1
|
Schaupp L, Addante A, Völler M, Fentker K, Kuppe A, Bardua M, Duerr J, Piehler L, Röhmel J, Thee S, Kirchner M, Ziehm M, Lauster D, Haag R, Gradzielski M, Stahl M, Mertins P, Boutin S, Graeber SY, Mall MA. Longitudinal effects of elexacaftor/tezacaftor/ivacaftor on sputum viscoelastic properties, airway infection and inflammation in patients with cystic fibrosis. Eur Respir J 2023; 62:2202153. [PMID: 37414422 DOI: 10.1183/13993003.02153-2022] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 05/21/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Recent studies demonstrated that the triple combination cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy elexacaftor/tezacaftor/ivacaftor (ETI) improves lung function and reduces pulmonary exacerbations in cystic fibrosis (CF) patients with at least one F508del allele. However, effects of ETI on downstream consequences of CFTR dysfunction, i.e. abnormal viscoelastic properties of airway mucus, chronic airway infection and inflammation have not been studied. The aim of this study was to determine the longitudinal effects of ETI on airway mucus rheology, microbiome and inflammation in CF patients with one or two F508del alleles aged ≥12 years throughout the first 12 months of therapy. METHODS In this prospective observational study, we assessed sputum rheology, the microbiome, inflammation markers and proteome before and 1, 3 and 12 months after initiation of ETI. RESULTS In total, 79 patients with CF and at least one F508del allele and 10 healthy controls were enrolled in this study. ETI improved the elastic modulus and viscous modulus of CF sputum at 3 and 12 months after initiation (all p<0.01). Furthermore, ETI decreased the relative abundance of Pseudomonas aeruginosa in CF sputum at 3 months and increased the microbiome α-diversity at all time points. In addition, ETI reduced interleukin-8 at 3 months (p<0.05) and free neutrophil elastase activity at all time points (all p<0.001), and shifted the CF sputum proteome towards healthy. CONCLUSIONS Our data demonstrate that restoration of CFTR function by ETI improves sputum viscoelastic properties, chronic airway infection and inflammation in CF patients with at least one F508del allele over the first 12 months of therapy; however, levels close to healthy were not reached.
Collapse
Affiliation(s)
- Laura Schaupp
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Lung Research (DZL), associated partner site, Berlin, Germany
- L. Schaupp, A. Addante, M. Völler and K. Fentker contributed equally as first authors
| | - Annalisa Addante
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Lung Research (DZL), associated partner site, Berlin, Germany
- L. Schaupp, A. Addante, M. Völler and K. Fentker contributed equally as first authors
| | - Mirjam Völler
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Lung Research (DZL), associated partner site, Berlin, Germany
- L. Schaupp, A. Addante, M. Völler and K. Fentker contributed equally as first authors
| | - Kerstin Fentker
- Proteomics Platform, Max-Delbrück-Center for Molecular Medicine, Berlin, Germany
- Institute for Chemistry and Biochemistry, Freie Universität Berlin, Berlin, Germany
- L. Schaupp, A. Addante, M. Völler and K. Fentker contributed equally as first authors
| | - Aditi Kuppe
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Lung Research (DZL), associated partner site, Berlin, Germany
| | - Markus Bardua
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Lung Research (DZL), associated partner site, Berlin, Germany
| | - Julia Duerr
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Lung Research (DZL), associated partner site, Berlin, Germany
| | - Linus Piehler
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Lung Research (DZL), associated partner site, Berlin, Germany
| | - Jobst Röhmel
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Lung Research (DZL), associated partner site, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Stephanie Thee
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Lung Research (DZL), associated partner site, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Marieluise Kirchner
- Proteomics Platform, Max-Delbrück-Center for Molecular Medicine, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Ziehm
- Proteomics Platform, Max-Delbrück-Center for Molecular Medicine, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Lauster
- Institute for Chemistry and Biochemistry, Freie Universität Berlin, Berlin, Germany
- Institute of Pharmacy, Biopharmaceuticals, Freie Universität Berlin, Berlin, Germany Berlin, Germany
| | - Rainer Haag
- Institute for Chemistry and Biochemistry, Freie Universität Berlin, Berlin, Germany
| | - Michael Gradzielski
- Institute of Pharmacy, Biopharmaceuticals, Freie Universität Berlin, Berlin, Germany Berlin, Germany
| | - Mirjam Stahl
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Lung Research (DZL), associated partner site, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Philipp Mertins
- Proteomics Platform, Max-Delbrück-Center for Molecular Medicine, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- P. Mertins, S. Boutin, S.Y. Graeber and M.A. Mall contributed equally as senior authors
| | - Sébastien Boutin
- Stranski-Laboratorium für Physikalische und Theoretische Chemie, Institut für Chemie, Technische Universität Berlin, Berlin, Germany
- Department of Infectious Diseases, Medical Microbiology and Hygiene, University of Heidelberg, Heidelberg, Germany
- Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein/Campus, Lübeck, Germany
- P. Mertins, S. Boutin, S.Y. Graeber and M.A. Mall contributed equally as senior authors
| | - Simon Y Graeber
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Lung Research (DZL), associated partner site, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- P. Mertins, S. Boutin, S.Y. Graeber and M.A. Mall contributed equally as senior authors
| | - Marcus A Mall
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Lung Research (DZL), associated partner site, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- P. Mertins, S. Boutin, S.Y. Graeber and M.A. Mall contributed equally as senior authors
| |
Collapse
|
2
|
Schaupp L, Muth S, Rogell L, Kofoed-Branzk M, Melchior F, Lienenklaus S, Ganal-Vonarburg SC, Klein M, Guendel F, Hain T, Schütze K, Grundmann U, Schmitt V, Dorsch M, Spanier J, Larsen PK, Schwanz T, Jäckel S, Reinhardt C, Bopp T, Danckwardt S, Mahnke K, Heinz GA, Mashreghi MF, Durek P, Kalinke U, Kretz O, Huber TB, Weiss S, Wilhelm C, Macpherson AJ, Schild H, Diefenbach A, Probst HC. Microbiota-Induced Type I Interferons Instruct a Poised Basal State of Dendritic Cells. Cell 2020; 181:1080-1096.e19. [PMID: 32380006 DOI: 10.1016/j.cell.2020.04.022] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/31/2019] [Accepted: 04/14/2020] [Indexed: 12/12/2022]
Abstract
Environmental signals shape host physiology and fitness. Microbiota-derived cues are required to program conventional dendritic cells (cDCs) during the steady state so that they can promptly respond and initiate adaptive immune responses when encountering pathogens. However, the molecular underpinnings of microbiota-guided instructive programs are not well understood. Here, we report that the indigenous microbiota controls constitutive production of type I interferons (IFN-I) by plasmacytoid DCs. Using genome-wide analysis of transcriptional and epigenetic regulomes of cDCs from germ-free and IFN-I receptor (IFNAR)-deficient mice, we found that tonic IFNAR signaling instructs a specific epigenomic and metabolic basal state that poises cDCs for future pathogen combat. However, such beneficial biological function comes with a trade-off. Instructed cDCs can prime T cell responses against harmless peripheral antigens when removing roadblocks of peripheral tolerance. Our data provide fresh insights into the evolutionary trade-offs that come with successful adaptation of vertebrates to their microbial environment.
