To assess the cardiac functional reserve of elderly hypertensives with left ventricular hypertrophy (LVH), we studied cardiac functions after isometric exercise and beta stimulation. Forty-two elderly hypertensives and 15 normotensives (NC group) were recruited for the study. Hypertensives were divided into 19 hypertensives with LVH (LVMI>130g/m2: H1 group) and 23 without LVH (H2 group). Echocardiographic studies were performed before and after isometric exercise (handgrip, HG) and isoproterenol administration (ISP). We measured LV mass index (LVMI), fractional shortening (FS), isovolumetric relaxation time (IRT), and the ratio of early and late diastolic transmitral flow velocity (A/E). FS at rest in the H1 group was significantly higher than in the H2 and NC groups. In the H1 group, IRT was elongated and A/E was greater than in the NC group, which indicated impaired diastolic function in the H1 group. After HG, FS in the H1 group significantly decreased while it did not change in the H2 or NC groups. FS increased in all three groups after the infusion of ISP, although the increment of FS was smaller in the H1 group. In conclusion, diastolic function was impaired whereas systolic function was supranormal at rest in the hypertrophied heart of the elderly hypertensives, and when exercise or pharmacological stress was loaded, the systolic function deteriorated, suggesting the impairment of cardiac reserve in those patients.
An active orthostatic stress test was conducted on 32 elderly patients over 65 years (elderly group) and 17 normal adults, for a comparative evaluation of their blood pressure, heart rates, and plasma catecholamine responses. In addition, 8 patients in the elderly group underwent a study of orthostatic responses with or without sublingual administration of isosorbide dinitrate (ISDN). The results of the orthostatic responses were evaluated by Schellong's method. The elderly group produced a positive reaction in one (3.1%), and a weakly positive reaction in two (6.3%), while the remaining 29 (90.6%) and all of the normal adults showed negative responses. The systolic blood pressure pattern that developed in response to rising among the elderly group was significantly different (p<0.001) from that of the normal adult group, but the response pattern seen in the heart rates of the former approximated that of the latter. The plasma norepinephrine concentration 10 minutes after rising increased significantly (p<0.001) in both the elderly and normal adult groups. This increase amounted to 1.5-fold in the elderly group and 2-fold in normal subjects, with a less prominent increase shown by the elderly. The norepinephrine levels of the elderly group were significantly higher than those of the normal adults both before and 10 minutes after rising (p<0.001 and p<0.01, respectively). In the elderly, ISDN caused a significant drop in the systolic blood pressure immediately after rising and a significant increase in the heart rate. Sublingual ISDN administration resulted in a significant increase in the norepinephrine level (p<0.05) in association with rising. These findings indicated that the circulatory responses to orthostatic stimuli are inappropriate as clinical data among the elderly and the administration of ISDN exaggerates this shortcoming further.
Transcranial Doppler method (TCD), newly developed in 1982, is ultrasound technology that measures physiologic parameters of blood flow in the major intracranial arteries. A major limitation of TCD is that, in some individuals, satisfactory recording is not possible, especially through the temporal windows. The purpose of the present study is to assess the rate of successful recording in TCD through the temporal ultrasonic windows in Japanese with special reference to aging and sex. In 423 Japanese (244 males and 179 females) aged from 25 to 93 years, measurement of blood flow velocity in basal cerebral arteries was performed by transcranial Doppler velocimenter with a 2MHz pulsed wave Doppler probe. The signal was successfully recorded in 299 of 423 Japanese (71%). In Japanese males, successful measurement was more frequent (206/244; 84%) than in Japanese females (93/179; 52%). The rate of successful recording was evaluated in every decade from the twenties to the eighties, and it was found to decrease significantly according to age (100%, 94%, 91%, 74%, 66%, 67%, and 46%, respectively). In females, it significantly decreased in those older than 50 years old (100%, 100%, 93%, 61%, 36% 43%, and 27%, respectively), but not in males (100%, 88%, 89%, 81%, 88%, 83%, and 69%, respectively). These findings suggest that this noninvasive method has clinical usefulness for evaluating intracranial circulation but has limitation for assessing the intracranial lesions of elderly Japanese women.
