Influence of meal intake on pulse wave indices in type 2 diabetes.

Augmentation index (AI), brachial-ankle pulse wave velocity (baPWV) and cardio-ankle vascular index (CAVI) are available for the assessment of arterial stiffness in clinical practices. However, influences of meal intake on these indices are still poorly understood. The aim of this study is to elucidate the effects of daily meal intake on pulse wave indices in patients with type 2 diabetes. We studied 17 patients with type 2 diabetes. AI was measured at fasting, 60 and 120 min after a commercial mixed meal (500 kcal) intake. The baPWV and CAVI were measured at fasting and 80-100 min after meal intake. All pulse indices decreased significantly after meal intake (AI, 89.3+/-9.7% to 77.9+/-9.4%, 82.0+/-8.4%, P<0.001; baPWV, 1652+/-286-1586+/-240 cm s(-1), P=0.002; CAVI, 9.52+/-0.92-9.20+/-0.89, P=0.037). Delta(120) (value 120 min after meal intake-fasting value) AI correlated significantly with age, body weight, Delta(120) systolic blood pressure (SBP), Delta(120) diastolic blood pressure, Delta(120) pulse pressure, Delta(120) heart rate and fasting AI. Delta (postprandial value-fasting value) baPWV correlated significantly with fasting baPWV, Delta SBP, Delta pulse pressure and HbA1c. In contrast, Delta CAVI did not correlate with any clinical variables. In conclusion, postprandial decreases in AI, baPWV and CAVI can lead to underestimate arterial stiffness in patients with type 2 diabetes. Postprandial changes in AI and baPWV, but not CAVI, are associated with changes in hemodynamic variables after daily meal intake.

A case of pulmonary stenosis after a repair for tetralogy of Fallot treated with percutaneous pulmonary valvuloplasty using a triple-balloon technique.

The patient was a 37-year-old female who had undergone a repair for tetralogy of Fallot (TOF) at the age of 4 years. Postoperative pulmonary stenosis remained, but she continued to be managed medically. Approximately 3 years ago, at the age of 34, she exhibited a worsening of fatigue and dyspnea during exertion (New York Heart Association III), and was therefore hospitalized for a detailed examination. In cardiac catheterization, a right ventricle to pulmonary artery peak-to-peak gradient of about 90 mmHg was observed. Since it appeared that medical treatment alone would not sufficiently control her heart failure, pulmonary valvuloplasty using a triple-balloon technique was performed for the pulmonary stenosis. The peak-to-peak gradient immediately after the procedure decreased to 13 mmHg. There were no indications of restenosis approximately 6 months after the procedure, and the symptoms of heart failure in her daily life improved thereafter.

Relationship between smaller calcifications and lipid-rich plaques on integrated backscatter-intravascular ultrasound.

We evaluated the relationship between coronary calcification and plaque characteristics using integrated backscatter-intravascular ultrasound (IB-IVUS), focusing on spotty calcification. Seventy-two patients with culprit plaques containing spotty calcification were evaluated. The average degree of all the spotty calcifications (averaged arc) negatively correlated with the % lipid volume (LV) on IB-IVUS. Multivariate analysis showed the averaged arc was an independent predictor of % LV. Our observations suggest that smaller plaque calcifications are associated with lipid-rich characteristics in patients with a spotty calcification pattern.

Dysfunctional central hemodynamic regulation after daily meal intake in metabolic syndrome.

OBJECTIVE: Postprandial hyperlipidemia and insulin resistance play roles in the development of atherosclerosis in metabolic syndrome (MetS); however, the clinical significance of postprandial hemodynamic variables in this condition is still in question. The aim of this study was to investigate hemodynamic and metabolic indicators related to MetS after a mixed meal (Calorie mate, 500 kcal). METHODS: Of 107 participants undergoing this investigation, 24 fulfilled ATPIII criteria for MetS. The remaining 83 subjects were controls. Both the augmentation index (AI) and late systolic blood pressure in the radial artery (rSBP2) as an index of central blood pressure were monitored using HEM-9000AI (Omron Healthcare, Kyoto, Japan) until 240 min after meal intake. RESULTS: Both AI and rSBP2 showed significant decreases after meal intake in both groups. Changes in postprandial AI showed a similar trend in the groups. rSBP2 reduction 60 min after meal ingestion was also comparable, -7.5+/-2.3 mmHg in MetS; -7.8+/-0.9 mmHg in control; however, delta rSBP2-120, the degree of rSBP2 reduction 120 min after meal ingestion comparing the fasting level, showed a significant difference between 2 groups, -0.5+/-2.0 mmHg in MetS; -5.3+/-0.9 mmHg in control, P<0.02. Stepwise regression analysis revealed low-density-lipoprotein cholesterol (beta=0.333, P=0.001), high-density-lipoprotein cholesterol (beta=-0.209, P<0.05) and systolic blood pressure (beta=-0.377, P<0.001) as independent variables for determining delta rSBP2-120. CONCLUSION: Subjects with MetS exhibit signs of blunted rSBP2 (=central blood pressure) regulation after food intake. Dysfunctional postprandial hemodynamic regulation is another feature of MetS that may contribute to the progression of cardiovascular disease.

