Mitral Valve Replacement for Enlarged Libman-Sacks Endocarditis in a Patient with Persistent Primary Antiphospholipid Syndrome and Recurrent Stroke: A Case Report.

BACKGROUND Anticardiolipin antibodies in patients with Libman-Sacks endocarditis (LS) are indicative of comorbid antiphospholipid syndrome (APS) and can result in cerebral infarctions. We describe a case of LS and primary APS with recurrent cerebral infarctions despite anticoagulation treatment. The patient underwent surgery for enlarged LS vegetation with high titers of antiphospholipid antibodies. CASE REPORT A 41-year-old Japanese man was admitted to hospital for small cerebral infarction recurrence in a left parietal lesion. At age 35, the patient had suffered multiple cerebral infarctions. He was found to have high serum titers of all 3 antiphospholipid antibodies. Transesophageal echocardiography (TEE) findings were normal. Differential diagnosis ruled out other autoimmune diseases and a clinical diagnosis of primary APS was made. Warfarin anticoagulation was started. When cerebral infarction recurred 6 years after the first episode, serum titers of antiphospholipid antibodies remained high, and TEE showed a 7×8 mm area of mitral vegetation. A TEE results from his first admission revealed a 5×6 mm area of mitral vegetation, which was believed to be related to the current vegetation. As anticoagulation produced no improvement, the mitral valve was replaced with a mechanical valve. Examination of the excised vegetation found it to be consistent with LS. The patient made good progress within 3 years after surgery. CONCLUSIONS LS size can increase despite anticoagulation in cases with high titers of all 3 antiphospholipid antibodies and cerebral infarction. Such patients require ongoing TEE follow-up and surgical treatment should be considered.

Farming habit, light exposure, physical activity, and depressive symptoms. A cross-sectional study of the HEIJO-KYO cohort.

BACKGROUND: Bright light therapy and exercise interventions are effective methods for treating seasonal and non-seasonal affective disorders. Synchronization of internal circadian rhythms with the external environment by light therapy and physical activity may partly explain its efficacy. In the present study, we objectively measured daytime light exposure and physical activity in real life situations with elderly participants, and investigated the association between farming habits and the prevalence of depressive symptoms. METHODS: This cross-sectional was conducted among 1005 participants (mean age: 71.5) of a community-based cohort study. Depressive symptoms were assessed by the Geriatric Depression Scale (GDS score ≥ 6) and administration of antidepressant. RESULTS: Farming habit with long duration (> 7.0 h/week) showed significantly lower odds ratios (OR) for depressive symptoms (adjusted OR 0.63, 95% confidential interval,0.41 to 0.96) compared with participants without farming habit independent of confounders such as age, gender, body mass index smoking, drinking, daytime ambulatory systolic blood pressure, diabetes, living alone, education, income, and daylength. Even in farming with short duration (≤ 7.0 h/week), we found significant association with lower OR for depressive symptoms (adjusted OR 0.64, 95%CI, 0.42 to 0.97). Light exposure and daytime physical activity measured by wrist actigraphy were significantly higher among participants with longer farming habits (p for trend < 0.01). Physical activity mediated 12.0% of association between farming habit and depressive symptoms. LIMITATIONS: A cross-sectional association may be found because the participants with depressive symptoms tended to avoid farming. A longitudinal study is warranted to determine the direction of causality. CONCLUSIONS: Participants with farming habit showed significantly lower OR for depressive symptoms than those without farming habit, and it was partly mediated by physical activity.

Association of HLA-A*31:01 Screening With the Incidence of Carbamazepine-Induced Cutaneous Adverse Reactions in a Japanese Population.

