Abnormal fatty acid metabolism in patients with coronary vasospasm

Although various noninvasive methods have been used to detect vasospasm, none of them are sensitive enough for patients with sporadic attacks. Since abnormal fatty acid metabolism is observed in ischemic myocardium, 123I-beta-methyl-p-iodophenyl pentadecanoic acid (BMIPP), a radiolabeled fatty acid analog, has recently been proposed as a useful tracer for detecting myocardial damage. The aim of this study was to clarify the clinical implications of decreased myocardial BMIPP uptake in patients with vasospastic angina. We evaluated 53 patients with vasospastic angina (32 with clinically documented vasospasm [Group-A] and 21 with vasospasm induced by ergonovine provocation [Group-B]) and 27 control subjects, 20 in Group-A were re-evaluated 6 months after medical treatment. The territorial regions of vasospasm-induced coronary artery, the wall motion by left ventriculography, and BMIPP uptake were compared. Vasospasm was induced in multiple coronary arteries in 29 (55%) patients. Reduced wall motion and decreased BMIPP uptake were observed in 19 (36%) patients and 47 (89%) patients, respectively. The sensitivity and specificity of determination of vasospasm-induced coronary arteries with BMIPP scintigraphy were 71% (69/97 coronary arteries) and 88% (126/143), respectively. Vasospasm was re-induced by ergonovine provocation in 8 patients (Group-I) and not re-induced in 12 (Group-II) after treatment. In Group-I, improvement of decreased BMIPP uptake was lower than in Group-II (19+/-11 vs. 59+/-22%, mean+/-SD, p < 0.001). The regions in which vasospasm was re-provoked exhibited decreased BMIPP uptake. Abnormal fatty acid metabolism was more often observed than wall motion abnormality in the vasospastic region in patients with vasospastic angina. BMIPP scintigraphy is a highly accurate and non-invasive technique for determining the presence and location of vasospasm.

Prediction of life expectancy in patients with primary pulmonary hypertension. A retrospective nationwide survey from 1980-1990

Primary pulmonary hypertension (PPH) is a progressive disease of unknown etiology usually followed by death within 5 years after diagnosis. Although heart-lung or lung transplantation is now offered to patients with advanced PPH, adequate criteria assessing an accurate prediction of life expectancy in PPH has been difficult to establish. The aims of this study were to identify the characteristic features associated with a poor prognosis in patients with PPH, and to attempt to establish an individual prognostic index that predicts with great accuracy survival or death of PPH after one year, thereby helping to define criteria for patient selection for transplantation. In 1991, a retrospective nation-wide survey on PPH was conducted in Japan, and the clinical and cardiorespiratory variables of 223 PPH cases (female; 144, male; 79) in the period from 1980-1990 were obtained. The mean pulmonary arterial pressure (PPA) was 57.5+/-17.2 mm Hg (mean+/-SD), and the overall median survival time was 32.5 months since the first diagnostic catheterization. The characteristic features of 61 patients who died within one year of catheterization (Nonsurvivors group) were compared to 141 patients who survived one year or more from the time of catheterization (Survivors group). Among several clinical and cardiorespiratory variables, heart rate, PPA, right atrial pressure (PRA), stroke volume index (SI), pulmonary vascular resistance, and partial pressure of carbon dioxide (PaCO2) were significantly different between the two groups. As the independent factors, PPA, PRA, SI, and PaCO2 were selected for the multiple logistic analysis. Using a 0.7 probability cut-point to separate Nonsurvivors from Survivors, 84.6% of Nonsurvivors and Survivors could be correctly predicted from this logistic regression equation. Predictive equations like the present preliminary one can be used in the future to better assess life expectancy in patients with PPH in whom transplantation will be considered.

[Estimated numbers of patients with intractable respiratory diseases]

To estimate the number of patients with intractable respiratory diseases, we conducted a two-stage nationwide epidemiological survey in 1997. The first survey was performed at randomly sampled hospitals to identify the number of patients treated. The second survey sought detailed clinico-epidemiological data on the patients reported in the first survey. The response rates were 54% for the first survey and 62% for the second. Based on the survey findings, we derived the following nationwide estimates: 450 patients (95% confidence interval: 360-530) with chronic thromboembolic pulmonary hypertension; 230 (200-260) with primary pulmonary hypertension; 180 (150-210) with obesity-associated hypoventilation syndrome; 40 (30-50) with primary alveolar hypoventilation syndrome; 160 (140-180) with histiocytosis X; and 190 (150-230) with juvenile pulmonary emphysema.

