A cluster randomized trial on the effect of a multifaceted intervention improved the technical quality of diabetes care by primary care physicians: The Japan Diabetes Outcome Intervention Trial-2 (J-DOIT2).

AIMS: To evaluate the effect of multifaceted interventions using the Achievable Benchmark of Care (ABC) method for improving the technical quality of diabetes care in primary care settings. METHODS: We conducted a 1-year cluster randomized controlled trial in 22 regions divided into an intervention group (IG) or control group (CG). Physicians in the IG received a monthly report of their care quality, with the top 10% quality of diabetes care scores for all physicians being the achievable benchmark. The change in quality-of-care scores between the IG and CG during follow-up was analysed using a generalized linear model considering clustering. RESULTS: A total of 2199 patients were included. Their mean (sd) age was 56.5 ± 5.9 years and the mean (sd) HbA1c level was 56.4 ± 13.3 mmol/mol (7.4 ± 1.2%). The quality-of-care score in the CG changed from 50.2%-point at baseline to 51%-point at 12 months, whereas the IG score changed from 49.9%-point to 69.6%-point, with statistically significant differences between the two groups during follow-up [the effect of intervention was 19.0%-point (95% confidence interval 16.7%- to 21.3%-point; P < 0.001)]. CONCLUSIONS: Multifaceted intervention, measuring quality-of-care indicators and providing feedback regarding the quality of diabetes care to physicians with ABC, was effective for improving the technical quality of care in patients with Type 2 diabetes in primary care settings. ( TRIAL REGISTRATION: umin.ac.jp/ctr as UMIN000002186).

High frequency of non-nocturnal hypoglycemia was associated with poor sleep quality measure by Pittsburg Sleep Quality Index in patients with diabetes receiving insulin therapy: Diabetes Distress and Care Registry at Tenri (DDCRT 4).

To investigate the temporal association between frequency of non-nocturnal hypoglycemia and sleep quality among patients with diabetes receiving insulin therapy.We used data from 1 513 patients with diabetes receiving insulin therapy. We estimated the relative risks (RR) of the frequency of non-nocturnal hypoglycemia for poor sleep quality measured by the Pittsburgh Sleep Quality Index.The average age and HbA1c value of the patients were 63.7 years and 7.8%, respectively. Compared with poor sleep quality in patients without any type of non-nocturnal disabling hypoglycemia (NNDH), the multivariable-adjusted RR values for poor sleep quality were 1.30 (95% confidence interval [CI], 1.06-1.61) and 1.37 (95% CI, 0.96-1.95) in patients who experienced 1-4 and ≥5 episodes of NNDH, respectively (p=0.004). Experiencing non-nocturnal severe hypoglycemia (NNSH) once in the past 90 days significantly increased the risk of poor sleep quality by 1.54 episodes (95% CI, 1.16-2.05; p=0.003). By adding the presence of depression as a variable to the multivariable-adjusted model, these associations were attenuated because we did not observe any significant association between NNDH and poor sleep quality (p=0.178). However, a significant association between NNSH and poor sleep quality was observed (RR=1.43; 95% CI, 1.09-1.90; p=0.011).A high frequency of non-nocturnal hypoglycemia was associated with poor sleep quality in patients with diabetes receiving insulin therapy. Our data also suggested that the association of NNDH, and not NNSH, was mediated by comorbid depression.

Comparative validity of the WHO-5 Well-Being Index and two-question instrument for screening depressive symptoms in patients with type 2 diabetes.

A simple tool consisting of two questions for screening depressive symptoms has been shown to be useful in primary care settings, but its validity in patients with diabetes has yet to be evaluated. We compared the test performance of this two-question instrument with that of WHO (The World Health Organization)-5. We consecutively enrolled 153 patients with type 2 diabetes who visited a diabetes clinic in Japan. Using the Center for Epidemiologic Studies Depression Scale as a reference standard of depressive symptoms, we calculated the sensitivity and specificity of the two-question instrument and WHO-5, and compared the area under the ROC curves of these tests. The two-question instrument had a sensitivity of 53.6% (95% CI, 39.7-67.0%) and specificity of 67.7% (95% CI, 58.1-74.9%). With the conventional cutoff point equal to or less than 13 points, the WHO-5 had a sensitivity of 57.1% (95% CI, 43.2-70.3%) and specificity of 82.5% (95% CI, 81.9-94.9%). The area under the ROC curve for the WHO-5 and two-item questionnaire, an indicator of discriminatory power, was 0.81 and 0.73, respectively, showing a statistically significant difference (P = 0.0453). The two-question instrument had statistically lower discriminatory power than the WHO-5 in screening depressive symptoms in patients with diabetes. We do not recommend the use of the two-question instrument for screening depressive symptoms in patients with diabetes.

