Restenosis after percutaneous transluminal coronary angioplasty in patients with non-insulin-dependent diabetes mellitus (NIDDM)

BACKGROUND

The effect of glycemic control on the incidence of restenosis after percutaneous transluminal coronary angioplasty (PTCA) in non-insulin-dependent diabetes mellitus (NIDDM) has not been well analysed.

METHODS

Out of 1282 consecutive patients who had undergone elective and successful PTCA over 8 years, 86 known to have NIDDM and 117 non-diabetic cases were analysed for restenosis following PTCA. Definition of restenosis is an increase from 50% to 75% diameter stenosis at the same lesion within 1 year after angioplasty. Those with familial hypercholesterolemia, renal failure, unstable angina pectoris, bypass graft surgery within 1 month were excluded. Blood pressure, body mass index, history of smoking, fasting blood glucose, post-prandial glucose, HbA1c, cholesterol, triglycerides, number of stenotic vessels, restenosis rate were studied - 6 months before PTCA and 1, 3, 6 and 12 months after PTCA.

RESULTS

The frequency of restenosis within 1 year of PTCA was significantly greater in poorly controlled NIDDM (75%) than in well or moderately controlled NIDDM (30-40%) or non-diabetic subjects (33%). Multivariate analysis showed that the degree of control of diabetes was significantly correlated with restenosis.

CONCLUSION

Restenosis following elective and successive PTCA was significantly more frequent in poorly controlled NIDDM compared with moderately or well-controlled NIDDM or non-diabetic subjects. Multivariate analysis also showed the significant correlation between restenosis and glycemic control. These findings indicate that control of diabetes plays an important role in reducing restenosis after PTCA.

Left ventricular mass regression after implantation of St. Jude Medical cardiac valves in small aortic roots

In this study, we analyzed the extent of regression of left ventricular hypertrophy in patients who received small St. Jude Medical (SJM) aortic valves and compared the results with those of another group receiving larger valves. Eighty-eight patients received either 19 or 21 mm valves (Group 1, 25 patients) or either 23 or 25 mm valves (Group 2, 53 patients). Echocardiographic studies were done before the operation and 5 years postoperatively. At follow-up a significant reduction in the left ventricular mass was found for both patient groups (p < 0.0001). Doppler echocardiography derived pressure gradients for both groups were obtained during the follow-up period. As expected, the patients in Group 1 had higher peak pressure gradients than did those in Group 2. However, there was no significant difference between the 2 groups or any significant correlations between peak pressure gradients and body surface area (BSA). Actuarial survival was 84.7% at 15 years for Group 1 and 85.9% at 17 years for Group 2. Actuarial freedom from valve related events was 91.4% at 15 years for Group 1 and 82.7% at 17 years for Group 2. There was no significant difference in survival or valve related event free curves between the 2 groups. After implantations of SJM valves in small aortic roots, significant left ventricular mass regression was obtained, and the results were comparable to those for valves of other sizes. The long-term performance of aortic valve replacement with small valves was satisfactory as judged by improvement in the functional class of patients and survival statistics, the durability of the prosthesis, and valve related morbidity comparable to that of valves of other sizes.

[Auditory brainstem responses (ABR) in patients with Wolfram syndrome]

Auditory brainstem responses (ABR) and other evoked potentials were studied in four patients with the Wolfram syndrome. In three cases ABR was abnormal in the early stage of the disease. There was no responses or only the wave V with prolonged latency at a stimulation level of 80 dBnHL. A prolongation of the I-V interpeak latency (IPL) was also revealed at a stimulation level of 105 dBnHL. The remaining patient showed shortening of the I-V IPL. The visual evoked potentials showed prolonged peak latency in three cases, and the median nerve short latency somatosensory evoked potentials were normal in two cases. These ABR findings indicated not only sensory neuronal hearing loss but also a degenerative change in the brain stem in the Wolfram syndrome.