Myocardial CD36 expression and fatty acid accumulation in patients with type I and II CD36 deficiency

Long-chain fatty acids (LCFA) are one of the major cardiac energy substrates, so understanding LCFA metabolism may help in elucidating the mechanisms of various heart diseases. CD36 is a multifunctional membrane glycoprotein that acts not only as a receptor for thrombospondin, collagen and oxidized low density lipoprotein but also as a receptor for LCFA. We investigated the relationship between CD36 expression in myocardial capillary endothelial cells and myocardial LCFA uptake in patients with CD36 deficiency. We analyzed CD36 expression in blood cells from 250 patients with heart diseases by means of a flow cytometer. In 218 patients, myocardial LCFA scintigraphy was performed with 123I-beta-methyl-p-iodophenyl pentadecanoic acid (BMIPP). In 5 patients, myocardial capillary endothelial cells were examined immunohistochemically for CD36 expression. Eleven patients (4%) showed signs of type I CD36 deficiency (neither platelets nor monocytes expressed CD36). Twenty patients (8%) had type II CD36 deficiency (monocytes expressed CD36 but platelets did not). In all 11 patients with type I CD36 deficiency, no BMIPP accumulation was observed in the heart, but in 13 patients with type II CD36 deficiency, BMIPP accumulation in the heart was focally reduced, but there were no patients without BMIPP accumulation in the heart. Although the myocardial capillary endothelial cells from two CD36-positive patients expressed CD36, those from two patients with type I CD36 deficiency did not. In a patient with type II CD36 deficiency, some capillary endothelial cells displayed patchy CD36 expression. CD36 deficiency was documented in 31 (12%) patients with heart diseases. Because CD36 was not expressed in the myocardial capillary endothelial cells in patients with type I CD36 deficiency, type I CD36 deficiency is closely related to lack of myocardial LCFA accumulation and metabolism in the myocardium.

[Epidemiology of acute coronary syndrome]

We reviewed the epidemiology of ischemic heart disease (IHD) focusing on acute myocardial infarction (AMI) in Japan. The age-adjusted mortality from IHD and the age-adjusted incidence of AMI in Japan were nearly the lowest in the world. Vital statistics of Japan showed that the age-adjusted mortality from IHD and AMI had been decreasing since the 1970's until 1993. Rates of new patients of AMI per day have been stable since the early 1980's according to "patient survey". Several population-based studies reported the unchanged age-adjusted incidence of AMI since the late 1950's. In conclusion, the mortality from IHD and the incidence of AMI are very low in Japan, and there is no epidemiological evidence showing an increase in either one.

Evolutionary characteristics of influenza B virus since its first isolation in 1940: dynamic circulation of deletion and insertion mechanism

New antigenic variants of B/Yamagata/16/88-like lineage which appeared in the season of 1997 as a minor strain tended to predominate in the following season. Also, we could observe for the first time, three peaks of activity caused by H3N2 virus and two variants of B influenza virus. Antigenic and phylogenetic analyses revealed that B/Victoria/2/87-like variants appeared again in Japan in 1997 after a nine-year absence. Influenza B viruses evolved into three major lineages, including the earliest strain (I), B/Yamagata/16/88-like variants (II), which comprised of three sublineages (II-(i), II-(ii), II-(iii)), and B/Victoria/2/87-like variants (III). Evolution of influenza B virus hemagglutinin was apparently distinguishable from that of influenza A virus, showing a systematic mechanism of nucleotide deletion and insertion. This phenomenon was observed to be closely related to evolutionary pathways of I, II-(i), II-(ii), II-(iii) and III lineages. It was noteworthy to reveal that the nucleotide deletion and insertion mechanism of influenza B virus completed one cycle over a fifty-year period, and that a three nucleotide deletion was again observed in 1997 strains belonging to lineage II-(iii). It was evident that amino acid substitutions accompanying nucleotide insertions were highly conserved.

