Unilateral necrosis of the tongue caused by embolisation of cholesterol crystals.

Cholesterol crystals embolise when an aortic atherosclerotic lesion ruptures and cholesterol crystals are scattered and obstruct small peripheral arterioles. Risk factors include both iatrogenic factors such as intravascular catheterisation, and spontaneous factors for atherosclerosis such as aging, hypertension, dyslipidaemia, and smoking. We describe the case of an 83-year-old Japanese man who developed unilateral, superficial necrosis of the tongue as a result of spontaneous embolisation of cholesterol crystals.

Changes in gait associated with acute stage II posterior tibial tendon dysfunction.

The purpose of this study was to examine differences in gait mechanics between patients with acute stage II PTTD and healthy volunteers. Hindfoot and midfoot kinematics, plantar foot pressures and electromyographic (EMG) activity of the posterior tibialis, gastrocnemius, anterior tibialis and the peroneals were measured in five patients with acute stage II PTTD. Kinematics and kinetics were compared to a database of 20 healthy volunteers. EMG and plantar pressure data were obtained from five healthy volunteers. Hindfoot moments and powers were also calculated. The center of pressure excursion index (CPEI) was calculated from the plantar pressures. Significant differences were observed between the two groups, which confirmed clinical observations. Limited hindfoot eversion and increased midfoot external rotation occurred during the first and third rockers. The EMG data suggested that tendon dysfunction in the posterior tibialis is associated with compensatory activity, not only in its antagonists (the peroneals), but also in the anterior tibialis and the gastrocnemius. These data suggest that non-operative treatment of patients with PTTD should consider minimizing the activity of the posterior tibialis as well as the peroneals, the anterior tibialis and the gastrocnemius.

Distribution of marker enzymes and mucin in intestinal metaplasia in human stomach and relation to complete and incomplete types of intestinal metaplasia to minute gastric carcinomas.

Intestinal metaplasia of the human stomach was classified into two types, complete and incomplete. The complete type was associated with the intestinal marker enzymes sucrose alpha-D-glucohydrolase, alpha, alpha-trehalase, aminopeptidase (microsomal) (APM), and alkaline phosphatase (ALP). Tissue of this type contained goblet cells and Paneth's cells but not high-iron diamine (HID)-positive mucin staining with HID-Alcian blue. The incomplete type of intestinal metaplasia was associated with sucrose alpha-D-glucohydrolase, APM, goblet cells, and HID-positive mucin but not with alpha, alpha-trehalase, ALP, or Paneth's cells. For the examination of the distribution of the complete and incomplete types in 84, 27, and 16 resected specimens of human stomach with gastric carcinoma, gastric ulcer, and duodenal ulcer, respectively, disaccharidases were located with Tes-Tape. Specimens with intestinal metaplasia were divided into three classes: complete type only (class I), incomplete type only (class II), and a mixture of areas of the complete and incomplete types (class III). Of the 84 specimens from patients with gastric carcinoma, intestinal metaplasia was found in 76 (01%), and the percentages of specimens of classes I, II, and III were 32, 22, and 46, respectively. In these specimens, the percent incidence of class I increased and that of class II decreased with age. Of the 27 specimens from patients with gastric ulcer, 16 (59%) shopwed intestinal metaplasia and 10 of the 16 (63%) specimens were of class II. Of the 16 specimens from patients with duodenal ulcer, only 3 (19%) specimens showed intestinal metaplasia and all of them were of class II. The relationships of the complete and incomplete types of intestinal metaplasia to gastric carcinoma wre studied in 26 foci of minute carcinoma of the stomach less than 5 mm in largest diameter. Nineteen of 20 (05%) foci of the intestinal type of minute carcinoma were surrounded by intestinal metaplasia and 16 foci (80%) were surrounded by the incomplete type of intestinal metaplasia.

Effect of the Kobe earthquake on stress and glycemic control in patients with diabetes mellitus.

OBJECTIVE: To examine the effects of the Kobe, Japan, earthquake, a life-threatening event, on stress and glycemic control in diabetic patients. PATIENTS AND METHODS: Hemoglobin A1c levels before and after the earthquake were evaluated in diabetic patients in Kobe (N = 157; magnitude, 7.2) and in Osaka, Japan, as a control (N = 277; magnitude, 4.2), where little damage to houses and traffic facilities occurred. Glycosylated hemoglobin levels were also compared with those of 2 years before and 1 year after the earthquake. The General Health Questionnaire (GHQ) and a self-administered questionnaire regarding damage to houses and relatives killed or injured were used to assess psychological and mental stresses on earthquake survivors. RESULTS: Glycemic control was aggravated in diabetic patients after the earthquake in Kobe but not in Osaka. THe GHQ scores were significantly higher in the patients in Kobe than those in Osaka. Increased hemoglobin A1c concentrations and high scores on the GHQ were especially evident in diabetic patients with severe damage to houses and/or with relatives killed or injured. CONCLUSION: These results suggest an association between chronic, life-threatening stress and the worsening of metabolic control in patients with diabetes mellitus.

