Clinical efficacy and indication of acetazolamide treatment on sleep apnea syndrome

The efficacy and indication of acetazolamide treatment on patients with sleep apnea syndrome (SAS) were discussed from assessing the changes of polysomnographic findings with the treatment in 75 SAS patients. For the patients as a whole, respiratory disorder variables improved significantly during the treatment. However, the number of acetazolamide treatment responders who showed a decrease of apnea hypopnea index (AHI) to 50% or less of the pretreatment value numbered only 34 (45.3%). The lower values of body mass index and AHI in the responder group indicated that monotherapy with acetazolamide is the treatment choice only for mild SAS cases without obesity. However, combined treatment with acetazolamide and uvulopalatopharyngoplasty was thought to be beneficial for severe cases.

Treatment of periodic leg movement disorder and restless leg syndrome with talipexole

In order to investigate the bedtime dose of talipexole, a D2 and alpha2 stimulant, on patients with periodic leg movement disorder (PLMD) and restless leg syndrome (RLS), we made a comparison of polysomnographic findings and subjective symptom ratings before and during 4 weeks of the treatment on five cases with RLS and PLMD. A significant decrease in both the frequencies of periodic leg movements and subjective symptom ratings and significant improvement of sleep composition were recognized during the treatment. We speculate that the combination of the agonistic action of D2 and alpha2 receptor with the drug might not only suppress PLMD and RLS but also improve sleep quality.

Mechanism of action and therapeutic indication of prosthetic mandibular advancement in obstructive sleep apnea syndrome

Prosthetic mandibular advancement (PMA) was applied to nine patients with obstructive sleep apnea syndrome (OSAS) and its therapeutic usefulness, mechanism of action, and clinical indication were discussed based on polysomnographic findings and serial examination of upper airway before and during PMA treatment. Apnea hypopnea index significantly decreased during PMA treatment compared with the value before treatment (P < 0.01) and the rate of the treatment responder counted 78.1%. Cephalometric variables indicated forward and inferior advancement of mandible in our subjects. Magnetic resonance imaging of the upper airway during sleep revealed a marked improvement of velophanryngeal obstruction in most subjects. In addition, intraesophageal negative pressure during sleep decreased significantly. Our results confirmed the high therapeutic efficacy of PMA for OSAS and indicated forward advancement of the mandible and decrease of negative pressure loading on upper airway with PMA might suppress velopharyngeal collapse. Thus, PMA was regarded as one of the treatments of choice for OSAS occurring based on with velopharyngeal narrowing.

Plasma concentration of immunoreactive vascular endothelial growth factor and its relation to smoking

We determined the plasma concentration of immunoreactive vascular endothelial growth factor (IR-VEGF) and searched for a relationship between it and the degree of microangiopathy. The plasma VEGF level was measured using an enzyme immunoassay in 110 non-insulin-dependent diabetes mellitus (NIDDM) patients with varying degrees of nephropathy or retinopathy (RP) and in 39 healthy controls and 30 nondiabetic patients for comparison. One fourth of the control subjects, 60% of whom were currently smokers, had plasma levels of IR-VEGF higher than the lower limit (15.6 pg/mL) of detection for this assay, whereas this was the case in half of the NIDDM patients. Plasma IR-VEGF was detectable in all patients with cerebral infarction, chronic renal failure, and severe infection, suggesting that tissue hypoxia might be a common cause for the elevation of plasma VEGF in these disorders. The prevalence of measurable plasma IR-VEGF levels increased in parallel with increases in the urinary albumin excretion rate ([UAER] 35.1% for UAER <30 mg/24 h, 54.8% for UAER 30 to 300 mg/24 h, and 61.3% for UAER >300 mg/24 h; P < .05 v UAER <30 mg/24 h). The mean measurable plasma concentration tended to increase with increasing UAER. However, there was no such correlation with the severity of RP. Smoking caused an acute increase of plasma IR-VEGF in only 22.6% (12 of 53) of the patients with a smoking habit. In conclusion, these findings suggest that circulating IR-VEGF may be linked to the progression of nephropathy, and smoking may facilitate this process by causing tissue hypoxia in susceptible patients.

