Effect of single oral administration of nilvadipine on cerebral blood flow in chronic cerebral infarction

The effect of nilvadipine, a newly developed calcium antagonist, on regional cerebral blood flow (rCBF) was investigated in 7 patients with chronic cerebral infarction. rCBF was measured by the 133Xenon inhalation method. Patients were given a single dose of 4 mg of nilvadipine after the first measurement of rCBF, and the second measurement was done one hour after the administration. All patients had hemiparesis and 2 of them had mild to moderate mental deterioration, but all patients could walk to the outpatient clinic by themselves.

RESULTS

(1) rCBF of the affected side significantly increased by 22.7% after single oral administration of nilvadipine (p < 0.05). The increase of rCBF was significantly marked in frontal regions of the affected hemispheres. (2) No significant changes in blood pressure or end tidal partial pressure of carbon dioxide were observed during the examination. These results indicate that nilvadipine has a potent selective vasodilatory action on the cerebral arteries in patients with cerebral infarction.

[A case of recurrent cerebral hemorrhage considered to be cerebral amyloid angiopathy by cerebrospinal fluid examination]

A 73-year-old man was admitted with gait disturbance and dysarthria. He showed right-side cerebellar ataxia. Computed tomography of brain showed left thalamic bleeding. Nine months later, he was admitted again because of seizure and consciousness disturbance. He had a history of diabetes mellitus and gout for five years, but no hypertension. On physical examination the lungs and heart were normal. On neurological examination, he showed stupor,pupils and eye position were normal. He showed right hemiparesis and urinary incontinence. The deep tendon reflexes were (+) at the upper limbs and (2+) at the right knee and ankle. Blood pressure was 162/88 mmHg and glucose was 275 mg/dl. Other laboratory data were normal. Brain CT showed hemorrhage of the left frontal lobe. The cystatin C level in cerebrospinal fluid was 68 ng/ml. Therefore we suspected cystatin C deposit amyloid angiopathy. In this case, thalamic hemorrhage was initially thought to be amyloid angiopathy. In cases of cerebral hemorrhage in the elderly without hypertension, we must be considered amyloid angiopathy.

Preliminary criteria for classification of adult Still's disease

We have attempted to design classification criteria for adult Still's disease by analyzing the data obtained through a multicenter survey of 90 Japanese patients with this disease and of 267 control patients. The proposed criteria consisted of fever, arthralgia, typical rash, and leukocytosis as major, and sore throat, lymphadenopathy and/or splenomegaly, liver dysfunction, and the absence of rheumatoid factor and antinuclear antibody as minor criteria. Requiring 5 or more criteria including 2 or more major criteria yielded 96.2% sensitivity and 92.1% specificity. However, an exclusion process will be needed for an accurate classification, since this disease is relatively rare.

[Studies on clinical subsets and severity of systemic lupus erythematosus based on a 1987 questionnaire conducted in Japan--clinical analysis of the outcome and treatments in clinical subsets]

A 1987 questionnaire sponsored by the Health and Welfare Ministry concerning the clinical subsets and severity of systemic lupus erythematosus (SLE) was distributed to 93 medial facilities. A clinical analysis of the outcome and treatments was accomplished on one thousand six hundred and fourteen SLE patients fulfilling ARA criteria. The outcome was evaluated into 6 categories, namely; complete remission, incomplete remission, no change, gradual worsening, rapid worsening and unknown. Treatments included (1) anti-inflammatory drugs, (2) initial dose of prednisolone (PSL) below 29 mg/day, (3) initial dose of PSL from 30 to 59 mg/day, (4) initial dose of PSL above 60 mg/day, (5) pulse therapy, (6) immunosuppressants, (7) plasmapheresis, and (8) hemodialysis. Statistical significances were determined with ridit analysis. The severity of the disease for 1,614 SLE patients was evaluated by the judgement of each medical facility independently, separating it into 3 grades. As a result, 16.8% was evaluated as severe, 54.6% was evaluated as moderate, and 28.6% was evaluated as mild. Clinical subsets were divided into 3 categories according to the outcome; (1) those with high complete remission rates (serositis, convulsion, oral ulcers, unconsciousness, hemolytic anemia and so on), (2) those with high incomplete remission rates (lupus nephritis, digital gangrene, hypertension, peripheral neuropathy, erythema, Raynaud's phenomenon and so on), and (3) those with high rates of no change or worsening (aseptic bone necrosis, pulmonary hypertension, pneumonitis, chronic renal failure and so on). SLE patients with persistent proteinuria below 3.4 g/day, pulmonary hypertension, or pneumonitis treated with large doses of PSL such as an initial dose of PSL above 60 mg/day and/or pulse therapy had a significantly higher remission rate than those treated with small dosages of PSL. Hereafter, the establishment of modes of treatments for increasing the remission rates of intractable clinical subsets in highly desired.

