2-Benzamide Tellurenyl Iodides: Synthesis and Their Catalytic Role in CO2 Mitigation

Benzamide-derived organochalcogens (chalcogen=S, Se, and Te) have shown promising interest in biological and synthetic chemistry. Ebselen molecule derived from benzamide moiety is the most studied organoselenium. However, its heavier congener organotellurium is under-explored. Here, an efficient copper-catalyzed atom economical synthetic method has been developed to synthesize 2-phenyl-benzamide tellurenyl iodides by inserting a tellurium atom into carbon-iodine bond of 2-iodobenzamides in one pot with 78-95 % yields. Further, the Lewis acidic nature of Te center and Lewis basic nature of nitrogen of the synthesized 2-Iodo-N-(quinolin-8-yl)benzamide tellurenyl iodides enabled them as pre-catalyst for the activation of epoxide with CO2 at 1 atm for the preparation of cyclic carbonates with TOF and TON values of 1447 h-1 and 4343, respectively, under solvent-free conditions. In addition, 2-iodo-N-(quinolin-8-yl)benzamide tellurenyl iodides have also been used as pre-catalyst for activating anilines and CO2 to form a variety of 1,3-diaryl ureas up to 95 % yield. The mechanistic investigation for CO2 mitigation is done by 125 Te NMR and HRMS studies. It seems that the reaction proceeds via formation of catalytically active Te-N heterocycle, an ebtellur intermediate which is isolated and structurally characterized.

Bowman's membrane lenticule tuck-in: A new approach for the management of neurotrophic ulcers

PURPOSE

To evaluate a new surgical method for managing nonhealing neurotrophic ulcers using a novel technique of tucking-in Bowman's membrane lenticule in the ulcer defect.

METHODS

A total of 22 eyes of 22 patients with neurotrophic ulcers of various etiologies and stages were included and underwent a surgical process where a donor Bowman's membrane lenticule was harvested and fashioned according to the lesion and tucked inside the ulcer after making a recess in anterior one-third of stroma all around 360 degrees. The primary outcomes measured were healing (stable epithelialization at 12 months) and best-corrected visual acuity (BCVA) improvement.

RESULTS

Twenty-two eyes of 22 patients with neurotrophic ulcers underwent Bowman's membrane lenticule tuck-in procedure. Complete re-epithelialization was achieved in 21 eyes (95.45%). The average healing time was 2.77 ± 0.79 weeks. The mean corneal thickness improved from 267.36 ± 94.56 mm preoperatively to 435.9 ± 47.71 mm at six months postoperatively. The mean BCVA also improved from 0.05 ± 0.07 preoperatively to 0.24 ± 0.24 postoperatively one year. One patient (4.54%) showed recurrence after one month, and the epithelial defect persisted till the end of the study.

CONCLUSION

Donor Bowman's membrane lenticule tuck-in for neurotrophic ulcers is a safe and highly effective treatment and requires minimal instruments and expertise.

Generation of post-meal insulin correction boluses in type 1 diabetes simulation models for in-silico clinical trials: More realistic scenarios obtained using a decision tree approach

BACKGROUND AND OBJECTIVE

In type 1 diabetes (T1D) research, in-silico clinical trials (ISCTs) notably facilitate the design/testing of new therapies. Published simulation tools embed mathematical models of blood glucose (BG) and insulin dynamics, continuous glucose monitoring (CGM) sensors, and insulin treatments, but lack a realistic description of some aspects of patient lifestyle impacting on glucose control. Specifically, to effectively simulate insulin correction boluses, required to treat post-meal hyperglycemia (BG > 180 mg/dL), the timing of the bolus may be influenced by subjects' behavioral attitudes. In this work, we develop an easily interpretable model of the variability of correction bolus timing observed in real data, and embed it into a popular simulation tool for ISCTs.

METHODS

Using data collected in 196 adults with T1D monitored in free-living conditions, we trained a decision tree (DT) model to classify whether a correction bolus is injected in a future time window, based on predictors collected back in time, related to CGM data, previous insulin boluses and subject's characteristics. The performance was compared to that of a logistic regression classifier with LASSO regularization (LC), trained on the same dataset. After validation, the DT was embedded within a popular T1D simulation tool and an ISCT was performed to compare the simulated correction boluses against those observed in a subset of data not used for model training.

RESULTS

The DT provided better classification performance (accuracy: 0.792, sensitivity: 0.430, specificity: 0.878, precision: 0.455) than the LC and presented good interpretability. The most predictive features were related to CGM (and its temporal variations), time since the last insulin bolus, and time of the day. The correction boluses simulated by the DT, after implementation in the simulation tool, showed a good agreement with real-world data.

CONCLUSIONS

The DT developed in this work represents a simple set of rules to mimic the same timing of correction boluses observed on real data. The inclusion of the model in simulation tools allows investigators to perform ISCTs that more realistically represent the patient behavior in taking correction boluses and the post-prandial BG response. In the future, more complex models can be investigated.

Delivering evidence-based interventions for type 1 diabetes in the virtual world - A review of UK practice during the SARS-CoV-2 pandemic

AIMS

This review considers the impact of the SARS-CoV-2 pandemic on access to interventions for those living with type 1 diabetes and discusses the solutions which have been considered and actioned to ensure ongoing access care.

METHODS

We performed a focussed review of the published literature, and the guidelines for changes that have been effected during the pandemic. We also drew from expert recommendations and information about local practice changes for areas where formal data have not been published.

RESULTS

Evidence based interventions which support the achievement of improved glucose levels and/or reduction in hypoglycaemia include group structured education to support self-management, insulin pump therapy and continuous glucose monitoring. The SARS-CoV-2 pandemic had impacted the ability of diabetes services to deliver these intervention. Multiple adaptations have been put in place - transition to online delivery of education and care, and usage of diabetes technology.

CONCLUSIONS

Although various adaptations have been made during the pandemic that have positively influenced uptake of services, there are many areas of delivery that need immediate improvement in the UK. We recommend a proactive approach in recognising the digital divide and inequity in distribution of these changes and we recommend introducing measures to reduce them.

