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Penetrating atherosclerotic ulcer (PAU) is defined as ulceration of an aortic atherosclerotic plaque penetrating through the internal elastic lamina into the media.1–3 PAU accounts for 2% to 7% of all acute aortic syndrome.4 PAU is at risk of intramural hematoma, pseudoaneurysm, aortic rupture, or an acute aortic dissection.5 Symptomatic PAU has to be assumed to indicate an emergency because the adventitia is reached and aortic rupture is expected.5 The rupture rate of symptomatic PAU has been reported to be as high as …

A 35-year-old Japanese woman for whom a previous health checkup showed normal blood pressure and urinalysis results without serological abnormalities developed nephrotic syndrome with severe hypertension at 15 gestational weeks. The renal biopsy performed at 17 weeks of gestation showed severe glomerular capillary endotheliosis. By means of electron microscopy, no electron-dense deposits were observed in glomeruli, and foot-process arrangement was normal. Histological findings indicated the patient's glomerular damage was caused by the mechanisms of preeclampsia. The patient underwent an elective abortion at 18 weeks of gestation. Clinical abnormalities vanished completely within 3 months after the elective abortion, which provided additional evidence that proteinuria and hypertension were caused purely by pregnancy. In general, the term preeclampsia refers to new onset of hypertension and proteinuria after 20 weeks of gestation. When proteinuria or hypertension is newly observed before 20 weeks of gestation, they are practically associated with triploidy, trophoblastic disease, or antiphospholipid syndrome. However, our case was not associated with them. Therefore, we called this case "pure" preeclampsia. We confirm the notion for the first time that preeclampsia associated with glomerular capillary endotheliosis can occur before 20 weeks of gestation. In addition, this report describes the earliest onset of preeclampsia compared with previously published reports. We also discuss causes of preeclampsia in early gestation and refer to the issue of the application of renal biopsies during pregnancy.

Seasonal variations in blood pressure (BP) have often been attributed to meteorological factors, especially changes in outdoor temperature. We evaluated the direct association between meteorological factors and circadian BP variability. Twenty-four-hour ambulatory BP was monitored continuously for 7 days in 158 subjects. Mean awake, asleep, morning (first 2 h after waking) BP, prewaking morning BP surge (morning systolic BP (SBP)-mean SBP during the 2-h period before waking) and nocturnal BP decline were measured each day. We compared BP values for the lowest and highest days with regard to the daily mean outdoor temperature and mean atmospheric pressure. Morning BP and prewaking morning BP surge on the coldest day were significantly higher than those on the warmest day (morning SBP, 136.6 ± 1.6 vs. 133.1 ± 1.5 mm Hg, P = 0.002; morning diastolic BP, 84.4 ± 0.9 vs. 82.6 ± 0.9 mm Hg, P = 0.02; and prewaking morning BP surge, 20.8 ± 1.3 vs. 15.3 ± 1.3 mm Hg, P = 0.0004). The magnitude of nocturnal BP decline on the coldest day was significantly greater than that on the warmest day (15.8 ± 0.7 vs. 13.9 ± 0.7%, P = 0.01). Outdoor temperature is an important determinant of morning BP, prewaking morning BP surge and the magnitude of nocturnal BP decline. These findings may have important implications in management of hypertension and prevention of cardiovascular events.

Although it is well recognized that acute mitral regurgitation (MR) is caused by acute myocardial infarction and infective endocarditis, blunt chest trauma is also, albeit rarely, reported as the cause. In most cases, acute MR provokes pulmonary edema and hemodynamic deterioration. We report a case of a 45-year-old man with atypical pulmonary edema caused by acute traumatic MR. The patient fell down the stairs and injured his …

We report a 35-year-old woman with active acromegaly despite pituitary surgery and irradiation who received continuous octreotide LAR treatment for the control of GH excess until discovery of her pregnancy. The patient delivered a healthy boy following an uneventful pregnancy after discontinuing octreotide LAR as soon as possible at the early phase of pregnancy. Despite a substantial maternal-fetal transfer of octreotide, postnatal development was normal at 3 years of age. In almost all previously described cases, octreotide was discontinued after pregnancy was confirmed. No side-effects of mother or fetus have been reported. Octreotide treatment in pregnancy seems to be feasible and safe. Due to the still-limited number of reported cases treated with octreotide LAR, the potential benefits of octreotide LAR treatment should be weighed carefully against its possible risks.

