Comparison of knee kinematics and ligament forces in single and multi-radius cruciate-retaining total knee arthroplasty: A computer simulation study

BACKGROUND

The single-radius design in total knee arthroplasty has been designed to develop a more fixed flexion-extension axis without mid-flexion instability compared with the multi-radius design. It remains unclear whether differences between the multi-radius and single-radius designs can affect kinematics and collateral ligament forces. This study aimed to simulate knee kinematics and kinetics between single-radius and multi-radius models using a musculoskeletal computer model.

METHODS

The single-radius and multi-radius femoral components were virtually implanted in a computer simulation using the same tibial insert. The effects of implant design on kinematics and medial collateral ligament forces during squatting and gait activities were analyzed.

RESULTS

During squatting, the multi-radius model exhibited paradoxical anterior translation on both the medial and lateral flexion facet center where peak anterior translation was 2.4 mm for medial flexion facet center and 2.2 mm for the lateral flexion facet center, while the peak anterior translation of the single-radius model was less than 1 mm at early flexion. A rapid decrease in medial collateral ligament tension was observed in the early flexion phase in the multi-radius model, which occurred simultaneously with paradoxical anterior translation, whereas the relatively constant medial collateral ligament tension was observed in the single-radius model. During gait activity, the single-radius model exhibited a more posterior position than the multi-radius model.

CONCLUSION

These suggest that abrupt changes in the medial collateral ligament force influence anterior sliding of the femur, and that the single-radius design is a reasonable choice for prevention of mid-flexion instability.

Patellar medial-lateral position can be used to correct the effect of leg rotation on preoperative planning in total knee arthroplasty for varus knees

BACKGROUND

Lower limb malrotations can be observed in long leg radiographs, affecting the measurement of the angle between the mechanical and anatomical axes. The purposes were to analyze the effect of limb rotation and to evaluate the accuracy of the corrected angle between the mechanical and anatomical axes based on the patellar ML position.

HYPOTHESIS

The hypothesis was that the correction of the angle between the mechanical and anatomical axes according to the patellar ML position can reduce the error from the angle in the true AP view in most of the knees.

PATIENTS AND METHODS

A total of 100 consecutive knees with varus deformity undergoing primary total knee arthroplasty were included. Computed tomography images were digitally reconstructed in the neutral position, and internally and externally rotated at 10° and 20°, respectively. The patellar ML position relative to the medial (0%) and lateral (100%) epicondyles and the angle between the mechanical and anatomical axes of the femur were measured. The corrected angle between the mechanical and anatomical axes was calculated using the averaged translational ratio.

RESULTS

In the neutral position, the patellar center position was 56.1% (standard deviation [SD]=4.7%), which was 31.4% (SD=7.2%) and 80.2% (SD=5.4%) in the 20° internal and external rotation, respectively. The angle between the mechanical and anatomical axes was 2.6° (SD=2.0°) and 8.1° (SD=2.1°) in the 20° internal and external rotation, respectively. On average, if the patellar center shifted 10%, the change of the angle between the mechanical and anatomical axes of the femur was 1.13°. Applying the corrected angle, a discrepancy from the neutral position decreased.

CONCLUSION

The method to correct the angle between the mechanical and anatomical axes according to the patellar ML position can be used to reduce the measurement error for preoperative planning using a long leg radiograph.

LEVEL OF EVIDENCE

III.

Excessive flexed position of the femoral component causes abnormal kinematics and joint contact/ ligament forces in total knee arthroplasty

Poor clinical outcomes are reported in excessive flexion of the femoral component in total knee arthroplasty (TKA), but their mechanisms have not yet been elucidated. This study aimed to investigate the biomechanical effect of flexion of the femoral component. Cruciate-substituting (CS) and posterior-stabilised (PS) TKA were reproduced in a computer simulation. The femoral component was then flexed from 0° to 10° with anterior reference, keeping the implant size and the extension gap. Knee kinematics, joint contact, and ligament forces were evaluated in deep-knee-bend activity. When the femoral component was flexed 10° in CS TKA, paradoxical anterior translation of the medial compartment was observed at mid-flexion. The PS implant was best stabilised with a 4° flexion model in mid-flexion range. The medial compartment contact force and the medial collateral ligament (MCL) force increased with the flexion of the implant. There were no remarkable changes in the patellofemoral contact force or quadriceps in either implant. In conclusions, excessive flexion of the femoral component yielded abnormal kinematics and contact/ligament forces. Avoiding excessive flexion and maintaining mild flexion of the femoral component would provide better kinematics and biomechanical effects in CS and PS TKA.

Kinematic comparison between asymmetrical and symmetrical polyethylene inserts during deep knee bend activity

BACKGROUND

The in vivo kinematic benefit of an asymmetrical polyethylene insert is still unknown in comparison with that of a symmetrical insert with the same femoral component design. The purpose of this study was to analyze the kinematic differences between symmetrical and asymmetrical polyethylene inserts and to detect the kinematic benefit in the asymmetrical polyethylene insert. The hypotheses are that greater axial rotation and more posterior rollback are observed in the asymmetrical polyethylene insert.

METHODS

The patients were randomly allocated to the following two groups: total knee arthroplasty with a symmetrical insert and with an asymmetrical insert. In vivo knee kinematics was analyzed in asymmetrical (17 knees) and symmetrical (16 knees) inserts using an image matching technique. The symmetrical polyethylene insert had the same geometry on both sides, whereas the asymmetrical polyethylene insert had a flat surface on the postero-lateral side. The anterior/posterior position and axial rotation were compared between the two polyethylene inserts.

RESULTS

The femoral component was significantly positioned posteriorly at 70° (p = 0.016) and 80° (p = 0.040) of knee flexion and externally rotated at 80° of knee flexion (p = 0.040) in the asymmetrical polyethylene insert as compared to the position of the symmetrical polyethylene insert. Femoral rollback and axial rotation from full extension to maximum flexion were greater in the asymmetrical polyethylene insert, although the difference was not significant.

CONCLUSIONS

In the asymmetrical polyethylene insert, slight kinematic benefit with greater axial rotation and more posterior rollback was observed in comparison with the symmetrical polyethylene insert. Further research should be required whether the kinematic benefit of an asymmetrical polyethylene insert will lead to better patient satisfaction and function.

Static Mediolateral Tilt of the Joint Line after Total Knee Arthroplasty Does Not Reflect Dynamic Tilt during a Stair Ascent Activity

The correlation between static and dynamic mediolateral (ML) tilts of the joint line in the coronal plane remains unknown after total knee arthroplasty (TKA). The purpose was to evaluate the ML tilt as measured by two-dimensional to three-dimensional registration during stair ascent in TKA patients, and to examine the correlation between the dynamic ML tilt and radiographic measurements of static indices. Thirty-two knees that underwent TKA using the mechanical alignment method were included. Continuous sagittal fluoroscopy was taken from before initial contact (IC) until after the toe-off (TO) phase during the stair ascent. The ML tilt of the tibial component relative to the ground was analyzed in terms of dynamic alignment using image-matching techniques, whereas static alignment was measured using standing long-leg radiographs. The correlation between static and dynamic ML tilts was evaluated. In the fluoroscopic analysis, the joint line was neutral (0.0 degree, standard deviation [SD] = 3.4 degrees) around IC phases, then was tilted valgus (5.5° valgus, SD = 2.6 degrees) in the mid-stance (MS) phase. After the TO phase, the joint line became almost neutral (0.4 degrees valgus, SD = 3.1 degrees). The dynamic ML tilt was significantly more varus during the IC phase and significantly more valgus in MS and TO phases than the static ML tilt (1.4 degrees valgus, SD = 2.0 degrees). No correlation was found between static and dynamic ML tilts in weight-bearing phases. During stair ascent, the static tilt had no correlation with the dynamic tilt in weight-bearing phases despite being in the same range. Static lower limb alignment does not reflect coronal alignment during motion. Further research should be conducted to determine whether the horizontal dynamic ML tilt can improve long-term durability and clinical outcomes after TKA.

