[Kidney transplantation for end-stage renal disease after third allogeneic hematopoietic stem cell transplantation for Philadelphia chromosome-positive acute lymphoblastic leukemia].

An 18-year-old man underwent allogenic bone marrow transplantation (BMT) for Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL). Ph+ALL relapsed 3 months after the first BMT, and the patient underwent a second BMT. However, Ph+ALL relapsed 4 months after the second BMT, and he received a haploidentical peripheral blood stem cell transplantation (haplo-PBSCT) from his father. Molecular complete remission was confirmed 29 days after haplo-PBSCT. However, the patient needed dialysis for end-stage renal disease due to thrombotic microangiopathy 3 years and 2 months after haplo-PBSCT. He received a kidney transplantation from his father 7 years and 10 months after haplo-PBSCT, and got off dialysis after the kidney transplantation. Immunosuppressive therapy with methylprednisolone, tacrolimus, and mycophenolate mofetil was started for kidney transplantation, but the dose of immunosuppressive agents was reduced successfully without rejection soon after kidney transplantation. The patient has maintained long-term remission since the haplo-PBSCT, and his kidney function was restored by the kidney transplantation from his father.

Real-World Effectiveness of Ramelteon and Suvorexant for Delirium Prevention in 948 Patients With Delirium Risk Factors.

OBJECTIVE: The aim of this study was to examine the effectiveness of ramelteon and suvorexant for delirium prevention in real-world practice. It explored whether ramelteon and/or suvorexant would affect delirium prevention among both patients at risk for but without delirium (patients at risk) and those with delirium the night before a consultation. METHODS: This multicenter, prospective, observational study was conducted by trained psychiatrists at consultation-liaison psychiatric services from October 1, 2017, to October 7, 2018. Patients who were aged 65 years or older and hospitalized because of acute diseases or elective surgery, had risk factors for delirium, and had insomnia or delirium on the night before the consultation were prescribed ramelteon and/or suvorexant. The decision to take medication was left to the discretion of each patient. The primary outcome was incidence of delirium based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, during the first 7 days. RESULTS: Among 526 patients at risk, those taking ramelteon and/or suvorexant developed delirium significantly less frequently than those who did not, after control for the effects of risk factors on the estimate of an independent association between the effects of ramelteon and/or suvorexant and the outcome of developing delirium (15.7% vs 24.0%; odds ratio [OR] = 0.48;, 95% CI, 0.29-0.80; P = .005). Similar results were found among 422 patients with delirium (39.9% vs 66.3%; OR = 0.36; 95% CI, 0.22-0.59; P < .0001). CONCLUSIONS: Ramelteon and suvorexant appear to be effective for delirium prevention in real-world practice.

[A clinical case of progressive supranuclear palsy with long-term frontal presentation preceding the onset of gaze palsy].

Progressive supranuclear palsy (PSP) is a neurodegenerative disorder with diverse clinical phenotypes characterized by supranuclear gaze palsy, parkinsonism with postural instability, and frontal dementia. The early and accurate diagnosis of PSP remains difficult because of the variable combination of symptoms and frequent lack of gaze abnormalities early in the disease course. Moreover, a subset of PSP shows behavioral changes as the initial presentation, which considerably overlaps with the clinical picture of frontotemporal dementia (FTD). Thus, this subgroup possibly needs psychiatric assessments. Here, we describe a clinical case of PSP difficult to differentiate from FTD because the frontal presentation persisted without gaze palsy until the late stage of the clinical course. A 58-year-old man was admitted to our hospital for the reconsideration of a diagnosis of FTD. Disinhibited and gambling behaviors inconsistent with his previous personality first appeared at around the age of 45, with gradual progression, followed by memory deficits, executive dysfunction, and a slowing of mental processes. Recurrent sexual disinhibition led him to undergo psychiatric consultation at the age of 57. Downward gaze palsy and postural instability with recurrent falls emerged 8 months after the first psychiatric examination, and he was clinically diagnosed with PSP 13 years after the initial frontal presentation. PSP should be considered in the differential diagnosis of patients presenting with frontal lobe symptoms, even in psychiatric practice.

Auditory hallucination coping techniques and their relationship to psychotic symptomatology.