Collapse
Affiliation(s)
- Laura Schaupp
- Laboratory of Innate Immunity, Department of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch Strasse 2, 10178 Berlin, Germany; Mucosal and Developmental Immunology, Deutsches Rheuma-Forschungszentrum, Charitéplatz 1, 10117 Berlin, Germany; Institute for Molecular Biology (IMB), Ackermannweg 4, 55128 Mainz, Germany
| | - Sabine Muth
- Institute of Immunology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany; Research Centre for Immunotherapy, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Leif Rogell
- Laboratory of Innate Immunity, Department of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch Strasse 2, 10178 Berlin, Germany; Mucosal and Developmental Immunology, Deutsches Rheuma-Forschungszentrum, Charitéplatz 1, 10117 Berlin, Germany; Max-Planck-Institute of Immunobiology and Epigenetics, Stübeweg 51, 79108 Freiburg, Germany
| | - Michael Kofoed-Branzk
- Laboratory of Innate Immunity, Department of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch Strasse 2, 10178 Berlin, Germany; Mucosal and Developmental Immunology, Deutsches Rheuma-Forschungszentrum, Charitéplatz 1, 10117 Berlin, Germany; Max-Planck-Institute of Immunobiology and Epigenetics, Stübeweg 51, 79108 Freiburg, Germany
| | - Felix Melchior
- Institute of Immunology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany; Research Centre for Immunotherapy, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Stefan Lienenklaus
- Institute of Immunology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany; Institute for Laboratory Animal Science, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Stephanie C Ganal-Vonarburg
- Department for BioMedical Research (DBMR), University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Murtenstrasse 35, 3008 Bern, Switzerland
| | - Matthias Klein
- Institute of Immunology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany; Research Centre for Immunotherapy, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Fabian Guendel
- Laboratory of Innate Immunity, Department of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch Strasse 2, 10178 Berlin, Germany; Mucosal and Developmental Immunology, Deutsches Rheuma-Forschungszentrum, Charitéplatz 1, 10117 Berlin, Germany
| | - Tobias Hain
- Institute of Immunology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany; Research Centre for Immunotherapy, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Kristian Schütze
- Institute of Immunology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany; Research Centre for Immunotherapy, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Ulrike Grundmann
- Institute for Medical Microbiology and Hygiene, University of Freiburg Medical Center, Hermann-Herder-Str. 11, 79104 Freiburg, Germany
| | - Vanessa Schmitt
- Immunopathology Unit, Institute of Clinical Chemistry and Clinical Pharmacology, Medical Faculty, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Martina Dorsch
- Institute for Laboratory Animal Science, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Julia Spanier
- Institute for Experimental Infection Research, TWINCORE, Centre for Experimental and Clinical Infection Research, a joint venture between the Helmholtz Centre for Infection Research and the Hannover Medical School, Feodor-Lynen-Strasse 7, 30625 Hannover, Germany
| | - Pia-Katharina Larsen
- Institute for Experimental Infection Research, TWINCORE, Centre for Experimental and Clinical Infection Research, a joint venture between the Helmholtz Centre for Infection Research and the Hannover Medical School, Feodor-Lynen-Strasse 7, 30625 Hannover, Germany
| | - Thomas Schwanz
- Institute of Medical Microbiology and Hygiene, University Medical Center Mainz, Obere Zahlbacher Strasse 67, 55131 Mainz, Germany
| | - Sven Jäckel
- Center for Thrombosis and Hemostasis, University Medical Center, Johannes Gutenberg University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Christoph Reinhardt
- Center for Thrombosis and Hemostasis, University Medical Center, Johannes Gutenberg University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Tobias Bopp
- Institute of Immunology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany; Research Centre for Immunotherapy, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany; University Cancer Center Mainz, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany; German Cancer Consortium (DKTK)
| | - Sven Danckwardt
- Center for Thrombosis and Hemostasis, University Medical Center, Johannes Gutenberg University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany; Posttranscriptional Gene Regulation, Cancer Research and Experimental Hemostasis, University Medical Centre Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany; Institute for Clinical Chemistry and Laboratory Medicine, University Medical Centre Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Karsten Mahnke
- Department of Dermatology, Ruprecht-Karls-University Heidelberg, D-69120 Heidelberg, Germany
| | - Gitta Anne Heinz
- Therapeutic Gene Regulation, Deutsches Rheuma-Forschungszentrum, Charitéplatz 1, 10117 Berlin, Germany
| | - Mir-Farzin Mashreghi
- Therapeutic Gene Regulation, Deutsches Rheuma-Forschungszentrum, Charitéplatz 1, 10117 Berlin, Germany
| | - Pawel Durek
- Therapeutic Gene Regulation, Deutsches Rheuma-Forschungszentrum, Charitéplatz 1, 10117 Berlin, Germany
| | - Ulrich Kalinke
- Institute for Experimental Infection Research, TWINCORE, Centre for Experimental and Clinical Infection Research, a joint venture between the Helmholtz Centre for Infection Research and the Hannover Medical School, Feodor-Lynen-Strasse 7, 30625 Hannover, Germany; Cluster of Excellence RESIST (EXC 2155), Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Oliver Kretz
- III. Department of Medicine, University Medical Center Hamburg Eppendorf, Hamburg, Germany; Department for Neuroanatomy, Anatomy and Cell Biology, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Tobias B Huber
- III. Department of Medicine, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Siegfried Weiss
- Institute of Immunology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Christoph Wilhelm
- Immunopathology Unit, Institute of Clinical Chemistry and Clinical Pharmacology, Medical Faculty, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Andrew J Macpherson
- Department for BioMedical Research (DBMR), University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Murtenstrasse 35, 3008 Bern, Switzerland
| | - Hansjörg Schild
- Institute of Immunology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany; Research Centre for Immunotherapy, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany; Helmholtz Institute Translational Oncology, Obere Zahlbacher Straße 63, 55131 Mainz, Germany.
| | - Andreas Diefenbach
- Laboratory of Innate Immunity, Department of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch Strasse 2, 10178 Berlin, Germany; Mucosal and Developmental Immunology, Deutsches Rheuma-Forschungszentrum, Charitéplatz 1, 10117 Berlin, Germany.
| | - Hans Christian Probst
- Institute of Immunology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany; Research Centre for Immunotherapy, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany.
