[Effects of home oxygen therapy on patients with chronic heart failure].

OBJECTIVES: Dyspnea on exertion and/or hypoxemia due to nocturnal respiratory disturbance may occur in patients with stable chronic congestive heart failure. Such patients with respiratory disorder during sleep have a poor prognosis. The effects of treatment with home oxygen therapy on patients with congestive heart failure are unclear when symptoms are stable at rest. This study investigated the effects of home oxygen therapy on patients with stable chronic congestive heart failure. METHODS: Thirty-three patients with stable chronic congestive heart failure(New York Heart Association functional class II-IV) and hypoxemia during exercise or sleep were treated with oxygen above the level of 90% SaO2. The following factors were compared before and after home oxygen therapy: Subjective minimal capacity on exercise(metabolic equivalents: METs) before and 1 month after patients first became aware of dyspnea on effort using the specific activity scale(SAS); SaO2 at rest before and 1 month after; and frequency of admission during 1 year due to deterioration of heart failure. RESULTS: After home oxygen therapy, SAS improved from 2.5 +/- 0.9 to 3.3 +/- 1.0 METs(p < 0.0001), and SaO2 at rest improved from 92.8 +/- 2.5% to 96.3 +/- 1.6%(p < 0.0001). The frequency of admission was decreased from 1.3 +/- 1.2 to 0.8 +/- 1.2 times(p = 0.03). CONCLUSIONS: Home oxygen therapy is effective for improving the symptoms and activity of daily life in patients with chronic heart failure. Home oxygen therapy may prevent the deterioration of heart failure.

[Severe pulmonary hypertension due to mitral regurgitation without overt sign of congestive heart failure: a case report].

A 49-year-old man was found to have a heart murmur at a local hospital and was referred to our hospital for further examination. Although he had no signs of congestive heart failure, echocardiography and cardiac catheterization showed severe pulmonary hypertension caused by severe mitral regurgitation. Mitral valve replacement was performed, followed by reduction of pulmonary artery pressure. This patient had an unusual combination of no signs of lung congestion despite severe mitral regurgitation with pulmonary hypertension.

Three-dimensional reconstruction of intravascular ultrasound images of coronary stents using an ECG-gated pull-back device.

Three-dimensional reconstruction (3D-R) of intravascular ultrasound (IVUS) images is not yet satisfactory because of artifacts caused by cardiac movement. This problem can be overcome with a new device, an electrocardiographic (ECG)-gated pull-back system. Using this device a catheter is pulled back stepwise gated by the ECG, and IVUS dynamic images of an entire cardiac cycle are acquired at each step. We performed 3D-R of IVUS images of stents using this new device in six patients with Palmaz-Schatz coronary stent implantation. We obtained precise 3D images in all cases, and stent structure was visualized in detail. In conclusion, use of an ECG-gated pull-back device enables precise 3D-R of IVUS images and provides useful information on the coronary artery.

Exercise beta-methyl iodophenyl acid (BMIPP) and resting thalium delayed single photon emission computed tomography (SPECT) in the assessment of ischemia and viability.

