A novel non-PPARgamma insulin sensitizer: MLR-1023 clinicalproof-of-concept in type 2 diabetes mellitus

AIM

MLR-1023, called Tolimidone when evaluated unsuccessfully by Pfizer for gastric ulcer disease, has been repurposed as a novel oral insulin sensitizer with its effects mediated by selective activation of Lyn kinase. We aimed to evaluate the optimal dose, efficacy and safety of MLR-1023 in patients with type 2 diabetes.

METHODS

Type 2 diabetes patients (18-75 years) on diet/exercise therapy were randomized and double-blinded to receive MLR-1023 (100-mg or 200-mg, once-daily [qd] or twice-daily [bid]) or matching placebo for 28 days. The primary endpoint was postprandial glucose (PPG) area under the curve (AUC_0-3h) in a mixed meal tolerance test (MMTT) at day 29. Secondary endpoints included changes in fasting plasma glucose (FPG), insulin, HbA1c, lipids and body weight and adverse events. ANCOVA model was used for efficacy analysis.

RESULTS

The placebo-corrected least-squares mean differences (ΔLSM) in MMTT PPG AUC0-3 h (mmol/L) were -5.96 and -5.6 (both p = 0.03) in the MLR-1023 100-mg qd and 100-mg bid groups, respectively. The placebo-corrected ΔLSM in FPG (mmol/L) was -2.34 (p = 0.003) in the MLR-1023 100-mg qd group. Triglycerides improved with MLR-1023 (ΔLSM, -0.56 mmol/L, p = 0.07 and -0.59 mmol/L, p = 0.05) in the 200mgqd and 200 mg bid groups, respectively. Reductions in fasting insulin, HbA1c and body weight were not statistically significant. Most common adverse events with MLR-1023 treatment were headache (4.2%) and somnolence (2.5%).

CONCLUSIONS

MLR-1023 100-mg once-daily for 4 weeks was the most effective dose with significant reduction in PPG AUC following a MMTT. MLR-1023 was safe and well-tolerated in patients with type 2 diabetes. Clinical Trials Registration Number: NCT02317796.

Comparisons of food security, dietary behaviors and nutrient intakes between adult North Korean Refugees in South Korea and South Koreans

BACKGROUND/OBJECTIVES

North Korean refugees (NKRs) in South Korea are a unique population as they must adapt in a new country with similar cultural traits but different social, political, and economic systems, but little research has been conducted on diet and nutrition in this population. This study examined food security, dietary behaviors, and nutrient intakes among adult NKRs living in South Korea and compared them to those of South Koreans.

SUBJECTS/METHODS

The subjects were 139 adult NKRs (25 men, 114 women) living in the Seoul metropolitan area, and 417 age- and sex-matched South Korean controls (SKCs; 75 men, 342 women) selected from the Korea National Health and Nutrition Examination Survey (KNHANES). Food security and dietary behaviors (meal skipping, eating-out, meals with family, nutrition education and counseling, and nutrition label knowledge and utilization) were obtained using self-administered questionnaires. Nutrient intakes were assessed by 24-hr recall. The statistical analysis was performed using IBM SPSS ver. 23.0.

RESULTS

In South Korea, food security had improved over the previous 12 months, but remained significantly poorer for NKR women than SKC women. Meal skipping was three times more frequent than for SKCs and eating-out was rare. Average energy intake was 1,509 kcal for NKR men and 1,344 kcal for NKR women, which was lower than those of SKCs (2,412 kcal and 1,789 kcal, respectively). Significantly more NKRs (men 24.0%, women 21.9%) showed simultaneously deficient intake in energy, calcium, iron, vitamin A, and riboflavin than SKCs (men 2.7% (P = 0.003), women 7.0% (P < 0.001)). NKR women had a significantly higher index of nutrient quality (INQ) for some nutrients than SK women.

CONCLUSIONS

This study reports significant differences in food security, dietary behaviors, and nutrient intakes between NKRs and SKCs. Generally, NKRs reported lower intakes despite improved food security, but relatively good INQs across nutrients. Further research is needed to understand processes of food choice and consumption among NKRs to provide appropriate support aimed at improving diets.

Fibrates Revisited: Potential Role in Cardiovascular Risk Reduction

Fibrates, peroxisome proliferator-activated receptor-α agonists, are potent lipid-modifying drugs. Their main effects are reduction of triglycerides and increase in high-density lipoprotein levels. Several randomized controlled trials have not demonstrated their benefits on cardiovascular risk reduction, especially as an "add on" to statin therapy. However, subsequent analyses by major clinical trials, meta-analyses, and real-world evidence have proposed their potential in specific patient populations with atherogenic dyslipidemia and metabolic syndrome. Here, we have reviewed and discussed the accumulated data on fibrates to understand their current status in cardiovascular risk management.

Habitual late sleep initiation is associated with increased incidence of type 2 diabetes mellitus in Korean adults: the Korean Genome and Epidemiology Study

STUDY OBJECTIVES

Although sleep duration and quality were significant risk factors of type 2 diabetes (T2D), the impact of sleep initiation time on the development of T2D has not been studied in large longitudinal studies.

