JPH11295304A - Method for screening invasion of serious illness - Google Patents

Abstract

PROBLEM TO BE SOLVED: To implement a screening method capable of simply screening the possibility that inflammatory diseases such as an external injury, infectious disease, autoimmune disease, malignant tumor will cause serious illness. SOLUTION: By detecting the presence or absence of PHP (peripheral hemophagocyte) that devours blood cells in peripheral blood, invasion of serious illness is screened. As invasion, either of an attack against a human body or a start of every disease is explained with examples. In addition, any of external injury, inflammatory disease, medicine, burning, pancreatitis, autoimmune disease, malignant tumor, etc., is explained with examples as the disease.

Description

DETAILED DESCRIPTION OF THE INVENTION

[0001]

TECHNICAL FIELD The present invention relates to a screening method capable of easily screening for the possibility of aggravation of inflammatory diseases such as trauma, infectious diseases, autoimmune diseases, and malignant tumors.

[0002]

2. Description of the Related Art When a foreign body (all non-self substances) invades a living body, the living body may be injured according to conditions such as the type and amount of the invaded foreign body; It can cause the development of inflammatory diseases such as infections, sepsis; autoimmune diseases; malignant tumors. In this case, it is extremely important clinically to determine whether or not the disease or the like becomes more serious and as quickly as possible. Depending on whether the disease or the like becomes more severe, the course of subsequent treatment (eg, a drug that places a large physical, mental, or economic burden on the patient, whether or not to give a treatment; use of a drug that has a large side effect) And so on) are greatly different.

For example, during the clinical course of the above-mentioned diseases, dysfunction of important organs that sometimes occurs has a great effect on the clinical course of the disease, while the disease etc. It is extremely difficult to determine at an early stage whether a dysfunction is to be complicated, which has greatly puzzled clinicians.

Recently, systemic inflammatory response syndrome (S)
The concept of IRS has been proposed (Members of the Am
erican College of Chest Physicians / Society of Crit
ical Care Medicine Consensus Conference Committe
e; American College of Chest Physicians / Societyof
Care Medicine Consensus Conference: Definitions f
or sepsis and organfailure and guidelines for the
use of innovative therapies in sepsis.Crit Care
Med, 20: 864-874, 1992).

[0005] The aforementioned concept of SIRS has been a reference value set as an entry criteria for a clinical trial on sepsis (sepsis), but in recent years, a warning of a severe case has been set.
Considered as a sign.

[0006]

According to the study of the present inventors, many cases satisfying the standard value of SIRS heal spontaneously and are not clinically useful. In other words, even in the case of this SIRS state, there are cases in which the case is naturally relieved and cases in which the disease becomes more severe. Therefore, it is hard to say that the diagnosis of the SIRS will immediately lead to a more severe case.

[0007] In view of the above, it is possible to easily determine the possibility of aggravation of inflammatory diseases such as trauma, infectious diseases, autoimmune diseases, and malignant tumors while reducing the burden on patients. It was strongly sought.

[0008] An object of the present invention is to provide a screening method capable of easily screening for the possibility of aggravation of inflammatory diseases such as trauma, infectious diseases, autoimmune diseases and malignant tumors. It is in.

[0009]

Means for Solving the Problems As a result of intensive studies, the present inventors have found that, in severely ill patients, "PHP (pe
ripheral hemophagocytes) appear in peripheral blood. "

The present inventors have further studied and found that the presence or absence of this phenomenon of "phagocytosis of blood cells by PHP" is extremely effective for predicting the severity of various invasions.

[0011] The screening method for severe invasion of the present invention is based on the above findings, and more particularly, is characterized by detecting the presence or absence of PHP that phagocytosed blood cells in peripheral blood. is there.

In the present invention, examples of the invasion include either an attack on the human body or the initiation of any disease. Examples of the disease include trauma, infectious diseases, drugs, burns, pancreatitis, autoimmune diseases, and malignant tumors.

The trauma is typically a physical injury or wound to the body; the infection is typically a bacterial, viral, parasite, fungal, Rickettsia, toxoplasma Any of the infections;
The drug is typically any of the drugs currently on the market; the burn is typically one of fire, chemical, electricity, or radiation; The disease is one that is typically characterized by a specific humoral or cellular immune response to its own tissue components (self antigens).

