Exploring a Suitable Marker of Glycemic Response to Dulaglutide in Patients with Type 2 Diabetes: A Retrospective Study

INTRODUCTION

Previous studies suggested that β-cell function markers such as fasting and postprandial serum C-peptide and C-peptide increment (FCPR, PCPR, and ΔCPR, respectively) may be useful in estimating glycemic response to glucagon-like peptide-1 receptor agonists. However, it remains elusive whether baseline glycemic control confounds these markers. Here we aimed to identify the least confounded β-cell function markers and investigate whether these markers could predict glycemic response to dulaglutide.

METHODS

We evaluated FCPR, PCPR, and ΔCPR levels in patients with type 2 diabetes who initiated dulaglutide treatment after a standardized meal tolerance test (MTT). We first investigated the confounding effects of baseline HbA1c on β-cell function markers using Pearson's correlation test. Then, we evaluated the association between each β-cell function marker and glycemic response (HbA1c change 0-6 months) to dulaglutide using generalized linear model and logistic regression analysis with adjustment for baseline HbA1c.

RESULTS

In 141 patients, baseline HbA1c was significantly inversely correlated with PCPR and ΔCPR (P < 0.01 for both) but not with FCPR (r = 0.02; P = 0.853), suggesting that FCPR was the marker least confounded by baseline glycemic control. Of all patients, 59 continued dulaglutide for at least 6 months without initiating any additional glucose-lowering medications. Mean ± SE HbA1c change 0-6 months was - 1.16 ± 0.17% (P < 0.001 vs. baseline). The β-cell function markers were significantly associated with HbA1c change 0-6 months in the generalized linear model. FCPR was also a significant predictor for achieving a reduction in HbA1c of at least 1% (P = 0.044) with an area under the receiver operating characteristic curve of 0.83 (sensitivity = 0.81 and specificity = 0.79).

CONCLUSION

Fasting and meal-induced C-peptide levels are associated with glycemic response to dulaglutide, among which FCPR is least confounded by baseline glycemic control, suggesting its utility as a marker for glycemic response to dulaglutide.

Efficacy and safety of live varicella zoster vaccine in diabetes: a randomized, double-blind, placebo-controlled trial

AIMS

To elucidate varicella zoster virus (VZV)-specific cell-mediated immunity and humoral immunogenicity against live attenuated Oka varicella zoster vaccine concurrently vaccinated with 23-valent pneumococcal polysaccharide vaccine (PPSV23) in elderly people with diabetes mellitus.

METHODS

This double-blind randomized controlled single-centre study of 60-70-year-old people with diabetes compared immunity and safety profiles 3 months after one dose of varicella zoster vaccine or placebo. PPSV23 was immunized simultaneously. Primary analysis evaluated cell-mediated immunity using the VZV skin test. Secondary analyses were a VZV interferon-γ enzyme-linked immunospot (ELISPOT) assay and immunoadherence haemagglutination test. Adverse experiences were recorded using diary questionnaires.

RESULTS

By intent-to-treat analysis, 27 participants with diabetes who had been administered the vaccine were compared with 27 participants who were given a placebo. Changes in skin test scores were 0.41 ± 0.80 and 0.11 ± 0.93 (P = 0.2155), and geometric mean fold rises of the ELISPOT counts were 1.2 [95% confidence interval (CI) 0.2, 7.9] and 1.2 (95% CI 0.2, 7.3) (P = 0.989) in the vaccine and placebo groups, respectively. The geometric mean titre did not increase 3 months after vaccination in either group. No vaccination-related severe adverse experience was reported and no participant developed herpes zoster.

DISCUSSION

Our previous results demonstrated that varicella zoster vaccine safely enhanced VZV-specific immunity in elderly people with or without diabetes. The results of this study showed that varicella zoster vaccine can be used safely, but it cannot boost virus-specific immunity in elderly people with diabetes when administered with concurrent PPSV23. Alternative strategies are needed to prevent VZV-associated diseases in this population.

A propensity score-matching analysis of transthoracic echocardiography and abdominal ultrasonography for the detection of abdominal aortic aneurysms

INTRODUCTION

We previously reported that the prevalence of abdominal aortic aneurysms (AAAs) was higher in patients undergoing scheduled transthoracic echocardiography (TTE) than in patients undergoing abdominal ultrasonography (AUS); however, intergroup patient backgrounds differed significantly in that report.