Effects of dietary betaine supplementation on growth performance, meat quality, muscle fatty acid composition and antioxidant ability in slow-growing broiler chickens

1. This study investigated the effects of dietary betaine supplementation on growth performance, meat quality, muscle fatty acid composition and antioxidant ability in slow-growing broiler chickens.2. In total, 400, one-day-old female Xueshan broiler chicks were randomly divided into five groups with eight replicates of ten chickens each for 102 d. Broilers were fed a basal diet supplemented with 0, 125, 250, 500 or 1,000 mg/kg betaine.3. Broilers fed betaine had better feed conversion efficiency and weight gain (P < 0.05) and increased meat redness and yellowness 24 h after slaughter. Supplementation linearly decreased cooking loss and drip loss from breast muscle (P < 0.05). Muscular resilience was improved and tenderness increased (P < 0.05). Intra-muscular saturated fatty acids decreased, while total monounsaturated fatty acids and polyunsaturated fatty acids increased (P < 0.05). Betaine increased activities of glutathione peroxidase (GPx) and total superoxide dismutase (SOD), glutathione (GSH) level, ratio of reduced glutathione/oxidised glutathione, and activity of scavenging hydroxyl radicals. It increased the activity of total antioxidant capacity (T-AOC) in the breast muscle (P < 0.05). Moreover, supplementation up-regulated (P < 0.05) mRNA expression levels of blood and antioxidant markers.4. In conclusion, 1000 mg/kg betaine can be recommended as a supplement for slow-growing, Xueshan chicken.

Biomechanical Comparison of Kinematic and Mechanical Knee Alignment Techniques in a Computer Simulation Medial Pivot Total Knee Arthroplasty Model

Several concepts may be used to restore normal knee kinematics after total knee arthroplasty. One is a kinematically aligned (KA) technique, which restores the native joint line and limb alignment, and the other is the use of a medial pivot knee (MPK) design, with a ball and socket joint in the medial compartment. This study aimed to compare motions, contact forces, and contact stress between mechanically aligned (MA) and KA (medial tilt 3° [KA3] and 5° [KA5]) models in MPK. An MPK design was virtually implanted with MA, KA3, and KA5 in a validated musculoskeletal computer model of a healthy knee, and the simulation of motion and contact forces was implemented. Anteroposterior (AP) positions, mediolateral positions, external rotation angles of the femoral component relative to the tibial insert, and tibiofemoral contact forces were evaluated at different knee flexion angles. Contact stresses on the tibial insert were calculated using finite element analysis. The AP position at the medial compartment was consistent for all models. From 0° to 120°, the femoral component in KA models showed larger posterior movement at the lateral compartment (0.3, 6.8, and 17.7 mm in MA, KA3, and KA5 models, respectively) and larger external rotation (4.2°, 12.0°, and 16.8° in the MA, KA3, and KA5 models, respectively) relative to the tibial component. Concerning the mediolateral position of the femoral component, the KA5 model was positioned more medially. The contact forces at the lateral compartment of all models were larger than those at the medial compartment at >60° of knee flexion. The peak contact stresses on the tibiofemoral joint at 90° and 120° of knee flexion were higher in the KA models. However, the peak contact stresses of the KA models at every flexion angle were <20 MPa. The KA technique in MPK can successfully achieve near-normal knee kinematics; however, there may be a concern for higher contact stresses on the tibial insert.

Length of anterior cruciate ligament affects knee kinematics and kinetics using a musculoskeletal computer simulation model

Introduction

The tension of anterior cruciate ligament (ACL) graft has an important role in antero-posterior (AP) and rotational stability of the knee. The purposes of this study were to analyze the kinematics and kinetics of normal knee models with loose and tight ACL tension, and to evaluate the effect of the tension of ACL on knee kinematics and kinetics.

Materials and methods

Slack and tight ACL models were constructed in a musculoskeletal computer simulation. The effect of ACL tension on kinematics, and femorotibial contact force during various activities was analyzed.

Results

During stair descent activity in the slack ACL models, the lateral femoral condyles were positioned posterior, and more external rotation of the femur was observed in comparison with the normal model. The contact forces at the lateral compartment in the tight models increased during all activities, and the tension of the medial collateral ligament (MCL) in the slack models increased during the stair descent activity, compared with the normal knee model.

Conclusion

AP and rotational instability and excessive MCL tension were observed in the ACL slack knees especially during stair descent movement, whereas the tibiofemoral contact force of the lateral compartment increased in the tight ACL knees.

Does surgical reconstruction produce better stability than conservative treatment in the isolated PCL injuries?

INTRODUCTION

The purpose of this study was to conduct a systematic review to address the stability outcome from reconstruction and conservative treatments.

MATERIALS AND METHODS

Inclusion criteria were as follows: (1) English language, (2) human subject, (3) measures of stability outcomes, and (4) patients with isolated PCL injuries. We did not limit the type of study design (interventional or non-interventional study) and included all published systematic reviews. The following data were extracted: the number of study populations, year of publication, baseline characteristics of patients, follow-up period, and outcome data. The primary outcome variable was side-to-side difference (STSD).

RESULTS

In the conservative treatment, the average STSD ranged from 3.5 to 5.3 mm on Telos™ (range 0.7-12.0 mm) and from 3.0 to 5.2 mm on KT-1000™ (range 0.5-10 mm). Among reconstructive treatment, the average STSD ranged from 2.0 to 3.7 mm on Telos™ (range 0-7 mm) and 0.7-5.9 mm on KT-1000™ (range -1 to 11.8 mm). In the conservative treatment, the estimated weighted mean STSD difference was 3.49 [95 % confidence interval (CI): 0.95-6.03] on Telos™ and 2.64 (95 % CI 0.76-4.51) on KT-1000™. On the other hand, in the reconstructive treatment, the estimated mean STSD difference was 8.09 (95 % CI 7.11-9.07) on Telos™ and 8.45 (95 % CI 6.44-10.47) on KT-1000™.

CONCLUSIONS

This systematic review noted more satisfactory and consistent stability in the reconstructive treatment group. However, more complications and small differences of stability between groups should be also considered.

Active Flexion in Weight Bearing Better Correlates with Functional Outcomes of Total Knee Arthroplasty than Passive Flexion

PURPOSE

Correlations between maximum flexion and functional outcomes in total knee arthroplasty (TKA) patients are reportedly weak. We investigated whether there are differences between passive maximum flexion in nonweight bearing and other types of maximum flexion and whether the type of maximum flexion correlates with functional outcomes.

MATERIALS AND METHODS

A total of 210 patients (359 knees) underwent preoperative evaluation and postoperative follow-up evaluations (6, 12, and 24 months) for the assessment of clinical outcomes including maximum knee flexion. Maximum flexion was measured under five conditions: passive nonweight bearing, passive weight bearing, active nonweight bearing, and active weight bearing with or without arm support. Data were analyzed for relationships between passive maximum flexion in nonweight bearing by Pearson correlation analyses, and a variance comparison between measurement techniques via paired t test.

RESULTS

We observed substantial differences between passive maximum flexion in nonweight bearing and the other four maximum flexion types. At all time points, passive maximum flexion in nonweight bearing correlated poorly with active maximum flexion in weight bearing with or without arm support. Active maximum flexion in weight bearing better correlated with functional outcomes than the other maximum flexion types.

CONCLUSIONS

Our study suggests active maximum flexion in weight bearing should be reported together with passive maximum flexion in nonweight bearing in research on the knee motion arc after TKA.

Can Serum Albumin Level and Total Lymphocyte Count be Surrogates for Malnutrition to Predict Wound Complications After Total Knee Arthroplasty?

BACKGROUND

Although the serum albumin level and total lymphocyte count (TLC) have been reported as valid and reliable markers for defining malnutrition, their cutoff levels and predictive values for wound complications in patients undergoing total knee arthroplasty (TKA) remain questionable.

METHODS

A total of 3169 TKAs performed between April 2003 and December 2013 were retrospectively reviewed. We determined the prevalence of malnutrition on applying different definitions, with various cutoff values of serum albumin and TLC and analyzed the variations in outcome. The differences between groups with and without malnutrition in terms of functional outcome and complications were determined using Student's t test and analysis of variance. Multivariate logistic regression analysis was conducted to identify the independent risk factors.

