Liraglutide administration in type 2 diabetic patients who either received no previous treatment or were treated with an oral hypoglycemic agent showed greater efficacy than that in patients switching from insulin

Aims/Introduction

Liraglutide, a glucagon‐like peptide‐1 receptor agonist, is expected to provide a new treatment option for diabetes. However, the suitable timing of liraglutide administration in type 2 diabetic patients has not yet been clarified.

Materials and Methods

We reviewed type 2 diabetic patients (n = 155) who visited the Osaka Red Cross Hospital for glycemic control, with administration of liraglutide at a dose of 0.6 mg (average glycated hemoglobin [HbA_1c] level, 8.7 ± 0.1%). The effect of liraglutide based on the pretreatment status was compared. We also analyzed the background factors of both a successful and failed group of patients who switched to liraglutide from insulin.

Results

An improvement in blood glucose levels was confirmed in 122 of 155 patients. During the 4‐month observation period, the improvement in HbA_1c levels was significantly greater in the group of drug‐naïve/previous oral hypoglycemic agent (9.1 ± 0.2 to 7.2 ± 0.2%) than that in the group switching from insulin (8.6 ± 0.2 to 7.8 ± 0.2%). In addition, C‐peptide immunoreactivity levels (fasting > 2.2 ng/mL; delta >1.6 ng/mL; urine > 70 μg/day), younger age and a smaller number of insulin units used per day were considered important when deciding on switching to liraglutide from insulin.

Conclusions

Liraglutide was more effective in patients who had not been treated previously or received oral hypoglycemic agents than in patients switching from insulin. With respect to switching to liraglutide from insulin, the most important factors to be considered were C‐peptide immunoreactivity levels, age, and the number of insulin units used per day.

Diabetic ketoacidosis accompanied by hypothermia: a case report

Diabetic ketoacidosis (DKA) is an acute, life-threatening complication of diabetes mellitus and is caused by insulin insufficiency. Hypothermia is defined as a core temperature of less than 35°C and is sometimes accompanied by DKA. We report two patients with diabetes who were admitted for DKA accompanied by hypothermia.

Estimation of Duration of Symptoms in Fulminant Type 1 Diabetes Mellitus Using HbA1c or Glycated Albumin

Fulminant type 1 diabetes mellitus (FT1DM) develops as a result of very rapid and almost complete destruction of pancreatic β cells. Because of an abrupt increase in plasma glucose, HbA_1c and glycated albumin (GA) might increase along with duration of symptoms in FT1DM patients. We attempted to devise a formula to estimate duration of symptoms based on the increased levels in HbA_1c or GA. Four patients who developed FT1DM during the course of type 2 diabetes mellitus and in whom HbA_1c was measured before onset were investigated in this study. The percents of the estimated duration of symptoms calculated from HbA_1c (four patients) and GA (two patients) to the actual duration were 137 ± 88% and 122%, respectively. In FT1DM patients in whom HbA_1c and/or GA before onset and at the time of ketoacidosis are measured, duration of symptoms might be estimated with using the increased levels in HbA_1c or GA.

Distal renal tubular acidosis that became exacerbated by proton pump inhibitor use

Acid-base imbalances and electrolyte disorders induced by proton pump inhibitors (PPIs) are extremely rare. However, under certain conditions, PPIs may cause metabolic acidosis or hypokalemia, probably due to an inhibitory action on the proton pump that contributes to H(+) and K(+) homeostasis in the kidney. We herein present a case of marked hypokalemia accompanied by distal renal tubular acidosis in which a PPI appeared to contribute to the pathophysiology of metabolic acidosis.

[Management of quadruple valves for severe infective endocarditis; report of a case]

A 74-year-old man had pustulant bilateral arthritis complicated with sepsis and disseminated intravascular coagulation (DIC). Microbiologic study of blood sample showed Streptococcus and methicillin resistant Staphylococcus aureus (MRSA). He was complicated with postulant diskitis since then. Medical treatment for DIC and administration of antibiotics were performed. Preoperative echocardiography revealed massive aortic regurgitation and vegetation of aortic valve, moderate pulmonary regurgitation and vegetation of pulmonary valve, massive mitral regurgitation, massive tricuspid regurgitation. He was diagnosed as infective quadruple valve endocarditis. He received aortic valve replacement, pulmonary valve replacement, mitral valve repair and tricuspid valve repair. Postoperative echocardiography showed satisfactory function of bioprosthesis. Postoperative course was uneventful.

