[Cerebrovascular disease in the elderly-risk factor, treatment and prognosis].
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Aged↗
Biomedical subjects
M Fujishima
Publications and source records attributed to M Fujishima.
[Guidelines on treatment of hypertension in the elderly, 1995--a tentative plan for comprehensive research projects on aging and health-- Members of the Research Group for "Guidelines on Treatment of Hypertension in the Elderly", Comprehensive Research Projects on Aging and Health, the Ministry of Health and Welfare of Japan].
We propose the following guidelines for treatment of hypertension in the elderly. 1. Indications for Treatment. 1) Age: Lifestyle modification is recommended for patients aged 85 years and older. Antihypertensive therapy should be limited to patients in whom the merit of the treatment is obvious. 2) Blood pressure: Systolic BP > 160 mmHg, diastolic BP > 90 approximately 10 mmHg. Systolic BP < age + 100 mmHg for those aged 70 years and older. Patients with mild hypertension (140-160/ 90-95 mmHg) associated with cardiovascular disease should be considered for antihypertensive drug therapy. 2. Goal of Therapy for BP: The goal BP in elderly patients is higher than that in younger patients (BP reduction of 10-20 mmHg for systolic BP and 5-10 mmHg for diastolic BP). In general, 140-160/< 90 mmHg is recommended as the goal. However, lowering the BP below 150/85 should be done with caution. 3. Rate of Lowering BP: Start with half the usual dose, observe at the same dose for at least four weeks, and reach the target BP over two months. Increasing the dose of antihypertensive drugs should be done very slowly. 4. Lifestyle Modification: 1) Dietary modification: (1) Reduction of sodium intake is highly effective in elderly patients due to their high salt-sensitivity. NaCl intake of less than 10 g/day is recommended. Serum Na+ should be occasionally measured. (2) Potassium supplementation is recommended, but with caution in patients with renal insufficiency. (3) Sufficient intake of calcium and magnesium is recommended. (4) Reduce saturated fatty acids. Intake of fish is recommended. (2) Regular physical activity: Recommended exercise for patients aged 60 years and older: peak heart rate 110/minute, for 30-40 minutes a day, 3-5 days a week. (3) Weight reduction. (4) Moderation of alcohol intake, smoking cessation. 5. Pharmacologic Treatment: 1) Initial drug therapy. First choice: Long-acting (once or twice a day) Ca antagonists or ACE inhibitors. Second choice: Thiazide diuretics (combined with potassium-sparing diuretic). 2) Combination therapy. (1) For patients without complications, either of the following is recommended. i) Ca antagoinst + ACE inhibitor, ii) ACE inhibitor + Ca antagonist (or low-dose diuretics), iii) diuretic + Ca antagonist (or ACE inhibitor), iv) beta-blockers, alpha 1-blockers, alpha + beta blockers can be used according to the patho-physiological state of the patient. (2) For patients with complications. Drug(s) should be selected according to each complication. 3) Relatively contraindicated drugs. beta-Blockers and alpha 1-blockers are relatively contraindicated in elderly patients with hypertension in Japan. Centrally acting agents such as reserpine, methyldopa and clonidine are also relatively contraindicated beta-Blockers are contraindicated in patients with congestive heart failure, arteriosclerosis obliterans, chronic obstructive pulmonary disease, diabetes mellitus (or glucose intolerance), or bradycardia. These conditions are often present in elderly subjects. Elderly subjects are susceptible to alpha 1-blocker-induced orthostatic hypotension, since their baroreceptor reflex is diminished. Orthostatic hypotension may cause falls and bone fractures in the elderly.
Aged↗
Use of endosonographic evaluation of colorectal tumor depth in determining the appropriateness of endoscopic mucosal resection.
