Analysis of the relationship between muscle sympathetic nerve activity and cardiac 123I-metaiodobenzylguanidine uptake in patients with Parkinson's disease.

To analyze the correlation between muscle sympathetic nerve activity (MSNA) and cardiac (123)I-metaiodobenzylguanidine (MIBG) uptake in patients with Parkinson's disease (PD), we measured both parameters in 14 PD patients who were 51 to 82 years of age (mean, 63.1 +/- 8.7 years). The duration of PD was 2 to 26 years, and the disability level (modified Hoehn and Yahr stage) ranged from 2.0 to 4.0 (mean, 3.2 +/- 0.5). MSNA was recorded from the peroneal nerve fascicles using microneurographic methods, and then cardiac MIBG scintigraphy was performed within 1 month. We analyzed the correlation between the standardized MSNA, expressed as a percentage of the predicted value based on control subject data, and the heart-to-mediastinum ratio (H/M) or washout ratio (WR) from early and delayed MIBG images. The relationships between disease duration or disability and MSNA, the H/M ratio, or the WR were also analyzed. No significant correlations were found between MSNA and H/M ratio or WR. Although MSNA was inversely correlated with disease duration and with disability level, neither the H/M ratio nor the WR showed a significant correlation with disease duration or disability level. Because MSNA and MIBG abnormalities were not related, functional changes in addition to organic changes in cardiac sympathetic nerve endings may result in abnormal uptake of MIBG in Parkinson's disease. .     

Falls among community-dwelling psychogeriatric patients

Although increasing interest has been focused on falling in the elderly, little is known about the incidence and consequence of falls in psychogeriatric outpatients. We conducted a 1-year prospective study of falling in 102 community-dwelling elderly patients with psychiatric morbidity (mean age: 70 years) and 100 mentally intact elderly patients (controls, mean age: 74 years). The subject group comprised 79 patients with depression, 14 with dementia and nine with combined disease based on DSM-III-R criteria. Overall, 216 falls in the subject group and 54 in the controls were reported. At the end of the study, recurrent fallers aged 75 years and older showed significant physical deterioration. Multiple logistic regression analysis of selected medical and demographic variables indicated that the most influential variable regarding falling of the subjects was severity of depression rated using the Hamilton scale. Unexpectedly, the analysis revealed that the use of antidepressants was associated with a lower likelihood of falling. On the basis of the two variables, 75% of all respondents were correctly classified as fallers or non-fallers.     

Mild hyperglycemia and insulin treatment in experimental cerebral ischemia in rats

We investigated the effects of mild hyperglycemia and insulin treatment on the metabolism of the ischemic brain in spontaneously hypertensive rats with acute hyperglycemia (n = 9), acute hyperglycemia treated with insulin during ischemia (n = 10), and normoglycemia (n = 10). Cerebral blood flow was measured by the H₂ clearance method. Cerebral ischemia induced occlusion of the bilateral carotid arteries. Cerebral glycolytic metabolites were measured enzymatically. Blood glucose levels were significantly higher in hyperglycemic animals (11.8 to 13.7 mM/I) than in normoglycemic animals (6.0 mM/I). At 60 min of ischemia, the blood flow to the parietal cortex was decreased to 3% of the resting value in all groups. Blood glucose levels at 60 min of ischemia in the hyperglycemic rats were 1.9–3 times higher than the treated hyperglycemic rats and normoglycemic rats. Glucose concentrations were significantly and positively correlated with the ATP level (p < .0001) but not with the lactate levels in the ischemic brain. Our results suggest that mild hyperglycemia may preserve glucose metabolism in the presence of ischemic insult.     