[Long-term follow-up of patients with small St. Jude aortic valve prostheses]

Thirty-five patients received small sized 19 or 21 mm valves (group I) and 53 patients received 23 or 25 mm valves (group II). At follow-up a significant reduction in the left ventricular mass was found for both patient groups (p < 0.0001). The patients in group I had higher peak pressure gradients than did those in group II. However, there was no significant difference between the two groups, or any significant correlation between peak pressure gradients and body surface area. Actuarial survival was 84.7% at 15 years for group I and 85.9% at 17 years for group II. Actuarial freedom from valve-related events was 91.4% at 15 years for group I and 82.7% at 17 years for group II. There was no significant difference in survival or valve-related event free curves between the two groups. After implantation of small SIM valves, significant left ventricular mass regression was obtained and the results were comparable to those for valves of other sizes. The long-term performance of aortic valve replacement with small valves was satisfactory as judged by improvement in the functional class of patients, survival statistics, the durability of the prosthesis, and valve related morbidity comparable to that of valves of other sizes.

First-pass radionuclide angiography using iodine-123 myocardial tracers and a multicrystal gamma camera

The purpose of this study was to validate the accuracy of the assessment of ventricular function by first-pass radionuclide angiography (FPRNA) with 123I myocardial tracers and a multicrystal gamma camera.

METHODS

Left ventricular ejection fraction (LVEF) and right ventricular ejection fraction were measured in 69 patients by FPRNA using 123I myocardial tracers (126 +/- 7 MBq) and 99mTc tracers (541 +/- 141 MBq) on a multicrystal gamma camera with a high-sensitivity collimator. For 44 patients, ejection fraction values measured by 123I-FPRNA were compared to those estimated by equilibrium radionuclide angiography (ERNA). Visual wall-motion analysis was also performed to judge clinical acceptability of 123I-FPRNA images for identification of wall-motion abnormality.

RESULTS

Mean LVEFs (%) estimated by 123I-FPRNA and by 99mTc-FPRNA were 49.6 +/- 13.6 and 49.1 +/- 14.1, respectively (nonsignificant p value). An excellent correlation was found between LVEFs estimated by 123I-FPRNA and 99mTc-FPRNA (r = 0.96, s.e.e. = 1.9%). Values of LVEF measured by 123I-FPRNA also demonstrated excellent correlation with those measured by ERNA (r = 0.95, s.e.e. = 2.2%). A good correlation was also noted between right ventricular ejection fractions measured by 123I-FPRNA and 99mTc-FPRNA (r = 0.72, s.e.e. = 4.0%). The Spearman rank correlation coefficient between 123I-FPRNA and ERNA wall-motion scores was 0.87 (n = 135, p < 0.001).

CONCLUSION

Resting ventricular function can be reliably measured with 123I-FPRNA in combination with a multicrystal gamma camera. This indicates that the assessment of ventricular function is feasible in conjunction with 123I myocardial imaging without an increase in cost or radiation dose to patients.

A study on home health care support information system for health evaluation

The need for home health care has been increasing in Japan and the application of various techniques such as medical informatics are desired to support home health care services. Therefore, we developed an information system for health evaluation of the elderly including patients at home by applying multifunctional telephone set and an IC memory card, by which complaints, symptoms, and conditions by them can be collected, recorded, and transmitted to medical facilities. We also conducted an experiment for trial use of the system with the cooperation of elderly female volunteers. It was recognized that the elderly volunteers could operate the system with the help of public health nurses and their health information could be collected by the system. Although the developed system has some problems, it was suggested that the system would be useful for the support of health evaluation of elderly at home.

[A case of ruptured descending thoracic aortic aneurysm due to Salmonella infection]

A 66-year-old male was admitted to our hospital because of pyrexia, chest pain and hemosptum. Inflammatory findings were made and salmonella enteritidis was detected by bacterial examination of sputum and stool. Enhanced chest CT examination disclosed a descending thoracic aortic aneurysm which had ruptured into the left lower lobe of the lung. Under a diagnosis of ruptured mycotic descending thoracic aortic aneurysm, an emergency operation was performed. A left posterolateral thoracotomy carried out after axillo-bilateral femoral bypass grafting. A pseudoaneurysm of the descending thoracic aorta had ruptured into the left lower lobe of the lung. After resection of the aneurysm, closure of both ends of the intact descending thoracic aorta and a left lower lobectomy were carried out. An ascending aorta-infrarenal abdominal aorta bypass was performed because of insufficient visceral arterial blood flow through the axillo-bilateral femoral bypass. The patient's immediate postoperative recovery was complicated by paraplegia. Chloramphenicol and levofloxacin were administered for three months, after which his recovery followed a good course.

