Idebenone improves cerebral mitochondrial oxidative metabolism in a patient with MELAS

We report a 36-year-old man with MELAS in whom a 5-month course of high-dose oral idebenone, a derivative of coenzyme Q10, increased markedly cerebral metabolic ratio of oxygen and oxygen extraction fraction without increased cerebral blood flow with PET. The results indicate that idebenone improves mitochondrial oxidative metabolism in the brain and suggest a therapeutic potential of idebenone for MELAS.

Application of percutaneous transluminal coronary angioplasty to coronary arterial stenosis in Kawasaki disease

BACKGROUND

Percutaneous transluminal coronary angioplasty (PTCA) has rarely been performed on patients with coronary lesions that result from Kawasaki disease. In this study, we retrospectively evaluated the effectiveness of PTCA in five patients with coronary arterial stenosis that resulted from Kawasaki disease and reviewed previous reports for possible indicators of PTCA effectiveness.

METHODS AND RESULTS

Five patients, ranging in age from 2 to 16 years (median 8 years) underwent conventional PTCA for localized stenosis. The lesion targeted for PTCA was located in the middle right coronary artery of three patients and in the left anterior descending artery in two patients. In four of the five patients, PTCA was angiographically effective, with stenosis rates improving from 84 +/- 10% to 33 +/- 11% (P<.05). When the previously reported cases of six similar patients were taken into consideration, the only predictor of successful PTCA seemed to be the time elapsed between the onset of Kawasaki disease and performance of this procedure.

CONCLUSIONS

In cases in which patients show significant localized stenosis as a result of Kawasaki disease, PTCA should be attempted within 6 to 8 years of the onset of the disease. Additionally, intravascular ultrasound imaging was found to be a useful tool for evaluating internal morphology before and after PTCA. In older patients with coronary calcification, other alternatives to PTCA, such as the use of a rotablator or an atherectomy catheter, should be considered.

Alterations in extracellular matrix components and integrins in patients with preeclamptic nephropathy

The glomerular features of patients with preeclampsia consist of swelling of endothelial cells, subendothelial deposits of incompletely defined material, and thickening of the capillary walls. These abnormalities are thought to resolve in the postpartum period. The distribution of extracellular matrix (ECM) components and integrins was investigated in 10 such patients. Frozen sections and paraffin-embedded sections were stained with antibodies to type IV collagen, laminin (LN), fibronectin (FN), vitronectin (VN), tenascin (TN), fibronectin receptor (FNR), and vitronectin receptor (VNR). In preeclamptic nephropathy, the accumulation of type IV collagen, LN, FN, TN, and FNR was observed in the thickened capillary walls, particularly in the subendothelial layer and, to some extent, in the mesangium. However, deposits of VN were sparse and the distribution of VNR was similar to that in normal kidney. In segmental sclerotic lesions, the amounts of type IV collagen, LN, FN, VN, and TN were increased, whereas those of FNR and VNR were markedly decreased. These results suggest that the materials deposited in the subendothelial space consist of ECM components as well as of plasma-derived proteins, and that the deposition of ECM components and of FNR may be involved in the development and the reparative process of the characteristic glomerular lesions. The formation of sclerotic lesions was linked to the accumulation of ECM components, but not to an interaction with integrins.

Angiographic assessment of the stretch-recoil-gain relation after balloon coarctation angioplasty and its relation to late restenosis

The effects of stretch and immediate recoil after balloon angioplasty were evaluated in 21 patients with coarctation of the aorta who underwent balloon coarctation angioplasty. A total of 28 procedures were performed in these patients, who ranged in age from 1 month to 17 years with a mean of 4.3 years. The systolic pressure gradient and coarcted diameter changed significantly from 42 +/- 22 to 14 +/- 9 mmHg (P < 0.0001) and from 4.0 +/- 1.7 to 6.1 +/- 2.0 mm (P < 0.001), respectively. Immediate recoil was responsible for the loss of 33% of the potentially achievable coarcted dimension. Recoil was determined mainly by the degree of arterial stretch. Gain increased exponentially with an increase in stretch. There was a narrow range of % stretch (60-80%) within which an effective diameter gain could be obtained. Both gain and stretch were the best predictors for late restenosis: patients with a larger immediate gain and stretch developed more restenosis. These results suggest that the stretch-recoil-gain relationship may be clinically important for evaluating the best predictor of late restenosis after balloon coarctation angioplasty.

