Novalvular (nonrheumatic) atrial fibrillation (NVAF) is the most common cardiac condition associated with presumed embolic stroke, accounting for approximately half of the cardiogenic embolic infarctions. Of autopsied stroke patients in the Tokyo Metropolitan Geriatric Hospital, cerebral infarction was found in 75%, intracranial hemorrhage in 19%, and coexisting cerebral hemorrhage and cerebral infarction in 6%. Twenty-eight percent of the cerebral infarctions were embolic infarctions of cardiac origin, 56% of which were caused by NVAF. The incidence of cardiogenic brain embolism ranged from 6 to 23% of the ischemic strokes, and NVAF is the most frequent substrate for brain embolism. Atrial fibrillation increases in its incidence with increasing age. Chronic AF was observed in 10%, and paroxysmal AF in 7% of the autopsied elderly patients. Most of them were nonrheumatic AF. Twenty-two percent of the AF patients had large cerebral infarction, and 15% had medium-sized cortical infarction at the autopsy. NVAF is a very important cause of fatal massive cerebral infarction in the elderly. Of 56 patients with fatal massive cerebral infarction who died within 2 weeks after the strokes, 25 (45%) had embolic stroke associated with NVAF. Anticoagulant therapy prevents recurrent cerebral embolism of cardiac origin. The proper time to initiate anticoagulant therapy following cardiac brain embolism is controversial. Immediate initiation of anticoagulant therapy can reduce the early recurrence, but can result in secondary brain hemorrhage or hemorrhatic transformation. Patients with NVAF may have a lower risk of recurrence during the first 2 to 4 weeks following the initial embolic stroke compared with other cardioembolic sources. Cerebral embolism with NVAF can recur during a long period. Long-term anticoagulant therapy (warfarin) prevented recurrent embolic brain infarction with a very low incidence of major hemorrhagic complications in elderly patients with NVAF. It appears that warfarin can be given safely in elderly patients over a long period, provided that adequate anticoagulation is maintained. Long-term anticoagulation is also standard therapy for the primary prevention of embolism in patients with AF who have rheumatic mitral stenosis or prosthetic valves. However, the role of anticoagulation for patients with NVAF has been uncertain. Recently, the results of three prospective randomized trials that examined the benefits of warfarin or aspirin for stroke prophylaxis (primary prevention) in patients with NVAF were reported. All three studies revealed a significant reduction in the stroke rate for patients treated with warfarin and a small incidence of major hemorrhagic complications. The role of aspirin for stroke prevention in NVAF is less clear, AFASAK study indicated no benefit of aspirin therapy, while SPAF study showed a reduction of stroke
Systemic hemodynamics and renal blood flow (RBF) were studied before and during isometric exercise (IE) in 48 hypertensive patients. Of the 48 hypertensives, 21 were unmedicated and the remaining 27 patients were given one of the following drugs for 3 days prior to the study: 15 patients were treated with Enalapril (5mg/day) and 12 patients were treated with Bunazosin (2mg/day). Cardiac output (CO) and RBF were measured simultaneously with two different thermodilutional catheters. To elucidate the influence of aging on the renovascular response to IE, each group was divided into younger (age>50) and older (age≥50) subgroups. RBF decreased and calculated renovascular resistance (RVR) increased significantly during IE in the unmedicated group, but showed no difference in the degree of changes in these parameters between the younger and older subgroups. In the Bunazosin group, RBF and RVR did not change during exercise in either subgroups. In the Enalapril group, RBF did not change in either subgroup, and RVR increased significantly in the younger subgroup, but was unchanged in the older subgroup. There was a negative linear relationship between ΔRVRI (change of RVR corrected by body surface area) and age (y=-0.15x+9.7, r=-0.59: p<0.05). Plasma norepinephrine increased after IE, but these changes were not significant in all 3 groups. These data suggest that the enhanced renovascular contractility during IE is accomplished mainly through α1-adrenoceptor, and the responsiveness of α1-adrenoceptor may decrease with age. The intrarenal or vascular renin-angiotensin system may partially influence the renovascular contractility, and the degree of modification on it may increase with age.
