Prasugrel-based de-escalation vs. conventional therapy after percutaneous coronary intervention in ACS patients according to the renal function

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): A consortium of six companies in Korea (Daiichi Sankyo, Boston Scientific, Terumo, Biotronik, Qualitech Korea, and Dio).

Background

Patients with coronary artery disease and impaired renal function are at higher risk for both bleeding and ischemic adverse events after percutaneous coronary intervention (PCI).

Purpose

We assessed the efficacy and safety of a prasugrel based de-escalation strategy in patients with impaired renal function.

Methods

We conducted a post-hoc analysis of the HOST-REDUCE-POLYTECH-ACS study. Patients with available estimated glomerular filtration rate (eGFR) (n=2,311) were categorized into three groups. (high eGFR: ≥90 mL/min; intermediate eGFR: ≥60 and <90 mL/min; low eGFR: <60 mL/min). The endpoints were bleeding outcomes (Bleeding Academic Research Consortium type 2, or higher), ischemic outcomes (cardiovascular death, myocardial infarction, stent thrombosis, repeat revascularization, and ischemic stroke), and net adverse clinical events (all cause death, BARC 2 or greater bleeding, MI, stent thrombosis, repeat revascularization, and ischemic stroke) at 1 year follow-up. The hazard ratio (HR) and 95% Confidence interval (CI) were calculated from the multivariate Cox proportional hazard regression analysis. Covariates that were considered clinically meaningful were included. The probability risk ratio was obtained by dividing ischemic hazard function from the bleeding hazard function.

Results

With respect to net adverse clinical events, prasugrel de-escalation was beneficial regardless of baseline renal function (p for interaction = 0.508). The relative reduction in bleeding risk from prasugrel de-escalation was higher in the low eGFR group compared with that from both the intermediate and high eGFR groups (relative reduction: 64% [HR 0.36, 95% CI 0.15–0.83] vs. 50% [HR 0.50, 95% CI 0.28-0.90] and 52% [HR 0.48, 95% CI 0.21-1.13] for low, intermediate, and high eGFR groups, p for interaction=0.646). Ischemic risk from prasgurel de-escalation was not significant in all eGFR groups ([HR 1.18, 95% CI 0.47-2.98], [HR 0.95, 95% CI 0.53-1.69], and [HR 0.61, 95% CI 0.26-1.39)], respectively, p for interaction=0.119). The probability risk ratio was highest in low eGFR group (1.06 vs. 1.26 vs. 1.36, for high, intermediate, and low eGFR groups, respectively, p for trend<0.001), suggesting higher relative bleeding risk above ischemic risk. Within those randomized to the de-escalation strategy, the mean probability risk ratio was not significantly different according to renal function (0.89, vs. 0.84 vs. 0.80 respectively, p for trend = 0.053), which was in contrast to those randomized to the conventional strategy where the mean probability risk ratio increased significantly as renal function decreased (1.24 vs. 1.67 vs. 1.94 respectively, p for trend<0.001).

Conclusion

The beneficial effect of prasugrel-based de-escalation strategy was consistent regardless of the baseline renal function, which was mostly driven by a reduction in bleeding risk which was greatest in those with low eGFR.

Sex-differences in prevalence and outcomes of the different endotypes of chronic coronary syndrome – analysis from the multi-center international ILIAS Registry

Introduction

Guideline-directed management of chronic coronary syndrome (CCS) remains focused on obstructive causes of angina, and is based on established therapies derived from studies predominantly including men. This occurs despite documented higher mortality from cardiovascular causes in women compared to men, which is hypothesized to be related to a higher prevalence of coronary microvascular dysfunction (CMD) in women. However, data on the relationship between sex, the different endotypes of CCS, and related sex-specific clinical outcomes are limited.

Purpose

This study aimed to investigate the relationship between sex and the different endotypes of CCS, as well as sex-specific clinical outcomes of CCS endotypes.

Method

In patients with stable angina undergoing coronary angiography, the following invasive coronary hemodynamics were characterized: fractional flow reserve (FFR; <0.80 considered abnormal), coronary flow reserve (CFR; <2.0 considered abnormal) and microcirculatory resistance (MR) (hyperemic microvascular resistance; >2.5mmHg/cm/sec or index of microvascular resistance >25 considered abnormal). Patients were stratified into three groups: 1) hemodynamically significant obstructive coronary artery disease (oCAD) (FFR abnormal or a severe coronary stenosis requiring revascularization), 2) no-obstructive coronary artery disease but with CMD (FFR normal, but abnormal CFR and/or MR), or 3) no-obstructive coronary artery disease and no CMD (FFR normal, and normal CFR and MR). We assessed the prevalence of the CCS endotypes across sex, and sex-specific cardiovascular outcomes over a follow-up of 7 years defined as the composite endpoint of death or acute myocardial infarction.

