Impact of intrathecal IgG synthesis on neurological disability in patients with multiple sclerosis

BACKGROUND

The association between routine laboratory findings, including cerebrospinal fluid biomarkers, and neurological outcomes in patients with multiple sclerosis (MS) has not been fully elucidated. In this study, we evaluated blood and cerebrospinal fluid (CSF) analysis results at diagnosis and before treatment in patients with MS and assessed their correlations with neurological outcomes.

MATERIALS AND METHODS

In this study, 38 consecutive patients with MS (36 with relapsing-remitting MS and 2 with primary progressive MS) were recruited. Before treatment, all patients underwent routine CSF analysis at the time of diagnosis, including evaluation of albumin and immunoglobulin G (IgG) levels. The association between laboratory data and neurological outcomes was comprehensively evaluated. Subsequent neurological outcome was assessed by using the Expanded Disability Status Scale (EDSS) score at 1 year and 5 years after diagnosis and relapse frequency in the first year and in the first 5 years.

RESULTS

The IgG level in the CSF (rho = 0.46, p = 0.004), oligoclonal band count (rho = 0.61, p = 0.006), ratio of IgG and total protein in CSF (rho = 0.59, p < 0.0001), and ratio of IgG and albumin in CSF (rho = 0.67, p < 0.0001) showed moderate to strong correlations with the subsequent EDSS score 1 year after diagnosis. These variables still showed significant correlations with EDSS 5 years later. Albumin and lactate dehydrogenase levels in CSF did not correlate with the subsequent EDSS score. Relapse frequency did not correlate with any of the studied serum and CSF biomarkers.

CONCLUSION

IgG levels in CSF at MS diagnosis are significantly correlated with the level of neurological disability independent of the relapse frequency. Markers of intrathecal IgG synthesis, such as the IgG index, are useful in estimating the present and subsequent clinical severity in patients with MS.

Ratio of diastolic to systolic blood pressure represents renal resistive index

Increased intrarenal vascular resistance is suggested to accompany chronic kidney diseases (CKD), which is known to be closely associated with hypertension. However, there are few studies that have examined the relationship between blood pressure and intrarenal vascular resistance. Renal color Doppler ultrasonography is one method that can non-invasively evaluate intrarenal vascular resistance. In this study, we comprehensively studied the correlations between ultrasonic parameters and blood pressure indices to elucidate their relationships. In total, 162 patients with suspected CKD were enrolled for this study. Demographics, blood pressure, blood test, urine test, and renal color Doppler ultrasonography data were obtained. The ratio of diastolic to systolic blood pressure (D/S ratio) and pulse pressure were calculated. Our results indicated strong negative correlations between the renal resistive index (RI) values in all four of the studied kidney regions and the D/S ratio. The RI values also showed significant correlations with diastolic pressure and pulse pressure, but they were weaker. Partial correlation coefficients between pulse pressure, mean arterial pressure, D/S ratio, and RI showed that D/S ratio significantly correlated with RI, but pulse pressure or mean arterial pressure did not. Systolic blood pressure did not correlate with any of the studied ultrasonic values. The negative correlation between RI values and the D/S ratio was still observed in subjects without renal dysfunction or any medications. In conclusion, D/S ratio, rather than pulse pressure or mean arterial pressure, would be the most appropriate index to estimate/calculate/judge intrarenal vascular resistance.

Characteristics and course of patients treated with Kampo Medicine in the Department of General Medicine

BACKGROUND

A recent investigation reported that 92.7% Japanese family physicians have prescribed Kampo medicine (KM). KM can treat a wide variety of conditions from mental disorders to physical weaknesses. However, the characteristics and course of patients treated with KM at the Department of General Medicine remain unclear.

AIMS

To investigate the characteristics and course of patients treated with KM in our hospital.

METHODS

Data on medical history, complaints, course after Kampo treatment, and Hamilton Depression Rating Scale (HAM-D) scores were retrogradely collected. The background of patients who received Kampo treatment was compared to that of patients who did not.