A case of hepatitis C-associated osteosclerosis in an elderly Japanese man

Hepatitis C-Associated Osteosclerosis (HCAO) is characterized by a marked increase in bone mass with deep bone pain. Since 1992, eleven cases of HCAO have been reported. This report describes an elderly Japanese man with HCAO, whose clinical course we followed for 3 years. A 68-year-old man developed pain in both pretibial regions in June 2000, and he had frequent episodic loss of muscular strength in his hands. He had recieved blood transfusion for a bleeding ulcer 43 years before and was seropositive for hepatitis C virus. His serum alkaline phosphatase (ALP) level was markedly increased, while his serum calcium was slightly decreased and serum phosphate was normal. Skeletal radiographs of the lower extremities showed a progressive increase in skeletal density, but did not show any apparent deformity. Administration of nonsteroidal anti-inflammatory drugs led to a reduction in bone pain. Treatment with vitamin D3 and calcium decreased the number of episodes of sudden muscular weakness and maintained serum calcium within the normal range. Three years after the onset of the disease, bone mineral density of his lumbar vertebrae and left hip rose from 0.963 g/cm2 to 1.096 g/cm2, and from 0.938 g/cm2 to 1.383 g/cm2, respectively. His serum ALP level decreased from 2889 to 277 IU/L (normal range: 104-338) and serum calcium normalized. These findings were accompanied by a decrease in bone pain. This case and previous reports suggest that the skeletal tissue of this disease appears to be of good quality.

[Patient-prosthesis mismatch after aortic valve replacement; tolerable lower limit of indexed effective orifice area]

This study was aimed at determining the tolerable lower limit of the indexed effective orifice area (EOAI) to prevent patient-prosthesis mismatch (PPM). Echocardiography was performed in 87 consecutive patients who underwent aortic valve replacement (AVR). EOAI was estimated for each type and size of prosthesis and used to define PPM as moderate if >0.65 cm2/ m2 and < or = 0.85 cm2/m2, and severe if < or = 0.65 cm/m2. Aortic valve pressure gradients, left ventricular dimensions, and outcome (in-hospital and 1-year) were analyzed in the presence or absence of abnormal gradients (> or = 40 mmHg) to assess the influence of a small valve (19 mm or less labeled size). Severe PPM was found in 23% of all patients, and 50% of the severe PPM patients had an abnormal gradient. There was 1 death and 1 brain damage from ventricular fibrillation because of severe PPM in the abnormal gradient group with a small valve. In PPM patients with a small valve, EOAI (0.61 +/- 0.04 vs 0.69 +/- 0.07) and preoperative interventricular septal thickness (IVST : 16.4 +/- 2.6 mm vs 13.5 +/- 1.5 mm) were significantly different between abnormal and normal gradient groups. An EOAI > or = 0.69 appeared to be tolerable in patients with a lower level of hypertrophy (IVST < 16 mm).

A rare case of shunt malfunction attributable to a broken Codman-Hakim programmable shunt valve after a blow to the head

We report a rare case of shunt malfunction resulting from breakage of the Codman-Hakim programmable shunt valve system following a blow to the head. Originally, the patient had suffered intraventricular hemorrhage a month after birth; ventriculoperitoneal shunt was performed at 7 months. After that, the shunt valve functioned well for 7 years. The patient presented with headaches after receiving a blow behind the right ear. The headache became exacerbated with activity and improved with rest. Damage to the shunt valve was identified during surgery, with a crack at the top of the valve housing. Symptoms resolved following a change of the complete shunt system. The possibility of damage to the shunt valve following a blow should be considered in shunt patients presenting with headaches.

