Global incidence, prevalence, and mortality of type 1 diabetes in 2021 with projection to 2040: a modelling study

3D evaluation of the extracellular matrix of hypoxic pancreatic islets using light sheet fluorescence microscopy

Pancreatic islet transplantation is a promising treatment for type 1 diabetes, but the survival and function of transplanted islets are hindered by the loss of extracellular matrix (ECM) during islet isolation and by low oxygenation upon implantation. This study aimed to evaluate the impact of hypoxia on ECM using a cutting-edge imaging approach based on tissue clearing and 3D microscopy. Human and rat islets were cultured under normoxic (O2 21%) or hypoxic (O2 1%) conditions. Immunofluorescence staining targeting insulin, glucagon, CA9 (a hypoxia marker), ECM proteins (collagen 4, fibronectin, laminin), and E-cadherin (intercellular adhesion protein) was performed on fixed whole islets. The cleared islets were imaged using Light Sheet Fluorescence Microscopy (LSFM) and digitally analyzed. The volumetric analysis of target proteins did not show significant differences in abundance between the experimental groups. However, 3D projections revealed distinct morphological features that differentiated normoxic and hypoxic islets. Under normoxic conditions, ECM could be found throughout the islets. Hypoxic islets exhibited areas of scattered nuclei and central clusters of ECM proteins, indicating central necrosis. E-cadherin was absent in these areas. Our results, demonstrating a diminution of islets' functional mass in hypoxia, align with the functional decline observed in transplanted islets experiencing low oxygenation after grafting. This study provides a methodology combining tissue clearing, multiplex immunofluorescence, Light Sheet Fluorescence Microscopy, and digital image analysis to investigate pancreatic islet morphology. This 3D approach allowed us to highlight ECM organizational changes during hypoxia from a morphological perspective.

Diabetes Technology and Waste: A Real-World Study in a Specialized Practice in Germany

BACKGROUND

Diabetes technology is a fundamental part of modern diabetes therapy. Its widespread usage is associated with an increasing amount of "diabetes technology waste." The aim of this study was to quantify this waste in a real-world situation in a specialized diabetes practice in Germany.

METHODS

Eighty patients with diabetes and insulin treatment participated and collected all of their therapy-associated waste for three months. Their attitude toward sustainability of antidiabetic therapy, waste generation, and their own waste reduction/separation behavior was surveyed.

RESULTS

In total, 23 707 pieces of therapy-associated waste were collected. They comprised 5362 test strips, 630 glucose sensors, 14 619 needles, 519 insulin cartridges, 599 pens, and 1463 pieces of aids for insulin pump therapy. Type and quantity of the collected waste depended on the type of diabetes and the respective therapy, ie, multiple daily injections, usage of glucose sensors, or pump therapy. Most participants (92%) were surprised by the amounts of waste and reported an increased awareness toward the resource consumption of their therapy (87%). The survey indicated an enhanced interest in waste separation (94%) and a demand for the reduction and recycling of devices/aids (93%).

CONCLUSIONS

Our data revealed the amount and complexity of the waste generated by modern diabetes therapy. Extrapolating these data, it can be estimated that around 1.2 billion pieces of diabetes technology waste are generated in Germany per year. The major concern of the study participants was the limited number of recycling options. A clear demand for improved sustainability of the medical products was expressed.

Insights into the development of insulin-producing cells: Precursors correlated involvement of microRNA panels

Type 1 diabetes (T1D) is a chronic autoimmune condition characterized by the destruction of pancreatic β cells, recently estimated to affect approximately 8.75 million individuals worldwide. At variance with conventional management of T1D, which relies on exogenous insulin replacement and insulinotropic drugs, emerging therapeutic strategies include transplantation of insulin-producing cells (IPCs) derived from stem cells or fully reprogrammed differentiated cells. Through the in-depth analysis of the microRNAs (miRNAs) involved in the differentiation of human embryonic stem cells (ESCs), mesenchymal stem cells (MSCs), and induced pluripotent stem cells (iPSCs), into insulin-producing cells, this review provides a comprehensive overview of the molecular mechanisms orchestrating the transformation of precursors to cells producing insulin. In addition to miR-375, involved in all differentiation processes, and to miR-7, mir-145 and miR-9, common to the generation of insulin-producing cells from at least two different sources, the literature reveals panels of miRNAs closely related to precursor cells and associated with specific events of the physiological β cell maturation. Since the forced modulation of miRNAs can direct cells development towards insulin-producing cells or modify their fate, a more comprehensive knowledge of the miRNAs involved in the cellular events leading to obtain efficient β cells could improve the diagnostic, prognostic, and therapeutic approaches to diabetes.

The immunology of type 1 diabetes

Following the seminal discovery of insulin a century ago, treatment of individuals with type 1 diabetes (T1D) has been largely restricted to efforts to monitor and treat metabolic glucose dysregulation. The recent regulatory approval of the first immunotherapy that targets T cells as a means to delay the autoimmune destruction of pancreatic β-cells highlights the critical role of the immune system in disease pathogenesis and tends to pave the way for other immune-targeted interventions for T1D. Improving the efficacy of such interventions across the natural history of the disease will probably require a more detailed understanding of the immunobiology of T1D, as well as technologies to monitor residual β-cell mass and function. Here we provide an overview of the immune mechanisms that underpin the pathogenesis of T1D, with a particular emphasis on T cells.

Evidence for C-Peptide as a Validated Surrogate to Predict Clinical Benefits in Trials of Disease-Modifying Therapies for Type 1 Diabetes

Type 1 diabetes is a chronic autoimmune disease in which destruction of pancreatic β-cells causes life-threatening metabolic dysregulation. Numerous approaches are envisioned for new therapies, but limitations of current clinical outcome measures are significant disincentives to development efforts. C-peptide, a direct byproduct of proinsulin processing, is a quantitative biomarker of β-cell function that is not cleared by the liver and can be measured in the peripheral blood. Studies of quantitative measures of β-cell function have established a predictive relationship between stimulated C-peptide as a measure of β-cell function and clinical benefits. C-peptide levels at diagnosis are often high enough to afford glycemic control benefits associated with protection from end-organ complications of diabetes, and even lower levels offer protection from severe hypoglycemia in type 1 diabetes, as observed in large prospective cohort studies and interventional trials of islet transplantation. These observations support consideration of C-peptide not just as a biomarker of β-cell function but also as a specific, sensitive, feasible, and clinically meaningful outcome defining β-cell preservation or restoration for clinical trials of disease-modifying therapies. Regulatory acceptance of C-peptide as a validated surrogate for demonstration of efficacy would greatly facilitate development of disease-modifying therapies for type 1 diabetes.

ARTICLE HIGHLIGHTS

Metabolic profiling reveals the nutraceutical effect of Gongolaria abies-marina and Rosmarinus officinalis extracts in a type 1 diabetes animal model

Nutraceuticals have gained increasing interest, prompting the need to investigate plant extracts for their beneficial properties and potential side effects. This study aimed to assess the nutraceutical effects of environmentally clean extracts from Rosmarinus officinalis and Gongolaria abies-marina (formerly Cystoseira abies-marina (Phaeophyceae)) on the metabolic profile of streptozotocin-induced diabetic rats. We conducted untargeted LC-QTOF-MS metabolic profiling on six groups of rats: three diabetic groups receiving either a placebo, R. officinalis, or G. abies-marina extracts, and three corresponding control groups. The metabolic analysis revealed significant alterations in the levels of various glycerophospholipids, sterol lipids, and fatty acyls. Both extracts influenced the metabolic profile, partially mitigating diabetes-induced changes. Notably, G. abies-marina extract had a more pronounced impact on the animals' metabolic profiles compared to R. officinalis. In conclusion, our findings suggest that environmentally clean extracts from R. officinalis and G. abies-marina possess nutraceutical potential, as they were able to modulate the metabolic profile in streptozotocin-induced diabetic rats. G. abies-marina extract exhibited a more substantial effect on metabolic alterations induced by diabetes compared to R. officinalis. These results warrant further exploration of these plant extracts for their potential in managing diabetes-related metabolic disturbances.

Severe Hypoglycemia and Impaired Awareness of Hypoglycemia Persist in People With Type 1 Diabetes Despite Use of Diabetes Technology: Results From a Cross-sectional Survey

OBJECTIVE

To determine how diabetes technologies, including continuous glucose monitoring (CGM) and automated insulin delivery (AID) systems, impact glycemic metrics, prevalence of severe hypoglycemic events (SHEs), and impaired awareness of hypoglycemia (IAH) in people with type 1 diabetes in a real-world setting within the U.S.

RESEARCH DESIGN AND METHODS

In this retrospective, observational study with cross-sectional elements, participants aged ≥18 years were enrolled from the T1D Exchange Registry/online community. Participants completed a one-time online survey describing glycemic metrics, SHEs, and IAH. The primary objective was to determine the proportions of participants who reported achieving glycemic targets (assessed according to self-reported hemoglobin A1c) and had SHEs and/or IAH. We performed additional subgroup analyses focusing on the impact of CGM and insulin delivery modality.

