Correlation of heart rate turbulence with sympathovagal balance in patients with acute myocardial infarction

To examine the relationship among heart rate turbulence parameters, arterial baroreflex sensitivity, and cardiac sympathetic nerve activity, 15 patients with acute myocardial infarction, presenting with sinus rhythm and > or = 3 ventricular premature beats/24 hr were studied at least 2 weeks after acute myocardial infarction. Turbulence onset (TO) and turbulence slope (TS) were averaged from 3 respective ventricular premature beats. Early heart-to-mediastinum ratio (H/M), delayed H/M, and washout rate were calculated from iodine-123-metaiodobenzylguanidine (123I MIBG) scintigraphy. Arterial baroreflex sensitivity was calculated by phenyrephrine method. Arterial baroreflex sensitivity correlated significantly with TO (r = - 0.75, p < .01) and TS (r = 0.53, p < .05). TO had no correlations with early H/M, delayed H/M, and washout rate. There were no significant correlations between TS and early H/M. However, TS had significant correlation with delayed H/M (r = 0.74, p < .01) and washout rate (r = -0.71, p < .01). Thus, heart rate turbulence of TO and TS parameters depend on sympathovagal balance.     

Effects of low-dose pergolide therapy on cardiac valves in patients with Parkinson's disease

BACKGROUND: Pergolide mesilate is widely used to treat Parkinson's disease in both the USA and Japan, but the maintenance dose is distinctly different between the USA (usually more than 1.5 mg/day) and Japan (usually less than 1.5 mg/day). Although several reports from the USA have suggested that mitral, aortic, and tricuspid valvular lesions were caused by pergolide, it is unclear whether low-dose pergolide therapy causes such valvular lesions. OBJECTIVES: The effects of low-dose pergolide therapy on cardiac valves were studied in Japanese patients with Parkinson's disease. METHODS: One hundred and five consecutive patients with Parkinson's disease approved for our protocol were enrolled in this study. Forty patients were treated with low-dose pergolide (0.05-1.5 mg/day for 2-115 months), and were included in the pergolide group (mean age 71 +/- 6 years). The other 44 patients received no ergot-derived dopamine receptor agonists, and 32 patients acted as age-matched controls (mean age 71 +/- 7 years). Both groups of patients underwent echocardiographic examination to detect organic lesions in cardiac valves such as thickening of the leaflet, annular calcification, restriction of valve motion and valvular tenting, and valvular regurgitation greater than 2 + on the 4-point scale. RESULTS: No significant difference was observed in the incidence of aortic, mitral and pulmonic valve lesions between the pergolide group and the control group. Although no organic lesions were detected in the tricuspid valve, the incidence of tricuspid regurgitation was significantly higher in the pergolide group than in the control group (p < 0.05). CONCLUSIONS: Although low-dose pergolide of less than 1.5 mg/day does not cause serious damage in the left-sided valves, it may induce tricuspid regurgitation.     

The U vector loop in normal and various abnormal states as studied by the summation method

Employing a summation method with a computer, the U vector loop can be obtained in a reproducible and reliable way. In this study we found that the U main vector loop in normal subjects was directed anteriorly, inferiorly and mostly slightly to the left. In right bundle branch block, Wolff-Parkinson-White syndrome type A, and right ventricular hypertrophy, the U main vector was directed more to the left than normal. In left bundle branch block, Wolff-Parkinson-White syndrome type B and left ventricular hypertrophy, it was directed to the right.These findings favor a speculation that the U vector originates from the repolarization of the last repolarized part of the ventricle.In anterior myocardial infarction and angina pectoris showing ST-T change in the electrocardiogram (ECG), the U main vector was directed to the right and anteriorly. In inferior myocardial infarction it was within normal limits on the average but it was shifted upwards in some cases.These findings suggest that, in myocardial infarction, injury or ischemia, the U vector was modified in direction by the local delay of repolarization, provided that the exploring electrodes are close enough to record the local changes.     

