Characteristics of individuals who developed type 2 diabetes from prediabetes despite undergoing interventions, and evaluation of the performance of urinary myo-inositol as a risk factor for developing diabetes

AIMS/INTRODUCTION

The aim of this study was to clarify the characteristics of individuals with prediabetes who developed type 2 diabetes despite undergoing interventions, and to evaluate the performance of urinary myo-inositol (UMI) as a noninvasive indicator for the risk of developing diabetes.

MATERIALS AND METHODS

A total of 51 individuals with prediabetes who underwent a 75-g oral glucose tolerance test, ΔUMI (the difference in the UMI : creatinine ratio between before and 120 min after 75-g glucose loading), fasting plasma glucose, insulin, hemoglobin A1c, noninvasive testing (age, body mass index, blood pressure) and general blood tests were measured at baseline, and underwent dietary/exercise guidance for 8 years were studied.

RESULTS

A total of 31 participants developed diabetes in 8 years. At baseline, the group that developed diabetes was characterized by high ΔUMI, hemoglobin A1c, fasting plasma glucose and low high-density lipoprotein cholesterol, and insulinogenic index (I.I.). I.I and ΔUMI showed a higher correlation than fasting plasma glucose and hemoglobin A1c. Regarding diabetes onset within 8 years, Cox regression analysis of diabetes onset showed the baseline ΔUMI is an independent predictor, adjusted for the result of not only noninvasive markers, but also that of noninvasive and general blood markers. The log-rank test showed that all glycemic indicators were significantly associated with diabetes onset.

CONCLUSION

Participants who developed type 2 diabetes from prediabetes despite undergoing interventions were characterized by high glycemic control markers and low I.I. As noninvasive measurement of ΔUMI is associated with I.I. and diabetes onset, it could be a useful indicator for identifying individuals with a high risk of diabetes onset.

Studies on GeF4 Valence and Rydberg States by Electron Impact Spectroscopy and Ab Initio Calculations

Electron energy loss (EEL) spectra of GeF₄ have been measured with incident electrons at 100 eV for 5° scattering angle and at 30 eV for 30° scattering angle, while sweeping the energy loss over the range 7.0-18.0 eV. Low-lying excited triplet, singlet, valence, and Rydberg states are investigated and the assignments supported by quantum chemical ab initio calculations. This provides the first comprehensive investigation of all singlet and triplet excited electronic states of germanium tetrafluoride up to the first ionization energy. The Rydberg series converging to the (lowest) ionization energy limits of GeF₄ are also identified according to the magnitude of the quantum defects (δ).

BF3 valence and Rydberg states as probed by electron energy loss spectroscopy and ab initio calculations

In this contribution we probe BF3 low-lying excited singlet states measured at 100 eV, 2.8° scattering angle and triplet states at 40 eV, 40° scattering angle, while sweeping the energy loss over the range 10.0-20.0 eV. The electronic state spectroscopy has been investigated and the assignments supported by quantum chemical calculations. This provides the first comprehensive investigation of all singlet and triplet excited electronic states of boron trifluoride up to the first ionization potential. A generalized oscillator strength analysis is employed to derive oscillator strength f0 value and integral cross sections (ICSs) from the corresponding differential cross sections (DCSs). The f0 value is compared with the optical oscillator strength (OOS) from photoabsorption, and the unscaled Born ICSs are then compared with relevant energy and binary-encounter and f-scaled Born cross section (BEf-scaling) results determined as a part of this investigation. The lowest n members of the Rydberg series have been assigned as converging to the lowest ionization energy limits of boron trifluoride and classified according to the magnitude of the quantum defects (δ).

Mass production of D-psicose from d-fructose by a continuous bioreactor system using immobilized D-tagatose 3-epimerase

An improved process for the mass production of D-psicose from D-fructose was developed. A D-fructose solution (60%, pH 7.0) was passed at 45 degrees C through a column filled with immobilized D-tagatose 3-epimerase (D-TE) which was produced using recombinant Escherichia coli, and 25% of the substrate was converted to D-psicose. After epimerization, the substrate, D-fructose, was removed by treatment with baker's yeast. The supernatant was concentrated to a syrup by evaporation under vacuum and D-psicose was crystallized with ethanol. Approximately 20 kg of pure crystal D-psicose was obtained in 60 d.

Two cases of recurrent IgA nephropathy following kidney transplantation

Recurrence of immunoglobulin (Ig) A nephropathy following kidney transplantation has been described as occurring in 40% to 60% of cases. Although this type of recurrence was considered a benign condition for a long time, more recent data showed that recurrent transplant IgA nephropathy may be a significant contributor to graft loss. We present 2 cases of recurrent IgA nephropathy following kidney transplantation. In case 1, renal function remained stable with a creatinine level of 1.2 mg/dL at 5 months after diagnosis and 61 months after transplantation. In case 2, the patient lost his graft and returned to regular hemodialysis at 36 months after diagnosis and 125 months after kidney transplantation.