Advance directives and other medical decisions concerning the end of life in cancer patients in Japan

The purpose of our survey was to investigate the experience of physicians regarding advance directives and other medical decisions concerning the end of life. A postal questionnaire was sent to 500 Japanese physicians who were most involved in medical care of terminal patients. A total of 339 (68%) physicians responded. In dealing with terminal patients, approximately half gave priority to their patients' wishes for medical care, if known, regardless of the patient's competency. Of the respondents, 149 had been presented with advance directives by their patients and 35% followed all advance directives presented in their practice. Cardiopulmonary resuscitation (CPR) for arrested patients to enable their family to be at the bedside at the time of the death was common. More than 60% of the respondents thought that active euthanasia and assisted suicide were never ethically justified. Our study indicates that the wishes of patients are currently not always given top priority in medical decisions concerning the end of life.

Hepatocellular carcinomas supplied by inferior phrenic arteries

PURPOSE

To assess the arterial supply to hepatocellular carcinomas (HCCs) by inferior phrenic arteries (IPA).

MATERIAL AND METHODS

A total of 126 consecutive cases of HCC were studied by contract-enhanced CT and conventional arteriography. Blood supply from an IPA was suspected when the size of the HCC mass as seen on contrast-enhanced CT did not match the size of the tumor mass as seen on hepatic arteriography. Inferior phrenic arteriography was employed to confirm these findings. HCCs fed by the IPA were analyzed in terms of size, location, and history of prior treatment.

RESULTS

In 14 (11%) of the 126 cases, the tumor was found to have a blood supply from an IPA. Eleven of these tumors were located in segments 2 and 7. Three tumors, which had not been treated previously, had a blood supply from an IPA. Six tumors were almost exclusively fed by an IPA and were located in segments 1, 1, and 4.

CONCLUSION

HCCs located in segments which form the bare area of the liver (S1, S2, S7) can be supplied by an IPA. This should be suspected when a lesion or part of a lesion is identified on contrast-enhanced CT but not on hepatic arteriography.

Malignant lymphoma demonstrating sick sinus syndrome

We report a case of T-cell-rich large B-cell lymphoma demonstrating sick sinus syndrome as a single initial symptom, followed by the retention of pericardial and pleural effusions. Intrapleural administration of interferon-alpha prevented reaccumulation of the pleural effusion for one and a half months, whereas systemic chemotherapy failed to control tumor growth in the skin and lymph nodes. The autopsy revealed involvement of the sinoatrial node of the heart by lymphoma cells.

Perfusion heterogeneity in the pulmonary acinus

There is little information on the distribution of acinar perfusion because it is difficult to resolve blood flow within such small regions. We hypothesized that the known heterogeneity of arteriolar blood flow and capillary blood flow would result in heterogeneous acinar perfusion. To test this hypothesis, the passage of fluorescent dye boluses through the subpleural microcirculation of isolated dog lobes was videotaped by using fluorescence microscopy. As the videotapes were replayed, dye-dilution curves were recorded from each of the tributary branches of Y-shaped venules that drained an acinus. From the dye curves, we calculated the mean appearance time of each curve. The difference in mean appearance times between venular tributary branches was small in most cases. In 43% of the observed venular branch pairs, the dye curves were essentially superimposable (the mean appearance-time difference was <5%); and in another 42%, the mean appearance-time difference between curves was 5-10%. From these results, we conclude that acinar perfusion is unexpectedly homogeneous.

Arterial and mixed venous oxygen desaturation during incremental exercise in patients with chronic pulmonary disease

We evaluated arterial and mixed venous oxygen desaturation during symptom-limited exercise in patients with chronic pulmonary disease. Patients were divided into five groups according to disease: [chronic pulmonary emphysema (CPE), chronic bronchitis (CB), pulmonary tuberculosis sequalae (TB-seq), fibrosing lung disease (FLD), and pulmonary vascular disease (PVD)]. There were no significant difference in the values of arterial (PaO2) and mixed venous (PvO2) oxygen tension before and at the end of exercise among the five groups, whereas absolute decreases in PvO2 were significantly larger in PVD and FLD. The changes in PvO2 were similar to the changes in the coefficient of oxygen delivery (COD) which is equal to oxygen transport divided by oxygen consumption. These results suggest that the relative decrease in oxygen transport during exercise due to the high ratio of oxygen extraction by tissues is an important factor to determine decreases in PvO2 in pulmonary hypertensive disease and fibrosing lung disease.

