Metformin or gliclazide, rather than glibenclamide, attenuate progression of carotid intima-media thickness in subjects with type 2 diabetes.

AIM/HYPOTHESIS: Metformin is a well-known oral hypoglycaemic agent and has been commonly used, in combination with sulphonylurea, to treat type 2 diabetes. However, the advantageous effect of metformin plus sulphonylurea on diabetic macroangiopathy has yet to be clarified. To evaluate whether sulphonylurea or sulphonylurea plus metformin prevent diabetic macroangiopathy, we examined the progression of carotid artery intima-media thickness (IMT) as a surrogate end point. METHODS: Subjects with type 2 diabetes were divided into three groups, receiving the following treatments: (i) glibenclamide (n=59); (ii) gliclazide (n=30); and (iii) glibenclamide + metformin (n=29). Maximum IMT and average IMT (the greatest value among 6 average values of each 3 points including greatest thickness) were measured at the beginning and end of the observation period. RESULTS: For the follow-up period of 3 years, the annual change in average IMT of the glibenclamide plus metformin group (0.003+/-0.048 mm) was smaller than that of the glibenclamide group (0.064+/-0.045 mm) and gliclazide group (0.032+/-0.036 mm) (p<0.0001 and p=0.043 respectively). In the gliclazide group, average IMT increased during the follow-up period, but annual change in average IMT was significantly smaller than that of the glibenclamide group (p=0.005). Glibenclamide + metformin or gliclazide also attenuated the progression of maximum IMT, compared with that of glibenclamide (0.041+/-0.105, 0.044+/-0.106, 0.114+/-0.131 mm/year respectively, p=0.029 and p=0.035 respectively). Multivariable regression analysis implied that administration of metformin or gliclazide significantly and independently (p<0.05) reduces the progression of average IMT, compared with glibenclamide monotherapy. CONCLUSIONS/INTERPRETATION: These data indicate that metformin or gliclazide, rather than glibenclamide, have a potent anti-atherogenic effect in type 2 diabetes.

Association of (-)786T-C mutation of endothelial nitric oxide synthase gene with insulin resistance.

AIMS/HYPOTHESIS: Endothelial derived nitric oxide synthase ( eNOS) gene polymorphisms affect eNOS activity and are associated with abnormal vasomotility and impaired local blood flow. A decrease in local blood flow has been reported to cause insulin resistance. The aim of this study was to examine a possible association of two eNOS polymorphisms, Glu298Asp (G894T) in exon 7 and (-)786T-C mutation with insulin resistance. METHODS: Genotypes of both Glu298Asp and (-)786T-C mutation were examined by the PCR-RFLP method. Plasma nitrate and nitrite concentrations were also measured. RESULTS: The allele frequencies of both polymorphisms showed no considerable differences in 233 non-diabetic subjects and 301 patients with Type II (non-insulin-dependent) diabetes mellitus. Non-diabetic subjects with the (-)786C allele had (p<0.05) higher fasting plasma insulin and homeostasis model assessment of insulin resistance than those with the (-)786T/ (-)786T genotype. Diabetic subjects with (-)786C allele showed higher HbA(1c) than those with the (-)786T/(-)786T genotype. A euglycaemic hyperinsulinemic clamp study done on 71 of the 301 patients showed a lower glucose infusion rate in diabetic patients with the (-)786C allele than those without it. In diabetic patients with the (-)786C allele, plasma nitrate and nitrite concentrations were lower than in subjects without it (p=0.026). No differences were observed between mutant carriers of Glu298Asp and non-carriers among both non-diabetic subjects and Type II diabetic patients. CONCLUSIONS/INTERPRETATION: The (-)786T-C mutation of the eNOS gene is associated with insulin resistance in both Japanese non-diabetic subjects and Type II diabetic patients.

Renal cell carcinoma with skull base metastasis preceded by paraneoplastic signs in a chronic hemodialysis patient.

A 59-year-old man who had received chronic hemodialysis developed left occipital pain and hypoglossal nerve palsy. He was diagnosed as having skull base metastasis from renal cell carcinoma related to acquired cystic kidney. Retrospective analysis revealed the patient had had elevated serum C-reactive protein and alkaline phosphatase levels before the symptoms appeared. Radiotherapy to the skull base relieved the pain. Finally he died with generalized metastases. Serum interleukin-6 levels measured during admission had been elevated, and interleukin-6 mRNA was detected in the autopsy specimen of renal cell carcinoma. Interleukin-6 might be involved in the etiology of paraneoplastic signs.