In the present invention, the autoimmune disease is exemplified by any of collagen disease, idiopathic interstitial pneumonia and idiopathic pulmonary fibrosis. Examples of the collagen disease include systemic lupus erythematosus (SLE), Either rheumatoid arthritis or scleroderma is exemplified.

According to the findings of the present inventors, PHP found in peripheral blood newly found this time is known as Hemophagocytic Syndro.
me (HPS), which is the main body of histioproliferative disease accompanied by hemophagocytosis, and monocyte-derived cells found in reticuloendothelial tissues such as bone marrow (Reference: Reiner AP and Spivak
JL: Hematophagic histiocyosis; a report of 23
new patients and a review of the literature.
cine 1988; 67: 369-388).

This PHP is classified into reticuloendothelial cells of Manoharan (Reference: ManoharanA, Catovsky D: Histio
cytic medullary reticulosis revisited. Disorders o
f the monocytemacrophage system.Haematol Blood T
ransfus 27: 205-210, 1981)
It was considered a phagocyte equivalent to ge5. Also, this P
Blood cells phagocytosed by HP were also considered to be random because of their low association with the underlying disease.

Although the pathophysiology of hemophagocytosis in the present invention is still unclear, the present inventors presume that macrophages and histiocytes activated by hypercytokinemia phagocytose autologous blood cells. We considered this hemophagocytosis to be evidence of self-organ injury that we can directly confirm. The present invention is based on the fact that the above-mentioned PHP was confirmed in peripheral blood of a case that became severe during the clinical course, and it was presumed that this PHP could be an indicator of self-organ injury, that is, severe disease. .

[0018]

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS Hereinafter, the present invention will be described more specifically with reference to the drawings as necessary. In the following description, “parts” and “%” representing quantitative ratios are based on weight unless otherwise specified.

(HPS) Generally, Hemophagocytic Syndro
histioproliferative disorders with blood cell phagocytosis, collectively referred to as me (HPS), are familial (familial) hemophagocytic lymphohi
primary HPS that is stiocyosis (FHL) and seconda
It is roughly divided into ryHPS. The latter secondary HPS
Has been reported to be caused by various causes such as malignant tumors in addition to viral and bacterial infections. In recent years, the involvement of cytokines has been pointed out in the pathological condition, and a review of treatment methods has been advocated. The diagnostic criteria at present are still severe and have been considered as one of the reasons for making HPS intractable, and recently it has even been said that its classification is important.

(Current HPS) (I) At present, the above-mentioned HPS has activated macrophages and histiocytes proliferating and differentiating in a reactive manner, further phagocytosing autologous blood cells, fever, cytopenia, hepatic dysfunction, It is a syndrome that presents unique findings such as LDH / ferritinemia.

(II) The causes of the HPS are various,
The above-mentioned FHL primary HPS, secondary infections after infection of various bacteria and viruses, malignant tumors and drug administration
aryHPS.

(III) Hypercytokinemia caused by various causes activates macrophages and histiocytes. Highly reported cytokines include interleukin (IL) -1β, interferon (INF) -γ, soluble interleukin-2 receptor, interleukin-6, monocy
te-macrophage colony stimulating factor (M-CS
F) -α and the like.

(IV) In virus infection and lymphoma, activated T cells secrete IL-2, INF-γ, M-CSF, etc., and in bacterial infection, elastase and IL-1β from neutrophils and activated macrophages. , TNF (tumor necros
is factor) -α, IL-6 and the like are secreted, and further form a cytokine network.

(V) It is considered that clinical symptoms such as fever, decrease in blood pressure, and tendency to drowsiness are caused by the action of each cytokine. Each cytokine has its own biological activity, and there is a correlation between the clinical symptoms presented by the case and the cytokine whose high value was indicated. (Reference: Hiroyuki Tsuda: For special issue on hemophagocytic syndrome. Daily practice and blood 7
(8): pp983-988, Pharmaceutical Journal, Tokyo, 199
7; Tsuda H: Hemophagocytic syndrome (HPS) in child
ren and adults.International Journal of Hematolog
y 65: 215-226, 1997; Shinsaku Imajuku: Hemophagocytic Syndrome, Hematology / Oncology, 33
(6), pp. 433-439, 1996; Shinsaku Imajuku: Involvement of cytokines in hemophagocytic syndrome associated with lymphoid tumors, clinician, 22 (7), 1996).

