Fasting hepatic insulin clearance reflects postprandial hepatic insulin clearance: a brief report.

BACKGROUND: Hepatic insulin clearance (HIC) is an important pathophysiology of type 2 diabetes mellitus (T2DM). HIC was reported to decrease in patients with type 2 diabetes and metabolic syndrome. HIC is originally calculated by post-load insulin and C-peptide from the oral glucose tolerance test (OGTT). However, OGTT or meal tolerance tests are a burden for patients, and OGTT is not suitable for overt diabetes due to the risk of hyperglycemia. If we can calculate the HIC from the fasting state, it is preferable. We hypothesized that fasting HIC correlates with postprandial HIC in both participants with T2DM and without diabetes. We investigated whether fasting HIC correlates with postprandial HIC in overt T2DM and nondiabetes subjects (non-DM) evaluated by using glucose clamp and meal load. METHODS: We performed a meal tolerance test and hyperinsulinemic-euglycemic clamp in 70 subjects, 31 patients with T2DM and 39 non-DM subjects. We calculated the postprandial C-peptide AUC-to-insulin AUC ratio as the postprandial HIC and the fasting C-peptide-to-insulin ratio as the fasting HIC. We also calculated whole-body insulin clearance from the glucose clamp test. RESULTS: The fasting HIC significantly correlated with postprandial HIC in T2DM (r_S = 0.82, P < 0.001). Nondiabetes subjects also showed a significant correlation between fasting and postprandial HIC (r_S = 0.71, P < 0.001). Fasting HIC in T2DM was correlated with BMI, HbA1c, gamma-glutamyl transpeptidase, HOMA-IR, HOMA-beta, M/I, and whole-body insulin clearance. Fasting HIC in nondiabetes subjects was correlated with HOMA-IR and HOMA-beta. CONCLUSIONS: These results suggest that fasting HIC is strongly correlated with postprandial HIC in both overt T2DM and non-DM patients, as evaluated by the meal test and glucose clamp method. Fasting HIC could be a convenient marker of HIC.

5-Aminolevulinic acid/sodium ferrous citrate improves the quality of heat-stressed bovine oocytes by reducing oxidative stress.

A high temperature-humidity index during summer has deleterious effects on mitochondrial function, reducing oocyte developmental competence. 5-Aminolevulinic acid (5-ALA) and sodium ferrous citrate (SFC) are both known to support mitochondrial function and have strong anti-oxidant and anti-apoptotic activities. This study aimed to determine the mechanism of action of 5-ALA/SFC on oocyte quality. Bovine oocytes were collected from medium-sized follicles during summer (July-September, temperature-humidity index:76.6), cultured with 0, 1, 2, 4, and 8 µM 5-ALA with SFC at a molar ratio of 1:0.125, fertilized, and cultured for 10 days. The addition of 8/1 µM 5-ALA/SFC had a deleterious effect on oocyte cleavage rate in comparison with control oocytes, but did not affect the blastocyst rate, while 1/0.125 µM 5-ALA/SFC had a significantly higher increase in blastocyst rate than 8/1 µM 5-ALA/SFC. The addition of 1/0.125 and 2/0.25 µM 5-ALA/SFC improved oocyte quality by increasing the mitochondrial distribution pattern and metaphase-II oocytes, reducing reactive oxygen species and upregulating nuclear factor erythroid-2-related factor 2, heme oxygenase-1, and superoxide dismutase-1 in oocytes, and nuclear factor erythroid-2-related factor 2 and mitochondrial transcription factor A in cumulus cells. These results indicate that 1/0.125 and 2/0.25 µM 5-ALA/SFC may support oocyte quality and developmental competence and provide anti-oxidant actions in cumulus-oocyte complexes.

Possibility of alleviating difficulties of health and social care professionals engaged in end-of-life care through Clinical Art program.

