A case of nephrotic syndrome with diabetes mellitus and primary aldosteronism]

A 65-year-old man had been followed by a family doctor for the treatment of hypertension and chronic hepatitis (type C) for about 20 years. Although he was pointed out to have impaired glucose tolerance and primary aldosteronism in 1995, he refused an adrenal tumor operation. He was admitted to our hospital on December, 1997 for further evaluation of general malaise, pitting edema of the legs, and positive urinary protein. A diagnosis of nephrotic syndrome was made on admission and a renal biopsy was performed. Histological findings indicated that he was at the early phase of diabetic nephropathy and hypertensive renal sclerosis. It is commonly believed that diabetic nephropathy develops after ten years of diabetic history and under poor control conditions. The diabetic history of this patient was only several years and the disease was under good control. In contrast to blood glucose, hypertension was not well-controlled with any antihypertensive drug, because he had a primary aldosteronism. Unfortunately, he could not take a spironolactone because of side effects. After removal of his adrenal tumor, his blood pressure was normalized gradually, and concomitantly his urinary protein was reduced and plasma protein and albumin were restored. Hypokalemia also disappeared. These findings suggest that uncontrolled hypertension may have accelerated the condition of diabetic nephropathy. The data indicates that the control of hypertension is important for inhibiting the progression of diabetic nephropathy.     

The addition of epinephrine increases intensity of sensory block during epidural anesthesia with lidocaine

BACKGROUND AND OBJECTIVES: Little is known about the effect of adding epinephrine to local anesthetic solutions on the intensity of sensory block during epidural anesthesia. This study examined development of sensory block during lumbar epidural anesthesia using a cutaneous current perception threshold (CPT) quantitative sensory testing device. METHODS: Twenty ASA I patients who were randomly divided to receive 10 mL 1% lidocaine with (group E) or without (group P) epinephrine 1:200,000. Current perception threshold at 2,000, 250, and 5 Hz stimulation at the trigeminal (V), ninth thoracic (T9), and second lumbar (L2) dermatomes, and the dermatomal levels of block of light touch, temperature, and pinprick discrimination were measured before and every 5 minutes, until 60 minutes after injection of epidural lidocaine. RESULTS: After epidural administration of lidocaine with epinephrine, all CPT significantly increased at T9 and L2, whereas no increase was detected after epidural plain lidocaine. Areas under the curves, calculated to express overall magnitude and duration of CPT values, were significantly larger in group E than those in group P at 2,000 and 250 Hz at T9. No differences were observed in the maximal levels of loss of cold, pinprick, and touch sensations between both groups. CONCLUSIONS: These results suggest that lumbar epidural anesthesia using 10 mL 1% lidocaine with epinephrine produces a more intense block of both large and small diameter sensory nerve fibers than that with plain lidocaine. It appears, therefore, that the addition of epinephrine improves the quality of sensory block during epidural anesthesia with lidocaine.     

Simultaneous transport and metabolism of ethyl nicotinate in hairless rat skin after its topical application: the effect of enzyme distribution in skin.

An in vitro permeation study of ethyl nicotinate (EN) was carried out using excised hairless rat skin, and simultaneous skin transport and metabolism of the drug were kinetically followed. Fairly good steady-state fluxes of EN and its metabolite nicotinic acid (NA) through the skin were obtained after a short lag time for all the concentrations of EN applied. These steady-state fluxes were not proportional to the initial donor concentration of EN: EN and NA curves were concave and convex, respectively, which suggests that metabolic saturation from EN to NA takes place in the viable skin at higher EN application. Further permeation studies of EN or NA were then carried out on full-thickness skin or stripped skin with an esterase inhibitor to measure their permeation parameters, such as partition coefficient of EN from the donor solution to the stratum corneum and diffusion coefficients of EN and NA in the stratum corneum and the viable epidermis and dermis. Separately, enzymatic parameters (Michaelis constant K(m) and maximum metabolism rate V(max)) were obtained from the production rate of NA from different concentrations of EN in the skin homogenate. The obtained permeation and enzymatic parameters were then introduced to differential equations showing Fick's second law of diffusion in the stratum corneum and the law with Michaelis-Menten metabolism in the viable epidermis and dermis. The calculated steady-state fluxes of EN and NA by the equations were very close to the obtained data. We then measured the esterase distribution in skin microphotographically using fluorescein-5-isothiocyanate diacetate. A higher enzyme concentration was observed in the epidermal cells and near hair follicles than in the dermis. Simulation studies using the even and the partial enzyme distribution models suggested that no significant difference between the models was observed in the skin permeations of EN and NA, whereas concentration-distance profiles of EN and NA were very different. This finding suggests that the total amount of enzyme in skin which converts EN to NA is a determinant of the metabolic rate of EN in skin. The present approach is a useful tool for analyzing simultaneous transport and metabolism of many drugs, especially those showing Michaelis-Menten type-metabolic saturation in skin.     

