Usefulness of troglitazone administration to obese hyperglycaemic patients with near-normoglycaemia

AIMS

We assessed the effectiveness of 400 mg/day of troglitazone administered to hyperglycaemic patients with near-normoglycaemia who were obese and who had hyperinsulinaemia.

RESULTS

The area under the plasma glucose curve in oral glucose tolerance tests (OGTT) significantly decreased from 39.8 +/- 19.4-20.5 +/- 10.2 mg/dL. h and the area under the insulin-response curve from 31.8 +/- 22.5-12.2 +/- 5.7 microU/ml x h 4 months after the start of treatment. The level of HbA1c significantly improved from 6.6 +/- 0.2 to 6.3 +/- 0.2% (p < 0.05) by 1 month after administration, and that of serum 1,5-anhydroglucitol (1,5-AG) from 12.6 +/- 1.1-18.3 +/- 2.5 micro/ml (p < 0.05). In some cases, recovery of the first-phase insulin secretion was observed.

CONCLUSIONS

These findings suggest that the administration of this insulin sensitizer is useful in the treatment of obese Japanese subjects with borderline or mild diabetics accompanied by hyperinsulinaemia.

Effects of omega-3 fatty acids in rat allogenic small intestinal transplantation

The aim of this study was to estimate the effect of omega-3 fatty acids on the recipient and graft immune response after rat allogenic small intestinal transplantation. Seven-week-old Lewis rats were randomly assigned to one of three groups according to the diet received: an FO group (fish oil supplemented), an SB group (soy bean oil supplemented) or a control group (normal rat chow). The recipient Lewis rats were each given their respective group diet for 12 days, and then, on the 19th day of gestation, a 2 cm jejunum from the donor fetal Fischer rat was transplanted into the abdominal wall of the recipient rats using a non-vascular anastomotic technique. The recipient rats were killed on day 2 after transplantation, and the recipient plasma IL-2, IFN-gamma and IL-1 beta levels were determined. In addition, the histological findings of the graft were analyzed. The cytokine levels of the FO group were significantly lower than the other two groups. In order to determine the grade of rejection, the morphological findings were blindly graded on a scale of 0-4. The mean grade of the FO group was also significantly lower than the other two groups. Omega-3 fatty acids are therefore considered to have an immunosuppressive effect on rat allogenic small intestinal transplantation based on the recipient plasma IL-1 beta, TNF and IL-2 levels and the histological findings of the grafts.

Retarded gastric acid secretion in rats infected with larval Taenia taeniaeformis

The influence of hepatic larval Taenia taeniaeformis infection on gastric acid secretory activity and gastric mucosal integrity was investigated. After 12 weeks of infection with 2,000 T. taeniaeformis eggs, the gastric pH values of control and infected rats were 4.1+/-0.6 (mean +/- SD) and 8.4+/-0.2, respectively. There was no difference in the basal acid secretion between control (1.7+/-0.7 micro Eq.H(+)/15 min) and infected (1.9+/-0.3) rats. However, infected rats failed to respond to histamine stimulation, the maximum acid output level being 2.8+/-0.4 in the infected rats, compared to 12.9+/-3.3 in control rats. Larval T. taeniaeformis infection resulted in the suppression of gastric acid secretion leading to hypergastrinemia.

[KRP-297, MCC-555]

KRP-297 and MCC-555, which are being developed in Japan as thiazolidinediones, uniquely bind and activate peroxisome proliferator-activated receptors(PPAR). KRP-297, unlike other thiazolidinediones, effects on not only PPAR gamma but also PPAR alpha. Furthermore, this compound acts directly on basal glucose uptake in the rat skeletal muscle. KRP-297 decreased plasma glucose and insulin levels, and also blood triglyceride and free fatty acid in diabetic animal models. MCC-555 has significant antidiabetic properties yet its binding affinity for PPAR gamma is less than 1/10 that of BRL 49653. Thus, it is regarded now as a PPAR gamma modulator rather than agonist, depending on cell type. At present, clinical phase II studies of both drugs are under way.