Relationship between abnormal sensation in the throat and menopause

Abnormal sensations in the throat (AST) are commonly encountered in general and otolaryngological practice, especially among middle aged women. These sensation may occur alone, or more often, in combination with the systemic symptoms, including those of menopause. We analyzed 26 Japanese women with a complaint of an abnormal sensation in the throat who were taking a synthetic sex hormone (Methermon-F). Multianalysis of variance (MANOVA) was used to evaluate the efficacy of the treatment using the quantitative scores of Kupperman's climacteric symptoms. The presence of the excessive perspiration and vertigo, insomnia, and the absence of fatigue were associated with clinical efficacy of the hormone, while the presence of hyposthenia and tingling sensation were associated with a poor response. Results suggested that the clinical efficacy of this hormone in treating middle-aged menopausal women with AST was related to the menopausal symptoms.

Corticosteroid therapy for ventricular tachycardia in children with silent lymphocytic myocarditis

OBJECTIVE

The objective of our study was to describe the efficacy of corticosteroids for ventricular tachycardia in four children with structurally normal hearts in whom endomyocardial biopsy revealed histologic changes of lymphocytic myocarditis.

PATIENTS

The four patients had unexplained ventricular tachycardia. Three dysrhythmias were sustained, and one was inducible by exercise. Patient ages ranged from 4 months to 12 years. Three of the four patients had no symptoms. In two of them, ventricular tachycardia was identified by mass screening for heart disease. Two patients received oral steroids and two received pulse steroid therapy.

RESULTS

In all four patients, significant underlying diseases were not found by noninvasive evaluation. Right ventricular endomyocardial biopsy revealed abnormal histologic findings of chronic lymphocytic myocarditis in all patients. Steroid therapy was effective in all four patients, two of whom received methylprednisolone pulse therapy.

CONCLUSIONS

We conclude that unexplained ventricular tachycardia may be the only manifestation of clinically silent myocarditis. Steroid therapy should therefore be considered if conventional antiarrhythmic medication is not effective and histologic findings confirm the presence of lymphocytic myocarditis.

In vivo light scattering intensity in the lens versus in vitro spectral transmission in the nuclear region

In order to understand the correlation between nuclear opacity and spectral light transmission factor, the in vivo light scattering intensity of Scheimpflug lens images and the light transmission through slices of surgically removed nucleus were examined densitometrically as well as spectrophotometrically respectively, using both human and Brown Norway rat lenses. The experiments using rat lenses showed that the increase of the light scattering intensity in the nuclear regions is correlated with a decrease of the spectral transmission factor. The transparent anterior cortical region did not influence the light transmission (T%) through the nucleus. No significant influence was seen from the application of freezing and thawing procedures to measure light transmission. The examinations of the human subjects which were based on the rat study showed that the light transmission of nuclear cataracts objectively evaluated as grade I was almost the same as that observed in noncataractous nuclei. The light transmission of nuclear cataracts graded II or above, however, showed around 50% of the spectral light transmission of noncataractous nuclei.

[Approximation of uroflowmetrograms using micturition model]

One hundred and two uroflowmetric curves obtained from adult men were approximated to investigate the individual micturition quantitatively. We obtained a differential equation under the hypothesis that the factors concerned with micturition are the vesical pressure as the driving force and inertia of urine, friction resistance and elasticity of urethra as resistance. Using one of the solutions of this differential equation, we could approximate the uroflowmetric curves for normal and abnormal micturition. Furthermore, we could describe the calculated vesical pressure curve from the differential equation. There was a lag in the phase of the calculated vesical pressure curve against the uroflowmetric curve, which was considered to appear according to the resistance due to both inertia of urine and elasticity of urethra. The mean value of the difference of the calculated vesical pressure during micturition in normal cases was larger than that in abnormal cases. This suggests that it is necessary to maintain a high vesical pressure during micturition in abnormal cases, to maintain a small difference of the vesical pressure. In conclusion, we approximated the uroflowmetric curves, described the calculated vesical pressure curves and estimated them quantitatively.

