It is well known that there is a close correlation between blood viscosity and blood flow. To clarify any relationship between blood viscosity and regional cerebral blood flow (rCBF) in the elderly, we simultaneously studied both CBF with PET (positron emission tomography) and blood viscosity with viscosimeter before and after phlebotomy in the elderly with various kinds of polycythemia. These subjects consisted of five male cases of secondary polycythemia due to pulmonary fibrosis, one male case of essential erythrocytosis (average age 66.6±4.6 years old) and one female case of stress polycythemia (47 years old). Before phlebotomy an increase in blood viscosity, decrease in rCBF and regional cerebral matablic rate of oxygen (rCMRO2) were observed in all cases. After phlebotomy (total amount of 800 to 1, 000ml) blood viscosity rapidly decreased, and both rCBF and rCMRO2 tended to increase. There was a significant negative or positive correlation between CBF and blood viscosity or rCMRO2, respectively. However, no increase in cerebral oxygen transport was observed in any subject after phlebotomy. It was noted that cerebral infarction is not infrequent among elderly visitors to Kusatsu spa, which is characterized by high temperature hot spring water. From the authors' observation of 23 cases of cerebral infarction encountered during the last five years, it is noteworthy that the disease tended to occur more frequently during midnight to morning, specially 3:00 to 6:00. Thus, to clarify the pathogenetic mechanism of the cerebral infarction occurring after bathing in hot spring water, we studied the changes in blood viscosity, blood pressure and coagulation-fibrinolytic system after bathing in hot spring water. The results obtained were as follows. After bathing in hot spring water (42-47°C for 3 to 10min, at 16:00), a significant elevation of blood viscosity was observed from 4:00 to 8:00 and a significant lowering of blood pressure from 20:00 to 8:00 compared with bathing in plain water. In addition, bathing in high temperature water resulted in a decrease in tPA (tissue-typed plasminogen activator) and an increase in PAI-1 (plasminogen activator inhibitor-1). An in vitro study using human umbilical vein endothelial cell (HUVEC) revealed that a high temperature during incubation stimulates secretion of PAT-1 into the blood stream from vascular endothelial cells. From these results it is speculated that hemoconcentration, vasodilatation and inhibition of the fibrinolytic system caused due to the thermal insulation effect of hot spring water might play some role in the pathogenetic mechanism of cerebral infarction, which tends to occur from midnight to the early morning in the elderly visitors.
Endocrine Hypertension, is, in a narrow sense, defined as adrenal hypertension, including mainly pheochromocytoma, Cushing's syndrome, a syndrome of primary aldosteronism and it's related minaralocorticoid excess disorders. In memory of a great contribution to hypertensiology by the late Prof. Murakami, who was the first author to write on pheochromocytoma in Japan, this paper is dedicated to reviewing the current status of adrenal hypertension in Japan from the epidemiological viewpoint, putting emphasis upon the clinical characteristics of aged patients with adrenal hypertension. Secondly, some topics in the research field of each adrenal hypertension are briefly introduced. Thirdly, our recent data are presented, showing 11β-hydroxysteroid dehydrogenase (11β-HSD) mRNA expression in resistance vessels and decreased 11β-HSD activities in vessels in SHR which supports the hypothesis that there might exist a subtype identified as partial impairment of 11β-HSD in patients with essential hypertension.
Histopathological diffuse pallor of the cerebral white matter on myelin staining is a characteristic feature of progressive subcortical vascular encephalopathy of the Binswanger type (PSVE). However, the reason for the diffuse pallor was unclear. In a previous electron microscopic study the author reported that the number of nerve fibers per unit area of the frontal white matter was significantly less in PSVE than in the controls. The white matter pallor in PSVE is mainly related to the loss of nerve fibers there. Dementia in PSVE is probably related to the loss of nerve fibers in the cerebral white matter. The sum of the number of oligodendrocytes and astrocytes in the deep white matter in PSVE was approximately half of that in age-matched controls. The number of oligodendrocytes, which were defined as cells with small, round and solid nuclei, also decreased in PSVE being half of that in the deep white matter of the controls. These data suggest that the loss of oligodendrocytes and astrocytes plays a role in the process of nerve fibers loss in PSVE. Diffuse atherosclerotic lesions in the main stem of cerebral arteries and severe hyalinotic changes in the white matter arterioles are characteristic arterial lesions of PSVE. On the basis of severe arteriosclerosis in the cerebral arteries, it was speculated that repeated hypotension or greater variability of casual blood pressure could induce PSVE in the elderly hypertensives. To confirm the hypothesis, casual blood pressure in PSVE was retrospectively studied. During the last 7 years prior to death, neither the annual variability nor the annual mean value of systolic or of mean arterial blood pressure in PSVE was different from that in cases of atherothrombotic cerebral infarction or of hypertensive cerebral hemorrhage. The retrospective study did not support the hypothesis.
Geriatric intermediate care facilities (GICF) were started by subsidies from the Ministry of Health and Welfare in 1987 to promote the return of elderly from hospitals to their homes or nursing homes and to give support to the cared elderly and their families. This paper describes about the function of a GICF established in a rural community in Oita, Kyushu. One handred seventy four elderly users (66 males, 108 females: mean age; 81 years old) who were discharged from the GIFC between July 1990 and June 1991 were studied. The main results were as follows: 1. The reason for admission to the GIFC of 174 elderly users were cerebrovascular disease in 50 cases, bone and/or joint diseases in 63, senile dementia in 25 and other diseases in 36.2. Eighty three persons (48%) needed continuous care. 3. The activities of daily living of approximately 37% of those who needed continuous care improved to some degree. 4. Niety six users were discharged and went home, 43 were readmitted to a hospital, 32 were admitted to a nursing home, and 3 died at the GIFC. 5. The situation as of September 1991 was 70 persons (40%) at home, 12 persons in hospital, 33 persons in the GICF, 35 persons in nursing homes and 24 deaths. 6. Fifty two persons (37%) used the GICF more than twice. These findings suggested that the GICF enabled care for weak elderly persons at home.
