Risk factor control and cardiovascular events in patients with type 2 diabetes mellitus

BACKGROUND

Since patients with type 2 diabetes mellitus (T2DM) have an increased risk of cardiovascular events, interventions addressing risk factors reduce the incidence of cardiovascular disease (CVD) events. This study aimed to evaluate the difference in the incidence of CVD events according to risk factor control in patients with diabetes with and without cardio-renal disease.

METHODS

We analyzed 113,909 patients with diabetes and 290,339 without diabetes using data released by the National Health Insurance Service (NHIS).

RESULTS

Among patients with diabetes with four or five poorly controlled risk factors, hazard ratio for CVD events was 1.19 (95% confidence interval [CI], 1.06-1.34) in patients with cardio-renal disease and 2.31 (95% CI, 1.95-2.74) in patients without cardio-renal disease compared to patients with diabetes without risk factors. In subjects with diabetes and cardio-renal disease, patients with four or five poorly controlled risk factors had a higher risk of CVD mortality compared to subjects without risk factors (hazard ratio, 1.64; 95% CI, 1.18-2.30).

CONCLUSION

Controlling cardiovascular risk factors reduced the incidence of CVD events in patients with diabetes, especially those without cardio-renal disease. The degree of risk control was strongly associated with CVD mortality in patients with diabetes with baseline cardio-renal disease.

Validation of the Framingham Diabetes Risk Model Using Community-Based KoGES Data

BACKGROUND

An 8-year prediction of the Framingham Diabetes Risk Model (FDRM) was proposed, but the predictor has a gap with current clinical standards. Therefore, we evaluated the validity of the original FDRM in Korean population data, developed a modified FDRM by redefining the predictors based on current knowledge, and evaluated the internal and external validity.

METHODS

Using data from a community-based cohort in Korea (n = 5,409), we calculated the probability of diabetes through FDRM, and developed a modified FDRM based on modified definitions of hypertension (HTN) and diabetes. We also added clinical features related to diabetes to the predictive model. Model performance was evaluated and compared by area under the curve (AUC).

RESULTS

During the 8-year follow-up, the cumulative incidence of diabetes was 8.5%. The modified FDRM consisted of age, obesity, HTN, hypo-high-density lipoprotein cholesterol, elevated triglyceride, fasting glucose, and hemoglobin A1c. The expanded clinical model added γ-glutamyl transpeptidase to the modified FDRM. The FDRM showed an estimated AUC of 0.71, and the model's performance improved to an AUC of 0.82 after applying the redefined predictor. Adding clinical features (AUC = 0.83) to the modified FDRM further improved in discrimination, but this was not maintained in the validation data set. External validation was evaluated on population-based cohort data and both modified models performed well, with AUC above 0.82.

CONCLUSION

The performance of FDRM in the Korean population was found to be acceptable for predicting diabetes, but it was improved when corrected with redefined predictors. The validity of the modified model needs to be further evaluated.

Non-alcoholic fatty liver disease is associated with hyperandrogenism in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a highly complex reproductive metabolic disorder and women with PCOS have high prevalence of non-alcoholic fatty liver disease (NAFLD). Despite both hyperandrogenism and insulin resistance are common pathophysiologies in NAFLD and PCOS, this association is still controversial. Therefore, the aim of this study is to evaluate the relationship between hyperandrogenism and NAFLD in females diagnosed with PCOS. We recruited 667 women diagnosed with PCOS and 289 women with regular menstrual cycles as control. The PCOS diagnosis was made using National Institute of Child Health and Human Disease criteria. Total and free testosterone levels (TT and TF, respectively), and free androgen index (FAI) were used as measures of hyperandrogenism. Fatty liver index and liver fat score (FLI and LFS, respectively), and hepatic steatosis index (HSI) were used to assess NAFLD. The prevalence of NAFLD in PCOS women evaluated by LFS, FLI, and HIS were 19.9, 10.3, and 32.2%, respectively. In the control group, the incidence was 2.1, 0.7, and 4.2%, respectively. Both FT and FAI levels showed significant association with increased NAFLD-related indices, after adjusting for insulin resistance and other factors (LFS (OR 3.18 (95% CI 1.53-6.63) in FT; 1.12 (1.04-1.22) in FAI), FLI (OR 2.68 (95% CI 1.43-5.03) in FT; 1.13 (1.06-1.20) in FAI), and HSI (OR 3.29 (95% CI 2.08-5.21) in FT; 1.5 (1.09-1.21) in FAI). TT did not exhibit association with any NAFLD index. In women with PCOS, significantly higher rate of NAFLD was observed compared to the control women. The FT and FAI were independently associated with NAFLD in women with PCOS. The findings suggest the possibility of hyperandrogenism contributing to the progression and/or development of NAFLD in PCOS.

Safety and efficacy of trastuzumab biosimilar plus irinotecan or gemcitabine in patients with previously treated HER2 (ERBB2)-positive non-breast/non-gastric solid tumors: a phase II basket trial with circulating tumor DNA analysis

BACKGROUND

Human epidermal growth factor receptor 2 (HER2) (ERBB2)-directed agents are standard treatments for patients with HER2-positive breast and gastric cancer. Herein, we report the results of an open-label, single-center, phase II basket trial to investigate the efficacy and safety of trastuzumab biosimilar (Samfenet®) plus treatment of physician's choice for patients with previously treated HER2-positive advanced solid tumors, along with biomarker analysis employing circulating tumor DNA (ctDNA) sequencing.

METHODS

Patients with HER2-positive unresectable or metastatic non-breast, non-gastric solid tumors who failed at least one prior treatment were included in this study conducted at Asan Medical Center, Seoul, Korea. Patients received trastuzumab combined with irinotecan or gemcitabine at the treating physicians' discretion. The primary endpoint was the objective response rate as per RECIST version 1.1. Plasma samples were collected at baseline and at the time of disease progression for ctDNA analysis.

RESULTS

Twenty-three patients were screened from 31 December 2019 to 17 September 2021, and 20 were enrolled in this study. Their median age was 64 years (30-84 years), and 13 patients (65.0%) were male. The most common primary tumor was hepatobiliary cancer (seven patients, 35.0%), followed by colorectal cancer (six patients, 30.0%). Among 18 patients with an available response evaluation, the objective response rate was 11.1% (95% confidence interval 3.1% to 32.8%). ERBB2 amplification was detected from ctDNA analysis of baseline plasma samples in 85% of patients (n = 17), and the ERBB2 copy number from ctDNA analysis showed a significant correlation with the results from tissue sequencing. Among 16 patients with post-progression ctDNA analysis, 7 (43.8%) developed new alterations. None of the patients discontinued the study due to adverse events.

CONCLUSIONS

Trastuzumab plus irinotecan or gemcitabine was safe and feasible for patients with previously treated HER2-positive advanced solid tumors with modest efficacy outcomes, and ctDNA analysis was useful for detecting HER2 amplification.

Preoperative Chemoradiotherapy With Capecitabine With or Without Temozolomide in Patients With Locally Advanced Rectal Cancer: A Prospective, Randomised Phase II Study Stratified by O6-Methylguanine DNA Methyltransferase Status: KCSG-CO17-02

AIMS

To evaluate the clinical efficacy of adding temozolomide (TMZ) to preoperative capecitabine (CAP)-based chemoradiotherapy in patients with locally advanced rectal cancer (LARC) and validate O⁶-methylguanine DNA methyltransferase (MGMT) methylation status as a predictive marker for TMZ combined regimens.

MATERIALS AND METHODS

LARC patients with clinical stage II (cT3-4N0) or III (cT_anyN+) disease were enrolled. They were stratified into unmethylated MGMT (uMGMT) and methylated MGMT (mMGMT) groups by methylation-specific polymerase chain reaction before randomisation and were then randomly assigned (1:1) to one of four treatment arms: uMGMT/CAP (arm A), uMGMT/TMZ + CAP (arm B), mMGMT/CAP (arm C) and mMGMT/TMZ + CAP (arm D). The primary end point was the pathological complete response (pCR) rate.

RESULTS

Between November 2017 and July 2020, 64 patients were randomised. Slow accrual caused early study termination. After excluding four ineligible patients, 60 were included in the full analysis set. The pCR rate was 15.0% (9/60), 0%, 14.3%, 18.8% and 26.7% for the entire cohort, arms A, B, C and D, respectively (P = 0.0498 between arms A and D). The pCR rate was 9.7% in the CAP group (arms A + C), 20.7% in the TMZ + CAP group (arms B + D), 6.9% in the uMGMT group (arms A + B) and 22.6% in the mMGMT group (arms C + D). Grade 1-2 nausea or vomiting was significantly more frequent in the TMZ + CAP treatment groups (arms B + D) than in the CAP treatment groups (arms A + C, P < 0.001) with no difference in grade 3 adverse events. There were no grade 4 or 5 adverse events.

CONCLUSION

The addition of TMZ to CAP-based chemoradiotherapy tended to improve pCR rates, particularly in those with mMGMT LARC. MGMT status may warrant further investigation as a predictive biomarker for chemotherapeutic agents and radiotherapy.