Use of coping techniques is of importance in the treatment for patients experiencing auditory hallucinations. Phenomenological features of auditory hallucinations and other psychotic symptoms are assumed to be factors influencing the coping activities. The aim of the present study was to determine psychotic symptoms including auditory hallucination phenomenological features that have effects on coping activities. The authors investigated 17 generally used coping techniques of 144 chronically psychotic patients who were currently experiencing auditory hallucination in DSM-IV schizophrenia or schizoaffective psychosis. Using factor analysis, scales characterizing the styles of coping application and efficacy were constructed. To assess the phenomenological features, the authors used the Matsuzawa Assessment Schedule for Auditory Hallucination (MASAH), which had been devised to assess four basic phenomenological features: intractability, delusion, influence, and externality. The Positive and Negative Syndrome Scale (PANSS) was also applied for the assessment of psychotic symptoms. Regression analyses were conducted to determine the features and symptoms that could have effects on coping activities. Constructed scales were those of distraction and counteraction styles for each of coping application and efficacy. It was found that MASAH influence and externality features had an activating effect on both distraction and counteraction coping application, and counteraction coping application, respectively, and that PANSS negative symptom clusters and MASAH delusion feature had an inhibiting effect on distraction and counteraction coping application, respectively. No salient factor for coping efficacy was recognized. The current study presents information on the relationship between coping activities and the psychotic experience features and symptoms, which can be of help for planning coping training programs.

Predicting features of later development of schizophrenia among patients with acute and transient psychotic disorder.

It is acknowledged that a considerable proportion of patients who have an episode of acute and transient psychotic disorder (ATPD), will develop schizophrenia after the episode is remitted. If features discriminating the patients who later developed schizophrenia from those who underwent a monomorphous ATPD-only course are discerned, they may be useful for predicting the prognosis. The authors performed a chart review study of those who were hospitalized with the diagnosis of ATPD and followed up thereafter for >5 years and compared two subject groups: 10 later-schizophrenia-developing (SD) patients and 15 non-schizophrenia-developing (non-SD) patients. Assessment of the subjects, conducted by two psychiatrist raters blind to the subject groups, included frequency of ATPD episodes, adaptation levels and life events before admission, and psychiatric symptoms before and after admission. The interrater reliability of the assessment proved to be favorable. As a result, early recurrence of psychotic episodes in the follow-up period, lack of acute upsurge of insomnia in an early phase of the episode and poor premorbid heterosexual relations characterized the SD patients. The result indicated heterogeneity of ATPD episodes.

Phenomenological features of auditory hallucinations and their symptomatological relevance.

Auditory hallucinations include particularly diverse phenomena that reflect various mental functions and pathologies. Their assessment may provide valuable clinical information. This article describes the development of the Matsuzawa Assessment Schedule for Auditory Hallucination (MASAH), which was designed to obtain a broadened view of the phenomena by investigating a wide range of their characteristics. The aim was to identify the basic phenomenological features of auditory hallucinations by performing a factor analytic study of the MASAH ratings of 214 patients with schizophrenia or schizoaffective disorder. Four identified factors were intractability, delusion, influence, and externality, on the basis of which we constructed composite scales that were assumed to represent the features. The correlation analysis of the scales with symptom dimensions derived from the positive and negative syndrome scale verified their clinical relevance. They were also interpretable in terms of human responses to the abnormal experience and some symptom constructs such as delusion and influence experience. It is concluded that the MASAH is an efficient means for evaluating the features, and that this study elicited new understandings of the phenomena such as their multifarious composition and contiguities with other psychotic symptoms.

Is there a gender difference in a factorial structure of the positive and negative syndrome scale? A test by structural equation modeling.

By means of the multisample structured means strategy, we examined gender differences in a five-factorial structure model of Positive and Negative Syndrome Scale (PANSS) ratings of 308 patients of both sexes with DSM-IV schizophrenia with comparable age at investigation and overall symptomatic severity across sex. The test indicated that the factors and component symptoms were common across sex, whereas the factor loadings might be different. However, the model that incorporated the difference in the factor loadings did not improve model fit indices. Therefore, it is concluded that this investigation elicited only minimal gender differences, and on the whole confirmed the PANSS five-factor structure for both sexes.