Efficacy and safety of dapagliflozin as a monotherapy for type 2 diabetes mellitus in Japanese patients with inadequate glycaemic control: a phase II multicentre, randomized, double-blind, placebo-controlled trial

AIM

Dapagliflozin is a selective sodium-glucose co-transporter 2 (SGLT2) inhibitor under development as a treatment for type 2 diabetes mellitus (T2DM). This study assessed the efficacy and safety of dapagliflozin monotherapy in Japanese T2DM patients with inadequate glycaemic control.

METHODS

Patients (n = 279) were randomized to receive dapagliflozin (1, 2.5, 5 or 10 mg/day) or placebo once daily for 12 weeks. The primary endpoint was change from baseline in haemoglobin A1c (HbA1c) at week 12. Secondary endpoints included change from baseline in fasting plasma glucose (FPG) and proportion of patients achieving HbA1c <7.0% at week 12.

RESULTS

Significant reductions in HbA1c were seen with all dapagliflozin doses (-0.11 to -0.44%) versus placebo (+0.37%). Reductions were also observed in FPG with dapagliflozin (-0.87 to -1.77 mmol/l [-15.61 to -31.94 mg/dl]) versus placebo (+0.62 mmol/l [+11.17 mg/dl]). No significant difference in the proportion of patients achieving HbA1c levels <7.0% was noted with dapagliflozin versus placebo. Adverse events (AEs) were more frequent with dapagliflozin (40.7-53.8%) versus placebo (38.9%) and were mostly mild/moderate in intensity. Three hypoglycaemic events were reported (1 each with placebo, dapagliflozin 2.5 mg and 10 mg). The frequency of signs and symptoms suggestive of urinary tract or genital infections was 0-3.8 and 0-1.8% respectively with dapagliflozin and 1.9 and 0% with placebo. No AEs of pyelonephritis were observed.

CONCLUSIONS

Compared with placebo, dapagliflozin significantly reduced hyperglycaemia over 12 weeks with a low risk of hypoglycaemia in Japanese T2DM patients with inadequate glycaemic control.

Common carotid intima-media thickness is predictive of all-cause and cardiovascular mortality in elderly community-dwelling people: Longitudinal Investigation for the Longevity and Aging in Hokkaido County (LILAC) study

Several cohort studies have examined the association of carotid intima-media thickness (IMT) with the risk of stroke or myocardial infarction in apparently healthy persons. We investigated the predictive value of IMT of cardiovascular mortality in elderly community-dwelling people, beyond the prediction provided by age and MMSE, assessed by means of a multivariate Cox model. Carotid IMT and plaque were evaluated bilaterally with ultrasonography in 298 people older than 75 years (120 men and 178 women, average age: 79.6 years). The LILAC study started on July 25, 2000. Consultations were repeated every year. The follow-up ended on November 30, 2004. During the mean follow-up span of 1152 days, 30 subjects (21 men and nine women) died. Nine deaths were attributable to cardiovascular causes (myocardial infarction: two men and three women; stroke: two men and two women). The age- and MMSE-adjusted relative risk (RR) and 95% confidence interval (95% CI) of developing all-cause mortality was assessed. A 0.3 mm increase in left IMT was associated with a RR of predicted 1.647 (1.075-2.524), and a similar increase in right IMT with a RR of 3.327 (1.429-7.746). For cardiovascular mortality, the corresponding RR values were 2.351 (1.029-5.372) and 2.890 (1.059-7.891), respectively. Carotid IMT assessed by ultrasonography is positively associated with an increased risk of all-cause and cardiovascular death in elderly community-dwelling people.

Depressive mood is independently related to stroke and cardiovascular events in a community