Serum free thyroxine and triiodothyronine concentrations in subacute thyroiditis.

Serum absolute free T4 (AFT4) and T3 (AFT3) concentrations were studied in 10 patients with subacute thyroiditis whose total serum T4 levels were elevated, and values were compared with those obtained in 10 patients with untreated Graves' disease, whose total serum T4 concentrations were elevated to the same level as in the former group. The mean (+/- SD) basal metabolic rate in patients with subacute thyroiditis was 16 +/- 14.8%, significantly (P less than 0.001) lower than that in patients with Graves' disease (48.7 +/- 15.7%). Serum T4-binding globulin concentrations measured by RIA were normal and did not differ from those in Graves' disease patients. The percentage of free T4 and AFT4 were both elevated in subacute thyroiditis to a degree comparable to that seen in Graves' disease. The serum total T3, serum free T3 fraction and AFT3 were also elevated, but both total T3 and AFT3 were significantly (P less than 0.05 and P less than 0.05, respectively) lower than in Graves' disease patients. Therefore, the ratios of T3 to T4 and AFT3 to AFT4 were significantly (P less than 0.01 and P less than 0.01, respectively) lower than in Graves' disease patients. These results indicate that the significantly lower basal metabolic rate and milder manifestations of thyrotoxic symptoms in subacute thyroiditis than in Graves' disease might be explained by the low ratios of T3 to T4 and AFT3 to AFT4 as well as the short duration of chemical hyperthyroidism.

Aldosterone synthase gene (CYP11B2) C-334T polymorphism, ambulatory blood pressure and nocturnal decline in blood pressure in the general Japanese population: the Ohasama Study.

OBJECTIVE: The C-344T polymorphism in the 5'-flanking region of the aldosterone synthase (CYP11B2) gene has been suggested to be associated with hypertension and disturbed circadian blood pressure (BP) rhythm through its effect on aldosterone synthesis. However, previous findings on this topic have been inconsistent. DESIGN: A cross-sectional study. SUBJECTS AND METHODS: We investigated the CYP11B2 C-344T genotype in 802 subjects, aged 40 and over, in a Japanese community, who gave written informed consent and were monitored for 24 h ambulatory BP. RESULTS: The frequencies of the CC, CT, and TT genotypes in these Japanese subjects were 0.14, 0.44, and 0.42, showing a higher frequency of the T allele (0.64) than in Caucasians. Although there was no significant difference in 24 h ambulatory BP levels among the genotypes, the nocturnal decline in BP was significantly greater in the CC homozygous subjects than in other subjects (P = 0.0065 for systolic and P = 0.031 for diastolic decline in nocturnal BP). Detailed analyses demonstrated that this association was significant only in aged (60 years and over) or male subjects. The prevalence of previous cardiovascular disease was significantly less in these subjects with the CC genotype than in those with the TC and TT genotypes, although age, body mass index, male gender, smoking, use of alcohol and antihypertensive medication did not differ among the three genotypes. There was no significant difference among the three genotypes in biochemical and hormonal parameters. CONCLUSION: Although the C-344 T polymorphism of CYP11B2 did not directly influence the level of 24 h BP, the CC genotype was associated with decreased nocturnal BP in elderly or male Japanese. Since prevalence of previous cardiovascular disease was significantly less in homozygous CC subjects, greater nocturnal BP decline in this genotype appears to be beneficial in the circadian BP rhythm.

Effect of angiotensin-converting enzyme inhibitor (enalapril or imidapril) on ventilation during exercise in patients with chronic heart failure secondary to idiopathic dilated cardiomyopathy.

Eighteen patients with heart failure were studied to clarify whether angiotensin-converting enzyme inhibitor treatment improves excess ventilation during exercise. Treatment with angiotensin-converting enzyme inhibitors had a beneficial effect on excess ventilation during exercise, without significant improvement in exercise capacity in patients with moderate congestive heart failure.

Clinical and electrocardiographic profiles producing exercise-induced U-wave inversion in patients with severe narrowing of the left anterior descending coronary artery.

To elucidate which clinical features produce U-wave inversion, 339 patients with severe narrowing of the left anterior descending artery were evaluated. In patients with anterior myocardial infarction, extensive coronary artery disease and protected left anterior descending arterial territory are essential in the development of U-wave inversion, whereas electrocardiographic changes at rest in addition to anterior lead ST depression, rather than coronary anatomy, are important in those without anterior myocardial infarction.

Delayed recovery of postexercise blood pressure in patients with chronic heart failure.

