Frequency and Overlap of Cachexia, Malnutrition, and Sarcopenia in Elderly Patients with Diabetes Mellitus: A Study Using AWGC, GLIM, and AWGS2019

This study aimed to estimate the frequency and overlap of cachexia, malnutrition, and sarcopenia in elderly patients with diabetes mellitus. Patients who were aged at least 65 years, had diabetes mellitus, and were regularly visiting the Ise Red Cross Hospital on an outpatient basis were included. The patients were assessed to determine whether they had cachexia, malnutrition, and sarcopenia according to the Asian Working Group for Cachexia criteria, the Global Leadership Initiative on Malnutrition criteria, and the Asian Working Group for Sarcopenia 2019 criteria. A total of 510 patients (310 men and 200 women) were analyzed in this study. Sarcopenia, cachexia, and malnutrition were found in 84 patients (16.4%), 40 patients (7.8%) (17.8% among patients with chronic diseases), and 110 patients (21.5%), respectively. Among patients with sarcopenia, the frequencies of cachexia and malnutrition were 30% and 71.4%, respectively. Among patients with cachexia, the frequencies of sarcopenia and malnutrition were 65% and 90%, respectively, and among those with malnutrition, the frequencies of sarcopenia and cachexia were 54% and 32.7%, respectively. The overlap among cachexia, malnutrition, and sarcopenia appears to be an important factor to be considered in the treatment of elderly patients with diabetes mellitus.

[Decreased family caregiver satisfaction with diabetes treatment of elderly patients is associated with patient depressive symptoms]

OBJECTIVE

To examine the relationship between the dissatisfaction of family caregivers with diabetes treatment and depressive symptoms among the elderly.

METHODS

The subjects were diabetic patients of 65 years of age or older and their family caregivers, who were outpatients at Ise Red Cross Hospital. The Japanese version of the Patient Health Questionnaire 9, which consists of nine items, was used to measure depressive symptoms. The Japanese version of the Treatment Satisfaction Scale for Caregivers of Dependent Diabetic Patients (STCD2-J) was used to measure the satisfaction of family caregivers with diabetes treatment. A logistic regression analysis was performed using depressive symptoms as dependent variable, satisfaction of the family caregiver with diabetes treatment as an explanatory variable, and adjustment variables.

RESULTS

In total, 272 patients were included in the analysis. Taking the quintiles of STCD2-J scores, the adjusted odds ratios for patient depressive symptoms in Q2 (27-29), Q3 (24-26), Q4 (22-23) and Q5 (14-21) based on Q1 (30-36) (the group with the highest STCD2-J scores) were 2.44 (95% confidence interval (CI), 0.69-8.61; P=0.163), 3.08 (95% CI, 0.93-10.12; P=0.063), 2.69 (95% CI, 0.68-10.65; P=0.156), and 4.54 (95% CI, 1.44-14.32; P=0.010), respectively.

CONCLUSION

We found that family caregivers' decreased satisfaction with diabetes treatment was associated with depressive symptoms. It is important to alert primary care physicians about depressive symptoms when they see family caregivers who show decreased satisfaction with diabetes treatment.

Development of the "Social Participation Barriers in Patients With Diabetes" Questionnaire for Older Patients With Diabetes and Evaluation of its Reliability and Validity

Objectives: To develop a questionnaire for evaluating the factors hindering social participation in older patients with diabetes (the Social Participation Barriers in Patients with Diabetes [SPBD] questionnaire) and assess its reliability and validity. Materials and Methods: This is a cross-sectional study. This study included outpatients aged ≥60 years having diabetes and undergoing treatment at the Ise Redcross Hospital. A draft questionnaire consisting of 20 questions was developed with reference to previous studies. Logistic regression analysis was conducted, and Cronbach's alpha coefficient was calculated. Exploratory factor analysis was conducted to test construct validity. Pearson's correlation coefficients between SPBD scores and frailty scores, social frailty scores and frequency of outings were calculated. Results: Overall, 353 patients were included in the analysis. After questions without an association in the logistic regression analysis were excluded and results of the exploratory factor analyses were obtained, 10 questions were excluded. As a result, we created a 10-item SPBD questionnaire. Cronbach's alpha coefficient was .87. The SPBD score was significantly associated with frequency of going out, and frailty. Conclusions: We created an SPBD questionnaire to assess barriers to social participation in older adult patients with diabetes. This study indicated the validity and reliability of the questionnaire.

Incidence of sarcopenic obesity in older patients with diabetes and association between sarcopenic obesity and higher-level functional capacity: evaluation based on a consensus statement

We used a consensus statement to diagnose sarcopenic obesity, evaluated incidence of sarcopenic obesity in older patients with diabetes, and examined whether sarcopenic obesity was associated with their higher-level functional capacity. Outpatients with diabetes (age, ≥65 years) undergoing treatment at Ise Red Cross Hospital were included. The Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC)-a self-administered questionnaire-was used to assess their higher-level functional capacity. Sarcopenic obesity was evaluated based on the consensus statement diagnostic criteria-i.e., presence or absence of decreased skeletal muscle mass was evaluated based on appendicular skeletal muscle mass/body weight and obesity was assessed based on body fat mass percentage. To calculate the adjusted β coefficient of sarcopenic obesity for higher-level functional capacity, multiple regression analyses were performed using TMIG-IC scores as the dependent variable and four categories (non-sarcopenia/non-obesity was used as a reference) that included sarcopenia and obesity as the predictor and moderator variables. Among the 310 patients included, the sarcopenic obesity incidence was 13.1% and 14.2% in men and women, respectively. When the non-sarcopenia/non-obesity group was used as a reference, the adjusted β coefficient of sarcopenic obesity for scores of the TMIG-IC was -2.09 (p = 0.014) in men. However, the women showed no relationship between sarcopenic obesity and TMIG-IC scores. In older men with diabetes, sarcopenic obesity was associated with a decline in higher-level functional capacity.

[Loneliness is associated with the risk of low nutrition in elderly diabetic patients]

OBJECTIVE

The purpose of this study was to examine the relationship between loneliness and malnutrition in elderly diabetic patients.

METHODS

The subjects were diabetic patients ≥65 years old who were outpatients at Ise Red Cross Hospital. The nutritional status was assessed using the Mini Nutritional Assessment Short Form (MNA-SF), and patients were defined as being undernourished if their total score was <11 points. Loneliness was assessed using the Japanese version of the short form of the loneliness scale, a self-administered questionnaire, and a total score of ≥6 was considered to indicate loneliness. A logistic regression analysis was used to calculate the adjusted odds ratio of loneliness to undernutrition, with the dependent variable being undernutrition, the explanatory variable being loneliness, and the adjustment variable being loneliness.

RESULTS

A total of 163 patients were included in the analysis of this study. Of these, 25.8% were lonely, and 33.7% were undernourished. The unadjusted and adjusted odds ratios of loneliness to undernutrition were 2.55 (95% confidence interval [CI], 1.24-5.27; P=0.011) and 3.81 (95% CI, 1.27-11.39; P=0.017), respectively.

CONCLUSION

Loneliness is associated with a low nutritional status in elderly diabetic patients. It is important to alert diabetic patients with loneliness to their low nutritional status when they are diagnosed.

[A study of the frequency of cachexia and its associated factors in elderly patients with diabetes mellitus]

OBJECTIVE

To investigate the frequency of cachexia and its associated factors in elderly diabetic patients.

METHODS

The subjects were diabetic patients ≥65 years old attending the outpatient diabetes clinic of Ise Red Cross Hospital. Cachexia was evaluated as having three or more of the following: (1) muscle weakness, (2) fatigue, (3) anorexia, (4) decreased lean body mass, and (5) biochemical abnormalities. A logistic regression analysis was used to identify factors associated with cachexia, with the dependent variable as cachexia and explanatory variables as various variables (basic attributes, glucose-related parameters, comorbidities, and treatment).

