Young children, adolescent girls and women with type 1 diabetes are more overweight and obese than reference populations, and this is associated with increased cardiovascular risk factors

AIM

Overweight and obesity are frequently reported in young persons with type 1 diabetes, however its relative magnitude in comparison to the general population is not well understood. This study compared the prevalence of overweight and obesity in young persons with type 1 diabetes to a reference population and explored possible associated factors, including gender, age, HbA_1c , insulin regimen, age at diagnosis, diabetes duration, socio-economic status and cardiovascular disease risk factors.

METHODS

A cross-sectional review was undertaken of data collected from youth (3-17 years) in 2016 and young adults (18-30 years) in 2015 with a diagnosis of type 1 diabetes for > 3 months attending diabetes centres in Newcastle, Australia. Rates of overweight and obesity were compared with matched population survey results.

RESULTS

Data from 308 youth and 283 young adults were included. In girls, significantly higher prevalence of overweight and obesity were seen in the 5-8 (43% vs. 18%), 13-16 (41% vs. 27%), 18-24 (46% vs. 34%) and 25-30 (60% vs. 43%) years age groups; whereas in boys increased prevalence was observed in the 5-8 years age group only (41% vs. 18%). Rates of overweight and obesity increased with age across sexes. In youth, BMI standard deviation score was correlated with socio-economic status, insulin regimen, blood pressure and blood lipids (P < 0.05). In adults, BMI was positively associated with blood pressure, and longer diabetes duration (P < 0.02).

CONCLUSIONS

Overweight and obesity are over-represented in young persons with type 1 diabetes, particularly girls. As overweight is associated with other cardiovascular disease markers early intervention is paramount.

An intravenous insulin protocol designed for pregnancy reduces neonatal hypoglycaemia following betamethasone administration in women with gestational diabetes

AIMS

Marked hyperglycaemia is common following betamethasone administration in women with gestational diabetes (GDM), and may contribute to neonatal hypoglycaemia. Validated protocols to deliver glycaemic stability following betamethasone are lacking. We hypothesized that an intravenous insulin (IVI) protocol for pregnancy-specific glycaemic targets (Pregnancy-IVI) would achieve greater at-target glycaemic control than a generic adult intravenous insulin protocol (Adult-IVI), and may reduce neonatal hypoglycaemia.

METHODS

A retrospective cohort study of the performance Adult-IVI and Pregnancy-IVI following betamethasone in GDM, sequentially implemented at a tertiary hospital, without change in indication for IVI. Cases were identified by electronic record search. Primary outcome was percentage of on-IVI time with at-target glycaemia [blood glucose level (BGL) 3.8-7 mmol/l]. Secondary outcomes were time with critical hyperglycaemia (BGL > 10 mmol/l), occurrence of maternal hypoglycaemia (BGL < 3.8 mmol/l), and incidence of neonatal hypoglycaemia (BGL ≤ 2.5 mmol/l) if betamethasone was administered within 48 h of birth.

RESULTS

The cohorts comprised 151 women (Adult-IVI n = 86; Pregnancy-IVI n = 65). The primary outcome was 68% time-at-target [95% confidence interval (CI) 64-71%) for Pregnancy-IVI compared with 55% (95% CI 50-60%) for Adult-IVI (P = 0.0002). Critical maternal hyperglycaemia (0% vs. 2%, P = 0.02) and hypoglycaemia (2% vs. 12%, P = 0.02) were both lower with Pregnancy-IVI than Adult-IVI. Neonatal hypoglycaemia was less common after Pregnancy-IVI (29%) than after Adult-IVI (54%, P = 0.03). A multiple logistic regression model adjusting for potential confounders gave an odds ratio for neonatal hypoglycaemia with Pregnancy-IVI of 0.27 (95% CI 0.10-0.76, P = 0.01).

CONCLUSIONS

An IVI protocol designed for pregnancy effectively controlled maternal hyperglycaemia following betamethasone administration in GDM. This is the first intervention to show a reduction in betamethasone-associated neonatal hypoglycaemia, linked with optimum maternal glycaemic control.

Insulin resistance correlates with maculopathy and severity of retinopathy in young adults with Type 1 Diabetes Mellitus

AIMS

To assess the relationship between insulin resistance (IR), retinopathy and maculopathy in young adults with Type 1 diabetes mellitus.