PURPOSE

We tested the hypothesis that TTE could detect AAA as effectively as AUS.

DESIGN

A propensity score-matching analysis of a cross-sectional study was adopted as the design for this study.

METHODS

We enrolled 7,619 and 15,433 patients scheduled to undergo TTE with additional evaluation of abdominal aorta at the end of the routine study and AUS, respectively, from 2009 to 2010 in our hospital, as reported. A propensity score for profiles of patients who underwent TTE or AUS was developed to adjust for potential confounding bias. Consequently, 4,388 patients in each group were matched for analyses.

RESULTS

In propensity-matched patients, AAA was detected in 59 patients of the TTE group and in 48 patients of the AUS group; the prevalence of AAA detection did not differ significantly between TTE and AUS groups (P = 0.331). Positive associations were observed between AAA detection and male sex (adjusted odds ratio [OR]: 3.25; 95% confidence interval [CI], 2.05–5.15; P < 0.001), older age (adjusted OR: 1.029; 95% CI: 1.01–1.04; P < 0.001), and the presence of ischemic heart disease (adjusted OR: 1.78; 95% CI: 1.04–3.03; P = 0.033) and hypertension (adjusted OR: 2.16; 95% CI: 1.38–3.37; P = 001).

CONCLUSION

TTE detected AAA with comparable efficacy as AUS in propensity-matched groups who underwent scheduled TTE and AUS.

Clinical heterogeneity of adult Japanese diabetes depending on titers of glutamic acid decarboxylase autoantibodies

Aims/Introduction:  We examined whether levels of glutamic acid decarboxylase autoantibodies (GADAb) might show the clinical heterogeneity of adult Japanese diabetes.

MATERIALS AND METHODS

  In this cross-sectional study, the serum levels of GADAb were measured in a total of 1857 consecutive adult diabetic patients aged 20 years or older. The patients with positive GADAb, arbitrarily defined as ≥1.5 U/mL, were divided into quartiles according to the number of patients. The age- and sex-matched diabetic patients without GADAb were selected as a control group.

RESULTS

  A total of 103 (5.5%) of the diabetic patients had GADAb, and showed higher HbA1c and serum high-density lipoprotein (HDL) cholesterol levels, lower body mass index (BMI), urinary C-peptide immunoreactivity (CPR), serum triglycerides (TG) and uric acid (UA) levels, and lower prevalence of metabolic syndrome than the control group (P < 0.05). Quartiles 3 and 4 (i.e. GADAb ≥4.6 U/mL) showed a higher HbA1c level, lower BMI, urinary CPR, serum TG and UA levels, quartile 2 (2.5 ≤ GADAb < 4.6 U/mL) showed a lower BMI level than the control group (P < 0.05). Among the clinical parameters, we observed significant upward trends for both HbA1c and serum HDL cholesterol levels, and significant downward trends for BMI, serum TG and UA, urinary CPR levels, and prevalence of metabolic syndrome across GADAb quartiles (P < 0.05 for trend).

CONCLUSIONS

  These results show that the clinical phenotype of adult Japanese diabetes correlates with GADAb levels, and that patients with GADAb (≥2.5 U/mL) show different characteristics from those without GADAb, although further longitudinal studies are required. (J Diabetes Invest, doi: 10.1111/j.2040-1124.2011.00190.x, 2011).

Ratio of peripheral blood absolute lymphocyte count to absolute monocyte count at diagnosis is associated with progression-free survival in follicular lymphoma

The prognosis of follicular lymphoma (FL) is significantly associated with host immunity and tumor microenvironment. Lymphopenia has been identified as a negative prognostic factor for FL. The association between monocytosis and progression-free survival (PFS) in FL remains controversial. It is unknown whether the ratio of peripheral blood absolute lymphocyte count to absolute monocyte count (ALC/AMC) at diagnosis is associated with FL prognosis. We studied 99 consecutive patients with FL who were treated with rituximab-containing chemotherapy at Kitano Hospital or Kyoto University Hospital between 2000 and 2012. We analyzed individual variables associated with the ALC/AMC ratio before treatment, as well as known prognostic factors of FL, and found that an ALC/AMC ratio of 4.7 was the best cut-off value for PFS. Kaplan-Meier analysis showed that a decreased ALC/AMC ratio was associated with inferior PFS (P = 0.022). Multivariate analysis showed that a decreased ALC/AMC ratio was a significant poor prognostic factor independent of other variables (hazard ratio, 2.714; 95 % confidence interval, 1.060-6.948; P = 0.037). The ALC/AMC ratio before treatment may be a significant prognostic factor predicting PFS of FL.

