Clinical features and treatment of hematopoietic stem cell transplantation-associated gastric antral vascular ectasia

Gastric antral vascular ectasia (GAVE) may occur after hematopoietic stem cell transplantation (HSCT) and cause severe and prolonged gastric bleeding. The underlying pathology of transplant-associated GAVE (HSCT-GAVE) is poorly understood and an effective therapeutic strategy has not been established yet. We retrospectively reviewed the medical records of 230 consecutive allogeneic transplant recipients in our institution between January 1997 and June 2002. We identified five patients who developed HSCT-GAVE (2.2%). Four patients had bleeding from HSCT-GAVE and one patient had HSCT-GAVE discovered incidentally. The clinical features of these patients were similar in that they all received conditioning treatment with busulfan and had history of thrombotic microangiopathy. Furthermore, treatment with a beta-blocker apparently improved the outcome of HSCT-GAVE in three patients.

A case of solid pseudopapillary neoplasm of the pancreas and tumor doubling time

BACKGROUND

Solid pseudopapillary neoplasm of the pancreas is a rare tumor with unique clinicopathological features. Although it is considered to grow slowly, little is known about its doubling time.

METHOD

We encountered a young Japanese woman with a solid pseudopapillary neoplasm of the pancreas that had been detected at another hospital 5 years previously but was resected at our hospital. The tumor showed only a solid component without any cysts. Computed tomographic scans taken 5 years apart were compared to determine the tumor doubling time.

RESULT

The tumor doubling time according to the formula of Schwartz and co-workers was determined to be 765 days.

CONCLUSION

These findings confirm that this tumor grows quite slowly and also support long disease-free periods even in patients who have recurrence or metastases.

Urinary antibody titers to Helicobacter pylori and an impact of clinical characteristics

This study evaluates the clinical usefulness of titers of antibody to Helicobacter pylori (Hp) in a urine-based enzyme-linked immunosorbent assay (URINELISA; Otsuka Pharmaceutical, Tokushima, Japan) by comparing values of serum antibody to Hp in an already commercialized kit in a population of 250 asymptomatic individuals. Influences of physical and laboratory characteristics on the relationship between serum and urinary titers of antibody to Hp were also estimated using simple and multiple regression analyses. Specific urine gravity, urine pH, proteinuria, and age of the subjects were regarded as significant factors relating to urinary titers of the anti-Hp antibody on simple regression analyses. Both the urinary and serum titers strongly correlated on simple regression analysis (r = 0.782, P < 0.0001). On multiple regression analysis, an additional two factors, specific urine gravity and urine pH, were picked up, and the correlation coefficient was improved (r = 0.795, P < 0.0001). The present results indicate that URINELISA had not only qualitative but quantitative accuracy. However, careful attention should be paid to cases with abnormalities in urinalysis when used quantitatively.

Gastric emptying of liquids is delayed by co-ingesting solids: a study using salivary paracetamol concentrations

BACKGROUND

Paracetamol concentrations in plasma, a frequently used index of gastric emptying (GE) of liquids, are closely correlated with those in saliva. GE of liquids is delayed by co-ingesting solids. No researchers have used salivary paracetamol concentrations to show this phenomenon. The aim of this study was to elucidate whether salivary paracetamol concentrations can detect the food-induced delay in liquid GE.

METHODS

Paracetamol absorption was measured twice in five healthy male volunteers. Following an overnight fast, they received 10 mg/kg paracetamol in 200 ml water alone on one occasion, and received this solution after consuming a 400 kcal-containing cookie on another occasion. After thorough rinsing of the month, 1 ml saliva was obtained, simultaneously with 2 ml blood, at 0, 0.25, 0.5, 0.75, 1.0, 2.0, 3.0, 4.0, and 6.0 h after paracetamol intake. The peak concentration (C(max)), the time to C(max) (t(max)), the area under the curve (AUC), and C(max)/AUC in plasma were calculated. Salivary C(max) and t(max) were also determined.

RESULTS

Plasma C(max) and AUC were not significantly different between the two occasions. In contrast, significant differences in plasma t(max) and C(max)/AUC ( P < 0.05) established the food-induced delay in GE. Salivary t(max) could detect the delayed GE, whereas salivary C(max) could not.

CONCLUSIONS

Salivary t(max) can document the solid meal-induced delay in liquid GE.

[The validity of serum acetaminophen concentration at 45 min as an index of gastric emptying rate: a study based on pharmacokinetic theories]

The reliability of the serum acetaminophen (APAP) concentration at 45 min (C45) as a measure of gastric emptying (GE) has been evaluated using a pharmacokinetic simulation work. The present results have revealed that C45 is a useful index to conveniently detect delayed GE, but it is unreliable to measure rapid GE. In addition, the following simple criteria for diagnosis of delayed GE has been proposed based on the pharmacokinetic theories: after ingestion of 20 mg/kg APAP dissolved in a 200 kcal-containing liquid meal, 1) the delayed GE is excluded when C45 > 5.0 micrograms/ml, 2) whether GE is delayed or not is inconclusive when 2.0 < C45 < 5.0 micrograms/ml, and 3) the delayed GE is confirmed when C45 < 2.0 micrograms/ml.