Combination of short-term prednisolone and adenine arabinoside in the treatment of chronic hepatitis B. A controlled study

The efficacy of adenine arabinoside (Ara-A) alone or in combination with prednisolone utilizing its withdrawal effect was studied in 43 patients with deoxyribonucleic acid polymerase- and hepatitis B e antigen-positive chronic hepatitis. Ten patients were treated with 10 mg/kg body wt of Ara-A alone for 4-8 wk. In 9 cases, prednisolone (40 mg/day) was given at a constant dosage for 4 wk before Ara-A treatment. Fourteen patients received oral prednisolone alone for 4 wk, and 10 patients served as untreated controls. Six of 9 patients (67%) undergoing the combination therapy became seronegative for hepatitis B e antigen, whereas only 4 of 24 patients (17%) treated either with Ara-A alone or prednisolone alone lost the antigen. Two of the 10 untreated patients became seronegative for hepatitis B e antigen during the same follow-up period of 9 mo. This prospective controlled study suggests that the combination of immunomodulation by steroid withdrawal and subsequent Ara-A is more effective in the treatment of patients with chronic liver disease and active hepatitis B virus replication than treatment with Ara-A alone.     

An aberrant ACTH-producing ectopic pituitary adenoma in the sphenoid sinus

A 32-year-old woman with an ectopic adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma (EAPA) is presented. She had rapidly gained weight and suffered recurrent facial acne for a few years but lacked the typical Cushingoid features. Endocrine examinations revealed that her plasma ACTH was markedly high (196 to 280 pg/ml) without showing normal circadian rhythm and failed to respond to corticotropin-releasing hormone stimulation. Her cortisol levels ranged from 22 to 30 microg/dl throughout observation but low doses (1 and 2 mg) of dexamethasone failed to suppress either ACTH or cortisol level. Magnetic resonance imaging study revealed a 3-cm mass occupying the sphenoidal sinus with partial enhancement by gadolinium, which was separated from the normal pituitary in the sella region. The tumor resected by transsphenoidal surgery was histologically diagnosed as an ACTH-producing pituitary adenoma. After surgery her weight gain and acne remitted in accordance with decreases in plasma ACTH. Analysis of patient plasma by gel filtration method revealed the existence of big ACTH molecules eluted with a peak of authentic 1-39 ACTH, suggesting that this biologically less-active ACTH might be the reason why overt features of Cushing's syndrome failed to develop in this case. Although EAPA is clinically rare in parasellar disorders, the presence of ectopic pituitary adenoma should be considered in such cases showing ACTH hypersecretion without typical Cushingoid features.     

Portographic Opacification of Hepatic Veins and (Anomalous) Anastomoses between the Portal and Hepatic Veins in Cirrhosis—Indication of Extensive Intrahepatic Shunts

On the premise that extensive intrahepatic portal-venous anastomoses known to occur in cirrhosis would be demonstrated by contrast medium directly placed in the portal vein, percutaneous transhepatic portograms were analyzed in 82 patients with liver cirrhosis in relation to the estimated degree of shunting. The degree of intrahepatic shunt was measured during transhepatic portography using 99mTc-macroaggregated albumin. Hepatic veins began to opacify at 4 to 10 s after the start of injection of contrast medium during portography in 20 patients with cirrhosis who had intrahepatic shunt indices of 58.5 +/- 18.5%, but it was not visualized in 62 patients with cirrhosis whose shunt indices were 19.9 +/- 14.1%. Anomalous large anastomoses of 1 or 2 mm in size between the right portal vein and the right hepatic vein were clearly visualized during portography in 18 of 20 patients in whom the hepatic vein was opacified. Frequency and time of beginning opacification of the hepatic vein were closely correlated with the degree of intrahepatic shunt. Thus, opacification of the hepatic vein and abnormal anastomoses between the portal and hepatic vein systems in an early phase of portography indicates extensive intrahepatic shunts.     

Progression of primary biliary cirrhosis after proctocolectomy for ulcerative colitis

We report a case of progression of primary biliary cirrhosis (PBC) after proctocolectomy for ulcerative colitis. A 43-year-old woman underwent a total proctocolectomy after being diagnosed with ulcerative colitis. In the course of the preoperative investigation, liver function test results were within the normal range. Four months after the proctocolectomy, the patient showed a high level of alkaline phosphatase (2398 IU/l) and a positive anti-mitochondrial antibody titer (>1 : 160). There were no associated symptoms. A liver biopsy demonstrated expansion of all portal areas by infiltrates of lymphocytes and histiocytes. These appearances indicated chronic biliary disease and were compatible with PBC. The association of PBC and ulcerative colitis is rare. However, a review of the recent literature suggests that PBC and ulcerative colitis may be associated; this combination should be kept in mind. Received: October 4, 1999 / Accepted: February 25, 2000     

Role of the low amplitude potential in the initial P wave signal-averaged electrocardiogram [corrected] in sick sinus syndrome.

