Development of a new scoring system for predicting the 5 year incidence of type 2 diabetes in Japan: the Toranomon Hospital Health Management Center Study 6 (TOPICS 6)

AIMS/HYPOTHESIS

The aims of this study were to assess the clinical significance of introducing HbA(1c) into a risk score for diabetes and to develop a scoring system to predict the 5 year incidence of diabetes in Japanese individuals.

METHODS

The study included 7,654 non-diabetic individuals aged 40-75 years. Incident diabetes was defined as fasting plasma glucose (FPG) ≥7.0 mmol/l, HbA(1c) ≥6.5% (48 mmol/mol) or self-reported clinician-diagnosed diabetes. We constructed a risk score using non-laboratory assessments (NLA) and evaluated improvements in risk prediction by adding elevated FPG, elevated HbA(1c) or both to NLA.

RESULTS

The discriminative ability of the NLA score (age, sex, family history of diabetes, current smoking and BMI) was 0.708. The difference in discrimination between the NLA + FPG and NLA + HbA(1c) scores was non-significant (0.836 vs 0.837; p = 0.898). A risk score including family history of diabetes, smoking, obesity and both FPG and HbA(1c) had the highest discrimination (0.887, 95% CI 0.871, 0.903). At an optimal cut-off point, sensitivity and specificity were high at 83.7% and 79.0%, respectively. After initial screening using NLA scores, subsequent information on either FPG or HbA(1c) resulted in a net reclassification improvement of 42.7% or 52.3%, respectively (p < 0.0001). When both were available, net reclassification improvement and integrated discrimination improvement were further improved at 56.7% (95% CI 47.3%, 66.1%) and 10.9% (9.7%, 12.1%), respectively.

CONCLUSIONS/INTERPRETATION

Information on HbA(1c) or FPG levels after initial screening by NLA can precisely refine diabetes risk reclassification.

Drug sensitivity test for primary culture of human cancer-cells using collagen gel embedded culture and image-analysis

A new drug sensitivity assay method using the collagen gel embedded culture and image analysis was developed. Human cancer cells cultured in collagen gels showed extremely high cloning efficiency and in vivo-like drug response. In addition, image analysis was used successfully for the first time to automatically discriminate cancer colonies from contaminating fibroblastic cells by taking advantage of the difference in shape between them after cultivation to determine the drug response of cultured cancer cells accurately and easily. A new approach for the practical use of the drug sensitivity test on human cancer cells is suggested.

Genetic and environmental factors affecting peak bone mass in premenopausal Japanese women

The purpose of this study was to examine the relationships between peak bone mass and genetic and environmental factors. We measured whole-body bone mineral density (BMD), lumbar spine BMD, and radius BMD with dual-energy X-ray absorptiometry (DXA) and analyzed eight genetic factors: vitamin D receptor (VDR)-3', VDR-5', estrogen receptor (ER), calcitonin receptor (CTR), parathyroid hormone (PTH), osteocalcin (OC), apolipoprotein E (ApoE), and fatty acid binding protein 2 (FABP2) allelic polymorphisms using polymerase chain reaction-restriction fragment length polymorphisms (PCR-RFLPs). We also surveyed menstrual history, food intake, and history of physical activity using questionnaires.After adjusting for age, body mass index (BMI), current smoking status, current Ca intake, alcohol intake, menoxenia, and physical activity, the mean BMD in subjects with the HH/Hh genotype was significantly higher than that of subjects with the hh genotype for whole-body BMD (mean±SD, 1.20±0.10 vs. 1.18±0.09 g/cm(2); HH/Hh vs. hh, p=0.04) and at lumbar spine BMD (mean±SD, 1.18±0.14 vs. 1.14±0.12 g/cm(2); HH/Hh vs. hh, p=0.02) in OC allelic polymorphism. Furthermore, the results of multiple regression analyses taking the 8 genetic factors plus the 7 environmental factors listed above into account showed that the strongest factor contributing to BMD was BMI at any site (whole-body and lumbar BMD p<0.0001, radius BMD p=0.0029). In addition, OC polymorphism (p=0.0099), physical activity (p=0.0245), menoxenia (p=0.0384), and PTH polymorphism (p=0.0425) were independent determinants for whole-body BMD, and OC polymorphism (p=0.0137) and physical activity (p=0.0421) were independent determinants for lumbar BMD and radius BMD, respectively.