It has been said that elderly patients generally have many diseases (polypathology) for which they consult multiple doctors and are given a wide variety of drugs by their attending doctors (polypharmacy). There is a tendency for elderly patients to buy various kinds of drugs from drug stores without medical prescriptions. However, little is known about the actual status of the numbers and kinds of drugs they take. To answer these questions, we studied 192 elderly patients who were regularly consulting the outpatient clinic of geriatric medicine at Kyoto University Hospital. Seventy nine patients (41%) were consulting other clinics of the same hospital in parallel with ours. Of these patients 81% were given some drugs at other clinics. Forty of 192 patients took a variety of OTC drugs, concerning which they did not inform their attending doctors. Among these, 24 patients took some kinds of traditional Chinese medicine. Thus, a considerable percentage of elderly patients were consulting more than one clinic and in most of these patients were given some drugs. Some of them also take, without permission, drugs other than those prescribed by attending doctors. These results led us to conclude that elderly patients should be under the strict control of a single attending doctor to avoid unexpected adverse effects.
A 70-year-old man was admitted to our hospital with pancytopenia. He was diagnosed as having MDS(RA), and therapy with subcutaneous S-CSF(100μg/day) was started. His leukocyte count increased from 800/μl to 1, 400/μl in two weeks. The dose of G-CSF was raised to 200μg/day in the third week, and leukocytes increased to 2, 00/μl. At the fifth week, intravenous EPO(6, 000U×3 times/week) was added. His leukocyte count increased to 4, 000/μl. EPO therapy was raised to 12, 000U×3 times/week at the eighth week, his leukocyte count remained at the same level. G-CSF and EPO was stopped at the eleventh week, and leukocytes decreased to the same level as before administration. Throughout the course, his platelet count and reticulocyte count did not change. G-CSF and EPO are known as the stimulators of granuriod and erythroid progenitor, respectively. However, in this case, combination therapy with G-CSF and EPO induced marked increase of granulocytes only. This was an interesting case in relation to the roles of these cytokines in the hematopoietic system.
A 65-year-old woman was admitted to our hospital on May 28, 1990, because of recurrent high fever, over 39°C, headache and general fatigue. In June 1988, she suffered the first episode of high fever, headache and general fatigue. Since then, those symptoms attacked her recurrently at intervals of 7 to 10 days. She was admitted to a hospital for two months in 1988. However, the etiology was unclear and treatment, including antibiotics, was not effective. After admission to our hospital, the symptoms of high fever, headache and general fatigue developed suddenly, lasted for 2 to 4 days, then disappeared spontaneously. These symptoms recurred periodically at intervals of 7 to 10 days. Findings of lumbar puncture during the period with severe symptoms revealed a leukocytic pleocytosis (polymorphonuclear neutrophil count: 1, 324/3mm3, mononuclear cell count: 48/3mm3, without Mollaret cells) increased protein (0.81g/l) and decreased glucose (0.28g/l). Cerebrospinal fluid (CSF) examination during the period without symptoms showed a dramatic decrease of pleocytosis (polymorphonuclear neutrophil count: 5/3mm3, mononuclear cell count: 17/3mm3, without Mollaret cells) with improved protein (0/64g/l) and glucose (0.40g/l). Various examinations revealed no evidence of infection, malignancy, collagen disease, endocrine disease or any disorders in the nervous system. Moreover, bacterial cultures of blood and CSF were negative and a brain CT scan showed no abnormal findings. We diagnosed this case as Mollaret's meningitis and gave 25mg indomethacin after every meal (75mg/day). Her symptoms was improved abruptly and the duration of symptoms shortened and symptom-free intervals became longer. After 1 month of indomethacin therapy, CSF examination during the period with symptoms showed pleocytosis (polymorphonuclear neutrophil count: 1, 412/3mm3, mononuclear ell count: 314/3mm3, without Mollaret cells), increased protein (1.08g/l) and decreased glucose (0.33g/l). On the other hand, during the period without symptoms it showed a dramatic decrease of pleocytosis (polymorphonuclear neutrophil count: 0.3mm3, mononuclear cell count: 29/3mm3, without Mollaret cells) and improved protein (0.67g/l) and glucose (0.43g/l). The findings of CSF remained slightly abnormal even after she stopped complaining of manifest symptoms. The patient was discharged from our hospital after 3 months of indomethacin administration. After 6 months from the start of administration of indomethacin, her symptoms disappeared completely. After 9 months, we reduced the dose of indomethacin from 75mg (t.i.d.) to 50mg (b.i.d.). Notwithstanding the reduction of the drug, she developed no symptoms. She visits our out-patient clinics every two weeks with no obvious complaints. Recurrent aseptic meningitis attacks 130 times during 33 months and the remarkable effectiveness of indomethacin amdinistration are characteristic of this case. Indomethacin could inhibit periodic abnormal generation of eicosanoid in the brain, because indomethacin inhibits the activity of cyclooxygenase in hypothalamus neurons, reducing fever. Indomethacin appears to be a useful drug for Mollaret's meningitis.