Objectives To investigate whether the ST changes in the aVR lead on 12-lead ECG can be used to identify infarct-related artery (IRA) in patients with acute inferior myocardial infarction.
Methods The ECG features were studied in 90 patients with acute inferior myocardial infarction where IRA was confirmed by coronary angiography.
Results Right coronary artery (RCA) and the left circumflex coronary artery (LCX) were identified as IRA in 70 and 20 patients, respectively. ST depression in aVR ≥0.1 mV was found in 14 (70%) patients who had LCX as the IRA, and in 4 (5.7%, p<0.001) patients with RCA as IRA. Using ST segment depression ≥0.1mV in aVR as a criterion, the sensitivity and specificity in differentiating LCX as IRA was 70.0% and 94.3%, respectively.
Conclusions ST depression in aVR is common in patients with LCX-related acute inferior myocardial infarction. The ST changes in this lead are associated with an excellent specificity and a good sensitivity in differentiating LCX from RCA as the IRA.

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Object The estimation of serum cystatin C and its practical use for the estimation of the glomerular filtration rate (GFR) in diabetic patients has been previously demonstrated, however, those studies did not use the chronic kidney disease GFR staging. Therefore, we performed this study in type 2 diabetic patients with the aim to examine the usefulness of serum cystatin C to detect early decline of GFR using the staging of chronic kidney disease defined by the National Kidney Foundation.
Methods A total of 102 Taiwanese type 2 diabetic patients were recruited from the Chung-Shan Medical University Hospital. Morning fasting blood and urine samples were obtained for basal metabolic parameters, serum creatinine, serum cystatin C, and albumin-creatinine ratio. GFR was determined by Cockcroft-Gault equation creatinine clearance (CG-CCr).
Results Of the 102 type 2 diabetic patients, 67, 25, and 10 had normo-, micro-, and macroalbuminuria, respectively. Serum cystatin C was superior to serum creatinine in detecting early decline of GFR. The diagnostic accuracy of serum cystatin C was better than serum creatinine for stage 1 and 2 chronic kidney disease (CG-CCr cut-off value of 90 ml/min and 60 ml/min). Furthermore, serum cystatin C was also correlated with urine albumin excretion, which was not true with serum creatinine.
Conclusions These results suggest that serum cystatin C may be an alternative serum marker for the early identification of subjects with a slight reduction of renal function, and also it may be a marker for early glomerular dysfunction in type 2 diabetes.

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Background and Objective The influence of glycemic control on cardiovascular (CV) complications or survival is not clear in diabetic patients with end-stage renal disease (ESRD). Although glycohemoglobin (HbA1c) is widely used as a marker of hyperglycemia in these patients, it may be unreliable because of shortened erythrocyte lifespan. Glycated albumin (GA) is an alternative marker. We investigated the relation between these markers and development of CV complications or survival in diabetic ESRD patients.
Patients and Methods We obtained three variables as markers of glycemic control: 1) mean HbA1c levels during 1-year after initiation of dialysis (HbA1c1), 2) mean HbA1c levels during 3 months from August to October 2002 (HbA1c2), 3) GA on October 2002 (GA2) from 78 type 2 diabetic patients on chronic hemodialysis. We examined the influence of these variables on survival or development of CV diseases using the multivariate Cox proportional-hazards models until September 2006.
Results The 3-year survival rate was 73%. A total of 27 patients died, 15 from CV diseases. A total of 23 CV diseases developed in 20 patients. Neither HbA1c1nor HbA1c2 was associated with all-cause mortality, CV mortality or development of CV diseases. GA2 was also not associated with mortality. However, the higher GA2 group (GA ≥ 23.0%) had a significantly higher rate of development of CV diseases than the lower GA2 group (GA < 23.0%) (log-rank test p=0.03). The higher GA2 group was significantly associated with development of CV diseases relative to the lower GA2 group (hazard ratio 3.25, p=0.04).
Conclusion Neither HbA1c levels nor GA levels, at initiation of dialysis or on chronic dialysis, predicted mortality in diabetic ESRD patients. However, poor glycemic control as reflected by higher GA levels may be associated with the development of CV diseases. More studies are needed to clarify the beneficial effect of glycemic control in these patients.

