Objective To evaluate the role of insulin resistance on coronary atherosclerosis, angiographic semiquantitative scores of coronary stenosis and calcification were evaluated. Subjects and Methods Ninety-five non-diabetic subjects with coronary arterial disease were selected from our angiographic data base. Hyperinsulinemia was defined as a serum insulin level of ≥60.4 IU/l at 120 minutes after 75 g oral glucose challenge. Results Twenty-three (24%) of the patients exhibited hyperinsulinemia. There was no difference in age or gender between the two subgroups. The incidence of hypertension, smoking habits, hypercholesterolemia, and hyperuricemia were also the same among the insulin resistance subgroups. Subjects with hyperinsulinemia had higher coronary artery scores of stenosis (11.9±5.6 vs 8.3±5.0, p<0.0001) and calcification (7.5±6.3 vs 4.8±4.9, p<0.0001). Moreover, the stenosis score had a close linear correlation with the 120 minutes serum insulin level (r=0.266, p=0.009), but not with the fasting level. Conclusion These results suggest that hyperinsulinemia is a risk for coronary arterial disease, and emphasize the severity of coronary atherosclerosis in normal glucose tolerant subjects.
(Internal Medicine 38: 691-697, 1999)

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Objective We examined the factors related to the impairment of activities of daily living (ADL). Methods ADL was evaluated by using ADL-20, which consists of 20 items from 4 major categories of activities; mobility, self-care, instrumental, and communication. The patients' gender, birth date, clinical diagnosis, past history, life styles, physical findings, laboratory data, and details of therapy were also recorded. Patients A total of 1, 163 outpatients aged 50 years or older were included. Data from 1, 093 patients were analyzed. Results We divided the subjects into two groups; Group I having full marks of ADL-20 (n=582) and group II exhibiting an impairment of ADL (n=511). Multiple logistic analysis revealed that in both sexes age and stroke were common independent factors related to the impairment of ADL. Other factors associated with impairment of ADL were smoking in men and presence of proteinuria in women. The presence of hyperlipidemia was associated with preservation of the ADL in women. Conclusion The results demonstrated significant associations of smoking in men and the presence of proteinuria in women with the impairment of ADL in elderly Japanese outpatients. There appears to be a sex difference in the risk factors of impairment of ADL.
(Internal Medicine 38: 698-704, 1999)

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Object The purpose of this study was to elucidate differences in readmission rates and late outcome in outpatients with chronic heart failure treated in different clinical settings. Patients and Methods This study included 65 consecutive patients who were admitted to our CCU due to acute heart failure for the first time and discharged from our institution. After their discharge, 31 were cared for by a cardiologist in the outpatient clinic of our institution (group A) and the other 34 were cared for by a general practitioner in a clinic (group B). The various findings during the acute phase and the follow-up period were retrospectively compared between the two groups. In addition, the incidence of unexpected readmission and prolonged outcomes were compared between the two groups. Results The patients in group B were older than those in group A, but no other differences were noted in patient characteristics. More patients in group A required more than one hospitalization within 6 months from discharge (group A, 35.5%; group B, 8.9%, p<0.01; follow-up period, 17.1±5.9 months). There was no difference in the survival rate between the groups. Conclusion We concluded that stabilized outpatients should receive comprehensive care from a general practitioner to avoid the need for readmission after discharge.
(Internal Medicine 38: 705-709, 1999)

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Object We conducted a prospective study to determine whether or not combined emergency percutaneous cardiopulmonary support (PCPS) and coronary reperfusion treatment are useful for acute myocardial infarction (MI) patients with unsynchronized electric shock-resistive ventricular fibrillation (VF). Patients and Methods Thirty-two acute MI patients who lapsed into the refractory VF were entered into the study. Group 1 consisted of 19 patients with VF outside the hospital, and Group 2 consisted of 13 patients with VF immediately after arrival at the hospital. The primary endpoint was successful reperfusion, return of spontaneous circulation and good recovery without neurologic disability. Results The infarct-related arteries showed a significant difference between Groups 1 and 2. However, the two groups had similar rates of successful reperfusion (84.6% vs 94.7%, respectively) and return of spontaneous circulation (89.5% vs 84.6%, respectively). The rates of good recovery were similarly low in both groups (5.3% vs 15.4%, respectively). Conclusion Combined emergency PCPS and reperfusion treatment produced high return of spontaneous circulation, however the neurologic outcome was low.
(Internal Medicine 38: 710-716, 1999)

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Object Previously, we reported the efficacy of pentoxifylline (PTX) treatment in human T-lymphotropic virus type I (HTLV-I)-associated myelopathy (HAM). Here, we clarify the relationship between the clinical efficacy of PTX treatment and elevation of T helper type 2 (Th2) cytokine levels in HAM patients. Patients and methods PTX (300mg) was administered daily by the oral route to 12 HAM patients for 4 weeks. We assessed the relationship between the changes in neurological status (motor disability scores, the degree of spasticity on neurological examination, and the time required to walk 10 m) and the changes in serum and cerebrospinal fluid (CSF) levels of interferon-γ (IFN-γ) as a Thl cytokine and interleukin-4 and -10 (IL-4 and -10) as Th2 cytokines measured by an EASIA (enzyme-amplified sensitivity immunoassay) kit. Results PTX treatment induced incremental increases in the levels of IL-4 and IL-10 in both sera and CSF of 6 HAM patients. Clinical improvement was associated with this elevation in IL-4 and IL-10. PTX treatment also induced a decrease in IFN-γ levels in the sera of 6 HAM patients, but this was not correlated with clinical improvement. Conclusion These results suggest that the correction of the immunological imbalance in Thl to Th2 cytokine responses, with upregulation of IL-4 and IL-10, may account for the clinical improvement in HAM patients treated with PTX.
(Internal Medicine 38: 717-721, 1999)

