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Global Health & Medicine Open
Volume 3, Number 1
August, 2023

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Print ISSN: 2436-293X
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GHM Open
GHM Open (Print ISSN 2436-293X, Online ISSN 2436-2956) is an international, open-access, peer-reviewed journal, publishedby the National Center for Global Health and Medicine (NCGM), which is a national research and development agency in Japanthat covers advanced general medicine, basic science, clinical science, and international medical collaboration. It is publishedby NCGM and supported by the International Research and Cooperation Association for Bio & Socio-Sciences Advancement(IRCA-BSSA).
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President,
National Center for Global Health and Medicine;
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The University of Tokyo.

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ii

CONTENTS		

Volume 3, Number 1, 2023

Policy Forum
1-6

Seven steps in the value chain of health products for equitable access and delivery in low- andmiddle-income countries.
Eiichi Shimizu, Yuta Yokobori, Kazuki Miyazaki, Kaori Ohara, Megumi Fujii, Tomoko Nishioka,
Noriko Fujita

Review
7-19

Association of adipokines with insulin resistance and metabolic syndrome including obesity anddiabetes.
Abhishek Gupta, Priyanka Gupta, Arun Kumar Singh, Vani Gupta

Original Article
20-27

Using eConsent to improve patient comprehension and solving issues for introduction,with special attention to the COVID-19 pandemic: A questionnaire survey by the Japan
Pharmaceutical Manufacturers Association.
Naoki Tomotsugu, Naoki Sakuma, Maki Dobashi, Miki Someya, Akiko Imai, Junichi Sakoda,
Masashi Fukuda, Katsuhiko Yoshimoto, Tatsuo Iiyama

28-36

Alpha and Delta variants and vaccination effectiveness against severity in COVID-19 inpatients
based on medical claims in Japan.
Shingo Mitsushima, Hiromasa Horiguchi, Kiyosu Taniguchi

Brief Report
37-41

Visualization of aerosol spread using a smoke tester during tracheal intubation performed in
an operating room.
Kohshi Hattori, Asako Eriguchi, Mayuko Omori, Osamu Nagata

42-46

Clinical features of cervical cancer at a national cancer center in Phnom Penh, Cambodia: A
descriptive cross-sectional study.
Aya Tanaka, Linka Koun, Rei Haruyama, Kyna Uy, Maryan Chhit, Lumpiny Kim, Noriko Fujita,
Yutaka Osuga, Tadashi Kimura, Kanal Koum

Case Report
47-50

Psychodynamic therapy for adverse childhood experience in a hospitalized girl with attention
deficit hyperactivity disorder.
Kaori Sugimoto, Toshinari Kurokouchi, Rena Shinohara, Yuuki Sakoh, Maiko Odaka,
Hikaru Sunakawa, Shuichi Tanese, Manao Seto, Masahiro Ishida, Yuta Yoshimura, Kotoe Itagaki,
Ikuhiro Harada, Saori Inoue, Yuki Hakoshima, Kumi Inazaki, Yuki Mizumoto, Masahide Usami

51-55

Pulmonary sclerosing pneumocytoma: A potential pitfall mimicking lung adenocarcinoma.
Himani Rai, Ipsita Dhal, Zachariah Chowdhury, Swapnil Patel, Durgatosh Pandeyiii

CONTENTS		

(Continued )Letter56-57

iv

Global vaccine equity: The G7's commitment and challenges.
Yudai Kaneda, Kenzo Takahashi, Akihiko Ozaki, Tetsuya Tanimoto

Policy ForumGHM Open. 2023; 3(1):1-6.
DOI: 10.35772/ghmo.2022.01008

Seven steps in the value chain of health products for equitable accessand delivery in low- and middle-income countries
Eiichi Shimizu*, Yuta Yokobori, Kazuki Miyazaki, Kaori Ohara, Megumi Fujii, Tomoko Nishioka, Noriko Fujita
Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan.

Abstract: The introduction of health products to low- and middle-income countries (LMICs) is hindered by several
barriers. Even when these barriers are overcome, improper use of health products can have a negative effect on
health outcomes. Health products may go unused due to a mismatch of product needs as well as a lack of public
infrastructure, spare parts and consumables, or trained technicians. This study presents a comprehensive framework of
the essential steps for effectively delivering quality health products to people in need based on our document reviews
and case studies. We divide the value chain of health products into seven steps: 1) situation analysis, 2) research anddevelopment, 3) regulatory authorization, 4) selection and prioritization, 5) public procurement, 6) distribution andstorage, and 7) health service delivery. We find that the practice of undertaking one step at a time leads to enormous
costs in terms of time and resources, often with little success. Failed attempts sometimes necessitate starting over fromthe beginning. Therefore, it is important to attempt each step while looking ahead to the end through the entire chainof seven steps. More in-depth analysis and lessons from best practices for each of the seven steps may need to beinvestigated further to consider possible interventions.
Keywords: access and delivery, health products, developing countries, medical devices, universal health coverage

Introduction(8). In LMICs where regulatory authorization is weakly
functioning, public procurement is a major means tosecure access to and delivery of safe and affordable
health products (9).
Several conceptual frameworks exist but there is nouniversal framework for effectively improving accessto and delivery of health products in LMICs (10).
Thus, this study attempts to create a series of steps that
correspond to the existing value chain of health products
by conducting a document review and case studies.
The following three cases describe the experiencesof the National Center for Global Health and Medicine(NCGM; Tokyo, Japan) in promoting access to anddelivery of health products in LMICs. Each case ispresented in the order of context, actions, outcomes,
and lessons learned. Based on these cases, we propose acomprehensive framework for describing characteristics,
with a view to enhance access to and delivery of healthproducts in LMICs.

As Goal 3 of the Sustainable Development Goals states,"access to quality essential healthcare services andaccess to safe, effective, quality and affordable essential
medicines and vaccines for all" are critical to achieving
universal health coverage (UHC) (1). Nevertheless, many
low- and middle-income countries (LMICs) lack accessto quality vaccines, medicines and medical devices(hereafter "health products"), health technologies, andhealth services (2), a situation that impacts the health ofthe population.
One reason for this challenge is that health products
are not always delivered in a manner appropriate for thecountry (3). In addition, improper use of health products
can have a negative impact on health outcomes (4).
Health products may go unused due to a mismatch of
product needs as well as a lack of public infrastructure,spare parts and consumables, or trained technicians (5).
Equitable delivery of health products and services
is becoming more complex due to pharmaceuticalregulations and geographic disparities, as seen in thedelivery of vaccines and related supplies for countering
COVID-19 (6,7). LMICs have limited access to safe andhigh-quality health products and must rely heavily on
donor support, exceeding 80% of supply in some cases

Case 1. Development of health products for LMICs
Working in hospitals and health centers in LMICs, wehave often observed situations where health products,
manufactured in high-income countries and provided byinternational agencies, were kept unused. In some cases,(1)

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products were never distributed from central storehouses.
For those that were distributed to health facilities, many
went unused or unopened because they did not suit the
local context and actual needs.
To ensure safe and quality health products are usedappropriately and continuously in LMICs, NCGM, aspart of advising the provision of health products by
Japanese grant aid and other Official Development
Assistance (ODA) agencies, launched a program in 2016
called "Supporting business plan of Medical Equipment
Development for Overseas based on local needs"(SMEDO) with funding from the Tokyo Metropolitan
Government (11). The program targets small andmedium-sized Japanese manufacturers aiming to develop
health products for LMICs, helping them to increase
their understanding of the on-the-ground reality throughlectures and site visits to health facilities in Vietnam andCambodia. Manufacturers also receive expert advice on
financing and business plans for overseas deployment.
The needs for health products vary from country
to country due to country-specific factors such as theeducational and technical level of the health workforce,
economic conditions, the health insurance system,
infrastructure development, lifestyles, and customs.
Through visits to facilities where their products are
actually used, manufacturers can better understandthe actual needs of the local health workforce, howequipment is maintained, and local business customs anddistribution methods.
Through this program, participating manufacturers
found that LMICs need low-cost, easy-to-use, andeasy-to-maintain products, leading them to reconsider
subsequent product development. This case demonstrates
the importance of conducting situational analyses of local
contexts and actual needs and incorporating the results in
the research and development (R&D) of health products
for use in LMICs.

of the equipment in medical procedures. In addition,
NCGM established an equipment management systemand provided comprehensive in-service training,
including radiation protection, to ensure provision ofsafe healthcare. The training also covered "Setsugu" (12),Japanese-style patient hospitality.
Subsequently, under the supervision of the
NCGM team, the UTH team successfully performed
Zambia's first coronary CT in February 2018, coronary
angiography (CAG) and percutaneous coronary
angiography (PCI) in November 2019. In addition, thenumber of CT scans performed at the hospital increasedby 129.6% from 2017 to 2019 (13). However, an
unexpected CT equipment failure in 2019 prevented us
from performing coronary CT. In response to this, UTH
signed a maintenance contract with the manufacturer
for its sustainable use. Consumables such as stents andcatheters are needed to perform CAG and PCI; thus, a
distribution system for these supplies was establishedbetween UTH and local distributors.
This case study yields three lessons from theperspectives of access and delivery. First, the capacityof the local health workforce should be evaluated when
delivering equipment. It is important to determine
whether there are enough trained technicians to operate
the equipment. If not, it will be necessary to provide
training. Second, it is important to ensure proper
equipment management, including daily inspections
and regular maintenance. Third, the introduction of
new technologies might necessitate the procurement ofconsumables that were not previously required.
Case 3. Introduction of health products for blood
safety in Myanmar
From 2005 to 2015, NCGM and the Ministry of Healthand Sports (MOHS) in Myanmar worked together
to improve blood transfusion services in Myanmar.
Then, to further improve the quality and safety ofblood transfusions for advanced therapies such astransplantation, NCGM and the Myanmar National
Blood Center (NBC) launched a new four-year projectin collaboration with Japanese medical equipment
manufacturers in 2015 (14).
In this project, an infectious disease control advisor
from NCGM coordinated between Japanese doctors,
nurses, and laboratory technicians and Myanmar
government officials and the NBC. The Japanese teamvisited the NBC and local hospitals to understand the
local conditions. Recognizing the need for further safety
improvements, the Japanese team provided training tolocal doctors, laboratory technicians, and nurses in blood
typing and clinical transfusion therapy. Simultaneously,
Japanese manufacturers provided equipment andconsumables, including refrigerators for blood packs,
centrifuges for component blood preparation, andleukocyte filters.

Case 2: Installation of radiological equipment inZambiaIn 2015, the Zambian Ministry of Health purchased
computed tomography (CT) and interventional
radiology (IVR) equipment for the University Teaching
Hospital (UTH) in order to improve the treatment ofcardiovascular disease (CVD). However, the hospital
staff lacked the training to operate the equipment andit went unused. Consequently, UTH continued to sendpatients in need of testing and treatment to healthinstitutions in neighboring countries.
Because the equipment was manufactured bya Japanese company, UTH requested that NCGM
provide technical support to their physicians, radiology
technologists, and nurses involved in diagnosing andtreating CVD. From 2017 to 2019, NCGM provided
hands-on technical assistance, including not only how
to use the equipment but also how to make the best use(2)

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H i g h - r a n k i n g o ff i c i a l s f r o m t h e M y a n m a r
government and the NBC visited Japan to learn about theJapanese blood transfusion system. To improve safety,
an annual blood transfusion seminar for policymakers
and clinicians was launched in Myanmar in collaboration
with the NBC. Furthermore, the infectious disease
control advisor assisted with the creation of Myanmar's
national blood transfusion guidelines. Through these
activities, Japanese blood transfusion-related products
were procured and distributed by the MOHS.
This case exemplifies technical cooperation that met
local needs and led to successful product procurement.
First, the relationship of trust fostered by long-termcooperation with MOHS and the NBC made it possible
to perform a more practical situation analysis that led
to technology transfers and training as well as R&D of
products that reflected actual needs. Second, involving
stakeholders facilitated coordination within the MOHS,
enhancing awareness of the importance of safety.
Consequently, Japanese products were procured by the
Myanmar government. Third, providing appropriate
training in collaboration with the NBC improved service
quality and led to nationwide product distribution.
Finally, Japanese manufacturers shifted their mindset
toward investing in the future, illustrating an effective
marketing strategy for expanding overseas.

1) situation analysis, 2) research and development, 3)
regulatory authorization, 4) selection and prioritization,5) public procurement, 6) distribution and storage, and
7) health service delivery (Figure 1). Below, we describe
the characteristics of each step.
Step 1. Situation analysis
This step involves thorough market research to identify
the end users, their needs, the circumstance in which
the intended product would be used, and prices inthe existing market. Critical questions include i) Can
health products be distributed to rural clinics? ii) Whatis the status of infrastructure such as water, electricity
and telecommunications? iii) What is the maintenancecapacity of local suppliers and service providers who use
health products? iv) What testing and medication costs
are affordable for residents? v) What health issues are
specific to the region? And vi) What are the projections
for demographic characteristics, emerging diseases,
socioeconomic status, and so on? It is also important tostudy competing products and examine related trends.
The SMEDO and Myanmar cases illustrated situational
analyses that led to effective interventions. In contrast,
the Zambia case demonstrated an inadequate analysisof the situation regarding trained technicians capable ofaccurately using and managing the product.

Framework of essential steps for better access to anddelivery of health products

Step 2. Research and development (R&D)

By reviewing the barriers and success factors in theabove cases, we concluded that the entire value chain
can be divided into seven steps to accelerate equitable
access to and delivery of health products in LMICs:

In this step, it is important to find appropriate partners
that can help collect data and verify the utility of the
product in LMICs. Some manufacturers may takeadvantage of the financial and technical support

Figure 1. Seven steps for equitable access to and delivery of health products. This framework represents the entire value
chain of health products divided into seven steps. The characteristics of each step are described in the box below.

(3)

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provided by academia, international organizations,and governments as they design and develop products
suitable for LMICs. In the case of Myanmar, theJapanese team collaborated with the NBC from the
beginning, and the Japanese manufacturer was able toobtain the necessary information to adapt its products tolocal conditions.

affordable prices to win global competitive bids.
Products that are already pre-qualified by the WHO andlisted in global product catalogs have an advantage. In
the case of Myanmar, the government directly procured
the products. The Japanese manufacturer's shift toward
investing in the future was an essential component ofcultivating the target country's market.

Step 3. Regulatory authorization

Step 6. Distribution and storage

The World Health Organization (WHO) and national
governments use their regulatory authority to assure thesafety and quality of health products. This step involves
confirming the WHO's prequalification and obtaining
national regulatory approval in the target country.
Manufacturers can apply for product approval, whichfacilitates subsequent steps, especially Steps 4 and 5.
However, this time-consuming and costly step requires
strategic planning (15). The abovementioned activities
in Myanmar were influential in obtaining regulatory
authorization. High-ranking government officials wereinvolved in the training and therefore played a crucialrole in the public procurement of Japanese products
because they understood their necessity and practicalapplications.

This step refers to the entire supply chain in theprovision of products and services. This involves a broad
range of activities from manufacturing including local
production, distribution, and storage, to user training
and maintenance. Manufacturers may need to set up
local production and distribution bases in the target
country. In the case of Myanmar, the NBC coordinatedthe nationwide distribution of the products. In the case ofZambia, the ability to provide a new kind of examination
service led to increased demand for consumables, which
opened up further sales opportunities.
Step 7. Health service delivery
To deliver and maintain health products locally, it isessential to provide local technicians with proper training
and guidance. It is also helpful to establish a maintenancesystem, secure distribution of spare parts, and provide amonitoring system to receive feedback from local healthfacilities. In Myanmar, provision of practical training
improved the quality of service, while the involvementof stakeholders facilitated the creation of nationalguidelines. The Zambia case suggested the importance of
keeping maintenance contracts and user training.

Step 4. Selection and prioritization
Obtaining product approval does not necessarily mean
the product should be selected for local usage. This
step involves efforts to list the final product in productcatalogs and to be covered by the national healthinsurance plan of the target government. National
governments may require a track record of sales resultsin different countries and examples of product use on
English-language websites. Among approved products,
those that should be used at the local health facility level
will tend to be prioritized. In some countries, a healthtechnology assessment is conducted for selection andprice-setting (16). In the Myanmar case, the nationaltransfusion guidelines created through the projectindicated the need for quality and safety standards.
Because the products met those standards, they wereselected and prioritized.

Perspectives in setting a universal framework foraccess and delivery
There are several existing conceptual frameworks that
describe the factors related to access to and delivery ofhealth products in LMICs. The United Nations proposeda pharmaceutical value chain, from the developmentof medicines to their appropriate use by patients, toensure access to safe, effective, and quality-assured
medicines, including controlled medicines (17). This
framework is characterized by the "Manufacturing" stepand by dividing "Health service delivery" into several
practical steps, which were modified by the WHO to
expand the focus to health products as a whole, with
post-marketing surveillance added at the end (18). In
addition, the UN Development Programme Access andDelivery Partnership (UNDP-ADP) suggested anotherframework of steps to help manufacturers deliver healthproducts to people in need (19). As shown in Table 1,
these frameworks are similar to ours in that they cover
the steps from R&D to health service delivery. However,there are some differences, including "Situation

Step 5. Public procurement
This step can occur in three ways: i) direct procurement
by national governments in LMICs, sometimes withfunding provided by international organizations (orprocured by international organizations on behalf of thegovernment); ii) procurement by donor governments forthe purpose of assisting LMICs; and iii) procurement
by United Nations agencies or other internationalorganizations for the purpose of supporting LMICs.
Challenges for manufacturers include establishing anadequate supply chain for mass production and setting(4)

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Table 1. Comparison of relevant frameworks for access to and delivery of health products
Items
TargetNumber of steps
Steps
Situation analysis
R&D

NCGM 7 steps
Health products
7① Situation analysis② R&D*Included in step ⑥

Manufacturing
Accreditation③ Regulatory authorization

Selection④ Selection and

Procurement
Distribution
Service provisionprioritization⑤ Public procurement⑥ Distribution and storage⑦ Health service delivery

UNDP-ADPUN pharmaceuticalvalue chain

WHO value chainof health products

Health products
6

Medicines
8

Health products
9① New medicines,① R&D and innovation① R&D and innovation② Manufacturing② Manufacturing④ Selection/pricing/④ Selection/pricing/vaccines, diagnostics② Regulatory

authorization③ Selection, prioritization
and resource allocation④ Public procurement⑤ Storage and distribution⑥ Health service delivery

Monitoring③ Marketing registration

reimbursement⑤ Procurement and supply⑥ Prescribing,⑦ Dispensing, and ⑧ Use③ Marketing registration

reimbursement⑤ Procurement and supply⑥ Prescribing,⑦ Dispensing, and ⑧ Use⑨ Post market surveillance*NCGM seven steps include "Manufacturing" in step of ⑥ Distribution and storage. NCGM, National Center for Global Health and Medicine;
UNDP-ADP, United Nations Development Programme Access and Delivery Partnership; R&D, Research and development.

analysis," which was incorporated into our framework as
the first step.
As stated in Cases 1 and 2, better understandingof local conditions is needed to ensure access to anddelivery of health products to people in need in LMICs
in order to achieve UHC. In particular, the following
perspectives should be considered at the "Situation
analysis" step: the distribution system of health products
to local health facilities; the status of basic infrastructure,including water, electricity, and telecommunications; themaintenance capacity of local suppliers; the affordabilityof services for local people; and compatibility with local
needs and demographic prospects. Although the "R&D"
step in other frameworks may include the investigationof local conditions, our framework places more emphasison "Situation analysis," which is the first and mostimportant step in supporting access to and delivery ofhealth products in LMICs. By analyzing local needs, it
might be possible to modify existing health products for
local markets without a long and costly R&D process.
In addition, analyzing the needs of marginalized
and vulnerable populations can facilitate the promotionof equitable access to healthcare in light of UHC. For
example, mobile X-ray equipment is a good exampleof how a product developed for home healthcare in
Japan was adapted for use in remote settings, leading tomarket expansion and better access for disadvantaged
populations in LMICs (20). No matter how innovatively
products are developed, if they do not contribute tomediating health equity issues, they will only create
health disparities.
Our seven-step approach serves as a road map
for a diverse range of stakeholders by clarifying core
principles at each step in the value chain and services tobe delivered to the population, with the aim of realizing
UHC. However, further research is required to strengthen
the evidence base for accurate conceptualization of the

topic. For example, our framework does not include a"Manufacturing" step, which is incorporated into the"Distribution and storage" step instead. This is because
we developed our framework based mainly on our
experience that manufacturing was included in a seriesof activities by manufacturers under distribution andstorage. However, the location, method, and cost of
manufacturing are important aspects in the value chain ofhealth products. Therefore, it remains to be determined
whether the "Manufacturing" step should be emphasized
more in our framework.
Lastly, our framework incorporates several
activities into the "Health service delivery" step. In
contrast, the UN has three separate steps ("Prescribing,""Dispensing," and "Use"), while the WHO added"Post market surveillance" as the final step after healthservice delivery. The need to monitor the progress ofaccess to and delivery of health products should also be
investigated in future research. We wish to explore morecase studies in order to identify challenges and lessons
learned in addressing how best each step should takeplace in the deliberation of accessible health products in
LMIC settings.
Conclusion
Our goal should be to provide people in LMICs withequitable access to safe, affordable, and reliable productsthat are suitable for local conditions and needs, with theaim of improving health outcomes. Instead of a narrowapproach that aims only to achieve WHO prequalificationor product approval, it is important to view the entire
value chain of health products comprehensively,
following the seven steps proposed in this article. Such acomprehensive, forward-thinking perspective would be
helpful in ensuring that the end user is always considered.
Our seven-step approach offers considerations that may(5)

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be useful for all stakeholders involved in access to anddelivery of health products. The approach will also
contribute to improving global health disparities.

10.

Acknowledgements
The authors would like to thank Drs. Masahiko Hachiya,
Yuriko Egami, Masami Fujita, Mari Nagai, and Shinsuke
Miyano as well as our colleagues who supported thework of the Bureau of International Health Cooperation
at NCGM to promote access to and delivery of healthproducts in LMICs by providing insight and technicalexpertise, which greatly assisted this research.

11.

12.
13.

Funding: This work was supported by a research grantfrom the Ministry of Health, Labour and Welfare(MHLW) of Japan (Grant No. 21BA1001).
Conflict of Interest: The authors have no conflicts ofinterest to disclose.

14.

References
1.

2.

3.
4.

5.

6.

7.

8.

9.

15.

The United Nations. Sustainable development goals. Goal
3: Ensure healthy lives and promote well-being for all
at all ages. https://www.un.org/sustainabledevelopment/
health/ (accessed September 9, 2022).
Compton B, Barash DM, Farrington J, Hall C, Herzog
D, Meka V, Rafferty E, Taylor K, Varghese A. Accessto medical devices in low-income countries: addressing
sustainability challenges in medical device donations.
NAM Perspectives. Discussion Paper, National
Academy of Medicine, Washington, DC. https://doi.
org/10.31478/201807a (accessed September 9, 2022).
Malkin RA. Barriers for medical devices for the developingworld. Expert Rev Med Devices. 2007; 4:759-763.
World Health Organization. Everybody's business:
strengthening health systems to improve health outcomes:
WHO's framework for action. https://apps.who.int/iris/handle/10665/43918 (accessed September 9, 2022).
Diaconu K, Chen YF, Cummins C, Jimenez Moyao G,
Manaseki-Holland S, Lilford R. Methods for medical
device and equipment procurement and prioritization
within low- and middle-income countries: findings of asystematic literature review. Global Health. 2017; 13:59.
Wakabayashi M, Ichimura Y, Shimizu E, Nishioka T,
Kono Y, Doi M, Egami Y, Kadowaki T, Iso H, Fujita N.
Global extension of Japanese medical products related to
COVID-19: a survey of WHO Emergency Use Listing.
GHM Open. 2022; 2:59-62.
World Health Organization. Assessment of the COVID-19
supply chain system: full report. https://www.who.int/
publications/m/item/assessment-of-the-covid-19-supplychain-system-report (accessed September 9, 2022).
World Health Organization. Medical devices: managing
the mismatch. https://apps.who.int/iris/bitstream/handle/10665/44407/9789241564045_eng.pdf (accessed
September 9, 2022).
World Health Organization. The Global Health
Observatory - Procurement of medical devices carriedout at the national level. https://www.who.int/data/gho/

16.

17.
18.

19.
20.

data/indicators/indicator-details/GHO/procurementof-medical-devices-carried-out-at-the-national-level(accessed September 9, 2022).
Kuupiel D, Bawontuo V, Drain PK, Gwala N, MashambaThompson TP. Supply chain management and accessibility
to point-of-care testing in resource-limited settings: asystematic scoping review. BMC Health Serv Res. 2019;19:519.
Tokyo Metropolitan Government. Supporting businessplan of medical equipment development for overseas
based on local needs. https://smedo.tokyo/english.html(accessed September 9, 2022).
Shimada H. Consideration of patient care from point ofview of radiological technologist. Iryo. 2007; 61:26-29. (inJapanese)
Kono Y, Shimizu E, Matsunaga F, Egami Y, Yoneda K,
Sakamoto K, Mubita M, Sichizya VS, Wakamatsu K,
Terashima M, Fujita N. Enhancing the use of computed
tomography and cardiac catheterization angiography in
Zambia: A project report on a global extension of medical
technology in Japan. Glob Health Med. 2021; 3:52-55.
Nozaki I, Aung T, Oo NN, Kodoi H, Ito Y, Inaba T, Shiratori
K. Enhancing the blood safety program in Myanmar: Reporton projects of global extension of medical technologies ofJapan. Glob Health Med. 2021; 3:48-51.
Vaz A, Roldão Santos M, Gwaza L, Mezquita González E,
Pajewska Lewandowska M, Azatyan S, Saint-Raymond A.
WHO collaborative registration procedure using stringent
regulatory authorities' medicine evaluation: reliance inaction? Expert Rev Clin Pharmacol. 2022; 15:11-17.
Oortwijn W, Broos P, Vondeling H, Banta D, Todorova
L. Mapping of health technology assessment in selected
countries. Int J Technol Assess Health Care. 2013; 29:42434.
The United Nations. The pharmaceutical value chain.
https://syntheticdrugs.unodc.org/syntheticdrugs/en/access/pharmaceutical/index.html (accessed September 9, 2022).
World Health Organization. Realizing equitable global
access interfaces between public health, innovation andintellectual property. https://www.wipo.int/edocs/mdocs/
mdocs/en/wipo_who_wto_gc_covid_19_21/wipo_who_
wto_gc_covid_19_21_3.pdf (accessed September 9, 2022).
The Access and Delivery Partnership. Strengthening
national health systems. https://adphealth.org/strengtheningnational-health-systems/ (accessed September 9, 2022).
National Center for Global Health and Medicine. Learningfrom domestic and overseas cases on the global expansionof medical products: development, regulatory approval,
and global public procurement. https://kyokuhp.ncgm.
go.jp/library/tenkai/2021/tenkaiseminar202203_light.pdf(accessed September 9, 2022). (in Japanese)---Received September 9, 2022; Revised October 13, 2022;
Accepted October 19, 2022.
Released online in J-STAGE as advance publication November
4, 2022.
*Address correspondence to:Eiichi Shimizu, Bureau of International Health Cooperation,
National Center for Global Health and Medicine, 1-21-1
Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
E-mail: eshimizu@it.ncgm.go.jp(6)Review

GHM Open. 2023; 3(1):7-19.
DOI: 10.35772/ghmo.2023.01004

Association of adipokines with insulin resistance and metabolic
syndrome including obesity and diabetes§§

Abhishek Gupta1,*, Priyanka Gupta2, Arun Kumar Singh1, , Vani Gupta1,
12

Department of Physiology, King George's Medical University, Lucknow, India;
Department of Medicine, King George's Medical University, Lucknow, India.