METHODS

A cross-sectional study at a regional Australian tertiary hospital. Retinal pathology, assessed by colour fundus photography, was correlated with two surrogate measures of IR: estimated Glucose Disposal Rate (eGDR) and Insulin Sensitivity Score (ISS), where lower scores reflect greater IR.

RESULTS

107 patients were recruited, with mean age 24.7years, 53% male, and mean duration of disease 10.8years. Mean eGDR scores (5.6vs 8.0 p<0.001) and ISS (4.7vs 7.9, p<0.001) were lower in subjects having at least moderate non-proliferative diabetic retinopathy (NPDR; relative to nil/mild-NPDR). Similarly, mean eGDR (4.2vs 6.2, p=0.001) and ISS (3.8vs 6.1, p=0.003) were lower in patients with maculopathy. Multivariate logistic regression modelling was used to control for confounding. For retinopathy severity, a unit increase in eGDR or ISS (representing lower IR) was associated with a 50% decrease in odds of moderate-NPDR or worse (eGDR OR 0.5, 95%CI 0.32-0.77, p=0.002; ISS OR 0.49, 95%CI 0.29-0.84, p=0.01). A unit increase in eGDR or ISS was associated with a 46-56% decrease in odds of maculopathy (eGDR OR 0.54, 95%CI 0.37-0.81, p=0.003; ISS OR 0.44, 95%CI 0.22-0.88, p=0.02).

CONCLUSIONS

IR correlates with more severe retinopathy in young adults with Type 1DM. This is the first description of a correlation between IR and maculopathy in Type 1DM, warranting further evaluation. Prospective studies examining whether reducing IR can improve microvascular complications are required.

The duration of intrapartum maternal hyperglycaemia predicts neonatal hypoglycaemia in women with pre-existing diabetes

AIM

There is a high incidence of neonatal hypoglycaemia in neonates born to mothers with pre-existing diabetes. This often necessitates admission to the neonatal intensive care. Guidelines suggest maintaining intrapartum blood glucose levels (BGLs) of 4-7 mmol/l in women with diabetes to reduce the risk of neonatal hypoglycaemia. This study assessed whether intrapartum BGLs in women with pre-gestational Type 1 and 2 diabetes were predictive of neonatal hypoglycaemia.

METHODS

A retrospective analysis of 261 births delivered at a tertiary hospital in Australia from 2009 to 2014.

RESULTS

There were 122 cases of neonatal hypoglycaemia (glucose ≤ 2.6 mmol/l) in 261 births (47%). The mothers in the neonatal hypoglycaemia group spent less time with BGL in the range 4-7 mmol/l [55 ± 37% vs. 65 ± 35%, P = 0.02; odds ratio (OR) 0.992, P = 0.03] and more time with BGL in the 7-10 mmol/l range (31 ± 34% vs. 18 ± 27%, P = 0.003; OR 1.013, P = 0.003) compared with those without neonatal hypoglycaemia. Although statistically significant, receiver operating characteristic (ROC) curve analysis showed that time spent with maternal BGLs in the range 4-7 mmol/l [area under the curve (AUC) = 0.58] or 7-10 mmol (AUC = 0.60) was not strong enough to be a useful clinical predictor of neonatal hypoglycaemia. HbA_1c in the second trimester of pregnancy (P = 0.02, OR 1.42) and percentage time spent in BGL range of 7-10 mmol/l (P = 0.001, OR 1.02) were both associated with a risk of neonatal hypoglycaemia in a logistic regression model. HbA_1c in the third trimester (P = 0.07, OR 1.28) approached, but did not reach, significance.

CONCLUSIONS

These data support a BGL range of 4-7 mmol/l as an intrapartum target. Glycaemic control in the second trimester is associated with neonatal hypoglycaemia. Improvement in ante- and intrapartum glycaemic control may reduce neonatal hypoglycaemia in women with pre-existing diabetes.