New mathematical model for accurate description of absorption kinetics of paracetamol given orally with a high calorie liquid meal

OBJECTIVE

Gastric emptying (GE) of liquids is quantified as the rate of paracetamol absorption in clinical and research settings (paracetamol method). A conventional 1-compartment model assumes the first-order rate kinetics for paracetamol absorption. This assumption seems improper when paracetamol is coingested with a caloric liquid meal, because the caloric liquid leaves the stomach at a constant rate (zero-order process). Theories based on the 1-compartment model reveal that tmax and Cmax/AUCinfinity accurately reflect the rate of paracetamol absorption, but whether this is also the case when paracetamol is administered with a caloric liquid, has not been investigated. The aims of this study were to propose a new mathematical model for accurately describing absorptive behaviors of paracetamol added to a caloric liquid meal, and, using the model, to clarify the characteristics of tmax and Cmax/AUCinfinity as rate parameters.

METHODS

Based on the newly developed model, tamx and Cmax/AUCinfinity were mathematically expressed in terms of GE rates. Subsequently, the characteristics of tmax and Cmax/AUCinfinity were elucidated by simulation works.

RESULTS

The simulation study showed that both tamx and Cmax/AUCinfinity could reflect GE rates, tmax was a more sensitive index of GE than Cmax/AUCinfinity and tmax was less reliable than Cmax/AUCinfinity if GE is very rapid.

CONCLUSIONS

In the paracetamol method using a caloric liquid test meal, tmax and Cmax/AUCinfinity are suitable for detecting delayed and rapid GE, respectively.

Ten-year prospective follow-up study on the relationship between Helicobacter pylori infection and progression of atrophic gastritis, particularly assessed by endoscopic findings

AIM

To ascertain the progression of atrophic gastritis due to Helicobacter pylori infection, we conducted a 10-year prospective follow-up study with annual endoscopy of the stomach.

METHODS

Prospective endoscopic observation was started in 53 subjects in 1989 and 1990 after informed consent was obtained. The progression of atrophic gastritis was evaluated mainly by the endoscopic pattern of atrophy. Histological assessment was performed on biopsy specimens taken from the lesser curvature of the lower corpus. By 2000, 43 patients (20 males, 23 females, mean age 56.7 years at entry) had completed at least 10 years of endoscopic follow-up.

RESULTS

Eight H. pylori-negative patients with normal fundic mucosa showed no change endoscopically or histologically. In 35 H. pylori-positive patients, the progression of histological atrophy was observed in 46% and intestinal metaplasia was observed in 49%. Fifteen of 35 H. pylori-positive cases exhibited a cephaloid shift of the endoscopic atrophic border. The cephaloid shift of the atrophic area occured suddenly. The cumulative progression rate of atrophic patterns was 6% after 2 years, 22% after 4 years, 34% after 6 years and 43% after 10 years. These atrophic changes were related to neutrophil infiltration.

CONCLUSION

The progression of atrophic gastritis is a result of chronic active gastritis caused by H. pylori infection.

Primary sclerosing cholangitis complicated with idiopathic thrombocytopenic purpura

We present a 66-year-old woman with primary sclerosing cholangitis (PSC) complicated with idiopathic thrombocytopenic purpura (ITP). Both PSC and ITP are considered to reflect an immunological disturbance. However, their coexistence is very rare and to the best of our knowledge this is only the second reported case. In Japan, PSC patients are rarely treated with liver transplantation. Fortunately, the present patient underwent successful hepatic transplantation from a brain-dead donor and simultaneous splenectomy. This case emphasizes the importance of liver transplantation as an effective treatment for primary sclerosing cholangitis.

Use of salivary acetaminophen concentration to assess gastric emptying rate of liquids

The gastric emptying rate (GER) of liquids can be quantified by calculating the rate of acetaminophen absorption from serial plasma concentrations. As acetaminophen concentrations in saliva are well correlated with those in plasma, the salivary concentrations may be suitable for use in GER measurement. To evaluate such suitability, salivary and plasma samples were simultaneously obtained from seven healthy volunteers at 0, 0.25, 0.5, 0.75, 1.0, 1.5, and 2.0 h after they had ingested 20 mg/kg of acetaminophen mixed with a 200-ml liquid meal (200 kcal). Commonly used parameters for the rate of acetaminophen absorption were calculated from the salivary and plasma data, including the maximum concentration (Cmax), the time to Cmax (t(max)), the concentration at 0.75 h (C0.75), the area under the curve from 0 to 1.0 h (AUC1.0), and the AUC(0.5)/AUC(2.0) ratio. The mean (SD) salivary/plasma concentration ratio was 2.48 (1.47) at 0.25 h, and the means were almost unity afterwards. Significant correlations between saliva and plasma were found in all parameters studied (r = 0.77-0.90; P < 0.05). However, except for t(max), the salivary parameters overestimated those of plasma. The present results suggest that: (1) the salivary acetaminophen concentration at 0.25 h (C0.25) is a poor reflection of plasma C0.25 (2) thereby the parameters embodying salivary C0.25 such as AUC1.0 and the AUC0.5/AUC2.0 ratio, are unreliable, and (3) liquid GER can be assessed by salivary t(max) with minimal distress to the patient.

[Troglitazone for treatment of polycystic ovary syndrome]

Polycystic ovary syndrome(PCOS) is characterized by clinical symptoms such as menstrual dysfunction, unovulatory infertility, masculinization, obesity, polycystic ovary by ultrasound, and endocrine abnormalities such as hyperandrogenism, and elevated LH to FSH ratio. Recent reports suggest that insulin resistance plays an important role in the pathogenesis of PCOS, and several insulin sensitizing agents have been used for the treatment of PCOS. Troglitazone, one of the thiazolidinediones, improves not only insulin sensitivity but also hyperandrogenism and ovulatory function. Troglitazone appears to be useful in treating women with PCOS. Further investigations are needed to assess the effectiveness and safety.

