Anticipated deaths with physician care (mitori) at home in one town in Japan: A preliminary report

Background

There are few reports on the numbers of anticipated deaths (mitori [り]) at home in Japan.

Method

We used the Japanese death certificate system (shiboukohyou []) for Toyono town citizens who died between 2020 and 2022 and judged a death to constitute mitori when the certificate was not written by a doctor referred from the police.

Results

Among 756 deaths, 109 (14.4%) were mitori at home. Deaths at home were 144 and mitori at home accounted for 75.7%.

Conclusion

Shiboukohyou appear to provide numbers of mitori at home. Death certificate should include a space which shows mitori or not.

Withdrawal of Glucocorticoid Therapy is Difficult in Women with Polymyalgia Rheumatica: An Observational Study

Objective

A total of 105 patients (64 women) who were started on glucocorticoid (GC) treatment for polymyalgia rheumatica (PMR) and/or remitting seronegative symmetrical synovitis with pitting edema (RS₃PE) syndrome at Ikeda City Hospital from July 2004 to December 2019 were reviewed (PMR: 81, overlap: 20, pure RS₃PE syndrome: 4). Then, 32 cases that had stopped GC and 17 cases that had continued GC for 7.5 years or longer were evaluated (women:men, stopped GC 12:20, continued GC 13:4, respectively) (PMR:overlap:pure RS₃PE syndrome, stopped GC 26:6:0, continued GC 14:2:1, respectively).

Methods

The GC continuation rate in all patients was examined using the Kaplan-Meier method. The following were compared between the two groups: age at starting GC; sex; erythrocyte sedimentation rate, C-reactive protein, hemoglobin, ferritin, aspartate aminotransferase, and alanine aminotransferase before starting GC; days from the onset of symptoms to GC initiation; GC maximum dose; GC dose half a year after its start; presence of relapse; and existence of concomitant malignant disease.

Results

The GC continuation rate 7.5 years after GC initiation was 52.5%, higher in women (69.2%), than in men (27.1%). The rates then remained unchanged for 15 years. Hemoglobin was high, and relapse was uncommon in the group that stopped GC. There were no differences in other items.

Conclusion

It is difficult to stop GC therapy for PMR in women in Japan, especially in cases with severe anemia.

Proteolytic cleavage of Podocin by Matriptase exacerbates podocyte injury

Podocyte injury is a critical step toward the progression of renal disease and is often associated with a loss of slit diaphragm proteins, including Podocin. Although there is a possibility that the extracellular domain of these slit diaphragm proteins can be a target for a pathological proteolysis, the precise mechanism driving the phenomenon remains unknown. Here we show that Matriptase, a membrane-anchored protein, was activated at podocytes in CKD patients and mice, whereas Matriptase inhibitors slowed the progression of mouse kidney disease. The mechanism could be accounted for by an imbalance favoring Matriptase over its cognate inhibitor, hepatocyte growth factor activator inhibitor type 1 (HAI-1), because conditional depletion of HAI-1 in podocytes accelerated podocyte injury in mouse model. Matriptase was capable of cleaving Podocin, but such a reaction was blocked by either HAI-1 or dominant-negative Matriptase. Furthermore, the N terminus of Podocin, as a consequence of Matriptase cleavage of Podocin, translocated to nucleoli, suggesting that the N terminus of Podocin might be involved in the process of podocyte injury. Given these observations, we propose that the proteolytic cleavage of Podocin by Matriptase could potentially cause podocyte injury and that targeting Matriptase could be a novel therapeutic strategy for CKD patients.

A double-lumen catheter for hemodialysis dislocated into the mediastinum

The insertion of a catheter into the mediastinum can occur in any patient as a complication. We must check for blood regurgitation not only in the blood removal line but also in the blood return line.

Cover Image

The cover image is based on the Case Report Case report: Gastric cancer‐associated membranous nephropathy that recurred after complete remission and formation of peritoneal dissemination by Nobuyuki Kajiwara et al., DOI: 10.1002/ccr3.2002.

Case report: Gastric cancer-associated membranous nephropathy that recurred after complete remission and formation of peritoneal dissemination

Membranous nephropathy associated with malignant neoplasm may remit completely with treatment of the underlying disease. In such cases, recurrence is very rare. However, after a recurrence, attention should be paid to the possible recurrence of the underlying disease.

