Dynamics of depressive states among university students in Japan during the COVID-19 pandemic: an interrupted time series analysis

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic was reported to have increased depression among university students which was associated with impairments in their campus lives. This study examined changes in depressive states among Japanese university students during the COVID-19 pandemic.

METHODS

A secondary data analysis from a factorial randomized controlled trial involving smartphone-based cognitive-behavioral therapy was performed. Six cohorts (N = 1626) underwent an 8-week intervention during the spring or autumn of 2019-2021, with a 9-month follow-up. We evaluated participants' depressive states weekly using the Patient Health Questionnaire-9 (PHQ-9) during the intervention, with monthly evaluations thereafter. The follow-up periods included Japan's four states of emergency (SOEs) to control COVID-19. Hypothesizing that SOEs caused a sudden worsening of depressive states, Study 1 compared the cohorts' PHQ-9 scores, and Study 2 employed time series analysis with a mixed-effects model to estimate identified changes in PHQ-9 scores.

RESULTS

Although no changes in depressive states were observed in relation to the SOEs, Study 1 identified sudden increases in PHQ-9 scores at the 28-week evaluation point, which corresponded to the beginning of the new academic year for the three autumn cohorts. In contrast, the three spring cohorts did not exhibit similar changes. Study 2 showed that, for all three autumn cohorts (n = 522), the 0.60-point change was significant (95% CI 0.42-0.78; p < .001) at 28 weeks; that is, when their timeline was interrupted.

CONCLUSIONS

While the results do not indicate any notable impact of the SOEs, they highlight the influence of the new academic year on university students' mental health during COVID-19. Trial registration UMIN, CTR-000031307. Registered on February 14, 2018.

Pembrolizumab plus lenalidomide and dexamethasone in treatment-naive multiple myeloma (KEYNOTE-185): subgroup analysis in Japanese patients

The global, randomized, open-label KEYNOTE-185 study closed early after an interim analysis showed an unfavorable benefit-risk profile with pembrolizumab plus lenalidomide and low-dose dexamethasone (Rd) versus Rd alone in treatment-naive, transplant-ineligible multiple myeloma. This subgroup analysis reported outcomes in the Japanese population. Patients were randomly assigned (1:1) to pembrolizumab plus Rd or Rd alone, stratified by age and International Staging System. The primary end point was progression-free survival (PFS). Fifty-two Japanese patients were randomly assigned to pembrolizumab plus Rd (n = 27) or Rd (n = 25). The median follow-up was 7.2 months (range, 0.4-13.8). The median PFS was not reached (NR); 6-month PFS was 91.2% versus 86.2% with pembrolizumab plus Rd versus Rd [hazard ratio (HR), 0.31; 95% CI, 0.06-1.63]. The median overall survival (OS) was NR; 6-month OS was 96.2% versus 95.7% with pembrolizumab plus Rd versus Rd (HR, 0.33; 95% CI, 0.03-3.72). With pembrolizumab plus Rd versus Rd, grade 3-5 adverse events occurred in 70.4% versus 69.6% of patients; serious adverse events occurred in 40.7% versus 52.5%. Although in the Japanese subgroup of KEYNOTE-185 adding pembrolizumab to Rd did not show an unfavorable risk-benefit, the analysis is limited by short follow-up and small sample size, affecting generalizability of the results.

KEYNOTE-025: Phase 1b study of pembrolizumab in Japanese patients with previously treated programmed death ligand 1-positive advanced non-small-cell lung cancer

Pembrolizumab, a humanized monoclonal antibody against programmed death 1 (PD-1), has been shown to improve overall survival (OS) in patients with previously treated advanced non-small-cell lung cancer (NSCLC) with programmed death ligand 1 (PD-L1) tumor proportion score (TPS) ≥1%. We report safety and efficacy results from the phase 1b KEYNOTE-025 study, which evaluated pembrolizumab in Japanese patients with previously treated NSCLC. Eligible patients had histologically/cytologically confirmed advanced NSCLC with PD-L1 TPS ≥1% and had received ≥1 platinum-doublet chemotherapy. Patients received pembrolizumab 10 mg/kg once every 3 weeks for 2 years or until disease progression/unacceptable toxicity. Primary objectives were to evaluate the safety of pembrolizumab in patients with PD-L1 TPS ≥1% and the objective response rate (ORR) per RECIST version 1.1 in patients with PD-L1 TPS ≥50%. Thirty-eight patients were enrolled and received ≥1 pembrolizumab dose. The median (range) age was 66.0 (41-78) years, and 61% had received ≥2 prior systemic therapies. Eleven patients (29%) experienced grade 3-5 treatment-related adverse events (AE); 9 patients (24%) experienced immune-mediated AE and infusion reactions, with pneumonitis (11%; any grade) being most common. Among evaluable patients with PD-L1 TPS ≥50% (n = 11), ORR was 27% (95% CI, 6-61). Among evaluable patients with PD-L1 TPS ≥1% (n = 37), ORR was 22% (95% CI, 10-38). Median (95% CI) progression-free survival and OS were 3.9 (2.0-6.2) months and 19.2 (8.0-26.7) months, respectively. In summary, pembrolizumab was generally well tolerated and showed promising antitumor activity in Japanese patients with previously treated PD-L1-expressing NSCLC. Outcomes were consistent with those from the phase 3 KEYNOTE-010 study. (Trial registration number: ClinicalTrials.gov, NCT02007070.).

Polymorphisms of the Beta Fibrinogen Gene and Plasma Fibrinogen Concentration in Caucasian and Japanese Population Samples

We reported previously that plasma fibrinogen was significantly higher in U.S. Caucasians than in Japanese, which may contribute to the higher mortality rate of coronary heart disease in the United States than in Japan. To examine the contribution of genetic variations to the race difference in plasma fibrinogen levels, restriction fragment length polymorphisms (RFLPs) of the beta fibrinogen gene were examined in 293 nonsmoking Caucasians and Japanese men and women aged 47-69 years. Three RFLPs were detected by digestion of genomic DNA using the BclI restriction enzyme, polymerase chain reaction (PCR) products using HaeIII and HindIII. The alleles B2 (4.2 kb, BclI digestion), H2 (957 b, HaeIII) and Hd2 (465 b, HindIII) were associated with higher fibrinogen concentrations in previous studies. Because of a strong linkage disequilibrium between HaeIII and HindIII polymorphisms, the data of HindIII was presented. The frequency of the B2 allele was 22% (95% Cl: 17-27%) for Caucasians and 13% (10-17%) for Japanese (the difference: p <0.01). The respective frequency of the Hd2 allele was 26% (21-31%) and 12% (8-16%) (p <0.001). After controlling for age, body mass index, alcohol intake, triglycerides, fish intake, and for women, menopausal status and hormone replacement therapy, the adjusted mean fibrinogen level among Caucasians was 289 mg/dl for genotype B1B1 and 301 mg/dl for genotype B1B2 or B2B2 combined (p = 0.18), and 285 mg/dl for Hd1Hd1 and 306 mg/dl for Hd1Hd2 or Hd2Hd2 combined (p = 0.03). The respective mean values among Japanese were 251 mg/dl for B1B1 and 257 mg/dl for B1B2 or B2B2 combined (p = 0.37), 248 mg/dl for Hd1Hd1 and 259 mg/dl for Hd1Hd2 or Hd2Hd2 combined (p = 0.16). These polymorphisms had a similar effect on plasma fibrinogen concentrations for both men and women. The results suggest that a genetic difference may partly explain the higher plasma fibrinogen in Caucasians than in Japanese.