Abstract: Adipose tissue (AT) acts as a highly active endocrine organ, which secretes a wide range of adipokine
hormones. In the past few years, several adipokines (leptin, adiponectin, resistin etc.) have been discovered showing
metabolic consequences in relation to insulin resistance (IR), obesity and diabetes. These adipokines are considered to
be an important component playing an important role in the regulation of energy metabolism. They have been shown
to be involved in the pathogenesis of metabolic syndrome (MetS) and cardiac diseases. The current article provides aholistic summary of recent knowledge on adipokines and emphasizes their importance in association with IR, obesity,
diabetes and MetS. Adipokines such as leptin, adiponectin, resistin and tumor necrosis factor-alpha (TNF-α) have been
involved in the regulation of an array of metabolic functions and disease associated with it, e.g. appetite and energybalance of the body, suppression of atherosclerosis and liver fibrosis, obesity with type 2 diabetes (T2D) and IR. An
important adipokine, Interleukin-6 (IL-6), also correlates positively with human obesity and IR and also the elevatedlevel of IL-6 predicts development of T2D. All of these hormones have important correlation with energy homeostasis,
glucose and lipid metabolism, cardiovascular function and immunity. All the possible connections have extended thebiological emphasis of AT secreted adipokines as an investigator in the development of MetS, and are now no longer
considered as only an energy storage site.
Keywords: adipose tissue, lipid, glucose, appetite, homeostasis

Introduction

tends to be more insulin resistant, hyperinsulinemic,
glucose intolerant and dyslipidemic than obesity with agreater proportion of lower body fat. So, the distributionof body fat tissue is an important correlate of MetS.
Due to the dramatic rise in obesity and associatedmetabolic abnormalities worldwide, research pertaining
to, adipose tissue (AT) has gained tremendous scientificinterest for several years. Previous research demonstrated
that AT acts in an autocrine, paracrine or endocrine
reservoir to control various metabolic functions and may
contribute to the development of obesity mediated MetS.
AT secretes various proteins or factors with diverse
functions termed as bioactive mediators or "adipokines"(previously designated as "adipocytokines") modulating
hemostasis, blood pressure, lipid and glucose metabolism,
inflammation, and atherosclerosis (Table 2). In 2004,
Trayhurn and Wood proposed an integrative term,"adipokinome", which, together with the lipid moieties
released and adipokines constitute the "secretome" of fat
cells (5). These adipokines secreted from adipocytes aredefined as insulin antagonists (TNF-α, IL-6 and Resistin)
and insulin sensitizers (Leptin and Adiponectin) (Figure1) (6). These adipokines may act locally or distally toalter insulin sensitivity in insulin-targeted organs such

Metabolic syndrome (MetS) is a constellation ofinterconnected physiological and biochemical
abnormalities characterized by high fasting glucose,abnormal cholesterol and triglyceride levels, hypertension,
central obesity and many more (1). MetS is a widelydistributed disorder present in 20-25% of the world's
adult population. Many factors such as genetic,
environmental, metabolic and others contribute to thedevelopment of MetS (2). Kim et al. demonstrated
the role and associated mechanisms of adipokines inthe development of MetS (3), but mechanisms remain
controversial and require further research to open
unexplored metabolic pathways. One of the mostaccepted classifications for defining MetS is the Third
Report of the National Cholesterol Education Program(NCEP) Expert Panel on Detection, Evaluation andTreatment of High Blood Cholesterol in Adults (Table
1) (4). Obesity is a well-recognized risk factor for thedevelopment of insulin resistance (IR) and MetS. An
increase in total body fatness and preferential upper body
accumulation of fat tissue is independently related to IR.
Obesity with a greater proportion of upper body fat tissue

(7)

(8)

Male

Obesity
FemaleMale

Dyslipidemia
FemaleBlood pressure

GlucoseInsulin resistance

OthersTG ≥ 150 mg/dl
TG ≥ 150mg/dl≥ 130/85 mmHg or Fasting Glucose >HDL-C < 40 mg/dl or on HDL-C < 50 mg/dl or on therapy
110 mg/dl
therapyon therapy(≥ 6.1 mmol/L)⸺⸺TG ≥ 150 mg/dl
TG ≥ 150mg/dl≥ 140/90 mmHg
T2DM,
IR measured under Urinary albumin(≥ 1.7 mmol/L) HDL-C (≥ 1.7 mmol/L)
IFG,
hyperinsulinaemic- excretion rate
< 35 mg/dl
HDL-C
IGT
euglycemic≥ 20 µg/min or(≤ 0.9 mmol/L)< 39 mg/dl
conditions
albumin: creatinine≤ 1.0 mmol/L)ratio ≥ 30 mg/g min
WC ≥ 94 cm
EGIRWC ≥ 80 cm
TG ≥ 177mg/dl≥ 140/90 mmHg or F a s t i n g G l u c o s e IR
(5th + ≥ 2 of any criteria),(≥ 2.0 mmol/L)
on medication>110 mg/dl (≥ 6.1
1999
HDL-C < 39 mg/dl
mmol/L)⸺(< 1.0 mmol/L)
AHA/ NHLBI or Updated W C ≥ 1 0 2 c m WC > 88 cm (Asian ≥ 80) TG ≥ 150mg/dl (≥ 1.7 TG ≥ 150mg/dl (≥ 1.7 ≥ 130/85 mmHg or Fasting Glucose >(Asian ≥ 90) or 40 or 36 inches
NCEP criteria,
mmol/L)
mmol/L)on medication
100 mg/dl
inches2005
HDL-C < 40 mg/dl (1.0 HDL-C < 50 mg/dl (1.0
(5.6 mmol /L)⸺⸺
mmol/L) or on therapy mmol/L) or on therapy
IDF
TG ≥ 150 mg/dl
TG ≥ 150 mg/dl≥ 130/85 mmHg or Fasting Glucose >Waist circumference ethnic specific(1st + ≥ 2 of any other (≥ 90 cm for men and ≥ 80 cm for women) for (≥ 1.7 mmol/L)(≥ 1.7 mmol/L)on therapy
100 mg/dl
criteria),
HDL-C < 40 mg/dl (1.03 HDL-C < 50 mg/dl(5.6 mmol /L)⸺⸺Asian Indian subjects
2005
or DM
*If BMI is > 30 Kg/m2, central obesity can be mmol/L) or on therapy (1.3 mmol/L) or on
therapy
assumed and WC does not need to be measured

NCEP-ATP III
Abdominal obesity Abdominal obesity(≥ 3 of any criteria),
WC ≥ 102 cm or 40 WC > 88 cm or 36 inches
2001
inches
WHR > 0.85
WHO
WHR > 0.90
and/or(5th or 6th + ≥ 2 of any and/or
BMI > 30 Kg/m2
criteria),
BMI > 30 Kg/m2
1999

Diagnosis

ObesityMets, metabolic syndrome; NCEP ATPIII, National Cholesterol Education Program-Adult Treatment panel III; WHO, World Health Organization; EGIR, European Group of Insulin Resistance; AHA/NHLBI, American
Heart Association/Normal Heart, Lung, and Blood Institute; IDF, International Diabetes Federation; WC, waist circumference; WHR, waist to hip ratio; BMI, body mass index; SBP, systolic blood pressure; DBP, diastolicblood pressure; TC, total cholesterol; HDL, high density lipoprotein; TG, triglyceride; LDL, low density lipoprotein; VLDL, very low density lipoprotein; FPG, fasting plasma glucose; FPI, fasting plasma insulin; HOMAIR, homeostatic model assessment-insulin resistance; DM, diabetes mellitus.

5.

4.

3.

2.

1.

No.

Table 1. Criteria for clinical diagnostic of the MetSGHM Open. 2023; 3(1):7-19.
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as muscle and liver or may act through neuro-endocrine,
autonomic or immune pathways. This disequilibrium
between pro and anti-inflammatory adipokines
induces low-grade inflammation, associated mainlywith adiposity and IR. In this regard, it is known that
increased adiposity is a major determinant of IR and thataltered adipokine regulation is the underlying reason.
Several of these adipokines are interdependent, andthe crosstalk among themselves may play an importantrole in the pathophysiology and management of MetS (7).
In this review article, our focus is on major adipokines,
the interplay between adipokines, and tries to ascertain
their role in MetS with the current state of information

available and how they may influence insulin sensitivity.
Adipokines, IR and central obesity
There is a close relationship between IR, central/visceraladiposity and adipokines (Figure 2). IR is associatedwith an overabundance of metabolic risk factors suchas abnormal elevated cholesterol or lipids, high bloodpressure, body functional inabilities, low level ofinflammation, dysregulated adipokine production andmany of these can either alone or jointly speedup theatherogenic process and malfunctioning of glucose
metabolism. IR should be conceptualized in a very broadmanner that takes into account the interplay between
nutrition, insulin and adipokines in various tissues ofmetabolic importance. IR correlates with the degree ofobesity (visceral obesity) and is a strong predictor of thedevelopment of T2D.
In 1988, it was hypothesized that IR is a contributory
central component of MetS or syndrome X. Insulin
action impaired in AT causes increased lipolysis andrelease of free fatty acid (FFA). The increased flux of
FFA not only impairs insulin secretion by pancreatic islet
β-cells, but also induces IR by interfering with glucose
transport and insulin-mediated glucose uptake in muscle
and liver. Adipokines appear to play a central role andplasma levels may serve as candidate biomarkers formediating both the MetS of IR and the endothelial
dysfunction in obesity. Adipokine levels appear tocorrelate closely with adiposity, with increasing levels
in subjects with higher body mass index (BMI) values.
Many of the pro-inflammatory adipokines exert multiple
actions in a variety of cellular processes leading to acomplex array of abnormalities and are characteristic

Table 2. Candidate biomarkers associated with MetS
Association

Candidates biomarkers

Genes causing monogenic obesity

Leptin
Leptin receptor
Melanocortin receptor
Adiponectin
Fatty acid binding protein-2
Lipases
Uncoupling proteins
Resistin
Peroxisome proliferators
Insulin receptor substrates
Skeletal muscle glycogensynthase 1
CD36
Apolipoprotein E
Upstream transcription factor 1
IL-6
TNF-α
C-reactive protein

Genes regulating FFA metabolism

Genes affecting insulin sensitivity

Genes affecting lipid metabolism
Genes related to inflammation

MetS, metabolic syndrome; FFA, free fatty acid; CD36, cluster ofdifferentiation; IL-6, interleukin-6; TNF-α, tumor necrosis factor-α.

Figure 1. Bioactive proteins secreted by adipose tissue that causes IR. IL-6, interleukin-6; TNF-α, tumor necrosis factor-α. IR,
insulin resistance.

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Figure 2. Pathophysiological mechanism of MetS. IL-6, interleukin-6; TNF-α, tumor necrosis factor-α. MetS, metabolic
syndrome.

of MetS whereas anti-inflammatory adipokines work
differently. The principal effects and the association of
AT derived adipokines with IR, obesity and MetS are
discussed in this article.

found increased leptin concentration to be associatedwith impaired vascular function, independent of themetabolic and inflammatory disturbances associated withobesity (10). Leptin makes an action on adipocyte cells
in a paracrine fashion. Leptin expression and secretionby adipocyte cells can be induced by IL-6 and inhibitedby TNF-α. In turn, leptin, suppresses the expression ofresistin and increases adiponectin expression in leptin
deficient ob/ob mice (11,12). It is expected that, in theabsence of AT, leptin levels are very low in generalized
lipodystrophy, and nonetheless the subjects are often
insulin resistant.
The concept of leptin resistance or an alternate
concept, "hypothalamic leptin insufficiency", has beenchallenged and is still unclear (12). The developmentof leptin resistance may involve several mechanisms
including mutation in the gene, permeability ofblood brain barrier, and self-regulation. One of thepossible mechanisms may be the induction of leptin on
suppressor of cytokine signaling-3, which interrupts
the intracellular pathway of leptin (13). Second, it may
be the diminished transport of leptin across the bloodbrain barrier (BBB), which inhibits leptin signaling (14).
Leptin signaling preserved the β-cells from the adverse
effects of excessive nutrition when the fat increases andlipid accumulates in the body. Thus, improving β-cells
function (15). Although, leptin receptor-mediated JAKSTAT and leptin-stimulated PI3-kinase signaling, appears
to be essential in glucose metabolism for the regulationof food intake and body weight regulation, respectively

Adipokines and their genetic interactions with IR,
obesity and MetS
Leptin
Leptin, 16kDa protein, is an adipokine secreted by AT
in proportion to its mass, regulate energy homeostasis,
facilitate glucose utilization, and improve insulin
sensitivity. Leptin, discovered in 1994, exerts its effects
through binding to the leptin receptor (Ob-R), a memberof the cytokine family of trans-membrane receptors.
Ob/Rb receptor has been identified as the best out ofsix forms of leptin receptor. The leptin receptor is in
the hypothalamus increases energy expenditure andreduce appetite. The receptor is also found in kidney,
liver, pancreas, smooth muscle and endometrium ofheart. Patients with a complete deficiency in leptin, as aresult of a mutation in the leptin gene, have been foundto possess beneficial effects on energy intake, fat mass,
hyperinsulinemia, and hyperlipidemia (8). However, inhumans, leptin levels correlate with body fat, MetS or
adiposity, suggesting that most obese individuals become
insensitive to endogenous leptin and exogenous leptin
administration is unlikely to have a major effect (9).
A study in normal adolescents with variable BMI(10)

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www.ghmopen.com(16). Leptin hinders de novo lipogenesis (DNL) andstimulates the oxidation of FFA in liver cells. This
induces lipotoxicosis and lipoapoptosis due to reductionof hepatic liver content (17). Leptin also reduces hepatic
glucose release by inhibiting glycogenolysis although
its molecular mechanism effecting gluconeogenesis
still remains to be elucidated. Suppression of hepatic
glucogenesis helps in creating an insulin-sensitizing
milieu and reduces glucotoxicity (18).
The obese (ob) gene of leptin (LEP) is an adipocyte
specific gene, which plays a central role in energy
metabolism and co-modulation of body weight. The
discovery of a mutation in the leptin ob-gene resultsin the complete absence of leptin in the ob/ob mouse.
The human homologue of the leptin gene is located on
chromosome 7q31.3. There are several other studies
indicating the involvement of leptin gene and its
receptor variations with MetS, IR, and obesity (1921). Common SNP in the promoter region (G-2548A)of the LEP gene has been associated with variations
in plasma leptin and body mass index (BMI) in obese
individuals (22,23). Leptin 2548 G/A and Gln223Arg
leptin receptor gene polymorphism were studied broadly
because 2548 G/A gene associated with the secretionand production of leptin while Gln223Arg associatedwith impaired signaling capacity of the leptin receptor(24,25). A functional study explains that Leptin G-2548A
polymorphism influenced leptin mRNA expression at thetranscriptional level and therefore also adipose secretionlevels of the hormone (24). However, supporting
evidence for an association of G2548A and Gln223Arg
polymorphism with leptin concentrations and MetS
conflict with other studies (26,27). A separate discovery
showed Leptin C/A polymorphism, at locus 2549 in the
promoter region and is related to serum leptin level inwestern populations (22). A study of Le Stunff and his
researchers has shown that girls of comparable adiposity
have different circulating leptin levels, depending on
their genotype at the promoter region of the leptin gene(23). Girls with Leptin 2549 C/A genotype have 25%
lower mean leptin levels than girls with other genotypes.
The study of the association between IR by Homeostatic
Model Assessment (HOMA) and leptin genotype
indicated that people carrying C-allele have more severe
IR (23). Leptin gene at position 2549 carrying AA
genotype was also strongly associated with cardio MetS(28).
In summary, leptin serves as a major "adipostat" byrepressing food intake and promoting energy expenditure,suggesting that leptin acts as a signal that contributes toregulation of total-body sensitivity to insulin.

homeostasis and insulin sensitivity. It was first isolated
during adipocyte differentiation of 3T3-L1 preadipocytes
following large-scale sequencing of the human adipose
cDNA library. In AT, human adiponectin was cloned after
mouse cloning. However, human adiponectin sharedover 80% similarity with the mouse amino acids (AA). It
is the only adipokine that is known to be downregulated
in obesity. In addition to the association with whole-body
fat mass, adiponectin levels differ with the distributionof body fat. Adiponectin is present at high concentrationsin the circulation of mice and healthy humans. A study
on obese mice lacking adiponectin show reduced
responsiveness to peroxisome proliferator-activatedreceptor-gamma (PPARγ) agonists and decreased hepatic
insulin sensitivity (29).
In human studies, plasma adiponectin levels arenegatively correlated with adiposity, waist-to-hip
ratio (WHR) and IR, dyslipidemia and MetS, whereas
levels are positively correlated with markers of insulin
sensitivity (30-32). Evidence suggested that adiponectin
is an important contributor to IR and MetS but the actual
physiological role of adiponectin is still unclear. Due
to insulin-sensitizing effect of adiponectin, it may alter
glucose metabolism by fat tissue through increasing
pancreatic insulin stimulated glucose uptake (33).
Adiponectin gene expression in human visceral AT is
negatively regulated by TNF-α and positively by insulin(34). Visceral fat was reported to be inversely associatedwith plasma adiponectin levels in healthy women (35).
In case-control studies, low plasma adiponectin was
an independent risk factor for development of T2D but
not for obesity (36,37). Variations in serum adiponectinconcentration have been proposed to have a strong
heritable component in both predominantly Pima Indianand Northern European populations (36,38). Anotherstudy showed the changes in serum adiponectin level inpostmenopausal women with MetS (39). Alternatively,
adiponectin secretion may be regulated by insulin andtherefore, circulating levels may be a marker of IR and acausal factor as well (40). Evidence suggests that there isa close association between IR and low adiponectin level(41).
Reproducible results of human genetic studies
of diverse ethnic origin may provide evidence for its
causative role in pathogenesis of the MetS and further
insight into the genetic constitutions of MetS. Adiponectin
is encoded by ADIPOQ (also known as APM1), locatedon chromosome 3q27, spans 17kb and contains 3 exonsand 2 introns. Human adiponectin gene polymorphism iscommonly found at the promoter region, exon and intron
2, and nonsynonymous mutations, which are rare atexon 3 region were repeatedly shown in different ethnic
populations associated with the phenotypes related tobody weight, glucose metabolism, insulin sensitivity,
T2D and MetS (42,43).
Notably, additional support for the importantrole of adiponectin in IR comes from genetic studies

Adiponectin
Adiponectin is the most abundant AT derived
adipocytokine comprised of a 247-amino acidprotein with an increasingly important role in energy(11)

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that have mapped a susceptibility locus for T2D and
MetS in which the gene is located (44). Adiponectin
gene transcription and secretion were decreased bypro-inflammatory markers, TNF-α and IL-6 (45).
Adiponectin SNPs have been associated variably withincreased BMI, IR-related traits and T2D (43). The
adiponectin gene has been found to be consistently andsignificantly associated with plasma adiponectin in
genetic association studies (46). The two most common
reported variants of the adiponectin gene in different
populations, a silent T/G substitution at position 45 inexon 2 and a G/T substitution at position 276 in intron 2,
were closely associated with type II diabetes in Chineseand Japanese, visceral obesity in Swedish and Taiwanese
populations and several components of MetS in Chineseand Caucasians, and IR syndrome in North Indian
populations (47-53). However, the findings are still
conflicting. Furthermore, +45T/G polymorphism was
associated with circulating adiponectin level that added
a much greater contribution to MetS. Adiponectin levels
might also influence cardiac stroke, which is considered
a cardiovascular event of MetS (54,55). An association
between the +276G/T genotype and adiponectin levels
has been observed in obese Japanese, and Spanish
populations (48,56). However, in a systematic metaanalysis of all published data on adiponectin SNPs, only
the +276G/T variant was a strong determinant of IR withminor allele homozygotes having a lower IR index (basedon HOMA) than carriers of other genotypes. These
human genetic studies on adiponectin and MetS strongly
suggest that adiponectin is one of the causative factors in
its pathogenesis and provide significant insights into thegenetic makeup of MetS.
In summary, adiponectin is an adipocyte-derived
protein with insulin sensitizing, anti-inflammatory,
anti-hyperglycemic, vascular protective and antiatherogenic properties. Although its physiological andpathophysiological roles have not been fully elucidated.
High levels of adiponectin may be an important factor,
which activates AMPK and stimulates phosphorylationof acetyl coenzyme A carboxylase (ACC), fatty-acidoxidation, glucose uptake and lactate production in
myocytes and reduction of glucose levels in vivo.
Adiponectin may provide a novel and potential treatment
modality for IR, obesity and MetS through therapeutic
modulation.

following exposure to Thiazolidinediones (TZDs). This
led to the discovery of a protein named "resistin", known
to be resistant to insulin (58).
Circulating resistin levels were found to be elevatedin both genetic and diet-induced obesity and IR models.
Therefore, it also serves as an important link between
obesity and IR. A study on mice suggested that resistin
selectively impairs the inhibitory action of insulin on
hepatic glucose production (59). Neutralization ofresistin by specific antibodies resulted in decreased blood
glucose levels and improved insulin sensitivity, thereby
providing a more direct link between fat mass and IR(58). By contrast, upregulated circulating resistin levels
might contribute to hyperglycemia, IR, T2D, MetS andcardiovascular disease (60-63).
Human resistin is a dimeric protein containing
108 amino acids, produced and secreted mainly by
peripheral-blood mononuclear cells. Human resistin is
only 59% similar to the mouse protein, and this may
indicate important differences in the endocrine functionsof adipocytes and resistin between rodents and humans.
It is also expressed and secreted by mature adipocytes.
The secreted protein was found to inhibit 3T3-LI
adipogenesis, and it was speculated that resistin wasa feedback regulator of adipogenesis. McTernan andcoworkers reported a higher mRNA resistin expression
in the abdomen than thigh region (64). Thus, this study
suggested that human resistin could play a significant
role in obesity-related IR. Furthermore, at least in part,elevated insulin and TNF-α levels in obesity inhibits
resistin expression, which may explain the lower levelof resistin found in obese diabetes. However, the role ofresistin in obesity-associated IR has become controversial
because additional evidence suggested that obesity and
IR are associated with decreased resistin expression inAT (65).
The resistin gene is located on chromosome 19p13
a short distance from the insulin receptor. It is a small
gene that spans less than 2kb and includes four exonsand three introns. Screening of the entire resistin genehas eight SNPs variants and a (GAT)n microsatellite
identified (66). Four SNPs were placed in the 5'-flanking
region; two in intron 2, and two in intron 3 in the mouseand two in humans, encode resistin (67). These genes arepresent on chromosome 8 in the mouse and chromosome
19 in humans. Controversial results have been foundfor SNP studies on genetic variations in the resistin
gene. Some case control studies demonstrated genetic
variations in the resistin gene to be associated with IR
and obesity in humans (68). Six SNPs were relatively
frequent, with allele frequencies ranging from 0.09 to
0.43. All SNPs were in significant linkage disequilibrium,with only five haplotypes accounting for more than
80% of control chromosomes. Several polymorphisms
in the resistin gene have been studied: only few haveminor allele frequencies while over 5% are associatedwith disease risk and a few located in the 5'-flanking

Resistin
Resistin, a 12.5kDa cysteine rich peptide, is derived
from AT that has been implicated in the development of
IR. Holcom et al. first proposed the gene family and its
tissue-specific distribution, identifying a protein foundin inflammatory zone called FIZZ1 i.e. also known as
resistin-like molecules (RELM) (57). Resistin was first
identified in a search for genes that were i) inducedwith adipocyte differentiation but ii) down-regulated(12)

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region (G–638A, A–537C, C–420G and G–358A) affectcirculating levels of resistin (69,70). Studies had reported
much more attention to resistin SNP -420C/G, locatedin the promoter region of the resistin gene, and is the
major determinant of plasma resistin concentration andinfluences resistin expression in humans (70). Several
research groups identified that the circulating resistin
level and specific SNPs are associated with adiposity,
MetS, IR and T2D (71-73). However, other studies failed
to identify changes in resistin levels or SNPs in similar
conditions (74,75). In addition to SNP 420C/G, it has
been reported that other polymorphisms (+299 G/A,
rs3219175, rs1423096, rs3745368, and rs1477341) of theresistin gene were strongly associated with circulating
resistin levels (69,76). Morever, it has been reported that
-638G/A (rs34861192) and -358G/A (rs3219175) had
the strongest association with circulating resistin levels
among the SNPs at the resistin locus (69,76).
In summary, resistin may represent a link between
inflammation and metabolic signals and circulating
resistin was more significantly correlated with central
obesity and IR.

(85). A biallelic polymorphism involves the substitutionof guanine by adenine at position –308 in the promoter
region, produces the less common homozygote TNF-α
allele, which has been associated with elevated serum
concentrations of TNF-α in certain clinical states (86,87).
Although controversial, the majority of the data
support a direct role for this biallelic polymorphism in
the elevation of TNF-α level observed in homozygotes
for the −308 A allele (88). Some studies have indicateda key role of the TNF-α gene for the −308 variant in
the pathogenesis of various components of MetS andIR (89,90). However, many other studies have reported
negative results, with no correlation between TNF-α SNP
and IR or any other MetS abnormality (91,92). A studyof Fernandez-Real et al. showed that the polymorphism
influenced insulin sensitivity via an increase in body fat
in a group of non-diabetic normotensive Spanish subjects(93). While another study by Hamann et al. showed nodifference between T2D patients and healthy control
subjects in the frequency of alleles at –308 (94). Walston
and coworkers reported that TNF-α polymorphism at–308 polymorphic sites did not relate to any traits ofobesity and IR in a group of non-diabetic subjects (95).
In summary, TNF-α seems to play an importantrole in the development of IR in rodents, but the in vivo
data in humans has not been as conclusive. Additional
human studies are needed to understand its role in thepathogenesis of IR in humans.

TNF-α
TNF-α is a pro-inflammatory cytokine that has
been implicated in the pathogenesis of IR. TNF-α isexpressed as a 26kDa cell surface trans-membraneprotein that undergoes cleavage to produce a 17kDa
soluble, biologically active form of TNF-α (77).
Increased TNF-α production has been observed in AT
derived from animal models of obesity and IR as well as
in human subjects (78).
In AT, TNF-α is not secreted in the systemic
circulation but acts in an autocrine and paracrine
fashion. TNF-α is over expressed in AT of obese
individuals. TNF-α is expressed more in visceral than in
subcutaneous fat tissue, and more abundantly producedby macrophages than adipocytes (79). In humans,
expression of TNF-α correlates with BMI, percent body
fat and hyperinsulinaemia and weight loss decreased
TNF-α levels (80). TNF-α significantly increases theexpression of IL-6, reduces the expression of resistin andstimulates the secretion of leptin in 3T3-L1 adipocytes(81-83). Potential mechanisms by which AT secreted
TNF-α increases IR include increased release of FFA by
adipocytes and reduction in adiponectin synthesis; thecytokine directly affects insulin sensitivity by inhibiting
insulin receptor signaling (45,84).
The TNF-α gene is located in the chromosomal
region 6p21.1–21.3, next to the major histocompatibility
complex (MHC). A SNP at position -308 upstream
from the transcription initiation site in the promoter
region demonstrated that polymorphism increases
transcriptional activation of the TNF-α gene. TNF-α
gene transcription is regulated by the promoter region,
which consists of an 1,100 base pair stretch of DNA

IL-6
IL-6 is a pleiotropic circulating cytokine with effects
ranging from inflammation to host defense to tissue
injury and it is one of several pro-inflammatory
cytokines that have been associated with MetS as a
biological marker. IL-6 is secreted by immune cells,
fibroblasts, endothelial cells, skeletal muscle and AT. It
circulates as a variably glycosylated 26kDa protein. IL-6
concentrations increase with adiposity, and 15-35% ofcirculating IL-6 may be released by AT in vivo. In AT,
IL-6 reduces lipoprotein lipase activity and increases
basal lipolysis (96).
Studies suggest that IL-6 may stimulate fat lipolysis
in human adipocytes thus leading to increase circulating
FFA (97). Fasting plasma IL-6 concentrations were
negatively correlated with the rate of insulin-stimulated
glucose disposal in Pima Indians (98). Bastard andcollogues reported that increased IL-6 values were morestrongly correlated with obesity and IR, significant
decreases in circulating IL-6 and TNF-α levels responsed
to diet-induced weight loss in obese women (98,99).
Other studies also had similar observations that weightloss results decrease circulating IL-6 levels (100).
Overall, the association of IL-6 and IR seems complex
and IL-6 alone might not be an appropriate marker ofIR or MetS. IL-6 may also exert its adverse effects bydecreasing adiponectin secretion.

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Our study showed increased circulating IL-6 levelsin obese and MetS women (101). Hyperinsulinemia
positively associated with TNF-α and IL-6 gene
expression while hyperinsulinemia and glucose
intolerance were negatively linked to adiponectin
expression in AT (102,103). IL-6 also increases theexpression of resistin in human peripheral bloods
mononuclear cells (104). Visceral AT releases two to
three times greater IL-6 compared to subcutaneous AT.
Although, it seems that the majority of AT-derived IL-6
comes from stromal immune cells and not adipocytes(105). Rotter et al. reported a reduction in the expressionof insulin receptor substrate-1 (IRS-1) and glucose
transporter 4 (GLUT4) in adipocytes response to IL-6
treatment (106). Due to visceral depots drain into theportal circulation, the metabolic effects of IL-6 in theliver become important. Indeed, there is evidence thatsuggests IL-6 inhibits insulin receptor signal transductionin hepatocytes that is mediated by induction of SOCS-3(107).
The association of IL-6 with MetS is supported by
epidemiological and genetic studies. Genetic studies
have also demonstrated a strong correlation between IR
and IL-6 gene polymorphisms in Native Americans andCaucasians (108). Another study, which is in agreementwith the study on Caucasian populations, suggests that
IL-6 receptor (IL-6R, rs8192284-A/C, Asp358Ala) SNPs
may play a role in the pathogenesis of MetS possibly
through modulating IL-6 levels (109). The −174 G/
C variant of IL-6 gene has been shown to influence
the transcriptional regulation of IL-6 and human −174
G allele carriers exhibit higher plasma IL-6 levels
compared with homozygous C-allele carriers, an effectwhich is modulated by age and gender both (110,111).
However, the results have been incompatible in otherstudies and subjects of different ethnic origins havelinked the −174 G/C variant of IL-6 gene to indices ofobesity and IR. In Native Americans and Caucasians, theGG genotype was associated with T2D whereas Swedishand French Canadian population showed that the C-allele
was associated with indices of obesity (108,112,113).
In Spanish populations, the G-allele has been related
to decreased insulin sensitivity, hyperglycemia andabnormalities in lipids (114,115).
Two other functional SNPs in the IL-6 promoter at
positions −597 and −572 were also identified (116,117).
It has also been shown that three SNPs (−174, −572,−597) of the IL-6 promoter do not act independently
in the regulation of IL-6 transcription (118). Studies
showed that an IL-6 SNP within a sequence, bearing
partial nucleotide homology with the Sma- and Madrelated protein 4 (Smad4) binding element and thepresence of the C-allele may bind Smad 4 more
effectively and inhibit IL-6 transcription (119). A studyof a lipopolysaccharide stimulated IL-6 production result
demonstrated that leucocytes from the homozygous
carrier of the GGG-haplotype (−597 GG, −572 GG and−174 GG) produced the highest amount of IL-6 (118).
In summary, IL-6 plays a crucial role in the regulationof many adipokines, modulation of immune function andthe regulation of a variety of cellular functions and IR.
Effect of adipokines on insulin signaling
Do the adipokines affect insulin sensitivity by altering
the mechanism of insulin signaling? Insulin binding toinsulin receptor activates IRS proteins that subsequently
recruit and activate the phosphoinositide 3-kinase (PI3K)
pathway. Reduced activation of PI3K by insulin is a
predominant feature of IR and has been implicated in thepathogenesis of hypertension in skeletal muscle.
PI3 kinase is able to play a central role in themetabolic and mitogenic actions of insulin. PI3K has
also been demonstrated to mediate some of the actionsof adiponectin and leptin in various tissues, including
vascular endothelium and skeletal muscle (120,121). In
skeletal muscle, adiponectin stimulates glucose transport
by increased GLUT4 translocation, activates insulin
signaling, and upregulates molecules involved in fatty
acid transport (122). Leptin has been demonstrated to
impair insulin signaling in adipocytes and modulate
insulin action in liver and muscle (123). Resistin, apotent inflammatory regulator, may exert an inhibitory
effect on nitric oxide production by inhibiting insulin
signaling and eNOS phosphorylation in endothelial
cells. IL-6 attenuates IRS-1 expression and insulinstimulated Akt activation in hepatocytes and adipocytes(106,107,124). The effects of leptin and IL-6 on insulin
signaling in the endothelium remain uncharted. However,TNF-α has been shown to interfere with intracellular
insulin signaling pathways in endothelial cells, andtherefore represents a candidate mechanism by which itleads to impaired insulin action (125). TNF-α has been
demonstrated to increase serine phosphorylation of IRS1 in adipocytes, which reduces its capacity to recruit andactivate downstream effectors of insulin (124,126).
Future prospective
MetS has reached dramatic proportions affecting
adults worldwide. MetS is associated with a plethoraof health problems including IR, hypertriglyceridemia,
atherosclerosis and T2D. Excess amounts of visceral fat
accumulation results in altered release of adipokines,
leading to IR. The syndrome epidemic affects children,
who are becoming overweight and obese at progressively
younger ages. Most of the clinical recommendations fortreatment of younger age obesity and associated disorders
are based on the combination of several lifestyleinterventions, such as eating habits, medication supportand regular physical activities. The role of adipokines asbiomarkers in physiology and pathophysiology has only
been appreciated recently.
Previous studies have shown that targeting circulating(14)

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adipokine levels and their receptors expression
can decrease IR, improve vascular function, andsignificantly lower the risk of cardiovascular morbidity
and mortality. At least some of the adipokines, suchas adiponectin, seems to be important in maintaining
metabolic homeostasis, but others may contribute to
the development of IR during the time when food isplentiful. The mechanisms by which adipokines promote
IR are complex. It appears that intense AT deposition in
the omental region, may be exorbitant partially throughthe secretion of adipokines such as resistin, TNF, and IL6. In contrast, the presence of AT is vital in the preventionof IR, at least in part, via leptin and adiponectin
secretion. Some of these adipokines are also recognizedin the immune system and may play a role in linking
the nutritional system with the immune system. Finally,
determining the relative contribution of adipokines to
MetS and elucidating the dynamic interactions between
adipokines as biomarkers for MetS should be a focus of
our research in the future.

