[Metformin role in the treatment of type 2 diabetes in 2008]

Treatment of type 2 diabetes includes lifestyle adaptations and drug treatment with the recent availability of many new substances. Metformin is the best first option at present due to its efficacy, its neutral effect on weight, its security profile and its cost. In addition, metformin can be associated with any other antidiabetic agent. Sulfonylureas remain the best choice for combination with metformin although their effectiveness on glucose control decrease with time more rapidly compared with glitazones. The GLP-1 (glucagon-like peptide 1) analogues and DPP-4 (di-peptidyl-peptidase-4) inhibitors are effective but need long-term evaluation of their security profile. Insulin can be used when the different oral options have failed.

[Evolution of orthodontic appliances from 1728 to 2007. Inaugural Conference of the 79th Scientific Meeting of the SFODF at Versailles, 31 May 2007]

The nature of orthodontic appliances depends, in part, on the development of therapeutic ideas and also on the materials and techniques that are available to practitioners. The first mechanisms appeared in 1728; they were attached to teeth by ligatures. Removable appliances, made of metal, ivory and, later, vulcanite developed as soon as practitioners became capable of taking reliable impressions, an epoch that began in 1840. A multiplicity of fixed appliances was introduced after the invention of a dental cement that could be used to attach them to teeth in 1871. But even before that, in 1860, dentists had begun to modify the form and the position of basal bone and to construct intra- and extra-oral appliances to accomplish this. And it wasn't until 1916 that Angle introduced the first bracket that allowed orthodontists to apply a couple of forces to teeth. For the most part, a new appliance didn't replace an older one. It was simply added to the armamentarium, which explains why we now have such a great diversity of systems at our disposal, and the imprecision of the indications for the use of many of them.

[Diabetes mellitus and driving]

Most studies, which are retrospective, show contradictory results regarding the incidence of road traffic accident among diabetic patients. The most frequent cause of accident is hypoglycemia. One should also consider impaired vision (retinopathy, maculopathy), neuropathy (feet insensitivity) and sleep apnoea in overweight patients. Hypoglycemia not only leads to impaired judgement during driving, but also to a reduction in performances, frequent hypoglycemias impair symptom recognition and increase the risk of loss of consciousness. Patients should benefit from teaching about hypoglycemia, i.e. how to recognize and correct it in order to avoid accidents. Generally they should not drive if their glycemia is under 5 mmol/l without correcting it with an adequate amount of carbohydrates.

[The diabetic patient at altitude: pathophysiology and practical implications]

The prevalence of diabetes is constantly growing and an ever increasing number of diabetics travel to moderate (1500-2000 m, 5000-6500 ft.) or high altitude (>2500 m, >8000 ft) for recreational purposes. Stays at moderate altitude are very well tolerated for a majority of diabetics, but can be limited by hypoxia or equipment failure due to freezing temperatures, or by the occurence of altitude-specific pathologies, as acute mountain sickness, which can mimick hypoglycemia in the diabetic. Beyond 2500 m, freezing, remoteness, hypoxia-induced anorexia, side effects of medications and the higher incidence of mountain sickness can make diabetes control difficult. A well informed and prepared diabetic patient, with sufficient and adequatly kept equipment, and a reasonably good fitness level, can enjoy and master mountaineering.

[Endocrinology]

For the 2006 Endocrine' News, we discuss the SERMs and their clinical effects. After the disappointing results of the recent studies on the cardiovascular effects of post-menopausal estrogen replacement therapy, the SERMs show no favourable effects on cardiovascular events either and even a small increase in stroke incidence. The second topic is focused on the controversial diagnosis and treatment of andropause. Finally, in the field of endocrine reproduction, there is some doubt about the optimal time at which a couple actively trying to have a child needs to undertake in vitro fertilization. A recent study suggests that patience may be rewarding.