METHODS

A total of 3689 participants without diabetes aged 40-69 years at baseline were enrolled from the Korean Genome and Epidemiology Study and followed up for 12 years. Participants were categorized based on habitual sleep initiation time by questionnaire as follows: 20:00-22:59 (early sleepers, ES, n = 766), 23:00-00:59 (usual sleepers, US, n = 2407), and 1:00-5:59 (late sleepers, LS, n = 516). Incident T2D was identified biennially by fasting plasma glucose or 2-hour glucose after 75-g oral glucose loading or use of anti-diabetes medication.

RESULTS

During follow-up, 820 cases of T2D were documented and the LS group showed the highest increase in insulin resistance. Hazard ratio (HR) (95% confidence interval) for T2D of LS compared to ES was 1.34 (1.04-1.74) after adjustment for covariates including sleep duration. The impact of late sleep on the development of T2D was more evident in older individuals (≥65 years at baseline) (HR = 4.24 [1.42-12.68] in older LS vs. older ES, HR = 1.27 [1.00-1.62] in younger LS vs. younger ES, pinteraction = 0.002). In addition, LS with low insulin secretion and sensitivity showed an approximately fivefold increased risk for T2D compared to ES with high insulin secretion and sensitivity.

CONCLUSIONS/INTERPRETATION

Habitual late sleep initiation is a significant risk factor for T2D in Koreans, especially in people with lower insulin sensitivity, lower β-cell function, and older age.

Epidemiology and Prognosis of Pheochromocytoma/Paraganglioma in Korea: A Nationwide Study Based on the National Health Insurance Service

BACKGROUND

Pheochromocytomas and paragangliomas (PPGLs) are rare endocrine tumors originating from chromaffin cells. PPGLs are associated with a high mortality rate and several complications. To date, no epidemiological studies have been conducted on PPGLs in Asia. This study aimed to investigate the epidemiology and prognosis of PPGLs in Korea using nationwide data.

METHODS

Using the National Health Insurance Service Database, subjects with a principal diagnosis of PPGLs on two or more occasions between 2003 and 2014 who satisfied the operational definition of PPGLs were included. Incidence, prevalence, complications, metastasis, and mortality were investigated.

RESULTS

In total, 1048 subjects with a mean age of 47.6±16.1 years were included. There was no sex preponderance. The overall prevalence of PPGLs was 2.13 per 100,000 persons, and the overall age-standardized incidence rate was 0.18 per 100,000 person-years. Malignant PPGLs accounted for 17.7% (185 of 1,048) of cases, and 94 subjects exhibited metastasis at the time of diagnosis. Among initially non-metastatic PPGLs, 9.5% (nine of 954) eventually metastasized after a mean duration of 78.1±41.4 months. The 5-year survival rates for non-metastatic and metastatic PPGLs at diagnosis were 97% and 84%, respectively. Multivariable Cox regression models adjusted for covariates showed that metastatic PPGLs were associated with a 2.40-fold higher risk of mortality than non-metastatic PPGLs (95% confidence interval, 1.38 to 4.17; P=0.002).

CONCLUSION

PPGLs are rare in Korea, and the prognosis of these endocrine tumors varies depending on whether they are benign or malignant. This epidemiological study paves the way for further research on PPGLs.

Incidence and Risk Factors for Dementia in Type 2 Diabetes Mellitus: A Nationwide Population-Based Study in Korea

BACKGROUND

Diabetes mellitus is associated with an increased risk of dementia. We aimed to comprehensively analyze the incidence and risk factors for dementia and young-onset dementia (YOD) in diabetic patients in Korea using the National Health Insurance Service data.

METHODS

Between January 1, 2009 and December 31, 2012, a total of 1,917,702 participants with diabetes were included and followed until the date of dementia diagnosis or until December 31, 2015. We evaluated the incidence and risk factors for all dementia, Alzheimer's disease (AD), and vascular dementia (VaD) by Cox proportional hazards analyses. We also compared the impact of risk factors on the occurrence of YOD and late-onset dementia (LOD).

RESULTS

During an average of 5.1 years of follow-up, the incidence of all types of dementia, AD, or VaD was 9.5, 6.8, and 1.3/1,000 person-years, respectively, in participants with diabetes. YOD comprised 4.8% of all dementia occurrence, and the ratio of AD/VaD was 2.1 for YOD compared with 5.5 for LOD. Current smokers and subjects with lower income, plasma glucose levels, body mass index (BMI), and subjects with hypertension, dyslipidemia, vascular complications, depression, and insulin treatment developed dementia more frequently. Vascular risk factors such as smoking, hypertension, and previous cardiovascular diseases were more strongly associated with the development of VaD than AD. Low BMI and a history of stroke or depression had a stronger influence on the development of YOD than LOD.

CONCLUSION

The optimal management of modifiable risk factors may be important for preventing dementia in subjects with diabetes mellitus.