RESULTS

Among all the patients (N = 3169), the serum albumin level and TLC varied widely, with means of 4.1 g/dL and 2189 cells/mm(3), respectively. The prevalence of malnutrition (21%) as per the conventional definition (serum albumin level <3.5 g/dL or a serum TLC <1500 cells/mm(3)) dropped to only 1.6% when malnutrition was defined as serum albumin <3.5 g/dL "and" TLC <1500/mm(3), indicating a very small overlap between the 2 markers. No differences were observed between 2 groups in functional outcomes and incidence of wound complications.

CONCLUSION

Our findings call into question the values of serum albumin level and TLC as a surrogate of malnutrition for predicting wound complications after TKA.

Multilevel Thoracolumbar Spondylolysis with Spondylolisthesis at L4 on L5

A 24-year-old male patient was initially evaluated for persistent back pain. The visual analogue scale (VAS) score was 7 points. Physical examination revealed a decreased range of lumbar spinal motion, which caused pain. Simple X-ray revealed Meyerding grade 1 spondylolisthesis at L4 on L5, with mild dome-shaped superior endplate and consecutive multilevel spondylolysis at T12-L5. Standing anteroposterior and lateral views of the entire spine revealed normal balance of sagittal and coronal alignment. A computed tomography scan revealed bilateral spondylolysis at T12-L4, left unilateral spondylolysis at L5, and spina bifida at L5 to sacral region. Magnetic resonance imaging revealed mild dural ectasia at the lumbar region. Due to the absence of any neurological symptoms, the patient was managed conservatively. He was rested a few weeks with corset brace and physiotherapy. After treatment, his back pain improved, VAS score changed from 7 to 2, and he was able to return to normal activity.

Correlation between dorsovolar translation and rotation of the radius on the distal radioulnar joint during supination and pronation of forearm

This study aimed to describe the patterns of movements about radius and ulna in individual degrees of forearm rotation. And, we also determined the effect of forearm rotation on translation and rotation of the radius with reference to the ulna, and to measure the relationship between forearm rotation, translation and rotation of the radius. Computed tomography of multiple, individual forearm positions, from 90° pronation to 90° supination, was conducted in 26 healthy volunteers (mean age, 43.9 years) to measure dorsovolar translation and rotation of the radius in the DRUJ in each forearm position. The mean dorsovolar translations were within 1.99 mm at 90° pronation to -2.03 mm at 90° supination. The rotations of the radius were 71.20° at 90° pronation and -46.63° at 90° supination. There were strong correlations between degrees of forearm rotation and dorsovolar translation (r=0.861, p<0.001) and rotation of the radius (r=0.960, p<0.001), suggesting that the DRUJ, carpal joints, and rotatory laxity of the carpal ligament, especially in supination, contribute to forearm supination and pronation. These findings provide an understanding of wrist kinematics, are may be useful in reconstructive wrist surgery to achieve normal range of motion, and are may be helpful for the design of DRUJ reconstruction using prostheses.

Is Knee Magnetic Resonance Imaging Overutilized in Current Practice?

Purpose

To determine what proportion of patients visiting a tertiary knee clinic had pre-obtained knee magnetic resonance imaging (MRI) and to assess the impact of pre-obtained knee MRI on the selection of treatment plans.

Materials and Methods

Six hundred and eighty patients were enrolled from patients who visited our knee clinic during a 6-month period. The proportion of patients with pre-obtained knee MRI was calculated, and associations of sociodemographic factors, disease category, and finally selected treatment options with knee MRI pre-obtainment were investigated. A utility assessment panel of five orthopaedic surgeons was formed and established utility assessment criteria. Two rounds of utility assessment (before and after MRI review) were performed.

Results

Of the 680 patients, 185 (27%) had pre-obtained knee MRI. In the first round of utility assessment, 39%, 18%, and 43% of the 185 knee MRIs were evaluated as useful, equivocal, and arguably useless, respectively, and almost identical results were obtained in the second round. The proportion of assessed 'useful MRI' was higher in sports related injury (84%) and other conditions (91%) than in degenerative joint disease (18%) and nonspecific knee pain (31%). Utility assessment results among panels varied little for practice patterns and education duration.

Conclusions

This study suggests clinicians should reconsider and counsel patients the expected utility of knee MRI acquisition.

Patients still wish for key improvements after total knee arthroplasty

Purpose

Our goals were to rigorously document and explore the interrelationships of various parameters in the aftermath of total knee arthroplasty (TKA), including patient characteristics, clinical scores, satisfaction levels, and patient-perceived improvements.

Materials and Methods

A questionnaire addressing sociodemographic factors, levels of satisfaction, and "wished-for" improvements was administered to 180 patients at least 1 year post primary TKA. Both satisfaction levels and wished-for improvements were assessed through nine paired parameters. Patients responded using an 11-point visual analogue scale (VAS) and the results were summarized as mean VAS score. Correlations between clinical scores and satisfaction levels and between satisfaction levels and desired improvements were analyzed.

Results

Patient satisfaction levels were only modest (mean score, 4-7) for eight of the nine parameters, including pain relief and restoration of daily living activities, the top two ranked parameters in wished-for improvement while high-flexion activity constituted the top source of discontent. Wished-for improvement was high in seven parameters, the top three being restoration of daily living activities, pain relief, and high-flexion activity. The effects of sociodemographic factors on satisfaction levels and wished-for improvement varied. Satisfaction levels correlated positively with functional outcomes, and satisfaction in pain relief and restoration of daily living activities correlated more often and most strongly with clinical scores.

Conclusions

Following TKA, patient satisfaction is not high for a number of issues, with improvements clearly needed in restoring daily living activities and relieving pain. Continued efforts to achieve better surgical outcomes should address patient-perceived shortcomings.

Continuous Improvements of a Clinical Pathway Increased Its Feasibility and Improved Care Providers' Perception in TKA

Purpose

We aimed to determine 1) whether dropout rate decreased and 2) whether health care providers' perceptions were changed with continued improvements of contents of clinical pathway (CP) for total knee arthroplasty (TKA).

Materials and Methods

This retrospective study included two separate analyses of patients and health care providers. In the analysis of patients, dropout rates and reasons were evaluated in two cohorts of patients who underwent TKA with CP applied at two different time periods (384 patients from 2009 to 2010 and 242 patients from 2012 to 2013). Contents of CP were continuously improved during the 3-year interval. Self-administered questionnaire surveys targeted to health care providers were carried out twice (2010 and 2013) and compared.

Results

Dropout rate decreased from 19.1% in the first time period to 10.4% in the second time period. Although overall satisfaction of care providers was high at both time-points, doctors had more favorable perceptions than nurses; most positive changes of perception were noted in nurses. The health care providers' perceptions for potential concerns of CP were improved while the perceptions for potential benefits and satisfaction were maintained.

Conclusions

Continuously improved CP has increased feasibility for TKA patients and reduced health care providers' concern about its value. We propose that CP can be implemented and actively used to improve the outcomes and efficacy of patient care for TKA, regardless of the rotation of care providers.

Neurophysiological study on sensorimotor control mechanism in superior colliculus of echolocating bat

This paper investigates the neural processes associated with bat sonar vocal production and their relationship with spatial orientation. The bat's heavy reliance on sound processing is reflected in specializations of auditory and motor neural structures. These specializations were utilized by investigating the mammalian superior colliculus (SC); a midbrain sensory motor nucleus mediating orientating behaviours in mammals, including vocal motor orientating. Behavioural and neurophysiological experiments were conducted in the insectivorous echolocating bat, Eptesicus fuscus. Chronic neural recording techniques were specifically developed to study neuronal activity. Potential application of the results on control systems is also addressed.

Insulin sensitivity in physically fit and unfit children of parents with Type 2 diabetes

AIMS

First-degree relatives of patients with Type 2 diabetes mellitus (T2DM) are often reported to be insulin resistant. We wanted to identify early metabolic abnormalities in this condition, and determine whether they are altered by regular physical training.

METHODS

We measured insulin sensitivity using the euglycaemic glucose clamp technique and insulin response to oral glucose in 10 unfit (did not participate in routine physical exercise) offspring of T2DM parents and 10 unfit control subjects, and compared them with six fit (routinely swam for 3 h/day 5 days/week) offspring of T2DM parents and six fit controls with no family history of T2DM.