A Mathematical Formula to Determine the Minimum Continuous Glucose Monitoring Duration to Assess Time-in-ranges: Sensitivity Analysis Over the Parameters

In diabetes management, the fraction of time spent with glucose concentration within the physiological range of [70-180] mg/dL, namely time in range (TIR) is often computed by clinicians to assess glycemic control using a continuous glucose monitoring sensor. However, a sufficiently long monitoring period is required to reliably estimate this index. A mathematical equation derived by our group provides the minimum trial duration granting a desired uncertainty around the estimated TIR. The equation involves two parameters, p_r and α, related to the population under analysis, which should be set based on the clinician's experience. In this work, we evaluated the sensitivity of the formula to the parameters.Considering two independent datasets, we predicted the uncertainty of TIR estimate for a population, using the parameters of the formula estimated for a different population. We also stressed the robustness of the formula by testing wider ranges of parameters, thus assessing the impact of large errors in the parameters' estimates.Plausible errors on the α estimate impact very slightly on the prediction (relative discrepancy < 5%), thus we suggest using a fixed value for α independently on the population being analyzed. Instead, p_r should be adjusted to the TIR expected in the population, considering that errors around 20% result in a relative discrepancy of ~10%.In conclusion, the proposed formula is sufficiently robust to parameters setting and can be used by investigators to determine a suitable duration of the study.

Intrauterine immunizations trigger antigen-specific mucosal and systemic immunity in pigs and passive protection in suckling piglets

We assessed whether vaccines administered to the uterus at breeding can lead to sufficient colostral antibodies to protect suckling piglets against Porcine Endemic Diarrhea Virus (PEDV). An antigen from Lawsonia intracellularis, a disease that impacts weanling intestinal health, was also included because we have extensive knowledge on the pig immune response to this antigen. Gilts were mock-bred at 2nd estrus with killed sperm including an intrauterine (i.u.) vaccine comprised of recombinant (r) PEDV Spike protein (rPEDVS1) and L. intracellularis flagellin (rFliC) formulated with poly I:C, host defense peptide, and polyphosphazene (TriAdj). Gilts returned to estrus within 3 weeks and they were inseminated with killed sperm (3rd estrus) or live sperm (4th estrus) with rPEDVS1-TriAdj vaccine. They also received an i.m. injection of rFliC-TriAdj at 3rd and 4th estrus to establish whether i.u. vaccination primes systemic immunity without inducing mucosal tolerance. Control gilts were administered semen alone at 2nd estrus which allowed us to compare litter weights and sizes to industry standards. Colostrum from gilts challenged with low dose PEDV plus alum was used as positive reference samples for neutralizing antibodies and passive protection. Thirteen weeks later, the i.u.-vaccinated gilts showed significant PEDVS1-specific serum, colostral, and uterine antibody titers and colostral PEDVS1-neutralizing antibodies but poor cell-mediated immunity. Piglets born to i.u. vaccinated gilts received partial passive protection from PEDV infection 3 days after birth but eventually succumbed to the disease. Immunization by the i.u./i.m. route triggered significant anti-FliC cell-mediated immunity and colostral FliC antibodies that remained high in weaned piglet serum. This trial and a repeat trial wherein gilts were immunized at 1st estrus without semen and at 2nd estrus with live semen showed that intrauterine immunization did not impact fertility, number of live births or piglet growth kinetics. Further optimization is needed to promote robust passive protection in suckling offspring.

Cerebroplacental ratio and aortic isthmus Doppler in early fetal growth restriction

PURPOSE

To assess the utility of cerebroplacental ratio (CPR) and fetal aortic isthmus (AoI) Doppler in the prediction of perinatal outcome in early fetal growth restriction (FGR).

METHODS

A prospective observational cohort study of 70 early FGR cases was conducted through serial Doppler examinations and findings of the last examination were correlated with perinatal outcome. Doppler blood flow measurements of AoI included end diastolic velocity (EDV), peak systolic velocity (PSV), pulsatility index (PI), resistance index (RI), and isthmic flow index (IFI).

RESULTS

Significant association of CPR and all Doppler indices of AoI with the overall adverse perinatal outcome was seen. The sensitivity of CPR was moderate (63.64%) but higher than most AoI indices. Most AoI Doppler indices (PI, RI, IFI) had higher specificities (100%). AoI PSV and EDV had higher sensitivities than CPR for the prediction of overall adverse perinatal outcome, with AoI PSV having the highest sensitivity (100%).

CONCLUSION

CPR shows significant association and moderate sensitivity for prediction of overall adverse perinatal outcome in early FGR; hence recommended in all cases of early FGR. AoI Doppler also appears to have a role in assessment and decision making in FGR in view of high sensitivity and high specificity of AoI indices in the prediction of perinatal outcome. However, larger studies are required to confirm its utility in the management of early FGR.

The transCampus Metabolic Training Programme Explores the Link of SARS-CoV-2 Virus to Metabolic Disease

Currently, we are experiencing a true pandemic of a communicable disease by the virus SARS-CoV-2 holding the whole world firmly in its grasp. Amazingly and unfortunately, this virus uses a metabolic and endocrine pathway via ACE2 to enter our cells causing damage and disease. Our international research training programme funded by the German Research Foundation has a clear mission to train the best students wherever they may come from to learn to tackle the enormous challenges of diabetes and its complications for our society. A modern training programme in diabetes and metabolism does not only involve a thorough understanding of classical physiology, biology and clinical diabetology but has to bring together an interdisciplinary team. With the arrival of the coronavirus pandemic, this prestigious and unique metabolic training programme is facing new challenges but also new opportunities. The consortium of the training programme has recognized early on the need for a guidance and for practical recommendations to cope with the COVID-19 pandemic for the community of patients with metabolic disease, obesity and diabetes. This involves the optimal management from surgical obesity programmes to medications and insulin replacement. We also established a global registry analyzing the dimension and role of metabolic disease including new onset diabetes potentially triggered by the virus. We have involved experts of infectious disease and virology to our faculty with this metabolic training programme to offer the full breadth and scope of expertise needed to meet these scientific challenges. We have all learned that this pandemic does not respect or heed any national borders and that we have to work together as a global community. We believe that this transCampus metabolic training programme provides a prime example how an international team of established experts in the field of metabolism can work together with students from all over the world to address a new pandemic.

