Development of new diabetes risk scores on the basis of the current definition of diabetes in Japanese subjects [Rapid Communication].

To develop diabetes risk score (RS) based on the current definition of diabetes, we retrospectively analyzed consecutive 4,159 health examinees who were non-diabetic at baseline. Diabetes, diagnosed by fasting plasma glucose (FPG) ≥7.0 mmol/L, 2hPG ≥11.1 mmol/L and/or HbA1c ≥6.5% (48 mmol/mol), developed in 279 of them during the mean period of 4.9 years. A full RS (RSFull), a RS without 2hPG (RS-2hPG) and a non-invasive RS (RSNI) were created on the basis of multivariate Cox proportional model by weighted grading based on hazard ratio in half the persons assigned. The RSs were verified in the remaining half of the participants. Positive family history (FH), male sex, smoking and higher age, systolic blood pressure (SBP), FPG, 2hPG and HbA1c were independent predictors for RSFull. For RS-2hPG, 7 independent predictors, exclusive of 2hPG and smoking but inclusive of elevated triglycerides (TG) comparing to RSFull, were selected. FH, male sex, and higher age, SBP and HbA1c were independent predictors in RSNI. In the validation cohort, C-statistic (95%CI) of RSFull, RS-2hPG and RSNI were 0.80 (0.76-0.84), 0.75 (0.70-0.78) and 0.68 (0.63-0.72), respectively, which were significantly different from each other (P <0.01). Absolute percentage difference between predicted probability and observed diabetes were 1.9%, 0.7% and 0.9%, by the three scores, respectively, and not significantly different from each other. In conclusion, diabetes defined by the current criteria was predicted by the new diabetes risk scores with reasonable accuracy. Nonetheless, RSFull with a postchallenge glucose value performed superior to RS-2hPG and RSNI.

Extraordinarily high aldosterone, 901.0 ng/dL, in a patient with primary aldosteronism: an insight into the underlying mechanism.

A 43-yr-old hypertensive male was admitted due to hypokalemia (1.8 mEq/L) and renal dysfunction (eGFR, 20.0 mL/min/1.73 m2). His plasma aldosterone was 901.0 ng/dL, plasma renin activity 5.7 ng/mL/hr, and aldosterone/renin activity ratio 158. Angiotensin II (AII) was 0.7 pg/mL, ACTH <1.0 pg/mL, and cortisol 21.6 µg/dL. Liquid chromatography-tandem mass spectrometry analysis showed that aldosterone (104 times the control) as well as its precursors were significantly elevated in the patient's plasma. A left adrenal (4-cm-diameter) tumor with 131I-Adosterol uptake was found and removed. Four days later, plasma aldosterone and renin activity had dropped to 7.73 ng/dL and 1.6 ng/mL/hr, respectively. However, they rose to 24.0 ng/dL and 10.9 ng/mL/hr, respectively, by Day 102. Nevertheless, magnetic resonance angiography found no evidence of a renovascular lesion. The tumor was a benign adrenocortical adenoma composed predominantly of clear cells positive for 17α-hydroxylase, [hydroxy-delta-5-steroid dehydrogenase, 3 beta- and steroid delta-isomerases], and aldosterone synthase. A quantitative real-time polymerase chain reaction analysis of the tumor cells revealed that expression of the gene encoding aldosterone synthase was 85 times the control level. In addition, the tumor cells harbored G151R mutation of the inward rectifying potassium channel subfamily j, member 5 gene. The striking overexpression of aldosterone synthase by the tumor cells was considered the primary mechanism for the extravagant overproduction of aldosterone in this case. This overexpression may have resulted from integration of signals from AII and forced membrane depolarization due to the potassium channel mutation.

Rapid conversion of autoimmune hypophysitis to an empty sella with immediate lowering of the serum IgG4 level. Case Report.