Results

Amongst a total of 1987 included patients, 1435 (72.2%) were men and 552 (27.8%) were women. oCAD occurred in 904 (45.5%) patients, which was significantly more prevalent in men (48.9% (701/1435) of men vs. 36.8% (203/552) of women, p<0.001). In contrast, CMD was significantly more prevalent in women (19.6% (281/1435) of men vs. 24.1% (133/552) of women, p=0.031). Across the population, either oCAD or CMD occurred in 68.4% of men versus 60.9% of women (p=0.002). There were no sex-specific differences in cardiovascular outcomes across CCS entities (Figure 1).

Conclusion

In patients evaluated for CCS who underwent clinically indicated coronary angiography and physiological assessment, men were more likely to have oCAD and women were more likely to be classified as CMD. There were no sex-related differences in the prognosis associated with the individual CCS endotypes. Therefore, pathophysiological changes in the coronary circulation potentially underlying angina pectoris are similarly prevalent in men and women, but the high incidence of CMD in women makes women prone to underdiagnosis if no additional physiological measurements are assessed.

Funding Acknowledgement

Type of funding sources: None.

Hyperaemic and non-hyperaemic pressure indices of coronary stenosis severity in patients with chronic kidney disease

Background

Evidence regarding the use of pressure indices for the assessment of coronary stenoses in patients with chronic kidney disease (CKD) is scarce.

Methods

We assessed the relation between eGFR, FFR and resting Pd/Pa in 1147 consecutive patients (1316 vessels) included in the International Collaboration of Comprehensive Physiologic Assessment Study. We also compared FFR and Pd/Pa against a standardized cut-off of coronary flow reserve (CFR<2.0). Finally, we examined the occurrence of vessel-oriented composite outcome (VOCO: cardiac death, vessel-specific revascularization, vessel-specific myocardial infarction) across negative/positive results of both FFR and CFR in patients with and without CKD.

Results

FFR increases as renal function worsens (beta −10.5, 95% CI −20.0 to −11.03, p=0.030), a relation that was not seen with resting Pd/Pa (beta −6.14, 95% CI −19.9 to 6.78, p=0.351). Both indices had similar diagnostic accuracies for the detection of a CFR<2.0 in the presence of CKD (AUC 0.629 for FFR vs 0.663 for resting Pd/Pa, p=0.192). However, CKD patients showed a higher proportion of vessels with negative FFR but low CFR (24.5% vs 13.4%, p=0.015).

CFR decreased linearly with deteriorating eGFR, and this was mainly driven by higher resting coronary flow in CKD patients (p=0.026), while hyperaemic coronary flow remained similar (p=0.403). IMR did not change significantly with eGFR (beta −0.02, 95% −0.09 to 0.05, p=0.557).

The incidence of VOCO was higher in patients with CKD and FFR>0.80 when compared to non-CKD patients and FFR>0.80 (12.7% vs 6.90%, p=0.062). Prognosis was worse for those with CKD, negative FFR and CFR<2.0 (20.59% vs. 8.44% in non-CKD, p=0.038).

Conclusions

The assessment of a given coronary stenosis in patients with CKD with either FFR or resting Pd/Pa is equivalent when compared to underlying coronary flow. In CKD, impaired CFR is caused by a state of increased resting flow. The assessment of CFR on top of standard pressure wire examination significantly improves prognostic stratification in CKD patients.

Funding Acknowledgement

Type of funding sources: None.

Aspirin vs. Clopidogrel as a Chronic maintenance monotherapy after PCI in patients with high ischemic risk and high bleeding risk: Subgroup analysis of the HOST-EXAM trial

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

on behalf of the HOST-EXAM investigators

Background

The HOST-EXAM randomized clinical trial recently performed a comparison of clopidogrel monotherapy vs. aspirin monotherapy in patients requiring indefinite antiplatelet monotherapy after percutaneous coronary intervention (PCI). This study randomized 5,438 patients who maintained dual antiplatelet therapy without clinical events for 6–18 months after PCI with drug-eluting stents (DES) to receive a monotherapy agent of clopidogrel 75 mg once daily or aspirin 100 mg once daily for 24 months. During the 24-month follow-up, the primary outcome (a composite of all-cause death, non-fatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and Bleeding Academic Research Consortium (BARC) bleeding type 3 or greater) rate was significantly lower in the clopidogrel group (hazard ratio [HR] 0.73 [95% CI 0.59–0.90]; p = 0.0035). However, it is uncertain whether the beneficial effect of clopidogrel will be consistent in patients with high ischemic risk or those with high bleeding risk.

