ヤクブツ チリョウ ニツイテ

Pharmacological therapy in diabetes mellitus has been changing in the last decade. Because conventional therapy for type 2 diabetes patients using sulfonylurea often caused secondary failure during long-term glycemic control, it was recognized that alpha-glucosidase inhibitors, metformin and thiazolidinedione which had hypoglycemic effects without exhaustion of beta cell function were beneficial. These drugs have efficacy not only for lowing plasma glucose concentration but for prevention of diabetes progression. Several clinical studies showed that angiotensin converting enzyme inhibitors, angiotensin Ⅱ receptor blockers and statins also had effects to prevent from type 2 diabetes. When we select diabetic therapy, especially to protect against the occurrence of macrovascular complications, it should be considered that type 2 diabetes has an aspect of metabolic syndrome. On the other hand, insulin therapy was reevaluated because of data from UKPDS and DCCT which demonstrated normoglycemia with intensive insulin therapy was critical goal to reduction in risk of diabetic complications. Very-rapid-acting insulin may be helpful for introduction of insulin therapy. To keep better glucose control, insulin may be considered until beta cell function is exhausted

上部消化管出血における血液凝固第XIII因子活性の低下

We report on blood coagulation factor XⅢ（F１３）activity in upper gastrointestinal bleeding （UGIB）due to peptic ulcer（PU）. 【Methods】From January ２０１１ to December ２０１６, 42 patients who had UGIB with PU, performed endoscopic hemostasis（EH）, and measured F１３ activity （normal range：７０‐１４０％）, were retrospectively studied. The clinical signs, peripheral blood, biochemistry, coagulation, F１３ activity, and endoscopic findings were examined by logistic regression analysis（LRA）in３２patients with successful hemostasis and１０patients with rebleeding. 【Results】There were２５elderly patients aged７０ and over. The average F１３ activity was ６５．７±２２．５％, ６８．３±２２．１％ in the case of successful hemostasis, below the lower limit of normal, and further decreased to ５７．５±１８．１％ in the case of rebleeding. LRA showed association with rebleeding in Forrest classification and F１３activity. 【Conclusion】F１３activity decreased in many cases of UGIB due to PU, and associated with rebleeding after EH

ICTP and vulnerable plaque

Evaluation of atherosclerotic plaques depends on invasive intravascular ultrasonography (IVUS). Carboxy-terminal telopeptide of type I collagen (ICTP) is produced by matrix metalloproteinase (MMP)-dependent digestion of type I collagen. Because vulnerable plaques are rich in type I collagen and MMPs from macrophages, we examined the association between serum ICTP and coronary plaques in patients with coronary disease. We recruited 46 men and 17 women without renal failure or bone diseases affecting serum ICTP, who underwent coronary IVUS. Serum ICTP levels were higher in patients with coronary plaques containing more than 10% necrotic core area than in patients with less than 10% necrotic core area. A positive correlation was found between serum ICTP and necrotic core area. Only serum ICTP was positively correlated with necrotic core area by multivariate analysis (p<0.05). These results suggest that serum ICTP can be used as a non-invasive marker of vulnerable plaques in atherosclerotic patients

Treatment algorithm of ACTH deficiency

Objective : To examine diagnostic performance of corticotropin-releasing hormone (CRH) test combined with baseline dehydroepiandrosterone sulfate (DHEA-S) in patients with a suspect of central adrenal insufficiency. Methods : Patients (n=215) requiring daily or intermittent hydrocortisone replacement, or no replacement were retrospectively checked with their peak cortisol after CRH test and baseline DHEA-S. Results : None of 106 patients with the peak cortisol ≥ 17.5 μg / dL after CRH test required replacement, and all 64 patients with the peak cortisol < 10.0 μg / dL required daily replacement. Among 8 patients with 10.0 μg / dL ≤ the peak cortisol < 17.5 μg / dL and baseline DHEA-S below the reference range, 6 patients required daily replacement and 1 patient was under intermittent replacement. Among 37 patients with 10.0 μg / dL ≤ the peak cortisol < 17.5 μg / dL and baseline DHEA-S within the reference range, 10 and 6 patients were under intermittent and daily replacement, respectively. Conclusions : No patients with the peak cortisol ≥ 17.5 μg / dL required hydrocortisone replacement, and all patients with the peak cortisol below 10.0 μg / dL required daily replacement. Careful clinical evaluation was required to determine requirement for replacement in patients with 10.0 μg / dL ≤ the peak cortisol < 17.5 μg / dL even in combination with baseline DHEA-S

トクシマケン イシカイ トウニョウビョウ タイサクハン ダイ1ジ ダイ2ジ カツドウ ノ セイカ

Objective : The effectiveness of diabetes prevention programs for the general population in Tokushima Prefecture was investigated. The programs were designed by Tokushima Medical Association’ s（TMA’s）Steering Committee for Diabetes Prevention. Research design and methods : The committee promoted diabetes prevention by disseminating educational messages on diabetes to the general public and medical care providers, and establishing a referral system among public health centers and medical institutes throughout Tokushima Prefecture during the period from ２００４ to ２００９. The outcome of these activities were evaluated by analyzing data from the Prefectural Health and Nutrition Survey in Tokushima conducted in１９９７（n＝ ９９８）,２００３ （n＝１００８） and ２０１０ （n＝１１３０）, and then comparing these results with those of the national survey at the corresponding times. Results : The percentage of subjects with glucose intolerance at the time of initiation of the prevention program in Tokushima tended to increase from １９９７ to ２００３, but was slightly decreased in ２０１０, although the differences were not statistically significant. However, the percentage of subjects with glucose intolerance was significantly increased throughout Japan during the same period. Obesity parameters, physical activity evaluated by the number of steps and the average total energy intake changed favorably in parallel with changes in the prevalence of diabetes during the study period in Tokushima. Conclusion : The diabetes prevention programs initiated by the TMA’s committee may be useful in ameliorating the situation of diabetes in Tokushima Prefecture

Decline in subarachnoid haemorrhage volumes associated with the first wave of the COVID-19 pandemic

BACKGROUND: During the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study\u27s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines. METHODS: We conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March-31 May 2020. The prior 1-year control period (1 March-31 May 2019) was obtained to account for seasonal variation. FINDINGS: There was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI -24.3% to -20.7%, p\u3c0.0001). Embolisation of ruptured aneurysms declined with 1170-1035 procedures, respectively, representing an 11.5% (95%CI -13.5% to -9.8%, p=0.002) relative drop. Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations, a 24.9% relative decline (95% CI -28.0% to -22.1%, p\u3c0.0001). A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1% (95% CI 32.3% to 50.6%, p=0.008) despite a decrease in SAH admissions in this tertile. INTERPRETATION: There was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction