Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Preferential changes of skeletal muscle echogenicity in myotonic dystrophy type 1

BACKGROUND AND PURPOSE

In myotonic dystrophy type 1 (DM1), weakness of distal limb muscles affects quality of life. Non-invasive evaluation of muscular involvement by muscle sonography could be useful for characterizing muscle-specific involvement.

METHODS

Sonography of the lower leg and forearm was performed in 19 patients with DM1 and 10 control subjects. The mean echo intensities (EIs) of seven limb muscles were obtained by computer-assisted histogram analysis and compared within DM1 according to the overall clinical severity.

RESULTS

The EIs of the muscles were significantly higher in DM1 than in the controls (P < 0.01), except for the soleus (P = 0.4). Comparison of adjacent muscles showed the following: (i) greater EIs in flexor digitorum profundus than flexor carpi ulnaris (P < 0.01) and flexor digitorum superficialis (P = 0.02), and (ii) greater EIs in the medial head of the gastrocnemius than the soleus (P < 0.00001). In a subgroup analysis of DM1 according to the modified Rankin Scale (mRS), the more severe subgroup (mRS = 4-5) had lower mean EIs than the less severe subgroup (mRS from 1-3) (P = 0.01) in the flexor digitorum superficialis but not in other muscles.

CONCLUSIONS

Preferential high echogenicity in the medial gastrocnemius and deep finger flexors is suggestive of DM1. Muscle echogenicity is not generally related to functional dysfunction in DM1.

REG Iα is a biomarker for predicting response to chemotherapy with S-1 plus cisplatin in patients with unresectable stage IV gastric cancer

Background:

The regenerating gene Iα (REG Iα) is involved in gastric carcinogenesis as an antiapoptotic factor. Therefore, we investigated whether REG Iα confers resistance to chemotherapeutic drugs in gastric cancer (GC) cells and whether REG Iα expression is useful for predicting the response to chemotherapy and outcome in patients with GC.

Methods:

A total of 70 patients with unresectable stage IV GC received first-line chemotherapy with S-1 and cisplatin (S-1/CDDP). The expression of REG Iα was evaluated immunohistochemically using biopsy samples obtained before chemotherapy, and its relationship to clinicopathological parameters was analysed statistically. The effects of REG Iα gene induction on resistance to 5-FU or CDDP treatment were examined by cell survival assay and flow cytometry.

Results:

Of the 70 patients with unresectable stage IV GC, 19 (27%) were positive for REG Iα expression. The expression of REG Iα was independently predictive of poorer progression-free and overall survival in such patients (hazard ratio (HR) 2.46; P=0.002 and HR 1.89; P=0.037, respectively). The gene induction of REG Iα conferred resistance to cell death induced by 5-FU or CDDP in GC cells.

Conclusion:

In patients with stage IV GC, REG Iα, which confers resistance to chemotherapeutic drugs in GC cells, is a potential biomarker for predicting resistance to S-1/CDDP treatment.

Prevalence of Parkinson's disease and atypical parkinsonian syndromes in a rural Japanese district

OBJECTIVES

To investigate the prevalence of Parkinson's disease (PD) and atypical parkinsonian syndromes (APS) in a rural Japanese district.

METHOD

Collaboration with the medical institutions, the long-term care insurance system facilities, and the public health office.

RESULTS

The crude prevalence rates were 175 per 100,000 (95% CI: 143-206) for PD, 18 (8-28) for progressive supranuclear palsy, 17 (7-26) for multiple system atrophy (MSA), and 9 (2-16) for corticobasal degeneration. The age-adjusted prevalence rates were 109 per 100,000 (88-134), 10 (2-17), 13 (4-21), and 6 (0-12), for each condition. There was a preponderance of women with PD and of men with APS. Nine of the 116 PD patients and 7 of the 29 APS patients were newly diagnosed in this study.

CONCLUSIONS

There are high prevalence rates for PD and APS and suboptimal recognition of APS. This is the first epidemiological prevalence study of MSA from Japan.

A phase-II trial of dose-dense chemotherapy in patients with disseminated thymoma: report of a Japan Clinical Oncology Group trial (JCOG 9605)

BACKGROUND

To evaluate the safety and efficacy of dose-dense weekly chemotherapy in the treatment of advanced thymoma.

METHODS

Subjects comprised patients with histologically documented chemotherapy-naïve thymoma with stage-IVa or IVb disease. Thymic carcinoma, carcinoid or lymphoma cases were excluded. Patients received 9 weeks of chemotherapy: cisplatin (25 mg m(-2)) on weeks 1-9; vincristine (1 mg m(-2)) on weeks 1, 2, 4, 6 and 8; and doxorubicin (40 mg m(-2)) and etoposide (80 mg m(-2)) on days 1-3 of weeks 1, 3, 5, 7 and 9. Chemotherapy courses were supported by granulocyte colony-stimulating factor. Post-protocol local therapy was allowed.

RESULTS

From July 1997 to March 2004, 30 patients were entered. Three were ineligible due to different histology. Chemotherapy-associated toxicity was mainly haematological and was well tolerated, with no deaths due to toxicity, and 87% of patients completed the planned 9-week regimen. Overall response rate was 59%, with 16 of the 27 eligible patients achieving partial response. Median progression-fee survival (PFS) was 0.79 years (95% confidence interval: 0.52-1.40 years), and PFS at 1 and 2 years was 37 and 15%, respectively. Overall survival rates at 2 and 5 years were 89 and 65%, respectively.

CONCLUSION

In stage-IV thymoma patients, weekly dose-dense chemotherapy offers similar activity to conventional regimens.

Association of genetic polymorphisms with interferon-induced haematologic adverse effects in chronic hepatitis C patients

Interferon (IFN)-based combination therapy with ribavirin has become the gold standard for the treatment of chronic hepatitis C virus infection. Haematologic toxicities, such as neutropenia, thrombocytopenia, and anaemia, however, frequently cause poor treatment tolerance, resulting in poor therapeutic efficacy. The aim of this study was to identify host genetic polymorphisms associated with the efficacy or haematologic toxicity of IFN-based combination therapy in chronic hepatitis C patients. We performed comprehensive single nucleotide polymorphism detection in all exonic regions of the 12 genes involved in the IFN signalling pathway in 32 healthy Japanese volunteers. Of 167 identified polymorphisms, 35 were genotyped and tested for an association with the efficacy or toxicity of IFN plus ribavirin therapy in 240 chronic hepatitis C patients. Multiple logistic regression analysis revealed that low viral load, viral genotypes 2 and 3, and a lower degree of liver fibrosis, but none of the genetic polymorphisms, were significantly associated with a sustained virologic response. In contrast to efficacy, multiple linear regression analyses demonstrated that two polymorphisms (IFNAR1 10848-A/G and STAT2 4757-G/T) were significantly associated with IFN-induced neutropenia (P = 0.013 and P = 0.011, respectively). Thrombocytopenia was associated with the IRF7 789-G/A (P = 0.031). In conclusion, genetic polymorphisms in IFN signalling pathway-related genes were associated with IFN-induced neutropenia and thrombocytopenia in chronic hepatitis C patients. In contrast to toxicity, the efficacy of IFN-based therapy was largely dependent on viral factors and degree of liver fibrosis.

Congenital duplication of lower extremity--a case report and review of the literature

Congenital duplication of the lower extremity is quite rare. Only 26 cases have been reported so far. A female infant with incomplete duplication of lower limb and with hypothyroidism was reported. Her mother's pregnancy and delivery was uneventful. A tube-like skin tissue was found on the posterior aspect of the infant's left thigh. Her left foot presented equinovarus deformity. There were three extra toes on the plantar side of her foot. A band of skin with a thin horny layer, similar to the dorsal surface, could be seen on the sole. The skin tube on the thigh was simply resected. A neuro-vascular-islanded toe was made from the plantar toes and rotated to restore five toes on the foot. The transferred toe thrived in accordance with the surrounding toes. The patient could run without difficulty at the age of 3. Previous reports about this case are summarised and reviewed here.

Transcranial magnetic stimulation for differential diagnostics in patients with parkinsonism

OBJECTIVE

We investigated transcranial magnetic stimulation (TMS) parameters in patients with parkinsonism, particularly in the early stages of the disease.

SUBJECTS AND METHODS

We performed TMS in 48 patients with PD, progressive supranuclear palsy (PSP) and multiple system atrophy (MSA). We measured motor threshold (MT), latency (L), motor-evoked potential amplitude and central motor conduction time (CMCT) and cortical silent period (CSP). Furthermore, we selected and compared 27 patients with a disease duration of less than 3 years.

