Yosei Fujioka

Association of sickness absence with poor sleep and depressive symptoms in shift workers.

A cross-sectional study was conducted to evaluate the contribution of daily sleep habits and depressive symptoms to sickness absences of shift workers. A self-administered questionnaire that solicited answers about sleep, symptoms of depression, sickness absence, diseases/injuries, and lifestyle factors was submitted to a sample of 522 rotating shift workers between the ages of 18–59 (mean 27) yrs of an electric equipment manufacturing company. The seven features of sleep queried were daily hours of sleep, time to fall asleep, awakening during sleep, early morning awakening, sleep well at night, sufficiency of sleep, and excessive daytime sleepiness at work. The responses were assessed over the subjects previous 1-yr period. Each sleep feature, except daily sleeping hours, was dichotomized by the following responses: (1) taking more than 30 min to fall asleep (difficulty initiating sleep; DIS), (2) awakening during sleep almost every day (difficulty maintaining sleep; DMS), (3) early morning awakening almost every day (EMA), (4) sleeping very poorly or not so well at night, (5) definite or somewhat insufficient nightly sleep, and (6) excessive daytime sleepiness at work almost every day (EDS). Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. Sickness absence was calculated by asking subjects “How many days in total have you been absent from work due to sickness, including paid vacation, in the last 1-yr period?” The responses were divided into three groups that included no (0 days) sickness absences (reference group, n = 235 subjects), 1 to 4 days (short-term, n = 199 subjects), and 5 days or more (long-term, n = 88 subjects). Compared to the prevalence of sleep features of the reference group, workers with short-term absence showed a significantly higher prevalence of EMA with an odds ratio (OR) of 5.3, 95% confidence interval (CI) 1.3–22.0. Long-term absence was significantly associated with DMS (OR = 2.1, 95%CI 1.0–4.6), EMA (OR = 5.6, 95%CI 1.0–28.7), sleeping poorly at night (OR = 2.6, 95%CI 1.4–5.0), and high depressive symptoms (OR = 2.0, 95%CI 1.0–3.7) according to the CES-D score of ≥16, after adjusting for multiple confounding variables. These data point to an association between both the parameters of poor sleep and symptoms of deep depression when self-reported sickness absence is frequent. The association is particularly strong with long-term absence in male shift workers.

Association of active and passive smoking with sleep disturbances and short sleep duration among Japanese working population

Background: The relationship between passive smoking and sleep is uncertain. Purpose: To examine the association of passive/active smoking with sleep disturbances. Method: 732 women and 1,896 men, working in a suburb of Tokyo, were surveyed using a self-administered questionnaire. Information on smoking, passive smoking exposure, and sleep was elicited. Exposure levels to passive smoking were assessed separately at work and at home as no, occasional, or regular exposure. Risk of sleep disturbances according to smoking status was estimated using logistic regression with odds ratios (OR) and 95% confidence intervals (CIs) as measures of association. Results: Compared to never smokers, odds of difficulty awakening in the morning (DAM) in current smokers were significantly higher for women (OR 1.95) and men (OR 1.50), while increased difficulty initiating sleep (OR 1.88) and decreased early morning awakening (OR 0.31) were found only in women. Never smoking men occasionally exposed to passive smoking at work but not at home had increased odds (OR 1.81) of short sleep duration (SSD, <6 h) than unexposed counterparts. Conclusions: The analyses suggest that exposure to passive smoking at work is associated with SSD in men, while current smoking relates to various subtypes of sleep disturbances in both sexes.

The prevalence and correlates of occupational injuries in small-scale manufacturing enterprises.