The effects of FK-506 and cyclosporin A on the proliferation of PHA-stimulated T cells in response to IL-2, IL-4 or IL-6

Stimulated by PHA, the T cells responded well to exogenous IL-2, IL-4 or IL-6, but the responses were inhibited by FK-506 or cyclosporin A (Cs A). In contrast, when stimulated by PMA, the T cells responded to IL-2 and IL-4, but not to IL-6 and the responses were not inhibited by FK-506 and Cs A. Kinetic studies showed that FK-506 and Cs A had no inhibitory effects on T cell proliferation in response to IL-2 and IL-4 after the resting T cells were pulsed with PHA alone for a certain time. However, the response of the PHA-pulsed T cells to IL-6 was still inhibited by FK-506 or Cs A, but the inhibitory effect gradually decreased as the time in which the PHA-pulsed T cells interacted with IL-6 was prolonged. In a control system, the proliferation of the T cells that were treated with FK-506 or Cs A for 3 h and washed 3 times was not inhibited when the T cells were stimulated with PHA in combination with either IL-2, IL-4 or IL-6. Our data suggest that FK-506 and Cs A interfere with the early steps of T cell proliferation after stimulation of PHA, but not PMA. It is likely that the two drugs inhibit the expression of lymphokine receptors, by interfering Ca(2+)-related signals and that IL-6 induces T cell proliferation in a different way than IL-2 and IL-4, which are FK-506- and Cs A-sensitive.

Characterization of N-terminal amino acid sequence of monoclonal nonspecific suppressor factor

Monoclonal nonspecific suppressor factor (MNSF), a product of a murine T cell hybridoma, suppresses the antibody response to lipopolysaccharide. In an attempt to clarify the N-terminal sequence, MNSF was prepared and purified by affinity chromatography with the use of an anti-MNSF monoclonal antibody (MO6), and reverse-phase high-pressure liquid chromatography. On the SDS-PAGE, the purified MNSF showed a single band with a molecular weight of 12,000. The N-terminal amino acid sequence of the protein was determined and showed no strong homology to any of the sequences of known biologically active proteins. However, the sequence revealed significant (60%) amino acid identity to transforming growth factor beta 2 (TGF beta 2).

IFN-gamma enhances the expression of cell surface receptors for monoclonal nonspecific suppressor factor

Monoclonal nonspecific suppressor factor (MNSF) is a lymphokine derived from a murine T cell hybridoma. The action of MNSF is mediated by specific cell-surface receptors. Since IFN-gamma alters the cellular response to MNSF (M. Nakamura, H. Ogawa, and T. Tsunematsu, J. Immunol. 138, 1799, 1987), we investigated whether IFN-gamma has an effect on the expression of MNSF receptor on target cells. IFN-gamma enhanced the expression of MNSF receptor on both MOPC-31C cells (a murine plasmacytoma line) and EL4 (a murine T lymphoma line). Incubation with IFN-gamma increased the number of specific MNSF-binding sites by about 50 to 90%, with no significant change in binding affinity. IFN-alpha and IFN-beta also increased MNSF binding, although the effect of the saturating amounts was lower than that seen with IFN-gamma. Maximal enhancement of receptor expression was observed after about 15 hr of incubation with IFN-gamma. No demonstrable change occurred in the kinetics of internalization of 125I-MNSF bound to MOPC-31C cells preincubated without or with IFN-gamma.

P300 event-related potentials correlated with cerebral blood flow in nondemented patients with lacunar infarction

We have studied the relationship between the P300 latency and regional cerebral blood flow (rCBF) in 25 nondemented patients who had lacunar infarctions in the territory of the deep perforating branches of the internal carotid artery system. A significant prolongation of the P300 latency with advancing age was observed. There was a negative correlation between the P300 latency and the rCBF. These results indicate that a combination of P300 latency and rCBF measurements might prove more sensitive in detecting mental decline than rCBF studies alone in nondemented patients with lacunar infarctions.