Pharmacokinetic interaction between acetaminophen and lansoprazole

Because of its minimal gastric toxicity, acetaminophen is the analgesic of choice for patients with gastric acid-related disorders. Because proton pump inhibitors are widely used, concomitant prescription of acetaminophen and lansoprazole would be prevalent. This crossover study was conducted to investigate an acetaminophen-lansoprazole interaction. On one occasion, each of six healthy, fasted, male volunteers ingested 1.0 g acetaminophen dissolved in 200 mL water. On another occasion, at least 1 week apart, 30 mg lansoprazole was administered orally, simultaneously with acetaminophen, after pretreatment with the same dose of lansoprazole once daily for 2 days. Plasma acetaminophen concentrations were measured at 0, 0.25, 0.5, 0.75, 1, 2, 3, 5, and 8 hours after dosing. The peak plasma concentration of acetaminophen and the time to its occurrence were significantly higher and shorter, respectively, during the lansoprazole session than during the control session. Neither the elimination half-life nor the area under the curve was significantly different between the two sessions. Lansoprazole hastens the absorption of acetaminophen solution, but little modifies its elimination rate and bioavailability.

Pharmacokinetic characteristics of minocycline in debilitated elderly patients

A pharmacokinetic study of minocycline was performed in 12 debilitated elderly patients who had suffered from acute bacterial respiratory infections. Serial intravenous administrations of 100 mg minocycline were performed at least 10 times (infused for 1 hour, every 12 hours). Blood samples were obtained at 0, 1, 3, and 10 hours after initiating the first and fifth dose and 1 hour after the ninth dose (total, 9 points). The serum concentrations of unchanged minocycline were measured using high-performance liquid chromatography. The obtained data were analyzed using a two-compartment model in 11 cases and a one-compartment model in 1 case. Other clinical data were also collected simultaneously. The mean age of the subjects was 82 +/- 6 years. The elimination half-lives at beta-phase averaged 25.0 +/- 16.4 hours, the volume of distribution averaged 32.9 +/- 13.4 L, and the total clearance averaged 1.14 +/- 0.49 L/h. The correlation coefficient between the expected trough concentration of minocycline in steady-state and the dose per 1 kg body weight was.54 (P =.06), suggesting that dosage should be adjusted by body weight when administered to debilitated elderly patients. The present data are considered to be important and clinically useful because little information is available concerning the pharmacokinetics of minocycline in elderly patients.

Polymorphism of the beta3-adrenergic receptor gene and weight gain in pregnant diabetic women

Inappropriate body weight gain during pregnancy has critical effects on the outcome for both mother and fetus. Therefore, body weight gain is an important issue in the management of pregnancy in women with diabetes. A Trp64Arg substitution in the beta3-AR gene has been reported to be associated with body weight gain and obesity in non-insulin-dependent diabetes mellitus (NIDDM) subjects. The aim of this study was to elucidate the contribution of the beta3-AR gene to body weight gain during pregnancy in subjects with diabetes. We analyzed 199 diabetic patients (NIDDM/IDDM; 131/68) and patient data was obtained from the first delivery of each individual. The mean age at diagnosis of diabetes was 22.9 +/- 7.5 years (mean +/- S.D.) and the mean age at delivery was 29.8 +/- 4.5 years. A polymorphism of the beta3-AR gene was detected by PCR-RFLP using Bst OI, which recognizes a Trp64Arg substitution. The frequency of the Trp64Arg allele was 0.15 in NIDDM and 0.17 in IDDM. Among the NIDDM subjects, excess weight gain during pregnancy, as defined by maximum BMI during pregnancy minus basal BMI before pregnancy exceeding five, was observed in 12.2% of the wild-type patients, 19.2% of heterozygotes and 28.6% of homozygotes. Homozygous subjects with NIDDM tended to show excess weight gain during pregnancy, however, this trend did not reach significance. None of the IDDM homozygotes showed excess weight gain. From our study, this beta3-AR gene polymorphism cannot be excluded as a contributing factor to excess weight gain during pregnancy in NIDDM subjects.

[Pathogenesis and management of gestational diabetes mellitus]

The definition of gestational diabetes mellitus (GDM) is carbohydrate intolerance of varying degrees of severity, with onset or first recognition during pregnancy. GDM develops due to insulin resistance during pregnancy and impaired insulin secretion. The problems of GDM are increasing the risk of adverse pregnancy outcome and development of diabetes later in life in the mother. To prevent adverse perinatal outcome, it is important to screen for glucose intolerance as early in pregnancy as possible, and to control maternal hyperglycemia intensively. To reduce the risk of future diabetes in the mother, patient should control weight and increase physical activity.