RESULTS

A total of 404 patients (233 males and 171 females) were included in the study. Twenty-two (9.4%) and twenty-two (12.8%) male and female patients, respectively, had cachexia. A logistic regression analysis showed that the HbA1c value (odds ratio [OR], 0.26,95% confidence interval [CI], 0.08-0.81; P=0.021) and cognitive and functional decline (OR, 11.81, 95% CI, 1.81-76.95; P = 0.010) were factors associated with cachexia. In women, type 1 diabetes (OR, 12.39, 95% CI, 2.33-65.87; P=0.003), the HbA1c value (OR, 1.71, 95% CI, 1.07-2.74; P=0.024), and insulin usage (OR, 0.14, 95% CI, 0.02-0.71; P=0.018) were cachexia-related factors.

CONCLUSIONS

The frequency of cachexia in elderly diabetic patients and its associated factors were identified. It is important to increase awareness of the risk of cachexia in elderly diabetic patients with poor glycemic control, cognitive and functional decline, type 1 diabetes mellitus, and insulin non-use.

[A low phase angle is a factor independently associated with falls in elderly diabetic patients]

OBJECTIVE

To examine the relationship between a low phase angle (PA) and falls in elderly diabetic patients.

METHODS

The subjects were diabetic patients ≥65 years old who were outpatients at Ise Red Cross Hospital. Patients were asked about their fall history using a self-administered questionnaire. The PA was measured by the multi-frequency bioelectrical impedance method, and the subjects were classified into two groups: the first quartile with the smallest PA (T1 group) and the second and third quartiles (T2/3 groups). A logistic regression analysis with falls as the dependent variable, PA as the explanatory variable, and adjustment variables was used to calculate the odds ratio of the PA for falls.

RESULTS

A total of 255 patients were included in the analysis of this study. Of these, 33.3% were in the T1 group, 66.7% were in the T2/3 group, and 28.2% had fallen. The unadjusted and adjusted odds ratios for falls in the PA were 2.92 (95% confidence interval [CI], 1.31-4.07; P=0.004) and 2.34 (95% CI, 1.07-5.09; P=0.031), respectively.

CONCLUSION

A low PA was associated with falls in elderly diabetic patients.

["Koshi-heso" (waist-umbilicus) test: A novel screening method for visceral fatty obesity]

OBJECTIVE

To evaluate the screening performance and validity of the "Koshi-heso" (waist-umbilicus) test for visceral fatty obesity in elderly diabetic patients.

METHODS

Subjects were diabetic patients ≥65 years old visiting our outpatient clinic. As a "Koshi-heso" test, the distance between the umbilicus and the superior border of the iliac crest (waist) was measured with the patient's own finger. When the index finger reached the umbilicus and there was a gap between the finger and the abdominal wall, the patient was classified as "smaller"; when the index finger reached the umbilicus and there was no gap between the finger and the abdominal wall, the patient was classified as "just fit"; and when the index finger did not reach the umbilicus, the patient was classified as "bigger". Abdominal circumference was used to assess visceral fat obesity, with a cut-off value of ≥85 cm for men and ≥90 cm for women. Visceral fat mass and body fat percentage were evaluated by the multi-frequency bioelectrical impedance method. The sensitivity and specificity of the waist-umbilical test for visceral fat obesity were calculated. Pearson's correlation coefficients between the "Koshi-heso" test and visceral fat mass and body fat percentage were calculated to evaluate the validity of the test. Furthermore, the association between the "Koshi-heso" test and risk factors for vascular disease, microvascular complications and cardiovascular disease was assessed by a logistic analysis.

RESULTS

A total of 221 patients were included in the analysis population of the study. The cut-off values of "just fit" in men (sensitivity 0.96, specificity 0.62) and "bigger" in women (sensitivity 0.76, specificity 0.78) were optimal. Furthermore, the "Koshi-heso" test was significantly correlated with abdominal visceral fat mass and body fat percentage as well as with vascular disease risk factors and microvascular complications.

CONCLUSION

The "Koshi-heso" test was able to be used as a screening method for visceral fatty obesity in elderly diabetic patients.

[Loneliness is associated with a reduced higher-level-function capacity in older diabetic patients]

OBJECTIVE

The present study examined the relationship between loneliness and higher-level functions in elderly diabetic patients.

METHODS

The subjects were diabetic patients ≥65 years old who were outpatients at Ise Red Cross Hospital. The Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC), a self-administered questionnaire, was used to assess higher-level functions. To evaluate loneliness, we used a shortened version of the Japanese version of the loneliness scale, a self-administered questionnaire. A multiple regression analysis with TMIG-IC scores as the dependent variable, loneliness as the explanatory variable, and adjustment variables was used to calculate the adjusted partial regression coefficients of loneliness on higher-level functions.

RESULTS

One hundred and seventy patients were included in the present analysis. Ninety-one patients (53.5%) had loneliness, and the mean TMIG-IC score was 11.3. The unadjusted and adjusted partial regression coefficients of loneliness on higher-level functions were -1.61 (95% confidence interval [CI], -2.31 to -0.91; < 0.001) and -0.88 (95% CI, -1.52 to -0.23; P=0.008), respectively.

CONCLUSION

Loneliness in elderly diabetic patients was found to be associated with lower higher-level functions. It is important to remind patients with diabetes mellitus who have loneliness about the risk of a decline in their higher-level functions.

[Association between the history of falls and being homebound in elderly diabetic patients]

OBJECTIVE

The purpose of this study was to investigate the relationship between a history of falls and being homebound in elderly diabetic patients.

METHODS

The subjects were diabetic patients ≥65 years old visiting the outpatient clinic of Ise Red Cross Hospital. Patients were defined as being confined if they went out less than once a day, and their history of falls in the past year was investigated. Adjusted odds ratios for being homebound were calculated using a logistic regression analysis with a dependent variable of being homebound and explanatory variables of a history of falls and adjustment factors (age, sex, duration of diabetes, HbA1c, cardiovascular disease, cognitive and functional decline, depression, living alone, isolation, and diabetes treatment).

RESULTS

A total of 564 patients (319 men and 245 women) were included in the study. The numbers of patients with a history of falls and who were homebound were 198 (35.1%) and 88 (15.6%), respectively. The adjusted odds ratio for being homebound to a history of falls was 2.69 (95% confidence interval, 1.31 to 5.52; P=0.007).

CONCLUSION

In this study, a history of falls was significantly associated with being homebound. It is important to pay close attention to homebound elderly diabetic patients with a history of falls.

Verification of the predictive validity for mortality of the SARC-F questionnaire based on a meta-analysis

BACKGROUND

Although the association between SARC-F questionnaire positivity and mortality has previously been studied, the results are inconsistent. Testing the predictive validity of the SARC-F questionnaire for clinically relevant outcomes of vital prognoses is important.

AIM

The objective of this study was to test the predictive validity of SARC-F by conducting a meta-analysis on the association between SARC-F, a screening tool for sarcopenia, and mortality.

METHODS

This meta-analysis used the MEDLINE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar databases for literature searches. Studies that examined the relationship between SARC-F questionnaire positivity and mortality and reported hazard ratios or odds ratios and 95% confidence intervals were included. A random-effects model was used for statistical analyses, and pooled hazard ratios, pooled odds ratios, and 95% confidence intervals were calculated.

RESULTS

Through the literature search, we found five studies (7501 individuals) that met the eligibility criteria for this study. The pooled hazard ratio for SARC-F questionnaire positivity and mortality was 1.87 (95% confidence interval 1.41-2.46; P < 0.001), indicating a significant association. The pooled odds ratio for SARC-F questionnaire positivity and mortality was 1.97 (95% confidence intervals 1.10-3.53; P = 0.02), showing a significant association.

CONCLUSIONS

There was a significant association between SARC-F positivity and future mortality, indicating the predictive validity of the SARC-F questionnaire.

TRIAL REGISTRATION

Not applicable.

[Multimodal treatment program for elderly diabetic patients with sarcopenia improves the muscle strength and physical function]

OBJECTIVE

To evaluate the effects of a multimodal treatment program on the muscle strength, physical function, and skeletal muscle mass in elderly diabetic patients with sarcopenia.

METHODS

Diabetic patients over 65 years old attending the Department of Diabetes and Metabolism, Ise Red Cross Hospital, were included. The diagnosis of sarcopenia was based on the Asian Working Group for Sarcopenia 2019. The measurement of extremity skeletal muscle mass was assessed by the multi-frequency bioelectrical impedance method, muscle strength was assessed by the grip strength, and the physical function was assessed by the 5-time chair stand test. The muscle strength, physical function, extremity skeletal muscle mass, and other parameters were assessed before and after 12 weeks of the multimodal treatment program (optimization of protein intake, resistance training, and patient education on sarcopenia) and then compared. Paired t-tests were used for the statistical analysis.

