Book reviews

Although it was expected by observers in Japan that the potency of belief in the superstition of the year of Fire-horse would be made apparent by a decrease in births and an increase of the induced abortion rate, an increase of infant mortality rate was not anticipated. However, an analysis of the early neonatal mortality rate of accidents and violence revealed a remarkable increase for girls but not for boys in 1966, the most recent year of Fire-horse. This fact is consistent with the superstition that women born in the year of Fire-horse are ill-fated.     

Simultaneous, clonally identical T cell expansion in tonsil and synovium in a patient with rheumatoid arthritis and chronic tonsillitis

In some patients with rheumatoid arthritis (RA), the disease improves following tonsillectomy. We describe a 28-year-old woman with treatment-resistant RA and chronic tonsillitis. Initially, her arthritis had been well controlled with methotrexate and corticosteroids, but the RA activity became difficult to control in spite of addition of bucillamine to the treatment regimen and repeated arthrocentesis with infusion of corticosteroid into her swollen joints. Closer examination revealed that the period of exacerbation of her chronic tonsillitis paralleled that of the systemic arthritis, and administration of antibiotics brought transient relief of the systemic symptoms. Her arthritis was ameliorated after successful tonsillectomy and synovectomy, with marked reduction of the serum rheumatoid factor concentration. Analysis of infiltrating T cell clones in tonsil and synovium using T cell receptor V(beta) repertoire and third complementarity-determining region size distribution analysis followed by nucleotide sequencing revealed common clonal T cell expansion in both tissues. This finding suggests the possible involvement of chronic focal infection in refractory RA.     

Effect of low-dose isoproterenol infusion on left atrial appendage function soon after cardioversion of chronic atrial tachyarrhythmias

BACKGROUND: Cardioversion of chronic atrial fibrillation or atrial flutter to sinus rhythm is often associated with transient atrial mechanical dysfunction, i.e. 'atrial stunning', which may increase the risk of subsequent thromboembolic events. We hypothesized that, because of its positive inotropic action, a low-dose isoproterenol infusion might improve postcardioversion atrial mechanical function. METHOD: Eighteen patients (15 male, three female; 12 atrial fibrillation, six atrial flutter; mean age 65+/-10 years) exhibiting atrial postcardioversion stunning were included in the study. Isoproterenol was infused for 10 min at a dose sufficient to increase the heart rate by about 10%. Using transesophageal echocardiography, both the left atrial appendage emptying/filling flow velocity and function (fractional area change) were examined at baseline, before isoproterenol (immediately after cardioversion) and after isoproterenol. RESULTS: With infusion of 0.005-0.008 microg/kg/min isoproterenol, heart rate increased by 11.1+/-2.9%, and left atrial appendage emptying velocity, which was diminished following cardioversion, increased significantly (P<0.001) (baseline, before and after isoproterenol: 41.1+/-18.0, 20.3+/-8.5 and 27.3+/-9.6 cm/s, respectively). No major complications were associated with isoproterenol infusion. CONCLUSIONS: Short-term infusion of low-dose isoproterenol improved atrial function after cardioversion of chronic atrial fibrillation and atrial flutter.     

Antithymocyte globulin in the treatment of D-penicillamine-induced aplastic anemia

A patient who received antithymocyte globulin therapy for aplastic anemia due to D-penicillamine therapy is described. Bone marrow recovery and peripheral blood recovery were complete 1 month and 3 months, respectively, after treatment, and blood transfusion or other therapies were not necessary in a follow-up period of more than 2 years. Use of antithymocyte globulin may be the optimal treatment of D-penicillamine-induced aplastic anemia.     

Patients in whom active tuberculosis was diagnosed after admission to a Japanese university hospital from 2005 through 2007

To identify problems in early diagnosis of tuberculosis and to design countermeasures against the disease, we examined the status of active tuberculosis among patients admitted to a university hospital that did not have an isolation ward for tuberculosis. Between 2005 and 2007, we analyzed demographic characteristics, disease type, chest radiologic findings, and the process leading to diagnosis. Active tuberculosis was diagnosed after admission in 55 patients (34 males and 21 females): pulmonary tuberculosis, 26; tuberculous pleuritis, 13; tuberculous meningitis, 6; miliary tuberculosis, 4; tuberculous pericarditis, 3; lymph-node tuberculosis, 2; and tracheal and bronchial tuberculosis, 1. Although radiographic examinations provided abundant information, chest radiography showed normal findings in 7 patients (12.7%). Computed tomographic scanning was useful for detailed evaluation of abnormalities. Twenty patients (36.4%) were given diagnoses at departments other than ours (Department of Pulmonary Medicine). Numbers of days between hospital admission and diagnosis of tuberculosis (50th percentile/80th percentile) were 8.0/37.8 for miliary tuberculosis, 8.0/8.0 for tracheal and bronchial tuberculosis, 7.5/17.8 for tuberculous pleuritis, 7.0/8.8 for tuberculous pericarditis, 6.0/15.6 for pulmonary tuberculosis, 3.5/4.4 for lymph-node tuberculosis, and 1/1 for tuberculous meningitis. Early diagnosis of tuberculosis requires adherence to the following precautions. Tuberculosis should be suspected in any patient with respiratory symptoms. Sputum tests for acid-fast bacteria should be performed at least three times initially. If findings on chest X-ray films are equivocal, high-resolution computed tomography should be performed to confirm details of shadows and to detect minimal pulmonary shadows or cavitary lesions. Physicians from all specialties should be repeatedly informed about the risk of tuberculosis and should include tuberculosis in the differential diagnosis in patients suspected to have pulmonary diseases.     