Background: Health and social care professionals experience high-stress levels during end-of-life care. Various intervention programs have been proposed to reduce stress and prevent burnout among physicians and nurses, including arts-based activities that have shown potential. However, it is unclear how art programs can alleviate stress among healthcare professionals providing end-of-life care. This study aimed to explore the potential of Clinical Art programs to alleviate distress in professionals providing end-of-life care. Methods: Two Clinical Art workshops, held in October and November 2020, were attended by local health and social care professionals. Focus groups were conducted with those who attended and consented to participate in the study. Verbatim transcripts were made, and a qualitative analysis of the text was conducted. Results: Thirteen health and social work professionals participated in the study. Perceived difficulties in end-of-life care included the complexity and uncertainty of end-of-life care services, the approaches to patients and families, and the difficulties due to human aspects of healthcare providers. The positive effects of Clinical Art included pure enjoyment of art, empathic communication with patients and families and the application of an ontological view of human beings, which were identified as reasons for Clinical Art's effectiveness and applicability to care. Conclusions: The results suggest that the Clinical Art program has a psychosocial moderating effect on health and social work professionals and can be used for empathic communication with patients and families in end-of-life care and for applying an ontological view of human beings in caring for patients.

Keep thinking about unanswered questions in primary care: Cultivating negative capability.

Negative capability or tolerance for uncertainty is important for primary care physicians. The 2022 edition of the Model Core Curriculum for Medical Education also states that the content of professionalism is to "keep thinking about unanswerable questions."

Late-Onset Intracranial Hemorrhage Presenting as Refractory Hyponatremia: A Case Report.

Here, we report a case of refractory hyponatremia and delayed intracranial hemorrhage following a head injury. A 70-year-old male patient was admitted with complaints of left chest pain and light-headedness after a fall. Hyponatremia recurred despite the correction with intravenous saline. Head computed tomography revealed a chronic subdural hematoma. The subsequent introduction of tolvaptan improved hyponatremia and disorientation. Delayed intracranial hemorrhage is a differential cause of refractory hyponatremia after head contusion. This case is clinically relevant because (i) the diagnostic delay of late-onset intracranial hemorrhage is common but fatal, and (ii) refractory hyponatremia can be a hint of late-onset intracranial hemorrhage.

The Effectiveness of the Multiple-Attending-Physicians System Compared With the Single Attending-Physician System in Inpatient Setting: A Mixed-Method Study.

OBJECTIVES: Medical facilities have been required to effectively utilize insufficient human resources in many countries. Therefore, we qualitatively and quantitively compared physicians' working burden, and assessed advantages and disadvantages of the single- and the multiple-attending physicians systems in inpatient care. METHODS: In this cross-sectional study, we extracted electronic health record of patients from a hospital in Japan from April 2017 to October 2018 to compare anonymous statistical data between the single-attending and multiple-attending-physicians system. Then, we conducted a questionnaire survey for all physicians of single and multiple-attending systems, asking about their physical and psychiatric workload, and their reasons and comments on their working styles. RESULTS: The average length of hospital stay was significantly shorter in the multiple-attending system than in the single-attending system, while patients' age, gender, and diagnoses were similar. From the questionnaire survey, no significant difference was found in all categories although physical burden in multiple-attending system tended to be lower than that in single-attending system. Advantages of multiple-attending system extracted from qualitative analysis are (1) improvement of physicians' quality of life (QOL), (2) lifelong-learning effect, and (3) improving the quality of medical care, while disadvantages were (1) risk of miscommunications, (2) conflicting treatment policies among physicians, and (3) patients' concern. CONCLUSIONS: The multiple-attending physician system in the inpatient setting can reduce the average length of stay for patients and also reduce the physical burden on physicians without compromising their clinical performance.

Effects of Using a Video-Sharing Application on Multidisciplinary Staff During Pre-discharge Home Assessment Visits for Elderly Hospitalized Patients.

