A fatty acid analogue, 123I-labelled beta-methyl iodophenyl pentadecanoic acid (BMIPP), has been used to identify ischaemic and metabolically impaired myocardium. However, the prognostic value of BMIPP imaging, particularly in relation to stress myocardial perfusion imaging, remains unclear. Data from 167 consecutive patients with angina pectoris but without prior myocardial infarction (MI) who had undergone both BMIPP and stress 201Tl (sTL) imaging were analysed. Tracer uptake was graded using a 13-segment, 4-point scoring model. Patients were followed up for 48 months with primary end points (cardiac death, non-fatal MI) as hard cardiac events and with secondary end points (late revascularisation, recurrent angina and heart failure) as soft events. For overall cardiac events (5 hard and 29 soft events), Kaplan-Meier analysis revealed significantly lower event rates in subgroups with normal BMIPP uptake, a summed difference score of sTL (SDS) of <3 or absence of diabetes mellitus when compared to each counterpart. Multivariate Cox's analysis revealed reduced BMIPP uptake, SDS > or =3, diabetes and reduced ejection fraction to be significant predictors. Negative predictive values of normal BMIPP and SDS <3 for all events were 91% and 84%, respectively. No hard event occurred in 66 patients with normal BMIPP uptake, whereas two patients with SDS <3 but impaired BMIPP uptake had hard events. In conclusion, normal BMIPP imaging is an excellent prognostic sign, independently of stress myocardial perfusion imaging, in patients with angina pectoris without prior MI.

The development of an unusual case of primary pleural effusion in a 90-year-old human immunodeficiency virus (HIV)-negative Japanese woman with no identifiable tumor mass has been described. Pleural effusion specimens contained large diffuse lymphoma cells, with the phenotype and genotype of a B-cell lineage (positive for CD20, CD79a and clonal rearrangement of Ig heavy chain) and the c-myc gene rearrangement, but were negative for T-cell markers (CD45RO and CD3). The patient was negative for human herpes virus 8 (HHV8), Epstein-Barr virus (EBV) and hepatitis C virus (HCV), as well as human T-cell lymphotropic virus type-1 (HTLV-1). The patient died of respiratory failure 5 months after the diagnosis of primary effusion lymphoma (PEL), and an autopsy was performed. Autopsy findings revealed no evidence of tumor mass or bone marrow involvement of lymphoma cells. This case has been considered as a PEL in a HIV-, HHV8-, EBV- and HCV-negative patient. Although cytomorphology of lymphoma cells was classified as large-cell lymphoma in this case, it is interesting that the present case may represent an unusual subset of Burkitt-like disease because of clear B-cell phenotype and c-myc gene rearrangement.

Measurement of skin perfusion pressure (SPP) using laser Doppler has become available for the assessment of peripheral arterial disease. We studied whether measurements of SPP can be used to identify hemodialyzed patients with peripheral arterial disease by comparing it with measurements of the ankle brachial pressure index (ABI). The ABI at rest and the SPP in the foot were measured in 59 Japanese hemodialyzed patients (118 limbs). Twenty-one patients had diabetes mellitus. Five had intermittent claudication; however, 20 patients were accompanied by other exertional leg symptoms. The SPP could not be measured in three limbs because of involuntary movement due to previous stroke or restless leg syndrome. The SPP was correlated with the ABI. Depending upon these results of the ABI, the 114 limbs from which both the ABI and the SPP could measured were divided into three groups: (A) ABI > or = 1.3, (B) 0.9 < or = ABI < 1.3, and (C) ABI < 0.9. The average SPP of group C was significantly decreased among the three groups. All subjects of the three groups were divided into an extra two groups according to the presence of diabetes (non-diabetes groups, -I; diabetes groups, -II). The average SPP of group B-II was significantly decreased compared with those of group B-I. The SPP measurement is a noninvasive, useful screening method for limb ischemia that can be applied to exercise tolerance limited patients. The SPP measurements are expected to be useful for the evaluation of limb ischemia in hemodialyzed patients at risk.