Headache prevalence and long working hours: the role of physical inactivity.

OBJECTIVES: Headaches and long working hours are important issues for workers. This study investigated the association between hours worked and the prevalence of headaches, and how that association varies with physical activity. STUDY DESIGN: Cross-sectional study with two-stage cluster sampling. METHODS: Using data from a nationally representative sample of households in Japan, people aged 20-65 years who worked ≥35 h/week were studied, and the cross-sectional association between the number of hours worked per week (35-45, 46-55 and >55 h/week) and the prevalence rates of headaches of different severity was evaluated. RESULTS: Of 721 workers, 307 reported experiencing at least one headache per month. Compared with working 35-45 h/week, the prevalence ratios of severe or disabling headaches among individuals working >55 h/week were 1.38 [95% confidence interval (CI) 1.06-1.78] and 1.63 (95% CI 1.09-2.43), respectively. After stratification by the level of physical activity, the prevalence ratios were greater in the low-physical-activity group: 1.56 (95% CI 1.11-2.19) for severe headaches and 2.20 (95% CI 1.31-3.68) for disabling headaches. The number of hours worked was not associated with headaches in the high-physical-activity group. CONCLUSIONS: Among workers in the general population, long working hours were associated with the prevalence of headaches, and the association may depend on a lack of physical activity.

Diabetes distress, but not depressive symptoms, is associated with glycaemic control among Japanese patients with type 2 diabetes: Diabetes Distress and Care Registry at Tenri (DDCRT 1).

AIMS: To investigate the association between glycaemic control, diabetes distress and depressive symptoms among Japanese patients with Type 2 diabetes. METHODS: Cross-sectional data from 3305 patients with Type 2 diabetes were obtained from a baseline assessment of a diabetes registry at a general hospital in Japan. The Centre for Epidemiologic Studies Depression scale and Problem Areas in Diabetes scale were used to measure depressive symptoms and diabetes-related distress, respectively. Modified Poisson regression analysis was used to estimate the relative risks for poor glycaemic control across the quartiles of Centre for Epidemiologic Studies Depression scale and Problem Areas in Diabetes scale scores. RESULTS: The average age of the participants was 64.9 years and the average HbA(1c) level was 58.1 mmol/mol (7.5%). Clinically significant levels of depressive symptoms (Centre for Epidemiologic Studies Depression scale scores ≥ 16) were reported by 27.8% of participants. These scores significantly correlated with Problem Areas in Diabetes scale scores (r = 0.4354, P < 0.0001). Diabetes distress, but not depressive symptoms, was significantly associated with higher HbA(1c) levels. The relative risks for poor glycaemic control (HbA(1c) ≥ 64 mmol/mol; 8.0%), when adjusted for age, sex, BMI, type of diabetes therapy and duration of diabetes, was 67% higher among patients with Problem Areas in Diabetes scale scores in the highest quartile (≥ 26.25) compared with those in the lowest quartile (0-3.75). CONCLUSION: A significant association between glycaemic control and diabetes-related distress, but not depressive symptoms, was observed in Japanese patients with Type 2 diabetes.

Diagnostic performance of chromoendoscopy and narrow band imaging for colonic neoplasms: a meta-analysis.

AIM: We conducted a meta-analysis to compare the diagnostic test performance of chromoendoscopy and narrow band imaging (NBI) for colonic neoplasms. METHOD: MEDLINE, EMBASE and the Cochrane Library were searched (1966 to March 2009). Articles were included if: (i) chromoendoscopy or NBI was used, (ii) sensitivity and specificity were reported; (iii) absolute numbers of true-positive, false-positive, true-negative and false-negative results were provided or could be calculated; and (iv) pathology was used as the reference standard. Sensitivity and specificity were pooled using random effects model. Secondary analyses were conducted by limiting the studies in which magnifying endoscopy was used alone as a diagnostic modality, and polyp size and macroscopic appearance of lesions were not considered. RESULTS: Of 1342 screened articles, 27 met the inclusion criteria. Pooled sensitivity for chromoendoscopy and NBI was 0.94 (95% CI, 0.92-0.95) and 0.94 (0.91-0.97), and specificity was 0.82 (0.77-0.88) and 0.86 (0.83-0.89), respectively. There were no differences in sensitivity (P = 0.99) or specificity (P = 0.54) between the two methods. In the secondary analysis, pooled sensitivity for choromoendoscopy and NBI was 0.93 (95% CI, 0.90-0.97) and 0.96 (0.93-0.99) and specificity was 0.80 (0.73-0.87) and 0.85 (0.78-0.92). respectively. Overall, the pooled false-negative rate was 0.057 (95% CI, 0.040-0.73) for chromoendoscopy and 0.057 (95% CI, 0.028-0.085) for NBI. CONCLUSION: Chromoendoscopy and NBI had similar diagnostic test characteristics in the assessment of colonic neoplasms; however, the false-negative rate for both methods of 5.7% is an unacceptably high rate and currently therefore, neither method is ready for general use.