No difference in seroprevalences of Helicobacter pylori infection between patients with pulmonary tuberculosis and those without

A previous article reported a possible relationship between a history of tuberculosis and Helicobacter pylori infection. Epidemiologic similarities exist between the two infections: Mycobacterium tuberculosis and H. pylori are transmitted from person to person and the risk of acquiring them is elevated in underprivileged environment. This study was conducted to investigate the relationship between the two infections. Serum concentrations of anti-H. pylori IgG antibody were measured in 40 tuberculosis inpatients on antituberculosis chemotherapy for no more than 3 months (group I; 52.4 +/- 21.4 years of age), 43 tuberculosis inpatients on it for more than 3 months (group II; 57.3 +/- 16.3 years), and 60 nontuberculosis outpatients (control subjects; 55.9 +/- 16.7 years). H. pylori seropositivities were similar among control subjects (73.3%), group I (65%), and group II (69.8%). The difference in the antibody concentrations was significant between control subjects and group I (353.7 +/- 321.2 vs. 176.5 +/- 197.9 U/ml) but was not significant between control subjects and group II (353.7 +/- 321.2 vs. 229.9 +/- 249.5 U/ml). The seroprevalences may not be different between patients with pulmonary tuberculosis and those without, and antituberculosis therapy may not decrease the antibody concentrations.

Guide for judicious use of the paracetamol absorption technique in a study of gastric emptying rate of liquids

The paracetamol absorption technique, a widely used method for evaluating the gastric emptying rate of liquids, appears to be performed inappropriately, resulting from a lack of consideration of pharmacokinetics in paracetamol absorption. This review suggests that appropriate study designs and logical choice of the parameters for the rate of paracetamol absorption are the cornerstone of reliable investigation of gastric emptying using the paracetamol method.

Spontaneous intramural hematoma localized in the proximal esophagus: truly "spontaneous"?

After a usual meal, a 57-year-old woman with normal hemostasis experienced a hematoemesis. She was then diagnosed endoscopically as having an intramural hematoma of the esophagus, which ranged from 18 cm to 24 cm from the incisors. The hematoma is considered to have developed not "spontaneously" but as a result of direct abrasive trauma by foodstuffs. The authors think it appropriate to use the term "spontaneous" only when the development of hematoma is unrelated to emetogenic events, impaired hemostasis, and food-induced injury.

Pharmacokinetic characteristics of cisapride in elderly patients

We demonstrated pharmacokinetic characteristics of cisapride in elderly patients (85+/-6 years) who had suffered from constipation based on intestinal motility dysfunction. After a single p.o. dose of 2.5 mg cisapride tablet on the first day, plasma unchanged cisapride concentrations were detected at 9 points within 24 hours, using high-performance liquid chromatography method. Subsequently, the patients were treated with cisapride 3 times daily during next 26 days (from the day 2 to the day 27). On the 28th day, a cisapride tablet was given once in the morning and blood samples were obtained with the same procedure as that on day 1. The obtained elimination half-life averaged 21.8+/-10.6 hours, which seems to be considerably longer than those previously reported. The area under the time-concentration curve (AUC) on the day 28 was 2.7 times larger than AUC on the day 1, suggesting that plasma cisapride concentrations can become higher than expected by physicians when given 3 times daily to extremely elderly patients. Because cisapride sometimes induces fatal ventricular arrhythmias and sudden death in a concentration-dependent manner, this medicine should be administered once or twice per day to such patients.

Digoxin-like immunoreactive substance in the elderly patient and its impact on the TDx digoxin assay

This study was undertaken to examine the impact of endogenous digoxin-like immunoreactive substance (DLIS) on the therapeutic drug monitoring of digoxin in elderly patients. Serum digoxin concentrations were detected by TDx digoxin assay in 220 patients 65 years of age and older who were not administered cardiac glycosides, spironolactone, or canrenone. The influence of clinical factors and laboratory parameters on the presence of DLIS was also evaluated. The concentration of DLIS averaged .07 ng/ml (range, 0-0.74 ng/ml), and in 25 subjects DLIS was observed over the detection limit of the assay. None of the parameters demonstrated a significant contribution to the presence of DLIS except one: continuous intravenous drip infusion therapy with a sodium-containing solution (DIV). The frequency of DLIS was significantly higher in the elderly subjects than in 121 control subjects younger than 35 years of age (p = 0.01). However, the difference became insignificant when subjects administered DIV were excluded from the analysis (p = 0.15). It was suggested that DIV may be clinically important in indicating the presence of DLIS.

[Pleural adenosine deaminase levels in tuberculous pleurisy--its diagnostic performance under the different prevalences in the different age of population]

In the diagnosis of pleural effusion, tuberculous pleurisy should always be considered because the prevalence of tuberculosis in Japan remains high. The measurement of adenosine deaminase (ADA) levels in pleural fluid is useful for the diagnosis of the tuberculous pleurisy because of its high sensitivity and specificity. However, no studies have addressed the post-test probability (= positive predictive value; PPV) of the test. Since the PPV depends on the pre-test probability (= prevalence) of the tuberculous pleurisy that varies with age, we have retrospectively evaluated the PPV in the different age population; the young (-35 years of age), the middle (36-65 years), and the old (66-years). A total of 208 data sets were collected; the tuberculosis (n = 52), malignancy (n = 34), non-specific infection (n = 31), transudates (n = 45), the others (n = 36), and unknown causes (n = 10). It was found that 1) the prevalence of tuberculous pleurisy was decreased with age, (70% in the young, 28.7% in the middle, and 8.5% in the old), 2) the PPV was the lowest in the old (53.8%), while the highest in the young (95.0%), and 3) no significant correlation was found between age and the ADA activity in pleural effusion.