Antigens of Tissue Plasminogen Activator and Plasminogen Activator Inhibitor 1: Correlates in Nonsmoking Japanese and Caucasian Men and Women

We reported in a 1987 preliminary study that tissue plasminogen activator antigen was significantly higher in American Caucasian men than in Japanese men. To further examine possible differences in fibrinolytic activity between the two races, an expanded study was conducted in a total of 300 nonsmoking men and women aged 47-69 years in two population-based samples: rural Japanese living in Akita and Caucasians living in Minneapolis-St. Paul, MN. Antigens of tissue plasminogen activator (t-PA) and plasminogen activator inhibitor 1 (PAI-1) were measured. Mean t-PA antigen was 2.3 ng/ml higher in Caucasian men than in Japanese men (P <0.001), but no race difference was seen for women (P = 0.59). Mean PAI-1 was higher in Caucasians than in Japanese for both sexes, and the race difference in mean was 1.8 ng/ml for men (P = 0.07) and 4.4 ng/ml for women (P <0.001). Both t-PA and PAI-1 were associated positively with body mass index and blood triglycerides for all sex-race groups, and positively with alcohol intake for Japanese and Caucasian men. Compared to Japanese, Caucasians of both sexes had higher levels of body mass index and blood triglycerides, and lower average intake of alcohol among men. Even when adjusted for body mass index, triglycerides, alcohol and other cardiovascular risk factors, the race difference in mean t-PA antigen persisted for men (P <0.001), as did the difference in mean PAI-1 for men (P = 0.03) and women (P = 0.001). If PAI-1 is a risk factor for coronary heart disease, a higher level in Caucasians than Japanese would correspond to the higher mortality rate from coronary heart disease in the United States than in Japan.

Enhancement of ADP-Induced Platelet Aggregation by Exercise Test in Coronary Patients and Its Prevention by Pyridinolcarbamate

ADP-induced platelet aggregation in citrated platelet rich plasma (CPRP) was examined using a photoelectric system. To exclude a variation in intensities of platelet aggregation in repeated measurements and to compare intensities of different samples, the maximum deflection of the optical density of CPRP induced by adding ADP solution was divided by a deflection of the optical density of the platelet free plasma and its value, shown as a percentage, was defined as an intensity of ADP-induced platelet aggregation. In this method, the linearity was found in the dose response curve of the platelet aggregation induced by 10−6, 3 × 10−6 and 10−5 molar of ADP with statistical significance. These variation coefficients were less than 5% in the responses induced by the higher doses of ADP. Changes in the ADP-induced platelet aggregation after a Master’s two step test were examined in 13 patients with angina pectoris 3 h after oral administration of placebo or 1 g of pyridinolcarbamate. Under placebo pretreatment, an enhancement of platelet aggregation was observed 1 min after the exercise test with statistical significance (P < 0.01 ∼ 0.05). In the cases of the same subjects pretreated with pyridinolcarbamate, such change was not observed at any time. Using a parallel line assay, an inhibitory effect of pyridinolcarbamate against enhancement of ADP-induced platelet aggregation after the exercise was also recognized with statistical significance (P < 0.01). In the 10 healthy volunteers, there was no statistically significant enhancement of ADP-induced platelet aggregation using any concentration of ADP 1 to 10 min after the exercise test.

Appearance of Thrombogenic Tendency Induced by Adrenaline and Its Prevention by β-Adrenergic Blocking Agent, Nialamide and Pyridinolcarbamate

In 52 men and 33 women, the total, adhesive and nonadhesive platelet counts, onestage prothrombin time, euglobulinlysis time, and plasma nonesterified fatty acid were measured before and after an intravenous injection with 0.1 μg/kg of adrenaline or 1-noradrenaline. Three hours before the injection, placebo, 30 mg of phenoxybenzamine, 300 mg of pronethalol, 100 mg of nialamide or 100 mg of pyridinolcarbamate was administered orally under the double blind technique. Five minutes after the injection with adrenaline in 15 cases pretreated with placebo, a decrease in adhesive platelet count, and a shortening of one-stage prothrombin time and euglobulin lysis time were observed with statistical significance (P ˂ 0.01 ∼ 0.05). These changes were not observed in 15 cases injected with saline or noradrenaline. The changes were not observed in 10 cases pretreated with pronethalol, but were observed in 10 cases pretreated with phenoxybenzamine. So the effect of adrenaline may be due to stimulation of ß-adrenergic receptor sites. Meanwhile, the decrease in adhesive platelet count and the enhancement of blood coagulability were prevented by nialamide and pyridinolcarbamate, while the enhancement of fibrinolysis was not. The preventive effect of nialamide was less than that of pyridinolcarbamate. Phenoxybenzamine and nialamide prevented an increase in systolic blood pressure induced by adrenaline, and pronethalol prevented tachycardia by adrenaline, while pyridinolcarbamate did not affect these changes. Changes in plasma nonesterified fatty acid showed no relationship to the above hematological changes.

Preventive Effect of Pyridinolcarbamate on Thrombohemorrhagic Phenomenon and Hemorrhagic Necrosis

Forty two rabbits were injected intravenously with 5 ml/kg of 0.5% agar solution or 100 μg/kg of bacterial endotoxin derived from Escherichia coli. After 1 min 0.1 ml of 500 μg/ml of adrenaline was injected intradermally in abdominal skin of each rabbit. After 24 hrs hemorrhage in adrenaline-injected regions was observed in 28 of 38 regions in abdominal skin of rabbits treated with agar and in 11 of 14 regions of rabbits treated with endotoxin. Both the hemorrhages were similarly reduced with the pretreatment of 40 μg of pyridinolcarbamate given locally with statistical significance (P < 0.01 and 0.05).