Pioglitazone prevents reactive hypoglycemia in impaired glucose tolerance

A 42-year-old woman with hypoglycemic symptoms that occurred several hours after a meal visited our hospital. The hypoglycemic symptoms appeared when she was 37 years old, and her plasma glucose level had been assessed as less than 60 mg/dL when she experienced the symptoms. One year before, she had been diagnosed with reactive hypoglycemia by 75 g-oral glucose tolerance test (OGTT), which showed a normal glucose tolerance (NGT) pattern, and had begun taking an alpha-glucosidase inhibitor and nutritional treatment. A 75 g-OGTT on admission showed hypoglycemia at 240 min after glucose loading, excessive insulin secretion and an impaired glucose tolerance (IGT) pattern. A euglycemic-hyperinsulinemic clamp study demonstrated decreased insulin sensitivity. Therefore, we suspected that she had reactive hypoglycemia associated with insulin resistance and treated her with 15 mg/day pioglitazone. Her hypoglycemic symptoms completely disappeared after treatment with pioglitazone; insulin sensitivity in a euglycemic-hyperinsulinemic clamp study improved. Another 75 g-OGTT revealed that the excessive insulin secretion and hypoglycemia at 240 min after glucose loading had disappeared, and glucose tolerance was normalized from an IGT pattern to an NGT pattern. Thus, we believe that pioglitazone is effective for reactive hypoglycemia and aggravated glycemic metabolism associated with insulin resistance.     

Low fasting plasma glucose level predicts morbidity and mortality in symptomatic adults with congenital heart disease

Background

Adults with complex congenital heart disease (ACHD) have a high prevalence of abnormal glucose regulation (AGR: impaired glucose tolerance and diabetes mellitus). However, the impact of AGR on the prognosis remains unclear.

Purpose

Our purpose was to clarify the prognostic value of AGR in ACHD.

Methods and results

We performed a 75 g oral glucose tolerance test in 438 consecutive patients with ACHD (age 26 ± 8 years), including 38 unrepaired, 148 Fontan, 252 biventricular, and 27 healthy subjects and investigated associations between AGR and clinical events that required hospitalization or caused deaths from all-causes. When compared with the healthy group, fasting blood glucose level (FPG, mg/dl) was lower in the unrepaired and Fontan subjects (p < 0.05–0.01) and the prevalence of low FPG (≤ 80 mg/dl) was also higher in the unrepaired (58%), Fontan (47%), and biventricular group (33%) than in the healthy control (11%) (p < 0.0001). Postprandial hyperglycemia (area under the curve of glucose: PG-AUC) was higher in all ACHD groups (p < 0.0001 for all). New York Heart Association class and lower FPG independently predicted the hospitalization (FPG ≤ 84 mg/dl) and mortality (FPG ≤ 80 mg/dl) (p < 0.05–0.0001), while the PG-AUC was not an independent predictor. When compared with the asymptomatic ACHD, symptomatic ACHD with lower FPG had high hazard ratios of 2.2 (95% confidence interval [CI]: 1.3–3.8, p < 0.002) and 3.3 (95% CI: 1.2–11.9, p < 0.03) for the hospitalizations and all-cause mortality, respectively.

Conclusions

Low FPG is not uncommon in ACHD and the low FPG predicts the morbidity and all-cause mortality in symptomatic ACHD.     

Upfront autologous stem-cell transplantation with melphalan,cyclophosphamide, etoposide,and dexamethasone (LEED) in patients with newly diagnosed primary central nervous system lymphoma

Treatment of primary central nervous system lymphoma (PCNSL) improved in recent years. However, the high neurotoxicity and low survival rates associated with this condition remain unresolved. We report 13 consecutive patients with PCNSL for whom upfront melphalan, cyclophosphamide, etoposide, and dexamethasone (known as LEED) followed by autologous stem-cell transplantation (ASCT) was planned at the Anjo Kosei Hospital. All patients were pathologically diagnosed with diffuse large B-cell lymphoma and were negative for human immunodeficiency virus. All patients were to receive three cycles of high-dose methotrexate-based induction chemotherapy, two cycles of high-dose AraC-based chemotherapy, and LEED followed by ASCT. All 13 patients achieved a partial response, and the 3-year overall survival (OS) rate was 76.2 %. Seven of the 13 patients were alive at the last follow-up, without any adverse events, including neurotoxicity. Six of the 13 (46.2 %) patients underwent ASCT and the 3-year OS rate was 80.0 %. Although this study included only a limited number of patients, these preliminary signs of efficacy and tolerability merit further consideration. To make further improvements in survival, the rate of patients undergoing ASCT should be increased. Other prospective studies involving greater numbers of patients are required to confirm these findings.