Proteomic analysis of the postsynaptic density implicates synaptic function and energy pathways in bipolar disorder

The postsynaptic density (PSD) contains a complex set of proteins of known relevance to neuropsychiatric disorders such as schizophrenia and bipolar disorder. We enriched for this anatomical structure in the anterior cingulate cortex of 16 bipolar disorder samples and 20 controls from the Stanley Medical Research Institute. Unbiased shotgun proteomics incorporating label-free quantitation was used to identify differentially expressed proteins. Quantitative investigation of the PSD identified 2033 proteins, among which 288 were found to be differentially expressed. Validation of expression changes of DNM1, DTNA, NDUFV2, SEPT11 and SSBP was performed by western blotting. Bioinformatics analysis of the differentially expressed proteins implicated metabolic pathways including mitochondrial function, the tricarboxylic acid cycle, oxidative phosphorylation, protein translation and calcium signaling. The data implicate PSD-associated proteins, and specifically mitochondrial function in bipolar disorder. They relate synaptic function in bipolar disorder and the energy pathways that underpin it. Overall, our findings add to a growing literature linking the PSD and mitochondrial function in psychiatric disorders generally, and suggest that mitochondrial function associated with the PSD is particularly important in bipolar disorder.

Early and late extensive chronic graft-versus-host disease in children is characterized by different Th1/Th2 cytokine profiles: findings of the Children's Oncology Group Study ASCT0031

Numerous mechanisms underlie chronic graft-versus-host disease (cGVHD), including skewing of Th1/Th2 cytokine expression. There are biological differences between early-onset and late-onset cGVHD. To test whether different Th1/Th2 cytokines are associated with early- or late-onset cGVHD, peripheral blood was collected from 63 children enrolled on the Children's Oncology Group Phase III trial ASCT0031 evaluating hydroxychloroquine therapy for newly diagnosed extensive cGVHD. mRNA expression of interferon (IFN)-γ and interleukin (IL)-2, -4, and -10 from stimulated peripheral blood mononuclear cells was evaluated by quantitative polymerase chain reaction. Early-onset cGVHD (n = 33) was characterized by decreased expression of IFN-γ and IL-2 mRNA after nonspecific phorbol 12-myristate 13-acetate-ionomycin stimulation. In contrast, late-onset cGVHD (n = 11) was characterized by decreased expression of IL-4 and IL-2 mRNA after anti-CD3 stimulation of T cells. Receiver-operating characteristic curve analysis revealed that IFN-γ expression was correlated with the absence of early cGVHD (area under the curve [AUC] = 0.77) and that IL-4 (AUC = 0.89) and IL-2 (AUC = 0.84) expression was correlated with the absence of late cGVHD. There was no correlation between cytokine expression and a specific immune cell subset. Increased expression of Foxp3 mRNA was seen in early-onset cGVHD and late controls. The different time-dependent cytokine profiles in patients with newly diagnosed cGVHD suggests that the mechanisms underlying cGVHD are temporally regulated. Although larger validation studies are needed, our data suggest that cytokine profiles have a potential use as biomarkers for the diagnosis of cGVHD.

Oxyntomodulin increases energy expenditure in addition to decreasing energy intake in overweight and obese humans: a randomised controlled trial

BACKGROUND

Oxyntomodulin has recently been found to decrease body-weight in obese humans and may be a potential anti-obesity therapy.

OBJECTIVE

To determine whether oxyntomodulin alters energy expenditure, in addition to reducing energy intake, in 'free-living' overweight and obese volunteers.

DESIGN

Randomized double-blind controlled cross-over trial.

SETTING

Community and hospital-based.

PARTICIPANTS

Fifteen healthy overweight and obese men and women (age: 23-49 years, BMI: 25.1-39.0 kg/m(2)). All volunteers completed the study protocol.

INTERVENTIONS

Four-day subcutaneous self-administration of pre-prandial oxyntomodulin, three times daily. Participants were advised to maintain their normal dietary and exercise regimen.

MEASUREMENTS

(1) Energy expenditure, measured by indirect calorimetry and combined heart rate and movement monitoring; (2) energy intake, measured during a study meal.

RESULTS

Oxyntomodulin administration reduced energy intake at the study meal by 128+/-29 kcal (P=0.0006) or 17.3+/-5.5% (P=0.0071), with no change in meal palatability. Oxyntomodulin did not alter resting energy expenditure; but increased activity-related energy expenditure by 143+/-109 kcal/day or 26.2+/-9.9% (P=0.0221); total energy expenditure by 9.4+/-4.8% (P=0.0454) and physical activity level by 9.5+/-4.6% (P=0.0495). A reduction in body weight of 0.5+/-0.2% was observed during the oxyntomodulin administration period (P=0.0232).