RESULTS

CMCT, MT, L and CSP were different among the three groups. Post hoc analyses revealed that CMCT and CSP were the shortest in PD, and that MT was significantly lower in PD than in MSA. In patients whose disease duration was less than 3 years, CMCT and CSP were different among the three groups. Post hoc analyses showed significantly shorter CMCT in PD.

CONCLUSIONS

TMS can detect the pathophysiological difference among the groups in the early stages of the disease.

Transarterial infusion chemotherapy alone versus transarterial chemoembolization for the treatment of hepatocellular carcinoma: Results of a multicenter randomized phase III trial

4643

Background: Transarterial chemoembolization (TAE) is widely used for patients (pts) with hepatocellular carcinoma (HCC) although evidence of a survival benefit remains controversial. A multicenter phase III trial was designed to compare the effects of TAE and transarterial infusion chemotherapy alone (TAI) on overall survival. Methods: Pts with newly diagnosed unresectable HCC were randomly assigned to either the TAE or the TAI group, stratified according to center and the serum alpha-fetoprotein level. Zinostatin stimalamer (SMANCS), up to a maximum of 6 mg, plus lipiodol emulsion with or without gelatin sponge was injected into the hepatic artery. Treatment was repeated when a follow-up computed tomography examination showed the appearance of new lesions in the liver or the regrowth of the treated tumors. Based on our previous phase II studies, reporting a 2-year survival rate of 80% in pts treated with TAE and of 60% in pts treated with TAI, 80 pts were needed in each group to achieve a level of statistical significance of 5% (2-sided) and a power of 80%. Results: From October 1999 to June 2003, 79 pts were assigned to the TAE group and 82 pts to the TAI group. The two groups were well balanced with regard to their baseline characteristics. The total number of treatment courses was 170 with a mean of 2.2 courses per patient (range, 1–9 courses) in the TAE group and 193 with a mean of 2.4 courses (range, 1–6 courses) in the TAI group. As of June 2005, 51 pts in the TAE group and 58 pts in the TAI group had died. The median overall survival time was 646 days in the TAE group and 679 days in the TAI group. No significant difference in survival was seen between the two groups (p=0.383). The mortality rate reduction for overall survival was 15.8% (95% CI, -24.1% to 42.9%) for the TAE relative to the TAI alone. Conclusions: This study suggests that treatment intensification as a result of embolization did not increase survival, compared with SMANCS transarterial chemotherapy alone, in pts with HCC.

No significant financial relationships to disclose.

Auditory and tactile processing in a postmeningitic deaf-blind patient with a cochlear implant

The authors examined the neural function of a postmeningitic deaf-blind patient who regained his hearing with a multichannel cochlear implant. Auditory stimuli activated the temporal cortices of both sides in a manner similar to that of controls, reflecting the successful recruitment of the auditory cortex after implantation. The patient's occipital lobes were deactivated during the tactile language task, the results of which were completely different from those before cochlear implantation.

Is the pattern of solid-phase gastric emptying different between genders?

BACKGROUND

In the 13C-octanoate breath test, the shape of the 13CO2 excretion curve in the ascending portion reflects a pattern of gastric emptying (GE). Recent scintigraphic studies have revealed an overall delay in solid GE in fertile women compared with men. However, it remains unknown whether women have a different GE pattern compared with men. As a symptomatic delay in solid GE is specific to the female gender, it could be hypothesized that the 13CO2 excretion curve is different in shape between genders.

MATERIALS AND METHODS

Because the ascending gradient of the 13CO2 excretion curve is often biphasic, the dual function of y(t) = ( a1 . tb1 + a2 . tb2) e(-K.t) was applied to fit the breath data, where a1, b1, a2, b2, and K are constants. Assessed on the 4 h-based breath samples obtained after ingestion of a 320-kcal muffin containing 100 mg 13C-octanoate, the time versus 13CO2 excretion curve was created from 31 adult volunteers (15 men and 16 women). The curve shape was characterized by the dual function, and was compared between genders.

RESULTS

In both genders, the ascending gradient exhibited the biphasic feature, characterized by an initial steep rise and the subsequent blunted increase, while the descending gradient followed the monotonous decay. The initial rise was steeper and the subsequent increase was more blunted in women than in men.

CONCLUSION

Women exhibit a gender-specific pattern of the 13CO2 excretion profile. A possible explanation for this gender difference is that the post-gastric feedback regulation is more potent in women than in men.

Adolescent smoking behaviour and cigarette brand preference in Japan

OBJECTIVES

As part of efforts to develop a smoking control strategy for Japanese adolescents, the results of two nationwide surveys on adolescent smoking behaviour were compared.

DESIGN

Descriptive study on smoking behaviour among high school students was conducted. Self-reporting anonymous questionnaires were administered to 115,814 students in 1996 and 106,297 in 2000 through randomly sampled junior and senior high schools throughout Japan.

MAIN OUTCOME MEASURES

Smoking prevalence, proportion of smokers by usual sources of cigarettes, national estimated cigarettes consumed by minors, share of cigarette brands smoked by high school students.

RESULTS

The experiment rate among junior high school boys decreased in 2000 compared with that in 1996, whereas current and daily smoking rates did not. Although prevalence among Japanese girls was much lower than that among boys, prevalence among girls increased in 2000. The main source of cigarettes among high school smokers was vending machines. The proportion of smokers who usually purchased cigarettes from vending machines increased in 2000, in spite of the 1998 introduction of restrictions on night-time operations. Japanese adolescents were more likely than adults to smoke American cigarette brands, and the adolescent market share of American brands has increased rapidly, especially for menthol brands.

CONCLUSIONS

This survey revealed the seriousness of the problem of smoking behaviour among Japanese high school students, and suggested that this behaviour may be influenced by social environmental factors, including the marketing strategies of the tobacco industry. Action should be taken to reduce the prevalence and impact of pro-tobacco marketing messages and to abolish cigarette vending machines.

Chronic active VZV infection manifesting as zoster sine herpete, zoster paresis and myelopathy

After lumbar-distribution zoster, an HTLV-1-seropositive woman developed chronic radicular sacral-distribution pain (zoster sine herpete), cervical-distribution zoster paresis and thoracic-distribution myelopathy. Detection of anti-varicella zoster virus (VZV) IgM and VZV IgG antibody in cerebrospinal fluid (CSF), with reduced serum/CSF ratios of anti-VZV IgG compared to normal serum/CSF ratios for albumin and total IgG, proved that VZV caused the protracted neurological complications. Diagnosis by antibody testing led to aggressive antiviral treatment and a favorable outcome.

Tau exon 10 +16 mutation FTDP-17 presenting clinically as sporadic young onset PSP

The authors describe a case of clinically diagnosed young onset progressive supranuclear palsy (PSP) with symptom onset at 40 years of age and no family history of neurodegenerative disease. There was no history of falls during the first year of symptoms. Genetic analysis identified this patient as having a tau exon 10 +16 mutation (MAPT, IVS10, C-U, +16). Neuropathologic examination confirmed the genetic diagnosis of frontotemporal dementia. An age at onset younger than 50 years combined with the absence of early falls may indicate the possibility of a tau mutation in clinically diagnosed PSP.

Do published criteria improve clinical diagnostic accuracy in multiple system atrophy?

OBJECTIVE

To assess the accuracy of a clinical diagnosis of multiple system atrophy (MSA) and compare it to the Quinn and Consensus criteria for MSA using neuropathologically examined cases from the Queen Square Brain Bank for Neurological Disorders.

METHODS

Fifty-nine cases with a neurologic diagnosis of MSA when last assessed prior to death were studied.

RESULTS

In 51 (86%) of these cases, the diagnosis of MSA was confirmed pathologically. False positive diagnoses included PD (n = 6), progressive supranuclear palsy (n = 1), and cerebrovascular disease (n = 1). When applying either set of diagnostic criteria, a diagnosis of probable MSA gave lower sensitivity but higher positive predictive value than one of possible MSA. Application of either set of diagnostic criteria was superior to actual clinical diagnosis made early in the disease, but there was little difference by the last clinic visit.

CONCLUSIONS

This study shows a high diagnostic accuracy for the clinical diagnosis of MSA by neurologists, with PD accounting for most of the false positive diagnoses. Application of either Quinn or Consensus criteria was superior to actual clinical diagnosis made early in the disease, but there was little difference by last clinic visit.

Asymmetric pharyngeal-cervical-brachial weakness associated with anti-GT1a IgG antibody

We report a case of markedly asymmetric pharyngeal-cervical-brachial weakness. Acute progression of symptoms, albuminocytologic dissociation in cerebrospinal fluid, electrophysiologic evidence of demyelination and elevation of IgG anti-GT1 a antibody titer paralleled the clinical course, support the diagnosis of Guillain-Barré syndrome. Guillain-Barré syndrome should be considered in the differential diagnosis of cranial neuropathy, even in cases where there is marked asymmetry.

