Sudden death of adults in Japan

Epidemiological features, risk factors and preventive methods of sudden death (SD) derived from studies the authors have performed since 1987 together with colleagues in Niigata University School of Medicine were reviewed. When SD was defined as death occurring within 24 hours of the onset of symptoms, the annual incidence was 145/100,000 for people aged 15 years and older in Niigata Prefecture. The incidence increased sharply along with the advance of age, while the proportion of SD to natural death due to circulatory diseases was higher in younger people. Though diseases of the circulatory system made up approximately 90 percent of all causes of death, SD due to ischemic heart disease was less frequent in Japan than in western countries. SD showed various patterns in seasonal and "within-a-day" occurrences according to sex, age and cause of death. The months of the highest SD occurrence differed by occupation and matched the busiest work periods. A decrease in sleeping hours and mental stress experienced during the preceding week were related to the occurrence of both sudden death and non-fatal acute myocardial infarction. People having structural circulatory diseases were shown to be predisposed to SD when stress occurred, because fatal arrhythmia is easily induced by the above factors in such people. Health examinations were shown to have preventive effects, though limited, against SD. Differences in the resuscitated rates in cases where a witness was present and where one was not indicates that educating people about correct resuscitation methods is important to minimizing SD.

Activity immediately before the onset of non-fatal myocardial infarction and sudden cardiac death

To investigate triggers for the occurrence of acute myocardial infarction (AMI) and sudden cardiac death (SCD), we examined the activities immediately before the time of onset in 149 cases of non-fatal AMI and 110 cases of SCD. All of the cases in which death occurred within 24 h from the onset of the underlying cause were considered SCD as long as the cause of death was of cardiac origin or unknown. We calculated the average time which is spent on each activity in the life cycle of Japanese people and estimated the number of incidence of each activity assuming a uniform distribution. Estimated values and actual values were compared. The results were as follows: 1) The incidence of non-fatal AMI and SCD was low while sleeping or resting or doing light work, and was high while using the toilet or doing sport or heavy work. 2) the incidence of SCD was also high even during moderate exertion, such as taking a bath or, walking or cycling, and it was significantly higher than that in the group of non-fatal AMI. 3) The incidence of non-fatal AMI was high while eating or drinking. 4) Many of the patients with SCD had past histories of circulatory diseases, compared to those with non-fatal AMI. This difference in past histories may account for the high incidence of SCD during moderate exertion.

[Clinical effects of beni-koji in mild essential hypertension--a multi-center double-blind comparison with placebo]

Antihypertensive effects of beni-koji were studied using 29 outpatients with mild hypertension in a placebo-controlled double-blind comparative fashion. After a 4-week vehicle (apple juice) run-in period, 13 patients were assigned to receive beni-koji aqueous extracts containing juice once daily (27 g of beni-koji eq. per day) for 8 weeks and 16 were assigned to vehicle. Two patients assigned to the vehicle group did not complete the study. In addition to casual blood pressure, 24-hr non-invasive ambulatory blood pressure (ABP) was monitored in 6 patients given the beni-koji drink and 5 patients given the vehicle. 1) In the beni-koji group, both casual systolic and diastolic pressure decreased significantly during the treatment period (from 150 +/- 10/96 +/- 6 mmHg to 140 +/- 10/89 +/- 10 mmHg, p < 0.01). The averages of the 24-hr blood pressure recorded in ABP (24-BP) also significantly decreased (from 141 +/- 17/95 +/- 13 mmHg to 132 +/- 21/86 +/- 10 mmHg, p < 0.05) when compared with those of the control period. Casual pressure normalized (less than 140/90 mmHg) in 4 patients who received beni-koji. Circadian variation of the blood pressure by ABP showed a significant decrease during the daytime. 2) In the vehicle group, casual systolic pressure did not change significantly (from 155 +/- 8 mmHg to 151 +/- 12 mmHg), but diastolic pressure decreased significantly (98 +/- 7 mmHg to 93 +/- 6 mmHg). Casual blood pressure did not normalize in any of the patients and 24-BP did not change significantly. 3) Summative evaluation of safety showed that no problems appeared in the beni-koji group. In conclusion, beni-koji appears to be an effective and safe food material for mild essential hypertension. The mechanism of the antihypertensive effect of beni-koji still remains to be investigated.