A reliable and convenient parameter of the rate of paracetamol absorption to measure gastric emptying rate of liquids

The rate of paracetamol absorption represents gastric emptying rate (GER) of liquids. Thus, the liquid GER is assessed by conventional pharmacokinetic parameters such as the maximum concentration and the time to maximum concentration after oral administration of paracetamol. However, the conventional parameters are subject not only to the rate but also to the extent of absorption. For the reliable assessment of GER we have proposed a new parameter, the C0.5/C0.25 ratio, for the rate of paracetamol absorption without being affected by the extent of absorption. Of 15 healthy male volunteers, 9 orally received 10 mg/kg of paracetamol with 200 ml of water as the "normal" GER group, and the other 6 took 10 mg/kg of paracetamol with 200 ml of a liquid nutrient (200 kcal/200 ml), which delays GER, as the "delayed" GER group. Blood samples were obtained at t = 0 (pre-dose), 0.25, 0.5, 0.75, 1.0, 1.5, 2.0, 3.0, 4.0, 6.0, and 8.0 hours (post-dose). In each subject, GER was assessed by the conventional parameters, the C0.5/C0.25 ratio, and the Wagner-Nelson method which provides an accurate estimate of the drug absorption rate. Using the C0.5/C0.25 ratio and the Wagner-Nelson method we could more clearly differentiate the delayed GER group from the normal GER group than by using the conventional parameters. This suggests that the C0.5/C0.25 ratio and the Wagner-Nelson method may be more reliable than the conventional parameters in detecting a delay in GER. Further, it should be noted that the C0.5/C0.25 ratio can be calculated from only 2 blood samples while the Wagner-Nelson method requires repeated blood sampling.

Intestinal Behçet's disease associated with non-Hodgkin's lymphoma

A 45-year-old man with intestinal Behçet's disease noticed an enlarged right cervical lymph node, and was diagnosed with diffuse large cell type, non-Hodgkin's lymphoma. The intrapelvic lymph tract was markedly deformed because of recurrent ileocecal ulceration, and conventional lymphoscintigraphy with a common tracer did not abolish the suspicion that lymphoma cells may have invaded the lymph nodes. Dynamic lymphoscintigraphy with a new tracer, 99mtechnetium-diethylene triamine pentaacetic acid-human serum albumin, because of its high detection sensitivity, was very useful for excluding this suspicion, and for determining the clinical stage of lymphoma. Combination induction chemotherapy led to complete remission without any adverse effects, but subsequent supportive therapy with same protocol could not be completed because of progression of the intestinal lesions. Special management for the intestinal lesions, such as bowel rest, may be essential with chemotherapy for patients with intestinal Behçet's disease.

Angiotensin II-induced pulmonary edema in a rabbit model

We conducted the present study to propose a rabbit model of pulmonary edema (PE) induced by angiotensin II (AII) and to test the preventive effect of losartan on this form of PE. AII was administered to rabbits intravenously at 50, 100, 150 or 300 microg/kg, either by continuous infusion (10 min) or by bolus injection (30 sec). Continuously administered AII (150 microg/kg) induced PE in most cases, while a bolus injection of the same dosage did not. Additionally, the incidence of PE increased with higher dosages of AII when it was infused continuously. A newly established parameter, the area under the systolic blood pressure-time curve corrected by baseline (cAUC), was prone to rise as the incidence of PE increased. Moreover, cAUC signficantly correlated with the wet-dry lung weight ratio (r=0.66, P<0.05). Subsequently, 0.5 or 3.0 mg/kg of losartan was given before continuous infusion of 150 microg/kg of AII. The higher dosage of losartan prevented PE completely, while the lower one did so moderately. We concluded that intravenous administration of AII induces PE, probably as a result of increasing afterload. Furthermore, an adequate dosage of losartan can prevent PE because it reduces the pressor effect of AII.

Insulin-like growth factors (IGFs) and IGF-binding proteins (IGFBP-1, -2 and -3) in diabetic pregnancy: relationship to macrosomia

To evaluate the role of insulin-like growth factors (IGFs) and IGF-binding proteins (IGFBPs) in excessive fetal growth (macrosomia) in diabetic pregnancy, 84 insulin-treated diabetic mothers and their infants were tested for serum concentrations of IGF-I, IFG-II, and IGFBP-1, -2 and -3. These parameters were correlated with the birth weight of neonates and placental weight. IGF-I and II levels were determined by specific radioimmunoassays (RIAs) after serum samples were extracted with aid-ethanol. IGFBPs were measured by Western immunoblot with specific antibodies to the respective IGFBP species. Serum concentrations of both IGF-I and IGF-II in mothers with either IDDM or NIDDM increased with the gestational period, reached a plateau at the third trimester, and returned to non-pregnant levels within 7 days after delivery. These values were not different from those in normal mothers before and throughout pregnancy. As previously reported, IGF-I concentrations in cord serum of neonates born to diabetic mothers were (P < 0.01) higher than those of newborns of normal mothers. Likewise, cord blood IGF-II levels were 2-fold higher in babies of diabetic mothers (P <0.001). Fetal IGF-I and IGF-II correlated with each other and with maternal HbA1C, and they positively correlated with either birth weight or placental weight. Cord IGFBP-3 concentrations were significantly higher in diabetic pregnancy, but IGFBP-2 concentrations were not different from those in normal pregnancy. Cord IGFBP-1 concentrations were significantly higher only in babies of mothers with IDDM. None of these cord IGFBP concentrations correlated with birth weight or placental weight. The data suggest that fetal IGF-II, like IGF-I, is involved in fetal and placental growth in diabetic pregnancy. The role of IGFBPs remained to be determined.