22-Oxacalcitriol upregulates p21(WAF1/Cip1) in human parathyroid glands. A preliminary report

In the era of 22-oxacalcitriol (OCT), newly synthesized 1 alpha,25-dihydroxyvitamin D(3) analogue, against secondary hyperparathyroidism, the indications of parathyroidectomy (PTx) has been restricted. Recent investigations on animal models have revealed the inhibitory effects on PTH secretion after OCT treatment, whereas there has been no evidence about human parathyroid glands. A 38-year-old man with a 19-year history of hemodialysis was performed PTx after the failure of OCT treatment. Expressions of proliferative nuclear cell antigen (PCNA), calcium-sensing receptor (CaSR), vitamin D receptor (VDR), p53 and p21(WAF1/Cip1) were analyzed by Western blotting and immunohistochemistry on resected parathyroid glands. We confirmed up-regulations of CaSR and VDR, which contribute the reduction of serum PTH, by OCT treatment. Concomitant up-regulation of p21(WAF1/Cip1) but not p53, especially in nodular hyperplasia, can be considered to induce cell cycle arrest of the parathyroid cells, but not cytocidal effect of OCT.

[Laparoscopic salvage of malfunctioning peritoneal dialysis catheters caused by ovarian fimbria: a case report]

We report a case of peritoneal dialysis catheter obstruction caused by ovarian fimbria, which was successfully treated with laparoscopic surgery. In June 2000, a 51-year-old woman, who started peritoneal dialysis in April 2000, complained of outflow obstruction of peritoneal dialysis fluid. Fluoroscopic imaging demonstrated the obstruction of peritoneal dialysis catheter by ovarian fimbria. Since the alpha technique under the fluoroscopic imaging did not improve the obstruction, the ovarian fimbria was removed laparoscopically in June 5, 2000. Peritoneal dialysis was successfully started the day after the surgery with no leakage of peritoneal dialysis fluid. The patient has remained without obstruction of peritoneal dialysis catheter for 8 months postoperatively.

Effects of i.v. metoclopramide, atropine and their combination on gastric insufflation in children anaesthetized with sevoflurane and nitrous oxide

METHODS

To determine effects of i.v. metoclopramide, atropine and their combination on the airway pressures at which gastric insufflation occurs in children, 45 healthy infants and children (ASA I) received an inhalational induction of anaesthesia with sevoflurane, N2O and O2. A blinded observer used a stethoscope to auscultate over the upper abdomen for any air entry. First, proximal airway pressure was slowly increased by closing the pop-off valve of the anaesthesia machine until gas was heard entering the stomach (pop-off point, control measurement). If the peak inspiratory pressure reached 40 cm H2O, the patient was to be excluded from the study. Then, all subjects randomly received i.v. atropine 0.01 mg.kg-1, metoclopramide 0.2 mg.kg-1, or atropine 0.01 mg.kg-1 plus metoclopramide 0.2 mg.kg-1 (n=15 each), and determination of the pop-off point was repeated 5 min later. The stomach was evacuated before each measurement.

RESULTS

Atropine significantly decreased the pop-off point [from 21 +/- 3 to 19 +/- 2 cm H2O (mean +/- SD), P < 0.05], while metoclopramide significantly increased the pop-off point (from 20 +/- 3 to 26 +/- 6 cm H2O, P < 0.05). The combination of metoclopramide and atropine did not alter the pop-off point (from 20 +/- 2 to 19 +/- 5 cm H2O).

CONCLUSION

Since metoclopramide exerts only mild effect on the pop-off point, cricoid pressure still remains the standard anaesthetic practice to prevent gastric insufflation in children. Prophylactic i.v. metoclopramide may be restricted to, and its clinical usefulness should be determined in, symptomatic patients with gastro-oesophageal reflux.

Microbial contamination of in-use lubricants for non-touch urethral catheters in intermittent self-catheterization

There are no reports on microbial contamination of repeatedly used lubricant (84-87% glycerin containing 0.02% benzalkonium chloride) for non-touch urethral catheters in intermittent self-catheterization. In this work, we evaluated microbial contamination of in-use lubricant and its prevention. Between September and December, 1996, microbial contamination and water activity of in-use lubricants in sheathed and lubricated non-touch catheters connected to a tube used by 46 outpatients at our hospital was examined. Microbial contamination was detected at 5 to 2.6 x 10(8) colony-forming units (CFU)/ml in 14 (30.4%) of 46 samples. With higher water activity of the lubricant (a higher dilution rate of the lubricant with water), a higher concentration of microbial contamination was observed. In 3 (21.4%) of the 14 patients using contaminated lubricant, urine samples showed the same microbial species as those detected in the lubricant. To prevent microbial contamination of the lubricant, dilution of the lubricant with water, as a result of repeated use, should be avoided.

Tracheal intubation with the Macintosh laryngoscope versus intubating laryngeal mask airway in adults with normal airways