Sjögren's syndrome concurrent with protein-losing gastroenteropathy with secondary systemic capillary leak syndrome : A case report

Sjögren's syndrome concurrent with protein-losing gastroenteropathy can develop into secondary systemic capillary leak syndrome. Thus, it is important to diagnose the condition as soon as possible and simultaneously administer treatment for Sjögren's syndrome, protein-losing gastroenteropathy, and systemic capillary leak syndrome.

First-visit patients without a referral to the Department of Internal Medicine at a medium-sized acute care hospital in Japan: an observational study

PURPOSE

We sought to profile first-time patients without a referral who sought medical care at the Department of Internal Medicine at a medium-sized acute care hospital in Japan. We anticipated that the analysis would highlight the demand for medical care needs from acute care hospitals and help confirm one of the problems associated with primary care in Japan.

PATIENTS AND METHODS

The study population comprised 765 patients who sought outpatient consultation without a referral at "the Department of General Internal Medicine" at the Ikeda City Hospital on Fridays over 4 years. Data on the following variables were collected: age, sex, examination date, reason for encounter (RFE), diagnosis, as well as history of consultation with or without antibiotic treatment at another medical institution for the same RFE. We used the International Classicication of Primary Care, Revised Second edition (ICPC-2-R) codes for RFEs and diagnoses.

RESULTS

The main RFE fields were digestive (ICPC-2-R Chapter D), general and unspecified (A), and respiratory (R). The main diagnosis fields were digestive (D), respiratory (R), general and unspecified (A), and musculoskeletal (L). In total, 27.6% of patients had sought consultation at another medical institution for the same RFE. Of these, 64.7% of patients for whom the RFE was cough (ICPC-2-R code, R05), and 72.0% for whom the RFE was fever (A03) were prescribed antibiotics. In total, 62.4% of patients underwent emergency investigations and waited for the results; 4.3% were hospitalized on the same day; and 60.5% were medicated at the initial examination. In 11.5%, the main underlying problem appeared to be psychosomatic.

CONCLUSION

We used the ICPC-2-R to analyze the state of first-visit patients without a referral visiting the Department of Internal Medicine at a medium-sized acute care hospital in Japan. Common RFEs were abdominal pain, cough, and fever. A tendency toward overprescription of antibiotics was observed among primary care physicians.

Impaired Podocyte Autophagy Exacerbates Proteinuria in Diabetic Nephropathy

Overcoming refractory massive proteinuria remains a clinical and research issue in diabetic nephropathy. This study was designed to investigate the pathogenesis of massive proteinuria in diabetic nephropathy, with a special focus on podocyte autophagy, a system of intracellular degradation that maintains cell and organelle homeostasis, using human tissue samples and animal models. Insufficient podocyte autophagy was observed histologically in patients and rats with diabetes and massive proteinuria accompanied by podocyte loss, but not in those with no or minimal proteinuria. Podocyte-specific autophagy-deficient mice developed podocyte loss and massive proteinuria in a high-fat diet (HFD)-induced diabetic model for inducing minimal proteinuria. Interestingly, huge damaged lysosomes were found in the podocytes of diabetic rats with massive proteinuria and HFD-fed, podocyte-specific autophagy-deficient mice. Furthermore, stimulation of cultured podocytes with sera from patients and rats with diabetes and massive proteinuria impaired autophagy, resulting in lysosome dysfunction and apoptosis. These results suggest that autophagy plays a pivotal role in maintaining lysosome homeostasis in podocytes under diabetic conditions, and that its impairment is involved in the pathogenesis of podocyte loss, leading to massive proteinuria in diabetic nephropathy. These results may contribute to the development of a new therapeutic strategy for advanced diabetic nephropathy.

Renal impairment during the treatment of telaprevir with peginterferon and ribavirin in patients with chronic hepatitis C

AIM

Renal damage has been reported as an important complication during combination treatment of peginterferon (PEG IFN), ribavirin (RBV) and telaprevir (TVR) for chronic hepatitis C. However, very little is known about this complication. We investigated the role TVR plays in renal damage during this triple therapy.

METHODS

Twenty-five chronic hepatitis C patients with genotype 1 and high viral load received TVR in combination with PEG IFN and RBV for 12 weeks followed by treatment with PEG IFN and RBV. Renal function of these patients was prospectively evaluated for 16 weeks.