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Object X-linked agammaglobulinemia (XLA) is one of the most common humoral immunodeficiencies characterized from childhood by the absence of peripheral B lymphocytes, reduced levels of serum immunoglobulins and recurrent and severe bacterial infections. These characteristics are the result of Bruton's tyrosine kinase (Btk) protein deficiency in peripheral B lymphocytes. In addition to typical XLA, several atypical cases have been recognized, who exhibited mild or even no clinical symptoms, although they were definitely deficient in Btk protein (atypical XLA). In these patients peripheral B lymphocytes and serum immunoglobulins (Igs) are detectable though at a lower level than in normal people. To clarify the discrepancies between the Btk gene mutations and the phenotypes more atypical patients should be examined. In this study we evaluated the cytoplasmic Btk protein in peripheral monocytes of some hypogammaglobulinemia adults by means of flowcytometric analysis. Materials and Methods Heparinized venous blood samples were collected from some hypogammaglobulinemia adults. Mononuclear cells were separated from their blood and first reacted with a phycoerythrin-labeled CD14 monoclonal antibody (MoAb) (staining of monocyte membrane). Next, the cells were fixed and permeabilized. And then these permeabilized cells were reacted with an anti-Btk MoAb (staining of cytoplasmic Btk protein) and incubated with a FITC-conjugated goat antimouse IgGl. The double-stained cells were analyzed on a flowcytometer. Results and Conclusion By means of flowcytometric analysis we diagnosed three hypogammaglobulinemia adults as XLA, who did not show typical clinical progress of XLA. Advancements in diagnostic methods has facilitated a prompt and definite diagnosis of this disease.
(Internal Medicine 38: 722-725, 1999)

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Spontaneous hemothorax in a 20-year-old boy was caused by rupture of an immature teratoma of the mediastinum. The tumor bled spontaneously into the right pleural space. This life-threatening complication necessitated emergency surgery. The unusual cause and the interesting clinical course of spontaneous hemothorax are described.
(Internal Medicine 38: 726-728, 1999)

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In systemic lupus erythematosus (SLE), peripheral neuropathies are relatively uncommon and rarely present as the initial symptom. We herein describe a 61-year-old woman who developed a sudden onset of drop foot, which was indistinguishable from Guillain-Barré syndrome based on the clinical symptoms alone. Antibodies against ganglioside GM1 were detected in the serum, while no antibodies to Campylobacter jejuni were observed. An electrophysiological study showed axonal impairment rather than demyelination. A pathological examination of a sural nerve biopsy specimen and further laboratory examinations suggested the observed peripheral neuropathies to have arisen due to lupus vasculitis. The serological activities of SLE responded well to treatment with corticosteroids, mizoribine and immunoadsorption therapies, however, the drop foot symptoms did not change remarkably.
(Internal Medicine 38: 729-732, 1999)

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Interstitial pneumonitis (IP) is a serious complication in polymyositis/dermatomyositis (PM/DM), leading to significant morbidity or mortality. Here, we report the successful treatment by pulse intravenous administration of Cyclophosphamide in the early course of lung involvement in PM, and with subsequent low-dosage oral administration of azathioprine in a patient with steroid-resistant IP associated with PM/DM. Although the precise pharmacological mechanism induced by Cyclophosphamide in this disease remains unclear, such a cytotoxic drug raises the possibility of control of steroid-resistant PM/DM-associated IP when used in the early course of IP.
(Internal Medicine 38: 733-738, 1999)

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Polyangiitis overlap syndrome is a new disease entity and the reported cases in the literature are still limited. We describe a female patient presenting with finger ulcers, skin eruptions, pleural effusion, interstitial pneumonia and eosinophilia. Skin biopsy showed systemic small-sized angiitis and thrombosis. She was diagnosed as having polyangiitis overlap syndrome and was successfully then treated with corticosteroid. It is also of interest that the disease activity was correlated with the number of eosinophils in peripheral blood. The measurement of the serum level of major basic protein released from eosinophils functioning as a coagulant indicated the possible association of eosinophilia with thrombosis and polyangiitis.
(Internal Medicine 38: 739-743, 1999)

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We compared the usefulness of a polymerase chain reaction (PCR) assay for the early diagnosis of invasive pulmonary aspergillosis with the serodiagnosis of sufficient concentrations of galactomannan using the same serum samples. A patient was treated with prednisolone for the management of hepatitis. Computed tomography (CT) scan of the chest showed the nodular shadow with a cavity containing a clear fungus ball. DNA of Aspergillus spp. from a serum sample was detected and using the same serum sample, both latex agglutination and sandwich enzyme-linked immunosorbent assay (ELISA) of galactomannan were negative. PCR assay provides an early diagnosis of invasive pulmonary aspergillosis compared with ELISA of galactomannan.
(Internal Medicine 38: 744-746, 1999)

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A case of a 71-year-old Japanese woman with toxic shock-like syndrome is reported. She was admitted to the hospital because of swelling of the right leg. On admission, right lower leg was erythematous and swollen with an erosive lesion. On the second day, she rapidly fell into shock. Phlegmasia cerulea dolens caused by massive iliofemoral venous thrombosis was suspected because she had a history of deep venous thrombosis. But deep venous thrombus was not detected by venography at emergent surgery for thromboembolectomy. She died 38 hours after admission despite maximal supportive therapy. Group A β-hemolytic streptococci were isolated from blood culture and soft tissue after the patient died.
(Internal Medicine 38: 747-750, 1999)

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