[Secondary abnormal development of the bronchial artery: report of a case]

A 65-year-old man was admitted to our hospital because of massive hemoptysis. The patient had suffered from pneumonia since 1999, but he had refused to undertake further examinations. In 2002, the patient was transferred to our emergency room because of massive hemoptysis. Following endotracheal intubation, the patient underwent bronchial artery embolization. The X-ray and computed tomography (CT) films on admission revealed localized bronchiectasis in the left upper lung. Bronchoscopic findings revealed massive bleeding from the left upper bronchus. Bronchial arteriography of the left bronchial artery showed peripherally hypervascular finding in the left upper lobe. A segmentectomy of the left upper division was performed as a radical therapy for localized lesions with massive hemoptysis. The pathological diagnosis was secondary abnormal development of the bronchial artery. We speculated that massive hemoptysis had occurred probably due to infection in the focus.

[A case of free-floating ball thrombus in left atrium with mitral stenosis]

We report a rare case of free-floating ball thrombus in the left atrium with mitral stenosis. The patient was 71-year-old woman who admitted to the local hospital for transient ischemic attack. Electrocardiography showed atrial fibrillation and an echocardiogram examination revealed free-floating ball thrombus in the left atrium with mitral stenosis. She was transferred to our hospital for emergency open heart operation. After removal of the ball thrombus, mitral valve replacement and modified MAZE procedure were successfully performed. The size of the ball thrombus was 40 x 30 x 33 mm and weighed 20 g. Postoperative course was uneventful.

Age changes of neuromuscular junctions in the extensor digitorum longus muscle of spontaneous thymoma BUF/Mna rats. A scanning and transmission electron microscopic study

BUF/Mna rats spontaneously develop thymomas and cause muscle weakness of hind legs at an advanced age. This rat strain has been recognized as a suitable animal model for human myasthenia gravis or related myopathies. To characterize the structural changes of neuromuscular junctions (NMJs) in BUF/Mna rats, subneural apparatuses (SNAs) of extensor digitorum longus muscles of young-adult (4-month-old) and aged (22- to 25-month-old) male rats were examined using scanning and transmission electron microscopy. The SNAs of NMJs in young rats consist of complex labyrinthine gutters with numerous slit-like junctional folds. SNAs in aged BUF/Mna rats, however, are characterized by: (1) a group of cup-like depressions with very wide slit-like junctional folds in relatively large muscle fibers (the major type), (2) the presence of slit-like folds on the flat sarcoplasm outside the cup-like depressions or on the protruded sarcoplasm, and (3) winding gutters or a small number of round depressions with poorly developed synaptic folds in small and medium-sized muscle fibers (the minor type). Since similar structural changes have been reported in dystrophic mice or normally aged rats, it is suggested that both the slowly progressing muscle atrophy and age-dependent turnover of muscle fibers may occur in the aged BUF/Mna rats.

[Malignant peripheral nerve sheath tumor with divergent cartilage differentiation from the acoustic nerve: case report]

Malignant peripheral nerve sheath tumors(MPNSTs) of the acoustic nerve are very rare. Only seven cases of MPNST arising from the acoustic nerve have been reported. The authors present a case of MPNST with divergent cartilage and melanotic differentiation of the acoustic nerve. The patient was a 69 year old man admitted to our neurosurgical service in January 1999 complaining of left facial nerve palsy and hearing difficulty of his left ear. The initial CT showed a tumor at the left cerebellopontine angle region. On MRI the tumor was depicted as low intensity on T 1-weighted image and high intensity on T 2-weighted image, the mass was heterogeneously enhanced after administration of Gd-DTPA. The partial removal of the tumor was performed in January 1999. He was discharged February 1999. But he was admitted again because of progressive cerebellar ataxia. MRI showed the rapid regrowth of the residual tumor. In March 1999, complete removal of the tumor was performed. Histopathological analysis revealed a malignant spindle cell neoplasm with divergent cartilage and melanotic differentiation. We review the relevant literature concerning MPNST of the acoustic nerve and discuss the clinical features of malignant eighth cranial nerve tumor.

[Clinical evaluation of granisetron hydrochloride for nausea and vomiting induced by oral anticancer drugs]

We investigated the antiemetic effect, safety and usefulness of granisetron hydrochloride tablets on nausea and vomiting induced by oral anticancer drugs used in chemotherapy for gastric cancer and colorectal cancer. In the present trial, oral administration of granisetron hydrochloride was performed during 5 days after nausea or vomiting. 1) Clinically, the effective rate of granisetron hydrochloride (the percentage of cases in which the drug was assessed as "Remarkably effective" or "Effective") was more than 75% on each day of administration. There were no adverse events or abnormal laboratory tests. 2) In terms of usefulness, granisetron hydrochloride was rated "Extremely useful" or "Useful" in 17 out of 23 cases (78.2%). The above results have shown that granisetron hydrochloride tablets, administrated orally once daily at a dose of 2 mg, have an excellent antiemetic effect, and that this is a safe and useful drug.