| |
Collapse
|
3
|
Bodenlenz M, Ellmerer M, Schaupp L, Jacobsen LV, Plank J, Brunner GA, Wutte A, Aigner B, Mautner SI, Pieber TR. Bioavailability of insulin detemir and human insulin at the level of peripheral interstitial fluid in humans, assessed by open-flow microperfusion. Diabetes Obes Metab 2015; 17:1166-72. [PMID: 26260082 DOI: 10.1111/dom.12551] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 07/30/2015] [Accepted: 08/06/2015] [Indexed: 11/28/2022]
Abstract
AIMS To find an explanation for the lower potency of insulin detemir observed in humans compared with unmodified human insulin by investigating insulin detemir and human insulin concentrations directly at the level of peripheral insulin-sensitive tissues in humans in vivo. METHODS Euglycaemic-hyperinsulinaemic clamp experiments were performed in healthy volunteers. Human insulin was administered i.v. at 6 pmol/kg/min and insulin detemir at 60 pmol/kg/min, achieving a comparable steady-state pharmacodynamic action. In addition, insulin detemir was doubled to 120 pmol/kg/min. Minimally invasive open-flow microperfusion (OFM) sampling methodology was combined with inulin calibration to quantify human insulin and insulin detemir in the interstitial fluid (ISF) of subcutaneous adipose and skeletal muscle tissue. RESULTS The human insulin concentration in the ISF was ∼115 pmol/l or ∼30% of the serum concentration, whereas the insulin detemir concentration in the ISF was ∼680 pmol/l or ∼2% of the serum concentration. The molar insulin detemir interstitial concentration was five to six times higher than the human insulin interstitial concentration and metabolic clearance of insulin detemir from serum was substantially reduced compared with human insulin. CONCLUSIONS OFM proved useful for target tissue measurements of human insulin and the analogue insulin detemir. Our tissue data confirm a highly effective retention of insulin detemir in the vascular compartment. The higher insulin detemir relative to human insulin tissue concentrations at comparable pharmacodynamics, however, indicate that the lower potency of insulin detemir in humans is attributable to a reduced effect in peripheral insulin-sensitive tissues and is consistent with the reduced in vitro receptor affinity.
Collapse
MESH Headings
- Adult
- Biological Availability
- Calibration
- Cross-Over Studies
- Dose-Response Relationship, Drug
- Extracellular Fluid/metabolism
- Glucose Clamp Technique
- Humans
- Hypoglycemic Agents/administration & dosage
- Hypoglycemic Agents/blood
- Hypoglycemic Agents/metabolism
- Hypoglycemic Agents/pharmacokinetics
- Infusions, Intravenous
- Insulin Detemir/administration & dosage
- Insulin Detemir/blood
- Insulin Detemir/metabolism
- Insulin Detemir/pharmacokinetics
- Insulin, Regular, Human/administration & dosage
- Insulin, Regular, Human/blood
- Insulin, Regular, Human/metabolism
- Insulin, Regular, Human/pharmacokinetics
- Inulin/administration & dosage
- Inulin/blood
- Inulin/metabolism
- Inulin/pharmacokinetics
- Lipoylation
- Male
- Metabolic Clearance Rate
- Muscle, Skeletal/metabolism
- Subcutaneous Fat/metabolism
- Tissue Distribution
- Young Adult
Collapse
Affiliation(s)
- M Bodenlenz
- HEALTH, Institute for Biomedicine and Health Sciences, Joanneum Research Forschungsgesellschaft m.b.H, Graz, Austria
| | - M Ellmerer
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - L Schaupp
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - J Plank
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - G A Brunner
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - A Wutte
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - B Aigner
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Division of General Dermatology, Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - S I Mautner
- HEALTH, Institute for Biomedicine and Health Sciences, Joanneum Research Forschungsgesellschaft m.b.H, Graz, Austria
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - T R Pieber
- HEALTH, Institute for Biomedicine and Health Sciences, Joanneum Research Forschungsgesellschaft m.b.H, Graz, Austria
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| |
Collapse
|
4
|
Donsa K, Beck P, Plank J, Schaupp L, Mader JK, Truskaller T, Tschapeller B, Höll B, Spat S, Pieber TR. A toolbox to improve algorithms for insulin-dosing decision support. Appl Clin Inform 2014; 5:548-56. [PMID: 25024768 DOI: 10.4338/aci-2014-04-ra-0033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 04/30/2014] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Standardized insulin order sets for subcutaneous basal-bolus insulin therapy are recommended by clinical guidelines for the inpatient management of diabetes. The algorithm based GlucoTab system electronically assists health care personnel by supporting clinical workflow and providing insulin-dose suggestions. OBJECTIVE To develop a toolbox for improving clinical decision-support algorithms. METHODS The toolbox has three main components. 1) Data preparation: Data from several heterogeneous sources is extracted, cleaned and stored in a uniform data format. 2) Simulation: The effects of algorithm modifications are estimated by simulating treatment workflows based on real data from clinical trials. 3) ANALYSIS: Algorithm performance is measured, analyzed and simulated by using data from three clinical trials with a total of 166 patients. RESULTS Use of the toolbox led to algorithm improvements as well as the detection of potential individualized subgroup-specific algorithms. CONCLUSION These results are a first step towards individualized algorithm modifications for specific patient subgroups.
Collapse
Affiliation(s)
- K Donsa
- HEALTH - Institute for Biomedicine and Health Sciences, JOANNEUM RESEARCH Forschungsgesellschaft mbH , Graz, Austria
| | - P Beck
- HEALTH - Institute for Biomedicine and Health Sciences, JOANNEUM RESEARCH Forschungsgesellschaft mbH , Graz, Austria
| | - J Plank
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz , Graz, Austria
| | - L Schaupp
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz , Graz, Austria
| | - J K Mader
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz , Graz, Austria
| | - T Truskaller
- HEALTH - Institute for Biomedicine and Health Sciences, JOANNEUM RESEARCH Forschungsgesellschaft mbH , Graz, Austria
| | - B Tschapeller
- HEALTH - Institute for Biomedicine and Health Sciences, JOANNEUM RESEARCH Forschungsgesellschaft mbH , Graz, Austria
| | - B Höll
- HEALTH - Institute for Biomedicine and Health Sciences, JOANNEUM RESEARCH Forschungsgesellschaft mbH , Graz, Austria
| | - S Spat
- HEALTH - Institute for Biomedicine and Health Sciences, JOANNEUM RESEARCH Forschungsgesellschaft mbH , Graz, Austria
| | - T R Pieber
- HEALTH - Institute for Biomedicine and Health Sciences, JOANNEUM RESEARCH Forschungsgesellschaft mbH , Graz, Austria ; Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz , Graz, Austria
| |
Collapse
|
5
|
Mader JK, Neubauer KM, Schaupp L, Aberer F, Donsa K, Augustin T, Höll B, Spat S, Beck P, Plank J, Pieber TR. Vergleich von zwei Algorithmen zur Basis-Bolus-Insulintherapie bei Patienten mit Diabetes mellitus Typ 2 im Krankenhaus. DIABETOL STOFFWECHS 2014. [DOI: 10.1055/s-0034-1374881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
6
|
Mader JK, Neubauer KM, Schaupp L, Augustin T, Beck P, Spat S, Höll B, Treiber GM, Fruhwald FM, Pieber TR, Plank J. Efficacy, usability and sequence of operations of a workflow-integrated algorithm for basal-bolus insulin therapy in hospitalized type 2 diabetes patients. Diabetes Obes Metab 2014; 16:137-46. [PMID: 23910952 DOI: 10.1111/dom.12186] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 05/14/2013] [Accepted: 07/29/2013] [Indexed: 11/29/2022]
Abstract
AIMS To evaluate glycaemic control and usability of a workflow-integrated algorithm for basal-bolus insulin therapy in a proof-of-concept study to develop a decision support system in hospitalized patients with type 2 diabetes. METHODS In this ward-controlled study, 74 type 2 diabetes patients (24 female, age 68 ± 11 years, HbA1c 8.7 ± 2.4% and body mass index 30 ± 7) were assigned to either algorithm-based treatment with a basal-bolus insulin therapy or to standard glycaemic management. Algorithm performance was assessed by continuous glucose monitoring and staff's adherence to algorithm-calculated insulin dose. RESULTS Average blood glucose levels (mmol/l) in the algorithm group were significantly reduced from 11.3 ± 3.6 (baseline) to 8.2 ± 1.8 (last 24 h) over a period of 7.5 ± 4.6 days (p < 0.001). The algorithm group had a significantly higher percentage of glucose levels in the ranges from 5.6 to 7.8 mmol/l (target range) and 3.9 to 10.0 mmol/l compared with the standard group (33 vs. 23% and 73 vs. 53%, both p < 0.001). Physicians' adherence to the algorithm-calculated total daily insulin dose was 95% and nurses' adherence to inject the algorithm-calculated basal and bolus insulin doses was high (98 and 93%, respectively). In the algorithm group, significantly more glucose values <3.9 mmol/l were detected in the afternoon relative to other times (p < 0.05), a finding mainly related to pronounced morning glucose excursions and requirements for corrective bolus insulin at lunch. CONCLUSIONS The workflow-integrated algorithm for basal-bolus therapy was effective in establishing glycaemic control and was well accepted by medical staff. Our findings support the implementation of the algorithm in an electronic decision support system.