RESULT

Of 362 patients, 51 were treated with KM. Symptoms for which KM was prescribed included pain, general malaise, or sensory disturbance of extremities. All patients treated with KM were screened and initially diagnosed with a functional disorder or noncritical condition. KM including a crude drug of saiko such as hochuekkito, shigyakusan, shosaikoto, and yokukansan, was frequently prescribed for patients. Subjective symptoms showed improvement (53%) and no change (47%), while worsening was not observed in any patient. HAM-D scores showed that patients treated with KM had higher anxiety levels and related symptoms as well as a higher frequency of mental disorders prior to presenting at the hospital.

CONCLUSION

Most complaints of the patients treated with KM were pain, general malaise, and sensory disturbance. KM is more likely to be prescribed in patients with health-related anxiety or a history of mental disorders.

Reno-protective effects of oral alkalizing agents in chronic kidney disease with aciduria: protocol for a randomized cohort study

Background

Aciduria caused by urinary excretion of acidic metabolic wastes produced in daily life is known to be augmented in patients with chronic kidney disease (CKD). To evaluate the reno-protective effect of oral alkalizing agents for the improvement of metabolic acidosis and neutralization of intratubular pH in the patients with mild stages of CKD. Also, to identify reno-protective surrogate markers in the serum and urine that can closely associate the effect of urine alkalization.

Methods

In this single-centered, open-labeled, randomized cohort study, patients with CKD stages G2, G3a and G3b, who visited and were treated at Tohoku University Hospital during the enrollment period were registered. We administered sodium bicarbonate or sodium-potassium citrate as the oral alkalinizing agents. A total of 150 patients with CKD will be randomly allocated into the following three groups: sodium bicarbonate, sodium-potassium citrate and standard therapy group without any alkalinizing agents. The data of performance status, venous blood test, spot urine test, venous blood-gas test, electrocardiogram, renal arterial ultrasonography and chest X-ray will be collected at 0, 6, 12 and 24 weeks (short-term study) from starting the interventions. These data will be also collected at 1 and 2 years (long-term study). The samples of plasma and serum and early-morning urine at every visit will be acquired for the analysis of renal function and surrogate uremic biomarkers.

The recruitment for this cohort study terminated in March, 2018, and the follow-up period for all the enrolled subjects will be terminated in December, 2020. The primary endpoint will be the development of originally-defined significant renal dysfunction or the occurrence of any cerebrovascular disease in the short-term study. The secondary endpoint will be the same endpoints as in the long-term study, or the patients with significant changes in the suggested the surrogate biomarkers.

Discussion

The findings of this study will address the importance of taking oral alkalizing agents in the patients with early stages of CKD, furthermore they could address any new surrogate biomarkers that can be useful from early stage CKD.

Trial registration

Registered Report Identifier: UMIN000010059 and jRCT021180043.

The trial registration number; 150.

Date of registration; 2013/02/26.

Risk factors of attacks in neuromyelitis optica spectrum disorders

Predisposing factors before the onset of neuromyelitis optica spectrum disorders (NMOSD) have not been systematically evaluated by now. We investigated the detailed pre-onset history in consecutive NMOSD patients. Thirteen of the enrolled 53 NMOSD patients (24.5%) had accompanying autoimmune diseases, such as Sjögren's syndrome. History of malignancy was seen in 8 of the 53 patients (15.1%). Recent history of non-neurological clinical episodes, such as systemic allergic reaction, systemic infection, surgical operation, or traumatic injury, was seen in 23 of the 53 patients (43.4%). NMOSD patients are likely to have pre-onset history of other autoimmune diseases, malignancy, or recent non-neurological systemic conditions, which may predispose or trigger the onset of NMOSD.

Number of MRI T1-hypointensity corrected by T2/FLAIR lesion volume indicates clinical severity in patients with multiple sclerosis

INTRODUCTION

Progressive brain atrophy, development of T1-hypointense areas, and T2-fluid-attenuated inversion recovery (FLAIR)-hyperintense lesion formation in multiple sclerosis (MS) are popular volumetric data that are often utilized as clinical outcomes. However, the exact clinical interpretation of these volumetric data has not yet been fully established.

