Characteristics and outcomes of school refusal in Hiroshima, Japan: proposals for network therapy.

The authors conducted a study on children undergoing treatment at major school refusal treatment centers in Hiroshima Prefecture. On the whole, school refusal in the prefecture was found to peak between 13 and 14 years of age. By age group, the main reason for school refusal in elementary school group was parent-child relationship with separation anxiety. Given additional problems such as neglect at home and complicated social situations in their schools, junior high school students were found to present diverse symptoms from introversion and self-analysis to extroversion, neglect of studies, and delinquency. Among high school students, there were more cases suffering withdrawal and schizophrenia spectrum disorders. The major task regarding treatment seems to lie in how to treat complex cases combining different problems. We summarized herein the studies we have carried out and propose a model for a network therapy system based on functional liaisons between treatment centers. With this system, a child psychiatric medical facility plays the part of a liaison center for the overall network system.</p

Home visits provide a better understanding of the psychopathology of a case of eating disorder

Eating disorders (ED) are characterized by abnormal eating behaviors that negatively affect the patient’s medical or psychiatric health, with symptoms usually developing during adolescence. Treatment for ED varies across patients and the disease time-course, reflecting differences in psychopathology and medical comorbidities. Here, we provide a brief review of the standard management strategy for ED and emphasize the importance of individualized treatment. To illustrate this, we present a case of ED in which a halt in development was observed during a home visit, which is an unusual component in the treatment of ED. Furthermore, as a result of our collective experience in treating ED, we recognize that discussion among multidisciplinary healthcare professionals is important to improve outcomes

Systemic and Ocular Determinants of Choroidal Structures on Optical Coherence Tomography of Eyes with Diabetes and Diabetic Retinopathy

Knowledgeof the choroidal structures in eyes with diabetes and diabetic retinopathy (DR) should provide information on the pathogenesis of DR. A prospective study was performed to determine the systemic and ocular factors that affect the choroidal structures in eyes with diabetes. Two-hundred consecutive diabetic subjects consisted of 160 treatment-naïve patients with different stages of DR and 40 patients with proliferative DR with prior panretinal photocoagulation (PRP). All underwent blood and urine tests and enhanced depth imaging optical coherence tomography (EDI-OCT). The cross-sectional EDI-OCT images of the subfoveal choroid were binarized to measure the total choroidal area (TCA), luminal area, and stromal area. Multivariate regression analyses were performed to determine the systemic and ocular factors that were significantly correlated with the choroidal structures. The subfoveal choroidal thickness, TCA, luminal area, and stromal area were larger at more advanced stage of DR, and smaller in eyes with PRP than those without (P < 0.001). The TCA and stromal area were significantly and positively correlated with the degree of albuminuria (P = 0.034, P = 0.025, respectively). The choroidal lumen and stroma may increase as the stages of DR progress and decrease after PRP. Albuminuria may be associated with the choroidal stromal edema

Hemangiopericytoma in the sacrococcygeal space: a case report

<p>Abstract</p> <p>Introduction</p> <p>A hemangiopericytoma is a rare, soft-tissue tumor of vascular origin derived from a pericyte of Zimmerman, which is a modified smooth muscle cell that surrounds the small blood vessels. Hemangiopericytomas can occur wherever there are vascular capillaries. However, there are no previous reports of a hemangiopericytoma in the sacrococcygeal space.</p> <p>Case presentation</p> <p>We describe the first reported case of a hemangiopericytoma found in the sacrococcygeal space. A 47-year-old Japanese woman presented with a palpable tumor on the left side of her anus. Preoperative imaging indicated that the tumor was in the sacrococcygeal space without invasion of other organs. A complete resection was performed via a parasacral incision. The histological and immunohistochemical staining patterns supported the diagnosis of a hemangiopericytoma.</p> <p>Conclusion</p> <p>A complete resection without piecemeal excision is the best way to treat a hemangiopericytoma. Recognizing the presence of a hemangiopericytoma in the sacrococcygeal space requires appropriate surgery.</p