Stat6 activation and Th2 cell differentiation [correction of proliferation] driven by CD28 [correction of CD28 signals]

CD28 engagement by specific monoclonal antibody (mAb) or binding of the natural ligands, CD80 and CD86, induces tyrosine phosphorylation of CD28, which in turn recruits and activates the signal transducer and activator of transcription 6 (Stat6). The Stat6 association with CD28 is specifically induced by CD80 or CD86 ligand binding and is not dependent upon the secretion of IL-4 or IL-13. Activated Stat6 translocates to the nucleus and binds to a Stat6-responsive element on the human IL-4 promoter. CD28 ligation induces Stat6-dependent transcriptional activation of a reporter gene under the control of a multimerized Stat6-responsive element fused to an essential part of the IL-4 promoter. Primary stimulation of naive CD4(+) T cells with anti-CD28 mAb in the presence of IL-2, but in the absence of anti-CD3 mAb induces preferential production of IL-4 and expression of CCR4 mRNA after secondary stimulation with anti-CD3, indicating the preferential differentiation of Th2 cells. These findings suggest that initial IL-4 production required for commitment of naive T cells toward Th2 cells may be provided in response to signals delivered via CD28 by antigen-presenting cells.

Morphological changes of capillaries in the rat soleus muscle following experimental tenotomy

We examined the structural changes of capillaries in the rat soleus muscle 4, 7, 14, and 35 days after experimental limb tenotomy. In the soleus muscles after tenotomy, muscle fibres degenerated and some of them were destroyed; the muscle did not seem to recover until the 35th day. On the 14th day, some small muscle fibres, probably regenerating muscle fibres, started forming within the basal-lamina tube and remained after necrosis of a pre-existing muscle fibre. Most capillaries at each stage were of the continuous type. However, about 10% of the capillaries around degenerated muscle fibres at days 4, 7 and 14 consisted of endothelial cells with a small number of fenestrae bridged by a single-layered diaphragm. On the 14th day, capillaries around small regenerating muscle fibres also often had a small number of fenestrations. Even on the 35th day, capillaries occasionally had fenestrations. Additionally, some of the fenestrated capillaries formed small pores at the fenestrated portion of the endothelial cells. The untreated muscles contained only continuous capillaries. These findings suggest that fenestrations in the endothelial cells may occur in intramuscular capillaries not only around degenerated muscle fibres but also around regenerating muscle fibres after tenotomy.

[Myelopathy caused by tentorial dural arteriovenous fistula: a rare case report]

A 51-year-old man with myelopathy due to intracranial dural arteriovenous fistula (dural AVF) is reported. At age 46, the patient experienced subarachnoid hemorrhage caused by rupture of the dural AVF and underwent embolization of the lesion at another hospital. At this time, the patient complained of numbness in his legs and showed paraplegic gait disturbance. MRI scan revealed swelling of the cervical spinal cord. Cerebral angiograms demonstrated the recurrence of tentorial dural AVF fed by bilateral meningohypopheseal trunks and the right posterior inferior cerebellar artery. Arteriovenous shunt (AV shunt) flow was drained into the anterior spinal vein. It seemed that the swelling of the spinal cord and myelopathy was caused by venous hypertension of spinal veins. After surgical interruption of the right petrosal vein which connected dAVF with cerebellar veins, AV shunt was obliterated successfully. Postoperative cerebral angiograms showed disappearance of dural AVF. The patient became ambulant and his cervical spinal cord appeared normal on the postoperative MRI scan. Surgical interruption of the draining vein was simple, effective and essential treatment.