RESULTS

A total of 2,074 individuals with type 1 diabetes were enrolled (mean ± SD age 43.0 ± 15.6 years and duration of type 1 diabetes 26.3 ± 15.3 years). The majority of participants (91.7%) were using CGM, with one-half (50.8%) incorporating AID. Despite high use of diabetes technologies, only 57.7% reported achieving glycemic targets (hemoglobin A1c <7%). SHEs and IAH still occurred, with ∼20% of respondents experiencing at least one SHE within the prior 12 months and 30.7% (95% CI 28.7, 32.7) reporting IAH, regardless of CGM or AID use.

CONCLUSIONS

Despite use of advanced diabetes technologies, a high proportion of people with type 1 diabetes do not achieve glycemic targets and continue to experience SHEs and IAH, suggesting an ongoing need for improved treatment strategies.

Sibling adjustment to diabetes and educational needs: A literature review

ABSTRACT

As cases of type 1 diabetes mellitus (T1DM) increase, so do their impact on sibling relationships. This literature review of four databases from 2010 to 2024 discusses findings from five studies and the themes that emerged: education needs and family functioning. Improvements in family-centered care and education are needed for siblings of children with T1DM.

Controlling autoimmune diabetes onset by targeting Protease-Activated Receptor 2

BACKGROUND

Type 1 diabetes (T1D) is a challenging autoimmune disease, characterized by an immune system assault on insulin-producing β-cells. As insulin facilitates glucose absorption into cells and tissues, β-cell deficiency leads to elevated blood glucose levels on one hand and target-tissues starvation on the other. Despite efforts to halt β-cell destruction and stimulate recovery, success has been limited. Our recent investigations identified Protease-Activated Receptor 2 (Par2) as a promising target in the battle against autoimmunity. We discovered that Par2 activation's effects depend on its initial activation site: exacerbating the disease within the immune system but fostering regeneration in affected tissue.

METHODS

We utilized tissue-specific Par2 knockout mice strains with targeted Par2 mutations in β-cells, lymphocytes, and the eye retina (as a control) in the NOD autoimmune diabetes model, examining T1D onset and β-cell survival.

RESULTS

We discovered that Par2 expression within the immune system accelerates autoimmune processes, while its presence in β-cells offers protection against β-cell destruction and T1D onset. This suggests a dual-strategy treatment for T1D: inhibiting Par2 in the immune system while activating it in β-cells, offering a promising strategy for T1D.

CONCLUSIONS

This study highlights Par2's potential as a drug target for autoimmune diseases, particularly T1D. Our results pave the way for precision medicine approaches in treating autoimmune conditions through targeted Par2 modulation.

Accuracy of Two Continuous Glucose Monitoring Devices During Aerobic and High-Intensity Interval Training in Individuals with Type 1 Diabetes

Background: This study aimed to evaluate the accuracy of Dexcom G6 (DG6) and FreeStyle Libre-2 (FSL2) during aerobic training and high-intensity interval training (HIIT) in individuals with type 1 diabetes. Methods: Twenty-six males (mean age 29.3 ± 6.3 years and mean duration of diabetes 14.9 ± 6.1 years) participated in this study. Interstitial glucose levels were measured using DG6 and FSL2, while plasma glucose levels were measured every 10 min using YSI 2500 as the reference for glucose measurements in this study. The measurements began 20 min before the start of exercise and continued for 20 min after exercise. Seven measurements were taken for each subject and exercise. Results: Both DG6 and FSL2 devices showed significant differences compared to YSI glucose data for both aerobic and HIIT exercises. Continuous glucose monitoring (CGM) devices exhibited superior performance during HIIT than aerobic training, with DG6 showing a mean absolute relative difference of 14.03% versus 31.98%, respectively. In the comparison between the two devices, FSL2 demonstrated significantly higher effectiveness in aerobic training, yet its performance was inferior to DG6 during HIIT. According to the 40/40 criteria, both sensors performed similarly, with marks over 93% for all ranges and both exercises, and above 99% for HIIT and in the >180 mg/dL range, which is in accordance with FDA guidelines. Conclusions: The findings suggest that the accuracy of DG6 and FSL2 deteriorates during and immediately after exercise but remains acceptable for both devices during HIIT. However, accuracy is compromised with DG6 during aerobic exercise. This study is the first to compare the accuracy of two CGMs, DG6, and FSL2, during two exercise modalities, using plasma glucose YSI measurements as the gold standard for comparisons. It was registered at clinicaltrials.gov (NCT06080542).

Fibroblast growth factor 23 and calcium-phosphate metabolism in relation to cardiovascular risk factors in patients with type 1 diabetes

BACKGROUND

Cardiovascular disease (CVD) is the major cause of mortality in type 1 diabetes (T1D). The objective of this study is to evaluate fibroblast growth factor 23 (FGF23) and calcium-phosphate metabolism in relation to cardiovascular risk factors in adults with and without T1D.

METHODS

A case-control study was conducted using data from patients with T1D and age- and sex matched controls without T1D from the Lifelines Cohort Study.

RESULTS

We included 302 adults in the T1D group and 302 adults in the control group. Median age was 42 years. Median glycosylated hemoglobin (HbA1c) in the T1D group was 7.8%. FGF23 of all patients with T1D was not significantly different from controls. Females with T1D had significantly higher FGF23 than males with T1D (83.3 vs 69.3 U/mL, p = 0.002), this was not observed in controls. Serum phosphate, calcium, and alkaline phosphatase were higher and parathyroid hormone was lower in patients with T1D, compared to controls (all p < .001), all within normal range. In the T1D group, FGF23 was positively correlated with serum phosphate (p < .001), alkaline phosphatase (p = .01), and calcium (p = .030), these correlations were not observed in controls. Median FGF23 was significantly higher in current smokers than in nonsmokers with T1D (84.9 vs 73.5 U/mL, p < .05).

CONCLUSIONS

Serum calcium, phosphate, and alkaline phosphatase were higher in patients with T1D than in controls and were positively correlated to FGF23 in patients with T1D. Current smokers with T1D had higher FGF23 than nonsmokers with T1D. These findings may contribute to the increased risk of CVD in patients with T1D.

Genetic Causality between Type 1 Diabetes and Arrhythmia Identified by a Two-sample Mendelian Randomization Study

BACKGROUND

Clinical studies have shown that cardiovascular diseases in patients with type 1 diabetes (T1D) are often atypical or asymptomatic. The link between T1D and arrhythmia remains unclear. To infer causality between T1D and arrhythmia at the genetic level, we conducted a Mendelian randomization study through the genetic tools of T1D.

METHODS

In this study, we used genetic variables and summary statistics from genome-wide association studies of T1D and arrhythmia. Single nucleotide polymorphisms were selected based on the assumptions of instrumental variables. The inverse variance-weighted method was used as the primary analysis to summarize the causal effects between exposure and outcome. The weighted median and weighted mode methods were used as secondary methods. We tested for horizontal pleiotropy using the MR-Egger method and detected heterogeneity using the Q-test. A leave-one-out sensitivity analysis was performed. Scatter plots, forest plots, and funnel plots were used to visualize the results of the MR analysis.

RESULTS

In this study, we selected 28 T1D-related SNPs as instrumental variables. The IVW [odds ratio (OR) = 0.98, 95 % confidence interval (CI) = 0.97-1.00, P = 0.008], weighted median (OR = 0.98, 95 % CI = 0.96 - 0.99, P = 0.009), and weighted mode (OR = 0.98, 95 % CI = 0.96-0.99, P = 0.018) analysis methods suggested a causal effect of T1D on arrhythmia. The MR-Egger method indicated no horizontal pleiotropy (P = 0.649), and the Q-test showed no heterogeneity (IVW, P = 0.653).

CONCLUSIONS

Our MR analysis revealed a causal association between T1D and the development of arrhythmia, indicating that patients with T1D had a higher risk of arrhythmia.

Early juvenile cataract in newly diagnosed type 1 diabetic patients: a description of two cases

OBJECTIVES

To analyze and summarize the clinical characteristics and treatment of juvenile patients with type 1 diabetes mellitus (T1DM) complicated by early cataract.

CASE PRESENTATION

This retrospective study collected clinical data from 210 children and adolescents newly diagnosed with T1DM who were admitted to the Department of Pediatrics, Tongji Hospital (Wuhan) between 2015 and 2022. Among 210 patients with T1DM, early cataract developed within 3 months before diabetes onset and 12 months thereafter in 2 (0.95 %) patients. The two patients were both females, aged 13 and 9 years, respectively. In both cases, cataracts in both eyes appeared in the early stages of T1DM, showing a short course and rapid development. After intensive insulin treatment for stringent and stable blood glucose control, one patient underwent cataract extraction with significant improvement, and her visual acuity returned to normal. The other patient received intensive insulin therapy and insulin pump therapy for 8 years. Subsequently, she underwent cataract surgery after achieving stable blood glucose levels, without complete recovery of vision.