Background: Pre-discharge home assessment visits for elderly hospitalized patients are conducted by the hospital staff to ensure a smooth transition to home care and are effective in preventing falls and reducing the rehospitalization rates. However, the effect of an application that enables the viewing of videos of the patient's home activities during the pre-discharge visit on the multidisciplinary professionals who provide services to the patient has not yet been fully clarified. Methods: Multidisciplinary professionals at 23 facilities located in western Tottori Prefecture who used a video-sharing application (Patto-Mie Net) were invited to be interview participants. Those who agreed were interviewed about the usefulness of the application in their work and its effect on multidisciplinary collaboration. A verbatim transcript was made, and thematic analysis was conducted using the qualitative analysis software NVivo. Results: Twenty-eight people participated in the interviews, including nurses, care managers, rehabilitation specialists, care workers, and other social care professions. Fourteen themes and five categories were generated from the analysis: comprehensive information visualization and transferability, identification of changes over time and prognostic prediction, promoting multidisciplinary collaboration, patient and family reality, and disadvantages and concerns. Conclusion: The use of an application that allows video-sharing of a patient's home movement status during a pre-discharge visit has revealed a variety of benefits for multiple professionals in hospitals and other facilities. In particular, the results were characterized by the psychological closeness between multiple professionals, promotion of interprofessional communication, and sharing of reality, including the psychosocial background of the patient and family.

Aldehyde dehydrogenase 2 polymorphism is an important gene for insulin resistance in Japanese patients with type 2 diabetes.

Background: Aldehyde dehydrogenase 2 (ALDH2) is an important enzyme involved in alcohol metabolism. ALDH2 polymorphism has been reported as a risk factor for type 2 diabetes mellitus (T2DM) and is associated with liver insulin resistance due to alcohol consumption in non-diabetic individuals. Herein, we investigated the association between ALDH2 polymorphisms and insulin resistance in patients with T2DM. Methods: We performed a meal tolerance test and the hyperinsulinemic-euglycemic clamp on 71 Japanese participants: 34 patients with T2DM, and 37 non-diabetic participants. We analyzed the ALDH2 polymorphism (ALDH2 rs67); GG type was defined as the T2DM high-risk group, compared with the low-risk AG and AA groups. Results: Glucose levels were similar in the high- and low-risk T2DM groups. The high-risk group for T2DM showed a significantly higher BMI (p < 0.005), insulin resistance in HOMA-IR (p < 0.05), and Insulin sensitivity index (p < 0.05); however, there were no significant differences in insulin resistance in the clamp test (p = 0.10). Alcohol consumption did not differ significantly between groups (p = 0.66). Non-diabetic participants also showed higher HOMA-IR insulin resistance in the high-risk group (p < 0.05), but insulin resistance levels in the glucose clamp tests (p = 0.56) and insulin secretion were not significant. Conclusion: The results suggest that ALDH2 is an important gene associated with insulin resistance and obesity in Japanese patients with type 2 diabetes.

Reduction of oocyte shedding and cecal inflammation by 5-aminolevulinic acid daily supplementation in laying hens infected with Eimeria tenella.

The present study aimed to evaluate the effects of 5-aminolevulinic acid (5-ALA) on Eimeria tenella infection in laying hens. Oocyst shedding and histopathology were evaluated. A reduced oocyst shedding was observed 5 and 7 days post-infection (dpi) in the 5-ALA-administered group, but the total number of oocysts during the first infection period was not different between control and 5-ALA-treated groups. After E. tenella attack infection, the period of oocyst shedding in the 5-ALA-administered group lasted less long than that in controls. During the attack infection period, the total number of fecal oocysts in the 5-ALA-treated group was significantly lower than that in the control group. However, the parasite burden score in hens receiving 5-ALA was higher than that in controls after E. tenella attack infection. The lesion scores at 5 and 30 dpi in the control group were significantly lower than those in the 5-ALA-administered group. Therefore, 5-ALA administration might be beneficial against E. tenella infection in laying hens.

A Case of Weight Gain and Edema With Difficulty in Moving Legs Due to Intravascular Large B-cell Lymphoma Diagnosed by Skin Biopsy.