Post-load glucose measurements in oral glucose tolerance tests correlate well with 1,5-anhydroglucitol, an indicator of overall glycaemic state, in subjects with impaired glucose tolerance

Using both cross-sectional and longitudinal methods, we investigated the relationship between post-load serum glucose concentration in a 75 g oral glucose tolerance test (OGTT) and overall glycaemic state in subjects with impaired glucose tolerance (IGT). Glycaemic state was assessed by measuring glycated haemoglobin (HbA1c) and the serum concentration of 1,5-anhydroglucitol (1,5-AG). In the cross-sectional study, the concentration of 1,5-AG, while remaining within a normal range, was reduced to a degree proportional to the post-load glycaemic level. Although the correlation between HbA1c and post-load plasma glucose was relatively weak (r=0.281, P<0.001), a significant inverse correlation (r=-0.824, P<0.0001) was found between 1,5-AG and mean post-load plasma glucose concentration in 211 subjects with IGT. Fasting plasma glucose (r=-0.539, P<0.0001) and 2 h plasma glucose (r=-0.621, P<0.0001) were correlated with 1,5-AG less strongly than was post-load glycaemia. Both 1,5-AG and HbA1c were correlated weakly but significantly with the fasting insulin concentration. In the longitudinal study we measured 1,5-AG and mean post-load plasma glucose with an OGTT once yearly for 10 years in 15 subjects with IGT. Strong inverse correlations were seen between 1,5-AG and mean post-load plasma glucose in each subject (range of r values among subjects of -0.584 to -0.978). These findings suggest a close relationship between post-load plasma glucose concentration measured by OGTT and overall glycaemic state in subjects with IGT.

The efficacy of predeposited autologous blood transfusions in general pediatric surgery

Allogeneic blood transfusions are associated with a risk of infection, immunological reactions, immunosuppression, and the induction of antibodies in blood cells. We report our results of giving predeposited autologous blood transfusions (PABT) to children when it was anticipated that transfusions would be required for an elective operation. Autologous blood was collected for deposit from 16 patients ranging in age from 1 to 11 years old (mean 5.6 years old, mode 4 years old), and weighing from 9.7 to 42 kg (mean 20.8kg). They included 12 patients with pectus excavatum (funnel chest) and 4 patients with choledochal cyst (CBD). Blood was collected once from 2 patients and twice from the other 14 patients, then centrifuged and stored in a freezer at -80 degrees C. Between 7 and 14 ml/kg was collected at one time, the total mean volume of predeposited blood being 21.0 +/- 3.3 ml/kg for the children operated on for funnel chest, and 16.2 +/- 4.5 ml/ kg for those operated on for CBD. None of the patients required allogeneic transfusions and no complications occurred. PABT was found to be a safe and effective means for elective general pediatric surgical procedures for avoidance of allogeneic blood transfusion.

Outcome of fetal cystic hygroma and experience of intrauterine treatment

OBJECTIVE

To review our cases of fetal cystic hygroma and to examine the prognostic factors with the goal of establishing criteria for the intrauterine treatment for cystic hygroma.

PATIENTS AND METHODS

Thirty-one cases of fetal cystic hygroma were managed by us from January 1988 to December 1997, and 21 cases were available for analysis. Three prognostic factors, namely chromosomal abnormality, structural anomaly and hydrops fetalis, were evaluated. We treated 2 cases of cystic hygroma associated with hydrops fetalis in utero using OK-432 injection under ultrasound guidance.

RESULTS

The fetuses without any of the prognostic factors listed above showed a good prognosis throughout the fetal and neonatal periods. However, in this group, 2 infants with large tumors died of hemorrhage from the tumor at 6 months and 3 years of age, respectively. Cases with hydrops fetalis without chromosomal abnormalities or structural anomalies (5 cases) resulted in either intrauterine fetal death (IUFD, 2 cases) or early perinatal neonatal death (early PND, 3 cases). The cause of early PND was circulatory failure. Most of the hydrops cases with either a chromosomal abnormality or structural anomaly resulted in IUFD before 22 weeks of gestation. The size of the cyst decreased in 1 of 2 cases treated in utero.