The event-related potential (ERP) and visual evoked potential (VEP) were recorded in 28 patients with Parkinson's disease (PD) and 28 normal subjects. Nine of the PD patients had dementia and 19 did not. Dementia was evaluated according to the criteria for dementia assigned by the DSM III-R, and mental faculties were estimated using the Mini-Mental State Examination (MMSE). ERP was recorded during auditory discriminative tasks. The latencies of N100, P200, N200 and P300 from the Pz region were measured. VEP was recorded during pattern reversal stimulation. The latency of P100 was measured for each eye stimulated. PD patients with dementia showed significant prolongation of the N200 and P300 latencies of ERP and of the P100 latency of VEP compared with the values in normal subjects and in PD patients without dementia. There was a significant correlation between the N200 latency of ERP and the P100 latency of VEP in PD patients with dementia. The findings indicate that the N200 and P300 latencies of ERP are related to cognitive information processing and also suggest that dysfunction in the central visual system plays a role in abnormal pattern VEP in patients with dementia. Furthermore, the disturbance of early sensory processing in response to visual stimuli may roughly parallel the impairment of cognitive information processing in terms of ERP in PD patients with dementia.
Blood flow patterns in the superior vena cava (SVC) obtained from 20 elderly cases of COPD (aged 60-81) were compared with those from 24 elderly normal subjects (aged 61-80). The peak flow velocity and duration of two major antegrade flows during systole and diastole (S & D wave) were both qualitatively and quantitatively assessed with pulsed Doppler echocardiography. While peak flow velocity and duration of the S and D waves increased during inspiration and decreased during expiration in normal subjects, respiratory variations of these antegrade waves were extremely greater in patients with COPD with augmented and/or fused antegrade waves during inspiration, and there decrease was associated with an upward shift above the zero level during expiration. The duration of the D wave was significantly longer in COPD patients than in normal subjects and also revealed a significantly positive correlation with FEV1.0%. These findings suggest that SVC flow pattern is useful for the assessment of early right ventricular dysfunction in patients with COPD, but further clinical studies are required to confirm this thesis.
The first choice for the treatment of gastric cancer is surgery. Presently, endoscopic therapy offers the possibility of cure for some types of early gastric cancer, especially among aged or poor surgical risk patients and has obtained excellent results. During the past 13 years and 6 months from April 1978 to September 1991, 55 lesions in 52 patients aged over 75 years old were treated by endoscopic therapy. During this same period, 57 patients aged over 75 years old were surgically treated for early gastric cancer. In this study we evaluated the efficacy of endoscopic therapy for the treatment of early gastric cancer, and furthermore we compared endoscopic therapy with surgery in relation to prognosis, complications and quality of life. The analysis of endoscopic treatment showed that in 72.7% of our cases local cure was obtained. Generally, early gastric cancers less than 20mm, of well differentiated type, restricted to the mucosa and without ulceration are suitable for endoscopic therapy. Local cure could be achieved in more than 90% of these cases. Among the 52 patients treated by endoscopic therapy, there were residual lesions after treatment in in 4 patients. They died of advanced disease or metastatic liver tumor. These patients were poor surgical risks and for this reason surgery was contraindicated. Analysis by the Kaplan-Meier method showed that in comparison with conventional surgery, endoscopic therapy showed better results in the first two years of follow up and almost the same results after three years. Our study therefore suggests that for the treatment of early gastric cancer in patients aged over 75, endoscopic therapy should be considered as the first method of choice.
To evaluate whether hemostatic abnormalities contribute to the increased risk of stroke, the authors prospectively studied the hemostatic markers (HM) (β-TG, PF4, FPA, TAT, PIC, D-dimer) in 34 elderly patients with atrial fibrillation (Af) without a history of stroke (mean age 79.2) and 14 age-matched controls. In the Af group FPA was significantly higher than in the control group (p<0.05). Among them, 8 patients showed a similar abnormal HM pattern as in cardioembolic is chemic stroke and in these, 4/8 patients had valvular disease (VD), 2/8 had hypertension (HT), 2/8 had congestive heart failure (CHF), 1/8 had diabetes mellitus (DM) and 1/8 had hyperlipidemia (HL). Eight patients showed the same abnormal HM pattern as atherothrombotic is chemic stroke and of these, 2/8 had HT as complications. Five patients showed combination of a HM abnormal pattern, that was observed in cardioembolic and atherothromboic ischemic stroke. The other 13 patients showed a normal HM pattern, were in these patients, 4/13 had HT, 1/13 had DM, 1/13 had VD, and 1/13 had CHF. The patients with VD complication tended to have embolic HM abnormality. Contrary to previous reports, nonvalvular Af patients do not necessarily tend to have high risk of cardioembolic stroke. Our data suggest difficulties in clinical diagnosis among Af patients with ischemic stroke whether it is cardio embolic or atherothrombotic.