Abstract A204: INCB024360 (Epacadostat) monotherapy and in combination with pembrolizumab in patients with advanced solid tumors: primary results from first-in-Japanese phase I study (KEYNOTE-434)

Background: INCB024360 (epacadostat) is an oral, potent, selective inhibitor of indoleamine 2,3-dioxygenase 1 (IDO1), a tryptophan-catabolizing enzyme that induces immune tolerance by T-cell suppression. Preliminary results from the phase I study of INCB024360 with pembrolizumab, an anti-PD-1 monoclonal antibody, exhibited an acceptable safety profile and promising clinical activities. This first-in-Japanese phase 1 study assessed the safety and the tolerability of INCB024360 monotherapy and in combination with pembrolizumab in Japanese patients with advanced solid tumors (ClinicalTrials.gov: NCT02862457). Materials and Methods: Patients with advanced solid tumors who had previously received standard-of-care were enrolled; patients previously treated with checkpoint inhibitors were excluded. Patients received INCB024360 25 mg or 100 mg BID monotherapy, or in combination with intravenous pembrolizumab 200 mg every 3 weeks (Q3W). Dose-limiting toxicities (DLTs) were evaluated for INCB024360 monotherapy and in combination with pembrolizumab. Response rate was also assessed by RECIST 1.1. Patients who had INCB024360 monotherapy subsequently received pembrolizumab combination after DLT evaluation. Results: Fifteen patients were enrolled (53% men; median age, 68.0 y; 33% ECOG PS 1): urothelial cancer, colon cancer, gastric cancer, ovarian cancer, urachal cancer, and cancer of unknown primary (n=2, each); duodenal papilla cancer, mesothelioma, and pancreatic cancer (n=1, each). Three patients each received 25 mg and 100 mg of INCB024360 monotherapy, showed no DLTs. In combination with pembrolizumab, three and six patients received INCB024360 dose of 25 mg and 100 mg, respectively. One DLT (grade 4, rhabdomyolysis) was observed in 100 mg cohort. Twelve patients (80.0%) experienced drug-related AEs (DRAEs); 2 patients (13.3%) had grade 3 DRAEs: grade 3 liver disorder and grade 4 rhabdomyolysis. There were no treatment-related deaths. In 15 patients who had target lesion, partial responses were observed in 4 patients (26.7%) and stable disease were 4 (26.7%). As of 2 June 2017, all responders with pancreatic cancer, urothelial cancer, colon cancer with MSI-high and cancer of unknown primary (n=1, each) remain on treatment at 21, 24, 31, and 34 weeks, respectively. Conclusion: INCB024360 monotherapy and in combination with pembrolizumab demonstrated tolerability and encouraging efficacy in the Japanese patients with advanced solid tumors. Latest safety as well as efficacy data will be presented.

Citation Format: Yutaka Fujiwara, Kohei Shitara, Toshio Shimizu, Kan Yonemori, Nobuaki Matsubara, Izumi Ohno, Takahiro Kogawa, Yoichi Naito, Lance Leopold, Kahori Sasahara, Naoyoshi Yatsuzuka, Tomoko Takami, Takashi Shimamoto, Noboru Yamamoto, Toshihiko Doi. INCB024360 (Epacadostat) monotherapy and in combination with pembrolizumab in patients with advanced solid tumors: primary results from first-in-Japanese phase I study (KEYNOTE-434) [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr A204.

Phase 1b study of pembrolizumab (MK-3475; anti-PD-1 monoclonal antibody) in Japanese patients with advanced melanoma (KEYNOTE-041)

PURPOSE

This phase I b study evaluated the safety and anti-tumor activity of pembrolizumab in Japanese patients with advanced melanoma.

METHODS

Pembrolizumab (2 mg/kg) was given every 3 weeks (Q3W) for up to 2 years or until confirmed progression or unacceptable toxicity. The tumor response was assessed as per the Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST v1.1) by both investigator review and central review.

RESULTS

Forty-two patients with advanced melanoma received pembrolizumab. A primary cutaneous histology was observed in 34 patients (81.0%), while a primary mucosal histology was observed in 8 patients (19.0%). Thirty-four patients (81.0%) experienced treatment-related adverse events (AEs). The most common treatment-related AEs were pruritus, maculopapular rash, malaise, and hypothyroidism. Grade 3-5 treatment-related AEs occurred in 8 patients (19.0%). The only grade 3-5 treatment-related AE reported in at least two patients was anemia. There were two treatment-related deaths (unknown cause and cerebral hemorrhage). Among the 37 evaluable patients, the confirmed overall response rates (ORRs) determined by central review were 24.1% (95% CI 10.3-43.5) for cutaneous melanoma and 25.0% (95% CI 3.2-65.1) for mucosal melanoma. The responses were durable, and the median duration of response was not reached in either population. The median overall survival (OS) was not reached, with a 12-month OS of 82.7% for cutaneous melanoma and 51.4% for mucosal melanoma.

CONCLUSION

The safety profile of pembrolizumab in Japanese patients was similar to that reported in the previous clinical studies. Pembrolizumab provided promising anti-tumor activity in Japanese patients with advanced melanoma.

Phase I study of pegylated interferon-alpha-2b as an adjuvant therapy in Japanese patients with malignant melanoma

In the adjuvant setting for malignant melanoma, interferon (IFN)-α-2b and pegylated (PEG) IFN-α-2b were approved in several countries including the USA before these were approved in Japan. To resolve the "drug-lag" issue, this phase I study was designed to evaluate the safety and tolerability in Japanese patients with stage II or III malignant melanoma who had undergone surgery, by treating with PEG IFN-α-2b. As with a previously reported phase III study, patients were to receive PEG IFN-α-2b 6 μg/kg per week s.c. during an 8-week induction phase, followed by a maintenance phase at a dose of 3 μg/kg per week up to 5 years. Dose-limiting toxicity and pharmacokinetics were assessed during the initial 8 weeks. Of the nine patients enrolled, two patients had dose-limiting toxicities that resolved after discontinuation of treatment. The most frequently reported drug-related adverse events (DRAE) included pyrexia, decreased neutrophil and white blood cell counts, and arthralgia. Grade 3 DRAE included decreased neutrophil count. No deaths, serious adverse events and grade 4 adverse events were reported. Distant metastasis occurred in one patient. No apparent differences in area under the concentration-time curve and maximum observed serum concentration were observed between Japanese and historical non-Japanese pharmacokinetic data, suggesting no marked racial differences. No neutralizing antibody was detected in these patient samples. PEG IFN-α-2b was tolerated in Japanese patients, and eventually approved in Japan in May 2015 for adjuvant therapy in patients with stage III malignant melanoma. Because the number of patients was limited, further investigation would be crucial.