Collapse
Affiliation(s)
- J K Mader
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Greiner H, Schaller-Ammann R, Huber A, O'Connell M, Krejci J, Porro G, Korsatko S, Gurban J, Deller S, Brunner M, Berghofer A, Priedl J, Zijlstra E, Heise T, Pieber TR, Schaupp L. Continuous Blood Glucose Monitoring (Cgm) System Based on Intravenous Microdialysis and Glucose Sensing. BIOMED ENG-BIOMED TE 2013; 58 Suppl 1:/j/bmte.2013.58.issue-s1-I/bmt-2013-4224/bmt-2013-4224.xml. [PMID: 24042873 DOI: 10.1515/bmt-2013-4224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
8
|
Schaller S, Willmann S, Lippert J, Schaupp L, Pieber TR, Schuppert A, Eissing T. A Generic Integrated Physiologically based Whole-body Model of the Glucose-Insulin-Glucagon Regulatory System. CPT Pharmacometrics Syst Pharmacol 2013; 2:e65. [PMID: 23945606 PMCID: PMC3828004 DOI: 10.1038/psp.2013.40] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 06/03/2013] [Indexed: 11/23/2022]
Abstract
Models of glucose metabolism are a valuable tool for fundamental and applied medical research in diabetes. Use cases range from pharmaceutical target selection to automatic blood glucose control. Standard compartmental models represent little biological detail, which hampers the integration of multiscale data and confines predictive capabilities. We developed a detailed, generic physiologically based whole-body model of the glucose-insulin-glucagon regulatory system, reflecting detailed physiological properties of healthy populations and type 1 diabetes individuals expressed in the respective parameterizations. The model features a detailed representation of absorption models for oral glucose, subcutaneous insulin and glucagon, and an insulin receptor model relating pharmacokinetic properties to pharmacodynamic effects. Model development and validation is based on literature data. The quality of predictions is high and captures relevant observed inter- and intra-individual variability. In the generic form, the model can be applied to the development and validation of novel diabetes treatment strategies.
Collapse
Affiliation(s)
- S Schaller
- 1] Bayer Technology Services GmbH, Computational Systems Biology, Leverkusen, Germany [2] Aachen Institute for Advanced Study in Computational Engineering Sciences, RWTH Aachen, Aachen, Germany
| | | | | | | | | | | | | |
Collapse
|
9
|
Mader JK, Neubauer KM, Schaupp L, Augustin T, Spat S, Höll B, Beck P, Pieber TR, Plank J. Anwenderakzeptanz von Insulindosierungsvorschlägen eines auf Basis-Bolustherapie basierenden Algorithmus bei hospitalisierten Patienten mit Diabetes mellitus Typ 2. DIABETOL STOFFWECHS 2013. [DOI: 10.1055/s-0033-1341900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
10
|
Bodenlenz M, Aigner B, Dragatin C, Liebenberger L, Zahiragic S, Höfferer C, Birngruber T, Priedl J, Feichtner F, Schaupp L, Korsatko S, Ratzer M, Magnes C, Pieber TR, Sinner F. Clinical applicability of dOFM devices for dermal sampling. Skin Res Technol 2013; 19:474-83. [PMID: 23581539 DOI: 10.1111/srt.12071] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sampling the dermal interstitial fluid (ISF) allows the pharmacokinetics and pharmacodynamics of dermatological drugs to be studied directly at their site of action. Dermal open-flow microperfusion (dOFM) is a recently developed technique that can provide minimally invasive, continuous, membrane-free (thus unfiltered) access to the dermal ISF. Herein, we evaluate the clinical applicability and reliability of novel wearable dOFM devices in a clinical setting. METHODS Physicians inserted 141 membrane-free dOFM probes into the dermis of 17 healthy and psoriatic volunteers and sampled dermal ISF for 25 h by using wearable push-pull pumps. The tolerability, applicability, reproducibility, and reliability of multiple insertions and 25 h continuous sampling was assessed by pain scoring, physician feedback, ultrasound probe depth measurements, and 25 h-drift and variability of the sodium relative recovery. RESULTS Insertion pain was moderate and decreased with each additional probe. Probe insertion was precise, although slightly deeper in lesional skin. The wearable push-pull pump enabled uninterrupted ISF sampling over 25 h with low variability. The relative recovery was drift-free and highly reproducible. CONCLUSION dOFM sampling devices are tolerable and reliable for prolonged continuous dermal sampling in a multiprobe clinical setting. These devices should enable the study of a wide range of drugs and their biomarkers in the skin.