By means of a multivariate Cox model, we investigated the predictive value of a depressive mood on vascular disease risk in middle-aged community-dwelling people. In 224 people (88 men and 136 women; mean age: 56.8 +/- 11.2 years) of U town, Hokkaido (latitude: 43.45 degrees N, longitude: 141.85 degrees E), a chronoecological health watch was started in April 2001. Consultations were repeated every 3 months. Results at the November 30, 2004 follow-up are presented herein. 7-day/24-h blood pressure (BP) and heart rate (HR) monitoring started on a Thursday, with readings taken at 30-min intervals between 07:00 h and 22:00 h and at 60-min intervals between 22:00 h and 07:00 h. Data stored in the memory of the monitor (TM-2430-15, A and D company, Japan) were retrieved and analyzed on a personal computer with a commercial software for this device. Subjects were asked to answer a self-administered questionnaire inquiring about 15 items of a depression scale, at the start of study and again after 1-2 years. Subjects with a score higher by at least two points at the second versus first screening were classified as having a depressive mood. The other subjects served as the control group. The mean follow-up time was 1064 days, during which four subjects suffered an adverse vascular outcome (myocardial infarction: one man and one woman; stroke: two men). Among the variables used in the Cox proportional hazard models, a depressive mood, assessed by the Geriatric Depression Scale (GDS), as well as the MESOR of diastolic (D) BP (DBP-MESOR) and the circadian amplitude of systolic (S) BP (SBP-Amplitude) showed a statistically significant association with the occurrence of adverse vascular outcomes. The GDS score during the second but not during the first session was statistically significantly associated with the adverse vascular outcome. In univariate analyses, the relative risk (RR) of developing outcomes was predicted by a three-point increase in the GDS scale (RR = 3.088, 95% CI: 1.375-6.935, P = 0.0063). Increases of 5 mmHg in DBP-MESOR and of 3 mmHg in SBP-Amplitude were associated with RRs of 2.143 (95% CI: 1.232-3.727, P = 0.0070) and 0.700 (95% CI: 0.495-0.989, P = 0.0430), respectively. In multivariate analyses, when both the second GDS score and the DBP-MESOR were used as continuous variables in the same model, GDS remained statistically significantly associated with the occurrence of cardiovascular death. After adjustment for DBP-MESOR, a three-point increase in GDS score was associated with a RR of 2.172 (95% CI: 1.123-4.200). Monday endpoints of the 7-day profile showed a statistically significant association with adverse vascular outcomes. A 5 mmHg increase in DBP on Monday was associated with a RR of 1.576 (95% CI: 1.011-2.457, P = 0.0446). The main result of the present study is that in middle-aged community-dwelling people, a depressive mood predicted the occurrence of vascular diseases beyond the prediction provided by age, gender, ABP, lifestyle and environmental conditions, as assessed by means of a multivariate Cox model. A depressive mood, especially enhanced for 1-2 years, was associated with adverse vascular outcomes. Results herein suggest the clinical importance of repetitive assessments of a depressive mood and the need to take sufficient care of depressed subjects. Another result herein is that circadian and circaseptan characteristics of BP variability measured 7-day/24-h predicted the occurrence of vascular disease beyond the prediction provided by age, gender, depressive mood and lifestyle, as assessed by means of a multivariate Cox model. Earlier, we showed that the morning surge in BP on Mondays was statistically significantly higher compared with other weekdays. Although a direct association between the Monday surge in BP and cardiovascular events could not be demonstrated herein, it is possible that the BP surge on Monday mornings may also trigger cardiovascular events. We have shown that depressive people exhibit a more prominent circaseptan variation in SBP, DBP and the double product (DP) compared to non-depressed subjects. In view of the strong relation between depression and adverse cardiac events, studies should be done to ascertain that depression is properly diagnosed and treated. Chronodiagnosis and chronotherapy can reduce an elevated blood pressure and improve the altered variability in BP and HR, thus reducing the incidence of adverse cardiac events. This recommendation stands at the basis of chronomics, focusing on prehabilitation in preference to rehabilitation, as a public service offered in several Japanese towns.

Arterial stiffness independently predicts cardiovascular events in an elderly community — Longitudinal Investigation for the Longevity and Aging in Hokkaido County (LILAC) study

We investigated the predictive value of arterial stiffness to assess cardiovascular risk in elderly community-dwelling people by means of a multivariate Cox model. In 298 people older than 75 years (120 men and 178 women, average age: 79.6 years), brachial-ankle pulse wave velocity (baPWV) was measured between the right arm and ankle in a supine position. The LILAC study started on July 25, 2000, consultation was repeated yearly, and the last follow-up ended on November 30, 2004. During this follow-up span of 1227 days, there were nine cardiovascular deaths, the cause of death being myocardial infarction for two men and three women or stroke for two men and two women. In Cox proportional hazard models, baPWV as well as age, Mini-Mental State Examination (MMSE), Hasegawa Dementia Scale Revised (HDSR) and the low-frequency/high-frequency (LF/HF) ratio showed a statistically significant association with the occurrence of cardiovascular death. A two-point increase in MMSE and HDSR score significantly protected against cardiovascular death, the relative risk (RR) being 0.776 (P = 0.0369) and 0.753 (P = 0.0029), respectively. The LF/HF ratio also was significant (P = 0.025), but the other indices of HRV were not. After adjustment for age and HDSR, a 200 cm/s increase in baPWV was associated with a 30.2% increase in risk (RR = 1.302, 95% CI: 1.110-1.525), and a 500 cm/s increase in baPWV with a 93.3% increase in risk (RR = 1.933, 95% CI: 1.300-2.874, P = 0.0011), whereas the LF/HF ratio was no longer associated with a statistically significant increase in cardiovascular mortality. In elderly community-dwelling people, arterial stiffness measured by means of baPWV predicted the occurrence of cardiovascular death beyond the prediction provided by age, gender, blood pressure and cognitive functions. baPWV should be added to the cardiovascular assessment in various clinical settings, including field medical surveys and preventive screening. The early detection of risk by chronomics allows the timely institution of prophylactic measures, thereby shifting the focus from rehabilitation to prehabilitation medicine, as a public service to several Japanese towns.

Fractal analysis of heart rate variability and mortality in elderly community-dwelling people — Longitudinal Investigation for the Longevity and Aging in Hokkaido County (LILAC) study

AIM

Fractal analysis of heart rate (HR) variability (HRV) has been used as a new approach to evaluate the risk of mortality in various patient groups. Aim of this study is to examine the prognostic power of detrended fluctuation analysis (DFA) and traditional time- and frequency-domain analyses of HR dynamics as predictors of mortality among elderly people in a community.