OBJECTIVES: To determine the efficacy with which endoscopic ultrasonography (EUS) is able to differentiate between mucosal and submucosal invasion for application of endoscopic resection. METHODS: We prospectively analyzed 60 patients who were diagnosed with early cancer by conventional EUS with regard to the accuracy of mucosal neoplasia as a function of gender, age, location, size, endoscopic configuration, histological diagnosis, and method of resection. RESULTS: Forty lesions interpreted as mucosal by EUS were shown histologically to include 32 lesions in the mucosa and eight in the submucosa or deeper, whereas 20 tumors interpreted as invasive cancer included six lesions in the mucosa and 14 in the submucosa or deeper. The accuracy of mucosal neoplasia (AMN) detection was 77% (true-positive and true-negative mucosal neoplasias divided by all lesions). Assessment of pure cancers without adenomatous components produced a significantly lower AMN (59%, p = 0.03) than the assessment of pure adenomas (95%) or cancers in adenomas (87%). However, there were no significant differences in the EUS assessment of intramucosal neoplasia as a function of sex, age, endoscopic configuration, size, location, or treatment. CONCLUSIONS: We conclude that conventional EUS interpretation alone cannot determine the appropriate treatment for early colorectal cancer.
Case-Control Studies↗
Primary jejunal malignant mixed tumor in a patient with von Recklinghausen neurofibromatosis.
A rare case of primary jejunal malignant mixed tumor arising in a 49-64-old Japanese male with von Recklinghausen's disease is reported. The patient, who had a past history of partial gastrectomy due to duodenal ulcer, was admitted with a complaint of epigastric pain. Upper gastrointestinal examinations showed a huge polypoid tumor located in the efferent loop of the gastrojejunostomy site. Because the tumor was strongly suggestive of leiomyosarcoma on histological examination of biopsy specimens, laparotomy was performed. The resected tumor measuring 10 X 7 X 7 cm was composed of adenocarcinoma admixed with various sarcomatous components, including rhabdomyosarcoma, osteosarcoma, and other sarcomas. Immunohistochemical analysis also supported this diagnosis. The features of this tumor closely resembled malignant mixed mullerian tumor of heterologous type that develops in female genital organs. It is well known that patients with von Recklinghausen neurofibromatosis have an increased incidence of mesenchymal tumors and malignant neoplasias, and therefore, it seems that there is a possible relationship between the histogenesis of this peculiar tumor and the genetic abnormality in this patient.
Humans↗
[Systemic vascular change associated with moyamoya-like cerebrovascular disease and microvascular coronary artery disease].
A 34-year-old man with hypertension and diabetes mellitus developed dizziness and visited our institute. He had history of headache with numbness of the right hand since age 15 years and left occipital lobe infarction at age 28 years. The cerebral angiogram showed several changes peculiar to advanced stage of moyamoya disease (spontaneous occlusion of the circle of Willis), i.e. segmental stenoses or occlusions of bilateral internal carotid arteries, left vertebral artery and left posterior cerebral artery with abnormal vascular networks at the bilateral basal ganglia. He was also diagnosed to have asymptomatic ischemic heart disease. The coronary angiogram showed diffuse sclerotic lesions of left anterior descending and right coronary arteries without significant stenosis, which suggested the presence of microvascular lesion as a cause of myocardial ischemia. Coronary disease has been rarely reported as a complication of moyamoya disease, and microvascular coronary artery disease has never been described. Moyamoya disease should be regarded as a part of systemic vascular disorders, and the evaluation of extracerebral cardiovascular system is necessary to clarify pathophysiology of this disease.
Adult↗
Correlation between disease activity and arterial blood pressure in Crohn's disease.