The Effect of Childhood Obesity or Sarcopenic Obesity on Metabolic Syndrome Risk in Adolescence: The Ewha Birth and Growth Study

The prevalence of obesity and metabolic syndrome (MetS) in the pediatric population has increased globally. We evaluated the impact of childhood obesity and sarcopenic obesity on the risk of MetS in adolescence using the Ewha Birth and Growth Cohort study data. In this study, we analyzed data from 227 participants who were followed up at the ages of 7-9 and 13-15 years. Overweight and obesity were defined as a body mass index of the 85th percentile or higher based on national growth charts, and sarcopenic obesity was defined using body composition data. Metabolic diseases in adolescence were identified by calculating the pediatric simple metabolic syndrome score (PsiMS), continuous metabolic syndrome score (cMetS), and single-point insulin sensitivity estimator (SPISE) as MetS indices. The prevalence of overweight was approximately 15% at both 7-9 and 13-15 years old, and that of sarcopenic obesity (7-9 years old) was 19.5%. Boys aged 13-15 years had a significantly larger waist circumference (WC) and higher systolic blood pressure (SBP) than girls. The MetS indices (PsiMS, cMetS, and SPISE) showed no significant differences by gender. Overweight and sarcopenic obese people have a higher overall risk of MetS components than normal people. The overweight group had a significantly higher prevalence of PsiMS and cMetS than the normal group, while the SPISE was significantly lower and the MetS indicator was worse in the overweight group than in the normal group. Similar results were obtained in the group with sarcopenic obesity. Both overweight and sarcopenic obesity remained significantly associated with MetS indicators, even after adjusting for covariates. Furthermore, metabolic health assessed by the cMetS in adolescence was affected not only by childhood overweight but also by adolescence, which showed an interaction effect. The results of this study emphasize the importance and need for early detection of childhood obesity and effective public health interventions.

Prospective association between phthalate exposure in childhood and liver function in adolescence: the Ewha Birth and Growth Cohort Study

BACKGROUND

Phthalate exposure is ubiquitous due to the widespread use of plastic products in daily life, and affects several health outcomes, including metabolic diseases. In this study, we evaluated the effects of phthalate exposure in childhood on liver function in adolescence.  METHODS: Among 164 Ewha Birth and Growth Cohort Study participants followed up during two exposure periods (when the children were aged 3-5 and 7-9 years), 126 were followed up at age 10-15 years. To investigate the relationship between phthalate exposure during the two periods and liver enzyme levels (ALT, AST, γ-GTP) in adolescence, differences between groups and the dose-response relationship were analyzed. In addition, we investigated differences in liver enzymes between groups based on the combined exposure levels (high or low) during the two periods. The interaction effect between phthalates and BMI on liver enzyme levels was evaluated, stratified by sex.  RESULTS: In the 3-5 year-old exposure period, ALT levels tended to increase as MECPP levels increased, while γ-GTP levels tended to increase as MiBP, MnBP, and ∑DBP levels increased. In addition, the group exposed to consistently high levels of phthalates at both time points had higher liver enzyme levels compared to the group that had lower exposure. In particular, the interaction effect between some phthalate metabolites and BMI in 3-5 year olds affected AST and γ-GTP levels in adolescence only in girls.

CONCLUSIONS

Exposure to phthalates in daily life during childhood affects liver enzyme levels in adolescence. Elevated liver enzyme levels are associated with the development of metabolic syndrome, implying that attention should be paid to phthalate exposure during childhood.

The effect of menopause on cardiovascular risk factors according to body mass index in middle-aged Korean women

BACKGROUND

Menopausal status and obesity are associated with an increased risk for cardiovascular diseases. However, there are few studies on the effect of menopause on cardiovascular risk factors according to the degree of obesity during the menopausal transition. We aimed to evaluate the effect of menopause on cardiovascular risk factors according to body mass index (BMI) in middle-aged Korean women.

METHODS

We analyzed 361 postmenopausal women and 758 premenopausal women (age: 45-55 years) without diabetes mellitus, hypertension, or dyslipidemia, using a cohort database released by the Korean National Health and Nutrition Examination Survey 2016-2018. Subjects were divided into two groups based on BMI. Women who underwent a hysterectomy or were pregnant were excluded from this study. Differences between groups adjusted for age and BMI were assessed.

RESULTS

Postmenopausal women (52 ± 2 years) were older than premenopausal women (48 ± 2 years), and BMI did not differ between the two groups (22.8 ± 2.9 vs. 23.0 ± 3.1 kg/m2). After adjustment for age and BMI in total and non-obese subjects (not obese subjects), postmenopausal women exhibited higher hemoglobin A1c and total cholesterol levels than premenopausal women. Subgroup analysis for 138 postmenopausal and 138 age- and BMI-matched premenopausal women showed that postmenopausal women had higher total cholesterol levels than premenopausal women with marginal significance (201 ± 25 vs. 196 ± 27 mg/dL).

CONCLUSION

Menopausal status was associated with increased glucose and cholesterol levels independent of age and BMI in middle-aged Korean women. Menopausal status showed a significant relationship with increased total cholesterol levels even after adjusting for age and BMI in non-obese women but not obese women. Therefore, intensive monitoring and treating of lipid status is necessary to prevent cardiovascular events during the menopausal transition, especially in non-obese subjects.

Relationship between age at menarche and metabolic diseases in Korean postmenopausal women: The Korea National Health and Nutrition Examination Survey 2016-2018

BACKGROUND

Cardiovascular disease is the leading cause of morbidity and mortality in postmenopausal women. Early menarche may be associated with an increased risk of metabolic diseases such as diabetes and cardiovascular disease. This study aimed to investigate the effect of menarche age and the risk of diabetes and metabolic syndrome in Korean postmenopausal women.

METHODS

We analyzed 4,933 postmenopausal women (mean age: 64.7 years) using the Korean National Health and Nutritional Examination Survey 2016-2018. Subjects were divided into three groups according to menarche age (early menarche: ≤ 12 years (n = 451), reference: 13-16 years (n = 3,421), and late menarche: ≥ 17 years (n = 1,061)). Logistic regression analysis was used to estimate the odds ratio (OR) for diabetes and metabolic syndrome.

RESULTS

Women with an early menarche age were younger, more educated, and had higher income than the other groups (p-value < 0.001). There were no differences in body mass index, blood pressure, fasting glucose, HbA1c, and cholesterol levels among the three groups. After adjusting for potential confounding factors, early menarche age was significantly associated with the risk of diabetes (OR 1.435, 95% confidence interval (CI): 1.069-1.928). The prevalence of metabolic syndrome in all subjects was 41.1%. After adjusting for potential confounding factors, the OR of metabolic syndrome in the early menarche group was 1.213 (95% CI: 0.971-1.515).

CONCLUSION

The risk of diabetes was 1.43 times higher in postmenopausal Korean women with early menarche. Although the risk of metabolic syndrome was not statistically significant, it showed a tendency to increase in the early menarche group. Our results suggest that age at menarche may be helpful in diabetes risk stratification and early interventions for postmenopausal women.

Sex Differences in the Effects of CDKAL1 Variants on Glycemic Control in Diabetic Patients: Findings from the Korean Genome and Epidemiology Study

BACKGROUND

Using long-term data from the Korean Genome and Epidemiology Study, we defined poor glycemic control and investigated possible risk factors, including variants related to type 2 diabetes mellitus (T2DM). In addition, we evaluated interaction effects among risk factors for poor glycemic control.

METHODS

Among 436 subjects with newly diagnosed diabetes, poor glycemic control was defined based on glycosylated hemoglobin trajectory patterns by group-based trajectory modeling. For the variants related to T2DM, genetic risk scores (GRSs) were calculated and divided into quartiles. Risk factors for poor glycemic control were assessed using a logistic regression model.

RESULTS

Of the subjects, 43% were in the poor-glycemic-control group. Body mass index (BMI) and triglyceride (TG) were associated with poor glycemic control. The risk for poor glycemic control increased by 11.0% per 1 kg/m2 increase in BMI and by 3.0% per 10 mg/dL increase in TG. The risk for GRS with poor glycemic control was sex-dependent (Pinteraction=0.07), and a relationship by GRS quartiles was found in females but not in males. Moreover, the interaction effect was found to be significant on both additive and multiplicative scales. The interaction effect was evident in the variants of cyclin-dependent kinase 5 regulatory subunit-associated protein 1-like (CDKAL1).

CONCLUSION

Females with risk alleles of variants in CDKAL1 associated with T2DM had a higher risk for poor glycemic control than males.

Body mass index and stroke risk among patients with diabetes mellitus in Korea

Background

Obesity and diabetes mellitus (DM) are both associated with cardiovascular disease. This study aimed to evaluate the association between body mass index (BMI) and stroke risk among patients with DM in Korea since relatively few studies have analyzed this area in detail.

Methods

We analyzed a total of 56,051 DM patients aged >30 years from the Korean National Health Insurance Service Cohort who had undergone at least one national health examination between 2002 and 2012. BMI scores were divided into six categories, while hazard ratios for stroke were calculated using Cox proportional hazard models.

Results

Overall stroke risk was positively associated with BMI for both men and women. For ischemic stroke, the risk was positively associated with BMI in women. However, for me, only patients with the highest BMI were at increased risk compared with patients with a BMI of 20–22.4 kg/m². For hemorrhagic stroke, the risk was significantly associated with BMI with a U-shaped association in men. In women, only patients with the lowest BMI had an increased risk of hemorrhagic stroke compared with patients that have a BMI of 20–22.4 kg/m².

Conclusion

BMI was positively associated with the overall risk of stroke among DM patients in Korea. The risk of ischemic stroke was higher in obese patients compared to overweight or normal-weight patients. However, the risk of hemorrhagic stroke was higher in slimmer patients compared with overweight or obese patients.

Quality of life with encorafenib plus cetuximab with or without binimetinib treatment in patients with BRAF V600E-mutant metastatic colorectal cancer: patient-reported outcomes from BEACON CRC

Background

In the BEACON CRC study (NCT02928224), encorafenib plus cetuximab with binimetinib {9.3 versus 5.9 months; hazard ratio (HR) [95% confidence interval (CI)]: 0.60 [0.47-0.75]} or without binimetinib [9.3 versus 5.9 months; HR (95% CI): 0.61 (0.48-0.77)] significantly improved overall survival (OS) compared with the previous standard of care (control) in patients with BRAF V600E metastatic colorectal cancer (mCRC). Quality of life (QoL) was a secondary endpoint, assessed using validated instruments.

Patients and methods

BEACON CRC was a randomized, open-label, phase III study comparing encorafenib plus cetuximab with or without binimetinib and the investigator’s choice of irinotecan plus cetuximab or FOLFIRI plus cetuximab (chemotherapy control) in patients with previously treated BRAF V600E mCRC. Patient-reported QoL assessments included the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC) and Functional Assessment of Cancer Therapy—Colorectal (FACT-C). The primary outcome for these tools was time to definitive 10% deterioration.

Results

Encorafenib plus cetuximab, both with and without binimetinib, was associated with longer median times to definitive 10% deterioration versus the control group in the EORTC Global Health Status scale [HR (95% CI): 0.65 (0.52-0.80) versus 0.61 (0.49-0.75), respectively] and the FACT-C functional well-being subscale [HR (95% CI): 0.62 (0.50-0.76) versus 0.58 (0.47-0.72), respectively]. Consistent results were observed across all subscales of the EORTC and FACT-C instruments. QoL was generally maintained during treatment for the global EORTC and FACT-C scales.

Conclusions

In addition to improving OS, encorafenib plus cetuximab with or without binimetinib delays QoL decline in previously treated patients with BRAF V600E-mutant mCRC.

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BEACON CRC compares encorafenib + cetuximab ± binimetinib to chemotherapy in previously treated BRAF V600E mCRC.

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Encorafenib + cetuximab had longer time to 10% deterioration versus control in QoL and functional well-being scales.

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Encorafenib + cetuximab ± binimetinib delays QoL decline in previously treated patients with BRAF V600E mCRC.

Waist circumference and mortality or cardiovascular events in a general Korean population

Background

Obesity is associated with cardiovascular diseases and is a risk factor for all-cause mortality. Until now, the associations between abdominal obesity and mortality or cardiovascular disease (CVD) incidence have not been conclusive. We aimed to evaluate the associations between waist circumference (WC) and mortality or CVD incidence in a general Korean population.

Methods

We analyzed a total of 204,068 adults older than 40 years of age who had undergone a national health examination at least once from 2009 to 2018 in the Korean National Health Insurance Service Cohort. WC was divided into five categories (< 80, 80–84.9, 85–89.9, 90–94.9, ≥ 95 cm). Hazard ratios for death and CVD incidence were calculated using Cox proportional hazards models.

Results

In men, WC and overall mortality showed a reverse J-shaped association. In women, the association between WC and overall mortality was not significant. For both men and women, WC was not associated with the risk of cardiovascular mortality. Contrary to the mortality trend, CVD incidence was positively associated with WC in both men and women, and the risk of the CVD incidence was the lowest in subjects with a WC < 80 cm.

Conclusions

WC exhibited a significant J-shaped association with overall mortality in men, where subjects who had central obesity showed a lower rate of mortality than those in the lowest or highest WC group. The risk of incident CVD showed a positive association with central obesity, where the lowest risk was observed for subjects in the lowest WC group in a general Korean population.

Association of serum creatinine levels and risk of type 2 diabetes mellitus in Korea: a case control study

BACKGROUND

Reduced skeletal muscle has been suggested as a potential risk factor for type 2 diabetes mellitus (T2DM). Serum creatinine is the primary metabolite of creatine in skeletal muscle. Therefore, low serum creatinine levels may be associated with an increased risk of T2DM. We aimed to evaluate the association between serum creatinine levels and the risk of T2DM in Korea.

METHODS

We analyzed a total of 264,832 nondiabetic adults older than 40 years of age who had undergone a national health examination at least once from 2009 to 2015 in the Korean National Health Insurance Service Cohort. Hazard ratios for T2DM were calculated.

RESULTS

In men, serum creatinine levels and the risk for T2DM showed an inverse J-shaped association. This association was confirmed after adjustment for age, body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), and fasting plasma glucose. In women, there was a trend that serum creatinine levels were inversely associated with the risk of T2DM among those with serum creatinine below 1.1 mg/dl. However, serum creatinine levels were not significantly associated with the risk of T2DM after adjustment for age, BMI, SBP, DBP, and fasting plasma glucose.

CONCLUSIONS

Reduced levels of serum creatinine were significantly associated with an increased risk of T2DM in men with creatinine below 1.20 mg/dl. There was a trend that decreased levels of serum creatinine were associated with an increased risk of T2DM among women with serum creatinine below 1.1 mg/dl, although this result was not statistically significant.

A population-based study for difference in contribution of type 2 diabetes mellitus to cardiovascular outcomes in adult cancer survivors and general population without history of cancer

Background/Introduction

Type 2 diabetes mellitus (T2DM) is a well-established risk factor for cardiovascular disease (CVD). However, evidence is scarce on the difference in burden of T2DM as a cardiovascular risk factor in adult cancer survivors compared to the general population without history of cancer. This evidence gap needs to be addressed as increased risk for CVD in adult cancer survivors compared to the general population has been consistently reported from observational studies.

Purpose

To investigate the association of T2DM with CVD in adult cancer survivors and general population without history of cancer and compare the magnitude of associations for each population using propensity score-matched analyses

Methods

For this population-based cohort study, we used the National Health Insurance Service-National Sample Cohort (NHIS-NSC) established in the Republic of Korea (2002–2015) to identity adult cancer survivors who were aged 18 years or older and survived more than 12 months after the first-ever cancer diagnosis and general population without history of cancer matched for age and sex in a 1:1 ratio. In both cohorts, those with history of CVD prior to the index date were excluded. We used Cox proportional hazards model to compute hazard ratios (HR) and 95% confidence intervals (95% CI) for incident CVD in those with T2DM compared to those without T2DM in both adult cancer survivors and the general population after adjusting for shared confounding factors (income status, cigarette smoking, alcohol consumption, physical inactivity, body mass index, blood pressure, lipid abnormalities, family history of CVD, and aspirin use). Furthermore, we used Q statistic to compare the magnitude of association between T2DM and CVD in this matched cohort.

Results

The overall age and sex matched cohort in the NHIS-NSC comprised of 5,163 adult cancer survivors and the equivalent number of participants categorized as general population without history of cancer. The adjusted HR for CVD among adult cancer survivors with T2DM, as compared to without T2DM was 2.27 (95% CI: 1.25–4.11). Similarly, T2DM was associated with an increased risk of CVD in the general population without cancer (HR=1.88; 95% CI: 1.03–3.42). However, no strong statistical evidence was found for difference in contribution of T2DM to CVD risk between adult cancer survivors and general population without history of cancer (Pheterogeneity = 0.662).

Conclusions

In this population-based cohort study, T2DM was associated with an increased risk for CVD in both adult cancer survivors and those without history of cancer. Difference in magnitude of T2DM-CVD associations between adult cancer survivors and the general population without history of cancer was not substantial from a statistical standpoint. However, adult cancer survivor with T2DM may still need additional clinical attention for CVD prevention compared to those without history of cancer.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Cancer Center (Republic of Korea)

Cohort profile: the Ewha Birth and Growth Study

With the introduction of life-course epidemiology, researchers realized the importance of identifying risk factors in early life to prevent chronic diseases. This led to the establishment of the Ewha Birth and Growth Study in 2001; the study is a prospective birth cohort designed to provide evidence of early life risk factors for a child's growth and health. Participants were recruited from those who visited Ewha Womans University Mokdong Hospital (a tertiary hospital in southwest Seoul, Korea) for prenatal care at 24-28 weeks of gestation. In total, 891 mothers enrolled in this study between 2001 and 2006 and their offspring (n=940) were followed-up. Regular check-up examinations of offspring were conducted at 3 years, 5 years, and 7 years of age and every year thereafter. To consider age-related health issues, extensive data were collected using questionnaires and measurements. In 2021, the study subjects will reach 19 years of age, and we are planning a check-up examination for early adulthood. About 20 years have passed since the cohort data were collected, and we have published results on childhood health outcomes associated with prenatal and birth characteristics, genetic and epigenetic characteristics related to childhood metabolism, the effects of exposure to endocrine disruptors, and dietary patterns in childhood. Recently, we started reporting on topics related to adolescent health. The findings will facilitate identification of early life risk factors for chronic diseases and the development of interventions for diseases later in life.