Methods

This is a post-hoc analysis of the HOST-EXAM trial. A high ischemic risk was defined as those who had at least 1 of the following procedural features: 3 vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation PCI, total stent length >60 mm, or left main PCI. Patients with high bleeding risk were defined according to the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria. The co-primary outcome were thrombotic endpoints (a composite of cardiac death, non-fatal myocardial infarction, ischemic stroke, readmission due to acute coronary syndrome, and definite or probable stent thrombosis) and bleeding endpoints (BARC type ≥2 bleeding events) at 24-month follow-up.

Results

 Among the total population, 22.1% had high ischemic risk and 21.4% had high bleeding risk. Complex PCI was not associated with a higher risk of thrombotic endpoints, nor bleeding endpoints. For patients with a high bleeding risk, these patients had a higher risk of both thrombotic endpoints (HR 1.545, 95% CI 0.141-2.092, p = 0.005) and bleeding endpoints (HR 3.418, 95% CI 2.413-4.840, p < 0.001). The primary results focusing on the interaction between high ischemic risk, high bleeding and the antiplatelet regimen will be presented.

Conclusion

The current post-hoc analysis of the HOST-EXAM trial will evaluate the efficacy of clopidogrel monotherapy vs. aspirin monotherapy during the chronic maintenance period after PCI, in patients with high ischemic risk or those with high bleeding risk.

A novel index reflecting both anatomical and physiologic parameters in coronary artery disease, the FFR adjusted SYNTAX score (FaSs)

Background

Various physiology-based indices have been proposed to predict adverse clinical events in patients with coronary artery disease (CAD), such as the sum of three vessel-fractional flow reserve (3v-FFR), and the functional SYNTAX score (fSS). However, these values could not fully reflect the anatomical factors, which remains as a barrier for clinical application of these indices.

Purpose

To propose a novel index which can reflect both anatomical and physiologic features in CAD patients, and evaluate the additional predictive value for cardiovascular adverse events compared to previous indices.

Methods

For an index which can reflect both anatomical and physiologic features, we proposed the FFR adjusted SYNTAX score (FaSs). The FaSs is calculated by adding the product of the SYNTAX score and `1-FFR', for all three major coronary arteries. Among the 1136 patients who enrolled at 3V FFR-FRIENDS study, we investigated 866 patients, after excluding those who had missing variables. The 3v-FFR, fSS and FaSs were calculated, derived from the baseline FFR and SYNTAX score. Patients were divided into two groups according to the median value of each index. The primary endpoint was major adverse cardiac events (MACE, a composite of cardiac death, myocardial infarction and ischemia-driven revascularization) at 2 years follow-up.

Results

Among the total population, MACE occurred in 35 (4.04%) patients. Using the median value in a multivariable COX regression model, only FaSs was associated with an increased risk of MACE, (Hazard Ratio [HR] 5.256, 95% confidence interval [CI] 2.014–13.720), while 3v-FFR (HR 1.383, 95% CI 0.685–2.790) and fSS (HR 1.640, 95% CI 0.830–3.243) were not significantly associated with a higher risk of MACE. This was also observed in the Kaplan Meier survival curve analysis (log-rank p value: p<0.001 for FaSs, 0.153 for 3v-FFR, and 0.061 for fSS; Figure 1) The sensitivity and specificity of the FaSs was 85.7% and 51.6%, which was higher compared to the 3v-FFR (62.9% and 49.3%, respectively) and fSS (57.1% and 58.5%, respectively). When these indices were combined with clinical risk factors (age, sex, hypertension, diabetes, hyperlipidemia, chronic renal failure, LVEF<40%), FaSs was superior compared with 3v-FFR and fSS assessed in regards of the predictive accuracy for MACE (Figure 2).

Conclusion

The FaSs, which is a novel index calculated by a formula using the SYNTAX score and FFR, showed a superior predictive value for MACE compared to previous indices. Our results confirm the importance of considering both anatomical and physiologic parameters in evaluating the patient's risk for cardiovascular adverse outcomes.

Funding Acknowledgement

Type of funding sources: None.

6113Gender differences in long-term outcomes in patients with deferred revascularization following fractional flow reserve assessment: international collaboration registry of physiologic evaluation

Background

Studies of sex differences in fractional flow reserve (FFR) measurements have shown that in comparison with men, angiographic lesions of similar visual severity are less likely to be ischemia producing in women. Gender specific differences may influence revascularization decision making and prognosis after deferred revascularization following FFR measurement.

Purpose

This study sought to investigate the gender difference in long-term prognosis of patients of deferred revascularization following FFR assessment.