Importance: Carbamazepine, a commonly used antiepileptic drug, is one of the most common causes of cutaneous adverse drug reactions (cADRs) worldwide. The allele HLA-A*31:01 is reportedly associated with carbamazepine-induced cADRs in Japanese and European populations; however, the clinical utility of HLA-A*31:01 has not been evaluated. Objective: To assess the use of HLA-A*31:01 genetic screening to identify Japanese individuals at risk of carbamazepine-induced cADRs. Design, Setting, and Participants: This cohort study was conducted across 36 hospitals in Japan from January 2012 to November 2014 among 1202 patients who had been deemed suitable to start treatment with carbamazepine. Preemptive HLA-A*31:01 genetic screening was performed for 1187 participants. Patients who did not start treatment with carbamazepine or alternative drugs were excluded. Participants were interviewed once weekly for 8 weeks to monitor the development of cADRs. Data analysis was performed from June 8, 2015, to December 27, 2016. Exposures: Neuropsychiatrists were asked to prescribe carbamazepine for patients who tested negative for HLA-A*31:01 and alternative drugs for those who tested positive for HLA-A*31:01. Main Outcomes and Measures: Incidence of carbamazepine-induced cADRs. Results: Of the 1130 included patients who were prescribed carbamazepine or alternative drugs, the mean (range) age was 37.4 (0-95) years, 614 (54.3%) were men, and 198 (17.5%) were positive for HLA-A*31:01. Expert dermatologists identified 23 patients (2.0%) who had carbamazepine-induced cADRs, of which 4 patients required hospitalization. Drug-induced hypersensitivity syndrome was observed for 3 patients, maculopapular eruption for 9 patients, erythema multiforme for 5 patients, and an undetermined type of cADR for 6 patients. No patient developed Stevens-Johnson syndrome or toxic epidermal necrolysis. Compared with historical controls, the incidence of carbamazepine-induced cADRs was significantly decreased (for BioBank Japan data: incidence, 3.4%; odds ratio, 0.60; 95% CI, 0.36-1.00; P = .048; for the Japan Medical Data Centre claims database: incidence, 5.1%; odds ratio, 0.39; 95% CI, 0.26-0.59; P < .001). Conclusions and Relevance: Preemptive HLA-A*31:01 genetic screening significantly decreased the incidence of carbamazepine-induced cADRs among Japanese patients, which suggests that it may be warranted in routine clinical practice.

Objective sleep quality and night-time blood pressure in the general elderly population: a cross-sectional study of the HEIJO-KYO cohort.

OBJECTIVES: Night-time blood pressure (BP) - prognostically more important than circadian BP variability - has not been evaluated for quantitative associations with objective sleep quality in large populations. METHODS: The cross-sectional study measured actigraphic sleep parameters and night-time BP for two nights in 1101 elderly participants. RESULTS: Mean age of the participants was 71.8 years, and mean night-time SBP and DBP were 115.9 ±â€Š16.2 and 66.9 ±â€Š8.4 mmHg, respectively. Multivariable analysis controlling for potential confounders revealed that the lowest sleep efficiency quartile group exhibited significantly higher night-time SBP and DBP than the highest quartile group [mean difference: SBP, 4.7 mmHg, 95% confidence interval (CI), 2.0-7.3; DBP, 2.3 mmHg, 95% CI 0.9-3.7]. The longest wake after sleep onset and sleep-onset latency quartile groups exhibited significantly higher night-time SBP (3.1 mmHg, 95% CI 0.3-5.9 and 3.4 mmHg, 95% CI 0.8-6.0) and DBP (2.0 mmHg, 95% CI 0.5-3.5 and 1.9 mmHg 95% CI 0.5-3.3), respectively, than the shortest quartile group. Significantly lower night-time SBP (3.0 mmHg, 95% CI 0.01-6.1) was observed in the longest total sleep time quartile group than in the shortest quartile group. These results were similar on sensitivity analyses excluding participants with possible sleep-disordered breathing (n = 69) or nocturnal hypertension (n = 503). CONCLUSION: Decreased sleep quality on actigraphy was significantly associated with higher night-time BP in a large general elderly population. Clinically significant increase in night-time BP exists in relation to decreased objective sleep quality.

[Paliperidone, risperidone].

Risperidone, a serotonin-dopamine antagonist, is effective in preventing delusions and hallucinations by D2 receptor antagonism and treating negative symptoms by 5-HT2A receptor antagonism. It is less likely to produce extrapyramidal symptoms than conventional antipsychotics, enabling safe drug therapy for schizophrenia. Paliperidone, based on 9OH-risperidone(major metabolite of risperidone), was developed to make the best use of the high therapeutic efficacy of Risperdal and enable continued treatment with lower prevalence of adverse events. Its mechanism of action as an extended-release tablet ensures slow release of the active ingredient, contributing to the lower prevalence of adverse events. With these pharmacological characteristics in mind, the two drugs can serve as safe and effective drug therapy.