The Eradication of Helicobacter pylori does not Affect Glycemic Control in Japanese Subjects with Type 2 Diabetes

Since infection with Helicobacter pylori has been suggested to play a pathogenic role in diabetes mellitus, we investigated whether eradication therapy for H. pylori might affect glycemic control in Japanese subjects with type 2 diabetes. A total of 72 subjects (55 males, 17 females; aged 63.7 years) with type 2 diabetes who received eradication therapy for H. pylori were included. The change of their blood glycosylated hemoglobin (A1C) levels 3 months before (−3 m) the H. pylori eradication, as well as 3 months (3 m) and 6 months (6 m) after were evaluated. Their A1C levels did not show any significant change after therapy {6.9 [0.1]% (−3 m) to 7.0 [0.1]% (3 m); P = 0.3, 7.0 [0.1] (6 m); P = 0.3}. Our findings suggest that the eradication therapy for H. pylori does not, at least profoundly, affect glycemic control in Japanese subjects with type 2 diabetes.

Possible link of pioglitazone with bladder cancer in Japanese patients with type 2 diabetes

We retrospectively examined the frequency of bladder cancer in Japanese patients with type 2 diabetes in relation to use of pioglitazone. Among a total of 663 patients identified to be taking pioglitazone, 9 had bladder cancer (1.36%). Overall the hazard ratio of 1.75 [95% CI: 0.89-3.45] for pioglitazone for bladder cancer was not significant. However the prevalence of bladder cancer was 2.10% in patients taking pioglitazone for less than 24 months which was significant increased (HR 2.73 [95% CI: 1.11-6.72]).

Usefulness of serum cystatin C in Japanese patients with type 2 diabetes mellitus and nephropathy

We examined usefulness of serum cystatin C to detect chronic kidney disease (CKD) stage >or=3, which was defined by Modification of Diet in Renal Disease formula. Serum cystatin C could detect CKD stage >or=3 with high efficacy in 289 Japanese patients with type 2 diabetes and nephropathy.

[Development of a Web-based laboratory data browser integrated with heterogeneous clinical information]

OBJECTIVE

To demonstrate the feasibility of a Web-based laboratory data browser integrated with heterogeneous clinical information in a hospital setting.

METHODS

A Java-based web application was developed in-house, using free open-source software. The server side manages queries to heterogeneous hospital databases containing patient data. Order entry information including laboratory test results, drug prescriptions, injection orders, physiological test orders and, imaging test orders, was retrieved from a replication database, and integrated with nursing data from a nursing system database. The result was visualized in a time-series table format, and accessed by web browsers on computers connected to the hospital intranet.

RESULTS

The laboratory data browser system achieved practical response times over huge databases (> 90 million records). The medical personnel accepted the system well, and applied the system to various clinical situations.

CONCLUSION

Integrating heterogeneous data from hospital databases in a Web-based laboratory data browser is a practical approach. Presenting relevant medical information simultaneously added value to the laboratory data, and may promote better medical management.

[Combining the use of dipstick protein and specific gravity accurately predicts pathological proteinuria in Japan]

Dipstick urine analysis is the most common and convenient examination in routine health care. The criteria for abnormal proteinuria is a level of more than (+). However, the interference of urine concentration should be considered in the judgement.

OBJECTIVE

The purpose is to demonstrate the effect of the combined use of specific gravity (SG) in the dipstick judgement to evaluate pathological proteinuria in Japanese people.

METHODS

The hospital laboratory database of Kitano hospital was searched for urine samples, for patients consulted at our nephrology department from Oct. 2004 to Sep. 2005 (n=1767), and simultaneously assayed for dipstick proteinuria(DSP), SG, urinary protein, urine creatinine (UC) and urinary protein-creatinine ratio (UPC ratio). To generate a model table, samples were stratified according to DSP and SG values. A DSP versus SG matrix (5 x 6)was created, and then all 30 cells were color-coded by the pathological proteinuria proportion (white: < 5%, gray: 5-95%, black: <95%).