METHODS

We examined 298 people older than 75 years (average age: 79.6 years) and 1-h ambulatory ECG was monitored. During the last 10 min, deep respiration (6-s expiration and 4-s inspiration) was repeated six times in a supine position. Time-domain and frequency-domain measures were determined by the maximum entropy method. Scaling exponents of short-term (<11 beats, alpha 1) and longer-term (>11 beats, alpha 2) were determined by the DFA method. Six estimates, obtained from 10-min segments, were averaged to derive mean values for the entire recording span. These average values were denoted Alpha 1 and Alpha 2, estimates obtained during the first 10-min segment Alpha 1 S and Alpha 2 S, and those during the last 10-min segment Alpha 1E and Alpha 2E, respectively. The LILAC study started on July 25, 2000 and ended on November 30, 2004. We used Cox regression analysis to calculate relative risk (RR) and 95% confidence interval (CI) for all-cause mortality. Significance was considered at a value of P < 0.05.

RESULTS

Gender, age and Alpha 2E showed a statistically significant association with all-cause mortality. In univariate analyses, gender was significantly associated with all-cause mortality, being associated with a RR of 3.59 (P = 0.00136). Age also significantly predicted all-cause mortality and a 5-year increase in age was associated with a RR of 1.49 (P = 0.01809). The RR of developing all-cause mortality predicted by a 0.2-unit increase in Alpha 2E was 0.58 (P = 0.00390). Other indices of fractal analysis of HRV did not have predictive value. In multivariate analyses, when both Alpha 2E and gender were used as continuous variables in the same model, Alpha 2E remained significantly associated with the occurrence of all-cause mortality (P = 0.02999). After adjustment for both gender and age, a 0.2-unit increase in Alpha 2E was associated with a RR of 0.61 (95% CI: 0.42-0.90, p = 0.01151).

CONCLUSION

An intermediate-term fractal-like scaling exponent of RR intervals was a better predictor of death than the traditional measures of HR variability in elderly community-dwelling people. It is noteworthy that the longer-term (alpha 2) rather than the short-term fractal component (alpha 1) showed predictive value for all-cause mortality, which suggests that an increase in the randomness of intermediate-term HR behavior may be a specific marker of neurohumoral and sympathetic activation and therefore may also be associated with an increased risk of mortality.

Positive impact of social intervention on disturbed neurobehavioral function in an elderly community-dwelling population: Longitudinal investigation for longevity and aging in Hokkaido county (LILAC)

Several kinds of health consultation and rehabilitation for functional disorders aimed at stroke prevention and maintenance of cognitive function in an elderly population in Hokkaido county, Japan. Changes in cardiovascular and neurobehavioral endpoints between 2000 and 2002 were assessed in 72 of 115 subjects over 75 years of age. Direct social intervention, including lifestyle modification can have a positive impact, notably on subjects with cardiovascular disorders.

Graded response of heart rate variability, associated with an alteration of geomagnetic activity in a subarctic area

It is becoming recognized that geomagnetic activity may influence biological processes, including the incidence of various human diseases. There is evidence that heart rate variability (HRV) may serve not only as an index of autonomic coordination of the circulation, but also as a powerful predictor of risk in apparently healthy subjects. This study focuses on the effects of geomagnetic disturbance on HRV, by comparing different indices of HRV of young, healthy men living in a subarctic area on days of low (Ap; 0-7), middle (Ap; 7-20), and high (Ap; 20-45) geomagnetic activity. The effect of geomagnetic disturbance on HRV is examined on the basis of 7-day records by Holter ECG, obtained longitudinally on 5 clinically healthy men, 21-31 years of age, in Alta, Norway (70 degree N). Frequency- and time-domain measures of HRV were analyzed for each subject on separate 24-hour spans. A graded alteration of HRV endpoints was found in association with increased geomagnetic activity. As time-domain measures of HRV, SDNNIDX and the 90% length of the Lorenz plot decreased statistically significantly on days with increased geomagnetic disturbance (p = 0.0144 and p = 0.0102, respectively). A graded decrease in frequency-domain HRV measures was also validated statistically for the total spectral power (decrease of 18.1% and 31.6% on days when 7 < Ap < 20 and 20 < Ap < 45 versus days when Ap < 7; p = 0.0013). The decrease in spectral power was mainly found at frequencies below 0.04 Hz, in the "ultra-low-frequency" (0.0001-0.003 Hz; 18.1% and 27.5% decrease, respectively; p = 0.0102) and "very-low-frequency" (0.003-0.04 Hz; 12.9% and 28.6% decrease, respectively; p = 0.0209) regions of the spectrum. The decrease in spectral power was much less pronounced around 10.5 sec ("low frequency"; N.S.) and around 3.6 sec ("high frequency"; N.S.). Evidence is provided here that HRV decreases on magnetically disturbed days, and that it does so in a dose-dependent fashion, HRV being depressed more on days when 20 < Ap < 45 than on days when 7 < Ap < 20, by comparison with days when Ap < 7. This graded response of HRV to geomagnetic activity should encourage us to search for human magnetoreceptors and for a better understanding of putative mechanisms of magnetoreception.