We tested the hypothesis that haemodynamic changes to intubation and postoperative pharyngolaryngeal morbidity are similar for blind intubating laryngeal mask (ILM)-guided compared with laryngoscope-guided tracheal intubation in adults with normal airways. We also compared intubation success rates and airway complications. One-hundred and fifty paralysed, anaesthetized adult patients undergoing elective surgery were randomly assigned to one of three equal-sized groups: 1. blind intubation via the ILM using a straight, silicone tube; 2. intubation with a Macintosh laryngoscope using a straight silicone tube and 3. intubation with a Macintosh laryngoscope using a polyvinyl chloride tube (controls). A standard sequence of adjusting manoeuvres was followed if intubation was difficult. The number of adjusting manoeuvres and intubation attempts, time to intubation, intubation success rate (first attempt and within 3 min), haemodynamic changes (pre-induction, post-induction, post-intubation), oesophageal intubation, mucosal trauma (blood detected), hypoxia (SpO2 < 95%) and postoperative pharyngolaryngeal morbidity (double-blinded) were documented. Time to successful intubation was longer (57 vs 35 s), and more intubation attempts were required in the ILM group (P < 0.0001). The intubation success rate was 100% (all first attempt) for the laryngoscope groups and 94% (56% first attempt) for the ILM group. There were no significant differences in heart rate or blood pressure among groups. Oesophageal intubation (26 v 0%) and mucosal trauma (19 v 2%) were more common in the ILM group. Hypoxia and postoperative pharyngolaryngeal morbidity were similar among groups. Blind intubation through the ILM offers no advantages over the Macintosh laryngoscope for adult patients requiring intubation for elective surgery with normal airways, but it is a feasible alternative.

A comparison of blind and lightwand-guided tracheal intubation through the intubating laryngeal mask

We have tested the hypothesis that intubation success rates, haemodynamic changes, airway complications and postoperative pharyngolaryngeal morbidity differ between blind and lightwand-guided intubation through the intubating laryngeal mask airway. One hundred and twenty paralysed anasthetised adult patients (ASA I-II, no known or predicted difficult airways) were assigned in a random manner to one of two equal-sized groups. In the blind group, patients were intubated blindly through the intubating laryngeal mask airway. In the lightwand group, patients were intubated through the intubating laryngeal mask airway assisted by transillumination of the neck with a lightwand. A standard sequence of adjusting manoeuvres was followed if resistance occurred during intubation or if transillumination was incorrect. The number of adjusting manoeuvres, time to intubation, intubation success rates, haemodynamic changes (pre-induction, pre-intubation, postintubation), oesophageal intubation, mucosal trauma (blood detected), hypoxia (oxygen saturation < 95%) and postoperative pharyngolaryngeal morbidity (double-blinded) were documented. Overall intubation success was similar (blind, 93%; lightwand, 100%), but time to successful intubation was significantly shorter (67 vs. 46 s, p = 0. 027) and the number of adjusting manoeuvres was significantly fewer (p = 0.024) in the lightwand group. There were no significant differences in blood pressure or heart rate between the groups at any time. Oesophageal intubation occurred more frequently in the blind group (18 vs. 0%, p = 0.002). The incidence and severity of mucosal injury, sore throat and hoarseness were similar between the groups. We conclude that lightwand-guided intubation through the intubating laryngeal mask is superior to the blind technique.

Effects of fructose and glucose on plasma leptin, insulin, and insulin resistance in lean and VMH-lesioned obese rats

To determine the influence of dietary fructose and glucose on circulating leptin levels in lean and obese rats, plasma leptin concentrations were measured in ventromedial hypothalamic (VMH)-lesioned obese and sham-operated lean rats fed either normal chow or fructose- or glucose-enriched diets (60% by calories) for 2 wk. Insulin resistance was evaluated by the steady-state plasma glucose method and intravenous glucose tolerance test. In lean rats, glucose-enriched diet significantly increased plasma leptin with enlarged parametrial fat pad, whereas neither leptin nor fat-pad weight was altered by fructose. Two weeks after the lesions, the rats fed normal chow had marked greater body weight gain, enlarged fat pads, and higher insulin and leptin compared with sham-operated rats. Despite a marked adiposity and hyperinsulinemia, insulin resistance was not increased in VMH-lesioned rats. Fructose brought about substantial insulin resistance and hyperinsulinemia in both lean and obese rats, whereas glucose led to rather enhanced insulin sensitivity. Leptin, body weight, and fat pad were not significantly altered by either fructose or glucose in the obese rats. These results suggest that dietary glucose stimulates leptin production by increasing adipose tissue or stimulating glucose metabolism in lean rats. Hyperleptinemia in VMH-lesioned rats is associated with both increased adiposity and hyperinsulinemia but not with insulin resistance. Dietary fructose does not alter leptin levels, although this sugar brings about hyperinsulinemia and insulin resistance, suggesting that hyperinsulinemia compensated for insulin resistance does not stimulate leptin production.

Identification of amino acid sequence in the hinge region of human vitamin D receptor that transfers a cytosolic protein to the nucleus

The localization of human vitamin D receptor (VDR) in the absence of its ligand 1,25-dihydroxyvitamin D(3) was investigated using chimera proteins fused to green fluorescent protein (GFP) at either the N or C terminus, and the nuclear localization signal (NLS) was identified. Plasmids carrying the fusion proteins were transiently or stably introduced into COS7 cells, and the subcellular distribution of the fusion proteins was examined. GFP-tagged wild-type VDRs were located predominantly in nuclei but with a significant cytoplasmic presence, while GFP alone was equally distributed throughout the cells. 10(-8) M 1,25-dihydroxyvitamin D(3) promoted the nuclear import of VDR in a few hours. To identify the NLS, we constructed several mutated VDRs fused to GFP. Mutant VDRs that did not bind to DNA were also localized predominantly in nuclei, while the deletion of the hinge region resulted in the loss of preference for nucleus. A short segment of 20 amino acids in the hinge region enabled cytoplasmic GFP-tagged alkaline phosphatase to translocate to nuclei. These results indicate that 1) VDR is located predominantly in nuclei with a significant presence in cytoplasm without the ligand and 2) an NLS consisting of 20 amino acids in the hinge region facilitates the transfer of VDR to the nucleus.