Impairment of lymphocyte function in patients with myelodysplastic syndrome and its correction by addition of Ca2+ ionophore and phorbol myristate acetate

T and B cell functions were evaluated in eight patients with myelodysplastic syndrome (MDS). We studied the response to stimulation with phytohemagglutinin, concanavalin A, and anti-CD3 monoclonal antibody (OKT3 mAb), and found impairment of response in T cells from MDS patients in comparison with age-matched controls. The decreased proliferative response was not restored by combining normal T cells with monocytes from MDS patients, or by using T cells from MDS patients together with normal monocytes. Furthermore, proliferative responses in the autologous and allogenic mixed lymphocyte reactions were significantly decreased in MDS patients. B cells from MDS patients incorporated significantly less tritiated thymidine than B cells from controls when stimulated with Staphylococcus aureus Cowan I (SAC), and SAC stimulation failed to cause efficient immunoglobulin production by MDS B cells. However, T cells from MDS patients reacted normally when stimulated by phorbol myristate acetate plus a Ca2+ ionophore (ionomycin). Abnormal lymphocyte function may contribute to the failure of hematopoietic regulation and may thus play an important role in the pathogenesis of MDS. The finding that the addition of specific signals allowed the stimulation pathway to function may have important therapeutic implications.

Diagnosis of cerebral amyloid angiopathy by enzyme-linked immunosorbent assay of cystatin C in cerebrospinal fluid

An abnormally low level of cystatin C in the cerebrospinal fluid is a diagnostic marker for the hereditary form of brain hemorrhage associated with amyloidosis that was first identified in Iceland. We developed an assay for cystatin C to use in the diagnosis of patients with cerebral amyloid angiopathy and brain hemorrhage. This test consists of a sandwich enzyme-linked immunosorbent assay using monoclonal mouse anticystatin C and polyclonal rabbit anticystatin C antibodies. The cystatin C level was assayed in cerebrospinal fluid samples from 29 patients with brain hemorrhage and 45 control patients with other neurological diseases. Fifteen patients with brain hemorrhage showed low cystatin C levels (less than or equal to 70 ng/ml) in a clinical setting in which the positive and negative findings were compatible with a diagnosis of cerebral amyloid angiopathy. Immunohistological examination of brain tissue obtained by biopsy from two of the 15 patients confirmed the diagnosis of cerebral amyloid angiopathy and identified the deposition of cystatin C and beta-protein. This enzyme-linked immunosorbent assay is simple to perform and may be useful for investigating patients suspected of having cerebral amyloid angiopathy with brain hemorrhage and the deposition of cystatin C.

[Carbohydrate auto-antigens in auto-immune hemolytic anemia]

Anti-erythrocyte antibodies which appear in the sera of patients with auto-immune hemolytic anemia frequently recognize carbohydrate auto-antigens. Most of cold agglutinins are known to recognize the Ii-antigens, and Donath-Landsteiner antibodies which appear in patients with paroxismal cold hemoglobinuria are almost exclusively directed to the P-antigen. These carbohydrate auto-antigens are strongly expressed in various tissues and organs other than erythrocytes, and behave as differentiation- or developmental-antigens, in both humans and mice. The study of nucleotide sequences of human and murine anti-Ii antibodies shows that these antibodies share a highly homologous antigen-binding site in their VH regions. These results indicate that the carbohydrate auto-antigens in autoimmune hemolytic anemia are evolutionally conserved developmental antigens, and suggest that the immunoglobulin genes which encode variable regions of the auto-antibodies directed to these antigens are also conserved evolutionally.

[The relationship between P300 latency and regional cerebral blood flow in patients with cerebral infarction in the territory of the deep perforators]

We studied the relationship between P300 latency and regional cerebral blood flow (rCBF) in nondemented patients with cerebral infarction. Subjects were 24 nondemented patients (mean age 64.1 years) who had a CT-proven infarct in the territory of the deep perforators of the internal carotid artery system and 53 controls (mean age 64.1 years). Prolongation of P300 latency with advancing age was observed in the both groups. There was no significant difference in P300 latency and rCBF between the two groups. There was a negative correlation between P300 latency and rCBF, especially in the bilateral fronto-parietal regions in the patient group. These results indicate that cognitive function assessed by P300 latency may be related to rCBF in the fronto-parietal region in the nondemented patients with lacunar infarctions.