CONCLUSION

Oxyntomodulin increases energy expenditure while reducing energy intake resulting in negative energy balance. This data supports the role of oxyntomodulin as a potential anti-obesity therapy.

Differential immune effects mediated by Toll-like receptors stimulation in precursor B-cell acute lymphoblastic leukaemia

Acute lymphoblastic leukaemia (ALL) is the most common paediatric malignancy and, although current therapy is widely effective, relapse remains a significant clinical problem for which new treatment strategies are required. The ligation of Toll-like receptors (TLR) on antigen-presenting cells stimulates the generation of strong T-cell helper type 1 (Th1) adaptive immune responses. Although TLR9 ligation has been shown to enhance immunogenicity of a number of leukaemia cell types, there have been few reports of the effects mediated through other TLR. In this study we analysed both the expression of TLR by B-cell precursor ALL cell lines and the effects of individual TLR ligation on the ability of ALL cells to stimulate allogeneic T cells. While ligation of TLR2, TLR 7 and TLR9 led to detectable changes in ALL costimulatory molecule expression, only TLR2 and TLR9 stimulation influenced T-cell responses. The TLR2 ligand Pam3CysSerLys4 provoked the most significant changes in T-cell response, dramatically augmenting interferon-gamma production. These results suggest that TLR ligands, in addition to TLR9 agonists, may provide a strategy to enhance the generation of anti-ALL immune activity by skewing responding T cells towards a Th1 response.

Immune evasion strategies of pediatric precursor-B acute lymphoblastic leukemia after allogeneic bone marrow transplantation—a case study

Bone marrow transplantation (BMT) is the primary curative option for refractory/relapsed pediatric acute lymphoblastic leukemia. Although post-transplantation relapse remains a frequent cause of transplantation failure, the mechanisms underlying this are poorly understood. In this study, we compared allogeneic T cell stimulation induced by sequentially obtained precursor-B acute lymphoblastic leukemia (ALL) samples from a single patient with overt graft versus leukemia (GVL) activity. We observed a loss of T cell stimulatory capacity by post-transplantation relapse samples and changes in expression of MHC and the costimulatory molecule CD137 ligand. This study suggests that escape from immune mechanisms after withdrawal of immune suppression is important to ALL progression.

Noncausal time response in frustrated total internal reflection?

Tunneling of photons in frustrated total internal reflection has been studied in the time domain with single-cycle femtosecond pulses. It is seen that both the phase and energy of the pulse travel faster than the speed of light in vacuum. Theoretical analysis of the experiments shows that the time-response function for electromagnetic waves propagating in the air gap is noncausal. However, it is found that superluminal signal propagation is not possible in this case because of the inevitable diffractive spreading of the signal beam.

Macroamylasaemia--a prognostic marker in a syndrome of malabsorption and complete villous atrophy? An uncommon clinical condition

We report a rare case of chronic persistent hyperamylasaemia secondary to macroamylasaemia in association with coeliac disease in a 56-year-old woman. Her symptoms, including macroamylasaemia, ebbed away following commencement of a gluten free diet. Only four cases of a similar nature have been described in the literature. The differential diagnosis of macroamylasaemia should include coeliac disease, and an awareness of this association might obviate a variety of unnecessary diagnostic investigations.

Dissociable deficits in the decision-making cognition of chronic amphetamine abusers, opiate abusers, patients with focal damage to prefrontal cortex, and tryptophan-depleted normal volunteers: evidence for monoaminergic mechanisms

We used a novel computerized decision-making task to compare the decision-making behavior of chronic amphetamine abusers, chronic opiate abusers, and patients with focal lesions of orbital prefrontal cortex (PFC) or dorsolateral/medial PFC. We also assessed the effects of reducing central 5-hydroxytryptamine (5-HT) activity using a tryptophan-depleting amino acid drink in normal volunteers. Chronic amphetamine abusers showed suboptimal decisions (correlated with years of abuse), and deliberated for significantly longer before making their choices. The opiate abusers exhibited only the second of these behavioral changes. Importantly, both sub-optimal choices and increased deliberation times were evident in the patients with damage to orbitofrontal PFC but not other sectors of PFC. Qualitatively, the performance of the subjects with lowered plasma tryptophan was similar to that associated with amphetamine abuse, consistent with recent reports of depleted 5-HT in the orbital regions of PFC of methamphetamine abusers. Overall, these data suggest that chronic amphetamine abusers show similar decision-making deficits to those seen after focal damage to orbitofrontal PFC. These deficits may reflect altered neuromodulation of the orbitofrontal PFC and interconnected limbic-striatal systems by both the ascending 5-HT and mesocortical dopamine (DA) projections.