[Different patterns of 123I-BMIPP myocardial accumulation in patients with type I and II CD36 deficiency]

The CD36 molecule is a multifunctional membrane type receptor glycoprotein that reacts with thrombospondin, collagen, oxidized LDL and long-chain fatty acids (LCFA). LCFA are one of the major cardiac energy substrates, hence LCFA metabolism may have an important role in cardiac diseases. In this study, we analyzed CD36 expression in 200 patients with heart diseases [44 patients with hypertrophic cardiomyopathy (HCM), 16 with dilated cardiomyopathy (DCM), 26 with old myocardial infarction (OMI), 55 with angina pectoris (AP) and 59 with other miscellaneous heart diseases] using a flow cytometer. 123I-beta-methyl-p-iodophenylpentadecanoic acid (BMIPP) myocardial accumulation was also examined in some patients. Eight patients (2 with HCM, 1 with DCM, 2 with OMI, and 3 with AP) were diagnosed as having type I CD36 deficiency (neither platelets nor monocytes expressed CD36). Sixteen patients (3 with HCM, 1 with DCM, 1 with OMI, 8 with AP, and 3 with other heart diseases) showed type II CD36 deficiency (monocytes expressed CD36 but platelets did not). In all 8 patients with type I CD36 deficiency, there was no BMIPP accumulation in the heart. However, in 13 patients with type II CD36 deficiency, focally reduced BMIPP accumulation was observed, but there were no patients without BMIPP accumulation. CD36 deficiency was observed in a higher proportion (12%) of patients with heart disease in this study than in a reported control study. Type I CD36 deficiency is associated with absence of BMIPP accumulation in the heart, hence it may have an important role in LCFA metabolic disorders and some types of cardiac hypertrophy as well as other heart diseases.

Familial aggregation and covariation of diseases in a Japanese rural community: comparison of stomach cancer with other diseases

PURPOSE

We investigated familial aggregation as well as familial covariation of diseases by means of a questionnaire survey dealing with family histories of stomach cancer, stroke, hypertension, diabetes and tuberculosis as well as life style among 2,769 inhabitants of a rural community (84% of census population).

METHODS

The strength of familial aggregation was shown by an odds ratio (OR) that compared the number of families in which siblings suffered from one of the above diseases among families in which at least one parent suffered from it, and among families in which neither did. Probands were divided into two groups for analysis: an under-55 "young group," and a 55-and-older "old group."

RESULTS

The OR for stomach cancer was lowest and insignificant in the young group, and significant (2.2, p < 0.05) only in the old group. The OR for stroke, hypertension, and tuberculosis was 4.5-5.1 (p < 0.05) in the young group but decreased to 2.3-3.2 in the old group. Diabetes increased from 3.9 to 5.7 (p < 0.05) with advancing age. Age-related OR trends were not affected by exposure to cigarette smoke in the past. Stomach cancer showed a borderline familial covariation with diabetes and a borderline inverse covariation with hypertension. Hypertension showed a familial covariation with stroke and diabetes.

CONCLUSIONS

Among the investigated diseases, familial aggregation was weakest for stomach cancer. The results suggest that stomach cancer may share a common familial etiologic factor with diabetes and hypotension.

Medical decisions concerning the end of life: a discussion with Japanese physicians

OBJECTIVES

Life-sustaining treatment at the end of life gives rise to many ethical problems in Japan. Recent surveys of Japanese physicians suggested that they tend to treat terminally ill patients aggressively. We studied why Japanese physicians were reluctant to withhold or withdraw life-support from terminally ill patients and what affected their decisions.

DESIGN AND PARTICIPANTS

A qualitative study design was employed, using a focus group interview with seven physicians, to gain an in-depth understanding of attitudes and rationales in Japan regarding medical care at the end of life.

RESULTS

Analysis revealed that physicians and patients' family members usually make decisions about life-sustaining treatment, while the patients' wishes are unavailable or not taken into account. Both physicians and family members tend to consider withholding or withdrawing life-sustaining treatment as abandonment or even killing. The strongest reason to start cardiopulmonary resuscitation- and to continue it until patients' family members arrive-seems to be the family members' desire to be at the bedside at the time of death. All physicians participating in our study regarded advance directives that provide information as to patients' wishes about life-sustaining treatment desirable. All expressed concern, however, that it would be difficult to forego or discontinue life-support based on a patient's advance directive, particularly when the patient's family opposed the directive.