Alterations of soluble L- and P-selectins during cardiac arrest and CPR

Objective: To investigate the relationship between cytokines and the inflammatory responses in patients with out-of-hospital cardiac arrest, we examined the changes of cytokines as well as alterations in the markers of neutrophil activation, platelet and endothelial activation, and endothelial injury. Design: Prospective, cohort study. Setting: General intensive care unit of a tertiary care center. Patients and participants: 26 out-of-hospital cardiac arrest patients were classified into two groups: those who achieved return of spontaneous circulation (ROSC) (n = 10) and those with no ROSC (n = 16). Eight normal healthy volunteers served as control subjects. Measurements and results: Serial levels of soluble L-selectin (sL-selectin), soluble P-selectin (sP-selectin), neutrophil elastase, and soluble thrombomodulin were measured during and after cardiopulmonary resuscitation (CPR). Serial levels of tumor necrosis factor α (TNFα) and interleukin-1β (IL-1β) were also measured. We could not find any elevations in either cytokine during the study period. In both groups, sP-selectin levels were significantly higher than those in control subjects from the time of arrival at the emergency department to 24 h after admission. sL-selectin levels in the two groups were markedly lower compared to those in control subjects at all sampling points. In patients with ROSC, cardiac arrest and CPR led to an increase in the levels of neutrophil elastase and soluble thrombomodulin that peaked 6 h or 24 h after arrival at the emergency department. No statistical differences in the levels of the two selectins, neutrophil elastase, and soluble thrombomodulin between the two groups were found during CPR. Conclusions: Out-of-hospital cardiac arrest and CPR induces platelet, neutrophil, and endothelial activation and is associated with endothelial injury. Inflammatory cytokines may not have an important role in human whole-body ischemia-reperfusion injury. Received: 2 November 1998 Final revision received: 3 March 1999 Accepted: 26 March 1999     

Rapid remission of pulmonary eosinophilic granuloma in a young male patient after cessation of smoking]

A 24-year-old asymptomatic man was referred to our hospital in October 7, 1997 for further examination of abnormal shadows detected on chest X-ray films that had been obtained during an annual health examination on September 12, 1997. The patient had suffered productive cough since the end of August 1997. A chest X-ray film obtained one year earlier showed no abnormalities. The patient had smoked 20 cigarettes per day since the age of 14. The findings of a physical examination and laboratory tests were unremarkable. A chest X-ray films showed micronodules 2-5 mm in size that were predominantly distributed in the upper and middle fields of both lungs. A chest computed tomogram (CT) showed multiple cysts measuring about 10 mm in diameter, with thick walls (2 to 3 mm) in addition to small nodular shadows. A transbronchial lung biopsy and a thoracoscopic lung biopsy revealed several stellate nodular fibrotic lesions containing some S-100 protein-positive, large mononuclear cells and lymphoid cells. An electron microscopic study found several Langerhans' cells with Birbeck's granules in their cytoplasm. A chest CT scan obtained 2 months after the patient stopped smoking (the day of admission) showed marked regression of the cystic shadows. Evidence suggests the pathogenesis of the disease is closely linked to smoking, and some case reports have documented clinical and radiographic improvements after patients stop smoking. Pulmonary small nodular lesions and cystic lesions with thick walls tend to undergo regression. Although surgical lung biopsy specimens disclosed several stellate nodular fibrotic lesions of eosinophilic granuloma that seemed to be histologically irreversible, our patient experienced remarkable regression of his pulmonary lesions within 2 months after the cessation of smoking.     

Lactic dehydrogenase virus infection inhibits allergic eosinophil reaction and IL-5 gene expression in vivo.

The effects of lactic dehydrogenase virus (LDV) infection on allergic eosinophil reaction and IL-5 gene expression were studied. LDV infection suppressed antigen-induced eosinophil recruitment into the peritoneal cavity in sensitized mice. The elevation of IL-5 gene expression in the spleen and mesenteric lymph nodes 6 h after ovalbumin challenge was significantly suppressed in LDV-infected mice compared with uninfected (control) mice. The expression of the interferon-gamma and IL-2 genes in the spleen, but not in mesenteric lymph nodes, was significantly suppressed in LDV-infected mice compared with control mice. The present results suggest, that suppression of IL-5 gene expression by LDV infection may not be mediated by a mutual inhibitory mechanism between Th1 and Th2 cells.     