[Coronary artery dissection following angioplasty evaluated by fractional flow reserve: report of three cases]

Fractional flow reserve was measured in three patients with coronary artery dissection occurring after percutaneous coronary intervention. In Case 1, fractional flow reserve decreased from 0.88 to 0.73 and angiography showed coronary artery dissection 20 min after balloon angioplasty. In Case 2, angiography showed good results, but the fractional flow reserve decreased to a low value(0.69). Intravascular ultrasonography revealed dissection. In Case 3, angiography clearly showed dissection, but fractional flow reserve remained high(0.91). Stent implantation was performed in all three patients, but might not have been necessary in Case 3. Dissection with low or diminished fractional flow reserve value may cause a pressure gradient in the true lumen. Stent implantation is necessary in such cases. On the other hand, cases of dissection in which the fractional flow reserve value is maintained may also cause a pressure gradient in true lumen, but stent implantation may not be necessary. Fractional flow reserve measurements may be useful for the assessment of coronary artery dissection and evaluating the indications for stent implantation.

Brain magnetic resonance imaging in 23 patients with mucopolysaccharidoses and the effect of bone marrow transplantation

A longitudinal study of cranial magnetic resonance imaging (MRI) was carried out in 23 patients with mucopolysaccharidoses (MPS); 1 each of types IH, VI, and VII; 2 of type IS; 10 of type II; and 4 each of types IIIB and IVA. Six types of distinct abnormalities were 1) cribriform changes or spotty changes in the corpus callosum, basal ganglia, and white matter; 2) high-intensity signal in the white matter on T2-weighted image; 3) ventriculomegaly; 4) diffuse cerebral cortical atrophy; 5) spinal cord compression; and 6) megacisterna magna. The cribriform changes that corresponded to dilated perivascular spaces were found in the patients with MPS IS, II, and VI. The patchy and diffuse intensity changes were found in the patient with MPS II and IIIB, respectively. MPS IH and the severe type of MPS II showed marked ventriculomegaly. Marked cerebral atrophy was observed in all MPS IIIB patients and in the severe type of MPS II patients. Spinal cord compression was a feature usually observed in MPS IH, IVA, VI, and VII. Megacisterna magna was frequent in the patients with MPS II (6/10). In two of five patients, the therapeutic effect of bone marrow transplantation (BMT) was remarkable. Both the cribriform changes and the intensity change of the white matter in a MPS VI patient disappeared eight years after the BMT. Slight improvement of cribriform change was noted in one patient with MPS II three years after the BMT. MRS was not sufficient to estimate the accumulation of glycosaminoglycans but was useful for evaluating neuronal damages.

[Depression of serum pyridoxal levels in theophylline-related seizures]

In order to study whether a theophylline-related seizure is caused by a decrease in serum vitamin B6, serum pyridoxal (PAL) levels were measured in children with bronchial asthma treated with theophylline. The serum PAL levels of asthmatic children (n = 31) treated with theophylline were significantly lower than those of control subjects (n = 21). Moreover, we evaluated PAL levels in four subjects within twenty-four hours after a seizure with or without fever. The level was low in three of the four. These results suggest that the decrease in PAL levels caused by theophylline may lower the seizure threshold.

Effect of HSR-903, a new fluoroquinolone, on the concentration of theophylline in serum

The effect of HSR-903, a new fluoroquinolone, on the concentration of theophylline in serum in healthy male volunteers was investigated. The concentration of theophylline in serum and the urinary excretion rates of theophylline on day 5 of concomitant dosing with HSR-903 tended to increase compared to those on day 4, when theophylline was given alone; however, the urinary excretion rates of 1-methyluric acid and 3-methylxanthine on day 5 of concomitant dosing with HSR-903 tended to decrease in comparison to those on day 4, when theophylline was given alone.

Sequential MRI, SPECT and PET in respiratory syncytial virus encephalitis

We report on a 3-year-old girl with respiratory syncytial virus (RSV) encephalitis manifested by disturbance of consciousness, conjugate eye deviation, anuria, truncal ataxia and intention tremor. T2-weighted magnetic resonance imaging (MRI) showed hyperintense areas in the cerebellar cortex. No lesion was detected in the cerebral cortex, pons or spinal cord. The hyperintense areas in the cerebellar cortex diminished with recovery from the clinical manifestations and had resolved 2 months after onset. The MRI lesions in the cerebellum were considered to be due to oedema. SPECT and positron emission tomography (PET), performed 3 months after onset, disclosed areas of hypoperfusion and hypometabolism at the same sites. One year after onset, MRI showed mild atrophy of the cerebellum. Hypoperfusion on SPECT and hypometabolism on PET remained. Neuroimaging showed that ataxia and tremor in this case were the result of cerebellitis. The patient has no neurological deficit except for mild truncal ataxia. This patient is a rare example of RSV encephalitis.

Interaction of citrus juices with pranidipine, a new 1,4-dihydropyridine calcium antagonist, in healthy subjects

OBJECTIVES

The study was conducted to investigate whether oral co-administration with citrus juices significantly affects the pharmacokinetics and/or pharmacodynamics of pranidipine, a new 1,4-dihydropyridine calcium antagonist, in healthy male subjects. Grapefruit juice and orange juice, which were both commercially available, were used in this study.