Neuraminidase-producing ability of intestinal bacteria isolated from coastal fish.

The neuraminidase-producing ability of bacteria from coastal fish intestines and their environments was determined using a fluorogenic substrate, 2'-(4-methylumbelliferyl)-alpha-D-N-acetylneuraminic acid. Of 836 isolates examined, 758 (90.7%) produced little or no neuraminidase (< 0.0002 U ml-1) while 78 (9.3%) produced >/= 0.0002 U neuraminidase ml-1. Of note, 10% of vibrios from fish intestines could produce neuraminidases, and 9% did it efficiently. This result suggests that the vibrios capable of producing neuraminidases are able to colonize and establish in the intestinal tract of coastal fish to some extent. Additionally, as many as 58% of the Vibrio isolates with high abilities were tentatively identified as Vibrio damsela.

[Primary pulmonary lymphoma presenting as an endobronchial polypoid tumor].

A 58-year-old woman because of coughing and an abnormality on a chest renggenogram was referred to our hospital. A chest X-ray film and a computed tomogram revealed atelectasis of the right lower lobe and a round tumor in the left lower lobe. Fiberoptic bronchoscopy revealed an endobronchial polypoid tumor in the intermediate bronchus, which completely obstructed the orifice of the right lower-lobe bronchus. Microscopical examination revealed B-cell diffuse, large, non-Hodgkin's lymphoma. No extrapulmonary lesion was found, and therefore primary pulmonary non-Hodgkin's lymphoma was diagnosed. Chemotherapy resulted in rapid and complete regression of the tumor, which was confirmed endoscopically and histologically. The patient was still in complete remission 8 months after the end of chemotherapy. There have been no additional interventions.

Effectiveness of aldose reductase inhibitors for diabetic gastroenteropathy with constipation.

We present a diabetic patient with long-standing constipation complicated by paralytic ileus and septic shock. She successfully recovered from a critical condition, and her diabetes was well controlled. However, the constipation did not improve even after the administration of conventional medications. Epalrestat, an aldose reductase inhibitor (ARI), improved her bowel motility and autonomic cardiovascular dysfunction, as evident from her heart rate and blood pressure response. Gastroenteropathy is a major diabetic complication which may cause disturbed bowel motility leading to serious enterobacterial infections, thus, its amelioration is important. ARI may be beneficial in the treatment of diabetic gastroenteropathy refractory to conventional therapies.

[Interstitial pneumonia associated with human adjuvant disease which developed 30 years after silicone augmentation mammoplasty].

A 51-year-old woman was admitted to our hospital with exertional dyspnea, swelling and stiffness in her fingers. Raynaud's phenomenon and mammary and axillary lymphadenopathy. She had received silicone augmentation mammoplasty 30 years ago, and had since noticed bilateral mammary and axillary lymphadenopathy that was stable in size. In the 2 years before admittance she had become aware of an exacerbation of the lymphadenopathy had begun to experience and exertional dyspnea several months before admission suggesting a connective tissue disease. Physical examination revealed symmetrical weakness of the proximal limb muscles and fine crackles in the base of both lungs. Elevated myogenic enzymes, inflammatory reactions, and positive anti-SSA antibody were noted. Based upon these findings, muscle and lip biopsy results, myogenic EMG, and an apple tree appearance on sialography, a differential diagnosis of polymypositis or sjögren's syndrome was made. Axillary lymph node biopsy findings were consistent with silicone lymphadenitis. In addition, chest roentgenogram and HRCT (which revealed decreased lung volumes and interstitial opacities with no honeycombing, present predominatly in the subpleural space), pulmonary function tests (decreased VC and DLco), bronchoalveolar lavage (elevated total cell count and neutrophil and eosinophil fractions), and transbronchial lung biopsy specimens (unevently distributed alveolitis with fibrosis) indicated concurrent interstitial pneumonia. The clinical correlation between exacerbation of silicone lymphadenopathy and the development of connective tissue disease with accompanying interstitial pneumonia strongly suggested human adjuvant disease (HAD) as the pathogenesis. To our knowledge, interstitial pneumonia associated with HAD is rare.