うつ病の治療中にアカシジアとジスキネジアを呈した一例

症例は60歳代男性，15年前より当科にてうつ病，アルコール依存症として治療していた．２年前より町内会の仕事で多大なストレスを感じ，１年前より身体不調から仕事を退職した．その後，過剰な飲酒が始まり，精神科病院に入院しアルコール依存症の治療が行われ，その際にオランザピンが投与された．その後は断酒ができていたが，町内会での大きな役割が回ってくる不安感からイライラ感が強くなり，オランザピンの増量，クロルプロマジンへの変更などを行ったが精神症状は改善せず，薬剤変更１ヶ月後より終日じっとしていられないアカシジア様症状と，舌が勝手に動く口舌ジスキネジア様症状，首下がり症状が出現した．抗精神病薬を中止したが症状改善せず，次第に食事摂取困難となり体重が減少，状態悪化のため当科入院となった．入院後，薬剤調整による抗うつ治療を行ったが改善なく，希死念慮の増悪を認めたため修正型電気けいれん療法（modified-electroconvulsive therapy: m-ECT）の適応と考えられ，全13回のm-ECT を施行した．m-ECT 施行により精神症状，アカシジア，ジスキネジア，首下がりが徐々に改善し，最終的には病状が著明に改善した．本症例のジスキネジアは薬剤性としては発現が急であり，また首下がりの症状を伴っていたため，パーキンソン病の存在が疑われた．頭部MRI，ドパミントランスポーターシンチグラフィでは異常はなかったが，MIBG 心筋シンチグラフィではFDG 集積の低下を認めた．入院時軽度の左右差のあるパーキンソニズムがあり，筋電図にて頸部伸展筋ミオパチーと診断された．以上から身体症状の原因は，臨床症状発現前のパーキンソン病を背景とする抗精神病薬の副作用であると考えられた．アカシジア，ジスキネジアは薬剤性に起因するものが多数であるが，その他の疾病の有無を注意深く観察することが必要であると考えられた．Here, we present a case study of a man in his sixties, under treatment for depression and alcoholism at our department for the past 15 years. 2 years ago, he began to experience high stress levels that he attributed to his work at the neighborhood association. One year after that, he retired from his job because of poor health. After his retirement, he began to consume alcohol excessively. Subsequently, he was admitted to our hospital and was treated for alcoholism with the antipsychotic drug olanzapine. Although he achieved abstinence, his frustration gradually increased because of the stress associated with his prominent role in his neighborhood association several months ahead. Therefore, he was administered a higher dose of olanzapine, which was then changed to chlorpromazine. However, his psychological symptoms did not improve. After about one month, he began to display symptoms of akathisia, characterized by an inability to stay still throughout the day. Additionally, his tongue began to move involuntarily, which is a common symptoms of dyskinesia. He also presented with the dropped head syndrome. His symptoms did not improve upon termination of antipsychotic drugs. He was subsequently hospitalized because of gradually decreasing appetite and weight. Because the antidepressant treatment had no effect and his suicidal feelings had exacerbated, he was subjected to 13 rounds of modified-electroconvulsive therapy (m-ECT). His mental condition improved and the akathisia, dyskinesia, and dropped head symptom decreased gradually. Parkinson’s disease would not have likely caused dyskinesia without long term medication with dopaminergic drugs. Additionally, because dyskinesia generally appears several years after initiation of antipsychotics therapy, dyskinesia in our case could not have occurred due to antipsychotic drugs in acute course of the symptoms. Head MRI and dopamine transporter scintigraphy did not show any abnormalities. In contrast, metaiodobenzylguanidine (MIBG) scintigraphy showed a decrease heart/mediastinum ratio (H/M ratio). He had been recognized as showing symptoms of parkinsonism with a slight laterality when he was initially hospitalized, and his EMG showed neck extensor myopathy, which is a characteristic of Parkinson’s disease. Thus, his physical symptoms were likely a side effect of short-term use of antipsychotic drugs for preclinical Parkinson’s disease. The most common cause of akathisia and dyskinesia is antipsychotics drug use, however it is necessary to check carefully for other diseases as well