CONCLUSIONS

Cataract is a rare complication in the early stages of T1DM in children and adolescents. Ophthalmic surgery is the preferred treatment for patients with diabetic cataract after achieving stable glycemic control, which may help prevent visual impairment.

Long-Term Cost-Effectiveness of Continuous Glucose Monitoring Versus Self-Monitoring of Blood Glucose in Adults With Type 1 Diabetes in Iran

OBJECTIVES

This study aimed to determine long-term cost-effectiveness of continuous glucose monitoring (CGM) technology versus self-monitoring of blood glucose (SMBG) in adults with type 1 diabetes (T1D) using multiple daily injections in Iran.

METHODS

According to available data, the long-term costs and clinical outcomes of CGM and SMBG were estimated using the Sheffield Type 1 Diabetes Model, with a lifetime horizon from a payer's perspective. The primary outcome was the cost per quality-adjusted life year (QALY) gained.

RESULTS

The lifetime cost-effectiveness analysis demonstrated that on average, the use of CGM increased life expectancy by 1.32 years and QALYs by 1.63, compared with SMBG. The CGM group had an average discounted total cost of $40 093 US dollars, whereas the SMBG group had an average discounted total cost of $13 366. This resulted in an incremental cost-effectiveness ratio (ICER) of $16 386 per QALY gained, which is less than the threshold of 3 times the gross domestic product (GDP) per capita of Iran ($24 561).

CONCLUSIONS

Considering 3 times the GDP per capita as the threshold, CGM is likely to be cost-effective in Iran. However, for CGM to be very cost-effective (ie, have an ICER less than 1 times the GDP per capita) and presumably more accessible, the price of CGM should decrease to $40 per sensor, each with a lifespan of 14 days.

The impact of early-life exercise on CREB-signaling pathway and hippocampus neuroplasticity in diabetic adult male rats; the study of developmental model

BACKGROUND

Childhood exercise enhances brain structure, while diabetes detrimentally affects it. This study examines early-life exercise's influence on adult diabetic rats' memory and neuroplasticity.

METHODS

Male Wistar pups were divided into Control, Diabetes, Exercise Training, and Diabetes exercise groups. Diabetes was induced on day 23 with Alloxan (200 mg/kg). A 3-week regimen included aerobic and resistance training thrice weekly. The aerobic intensity was 70%, and resistance varied from 50% to 100% of the maximal carrying capacity (MCC). Following the last training sessions, spatial memory and retrieval tests were performed in infancy, childhood, and emerging adulthood using the Morris Water Maze test (MWM). The hippocampus was excised to measure protein and gene expression of brain-derived neurotrophic factor (BDNF), calmodulin-dependent protein kinase (CAMKII), N-methyl-D-aspartate receptors (NMDAR), and cAMP-response element-binding protein (CREB) by western blotting and reverse transcription-polymerase-chain reaction (RT-PCR) methods. Blood samples were collected during each developmental stage to measure glucose levels, at the study's conclusion, to assess Interleukin-1β levels using the ELISA method. The Nissel staining assessed dead hippocampal cells in CA1.

RESULTS

Post-natal exercise improved spatial memory (p < 0.05) and glucose levels (p < 0.05) in diabetic rats during adolescence and emerging adulthood. Despite reduced mRNA expression (NMDAR 40%, BDNF 62%, CREB 43%, CAMKII 66%), diabetic rats, by study end, showed increased BDNF, NMDARR, CAMKII, CREB protein/gene expression (p < 0.05) in emerging adulthood for both training groups.

CONCLUSION

Early-life exercise influenced hippocampal BDNF/NMDAR-CAMKII/CREB pathways in a diabetic rat model, highlighting post-natal exercise's role in neuroplasticity memory enhancement and improved glucose level.

Effects of digital self-care intervention for Korean older adults with type 2 diabetes: A randomized controlled trial over 12 weeks

This study developed and assessed the impact of a digitally enabled self-care intervention program tailored for older adults with type 2 diabetes led by nursing professionals. A randomized controlled trial of a 12-week digital self-care intervention was conducted with 105 older Korean adults with type 2 diabetes. The intervention involved self-recording in the DiaNote application, newly developed for the study and a phone visit. Participants were randomly allocated to DiaNote or traditional logbook groups. Outcomes were collected at baseline and again after 12 weeks. Generalized estimating equations indicated that HbA1c level changes over time significantly in DiaNote group. Diabetes self-care activities and quality of life changed over time in both groups. Self-efficacy did not significantly differ between groups or over time. The digital self-care intervention was beneficial for blood sugar control, being equivalent to using a traditional diabetes logbook for quality of life and diabetic self-care.

The Extra-Islet Pancreas Supports Autoimmunity in Human Type 1 Diabetes

In autoimmune Type 1 diabetes (T1D), immune cells infiltrate and destroy the islets of Langerhans - islands of endocrine tissue dispersed throughout the pancreas. However, the contribution of cellular programs outside islets to insulitis is unclear. Here, using CO-Detection by indEXing (CODEX) tissue imaging and cadaveric pancreas samples, we simultaneously examine islet and extra-islet inflammation in human T1D. We identify four sub-states of inflamed islets characterized by the activation profiles of CD8 + T cells enriched in islets relative to the surrounding tissue. We further find that the extra-islet space of lobules with extensive islet-infiltration differs from the extra-islet space of less infiltrated areas within the same tissue section. Finally, we identify lymphoid structures away from islets enriched in CD45RA + T cells - a population also enriched in one of the inflamed islet sub-states. Together, these data help define the coordination between islets and the extra-islet pancreas in the pathogenesis of human T1D.

Gut Inflammation Markers, Diet, and Risk of Islet Autoimmunity in Finnish Children - A Nested Case-Control Study

BACKGROUND

Gut dysbiosis and increased intestinal permeability have been reported to precede type 1 diabetes-related autoimmunity. The role of gut inflammation in autoimmunity is not understood.

OBJECTIVES

This study aimed to assess whether gut inflammation markers are associated with risk of islet autoimmunity and whether diet is associated with gut inflammation markers.

METHODS

A nested case-control sample of 75 case children with islet autoimmunity and 88 control children was acquired from the Finnish Type 1 Diabetes Prediction and Prevention cohort. Diet was assessed with 3-d food records, and calprotectin and human β-defensin-2 (HBD-2) were analyzed from stool samples at 6 and 12 mo of age. Conditional logistic regression analysis was used in a matched case-control setting to assess risk of autoimmunity. Analysis of variance, independent samples t test, and a general linear model were used in secondary analyses to test associations of background characteristics and dietary factors with inflammation markers.

RESULTS

In unadjusted analyses, calprotectin was not associated with risk of islet autoimmunity, whereas HBD-2 in the middle (odds ratio [OR]: 3.23; 95% confidence interval [CI]: 1.03, 10.08) or highest tertile (OR: 3.02; 95% CI: 1.05, 8.69) in comparison to the lowest at 12 mo of age showed borderline association (P-trend = 0.063) with higher risk of islet autoimmunity. Excluding children with cow milk allergy in sensitivity analyses strengthened the association of HBD-2 with islet autoimmunity, whereas adjusting for dietary factors and maternal education weakened it. At age 12 mo, higher fat intake was associated with higher HBD-2 (β: 0.219; 95% CI: 0.110, 0.328) and higher intake of dietary fiber (β: -0.294; 95% CI: -0.510, -0.078), magnesium (β: -0.036; 95% CI: -0.059, -0.014), and potassium (β: -0.003; 95% CI: -0.005, -0.001) with lower HBD-2.

CONCLUSIONS

Higher HBD-2 in infancy may be associated with higher risk of islet autoimmunity. Dietary factors play a role in gut inflammatory status.

Targeting skeletal muscle health with exercise in people with type 1 diabetes: A protocol for HOMET1D, a prospective observational trial with matched controls

INTRODUCTION

Individuals with type 1 diabetes (T1D) experience a complex set of alterations to skeletal muscle metabolic, neuromuscular, and vascular health; collectively referred to as diabetic myopathy. While the full scope of diabetic myopathy is still being elucidated, evidence suggests that even when individuals with T1D are physically active, indices of myopathy still exist. As such, there is a question if adherence to current physical activity guidelines elicits improvements in skeletal muscle health indices similarly between individuals with and without T1D. The objectives of this trial are to: 1) compare baseline differences in skeletal muscle health between adults with and without T1D, 2) examine the association between participation in a home-based exercise program, detraining, and retraining, with changes in skeletal muscle health, and 3) examine the roles of age and sex on these associations.