Serum albumin for estimating creatinine clearance in the elderly with muscle atrophy

The present study was conducted to develop a special formula to predict creatinine clearance (CCr, ml/min) in the elderly with chronic muscle atrophy using serum albumin (Alb, g/dl). We obtained 90 data sets including actual body weight (BW, kg), urinary creatinine excretion (UCr, mg/24 h), serum creatinine (SCr, mg/dl), and Alb from 90 inpatients aged 60-92 years. Regression equations were determined between the dependent variable of UCr/BW and the explanatory variable of Alb as follows: For males Ucr/BW = 2.695 Alb + 4.665 For females Ucr/BW = 1.827 Alb + 4.146. Then, the new predictive formula was derived from the equations: For males CCr = (19Alb + 32)BW/(100 x SCr) For females CCr = (13Alb + 29)BW/(100 x SCr). Evaluations for the predictive error (predicted CCr- measured CCr) showed that the new formula could provide more accurate and less biased estimates of CCr than the Cockcroft and Gault formula could, even in patients with renal insufficiency and in those with Alb < or = 2.8 g/dl.

Accumulation of phosphatydilcholine-hydroperoxide in dialysis patients with diabetic nephropathy

Plasma lipid peroxidation in noninsulin dependent diabetes mellitus (DM) patients were evaluated in DM patients undergoing hemodialysis (HD) by means of a chemiluminescence-HPLC for the specific determination of phosphatidylcholine hydroperoxide (PCOOH). Thirty-three uremic patients with DM nephropathy, undergoing 12 hours HD a week using polymethylmethacrylate membrane, were studied. Of them 22 DM patients on HD were divided into 2 age and sex matched groups treated and conventional group in order to clarify therapeutic effect of 500 mg alfa-tocopherol and 600 mg probucol daily. Fifty DM patients without end-stage renal disease (ESRD) who were age-, period of diabetes-, and sex-matched, were selected as positive control of the subjects. Plasma PCOOH levels were significantly elevated in both DM patients, while the plasma PCOOH in normal controls were 227.0 +/- 68.7 pmol/ml. Plasma PCOOH levels of DM patients undergoing HD were significantly higher than that of patients without ESRD (1,330.8 +/- 642.7 pmol/ml vs. 756.6 +/- 431.9 pmol/ml, p < 0.025). Partial correlation coefficient of plasma PCOOH level demonstrated PCOOH and period of HD in DM patients were highly significantly positively correlated (p < 0.01), although single session of HD was not found to produce significantly increased lipid-peroxidation. Plasma PCOOH roughly remained within similar levels as base lines by medication with anti-oxidant compared to that of conventional group. From these results we conclude that HD intensifies lipid peroxidation and such accumulation of hydroperoxide could account for accelerated progress of atherosclerosis in DM patients with renal insufficiency. It is worthwhile to try an administration of free radical scavenger in order to reduce PCOOH and slow down the progression of atherosclerotic vascular disease.

Mutation in the mitochondrial tRNA(leu) at position 3243 and spontaneous abortions in Japanese women attending a clinic for diabetic pregnancies

Mitochondrial DNA is exclusively maternally inherited. We recently found the prevalence of diabetic patients with an A to G transition at position 3243 of leucine tRNA (3243 base pair (bp) mutation) to be nearly 1% in randomly selected Japanese subjects. Here, we report the higher prevalence of diabetic patients with the 3243 bp mutation in a specific Japanese population of women attending a diabetic pregnancy clinic. Of 102 patients with non-insulin-dependent diabetes mellitus 6 (5.9%) were positive for the mutation, 1 (8.3%) of 12 patients with gestational diabetes and 2 (5.9%) out of 34 borderline diabetic patients. In contrast, none of 64 patients (0%) with insulin-dependent diabetes mellitus had the 3243 bp mutation. Moreover, there was a difference in the prevalence of spontaneous abortions between patients with and without this mutation (27.3 vs 12.4%). Among nine probands with the mutation, four had a history of one spontaneous abortion (p = 0.0518) and two had a history of two abortions (p = 0.0479). Two probands had a spontaneous abortion even while under strict diabetic metabolic control. The 3243 bp mutation thus may cause spontaneous abortion during pregnancy.

Pulmonary edema induced by angiotensin II in rats

We performed this study to demonstrate the experimental procedure for inducing pulmonary edema by angiotensin II (AT II) in rats and to determine the mechanism of hemodynamic pulmonary edema. In the pilot study, 10 micrograms/ml of AT II was found to be adequate as the edematogenic dose for inducing pulmonary edema. The edematogenic dose of AT II was intravenously given to rats pretreated with 20 mg/kg of an AT II-receptor antagonist, E 4177 (3-[(2'-carboxybiphenyl-4-yl)methyl]-2-cyclopropyl-7-methyl-3H- imidazo[4,5-b]pyridine), and to rats given 10 mg/kg of an alpha-adrenergic blocker, phentolamine. Similarly, pulmonary edema was induced by 25 micrograms/ml of adrenaline in rats pretreated with E 4177 (20 mg/kg) and rats with no pretreatment. E 4177 completely suppressed the development of AT II-induced pulmonary edema, whereas phentolamine could not. On the contrary, E 4177 could not suppress the development of adrenaline-induced pulmonary edema. We concluded that AT II-induced pulmonary edema will develop via the specific AT II receptor without the indirect action of adrenaline.