METHODS

Sixteen healthy male Japanese subjects participated in this study and were divided into two groups for grapefruit juice and orange juice treatment. The study followed an open-labelled crossover design, comparing the effects of a single oral dose of 2 mg pranidipine taken together with 250 ml citrus juice or 250 ml water. Serum pharmacokinetics of pranidipine, adverse reactions, blood pressure, heart rate, 12-lead ECG, haematology, clinical chemistry and urinalysis were measured throughout the study.

RESULTS

For grapefruit juice, mean Cmax and AUC0-24 h were significantly higher than those of water (P=0.0003 and 0.0005, respectively, ANOVA) with the ratios of log transformed values being 1.50 and 1.74, respectively. There were no differences in tmax and t1/2 between the juice and water treatments. A significant increase in heart rate (P=0.0240, ANOVA with repeated measurements) was observed in the juice treatment whereas there were no significant differences in systolic and diastolic blood pressure between the two treatments. For orange juice, a small decrease in mean Cmax was observed compared with water (P=0.0218, ANOVA) with the ratio being 0.86, but there was no significant difference in AUC0-24h between the two treatments. No marked differences were observed in tmax and t1/2. Oral pranidipine administration with orange juice did not affect heart rate, systolic and diastolic blood pressures or other parameters for safety evaluation.

CONCLUSIONS

Oral co-administration with grapefruit juice and pranidipine was associated with increased bioavailability and changed the pharmacodynamics of pranidipine, particularly with regard to heart rate. Orange juice intake with pranidipine did not markedly affect the pharmacokinetics and no clinically significant changes were observed in the pharmacodynamics and safety evaluation.

[Auditory brainstem responses (ABR) in patients with Wolfram syndrome]

Auditory brainstem responses (ABR) and other evoked potentials were studied in four patients with the Wolfram syndrome. In three cases ABR was abnormal in the early stage of the disease. There was no responses or only the wave V with prolonged latency at a stimulation level of 80 dBnHL. A prolongation of the I-V interpeak latency (IPL) was also revealed at a stimulation level of 105 dBnHL. The remaining patient showed shortening of the I-V IPL. The visual evoked potentials showed prolonged peak latency in three cases, and the median nerve short latency somatosensory evoked potentials were normal in two cases. These ABR findings indicated not only sensory neuronal hearing loss but also a degenerative change in the brain stem in the Wolfram syndrome.

Assessment of vasoactive agents and vascular aging by the second derivative of photoplethysmogram waveform

To evaluate the clinical application of the second derivative of the fingertip photoplethysmogram waveform, we performed drug administration studies (study 1) and epidemiological studies (study 2). In study 1, ascending aortic pressure was recorded simultaneously with the fingertip photoplethysmogram and its second derivative in 39 patients with a mean+/-SD age of 54+/-11 years. The augmentation index was defined as the ratio of the height of the late systolic peak to that of the early systolic peak in the pulse. The second derivative consists of an a, b, c, and d wave in systole and an e wave in diastole. Ascending aortic pressure increased after injection of 2.5 microg angiotensin from 126/74 to 160/91 mm Hg and decreased after 0.3 mg sublingual nitroglycerin to 111/73 mm Hg. The d/a, the ratio of the height of the d wave to that of the a wave, decreased after angiotensin from -0.40+/-0.13 to -0.62+/-0.19 and increased after nitroglycerin to -0.25+/-0.12 (P<0.001 and P<0.001, respectively). The negative d/a increased with increases in plethysmographic and ascending aortic augmentation indices (r=0.79, P<0.001, and r=0.80, P<0.001, respectively). The negative d/a reflects the late systolic pressure augmentation in the ascending aorta and may be useful for noninvasive evaluation of the effects of vasoactive agents. In study 2, the second derivative of the plethysmogram waveform was measured in a total of 600 subjects (50 men and 50 women in each decade from the 3rd to the 8th) in our health assessment center. The b/a ratio increased with age, and c/a, d/a, and e/a ratios decreased with age. Thus, the second derivative aging index was defined as b-c-d-e/a. The second derivative wave aging index (y) increased with age (x) (r=0.80, P<0.001, y=0.023x-1.515). The second derivative aging index was higher in 126 subjects with any history of diabetes mellitus, hypertension, hypercholesterolemia, and ischemic heart disease than in age-matched subjects without such a history (-0.06+/-0.36 versus -0.22+/-0.41, P<0.01). Women had a higher aging index than men (P<0.01). The b-c-d-e/a ratio may be useful for evaluation of vascular aging and for screening of arteriosclerotic disease.

CT and MR imaging of cerebral tuberous sclerosis

Tuberous sclerosis is a heredofamilial neurocutaneous syndrome, or phakomatosis, with multisystem involvement including the brain, kidney, skin, retina, heart, lung, and bone. The brain is the most frequently affected organ in tuberous sclerosis. Brain lesions in tuberous sclerosis are of three kinds; cortical tubers, white matter abnormalities, and subependymal nodules. We review the computed tomography (CT) and magnetic resonance (MR) features of the brain lesions in patients with tuberous sclerosis. CT clearly demonstrates calcified subependymal nodules. MR imaging demonstrates more clearly cortical, and white matter lesions than CT, since MR imaging shows excellent image contrast between various normal structures and high sensitivity in detecting pathological states due to intrinsic differences in proton density and in particular, in proton relaxation times of tissues. Possible pathogenesis of this disorder is also discussed.