RESULTS

Creatinine clearance decreased significantly during PEG IFN/RBV/TVR treatment. Consequently, serum creatinine and cystatin C significantly rose during PEG IFN/RBV/TVR treatment. Serum creatinine returned to pretreatment levels after the termination of TVR. The increase of serum creatinine and cystatin C from baseline significantly correlated with serum TVR level at day 7, which was determined by starting dose of TVR per bodyweight . When the patients were classified according to the starting dose of TVR per bodyweight, renal impairment was observed only in the high-dose (TVR ≥33 mg/kg per day) group, not in the low-dose (TVR <33 mg/kg per day) group.

CONCLUSION

These results suggest that TVR dose per bodyweight is important for the occurrence of renal impairment in PEG IFN/RBV/TVR treatment.

Two brothers with collagenofibrotic glomerulopathy

Collagenofibrotic glomerulopathy is a rare glomerular disease characterized by extensive accumulation of atypical type III collagen fibers within the mesangial matrix and subendothelial space. Laboratory evaluation of this disease shows a marked increase in serum procollagen III peptide (P III P) levels. Here, we report the case of two brothers with collagenofibrotic glomerulopathy confirmed by histology. Patient 1 presented with proteinuria and hypertension and patient 2 presented with nephrotic-range proteinuria. Immunohistochemistry revealed strong staining for antibodies to type III collagen in the widened subendothelial spaces in both patients. Electron microscopy revealed numerous collagenous fibers in the mesangium and subendothelial space. P III P levels were elevated in both patients. Most reported cases of collagenofibrotic glomerulopathy, including the adult-onset type, have been sporadic. Within the limits of our literature search, this is only the third report of adult siblings with collagenofibrotic glomerulopathy confirmed by histology. This report indicates that it may be beneficial to measure serum P III P levels in the siblings of patients diagnosed with adult-onset collagenofibrotic glomerulopathy.

Restructuring the Ikeda City school urinary screening system: report of a screening survey

BACKGROUND

Annual urinary screening is conducted at municipal kindergartens, elementary schools, and junior high schools in Ikeda City, Osaka, Japan (Ikeda City School System), and the results are reviewed by a general physician, but standards for when to recommend specialist referral have not been clear.

METHODS

In all children attending the Ikeda City School System in 2012, dipstick urinalysis of a first-morning urine specimen was recommended once or twice, and if a second urinalysis showed proteinuria (≥1+), the urinary protein/creatinine ratio was measured. If this showed ≥0.2 g/g of creatinine (g/gCr), it was recommended that the child be evaluated by a specialist at Ikeda City Hospital.

RESULTS

Urinary screening was performed in about 20% (388) of kindergarten, about 90% (5363) of elementary school, and about 86% (2523) of junior high school children living in Ikeda City. Urine samples were obtained from 387, 5349, and 2476 children, respectively. The urinary protein/creatinine ratio was ≥0.2 g/gCr in 13 children, including 1 elementary and 12 junior high children. In these 13 children, chronic nephritic syndrome (CNS) was suspected in 6 junior high school children, and of these, this was a new finding in 5, and renal biopsy was indicated in 3. In Ikeda City, the prevalence of CNS in elementary school children was <0.03%, the prevalence of CNS in junior high school children was 0.29%, and a renal biopsy was indicated in 0.14%. By eliminating the costs associated with assessment of the results by the Ikeda Medical Association, and by directly contracting with the testing company, the expenses paid by Ikeda City for the system itself decreased from 2,508,619 yen to 966,157 yen.

CONCLUSIONS

Incorporating the urinary protein/creatinine ratio into the school urinary screening system in the Ikeda City School System and clarifying standards for specialist referral has enabled restructuring of the system so that is efficient and its effectiveness can be assessed.