Collapse
Affiliation(s)
- M Bodenlenz
- HEALTH - Institute for Biomedicine and Health Sciences, Joanneum Research Forschungsgesellschaft m.b.H., Graz, Austria
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Schaller R, Feichtner F, Köhler H, Bodenlenz M, Plank J, Wutte A, Mader JK, Ellmerer M, Hellmich R, Wedig H, Hainisch R, Pieber TR, Schaupp L. A novel automated discontinuous venous blood monitoring system for ex vivo glucose determination in humans. Biosens Bioelectron 2008; 24:2239-45. [PMID: 19135351 DOI: 10.1016/j.bios.2008.11.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Revised: 11/27/2008] [Accepted: 11/28/2008] [Indexed: 11/26/2022]
Abstract
Intensive insulin therapy reduces mortality and morbidity in critically ill patients but imposes great demands on medical staff who must take frequent blood samples for the determination of glucose levels. A solution to this resourcing problem would be provided by an automated blood monitoring system. The aim of the present clinical study was to evaluate such a system comprising an automatic blood sampling unit linked to a glucose biosensor. Our approach was to determine the correlation and system error of the sampling unit alone and of the combined system with respect to reference levels over 12h in humans. Two venous cannulae were inserted to connect the automatic and reference systems to the subjects. Blood samples were taken at 15 and 30 min intervals. The median Pearson coefficient of correlation between manually and automatically withdrawn blood samples was 0.982 for the sampling unit alone and 0.950 for the complete system. The biosensor had a linear range up to 20 mmoll(-1) and a 95% response time of <2 min. Clark Error Grid analysis showed that 96.93% of the data (228 data pairs) was in zone A and 3.07% in zone B. Insulin Titration Error Grid analysis suggested an acceptable treatment in 99.56% of cases. Implementation of a "Keep Vein Open" saline infusion into the automated blood sampling system reduced blood withdrawal failures through occluded catheters fourfold. In summary, automated blood sampling from a peripheral vein coupled with automatic glucose determination is a promising alternative to frequent manual blood sampling.
Collapse
Affiliation(s)
- R Schaller
- Joanneum Research Forschungsgesellschaft mbH, Institute of Medical Technologies and Health Management, Elisabethstrasse 11a, 8010 Graz, Austria
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Feichtner F, Schaller R, Fercher A, Schaupp L, Plank J, Wutte A, Ellmerer M, Pieber T. Continuous glucose monitoring for intensive care patients using whole blood microdialysis. Crit Care 2007. [PMCID: PMC4095197 DOI: 10.1186/cc5303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
13
|
Schaller R, Feichtner F, Fercher A, Schaupp L, Bodenlenz M, Köhler H, Plank J, Wutte A, Ellmerer M, Hainisch R, Pieber T. System for automated discontinuous venous blood withdrawal for glucose determination of patients in the intensive care unit. Crit Care 2007. [PMCID: PMC4095183 DOI: 10.1186/cc5289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
14
|
Schaller HC, Schaupp L, Bodenlenz M, Wilinska ME, Chassin LJ, Wach P, Vering T, Hovorka R, Pieber TR. On-line adaptive algorithm with glucose prediction capacity for subcutaneous closed loop control of glucose: evaluation under fasting conditions in patients with Type 1 diabetes. Diabet Med 2006; 23:90-3. [PMID: 16409572 DOI: 10.1111/j.1464-5491.2006.01695.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS To evaluate an algorithm with glucose prediction capacity and continuous adaptation of patient parameters-a model predictive control (MPC) algorithm-to control blood glucose concentration during fasting conditions in patients with Type 1 diabetes. In the subcutaneous (sc) route within a closed loop system. METHODS Paired experiments were performed in six patients. Over 8 h the MPC algorithm was used to control glucose with s.c. insulin administration and two different glucose monitoring protocols: first, the algorithm was provided with intravenous (i.v.) glucose values for insulin dosage calculation directly (i.v.-s.c. route). Then, in the second experiment, i.v. glucose values were fed to the MPC with a delay of 30 min to simulate s.c. glucose measurements ('s.c.'-s.c. route). In both experiments plasma glucose, insulin dosage, and serum insulin levels were analysed. RESULTS Glucose concentration was brought from hyper- to normoglycaemia and kept in the physiological range (6-7 mmol/l) with both routes in all subjects. Mean glucose concentration reached the threshold of 7 mmol/l approximately 2 (i.v.-s.c. route) and 3 ('s.c.'-s.c. route) hours after the start of glucose control with the MPC. During the last 2 h of automated glucose control, mean glucose concentration was 6.3 +/- 0.2 mmol/l and 6.6 +/- 0.3 mmol/l for i.v.-s.c. and 's.c.'-s.c. route, respectively. Glucose concentration, insulin doses, and serum insulin levels did not differ significantly between routes (P > 0.05). CONCLUSIONS The MPC algorithm is suitable for glucose control during fasting within an extracorporeal artificial beta-cell in the subcutaneous route Type 1 diabetic patients.
Collapse
Affiliation(s)
- H C Schaller
- Department of Biophysics, Institute of Biomedical Engineering, University of Technology Graz, Graz, Austria.
| | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Plank J, Schaller R, Ellmerer M, Koller D, Eberhardt R, Köhler G, Shoemaker M, Obermaier K, Toller W, Pieber T, Schaupp L. Crit Care 2006; 10:P254. [DOI: 10.1186/cc4601] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
16
|
Plank J, Ellmerer M, Toller W, Rigler B, Amegah-sakotnik A, Hovorka R, Willinskaja M, Agbaje O, Plasnik A, Schaupp L, Pieber T. Crit Care 2005; 9:P386. [DOI: 10.1186/cc3449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
17
|
Bodenlenz M, Schaller HC, Sommer R, Wutte A, Druml T, Sinner F, Regittnig W, Schaupp L, Pieber TR, Wach P. HORMONMESSUNG IN PERIPHEREN GEWEBEN MITTELS OFFENER MIKROPERFUSION UND DER NO-NET-FLUX TECHNIK. BIOMED ENG-BIOMED TE 2003. [DOI: 10.1515/bmte.2003.48.s1.318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
18
|
Regittnig W, Ellmerer M, Schaller-Farmer H, Bodenlenz M, Köhler H, Schaupp L, Wach P, Pieber T. IONEN ALS KALIBRATOREN BEI DER OFFENEN MIKROPERFUSIONSTECHNIK: BESTIMMUNG DES GÜLTIGKEITSBEREICHES. BIOMED ENG-BIOMED TE 2003. [DOI: 10.1515/bmte.2003.48.s1.316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
19
|
Brunner GA, Balent B, Ellmerer M, Schaupp L, Siebenhofer A, Jendle JH, Okikawa J, Pieber TR. Dose-response relation of liquid aerosol inhaled insulin in type I diabetic patients. Diabetologia 2001; 44:305-8. [PMID: 11317660 DOI: 10.1007/s001250051618] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS/HYPOTHESIS The AERx insulin Diabetes Management system (AERx iDMS) is a liquid aerosol device that enables insulin to be administered to the peripheral parts of the lung. This study aimed to compare the pharmacokinetic and pharmacodynamic properties of insulin which is inhaled using AERx iDMS with insulin which is subcutaneously administered. METHODS In total, 18 C-peptide negative patients with Type I (insulin-dependent) diabetes mellitus participated in this randomised, open-label, 5-period crossover trial. Human regular insulin was administered subcutaneously (0.12 U/kg body weight) or inhaled by means of the AERx iDMS (dosages 0.3, 0.6, 1.2, and 1.8 U/kg body weight). Thereafter plasma glucose was kept constant at 7.2 mmol/l for a 10-h period (glucose clamp technique). RESULTS Inhaled insulin provided a dose-response relation that was close to linear for both pharmacokinetic (AUC-Ins(0-10 h); Cmax-Ins) and pharmacodynamic (AUC-GIR(0-10 h); GIRmax) parameters. Time to maximum insulin concentration (Tmax-Ins) and time to maximum glucose infusion rate (TGIRmax) were shorter with inhaled insulin than with subcutaneous administration. The pharmacodynamic system efficiency of inhaled insulin (AUC-GIR(0-6 h) was 12.7% (95% C.I.: 10.2-15.6). CONCLUSION/INTERPRETATION The inhalation of soluble human insulin using the AERx iDMS is feasible and provides a clear dose response. Further long-term studies are required to investigate safety aspects, HbA1c values, incidence of hypoglycaemic events and the quality of life.
