Descriptive epidemiology of IDDM in Hokkaido, Japan: the Childhood IDDM Hokkaido Registry

OBJECTIVE

To identify the incidence of IDDM with regard to sex, age, family history of diabetes, season, and 5-year period of childhood IDDM among children ages 0-14 years from a population-based epidemiological study in Hokkaido, Japan, from 1973 to 1992.

RESEARCH DESIGN AND METHODS

Registration of all new IDDM cases in Hokkaido was conducted by the Childhood IDDM Hokkaido Registry Study Group from 1973 to 1992. The cases were selected from among 1) patients who were admitted to the member hospitals of the study group, 2) patients who answered a questionnaire distributed to hospitals and diabetic clinics throughout Hokkaido, and 3) patients whose cases were recorded in free-treatment medical records of urban and rural districts. The case ascertainment rate was estimated to be 100%. Differences in incidence with regard to sex, age, family history of diabetes, season, and year period were analyzed by the Poisson regression analysis by GENMOD.

RESULTS

During the 20-year period studied, 396 cases (181 boys, 215 girls) of abrupt-onset IDDM were registered. Statistically significant differences in annual incidence were found according to sex (female), age (8-14 years), history (having no diabetes in family), season (spring), and 5-year period.

CONCLUSIONS

This is the first population-based, long-term epidemiological study of childhood IDDM from Japan. We observed a significantly higher annual incidence (per 100,000/year) of IDDM in female subjects (1.81), older age-groups (2.25 for 8-14 years), subjects with no family history of diabetes (1.26), diabetes onset in the spring (2.20), and an increased trend over the 20 years. In addition, the heterogeneity of IDDM among Japanese children needs to be elucidated.

Onset age-dependent variations of three islet specific autoantibodies in Japanese IDDM patients

The age related incidence rate of insulin-dependent diabetes mellitus shows a bimodal distribution, not only in Caucasians but also in Japanese. To evaluate the onset age-related autoimmune profile at presentation in insulin-dependent diabetes mellitus (IDDM), glutamic acid decarboxylase (GAD) autoantibody, islet cell antibody (ICA), and insulin autoantibody (IAA) were measured in 137 newly diagnosed Japanese IDDM patients with onset ages between 0-29 years. The prevalence of GAD autoantibody was significantly increased from the lowest (32%) in the 0-5 years onset age group to 75% in the 13-19 years onset age group (P < 0.05), whereas the IAA prevalence significantly decreased from the peak (48%) in the 6-12 years onset age group to 10% in the 20-29 years onset age group (P < 0.05). The ICA prevalence was increased from the lowest (32%) in the 0-5 years onset age group to the highest (53%) in the 20-29 years onset age group similar to that for the GAD autoantibody. Such results demonstrate that there was age-related autoimmune characteristics at presentation of IDDM in Japanese as well as in Caucasians.

Delayed kinetics of oxygen uptake during recovery after exercise in cardiac patients

PURPOSE

Little is known about cardiovascular responses during recovery from exercise in patients with cardiovascular disease. The aim of this study was to determine the time constants of the kinetics of oxygen uptake and heart rate during recovery from exercise and to evaluate the influence of resting cardiac function on these kinetics in patients with left ventricular dysfunction.

METHODS

A moderate exercise test was performed by 40 patients (57+/-10 yr old) with prior myocardial infarction at a constant work rate (40+/-8 W) for 6 min on a cycle ergometer. The time constants of oxygen uptake and heart rate during 6 min of recovery were compared in patients whose left ventricular ejection fractions were > or =35% (group 1, N = 20) and those with ejection fractions <35% (group 2, N = 20).

RESULTS

The time constant of the decrease in oxygen uptake during exercise recovery was significantly prolonged (oxygen requirement was increased) in group 2 compared with group 1. Heart rate during recovery was consistently higher, and its time constant was prolonged in group 2 compared with group 1. The time constant of oxygen uptake was positively correlated with the time constant of heart rate.