Time in range: A best practice guide for UK diabetes healthcare professionals in the context of the COVID-19 global pandemic

The emergence of continuous glucose monitoring has driven improvements in glycaemic control and quality of life for people with diabetes. Recent changes in access to continuous glucose monitoring systems within UK health services have increased the number of people able to benefit from these technologies. The COVID-19 pandemic has created an opportunity for diabetes healthcare professionals to use continuous glucose monitoring technology to remotely deliver diabetes services to support people with diabetes. This opportunity can be maximized with improved application and interpretation of continuous glucose monitoring-generated data. Amongst the diverse measures of glycaemic control, time in range is considered to be of high value in routine clinical care because it is actionable and is visibly responsive to changes in diabetes management. Importantly, it is also been linked to the risk of developing complications associated with diabetes and can be understood by people with diabetes and healthcare professionals alike. The 2019 International Consensus on Time in Range has established a series of target glucose ranges and recommendations for time spent within these ranges that is consistent with optimal glycaemic control. The recommendations cover people with type 1 or type 2 diabetes, with separate targets indicated for elderly people or those at higher risk from hypoglycaemia, as well as for women with type 1 diabetes during pregnancy. The aim of this best practice guide was to clarify the intent and purpose of these international consensus recommendations and to provide practical insights into their implementation in UK diabetes care.

Distal technology interventions in people with diabetes: an umbrella review of multiple health outcomes

AIM

To summarize and evaluate the existing evidence on the effectiveness of distal technology with regard to multiple health outcomes in people with diabetes.

METHODS

We searched PubMed, EMBASE and the Cochrane Database of Systematic Reviews from database inception to 31 August 2018 for systematic reviews and/or meta-analyses of studies that examined the impact of distal technology and reported any clinical or patient-related outcomes among people with type 1 or type 2 diabetes.

RESULTS

The umbrella review identified 95 reviews, including 162 meta-analyses with 46 unique outcomes. Evidence from meta-analyses of randomized controlled studies supports the use of distal technology, especially telehealth and mHealth (healthcare delivered by mobile technology), in people with diabetes for improving HbA_1c values by 2-4 mmol/mol (0.2-0.4%). For other health outcomes, such as changes in fasting plasma glucose levels, risk of diabetic ketoacidosis or frequency of severe hypoglycaemia, the evidence was weaker. No evidence was reported for most patient-reported outcomes including quality of life, self-efficacy and medication-taking. The evidence base was poor, with most studies rated as low to very low quality.

CONCLUSION

Distal technologies were associated with a modest improvement in glycaemic control, but it was unclear if they improved major clinical outcomes or were cost-effective in people with diabetes. More robust research to improve wider outcomes in people with diabetes is needed before such technologies can be recommended as part of routine care for any patient group.

Do-it-yourself closed-loop systems for people living with type 1 diabetes

Growing numbers of people with type 1 diabetes are using do-it-yourself closed-loop systems. While these technologies are not approved by regulatory bodies and are not commercially available, users of the technology report improvements in HbA_1c and time in range, and reduced burden of diabetes. Healthcare professionals have expressed their concern that legal or regulatory body actions could ensue if they support people who choose to use do-it-yourself closed-loop systems. Diabetes UK's position statements make recommendations that aim to provide guidance for both people with diabetes and healthcare professionals, based on the current professional and legal situation. They respect an individual's right to make their own informed decisions about their diabetes management, and recommend that they should have access to the technology they need for optimal diabetes management. People who wish to use do-it-yourself closed-loop systems should continue to receive support and care from their diabetes team. Healthcare professionals should engage in conversations around do-it-yourself closed-loop systems, if the issue is raised, to allow a balanced discussion of risks and benefits. However, healthcare professionals cannot recommend the use of do-it-yourself closed-loop systems because of a lack of regulatory body approval and robust, published research to support safety or effectiveness. People using this technology should be aware that they do so at their own risk. This position statement recognizes that the development of diabetes technology is a rapidly changing environment, and guidance around do-it-yourself systems is required from professional and regulatory bodies.

Arabidopsis SMALL DEFENSE-ASSOCIATED PROTEIN 1 Modulates Pathogen Defense and Tolerance to Oxidative Stress

Salicylic acid (SA) and reactive oxygen species (ROS) are known to be key modulators of plant defense. However, mechanisms of molecular signal perception and appropriate physiological responses to SA and ROS during biotic or abiotic stress are poorly understood. Here we report characterization of SMALL DEFENSE-ASSOCIATED PROTEIN 1 (SDA1), which modulates defense against bacterial pathogens and tolerance to oxidative stress. sda1 mutants are compromised in defense gene expression, SA accumulation, and defense against bacterial pathogens. External application of SA rescues compromised defense in sda1 mutants. sda1 mutants are also compromised in tolerance to ROS-generating chemicals. Overexpression of SDA1 leads to enhanced resistance against bacterial pathogens and tolerance to oxidative stress. These results suggest that SDA1 regulates plant immunity via the SA-mediated defense pathway and tolerance to oxidative stress. SDA1 encodes a novel small plant-specific protein containing a highly conserved seven amino acid (S/G)WA(D/E)QWD domain at the N-terminus that is critical for SDA1 function in pathogen defense and tolerance to oxidative stress. Taken together, our studies suggest that SDA1 plays a critical role in modulating both biotic and abiotic stresses in Arabidopsis (Arabidopsis thaliana) and appears to be a plant-specific stress responsive protein.

Reducing the burden of hypoglycaemia in people with diabetes through increased understanding: design of the Hypoglycaemia REdefining SOLutions for better liVEs (Hypo-RESOLVE) project

BACKGROUND

Hypoglycaemia is the most frequent complication of treatment with insulin or insulin secretagogues in people with diabetes. Severe hypoglycaemia, i.e. an event requiring external help because of cognitive dysfunction, is associated with a higher risk of adverse cardiovascular outcomes and all-cause mortality, but underlying mechanism(s) are poorly understood. There is also a gap in the understanding of the clinical, psychological and health economic impact of 'non-severe' hypoglycaemia and the glucose level below which hypoglycaemia causes harm.