Lymphedema due to chronic penile strangulation: a case report

A 62-year-old man was admitted with swelling of the penis caused by long term use of a penis enlarging ring. For the previous 20 years, he had noticed small pruritic nodules on his penis. He had no micturitional or ejaculatory impairment. The penis had a diameter of 6 cm, a length of 10 cm, and was covered with thickened skin. The penis and the scrotal skin were covered with scattered, small, hemispheric nodules and papules ranging in size from 2 mm to 1 cm. Pathologic examination of the biopsied specimen from a nodule revealed enlargement of the lymphatic vessels of the dermis and fibrosis. This was compatible with lymphedema due to chronic strangulation by the ring. Scar resection and full thickness skin grafting was performed to prevent malignant changes in the lesions.

[Prognostic value of acute pulmonary vascular response to oxygen inhalation in patients with chronic obstructive pulmonary disease]

Seventy-two patients with chronic obstructive pulmonary disease (COPD) underwent right heart catheterization when they were clinically stable and the relationship between length of survival and acute pulmonary vascular response to 100% oxygen inhalation was studied. Oxygen inhalation significantly reduced mean pulmonary arterial pressure (PPA), cardiac index (CI), and pulmonary arteriolar resistance (PAR). The percent change in PAR (% delta PAR) was used as an index of the acute pulmonary vascular response to 100% oxygen inhalation. Each patient was classified as a responder (% delta PAR > or = 15%) or a nonresponder (% delta PAR < 15%). The cumulative survival rates of these two groups were compared. Responders survived significantly longer than did nonresponders (mean survival times were 2571 days and 1432 days, respectively). The two groups did not differ significantly in anthropometic data, pulmonary hemodynamics, or blood gas data measured at base line during air inhalation. However, FEV1 and VC were significantly lower in nonresponders than in responders. The % delta PAR was not significantly related to age, PPA, PAR on air inhalation, FEV1, FEV1%, VC or VC%. We conclude that the pulmonary vascular response to oxygen inhalation (% delta PAR) may be an independent prognostic factor in patients with COPD.

[High-dose inhaled beclomethasone in long-term management of chronic severe asthma--usefulness and dose-dependence]

We studied the usefulness of 18 weeks of therapy with two high doses of inhaled beclomethasone dipropionate (BDP) in the management of severe asthma in adults. The patients had asthma symptoms that had not been controlled by combination therapy with BDP (800 micrograms/day) and bronchodilators. They were divided into two groups. Patients in group A (n = 16) were treated with 1800 micrograms/day of BDP and bronchodilators. Patients in group B (n = 10) were treated with 1400 micrograms/day of BDP and bronchodilators. BDP was inhaled via a large spacer (Volumatic). Eleven patients in group A and 6 patients in group B had been given an oral steroid regularly before the study. Asthma symptom scores, peak expiratory flow (PEF), pulmonary function, bronchial reactivity to methacholine, the total amount of oral steroid, and adrenocortical function were recorded. Results. 1) Clinical characteristics before the start of the study did not differ between groups. 2) Asthma symptom scores decreased to a greater extent in patients who received the higher dose of BDP than in those who received the lower dose. 3) Only the higher dose of BDP significantly increased evening and morning % PEF, as measured 6 weeks and 8 weeks after the start of the treatment. 4) Only the higher dose of BDP significantly increased the FEV1 and the PC20 for methacholine. FVC did not increase. 5) Only the higher dose of BDP significantly decreased the total amount of oral steroid needed to control asthma. 6) Results of the rapid ACTH test indicated that neither dose of BDP suppressed adrenocoritical function. Furthermore, the serum cortisol level measured early in the morning increased to within the normal range in the three patients in whom oral steroid therapy could be reduced or stopped after treatment. These data indicate that 1800 micrograms of BDP per day is more effective than 1400 micrograms/day at the beginning of long-term management of severe chronic asthma in adults whose symptoms are not controlled with the combination of 800 micrograms/day BDP and bronchodilators. Therapy with a higher dose (at least 1600 micrograms/day) of an inhaled steroid is more useful and should be promptly begun to treat severe asthma.

