Objective: A regular electrocardiogram (ECG) performed for about 20 seconds may fail to detect arrhythmia, whereas a prolonged ECG may detect arrhythmia in cases where the regular ECG is negative. In the present study, we examined the effectiveness of a 3-minute ECG for detection of arrhythmia. Methods: The frequency of newly detected arrhythmia in the 3-minute ECG was calculated and compared between subjects and normal controls. Patients: Subjects with arrhythmia in a resting ECG and subjects with past histories or symptoms of arrhythmia or heart diseases (n=1,525) and randomly selected normal controls (n=363) who visited our hospital to check up their health were examined. Results: A regular ECG showed that 372 subjects had arrhythmia. Of the remaining 1,153 subjects, the 3-minute ECG detected arrhythmia in 104 subjects. Detection of arrhythmia in the 3-minute ECG was more frequent in the subjects than in normal controls (9.0% vs. 1.7%, p<0.05). The 3-minute recording detected arrhythmia more frequently in subjects with a past history of premature contraction or in subjects with palpitation than in the controls (10.0%, or 9.9% vs. 1.7%, p<0.05, respectively). Conclusion: A 3-minute ECG recording appears to be useful for detecting premature contractions in subjects with a past history of premature contraction and/or palpitation, even if arrhythmia is not shown on a regular ECG recording at rest.
Objective: C-reactive protein (CRP) is not only an acute phase reactant but also a sensitive marker of subclinical inflammation associated with atherosclerosis. The aim of the present study was to determine whether glycemic control or blood pressure influences the vascular microinflammation as evaluated by CRP levels in the very elderly. Methods: The study group consisted of 195 residents aged 85 years. The subjects were divided into three groups according to their CRP levels; a low (<1 mg/L), an average (1 to 3 mg/L), and a high (3 to 10 mg/L) CRP group. Hemoglobin A1c (HbA1c) levels were used as an index of glycemic control. Results: The HbA1c level showed a significant positive correlation with the CRP level (r=0.289, p<0.0001). In contrast, systolic and diastolic blood pressures failed to correlate with the CRP level. The HbA1c was significantly greater in the high CRP group compared to the average and the low CRP groups (6.01±0.29%, 5.57±0.09% and 5.42±0.05%, respectively). Furthermore, the HbA1c adjusted by sex, body mass index, systolic blood pressure, serum triglyceride and current smoking status was significantly higher in the high CRP group than in the average and the low CRP groups. Multiple regression analysis also revealed that the HbA1c level was significantly and independently associated with the CRP level. Conclusions: These results suggest that tight good glycemic control, even in very elderly subjects, may be able to reduce the systemic inflammation that contributes to leads to atherosclerosis.
Objective: There is no standardized therapy for renal amyloidosis, which shows rapid progression and poor prognosis. Here, we used cluster analysis to examine the correlation between amyloid-related renal damage and prognosis, and determined the clinicopathological prognostic factors for renal amyloidosis. Methods and Patients: We analyzed 125 patients with renal amyloidosis (men/women: 43/82; mean age at renal biopsy: 58.8±11.1 years, ±SD; range: 21-78 years). Cluster analysis was performed using clinical parameters, renal histological findings, type of renal amyloidosis, and follow-up data. We also analyzed survival data. Results: We divided 125 cases (prognosis was checked in 97 [77.6%] cases) into three groups by cluster analysis. In the cluster groups, accelerated progression correlated with serum creatinine (s-Cr) levels at renal biopsy and histological grade of renal damage by amyloid deposition (p<0.0001). The most important prognostic factors were glomerular, tubulointerstitial, and vascular lesions induced by amyloid deposition at biopsy (p<0.0001). We also found that amyloid-A (AA) type amyloidosis correlated is more significantly with amyloid-mediated vascular (P=0.0010) and tubulointerstitial lesions (p=0.0705) than with amyloid-L (AL) type amyloidosis. Proteinuria and nephrotic syndrome were more severe in AL than AA amyloidosis (p=0.0836). The 10-year individual survival rate was about 20%, and most deaths were due to cardiovascular disease and infection. Conclusion: Our results indicate that the quantity of amyloid deposition in the kidney, and the extent of glomerular, tubulointerstitial, and vascular damage are significant renal prognostic factors in amyloidosis.