AIM

To increase understanding of hypoglycaemia by addressing the above issues over a 4-year period.

METHODS

Hypo-RESOLVE is structured across eight work packages, each with a distinct focus. We will construct a large, sustainable database including hypoglycaemia data from >100 clinical trials to examine predictors of hypoglycaemia and establish glucose threshold(s) below which hypoglycaemia constitutes a risk for adverse biomedical and psychological outcomes, and increases healthcare costs. We will also investigate the mechanism(s) underlying the antecedents and consequences of hypoglycaemia, the significance of glucose sensor-detected hypoglycaemia, the impact of hypoglycaemia in families, and the costs of hypoglycaemia for healthcare systems.

RESULTS

The outcomes of Hypo-RESOLVE will inform evidence-based definitions regarding the classification of hypoglycaemia in diabetes for use in daily clinical practice, future clinical trials and as a benchmark for comparing glucose-lowering interventions and strategies across trials. Stakeholders will be engaged to achieve broadly adopted agreement.

CONCLUSION

Hypo-RESOLVE will advance our understanding and refine the classification of hypoglycaemia, with the ultimate aim being to alleviate the burden and consequences of hypoglycaemia in people with diabetes.

ZnO-Modified g-C3N4: A Potential Photocatalyst for Environmental Application

Solar energy-driven practices using semiconducting materials is an ideal approach toward wastewater remediation. In order to attain a superior photocatalyst, a composite of g-C3N4 and ZnO (GCN-ZnO) has been prepared by one-step thermal polymerization of urea and zinc carbonate basic dihydrate [ZnNO3]2·[Zn(OH)2]3. The GCN-ZnO0.4 sample showed an evolved morphology, increased surface area (116 m2 g-1), better visible light absorption ability, and reduced band gap in comparison to GCN-pure. The GCN-ZnO0.4 sample also showed enhanced adsorption and photocatalytic activity performance, resulting in an increased reaction rate value up to 3 times that of GCN-pure, which was attributed to the phenomenon of better separation of photogenerated charge carriers resulting because of heterojunction development among interfaces of GCN-pure and ZnO. In addition, the GCN-ZnO0.4 sample showed a decent stability for four cyclic runs and established its potential use for abatement of organic wastewater pollutants in comparison to GCN-pure.

Recurrent diabetic ketoacidosis and a brief history of brittle diabetes research: contemporary and past evidence in diabetic ketoacidosis research including mortality, mental health and prevention

Pharmacological, technological and educational approaches have advanced the treatment of Type 1 diabetes in the last four decades and yet diabetic ketoacidosis (DKA) continues to be a leading cause of admission in Type 1 diabetes. This article begins by reviewing the contemporary epidemiological evidence in DKA. It highlights a rise in DKA episodes in the last two decades, with DKA continuing to be the leading cause of death in young people with Type 1 diabetes, and that DKA episodes are a marker for subsequent all-cause mortality. It also summarizes the limited evidence base for DKA prevention and associations with psychopathology. To emphasize the importance of this group with high-risk Type 1 diabetes and the degree to which they have been overlooked in the past two decades, the article summarizes the research literature of recurrent DKA during 1976-1991 when it was extensively investigated as part of the phenomenon of 'brittle diabetes'. This period saw numerous basic science studies investigating the pathophysiology of recurrent DKA. Subsequently, research centres published their experiences of brittle diabetes research participants manipulating their treatment under research conditions. Unfortunately, the driver for this behaviour and whether it was indicative of other people with ketoacidosis was not pursued. In summary, we suggest there has been a stasis in the approach to recurrent DKA prevention, which is likely linked to historical cases of mass sabotage of brittle diabetes research. Further investigation is required to clarify possible psychological characteristics that increase the risk of DKA and thereby targets for DKA prevention.

Use of sensor-integrated pump therapy to reduce hypoglycaemia in people with Type 1 diabetes: a real-world study in the UK

AIMS

To assess the efficacy of insulin pumps with automated insulin suspension systems in a real-world setting.

METHODS

We analysed anonymized data uploaded to CareLink^™ by people (n=920) with Type 1 diabetes using the MiniMed Paradigm Veo system and the MiniMed 640G system (Medtronic International Trading Sàrl, Tolochanez, Switzerland) with SmartGuard technology, with or without automated insulin suspension enabled, between February 2016 and June 2018. Users with ≥15 days of sensor data and ≥70% sensor-wear time were classified as sensor-augmented pump alone, sensor-integrated pump with low glucose suspend enabled or sensor-integrated pump with predictive low glucose management enabled.

RESULTS

The median (25^th -75^th percentile) system use was 161 (58-348) days. The median time spent with sensor glucose values ≤3 mmol/l was 0.8 (0.3-1.7)% in the sensor-augmented pump group, 0.3 (0.1-0.7)% in the sensor-integrated pump with low glucose suspend group, and 0.3 (0.1-0.5)% in the sensor-integrated pump with predictive low glucose management group. In individuals switching from sensor-augmented pump to sensor-integrated pump with low glucose suspend (n=31), there were significant reductions in the monthly rate of hypoglycaemic events <3 mmol/l (rate ratio 0.63, 95% CI 0.45-0.89; P=0.009) and in the percentage of time with glucose values ≤3 mmol/l [sensor-augmented pump: 0.63% (95% CI 0.34-1.29), sensor-integrated pump with low glucose suspend: 0.33% (95% CI 0.16-0.64); P=0.001]. The monthly rate of hypoglycaemic events decreased further in individuals (n=139) switching from sensor-integrated pump with low glucose suspend to sensor-integrated pump with predictive low glucose management [rate ratio 0.82 (95% CI 0.69-0.98); P<0.0274]. Similar results were seen for events <3.9 mmol/l. There was no difference in median time spent in target glucose range.

CONCLUSION

Real-world UK data show that increasing automation of insulin suspension reduces hypoglycaemia exposure in people with Type 1 diabetes.

