Lower mortality in patients with the DD genotype of the angiotensin-converting enzyme gene after acute myocardial infarction

OBJECTIVE

The angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism has been associated with different serum ACE concentrations and cardiac ACE activity. We assessed whether the ACE gene I/D polymorphism influenced cardiac mortality in Japanese patients with acute myocardial infarction.

METHODS AND RESULTS

The ACE gene I/D polymorphism was determined in 441 consecutive patients with a first myocardial infarction. There were 69 patients (16%) with the DD genotype, 194 patients (44%) with the ID genotype, and 178 patients (40%) with the II genotype. During a mean follow-up of 9.4 months, there were 49 cardiac deaths (DD, n = 4; ID, n = 26; II, n = 19). The DD genotype was significantly associated with a lower mortality than the other genotypes (p = 0.0363) by Cox regression analysis adjusted for age, sex, site of myocardial infarction, Killip functional class, reperfusion therapy during acute phase, ACE inhibitor use, and beta-blocker use.

CONCLUSIONS

In a selected cohort of Japanese patients, the DD genotype was associated with a significantly lower cardiac mortality after a first myocardial infarction.

Correcting for measurement error in binary and continuous variables using replicates

Measurement error in exposures and confounders leads to bias in regression coefficients. It is possible to adjust for this bias if true values or independent replicates are observed on a subsample. We extend a method suitable for quantitative variables to the situation where both binary and quantitative variables are present. Binary variables with independent replicates introduce two extra problems: (i) the error is correlated with the true value, and (ii) the measurement error probabilities are unidentified if only two replicates are available. We show that - under plausible assumptions - adjustment for error in binary confounders does not need to address these problems. The regression coefficient for a binary exposure is overadjusted if methods for continuous variables are used. Correct adjustment is possible either if three replicates are available, or if further assumptions can be made; otherwise, bounds can be put on the correctly adjusted value, and these bounds are reasonably close together if the exposure has prevalence near 0.5.

Lupus anticoagulant in myasthenia gravis associated with IgM gammopathy

The plasma of a patient with myasthenia gravis had strong lupus anticoagulant activity and his IgM paraprotein displayed non-specific inhibition to coagulation factors IX, XI, XII, prekallikrein, and high molecular weight kininogen. He was placed on prednisolone, which resulted in improvement in his myasthenic symptoms, but the prolongation of APTT and macroglobulinemia remained. Double filtration plasmapheresis successfully decreased the serum IgM level from 1,190 mg/dl to 375 mg/dl and APTT improved from 58 s to 38 s. Myasthenia gravis is frequently associated with other autoimmune diseases, but the association with lupus anticoagulant and IgM gammopathy is rare.

Depression among caregivers of elderly patients on chronic hemodialysis

The present study was conducted to investigate depression in caregivers of elderly hemodialysis patients. Caregivers answered a self-administered questionnaire about various factors that may affect their depression, and also completed a Center for Epidemiologic Studies Depression Scale evaluation (CESD). The frail elderly who received regular nurse visits were used as controls. Compared with the caregivers of controls, those of hemodialysis patients spent less time on caregiving and had more time to go out unaccompanied by their patients. Males were numerous among hemodialysis patients than in the controls. Compared with the controls, hemodialysis patients were less likely to be older old (80 years old and more), diagnosed as demented or severely limited in activities of daily living (ADL). On the other hand, we did not find any significant difference between the two groups with regard to either the prevalence of depression, the rate of those who experienced any life event such as to cause depression within 6 months (e.g., death of family member), duration of caregiving or time looking after patients. Caregivers of hemodialyis patients may feel a heavy burden because they are obliged to play an important role in supporting patients on dialysis. They seem to need more social support regardless of whether or not their patients suffer from dementia.

Prevalence and mortality of the Brugada-type electrocardiogram in one city in Japan

OBJECTIVES

We sought to study the prevalence and mortality of subjects exhibiting the Brugada-type electrocardiogram (ECG) in a community-based population in Japan.

BACKGROUND

The Brugada syndrome has been associated with sudden death in subjects without structural heart disease. Hospital-based studies showed 11% to 38% annual fatal arrhythmic events in patients with the Brugada syndrome.