High oolong tea consumption predicts future risk of diabetes among Japanese male workers: a prospective cohort study.

AIMS: Acute administration of oolong tea decreases blood glucose levels. We investigated the association between long-term oolong tea intake and subsequent risk of developing diabetes among men of working age. METHODS: Data were analysed from a cohort of participants in the High-risk and Population Strategy for Occupational Health Promotion Study (HIPOP-OHP), conducted in Japan from 1999 to 2004. Oolong tea intake at baseline and subsequent risk of diabetes was evaluated using a Cox proportional hazards model. RESULTS: Of 4975 male workers, a total of 201 cases of diabetes were reported over a median of 3.4 years of follow-up. Mean age and BMI of all participants at baseline were 38.3 years and 22.9 kg/m(2) , respectively. Compared with those not consuming oolong tea, multivariable adjusted hazard ratios for developing diabetes were 1.00 (95% CI 0.67-1.49) for those who drank one cup of oolong tea per day and 1.64 (95% CI 1.11-2.40) for those drinking two or more cups per day. Fasting blood glucose increment per year was 0.11 mmol/l (95% CI 0.09-0.12 mmol/l), 0.12 mmol/l (95% CI 0.09-0.15 mmol/l) and 0.15 mmol/l (95% CI 0.11-0.18 mmol/l), respectively, for oolong tea consumption of 0, 1 and ≥ 2 cups/day, with a significant linear trend (P < 0.0001). CONCLUSIONS: Long-term consumption of oolong tea may be a predictive factor for new onset diabetes. Further studies are necessary to elucidate the role of oolong tea in the risk of developing diabetes.

Depressive symptoms, not completing a depression screening questionnaire, and risk of poor compliance with regular primary care visits in patients with type 2 diabetes: the Japan Diabetes Outcome Intervention Trial 2 (J-DOIT2) study group.

OBJECTIVES: To explore the association between depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale or not completing the questionnaire and subsequent risk of poor compliance with regular visits to primary care physician in patients with type 2 diabetes. METHODS: Using data from patients with type 2 diabetes who participated in the Japan Diabetes Outcome Intervention Trial 2 (J-DOIT2) Pilot Study, which was conducted at primary care settings, we examined the association between depressive symptoms or not completing the questionnaire and risk of poor compliance with regular visits as an event. RESULTS: Among 1 584 patients who participated in the J-DOIT2 Pilot Study, we excluded 140 who did not meet inclusion criteria or who declined participation after randomization, leaving 1 444 for entry in the present analysis. During 1 409 person-years of follow-up (median 1 year), 90 events were observed (incidence rate 63.9/1 000 person-years). The multivariable-adjusted hazard ratio of poor compliance with regular visits in those having depressive symptoms was 1.23 (95% CI: 0.46-3.31). In contrast, the multivariable-adjusted hazard ratio of poor compliance in those not completing the questionnaire was 2.26 (95% CI: 1.94-2.63). CONCLUSION: Not completing a questionnaire was significantly associated with an increased risk of poor compliance with the maintenance of regular visits to a primary care physician in patients with type 2 diabetes. Patients who do not comply with questionnaire surveys require increased attention to ensure their compliance with regular visits, and thereby ensure better diabetes outcomes.

Low health-related quality of life is associated with all-cause mortality in patients with diabetes on haemodialysis: the Japan Dialysis Outcomes and Practice Pattern Study.