RESULTS

Fourteen patients (3 men and 11 women) were included in the analysis of this study. The mean age was 74.4±4.7 years old. Significant improvements in the grip strength (male, 23.2±5.6 kg to 25.6±5.5 kg, P=0.014; female, 15.5±5.0 kg to 18.9±5.0 kg, P<0.001) and 5-time chair stand test (11.2±2.5 seconds to 8.6±1.7 seconds, P=0.002) were found with the multimodal treatment program. There was also a significant decrease in HbA1c (8.1±0.7% to 7.7±0.9%, P=0.004). However, although an increasing trend in the amount of extremity skeletal muscle mass was noted, there was no significant difference.

CONCLUSIONS

A multimodal treatment program for elderly diabetic patients with sarcopenia showed an improvement in the muscle strength and physical function.

Are diabetes-related factors associated with the social roles of elderly patients with diabetes?

AIMS

To identify factors associated with social roles, including glycemic parameters, diabetic complications, and diabetes treatment, in elderly patients with diabetes.

METHODS

We included diabetic patients aged ≥65 years undergoing outpatient treatment at Ise Red Cross Hospital. Functional capacity was assessed using the social role subscale, included in the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC). Multiple regression analyses were performed using social roles as dependent variables and age, body mass index, HbA1c, glycoalbumin/HbA1c, hypertension, dyslipidemia, diabetic microangiopathy, cardiovascular disease, depression, sleep disturbance, living alone, frailty, diabetic drug as explanatory variables.

RESULTS

In total, 367 patients (208 males and 159 females) were included. In men, diabetic nephropathy (coefficient, -0.496; 95% confidence interval (CI), -0.900 to -0.091; P = 0.017), depression (coefficient, -0.497; 95% CI, -0.942 to -0.051; P = 0.029), and frailty (coefficient, -0.595; 95% CI, -1.048 to -0.142; P = 0.010) were associated with a decline in social roles. In women, frailty (coefficient, -0.826; 95% CI, -1.306 to -0.346; P = 0.001) was associated with a decline in social roles.

CONCLUSIONS

Social roles may decline in elderly male diabetic patients with nephropathy, depression, and frailty and in elderly female diabetic patients with frailty.

Effects of Antidiabetic Drugs on Muscle Mass in Type 2 Diabetes Mellitus

BACKGROUND

When considering the administration of glucagon-like peptide-1 receptor agonists (GLP-1RAs), sodium-glucose cotransporter-2 (SGLT2) inhibitors, or metformin, it is important to understand their weight loss effect as well as the degree of muscle loss caused by each drug in clinical practice.

OBJECTIVE

To comparatively examine the effects of GLP-1RAs and oral antidiabetic drugs, including SGLT2 inhibitors and metformin, on muscle mass and body weight in patients with type 2 diabetes via a network meta-analysis of randomized controlled trials.

METHODS

We included randomized controlled trials evaluating the effects of antidiabetic drugs on muscle mass and body weight. Mean difference (MD) and 95% confidence intervals (CIs) were calculated using a random-effects network meta-analysis.

RESULTS

Of the studies identified, 18 randomized controlled trials (1, 363 subjects) satisfied the eligibility criteria. In all studies, the effects of these drugs on fat-free mass (FFM) were evaluated. Therefore, FFM, which is used as an alternative index of muscle mass, was included in the study. Semaglutide (MD: -1.68, 95% CI: -2.84 to -0.52), dapagliflozin (-0.53, -0.93 to -0.13), and canagliflozin (-0.90, -1.73 to -0.07) showed a significant decrease in FFM compared with the placebo. Metformin did not show a significant decrease in FFM compared with the placebo. When compared with the placebo, semaglutide, dapagliflozin, ipragliflozin, and canagliflozin showed a significant weight loss.

CONCLUSION

Although semaglutide, dapaglifrozin, and canagliflozin have a large weight loss effect, it is important to pay attention to muscle loss because a decrease in FFM was observed.

Factors associated with social isolation and being homebound among older patients with diabetes: a cross-sectional study

OBJECTIVE

We aimed at investigating factors associated with social isolation and being homebound in older patients with diabetes.

DESIGN

Cross-sectional study.

SETTINGS

Those undergoing outpatient treatments at Ise Red Cross Hospital, Mie Prefecture.

PARTICIPANTS

Patients with diabetes aged ≥65 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Social isolation was defined as indulging in less than one interaction per week with individuals other than cohabiting family members. We defined homebound as going outside home less than once a day. To identify factors associated with social isolation and being homebound, we performed logistic regression analysis. The dependent variable was social isolation or homebound and independent variables were basic attributes, glycaemic parameters, complications and treatment details.

RESULTS

We analysed 558 cases (320 men and 238 women). Among these, 174 (31.2%) were socially isolated; meanwhile, 87 (15.6%) were homebound. The glycoalbumin/haemoglobin A1c ratio (OR 4.52; 95% CI 1.07 to 19.1; p=0.040) and the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC) scores (OR 0.72; 95% CI 0.57 to 0.90; p=0.006) had significant associations with social isolation. TMIG-IC scores (OR 0.78; 95% CI 0.66 to 0.92; p=0.003) and insulin use (OR 4.29; 95% CI 1.14 to 16.1; p=0.031) were associated with being homebound.

CONCLUSION

In older patients with diabetes, glycaemic fluctuations and insulin use are associated with social isolation and being homebound, respectively. In addition, a decline in higher level functional capacity is a common factor associated with social isolation and being homebound. Thus, it is important to pay attention to social isolation and being homebound when a decline in higher level functional capacity, increased glycaemic fluctuations and insulin use in older patients with diabetes are observed.

Preparation of the Japanese Version of the Diabetes Caregiver Activity and Support Scale and Verification of Its Reliability and Validity

PURPOSE

The purpose of the study was to adapt and psychometrically evaluate a Japanese language version of the Diabetes Caregiver Activity and Support Scale (D-CASS-J) to be culturally relevant for people with diabetes living in Japan.

METHODS

A Japanese translation of the original version of the D-CASS was prepared, corrected, and back-translated. Family caregivers of patients with diabetes mellitus ages ≥65 years who visited the outpatient diabetes clinic of Ise Red Cross Hospital were included. Cronbach's α coefficients were calculated as an assessment of internal consistency. Exploratory factor analyses were performed to verify construct validity. Hierarchical multiple regression analyses were performed using depression as the dependent variable and D-CASS-J and other variables as explanatory variables. Pearson's correlation coefficients between D-CASS-J scores and the support burden scale scores were calculated to verify criterion-related validity.

RESULTS

This analysis included 268 subjects. Cronbach's α coefficient was .86. Factor analyses showed the same single-factor structure as the original version of the D-CASS. Hierarchical multiple regression analyses based on the conceptual model demonstrated construct validity. D-CASS-J scores were significantly correlated with support burden scale scores.

CONCLUSIONS

For family caregivers of elderly patients with diabetes in Japan, D-CASS-J can be used as a tool to evaluate difficulties experienced while providing support to patients.

Frequency of Social Isolation and Homeboundness and Their Relationships with High-Level Functional Capacity in Elderly Diabetic Patients

PURPOSE

To determine the frequency of social isolation (hereinafter, isolation) and homeboundness in elderly diabetic patients and to investigate their relationships with high-level functional capacity.

PATIENTS AND METHODS

Subjects were diabetic outpatients aged 65 years and older who were visiting the Japanese Red Cross Ise Hospital. Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC) was used to evaluate high-level functional capacity. Isolation was defined as having less than one interaction per week with someone other than co-habiting family members. Homeboundness was defined as leaving the house less than once a day. Multiple regression analysis was performed with the TMIG-IC score as the dependent variable and isolation and homeboundness as independent variables.