We studied the correlation between clinical and CT-findings in 33 cases with hemiballismus. Of these 33 cases, 4 cases were examined by the authors and 29 cases were obtained from the literature. Cerebrovascular disease was present in 27 cases and the localization of the lesion was examined with CT. Of these 10 cases had lesions in the subthalamus, while 17 cases had lesions outside the subthalamus. In 6 cases, the location of the lesion was not recognized on CT. In cases with lesions outside the subthalamus, 11 cases had lesions in the putamen, 10 cases had lesions in the caudate. Therefore the lesion were largely located in the striatum. Typical hemiballismus was seen in 16 cases. In this group, 6 cases had lesions in the subthalamus, 5 cases had lesions in the putamen, and 3 cases had lesions in the caudate. Hemiballismus accompanied by hemichorea was seen in 17 cases. In this group, while 9 cases had hemichorea with ballismus, and 5 out of 9 cases had lesions in the caudate, 4 cases had lesions in the putamen. Thus, all lesions were located in the striatum. Eight out of 17 cases had hemiballismus with chorea. In these 8 cases, 4 cases had lesions in the subthalamus, these were 2 cases in the putamen, and 2 cases had lesions in the caudate. When all cases were examined in terms of clinical manifestations, 10 cases were considered to have lesions in the caudate and 7 out of 10 cases involved chorea. Ten cases had lesions in the subtalamus, while 6 out of 10 cases showed typical hemiballismus. From these observation, typical hemiballismus was largely seen in cases with lesions in the subthalamus, while in cases which involved chorea, the lesions tended to involve the striatum, especially the caudate.
Using reverse genetic techniques, the gene responsible for familial Alzheimer's disease (FAD) is one of the clues to identify the pathogenesis of Alzheimer's disease (AD). Recently a missense mutation in the APP (amyloid precursor protein) gene (generally this mutation was called APP717) was detected in 2 Caucasian AD families and the same mutation was found in 3 Japanese AD families. We experienced brother's cases who were diagnosed as AD. Both of them and one normal person of the next generation had APP717. The first symptom of the elder brother (case 1) was forgetfulness at 52 years old, then dementia was advanced. In his clinical course there were characteristic findings such as the mirror sign, pseudodialog and jargon which has been rarely described in the Japanese literature. Finally he died of pneumonia at 57 years old. He was diagnosed as AD pathologically and physical findings of brain CT, SPECT (single photon emission computed tomography) and EEG supported this diagnosis clinically. The first symptom of the younger brother (case 2) was also forgetfulness at 45 years old, then severe dementia was advanced, at last he died of pneumonia at age 53 old. On the other hand the mother of the brothers died of severe dementia, so it was suspected that brothers died of sever dementia, so it was suspected that she had had AD. The clinical courses and pathological findings were thought to be typical of AD, namely there were no significant differences in comparison with other cases of FAD and sporadic AD. Special features included jargon clinically, in addition to free melanin granules and neuronal loss in the substantia nigra pathologically. We discussed the importance of investigation of Japanese AD families and future strategies of molecular biological analysis of FAD.
A 72-year-old male was admitted to our hospital with a 2-year history of polyuria, prosopagnosia and aphasia. He showed characteristric clinical features of Pick's disease such as stereotyped verbal output and behavior and personality changes. CT and MRI scans showed marked atrophy in the bilateral anterior temporal lobes mild atrophy of the bilateral frontal lobes. SPECT scans revealed perfusion abnormalities in corresponding areas. A 6-hour-water deprivation test resulted in decrease in the urine volume and in concentration of the urine, suggesting abnormality of his secondary drinking behavior. Polyposia resulting in polyuria as a clinical manifestation may be due to stereotypic behavior which is often seen in Pick's disease.
A 65-year-old male presented with postprandial hypoglycemic episodes. He had normal glucose tolerance, but plasma glucose reached a hypoglycemic level of 31mg/dl at 120min during 75g oral glucose tolerance test. He had markedly increased insulin response to oral glucose but not to intravenous glucose, intravenous arginine or intravenous glucagon. Hyperresponse of insulin after oral but not intravenous glucose suggested the possible involvement of insulinotropic hormonal factor in the gut (incretin) in hyperinsulinemia of this patient. Therefore we evaluated the secretory response of glucagon like peptide-1 (GLP-1), a most likely candidate for incretin, to oral and intravenous glucose administration. Plasma GLP-1 response to oral glucose was almost five times greater than that of normal subjects. On the other hand, there was no significant response in plasma GLP-1 after intravenous glucose. These results suggest that hypersecretion of GLP-1 may be responsible for the hyperinsulinemia after oral glucose in this patient.