Methods

A total of 879 patients (879 vessels) with deferred revascularization with FFR >0.75 who underwent FFR and CFR measurements were enrolled from 3 countries (Korea, Japan, and Spain). Long-term outcomes were assessed in 649 men and 230 women by the patient-oriented composite outcome (POCO, a composite of any death, any myocardial infarction [MI], and any revascularization). We applied inverse-probability weighting (IPW) based on propensity scores to account for differences at baseline between women and men (age, hypertension, hyperlipidemia, diabetes mellitus, lesion location, clinical status, FFR, Reference diameter, Diameter stenosis, lesion length). The median follow-up duration was 1855 days (745–1855 days).

Results

Median FFR values were 0.88 (0.83–0.93) in men and 0.89 (0.85–0.94) in women, respectively. The occurrences of POCO were significantly high in men compared with that in women (10.5% vs 4.2%, P=0.007). Kaplan–Meier analysis revealed that women had a significantly lower risk of POCO (χ2=7.2, P=0.007). Multivariate COX regression analysis revealed that age, male, diabetes mellitus, diameter stenosis, lesion length, and coronary flow reserve were independent predictors of POCO. After applying IPW, the hazard ratio of male for POCO was 2.20 (95% confidence interval: 1.12 to 4.33, P=0.023).

Conclusion

This large multinational study reveals that long-term outcome differs between women and men in favour of women after FFR-guided revascularization deferral.

Acknowledgement/Funding

None

Application of the Adverse Outcome Pathway Framework to Risk Assessment for Predicting Carcinogenicity of Chemicals

As industry develops in modern society, many chemicals are being used. The safety of chemicals is an important issue because humans are constantly exposed to chemicals throughout their daily life. Through a risk assessment, the hazardous human effects of chemicals can be identified. Recently, the adverse outcome pathway (AOP) framework has been used to predict the adverse effects of chemicals. As a conceptual framework for organizing existing biological knowledge, the AOP consists of a molecular initiating event, key events, and an adverse outcome. These independent elements represent biological responses and are connected by key event relationships. This AOP framework provides intuitive hazard identification that can be helpful for carcinogenic risk assessment of chemicals. In this review, we introduce the application of the AOP framework to risk assessment for predicting carcinogenicity of chemicals and illustrate the utility of this approach for cancer prevention.

The impact of multidisciplinary nutritional team involvement on nutritional care and outcomes in a medical intensive care unit

The aim of this study was to evaluate nutritional care and outcomes in a medical intensive care unit (ICU) following multidisciplinary nutritional team (MNT) involvement. The authors retrospectively reviewed the data of all patients admitted to a medical ICU from April to October 2013 (pre-MNT period) and from April to October 2014 (post-MNT period). In total, 140 patients were included and allocated to the pre-MNT group (n=70) or the post-MNT group (n=70). The post-MNT group was more likely to use enteral nutrition (61.4 vs 37.1%, P=0.002). In terms of total calories and protein provided, the number of nutritional goal-achieved days during stays in ICU was significantly greater in the post-MNT group than in the pre-MNT group (63.7% vs 47.6%, P<0.05 and 44.3% vs 29.9%, respectively, P<0.05). The MNT activities resulted in significant improvements in terms of nutritional provision and adequacy in a medical ICU.

Tuberculosis is frequently diagnosed within 12 months of diabetes mellitus

BACKGROUND

Evidence regarding the effects of tuberculosis (TB) screening among patients with diabetes mellitus (DM) in intermediate TB burden countries is insufficient, and the most appropriate time point for TB screening is unclear.

OBJECTIVE

To investigate trends in TB incidence among newly diagnosed DM patients.

DESIGN

A retrospective cohort study of the claims database of the Health Insurance Review and Assessment Service in Korea was performed. Participants were newly diagnosed with type 2 DM in 2009. The study outcome was TB incidence between 2009 and 2011 among participants according to duration of type 2 DM.

RESULTS

A cohort of 331,601 patients with newly diagnosed type 2 DM in 2009 was identified. During the 3-year follow-up period, 1533 patients were diagnosed with TB. The estimated incidence of TB among newly diagnosed type 2 DM patients was 18/10,000 patient-years (py) (95%CI 17.5-19.4). TB incidence was 33/10,000 py (95%CI 30.0-35.6) in the first 6 months, and 19/10,000 py (95%CI 16.5-20.6) in the following 6-month period.

CONCLUSIONS

The risk of developing TB was increased among DM patients, particularly during the first 12 months after DM diagnosis.

The effects of statin use on the development of tuberculosis among patients with diabetes mellitus

OBJECTIVE

To evaluate whether statin use affects the development of tuberculosis (TB) among patients with diabetes mellitus (DM).

METHODS

This is a retrospective cohort study of patients with newly diagnosed type 2 DM based on the South Korean nationwide claims database. The participants were type 2 DM patients aged 20-99 years who were newly treated with anti-diabetic drugs between 1 January 2007 and 31 December 2010. Patients who had statin prescriptions before a diagnosis of diabetes or were diagnosed with TB before diabetes were excluded.