A modelling study of the budget impact of improved glycaemic control in adults with Type 1 diabetes in the UK

AIMS

To develop a novel interactive budget impact model that assesses affordability of diabetes treatments in specific populations, and to test the model in a hypothetical scenario by estimating cost savings resulting from reduction in HbA_1c from ≥69 mmol/mol (8.5%) to a target of 53 mmol/mol (7.0%) in adults with Type 1 diabetes in the UK.

METHODS

A dynamic, interactive model was created using the projected incidence and progression over a 5-year horizon of diabetes-related complications (micro- and macrovascular disease, severe hypoglycaemia and diabetic ketoacidosis) for different HbA_1c levels, with flexible input of population size, complications and therapy costs, HbA_1c distribution and other variables. The model took a National Health Service and societal perspective.

RESULTS

The model was developed, and in the proposed hypothetical situation, reductions in complications and expected costs evaluated. Achievement of target HbA_1c in individuals with HbA_1c ≥69 mmol/mol (8.5%) would reduce expected chronic complications from 6.8 to 1.2 events per 100 person-years, and diabetic ketoacidosis from 14.5 to 1.0 events per 100 person-years. Potential cumulative direct cost savings achievable in the modelled population were estimated at £687 m over 5 years (£5,585/person), with total (direct and indirect) savings of £1,034 m (£8,400/person).

CONCLUSIONS

Implementation of strategies aimed at achieving target glucose levels in people with Type 1 diabetes in the UK has the potential to drive a significant reduction in complication costs. This estimate may provide insights into the potential for investment in achieving savings through improved diabetes care in the UK.

A Type 1 diabetes technology pathway: consensus statement for the use of technology in Type 1 diabetes

In both adults and children with diabetes, technologies such as continuous subcutaneous insulin infusion using insulin pumps and continuous glucose monitoring can help improve diabetes control, reduce hypoglycaemia and improve quality of life. Access to these technologies in the UK is very variable. Some technologies are recommended by the National Institute for Health and Care Excellence, while others have not been appraised, and new technologies are emerging all the time. Additionally, different guidelines for adults and children further complicate access to diabetes technology in the transition from paediatric to adult care. Against this background, Diabetes UK and NHS England have brought together a multidisciplinary group of experts, including clinicians and people with diabetes, to develop this consensus guideline, combining the different technologies into a common pathway to aid clinical and policy decision-making. We created a pathway that supports the incremental addition of technology as monotherapy and then dual therapy in the same way that we incrementally add in therapeutic agents to support people with Type 2 diabetes to achieve their personalized glycaemic targets. The pathway emphasizes the importance of structured education, specialist support and appropriate access to psychological therapies, as essential pillars for optimized use of diabetes-related technology, and recommends the re-evaluation of its use when the individual is unable either to use the technology appropriately or to achieve the intended outcomes. This pathway is endorsed by UK-wide clinical and patient associations and we recommend that providers and commissioners use it to ensure the right individual with diabetes has access to the right technology in a timely way to help achieve better outcomes.

VASCULAR PLANT ONE-ZINC FINGER1 (VOZ1) and VOZ2 Interact with CONSTANS and Promote Photoperiodic Flowering Transition

In plants, endogenous and environmental signals such as light control the timing of the transition to flowering. Two phytochrome B-interacting transcription factors, VASCULAR PLANT ONE-ZINC FINGER1 (VOZ1) and VOZ2, redundantly promote flowering in Arabidopsis (Arabidopsis thaliana). In the voz1 voz2 mutant, the expression of FLOWERING LOCUS C (FLC) was up-regulated and that of FLOWERING LOCUS T (FT) was down-regulated, which was proposed to be the cause of late flowering in voz1 voz2 However, the detailed mechanism by which the VOZ genes promote flowering is not well understood. Here, we show that neither the reduced FT expression nor the late-flowering phenotype of voz1 voz2 is suppressed in the voz1 voz2 flc triple mutant. Genetic interaction experiments between voz1 voz2 and constans-2 (co-2) mutants reveal that the VOZs and CO work in the same genetic pathway. Using in vitro pull-down, electrophoretic mobility shift, and bimolecular fluorescence complementation assays, we show that VOZ1 and VOZ2 interact with CO. The voz1 voz2 35S::CO:YFP plants show suppression of the early-flowering phenotype induced by CO overexpression, suggesting that CO requires VOZ for the induction of flowering. Determination of the VOZ consensus-binding site followed by genome-wide sequence analysis failed to identify any VOZ-binding sites near known flowering time genes. Together, these results indicate that the VOZ genes regulate flowering primarily through the photoperiod pathway, independent of FLC, and suggest that VOZs modulate CO function to promote flowering.

Optimal prandial timing of bolus insulin in diabetes management: a review

The inability to achieve optimal diabetes glucose control in people with diabetes is multifactorial, but one contributor may be inadequate control of postprandial glucose. In patients treated with multiple daily injections of insulin, both the dose and timing of meal-related rapid-acting insulin are key factors in this. There are conflicting opinions and evidence on the optimal time to administer mealtime insulin. We performed a comprehensive literature search to review the published data, focusing on the use of rapid-acting insulin analogues in patients with Type 1 diabetes. Pharmacokinetic and pharmacodynamic studies of rapid-acting insulin analogues, together with postprandial glucose excursion data, suggest that administering these 15-20 min before food would provide optimal postprandial glucose control. Data from clinical studies involving people with Type 1 diabetes receiving structured meals and rapid-acting insulin analogues support this, showing a reduction in post-meal glucose levels of ~30% and less hypoglycaemia when meal insulin was taken 15-20 min before a meal compared with immediately before the meal. Importantly, there was also a greater risk of postprandial hypoglycaemia when patients took rapid-acting analogues after eating compared with before eating.

Proportion of daily capillary blood glucose readings required in the target range for target glycaemic control: shift of focus from target range to proportion in range

AIM

Most guidelines provide people with Type 1 diabetes with pre- and post-meal capillary blood glucose (CBG) targets to achieve optimal glycaemic control. We evaluated the proportion of daily CBG readings between 4 and 10 mmol/l in people achieving different HbA_1c levels.