Fetal monitor for non-stress-test screening at home

A fetal monitoring device developed for non-stress-test (NST) screening at home works on battery power, and is so small and lightweight (152 x 120 x 64 mm, 600 g) that a pregnant woman can monitor fetal Doppler ultra-sound and record fetal heart rate (FHR) and uterine contraction (UC) data on an attached memory IC card at any time and in any place away from a hospital. The physician can evaluate these data, transmitted via public telephone lines, using a built-in modem in the monitor. The combination of the memory IC card as a temporary storage device with the intermittent data transmission to the host provides endless data storage. The input-output relationship of the device was quantitatively evaluated using a Doppler ultrasound heart rate simulator. Forty pregnant women participated in an evaluation of this system. The total number of NST data transmissions was 648, and the total amount of data received was more than 6.7 Mbytes. Of the 648 transmissions, 475 were adequate for clinical interpretation. Of the 101 failed NST data transmissions, 85 resulted from patient handling errors. However, 82.4% of these errors resulted in reexamination and transfer of new data by the patients, who were aware of the insufficiency of the original data. The main cause of the noise in the data was zero-count data; this noise rate accounted for 4.1% of the data abnormalities. A questionnaire survey found that 96% of the participants wanted to use the monitor again in their next pregnancies, and 83% would recommend its use to pregnant friends. The system was easily used and accepted by pregnant women, and the NST data obtained were sufficient for clinical interpretation.

The diagnosis and management of splanchnic artery aneurysms. Report of 8 cases

The purpose of this report is to describe the clinical characteristics and surgical technique for splanchnic artery aneurysms. Over the past 10 years we have surgically resected 8 cases of splanchnic artery aneurysms including 2 cases involving the superior mesenteric artery, 3 involving the renal artery, 1 involving the hepatic artery and 2 involving the splenic artery. Diagnosis was established preoperatively in all patients by splanchnic angiography. Surgical treatment for splanchnic artery aneurysms is indicated in any symptomatic patient, in all symptomatic patients with suspected renal aneurysmal expansion and in patients who have renal aneurysms occurring with functionally important renal stenosis, usually associated with hypertension, in all patients with surgical accessible hepatic artery aneurysms, in all patients who have superior mesenteric artery aneurysms having a high tendency to rupture, and in all patients with an asymptomatic splenic artery aneurysms 1.5 cm or larger in diameter. Although splanchnic artery aneurysms are uncommon and asymptomatic, we recommend that splanchnic arteries should be treated surgically because of their tendency to rupture or organ failure.

[Brain damage after surgery for thoracic aortic aneurysm]

We analyzed cases with brain damage after surgery for thoracic aortic aneurysm in our institution and investigated the causes, risk-factors and preventive measures for this disastrous postoperative complication. Irreversible brain damage was a complication in 25 out of 184 operative cases (13.6%) over a 21-year period. The cause of brain damage was determined to be embolism by manipulation of the aorta in six cases, clamping of the left subclavian artery in four cases, technical problems of separate cerebral perfusion (SCP) in four cases, severe shock in three cases, embolism unrelated to operative maneuver in three cases, stenosis of a branch of the arch with aortic dissection in two cases, and air embolism, circulatory arrest with insufficient hypothermia and hypoperfusion of a temporary bypass to the left carotid artery in one case each. The neurological symptom improved in eight cases and was unchanged in 17 cases. Eighteen cases died in the hospital. In the univariate analysis, age (p = 0.048), a portion of the aneurysm (p = 0.035), preoperative brain complication (p = 0.003), emergency operation (p = 0.033) and clamping of the arch (p = 0.001) were found to be prominent risk factors for brain damage. In the multivariate analysis, clamping of the arch (p = 0.0310), SCP (p = 0.0327) and emergency operation (p = 0.0223) were prominent. To prevent postoperative brain damage, the arch should not be clamped, appropriate operative techniques to avoid bleeding and to shorten SCP time should be employed, and proper and prompt management of the emergency operation and caution in clamping the left subclavian artery are considered to be necessary.