Thirty-four patients with idiopathic dilated and ischemic cardiomyopathy underwent a symptom-limited cardiopulmonary exercise testing to evaluate the significance of postexercise blood pressure (BP) response. The postexercise BP response was useful in assessing the impaired exercise capacity and increased sympathetic activity in patients with heart failure.

Diagnostic significance of an exercise-induced prominent U wave in acute myocardial infarction.

A prominent U wave induced by exercise testing in patients with anterior wall myocardial infarction is a highly specific but insensitive marker for the narrowing of the left circumflex or right coronary artery, although a U-wave increase alone with or without ST-segment depression may help better identify these coronary artery narrowings. In patients with inferior and/or posterior myocardial infarction, a prominent U wave is regarded as a simple electrocardiographic marker for inferior and/or posterior residual ischemia.

Three-dimensional CT of the bronchial tree. A trial using an inflated fixed lung specimen.

Three-dimensional (3D) reconstruction of the bronchial tree from contiguous scanning of thin-section CT was performed. Automatic extraction of the bronchial inner space was tried by means of thresholding CT numbers, using a left lower lobe obtained at autopsy and fixed in the air-filled state. Anatomic accuracy of the reconstructed 3D image was determined by correlating the image with the sliced lung specimen. Because of the partial volume effects of the bronchial walls, the area in which bronchi could be reconstructed was limited. The smallest reconstructed branch was 1.4 mm in inner diameter, and the spatial relationship among the branches was easily understood.

Human placental thyroxine inner ring monodeiodinase in complicated pregnancy.

Production of rT3 from T4 in the placenta were measured in four patients with induced abortion, in three patients with spontaneous abortion, in 19 patients with various complications of pregnancy including Graves' disease, and in 18 normal pregnancies. The placentas, obtained at delivery, were homogenized and centrifuged at 800 X g. Supernatants (1 mg protein) were incubated with 1 microgram of stable T4 and 50 mmol/L dithiothreitol at 37 degrees C for 60 minutes. The generated rT3 was measured by radioimmunoassay (RIA). In patients who delivered at 38 to 41 weeks with complicated pregnancy, the net placental rT3 production from T4 was 7.3 +/- 2.5 ng/tube, which was not significantly different from that obtained in normal pregnancy (8.5 +/- 2.4) at an equivalent gestational age. In patients with abortions, the net placental rT3 generation from T4 was very high, and there was a significant negative correlation between the net placental rT3 production from T4 and gestational age. These results indicate that the net placental rT3 production from T4 is not affected by complications of pregnancy, but shows a significant change with the progress of gestation.

Branching design of the bronchial tree based on a diameter-flow relationship.

We propose a method for designing the bronchial tree where the branching process is stochastic and the diameter (d) of a branch is determined by its flow rate (Q). We use two principles: the continuum equation for flow division and a power-law relationship between d and Q, given by Q approximately dn, where n is the diameter exponent. The value of n has been suggested to be approximately 3. We assume that flow is divided iteratively with a random variable for the flow-division ratio, defined as the ratio of flow in the branch to that in its parent branch. We show that the cumulative probability distribution function of Q, P(> Q) is proportional to Q-1. We analyzed prior morphometric airway data (O. G. Raabe, H. C. Yeh, H. M. Schum, and R. F. Phalen, Report No. LF-53, 1976) and found that the cumulative probability distribution function of diameters, P(> d), is proportional to d-n, which supports the validity of Q approximately dn since P(> Q) approximately Q-1. This allowed us to assign diameters to the segments of the flow-branching pattern. We modeled the bronchial trees of four mammals and found that their statistical features were in good accordance with the morphometric data. We conclude that our design method is appropriate for robust generation of bronchial tree models.

A three-dimensional model of the human pulmonary acinus.

A three-dimensional (3-D) model of the human pulmonary acinus, a gas exchange unit, is constructed with a labyrinthine algorithm generating branching ducts that fill a given space completely. Branching down to the third respiratory bronchioles is generated with the proposed algorithm. A subacinus, a region supplied by the last respiratory bronchiole, is approximated to be a set of cubic cells with a side dimension of 0.5 mm. The labyrinthine algorithm is used to determine a pathway through all cells only once, except at branching points with the smallest path lengths. In choosing each step of a pathway, random variables are used. Resulting labyrinths have equal mean path lengths and equal surface areas of inner walls. An alveolus can be generated by attaching alveolar septa, 0.25 mm long and 0.1 mm wide, to the inner walls. Total alveolar surface area and numbers of alveolar ducts, alveolar sacs, and alveoli in our 3-D acinar model are in good accordance with those reported in the literature.

A three-dimensional model of the human airway tree.