METHOD

We analysed CBG data from routine pump/meter downloads from 201 adults treated with continuous subcutaneous insulin infusion (CSII) at a single hospital clinic. Exclusion criteria were CSII < 6 months, < 3 CBG/day, pregnancy, haemoglobinopathy and continuous sensor use. People were categorized into three groups based on HbA_1c : < 58 mmol/mol, < 7.5% (n = 58); 58-74 mmol/mol, 7.5-8.9% (n = 107); and ≥ 75 mmol/mol, ≥ 9.0% (n = 36).

RESULTS

Participants had a mean age of 43 ± 13 years and mean HBA_1c of 64 mmol/mol (8.0 ± 1.1%). 47% of people started CSII for raised HbA_1c , 25% due to hypoglycaemia and the rest during pregnancy. Downloads contained a mean of 22 ± 6.8 days of data per participant. CBG frequency was similar between the three groups (5.6 ± 2.0, 5.6 ± 1.9 and 5.4 ± 1.2 CBG/day; P = 0.468). The proportion of CBG readings between 4 and 10 mmol/l (72-180 mg/dl) was 57.3 ± 25.4%, 50.6 ± 11.1% and 39.9 ± 16.5% (P < 0.0001); < 4 mmol was 13.8%, 8.8% and 4.4% (P < 0.0001) and > 10 mmol/l was 28.9 ± 16.5%, 40.6 ± 12.1% and 55.6 ± 17.9% (P < 0.0001) in the three groups respectively.

CONCLUSIONS

Participants achieving HBA_1c < 58 mmol/mol (< 7.5%) had ~ 60% of CBG readings in range (4-10 mmol/l), with up to 30% of readings > 10 mmol/l. This target of achieving 60% or more readings within target, and being permissive with up to 30% readings > 10 mmol/l may be a novel target for people with diabetes, and may reduce anxiety associated with readings out of range.

JMJ27, an Arabidopsis H3K9 histone demethylase, modulates defense against Pseudomonas syringae and flowering time

Histone methylation is known to dynamically regulate diverse developmental and physiological processes. Histone methyl marks are written by methyltransferases and erased by demethylases, and result in modification of chromatin structure to repress or activate transcription. However, little is known about how histone methylation may regulate defense mechanisms and flowering time in plants. Here we report characterization of JmjC DOMAIN-CONTAINING PROTEIN 27 (JMJ27), an Arabidopsis JHDM2 (JmjC domain-containing histone demethylase 2) family protein, which modulates defense against pathogens and flowering time. JMJ27 is a nuclear protein containing a zinc-finger motif and a catalytic JmjC domain with conserved Fe(II) and α-ketoglutarate binding sites, and displays H3K9me1/2 demethylase activity both in vitro and in vivo. JMJ27 is induced in response to virulent Pseudomonas syringae pathogens and is required for resistance against these pathogens. JMJ27 is a negative modulator of WRKY25 (a repressor of defense) and a positive modulator of several pathogenesis-related (PR) proteins. Additionally, loss of JMJ27 function leads to early flowering. JMJ27 negatively modulates the major flowering regulator CONSTANS (CO) and positively modulates FLOWERING LOCUS C (FLC). Taken together, our results indicate that JMJ27 functions as a histone demethylase to modulate both physiological (defense) and developmental (flowering time) processes in Arabidopsis.

Sudden cardiac death in adults with congenitally corrected transposition of the great arteries

Background

Congenitally corrected transposition of the great arteries (ccTGA) is a rare congenital heart disease. There have been only few reports of sudden cardiac death (SCD) in patients with ccTGA and reasonable ventricular function.

Methods

A retrospective review of the medical records of all patients attending our adult congenital heart centre, with known ccTGA.

Results

From a database of over 3500 adult patients with congenital heart disease, we identified 39 (∼1%) with ccTGA and ‘two-ventricle’ circulations. 65% were male. The mean age at diagnosis was 12.4±11.4 years and the mean age at last time of review was 34.3±11.3 years. 24 patients (56%) had a history of surgical intervention. 8 (19%) had had pacemaker implantation and 2 had had a defibrillator implanted for non-sustained ventricular tachycardia (NSVT). In 544 years of patient follow-up, there had been five cases of SCD in our population; 1 death per 109 patient-years. Two of these patients had had previously documented supraventricular or NSVT. However, they were all classified as New York Heart Association (NYHA) class I or II, and systemic (right) ventricular function had been recorded as normal, mildly or mildly–moderately impaired, at most recent follow-up.

Conclusions

Our experience suggests the need for improved risk stratification and/or surveillance for malignant arrhythmia in adults with ccTGA, even in those with reasonable functional class on ventricular function.

Defining the Metabolic Functions and Roles in Virulence of the rpoN1 and rpoN2 Genes in Ralstonia solanacearum GMI1000

The alternative sigma factor RpoN is a unique regulator found among bacteria. It controls numerous processes that range from basic metabolism to more complex functions such as motility and nitrogen fixation. Our current understanding of RpoN function is largely derived from studies on prototypical bacteria such as Escherichia coli. Bacillus subtilis and Pseudomonas putida. Although the extent and necessity of RpoN-dependent functions differ radically between these model organisms, each bacterium depends on a single chromosomal rpoN gene to meet the cellular demands of RpoN regulation. The bacterium Ralstonia solanacearum is often recognized for being the causative agent of wilt disease in crops, including banana, peanut and potato. However, this plant pathogen is also one of the few bacterial species whose genome possesses dual rpoN genes. To determine if the rpoN genes in this bacterium are genetically redundant and interchangeable, we constructed and characterized ΔrpoN1, ΔrpoN2 and ΔrpoN1 ΔrpoN2 mutants of R. solanacearum GMI1000. It was found that growth on a small range of metabolites, including dicarboxylates, ethanol, nitrate, ornithine, proline and xanthine, were dependent on only the rpoN1 gene. Furthermore, the rpoN1 gene was required for wilt disease on tomato whereas rpoN2 had no observable role in virulence or metabolism in R. solanacearum GMI1000. Interestingly, plasmid-based expression of rpoN2 did not fully rescue the metabolic deficiencies of the ΔrpoN1 mutants; full recovery was specific to rpoN1. In comparison, only rpoN2 was able to genetically complement a ΔrpoN E. coli mutant. These results demonstrate that the RpoN1 and RpoN2 proteins are not functionally equivalent or interchangeable in R. solanacearum GMI1000.