RESULTS

Of 840,899 newly diagnosed type 2 DM patients, 281,842 (33.5%) patients were statin users and 559,057 (66.5%) were non-users. During the study period, 4075 [corrected] individuals were diagnosed with TB; the estimated incidence of TB in our cohort was 251/100,000 patient-years (95%CI 243-258). In comparison to non-TB patients, statin users were less frequent among TB patients (19.2% vs. 33.6%). After adjustment for potential baseline confounders, statin use was not associated with the development of TB in DM patients (aHR 0.98; 95%CI 0.89-1.07).

CONCLUSIONS

TB development among newly diagnosed type 2 DM was considerable, and statin use among these diabetics was not associated with a protective effect on TB incidence.

Expression of an ASCL2 related stem cell signature and IGF2 in colorectal cancer liver metastases with 11p15.5 gain

BACKGROUND AND AIMS

Liver metastases are the leading cause of death in colorectal cancer. To gain better insight into the biology of metastasis and possibly identify new therapeutic targets we systematically investigated liver-metastasis-specific molecular aberrations.

METHODS

Primary colorectal cancer (pCRC) and matched liver metastases (LMs) from the same patients were analysed by microarray-based comparative genomic hybridisation in 21 pairs and gene expression profiling in 18 pairs. Publicly available databases were used to confirm findings in independent datasets.

RESULTS

Chromosome aberration patterns and expression profiles of pCRC and matched LMs were strikingly similar. Unsupervised cluster analysis of genomic data showed that 20/21 pairs were more similar to each other than to any other analysed tumour. A median of only 11 aberrations per patient was found to be different between pCRC and LM, and expression of only 16 genes was overall changed upon metastasis. One region on chromosome band 11p15.5 showed a characteristic gain in LMs in 6/21 patients. This gain could be confirmed in an independent dataset of LMs (n=50). Localised within this region, the growth factor IGF2 (p=0.003) and the intestinal stem cell specific transcription factor ASCL2 (p=0.029) were found to be over-expressed in affected LM. Several ASCL2 target genes were upregulated in this subgroup of LM, including the intestinal stem cell marker OLFM4 (p=0.013). The correlation between ASCL2 expression and four known direct transcriptional targets (LGR5, EPHB3, ETS2 and SOX9) could be confirmed in an independent expression dataset (n=50).

CONCLUSIONS

With unprecedented resolution a striking conservation of genomic alterations was demonstrated in liver metastases, suggesting that metastasis typically occurs after the pCRC has fully matured. In addition, we characterised a subset of liver metastases with an ASCL2-related stem-cell signature likely to affect metastatic behaviour of tumour cells.

The effects of total energy expenditure from all levels of physical activity vs. physical activity energy expenditure from moderate-to-vigorous activity on visceral fat and insulin sensitivity in obese Type 2 diabetic women

AIMS

We examined the effects of physical activity with or without dietary restriction for 3 months on regional fat and insulin sensitivity and compared the effect of total energy expenditure from all levels of physical activity with that of physical activity energy expenditure from moderate-to-vigorous exercise in obese women with Type 2 diabetes.

METHODS

In this randomized, controlled trial, we assessed change of body weight, abdominal visceral fat area, subcutaneous fat area and insulin sensitivity, expressed as K(ITT), and monitored total energy expenditure and physical activity energy expenditure using an accelerometer during a 12-week intervention in four groups: control, diet, exercise and diet plus exercise.

RESULTS

The mean body mass index was 28.0 +/- 2.7 kg/m(2) and the mean duration of diabetes was 8 +/- 6 years. Both the diet and diet plus exercise groups showed significant body weight loss compared with the control group (P < 0.05). However, the visceral fat area was reduced only in the diet and exercise group (P = 0.017) and the subcutaneous fat area was reduced only in the diet group (P = 0.009). Mean energy intake was an independent determinant of the change in subcutaneous fat area (P = 0.020) and mean total anergy expenditure was an independent determinant of visceral fat area (P = 0.002). Insulin sensitivity K(ITT) was associated with physical activity energy expenditure (P = 0.006), energy intake (P = 0.047) and the change in fructosamine level (P = 0.016) but not with changes in body weight, subcutaneous fat area, visceral fat area or adipokine level.

CONCLUSIONS

Exercise had an additive effect to dietary restriction on visceral fat reduction. Visceral fat area was associated with total energy expenditure, but insulin sensitivity was associated with physical activity energy expenditure.