METHODS

We enrolled 42 consecutive patients with MS who fulfilled the revised McDonald criteria of 2010. They were followed-up for more than 3 years from onset, and cross-sectional brain volumetry was performed. Patients with no brain lesions were excluded in advance from this study. For the brain volumetric data, we evaluated several parameters including age-adjusted gray-matter volume atrophy, age-adjusted white-matter volume atrophy, and T2-FLAIR lesion volume. The numbers of T1-hypointense and T2-FLAIR-hyperintense areas were also measured along the same timeline. The clinical data pertaining to disease duration, expanded disability status scale (EDSS), and MS severity score (MSSS) at the timing of volumetry were collected.

RESULTS

Among the 42 patients with MS and brain lesions, the number of T1-hypointensity (rho = 0.51, p<0.001), gray-matter atrophy (rho = 0.40, p<0.01) and white-matter atrophy (rho = 0.49, p<0.001) correlated with the EDSS. T1-hypointensity count divided by FLAIR lesion volume correlated with the MSSS (rho = 0.60, p<0.001). Meanwhile, counts or volumes of FLAIR-hyperintense lesions were associated only with the times of past relapses, and did not correlate with present neurological disability level or ongoing disease activity. These findings were consistent regardless of the presence of spinal cord lesions.

CONCLUSION

Numbers of T1-hypointensities and brain atrophy equally indicated the current neurological disability in MS. The number of T1-hypointensities divided by FLAIR lesion volume represented the clinical severity. The size or number of FLAIR lesions reflected earlier relapses but was not a good indicator of neurological disability or clinical severity.

Clinical Usefulness of Endoscopy, Barium Fluoroscopy, and Chest Computed Tomography for the Correct Diagnosis of Achalasia

Objective The definite diagnosis of esophageal achalasia is established using manometry, which is performed in patients with suspected achalasia based on the findings of screening examinations, such as upper gastrointestinal endoscopy, chest computed tomography (CT), or a barium swallow test. However, the exact values of test characteristics in these supportive diagnostic examinations remain unclear. Methods We estimated the sensitivity and specificity of characteristic findings in the supportive diagnostic examinations for achalasia by comparing the data of a large number of achalasia patients and others with digestive symptoms. Patients Achalasia patients (n=119) and non-achalasia patients with suspected achalasia and repeated feelings of chest discomfort (n=37) who were treated in a single university hospital. Results Characteristic findings on chest CT (i.e., dilated esophagus, air-fluid level formation) and barium swallow tests were observed in more than 80% of achalasia patients but in less than 10% of non-achalasia patients. In contrast, conventional characteristic findings of upper gastrointestinal endoscopy (i.e., intra-esophageal food debris, feeling of resistance at the esophagogastric junction) were seen in only 40-70% of achalasia patients. In particular, the feeling of resistance at the esophagogastric junction was observed by the examiner in only 30-50% of patients. Conclusion Intra-esophageal food debris or resistance at the esophagogastric junction on upper gastrointestinal endoscopy will be positive in only about half of patients with achalasia. Other supportive diagnostic examinations, such as chest CT or barium fluoroscopy, should therefore be included in order to avoid overlooking the disease.

Successful Treatment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome with Chronic Febricula Using the Traditional Japanese Medicine Shosaikoto

We herein report the case of a 14-year-old girl who had been experiencing chronic fatigue, febricula, and social withdrawal for 20 months. No notable abnormalities were identified during routine checkups at a general pediatric hospital; symptomatic treatments did not affect her condition. She was diagnosed with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Based on the concepts of Japanese traditional medicine, she was administered shosaikoto-based treatment. After several weeks of treatment, all of the symptoms had been dramatically alleviated, consequently resolving the issue of non-attendance at school. Shosaikoto-based medication may be a therapeutic option for treating ME/CFS in patients presenting with chronic febricula.

Protein-losing gastroenteropathy with severe hypoalbuminemia associated with Sjögren's syndrome: A case report and review of the literature

A 30-year-old man with severe hypoalbuminemia (serum albumin: 0.9 g/dL) was admitted with severe bilateral leg edema and unilateral pleural effusion. Serum anti-SS-A and SS-B antibody levels were abnormally elevated, and his symptoms fulfilled the diagnostic criteria for Sjögren's syndrome. Technetium-99m albumin scintigraphy revealed protein leakage from a large area of the small intestine. Immunohistochemistry revealed perivascular deposition of C1q, C3d, and immunoglobulin G in the duodenal mucosa. The patient was diagnosed with protein-losing gastroenteropathy associated with Sjögren's syndrome. Within 2 months of treatment with oral prednisolone and mycophenolate mofetil, the clinical symptoms of hypoalbuminemia and Sjögren's syndrome disappeared completely.