We report a case of intravascular large B-cell lymphoma (IVL) with spinal cord involvement. A 76-year-old woman was referred to our department due to generalized edema and weight gain. She also had difficulty moving her legs. She had no superficial lymphadenopathy upon examination. Her laboratory tests showed a markedly elevated blood lactate dehydrogenase (LDH) level. Although heart failure or interstitial lung disease was initially suspected, she was diagnosed with IVL by skin biopsy. An MRI revealed spinal cord involvement. Post-hospitalization, she began rituximab-combined chemotherapy. In this case, we considered that the spinal cord involvement of the lymphoma caused the neurogenic bladder and leg weakness. IVL often infiltrates the central nervous system and presents with neurological symptoms, including neurogenic bladder. Therefore, imaging studies should be planned to search for the involvement of the central nervous system in lymphoma if accompanied by neurological symptoms. In addition, in patients with a markedly elevated LDH or soluble interleukin-2 receptor level without lymphadenopathy, IVL should be suspected, and consultation with hematologists should be considered.

The experience of providing end-of-life care at home: The emotional experiences of young family physicians.

Background: End-of-life care is now a major issue in Japan as a result of the rapidly aging population; hence, the need for fostering family physicians to be engaged in end-of-life care at home is increasing. Studies in the United States and the United Kingdom have shown that physicians feel emotional and moral distress in end-of-life care, and that they develop detachment and dehumanizing attitudes toward patients as a coping mechanism. However, few studies have explored the emotional experiences that family physicians have during home-based end-of-life care. The aim of this study is to explore the emotional experiences of young family physicians in such situations. Methods: We conducted a qualitative analysis of interviews with family medicine residents or family physicians who had just completed their residency. The interviews were audio-recorded and transcripts were prepared. The coded data were analyzed according to thematic analysis using NVivo 10 software. Results: Study participants were 12 family physicians of PGY 5-11, with experienced end-of-life care cases of 3-20. Thirteen themes were extracted from the data, which were categorized into five domains: difficulties in end-of-life discussion, emotions of physicians, the role of physicians, communicating with the family, and positivity in end-of-life care. The physicians experienced various emotions and struggles within these domains, but they also felt something positive through providing care for the dying patients and their families. Conclusion: Family physicians experience various emotional difficulties during end-of-life home care. However, positive emotions at the end of life were also experienced through their care.

5-Aminolevulinic acid combined with sodium ferrous citrate mitigates effects of heat stress on bovine oocyte developmental competence.

High summer temperatures have deleterious effects on oocyte developmental competence. The antioxidant and autophagy-related properties of 5-aminolevulinic acid (5-ALA) gives the compound a broad range of biological activities. This study aimed to evaluate the effects of: 1) a high temperature-humidity index (THI) on the developmental competence of bovine oocytes, and 2) 5-ALA administration in combination with sodium ferrous citrate (SFC) during in vitro maturation (IVM) on bovine oocyte developmental competence evaluated at high THI. Bovine ovaries were collected from a local slaughterhouse at moderate environmental temperature (MT; THI of 56.2) and high environmental temperature (HT; THI of 76.7) periods; cumulus-oocyte complexes (COCs) were aspirated from medium-sized follicles, matured in vitro for 22 h, fertilized, and cultured for 10 days. For COCs collected during the HT period, 0 (control), 0.01, 0.1, 0.5, or 1 µM 5-ALA was added to the maturation medium in combination with SFC at a molar ratio of 1:0.125. The results showed that HT adversely affected blastocyst and hatching rates compared with MT. Adding 5-ALA/SFC (1 µM/0.125 µM) to the maturation medium of oocytes collected during the HT period improved cumulus cell expansion and blastocyst rates compared with the no-addition control. In conclusion, this study showed that high THI can disrupt bovine oocyte developmental competence. Adding 5-ALA to SFC ameliorates this negative effect of heat stress and improves subsequent embryo development.

Dipeptidyl peptidase 4 inhibitor improves insulin resistance in Japanese patients with type 2 diabetes: a single-arm study, a brief report.