Relationship between faecal calprotectin and inflammation in peripheral joints and entheses in axial spondyloarthritis

Objectives: To compare faecal calprotectin levels according to the type of manifestation and to investigate factors associated with increases in faecal calprotectin in patients with axial spondyloarthritis (axSpA). Method: The study enrolled 190 patients fulfilling the imaging arm of the Assessment of SpondyloArthritis international Society axSpA criteria. Faecal calprotectin levels were measured in an enzyme-linked immunosorbent assay. Systemic inflammatory markers and the Ankylosing Spondylitis Disease Activity Score (ASDAS) were also assessed. Peripheral joint involvement was assessed using the 44-joint examination and Spondyloarthritis Research Consortium of Canada Enthesitis Index. Results: Of 190 patients, 34 (18%) had increased faecal calprotectin levels. These patients were more likely to have ongoing peripheral arthritis and enthesitis (p = 0.016 and 0.001, respectively). A history of psoriasis and uveitis, or current uveitis symptoms, had no bearing on faecal calprotectin levels. Faecal calprotectin levels increased along with ASDAS-C-reactive protein (CRP), and correlated with ASDAS-erythrocyte sedimentation rate (ESR) (r = 0.240, p = 0.001), ASDAS-CRP (r = 0.162, p = 0.025), ESR (r = 0.228, p = 0.002), and CRP levels (0.258, p < 0.001). Tender joint and swollen joint counts also correlated with faecal calprotectin levels (r = 0.252 and 0.205, p < 0.001 and p = 0.005, respectively). Faecal calprotectin levels were higher in patients with current peripheral symptoms (p = 0.003). Peripheral symptoms were independently associated with increased faecal calprotectin levels (odds ratio = 4.083; 95% confidence interval 1.580-10.556). Conclusions: Faecal calprotectin levels in axSpA patients were associated with disease activity. Subclinical gut inflammation (assessed by measuring faecal calprotectin) in axSpA is more closely related to peripheral joint inflammation than to axial joint inflammation.

The association between metabolic components and markers of inflammatory and endothelial dysfunction in adolescents, based on the Ewha Birth and Growth Cohort Study

We assessed the association between metabolic health and markers of inflammation and of endothelial dysfunction using data from the Ewha Birth and Growth Cohort Study. The data of 195 subjects aged 13–15 years were analyzed. To assess metabolic syndrome, continuous metabolic syndrome (cMets) scores were calculated. We measured the levels of high-sensitivity C-reactive protein (hs-CRP), intercellular adhesion molecule 1 (ICAM-1), and vascular cell adhesion molecule 1 (VCAM-1) as markers of inflammation and endothelial dysfunction. An increase of one SD in the cMets score resulted in a 1.25-fold (95% CI 1.10–1.42) increase in the risk of acute inflammatory status and a 1.26-fold (95% CI 1.11–1.43) increase in the risk of endothelial dysfunction as defined by ICAM-1, while VCAM-1 showed a meaningless trend. Of the metabolic components, body mass index (BMI) was positively associated with elevated hs-CRP levels and high-density lipoprotein cholesterol (HDL-c) levels were negatively associated with elevated ICAM-1 levels. Additionally, a mediation analysis showed that a high BMI was directly related to elevated hs-CRP levels and indirectly related to elevated ICAM-1 levels via HDL-c. Our findings show that poor metabolic health was related to an unfavorable inflammatory status and endothelial dysfunction in adolescents.

SUN-020 Waist Circumference Is Associated with Insulin Resistance in Young Korean Women with Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder and associated with metabolic disturbances such as insulin resistance (IR) and obesity which are risk factors for cardiovascular diseases. Many studies have shown that waist circumference (WC) representing abdominal obesity is an important risk factor for IR. However, there were few studies whether WC were associated with IR in young women with PCOS. We aimed to evaluate the role of WC in IR among young Korean women with PCOS. We enrolled age- and body mass index-matched women with PCOS (n = 100) and controls (n = 100). WC was measured and the 75-gram oral glucose tolerance test (OGTT) was performed. Insulin sensitivity was assessed by the Stumvoll index which was calculated from an OGTT. Multiple linear regression analysis was performed to evaluate the association between WC and IR. WC, fasting glucose, post-load 2-hour glucose, fasting insulin, and post-load 2-hour insulin did not differ between women with PCOS and controls. Women with PCOS had lower values of the Stumvoll index than the controls. In correlation analysis, WC was negatively correlated with the Stumvoll index in women with PCOS, however not in controls. In multiple regression analysis, WC was negatively associated with the Stumvoll index even after adjustment for age, total cholesterol, and total testosterone in women with PCOS. In young Korean women with PCOS, WC was negatively associated with insulin sensitivity independent of hyperandrogenemia. Simply measuring of WC could be used to screen the high risk group having IR in young women with PCOS.

Trabecular bone score value is associated with new bone formation independently of fat metaplasia on spinal magnetic resonance imaging in patients with ankylosing spondylitis

OBJECTIVE

To evaluate the association between trabecular bone score (TBS) and new bone formation in ankylosing spondylitis (AS) patients, and to investigate whether TBS is independently associated with new bone formation.

METHOD

Sixty-eight patients with AS underwent spinal magnetic resonance imaging (MRI) and dual-energy X-ray absorptiometry of the lumbar spine to measure TBS and bone mineral density at baseline. Lateral radiographs of the cervical and lumbar spine (baseline and 2 years) were assessed for new bone formation (syndesmophyte formation and/or growth combined), and spinal MRIs were assessed for the presence or absence of fat metaplasia (FM) at the first to fourth lumbar vertebrae. The factors associated with new bone formation were analysed at the patient level and the vertebral level.

RESULTS

New bone formation had developed in 17 patients (25%) at 2 year follow-up. Patients with new bone formation had a higher prevalence of FM and lower TBS at baseline than patients without new bone formation (p = 0.013 and p = 0.041). At the patient level, FM on MRI and low TBS (< 1.23) were significantly associated with new bone formation. At the vertebral level, new bone formation had developed in 25 out of 231 vertebrae (11%) after 2 years. Vertebrae with both FM on MRI and low TBS tended to have more new bone formation (p < 0.001). Syndesmophytes and low TBS (< 1.23) independently increased the risk of new bone formation at the level of individual vertebrae.

CONCLUSION

At both patient and individual vertebral levels, low TBS was associated with new bone formation independently of FM on MRI.

Nintedanib for the treatment of patients with refractory metastatic colorectal cancer (LUME-Colon 1): a phase III, international, randomized, placebo-controlled study

Background

Angiogenesis is critical to colorectal cancer (CRC) growth and metastasis. Phase I/II studies have demonstrated the efficacy of nintedanib, a triple angiokinase inhibitor, in patients with metastatic CRC. This global, randomized, phase III study investigated the efficacy and safety of nintedanib in patients with refractory CRC after failure of standard therapies.

Patients and methods

Eligible patients (Eastern Cooperative Oncology Group performance status 0–1, with histologically/cytologically confirmed metastatic/locally advanced CRC adenocarcinoma unamenable to surgery and/or radiotherapy) were randomized 1 : 1 to receive nintedanib (200 mg twice daily) or placebo (twice daily), until disease progression or undue toxicity. Patients were stratified by previous regorafenib, time from onset of metastatic disease to randomization, and region. Co-primary end points were overall survival (OS) and progression-free survival (PFS) by central review. Secondary end points included objective tumor response and disease control by central review.

Results

From October 2014 to January 2016, 768 patients were randomized; 765 were treated (nintedanib n = 384; placebo n = 381). Median follow-up was 13.4 months (interquartile range 11.1–15.7). OS was not improved [median OS 6.4 months with nintedanib versus 6.0 months with placebo; hazard ratio (HR), 1.01; 95% confidence interval (CI), 0.86–1.19; P = 0.8659]. There was a significant but modest increase in PFS with nintedanib versus placebo (median PFS 1.5 versus 1.4 months, respectively; HR 0.58; 95% CI 0.49–0.69; P < 0.0001). There were no complete or partial responses. Adverse events (AEs) occurred in 97% of 384 nintedanib-treated patients and 93% of 381 placebo-treated patients. The most frequent grade ≥3 AEs were liver-related AEs (nintedanib 16%; placebo 8%) and fatigue (nintedanib 9%; placebo 6%).

Conclusions

The study failed to meet both co-primary end points. Nintedanib did not improve OS and was associated with a significant but modest increase in PFS versus placebo. Nintedanib was well tolerated.

ClinicalTrials.gov number

NCT02149108 (LUME-Colon 1).

Vitamin D receptor and binding protein polymorphisms in women with polycystic ovary syndrome: a case control study

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women of reproductive age, characterized by hyperandrogenism, oligomenorrhea, polycystic ovary morphology, and insulin resistance. Vitamin D deficiency and vitamin D receptor (VDR)/vitamin D binding protein (VDBP) gene variants could play an important role in susceptibility to PCOS and contribute to metabolic disturbances and menstrual dysfunction. We aimed to investigate the associations of VDR gene and VDBP gene polymorphisms with PCOS susceptibility and to elucidate the impacts of these polymorphisms on the hormonal and metabolic parameters of PCOS.

METHODS

We recruited 432 women with PCOS and 927 controls. Polymorphisms in the VDR gene (VDR Fok-I, Cdx2, Apa-I, and Bsm-I) and VDBP gene (VDBP rs4588, rs7041, and rs22822679) were genotyped. A 75-g oral glucose tolerance test was performed.