METHODS

Prevalence and mortality of the Brugada-type ECG were studied in subjects who had ECGs during a health examination in Moriguchi, Osaka, Japan. Information about death and relocation from Moriguchi city was obtained prospectively.

RESULTS

The Brugada-type ECG was found in 98 of 13,929 study subjects (0.70%, 95% confidence interval [CI]: 0.57% to 0.86%). The typical coved-type with an rsR' pattern in V(1) lead ("typical" Brugada-type) was found in 0.12% of subjects (95% CI: 0.07% to 0.20%). The prevalence for male subjects with the Brugada-type ECG (81%) was significantly higher than it was for those without (26%, p < 0.0001). In male subjects, the Brugada-type ECG was found in 2.14% (95% CI: 1.70% to 2.66%), and the "typical" Brugada-type was found in 0.38% (95% CI: 0.21% to 0.64%). After 2.6 +/- 0.3 years of follow-up, there was 1 death (1.0%, 95% CI: 0.03% to 5.6%) of a subject with the Brugada-type ECG, whereas there were 139 deaths (1.0%, 95% CI: 0.85% to 1.2%) of those without the Brugada-type ECG (p = 0.9943, log-rank test).

CONCLUSIONS

A substantial number of the Brugada-type ECG were observed in subjects in a community-based population in Japan, especially in men. The total mortality of subjects with the Brugada-type ECG did not differ from the mortality of those without the Brugada-type ECG in a community-based population.

Role of hypertension, dyslipidemia and diabetes mellitus in the development of coronary atherosclerosis in Japan

The present study evaluated the effect of hypertension (HT), dyslipidemia and diabetes mellitus (DM) on the development of coronary atherosclerosis in the Japanese population, using a cross-sectional study of 433 patients (254 men and 179 women) aged 30 years or older who underwent coronary angiography for suspected or known coronary heart disease angina at 5 cardiology departments in the Fukuoka area between September 1996 and August 1997. Patients with a disease duration of 6 months or more were excluded. The main outcome measure was angiographically defined coronary artery stenosis and was found to a significant degree in 146 patients (33.7%). HT, DM, low levels of high-density lipoprotein cholesterol (HDL-C) and hypertriglyceridemia remained as significant coronary artery disease (CAD) risk factors even after controlling for age, sex, hospital, smoking, alcohol use, body mass index and leisure time physical activity. However, hypercholesterolemia was not a significant risk factor after adjusting for these variables. After controlling for these variables, DM, low HDL-C and hypertriglyceridemia were significant CAD risk factors for men, but only DM was a significant CAD risk factor in women. These results indicate that in Japan DM, low HDL-C and hypertriglyceridemia may be more important CAD risk factors than hypercholesterolemia.

Extraction of arsenic in a synthetic arsenic-contaminated soil using phosphate

An environment-friendly and cost-effective extraction method has been studied for the removal of arsenic from contaminated soil. A yellow-brown forest soil was contaminated with arsenic(V) and used as a model soil. Among various potassium and sodium salts, potassium phosphate was most effective in extracting arsenic, attaining more than 40% extraction in the pH range of 6-8 with minimum damage to the soil properties. Exchange mechanism is proposed for the extraction of arsenic from soil by phosphate. Sequential extraction shows that phosphate is effective in extracting arsenic of Al- and Fe-bound forms. Arsenic of residual form was not extracted. Arsenic was efficiently extracted by phosphate solution of pH 6.0 at 300 mM phosphate concentration and at 40 degrees C.

Association between blood concentration of polychlorinated biphenyls and manifestations of symptoms and signs in chronic "Yusho" patients from 1986 to 1997

To examine the association between blood PCB level and manifestations of symptoms and signs by Yusho patients, a cross-sectional study was conducted using the results of nationwide health examination for Yusho. The subjects were the officially identified Yusho patients who admitted the health examination from 1986 to 1997. The number of examinees with known blood PCB level was 334 in 1986, and decreased to 214 in 1997. The numbers of male and female patients were similar. The geometric mean (95% confidence interval) of blood PCBs concentration was 4.05 ppb (3.75 to 4.37) in 1986 and 2.85 ppb (2.63 to 3.08) in 1997. Multiple logistic regression analysis was carried out for the data of each year with log-transformed blood PCB level as an explanatory variable and a manifestation of a sign or symptom as a response variable. Sex and age adjusted odds ratio and significance level (P) were computed. Positive association of blood PCB level with manifestations of comedones on the trunk and acneiform eruptions on the genital and gluteal regions was statistically significant for five, eight and six times, respectively. No other symptoms or signs showed such strong associations. Associations between manifestations of these signs and blood PCB level, however, did not seem to diminish in the twelve years of observation. It is suggested that the positive association of these signs with blood PCB level will still be maintained.