RESULTS

Four hundred fifty-one patients were included in the analysis. The frequency of isolation and homeboundness affected 37% and 13.3% of men and 28.9% and 20.6% of women, respectively. The adjusted partial regression coefficient of the TMIG-IC scores of isolated, homebound, and isolated+homebound men was -0.94 [95% confidence interval (CI), -1.68 to -0.21; P = 0.012], -0.27 (95% CI, -1.93 to 1.39; P = 0.746), and -4.03 (95% CI, -5.37 to -2.68; P < 0.001) in relation to that of the non-isolated and non-homebound group as reference. In women, the respective coefficients to the reference were -1.33 (95% CI, -2.93 to 0.25; P = 0.099), -0.65 (95% CI, -2.56 to 1.26; P = 0.501), and -3.01 (95% CI, -4.92 to -1.1; P = 0.002), respectively.

CONCLUSION

The frequency of isolation was high in both female and male elderly diabetic patients. In men, there was a significant relationship between isolation and decline in high-level functional capacity. In both men and women, there was a significant relationship between isolation+homeboundness and decline in high-level functional capacity.

Verification of the predictive validity for mortality of the SARC-F questionnaire based on a meta-analysis

BACKGROUND

Although the association between SARC-F questionnaire positivity and mortality has previously been studied, the results are inconsistent. Testing the predictive validity of the SARC-F questionnaire for clinically relevant outcomes of vital prognoses is important.

AIM

The objective of this study was to test the predictive validity of SARC-F by conducting a meta-analysis on the association between SARC-F, a screening tool for sarcopenia, and mortality.

METHODS

This meta-analysis used the MEDLINE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar databases for literature searches. Studies that examined the relationship between SARC-F questionnaire positivity and mortality and reported hazard ratios or odds ratios and 95% confidence intervals were included. A random-effects model was used for statistical analyses, and pooled hazard ratios, pooled odds ratios, and 95% confidence intervals were calculated.

RESULTS

Through the literature search, we found five studies (7501 individuals) that met the eligibility criteria for this study. The pooled hazard ratio for SARC-F questionnaire positivity and mortality was 1.87 (95% confidence interval 1.41-2.46; P < 0.001), indicating a significant association. The pooled odds ratio for SARC-F questionnaire positivity and mortality was 1.97 (95% confidence intervals 1.10-3.53; P = 0.02), showing a significant association.

CONCLUSIONS

There was a significant association between SARC-F positivity and future mortality, indicating the predictive validity of the SARC-F questionnaire.

TRIAL REGISTRATION

Not applicable.

Preparation, Reliability, and Validity of a Japanese Version of the "Satisfaction of Treatment among Caregivers of Dependent Type 2 Diabetic Patients" Questionnaire

The aim of this study was to prepare a Japanese version of the "Satisfaction of Treatment among Caregivers of Dependent Type 2 Diabetic Patients" (STCD₂-J) questionnaire, which is used to assess the satisfaction of family caregivers with respect to the treatment for elderly patients with type 2 diabetes mellitus who require support. In addition, the reliability and validity of the STCD₂-J questionnaire were analyzed. A Japanese version of the original STCD₂ questionnaire was prepared, revised, and back-translated; the back-translated version was sent to the authors of the original version for confirmation. Family caregivers of patients with type 2 diabetes mellitus aged ≥65 years who regularly underwent medical examinations at the diabetes mellitus outpatient clinic of Ise Red Cross Hospital were included. Cronbach's α coefficient was calculated to assess internal consistency. Exploratory factor analyses were performed to assess construct validity, and Pearson's correlation coefficients between STCD₂-J score and HbA1c as well as the degree of satisfaction with patients' blood glucose levels, depression, and negative self-assessment of nursing care were calculated to assess criterion-related validity. This study included 208 individuals (55 males and 153 females). Cronbach's α coefficient was 0.88. Factor analyses showed a single-factor structure both with and without rotation. The STCD₂-J scores were significantly inversely correlated with HbA1c (r = -0.27, P < 0.001). Significant correlations were observed between the STCD₂-J scores and degree of satisfaction with patients' blood glucose levels (r = 0.43, P < 0.001), depression (r = -0.20, P = 0.003), and negative self-assessment of nursing care (r = -0.19, P = 0.004). The reliability and validity of the STCD₂-J questionnaire were confirmed. The STCD₂-J questionnaire can be used in Japan as a tool to assess the satisfaction of family caregivers with the treatment of elderly patients with type 2 diabetes mellitus requiring support.

Effects of Flash Glucose Monitoring on Dietary Variety, Physical Activity, and Self-Care Behaviors in Patients with Diabetes

The aim of this study was to evaluate the effects of flash glucose monitoring on dietary variety, physical activity, and self-care behavior in patients with diabetes. This study included outpatients with diabetes using insulin who presented at the Department of Diabetes and Metabolism of the Ise Red Cross Hospital. Before initiating flash glucose monitoring and 12 weeks after its initiation, blood glucose-related parameters were assessed and self-administered questionnaires were completed (Dietary Variety Score (DVS), the International Physical Activity Questionnaire (IPAQ), the Summary of Diabetes Self-Care Activities Measure (SDSCA), and the Diabetes Treatment Satisfaction Questionnaire (DTSQ)) and compared between the two time points. We analyzed 42 patients with type 1 diabetes mellitus and 48 patients with type 2 diabetes mellitus. In patients with type 2 diabetes mellitus, but not type 1 diabetes mellitus, there was an increase in moderate/high category scores for IPAQ (P < 0.001) and for treatment satisfaction reported via DTSQ. Furthermore, in patients with type 2 diabetes mellitus, the glycemic excursion index improved significantly and HbA1c decreased significantly (from 7.7 (1.2) to 7.4 (0.8), P = 0.025). Results showed that standard deviation and mean amplitude of glycemic excursions significantly decreased in patients with type 1 diabetes mellitus (from 71.2 (20.4) to 66.2 (17.5), P = 0.033 and from 124.6 (31.9) to 108.1 (28.4), P < 0.001, respectively). Flash glucose monitoring is a useful tool to improve physical activity in patients with type 2 diabetes.

[Relationship of sarcopenic obesity with left ventricular diastolic dysfunction in elderly patients with diabetes]

AIM

This study aimed to examine the relationship of obesity, sarcopenia, and sarcopenic obesity (SO) with left ventricular diastolic dysfunction (LVDD) in elderly patients with diabetes.

METHODS

Subjects included in this study were patients with diabetes ≥65 years of age and who were receiving treatment on an outpatient basis at the Ise Red Cross Hospital. To determine the presence of LVDD, we divided the early diastolic left ventricular filling velocity (E) by the early mitral annular motion velocity (E') (E/E'), which was measured using tissue Doppler imaging. To evaluate sarcopenia, SARC-F-J, a self-administered questionnaire consisting of five items, was used. Obesity was defined as a body mass index >25. Using a multiple logistic regression analysis with LVDD as the dependent variable and sarcopenia, obesity, and SO as explanatory variables, we calculated the odds ratios of LVDD for each variable.

RESULTS

The subjects were 291 (157 male and 134 female) patients. Among male patients, the odds ratios after moderating for LVDD in the sarcopenia, obese, and SO groups were 0.82 (95% confidence interval [CI) ], 0.20 to 3.27, P=0.784), 1.92 (95% CI, 0.69 to 5.32, P=0.207), and 6.41 (95% CI, 1.43 to 28.53, P=0.015), respectively, whereas among female patients, these ratios were 1.31 (95% CI, 0.31 to 5.51, 0.708), 1.41 (95% CI, 0.45 to 4.37, P=0.551), and 3.18 (95% CI, 0.93 to 10.9, P=0.064), respectively.

CONCLUSIONS

In male elderly patients with diabetes, SO was significantly correlated with LVDD. We believe that it is important to consider LVDD when examining male elderly patients with SO.

Relationship between frailty and mortality, hospitalization, and cardiovascular diseases in diabetes: a systematic review and meta-analysis

Background

In patients with diabetes, death and cardiovascular diseases are attributed to classical risk factors such as hypertension, dyslipidemia, and smoking habit, whereas these events are attributed to frailty in the remaining patients. In this meta-analysis, we examined the relationship between frailty and mortality, hospitalization, and cardiovascular diseases in patients with diabetes.

Methods

Literature search was conducted using databases such as MEDLINE, Cochrane Controlled Trials Registry, and ClinicalTrials.gov. Studies that examined the relationship between frailty and mortality, hospitalization, and cardiovascular disease and included hazard ratios (HRs), odds ratios (ORs), and 95% confidence intervals (CIs) were included. Statistical analysis was performed using a random effects model, and pooled HRs, pooled ORs, and 95% CIs were calculated.