9.
10.

11.

12.

13.
14.

Acknowledgements
We would like to thank everyone who participated andprovide suggestions with intense discussions as well as
critical review of the manuscript.

15.

Funding: None.

16.

Conflict of Interest: The authors have no conflicts ofinterest to disclose.

17.

References
1.
2.
3.

4.

5.
6.
7.

8.

18.

Saklayen MG. The global epidemic of the metabolic
syndrome. Curr Hypertens Rep. 2018; 20:1-8.
Gupta A, Gupta V. Metabolic syndrome: what are the risks
for humans? Biosci Trends. 2010; 4:204-212.
Kim JE, Kim JS, Jo MJ, Cho E, Ahn SY, Kwon YJ, Ko
GJ. The roles and associated mechanisms of adipokines
in development of metabolic syndrome. Molecules. 2022;
27:334.
Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. Executive summary of
the Third Report of the National Cholesterol Education
Program (NCEP) Expert Panel on Detection, Evaluation,
and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III). JAMA. 2001; 285:2486-2497.
Trayhurn P, Wood IS. Adipokines: inflammation and thepleiotropic role of white adipose tissue. Br J Nutr. 2004;
92:347-355.
A n a s t a s s i o s G P, N a n d i n i A J , G r e e n b e r g A S .
Adipocytokines and insulin resistance. J Clin Endocrinol
Metab. 2004; 89:447-452.
Fahed G, Aoun L, Zerdan MB, Allam S, Zerdan MB,
Bouferraa Y, Assi HI. Metabolic syndrome: updates on
pathophysiology and management in 2021. Int J Mol Sci.
2022; 23:786.
Obradovic M, Sudar-Milovanovic E, Soskic S, Essack M,
Arya S, Stewart AJ, Gojobori T, Isenovic ER. Leptin and

19.

20.

21.

22.

23.

(15)

obesity: role and clinical implication. Front Endocrinol(Lausanne). 2021; 12:585887.
Martins Mdo C, Lima Faleiro L, Fonseca A. Relationshipbetween leptin and body mass and metabolic syndrome inan adult population. Rev Port Cardiol. 2012; 31:711-719.
Singhal A, Farooqi S, Cole TJ, O'Rahilly S, Fewtrell M,
Kattenhorn M, Lucas A, Deanfield J. Influence of leptin
on arterial distensibility: a novel link between obesityand cardiovascular disease? Circulation. 2002; 106:19191924.
Delporte ML, El Mkadem SA, Quisquater M, Brichard
SM. Leptin treatment markedly increased plasma
adiponectin but barely decreased plasma resistin of
ob/ob mice. Am J Physiol Endocrinol Metab. 2004;
287:E446-E453.
Masuzaki H, Tanaka T, Ebihara K, Hosoda K, Nakao
K. Hypothalamic melanocortin signaling and leptin
resistance—perspective of therapeutic application forobesity-diabetes syndrome. Peptides. 2009; 30:1383-1386.
Munzberg H, Myers MG Jr. Molecular and anatomical
determinants of central leptin resistance. Nat Neurosci.
2005; 8:566-570.
Kalra SP. Central leptin insufficiency syndrome: aninteractive etiology for obesity, metabolic and neuraldiseases and for designing new therapeutic interventions.
Peptides. 2008; 29:127-138.
Morioka T, Asilmaz E, Hu J, Dishinger JF, Kurpad AJ,
Elias CF, Li H, Elmquist JK, Kennedy RT, Kulkarni RN.
Disruption of leptin receptor expression in the pancreas
directly affects beta cell growth and function in mice. J
Clin Invest. 2007; 117:2860-2868.
Morton GJ. Hypothalamic leptin regulation of energy
homeostasis and glucose metabolism. J Physiol. 2007;
583:437-443.
Martínez UM, López MY, Diéguez C, Fernández-Rojo
MA, Novelle MG. Unraveling the role of leptin in liverfunction and its relationship with liver diseases. Int J Mol
Sci. 2020; 21:1-33.
Moon HS, Dalamaga M, Kim SY, Polyzos SA, Hamnvik
OP, Magkos F, Paruthi J, Mantzoros CS. Leptin's role inlipodystrophic and nonlipodystrophic insulin-resistant anddiabetic individuals. Endocr Rev. 2013; 34:377-412.
Shramko II, Ageeva ES, Maliy KD, Repinskaya IN,
Tarimov CO, Fomochkina II, Kubishkin AV, Ostapenko
OV, Gurtovaya AK, Shekhar S. Association between
adiponectin and leptin receptor genetic polymorphisms
and clinical manifestations of metabolic syndrome. J
Diabetes Res. 2022; 2022:9881422.
Adiga U, Banawalikar N, Mayur S, Bansal R, Ameera
N, Rao S. Association of insulin resistance and leptin
receptor gene polymorphism in type 2 diabetes mellitus. J
Chin Med Assoc. 2021; 84:383-388.
Hastuti P, Zukhrufia I, Made Padwaswari MH, Nuraini A,
Sadewa AH. Polymorphism in leptin receptor gene wasassociated with obesity in Yogyakarta, Indonesia. Egypt J
Med Hum Genet. 2016; 17:271-276.
Mammes O, Betoulle D, Aubert R, Giraud V, Tuzet
S, Petiet A, Colas-Linhart N, Fumeron F. Novel
Polymorphisms in the 5' region of the LEP Gene:
Association with Leptin Levels and Response to LowCalorie Diet in Human Obesity. Diabetes. 1998; 47:487489.
Le Stunff C, Le Bihan C, Schork NJ, Bougneres P. A
common promoter variant of the leptin gene is associatedwith changes in the relationship between serum leptin andGHM Open. 2023; 3(1):7-19.

www.ghmopen.com

fat mass in obese girls. Diabetes. 2000; 49:2196-2200.
24. Hoffstedt J, Eriksson P, Mottagui-Tabar S, Arner P. A
polymorphism in the leptin promoter region (–2548 G/A)
influences gene expression and adipose tissue secretion of
leptin. Horm Metab Res. 2002; 34:355-359.
25. Yiannakouris N, Yannakoulia M, Melistas L, Chan
JL, Klimis-Zacas D, Mantzoros CS. The Q223R
polymorphism of the leptin receptor gene is significantly
associated with obesity and predicts a small percentage
of body weight and body composition variability. J Clin
Endocrinol Metab. 2001; 86:4434-4439.
26. Boumaiza I, Omezzine A, Rejeb J, Rebhi L, Ouedrani A,
Ben Rejeb N, Nabli N, Ben Abdelaziz A, Bouslama A.
Relationship between leptin G2548A and leptin receptor
Q223R gene polymorphisms and obesity and metabolic
syndrome risk in Tunisian volunteers. Genet Test Mol
Biomarkers. 2012; 16:726-733.
27. Komşu-Ornek Z, Demirel F, Dursun A, Ermiş B, Pişkin E,
Bideci A. Leptin receptor gene Gln223Arg polymorphism
is not associated with obesity and metabolic syndrome
in Turkish children. Turk J Pediatr. 2012; 54:20-24. (inTurkish)28. Kumar S, Srivastava N, Mishra S, Natu SM, Roy U,
Chandra A, Kumar S, Gupta V. Association of leptin
2549C/A gene polymorphism with metabolic risk markers
in adult women of North India. Inter J Biol Pharma Res.
2014; 5:921-926.
29. Nawrocki AR, Rajala MW, Tomas E, Pajvani UB, Saha
AK, Trumbauer ME, Pang Z, Chen AS, Ruderman NB,
Chen H, Rossetti L, Scherer PE. Mice lacking adiponectinshow decreased hepatic insulin sensitivity and reduced
responsiveness to peroxisome proliferator-activatedreceptor gamma agonists. J Biol Chem. 2006; 281:26542660.
30. Cnop M, Havel PJ, Utzschneider KM, Carr DB, Sinha
MK, Boyko EJ, Retzlaff BM, Knopp RH, Brunzell
JD, Kahn SE. Relationship of adiponectin to body fat
distribution, insulin sensitivity and plasma lipoproteins:evidence for independent roles of age and sex.
Diabetologia. 2003; 46:459-469.
31. Karasek D, Vaverkova H, Halenka M, Jackuliakova
D, Frysak Z, Novotny D. Total adiponectin levels indyslipidemic individuals: relationship to metabolic
parameters and intima-media thickness. Biomed Pap Med
Fac Univ Palacky Olomouc Czech Repub. 2011; 155:5562. (in Czech)
32. Hung J, McQuillan BM, Thompson PL, Beilby JP.
Circulating adiponectin levels associate with inflammatory
markers, insulin resistance and metabolic syndrome
independent of obesity. Int J Obes (Lond). 2008; 32:772779.
33. Okamoto M, Ohara-Imaizumi M, Kubota N, Hashimoto
S, Eto K, Kanno T, Kubota T, Wakui M, Nagai R, Noda
M, Nagamatsu S, Kadowaki T. Adiponectin induces
insulin secretion in vitro and in vivo at a low glucose
concentration. Diabetologia. 2008; 51:827-835.
34. Boullu-Ciocca S, Achard V, Tassistro V, Dutour A, Grino
M. Postnatal programming of glucocorticoid metabolism
in rats modulates high-fat diet-induced regulation ofvisceral adipose tissue glucocorticoid exposure andsensitivity and adiponectin and proinflammatory
adipokines gene expression in adulthood. Diabetes. 2008;
57:669-677.
35. Kwon K, Jung SH, Choi C, Park SH. Reciprocal
association between visceral obesity and adiponectin:

36.

37.

38.

39.

40.
41.

42.

43.
44.

45.

46.

47.
48.

49.

(16)

in healthy premenopausal women. Int J Cardiol. 2005;
101:385-390.
Lindsay RS, Funahashi T, Hanson RL, Matsuzawa
Y, Tanaka S, Tataranni PA, Knowler WC, Krakoff J.
Adiponectin and development of type 2 diabetes in thePima Indian population. Lancet. 2002; 360:57-58.
Magge SN, Stettler N, Koren D, Levitt Katz LE, Gallagher
PR, Mohler ER 3rd, Rader DJ. Adiponectin is associatedwith favorable lipoprotein profile, independent of BMI
and insulin resistance, in adolescents. J Clin Endocrinol
Metab. 2011; 96:1549-1554.
Comuzzie AG, Funahashi T, Sonnenberg G, Martin LJ,
Jacob HJ, Black AE, Maas D, Takahashi M, Kihara S,
Tanaka S, Matsuzawa Y, Blangero J, Cohen D, Kissebah
A. The genetic basis of plasma variation in adiponectin,a global endophenotype for obesity and the metabolic
syndrome. J Clin Endocrinol Metab. 2001; 86:4321-4325.
Srivastava N, Gupta V, Kumar S. Association between
circulating adiponectin level and metabolic risk factors inpostmenopausal women: a population based study. Inter J
Biol Pharma Res. 2015; 6:939-943.
Ruan H, Dong LQ. Adiponectin signaling and function in
insulin target tissues. J Mol Cell Biol. 2016; 8:101-109.
H ive rt M F, Sulliva n LM , Fox C S, N a tha n DM,
D'Agostino RB Sr., Wilson PW, Meigs JB. Associationsof adiponectin, resistin, and tumor necrosis factor-alphawith insulin resistance. J Clin Endocrinol Metab. 2008;
93:3165-3172.
Filippi E, Sentinelli F, Trischitta V, Romeo S, Arca M,
Leonetti F, Di Mario U, Baroni MG. Association of thehuman adiponectin gene and insulin resistance. Eur J Hum
Genet. 2004; 12:199-205.
Menzaghi C, Trischitta V, Doria A. Genetic influencesof adiponectin on insulin resistance, type 2 diabetes, andcardiovascular disease. Diabetes. 2007; 56:1198-1209.
Vionnet N, Hani El H, Dupont S, Gallina S, Francke S,
Dotte S, De Matos F, Durand E, Leprêtre F, Lecoeur C,
Gallina P, Zekiri L, Dina C, Froguel P. Genome wide
search for type 2 diabetes-susceptibility genes in French
whites: evidence for a novel susceptibility locus for earlyonset diabetes on chromosome 3q27-qter and independent
replication of a type 2-diabetes locus on chromosome
1q21–q24. Am J Hum Genet. 2002; 67:1470-1480.
Bruun JM, Lihn AS, Verdich C, Pedersen SB, Toubro
S, Astrup A, Richelsen B. Regulation of adiponectin byadipose tissue-derived cytokines: in vivo and in vitro
investigations in humans. Am J Physiol Endocrinol Metab.
2003; 285:E527-E533.
Ling H, Waterworth DM, Stirnadel HA, Pollin TI, Barter
PJ, Kesaniemi YA, Mahley RW, McPherson R, Waeber G,
Bersot TP, Cohen JC, Grundy SM, Mooser VE, Mitchell
BD. Genome-wide linkage and association analyses to
identify genes influencing adiponectin levels: the GEMS
study. Obesity (Silver Spring). 2009; 17:737-744.
Wang WL, Zhu H, Xie Y, Li J. Relation between ADIPOQ
gene polymorphisms and type 2 diabetes in a Chinese
population. Int J Clin Exp Med. 2015; 15:6124-6128.
Hara K, Boutin P, Mori Y, et al. Genetic variation in thegene encoding adiponectin is associated with an increased
risk of type 2 diabetes in the Japanese population.
Diabetes. 2002; 51:536-540.
Ukkola O, Ravussin E, Jacobson P, Sjostrom L, Bouchard
C. Mutations in the adiponectin gene in lean andobese subjects from the Swedish obese subject cohort.
Metabolism. 2003; 52:881-884.

GHM Open. 2023; 3(1):7-19.

www.ghmopen.com

50. Yang WS, Yang YC, Chen CL, Wu IL, Lu JY, Lu FH,
Tai TY, Chang CJ. Adiponectin SNP276 is associatedwith obesity, the metabolic syndrome, and diabetes in theelderly. Am J Clin Nutr. 2007; 86:509-513.
51. Gao M, Ding D, Huang J, Huang J, Qu Y, Wang Y, Huang
Q. Association of genetic variants in the adiponectin genewith metabolic syndrome: a case-control study and asystematic meta-analysis in the Chinese population. PLoS
One. 2013; 8:e58412.
52. Menzaghi C, Ercolino T, Di Paola R, Berg AH, Warram
JH, Scherer PE, Trischitta V, Doria A. A haplotype at the
adiponectin locus is associated with obesity and otherfeatures of the insulin resistance syndrome. Diabetes.
2002; 51:2306-2312.
53. Prakash J, Mittal B, Awasthi S, Srivastava N. Associationof adiponectin gene polymorphism with adiponectin levels
and risk for insulin resistance syndrome. Int J Prev Med.
2015; 6:31.
54. Wu J, Liu Z, Meng K, Zhang L. Association of
adiponectin gene (ADIPOQ) rs2241766 polymorphismwith obesity in adults: a meta-analysis. PLoS One. 2014;
9:e95270.
55. Hao G, Li W, Guo R, Yang JG, Wang Y, Tian Y, Liu MY,Peng YG, Wang ZW. Serum total adiponectin level andthe risk of cardiovascular disease in general population: ameta-analysis of 17 prospective studies. Atherosclerosis.
2013; 228:29-35.
56. de Luis DA, Izaola O, de la Fuente B, Primo D, Fernandez
Ovalle H, Romero E. rs1501299 Polymorphism in
the adiponectin gene and their association with total
adiponectin levels, Insulin resistance and metabolic
syndrome in obese subjects. Ann Nutr Metab. 2016;
69:226-231.
57. Holcomb IN, Kabakoff RC, Chan B, Baker TW, Gurney A,
Henzel W, Nelson C, Lowman HB, Wright BD, Skelton
NJ, Frantz GD, Tumas DB, Peale FV Jr, Shelton DL,
Hébert CC. FIZZ1, a novel cysteine-rich secreted protein
associated with pulmonary inflammation, defines a newgene family. EMBO J. 2000; 19:4046-4055.
58. Steppan CM, Bailey ST, Bhat S, Brown EJ, Banerjee
RR, Wright CM, Patel HR, Ahima RS, Lazar MA. The
hormone resistin links obesity to diabetes. Nature. 2001;
409:307-312.
59. Rajala MW, Obici S, Scherer PE, Rossetti L. Adiposederived resistin and gut-derived resistin-like molecule
selectively impair insulin action on glucose production. J
Clin Invest. 2003; 111:225-230.
60. Chen BH, Song, Y, Ding EL, Roberts CK, Manson JE,
Rifai N, Buring JE, Gaziano JM, Liu S. Circulating levelsof resistin and risk of type 2 diabetes in men and women:
results from two prospective cohorts. Diabetes Care. 2009;
32:329-334.
61. Gupta V, Singh AK, Gupta A, Gupta V, Kumar S,
Srivastava N, Jafar T, Pant AB. Association of circulating
resistin with metabolic risk factors in Indian females
having metabolic syndrome. Toxicol Int. 2011; 18:168172.
62. Singh AK, Tiwari S, Gupta A, Natu SM, Mittal B, Pant
AB. Association of resistin with metabolic syndrome inIndian Subjects. Metab Syndr Relat Disord. 2012; 10:286291.
63. Singh AK, Tiwari S, Gupta A, Shukla KK, Chhabra KG,
Pandey A, Pant AB. Association of resistin with Insulin
resistance and factors of metabolic syndrome in North
Indians. Indian J Clin Biochem. 2015; 30:255-262.

64. McTernan CL, McTernan PG, Harte AL, Levick PL,
Barnett AH, Kumar S. Resistin, central obesity, and type 2
diabetes. Lancet. 2002; 359:46-47.
65. Way JM, Gorgun CZ, Tong Q, Uysal KT, Brown KK,Harrington WW, Oliver WR Jr, Willson TM, Kliewer
SA, Hotamisligil GS. Adipose tissue resistin expression
is severely suppressed in obesity and stimulated byperoxisome proliferator-activated receptor gamma
agonists. J Biol Chem. 2001; 276:25651-25653.
66. Ma X, Warram JH, Trischitta V, Doria A. Genetic
variants at the resistin locus and risk of type 2 diabetes
in Caucasians. J Clin Endocrinol Metab. 2002; 87:44074410.
67. Ghosh S, Singh AK, Aruna B, Mukhopadhyay S,
Ehtesham NZ. The genomic organization of mouse
resistin reveals major differences from the human resistin:functional implications. Gene. 2003; 305:27-34.
68. Wang H, Chu WS, Hemphill C, Elbein SC. Human resistin
gene: molecular scanning and evaluation of association
with insulin sensitivity and type 2 diabetes in Caucasians.
J Clin Endocrinol Metab. 2002; 87:2520-2524.
69. Asano H, Izawa H, Nagata K, Nakatochi M, Kobayashi
M, Hirashiki A, Shintani S, Nishizawa T, Tanimura D,
Naruse K, Matsubara T, Murohara T, Yokota M. Plasma
resistin concentration determined by common variants in
the resistin gene and associated with metabolic traits in anaged Japanese population. Diabetologia. 2010; 53:234246.
70. Cho YM, Youn BS, Chung SS, Kim KW, Lee HK, Yu
KY, Park HJ, Shin HD, Park KS. Common genetic
polymorphisms in the promoter of resistin gene are major
determinants of plasma resistin concentrations in humans.
Diabetologia. 2004; 47:559-565.
71. Boumaiza I, Omezzine A, Rejeb J, Rebhi L, Rejeb NB,
Nabli N, Abdelaziz AB, Bouslama A. Association between
four resistin polymorphisms, obesity, and metabolic
syndrome parameters in Tunisian volunteers. Genet Test
Mol Biomarkers. 2012; 16:1356-1362.
72. Osawa H, Tabara Y, Kawamoto R, Ohashi J, Ochi M,
Onuma H, Nishida W, Yamada K, Nakura J, Kohara K,
Miki T, Makino H. Plasma resistin associated with single
nucleotide polymorphism -420, is correlated with insulin
resistance, lower HDL cholesterol, and high sensitivity
C-reactive protein in the Japanese general population.
Diabetes Care. 2007; 30:1501-1506.
73. Rathwa N, Patel R, Palit SP, Ramachandran AV, Begum
R. Genetic variants of resistin and its plasma levels:
association with obesity and dyslipidemia related to type 2
diabetes susceptibility. Genomics. 2019; 111: 980-985.
74. Pagano C, Soardo G, Pilon C, Milocco C, Basan L, Milan
G, Donnini D, Faggian D, Mussap M, Plebani M, Avellini
C, Federspil G, Sechi LA, Vettor R. Increased serum
resistin in nonalcoholic fatty liver disease is related toliver disease severity and not to insulin resistance. J Clin
Endocrinol Metab. 2006; 91:1081-1086.
75. Beckers S, Peeters AV, Freitas F, Mertens IL, Hendrickx
JJ, Van Gaal LF, Van Hul W. Analysis of genetic variationsin the resistin gene shows no associations with obesity inwomen. Obesity (Silver Spring). 2008; 16:905-907.
76. Onuma H, Tabara Y, Kawamura R, Tanaka T, Ohashi J,
Nishida W, Takata Y, Ochi M, Yamada K, Kawamoto
R, Kohara K, Miki T, Makino H, Osawa H. A at single
nucleotide polymorphism-358 is required for G at -420 toconfer the highest plasma resistin in the general Japanese
population. PLoS One. 2010; 5:e9718.

(17)

GHM Open. 2023; 3(1):7-19.

www.ghmopen.com

77. Ji ZZ, Dai Z, Xu YC. A new tumor necrosis factor (TNF)-αregulator, lipopolysaccharides-induced TNF-α factor, isassociated with obesity and insulin resistance. Chin Med J(Engl). 2011; 124:177-182.
78. Hotamisligil GS, Arner P, Caro JF, Atkinson RL,
Spiegelman BM. Increased adipose tissue expression oftumor necrosis factor alpha in human obesity and insulin
resistance. J Clin Invest. 1995; 95:2409-2415.
79. Maury E, Noel L, Detry R, Brichard SM. In vitro hyperresponsiveness to TNF-α contributes to adipokine
dysregulation in omental adipocytes of obese subjects. J
Clin Endocrinol Metab. 2009; 94:1393-1400.
80. Jellema A, Plat J, Mensink RP. Weight reduction, but nota moderate intake of fish oil, lowers concentrations ofinflammatory markers and PAI-1 antigen in obese men
during the fasting and postprandial state. Eur J Clin Invest.
2004; 34:766-773.
81. Fasshauer M, Klein J, Lossner U, Paschke R. Interleukin-6
mRNA expression is stimulated by insulin, isoproterenol,
tumour necrosis factor alpha, growth hormone, and IL-6
in 3T3-L1 adipocytes. Horm Metab Res. 2003; 35:147152.
82. Fasshauer M, Klein J, Neumann S, Eszlinger M, Paschke
R. Tumor necrosis factor alpha is a negative regulatorof resistin gene expression and secretion in 3T3-L1
adipocytes. Biochem Biophys Res Commun. 2001;
288:1027-1031.
83. Trujillo ME, Lee MJ, Sullivan S, Feng J, Schneider SH,
Greenberg AS, Fried SK. Tumor necrosis factor alpha andglucocorticoid synergistically increase leptin production
in human adipose tissue: role for p38 mitogen-activatedprotein kinase. J Clin Endocrinol Metab. 2006; 91:14841490.
84. Greenberg AS, McDaniel ML. Identifying the links
between obesity, cytokines in the pathogenesis of type 2
diabetes. Eur J Clin Invest. 2002; 32:24-34.
85. Wilson AG, de Vries N, Pociot F, di Giovine FS, van der
Putte LB, Duff GW. An allelic polymorphism within thehuman tumor necrosis factor promoter region is strongly
associated with HLA A1, B8 and DR3 alleles. J Exp Med.
1993; 177:557-560.
86. Wilson AG, Symons JA, McDowell TL, McDevitt HO,
Duff GW. Effects of a polymorphism in the human tumor
necrosis factor promoter on transcriptional activation.
Proc Natl Acad Sci USA. 1997; 94:3195-3199.
87. Gupta V, Gupta A, Jafar T, Gupta V, Agrawal S,
Srivastava N, Kumar S, Singh AK, Natu SM, Agarwal
CG, Agarwal GG. Association of TNF-α promoter gene
G-308A polymorphism with metabolic syndrome, insulin
resistance, serum TNF-α and leptin levels in Indian adultwomen. Cytokine. 2012; 57:32-36.
88. Abraham LJ, Kroeger KM. Impact of the -308 TNF
promoter polymorphism on the transcriptional regulationof the TNF gene: relevance to disease. J Leukoc Biol.
1999; 66:562.
89. Joffe YT, Merwe LVD, Carstens M, Collins M, Jennings
C, Levitt NS, Lambert EV, Goedecke JH. Tumor Necrosis
Factor-α Gene -308 G/A Polymorphism Modulates theRelationship between Dietary Fat Intake, Serum Lipids,
and Obesity Risk in Black South African Women. J Nutr.
2010; 140:901-907.
90. Sookoian SC, González C, Pirola CJ. Meta-analysis on
the G-308A tumor necrosis factor alpha gene variant andphenotypes associated with the metabolic syndrome. Obes
Res. 2005; 13:2122-2131.

91. Mirhafez SR, Avan A, Pasdar A, Kazemi E, Ghasemi F,
Tajbakhsh A, Tabaee S, Ferns GA, Ghayour-Mobarhan M.
Association of tumor necrosis factor-α promoter G-308A
gene polymorphism with increased triglyceride level ofsubjects with metabolic syndrome. Gene. 2015; 568:8184.
92. Pyrzak B, Wisniewska A, Rymkiewicz-Kluczynska B.
Tumor necrosis factor alpha (TNF-α) gene G- 308A
polymorphism relationship to insulin resistance andlipid abnormalities in children with obesity. Endokrynol
Diabetol Chor Przemiany Materii Wieku Rozw. 2006;
12:171-174. (in Polish)
93. Fernandez-Real JM, Gutierrez C, Ricart W, Casamitjana
R, Fernandez- Castaner M, Vendrell J, Richart C, Soler
J. The TNF-α gene NCO I polymorphism influences
the relationship among insulin resistance, percent bodyfat, and increased serum leptin levels. Diabetes. 1997;
46:1468-1472.
94. Hamann A, Mantzoros C, Vidal-Puig A, Flier JS. Genetic
variability in the TNF-α promoter is not associated with
type II diabetes mellitus (NIDDM). Biochem Biophys Res
Commun. 1995; 211:833-839.
95. Walston J, Seibert M, Yen CJ, Cheskin LJ, Andersen RE.
Tumor necrosis factor-alpha-238 and-308 polymorhisms
do not associate with traits related to obesity and insulin
resistance. Diabetes. 1999; 48:2096-2098.
96. Mattacks CA, Pond CM. Interactions of noradrenalin andtumor necrosis factor, interleukin-4 and interleukin-6 inthe control of lipolysis from adipocytes around lymph
nodes. Cytokine. 1999; 11:334-346.
97. Path G, Bornstein SR, Gurniak M, Chrousos GP,
Scherbaum WA, Hauner H. Human breast adipocytes
express interleukin-6 (IL-6) and its receptor system:
increased IL-6 production by beta-adrenergic activationand effects of IL-6 on adipocyte function. J Clin
Endocrinol Metab. 2001; 86:2281-2288.
98. Vozarova B, Weyer C, Hanson K, Tataranni PA, Bogardus
C, Pratley RE. Circulating interleukin-6 in relation toadiposity, insulin action, and insulin secretion. Obes Res.
2001; 9:414-417.
99. Bastard JP, Jardel C, Bruckert E, Blondy P, Capeau
J, Laville M, Vidal H, Hainque B. Elevated levels ofinterleukin 6 are reduced in serum and subcutaneous
adipose tissue of obese women after weight loss. J Clin
Endocrinol Metab. 2000; 85:3338-3342.
100. Kopp HP, Kopp CW, Festa A, Krzyzanowska K,
Kriwanek S, Minar E, Roka R, Schernthaner G. Impact ofweight loss on inflammatory proteins and their association
with the insulin resistance syndrome in morbidly obese
patients. Arterioscler Thromb Vasc Biol. 2003; 23:10421047.
101. Gupta A, Gupta V, Singh AK, Tiwari S, Agrawal S, Natu
SM, Agrawal CG, Negi MP, Pant AB. Interleukin-6
G-174C gene polymorphism and serum resistin levels
in North Indian women: potential risk of metabolic
syndrome. Hum Exp Toxicol. 2011; 30:1445-1453.
102. Krogh-Madsen R, Plomgaard P, Keller P, Keller C,
Pedersen BK. Insulin stimulates interleukin-6 and tumor
necrosis factor-α gene expression in human subcutaneous
adipose tissue. Am J Physiol Endocrinol Metab. 2004;
286:E234-E238.
103. Fasshauer M, Klein J, Neumann S, Eszlinger M, Paschke
R. Hormonal regulation of adiponectin gene expression
in 3T3-L1 adipocytes. Biochem Biophys Res Commun.
2002; 290:1084-1089.