CONCLUSIONS

The fetal cases of cystic hygroma showing hydrops fetalis without chromosomal abnormalities or structural anomalies are considered to be possible candidates for intrauterine therapy. Those with very large cystic hygroma without any of the three prognostic factors are also thought to be candidates for fetal treatment. Based on our clinical experience, sclerotherapy using OK-432 is considered to be a treatment option in selected cases with fetal cystic hygroma.

Manganese intoxication during intermittent parenteral nutrition: report of two cases

BACKGROUND AND METHODS

The administration of trace elements is thought to be needed in patients receiving long-term parenteral nutrition. Recently, manganese intoxication or deposition was documented in such patients. We report two cases of manganese intoxication during intermittent parenteral nutrition including manganese. Manganese had been administered for 4 years at a frequency of one or two times per week in one case and for 5 years at a frequency of one or two times per month in the other case. Both cases showed mild symptoms with headache and dizziness. One case had mild hepatic dysfunction and the other did not. The whole-blood manganese level increased in one case, but not in the other case. T1-weighted magnetic resonance images revealed symmetrical high-intensity areas in basal ganglia and thalamus in both cases. After the administration of manganese was stopped, these symptoms all disappeared and the magnetic resonance images abnormalities gradually improved in both patients. Mild long-term manganese intoxication is thus considered to occur regardless of the frequency of using a manganese supplement.

CONCLUSIONS

Patients should be carefully monitored when receiving long-term parenteral nutrition including manganese, even when the manganese dose is small and the frequency of receiving a manganese supplement is low.

The influence of traditional Chinese herbal drugs on serum 1, 5-anhydroglucitol levels

The serum concentration of 1,5-anhydroglucitol (1,5-AG), a polyol which originates mainly in the diet, is used in Japan as a new marker for glycemia. To evaluate the potential interference of 1, 5-AG measurements by traditional Chinese medicines (Kampo), we examined the 1,5-AG content in 32 types of concentrated dosage forms of Kampo using high performance liquid chromatography (HPLC). The 32 types of Kampo were the most frequently used in Japan, two of which, Ninjin-yoei-to (7030 microg/g dry weight) and Kami-kihi-to (6700 microg/g dry weight), contained large amounts of 1,5-AG. Six others contained small amounts of 1,5-AG. Both Ninjin-yoei-to and Kami-kihi-to contain the same ingredient, Polygalae radix, which is a crude form of polygalitol (1,5-AG). To confirm the effects of these Kampo medicines on the serum levels of 1,5-AG, we administered Ninjin-yoei-to (7.5 g/day) for 8 weeks to 18 patients with Type 2 diabetes mellitus (Type 2 DM). The serum level of 1,5-AG increased from 9.8+/-8.9 to 28.1+/-17.5 microg/ml by week 8. Hemoglobin A1c (HbA1c) had not changed by week 8. Thus, an abnormal serum 1,5-AG level may be present in patients taking Kampo which contains Polygalae radix.

The validity of bioelectrical impedance phase angle for nutritional assessment in children

BACKGROUND/PURPOSE

Bioelectrical impedance analysis (BIA) is a quick and noninvasive method for estimating body composition. Many prediction equations have been reported recently using bioelectrical impedance to calculate fat free mass (FFM) and fat mass (FM). These equations are based on the assumption that the composition and density of FFM are stable. In children, the composition and density of FFM vary according to age and clinical state, so the use of these equations is limited. However, phase angle is directly determined from resistance (Rz) and reactance (Xc) without equations and reflects body cell mass. The authors, therefore, investigated the validity of phase angle for nutritional assessment in children.

METHODS

Bioelectrical impedance analysis and anthropometric measurements were performed in 81 patients, including 71 well-nourished and 10 malnourished children.

RESULTS

Phase angle correlated with body weight (R = 0.818) and arm muscle circumference (r = 0.901) in well-nourished children. Malnourished patients showed lower phase angle than that of well-nourished children.

CONCLUSION

Bioelectrical impedance phase angle is a useful parameter for nutritional assessment in children.