CONCLUSION

The recovery of oxygen uptake after exercise was significantly delayed, associated with delayed recovery of heart rate, in patients with severely impaired left ventricular function.

Effects of isosorbide dinitrate on oxygen uptake kinetics in cardiac patients

PURPOSE

Although nitrates are known to improve indices of exercise capacity in patients with coronary artery disease, their effects on oxygen uptake kinetics during the onset of exercise have not been clarified. We evaluated the acute effects of isosorbide dinitrate on the kinetics of oxygen uptake during the onset of exercise at a constant work rate in patients with coronary artery disease.

METHODS

We studied 14 patients with coronary artery disease who performed 6 min of low-intensity exercise at a constant work rate on a cycle ergometer 30 min after oral administration of 10 mg of isosorbide dinitrate or placebo in a double-blind, crossover manner. Oxygen uptake was calculated from breath-by-breath analysis of respired gases. The time constant of oxygen uptake kinetics during the onset of exercise was determined by fitting a single exponential function to the oxygen uptake response.

RESULTS

Heart rate was significantly increased at rest, and systolic blood pressure was significantly decreased both at rest and during exercise after administration of isosorbide dinitrate. The time constant of oxygen uptake was significantly shorter (the kinetics were faster) after administration of isosorbide dinitrate (39.4+/-10.1 vs 44.5+/-10.5 s, P = 0.038).

CONCLUSIONS

Isosorbide dinitrate was found to speed the kinetics of the increase in oxygen uptake during constant work-rate exercise. The time constant of oxygen uptake, which reflects the rapidity of cardiovascular adaptation at the onset of exercise, seems to be a useful parameter of the effectiveness of therapy in patients with coronary artery disease.

Cardiomyopathy in a case of Crow-Fukase syndrome

Crow-Fukase syndrome or POEMS syndrome is a variant of plasma cell dyscrasia that is characterized by polyneuropathy, organomegaly, endocrinopathy, the presence of M-protein in serum, and dermatological changes. A 60-year-old man presented with features of Crow-Fukase syndrome, such as the presence of M-protein in serum, dermatological changes, and osteosclerotic changes, but did not have polyneuropathy. To our knowledge, this is the first case of Crow-Fukase syndrome in which the presence of hypertrophic cardiomyopathy has been confirmed by a left endomyocardial biopsy. The findings suggest that hypertrophic cardiomyopathy may be a manifestation of organomegaly in patients with Crow-Fukase syndrome.

Lung function and exercise gas exchange in chronic heart failure

BACKGROUND

The ventilatory response to exercise in patients with chronic heart failure (HF) is greater than normal for a given metabolic rate. The objective of the present study was to determine the mechanism(s) for the high ventilatory output in patients with chronic HF.

METHODS AND RESULTS

Centers in Germany, Italy, Japan, and the United States participated in this study. Each center contributed studies on patients and normal subjects of similar age and sex. One hundred thirty patients with chronic HF and 52 healthy subjects participated. Spirometric and breath-by-breath gas exchange measurements were made during rest and increasing cycle exercise. Arterial blood was sampled for measurement of pH, PaCO2, PaO2, and lactate during exercise in 85 patients. Resting forced expiratory volume in 1 second (FEV1) and vital capacity (VC) were proportionately reduced at all levels of impairment. Patients with more severe HF had greater tachypnea and a smaller tidal volume (VT) at a given exercise expired volume per unit time (VE). This was associated with an expiratory flow pattern characteristic of lung restriction. VE and VCO2 as a function of VO2 were increased during exercise in HF patients. The increases were greater the lower the peak VO2 per kilogram of body weight. The ratio of VD (physiological dead space) to VT and the difference between arterial and end tidal PCO2 at peak VO2 also increased inversely with peak VO2/kg. In contrast, the difference between alveolar and arterial PO2 and PaCO2 were both normal, on average, at peak VO2 regardless of the level of impairment. The more severe the exercise limitation, the higher the lactate and the lower the HCO3- at a given VO2, although pH was tightly regulated.