Results

The literature search extracted 8 studies (565,039 patients) that met our inclusion criteria, which were included in this meta-analysis. The pooled HR of prefrailty and frailty related to mortality was 1.09 (95% CI 1.01–1.17; P = 0.02) and 1.35 (95% CI 1.05–1.74; P = 0.02), respectively, indicating a significant relationship between them. The pooled OR of prefrailty and frailty related to hospitalization was 2.15 (95% CI 1.30–3.54; P = 0.003) and 5.18 (95% CI 2.68–9.99; P < 0.001), respectively, indicating a significant relationship. Although a significant relationship was found between frailty and cardiovascular diseases, we found only few related studies; thus, robust results could not be obtained.

Conclusions

In patients with diabetes, a significant relationship was observed between frailty and mortality and hospitalization. However, only few heterogeneous studies were included, warranting further examination.

Association between sarcopenia and sleep disorder in older patients with diabetes

AIM

In the present study, we aimed to examine the association between sarcopenia and sleep disorder in older patients with diabetes using the Japanese version of SARC-F (SARC-F-J).

METHODS

Outpatients with diabetes (aged ≥65 years) at the Ise Red Cross Hospital were included in the present study. We used the Japanese version of the Pittsburgh Sleep Quality Index, which is a self-administered questionnaire, to measure sleep disorder. To evaluate sarcopenia, we used SARC-F-J, a self-administered questionnaire, comprising five items. For multiple logistic regression analysis, the dependent variable was sleep disorder and the explanatory variable was sarcopenia, and these were used for calculating the odds ratios of sarcopenia with regard to sleep disorder.

RESULTS

In total, 318 patients were included in this study (189 men and 129 women). The prevalence of sarcopenia was 22.5% and that of sleep disorder was 44.8%. Adjusted odds ratios of sarcopenia and sleep disorder were 6.04 in men (95% CI 1.71-21.36, P = 0.005) and 6.33 in women (95% CI 1.91-20.97, P = 0.003).

CONCLUSIONS

We found a statistically significant association between sarcopenia and sleep disorder in older patients with diabetes using SARC-F-J. Therefore, older patients with diabetes should be cautioned regarding sleep disorder if they are diagnosed with sarcopenia. Geriatr Gerontol Int 2019; 19: 399-403.

Association between Sarcopenia and Overactive Bladder in Elderly Diabetic Patients

OBJECTIVES

To determine the association between sarcopenia and overactive bladder (OAB) in elderly diabetic patients using the Japanese version of SARC-F called SARC-F-J.

DESIGN

Cross-sectional study.

SETTINGS AND PARTICIPANTS

The study included 329 elderly diabetic patients (aged ≥65 years) who regularly visited the outpatient clinic at Community hospital in Japan.

MEASUREMENTS

The condition of OAB was evaluated using the OAM symptom score, which involves a self-administered questionnaire, and sarcopenia was evaluated using the self-administered SARC-F-J questionnaire comprising five items. The odds ratio for OAB due to sarcopenia was calculated using multiple logistic regression analysis, with OAB as the dependent variable and sarcopenia as the explanatory variable.

RESULTS

A total of 329 patients (186 males, 143 females) were included for analysis in the present study. Of these patients, 22.9% had sarcopenia and 18.7% had OAB. After adjusting the variables, the odds ratio for OAB due to sarcopenia was 4.46 (95% confidence interval [CI], 1.14-17.36, P = 0.031) and 2.09 (95% CI, 0.52-8.26, P = 0.293) for males and females, respectively.

CONCLUSION

This study found that sarcopenia was significantly associated with OAB in elderly diabetic male patients based on SARC-F-J. Moreover, the possibility of the development of OAB should be considered during the medical examinations of elderly diabetic male patients with sarcopenia.

Association between Sarcopenia and Renal Function in Patients with Diabetes: A Systematic Review and Meta-Analysis

Previous studies involving patients with diabetes have indicated that sarcopenia is related to renal function. The objective of the present study was to investigate the association between sarcopenia and urinary albumin level, urinary protein level, and estimated glomerular filtration rate (eGFR) in patients with diabetes. A meta-analysis of observational studies was conducted. A literature search was performed using MEDLINE, Cochrane Controlled Trials Registry, and ClinicalTrials.gov. Data were extracted from studies investigating the association between sarcopenia and urinary albumin level, urinary protein level, and eGFR and by calculating odds ratio (OR) and 95% confidence intervals (CIs). Statistical analysis was performed using a random-effects model to calculate pooled OR and 95% CI. Six studies (2662 patients) that met the criteria were included in the meta-analysis. Sarcopenia was significantly associated with urinary albumin level with a pooled OR of 2.11 (95% CI, 1.55-2.88; P < 0.001). The pooled ORs of the associations between sarcopenia and urinary protein level and decreased eGFR were 1.82 (95% CI, 1.13-2.92; P = 0.01) and 3.75 (95% CI, 1.24-11.41), respectively. Sarcopenia was significantly associated with urinary albumin level, urinary protein level, and decreased eGFR. However, further investigations are needed, including meta-analyses with a larger number of studies.

Development of a Japanese version of the SARC-F for diabetic patients: an examination of reliability and validity

BACKGROUND

SARC-F is a 5-item, self-administered questionnaire developed to screen sarcopenia. To date, no Japanese version of the SARC-F has been developed.

AIMS

To create a Japanese version of the SARC-F (SARC-F-J), a questionnaire for diabetic patients, and to investigate its reliability and validity.

METHODS

This was a cross-sectional study. A Japanese translation of the SARC-F was created and revised, and the authors of the original version of the SARC-F verified the back-translation. The questionnaire was tested in diabetic outpatients aged ≥65 years who had received treatment at our hospital. After 14 weeks, the kappa coefficient was used to evaluate the retest reliability. Using the diagnostic criteria for sarcopenia based on the European Working Group on Sarcopenia in Older People as the reference standard, we calculated the sensitivity, specificity, positive predictive value, and negative predictive value of the SARC-F-J.

RESULTS

The study comprised 207 patients (men, 60.8%; women, 39.2%). The kappa coefficient was 0.66. For men and women, the sensitivities were 14.6 and 33.3%, specificities were 85.8 and 72.4%, positive predictive values were 33.3 and 17.3%, and negative predictive values were 65.7 and 86.2%, respectively.

DISCUSSION

The probability of identifying the condition is considered high when patients are diagnosed with sarcopenia using SARC-F-J.

CONCLUSIONS

The retest reliability of SARC-F-J was regarded to be good. When EWGSOP was assumed as a reference, the specificity of SARC-F-J was high. Because the sensitivity was low, patients with sarcopenia could not be screened, and hence, attention is needed.

[A comparison of the associations of dynapenia and sarcopenia with fear of falling in elderly diabetic patients]

AIM

To comparatively investigate whether dynapenia and sarcopenia, as defined by the Asian Working Group for Sarcopenia (AWGS), are associated with fear of falling in elderly patients with diabetes.

METHODS

The subjects were outpatients with diabetes who were at least 65 years of age when they visited our hospital. Sarcopenia was evaluated based on the AWGS definition. The cutoff values for the appendicular skeletal mass index (multi-frequency bioelectrical impedance method), grip strength, and walking speed were, respectively, 7.0 kg/m² for men and 5.7 kg/m² for women, 26 kg for men and 18 kg for women, and ≤0.8 m/s for both men and women. Those with grip strength of less than or equal to the cutoff value were considered to have dynapenia. Fear of falling was assessed by a self-administered questionnaire survey with the Fall Efficacy Scale (FES) Japanese version. A multiple regression analysis was conducted using the FES score as a dependent variable and dynapenia or sarcopenia and moderators as explanatory variables.

RESULTS

A total of 202 patients (male, n=127; female, n=75) were analyzed in this study. The FES scores of the patients with and without sarcopenia did not differ to a statistically significant extent in either male or female patients. The multiple regression analysis revealed a statistically significant association between dynapenia and the FES score in men (P=0.028).