Phase 1 study of pembrolizumab (MK-3475; anti-PD-1 monoclonal antibody) in Japanese patients with advanced solid tumors

Background This phase I study evaluated the safety and tolerability, pharmacokinetics and pharmacodynamics, immunogenicity, and antitumor activity of pembrolizumab in Japanese patients with advanced solid tumors. Methods Following an initial dose and a 28-day rest (cycle 1), pembrolizumab was administered as an intravenous infusion at escalating doses (2 or 10 mg/kg) every 2 weeks (Q2W) until disease progression or unacceptable toxicity. Adverse events (AEs) were assessed using CTCAE v4.0, and tumor response was assessed using both RECIST v1.1 and immune-related response criteria (irRC). Full pharmacokinetic sampling was performed during cycle 1. Results Three patients received pembrolizumab at 2.0 mg/kg and seven at 10 mg/kg. No dose-limiting toxicities were observed during cycle 1. Eighty percent of patients experienced drug-related AEs (mostly grade 1 or 2); the most common drug-related AEs were nausea, malaise, pyrexia, and aspartate aminotransferase/alanine transaminase (AST/ALT) elevations (n = 2 each). No drug-related grade 4 or 5 AEs occurred. Immune-related AEs comprised grade 3 ALT elevation (n = 1), grade 3 AST elevation (n = 1), grade 1 pneumonitis (n = 1), and grade 1 thyroid-stimulating hormone elevation (n = 1). The safety and pharmacokinetic profiles of Japanese patients were similar to those previously reported for Caucasian patients. A partial tumor response was observed in one patient with non-small-cell lung cancer (NSCLC) and in one patient with melanoma. Conclusions Pembrolizumab at both 2 and 10 mg/kg Q2W was well tolerated in Japanese patients with advanced solid tumors and showed encouraging anti-tumor activity against melanoma and NSCLC.

Impact of sea-level rise on cross-shore sediment transport on fetch-limited barrier reef island beaches under modal and cyclonic conditions

A one-dimensional wave model is combined with an analytical sediment transport model to investigate the likely influence of sea-level rise on net cross-shore sediment transport on fetch-limited barrier reef and lagoon island beaches. The modelling considers if changes in the nearshore wave height and wave period in the lagoon induced by different water levels over the reef flat are likely to lead to net offshore or onshore movement of sediment. The results indicate that the effects of SLR on net sediment movement are highly variable and controlled by the bathymetry of the reef and lagoon. A significant range of reef-lagoon bathymetry, and notably shallow and narrow reefs, appears to lead hydrodynamic conditions and beaches that are likely to be stable or even accrete under SLR. Loss of reef structural complexity, particularly on the reef flat, increases the chance of sediment transport away from beaches and offshore.

Phase 1 pharmacokinetic study of the oral pan-AKT inhibitor MK-2206 in Japanese patients with advanced solid tumors

PURPOSE

MK-2206 is an oral, highly selective inhibitor of AKT. The safety, tolerability, pharmacokinetics (PK), and anti-tumor activity of MK-2206 was evaluated in Japanese patients with advanced solid tumors.

METHODS

Patients received a single oral dose of MK-2206 according to an every other day (QOD) dosing schedule or a once weekly (QW) dosing schedule in repeating 28-day treatment cycles, with a 7-day rest after only the first cycle. The dose-limiting toxicities (DLTs) were evaluated during Cycle 1. Full PK sampling was performed during Cycle 1.

RESULTS

Twenty-four patients were treated at 45 mg (n = 3) or 60 mg (n = 9) QOD or at 135 mg (n = 3) or 200 mg (n = 9) QW. One patient experienced a DLT at 60 mg QOD, and three patients experienced DLTs at 200 mg QW. No DLTs were observed at 45 mg QOD or at 135 mg QW. The DLTs included mucosal inflammation, hyponatremia, face edema, erythema multiforme, and hyperglycemia. Common adverse events related to MK-2206 included rash, an elevated insulin c-peptide level, stomatitis, pyrexia, eosinophilia, leukopenia, and hyperglycemia. PK differences in MK-2206 exposure were observed between Japanese patients and non-Japanese patients. The higher exposure in Japanese patients was likely caused by the relatively lower weight of Japanese patients versus non-Japanese patients. No tumor responses were observed, but six patients exhibited stable disease lasting longer than 4 months.

CONCLUSIONS

MK-2206 has an acceptable safety profile in Japanese patients with advanced solid tumors and warrants further investigation.

A multicentre phase II study of vorinostat in patients with relapsed or refractory indolent B-cell non-Hodgkin lymphoma and mantle cell lymphoma

Although initial rituximab-containing chemotherapies achieve high response rates, indolent B-cell non-Hodgkin lymphoma (B-NHL), such as follicular lymphoma (FL), is still incurable. Therefore, new effective agents with novel mechanisms are anticipated. In this multicentre phase II study, patients with relapsed/refractory indolent B-NHL and mantle cell lymphoma (MCL) received vorinostat 200 mg twice daily for 14 consecutive days in a 21-d cycle until disease progression or unacceptable toxicity occurred. The primary endpoint was overall response rate (ORR) in FL patients and safety and tolerability in all patients. Secondary endpoints included progression-free survival (PFS). Fifty-six eligible patients were enrolled; 50 patients (39 with FL, seven with other B-NHL, and four with MCL) were evaluable for ORR, and 40 patients had received rituximab-containing prior chemotherapeutic regimens. For the 39 patients with FL, the ORR was 49% [95% confidence interval (CI): 32·4, 65·2] and the median PFS was 20 months (95% CI: 11·2, 29·7). Major toxicities were manageable grade 3/4 thrombocytopenia and neutropenia. Vorinostat offers sustained antitumour activity in patients with relapsed or refractory FL with an acceptable safety profile. Further investigation of vorinostat for clinical efficacy is warranted.

Phase 1 pharmacokinetic study of MK-0646 (dalotuzumab), an anti-insulin-like growth factor-1 receptor monoclonal antibody, in combination with cetuximab and irinotecan in Japanese patients with advanced colorectal cancer

PURPOSE

The safety, tolerability, and pharmacokinetic (PK) interactions of MK-0646 in combination with cetuximab and irinotecan were investigated in Japanese patients with advanced colorectal cancer.