(VI) Pancytopenia, hyperLDHemia and hyperferritinemia, which are cited as diagnostic criteria for HPS, are due to the proliferation and differentiation of monocytes and macrophages, and phagocytosis by activated macrophages. It has been. The mechanism is still unknown, but has been attributed to non-specific phagocytosis via cytokines or specific phagocytosis via antibodies (Reference: Shunichi Kumakura,
Others: Autoimmune-associated hemophagocytic syndrome, history of medicine, 17
7 (10), pp. 683-689, 1996).

The problem with HPS is that it is intractable (mortality rate 30%) and its causes are diverse; its mechanism is unknown; its diagnostic criteria are severe; its treatment policy is not established. Has become.

At present, measures against HPS include (a) classification of disease systems due to causes (primary HPS and secondary
There is an urgent need to establish a treatment method in line with the HPS); (b) pathological stage classification; (c) early treatment by early diagnosis; and (d) pathological pathological stage classification. Of these measures,
(A) Classification of disease systems by cause is important for treatment of the cause, but has been almost classified by Imajuku, Kawa, Tsuda et al. (Reference: Shinsaku Imajuku: Hemophagocytic Syndrome, Hematology and Oncology, 33 (6), pp. 433-439, 1996;
Tsuda H: Hemophagocytic syndrome (HPS) in child
ren and adults.International Journal of Hematology
65: 215 ~ 226, 1997; Keiyo Kawa, et al .: Hematological malignancies and hemophagocytic syndrome, History of Medicine, 177 (1
0), pp 673-676, 1996).

The reason why the above (b) to (d) do not progress is considered to be that the mechanism of poor eating is still unknown, but this poor eating is described in (III) and (IV) above. Since the cytokine network is involved and presents the above-mentioned clinical symptoms (V) and (VI), the present diagnostic criteria have been proposed using these as indices (Reference: Tsuda H: Hemophagocytic syndrome (HPS) in
children and adults.International Journal of Hem
atology 65: 215-226, 1997; Shinsaku Imajuku: Hemophagocytic Syndrome, Hematology / Oncology, 33
(6), pp. 433-439, 1996; Shinsaku Imajuku: hemophagocytic syndrome, pediatric practice, 56 (extra number), pp. 200,, 1993).

The contents of the "current diagnostic criteria" include sustained high fever for one week, high LDH blood, hyperferritinemia, and evidence of hemophagocyte by bone marrow aspiration. However, these diagnostic criteria involve test values that appear after the disease state has progressed to some extent, or involve invasive tests, and are consequently strict (not easily performed; early diagnosis cannot be made).

At present, the above (c) early diagnosis, early treatment,
(B) Pathological staging (review of diagnostic criteria, classification of pathological conditions) is regarded as urgent and has been the basis for the purpose of establishing treatments in line with (d) pathological staging. The usefulness of cytokine measurement has been pointed out (but cytokine measurement is expensive).

Further, according to the findings of the present inventors, (d)
Regarding the establishment of treatments in line with the staging of pathological conditions, treatment initiation and treatment based on the diagnosis of HPS based on the current diagnostic criteria will not change the current treatment. However, the survival rate cannot be improved much. Therefore, (c) early diagnosis and early treatment are important for improving the survival rate.

(Peripheral blood) Peripheral blood refers to blood flowing through blood vessels. A term for bone marrow fluid.

More specifically, "peripheral blood" is all blood that has exited the bone marrow and is blood flowing through blood vessels (eg, earlobe blood, venous blood, arterial blood, etc.). The blood collection site for peripheral blood is not particularly limited, but a typical blood collection site is
Limb artery or vein. Peripheral blood contains red blood cells, white blood cells, platelets, and the like as main components, and the normal values of these components are usually 3.5 million to 4.5 million / μl of red blood cells, 4000 to 6000 / μl of white blood cells, and 150,000 to 350,000 / μm of platelets.
(For details of such “peripheral blood,” see, for example, Susumu Shibata, “Illustrated Hematology,” p. 30 (199)
6) Kinhodo, can be referred to).