RESULTS

Unfit offspring had a higher plasma glucose response than the other three groups. The mean area under the glucose curve was also significantly higher in unfit offspring than in the other three groups (12.6 +/- 0.6 vs. 10.4 +/- 0.4, 9.6 +/- 0.5, and 9.5 +/- 0.7 mmol/l per hour for the unfit controls, fit offspring and fit controls, respectively; P < 0.05). The corresponding insulin response of unfit offspring was significantly higher at 60 min in the oral glucose tolerance test (OGTT) that that of fit offspring or fit controls. In addition, the mean area under the insulin curve was significantly greater in unfit offspring than in either fit offspring or fit controls (868 +/- 172 vs. 294 +/- 71, 287 +/- 43 mmol/l per hour, respectively; P < 0.05). Moreover, the glucose disposal rate (GDR), measured using a euglycaemic clamp, was significantly lower in unfit and fit offspring than in unfit and fit controls (5.6 +/- 0.3 vs. 8.6 +/- 0.3 mg/kg per minute; P < 0.01 and 9.3 +/- 0.9 vs. 12.1 +/- 0.8 mg/kg per minute, respectively; P < 0.015), whereas the GDR was similar in unfit controls and fit offspring (8.6 +/- 0.4 vs. 9.3 +/- 0.9 mg/kg per minute; P > 0.05).

CONCLUSION

These results support the concept that early metabolic abnormalities, as reflected by a decreased GDR (insulin sensitivity) in the offspring of T2DM patients, may be improved by increased physical fitness.

Therapeutic effect of recombinant human erythropoietin on anaemia with erythropoietin deficiency in diabetic patients

AIMS

The aim of this study was to investigate the therapeutic effect of recombinant human erythropoietin (rHuEpo) on anaemia with erythropoietin deficiency in diabetic patients.

METHODS

Twenty diabetic patients with anaemia and Epo deficiency were enrolled. All patients were treated with rHuEpo (Epokine; 4000 U/day s.c., three times a week) for 8 weeks.

RESULTS

The responder group (n = 14) had significant increments in haemoglobin compared with the non-responder group (n = 6) (P < 0.05). No significant differences were found between the responder and non-responder groups in terms of duration of diabetes mellitus, serum creatinine level, 24-h urine albumin excretion rates, frequency of diabetic microangiopathy, or HbA1c. There was no difference between the two groups in terms of serum iron and total iron-binding capacity (TIBC). Serum ferritin level was significantly higher in the responder group than in the non-responder group (240.3 +/- 108.4, 25.8 +/- 3.0 micro g/l, P < 0.05), as was transferrin saturation (32.7 +/- 7.9%, 21.2 +/- 5.3%, P < 0.05).

CONCLUSIONS

rHuEpo could be useful in the treatment of anaemia with erythropoietin deficiency in diabetic patients, and the degree of iron storage and functional iron deficiency might be the main cause of hyporesponsiveness to rHuEpo.

Clinical characteristics, GAD antibody (GADA) and change of C-peptide in Korean young age of onset diabetic patients

AIMS

To investigate the association of clinical and immunological markers with diabetes classification in newly diagnosed young diabetic patients at disease onset.

METHODS

Eighty-two diabetic patients recruited within 1 year of onset (mean age 23.0 +/- 7.1, M:F = 46:36) were divided into three groups, namely: a low fasting C-peptide (FC) level at baseline group (the low FC group (n = 14, FC < 0.18 nmol/l)), an intermediate FC group (n = 29, 0.18 nmol/l < or = FC < 0.37 nmol/l), and a high FC group (n = 39, 0.37 nmol/l < or = FC). Patients were reclassified at follow-up (mean follow-up period 3.7 +/- 1.4 years) in the same manner as described above into low FC group (n = 31), intermediate FC group (n = 20), and high FC group (n = 31). The clinical characteristics and prevalence of GADA were compared.

RESULTS

Patients in the high FC group at baseline had a higher body mass index (BMI), a higher frequency of a family history of diabetes, a higher meal-stimulated C-peptide increment, a lower frequency of ketonuria, a lower frequency of history of diabetic ketoacidosis, and a lower frequency of insulin therapy at diagnosis than those in the low and intermediate FC groups at baseline. Insulin secretory capacity, which was represented by fasting C-peptide, was affected by BMI at diagnosis and the presence of GADA. All the patients of the low FC group on follow-up were finally classified as having Type 1 diabetes; moreover, the factors that determined the type of diabetes were lower BMI at onset, GADA positivity, insulin therapy, lower fasting C-peptide level and lower meal-stimulated C-peptide increment at initial admission.

CONCLUSIONS

Our study suggests that follow-up involving C-peptide and GADA measurements in combination with clinical characteristics is useful for discriminating between the types of diabetes in these groups.

(AC)(n) polymorphism of aldose reductase gene and diabetic microvascular complications in type 2 diabetes mellitus

Recent studies suggest that the gene encoding aldose reductase, the enzyme that converts glucose to sorbitol, may confer susceptibility to microvascular disease. The aim of this study therefore, was to investigate the relationship between the aldose reductase gene and type 2 diabetic microvascular complications such as diabetic nephropathy and retinopathy. DNA from 127 Korean patients with type 2 diabetes was typed for an (AC)(n) dinucleotide repeat polymorphic marker at the 5'-end of the aldose reductase gene using polymerase chain reaction. No significant difference in the frequency of the putative risk allele Z-2 was found in patients of nephropathy and retinopathy groups compared with the uncomplicated group (32.2, 34.1 vs. 25.1%, respectively, P>0.05). Similarly, no difference was found in the frequency of the putative protective allele Z+2 among any of the study groups. In conclusion, the results of the study in Korean type 2 diabetic patients do not support the hypothesis that polymorphism at the 5' end of the aldose reductase gene contributes to the susceptibility to diabetic microvascular complications.

Polycystic ovarian syndrome (PCOS) and insulin resistance

OBJECTIVES

Polycystic ovary syndrome (PCOS) presents a high risk of developing type 2 diabetes mellitus. We studied a group of women with PCOS and evaluated this defect in insulin action.

METHODS

The study population consisted of nine PCOS women, six obese type 2 diabetic patients, and five controls whose body mass index (BMI) was similar to that of the nine PCOS women. The 75-g oral glucose tolerance test (OGTT) and the hyperinsulinemic euglycemic glucose clamp test were performed. Clinical characteristics and the metabolic profiles, including the insulin sensitivity index (ISI), were compared.

RESULTS

PCOS women showed significantly elevated insulin responses during OGTT, but their blood glucose levels were comparable with the controls. The subjects with PCOS had more insulin resistance than the other groups. There was no difference among the groups in terms of clinical characteristics and metabolic profiles, except age, luteinzing hormone (LH), testosterone, and sex hormone binding globulin (SHBG).

CONCLUSION

We conclude that PCOS women have significant insulin resistance which is independent of adiposity.

Low-dose growth hormone treatment combined with diet restriction decreases insulin resistance by reducing visceral fat and increasing muscle mass in obese type 2 diabetic patients

OBJECTIVE

To evaluate the effects of low-dose growth hormone (GH) therapy combined with diet restriction on changes in body composition and the consequent change in insulin resistance in newly-diagnosed obese type 2 diabetic patients.

DESIGN

Double-blind and placebo-controlled trial of 25-kcal/kg IBW diet daily with GH (n=9; rhGH, 0.15 IU/kg body weight/week) or placebo (n=9) for 12 weeks.

SUBJECTS

Eighteen newly-diagnosed obese type 2 diabetic patients (age 42--56 y, body mass index 28.1+/-2.7 kg/m(2)).

MEASUREMENTS

Body composition and fat distribution parameters (by bioelectrical impedance analyzer and CT scans), serum IGF-1; serum glucose, insulin and free fatty acid (FFA) during oral glucose tolerance test (OGTT); HbA(1c); serum lipid profiles; and glucose disposal rate (GDR) by euglycemic hyperinsulinemic clamp at baseline and after treatment.

