Reduced GFR and microalbuminuria are independently associated with prevalent cardiovascular disease in Type 2 diabetes: JDDM study 16

AIMS

We investigated whether a reduced estimated glomerular filtration rate (eGFR) was associated with cardiovascular disease (CVD) prevalence, independent of the effect of microalbuminuria in patients with diabetes.

METHODS

In a multicentre, large-scale cohort including 3002 Japanese patients with Type 2 diabetes without macroalbuminuria, the relationship of a reduced eGFR and microalbuminuria with CVD was investigated.

RESULTS

Of those patients, 4.8% had a reduced eGFR and microalbuminuria, 12.7% had a reduced eGFR without microalbuminuria and 18.7% had microalbuminuria but normal eGFR. A reduced eGFR and microalbuminuria were each associated with a doubling of the prevalence of CVD. Compared with patients with no microalbuminuria/normal eGFR [odds ratio (OR) 1.0], the OR for CVD was significantly higher in those with a reduced eGFR without microalbuminuria (OR 1.97) and similarly higher in those with microalbuminuria without a reduced eGFR (OR 1.85). The OR was highest in those with both a reduced eGFR and microalbuminuria (OR 3.97, 95% confidence interval 2.55-6.20). The OR for CVD remained significant after adjustments for age, sex, hypertension, dyslipidaemia, smoking, body mass index, glycated haemoglobin and the duration of diabetes, and remained significant if the cut-off point for microalbuminuria was set at the median albumin : creatinine ratio (13.7 mg/g creatinine). In patients without microalbuminuria, a reduced eGFR was associated with CVD only in the older and male groups.

CONCLUSION

A reduced eGFR and the presence of microalbuminuria were each associated with a near doubling of the prevalence of CVD, independently of traditional CVD risk factors and glycaemic control in patients with Type 2 diabetes.

Facial nerve motor-evoked potential monitoring during skull base surgery predicts facial nerve outcome

OBJECTIVE

To determine whether monitoring facial nerve motor-evoked potentials (FNMEPs) elicited by transcranial electrical stimulation during skull base tumour surgery is useful for predicting facial nerve outcome.

METHODS

This study analysed FNMEP findings in 26 patients with skull base tumours. Corkscrew electrodes positioned at C3 or C4 and Cz were used to deliver supramaximal stimuli (180-550 V). FNMEPs were recorded from the orbicularis oculi and oris muscles. The correlation between the final-to-baseline FNMEP ratio and postoperative facial nerve function was examined.

RESULTS

Postoperative facial nerve function correlated significantly with the FNMEP ratios in the orbicularis oculi (p = 0.004) and orbicularis oris (p<0.001) muscles. An FNMEP ratio of <50% consistently predicted immediate postoperative facial palsy, although the degree of palsy differed among patients. All patients had satisfactory facial nerve function (House and Brackmann grades I and II) postoperatively if the FNMEP ratio remained at >50%.

CONCLUSIONS

Intraoperative FNMEP monitoring can be useful for predicting facial nerve function after skull base surgery. This new method is a valuable adjunct to conventional facial nerve monitoring.

Magnetic stimulation in cervical radiculopathy and health controls

Magnetic stimulation was performed in 15 cases of unilateral cervical radiculopathy and 16 age-matched healthy controls. Among the muscle potentials which have acute slope and high amplitude, the difference between the minimal and the maximal latency in the same muscle was defined as variability. In the healthy control group, the variability of the muscle potentials evoked by head magnetic stimulation was approximately 2 ms. In cervical radiculopathy, the muscle potential latencies in head magnetic stimulation were normal except for one case because of the wide normal range. However, the interside difference of the muscle potential latency in head magnetic stimulation was significantly greater in the cervical radiculopathy group than in the healthy control group. This suggests that the interside difference of the muscle potential latency is more sensitive than the muscle potential latency in head magnetic stimulation in unilateral radiculopathy.