Comparison of lumen area after PTCA by IVUS and QCA

The coronary lumen area just after percutaneous transluminal coronary angioplasty (PTCA) was assessed by intravascular ultrasonography (IVUS) with 4.3 F cardiovascular imaging systems (CVIS) and quantitative coronary angiography (QCA) with Kontron CARDIO 500. Altogether 34 lesions were divided into two groups by IVUS findings using Nissen's circular shape factor (CSF), which was defined by the (calculated perimeter/observed perimeter), expressing lumen eccentricity. The eccentric group (CSF < or = 0.92) was 22, and concentric group (CSF > 0.92) was 12. The minimum lumen diameter by IVUS and QCA (both edge-detection and densitometric methods) correlated in both the eccentric and concentric groups. As for the lumen area, only the QCA densitometric method in the concentric group correlated with the lumen area determined by IVUS. Despite using QCA, it is almost impossible for angiography to determine the lumen area just after PTCA if an eccentric lesion with a tear or dissection had occurred.

Efficient isolation of subacute sclerosing panencephalitis virus from patient brains by reference to magnetic resonance and computed tomographic images

Subacute sclerosing panencephalitis virus has been isolated with difficulty from brains of infected patients. More strains are needed for the study of the pathogenesis of this virus. To make the isolation more efficient, we selected portions to be examined from the brains of three patients with reference to findings of repeated magnetic resonance and computed tomographic imaging. Three cell lines susceptible to measles virus field strains were used. In all three cases viruses were isolated most effectively from recent lesions and with Vero cells. Our results suggested that these imaging methods and Vero cells could be used for improvement in the efficiency of isolation of this virus from patient brains.

Subacute sclerosing panencephalitis aggravated during the intraventricular interferon administration therapy

Human lymphoblastoid interferon-alpha was given by intraventricular administration via an Ommaya reservoir to a woman who entered Jabbour stage III at the age of 25 years. The first dose was of 150,000 IU, and daily doses were gradually increased; the total dose over a 42-day period was 33,550,000 IU. The patient's neurological disability index score before this treatment was 56.3%, and 75% after interferon treatment ended. After other treatment for 6 months, the patient died. Results of the autopsy showed perivascular lymphocyte infiltration in the cerebrum and brain stem, with diffuse gliosis and demyelination. The virus was isolated from the frontal lobes, also. The interferon treatment may have been a factor in this patient's deterioration.

A case of cerebral aneurysm associated with complex partial seizures

We report a 20-month-old girl with an unruptured aneurysm of the middle cerebral artery. The initial sign was complex partial seizures. Magnetic resonance angiography showed an aneurysm of the right middle cerebral artery. Cerebral angiography confirmed the presence of a saccular aneurysm. After 3 months, the aneurysm spontaneously thrombosed without neurological deficit. The seizures were controlled by anti-convulsants. The aneurysm was probably near the focus of the complex partial seizures. This is a rare case of a childhood cerebral artery aneurysm that first manifested itself by complex partial seizures.

Ferritin, creatine kinase, and neopterin in subacute sclerosing panencephalitis

To study the disease process in the brain in subacute sclerosing panencephalitis (SSPE), sequential changes in ferritin, creatine kinase (CK), and neopterin in the cerebrospinal fluid (CSF) of two patients with SSPE were compared with the changes in the clinical signs and symptoms and the findings by magnetic resonance imaging (MRI). On the basis of changes in various substances in the CSF, especially ferritin, CK and neopterin, we concluded that the high-intensity area in MRI might be evidence of local inflammation and the resulting cell damage. Ferritin, CK and neopterin seemed to be biochemical markers in patients with SSPE for detection of the extent of lesions, and their measurement may provide information useful for evaluation of the therapeutic response.

MR imaging of the brain in patients with mucopolysaccharidosis

MR imaging of the brain was performed in eight patients with mucopolysaccharidosis (MPS). Two had MPS I S, one had MPS IIA, two had MPS IIB, two had MPS IIIB, and one had MPS VI. In the patients with MPS IIA and MPS VI, T1 and T2 were prolonged in various areas of the cerebral white matter. These findings seemed to correspond with the development of pathologic changes in MPS, such as perivascular pits in the white matter observed on slices of the fixed brain. In the patients with MPS IIA and MPS IIIB, the white matter did not show the proper signal intensity, which suggested that myelination was insufficient and that infiltration or deposition of glycosaminoglycan had occurred; this was consistent with the association of these two types with mental retardation. In the patients with MPS I S, no intracranial abnormalities were detected on MR images. MR imaging of the brain may be used to obtain a differential diagnosis of the various types of MPS, to estimate the extent of mental retardation, and to monitor the progress of this disease.