Rapid and accurate estimation of creatinine clearance in the muscle-wasted elderly by computed tomography

To develop a new method for accurately predicting creatinine clearance (Ccr) in the debilitated elderly without urine collections, the total muscle volume of both thighs (MV thigh), as a new predictive parameter, was calculated using computed tomography in 68 debilitated patients aged 61-92 years. A regression line between 24-hour urinary creatinine excretion and MV thigh was divided by serum creatinine (Scr), and then the following formula was derived: Ccr (ml/min) = 9 x [MV thigh (cm3) - 100]/[1,000 x Scr (mg/dl)] Predicted Ccr by the new method more closely correlated with measured Ccr (r = 0.862) than did predicted Ccr by Cockcroft and Gault's method (the C-G method) (r = 0.727). Statistical analysis of prediction error (= predicted Ccr-measured Ccr) suggested that the new method could provide more accurate and less biased estimations of Ccr than did the C-G method, even in patients with renal insufficiency. By using computed tomography, we have proposed a more accurate method for predicting Ccr of the debilitated elderly than the C-G method, although the new method has inherent disadvantages of radiation exposure and high cost.

Current status of pregnancy in diabetic women. A comparison of pregnancy in IDDM and NIDDM mothers

Pregnancy in diabetic patients was uncommon before 1960 in Japan. It has increased recently and there has been a 3-fold increase since 1971. Only 26% of the cases of diabetic pregnancy had IDDM; the rest of cases had NIDDM. The perinatal mortality of infants decreased from 10.8% in 1971-1975 to 1.1% in 1986-1990, but the incidence of congenital malformations remained at 5.7-8.2% during this period. From 1988 to 1992, we experienced 207 deliveries at the Diabetes Center, Tokyo Women's Medical College. The ratio of IDDM to NIDDM of the mothers was 33:67. The onset of diabetes of pregnant women occurred earlier and the duration of diabetes was longer in IDDM than in NIDDM (mean onset, 17.8 vs. 26.0 years; mean duration, 11.5 vs. 5.6 years). The prevalence of maternal complications was similar between the IDDM and NIDDM mothers. Proliferative retinopathy in NIDDM was often detected for the first time during pregnancy. Major congenital malformations were found in none of the infants of IDDM mothers but in 5.8% of the infants of NIDDM mothers. This is probably related to the poor management of diabetes in NIDDM before pregnancy.

Insulin-receptor kinase is enhanced in placentas from non-insulin-dependent diabetic women with large-for-gestational-age babies

The function of insulin receptor and IGF-1 receptor was investigated in placentas from 10 healthy control mothers, 8 diabetic mothers with appropriate-for-gestational-age babies (AGA group) and 9 diabetic mothers with large-for-gestational-age babies (LGA group). None of the diabetic mothers were obese before pregnancy; their blood glucose was well controlled during pregnancy and glycosylated HbA1c was 6.52 +/- 0.71% (M +/- S.E.). Insulin and IGF-1 receptors were partially purified from placentas using wheat germ agglutinin chromatography. The insulin-binding capacity was significantly increased in both the AGA and the LGA groups compared to the control, whereas the IGF-1 binding capacity was similar in the three groups. Autophosphorylation studies were performed with partially purified receptors equalized for similar binding capacity, then immunoprecipitated with anti-insulin receptor antibody or anti-IGF-1 receptor antibody. Insulin-stimulated 32P-incorporation into the insulin receptor beta-subunit was increased by 133% in the LGA group versus the control, whereas incorporation in the AGA group was equivalent to the control. Insulin-stimulated tyrosine kinase activity of the receptor preparation for histone H2B phosphorylation was also significantly increased in the LGA group compared to the control. 32P-incorporation into beta-subunit IGF-1 receptor and IGF-1-stimulated tyrosine kinase activity did not show any significant differences among the three groups. The data in the present study suggest that elevated insulin receptor kinase might be involved in fetal overgrowth in diabetic mothers.

Comparison of diagnostic criteria of IGT, borderline, and GDM. Blood glucose curve and IRI response

A 75-g oral glucose tolerance test (OGTT) was performed in 615 nonobese pregnant women (mean +/- SD age 29.7 +/- 4.3 yr) who were referred to the Division of Internal Medicine at our diabetes center because of glycosuria. Seventy-seven cases were found to have urinary glucose at the first trimester, 185 at the second trimester, and 353 at the third trimester. With their 75-g OGTT results, the diagnostic criteria of borderline (formulated by the Japan Diabetes Society), impaired glucose tolerance (IGT; defined by the World Health Organization [WHO]), and gestational diabetes mellitus (GDM; determined by the Japan Society of Obstetrics & Gynecology standards) were compared through blood glucose (BG) curves and immunoreactive insulin (IRI) responses. Borderline (fasting BG greater than or equal to 6.1 and less than 7.8 mM and 2-h BG greater than or equal to 6.7 and less than 11.1 mM) is neither diabetes nor normal. IGT is as referred to by the WHO. GDM exceeds two points of fasting BG greater than or equal to 5.6 mM, 1-h BG greater than or equal to 10.0 mM, or 2-h BG greater than or equal to 8.3 mM. Diabetes mellitus (DM) is as referred to by the Japan Diabetes Society (same as the WHO). The prevalence of abnormal glucose tolerance among all 615 pregnant women was 54.6% in borderline, 24.5% in IGT, 7.3% in GDM, and 3.4% in DM. The 2-h BG levels in IGT during the first trimester were higher than in borderline (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of diabetes on the free polyol pattern in cataractous lenses