Rapid increase in circulating leptin in ventromedial hypothalamus-lesioned rats: role of hyperinsulinemia and implication for upregulation mechanism

The mechanisms of marked increase in plasma leptin soon after ventromedial hypothalamus (VMH) lesions were investigated. Although rats did not gain body weight or parametrial fat-pad mass 24 h after the operation, the acute VMH-lesioned rats exhibited substantial five- and fourfold increases in plasma leptin levels compared with sham-operated control rats in fed (22.6 +/- 3.2 vs. 5.8 +/- 1.2 ng/ml) and fasted (8.8 +/- 2.0 vs. 2.3 +/- 0.3 ng/ml) states, respectively. Plasma insulin concentration was doubled in VMH-lesioned rats compared with sham-operated controls in both fed and fasting states. Northern blot analysis revealed that mRNA of ob gene was not increased in parametrial fat pad of animals 24 h after the creation of VMH lesions. However, leptin content in the fat pad was significantly increased in VMH-lesioned rats compared with sham-operated controls (32.2 +/- 4.7 vs. 17.4 +/- 2.3 ng/g wet tissue). The leptin content in parametrial fat pad was highly correlated with plasma leptin concentrations (r = 0.898, P < 0.001). To define the effect of hyperinsulinemia on their hyperleptinemia, a small dose of streptozotocin (STZ) (25 mg/kg body wt) was intravenously administered into rats 5 days before the creation of VMH lesions. Plasma insulin levels were not increased after VMH lesions in STZ-pretreated rats. Plasma leptin levels were halved in the absence of hyperinsulinemia, but still remained twofold higher than those in their sham-operated counterparts (9.9 +/- 1.3 vs. 4.8 +/- 0.7 ng/ml). These results indicate that the destruction of VMH rapidly promotes leptin production before obesity develops through an enhanced translational process in which hyperinsulinemia occurring after VMH lesioning plays an important role. The present study also suggests that there are other mechanisms that rapidly upregulate leptin production in adipocytes in VMH-lesioned rats in which the target organ of this hormone has been destroyed.

Plasma leptin levels and triglyceride secretion rates in VMH-lesioned obese rats: a role of adiposity

To explore the role of adiposity on hypertriglyceridemia associated with obesity, we examined the relation between triglyceride secretion rate (TGSR) and plasma leptin, insulin, or insulin resistance in ventromedial hypothalamus (VMH)-lesioned rats in the dynamic and static phases (2 and 14 wk after lesions, respectively). VMH-lesioned rats gained body weight (BW) at fivefold higher rates in the dynamic phase compared with sham-operated control (sham) rats, and BW gain reached a plateau in the static phase. Parametrial fat pad mass was increased 2.5-fold in VMH-lesioned rats compared with sham rats in both phases. Leptin levels were sixfold higher in VMH-lesioned rats of the dynamic phase and even higher in the static phase. Insulin levels were twofold higher in VMH-lesioned rats than in sham rats in both phases. In the dynamic phase, VMH-lesioned rats had 2-fold higher plasma triglyceride (TG) levels and 2.6-fold higher TGSRs, whereas steady-state plasma glucose (SSPG) values, an indicator of insulin resistance, were lower. SSPG values became significantly higher in VMH-lesioned rats in the static phase, but TGSR was not further accelerated. TGSR was significantly associated with leptin, independent of insulin. Leptin was highly correlated with BW, fat mass, and nonesterified fatty acids (NEFA). These results suggest that adiposity itself plays a critical role in TGSR probably through increased NEFA flux from enlarged adipose tissues. Insulin resistance is not associated with the overproduction of TG in this animal model for obesity.

[Ketamine infusion therapy for refractory neuralgia in spinal disease: report of two cases]

We report two cases of refractory pain in a spinal disease. One case was a 60-year-old male who presented intractable pain in bilateral upper extremities after anterior fusion (C5/6, 6/7) for cervical spondylosis. The other was a 63-year-old female who also had intractable pain in the left anterio-lateral chest wall with no remarkable past history. Both cases were refractory to nonsteroidal anti-inflammatory drugs (NSAIDs) or minor tranquilizer or local anesthesia with bupivacaine. However, their pain was significantly relieved by the intravenous administration of a test dose (5mg) of ketamine which is a noncompetitive blocker of N-methyl-D-aspartate (NMDA) receptors. As for case 1, the effect of the injection of the test dose lasted, so continuing infusion therapy of ketamine was cancelled. In case 2, recurrence of the pain was recognized gradually. She underwent continuing infusion therapy of 2mg/kg of ketamine, and it brought about continued pain relief. We conclude that ketamine infusion therapy should also be considered for therapy of refractory neuralgia in spinal disease.