Resistance Exercise Did Not Alter Intramuscular Adipose Tissue but Reduced Retinol-binding Protein-4 Concentration in Individuals with Type 2 Diabetes Mellitus

Lipid accumulation in muscle is associated with diminished insulin sensitivity. It was hypothesized that resistance exercise decreases muscular adipose tissue and reduces the level of retinol-binding protein-4 (RBP4), which is linked to adipose tissue and insulin sensitivity in diabetics. Forty-four women with type 2 diabetes were randomly assigned to three groups for a period of 12 weeks: control (asked to maintain a sedentary lifestyle); resistance exercise (elastic band exercise at moderate intensity five times per week); and aerobic exercise (walking for 60 min at moderate intensity five times per week). Subcutaneous (SCAT), subfascial (SFAT) and intramuscular (IMAT) adipose tissues at mid-thigh level were assessed using computed tomography, and RBP4 level and insulin sensitivity (fractional disappearance rate of insulin, kITT) were assessed before and after intervention. Changes in SCAT, SFAT, IMAT, RBP4 and kITT were similar among the three groups. Within-group analysis revealed that body mass index and waist circumference decreased significantly in both exercise groups, but RBP4 decreased significantly only with resistance exercise. Resistance exercise did not alter muscular adipose tissue or improve insulin sensitivity.

Fulminant type 1 diabetes in Korea: high prevalence among patients with adult-onset type 1 diabetes

AIMS/HYPOTHESIS

The aim of this study was to investigate the prevalence of fulminant type 1 diabetes and the clinical characteristics of the disease among newly diagnosed Korean patients.

METHODS

Using data retrieved from the Seoul National University Hospital database, we identified all patients newly diagnosed with type 1 diabetes from 1 January 1999 to 31 July 2006. Information on clinical manifestations and laboratory data, including the presence of islet autoantibodies detected at diagnosis, were obtained by reviewing medical records.

RESULTS

We identified 99 patients newly diagnosed with type 1 diabetes. Seven patients (7.1%) fulfilled the criteria for fulminant type 1 diabetes. Among the patients aged > or =18 years at onset, 30.4% had fulminant type 1 diabetes. Patients with this diabetes subtype tested negative for islet autoantibodies, had a higher age of onset (median 28 vs 10 years, p < 0.001) and a markedly shorter duration from onset of hyperglycaemic symptoms to first hospital visit (median 3 vs 30 days, p < 0.001) than patients with non-fulminant type 1 diabetes, and showed trends of increased serum aspartate aminotransferase and amylase levels and a decreased glucagon-stimulated serum C-peptide response.

CONCLUSIONS/INTERPRETATION

In Korea, the prevalence of fulminant type 1 diabetes was 7.1% among all patients newly diagnosed with type 1 diabetes and 30.4% among patients with adult-onset diabetes. The clinical and metabolic characteristics of the patients with fulminant type 1 diabetes were similar to those reported in Japanese studies.

Polymorphisms of KCNJ11 (Kir6.2 gene) are associated with Type 2 diabetes and hypertension in the Korean population

AIMS

Kir6.2 is found in the pancreatic B-cell, cardiac and skeletal muscle and non-vascular smooth muscle. KCNJ11, encoding Kir6.2, has been shown to be associated with both Type 2 diabetes mellitus and cardiovascular disease in several populations. In this study, we investigated whether polymorphisms in KCNJ11 are associated with Type 2 diabetes and other metabolic phenotypes in the Korean population.

METHODS

We sequenced KCNJ11 to identify common polymorphisms using 24 Korean DNA samples. Of the 14 polymorphisms found in KCNJ11, six common ones [genomic sequence (g.)-1709A>T, g.-1525T>C, g.67G>A (E23K), g.570C>T (A190A), g.1009A>G (I337V), and g.1388C>T] were genotyped in 761 Type 2 diabetic patients and in 630 non-diabetic subjects.

RESULTS

All the polymorphic loci in KCNJ11 are in strong linkage disequilibrium in the Korean population and act as one haplotype block. g.67G>A and g.1009A>G were associated with an increased risk of Type 2 diabetes [age, sex, and body mass index (BMI)-adjusted odds ratios (OR) = 1.376 (1.085-1.745), P = 0.008 and 1.411 (1.111-1.791), P = 0.005, respectively], as was one haplotype (A-T-A-C-G-C in the order of polymorphisms as shown above) containing g.67A and g.1009G [OR = 1.359 (1.080-1.709), P = 0.009]. The haplotype (A-T-A-C-G-C) was also strongly associated with hypertension [OR = 1.655 (1.288-2.126), P < 0.001].

CONCLUSIONS

Polymorphisms in KCNJ11 are associated with Type 2 diabetes and also with hypertension in the Korean population.