OBJECTIVE: The aim of this study is to assess haemodynamics in patients with Crohn's disease (CD) receiving total parenteral or enteral nutrition (TPEN). METHODS: We compared changes in systemic arterial blood pressure (BP) before and after 48 courses of TPEN in 34 patients with CD and 19 courses of TPEN in 10 patients with other gastrointestinal diseases. We simultaneously measured the Crohn's disease activity index (CDAI) and biochemical parameters. RESULTS: BP increased significantly during TPEN in CD patients (after: 85.1 +/- 7.4 mmHg vs. before: 75.2 +/- 7.9 mmHg, P < 0.001). The increase in BP was negatively correlated with changes in the Crohn's disease activity index. BP decreased significantly after TPEN in patients with other diseases (P < 0.001), despite an improvement in their general condition. There was no significant difference in volume status between CD patients and patients with other diseases. CONCLUSION: These findings suggest that determination of arterial blood pressure may be useful for assessing disease severity in patients with CD and that a fall in blood pressure may contribute to disease activity.
Adult↗
[Prospective population survey of IGT in a Japanese community, Hisayama].
To elucidate the prevalence and relevant factors of glucose intolerance and its effect on the development of cardiovascular disease in the current general Japanese population, we conducted a cross-sectional survey of glucose intolerance by a 75-g oral glucose tolerance test in 2,490 subjects aged 40-79 years old selected from a Japanese community, Hisayama, in 1988, and followed them for 5 years. The prevalence of diabetes (NIDDM) was 13% for men and 9% for women, and that of impaired glucose tolerance (IGT) was 20% and 19%, respectively. Both IGT and NIDDM were significantly associated with factors related to insulin resistance including the sum of insulin concentrations. In addition, subjects with IGT and NIDDM had a significantly higher risk of occurrence of cardiovascular disease (stroke and coronary heart disease) than did those with normal glucose tolerance.
Adult↗
Steroid-resistant nephrotic syndrome associated with malignant thymoma.
Two patients with malignant thymoma of lymphoepithelial cell type developed nephrotic syndrome and irreversible acute renal failure 18 months after the radiation therapy. Repeated renal biopsies revealed focal segmental glomerulosclerosis (FSGS) in both cases (a 66-year-old female and a 82-year-old female). Several immunological disorders were found, being a presence of autoantibodies such as antinuclear antibody, anti-acetylcholine receptor antibody, antistriatal antibody and an elevation of serum IgM. In both cases the nephrotic syndrome was resistant to corticosteroid as well as cyclophosphamide. Renal dysfunction eventually progressed to end-stage renal failure requiring regular hemodialysis treatment. A sustained immunological impairment related to the residual malignant thymoma was considered to be of pathogenic importance for the delayed occurrence of nephrotic syndrome. Fifteen thymoma cases with nephrotic syndrome from the previous reports are also reviewed.
Aged↗
Minimal daily variations of plasma and urinary endothelin-1 in healthy subjects.
The daily profiles of both the plasma level and the urinary excretion rate of endothelin-1 were examined in 13 healthy volunteers (9 males and 4 females, aged 22 +/- 1 [SEM]). Plasma endothelin-1 (PET) was measured after a one-hour recumbency every 6 hours at 8 a.m., 2 p.m., 8 p.m. and 2 a.m. and the urinary excretion rate of endothelin-1 (UET) was determined in the urine collected every 6 hours. PET was found to be quite stable throughout the day, being 1.57 +/- 0.25 pg/ml at 8 a.m., 1.88 +/- 0.21 at 2 p.m., 2.2 +/- 0.24 at 8 p.m. and 1.90 +/- 0.20 at 2 a.m. After a one-hour ambulation, PET showed no statistical difference. UET also remained unchanged for each 6-hour collecting period, measuring 4.61 +/- 0.69, 3.98 +/- 0.46, 4.63 +/- 0.73 and 3.42 +/- 0.49 ng/hr, respectively. The absence of any daily variations in either PET or UET thus suggests that apparently no specific considerations need be applied regarding the time of taking samples to measure the plasma and urinary endothelin-1.
Adult↗
[Recurrent aseptic meningitis caused by rupture of a pineal cyst].