Collapse
Affiliation(s)
- G A Brunner
- Department of Internal Medicine, Karl-Franzens University, Auenbruggerplatz 15, A-8036 Graz, Austria
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Brunner GA, Hirschberger S, Sendlhofer G, Wutte A, Ellmerer M, Balent B, Schaupp L, Krejs GJ, Pieber TR. Post-prandial administration of the insulin analogue insulin aspart in patients with Type 1 diabetes mellitus. Diabet Med 2000; 17:371-5. [PMID: 10872536 DOI: 10.1046/j.1464-5491.2000.00289.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIMS In intensified insulin therapy, the recent development of short-acting insulin analogues with a very rapid onset of action forces a new discussion in terms of the optimal injection-meal interval. This study evaluated prandial glycaemia in patients with Type 1 diabetes following the subcutaneous injection of soluble human insulin (HI) and the insulin analogue insulin aspart (IAsp) at different injection-meal intervals and investigated whether administration of IAsp after the meal might provide satisfactory metabolic control. METHODS In a randomized, double-blind, double-dummy, four-period crossover study, 20 Type 1 diabetic patients were investigated. Prandial insulin was administered 15 min before the start of the meal (HI(-15min)), immediately before the meal (HI(0min); IAsp(0min)) and 15 min after the start of the meal (IAsp(+15min)). RESULTS Plasma glucose excursions from baseline levels during the 4 h (PGexc) were highest with HI(0min) (17.9 mmol.l(-1).h; P < 0.05 vs. other treatments) and were not statistically different for HI(-15min), IAsp(0min) and IAsp(15min) (13.6, 11.9 and 14.2 mmol.l(-1).h, respectively). Maximum concentration of plasma glucose (PGmax) was lowest with IAsp(0min) (11.2 mmol/l; P < 0.05 vs. other treatments). PGmax was comparable with HI(-15min), HI(0min) and IAsp(+15min) (13.3, 14.1 and 13.2 mmol/l, respectively). CONCLUSIONS With regard to prandial glycaemia IAsp(+15min) is as effective as HI(-5min) and superior to HI(0min). Thus, post-prandial dosing of the insulin analogue IAsp offers an attractive and feasible therapeutic option for well-controlled patients with Type 1 diabetes mellitus.
Collapse
Affiliation(s)
- G A Brunner
- Department of Internal Medicine, Karl-Franzens University, Graz, Austria.
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Ellmerer M, Schaupp L, Brunner GA, Sendlhofer G, Wutte A, Wach P, Pieber TR. Measurement of interstitial albumin in human skeletal muscle and adipose tissue by open-flow microperfusion. Am J Physiol Endocrinol Metab 2000; 278:E352-6. [PMID: 10662720 DOI: 10.1152/ajpendo.2000.278.2.e352] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The absolute concentration of albumin was measured in the interstitial fluid of subcutaneous adipose tissue and skeletal muscle in six healthy volunteers by combining the method of open-flow microperfusion and the no-net-flux calibration technique. By use of open-flow microperfusion, four macroscopically perforated double lumen catheters were inserted into the tissue regions of interest and constantly perfused. Across the macroscopic perforations of the catheters interstitial fluid was partially recovered in the perfusion fluid. Catheters were perfused with five solutions, each containing different concentrations of albumin. Absolute interstitial albumin concentrations were calculated by applying linear regression analysis to perfusate vs. sampled albumin concentration (no-net-flux calibration technique). Interstitial albumin concentrations were significantly lower (P < 0.0001) in adipose tissue (7.36 g/l; r = 0.99, P < 0.0003; range: 4.3-10.7 g/l) and in skeletal muscle (13.25 g/l; r = 0.99, P < 0.0012; range: 9.7 to 15.7 g/l) compared with the serum concentration (48.9 +/- 0.7 g/l, mean +/- SE, n = 6; range: 46.4-50.4 g/l). Furthermore, interstitial albumin concentrations were significantly higher in skeletal muscle compared with adipose tissue (P < 0.01). The study indicates that open-flow microperfusion allows stable sampling of macromolecules from the interstitial space of peripheral tissue compartments. Moreover, the present data report for the first time in healthy humans in vivo the true albumin concentrations of interstitial fluid of adipose tissue and skeletal muscle.
Collapse
Affiliation(s)
- M Ellmerer
- Department of Internal Medicine, Diabetes and Metabolism, Karl Franzens University Graz, Auenbruggerplatz 15, A-8036 Graz, Austria
| | | | | | | | | | | | | |
Collapse
|
22
|
Regittnig W, Trajanoski Z, Leis HJ, Ellmerer M, Wutte A, Sendlhofer G, Schaupp L, Brunner GA, Wach P, Pieber TR. Plasma and interstitial glucose dynamics after intravenous glucose injection: evaluation of the single-compartment glucose distribution assumption in the minimal models. Diabetes 1999; 48:1070-81. [PMID: 10331412 DOI: 10.2337/diabetes.48.5.1070] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Recent experimental evidence suggests that estimates of glucose effectiveness (S(G)) from the minimal model of unlabeled glucose disappearance (Cold-MM) are in error. The single-compartment glucose distribution assumption embedded in the model has been indicated as a possible source of error. In this study, to directly examine the single-compartment assumption, we measured plasma and interstitial glucose concentrations after intravenous glucose injection. Additionally, we compared the accuracy of the estimates of glucose effectiveness from the Cold-MM and the single-compartment tracer minimal model (Hot-MM). Paired labeled intravenous glucose tolerance tests (IVGTTs) were performed in each of six C-peptide-negative type 1 diabetic subjects. Two different insulin infusion protocols were used: an infusion at constant basal rates and an infusion at variable rates to mimic a normal insulin response. During the labeled IVGTT with basal insulin infusion, the microperfusion technique was employed to sample adipose tissue interstitial fluid. Marked differences between the plasma and interstitial dynamics of (cold) glucose were observed during the first 22 min after glucose injection. These results suggest that the requirements for a single-compartment representation of glucose kinetics are not satisfied during at least the first 22 min of an IVGTT. Data from the labeled IVGTT with normal insulin response were used to identify the minimal-model parameters. The measure of S(G) derived using the Cold-MM was 3.44-fold higher than the direct measure obtained from the labeled IVGTT with basal insulin infusion (0.0179+/-0.0027 vs. 0.0052+/-0.0010 min(-1), P<0.01). The measure of glucose effectiveness (S(G)*) derived by the Hot-MM was 1.36-fold higher than the direct measure available from the labeled IVGTT with basal insulin infusion (0.0079+/-0.0013 vs. 0.0058+/-0.0004 min(-1), P>0.26). These results suggest that the Hot-MM is more appropriate for the evaluation of glucose effectiveness than the Cold-MM.