[A successful case of omentopexy for bronchopleural fistula and empyema after right pneumonectomy].

A 59-year-old male was performed right pneumonectomy with R 2 b lymph node dissection and intercostal muscle flap to the bronchial stump for squamous cell carcinoma of right upper lobe of the lung (cT 2 N 2 M 0-stage III A). But four weeks later bronchial stump was suddenly reopened and he developed empyema. Omentopexy for bronchopleural fistula (15 x 11 mm in size) and thoracoplasty for empyema was performed. Bronchoscopically the fistula is 2 mm in diameter and reepithelization is started around the fistula at 14 POD and the fistula is completely closed and covered with reepithelized mucosa without inflammation at 100 POD. We think omentopexy for bronchopleural fistula after pneumonectomy is very effective procedure, so we should be considered this method at first. But if the fistula is accompanying empyema as our case thoracoplasty should be added.

[A new index of acceleration plethysmogram and its clinical physiological evaluation].

The purposes of the present study were to examine a new index of acceleratingly plethysmogram (APG) and to discuss the possibility to apply the APG index. One hundred sixty-three subjects voluntarily participated in the present study. The mean values (n = 10) of individual coefficient of variance were 7.22% in wave height B, 8.26% in the total area of the lower part under the base line, and 7.28% in a new APG index. The coefficient of variance in the APG index calculated from the previous method (18.67%) was larger than that of the present study. We recognized the significantly polynomial relationship between the new APG index and types of APG. Further, the value of new APG index remarkably increased when the index was beyond 50. There were significant differences in age, blood pressure, rate of body fat, blood glucose, total cholesterol, HDL cholesterol, and index of arteriosclerosis between above 50 and below 50 in the new APG index. These results suggest that the present APG index is adequate about about the individual reproducibility, and it has the possibility to apply as an index of arteriosclerosis.

Hypergalactosaemia in a patient with portal-hepatic venous and hepatic arterio-venous shunts detected by neonatal screening.

Hypergalactosaemia was discovered in a newborn girl during routine metabolic screening. Hereditary enzyme deficiency was ruled out. She had multiple hepatic haemangiomas with portal-hepatic venous and hepatic arterio-venous shunts. Since she showed signs of high-output heart failure due to the arterio-venous shunt, hepatic artery embolization was performed at age 3 months. A galactose tolerance test was performed before and after embolization and when the haemangioma no longer appeared on ultrasonography. Even after embolization, the level of blood galactose was abnormally elevated in the galactose tolerance test, but the blood galactose was eliminated more rapidly than before embolization. When the hepatic haemangioma was no longer detected by ultrasonography, the peak galactose level decreased. We surmise that the hypergalactosaemia was due to these shunts. In cases of hypergalactosaemia of unknown cause; liver haemangioma with portal-hepatic venous shunting should be considered as a possible cause. If a hepatic arterio-venous shunt also exists, this may contribute to the effect of the portosystemic shunting.

[Leptomeningeal abnormality on Gd-DTPA enhanced MRI in a case of SLE presenting diffuse organic brain syndrome].

Involvement of the central nervous system associated with SLE (CNS lupus) is not rare. Two types of CNS lupus are noted clinically; one group manifesting focal neurological symptoms and another group showing mental symptoms. Though it is well known that neurological symptoms are caused by arteritis and thrombus, pathophysiological mechanisms leading to mental symptoms remain obscure and there is no established clinical evidence responsible for these symptoms. A 41-year-old woman was confused and her attention was markedly impaired. Her mental symptoms consisted of disorientation, restlessness, euphoria and emotional incontinence. There were neither focal neurological signs nor meningeal signs. Cerebrospinal fluid (CSF) examination showed increased number of polymorphonuclear cells and permeability of the blood-brain barrier, calculated based on the CSF/plasma protein ratio, was also elevated. Repeated bacteriological examinations revealed to be negative. Gd-DTPA MRI demonstrated diffuse enhancement of the cerebral leptomeninges. Methylprednisolone pulse therapy ameliorated her mental deterioration effectively, and subsequently the leptomeningeal enhancement with Gd-DTPA MRI disappeared in parallel. These radiological and laboratory findings suggest that SLE itself causes inflammation of vessels in the leptomeninges and adjacent cerebral cortex. We consider mental symptoms associated with SLE may be caused, at least in part, by this mechanism. To our knowledge, we could not find similar reports in the literature. Gd-DTPA enhanced MRI seems to be of clinical use for making diagnosis, evaluating clinical activity and understanding of CNS lupus.