A 40-year-old woman experienced three attacks of aseptic meningitis in 19 months. Each attack was characterized by sudden onset of meningeal irritation followed by spontaneous remission in several days. The patient was free of neurological symptoms between the attacks. In the acute phase of each attack, her cerebrospinal fluid (CSF) showed mononuclear pleocytosis and increased protein concentration. Epithelial cell clusters in the CSF were evident during the third episode. No pathogenic microorganisms were identified in CSF or blood cultures. Brain imaging revealed a pineal cyst, 1 cm in diameter, and we suspected that the epithelial cell clusters represented the ruptured cystic wall and that the recurrent aseptic meningitis was triggered by spontaneous rupture of the cyst. Recently several new etiologies for the benign recurrent aseptic meningitis (Mollaret's meningitis) have been reported, but its existence as a clinical entity is still in dispute. Our case appears to support "spontaneous rupture of central nervous system epidermoid cysts" as one of the etiologies of recurrent aseptic meningitis.
Adult↗
The alpha 1-adrenoceptor antagonist, doxazosin, modulates the lower limit of autoregulation of cerebral blood flow during hemorrhagic hypotension in anesthetized hypertensive rats.
The objective of the present study was to examine the effects of administration of an alpha 1-adrenoceptor antagonist, doxazosin, for 7 days on cerebral blood flow and the autoregulatory response to hypotension in anesthetized spontaneously hypertensive rats. We determined the cerebral blood flow at rest and during hemorrhagic hypotension in 14 rats of each group using laser-Doppler flowmetry, and at the same time, the absolute baseline cerebral blood flow values at the parietal cortex were also quantified in some of the rats with the hydrogen clearance method. Baseline mean arterial pressure was significantly lowered, by 41 mm Hg, in the doxazosin-treated group, while the baseline cerebral blood flow was 31 +/- 4 ml/100 g/min(mean +/- S.D.) which was almost the same as the 32 +/- 5 ml/100 G/min in the control group. The lower limits of cerebral blood flow autoregulation were 139 +/- 9 mm Hg in the control group and 96 +/- 12 mm Hg in the treated group; the difference was significant (P < 0.001). The present results demonstrated that the lower limit of cerebral blood flow autoregulation shifts to a lower level after chronic treatment with doxazosin, an effect which is favorable for the maintenance of cerebral blood flow under hypotensive conditions.
Adrenergic alpha-1 Receptor Antagonists↗
L-arginine ameliorates cerebral blood flow and metabolism and decreases infarct volume in rats with cerebral ischemia.
Effects of L-arginine, 300 mg/kg, i.p., on the regional cerebral blood flow (rCBF), brain metabolism, and infarct volume were examined in spontaneously hypertensive rats subjected to occlusion of both left middle cerebral artery and left common carotid artery. Rats treated with L-arginine had higher rCBF, determined by hydrogen clearance method, in the ischemic core (7 +/- 1 ml/100 g/min, mean +/- S.E.M.) and penumbral regions (16 +/- 2) than did rats treated with saline (5 +/- 0 and 7 +/- 1, respectively). Simultaneously, L-arginine attenuated metabolic derangement in the ischemic tissue at 60 min, i.e. well maintained adenosine triphosphate (ATP) in ischemic region (1.29 +/- 0.07 mmol/kg in L-arginine group vs. 1.05 +/- 0.06 in saline group), and also close to normal levels in ATP (2.61 +/- 0.02 mmol/kg vs. 2.45 +/- 0.05), glucose (2.29 +/- 0.12 mmol/kg vs. 1.80 +/- 0.17) and lactate (1.63 +/- 0.10 mmol/kg vs. 2.24 +/- 0.21) in periischemic region. In another experiment, the effects of L-arginine on rCBF in the subcortical regions and on infarct volume were evaluated. L-arginine, compared with saline, increased rCBF by 8 ml/100 g/min in the ischemic side and reduced infarct volume by 29% at 24 h of ischemia. These findings support that L-arginine may be potentially useful for the treatment of acute cerebral ischemia.