Prediction of coronary artery lesions in unstable angina by iodine 123 beta-methyl iodophenyl pentadecanoic acid (BMIPP), a fatty acid analogue, single photon emission computed tomography at rest.

Iodine 123 beta-methyl iodophenyl pentadecanoic acid (123I-BMIPP), a beta-methyl-branched fatty acid analogue, has been proven by experimental studies to reveal abnormalities in fatty-acid-related metabolism. This study was undertaken to validate the accuracy and limitations of 123I-BMIPP imaging at rest in detecting myocardial metabolic abnormalities and predicting coronary lesions in unstable angina (UA). One hundred UA patients without prior myocardial infarction were studied. 123I-BMIPP and thallium 201 chloride (201TlCl) imaging with single photon emission computed tomography (SPECT) and coronary and left ventricular cineangiography (LVC) were performed 1 week after the last episode of angina. There was reduced uptake of 123I-BMIPP imaging in 70 patients, reduced uptake of 201TlCl in 41, and abnormal LVC contraction in 49 patients. There were significant increases in severity scores of 123I-BMIPP imaging along with increases in the number of stenosed coronary arteries and the severity of stenosis in individual coronary arteries. There was a significant reduction in 123I-BMIPP severity scores 1 month after percutaneous transluminal coronary angioplasty (p < 0.01) and a significant correlation between the severity scores of 123I-BMIPP and LVC (r=0. 579, p<0.001). Overall rates of sensitivity and specificity in detecting significant coronary stenosis by 123I-BMIPP imaging were 74% and 86%, respectively, whereas rates of sensitivity and specificity in detecting significant coronary stenosis by 201TlCl were 31% and 91%, respectively. 123I-BMIPP sensitivity increases to 86% if only advanced coronary stenosis of >90% is included. In conclusion, 123I-BMIPP myocardial imaging is an effective method of predicting coronary artery lesions of UA patients without provocative test.     

Pilocarpine-induced cholinergic sweat secretion compared with emotional sweat secretion in atopic dermatitis

We studied pilocarpine-induced cholinergic sweating, emotional sweating and sympathetic reflex sweating in atopic dermatitis (AD) patients. Secreted sweat was measured both with equipment that continuously records sweat rate and with a filter paper method that measures sweat weight absorbed. Comparison of the two methods revealed that the filter paper method underestimated the sweat secretion in AD patients. While AD patients showed no significant abnormalities in emotional sweating and sympathetic reflex sweating, the duration of pilocarpine-induced sweating was prolonged. The time from the maximal sweat rate until the sweat rate fell to half of the maximal rate was significantly longer in AD patients than in control subjects. In contrast, the time from the beginning of sweat secretion until the maximal sweat rate was not significantly different between AD patients and control subjects. There was no significant difference between AD patients and control subjects in sweat volume secreted in 20 min after pilocarpine iontophoresis. In AD patients, the total sweat volume secreted after pilocarpine iontophoresis was greater than in control subjects, although not significantly. These results suggest that the system of deactivation of pilocarpine-induced sweat secretion is impaired in AD patients whereas the activation system is not altered.     

Germinal matrix hemorrhage and hydrocephalus in premature infants]

An analysis of 25 preterm infants with grade 3 or 4 intraventricular hemorrhage and surgically treated progressive hydrocephalus was undertaken to assess mortality, cognitive outcome and motor deficit. All patients underwent surgery at the author's institute since 1981 and represented 4.7% of all intraventricular hemorrhage in premature infants. Surgical procedure was initial placement of a miniature Ommaya's reservoir and conversion to a ventriculoperitoneal shunt diversion. Overall, outcomes were achieved in 64.7% of ambulatory and improvement of cerebroventricular index on follow-up CT image from 0.68 +/- 0.36% to 0.36 +/- 0.31%. The presence of intraventricular hemorrhage continues to be a major problem in low birth weight infants whose rate survival continues to increase as the major improvements in perinatal medicine. We feel that miniature Ommaya's reservoir is quite helpful in the treatment of posthemorrhagic hydrocephalus in the preterm infant who prove refractory to aggressive conservative therapy.