Glycemic control and prevention of retinopathy in Japanese NIDDM patients. A 10-year follow-up study

OBJECTIVE

To examine glycemic control for the prevention of retinopathy in early diagnosed Japanese NIDDM patients.

RESEARCH DESIGN AND METHODS

There were 137 patients with NIDDM but without retinopathy who first visited our facility from 1983-1985. Their age at diagnosis ranged from 30-65 years, with a disease duration of < 3 years. The optic fundi were examined at least annually. The prevalence of retinopathy in the 10th year after registration in the study was compared in four groups stratified by mean HbA1c values for 10 years. Multiple logistic regression analysis was used to assess the relationship between retinopathy and covariates.

RESULTS

None of the patients with a mean HbA1c < 6% had retinopathy. The prevalence of retinopathy was 17.2% in the group with a mean HbA1c of 6-6.9%, 14.3% in the group with a mean HbA1c of 7-7.9%, 41.9% at a mean HbA1c of 8-8.9%, and 54.8% when the mean HbA1c exceeded 9%. The prevalence of retinopathy increased with the increase in the mean HbA1c values over 10 years (trend, P < 0.005). Multiple logistic regression analysis revealed that mean HbA1c was the only significant risk factor for the development of retinopathy.

CONCLUSIONS

Our results support the concept that an early diagnosis and better control lessen the risk for the development of retinopathy in Japanese NIDDM patients.

[Neonatal apnea after general anesthesia--effects of intraoperative hyperventilation and serum ionized Ca concentration]

The relationship between neonatal apnea following general anesthesia and serum ionized calcium (Ca2+) concentration was examined in 13 neonates who had received intraoperative hyperventilation. In all cases, preoperative serum Ca2+ concentration was within normal limits. The anesthesia was maintained by nitrous oxide and oxygen. At the end of anesthesia, the incidence of abnormal breathing such as apnea, periodic breathing or subcostal retraction and their activity were investigated. Five minutes after intravenous administration of 2% CaCl2 solution (16 mg.kg-1), the same parameters were compared with the values before CaCl2 administration. As we used only Ca2+ free solution for fluid therapy during operation, serum Ca2+ concentration decreased gradually under general anesthesia, but after CaCl2 administration, it increased and the incidence of abnormal breathing decreased. To determine the relationship between hyperventilation and the incidence of abnormal breathing, the data were analyzed by dividing the patients into two groups based on PaCO2 level, a lower PaCO2 group (intraoperative PaCO2 < 30 mmHg, n = 5) and a higher PaCO2 group (PaCO2 > or = 30 mmHg, n = 8). But there was no significant relationship between them. In conclusion, this study demonstrates that the Ca administration has a favorable effect on respiratory system and motor activity, but we cannot relate the incidence of postoperative abnormal breathing to the degree of hyperventilation.

Isolation of a carrot gene expressed specifically during early-stage somatic embryogenesis

We report the first successful isolation by subtractive hybridization of a gene expressed specifically during somatic embryogenesis. Embryogenic cell clusters, 32-50 microns in diameter, were isolated by sieving and density-gradient centrifugation. The cDNA library was constructed from proglobulars which were formed from embryogenic cell clusters 3 days after transfer to auxin-free modified Lin and Staba's medium. For use as probe in screening, the same cDNA used for library construction was enriched for specific sequences using subtractive hybridization. The cDNA used for subtraction was prepared from suspension cultures 5 days after subculturing in auxin-containing medium. Nine independent differentially expressed cDNA clones were obtained from a screen of 150,000 recombinant phages. Northern analysis indicated one of these, CEM6, to be expressed specifically during somatic embryogenesis. In addition, one hybridizing transcript was detected in plantlet cotyledons, and two transcripts were detected in hypocotyls. Two separate and distinct hybridizing transcripts are expressed specifically in hypocotyl tissue. The amino acid sequence deduced from the nucleotide sequence of the CEM6 cDNA indicates that it encodes a glycine-rich protein containing a hydrophobic signal-sequence like domain. Its early embryo-specific expression and sequence characteristics suggest an important role as a cell wall protein in embryogenesis.