Alcohol consumption and severity of angiographically determined coronary artery disease in Japanese men and women

The relation of alcohol consumption to the severity of coronary atherosclerosis was examined among 323 men and 220 women who underwent coronary arteriography. Severity of coronary atherosclerosis was assessed by the number of vessels obstructed > or =75% in diameter and Gensini's severity score. Alcohol consumption was divided into 5 categories in men (never, past, 1-24, 25-49, and > or =50 ml per day) and 3 categories in women (never, past, and current). Among men, odds ratios of severe stenosis (multiple-vessel disease or Gensini's score >15) decreased substantially and significantly in all current drinking categories but without dose-response effect. There was a weak, inverse association of current alcohol consumption with one-vessel disease, but not with moderate stenosis in terms of Gensini's score (< or =15). Past drinkers showed a fairly large, but statistically nonsignificant, decrease in the odds ratios of not only severe stenosis but also of moderate stenosis. Among women, current drinkers showed a small, statistically nonsignificant decrease in the risk of severe stenosis in terms of Gensini's score. These associations with alcohol use did not change after adjustment for known coronary risk factors. The present findings add to evidence that alcohol drinking confers protection against coronary atherosclerosis.

Successful staged-Fontan operation in a patient with ectopia cordis

Ectopia cordis is a very rare and often fatal disease. We report a successful surgery case of thoracoabdominal ectopia cordis with univentricular heart. This patient underwent a three-stage Fontan procedure, a right-modified Blalock-Taussig shunt at the age of 1 month, bidirectional Glenn shunt and pulmonary arterioplasty at 2 years 8 months, and finally a total cavopulmonary connection at 4 years. This patient was discharged from the hospital in good condition and has been doing well since. Thus, ectopia cordis is not a contraindication for a Fontan operation.

Obesity, body fat distribution and coronary atherosclerosis among Japanese men and women

OBJECTIVE

To investigate the relation of the obesity and body-fat distribution with angiographically defined coronary atherosclerosis.

DESIGN

Cross-sectional study in a clinical setting.

SUBJECTS

Three hundred and twenty men (median age, 59 y) and 212 women (median age, 67 y) who underwent coronary angiography for suspected or known coronary heart disease at 5 cardiology departments between September 1996 and August 1997. Patients with disease duration >1 y were excluded.

MEASUREMENTS

The body mass index (BMI) and the waist to hip circumference ratio (WHR) were used as main exposure variables, and either the presence of significant coronary stenosis or the Gensini's score (> or =10 vs<10) as an outcome variable, in a sex-specific multiple logistic regression analysis controlling for age, hospital, and other coronary risk factors.

RESULTS

Among male patients, BMI was progressively higher with an increasing number of vessels involved (P trend=0.05); the adjusted odds ratios for the presence of significant stenosis across quartiles of BMI were 1.0 (reference), 1.1, 1.9 and 2.5 (P trend=0.02), and the positive association was more pronounced for younger patients. Among females, however, such associations were not evident. Employing the Gensini's score as an outcome gave similar results. WHR was not significantly associated with either outcome regardless of sex.

CONCLUSION

These results suggested that BMI was predictive of coronary stenosis among male patients, but not among female patients. Unlike most previous studies, this study failed to detect a positive association with WHR.

Fibrinogen Matsumoto V: a variant with Aalpha19 Arg-->Gly (AGG-->GGG). Comparison between fibrin polymerization stimulated by thrombin or reptilase and fibrin monomer polymerization

Fibrinogen Matsumoto V (M-V) is a dysfibrinogen identified in a 52-year-old woman with systemic lupus erythematous. The triplet AGG encoding the amino acid residue Aalpha19 was replaced by GGG, resulting in the substitution of Arg-->Gly. Residue Aalpha19 has been shown to be one of the most important amino acids in the so-called 'A' site or alpha-chain knob. The thrombin-catalyzed release of fibrinopeptide A from M-V fibrinogen was only slightly delayed yet release of fibrinopeptide B was significantly delayed. Both thrombin-catalyzed fibrin polymerization and fibrin monomer polymerization were markedly impaired compared to normal fibrinogen. In addition, reptilase-catalyzed fibrin polymerization of M-V was much more impaired than thrombin-catalyzed fibrin polymerization. These results indicate 'B' and/or 'b' site of M-V fibrinogen play a more important role in thrombin-catalyzed fibrin polymerization than that of normal control fibrinogen.