An 87-year-old man was admitted with fatigue, anorexia, vomiting, urinary incontinence, and a depressive state. His consciousness was evaluated as a 13 on the Glasgow Coma Scale (E4V3M6), and he had a body temperature of 36.4°C, a blood pressure of 91/60 mmHg, and a heart rate of 88 beats/min. General laboratory data were unremarkable except for a mildly elevated serum creatinine level. The plasma levels of growth hormone, luteinizing hormone, and follicle stimulating hormone were depressed. On the other hand, the prolactin level was elevated, and the corticotropin, cortisol, and thyrotropin levels were within the reference ranges. Cranial magnetic resonance imaging (MRI) revealed the marked swelling of the pituitary gland and the infundibular stalk, and the serum immunoglobulin G4 (IgG4) level was elevated (2.85 g/L; reference range, 0.048-1.05 g/L). Accordingly, a diagnosis of IgG4-related autoimmune hypophysitis (AH) was made. The patient responded well to glucocorticoid therapy, but the presence of diabetes insipidus was revealed and was subsequently controlled using desamino-D-arginine vasopressin (DDAVP). To our surprise, an empty sella was apparent on an MRI examination performed on Day 12. The patient's serum IgG4 level had decreased in a log-linear manner with a half-life of 30 days, which was comparable to the half-life of IgG4 in control subjects (21 days). At a 16-month follow-up examination, no substantial changes in the morphology or function of the pituitary gland were noted. In conclusion, an empty sella developed within 12 days after the clinical onset of AH in the present case, suggesting that an empty sella may be the direct outcome of AH. The conversion of AH to an empty sella was associated with an immediate shutdown of IgG4 overproduction.

Paradoxical surge of corticotropin after glucocorticoid replacement in central adrenal insufficiency.

A 78-yr-old man was admitted in emergency with fatigue, anorexia, vomiting, hypothermia (35.1 °C on a hot August day), hypotension (89/56 mmHg) and hyponatraemia (126 mEq/l). Plasma corticotropin and cortisol were severely depressed: 0.84 pmol/L and 33.1 nmol/L respectively (reference range, 1.5-13.9 pmol/L and 110-505 nmol/L, respectively). Thyroid stimulating hormone was low-normal and free-triiodothyronine and free-thyroxine were subnormal. Magnetic resonance imaging revealed swelling of the pituitary gland and the stalk. The patient recovered after glucocorticoid replacement (200 mg/day intravenous hydrocortisone on Day 1 followed by tapering). Central diabetes insipidus which had become apparent had been treated with 1-desamino-8-D-arginine vasopressin. A surge of corticotropin and cortisol, 19.4 pmol/L and 712.1 nmol/L respectively, was found on Day 5 when luteinizing hormone, follicle stimulating hormone, and testosterone were subnormal and prolactin was slightly elevated. Subsequently, corticotropin and cortisol levels normalized together with normalization of luteinizing hormone, follicle stimulating hormone, anti-diuretic hormone, thyroid stimulating hormone, prolactin, testosterone and thyroid hormone levels. Shrinkage of the pituitary gland occurred after one month. Serum immunoglobulin G4 was elevated (3.21 and 6.02 g/l at 1- and 3-month follow-ups respectively). In conclusion, a paradoxical surge of corticotropin after glucocorticoid replacement was observed in a patient with central adrenal insufficiency due to immunoglobulin G4-related hypophysitis. Surge of ACTH in central adrenal insufficiency after glucocorticoid replacement has rarely been reported, and this is the second such case report.

Normal delivery following resection of an androgen-secreting adrenal carcinoma.

A 31-year-old female presented to a gynecological clinic complaining of amenorrhea and virilism over a 2-month period. Blood tests revealed high serum total testosterone and free testosterone levels. A left adrenal tumor was identified following computed tomography and she was referred to our clinic where a laparoscopic left adrenalectomy was performed. The tumor weighed 98 g and the pathological diagnosis according to Weiss' criteria was adrenocortical carcinoma. The post-operative course was uneventful; her serum free testosterone level normalized and regular menstruation was observed 1 month post-operatively. The patient became pregnant 1 year later, resulting in the normal delivery of a girl.

[Ejaculatory disorder caused by doxazosin administration for blood pressure control in patient with pheochomocytoma].