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Object We examined the prognosis of patients with onset of new primary renal vasculitis (PRV) in Miyazaki Prefecture.
Patients and Methods We enrolled and followed-up 56 patients (age, 70.4 ± 10.9 years, mean ± SD) with onset of new PRV between January 2000 and December 2004, for a median of 24 months. Patients with PRV were defined according to the EUVAS (European Systemic Vasculitis Study Group) criteria. Outcome and factors predicting unfavorable outcome of death were examined.
Results Among the patients, 25% (n=14) required dialysis therapy immediately at the start of immunosuppressive therapy and of these, renal function recovered in only 3 and 6 died during the first admission. On the other hand, 75% (n=42) did not require immediate dialysis, but 8 patients were introduced to dialysis therapy thereafter. At the end of follow-up, 26 (46%) had survived without dialysis, 10 (18%) were dependent on dialysis and 20 (36%) had died. Infection was the major cause of death (n=11) . The Cox proportional hazards model showed that the presence of lung lesions and immediate dialysis therapy conferred poorer survival rates (HR, 3.32, 95% CI, 1.14 to 9.71; HR 2.73, 95% CI, 1.03 to 7.23, respectively).
Conclusion A poor survival rate is independently associated with the presence of lung lesions and advanced renal failure at the start of immunosuppressive therapy in patients with PRV. Half of the deaths were due to infection. Thus, PRV should be identified at an early stage and the treatment protocol should prevent infectious complications. These measures should improve the prognosis of patients with PRV.

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Objective Patients with impaired renal function or diabetes are considered to be prone to hyperkalemia. Furthermore, hyperkalemia is an adverse drug reaction of inhibitors of the renin-angiotensin system (RAS) that are established to be efficacious in these patients. However, the current status of hyperkalemia in the clinical setting remains obscure.
Methods A total of 9,117 patients treated at Toranomon Hospital between January and October 2005, who had serum creatinine levels below 5 mg/dL were studied. Patients on dialysis and patients using cation exchange resin or diuretics that lower serum potassium were excluded.
Results Serum potassium increased significantly accompanying the increase in serum creatinine, and was significantly elevated in diabetic patients compared to non-diabetic patients. Serum potassium also increased significantly with the administration of angiotensin-II receptor blockers (ARB), angiotensin-converting-enzyme inhibitors (ACEI) or beta-blockers. A combination of diabetes and RAS inhibitor administration significantly increased serum potassium compared to each factor alone in patients with a serum creatinine level below 1.5 mg/dL but not in those with a higher serum creatinine level. According to step-wise multiple regression analyses, an elevated serum creatinine level had the strongest positive correlation with the serum potassium level, followed by diabetes, ACEI use, ARB use, and age.
Conclusion Lowered renal function, diabetes, use of RAS inhibitors and old age are independent factors that increase the serum potassium level. Caution should be exercised when using RAS inhibitors in diabetic patients even if their renal function is relatively preserved. In selected patients with diabetes or impaired renal function, however, RAS inhibitors can be used without hyperkalemia.

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Object This study was undertaken to investigate the frequency of pulmonary hypertension (PH), and clinical parameters associated with PH in patients with idiopathic interstitial pneumonias (IIPs) and collagen vascular disease-associated interstitial pneumonias (CVD-IPs).
Patients and Methods Retrospective analyses were performed in 163 consecutively enrolled patients (78 IIPs and 85 CVD-IPs) who were being evaluated for PH by Doppler echocardiography. PH was defined as an estimated systolic pulmonary artery pressure (sPAP) of ≥40 mmHg. The frequency of PH was evaluated and clinical parameters were compared between patients with PH and those without PH.
Results Among patients successfully evaluated for sPAP by echocardiography, 20 of 70 (28%) patients with IIPs and 17 of 80 (21%) patients with CVD-IPs had PH. Among patients with IIP and CVD-IP, those with PH were more frequently treated with supplemental oxygen. Patients with IIP who had PH tended to be older and had decreased % diffusion capacity of carbon monoxide (%D_LCO). Additionally, in patients with IIP, sPAP was negatively correlated with %D_LCO. However, this association was not found in patients with CVD-IP. Patients with CVD-IP who had PH were predominantly male.
Conclusion PH was frequently observed in patients with both IIPs (28%) and CVD-IPs (21%) in the chronic phase of the disease. PH should be evaluated in patients with IPs who need supplemental oxygen, IIP patients with decreased diffusing capacity, and in patients with CVD-IP.