Mechanism of balloon angioplasty in children with arterial stenosis assessed by intravascular ultrasound and angiography

Fifteen patients were examined before and immediately after balloon angioplasty with a 4.3F, 30 MHz rotational tip intravascular ultrasound system. In 12 (80%) patients, 13 procedures could be analyzed because of sufficient image quality. The lesions for intravascular ultrasound (IVUS) study consisted of pulmonary arterial stenosis in 4 patients, Blalock-Taussig shunt stenosis in 3, coarctation of the aorta in 2, subclavian artery stenosis in 1, renal artery stenosis in 1, and ductus arteriosus in 1. Three distinctive morphologic types were identified: Group I had arterial stretching (3 patients); group IIa had superficial tearing (3); group IIb had deep intimal-medial tearing (5); group III had dissection (2). In the narrowest site, minimal and maximal luminal diameters, luminal area before and after balloon angioplasty were 3.5 +/- 1.8 mm vs 4.5 +/- 2.5 mm, 4.1 +/- 2.1 mm vs 5.4 +/- 3.5 mm, and 49.8 +/- 30.2 mm vs 88.3 +/- 45.2 mm2, respectively. The recoil value of group IIb with appropriate balloon angioplasty was approximately 0.3. IVUS may be an useful modality for evaluating the morphologic mechanism of dilatation after balloon angioplasty.

[The activity of superoxide dismutase in patients with taste and smell dysfunction]

It was revealed that Zinc deficiency might cause taste and smell dysfunction. Superoxide dismutase (SOD), which scavenges superoxide, is a type of zinc enzyme. It was also demonstrated that the overproduction of superoxide damages normal tissue. We therefore measured the activity of SOD in serum and saliva of patients with taste or smell dysfunction by the cytochrome C reduction method using a xanthine-xanthine oxidase system. As a result, in the patients with taste dysfunction, the activities of SOD in both serum and saliva were normal, but mean level of serum Zinc was near to the lower normal limit. On the other hand, in the patients with smell dysfunction caused by chronic sinusitis or common cold, the activity of SOD in serum was significantly lower than that of healthy volunteers, and that in saliva was normal. These results suggest that Zinc enzymes, except serum and salivary SOD, are involved in the sense of taste, and that further investigation is necessary to clarify the relation between serum SOD deficiency and olfactory dysfunction.

Magnetic resonance imaging and brain-stem auditory evoked potentials in neuro-Behçet's disease

We studied central nervous system lesions in patients with neuro-Behcet's disease using magnetic resonance imaging (MRI) of the brain and recording of brain-stem auditory evoked potentials (BAEPs). MRI revealed abnormal findings in seven of eight patients. MRI studies demonstrated extensive regions with high intensity signal in the brain stem and/or basal ganglia on T2-weighted images obtained during the acute stage of the disease in three patients. One of these patients had a strongly gadolinum-enhanced round lesion in the lower pons. In four of the other five patients with chronic disease, brain-stem atrophy was observed on T1-weighted images. Atrophic changes were more severe in the brain stem than in the cerebellum. Abnormal BAEPs were observed in three patients and consisted of prolongation of interpeak latency of waves III-V and defects of wave III or V. Abnormal BAEPs were recorded in patients with severe inflammatory changes or progression of atrophic changes in the brain stem. Our findings show that MRI and BAEPs are useful in detecting the presence and assessing the degree of neurological involvement in patients with neuro-Behçet's disease.

Criteria for differentiation of normal and abnormal uroflowmetrograms in adult men

OBJECTIVE

To study parameters which serve as criteria for differentiation of normal and abnormal uroflowmetrograms.