An integrated modelling and multicriteria analysis approach to managing nitrate diffuse pollution: 1. Framework and methodology

As trade-off relationships between the agronomy and the environment are common over land uses within a catchment, one of major concerns of catchment management plans is how to balance the trade-offs over land uses at the catchment-scale. In this two-part paper, an integrated modelling and multicriteria analysis (MCA) methodology is presented which can be used to evaluate a set of land use alternatives and to identify an 'ideal' compromise between economic return and environmental pollution. This 'ideal' compromise here is achieved by land use optimisation of which the objective is to minimise the environmental pollution (nitrate leaching rate) and to maximise the economic return (agronomic gross margin), considering both environmental and economic potential across the catchment in a site-specific manner. The suggested methodology can be used to produce a site-specifically optimised land use scenario that is an 'ideal' compromise between nitrate diffuse pollution and agronomy at the catchment-scales. Some issues on the actual application of the methodology are also discussed.

An integrated modelling and multicriteria analysis approach to managing nitrate diffuse pollution: 2. A case study for a chalk catchment in England

The site-specific land use optimisation methodology, suggested by the authors in the first part of this two-part paper, has been applied to the River Kennet catchment at Marlborough, Wiltshire, UK, for a case study. The Marlborough catchment (143 km(2)) is an agriculture-dominated rural area over a deep chalk aquifer that is vulnerable to nitrate pollution from agricultural diffuse sources. For evaluation purposes, the catchment was discretised into a network of 1 kmx1 km grid cells. For each of the arable-land grid cells, seven land use alternatives (four arable-land alternatives and three grassland alternatives) were evaluated for their environmental and economic potential. For environmental evaluation, nitrate leaching rates of land use alternatives were estimated using SHETRAN simulations and groundwater pollution potential was evaluated using the DRASTIC index. For economic evaluation, economic gross margins were estimated using a simple agronomic model based on nitrogen response functions and agricultural land classification grades. In order to see whether the site-specific optimisation is efficient at the catchment scale, land use optimisation was carried out for four optimisation schemes (i.e. using four sets of criterion weights). Consequently, four land use scenarios were generated and the site-specifically optimised land use scenario was evaluated as the best compromise solution between long term nitrate pollution and agronomy at the catchment scale.

Decreased insulin sensitivity is associated with the extent of coronary artery disease in patients with angina

BACKGROUND

Insulin resistance has been proposed as an important risk factor in the development of atherosclerosis.

AIM

To evaluate the association of insulin resistance and coronary atherosclerosis, we investigated the correlation between insulin sensitivity and the degree of coronary stenosis in patients with angina pectoris.

METHODS

The study population consisted of 74 subjects with angina (54 men and 20 women) aged from 31 to 73 years. Coronary angiograms were evaluated by three semiquantitative scoring systems (vessel score, stenosis score and extent score) to estimate the extent of focal and diffuse coronary artery disease (CAD). Insulin sensitivity (K(ITT)) was determined by the insulin tolerance test.

RESULTS

There were significant correlations existed between K(ITT) and all three coronary scores. Multivariate analysis revealed significant and independent correlations of all three coronary scores with K(ITT) (vessel score: beta = -0.349, p = 0.004; stenosis score: beta = -0.487, p < 0.001; extent score: beta = -0.481, p < 0.001), even in patients without diabetes mellitus (vessel score: beta = -0.387, p = 0.008; stenosis score: beta = -0.469, p < 0.001; extent score: beta = -0.559, p < 0.001). K(ITT) was significantly lower in patient with diffuse CAD than without diffuse CAD (2.13 +/- 0.66 vs. 2.57 +/- 0.79%/min, p < 0.05). However, K(ITT) was not different between patients with and without focal CAD.

CONCLUSIONS

Insulin sensitivity has statistically significant and independent associations with the extent of coronary stenosis. These results suggest that insulin resistance may play a major role in the development of diffuse coronary artery stenosis.

Postinfarction left ventricular rupture misdiagnosed ruptured intramural hematoma of aorta

Left ventricular rupture is a fatal complication of acute myocardial infarction, however accurate preoperative diagnosis is still difficult. We experienced a postinfarction left ventricular rupture patient whose symptoms and radiologic findings mimicked those of acute intramural hematoma of the aorta. Upon emergency operation, he was proven to have a postinfarction LV rupture and underwent successful surgery. We herein report the case with a brief review of the literature.