For this study we enrolled 1,615 males who were admitted to our hospital for a general health check-up. Plasma glucose (PG) and insulin were measured during 75 g OGTT, and abdominal obesity was assessed by ultrasonography in all subjects. We divided them into several groups: normal glucose tolerance (NGT), high-normal glucose tolerance (h-NGT) who showed >10.0 nmol/l at 1 hr PG among those with NGT, impaired fasting glucose (IFG), impaired glucose tolerance (IGT), IFG + IGT, and DM, according to the results of 75 g OGTT. The aim of the present study was to clarify the clinical characteristics of pre-diabetic disorders relating to metabolic syndrome by comparing various parameters including body mass index (BMI), blood levels of various lipids and abdominal wall fat index (AFI) calculated from the thickness of preperitoneal (Pmax) and subcutaneous (Smin) fat layer in the abdomen estimated by ultrasonography with insulin sensitivity determined by homeostatic model assessment (HOMA-IR) in each type of abnormal glucose regulation as classified by PG changes in 75 g OGTT. We also investigated the relationship between insulin secretion capability and insulin sensitivity to delineate the characteristics of each type of abnormal glucose regulation, and compared the area under the insulin curve (AUCins) and the time axis, and the ability of early insulin secretion by glucose loading (insulinogenic index: I.I.) in each type of abnormal glucose regulation. There was a significant positive correlation between HOMA-IR and Smin or Pmax, suggesting that Smin and Pmax may reflect insulin sensitivity. Abdominal obesity, which was diagnosed from the data of AFI, was present in the h-NGT and IFG + IGT groups, suggesting that those groups belong to the clinical entity of metabolic syndrome. HOMA-IR was higher in IFG than in IGT, although I.I. was reduced and AUCins was increased in IFG as well as in IGT. h-NGT demonstrated a slightly lower I.I. and higher AUCins, compared with IGT. IFG demonstrated much stronger insulin resistance than IGT, although I.I. was reduced and AUCins was increased in IFG and IGT. Thus, it is suggested that insulin sensitivity may partly account for the difference in pathogenesis between IFG and IGT; and that h-NGT, which showed abdominal obesity assessed as AFI by ultrasonography, should be recognized as a disease state of metabolic syndrome with impaired glucose regulation.

The development of functional mitral regurgitation (MR) in dilated cardiomyopathy (DCM) has been attributed to altered left ventricular (LV) geometry and annular dilatation. We propose the hypothesis that intraventricular dyssynchrony may play a role in the development of MR in DCM.Tissue Doppler echocardiography was performed in 32 DCM patients to assess the time from the onset of the QRS complex to the peak systolic myocardial strain (Ts) at 2 segments adjacent to the anterolateral and posteromedial papillary muscles from a short axis view. The time difference corrected by the RR interval (DeltaTs/ radicalRR) was used to evaluate dyssynchrony of these segments. There was no difference in the QRS duration (103 +/- 29 ms versus 95 +/- 22 ms, P = .38) or the presence of left bundle branch block (39% versus 14 %, P = .25) between 18 patients with MR and 14 patients without MR. However, DeltaTs/ radicalRR was significantly increased in the patients with MR, compared with those without MR (104 +/- 67 ms versus 5 +/- 16 ms, P.0001). Stepwise multiple regression analysis showed that DeltaTs/ radicalRR was independent contributing factor of MR.Dyssynchrony of myocardial segments adjacent to the papillary muscles may disturb synchronized closure of the mitral leaflets and cause MR in DCM.

症例は36歳,男性.健診の腹部エコーで両側副腎部に腫瘍を指摘された.尿中カテコラミン高値であり,腹部CT上両側副腎部に腫瘤を認め,またMIBGシンチ上同部に集積を認めたことから褐色細胞腫と診断した.生涯の補充療法の負担と副腎クリーゼのリスクを考慮して右副腎全摘,左側腫瘍核出術を施行した.本手術施行例は稀少で報告例も少ない.また家系内に両側褐色細胞腫が多発する興味深い症例であるので報告した.