AIMS: Whether health-related quality of life (HRQoL) can be accurately predicted in patients with extremely low HRQoL as a result of diabetic complications is unclear. We investigated the impact of HRQoL on mortality risk in patients with diabetes on haemodialysis. METHODS: Data from the Dialysis Outcomes Practice Pattern Study (DOPPS) were analysed for randomly selected patients receiving haemodialysis in Japan. Information regarding the diagnosis of diabetes and clinical events during follow-up was abstracted from the medical records at baseline and HRQoL was assessed by a self-reported short form (SF)-36 questionnaire. The association between physical component score and mental component score in the SF-36 and mortality risk was analysed using a Cox proportional hazard model. RESULTS: Data from 527 patients with diabetes on haemodialysis were analysed. The mortality age-adjusted hazard ratio of having a physical component score greater than or equal to the median was 0.27 [95% confidence interval (CI) 0.08-0.96] and the multivariable-adjusted mortality hazard ratio of having an mental component score greater than or equal to the median was 1.21 (95% CI 0.44-3.35). CONCLUSIONS: The physical component score derived from the SF-36 is an independent risk factor for mortality in patients with diabetes on haemodialysis who generally had very low HRQoL scores. Baseline mental component score was not predictive of mortality. Patient self-reporting regarding the physical component of health status may aid in risk stratification and clinical decision making for patients with diabetes on haemodialysis.

Depressive symptoms predict the future risk of severe pruritus in haemodialysis patients: Japan Dialysis Outcomes and Practice Patterns Study.

BACKGROUND: Recent reports suggest a cross-sectional association between psychiatric distress and pruritus in patients on haemodialysis (HD). However, no study has examined the likelihood of developing severe pruritus in patients on HD with depressive symptoms. OBJECTIVES: To evaluate the relationship between baseline depressive symptoms and subsequent risk of developing severe pruritus. METHODS: A longitudinal study with a 0.5-2.5-year follow-up period was performed using 1799 patients on HD who had no/mild pruritus at baseline, based on the Japan Dialysis Outcomes and Practice Patterns Study (1996-2004), a cohort study composed of a representative sample of patients on HD. We assessed pruritus after the follow-up period using a self-reported questionnaire and depressive symptoms using scores from the five-item version of the Mental Health Inventory (MHI-5). RESULTS: The 1799 patients had a mean age of 56.9 years, 59.5% were men, and 23.6% presented depressive symptoms. Multivariable analysis revealed that patients with depressive symptoms had significantly higher odds of developing severe pruritus during the 0.5-2.5-year follow-up period [adjusted odds ratio (AOR) 1.57, 95% confidence interval 1.22-2.01, P < 0.001]. In addition, a significant linear trend was observed between baseline MHI-5 scores and risk of developing severe pruritus, with AORs for third, second and first MHI-5 score quartiles of 1.08, 1.51 and 1.95, respectively (P for trend < 0.0001). CONCLUSIONS: Our results suggest that depressive symptoms measured by MHI-5 may predict the future risk of developing severe pruritus in patients on HD.

Relationship between diabetes mellitus and excessive sleepiness during driving.

OBJECTIVES: It is still unclear whether patients with diabetes feel excessive daytime sleepiness or dose/sleep during driving in patients more frequently. METHODS: A population-based cross-sectional survey was conducted in a rural town. Multivariable-adjusted logistic regression models were used to explore the association between prevalent diabetes cases and excessive daytime sleepiness or dose/sleep during driving. RESULTS: Of 4540 participants, a total of 470 diabetes cases were identified. Compared with those in the never doze/sleep category, multivariate-adjusted odds ratios of diabetes was 0.41 (95%CI, 0.12-1.35) in slight category of dozing or sleeping when stopped for a few minutes in traffic while driving and 2.97 (95%CI, 1.19-7.41) in the moderate to high categories of dozing or sleeping when stopped for a few minutes in traffic while driving. This association remained significant after adjusting for the presence of poor sleep quality defined by the global Pittsburgh Sleep Quality Index score equal or greater than 5. CONCLUSION: Compared to individuals without diabetes, patients with diabetes experienced excessive daytime sleepiness or dozing/sleeping when stopped for a few minutes in traffic while driving more often independent of poor sleep quality. From the public health perspective, all patients with diabetes should be asked about a history of excessive daytime sleepiness or dozing/sleeping while driving, which is a known risk factor for future traffic accidents.

Normal fasting plasma glucose levels and type 2 diabetes: the high-risk and population strategy for occupational health promotion (HIPOP-OHP) [corrected] study.