[Relation of pulmonary hemodynamics and ventilation to tissue hypoxia during exercise in patients with tuberculosis sequelae]

We examined a relationship between tissue hypoxia and pulmonary hemodynamics or ventilatory capacity during rest and exercise in patients with tuberculosis sequelae. Nine patients performed exercise test until their symptom limit. Mean pulmonary arterial pressure (PPA) during exercise was plotted against cardiac index (C.I.) from rest to maximum exercise in each patient. In most of the patients, the changes of PPA showed linear relation with the C.I., and a slope (P-F slope) was obtained from the regression equation in each patient, and it was used as an index of circulatory disability during exercise. At the same time a coefficient of oxygen delivery (COD) was calculated and mixed venous oxygen tension (PvO2) was measured to evaluate a tissue hypoxia at rest and during exercise. The changes of COD were similar to those of PvO2 during exercise. COD positively correlated with PvO2 (R = 0.873, P < 0.01) from rest to maximal exercise, indicating that the values of PvO2 depended on those of COD. P-F slope negatively correlated with S.I. (R = -0.887, P < 0.01), oxygen transport (R = -0.780, P < 0.01), COD (R = -0.827, P < 0.01) and PvO2 (R = -0.760, P < 0.01) at maximal exercise. Whereas no significant relationship between ventilatory variables and COD or PvO2 was noted at maximal exercise. In conclusion, the patients with pulmonary tuberculosis sequelae who had a step P-F slope showed low mixed venous oxygen tension during exercise as a result of limited oxygen transport in consequence of low stroke volume.

Daily peaks in the incidence of sudden cardiac death and fatal stroke in Niigata Prefecture

To clarify the circadian variation in sudden death (SD) in Japan, where the causes of sudden death differ from those in the USA, we examined all of the death certificates from 1984 to 1986 in Niigata Prefecture, Japan. We defined SD as death which occurred within 1 h from the onset of the underlying cause. A significant circadian variation, with a high incidence between 6 and 8 am and a secondary peak between 6 and 8 pm, was found in the occurrence of sudden cardiac death (SCD, n = 2953). Although the proportion of SCD due to acute myocardial infarction (AMI) was as low as 28% of SCD cases, the circadian variation of SCD was similar to that previously reported in the USA. In SCD due to AMI in males (n = 487), a significant circadian variation with 3 peaks, including a primary peak between 4 and 6 am, was evident. There was also a marked increase in the incidence of fatal stroke between 6 and 8 pm (n = 529). We concluded that 1) a circadian variation with two peak incidences, one between 6 and 8 am, and one between 6 and 8 pm, was characteristic of SCD in general, 2) there was a primary peak between 4 and 6 am for SCD due to AMI in males, and 3) there was a peak between 6 and 8 pm in the incidence of fatal stroke for both men and women.

[Comparison of hormone therapy alone and in combination with chemotherapy of cisplatin and methotrexate in newly diagnosed patients with stage D2 prostatic cancer]

BACKGROUND

Prognosis of hormone-refractory prostatic cancer is dismal. We evaluated the efficacy of cytotoxic chemotherapy in combination with hormone therapy in patients with newly diagnosed metastatic prostatic cancer.

METHODS

From February 1984 to March 1992, 39 newly diagnosed patients with stage D2 prostatic cancer were randomized to orchiectomy plus diethylistilbestrol diphosphate or orchiectomy plus diethylstilbestrol diphosphate plus combination chemotherapy with cisplatin and methotrexate.

RESULTS

There was not significant difference in survival or progression-free survival between the two groups.

CONCLUSION

Chemotherapy has not been proved to prolong survival or progression-free survival in patients who received hormone therapy.

[Benefits and adverse effects of post-operative radiation therapy after radical cystectomy for patients with advanced bladder cancer]

BACKGROUND

The benefits and adverse effects of post-operative irradiation for advanced bladder cancer patients were investigated.