RESULTS

The fraction of body weight lost as fat lost was significantly greater (0.98+/-0.39 vs 0.52+/-0.32 kg/kg, P<0.05) and visceral fat area was decreased more in the GH-treated group compared to the placebo-treated group (27.9 vs 21.6%, P<0.05). Lean body mass and muscle area were reduced in the placebo-treated group, whereas an increase in both was observed in the GH-treated group. GDR the was significantly increased in only the GH-treated group (4.67+/-1.05 vs 6.95+/-0.91 mg/kg/min, P<0.05). The GH-induced increase in GDR was positively correlated with the decrease in the ratio of visceral fat area/muscle area (r=0.588, P=0.001). Serum glucose levels and insulin- and FFA-area under the curve during OGTT and HbA(1c) were significantly decreased after GH treatment. LDL-cholesterol level was decreased in only the GH-treated group.

CONCLUSION

Low-dose GH treatment combined with dietary restriction resulted not only in a decrease of visceral fat but also in an increase of muscle mass with a consequent improvement of the insulin resistance observed in obese type 2 diabetic patients.

beta-Cell dysfunction rather than insulin resistance is the main contributing factor for the development of postrenal transplantation diabetes mellitus

BACKGROUND

Our study was undertaken to investigate the pathogenesis and possible risk factors for postrenal transplantation diabetes mellitus (PTDM).

METHODS

We recruited 114 patients with normal glucose tolerance (NGT) and performed both 75-g oral glucose tolerance tests (OGTT) and short insulin tolerance tests 1 week before and 9-12 months after transplantation.

RESULTS

The subjects were classified into three groups by World Health Organization criteria on the basis of OGTT after transplantation: (a) 36 (31.6%) subjects with normal glucose tolerance; (b) 51 (45.7%) subjects with impaired glucose tolerance (IGT); and (c) 27 (23.7%) subjects with postrenal transplantation diabetes mellitus. Dosages of steroid and cyclosporine were equivalent among the three groups. Before transplantation, the fasting and 2-hr plasma glucose and proinsulin/insulin (PI/I) ratios were significantly higher in the IGT and PTDM groups than in the NGT group, but the insulin sensitivity index (ISI) was not significantly different among the three groups. In addition, the area under the curve-insulin on OGTT was significantly lower in the PTDM group than in the NGT group. After transplantation, however, the ISI was increased in all groups. Furthermore, the ISI and PI/I ratios revealed significantly higher values in the PTDM group than in the NGT group after transplantation.

CONCLUSIONS

These results revealed that fasting and 2-hr plasma glucose levels, as well as the proinsulin/insulin ratio before transplantation, are both possible indicators of beta-cell dysfunction and may be predictors for the development of PTDM. Furthermore, beta-cell dysfunction, rather than insulin resistance, was proven to be the main factor for the pathogenesis of PTDM.

Decrease in carotid intima media thickness after 1 year of cilostazol treatment in patients with type 2 diabetes mellitus

A multicenter exploratory study at three university hospitals was performed to evaluate the effect of oral cilostazol on intima media thickness (IMT) in diabetic patients. A total of 141 patients was recruited in this study and randomized into a cilostazol group and a placebo (control) group. One hundred and twenty patients completed the study (i.e. 60 on cilostazol and 60 on placebo). Biochemical profiles and the IMT of the common carotid artery (CCA) determined by high-resolution B-mode ultrasonography were measured at 0, 6, and 12 months after the oral administration of 100--200 mg of cilostazol or placebo (i.e. two or four times daily for 12 months). Clinical and biochemical characteristics, the treatment modality, and microvascular diabetic complications after randomization were not significantly different between the two groups after the study. In the cilostazol treatment group, left CCA average IMT significantly decreased from 0.94+/-0.03 to 0.91+/-0.02 mm at 6 months (P<0.05), and thereafter increased to 0.92+/-0.01 mm (P>0.05) at 12 months, whereas in the control group, it increased from 0.92+/-0.03 to 0.93+/-0.01 mm at 6 months (P>0.05), and to 0.94+/-0.01 mm at 12 months (P>0.05). As for the right CCA average IMT, it decreased from 0.83+/-0.03 to 0.82+/-0.01 mm at 6 months (P<0.05), and to 0.81+/-0.01 mm at 12 months (P<0.05) in the cilostazol group, whereas it increased from 0.87+/-0.03 to 0.89+/-0.01 mm at 6 months (P<0.05), and to 0.90+/-0.01 mm at 12 months (P<0.05) in the control group (P<0.05). After correction for risk factors such as blood pressure, smoking, and lipid profiles, there were significant changes in left and right CCA average IMT for both groups (P<0.05). Left and right CCA average IMT was significantly different between the two groups (P<0.05). After making statistical corrections for blood pressure, smoking, and lipid profiles, the differences between these two groups remained significant (P<0.05). Meanwhile, there were no differences between the groups in the change of risk factors such as BMI, blood pressure, blood sugar, HbA(1c), and lipid profiles. Generally, cilostazol was well tolerated and the most common side effect in the cilostazol group was headache (12/60), mostly early in the treatment regimen. The results suggest that oral cilostazol may be helpful in the treatment of atherosclerosis in type 2 diabetic patients, although conventional cardiovascular risk factors remained unmodified.

Mutation in hepatocyte nuclear factor-1alpha is not a common cause of MODY and early-onset type 2 diabetes in Korea

Maturity-onset diabetes of the young (MODY)-3 with a mutation in hepatocyte nuclear factor (HNF)-1alpha has been identified in most races, but the prevalence of Korean MODY and early-onset type 2 diabetes with a mutation in this gene is unknown. To determine the prevalence of MODY and early-onset type 2 diabetes with the mutation of HNF-1alpha gene in Korea, we analyzed this gene in 69 Korean early-onset type 2 diabetics and in 35 healthy persons using the single-strand conformation polymorphism (SSCP) technique and direct sequencing. We identified one mutation in exon 4 (C900A) in only one of the 69 Korean subjects with early-onset type 2 diabetes; this mutation was silent and did not change the amino acid (Pro300). Additionally, we identified four polymorphisms: S487N, AAC-->AGC, intron 2 (nt -23), intron 7: (nt +7) and intron 9 (nt -24). However, there was no significant difference in frequencies of the four polymorphisms between the type 2 diabetes and control groups. Among type 2 diabetics, codon 487 variant showed no relationship to age at onset, body mass index, fasting blood glucose, HbA1c, lipid profile, basal C-peptide and 2 hour C-peptide. We concluded that this genetic mutation in HNF-1alpha gene may not be a common contributor to MODY and early-onset type 2 diabetes susceptibility in Korea.

Identification of glucokinase mutation in subjects with post-renal transplantation diabetes mellitus

Mutations in the glucokinase (GCK) gene are considered to be a possible cause of maturity-onset diabetes of the young. The purpose of this study was to evaluate the contribution of this gene to the development of post-renal transplantation diabetes mellitus (PTDM). Identification of the GCK mutation was attempted in 58 selected renal allograft recipients with PTDM and 45 normal controls. The exons in the GCK gene were examined using polymerase chain reaction (PCR), followed by an analysis of single-stranded DNA conformational polymorphism (SSCP). The abnormal bands were then confirmed by DNA sequencing analysis. The family members of the patients affected with GCK mutation were also examined. Two of the 58 PTDM patients (3. 4%) were found to have GCK mutations. One had the mutation on exon 5 and the other on intron 7. One control subject had the mutation on intron 9. The mutation on exon 5 was identified as a substitution of CCT (proline) for CTT (leucine) at codon 164, which has never been reported before. The family members of the PTDM patient with a mutation on exon 5 were analyzed by PCR, followed by SSCP, and two of them had the same mutation. The abnormal band seen on SSCP analysis of exon 7 was identified as the C-->T substitution at the 39th nucleotide in intron 7. Two of the family members also displayed the same bands on the SSCP. One of the 45 normal controls had a known polymorphism located at the 8th nucleotide in intron 9. We found a GCK mutation on the exon in subjects with PTDM and we speculate that this mutation may be one of the possible contributing factors of PTDM, although variations of the GCK gene are not common causes of PTDM.