The Prevalence and Correlates of Occupational Injuries in Small‐Scale Manufacturing Enterprises: Akinori Nakata, et al. National Institute of Occupational Safety and Health—Workers involved in small‐scale manufacturing businesses are known to comprise a high‐risk population for occupational injury. The present study investigated the prevalence and correlates of occupational injury in this population. A self‐administered questionnaire that solicited answers about occupational information including injury, demographic characteristics, health conditions and lifestyle factors was collected from a sample of 1,298 workers in 228 small‐scale manufacturing enterprises (defined as fewer than 50 workers) aged 16–78 (mean 46) yr in Yashio city, Saitama, Japan (response rate 65.5%). The enterprises were randomly selected from the 2000 edition of the city commercial directory corresponding to the distribution of types of businesses in the city. Occupational injury was assessed by asking subjects, ‘Have you ever been injured during your work, including minor scratches and cuts in the previous 1‐yr period?’ The possible response was either ‘yes’ or ‘no.’ The prevalence of study‐defined occupational injury among the workers was 35.6% (male 43.0%, female 17.9%). Among job types, manufacturing (44.2%) and driving (43.5%) had high rates of occupational injuries. Similarly, occupational injuries were high in the papermaking (54.5%) and machinery (47.7%) industries. For males, younger age, current or former smoking, insomnia symptoms, and disease(s) currently under treatment were correlated with injury, whereas for females, being unmarried, higher educational status, and insomnia symptoms were the correlating factors. Occupational injury is common among small‐scale manufacturing businesses, and is associated with multiple controllable factors. Countermeasures such as prohibiting smoking during work, sleep health education, job safety training for young/inexperienced workers are appropriate methods for eliminating or reducing injuries.

Development of the Japanese Version of the Psychosocial Assessment of Candidates for Transplantation in Allogeneic Hematopoietic Stem Cell Transplantation

BACKGROUND The Psychosocial Assessment of Candidates for Transplantation (PACT) is a validated instrument for evaluating psychosocial risk factors in transplant candidates. OBJECTIVES This study examined reliability and validity of the Japanese version of the PACT (J-PACT). METHODS PACT is a clinician-rated scale consisting of an initial rating, 8 subscales, and a final rating. J-PACT was developed through a translation and back-translation procedure. Seventy adult patients who underwent allogeneic hematopoietic stem cell transplant between April 2009 and December 2013 received retrospective J-PACT ratings based on medical records. Interrater reliability and concurrent validity with Hospital Anxiety and Depression Scale (HADS) and Profile of Mood Status (POMS) scores were assessed. RESULTS Interrater reliability for each J-PACT item was generally high, ranging from 0.53 (drug and alcohol use)-0.93 (support stability). The concurrent validity analyses revealed the following significant relationships (p < 0.05). Higher support stability was associated with lower HADS depression (p = 0.02), POMS anger (p = 0.001), POMS fatigue (p = 0.03), and POMS confusion (p = 0.01) scores. Higher support availability was associated with lower POMS anger scores (p = 0.01). More suitable personality was associated with lower HADS anxiety (p = 0.04) and HADS depression (p = 0.048) scores. Better scores on lifestyle factors and alcohol use were both associated with lower POMS confusion scores (p = 0.01, 0.04, respectively). Better final rating was associated with lower HADS anxiety (p = 0.03) and HADS depression (p = 0.02) scores. CONCLUSION J-PACT was reliable and valid, although further study is needed to confirm these findings.

Follicular lymphoma presenting with massive splenomegaly

A 56-year-old male presented with abdominal distension and weight loss. Physical examination detected a giant spleen extending to the pelvic brim with a hard texture on palpation. Laboratory findings included a serum lactate dehydrogenase level of 319 U/L and a soluble interleukin2 receptor level of 4013 U/mL. Computed tomography scan was remarkable for massive splenomegaly and lymphadenopathy (Fig. 1, left upper panel). F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) revealed increased uptakes in the markedly enlarged spleen and lymph nodes (Fig. 1, middle panel). Biopsy of the enlarged cervical node led to a diagnosis of follicular lymphoma (Fig. 1, left lower panel). Flow cytometry showed that the neoplastic cells were positive for CD10, CD19, CD20, and CD38. Monotypic expression of kappa light chain was noted. Cytogenetic study disclosed chromosomal abnormalities including t(14;18)(q32;q21.3), t(3;22)(q27;q11.2) and del(6)(q21q23) in 19 of 20 metaphases was analyzed. BCL2-IGH fusion signal was detected by fluorescence in situ hybridization analysis. Bone marrow biopsy showed paratrabecular proliferation of lymphoma cells. Reverse transcriptase-polymerase chain reaction for BCR-ABL1 mRNA and sequencing analysis for JAK2 V617F mutation were negative. Given these data, we concluded that the splenomegaly was attributable to infiltration of lymphoma. Treatment with six cycles of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP) regimen was initiated. F-18 FDG-PET after the chemotherapy showed normalization of the spleen (Fig. 1, right panel) To our knowledge, this is the first case of follicular lymphoma manifesting with massive splenomegaly. Among hematological malignancies, massive splenomegaly is usually associated with chronic myeloid leukemia, primary myelofibrosis, chronic lymphocytic leukemia, or splenic marginal zone lymphoma. The present case suggests that follicular lymphoma should also be considered as a cause of massive splenomegaly.