CONCLUSIONS

In elderly outpatients with diabetes, no association was found between sarcopenia and the fear of falling in either men or women. In contrast, a statistically significant association was found between dynapenia and fear of falling in men. This suggests the importance paying attention to the fear of falling when examining elderly male diabetes patients with dynapenia.

Effect of trelagliptin on vascular endothelial functions and serum adiponectin level in patients with type 2 diabetes: a preliminary single-arm prospective pilot study

Background

Trelagliptin, an oral DPP-4 inhibitor, which is administered once per week and characterized by a long half-life in blood. The effects of trelagliptin on vascular endothelial functions have not been clarified to date. The objective of the present study was to examine the effects of trelagliptin on vascular endothelial functions in patients with type 2 diabetes mellitus (DM) using flow-mediated dilatation (FMD), adiponectin, and asymmetric dimethylarginine (ADMA) as evaluation indicators.

Methods

This study was a preliminary single-arm prospective pilot study. The subjects of this study were type 2 DM patients aged 20–74 years, who visited our outpatient department. The patients were treated with trelagliptin, and their FMD, adiponectin, and ADMA levels were measured at baseline and at 12 weeks after initial treatment to determine the changes during the study period.

Results

A total of 27 patients, excluding three dropouts, were included in the population for analysis. Trelagliptin treatment showed no significant changes in FMD (2.42 ± 2.7% at baseline vs. 2.66 ± 3.8% post-treatment, P = 0.785) and ADMA (0.41 ± 0.0 µg/mL at baseline vs. 0.40 ± 0.0 µg/mL post-treatment, P = 0.402). Trelagliptin treatment resulted in a significant increase of serum adiponectin level (7.72 ± 6.9 µg/mL at baseline vs. 8.82 ± 8.3 µg/mL post-treatment, P < 0.002).

Conclusions

In this pilot study, trelagliptin treatment showed no significant changes in FMD. On the other hand, it was believed that trelagliptin treatment may increase serum adiponectin level.

Trial Registrationhttp://www.umin.ac.jp (Trial ID UMIN000018311)

Clinical Utility of Diagnostic Laboratory Tests in Dogs with Acute Pancreatitis: A Retrospective Investigation in a Primary Care Hospital

BACKGROUND

Acute pancreatitis (AP) occurs frequently in dogs, but most previous studies examining the diagnosis of AP have used data from secondary care hospitals.

HYPOTHESIS/OBJECTIVES

The aim of this study was to investigate the clinical utility of diagnostic laboratory tests in dogs with AP in a primary care hospital.

ANIMALS

Sixty-four dogs with clinical signs suggestive of AP diagnosed with nonpancreatic disease (NP) or AP.

METHODS

Medical records were retrospectively reviewed, including diagnostic laboratory tests considered potentially useful in the diagnosis of AP. The diagnostic accuracy of amylase and FUJI DRI-CHEM lipase (FDC lip) were investigated using receiver operating characteristics (ROC). In addition, we verified whether diagnostic laboratory tests were useful for evaluating duration of hospitalization and as biomarkers for monitoring recovery.

RESULTS

Activities of amylase and FDC lip were significantly higher in the AP group than in the NP group (P = .001, P < .001, respectively). The sensitivity of FDP lip activity for diagnosing AP was 100% (95% confidence interval [CI], 87.7-100%); the specificity was 89.5% (95% CI, 66.9-98.7%). Area under the ROC curve for FDC lip activity was 0.98 (95% CI, 0.93-1). High alanine aminotransferase (ALT) activity was associated with extended duration of hospitalization (P = .04). A significant difference in C-reactive protein (CRP) concentration before and 5 days after treatment was found (P = .001).

CONCLUSIONS AND CLINICAL IMPORTANCE

Measurement of FDC lip activity appears useful for diagnosing AP. High ALT activity might be associated with prolonged duration of hospitalization, and CRP might be useful as a biomarker for monitoring recovery from AP.

[Differentiation of hypertrophic cardiomyopathy and hypertensive cardiac hypertrophy using the patterns of interventricular septum hypertrophy]

The patterns of interventricular septal hypertrophy were analyzed on two-dimensional echocardiograms to differentiate hypertrophic cardiomyopathy (HCM) from hypertensive cardiac hypertrophy. The control group comprised 110 patients without cardiovascular disease who were matched for age and gender with the hypertension group. The hypertension group comprised 110 patients with uncomplicated essential hypertension, and the HCM group comprised 32 patients in whom the wall thickness of the interventricular septum was 12 mm or more at the mid-portion and no underlying heart disease responsible for cardiac hypertrophy was detected. The interventricular septal thickness was measured both at the thickest portion within 15 mm distal to the aortoseptal junction (basal portion: B) and at the mid-portion (M) in the end-diastolic image on the left parasternal long-axis tomograms, and the B/M ratio was calculated in each patient. The B/M ratio was 1.07 +/- 0.16 in the control group, 1.19 +/- 0.18 in the hypertension group, and 0.83 +/- 0.12 in the HCM group. Compared with the control group, the B/M ratio was significantly high in the hypertension group (p < 0.05) and significantly low in the HCM group (p < 0.01). These results indicate that hypertrophy of the interventricular septum is dominant at the basal portion in hypertensive patients but at the mid-portion in patients with HCM.

Abnormal Q wave, ST-segment elevation, T-wave inversion, and widespread focal myocytolysis associated with subarachnoid hemorrhage

A 74-year-old Japanese woman with subarachnoid hemorrhage was admitted to our hospital. During her hospitalization, serial electrocardiograms showed the combination of abnormal Q waves, ST-segment elevation, and T-wave inversion, which strongly suggested acute myocardial infarction. However, postmortem examination revealed widespread focal myocytolysis of the myocardium which was unrelated to vascular distribution.

Diversity of the synthetic-state smooth-muscle cells proliferating in mechanically and hemodynamically injured rabbit arteries

Vascular smooth muscles contain at least three types of developmentally regulated myosin heavy-chain (MHC) isoforms; SM1, SM2, and SMemb. By investigating the expression of the three MHC isoforms, we previously demonstrated in rabbits that smooth muscles proliferating in the neointima of arterio- and atherosclerotic lesions regain an "embryonic" phenotype. In the present study, we examined if neointimal cells are morphologically similar to embryonal smooth muscles and if dedifferentiation of neointimal smooth muscles is a reversible process. Vascular injury was produced in rabbits either by endothelial cell denudation of the aorta or by poststenotic dilation of the carotid artery. We have demonstrated in this study that the proliferating neointimal cells expressed SM1 and SMemb, but not SM2, indicating smooth muscles of an "embryonic" phenotype. The dedifferentiation of neointimal smooth muscles was found to be reversible; at 4 to 8 weeks after injury, a majority of the cells reexpressed both SM1 and SM2, but not SMemb. By electron microscopy, we have revealed smooth-muscle phenotypes determined by MHC isoforms to correspond to the morphologic phenotypes as an increase in membranous organelles, and a decrease in myofilaments was associated with the reexpression of SMemb. Interestingly, we also found that in the medial wall at 4 to 8 weeks after ballooning injury, a number of SM1-negative cells proliferated rapidly, replacing normal smooth muscles. These cells were negative against SM1 and SM2 but positive for SMemb. These SM1-negative cells contained abundant membranous organelles and few myofilaments. These cells did not express SM1 or SM2 even after 8 weeks postinjury. We conclude from these results that the proliferating synthetic-type smooth muscles after vascular injury are composed of SM1-positive cells that are morphologically similar to embryonal smooth muscle and that maintain ability to redifferentiate, and SM1-negative cells that contain few myofilaments and remain dedifferentiated.

[Perceived quality of life and social factors in elderly hypertensive patients]

We conducted a cross-sectional study of elderly outpatients with hypertension to examine the relationship between quality of life (QOL) scores and social background factors. The subjects consisted of 516 outpatients (267 females), age of 60 or over, at nine clinics of major hospitals which participated in the National Cardiovascular Center Research Project. The perceived QOL was evaluated by the QOL scale originally based on Japanese patients with cardiovascular diseases. The scale consisted of the following 5 subscales; difficulty due to disease, psychological stability, independence, satisfaction in daily living and vitality. The background factors included family structure, socioeconomic factors and work status, and physical activity of daily living (ADL). After adjusting for age, sex, administered drugs and complicating conditions such as ischemic heart disease and/or apoplexy, a significant odds ratio of a low score of difficulty due to disease, psychological stability, satisfaction in daily living and vitality was found in the impaired physical ADL group with low socioeconomic class, and a significant odds ratio of low score of independence were found in the impaired physical ADL group who had lost jobs due to illness and had no children.