METHODS

Ten patients with pT3b, pT4 or pN+ bladder cancer who underwent radical cystectomy at Yamanashi Medical University hospital during 7 years and 3 months from October 1983 to December 1991 received adjuvant chemotherapy and radiotherapy (Group 1). During the same period, six patients with recurrent tumor after radical cystectomy were treated by radiotherapy (Group II). Stages of the primary tumors were pT2 in 1, pT3a in 2, pT3b in 6 and pT4 in 7 cases. In addition, 10 of 16 patients (63%) had positive nodes.

RESULTS

During the follow up period, seven patients died of cancer, and one died of other cause. As a result eight patients (5 in Group I, 3 in Group II) are alive. The cumulative 5-year survival rate is 50%. However, nine of the 16 patients (56%) suffered from the small bowel obstruction as an adverse effect of irradiation. Six patients required resection of the small bowel or bypass surgery.

CONCLUSIONS

Radiation after radical cystectomy seemed to be effective for the local control of the tumor, but the adverse effect to the digestive system was very severe and common.

[Cystic disease of the kidney]

The kidney is one of the most common sites of cyst. Since cystic disease of the kidney includes various disorders, it is difficult to classify the diseases systematically. It appears that the classification of the American Academy of Pediatrics is suitable for clinical side for the present. In this paper the cystic disease of the kidney is explained on actual cases. Recently, development of imaging diagnosis is contributing widely to the diagnosis of the diseases. Treatment of the diseases, however, is not established satisfactorily. It is hoped that the mechanism of occurrence of the diseases is known further and that regulation of the classification and establishment of the treatment will become available.

Effects of Mg2+ on the stimulation-induced changes in transmitter release at the frog neuromuscular junction

Four components of stimulation-induced changes in neurotransmitter release are known as the synaptic plasticity at the frog neuromuscular junction. These are: fast and slow facilitation, augmentation and potentiation, classified by their decay time constants after repetitive nerve stimulation. Most experiments support the view that fast facilitation is caused by residual Ca2+. However, the causes of the other three components are not clear. We have studied electrophysiologically the effect of Mg2+ on these three components. Transmitter release was estimated by the amplitudes of endplate potential (EPP) and by the frequencies of miniature endplate potential (MEPP). The increase in the transmitter release by nerve stimulation is described as the product of four components. The magnitude of potentiation of MEPP frequencies after a tetanic nerve stimulation (100 Hz, 5000 times) increased markedly in high Mg2+ concentrations. Conversely, the magnitude of augmentation (MEPP frequencies and EPP amplitude) decreased in the higher Mg2+ Ringer solution.

[A case of idiopathic pulmonary arteritis with positive anti-myeloperoxidase antibodies]

A 38-year-old woman was referred to our hospital for severe pulmonary hypertension (pulmonary arterial pressure 63/36 mmHg). Digital subtraction angiography showed complete obstruction of the right main pulmonary artery and severe stenosis of the left main pulmonary artery. Although there were no symptoms or signs of systemic arterial lesions, the initial diagnosis was aortitis syndrome with pulmonary arterial involvement, and prednisolone therapy was started (60 mg/day). Pulmonary arterial pressure decreased to 53/12 mmHg. At a dosage of 20 mg/day, however, multiple nodular shadows were present on the X-ray film of the chest, but they disappeared after the dosage was increased. The level of anti-myeloperoxidase antibodies in her serum changed at almost the same time as multiple nodular shadows appeared on the chest X-ray film. Because anti-MPO antibodies have been never detected in patients with aortitis syndrome, polyangitis overlap syndrome was suspected. However, we found no evidence of systemic vasculitis; that is, vasculitis in other organs, including the kidney and the skin. Therefore, we made a diagnosis of idiopathic pulmonary arteritis with positive anti-MPO antibodies.

Acute occlusion due to coronary dissection as a PTCA complication resolved by reentry achieved by pulling an inflated balloon in the true lumen

We experienced 2 patients in whom conventional percutaneous methods were not useful for acute occlusions sequel to coronary angioplasty. Acute occlusions seemed to be caused by large dissections. Pulling an inflated balloon at the dissected lesions achieved reentry from the false lumen to the true lumen, thus resolving collapse of the true lumen and recanalizing the occluded coronary artery.