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GHM Open. 2023; 3(1):7-19.

www.ghmopen.com

104. Kaser S, Kaser A, Sandhofer A, Ebenbichler CF, Tilg
H, Patsch JR. Resistin-mRNA expression increased byproinflammatory cytokines in vitro. Biochem Biophys Res
Commun. 2003; 309:286-290.
105. Gomez-Huelgas R, Ruiz-Nava J, Santamaria-Fernandez
S, Vargas-Candela A, Alarcon-Martin AV, Tinahones
FJ, Bernal-Lopez MR. Impact of intensive lifestylemodification on levels of adipokines and inflammatory
biomarkers in metabolically healthy obese women.
Mediators Inflamm. 2019; 2019:4165260.
106. Rotter V, Nagaev I, Smith U. Interleukin-6 (IL-6)
induces insulin resistance in 3T3-L1 adipocytes and is,like IL-8 and TNF-α, overexpressed in human fat cells
from insulin-resistant subjects. J Biol Chem. 2003;
278:45777-45784.
107. Senn JJ, Klover PJ, Nowak IA, Zimmer TA, Koniaris
LG, Furlanetto RW, Mooney RA. Suppressor of cytokine
signaling-3 (SOCS3), a potential mediator of interleukin-6
dependent insulin resistance in hepatocytes. J Biol Chem.
2003; 278:13740-13746.
108. Vozarova B, Fernandez-Real JM, Knowler WC, Gallart
L, Hanson RL, Gruber JD, Ricart W, Vendrell J, Richart
C, Tataranni PA, Wolford JK. The interleukin-6 (174) G/C
promoter polymorphism is associated with type-2 diabetes
mellitus in Native Americans and Caucasians. Hum Genet.
2003; 112:409-413.
109. Jiang CQ, Lam TH, Liu B, Lin JM, Yue XJ, Jin YL,
Cheung BM, Thomas GN. Interleukin-6 receptor gene
polymorphism modulates interleukin-6 levels and themetabolic syndrome: GBCS-CVD. Obesity (Silver
Spring). 2010; 18:1969-1974.
110. Fishman D, Faulds G, Jeffery R, Mohamed-Ali V,
Yudkin JS, Humphries S, Woo P. The effect of novel
polymorphisms in the interleukin-6 (IL-6) gene on IL-6transcription and plasma IL-6 levels, and an association
with systemic-onset juvenile chronic arthritis. J Clin
Invest. 1998; 102:1369-1376.
111. Olivieri F, Bonafe M, Cavallone L, Giovagnetti S,
Marchegiani F, Cardelli M, Mugianesi E, Giampieri C,
Moresi R, Stecconi R, Lisa R, Franceschi C. The −174
C/G locus affects in vitro/in vivo IL-6 production during
aging. Exp Gerontol. 2002; 37:309-314.
112. Berthier MT, Paradis AM, Tchernof A, Bergeron J,
Prud'homme D, Després JP, Vohl MC. The interleukin
6 −174G/C polymorphism is associated with indices ofobesity in men. J Hum Genet. 2003; 48:14-19.
113. Wernstedt I, Eriksson AL, Berndtsson A, Hoffstedt J,
Skrtic S, Hedner T, Hultén LM, Wiklund O, Ohlsson C,
Jansson JO. A common polymorphism in the interleukin-6
gene promoter is associated with overweight. Int J Obes
Related Metab Disord. 2004; 28:1272-1279.
114. Fernandez-Real JM, Broch M, Vendrell J, Gutiérrez
C, Casamitjana R, Pugeat M, Richart C, Ricart W.
Interleukin-6 gene polymorphism and insulin sensitivity.
Diabetes. 2000; 49:517-520.
115. Fernandez-Real JM, Broch M, Vendrell J, Richart C,
Ricart W. Interleukin-6 gene polymorphism and lipid
abnormalities in healthy subjects. J Clin Endocrinol
Metab. 2000; 85:1334-1339.
116. Kitamura A, Hasegawa G, Obayashi H, Kamiuchi K, Ishii
M, Yano M, Tanaka T, Yamaguchi M, Shigeta H, Ogata M,

Nakamura N, Yoshikawa T. Interleukin-6 polymorphism(−634C/G) in the promotor region and the progressionof diabetic nephropathy in type-2 diabetes. Diabet Med.
2002; 19:1000-1005.
117. Villuendas G, San Millan JL, Sancho J, Escobar-Morreale
HF. The −597 G→A and −174 G→C polymorphisms
in the promoter of the IL-6 gene are associated withhyperandrogenism. J Clin Endocrinol Metab. 2002;
87:1134-1141.
118. Muller-Steinhardt M. Cooperative influence of theinterleukin-6 promoter polymorphisms −597, −572
and −174 on long-term kidney allograft survival. Am J
Transplant. 2004; 4:402-406.
119. Zawel L, Dai JL, Buckhaults P, Zhou S, Kinzler KW,
Vogelstein B, Kern SE. Human Smad3 and Smad4 aresequence- specific transcription activators. Mol Cells.
1998; 1:611-617.
120. Chen H, Montagnani M, Funahashi T, Shimomura I, Quon
MJ. Adiponectin stimulates production of nitric oxide invascular endothelial cells. J Biol Chem. 2003; 278:4502145026.
121. Maroni P, Bendinelli P, Picoletti R. Early intracellular
events induced by in vivo leptin treatment in mouseskeletal muscle. Mol Cell Endocrinol. 2003; 201:109-121.
122. Ceddia RB, Somwar R, Maida A, Fang X, Bikopoulos
G, Sweeney G. Globular adiponectin increases GLUT 4translocation and glucose uptake but reduces glycogensynthesis in rat skeletal muscle cells. Diabetologia. 2005;
48:132-139.
123. Perez C, Fernandez-Galaz C, Fernandez-Agullo T, Arribas
C, Andrés A, Ros M, Carrascosa JM. Leptin impairs
insulin signalling in rat adipocytes. Diabetes. 2004;
53:347-353.
124. Aguirre V, Uchida T, Yenush L, Davis R, White MF. The
c-Jun NH(2)-terminal kinase promotes insulin resistanceduring association with insulin receptor substrate-1
and phosphorylation of Ser(307). J Biol Chem. 2000;
275:9047-9054.
125. Kanety H, Feinstein R, Papa MZ, Hemi R, Karasik A.
Tumor necrosis factor alpha-induced phosphorylationof insulin receptor substrate-1 (IRS-1). Possible
mechanism for suppression of insulin-stimulated tyrosine
phosphorylation of IRS-1. J Biol Chem. 1995; 270:2378023784.
126. Gao Z, Hwang D, Bataille F, Lefevre M, York D, Quon
MJ, Ye J. Serine phosphorylation of insulin receptor
substrate 1 by inhibitor κB kinase complex. J Biol Chem.
2002; 277:48115-48121.
---Received June 8, 2023; Revised July 18, 2023; Accepted July25, 2023.
Released online in J-STAGE as advance publication July 28,
2023.
§

These authors contributed equally to this work.
*Address correspondence to:Abhishek Gupta, Department of Physiology, King George's
Medical University, Lucknow-226003, Uttar Pradesh, India.
E-mail: abhikgmu@gmail.com(19)Original Article

GHM Open. 2023; 3(1):20-27.
DOI: 10.35772/ghmo.2023.01000

Using eConsent to improve patient comprehension and solving issues
for introduction, with special attention to the COVID-19 pandemic:
A questionnaire survey by the Japan Pharmaceutical Manufacturers
Association
Naoki Tomotsugu1, Naoki Sakuma2, Maki Dobashi3, Miki Someya4, Akiko Imai5, Junichi Sakoda6, Masashi Fukuda7,
Katsuhiko Yoshimoto8, Tatsuo Iiyama1
1

National Center for Global Health and Medicine, Tokyo, Japan;
Teijin Pharma Limited, Tokyo, Japan;
3
Kissei Pharmaceutical Co., Ltd., Tokyo, Japan;
4
Pfizer R&D Japan G.K., Tokyo, Japan;
5
Otsuka Pharmaceutical Co., Ltd., Tokyo, Japan;
6
Novartis Pharma K.K., Tokyo, Japan;
7
Sumitomo Pharma Co., Ltd., Tokyo, Japan;
8
Nippon Shinyaku Co., Ltd., Kyoto, Japan.
2

Abstract: The environment surrounding clinical trials is evolving rapidly with the advancement of digitaltransformation (DX). Especially during the COVID-19 pandemic, digital methods are effective in promoting
multiregional clinical trials (MRCT). eConsent is an electronic tool for obtaining informed consent that is expected asa key solution to improve patient understanding. According to the report by Pietrzykowski et al., patient understanding
in clinical trials is surprisingly low, and this is a significant ethical problem. Despite the current situation, the useof eConsent has not significantly progressed at least in Japan. This study aimed to identify the current issues foreConsent and consider measures to solve them. In January 2022, an online questionnaire survey was sent to 69 member
companies of the Japan Pharmaceutical Manufacturers Association (JPMA), and 52 companies (75.4%) responded.
Thirteen companies (25.0%) conducted a trial using eConsent. Among the 13 companies, 17 trials were conducted by
8 companies during or after the COVID-19 pandemic (summer 2020), compared to 8 trials by 5 companies before thepandemic. We found that the biggest obstacles to the spread of eConsent are the lack of awareness of eConsent use
and the development of provisions for treating electronic files as source records in medical institutions. In conclusion,
we need to encourage medical institutions to update provisions for handling electronic source documents and to notify
them of the importance of eConsent. Thus, further promotion of eConsent is needed to increase patient understanding
and enable more efficient clinical trials.
Keywords: electronic signature, patient centricity, patient protection, decentralized clinical trial (DCT), multi-regional
clinical trials (MRCT)

Introduction

eConsent is a vital component because it increases theparticipant's understanding of clinical trials and, inprinciple, enables remote informed consent (3).
In the Use of Electronic Informed Consent in Clinical
Investigations - Questions and Answers published by the
Food and Drug Administration (FDA) in 2016 (4), theimportance of ensuring the rights, safety, and welfare ofpatients and improving their understanding of clinical
trials was emphasized. However, Pietrzykowski et al.
reported that the level of comprehension regarding
informed consent components, such as voluntary
participation, blinding, and freedom to withdraw, was

The environment surrounding clinical trials is evolving
rapidly with the advancement of digital transformation(DX) (1). Especially during an infectious emergency
such as the COVID-19 pandemic, digital methods
are effective in promoting multiregional clinical trials(MRCT). Furthermore, it is widely believed that in
the near future, decentralized clinical trials (DCT) (2),in which clinical trials are conducted with subjects
making few visits to medical institutions, will become areality. Among the various technological developments,(20)

GHM Open. 2023; 3(1):20-27.

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low, being understood by only 50% of patients (5). In
light of the philosophy of the Declaration of Helsinki(6), this would seriously undermine the ethical basis of
the current practice for obtaining informed consent inclinical trials.
Since eConsent can interactively combine not only
documents but also various types of content such asanimation, video, and audio, it can provide the necessary
explanations for informed consent very effectively and isconsidered to be a method that greatly contributes to theimprovement of the understanding of the participants.
However, the traditional paper written informed consent
requires the clinical research associates (CRAs) of
the pharmaceutical company or the clinical researchorganization (CRO) to visit the research sites in person
to confirm the original written consent form and related
information, which is problematic in terms of efficiency
and information management. Therefore, we believe thateConsent needs to be promoted more aggressively.
Despite the current situation, the use of eConsent
has not progressed in Japan. We thought it necessary
to understand the current situation more accurately to
overcome this situation. Therefore, we conducted aquestionnaire survey of all 69 pharmaceutical companies
that belong to the Japan Pharmaceutical Manufacturers
Association (JPMA) to investigate current practices andinitiatives related to eConsent and to identify the issues
that need addressing and measures that can be taken
to solve them. Furthermore, the summer of 2020 was
defined as the time when the first wave of the COVID-19
pandemic began, and Japan decided to postpone theOlympic Games by one year. Based on these experiences,many business behavior changes occurred during or
after the summer of 2020, so we asked questions basedon before, during or after the summer of 2020. We also
asked if and why the COVID-19 pandemic affected theimplementation of eConsent.

to the questionnaire, free-text responses were allowed.
We extracted the essence of these free-text responses,
categorized and tabulated them. To avoid personal bias,
all categorizations were repeatedly reviewed by all theauthors until everyone agreed.
For companies that responded to the trigger question
with answer choice [1] studies were conducted with
eConsent: We asked about their experience with "hybrid
operations" and the number of studies they conductedin such manner. Here, "hybrid operation" means that all
studies did not necessarily operate only electronically,such as using paper or electronic consent for some sites,or using paper only for consent signature.
Companies that responded that they used "hybrid
operations" were asked about their experience using
paper only for consent signatures, including the numberof studies conducted and the reasons why paper was used
only for consent signatures.
Among the eConsent studies, we asked whether
they were conducted before the COVID-19 pandemic(summer 2020), the number of studies conducted, theirstudy phase (I, II, III, IV, PMS, and others), and whether
the studies were Japanese domestic or international
collaborative studies. We also asked the same question
during or after the COVID-19 pandemic (summer 2020).
As we described in the introduction, in this study, we set
summer 2020 as the starting point for "the COVID-19
pandemic" because the first wave of the COVID-19
pandemic began in Japan, and the Japanese government
decided to postpone the Olympic Games by one year.
Based on these experiences, many business behavior
changes occurred after the summer of 2020. We also
defined the "during or after COVID-19 pandemic" period
as the period from the summer of 2020 through the endof 2021, when the questionnaire survey was conducted.
For companies that responded to the trigger question
with answer choice [1] Studies were conducted with
eConsent or [2] Considerations for introducing eConsent
were made, but actual studies were not conducted with
eConsent: When conducting (or considering) studies
with eConsent, we asked about any issues encounteredand their details. We asked if there was anything thatshould be improved with eConsent and what and how it
should be improved.
For companies that responded to the trigger question
with answer choice [3] No studies were conducted orconsidered with eConsent: We asked why they had notconducted or considered studies with eConsent.
For all companies: We asked if they would use (orconsider using) eConsent in the future, and why.

Materials and Methods
In January 2022, an online questionnaire was sent to
69 member companies of the JPMA. The questionnaire
contents are shown in the Supplemental File (https://www.ghmopen.com/site/supplementaldata.html?ID=66).
Responses to the questionnaire were provided once
per company. The first question (the trigger question)
asked the participants about their previous experience
with eConsent implementation; and the subsequent
question was based on their answer. The answer choices
for the trigger questions included: [1] Studies wereconducted with eConsent (e.g., eConsent was used for
informed consent in actual studies), [2] Challenges forthe introduction of eConsent were made (e.g., selectionof eConsent vendors and so on), but actual studies were
not conducted with eConsent, and [3] No studies wereconducted or considered with eConsent.
To elicit free and candid opinions when responding

Results
The online questionnaire survey on eConsent was sent
to 69 JPMA companies between January 5, 2022 andJanuary 25, 2022, and 52 companies (75.4%) responded.
When asking companies about their eConsent(21)

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experience (the trigger question) we found that [1] 13
companies (25.0%) had conducted studies using eConsent,[2] 7 companies (13.5%) considered the introduction ofeConsent (e.g., the selection of eConsent vendors wasconsidered), but actual studies were not conducted with
eConsent, and [3] 32 companies (61.5%) did not conduct
or consider studies using eConsent (Figure 1).

and 17 studies during or after the COVID-19 pandemic(summer 2020). Before the COVID-19 pandemic,
there were 0, 2, and 6 studies for phases I, II, and III,
respectively. During or after the COVID-19 pandemic(summer 2020), there were 3, 3 and 11 studies for Phase I,
II, and III respectively. In addition, before the COVID-19
pandemic, there were 2 studies in Japan and 6 studies
internationally. During or after the COVID-19 pandemic(summer 2020), there were 4 studies in Japan and 13
studies internationally. The number of studies using
eConsent before, and during or after the COVID-19
pandemic (summer 2020) is shown in Table 2.

For the 13 companies that responded to the trigger
question with answer choice [1] Studies were conductedwith eConsent
When asked about their experience with "hybrid
operations" and the number of studies they conducted, 12
companies had experience with hybrid operations, withan average of 1.8 hybrid studies (maximum 6, minimum1) per company. Only one company operated completely
electronically.
When the 12 companies that responded that they had
experience with "hybrid operations" were asked about
their experience using paper only for consent signatures,nine companies used paper only for consent signatures,and the average number of studies was 1.4 (maximum
3, minimum 1). The reasons given for using paper only
for consent signatures were "sites' implementation for
eConsent is not in place" (4 companies), "site specificforms" (3 companies), "concerns about personal
information protection" (3 companies), "pilot trials" (2companies), "concerns about obtaining electronic consent(companies)" (2 companies), and "time constraints". The
reasons for using paper only for consent signatures areshown in Table 1.
Of the 13 companies that used eConsent, 5companies used it for 8 studies before the COVID-19
pandemic (summer 2020), compared to 8 companies

For the 20 companies that responded to the trigger
question with answer choices [1] Studies were conductedwith eConsent (13 companies) and [2] Considerations
for introducing eConsent were made, but actual studies
were not conducted with eConsent (7 companies)
When conducting (or considering) studies with eConsent,

Table 1. The reasons given for using paper only forconsent signatures
ReasonSites' implementation for eConsent is not in
place
Site specific forms
Concerns about personal information
protection
Pilot trials
Concerns about obtaining electronic
consent (companies)
Time constraints
Total

Frequency (multiple
answers allowed) n = 9
4
3
3
2
2
1
15

Figure 1. The online questionnaire survey on eConsent for 52 JPMA companies between January 5, 2022 and January 25,
2022.

(22)

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14 companies in the 20 companies of [1] and [2] said
they encountered some issues, and 6 said they did not.
[1] The 14 companies that used eConsent reported thefollowing issues, with the number of companies reportingthat issue: system (language): 2, systems (individual
customization): 2, sites' implementation for eConsent is
not in place: 2, communications environments: 2, cost: 1,
content issues (not suitable for Japan): 1, system (bug):
1, installation schedule: 1, inability to fully comply withJapanese regulatory requirements electronic records/
electronic signatures (ER/ES): 1, lack of understandingof monitors: 1, patient request (if symptoms make it
impossible to operate, patients request paper-based
informed consent): 1, concern about personal information
protection by company: 1, and site-specific form: 1. On
the other hand, [2] the seven companies that consideredintroducing eConsent, but did not conduct studies with

eConsent reported the following issues: system (bug): 1,
sites' implementation for eConsent is not in place: 1, cost:
2, concern about BYOD (bring your own device support:
1, benefits are reduced by half due to hybrid operations:
1, and not seeing the significance of eConsent as it
requires face-to-face signatures: 1. Details of the issues
encountered when introducing eConsent are presented inTable 3.
When these 20 companies were asked if there were
any improvements to be made in relation to eConsent,
17 companies said there were points to be improved, and3 companies said there were no points to be improved.
The following details for improvements were suggested,followed by the number of companies reporting thatsuggestion. [1] The 13 companies that conductedstudies with eConsent reported the following: a lack of
coordination of awareness of eConsent use (sponsors/
medical institution): 5, eConsent systems were not up
to the required level in Japan: 5, the cost of introduction
was high: 3, guidelines were not developed: 2, systems
take a long time to build: 2, sites' implementation ofeConsent is not in place: 2, remote consent should beallowed with video calls: 1, cost of device rentals issignificant: 1, system errors are frequent: 1, and theprocess of re-consent with eConsent is complicated:
1. On the other hand, [2] the seven companies thatconsidered introducing eConsent, but did not conduct
studies with eConsent reported the following: a lack of
coordination of awareness of eConsent use (sponsors/
medical institution): 2, eConsent systems were not up
to the required level in Japan: 2, the cost of introduction
was high: 1, guidelines were not developed: 1, systems
take a long time to build: 1, and remote consent should

Table 2. The number of studies using eConsent before, andduring or after the COVID-19 pandemic (summer 2020)
Study phase / type

Phase Ⅰ (Japan only)
Phase Ⅰ (International)
Phase Ⅱ (Japan only)
Phase Ⅱ (International)
Phase Ⅲ (Japan only)
Phase Ⅲ (International)
Total

Before COVID-19
Pandemic(Summer 2020)(5 Companies)

During or after
COVID-19 Pandemic(Summer 2020)(8 companies)

0
0
1
1
1
5
8

2
1
1
2
1
10
17

In this study, we set the summer 2020 as the starting point for"the COVID-19 pandemic". We also defined the "after COVID-19
pandemic" period as the period from the summer 2020 through theend of 2021, when the questionnaire survey was conducted.

Table 3. Issues encountered when introducing eConsent

Details of Issues(1) Companies that conducted (2) Companies that considered introducing
studies with eConsent
eConsent, but actual studies were not(Multiple answers allowed) n = 13 conducted with eConsent (multiple answers
allowed) n = 7
2
2
2
2
1
1
1
1
1

System (Language)
System (Individual customization)
Sites' implementation for eConsent is not in place
Communications environments
Cost
Content issues (not suitable for Japan)
System (bug)Installation schedule
Inability to fully comply with Japanese regulatory requirements(ER/ES) that is developed based on 21 CFR Part 11
Lack of understanding of monitors
Patient's request (if symptoms make it impossible to operate,patients request paper-based informed consent)
Concern about personal information protection by company
Site specific form
Concern about BYOD support
Benefits are reduced by half due to hybrid operations
Not seeing the significance of eConsent as it requires face-toface signatures.
Total

1
1
2

1
1
1
1

17

BYOD, bring your own device; CFR, Code of Federal Regulations, ER/ES, electronic records/electronic signatures

(23)

1
1
1
7

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be allowed with video calls: 1. The points to be improved
are listed in Table 4.
Five companies reported that the COVID-19
pandemic had an impact on their eConsent
implementation, however, 15 companies reported no
impact. Companies that reported an impact cited the useof eConsent to prevent infection among the medical staff,
and the pandemic promoted the use of DCT as the main
reasons. However, companies that did not report the
impact of the pandemic indicated that eConsent had beenin place before the pandemic and did not change muchafter the pandemic, as in-person consent signatures werestill required in most cases.

compatibility with studies: 1, improved understanding ofparticipants: 2, making efficient study management tasks:
1 (management of ICF versions and consent acquisition
status), development of guidelines: 2, consideration ina global implementation trial: 1, clarification of user
benefits: 1, and cost benefits: 1. One of [2] the sevencompanies that considered introducing eConsent, but
did not conduct studies with eConsent reported thatthey would not consider using eConsent in the future,and the reason for this was that face-to-face informed
consent is indispensable. Furthermore, 21 of [3] the 32
companies that responded that they did not conducted a
trial or were not considering eConsent reported that theywould consider using eConsent in the future, with themain reasons cited as realization of DCT: 7, monitoring
industry trend: 6, reduced burden on subjects: 4, improved
understanding of subjects: 3, making efficient study
management tasks (management of ICF versions andconsent acquisition status): 6, and cost benefits: 2. Elevenof [3] the 32 companies that responded that they had
not conducted a trial or were not considering eConsent
reported that they would not consider using eConsent in
the future due to the following: monitoring industry trend:
1, compatibility with studies: 2, cost disadvantage: 2,
overseas initiative: 2, no clinical trial: 2, no necessity: 2,
must be implemented in combination with online medicalcare to be beneficial: 1, burden on organization from theintroduction of new technology (securing resources forconsideration): 1, and delayed response to digitization: 1.
The future plan for eConsent and its reasons are listed inTable 5.

For the 32 companies that responded to the trigger
question with answer choice [3] Did not conduct orconsider studies with eConsent
When we asked why they had not conducted studies
with eConsent in the past, the reasons included lack ofnecessity, regulatory challenges, cost, support for elderly
patients, overseas initiative, lack of experience among
Japanese CROs, and time constraints.
For all companies (52 companies)
When asked whether they would use (or are considering
using) eConsent in the future and why, [1] all 13
companies that conducted studies using eConsent
answered that they would consider using eConsent in the
future, citing the following reasons: realization of DCT: 6,
monitoring industry trend: 3, compatibility with studies: 2,
improved understanding of subjects: 2, making efficientstudy management tasks: 1 (management of informed
consent form (ICF) versions and consent acquisition
status), establishment of site implementation for eConsent:
1, and improvement of clinical trial efficiency: 1. Sixof [2] the seven companies that considered introducing
eConsent, but did not conduct studies with eConsent
reported that they would consider using eConsent in the
future for the following reasons: realization of DCT: 2,

Discussion
Our study has four major findings. First, although ourstudy showed that the number of studies with eConsent
increased before, and during or after the COVID-19
pandemic (summer 2020), the study participants reported
that the pandemic did not significantly affect theimplementation of eConsent. Second, the results suggestthat raising the awareness of eConsent in medical

Table 4. Points to be improved
Points to be improved(1) Companies that conducted (2) Companies that considered introducing
studies with eConsent (Multiple eConsent, but actual studies were not conducted
answers allowed) n = 13
with eConsent (multiple answers allowed) n = 7

Lack of coordination of awareness of eConsent use(sponsors / medical institution)eConsent systems were not up to the required level in JapanThe cost of introduction was high
Guidelines were not developed
Systems take long time to build
Sites' implementation for eConsent is not in place
Remote consent should be allowed with video calls
Cost of device rentals is significant.
System errors are frequent
Process of re-consent with eConsent is complicated
Total

(24)

5

2

5
3
2
2
2
1
1
1
1
23

2
1
1
1
1

8

GHM Open. 2023; 3(1):20-27.

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institutions is vital. Third, the cost of using eConsent
is one of the major issues preventing pharmaceuticalcompanies from introducing eConsent. Fourth, ourresults indicated that the most of the hybrid operations
used paper only for consent signatures.

medical staff as their reason.
However, even when eConsent was used, the resultsof this study show that, at present, there are many
instances of face-to-face use of eConsent. AlthougheConsent reduces the time of direct contact with patients,
there is still a certain amount of face-to-face time;
therefore, its significance in preventing infection isconsidered to be limited.
On the other hand, several companies reported that
the COVID-19 pandemic had no impact on them andcited the fact that they had been working on eConsent
before the COVID-19 pandemic and were currently
obtaining informed consent with eConsent face-to-faceas the reasons. The number of companies that reported
no impact of eConsent implementation was three times
greater than those that did.
Although the COVID-19 pandemic may have affected
people's mindset, the global trend toward digitalization
began before the COVID-19 pandemic, and the increasein the number of eConsent implementations observed
during or after the COVID-19 pandemic was considered
consistent with this major trend toward digitalization. As
the trend toward digitalization is expected to continue,

COVID-19 pandemic effects on the use of eConsent
An online questionnaire on eConsent was sent to 69
companies of the Japan Pharmaceutical Manufacturers
Association on January 5, 2022, and 52 companies(75.4%) responded. This study reconfirmed that use ofeConsent is not widespread, at least in Japan. For the
20 companies that responded to the trigger question
with answer choices [1] studies were conducted with
eConsent (13 companies) and [2] considered theintroduction of eConsent, but actual studies were notconducted with eConsent (7 companies), we have shownthat 5 companies indicated that the COVID-19 pandemic
affected their eConsent implementation, and 15
companies indicated that it did not. One of the companies
that indicated that the pandemic did affect their eConsent
implementation cited the prevention of infection among

Table 5. Whether companies would use (or are considering using) eConsent in the future and why( 1 ) C o m p a n i e s t h a t ( 2 ) C o m p a n i e s t h a t c o n s i d e r e d (3) Companies that did
conducted studies with introducing eConsent, but actual studies not conduct or consider
eConsent (Multiple answers were not conducted with eConsent studies with eConsent (nallowed) n = 13
(multiple answers allowed) n = 7= 32)
Would you consider using eConsent in the
future? (Y/N)

Y(n = 13)Y(n = 6)

Realization of decentralized clinical trial (DCT)
Monitoring industry trend
Compatibility with studies
Improved understanding of subjects
Making efficient of study management tasks(management of informed consent form
versions and consent acquisition status)
Establishment of sites' implementation for
eConsent
Improvement of clinical trial efficiency
Development of guidelines
Consideration in a global implementation trial
Clarification of user benefits
Cost benefits
Cost demerit
Cost unknown
Face-to-face informed consent is indispensable
Reduced burden on subjects
Overseas initiative
Expanding options for subjects
Improved engagement with subjects
No clinical trial
No necessity
Must be implemented in combination with
online medical care to be beneficial
Burden on organization from introductionof new technology (securing resources forconsideration)
Delayed response to digitization
Total

6
3
2
2
1

2

N
(n = 1)Y(n = 21)
7
6
2
3
6

1
2
1

1

N
(n = 11)
1
2

1

1

2
1
1
1

1
2
1

1
4
1
1
1

2

2
2
2
1
1

16

11

(25)

1

36

1
14

GHM Open. 2023; 3(1):20-27.