Neuromyelitis optica spectrum disorders with unevenly clustered attack occurrence

Objective

The aim of this study was to elucidate the characteristics of clinical attacks in neuromyelitis optica spectrum disorders (NMOSDs) with positive serum anti-aquaporin-4 antibody. Both the timing and sequential pattern of clinical types were analyzed.

Methods

A total of 69 patients with NMOSD were enrolled in this study, all of whom were treated at a single university hospital. All data regarding the clinical attacks (including types and date) together with other clinical information were collected.

Results

Analysis of clinical attacks from the enrolled patients showed that there were 2 distributional patterns of attack occurrence in each patient: (1) “clustered” occurrences, which occurred within 12 months from the previous attack, and (2) “nonclustered” intermittent occurrences, which occurred ≥12 months after the previous attack. These occurrences were regardless of the duration from the onset. During the “clustered” period, clinical attacks were more likely to show a similar clinical manifestation, such as optic neuritis or myelitis. After entering the “nonclustered” intermittent period, the relapses were of random clinical type, regardless of the previous clinical manifestation.

Conclusions

Patients with NMOSD showed mixed periods of “clustered” occurrence with frequent attacks presenting with similar manifestations and “nonclustered” intermittent periods with sparse relapses. Approximately half of the relapses occurred during the “clustered” period within 12 months of the last clinical attack. Clinicians should pay special attention to whether the patients are presently in the “clustered” or “nonclustered” period to decide optimal relapse-preventive strategies.

Osmotic pressure of serum and cerebrospinal fluid in patients with suspected neurological conditions

Interstitial fluid movement in the brain parenchyma has been suggested to contribute to sustaining the metabolism in brain parenchyma and maintaining the function of neurons and glial cells. The pulsatile hydrostatic pressure gradient may be one of the driving forces of this bulk flow. However, osmotic pressure-related factors have not been studied until now. In this prospective observational study, to elucidate the relationship between osmolality (mOsm/kg) in the serum and that in the cerebrospinal fluid (CSF), we simultaneously measured the serum and CSF osmolality of 179 subjects with suspected neurological conditions. Serum osmolality was 283.6 ± 6.5 mOsm/kg and CSF osmolality was 289.5 ± 6.6 mOsm/kg. Because the specific gravity of serum and CSF is known to be 1.024–1.028 and 1.004–1.007, respectively, the estimated average of osmolarity (mOsm/L) in the serum and CSF covered exactly the same range (i.e., 290.5–291.5 mOsm/L). There was strong correlation between CSF osmolality and serum osmolality, but the difference in osmolality between serum and CSF was not correlated with serum osmolality, serum electrolyte levels, protein levels, or quotient of albumin. In conclusion, CSF osmolarity was suggested to be equal to serum osmolarity. Osmolarity is not one of the driving forces of this bulk flow. Other factors such as hydrostatic pressure gradient should be used to explain the mechanism of bulk flow in the brain parenchyma. This study was approved by the Institutional Review Board of the Tohoku University Hospital (approval No. IRB No. 2015-1-257) on July 29, 2015.

Application of Large Electronic Medical Database for Detecting Undiagnosed Patients in the General Population

Clinical application of accumulated medical big data is a hot topic in medical informatics. Not only for suggesting possible diagnoses in each individual, large medical database can be possibly used for detecting undiagnosed patients in the general population. In this study, we tried to develop a computerized system of detecting overlooked undiagnosed patients with rare chronic diseases in the community population by utilizing the uniformed national medical insurance record database. A cumulative total of 489,823 hospital visits at one tertiary medical center were collected for this project. As the target disease, we selected esophagogastric junction outflow obstruction (EGJOO), including achalasia, which is known to be easily overlooked without performing a barium swallow test. Patient selection software automatically picked out 17,814 individuals with the given suspected diagnoses that could be misdiagnosed in patients with the target disease, from which the software further picked out 526 individuals who underwent upper endoscopy but did not undergo barium swallow test. Of them, the hospital medical records suggested that 39 people still suffered from prolonged symptoms lasting for more than 6 months after the first hospital visit. Among them, 16 individuals agreed to undergo the barium swallow test. One of them was confirmed to suffer from EGJOO, possibly based on some undiagnosed connective tissue diseases. An automated computerized detection system with uniform big medical data would realize more efficient and less expensive screening system for undiagnosed chronic diseases in the general population based on symptoms and previously performed examinations in each individual.