SUBJECTS AND METHODS

A total of 105 subjects were investigated, 43 of whom had no symptoms of dysuria, 57 of whom had dysuria demonstrated as an abnormal uroflowmetrogram, subjective symptoms and a small residual urine volume, and five patients who were about to undergo transurethral resection of the prostate. The three parameters used to specify the shapes of the uroflowmetrogram curves were: (i) the ratio of the maximum flow rate (Qmax) and the voiding time (T100), Qmax/T100; (ii) the ratio of the time to peak flow (TQmax) and the voiding time, TQmax/T100; and (iii) the newly introduced voiding efficiency (epsilon), measured by the ratio of the voided volume (VV) and T100 x Qmax, epsilon = VV/(T100 x Qmax), were taken for each patient.

RESULTS

The criteria for normal uroflowmetrograms were: Qmax/T100 > or = 0.78, 0.32 < or = TQmax/T100 < or = 0.54, 0.63 < or = epsilon < 1, respectively. In the patients who underwent transurethral resection of the prostate the values of all three parameters improved and returned almost to normal after operation.

CONCLUSION

Using these three parameters the micturition pattern can be expressed quantitatively.

[A case report of ureteral stump metastasis from renal-cell carcinoma]

This is a case report of the 21st documented case of ureteral metastasis from renal cell carcinoma. A 75-year-old woman was admitted because of asymptomatic gross hematuria. Right radical nephrectomy for renal cell carcinoma had been performed 2 years and 9 months prior to admission. Cystoscopy revealed efflux of blood from right ureteral orifice. Right retrograde ureterogram revealed a filling defect at the upper end of the stump, where a soft tissue mass was observed by computerized tomographic scan. She underwent right ureteral stump excision with a bladder-cuff. Pathological study was consistent with metastatic renal cell carcinoma. The literature on ureteral metastasis from renal cell carcinoma is briefly reviewed and a mechanism for the metastasis is proposed.

Dilation of intra-atrial baffle fenestrations: results in vivo and in vitro

Spontaneous closure of intra-atrial baffle fenestrations occurred early postoperatively following a Fontan procedure in three patients (ages 0.8-2 yr) and were reopened using transvenous balloon dilation. Following this clinical experience with this complication we studied the effects of high pressure balloons of different sizes on fenestrations created in polytetrafluoroethylene (PTFE) patches. The intra-atrial baffle fenestration was found closed within hours after surgery in two patients and 32 days postoperatively in the other. Increasing edema, chest tube drainage, and renal dysfunction ensued rapidly. At catheterization the balloon dilation in two patients reduced the elevated right atrial pressure, edema, and pleural effusion and allowed an acceptable arterial saturation. In the other patient, with acidosis and a low cardiac output, transient cardiac arrest occurred following passage of the catheter through the fenestration and during later unsuccessful operation the fenestration, although open, was traversed by strands of clot. In the experimental study, a total of 45 fenestrations 4 mm in diameter were dilated with 5, 6, 7, 8, and 9 mm balloons. The fenestration areas remained increased significantly during the 14 days of observation in room air, with the larger balloons producing larger holes. Balloon dilation may be effective for spontaneous fenestration closure occurring in the early postoperative period after a fenestrated Fontan procedure. Our experimental data may be useful in selecting the balloon size in this setting.

Inguinal lymph node metastasis from contralateral testicular origin

A twenty-eight-year-old man had a testis tumor eighteen years after orchiopexy and inguinal lymph node metastasis in the contralateral side. It is suggested that scrotal surgery may lead to the formation of new lymph channels and alter the pattern of nodal metastases.

Two cases of urothelial tumor with high serum level of carcinoembryonic antigen and TA-4

Two rare cases of urothelial tumor with high serum carcinoembryonic antigen (CEA) and TA-4 levels are presented. One is a case of lymph node metastasis due to bladder tumor: pathological diagnosis revealed mucoepidermoid carcinoma. The other is a case of left renal pelvic tumor: pathological diagnosis revealed transitional cell carcinoma with glandular and squamous differentiation. The serum CEA and TA-4 levels, high before surgery, decreased after surgery.