Changes in the Quality of Life in Patients with Type 2 Diabetes Mellitus According to Physician and Patient Behaviors

BACKGROUND

Diabetes mellitus (DM) is the most common chronic metabolic disorder with an increasing prevalence worldwide. According to a previous study, physicians' treatment patterns or patients' behaviors change when they become aware of the risk for cardiovascular (CV) disease in patients with DM. However, there exist controversial reports from previous studies in the impact of physicians' behaviors on the patients' quality of life (QoL) improvements. So we investigate the changes in QoL according to physicians and patients' behavioral changes after the awareness of CV risks in patients with type 2 DM.

METHODS

Data were obtained from a prospective, observational study where 799 patients aged ≥40 years with type 2 DM were recruited at 24 tertiary hospitals in Korea. Changes in physicians' behaviors were defined as changes in the dose/type of antihypertensive, lipid-lowering, and anti-platelet therapies within 6-month after the awareness of CV risks in patients. Changes in patients' behaviors were based on lifestyle modifications. Audit of Diabetes Dependent Quality of Life comprising 19-life-domains was used.

RESULTS

The weighted impact score change for local or long-distance journey (P=0.0049), holidays (P=0.0364), and physical health (P=0.0451) domains significantly differed between the two groups; patients whose physician's behaviors changed showed greater improvement than those whose physician's behaviors did not change.

CONCLUSION

This study demonstrates that changes in physicians' behaviors, as a result of perceiving CV risks, improve QoL in some domains of life in DM patients. Physicians should recognize the importance of understanding CV risks and implement appropriate management.

Body Weight Variability Increases Dementia Risk Among Older Adults: A Nationwide Population-Based Cohort Study

Background: Recent growing evidences suggest that body weight (Bwt) variability, a repeated loss and regain of weight within a specific period, causes metabolic disturbances and can be a marker for poor homeostasis. Although there have been many studies about the association between Bwt variability and various health status, its association with the incidence of dementia among elderly people has not been examined. Methods: We performed a retrospective elderly cohort study from 19,987 participants with mean age 73 years old in the Korean National Health Insurance Service. We examined the risk of incident dementia, including Alzheimer's dementia and vascular dementia, according to the quartile of Bwt variability, represented as coefficient of variation (Bwt-CV), SD (Bwt-SD), and variability independent of the mean (Bwt-VIM). Results: In fully adjusted model, the group with the highest Bwt variability (Bwt-VIM Q4) showed an increased risk of all-cause dementia (hazard ratio [HR] 1.39, 95% confidence interval [CI] 1.206-1.603) and Alzheimer's dementia (HR 1.46, CI 1.240-1.724) compared to the lowest quartile (Bwt-VIM Q1). We also found that subjects with the highest Bwt variability (Q4) and underweight BMI had a significantly increased risk of developing dementia (HR 1.994, 95% CI 1.302-3.054), while subjects with low Bwt variability (Q1 and Q2) and obese BMI had decreased risk of dementia (HR 0.664, 95% CI 0.505-0.872 and HR 0.648, 95% CI 0.493-0.852, respectively) compared to reference group (lowest Bwt variability (Q1) with normal baseline BMI). The effect of Bwt variability on the incidence of dementia was more prominent in subjects <75 years old and abnormal BMI groups (P for interaction < 0.05). Conclusion: The present study revealed that high Bwt variability was associated with an increased risk of dementia in the elderly.

Actual causes of death in thyroid cancer patients in Korea: A Nationwide Case Control Cohort Study

OBJECTIVE

Thyroid cancer (TC) incidence has increased robustly in Korea. However, the actual cause of death, overall mortality risk, and cause-specific mortality risk in TC patients have not been clearly elucidated.

DESIGN

Retrospective cohort study.

METHODS

We analyzed 4082 TC patients from the Korean National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS, 2002-2013) with a median of 48-month follow-up. We compared these patients with 12 246 controls matched for age, sex, and histories of major cardiovascular disease (CVD) to investigate the cause of death and risks of overall and cause-specific mortality.

RESULTS

Overall, 61 deaths (1.5%) occurred in the TC group. The most common cause of death was TC-specific mortality (32.8%), followed by other malignancy-related mortality (31.1%) and CVD mortality (13.1%). The overall mortality risk was comparable between the TC and control groups (unadjusted hazard ratio (HR): 1.17; 95% confidence interval (CI): 0.87-1.58); the adjusted HR remained at 1.25 (95% CI: 0.90-1.74) after multivariate adjustment for body mass index (BMI), socioeconomic status (SES), smoking, alcohol consumption, and histories of hypertension, diabetes mellitus, and dyslipidemia. In addition, there was not enough evidence against the surmise that the CVD mortality risk was similar between the TC and control groups, with an HR of 0.50 (95% CI: 0.22-1.16) after adjustment for CVD risk factors.

CONCLUSIONS

Excellent overall survival was observed in TC patients. The most common cause of death was TC-specific mortality, suggesting the importance of thyroid cancer treatment. The overall and cause-specific mortality risks, particularly CVD mortality risk, did not differ between TC patients and the general population.