RESULTS

The distributions of genotypes and allele frequencies in VDR and VDBP genes did not differ between PCOS and control. In women with PCOS, compared to the VDR Fok-I GG genotype, the VDR Fok-I AG genotype was significantly associated with increased levels of total testosterone (β = 5.537, P = 0.005). Compared to the VDR Cdx2 AC genotype, the VDR Cdx2 CC genotype was associated with increased levels of fasting insulin and HOMA-IR in women with PCOS, however, the associations were not statistically significant.

CONCLUSIONS

This finding indicates that genetic variations in VDR and VDBP were not associated with increased risk for PCOS. In contrast, the VDR Fok-I polymorphism was associated with testosterone level and the Cdx2 polymorphism with insulin sensitivity in PCOS. However, the Cdx2 polymorphism was not significantly associated with increased insulin and insulin sensitivity in women with PCOS after multiple linear regression.

Prevalence of measles IgG antibodies among immigrant workers in South Korea

Background

After the national vaccination for measles was introduced in 1985, the measles has been controlled in South Korea despite the epidemic in 2000-2001. Current cases in Korea were assumed to be transmitted from outside the country. Because the dynamics and social changes of the population has emerged as important factors in the measles epidemic, this study aimed to assess the prevalence of measles IgG antibodies among immigrant workers.

Methods

The cross sectional seroprevalence survey was conducted in Gyeongsangnamdo province, Korea. Because the representative sampling frame could not be possible, the voluntary foreign workers who have agreed informed consents with a translated format into the native language, participated in this study. IgG antibodies of measles was examined by ELISA using the automation equipment (BEP III- ELISA). This study obtained the approval of Dong-A University Clinical Research Ethics Review Committee.

Results

364 people of foreign workers participated in the study. Regional distribution for study participants was composed of 30 people in Vietnam (16.5%), Uzbekistan 71 people (19.5%), Thailand 70 people (19.2%), China 60 people (16.5%), Philippines 36 people (9.9%), and Indonesia 32 people (8.8%). The average age was 33.0 ± 6.9 years old and 86.5% of the total was men. High school or higher education accounted for 74%. 93.7% showed positivity (95% CI: 95.7-98.9%) for measles IgG antibody and 3.6% showed equivocal.

Conclusions

The measles seropositivity among immigrant workers in Korea was considered to be at the recommended level.

Key messages

The measles seropositivity among immigrant workers in Korea was considered to be at the recommended level. International cooperation is needed to prevent global measles epidemic.

Altered functional connectivity in the fear network of firefighters with repeated traumatic stress

BACKGROUND

Firefighters are routinely exposed to various traumatic events and often experience a range of trauma-related symptoms. Although these repeated traumatic exposures rarely progress to the development of post-traumatic stress disorder, firefighters are still considered to be a vulnerable population with regard to trauma.AimsTo investigate how the human brain responds to or compensates for the repeated experience of traumatic stress.

METHOD

We included 98 healthy firefighters with repeated traumatic experiences but without any diagnosis of mental illness and 98 non-firefighter healthy individuals without any history of trauma. Functional connectivity within the fear circuitry, which consists of the dorsal anterior cingulate cortex, insula, amygdala, hippocampus and ventromedial prefrontal cortex (vmPFC), was examined using resting-state functional magnetic resonance imaging. Trauma-related symptoms were evaluated using the Impact of Event Scale - Revised.

RESULTS

The firefighter group had greater functional connectivity between the insula and several regions of the fear circuitry including the bilateral amygdalae, bilateral hippocampi and vmPFC as compared with healthy individuals. In the firefighter group, stronger insula-amygdala connectivity was associated with greater severity of trauma-related symptoms (β = 0.36, P = 0.005), whereas higher insula-vmPFC connectivity was related to milder symptoms in response to repeated trauma (β = -0.28, P = 0.01).

CONCLUSIONS

The current findings suggest an active involvement of insular functional connectivity in response to repeated traumatic stress. Functional connectivity of the insula in relation to the amygdala and vmPFC may be potential pathways that underlie the risk for and resilience to repeated traumatic stress, respectively.Declaration of interestNone.

Associations of phthalate exposure with lipid levels and insulin sensitivity index in children: A prospective cohort study

We performed repeated measurements of phthalate metabolite concentrations during childhood and investigated the association of phthalate exposure with lipid levels and insulin resistance. This study included 164 subjects from the Korean Ewha Birth and Growth Cohort Study who underwent follow-up examinations at 3-5 and 7-9 years of age. We measured nine urinary phthalate metabolites, as well as fasting blood glucose, triglyceride (TG), and high-density lipoprotein-cholesterol (HDL-c) levels and the homeostatic model assessment for insulin resistance (HOMA-IR) value. We found that phthalate levels were higher in children at 3-5 years than at 7-9 years of age. Some phthalate metabolites were associated with increased TG and HOMA-IR levels at both age ranges. Repeated measurements of phthalate metabolites were performed to identify long-term exposure patterns. An increased level of mono(2‑ethylhexyl) phthalate (MEHP) was significantly associated with an increased TG level, and increased levels of MEHP, mono(2‑ethyl‑5‑oxohexyl) phthalate (MEOHP), and monoisononyl phthalate (MiNP) were significantly associated with an increased HOMA-IR value, at both age ranges. An increased level of mono-benzyl phthalate was associated with a decreased level of HDL-c at both ages. Our findings suggest that phthalate exposure during childhood is association with effects in terms of insulin-sensitivity index.

Insulin resistance is associated with hirsutism in unselected reproductive-aged women

OBJECTIVE

Hirsutism affects 5%-10% of reproductive-aged women worldwide and exhibits clinical importance as a cutaneous manifestation of underlying hyperandrogenism. Racial and genetic factors play roles in manifestation of hirsutism, and the prevalence of hirsutism seems to be low in East Asians. However, the reference value of the modified Ferriman-Gallwey (mFG) score to diagnose hirsutism and the prevalence of hirsutism have not been determined in Korean populations to date. We aimed to investigate the distribution of the mFG score and establish its reference value for defining hirsutism and to examine its relationship with metabolic and reproductive traits in reproductive-aged Korean women.

DESIGN, PATIENTS AND MEASUREMENTS

We enrolled 2139 female volunteers of reproductive age (15-39 years). We recorded mFG scores from 0 to 4 on 9 different body locations (upper lip, chin, chest, arm, upper abdomen, lower abdomen, upper back, lower back and thighs). Hirsutism was defined as >95th percentile of mFG score. In addition, a 75-g oral glucose tolerance test was performed, and the homoeostasis model assessment of insulin resistance (HOMA-IR) was calculated.

RESULTS

The mFG values of the 50th, 75th, 90th and 95th percentiles were 0, 1, 4 and 6, respectively. Therefore, the mFG score was indicative of hirsutism when the score was 6 or greater, which represents the 95th percentile. In the correlation analysis, total testosterone, free testosterone, fasting plasma insulin and HOMA-IR were positively correlated with mFG score (all Ps <0.05). Multiple linear regression analysis revealed that HOMA-IR (β = 0.081) was positively associated with mFG score after adjustments for age, body mass index, total testosterone and the number of menses per year (P < 0.001).

CONCLUSIONS

In conclusion, setting the 95th percentile of the mFG score as normal, the reference value to define hirsutism was 6 in reproductive-aged Korean women. HOMA-IR was positively associated with the mFG score even after adjustment for biochemical hyperandrogenism.

Fine particulate matter and incidence of metabolic syndrome in non-CVD patients: A nationwide population-based cohort study

BACKGROUND

It has been reported that particulate matter (PM) is associated with cardiovascular diseases (CVD) while metabolic syndrome is also an important risk factor for CVD. However, few studies have investigated the epidemiological association between PM and metabolic syndrome.

OBJECTIVE

To investigate the association between one-year exposure to PM with an aerodynamic diameter <2.5 μm (PM_2.5) and the risk of metabolic syndrome in Korean adults without CVD.

METHODS

Exposure to PM_2.5 was assessed using a Community Multiscale Air Quality (CMAQ) model. Metabolic syndrome was defined by National Cholesterol Education Program Adult Treatment Panel III. Andersen and Gill model with time-varying covariates, considering recurrent events, was used to investigate the association between one-year average PM_2.5 and the risk of incident metabolic syndrome in 119,998 adults from the national health screening cohort provided by Korea National Health Insurance from 2009 to 2013.

RESULTS

Higher risk of metabolic syndrome, waist-based obesity, hypertension, hypertriglyceridemia, low HDL cholesterol, and hyperglycemia were significantly associated with a 10-μg/m³ increase in PM_2.5 [adjusted hazard ratio (HR): 1.070, 1.510, 1.499, 1.468, 1.627 and 1.380, respectively]. In addition, the risk of metabolic syndrome associated with PM_2.5 exposure was significant in the consistently obese group (obese at baseline and endpoint).

CONCLUSION

Exposure to one-year average PM_2.5 is associated with an increased risk of metabolic syndrome and its components in adults without CVD. These associations are particularly prominent in the consistently obese group (obese at baseline and endpoint). Our findings indicate that PM_2.5 affects the onset of MS and its components which may lead to increase the risk of CVD.

A prospective cohort study of the association between bisphenol A exposure and the serum levels of liver enzymes in children

BACKGROUND

Bisphenol A (BPA) is an endocrine disrupter that acts in an estrogen-like manner. Few studies have investigated the association between urinary BPA concentrations and adverse liver function. Additionally, most studies were cross-sectional in nature and included only adults.

OBJECTIVES

We evaluated BPA exposure levels and prospectively explored the association between BPA exposure and liver function in children.