Characterization of cell-surface receptors for monoclonal-nonspecific suppressor factor (MNSF)

Monoclonal-nonspecific suppressor factor (MNSF) is a lymphokine derived from murine T cell hybridoma. The target tissues are both LPS-stimulated B cells and Con A-stimulated T cells. Since the action of MNSF may be mediated by its binding to specific cell surface receptors, we characterized the mode of this binding. The purified MNSF was labeled with 125I, using the Bolton-Hunter reagent. The labeled MNSF bound specifically to a single class of receptor (300 receptors per cell) on mitogen-stimulated murine B cells or T cells with an affinity of 16 pM at 24 degrees C, in the presence of sodium azide. Competitive experiments showed that MNSF bound to the specific receptor and that the binding was not shared with IL2, IFN-gamma, and TNF. Various cell types were surveyed for the capacity to specifically bind 125I-MNSF. 125I-MNSF bound to MOPC-31C (a murine plasmacytoma line) and to EL4 (a murine T lymphoma line). The presence of specific binding correlates with the capacity of the cells to respond to MNSF. These data support the view that like other polypeptide hormones, the action of MNSF is mediated by specific cell surface membrane receptor protein. Identification of these receptors will provide insight into the apparently diverse activities of MNSF.

Adult Still's disease: a multicenter survey of Japanese patients

A comprehensive survey of Japanese patients with adult Still's disease was made by questionnaire which was sent to major institutions with rheumatology units in Japan. Of 146 cases from 32 institutions, 90 were judged to be definitely diagnosed as adult Still's disease. The major clinical features in these 90 patients consisted of high fever, polyarthralgia, rash, increased erythrocyte sedimentation rate, negative autoantibodies, leukocytosis, liver dysfunction, and hyperferritinemia. The incidence of several features showed significant differences between these cases and previous nonJapanese cases.

Frontal white matter lesions and dementia in lacunar infarction

We studied the associations of mental deterioration and blood pressure with severity and location of lesions in the cerebral white matter of 35 patients (27 men and eight women) aged 52-84 (mean 70.9) years with multiple lacunar infarcts; 21 had no dementia and 14 were demented. Using magnetic resonance imaging to evaluate lesion severity, we determined that demented patients had more severe lesions than nondemented patients; this difference was especially prominent for lesions in the frontal lobe (p less than 0.001). Score on the dementia rating scale of Hasegawa et al was negatively correlated with severity of the lesions in the frontal lobe. Blood pressure was positively correlated with the severity of white matter lesions. We show that severity of lesions in the white matter, especially in the frontal lobe, is correlated with mental deterioration of patients with multiple lacunar infarcts. Because uncontrolled hypertension is related to the severity of such lesions, careful selection of antihypertensive treatment is important in preventing both the cerebral lesions and the associated mental deterioration.

[An association of Shy-Drager syndrome with moyamoya disease--a case report]

A 58-year-old female was admitted to our hospital because of orthostatic syncope, and difficulty in urination and walking for 2 years. At age 35, she suffered from cerebral hemorrhage and was diagnosed as Moyamoya disease (MD). Neurological examination on admission revealed severe orthostatic syncope so that she could not stand. At that time, her blood pressure and heart rate were 104/74 mmHg and 78/min in supine position and 52/48 mmHg and 52/min in 60 degrees head-up position. She also had severe pollakisuria, cerebellar ataxia and dysarthria. Cranial nerves, motor strength and deep reflexes were normal. ECG, chest X-ray, and EEG were normal. Aschner, Czermak, and cold pressor tests revealed no response. Urodynamic study revealed autonomic bladder. MRI showed only enlarged fourth ventricle because of atrophy of the pons. Bilateral CAG revealed "Moyamoya" vessels in the cerebral basal regions. Cerebral blood flow (CBF) was measured by 133Xe inhalation method. Mean arterial blood pressure changed from 134 mmHg to 126 mmHg in 45 degrees head-up tilting and CBF decreased from 47.5 mg/100 g/min to 37 ml/100 g/min position. Though there was no relationship between SDS and MD, each one shows dysautoregulation of CBF, it is supposed that a severe orthostatic syncope attack was resulted from synergism of both effects.

Increased external carotid artery blood flow in headache patients induced by cilostazol. Preliminary communication

Cilostazol (6-[4-(1-cyclohexyl-1H-tetrazol-5-yl)butoxy]-3,4-dihydro-2 (1H)-quinolinone, OPC-13013) is an anti-platelet aggregating and vasodilating drug. But cilostazol is known to have a tendency to cause headache, which is thought to be due to the dilatation of the external carotid artery. In the present study the effect of cilostazol on the blood flow in the carotid arteries was established by the Doppler ultrasound technique. Twelve patients with cerebral infarction (mean age 66.3 years) were divided into two groups consisting of 9 patients (Group 1) who did not have headache during treatment with cilostazol and 3 patients (Group II) who complained of headache. The systolic peak frequency (PEAK) of the common and external carotid arteries was measured using a Doppler ultrasound device. The PEAK of the common and external carotid arteries were examined before and 4 weeks after oral administration of 200 mg/d, 100 mg twice a day, cilostazol. In Group I, the PEAK in bilateral common carotid arteries increased significantly after treatment with cilostazol, but the PEAK in bilateral external carotid arteries showed no significant change. In Group II, the PEAK in both common carotid arteries showed no significant change after treatment with cilostazol, but the PEAK in the right external carotid artery increased significantly.