Postoperative brain complications following retrograde cerebral perfusion

This study was undertaken to investigate the neurological risk factors associated with the retrograde cerebral perfusion (RCP) technique, by examining the relationship between intraoperative parameters and post-operative brain complications. A total of 12 patients who underwent surgery for thoracic aortic aneurysms using the RCP technique were included in this study. Profound hypothermia was induced through cardiopulmonary bypass which was established with a femoral arterial cannula and bicaval return. During RCP, a venous drainage cannula from the superior vena cava (SVC) was switched over to the arterial return circuit, and oxygenated blood was retrogradely infused through the SVC. The perfusion flow rate was maintained at 273 +/- 113 ml/min and the SVC pressure was maintained at 15 +/- 6 mmHg. The RCP time was 68 +/- 27 min with a range of 27-130 min, and the lowest rectal temperature was 16 +/- 1 degrees C. The total elapsed time until emergence from anesthesia after the operation was 12 +/- 6 h. The operation time correlated with the awakening time (r = 0.729, P = 0.0088). Longer RCP times of up to 101 and 130 min tended to result in post-operative brain damage. The lowest rectal temperature also correlated with the awakening time (r = 0.697, P = 0.0149), and an inverse correlation between the SVC pressure and the awakening time was observed (r = -0. 727, P = 0.0091). These findings demonstrate the importance of reducing both the RCP and operation times to decrease the incidence of brain damage. If carried out under optimal conditions, including perfusion pressure and brain temperature, RCP could be marginally prolonged safely without causing major neurological complications.

[Supratentorial ectopic ependymoma: a case report]

Ependymomas usually arise from the ventricular surface and approximately two-thirds of them are infratentorial. We present an unusual case of supratentorial ependymoma located in the parietal parenchyma and exhibiting no continuity with the ventricular system. On March 30, 1998, a 63-year-old woman was admitted to our neurosurgical service because of a sudden consciousness loss attack two weeks before. On admission, neurological examination revealed no abnormal findings. Computerized tomography (CT) revealed a mass lesion of the parietal lobe which was enhanced homogeneously. Magnetic resonance imaging (MRI) also showed the mass of the parietal lobe which was iso-intense on T1-weighted images, iso and high intense on T2-weighted images and homogeneously enhanced by administration of Gd-DTPA. In the angiography, left carotid angiograms showed a tumor stain. On February 26, 1998, total removal of the tumor was performed using stereotactic craniotomy with neuronavigator and intraoperative echography. After surgery, focal radiation therapy (56Gy) was carried out. The pathological diagnosis was cellular ependymoma with partial clear cell components. Several kinds of tumor may occur in the cerebral parenchyma. We conclude, however, that ependymoma has to be included in the differential diagnosis when the tumor location is distant from the ventricles.

[Efficacy of adjuvant hepatic arterial infusion chemotherapy following resection of colorectal liver metastases]

PURPOSE

The aim of this study is to evaluate the effect of adjuvant hepatic arterial infusion chemotherapy (HAIC) following liver resection on the frequency of residual liver recurrence and overall survival.

PATIENTS AND METHODS

During 1992 to 1997, 84 patients with liver metastasis from colorectal cancer resected curatively had undergone adjuvant HAIC. The regimen of the HAIC is 1,500 mg of 5-FU by 24-hr continuous infusion once a week for eight weeks. 37 cases in the HAIC group, including patients given more than 7 g of 5-FU, were compared with the control group.

RESULT

The cumulative 5-year liver recurrence-free ratios were 72.6% in the HAIC group and 29.8% in the control group (p = 0.0005). The cumulative 5-year survival ratios were 61.4% in the HAIC group and 28.0% in the control group (p = 0.0069). Multivariate analysis revealed that more than 5 mm of surgical margin and adjuvant HAIC significantly decreased the risk of recurrences in residual liver.

CONCLUSION

Adjuvant HAIC is an effective procedure to prevent recurrence in residual liver and improve the prognosis of patients with liver metastasis from colorectal cancer.