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we believe that the introduction of eConsent will befurther promoted in the future. Of the 52 companies that
responded, 40 said that they would continue to consider
adopting eConsent for DCT in the future, revealing highexpectations for future DCT, reducing the burden on
participants, increasing participant understanding, andconducting more efficient clinical trials. Therefore, we
believe that the promotion speed of eConsent needs to beaccelerated within industry, government, and academia
for the appropriate and efficient conduct of clinical trials.

of support for Japanese fonts, some systems were notconsidered to be able to withstand the detailed demandsof each site, and that it was not worth the cost or theeffort. From the point of view of vendors providing
eConsent, it is possible that the level of functionality
required by the industry is not consistent, resulting inprice instability. Although some aspects of eConsent
alone may not be worth the cost at the present time, using
eConsent may be necessary when considering increasing
participant's understanding, industry-wide improvementsin the monitoring efficiency and overall clinical trial
scheme and the future of DCT.

Raising awareness in medical institutions
Our results repeatedly pointed out that one of the major
impediments to the implementation of eConsent was theacceptance of medical institutions and the developmentof standard operating procedures (SOPs) or provisions
in medical institutions (Tables 1, 3, 4, and 5). Even if
pharmaceutical companies tried to promote eConsent,
there seems to be many cases where it was not acceptable
to use electronic documents and signatures as source
records because it is expected that the SOPs or provisions
in medical institutions stipulate that the source records
should be paper. eConsent can be seen as a significant
benefit to medical institutions. In addition to protecting
participants and promoting better understanding, consent
forms or records can be managed online and are lesslikely to be lost. They can also manage online which
participants have given re-consent and which have not,such as version control, when re-consent is required,thus enabling efficient management. The audit trail is
automatically captured, including login information,
time spent reading materials, time signed, and question
exchanges. Furthermore, it allows the reduction of the
response time to source data verification (SDV) by
pharmaceutical companies or CRO and reduces thepaper storage space. In fact, when you experience anelectronic file as a source record, you do not want toreturn to the paper world. Therefore, it is necessary forthe pharmaceutical industry and academia to enlighten
medical institutions about the significance of eConsent,
improve their understanding of the subject, and propose
concrete measures for improvement, such as proposing
a model for propositions or SOPs that allow electronic
files as source records.

Regulatory for eConsent
Our study found that of the 13 companies that said theyused eConsent, 9 used it face-to-face, and consent forms
were paper-signed in hybrid operations.
The administrative notification of the Pharmaceutical
Evaluation and Licensing Division and Medical Devices
Evaluation and Licensing Division, the Ministry of
Health, Labour and Welfare, dated April 7, 2022 (7)states that, "In the case that a clinical trial is to be
conducted on patients with infectious diseases, including
novel coronavirus infection, and it is difficult to preserve
the signed consent documents from the viewpoint ofcontagiousness of the disease, etc., according to theprotocol or hospital regulations, if a patient signs theconsent document in his/her own handwriting using
a tablet device and it is stored electromagnetically",
with reference to the "Use of electromagnetic records
and electronic signatures in applications for approvalor permission for drugs, etc." (8), the document can betreated as a source record, provided that a procedure
manual is in place on how to preserve the document,
the document is preserved in a readable condition,
and a copy of the consent document (e.g., an output
of electromagnetic record) is delivered to the subject
in accordance with Article 53 of the "Pharmaceutical
GCP Ministerial Ordinance, Article 73 of the Medical
Device GCP Ministerial Ordinance", or Article 73 of the"Regenerative Medicine GCP Ministerial Ordinance".
This information shows the direction of accepting
electronic files signed on tablets as source records. The
results in Table 1 also show that there were only twocompanies with concerns about obtaining electronic
informed consent, which suggests that pharmaceuticalcompanies do not have major concerns about having anelectronic file signed on a tablet as the source record.
In December 2021, the Cabinet Office Council for
Promotion of Regulatory Reform issued a report entitled"Immediate Regulatory Reform Implementation Items"(9), which says "guidance should be developed on
appropriate methods for physicians at the investigationalsites to provide necessary explanations to subjects
about the clinical trial and to obtain informed consent
non-face-to-face and remotely, and on ensuring theeConsent Installation Cost
This study showed that there are different opinions andpositions on the installation cost of eConsent (Tables 3,4, and 5). Some companies reported that eConsent was
expensive, while others reported that they could savemoney by making it more efficient. The conflicting
reasons could depend on how each company views
eConsent and how the studies are conducted. In the raw
data from the survey responses, there were some cases
where it was functionally inadequate, such as the lack

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reliability of the data". On March 30, 2023, the Japanese
government issued the guidance "Points to Consider for
the Informed Consent Using Electromagnetic Methods
in Clinical Trials and Post-Marketing Studies" (10) for
the implementation of eConsent, we hope that eConsent
should become more widespread and implemented.
The limitation of the study is that the questionnaire
survey in this study covers only JPMA member
companies and does not reflect the opinions of otherpharmaceutical companies, medical institutions, orparticipants.

1184.
Vanaken H Ir, Masand SN. Awareness and collaboration
across stakeholder groups important for eConsent
achieving value-driven adoption. Ther Innov Regul Sci.
2019; 53:724-735.
4. U.S. Food & Drug. Use of electronic informed consent inclinical investigations – questions and answers. December,2016. https://www.fda.gov/regulatory-information/
search-fda-guidance-documents/use-electronic-informedconsent-clinical-investigations-questions-and-answers(Accessed April 1, 2023).
5. Pietrzykowski T, Smilowska K. The reality of informed
consent: Empirical studies on patient comprehensionsystematic review. Trials. 2021; 22:57.
6. Word Medical Association. WMA Declaration of Helsinki- Ethical Principles for Medical Research Involving
Human Subjects. https://www.wma.net/policies-post/wmadeclaration-of-helsinki-ethical-principles-for-medicalresearch-involving-human-subjects/ (Accessed April 1,2023).
7. The Ministry of Health, Labour and Welfare, Division of
Medical Device Review and Administration. Handlingof Preservation of Consent Documents in Clinical. Trials
April 7, 2022. https://www.mhlw.go.jp/web/t_doc?dataId=00tc4962&dataType=1&pageNo=1 (Accessed April 1,2023). (in Japanese)
8. Director General, Pharmaceutical and Food Safety
Bureau, the Ministry of Health, Labour and Welfare, PFSB
Notification No. 0401022. Use of electromagnetic records
and electronic signatures in applications for approval or
permission of pharmaceuticals, etc. (ER/ES Guidelines).
April 1, 2005. https://www.pmda.go.jp/files/000158308.
pdf (Accessed April 1, 2023). (in Japanese)
9. Cabinet Office Regulatory Reform Promotion Council.
Immediate Regulatory Reform Implementation Items.
December, 2021. https://www8.cao.go.jp/kisei-kaikaku/
kisei/publication/opinion/211222.pdf (Accessed April 1,2023). (in Japanese)
10. The Ministry of Health, Labour and Welfare. Points toConsider for the Informed Consent Using Electromagnetic
Methods in Clinical Trials and Post-Marketing Studies,
March 30, 2023. https://www.jmha.or.jp/jmha/news/
info/13797 (Accessed April 1, 2023). (in Japanese)
3.

Conclusion
This study revealed that eConsent is not widely used
at least in Japan. It also discovered that one of thereasons why eConsent is not widely used is that medical
institutions have not developed their provisions or SOPs
to treat electronic files as source records. Since eConsent
will help patients to better understand and enable more
efficient clinical trials, we need to enlighten medical
institutions about the significant merit of eConsent andpromote the widespread use of eConsent.
Acknowledgements
The authors thank the Japan Pharmaceutical
Manufacturers Association (JPMA) and colleagues in
the member companies for their timely cooperation incompleting the survey.
Funding: This research was supported by the Japan
Pharmaceutical Manufacturers Association (JPMA) andthe intramural research fund of the National Center for
Global Health and Medicine (NCGM).
Conflict of Interest: The authors have no conflicts ofinterest to disclose.

---Received January 15, 2023; Revised April 12, 2023; Accepted
May 17, 2023.

References
1.

2.

Inan OT, Tenaerts P, Prindiville SA, Reynolds HR, Dizon
DS, Cooper-Arnold K, Turakhia M, Pletcher MJ, Preston
KL, Krumholz HM, Marlin BM, Mandl KD, Klasnja P,
Spring B, Iturriaga E, Campo R, Desvigne-Nickens P,
Rosenberg Y, Steinhubl SR, Califf RM. Digitizing clinical
trials. NPJ Digit Med. 2020; 3:101.
Pennestrì F, Banfi G, Tomaiuolo R. Remote decentralized
clinical trials: a new opportunity for laboratory medicine.
Clin Chem Lab Med. 2023 Jan 5. doi: 10.1515/cclm-2022-

Released online in J-STAGE as advance publication June 15,2023.
*Address correspondence to:
Naoki Tomotsugu, Department of International Trials, Centerfor Clinical Trials, National Center for Global Health andMedicine, 1-21-1, Toyama, Shinjuku, Tokyo 162-8655, Japan.
E-mail: ntomotsugu@hosp.ncgm.go.jp(27)Original Article

GHM Open. 2023; 3(1):28-36.
DOI: 10.35772/ghmo.2023.01005

Alpha and Delta variants and vaccination effectiveness against
severity in COVID-19 inpatients based on medical claims in Japan
Shingo Mitsushima1,*, Hiromasa Horiguchi2, Kiyosu Taniguchi3,41

Center for Field Epidemic Intelligence, Research and Professional Development, National Institute of Infectious Diseases, Tokyo, Japan;
Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization Headquarters, Tokyo, Japan;
3
National Hospital Organization Mie National Hospital, Mie, Japan;
4
The Tokyo Foundation for Policy Research, Tokyo, Japan.
2

Abstract: Some mutated strains of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presumably havehigh infectivity and pathogenicity. Using Japanese medical claims data, we assessed the pathogenicity of Alpha andDelta variants and vaccine effectiveness by severity. Inpatient records from the Medical Information Analysis Databankfor the National Hospital Organization were used. Severity was defined as the proportion of inpatients using respiratory
ventilators among inpatients with oxygen administration. We regressed severity and fatality on the proportion ofpatients with Alpha or Delta variant and on vaccination coverage, while allowing for some lag to reflect developmentfrom infection to hospitalization. We also examined results obtained when using data for all new inpatients, insteadof inpatients with oxygen administration, as the denominator for severity. Estimation results were better when using
severity defined by inpatients with oxygen administration as the denominator than when using all new inpatients.
Especially for severity measures for inpatients 65 years old or older with oxygen administration, we confirmed an
association of vaccination with lower severity and an association of Delta variant infection with high severity. Vaccines
were most effective for people 65 years old or older. The age distributions of inpatients and confirmed patients weregreater than for people younger than 65 years old. Vaccination reduced severity and fatality and Alpha and Delta
variants might increase severity and fatality among inpatients 65 years old or older receiving oxygen therapy.
Keywords: COVID-19, mutated strains, fatality, medical claim data, vaccine

Introduction

variants (9). Therefore, the object of this study wasevaluation of the severity of Alpha and Delta variants
while considering vaccine effectiveness.
Japan's National Hospital Organization (NHO), an
organization of regional core hospitals and 140 medical
facilities with about 52,000 beds, represents about 3.4%of all beds in Japan (10).The NHO provides a database,the Medical Information Analysis Databank (MIA),
which contains medical claims from 60 representative
NHO hospitals, including data related to the numbersof inpatients and outpatients, diagnoses, medical
interventions including oxygen administration and theuse of respiratory ventilators, in addition to outcomessuch as discharge and death (11). Representative 60
hospitals were the hospitals whose data on medical claim
were available as MIA data at the beginning of this study.
They locate in each region and we regarded and assumed
that they are representative of patients in each region. The
database does not include data related to the vaccination
history or causative strain. COVID-19 had a significant
impact on the medical setting for outpatients andinpatients (12-14). The number of patients of COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) causes coronavirus disease 2019 (COVID-19).
COVID-19 spread throughout Japan from January
2020. The number of COVID-19 patients increased anddecreased due to individual infection prevention andsome political policies such as a state of emergency (1-4).
Some mutated strains such as Alpha and Delta
variants including B.1.1.7 (Alpha variant) and B.1.617.2(Delta variant) are likely to induce severe symptoms (57). In Japan, an epidemic of the Alpha variant occurredfrom March 2021 (Weeks 9–13, Wave 4). An epidemicof the Delta variant was reported from July 2021 (Weeks
27–30, 2021, Wave 5).
Development of vaccination against SARS-CoV-2
was initiated around the world after the emergence of
COVID-19 (8). Vaccination in Japan started from 17
February 2021 (Week 7, 2021, Wave 3) using BNT162b2
mRNA (Pfizer Inc., BioNTech SE) and mRNA-1273(Moderna, Inc.). Clinical trials proved the vaccines'
efficacy for preventing infection against Alpha and Delta(28)

GHM Open. 2023; 3(1):28-36.

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increased rapidly from July 2021 (Weeks 26–30, 2021,
Wave 5) because of the spreading Delta variant. In the
period during which the Delta variant spread, nationwide
demand for medical resources such as hospital beds andrespiratory ventilators threatened to exceed the capacityof medical resources allocated for COVID-19 patients.
Therefore, asymptomatic patients and some patients withmild symptoms were not hospitalized during that period,
even though such patients had been hospitalized earlier
during the pandemic. In other words, the COVID-19
patient criteria for hospitalization changed to reflect theoutbreak scale and the available capacity of medical
resources. For that reason, when examining COVID-19
pathogenicity, the fraction of patients with severe
symptoms or cases of fatality beyond the hospitalizedcases might not be appropriate to evaluate pathogenicity
because the criteria for hospitalization were not constant.
The criteria were not based solely on medical necessity.
To avoid inconsistency in the data, the number ofhospitalizations had to be adjusted. Therefore, this study
specifically examined patients who required oxygentherapy.

1) to 21 November 2021 (Week 46, 2021, Wave 5). All
MIA data for patients were counted based on the week ofadmission.
Additionally, we used background COVID-19
patient data nationwide, including the number of newly
confirmed patients and deaths, published between 1
January 2020 (Week 1, 2020, Wave 1) and 21 November
2021 (Week 46, 2021, Wave 5) from the Ministry of
Health, Labour and Welfare (MHLW) (15). Hereinafter,
we designate data from MHLW as "national data". Data
related to vaccine administration (such as the number ofpeople receiving at least one dose, which means one or
two doses, and those who had received the second dose)were published by the Cabinet Secretariat (16). For the
study period, the third and subsequent doses were notavailable. Data related to the Alpha and Delta variants
were referred from a monitoring meeting in Tokyo (17).
Definition of waves
As of November 2021, Japan experienced five waves,which mean movements of the number of COVID-19
patients shown as Figure 1. In this study, the COVID-19
outbreak waves in Japan were classified by the numberof newly confirmed patients from the trough of the priorwave to the trough of the current wave (4). That method
clearly distinguished five waves through the end of
November 2021: the wave 1 extended from week 1 of2020 through week 23 of 2020; the wave 2 lasted fromweek 24 of 2020 through week 39 of 2020; the wave 3

Materials and Methods
Data sourceThis study used MIA data from the NHO such as thenumber of inpatients with oxygen therapy, ventilation,and deaths from 1 January 2020 (Week 1, 2020, Wave

Figure 1. Newly confirmed COVID-19 patients in national data and new COVID-19 hospitalizations in MIA data. Notes:
Bars show the numbers of newly confirmed COVID-19 patients in national data (left scale). The line shows the numbers of new
COVID-19 hospitalizations in MIA data (right scale).

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was recorded from week 40 of 2020 through week 8 of
2021; the wave 4 occurred from week 9 of 2021 throughweek 24 of 2021; and the wave 5 was from week 25 of
2021 through week 46 of 2021.

have also demonstrated that Alpha and Delta variants
are associated with increased severity and higher
fatality rates (5-7,18,19). Therefore, we expected tofind a positive association among severity, fatality, andvaccination, and a negative association for the proportionof Alpha and Delta variants.

DesignAssociations between the severity or fatality rate among
inpatients with oxygen therapy and the vaccination
coverage and/or the proportions of Alpha and Delta
variants were examined. Additionally, we sought toascertain the most appropriate length from infection
to hospitalization by adjusting the delay in the timingof vaccination coverage two weeks prior and the
proportions of Alpha and Delta variants. Specifically, we
examined no delay and 1–4 or more weeks' delay. For nodelay, vaccination coverage was recorded for two weeks
before hospitalization; the proportions of Alpha and Delta
variants were measured the same week of hospitalization.
For 1–4 weeks' delay, the vaccination coverage 3–6
weeks before hospitalization or the proportions of Alphaand Delta variants were measured at 1–4 weeks before
hospitalization.
The study period for analysis was from the first weekof 2021 (Wave 1) through the 46th week of 2021 (Wave 5)
because vaccination against COVID-19 had not started
and Alpha and Delta variants had not emerged before thestudy period.

Statistical analysis
We applied ordinary least squares regression, withdependent variables of the severity rate among patientswith oxygen therapy and the fatality rate among patients
who had received oxygen therapy. Vaccination coverageand the proportions of Alpha and Delta variants wereused as explanatory variables.
Statistical analyses were also performed after patient
data were divided into those for age groups, with patients
who were 65 years old or older and patients younger
than 65 years. First, we identified the optimal period
from infection to hospitalization for all ages, and by age
classification, by outcome, severity rate, and fatality
rate. Then, we discussed estimation results under the
optimal period for each category. We adopted 5% as thesignificance level. All statistical analyses were conductedusing software (STATA SE 17.0; Stata Corp.).
Ethical considerations
This study was approved by the Ethics Committee of
Mie Hospital (Approval No. 2020-89). Permission to use
MIA data was obtained from the NHO (Registration No.
1201003).

Definitions
Patients were limited to hospitalized patients with a
COVID-19 infection confirmed by PCR test or antigen
test and those who received oxygen therapy during their
hospitalization. It is noteworthy that the timing of oxygentherapy did not matter: only that it was administeredduring their hospitalization. Furthermore, comorbidities
did not matter for the patient definitions or outcome
measures presented below.
The severity rate among patients was defined as
the number of patients with ventilation during their
hospitalization among patients who were admitted duringa week, by the number of patients administered oxygentherapy who had been admitted during the same week.
The timing of ventilation use did not matter: only that it
was administered their hospitalization. The fatality rate
among patients was defined as the number of fatalities
among patients who were admitted in a week, divided by
the number of patients administered oxygen therapy who
had been admitted during the same week. The main or
direct cause of death does not matter: only that they had
been diagnosed as COVID-19-infected.

Results
Figure 1 presents the number of newly confirmed
COVID-19 patients from national data and the number of
new COVID-19 hospitalizations from MIA data. Figure 2
presents the number of fatalities attributed to COVID-19
from national data and the number of fatalities from
MIA data. The number of newly confirmed COVID-19
patients from national data was shown by the diagnosed
week. The number of new hospitalizations from MIA
data is shown by the hospitalized week. The numbersof fatalities from national data and MIA data are shownby their death and discharge weeks. Vertical lines in
Figures 1–5 represent periods between waves. Figure
1 shows similar trends obtained from the number of
newly confirmed COVID-19 patients and the numberof newly hospitalized patients. Figure 2 also shows thatthe number of fatalities from national data presents asimilar trend to that of the number of fatalities from MIA
data. Correlation between them was 0.8830, which wasinferred as significant. The wave 5 showed the greatest
number of newly confirmed cases (Figure 1). The wave
4 showed the greatest number of fatalities (Figure 2).
Figure 3 and Figure 4 respectively portray the

Hypothesis
Results of earlier studies have demonstrated thatvaccination decreased severity and fatality rates. They

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severity rate with ventilator usage among patients withoxygen therapy and the fatality rate among patients withoxygen therapy for all ages, and by age classification. At
first glance, all lines were declining in the latter period of
the study period when bottom from wave 5 to 6. Figure

5 shows vaccination coverage with at least one dose in
the entire population, younger than 65 years old, and 65
years old or older, in addition to the proportions of Alphaand Delta variants in Tokyo. The proportions of the Delta
variant showed a similar increase to that of vaccination

Figure 2. Fatalities with COVID-19 in national data and in MIA data. Notes: The blue line denotes the number of fatalities
with COVID-19 in National data (left scale). Orange line denotes the numbers of fatalities by hospitalized week in MIA data (rightscale).

Figure 3. Severity rate among inpatients administered oxygen therapy. Notes: Blue, orange, and gray lines respectively show
the severity rate with ventilator use among inpatients with oxygen therapy in the entire population, younger than 65 years old, and65 years old or older. Severity was defined as the proportion of ventilator use. All data were sourced from MIA data.

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coverage for patients 65 years old or older.
Table 1 presents coefficients of determination using
proportions of Alpha and Delta variants and vaccination
coverage in the hospitalized week, or 1–4 weeks before

hospitalization for all ages and by age classification. The
findings indicate the highest coefficients of determination
for three weeks before for severity and one week before
for fatality for all ages.

Figure 4. Fatality rate among inpatients administered oxygen therapy. Notes: Blue, orange, and gray lines respectively
represent the fatality rate among inpatients with oxygen therapy in the entire population, younger than 65 years old, and 65 years
old or older. All data sources were MIA data.

Figure 5. Vaccination coverage with at least one dose in Japan, in addition to proportions of Alpha and Delta variantsin Tokyo. Notes: Yellow and light blue lines respectively represent the proportions of the Alpha and Delta variants. Data of the
proportions of the Alpha and Delta variants were published by the Cabinet Secretariat. Blue, orange, and gray lines respectively
represent vaccination coverage with at least one dose in the entire population, younger than 65 years old, and 65 years old orolder. Data of the vaccination coverage were published by the monitoring meeting in Tokyo.

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Among inpatients 65 years old or older, the highest
coefficients of determination for the severity rate and forthe fatality rate were the same: one week. Conversely,
among inpatients younger than 65 years old, although
the highest coefficients of determination for the fatality
rate were the same week with hospitalization, it was six
weeks for the severity rate.
Table 2 presents estimation results obtained frommultivariable analyses of the association between theseverity and fatality rates among inpatients with oxygentherapy and vaccination coverage or Alpha and Delta
variant proportions for all ages and by age class. Eachestimation result was obtained under the optimal period
for each category shown in Table 1. For patients of allages, at least one dose vaccination and the proportion of
Delta variant were found to be associated significantlywith the severity rate. Also, the proportion of Alphavariant was associated significantly with the fatality

rate. The results were mixed: the negative sign of the
proportion of Alpha variant was unexpected from the
hypothesis defined in Method. However, the negative
sign of at least one dose vaccination and the positive
sign of the proportion of Delta variant were expected.
For patients younger than 65 years old, the proportionof the Alpha variant and Delta variant showed negative
association with the severity rate significantly, whichwere unexpected. For all age patients, at least one dose
vaccination was negatively associated with the severity
and fatality rates. The proportion of Delta variant was
positively associated with the severity and fatality rates.
Discussion
All COVID-19 patients, including asymptomaticpatients, be admitted mandatory to medical facilities
through March 2020. Subsequently, asymptomatic

Table 1. Coefficients of determination obtained using proportions of Alpha and Delta variants and vaccination coverage inthe hospitalized week, or 1–4 weeks before hospitalization in all age and by age classification
Length of delay in vaccination coverage and Proportion of Alpha and Delta variants
All ages with oxygen therapy
Severity rate
Fatality rate
Among patients younger than 65 years old
Severity rate
Fatality rate
Among patients 65 years old or older
Severity rate
Fatality rate

0

1

2

3

4

0.33
0.17

0.37
0.49

0.40
0.47

0.43
0.47

0.42
0.48

0.17
0.07

0.18
0.05

0.23
0.06

0.24
0.07

0.25
0.07

0.21
0.36

0.42
0.52

0.40
0.51

0.40
0.49

0.38
0.48

Note: The highest coefficient of determination for the severity rate among inpatients younger than 65 years old with oxygen therapy was 0.2779
when vaccination coverage and the prevalence of the mutated strains were measured six weeks before.

Table 2. Results of multivariate analysis of the association between severity/ fatality and vaccination coverage or
proportion of variants among inpatients with oxygen therapy for cases of vaccination coverage two weeks prior and the
proportion of Alpha and Delta variants measured several weeks before their hospitalized week determined by Table 1
Variables
All ages
At least one dose vaccination 14 days prior
Alpha variant
Delta variant
Constant
Younger than 65 years old
At least one dose vaccination 14 days prior
Alpha variant
Delta variant
Constant
65 years old or older
At least one dose vaccination 14 days prior
Alpha variant
Delta variant
Constant

Severity Rate

Fatality Rate

Estimated coefficient

p value

Estimated coefficient

p value

-0.40
-0.03
0.18
12.21

0.00
0.10
0.02
0.00

0.03
-0.05
-0.12
12.57

0.79
0.04
0.09
0.00

1.55
-0.16
-0.21
14.59

0.07
0.00
0.01
0.000

0.16
-0.01
-0.08
2.27

0.10
0. 73
0.14
0.19

-0.12
0.02
0.18
11.54

0.00
0.50
0.01
0.00

-0.14
0.00
0.18
16.69

0.00
0.89
0.03
0.00

Notes: Vaccination coverage and proportions of Alpha and Delta variants were measured three weeks before the hospitalized week for severity
rates for all ages. These lags for inpatients younger than 65 years old were zero for severity and six for fatality. For inpatients 65 years old orolder, these were one for both dependent variables. The severity rate was defined as the rate of patients who used a respiratory ventilator during
their hospital stay among all infected inpatients who were hospitalized the same week. The fatality rate was defined as the rate of inpatients whodied among all infected inpatients who were hospitalized the same week. The study period was from week 1 (Wave 1) through week 46, 2021 (Wave5). The parts highlighted in yellow are significant except for constant terms.

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patients or patients with mild symptoms who requiredno oxygen therapy were admitted optionally based on
medical criteria for high risk of exacerbation. They wereallowed to stay at home if the number of COVID-19
patients was increasing (20). Furthermore, in cases ofan explosive increase, the criteria of hospitalization forasymptomatic patients or patients with mild symptoms
who did not require oxygen therapy were probably
affected heavily by the scarcity of medical resources
or social situations such as support for their staying at
home and recuperation at home, aside from pure medical
criteria. Under these circumstances, we evaluated thepathogenicity of Alpha and Delta variants and vaccine
effectiveness in 2021.
Because the criteria of hospitalization for patientswith COVID-19 might have differed for the wave 5,
we defined the severity and fatality rates for inpatientswith oxygen therapy. From a medical perspective, thecriteria for oxygen therapy might be less affected bysocial situations such as scarcity of medical resources
than by criteria for hospitalization. Because the numberof inpatients with oxygen therapy was not publishedin general, we had to use database covering several
hospitals and thus covering a sufficient number of
inpatients potentially to evaluate of the severity of Alphaand Delta variants and vaccine effectiveness.
As shown in Table 2, the severity and fatality rates
for patients 65 years old or older showed negative
association with vaccination coverage and positive
association with the Delta variant. Findings indicate thatvaccination reduced the severity and that the proportionof the Delta variant increased severity, which findings
are consistent with those obtained from earlier studies (57,18,19).
However, some results were not consistent with thosereported from earlier studies. For example, the proportionof the Alpha variant and Delta variant were negatively
associated with the severity rate for patients younger than
65 years old. However, no report of the relevant literature
has described a study of lower pathogenicity for Alphaand Delta variants.
Some results in severity and fatality were notconsistent. This difference might indicate that patients
who finally died became more severely ill even in a few
weeks than patients who eventually survived, but who
received oxygen therapy.
For patients younger than 65 years old, theproportions of Alpha and Delta variant showedsignificantly negative association with the severity rate,
which means that the Alpha and Delta variants had
less pathogenicity for patients younger than 65 years
old. These results were unexpected. In Table 1, thehighest coefficient of determination for severity was
six weeks before. It might be too long a period from
infection to hospitalization for inpatients with oxygentherapy. Overall, coefficients of determination among
younger patients were lower than they were amongolder inpatients. In this sense, the estimation for severity
among younger inpatients might not be credible. Thismight be the reason that these results for patients younger
than 65 years old were unexpected. Furthermore, one
potential reason for the lower pathogenicity of Alphaand Delta variants might be differences of the age
distribution of patients with oxygen therapy between
waves for which the original strain was dominant andones for which Alpha and Delta variants were dominant.
One potential reason for the lower pathogenicity ofAlpha and Delta variants might be differences of age
distributions of patients with oxygen therapy amongwaves dominated by the original or Alpha and Delta
variants. The proportion of inpatients younger than 65
years old with oxygen therapy in the wave 3, which was
dominated by the original variant, was 28.0%. Their
proportion in the wave 4, which was dominated by theAlpha variant, was 43.9%. However, their proportion in
the wave 5, which was dominated by the Delta variant,became to be 78.7%. Consequently, the proportion of
inpatients younger than 65 years old with oxygen therapy
increased. If the severity and fatality rates were lower forpatients younger than 65 years old than for patients 65
years old or older, then the results of the Alpha and Delta
variants would not be significantly positive for patientsof all ages and for patients younger than 65 years old.
Whichever might be true, because the results were thoseof mixed association among Alpha and Delta variants
and pathogenicity, more sophisticated analyses using
more data must be done to reach a definitive conclusion.
An earlier study investigating the effectiveness of
vaccination against Alpha and Delta variants showedthat vaccination reduced hospitalizations or deaths.
Moreover, its effectiveness for patients 60 years old orolder was lower than that for patients younger than 60
years old in test-negative design (19). Another study
presented that the case fatality rate was decreasing, andJapan achieved high vaccination rate (21). In our study,
the vaccination coverage for all ages and for patients
65 years old or older was found to be significant, asshown in Table 2. These findings might depend on thevaccination strategy pursued in Japan. Vaccination for
healthcare workers started on 17 February 2021 (Week
7, 2021, Wave 3). Later, vaccination for patients 65
years old or older started on 12 April 2021 (Week 15,
2021, Wave 4). The proportion of that age group who
had at least one vaccination was about 80% by July, as
presented in Figure 5. The severity and mortality rates forpatients 65 years old or older appears to be declining in
Figures 3 and 4, possibly because the starting vaccination
was in the same period as the Delta variant emerged, aspresented in Figure 5. For all ages, vaccination coveragewith at least one vaccination was only 40–50% by lateAugust, when the Delta variant emerged. Vaccination
coverage was not associated significantly with severity or
fatality for patients younger than 65 years old, probably
because vaccination had started for patients 65 years(34)

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old or older. Most patients younger than 65 years old
were not vaccinated at that time. Results might reflect
vaccine effects for patients 65 years old or older. The age
distribution of inpatients and of confirmed patients cameto reflect more patients younger than 65 years old, forwhom the severity and fatality risk were lower than forother patients.
Definition of severity as extracorporeal membrane
oxygenation (ECMO) using instead of ventilator using
in this study might be possible potentially. However,limitation in capacity of ECMO system in a hospitalmight be tight especially in the latter study period. If so,severity should be downward biased during capacity of
ECMO system was insufficient. Therefore, we avoided
the definition of severity by ECMO using.
This study has three limitations. First, as explanatory
variables, we considered only the vaccination coverageand the proportions of Alpha and Delta variants. Other
factors such as treatment must also be considered. For
example, some types of drugs (22) such as remdesivir(23), dexamethasone (24), baricitinib (25), casirivimab/
imdevimab (26,27) and sotrovimab (28) were approved
for COVID-19 in the study period and more widely
administered in the latter period. These drugs may
decrease severity and fatality and thus create lower
severity and fatality in younger patients during themutated variants strain dominated. Unfortunately, we
cannot use some information of the administered drugin this study. Pathogenicity of the mutated strain andvaccine effectiveness controlled drug administration
remained as the next challenge.
Second, although we confirmed therepresentativeness of fatality cases from MIA data, theexact numbers of patients with oxygen therapy andventilation in Japan have not been published. Therefore,
the representativeness of case severity could not be
confirmed.
Third, the only targets of this study were hospitalized
patients, for whom "severity rates" and "fatality" might
differ from people of the general public. This point must
be interpreted carefully because MIA data did not include
patients who were not hospitalized.
Even in controlling inpatients' condition as necessary
for oxygen therapy, we confirmed that vaccination
reduced severity and fatality, and that the Alpha variant
and Delta variant might increase severity and fatality
among inpatients 65 years old or older, as earlier studies
have shown, though such a controlling patients' condition
had been never examined.