Effect of Epidural Analgesia on Metabolic Response to Major Upper Abdominal Surgery

Blood concentrations of glucose, lactate, non-esterified fatty acids (NEFA) and insulin (IRI) were measured in two groups of ten patients undergoing elective gastrectomy under general anesthesia with halothane (Group G) or epidural analgesia extending from Th3-4 to L1-2 without halothane (Group E). The rise in blood glucose and the rise in NEFA in group E during operation were significantly less than in Group G. Blood lactate levels during operation were lower in group E than in group G although the difference was not statistically significant. The increase in IRI/glucose ratio on postoperative day 1 was significantly less in Group E than in Group G, suggesting that insulin sensitivity after surgery was higher in Group E. The postoperative course was uneventful in all subjects. These results suggest that the endocrine-metabolic response to major upper abdominal surgery can be inhibited by epidural analgesia.     

Hyperchloremic acidosis in an infant with imperforate anus and rectourethral fistula

A case of hyperchloremic acidosis in an infant with imperforate anus and rectourethral fistula, showing lethargy, tachypnea, vomiting, and dehydration, is reported. Surgical correction by abdominoperineal pull-through and division of the rectourethral fistula was performed after doing a cystocutaneostomy to eliminate the diversion of urine into the rectum.     

Stepwise revascularization for prevention of postoperative hyperperfusion

Abrupt normalization of cerebral blood flow (CBF) after surgical procedures to improve excessive cerebral hypoperfusion can cause irreversible brain parenchymal damage. Such hyperperfusion, which is caused by inflow at normal blood pressure into maximally dilated fine vessels, is an important complication following carotid endarterectomy (CEA). Strict control of blood pressure in the perioperative period can prevent this complication except in a few patients, who have severe cerebral hypoperfusion and poor cerebrovascular reserve due to extremely severe stenosis of the ipsilateral or the bilateral carotid arteries, for which CEA is indicated. The requirement for improved CBF and the risk of postoperative hyperperfusion conflict in the pathogenesis of these patients. We tried to prevent abrupt improvement in perfusion by attempting gradual restoration of CBF. Superficial temporal artery-middle cerebral artery anastomosis was first performed to improve the poor cerebrovascular reserve by allowing insufficient blood flow. A few weeks later, CEA was performed to completely restore CBF. This surgical approach obtained good results without postoperative problems in four patients. The indications of this surgical management and efficacy of stepwise restoration of CBF to prevent postoperative hyperperfusion depend on careful preoperative evaluation of perfusion studies.     

Surgical significance of undescended parathyroid gland in renal hyperparathyroidism

BACKGROUND: In renal hyperparathyroidism, in which basically all parathyroid glands are hyperplastic, overlooking one undescended parathyroid gland becomes important. METHODS: Between July 1973 and December 2004, 1750 patients in our department underwent parathyroidectomy for severely advanced renal hyperparathyroidism. We evaluated the frequency and location of undescended parathyroid glands and the clinical findings and the prognosis of patients with such glands. RESULTS: Undescended parathyroid glands in our series of renal hyperparathyroidism numbered 16 of 1750 cases (0.91%). In 9 patients, the glands were removed at the initial parathyroidectomy in our hospital. Two of these glands were detected by preoperative imaging; 6 glands were removed with an undescended thymus. The mean weight of the undescended parathyroid glands that were removed at initial operations was 470 mg (30 to 1392 mg). In 7 other patients, unrecognized undescended glands were responsible for persistent hyperparathyroidism in 6 patients and recurrent disease in 1 patient. In 4 of these 7 patients, the initial parathyroidectomy was performed at our hospital; in the other 3 patients, the initial parathyroidectomy had been done at another hospital, and the glands were removed on reoperation. The mean weight of these glands was 1295 mg (range, 444-2396 mg). In 12 of a total of 16 patients with undescended glands, there appeared to be an inferior parathyroid gland, and the other 4 glands appeared to be a superior gland. No glands were detected by sestamibi scans. CONCLUSION: In operations for renal hyperparathyroidism, an undescended parathyroid gland can be readily overlooked, which leads to persistent or recurrent hyperparathyroidism. Because an undescended parathyroid gland is not always an inferior gland, in surgery for persistent and/or recurrent renal hyperparathyroidism, it is very important to examine carefully the submandibular portion to detect such an undescended gland.