Magnetic resonance images of tuberous sclerosis. Further observations and clinical correlations

The cerebral lesions in tuberous sclerosis are of three kinds: subependymal nodules, cortical tubers, and cluster of heterotopic cells in the white matter. Understanding of these hamartomas is still incomplete even with modern imaging modalities. Magnetic resonance (MR) images of ten patients with tuberous sclerosis were reviewed and compared to computed tomographic (CT) scans and to the clinical severity of the disease. T2 weighted spin echo (TR = 1800, TE = 120) images and inversion recovery (TR = 2100, TI = 500-600, TE = 40) images were obtained at the same axial planes. Periventricular nodules were better seen, because of their calcifications, with CT than with MR imaging. They were demonstrated as iso- to low intensity depending on the amount of calcification on T2 weighted images, and as a similar intensity to the white matter on IR images. Small peripheral lesions in the hemispheres, which were only occasionally seen as small low density areas on CT scans, were well demonstrated on MR images. These foci were hyperintense on T2 weighted images, and hypointense on IR images. Exact location of these was not in the cortex, but in the subcortical white matter. The findings indicate that these foci represent the pathologically well known demyelinating foci, which are commonly present under the cortical tuber, but may be independent of them. Cortical tubers were not confidently identified, which suggested that they might have similar intensity to the cortical gray matter.(ABSTRACT TRUNCATED AT 250 WORDS)

Property of TS-16N solid state nuclear track detectors as an imaging medium for macroautoradiography of alpha-emitters in biological specimens

Feasibility of TS-16N solid state nuclear track detectors for an imaging medium of rapid autoradiography of alpha-emitters is described. Though a little longer etching time was required, the contrast of autoradiographic image on this detector proved to be superior to CR-39 detectors whose property for macroautoradiography was previously reported by the authors. The resolutions of these two different type detectors were almost equivalent to each other. The autoradiography taken by way of trial proved that this detector could be used to study metabolism and dosimetry of internally deposited alpha-emitters. With further study, the inherent properties of this detector such as low background or high sensitivity should extend the field of track etch imaging technique such as fast neutron radiography.

Efficacy of kan-baku-taiso-to (TJ-72) on breath-holding spells in children

When Kan-baku-taiso-to (TJ-72) (0.1-0.25 g/kg/day) was given to 12 children with breath-holding spells (BHS) of the cyanotic type, the attacks were lessened starting in the second week of administration. There were no side effects even when administration was continued for more than one year. We think that the drug should be given primarily for BHS when the frequency of severe attacks is high and also to patients who did not respond to other medication.

Autoradiography of alpha- and beta-emitters using a charged-particle imaging system

A newly developed charged-particle imaging system was applied to rapid measurements of the distribution of alpha- and beta-emitters. The imaging system consists of a ZnS(Ag) screen, two tapered fibers, an image intensifier, and a Polaroid film. The image obtained with the system shows very good quality, namely, a spatial resolution of more than 6 line pairs (lp)/mm and a distortion of less than 2.5%. As the system is capable of detecting each alpha-particle separately, the distribution of alpha-emitters can be quantitatively determined. The autoradiograms of the sections of mice with beta-emitters administered can be obtained with an exposure time of only 2 min compared with 2 weeks by a conventional technique.

Serial magnetic resonance imaging in subacute sclerosing panencephalitis

Magnetic resonance (MR) imaging of a 17-year-old girl with subacute sclerosing panencephalitis (SSPE) was done several times to monitor the morphological changes and clinical course of the disease by comparison with computed tomographic (CT) scans. The MR image showed lesions that corresponded to the clinical symptoms in the early stages where no abnormalities appeared on the CT scans. The MR images delineated the extent of abnormal areas more clearly than the CT scans. However, the course of neurological manifestations did not always correspond to the MR findings. Serial MR imaging was useful in the detection and observation of the stages and clinical progress of SSPE.

Age dependent change in size distribution of blood cells in fetal and young mice

The mean corpuscular volume (MCV) and the size distribution of circulating blood cells were determined in the fetal mice of C3H/He strain by using a new electric cell size analyser, Coulter Channelyzer C-256. On the 12th day of gestation, the volume of circulating blood cells was distributed between approximately 240-820 fl (mode at 470 fl), and the MCV was 534.9 +/- 30.1 fl, i. e., ten to eleven times that of adult one. On the 14th day, two types of cell population were observed; one with smaller cell volume and another with larger one corresponded to that of the blood cells on day 12. Therefore, two peaks were observed to be at 140 and 501 fl in the size distribution curve. The cell population with large volume observed on day 12-14 had been almost disappeared by the 16th day of gestation, and the small blood cells became dominant. The MCV of blood cells was then decreased with the development of fetus, from 188.2 +/- 19.3 fl on day 16, to 135.1 +/- 7.3 fl on day 18, and 117.5 +/- 7.2 fl on day 20. The size of blood cells continued to decrease gradually after birth, and became adult range by 8 weeks after birth. The MCV values of the blood cells were 120.9 +/- 8.6 fl, 87.5 +/- 6.2 fl, and 48.7 +/- 0.8 fl for the newborns of 1 day and 7 days old, and the adult mice, respectively. White blood cells were not separated from the blood samples in this study. However, the size distribution and MCV presented above were appeared to be related essentially to the red blood cells, since the number of white blood cells are negligible small compared with that of the red cells.