Health, Labour, and Welfare (grant number 20HA1005).
Conflict of Interest: The authors have no conflicts ofinterest to disclose.
References
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Acknowledgements
We acknowledge Mr. Masaya Nakadera and Mr. Masato
Koizumi, who prepared the database, and thank all
hospitals for submitting patient data.

13.

Funding: This work was supported by the Ministry of(35)

Sawakami T, Karako K, Song P, Sugiura W, Kokudo N.
Infectious disease activity during the COVID-19 epidemic
in Japan: Lessons learned from prevention and control
measures. Biosci Trends. 2021; 15:257-261.
Karako K, Song P, Chen Y, Karako T. An average ofnearly 200,000 new infections per day over a six-weekperiod: What is the impact of such a severe COVID-19
pandemic on the healthcare system in Japan? Biosci
Trends. 2022; 16:371-373.
Karako K, Song P, Chen Y, Tang W, Kokudo N. Overview
of the characteristics of and responses to the three waves
of COVID-19 in Japan during 2020-2021. Biosci Trends.
2021; 15:1-8.
Song P, Karako T. The strategy behind Japan's response to
COVID-19 from 2020-2021 and future challenges posedby the uncertainty of the Omicron variant in 2022. Biosci
Trends. 2022; 15:350-352.
Ong SWX, Chiew CJ, Ang LW, et al. Clinical andvirological features of SARS-CoV-2 variants of concern:a retrospective cohort study comparing B.1.1.7 (Alpha),
B.1.315 (Beta), and B.1.617.2 (Delta). Clin Infect Dis.
2022; 75:e1128-e1136.
Twohig KA, Nyberg T, Zaidi A, et al. Hospital admission
and emergency care attendance risk for SARS-CoV-2
delta (B.1.617.2) compared with alpha (B.1.1.7) variantsof concern: A cohort study. Lancet Infect Dis. 2022;
22:35-42.
Fisman DN, Tuite AR. Evaluation of the relative
virulence of novel SARS-CoV-2 variants: A retrospective
cohort study in Ontario, Canada. CMAJ. 2021;
193:E1619-E1625.
Chen Y, Cheng L, Lian R, Song Z, Tian J. COVID-19
v a c c i n e r e s e a r c h f o c u s s e s o n s a f e t y, e ff i c a c y,immunoinformatics, and vaccine production and delivery:
A bibliometric analysis based on VOSviewer. Biosci
Trends. 2021; 15:64-73.
Thompson MG, Burgess JL, Naleway AL, et al.
Prevention and attenuation of Covid-19 with the
BNT162b2 and mRNA-1273 vaccines. N Engl J Med.
2021; 385:320-329.
Ministry of Health, Labour and Welfare of Japan. Surveyof medical institutions. https://www.mhlw.go.jp/toukei/
saikin/hw/iryosd/20a/ (Accessed February 10, 2023). (inJapanese)
Kanazawa N, Tani T, Imai S, Horiguchi H, Fushimi K,
Inoue N. Existing data sources for clinical epidemiology:
Database of the national hospital organization in Japan.
Clin Epidemiol. 2022; 14:689-698.
Sato K, Mano T, Niimi Y, Iwata A, Toda T, Iwatsubo T.
The impact of COVID-19 pandemic on the utilization of
ambulatory care for patients with chronic neurologicaldiseases in Japan: Evaluation of an administrative claims
database. Biosci Trends. 2021; 15:219-230.
NHK WORLD-JAPAN. Tokyo's COVID-19 cases hit
all-time high despite state of emergency. https://www3.
nhk.or.jp/nhkworld/en/news/backstories/1725/ (Accessed
February 10, 2023).

GHM Open. 2023; 3(1):28-36.

www.ghmopen.com

14. The Japan Times. Japan changed its COVID-19
hospitalization policy: Here's what you need to know.
https://www.japantimes.co.jp/news/2021/08/06/national/suga-covid-19-hospitalization-policy-explainer/ (Accessed
February 10, 2023).
15. Ministry of Health, Labour and Welfare of Japan.
Published database on the number of patients diagnosed
as COVID-19 2023. https://www.mhlw.go.jp/stf/covid-19/
open-data.html (Accessed February 10, 2023). (inJapanese)
16. The Cabinet Secretariat. Vaccination against SARSCoV-2. https://www.kantei.go.jp/jp/headline/kansensho/
vaccine.html (Accessed February 10, 2023). (in Japanese)
17. A monitoring meeting in Tokyo. Conference material,h t t p s : / / w w w. b o u s a i . m e t ro . t o k y o . l g . j p / t a i s a k u /saigai/1013388/index.html (Accessed February 10, 2023).
(in Japanese)
18. Chia PY, Ong SWX, Chiew CJ, et al. Virological andserological kinetics of SARS-CoV-2 Delta variant vaccine
breakthrough infections: A multicentre cohort study. Clin
Microbiol Infect. 2022; 28:612.e1-612.e7.
19. Nasreen S, Chung H, He S, et al. Effectiveness of
COVID-19 vaccines against symptomatic SARS-CoV-2
infection and severe outcomes with variants of concern in
Ontario. Nat Microbiol. 2022; 7:379-385.
20. Ministry of Health, Labour and Welfare of Japan. Revisionof each measure (surveillance, measures to prevent the
spread of infection, medical system) in case of increasingin the number of COVID-19 patients in a region. https://www.jvnf.or.jp/newinfo/2019/20200301tsuchi.pdf(Accessed February 10, 2023). (in Japanese)
21. Karako K, Song P, Chen Y, Karako T. Trends in managing
COVID-19 from an emerging infectious disease to acommon respiratory infectious disease: What are thesubsequent impacts on and new challenges for healthcare
systems? Biosci Trends. 2022; 16:381-385.
22. Shao Y, Chen J, Lu H. Update: Drug treatment options
for coronavirus disease 2019 (COVID-19). Biosci Trends.
2021; 15:345-349.

23. Mozaffari E, Chandak A, Zhang Z, Liang S, Thrun M,
Gottlieb RL, Kuritzkes DR, Sax PE, Wohl DA, CascianoR, Hodgkins P, Haubrich R. Remdesivir treatment in
hospitalized patients with coronavirus disease 2019
(COVID-19): A comparative analysis of in-hospital allcause mortality in a large multicenter observational cohort.
Clin Infect Dis. 2022; 75:e450-e458.
24. RECOVERY Collaborative Group; Horby P, Lim WS, etal. Dexamethasone in hospitalized patients with Covid-19.
N Engl J Med. 2021; 384:693-704.
25. Marconi VC, Ramanan AV, de Bono S, et al. Efficacy
and safety of baricitinib for the treatment of hospitalised
adults with COVID-19 (COV-BARRIER): A randomised,double-blind, parallel-group, placebo-controlled phase 3
trial. Lancet Respir Med. 2021; 9:1407-1418.
26. Su J, Lu H. Opportunities and challenges to the useof neutralizing monoclonal antibody therapies for
COVID-19. Biosci Trends. 2021; 15:205-210.
27. Weinreich DM, Sivapalasingam S, Norton T, et al.
REGEN-COV antibody combination and outcomes in
outpatients with Covid-19. N Engl J Med. 2021; 385:e81.
28. Gupta A, Gonzalez-Rojas Y, Juarez E, et al. Early
treatment for Covid-19 with SARS-CoV-2 neutralizing
antibody sotrovimab. N Engl J Med. 2021; 385:19411950.
---Received April 16, 2023; Revised June 12, 2023; Accepted
July 13, 2023.
Released online in J-STAGE as advance publication July 16,
2023.
*Address correspondence to:
Shingo Mitsushima, Center for Field Epidemic Intelligence,
Research and Professional Development, National Institute of
Infectious Diseases, 1-23-1 Toyama, Shinjuku-ku, Tokyo 1628640, Japan.
E-mail: mitsushi@niid.go.jp(36)

Brief Report

GHM Open. 2023; 3(1):37-41.
DOI: 10.35772/ghmo.2022.01007

Visualization of aerosol spread using a smoke tester during tracheal
intubation performed in an operating room
Kohshi Hattori1,*, Asako Eriguchi2, Mayuko Omori1, Osamu Nagata1
12

Department of Anesthesiology, National Center Hospital of Global Health and Medicine, Tokyo, Japan;
Department of Dental Anesthesiology, Tokyo Dental College, Tokyo, Japan

Abstract: Tracheal intubation is an essential procedure in the induction of general anesthesia; however, it isalso a main source of infectious aerosols such as severe acute respiratory virus 2 (SARS-CoV-2). For protection
from infectious aerosols, an air conditioning system which provides continuous laminar air flow from the ceilingand a local isolating device are widely used in typical operating rooms. However, how aerosols spread in an
actual operating room has not been visualized, especially during tracheal intubation. In this study, we observed
the spread of aerosols under several circumstances. To recreate the scenario of general anesthesia induction, we
substituted aerosol spray with smoke from a smoke tester device in the mouth of a human body model placed on
the operating table. Then we measured the maximum height of aerosol spread every second for 9 seconds. To verify
the contribution of air conditioning and an isolating device, we compared four situations based on their presence orabsence. The maximum height of aerosol spread was significantly lower in the presence of laminar air flow fromthe ceiling. An isolating device contributed to initially enclosing the aerosol; however, some aerosol leaked anddiffused depending on the air flow outside the device. During tracheal intubation in typical operating room, airconditioned laminar air flow can contribute to prevent infectious aerosol spread, and an isolating device can provide
supplementary protection.
Keywords: aerosol infection, tracheal intubation, laminar air flow, smoke tester, operating room

Introduction

these reports were based upon several presuppositions,so the results might not necessarily describe actual
aerosol spread and may overlook unexpected factors.
In the occupational health field, air flow is commonlychecked using a smoke tester, which can provide
visible white smoke. This approach can elucidate thegeneral condition of aerosol spread instantly with all
surrounding factors considered.
In our central operating department, aerosol
infection of COVID-19 has been a great threat (4),because operating room activities cannot be suspended
and the room itself can be an epicenter of an infectious
outbreak. In a modern operating room, purified laminar
air flow is constantly provided from the ceiling to thefloor. Additionally, to protect from droplet infection,
medical staff undertake standard precautions andoccasionally use an isolating device. However, whether
such protective gadgets can actually control aerosol
spread is not fully understood.
Therefore, we duplicated the scenario of performing
tracheal intubation in an air-conditioned operating roomwith an isolating device, and visualized how exhalation
can spread by substituting the aerosol for test smoke.

Tracheal intubation is an essential procedure in
general anesthesia; however, it exposes medical
staff to infectious aerosols derived from the patient's
exhalation, which can be a potential risk of respiratory
infections, such as that caused by SARS-CoV-2 (1).
Therefore, to protect staff from aerosol infection, it isvery important to elucidate how aerosols spread acrossan operating room.
The most fundamental prevention from infectionof coronavirus infectious disease, emerged in 2019
(COVID-19) is hand hygiene (2), however, in somecases such as tracheal intubation, isolation of aerosol
is attempted (3). In fact, plenty of cluster cases of
COVID-19 infection occurred not only in restaurants
but also in medical settings, the main cause of whichmight be from aerosol droplets. Hence, the most basic
characteristics of aerosol infection, in other words, how
the actual aerosol spread has not been fully visualized
and reported.
Several previous studies have reported simulations
with moving images of aerosol spread from coughing
patients calculated using supercomputers; however,(37)

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Materials and Methods
Experiment conditions
We performed this study in the operating room in theCentral Operation Center in the Center Hospital of
National Center of Global Health and Medicine from
July 2020 to February 2021. The cleanliness of theoperating room was equivalent to class 2 of healthcare
engineering. association of Japan standard-02-2013(HEAS-02-2013), and air was circulated 15 times perhour with laminar air flow from the ceiling to the floor.
We replicated aerosol release from tracheal
intubation as follows; first, we set a human bodymodel (Laerdal® Airway Management Trainer, Laderal,
Stavanger, Norway) on the operating table; second,
we substituted test smoke for the patient's exhalation
during manual ventilation using a smoke tester (Smoke
tester kit 500, Gastec Co., Ayase, Kanagawa, Japan),which can provide constant amounts of white smoke(and is usually used for air conditioning managementin occupational health); third, we setup an isolating
device, shown in Figure 1 (available elsewhere), which
was originally used in our hospital. The device wasplaced between the human body model and a memberof the medical staff, so as to cover the patient's face
except for two small holes positioned on both sides
caudally for arm access to perform tracheal intubation.
We recorded aerosol spread using a high-resolution
video camera (RX-100M5A, SONY, Japan) from theleft side of the operating table.

reviewers performed evaluations of the maximum
height of the smoke with all images randomized to
avoid bias based on the conditions and reviewers.
We evaluated the spread of smoke by its maximum
height because we especially wanted to monitor how
the spread of aerosols can be suppressed by laminar
air flow, from the ceiling of the operating room, in
conjunction with an isolating device. The obtained data
are expressed as average ± standard deviation with one
way ANOVA for every condition using the R project for
statistical computing.

Experimental protocol and analysis

Results and Discussion

We observed the air flow in four different conditions
based upon whether air conditioning and an isolating
device were provided:

The change over time of the highest point of aerosol
diffusion in each condition is shown in Figure 2 andTable 1. The characteristic diffusion of aerosol in eachcondition is shown in Figure 3.
The presence of laminar air flow significantly
contributed to suppress the diffusion of aerosol
throughout the experiment. In addition, under laminar
air flow circumstances, no additional effect wasobserved regardless of the presence of the isolation
device. On the other hand, without laminar air flow, theisolation device significantly suppressed the diffusionof aerosol at first, however, over time, the aerosols
leaked outside the device and diffused.
We visualized the distribution of aerosol in an
operating room effectively and conveniently using our
test smoke model. It strongly suggests that continuous
laminar air flow from the ceiling plays a major role in
the evacuation of aerosol.
In contrast, use of an isolating device provided
mixed effects. It completely enclosed the aerosol
derived from the cough reflex at an early phaseregardless of the presence of laminar air flow. However,the leaked aerosol diffused depending on the presence

(−)
(−)
(+)
(+)

Figure 1. An isolating device originally used in the
National Center Hospital of Global Health and Medicine(height, 50 cm × length, 30 cm × width, 45 cm).

Condition 1: laminar air flow (+), isolating device
Condition 2: laminar air flow (−), isolating device
Condition 3: laminar air flow (+), isolating device
Condition 4: laminar air flow (−), isolating device

All experiments were performed after the air
conditioning system had worked sufficiently or wascompletely stopped. We sprayed a constant amountof smoke from the right corner of the model's mouth
duplicating a patient's exhalation, and recorded,from the side of the operating table, how the smoke
spread across the operating room for 9 seconds. Eachmeasurement was performed 5 times per condition.
Next, we extracted still images for every second
from the recorded moving images and 2 independent(38)

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Figure 2. Distribution of aerosol in each condition. Condition 1: laminar air flow (+), isolating device (−); Condition 2:
laminar air flow (−), isolating device (−); Condition 3: laminar air flow (+), isolating device (+); Condition 4: laminar air flow (−),
isolating device (+).

of air flow outside the device, and by contrast,
contaminated aerosol inside the device was trapped fora long time.
The risk of aerosol infection is widely known
from previous studies (4). However, with the use ofvisualized smoke, our study shows that there is no
exhaust route for the isolated aerosols, which leak fromthe edge of the isolating box at the very early stage of
inhalation.
These findings suggest that an air-conditioned
operating room is suitable for infection-safe tracheal
intubation, with recommended addition of an isolating
device in the case of a risk of convulsive exhalation,such as during a cough reflex and mask ventilation.
Tracheal intubation performed without an air
conditioning system or solely using an isolating device
might place medical staff at potential risk of exposure
to patient-derived aerosols.
In our study, we used a smoke tester, which is
widely used in industrial hygiene departments, tovisualize aerosol spread from a patient. The smoke
tester can provide a constant amount of smoke

containing particles with similar size and characteristics
to exhaled aerosols. Moreover, it has excellent visual
recognizability and low toxicity. Thus, this smoke tester
model is suitable for visually evaluating the distributionof aerosols in other areas outside of the operating room.
The effectiveness of air conditioning in theoperating room depends on several factors, including
the size of the room and arrangement of equipment
for surgery, which might unexpectedly interrupt
air conditioning. Therefore, this practical air flow
simulation system may contribute to preventing
aerosol-based infection at clinical sites. Conversely, anisolation device blocked laminar air flow completely on
the patient, resulting in aerosol drifting in the isolatedarea during measurement. This result suggests that
we should pay special attention to aerosol infection"inside" the isolated area and "recurrence" of aerosol
diffusion when removing the device. Nevertheless,isolating devices can be effective in suppressing theearly phase of aerosol diffusion derived from aerosol
spouting, such as that due to the cough reflex; however,
our result showed that for subsequent control of aerosol(39)

< 0.001
0.163< 0.001< 0.001
0.611< 0.001< 0.001
0.033< 0.001< 0.001
0.032< 0.001< 0.001
0.184< 0.001< 0.001
0.002< 0.001< 0.001
0.215< 0.001< 0.001< 0.0010.015< 0.001
0.524
0.002< 0.001< 0.001
0.113< 0.0010.396
0.013< 0.001< 0.001
0.646

Figure 3. Characteristic diffusion of aerosol in eachcondition. Condition 1: laminar air flow (+), isolating device(−); Condition 2: laminar air flow (−), isolating device (−);
Condition 3: laminar air flow (+), isolating device (+);
Condition 4: laminar air flow (−), isolating device (+). The
aerosol is confined by laminar air flow (yellow arrows), anddiffuses without the presence of laminar air flow (red arrows).
Inside the isolated area, the aerosol drifts with/without thepresence of laminar air flow (white stars).

< 0.001
0.15
0.85< 0.001< 0.001
1
0.029
0.367
1
1
0.007
0.098

< 0.001
0.208
0.099< 0.001< 0.0011

167.7 ± 172.7
938.0 ± 184.4
384.2 ± 5.9
773.9 ± 271.2< 0.001
162.4 ± 156.8
992.6 ± 188.2
383.7 ± 5.5
751.6 ± 283.2< 0.001
283.9 ± 140.5 277.4 ± 181.7 236.2 ± 156.2 213.6 ± 162.4
940.6 ± 177.1 1003.5 ± 162.8 1044.0 ± 177.7 1046.0 ± 183.7
383.7 ± 5.5
383.7 ± 5.5
383.7 ± 5.5
383.7 ± 5.5
542.1 ± 156.4 618.0 ± 234.6 725.3 ± 288.1
476.3 ± 86.8
< 0.001< 0.001< 0.001< 0.001
273.9 ± 96.6
591.9 ± 151.3
368.2 ± 17.3
341.5 ± 20.1
< 0.001
138.7 ± 14.9
181.0 ± 39.0
165.9 ± 41.7
128.1 ± 21.8
0.0031

290.1 ± 118.9
787.0 ± 146.9
383.7 ± 5.48
408.9 ± 44.0
< 0.001

www.ghmopen.com

diffusion, laminar air flow is an essential factor and therole of the isolating device remains limited.
Computer simulation is another effective methodof elucidating aerosol behavior. It has superior
reproducibility and can provide quantitative evaluations.
However, these simulations require a supercomputer,the availability of which is often limited. Additionally,it also requires all preconditions to be converted
to numerical parameters, some of which might not
be quantized properly or remain unintentionallyoverlooked. By contrast, observing air flow using asmoker tester is relatively easy and inexpensive, which
can help manage prevention of aerosol-based infection.
In conclusion, our smoke tester model is a simple
and practical tool for visualizing actual air flow inan operating room with a potential risk of aerosol
infection. Based upon our results, we recommend that
infection-safe tracheal intubation should be performed
in facilities with a laminar air flow system installed,
such as in an operating room.

Average ± SD (Condition 1)
Average ± SD (Condition 2)
Average ± SD (Condition 3)
Average ± SD (Condition 4)
p value (ANOVA)p value (Bonferroni test)
Condition 1 vs. 2 (air-condition on/off without isolation device)
Condition 1 vs. 3 (isolation device on/off with air-condition)
Condition 1 vs. 4 (air-condition vs isolation device)
Condition 2 vs. 3 (both on/off)
Condition 2 vs. 4 (isolation device on/off without air-condition)
Condition 3 vs. 4 (air-condition on/off with isolation device)2
1
Seconds

Table 1. Qualitative description and maximum height of aerosol spread in conditions 1 to 4

3

4

5

6

7

8

9

GHM Open. 2023; 3(1):37-41.

Funding: This study was funded by Japan Society for
the Promotion of Science (JP20K17776).
Conflict of Interest: The authors have no conflicts ofinterest to disclose.

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References
1.

2.

3.

4.

Sommerstein R, Fux C, Vuichard-Gysin D, Abbas M,
Marschall J, Balmelli C, Troillet N, Harbarth S, Schlegel
M, Widmer A; Swissnoso. Risk of SARS-CoV-2
transmission by aerosols, the rational use of masks,and protection of healthcare workers from COVID-19.
Antimicrob Resist Infect Control. 2020; 9:100.
Rundle CW, Presley CL, Militello M, Barber C,
Powell DL, Jacob SE, Atwater AR, Watsky KL, Yu
J, Dunnick CA. Hand hygiene during COVID-19:
Recommendations from the American Contact Dermatitis
Society. J Am Acad Dermatol. 2020; 83:1730-1737.
Tang S, Mao Y, Jones RM, Tan Q, Ji JS, Li N, Shen J, Lv
Y, Pan L, Ding P, Wang X, Wang Y, MacIntyre CR, Shi
X. Aerosol transmission of SARS-CoV-2? Evidence,
prevention and control. Environ Int. 2020; 144:106039.

Dexter F, Parra MC, Brown JR, Loftus RW. Perioperative
COVID-19 defense: An evidence-based approach for
optimization of infection control and operating room
management. Anesth Analg. 2020; 131:37-42.

---Received July 31, 2022; Revised October 30, 2022; Accepted
November 13, 2022.
Released online in J-STAGE as advance publication
November 28, 2022.
*Address correspondence to:Kohshi Hattori, Department of Anesthesiology, National
Center Hospital of Global Health and Medicine, 1-21-1
Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
E-mail: khatsutori-tky@umin.org(41)

Brief Report

GHM Open. 2023; 3(1):42-46.
DOI: 10.35772/ghmo.2023.01002

Clinical features of cervical cancer at a national cancer center inPhnom Penh, Cambodia: A descriptive cross-sectional study
Aya Tanaka1, Linka Koun2, Rei Haruyama1,*, Kyna Uy2, Maryan Chhit2, Lumpiny Kim2, Noriko Fujita1, Yutaka Osuga3,
Tadashi Kimura4, Kanal Koum5
1

Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan;
Department of Obstetrics and Gynecology, Khmer-Soviet Friendship Hospital, Phnom Penh, Cambodia;
3
Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan;
4
Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan;
5
Cambodian Society of Gynecology and Obstetrics, Phnom Penh, Cambodia.
2

Abstract: The clinical features of newly diagnosed cervical cancer in Cambodia are poorly documented. We aimed
to describe the histologic type and stage distributions of newly diagnosed cervical cancer patients at the Khmer Soviet
Friendship Hospital in Phnom Penh, which is one of the two national cancer centers in Cambodia. A descriptive crosssectional study was conducted using the Gynecologic Test Registry of the gynecology department between January andDecember 2019. In 2019, 351 women were histologically diagnosed with cervical cancer, representing approximately
one-third of the estimated total cases occurring in the country. The mean age at presentation was 54.7 years. The
histologic type distribution was largely consistent with other Asian countries, with squamous cell carcinoma accounting
for 83.8%, followed by adenocarcinoma (15.4%). Among 309 patients with recorded staging information, 57.6% wereadvanced-stage cancers (i.e. stage IIB or higher). Raising awareness of early symptoms of cervical cancer, increasing
access to cancer diagnosis, and better recording of patients’ clinical information are important to improve cervicalcancer management in Cambodia.
Keywords: uterine cervical neoplasms, delayed diagnosis, neoplasms by histologic type, Cambodia

Introduction

recognized by many women. In a 2016 populationbased survey, the percentage of women aged 18–69
years who have ever had cervical cancer screening was
only 11.3% (5). Often, women visit health facilities
only when they have recurring symptoms of abnormal
vaginal bleeding. The exact number of women affectedwith the cancer and their clinical features, including
stage at diagnosis, remain unknown due to a lack ofcancer registration system. Previous studies on cervicalcancer in Cambodia are limited to those on cancer
awareness and the prevalence of HPV and cervical
dysplasia (6-9).
The Khmer-Soviet Friendship Hospital (KSFH)
is a national cancer center located in Phnom Penh,the capital city of Cambodia. It is one of four public
hospitals with pathology services and one of two withcancer treatment capacity. Women suspected of having
cervical cancer are referred to a gynecology department
across the country. In this study, we aimed to describe
the histologic type and stage distributions of newly
diagnosed cervical cancer patients presenting at the
KSFH.

Cervical cancer is caused by persistent infection
with oncogenic human papillomavirus (HPV), which
progresses slowly from precancerous lesions toinvasive carcinoma (1). If detected at an early stageof progression, it is more likely treatable with good
survival prognosis (2). However, in countries without
effective cervical cancer screening and early diagnosis
programs, patients are often diagnosed as advancedstage cancer with high mortality.
In Cambodia, cervical cancer is one of the leading
cancers in women with an estimated 1,100 new casesand 600 deaths in 2020 (3). These numbers correspondto an age-standardized incidence rate of 14.0 per
100,000 and mortality rate of 8.3 per 100,000, both ofwhich are higher than global estimates. The Cambodian
Ministry of Health has placed cervical cancer as one ofits priorities for non-communicable disease agenda, andvaginal inspection-based screening is offered to womenin some health centers and hospitals (4). However, thescreening test is not yet freely available and widely(42)

GHM Open. 2023; 3(1):42-46.