An in vitro chemosensitivity test for solid human tumors using collagen gel droplet embedded cultures

In vitro chemosensitivity testing using a collagen gel droplet embedded culture drug sensitivity test (CD-DST), was conducted with several types of solid cancer. The overall evaluable rate was 80% (443/554), including 76% for lung (n=243), 78% for breast (n=110), 87% for gastric (n=62), 83% for colorectal (n=107) cancers and 88% for 32 metastatic brain tumors. The in vitro sensitivity of breast, gastric and colorectal cancers to mitomycin C (MMC), cisplatin (CDDP), 5-fluorouracil (5-FU) and doxorubicin (DXR) was similar to the efficacy rates reported for each drug. This was also observed with lung cancer, the sensitivity of which to MMC, CDDP, vindesine (VDS) and etoposide (VP-16) was similar to the clinical efficacy. The clinical response to chemotherapy was compared with the results of in vitro chemosensitivity testing in Il patients: the clinical correlation was 91%, with a 80% true positive and 100% true negative rate. These results suggest that the CD-DST may be clinically useful by allowing the prediction of clinical response in various solid cancers.

High normal HbA(1c) levels were associated with impaired insulin secretion without escalating insulin resistance in Japanese individuals: the Toranomon Hospital Health Management Center Study 8 (TOPICS 8)

AIMS

We aimed to characterize the association of insulin resistance, impaired insulin secretion and β-cell dysfunction in relation to HbA(1c) levels in a non-diabetic range in Japanese individuals without clinically diagnosed diabetes.

METHODS

This cross-sectional study included 1444 individuals without a history of outpatient treatment of diabetes or use of insulin or oral hypoglycaemic agents. The homeostasis model assessment of insulin resistance and beta-cell function, insulinogenic index, Matsuda index and disposition index were calculated using data from 75-g oral glucose tolerance tests and compared across quintile (Q) categories of HbA(1c) levels.

RESULTS

Fasting plasma glucose and 30-min and 60-min plasma glucose (PG) levels were significantly higher when HbA(1c) exceeded 36 mmol/mol (5.4%). A HbA(1c) concentration of 36-37 mmol/mol (5.4-5.5%) (Q3) was significantly associated with a 15% lower homeostasis model assessment of β-cell function value and 31% lower insulinogenic index value compared with HbA(1c) ≤ 32 mmol/mol (≤ 5.1%) (Q1) (P <0.01). Further, a HbA(1c) concentration of 38-40 mmol/mol (5.6-5.8%) (Q4) was associated with 17% (P <0.01) and 24% (P <0.05) reductions in those indexes, respectively. However, the homeostasis model assessment of insulin resistance was not significantly elevated and the Matsuda index was not significantly lower unless HbA(1c) exceeded 41 mmol/mol (5.9%). Individuals with HbA(1c) ≥ 41 mmol/mol (≥ 5.9%) (Q5) had a 69% lower disposition index than those with a HbA(1c) concentration of ≤ 32 mmol/mol (≤ 5.1%) (Q1).

CONCLUSIONS

Elevated HbA(1c) levels ≥ 41 mmol/mol (≥ 5.9%) were associated with substantial reductions in insulin secretion, insulin sensitivity and β-cell dysfunction in Japanese individuals not treated for diabetes. High normal HbA(1c) levels of 36-40 mmol/mol (5.4-5.8%) were also associated with impaired insulin secretion without marked insulin resistance in Japanese individuals.

Screening for pre-diabetes to predict future diabetes using various cut-off points for HbA(1c) and impaired fasting glucose: the Toranomon Hospital Health Management Center Study 4 (TOPICS 4)

AIM

To evaluate various screening criteria for pre-diabetes to identify which combination of impaired fasting glucose and elevated HbA(1c) values performs most effectively in predicting future diabetes in a large cohort of Japanese individuals.