[Clinical evaluation of intra-arterial methotrexate, vinblastine, doxorubicin and cis-platinum for bladder cancer]

Chemotherapy regimens including Methotrexate, Vinblastine. Doxorubicin and Cis-platinum (M-VAC) have shown objective responses in more than 50% of uroepithelial tumors. And intra-arterial chemotherapy can theoretically increase the drug concentration delivered to the tumor with maximum efficacy and less toxicity. In this report we review our experience at Matsuyama Red Cross Hospital between September 1987 and February 1991 using intra-arterial M-VAC in 21 evaluable patients with bladder cancer. Response was observed in 62% of the treated patients, two with complete remission and eleven with partial remission. WBC nadir and platelet nadir were mild to moderate. Other adverse effects such as mucositis, hair loss and creatinine elevation were seen in a small number of patients. Intra-arterial M-VAC can be one of the most useful forms of chemotherapy for patients with bladder cancer.

[Evaluation of physical fitness and exercise performance in patients with chronic pulmonary emphysema]

Physical fitness was studied in patients with chronic pulmonary emphysema using Kraus-Weber methods in addition to pulmonary function and exercise tolerance. In Kraus-Weber tests, explosive strength of abdominal muscles in these patients were within the normal range, but both abdominal and back muscle endurance were significantly diminished compared to age-matched controls. On the other hand, flexibility was not different between the patients and the controls, although large variation was present. Exercise performance as assessed by 6 minutes' walk distance in patients was significantly correlated with FEV1.0, DLco and maximal inspiratory mouth pressure, as well as explosive strength of abdominal muscles and abdominal and back muscle endurance capacity. Treadmill walking training for 20 minutes with a load greater than 80% VO2max, twice a week for 2 months was performed in 11 patients with mild to moderate pulmonary emphysema. Six minutes' walk distance (6MD) was significantly prolonged with improvement of back muscle endurance and flexibility. Another walking training consisting of five repetitions of two minutes' near maximal walking and a two minute interval of rest was performed in 6 patients with severe pulmonary emphysema. 6MD tended to increase with improvement of both back and abdominal muscle endurance. However, pulmonary function tests and VO2max showed no significant changes after both types of training. Improved walked distance after the training was significantly correlated with improved VO2 at AT. Furthermore VO2, VE, HR and lactate production during exercise at the same load were significantly decreased compared to pre-training. Dyspnea sensation measured by modified Borg scale during exercise was improved after the training. It is concluded that a physical training program adapted to the condition of the individual patients could improve exercise performance, and should be prescribed in addition to medication.

Intermediate-term results of balloon valvuloplasty for isolated and complicated pulmonary valve stenosis

The purpose of this study is to report our experience regarding the acute and intermediate-term results of balloon pulmonary valvuloplasty (BPV) in various types of congenital pulmonary valve stenosis.

METHODS AND RESULTS

Twenty-four consecutive patients with a median age of 6.6 years (ranging from 1 month to 24 years old) underwent BPV between January 1988 and September 1991. These patients were divided into 2 groups; Group 1 consisting of 13 patients with isolated pulmonary valve stenosis, and Group 2 consisting of 11 patients with complicated pulmonary valve stenosis (supravalvular, subvalvular, valved conduit and post-right ventricular outflow reconstruction). Mean peak systolic pressure gradients from the right ventricle to the pulmonary artery were as follows: In group 1, 48 +/- 21 (mean +/- SD) mmHg before BPV, 18 +/- 8 mmHg immediately after BPV and 13 +/- 5 mmHg at the longest follow-up based on catheterization or Doppler echocardiographic studies. The gradients in group 2 were 65 +/- 28 mmHg before BPV, 46 +/- 25 mmHg immediately after BPV and 47 +/- 21 mmHg at the longest follow-up.

CONCLUSIONS

BPV provides both acute and intermediate-term gradient relief in patients with isolated pulmonary valve stenosis. In complicated pulmonary valve stenosis, on the other hand, the effect of BPV was unsatisfactory and appears to depend on the mechanism of associated obstruction. Therefore accurate evaluation of the anatomy of associated obstruction in the pulmonary valve region is needed to determine that BPV is indicated.