RESULTS

SG was positively associated with UC. In the patients, SG < or = 1.005 and DSP(-), 12/70 (17.1%) was > or =300 mg/gCr. Moreover in the patients, both 1.005 < SG < or = 1.010 and DSP(+/-), 21/32 (65.6%) had pathological proteinuria. We confirmed the consistency for this combination table in the urine samples of another 1111 out-patients. Moreover, the area under the curve in DSP(+/-) suggests that the patients whose SG was < or = 1.011 might have pathological proteinuria (sensitivity; 82.1%, specificity; 89.3%).

CONCLUSION

We recognized that the combination of DSP and SG enhances a more accurate proteinuria judgement. DSP(- approximately +/-) in diluted urine (SG < or = 1.1011) has the potential for pathological proteinuria. Therefore, diluted urine samples should be re-examined.

Health effects and exposure assessment of aerosolized pentamidine handlers

Nurses administering aerosolized pentamidine (AP) were studied to determine any effect AP may be having on their health. Exposure was determined by each nurse's self-report of treatment given as recorded in a daily log and personal and area pentamidine sampling. Outcome measures were self-reported symptoms recorded in a daily log and peak expiratory flow rates (PEFR) and cross-shift and cross-week pulmonary function tests (PFTs). Results revealed no dose-response effect of pentamidine exposure on cross-shift and cross-week PFTs. However, declines in cross-shift PEFRs, diffusion capacities, and increased symptom complaints were observed for a subset of the study population. This suggested that outcomes were modulated by host factors (history of hay fever and allergy) as well as exposure doses. Treatment both efficacy in containing fugitive AP aerosol was also corroborated as a means of minimizing worker exposure.

Abnormal facilitative glucose transporter gene expression in human islet cell tumors

Our previous studies have shown that increased expression of GLUT1/erythrocyte and GLUT3/brain type glucose transporter genes in human tumors is associated with cellular transformation. We have now determined the levels of messenger RNAs (mRNAs) encoding these two glucose transporter isoforms as well as that of GLUT2/liver isoform in insulin-, glucagon-, and gastrin-secreting islet cell tumors. Northern blot analysis and reverse transcriptase-polymerase chain reaction revealed the presence of GLUT1 and GLUT3 mRNA in all human islet cell tumors and normal islets examined. In contrast, GLUT2 mRNA, which is present at high levels in normal islets, was not detected in insulinomas or other types of islet cell tumors. These results imply that GLUT1 and GLUT3 are primarily responsible for glucose uptake by these tumors.

Oral erythromycin prophylaxis against Streptococcus pyogenes infection in penicillin-allergic military recruits: a randomized clinical trial

Historically, military recruits have required benzathine penicillin G to prevent epidemics of Streptococcus pyogenes. In this randomized clinical trial, low-dose oral erythromycin was evaluated as an alternative for prophylaxis against group A beta-hemolytic streptococci in penicillin-allergic recruits. US Marine Corps recruits (186) reporting penicillin allergy were randomly given either oral erythromycin (250 mg twice a day) or a vitamin (one tablet daily) for 60 days. Evidence of infection was defined as a two-dilution rise in anti-streptolysin O titer. The erythromycin group had a significantly lower risk of S. pyogenes infection than did the vitamin group (relative risk 0.44; 95% confidence interval, 0.22-0.89). There was no significant difference among the treatment groups in isolation of group A beta-hemolytic streptococci from throat cultures. Low-dose oral erythromycin appears as effective as benzanthine penicillin G in preventing S. pyogenes infection.

Interrelationships between blood pressure, sodium, potassium, serum cholesterol, and protein intake in Japanese

Interrelationships among blood pressure (BP), sodium (Na), potassium (K), dietary protein, and serum cholesterol level (Chol) were examined in 62% (1120) of 1818 Japanese inhabitants of both sexes aged over 30 years who lived in a rural village in Japan. Fasting single-spot urine specimens were collected in the morning to measure Na, K, urea nitrogen (UN), inorganic sulfate (SO4), and creatinine (Cr). The Cr ratios of Na, K, UN, SO4, Na/K, and SO4/UN were analyzed by multiple regression analysis to determine independent associations with BP together with age, obesity index, hematocrit (Hct), Chol, triglyceride (TG), and fasting serum glucose level (Glu). Except for Na/Cr in men, Na/Cr and Na/K were found to be independently and positively related to BP, particularly to systolic BP (SBP). In contrast, K/Cr and SO4/UN (an index related to the dietary score of sulphur-containing amino acids derived mainly from animal protein) were both negatively associated with SBP, and UN/Cr (an index of total protein intake) was positively associated with SBP in men. Chol was linked to BP negatively in men but positively in women. Age, obesity index, TG, and Hct were generally positively and significantly related to BP in both sexes. The results confirmed on epidemiological grounds the positive link of Na and the negative link of K to BP within a single population in Japan. They further suggest, although only in men, that there is a negative relationship of Chol and dietary animal protein with BP.