Sustained benefit of continuous subcutaneous insulin infusion on glycaemic control and hypoglycaemia in adults with Type 1 diabetes

AIM

To evaluate the sustainability of the benefits of continuous subcutaneous insulin infusion therapy in routine practice in a cohort of adults with diabetes.

METHODS

The clinical records of all adults starting continuous subcutaneous insulin infusion over 12 years at our centre were included in this study. Baseline and mean annual HbA(1c) levels were recorded. The frequency of mild-to-moderate and severe hypoglycaemia and hypoglycaemia awareness were analysed in a subgroup.

RESULTS

Adequate data were available from 327 patients, of whom 71% were female. The patients' mean ± sd age was 41 ± 14 years, the mean ± sd (range) follow-up for continuous subcutaneous insulin infusion was 4.3 ± 2.7 (1-12) years. The mean ± sd HbA(1c) concentration fell by 8 ± 5 mmol/mol (0.7 ± 0.5%) at year 1 [to 63 ± 12 mmol/mol from 70 ± 18 mmol/mol (7.9 ± 1.1% from 8.6 ± 1.6%); P < 0.0005], sustained to year 5. In patients with initial poor control, HbA(1c) dropped by 12 ± 11 mmol/mol (1.1 ± 1.0%; P < 0.0005) at year 1, sustained to year 6. The percentage of patients with ≥ 5 mild to moderate hypoglycaemic episodes per week fell from 29 to 12% (n = 163; P = 0.006). In the subgroup (n = 87; follow-up 2.5 ± mean ± sd 1.1 years), the frequency of severe hypoglycaemia fell from 0.6 ± 1.7 episodes per patient per year to 0.3 ± 0.9 (P = 0.047). Of 24 patients with impaired awareness of hypoglycaemia (Gold score ≥ 4), the mean ± sd Gold score improved from 4.9 ± 0.9 to 3.8 ± 1.7 (P = 0.011). Nine people regained awareness. No deterioration in HbA(1c) was seen in the hypoglycaemia-prone groups.

CONCLUSIONS

The benefits of continuous subcutaneous insulin infusion with regard to improving glycaemic control and reducing hypoglycaemia frequency, along with improvement in hypoglycaemia awareness without deterioration in glycaemic control, can be sustained over several years in clinical practice.

EXTENSIN18 is required for full male fertility as well as normal vegetative growth in Arabidopsis

EXTENSINS (EXTs) are a 65-member subfamily of hydroxyproline-rich glycoproteins (HRGPs) of which 20 putatively form crosslinking networks in the cell wall. These 20 classical EXTs are involved at the start of new wall assembly as evidenced by a requirement for EXT3 during cytokinesis, and the ability of some EXTs to polymerize in vitro into dendritic patterns. EXT3 was previously shown to form pulcherosine (three Tyrosines) cross-links. Little direct data exists on the other 19 classical EXTs. Here, we describe the phenotypes of ext18 mutants and rescued progeny as well as associated expression profiles of all 20 classical EXT genes. We found that EXT18 is required for full male fertility, as well as for normal vegetative growth. EXT18 has potential to form crosslinking networks via di-iso-di-tyrosine (four Tyrosines) covalent bonds, and not via pulcherosine due to deficit of lone Tyrosines. This together with ext18 defective pollen grains and pollen tubes, and reduced plant size, suggests that EXT18-type EXTs are important contributors to wall integrity, in pollen and other rapidly extending walls. The data also show that a knockout of EXT18 had a pleiotropic affect on the expression of several EXTs, as did the reintroduction of the native EXT18 gene, thus supporting the thesis that transcription of groups of EXTs are co-regulated and work in different combinations to make distinctive inputs into wall assembly of different cell types. These insights contribute to basic knowledge of cell wall self-assembly in different cell types, and potentially enable biotechnological advances in biomass increase and plant fertility control.

Unsupervised home use of an overnight closed-loop system over 3-4 weeks: a pooled analysis of randomized controlled studies in adults and adolescents with type 1 diabetes

AIMS

To compare overnight closed-loop and sensor-augmented pump therapy in patients with type 1 diabetes by combining data collected during free-living unsupervised randomized crossover home studies.

METHODS

A total of 40 participants with type 1 diabetes, of whom 24 were adults [mean ± standard deviation (s.d.) age 43 ± 12 years and glycated haemoglobin (HbA1c) 8.0 ± 0.9%] and 16 were adolescents (mean ± s.d. age 15.6 ± 3.6 years and HbA1c 8.1 ± 0.8%), underwent two periods of sensor-augmented pump therapy in the home setting, in combination with or without an overnight closed-loop insulin delivery system that uses a model predictive control algorithm to direct insulin delivery. The order of the two interventions was random; each period lasted 4 weeks in adults and 3 weeks in adolescents. The primary outcome was time during which sensor glucose readings were in the target range of 3.9-8.0 mmol/l.

RESULTS

The proportion of time when sensor glucose was in the target range (3.9-8.0 mmol/l) overnight (between 24:00 and 08:00 hours) was 18.5% greater during closed-loop insulin delivery than during sensor-augmented therapy (p < 0.001). Closed-loop therapy significantly reduced mean overnight glucose levels by 0.9 mmol/l (p < 0.001), with no difference in glycaemic variability, as measured by the standard deviation of sensor glucose. Time spent above the target range was reduced (p = 0.001), as was time spent in hypoglycaemia (<3.9 mmol/l; p = 0.014) during closed-loop therapy. Lower mean overnight glucose levels during closed-loop therapy were brought about by increased overnight insulin delivery (p < 0.001) without changes to the total daily delivery (p = 0.84).

CONCLUSION

Overnight closed-loop insulin therapy at home in adults and adolescents with type 1 diabetes is feasible, showing improvements in glucose control and reducing the risk of nocturnal hypoglycaemia.