A 29-year-old man had been treated for hypertension for 10 years. He suffered from speech disturbance caused by cerebral infarction, and further examinations were performed. Computerized tomography scan and magnetic resonance imaging revealed a left adrenal tumor 6 cm in size. The radioisotope (MIBG) accumulated in the left adrenal gland. The serum noradrenalin levels were high. Thus, the diagnosis of pheochomocytoma in left adrenal tumor was made. He noticed ejaculation disturbance 5 days after starting administration of doxazosin at the dose of 3 mg/day for pre-operative blood pressure control. Sperm was observed in the urine sampling obtained after masturbation, thus his ejaculation disturbance was considered to be retrograde ejaculation. Laparoscopic left adrenalectomy was performed. After the operation, his blood pressure normalized and the administration of doxazosin has not been necessary. He could perform ejaculation without any trouble after stopping doxazosin intake. The bladder neck conditions measured by ultrasonography were the same before and after the administration of doxazosin. The present case is a very rare case of ejaculation disturbance caused by non-selective alpha 1 blocker doxazosin.

CDK5-dependent phosphorylation of the Rho family GTPase TC10(alpha) regulates insulin-stimulated GLUT4 translocation.

Insulin stimulation results in the activation of cyclin-dependent kinase-5 (CDK5) in lipid raft domains via a Fyn-dependent phosphorylation on tyrosine residue 15. In turn, activated CDK5 phosphorylates the Rho family GTP-binding protein TC10alpha on threonine 197 that is sensitive to the CDK5 inhibitor olomoucine and blocked by small interfering RNA-mediated knockdown of CDK5. The phosphorylation deficient mutant T197A-TC10alpha was not phosphorylated and excluded from the lipid raft domain, whereas the phosphorylation mimetic mutant (T197D-TC10alpha) was lipid raft localized. Insulin resulted in the GTP loading of T197D-TC10alpha but not T197A-TC10alpha and in parallel, T197D-TC10alpha but not T197A-TC10alpha depolymerized cortical actin and inhibited insulin-stimulated GLUT4 translocation. These data demonstrate that CDK5-dependent phosphorylation maintains TC10alpha in lipid raft compartments thereby disrupting cortical actin, whereas subsequent dephosphorylation of TC10alpha through inactivation of CDK5 allows for the re-assembly of F-actin. Because cortical actin reorganization is required for insulin-stimulated GLUT4 translocation, these data are consistent with a CDK5-dependent TC10alpha cycling between lipid raft and non-lipid raft compartments.

Development, worsening, and improvement of diabetic microangiopathy in older people: six-year prospective study of patients under intensive diabetes control.

OBJECTIVES: To examine retinopathy and nephropathy in elderly patients with diabetes mellitus (DM) under intensive multifactorial DM control. DESIGN: Six-year interventional observation study. SETTING: Multicenter study including four hospitals. PARTICIPANTS: Four hundred thirteen elderly (> or = 65) patients with type 2 DM attending each hospital for 1 year or longer; those receiving hemodialysis or with uncured malignancy were excluded. MEASUREMENTS: Development, worsening, and improvement of retinopathy and nephropathy and respective risk factors. RESULTS: The mean baseline hemoglobin (HbA1c), blood pressure (BP), and total cholesterol were 6.8%, 137/74 mmHg, and 5.13 mmol/L, respectively. Retinopathy developed in 45 of 168 (27%) patients and, of 63 with nonproliferative retinopathy, worsened and improved in 11 (17%) and 23 (37%), respectively. Nephropathy developed in 53 of 227 (23%) patients and improved in 13 of 51 (25%) having it baseline. The mean change in glomerular filtration rate (DeltaGFR, baseline GFR-GFR at the end of the study period) in those with nephropathy at baseline was 21.5 mL/min. HbA1c was related to development of retinopathy (P=.001, odds ratio (OR)=1.91), and serum creatinine (P=.03, OR=1.02), systolic BP (SBP) (P=.03, OR=1.22), and prior stroke (P=.005, OR=3.21) were related to development of nephropathy. In patients with nephropathy at baseline, SBP (P=.03, Spearman's rho (rho)=0.310), total cholesterol (P=.01, rho=0.361), and low-density lipoprotein cholesterol (P=.03, rho=0.322) were correlated with DeltaGFR. CONCLUSION: In elderly patients under intensive control for DM, the outcome of microangiopathy is favorable. Modifiable risk factors were hyperglycemia for development of retinopathy and hypertension and hypercholesterolemia for development or worsening of nephropathy; prior stroke was an unmodifiable risk factor for development of nephropathy.