Human blood monitoring program in Japan: contamination and bioaccumulation of persistent organochlorines in Japanese residents

Concentrations of persistent organochlorines (OCs)-such as polychlorinated biphenyls (PCBs), 1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethane (DDT) and its metabolites (DDTs), hexachlorocyclohexane isomers (HCHs), chlordane compounds (CHLs), hexachlorobenzene, and tris(4-chlorophenyl)methane [TCPMe]-were determined in plasma samples from residents of three sub-metropolitan locations in Japan (Miyako, Saku, and Tottori) for the purpose of studying the geographic variation and specific accumulation of OCs. Residue concentrations of PCBs and DDTs were the highest in samples collected in Saku (400 and 370 ng/g lipid wt, respectively) whereas samples from Miyako contained greater CHL residues (70 ng/g lipid wt) than those from the other two locations. This contamination pattern reflects the historic use of OCs in each area. For the first time, tris (4-chlorophenyl) methane (TCPMe) concentrations were detected in most of the plasma sample analyzed. Concentrations of TCPMe which ranged from <0.1 to 8.1 ng/g lipid wt eight, were lower than those previouly reported in other human tissue. Larger geographic differences in OC accumulation were observed for PCBs and CHLs, whereas DDTs and HCHs exhibited little variability. PCB concentrations in samples from Saku residents were higher than those from residents of countries in the circumpolar Arctic region but lower than those reported for some populations in the United States and Western European countries. Interestingly, CHL residue concentrations in human blood from Japan are among the highest values reported for the countries examined, suggesting continued increased exposure to CHLs of the Japanese population. Time-trend analysis of CHLs in human blood samples from Miyako (Okinawa prefecture) showed that CHL residues have decreased substantially during the last decade, indicating the effect of the official ban of CHLs in 1986 in Japan. Isomer-specific analysis of PCBs revealed lower proportions of higher chlorinated congeners such as hepta- and octachlorobiphenyls in women than in men, suggesting the possibility of preferential elimination of higher chlorinated biphenyls in women. The difference in sex-dependent accumulation of OC compounds in healthy and ill persons was suggested. To our knowledge, this is the first report on the specific accumulation of persistent QCs, including TCPMe, in human blood samples from Japan.

Contamination by persistent organic pollutants in dumping sites of Asian developing countries: implication of emerging pollution sources

In Asian developing countries, large amounts of municipal wastes are dumped daily in open dumping sites without proper management. This practice may cause several adverse environmental consequences and increased health risk to local communities. To elucidate contamination by persistent organic pollutants (POPs)--including dichloro-diphenyl-trichloroethane and its metabolites (DDTs), hexachlorocyclohexanes (HCHs), chlordanes, hexachlorobenzene (HCB), and polychlorinated biphenyls (PCBs)--in such dumping sites, soil samples were collected from open dumping sites and respective control sites in Cambodia, India, and Vietnam from 1999 through 2001. Our results demonstrated that DDTs, PCBs, and HCHs were dominant contaminants in the dumping sites. However, the contamination pattern was not consistent, showing higher HCHs in India than in Cambodia and Vietnam. Interestingly, in all of the countries, extremely higher levels of POPs were observed in the dumping sites compared with those in the respective control sites, suggesting significant amplification of POP contamination in the dumping sites of Asian developing countries. Mean concentrations of DDTs and PCBs were 350 and 140 ng/g dry weight, respectively, in the dumping sites of Cambodia and 26 and 210 ng/g, respectively, in India. These residue levels were hundreds to thousands times higher than those in general soils, implying possible risk to human health of the local communities, especially to the rag pickers, including children who work in these sites to collect recyclable materials. Composition of DDT compounds suggested their recent use in populated areas, which in turn might have caused increased levels of DDTs in the open dumping sites. In addition, composition of HCH isomers revealed their different use pattern in different countries.

Organochlorine pesticides, polychlorinated biphenyls, and polybrominated diphenyl ethers in Irrawaddy dolphins from India

The Irrawaddy dolphin (Orcaella brevirostris) is at risk of extinction throughout its range as a result of incidental catches, habitat degradation, and pollution. Populations of Irrawaddy dolphins are constrained by the species' narrow habitat requirement-lagoons, estuaries, rivers, and lakes-and are therefore particularly vulnerable to the effects of human activities. In this study, for the first time, concentrations of organochlorine (OC) pesticides, polychlorinated biphenyls (PCBs), and polybrominated diphenyl ethers (PBDEs) were determined in tissues of Irrawaddy dolphins collected from Chilika Lake, India, to understand the status of contamination. Dichlorodiphenyltrichloroethane and its metabolites (DDTs) were the predominant contaminants found in Irrawaddy dolphins; the highest concentration found was 10,000 ng/g lipid weight in blubber. Hexachlorocyclohexanes (HCHs) were the second most prevalent contaminants in dolphin tissues. Concentrations of PCBs, chlordanes, hexachlorobenzene, tris(4-chlorophenyl)methane, and tris(4-chlorophenyl)methanol were in the ranges of few ng/g to few hundreds of ng/g on a lipid-weight basis. In general, concentrations of OC pesticides and PCBs in Irrawaddy dolphins were lower than the concentrations reported for coastal and riverine dolphins collected in Asia. PBDEs were detected in the blubber of Irrawaddy dolphins at concentrations ranging from 0.98 to 18 ng/g lipid weight. BDE congener 47 accounted for 60% to 75% of the total PBDE concentrations. Although these results establish the baseline levels of persistent organic pollutants in Irrawaddy dolphins, efforts should be made to decrease the sources of contamination by DDTs and HCHs in Chilika Lake.