Effects of cilostazol on cerebral blood flow, P300, and serum lipid levels in the chronic stage of cerebral infarction

The effects of cilostazol (Pletaal, Otsuka Pharmaceutical Co., Tokyo, Japan) on cerebral blood flow, P300 event-related potentials, and serum lipid levels were examined in patients in the chronic stage of cerebral infarction. This study included 20 patients (13 men and 7 women, mean age 67 +/- 11 years) with cerebral infarction who had taken ticlopidine (100 mg orally, twice a day). Quantitative cerebral blood flow measurements by Patlak plot analysis, ultrasound examinations of the common carotid arteries, and measurements of P300 event-related potentials and serum lipid levels were performed. Ticlopidine was then replaced with cilostazol (100 mg orally, twice a day) while other medications remained unchanged. The same examinations were performed again 3 months later. After replacement of ticlopidine with cilostazol, cerebral blood flow significantly increased in the frontal white matter, temporal cortex, and occipital cortex compared with cerebral blood flow before replacement with cilostazol. Ultrasonograms of the common carotid arteries showed no significant differences in intima-media thickness before and after replacement. However, peak systolic velocity, time-averaged peak velocity, and volume flow all significantly increased after replacement. Blood flow in the frontal white matter showed a significant negative correlation with P300 latency before and after replacement of ticlopidine with cilostazol. And P300 latency improved significantly after replacement with cilostazol. Regarding lipid levels, total cholesterol, triglycerides, and remnant-like particles-cholesterol all decreased significantly after replacement with cilostazol. Cilostazol, an inhibitor of platelet aggregation, was thus concluded to be effective in improving cerebral blood flow, cerebral function, and serum lipid levels in patients in the chronic stage of cerebral infarction.

Time and cost involved in the care of newly registered patients with diabetes mellitus and other lifestyle diseases at diabetes clinics in Japan (JDDM 4)

AIMS

To study the time and cost involved in the care of newly registered outpatients with Type 2 diabetes mellitus (DM), compared with patients with hypertension and/or hyperlipidaemia (HTL).

METHODS

A total of 313 patients with DM and 58 patients with HTL without diabetes were registered on their first visits to 11 diabetes clinics across Japan. The time and cost involved in their care was recorded over the following 5 months.

RESULTS

In the first 3 months, there was an extensive time commitment to both groups. The time spent by physicians was 1.5 times longer for DM than for HTL. The total care time spent by all the care providers for DM was twice that for HTL. The cost of DM care was twice that for HTL, with the cost of medicines excluded. However, half of the cost for DM was for laboratory tests. When these were excluded, and the remaining cost divided by the time spent, the amount for DM was half of that for HTL. Over the 5 months, mean glycated haemoglobin (HbA(1c)) in DM patients improved from 8.0% to 6.5%, and 72% of DM patients achieved the glycaemic target of HbA(1c) < or = 6.5%.

CONCLUSIONS

DM care in a diabetes clinic requires a great deal more time and resources than HTL to achieve the best outcome. An educational system for self care, presently lacking in the primary care setting in Japan, would improve glycaemic control for DM patients in the community.

[A case of urethral stricture diagnosed by transrectal ultrasonography (TRUS) at voiding]

Subcapsral prostatectomy was performed in a 75-year-old male, with the diagnosis of benign prostatic hyperplasia. Total prostate volume was 105 ml by transrectal ultrasonography (TRUS) and the excised prostate weighed in 90 g. After the surgery, he recovered from urinary disturbance once, but, he again complained of severe dysuria 12 days after the surgery. With the aim of non-invasive examination, we performed TRUS at voiding. Urethral stricture was definitely diagnosed using TRUS during micturition. Thus voiding TRUS was very effective in diagnosing urethral stricture.

u-SHARE: web-based decision support/risk communication tool for healthcare consumers with unruptured intracranial aneurysms

PURPOSE

Clinical management for unruptured intracranial aneurysms (UIA) is controversial and requires professional knowledge which is the main reason that patients have difficulty in making decisions. The purpose of this study is to develop a tool that aids healthcare consumers in making optimal shared decisions with decision analysis.

METHODS

The decision model and relevant data were derived from published literature. A web-based decision analytic tool was designed to provide a systematic guide for patients to understand favorable treatment options, intrinsic uncertainty, and critical factors for decision making. Twenty-nine testers evaluated content appropriateness, usability and clinical usefulness of the tool.

RESULTS

The decision analytic tool has been successfully implemented and evaluated. Testers generally judged the web-based decision analytic tool as functional and useful. Acceptance rate for decision analysis was higher in nonhealthcare professionals than health care professionals.