On the other hand, the above-mentioned "bone marrow fluid" is a fluid of the medulla of bone and is usually collected by bone marrow aspiration. The place where the bone marrow fluid is collected typically includes the upper tibia and the lumbar spinous process in infants; the upper sternum, the posterior iliac crest, and the iliac crest in children; and the sternal plate, iliac crest, and the like in adults. The bone marrow fluid contains 150,000 to 350,000 nucleated cells / 50 megakaryocytes of bone marrow.
１５０150 / μl or the like as a main component. When observing the bone marrow fluid, a slightly viscous blood contains whitish lumps and fats that clump cells (for details of such "bone marrow fluid", see, for example, Susumu Shibata, "Illustrated Hematology" 38 (1996) Kinhodo).

Therefore, the above-mentioned “peripheral blood” and “bone marrow fluid” can be distinguished at the place of collection.
It is also possible to distinguish from the components.

(Phagocytic cells) Phagocytic cells (or phagocytic cells, ph
“Agocyte” is a general term for cells that treat a foreign body (a solid body other than healthy cells of the own body) when the body invades the living body. Typical cells are macrophages (macrophages), and mononuclear cells (histiocytes and monocytes) that mainly become scavenger cells and ingest necrotic tissues and degenerated cells. Here, the "foreign body" generally includes exogenous parasites (bacteria, fungi, viruses, and the like), non-living organisms (dust, soot, and the like), aging cells, and the like.

(Phagocytosis) Phagocytosis (or phagocytosis)
Is also referred to as phagocytosis, and refers to the action of the cell body to take up foreign substances into the cytoplasm. The main processes are (1) adhesion of a foreign substance to a cell membrane (a phenomenon mediated by an adhesion factor, which is a state in which the adhesion factor is used as a bridge), (2) ingestion into a cell (contamination of a foreign substance into the cytoplasm). (3) Intracellular digestion (change of foreign substances into substances that can be absorbed and assimilated).
Divided into stages.

For details of the above-described phagocytic cells or phagocytosis, see, for example, Sugishi Otani et al., “Dorland Illustrated Medical Dictionary,” p. 1396 (1980) Hirokawa Shoten; 676 pages (1987)
You can refer to Medical and Dental Medicine Publishing Co., Ltd.

(Blood cells) Blood cells refer to cells floating in blood, and are usually classified into red blood cells, white blood cells, and platelets. The screening method of the present invention is characterized by detecting the presence or absence of PHP that engulfs blood cells (for example, red blood cells, white blood cells, and platelets, whose maturity is not limited). The morphology was limited here by observation (for details of such "blood cells", see, for example, Susumu Shibata, "Illustrated Hematology", page 2, 21-
23 (1996) Kinhodo; Goto, M. et al., "Latest Dictionary of Medical Science", p. 395 (1987), Medical and Dental Publishing Co., Ltd.).

(PHP) PHP (peripheral hemophago)
cyte) is a phagocytic cell (phagocyte) found in peripheral blood, but unlike the phagocytic (phagocyte) cell (phagocyte) described above, phagocytic (phagocyte) cell phagocytosing blood cells
It is. Usually, these cells are not found in peripheral blood.

In the screening method of the present invention, the pathogenic PHP is derived from monocytes. There are various theories regarding the development and differentiation of monocytes and histiocytes, but the estimation based on the findings of the present inventors is as follows. In other words, the head of monocyte development is the bone marrow, where the sensitized monocytes differentiate and proliferate, gradually increase in number, and eventually exude into the peripheral blood. The details of the life cycle of monocytes are unknown, but it takes about 7 days for immature monocytes to mature and become peripheral.
It takes days, the time to stay in the blood (half-life) is estimated to be about 3 days, and the life of the cells that have invaded the tissue is estimated to be several months.

Considering the physiological development and differentiation of monocytes,
When any invasion is applied to the body, hypercytokinemia is induced, and activated monocytes acquire differentiation and proliferation ability and phagocytic ability, differentiate and proliferate into histiocytes / macrophages, and gradually increase in number. The pathology of HPS is increased.
Fever is a result of hypercytokinemia, pancytopenia is a result of phagocytosis by histiocytes, and hyperLDH / hyperferritinemia is a state of further phagocytosis. When the neck moves to the liver, spleen, and lymph nodes, it is presumed that organ damage accompanying inflammatory changes in each organ will be observed.