Organochlorine pesticides and polychlorinated biphenyls in California sea lions

Concentrations of polychlorinated biphenyls (PCBs), DDTs, chlordanes, HCHs, hexachlorobenzene (HCB), dieldrin, heptachlor epoxide, tris(4-chlorophenyl)methane (TCPMe), and tris(4-chlorophenyl)methanol (TCPMOH) were measured in the blubber of California sea lions (Zalophus californianus) collected in 2000. DDTs were the most predominant contaminants, followed by PCBs, chlordanes, TCPMe, HCHs, TCPMOH, dieldrin, and heptachlor epoxide. Concentrations of PCBs and DDTs varied from a few microg/g to several hundreds of microg/g on a lipid weight basis. Concentrations of DDTs have declined by an order of magnitude over the last three decades in California sea lions; nevertheless, the measured concentrations of PCBs and DDTs in California sea lions are still some of the highest values reported for marine mammals in recent years. Concentrations of organochlorines were highly correlated with one another. Concentrations of PCBs and DDTs in the blubber of gray whale, humpback whale, northern elephant seal, and harbor seal, and in the adipose fat of sea otter, were lower than the levels found in California sea lions, and were in the range of a few to several microg/g on a lipid weight basis.

Contamination by persistent organochlorines in cetaceans incidentally caught along Brazilian coastal waters

Wide ranges of organochlorine residues were determined in the blubber of franciscana (Pontoporia blainvillei), estuarine dolphin (Sotalia guianensis), Atlantic spotted dolphin (Stenella frontalis), and long-beaked common dolphin (Delphinus capensis) incidentally caught along Brazilian coastal waters. Concentrations of DDTs and PCBs were the highest, followed by CHLs, TCPMOH, dieldrin, TCPMe, heptachlor epoxide, HCB, and HCHs. Unexpectedly, significant pollution of PCBs, DDTs, TCPMe, and TCPMOH were observed in cetaceans from Brazil, implying the occurrence of local sources in the Southern Hemisphere comparable to those in the Northern Hemisphere, probably by high industrialization in Brazil. On the other hand, CHLs, HCB, HCHs, heptachlor epoxide, and dieldrin residue levels in Brazilian dolphins were much lower than those in other species from the Northern Hemisphere. Significant correlations of TCPMe and TCPMOH were found along with PCBs and DDTs, indicating the highly bioaccumulative nature of all these compounds and/or possible similar pollution sources.

Organochlorine and organotin compounds in Caspian seals (Phoca caspica) collected during an unusual mortality event in the Caspian Sea in 2000

Polychlorinated biphenyls (PCBs), organochlorine pesticides and organotin compounds were determined in the blubber and liver of Caspian seals (Phoca caspica) found stranded on the coast of the Caspian Sea during an outbreak of canine distemper virus (CDV) in 2000. Among organochlorines analyzed, DDTs were the most dominant contaminants with concentrations ranging from 6.3 to 470 microg/g on a lipid-weight basis. Caspian seals collected in 2000 during the epizootic had higher concentrations of organochlorines than healthy individuals sampled in 1998. However, the blubber layer was generally thinner in the seals collected in 2000 than those in the previous surveys. Although compositions of organochlorine pesticides in seals suggested that the contamination status in the Caspian Sea is improving, the levels found in Caspian seals in 2000 were comparable to those in other marine mammals that have suffered from epizootics. This implies that the present status of contamination found in Caspian seals poses a risk of immunosuppression. Concentrations of butyltin compounds in livers of seals ranged from 0.49 to 17 ng/g on a wet-weight basis and octyltin compounds were below limit of detection in all the samples analyzed, suggesting less contamination by organotin compounds in the Caspian Sea.