Effects of nonpulsatile left heart bypass on renal sympathetic nerve activity in rabbits

To determine the effects of nonpulsatile left heart bypass (LHB) on sympathetic nerve activity the renal sympathetic nerve activity (RSNA) was directly measured in rabbits. In anaesthetized rabbits (n=6), LHB was instituted with a centrifugal pump. Before and during LHB, heart rate (HR), arterial pressure (AP), central venous pressure (CVP), left atrial pressure (LAP) and spike counts of RSNA were measured. After bilateral vagotomy (section of the afferent inputs of the cardiac reflex arc) the same parameters were measured before and during LHB. Data were obtained at the same level of mean AP before and during LHB. Mean AP and CVP were not changed by LHB before and after vagotomy. LAP was significantly decreased by LHB before and after vagotomy. RSNA and HR were not significantly changed by LHB before and after vagotomy. Our results clarify the complex baroreflex control during nonpulsatile LHB and indicate that RSNA is not altered by LHB.

[Patching of the raw surface of the posterior right ventricular wall in Ross procedure to prevent bleeding and to confirm anastomosis of the conduit]

An 8-year-old boy underwent Ross procedure to repair aortic regurgitation and subaortic stenosis. In reconstruction of the right ventricular outflow tract, the raw surface of the right ventricular posterior wall was covered with autologous pericardial patch to prevent bleeding and to confirm the anastomosis of the pulmonary tract conduit made of expanded polytetrafluoroethylene. Bleeding from the posterior wall was absent and he led uneventful postoperative course. Same technique was used in 4 other patients, and satisfactory results were obtained. This technique, first reported from India, seems very useful in Ross procedure.

Determinants of ventricular arrhythmias in hemodialysis patients. Evaluation of the effect of arrhythmogenic substrate and autonomic imbalance

BACKGROUND/AIMS

In chronic hemodialysis patients, we evaluated determinants of repetitive ventricular tachyarrhythmias which included late potentials and heart rate variability.

METHODS

We compared the presence of late potentials and heart rate variability obtained by ambulatory electrocardiogram (ECG), findings of echocardiography, and laboratory data between patients with and those without ventricular arrhythmias of Lown class 4A or 4B. Ambulatory ECG was recorded for 24 h from the beginning of hemodialysis. Heart rate variability was evaluated by the standard deviation of the normal RR interval (SDNN).

RESULTS

Thirty patients (17%) had ventricular arrhythmias of Lown class 4A or 4B. They were older than patients without such arrhythmias (p=0.0021). Left-ventricular wall motion score (2.0+/-3.9 and 0.3+/-1.2, respectively, p < 0.0001) and left-ventricular mass index (167 +/-59 and 140+/-44 g/m2, respectively, p=0.0053) were larger in patients with ventricular arrhythmias of Lown class 4A or 4B than in those without. Stepwise logistic regression analysis was performed to select variables related to ventricular arrhythmias of Lown class 4A or 4B from the following 8 candidate variables; age, sex, presence of ischemic heart disease, diabetic nephropathy as the primary renal disease, presence of late potentials, SDNN, left-ventricular wall motion score and left-ventricular mass index. Higher left-ventricular wall motion score (p < 0.0001), older age (p=0.0022) and male sex (p=0.0235) were the variables associated with ventricular arrhythmias of Lown class 4A or 4B.

CONCLUSION

In patients receiving hemodialysis, predominantly with chronic glomerulonephritis, ventricular arrhythmias of Lown class 4A or 4B were not associated with arrhythmogenic substrate revealed by late potentials or autonomic dysfunction assessed by heart rate variability. Left-ventricular wall motion abnormalities, age and sex were significant factors.