Association of serum sclerostin levels with low skeletal muscle mass: The Korean Sarcopenic Obesity Study (KSOS)

BACKGROUND

Sclerostin is an osteocyte-derived circulating protein that inhibits the Wnt/β-catenin signaling pathway. The Wnt signaling pathway plays an important role in bone and dysregulation of the Wnt signaling pathway results in insulin resistance, inflammation, and metabolic disturbance. The aim of our study was to investigate the implication of sclerostin in low muscle mass in healthy subjects.

METHODS

The cross-sectional study analyzed 240 healthy non-diabetic subjects from the Korean Sarcopenic Obesity Study (KSOS). Low muscle mass was defined as the sum of the appendicular skeletal muscle mass divided by the square of height (ASM/height²) as proposed by the Asian Working Group for Sarcopenia.

RESULTS

Serum sclerostin was significantly higher in the low muscle mass group than the normal muscle mass group (151.3 [79.2-187.9] vs. 74.8 [47.6-119.6] pg/mL, p = 0.001). In the partial correlation analyses adjusted for age, sex, and body mass index, ASM/height² was negatively associated with sclerostin levels (r = -0.245, p < 0.001). Furthermore, sclerostin levels decreased linearly according to the first, second, and third tertiles of ASM/height² even after adjusting for sex, age, body mass index, life style parameters, fasting plasma glucose, bone mineral content (BMC), and total body fat mass.

CONCLUSIONS

Serum sclerostin levels were negatively correlated to skeletal muscle mass independent of confounding factors including BMC and total body fat mass.

Use of fenofibrate on cardiovascular outcomes in statin users with metabolic syndrome: propensity matched cohort study

OBJECTIVE

To investigate whether fenofibrate as add-on to statin treatment reduce persistent cardiovascular risk in adults with metabolic syndrome in a real world setting.

DESIGN

Propensity matched cohort study.

SETTING

Population based cohort in Korea.

PARTICIPANTS

29 771 adults with metabolic syndrome (≥40 years) receiving statin treatment. 2156 participants receiving combined treatment (statin plus fenofibrate) were weighted based on propensity score in a 1:5 ratio with 8549 participants using statin only treatment.

MAIN OUTCOME MEASURE

Primary outcome was composite cardiovascular events including incident coronary heart disease, ischaemic stroke, and death from cardiovascular causes.

RESULTS

The incidence rate per 1000 person years of composite cardiovascular events was 17.7 (95% confidence interval 14.4 to 21.8) in the combined treatment group and 22.0 (20.1 to 24.1) in the statin group. The risk of composite cardiovascular events was significantly reduced in the combined treatment group compared with statin group (adjusted hazard ratio 0.74, 95% confidence interval 0.58 to 0.93; P=0.01). The significance was maintained in the on-treatment analysis (hazard ratio 0.63, 95% confidence interval 0.44 to 0.92; P=0.02). The risk of incident coronary heart disease, ischaemic stroke, and cardiovascular death was lower in the combined treatment group than statin group but was not significant. Participant characteristics did not appear to be associated with the low risk of composite cardiovascular events with combined treatment.

CONCLUSION

In this propensity weighted cohort study of adults with metabolic syndrome, the risk of major cardiovascular events was significantly lower with fenofibrate as add-on to statin treatment than with statin treatment alone.

Effectiveness and Safety of Adding Basal Insulin Glargine in Patients with Type 2 Diabetes Mellitus Exhibiting Inadequate Response to Metformin and DPP-4 Inhibitors with or without Sulfonylurea

BACKGROUND

We aimed to investigate the effectiveness and safety of adding basal insulin to initiating dipeptidyl peptidase-4 (DPP-4) inhibitor and metformin and/or sulfonylurea (SU) in achieving the target glycosylated hemoglobin (HbA1c) in patients with type 2 diabetes mellitus (T2DM).

METHODS

This was a single-arm, multicenter, 24-week, open-label, phase 4 study in patients with inadequately controlled (HbA1c ≥7.5%) T2DM despite the use of DPP-4 inhibitor and metformin. A total of 108 patients received insulin glargine while continuing oral antidiabetic drugs (OADs). The primary efficacy endpoint was the percentage of subjects achieving HbA1c ≤7.0%. Other glycemic profiles were also evaluated, and the safety endpoints were adverse events (AEs) and hypoglycemia.

RESULTS

The median HbA1c at baseline (8.9%; range, 7.5% to 11.1%) decreased to 7.6% (5.5% to 11.7%) at 24 weeks. Overall, 31.7% subjects (n=33) achieved the target HbA1c level of ≤7.0%. The mean differences in body weight and fasting plasma glucose were 1.2±3.4 kg and 56.0±49.8 mg/dL, respectively. Hypoglycemia was reported in 36 subjects (33.3%, 112 episodes), all of which were fully recovered. There was no serious AE attributed to insulin glargine. Body weight change was significantly different between SU users and nonusers (1.5±2.5 kg vs. -0.9±6.0 kg, P=0.011).