Organochlorine pesticides, polychlorinated biphenyls, and butyltin compounds in blubber and livers of stranded California sea lions, elephant seals, and harbor seals from coastal California, USA

Concentrations of polychlorinated biphenyls (PCBs), DDTs (p,p'-DDE, p,p'-DDD, p,p'-DDT), chlordanes (CHLs; cis-chlordane, cis-nonachlor, trans-nonachlor, and oxychlordane), hexachlorocyclohexane isomers (HCHs), hexachlorobenzene (HCB), tris(4-chlorophenyl)methane (TCPMe), tris(4-chlorophenyl)methanol (TCPMOH), and mono- (MBT), di-(DBT), and tri-butyltin (TBT) were determined in blubber and livers of 15 California sea lions (Zalophus californianus), 6 northern elephant seals (Mirounga augustirostris), and 10 harbor seals (Phoca vitulina) found stranded along the coasts of California, USA, during 1991-1997. Among the organochlorines analyzed, DDTs were predominant, followed in decreasing order by PCBs, CHLs, TCPMe, TCPMOH, HCHs, and HCB. The greatest concentrations of organochlorines were found in California sea lions. The highest DDT and PCB concentrations found in the blubber of California sea lions were 2,900 and 1,300 microg/g, lipid weight, respectively. Concentrations of TCPMe and TCPMOH in California sea lions were correlated significantly with DDT concentrations. Concentration ratios of various organochlorines in harbor seal livers were different from those in California sea lions and elephant seals, which suggested that the sources of exposure of harbor seals to organochlorines were different from those in the other two species. Concentrations of butyltin compounds in livers of pinniped species ranged from 2 to 99 ng/g, wet weight, which were less than those observed in cetaceans and in California sea otters.

Expression analysis of the 5'-upstream region of mouse P/Q-type Ca(2+) channel alpha( lA) subunit gene fused to Escherichia coli lacZ reporter gene in the spinal cord using transgenic mice

The P/Q-type Ca(2+) channel alpha(1A) subunit is expressed in spinal cord including ventral motor neurons and interneurons and dorsal horn. To identify the transcriptional mechanisms of the mouse alpha(IA) subunit gene in spinal cord, transgenic mice carrying a 0.5, 1.5, 3.0 or 6.3-kb 5'-upstream region fused to the Escherichia coli lacZ reporter gene were examined. Transgenic mice carrying the 3.0-kb region expressed the reporter gene in dorsal horn and interneurons of ventral horn, although those with the 0.5-kb, 1.5-kb or 6.3-kb region did not. No transgenic mice expressed the reporter gene in motor neurons of ventral horn. These results suggest that in spinal cord, the expression mechanisms of the alpha(1A) subunit gene are complex, involving both positive and negative cis-regulatory elements, and the 6.3-kb 5'-upstream region alone is not sufficient for the expression.

Expression analysis of Escherichia coli lacZ reporter gene in transgenic mice

To define a gene expression mechanism, it is often advantageous to use a reporter gene and transgenic mouse. The lacZ reporter gene is particularly useful for studies of the cis-regulatory element for tissue-specific expression in transgenic mice because of the ease of the enzyme assay and visualization on sections. In this report, we describe our method for examining the cis-regulatory element in transgenic mice, including choice of the lacZ gene, generation of transgenic mice, and analysis of beta-galactosidase activity.

Neuron-specific expression of reporter gene in transgenic mice carrying the 5'-upstream region of mouse P/Q-type Ca2+ channel alpha 1A subunit gene fused to E. coli lacZ reporter gene