Effects of intra-aortic ballon pumping on renal sympathetic nerve activity and renal circulation in dogs

BACKGROUND

Little is known on how intra-aortic balloon pumping (IABP) affects neural circulatory regulation, even though many studies have been done to clarify the effects of IABP on hemodynamics. Although IABP is used clinically in patients with severe heart failure, whose sympathetic nerve activity is increased, there are no previous reports that demonstrate the effects of IABP on neural regulation in heart failure. The aim of this study is to determine the effects of IABP on neural regulation of renal circulation with both normal and failing heart condition in dogs.

METHODS

We directly measured renal sympathetic nerve activity and hemodynamic parameters (heart rate, central venous pressure, distal aortic pressure, proximal aortic pressure, left ventricular pressure, renal sympathetic nerve activity, ascending aortic flow, and renal arterial flow) before and during IABP driving in both normal and failing heart condition in dogs (n=7). Acute heart failure models were made by coronary ligation.

RESULTS

IABP driving inhibits renal sympathetic nerve activity and improves renal circulation in failing heart condition, while these phenomena do not occur in normal heart condition.

CONCLUSIONS

These findings suggest that IABP may show its full effect on renal circulation via neural regulation especially in failing heart condition.

A chromosomal locus encoding a phosphoserine phosphatase- and a truncated MinD-like protein affects differentiation in Streptomyces azureus ATCC14921

We isolated BalA1, a representative transformant of thiostrepton-producing strain Streptomyces azureus ATCC14921, which carries an approximately 2.5-kb chromosomal DNA fragment on a high-copy-number plasmid. While strain BalA1 formed little aerial hyphae, its morphological defect was restored by cultivation with S. azureus, S. laurentii, etc. Strain BalA1 strongly inhibited the growth of Bacillus subtilis more than its parent strain, and also inhibited the development of its parent and some Streptomyces strains with thiostrepton resistance. Furthermore, it induced Streptomyces coelicolor A3(2) to produce undecylprodigiosin, at an early stage of growth. The 2.5-kb fragment contained two orfs, orf1 and truncated orf2. The deduced products were somewhat similar to phosphoserine phosphatase-like protein and the N-terminal region of MinD-like protein, respectively. The individual function of orf1 or the function of both orf1 and truncated orf2 seems to induce particular phenotypes or properties in strain BalA1.

Relation between green tea consumption and the severity of coronary atherosclerosis among Japanese men and women

PURPOSE

To examine the relation between green tea consumption and arteriographically determined coronary atherosclerosis.

METHODS

Study subjects were 512 patients (302 men and 210 women) aged 30 years or older who underwent coronary arteriography for the first time at four hospitals in Fukuoka City or one hospital in an adjacent city between September 1996 and August 1997. Lifestyle characteristics including green tea consumption were ascertained before arteriography by a questionnaire supported with interview.

RESULTS

117 men (38.7%) and 50 women (23.8%) had significant stenosis of one or more coronary arteries. Green tea consumption tended to be inversely associated with coronary atherosclerosis in men, but not in women. An evident, protective association between green tea and coronary atherosclerosis was observed in a subgroup of 262 men excluding those under dietary or drug treatment for diabetes mellitus. In this subgroup, after adjustment for traditional coronary risk factors and coffee, odds ratios of significant stenosis for consumption of 2-3 cups and 4 or more cups per day were 0.5 (95% confidence interval 0.2-1.2) and 0.4 (0.2-0.9), respectively, as compared with a consumption of one cup per day or less.

CONCLUSIONS

The results indicate that green tea may be protective against coronary atherosclerosis at least in men.

Extraction of heavy metals from MSW incinerator fly ash using saponins

An extraction process with saponins was evaluated for removing heavy metals from MSW (municipal solid waste) incinerator fly ashes. Two different fly ashes, A and B, were treated on a laboratory scale with three triterpene-glycoside type of saponins, M, Q, and T, in the pH range 4-9. The results were compared with those of the HCI and EDTA treatment. The treatment with saponins extracted 20-45% of Cr from the fly ashes. Saponins were also effective in extracting Cu from fly ash A attaining 50-60% extraction. Saponin T extracted 100% of Pb from fly ash A at pH around 4. The extraction of Zn with the saponin treatment was similar to that of the HCl treatment. Further, Cr, Cu, Pb, and Zn were fractionated by sequential extraction to investigate the effect of saponins on each fraction. Extraction behavior of other elements during the saponin treatment was also studied. The leaching test on the residues received after the saponin treatment showed that the fly ashes were successfully detoxified to meet the landfilling guideline.