Normal mortality in the elderly with diabetes under strict glycemic and blood pressure control: outcome of 6-year prospective study.

Mortality, macroangiopathic events and end-stage renal disease (ESRD) in the elderly under long-term, intensive multifactorial diabetes control were prospectively investigated. Three hundred and eighty-eight elderly patients (> or =65 years) with type 2 diabetes (the mean age 72.9 years, men/women ratio 176/212) were followed-up for 6 years with HbA1c 7.0%, BP 145/80 mmHg and total cholesterol<240 mg/dl as targets. The mean baseline HbA1c was 6.8%, BP 137/74 mmHg and total cholesterol 196 mg/dl, and corresponding values upon closing 6.9%, 134/72 mmHg and 188 mg/dl respectively. Mortality rate was 19.6%/6 years (1.01 times that of age- and sex-matched general population), and macroangiopathic events developed in 142 (36.6%) and ESRD in 9 (2.3%). Independent risk factors: low glomerular filtration rate (GFR) (P<0.001), prior stroke (P=0.002), age (P=0.001) and DeltaBMI (P=0.001) for mortality; prior stroke (P<0.001) and coronary events (P=0.042), high LDL-cholesterol (P=0.004), low GFR (P=0.028), and past maximum BMI (P=0.032) and age (P=0.019) for macroangiopathy; low GFR (P<0.001) for ESRD. No smoking was an independent protective factor for mortality (P=0.008). In conclusion, normal mortality was attained in the elderly under intensive mutifactorial diabetes control. Renal dysfunction, prior stroke, high LDL-cholesterol, and prior obesity were prominent risks for mortality, macroangiopathy and/or ESRD.

Octreotide as a rapid and effective painkiller for metastatic carcinoid tumor.

Octreotide is one of the somatostatin analogue used for the treatment of endocrine tumors principally to suppress hormone secretion and to inhibit tumor growth. We experienced a case with multiple endocrine neoplasia type 1 who small amount of octreotide dramatically relieved the lumber pain caused by metastatic bone tumor. He had recurrent bronchial carcinoid tumors that metastasized to liver and bones. The spontaneous and radiated pain by bone tumors subsided within a few minutes after the initial injection of octreotide and the effect persisted for several hours. Combination therapy of octreotide and interferon alpha-2b significantly reduced the size of metastatic liver tumors and inhibited further growth of metastatic bone tumors for the last 27 months. The use of octreotide may be a good option for controlling pain by metastatic bone disease and combination therapy of octreotide and interferon alpha-2b is worth to try for patients with inoperable metastatic carcinoid tumor.

Vascular endothelial cell growth factor attenuates actions of transforming growth factor-beta in human endothelial cells.

Because vascular endothelial cell growth factor (VEGF) and transforming growth factor-beta (TGF-beta) are both involved in cellular growth and differentiation, we examined whether VEGF modifies TGF-beta signaling cascade in human umbilical cord vein endothelial cells (HUVEC). Production of plasminogen activator inhibitor-1 (PAI-1), which is under the specific control of TGF-beta, was strongly enhanced (3.5-fold) by TGF-beta treatment. Remarkably, physiological concentration of VEGF (30 nm) profoundly (by 60%) attenuated the TGF-beta stimulation of PAI-1 production without an effect on the basal PAI-1 production. In HUVECs transiently transfected with an expression construct containing a PAI-1 promoter fused to luciferase reporter gene, TGF-beta-stimulation of transcription of PAI-1 was clearly (by 60%) inhibited by VEGF. TGF-beta phosphorylation of Smad2/3, an obligatory step of intracellular TGF-beta signaling, was also suppressed by VEGF. VEGF attenuation of TGF-beta action was also demonstrated in two other endothelial cell lines. In conclusion, VEGF attenuates TGF-beta action in the human endothelial cell, specifically at the level of transcription of PAI-1 gene and Smad2/3 phosphorylation.