CONCLUSIONS

Our decision analytic tool was well accepted especially by healthcare consumers. The tool enables UIA patients to enhance their knowledge and understanding toward optimal shared decision making and can be an alternative "structured informed consent tool".

Comparison of the utility of sympathetic skin response and current perception threshold examinations with conventional examinations for the early electrophysiological diagnosis of diabetic polyneuropathy

We compared the utility of sympathetic skin response (SSR) and current perception threshold (CPT) with that of conventional electrophysiological examinations like sural sensory conduction velocity, sensory nerve action potential (SNAP), peroneal motor conduction velocity, compound muscle action potentials, and F-wave latency. Twenty-two type II diabetic patients (mean age, 69.6 years) without sensory symptoms and with a mean glycosylated hemoglobin (HbA1c) level of 7.1%, along with 26 age-matched control patients, were examined. Among the conventional examinations, only the sural SNAP was considerably (although not significantly) depressed in the diabetic group. On the other hand, the mean SSR amplitude in the diabetic group was approximately half of the value in the control group. All the CPT values were also considerably lower in the diabetic group than in the control group, although only the values for hand stimulation at 2000 and 250 Hz were significant. No correlations were observed between the SSR amplitudes and the CPT values at any of the test frequencies. However, a positive correlation between the mean HbA1c level and the CPT value was seen at all frequencies. We concluded that SSR amplitude measurements are superior to conventional examinations and CPT studies with regard to the early electrophysiological diagnosis of diabetic polyneuropathy. Furthermore, CPT values may be useful as an electrophysiological surrogate indicator of recent glycemic control.

Development of a novel systemic gene delivery system for cancer therapy with a tumor-specific cleavable PEG-lipid

For successful cancer gene therapy via intravenous (i.v.) administration, it is essential to optimize the stability of carriers in the systemic circulation and the cellular association after the accumulation of the carrier in tumor tissue. However, a dilemma exists regarding the use of poly(ethylene glycol) (PEG), which is useful for conferring stability in the systemic circulation, but is undesirable for the cellular uptake and the following processes. We report the development of a PEG-peptide-lipid ternary conjugate (PEG-Peptide-DOPE conjugate (PPD)). In this strategy, the PEG is removed from the carriers via cleavage by a matrix metalloproteinase (MMP), which is specifically expressed in tumor tissues. An in vitro study revealed that the PPD-modified gene carrier (Multifunctional Envelope-type Nano Device: MEND) exhibited pDNA expression activity that was dependent on the MMP expression level in the host cells. In vivo studies further revealed that the PPD was potent in stabilizing MEND in the systemic circulation and facilitating tumor accumulation. Moreover, the i.v. administration of PPD or PEG/PPD dually-modified MEND resulted in the stimulation of pDNA expression in tumor tissue, as compared with a conventional PEG-modified MEND. Thus, MEND modified with PPD is a promising device, which has the potential to make in vivo cancer gene therapy achievable.

Prevention of abdominal aortic aneurysms by simultaneous inhibition of NFkappaB and ets using chimeric decoy oligonucleotides in a rabbit model

Abdominal aortic aneurysm (AAA) is one of the major vascular diseases caused by atherosclerosis. Because treatment for AAA mainly consists of surgery to prevent deaths from AAA rupture and there is a conspicuous absence of alternative therapeutic strategies, the development of minimally invasive treatment is needed. To develop a novel therapeutic approach, we examined the simultaneous inhibition of the transcription factors NFkappaB and ets, which regulate inflammation and matrix degradation, in a rabbit AAA model. In this study, we employed chimeric decoy oligodeoxynucleotides (ODN), containing the consensus sequences of both the NFkappaB- and ets-binding sites, to inhibit both the transcription factors simultaneously. Using a delivery sheet, we examined the inhibitory effect of chimeric decoy ODN on aortic dilatation. Ultrasound and angiographic analysis demonstrated that treatment with chimeric decoy ODN significantly prevented the progression of elastase-induced aortic dilatation. The inhibitory effect of chimeric decoy ODN on aortic dilatation was also confirmed by histological studies. Treatment with chimeric decoy ODN reduced the activities of matrix metalloproteinase (MMP)-2 and MMP-9 and markedly inhibited the proteolysis of elastin as compared to scrambled decoy ODN. Interestingly, treatment with chimeric decoy ODN also suppressed VCAM-1 and MCP-1 gene expression, leading to inhibition of macrophage infiltration in the adventitia and media. The present study in a rabbit model provides a novel strategy to treat AAA by the simultaneous inhibition of both NFkappaB and ets using chimeric decoy ODN. Further modification of chimeric decoy ODN would be useful to treat AAA as a decoy-based therapy.