[Relation of pulmonary vascular response to pressure-flow relationship during incremental exercise in patients with chronic obstructive pulmonary disease (COPD)]

Twenty-eight COPD patients underwent right heart catheterization while in clinically stable condition. Pulmonary vascular response to oxygen was evaluated by the percent change in pulmonary arteriolar resistance after 100% oxygen inhalation (% delta PAR), and its relation to the pressure-flow relationship during incremental exercise was assessed. Mean pulmonary arterial pressure (PPA) during exercise was plotted against the cardiac index (C.I.) from rest to maximal exercise in each patient. In most of the patients, the changes in PPA were nearly linear to the C.I. Therefore, a slope could be obtained from the regression equation in each patient. Patients were divided into two groups according to whether their % delta PAR was greater than 20 defined as a responder (RES), or less than five defined as a non-responder (N-RES). Seven out of 28 patients were RES, nine were N-RES, RES showed a higher %FEV1.0 level, C.I. and stroke volume index (S.I.) at maximal exercise, and a lower level of RV/TLC as well as slope. The slope correlated significantly with %DLCO (r = -0.724, p < 0.01), baseline PAR (r = 0.562, p < 0.01) and % delta PAR (r = -0.522, p < 0.01). These results suggest that the diminished pulmonary vascular bed, and the distensibility of pulmonary vessels, appear to contribute to the steepness of the slope and reduced % delta PAR in patients with COPD.

[Results of radical cystectomy for bladder cancer]

During 7 years and 3 months from October 1983 to December 1990, 68 patients underwent radical cystectomy for primary bladder cancer at Yamanashi Medical College. Of these 68 bladder cancers, 16 were superficial and 52 were invasive. Among the 52 patients with invasive cancer, a combination chemotherapy of methotrexate and cisplatin and/or radiotherapy were given in 18 as an adjuvant therapy. All the adjuvant therapies were performed after the operation except for 2 patients with T4 bladder cancer who received chemotherapy before the operation. There were 23 recurrences and 25 deaths, 20 from bladder cancer and 5 from other causes. Of 20 bladder cancer deaths, 17 deaths (85%) were observed within 2 years after the operation. The 5-year survival rates were 92% for stage pTa-pT1, 83% for stage pT2, 80% for stage pT3a, 24% for stage pT3b and 43% for stage pT4-T4, respectively. A significant difference (p < 0.05) in survival curve was observed between pT3a and pT3b. The 5-year survival rate for pT2-pT3a without nodal metastases was as high as 89% (95% confidence limits 75 to 100%) although 18 out of 19 patients received no adjuvant therapy. On the other hand, the 5-year survival rate for pT3b-pT4 without nodal metastases (25%) was as low as that of patients for any T category with nodal metastases (35%). Most patients with tumor confined within bladder wall seemed to be cured by surgery only. Therefore, any adjuvant chemotherapy with severe side effects seemed not to be justified for these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[The incidence of atherosclerotic lesions of the carotid artery in people of one community]

Carotid sonography were conducted in people of one community (122 males and 243 females) in 1990 and 1991. The intima-media thickness (IMT) in the main trunk and bifurcation-bulb areas of bilateral carotid arteries were measured in 122 males. IMTs of four areas increased with aging. In all cases, the average IMT of the right main trunk was 0.8 +/- 0.1 mm (mean +/- SD) and those of the remaining three areas were 0.9 +/- 0.2 mm. The IMT of the right bifurcation area in males aged 75 years or older was the thickest; i.e., 1.1 +/- 0.3 mm. Therefore, atherosclerotic lesions (AL) were defined as an IMT of 1.5 mm or more. The incidence of AL increased along with aging both in males and females. In those who were less than 65 years old, the incidence in males was 12.8% (10/78) and that in females was 9.0% (12/134). In those who were 65 years old or older, the incidence in males was 31.8% (14/44) and that in females was 26.9% (29/109). The incidence of AL tended to increase rapidly from 65 years of age in both males and females. Moreover, the incidence of AL in bilateral carotid arteries increased along with aging as well. Since IMT, the incidence of AL and that of AL in bilateral carotid arteries increased with aging, we considered that these parameters could be used as indices of the degree of general atherosclerosis.