The retinoic acid-responsive proline-rich protein is identified in promyeloleukemic HL-60 cells.

To identify new genes that retinoic acid activates, we employed an mRNA differential display technique and screened for genes that are differentially expressed in promyeloleukemic HL-60 cells incubated in the presence of all-trans-retinoic acid (ATRA) compared with the absence of ATRA. We cloned the coding region of a retinoic acid-induced gene from a human thymus library, which was the mRNA encoding the 666-amino acid human homologue of mouse proline-rich protein 76. We have designated it RARP1 (retinoic acid response proline-rich protein 1). Transcription of an approximately 2.4-kbp mRNA occurred mainly in organs with immune functions, such as thymus, spleen, and peripheral leukocytes. Cycloheximide blocked the ATRA-induced expression. In megakaryocyte-like human erythroleukemia HEL cells, the amount of RARP1 mRNA was high, but it was low in human T-lymphoblastoid Jurkat cells. A specific antibody against RARP1 recognized a 110-kDa protein, which accumulates after incubation of HL-60 cells with ATRA. In immunohistochemical experiments, strong RARP1 staining was observed in the megakaryocytes of bone marrow and spleen, and heterogeneous stain was seen in thymus. Transcriptional studies showed that RARP1 expression impaired the transactivation through activator protein1 and serum response-element in all cell lines we checked, whereas it did not affect the transactivation through cAMP-response element in the same cell lines. Further analysis demonstrated that proline-rich regions of RARP1 are the functional regions regulated for suppression of activator protein1 transactivation. These data suggest that ATRA-inducible RARP1 selectively affects signal transduction and may contribute to myeloid and megakaryocytic differentiation.

Prospective analysis of mortality, morbidity, and risk factors in elderly diabetic subjects: Nagano study.

OBJECTIVE: To clarify mortality and morbidity of intensively managed elderly diabetic individuals and to explore factors predicting mortality and diabetes-related end points. RESEARCH DESIGN AND METHODS: A total of 390 elderly (>or=65 years of age) outpatients with type 2 diabetes ( 173 men and 217 women, mean age 73.0 years) were analyzed. The mean HbA(1c) upon entry was 6.8% (332 receiving oral hypoglycemics and/or insulin) and blood pressure upon entry was 136/74 mmHg (219 receiving antihypertensive drugs). The patients have been followed-up for 3 years with HbA(1c) <7.0% and blood pressure <145/80 mmHg as targets, with mortality and an aggregate of fatal and nonfatal diabetes-related events as end points. Mortality rate and causes of mortality, as well as risk factors for mortality and morbidity, were determined. RESULTS: The mortality rate, 2.9% per year, was comparable to that of the age- and sex-matched general population. Stroke was a leading cause of mortality after malignancy. By the univariate Cox proportional hazards model, only high serum creatinine and prior stroke were highly significant and strong risks for both end points. In those without prior stroke and receiving antihypertensive agents, the incidence of the diabetes-related end point based on their systolic blood pressure (SBP) quartile was U-shaped, with the nadir at the 3rd (SBP, 137-147 mmHg) and the peak at the 1st (SBP

Suppression of insulin-induced AP-1 transactivation by menin accompanies inhibition of c-Fos induction.

The translation product of the MEN1 gene, menin, has been reported to suppress JunD-mediated activator protein-1 (AP-1) transactivation and inhibit Ras-mediated tumor formation, but its molecular mechanisms and physiologic significance have been poorly elucidated. To better understand the function of menin as a tumor suppressor, we examined the effect of menin on physiologically induced AP-1 activity. Overexpression of menin strongly suppressed insulin-induced AP-1 activity in CHO-IR cells, which express high levels of insulin receptor. We found that menin suppressed c-Fos induction at the transcriptional level, although that cannot explain the entire mechanism of AP-1 suppression by menin. Menin did not alter the expression levels of AP-1 proteins except c-Fos, phosphorylation of c-Jun and JunD and DNA binding properties of AP-1 proteins. Suppression of AP-1 activation by menin may be exerted through 2 independent mechanisms, direct inhibition on AP-1-mediated transcription and suppression of c-Fos induction. The molecular mechanism of inhibition of AP-1 function by menin needs further elucidation.