CONCLUSIONS

The increase in VE in chronic HF patients is caused by an increase in VD/VT due to high ventilation/perfusion mismatching, an increase in VCO2 relative to VO2 resulting from HCO3- buffering of lactic acid, and a decrease in PaCO2 due to tight regulation of arterial pH. With regard to the excessive VE in HF patients, the increases in VD/VT and VCO2 relative to VO2 are more important as the patient becomes more exercise limited. Regional hypoperfusion but not hypoventilation typifies lung gas exchange in HF. This and other mechanisms might account for the restrictive changes leading to exercise tachypnea in HF patients.

Preserved musical abilities following right temporal lobectomy

It has been widely accepted that the right temporal lobe plays a major role in the processing of music. One of the main lines of evidence was derived from Milner's study, published in 1962, which reported that right temporal lobectomy led to a decline in patient scores on four of the six subtests (Tonal Memory, Timbre, Loudness, and Time subtests) of the Seashore Measures of Musical Talents. That finding had led some surgeons and patients to hesitate in choosing right temporal lobectomy as a treatment for intractable epilepsy. The authors examined performance on the Seashore Measures before and after operations in 20 patients with right temporal lobectomy and nine patients with left temporal lobectomy. No disturbances in the Seashore Measures were detected after temporal lobectomy on either side. The extent of these temporal lobectomies was smaller than that of the temporal lobectomies in Milner's study, as measured along the sylvian fissure (1.5-4 cm; mean 2.7 cm, standard deviation (SD) 0.92 cm) and the base of the temporal lobe (3.5-5.5 cm; mean 4.7 cm, SD 0.63 cm). These findings indicate that the region resected on right temporal lobectomy in the present study is not essential for basic musical processing.

[Serum eosinophil cationic protein in infants during first wheezing episode]

We measured serum ECP levels in infants during first wheezing episode. Serum ECP in these infants are significantly higher than in control infants, although much higher in children with asthma. Serum ECP in these infants with high serum IgE and/or positive RAST score are higher than in infants with normal serum IgE and negative RAST score. In children with bronchial asthma serum ECP is correlated with peripheral eosinophil counts, but in infants during first wheezing episode serum ECP is often elevated not associated with increased peripheral eosinophil counts. These suggest that activated eosinophils could be responsible for bronchoconstriction in wheezing patients with atopic diathesis even in very early phase and that these eosinophilic inflammations could contribute to formation of increased airway reactivity and bronchial asthma.

Does appropriate endurance exercise training improve cardiac function in patients with prior myocardial infarction?

OBJECTIVE

The objective of the present study was to determine whether appropriate endurance exercise training improves cardiac function in patients with prior myocardial infarction.

METHODS

Twenty-nine patients with prior myocardial infarction were divided into three groups (Group 1: control, Group 2: low-intensity training, Group 3: high-intensity training). Low and high training intensities were determined according to the gas exchange threshold of each patient. The patients in Groups 2 and 3 performed 15 min of home-based physical training safely, twice a day, 5 days a week for 2 months. Prior to and following this training, each patient performed two constant work rate tests (moderate and heavy intensity) and a symptom-limited incremental exercise test.

RESULTS

Heart rates at rest and during exercise were decreased significantly after 2 months in all three groups. Stroke volume at rest increased significantly after 2 months only in Group 3. Stroke volume after 6 min of heavy-intensity exercise increased significantly in Groups 2 and 3. However, the ejection fraction at 6 min of heavy-intensity exercise increased significantly only in Group 3. The maximal work rate attained during incremental exercise testing increased significantly in Groups 2 and 3. This parameter did not significantly change in the control group.