To dissect the molecular mechanisms underlying the neuron-specific expression of the P/Q type calcium channel alpha 1A subunit gene, transgenic mice carrying a 0.5-kb, 1.5-kb, 3.0-kb or 6.3-kb 5'-upstream region of the gene fused to Escherichia coli lacZ reporter gene were produced. In transgenic mice carrying the 1.5-kb, 3.0-kb or 6.3-kb 5'-upstream region, the reporter gene was exclusively expressed in the nervous system, although those with the 0.5-kb 5'-upstream region failed to show reporter expression. Histological examinations showed that the three 5'-upstream regions induced distinct expression patterns of the reporter gene in the CNS and adrenal medulla. The 1.5-kb 5'-upstream region drove reporter gene expression in the olfactory bulb, dorsal cortex and hippocampus, while the regulatory element for the expression in the amygdaloid nucleus, septum, habenula medial nucleus, choroid plexus, substantia nigra, inferior colliculus, pontine nucleus and cerebellum was located in the 5'-upstream sequence between 1.5 kb and 6.3 kb. In the cerebellum, the expression of the reporter gene was induced by the 3.0-kb region in granule cells, whereas it was induced by the 6.3-kb region in Purkinje cells. The expression of the reporter gene in chromaffin cells in the adrenal medulla was induced only by the 6.3-kb 5'-upstream region. These results suggest that the expression of the mouse P/Q-type Ca2+ channel alpha 1A subunit gene is regulated in a complex fashion by both positive and negative cis-regulatory elements.

Structure and function of human prepro-orexin gene

Orexin-A and -B are recently identified potent orexigenic peptides that are derived from the same precursor peptide and are highly specifically localized in neurons located in the lateral hypothalamic area, a region classically implicated in feeding behavior. We cloned the whole length of the human prepro-orexin gene and corresponding cDNA. The human prepro-orexin mRNA was predicted to encode a 131-residue precursor peptide (prepro-orexin). The human prepro-orexin gene consists of two exons and one intron distributed over 1432 base pairs. The 143-base pair first exon includes the 5'-untranslated region and a small part of the coding region that encodes the first seven residues of the secretory signal sequence. The second exon contains the remaining portion of the open reading frame and 3'-untranslated region. The 3.2 kilobase pairs of the 5'-upstream region from a cloned human prepro-orexin gene promoter is sufficient to direct the expression of the Escherichia coli beta-galactosidase (lacZ) gene in transgenic mice to neurons in the lateral hypothalamic area and adjacent regions. The lacZ-positive neurons were positively stained with anti-orexin antibody but not with anti-melanin-concentrating hormone antibody. These findings suggest that this genomic fragment contains all the necessary elements for appropriate expression of the gene and will be useful for the targeted expression of the exogenous gene in orexin-containing neurons. These mice might also be useful for examining the molecular mechanisms by which orexin gene expression is regulated.

Left ventricular geometric patterns and QT dispersion in borderline and mild hypertension: their evolution and regression

To investigate whether QT dispersion increases in borderline and mild hypertension during a longitudinal observation of > 3 years and whether it is improved with medications, left ventricular geometric patterns and QT dispersion were studied with special regard to their longitudinal changes in 85 male borderline and mild hypertensive subjects with left ventricular mass index < 125 g/m2. These subjects were followed for > 3 years without medication. Thirty-two patients with a left ventricular mass index > 125 g/m2 at the end of follow-up period were further observed using antihypertensive drugs for an additional 3 years. Echocardiograms and electrocardiograms were obtained at the beginning and end of the follow-up period. At the end of the follow-up period, subjects were classified into four groups based on ventricular geometric patterns determined by left ventricular mass index and relative wall thickness in diastole. The QT dispersion was greater in patients with concentric hypertrophy (56+/-18 msec) than in patients with normal geometry (41+/-17 msec) (P < .05) and increased significantly in the former group during the follow-up period. After medication, the left ventricular mass index regressed and the QT dispersion decreased (from 55+/-21 to 50+/-26 msec, P < .01) in these patients. Thus, these findings suggest that changes in the QT dispersion reflect both concentric evolution and regression of left ventricular hypertrophy.

Effects of long-term antihypertensive therapy on physical fitness of men with mild hypertension

This study was conducted to investigate the effects of long-term administration of a calcium-channel antagonist (nifedipine) and a beta-blocker (acebutolol) on physical fitness in men with mild hypertension. All subjects underwent symptom-limited treadmill stress testing and routine echocardiographic studies. Twenty-two subjects who had either a causal diastolic blood pressure of more than 105 mmHg or a left ventricular mass index (LVMI) of 125 g/m2 or more during follow-up were assigned to receive medical therapy. The other 31 men who did not meet either criterion were continuously followed-up without medication. Among the 22 treated men, the age-adjusted treadmill time (normalized treadmill time, TMTn) significantly decreased before the initiation of medication, while 31 untreated men showed no change in TMTn throughout the study. The 22 treated subjects were subsequently divided into two groups; 13 were given nifedipine and 9 were given acebutolol. All treated subjects were followed-up for more than 3 years. After treatment, the two groups showed similar reductions in blood pressure and LVMI, but a different outcome for TMTn: TMTn increased from 104 +/- 8% to 115 +/- 16% in subjects given nifedipine (p < 0.05) and decreased from 106 +/- 12% to 99 +/- 10% (p < 0.01) in those given acebutolol. Thus, the physical fitness of subjects who required medication significantly deteriorated without medication; their physical fitness improved after treatment with a calcium-channel antagonist and deteriorated after treatment with a beta-blocker.