Propiverine hydrochloride, an anti-pollakiuric agent, inhibits the activity of actomyosin ATPase from the urinary bladder

The present study was performed to investigate the effects of propiverine hydrochloride (1-methyl-4-piperidyl diphenylpropoxyacetate hydrochloride, P-4), a novel anti-pollakiuric agent, on the contractile proteins of smooth muscle. P-4 (30-300 microM) inhibited the activity of native actomyosin adenosine triphosphatase (ATPase) that had been freshly purified from canine urinary bladder, and calmodulin at 10 microM overcame this inhibition. P-4 also inhibited myosin light chain kinase from smooth muscle in a dose-dependent manner. However, at 300 microM, P-4 was unable to inhibit by 50% the activity of trypsin-treated myosin light chain kinase, which was independent of Ca2+/calmodulin. 1 mol of calmodulin bound 4 to 5 mol of [14C]P-4 in a Ca2+-dependent manner with a K(d) of 77.4 microM. These results indicate that calmodulin is one of the intracellular target molecules for P-4 and that inhibition of the action of calmodulin by P-4 might cause the inhibition of actomyosin ATPase activity, with subsequent relaxation of the smooth muscle of the urinary bladder.

[Ruptured descending thoracic aortic aneurysm due to aortitis syndrome--a case report]

Ruptured fusiform descending thoracic aortic aneurysms due to aortitis syndrome are rare. A 29-year-old woman was readmitted to our hospital with a chief complaint of back pain and shock, and diagnosed as having rupture of a descending thoracic aortic aneurysm. She had a past history of aortitis syndrome beginning eight years ago. On chest CT examination earlier a year, the descending thoracic aortic aneurysm was 4.5 cm in diameter, and calcification we observed in the aortic wall. An inflammatory reaction had been controlled by steroid therapy and her blood pressure had been controlled by vasodilator drugs. Emergent graft replacement of a descending aortic aneurysm was successfully performed under a femoro-femoral bypass using a centrifugal pump and membrane oxygenerator, and Cell Sver. Although in the literature surgical treatment is indicated only if there is a symptomatic or enlarging aneurysm especially of saccular type and no operation is justified for an aortic aneurysm showing marked calcification, we concluded that aggressive surgical treatment was necessary for this fusiform aneurysm due to aortitis syndrome.

Existence of three regulatory regions each containing a highly conserved motif in the promoter of plastid-encoded RNA polymerase gene (rpoB)

The plastid gene rpoB encodes a plastid-specific, DNA-dependent RNA polymerase. A study of a barley mutant, albostrians, indicated that rpoB itself is transcribed by a nuclear-encoded RNA polymerase. However, the molecular nature of the nuclear-encoded RNA polymerase and mechanisms of the transcriptional regulation of rpoB expression have not been elucidated. Using an in vivo transient assay system for gene expression in plastids, the 5'-flanking region of rpoB from Arabidopsis thaliana in plastids of cultured BY-2 tobacco cells was analyzed. A series of deletion analyses of the 5'-flanking region indicated that there were two positive and one negative regulatory regions for rpoB expression. Comparison of the 5'-flanking sequences of rpoB among several plant species revealed the existence of three conserved motifs in these regions.

[Recurrent intrathoracic dissemination of thymoma with myasthenia gravis: a case report]

A 48-year-old man was readmitted to our hospital with a chief complaint of left anterior chest mass. He had a past history of thymo-thymomectomy six years earlier. On chest CT examination, multiple tumor shadows were noted within the left thoracic cavity. All visible tumors were resected. His postoperative course was favorable, and no signs of recurrence have been recognized on CT to date (three years and six months postoperatively). However, in view of the possible recurrence of the present disease after a long period, strict observation of the course of the disease is necessary.

QM is a novel zinc-binding transcription regulatory protein: its binding to c-Jun is regulated by zinc ions and phosphorylation by protein kinase C

A novel method was developed for cloning of zinc-binding proteins. We used 65Zn2+ as a probe to screen a human lung cDNA library, and isolated QM using this approach. QM appears to be a negative regulator of c-Jun that acts by binding to the leucine zipper region of c-Jun. We demonstrated that QM bound zinc ions and that such binding was necessary for the interaction of QM with c-Jun. We also showed that protein kinase C introduced about 1 mol of phosphate into 1 mol of QM. The binding of QM to c-Jun was decreased by 60% when QM had been phosphorylated. These results suggest that QM is a novel zinc-binding transcription regulatory protein and that interaction between QM and c-Jun is regulated by zinc ions and phosphorylation.