Transport of 1,5-anhydro-D-glucitol into insulinoma cells by a glucose-sensitive transport system

The uptake of 1,5-anhydro-D-glucitol (1,5-AG) occurs by passive mechanisms in cells or tissues that have passive glucose transporters. It is known that serum 1,5-AG concentrations are reduced in patients with diabetes mellitus. To elucidate the metabolism of this substance and its physiological role in pancreatic beta-cells, we assayed 1,5-AG transport in the insulinoma-derived cell lines, RINr and MIN6. Both cell lines showed an insulin-insensitive, concentration-dependent uptake of 1,5-AG with a saturation time of approximately 120 min, and most of the 1,5-AG in the cytoplasm was in the free form. A biphasic saturation curve was obtained using a wide range of 1,5-AG concentrations, suggesting that accumulation was mediated by a high affinity and a low affinity transporter. The high affinity transporter had a K(m) of 10.4 in RINr cells and 13.0 mM in MIN6 cells, and the low affinity transporter had a K(m)100 times, being much higher than the physiological concentrations of 1,5-AG. These results indicate that the 1,5-AG carrier system in insulinoma cells is distinct from that in either the somatic cells or renal tubular cells. These findings also suggest that a unique 1,5-AG transport system is present in pancreatic beta-cells.

[Troglitazone]

There are good responders to troglitazone in whom sulfonylurea had failed to improve glycemia. The anti-diabetic effect of this agent seems to be partially composed of prolonged action. The action on different adipose tissue depots of troglitazone may be involved in this slow action. Significant decrease in fasting plasma glucose occurred. The effect may be related to reducing nocturnal hepatic glucose output by the drug. The efficacy of troglitazone is dependent on the levels of circulating insulin. Recent reports demonstrate the good therapeutic power of troglitazone in combination with a sulfonylurea or metformin, or insulin. Thus, we got a new approach of oral therapy to patients with type 2 diabetes in sulfonylurea failure before entering the insulin treatment. Because of low frequency of hypoglycemia, we can safely continue to use this drug in patients with euglycemia by the therapy for preventing return to hyperglycemia.

"Gut-feeling" or evidence-based approaches in the evaluation and treatment of human short-bowel syndrome

Short bowel syndrome is the malabsorptive state that often follows extensive resection of the small intestine. Long-term survival without parenteral nutrition depends on the process of intestinal adaptation, through which the remaining small bowel gradually increases its absorptive capacity. The process of intestinal adaptation is almost exclusively luminal nutrient dependent. To date the clinical management of short bowel patients is mostly based on a 'trial and error' regimen because human data and randomised trials using trophic substances are lacking due to the small number of patients annually present in pediatric surgical centres. We evaluate here the currently available as well as some more recently developed methods of measuring intestinal absorption and adaptation in short bowel patients. New techniques such as measurements of (1) intestinal permeability and carbohydrate absorption using the sugar absorption test, (2) gastrointestinal hormone production of gastrin, cholecystokinin and peptide YY, (3) transmural potential difference of the gastrointestinal tract using electrophysiology and (4) mucosal enzyme expression of lactase and sucrase-isomaltase using immunohistochemistry were evaluated. These new techniques are promising in monitoring the process of adaptation of the remaining intestine and evaluating the effect of therapeutic interventions in patients with short bowel syndrome.

Fetal stabilization for antenatally diagnosed diaphragmatic hernia

BACKGROUND/PURPOSE

Infants with congenital diaphragmatic hernia have pulmonary hypoplasia resulting in persistent pulmonary hypertension of neonates (PPHN), which is the main contributor to both high mortality and morbidity. The pulmonary artery bed in patients with congenital diaphragmatic hernia (CDH) is underdeveloped and is very sensitive to slight stimuli. It is, therefore, vital to avoid any factors that might increase pulmonary vascular resistance during the perinatal treatment of these patients. Recently, fetal anesthesia for perinatal stabilization in patients with CDH has been reported. However, the efficacy of this method remains controversial. The aim of this study is to analyze the benefits of fetal stabilization using fetal anesthesia in patients with CDH.

METHODS

The authors have seen 9 cases of antenatally diagnosed CDH and attempted fetal stabilization. The indication for fetal stabilization was a lung thoracic ratio of less than 0.2, without any severe associated anomalies. The protocol for fetal stabilization was (1) monitoring the fetal respiratory movement and heart beat by ultrasonography, (2) the administration of morphine (20 to 30 mg) and diazepam (5 mg) to the mother, (3) the confirmation of any interruptions in fetal movement followed by a cesarean section, (4) pancuronimum (0.5 mg) was given through the umbilical vessels, (5) intubation before clamping of the umbilical cord, and (6) high-frequency oscillatory ventilation (HFO) without bagging.

