Clinical Features of Autoimmune Autonomic Ganglionopathy and the Detection of Subunit-Specific Autoantibodies to the Ganglionic Acetylcholine Receptor in Japanese Patients

Autoimmune autonomic ganglionopathy (AAG) is a rare acquired channelopathy that is characterized by pandysautonomia, in which autoantibodies to ganglionic nicotinic acetylcholine receptors (gAChR) may play a central role. Radioimmunoprecipitation (RIP) assays have been used for the sensitive detection of autoantibodies to gAChR in the serum of patients with AAG. Here, we developed luciferase immunoprecipitation systems (LIPS) to diagnose AAG based on IgGs to both the α3 and β4 gAChR subunits in patient serum. We reviewed the serological and clinical data of 50 Japanese patients who were diagnosed with AAG. With the LIPS testing, we detected anti-α3 and -β4 gAChR antibodies in 48% (24/50) of the patients. A gradual mode of onset was more common in the seropositive group than in the seronegative group. Patients with AAG frequently have orthostatic hypotension and upper and lower gastrointestinal tract symptoms, with or without anti-gAChR. The occurrence of autonomic symptoms was not significantly different between the seropositive and seronegative group, with the exception of achalasia in three patients from the seropositive group. In addition, we found a significant overrepresentation of autoimmune diseases in the seropositive group and endocrinological abnormalities as an occasional complication of AAG. Our results demonstrated that the LIPS assay was a useful novel tool for detecting autoantibodies against gAChR in patients with AAG

The development of the mother-infant relationship in very low birth weight infants and the nursing care provided to them.

本研究はNICUに入院中の極低出生体重児の母子関係の傾向をとらえ,行われた看護援助について検討することを目的とした.第1回調査の対象は,静岡県内のA総合病院NICUを退院した極低出生体重児と母親9事例およびプライマリーナース9名で,後方視的に半構成インタビューによりデータ収集し,内容を分析した.第2回調査の対象は静岡県内のA,B2つの総合病院NICUに入院中の極低出生体重児と母親12事例で,前方祝的に観察記録用紙を用いてデータ収集し,内容を分析した.この結果,以下のことが明らかになった.1.母親の感情・言動と児へのかかわりは5つのステージに分かれ,修正在胎週数およそ30週前後とおよそ34週以降に2つの転換の時期が認められた.2.各ステージの特徴と必要な看護援助は,ステージI:児をイメージする初回面会前までの時期(母親の心身回復への援助),ステージII:恐れの強い時期(母親の恐れの感情に特に配慮した援助),ステージIII:主体的かかわりの芽生えの時期(母親の育児行為の広がりを支える援助),ステージIV:主体的かかわり・母子相互作用の芽生えの時期(母親の主体的な育児行為を尊重した援助),ステージV:母子相互作用の安定の時期(退院に向けての情報提供と新たな不安の受止)であった.3.全ステージに共通する看護援助は,母親の気持ちに添ってタイミングを計った援助,予期的・予測的な児に関する情報提供,受容的態度を具体的に表す看護婦からの言葉かけであった.The purpose was to find the pattern of the relationship between mothers and VLBW (very low birth weight ) infants who are hospitalized in NICU and to describe the nursing care given to them. The first study included nine mother-VLBW infant pairs and nine primary nurses. Each infant and mother had already been discharged when surveyed. The retrospective data was collected by semi-structured interviews. The second study included twelve mother-infant pairs ,where the VLBW infant was hospitalized. The progressive data was collected by documenting information on observation forms. The results were as follows: 1. The mother's emotions and behaviors towards the infant go through five stages. The relationship undergoes two positive changes: they occur around the 30th and 34th gestational week of age. 2. The characteristics of each stage and the necessary nursing care. Stage I. Before the mother is able to meet the infant for the first time, she develops an image of her child. (Care and support for the mother's emotional and physical recovery is needed.) Stage II. The mother experiences a strong fear. (Support for these fears in particular must be given. ) Stage III. The mother grows to communicate with her infant independently. (Support of the expansion of the mother's infant care.) Stage IV. The mother develops an independent relationship with her infant and mother-infant interaction begins. (Support and respect for the mother's independent care of her infant.) Stage V. The mother-infant bond is strong. (Support by giving information to the mother before being discharged to ease anxieties.) 3. The nursing care at every stage has three things in common: appropriate and timely support, which considers the mother's feeling's. Information about the expected and predicted future of the infant. Open communication with the mother in full acceptance of her fears and emotions

LIPS for gAChR in the sera from patients with autoimmune autonomic ganglionopathy (AAG) and controls.

<p>We tested the sera from patients with AAG, disease controls (DC), and healthy controls (HC). a) Anti-gAChRα3 antibodies were detected in 23 samples. The mean anti-gAChRα3 antibody level in the HC was 0.305 antibody index (A.I.), which was significantly lower than in the AAG samples with a mean level of 1.210 A.I. (<i>p</i> < 0.001). b) Anti-gAChRβ4 antibodies were also detected in seven samples, as shown in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0118312#pone.0118312.g004" target="_blank">Fig. 4B</a> (<i>p</i> = 0.005). The mean anti-gAChRβ4 antibody level in the HC was 0.367 A.I., which was significantly lower than the measn level of 0.618 A.I. in the AAG samples (<i>p</i> < 0.001).</p

Schematic representation of the acetylcholine receptor (AChR) α3-<i>Gaussia</i> luciferase (GL) ⁸⁹⁹⁰.

<p>For the ganglionic AChR (gAChR)-LIPS assay, human embryonic kidney (HEK) 293 cells were transfected with an expression plasmid for the gAChRα3 or β4-GL reporter.</p

Autonomic function tests at baseline of anti-gAChR Ab positive AAG patients.

<p>Anti-gAChRα3 Ab = ganglionic acetylcholine receptor α3 antibody; Anti-gAChRβ4 Ab = ganglionic acetylcholine receptor β4 antibody; A.I. = Antibody Index; OH = orthostatic hypotension; HUTT = head-up tilt test; CV R-R = CV = coefficient of variation R-R interval; H/M ratio = heart-to-mediastinum ratio in ¹²³I-MIBG myocardial scintigraphy; TST = thermoregulatory sweat test; NE = norepinephrine; SSR = sympathetic skin response; QSART = quantitative sudomotor axon reflex test; CSF = cerebrospinal fluid</p><p>Autonomic function tests at baseline of anti-gAChR Ab positive AAG patients.</p

Clinical features of patients with AAG/APD.

<p>a. We reviewed the 26 male patients only.</p><p>b. Numbness, mental symptom, dementia, character change, and back pain</p><p>c. Amenorrhea, eating disorder, SIADH (Syndrome of inappropriate secretion of antidiuretic hormone), and panhypopituitarism</p><p>d. Still disease, PBC (primary biliary cirrhosis), Hashimoto disease, PMR (polymyalgia rheumatica), SLE (systemic lupus erythematosus), SS (Sjögren's syndrome), Graves’ disease, RA (rheumatoid arthritis), fibromyalgia, and other autoantibodies positive</p><p>e. Ovarian tumor, pancreas cancer, mediastinal tumor, and paranasal cancer</p><p>Clinical features of patients with AAG/APD.</p

The Luciferase Immunoprecipitation Systems (LIPS).

<p>The soluble fractionated component from the solubilized HEK 293F cells, including the gAChRα3 or β4-GL, reacted with human serum, and the specific luciferase activities of the gAChRα3 or β4-GL were found with the luminometer. The <i>in vitro</i> LIPS assay can quantitatively evaluate an interaction between an antigen and an antibody with high sensitivity and without a radioisotope.</p