Animals↗
Heparin inhibits the accumulation of re-esterified cholesterol in macrophages loaded with acetylated low-density lipoprotein.
Heparin enhances the endocytosis of low density lipoprotein (LDL) in macrophages via a formation of complex with LDL. The direct effect of heparin on the metabolism of cholesterol in macrophages has not been elucidated. We therefore evaluated the effects of heparin on the accumulation and reesterification of cholesterol in cultured macrophages. We used acetylated LDL (acetyl-LDL), which lacks an affinity for heparin. Rat peritoneal macrophages induced with thioglycollate were incubated with 100 micrograms of acetyl-LDL for 14 h. Heparin significantly inhibited the accumulation of total and esterified cholesterol but did not affect the binding of 125I-labeled acetyl-LDL to macrophages or its cellular degradation. Heparin at concentration above 5 micrograms/ml inhibited the incorporation of [3H]oleate into cholesteryl oleate in macrophages. Heparin significantly inhibited the acyl CoA:cholesterol acyl transferase (ACAT) activity of macrophages by 68%. Data suggest that heparin inhibits the accumulation and reesterification of cholesterol in macrophages loaded with acetyl-LDL. Heparin-like proteoglycans may thus protect the macrophages against the excessive accumulation of esterified cholesterol.
Animals↗
Treatment of warfarin-induced hair loss with ubidecarenone.
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Alopecia↗
Isradipine, a calcium channel blocker, attenuates the ischemia-induced release of dopamine but not glutamate in rats.
This study was designed to investigate the role of the L-type voltage sensitive calcium channel blocker, isradipine, in the ischemia-induced release of neurotransmitters. Male spontaneously hypertensive rats were subjected to cerebral ischemia for 60 min by bilateral carotid artery occlusion, and recirculated for 120 min. Isradipine (0.25 mg/kg n = 6) or vehicle (n = 6) was administered subcutaneously at 20 min before ischemia. In the striatum, cerebral blood flow was determined by the hydrogen clearance method and concentrations of extracellular dopamine and glutamate were measured by in vivo brain dialysis technique. Extracellular dopamine in the vehicle-treated group increased by 180-fold from the basal level, and glutamate by 24-fold during cerebral ischemia. Isradipine significantly attenuated the ischemic release of dopamine to 33-34% (P < 0.05) of the vehicle group, while it did not affect glutamate release. It is suggested that the release mechanism of dopamine and glutamate during cerebral ischemia may be different, especially in the dependence on the L-type calcium channels.
Animals↗
Heparin inhibits rat peritoneal macrophages to reesterify cholesterol.
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Animals↗
[Epidemiological changes in cerebrovascular disorders].
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Adult↗
Endoscopic evaluation of gastric inflammatory fibroid polyp.
Clinical and endoscopic manifestations of 18 gastric inflammatory fibroid polyps (IFP) in 16 patients who underwent endoscopic or surgical removal were retrospectively analyzed. All of the lesions were located within the pyloric antrum, and the sizes varied from 0.8 to 7.0 cm. On endoscopy, six polyps which measured 1.0 cm or less uniformly seemed to be sessile or intramural tumors, whereas four of the nine polyps between 1.1 and 2.0 cm in size were additionally accompanied by a central depression. The remaining three, which measured more than 2.0 cm, showed characteristic polypoid growth with ulcerations. Three polyps more than 1.0 cm in size occasionally prolapsed into the duodenal bulb. Three patients with these prolapsing polyps and two with polyps accompanied by ulcerations experienced abdominal pain, nausea, or severe anemia. Two polyps (11%) were precisely diagnosed as IFP by means of conventional forceps biopsy. Histological examinations revealed that all of the polyps proliferated within the submucosa. Therefore, this type of polyp may be subject to endoscopic removal to enable a precise diagnosis and treatment.
Adult↗