METHODS AND ANALYSIS

This will be a prospective interventional trial. Younger (18-30 years) and older (45-65 years) males and females with T1D and matched individuals without T1D will engage in a four-phase, 18-week study sequentially consisting of a one-week lead-in period, 12-week exercise training program, one-week detraining period, and four-week retraining period. The exercise program will consist of aerobic and resistance exercise based on current guidelines set by Diabetes Canada. Metabolic, neuromuscular, and vascular outcome measures will be assessed four times: at baseline, post-exercise program, post-detraining, and post-retraining. Differences in baseline metrics between those with and without T1D will be examined with independent sample t-tests, and with two-way analyses of variance for age- and sex-stratified analyses. Changes across the duration of the study will be examined using mixed-model analyses.

DISSEMINATION

Findings from this research will be shared locally and internationally with research participants, clinicians, diabetes educators, and patient advocacy organizations via in-person presentations, social media, and scientific fora.

TRIAL REGISTRATION NUMBER

NCT05740514.

A multi-ancestry genome-wide association study in type 1 diabetes

Type 1 diabetes (T1D) is an autoimmune disease caused by destruction of the pancreatic β-cells. Genome-wide association (GWAS) and fine mapping studies have been conducted mainly in European ancestry (EUR) populations. We performed a multi-ancestry GWAS to identify SNPs and HLA alleles associated with T1D risk and age at onset. EUR families (N = 3223), and unrelated individuals of African (AFR, N = 891) and admixed (Hispanic/Latino) ancestry (AMR, N = 308) were genotyped using the Illumina HumanCoreExome BeadArray, with imputation to the TOPMed reference panel. The Multi-Ethnic HLA reference panel was utilized to impute HLA alleles and amino acid residues. Logistic mixed models (T1D risk) and frailty models (age at onset) were used for analysis. In GWAS meta-analysis, seven loci were associated with T1D risk at genome-wide significance: PTPN22, HLA-DQA1, IL2RA, RNLS, INS, IKZF4-RPS26-ERBB3, and SH2B3, with four associated with T1D age at onset (PTPN22, HLA-DQB1, INS, and ERBB3). AFR and AMR meta-analysis revealed NRP1 as associated with T1D risk and age at onset, although NRP1 variants were not associated in EUR ancestry. In contrast, the PTPN22 variant was significantly associated with risk only in EUR ancestry. HLA alleles and haplotypes most significantly associated with T1D risk in AFR and AMR ancestry differed from that seen in EUR ancestry; in addition, the HLA-DRB1*08:02-DQA1*04:01-DQB1*04:02 haplotype was 'protective' in AMR while HLA-DRB1*08:01-DQA1*04:01-DQB1*04:02 haplotype was 'risk' in EUR ancestry, differing only at HLA-DRB1*08. These results suggest that much larger sample sizes in non-EUR populations are required to capture novel loci associated with T1D risk.

Ultrashort-Peptide-Responsive Gene Switches for Regulation of Therapeutic Protein Expression in Mammalian Cells

Despite the array of mammalian transgene switches available for regulating therapeutic protein expression in response to small molecules or physical stimuli, issues remain, including cytotoxicity of chemical inducers and limited biocompatibility of physical cues. This study introduces gene switches driven by short peptides comprising eight or fewer amino acid residues. Utilizing a competence regulator (ComR) and sigma factor X-inducing peptide (XIP) from Streptococcus vestibularis as the receptor and inducer, respectively, this study develops two strategies for a peptide-activated transgene control system. The first strategy involves fusing ComR with a transactivation domain and utilizes ComR-dependent synthetic promoters to drive expression of the gene-of-interest, activated by XIP, thereby confirming its membrane penetrability and intracellular functionality. The second strategy features an orthogonal synthetic receptor exposing ComR extracellularly (ComREXTRA), greatly increasing sensitivity with exceptional responsiveness to short peptides. In a proof-of-concept study, peptides are administered to type-1 diabetic mice with microencapsulated engineered human cells expressing ComREXTRA for control of insulin expression, restoring normoglycemia. It is envisioned that this system will encourage the development of short peptide drugs and promote the introduction of non-toxic, orthogonal, and highly biocompatible personalized biopharmaceuticals for gene- and cell-based therapies.

GLP-1 Analogue-Loaded Glucose-Responsive Nanoparticles as Allies of Stem Cell Therapies for the Treatment of Type I Diabetes

Type 1 diabetes (T1D) is characterized by insufficient insulin secretion due to β-cell loss. Despite exogenous insulin administration being a lifesaving treatment, many patients still experience severe glycemic lability. For these patients, a β-cell replacement strategy through pancreas or pancreatic islet transplantation is the most physiological approach. However, donors' scarcity and the need for lifelong immunosuppressive therapy pose some challenges. This study proposes an innovative biomimetic pancreas, comprising β- and α-cells differentiated from human induced pluripotent stem cells (hiPSCs) embedded in a biofunctional matrix with glucose-responsive nanoparticles (NPs) encapsulating a glucagon-like peptide 1 (GLP-1) analogue, which aims to enhance the glucose responsiveness of differentiated β-cells. Herein, glucose-sensitive pH-responsive NPs encapsulating exenatide or semaglutide showed an average size of 145 nm, with 40% association efficiency for exenatide-loaded NPs and 55% for semaglutide-loaded NPs. Both peptides maintained their secondary structure after in vitro release and showed a similar effect on INS-1E cells' insulin secretion. hiPSCs were differentiated into β- and α-cells, and insulin-positive cells were obtained (82%), despite low glucose responsiveness, as well as glucagon-positive cells (17.5%). The transplantation of the developed system in diabetic mice showed promising outcomes since there was an increase in the survival rate of those animals. Moreover, diabetic mice transplanted with cells and exenatide showed a decrease in their glucose levels. Overall, the biomimetic pancreas developed in this work showed improvements in diabetic mice survival rate, paving the way for new cellular therapies for T1D that explore the synergy of nanomedicines and stem cell-based approaches.

Appropriateness and acceptability of continuous glucose monitoring in people with type 1 diabetes at rural first-level hospitals in Malawi: a qualitative study

OBJECTIVES

The purpose of this qualitative study is to describe the acceptability and appropriateness of continuous glucose monitoring (CGM) in people living with type 1 diabetes (PLWT1D) at first-level (district) hospitals in Malawi.

DESIGN

We conducted semistructured qualitative interviews among PLWT1D and healthcare providers participating in the study. Standardised interview guides elicited perspectives on the appropriateness and acceptability of CGM use for PLWT1D and their providers, and provider perspectives on the effectiveness of CGM use in Malawi. Data were coded using Dedoose software and analysed using a thematic approach.

SETTING

First-level hospitals in Neno district, Malawi.

PARTICIPANTS

Participants were part of a randomised controlled trial focused on CGM at first-level hospitals in Neno district, Malawi. Pretrial and post-trial interviews were conducted for participants in the CGM and usual care arms, and one set of interviews was conducted with providers.

RESULTS

Eleven PLWT1D recruited for the CGM randomised controlled trial and five healthcare providers who provided care to participants with T1D were included. Nine PLWT1D were interviewed twice, two were interviewed once. Of the 11 participants with T1D, six were from the CGM arm and five were in usual care arm. Key themes emerged regarding the appropriateness and effectiveness of CGM use in lower resource setting. The four main themes were (a) patient provider relationship, (b) stigma and psychosocial support, (c) device usage and (d) clinical management.

CONCLUSIONS

Participants and healthcare providers reported that CGM use was appropriate and acceptable in the study setting, although the need to support it with health education sessions was highlighted. This research supports the use of CGM as a component of personalised diabetes treatment for PLWT1D in resource constraint settings.

TRIAL REGISTRATION NUMBER

PACTR202102832069874; Post-results.

Does vitamin D supplementation benefit patients with type 1 diabetes mellitus who are vitamin D deficient? A study was performed at the Sudan Childhood Diabetes Center from 2019 to 2022

Objectives

Type 1 diabetes mellitus is a chronic autoimmune disease caused by insufficient production of insulin. Many studies have linked type 1 diabetes mellitus to vitamin D3 deficiency. We investigated the prevalence of vitamin D deficiency in Sudanese children and adolescents with type 1 diabetes mellitus and assessed the impact of vitamin D deficiency treatment on their glycemic control.

Methods

In 2019-2022, we conducted a quasi-experimental study on 115 children with type 1 diabetes mellitus (1-19 years old) at the Sudan Childhood Diabetes Center. Vitamin D supplements were given orally to deficient patients for 3 months. The concentrations of hemoglobin A1c, fasting blood glucose, insulin dosage, and vitamin D (25-hydroxyvitamin D (25(OH)D)) were measured before and after vitamin D3 administration. One-way ANOVA and paired sample t-tests were used to evaluate the effect of supplementation.