To clarify the significance of exercise BMIPP (beta-methyl iodophenyl pentadecanoic acid) and resting T1 delayed single photon emission computed tomography (SPECT) in the assessment of ischemia and viability, we studied maximal exercise-loading BMIPP SPECT following rest-injected T1 3 h SPECT in 11 control subjects, 20 patients with effort angina and 38 patients with old myocardial infarction. The left ventricular wall on ECT was divided into 9 segments. BMIPP and T1 uptake were scored as 0 = normal, 1 = reduced, 2 = severely reduced, or 3 = absent. Discordance was defined as when segments with a reduced BMIPP uptake had a better resting T1 uptake. Significant coronary artery stenosis was defined as stenosis of 75% or greater on coronary arteriogram. Left ventricular wall motion was assessed as either normokinesis, hypokinesis, severe hypokinesis, akinesis or dyskinesis on left ventriculogram. When discordance was considered to be a marker of ischemia, the sensitivity and specificity in effort angina and control subjects were 95.2% and 84.6% for patients and 83.9% and 94.4% for diseased vessels, respectively. There were no differences between the sensitivity and specificity in left anterior descending artery (LAD), left circumflex artery (LCx) and right coronary artery (RCA) lesions (83.3%, 95.5% in LAD, 83.3%, 95.5% in LCx, 85.7%, 92.6% in RCA, respectively). All of the patients with old myocardial infarction had reduced exercise BMIPP uptake in infarcted regions. In old myocardial infarction, 35 patients had segments with discordant uptake. Discordance was observed in 75 (91.5%) of 82 segments with hypokinesis, and in 24 (92.3%) of 26 segments with severe hypokinesis. Even among the 36 segments with akinesis or dyskinesis, 25 (69.0%) had discordant uptake. When discordance in the infarcted region was considered to be a marker of viability, regions with severe asynergy showed a high possibility of viability. Thus, discordant uptake on exercise BMIPP and resting T1 delayed SPECT may be a useful marker of ischemia in effort angina and of viability in old myocardial infarction.

Incidence of fundic gland polyps in patients without familial adenomatous polyposis.

The incidence of fundic gland polyps was evaluated using a high-resolution videoendoscope. In 1388 upper gastrointestinal endoscopic studies, 26 cases of fundic gland polyps (1.9% of the studied cases) were found. None of these patients had evidence of familial adenomatous polyposis. Fifteen of these patients (58%) had a solitary polyp in the gastric body, most of which were small sessile polyps of less than 2 mm in diameter. The results of this study indicated that a small solitary fundic gland polyp is not a rare gastric lesion and that little relationship exists between these solitary fundic gland polyps and familial adenomatous polyposis.

Acinar cell carcinoma of the pancreas with elevated serum alpha-fetoprotein levels: a case report and a review of 28 cases reported in Japan.

A 60-year-old male with elevated serum AFP levels is reported. Other tumor markers apart from AFP were normal. Serum AFP did not bind to Con A or Lentil-lectin by affinity chromatography. Abdominal ultrasonography, computed tomography and endoscopic retrograded cholangiopancreatography demonstrated a tumor extending from the body to the tail of the pancreas. The tumor was strongly suggested to be an acinar cell carcinoma of the pancreas, based on the histological findings of the resected specimen. The peroxidase-antiperoxidase method showed cancer cells to be positive for AFP. In Japan, only 27 cases of pancreatic cancer with elevated serum AFP level have been reported. This is the first Japanese case of pancreatic cancer in which the binding of serum AFP to lectins was investigated.

Fentanyl for sedation during upper gastrointestinal endoscopy.

The effects of sedation by intravenous fentanyl on the rate-pressure product (pulse rate x systolic blood pressure/100), arterial oxygen saturation, electrocardiographic change, and serum cortisol concentration were studied during gastroduodenoscopy in 84 patients randomized to receive fentanyl or no intravenous sedative (controls). Fentanyl administration increased the tolerance of patients and attenuated the endoscopy-induced rise in rate-pressure product and serum cortisol concentration. Desaturation of arterial oxygen was minimal and there was no difference in arterial oxygen saturation between the fentanyl group and the control group. Therefore, fentanyl appears to be a favorable sedative for upper gastrointestinal endoscopy, since its administration increased the tolerance of patients and decreased cardiac oxygen consumption.

Effects of cisapride on gastrointestinal motor activity and gastric emptying of disopyramide.