Collapse
Affiliation(s)
- W Regittnig
- Department of Biophysics, Institute of Biomedical Engineering, Graz University of Technology, Austria.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Schaupp L, Ellmerer M, Brunner GA, Wutte A, Sendlhofer G, Trajanoski Z, Skrabal F, Pieber TR, Wach P. Direct access to interstitial fluid in adipose tissue in humans by use of open-flow microperfusion. Am J Physiol 1999; 276:E401-8. [PMID: 9950802 DOI: 10.1152/ajpendo.1999.276.2.e401] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
To gain direct access to the interstitial fluid (ISF), a new technique called open-flow microperfusion has been evaluated. This method is based on a double-lumen catheter with macroscopic (0.3-0.5 mm diameter) perforations that is inserted into the subcutaneous adipose tissue and constantly perfused. Thus partial equilibration between the ISF and the perfusion fluid occurs. The glucose concentration of the ISF was determined by established (zero flow rate, no net flux, and recirculation procedures) and new (ionic reference and suction technique) calibration methods by use of open-flow microperfusion. The data show that 1) the glucose concentration in the ISF is significantly lower than the corresponding arterialized venous plasma values during basal steady-state conditions (adipose tissue 3.2 +/- 0.10 mM, plasma 5.27 +/- 0.12 mM) as well as during hyperglycemic clamp experiments (adipose tissue 7.3 +/- 0.13 mM, plasma 9.91 +/- 0.16 mM), and 2) it is possible to determine the recovery continuously by using the ion concentration of the ISF as an internal standard (ionic reference).
Collapse
Affiliation(s)
- L Schaupp
- Department of Biophysics, Institute of Biomedical Engineering, Graz University of Technology, A-8010 Graz, Austria
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Ellmerer M, Schaupp L, Sendlhofer G, Wutte A, Brunner GA, Trajanoski Z, Skrabal F, Wach P, Pieber TR. Lactate metabolism of subcutaneous adipose tissue studied by open flow microperfusion. J Clin Endocrinol Metab 1998; 83:4394-401. [PMID: 9851784 DOI: 10.1210/jcem.83.12.5303] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Open flow microperfusion and a novel calibration technique (ionic reference technique) were evaluated for the frequent measurement of the absolute lactate concentration in sc adipose tissue. Furthermore, the influence of the plasma insulin concentration on the lactate concentration of sc adipose tissue was investigated during hyperglycemia. Sixteen lean healthy young men participated in the studies. In the postabsorbtive state the mean sc lactate concentrations were 1.29 and 1.36 mmol/L for the ionic reference technique and the no net flux protocol, respectively (not significant, P > 0.05). The simultaneously measured arterialized plasma lactate concentration was significantly lower at 0.77 mmol/L (P < 0.05). Both the sc lactate concentration (1.8+/-0.33 mmol/L) and the plasma lactate concentration (0.96+/-0.03 mmol/L) were significantly elevated during a hyperinsulinemic euglycemic clamp experiment. During a hyperglycemic clamp experiment the sc lactate concentration reached a significantly elevated plateau (2.15+/-0.27 mmol/L) that was not influenced by the increasing plasma insulin concentration. It is concluded that 1) open flow microperfusion combined with the ionic reference technique enables frequent measurement of the sc lactate concentration; 2) sc adipose tissue is a significant source of lactate release in the postabsorbtive state as well as during hyperinsulinemic clamp conditions; and 3) insulin concentrations greater than 180 pmol/L have no further influence on adipocyte stimulation of sc adipose tissue with respect to lactate release.
Collapse
Affiliation(s)
- M Ellmerer
- Department of Internal Medicine and Diabetes and Metabolism, Karl Franzens University Graz, Austria
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Gfrerer RJ, Brunner GA, Trajanoski Z, Schaupp L, Sendlhofer G, Skrabal F, Jobst G, Moser I, Urban G, Pieber TR, Wach P. Novel system for real-time ex vivo lactate monitoring in human whole blood. Biosens Bioelectron 1998; 13:1271-8. [PMID: 9883561 DOI: 10.1016/s0956-5663(98)00090-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The objective of the study was to evaluate the performance of an amperometric enzyme based lactate sensor and to investigate the possibility of replacing a double lumen catheter based blood withdrawal system with a heparin coated single lumen system. The inner lumen of a double lumen catheter which was placed in a peripheral vein was perfused with heparin solution. The outer lumen was used to collect heparinized blood samples at a defined flow rate. The single lumen system was attached to a heparinized catheter which was also placed in a peripheral vein. The undiluted blood samples were collected at a specified flow rate. A sensor flow chamber incorporating an amperometric thin-film lactate microbiosensor was placed in the sampling line for real-time lactate monitoring. Plasma lactate concentrations were measured during frequently performed hyperlactatemia bicycle ergometer experiments in six healthy volunteers (age 25.8 +/- 2.8 years, BMI 22.7 +/- 1 kg/m2). Additionally, plasma lactate was measured in real-time using the lactate sensors. The first three experiments were performed with a double lumen based catheter system whereas the following three experiments were performed with a heparin coated catheter system. The correlation coefficients of sensor readings and laboratory analyzer results in all six experiments were between 0.93 and 0.99, respectively (P < 0.001). The miniaturized lactate sensors showed a linear range up to 25 mmol/l lactate concentration and 95% response times < 30 s in undiluted serum. During the experiments maximum lactate concentrations of 14 mmol/l were achieved. Improvements of system performance using heparin coated catheter systems could be shown. The overall SD of the sensor readings compared to laboratory results using three double lumen catheter based systems was 0.91 mmol/l whereas the SD using three heparin coated systems was 0.65 mmol/l. In summary, real-time monitoring of lactate in human whole blood is feasible with such a device and can be improved by using heparin coated catheter systems.