Prediction of early development of chronic nonrheumatic atrial fibrillation

The purpose of this study was to identify predictors of development of chronic nonrheumatic atrial fibrillation within one year of onset, thereby minimizing the risk of embolic complications and death. We retrospectively studied 137 patients with new-onset nonrheumatic atrial fibrillation. Chronic atrial fibrillation developed in 30 patients at the end of one year (chronic group). Atrial fibrillation remained paroxysmal in 107 patients (paroxysmal group). Clinical characteristics, electrocardiograms, and echocardiograms at the time of the onset of atrial fibrillation were compared in the two groups. Patients in the chronic group were significantly older than patients in the paroxysmal group (70.1 +/- 8.2 vs. 62.4 +/- 11.0 years, p < 0.01) and had a significantly higher incidence of congestive heart failure (13% vs. 3%, p < 0.05) and diabetes mellitus (37% vs. 19%, p < 0.05). The chronic group also exhibited higher cardiothoracic ratio (52.0 +/- 5.7% vs. 47.6 +/- 5.0%, p < 0.01), greater f-wave amplitude in lead V1 (1.48 +/- 0.91 vs. 1.06 +/- 0.45 mm, p < 0.05), larger left atrial dimension (41.0 +/- 6.4 vs. 34.2 +/- 7.6 mm, p < 0.01), and lower left ventricular ejection fraction (71.4 +/- 5.6% vs. 75.5 +/- 8.2%, p < 0.05). The presence of four or more of the following seven factors strongly predicted the development of chronic nonrheumatic atrial fibrillation within one year (88% to 100%): age > or = 65 years, congestive heart failure, diabetes mellitus, cardiothoracic ratio > or = 50%, f-wave amplitude > or = 2.0 mm, left atrial dimension > or = 38 mm, and ejection fraction < or = 76%.

[Echocardiographic assessment of cardiac basal hypertrophy represented by increased base to mid thickness ratio (B/M ratio) in the ventricular septum and its relation to age]

The basal part of the interventricular septum may easily become hypertrophic because it is exposed to strong hemodynamic stress compared to the other portions of the left ventricle. We measured the end-diastolic interventricular wall thickness both at the base and in the midsection by 2D echocardiography in 122 normotensives, and examined whether the basal thickness increases with age. The basal thickness (B) increased with age in both sexes. In males the thickness averaged 10.1 mm in the 50-59 age group, 10.2 m in those aged 60-69 and 11.4 mm (p < 0.01) in those 70 or older compared to 9.4 mm in those aged 49 or younger. In females it was 8.1 mm (p < 0.05) in the 50-59 age group, 8.3 mm (p < 0.05) in those aged 60-69 and 10.0 mm (p < 0.01) in those 70 or older compared to 6.8 mm in those 49 or younger. Concerning the midwall thickness (M), there were no significant changes among the respective age groups in either sex. As a result, a close correlation was found between the B/M ratio, a new and simple index for basal hypertrophy, and age (R = 0.46, p < 0.01 in males and R = 0.43, p < 0.01 in females). Comparison of the B/M ratio between the two age groups 49 or younger and 70 or older was as follows; 1.08 vs 1.30 (p < 0.01) in males and 1.01 vs 1.27 (p < 0.01) in females. Increase of basal hypertrophy in the aged was clearly indicated by the B/M ratio.

A new model for infective endocarditis of the mitral valve in rabbits

To produce an experimental model of infective endocarditis without inserting catheters into the heart, we injected a bacterial suspension into rabbits in which mitral complex lesions had been induced by electrical stimulation of the cervical vagus. Typical infective vegetations grew on the surface of the mitral valves 1 week later. The formation of vegetations was related to the timing of the inoculation. Streptococcus viridans injected just after vagal stimulation produced vegetations in 10 of 17 animals (58.8%), but the same bacteria injected 14 days after vagal stimulation did so in only 2 of 11 animals (18.2%). The incidence of infective endocarditis was significantly higher after early inoculation compared with delayed inoculation (p < 0.01). The susceptibility to infection depended on the species of bacteria injected. Both S. viridans and Pseudomonas pseudoalkaligenes injected just after vagal stimulation produced vegetations in 10 of 17 (58.8%) and 6 of 13 (46.2%) animals, respectively, but Staphylococcus epidermidis injected just after vagal stimulation did not produce vegetations in any of the 10 animals. S. viridans injected into nine normal animals never produced vegetations. These findings indicate that infective endocarditis develops after intravenous injection of bacterial suspensions alone in rabbits with mitral complex lesions.

[Age-associated morphological change in interventricular septum]

To investigate the morphological features of the interventricular septum (IVS) in the senile heart, we examined 123 normotensives (59 males and 64 females), ranging in age from 22 to 91 yrs using 2D echocardiography. End-diastolic IVS thickness was measured at the mid-portion (M) and at the thickest portion within 15 mm distal to the aorto-septal junction (basal portion, B) on left parasternal long-axis tomogram. The sigmoid shape of the basal portion was evaluated in terms of aorto-septal (AS) angle. M showed no correlation with age, whereas B increased significantly with age in both sexes (males, r = 0.42, p < 0.01; females, r = 0.51, p < 0.01). B/M ratio, therefore, also increased with age (males, r = 0.49, p < 0.01; females, r = 0.39, p < 0.01). The AS angle decreased with age in both sexes (males, r = -0.33, p < 0.01; females, r = -0.51, p < 0.01). There was a significant inverse correlation between B/M ratio and AS angle (males, r = -0.31, p < 0.05; females, r = -0.50, p < 0.01). We conclude that the B/M ratio is a novel index reflecting heterogenously distributed hypertrophy in the IVS associated with age.

Cellular and molecular bases for the immunopathology of the myocardial cell damage involved in acute viral myocarditis with special reference to dilated cardiomyopathy

Cell-mediated autoimmunity has been strongly implicated in the pathogenesis of the myocardial cell damage involved in viral myocarditis. To investigate the cellular and molecular bases of both target cells and effector cells for cell-mediated cytotoxicity involved in viral myocarditis and dilated cardiomyopathy, we first examined the expression of major histocompatibility complex (MHC) antigens and a cell adhesion molecule, intercellular adhesion molecule-1 (ICAM-1) in myocardial cells of a murine model of viral myocarditis and in patients with acute myocarditis and dilated cardiomyopathy. Secondly, we analyzed the characteristics of the infiltrating cells in the heart, especially the expression of a cytolytic factor, perforin. We found that Coxsackievirus B3 (CVB3)-induced murine acute myocarditis resulted in enhanced expression of MHC (class I) antigens and ICAM-1 on myocardial cells, and that perforin was abundantly expressed in NK (natural killer)-like large granular lymphocytes (LGL), which represent the main infiltrating cell type in the early stage. Immunoelectron microscopic study showed killer cells directly damaging cardiac myocytes by the release of perforin. Perforin was also expressed in the infiltrating cells in the heart of a patient with acute myocarditis. Both MHC antigens and ICAM-1 were clearly expressed in the hearts of patients with acute myocarditis and dilated cardiomyopathy. These data provided direct evidence that cell-mediated cytotoxicity plays a critical role in the myocardial cell damage involved in viral myocarditis.

Abscess within a glioblastoma multiforme--case report

A rare case of abscess within a glioblastoma with an unusual presentation occurred in a 46-year-old female who developed right hemiparesis and seizure. Computed tomography and magnetic resonance imaging demonstrated hemorrhage which mimicked hemorrhagic infarction. However, the lesions developed ring enhancement. Aspiration showed one to be an abscess, which collapsed by drainage but later re-expanded. The mass was removed, and histological examination revealed glioblastoma.

[Immunological detection of fecal occult blood-follow up study on patients with positive testing]

To evaluate its clinical utility in the early detection of colorectal diseases, we carried out the immunological fecal occult blood test in 922 patients and monitored the clinical course of the 87 patients in whom it was positive. Thirty-five (40.2%) of these patients underwent subsequent X-ray and colonoscopy, and colorectal cancer was detected in 8 (20%). Our findings confirm the clinical usefulness of this test.