Detection of insulin mRNA in the peripheral blood after human islet transplantion predicts deterioration of metabolic control

Recent updates of the Edmonton trial have shown that insulin independence is progressively lost in approximately 90% of islet transplant recipients over the first 5 years. Early prediction of islet graft injury could prompt the implementation of strategies attempting to salvage the transplanted islets. We hypothesize that islet damage is associated with the release and detection of insulin mRNA in the circulating blood. Whole blood samples were prospectively taken from 19 patients with type 1 diabetes receiving 31 islet transplants, immediately prior to transplantation and at regular time-points thereafter. After RNA extraction, levels of insulin mRNA were determined by quantitative reverse tran-scriptase-polymerase chain reaction. All patients exhibited a primary peak of insulin mRNA immediately after transplantation, without correlation of duration and amplitude with graft size or outcome. Twenty-five subsequent peaks were observed during the follow-up of 17 transplantations. Fourteen secondary peaks (56%) were closely followed by events related to islet graft function. Duration and amplitude of peaks were higher when they heralded occurrence of an adverse event. Peaks of insulin mRNA can be detected and are often associated with alterations of islet graft function. These data suggest that insulin mRNA detection in the peripheral blood is a promising method for the prediction of islet graft damage.

Sequential kidney/islet transplantation: efficacy and safety assessment of a steroid-free immunosuppression protocol

The aim of this study was to assess the efficiency and safety of the Edmonton immunosuppression protocol in recipients of islet-after-kidney (IAK) grafts. Fifteen islet infusions were administered to 8 patients with type 1 diabetes and a functioning kidney graft. Immunosuppression was switched on the day of transplantation to a regimen associating sirolimus-tacrolimus-daclizumab. Insulin-independence was achieved in all patients for at least 3 months, with an actual rate of 71% at 1 year after transplantation (5 of 7 patients). After 24-month mean follow-up, five have ongoing insulin independence, 11-34 months after transplantation, with normal HbA1c, fructosamine and mean amplitude of glycemic excursions (MAGE) values. Results of arginine-stimulation tests improved over time, mostly after the second islet infusion. Severe adverse events included bleeding after percutaneous portal access (n=2), severe pneumonia attributed to sirolimus toxicity (n=1), kidney graft loss after immunosuppression discontinuation (n=1), reversible humoral kidney rejection (n=1) and fever of unknown origin (n=1). These data indicate that the Edmonton approach can be successfully applied to the IAK setting. This procedure is associated with significant side effects and only patients with stable function of the kidney graft should be considered. The net harm versus benefit has not yet been established and will require further studies with larger numbers of enrolled subjects.

[Should we treat all diabetic patients with aspirin in primary prevention?]

Patients with diabetes have a higher risk of atherothrombotic disease. These patients have up to 4-fold more coronary artery diseases compared with patients without diabetes. Aspirin is one of the most prescribed treatments in the prevention of cardiovascular diseases. This article focuses on the effect of aspirin in primary prevention with a summary of interventional studies including diabetic patients. The guidelines from different speciality societies, notably the American Diabetes Association, are positive. However, the results of these studies are not conclusive. Cautions recommendations are proposed.

Protein hydrolysates stimulate proglucagon gene transcription in intestinal endocrine cells via two elements related to cyclic AMP response element

AIMS/HYPOTHESIS

Protein hydrolysates (peptones) increase not only glucagon-like peptide-1 (GLP-1) secretion but also transcription of the proglucagon ( PG) gene in the intestine. The critical physiological roles of gut-derived GLPs raised hope for their therapeutic use in several disorders, especially GLP-1 in diabetes. We aimed to investigate the molecular mechanisms involved in this nutrient- PG gene interaction.

METHODS

Wild-type and mutated PG promoter fragments fused to the luciferase reporter gene were transfected into enteroendocrine STC-1 cells, which were then either treated or not with peptones. Co-transfection with expression vectors of dominant-negative forms of cAMP response element binding protein (CREB) and protein kinase A (PKA) proteins were performed, as well as electrophoresis mobility shift assays.

RESULTS

Deletion analysis showed that the promoter region spanning between -350 and -292 bp was crucial for the transcriptional stimulation induced by peptones. Site-directed mutagenesis of the canonical cAMP response element (CRE(PG)) and of the adjacent putative CRE site (CRE-like1) led to a dramatic inhibition of the promoter responsiveness to peptones. Over expression of a dominant-negative mutant of CREB or of PKA produced a comparable and selective inhibitory effect on the activity of transfected promoter fragment containing the -350/-292 sequence. EMSA showed that CREB and fra2 transcription factors bound to CRE(PG) and CRE-like1 elements respectively, independently of peptone treatment.

CONCLUSIONS/INTERPRETATION

Our report identified cis- and trans-regulatory elements implicated in the transcriptional control of PG gene by nutrients in enteroendocrine cells. It highlights the role of a previously unsuspected CRE-like1 element, and emphasises the importance of CRE-related sequences in the regulation of PG gene transcription in the intestine.