Characterization of a novel promoter structure and its transcriptional regulation of the murine laminin B1 gene.

Expression of the laminin B1 gene is known to be induced late during the differentiation of F9 cells by retinoic acid (RA) and dibutyryl cAMP. The involvement of retinoic acid receptors (RARs) has been demonstrated recently in the late induction of laminin B1 gene expression, although the precise regulatory mechanism is not known. In this study, we have reconstituted an efficient in vitro transcription system using F9 nuclear extracts and defined the core promoter structure of the murine laminin B1 gene. The laminin B1 gene was shown to lack a TATA box. The level of the in vitro transcription of the laminin B1 gene was determined by at least three regions between the transcription initiation sites and -100. The most distal region (from -89 to -69) contained three GC boxes. The second region (from -62 to 47) contained a direct repeat of TG(C/A)GCA motif. The proximal region (from -45 to -11) contained another direct repeat of CCTCCCT(C/A)GG motif. A deletion of any one of the three regions respectively decreased the level of transcription to about 20% of wild type DNA. The protein binding analyses revealed that F9 cells contain a factor(s) binding to the TG(C/A)GCA repeat, which was also found in HeLa cells. Together with the observation that the 5' ends of the laminin B1 mRNA from the differentiated F9 cells were identical to those from the undifferentiated F9 cells, it was concluded that the three regions identified here constitute the core promoter of the laminin B1 gene.

Cloning of the 5' flanking region of the murine laminin B1 gene by genomic PCR.

Induction of the murine laminin B1 gene in F9 cells occurs 24-48 hours after the retinoic acid (RA) addition. In order to reveal the mechanism of the late induction of the laminin B1 gene, it is necessary to understand fully the promoter structure of it. We report here that the promoter region of the laminin B1 was rapidly isolated utilizing the genomic PCR technique. MgCl2, formamide concentration, and annealing temperature were optimized for PCR. The result showed that MgCl2 concentration profoundly affects the efficiency in amplifying the specific DNA. The annealing temperature (51 degrees C-63 degrees C) did not significantly affect the yield. Under the optimal conditions, about 50 ng of the specific DNA was obtained from 1 microgram of total genomic DNA after 20 cycles of amplification, indicating that approximately 2 x 10(5) fold specific amplification had occurred. Southern blot analysis and sequence data proved that the amplified DNA fragment contained the promoter region of the laminin B1 gene.

[Therapeutic embolization of infantile hemangioendothelioma of the liver].

A distinct syndrome in infantile hemangioendothelioma consist of high-output congestive heart failure, hepatomegaly and cutaneous hemangiomas. Early therapy aimed at reduction of the shunt is essential if life is to be saved once cardiac failure becomes manifest. We report a case of infantile hemangioendothelioma with massive A-V and P-V shunt successfully treated by transcatheter embolization.

[A case of malignant melanoma responded to chemotherapy including DTIC and local injection of OK-432].

A 33-year-old woman with malignant melanoma well responded to a chemotherapy including DTIC, ACNU, and VCR, and intralegional injection of OK-432. Four years prior to admission, a lentigo of 5 mm diameter at her left frontal chest was found, but, histological examination resulted in no distinctly malignant findings. In November 1979, multiple subcutaneous tumors appeared over posterior surface of the chest and left axillar region, which were gradually increasing in number and size, then she was admitted to our hospital in June, 1980. Biopsy of subcutaneous tumors revealed a malignant melanoma and its metastasis to skin. Immunochemotherapy was started immediately based upon this diagnoses. The patient received 100mg DTIC i.v. for 4 days, 100mg ACNU i.v. for one day and 1 mg VCR i.v. for one day. OK-432 was locally injected into some tumors as an immunotherapy. On completion of the third course of chemotherapy, all subcutaneous tumors were decreased in size, especially the tumors injected with OK-432. However, patient didn't respond to a repeated chemotherapy, thereafter malignant melanoma was metasized to uterus and peritoneum in May, 1981, and she died in September, 1981. Major side effects of this chemotherapy were nausea and mild transient leukocytopenia. The combination of chemotherapy including DTIC and local injection of OK-432 appeared to be effective for malignant melanoma.