BACKGROUND: Dipeptidyl peptidase 4 inhibitor (DPP4i) is an effective medicine for type 2 diabetes mellitus (T2DM). Some articles reported DPP4i improves insulin secretion and insulin resistance. However, these effects are not well established by glucose clamp test and test meal in Japanese. We investigated the effect of DPP4i on insulin resistance and insulin secretion by using the glucose clamp test and meal tolerance test (MTT). METHODS: We performed a MTT, and the hyperinsulinemic-euglycemic clamp in 8 Japanese patients with T2DM. This study was a single-arm study. We measured fasting and postprandial glucose, insulin, incretins, and glucagon levels. We also measured serum adiponectin levels. RESULTS: HbA1c was significantly decreased after 3 months. The fasting and postprandial glucose levels were significantly decreased. Fasting and postprandial insulin levels were not changed. The insulin resistance derived from the glucose clamp test was significantly improved. HOMA-IR was not significantly changed. GLP-1 and GIP were significantly increased but glucagon did not change. Adiponectin was not significantly changed. CONCLUSIONS: Although the number of patients was very small, these results suggested that DPP4i treatment might improve insulin resistance without changing insulin secretion.

Lactobacillus gasseri PA-3 reduces serum uric acid levels in patients with marginal hyperuricemia.

Several studies have reported that Lactobacillus gasseri PA-3 reduces the level of serum uric acid (SUA) in patients with hyperuricemia. However, it remains unknown how PA-3 affects uric acid metabolism. In the present study, we examined effects of PA-3-containing yoghurt on uric acid metabolism in patients with marginal hyperuricemia. Sixteen patients with SUA > 357 µmol/L (marginal hyperuricemia) were enrolled. PA-3-containing yoghurt was administered for 8 weeks. Uric acid metabolism was evaluated just before and 8 weeks after the administration and at 4 weeks after the administration ended (post-administration). SUA levels after the administration were significantly lower than that before the administration and remained low at post-administration. Urinary uric acid concentration (Uur) after the administration were significantly lower than that before the administration. However, post-administration Uur levels were comparable to those before the administration. Therefore, PA-3-containing yoghurt significantly reduced the levels of SUA and Uur in patients with marginal hyperuricemia.

The sodium-glucose cotransporter 2 inhibitor ipragliflozin improves liver function and insulin resistance in Japanese patients with type 2 diabetes.

Sodium-glucose cotransporter 2 inhibitor (SGLT2i) treatment is a therapeutic approach for type 2 diabetes mellitus (T2DM). Some reports have shown that SGLT2i treatment improves insulin resistance; however, few studies have evaluated insulin resistance by the glucose clamp method. Hepatic insulin clearance (HIC) is a new pathophysiological mechanism of T2DM. The effect of SGLT2i treatment on hepatic insulin clearance and insulin resistance is not well known. We investigated the effect of SGLT2i treatment on insulin resistance, insulin secretion, incretin levels, body composition, and hepatic insulin clearance. We conducted a meal tolerance test (MTT) and a hyperinsulinemic-euglycemic clamp test in 9 T2DM patients. Ipragliflozin (50 mg/day) was administered, and the MTT and clamp test were performed after 4 months. We calculated HIC as the postprandial C-peptide AUC-to-insulin AUC ratio. We also measured GLP-1, GIP, and glucagon levels during the MTT. Body weight and HbA1c were decreased, although not significantly, after 4 months of treatment. Postprandial glucose, fasting insulin and postprandial insulin were significantly decreased. Insulin resistance with the glucose clamp was not changed, but the HOMA-IR and insulin sensitivity indices were significantly improved. Incretin and glucagon levels were not changed. Hepatic insulin clearance was significantly increased, but whole-body insulin clearance was not changed. The FIB-4 index and fatty liver index were significantly reduced. The HOMA-beta and insulinogenic indices were not changed, but the C-peptide index was significantly increased. Although the number of patients was small, these results suggested that SGLT2i treatment improved liver function, decreased hepatic insulin resistance, and increased hepatic insulin clearance, despite the small weight reduction.

Hyperthyroidism in Graves Disease Causes Sleep Disorders Related to Sympathetic Hypertonia.

