeminal reflexes were markedly abnormal. Since the afferents for the jaw-jerk have their cell body within the central nervous system instead of the ganglion, the selective sparing of the jaw-jerk indicates a trigeminal ganglionopathy.

Serum-stimulated, rapamycin-sensitive phosphorylation sites in the eukaryotic translation initiation factor 4GI

The eukaryotic translation initiation factor 4G (eIF4G) proteins play a critical role in the recruitment of the translational machinery to mRNA. The eIF4Gs are phosphoproteins. However, the location of the phosphorylation sites, how phosphorylation of these proteins is modulated and the identity of the intracellular signaling pathways regulating eIF4G phosphorylation have not been established. In this report, two-dimensional phosphopeptide mapping demonstrates that the phosphorylation state of specific eIF4GI residues is altered by serum and mitogens. Phosphopeptides resolved by this method were mapped to the C-terminal one-third of the protein. Mass spectrometry and mutational analyses identified the serum-stimulated phosphorylation sites in this region as serines 1108, 1148 and 1192. Phosphoinositide-3-kinase (PI3K) inhibitors and rapamycin, an inhibitor of the kinase FRAP/mTOR (FKBP12-rapamycin-associated protein/mammalian target of rapamycin), prevent the serum-induced phosphorylation of these residues. Finally, the phosphorylation state of N-terminally truncated eIF4GI proteins acquires resistance to kinase inhibitor treatment. These data suggest that the kinases phosphorylating serines 1108, 1148 and 1192 are not directly downstream of PI3K and FRAP/mTOR, but that the accessibility of the C-terminus to kinases is modulated by this pathway(s).

Eukaryotic translation initiation factor 4E (eIF4E) binding site and the middle one-third of eIF4GI constitute the core domain for cap-dependent translation, and the C-terminal one-third functions as a modulatory region

The mammalian eukaryotic initiation factor 4GI (eIF4GI) may be divided into three roughly equal regions; an amino-terminal one-third (amino acids [aa] 1 to 634), which contains the poly(A) binding protein (PABP) and eIF4E binding sites; a middle third (aa 635 to 1039), which binds eIF4A and eIF3; and a carboxy-terminal third (aa 1040 to 1560), which harbors a second eIF4A binding site and a docking sequence for the Ser/Thr kinase Mnk1. Previous reports demonstrated that the middle one-third of eIF4GI is sufficient for cap-independent translation. To delineate the eIF4GI core sequence required for cap-dependent translation, various truncated versions of eIF4GI were examined in an in vitro ribosome binding assay with beta-globin mRNA. A sequence of 540 aa encompassing aa 550 to 1090, which contains the eIF4E binding site and the middle region of eIF4GI, is the minimal sequence required for cap-dependent translation. In agreement with this, a point mutation in eIF4GI which abolished eIF4A binding in the middle region completely inhibited ribosomal binding. However, the eIF4GI C-terminal third region, which does not have a counterpart in yeast, modulates the activity of the core sequence. When the eIF4A binding site in the C-terminal region of eIF4GI was mutated, ribosome binding was decreased three- to fourfold. These data indicate that the interaction of eIF4A with the middle region of eIF4GI is necessary for translation, whereas the interaction of eIF4A with the C-terminal region plays a modulatory role.