CONCLUSION

Our group interview suggested several possible barriers to death with dignity and the appropriate use of advance directives in Japan. Further qualitative and quantitative research in this regard is needed.

Seasonal variation in the incidence of sudden death according to occupation of householder in Japan

To examine the relationship between overwork and the occurrence of sudden death, the relation between occupation and seasonal variation in sudden death was studied. A total of 8481 cases of sudden death (among subjects aged over 24 years) were selected from all deaths between 1984 and 1986 in the Niigata Prefecture, Japan, based on a death certificate survey. Sudden death was defined as death within 24 h of the onset of the underlying disease. We divided subjects into 4 groups according to the occupation of the householder: agricultural workers, employees, the self-employed, and other occupations. As the incidence of sudden death in the 'other occupation' group did not show any significant seasonal variation, this group was considered to be a control group. Among young to middle-aged men (25-65 year old), the incidence of sudden death was higher than in the control group for agricultural workers in April and September and for employees in March and September. However, in older men (over 65) the incidence for agricultural workers was higher only in April. Among women, there was no such spring rise in the incidence of sudden death in any occupational group. The months featuring a high incidence of sudden death coincided with the busiest occupational months only for people who were actually working and not for those who had already retired.

Effect of smoking on the serum concentration of erythropoietin and granulocyte-colony stimulating factor

Smoking is the most common cause of secondary polycythemia and may induce leukocytosis. We studied the relationship between hematopoietic growth factors and erythrocytosis and leukocytosis. Two sets of healthy male volunteers, consisting of 177 and 202 (age: 19-59 years) were each divided into four groups according to whether or not they smoked at least one package daily and their leukocyte count. Serum erythropoietin (Epo) concentration and granulocyte-colony stimulating factor (G-CSF) concentration were measured in the 177 and 202 volunteers, respectively. The mean serum Epo concentration was lower in smokers than in nonsmokers (p = 0.01 in the subjects without leukocytosis and p = 0.107 in those with leukocytosis, respectively). After 3 smokers stopped smoking, the Epo concentration increased 2 weeks later, and remained constant for 20 weeks. Smokers tended to have a higher mean serum G-CSF concentration than nonsmokers in the subjects without leukocytosis. Neither Epo nor G-CSF is the main etiology of smokers' polycythemia, and Epo production may be down-regulated by an elevated red-cell volume.

The efficacy of pulmonary thromboendarterectomy on long-term gas exchange

It has not been delineated in detail how pulmonary thromboendarterectomy (PTE) affects gas exchange through long-term follow-up. In Japan, this surgery has been undertaken in a limited number of institutions, and the results of PTE have not been well publicized. A total of 25 patients were operated on during the period from 1985 to 1996 at our institution, and the overall mortality rate was 16%. Our criteria for PTE were based on the following: 1) thrombi surgically accessible as judged by angiographic study; 2) mean pulmonary arterial pressure > or = 30 mmHg. The efficacies of PTE were analysed on haemodynamics as well as gas exchange at one month postsurgery and during follow-up (6-24 months). Significant haemodynamic improvement was obtained as early as 1 month after surgery. Improvement of gas exchange lagged, but was then observed during follow-up, and the improvement level of pulmonary haemodynamics was sustained. The early postoperative restrictive impairment and ventilation-perfusion abnormality on lung perfusion scan resolved during the follow-up period. It was concluded that the early postoperative efficacy of pulmonary throm-boendarterectomy was mainly achieved due to the reduction of pulmonary hypertension, whereas improvement in gas exchange was obtained over the longer term.

[Hypertrophic cardiomyopathy showing no 123I-BMIPP myocardial accumulation with type I CD36 deficiency]

A 57 years old male consulted our hospital in complaining chest oppression and short of breath. Familial and dilated phase hypertrophic cardiomyopathy (HCM) was detected by ECG, echocardiography, left ventriculography and left ventricular endomyocardial biopsy. 201T1 SPECT showed regional increased accumulation in the ventricular septum, however, no myocardial accumulation of 123I-beta-methyl-p-iodophenylpentadecanoic acid (123I-BMIPP) was observed. We analyzed CD36 in this patient, and found he had type 1 CD36 deficiency. Myocardial uptake of long-chain fatty acids occurs via a specific transporter, which is homologous with human CD36. We hypothesize that CD36 deficiency, especially type 1 CD36 deficiency, might be one factor of no myocardial 123I-BMIPP uptake.