METHODS

Twenty patients were treated in the following study arms in combination with cetuximab and irinotecan: A [MK-0646 (10 mg/kg) weekly starting on Day 22], B [MK-0646 (15 mg/kg) on Day 8, followed by 7.5 mg/kg every 2 weeks], or C [MK-0646 (10 mg/kg) on Day 1 and weekly starting on Day 22]. Dose limiting toxicities (DLTs) were evaluated during a prespecified 4-week period in arms A and B. Full PK sampling was performed to evaluate the PK interactions.

RESULTS

One of the 6 evaluable patients in arm A developed a DLT (grade 3 hyperglycemia); no DLTs occurred in the 6 patients in arm B. Common treatment-related adverse events included leukopenia, neutropenia, dermatitis acneiform, paronychia, nausea, stomatitis, diarrhea, and decreased appetite. The co-administration of cetuximab and irinotecan with MK-0646 increased the MK-0646 AUC0-168h by 25 %, with MK-0646 accumulation from the previous dose contributing to the observed increase. The co-administration of MK-0646 with cetuximab and irinotecan did not affect the PK of cetuximab and irinotecan, but reduced the C max (from 16.8 to 13.0 ng/mL) and the AUC0-24h (by 13 %) of SN-38, the active metabolite of irinotecan.

CONCLUSIONS

The triple combination of MK-0646, cetuximab, and irinotecan was well tolerated in Japanese patients with advanced colorectal cancer. These results indicate a minimal potential for PK interactions between MK-0646 and cetuximab and between MK-0646 and irinotecan/SN-38.

Adult height and body mass index in relation to risk of total stroke and its subtypes: the circulatory risk in communities study

BACKGROUND

Several studies have reported that height and risk of stroke are inversely associated based on the hypothesis that height is a marker of childhood physical condition. However, a limited number of studies have taken account of the effect of current physical condition on the relationship between height and risk of stroke.

METHODS

We conducted a prospective cohort study of 12,222 40- to 69-year-old Japanese patients under systematic surveillance for stroke incidence. Because body mass index (BMI) is regarded as a surrogate marker of current physical condition for cardiovascular risk, we performed a stratified analysis of this risk based on BMI.

RESULTS

During the median 17-year follow-up, there were 565 incident strokes (326 ischemic and 186 hemorrhagic strokes) showing an inverse association between height and risk of stroke independent of classical cardiovascular risk factors. Compared with the lowest height group (<159 cm for men and <148 cm for women) as reference, the multivariable hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the highest height group (>166 cm for men and >154 cm for women) were 0.70 (95% CI 0.49-1.00; P = .043) for men and 0.44 (95% CI 0.27-0.70; P < .001) for women. When the analysis was restricted to those with BMI <23 kg/m(2), the associations were stronger for both hemorrhagic and ischemic stroke.

CONCLUSIONS

Height was found to be inversely associated with risk of stroke for middle-aged Japanese men and women, especially with lower BMIs. Our findings suggest that childhood social and physical conditions may contribute to the development of stroke in adulthood because height is a surrogate marker of these conditions.

Possible effects of diets on serum lipids, fatty acids and blood pressure levels in male and female Japanese university students

OBJECTIVES

To prepare a dietary recommendation for young Japanese for the prevention of coronary heart disease, we surveyed the dietary habits, serum lipids, serum fatty acids and blood pressure levels among male and female students.

METHODS

In this study, 175 male and 246 female university students were interviewed for the frequency of consumption of selected food items and the habit of skipping breakfast. Serum fatty acids were analyzed by gas chromatography.

RESULTS

The frequencies of consumption of dishes cooked with oil and intake of vegetables were higher in female students than in male students. Serum n-6 polyunsaturated fatty acids were slightly higher in females students than in male students while that of serum n-3 polyunsaturated fatty acids was 6.4% in both sexes. For both males and females, those who skipped breakfast at least once a week were less likely to consume vegetables and fruits than those who did not. Female students who skipped breakfast were also less likely to consume fish and had lower composition of n-3 polyunsaturated fatty acid and higher systolic and diastolic blood pressure levels than males. For female, the intake of milk and dairy products correlated inversely with systolic blood pressure levels and the intake of n-3 polyunsaturated fatty acids correlated inversely with diastolic blood pressure levels. For males, the intake of fruits and consumption of dishes cooked with oil correlated inversely with systolic and diastolic blood pressure levels.

CONCLUSION

Our findings suggest that increased intake of fish, milk and dairy products, fruits and vegetables from early adulthood and a regular dietary pattern are important to reduce the risk factors for coronary heart disease.

Alkaline phosphatase and risk of stroke among Japanese: the Circulatory Risk in Communities Study (CIRCS)

Although serum alkaline phosphatase (ALP) levels have been associated with mortality from all-cause and from either ischemic or hemorrhagic stroke, no study has been published of the associations between ALP and the incidence of stroke. We therefore examined the associations of ALP with risk of stroke among Japanese, stratified by drinking status because ALP is known as an enzyme affected by alcohol consumption. We conducted a prospective cohort study of 10,754 Japanese subjects (4098 men and 6656 women) aged 40-69 years and living in 4 communities under systematic surveillance for stroke incidence. During the 16-year follow-up, we documented 264 strokes (164 ischemic strokes and 69 hemorrhagic strokes) for men and 225 strokes (118 ischemic strokes and 89 hemorrhagic strokes) for women. There was a U-shaped association between ALP level and stroke incidence in both men and women, which was confined primarily to nondrinkers. For nondrinkers, higher ALP levels were associated with an elevated risk of ischemic stroke for men and of hemorrhagic stroke for women, whereas lower ALP levels were associated with elevated risks of ischemic and hemorrhagic strokes in both men and women. Our data indicate that not only higher, but also lower, serum ALP level may be a predictor for the risk of stroke in nondrinking men and women.

A wavelength modulation system for highly sensitive absorption spectroscopy

We developed a newly designed wavelength modulation (WM) system for highly sensitive absorption spectroscopy. In our system, the WM is realized by yawing an output mirror in a monochromator. In order to control an amplitude Δλ of the WM in a wide range, we employed a forced vibration of a permanent magnet driven by a magnetic field of a solenoid. Our system has an advantage of that the WM amplitude Δλ can be adjusted in extensively wide range from 0.08 nm to 11 nm only by tuning a driving frequency of the applying current to the solenoid, because we utilize a resonance phenomenon of the forced vibration for adjustment of the WM amplitude. By using our system, we measured WM absorption spectra of a Cu(2)O thin film and found clearly spectral structures for weak 2-4P excitonic resonances in the WM absorption spectra.