Time-dependent stimulation of insulin exocytosis by 3',5'-cyclic adenosine monophosphate in the rat islet beta-cell.

Isolated rat islets were exposed to cAMP-elevating agents and/or nutrients. Insulin exocytosis subsequently triggered by a depolarizing concentration of K(+) or a stimulatory concentration of glucose was employed as an index of time-dependent potentiation (TDP). Stimulatory concentrations (>or=5.5 mM) of glucose caused TDP, and 6 micro M forskolin (an activator of adenylyl cyclase) significantly enhanced it (3.1-fold at most). Forskolin produced an 8.0-fold increase in islet cell cAMP; however, it returned to the baseline after washout by the time of stimulation of exocytosis. Two millimoles of dibutyryl cAMP (a cAMP analog), 0.1 mM isobutylmethylxanthine (a phosphodiesterase inhibitor), and 100 nM glucagon-like peptide-1 (an incretin hormone) also enhanced glucoseinduced TDP. The time-dependent effect of cAMP was not attenuated by protein kinase A inhibitors (200 micro M adenosine 3',5'-cyclic monophosphothioate, Rp isomer, and 10 micro M H89). Although glucose-induced TDP was attenuated by NaN(3) (a mitochondrial poison) and cerulenin (an inhibitor of protein acylation), cAMP enhancement of it was unaffected by these agents. In conclusion, cAMP time-dependently stimulates insulin exocytosis, provided the extracellular glucose concentration is equivalent to or higher than ambient plasma levels. Protein kinase A, mitochondrial metabolism, and protein acylation are not involved in this cAMP action. Incretin stimulation of insulin exocytosis may occur in part via this mechanism.

Triggering of insulin release by a combination of cAMP signal and nutrients: an ATP-sensitive K+ channel-independent phenomenon.

Nutrient augmentation of Ca(2+)-triggered insulin release occurs in an ATP-sensitive K(+) (K(ATP)) channel--independent manner. Here, using rat islets, we explored the possibility of the K(ATP) channel-independent nutrient triggering of insulin release. In the presence of 250 micromol/l diazoxide, simultaneous application of forskolin and 16.7 mmol/l glucose strongly stimulated insulin release: fourfold and eightfold increases with 1 and 30 micromol/l forskolin, respectively. alpha-Ketoisocaproate (KIC) and 3-isobutylmethylxanthine (IBMX) could be used in place of glucose and forskolin, respectively, to trigger insulin release in the presence of diazoxide. Triggering of insulin release by a combination of nutrients and forskolin was not attenuated by 10 micromol/l nifedipine (a blocker of voltage-dependent Ca(2+) channels) and 2 micromol/l thapsigargin (an inhibitor of intracellular Ca(2+)-ATPase), ascertaining independence of this phenomenon from Ca(2+) entry and from intracellular Ca(2+) liberation. As anticipated, the action of glucose and KIC was greatly (>80%) suppressed by inhibition of mitochondrial metabolism by 2 mmol/l sodium azide (NaN(3)). A combination of palmitate and dimethyl glutamate (a cell-permeable glutamate donor), but not either one alone, weakly but unequivocally triggered insulin release when applied simultaneously with forskolin. In this case, however, mitochondrial poisoning by azide was without effect. The finding suggests that a combination of induced palmitoylation and cytosolic glutamate accumulation partially reconstituted signaling beyond mitochondrial metabolism in the beta-cell upon glucose stimulation. In conclusion, a combination of cAMP signal and nutrients potently triggers insulin release under full activation of the K(ATP) channel, indicating the multiplicity of driving force for insulin exocytosis.