The objective of this study is to ascertain if higher normal fasting glucose levels are also an independent risk of developing diabetes in an Asian population, and we thus analysed data from a cohort of healthy Japanese workers. We used data from the non-randomised trial on health promotion intervention, High-risk and Population Strategy for Occupational Health Promotion (HIPOP-OHP) Study. Diabetes cases and those who had fasting blood glucose levels equal to or greater than 100 mg/dl at baseline were excluded, and the Cox proportional-hazards model was used for the analysis. During the four-year follow-up of 2212 participants, we found 37 diabetes cases. In the multivariable model, people with blood glucose levels in the 4th quartile had a higher risk of diabetes than those in the bottom quartile; the multivariable-adjusted odds ratio was 2.52. The risk of diabetes abruptly rose in persons with blood glucose levels higher than 94 mg/dl (fourth quartile). A significant linear trend was not observed in the 1st to 3rd quartiles (p=0.726). In conclusion, higher fasting glucose level was associated with the risk of diabetes, and we found a threshold in the association between fasting blood glucose levels and risk of diabetes in an Asian population.

Diabetes, glycaemic control and mortality risk in patients on haemodialysis: the Japan Dialysis Outcomes and Practice Pattern Study.

AIMS/HYPOTHESIS: There are few data on the target level of glycaemic control among patients with diabetes on haemodialysis. We investigated the impact of glycaemic control on mortality risk among diabetic patients on haemodialysis. SUBJECTS AND METHODS: Data were analysed from the Dialysis Outcomes Practice Pattern Study (DOPPS) for randomly selected patients on haemodialysis in Japan. The diagnosis of diabetes at baseline and information on clinical events during follow-up were abstracted from the medical records. A Cox proportional hazards model was used to evaluate the association between presence or absence of diabetes, glycaemic control (HbA(1c) quintiles) and mortality risk. RESULTS: Data from 1,569 patients with and 3,342 patients without diabetes on haemodialysis were analysed. Among patients on haemodialysis, those with diabetes had a higher mortality risk than those without (multivariable hazard ratio 1.37, 95% CI 1.08-1.74). Compared with those in the bottom quintile of HbA(1c) level, the multivariable-adjusted hazard ratio for mortality was not increased in the bottom second to fourth quintiles of HbA(1c) (HbA(1c) 5.0-5.5% to 6.2-7.2%), but was significantly increased to 2.36 (95% CI 1.02-5.47) in the fifth quintile (HbA(1c) > or = 7.3%). The effect of poor glycaemic control did not statistically correlate with baseline mortality risk (p = 0.27). CONCLUSIONS/INTERPRETATION: Among dialysis patients, poorer glycaemic control in those with diabetes was associated with higher mortality risk. This suggests a strong effect of poor glycaemic control above an HbA(1c) level of about 7.3% on mortality risk, and that this effect does not appear to be influenced by baseline comorbidity status.

Thermal detrapping rates of atomic hydrogen and atomic deuterium trapped in double four-ring Si8O12 cages measured simultaneously using EPR.

Does atomic hydrogen or atomic deuterium escape faster from the D4R cage of Q8M8 in thermal detrapping? An isotope effect was clearly observed by a simultaneous measurement using EPR. Arrhenius parameters were obtained and allowed the application of the absolute rate theory to explain the process.

[A case of intravascular malignant lymphomatosis presenting as cerebral infarction].

A case of intravascular malignant lymphomatosis (IML) presenting as progressive cerebral infarction is reported. A 62-year-old previously healthy male developed progressive dementia. MRI of the brain at the nearest hospital revealed multiple infarcts with unknown etiology. His level of consciousness deteriorated rapidly, and then he was transferred to our hospital for further evaluation. High grade fever, raised serum C reactive protein (CRP), and raised lymphoma markers (serum LDH and soluble IL-2 receptor (sIL-2R)) were observed. Repeated brain MRI disclosed progression of multifocal cerebral infarctions. We considered IML most likely, and we performed muscle biopsy. However muscle biopsy didn't demonstrate any proliferation of neoplastic cells of lymphoid origin within small vessels. Thereafter IML was diagnosed by brain biopsy. The patient underwent chemotherapy, but died of pneumonia due to severe myelosuppression. IML is a rare disease but most commonly shows neurological symptomatology as its clinical manifestation. Dementia is the most common neurological symptom, and progressive multiple infarction is the most common of the MRI findings. Rapidly progressive dementia associated with multiple infarction, when elevated CRP, LDH and sIL-2R are observed in the laboratory data, is suggestive of IML.