A multicenter phase II study of vorinostat in patients (pts) with relapsed or refractory indolent B-cell non-Hodgkin lymphoma (B-NHL) or mantle cell lymphoma (MCL)

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Background: Most pts with indolent B-NHL relapse even after rituximab-containing chemotherapy. Vorinostat is an orally active histone deacetylase (HDAC) inhibitor, and is under investigation as monotherapy or in combination regimens in various hematologic malignancies. It has been reported that the histone acetyltransferase genes (EP300 and CREBBP) are frequently mutated in NHL, suggesting the potential usefulness of HDAC inhibitors in its treatment. Methods: We conducted a phase 2 study to investigate the efficacy, safety and tolerability of vorinostat in pts with indolent B-NHL or MCL with the overall response rate (ORR) against follicular lymphoma (FL) as the primary endpoint. The primary hypothesis was to demonstrate the efficacy in FL pts as measured by the ORR. Assuming the true ORR with vorinostat of 50% and without vorinostat of less than 25%, 39 pts will provide 90% power to demonstrate an ORR>25%. Vorinostat was administered at the dose of 200 mg BID for 14 consecutive days in a 21-day cycle. The ORR and PFS were determined by an independent review panel in the Full Analysis Set (FAS) population. Results: A total of 56 pts with a median age of 60 years (range: 33 - 75) were enrolled, and 50 of them (39 with FL, 11 with other subtypes of indolent B-NHL or MCL) were included in the FAS population. The number of prior therapeutic regimens was 2 (range: 1 - 4) and 41 pts have previously received rituximab-based regimens.. The percentages of pts with FLIPI at low risk, intermediate risk and high risk were 41%, 39%, and 21%, respectively. The ORR in 39 pts with FL was 49% (95% CI: 32, 65), and the pre-specified statistical success criterion was met. The median PFS in 39 pts with FL was 17.5 months (range: 2, 22+), especially the median PFS in 19 responders with FL has not yet been reached. The major toxicities were hematologic and gastrointestinal ones, which were reversible and manageable. Grade 3/4 infection was observed in 2%. Conclusions: This phase 2 study demonstrated that oral vorinostat is an agent with sustained antitumor activity in pts with relapsed or refractory indolent B-NHL, with acceptable safety profiles, warranting further investigations.

Phase I and pharmacokinetic study of the oral histone deacetylase inhibitor vorinostat in Japanese patients with relapsed or refractory cutaneous T-cell lymphoma

A phase I study was conducted to evaluate the safety, tolerability, pharmacokinetics (PK) and efficacy of the oral histone deacetylase (HDAC) inhibitor vorinostat in Japanese patients with relapsed or refractory cutaneous T-cell lymphoma (CTCL). Six patients received vorinostat (400 mg p.o., once daily). Dose-limiting toxicities (DLT) were evaluated in all six patients during the 28 days of the first cycle. One of the six patients who received vorinostat developed a DLT (grade 4 thrombocytopenia). The most common drug-related adverse events included nausea (4/6, 67%), thrombocytopenia (4/6, 67%), hyperbilirubinemia (3/6, 50%) and vomiting (3/6, 50%). Most of these events were reversible and were resolved by supportive care and/or the interruption of vorinostat treatment. The safety and PK profiles of vorinostat in Japanese patients with CTCL did not appear to differ from those previously observed in non-Japanese and Japanese patients with advanced solid tumors. None of the patients achieved an objective response in this study. However, one unconfirmed partial response and two cases of sustained stable disease for 12 weeks or longer were observed among the six patients in the study. One of the three evaluable patients experienced pruritus relief. Vorinostat was well tolerated at a dose of 400 mg p.o. once daily and showed potential efficacy in Japanese patients with CTCL, warranting further investigation.

Trends in sudden cardiac death and its risk factors in Japan from 1981 to 2005: the Circulatory Risk in Communities Study (CIRCS)

OBJECTIVE

There is little evidence whether sudden cardiac death (SCD) is increasing in Asia, although the incidence of coronary heart disease among urban middle-aged Japanese men has increased recently. We examined trends in the incidence of SCD and its risk factors in the Circulatory Risk in Communities Study.

DESIGN AND SETTING

This was a population-based longitudinal study. Surveillance of men and women for SCD incidence and risk factors was conducted from 1981 to 2005.

SUBJECTS

The surveyed population was all men and women aged 30-84 years who lived in three rural communities and one urban community in Japan.

MAIN OUTCOME MEASURES

Trends in SCD incidence and its risk factors.

RESULTS

Age-adjusted and sex-adjusted incidence of SCD decreased from 1981-1985 to 1991-1995, and plateaued thereafter. The annual incidence per 100 000 person-years was 76.0 in 1981-1985, 57.9 in 1986-1990, 39.3 in 1991-1995, 31.6 in 1996-2000 and 36.8 in 2001-2005. The prevalence of hypertension decreased from 1981-1985 to 1991-1995, and plateaued thereafter for men and women. The age-adjusted prevalence of current smoking for men decreased while that of diabetes mellitus increased for both sexes from 1981-1985 to 2001-2005.

CONCLUSIONS

The incidence of SCD decreased from 1981 to 1995 but was unchanged from 1996 to 2005. Continuous surveillance is necessary to clarify future trends in SCD in Japan because of an increasing incidence of diabetes mellitus.

Phase I study for ridaforolimus, an oral mTOR inhibitor, in Japanese patients with advanced solid tumors

Purpose

Ridaforolimus is a non-prodrug mTOR inhibitor. The safety, pharmacokinetics (PK), and antitumor activity of oral ridaforolimus were assessed in Japanese patients with refractory solid tumors.

Methods

Ridaforolimus (20 or 40 mg) was administered as a single dose on Day 1, followed by once daily dosing five times a week for a 3-week cycle beginning on Day 8. Full PK sampling was performed on Days 1 and 26.

Results

Thirteen patients (7 at 20 mg and 6 at 40 mg) were enrolled. The median treatment duration was 82 days. The most common drug-related adverse events were stomatitis, hypertriglyceridemia, and proteinuria. Two patients had dose-limiting toxicities (grade 3 stomatitis at 20 mg, and grade 3 anorexia and vomiting at 40 mg). Four patients had grade 1 interstitial pneumonitis. Ridaforolimus in the whole blood was rapidly absorbed and slowly eliminated with a half-life of approximately 56–58 h after a single dose. Two patients (with non-small cell lung cancer and angiosarcoma, respectively) achieved a partial response, and five patients (one with thymic cancer and four with soft tissue sarcomas) had a stable disease for ≥16 weeks.

Conclusions

Ridaforolimus was well tolerated up to a dose of 40 mg in Japanese patients. Preliminary evidence of antitumor activity was observed for patients with solid tumors. Further investigation at this dose is warranted.