Increased uncoupling protein-2 and -3 gene expressions in skeletal muscle of STZ-induced diabetic rats

Streptozotocin (STZ)-induced diabetic animals are vulnerable to cold stress. Uncoupling proteins (UCPs) play an important role in regulating thermogenesis. We investigated the gene expressions of UCPs in brown adipose tissue (BAT), white adipose tissue (WAT), liver and gastrocnemius muscle of STZ-diabetic rats using Northern blot. UCP-1, -2 and -3 mRNA expressions in BAT were all remarkably lower in STZ-diabetic rats than those in control rats. Both UCP-2 and -3 gene expressions in gastrocnemius muscle were substantially elevated in STZ-diabetic rats and insulin treatment restored UCP gene expressions to normal levels. These results suggest that in STZ-diabetic rats, the overexpression of UCP-2 and UCP-3 in skeletal muscle provides a defense against hypothermogenesis caused by decreased UCPs in BAT.

[Urolithiasis associated with Crohn's disease: a case report]

We report a case of urolithiasis caused by surgical treatment for Crohn's disease. A 28-year-old woman was referred to our department for further examination of renal stones from the medical department in September, 1995. She suffered from Crohn's disease and had a history of jejuno-ileal resection because of perforation of the ileum in 1988. Radiographs revealed multiple bilateral renal stones, and the urine oxalate concentration was elevated. She was treated with extracorporeal shock wave lithotripsy and the administration of sodium bicarbonate and citrate, but these treatments did not prevent recurrence and enlargement of stones. Renal function was gradually worsened and we performed transurethral lithotomy and percutaneous nephrolithotripsy. The stones were mainly composed of oxalate calcium monohydrate. A renal biopsy was performed at the operation, showing deposition of crystals in almost all renal tubules. Diet therapy (low oxalate and low fat) and the administration of sodium bicarbonate and citrate were performed strictly and recurrence was not recognized 10 months after complete removal of the stones.

Studies on nonpeptide angiotensin II receptor antagonists. IV. Synthesis and biological evaluation of 4-acrylamide-1H-imidazole derivatives

A novel series of nonpeptide angiotensin II antagonists containing the acrylamide group at the 4-position of the imidazole ring was synthesized and their antagonistic activity was examined by functional assay in rabbit aorta. The acrylamide group was selected as a large lipophilic surrogate for the chloro group of EXP3174. A structure-activity relationship study of the acrylamide moiety has shown that substitution at the 4-position with the N-methyl-3,3-dimethylacrylamide group resulted in the optimal compound, 2-butyl-4-[(3,3-dimethylacryloyl)methyl-amino]-1-[[2'-(1H-tetra zol-5- yl)biphenyl-4-yl]methyl]-1H-imidazole-5-carboxylic acid (1), which was superior to EXP3174 in vitro. Since 1 showed only poor activity against angiotensin II-induced pressor response in rats after oral administration, the carboxylic acid function of 1 was converted into prodrug esters (13). Among these, the 1-[(ethoxycarbonyl)oxy]ethyl ester (13a) showed the most potent and longest-lasting activity when given orally to rats. When administered orally to conscious furosemide-treated dogs, 13a showed an approximately 3-fold increased hypotensive activity in comparison with DuP 753. These data suggest that 13a may be an useful agent for the treatment of angiotensin II-dependent diseases, such as hypertension.

Studies on nonpeptide angiotensin II receptor antagonists. III. Synthesis and biological evaluation of 5-alkylidene-3,5-dihydro-4H-imidazol-4-one derivatives

5-Alkylidene-3,5-dihydro-4H-imidazol-4-one derivatives were synthesized and evaluated for activity as angiotensin II receptor antagonists. Substitutions at C-2 and C-5, respectively, with a propyl group and a 1-methylethylidene group resulted in the optimal compound, 3,5-dihydro-5-(1-methylethylidene)-2-propyl-3-[[2'-(1H-tetrazol - 5-yl)biphenyl-4-yl]methyl]-4H-imidazol-4-one (2b), with a pA2 value of 8.85 in rabbit aorta. When administered orally to rats, 2b showed a greater inhibitory effect on angiotensin II-induced pressor response than DuP 753. Compound 2b also showed a good antihypertensive effect when administered orally to conscious sodium-depleted spontaneously hypertensive rats, with a duration of action of 24 h. These data suggest that 2b may be a useful agent for the treatment of angiotensin II-dependent diseases such as hypertension.

Studies on nonpeptide angiotensin II receptor antagonists. II. Synthesis and biological evaluation of 5H-pyrazolo[1,5-b][1,2,4]triazole derivatives with a C-linked oxygen functional group at the 6-position

2,7-Diethyl-5H-pyrazolo[1,5-b][1,2,4]triazole derivatives were synthesized and evaluated for activity as angiotensin II receptor antagonists. Replacement of the C-6 hydrogen with C-linked oxygen functional groups led to derivatives with increased in vitro activities. Among these compounds, 2,7-diethyl-5-[[2'-(1H-tetrazol-5-yl)biphenyl-4-yl]methyl]-5H- pyrazolo[1,5-b][1,2,4]triazole-6-carboxylic acid (2d) showed potent, insurmountable antagonism, but had poor oral potency against angiotensin II-induced pressor response in rats. In order to improve the oral activity, the carboxylic acid function of 2d was converted into a double ester. This modification afforded (+/-)-1-[(ethoxycarbonyl)oxy]ethyl 2,7-diethyl-5-[[2'-(1H-tetrazol-5-yl)biphenyl-4-yl]methyl]-5H- pyrazolo[1,5-b][1,2,4]-triazole-6-carboxylate (2f), which was orally active in rats, and produced a dose-dependent decrease in blood pressure when administered orally to conscious furosemide-treated dogs, with ca. 3-fold increased potency in comparison with the parent C-6 hydrogen compound.