Superluminal terahertz pulses

In femtosecond terahertz-pulse (T-ray) imaging of metal structures with dimensions of the order of the wavelength, it is observed that the T rays propagate faster than the vacuum speed of light. In the case of apertures this can be understood as a waveguide effect in which superluminal velocities are expected close to the cutoff frequency. However, the effect is also observed close to knife edges and in propagation past thin metal wires.

Regenerative amplification of 30-fs pulses in Ti:sapphire at 5 kHz

18-fs pulses from a self-mode-locked Ti:sapphire laser are amplified to 60 microJ of energy at 4.9 kHz with chirped-pulse amplification in a Ti:sapphire regenerative amplifier. After recompression, 30-35-fs, near-transform-limited pulses are obtained.

Effects of 2-hydroxyoestradiol-17 beta on plasma luteinizing hormone, follicle-stimulating hormone and prolactin, and nuclear translocation of pituitary oestrogen receptors in ovariectomized ewes

The ability of oestradiol-17 beta (OE2) and 2-hydroxyoestradiol (2OH-OE2) to translocate pituitary oestrogen receptors to the nuclear compartment and to affect plasma concentrations of LH, FSH and prolactin was studied in ovariectomized ewes. Mean (+/- S.E.M.) nuclear oestrogen receptor levels (% of total pituitary oestrogen receptors) after intracarotid injections of 1.25 micrograms OE2, 400 micrograms 2OH-OE2 or vehicle were 8.7 +/- 2.3, 16.9 +/- 3.2 and 0.8 +/- 0.1% respectively. Whereas 1.25 or 12.5 micrograms OE2 significantly lowered plasma LH and FSH, 400 micrograms 2OH-OE2 did not affect plasma LH or FSH levels. Injection of 4000 micrograms 2OH-OE2 however, significantly affected plasma LH and FSH. Plasma prolactin levels were not significantly affected by the treatments. These data indicate a discrepancy between oestrogen receptor occupancy and effects on gonadotrophin and prolactin secretion after injection of catechol oestrogen.

19-Nor deoxycorticosterone (19-nor DOC): mineralocorticoid receptor affinity higher than aldosterone, electrolyte activity lower

By screening urine extracts from rats with adrenal regeneration hypertension, Gomez-Sanchez et al. found a steroid, subsequently identified as 19-nor DOC, with high affinity for tritiated aldosterone (3HA) binding sites in rat kidney cytosol. We here report studies on the affinity of authentic 19-nor DOC for mineralocorticoid receptors, its binding in plasma and its activity in the rat urinary mineralocorticoid assay. When kidney slices from adrenalectomized rats were incubated in protein-free buffer with 3HA, 19-nor DOC consistently competed better (approximately 140%) for 3HA binding sites than did equivalent concentrations of non-radioactive aldosterone. Under identical conditions, save for the inclusion of 20% adrenalectomized rat plasma in the incubation medium, 19-nor DOC shows only approximately 40% the potency of aldosterone in displacing 3HA. Determination of renal binding of 3HA after injection of 3HA +/- aldosterone +/- 19-nor DOC in vivo similarly shows 19-nor DOC to be approximately one third as potent a competitor for 3HA binding sites as aldosterone. In the rat urinary bioassay, 19-nor DOC shows no antagonist activity when injected with aldosterone; in the absence of aldosterone, 19-nor DOC acts as a mineralocorticoid agonist, with an apparent potency 10-30% that of aldosterone. Conclusions of the study are therefore (i) at a molecular level, 19-nor DOC has a higher affinity than aldosterone for mineralocorticoid receptors, (ii) in vivo, its potency in terms of receptor occupancy is markedly lower than that of aldosterone, due to higher levels of plasma binding, (iii) in effector terms, 19-nor DOC is a full agonist without antagonist activity.