Sensitivity and specificity of meningeal signs in patients with meningitis

BACKGROUND

Several types of physical examinations are used in the diagnosis of meningitis, including nuchal rigidity, jolt accentuation, Kernig's sign, and Brudzinski's sign. Jolt accentuation was reported to have sensitivity of nearly 100% and to be highly efficient for excluding meningitis, but more recent studies showed that a number of patients with meningitis may present negative in this test.

METHODS

We systematically reviewed studies on the above-mentioned physical examination tests and performed meta-analysis of their diagnostic characteristics to evaluate the clinical usefulness. Nine studies, comprising a total of 599 patients with pleocytosis in the cerebrospinal fluid (CSF) and 1216 patients without CSF pleocytosis, were enrolled in the analysis.

RESULTS

Jolt accentuation showed a decent level of odds ratio (3.62; 99% confidence interval (CI): 1.13-11.60, P = 0.004) comparable to that in nuchal rigidity (2.52; 1.21-5.27, P = 0.001) for the correct prediction of CSF pleocytosis among subjects with suspected meningitis. The estimated sensitivity was relatively high (40%-60%) in nuchal rigidity or jolt accentuation tests. On the other hand, Kernig's and Brudzinski's signs exhibited relatively low sensitivity (20%-30%). The estimated specificity was higher in Kernig's and Brudzinski's signs (85%-95%) than in nuchal rigidity or jolt accentuation tests (65%-75%).

CONCLUSION

Approximately half of the patients with meningitis may not present typical meningeal signs upon physical examination. Combining several examinations for the detection of meningeal signs may decrease the risk of misdiagnosis.

Influence of renal function and demographic data on intrarenal Doppler ultrasonography

Intrarenal Doppler ultrasonography is a non-invasive method to evaluate the renal blood flow in patients with renal arterial stenosis as well as chronic kidney diseases (CKD). Until recently, the relationship between ultrasonography findings and CKD stage has not been fully understood. Overall, 162 patients with CKD without apparent renal arterial stenosis were included in this study, and the pulsed-wave Doppler ultrasonography findings were evaluated in terms of the following parameters: peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistive index (RI) at the renal arterial trunk, hilum, segmental, and interlobar regions. Age showed a significant negative correlation with the estimated glomerular filtration rate (eGFR), kidney size, and aortic PSV. Additionally, age showed a significant positive correlation with RI in all 4 regions. The eGFR showed a positive correlation with the aortic PSV and kidney size, but a negative correlation with RI. Both age and eGFR were found to be independently associated with aortic blood flow. On the intrarenal ultrasound, EDV and RI showed stronger correlations with eGFR than PSV, suggesting that the former indices would be better markers of renal function. In particular, the interlobar EDV was found to be the best index that reflects renal function. Although the RI is also a good marker of renal function, it is confounded by age; thus, its utility would be weaker than that of the EDV. In conclusion, intrarenal pulsed-wave Doppler ultrasonography is a useful tool to estimate and evaluate the renal function; the interlobar EDV may be the best index to estimate the effective perfusion and filtration of the kidneys.