Composite diffuse large B-cell lymphoma and CD20-positive peripheral T-cell lymphoma

Composite lymphoma is defined as two or more distinct types of lymphoma in a single anatomical site. Among various combinations, composite B‐cell and T‐cell non‐Hodgkins lymphomas (CBTL) are very infrequent. Herein we describe a 66‐year‐old female with CBTL presenting with lymphadenopathy, multiple bone lesions and an epidural tumor. Light microscopic examination of a biopsied cervical node revealed a dual population of lymphoid cells: sheets of large cells admixed with medium‐sized cells. The large cells expressed B‐cell markers and showed immunoglobulin light chain restriction, consistent with diffuse large B‐cell lymphoma (DLBCL). The medium‐sized cells were positive for CD20 as well as T‐cell markers. Because polymerase chain reaction amplification showed monoclonal rearrangement of the T‐cell receptor β chain gene, this population was compatible with peripheral T‐cell lymphoma not otherwise specified (PTCL‐NOS). We therefore made a diagnosis of composite DLBCL and CD20‐positive PTCL‐NOS. Complete remission was achieved after six cycles of R‐CHOP regimen (rituximab, doxorubicin, vincristine, cyclophosphamide and prednisolone). This is the first report of CD20‐positive PTCL‐NOS associated with composite lymphoma. Moreover, a literature review of composite DLBCL and PTCL‐NOS indicates that this rare clinical entity may be featured by efficacy of systemic chemotherapy in spite of prevalent extranodal lesions.

Extranodal NK/T-cell lymphoma of the nasal cavity developed in a patient with intestinal Epstein–Barr virus-positive T/NK-cell lymphoproliferative disorder

Extranodal NK/T cell lymphoma, nasal type (ENKL) developed in a patient with intestinal Epstein-Barr virus (EBV)-positive T/NK-cell lymphoproliferative disorder (LPD). The patient was a 46-year-old Chinese man who complained of diarrhea and abdominal pain without immune-deficiency. Endoscopy demonstrated ileum ulcers like Crohns disease, without histological granulomas. His symptoms continued waxing and waning for 3 years until he developed overt lymphoma (ENKL) in the nasal cavity. The ileum lesions exacerbated into a large deep ulcer, and the biopsy specimens from the ileum, including the one 3 years ago, showed infiltration of small lymphocytes containing many EBV-positive T/NK cells without atypia. Thus, the patient illness of intestine was revealed as intestinal EBV-positive T/NK-cell LPD, which might be closely associated with development of ENKL in this patient. In cases of inflammatory bowel disease without typical clinical courses and histological findings, check-up of EBV in the biopsy might help correct diagnosis.