beta-Thromboglobulin and 11-dehydrothromboxane B in tension-type headache

Platelet factor 4, beta-thromboglobulin, thromboxane B2, and 11-dehydrothromboxane B2 were investigated in tension-type headache. Ten cases of episodic tension-type headache (mean age 42.5 years), 10 cases of chronic tension-type headache (mean age 45.3 years), and 10 age-matched healthy controls were studied. The platelet factor 4, beta-thromboglobulin, thromboxane B2 and 11-dehydrothromboxane B2 concentrations in the plasma were significantly higher in the episodic tension-type headache group than in the chronic tension-type headache and healthy control groups. Platelets may be involved in episodic tension-type headache.

Intratumoural expression of thymidylate synthase is an independent predictor of prognosis in patients with squamous cell carcinoma of the tongue: results from a retrospective study

The aim of this study was to assess the importance of immunohistochemical thymidylate synthase (TS) expression level as a prognostic marker in tongue cancer patients. In 140 patients with primary squamous cell carcinoma (SCC) of the tongue, intratumoural TS expression was evaluated by immunohistochemistry. The level of TS expression was determined by a semiquantitative scoring system, ranging from 1+ to 3+ according to the ratio of TS-positive cells. Of 140 patients, 64 (45.7%), 49 (35.0%) and 27 (19.3%) were assessed as 1+, 2+ and 3+, respectively. Univariate analyses demonstrated that both disease-free survival (DFS) and overall survival (OS) were significantly lower in patients with a TS 3+ tumour than in those with a TS 1+/2+ tumour (DFS: P = 0.0082, OS: P = 0.0100). In a multivariate analysis using the Cox regression model, cervical lymph-node status and TS expression level were selected as independent factors for DFS and OS. Maintenance adjuvant chemotherapy by oral 5-fluorouracil (5-FU) significantly improved DFS and OS in patients with a TS 1+/2+ tumour (DFS: P = 0.0027, OS: P = 0.0398). These data suggest that the level of immunohistochemical TS expression is an independent prognosticator in patients with tongue SCC, and may be useful in the selection of patients who would benefit from oral 5-FU adjuvant chemotherapy.

Inhibition of ets, an essential transcription factor for angiogenesis, to prevent the development of abdominal aortic aneurysm in a rat model

The pathophysiology of abdominal aortic aneurysms (AAA) is considered to be complicated. As matrix degradation contributes to the progression of AAA, the destruction and degradation of elastin fibers caused by an increase in matrix metalloproteinases (MMPs) plays a pivotal role in the development of AAA. Although ets, an essential transcription factor for angiogenesis, regulates MMPs, the role of ets in the development of AAA has not yet been clarified. Thus, we evaluated the role of ets in a rat AAA model using a decoy strategy. Transfection of ODN into AAA was performed by transient aortic perfusion of elastase and by wrapping the AAA in a delivery sheet containing decoy ODN. The inhibitory effect of ets decoy ODN on ets binding activity was confirmed by gel mobility shift assay. MMPs expression was decreased in the aorta transfected with ets decoy ODN as compared to scrambled decoy ODN. Also, ultrasound study demonstrated that elastase-induced aneurismal dilation was significantly suppressed by transfection of ets decoy ODN at 4 weeks after treatment as compared to scrambled decoy ODN. Moreover, the destruction of elastin fibers was inhibited in the aorta transfected with ets decoy ODN, accompanied by a reduction of MMPs expression. An inhibitory effect of decoy ODN on MMP expression was confirmed by ex vivo experiments showing that transfection of decoy ODN into an organ culture of human aorta resulted in significant inhibition of the secretion of both MMP-1 and MMP-9. Here, we demonstrated that ets may play a pivotal role in the progression of AAA through the activation of MMPs in a rat model. Ets might be a potential target to develop pharmacotherapy/gene therapy to treat AAA through the inhibition of MMPs.