[A case report of malignant schwannoma of the chest wall]

We described a very rare case of malignant schwannoma of the chest wall, which was surgically resected. The patient, a 40-year-old woman, came to our hospital because of an abnormal shadow in the right chest wall of an X-ray film without any symptoms. Computed tomography revealed a solid tumor attached to the posteroinferior aspect of the intrathoracic chest wall. The tumor was a 2.5 x 2.1 cm, mass originating from the seventh intercostal nerve without pulmonary adhesion, and the patient underwent en bloc resection of the tumor. The pathological diagnosis was malignant schwannoma. The postoperative course was uneventful, and the patient, eight years after the operation is now doing well without local recurrence or distant metastasis. We reviewed seven cases of this type of tumor reported in the Japanese literature.

[Traumatic injuries of the thoracic aorta--report of five cases]

Five cases of traumatic aneurysm of the thoracic aorta associated with blunt chest trauma are described. Although we lost one case, four cases were successfully treated. Case 1, This was a 22-year-old female who underwent surgery for graft replacement of the descending thoracic aorta under extracorporeal circulation two days after injury. Case 2, This was a 17-year-old male who underwent surgery for graft replacement of the descending thoracic aorta under extracorporeal circulation 24 hours after injury. Case 3, This was a 56-year-old female who underwent surgery for graft replacement of the descending thoracic aorta under extracorporeal circulation 24 hours after injury. Case 4, This was a 69-year-old male who underwent surgery for graft replacement with three branches for an aortic arch aneurysm under extracorporeal circulation one month after injury. Despite an emergency operation, we lost case 5 (a 21-year-old male) because of a complete discontinuity of the aortic isthmus. The postoperative course of the other four cases was uneventful. Vessel injury may be more widespread than preoperative radiographic findings demonstrates. Blunt chest trauma is usually accompanied by multisystem injury. Therefore, it is imperative to determine the first priority of treatment based on further preoperative examination in cases having associated injuries.

[Result of surgery for aneurysms of distal aortic arch and proximal descending aorta]

We examined the surgical result for non-dissecting aneurysm of distal aortic arch and proximal descending aorta, for which aneurysm, proximal aortic clamp cannot be set at descending aorta because of the proximal progression of aneurysm. In 25 cases out of all 46 cases for 18 years, before 1990, aortic arch was clamped for proximal aortic control with the aid of temporary bypass, femoral artery-vein bypass or left heart bypass (clamp group). In 10 cases proximal aortic clamp was set between innominate and left common carotid artery and in 15 cases between left common carotid artery and left subclavian artery. In the former, temporary or permanent bypass was made to left common carotid artery. After 1990, in 21 cases, aortic arch was not clamped with the aid of separate cerebral perfusion (no clamp group). In the comparison of surgical result between two groups, no clamp group showed less postoperative complication rate in brain damage (28% vs 14%) and bleeding (16% vs 5%) and showed better operative mortality (20% vs 14%) and better hospital mortality (32% vs 19%). Now, in the surgery for non-dissecting aneurysm of diatal aortic arch and proximal descending aorta, it is preferable not to clamp aortic arc, employing separate cerebral perfusion.

[Long-term results of emergency coronary artery bypass grafting]

During a 20-year period, 364 patients underwent coronary artery bypass grafting (CABG) for the treatment of ischemic heart disease. Among these patients, 28 underwent emergency surgery. The reasons for performing emergency CABG were unstable angina in 15 patients, impending myocardial infarction in 12 patients, and congestive heart failure in 1 patient. Eleven patients died postoperatively. Eight variables were examined by univariate analysis for their influence on the occurrence of a hospital death. IABP and acute coronary occlusion were found to be predictors of hospital death and previous myocardial infarction was a predictor of hospital survival. Seventeen patients were followed up for 12 years. There was no cardiac death and actuarial survival at 12 years was 63%. The 14 survivors are now in NYHA functional class I or II. Although the operative mortality rate is high after emergency CABG, the patient's prognosis is good.

Sweet syndrome in a child with aplastic anemia receiving recombinant granulocyte colony-stimulating factor

PURPOSE

To elucidate the pathogenesis of Sweet syndrome, one patient with aplastic anemia was evaluated.

PATIENT AND METHODS

A 15-year-old girl presented with intermittent fever and progressive pallor for 3 months after non-A, non-B, non-C hepatitis. Aplastic anemia was diagnosed and therapy was begun with recombinant granulocyte colony-stimulating factor (G-CSF), methylprednisolone pulse therapy, antilymphocyte globulin and cyclosporin A. There was only an increase in the neutrophil counts. We continued G-CSF therapy of 300 micrograms/m2 on alternate days for 7 months. At this time the white blood cell count was 10,000/microliters and the patient developed high-grade fever and a painful, erythematous, tender plaque (3 X 3 cm) on the left thigh. We diagnosed the lesion as a skin infection and stopped G-CSF therapy and started antibiotics. Cultures were negative. The lesion slowly resolved, G-CSF was restarted after 2 months, and 1 month later disseminated lesions occurred. Antibiotic therapy was not effective.