The lurking potential of tangential forces: A case of an arteriovenous shunt developed by percutaneous coronary intervention for the septal branch.

We describe the case of a 59-year-old male. His first percutaneous coronary intervention (PCI) using a bare metal stent was performed for a 90% stenosis in the mid portion of the left anterior descending artery (LAD). However, we performed re-PCI because in-stent restenosis developed during a chronic stage. After the first dilatation of the restenotic lesion, using a cutting balloon, the stenosis at the ostium of the septal branch, which takes off from the stent strut, became exacerbated. Therefore, after selective guidewire insertion to the septal branch, we performed balloon inflation. Unfortunately, a coronary dissection and perforation developed in the septal branch and a coronary arteriovenous shunt was also formed. Additional inflation for in-stent restenosis with a perfusion balloon provided successful occlusion of the ostium of the septal branch and the shunt flow disappeared. After careful re-selection of a guide wire into the septal branch, the perforated portion was then dilated using a small-sized conventional balloon. Finally, reperfusion of the septal branch was accomplished without any angiographic sign of coronary dissection, perforation or shunt. We herein report a rare case of coronary arteriovenous shunt formation due to the dissection and perforation of a coronary artery.

[A case of tuberculous pyometrium concurrent with tuberculous pleurisy].

An 84-year-old woman began to have low fever below 38 degrees C with slight lassitude from June 19, 2002. Despite oral administration of Clarithromycin for 3 days, the fever did not subside and the lassitude increased, so she was admitted to our department. While inflammatory findings were noticed, the cause was not identified by blood and imaging examinations (thoracoabdominal CT, etc.). Although her tuberculin reaction was positive, symptoms indicative of pulmonary tuberculosis were absent. Administration of Cefotiam and Imipenem Cilastatin sodium was ineffective. Pyometra was diagnosed. After drainage, the uterine cavity was washed every day. On the basis of culture of fluid retained a few colonies of Gram-negative bacteria were isolated, but were not identified, Cefpirome was administered, whereupon the fever subsided gradually, but mild inflammatory findings remained. Even after discharge on July 24, the retention increased, so drainage and washing were done repeatedly. However, mild inflammatory findings persisted. She began to have a fever from September 17 and was readmitted. After admission, administration of Flomoxef sodium was started, but no improvement was seen. A small amount of hydrothorax appeared on the left. Thoracocentesis yielded a bloody, slightly turbid exudative. Acid-fast staining and Mycobacterium tuberculosis specific PCR of pleural effusion were negative, but adenosindeaminase was 87.4 U/l. Therefore, a diagnosis of tuberculous pleurisy was made. DNA/PCR of tubercle bacilli in the fluid retained in the uterus was positive, and re-retention was prevented by administration of anti-tuberculosis drugs. These findings suggest a strong possibility of tubercle bacillus having been the causative bacteria. Particularly in the case of the elderly, it appears important that pyometra be included in differential diagnosis as the cause of fever even without gynecological symptoms and that tubercle bacillus be considered the causative bacterium.

Ischemia in the territory of the first major septal perforator branch anomalously originating from the first diagonal branch leads to a transient leftward shift of the QRS axis in the frontal plane: a case report.

A patient with non-Q wave myocardial infarction had severe luminal narrowing in the first major septal perforator branch, which arose anomalously from the first diagonal branch. In this case, an exercise ECG showed a transient leftward QRS axis shift.

[A rare case illustrating the difficulty of diagnosing and treating elderly patient with CAPD-related peritonitis caused by the perforation of sigmoid colon diverticulum].