METHODS

Data were retrieved from the ongoing prospective Ewha Birth and Growth Cohort Study. Urinary BPA concentrations were measured in 164 children at 3-5 and 7-9 years of age. At each visit, fasting blood and urine samples were collected, and questionnaires were completed. The associations between the BPA concentrations at these ages and the serum levels of liver enzymes measured at 10-13 years of age were analyzed (n = 113). Multiple regression analysis was performed with adjustment for covariates. We also explored whether the BPA level exhibited dose-response relationships with liver enzyme levels.

RESULTS

The median urinary BPA concentrations were 0.76μg/g creatinine at 3-5 years and 0.61μg/g creatinine at 7-9 years of age. The urinary BPA concentrations at the two ages were correlated significantly (r = 0.23, p < 0.01). The urinary BPA concentrations at 7-9 years, but not that at 3-5 years, was associated significantly with the serum levels of liver enzymes at 10-13 years of age (p < 0.05). Those in the top tertile of urinary BPA concentration had higher levels of liver enzymes than did others. After adjustment for covariates, dose-response relationships of the BPA level with liver enzyme levels were evident at 7-9 years, but not at 3-5 years. Notably, the effect size was larger and the dose-response relationships were more evident in boys than in girls.

CONCLUSIONS

Exposure of children to even low doses of BPA may adversely affect later liver function.

Natural Products from Single Plants as Sleep Aids: A Systematic Review

Insufficient sleep, insomnia, and sleep-related problems are important health issues, as their overall prevalence accounts for about 30% of the general population. The aim of this study was to systematically review previous studies investigating the effects of orally administered single plant-derived extracts on sleep-related outcomes in humans. Data sources were PubMed, Google Scholar, and Cochrane Library. The data search was conducted in two steps: step 1, names of plants which have been studied as sleep aids in humans were searched and retrieved; and step 2, each ingredient listed in step 1 was then added into the search term. Only original articles or reviews were applicable to the scope of this review. Studies on human subjects, with or without sleep-related disorders, were included. Sleep-related disorders refer to not only insomnia or sleep behavior disorders but also diseases with sleep-related symptoms. Studies were considered eligible for this review when the plant extracts were administered orally. Outcome measures relevant to sleep quality, duration, or other sleep-related problems were included. Twenty-one plants were listed in the first step of the search as potential candidates for natural sleep aids. Seventy-nine articles using these single plant-derived natural products were included in the final review. Although valerian was most frequently studied, conflicting results were reported, possibly due to the various outcome measures of each study. Other plants were not as rigorously tested in human studies. There was limited evidence with inconclusive results regarding the effects of single plant-derived natural products on sleep, warranting further studies.

Malignancy Risk and Related Factors of Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance in Thyroid Fine Needle Aspiration

Atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) in thyroid fine needle aspiration (FNA) is a challenging category. The malignancy risk is different by multiple factors and subsequent management strategy is inconclusive. Therefore, we analyzed the malignancy risk of AUS/FLUS according to radiological and clinical features. A total of 687 nodules that had been initially diagnosed as AUS/FLUS were retrospectively reviewed from 6365 thyroid FNAs between 2011 and 2014. The ultrasonographic (US) features were categorized using the Korean Thyroid Imaging Reporting and Data System. Radiological and clinical features were compared according to the second FNA results or histologically confirmed results from surgery. Repeat FNA was performed on 248 (36%) nodules, and 49 (7%) nodules underwent immediate surgery. Among the 248 nodules subjected to repeated FNA, 49 (20%) nodules were diagnosed again as AUS/FLUS, 123 (50%) were found to be benign, and 47 (19%) were diagnosed as follicular neoplasm, suspicious for malignancy or malignant. Among histologically confirmed nodules, the US features were more unfavorable in malignant nodules, and hypo- or anechogenicity was associated with a higher risk of malignancy after adjusting for age, size, and other US features (P < 0.01). In conclusion, we observed that malignant nodules tended to show unfavorable US features, especially hypo- or anechogenicity. Age, sex, and thyroid function were not significantly associated with malignancy risk. We also found out that malignancy risk was not different between the group which underwent immediate operation following the AUS/FLUS diagnosis and the group which underwent repeated FNA after the initial diagnosis.

Heart Rate Variability Measurement in Sepsis Patients

Objectives

Inflammation makes an influence on autonomic nervous system and a change in autonomic nervous activity affects heart rate. Heart rate variability (HRV) test can quantify the autonomous nervous activity. In this study, we evaluated the meaning of heart rate variability in sepsis patients.

Methods

Heart rate variability test was performed for sepsis patients and healthy volunteers. Normalised low frequency power, reflecting sympathetic activity, was compared to acute physiology and chronic health evaluation II (APACHE II) score and mortality in emergency department sepsis (MEDS) score in sepsis patients. Then the patients were divided into four groups: 1) severe sepsis patients, 2) sepsis patients admitted to general ward, 3) sepsis patients discharged within 24 hours and 4) healthy volunteers. We obtained averages for the HRV results in all four groups. The receiver operating characteristics curve was examined to determine whether or not HRV variables could be used to triage sepsis patients.

Results

Correlations between normalised low frequency power (LFnu) with APACHE II score and MEDS score were −0.595 and −0.514, respectively. Low frequency power (LF) and LFnu values decreased in sepsis patients with the higher scores observed in the discharged sepsis patients and healthy volunteers. The areas under the curve for the values of LF and LFnu in the admission and discharge groups were 0.746 and 0.635, respectively (p<0.05).

Conclusion

Variables related to heart rate variability are significantly correlated with the severity of sepsis patients. Although the HRV test alone cannot accurately predict the disposition of sepsis patients, in the emergency room setting it helps to assign beds to sepsis patients within the triage system, and avoid over-population. (Hong Kong j.emerg.med. 2014;21:73-79)

Recurrent Obturator Hernia as a Cause of Nonspecific Abdominal Pain: A Case Report

Many patients visit the emergency department (ED) with abdominal pain. Sometimes, physicians are faced with diagnostic challenges, particularly for older patients. We recently had an elderly female patient who visited the ED several times with non-specific abdominal pain caused by an unusual hernia. One year before, an 81-year-old female visited our ED complaining of abdominal pain radiating to the right inguinal/femoral area. An incarcerated obturator hernia was found on an abdomino-pelvic computed tomography (CT) scan, and she underwent a laparoscopic hernioplasty. However, 1 year later, she revisited complaining of abdominal pain similar to the previous episode. Eventually, the diagnosis of recurrent obturator hernia was made, and a second operation was performed. An obturator hernia may be the cause of non-specific abdominal pain and small bowel obstruction in elderly emaciated females. Recognising the clinical signs and characteristics of this disease is necessary for a prompt diagnosis and treatment.

Polycystic ovary morphology is associated with insulin resistance in women with polycystic ovary syndrome

BACKGROUND/OBJECTIVES

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder characterized by chronic anovulation, hyperandrogenism, polycystic ovary morphology (PCOM) and metabolic disturbances including insulin resistance and type 2 diabetes mellitus. Although insulin resistance could be associated with PCOM, recent studies have shown controversial results. The aim of this study was to determine the relationship between PCOM and insulin resistance.

SUBJECTS/METHODS

This was a cross-sectional clinical study. A total of 679 women with PCOS who were diagnosed using the National Institute of Child Health and Human Disease (NICHD) criteria and 272 control women were analysed. We measured fasting glucose and insulin levels, 75 g oral glucose tolerance test-derived glucose and insulin levels, testosterone levels, ovarian volume and follicle number.

RESULTS

Polycystic ovary morphology was described in 543 women (80.0%) with PCOS. Women with PCOS had significantly higher 2 hours postload glucose, fasting and 2 hours postload insulin levels, ovarian volume, ovarian follicle numbers and lower insulin sensitivity compared with those of the controls (all P<.01). In women with PCOS, ovarian volume and ovarian follicle number were negatively associated with the quantitative insulin sensitivity check index after adjusting for age, body mass index and total testosterone; however, this association was not observed in the controls. In the logistic regression analysis, increased ovarian follicle number was associated with decreased insulin sensitivity in women with PCOS.

CONCLUSIONS

In PCOS, enlarged ovarian volume and follicle excess were associated with insulin resistance, and the number of ovarian follicles could be a predictor of insulin resistance.

Brain changes in overweight/obese and normal-weight adults with type 2 diabetes mellitus

AIMS/HYPOTHESIS

Overweight and obesity may significantly worsen glycaemic and metabolic control in type 2 diabetes. However, little is known about the effects of overweight and obesity on the brains of people with type 2 diabetes. Here, we investigate whether the presence of overweight or obesity influences the brain and cognitive functions during early stage type 2 diabetes.

METHODS

This study attempted to uncouple the effects of overweight/obesity from those of type 2 diabetes on brain structures and cognition. Overweight/obese participants with type 2 diabetes had more severe and progressive abnormalities in their brain structures and cognition during early stage type 2 diabetes compared with participants with normal weight. Relationships between each of these measures and disease duration were also examined.

RESULTS

Global mean cortical thickness was lower in the overweight/obese type 2 diabetes group than in the normal-weight type 2 diabetes group (z = -2.96, p for group effect = 0.003). A negative correlation was observed between disease duration and global mean white matter integrity (z = 2.42, p for interaction = 0.02) in the overweight/obese type 2 diabetes group, but not in the normal-weight type 2 diabetes group. Overweight/obese individuals with type 2 diabetes showed a decrease in psychomotor speed performance related to disease duration (z = -2.12, p for interaction = 0.03), while normal-weight participants did not.