Collapse
Affiliation(s)
- R J Gfrerer
- Department of Biophysics, Graz University of Technology, Austria.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Ellmerer M, Schaupp L, Trajanoski Z, Jobst G, Moser I, Urban G, Skrabal F, Wach P. Continuous measurement of subcutaneous lactate concentration during exercise by combining open-flow microperfusion and thin-film lactate sensors. Biosens Bioelectron 1998; 13:1007-13. [PMID: 9839389 DOI: 10.1016/s0956-5663(98)00002-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The present study was carried out to investigate in vivo in healthy humans the method of open-flow microperfusion for monitoring of the subcutaneous (s.c.) lactate concentration during rest and cycle ergometer exercise. Using open-flow microperfusion, a perforated double lumen catheter with an inflow and an outflow connection is inserted into the s.c. adipose tissue and perfused with a sterile, isotonic, ionfree fluid. Due to the low flow rate, the fluid partially equilibrates with the surrounding tissue. The equilibrated perfusate passes a sensor flow chamber where the substance of interest and the rate of recovery (i.e. the ratio of sampled concentration to interstitial concentration) are continuously monitored. Within this study, the method was evaluated in four healthy volunteers during cycle ergometer exercise. The relative increase of the lactate concentration was approximately a third in the s.c. tissue compared to the capillary blood and the peak time was delayed on average by 10 min. The correlation coefficient between blood and s.c. tissue lactate concentration ranged from r = 0.41 to r = 0.90 (n = 29) in the individual experiments. The combination of open-flow microperfusion and lactate and conductivity sensors enables on-line monitoring of the s.c. lactate concentration without in vivo calibration during steady-state and cycle ergometer exercise.
Collapse
Affiliation(s)
- M Ellmerer
- Department of Biophysics, Graz University of Technology, Austria.
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Brunner GA, Ellmerer M, Sendlhofer G, Wutte A, Trajanoski Z, Schaupp L, Quehenberger F, Wach P, Krejs GJ, Pieber TR. Validation of home blood glucose meters with respect to clinical and analytical approaches. Diabetes Care 1998; 21:585-90. [PMID: 9571347 DOI: 10.2337/diacare.21.4.585] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the clinical and analytical accuracy of home blood glucose meters. RESEARCH DESIGN AND METHODS Six blood glucose meters--Reflolux S (Boehringer Mannheim, Mannheim, Germany), One Touch II (LifeScan, Milpitas, CA), Glucocard Memory (Menarini, Florence, Italy), Precision QID (Medisense, Cambridge, U.K.), HaemoCue (HaemoCue, Angelholm, Sweden), and Accutrend alpha (Boehringer Mannheim, Mannheim, Germany)--were compared with a reference method (Beckman Glucose Analyzer II) under controlled conditions (glucose clamp technique). Validation of the blood glucose meters was accomplished by clinically oriented approaches (error grid analysis), statistical approaches (variance components analysis), and by the criteria of the American Diabetes Association (ADA), which recommend a target variability of < 5%. RESULTS A total of 1,794 blood glucose monitor readings and 299 reference values ranging from 2.2 to 18.2 mmol/l were analyzed (705 readings < 3.89 mmol/l, 839 readings between 3.89 and 9.99 mmol/l, and 250 readings > 9.99 mmol/l). According to error grid analysis, only Reflolux S and Glucocard M had 100% of estimations within the clinically acceptable zones A and B. Assessment of analytical accuracy revealed substantial differences between the glucose meters after separation of the data into defined glycemic ranges. None of the devices met the ADA criteria. CONCLUSIONS To evaluate accuracy of blood glucose meters, error grid analysis, as well as statistical models, are helpful means and should be performed together. Analytical performance of currently available home blood glucose meters differs substantially within defined glycemic ranges.
Collapse
Affiliation(s)
- G A Brunner
- Department of Internal Medicine, Karl Franzens University Graz, Austria
| | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Ellmerer M, Schaupp L, Sendlhofer G, Wutte A, Brunner G, Trajanoski Z, Pieber T, Wach P. Absolute Lactate Concentration in Subcutaneous Adipose Tissue Measured by Open Flow Microperfusion. BIOMED ENG-BIOMED TE 1998. [DOI: 10.1515/bmte.1998.43.s2.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
29
|
Trajanoski Z, Brunner GA, Schaupp L, Ellmerer M, Wach P, Pieber TR, Kotanko P, Skrabal F. Open-flow microperfusion of subcutaneous adipose tissue for on-line continuous ex vivo measurement of glucose concentration. Diabetes Care 1997; 20:1114-21. [PMID: 9203447 DOI: 10.2337/diacare.20.7.1114] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To evaluate a novel technique for on-line continuous glucose measurement in subcutaneous adipose tissue, and to investigate its accuracy for detection of hypoglycemia. RESEARCH DESIGN AND METHODS The method combined an open-flow microperfusion of subcutaneous adipose tissue using a double lumen catheter and an extracorporeal sensor cell. An isotonic ion-free solution was perfused through the inner lumen of the catheter, equilibrated with the subcutaneous tissue fluid, and sampled through the outer lumen. The recovery was continuously monitored as the ratio between the measured sampled fluid conductivity and the subcutaneous tissue fluid conductivity (assumed to have a constant value of 1.28 S/m at 25 degrees C). Glucose concentration was calculated on-line from the measured glucose in the sampled fluid and the measured recovery in healthy volunteers during hyperglycemic glucose loads (n = 8), hypoglycemic hyperinsulinemic clamp (n = 6), and a 24-h monitoring period (n = 7). RESULTS Subcutaneous glucose concentrations in the fasting state were 94% of the plasma glucose concentrations in arterialized venous samples. According to the error grid analysis, 96.9% of the on-line measured subcutaneous glucose concentrations during hyperglycemia and 96.3% during hypoglycemia were in accurate or acceptable zones. The mean differences between the measured subcutaneous glucose and the actual plasma glucose concentration were -0.06-3.3 mmol/l (hyperglycemia), and -0.6-1.1 mmol/l (hypoglycemia). CONCLUSIONS By combining open-flow microperfusion, glucose sensor, and conductivity measurement, glucose concentration in the subcutaneous adipose tissue can be monitored on-line, extracorporeally, and continuously without any in vivo calibration, and gives accurate measurements during hyper- and hypoglycemia.
Collapse
Affiliation(s)
- Z Trajanoski
- Department of Biophysics, Institute of Biomedical Engineering, Graz University of Technology, Austria.
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Trajanoski Z, Wach P, Schaupp L, Ellmerer M, Brunner GA, Urban G, Skrabal F. Offene Mikroperfusion: Eine neue Samplingtechnik. BIOMED ENG-BIOMED TE 1996. [DOI: 10.1515/bmte.1996.41.s1.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
31
|
Ellmerer M, Trajanoski Z, Schaupp L, Wach P, Brunner G, Pieber T, Skrabal F. Subkutanes Glucose Monitoring im hypoglykämischen Bereich mit offener Mikroperfusion. BIOMED ENG-BIOMED TE 1996. [DOI: 10.1515/bmte.1996.41.s1.502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
32
|
Hadl J, Jeuschnigger J, Schaupp L, Pribyl W. Hochwertige Vorstufen für Biosignalverstärker. BIOMED ENG-BIOMED TE 1992. [DOI: 10.1515/bmte.1992.37.s2.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|