(Detection of PHP) In the present invention, PHP to be phagocytosed by normal cells (blood cells) is basically formed by a conventional Harugi (flow cytometry method, laser method, cell image analysis system (for example, manufactured by Coulter Inc.) Product Name: MICR
0-21, etc.) can be suitably detected. In the present invention, these conventional devices have a PH
It may be used after P is recognized. For example, in the above-mentioned MICR0-21 cell image analysis system manufactured by Coulter, a computer program for fetching and processing image data into a computer may be appropriately created and applied to the system.

At the time of detecting PHP, the cells may be stained using a conventional method, for example, Romanoskey staining (Giemsa staining, Light Giemsa staining, May Giemsa staining, etc.). To enable clearer classification, it is also possible to use a special staining method (for example, an immunostaining method using a monoclonal antibody specific to the cell). Further, a separation detection method by centrifugation may be combined with the above detection method.

[0045]

[Example] Example 1 From January 1997 to December 1997, 1,000 patients were randomly selected from patients who visited or were admitted to the outpatient clinic of Kannamoto Hospital in Kumamoto City, Kumamoto Prefecture, and PHP was searched. Was positive, but the SI shown in the following (Table 1) in all four cases
The diagnostic criteria for RS (diagnostic criteria from the American Thoracic Society) were met. Furthermore, among the cases that satisfied the diagnostic criteria of SIRS, a group in which PHP was observed (10 cases were arbitrarily selected from the case group in which PHP was observed) and a group in which PHP was not observed (from the group in which PHP was not observed) Age, causal disease, treatment, morbidity, and outcome were compared in two groups (arbitrarily selected 10 cases).

[0046]

[Table 1]

Based on the above (Table 1), SIRS was diagnosed on the day when the diagnosis was obtained as the date of onset (day 0). From the date of onset, when a blood test is requested by the attending physician, a smear sample is taken. If PHP is found in the peripheral blood, it is considered positive (+), and if it is not found, it is negative (-). Indicated. The date on which PHP was confirmed is indicated as the date of appearance.

After exiting the SIRS state, the CRP (C-reactive
protein) was 1.0 mg / dl or less, and the day when treatment was discontinued at the discretion of the attending physician was defined as the remission day, and the period from onset to the remission day or death day was defined as the morbidity period. The details of the treatment were determined by the attending physician to be necessary and sufficient according to the condition of the case, and a summary of the drugs used during the disease stage was given.

As a result of the above-mentioned study, phagocytes which phagocytosed blood cells such as platelets, white blood cells including red blood cells and monocytes were observed in peripheral blood of severe SIRS cases. Micrographs (magnification: 500 times) showing this phagocytosis are shown in the photographs of FIGS.

[0050] In some cases, a single type of cells was phagocytosed by PHP, but there was no association with the causative disease, which was not constant.

The age of all the above SIRS cases (20 cases) is 22 to 92 years, the average is 71.6 ± 16.6 years, the average of the positive group is 78.4 ± 11.5 years, and the average of the negative group is Is 63.
There was no significant difference in age at 2 ± 18.4 years. The average date of appearance was 3.4 ± 1.1 days. Regarding the treatment, the positive group obviously required a large amount of various drugs. The mean morbidity excluding deaths in the positive group was 16.6 ±
The average disease stage of the negative group at 8.5 days was 4.9 ± 2.7 days, indicating a significant difference (p <0.01). In the outcome,
The positive group included two deaths. (See Table 2 below).

[0052]

[Table 2]

In the comparative study of the clinical courses of the above-mentioned PHP positive group and the negative group, the average age of the positive group was older because the elderly were targeted because of the patient group who visited the hospital. There was no significant difference between the groups.
On the other hand, there was a clear difference in treatment, morbidity, and outcome,
In the positive group, in addition to prolonged morbidity, expensive and diverse drugs were required, and some patients died.

Physiologically, monocyte cells are activated and proliferated and appear in peripheral blood about 7 days later, and if they are further invasive, the rate of appearance becomes 2-3 times. It is considered that it is important to search for about one week from the date of onset, including the present results, and it is necessary to pay particular attention to the search on the second to fifth days.

From the results of the above-mentioned comparative study, it was determined that the presence or absence of phagocytosis of blood cells by PHP was a sufficient indicator of the severity of the disease.