CONTEXT: It is well known that Graves disease (GD) causes sleep disorders (SDs). However, the characteristics and associated factors of SD and its clinical course post hyperthyroidism normalization remain unclear. OBJECTIVE: To clarify the characteristics and associated factors of subjective SD and its clinical course after GD treatment. METHODS: From November 2017 to October 2020, we enrolled 72 participants (22 newly diagnosed with GD with untreated hyperthyroidism, 20 previously diagnosed with GD with normal thyroid function, and 30 normal controls) with no other underlying SD-related diseases. We compared the groups at enrollment and conducted prospective observations after 12 months of treatment on participants with newly diagnosed GD. Main outcome measures were differences and changes in the Pittsburgh Sleep Quality Index (PSQI) global and component sleep quality scores. RESULTS: PSQI global sleep quality scores (P = .036) and sleep disturbance scores (P = .011) were significantly different among the 3 groups, and were highest in the untreated hyperthyroidism group. Multiple regression analysis demonstrated that free thyroxine level, which was positively correlated with sympathetic tone (ST) as evaluated by pulse rate, and urinary total metanephrines was associated with poorer PSQI global sleep quality scores independently of other factors (P = .006). Prospective observation showed that PSQI global sleep quality scores (P = .018) and sleep disturbance scores (P = .011) significantly improved with thyroid function normalization and ST attenuation. CONCLUSION: Hyperthyroidism caused by GD augmented ST and exacerbated subjective SD. Normalization of hyperthyroidism caused by GD improved subjective SD.

Anorexia in a hemodialysis patient due to pneumatosis intestinalis: A case report.

We report a case of pneumatosis intestinalis (PI) in a hemodialysis patient who presented with anorexia and nausea. Anorexia with postprandial nausea can be caused by gastrointestinal diseases, with one of the rare causes being PI. PI may occur in hemodialysis patients, but it is rarely reported. We experienced a case of benign PI in a hemodialysis patient, for whom the conservative treatment with antibiotics improved the patient's clinical symptoms. In patients with PI, it is important to rule out potentially life-threatening complications, such as the presence of hepatic intraportal gas on CT scan.

Significance of pancreatic duodenal homeobox-1 (PDX-1) genetic polymorphism in insulin secretion in Japanese patients with type 2 diabetes.

INTRODUCTION: Pancreatic and duodenal homeobox factor-1 (PDX-1) is an imperative gene for insulin secretion in maturity-onset diabetes of the young 4. PDX-1 gene polymorphism was associated with lower first-phase insulin secretion in a genome-wide association study of intravenous glucose tolerance test. It was not associated with type 2 diabetes risk and insulin secretion in a genome-wide oral glucose tolerance test study. However, there have been no reports of overt type 2 diabetes and insulin resistance evaluation using a glucose clamp. We investigated PDX-1 polymorphism, insulin secretion, and insulin resistance in overt type 2 diabetes. RESEARCH DESIGN AND METHODS: We performed a meal tolerance test (MTT) and hyperinsulinemic-euglycemic clamping on 63 Japanese subjects, 30 with type 2 diabetes and 33 non-diabetic. We analyzed the rs1124607 PDX-1 gene polymorphism and defined A/C and C/C as the high-risk group and A/A as the low-risk group. RESULTS: HOMA-beta (homeostatic model assessment beta-cell function) was significantly lower in the high-risk group than in the low-risk group for all subjects (72.9±54.2% vs 107.0±63.5%, p<0.05). Glucose levels and glucose area under the curve (AUC) were not significantly different between both the risk groups. The insulin levels at 60 and 120 min and the insulin AUC after MTT were remarkably lower in the high-risk group than those in the low-risk group for all subjects (AUC 75.7±36.7 vs 112.7±59.5, p<0.05). High-risk subjects with type 2 diabetes had significantly lower insulin levels at 30 and 60 min and insulin AUC than low-risk subjects. Non-diabetic high-risk subjects depicted significantly lower insulin levels at 120 and 180 min. There were negligible differences in insulin resistance between the risk groups. CONCLUSIONS: These results suggest that the PDX-1 genetic polymorphism is crucial for insulin secretion in Japanese patients with type 2 diabetes.

Death education for doctors: Introducing the perspective of death and life studies into primary care physician training.

Primary care physicians need opportunities to learn about issues related to dealing with patient deaths, especially coping with emotional conflicts. Introduction of the perspective of death and life studies may have great educational significance.