RESULTS

The lung-thratic ratio (LTR) was between 0.06 to 0.17 (average, 0.10+/-0.04). Operation was performed in 7 of 9 patients at between 2.5 and 27 hours after birth. The overall survival rate was 66.7% (6 of 9). All of the patients who underwent operation within 5 hours after birth survived.

CONCLUSIONS

Perinatal stabilization using fetal anesthesia was found to be effective in preventing PPHN and shortening the period of preoperative stabilization. It also improved the survival rate of patients with severe CDH.

Complications in neonates with short bowel syndrome and long-term parenteral nutrition

BACKGROUND

Because of advances in parenteral nutrition (PN), the prognosis for patients with short bowel syndrome (SBS) has recently shown great improvement. Even infants with a small bowel measuring only 20 cm either with or without an ileocoecal valve can now survive. However, because of the increased periods of PN, severe complications associated with PN have been observed.

PATIENTS AND METHODS

We analyzed 17 patients with SBS treated by long-term PN to investigate the complications of PN, particularly hepatic dysfunction, micronutrient deficiency, and intoxication.

RESULTS

Eleven of 17 patients (64.7%) had hepatic dysfunction, mostly cholestasis. The main causes of hepatic dysfunction were loss of enteral feeding and infections. Regarding the complications of the micronutrients, zinc and copper deficiencies have been observed less often because of trace element supplements. However, manganese deposition, especially in the basal ganglia, was recognized in one patient.

CONCLUSIONS

We therefore need to pay more attention to these problems when treating this disease in order to improve the overall prognosis significantly.

[Insulin-sensitizing agent]

Troglitazone is a new oral insulin-sensitizing agent from the thiazolidinedione group of compounds that has been developed in Japan Thiazolidinediones improve the insulin sensitivity at muscle, adipose tissue and liver. The overall effectiveness of troglitazone seems to be less potent than is usually seen with sulfonylureas, however, there are good responders to troglitazone, in which sulfonylurea had failed to improve glycemia. It is frequently very effective for those who are very obese and show hyperinsulinemia. Recent reports demonstrate the good therapeutic power of troglitazone in combination with a sulfonylurea or metformin, or insulin. In future, a possibility that reduction of insulin resistance by troglitazone reduce cardiovascular risk will be discussed. Unfortunately, wider use has led to recognition of potential for serious liver damage. Until now, the mechanisms of the liver toxicity has not been known. We have to monitor GOT, GPT and LDH levels as recommended.

Alterations of the intramural nervous distributions in a chick intestinal atresia model

The postoperative intestinal dysmotility seen in intestinal atresia (IA) is usually found in association with a dilatation of the proximal intestinal segment, but the etiology of this disorder is not yet fully understood. A chick IA model was made by cutting the postumbilical midgut on d 11 in ovo. The operated chicks were euthanized 2 d after hatching. The samples were divided into two groups according to the extent of the dilatation of proximal ileal segments. Cryostat sections were processed for immunohistochemistry by the use of antisera to protein gene product 9.5, vasoactive intestinal polypeptide, substance-P, and alpha-smooth muscle actin and were also stained by NADPH-diaphorase. Tn highly dilated proximal segments, a decreased number of protein gene product 9.5-positive fibers was found in both the circular muscle and submucous layers. The number of nerve fibers positive for vasoactive intestinal polypeptide, substance-P, and NADPH-diaphorase also decreased in the circular muscle layer, particularly in the deep muscular plexus. Hypertrophy and an alteration of the staining intensities in the circular muscle layer were also revealed by a-smooth muscle actin staining. The nerve distribution of the distal segments was indistinguishable from that of the age-matched controls and the sham-operated group. Abnormalities in the intramural nerves are only found in the proximal ileal segment of the IA models. The abnormal nerve distribution of the proximal segment might thus be implicated in the postoperative dysmotility of the intestine in IA.