CONCLUSION

The combination add-on therapy of insulin glargine, on metformin and DPP-4 inhibitors with or without SU was safe and efficient in reducing HbA1c levels and thus, is a preferable option in managing T2DM patients exhibiting dysglycemia despite the use of OADs.

Effects of long-term glycemic variability on incident cardiovascular disease and mortality in subjects without diabetes: A nationwide population-based study

Increased glycemic variability (GV) is an independent risk factor for cardiovascular complications in patients with diabetes. We evaluated the risk of future development of cardiovascular disease (CVD) and death according to GV in a general population without diabetes.We used the National Health Insurance Service, providing a population-based, nationwide database of Koreans. We included individuals without diabetes who underwent glucose measurement at least 3 times during 2002 to 2006. GV was calculated as standard deviation (SD) of fasting plasma glucose (FPG) levels. We observed development of CVD or all-cause death from 2007 to 2015, and also evaluated the mortality within 1 year after CVD.Among 3,211,319 people, we found 23,374 incident cases of myocardial infarction (MI), 27,705 cases of stroke, and 63,275 deaths during 8.3 years of follow-up. After multivariate adjustment, GV was found to be a significant predictor of MI, stroke and all-cause death for their highest quartile, with corresponding hazard ratios (HR) of 1.08 (95% confidence interval, CI 1.04-1.11), 1.09 (95% CI 1.06-1.13), and 1.12 (95% CI 1.10-1.15), respectively. The risk of death increased more in those who had both impaired fasting glucose and the highest quartile of GV (HR 1.24 [95% CI 1.21-1.28]). Moreover, early death rate after 1 year of CVD was higher in the highest quartile of GV compared to the lowest quartile (HR 1.21 [95% CI 1.03-1.41]).Long-term FPG variation was independently associated with CVD and mortality in a general population without diabetes.

γ-Glutamyltransferase Variability and the Risk of Mortality, Myocardial Infarction, and Stroke: A Nationwide Population-Based Cohort Study

Although it has been suggested that the γ-glutamyltransferase (GGT) level is an indicator of cardiometabolic disorders, there is no previous study to evaluate the implication of GGT variability on the development of myocardial infarction (MI), stroke, all-cause mortality, and cardiovascular disease (CVD)-related mortality. GGT variability was measured as the coefficient variance (GGT-CV), standard deviation (GGT-SD), and variability independent of the mean (GGT-VIM). Using the population-based Korean National Health Insurance Service-Health Screening Cohort, we followed 158,736 Korean adults over a median duration of 8.4 years. In multivariable Cox proportional hazard analysis, the risk of mortality, MI, and stroke showed a stepwise increase according to the quartiles of GGT-CV, GGT-SD or GGT-VIM. In the highest quartile of GGT-CV compared to the lowest quartile after adjusting for confounding variables including mean GGT, the hazard ratios (HRs) for incident MI, stroke, mortality, and CVD-related mortality were 1.19 (95% confidence interval (CI), 1.06–1.34; p < 0.001), 1.20 (95% CI, 1.10–1.32; p < 0.001), 1.41 (95% CI, 1.33–1.51; p < 0.001), and 1.52 (95% CI, 1.30–1.78; p < 0.001), respectively, which were similar or even higher compared with those associated with total cholesterol variability. This is the first study to demonstrate that high GGT variability is associated with increased risk of MI, stroke, all-cause mortality, and CVD-related mortality in the general population.

Untreated primary hypothyroidism with simultaneous rhabdomyolysis, pericardial effusion, and sudden sensorineural hearing loss: a case report

BACKGROUND

Hypothyroidism, one of the prevalent endocrine disorders worldwide, has a broad spectrum of clinical manifestations, from an asymptomatic condition to myxedema coma. Although the majority of patients with hypothyroidism have minor clinical symptoms, which are recovered with levothyroxine treatment, some patients occasionally do experience fatal complications. Here we report, for the first time, the case of a patient who had hypothyroidism with simultaneous occurrence of rhabdomyolysis with acute kidney injury, moderate pericardial effusion, and sudden sensorineural hearing loss.

CASE PRESENTATION

A 57-year-old man with a previous history of dyslipidemia and untreated hypothyroidism was admitted to the hospital due to shortness of breath, lethargy, lower extremity discomfort, and unilateral hearing loss. Laboratory results revealed rhabdomyolysis with acute kidney injury and severe hypothyroidism. We detected cardiomegaly without lung parenchymal infiltration on chest radiography and moderate pericardial effusion on transthoracic echocardiography. We performed pure tone audiometry and identified profound unilateral sensorineural hearing loss. Aggressive fluid resuscitation, levothyroxine treatment, and systemic and intratympanic steroid therapy alleviated the patient's severe hypothyroidism, rhabdomyolysis, and pericardial effusion; however, sensorineural hearing loss was not fully recovered.

CONCLUSIONS

Early recognition of life-threatening complications is important in patients with severe hypothyroidism to prevent adverse outcomes. This case suggests that hypothyroidism should be considered in patients who have rhabdomyolysis with acute kidney disease and pericardial effusion. Moreover, sudden sensorineural hearing loss should be kept in mind as a rare complication of hypothyroidism.