The relationship of hyperinsulinemic state to left ventricular hypertrophy, microalbuminuria, and physical fitness in borderline and mild hypertension

The relationship of the hyperinsulinemic state to left ventricular hypertrophy, left ventricular geometric patterns, microalbuminuria, and physical fitness were studied in 52 middle-aged unmedicated men with borderline and mild hypertension. Left ventricular mass index and relative wall thickness were assessed by echocardiography. Physical fitness was determined by symptom-limited maximal treadmill stress testings. The urinary concentration of microalbumin and C-peptide was measured in 24-h urine samples by radioimmunoassey. The 24-h urinary C-peptide excretion rate was correlated with left ventricular mass index (r = 0.46), relative wall thickness (r = 0.41), treadmill time (r = -0.35), normalized treadmill time (r = -0.52), systolic blood pressure at peak exercise (r = 0.29), and 24-h urinary microalbumin excretion (r = 0.48). Stepwise multiple regression analysis identified the left ventricular mass index, the 24-h urinary albumin excretion, and the normalized treadmill time as variables in the equation for the 24-h urinary C-peptide excretion. Thus, the hyperinsulinemic state is related to left ventricular hypertrophy, microalbuminuria, and impaired physical fitness in patients with borderline and mild hypertension.

Prospective studies on left ventricular geometric patterns and exercise tolerance in unmedicated men with borderline and mild hypertension

OBJECTIVE

This study was designed and conducted to assess the clinical significance of left ventricular geometric patterns and physical fitness in subjects with untreated borderline and mild hypertension.

METHODS

Symptom-limited maximal treadmill stress testings and echocardiographic examinations were administered to 192 previously unmedicated men. Left ventricular geometric patterns were determined by the combined criteria of left ventricular mass index and relative wall thickness. Subjects whose left ventricular mass index was < 125 g/m2 were followed up for more than 3 years.

RESULTS

Normalized treadmill time was lower and pressure rate products at peak exercise were higher in patients with concentric hypertrophy than in those with normal geometry. Of the 77 patients who revealed left ventricular mass index at baseline < 125 g/m2 and who were successfully followed without medication for more than 3 years, 18 demonstrated concentric hypertrophy at the final follow-up examination. During the follow-up period, these 18 patients had significant further augmentation of concentric geometric features, significant decreases in both cardiac output and normalized treadmill time, and significant increases in casual blood pressure and total peripheral resistance compared with those at baseline.

CONCLUSION

Patients with concentric hypertrophy exhibited slightly but significantly impaired levels of physical fitness and cardiac work efficiency, and the progression of concentric hypertrophy demonstrated further impairments of these conditions. Therefore, not only lowering blood pressure, but also improving left ventricular hypertrophy, cardiovascular hemodynamics, and physical fitness might be required in patients with concentric hypertrophy.

Vertical transmission to embryo and fetus in maternal infection with rat virus (RV)

The influence of maternal rat virus (RV) infection on rat embryogenesis and fetus was examined by viral reisolation, immunostaining and PCR analysis. Vertical transmission caused by the UT-1 strain of RV depended on the stage of gestation when maternal infection occurred. When females were infected at the pre-mating point, the number of fetuses was smaller than that normally obtained, possibly due to infection at the stage of the hatched blastocyst, but almost all of the fetuses obtained were free from infection and developed normally. The incidence of transplacental infection was the highest when pregnant females were infected in the middle of the gestation stage, and some of the fetuses died. In pregnant females which were infected late in the gestation stage, all fetuses developed normally. Some of them were infected transplacentally and harbored the infectious virus. Much attention should be paid to performing reliable rederivation of RV-infected rat colonies by hysterectomy and embryo transfer.