Augmentation of CTLA-4 expression by wortmannin: involvement of lysosomal sorting properties of CTLA-4

CTLA-4 (CD152) is transiently induced on the cell surface of activated T cells and expression is limited at a low level. In this study, we investigated the possibility that phosphatidylinositol 3 kinase (PI 3-K) and other related PI kinases associated with the cytoplasmic domain of CTLA-4 are involved in intracellular trafficking and sorting of CTLA-4 protein. Treatment with micromolar concentrations of wortmannin (WN) for >4 h enhanced both cell-surface and intracellular CTLA-4 without affecting its transcriptional activities in a murine mastocytoma cell line transfected with the human CTLA-4 gene and normal activated CD4(+) T cells. However, a more specific PI 3-K inhibitor, LY294002, failed to affect CTLA-4 expression, indicating that the action of WN is independent of conventional PI 3-K activities. WN down-regulated specific association of CTLA-4 with adaptor proteins and its endocytosis. The fact that lysosomotropic agents, ammonium chloride and monensin, enhanced CTLA-4 expression suggests that WN may also block lysosomal sorting and consequent degradation of CTLA-4. Co-localization of CTLA-4 and lysosome-associated membrane protein-1 detected by immunofluorescence microscopy indicates the actual lysosomal sorting of CTLA-4. Our data suggest the existence of WN-sensitive enzymes, which promote lysosomal sorting of CTLA-4. In addition to rapid endocytosis by clathrin-associated adaptor complex, a prompt sorting of CTLA-4 to lysosomes may be one of the regulatory mechanisms for managing CTLA-4 signals in intracellular trafficking pathways.

Autoantibodies to T cell costimulatory molecules in systemic autoimmune diseases

To determine whether antilymphocyte Abs to T cell costimulatory molecules are generated in patients with autoimmune diseases and, if they exist, to clarify the mechanism of their production and pathological roles, we investigated the presence of autoantibodies to CTLA-4 (CD152), CD28, B7-1 (CD80), and B7-2 (CD86) in serum samples obtained from patients with various autoimmune diseases and from normal subjects using recombinant fusion proteins. In ELISAs, anti-CD28, anti-B7-1, and anti-B7-2 Abs were rarely seen, whereas anti-CTLA-4 Abs were detected in 8.2% of the patients with systemic lupus erythematosus, 18.8% of those with rheumatoid arthritis, 3.1% of those with systemic sclerosis, 31.8% of those with Behçet's disease, 13.3% of those with Sjögren's syndrome, and 0% of healthy donors. This reactivity was confirmed by immunoblotting. More importantly, the purified anti-CTLA-4 Abs reacted with CTLA-4 expressed on P815 cells by flow cytometry. In addition, we found at least three epitopes on the CTLA-4 molecule. Furthermore, among the patients with Behçet's disease, uveitis was seen significantly less frequently in the anti-CTLA-4 Ab-positive patients. Taken collectively, these data indicate that anti-CTLA-4 autoantibodies are generated in systemic autoimmune diseases by an Ag-driven mechanism and may modulate the immune response in vivo by binding to CTLA-4 on T cells.

Outcomes of surgical treatment for cervical myelopathy in patients more than 75 years of age

STUDY DESIGN

Retrospective study on the results of surgical treatment of compressive cervical myelopathy in patients more than 75 years of age.

OBJECTIVES

To investigate clinical features and surgical outcomes of compressive cervical myelopathy in aged patients and to discuss the role of surgical treatment.

SUMMARY OF BACKGROUND DATA

There are few data focused on the outcomes of surgery in patients with cervical myelopathy who are more than 75 years of age.

METHODS

Seventeen patients with compressive cervical myelopathy who underwent surgery were reviewed. The average age at the time of surgery was 77.2 years. Posterior decompression in 15 patients and anterior decompression in 2 patients were performed. Neurologic deficits before and after surgery were assessed using a scoring system proposed by the Japanese Orthopaedic Association (JOA score). Independence of daily living was evaluated. Radiologic features were examined with radiographs and magnetic resonance imaging. Clinical results were compared with those of patients less than 65 years old as a control.

RESULTS

The preoperative mean JOA score was 6.1, the postoperative maximum JOA scores averaged 11.4, and the recovery rate was 48.4%. These were significantly inferior to scores in those less than 65 years of age. All seven of the patients who could not walk even with aids before surgery became independent in daily activities after surgery. At the final follow-up, the mean JOA score had decreased to 10.7 and the recovery rate to 39.1%. Five of nine patients whose follow-up periods were more than 5 years showed decreases in JOA score, although all patients were still ambulatory.

CONCLUSIONS

Surgical decompression for cervical myelopathy appears to be beneficial, even in patients more than 75 years of age, in improving neurologic function and ability to engage in activities of daily living.