Psychosocial Assessment of Candidates for Transplantation scale (PACT) and survival after allogeneic hematopoietic stem cell transplantation

Recent findings suggest that patient pre-transplant psychosocial risk factors predict survival after hematopoietic stem cell transplant (HSCT) and importance of comprehensive psychosocial assessment during pre-transplant period is increasingly acknowledged. Psychosocial screening process, however, has not been standardized across transplant centers and its predictive value has not yet been confirmed. An observational cohort study was conducted to explore the relationships between psychosocial variables, assessed with the Psychosocial Assessment of Candidates for Transplantation (PACT) scale, and post-transplant overall survival (OS) of patients with hematologic malignancies who received allogeneic HSCT as treatment. Overall, 119 patient medical records were reviewed to determine the PACT score. After controlling for clinical and demographic covariates, lower PACT scores in the domain of compliance with medications and medical advice were significantly associated with poorer OS (HR = 1.75, P = 0.03). Lower PACT ratings in the subscales of personality and psychopathology (HR = 1.35, P = 0.08), lifestyle factors (HR = 1.43, P = 0.08), and relevant disease knowledge and receptiveness to education (HR = 1.32, P = 0.08) tended to be associated with shorter OS. These findings suggested the association between pre-transplant psychosocial factors using PACT and post-transplant OS in patients receiving allogeneic HSCT.

Extranodal NK/T cell lymphoma in a living donor liver transplant recipient

Dear Editor, Previous literatures showed that 0.5–8.3% of non-Hodgkin lymphomas after solid organ transplantation were NK/T cell lymphomas [1, 2]. Although some cases of extranodal NK/T cell lymphoma, nasal type (ENKL) after kidney transplantation were reported [1, 3–6], ENKL after liver transplantation has not been reported so far. A 62-year-old woman presented with progressive gingival ulcers in the upper jaw. She had undergone living donor liver transplantation for liver cirrhosis with chronic hepatitis C 9 years before and had been taking immunosuppressants for prevention of allograft rejection. We usually use tacrolimus and methylprednisolone for this purpose; however, in this case, we changed tacrolimus to mycophenolate mofetil due to refractory diarrhea. Incisional biopsy sample of the gingiva showed middle-sized atypical lymphoid cell infiltration. In immunohistochemical staining, these lymphoid cells were CD3(+), CD4(−), CD5(weak), CD8(+), CD20(−), and CD56(weak). Epstein-Barr virus-encoded RNA in situ hybridization (EBER-ISH) gave a positive result. Contrast-enhanced computed tomography scan revealed paraaortic lymph nodes swelling and a left pararenal tumor. Fluorodeoxyglucose positron emission tomography (FDG-PET) scan also detected intense signals at the upper jaw, paraaortic lymph node area, and left pararenal lesion. Bone marrow examination showed no infiltration of atypical lymphoid cells. She was diagnosed with stage IV ENKL. In view of old age and liver dysfunction, induction chemotherapy was initiated with reduced-dose (67%) dexamethasone, high-dose methotrexate, ifosphamide, Lasparaginase, and etoposide (SMILE) regimen. Additionally, because of prolonged myelosuppression and cytomegalovirus viremia, SMILE was reduced to a half dose in the second course. FDG-PET after two cycles of SMILE therapy confirmed complete remission (CR). Further chemotherapy was not administered due to recurrent aspiration pneumonia. She has been free from relapse for 5 months. Post-transplant lymphoproliferative disorders (PTLD) are life-threatening complications of solid organ and allogeneic hematopoietic stem cell transplantation. EBV infection is a well-known risk factor of B cell PTLD and is strongly involved in the pathogenesis of ENKL. It is likely that longterm immunosuppressive therapy allowed for the expansion of EBV-infected cells and contributed to the pathogenesis of post-transplant ENKL. In the phase II study of SMILE therapy for patients with ENKL, CR rate was 45%, and the relative dose intensity of L-asparaginase in CR patients was 92% [7]. In this case, she achieved CR in spite of reduced dose intensity. ENKL after liver transplantation might be exceptionally sensitive to cytotoxic therapy. Since a previous literature reported that ENKL after kidney transplantation was associated with dismal prognosis [5], a long-time follow-up is required to characterize the disease entity. Contrary to the higher overall incidence of PTLD in liver transplantation than that in kidney transplantation [8], this is the first report of ENKL in a liver transplant recipient. Although the detailed mechanism regarding the low incidence of ENKL in the setting of liver transplantation still remains * Mineo Kurokawa kurokawa-tky@umin.ac.jp