Studies on nonpeptide angiotensin II receptor antagonists. I. Synthesis and biological evaluation of pyrazolo[1,5-b][1,2,4]triazole derivatives with alkyl substituents

Alkyl-substituted pyrazolo[1,5-b][1,2,4]triazole derivatives were synthesized and evaluated for activity as angiotensin II receptor antagonists. Molecules with the (methylbiphenylyl)tetrazole moiety and N-5 were the preferred compounds. Ethyl substitutions at both C-2 and C-7 resulted in the optimal compound, 2,7-diethyl-5-[[2"-(1H -tetrazol-5-yl)biphenyl-4-yl]methyl]-5H-pyrazolo[1,5-b][1,2,4]tria zole (5n), with a pA2 value of 8.774 in rabbit aorta. In the in vivo tests, 5n inhibited the angiotensin II-induced pressor response in rats after oral administration. This compound also produced a dose-dependent decrease in blood pressure when administered orally to conscious furosemide-treated dogs, having a longer duration of action as compared to DuP753. These data suggest that 5a may be a useful agent for the treatment of angiotensin II-dependent disease, such as hypertension.

Effect of oral adsorbent AST-120 on cyclosporin absorption in rats

The oral adsorbent AST-120 is used to inhibit the progression of renal failure by adsorbing uraemic toxins in the gastrointestinal tract. When AST-120 is administered to patients receiving immunosuppressive medicines, it is important to study the effect of AST-120 on the amount of these and other drugs absorbed. We have, therefore, studied the in-vitro adsorption of cyclosporin by AST-120 and investigated the effect of oral administration of AST-120 on the absorption of cyclosporin in rats. The in-vitro adsorption ratios of AST-120 for cyclosporin were more than 80%. When pure cyclosporin powder was administered with AST-120, blood cyclosporin concentrations were significantly higher than when cyclosporin was administered alone. When cyclosporin dissolved in medium-chain triglyceride was administered to rats by intramuscular injection there was no significant difference in the blood cyclosporin concentration of rats given combined AST-120 and cyclosporin and those given cyclosporin alone. There was no significant difference between the serum concentration of total bile acids, in rats receiving combined oral AST-120 and cyclosporin dissolved in olive oil, and those receiving orally solely a solution of cyclosporin dissolved in olive oil. These results suggest that oral administration of AST-120 accelerates the absorption of orally administered cyclosporin from the gastrointestinal tract and does not affect the metabolism of cyclosporin. When a solution of cyclosporin in olive oil is administered orally, however, oral administration of AST-120 has no influence on cyclosporin absorption and does not affect the enterohepatic circulation of bile acids.

Transitional cell carcinoma of the renal pelvis with vena caval tumor thrombus

We report a case of transitional cell carcinoma of the renal pelvis with vena caval tumor thrombus. To our knowledge only 14 cases of transitional cell carcinoma of the renal pelvis protruding into the vena cava have been reported. The literature regarding these cases is reviewed, and the differential diagnosis of this tumor from renal cell carcinoma is discussed.

[Clinical study of radiation pneumonitis over 10 years]

We studied clinical aspects of radiation pneumonitis from 1983 to 1992. Fifty seven patients admitted to our hospital because of lung cancer were treated with radiotherapy, and radiation pneumonitis developed in 20 (35.1%). The incidence of radiation pneumonitis was closely related to male sex, chronic obstructive lung disease, and chemotherapy. Pneumonitis was not related to age, or to the area or amount of radiation. Eighteen cases (90%) of pneumonitis occurred during or within one month after radiotherapy. In all but five cases (25%), pneumonitis was limited to the area of radiation. Treatment was mainly with steroids. In 4 cases (20%), pneumonitis recurred when steroid therapy was reduced, and five patients (10%) died.

[Decrease of nosocomial bacteremia and nosocomial pneumonia after introduction of preventive measures of hospital infection]

In the early 1980's methicillin-resistant staphylococcus aureus (MRSA) was reported as a major pathogenic organism of geriatric hospital infection in Japan. At the same time in the A geriatric hospital MRSA infection was prevalent. To decrease nosocomial infections some active preventive measures against hospital infection were taken since Oct. 1991. About a year before introduction of prevention of hospital infection in the geriatric ward (190 beds) of A hospital 193 episodes of nosocomial bacteremia were observed. However a year after introduction of preventive measures episodes of nosocomial bacteremia were decreased to less than a half (45.6%) in comparison to the number before introduction of prevention. As a causative organism gram-positive bacteria including MRSA were markedly decreased. Major portals of entry of bacteremia (74.9%) were urinary-tract system, intravenous hyperalimentation (IVH) catheter, and pressure sores. MRSA-positive pressure sores were decreased to 20.4% of those before prevention. On the other hand 87 episodes of nosocomial pneumonia were observed before prevention. However a year after introduction of preventive measures episodes of nosocomial pneumonia were decreased to less than a half (44.8%) in comparison to the number before introduction of prevention. After prevention MRSA and mixed infection of P. aeruginosa and MRSA were markedly decreased. The decrease of bacteremia and nosocomial pneumonia were caused by cleaning hands, the preventive measures for decrease and improvement of pressure sores, cleaning the upper respiratory tract for prevention of lower respiratory-tract infection cleaning floors and education of the staff, etc.