Islet of langerhans allogeneic transplantation at the university of geneva in the steroid free era in islet after kidney and simultaneous islet-kidney transplantations

AIMS

We report a single-center experience of islet allogeneic transplantation in islet after kidney (IAK) and simultaneous islet-kidney (SIK) type 1 diabetic recipients using a steroid-free immunosuppressive regimen.

METHODS

Eight patients received 12 islet infusions in 5 IAK and 3 SIK procedures. Median age was 51 years (range, 30-58 years) with a male:female ratio of 2:6. IAK was considered only for patients with a stable kidney function and a creatinine clearance level >60 mL/min. SIK was considered for patients with a counterindication for simultaneous kidney-pancreas transplantation. Immunosuppression was based on sirolimus/tacrolimus combined with daclizumab induction. Two consecutive infusions of >5000 islet equivalents (IEQ)/kg were planned.

RESULTS

Five patients completed the transplantation course, whereas 3 patients received only 1 islet infusion. All patients have functional grafts (C-peptide >166 pmol/L) at 6-month median follow-up. Of 5 patients who completed their transplantation course 4 became insulin independent. HbA1c and fructosamine decreased over time, showing improved metabolic control. Severe adverse events were observed in 4 patients. One SIK patient died after OKT-3 treatment of severe kidney rejection.

CONCLUSIONS

The Edmonton immunosuppressive protocol can be applied for patients undergoing either IAK or SIK procedures, with a high rate of graft function and insulin independence. Morbidity is higher than among patients undergoing solitary islet transplantation for type 1 brittle diabetes.

Islet autotransplantation for the prevention of surgical diabetes after extended pancreatectomy for the resection of benign tumors of the pancreas

OBJECTIVE

The objective of this article is to report a single-center experience with islet autotransplantation after extensive pancreatic resection for benign tumors of the pancreas.

MATERIALS AND METHODS

Seven patients underwent extensive left pancreatectomy for benign lesions located at the neck of the pancreas. Once an unequivocal diagnosis of a benign nature was ascertained, the rest of the specimen was processed and the unpurified pancreatic digest was infused into the portal vein. The results were compared with those of 8 autotransplantations performed for chronic pancreatitis over the same period.

RESULTS

Tumors were 4 cystadenomas, 2 insulinomas and 1 neuroendocrine tumor. Mean islet yields were 275,000 islet equivalents (IEQ) versus 129,000 in chronic pancreatitis (P =.04) or 6700 IEQ/g of tissue versus 1900 (P =.002), resulting in transplantation of 4200 IEQ/kg body weight vs 2150 in chronic pancreatitis (P =.03), respectively at 4-month to 7.5-year follow-up, all patients are alive and 6 of 7 are off insulin. All patients off insulin after at least 1 year currently have a normal IVGTT, with K values ranging between -1.19 and -2.36 (normal < -1.00). All patients, including 1 on insulin, display positive basal and glucagon-stimulated C-peptide levels.

CONCLUSIONS

Compared with chronic pancreatitis tissue resected for benign tumors is more likely to achieve good islet yields, and thus insulin independence after autotransplantation. Islet autotransplantation should be considered when extensive pancreatectomy is required for resection of a benign tumor, and only if the benign nature of the lesion is demonstrated unequivocally.

[The causes of incisal overbite]

Why does the eruption of some incisors cease when overbite has reached 3 mm and continue in other cases? Eruption stops only when an opposing force confronts it; normally, this is what occurs when incisors erupt into end-to-end occlusion. Tongue thrusting between molar teeth plays an etiological role only when it interferes with vertical dimension. Incisal overbite diminishes when incisal inclination increases: orthodontists can eliminate incisal overbite by inclining the anterior teeth labially. But a low interincisive angle is no assurance against relapse, because retention, to be reliable, must include a dynamic element, natural or artificial, blocking over-eruption.

Ectopic expression of the beta-cell specific transcription factor Pdx1 inhibits glucagon gene transcription

AIMS/HYPOTHESIS

The transcription factor Pdx1 is required for the development and differentiation of all pancreatic cells. Beta-cell specific inactivation of Pdx1 in developing or adult mice leads to an increase in glucagon-expressing cells, suggesting that absence of Pdx1could favour glucagon gene expression by a default mechanism.