METHODS

The study included 4670 men and 1571 women without diabetes (diabetes: fasting plasma glucose ≥ 7.0 mmol/l, HbA(1c) ≥ 48 mmol/mol (≥ 6.5%), or self-reported clinician-diagnosed diabetes). Pre-diabetes was diagnosed by a combination of impaired fasting glucose (fasting plasma glucose 5.6-6.9 mmol/l or 6.1-6.9 mmol/l) and elevated HbA(1c) [39-46 mmol/mol (5.7-6.4%) or 42-46 mmol/mol (6.0-6.4%)].

RESULTS

During a 5-year follow-up, 338 incident cases of diabetes occurred. The combination of HbA(1c) 39-46 mmol/mol (5.7-6.4%) and fasting plasma glucose 5.6-6.9 mmol/l yielded the highest sensitivity (86%) and generated a large population-attributable per cent risk (78%) for predicting development of diabetes. Among individuals classified as having pre-diabetes by any of the four combined criteria, 20.5-32.0% reverted to the normoglycaemic state as having neither elevated HbA(1c) nor impaired fasting glucose at the last follow-up examination. At 5.6 years after the baseline examination, however, pre-diabetic individuals who fulfilled both HbA(1c) 42-46 mmol/mol (6.0-6.4%) and fasting plasma glucose 6.1-6.9 mmol/l had a 100% cumulative risk of developing diabetes.

CONCLUSIONS

The combination of HbA(1c) 39-46 mmol/mol (5.7-6.4%) and fasting plasma glucose 5.6-6.9 mmol/l would have the best performance in reducing the likelihood of missing future cases of diabetes. Identifying pre-diabetic individuals who strictly fulfil HbA(1c) 42-46 mmol/mol (6.0-6.4%) and fasting plasma glucose 6.1-6.9 mmol/l would predict definite progression to diabetes.

Three-dimensional echocardiographic pictures of isolated double-orifice mitral valve

We present a case of a 12-year-old boy with a rare form of cardiac anomaly, isolated double-orifice mitral valve. He was referred to our hospital at 1.5 years old because of heart murmur. Two-dimensional echocardiography showed double-orifice mitral valve without any associated cardiac anomalies. He has been followed carefully without any medication for 11 years. He has had no symptoms and an excellent natural course thus far.

Microsomal prostaglandin E synthase-1 is involved in multiple steps of colon carcinogenesis

Accumulating evidence indicates that cyclooxygenase (COX)-2-derived prostaglandin (PG) E(2) is involved in the development of various tumors, including colorectal cancer. However, the precise contribution of microsomal PGE synthase (mPGES)-1, a terminal enzyme that acts downstream of COX-2 in the PGE(2)-biosynthetic pathway, to multiple processes of tumor development is not yet fully understood. Here, we show the pro-tumorigenic role of mPGES-1 in chemical carcinogen-induced colon carcinogenesis and intrasplenic tumor transplantation models. Genetic deletion of mPGES-1 significantly reduced both the total number and size of colorectal polyps at 18 weeks after azoxymethane administration with reduced nuclear translocation of β-catenin, altered expression profiles of chemokines/cytokines and increased production of antitumorigenic PGs, prostaglandin D(2) and prostacyclin in tumor tissues. At an early stage (6 weeks), mPGES-1 deficiency significantly reduced the number of aberrant crypt foci, while its transgenic overexpression increased the number. Furthermore, the growth of intrasplenically transplanted tumor cells was suppressed in mPGES-1 knockout (KO) mice. Co-culture of tumor cells with bone marrow-derived macrophages (BM-MΦs) isolated from wild-type (WT) mice resulted in the induction of mPGES-1 in BM-MΦs and increased the growth of tumor cells in vitro, whereas mPGES-1-null BM-MΦs failed to facilitate tumor growth. The adoptive transfer of WT BM-MΦs into mPGES-1 KO mice restored the growth of transplanted tumor cells, indicating that mPGES-1 in MΦs is important for the growth of adjacent tumor cells. Taken together, our findings suggest that the inhibition of mPGES-1 is an alternative therapeutic target for colorectal and possibly other cancers.