To obtain information about the effects of lenticular polyols on the prevention, initial stages, and development of diabetic cataracts, we identified and determined with gas-liquid chromatography or gas-liquid chromatography/mass spectrometry eight polyols in cataractous lenses of non-insulin-dependent diabetes mellitus patients and nondiabetic subjects. In the diabetics' lenses, the concentrations of polyols (e.g., sorbitol, fructose, mannitol, and adonitol) were higher than in the nondiabetics' lenses, whereas the concentration of 1-deoxyglucose was lower. The mean concentration of myo-inositol in lenses of diabetics was lower than that of nondiabetics, but this difference was statistically not significant. The total content of eight polyols in the diabetics' lenses did not differ significantly from that in the nondiabetics. In the lenses of diabetics, the content of glucose correlated positively with that of adonitol, fructose, and sorbitol. In the lenses of nondiabetics, the content of glucose correlated positively with that of mannitol and inversely with that of 1-deoxyglucose and myo-inositol. In diabetics, hemoglobin A1 (%) correlated positively with the concentration of adonitol in the lenses and inversely with the concentration of lens myo-inositol; however, it did not correlate with the concentration of glucose in lenses. Regulation of both the metabolism of lenticular polyols and the pattern of polyols in serum may be necessary for normalizing lenticular polyol content.

Effect of diabetes on the free polyol pattern in cataractous lenses

To obtain information about the effects of lenticular polyols on the prevention, initial stages, and development of diabetic cataracts, we identified and determined with gas-liquid chromatography or gas-liquid chromatography/mass spectrometry eight polyols in cataractous lenses of non-insulin-dependent diabetes mellitus patients and nondiabetic subjects. In the diabetics' lenses, the concentrations of polyols (e.g., sorbitol, fructose, mannitol, and adonitol) were higher than in the nondiabetics' lenses, whereas the concentration of 1-deoxyglucose was lower. The mean concentration of myo-inositol in lenses of diabetics was lower than that of nondiabetics, but this difference was statistically not significant. The total content of eight polyols in the diabetics' lenses did not differ significantly from that in the nondiabetics. In the lenses of diabetics, the content of glucose correlated positively with that of adonitol, fructose, and sorbitol. In the lenses of nondiabetics, the content of glucose correlated positively with that of mannitol and inversely with that of 1-deoxyglucose and myo-inositol. In diabetics, hemoglobin A1 (%) correlated positively with the concentration of adonitol in the lenses and inversely with the concentration of lens myo-inositol; however, it did not correlate with the concentration of glucose in lenses. Regulation of both the metabolism of lenticular polyols and the pattern of polyols in serum may be necessary for normalizing lenticular polyol content.

Quantitative analysis of serum alpha 1-acid glycoprotein levels in normal and diabetic pregnancy

In an attempt to clarify the mechanism of lipid metabolism during pregnancy, alpha 1-acid glycoprotein (alpha 1-AG) was analyzed in normal and diabetic pregnant women. Seventy-two determinations of serum alpha 1-AG levels were performed in 18 diabetic pregnant women and 82 determinations in 82 normal pregnant women in all three trimesters and within 14 days postpartum. Serum alpha 1-AG levels in both normal and diabetic pregnant women decreased throughout pregnancy and rapidly increased postpartum. In all gestational stages, the serum alpha 1-AG levels were lower in diabetic women than in normal women, but the differences were not significant. No significant correlation was obtained between serum alpha 1-AG and hemoglobin A1 (HbA1) in diabetic patients. On the contrary, the serum triglyceride levels increased during pregnancy and decreased postpartum in both groups of subjects. These findings suggest that serum alpha 1-AG plays an important role in the activation of lipoprotein lipase during pregnancy.

Elevation of immunoreactive platelet prostaglandin E and plasma prostaglandin F2 alpha in diabetic pregnancy

Platelet prostaglandin (PG) E and plasma PGF2 alpha concentrations were measured by radioimmunoassay methods and compared in non-pregnant and pregnant, normal and diabetic subjects. The blood samples were obtained in the follicular phase in the non-pregnant women and in the third trimester and after delivery in the pregnant women. The immunoreactive platelet PGE (IRPGE) levels were significantly higher in the pregnant diabetic women than in the normal non-pregnant and pregnant women and diabetic non-pregnant women. The immunoreactive plasma PGF2 alpha (IRPGF2 alpha) concentrations were significantly higher in the non-pregnant diabetic women than in the normal non-pregnant and pregnant women. During pregnancy, the plasma IRPGF2 alpha were further increased significantly in the diabetic subjects compared to the non-pregnant diabetics. Both the platelet IRPGE and plasma IRPGF2 alpha concentrations were higher in the pregnant diabetic subjects with retinopathy than in those without retinopathy. These findings suggest that pregnancy and diabetes influence the synthesis of PGE and PGF2 alpha in the platelets and plasma, respectively. The increased production of these prostaglandins are possible exacerbating factors of diabetic retinopathy during pregnancy.