[Diagnosis of cerebral amyloid angiopathy with cerebral hemorrhage by enzyme linked immunosorbent assay (ELISA) of cystatin C in the cerebrospinal fluid]

The lower level of cystatin C in cerebrospinal fluid (CSF) is one of the useful diagnostic markers of hereditary cerebral hemorrhage with amyloidosis in Iceland. We attempted to establish an assay to determine the level of cystatin C in CSF for diagnosis of CAA due to the deposition of cystatin C in CSF for diagnosis of CAA due to the deposition of cystatin C. We carried out the sandwich enzyme immunosorbent assay with the use of monoclonal mouse anti-cystatin C and polyclonal rabbit anti-cystatin C antibodies. CSF from nine cases of cerebral hemorrhage and fifty reference cases with other neurological diseases were examined. Four patients with cerebral hemorrhage showed a low level of cystatin C and clinical manifestations suggestive of CAA. Our study showed the feasibility of using ELISA for the diagnosis of cerebral amyloid angiopathy that causes cerebral hemorrhage with the deposition of cystatin C.

Pulmonary hypertension in connective tissue disease. Clinical analysis of sixty patients in multi-institutional study

Clinical features and prognosis of sixty patients with connective tissue disease accompanied by pulmonary hypertension (PH) (26 MCTD, 20 SLE, and 14 PSS) reported retrospectively by multi-institutions were compared. Though the obtained data were incomplete and lacking in uniformity, no significant difference in the clinical features among the three diseases were observed except high incidence of pulmonary fibrosis and low % VC in PSS and PH patients. Statistically significant difference, however, was observed between live and dead patients of three diseases gathered in post sternal pain, pulmonary diastolic murmur, right ventricular hypertrophy on ECG and mean pressure of pulmonary artery. Higher incidence of anti-nRNP antibody was observed in SLE with PH and PSS with PH patients than with the general population. A quicker occurrence of PH and shorter survival time were observed in MCTD patients with PH than in SLE and PSS patients with PH.

Effects of a novel immunosuppressive agent, FK506, on human B cell activation

We examined the effect of new immunosuppressive agent, FK506, on the human B cell function, in comparison with that of cyclosporin A (CyA) and tried to define the discrete activation step(s) which is selectively affected by FK506 and CyA. We used polyclonal B cell activators, Staphylococcus aureus Cowan I (SAC) and pokeweed mitogen (PWM). We found that (i) the initial B cell activation process by PWM, which is on the basis of T cell-dependent manner, is susceptible to the inhibitory effects of FK506 and CyA, while initial B cell activation on the basis of T cell-independent manner by SAC is resistant to these drugs; (ii) they also inhibit helper factor production by T cells; (iii) once they are activated, the B cells become resistant to inhibition by the drugs; and (iv) on an equimolar basis, FK506 exhibits 100-fold greater inhibitory activity than does CyA. Thus FK506 mainly interferes with interactions between T cells and other cells which are essential for B cell activation process, resulting in inhibition of B cell function.

Prevalence of Parkinson's disease in Izumo City, Japan

The prevalence of Parkinson's disease was studied in Izumo City, the Shimane prefecture having the largest population of the elderly in the country. The adult population of Izumo City (56,869 people over 20 years of age) were screened by means of questionnaires sent by mail and by other methods. A total of 66 people, 18 males and 48 females, were found to have Parkinson's disease. The prevalence of this disease was 82.0/100,000 population, the highest reported in Japan to date. Of the patients affected, 17.1% showed apparent dementia. Those with dementia were older and were classified at a more advanced Yahr stage than were the nondemented cases. The prevalence of Parkinson's disease in the growing geriatric population has major medical and socioeconomic implications.

Age-related changes in cerebral white matter measured by computed cranial tomography

Changes in the cerebral white matter in relation to aging were studied quantitatively by computed cranial tomography (CT) in 70 healthy subjects aged 30 to 94 years. There were no age-related changes in the CT number of the white matter (WMCT) in 41 younger subjects aged 30 to 65 years. But, there was a significant negative correlation between age and the WMCT in 29 elderly subjects aged 66 to 94 years. Brain atrophy was significantly correlated with the WMCT. The WMCT decreased with aging even in neurologically healthy elderly persons.