Adynamic bone disease in HD patients is characterized by skeletal resistance to parathyroid hormone (PTH) or suppression of PTH release, leading to a downregulated bone turnover and bone fracture. Hence, we examined the efficacy of weekly teriparatide for HD patients with low PTH indicating adynamic bone disease without a history of parathyroidectomy. Fifteen HD patients with low PTH were recruited in this prospective observational study. Of them, 10 received teriparatide for 12 months and five nontreated patients were enrolled as control. Primary outcomes were defined as the changes in bone mineral density and bone turnover markers. Bone mineral density at the lumbar spine increased by 3.7% and 2.5% at 6 and 12 months, respectively, and bone formation markers increased, while bone resorption markers did not change in the teriparatide group. At 12 months after teriparatide administration, endogenous PTH was secreted followed by the recovery of low bone turnover. 40% of patients in the teriparatide group dropped out due to adverse events and the most common adverse event was transient hypotension. This study suggests that weekly teriparatide for HD patients with low PTH in the absence of parathyroidectomy accelerates bone formation and bone turnover, leading to increased trabecular bone mass and secretion of endogenous PTH.

Our previous studies have shown that a suppressed pressure natriuresis may contribute to the hypertensive mechanism in patients with essential hypertension (EHT), particularly in low renin patients (LRH). In this study, in order to clarify the role of renal dopaminergic activity in the blunted natriuresis of LRH, the conversion of 1-dopa (DOPA) to dopamine (DA) in the kidneys was investigated in 9 normotensive subjects (NT) and 20 EHT, including 15 normal renin EHT (NRH) and 5 LRH. All subjects were hospitalized and received a constant diet (Na:120mEq, K:75mEq daily). Plasma DOPA concentration (p-DOPA:HPLC-ECD), creatinine clearance (Ccr), urinary excretion of sodium (UNaV) and DA (UDA), as well as fractional excretion of sodium (FENa) were measured before and after the single oral administration of 1-DOPA (400mg). DOPA administration caused a significant increase of p-DOPA, UDA and FENa with undetectable DOPA levels in the urine in EHT. In addition, under the basal condition, UDA correlated positively with p-DOPA or the product of p-DOPA x Ccr, which might reflect the DOPA delivery at the renal proximal tubule. No significant difference was found in p-DOPA and the product of p-DOPA x Ccr among NT, NRH and LRH. However, the ratio of UDA/(p-DOPA x Ccr), which may indicate the conversion from DOPA to DA in the kidneys, was lower in EHT, especially in LRH, than that in NT. These results suggest that a reduced renal conversion from DOPA to DA may contribute to the attenuated natriuresis as well as renal dopaminergic activity in LRH.

OBJECTIVEThe degree of interdialytic weight gain (IDWG) may have an influence on anemia results. This article reports the variation of hemoglobin (Hgb) or hematocrit (Hct) levels associated with the timing of blood collection in outpatients on hemodialysis.METHODSPre‐dialysis blood samples for measurement were drawn on both the mid‐week treatment (Wednesday or Thursday) and the beginning of the next dialysis week treatment (Monday or Tuesday) in 69 patients who were hemodialyzed 3 times a week.RESULTSHgb or Hct results from mid‐week were significantly higher than those from the beginning of the next week. Change in Hgb or Hct was correlated negatively with change in IDWG.DISCUSSIONIt seems that there was a difference in Hgb or Hct levels associated with IDWG on the day of the week on which blood was collected.

Table 1 Comparisons of age, heart rate (HR), mean arterial pressure (MAP), the coefficient of variation of RR intervals (CVRR), plasma noradrenaline concentration (pNA) and plasma adrenaline concentration (pAd) between normotensives (NT) and essential hypertensives (EHT). Fig. 1 Correlation between age and the coefficient of variation of RR intervals (CVRR) in normotensives (NT) and essential hypertensives (EHT). NT n=37 r=-0.54 p<0.001 EHT n=47 r=-0.41 p<0.005

The hemodialysis procedure is thought to be a physical stressor in the majority of hemodialyzed patients. Previous studies suggest that elevated salivary amylase level may correlate with increased plasma norepinephrine level under psychological and physical stress conditions. In this study, we investigated biological stress reactivity during hemodialysis treatment using salivary amylase activity as a biomarker. Seven patients (male/female = 5/2, age: 67.7+/−5.9 years) who had been receiving regular 4 h hemodialysis were recruited. Salivary amylase activity was measured using a portable analyzer every hour during the hemodialysis session. Salivary amylase activity was shown to be relatively stable and constant throughout hemodialysis, whereas there were significant changes in systolic blood pressure and pulse rate associated with blood volume reduction. Our results show that hemodialysis treatment per se dose not affect salivary amylase activity.