Variability in Total Cholesterol Concentration Is Associated With the Risk of Dementia: A Nationwide Population-Based Cohort Study

Introduction: Although total cholesterol (TC) variability is suggested as a risk factor for cardiovascular and cerebrovascular disease, there is no previous study to evaluate the association between TC variability and the development of dementia. Methods: Using the Korean National Health Insurance Service-Health Screening Cohort (NHIS-HEALS), the main outcomes were newly diagnosed all-cause dementia, Alzheimer's disease (AD), or vascular dementia (VaD) between January 1, 2008, and December 31, 2015. Visit-to-visit TC variability was measured as variability independent of the mean (TC-VIM), coefficient variance (TC-CV), and standard deviation (TC-SD). Results: In a total of 131,965 Koreans, there were 3,722 all-cause dementia (2.82%), 2,776 AD (2.10%), and 488 VaD (0.37%) during the median follow-up of 8.4 years. Kaplan-Meier curves showed increased cumulative incidences for all in the group of the highest quartiles of TC variability compared to the others. Regression using the Fine and Gray hazards model showed a steadily increasing risk of all-cause dementia with higher quartiles of TC variability. After adjusting for confounders including mean TC level and comparing the highest and lowest TC-VIM quartiles, the hazard ratios (HRs) for all-cause dementia and AD were 1.15 [95% confidence interval (CI) = 1.05-1.27; P = 0.003] and 1.12 (95% CI = 1.00-1.25; P = 0.040), respectively. The incidence of VaD was not significantly higher in the higher-quartile groups compared to that in the lowest-quartile group in TC-VIM variability (HR 1.22; 95% CI = 0.95-1.59; P = 0.122). These associations were consistent with TC variability defined by TC-CV or TC-SD. Conclusions: For the first time, we have demonstrated that a higher visit-to-visit variability in TC independent of mean TC is associated with an increased risk of all-cause dementia and AD in the general population.

Total cholesterol variability and risk of atrial fibrillation: A nationwide population-based cohort study

Background

Long-term variability of cardiometabolic risk factors have been suggested as the risk factors for cardiovascular disease and mortality. However, the effect of long-term variability of total cholesterol (TC) on incident atrial fibrillation (AF) has not been examined.

Methods and findings

We explored whether visit-to-visit TC variability are associated with the risk of incident AF in 160,165 Korean adults, using the population-based Korean National Health Insurance Service–Health Screening Cohort (NHIS-HEALS) database, over a median duration of 8.4 years. TC variability was measured as coefficients of variance (TC-CV), standard deviation (TC-SD), and variability independent of the mean (TC-VIM). Kaplan–Meier analysis demonstrated a decreased disease-free probability in the highest quartile group of TC variability compared to that in the other groups. In the multivariate Cox proportional hazard analysis, the risk of AF increased significantly in the highest quartile group of TC variability. After multivariate adjustment for confounding variables including mean TC levels, the hazard ratio for incident AF was 1.15 (95% confidence interval 1.05–1.25; P = 0.0035) when comparing the highest with the lowest TC variability quartile (TC-CV). These relationships were consistent with TC variability defined using TC-SD or TC-VIM. Subgroup analyses, including age, sex, body mass index, and cardiometabolic disorders, showed similar results.

Conclusions

The present study is the first to demonstrate that high TC variability was associated with an increased risk of AF.

Pre-treatment 18F-FDG PET-based radiomics predict survival in resected non-small cell lung cancer

AIM

To assess the prognostic value of 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)-based radiomics using a machine learning approach in patients with non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Ninety-three patients with stage I-III NSCLC who underwent combined PET/computed tomography (CT) followed by curative resection. A total of 35 unique quantitative radiomic features was extracted from the PET images, which included imaging phenotypes such as pixel intensity, shape, and texture. Radiomic features were ranked based on score according to their correlation with disease recurrence status within a 3-year follow-up. The recurrence risk classification performances of machine learning algorithms (random forest, neural network, naive Bayes, logistic regression, and support vector machine) using the 20 best-ranked features were compared using the areas under the receiver operating characteristic curve (AUC) and validated by the random sampling method.

RESULTS

Contrast and busyness texture features from neighbourhood grey-level difference matrix were found to be the two best predictors of disease recurrence. The random forest model obtained the best performance (AUC: 0.956, accuracy: 0.901, F1 score: 0.872, precision: 0.905, recall: 0.842), followed by the neural network model (AUC: 0.871, accuracy: 0.780, F1 score: 0.708, precision: 0.755, recall: 0.666).

CONCLUSION

A PET-based radiomic model was developed and validated for risk classification in NSCLC. The machine learning approach with random forest classifier exhibited good performance in predicting the recurrence risk. Radiomic features may help clinicians to improve the risk stratification for clinical practice.