Objective: Familial Mediterranean fever (FMF) had been considered a rare disease in Japan, but since the identification of the causative gene (MEFV) for pyrin/marenostrin in 1997, the occurrence of FMF has been successively reported. We reviewed the clinical features of 7 patients diagnosed with FMF by gene analysis. Methods: During April 2003 and March 2005, we investigated the clinical symptoms, treatment and MEFV types of 7 FMF patients who consulted the General Outpatient Clinic of Chiba University Hospital. Results: Six patients were in their 20-30s, and one was 54 years of age. There were 4 males and 3 females including a mother and child, and an adult male and his female cousin. Three were solitary incidences. In addition to intermittent fever, 4 patients had chest pain, 1 had abdominal pain, and 1 had chest or abdominal pain. The frequency of attacks was once per 3 months to 1 year in the early stage of the disease, but it slowly increased with disease progression. Leukocytosis and C-reactive protein (CRP) elevation were noted during attacks in all patients. On investigation of MEFV, heterozygosity for the compound pyrin L110P-E148Q/M694I, E148Q/M694I, L110P/E148Q and heterozygosity for pyrin variant M694I alone were detected. Daily administration of colchicine at 0.5 mg prevented attacks in 6 patients, however 1 patient required 1.0 mg for adequate prevention. Conclusions: Although the incidence is rare, internists should be aware of the characteristic symptoms of FMF: periodic fever and serositis symptoms, and its presence in Japan despite the disease name.
Objective: The objective of this study was to compare doctor-patient communications in clinical consultations via telemedicine technology to doctor-patient communications in face-to-face clinical consultations. Method: Five doctors who had been practicing internal medicine for 8 to 18 years, and twenty patients were enrolled in this study; neither doctors nor patients had previous experience of telemedicine. The patients received both a telemedicine consultation and a face-to-face consultation. Three measures - video observation, medical record volume, and participants' satisfaction - were used for the assessment. Results: It was found that the time spent on the telemedicine consultation was substantially longer than the time spent on the face-to-face consultation. No statistically significant differences were found in the number of either closed or open-ended questions asked by doctors between both types of consultation. Empathy-utterances, praise-utterances, and facilitation-utterances were, however, seen less in the telemedicine consultations than in the face-to-face consultations. The volume of the medical records was statistically smaller in the telemedicine consultations than in the face-to-face consultations. Patients were satisfied with the telemedicine consultation, but doctors were dissatisfied with it and felt hampered by the communication barriers. Conclusions: This study suggests that new training programs are needed for doctors to develop improved communication skills and the ability to express empathy in telemedicine consultations.
We encountered a case of portal vein thrombosis (PVT) after treatment for portal hypertension due to pancreatic arteriovenous malformation (PAVM). A 75-year-old man was admitted for the treatment of esophageal varices. Diffuse PAVM and aneurysm in the celiac and superior mesenteric arteries were detected via abdominal computed tomography and angiography. Although endoscopical sclerotherapy was performed, PVT was identified after the treatment and variceal bleeding continued. Autopsy was performed and the thrombus and malformation were pathologically confirmed. This case indicates that PVT can be associated with PAVM.
Insulin Autoimmune Syndrome (IAS) is a rare disease characterized by hypoglycemia and autoantibodies to insulin without prior insulin administration. Here, we report a case of IAS associated with alpha lipoic acid (ALA). The patient is a 55-year-old man. He began to complain of hypoglycemic symptoms after taking ALA. He lost consciousness in the late postprandial period and blood glucose was found to be 27 mg/dl. A high insulin level and high titers of insulin antibodies were detected. His HLA genotype contains DRB1* 0406. As ALA comes to be used widely, the incidence of IAS due to ALA might increase.
A 60-year-old woman was admitted because of multiple bone pain. Examination revealed hypophosphatemic osteomalacia and acquired Fanconi syndrome. Further exploration revealed monoclonal gammopathy of undetermined significance (MGUS) excreting urinary Bence Jones protein (kappa light chain). Renal biopsy showed non-specific tubulointerstitial nephritis, yet neither crystalline inclusions in the cytoplasm of the tubular epithelium nor myeloma casts nor amyloid deposits were found. She was treated with supplementation by phosphate, alkali agents, and vitamin D, and responded well to the treatment symptomatically and biochemically. MGUS was observed without chemotherapy. Myeloma had not developed after 10 months follow-up.
A 34-year-old woman with hyperthyroidism, who had been previously treated with propylthiouracil (PTU) is reported. She was admitted because of clumsiness in her left hand and abnormal behavior. A neurological examination demonstrated impairment of higher cortical function, and weakness and hyperreflexia of the left leg. An MRI scan with gadolinium enhancement showed pachyleptomeningeal thickening in the right frontoparietal lobe. Blood tests revealed a high MPO-ANCA titer of 122 EU (normal:<10 EU). After steroid administration, the neurological symptoms and the MRI findings improved markedly. This is the first report of PTU-induced cerebral pachyleptomeningitis associated with a high serum MPO-ANCA titer.
We report a patient with Sjögren's syndrome and chronic natural killer lymphocytosis, who developed severe neutropenia, autoimmune hemolytic anemia, and immune thrombocytopenia. High-dose prednisolone therapy improved the hemolytic anemia and thrombocytopenia, but not the CD16+ CD56- NK lymphocytosis completely. Interestingly, indomethacin farnesil (a prodrug of indomethacin) was effective for myalgia and also decreased the number of CD16+ CD56- NK cells. NK lymphocytosis is rarely associated with autoimmune disease, but the combination of indomethacin and steroid therapy may have a favorable effect for such patients.