BACKGROUND: The cause of abnormally low amplitude of the initial P wave signal-averaged electrocardiogram (P-SAECG) in patients with sick sinus syndrome (SSS) is unknown. METHODS AND RESULTS: Thirteen normal patients (Group C) and 33 with SSS (Group S) were examined. The root mean square amplitude for the initial 30 ms (EP30) and the duration of below-4 microV signals of the filtered P waves (ED4) were measured using the P-SAECG. The interval from an atrial potential on the sinus-node electrogram (SNE) to P wave onset (AS-P), and the interval from the P wave to the atrial potential on the His-bundle-electrogram (P-AH) were measured in the electrophysiological study. The sino-atrial conduction time was measured by a conventional method (indirect sino-atrial conduction time (SACTi)) and using SNE (direct sino-atrial conduction time (SACTd)). The EP30 was significantly lower and the ED4 significantly longer in Group S. The AS-P was significantly longer in Group S (p<0.01), but the P-AH was not different. In Group S, the AS-P was significantly correlated with EP30 and ED4 (p<0.01), but the P-AH was uncorrelated. The SACTi was significantly correlated with EP30 and ED4 (p<0.05), but the SACTd was uncorrelated. CONCLUSION: The abnormality of the initial portion of the P-SAECG observed in SSS appears to be due to disturbed conduction through the atrial myocardium around the sino-atrial node.     

Involvement of cyclo-oxygenase-generated vasodilating eicosanoid(s) in addition to nitric oxide in endothelin-1-induced endothelium-dependent vasorelaxation in guinea pig aorta

Summary This study investigates the vasodilatory effects of endothelin-1 (ET-1) in isolated guinea pig aortic rings in vitro. Cumulative dose-response curves to ET-1 were constructed and ET-1 actions on prostaglandin F₂ (PGF₂)-precontraction were studied in both endothelium-intact and endothelium-denuded preparations, in the presence or absence of a cyclooxygenase inhibitor (indomethacin) and/or nitric oxide inhibitors (N^G-nitro-L-arginine methyl ester and hemoglobin). In endothelium-intact preparations, pretreatment with indomethacin (10^–5M, 30 min), alone or in combination with N^G-nitro-L-arginine methyl ester (L-NAME, 10^–4M), significantly augmented the constrictive responses to ET-1, whereas indomethacin, L-NAME, and hemoglobin (10^–5M) had no significant effects in the endothelium-denuded preparations. Furthermore, in PGF₂-precontracted, endothelium-intact preparations, ET-1, at a dose of 10^–9M, induced initial relaxation followed by subsequent contraction, while it only contracted the endothelium-denuded preparations. The initial relaxation was abolished by indomethacin, but not by L-NAME or hemoglobin. In addition, this relaxation was not inhibited by a specific ET_A receptor antagonist, BQ-123 (6 × 10^–6M). In addition to the involvement of nitric oxide, these results show the involvement of cyclo-oxygenase-generated vasodilating eicosanoid(s) derived from endothelium in ET-1-induced vasorelaxation in guinea pig aorta in vitro. The results also indicate that this vasorelaxation is mediated by ET_B receptor activation.This study was financially supported by Toyobo Biotechnology Foundation, and by Grants-in-Aid for scientific research from the Ministry of Education, Science and Culture of Japan (project numbers: 3770533 and 04670571) and the Ministry of Health and Welfare of Japan.     

Case of macrolide-ineffective Mycoplasma pneumoniae pneumonia successfully treated with intravenous ciprofloxacin]

A 18-year-old man complaining of remittent fever and nonproductive cough visited a nearby clinic. He did not recover despite treatment of oral azithromycin. We admitted him because his chest radiograph showed consolidation in the left upper lung field. We diagnosed his pneumonia as co-infection by non-bacterial and bacterial pathogens, and initiated treatment with intravenous ampicillin and oral clarithromycin. On the 3rd day after admission his symptom had not improved, so his treatment was changed to intravenous panipenem/betamipron and erythromycin. Ciprofloxacin was administered intravenously because consolidative shadows with atelectasis increased on the chest radiograph on the 6th day. Clinical symptoms such as fever, CRP and chest radiograph findings were rapidly improved after the start of ciprofloxacin treatment. He was discharged on the 22nd hospital day. Since serum antibody titer against Mycoplasma pneumoniae was elevated to x 20,480 on the 13th hospital day, it is confirmed that causative pathogen was macrolide-ineffective Mycoplasma Pneumoniae.