A 67-year-old man was admitted with abdominal pain on April 23, 2000. Continuous ambulatory peritoneal dialysis (CAPD)-related peritonitis was diagnosed. Administration of antibiotics for five days obtained no improvement. Therefore the peritoneal catheter was removed on April 28th. Although his condition became settled, C-reactive protein remained positive. Moreover, two kinds of bacilli were detected from the CAPD fluid, just before the catheter was removed. As abnormalities in the colon were possible, an enema examination was performed on May 23rd. A constriction and several diverticula of the sigmoid colon were detected. High grade fever appeared on May 23rd, and the patient complained of abdominal pain the next day. As there was no improvement, we performed enhanced computed tomography and detected an abscess in the Douglas pouch on May 29th. The abscess was resected on the same day, and he was discharged. The number of patients with chronic renal failure has increased in recent years. Although hemodialysis has been the treatment of choice, peritoneal dialysis should be considered. More investigations into complications created by peritoneal dialysis are required, especially in elderly people who seldom show symptoms of CAPD-related peritonitis until they reach a critical condition. If peritoneal dialysis is being performed and inflammation reactions continue, it is necessary to examine the patient for perforated peritonitis and abscess formation.

Relationship between cardiomyocyte cell death and cardiac function during hypertensive cardiac remodelling in Dahl rats.

The exact mechanisms responsible for the progression of heart failure remain unclear. We investigated the in vivo relationship between the incidence of apoptotic cell death and left ventricular function serially from the beginning of hypertension to decompensated heart failure in Dahl salt-sensitive rats. Dahl salt-resistant and Dahl salt-sensitive rats were fed on a high-salt diet from 6 weeks of age. Systolic blood pressure was recorded by the tail-cuff method every week. Cardiac function in vivo was evaluated by echocardiography and cardiac catheterization. Cardiomyocyte apoptosis was detected by the TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling) method. The gene expression of Bax, Bcl-2 and Bcl-xL was analysed by Northern blotting. The TUNEL method revealed that the incidence of cardiomyocyte apoptosis was significantly increased in the hearts of 18-week-old Dahl salt-sensitive rats (apoptotic index 1.3 +/- 0.1%). Northern blot analysis revealed that the Bcl-xL mRNA level increased gradually during the progression towards heart failure. In conclusion, these data suggest that cardiomyocyte apoptosis is a terminal event, and plays a role as an aggravating factor in the vicious cycle of heart failure.

[An elderly case of cytomegalovirus enterocolitis associated with a malignant tumor].

An 83-year-old man was given a diagnosis of left parotid cancer in our hospital in November 1997. He refused to undergo a surgical procedure because of his advanced age. Therefore chemotherapy and radiotherapy were used. Chemotherapy with CAP (Cyclophosphamide, Adriacin, and CDDP) was conducted on 6 occasions between December 1997 to July 2000. Prednisolone (15 mg) was administered daily from July 15, 2000. The patient started suffering from diarrhea on August 2, 2000. As the patient also began to suffer high grade fevers and stomachaches, he was admitted on a diagnosis of acute enterocolitis. He had bloody stool on August 11. On emergency colonoscopy, an ulceration with bleeding was located in the lower rectum. The biopsy specimen revealed intranuclear inclusion bodies and positively staining cells for monoclonal antibody to cytomegalovirus through the immunohistochemical technique, and it was diagnosed as cytomegalovirus enterocolitis. He was treated with ganciclovir. One month later, his clinical symptoms had improved. Cytomegalovirus enterocolitis is an opportunistic infection, so immunocompromised hosts (such as cancer patients, patients using immunosuppressants, old people) have a greater probability of contracting cytomegalovirus infection. A ganciclovir is an effective treatment. A cytomegalovirus enterocolitis should considered in the differential diagnosis of enterocolitis, when alimentary symptoms like diarrhea or bloody stool are found in immunocompromised hosts.

[An elderly case suspected of familial hypocalciuric hypercalcemia subsequent to manifestation of hypercalcemia].

Familial hypocalciuric hypercalcemia (FHH) is a relatively rare disease showing autosomal dominant heredity. Despite hypercalcemia, it shows a low urinary calcium excretion rate, and calcium clearance-creatinine clearance ratio. Since the serum calcium level does not increase to more than 12 mg/dl, this disease is basically asymptomatic and is incidentally found on medical examinations in many cases. However, it sometimes presents dangerous hypercalcemia and requires treatment. In this disease, parathyroidectomy is not sufficiently effective to cure hypercalcemia. We encountered a female patient with advanced age who presented marked hypercalcemia. Several examinations suggested FHH. While we had difficulty in controlling the serum calcium level, periodic administration of alendronate sodium hydrate, a bone resorption inhibitor, was effective. In this patient, the serum calcium level was normal on the examination about a year and a half before the appearance of symptoms, and hypercalcemia manifested itself in her advanced age, which is different from the usual course of FHH. This case presumably suggests that the pathophysiology of FHH is varied.