A case of adenocarcinoma arising within a urethral diverticulum diagnosed only by the surgical specimen

We report an extremely rare case of a 50-year-old woman with an adenocarcinoma arising within a urethral diverticulum. She could not be diagnosed correctly before operation and the microscopic pathological examination of the surgical specimen was the only indication showing the cancer origin.

Determination of the distance between the laryngoscope blade and the upper incisors during direct laryngoscopy: comparisons of a curved, an angulated straight, and two straight blades

We compared visibility and dental complications from a variety of blades during tracheal intubation. Ninety-eight patients who received tracheal intubation were enrolled. They were divided into two groups: Study 1 (n = 50) and Study 2 (n = 48). Four laryngoscopic evaluations were planned for each patient using Miller and Wisconsin straight blades with different heel heights, a Macintosh curved blade, and a Belscope angulated straight blade (Study 1: Miller No. 3, Wisconsin No. 3, Macintosh No. 4, and Belscope medium; and Study 2: Miller No. 2, Wisconsin No. 2, Macintosh No. 3, and Belscope medium, respectively). All laryngoscopies were performed by the same anesthesiologist. The distance between the blade and the upper central incisors was measured when the optimum visibility of the glottis was obtained. The visibility was determined according to the Cormack and Lehane grading. Analysis of the distance between the blade and upper incisors was performed using the results of the 44 patients (166 distances) in Study 1 and the 48 patients (181 distances) in Study 2 who had a visibility of two or better. The Belscope blade provided a significantly greater visual field than the other types of blade. Two patients sustained a fracture of the central incisor and subluxation of the central incisor, respectively, during laryngoscopy in which a Wisconsin blade was used. The average incidence of dental injury was 1/191. The Belscope blade may contribute to a reduced likelihood of upper dental injuries during laryngoscopy.

Predictive factors for the histologic nature of residual tumor mass after chemotherapy in patients with advanced testicular cancer

OBJECTIVES

To further improve the accuracy of the prediction of histologic findings in the residual mass after chemotherapy in patients with metastatic germ cell tumors, various predictive factors were investigated.

METHODS

A total of 23 patients with advanced testicular cancer underwent combination chemotherapy based on cisplatin following surgical removal of residual tumor mass in 20 patients and observation in 3.

RESULTS

Complete fibrosis and/or necrosis was found in 6 (30%) operative specimens, teratoma in 3 (15%), and viable malignant tumor in 11 (55%). Three patients had no evidence of disease for a mean follow-up of 45 months. Five of the 6 patients and all of the 11 patients' results could be predicted by a combination of 4 factors, including absence of teratomatous element in the primary tumor, greater than 85% tumor reduction rate after chemotherapy, normal alpha-fetoprotein and beta-subunit of human chorionic gonadotropin levels after chemotherapy, and actual half-life of alpha-fetoprotein less than 7 days. Among these factors the tumor reduction rate and the actual half-life of alpha-fetoprotein were the most important predictions statistically on multivariate analysis. With the use of these criteria, the sensitivity rate, specificity rate, and overall predictive value of diagnosis for existence of viable malignant tumors were 83.3%, 100%, and 94.1%, respectively.

CONCLUSIONS

By determining these factors it seems possible to avoid surgical removal of the postchemotherapy residual mass in approximately 30% of patients with advanced metastatic testicular cancer.

A "bubble-tip" (Airguide) tracheal tube system: its effects on incidence of epistaxis and ease of tube advancement in the subglottic region during nasotracheal intubation

Epistaxis and tubal obstruction in the subglottic region are difficulties encountered during nasotracheal intubation. Trauma to the nasal airway must be avoided, especially in patients receiving anticoagulant therapy. In addition, smooth passage of the tracheal tube through the larynx is desired. The tip of an Airguide tracheal tube system has a soft, round, glossy balloon head which should be less traumatic to the nasal mucosa than other more commonly used tubes. We, therefore, determined whether the Airguide reduces the incidence of epistaxis and increases smooth passage of the tracheal tube in the subglottic region during nasotracheal intubation. Sixty-six patients were divided into two groups, Airguide (n = 39) and Standard (n = 27). Each group was divided into two subgroups, topical epinephrine application as a mucosal decongestant and non-epinephrine. The incidences of epistaxis and smooth passage were compared between the two groups. The Airguide group had a significantly lower incidence of epistaxis (9/39 vs 13/26; P < 0.05; bleeding was not checked in one patient in the Standard group) and provided a significantly smoother passage in the subglottic region than the Standard group (tube impingement in the subglottic region, 0/39 vs 11/27; P < 0.01). There was no significant difference in the incidence of epistaxis between the subgroups with and without topical application of epinephrine. The Airguide helps to minimize epistaxis and increases navigability in the subglottic region during nasotracheal intubation.