Results

Only 27% of type 1 diabetes mellitus children were deficient in vitamin D, whereas 31.1% were inadequate and 40.9% were sufficient. The administration of vitamin D supplements slightly improved hemoglobin A1c levels in 67.7% of the patients, but the difference was not significant (mean 10.8 ± 2.1% before, 10.1 ± 2.5% after, p0.05 = 0.199). However, there was a significant decrease in the fasting blood glucose level (mean: 174.978.5-136.759.1 ng/ml; p0.05 = 0.049). Vitamin D levels were significantly increased after treatment (mean = 49.6 ng/mL; t-test = -11.6, 95% CI 40.8-(-28.6); p0.05 = 0.000). After vitamin D3 supplementation, 25.8% of individuals changed their insulin dosage; however, there was no significant variation in insulin needs.

Conclusions

The prevalence of vitamin D deficiency in children and adolescents with type 1 diabetes mellitus in Sudan is relatively high; incorporating vitamin D supplements in their treatment plan may improve their glycemic control.

Insulin sensitivity estimates and their longitudinal association with coronary artery disease in type 1 diabetes. Does it matter?

BACKGROUND

Insulin resistance and chronic kidney disease are both associated with increased coronary artery disease risk. Many formulae estimating glucose disposal rate in type 1 diabetes infer insulin sensitivity from clinical data. We compare associations and performance relative to traditional risk factors and kidney disease severity between three formulae estimating the glucose disposal rate and coronary artery disease in people with type 1 diabetes.

METHODS

The baseline glucose disposal rate was estimated by three (Williams, Duca, and Januszewski) formulae in FinnDiane Study participants and related to subsequent incidence of coronary artery disease, by baseline kidney status.

RESULTS

In 3517 adults with type 1 diabetes, during median (IQR) 19.3 (14.6, 21.4) years, 539 (15.3%) experienced a coronary artery disease event, with higher rates with worsening baseline kidney status. Correlations between the three formulae estimating the glucose disposal rate were weak, but the lowest quartile of each formula was associated with higher incidence of coronary artery disease. Importantly, only the glucose disposal rate estimation by Williams showed a linear association with coronary artery disease risk in all analyses. Of the three formulae, Williams was the strongest predictor of coronary artery disease. Only age and diabetes duration were stronger predictors. The strength of associations between estimated glucose disposal rate and CAD incidence varied by formula and kidney status.

CONCLUSIONS

In type 1 diabetes, estimated glucose disposal rates are associated with subsequent coronary artery disease, modulated by kidney disease severity. Future research is merited regarding the clinical usefulness of estimating the glucose disposal rate as a coronary artery disease risk factor and potential therapeutic target.

Prevalence and predictive features of metabolic dysfunction-associated steatotic liver disease in type 1 diabetes

AIMS/HYPOTHESIS

The prevalence and severity of metabolic dysfunction-associated steatotic liver disease (MASLD) in type 1 diabetes remain unclear. Therefore, we investigated the prevalence and severity of MASLD in type 1 diabetes and assessed which clinical features are most important in predicting MASLD severity.

METHODS

A total of 453 individuals with type 1 diabetes (41.6 ± 15.0 years, 64% female, body mass index [BMI] 25.4 ± 4.2 kg/m2, and HbA1c 55.6 ± 12 mmol/mol) underwent vibration-controlled transient elastography (VCTE), with a controlled attenuation parameter (CAP) score for steatosis (≥280.0 dB/m) and a liver stiffness measurement (LMS) for fibrosis (≥8.0 kPa). A machine learning Extra-Trees classification model was performed to assess the predictive power of the clinical features associated with type 1 diabetes with respect to steatosis and fibrosis.

RESULTS

The prevalence of hepatic steatosis and fibrosis was 9.5% (95% CI, 6.8-12.2) and 3.5% (95% CI, 1.8-5.2). Higher LMS was associated with a longer duration of type 1 diabetes (median 30.5 [IQR 18.0-39.3] years vs 15.0 [IQR 6.0-27.0] years), and individuals were older, had a higher BMI (mean 27.8 ± 5.2 vs 25.3 ± 4.1 kg/m2), and a higher CAP score (mean 211.4 ± 51.7 dB/m vs 241.4 ± 75.6 dB/m). The most important predictive features of fibrosis were duration of type 1 diabetes, age, and systolic blood pressure, with a mean ± SD area under the curve of 0.73 ± 0.03.

CONCLUSION

Individuals with type 1 diabetes and high blood pressure, older age, higher BMI, and longer duration of disease could be considered at high-risk for developing MASLD.

Does size matter? Hospital volume and resource use in paediatric diabetes care

AIMS

Paediatric diabetes care has become increasingly specialised due to the multidisciplinary approach and technological developments. Guidelines recommend sufficient experience of treatment teams. This study evaluates associations between hospital volume and resource use and hospital expenditure in Dutch children with diabetes.

METHODS

Retrospective cohort study using hospital claims data of 5082 children treated across 44 Dutch hospitals (2019-2020). Hospitals were categorised into three categories; small (≥20-100 patients), medium (≥100-200 patients) and large (≥200 patients). All-cause hospitalisations, consultations, technology and hospital expenditure were analysed and adjusted for age, sex, socio-economic status (SES) and hospital of treatment.

RESULTS

Fewer hospitalisations were observed in large hospitals compared to small hospitals (OR 0.48; [95% CI 0.32-0.72]; p < 0.001). Median number of yearly paediatrician visits was 7 in large and 6 in small hospitals, the significance of which was attenuated in multilevel analysis (OR ≥7 consultations: 1.89; [95%CI 0.74-4.83]; p = 0.18). Technology use varies between individual hospitals, whereas pump usage and real-time continuous glucose monitoring showed no significant differences between hospital volumes. Mean overall expenditure was highest in medium-sized centres with €6434 per patient (IQR €2555-7955); the difference in diabetes care costs was not significant between hospital patient volumes.

CONCLUSIONS

Care provision patterns vary by hospital patient volume. Large hospitals had the lowest hospitalisation rates. The use of diabetes technology was not different between hospital patient volumes. Medium-sized hospitals showed the highest overall expenditure, but diabetes care costs were similar across hospital volumes.

Conveying the pathogenesis of type 1 diabetes to the blind, low-vision and diverse needs communities through sensory stimulation

To educate members of the blind, low-vision and diverse needs communities on the pathogenesis of the chronic autoimmune disease, type 1 diabetes, members of our team with research expertise in immune-mediated diseases, participated in the 2023 Monash Sensory Science (MSS) Exhibition. Using QR code linked audio commentary, participants were guided through tactile displays demonstrating normal insulin action in the regulation of blood glucose levels and its vital role in providing energy to tissues, followed by displays describing the various stages of the immune system's aberrant attack and the eventual complete destruction of the insulin producing beta-cells of the pancreatic islets in type 1 diabetes. These models conveyed to the participants the huge effect that this autoimmune-mediated disease has on the quality of life of affected individuals including the subsequent lifelong reliance on insulin injections to maintain glucose homeostasis. This MSS Exhibition provided a unique opportunity for our researchers to engage with under-represented members of the community and to raise awareness about such a debilitating and common autoimmune disease.

Familial aggregation and heritability of childhood-onset and adult-onset type 1 diabetes: a Swedish register-based cohort study

BACKGROUND

Type 1 diabetes in children is known to be highly heritable, but much less is known about the heritability of adult-onset type 1 diabetes. Thus, our objective was to compare the familial aggregation and heritability of type 1 diabetes in adults and children.

METHODS

This Swedish nationwide register-based cohort study included individuals born from Jan 1, 1982, to Dec 31, 2010, identified through the Medical Birth Register who were linked to their parents, full siblings, half siblings, and cousins through the Multi-Generation Register (MGR). We excluded multiple births, deaths within the first month of life, individuals who could not be linked to MGR, or individuals with contradictory information on sex. Information on diagnoses of type 1 diabetes was retrieved by linkages to the National Diabetes Register and National Patient Register (1982-2020). Individuals with inconsistent records of diabetes type were excluded. We estimated the cumulative incidence and hazard ratios (HRs) of type 1 diabetes in adults (aged 19-30 years) and children (aged 0-18 years) by family history of type 1 diabetes and the heritability of adult-onset and childhood-onset type 1 diabetes based on tetrachoric correlations, using sibling pairs.

FINDINGS

2 943 832 individuals were born in Sweden during the study period, 2 832 755 individuals were included in the analysis of childhood-onset type 1 diabetes and 1 805 826 individuals were included in the analysis of adult-onset type 1 diabetes. 3240 cases of adult-onset type 1 diabetes (median onset age 23·4 years [IQR 21·1-26·2]; 1936 [59·7%] male and 1304 [40·2%] female) and 17 914 cases of childhood-onset type 1 diabetes (median onset age 9·8 years [6·2-13·3]; 9819 [54·8%] male and 8095 [45·2%] female) developed during follow-up. Having a first-degree relative with type 1 diabetes conferred an HR of 7·21 (95% CI 6·28-8·28) for adult-onset type 1 diabetes and 9·92 (9·38-10·50) for childhood-onset type 1 diabetes. The HR of developing type 1 diabetes before the age 30 years was smaller if a first-degree relative developed type 1 diabetes during adulthood (6·68 [6·04-7·39]) rather than during childhood (10·54 [9·92-11·19]). Similar findings were observed for type 1 diabetes in other relatives. Heritability was lower for adult-onset type 1 diabetes (0·56 [0·45-0·66]) than childhood-onset type 1 diabetes (0·81 [0·77-0·85]).