Chronic alcohol intake differently influences glucose metabolism according to nutritional status

We investigated the potential different effects of a chronic alcohol intake on glucose metabolism according to nutritional status in growing rats. Eighty weanling 4-week-old male Sprague Dawley rats were fed with low (5%, wt/wt) or control (22%) protein diet for 8 weeks. Each group was subdivided into alcohol (5 g/kg(-1) x day(-1)) or saline gavage rats during the last 4 weeks. At 12 weeks of age, we measured the weights of the body, pancreas, and epididymal fat; glycogen synthase activity of gastrocnemius muscle; and insulin content of the pancreas. We performed an ip glucose tolerance test and a euglycemic hyperinsulinemic clamp test. Weight gain was almost arrested in protein-deficient rats. The relative weight and insulin content of the pancreas and glycogen synthase activity were not different among the four groups, but the relative amount of epididymal fat decreased only in protein-deficient saline rats. Insulin response after glucose challenge and glucose disposal rate during the euglycemic clamp were both markedly decreased in protein-deficient saline rats, but not changed in protein-deficient alcohol rats. Protein-deficiency per se causes deterioration both in insulin secretory function and in sensitivity, but these defects are protected by a chronic alcohol intake. In a protein-sufficient state, alcohol intake gives no additional effects on glucose metabolism. Therefore, according to individual nutritional status, the metabolic effect of alcohol intake appears differently.

Reduced erythropoietin responsiveness to anemia in diabetic patients before advanced diabetic nephropathy

We often encounter diabetic patients with anemia in whom the causes of anemia were not clearly identified despite differential hematologic studies. We therefore studied the clinical and biochemical characteristics of diabetic patients with anemia of uncertain cause and measured erythropoietin (Epo) concentrations in 35 diabetic subjects without significant diabetic renal disease. Among 62 medical records of diabetic patients with anemia, showing no evidence of advanced diabetic nephropathy (creatinine clearance > or = 30 mg/kg/1.73 m2), the causes of the anemia were not able to be identified in 28 cases (45.2%). In addition, we enrolled 35 diabetic patients with uncertain causes of anemia in order to evaluate the serum Epo responsiveness to anemia, and compared levels to a group of non-diabetic subjects also with anemia. The serum Epo concentrations of diabetic patients (17.6 +/- 8.1 mIU/ml) were significantly lower than those of non-diabetic patients with similar degree of decrease in hemoglobin concentrations (144.9 +/- 108.0 mIU/ml, P<0.001). The hemoglobin concentrations of diabetic patients correlated with creatinine clearance (r = 0.34, P = 0.03), serum creatinine (r = -0.49, P = 0.003) and albumin excretion rate (r = -0.44, P = 0.009), but showed no relation to age, duration of diabetes, glycated hemoglobin, presence of retinopathy or neuropathy. We concluded that reduced Epo responsiveness to anemia could explain the anemia present in diabetic patient but without advanced diabetic nephropathy. This may reflect early renal interstitial damage.

Effects of long-acting somatostatin analogue (Sandostatin) on manifest diabetic ketoacidosis

Insulin deficiency and counterregulatory hormone excess are the basic process in the development of diabetic ketoacidosis (DKA). Somatostatin, which suppresses the secretion of glucagon and growth hormone, has been known to attenuate the rate of gluconeogesis and ketogenesis in insulin-dependent diabetes mellitus patients. However, the therapeutic efficacy of somatostatin has not been approved to be practical in the treatment of manifest DKA. To examine the additive effect of octreotide, the synthetic long-acting somatostatin analogue SMS 201-995, to conventional treatment of manifest DKA, we compared the correction time of acidosis, ketonuria, and hyperglycemia of patients treated with an intravenous infusion of low-dose insulin (4 units per hour) plus subcutaneous injection of octreotide (50 microg every 6 hours) by low-dose insulin alone. The correction time for hyperglycemia and acidosis did not show any difference between groups (p = 0.089, p = 0.82). However, the time for disappearance of ketonuria of the octreotide-treated group (38.0 +/- 32.0 h) was reduced significantly compared to other group (68.3 +/- 26.0 h) (p = 0.048). These results indicated that the addition of octreotide to conventional treatment of DKA might improve the correction of ketosis, but would not allow more rapid control of acidosis and hyperglycemia in manifest DKA.

Low-dose growth hormone treatment with diet restriction accelerates body fat loss, exerts anabolic effect and improves growth hormone secretory dysfunction in obese adults

Growth hormone (GH) can induce an accelerated lipolysis. Impaired secretion of GH in obesity results in the consequent loss of the lipolytic effect of GH. Dietary restriction as a basic treatment for obesity is complicated by poor compliance, protein catabolism, and slow rates or weight loss. GH has an anabolic effect by increasing insulin-like growth factor (IGF)-I. We investigated the effects of GH treatment and dietary restriction on lipolytic and anabolic actions, as well as the consequent changes in insulin and GH secretion in obesity. 24 obese subjects (22 women and 2 men; 22-46 years old) were fed a diet of 25 kcal/kg ideal body weight (IBW) with 1.2 g protein/kg IBW daily and were treated with recombinant human GH (n = 12, 0.18 U/kg IBW/week) or placebo (n = 12, vehicle injection) in a 12-week randomized, double-blind and placebo-controlled trial. GH treatment caused a 1.6-fold increase in the fraction of body weight lost as fat and a greater loss of visceral fat area than placebo treatment (35.3 vs. 28.5%, p < 0.05). In the placebo group, there was a loss in lean body mass (-2.62 +/- 1.51 kg) and a negative nitrogen balance (-4.52 +/- 3.51 g/day). By contrast, the GH group increased in lean body mass (1.13 +/- 1.04 kg) and had a positive nitrogen balance (1.81 +/- 2.06 g/day). GH injections caused a 1.6-fold increase in IGF-I, despite caloric restriction. GH response to L-dopa stimulation was blunted in all subjects and it was increased after treatment in both groups. GH treatment did not induce a further increase in insulin levels during an oral glucose tolerance test (OGTT) but significantly decreased free fatty acid (FFA) levels during OGTT. The decrease in FFA area under the curve during OGTT was positively correlated with visceral fat loss. This study demonstrates that in obese subjects given a hypocaloric diet, GH accelerates body fat loss, exerts anabolic effects and improves GH secretion. These findings suggest a possible therapeutic role of low-dose GH with caloric restriction for obesity.

The validity of random urine specimen albumin measurement as a screening test for diabetic nephropathy

To assess the validity of urine albumin concentration (UAC) and the urine albumin:creatine ratio (UACR) in a random urine specimen (RUS) for screening diabetic nephropathy in Korea, a total of 105 ambulatory diabetes mellitus patients (male:female, 52:53), ages 40-75 years (median 59 years) collected 105 RUSs after completing a timed 24 hour urine collection. Albumin was measured by immunonephelometry. According to the timed urinary albumin excretion rate (UAER) measured in the 24 hour collection (criterion standard), samples were classified normoalbuminuric (UAER < 20 micrograms/min; n = 50), microalbuminuric (UAER 20-200 micrograms/min; n = 30), and macroalbuminuric (UAER > 200 micrograms/min; n = 25). The receiver operating characteristics (ROC) curve of UAC and UACR in a RUS for screening of microalbuminuria (normo- and microalbuminuric samples; n = 80) and macroalbuminuria (micro- and macroalbuminuric samples; n = 55) were plotted. Pearson's coefficients of correlation of 24 hour UAER vs. UAC and UACR were 0.81 and 0.75, respectively (P < 0.001). The point of intersection with a 100%-to-100% diagonal for microalbuminuria were as follows: 31.0 mg/l for UAC and 32.5 mg/g for UACR; for macroalbuminuria 181 mg/l for UAC and 287.3 mg/g for UACR. The sensitivity and specificity of the cut-off points for microalbuminuria were 77% and 82% for UAC and 77% and 92% for UACR. The sensitivity and specificity of the cut-off points for macroalbuminuria were 84% and 90% for UAC and 88% and 90% for UACR. In present study, no difference was observed when comparing the performance of UAC and UACR based on a statistical comparison by McNemar test. The repeated measurements of UAC and UACR in the same individual were statistically similar and were correlated with each other. Based on these results, albumin measurements (UAC and UACR) in a RUS were considered as a valid test for screening diabetic nephropathy.