Canagliflozin and Cardiovascular and Renal Outcomes in Type 2 Diabetes Mellitus and Chronic Kidney Disease in Primary and Secondary Cardiovascular Prevention Groups

Background: Canagliflozin reduces the risk of kidney failure in patients with type 2 diabetes mellitus and chronic kidney disease, but effects on specific cardiovascular outcomes are uncertain, as are effects in people without previous cardiovascular disease (primary prevention). Methods: In CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation), 4401 participants with type 2 diabetes mellitus and chronic kidney disease were randomly assigned to canagliflozin or placebo on a background of optimized standard of care. Results: Primary prevention participants (n=2181, 49.6%) were younger (61 versus 65 years), were more often female (37% versus 31%), and had shorter duration of diabetes mellitus (15 years versus 16 years) compared with secondary prevention participants (n=2220, 50.4%). Canagliflozin reduced the risk of major cardiovascular events overall (hazard ratio [HR], 0.80 [95% CI, 0.67-0.95]; P=0.01), with consistent reductions in both the primary (HR, 0.68 [95% CI, 0.49-0.94]) and secondary (HR, 0.85 [95% CI, 0.69-1.06]) prevention groups (P for interaction=0.25). Effects were also similar for the components of the composite including cardiovascular death (HR, 0.78 [95% CI, 0.61-1.00]), nonfatal myocardial infarction (HR, 0.81 [95% CI, 0.59-1.10]), and nonfatal stroke (HR, 0.80 [95% CI, 0.56-1.15]). The risk of the primary composite renal outcome and the composite of cardiovascular death or hospitalization for heart failure were also consistently reduced in both the primary and secondary prevention groups (P for interaction &gt;0.5 for each outcome). Conclusions: Canagliflozin significantly reduced major cardiovascular events and kidney failure in patients with type 2 diabetes mellitus and chronic kidney disease, including in participants who did not have previous cardiovascular disease

DOCK2 is involved in the host genetics and biology of severe COVID-19

「コロナ制圧タスクフォース」COVID-19疾患感受性遺伝子DOCK2の重症化機序を解明 --アジア最大のバイオレポジトリーでCOVID-19の治療標的を発見--. 京都大学プレスリリース. 2022-08-10.Identifying the host genetic factors underlying severe COVID-19 is an emerging challenge. Here we conducted a genome-wide association study (GWAS) involving 2, 393 cases of COVID-19 in a cohort of Japanese individuals collected during the initial waves of the pandemic, with 3, 289 unaffected controls. We identified a variant on chromosome 5 at 5q35 (rs60200309-A), close to the dedicator of cytokinesis 2 gene (DOCK2), which was associated with severe COVID-19 in patients less than 65 years of age. This risk allele was prevalent in East Asian individuals but rare in Europeans, highlighting the value of genome-wide association studies in non-European populations. RNA-sequencing analysis of 473 bulk peripheral blood samples identified decreased expression of DOCK2 associated with the risk allele in these younger patients. DOCK2 expression was suppressed in patients with severe cases of COVID-19. Single-cell RNA-sequencing analysis (n = 61 individuals) identified cell-type-specific downregulation of DOCK2 and a COVID-19-specific decreasing effect of the risk allele on DOCK2 expression in non-classical monocytes. Immunohistochemistry of lung specimens from patients with severe COVID-19 pneumonia showed suppressed DOCK2 expression. Moreover, inhibition of DOCK2 function with CPYPP increased the severity of pneumonia in a Syrian hamster model of SARS-CoV-2 infection, characterized by weight loss, lung oedema, enhanced viral loads, impaired macrophage recruitment and dysregulated type I interferon responses. We conclude that DOCK2 has an important role in the host immune response to SARS-CoV-2 infection and the development of severe COVID-19, and could be further explored as a potential biomarker and/or therapeutic target

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to &lt;90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], &gt;300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of &lt;15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P&lt;0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P&lt;0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years