Solution structure of the dimeric cytoplasmic domain of syndecan-4

The syndecans, transmembrane proteoglycans which are involved in the organization of cytoskeleton and/or actin microfilaments, have important roles as cell surface receptors during cell-cell and/or cell-matrix interactions. Since previous studies indicate that the function of the syndecan-4 cytoplasmic domain is dependent on its oligomeric status, the conformation of the syndecan-4 cytoplasmic domain itself is important in the understanding of its biological roles. Gel filtration results show that the syndecan-4 cytoplasmic domain (4L) itself forms a dimer stabilized by ionic interactions between peptides at physiological pH. Commensurately, the NMR structures demonstrate that syndecan-4L is a compact intertwined dimer with a symmetric clamp shape in the central variable V region with a root-mean-square deviation between backbone atom coordinates of 0.95 A for residues Leu(186)-Ala(195). The molecular surface of the 4L dimer is highly positively charged. In addition, no intersubunit NOEs in membrane proximal amino acid resides (C1 region) have been observed, demonstrating that the C1 region is mostly unstructured in the syndecan-4L dimer. Interestingly, two parallel strands of 4L form a cavity in the center of the dimeric twist similar to our previously reported 4V structure. The overall topology of the central variable region within the 4L structure is very similar to that of 4V complexed with the phosphatidylinositol 4,5-bisphosphate; however, the intersubunit interaction mode is affected by the presence of C1 and C2 regions. Therefore, we propose that although the 4V region in the full cytoplasmic domain has a tendency for strong peptide--peptide interaction, it may not be enough to overcome the repulsion of the C1 regions of syndecan-4L.

Introduction of HIV type 1 subtype E virus into South Korea

Subtype E HIV-1 is the most prevalent strain in Southeast Asia. Although subtype B is prevalent in Korea, geographical distance and increases in travel may lead to the spread of subtype E in Korea. Therefore, we tried to identify and monitor the patterns of HIV subtype E virus introduction into Korea. The divergence of nucleotide sequences within the envelope region (V3 to V5) of Korean subtype E isolates ranged from 4.3 to 14.6% (n = 8; mean, 9.5 +/- 2.8%). In pairwise comparisons of subtype E isolates between Korea and other regions, the divergence of nucleotide sequences between 8 Korean and 16 Asian subtype E variants ranged from 1.3 to 15.2% (mean, 7.8 +/- 2.6%), whereas the divergence of nucleotide sequences between 8 Korean and 2 African variants ranged from 11.7 to 20.7% (mean, 15.4 +/- 2.2%). A phylogenetic tree showed that Korean subtype E isolates cluster with the Asian isolates but far from the African isolates. These epidemiological and molecular epidemiological data suggest that HIV-1 subtype E strains have been transmitted into Korea from endemic areas of Southeast Asia rather from Africa.

Infantile spasms: cerebral blood flow abnormalities correlate with EEG, neuroimaging, and pathologic findings

This ongoing study examines abnormalities of cerebral perfusion in a consecutive series of children with infantile spasms and correlates cerebral blood flow (CBF) abnormalities with electroencephalographic (EEG), neuroimaging, and pathologic findings. A consecutive series of children with infantile spasms, diagnosed by standard clinical and EEG criteria, had cerebral perfusion studies using 99Tc-HmPAO single photon emission computed tomography (SPECT), together with neuroimaging studies using computed tomography (CT) and/or magnetic resonance imaging (MRI), interpreted independently and correlated with surgical pathologic findings. Twenty children aged 2-13 months (mean 9.3 months) were studied over a 4-year period; 60% had symptomatic infantile spasms due to cerebral dysgenesis (33%), other congenital lesions (25%), tuberous sclerosis (17%), or other causes (25%), and the remaining patients were cryptogenic (40%). CBF abnormalities were present in 85%: multifocal decrease (40%), focal increase (25%), diffuse decrease (15%), and focal increase (10%), while the remaining 15% had normal cerebral blood flow. Focal cortical lesions may lead to infantile spasms, even in cryptogenic patients diagnosed by functional neuroimaging such as 99Tc-HmPAO SPECT. In selected patients, surgical excision of the cortical lesions leads to improved seizure control and possibly outcome. The localization and surgical excision of focal cortical lesions in infantile spasms required further investigation with functional and structural neuroimaging, EEG, and intraoperative electrocorticography.

Magnetic resonance imaging evaluation of delayed myelination in Down syndrome: a case report and review of the literature

Magnetic resonance imaging has been found to be useful in assessing brain myelination and provides information on brain maturation. The normal pattern of brain myelination conforms to a fixed sequence, with good pathologic and MRI correlation. Neuropathologic analysis of myelination has shown delayed central myelination in Down syndrome. Delayed myelination on MRI in Down syndrome has not previously been reported. We report a case of Down syndrome with a significant delay in myelination as demonstrated on MRI. This 18-month-old infant had brain myelination equivalent to that expected for an 11-month-old infant. To determine the relative incidence, extent of delayed myelination, and time for recovery to full myelination in Down syndrome, more cases require examination and assessment. Magnetic resonance imaging has the advantage of serial assessment of myelination during brain maturation.