[Clinical study of sonography and percutaneous nephrostomy in pyonephrosis]

Sonography and percutaneous nephrostomy (PNS) were performed on 16 patients with pyonephrosis and the following results were obtained. Sonography revealed a dilated collecting system in all cases within which, however, neither debris nor gas was observed in any case, the pelvocaliceal system appeared hypoechoic in 2 cases and anechoic in 14 cases. From the clinical symptoms and the dilated collecting system demonstrated by sonography, pyonephrosis was diagnosed in 14 cases. The purulent fluid aspirated from the collecting system confirmed the diagnosis in all cases. The clinical condition was stabilized by PNS and antibacterial therapy in all cases. However, in 5 of the patients with pyrexia for more than 6 days before PNS, sepsis developed in 3 cases and pyrexia continued for more than 3 days after the treatment in 4 cases. The affected 11 kidneys showing recovery of renal function following PNS were all salvaged by elective surgery. These findings suggest that prompt diagnosis by needle aspiration is necessary, even in the absence of any sonographically characteristic findings, whenever pyonephrosis is suspected. Our experience suggests that PNS is a useful therapeutic procedure for pyonephrosis.

[Clinical studies on mycosis especially deep-seated candidiasis in blood disorder patients]

Deep-seated mycosis is prominently increasing as a terminal infection in compromised hosts with malignant blood disorders or malignant tumors. Moreover, localized candidal abscess of visual organs has recently been reported in several laboratories. We investigated the occurrence of deep-seated mycosis in 105 autopsied cases with blood disorders in our clinic from 1980 to 1987. Forty-four of those cases had died of various infections, and 80% of them were fungal infections. More than half of the fungal infections were aspergillosis. Deep-seated candidiasis was recognized in 10 cases, 6 of which were systemic candidiasis, the average duration of neutropenia below 500/mm3 was 19.7 days that of lymphopenia was 36.5 days. Two cases were complicated with GI-tract ulcer, and involved with hepatic candidiasis. On the other hand, in the 4 cases of localized candidial abscess, the duration of neutropenia was 58.5 days and that of lymphopenia was 28.8 days. These four cases were complicated with GI-tract ulcer. Histologically, Candida spp. were recognized at the bottom of the ulcer and invasion by inflammatory cells or tumor cells was found in the portal vein. We surmised that GI-tract ulceration is a very important complication of hepatic candidiasis or liver abscess, and the occurrence of localized candidiasis seems to depend on the duration and severity of neutropenia.

Protective effect of recombinant murine granulocyte-macrophage colony-stimulating factor against Pseudomonas aeruginosa infection in leukocytopenic mice

The effects of recombinant murine granulocyte-macrophage colony-stimulating factor (rmGM-CSF) against Pseudomonas aeruginosa infection in ICR mice were investigated. Mice were treated with cyclophosphamide (CPA) and were then injected intraperitoneally with rmGM-CSF three times daily, beginning on the day after CPA treatment, for 7 days. The number of peripheral blood leukocytes in both CPA- and rmGM-CSF-treated mice and control CPA-treated mice reached a nadir on day 4, when P. aeruginosa was injected intraperitoneally. The administration of rmGM-CSF significantly increased the proportion of survivors among mice infected with a lethal dose of P. aeruginosa. This effect was further analyzed by monitoring sequential changes in leukocyte count and bacterial growth in various organs. The number of bacteria in the peritoneal cavities, peripheral blood samples, and livers of GM-CSF-treated mice decreased to an undetectable level after a transient increase, and the number was significantly lower than that in control mice. In GM-CSF-treated mice, the neutrophil levels in peripheral blood started to increase 5 days after CPA administration and were consistently higher than those in controls. Furthermore, the neutrophils in GM-CSF-treated mice were more mature morphologically. Thus, the prophylactic effect of rmGM-CSF against P. aeruginosa infection may result from a rapid recovery of myelopoiesis and a partial enhancement of mature neutrophil function.

Effects of dietary casein and soybean protein on triglyceride turnover in rat liver

We previously found that hepatic lipogenic enzyme induction, fatty acid synthesis, and triglyceride level were markedly lower in rats fed soybean protein than in those fed casein (Iritani et al. (1986): J. Nutr., 116: 190). After labeling triglycerides with tritiated water, the effects of dietary protein on the triglyceride degradation have been investigated. After the injection of tritiated water into rats, the radioactivities of fatty acids and triglycerides reached a plateau in 1-2 days and were markedly lower in the soybean protein group than in the casein group. The decreasing rates of triglyceride radioactivities were similar between the casein and soybean protein groups. The enzyme activities in glycerolipid synthesis were similar between the groups. Therefore, the lowering effects of soybean protein on triglyceride levels appear to be ascribed to triglyceride synthesis (due to fatty acid synthesis) rather than to the degradation.

[Clinical evaluation of Cernilton in benign prostatic hypertrophy]

Twenty patients with benign prostatic hypertrophy were treated with Cernilton, 6 tablets a day for an average of 13.2 weeks. Subjective effectiveness was observed in the improvement of sense of residual urine (92%), retardation (86%), night frequency (85%), strain on urination (56%), protraction (53%) and forceless urinary stream (53%). The overall subjective effectiveness was 80% of patients, and the overall objective effectiveness was 54% of patients. Night frequency, residual urine volume and tidal urine volume were improved significantly. The overall effectiveness was 80%. No side effects were observed.