METHOD

We investigated the inhibitory role of Pdx1 on glucagon gene expression in vitro. The glucagonoma cell line InR1G9 was transduced with a Pdx1-encoding lentiviral vector and insulin and glucagon mRNA levels were analysed by northern blot and real-time PCR. To understand the mechanism by which Pdx1 inhibits glucagon gene expression, we studied its effect on glucagon promoter activity in non-islet cells using transient transfections and gel-shift analysis.

RESULTS

In glucagonoma cells transduced with a Pdx1-encoding lentiviral vector, insulin gene expression was induced while glucagon mRNA levels were reduced by 50 to 60%. In the heterologous cell line BHK-21, Pdx1 inhibited by 60 to 80% the activation of the alpha-cell specific element G1 conferred by Pax-6 and/or Cdx-2/3. Although Pdx1 could bind three AT-rich motifs within G1, two of which are binding sites for Pax-6 and Cdx-2/3, the affinity of Pdx1 for G1 was much lower as compared to Pax-6. In addition, Pdx1 inhibited Pax-6 mediated activation through G3, to which Pdx1 was unable to bind. Moreover, a mutation impairing DNA binding of Pdx1 had no effect on its inhibition on Cdx-2/3. Since Pdx1 interacts directly with Pax-6 and Cdx-2/3 forming heterodimers, we suggest that Pdx1 inhibits glucagon gene transcription through protein to protein interactions with Pax-6 and Cdx-2/3.

CONCLUSION/INTERPRETATION

Cell-specific expression of the glucagon gene can only occur when Pdx1 expression extinguishes from the early alpha cell precursor.

An arginine to cysteine(252) mutation in insulin receptors from a patient with severe insulin resistance inhibits receptor internalisation but preserves signalling events

AIMS/HYPOTHESIS

We examined the properties of a mutant insulin receptor (IR) with an Arg(252) to Cys (IR(R252C)) substitution in the alpha-subunit originally identified in a patient with extreme insulin resistance and acanthosis nigricans.

METHODS

We studied IR cell biology and signalling pathways in Chinese Hamster Ovary cells overexpressing this IR(R252C).

RESULTS

Our investigation showed an impairment in insulin binding to IR(R252C) related mostly to a reduced affinity of the receptor for insulin and to a reduced rate of IR(R252C) maturation; an inhibition of IR(R252C)-mediated endocytosis resulting in a decreased insulin degradation and insulin-induced receptor down-regulation; a maintenance of IR(R252C) on microvilli even in the presence of insulin; a similar autophosphorylation of mutant IR(R252C) followed by IRS 1/IRS 2 phosphorylation, p85 association with IRS 1 and IRS 2 and Akt phosphorylation similar to those observed in cells expressing wild type IR (IRwt); and finally, a reduced insulin-induced Shc phosphorylation accompanied by decreased ERK1/2 phosphorylation and activity and of thymidine incorporation into DNA in cells expressing IR(R252C) as compared to cells expressing IRwt.

CONCLUSION/INTERPRETATION

These observations suggest that: parameters other than tyrosine kinase activation participate in or control the first steps of IR internalisation or both; IR-mediated IRS 1/2 phosphorylation can be achieved from the cell surface and microvilli in particular; Shc phosphorylation and its subsequent signalling pathway might require IR internalisation; defective IR endocytosis correlates with an enhancement of some biological responses to insulin and attenuation of others.

The pancreatic beta-cell-specific transcription factor Pax-4 inhibits glucagon gene expression through Pax-6

AIMS/HYPOTHESIS

The paired-homeobox genes pax-4 and pax-6 are crucial for islet development; whereas the null mutation of pax-6 results in the nearly absence of glucagon-producing alpha cells, pax-4 homozygous mutant mice lack insulin and somatostatin-producing beta and delta cells but contain an increased number of alpha cells suggesting that alpha cells could develop by a default mechanism.

METHODS

To investigate whether beta-cell specific factors act negatively on glucagon gene transcription, we ectopically expressed pax-4 in glucagon producing InR1G9 cells; Pax-4 inhibited basal transcription of the glucagon gene promoter by 60%. To assess the mechanism of this inhibition, we cotransfected the non-islet cell line BHK-21 with Pax-4 and various transcription factors present in alpha cells.