RESULTS

Biopsy of the lesion demonstrated infiltration of the dermis by sheets of neutrophils. We stopped G-CSF and began corticosteroid therapy. The skin lesions resolved rapidly.

CONCLUSION

We postulated that Sweet syndrome was induced by G-CSF treatment.

Long-term results of emergency coronary artery bypass grafting

During a 20-year period, 364 patients underwent coronary artery bypass grafting (CABG) for the treatment of ischemic heart disease. Among these patients, 28 underwent emergency surgery. The reasons for performing emergency CABG were unstable angina in 15 patients, impending myocardial infarction in 12 patients and congestive heart failure in 1 patient. Eleven patients died postoperatively. Eight variables were examined by univariate analysis for their influence on the occurrence of a hospital death. Lack of a history of myocardial infarction, intraaortic balloon pumping (IABP) and acute coronary occlusion were all found to be predictors of hospital death. Seventeen patients were followed up for 12 years. There was no cardiac death and actuarial survival at 12 years was 63%. The 14 survivors are now in NYHA functional class I or II. Although the operative mortality rate is high after emergency CABG, a fair prognosis can be expected if the patients survive surgery.

Risk factor analyses for macrovascular complication in nonobese NIDDM patients. Multiclinical Study for Diabetic Macroangiopathy (MSDM)

To examine the characteristic features of risk factors for macroangiopathy (MA) in nonobese Japanese NIDDM patients, 899 NIDDM patients with and without MA were registered from 40 facilities. Of these, 386 subjects were identified as having any form of MA (total MA); these included 211 with ischemic heart disease (IHD), 163 with cerebrovascular disease (CVD), and 77 with peripheral vascular disease (PVD). Univariate analyses revealed the following common risk factors for total MA, IHD, CVD, and PVD: age, hypertension, systolic blood pressure (sBP) or diastolic blood pressure (dBP), duration of diabetes, diabetic microangiopathy (retinopathy, nephropathy, and neuropathy), low HDL cholesterol level, and higher LDL cholesterol/HDL cholesterol ratio. Additional significant risk factors for specific conditions were also identified, respectively, as male sex for total MA, IHD, and PVD, smoking for IHD and PVD, and high fasting plasma glucose level for total MA and CVD. With stepwise multivariate logistic regression analysis, older age, duration of diabetes, smoking, and low LDL cholesterol/HDL cholesterol ratio were identified as significant and independent risk factors for total MA, IHD, CVD, and PVD. Other risk factors identified were high dBP for IHD, CVD, and PVD, high sBP for total MA, and low BMI for PVD. These results clearly demonstrated that duration of diabetes, smoking, hypertension, and dyslipidemia are major risk factors for MA in NIDDM patients. Since the mean BMI was similar for both groups (approximately 23 kg/m2) and there were no significant differences in immunoreactive insulin levels before and after 75-g oral glucose challenge testing, obesity and hyperinsulinism at the time of the analyses were not considered to play an important role for the pathogenesis of MA in Japanese NIDDM patients. By using the chi 2 test, cutoff points were determined for six of the most commonly measured risk factors. The cutoff point was the level beyond which a significantly higher prevalence of MA occurred. The cutoff points (rounded slightly upward in some cases) for fasting plasma glucose, sBP, dBP, serum total cholesterol level, serum triglyceride level, and BMI were 140 mg/dl, 140 mmHg, 80 mmHg, 180 mg/dl, 120 mg/dl, and 23 kg/m2, respectively. When these cutoff points were used as control criteria, the prevalence of MA was significantly lower in subjects whose risk factor measurements remained under the proposed control criteria for four or more of the six variables. In conclusion, in nonobese NIDDM patients, age, hypertension, and dyslipidemia were found to be risk factors for MA. Duration of diabetes was also demonstrated as an independent risk factor, indicating the close association of deranged glucose metabolism with the pathogenesis of MA in NIDDM patients. It seems to be crucial to control these risk factors for the prevention of MA in NIDDM patients.