Pulmonary deposition and effects of inhaled silica particles after short-term exposures in the rat

The present study was designed to evaluate the pulmonary deposition and the effects of inhaled silica particles in the rat model. Wistar (W/M strain) rats were exposed to silica aerosols generated from a fluidized bed dust generator for 1 hr a day, intermittently for 6 days, using a "nose-only" inhalation chamber. After the cessation of the exposures, analysis of lavaged bronchoalveolar cells (BAC) and histological examinations of lungs and tracheobronchial lymph nodes (TBLN) were performed during a period of 6 months. Total cell yields and the proportions of alveolar macrophages (AM) in BAC were not altered, whereas the proportions of lymphocytes in BAC were significantly increased in the exposed animals. Although the proportions of silica-laden AM in BAC were gradually decreased during the 6 months, particle-laden AM were predominantly and persistently observed in the alveoli under light microscopy. Silica particles were also identified in macrophages of granulomatous nodules in pulmonary peribronchial lymphoid tissues(PBLT) and TBLN, indicating the translocation of particles via the lymph. Associated with pulmonary particle deposition, some characteristic histopathological features were evident, including thickening of alveolar duct bifurcations and lymphocyte infiltrations both in the alveolar sacs and around the interstitial blood vessels. At later months after the exposures, the alveolar interstitium was thickened with the increase of fibroblasts and collagen. These results implicate that short-term exposures of silica particles in the rat can evoke histopathologic changes in the lungs and lymphatic tissues, associated with their deposition and translocation.

Clinical disorders observed in a beagle breeding colony

Disorders in a beagle breeding colony were discussed, based on 472 clinical charts made in 1974-1983. In 201 neonates less than a week old, hypothermia associated with pneumonia was mostly seen. In 31 puppies from one week to two months old and in 46 young dogs from two months to a year old, pneumonia, canine parvovirus infection, dermal abscess and dermatosis were mostly found. In 91 dogs aged from one to five, trauma, intervertebral disc protrusion, dermal abscess, dystocia, claudication and otohematoma were frequently noted. In 103 animals over five years old, intervertebral disc protrusion, tumors, abscess, trauma and otohematoma were observed most often.

[Estimation of inhalation volume in rats]

The present study was carried out to develop the inhalation system possible to measure the respiratory volume in rats during the inhalation. The conventional body plethysmography was confirmed to be able to measure the respiratory volume of anesthetized rats accurately. Consequently, this method made it possible to measure the respiratory volume of rats during the inhalation studies by using animal restraint holders combined with the inhalation chamber as body plethysmography boxes. The practical availability of this inhalation system was proved in the inhalation studies of latex particles, in which the number of particles inhaled by each rat could be estimated by measuring the air concentration of latex particles as well as the respiratory volume of each animal.

Time-dependent changes of microscopic localization of intravenously administered colloidal carbon particles in mouse lymph nodes

Time-dependent changes of microscopic localization of intravenously administered colloidal carbon particles were studied in mouse lymph nodes. Carbon particles were preferentially trapped by postcapillary venules (PCV) immediately after injection, and migrated easily outside of PCV either through intercellular space of the PCV endothelium or by phagocytic process during the 1 hr after injection. Particles were thereafter up-taken by pericytes and macrophages around PCV during the 24 hr, and consequently distributed throughout the cortex and medulla. Finally, they migrated to the medullary lymphatic sinuses, and phagocytosed by endothelial cells. Redistribution process of particles via the lymphatic sinuses from the regional lymph was observed during 30 minutes or 10 to 14 days after injection in different lymph nodes.

Dependence on particle size in the phagocytosis of latex particles by rabbit alveolar macrophages cultured in vitro

The dependence of the phagocytosis of particulate materials on their size was studied. Rabbit alveolar macrophages (AMs) obtained by lung lavage were cultured in suspensions or monolayers with Latex particles of 1 micron or 2 microns in diameter. After culturing AMs with 10(7)(-5) X 10(9) Latex particles per ml for 15 to 360 minutes, the number of phagocytized particles in each of 100 individual cells was counted by light microscopy. In suspension culture, there was no significant difference in the average number of particles phagocytized per AM between 1 micron and 2 microns particles in the identical conditions as to the particle concentration (particle number/ml) and the incubation time. In monolayer culture, it was difficult to compare the average number of 1 micron particles phagocytized by AM with that of 2 microns ones in the identical condition as to the particle concentration, since the sedimentation velocities at which particles sank to the bottom of culture chamber were different between both particles, resulting in the difference of particle concentration around AMs. The sign of saturation was observed when the average number of phagocytized particles reached approximately 10 particles per AM in either case of suspension culture with 1 micron or 2 microns particles and approximately 45 of 1 micron and 10 of 2 microns particles in monolayer culture.

Adrenoleukodystrophy: new CT findings

Three cases of adrenoleukodystrophy are presented with sequential findings by computed tomography (CT). In two cases, CT confirmed not only the findings of several previous reports of a caudocranial direction of low-density white matter and contrast enhancement at the periphery of affected regions during the active demyelinating process, but also two other unusual features: (1) calcification in the affected white matter along the trigones of the lateral ventricles and (2) development of a mass effect during the active demyelinating period. Calcification alone without low-density white matter was the initial CT presentation in one case. Periventricular calcification may be specific for adrenoleukodystrophy in the appropriate clinical setting.