Consideration of gravity as a possible etiological factor in amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease with an unknown mechanism of onset that predominantly impairs the upper and lower motor neurons. Components of the sensory and autonomic nervous system were once thought to be spared in the disease, but more recently they have been identified to be impaired at various levels. However, some of the motor neurons such as oculomotor, abducens, or pudendal nerves are spared even in the later stages of ALS. The mechanism of such complex and heterogeneous neuronal loss in typical ALS is still unknown. In this study, the characteristics of the nervous system involved in the pathogenesis of ALS were comprehensively reviewed. As a result, the direction of the axon in the anatomical position, rather than the functional type or length of the axon, was suggested to contribute the most to the onset of ALS. This finding suggested that downward directed axons, represented by motor neurons, require extra energy to move waste or unnecessary substances from the synapse side to the neural cell body with retrograde fast axonal transport. Based on this theory, the extra energy that is required in vertically directed axons due to the effect of gravity was mathematically estimated. As a result, several percent more adenosine triphosphate molecules were suggested to be consumed in vertical axonal transport by gravity, compared to those consumed in transverse axonal transport. Because most of the motor neurons project downward in the anatomical position, unretrieved waste will gradually sediment in axon terminals by gravity, which could eventually result in motor neuron-dominant neuronal loss. Although the theory that gravity is one of the mechanisms responsible for ALS is still hypothetical, it is theoretically reasonable and compatible with the clinical manifestations of the disease. Further basic research studies with cultured neurons or animal models are necessary to confirm the association between gravity and the onset of ALS.

CD45+CD326+ Cells are Predictive of Poor Prognosis in Non-Small Cell Lung Cancer Patients

PURPOSE

The epithelial-to-mesenchymal transition, the major process by which some cancer cells convert from an epithelial phenotype to a mesenchymal one, has been suggested to drive chemo-resistance and/or metastasis in patients with cancer. However, only a few studies have demonstrated the presence of CD45/CD326 doubly-positive cells (CD45/CD326 DPC) in cancer. We deployed a combination of cell surface markers to elucidate the phenotypic heterogeneity in non-small cell lung cancer (NSCLC) cells and identified a new subpopulation that is doubly-positive for epithelial and non-epithelial cell-surface markers in both NSCLC cells and patients' malignant pleural effusions.

EXPERIMENTAL DESIGN

We procured a total of 39 patients' samples, solid fresh lung cancer tissues from 21 patients and malignant pleural effusion samples from 18 others, and used FACS and fluorescence microscopy to check their surface markers. We also examined the EGFR mutations in patients with known acquired EGFR mutations.

RESULTS

Our data revealed that 0.4% to 17.9% of the solid tumor tissue cells and a higher percentage of malignant pleural effusion cells harbored CD45/CD326 DPC expressing both epithelial and nonepithelial surface markers. We selected 3 EGFR mutation patients and genetically confirmed that the newly identified cell population really originated from cancer cells. We also found that higher proportions of CD45/CD326 DPC are significantly associated with poor prognosis.

CONCLUSIONS

In conclusion, varying percentages of CD45/CD326 DPC exist in both solid cancer tissue and malignant pleural effusion in patients with NSCLC. This CD45/CD326 doubly-positive subpopulation can be an important key to clinical management of patients with NSCLC.

A 29-year-old Woman with Recurrent Pregnancy-induced Hypertension Based on Vascular Compression of the Medulla Oblongata

We present a report of a 29-year-old woman with non-dipper type refractory hypertension due to the vascular compression of the medulla oblongata. The patient was diagnosed with hypertension at 17 years of age and underwent emergency Caesarean section at 26 weeks of gestation during 2 pregnancies due to severe high blood pressure. We suspected medullary compression by the curved posterior inferior cerebellar artery as the cause of her intractable hypertension, and she underwent Jannetta's decompression surgery. After the surgery, her blood pressure swiftly decreased to almost within the normal range, and her blood pressure pattern normalized to dipper type.

Successful treatment of intractable menstrual migraine with the traditional herbal medicine tokishakuyakusan

In this report, we present the successful treatment of five consecutive cases of premenopausal women suffering from severe menstrual migraine with tokishakuyakusan (TSS). Two patients were complicated by tension-type headache (TTH), and another patient was by medication overuse headache (MOH). The effects of triptans were limited in all of them. After starting TSS, they showed dramatic improvement in the severity and frequency of their attacks. The patients with TTH and MOH also showed dramatic improvement in their symptoms. TSS could be a promising alternative choice for patients with intractable menstruation-related headaches that are refractory to conventional treatments, including triptans.

The human central nervous system discharges carbon dioxide and lactic acid into the cerebrospinal fluid

BACKGROUND

The central nervous system was previously thought to draw oxygen and nutrition from the arteries and discharge carbon dioxide and other metabolic wastes into the venous system. At present, the functional role of cerebrospinal fluid in brain metabolism is not fully known.