Example 2 According to the findings of the present inventors, the newly found PHP in peripheral blood is Hemophagocytic Syndrome (HPS).
Monocytes derived from reticuloendothelial tissues such as bone marrow, which constitute the main body of histioproliferative diseases with hemophagocytosis, collectively referred to as “Reiner AP and Spivak JL: Hematop
hagic histiocyosis; a report of 23new patients a
nd a review of the literature. Medicine 1988;
67: 369-388), and furthermore, it was presumed that PHP was physiologically derived from bone marrow, and among patients who met the diagnostic criteria of SIRS, And hemoph in the bone marrow
The presence or absence of PHP in peripheral blood with respect to the appearance ratio of agocytes was examined (see Table 3 below).

[0057]

[Table 3]

As shown in Table 3 above, heme in bone marrow
A difference was observed in the presence or absence of PHP in peripheral blood at about 1.0% of the appearance ratio of mophagocytes.

From the examination of the presence or absence of PHP in peripheral blood with respect to the appearance ratio of hemophagocyte in the bone marrow, hemophagocyte appeared in the bone marrow in all cases of SIRS, and further, from the early stage when hemophagocyte increased in the bone marrow. (The reason for the early judgment was that PHP was negative at an incidence of 0.9% in the bone marrow, and at that time, even in SIRS cases, it was treated with an orally administered drug in an outpatient setting) Because it is the level that you are doing). Furthermore, the appearance rate in the bone marrow is 3.0%
Beyond is HPS. In addition, at present, there are many hematological reports as causative diseases of HPS, and other kinds of diseases have been questioned. However, according to the present inventors, pneumonia, perforated peritonitis, and postoperative disease in which SIRS was observed. Hemophagocytes appeared in peripheral blood in cases of suture failure and acute pancreatitis, after which DIC (d
I have experienced a case with isseminated intravascular coagulation). Therefore, SIRS for any disease
After that, HPS could occur and it was confirmed that HPS was a partial symptom of SIRS (see Table 4 below and FIG. 3).

[0060]

[Table 4]

Further, as described above, hemoph in peripheral blood
Since agocytes appeared and then hemophagocytosis by PHP led to platelet depletion and a case with DIC complicated, in the pathogenesis of critical organ dysfunction during invasion, macrophages themselves It was considered that a pancytopenia and further a disease state involving DIC should be added (see FIG. 4).

[0062]

As described above, according to the present invention, there is provided a screening method for aggressive invasion, characterized by detecting the presence or absence of PHP that phagocytoses blood cells in peripheral blood.

The screening method of the present invention uses a peripheral blood image with a small burden on the patient and uses PHP having a characteristic morphology, so that it can be easily distinguished from other cells. In addition, PHP in the peripheral blood image has a tendency to gather at the edge of the smear sample and at the end of pulling, so that observation of the “edge” or “end of pulling” enables easy observation of PHP. It is.

Therefore, according to the present invention, it is possible to easily screen for the possibility of aggravation of inflammatory diseases such as trauma, infectious diseases, autoimmune diseases, and malignant tumors. The possibility of early detection of the disease and early treatment appropriate for the symptoms can be significantly increased.

[Brief description of the drawings]

FIG. 1 is a photomicrograph (magnification: 500 ×) of peripheral blood showing a state in which a large mature histiocyte phagocytoses platelets, erythrocytes, monocytes, and the like (magnification: 500 times) (stage 5 in Monoharan classification).

FIG. 2 is a micrograph of peripheral blood showing that a large mature histiocyte phagocytoses neutrophils, monocytes, etc. (magnification:
500 times) (stage 5 in Monoharan classification).

FIG. 3 is a diagram showing the interrelationship between biological responses to invasion based on the findings of the present inventors.

FIG. 4 is a diagram showing a mechanism of the occurrence of important organ dysfunction at the time of invasion based on the findings of the present inventors.

Claims (4)

[Claims] 1. PH that phagocytosed blood cells in peripheral blood
A method for screening for a severe invasion, comprising detecting the presence or absence of P (peripheral hemophagocyte). 2. The screening method according to claim 1, wherein the invasion is either an attack or initiation of a human body with any disease. 3. The systemic inflammatory response s
3. The screening method according to claim 2, which is a yndrome (SIRS). 4. The systemic inflammatory response s
yndrome (SIRS) by Hemophagocyticsyndrome (HP
4. The screening method according to claim 3, which is S).