Property variations of stone casts following high-temperature sterilization

The effects of high-temperature sterilization methods (boiling, dry-heating, autoclaving and chemiclaving) on the properties of four types of stone cast were determined. SEM observations were made of the cast surface before and after sterilization. High-temperature sterilization affected the properties of the stone casts. Boiling, dry-heating and autoclaving were considered to be unacceptable methods for sterilizing stone casts before making prosthetic restorations.

Angiotensin II receptors in the rat urinary bladder smooth muscle: type 1 subtype receptors mediate contractile responses

Angiotensin II (Ang II) receptors in the rat urinary bladder smooth muscle were investigated by in vitro responses of smooth muscle strips to exogenous Ang II stimulation and in radioligand binding assays. Ang II (10(-10) M. to 10(-5) M.) caused a potent contractile response in a concentration-dependent manner. Using the recently developed nonpeptide subtype-selective antagonists, the Ang II-induced contractile response was further characterized. The Ang II-induced contractile response was inhibited weakly by the type 2 subtype (AT2)-selective antagonist PD123319 but was potently inhibited by the type 1 subtype (AT1)-selective antagonist DuP 753 with a pA2 value of 9.03, suggesting that the response is mediated predominantly by AT1 receptors. [125I]Ang II was used to specifically label a single class of binding sites with a dissociation constant of 0.31 nM. and a maximal binding capacity of 41.5 fmol./mg. of protein. DuP 753 could completely antagonize the binding of Ang II in a particulate fraction of rat bladder (Ki = 14 nM), whereas PD123319 did not have any effect in the concentration range of 10(-9) to 10(-5) M. The results suggest that AT1 receptors rather than AT2 receptors predominantly mediate Ang II-induced contraction in the rat urinary bladder.

[A case of pulmonary thromboembolism associated with heparin-induced thrombocytopenia]

A 41-year-old man was admitted to our hospital for dyspnea on exertion and chest oppression. He was diagnosed as having pulmonary thromboembolism by pulmonary perfusion scan and angiography. An anticoagulant (heparin) and fibrinolytic (urokinase) therapy were administered to him as standard therapy. Six days after continuous infusion of heparin, however, he complained of worsening of dyspnea associated with severe hypoxemia and thrombocytopenia. Because heparin-induced thrombocytopenia was suspected, heparin administration was discontinued. Shortly after switching anticoagulant therapy from heparin to warfarin, the patient's symptom improved and his platelet count returned to the pretreatment value. In this case, it was thought that an immune-mediated response contributed to this heparin-induced thrombo-cytopenia. Moreover, we revealed platelet aggregating factor in the patient's plasma. This case illustrates that caution must be taken in the use of heparin for anticoagulant therapy in patients with pulmonary thromboembolism.

[A case of primary pulmonary artery sarcoma]

A 39-year-old male was admitted with persistent cough, palpitations and dyspnea on exertion. Chest X-ray showed cardiomegaly, left pleural effusion and left hilar mass shadow. Echocardiogram revealed dilatation and hypertrophy of the right atrium and ventricle. Perfusion lung scintigram disclosed a complete defect of the left lung and a partial defect of the right upper lobe. CT scan showed an intravascular tumor mass in the bilateral main pulmonary arteries. Digital subtraction angiography of the pulmonary artery revealed complete obstruction of the left pulmonary artery and stenosis of the right pulmonary artery. MR image showed intravascular tumor infiltrating the mediastinum and surrounding tissue. Sarcoma was highly suspected, but a histopathological diagnosis could not be made. The patient died of heart failure two months after admission to our hospital. Postmortem examination showed that the pulmonary trunk and left main pulmonary artery were markedly dilated and completely occluded by the tumor. Tumor infiltrated into the left upper lobe and mediastinal lymph nodes. The tumor was histologically diagnosed as undifferentiated sarcoma.