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Materials and Methods

Table 1. Sociodemographic and clinical characteristics ofthe study sample

Study design and sample

Characteristics
Total
Age, years
Mean
30–39
40–49
50–59
60–69
≥ 70
Parity0
0–3≥4
Not reported
Place of residence
Phnom Penh or Kandal
Adjacent province of Kandal†
Distant province
Histopathology result of cervical biopsy
Squamous cell carcinoma
Adenocarcinoma
Small cell carcinoma
Undifferentiated carcinoma
Stage at diagnosis
I
IA
IB
II
IIA
IIB
Unknown subclassification
III
IIIA
IIIB
Unknown subclassification
IV
IVA
IVB
Unknown subclassification
Unknown stage

This descriptive cross-sectional study was conductedusing the Gynecologic Test Registry of the gynecology
out-patient department of the KSFH between January
and December 2019, before the COVID-19 pandemic.
This registry compiled information on patients who
underwent gynecological tests, such as cytology,
colposcopy, and biopsy. In addition to patient name,identification number, age, parity, place of residence,and type of test received, the registry also included test
results, clinical diagnosis, and stage at diagnosis formalignant cases. For cervical cancer patients, staging
was recorded using the 2009 International Federation of
Gynecology and Obstetrics (FIGO) staging system (10).
We extracted data of histologically confirmed cervicalcancer patients for this study.
Data analysis
Descriptive statistics were performed to examine thesociodemographic and clinical characteristics of thestudy participants. As in previous studies, we defined
FIGO stage IA to IIA patients as early-stage cancer,
and FIGO stage IIB or higher as advanced-stage cancer(11-14). At the KSFH, early-stage cancers are usuallyoperated surgically with or without adjuvant externalbeam radiotherapy and chemotherapy (brachytherapy
is being planned for installation, but not yet available).
Excluding cases with missing staging information,
univariate logistic regression analysis was performed
to examine factors associated with advanced-stage
presentation. Data analysis was performed using Stata/
SE 16.1 (Stata Corporation, College Station, TX, USA).
Statistical significance was set at p ≤ 0.05. Ethicalapproval was obtained from the Cambodia National
Ethics Committee for Health (312 NECHR) and Ethics
Committee of the National Center for Global Healthand Medicine in Japan (NCGM-G-004021-00). Since
the study used an existing database, informed consent
was substituted by making research information widely
available and ensuring that women had the opportunity
to opt out of the study.

n (%)
351
.
54.7 ± 9.6
20 (5.7)
77 (21.9)
148 (42.2)
80 (22.8)
26 (7.4)
30 (8.6)
136 (38.8)
181 (51.6)
4 (1.1)101 (28.8)
126 (35.9)
124 (35.3)
294 (83.8)
54 (15.4)
2 (0.6)
1 (0.3)2 (0.6)48 (13.7)
81 (23.1)
78 (22.2)
1 (0.3)38 (10.8)
44 (12.5)
6 (1.7)3 (0.9)1 (0.3)7 (2.0)42 (12.0)†

Prey Veng, Kampong Cham, Kampong Chhnang, Kampong Speu, or
Takeo

cervical biopsy, and pathological results were recorded.
Squamous cell carcinoma (SCC) accounted for 83.8%of the cases, followed by adenocarcinoma (15.4%),
small cell carcinoma (0.6%), and undifferentiatedcarcinoma (0.3%). Staging information was recordedfor 309 patients (88.0%). Among them, 57.6% wereadvanced-stage cancers (Table 2). The proportions ofadvanced-stage cancer were high in women who wereaged 30–39 years (68.4%), over 70 years (65.2%), had
1–3 children (61.2%), or lived in adjacent provinces of
Kandal (61.4%); however, no statistically significant
association was observed.
This study examined the histologic type and stage
distributions of newly diagnosed cervical cancer
patients that presented to the KSFH in 2019. Although
this was a single-center analysis, it is the first to
describe the clinical features of cervical cancer at anational cancer center in Cambodia. Overall, there were351 patients, representing approximately one-third of
the estimated total cases occurring in the country (3).
Cervical cancer was more commonly diagnosed among

Results and Discussion
A total of 351 histologically confirmed cervical cancer
patients were analyzed in this study (Table 1). The
mean age at presentation was 54.7 ± 9.6 years, ranging
between 30–81 years. Women presented from acrossthe country, with 28.8% from Phnom Penh or Kandal(i.e., a province surrounding Phnom Penh), 35.9%
from the five adjacent provinces of Kandal, and theremaining 17 distant provinces located over 3–10
h drive to Phnom Penh. All the patients underwent(43)

GHM Open. 2023; 3(1):42-46.

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Table 2. Advanced-stage presentation and its associated factors
Advanced-stage presentation
Characteristics
Total
Age
30–39
40–49
50–59
60–69
≥ 70
Parity0
1–3≥4
Not reported
Place of residence
Phnom Penh or Kandal
Adjacent province of Kandal†
Distant province
Histologic typeSquamous cell carcinoma
Non-squamous cell carcinoma

Crude odds ratio (95% CI)

p value

6 (31.6)
28 (41.2)
53 (40.5)
36 (52.9)
8 (34.8)

1.5 (0.5–4.1)
1.0 (0.5–1.8)
1
0.6 (0.3–1.1)
1.3 (0.5–3.2)

0.5
0.9
NA
0.1
0.6

12 (44.4)
74 (61.2)
90 (57.0)
2 (66.7)

15 (55.6)
47 (38.8)
68 (43.0)
1 (33.3)1
2.0 (0.8–4.6)
1.7 (0.7–3.8)
2.5 (0.2–31.0)

NA
0.1
0.2
0.5

51 (58.0)
70 (61.4)
57 (53.3)

37 (42.0)
44 (38.6)
50 (46.7)

1
1.2 (0.7–2.0)
0.8 (0.5–1.5)

NA
0.6
0.5

150 (58.4)
28 (53.9)

107 (41.6)
24 (46.1)

1
0.8 (0.5–1.5)

NA
0.5

Yes n (%)

No n (%)

178 (57.6)

131 (42.4)

13 (68.4)
40 (58.8)
78 (59.5)
32 (47.1)
15 (65.2)†

Prey Veng, Kampong Cham, Kampong Chhnang, Kampong Speu, or Takeo. CI: confidence interval

A systematic review of 25 studies examining thedeterminants of advanced-stage presentation foundthat women with no formal education and thoseresiding in rural areas were significantly more likely
to present in the advanced stage than their counterparts(19). However, in our study, these factors showedno association. Lack of association with place ofresidence was contrary to our expectation, because
public hospitals with pathology laboratories are only
located in Phnom Penh and patients have to visit oneof these hospitals themselves, including the KSFH, fora biopsy and pathological examination. An explanation
may be that women suspected of having advancedstage cervical cancer but living in rural provinces may
be unable to reach the KSFH for definitive diagnosis
and treatment. In contrast, women suspected of having
early-stage cervical cancer and living in Phnom Penh
and Kandal may visit other hospitals from the outset,
including those in neighboring countries, such as
Thailand, Singapore, and Vietnam.
This study utilized a clinical registry introduced
through a cervical cancer prevention and control projectby professional societies in Cambodia and Japan (20). It
contained minimum possible information of all patients
receiving gynecologic tests at the KSFH. Although
we examined the clinical features of newly diagnosed
cervical cancer patients presenting at a national cancer
center for the first time, there are several limitations.
First, data on patients' education, occupation, householdincome, comorbidity, and history of screening were
not available in the registry, and we could not fully
examine the baseline characteristics of the patients, aswell as the adjusted effect of these factors on advancedstage presentation. Second, we were unable to identify
whether the patients underwent any treatment because
this information was not included in the registry,

women in their 50s. Histologically, SCC accounted
for 83.8% of the cases, followed by adenocarcinoma(15.4%). Among patients with recorded staging
information, 57.6% were in their advanced stage (i.e.,
stage IIB or higher).
Cervical biopsy and pathological examination arenecessary to establish a definitive diagnosis of cancer
and identify the histologic type (15). This analysis
confirmed that all suspected and clinically diagnosed
cervical cancer patients underwent biopsy at the KSFH.
The proportion of SCC was largely consistent withstudies from Thailand (71.1%), China (74.5%), andJapan (72.6%) (16-18).
The proportion of advanced-stage cancer (i.e., stage
IIB or higher) was unexpectedly lower than that instudies conducted in similar settings of lower-middle
income countries. The advanced-stage cervical cancer
presentation was reported to be 64% of 202 patients at
a referral hospital in Tanzania, 78% of 246 at a regional
cancer center in India, and 81% of 110 at two referral
hospitals in Nepal (11,13,14). This may be due tosuccessful early referrals of suspected cervical cancer
patients from district hospitals and non-governmentalorganization clinics to the KSFH. However, this may
also be because many of the patients we excluded
due to missing information on staging (12% of 351
patients) may be advanced-stage cancers. The KSFH
is a public hospital that serves many patients with low
socioeconomic status, and some women refuse to get
tested and treated due to fear of procedures and highhealthcare costs. Pelvic examination, transvaginalultrasound, and renal ultrasound are usually performed;
however, computed tomography and magnetic
resonance imaging are rare (< 10%), thereby limiting
the evaluation of lymph nodes, local extension, andsystemic spread.

(44)

GHM Open. 2023; 3(1):42-46.

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and individual medical records do not exist at thegynecology department of KSFH. We attempted togo through the surgical records and pathology resultsof surgical specimens for early-stage patients, but wefound that personal identification numbers are often
incorrectly recorded, or two or more numbers exist
for one person. It was also difficult to identify patients
who underwent radiotherapy or chemotherapy at the
oncology department or those who were referredelsewhere. It is critical to improve the recording ofeach patient's clinical information to better understandthe current situation in the management of cervicalcancer and formulate strategies to reduce preventable
deaths. This will become even more important withthe government's recent move to scale-up cervicalcancer screening, as screen-detected invasive cancer
will surely increase in previously unscreened large
populations (2,21).
In conclusion, our study showed that over halfof women presented at an advanced stage. Raisingawareness of early symptoms of cervical cancer,
increasing access to cancer diagnosis, and better
recording of patients' clinical information are important
to improve cervical cancer management in Cambodia.

7.

Funding: This work was supported by Japan
International Cooperation Agency Partnership Program,by National Center for Global Health and Medicine
Intramural Research Fund (20A08), and by Health
Labour Sciences Research Grant (23EA3201).

13.

Conflict of Interest: The authors have no conflicts ofinterest to disclose.

15.

8.

9.

10.
11.

12.

14.

16.

References
1.
2.

3.
4.

5.

6.

Schiffman M, Castle PE, Jeronimo J, Rodriguez AC,
Wacholder S. Human papillomavirus and cervical cancer.
Lancet. 2007; 370:890-907.
World Health Organization. WHO Framework forstrengthening and scaling-up of services for the
management of invasive cervical cancer. https://www.
who.int/publications/i/item/9789240003231 (accessed
January 20, 2023)
International Agency for Research on Cancer, Global
Cancer Observatory: Cancer Today. 2020. https://gco.
iarc.fr/today/ (accessed June 6, 2023).
Ministry of Health Cambodia. National Strategic Planfor the Prevention and Control of Noncommunicable
Diseases 2022-2030, Ministry of Health Cambodia,
Phnom Penh, Cambodia, 2022; pp.18-39.
University of Health Sciences Cambodia, Ministry of
Health Cambodia. Prevalence of Non-Communicable
Diseases Risk Factors in Cambodia (STEPS survey2016). Ministry of Health Cambodia, Phnom Penh,
Cambodia, 2016; pp.81-82.
Touch S, Oh JK. Knowledge, attitudes, and practices
toward cervical cancer prevention among women in
Kampong Speu Province, Cambodia. BMC Cancer.
2018; 18:294.

17.

18.

19.

20.

(45)

Soeung SC, Komagata T, Darapheack C, Kikuchi S,
Obara H, Haruyama R, Kanal K, Fujita N, Yanaihara
N, Okamoto A, Kumura T. Knowledge and practice for
cervical cancer among female primary school teachers inPhnom Penh, Cambodia: A cross-sectional phone-based
survey. GHM Open. 2022; 2:25-30.
Ueda Y, Kawana K, Yanaihara N, et al. Development
and evaluation of a cervical cancer screening system in
Cambodia: A collaborative project of the CambodianSociety of Gynecology and Obstetrics and Japan Societyof Obstetrics and Gynecology. J Obstet Gynaecol Res.
2019; 45:1260-1267.
Thay S, Peprah SA, Hur C, Tramontano AC, Maling
E, Goldstein AT, Hong C. Prevalence of cervical
dysplasia in HIV-positive and HIV-negative women at
the Sihanouk Hospital Center of HOPE, Phnom Penh ,Cambodia. Asian Pac J Cancer Prev. 2019; 20:653-659.
Pecorelli S. Revised FIGO staging for carcinoma of thevulva, cervix, and endometrium. Int J Gynaecol Obstet.
2009; 105:103-104.
Mlange R, Matovelo D, Rambau P, Kidenya B. Patientand disease characteristics associated with late tumour
stage at presentation of cervical cancer in northwestern
Tanzania. BMC Womens Health. 2016; 16:5.
Dunyo P, Effah K, Udofia EA. Factors associated withlate presentation of cervical cancer cases at a district
hospital: A retrospective study. BMC Public Health.
2018; 18:1156.
Gyenwali D, Pariyar J, Onta SR. Factors associated withlate diagnosis of cervical cancer in Nepal. Asian Pac J
Cancer Prev. 2013; 14:4373-4377.
Senapati R NB, Kar S K, Dwibedi B. Why cervicalcancer cases are being lately diagnosed in Eastern India?
An analysis of the associated factors. Indian Journal of
Obstetrics and Gynecology Research. 2016; 3:418-421.
Bhatla N, Aoki D, Sharma DN, Sankaranarayanan R.
Cancer of the cervix uteri: 2021 update. Int J Gynaecol
Obstet. 2021; 155 Suppl 1:28-44.
Rudtanasudjatum K, Charoenkwan K, Khunamornpong
S, Siriaunkgul S. Impact of histology on prognosis ofpatients with early-stage cervical cancer treated withradical surgery. Int J Gynaecol Obstet. 2011; 115:183187.
Meng Y, Chu T, Lin S, Wu P, Zhi W, Peng T, Ding W,
Luo D, Wu P. Clinicopathological characteristics andprognosis of cervical cancer with different histologicaltypes: A population-based cohort study. Gynecol Oncol.
2021; 163:545-551.
Nagase S, Ohta T, Takahashi F, Yamagami W, Yaegashi N,
Board Members of the 2020 Committee on Gynecologic
Oncology of the Japan Society of Obstetrics andGynecology. Annual report of the Committee on
Gynecologic Oncology, the Japan Society of Obstetrics
and Gynecology: Annual Patient Report for 2018 andAnnual Treatment Report for 2013. J Obstet Gynaecol
Res. 2022; 48:541-552.
Tekalign T, Teshome M. Prevalence and determinants oflate-stage presentation among cervical cancer patients, asystematic review and meta-analysis. PLoS One. 2022;
17:e0267571.
Kanal K, Fujita N, Soeung SC, Sim KL, Matsumoto
Y, Haruyama R, Banno K, Kimura T. The cooperation
between professional societies contributes to the capacity
building and system development for prevention andcontrol of cancer in low- and middle-income countries:

GHM Open. 2023; 3(1):42-46.

www.ghmopen.com

14, 2023.

the practice of Cervical Cancer Prevention and Control
Project in Cambodia. Glob Health Med. 2020; 2:48-52.
21. Elit L, Haruyama R, Gatti A, Howard SC, Lam CG,
Fidarova E, Angioli R, Cao X, Trapani D, Ilbawi
A. Examining policy cohesion for cervical cancer
worldwide: Analysis of WHO country reports. ESMO
Open. 2020; 5:e000878.

Released online in J-STAGE as advance publication June 18,
2023.
*Address correspondence to:Rei Haruyama, Bureau of International Health Cooperation,
National Center for Global Health and Medicine, 1-21-1
Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
E-mail: rharuyama@it.ncgm.go.jp---Received April 6, 2023; Revised June 9, 2023; Accepted June(46)

Case Report

GHM Open. 2023; 3(1):47-50.
DOI: 10.35772/ghmo.2023.01003

Psychodynamic therapy for adverse childhood experience in a
hospitalized girl with attention deficit hyperactivity disorder
Kaori Sugimoto1, Toshinari Kurokouchi1, Rena Shinohara1, Yuuki Sakoh1, Maiko Odaka1, Hikaru Sunakawa2,
Shuichi Tanese3, Manao Seto1, Masahiro Ishida1,4, Yuta Yoshimura5, Kotoe Itagaki6, Ikuhiro Harada4, Saori Inoue1,7,
Yuki Hakoshima1, Kumi Inazaki1, Yuki Mizumoto1,8, Masahide Usami1,8,*
1Department of Child and Adolescent Psychiatry, Kohnodai Hospital, National Center for Global Health and Medicine, Ichikawa, Japan;
Department of Pediatrics, Shimoshizu Hospital, Chiba, Japan;
3
Matsudo city Child Develpoment Center, Matsudo, Japan;
4
Department of Social Work, Kohnodai Hospital, National Center for Global Health and Medicine, Ichikawa, Japan;
5
Department of Psychiatry, Department of Psychiatry, Faculty of Medicine, Fukuoka University, Fukuoka, Japan;
6
Department of Clinical Psychology, Kohnodai Hospital, National Center for Global Health and Medicine, Ichikawa, Japan;
7
Department of Neuropsychiatry, Ehime University Graduate School of Medicine, Toon City, Japan;
8
Clinical Center for Children's Mental Health, Kohnodai Hospital, National Center for Global Health and Medicine, Ichikawa, Japan.
2

Abstract: Child abuse and neurodevelopmental disorders are serious social issues in Japan. Abused children may
present with symptoms similar to attention deficit/hyperactivity disorder (ADHD), such as increased impulsivity
and difficulty concentrating. It is also known that children with ADHD are more likely to suffer from maltreatment,
which can lead to psychiatric symptoms such as low self-esteem, depression, and defiant, challenging attitudes. Child
psychiatric treatment needs to take both perspectives, childhood adversity and neurodevelopmental disorders, into
account. In this case (A), there was a history of impulsive challenging behavior; in addition to the ADHD symptoms,
the abusive upbringing from an early age had resulted in increased aggression, psychological damage, and low selfesteem. The abusive mother was also a competitor to her and was vulnerable and unable to present a healthy femininity
to her. She entered adolescence without sufficient support from her mother before puberty. The ambivalence ofdependence and rebellion extremely increased, and the problem manifested as withdrawal. In the treatment, whilesetting limits, positive evaluations of the positive aspects were actively communicated. Her therapist was particularly
aware of becoming a part of her ego function different from her mother. A's challenging behavior was gradually
reduced, and she was able to develop the right self-image. This is a case in which the structure of the hospitalization
enabled the work of limiting the patient while protecting and accepting her. Clinical serious issues such as withdrawal,
defiant challenging behavior, and symptoms of hyperactive impulsive inattention in adolescents require consideration
and response to background adversity experiences and child abuse factors.
Keywords: inpatient, child, child abuse, ADHD

Introduction

mood disorders, such as severe emotional dysregulation(2,3). Close attention should be paid to environmental
factors (e.g., bullying, teacher reprimands, parental
abuse) that may influence the symptoms of ADHD. For
example, of the 878 patients prescribed the three antiADHD medications Methylphenidate, Atomoxetine, andGanfacine, 43 (4.9%) had used all three medications,indicating that children with severe ADHD symptoms,
autistic features and child-parent violence are more likely
to experience all three during their treatment have beenfound to be more likely to experience three medications
during treatment (4). Therefore, it is crucial to assess
the background of ADHD symptoms and, in doing so,
consider interventions for these background factors.

In Japan, several social issues exist, including thelack of child psychiatrists and child psychiatricwards as well as the rapid increase in the prevalenceof child abuse. The prevalence of attention deficit/
hyperactivity disorder (ADHD), which is one of themost common neurodevelopmental disorders, as well
as autism spectrum disorders, is estimated to be 7.2%
(1). Individuals with ADHD exhibit hyperactivity,
impulsivity, and inattention. Furthermore, this condition
is complex and involves a combination of biologicaland psychosocial factors, e.g., increased impulsivity andirritability due to attachment difficulties and possible(47)

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The 5th edition of the Guidelines for the Diagnosis
and Treatment of ADHD in Children was publishedin 2022 (5). It recommends focusing on psychosocial
treatment rather than pharmacotherapy and statesthat the treatment goal "should not be the complete
elimination of the three main symptoms of ADHD,
but rather the improvement of the vicious cycle ofmaladaptive conditions at school and at home with
the improvement of these symptoms and the ability
to accept ADHD symptoms as personality traits ofindividual". The goals of ADHD treatment are thedevelopment of moderate self-esteem through theacceptance of the disorder and the development of an
adaptive personality based on ADHD characteristics.
An appropriate psychosocial treatment should be
provided on the basis of thorough understanding ofthese treatment goals. After providing psychosocial
treatment, minimal medication should be considered.
We have experienced an inpatient treatment of a girlwith ADHD who had been brought up in an abusive
environment. Children that have been abused can
exhibit increased hyperactivity and impulsivity, which
are very similar to the primary symptoms of ADHD.
Simultaneously, children with ADHD are likely to be
exposed to abusive parenting, e.g., harsh reprimands,
because of their symptoms. As a result, they tend to show
psychiatric symptoms, such as damaged self-esteem,
further deterioration of impulse control, and increased
aggression.
Consent for the presentation of the case was obtained
from the patient and their families.

No major problems in perinatal or infantile development.
There was domestic violence from the father to themother, and parents divorced when A was 2 years old.
She was first seen at our clinic in year X-8 (age 6, 1stgrade). In junior high school, she stopped attending
school and became violent at home. She was voluntarily
admitted to our clinic in April, year X (age 14, 3rd grade
junior high school).
Psychological test results: When A was 14 years old,
she took the Wechsler Intelligence Scale for Children,
Fourth Edition, and obtained the following scores: FullScale Intelligence Quotient, 124; Verbal Comprehension
Index, 103; Perceptual Reasoning Index, 122; Working
Memory Index, 100; and Processing Speed Index, 132.
Child and adolescent psychiatric ward: The childpsychiatric ward is located in a general hospital. It is an
open ward with 45 beds. It has 8 four-bed rooms and
13 private rooms for children from the upper grades ofprimary school to the third grade of junior high school.
The children can attend school at the hospital.
Assessment and treatment plan at the time ofadmission: At the time of admission, there was no
information regarding abuse by the stepfather andmother, or regarding the mother's difficult upbringing andmental state. We considered this to be a case of repeatedmaladjustment due to ADHD symptoms and difficulties
in family relationships leading to the patient's nonattendance at school. The treatment plan was to provide
the patient and parents with psychoeducation about
ADHD and to reintegrate A into the same generationalgroup. A female child psychiatrist became A's therapist,and a female nurse became A's charge nurse.
Pharmacotherapy: Methylphenidate hydrochloride 36
mg/day.

Case Report (A)Basic characteristics

Treatment

To ensure anonymity, some parts not related to thetreatment were modified. For the western calendar year,
the year of admission was set as X, with ± denoting thenumber of years before and after.
The basic characteristics of this case are as follows: i)
Age: 14 years old; ii) Sex: Female; iii) Main complaint:
hyperactivity, impulsivity, inattention; iv) Medical
history: No history of psychiatric illness; v) Family
structure: A's mother was a secondary school graduate
and a housewife. She suffered from dissociative disorderand depression. She had been neglected, raped, got
pregnant at 15, and had an abortion. In addition, she
had been arrested for using methamphetamine. She wasconstantly verbally abusive and violent toward A. She
repeatedly cut her wrist and overeat and vomits in frontof A. On the other hand, A's stepfather was a high school
graduate and a carpenter; he was sometimes violent
toward A. A has two younger sisters from her mother andstepfather.

Phase 1 (April – August, year X)
A spent a lot of time fussing and talking aggressively
to other children she had never met before. She did
not attempt to interact much with adults. Her motherrefused to take her home on holidays or visit her. She
continued to cope with her feelings of loneliness without
acknowledging them and gradually became isolated
from her friends. She always had a conflict with otherchildren. However, she usually helped the staff in minor
situations and calmed other children who were acting
out in the ward. Her therapist told A that there was agood side to her and that she was repeatedly trying todeal with her negative feelings in a manic way, which
was extremely hurtful. Then, A began to show signs ofdependence on the therapist, such as quietly approaching
her when she was anxious. A said, "I do not like girls.
Girls are vulnerable and fragile. They irritate me when I
see them. They are different from me". She often wore
men's clothes. Once, when the therapist reported to A's
mother that she was having a good time on the ward,

Growth and current medical history(48)

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her therapist reminded her of deadlines and commitments
and urged her to stick to the rules. When the therapist
praised her attitude and efforts, she looked good andconfident.

she expressed her rejection of A even more strongly
than before. The mother told the therapist that her own
mental health was very poor; she had been abused sincechildhood; she hated A, who had repeatedly caused her
problems; and she wanted a life without A. A's mother,
who had survived difficult circumstances, was unable
to deal with her own childhood experiences and turned
against A.

Phase 3 (February – March, year X+1)
Although she continued showing problematic behaviors
and experienced restrictions from her therapist on several
occasions, she did not rebel as much as before. A's
mother, a high school dropout and a secondary school
graduate, was reluctant and critical of her support for
A going to high school, but A decided to enroll in acorrespondence high school and always attended the first
period of her class at the hospital to practice commuting
to school.
She strongly objected to the idea of all the girls
dancing together in beautiful skirts at the farewell party
in the hospital ward and was very insistent that she
would not participate. However, through communication
with the charge nurse and her therapist, she eventually
decided to attend and was able to dance with a smileon her face. She even hesitated to take off the costume
immediately after the party. After leaving the hospital,
she went to a correspondence school and worked parttime. She sometimes forgot to go to the outpatient clinic
or argued with her mother, but she found her placeoutside the home.

Phase 2 (August, year X – January, year X+1)
We repeatedly lost contact with A's mother, and she hadrefused A's temporary return for holidays and cancelledinterviews without prior notice. During meetings with
her therapist, A avoided important topics and instead
repeated physical complaints. There was an increase inchallenging behavior, such as repeatedly visiting otherrooms to compete with rival girls and making noise in
the corridors at night. The therapist understood that A's
problematic behavior was a manifestation of her own
pain, and she repeatedly told her she was concerned
about her. Gradually, A began to talk more about her
feelings. However, shortly after the meeting, it was
decided that she would not be allowed to leave her roomat night in order to deal with the problem of trespassing
in other rooms. As this happened right after we hadtalked about confidentiality, A said, "I don't think I cantalk to you anymore". She stopped talking about anything
during the interview. The therapist was so preoccupied
with the superficiality of the problem that she felt
helpless, as if she had missed something important. In
November, A was not speaking to her therapist and wascontinuing to lose weight. Thus, the therapist decided
to increase the frequency of interviews to twice a week
and give her a private room to let her know that we caredabout her and wanted to protect her. When the therapist
told her this, she looked relieved and nodded her headwith tears in her eyes.
In December, influenced by the removal of
behavioral restrictions for hostile girls in the same year,
she continued leaving her room without permission
and making noise in the ward at night. Her therapist
repeatedly told her to communicate her feelings andthoughts to the therapist instead of expressing themthrough behavior, but the conversation continued with
name-calling and silent confrontations that lasted dozens
of minutes and exhausted even the therapist.
The ward staff discussed the issue and decided thatthe nurse should invite A to go for a walk every day andcreate opportunities for the adult and A to engage witheach other. A refused, saying "walking is such a hassle,
I'll never go". However, she looked happy every time she
was invited.
The same situation continued in our meeting.
However, she did not refuse the meeting and repeatedthe same exchange twice a week. A gradually began togo for walks and complain about her therapist and family
only on days when the charge nurse invited her. Again,

Discussion
Phase 1 (April – August, year X) included psychologicaltreatment, which involved relationship building andunderstanding pathological conditions. There was amajor problem in A's family: she had no experience ofemotional acceptance. She had no choice but to express
her negative feelings through aggression and impulsive
challenging behavior. It was important for the therapist
to acknowledge A's feelings and positive aspects and topresent an image of women other than A's mother.
Phase 2 (August, year X – January, year X+1)
included very important clinical sessions to help withacceptance and limits owing to her impulsivity and low
self-esteem. When her therapist set the limits, she would
violently rebel and direct her strong aggression toward
her. The limits were not an attack or punishment on A
but were intended to protect her from being hurt by her
challenging behavior. Several studies have demonstrated
that low self-esteem resulting from childhood adversity
experiences has a significant impact on children's lives(6,7). A was abused by her family and, as a result, did
not develop self-esteem and emotional regulation.
Treatment staff continued to show A acceptance
while restricting her. Thus, it was necessary for her toexperience controlling her own impulsivity throughinteraction with treatment staff and other children in thecontrolled environment of the inpatient treatment. Fromthe perspective of family therapy, the first step was to(49)

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ask the mother about her own upbringing and symptoms.
The therapist told her that she also wanted to support andhelp her and proceeded to adjust the environment while
listening to her story.
Phase 3 (February – March, year X+1) involved
gaining a modified emotional experience throughinpatient treatment by establishing a bilateral relationshipwith the attending her therapist and interacting withpeers and teachers in the inpatient classrooms. A had anambivalent attitude toward a group therapy including
junior high school girls. When she was asked to dancewith a group of girls at the farewell party at the end of
the school year, she showed both a vehement refusal
and a desire to join. A's therapist team encouraged her
to participate because they felt that it was important forher to learn to accept her own female identity. She wasable to work with the female staff and seemed to accept
them as a female role model who were different fromher mother. Eventually, she danced in her high school
uniform. At the end of the meeting, she gave a great
speech as a representative of the graduating class in her
uniform and was discharged from the hospital in March,year X+1.

Aid for Research from the National Center for Global
Health and Medicine (23A 3002).
Conflict of Interest: The authors have no conflicts ofinterest to disclose.
References
1.

2.
3.

4.

5.

Conclusion
In this case, there was a history of impulsive
challenging behavior; in addition to the ADHD
symptoms, the abusive upbringing from an early age
had resulted in increased aggression, psychologicaldamage, and low self-esteem. The abusive motherwas also a competitor to her and was vulnerable andunable to present a healthy femininity to her. A enteredadolescence without sufficient support from her motherbefore puberty. The ambivalence of dependence
and rebellion extremely increased, and the problem
manifested as withdrawal. In the treatment, whilesetting limits, positive evaluations of the positive
aspects were actively communicated. The staff wereparticularly aware of becoming a part of her ego
function different from her mother. A's challenging
behavior was gradually reduced, and she was able todevelop the right self-image. This is a case in which
the structure of the hospitalization enabled the work oflimiting the patient while protecting and accepting her.

6.

7.