An 81-year-old female patient with an 8-year history of Parkinson's disease was hospitalized because of aspiration pneumonia. The clinical course of her pneumonia was prolonged because of dysphagia with a short period of remission, and she required a long period of bed rest. She received supportive nutrition via a nasogastric tube and many peroral medications that consisted of 3 anti-Parkinsonian drugs and 5 anti-bacterial or anti-tussive agents. Six months after admission, she vomited fresh blood through the nasogastric tube, then went into hypovolemic shock. Hemodynamic stability was temporarily achieved by blood transfusion. Gastroduodenal endoscopic examination could not reveal the exact bleeding site because of massive blood clots. Five days later, the patient died of a massive hematemesis. Autopsy revealed 2 chronic longitudinal ulcers, each 1.7×0.4cm in size, in the upper portion of the esophagus. One of them had developed a fistula to the aorta. Neither esophageal carcinoma nor a foreign body was detected around the fistula. Atherosclerosis of the aorta was mild and the perforation channel was covered with the esophageal epithelium. The fistula was assumed to be a product of local esophageal injury due to drug retention.
A 67-year-old male case of normal pressure hydrocephalus (NPH) after subarachnoid hemorrhage with orthostatic hypotension is reported. He was admitted with gait disturbance two months after a V-P shunt procedure for NPH. Because of shunt malfunction, a triad of clinical symptoms of NPH (dementia, gait disturbance and urinary incontinence) appeared and orthostatic hypotension developed. These conditions gradually worsened. After a reshunting procedure, the triad of NPH symptoms diminished and orthostatic hypotension disappeared. The same etiology that induced NPH symptoms was suspected in this orthostatic hypotension. Tension against the frontal lobes and on the walls of the third ventricle may affect the higher blood pressure regulatory apparatus of the autonomic nervous system which consisted of frontal lobe cortex, limibic system and hypothalamus.
Dietary supplement with soluble fibers was given to 3 patients with stroke and dysphagia and obtained improved defecation condition. These clinical effects of soluble fibers should reduce the burden of the patients and families. Long-term inaction of the gastrointestinal tract or continuation of supplementary diet without fibers will induce atrophic intestinal mucosa and abnormal intestinal function. The addition of dietary soluble fibers into supplementary diet can improve the atrophy of the intestinal mucosa and the decline in function of the intestine, constipation and meteorism. The serum diamine oxidase activity, which is regarded as a parameter of intestinal mucosal atrophy, increased with the improvement of constipation and meteorism after addition of dietary soluble fibers. We think that dietary soluble fibers are necessary, especially for the patients who have low diamine oxidase activity. The measurement of serum diamine oxidase activity should be an effective method to evaluate intestinal mucosal atrophy and estimate dietary fibers. We selected a supplementary diet, Enrich-SF, which contains Fibaron, a kind of soluble fiber, galactomannan purified from guar, because this canned supplementary diet has only one kind of soluble fiber. Some consider that soluble fibers are fermented to short-chain fatty acids in the intestinal tract, and improve the disordered bacterial flora in the intestine, resulting in more regular intestinal function. Attention should be paid to dietary fibers in cases of long-term tube feeding.
An electrophysiologic study was performed in a 95-year-old man with bifascicular block (right bundle branch block and left anterior hemiblock). During sinus rhythm (AA interval=980ms), every sinus beat was conducted to the ventricle. The AH interval was 130ms and HV interval was 50ms. A programmed premature atrial stimulation was performed after 8 paced beats at a slightly shorter cycle length than the sinus cycle length (900ms). As the atrial coupling interval was shortened, the H1H2 interval also shortened. At an H1H2 interval of 680ms the premature atrial beat was blocked distal to the recording site of the His potential. The block persisted up to an H1H2 interval of 560ms. AV conduction resumed paradoxically when the H1H2 interval was further shortened to intervals lasting 540-490ms. During this period the H2V2 interval was 50ms. At still shorter H1H2 intervals, H2 was again blocked. The H2V2 intervals during this phase of improved conduction were unchanged compared with those of other conducted beats. Therefore normalization due to the gap phenomenon could be ruled out, and the improved conduction could be explained by a phenomenon of supernormal conduction in the posterior division of left bundle branch.