The effects of cisapride on the gastrointestinal contractile activity and pharmacokinetics of disopyramide were determined in beagle dogs and patients with arrhythmia. In the animal experiments, the gastric motor index was significantly decreased by i.v. administration of disopyramide in a dose-dependent fashion. The peak decrease of the motor index was observed within 5 min after i.v. injection of disopyramide; the motor index then recovered gradually to the level present prior to drug administration. I.v. administration of cisapride (0.5 mg/kg) markedly increased gastrointestinal contractile activity following the decrease induced by disopyramide pretreatment (5 mg/kg, i.v.). In the clinical studies, the gastric emptying test was performed using the acetaminophen method. A significant correlation between plasma concentrations of disopyramide and gastric emptying time has been found (p < 0.001). The combination of disopyramide (100 mg t.i.d.) and cisapride (2.5 mg t.i.d.) significantly increased gastric emptying compared with that induced by disopyramide alone. The peak plasma concentration of disopyramide in association with cisapride oral administration was significantly higher, and the apparent absorption rate constant and lag time of disopyramide were about 2-fold higher and 2-fold shorter, respectively, than for disopyramide alone. Cisapride, acting as a cholinergic agonist, may counteract the anticholinergic effect of disopyramide on gastric motility. As a factor influencing drug absorption, gastric emptying is of importance, as it determines the rate of drug delivery to the small intestine. Therefore, the oral administration of disopyramide with cisapride may be useful for patients with delayed gastric emptying.

Gastroesophageal reflux after endoscopic injection sclerotherapy.

The effect of sclerotherapy of esophageal varices on the gastroesophageal reflux was studied. Gastroesophageal reflux was monitored by a 24-h pH-monitoring catheter introduced into the distal esophagus. The results of pH monitoring of 16 patients who underwent sclerotherapy were compared with those of 21 patients with untreated varices. Seven of the 16 treated patients showed high occurrence rates of gastroesophageal reflux comparable to those observed in cases with severe reflux esophagitis. In the untreated group, only one patient showed pathological reflux (there was a significant difference between treated and untreated groups; p less than 0.01). When the level of reflux was compared with factors that might influence sclerotherapy-induced gastroesophageal reflux, there was a positive correlation between the magnitude of reflux and amount of sclerosant injected paravariceally in the submucosal tissue (p less than 0.05). The results indicate that the paravariceal injection of sclerosant for the treatment of esophageal varix may cause pathological gastroesophageal reflux after sclerotherapy is completed.

[Age-related effects of gastroduodenoscopy on arterial oxygen saturation].

Although endoscopy is widely used for safe and accurate examinations of gastroduodenal disease cases, several investigators reported arterial oxygen desaturation occurring during endoscopy. Endoscopy-induced oxygen desaturation is hazardous because it increases the risk of cardiac arrhythmia. This study is designed to investigate whether gastroduodenal endoscopy causes remarkable oxygen desaturation in elderly patients in comparison with younger ones and to study whether nasal oxygen administration can prevent it. Forty-four patients over 61 years old and 37 patients younger than 60 were divided into two groups, to one of which 100% oxygen (2 l/min) was administered through nasal prongs. During endoscopy, blood pressure, pulse rate, and arterial oxygen saturation (SaO2) were recorded at one-minute intervals by a pulse oximeter. Intubation of the endoscope caused a transient drop in oxygen saturation both younger and older patients with greater drops in older subjects (1.7 +/- 0.4% in the young and 3.3 +/- 0.8% in the old groups). In the older groups, two out of 20 patients who had no oxygen administration showed a saturation decrease of over 7%. On the other hand, no younger subject showed such a large degree of oxygen desaturation. Oxygen administration effectively prevented the endoscopy-induced desaturation both in younger and in older patients. In summary, the results of this study suggested that older subjects had a greater decrease of oxygen saturation during gastroduodenofiberscopy and that oxygen administration is useful to prevent the endoscopy-induced desaturation.

Arterial oxygen saturation, blood pressure, and pulse rate during upper gastrointestinal endoscopy--influence of sedation and age.

We studied the effect of sedation by I.V. meperidine on blood pressure, pulse rate, and arterial oxygen saturation during upper gastrointestinal endoscopy. Meperidine increased the tolerance of the patients and attenuated the endoscopy-induced rise in blood pressure and pulse rate. Arterial oxygen saturation was transiently depressed in the first few minutes of the endoscopic procedure even without sedation, and meperidine administration did not aggravate this oxygen desaturation. Therefore, meperidine may be a favorable sedative for upper gastrointestinal endoscopy because its treatment increases the tolerance of patients and decreases cardiac oxygen demand without decreasing arterial oxygen saturation.