Thomas R, Sanders S, Doust J, Beller E, Glasziou P.
Prevalence of attention-deficit/hyperactivity disorder: A
systematic review and meta-analysis. Pediatrics. 2015;
135:e994-e1001.
Retz W, Rösler M. Association of ADHD with reactive
and proactive violent behavior in a forensic population.
Undefined. 2010; 2:195-202.
Yu R, Aaltonen M, Branje S, Ristikari T, Meeus W,
Salmela-Aro K, Goodwin GM, Fazel S. Depression andviolence in adolescence and young adults: Findings fromthree longitudinal cohorts. J Am Acad Child Adolesc
Psychiatry. 2017; 56:652-658.e1.
Sasaki Y, Tsujii N, Sasaki S, et al. Current use of attentiondeficit hyperactivity disorder (ADHD) medications andclinical characteristics of child and adolescent psychiatricoutpatients prescribed multiple ADHD medications inJapan. PLoS One. 2021; 16:e0252420.
Study Group on Diagnostic and Treatment Guidelines
for ADHD. Guidelines for the Diagnosis and Treatment
of Attention Deficit/Hyperactivity Disorder-ADHD–5thedition (Saito K, Iida J, eds.). Jiho Corporation, Tokyo,
Japan, 2022. (in Japanese)
Kuhar M, Zager Kocjan G. Adverse childhood experiences
and somatic symptoms in adulthood: A moderated
mediation effects of disturbed self-organization andresilient coping. Psychol Trauma. 2022; 14:1288-1298.
Matsuura N, Hashimoto T, Toichi M. Correlations among
self-esteem, aggression, adverse childhood experiencesand depression in inmates of a female juvenile correctional
facility in Japan. Psychiatry Clin Neurosci. 2009; 63:478485.

---Received April 12, 2023; Revised July 31, 2023; Accepted
August 6, 2023.
Released online in J-STAGE as advance publication August
10, 2023.
*Address correspondence to:Masahide Usami, Department of Child and Adolescent
Psychiatry, Kohnodai Hospital, National Center for Global
Health and Medicine, 1-7-1 Kohnodi, Ichikawa, Chiba, Japan.
E-mail: usami.masahide@hospk.ncgm.go.jp

Funding: This work was supported in part by Grants-in-(50)

Case Report

GHM Open. 2023; 3(1):51-55.
DOI: 10.35772/ghmo.2023.01009

Pulmonary sclerosing pneumocytoma: A potential pitfall mimicking
lung adenocarcinoma
Himani Rai1, Ipsita Dhal1,*, Zachariah Chowdhury1, Swapnil Patel2, Durgatosh Pandey2
1
2

Department of Onco-pathology, Homi Bhabha Cancer Hospital and Mahamana Pandit Madan Mohan Malaviya Cancer Centre, Varanasi, India;
Department of Surgical Oncology, Homi Bhabha Cancer Hospital and Mahamana Pandit Madan Mohan Malaviya Cancer Centre, Varanasi, India.

Abstract: Pulmonary sclerosing pneumocytoma (PSP), a rare benign lung tumor of primordial epithelial origin,commonly effects middle-aged Asian females. Diagnosis of this entity is challenging because of the non-specificradiological characteristics that resemble malignancies and its histological heterogeneity. Main differential diagnoses
considered are adenocarcinoma lung and carcinoid tumor. In this case report, we discuss our experience of diagnosing
a case of pulmonary sclerosing pneumocytoma, which showed increased SUV uptake in PET-CT indicating towards
a malignancy and was also misdiagnosed as adenocarcinoma in CT-guided FNAC. The histology showed variablemorphological features and there was a differential staining pattern of TTF1 and napsin A in the cells. We havehighlighted the differential diagnosis and the challenges faced for diagnosing this benign, rare entity.
Keywords: pulmonary sclerosing pneumocytoma, adenocarcinoma, fine needle aspiration cytology

Introduction

right lung lower lobectomy after receiving a diagnosis oflung adenocarcinoma which subsequently turned out tobe PSP in detailed histological and immunohistochemicalevaluation after receiving informed consent from thepatient.

Pulmonary sclerosing pneumocytoma (PSP) is a rare
benign neoplasm, which most frequently affects middleaged women. This entity was named "sclerosing
pneumocytoma" and was moved from the "miscellaneoustumors" category to "Adenomas" in the 2015 WHO
Classification of lung tumors. It is typically a benign
tumor, however, lymph node recurrence, pleural andbony metastases and malignant transformation can occur
very rarely. The presence of two cell types, cuboidal
surface cells and stromal round cells, both of which are
regarded as neoplastic, are the primary characteristic
morphological features of PSP (1).
An isolated, well-circumscribed lump or tumor is
the typical radiological appearance of a pulmonary
sclerosing pneumocytoma. Most cases are detected as anincidental finding during routine medical examinations
without any noticeable clinical symptoms. Chest
tightness, coughing, and chest pain may be present
in certain individuals, which may be because of lungtissue compression by an enlarged lesion (2). When thenature of the lesion cannot be determined on computed
tomography (CT), the 18F-fluorodeoxyglucose positronemission tomography (FDG PET)/CT is an appropriate
option. However, a larger lesion size may have more
active cell proliferation, which could result in a higher
uptake of the fluorodeoxyglucose 18F-FDG and be
mistaken for a malignant tumor (3).
Here we discuss a case of a woman who underwent a

Case Report
A 30-year-old-female came to our emergency department
with complaint of hemoptysis for 25 days. She wasadmitted to our hospital on September 2, 2021. She hadno history of smoke exposure (either active or passive).
PET-CECT was done in an outside centre, which showeda mass in the right lung lower lobe with increased SUV
uptake and no other abnormal findings elsewhere.
CT guided FNAC from lung mass revealed small
clusters of medium to large sized cells showing moderate
pleomorphism, nuclear hyperchromasia, inconspicuous
nucleoli and moderate amount of cytoplasm (Figure1A). Cytology was reported as positive for malignancy,suggestive of non-small cell carcinoma with possibilityof adenocarcinoma and histopathological examination
was advised for confirmation. The outside biopsy was
also reported as adenocarcinoma.
Right lower lobectomy was done and we received
the surgical specimen. On gross examination, a welldefined solid lesion was identified, measuring 3.8 × 2 ×
3 cm. Cut section showed variegated and hemorrhagicareas (Figure 1B). On microscopy, lower magnification
demonstrated cells arranged in a papillary pattern and(51)

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Figure 1. (A) Cyto smears showed small clusters of cells
having nuclear hyperchromasia, inconspicuous nucleoli andmoderate amount of cytoplasm. (B) Gross image: Cut section
is variegated and shows hemorrhagic areas. (C) Histopathology
shows cells arranged in papillary pattern with dual cell
population: papillae are lined by cuboidal surface cells andpapillary cores show round stromal cells (H&E, 40×). (D) Cells
are arranged in solid sheets along with areas of hemorrhage.
Cells are polygonal with abundant eosinophilic cytoplasm, oval
nuclei, even chromatin, indistinct nucleoli, hyperchromasia,
pleomorphism (H&E, 40×). (E) Sclerotic stroma along withfoamy histiocytes (H&E, 40×). (F) Papillae are lined bycuboidal cells and papillary cores show round cells. Few cells
show intranuclear inclusions (arrow).

Figure 3. (A) TTF1 highlights the surface epithelial cells
along with few stromal cells. (B) Surface epithelial cells show
positivity to napsin A while stromal cells are negative. (C) AE1/
AE3 highlights the surface epithelial cells. (D) CK7 shows
positivity in surface epithelial cells while stromal cells arenegative. (E) Both stromal cells and surface cells are positivefor vimentin. (F) EMA highlights the surface epithelial cells
and not the stromal cells. (40× magnification)solid sheets with large areas of hemorrhage. Higher
power revealed proliferation of dual cell population,
comprised of surface cuboidal cells resembling type II
pneumocytes lining the papillary structures, and roundedstromal cells within the papillary cores, having moderate
to abundant eosinophilic to vacuolated cytoplasm, oval
nuclei with mild pleomorphism, fine even chromatin,
and indistinct nucleoli (Figure 1C). The stroma wassclerotic with presence of sheets of foamy histiocytes.
Areas of blood lakes, hemosiderin-laden macrophages,
and cholesterol clefts were noted. Numerous lamellated
surfactant like structures were seen interspersed within
the tumor cells. Occasional multinucleated giant cells
were also identified (Figure 2).
On immunohistochemistry (IHC), a distinct pattern ofstaining was identified, as TTF1 was positive in both thestromal cells as well as the pneumocytes, while napsin
A highlighted the pneumocytes only. Stromal cells were
negative for napsinA. The surface lining cells also werepositive for Pan CK, CK7, vimentin and EMA (Figure 3).
Diagnosis of PSP was done and the patient was advised
to follow up. The last follow up of the patient was on
January 3, 2023, and she was completely symptom free
except for mild headache.

Figure 2. (A) Microsection shows cholesterol clefts alongwith numerous rounded lamellated structures (H&E, 20×). (B)Lamellated surfactant-like substance (H&E, 40×). (C) Areasof calcification with surrounding stromal cells exhibiting mild
nuclear pleomorphism (H&E, 40×). (D) Multinucleated giant
cells are seen (arrow).

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Discussion

cytologic and histological PSP findings, and in thesestudies, intraoperative frozen sections (FS), EBUSTBNA, or computed tomography (CT)-guided FNA
frequently resulted in incorrect diagnosis (7). In thepresent case report, also cytology report was suggestiveof non-small cell carcinoma, as the cytological features
were overlapping with that of lung adenocarcinoma.
In any case, the cytologic heterogeneity of this tumor
makes the diagnosis difficult because the smears
can range from hypocellular, bloody, sclerotic tohypercellular, loaded with stromal fragments, and/or
showing epithelial cell proliferation, depending on theneedle biopsy sampling area (8).
Cytological features of PSP demonstrated cells
arranged in cohesive papillae, clusters or flat sheets,
an abundant dual population of polygonal type II
pneumocytes and spindle cells. These cells havespherical, bland nuclei with inconspicuous nucleoli andan abundance of pale, eosinophilic cytoplasm. Patentintranuclear inclusions are a valuable indicator thathas to be looked into and should be appreciated (10).
Hyalinized stromal tissue microfragments are also seen.
The absence of necrosis and mitoses, which highlightthe benign nature of the tumor, is a crucial observation.
If all of these important cytological quirks are seen on
smears, a skilled cytopathologist can quickly determine
the diagnosis (10).
However, we must remember that there are various
pitfalls in the cytopathological diagnosis of PSP, because
papillary pattern of arrangement of the tumor cells in
PSP can mimic lepidic type well-differentiated lungadenocarcinoma, papillary thyroid gland carcinoma andmesothelioma. In these scenarios, nuclear morphology
can be helpful. Round cells and typical papillary areas
in cytology smears may mimic a carcinoid tumor. The
key differentiating features are a monotonous populationof only one cell type, that helps distinguish it from PSP.
Also areas of neoplastic clear cells in cytology may
be confused with renal cell carcinoma with metastases
which we can be ruled out by nuclear morphology,
pleomorphism and frequent mitotic figures and alsowith the help of proper clinical history, and radiologicalcorrelation (10).
Microscopy in PSP shows morphologicalheterogeneity. The surface cells line the papillae andthe round cells are found inside papillary cores andcan also be arranged in solid sheets. The surface cells
are cuboidal in shape and few of them may havenuclear pseudoinclusions. Multinucleated cells, andfoamy histiocytes are common. Stromal cells haveirregular cell boundaries, oval nuclei, even chromatin,
indistinct nucleoli, and are polygonal. They may also
exhibit cytoplasmic vacuolization, hyperchromasia,
and pleomorphism. Stroma is predominantly sclerotic,
frequently exhibit areas of haemorrhage, blood lakes,
histiocytic aggregates, chronic inflammation, lamellar
structures (extracellular surfactant), and cholesterolosis.

This case report demonstrates the best diagnostic
procedure for a patient with a questionableradiographic and pathological finding. Because PSP
is often misdiagnosed as well-differentiated lungadenocarcinoma, it is critical to recognize this entity andits significant pathological variations.
PSP should be taken into account for a young
woman who has a single round to oval-shaped
nodule, smooth boundaries, and strong, homogenous
enhancement on contrast-enhanced CT, with or without
overlaying vascular sign, halo sign, or air crescent sign.
However, only 30% of enhanced CT diagnoses for PSP
are accurate (2).
In general, 18F-FDG PET/CT scan results areinterpreted as positive for malignancy when FDG
uptake of a pulmonary nodule on qualitative assessment
is greater than background mediastinal blood pool
activity or when SUVmax values exceed 2.5 (4). In thepresent case, 18F-FDG PET/CT showed a false positive
result, indicating malignancy. 44.7% of tumors arejuxtapleural or juxtafissural, and the lesions are typicallysmaller than 30 mm in diameter and frequently situatedin the periphery. It can occasionally be misinterpreted
as a bronchial cyst, lung cancer, pulmonary carcinoid,
pulmonary hamartoma, tuberculoma, or inflammatory
nodule. Although PSP displays varied FDG
accumulations, 18F-FDG PET is frequently helpful in
identifying benign from malignant tumors. As comparedto the asymptomatic group, PSP patients, which are
symptomatic displayed a greater maximal standardised
uptake value (5). The cause of this intense SUV uptake
can be due to active proliferation of round cells withpoor differentiation and various tumor cells (6,7). Whenthe lesion is tiny and located peripherally, bronchoscopic
diagnosis can be challenging (5).
When possible, pre-operative diagnosis is usefulfor determining the best course of treatment. PSP is
well known for having two distinct cell populations,surface lining cells and round stromal cells, which
are commonly arranged in four different architectural
patterns: papillary, sclerotic, solid, and hemorrhagic.
At least two of the four architectural patterns, mosttypically the papillary and solid patterns occur in all
patients, and three of the patterns are present in 95% of
patients (8). The present case has all the four describedhistological patterns.
Gal et al. were the first to note that the identificationof the dual cell population, which is made up of a lotof stromal cells and few surface cells, is necessary forthe cytologic diagnosis of this condition (9). Due to therarity of the disease and possible pathologists' lack ofacquaintance with its cytologic features, fine-needle
aspiration (FNA) cytology is problematic since it is notalways able to distinguish between the two tumor cell
types. Few case reports exist that describe preoperative(53)

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The present case has all these morphologic findings.
Rare granulomatous reaction can also be seen andmitosis is infrequent. Angiolymphatic invasion andnecrosis are absent (1).
The common differential diagnosis are welldifferentiated adenocarcinoma of lung, particularly thelepidic variety, carcinoid tumor, alveolar adenomas,
and lung papillary adenomas. Cellular and nuclear
morphology plays a significant role in these situations.
Lung adenocarcinomas, often show necrosis, irregularnuclear shapes, amd higher N/C ratio. IHC analysis
shows diffuse positivity of tumor cells with TTF-1
and napsin A, without a differential staining pattern
like PSP. Carcinoid tumors lack the hyalinized stroma
and consist of a uniform population of cells with salt
and pepper nuclear chromatin. Immunohistochemical
analysis shows positive staining of the tumor cells forneuroendocrine markers (INSM 1, synaptophysin andchromogranin) in all cases, and is positive for TTF1 (1). Alveolar adenomas shows lack of the typicalmorphological patterns of PSP (solid, papillary,sclerotic and hemorrhagic). Also the stromal cells arenegative for TTF1 in alveolar adenomas. Sclerosing
pneumocytoma lacks cystic spaces and shows TTF1
positive stromal cells (1). Lung papillary adenomas are
well-circumscribed papillary neoplasms composed of
cuboidal to columnar cells that line the fibrovascular
centres and are cytologically bland. Only thesurface epithelial cells are positive for TTF1, CK7,
pancytokeratin, surfactant protein, and EMA while
the stromal cells are negative. In contrast, sclerosing
pneumocytoma is composed of two cell types, withpapillary structures containing a TTF1-positive cellularrather than a fibrovascular core and more-varied growth
patterns (1).
There have been a number of reports on themalignant potential of PSP, lymph node metastases and/or local recurrence. Although these malignant potentials
do not appear to have an impact on the prognosis ofPSP, there are other variables that may be relevant. The
common presentation in females is supposed to be dueto the presence of progesterone (11).
Treatment options for this benign tumor are still
debatable. The main course of treatment is surgery.
For peripheral small-sized tumors, sublobectomy, mostcommonly segmentectomy and wedge resection arefavoured. However, it has not been fully addressed as towhat resection extent is ideal (11).
Few studies have reported gene mutations in PSP.
AKT1, was the genetic signature of PSP. It causes cell
growth and morphological changes, however, it does notcause progression to cancer. The second most frequentgene mutation in PSP is beta-catenin, which may also
contribute to the development of benign tumors rather
than malignant ones. In addition to AKT1 and betacatenin, mutations in the tumor-related genes PTEN,
BRAF V600E, BLM, and KMT2D were also found in

the sclerosing pneumocytoma, though at a comparatively
lower frequency (11).
Conclusion
Diagnosis of pulmonary sclerosing pneumocytoma isdifficult in frozen sections, small biopsies and cytology
where they can be mistaken for adenocarcinoma or
carcinoid tumors. These tumors have a benign clinicalcourse and metastases are extremely rare. Surgicalresection is part of the treatment for PSP, and theprognosis is favourable. There have been no reportsof recurrence after surgery or death due to PSP. A
critical factor in optimising the treatment strategy is thedifferential diagnosis of PSP from adenocarcinoma andcarcinoid by characteristic round and surface cells andspecific IHC staining.
Funding: None.
Conflict of Interest: The authors have no conflicts ofinterest to disclose.
References
1.
2.
3.
4.

5.

6.

7.

8.

9.

(54)

WHO Classification of Tumor Editorial Board. Thoracic
Tumors. Lyon (France): International Agency of Research
on Cancer; 2021.
Song L, Yan P, Mo G. Sclerosing pneumocytoma: A
carcinoma mimicker. Integr Cancer Sci Ther. 2021; 8:1-3.
Cheung YC, Ng SH, Chang JW, Tan CF, Huang SF, Yu
CT. Histopathological and CT features of pulmonary
sclerosing haemangiomas. Clin Radiol. 2003; 58:630-635.
Lim JH, Lee N, Choi DW, Oh HJ, Park HY, Kim KH, Kim
TO, Park CK, Shin HJ, Choi YD, Yun JS, Song SY, Oh
IJ. Pulmonary sclerosing pneumocytoma mimicking lungcancer: Case report and review of the literature. Thorac
Cancer. 2016; 7:508-511.
Muto Y, Kuse N, Inomata M, Awano N, Tone M,
Minami J, Takada K, Fujimoto K, Wada A, Nakao K,
Furuhata Y, Hori C, Bae Y, Kumasaka T, Izumo T. A
case of pulmonary sclerosing pneumocytoma diagnosed
preoperatively using transbronchial cryobiopsy. Respir
Med Case Rep. 2021; 34:101494.
Lee E, Park CM, Kang KW, Goo JM, Kim MA, Paeng JC,
Lee HJ, Park HS, Chung DH. 18F-FDG PET/CT featuresof pulmonary sclerosing hemangioma. Acta Radiol. 2013;
54:24-29.
Jiang L, Huang Y, Tang Q, Zhao Q, Li Y, Wu X, Wang H.
18F-FDG PET/CT characteristics of pulmonary sclerosing
hemangioma vs. pulmonary hamartoma. Oncol Lett. 2018;
16:660-665.
Trabucco SMR, Brascia D, Cazzato G, De Iaco G,
Colagrande A, Signore F, Ingravallo G, Resta L, Marulli
G. Pulmonary sclerosing pneumocytoma: A pre andintraoperative diagnostic challenge. Report of two cases
and review of the literature. Medicina (Kaunas). 2021;
57:524.
Gal AA, Nassar VH, Miller JI. Cytopathologic diagnosisof pulmonary sclerosing hemangioma. Diagn Cytopathol.
2002; 26:163-166.

GHM Open. 2023; 3(1):51-55.

www.ghmopen.com

August 10, 2023.

10. Onorati M, Nicola M, Bianchi CL, Bini F, Bellaviti N, Di
Nuovo F. Pitfalls and key features of a case of sclerosing
pneumocytoma: A cytological challenge? Acta Cytol.
2016; 60:85-88.
11. Zheng Q, Zhou J, Li G, Man S, Lin Z, Wang T, Chen B,
Lin F. Pulmonary sclerosing pneumocytoma: Clinicalfeatures and prognosis. World J Surg Oncol. 2022;
20:140.

Released online in J-STAGE as advance publication August17, 2023.
*Address correspondence to:
Ipsita Dhal, Department of Onco-pathology, Homi Bhabha
Cancer Hospital and Mahamana Pandit Madan Mohan
Malaviya Cancer Centre, Varanasi, Uttar Pradesh 221005,
India.
E-mail: dripsitadhal@gmail.com---Received May 23, 2023. Revised July 27, 2023; Accepted(55)

Letter

GHM Open. 2023; 3(1):56-57.
DOI: 10.35772/ghmo.2023.01006

Global vaccine equity: The G7's commitment and challenges
Yudai Kaneda1,*, Kenzo Takahashi2, Akihiko Ozaki3, Tetsuya Tanimoto4
1

School of Medicine, Hokkaido University, Hokkaido, Japan;
Graduate School of Public Health, Teikyo University, Tokyo, Japan;
3
Department of Breast and Thyroid Surgery, Jyoban Hospital of Tokiwa Foundation, Fukushima, Japan;
4
Department of Internal Medicine, Jyoban Hospital of Tokiwa Foundation, Fukushima, Japan.
2

Abstract: The "Hiroshima Vision", unveiled at the G7 Hiroshima Summit in 2023, leaves room for enhancement in
the specific content of equitable global vaccine distribution plans. Despite the efforts of COVID-19 Vaccines Global
Access (COVAX), vaccine supply faces severe disparities, with high-income countries receiving a disproportionately
larger share. To mitigate future public health crises, mechanisms proven by past instances, such as establishingregional vaccine hubs, promoting technology transfers, and considering early patent rights relinquishment, need
to be implemented. Correcting vaccine inequity necessitates learning from the COVID-19 pandemic and demands
global cooperation and consensus from the G7.
Keywords: G7 Hiroshima Summit, global vaccine equity, COVID-19, COVAX, Japan

G7 Hiroshima Summit, held in May, 2023, released the"Hiroshima Vision", initiating a partnership for bettermedical countermeasure access and delivery basedon equity, efficiency, and speed principles (1). Yet,
more realistic global vaccine plans should have been
incorporated from the experience of the coronavirus
disease 2019 (COVID-19) pandemic.
One of the lessons to be learned is the significant
global disparity in vaccine supply. Although the
COVID-19 Vaccines Global Access (COVAX) is a joint
initiative of global health entities to equitably distribute
vaccines to mitigate the health and economic impactof the pandemic, according to the latest statistics of
two-dose supplies, high-income countries are suppliedwith 75%, while only 26% of vaccines are supplied
to low-income countries (2). This was because highincome countries prioritized the vaccination of theircitizens, especially the newly developed and effectivemRNA vaccines failed to reach low- and middle-income
countries (LMICs).
Although the number of deaths was relatively low in
Africa and other countries due to younger populations
compared to developed countries, continued effort to
distribute mRNA vaccines, which is also effective inpreventing long covid, should be explored because
COVID-19 will not cease in the foreseeable future (3).
Moreover, considering the increased risk from the global
population aging, establishing a global vaccine hub is
urgently needed, as low-income regions such as Africa
may become the next endemic area (4).

However, as it is unclear to what extent the establishmentof one company's vaccine production base overseas, as
Pfizer is currently doing in South Africa (5), for example,
will contribute to equitable vaccine distribution, one
possible solution is to share the technology itself
in addition to the factory, with LMICs. Previously,
Sumitomo Chemical, a Japanese company, transferred its
insecticide-laden mosquito net manufacturing technology
license-free to stakeholders in LMICs such as Tanzania(6). Such an approach highlights the challenges andpossibilities of strengthening the ecosystem throughprivate sector involvement in global health initiatives
and should also be considered in the context of this
COVID-19 reflection, as well as disruptive innovation.
Additionally, the early relinquishment of patentrights for mRNA vaccines should be considered a viable
solution to redress vaccine inequities. The efficacy of
positioning vaccines, testing equipment, and treatments
as global public goods is suggested by the World HealthOrganization's decision in 2005 to essentially waive theintellectual property rights to Antiretroviral drugs (ARVs)
for the treatment of HIV/AIDS, to improve access tothese ARVs in LMICs (7). As a result, countries like
Kenya could import generic drugs through compulsory
licenses, reducing the cost of ARVs. It may also be
effective to encourage the relinquishment of intellectual
property rights by companies like Pfizer and Moderna
for mRNA vaccines under the cooperation of the G7.
Vaccines, funded heavily by public money, should
not be controlled by a few entities but should be global(56)

GHM Open. 2023; 3(1):56-57.

www.ghmopen.com

public assets for sustainable scaling and vaccine inequity.
Intellectual property exemptions, providing regional
vaccine production networks, and technology transfers
can help achieve this. These approaches will require
global cooperation, funding, and political will, andfurther discussion and G7 consensus is desired.

4.

5.

Funding: None.

6.

Conflict of Interest: Dr. Ozaki reported personal feesfrom Medical Network Systems Inc. and Kyowa Kirin
co. ltd. outside the submitted work. Dr. Tanimoto
reported personal fees from Medical Network Systems
Inc. and Bionics co. ltd., outside the submitted work. No
other disclosures were reported.

7.

References
1.
2.
3.

Chang AY, Skirbekk VF, Tyrovolas S, Kassebaum NJ,
Dieleman JL. Measuring population ageing: An analysisof the Global Burden of Disease Study 2017. Lancet
Public Health. 2019; 4:e159-e167.
Becker Z. South Africa's Biovac produces first Pfizer
COVID-19 vaccine doses: Report 2022. https://www.
fiercepharma.com/vaccines/south-africas-biovacproduces-first-pfizer-covid-19-doses-bloomberg-reports(accessed May 27, 2023).
Gradl C. Sumitomo Chemical and the FightAgainst
Malaria Using Bednets: A Case Study. https://www.hks.
harvard.edu/sites/default/files/centers/mrcbg/programs/
cri/files/report_52_Sumitomo.pdf (accessed July 13,2023).
UNAIDS. Using TRIPS flexibilities to improve access to
HIV treatment 2015. https://www.unaids.org/sites/default/
files/media_asset/JC2049_PolicyBrief_TRIPS_en_1.pdf(accessed May 27, 2023).

---Received June 14, 2023; Revised July 13, 2023; Accepted July
14, 2023.

Ministry of Foreign Affairs of Japan. G7 Hiroshima
Leaders' Communiqué 2023. https://www.mofa.go.jp/
mofaj/files/100506909.pdf (accessed May 27, 2023).
World Health Organization. COVAX DATA BRIEF
2023. https://www.gavi.org/sites/default/files/covid/covax/
COVAX-data-brief_22.pdf (accessed May 27, 2023).
Byambasuren O, Stehlik P, Clark J, Alcorn K, Glasziou P.
Effect of covid-19 vaccination on long covid: Systematic
review. BMJ Medicine. 2023; 2:e000385.

Released online in J-STAGE as advance publication July 16,
2023.
*Address correspondence to:
Yudai Kaneda, School of Medicine, Hokkaido University,
Kita15, Nishi 7, Kita-ku, Sapporo, Hokkaido 0608638, Japan.
E-mail: nature271828@gmail.com(57)

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dissemination of information. Please note that the manuscript
will not proceed to the next step in publication until the
JPA Form is received. In addition, if excerpts from othercopyrighted works are included, the author(s) must obtainwritten permission from the copyright owners and credit thesource(s) in the article.

Article-processing Charges: The open-access policy of GHM
Open will allow all readers from the medical and scientificcommunity to freely utilize material published in the journal.
To achieve open access, article-processing charges ($150 per
page for black & white pages, $300 per page for color pages)
will be levied for manuscripts accepted for publication in
GHM Open. In exceptional circumstances, the author(s) may
apply to the editorial office for a waiver of the publication
charges at the time of submission. All invited articles are freeof charge.
Article-processing charges pay for: Immediate, worldwide
open access to the full article text; Preparation in various
formats for print & online publication; Inclusion in global
important platforms, enabling electronic citation in otherjournals that are available electronically.

Peer review: GHM Open uses single-blind peer review,which means that reviewers know the names of the authors,
but the authors do not know who reviewed their manuscript.
The external peer review is performed for research articles
by at least two reviewers, and sometimes the opinions ofmore reviewers are sought. Peer reviewers are selectedbased on their expertise and ability to provide high quality,
constructive, and fair reviews. For research manuscripts,
the editors may, in addition, seek the opinion of a statisticalreviewer. Consideration for publication is based on thearticle’s originality, novelty, and scientific soundness, and theappropriateness of its analysis.

Misconduct: GHM Open takes seriously all allegations ofpotential misconduct and adheres to the ICMJE Guideline(http://www.icmje.org/recommendations) and COPE Guideline(http://publicationethics.org/files/Code_of_conduct_for_
journal_editors.pdf). In cases of suspected research or
publication misconduct, it may be necessary for the Editor or
Publisher to contact and share submission details with third
parties including authors’ institutions and ethics committees.
The corrections, retractions, or editorial expressions of concern
will be performed in line with above guidelines.

Suggested Reviewers: A list of up to 3 reviewers whoare qualified to assess the scientific merit of the study iswelcomed. Reviewer information including names, affiliations,addresses, and e-mail addresses should be provided at thesame time the manuscript is submitted online. Please do notsuggest reviewers with known conflicts of interest, including
participants or anyone with a stake in the proposed research;
anyone from the same institution; former students, advisors,
or research collaborators (within the last three years); or close
personal contacts. Please note that the Editor-in-Chief may
accept one or more of the proposed reviewers or request areview by other qualified persons.

(As of January 2022)

GHM Open
National Center for Global Health and Medicine,
1-21-1 Toyama Shinjuku-ku, Tokyo 162-8655, Japan
URL: www.ghmopen.com
E-mail: office@ghmopen.com(P4)