Dipeptidyl peptidase-4 inhibitor compared with sulfonylurea in combination with metformin: cardiovascular and renal outcomes in a propensity-matched cohort study

Background

To determine the impact of dipeptidyl peptidase-4 inhibitor (DPP4i) on the risk of major cardiocerebrovascular and renal outcomes compared with sulfonylurea (SU) combined with metformin in patients with type 2 diabetes from a population-based cohort.

Methods

From a nationwide cohort in Korea (2008–2013), 23,674 patients with type 2 diabetes treated with DPP4i plus metformin or SU plus metformin were selected and matched by propensity score. Composite cardiocerebrovascular events including incident ischemic heart disease (IHD), ischemic stroke (IS), hospitalization for heart failure (HHF), and cardiocerebrovascular death, as well as renal events including incident end-stage renal disease or initiation of renal-replacement therapy were assessed by Cox proportional-hazards models.

Results

During a median follow-up of 19.6 months (interquartile range 7.2–36.4), 762 composite cardiocerebrovascular events and 17 end-stage renal events occurred. There was no significant difference in the risk of IHD (hazard ratio [HR], 1.00; 95% CI 0.81–1.23), IS (HR, 0.95; 95% CI 0.74–1.23), or cardiocerebrovascular death (HR, 0.74; 95% CI 0.46–1.18) in the DPP4i group compared to that in the SU group. Likewise, DPP4i therapy was not associated with the risk of end-stage renal outcomes (HR, 1.23; 95% CI 0.41–3.62). However, the risk of HHF was significantly higher in the DPP4i group than in the SU group (HR, 1.47; 95% CI 1.07–2.04).

Conclusions

This real-world database analysis showed that DPP4i therapy did not increase the overall risk of major cardiovascular and renal outcomes compared to SU therapy. However, the DPP4i-associated risk of HHF remained significant.

Electronic supplementary material

The online version of this article (10.1186/s12933-019-0835-z) contains supplementary material, which is available to authorized users.

Effects of Dipeptidyl Peptidase-4 Inhibitors on Renal Outcomes in Patients with Type 2 Diabetes: A Systematic Review and Meta-Analysis

BACKGROUND

To investigate the effects of dipeptidyl peptidase-4 (DPP-4) inhibitors on renal outcomes in patients with type 2 diabetes.

METHODS

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched to identify randomized controlled trials (RCTs) of DPP-4 inhibitors from inception to September 2017. We selected eligible RCTs comparing DPP-4 inhibitors with placebo or other antidiabetic agents and reporting at least one renal outcome. A meta-analysis was conducted to calculate standardized mean differences, weighted mean differences (WMDs), relative risks (RRs), and 95% confidence intervals (CIs) for each renal outcome.

RESULTS

We included 23 RCTs with 19 publications involving 41,359 patients. Overall changes in urine albumin-to-creatinine ratio were comparable between DPP-4 inhibitors and controls (P=0.150). However, DPP-4 inhibitors were associated with significantly lower risk of incident microalbuminuria (RR, 0.89; 95% CI, 0.80 to 0.98; P=0.022) and macroalbuminuria (RR, 0.77; 95% CI, 0.61 to 0.97; P=0.027), as well as higher rates of regression of albuminuria (RR, 1.22; 95% CI, 1.10 to 1.35; P<0.001) compared with controls. Although DPP-4 inhibitors were associated with small but significantly lower estimated glomerular filtration rate (WMD, -1.11 mL/min/1.73 m²; 95% CI, -1.78 to -0.44; P=0.001), there was no difference in the risk of end-stage renal disease between two groups (RR, 0.93; 95% CI, 0.76 to 1.14; P=0.475).

CONCLUSION

DPP-4 inhibitors had beneficial renal effects mainly by reducing the risk of development or progression of albuminuria compared with placebo or other antidiabetic agents.

Proportion and Characteristics of the Subjects with Low Muscle Mass and Abdominal Obesity among the Newly Diagnosed and Drug-Naïve Type 2 Diabetes Mellitus Patients

BACKGROUND

Sarcopenic obesity (SO) is a serious public health concern, few studies have examined the clinical implications of SO in newly-diagnosed type 2 diabetes mellitus (T2DM) patients. We evaluated the prevalence of the newly diagnosed, drug-naïve T2DM patients with low muscle mass with abdominal obesity and its association with insulin resistance and other diabetic complications.

METHODS

We classified 233 drug-naïve T2DM subjects into four groups according to abdominal obesity (waist circumference ≥90 cm in men and ≥85 cm in women) and low muscle mass status (appendicular skeletal muscle <7.0 kg/m² for men and <5.4 kg/m² for women).

RESULTS

The proportion of the subjects with low muscle mass and abdominal obesity among the newly diagnosed, drug-naïve T2DM patients was 8.2%. Homeostasis model assessment of insulin resistance (HOMA-IR) increased linearly according to body composition group from normal to abdominal obesity to both low muscle mass and abdominal obesity. The multiple logistic regression analysis indicated that subjects with low muscle mass and abdominal obesity (odds ratio [OR], 9.39; 95% confidence interval [CI], 2.41 to 36.56) showed a higher risk for insulin resistance, defined as HOMA-IR ≥3, than those with abdominal obesity (OR, 5.36; 95% CI, 2.46 to 11.69), even after adjusting for other covariates. However, there were no differences in lipid profiles, microalbuminuria, or various surrogate markers for atherosclerosis among the four groups.