RESULTS

In addition to a general repressor activity on basal glucagon gene promoter activity of 30-50%, a specific 90% inhibition of Pax-6 mediated transactivation was observed. In contrast, Pax-4 had no effect on Cdx-2/3 or HNF3alpha mediated transcriptional activation. Pax-4 showed similar affinity to the Pax-6 binding sites on the glucagon gene promoter compared to Pax-6, but varying with KCl concentrations.

CONCLUSION/INTERPRETATION

Pax-4 impairs glucagon gene transcription specifically through inhibition of Pax-6 mediated transactivation. Transcriptional inhibition seems to be mediated by direct DNA binding competition with Pax-6 and potentially additional mechanisms such as protein-protein interactions and a general repressor activity of Pax-4. Glucagon gene expression in alpha cells could thus result from both the presence of islet cell specific transcription factors and the absence of Pax-4.

New elements in human renin promoter involved in cell-specific expression

1. The renin-angiotensin system plays a major role in blood pressure regulation and electrolyte homeostasis through the action of angiotensin (Ang) II. The first and rate-limiting step in the production of AngII is the conversion of angiotensinogen into AngI, which is catalysed by the aspartyl protease renin (EC 3.4.23.15). Circulating active renin is mainly synthesized, processed and secreted by the juxtaglomerular cells within the kidney. 2. To determine the renin 5'-flanking sequences involved in cell and tissue specificity, ex vivo and in vivo studies were performed. Several constructs of various lengths of renin promoter linked to the luciferase gene were first tested ex vivo by transfection in primary cultures of human chorionic cells. The constructs giving a high and specific expression in renin-producing cells were then tested in vivo in a transgenic mice model. 3. The reporter gene chosen to generate transgenic mice was LacZ and the screening was performed in embryos at the embryonic day (E) 15 stage, at which mouse renin is expressed in the developing vessels of the kidney. 4. Only constructs containing more than 5.7 kb of the human renin promoter lead to specific expression of beta-galactosidase in the kidney. 5. Our results demonstrate that the human renin distal promoter region allows a more restricted expression of LacZ in the renin-expressing cells in transgenic mice.

Insulin independence and normalization of oral glucose tolerance test after islet cell allotransplantation

To achieve permanent normoglycemia in patients with type I diabetes, it is necessary to renew the insulin-producing beta-cells by transplantation of either a vascularized pancreatic graft or isolated islets of Langerhans. Presently, about 10% of patients with type I diabetes undergoing islet allotransplantation achieve insulin independence; however, glucose intolerance remains in the majority of cases. We report a case of long-term insulin independence after islet allotransplantation in a type I diabetic patient. Three years after islet transplantation, the patient remains insulin-independent with a normal oral glucose tolerance test (OGTT). The patient therefore no longer meets the World Health Organization criteria for the diagnosis of diabetes mellitus and demonstrates that islet transplantation can cure diabetes in type I diabetic patients.

Pdx1 level defines pancreatic gene expression pattern and cell lineage differentiation

The absence of Pdx1 and the expression of brain-4 distinguish alpha-cells from other pancreatic endocrine cell lineages. To define the transcription factor responsible for pancreatic cell differentiation, we employed the reverse tetracycline-dependent transactivator system in INS-I cell-derived subclones INSralphabeta and INSrbeta to achieve tightly controlled and conditional expression of wild type Pdx1 or its dominant-negative mutant, as well as brain-4. INSralphabeta cells express not only insulin but also glucagon and brain-4, while INSrbeta cells express only insulin. Overexpression of Pdx1 eliminated glucagon mRNA and protein in INSralphabeta cells and promoted the expression of beta-cell-specific genes in INSrbeta cells. Induction of dominant-negative Pdx1 in INSralphabeta cells resulted in differentiation of insulin-producing beta-cells into glucagon-containing alpha-cells without altering brain4 expression. Loss of Pdx1 function alone in INSrbeta cells, which do not express endogenous brain-4 and glucagon, was also sufficient to abolish the expression of genes restricted to beta-cells and to cause alpha-cell differentiation. In contrast, induction of brain-4 in INSrbeta cells initiated detectable expression of glucagon but did not affect beta-cell-specific gene expression. In conclusion, Pdx1 confers the expression of pancreatic beta-cell-specific genes, such as genes encoding insulin, islet amyloid polypeptide, Glut2, and Nkx6.1. Pdx1 defines pancreatic cell lineage differentiation. Loss of Pdx1 function rather than expression of brain4 is a prerequisite for alpha-cell differentiation.