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Object Anemia and leukopenia caused by copper deficiency are well-documented consequences of long-term total parenteral nutrition. We measured the serum copper levels of bed-ridden patients receiving enteral feeding, and evaluated optical and ultrastructural features of bone marrow before and after copper supplementation.
Patients and Methods Serum samples were obtained from 15 bed-ridden elderly patients receiving tube feeding (TF) and 10 age-matched bed-ridden patients who took food orally (CO), and the copper ceruloplasmin concentration of each sample was measured. Bone marrow samples were obtained from patients who exhibited copper deficiency and leukopenia and/or anemia before and after the copper supplementation, for use in light and electron microscopic analysis.
Results The tube-fed patients had significantly lower mean serum copper and ceruloplasmin concentrations than the control patients. Seven of the 15 tube-fed patients had reduced serum copper concentrations and leukopenia. Six of those 7 patients also had anemia. Copper sulfate was administered to those 7 patients by enteral tube;their copper concentration, anemia and leukopenia improved within 1 month after they were administered copper sulfate. In the bone marrow examination before copper supplementation, light microscopy showed cytoplasmic vacuolization in both myeloid and erythroid precursors, and electron microscopy showed electron-dense deposits in mitochondria and cytoplasm of erythroid and myeloid cells. After copper supplementation, these pathological changes disappeared.
Conclusions Bicytopenia is likely to occur in tube-fed patients with copper deficiency. Copper deficiency appears to be associated with cytoplasmic vacuolization and electron-dense deposits in mitochondria in erythroid and myeloid cells.

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A 71-year-old man was admitted to our hospital with abdominal pain. Hepatocellular carcinoma (HCC) had been diagnosed 2 years earlier and he had undergone 7 courses of intra-hepato-arterial chemotherapy (IHAC). We performed gastrointestinal fiberscopy and identified a massive protrusion on the lesser curvature. Abdominal contrast-enhanced computed tomography revealed multiple hepatic masses and an extrahepatic enlarged mass with invasion to the pancreas and stomach. A specimen for endoscopic biopsy revealed adenocarcinoma that stained positive for α-fetoprotein. Gastrointestinal bleeding resulting from direct invasion of HCC is unusual.

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A 72-year-old male visited our hospital for further evaluation of esophageal varices. Telangiectasias were present in the stomach. He had recurrent epistaxis, which was also confirmed in his family's medical history. We diagnosed this case as Osler-Weber-Rendu disease. He had concomitant with hepatic nodular change. Abdominal angiography showed arterio-portal (A-P) shunts, superior mesenteric artery (SMA)-superior mesenteric vein (SMV) shunt, extension of SMV, and dilated and meandering portal vein. Esophageal varices were treated by endoscopic variceral ligation (EVL) and argon plasma coagulation (APC) therapy for prophylaxis of bleeding.

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Gastric inflammatory fibroid polyps (IFPs) are rare benign lesions that occur in the distal stomach. We describe a 56-year-old woman with Helicobacter pylori (H. pylori)-positive gastric IFP treated with eradication. Endoscopic examination revealed a submucosal tumor, 35 mm in diameter, with an ulcerated apex at the antrum. H. pylori were positive by both histology and tissue culture, and eradication (a proton pump inhibitor, amoxicillin, and clarithromycin) was performed. After 6 months, the tumor morphologically changed and decreased in size. This case suggests that H. pylori may play a role in the pathogenesis of gastric IFPs.

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A 35-year-old male was diagnosed as angina pectoris and showed severe stenosis with soft plaque in the proximal segment of the left anterior descending (LAD) coronary artery as detected by multi-detector row computed tomography (MDCT). Although percutaneous coronary stent implantation to the LAD lesion was performed, soft plaque remained in the proximal lesion of the stent. Atorvastatin increased the coronary plaque density at the 6-month follow-up MDCT examination, and the low-density lipoprotein cholesterol level fell from 141 to 63 mg/dl after 6 months. This case may indicate that assessment of the shape or composition of coronary plaque by MDCT is a useful strategy for judging the effects of intensive lipid-lowering therapy using statin.

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The development of infected coronary aneurismal fistula following stenting seems exceedingly rare. A sirolimus-eluting stent (SES) was implanted in a 70-year-old male patient for acute coronary syndrome. His fever persisted despite treatment with adapted antibiotics. Coronary angiography and 16-multidetector row computed tomography demonstrated the huge right coronary aneurysm forming a fistula to the right ventricle. The aneurysm was excised by surgical treatment. Histopathological examination of the resected mass revealed leucocyte infiltration at the stent site, which lead to the diagnosis of mycotic aneurysm. SESs may play a potential role in locally blunting the innate response to bacterial agents.

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We report the case of a 59-year-old woman who developed rapid-onset type 1 diabetes associated with a marked increase in anti-glutamic acid decarboxylase antibody titer (317.5 U/ml), mild increase in HbA1c level (6.8%), diabetic ketoacidosis, and cytomegalovirus enterocolitis. She was a heterozygote for HLA class II DRB1^*0901-DQA1^*03-DQB1^*0303, and she had HLA class I A24, which may have contributed to the rapid beta cell destruction. Based on the putative molecular mimicry of GAD65 by cytomegalovirus antigen, we hypothesize that the type 1 diabetes in this case was associated with cytomegalovirus infection.