Changes in liver function parameters after occlusion of gastrorenal shunts with balloon-occluded retrograde transvenous obliteration

OBJECTIVE AND METHODS

To evaluate the effects of portal blood flow on liver function, this pilot study investigated the correlation between changes in portal blood flow as measured by image-directed Doppler ultrasonography and liver function tests in nine patients with cirrhosis who were treated with balloon-occluded retrograde transvenous obliteration. All patients had large gastric varices and prominent gastrorenal shunts.

RESULTS

Treatment caused a significant increase (p < 0.01) in portal blood flow; we documented reversion from hepatofugal to hepatopetal portal flow in one patient and increases in hepatopetal flow from 5.4 +/- 1.1 to 7.85 +/- 1.4 cm/s (mean +/- SD) in eight patients. All patients showed decreases in gastric variceal size. However, portal pressure rose significantly in all patients after treatment from 25.4 +/- 7.6 to 30.7 +/- 5.8 mmH2O (n = 7, mean +/- SD), and two of nine patients had worsening of esophageal varices. All nine patients showed improvement in the 15-min retention rate of indocyanine green from 31.8 +/- 16.1 to 21.8 +/- 12.4% (mean +/- SD, p < 0.01), whereas seven patients showed increased serum albumin levels after treatment.

CONCLUSIONS

These results suggest balloon-occluded retrograde transvenous obliteration increases hepatic portal blood flow, which may be accompanied by improvements in liver function.

The role of lymphadenectomy in the treatment of transitional cell carcinoma of the upper urinary tract

PURPOSE

We evaluated the efficacy of lymphadenectomy in conjunction with nephroureterectomy in patients with transitional cell carcinoma of the upper urinary tract.

MATERIALS AND METHODS

Data were evaluated retrospectively in 21 consecutive men and 15 women (mean age 67 years) who underwent total nephroureterectomy with lymphadenectomy between January 1985 and December 1993.

RESULTS

Of the 36 patients 11 (31%) had lymph node metastases. Of 20 patients with stages pT3 to 4 or pN+ tumors 12 received cisplatin based chemotherapy (11 postoperatively and 1 preoperatively). Followup ranged from 3 to 135 months (mean 55). Among 13 patients who died by May 1996 tumor was the cause of death in 8, while 5 died of unrelated causes. The probability of a cause specific survival at 5 years was 100% in patients with stages pTa to 1, 80% with stage pT2, 59% with stage pT3 and 0% with stage pT4 cancer. The probability of a cause specific survival at 5 years in patients with nodal metastasis was 21%. No patient without nodal metastasis died of tumor related causes.

CONCLUSIONS

Lymphadenectomy may provide therapeutic benefit in select patients with lymph node metastasis. It also may be a useful indicator of candidates for adjuvant chemotherapy if an effective regimen is established because lymph node metastasis is common in patients with carcinoma of the upper urinary tract and is critical in establishing the prognosis.

Effects of ONO-2235, an aldose reductase inhibitor, on muscarinic receptors and contractile response of the urinary bladder in rats with streptozotocin-induced diabetes

This study was conducted to evaluate effects of the aldose reductase inhibitor ONO-2235 on the contractile response to acetylcholine of the urinary bladder dome of streptozotocin-induced diabetes mellitus (DM) rats and simultaneously observe the changes in the function and number of muscarinic receptors and the sorbitol content of the bladder. The contractile response to acetylcholine increased 51% in the DM rat bladder dome compared to the normal rats; however, this was attenuated to a 10% increase by administration of 100 mg/kg ONO-2235 for 2 weeks. Treatment with ONO-2235 significantly decreased the specific [3H]quinuclidinyl benzilate binding in DM rats. However there was no significant dose-dependency among the ONO-2235-treated groups. The sorbitol levels of the sciatic nerve and the bladder were higher in the DM rats compared to the control rats; ONO-2235 decreased the level, although it did not completely reverse them to the control level. These results suggest that an aldose reductase inhibitor attenuates the increase of the muscarinic receptor number and normalizes the enhanced contractile response to acetylcholine caused by hyperglycemia and diuresis, probably through suppression of the polyol-pathway in the DM rat bladder dome.