INTERPRETATION

Adult-onset type 1 diabetes seems to have weaker familial aggregation and lower heritability than childhood-onset type 1 diabetes. This finding suggests a larger contribution of environmental factors to the development of type 1 diabetes in adults than in children and highlights the need to identify and intervene on such factors.

FUNDING

Swedish Research Council, the Swedish Research Council for Health, Working Life and Welfare, Swedish Diabetes Foundation, and the China Scholarship Council.

A Gene-Switch Platform Interfacing with Reactive Oxygen Species Enables Transcription Fine-Tuning by Soluble and Volatile Pharmacologics and Food Additives

Synthetic biology aims to engineer transgene switches for precise therapeutic protein control in cell-based gene therapies. However, off-the-shelf trigger-inducible gene circuits are usually switched on by single or structurally similar molecules. This study presents a mammalian gene-switch platform that controls therapeutic gene expression by a wide range of molecules generating low, non-toxic levels of reactive oxygen species (ROS). In this system, KEAP1 (Kelch-like ECH-associated protein 1) serves as ROS sensor, regulating the translocation of NRF2 (nuclear factor erythroid 2-related factor 2) to the nucleus, where NRF2 binds to  antioxidant response elements (ARE) to activate the expression of a gene of interest. It is found that a promoter containing eight-tandem ARE repeats is highly sensitive to the low ROS levels generated by the soluble and volatile molecules, which include food preservatives, food additives, pharmaceuticals, and signal transduction inducers. In a proof-of-concept study, it is shown that many of these compounds can independently trigger microencapsulated engineered cells to produce sufficient insulin to restore normoglycemia in experimental type-1 diabetic mice. It is believed that this system greatly extends the variety of small-molecule inducers available to drive therapeutic gene switches.

The effect of exercise on sleep habits of children with type 1 diabetic: a randomized clinical trial

BACKGROUND

Adequate sleep and exercise are important components of the human lifestyle. Paying attention to these two factors is very important to improve the condition of children with type 1 diabetes. Therefore, this study aimed to investigate the effect of exercise on sleep habits in children with type 1 diabetes.

MATERIAL & METHODS

62 children with type 1 diabetes participated in this clinical trial. They will be divided into the intervention group (31) and the control group (31). Sleep habits were measured using the Children's Sleep Habits Questionnaire (CSHQ). All children's parents completed the CSHQ. The intervention for the experimental group consisted of 8 weeks of regular exercise program. The exercise program was prepared as an educational video and provided to parents. Paired sample t-test and ANCOVA test were used with SPSS 23.

RESULTS

62 children with an average age of 9.32 ± 2.02 were studied. Fifty-four and eight% of the children were girls and the rest were boys. The analysis of the variance test showed a significant difference (F = 144.72, P ≤ 0.01) between the average score of the sleep habits of the control group (62.45 ± 5.12) and the experimental group (47.06 ± 4.39).

CONCLUSION

Sleep habits in the experimental group improved after 8 weeks of exercise training using educational videos. Exercise as a non-pharmacological treatment is an effective way to manage diabetes and improve sleep quality in diabetic children.

Living with type 1 diabetes and schooling among young people in Ghana: a truism of health selection, inadequate support, or artefactual explanation of educational inequalities?

INTRODUCTION

Type 1 diabetes mellitus (T1DM) is mostly diagnosed among young people. Despite the evidence that T1DM is disruptive, and affects individuals' health and cognitive ability, there is dearth of knowledge on the impact of T1DM on schooling in LMICs including Ghana. In this research, we explored the impact of T1DM on the schooling of young people living with the disease, and discussed the results within health selection, social support, and artefactual perspectives of inequality.

METHODS

Data were extracted from a qualitative project on T1DM lived experiences in southern Ghana. The study participants were young persons living with T1DM (n = 28) and their caregivers (n = 12). They were purposively recruited to participate in the study using maximum variation and snowball sampling techniques and interviewed in their support group centres, homes, or healthcare facilities using semi-structured interview guides. A computer-assisted qualitative data analysis was performed using QSR NVivo 14 software, and the results were categorised into themes.

RESULTS

Three themes were identified from the transcripts. These themes were school and classroom attendance, choice of school, and school/academic performance. T1DM was a major reason for patients' limited contact hours with teachers, school drop-out, preference for day schools rather than boarding, opting for vocational training instead of continuation of formal education, limited concentration at school, and delayed educational progression.

CONCLUSION

T1DM impacted the schooling of young people living with the disease. The mechanisms of these impacts, and young peoples lived experiences are not artefactual, but rather support discourses on health selection and inadequate social support for young people living with the disease. The results call for the need to develop educational and social interventions to address these barriers. The full implementation of the Inclusive Education Policy (IEP) may contribute to reducing educational and social inequalities caused by ill-health.

Prevalence of Type 1 Diabetes Among US Children and Adults by Age, Sex, Race, and Ethnicity

This study uses data from the 2019 to 2022 cycles of the National Health Interview Survey to estimate the prevalence of type 1 diabetes among US youths and adults.

Q-Score Complements the Time in Range in the Evaluation of Short-Term Glycemic Control

BACKGROUND AND AIMS

The Q-Score is a single-number composite metric that is constructed based on the following components: central glycemic tendency, hyperglycemia, hypoglycemia, and intra- and interday variability. Herein, we refined the Q-Score for the screening and analysis of short-term glycemic control using continuous glucose monitoring (CGM) profiles.

METHODS

Continuous glucose monitoring profiles were obtained from noninterventional, retrospective cross-sectional studies. The upper limit of the Q-Score component hyperglycemia' that is, the time above target range (TAR), was adjusted from 8.9 to 10 mmol/L (n = 1562 three-day-sensor profiles). A total of 302 people with diabetes mellitus treated with intermittent CGM for ≥14 days were enrolled. The time to stability was determined via correlation-based analysis.

RESULTS

There was a strong correlation between the Q-Scores of the two TARs, that is, 8.9 and 10 mmol/L (Q-ScoreTAR10 = -0.03 + 1.00 Q-ScoreTAR8.9, r = .997, p < .001). The times to stability of the Q-Score and TIR were 10 and 12 days, respectively. The Q-Score was correlated with fructosamine concentrations, the glucose management indicator (GMI), the time in range (TIR), and the glycemic risk index (GRI) (r = .698, .887, -.874, and .941), respectively. The number of Q-Score components above the target increased as the TIR decreased, from two (1.7 ± 0.9) in CGM profiles with a TIR between 70% and 80% to four (3.9 ± 0.5) in the majority of the CGM profiles with a TIR below 50%. A conversion matrix between the Q-Score and glycemic indices was developed.

CONCLUSIONS

The Q-Score is a tool for assessing short-term glycemic control. The Q-Score can be translated into clinician opinion using the GRI.

Revolutionizing pancreatic islet organoid transplants: Improving engraftment and exploring future frontiers

Type-1 Diabetes Mellitus (T1DM) manifests due to pancreatic beta cell destruction, causing insulin deficiency and hyperglycaemia. Current therapies are inadequate for brittle diabetics, necessitating pancreatic islet transplants, which however, introduces its own set of challenges such as paucity of donors, rigorous immunosuppression and autoimmune rejection. Organoid technology represents a significant stride in the field of regenerative medicine and bypasses donor-based approaches. Hence this article focuses on strategies enhancing the in vivo engraftment of islet organoids (IOs), namely vascularization, encapsulation, immune evasion, alternative extra-hepatic transplant sites and 3D bioprinting. Hypoxia-induced necrosis and delayed revascularization attenuate organoid viability and functional capacity, alleviated by the integration of diverse cell types e.g., human amniotic epithelial cells (hAECs) and human umbilical vein endothelial cells (HUVECs) to boost vascularization. Encapsulation with biocompatible materials and genetic modifications counters immune damage, while extra-hepatic sites avoid surgical complications and immediate blood-mediated inflammatory reactions (IBMIR). Customizable 3D bioprinting may help augment the viability and functionality of IOs. While the clinical translation of IOs faces hurdles, preliminary results show promise. This article underscores the importance of addressing challenges in IO transplantation to advance their use in treating type 1 diabetes effectively.