METHODS

In this prospective observational study, we performed gas analysis on venous blood and cerebrospinal fluid simultaneously acquired from 16 consecutive preoperative patients without any known neurological disorders.

RESULTS

The carbon dioxide partial pressure (pCO₂) (p < 0.0001) and lactic acid level (p < 0.001) in the cerebrospinal fluid were significantly higher than those in the peripheral venous blood, suggesting that a considerable proportion of metabolic carbon dioxide and lactic acid is discharged from the central nervous system into the cerebrospinal fluid. The oxygen partial pressure (pO₂) was much higher in the cerebrospinal fluid than in the venous blood, corroborating the conventional theory of cerebrospinal fluid circulatory dynamics. The pCO₂ of the cerebrospinal fluid showed a strong negative correlation with age (R = - 0.65, p = 0.0065), but the other studied variables did not show significant correlation with age.

CONCLUSION

Carbon dioxide and lactic acid are discharged into the circulating cerebrospinal fluid, as well as into the venules. The level of carbon dioxide in the cerebrospinal fluid significantly decreased with age.

High glucose level and angiotensin II type 1 receptor stimulation synergistically amplify oxidative stress in renal mesangial cells

Oxidative stress in renal mesangial cell causes diabetic glomerular changes. High glucose levels and angiotensin II (Ang II) are known to stimulate superoxide production in renal mesangial cells. However, it has been unclear whether Ang II stimulation and pre-conditioning with high glucose affects the same pathway of superoxide production in renal mesangial cells or not. In this study, we examined the levels of oxidative stress under Ang II stimulation in renal mesangial cells preincubated for six hours at various glucose levels. Intracellular levels of reactive oxidative species (ROS) were measured using dihydroethidium or 5′,6′-chloromethyl- 2′,7′ dichlorodihydro-fluorescein diacetate, which facilitates the detection of intracellular ROS under real-time fluorescent microscope. Ang II-induced elevated intracellular ROS levels were detected only when the cells were pre-incubated with high levels of glucose (13.5 mM, 27.8 mM), but was not detected under normal glucose condition (5.5 mM). Production of Ang II-induced intracellular ROS was higher under pre-treatment with 27.8 mM glucose compared to pretreatment with 13.5 mM glucose level. This ROS production in mesangial cells was induced within several minutes of the initiation of Ang II stimulation under high glucose levels. The production of intracellular ROS was significantly reduced in the presence of angiotensin II type1-receptor (AT1R) antagonist, whereas it was augmented in the presence of angiotensin II type2-receptor antagonist. In conclusion, Ang II-induced oxidative stress was augmented by high glucose levels and ROS levels were further alleviated in the presence of AT1R antagonists.

Importance of Barium Swallow Test and Chest CT Scan for Correct Diagnosis of Achalasia in the Primary Care Setting

Esophageal achalasia is a disease characterized by the impaired esophageal peristalsis and non-relaxation of the lower esophageal sphincter muscle with unknown causes. Clinical manifestation of the disease is nonspecific (e.g., weight loss, vomiting, and persistent cough); namely, early diagnosis of the disease is often difficult. Delayed diagnosis of the disease is known to impair the patients' quality of life. Identifying the diagnostic factors that could cause diagnostic delay is needed. In this study, we collected data from 38 patients with achalasia and searched for diagnostic factors associated with delayed diagnosis (i.e., ≥ 6 months from the first hospital visit to diagnosis). The enrolled patients, diagnosed with achalasia based on esophageal manometry findings, had undergone surgical myotomy. As a result, the diagnosis of achalasia was likely to be delayed when the physician who had first contacted the patient did not perform a barium swallow test (p < 0.0001) or chest CT scan (p < 0.01) in a timely fashion. Among the patients with a delayed diagnosis (n = 15), none underwent a barium swallow test or chest CT within 6 months from their first hospital visit. The estimated sensitivities of diagnostic examinations for achalasia based on the enrolled 38 patients were higher than 80% for the barium swallow test and chest CT scan, but only 50-81% for endoscopy. To avoid the delayed diagnosis of achalasia, performing a barium swallow test or chest CT scan in a timely fashion, in addition to routine endoscopy, appears to be highly important.