CONCLUSIONS

Effects of physical training on maximal exercise capacity were noted in both exercise training groups. However, improvement in cardiac function (such as stroke volume), both at rest and during exercise, was noted only in the high-intensity training group. Our results suggest that relatively high-intensity training may improve exercise capacity and cardiac function of patients with prior myocardial infarction.

Protective effects of dimethyl amiloride against postischemic myocardial dysfunction in rabbit hearts: phosphorus 31-nuclear magnetic resonance measurements of intracellular pH and cellular energy

The effects of 5-(N,N-dimethyl)amiloride, a potent and specific Na(+)-H+ exchange inhibitor, were investigated in isolated perfused rabbit hearts subjected to ischemia and reperfusion. Phosphorus 31-nuclear magnetic resonance spectroscopy was used to monitor intracellular pH, creatine phosphate, beta-adenosine triphosphate, and inorganic phosphate. After cardioplegic arrest with St. Thomas' Hospital solution, normothermic (37 degrees C) global ischemia was induced for 45 minutes, and the hearts were reperfused for 50 minutes. Dimethyl amiloride at 10 mumol/L, which has minimal inotropic and chronotropic effects on the nonischemic heart, was added to the cardioplegic solution. Treatment with dimethyl amiloride reduced the elevation of left ventricular end-diastolic pressure during and after the ischemia and improved the postischemic recovery of developed pressure from 76% +/- 3.2% at 30 minutes of reperfusion in control hearts (n = 6) up to 99% +/- 1.9% in hearts treated with dimethyl amiloride (n = 8). Dimethyl amiloride did not affect the decline in intracellular pH during ischemia for up to 30 minutes but enhanced the intracellular acidosis thereafter. The intracellular pH at the end of ischemia was 6.21 +/- 0.05 in control hearts compared with 5.24 +/- 0.17 in hearts treated with dimethyl amiloride (p < 0.05). During reperfusion, intracellular pH of hearts treated with dimethyl amiloride was less than control for 5 minutes, but subsequent recovery of intracellular pH was similar to control. Treatment with dimethyl amiloride did not affect creatine phosphate breakdown, inorganic phosphate accumulation, and beta-adenosine triphosphate depletion during 45 minutes of ischemia. The creatine phosphate resynthesis and inorganic phosphate reduction during reperfusion were also unaffected. These findings suggest that Na(+)-H+ exchange plays an important role not only during reperfusion but also during ischemia for the development of postischemic cardiac dysfunction most likely by inducing primary Na+ and secondary Ca2+ overload. Specific Na(+)-H+ exchange inhibitors like dimethyl amiloride would have a potential therapeutic profile in cardiac surgery, especially if added before ischemia.

Prognostic value of preoperative immunosuppressive acidic protein in patients with gastric carcinoma. Findings from three independent clinical trials. Tumor Marker Committee for the Study Group of Immunochemotherapy with PSK for Gastric Cancer

BACKGROUND

Immunosuppressive acidic protein (IAP) has been reported to have close correlation with the impairment of host immune response. To evaluate the significance of IAP in clinical studies, the prognostic value of preoperative IAP was investigated in clinical trials of patients with gastric carcinoma after curative resection.

METHODS

An appropriate IAP threshold value of 580 micrograms/mL was determined using Cox's proportional hazards model. Five-year survival rates were estimated for high and low IAP groups in three different clinical studies. Meta-analysis was performed based on individual patient data, and summarized hazard ratios were estimated using a stratified proportional hazards model.

RESULTS

Meta-analysis of the three clinical trials demonstrated that patients with preoperative IAP levels above the threshold had significantly poorer cancer related survival (P = 0.0039) and absolute survival (P = 0.0023), even after adjustment for the major prognostic factors.

CONCLUSIONS

Gastric carcinoma patients with an IAP value above the threshold level of 580 micrograms/mL have a higher risk of cancer death and absolute death than patients with an IAP value below the threshold value.