[Trends in antihypertensive drugs used for elderly patients]

The admission of antihypertensive medications in the elderly (65 y.o. or more, 269 pts) was compared to that in younger cases (less than 65 y.o., 348 pts). All were outpatients who visited our clinic in 1990. The number of patients on a single therapeutic regimen was almost equal in both age groups. Once-a-day regimens were more common in the young (56.9% vs 48.3%, p less than 0.05), and three times-a-day regimens were more common in the elderly (14.7% vs 23.1%, p less than 0.01). The choice of antihypertensive drugs in patients with single therapy or combined therapy in the young was beta blockers in 49.7%, Ca blockers in 39.4%, diuretics in 30.7% and ACE inhibitors in 17.8%, and those in the elderly were Ca blockers in 46.1%, diuretics in 44.2%, beta blockers in 33.8%, and ACE inhibitors in 16.4%. The patients were subdivided into three groups according to the time of the initial visit to the clinic; initial visit during 1969-1979 (phase 1), 1980-1984 (phase 2) and 1985-1990 (phase 3). In the young, choice of beta blockers and diuretics was most popular in phase 1. However, the choice of diuretics decreased in phase 2, and in phase 3 beta blockers were used in 50.4%, Ca blockers in 43.2%, ACE inhibitors in 22.3% and diuretics in only 17.3%. In the elderly, diuretics were most popular followed by Ca blockers and beta blockers in phase 1 and phase 2. In phase 3 Ca blockers were selected in 58.2% followed by both beta blockers and ACE inhibitors in 28.4% then diuretics in 23.9%.(ABSTRACT TRUNCATED AT 250 WORDS)

Heterogeneity in smooth muscle cell population accumulating in the neointimas and the media of poststenotic dilatation of the rabbit carotid artery

Rabbit smooth muscles contain at least three types of myosin heavy chain (MHC) isoforms; SM1, SM2 and SMemb (NMHC-B), the expression of which is developmentally regulated. We have recently reported that smooth muscles with the embryonic phenotype accumulate in the neointimas produced by endothelial denudation or high-cholesterol feeding. In this study, we examined MHC isoform expression in the neointimas and the media of poststenotic dilatation of the rabbit carotid artery, and determined the phenotype of the smooth muscle cell in the dilated segment. We report here that neointimal cells in the dilated segment are smooth muscle cells with the embryonic phenotype as previously reported in our ballooning-injury study. The medial smooth muscles, however, are composed of heterogeneous population of smooth muscles which differ in stage of differentiation as determined by the MHC isoform expression. These results indicate that MHC isoforms are useful molecular markers to identify abnormally proliferating smooth muscles in diseased arteries and to understand the process of atherogenesis occurring following vascular injury.

[Spontaneous reversion to sinus rhythm in a case of lone atrial fibrillation of fifteen years duration]

A 69-year-old male visited our clinic in 1973 because of atrial fibrillation noted during an annual check-up for the aged. Blood pressure, heart rate and CTR in chest X-ray films showed 110/80 mmHg, 150/min and 55%, respectively. There were no signs of valvular heart diseases, and a diagnosis of lone atrial fibrillation was convincing. Since then, repeated ECGs recorded twice or more a year had shown atrial fibrillation until 1988, when sinus rhythm with both first degree AV block and low P-wave amplitude appeared. The motion pattern of the anterior mitral leaflet on M mode echocardiography was abnormal with almost complete disappearance of the A-wave, whereas the motion pattern of the tricuspid valve was normal.

[Establishment of permanent atrial fibrillation and time course of the amplitude of the f wave]

Atrial fibrillation is one of the arrhythmias that increase with increasing age. In this study we compared transition intervals from sinus rhythm to permanent atrial fibrillation and the time course of the f wave amplitude immediately after the transition between 32 younger (less than 65 years) and 44 elderly patients (greater than or equal to 65 years) in whom transition from sinus rhythm to permanent atrial fibrillation was confirmed on serial ECG recordings. Each group was classified into three categories according their underlying diseases: hypertensive heart disease, valvular disease, and lone atrial fibrillation. In patients with hypertensive heart disease or lone atrial fibrillation, there was no significant difference in the transition intervals between the younger and the elderly groups. In both groups the transition intervals were significantly (p less than 0.05) longer in patients with lone atrial fibrillation than those in patients with hypertensive heart disease (44.6 vs. 12.5 months in younger and 26.8 vs. 12.9 months in elderly). A significant positive correlation (r = 0.58, p less than 0.01) was observed between the final P wave and the initial f wave amplitude on establishment of permanent atrial fibrillation in all patients. In the younger group, the initial f wave amplitude of patients with valvular disease (0.27 +/- 0.04 mV, mean +/- SE) was significantly larger than those of patients with hypertensive heart disease (0.15 +/- 0.03 mV, p less than 0.05) and of patients with lone atrial fibrillation (0.16 +/- 0.01 mV, p less than 0.05). The f wave amplitude of valvular disease was significantly decreased after 1 year (0.22 +/- 0.03 mV, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Expression of major histocompatibility complex class I antigen in murine ventricular myocytes infected with Coxsackievirus B3

Evidence has accumulated that T cell-mediated autoimmunity plays an important role in the pathogenesis of viral myocarditis. T lymphocytes are known to recognize antigen-presenting cells, such as virus-infected cells, being restricted by syngeneic major histocompatibility complex (MHC) antigens. To clarify in more detail the immunological mechanisms involved, we induced acute viral myocarditis in C3H/He mouse ventricles with coxsackievirus B3 (CVB3) and examined, by immunofluorescence, the expression of MHC class I and II antigens, previously reported not to be expressed by normal cardiac myocytes. Furthermore, to confirm the expression of MHC class I (H-2Kk) antigens at the cellular level, we treated cultured cardiac myocytes with interferon gamma and examined the antigen expression by immunofluorescence and Northern blot hybridization, using an antisense RNA probe for MHC messenger RNA. Our observations demonstrated 1) CVB3-induced myocarditis resulted in the enhanced expression of MHC class I (H-2Kk) gene product on the surface of cardiac myocytes but low or undetectable levels of MHC class II or H-2Dk gene products, and moderate focal transient (days 5-7) expression of both MHC class I (Kk + Dk) region gene products and MHC class II antigens were induced on capillary endothelial cells; 2) murine fetal cardiac myocytes cultured in vitro in the presence of interferon gamma similarly were shown to express marked levels of MHC class I (H-2Kk) but low to undetectable levels of the H-2Dk gene product; however, weak to moderate MHC Class II antigens were expressed by these cultured myocytes; and 3) the expression of MHC antigens in cardiac myocytes was modulated at the transcriptional level.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracellular assembly of newly synthesized canine cardiac myosins

To investigate how newly synthesized cardiac myosins are assembled into myofilaments, we analysed the distribution of newly produced alpha-myosin heavy chain isozyme in sarcomeres by immunoelectron microscopy using a monoclonal antibody (CMA19), which is specific for alpha-myosin heavy chain. Isozymic changes in myosin heavy chains from beta to alpha type were induced in canine ventricular muscles and cultured ventricular myocytes by administration of 1-thyroxine. We incubated the glycerinated ventricular muscles or cultured ventricular myocytes with the enzyme (horseradish peroxidase) labelled Fab fragment of CMA19. After the reaction with 3, 3'-diaminobenzidine and osmification, we prepared ultrathin sections of the ventricular muscles or cultured ventricular myocytes and analysed their staining patterns by electron microscopy. There was apparent heterogeneity in the staining intensity of the myofilaments among different cells, among different myofibrils and even intramyofibrillarly. Higher magnification revealed that there were scattered foci of strong reaction which appeared to be foci of assembly of the newly synthesized alpha-myosin heavy chain. Immunocytochemical study also showed heterogeneous reactions within myofilaments and that there were scattered foci of myofilament assembly, which were closely associated with polyribosomes producing newly induced alpha-myosin heavy chain. These data suggest that newly synthesized cardiac myosins are assembled into myofilaments from the sites of synthesis, that is polyribosomes. This may explain the heterogeneity of the assembly pattern of newly synthesized cardiac myosins at the subcellular level.