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Journal Club

Journal Club. Bang H, Edwards AM, Bomback AS, Ballantyne CM, Brillon D, Callahan MA, Teutsch SM, Mushlin AI, Kern LM. Development and Validation of a Patient Self-assessment Score for Diabetes Risk. Ann Intern Med. 2009 Dec 1;151(11):775-83.

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Journal Club

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  1. Journal Club Bang H, Edwards AM, Bomback AS, Ballantyne CM, Brillon D, Callahan MA, Teutsch SM, Mushlin AI, Kern LM. Development and Validation of a Patient Self-assessment Score for Diabetes Risk. Ann Intern Med. 2009 Dec 1;151(11):775-83. Frulloni L, Lunardi C, Simone R, Dolcino M, Scattolini C, Falconi M, Benini L, Vantini I, Corrocher R, Puccetti A. Identification of a novel antibody associated with autoimmune pancreatitis. N Engl J Med. 2009 Nov 26;361(22):2135-42. 埼玉医科大学　総合医療センター　内分泌・糖尿病内科 Department of Endocrinology and Diabetes, Saitama Medical Center, Saitama Medical University 松田　昌文 Matsuda, Masafumi 2009年12月３日　8:30-8:55 ８階　医局

  2. Weill Medical College of Cornell University, Columbia University College of Physicians and Surgeons, and FOJP Service Corporation, New York, New York; Baylor College of Medicine, and Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart Center, Houston, Texas; and Los Angeles County Department of Public Health, Los Angeles, California. Ann Intern Med. 2009;151:775-783.

  3. Background and Aim National guidelines disagree on who should be screened for undiagnosed diabetes. No existing diabetes risk score is highly generalizable or widely followed. To develop a new diabetes screening score and compare it with other available screening instruments (Centers for Disease Control and Prevention, American Diabetes Association, and U.S. Preventive Services Task Force guidelines; 2 American Diabetes Association risk questionnaires; and the Rotterdam model).

  4. Method Design: Cross-sectional data. Setting: NHANES (National Health and Nutrition Examination Survey) 1999 to 2004 for model development and 2005 to 2006, plus a combined cohort of 2 community studies, ARIC (Atherosclerosis Risk in Communities) Study and CHS (Cardiovascular Health Study), for validation. Participants: U.S. adults aged 20 years or older. Measurements: A risk-scoring algorithm for undiagnosed diabetes, defined as fasting plasma glucose level of 7.0 mmol/L (126 mg/dL) or greater without known diabetes, was developed in the development data set. Logistic regression was used to determine which participant characteristics were independently associated with undiagnosed diabetes. The new algorithm and other methods were evaluated by standard diagnostic and feasibility measures.

  5. Calculation We computed standard validation measures: the proportion of high-risk persons sensitivity specificity positive predictive value (PPV) negative predictive value (NPV) Youden index (1 － false-positive rate － falsenegative rate ＝ sensitivity ＋ specificity － 1) likelihood ratios for a positive test result (sensitivity/[1 － specificity]) for a negative test result : ([1 － sensitivity]/specificity) a discrimination statistic : the area under the receiver-operating characteristic curve (AUC)

  6. Youden index

  7. ADA － American Diabetes Association; ARIC － Atherosclerosis Risk in Communities; BMI － body mass index; CDC － Centers for Disease Control and Prevention; CHS － Cardiovascular Health Study; LR － likelihood ratio; NA － not available; NHANES － National Health and Nutrition Examination Survey; NPV － negative predictive value; PPV － positive predictive value; USPSTF － U.S. Preventive Services Task Force. *Data on history of the polycystic ovary syndrome, history of impaired fasting glucose or impaired glucose tolerance, and pregnancy were not collected, so these conditions were omitted for the ADA guideline. Both ARIC and NHANES 2005 to 2006 collected the data on family history of diabetes but not separately for parents and siblings, so we replaced parental history with family history for the ADA questionnaires. † A smaller number indicates that a person knows their obesity status or BMI.

  8. ADA － American Diabetes Association; ARIC － Atherosclerosis Risk in Communities; BMI － body mass index; CDC － Centers for Disease Control and Prevention; CHS － Cardiovascular Health Study; LR － likelihood ratio; NA － not available; NHANES － National Health and Nutrition Examination Survey; NPV － negative predictive value; PPV － positive predictive value; USPSTF － U.S. Preventive Services Task Force. * Data on history of the polycystic ovary syndrome, history of impaired fasting glucose or impaired glucose tolerance, and pregnancy were not collected, so these conditions were omitted for the ADA guideline. Both ARIC and NHANES 2005 to 2006 collected the data on family history of diabetes but not separately for parents and siblings, so we replaced parental history with family history for the ADA questionnaires. † A smaller number indicates that a person knows their obesity status or BMI. ‡ CDC: All adults aged 25 years or older. § ADA: All adults aged 45 years or older and younger adults who are overweight or obese (BMI －25 kg/m2) and have at least 1 other risk factor, including physical inactivity, family history of diabetes, minority ethnicity, history of gestational diabetes or delivery of a baby weighing －9 lb, hypertension, high-density lipoprotein cholesterol level －0.9 mmol/L (－35 mg/dL) or triglyceride level －2.83 mmol/L (－250 mg/dL), women with the polycystic ovary syndrome, history of impaired fasting glucose or impaired glucose tolerance, other clinical conditions associated with insulin resistance (for example, severe obesity), or history of cardiovascular disease. From reference 12. － USPSTF: All adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. From reference 13. ¶ ADA diabetes questionnaire I: score－Herman －10, in which score－Herman － (woman who delivered a baby weighing －9 lb) － 1 － (parental history of diabetes) － 1 － (sibling’s history of diabetes) － 1 － (BMI －27 kg/m2) － 5 － (age －65 y and not physically active) － 5 － (45 y － age － 65 y) － 5 － (age －65 y) － 9. From reference 14. ** ADA diabetes questionnaire II: A function of age, waist, weight, height, gestational diabetes, parental and sibling diabetes history, race, high blood pressure, and exercise. See reference 4 for a graphical presentation of this algorithm. †† Rotterdam model: score－Rotterdam －6, in which score－Rotterdam － 2 per 5-y increment from 55 y － (male) － 5 － (use of antihypertensive medications) － 4 － (BMI －30) － 5. From reference 29. ‡‡ New screening score: score－new －5, in which score－new － (40 y － age － 50 y) － 1 － (50 y － age － 60 y) － 2 － (age －60 y) － 3 － (male) － 1 － (family history of diabetes) － 1 － (history of hypertension) － 1 － (overweight) － 1 － (obese) － 2 － (extremely obese) － 3 – (exercise) － 1.