Isolation and characterization of homeobox-containing genes of carrot

Homeodomains (HDs) are DNA-binding domains that have been well characterized in animals, and HD proteins are thought to be regulators of transcription. To investigate the regulation of gene expression during somatic embryogenesis in carrot, an attempt was made to isolate cDNA clones that encode HD proteins. A cDNA library from carrot somatic embryos was screened with a degenerate oligonucleotide probe that corresponded to a conserved amino acid sequence of HDs, and one cDNA clone (CHB1) encoding an HD protein was isolated. The amino acid sequence deduced from the nucleotide sequence of this clone contained a putative leucine zipper motif adjacent to the anticipated HD. The homeodomain/leucine zipper (HD-Zip) sequence of this cDNA was used for further screening, and five additional independent clones (CHB2 through CHB6) were isolated. Although the HD-Zip sequences encoded by these clones were similar to each other, the sequences beyond the HD-Zip regions varied greatly. Transcripts corresponding to CHB1 through CHB6 were expressed at different times during somatic embryogenesis. In particular, transcripts corresponding to CHB2 were expressed in close association with the early development of embryos.

Dropout of young non-insulin-dependent diabetics from diabetic care

We investigated the follow-up status and prognosis of 109 patients with non-insulin-dependent diabetes mellitus aged from 10 to 19 years old (66 males and 43 females). Patients who had not attended hospital for at least 20 months up to the end of September 1990 were regarded as defaulters, and were surveyed by questionnaire. There were 62 defaulters (56.9%) among the 109 patients originally enrolled in diabetes care. The defaulters had a significantly higher body mass index (both males and females), mean arterial blood pressure, and fasting blood glucose level than the patients still attending the diabetes clinic, as well as a significantly worse lipid profile. The main reason given for non-attendance was a busy schedule. Compared with patients attending the diabetes clinic, a lower percentage of the defaulters remained on a diet or took regular exercise. Rapid eating was more common among the defaulters than the attendees (92.9% vs. 60%, P = n.s.). Thus, the lifestyle of the defaulters seemed to be undesirable for young diabetic patients. These findings emphasize the importance of effective education and follow-up for young obese patients with non-insulin-dependent diabetes mellitus.

[Two cases of tension pneumothorax caused by tracheal suction during the operation of pectus excavatum]

Rehbein's method is one of the surgical procedures for pediatric pectus excavatum, which constructs thorax by lifting and fixating the sternum using metal strut inserted into bone marrow of bilateral ribs. We experienced two pediatric cases of tension pneumothorax caused by tracheal suctioning during the operation by this method. The etiology of tension pneumothorax was thought to be as follows. A small pleural hole was made during separation of ribs from surrounding tissues and a large amount of air entered into the pleural space and check valve mechanism worked at the pleural hole when the lung was collapsed on tracheal suctioning. In anesthetic management of pectus excavatum by Rehbein's method, we should always be cautious of the possible occurrence of tension pneumothorax.

[The severity of dementia and brainstem auditory evoked potentials--the amplitude of waves I, III and V]

The correlation between the severity of dementia and the amplitudes of brainstem auditory evoked potentials (BAEPs) was studied. The subjects were 78 patients with dementia (20 males, 58 females) whose mean age was 80.5 +/- 6.7 years. Normal subjects were 9 elderly persons (2 males, 7 females) whose mean age was 79.2 +/- 6.0 years. The amplitudes of wave-I, -III and -V were measured. As for individual differences: (1) The amplitudes of BAEPs in the male group were lower than that in the female group, there was no significant difference. (2) The amplitudes of wave-V in female patients with vascular dementia were significantly lower than that of degenerative dementia. (3) The amplitudes of wave-III reduced as the duration of illness prolonged. Dividing the patients into three groups according to the severity of dementia which are mild, moderate and severe. (4) The amplitudes of the wave-V reduced significantly as the severity of dementia advanced. There was a significantly positive correlation between the amplitudes of the wave-V and the Hasegawa's dementia scores (r = 0.404759, p < 0.05) Based upon the above results, the brainstem dysfunction might progress with the severity of dementia.