Late outcomes in adults with coarctation of the aorta

AIMS

Previous cohort studies of patients with coarctation of the aorta (CoA) demonstrate reduced long-term survival. Improved surgical outcomes in children and evolution of adult congenital heart disease (ACHD) services have resulted in improved survival in patients with other CHDs. We hypothesise that for young adult patients with CoA long-term outcomes have improved in the contemporary era.

METHODS

151 patients (58% men) with simple CoA followed up at a tertiary ACHD service in Sydney, Australia, from 1993 to 2013 were included. We documented mortality and major morbidity such as the need for re-intervention for re-coarctation or aneurysms.

RESULTS

140 patients (mean age 35±15 years) underwent CoA repair at median age of 5 (IQR 0-10) years. Initial surgical strategy included end-to-end repair in 43, subclavian flap aortoplasty in 28 and patch aortoplasty in 31 patients (and was not documented in 28 cases). 6 patients had endovascular repair, 4 had interposition tube grafts and 11 were unrepaired. There were a total of seven deaths at a median age of 60 years. Actuarial survival was 98% at 40, 98% at 50 and 89% at 60 years of age. Re-coarctation occurred in 34% and descending aortic aneurysms were noted in 18%. Patients with end-to-end repair had lower rates of significant re-coarctation or descending aortic aneurysms (p=0.026 and <0.001, respectively). 66% had bicuspid aortic valve and 44% were hypertensive.

CONCLUSIONS

Patients with CoA who reach adolescence demonstrate very good long-term survival up to age 60 years. Long-term morbidity is common, however, related largely to aortic complications and late hypertension.

Modification of human islet preparation: an effective approach to improve graft outcome after islet transplantation?

Revascularisation of transplanted islets is an essential prerequisite for graft survival and function. However, current islet isolation procedures deprive the islets of endothelial tubulets. This may have a detrimental effect on the revascularisation process of islets following transplantation. We hypothesise that modification of the isolation procedure that preserves islet endothelial vessels may improve the islet revascularisation process following transplantation. Here, we present a modified islet isolation method by which a substantial amount of endothelial cells still attached to the islets could be preserved. The islets with preserved endothelial cells isolated by this method were revascularised within 3 days, not observed in islets isolated by standard methods. Further, we observed that grafts of islets isolated by standard methods had more patches of dead tissue than islet grafts obtained by the modified method, indicating that attached endothelial cells may play an important role in the islet revascularisation process and potentially help to improve the transplantation outcome.

Outcomes for adults with type 1 diabetes referred with severe hypoglycaemia and/or referred for islet transplantation to a specialist hypoglycaemia service

Islet transplantation alone (ITA) is indicated for patients with type 1 diabetes (T1D) with disabling severe hypoglycaemia (SH) despite optimised medical therapy. We examined outcomes for patients referred to an islet transplant unit with recurrent SH. Retrospective case note audit of 45 patients with ≥1 SH per year who were referred to our ITA unit between 2009-2012; 36 patients attended follow-up appointments. The cohort was 52.8% male, mean (± SD) age 43.9 (± 11.4) years, and duration of diabetes 26.5 (± 12.9) years. Baseline HbA1c was 8.3% (± 1.7) (67.2 mmol/mol), median (IQR) frequency of SH was 6.0 (2.0-24.0) per/patient/year and 83.3% had impaired awareness of hypoglycaemia (IAH). 80.6% of patients were referred from other secondary diabetes services, 22.2% had completed structured education, and 30.6% were using continuous subcutaneous insulin infusion (CSII). Seventeen patients were optimised with conventional therapy; SH reduced from 2.0 (1.5-9.0) to 0.0 (0.0-0.5) episodes/patient/year; p<0.001, and there was concurrent improvement in HbA1c (8.1-7.7%; 65.0 vs. 60.7 mmol/mol; p=0.072). Ten patients were listed for transplantation as they were not optimised despite structured education, CSII, and continuous glucose monitoring (CGM). The remaining 9 had a reduction in SH [7.0 (4.8-40.5) to 4.0 (2.5-6.3) episodes/patient/year; p=0.058] and either left the service (n=5) or are still being optimised (n=4). In conclusion, 47.2% of patients presenting with problematic hypoglycaemia resolved with optimal medical therapy, with a further 25% achieving clinically relevant improvement, however 27.8% required transplantation despite access to all therapies. Provision of expertise in hypoglycaemia management is essential to focus limited transplant resources on those who need it most.

Improving the diagnosis of LV non-compaction with cardiac magnetic resonance imaging

BACKGROUND

Current diagnostic criteria for left ventricular non-compaction (LVNC) poorly correlate with clinical outcomes. We aimed to develop a cardiac magnetic resonance (CMR) based semi-automated technique for quantification of non-compacted (NC) and compacted (C) masses and to ascertain their relationships to global and regional LV function.

METHODS

We analysed CMR data from 30 adults with isolated LVNC and 20 controls. NC and C masses were measured using relative signal intensities of myocardium and blood pool. Global and regional LVNC masses was calculated and correlated with both global and regional LV systolic function as well as occurrence of arrhythmia.

RESULTS

LVNC patients had significantly higher end-systolic (ES) and end-diastolic (ED) NC:C ratios compared to controls (ES 0.21 [SD 0.09] vs. 0.12 [SD 0.02], p<0.001; ED 0.39 [SD 0.08] vs. 0.26 [SD 0.05], p<0.001). NC:C ratios correlated inversely with global ejection fraction, with a stronger correlation in ES vs. ED (r=-0.58, p<0.001 vs. r=-0.30, p=0.03). ES basal, mid and apical NC:C ratios also showed a significant inverse correlation with global LV ejection fraction (ES basal r=-0.29, p=0.04; mid-ventricular r=-0.50, p<0.001 and apical r=-0.71, p<0.001). Upon ROC testing, an ES NC:C ratio of 0.16 had a sensitivity of 70% and a specificity of 95% for detection of significant LVNC. Patients with sustained ventricular tachycardia had a significantly higher ES NC:C ratio (0.31 [SD 0.18] vs. 0.20 [SD 0.06], p=0.02).

CONCLUSIONS

The NC:C ratio derived from relative signal intensities of myocardium and blood pool improves the ability to detect clinically relevant NC compared to previous CMR techniques.