Protruding atherosclerotic aortic plaques and dyslipidaemia: correlation to subtypes of ischaemic stroke

AIMS

To evaluate whether thoracic aortic plaques together with dyslipidaemia are related to ischaemic stroke, and if so, to which of the subtypes of stroke.

METHODS AND RESULTS

We performed transoesophageal echocardiography in 50 patients with acute ischaemic stroke and in 401 controls. The aorta was divided into two segments: (1) the proximal, proximal to the left subclavian artery, and (2) the distal aorta. Protruding plaques (Intima > or =4 mm in thickness) in the proximal aorta were detected in 14 of the 50 patients (28%) with stroke, and in 53 of the 401 controls (13%) (P<0.01). Plaque score in the proximal aorta (2.1 +/- 1.8 vs 0.9 +/- 0.7; P<0.05), low-density lipoprotein cholesterol level (3.60 +/- 0.85 vs 2.87 +/- 0.72 mmol/l; P<0.05), and apolipoprotein B/A-I ratio (0.98 +/-0.17 vs 0.73 +/- 0.16; P<0.005) were higher in patients with athero-thrombotic than in cardioembolic stroke. The score in the proximal aorta correlated with low-density lipoprotein cholesterol level (r=0.44, P<0.005) and apolipoprotein B/A-I ratio (r=0.40, P<0.01).

CONCLUSION

Severe plaques in the proximal aorta together with dyslipidaemia are seen more frequently in patients with atherothrombotic stroke. Lipid analysis may contribute to the prediction and the treatment of the patients who are at high risk for atherothrombotic stroke.

Multicenter prospective analysis of newly diagnosed hepatocellular carcinoma with respect to the percentage of Lens culinaris agglutinin-reactive alpha-fetoprotein

BACKGROUND AND AIM

The Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein (AFP-L3) has been reported to be a highly useful marker for hepatocellular carcinoma (HCC) compared with a conventional serum AFP concentration, which allows earlier detection of HCC compared with using other imaging modalities and predicting prognosis after therapy. A collaborative prospective study involving nine Japanese hospitals was conducted to analyze the relationships between the tumor characteristics of a HCC patient and the percentage of AFP-L3/AFP total at the initial detection.

METHODS

Between 1 October 1996 and 30 September 1997, a total of 388 patients with newly diagnosed HCC were registered.

RESULTS

The cut-off level of the percentage of AFP-L3 was altered from 15 to 10%. The AFP-L3-positive HCC patients demonstrated the characteristics of having an advanced tumor, such as the number of tumors, maximum diameter, tumor spread, portal vein invasion, tumor stage, and tumor classification. With the conventional cut-off level of 15% of the percentage of AFP-L3, the malignant characteristics were more definite than that of 10%. However, no significant differences of serum AFP concentration were observed for malignant characteristics such as maximum diameter and histopathological grading.

CONCLUSION

Serum AFP concentration does not reveal a malignancy of HCC, however, the AFP-L3-positive HCC has biologically malignant characteristics, especially portal vein invasion and lower tumor classification, and is an advanced tumor regardless of small tumor size and lower serum AFP concentration. As AFP-L3 shows the tumor characteristics, its presence should be an important factor in the determination of therapy and prognosis of patients.

[Percutaneous radiofrequency ablation (PRFA) for hepatocellular carcinoma]

Percutaneous local treatment for hepatocellular carcinoma is minimally invasive. Moreover, since local radical cure may be possible, the procedure has become widely performed. Percutaneous radiofrequency ablation (PRFA) was recently introduced in Japan. Excellent results are expected. PRFA was conducted on 244 tumor nodules found in 177 cases of hepatocellular carcinoma (a total of 349 procedures), and the usefulness was examined. 1. Tumor markers significantly decreased after PRFA and a favorable necrotic effect was obtained on CT images. 2. Mild post-operative inflammatory reaction and exacerbation of liver dysfunction was noted, but recovery was achieved in one week. There were no major complications. 3. The cumulative local recurrence in 1 year was 5.4%, which is lower than that with percutaneous microwave coagulation therapy. 4. PRFA is a safe and handy procedure for hepatocellular carcinoma, which promises the favorable effect of coagulation necrosis. PRFA will likely become a key method among local ablation therapies.