CONCLUSIONS/INTERPRETATION

The current study attempted to uncouple the effects of overweight/obesity from those of type 2 diabetes on brain structures and cognition. Overweight/obese participants with type 2 diabetes had more severe and progressive abnormalities in brain structures and cognition during early stage type 2 diabetes compared with normal-weight participants.

Insulin resistance according to β-cell function in women with polycystic ovary syndrome and normal glucose tolerance

BACKGROUND

Polycystic ovary syndrome (PCOS) is associated with insulin resistance (IR) and compensatory hyperinsulinemia. IR is recognized as a major risk factor for the development of type 2 diabetes mellitus. However, few studies have investigated IR in women with PCOS and normal glucose tolerance. The objective of this study was to evaluate IR and β-cell function in women with PCOS and normal glucose tolerance. Additionally, we sought to evaluate the usefulness of oral glucose tolerance test (OGTT)-derived IR indices in lean women with PCOS.

METHODS

We recruited 100 women with PCOS and normal glucose tolerance and 100 age- and BMI-matched women as controls. IR and insulin secretory indices, including the homeostasis-model assessment (HOMA)-IR, HOMA-M120, HOMA-F and the Stumvoll index, were calculated from an OGTT. Increased β-cell function was defined as>75th percentile for the HOMA-F in control women.

RESULTS

Women with PCOS had higher values for post-load 2-hour glucose, fasting insulin, post-load 2-hour insulin, HOMA-IR, HOMA-M120, HOMA-F and lower values for the Stumvoll index than the controls (all Ps<0.05). Women with PCOS and increased β-cell function showed lower Stumvoll index values than the matched controls (P<0.05). The HOMA-F was significantly associated with the HOMA-M120 and Stumvoll index when adjusted for age and BMI in a multiple regression analysis (all Ps<0.05). The HOMA-M120 was positively correlated with triglycerides and free testosterone, and the Stumvoll index was negatively correlated with triglycerides and free testosterone in lean women with PCOS (all Ps<0.05).

CONCLUSIONS

Women with PCOS and normal glucose tolerance showed higher IR than controls matched for age, BMI, and β-cell function. β-cell function was increased in women with PCOS when compared to the matched controls, but not when the lean subjects were compared to the matched controls separately. Therefore, early evaluation of IR in women with PCOS and normal glucose tolerance may be needed.

Urinary bisphenol A is associated with insulin resistance and obesity in reproductive-aged women

BACKGROUND/OBJECTIVES

The prevalence of obesity has markedly increased and is closely related to insulin resistance. Although lifestyle and genetic predisposition are significant factors influencing the pathophysiology within the body, endocrine-disrupting chemicals (EDCs) are also important triggers of metabolic disturbance. We investigated the relationship between exposure to EDCs and insulin resistance and obesity in healthy, reproductive-aged women.

SUBJECTS/METHODS

This cross-sectional analysis included 296 healthy, reproductive-aged women between 30 and 49 years. Metabolically healthy was defined as an absence of the components of metabolic syndrome. Urinary levels of bisphenol A (BPA), mono-(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP), mono-(2-ethyl-5-oxohexyl) phthalate (MEOHP) and mono-n-butyl phthalate (MnBP) were measured by high-performance liquid chromatography and tandem mass spectroscopy (LC-MS). Homoeostatic model analysis of insulin resistance (HOMA-IR) was utilized as an index of insulin resistance.

RESULTS

Urinary BPA levels were positively correlated with BMI, waist circumference, fasting serum insulin and HOMA-IR. MEHHP, MEOHP and MnBP were not associated with any of the above parameters. In the multiple regression analysis, the BPA levels were significantly associated with BMI and waist circumference after adjusting for age, smoking and alcohol consumption status, triglycerides (TG), total cholesterol (TC) and high-density lipoprotein (HDL). Fasting insulin and HOMA-IR values were also significantly related to urinary BPA concentration after adjusting for confounding variables. Metabolically unhealthy women exhibited significantly higher levels of urinary BPA (P = 0·01) compared to metabolically healthy women.

CONCLUSIONS

Higher urinary BPA levels are associated with obesity, insulin resistance and metabolic disruption in Korean reproductive-aged women. BPA could play an important role in the pathogenesis of metabolic abnormalities. Further studies are required to elucidate the relationship between EDCs and metabolic disturbances in various age and sex groups.

Serum Levels of Persistent Organic Pollutants and Insulin Secretion among Children Age 7-9 Years: A Prospective Cohort Study

BACKGROUND

Persistent organic pollutants (POPs) are endocrine disruptors and have been suggested as possible risk factors for diabetes. Few studies have been performed to investigate this association among children.

OBJECTIVES

In this study, we prospectively examined the relationship between the serum concentration of POPs and glucose metabolism in children.

METHODS

Data were collected from the Ewha Birth & Growth Cohort Study, an ongoing birth cohort study initially constructed between 2001 and 2006. In 2010-2012, the POP concentration was measured in serum from a total of 214 children, 7-9 years of age. Using fasting glucose and insulin measurements at both baseline and the second year of follow-up, the homeostatic model assessment of beta-cell function (HOMA-β) and homeostatic model assessment of insulin resistance (HOMA-IR) were calculated. Multiple linear regression analysis and a linear mixed-effects model were used to determine the relationship between POP tertiles and metabolic biomarkers.

RESULTS

Compared with the lowest tertile of total marker PCBs, participants in the third tertile had decreased HOMA-β values, after adjustment for age, sex, body mass index z-score, mother's education, ponderal index, and history of breastfeeding (-18.94%; 95% CI: -32.97%, -1.98%). In a linear mixed model, the HOMA-β values were still lower in subjects in the highest compared with the lowest tertile of total PCBs at the 2-year follow-up period (108.3 vs. 135.0, respectively).

CONCLUSION

The results of the study suggested that exposure to POPs among children might affect insulin secretory function, which could lead to an increased risk of developing diabetes. Citation: Park SH, Ha EH, Hong YS, Park H. 2016. Serum levels of persistent organic pollutants and insulin secretion among children age 7-9 years: a prospective cohort study. Environ Health Perspect 124:1924-1930; http://dx.doi.org/10.1289/EHP147.

The association of thyroid hormones and blood pressure in euthyroid preadolescents

BACKGROUND

Hypertension is the leading cause of cardiovascular disease worldwide, and both high and low blood pressures are associated with various chronic diseases. Thyroid hormones have profound effects on cardiovascular function, including on blood pressure. Recent studies have shown that childhood hypertension can lead to adult hypertension. Therefore, adequate blood pressure control is important from early life. Employing a life-course approach, we aimed to investigate the association between thyroid hormones and blood pressure in children.

METHODS

A total of 290 children from the Ewha Woman's University Hospital birth cohort participated in a preadolescent check-up program. We assessed the levels of serum thyroid-stimulating hormone (TSH) and free thyroxine (FT4) and the blood pressure status in these children. Thyroid hormone concentrations were measured using an electro-chemiluminescence immunoassay (ECLIA), and hypertension was defined according to the guideline of the Korea Centers for Disease Control and Prevention.

RESULTS

The sex-, age-, and height-adjusted prevalence of hypertension was 27.0% in the present study. On regression analysis, serum FT4 showed significantly negative association with diastolic blood pressure (DBP; β=-8.24, 95% CI: -14.19-2.28, p=0.007). However, these relationships were not significant after adjustment for sex, age, and current body mass index. The levels of serum TSH showed no relationship with mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) after adjustment. No significant differences in serum TSH and FT4 levels according to hypertension status were found.

CONCLUSIONS

These findings suggest that thyroid hormone is not independently associated with increased blood pressure in euthyroid preadolescents.

The Effect of Exposure to Persistent Organic Pollutants on Metabolic Health among KOREAN Children during a 1-Year Follow-Up

Previous evidence suggests the potential for adverse effects of persistent organic pollutants (POPs) on metabolic health even at low-dose exposure levels common among the general population, but there is less evidence of these associations among children. Therefore, as part of a prospective cohort study, 214 children were measured for POPs exposure. After the 1-year follow-up, we assessed the effect of circulating POPs exposure among 158 children aged 7-9 years (at baseline) on the change of metabolic components of metabolic syndrome using multiple regression analysis. In addition, we calculated the continuous metabolic syndrome (cMetS) score and assessed the variation among individuals by POPs exposure. The concentrations of marker polychlorinated biphenyls (PCBs) were significantly associated with increased change in diastolic blood pressure (BP) and triglyceride levels during a 1-year follow-up, after controlling for sex, age, household income, and change in body mass index. Total PCBs also showed a marginal association with increasing cMetS score from the baseline. Of the metabolic components, change in diastolic BP over time showed a notable association with specific PCBs, but no association with organochlorine pesticides. Here, we found that low-dose exposures to PCBs among children in the general population could negatively influence metabolic health, particularly diastolic BP. Increased disease sensitivity during childhood can continue to adulthood, thus, these results support the need for continuous assessment of the health impact of POPs.