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We encountered a 49-year-old Japanese man in whom tumor-like renal lesions developed as a result of chronic Staphylococcus aureus pyelonephritis. The patient complained of general fatigue, weight loss, and anorexia for 6 months. Contrast-enhanced computed tomography (CT) of the abdomen revealed multiple low-density lesions in both kidneys and paraaortic lymphadenopathy. A strong uptake of Ga⁶⁷ citrate in the lesions and elevation of serum soluble interleukin-2 receptor and thymidine kinase activity were strongly suggestive of primary renal lymphoma; however, histologic examination of renal biopsy specimens revealed severe tubulointerstitial change, consistent with chronic pyelonephritis. Following systemic antibiotic treatment, multiple tumor-like lesions regressed 4 months later. This case suggested that chronic pyelonephritis could present as bilateral renal tumors.

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A 53-year-old woman diagnosed with small-cell lung carcinoma (SCLC) was referred to our hospital because of general malaise and inappetence. Serum amylase levels were drastically elevated at 13,920 IU/l, with the salivary type dominating. She suffered multiple liver metastases and presented with disseminated intravascular coagulation (DIC). She succumbed to progressive malaise one month after admission. The amylase level was increased to 18,630 IU/l just before her death. Necropsy of the right supraclavicular lymph node confirmed SCLC with partial necrosis. Immunohistological analysis revealed that the SCLC produced salivary-type amylase. A rare case of salivary-type amylase-producing SCLC with a futile outcome was reported with review of the previous literature.

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This is the first case report of acute respiratory distress syndrome (ARDS) due to chronic necrotizing pulmonary aspergillosis (CNPA). This patient had pulmonary fibrosis of unknown etiology with a right upper bulla. The wall of the bulla became thicker with the surrounding lung infiltration and the patient suddenly developed severe respiratory failure. It is necessary to confirm the possibility that ARDS may occur in CNPA and that peripheral eosinophilia might forebode worsening of CNPA.

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We report a 16-year-old man with severe heart failure due to idiopathic pulmonary arterial hypertension (IPAH). The patient was initially treated with a combination of beraprost, a prostacyclin analog, and sarpogrelate, a serotonin receptor inhibitor. However, he was unresponsive to the treatment. We then changed the treatment to sildenafil, and his condition dramatically improved. Sildenafil has an immediate pulmonary vasodilator effect in patients already receiving vasodilators for IPAH.

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'Idiopathic systemic capillary leak syndrome (SCLS), or Clarkson's disease is an unusual entity first described 45 years ago. It presents with recurrent episodes of shock due to leakage of the plasma, which is reflected by accompanying hemo-concentration, hypo-albuminemia and edema. We report the case of a young man with multiple episodes of shock with generalized edema and pleural effusion. An initial diagnosis of sepsis was made, but the lack of fever and absence of a demonstrable organism or source led to a revision of diagnosis to SLCS. The last review of this syndrome which analyzed 24 cases was published in 1990. Since then, 75 more cases have been reported. This article reviews these cases.

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Henoch-Shönlein purpura (HSP) is a form of systemic vasculitis involving both arterioles and capillaries. HSP frequently is seen in children between the ages of 2 and 11 years, though adults with this disease are occasionally encountered. Although it primarily is a disease of early childhood, it can occur at any age. The clinical manifestations include a classic tetrad: rash, arthralgias, abdominal pain and renal disease. However, it may affect almost any other bodily tissue, such as myocardium, lungs, ureter and nervous system. Pulmonary hemorrhage is a rare complication of HSP, which largely has been observed in adolescents and adults. Pulmonary hemorrhage in HSP is associated with significant morbidity and mortality. We present the successful treatment of a 78-year-old woman with HSP complicated by pulmonary hemorrhage.

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Although utility of ¹⁸F-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) has been rehearsed in large vessel vasculitides, it is not known if small vessel vasculitides are also associated with increased FDG uptake. Hereby described is a 64-year-old female patient with prolonged fever and splenomegaly, which was depicted as a hot area in FDG-PET. Splenectomy disclosed microaneurysms, giant cell granuloma, perivascular leukocytic infiltration with fibrinoid necrosis, consistent with granulomatous angitis. Serum myeloperoxidase-antineutrophil cytoplasmic antibody was positive. The present case illustrates that vasculitides affecting small vessels present increased FDG uptake as do those affecting large vessels.

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