  9. Results Age, sex, family history of diabetes, history of hypertension, obesity, and physical activity were associated with undiagnosed diabetes. In NHANES (ARIC/CHS), the cut-point of 5 or more points selected 35% (40%) of persons for diabetes screening and yielded a sensitivity of 79% (72%), specificity of 67% (62%), positive predictive value of 10% (10%), and positive likelihood ratio of 2.39 (1.89). In contrast, the comparison scores yielded a sensitivity of 44% to 100%, specificity of 10% to 73%, positive predictive value of 5% to 8%, and positive likelihood ratio of 1.11 to 1.98.

  10. Conclusion This easy-to-implement diabetes screening score seems to demonstrate improvements over existing methods. Studies are needed to evaluate it in diverse populations in real-world settings.

  11. Editors' Notes Context Guidelines disagree about who should receive screening for diabetes. Screening all adults would be expensive and lead to many false-positive results. Contribution The authors created a tool that allows people to estimate their own diabetes risk with questions they can easily answer (age, sex, family history of diabetes, personal history of high blood pressure, obesity, and physical activity). This tool performs better than other available methods. Implication People can use this tool to help decide whether their risk for diabetes is high enough to warrant seeing a doctor to have blood glucose measured.

  12. Message 糖尿病になった場合の合併症評価のリスクエンジンが議論になってきたが、糖尿病になるリスクについてスコア化はあまりよいものがなかった。まぁ今回のものは少しはよさそうだが、それほどまだ強力とは言えそうもないように思うが。（日本人では？） リスク因子はこれまで言われてきたようなものである。

  13. the Sections of Gastroenterology (L.F., C.S., L.B., I.V.), Internal Medicine (C.L., R.S., R.C.), and Endocrine Surgery (M.F.), University of Verona, Verona; and the Clinical and Experimental Immunology Unit, Giannina Gaslini Institute (M.D., A.P.), and the Section of Histology, University of Genoa (A.P.), Genoa N Engl J Med 2009;361:2135-42.

  14. Background Autoimmune pancreatitis is characterized by an inflammatory process that leads to organ dysfunction. The cause of the disease is unknown. Its autoimmune origin has been suggested but never proved, and little is known about the pathogenesis of this condition.

  15. Method To identify pathogenetically relevant autoantigen targets, we screened a random peptide library with pooled IgG obtained from 20 patients with autoimmune pancreatitis. Peptide-specific antibodies were detected in serum specimens obtained from the patients.

  16. Results Among the detected peptides, peptide AIP1-7 was recognized by the serum specimens from 18 of 20 patients with autoimmune pancreatitis and by serum specimens from 4 of 40 patients with pancreatic cancer, but not by serum specimens from healthy controls. The peptide showed homology with an amino acid sequence of plasminogen- binding protein (PBP) of Helicobacter pylori and with ubiquitin-protein ligase E3 component n-recognin 2 (UBR2), an enzyme highly expressed in acinar cells of the pancreas. Antibodies against the PBP peptide were detected in 19 of 20 patients with autoimmune pancreatitis (95%) and in 4 of 40 patients with pancreatic cancer (10%). Such reactivity was not detected in patients with alcohol-induced chronic pancreatitis or intraductal papillary mucinous neoplasm. The results were validated in another series of patients with autoimmune pancreatitis or pancreatic cancer: 14 of 15 patients with autoimmune pancreatitis (93%) and 1 of 70 patients with pancreatic cancer (1%) had a positive test for anti–PBP peptide antibodies. When the training and validation groups were combined, the test was positive in 33 of 35 patients with autoimmune pancreatitis (94%) and in 5 of 110 patients with pancreatic cancer (5%).

  17. Conclusion The antibody that we identified was detected in most patients with autoimmune pancreatitis but also in some patients with pancreatic cancer, making it an imperfect test to distinguish between these two conditions.

  18. Message 自己免疫性膵炎は糖尿病を呈する点からよく話題になり、これまでIgG4の特異性が言われてきたがそれだけでば診断が難しかった。結局癌と鑑別が難しい場合があり手術が行われてきた。 で、今回のマーカーでもやはり手術しないといけないようである。 自己免疫性膵炎にピロリ菌感染が関係していそうだというのが印象的！

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