Angiotensinogen gene variation and hypertension in a cohort study in Japanese

Many recent case-control studies have suggested a significant relationship between M235T (the substitution of threonine for methionine at position 235 codon) polymorphism of the angiotensinogen (AGT) gene and hypertension. To investigate whether the M235T polymorphism of AGT gene affects the incidence of hypertension, a retrospective cohort study was performed among Japanese workers. The subjects were Japanese workers at an occupational site in Shimane Prefecture in Japan. The baseline data were set at the received regular health examination in 1992, and a retrospective cohort study was performed for analyzing the incidence of hypertension in 1998. The rates of M235M (MM), M235T (MT) and T235T (TT) genotypes were 4%, 32% and 64%, respectively. The relative risks of MT and TT against MM for the incidence of hypertension by single variance analysis were 1.47 [95% confidence interval (CI) 0.50 - 4.33] and 1.35 (95% CI 0.47 - 3.90), respectively. The relative risks of MT and TT against MM for the incidence of hypertension, adjusted for sex, age, body mass index, fasting glucose and cigarette smoking, drinking and exercise in 1992, were 1.49 (95% CI 0.49 - 4.53) and 1.25 (95% CI 0.42 3.74), respectively. The data from this study suggest that the M235T polymorphism of AGT gene has a weak role in the manifestation of hypertension. Further comprehensive studies are needed to resolve this issue.

[Drinking behaviors of Japanese adolescents' problem drinker--report of 1996 national survey]

The first national survey of Japanese adolescent drinking behaviors was conducted in 1996. Based on the survey results, this study focused on high risk drinking behaviors of Japanese adolescent problem drinkers. The subjects were 42,183 junior high school students and 72,396 senior high school students who responded to questions on drinking frequency and drinking quantity among the national survey subjects. The subject students were divided into three groups: normal adolescents, drinkers and problem drinkers by the QF scale. The problem drinkers according to the QF scale accounted for 3% of the junior high school students and 14% of senior high school students. Problem drinkers among both junior and senior high school students had characteristic drinking behaviors such as various drinking occasions, obtaining alcoholic drinks by various methods, drinking hard liquor, and many instances of vomiting or blackouts due to drinking. Many problem drinkers considered that the national law prohibiting minors from drinking was unnecessary because they have the right to decide whether to drink. Both junior and senior high school problem drinkers showed high risk drinking behaviors.

Factors associated with earthquake deaths in the great Hanshin-Awaji earthquake, 1995

The authors conducted descriptive and case-control studies to find factors associated with earthquake deaths due to the Great Hanshin-Awaji earthquake on January 17, 1995, in Nishinomiya, Japan. In the case-control study, cases included all 1,104 deaths. Controls were randomly selected from survivors. Earthquake mortality increased for people over age 50 years. Mortality among people who had lived in dwellings that were completely destroyed was much higher. One risk factor was physical disabilities (odds ratio = 1.9, 95% confidence interval (CI): 1.0, 3.4). When the analysis was limited to the people who had lived in intact or partially destroyed dwellings, the odds ratio rose to 5.6 (95% CI: 1.6, 19.8).

[Smoking behaviors among medical doctors in Fukui, Japan]

This study was conducted in order to identify the smoking prevalence among all doctors (N = 874) belonging to the medical associations in Fukui Prefecture and factors that might possibly indicate causal smoking habits. A survey was conducted from December of 1996 to February of 1997, using a self-administered questionnaire, and the response rate for the survey was 91%. The main results of this survey were as follows: The prevalence of smoking among male and female medical doctors was 28% and 8% respectively, which was lower than that of adults in the general population, but higher than that of doctors in the developed countries. The prevalence of smoking among doctors was almost highest when they were 20 to 29 years old, and that among medical practitioners with their own institution was higher than doctors employed by an institution. In particular, medical practitioners who did not smoke were more likely to restrict or ban smoking in their hospitals or clinics.

Behaviors and attitudes towards smoking among the nurses in Japan

The study was carried to investigate on the actual conditions related to smoking of the nurses working in all medical institutions under a regional medical association in Mie Prefecture (regional medical institutions). Results obtained were as follows: smoking prevalence of female nurses is considered to be equal to that of the general female population in Japan. About 35% of the nurses with the smoking habit had an opinion to quit it, and about 45% of them practiced it seriously. Nearly 80% nurses favored restriction. In the way of thinking related to smoking, more than 90% of the nurses answered that women should not smoke for the health of the fetuses and infants, while only about 30% of them agreed to stop smoking working as members of the medical staff. The survey suggests that anti-smoking program is necessary to develop for smoking nurses working at medical facilities.