Early experience of off-pump coronary artery bypass using Octopus Tissue Stabilizer

OBJECTIVE

The Octopus Tissue Stabilizer stabilizes segments of the beating heart using a series of suction cups that do not damage myocardial tissue or compromise hemodynamics. This allows the heart to be positioned with the arterial target on a stable platform. In this study we present our early experience of off-pump coronary artery bypass using the Octopus Tissue Stabilizer.

METHODS

Between October 1997 and June 1998, 50 patients underwent off-pump coronary artery bypass using the Octopus Tissue Stabilizer (7.5% of all coronary artery bypass cases; average age: 67.0 +/- 12.2). Preoperative ejection fraction was 15-70% (43.0 +/- 14.0%). Median sternotomy was used for all operations.

RESULTS

The average number of grafts per patient was 2.5 +/- 0.9. The average operating time was 191 +/- 47 minutes. No patients returned to the operating room for postoperative bleeding or tamponade. Average intraoperative blood loss was 297 +/- 190 ml. No patient experienced perioperative myocardial infarction. There were five hospital deaths and one late death. All patients were free of angina at discharge. No patients returned with angina or required clinical restudy.

CONCLUSIONS

Off-pump coronary artery bypass offers the surgeon another tool to apply for appropriate patients. The Octopus Tissue Stabilizer allows the surgeon access to all parts of coronary circulation, extending the range of off-pump coronary artery bypass procedures, when the anatomy is appropriate.

Extraction of heavy metals from MSW incinerator fly ashes by chelating agents

An extraction process has been studied on a laboratory scale for the pretreatment of municipal solid waste (MSW) incinerator fly ash to remobilize Cr, Cu, Pb, and Zn. Five different types of fly ashes were treated with HCl, nitrilotriacetic acid (NTA), ethylendiaminetetraacetate (EDTA), or diethylenetriaminepentaacetate (DTPA) in a batch process in the pH range 2.5-10. The extraction of heavy metals by HCl was dependent on pH, increasing with increasing acid concentration. The efficiency of the chelating agents was independent of pH. By the treatment with 3.0% EDTA or DTPA, 20-50% of Cr, 60-95% of Cu, 60-100% of Pb, and 50-100% of Zn were extracted in the pH range 3-9. NTA was also effective in extracting Cr, Cu, and Zn. The maximum extraction of Cr, Cu, Pb, and Zn was obtained at 0.3-1.0% concentration of the chelating agents. NTA was effective in extracting Pb at a concentration as low as 0.1%. Extraction behavior of other elements during the treatment was also studied. The leaching test on the residues after the treatment with chelating agents showed that the fly ashes were successfully detoxified to meet the guideline for landfilling.

Job strain, Type A behavior pattern, and the prevalence of coronary atherosclerosis in Japanese working men

OBJECTIVE

To examine the relation of type A behavior pattern and job strain to angiographically documented coronary stenosis.

METHODS

Subjects were 197 male Japanese patients with a full-time job. A questionnaire-based interview elicited psychosocial and other factors. Type A behavior pattern was measured by 12 questions, and job strain by the method of Karasek. Significant coronary stenosis was defined when a 75% or greater luminal narrowing occurred at one or more major coronary arteries or when a 50% or greater narrowing occurred at the left main artery. Logistic regression analysis was used to calculate odds ratio (OR) and 95% confidence interval (CI) with adjustment for traditional coronary risk factors and job type.

RESULTS

Type A behavior pattern was related to a statistically non-significant lower prevalence of the coronary stenosis especially in the absence of job strain (adjusted OR 0.6, 95% CI 0.3-1.2). Job strain was non-significantly associated with a modestly increased prevalence of coronary stenosis (OR 1.7, 95% CI 0.6-5.2).

CONCLUSION

These findings suggest that both the behavioral pattern and psychosocial work environment may be related to coronary artery stenosis.