Low serum potassium levels and risk of type 2 diabetes: the Toranomon Hospital Health Management Center Study 1 (TOPICS 1)

AIMS/HYPOTHESIS

Evidence has suggested that low serum potassium concentrations decrease insulin secretion, leading to glucose intolerance, and that hypokalaemia induced by diuretics increases the risk for diabetes in hypertensive individuals. However, no prospective study has investigated the association between serum potassium and the development of type 2 diabetes in a healthy cohort comprised of Asian individuals not being administered antihypertensive medications. This study aimed to investigate whether low serum potassium is associated with increased risk of type 2 diabetes in apparently healthy Japanese men.

METHODS

We followed 4,409 Japanese men with no history of diabetes, use of antihypertensives, renal dysfunction or liver dysfunction (mean ± SD age, 48.4 ± 8.4 years). Cox proportional hazards regression was used to estimate HRs for incident diabetes (fasting plasma glucose level ≥ 7.0 mmol/l, HbA(1c) ≥ 6.5% or self-reported) including serum potassium concentration as either a categorical or a continuous variable.

RESULTS

During a 5 year follow-up, 250 individuals developed type 2 diabetes. The lowest tertile of serum potassium (2.8-3.9 mmol/l) was independently associated with the development of diabetes after adjustment for known predictors (HR 1.57 [95% CI, 1.15-2.15]) compared with the highest tertile (4.2-5.4 mmol/l). Every 0.5 mmol/l lower increment in the baseline serum potassium level was associated with a 45% (12-87%) increased risk of diabetes.

CONCLUSIONS/INTERPRETATION

Mild to moderately low serum potassium levels, within the normal range and without frank hypokalaemia, could be predictive of type 2 diabetes in apparently healthy Japanese men.

[Clinical analysis of resected pulmonary pleomorphic carcinoma]

OBJECTIVE

We studied the clinical feature of pulmonary pleomorphic carcinoma.

PATIENTS

Of 1,073 patients underwent the resection of lung cancer in our hospital, 15 patients (1.4%) had primary pulmonary pleomorphic carcinoma.

RESULTS

All patients were male, and the age was ranged from 57 to 83, mean 70.3 years old. The mean Brinkman Index was 1,028.7. Thirteen patients underwent the lobectomy with lymph node dissection, 1 patient underwent the bilobectomy with lymph node dissection, and the wedge resection was done for the remaining one. Four patients were in stage IA, 5 were in stage IB, 2 were in stage IIB, 1 was in stage IIIA, 2 were in stage IIIB, and 1 was in stage IV. Histologically, the vascular invasion was showed in 8 of 15 patients. The recurrence was occurred on 9 patients, from 1 to 20 months after surgery. The site of recurrence was lung in 3 patients, brain in 3, and abdominal lymphnodes, subcutaneous soft tissue of shoulder, carcinomatous pleurisy was observed in one patient each. The 1-year survival was 62.5% , and the 3-year survival was 46.9%. Conclusion : The prognosis for pulmonary pleomorphic carcinoma is poor. More meticulous follow up is necessary for patients with pleomorphic carcinoma than those with common non-small cell carcinoma.

Development of an all-permanent-magnet microwave ion source equipped with multicusp magnetic fields for high current proton beam production

An all-permanent-magnet (APM) microwave hydrogen ion source was developed to reduce the size and to simplify structure of a conventional solenoid coil microwave ion source developed for reliability improvement of high current proton linac application systems. The difficulty in developing the APM source was sensitive dependence of the source performance on axial magnetic field in the microwave discharge chamber. It was difficult to produce high current proton beam stably without precise tuning of the magnetic field using solenoid coils. We lowered the sensitivity using multicusp magnetic fields for plasma confinement at the discharge chamber sidewall of the source. This enabled stable high current proton beam production with the APM microwave ion source with no tuning coil. The water cooling and the power supply for the coils are not necessary for the APM source, which leads to better reliability and system simplification. The outer diameter of the APM source was around 300 mm, which was 20% lower than the coil source. The APM source produced a maximum hydrogen ion beam current of 65 mA (high current density of 330 mA/cm(2), proton ratio of 87%, and beam energy of 30 keV) with a 5 mm diameter extraction aperture, pulse width of 400 micros, and 20 Hz repetition rate at 1.3 kW microwave power. This performance is almost the same as the best performances of the conventional coil sources. The extracted ion beams were focused with electrostatic five-grid lens to match beam to acceptance of radio-frequency quadrupole linacs. The maximum focused beam current through the orifice (5 mm radius) and the lens was 36 mA and the 90% focused beam half-width was 1-2 mm.