GH-binding protein in obese men with varying glucose tolerance: relationship to body fat distribution, insulin secretion and the GH-IGF-I axis

Bioelectrical impedance for measurement of total body fat and computed tomography for visceral and subcutaneous fat at umbilicus levels were performed in 34 obese and 10 lean men. Insulin secretion in response to an oral glucose tolerance test (OGTT) and a GH stimulation test by L-dopa, growth hormone-binding protein (GHBP) and IGF-I were measured. Obese subjects were divided into three groups according to the OGTT. The obese type II diabetes mellitus group had the highest GHBP levels and the most visceral fat. GHBP levels were most strongly correlated with the ratio of visceral fat area to body weight (VWR) above any other parameters (r = 0.725, P<0.001). The insulin and free fatty acid (FFA) areas under curves (AUC) during the OGTT, and the IGF-I level, were also positively correlated with GHBP levels (r = 0.474, P<0.005; r = 0.572, P<0.005; r = 0.453. P<0.005). GH-AUC to the L-dopa stimulation test was negatively correlated with GHBP levels (r = -0.432. P<0.005). Stepwise multiple linear regression analysis showed that VWR, FFA-AUC and insulin-AUC significantly contributed to the variability of GHBP (r2 = 0.58). In conclusion, we demonstrated that: (i) visceral fat amount mainly determined GHBP levels in obese men with varying glucose tolerance: (ii) hyperglycemia per se did not influence the GHBP level, whereas insulin and FFA could play a role in regulation of GHBP: and (iii) although GH was not the main regulator of GHBP, the unchanged IGF-I level despite GH hyposecretion suggests that increased GHBP levels reflect GH hypersensitivity in order to compensate for decreased GH secretion in obesity.

Effect of obesity on total and free insulin-like growth factor (IGF)-1, and their relationship to IGF-binding protein (BP)-1, IGFBP-2, IGFBP-3, insulin, and growth hormone

OBJECTIVES

We investigated the effect of obesity on the serum levels of total and free IGF-1 and their relationship to the circulating levels of insulin and IGF binding proteins (IGFBPs) in age and sex-matched groups.

SUBJECTS

The study included 43 obese subjects (ideal body weight; IBW > 120%) and 45 controls (IBW < 100%). All of the subjects were male.

MEASUREMENT

Total IGF-1, free IGF-1, IGFBP-1, IGFBP-2, IGFBP-3, and insulin were measured in obese subjects and normal control subjects.

RESULTS

No significant differences in the circulating levels of total and IGFBP-3 were observed between the obese and control groups. In contrast to total IGF-1, free IGF-1 in obese subjects was significantly increased compared to normal controls (P < 0.05). Serum total and free IGF-1 were inversely correlated with age (r = -0.42, P = 0.001, and -0.44, P = 0.001). Fasting serum insulin concentrations were elevated in all the obese subjects (P < 0.05) and positively correlated with IBW (r = 0.57, P = 0.001). The levels of serum GH and IGFBP-1 were suppressed in all the obese subjects (P < 0.05). IGFBP-1 was inversely correlated with IBW (r = -0.51, P = 0.001) and serum insulin concentrations (r = -0.48, P = 0.001). The IGFBP-2 concentrations were also suppressed in obese subjects and inversely related to free IGF-1 (r = -0.48, P = 0.001). Using multiple linear regression analysis, total IGF-1 and insulin concentrations were positively correlated (r = 0.58, P = 0.001) and free IGF-1 and IGFBP-1 concentrations were negatively correlated (r = -0.57, P = 0.001).

CONCLUSION

We confirmed that total IGF-1 and IGFBP-3 concentrations were not significantly different between the obese and control groups, despite GH hyposecretion in obesity. We also found that free IGF-1 concentrations were higher in obese subjects than in normal controls. It seems likely that overnutrition and chronic hyperinsulinaemia in obesity may alter this regulated growth response by insulin stimulation of IGF-1 production and suppression of hepatic IGFBP-1 and IGFBP-2 production, which may inhibit IGF-1 bioactivity.

Mitochondrial gene transfer ribonucleic acid (tRNA)Leu(UUR) 3243 and tRNA(Lys) 8344 mutations and diabetes mellitus in Korea

The high prevalence of diabetic patients with a mutation in the mitochondrial gene (the 3243 and 8344 bp mutations) has been identified in Japan. To determine the prevalence of diabetic patients with those mutations in Korea, we randomly screened selected 503 clinical diabetic patients regardless of their diabetes types. We found only 1 patient with the mitochondrial DNA mutation at position 3243 (percent mutation, 32%), and the mitochondrial DNA mutation at position 8344 was not found in any of the patients. The affected subject was a 22-yr-old man with a history of myoclonic epilepsy and mild sensorineural hearing loss, a 1-yr duration of diabetes mellitus, and a low level C peptide response to oral glucose. Because of the low frequency of these mutations in the Korean diabetic population, we concluded that these particular mutations of mitochondrial DNA may not be a common contributor to diabetes mellitus in Korea.

The role of insulin resistance in Korean patients with coronary atherosclerosis

To determine whether dietary modification improves insulin resistance and coronary atherosclerosis, we randomly assigned 14 Korean patients to an experimental group (low-fat, low-cholesterol diet, high polyunsaturated/saturated fatty acid ratio, and calorie restriction) or to a control group (no dietary change). Coronary artery lesions were analyzed by quantitative coronary angiography, and postglucose insulin responses were measured. At baseline, there were no significant differences in body weight, BMI, waist-to-hip ratio (WHR), and plasma lipid and insulin levels between the two groups. After completion of the 1-year diet program, the experimental group showed significant reductions in body weight (66.0 +/- 3.2 to 61.6 +/- 3.8 kg [means +/- SE], P < 0.01) and WHR (O.96 +/- 0.01 to 0.93 +/- 0.01, P < 0.05). Total cholesterol (5.45 +/- 0.45 to 4.50 +/- 0.44 mmol/l, P < 0.05), LDL cholesterol (3.71 +/- 0.36 to 2.98 +/- 0.37 mmol/l, P < 0.05), and triglyceride (1.91 +/- 0.28 to 1.29 +/- 0.17 mmol/l, P < 0.05) were also significantly reduced in the experimental group. The mean insulin response during an oral glucose tolerance test was also significantly decreased (258.6 +/- 26.4 to 181.8 +/- 6.6 pmol/l, P < 0.05). In contrast, there were no significant changes in these parameters in the control group. When only coronary artery lesions > 50% stenosed were analyzed, the average percentage diameter stenosis regressed from 63.2 to 56.8% in the experimental group. However, there were no significant changes in the control group. Our trial suggests that decreases in body weight and WHR and an improvement in insulin resistance with a low-fat, low cholesterol diet and caloric restriction may reduce risk factors and reverse coronary atherosclerotic lesions in 1 year.

Swelling of the vesicle is prerequisite for PTH secretion

Unlike most secretory cells, high extra cellular calcium inhibits rather than stimulates hormonal secretion in several cells such as parathyroid cells, Juxtaglomerular cells and osteoclast. To gain further insight into the common but unique stimulus-secretion coupling mechanism in these cells, bovine parathyroid slices were incubated in various conditions of Krebs-Ringer (KR) solution containing essential amino acids. Parathyroid cells showed the inverse dependency of secretion on extra cellular calcium concentration as we expected. Ammonium acetate overcame the inhibitory effect of 2.5 mM of calcium and the maximum effect was as much as the five times of the basal value, while there was a little additive effect under 0 mM CaCl2. PTH secretion was biphasic according to the change of extra cellular osmolarity and the lowest response was observed at 300 mOsm/l. In Na-rich KR solution, high concentration of nigericin (> 10(-4)M) completely overcame the inhibitory effect of 2.5 mM CaCl2 and the maximum stimulatory effect was 8 times greater whereas it was only 2 times greater without CaCl2. In K-rich KR solution that abolished the K-gradient between the extra cellular solution and the cytoplasm, the rate of PTH secretion increased, and furthermore the addition of nigericin increased the rate of secretion significantly. The results above suggested that the osmotic swelling of the secretory vesicle in parathyroid cells might promote exocytosis as in Juxtaglomerular cells. We propose that the swelling of the vesicle is also prerequisite for secretion in several cells inhibited paradoxically by Ca++, whatever the signal transduction pathway for swelling of the secretory granules induced by the lowering of Ca++ in cytoplasm are.