Efficacy of the hybrid closedloop insulin delivery system in children and adolescents with type 1 diabetes: a meta-analysis with trial sequential analysis

The aim of this study was to assess the efficacy and safety of hybrid closed-loop (HCL) systems for insulin delivery in children and adolescents with type 1 diabetes (T1D). We searched Embase, PubMed, and Cochrane Library for randomized controlled trials (RCTs) published until March 2023 comparing the HCL therapy with control therapies for children and adolescents with T1D. We computed weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) with 95% confidence intervals (CIs) for binary endpoints. Four RCTs and 501 patients were included, of whom 323 were randomized to HCL therapy. Compared with control therapies, HCL significantly improved the period during which glucose level was 70-180 mg/dL (WMD 10.89%, 95% CI 8.22-13.56%) and the number of participants with glycated hemoglobin (HbA1c) level < 7% (RR 2.61, 95% CI 1.29-5.28). Also, HCL significantly reduced the time during which glucoselevel was > 180 mg/dL (WMD-10.46%, 95% CI-13.99 to-6.93%) and the mean levels of glucose (WMD-16.67 mg/dL, 95% CI-22.25 to-11.09 mg/dL) and HbA1c (WMD-0.50%, 95% CI-0.68 to-0.31). There were no significant differences between therapies regarding time during which glucose level was < 70 mg/dL or <54 mg/dL or number of episodes of ketoacidosis, hyperglycemia, and hypoglycemia. In this meta-analysis, HCL compared with control therapies was associated with improved time in range and HbA1c control in children and adolescents with T1D and a similar profile of side effects. These findings support the efficacy of HCL in the treatment of T1D in this population.

Simplified integration of optimal self-management behaviors is associated with improved HbA1c in patients with type 1 diabetes

PURPOSE

Living with type 1 diabetes requires burdensome and complex daily diabetes self-management behaviors. This study aimed to determine the association between integrated behavior performance and HbA1c, while identifying the behavior with the most significant impact on HbA1c.

METHODS

A simple and feasible questionnaire was used to collect diabetes self-management behavior in patients with type 1 diabetes (n = 904). We assessed six dimensions of behavior performance: continuous glucose monitor (CGM) usage, frequent glucose testing, insulin pump usage, carbohydrate counting application, adjustment of insulin doses, and usage of apps for diabetes management. We evaluated the association between these behaviors and HbA1c.

RESULTS

In total, 21.3% of patients performed none of the allotted behavior, while 28.5% of patients had a total behavior score of 3 or more. 63.6% of patients with a behavior score ≥ 3 achieved HbA1c goal, contrasting with only 30.4% of patients with a behavior score of 0-1. There was a mean 0.54% ± 0.05% decrease in HbA1c for each 1-unit increase in total behavior score after adjustment for age, family education and diabetes duration. Each behavior was independently correlated with a lower HbA1c level, with CGM having the most significant effect on HbA1c levels.

CONCLUSIONS

Six optimal self-management behaviors, especially CGM usage, were associated with improved glycemic control, emphasizing the feasibility of implementing a simplified version of DSMES in the routine clinical care.

REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT03610984.

The risk of Type 1 diabetes in children born after ART: a Nordic cohort study from the CoNARTaS group

STUDY QUESTION

Do children born after ART have a higher risk of developing Type 1 diabetes (DM1) than children conceived without ART?

SUMMARY ANSWER

The risk of DM1 was similar for children conceived with and without ART, and there were no clear differences in risk according to method of fertility treatment.

WHAT IS KNOWN ALREADY

ART is associated with a higher risk of adverse perinatal outcomes, and the risk depends on the method of ART. The Developmental Origins of Health and Disease theory proposes that prenatal stress can provoke changes in endocrine processes which impact health later in life.

STUDY DESIGN SIZE DURATION

A Nordic register-based cohort study was carried out, including all children born in Denmark (birth years 1994-2014), Finland (1990-2014), and Norway (1984-2015). The study included 76 184 liveborn singletons born after ART and 4 403 419 born without ART. Median follow-up was 8.3 and 13.7 years in the ART and non-ART group, respectively.

PARTICIPANTS/MATERIALS SETTING METHODS

The cohort, initiated by the Committee of Nordic Assisted Reproductive Technology and Safety (CoNARTaS), was established by linking national registry data from the medical birth registries and national patient registries available in the Nordic countries. We performed multivariable logistic regression analyses for the birth year intervals 1984-1990, 1991-1995, 1996-2000, 2001-2005, 2006-2010, and 2011-2015, while adjusting for year of birth within each interval, sex of the child, parity, maternal age, maternal diabetes, and maternal smoking during pregnancy as potential confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

During follow-up, 259 (3.4‰) children born after ART were diagnosed with DM1, while this was the case for 22 209 (5.0‰) born without ART, corresponding to an adjusted odds ratio of 0.98 (95% CI: 0.861.11). Within the different birth year intervals, no significant difference in risk of DM1 between the two groups was found, except for the youngest cohort of children born 2011-2015 where ART was associated with a higher risk of DM1. We found no significant differences in risk of DM1 when comparing children born after IVF versus ICSI or fresh versus frozen embryo transfer, but with only few cases in each group.

LIMITATIONS REASONS FOR CAUTION

The main limitation of the study is the relatively short follow-up time. The incidence rate of DM1 peaks during ages 10-14 years, hence a longer follow-up would benefit all analyses and, in particular, the subgroup analyses.

WIDER IMPLICATIONS OF THE FINDINGS

Overall, our findings are reassuring especially considering the concomitantly increasing number of children born from ART and the increasing incidence of DM1 globally.

STUDY FUNDING/COMPETING INTERESTS

This Nordic registry study has been supported by the Nordic Trial Alliance/NORDFORSK and Rigshospitalets Research Foundation. The funding sources had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. None of the authors has any conflicts of interest to declare regarding this study.

TRIAL REGISTRATION NUMBER

ISRCTN11780826.

Factors Governing B Cell Recognition of Autoantigen and Function in Type 1 Diabetes

Islet autoantibodies predict type 1 diabetes (T1D) but can be transient in murine and human T1D and are not thought to be directly pathogenic. Rather, these autoantibodies signal B cell activity as antigen-presenting cells (APCs) that present islet autoantigen to diabetogenic T cells to promote T1D pathogenesis. Disrupting B cell APC function prevents T1D in mouse models and has shown promise in clinical trials. Autoantigen-specific B cells thus hold potential as sophisticated T1D biomarkers and therapeutic targets. B cell receptor (BCR) somatic hypermutation is a mechanism by which B cells increase affinity for islet autoantigen. High-affinity B and T cell responses are selected in protective immune responses, but immune tolerance mechanisms are known to censor highly autoreactive clones in autoimmunity, including T1D. Thus, different selection rules often apply to autoimmune disease settings (as opposed to protective host immunity), where different autoantigen affinity ceilings are tolerated based on variations in host genetics and environment. This review will explore what is currently known regarding B cell signaling, selection, and interaction with T cells to promote T1D pathogenesis.

Abaloparatide is more potent than teriparatide in restoring bone mass and strength in type 1 diabetic male mice

This study investigated the efficacy of the two FDA-approved bone anabolic ligands of the parathyroid hormone receptor 1 (PTH1R), teriparatide or human parathyroid hormone 1-34 (PTH) and abaloparatide (ABL), to restoring skeletal health using a preclinical murine model of streptozotocin-induced T1-DM. Intermittent daily subcutaneous injections of equal molar doses (12 pmoles/g/day) of PTH (50 ng/g/day), ABL (47.5 ng/g/day), or vehicle, were administered for 28 days to 5-month-old C57Bl/6 J male mice with established T1-DM or control (C) mice. ABL was superior to PTH in increasing or restoring bone mass in control or T1-MD mice, respectively, which was associated with superior stimulation of trabecular and periosteal bone formation, upregulation of osteoclastic/osteoblastic gene expression, and increased circulating bone remodeling markers. Only ABL corrected the reduction in ultimate load, which is a measure of bone strength, induced by T1-DM, and it also increased energy to ultimate load. In addition, bones from T1-DM mice treated with PTH or ABL exhibited increased ultimate stress, a material index, compared to T1-DM mice administered with vehicle. And both PTH and ABL prevented the increased expression of the Wnt antagonist Sost/sclerostin displayed by T1-DM mice. Further, PTH and ABL increased to a similar extent the circulating bone resorption marker CTX and the bone formation marker P1NP in T1-DM after 2 weeks of treatment; however, only ABL sustained these increases after 4 weeks of treatment. We conclude that at equal molar doses, ABL is more effective than PTH in increasing bone mass and restoring the cortical and trabecular bone lost with T1-DM, due to higher and longer-lasting increases in bone remodeling.

Immune checkpoint modulators in early clinical development for the treatment of type 1 diabetes

INTRODUCTION

Despite the improvements of insulin therapy, people with type 1 diabetes (T1D) still suffer from a decreased quality of life and life expectancy. The search toward a cure for T1D is therefore still a scorching open field of research.