Prospective adjuvant therapy with mitomycin C and carmofur (HCFU) for colorectal cancer, 10-year follow-up: Tokai HCFU Study Group, the first study for colorectal cancer

A joint study was performed by the Tokai HCFU study group, which included 41 institutions to study the usefulness of the concomitant therapy with Mitomycin C (MMC) and Carmofur (HCFU) as a postoperative adjuvant chemotherapy in patients with colorectal cancer who had curative resection. Patients were divided into two groups, Group MMC and Group MMC+HCFU, using the "envelope" method. Among the 172 patients who had the envelope opened, 149 evaluable cases were analyzed for evaluation of the drug. The cumulative 10-year survival rates of Group MMC+HCFU had a statistically significant increase in survival rate compared with Group MMC. In particular, the rate was statistically significant in patients with colorectal cancer who had lymph node invasion. There were no severe side effects due to the adjuvant chemotherapy with MMC+HCFU. Thus the adjuvant chemotherapy with MMC+HCFU is suggested to be a useful and safe postoperative adjuvant chemotherapy.

Relation between oxygen uptake and carbon dioxide output during constant work rate exercise in patients with mild congestive heart failure

The gas exchange (anaerobic) threshold, a useful index of exercise capacity, is determined as the oxygen uptake (VO2) value at which the ratio of the increase in carbon dioxide output (VCO2) to the increase in VO2 becomes > 1 during incremental exercise (V-slope method). However, this method has not been applied to the constant work rate exercise. We evaluated whether a similar threshold phenomenon (i.e., the gas exchange threshold) could be detected during exercise performed at a constant work rate. Thirty-seven patients with a variety of cardiovascular diseases and 27 normal subjects performed symptom-limited incremental exercise and 6 minutes of 50 W constant work rate exercise. The gas exchange threshold could be determined during both symptom-limited incremental exercise (GETi) and constant work rate exercise (GETc) in all subjects, except for 3 normal subjects, by using the V-slope method. There was a significant correlation between GETc and GETi (r=0.80, p<0.0001). GETc was significantly correlated with peak VO2 obtained during the incremental exercise test (r=0.69, p<0.0001). The results suggest that the gas exchange threshold during constant work rate exercise, which does not require the subject's maximal effort, is a useful measure of exercise capacity in patients with cardiovascular disease.

Time- versus frequency-domain analysis in predicting cycle length of inducible ventricular tachycardia after myocardial infarction

To determine whether time- and frequency-domain analyses differ in their ability to predict sustained ventricular tachycardia (VT) induced by programmed ventricular stimulation, 60 consecutive patients with myocardial infarction and 30 healthy control subjects were evaluated. Programmed ventricular stimulation using three extrastimuli and signal-averaged ECG recordings were performed in patients with myocardial infarction. Of the 60 patients, sustained monomorphic VT (SMVT) with cycle length (CL) > or = 250 ms (slow SMVT) was inducible in 9, and SMVT with CL < 250 ms (fast SMVT) was inducible in 9. The durations of the filtered QRS (f-QRS) at each high-pass filter (25, 40, and 80 Hz) and the low amplitude signal (LAS) at 25-Hz high-pass filtering were significantly longer in the slow SMVT group than in the fast SMVT, no VT, or normal control group. The root-mean-square voltages at 25-Hz and 80-Hz high-pass filters in the slow SMVT group were significantly lower than in the fast SMVT, no VT, or normal control group. There was no significant difference in time-domain variables among fast SMVT, no VT, and normal control groups. The CL of the induced sustained VT was significantly correlated with the durations of f-QRS and LAS. Concerning frequency-domain variables (area ratio and factor of normality), there was no significant difference between slow and fast SMVT groups. Both the slow and fast SMVT groups had a significantly higher area ratio and a significantly lower factor of normality than the group with no VT or the normal control subjects. In conclusion, there were significant correlations between time-domain variables and CL of SMVT, while there was no correlation when using frequency-domain parameters.