The role of wet-dog shakes during amygdaloid electrical and methionine-enkephalin kindling in the rat

The role of wet-dog shakes (WDS) in the kindling phenomenon was investigated in the rat using amygdala (AM) electrical kindling (E-K group), methionine-enkephalin (ME) chemical kindling (ME-K group) and ME-chemical kindling after the completion of electrical kindling (E-M group). The AM electrical kindling was carried out with 200 microA stimulation. Repeated microinjections of 10 micrograms ME into the AM were given for ME chemical kindling. EEG and behavioral seizures were recorded from the beginning of the electrical stimulation or ME microinjection to 2 min after the end of the after-discharge (AD). The mean number of WDS in ME-K and E-M groups during the chemical kindling, in contrast to that in E-K group, was significantly decreased as the kindling stages progressed. In the ME-K group, WDS completely disappeared when the stage developed into stage 5. In all the three groups, the maximum incidence of WDS in each stage appeared near the termination of AD, which was accordant with the end of the convulsive seizures. These results suggest that WDS may be associated with the kindling stage and the end of the convulsive seizure or the AD. Furthermore, the disappearance of WDS could be a behavioral index of the fully kindled state in some kinds of kindling models.

A gene expressed preferentially in the globular stage of somatic embryogenesis encodes elongation-factor 1 alpha in carrot

We have isolated cDNA of genes that are preferentially expressed during somatic embryogenesis of carrot (Daucus carota L.) by differential screening of globular embryos and cells that are dividing in an unorganized manner. As a result of Northern-blot analysis, one of the genes identified in this way, which we refer to as CEM1, was found to be expressed at high levels in somatic embryos at the globular and heart-shaped stages. In-situ hybridization using globular embryos revealed that the mRNA transcribed from CEM1 was located preferentially in the spherical region of the globular embryo. A homology search using the amino acid sequence deduced from the nucleotide sequence of the CEM1 cDNA revealed that CEM1 encodes the eukaryotic translational elongation-factor 1 alpha.

[A case of malignant localized visceral pleural mesothelioma]

We experienced malignant localized mesothelioma of which origin was visceral pleura. According to, 1) the preoperative chest X-ray and chest CT which showed extra-pleural sign, 2) the rapid tumor growth, and 3) the result from needle biopsy, we diagnosed malignant localized mesothelioma of which origin was parietal pleura. Surgical treatment was performed, and diagnosed that its origin was visceral pleura. The tumor invaded the lung. It is dangerous to diagnose by means of needle biopsy because of malignant cell implantation. We recommend that firstly the surgical treatment should be carried out for malignant mesothelioma, which needs extended resection for preventing its recurrence.

[Anesthetic management of a neonate with esophageal atresia with double tracheoesophageal fistulae]

We reported the anesthetic management of a 1-day-old female neonate (2,110 gm) with esophageal atresia combined with double tracheoesophageal fistulae, which is classified as Gross type D. Though Gross type C was suspected preoperatively, the proximal fistula was found coincidentally during the preparation of the upper pouch. Because, for one thing, the origin of the proximal fistula was close to the end of the upper pouch (1cm), and for another, the distance between the both fistulae was short (1cm). As for the proximal fistula, it was 2 mm in diameter, and it was easily sealed with the side of the endotracheal tube. No other respiratory managements were needed except frequent suctionings of copious intratracheal secretions. On the other hand, the distal fistula, 10 mm in diameter, caused hypercapnea due to hypoventilation before gastrostomy. It was so big that it is easily intubated. This type of tracheoesophageal fistula is extraordinarily rare and its proximal fistula is difficult to find before, during, and even after operation. The missing of the proximal fistula often provokes severe respiratory infections and furthermore, sepsis postoperatively. It is concluded that in all the cases of tracheoesophageal fistula, the existence of the proximal fistula should be considered without fail and managed accordingly. To diagnose correctly, the use of preoperative bronchofiberscopy is also recommended.