Serum concentrations of PCBs and OCPs among prepubertal Korean children

Although children are more vulnerable than adults to environmental hazards, due to their physiological and behavioral characteristics, few studies have assessed their internal exposure to persistent organic pollutants (POPs). The objective of this study was to determine the serum levels of certain polychlorinated biphenyls (PCBs) and organochlorine pesticides (OCPs) among pre-pubertal children in Korea and examine their variation with age and gender. We analyzed a total of 51 POPs in 214 children (age range, 7-9 years), using data from the Ewha Birth and Growth Cohort Study. To examine change over time, POP concentrations were measured at both 7 and 9 years of age in a sub-cohort of 26 children. The median and interquartile range (IQR, 25th to 75th percentiles) data for the sum of PCB congeners was 26.44 ng/g lipid (18.27-37.63 ng/g lipid). The median (IQR) concentration for the sum of OCPs was 74.82 ng/g lipid (51.11-112.45 ng/g lipid). Our results showed significant increases in serum concentrations of total PCBs with age (p = 0.0001), no gender dependence of total PCBs (p = 0.38) and total OCPs (p = 0.12), and strong correlations between individual POPs. Childhood exposure to POPs was relatively low compared to other studies carried out in different countries. However, even though the use of POPs has been banned since 2001, our results indicated that children in the general population are still exposed to various POPs. Because long-term, low-level exposure to POPs in the general population remains a concern for human health, future research should examine major routes of exposure and identification of risk factors.

Prevalence and clinical significance of cellular and acellular mucin in patients with locally advanced mucinous rectal cancer who underwent preoperative chemoradiotherapy followed by radical surgery

AIM

The frequent presence of acellular mucin in specimens showing pathological complete response to preoperative chemoradiotherapy (CRT) and the poor response to preoperative CRT in mucinous rectal cancer have been reported. However, the prevalence and prognostic significance of cellular and acellular mucin have not been evaluated in resected specimens from patients with mucinous rectal cancer who undergo preoperative CRT.

METHOD

We retrospectively evaluated the clinicopathological features and prognostic significance of mucin in resected specimens from 59 consecutive patients with mucinous rectal cancer who underwent long-course CRT followed by resection between January 2000 and December 2009. Patients were categorized according to the presence of mucin, as identified by pathological analysis. The clinicopathological findings and oncological results were compared.

RESULTS

Mucin was identified in 25 of 59 patients with mucinous rectal cancer (42.4%). Mucin was more frequent in men (hazard ratio = 23.94, 95% confidence interval = 1.875-305.504, P = 0.015) and in specimens showing a good tumour response grade (hazard ratio = 64.26, 95% confidence interval = 6.940-595.045, P < 0.001). With a median follow-up of 67.7 (range 8.6-133.2) months, the 5-year overall survival (60.7% without mucin vs 51.4% with mucin, P = 0.898) and disease-free survival (59.9% without mucin vs 56.9% with mucin, P = 0.813) did not differ between the groups.

CONCLUSION

The presence of mucin in rectal cancer with mucinous differentiation after preoperative CRT and resection is associated with male gender and a good tumour response grade, without significant impact on oncological outcome.

[Development of guide to clinical performance and basic clinical skills for medical students]

The aim of this report was to discuss the development and content of a guide on clinical performance and basic clinical skills for medical students. We published the first edition of this guide in 2010 and will publish the second edition in 2016. Initially, we took a survey on important clinical presentations and fundamental clinical and technical skills in 41 medical schools in Korea. Ultimately, we chose 80 core clinical presentations and 56 clinical skills. In the guide to basic clinical skills, we described the physical examination and technical skills according to the preprocedural preparation, procedure, and postprocedural process. In the guide on clinical performance, we reviewed patient encounters-from history taking and the physical examination to patient education. We included communication skills, principles of patient safety, and clinical reasoning schemes into the guides. In total, 43 academic faculty members helped develop the basic clinical skills guide, 75 participated in establishing the clinical performance guide, and 16 advisors from 14 medical specialty societies contributed to the guide. These guides can help medical students approach patients holistically and safely.

A randomised, double-blind, placebo-controlled multi-centre phase III trial of XELIRI/FOLFIRI plus simvastatin for patients with metastatic colorectal cancer

Background:

The purpose of this randomised phase III trial was to evaluate whether the addition of simvastatin, a synthetic 3-hydroxy-3methyglutaryl coenzyme A reductase inhibitor, to XELIRI/FOLFIRI chemotherapy regimens confers a clinical benefit to patients with previously treated metastatic colorectal cancer.

Methods:

We undertook a double-blind, placebo-controlled phase III trial of 269 patients previously treated for metastatic colorectal cancer and enrolled in 5 centres in South Korea. Patients were randomly assigned (1 : 1) to one of the following groups: FOLFIRI/XELIRI plus simvastatin (40 mg) or FOLFIRI/XELIRI plus placebo. The FOLFIRI regimen consisted of irinotecan at 180 mg m⁻² as a 90-min infusion, leucovorin at 200 mg m⁻² as a 2-h infusion, and a bolus injection of 5-FU 400 mg m⁻² followed by a 46-h continuous infusion of 5-FU at 2400 mg m⁻². The XELIRI regimen consisted of irinotecan at 250 mg m⁻² as a 90-min infusion with capecitabine 1000 mg m⁻² twice daily for 14 days. The primary end point was progression-free survival (PFS). Secondary end points included response rate, duration of response, overall survival (OS), time to progression, and toxicity.

Results:

Between April 2010 and July 2013, 269 patients were enrolled and assigned to treatment groups (134 simvastatin, 135 placebo). The median PFS was 5.9 months (95% CI, 4.5–7.3) in the XELIRI/FOLFIRI plus simvastatin group and 7.0 months (95% CI, 5.4–8.6) in the XELIRI/FOLFIRI plus placebo group (P=0.937). No significant difference was observed between the two groups with respect to OS (median, 15.9 months (simvastatin) vs 19.9 months (placebo), P=0.826). Grade ⩾3 nausea and anorexia were noted slightly more often in patients in the simvastatin arm compared with with the placebo arm (4.5% vs 0.7%, 3.0% vs 0%, respectively).

Conclusions:

The addition of 40 mg simvastatin to the XELIRI/FOLFIRI regimens did not improve PFS in patients with previously treated metastatic colorectal cancer nor did it increase toxicity.

Increased Epicardial Adipose Tissue Thickness in Type 2 Diabetes Mellitus and Obesity

BACKGROUND

Epicardial adipose tissue (EAT) is suggested to play an important role in the progression of metabolic syndrome. We aimed to establish a simple method to measure EAT and examine the differences in EAT thickness according to the presence of type 2 diabetes mellitus or obesity.

METHODS

A total of 94 patients (42.6% type 2 diabetes mellitus, 53.2% obese, mean age 61±13) who underwent multidetector computed tomography were enrolled. Thickness of EAT was measured on the parasternal short and horizontal long axis view. Epicardial fat area (EFA) was measured at the level of left main coronary artery (LMCA).

RESULTS

All EAT thicknesses were correlated with EFA at the LMCA level (r=0.235 to 0.613, all Ps<0.05), and EAT thickness in the left atrioventricular groove (LAVG) had the highest correlation coefficient (r=0.613). EFA, and EAT thicknesses in the LAVG and the left ventricular apex were higher in the group with type 2 diabetes mellitus than in the group without type 2 diabetes mellitus when adjusted only for body mass index. When adjusted only for type 2 diabetes mellitus, EFA, and EAT thicknesses in the LAVG and the right atrioventricular groove were higher in obese group than in nonobese group.

CONCLUSION

In conclusion, EAT thickness can be easily measured and represent EFA. EAT thickness, especially in LAVG, was higher in groups with type 2 diabetes mellitus and obesity independently. These findings implicate that EAT thickness may be a useful indicator for type 2 diabetes mellitus and obesity.

FTO Gene Variants Are Associated with PCOS Susceptibility and Hyperandrogenemia in Young Korean Women

BACKGROUND

The fat mass and obesity-associated (FTO) gene is associated with obesity and type 2 diabetes mellitus. Obesity and insulin resistance are also common features of polycystic ovary syndrome (PCOS). Therefore, the FTO gene might be a candidate gene for PCOS susceptibility. The aim of the present study was to evaluate the effects of FTO gene variants on PCOS susceptibility and metabolic and reproductive hormonal parameters.

METHODS

We recruited 432 women with PCOS (24±5 years) and 927 healthy women with regular menstrual cycles (27±5 years) and performed a case-control association study. We genotyped the single nucleotide polymorphisms rs1421085, rs17817449, and rs8050136 in the FTO gene and collected metabolic and hormonal measurements.

RESULTS

Logistic regression revealed that the G/G genotype (rs1421085, 1.6%), the C/C genotype (rs17817449, 1.6%), and the A/A genotype (rs8050136, 1.6%) were strongly associated with an increased risk of PCOS (odds ratio, 2.551 to 2.559; all P<0.05). The strengths of these associations were attenuated after adjusting for age and BMI. The women with these genotypes were more obese and exhibited higher free androgen indices (P<0.05) and higher free testosterone levels (P=0.053 to 0.063) compared to the other genotypes. However the significant differences disappeared after adjusting for body mass index (BMI). When we analyzed the women with PCOS and the control groups separately, there were no significant differences in the metabolic and reproductive hormonal parameters according to the FTO gene variants.

CONCLUSION

The rs1421085, rs17817449, and rs8050136 variants of the FTO gene were associated with PCOS susceptibility and hyperandrogenemia in young Korean women. These associations may be mediated through an effect of BMI.