Effects of low doses of caffeine on aggressive behavior of male rats

To date, the effect of low doses of caffeine on aggression has not been systematically examined. Doses of caffeine greater than 30 mg/kg appear to reduce social interaction and aggression in all species studied. In a double blind study of the effects of low doses of caffeine on aggression, rats were housed four per cage, and aggressive behavior against an intruder was recorded during baseline and following administration of 2.5, 5, 10, and 20 mg/kg caffeine. Aggressive behavior was significantly increased following administration of the higher doses of caffeine. Doses of 5, 10, and 20 mg/kg caffeine all were effective in increasing pushing behavior, whereas doses of 5 and 10 mg/kg were most effective in increasing boxing behavior, and a dose of 10 mg/kg was significantly more effective than other doses in increasing chasing and roll-tumble-bite behaviors. Based on these results and other published reports, the inverted-U shaped dose-dependent effect of caffeine on aggression appears to apply, with aggressive behavior being most elevated following doses of 5-20 mg/kg caffeine, less elevated following 2.5 mg/kg or 30 mg/kg, and significantly reduced with doses above 40 mg/kg and at doses below 2.5 mg/kg.

[Response to immunoadsorption and steroid therapies in a patient with carcinomatous Lambert-Eaton myasthenia syndrome accompanied by disturbed consciousness]

A 75 year-old man developed gait disturbance and somnolence over a period of three months. Electroencephalography indicated theta slowing and cerebrospinal fluid (CSF) examination showed an increased cell count of 23/microliter and IgG of 7.2 mg/dl. He showed fatigue-inducing muscle weakness and the Harvey-Masland test demonstrated a low M-wave amplitude of 0.6 mV which increased to 3 mV with 50 Hz high-frequency stimulations. The serum titer of P/Q type anti-voltage-gated calcium channel (VGCC) antibody was quite high at 11,901 pmol/L (< 20 pmol/L). The patient was diagnosed as Lambert-Eaton myasthenia syndrome (LEMS) although at first no carcinoma was detected. Immunoadsorption therapy with a phenilalanine absorber column resulted in a reduction in the titer of anti-VGCC antibody to half of the initial concentration, but it increased again within several days. Six repeats of immunoadsorption and concomitant administration of prednisolone at a dose of 40 mg daily succeeded in reducing the anti-VGCC antibody titer of to below 390 pmol/L. The patient's consciousness disturbance and muscle weakness improved simultaneously over the next month and the lumbar puncture and electroencephalography showed normal results. Prednisolone administration was maintained at a dose of 30 mg daily and one year after occurrence of the first symptoms, a small cell lung carcinoma was detected. There was no evidence of limbic encephalitis such as an elevation of anti-Hu antibody in his CSF and serum or abnormal signal intensities in the hippocampal formations on MR imaging. The etiology of his disturbed consciousness remained unclear, but, in the case of LEMS, it could be a manifestation of a paraneoplastic syndrome associated with small-cell lung carcinoma. It is noteworthy that the anti-VGCC antibody titer rose to 1,262 pmol/L 2 months before his tumor was detected and decreased to 286 pmol/L after chemotherapy. P/Q type anti-VGCC antibody could therefore be a useful tumor marker reflecting activity of small-cell carcinoma.

Small cell carcinoma of the bladder. Two cases diagnosed by urinary cytology

BACKGROUND

Primary small cell carcinoma (SCC) of the bladder is a rare but important entity. We report two cases of SCC of the bladder diagnosed by urinary cytology.

CASES

A 71-year-old male (case 1) and a 79-year-old female (case 2) presented with asymptomatic gross hematuria. Urinary cytology in case 1 showed the presence of a few undifferentiated malignant small cells and many transitional cell carcinoma (TCC) cells with a bloody and necrotic background. The former cells were small and round, with naked, hyperchromatic nuclei and finely granular chromatin. Pathologic diagnosis after total cystectomy was TCC > SCC > adenocarcinoma, T2M0N0. Urinary cytology of case 2 showed the presence of many undifferentiated malignant small cells and many TCC cells with or without squamous metaplasia. Cytologic features of the former cells were almost the same as those in case 1. Moreover, these cells were neuroendocrine marker positive by immunocytochemistry. Pathologic diagnosis after tumor resection was SCC and TCC > squamous cell carcinoma, T1b.

CONCLUSION

The prognosis of primary SCC of the bladder is usually poor. Because our cases were found by urinary cytology at a relatively early stage, both have been well, without any evidence of recurrence, 30 and 25 months after surgery even without adjuvant therapy.