A three-dimensional (3D) model of the human airway tree is proposed using a deterministic algorithm that can generate a branching duct system in an organ. The algorithm is based on two principles: 1) the amount of fluid delivery through a branch is proportional to the volume of the region it supplies; and 2) the terminal branches are arranged homogeneously within the organ. These principles define the basic process of branching: generation of the dimensions and directionality of two daughter branches is governed by the properties of the parent branch and the region the parent supplies. The algorithm is composed of nine basic rules and four complementary rules. When the contour of an organ and the position of the trunk are specified, branches are successively generated by the algorithm. Applied to the human lung, the algorithm generates an airway tree that consists of approximately 54,000 branches. Its morphometric characteristics are in good agreement with those reported in the literature. The algorithm and the 3D airway model are useful for studying the structure-function relationship in the lung.

Low dose dobutamine stress echocardiography predicts the improvement of left ventricular systolic function in dilated cardiomyopathy.

OBJECTIVE: To determine whether dobutamine stress echocardiography can predict the improvement of left ventricular systolic function in patients with dilated cardiomyopathy (DCM). METHODS: Myocardial contractile reserve, as assessed by dobutamine stress echocardiography, was determined in 18 patients with DCM (mean (SD) age 53 (13) years, left ventricular ejection fraction (LVEF) 28 (10)%) and compared with changes in LVEF during a follow up period of 15 (8) months. The LVEF and regional left ventricular wall motion score (0, normal to 4, dyskinesis) of 12 segments in short axis and four chamber views were analysed before and after dobutamine infusion (5-20 microg/kg/min). RESULTS: During a follow up period of 15 (8) months, a significant improvement in LVEF (> 20%) was found in seven patients but not in the remaining 11. Baseline haemodynamic findings were similar in both groups. Patients with an improvement in follow up LVEF showed a greater change in wall motion score from baseline during dobutamine infusion than patients with no improvement (at rest, 1.7 (0.4) v 1.9 (0.2), NS; dobutamine 10 microg/kg/min, 0.6 (0.4) v 1.2 (0.4), p < 0.05). The percentage change in LVEF during dobutamine infusion was also significantly greater in patients who showed improvement than in those who did not. The change in LVEF during the follow up period (follow up LVEF/baseline LVEF) correlated well with the change in LVEF during dobutamine stress (LVEF at rest/LVEF at dobutamine 10 microg/kg/min; r = 0.74, p < 0.001). CONCLUSIONS: Changes in left ventricular systolic performance during low dose dobutamine stress echocardiography are a useful marker to predict the outcome of left ventricular systolic function in patients with DCM.

Postprandial hypotension in patients with non-insulin-dependent diabetes mellitus.

This study attempted to determine whether postprandial hypotension (PPH) is associated with diabetes mellitus by 24-h ambulatory blood pressure monitoring (24-h ABPM) and by monitoring blood pressure during 75-g oral glucose tolerance test (75-g OGTT) in 15 normal subjects and 35 patients with non-insulin-dependent diabetes mellitus. When we defined PPH as a postprandial decrease in systolic blood pressure of greater than 20 mmHg, the incidence of PPH in diabetics was 37% by 24-h ABPM and 20% by 75-g OGTT. The incidence of proliferative retinopathy and proteinuria was greater in diabetics with PPH than in those without PPH. All of the patients with PPH had somatic and autonomic neuropathy. The C-peptide response was lower in diabetics with PPH than in those without PPH. We revealed the presence of PPH in diabetics, and found that PPH was closely related to disease severity, especially diabetic autonomic neuropathy.

Oval pupil in patients with diabetes mellitus: examination by measurement of the dark-adapted pupillary area and pupillary light reflex.

Determination of the dark-adapted pupillary area (DAPA) by infrared photography revealed that some diabetic patients show corectopia (oval pupil) in addition to the small DAPA as pupillary abnormalities. The prevalence and clinical details of oval pupil were compared between diabetic patients and healthy subjects. Pupillary light reflexes were also analyzed with an infrared videopupillography in some of the diabetic patients. The healthy subjects were examined for the influence of age on the ratio of the pupillary diameter of the major and minor axes. The ratio was 1.04 +/- 0.02 (mean +/- S.D.) in the healthy subjects, and cases in which the ratio was +2 S.D. or higher than the mean ratio were defined as oval pupil. Oval pupil was observed in 21 (24%) of 86 diabetic patients, and was correlated with heart rate variation (P < 0.05) and DAPA (P < 0.01), which represent an autonomic dysfunction. Quantitative analysis of pupillary light reflexes with an infrared videopupillography revealed that the dark-adapted pupillary area before photic stimulation (P < 0.01) and the maximum %-velocity of constriction (P < 0.05) were significantly less in the oval pupil group than in the round pupil group. Cranial magnetic resonance imaging revealed no abnormalities in the oval pupil group. From these results, a peripheral autonomic disorder was implicated in the etiology of oval pupils in diabetic patients.