Lack of association between vitamin D receptor genotypes and osteoporosis in Koreans

To evaluate whether common allelic variants in the gene encoding the vitamin D receptor (VDR) were useful in predicting differences in bone mineral density (BMD) and bone turnover rate in Koreans, we analyzed the restriction pattern of the polymerase chain reaction product of the VDR gene with the Bsm1 enzyme and serum osteocalcin in patients with osteoporosis. The prevalence of the BB genotype in the controls was extremely low when compared with that in other reports: the BB, Bb, and bb genotypes accounted for 1.4%, 12.9%, and 85.7%, respectively. Only 2.8% of those patients with osteoporosis had the BB genotype. In contrast, 12.5% had the Bb genotype, and 84.7% had the bb genotype. The prevalence of the BB genotype in patients with severe osteoporosis was also extremely low: the BB, Bb, and bb genotypes accounted for 0%, 12.4%, and 87.6%, respectively. Compared with the mean serum osteocalcin level of the pre- and post-menopausal controls, the level in patients with severe osteoporosis was higher, and this was statistically significant. As expected, a negative correlation was observed between the serum osteocalcin levels and the age-matched Z scores for spinal BMD. However, no correlation was found in the femoral neck BMD. These results suggest that restriction fragment length polymorphism analysis of the VDR gene with a Bsm1 restriction enzyme in Koreans is not helpful for early detection of patients at risk of developing osteoporosis. This is true even in patients with a high rate of bone turnover. Our data suggest extreme ethnic differences in the pattern of prevalence of the VDR allele.

Acipimox potentiates growth hormone response to growth hormone-releasing hormone by decreasing serum free fatty acid levels in hyperthyroidism

Hyperthyroidism is associated with an impairment of growth hormone (GH) responses to secretagogues. The aim of this study was to evaluate the effect of acipimox, an antilipolytic agent able to decrease free fatty acids (FFA), on GH response to GH-releasing hormone (GHRH) in hyperthyroid and normal control subjects. We studied six men with hyperthyroidism; seven normal men served as control subjects. Each subject underwent treatment with (1) 2 tablets of placebo orally or (2) 500 mg acipimox orally, 120 minutes before intravenous (IV) injection of 1 microgram/kg GHRH-(1-29)NH2. GH response to GHRH in hyperthyroid patients was markedly reduced; the mean peak GH response (9.6 +/- 1.0 microgram/L) and the area under the GH response curve (12.9 +/- 1.3 micrograms/L x 2 h) were lower than those of control subjects (25.7 +/- 1.8 micrograms/L, P < .05; 28.7 +/- 2.1 micrograms/L x 2 h, P < .05). Hyperthyroid patients had higher baseline levels of plasma FFA than control subjects (998.0 +/- 38.9 v 498.0 +/- 36.0 muEq/L, P < .01). Acipimox decreased FFA levels in both hyperthyroid and control subjects; the lowest FFA levels of hyperthyroid subjects induced by acipimox were similar to those of control subjects. After acipimox pretreatment, GH responses to GHRH increased significantly (P < .05); the mean peak plasma GH level (25.9 +/- 4.6 micrograms/L) was similar to the peak GH levels of control subjects during the GHRH test, and the area under the GH response curve (41.1 +/- 6.7 micrograms/L x 2 h) was even higher than that of control subjects with the GHRH test.(ABSTRACT TRUNCATED AT 250 WORDS)

Acipimox potentiates growth hormone (GH) response to GH-releasing hormone with or without pyridostigmine by lowering serum free fatty acid in normal and obese subjects

Obesity is associated with an impairment of normal GH secretion and blunted responses to all stimuli. Recent reports suggest that increased somatostatinergic activity is the basis for the GH derangement of obesity. However, the basic mechanism of this alteration is still being debated. The high plasma free fatty acid (FFA) is frequently observed in obesity. FFA participates in the regulation of pituitary GH secretion. To determine whether the derangement of GH secretion in obesity is associated with high plasma FFA levels, several tests with GHRH with or without pyridostigmine (PYR) and acipimox (ACX), antilipolytic agents able to decrease FFA, were undertaken in six obese and seven normal control subjects. In obese subjects, the GH response (mean peak +/- SEM: 8.9 +/- 1.1 ug/L) to GHRH-(1-29) (1 ug/kg, i.v.) was significantly blunted when compared with the response in normal control subjects (25.7 +/- 1.8 ug/L; P < 0.05). After PYR (120 mg), the response to GHRH was enhanced in the obese subjects (21.4 +/- 4.9 ug/L; P < 0.05) and was similar to that of the controls with GHRH only, but remained significantly reduced compared with controls treated with PYR plus GHRH (43.2 +/- 6.0 ug/L; P < 0.05). Basal FFA levels were higher than those of normal controls (P < 0.05). ACX (500 mg) decreased FFA levels in both obese and normal subjects; the lowest FFA levels of obese subjects at 15 min were similar to those of normal controls. ACX also potentiated GHRH-stimulated GH response in both obese and normal subjects. The GH responses potentiated by ACX in obesity (22.7 +/- 5.5 ug/L) were similar to those of PYR plus GHRH in obese subjects and GHRH in normal controls, but they were lower than those of control treated with ACX plus GHRH (50.8 +/- 6.7 ug/L; P < 0.05). After the combined pretreatment with ACX and PYR, GH responses in obesity (44.1 +/- 6.0 ug/L) were significantly higher than those in GHRH test, PYR plus GHRH, and ACX plus GHRH in obese subjects (P < 0.05), and they were similar to PYR plus GHRH or ACX plus GHRH in normal controls. However their enhanced GH responses were reduced compared with the control with ACX plus PYR plus GHRH (64.9 +/- 4.5 ug/L; P < 0.05). Our results are in agreement with the hypothalamic hypothesis: an increase in somatostatinergic tone is responsible for the blunted GH response to GHRH in obesity.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationships among 64k autoantibodies, pancreatic beta-cell function, HLA-DR antigens and HLA-DQ genes in patients with insulin-dependent diabetes mellitus in Korea

OBJECTIVES

Among autoantibodies detected in patients with insulin-dependent diabetes mellitus (IDDM), antibodies to 64,000(Mr) islet protein(64k), now recognized as glutamic acid decarboxylase(GAD), appear to be an even more predictive marker of IDDM than islet cytoplasmic antibody (ICA) or insulin autoantibody (IAA). We examined the relationships among 64k autoantibodies, pancreatic beta-cell function, HLA-DR antigens and HLA-DQ genes in patients with IDDM in Korea.

METHODS

To identify the 64k autoantibody, the immunoprecipitation method was performed for 35 patients with IDDM and 10 normal controls. In patients with IDDM, serum C-peptide levels were measured and HLA-DR typings and HLA-DQA1 and DQB1 gene typings were performed.

RESULTS

12 of 35 (34%) patients with IDDM were positive for 64k autoantibody in contrast to none of 10(0%) normal controls. There were no differences in residual pancreatic beta-cell function between 64k autoantibody positive and negative groups. 64k autoantibody was detected more frequently in patients with recent (duration < 6 months, 10/25[40%]) and young -aged(aged < 15 years, 7/18[39%]) onset of IDDM. All of 3(100%) patients with HLA-DR3/DR4 heterotypes were positive in 64k autoantibody, in contrast to 1 of 7(14%) patients without HLA-DR3 nor DR4. The frequencies of HLA-DQA1*0301, HLA-DQB1*0201, DQB1* 0302 and DQB1*0303 gene types were higher in patients with 64k autoantibody (12/12 [100%]) vs. without 64k autoantibody 18/22[81%], 5/11[45%] vs. without 64k autoantibody 5/22[23%], 5/11[45%] vs. without 64k autoantibody 8/22[36%] and 6/11 [55%] vs. without 64k autoantibody 9/22[41%].

CONCLUSIONS

There results suggest that 64k autoantibodies have some relationship with HLA-DR, DQA1 and DQB1 genes, but not with residual pancreatic beta-cell function in Korean patients with IDDM.