Dietary risk factors of stroke and hypertension in Japan -- Part 2: Validity of urinalysis for dietary salt and protein intakes under a field condition

Utility of urinalysis as a method for estimating dietary salt and protein intakes was examined in volunteers from farming and fishing villages in Japan and the data was compared to findings in a survey on diets. We found that partial urine samples and even a fasting single spot urine in the a.m. could serve as valid substitutes for 24-hour (hr) urine collections. Further, significant correlations were obtained between levels of salt in the diet estimated by survey interviews and urinary sodium (Na) and between interview-estimated dietary total or animal protein and urinary inorganic sulfate (SO4). In comparative studies between farming and fishing villages, almost the same findings, higher salt in a farming village and higher animal protein in a fishing village, were obtained in the urinalysis and the survey on diets. These findings clearly indicate that urinalysis, as a method for estimating dietary salt and protein intake in population surveys, has distinct advantages.

Dietary risk factors of stroke and hypertension in Japan -- Part 1: Methodological assessment of urinalysis for dietary salt and protein intakes

In our attempt to design a method which would be more reliable than dietary survey interviews when estimating salt and protein intakes in a population survey, a urinalysis-related study was done on volunteers. Urinary sodium (Na), urea nitrogen (UN) and inorganic sulfate (SO4), all indices of dietary salt, protein and sulfoamino acids, respectively, were confirmed to reflect the nutritional condition. Interaction between salt and protein was not observed at least at the dietary levels used in the present study (for salt, 0.33 and 0.1 g/kg body weight/day; for protein, 1.6 and 0.7 g/kg body weight/day). Excretion of components was delayed several days or more after dietary ingestion, and nutritional estimation by urinalysis, therefore, may not be so much affected by daily variables in the diet intake. Further, partial urine samples proved to have a highly significant correlation with 24-hour (hr) urine, as for urinary Na, potassium (K), SO4, UN and their creatinine (Cr) ratios, thus indicating the availability of partial urine samples as substitutes for 24-hr urine specimens. Thus, urinalysis is a more readily facilitated, more scientific and more quantitative method for epidemiological nutritional surveys.

Dietary risk factors of stroke and hypertension in Japan -- Part 3: Comparative study on risk factors between farming and fishing villages in japan

General medical examinations were performed in two rural areas of Shimane Prefecture in Japan, one was a farming village and the other a fishing village where incidences of death due to stroke differed, higher in the former and lower in the latter. Comparisons were made on salt and protein intake by analyzing the fasting single spot urine collected in the morning and by blood tests. Urine samples were analyzed for sodium (Na), potassium (K), urea nitrogen (UN), inorganic sulfate (SO4) and creatinine (Cr) and blood samples for cholesterol (Chl), triglyceride (TG), hematocrit (Ht) and hemoglobin (Hb). Blood pressure, Na/Cr, Na/K and Ht were higher in the farming village and K/Cr, UN/Cr, SO4/Cr, SO4/UN, Chl and TG were higher in the fishing village. These findings indicate the higher salt intake and lower intake of K, animal protein and fat in the farming village. This typical dietary pattern of the Japanese may explain the higher incidence of hypertension and stroke in the farming village.

Effect of acute arterial hypertension in stroke-prone and stroke-resistant SHR

Acute transient hypertension by norepinephrine was loaded to stroke-resistant (SHRSR), stroke-prone (SHRSP), and normotensive Wistar Kyoto (WK) rats. (SHRSP were most sensitive to norepinephrine in young pre-hypertensive group.) Its effects on cerebral small vessels were studied using Evans Blue to detect the increase of vascular permeability. Severe macroscopic dye-leakages were observed in the areas of "recurrent branching" and "boundary zone", especially among young SHRSP, while SHRSR seemed to be least prone to dye-leakage both in young and adult groups. Among the adults, there was little difference between SHRSP and WK, probably because of the adaptive structural changes of arterial walls in SHRSP caused by long-standing hypertension.