Chronic kidney disease and drinking status in relation to risks of stroke and its subtypes: the Circulatory Risk in Communities Study (CIRCS)

BACKGROUND AND PURPOSE

Several epidemiological studies have established an association between chronic kidney disease (CKD), based on estimated glomerular filtration rate (GFR), and risk of stroke. However, sex-specific evidence for the relationship between CKD and risk of stroke and its subtypes is still limited.

METHODS

We conducted a prospective cohort study of 12 222 Japanese men and women age 40 to 69 years living in 4 communities under systematic surveillance of stroke incidence to determine the relationship between CKD and risk of stroke and its subtypes.

RESULTS

During the 17-year follow-up, there were 566 strokes (327 ischemic and 186 hemorrhagic strokes). GFR was inversely associated with age- and community-adjusted risk of total stroke for both men and women. Compared with the reference group without CKD (GFR ≥60 mL/min per 1.73m(2)), the adjusted risks of total stroke for subjects with CKD (GFR <60 mL/min per 1.73m(2)) were 1.63 (1.22-2.17) for men and 1.51 (1.13-2.02) for women. Excess risk of stroke associated with CKD was identified primarily for hemorrhagic stroke among men and for ischemic stroke among women. After adjustment for traditional cardiovascular risk factors, associations remained statistically significant. When stratified by drinking status, excess risk of hemorrhagic stroke with CKD was confined to drinkers; adjusted risks were 4.18 (2.31-7.57) for men and 7.00 (1.92-25.56) for women.

CONCLUSIONS

CKD was associated with increased risk of hemorrhagic stroke for men, and of ischemic stroke for women. This sex difference may partly be explained by the difference in prevalence of drinkers between men and women.

Low-density lipoprotein cholesterol and risk of coronary heart disease among Japanese men and women: the Circulatory Risk in Communities Study (CIRCS)

OBJECTIVE

The objective of this study was to assess the association between serum LDL-cholesterol levels and risk of coronary heart disease (CHD) among Japanese who have lower means of LDL-cholesterol than Western populations.

METHODS

The predictive power of estimated serum LDL-cholesterol levels in casual blood samples for risk of CHD was evaluated among residents from four Japanese communities participating in the Circulatory Risk in Communities Study (CIRCS). A total of 8131 men and women, aged 40 to 69 years with no history of stroke or CHD, completed baseline risk factor surveys between 1975 and 1987. By 2003, 155 cases of incident CHD (myocardial infarction, angina pectoris and sudden cardiac death) had been identified.

RESULTS

Mean LDL-cholesterol values were 99.4 mg/dL for men and 109.4 mg/dL for women. The crude incidence rate (per 100,000 person-years) of CHD was 152.0 for men and 51.9 for women. The respective multivariable hazard ratios for ≥ 140 mg/dL versus <80mg/dL LDL-cholesterol were 2.80 (95% confidence interval: 1.59 to 4.92) for total CHD, 3.83 (1.78-8.23) for myocardial infarction, 4.07 (2.02-8.20) for non-fatal CHD, and 1.24 (0.44-3.47) for fatal CHD.

CONCLUSION

Serum LDL-cholesterol levels ranging from around 80 mg/dL to 200mg/dL were positively associated with risk of CHD in a Japanese population.

Nocturnal intermittent hypoxia and C reactive protein among middle-aged community residents: a cross-sectional survey

BACKGROUND

There are conflicting results for the association between obstructive sleep apnoea and raised C reactive protein (CRP) levels. A study was undertaken to investigate whether nocturnal intermittent hypoxia, a surrogate marker for obstructive sleep apnoea, was associated with CRP levels among a community-dwelling Japanese population.

METHODS

Among participants in the Circulatory Risk in Communities Study (CIRCS), 1422 male and 2466 female community residents aged 40-69 years were tested during sleep. No nocturnal intermittent hypoxia, mild nocturnal intermittent hypoxia and moderate to severe nocturnal intermittent hypoxia were defined using 3% oxygen desaturation index cut-off points at 5 and 15 events/h, respectively. High-sensitivity CRP levels were measured using a latex particle-enhanced immunonephelometric assay. Multivariate analysis was adjusted for age, sex, body mass index, smoking status, current alcohol intake, hypertension, hypercholesterolaemia, diabetes mellitus and menopausal status for women.

RESULTS

Multivariable-adjusted mean CRP levels among men were 0.70 mg/l (95% CI 0.65 to 0.75) for no nocturnal intermittent hypoxia, 0.82 mg/l (95% CI 0.74 to 0.89) for mild nocturnal intermittent hypoxia and 0.84 mg/l (95% CI 0.70 to 1.00) for moderate to severe nocturnal intermittent hypoxia (p for trend=0.03). The values for women were 0.59 mg/l (95% CI 0.57 to 0.62), 0.66 mg/l (95% CI 0.59 to 0.73) and 0.82 mg/l (95% CI 0.62 to 1.03), respectively (p for trend=0.008). Compared with no nocturnal intermittent hypoxia, the prevalence of a high CRP level (>or=1.0 mg/l) was 1.4-1.7-fold higher for mild to severe nocturnal intermittent hypoxia in both sexes.

CONCLUSIONS

Nocturnal intermittent hypoxia is associated with raised serum CRP levels among middle-aged Japanese subjects.

Ten-year evaluation of homogeneous low-density lipoprotein cholesterol methods developed by Japanese manufacturers. Application of the Centers for Disease Control and Prevention/Cholesterol Reference Method Laboratory Network lipid standardization protocol

AIM

The risk index for atherosclerotic cardiovascular diseases in the Japanese metabolic syndrome-focused health checkup program was changed from total cholesterol (TC) to low-density lipoprotein cholesterol (LDL-C). We discuss the validity of this change with respect to standardization.

METHODS

The beta-quantification procedure of the Centers for Disease Control and Prevention (CDC) uses the LDL-C reference value as a target. Clinical laboratories and commercial manufacturers use homogeneous LDL-C methods for standardization. (A) For clinical laboratories, LDL-C in 648 samples requested from 108 hospitals was analyzed. (B) Manufacturers participated in the CDC/Cholesterol Reference Method Laboratory Network LDL-C standardization protocol. The standardization was conducted with a performance follow-up for the 10-year period from 1998 to 2008 at 2-year intervals, 6 times.