AREAS COVERED

Tackling the immune checkpoint signaling pathways has gained importance in the field of cancer immunotherapy. The same pathways can be targeted in autoimmunity with an opposite principle: to dampen the exaggerated immune response. In this review, we report a comprehensive excursus on the cellular and molecular mechanisms that lead to loss of immunological tolerance, and recent evidence on the role of immune checkpoint molecules in the development of T1D and their potential application for the mitigation of autoimmune diabetes.

EXPERT OPINION

Contrasting results about the efficacy of immune checkpoint modulators for T1D have been published, with very few molecules from preclinical studies eligible for use in humans. The heterogeneous and complex pathophysiology of T1D may explain the conflicting evidence. Designing clinical trials that acknowledge the pathophysiological and clinical complexity of T1D and that forecast the need of simultaneously tackling different disease pathways will be crucial to enhance the benefits which may be gained by such compounds.

Appropriate glycemic management protects the germline but not the uterine environment in hyperglycemia

Emerging evidence indicates that parental diseases can impact the health of subsequent generations through epigenetic inheritance. Recently, it was shown that maternal diabetes alters the metaphase II oocyte transcriptome, causing metabolic dysfunction in offspring. However, type 1 diabetes (T1D) mouse models frequently utilized in previous studies may be subject to several confounding factors due to severe hyperglycemia. This limits clinical translatability given improvements in glycemic control for T1D subjects. Here, we optimize a T1D mouse model to investigate the effects of appropriately managed maternal glycemic levels on oocytes and intrauterine development. We show that diabetic mice with appropriate glycemic control exhibit better long-term health, including maintenance of the oocyte transcriptome and chromatin accessibility. We further show that human oocytes undergoing in vitro maturation challenged with mildly increased levels of glucose, reflecting appropriate glycemic management, also retain their transcriptome. However, fetal growth and placental function are affected in mice despite appropriate glycemic control, suggesting the uterine environment rather than the germline as a pathological factor in developmental programming in appropriately managed diabetes.

Exploring Technology's Influence on Health Behaviours and Well-being in Type 1 Diabetes: a Review

PURPOSE OF REVIEW

Maintaining positive health behaviours promotes better health outcomes for people with type 1 diabetes (T1D). However, implementing these behaviours may also lead to additional management burdens and challenges. Diabetes technologies, including continuous glucose monitoring systems, automated insulin delivery systems, and digital platforms, are being rapidly developed and widely used to reduce these burdens. Our aim was to review recent evidence to explore the influence of these technologies on health behaviours and well-being among adults with T1D and discuss future directions.

RECENT FINDINGS

Current evidence, albeit limited, suggests that technologies applied in diabetes self-management education and support (DSME/S), nutrition, physical activity (PA), and psychosocial care areas improved glucose outcomes. They may also increase flexibility in insulin adjustment and eating behaviours, reduce carb counting burden, increase confidence in PA, and reduce mental burden. Technologies have the potential to promote health behaviours changes and well-being for people with T1D. More confirmative studies on their effectiveness and safety are needed to ensure optimal integration in standard care practices.

Changing landscape of diabetes in Asia - What are the unmet needs?

The incidence rates of type 2 diabetes among adults in Asia have been stable, but the rates in youth and young adults have increased. In territory-wide surveillance in Hong Kong, Special Administrative Region of People's Republic of China, all-cause mortality rates among people with diabetes have exhibited a declining trend in the past 15 years, with a narrowing in the mortality gap between people with and without diabetes. At the same time, the improvement in survival resulted in a changing age structure and disease profile of people with diabetes, towards an increasing proportion of older people with long diabetes duration and multi-morbidities. Reductions in event rates were not observed in the youngest age group who also had the least gains in risk factor control and uptake in organ protective drugs over time. A young age at diabetes diagnosis, associated with exposure to high glycemic burden from an early age, predicted higher risks of complications and premature mortality compared with later-onset of diabetes. People presenting with type 2 diabetes below 40 years of age were 5-fold more likely to die and their life expectancy was shortened by 8 years than age-matched counterparts without diabetes. Analysis of population-based data in Hong Kong Chinese identified hypertension followed by chronic kidney disease as the leading contributor to mortality in young people, indicating that efforts to optimize non-glycemic risk factors and organ protection are as important in young individuals as it is in the older population.

Carbohydrate counting knowledge and ambulatory glucose profile in persons living with type 1 diabetes

CONTEXT

The amount of consumed carbohydrates is the strongest factor influencing glucose levels during the four hours following a meal. Our aim was to evaluate the association between carbohydrate counting knowledge and continuous glucose monitoring (CGM) parameters in patients with type 1 diabetes (T1D) using different insulin regimens.

METHOD

In this multicenter prospective study, the GluciQuizz questionnaire was used to evaluate carbohydrate knowledge. CGM data for the 14 days preceding completion of the questionnaire were analyzed. The primary endpoint was evaluation of the correlation between the GluciQuizz total score and time in range (TIR) in the study population.

RESULTS

The mean age of the 170 participants was 40.7 ± 14.8 years and duration of T1D 18.8 ± 12.1 years. The mean GluciQuizz total score for all participants was 66 ± 13 %. Mean TIR was 58.6 ± 18.7 %. GluciQuizz total score positively correlated with TIR (r = 0.3001; p < 0.0001). This correlation was observed in CSII users (r = 0.2526; p < 0.05) but not in MDI (r = 0.2510; p = 0.1134) and HCL users (r = -0.1065; p = 0.4914). TIR was also negatively correlated with the mean carb count error in all study participants (r = -0.2317; p < 0.01).

CONCLUSION

In conclusion, as the Gluciquizz score was associated with metabolic control, this easy-to-use self-administered questionnaire could be used widely on a routine basis to assess the carbohydrate knowledge of T1D patients and to offer them targeted education tailored to their needs.

Autoimmune diseases: targets, biology, and drug discovery

Autoimmune diseases (AIDs) arise from a breakdown in immunological self-tolerance, wherein the adaptive immune system mistakenly attacks healthy cells, tissues and organs. AIDs impose excessive treatment costs and currently rely on non-specific and universal immunosuppression, which only offer symptomatic relief without addressing the underlying causes. AIDs are driven by autoantigens, targeting the autoantigens holds great promise in transforming the treatment of these diseases. To achieve this goal, a comprehensive understanding of the pathogenic mechanisms underlying different AIDs and the identification of specific autoantigens are critical. In this review, we categorize AIDs based on their underlying causes and compile information on autoantigens implicated in each disease, providing a roadmap for the development of novel immunotherapy regimens. We will focus on type 1 diabetes (T1D), which is an autoimmune disease characterized by irreversible destruction of insulin-producing β cells in the Langerhans islets of the pancreas. We will discuss insulin as possible autoantigen of T1D and its role in T1D pathogenesis. Finally, we will review current treatments of TID and propose a potentially effective immunotherapy targeting autoantigens.

Machine learning for the early prediction of acute respiratory distress syndrome (ARDS) in patients with sepsis in the ICU based on clinical data

Background

Acute respiratory distress syndrome (ARDS) is a fatal outcome of severe sepsis. Machine learning models are helpful for accurately predicting ARDS in patients with sepsis at an early stage.

Objective

We aim to develop a machine-learning model for predicting ARDS in patients with sepsis in the intensive care unit (ICU).

Methods

The initial clinical data of patients with sepsis admitted to the hospital (including population characteristics, clinical diagnosis, complications, and laboratory tests) were used to predict ARDS, and screen out the crucial variables. After comparing eight different algorithms, namely, XG boost, logistic regression, light GBM, random forest, GaussianNB, complement NB, support vector machine (SVM), and K nearest neighbors (KNN), rebuilding a prediction model with the best one. When remodeling with the best algorithm, 10% was randomly selected to test, and the remaining was trained for cross-validation. Using the area under the curve (AUC), sensitivity, accuracy, specificity, positive and negative predictive value, F1 score, kappa value, and clinical decision curve to evaluate the model's performance. Eventually, the application in the model illustrated by the SHAP package.

Results

Ten critical features were screened utilizing the lasso method, namely, PaO2/PAO2, A-aDO2, PO2(T), CRP, gender, PO2, RDW, MCH, SG, and chlorine. The prior ranking of variables demonstrated that PaO2/PAO2 was the most significant variable. Among the eight algorithms, the performance of the Gaussian NB algorithm was significantly better than that of the others. After remodeling with the best algorithm, the AUC in the training and validation sets were 0.777 and 0.770, respectively, and the algorithm performed well in the test set (AUC = 0.781, accuracy = 78.6%, sensitivity = 82.4%, F1 score = 0.824). A comparison of the overlap factors with those of previous models revealed that the model we developed performs better.

Conclusion

Sepsis-associated ARDS can be accurately predicted early via a machine learning model based on existing clinical data. These findings are helpful for accurate identification and improvement of the prognosis in patients with sepsis-associated ARDS.