Primary chylopericardium with pulmonary shadow and large granular lymphocytosis: a case report.

A 79-year-old man with primary chylopericardium associated with large granular lymphocytosis was followed for more than 26 years. Except for development of dyspnea on exertion during the past four years and more recently cough with sputum production, he has remained largely asymptomatic over this interval. Based on detailed examinations of cellular and humoral immunity, we speculate that increased natural killer cell activity and an increased number of large granular lymphocytes circulating in his peripheral blood represent a reactive response to production of various cytokines secondary to persistent loss (? chyloptysis) and sequestration of central lymph.

Primary amyloidosis with dry eyes and dry mouth--a case report.

We report a rare case of dry eyes and dry mouth caused by primary amyloidosis. A 66-year-old woman with keratoconjunctivitis sicca and xerostomia died of acute respiratory failure. Shirmer's test, gum test, and sialography indicated Sjögren's syndrome. Lip biopsy revealed amyloid deposition around the salivary ducts. Bence-Jones protein was noted in the urine. At autopsy, amyloid deposition was identified histochemically in many organs, mainly on the vessel walls. Primary amyloidosis should be considered as a differential diagnosis of Sjögren's syndrome.

A case of gastric plasmacytoma: genetic analysis and immunofixation electrophoresis.

A case of early gastric plasmacytoma in a 66-yr-old woman is reported. The demonstration of monotypic IgM lambda immunoglobulin in plasma cells infiltrating the gastric antrum contributed the histological diagnosis. Genetic analysis of the tumor cells confirmed the presence of a monoclonal neoplastic population of plasma cells in the tumor. Monoclonal immunoglobulin (IgM lambda) was demonstrated in serum, not by conventional immunoelectrophoresis, but by a highly sensitive immunofixation electrophoresis technique. Serum monoclonal immunoglobulin disappeared after subtotal gastrectomy. The value of immunofixation electrophoresis of serum protein and DNA analysis of tumor cells was emphasized for the diagnosis of gastric plasmacytoma.

Ga-67 myocardial scintigraphy in patients with acute myocarditis.

Four patients with acute myocarditis were examined by Ga-67 myocardial scintigraphy. Two cases showed positive scintigram. In one of these cases, the first scintigram showed positive one month after onset of acute myocarditis, and three and four months after its onset, Ga accumulation slightly decreased intermittently. However, six months after its onset, the scintigram showed strongly positive again. Endomyocardial biopsy of this case six months from its onset showed some mononuclear cell infiltration in the myocardial interstitium. From these changes of scintigram during the course of the disease and biopsy findings, this case appeared to be one of "smoldering" or "chronic recurrent" myocarditis. Another case showed weakly positive one month after onset of disease, in spite of a negative CRP. In the remaining two cases, Ga-67 scintigram showed negative, although CRP was + and 5+, respectively. The sensitivity of the Ga-67 myocardial scintigram may not be very high. But when it continues to show positive, acute myocarditis seems to be "smoldering" and transferring to DCM. Ga scintigram is a noninvasive examination for myocarditis and is a useful screening test for identifying myocarditis, and serial scans may eliminate the need for frequent biopsies in suspected myocarditis cases.

Hypocalcemic crisis in alcoholic fatty liver: transient hypoparathyroidism due to magnesium deficiency.

Hypocalcemic crisis developed in a patient with acute alcoholic fatty liver. In addition to jaundice and marked hepatomegaly, the patient presented with hypocalcemic crisis associated with hypomagnesemia, low plasma 1,25(OH)2-vitamin D and undetectable plasma parathyroid hormone (PTH) concentration. Subsequent computerized tomographic scan and liver biopsy showed the presence of severe fatty liver. With the improvement of liver function, the serum calcium level increased, and was accompanied by normalization of plasma PTH, serum magnesium, and plasma 1,25(OH)2-vitamin D levels. Serial ethylenediaminetetraacetic acid infusion tests demonstrated the reversal of the impaired PTH secretion. Thus, hypocalcemic crisis in this patient appeared to result from transient hypoparathyroidism induced by magnesium deficiency.