CONCLUSION

Subjects with both low muscle mass and abdominal obesity had a higher risk of insulin resistance than those with low muscle mass or abdominal obesity only.

Impact of Visit-to-Visit Fasting Plasma Glucose Variability on the Development of Type 2 Diabetes: A Nationwide Population-Based Cohort Study

OBJECTIVE

Although increasing evidence suggests the association between short-term variability of fasting plasma glucose (FPG) and diabetic complications or mortality, the impact of visit-to-visit variability of FPG on the development of type 2 diabetes (T2D) has not been evaluated.

RESEARCH DESIGN AND METHODS

Our analysis included 131,744 Korean men and women without diabetes using the Korean National Health Insurance System cohort with periodic health examination program. FPG variability was calculated using the coefficient of variation (FPG-CV), SD (FPG-SD), and variability independent of the mean (FPG-VIM).

RESULTS

During the median follow-up time of 8.3 years, Kaplan-Meier curves demonstrated lower disease-free probability in the higher FPG variability group compared with the lower FPG variability group. Multivariable Cox proportional hazards analysis exhibited that the hazard ratio for incident T2D was 1.67 (95% CI 1.58-1.77, P < 0.001) in the highest quartile of FPG-CV compared with the lowest quartile of FPG-CV after adjusting for confounding variables, including mean FPG. The association between FPG variability and the risk of T2D was consistent when modeling using FPG-SD and FPG-VIM in both normal and impaired fasting glucose groups. A 1 SD increase in the FPG-CV was associated with a 24% increased risk of T2D in the fully adjusted model.

CONCLUSIONS

Increased variability of FPG is associated with the development of T2D independently of diverse risk factors.

A novel adiposity index as an integrated predictor of cardiometabolic disease morbidity and mortality

We propose a new anthropometric index, weight-adjusted-waist index (WWI), to assess adiposity by standardizing waist circumference (WC) for weight. WWI, calculated as WC (cm) divided by the square root of weight (kg) (cm/√kg), was measured from 465,629 subjects in the Korean nationwide cohort (2008-2013). Cox regression analysis was used to compare WWI with BMI, WC, waist-to-height ratio (WHtR), and a body shape index (ABSI) for cardiometabolic morbidity and mortality risk in diagnostic and prognostic prediction models. For incident hypertension, type 2 diabetes and cardiovascular disease (CVD), BMI had the strongest predictive power, followed by WWI and WC. However, WWI showed the best predictive performance for CVD mortality. Also, a linear positive association between adiposity indices and cardiovascular and all-cause mortality was only shown in WWI and ABSI, not BMI, WC and WHtR which showed inverse J-shaped patterns. In the test of joint effects of each index, WWI combined with BMI was the strongest in both diagnostic and prognostic models. WWI is a unique adiposity index that shows linear positive association with both cardiometabolic morbidity and mortality. It also predicts incident cardiometabolic disease, cardiovascular and all-cause mortality risk with excellence in predictive power, especially when combined with BMI.

Association of serum Sestrin2 level with metabolic risk factors in newly diagnosed drug-naïve type 2 diabetes

AIMS

Previous in-vitro and in-vivo experimental studies have shown that Sestrin2 attenuates oxidative stress and the pro-inflammatory pathway, resulting in improving metabolic homeostasis. However, the relationship between circulating Sestrin2 concentration and cardiometabolic risks in humans has not been explored.

METHODS

Sestrin2 concentration was measured in 240 subjects (46 without diabetes and 194 with diabetes), and the associations between Sestrin2 level and various cardiometabolic risk factors including body composition, insulin resistance, and atherosclerosis was assessed.

RESULTS

Sestrin2 concentration showed a trend of increasing in subjects with metabolic syndrome. After adjustment for age and gender, Sestrin2 level had a positive relationship with serum triglyceride, alanine aminotransferase (ALT), and creatinine levels, but no association with carotid atherosclerosis. Especially, in subjects with type 2 diabetes Sestrin2 concentration exhibited a significant positive correlation with body mass index (P = 0.015), waist circumference (P = 0.020), high-sensitivity C-reactive protein (P = 0.008), Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) (P = 0.041), percentage body fat (P = 0.001), and truncal fat mass (P = 0.005) after adjusting age and gender. Multiple stepwise regression analysis identified age, serum ALT and creatinine levels, and percentage body fat as independent determining factors for Sestrin2 concentration in patients with type 2 diabetes (R² = 0.173).

CONCLUSIONS

This study is the first to demonstrate a trend for increased Sestrin2 level in subjects with metabolic syndrome. In particular, in subjects with type 2 diabetes, Sestrin2 was significantly related to insulin resistance and percentage body fat, suggesting its potential as a novel modulatory factor for metabolic disorders in humans.