Multicentric Castleman disease with secondary AA renal amyloidosis, nephrotic syndrome and chronic renal failure, remission after high-dose melphalan and autologous stem cell transplantation

Multicentric Castleman disease is a systemic lymphoproliferative disease with incomplete understood etiology. The various renal complications of this disease may include minimal change disease, mesangial proliferative glomerulonephritis, membranous glomerulonephritis and nephrotic syndrome, caused by secondary amyloidosis. In several reported cases of localized Castleman disease associated with renal amyloidosis and nephrotic syndrome, resection of organs involved by lymphoid proliferation resulted in complete remission. However, therapy of multicentric Castleman disease with renal amyloidosis is not well-established. We treated a case of a 39-year-old woman with multicentric Castleman disease complicated by nephrotic syndrome caused by secondary AA amyloidosis. The patient underwent autologous peripheral blood stem cell transplantation (auto-PBSCT), achieving complete remission. Autologous stem cell transplantation may be an attractive choice in therapy for refractory multicentric Castleman disease.

A pediatric occurrence of crescentic glomerulonephritis associated with antineutrophil cytoplasmic antibodies and mesangial IgA deposits

Antineutrophil cytoplasmic antibody-(ANCA) associated glomerulonephritis usually shows histopathologic features of pauciimmune crescentic glomerulonephritis and occurs late in life. We report a 14-year-old Japanese girl presenting with proteinuria, hematuria and mildly elevated serum creatinine. A renal biopsy specimen demonstrated crescentic glomerulonephritis, immunofluorescence showed mesangial IgA staining. Electron microscopic examination disclosed paramesangial deposits. Serum ANCA against myeloperoxidase (MPO) were detected at high titers. Myeloperoxidase-ANCA-related nephritis accompanied by IgA nephropathy is considered rare in childhood and teen years. Yet, if ANCA assays and detailed electron microscopic examination of renal specimens were performed routinely in patients with rapidly progressive glomerulonephritis, the diagnosis might be more frequent in young patients.

MR-sialography as functional separate imaging of salivary gland for evaluation of radiation-induced xerostomia

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Background: For head and neck cancer (HNC) patients who receive curative irradiation (RT), RT-induced xerostomia is a frequent and troublesome adverse event diminishing quality of life. In this prospectve study, morphological changes in salivary glands were evaluated by means of MR volume calculation and examination of the functional changes in MR-sialography as compared with subjective symptoms. Materials and Methods: Sixteen HNC patients (15 squamous cell carcinomas and 1 lymphoma) scheduled to receive more than 44 Gy to the primary tumor were registered (median dose to salivary glands: 60 Gy). MRI was performed prior to start of RT (pre-RT), as well as 2–4 weeks after completion of RT (post-RT). Evaluations were undertaken as follows: 1) Subjective symptoms of oral dry sensation were scaled by visual analogue scale (pre-RT VAS, post-RT VAS); 2) Changes in depictions of MR-sialography (heavy T2WI) following tartaric acid stimulation were graded into three categories (good,fair, poor); and, 3) Changes in salivary gland volume were measured as reduction ratio(%) = (pre-RT volume - post -RT volume) / pre-RT volume × 100. Results: Post-RT VAS of oral dry sensation was greater than that of pre-RT (p=0.001). Clinical symptoms (changes in VAS) did not correlate with salivary gland reduction ratio nor radiation dosage for either the parotid (PG) or submandibular glands (SG). RT dosage and reduction ratio correlated well (r=0.62). Reactivity of MR-sialography stimulated by tartaric acid became poor after RT. The mean RT dosages to PG and SG of the poor group were higher than those of the good group (p<0.05). Conclusions: MR-sialography after RT showed a poor response to secretion stimulation, which correlated with RT dosage. Moreover, MR- sialography with secretion stimulation may have the potential to be a non-invasive and sensitive method by which to assess the severity of xerostomia of each gland separately as ‘functional MR - sialography‘. More cases and longer follow up, and dose-volume histogram evaluation of each salivary gland are required to confirm the results.

No significant financial relationships to disclose.