RESULTS

(A) In clinical laboratories, acceptable LDL-C levels within ±4% of the CDC's criteria remained 70.4%, 456 of 648 subjects. Negative maximum bias deviating from the LDL-C target value was -35.8%, -52.5 mg/dL, and positive maximum bias was +24.5%, +32.3 mg/dL. (B) For manufacturers, the standardization achievement rate of the analytical reagent/instrument/calibrator system in the last four standardizations from 2002 to 2008 remained on average 66.6%, far lower than the level required.

CONCLUSIONS

The standardization achievement rate of homogeneous LDL-C methods was much low-er than that of TC. TC should still be used as a risk index for atherosclerotic cardiovascular diseases. The standardization achievement rate of homogeneous LDL-C should be maintained at 100%, at least using samples with normal lipoprotein profiles. The accuracy and specificity of LDL-C should be further improved before practical and clinical use.

Towards a compatible probiotic-antibiotic combination therapy: assessment of antimicrobial resistance in the Japanese probiotics

AIM

To determine the antimicrobial resistance of the Japanese probiotics available in the market without a pharmacist's supervision.

METHODS AND RESULTS

A total of 43 isolates were obtained from 40 samples of probiotics (30 dairy products and 10 products in tablet form). Isolates were identified using 16S rRNA gene sequencing and tested for their susceptibility to 14 antimicrobials. They were screened using PCR for some antibiotic resistance genes. Inactivation of cefepime, clarithromycin and vancomycin by different inocula of 11 strains was evaluated using the antibiotic inactivation bioassay. None of the dairy probiotics showed a level of constitutive resistance or carried inducible resistance genes, making them suitable to be administrated with macrolides. Among the probiotics in tablet form only Enterococcus faecium strains carrying the msrC gene showed an MIC(90) of 4 μg ml(-1). Extended-spectrum β-lactams, tetracyclines and ampicillin exhibited powerful germicidal activity against the vast majority of the probiotic strains.

CONCLUSIONS

There is a limited choice of the Japanese probiotics that can be administered with clinically used antibiotics.

SIGNIFICANCE AND IMPACT OF THE STUDY

Japanese probiotics are widely distributed all over the world. Through the findings of our study, we have attempted to provide guidance for clinicians interested in using the Japanese probiotics in combination with antibiotics.

[Trends in cardiovascular risk factors among urban Japanese male employees from 1977 to 2008]

OBJECTIVE

In Japan, there is growing concern that employees' health condition has been worsening under the severe labor conditions of the continuing recent deep recession. To determine trends in the prevalence of cardiovascular risk factors among employees, we analyzed 32 yr of systematic surveillance of urban Japanese employed men.

SUBJECTS AND METHODS

The surveyed population included male employees aged 40 to 59 yr who worked for four companies, a trading company, two banks and a company maintaining expressways in Osaka. Surveillance of cardiovascular risk factors was conducted from 1977 to 2008. We examined the annual mean values of systolic blood pressure, diastolic blood pressure, body mass index, and total serum cholesterol, and the prevalence of hypertension, obesity, hypercholesterolemia, smoking, alcohol drinkers, and high risk individuals who had two or more risk factors: (high blood pressure, high glucose and dyslipidemia).

RESULTS

The total number of employees aged 40-59 yr increased from 822 in 1977 to 2,651 in 1992, but then declined gradually to 1,455 in 2008. Among men aged 40-49 and 50-59, the prevalence of hypertension decreased from 25% and 39% in 1977 to 14% and 23% in 1992, respectively. However, the respective prevalence of hypertension started to rise thereafter to 29% and 47% in 2008, accompanied by an increase in blood pressure levels and the prevalence of antihypertensive medication use. Mean body mass index and the prevalence of obesity showed significant upward linear trends from the mid-1980's to 2008. Therefore, we speculate that the increase in blood pressure levels seen after the early 1990's associated with an increase in obesity. However the proportion of hypertension among non-overweight men also increased between the early 1990's and 2008, suggesting other factors are also involved in the increase of hypertension. The prevalence of hypercholesterolemia and high-risk individuals with obesity also increased in recent years. Mean total cholesterol level showed a linear increase from 195 mg/dl for men aged 40-49 and 196 mg/dl for men aged 50-59 in 1977 to 204 mg/dl and 207 mg/dl in 2008, respectively. The prevalence of high-risk individuals with obesity was 13% for men aged 40-49 and 15% for men aged 50-59 in 2008. Among men aged 50-59, the prevalence of non-overweight high-risk individuals became higher than that of high-risk individuals with obesity over time.

CONCLUSIONS

Although these findings were limited to the study companies, our data support evidence that Japanese employees have become increasingly at risk of cardiovascular diseases under the severe working conditions experienced since the 1990's. It is important to improve working conditions as well as personally control risk factors from the point of public health.

Nocturnal intermittent hypoxia and the development of type 2 diabetes: the Circulatory Risk in Communities Study (CIRCS)

AIMS/HYPOTHESIS

Although the associations between obstructive sleep apnoea and type 2 diabetes mellitus have been reported in cross-sectional design studies, findings on the prospective association between the two conditions are limited. We examined prospectively the association between nocturnal intermittent hypoxia as a surrogate marker of obstructive sleep apnoea and risk of type 2 diabetes.

METHODS

A total of 4,398 community residents aged 40 to 69 years who had participated in sleep investigation studies between 2001 and 2005 were enrolled. Nocturnal intermittent hypoxia was assessed by pulse-oximetry and defined by the number of oxygen desaturation measurements < or =3% per h, with five to <15 per h corresponding to mild and 15 events or more per h corresponding to moderate-to-severe nocturnal intermittent hypoxia, respectively. The development of type 2 diabetes was defined by: (1) fasting serum glucose > or =7.00 mmol/l (126 mg/dl); (2) non-fasting serum glucose > or =11.1 mmol/l (200 mg/dl); and/or (3) initiation of glucose-lowering medication or insulin therapy. Multivariable model accounted for age, sex, BMI, smoking status, current alcohol intake, community, borderline type 2 diabetes, habitual snoring, excessive daytime sleepiness, sleep duration and (for women) menopausal status.

RESULTS

By the end of 2007, 92.2% of participants had been followed up (median follow-up duration [interquartile range] 3.0 [2.9-4.0] years) and 210 persons identified as having developed diabetes. The multivariable-adjusted hazard ratio (95% CI) for developing type 2 diabetes was 1.26 (0.91-1.76) among those with mild nocturnal intermittent hypoxia and 1.69 (1.04-2.76) among those with moderate-to-severe nocturnal intermittent hypoxia (p = 0.03 for trend).

CONCLUSIONS/INTERPRETATION

Nocturnal intermittent hypoxia was associated with increased risk of developing type 2 diabetes among middle-aged Japanese.