[Serum catecholamine concentrations and hemodynamics during operations on 23 children with neuroblastoma]

The purpose of the present report is to reveal the relation between hemodynamic changes and serum catecholamine concentrations during operation of 23 neuroblastoma patients. The patients were aged from 6 months to 7 years (mean 1.2 year), and 20 patients (86%) were under 1 year of age. All the patients were in early stage of tumor development because they were diagnosed as neuroblastoma mainly by mass screening test for VMA and HVA in urine utilizing HPLC. This urinary mass screening test for infants is performed routinely in Japan. Operative manipulation of tumor provoked the significant elevation of blood pressure, and the increasing tendency of heart rate and rectal temperature. The mean concentrations of three kinds of serum catecholamine, epinephrine, norepinephrine and dopamine, were all very high during manipulation of tumor. Especially, the norepinephrine concentration was 90.2 times higher than the preoperative value. The children who showed high blood pressure, over 70% of the control level, showed high urinary VMA and VMA/HVA ratio preoperatively and a high norepinephrine secretion during operation. We conclude that for the anesthetic management of neuroblastoma, it is necessary to control the elevation of blood pressure even in small children, especially in the patients who have showed high values of urinary VMA and VMA/HVA ratio preoperatively.

[The severity of dementia and brainstem auditory evoked potentials--peak latency and interpeak latency]

We have examined the correlation of dementia severity and brainstem auditory evoked potentials. The subjects were 80 patients with dementia (20 males, 60 females) whose mean age was 80.7 years. Normal controls were 9 elderly subjects (2 males, 7 females) whose mean age was 80.4 years. The following parameters were measured: peak latencies (I, III and V), interpeak latencies (I-III, III-V and I-V) and interaural latency differences (V PLDs and I-V IPLDs). As for clinical items and sex differences; (1) There were sex differences recognized between peak latency of III and V, interpeak latency of III-V and I-V. (2) There was a significant difference in interaural differences of V PL Ds between vascular dementia and degenerative dementia (dementia of the Alzheimer's type and Parkinson's disease). Duration of illness had no correlation with latencies of BAEPs. Dividing the patients into three groups according to the severity of dementia which are mild, moderate and severe, (3) peak latency of III, V and interpeak latency of I-III, III-V, I-V and interaural latency differences of V PL Ds prolonged significantly with the increasing severity of dementia. From these results, it is suggested that brainstem dysfunction progresses with the increasing severity of the dementia.

Population study on the adipose tissue distribution in Japanese women born in 1948

We examined the relationship between body fat distribution and glucose metabolism and sex hormones in Japanese premenopausal women born in 1948. 1. There was a significant positive correlation shown between the waist circumference or skinfolds of the upper body, and the fasting insulin and C-peptide levels. 2. A positive correlation was seen between W2-3/H, and both insulin (r = 0.29, 0.30, P less than 0.05) and C-peptide levels (r = 0.40, 0.33, P less than 0.01, 0.05). 3. A significant negative correlation was seen between the SHBG level, and BMI (r = -0.39, p less than 0.01), W3/H (r = -0.46, P, 0.01), insulin (r = -0.28, P less than 0.05), and C-peptide (r = -0.46, P less than 0.01). 4. A significant negative correlation was seen between SHBG and W3/H (r = -0.31, P less than 0.05) after adjustment for BMI. These results suggest that the association of body fat distribution and glucose metabolism and androgeneity even if taking account of BMI, exists in non-obese women.

Adverse effects of obesity on lipid and lipoprotein levels in the patients with non-insulin dependent diabetes in the young

We studied the association of obesity with serum lipid and lipoprotein concentrations in 117 patients (62 males and 55 females) with NIDDY and in 40 nondiabetic control subjects (21 males and 19 females). Obesity at a young age was related to increased lipid and lipoprotein levels both in the patients with NIDDM and the control group. Moreover, low HDL-c levels were aggravated by diabetic status only in males. The BMI and fasting insulin level had a statistically significant correlation with the TG and HDL-c level and various atherogenic factors. Therefore, it is suggested that the lipid abnormalities seen in obesity may be associated with hyperinsulinemia. We conclude that obesity in adolescence leads to aberrations of the serum lipid and lipoprotein levels, particularly in obese males with NIDDY.